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LECTURES
         0/
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I  ON
OBSTETRIC OPERATIONS 
                        ljy the same Author,

A Clinical History of the Medical  and Surgical Diseases of
    Women.  Second  Edition.  With 181 Engravings, 8vo,  28s.
A System  of  Obstetric Medicine  and  Surgery, Theoretical
     and  Clinical, for the Student and Practitioner.  By Robert
     Barnes and Fancourt  Barnes.  2 vols.   1884—1885. 
LECTURES
OBSTETRIC  OPERATIONS
THE TREATMENT OF HEMORRHAGE
AND FORMING
^ (Svaitt to % lltanagcmmf of giffitult labour
/
    EOBEET BAENES,  M.D. Lond., F.E.C.P.
           • • »
          LATE CENSOR OF THE ROYAL COLLEGE OF PHYSICIANS J
CONSULTING OBSTETRIC PHYSICIAN TO ST. GEORGE'S HOSPITAL, THE ROYAL MATERNITY CHARITY, AND THE CHELAE*
 HOSPITAL FOR "WOMEN; HONORARY PRESIDENT OF THE BRITISH GYNAECOLOGICAL SOCIETY J LATE EXAMINER
   IN OBSTETRICS TO THE UNIVERSITY OF LONDON, TO THE ROYAL COLLEGE OF PHYSICIANS AND THE
    ROYAL COLLEGE OF SURGEONS; FORMERLY OBSTETRIC PHYSICIAN TO THE LONDON AND
              TO ST. THOMAS'S HOSFITAL**
IFaurtI; (Pfutian.
         PHILADELPHIA
P. BLAKISTON,  SON & CO.
      1012 WALNUT STREET
1886 
WQ
 ll(o[e 
          DEDICATION  OF  THIRD  EDITION.












               TO   PROFESSOK  P A J 0 T.




Dkak Pkofessok Pajot,




         You have  thrown  the  yEgis of your great  reputation  over




the  French  Editions  of  my  works.   You  have  thus  given  me




a  claim  to  place  this  third  English  Edition   under  the  same




protection.




    In  dedicating  this  book to  you,  who  inherit  the  glorious




traditions of the French school, and enrich  that noble  heritage,




permit me to express my gratitude for all I  owe to that school,




to many of  its  teachers,  and  especially to  him  whose  memory




we  alike revere,  your illustrious predecessor,  Dubois.






                                         ROBERT  BARNES.
December, 1875. 
 
C \
PREFACE   BY  PROFESSOR  PA JOT  TO  THE
                 FRENCH  EDITION.
During the .last thirty years French obstetric physicians  have  paid  but
Uttle attention to the advances made in this department by their neighbours.
  Two manuals of merit, though incomplete, by Naegele  and Scanzoni, are
almost the only foreign works which ha\e been translated into our language
since the beginning of the latter half  of  this century.
  This sad  indifference has, under  the influence of our  public misfortunes,
now given  way  to an  earnest desire  to observe the progress  made  by
foreigners of distinction in the different branches of science and art.   Every
effort,  therefore,  which is  destined to  spread  in France  the  knowledge
acquired by other  nations deserves encouragement;  and  French physicians
will surely  be  grateful to the industrious translator*  of these  Lectures on
Obstetric  Operations, the most positive branch of Medicine.  The comparison
of the foreign  methods, modes, and instruments with  our own may become
the  source  of  improvements  advantageous to  women  and  children, whose
lives so often depend on our means of action and  on our skill.
  To add  to  our French  science  that  of  other  countries is not  only to
know more, but to know better.
  Without  going  quite  so  far  as  Dr. Barnes,  when he says,  "Even more
than  surgery and  medicine, obstetrics calls  for promptitude in judgment,
courage  under difficulties,  and  skill  in  execution," we  will  say,  to keep
within the mark,  at  hast  as  much, and  those physicians and surgeons who
are ignorant of  the  difficulties  in  obstetrics  will alone  venture to dispute
this assertion.
  The book of  Dr. Barnes  is  not, properly  speaking, a dogmatic  treatise
on  obstetric operations;  it is a series  of original lectures,  comprising  at
one  and  the  same  time a  practical analysis of the serious  accidents  in
parturition, the reasoned-out  indications  for,  and the most judicious  re-
searches  in, the manner of operating, the method  to choose, the instrument
                          * Dr.  Cordes, of Geneva. 
viii            PREFACE  TO  THE  FRENCH  EDITION.
 to  prefer, and  the details  of  the  manoeuvres required  to insure success.
 The clearness of the  style is perfect.  The  order, without  being altogether
 rigorous,  is what it is able to  be generally in a series of  clinical  lectures.
 But this  translation will  have, above all, the  great advantage of making
 known in France the  actual  state of obstetric  surgery in  England.
   It  will  be remarked,  with a  real  feeling  of  satisfaction,  that certain
 prejudices which were rife  in  the  United Kingdom only  forty years ago,
 at  length show  signs  of  being laid aside.  For example,  the  use of our
 long  forceps  and  of  the cephalotribe,  which were  formerly  absolutely
 discarded  and  almost ridiculed, now find among  the  leading accoucheurs
 of  England  more than one  partisan  and more  than one  staunch defender;
 nay,  the  author himself  has not hesitated to assign  an  important  place
 to the use of these instruments.
   There is, however,  as  regards  cephalotripsy, and  I  might  say,  for my
 p.irt,  as regards  all the operations,  an  opinion peculiar to  the author, and
 one to  which I  should not  readily give  my  assent.  I  believe it is  dan-
 gerous, full of peril  of  all  kinds, and only calculated to  please a public,
 always  an ignorant judge, always ready to misinterpret  an  operation not
 completed at one sitting.
  Doing me  the  honour to quote my method of cephalotripsy, Dr.  Barnes
 adds,  " However, I cannot help  thinking that it should be  terminated at
 one sitting."
  In  1853, having been  witness  more  than once of the  deplorable conse-
 quences of the obstinate  tradition of wishing  to finish "then  and there"
 an  impossible  operation,   I   had   already  written  against  this  pretended
 necessity  of  finishing obstetric  operations  at a   single  sitting,   thus—
 "Whence  this  important  precept,  the  more  important  because   openly
 opposed to the  accepted  surgical rule :  ' in labours one  must  know when
 to stop in time.'"   The  surgical  precept,  "always  finish," would  be
 disastrous  in obstetrics.   The  best  way  to do for  the mother and  child
that  which science and  our conscience bid us,  "is to  dare to  stop  in
 time,"  not to fear to  give  up for the moment a dangerous  or impossible
 operation,  the end of which will oftentimes be  made more easy  and less
perilous by a few hours' patience.
  Granted with  reference  to  the forceps, these  precepts  seem to me  equally
 applicable to cephalotripsy and  to other  operations,  and  the  twenty years
 which have elapsed since  the day when I enunciated  them,  have  convinced
me more and more  of  their utibty and their prudence.
  Ko?i  vi, sed arte, was  the  rule  of  a  fellow-countryman of  the author's.
 It is  mine too.
  Setting  aside  this  difference  of opinion,  and a  certain  distrust on the
 subject  of  the possibility of the  appUcation of a new  method of cephalotomy,
 I am  happy to be able to bear witness to  the numerous clinical truths  sown
over every page  of  this book. 
               PREFACE  TO THE FRENCH  EDITION.             ix

  The description of the instruments, the application of the forceps, cephalo-
tripsy,  embryotomy, Caesarian section, the practical refiections on narrowing
and  malformation of the pelvis,  ruptures of the uterus,  placenta  prtevia,
hicmorrhage, and, in fact, all the grand  questions in obstetrics are treated
with accurate good sense.   At each instant  by  some remark  or  other  is
revealed a  superior mind,  ripened by  having  seen  much and meditated
much.
  Certain judgments doubtless will be questioned, some operations contested;
but these lectures will none  the less remain interesting, instructive,  useful;
and  will prove once more that the  fatherland of so many celebrated men,
as Chamberlin, Smellie,  Denman, Burns,  Ramsbotham, Simpson, and many
others,  possesses to-day their worthy successors.  Uniting their  talents and
their knowledge,  they have founded  the  eminent Obstetrical   Society  of
London, of  which Dr. Barnes has had  the well-merited honour  of  being a
President.

                                                           PAJOT.
A 3 
 
AUTHOR'S  PREFACE  TO THE  THIRD EDITION.
When I first ventured  to  describe  this  book as  "a guide to the
management of difficult  labour," I did so  with hesitation.   Methods
of practice  which,  by multiplied  experiences  and anxious  thought,
had  assumed in  my  mind  something  of the precision  of definite
rules, might not commend  themselves to the judgment of others,
and  I might fail  to set them forth in such a manner as to  make
them intelligible.    In the  latter  object,  at  any rate,  success has
been  achieved.  A  large number  of practitioners  have  assured  me
that by following  the directions  in  this  book  they have  acquired
practical skill in  obstetric operations ;  and many more have assured
me  that  when called  upon  to  act  in  the  sudden and pressing
emergencies  of obstetric  practice,  they  have  found  information and
counsel which have brought safety to  their patients, and comfort to
themselves.  The somewhat ambitious title, then, has been justified
to a degree surpassing my  expectation.
   The success achieved  increases responsibility  and the correlative
duty  to make the  work  still more useful to  those  who honour me
by their  confidence.   To this  end I have done  my  best.   Without
materially  modifying the doctrines  set forth in former  editions,  I
have  sought to make them  more  clear  by new  illustrations and
careful revision.
   A short  lecture on  the signs of "Dystocia," and the general indi-
cations for operative interference,  has been added as an introduction.
   In  discussing " Inversion "  and  " Rupture "—calamities fraught
with  so  much  peril  to the  patients, and  so  much  risk to  the
reputation  of the surgeon—I have striven not only to explain more
fully the conditions  under which these injuries occur, with a view to 
 xii      AUTHOR'S PREFACE TO  THE THIRD EDITION.

 their prevention, but  also  to  illustrate the  difficulties of diagnosis,
 and other cognate  points,  in such  a manner as  to  aid  in  the
 appreciation  of  the  medico-legal  questions that arise in  connection
 with these catastrophes.
   I have felt doubly  bound to  introduce  this  edition by Professor
 Pajot's  Preface to the  French  edition.   This  seemed to be the most
 fitting way in which  to  express  my  sense  of the  honour  he has
 conferred upon  me;  and I am  anxious to  give  prominence to  his
 objection therein stated to  what  I have said  upon the importance  of
 completing delivery after cephalotomy  at one  sitting.   One cannot
 differ from authority so great  without  misgiving.   But I  venture  to
 plead that the difference is not  so wide as it appears..   It is not
 one of  principle,  but one  of  minor  application.    The principle  of
 deliberation,  to  the  extent even of  interrupted  action  during  an
 operation, is  one of large application.  I  give  it  my cordial assent.
 The whole tenor of my teaching  as  regards the treatment of Placenta
 Praevia  is  in harmony  with  this  principle.   But  in  the  case  of
 cephalotomy  it may be  easily  overstrained.   As a general rule it  is
 surely right to complete as  quickly as can reasonably be -done, what,
 in  the interest of the patient, it is recognized  as necessary to do.
 Until within  recent  years, the  fault, in this country at  least,  has not
 been on  the  side of  precipitate resort to operation.   The  patient has
 often drifted  dangerously near to the rock   of irretrievable  disaster
 before  help was  given.   Help, then, should not  be tardy  or long
 drawn-out, lest the  patient  sink  under the trial.  But  does not the
 question turn greatly  on the  method  of operating ?   Granted that
 extraction after cephalotomy can be safely carried  out at one sitting,
 should it not be done?  Delivery  is necessary to save the  woman
 from the perils  of  protracted  labour.   Why leave to an exhausted
 woman  the  labour  of  moulding  the  crushed  head, when,  by the
 skilful use of  instruments, you  can accomplish the  end ?   If  cephalo-
 tripsy be supplemented  by picking  off the broken bones  of the
 vault of the  cranium,  or by making sections by the  wire-ecraseur—
 operations  bearing upon the foetal head, and not adding  materially
 to  the  suffering of  the  mother-then, it   appears  to  me,  "hand
 mexperto," that delay is  more dangerous  than action.
  In revising  the   lectures on   " Haemorrhage,"  I have carefully
 weighed  the  theoretical  objections  and the authentic  facts which
have been urged against the  intra-uterine  application of  styptics
 This treatment no  longer rests upon  my individual authority   By 
AUTHOR'S PREFACE  TO THE  THIRD EDITION.
xin
wide experience of men  entitled to credit, it  is  amply  vindicated
in those most  critical cases where  the uterus  is  dead to reflex or
centric stimulus to contraction ;  and where, but for the application
of the new principle  of local  haemostasis, the woman  would too
probably perish.
  I cannot  conclude  without making  my best  acknowledgments to
Dr. Cordes  for the enterprise and care he  has  shown  in translating
this  work into French ; to Dr.  Conradi, of Christiania, for the like
service in translating it into Norwegian; to Professor Lazarewitch, of
Kharkhof, for his  proposal, I believe in course of execution, to direct
a translation  into Russian ;  and,  lastly,  to  my son,  Dr. Fancourt
Barnes, for useful aid in the irksome task of revision.

                                           ROBERT BARNES.
JJecember, 1875. 
PREFACE  TO  FOURTH EDITION.
The issue of the fourth edition of this work  demands but few words
of preface.   The  third  edition has  long been exhausted.   Engage-
ments that could not be deferred  have hindered the task of  revision,
and  I felt that this revision ought to be thorough.   The remarkable
success of the work must be accepted as evidence that the design
and  execution  are  satisfactory.   I have  been  careful  to  note the
advances that have  been made.  I have not  found much to correct.
The  doctrines set forth have been more and  more generally  adopted.
It is widely consulted  as  a guide in  the  difficulties  of  practice;
and  its  teaching  has  permeated the  obstetric  literature  of  all
countries.
  I refer  with  especial gratification  to the  now  general recognition
of my theory of  Placenta Praevia.   The division  of  the uterus  into
zones, and   particularly  the  physiological   boundary  between  the
lower and equatorial zones, which I had discovered and demonstrated
by clinical observation, has received the final  proof in  the anatomical
description by Bandl.   My " physiological boundary " and " Bandl's
ring"  are identical.
  I have  revised the sketch of Natural Labour,  in  order  to show
the action of "the  three  curves."   The  ordinary  text-books   take
note  of only one,  namely, Cams' curve, scarcely glancing  at  the
part  played  by the  other two.  Yet  a correct understanding of the
mechanism of natural labour,  and of labour with deformed pelvis,
is impossible without a  full appreciation of all three.
  As in my other works, I have taken pains to evolve the propositions
set  forth  out of  their  anatomical and physiological  bases,  and to
illustrate  them by diagrams and cases  in point.   The illustrations
are  nearly all original;  those  borrowed are acknowledged.
  This  feature of  the  work not  only  gives  it  a  more  scientific
character, and makes it more  pleasant reading,  but it is, I believe
a main reason  why it is so largely referred  to in elucidation of the
problems  in  forensic medicine, which so often arise  in connection
with obstetric practice.

                                         ROBERT  BARNES.
  15, Harley  Street, London,
        January, 18S6. 
0 0 N T E X T S.
                               LECTURE  I.

Definition of  Eutocia  and  Dystocia—Signs  of Dystocia :   Particular Cases ;
    Defect of Expelling Power ; AVant  of Correlation  between the Child and
    the Passages      ...     ...     ...     ...    ...     ...     ...     ...'...


                              LECTURE  II.

0''stetrie Instruments—The Armamentarium Obstetriciuni
                              LECTURE  III.

 T!:e Mechanism of  Head-labour—The Three Parturient Curves—The Powers of
     the Forceps—The Force by which it Holds the Head—The Compressibility
     of the Child's Head—The Lever—Demonstration that the Lever is a Lever,
     not a Tractor ;  also that the Forceps is a Lever


                              LECTURE  IV.
 The Application of the Short Forceps—Head in First  Position—Head in Second
     Position—Objections to  Short Forceps—The  Application of the  Long  or
     Double-cuived Forceps—Introduction of  the Blades—Use of Long Forceps
     —Locking—Oauses of  Failure in Locking—Extraction—How to  Measure
     the Advance of the Head—The Maiueuvre of " Shelling-out " the Head
     Delayed at the Outlet—Relocking—The Head is seized  obliquely by the
     Forceps—Time  required for Extraction...


                              LECTURE  V.

Causes of  Arrest in First  Labours—Disturbed or Diverted Nerve-force—The
    Uterine  and  Pcrinaeal  Valves—The  Ponding-up of Liquor Amuii—The
    Forceps  to Deliver the  After-coming Head—The  Long Forceps (continued;
    —Application in Occipito-Posterior Positions of the Head—The Mechanism
    by which  Fronto-Anterior, Forehead, and Face Positions generally,  are
    produced—Friction in Labour—The  Management cf these Cases   ...... 
XVI
CONTENTS.
                             LECTURE  VI.
                                                                         i
The Forceps in Disproportion of the  Pelvis : Degrees of Disproportion : Indi-
    cations in Practice—The Mechanism of Labour  in  Contraction from  Pro-
    jecting Promontory: The Curve  of the  False Promontory—Debatable
    Territory on the Confines of  the several Operations—Pendulous Abdomen :
    the Cause, of Difficulty  in Pendulous Abdomen : Suspended Labour; the
    Mode of Management


                             LECTURE  VII.

Dystocia from Faulty Condition  of the Soft Parts—Contraction of the Cervix
    Uteri—Rigidity — Spasm — Deviation — Hypertrophy—Cicatrix—Closure—
    (Edema—Thrombus— Cancer—Fibroid Tumours—The Natural Forces  that
    Dilate the Cervix—The Artificial Dilating Agents—The Hydrostatic Dilator
    —Agents  which  moderate  Uterine Action  or  Resistance —Chloroform—
    Chloral — Opium — Nitrite  of  Amyl — Physostigma—Tartar  Emetic-
    Bleeding—Vaginal  Irrigation—Ergot—Dilatation  by Hand :  by Water-
    pressure :  by Incision—Resistance  offered  by  the Vagina,  Vulva,   and
    Perinamm  ...
                            LECTURE  VIII.

Turning—Definition—The Conditions which determine the Normal Position of
    F<etus—Properties  of the Fcetus, Living and Dead—Causes of Malposition
    —Frequency  of Change of Position of Foetus in Utero—The Powers of
    Nature in  dealing with Unfavourable Positions  of the Child—Denman's
    Account  of the Spontaneous Evolution of the Child—The  Mechanism of
    Head-labour the type of that of Labour with Shoulder-presentation


                             LECTURE  IN.

Definition  of Spontaneous  Version and  Spontaneous  Evolution—Shoulder-
    presentation,  how produced—Varieties of Spontaneous Version—Mechanism
    of Spontaneous Version by the Breech—Spontaneous Evolution—Mechanism
    of,  in  the First  Shoulder-presentation,  Dorso-Anterior—Mechanism  in
    Abdomino-anterior  Position — Spontaneous Evolution  by  the Head__
    Mechanism of Spontaneous  Version and  Spontaneous Evolution further
    Illustrated—The Conditions requisite for Spontaneous Version—Examples
    of Spontaneous Version  by Head


                               LECTURE  X.

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—Reason why Version by the Breech is commonly preferred__
    Illustrations  of Head-turning, or  Correction of the  Presentation,  before
    and during  Labour in  obliquity  of  the  Uterus  and Fcetus—Shoulder-
    presentation—Forehead  and Face Presentations—Descent  of Hand  with
    Head—Descent of Umbilical Cord     ...... 
CONTENTS.
xvn
                              LECTURE  XI.
                                                                         PAfiK
Prolapse of Umbilical Cord—How Produced—How Treated—The Cord round the
    Neck—Signs of Death of Child—Asphyxia of Child, Paralytic and Simple
    —Influence  of Placental  and Aerial Respiration Compared—Treatment of
    Asphyxia :  by Reflex Irritation ; by Artificial Respiration ; Marshall Hall,
    Sylvester, Pacini, Bain, Howard, Richardson...............125


                              LECTURE  XII.

Turning (continued) : The  Management of  Certain  Difficult Breech-presenta-
    tions—The Management of Twin-labour—Locked Twins—Dorsal Displace-
    ment of the Ann—Double Monsters—Single Monsters     ...    ...    ... 1;>S
                             LECTURE  XIII.
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 157


                             LECTURE  XIV.
The Operation  of  Extraction  after Podalic Version, or other  Breech-first
    Labours—The Three  Acts in  Extraction :  The  Birth of the Trunk, in-
    eluding the Care of the Umbilical Cord—The Liberation of  the Arms -
    The Extraction  of  the  Head   .....................169


                              LECTURE XV.
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     ........................179


                             LECTURE  XVI.
Turning in  the Abdomino-anterior  Position—Incomplete Version, the  Head
    remaining  in  Iliac  Fossa, Causes of—Compression of Uterus, Treatment
    of—Bi-manual or Bi-polar Turning when Shoulder is Impacted in Brim of
    Pelvis—Imitation or  Facilitation of  Delivery by Process of Spontaneous
    Evolution—Evisceration—Decapitation—Extraction of a Detruncated  Head
    from the Uterus...........................185

                              LECTURE XVII.

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—The Indications  for
    Turning in Contracted Pelvis—The Operation...............197 
xvm
CONTENTS.
                            LECTURE  XVIII.
                                                                         PA UK
Mechanical Complications of Pregnancy and  Labour: Dystocia from Displace-
    ment of  the Womb : Retroversion—History of Retroversion and Retro-
    flexion of the Gravid  Womb—Origin of Retroversion and Retroflexion in
    the Early Months, Complete and  Incomplete—Incomplete Retroflexion at
    the  End of  Gestation—Diagnosis from Extra-uterine Gestation—From
    Pelvic Cellulitis—From  Retro-uterine Haematocele—Prolapsus and Proci-
    dentia  Uteri  and Hypertrophic Elongation   of  the  Cervix  Uteri-
    Treatment  ..............................212

                             LECTURE  XIX.
Mechanical Complications of  Labour  (continued)— Dystocia  from Tumours  :
    Fibroid  or  Myoma—Polypus—Ovarian—Extra-uterine   Gestation-cyst—
    Condylomata—Retro-uterine Haematocele    ..............237

                              LECTURE  XX.
Mechanical Complications of Pregnancy and Labour (continued)—Deformities of
    the  Skeleton—The Rachitic  Pelvis—The  Kyphotic  Pelvis—The Osteo-
    malacic  Pelvis—The  Spondylolisthetic  Pelvis—Disease  of the  Pelvic
    Articulations—Naegele's  Pelvis—Fractures  of  the  Pelvic  Bones — The
    "Thorny" Pelvis—Diagnosis of Pelvic Deformity—Peculiarities of Labour
    in Deformed Pelvis     ......    ...     ...     ...    •••    •••     ■•• 254

                             LECTURE XXI.
Rupture of the Uterus, Vagina,  and Perinaeum—Definition of Laceration,
    Rupture, and Perforation—Premonitory Signs and Prophylaxis—The Con-
    ditions under which Rupture occurs :  in Non-pregnant Uterus ;  during
    Pregnancy ;  during Labour—Lacerations  from  Obstruction to Labour—
    Laceration of  the Vagina—Traumatic  Lacerations—The Symptoms and
    Course of Cases of Laceration—The  Treatment—Difficulties in Diagnosis
    —Illustrations of Sources of Error—Descent of Intestine...    ...     ... 267

                             LECTURE  XXII.
Inversion  of the  Uterus—Definition—Acute  and  Chronic—Spontaneous  or
    Produced by External Force—Conditions of its Occurrence : John Hunter's
    Theory—Crosse's Three Degrees—Symptoms and Diagnosis—Terminations  :
    Shock—Haemorrhage—Death—Gangrene—Transition to  Chronic  Form—
    Spontaneous Reduction—Treatment: Modes of Reduction  ...     ...    ... 312

                            LECTURE   XXIII.
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
    Crotchet, by Turning—Delivery  by the Craniotomy-Forceps ;  Use of, as an
    Extractor, 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—Lamination :  Van Huevel's  Forceps-Saw—Delivery by the
    Author's Method of Embryotomy by the Wire-Ecraseur—Tarnier's Method
    —Injuries that may Result from Craniotomy      ...     ...    ...        326 
CONTENTS.
xix
                            LECTURE  XXIV.
                                                                         PAGE
The Ciesarian Section—The Indications for—The  Moral Aspect of the Operation
    as between Mother and Child—The Conditions  that render the Operation
    Necessary—Question between Caesarian Section  and  Turning in Dying 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—Symphysiotomy........     ............345

                             LECTURE  XXV.
The Induction of Premature Labour—The Moral Bearing of the Operation—The
    Fitness  of the System and of the Genital Organs for Premature Labour—
    The Insufficiency of Simply  Provocative Means—Two  Stages of Premature
    Labour  Artificially Induced : The  Provocative ; The Accelerative—Discus-
    sion of the Various Provocative Agents : Danger of the Douche—Action of
    the Various Dilators—The  Mode of Proceeding—Provocation Overnight—
    Acceleration and Conclusion of Labour  Next Day—Description of Cases
    Demanding Induction of  Labour—Question of Starving the  Mother—Mode
    of Determining  Epoch of Gestation—Proceeding in Contracted Pelvis  or
    other Mechanical Obstructions—In Cases  of  Urgent  Distress of Mother,  as
    Convulsions, Heart Disease,  Phthisis—In  Cases where  the Child is Dead—
    Missed Labour—Care of Child when Born  Alive     ......    ...    ... 365

                            LECTURE  XXVI.
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-
    Hot Water—Perchloride of Iron—Prophylaxis—Hydatidiform Degeneration
    of the Ovum       ...........................386

                            LECTURE  XXVII.
Placenta Praevia—Historical References : Mauriceau, Portal,  Levret, and Rigby—
    Modern Doctrines expressed  by Denman, Ingleby, Churchill, and Simpson
    —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 Plaeenta—
    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 "..................398

                            LECTURE XXVIII.
Hiemorrhage after the Birth of the Child—Cases in which the Placenta is Retained
    —Consequences of Retention of Placenta—The Prophylaxis of Hemorrhage—
    Cases after the Removal of the  Placenta—Secondary Hiemorrhage—Causes
    of Retention of Placenta—Mode of Conducting Third  Stage  of Labour-
    Encysted  or Incarcerated Placenta—Apparent Encystment from Growth in
    One Horn of  a Two-Horned Uterus—Hour-Glass Contraction—Means  of
    Effecting Detachment and Expulsion of Placenta—Adhesion of the Placenta
    —Causes—Treatment—Placenta Succenturiata—Placenta Duplex—Placenta
    Velamentosa      ...    ...     ...     •••     •••    •••     ••    •••     ••• 428 
XX
CONTENTS.
                            LECTURE  XXIX.
                                                                         PAO K
 Hiemorrhage after the Removal of the Placenta—Three Forms: Immediate, Paulo-
     post, and  '' Secondary" or Remote—Two Sources : The Placental Site ; the "*
     Cervix Uteri—The Natural Loss of Blood—Natural  Agents in Arresting
     Hiemorrhage—Symptoms, Diagnosis, and Prognosis of Hiemorrhage  from
     Inertia, from Tumours or Polypus, from Retroflexion—Artificial Means of
     Arresting  Hiemorrhage—Means Designed to Cause Uterine  Contraction :
     Passing the Hand into the Uterus, Ergot, Turpentine,  Cold, Kneading the
     Uterus, Compression  of the Aorta, Compression of the Uterus, Binder and
     Compress, Plugging the Uterus—Indications How Far to Trust the Fore-
     going Agents—The Dangers attending them—Means designed to Close the
     Bleeding Vessels : Styptics, the Perchloride of Iron—History : Dangers of,
     Discussed—Shock—Septicemia—Mode of Applying  the Iron—Restorative
     Means : Opium, Cordials,  Salines, Rest, Iodine     ............440

                            LECTURE XXX.
Secondary or Remote Puerperal Hiemorrhage—Causes: Local and Constitutional
    —Retention of Placenta—Blood-clot—Laceration of Cervix or other Parts-
    Thrombus  or  Hematoma— Retroflexion—Fixing of Uterus by  Perimetric
    Deposit    ......•    ........................4Q5


                            LECTURE  XXXI.
Transfusion     ..      ...     ...                                             A-ja 
INDEX  TO   ENGRAVINGS.
FIU.

 1.
 9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
24.
33.
34.
Chiara's Frozen Section to  show the Axes and Three Curves of the Uterus
    and  Pelvis
Feetal Head before being acted upon by Labour
    ,,      after Moulding by Labour ...
Diagram showing Action of Lever
Short Forceps
Single and Double-Curved Forceps in situ
Application of Long Forceps
           ,,   Action of Uterine and Perinaeal Valves in Labour
   ,,       ,,         ,,        >>        >>         >>      "
Application of Forceps to After-coming Head............
               ,,     in Fronto-anterior Position  ...
Diagram showing how to obviate Face-presentation.........
          „     Long Forceps in Face-presentation.....
                persistent Face-presentation;  Chin keeping backwards
   ,,    of Normal Pelvis (Cams'Curve)    ............
        of Contracted Pelvis, showing "Curve of False Promontory"
        showing Extraction of Head by Forceps through the two Pelvic
                   Curves    ...    ...    •••    •••    ......
           ,,   Labour in Pendulous Uterus............
   ,,                ,,         >>        "
                use of Hydrostatic Dilator............ 
xxii                    INDEX TO  ENGRAVINGS.
FIG.
 35,  Diagram showing Dilatation of Cervix Uteri by Incision
 :J6.     ,,    of Pelvis to help in Study of Labour...............9/
 37.     ,,    showing how Shoulder-presentation is produced   .........  99
 38.     ,,       ,,          ,,          ,,          ,,        .........100
 39.     ,,       ,,          ,,          ,,          „        .........102
 40.     ,,       ,,          ,,          ,,     obstructs Labour    ......103
 41.     „       ,,   Mechanism of Labour in Shoulder-presentation ...     ... 105
 42.     ,,       ,,         ,,         ,,           ,,         „       ......106
 43.     „       „         „         „           „         „       ......107
 44.     „       ,,         ,,         ,,           ,,          „       ......108
 «•     „       „         „         „           „          „       .....109
 46.     ,,       „         ,,         ,,           „          ,,       ......110
 47.     ,,       ,,   Spontaneous Version  ...     ...     ...     ...     ...     ... Ill
 48.     ,,    illustrating Spontaneous Evolution...............112
 49-     ,.        »           „         „       ...............113
 50. Roberton's Funis-replacer......     ...     ...     ...     ...     ...     ... 127
 51. Diagram showing how to Replace Prolapsed Funis   ............128
 52. Richardson's Double-bellows for Artificial Respiration       .........136
53. Diagram showing how to Deliver in Breech-presentation    .........139
54.    ,,        ,,   difficulty in Breech-presentation   ...     ...     ...     ...  140
55.    ,,        ,,   Labour in Breech-presentation     ............141
                                                                            143
56.
57.    ,,        ,,    how to Deliver in difficult Breech-presentation......144
58-    "        »       »      ..        »         „       „       ......145
59-    >.        ,,    Giffard's mode of Delivery in difficult Breech-cases    ...  146
60.    ,,        ,,    Head-locking in  Twin-labour     ............149
61-    »        »>         »      »       »     ...............151
62.    ,,        ,,   Dorsal or Nuchal Hitching of Arm............153
63.    ,,     illustrating Bi-polar Turning...............         163
                                        ..................164
                                        ..................165
        '        "         »       >»     ..................166
                                        ..................167
        ,        ,,    Extraction after  Turning...............170
        ,        ,,    Liberation of Arms after Turning...     ...     ...      ..172
64
65.
66.
67.
69.
70.
n.    „        „         „         ;;         ;;    ...
72.    „        „         „         „         „    ...
73.    ,,        ,,    Extraction of Head after Turning...
74.    ,,     after Scanzoni, showing his Error in seizing Nearest Leg to Turn...  182
75.    ,,     showing Advantage of seizing Further Knee in Turning......183
7^   "       "         "        »           .»          ,,       ......183
77. Braun's Sling Carrier     ...     ......     ...    ...    ._               2g,
    Diagram illustrating Turning in Abdomino-anterior Position      ...     ..186
79.
80.
81.
82.
83.
84.
85.
173
174
175
176
                          »       »        »          ......187
    "        . "           "       >>        ,,          ......188
    ,,      Bi-polar Turning when Shoulder is Impacted......189
    ,,      Delivery in Imitation of Spontaneous Evolution    ...190
    ,,      Decapitation in Impacted Foetus      ......        193
 ,   '.'   ,       "            »       "         .........194
showing how to Deliver a Detruncated Head      ........195
    ,,    Head entering Pelvic Brim in Contracted Pelvis       ...205
    „    Extraction after Turning in Contracted Pelvis.....209 
INDEX TO  ENGRAVINGS.
xxm
no.                                                                       PAGE
 88.  Diagram showing Retroversion of Gravid Womb   ...     ...     ...     .. 214
 89.     ,,         ,,   Incomplete Retroflexion of Gravid Womb      ...    ... 216
 90.  Drawing of Case of Partial Retroflexion     ...    ...     ...     ...    ... 219
 91.  Encysted Retro-uterine Haematocele   ...     ...    ...     ...     ...    ... 224
 92.  Case of  Retro-uterine Gestation...     ...     ...    ...     ...     ...     .. 226
 93.  Diagram showing how to Reduce Retroverted Womb       ...     ...    ... 229
 94.  Labour  Obstructed by Hypertrophic Elongation of the Cervix    ...    ... 234
 95.  Case of  Pregnancy in Double Uterus (Oldham)    ...     ...     ...    ... 235
 96.  Diagram illustrating Pregnancy complicated with Ovarian Tumour     ... 246
 97.     „         „         „          ,,            „         „        ... 250
 98.  Figure of  a Standard Pelvis    ................  ......255
 99.     „      an Extreme Rachitic Pelvis ...    ...     ............256
100.     ,,      a Kyphotic Pelvis (Hugenberger)  ...    ...     ...     ...    ... 257
101.     ,,      Osteomalacic Pelvis  ...     ...     ...    ...     ...     ...    ... 259
102.     ,,      Spondylolisthetic Pelvis    ..................260
103.     ,,      Naegele's Pelvis      .....................261
104. Diagram showing Sections  of Various Forms of Pelvic Distortion ...    ... 262
105.    ,,       ,,    Thinning of Lower Segment of Uterus (Bandl)...    ... 276
106. Case of Rupture of Uterus.....................279
107.    „       „        ,,        .....................281
108.    „       „        „        .....................282
109.    ,,   Sacral Tumour in a Foetus     ...........     ......306
110. Diagram showing degrees of Inversion of Uterus (Crosse) ...    ...    ... 313
111. Case of Inversion of Uterus    .....................313
112. Diagram illustrating Reduction of Inverted Uterus (McClintock) ..    ... 324
113. Oldham's Perforator     .......................330
114. Diagram showing Extraction of Head after Removal of Calvarium     ... 333
115.     „       „        „          „           ,,          „          - 334
116.    ,,       ,,     Application of Cephalotribe     ............338
117.    M       „     Author's Operation of Cephalotomy by Wire-ecraseur ... 342
118. Dr. Newman's Case of Caesarian Section (the Uterus)     .........360
119. Diagram showing Author's Theory of Placenta Praevia    .........407
120.     ,,       ,,    Lateral Placenta descending to Cervical Zone  ......409
121. Section of Uterus and Cervix  in Eighth Month of Gestation (Bandl)    ... 410 
 
OBSTETRIC   OPERATIONS.
                        LECTURE   I.

     DEFINITION OF EUTOCIA AND DYSTOCIA--SIGNS OF DYSTOCIA.

Before entering upon a description of the particular forms of Difficult
Labour and of the modes of dealing with them, it will be useful to
acquire a general  idea  of what Difficult  Labour is.
  There are two ways of studying medicine: the abstract or theoretical,
and the clinical or analytical.
  The latter is the method which the practitioner must of necessity
follow.  At the bedside he finds his patient  suffering from a  com-
bination of symptoms,  the significance of which  is the problem he
must try to solve.   In this analytical task he summons to his aid the
theoretical knowledge drawn from his own experience and the teaching
of others.
  The problem before us is the estimation and management of Difficult
Labour.   If we try to define this term,  we encounter at the outset the
difficulties that surround all attempts  at definition.   A simple  object
or idea may  be  defined  or described with tolerable precision.  But a
complex state, the outcome of a number of concurrent or  conflicting
conditions, will  always evade rigorous  definition.  This is eminently
the case with Difficult Labour.   In dealing with this subject, therefore,
we are compelled to start with the most general idea ; and then to seek
for precision  by a process of  disintegration, breaking up the general
summary into parts, which admit  of more particular examination and
description.
  The  term  " Dystocia " comes down  to us from Hippocrates.  Its
counterpart  is  "Eutocia."   These terms are convenient from  their
                                                            B 
2
OBSTETRIC OPERATIONS.
conciseness.  It only remains to endeavour to attach to them a definite
meaning.   We  may  sufficiently  define  "Eutocia"  as labour pro-
ceeding smoothly and terminating favourably under the natural forces.
Accepting this, we should be driven to define " Dystocia " as labour in
which the converse conditions occur.  It would not be easy to devise a
better positive definition than that  of Harvey, a man  who would have
been revered as the most illustrious of  obstetricians if he had not
blinded  us to all his other merits by the  dazzling  splendour of the
grandest discovery in  medicine.  "Fit partus," he says, "difficilis et
laboriosus, quod nee modo negue ordine debito res peragatur aut pravis
aliquibus  symptomatibus impediatur."
  Many authors invest the subject at  the very threshold with needless
difficulty  by confounding  definition  with  classification, by drawing
descriptions based upon knowledge which can only be completed when
the labour is over.  That is, too late to  be of any  use  to the  prac-
titioner  at the bedside watching  for indications  when and how to act.
Of what clinical value, for example, is a definition based upon the time
expended  in the  labour ?  We  can only know that an  unduly long
labour was a case of dystocia when  it  is all over.  A similar objection
applies  to other definitions, especially to those which invoke a know-
ledge of the causes of  the  difficulty, such as  contracted pelvis, mal-
position of the child, and so forth.   "Felix qui potuit  rerum cognoscere
causas!"   The discovery of the causes is  a subsequent and  distinct
problem.
  We want to  know,  as early as possible, when in the presence of a
woman  in  labour, whether her case is  going  on  smoothly  or not,
whether or no she is drifting into danger, and what are the symptoms
that dictate the necessity of interfering.
  We must then begin by observing the course of  the  labour.  The
points for observation are: 1, the time  spent  in the process ; 2, the
character of the pains; 3, the effects on the patient as revealed by the
study of the subjective  and objective  signs.   Observation  of these
points will tell if the  labour is difficult.   Examination internally may
reveal the  cause of  the difficulty,  and  supply the indication  for
treatment.
   Labour is a problem in dynamics.   Three factors are concerned in
the solution: 1st, there is the fcetus, the body to be expelled; 2ndly,
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
resisting  force, the  obstacle to  be  overcome;  3rdly,  there is the
 expelling power, the  uterus  and auxiliary forces.    This  last  factor
 presupposes a healthy  condition  of the  vascular,  respiratory,  and
 nervous  systems.  All these factors must  be  harmoniously  balanced
 to  produce a healthy  labour.  Labour  may  come  to a stand, or be
 disturbed from error in  any one  of  these  factors, or from disorder in 
EUTOCIA.
3
 their correlation.  What then  are the signs of disorder in the correla-
 tion of the forces of labour ?
   Natural or  easy labour,  propitious both for mother and child, is a
 continuous process going  steadily on towards the accomplishment of
 its object.  It is divided into  three  stages, the conclusion of each of
 which is marked by a distinct event.   Thus, the  first  ends  with the
 expansion of the cervix uteri and the rupture of the membranes ; the
 second,  with  the extrusion of the child;  and  the third with the
 casting-off and  removal  of the placenta.   These  three  stages not
 uncommonly overlap each  other, or are  so far continuous that two of
 the events named—that is, the bursting of  the membranes and the
 expulsion of the child, or the expulsion of the child and the casting-off
 of the  placenta—are  accomplished  by  the  same  effort.  Still, these
 stages  are marked  by distinctive  characters, and include  distinct
 physiological acts.  The great  feature  pervading all  three is uterine
 contraction.  It is by this  that each step of the process and the final
 safety against bleeding, when the vessels which united the placenta to
 the uterus are severed, are accomplished.   But the characters of the
 contraction change with the stage of labour; and especially do  they
 change if undue resistance or other disturbing influence  intervene.
   By  a well-known figure of  speech, we use the word "pains"  to
 describe the " expulsive forces."  That is, we put the effect for the
 cause.   It  is  too  true  that  expulsive  effort and  pain  commonly go
 together.  But they are  essentially distinct; they  have no  necessary
 correlation.  In  the most  propitious labours, although the contractile
 power is active and vigorous, there  may be  little or no  pain.  It may
 even be stated as a general  truth that the greater the pain the wider is
 the departure from propitious labour.   WThere pain predominates, more
 or less  disturbance  of the typical  harmony between the factors  of
 labour is certainly  entailed.   The  nervous  energy, instead of being
 concentrated  upon  the  duty of supplying  the  uterus  and  auxiliary
 muscles  with contractile power, is  in great measure wasted in other
 directions.  Two evil consequences result: first, the labour itself  fails
 to proceed as  it ought; secondly, the system at large  is injuriously
 affected.  It is in the observation of  these two conditions that we find
 the proofs of dystocia.  These proofs are thus naturally divided  into
 two orders : 1, the local; 2, the general.   Our attention  is, in the  first
 place,  necessarily drawn  to the  general signs.   The woman shows
 manifest evidence of suffering,   of distress.
   A function which is going on naturally to the accomplishment of its
 object may, indeed, sometimes be attended with some degree of pain;
but that pain exerts no injurious or depressing effect upon the system.
 On the contrary,  a sense of  ease, even of satisfaction, is  felt.  Labour
is no exception to this law.   If pain arise, it is because the resistance
is in excess of the expelling  force, or because the subject  is abnormally
                                                           b 2 
*
4                    OBSTETRIC OPERATIONS.

sensitive.   In  either case pain,  an  abnormal  element,  disturbs the
equable course.  The moral, or rather the emotional, element is also
disordered.   Instead of  the  healthy invigorating influence  of  satis-
faction and  confidence which attends a smoothly advancing labour,
mental depression  and loss of nervous energy  ensue.
  The characters that mark  propitious labour  then  are :—A cheerful
contented state of mind ; absence of bodily restlessness ;  ability to walk
about, to sit,  or lie down without distress ; regularly  recurring uterine
contractions,  not inducing acute pain ; perfect remission of pain during
the intervals between the uterine contractions ;  recovery of strength
between the contractions;  a sense of something gained  by the expul-
sive efforts ; a moderate increase  in the frequency of the pulse during
the uterine  contraction, and return  to healthy  frequency and rhythm
on the subsidence of the contraction  ; preservation of normal tempera-
ture ;  easy excretion of pale urine.
  The manifestations of the contractions  vary with the stage of labour.
In the first stage the contractions are strictly uterine ; they are period-
ical, but  the  intervals are longer than in the  later  stages ;  they are
sometimes painless, but  the hand laid on the  abdomen feels a wavy
(peristaltic) roll, the uterus hardens  and slightly changes its position
behind the abdominal wall.   These  contractions  are involuntary, but
they are under the  influence of emotions just as are the movements
of the heart, bladder, or  rectum.   A little later these contractions
generally evoke pain ; this is  when  they become stronger, and  when
resistance is encountered.   The contractions  observe  a regular course:
there  is first  a  stage of  increment; 2, of  acme;  3,  of  decrement.
These combined form the systole.   Then  follows diastole, a stage  of
repose, which should be  painless.
  These  contractions cause the membranes  to  bulge through the  os
uteri and move the child.   When fairly begun they cannot be arrested.
The resistance to the contractions during the first stage of labour  is
mainly in the cervix uteri.  This is the first obstacle  to be overcome.
  At  this  time, when the cervix  is expanding under the  contact and
pressure  of the membranes and  head,  shivering, even  vomiting, not
seldom attend the  uterine contractions.  This  is  simply a healthy
reflex act.  It is even observed  that the  process of dilatation often
goes on more easily under its influence.  It is no more dangerous than
is the ordinary vomiting of early pregnancy.
  At  the  commencement of the  second  stage the membranes should
burst, and a  great part at least  of  the liquor amnii  should escape.
Unless this take place the uterus cannot act at full  advantage.  Part
of the expulsive force is lost in hydrostatic compression.  The  labour
then  would  linger, and  the "pains"   would  exhibit  an abortive
character.  But in  the normal event, the  uterine contractions, acting
directly on  the body of  the fcetus, drive it  onward through the 
DYSTOCIA.
5
 cervix  and  os  externum  uteri,  acquiring  power  as  the  head  de-
 scends  and  rotates  in the pelvis.   The  "pains"  become  expulsive
 or "'bearing-down ; " evoking powerful reflex  action, they call  forth
 the stored-up nervous energy, and excite the  semi-voluntary, semi-
 reflex contractions of the diaphragm, abdominal, and other expiratory
 muscles.
   The  uterus must  be supported  by the diaphragm and  abdominal
 muscles.   The  diaphragm  is not a direct agent; it  acts by supplying
 a point d'appui  to  the  abdominal  muscles; the chest expands,  the
 lungs fill, the glottis closes.  The diaphragm then contracting gives to
 the base  of  the thorax,  supported by the lungs distended with air,
 the solidity  required  for the effective action of the muscular forces.
 The uterus,  in  its turn,  supported  and compressed  by the diaphragm
 and abdominal muscles, is excited to further  exertion.   The  body is
 arched  forward, the thighs are  flexed upon the belly, the  pelvis is
 tilted up so  as  to bring its axis  more nearly into coincidence with  the
 axis  of the  trunk.   Everything conspires  to  aid  extrusion.  The
 uterine  contractions  become more  frequent;   and when  the  head
 comes  down  upon the perinagum, pressing upon the anal and vulvar
 sphincters,  reflex  action is  irresistibly  exerted, and new vigour is
 added to the expulsive efforts.  At  this critical moment the nervous,
 vascular, and muscular systems  are at the  highest pitch of tension.
 Unless  the various forces  are exactly balanced, or unless  provision
 is at hand to moderate  the  resisting force  on the  one hand, or the
 driving force on the other, danger  is imminent.  Thus the vascular
 tension may  issue in apoplexy, or the muscular tension may issue in
 bursting of  the uterus  or  laceration of  the  perinaeum.   These  evils
 are averted by  the yielding of the  vulva  before  the advancing head,
 and often  by the opening of the glottis under the sense of pain;
 when, the  point d'appui being lost, the  abdominal muscles quickly
 relax, and  the dangerous strain  is  taken  off.
   The conditions ascertained on examination are : the regular  succes-
 sion and progress of dilatation of the cervix uteri, the rupture of the
 membranes, discharge of liquor amnii, and propulsion of the foetus.
   Now, if  any cause of  obstruction intervene, the  progress  or order
 of  the  labour  is interrupted, and  the  characters  of  the  " pains"
 change.
   The characters that mark  an unpropitious labour are : irritability
 of mind, anxiety, bodily restlessness ; continuous  pain,  exacerbated
 on return of  the uterine contractions ; tenderness  on pressure upon
 the uterus;  the uterine contractions assuming a peculiar  abortive
 or ineffectual  character—that is, having  a wearying, irritating effect
upon  the system, and leaving a sense of  having been of no  use  in
advancing  the labour.  This is  expressed in the utterances of the
woman  in  a way easily interpreted  by  the  skilled  observer.   If, 
6                   OBSTETRIC  OPERATIONS.

instead of aiding the  "pains" with a cheerful will, she dread  their
return and  is careful  not to add force to an effort which  she feels
will  be useless,  and which exhausts her strength ; if the pulse rise
to 100 or above, and maintain  this during the intervals of  uterine
contraction ; if the temperature  rise to  100° F. or  above;  if there
be excessive perspiration, or a hot dry skin;  scanty secretion of high-
coloured urine;  or vomiting, which is  now of ominous import, being
no longer the result  of healthy  reflex excitation,  but of prostration
and  perverted nervous  action,  there is  obstructed  labour ; danger is
at hand.
  The conditions made out by examination are: generally, persistent
spasmodic rigidity  of the  body  of  the  uterus;  occasionally, great
tenderness and heat of the vaginal passage ; tumid or unyielding  state
of the os and cervix uteri;  stationary position of the foetus ; increasing
tumefaction  of  the  scalp  (caput  succedaneum) if the child is alive.
These conditions rarely arise during the first stage of labour.  For the
most part, they arise after the rupture of the membranes and escape of
the liquor amnii.
  When these conditions are manifested  there  is  dystocia; and the
physician is  called upon to  act.   His first duty plainly is to discover
the cause of the dystocia;  the  second is to study and  to  apply the
appropriate remedy.
  Two things have to be considered when attempting  to  describe the
operations in midwifery—
  1.  What are the emergencies  which call upon  the practitioner to
operate ?
  2.  What are the means, medicinal or instrumental, at his disposal?
  If  each accident or difficulty in  labour were uniform and constant in
all its conditions,  it might be possible to apply to its relief the same
operation or the same instrument.  Could we accept Levret's definition
that  "Labour is a natural operation, truly mechanical, susceptible of
geometrical  demonstration," 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 realised.   In
proportion  as observation  unfolds  these  combinations,  ingenuity is
ready to multiply the resources  of art.   To describe these combina-
tions,  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 in 1866, vast  as  it  was,  gave  but  a  feeble idea of the
luxuriant variety that have been devised.   If all these had their indi-
vidual merits and uses, endless would be the labour of appreciation; the
task  of describing the operations of midwifery  would be hopeless.  It is,
indeed, true that every instrument, even every modification of an instru- 
DISTURBANCE OF FACTORS  OF LABOUR.
7
ment, represents an idea, although sometimes this idea is not easy to
understand. Fortunately, it is not always important that the idea should
be understood.  Many of these instruments are suggested by imperfect
observation, by ill-digested experience ; many are insignificant  varia-
tions 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 burnt 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 of gain, of going back as well as  of going forward.   These
historical specimens will also serve the useful office of warning against
the repetition of  exploded errors,  and of  saving  men the trouble and
vexation of re-inventing.
   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 subordinate  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 skilful  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 encountered and  thrust  aside ; in which action  must be
prompt and  skilful.
   To produce a healthy labour its  three factors must be harmoniously
balanced.  Labour 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.   Let us take one factor, the
expelling power.   This may  be deficient, the other factors preserving
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, 
8
OBSTETRIC OPERATIONS.
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 ?   Can we apply
direct mechanical  force to push the fcetus out of the uterus, instead of
dragging it out ?  Now, in some cases this is possible.   Von Ritgen,*
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 is  by dragging  out;  and asked  very  pertinently,
" Why  do we always  drag and never push out the foetus ?"   Dr.
Hoening  (Scanzoni's Beitrdge, 1870) says this was known to Celsus.
It was strongly urged by Benjamin Pugh.   The principle is seen rudely
applied amongst some savage races, in the  practice of sitting upon the
belly of the woman in labour.  Dr. Kristellerf 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 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.   Poppel \ estimates,
from experiments made to determine the power necessary to burst the
membranes, that the  force necessary to effect an  easy labour does not
much exceed  four pounds.  The driving-power exerted  in labour must
necessarily be equal to the weight of the child.  This has to be propelled
horizontally,  retarded to  a  variable  extent  by friction.   Taking  the
average weight  at seven or eight pounds,  and adding as much for
friction, we shall arrive  at a  fair approximate  estimate, probably not
less trustworthy than estimates based upon experiments in which some
factor or other is generally overlooked.  It  is needless to premise that
the presentation 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 pressure will
often excite uterine contraction to aid or  even supplant the operator.
But it  seems that pressure  alone is sometimes sufficient.   As an
adjuvant to extraction, pressure is, I know, of great value.  I never use
the forceps or any extracting means without  getting an assistant to
compress the  uterus firmly, to maintain it  in its proper relation to the
axis of the brim,  and to help in the extrusion of the fcetus.   This
resource, then, should not be  lost sight of.   In certain cases it may
obviate the necessity of using the forceps ;  or it may stand you in good
stead when instruments are not at hand.    When a vis a tergo cannot
    * "Monatsschr. f. Geburtsk.,"  1856.   t Ibid., 1867.    £ Ibid., 1863. 
DYSTOCIA.
9
be had, we have the alternative of supplying power by importing a vis
a fronte.   In the case we are supposing, the means of doing this reside
chiefly in two instruments:  the forceps when the head presents;  the
hand when other parts present.
   In the  second order of cases there is a want of correlation 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 opposed 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  and temperature
rise, and  the patient show signs of distress, it  is  proper to help.  I
have no faith in belladonna.  To  excite vomiting by tartar emetic is
to add to the distress of the patient 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 a  doubt-
ful gain.   We have two mechanical  resources  to meet  this  strictly
mechanical difficulty.   There is the hydrostatic dilator, which I have
contrived for the express purpose of expanding the cervix.   In the case
of a cervix free from disease, dilatation will commonly proceed rapidly
and smoothly 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  will 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  distension with
the water-bags the  cervix may be safely and sufficiently dilated.
   The fcetus and the channel may be duly proportioned, but the position
of the child is unpropitious.   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  themselves,  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 by  the
forceps.   The second by reducing the bulk of the  child to  such  dimen- 
10
OBSTETRIC OPERATIONS.
sions  as will permit it to pass through the contracted channel.   The
perforator,  the crotchet,  the craniotomy-forceps or  cranioclast,  the
cephalotribe, the  forceps-saw, and the wire-ecraseur 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 fcetus and pelvis,
by extracting the foetus through  an artificial opening  in the mother's
abdomen.  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. 
LECTUEE  II.
   OBSTETBIC INSTEUMENTS--THE  AEMAMENTABIUM  OBSTETBICIUM.

                         To  save  the child.
   1. A lever.  (This may be  dispensed with.)
   2. A long double-curved forceps.
   3. Koberton's apparatus for returning the prolapsed funis.
   4. Bichardson's or  Bibemont-Dessaigne's  apparatus to restore the
child from asphyxia.

                  To reduce  the bulk  of tlie  child.
   5. A craniotome or perforator.
   6. A crotchet.
   7. A craniotomy-forceps or cranioclast.
   8. A cephalotribe.
   9. A wire-6craseur and an embryotomy-scissors.
   10.  Bamsbotham's or Braun's decapitating hook.
   11.  A  blunt hook, slightly flexible.

                  To induce or accelerate labour.
   12.  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.
   13.  Higginson's syringe, fitted with a flexible uterine tube, or better,
a grooved glass tube on Burkhardt's model,  nine inches long, which
serves  for the injection of hot water or styptics ;  and which also serves
to expand.
   14.  A  set of my caoutchouc hydrostatic uterine dilators.
   15.  Three or four elastic male bougies (No. 8 or 9).
   16.  A  porcupine quill to rupture the membranes.
   17.  A  flexible  male catheter, and a glass catheter.   The short silver
female catheter commonly sold  is often useless.   The male catheter is
more useful during labour ; the glass catheter is best for the puerperal
state, being more secure from foulness.
   18.  Scissors and thread, or narrow tape. 
12
OBSTETRIC OPERATIONS.
      For the Ccesarian section, and to repair a torn perinmtm. .
  19. A  bistoury, forceps, director, silk  and silver sutures, needles,
artery-forceps.    For Porro's  operation,  Koeberle's  serre-noeud,  or
Cintrat's ligateur, or an elastic band. Sydney Jones'  ovariotomy clamp-
forceps.
                       To restore the mother.
  20. A  transfusion  apparatus.  21.  A  hypodermic syringe to hold
60 minims.
                            MEDICINES.
  1. Chloroform or ether and inhaler.
  2. Chloral.
  3. Laudanum.
  4. Hofmann's anodyne.
  5. Nitrite of amyl, and  nitro-glycerine.   Some may be carried  in
Martin dale's capsules.
  6. Ergot of rye.
  7. Ferric chloride.
  The iron, carbolic  acid, solution of iodine,  and  mercuric chloride
may be conveniently stowed in a separate case with the Higginson's
syringe, the dilators, and  uterine  tube.   §ij. of the  ferric chloride
dissolved in Jx. of water makes the "styptic injection."   The mercuric
chloride may be kept  in a solution of 1 in 200, so that by  adding  10
parts of water, we get a solution of 1 in 2,000 for use.  Vaseline with
carbolic acid, 1 in 20, or boracic acid.  This may be carried in an artist's
compressible  colour-tube.   Cold  cream, lard, oil, may be impure, and
should be rigorously discarded.
  The most convenient mode  of packing these things is to adapt a
travelling leather bag.   There is always spare room for  anything likely
to be wanted, besides its  ordinary  furniture, or for bringing away a
pathological specimen ;  and by turning out the obstetric furniture you
have a travelling bag again.
  I  will  now  say  a few  words in  explanation  of the instruments
recommended.
  The Forceps.—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 and a half;
the length of the arc of the cranial bow of about seven inches, to adapt
it to the elongation of the foetal head during protracted  labour.  There
should be between the springing of the bows and the  lock a straight
shank to He parallel with its fellow, to carry the lock clear of the vulva
and to save the perinaeum.   In my forceps the shank is further length-
ened by a semi-circular 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 
IXSTRUMENTS SHOULD  BE  POWERFUL.          13
whilst 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
instrument can be worked with the utmost nicety and economy  of
muscular force.   A single-handed instrument is necessarily a weak one.
The absurd dread of possessing powerful instruments has long been the
bugbear of English Midwifery.   It has  been sought to make an instru-
ment 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  sometimes necessary to keep  up a considerable
degree  of force for some time, and not seldom in a constrained position.
Fatigue follows ;  the  operator's muscles become unsteady ;  the  hand
loses its deHcacy of diagnostic touch, and that exactly balanced control
over its movements which it  is all-important to preserve.  Under these
circumstances the surgeon 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 he  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.   Violence is the  result  of  struggling
feebleness, not of conscious  power.   Moderation  must emanate from
the will of the operator;  it must  not be looked  for in the imper-
fection 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 accurate sense of resistance which tells the operator  the  mini-
mum degree of force that is necessary, and warns  him when to desist.
   In Barnes' System of Obstetrics, vol. ii., 1885, the  varieties of forceps
are more particularly described.  Three types are  pointed  out, each
characterized by  a curve.
   The  first  type  possesses only the head-curve.   This is  the  " short
forceps."  The second type  is  marked by the addition of the pelvic
curve.   The third type is the latest development.  It is marked by the
addition  of the  perinaeal or  Aveling's  curve.
   Aveling exhibited his  sigmoid forceps to the  Obstetrical Society  in 
14
OBSTETRIC OPERATIONS.
1868.  Tarnier brought out his axis-traction forceps in 1877.   These
instruments will be iUustrated in  a subsequent  lecture ;  and  their
special  advantages  in favouring  axis-traction  will  appear  when
describing the operations.
  Boberton's 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
Boberton's  appears  to me the  most  simple.   By  the  knee-elbow
posture, indeed,  all instruments may occasionally 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  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.  The form most in use in this country is some
modification of Smellie's wedge-shaped scissors.  But  many of these
instruments are very clumsy and inefficient.   It  requires sometimes
considerable force to penetrate the cranium.  A weak instrument here
is especially dangerous: it is apt to slip, to glide off the globe of the
head at a tangent, 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  modifica-
tion of Holmes' and Naegele's by Dr. Oldham; it fulfils every indication.
On  the Continent, especially in Germany, the trepan, first introduced
by Assalini, and variously modified, is greatly 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 other cases,  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 application of
the  instrument.   I found no difficulty  with Oldham's  perforator ;  it
will run up through the merest fissure wherever the finger will go to
guide it, and will readily penetrate any part of the skull.  This, then
is the perforator to be preferred.  Various guards have been adapted to
the  scissor or spear-head perforators.   These consist of sliding sheaths,
which cover the sharp edges of the instrument during introduction and
which can be drawn back when the adjustment for operation is made.
They  appear to me to  constitute  unnecessary  complications;  they 
INSTRUMENTS DESCRIBED.
15
rather hinder than aid the working of the instrument.   The most
trustworthy guard is the finger of the operator.
  The Grotcliet.—The design of the crotchet was to seize and extract,
by  taking  a hold  inside  the cranium, after  perforation.   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 craniotomy -
forceps and the cephalotribe.   The use to which I now almost  restrict
the crotchet is to break up the brain and tentoria, so as to facilitate the
evacuation and collapse of the skull.
  The Craniotomy-Forceps, or Granioclast.—The  use of this  instru-
ment 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 latter 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 instru-
ments 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 best hold is obtained by com-
pression, 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
separately, like the ordinary forceps.   These principles are fairly carried
out in my craniotomy-forceps, and others  as  well  as myself are well
satisfied with this instrument.  In selecting the instrument, it is neces-
sary to see that these essentials have been preserved by  the maker.  I
have  been shown many  specimens as mine  which I  should utterly
condemn.  Braun's cranioclast is made somewhat  like  Simpson's and
mine.  It  is much used on the Continent, but  it is too  much  curved,
and is in  other respects  an  inferior  instrument.   A further improve-
ment may be made in my instrument by adapting a moderate perinaeal
curve.  Hall Davis' and  Matthews' instruments are excellent.
   The Basilyst.—The most unyielding part of the skull is the base.
To break up this, several  instruments have been contrived.   Hubert in
1860, Guyon in 1865, described instruments for this purpose.   Tarnier
invented a basiotribe which  fulfilled the  double purpose of breaking
up  the base and  crushing it in.    A. K. Simpson's  basilyst is  an 
16
OBSTETRIC OPERATIONS.
instrument made to perforate the cranial  vault, and  then to' traverse
the cranial cavity, and perforate the base.
  The Cephalotribe.—hi cases of great, but not of extreme, distortion
of the pelvis, the cephalotribe is an instrument capable of materially
accelerating delivery.  After perforation, the powerful blades applied to
the head crush in and flatten it, so that  it can be  drawn  through a
comparatively narrow  passage.   The  unwieldy bulk and formidable
appearance of most of the Continental cephalotribes, requiring, as they
do, an assistant in their  use, must  preclude their  extensive  adoption.
Braxton  Hicks's modification  of Simpson's  cephalotribe is,  in my
experience, a  little too  short.   It is  slightly curved in the  blades.
Dr. Kidd, of Dublin, has  also contrived an excellent instrument;  he
has made the blades straight.   Either  of these can be worked by the
operator  unaided; and can be carried in the bag with the other pieces
of the obstetric armamentarium.  Sufficient power to crush down the
roof of the cranium upon the base after perforation is combined with a
minimum of  size and weight.  The best cephalotribe I have used  is
that designed by  Fancourt Barnes.   It is  light and manageable with-
out sacrificing  power.   It is  distinguished  by the  adaptation of a
moderate perinaeal curve.   It is  figured as in  action in the lecture on
" Cephalotripsy."
   The Wire-ecraseur.—This instrument I propose to add in order  to
execute the new method  of Embryotomy I  have designed, to  effect
delivery  in extreme cases of pelvic deformity.  Its  use  is  to  make
sections  of the head  in  utero, so as to reduce it to a bulk easy for
extraction.  This proceeding is called  " Lamination," because  slices
are taken out  of  the  head.   The instrument must  be  a  powerful
one;  and it should have  an endless or Archimedean-screw movement
on Weiss's principle, so as to work  a loop of wire large  enough to take
the head in its equator.  Other instrument manufacturers make excellent
ecraseurs, which can be used for this and  other surgical purposes.  In
connection with this operation it is also necessary to  be provided with
a  pair of Embryotomy-scissors  to  cut up the trunk.  The wire can
also  be  used as a  decapitator, instead of Bamsbotham's  hook.   It
further forms an excellent snare to catch  a foot when too remote to be
seized by a loop of tape carried by the fingers.
   The Decapitating  Hook, Bamsbotham's  and  Braun's.—This  in-
strument will be rarely  required,  but when the occasion arises, the
service it  renders is  very great.   In  a protracted  transverse presen-
tation, when the child  is dead from  compression,  the  uterus spas-
modically  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  obviously  preferable—the child
being past help—to spare the mother to  the  utmost.  This hook can
be carried over  the  child's neck,  and  by a movement of sawing  and 
THE HAND.
17
 traction, the neck can  be  severed  in a few seconds.  It is seen as in
 action in the Lecture on '' Embryotomy.''  Then the body is extracted by
 pulling on the prolapsed  arm.  The head, remaining  alone in utero,
 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
 object can be obtained by a pair of strong scissors (Dubois) which is
 made to  divide the cervical  spine.   An excellent  decapitator was
 contrived by Jacquemier ;  in general form it resembles Bamsbotham'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.  The operation may  also be
 effected by the wire-ecraseur.
   The Blunt Hook.—A blunt hook at the end of a  slightly  flexible
 stem, and eighteen  inches long, is a useful instrument in seizing the
 child's limbs in certain cases of turning, and in canting the base of the
 skull after craniotomy.
   The Syringe,  Uterine Tube, and Caoutchouc Dilators.—These are
 perhaps the most frequently  useful  of all the instruments enumerated.
 A  Higginson's  syringe 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 sufficient.
   The elastic  male bougies  are useful as the best means of inducing
 labour, that is, of provoking labour.
   The porcupine quill is a most convenient instrument for piercing the
 membranes ; and although a common quill or steel pen will answer the
 purpose, these are not always at hand.
   The instruments  will be more fully described with  the operations
 in which they are used.
   To carry a complete armamentarium in one bag would be inconvenient.
 I have therefore proposed to  divide  the constituent parts into two sets :
 the  first  to comprise the conservative  appliances.   These  are:  the
 forceps ;  Boberton's instrument to replace the funis;  an apparatus to
 restore the child  from asphyxia; bistoury  and  scissors;  sutures;
 ligatures ;  elastic bougies  or  glass catheter;  Higginson's syringe with
 the hydrostatic  dilators ;  a hypodermic syringe ; Aveling's transfusion
 apparatus ; the medicines already specified.
   These  things do  not take up much  room.   They will carry  the
 surgeon through most of the emergencies of labour.  When it becomes
 a question as to sacrificing the  child, there is generally time to send for
 the sacrificial instruments.
   And lastly, let me add a few  words concerning the obstetric hand, as
 the master instrument  of all, not only as guiding all the rest, but  as
 performing many most  important  operations unarmed.   In ordinary
labour it  is the only instrument required.  It is also the  only in-
strument called for in many of the greatest difficulties.   In malpresent-
                                                             c 
18
OBSTETRIC OPERATIONS.
ations, in  placenta praevia, in many cases of contracted pelvis, m not a
few cases where, after perforation, the crotchet and craniotomy-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 or single-curved 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 craniotomy
forceps, is the result of the great study directed to the  perfecting
of  the cephalotribe.  At  the  present day we may boast  of having
good  and  effective  instruments  of all kinds, each capable of doing
excellent  work  in  its  own peculiar  sphere,  and endowed with  a
certain capacity for  supplanting its rival instruments.   For example,
the long  double-curved forceps  is  adapted to  supplant craniotomy
in  a certain  range  of  cases  of  minor   disproportion.   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 which  destroys
life.  At the same time, it is eminently desirable to possess the most
perfect means of bringing a foetus through a very narrow pelvis, in
order  to  exclude or to minimize  the  necessity of resorting to  the
Caesarian 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 perseverance, marvellous and fertile the ingenuity,
that have been brought to this task.  I will not say that it has all been
misdirected;  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 be not less  instructive  than curious to carry our
 minds back to the  days when the forceps  and other instruments now
 in  use were unknown, and  to confront the problem  which  our  pre-
 decessors, Ambroise  Pare, Guillemeau, and others  had  to  solve—
 namely, how to deliver a woman with deformed pelvis without instru-
 ments.   That  they did successfully accomplish in  many instances
 with  the unarmed hand what we now do with the aid  of various
 weapons, there can be no doubt.   If this  implies greater poverty of
 resources on their part, it not  the  less implies  also greater manual
 skill.  I  am  confident that the possession  of  instruments, especially
 the  craniotomy  instruments, has  led,  within the present  century, to
 a  neglect of the proper uses of  the hands, which  is  much to  be
 deplored. 
LECTUBE   III.
THE MECHANISM  OF HEAD-LABOUR--THE THEEE PARTUEIENT CURVES
     —THE  POWEES  OF  THE  FOECEPS--THE  FOECE BY  WHICH  IT
     HOLDS THE  HEAD--THE COMPEESSIBILITY OF  THE  CHILD'S  HEAD
     --THE LEVEE--DEMONSTEATION  THAT  THE LEVER  IS A LEVER,
     NOT  A TRACTOR ;  ALSO  THAT THE FORCEPS IS A LEVEE.

The description of the forceps may fitly be preceded by a sketch of the
mechanism of head-labour.   This sketch will  also be useful to refer to
subsequently when  studying the  mechanism of shoulder-presentation.
The mechanism of  labour, showing the influence of the lumbo-sacral
or Barnes'  curve, Carus' curve, and the perinaeal or Aveling's curve,
is described  with great care  in  Barnes'  " System of  Obstetrics,"
vol.  ii.,  1885.   In  that work   also  the  theory  of  Synclitism is
discussed.  The three curves are  shown in Fig. 1, p.  20.
  Bi 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
downwards to the os uteri, whilst 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 left cotyloid cavity descends and approaches the centre of the brim,
the chin is  strongly pressed upon the chest, the back  of the neck comes

  *  The student is earnestly advised to follow and execute the ensuing description
with a foetal skull and a female pelvis.
  It will here be useful to  define the meaning we attach to the terms,  "Vertex,"
" Position," and " Presentation."  1.  By Vertex, we mean the highest point of the
head in the erect posture.  This is the  space between  the two fontanelles and the
parietal protubeiances.   Although the  central  point of this space rarely is exactly
the lowest in labour, yet in natural head-labour the presenting part is always some
point within  this space.  2. By Position, we mean the relation of the head or other
presenting  part to the plane of  the pelvic  brim, that is, to  the diameters of the
brim.   3. By Presentation, we mean the part of the fetus which is most  prominent
iu the line  of the axis of the pelvis, whether  at brim, cavity, or outlet.
                                                               c 2 
20
OBSTETRIC OPERATIONS.
to bear upon the cotyloid wall, whilst 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.  This movement is an exaggeration of the natural flexion which
exists before labour begins.   In  several cases of women dying unde-
livered at the end of gestation, I have had the opportunity of observing
                               Fig. 1.
CONSTRUCTED ON CHIARA's FROZEN SECTION TO SHOW THE AXES AND CURVES OP THE UTERUS AND
                         PELVIS. (ROBERT BARNES.)
 A D. Axis of brim of pelvis,  a u. Axis of uterus.  Aba. Angle of divergence of uterine axis
from pelvic axis,  p B. Plane of brim, p C. Plane of cavity, p D. Plane of outlet, ef. Barnes'
curve.  >j h. Carus'curve. PC. Parturient curve.

in  the dead body the position  of the child : the  chin was flexed upon
the chest, and the presentation was oblique.
   2. A  Movement of Descent  or Progression.—This begins commonly
with the escape  of the head from the mouth of the uterus, the clearing
of  the brim, and ends  with the total extrusion of the child.   It  con-
tinues in the same line—that is, in the axis of the  brim—until the
head  reaches the floor of the pelvis. 
MECHANISM OF NATURAL LABOUR.
21
  3. A Movement of Botation.—This takes place chiefly in the lower
part of the pelvic cavity.   The forehead and the anterior 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 backwards
and downwards, turning towards  the  sacral cavity, whilst the back of
the neck slides behind the left foramen ovale, or the left anterior wall
of the pelvis, and, following the incline forwards, and a little upwards,
turns towards 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  successively over the posterior commissure of the
vulva, traversing the concavity of the lower part of the sacrum  and
the distended perinaeum.   This movement in a circle  does not begin
until  the head has reached the floor of the pelvis, nor until the move-
ment of rotation (3) is completed, or nearly so, that is, when the
occiput  becomes engaged under the pubic arch.
  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 fore-
head to the right.  This last movement of the head is the effect of the
first of a series of movements similar to those described by the head,
and which are now described by the trunk.   The shoulders  entering
the brim in the left oblique diameter, turn the head, now freed from all
restraint, bringing  the  face  forwards to the right.
  The movements undergone by the trunk arc three :—
  1. A Movement of Descent or Continuous Progression.—The right
shoulder is forward to the right, the left is  behind  to the left: the
child's back  is  directed forwards to the left.
  2. A Movement of Rotation.—The shoulders and the upper part of
the trunk  having descended into the excavation,  the right  shoulder
turns towards the apex  of the pubic arch, and the left rotates towards
the concavity of the  sacrum.  The child's back, after the rotation, is
turned to the left.
  3. A Movement in a Circle.—The right shoulder remaining compara-
tively fixed beneath  the pubic  arch, the left shoulder, followed by the
corresponding side  of the trunk and the left hip,  describes the arc of a
circle ; and gradually the  right shoulder rises over the mons Veneris,
whilst the parts  placed behind traverse the sacro-perinaeal concavity.
  These  movements  are governed  by the form  of  the pelvis.
  Powers of the Forceps.—To arrive at a just idea as to the application
of instruments 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 labour—that is, of the 
22
OBSTETRIC OPERATIONS.
difficulty to be overcome—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 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.
  Three  distinct  powers  or  forces can  be  developed in the forceps.
First, by simply grasping the head and drawing upon  the handles, it is
a tractor, supplementing  a vis a fronte for the  defective vis a tergo.
Secondly,  the forceps consisting  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 degrees 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 deliver the
child when the head  is in the pelvis,  when a little  leverage or very
little  tractile power  is required.  Ask  yourselves  what  this means.
What is the consequence in practice ?   Simply this :  you are driven in
a multitude of cases to perforate, to destroy the child.  Such an alter-
native may well make us  reflect whether we cannot extend the powers
and the application 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 on  the  brim of the
pelvis.  By moderately lengthening the handles and making the instru-
ment stronger, we  increase  the leverage 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 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 con-
cerning these limits  that  authorities have  differed.   Some men are
afraid of giving power, lest it should be abused.  They are so terrified 
POWERS  OF  THE FORCEPS.
23
at the possible mischief which great power may work, that they would
rather abandon the good which great power is equally capable of work-
ing.   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 forceps 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,  ex-
cludes progress 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  disproportion at the brim, if
he always delivers under this difficulty by perforating ?   Clearly, he bars
himself from acquiring  that knowledge ; and, giving up his intelligence
to the delusive  dictates of his wilfully limited experience, he refuses
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.
  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 power.  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 to 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.   The  effect  of  pressure  upon  the  bows  of the  blades in
maintaining the hold  is again proved  by  the  readiness with  which
the blades slip off  as soon  as the equator of the head has cleared
the outlet.  In  many  cases,  this  outer 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 
24
OBSTETRIC OPERATIONS.
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
is constructed on this principle.  It is essentially a tractor with slight
leverage power.  Professor Lazarewitch,  of Charkoff, uses  a beautiful
forceps  constructed on  Assalini's principle.  This  instrument  I tested
in two cases on the same day.  It held admirably ; but all its holding
power is due  to  the great curvature of the blades, and hence to the
pressure exerted by the mother's  parts  upon the blades.   Dr. Inglis,
of Aberdeen, 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 sacrifice 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 greatly  due to the adaptation of the curved blades  and
the outer 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 fenestra?.   If the
curve is one of large radius, so that the two blades, when in opposition,
approach parallelism, and especially if the fenestra? be narrow, the hold
will be feeble,  and moderate traction will cause the forceps to slip,  and
this in  spite of any compression  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 inconsiderable in
almost all the English forceps, but is an important feature in most
of the foreign  long forceps.   The essential conditions for compression
are, indeed, present in English  and foreign.   These consist  in  the
crossing of the blades,  and in the  greatest divergence  of the blades,
when  the  handles are brought together, being less than the greatest
transverse diameter of the child's head.  This diameter is normally from
3f to  4  in.;  the greatest divergence of the blades is rarely more than
3 in.   Therefore, when the blades are sitting loosely on the head, the
handles diverge.  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  longitudinal diameter.
This,  of course, is  even  longer than  the transverse.   Now, if we are to
exert  any  direct  compression upon the  head,  we can only do it by 
MOULDING OF THE  HEAD.
25
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 diminish some of its diameters by lengthening others—is easily
proved.
  Firstly. It is known that in  normal pelves the head in passing, if
the labour  be   protracted,  undergoes  elongation;  from spherical it
becomes conical;  the greatest transverse diameter—the inter-parietal
—becomes reduced to approximation  to the lesser or interauricular,
whilst the longitudinal diameters are correspondingly increased.

              Fig.  2.                          Fig. 3.
  1.—THE NORMAL SHAPE OK THE FOJTAL SKULL.      2.—HEAD MOULDED IN LABOUR.
  1 to  2. Oc cipito-frontal.  1 to 3.  Oecipito-mental.  a.  Frontal bone.   b. Parietal bone.
c. Occipital b one.

   These  changes I have demonstrated  by  actual measurements and
outlines.*  Diagrams  1 and 2 may be taken as types  of the normal
head  and of the form impressed in protracted labour.
  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 in moulding the
head  to  allow  of its  passing.   Indeed, I think this pressure almost
entirely accounts for the  alteration  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 labour  as  they often are
under  forceps  delivery.
  Secondly. Numerous  experiments  have  been  made  with  strong
forceps upon dead children  to  determine this point.    Baudelocque
found that he  could lessen the transverse diameter  by a quarter to a
third of an inch.   Siebold gained half an inch.   Osiander and  Velpeau
                  * "Obstetrical Transactions," vol. vii.
 
26
OBSTETRIC OPERATIONS.
claim  quite  as much.   More  conclusive are the  observations  of
M.  Joulin  and of M. Chassagny.   These  gentlemen, in  experiments
designed to demonstrate the utility of continuous  compression and
traction by powerful forceps upon  the  head in difficult labour, have
completely proved  that  a  degree of moulding may be effected  much
beyond that  commonly observed.   This  moulding  consists in  the
elongation of the head, the elongation being gained by the lessening of
the equatorial diameters.  The process resembles that of reducing wire
by  drawing it  through holes in an  iron  plate.
  Now, another question arises : the head is indeed  compressible, but
to what extent is it  compressible without sacrificing  the  child's life?
For if the maximum of plasticity compatible with life be represented
by that degree which is  common in  severe first labours, then we  ought
to give the mother all the ease in our  power by lessening the  diameter
of the child's head by perforating.   It is very difficult 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.
Experiments  on the dead foetus are of  doubtful value.  The conditions
are so different, that  application of these experiments to clinical use
might lead to serious error.   The degree of compressibility compatible
with  life is no  doubt a variable quantity.   The  following conditions
influence the  result:—The degree 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 secur-
ing 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 ex-
tremities 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, giving periods of rest during
which it is presumed that the brain may better adapt itself, and its
circulation be maintained.  Hence  the  law that we ought in forceps
labours, and  generally in  all operative  labours, to  imitate this inter-
mitting action by interposing intervals of rest, endeavouring 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  physi-
ology.  It is not wise to disregard it.  But experience proves that there
are cases where the  moulding of the  head can be accomplished more
quickly, and  without endangering  the  child, by continuous  pressure.
Some  practitioners,  therefore,  have  recurred to  the   old  practice. 
USE OF THE FORCEPS.
27
Delore,* who has made many dynamometric observations, concludes
that pressure exerted either by the forceps or by the genital organs,
may be harmless 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 tlie 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, increasing  with every degree of
angular difference.  This  object is most surely secured by the  axis-
traction forceps.
  Thirdly. To use slight movements of laterality or oscillation.
  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  the 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  in England than  it was during the
first half  of  the  present century.
  It is no valid objection to the forceps to urge that in extreme cases it
will probably deliver the child dead from  excessive compression.  The
child has had  the best  chance of  life.   The  alternative, craniotomy,
gives none.
  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  descended  into the cavity of  a well-formed  pelvis, and
is arrested 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
will be  quite  sufficient.  The moulding or diminution of the equatorial
                   *  " Gazette Hebdomadaire," 1865. 
28
OBSTETRIC  OPERATIONS.
diameters  will  be  effected  by the sole  compression of the mother's
structures.   The occiput lying behind the left foramen ovale, the lever
may be slipped over it, and the head drawn down towards the pubic
                             Fig.  4.
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 lever may be shifted  to the opposite  side,  so  as to  lie over the
                             Fig.  5.
child's face  and chin in the hollow of the sacrum.   Then  drawing
down, you give the extension movement to the  head, and the  cranium
soon emerges through the  outlet.   Several  skilful practitioners, who 
ACTION  OF  LEVER.
29
frequently resort to this instrument, contend that it is a true tractor,
and point, in confirmation of this view, to the great  curve of the blade.
Fig. 6.
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
opposite point or pole as a centre, its axis representing another lever. 
30
OBSTETRIC OPERATIONS.
If the point opposite to that seized by the lever be moveable, 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 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 diagrams 4, 5, 6, 7, 8, 9, 10, 11, will illustrate the action of the
lever bringing the head down by alternate flexion and extension.   The
lever is supposed to be applied alternately over the occiput and the face.

                              Fig.  8.
In Fig. 4, c represents the centre of rotation.  The lever applied to the
occiput will bring down the pubic hemisphere of the head-globe, the
forehead  remaining nearly fixed against the sacrum  at c.  Flexion is
preserved.
  In Fig. 5 the lever is reversed.  The centre, c, is at the pubes ;  the
facial or sacral hemisphere descends with extension.
  La  Fig. 6 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. 4.
  In Fig. 7 the lever shifts to the face.   The centre,  c, is again at the 
ACTION  OF LEVER.
31
pubic arch.   The facial  hemisphere is now made to sweep down over
the perinaeum, performing the extension-movement of delivery.
  Li Fig. 8 the lever is seen applied to the occiput, bringing down the
pubic hemisphere, whilst the opposite point is fixed in flexion at c in
the sacrum.:|:
  In Fig. 9 the lever is applied over the face, which is brought down
in extension, the occiput resting against the pubes.
  An instrument which claims to be  considered with the lever is the
whalebone fillet  or  loop.   Its  action  is entirely similar.   If the loop
of the fillet be supposed  to  be substituted in Figs. 8  and 9  for the
  f                             Fig. 9.
lever,  the demonstration  will equally apply.   The fillet has lost its
place in  scientific works;  but it  is, I believe, largely used by  some
practitioners, and with great success.  The  instrument deserves  to
be  remembered  for  this  reason:  it can  be  extemporized.  Under
exceptional circumstances, when  no  instruments  are to be  had, a
bit  of  whalebone can  be  bent and applied over the occiput or face,
  *  This alternate  leverage action is sometimes  called oscillation.  " By some
ingenious writers it  is distinguished as the  'pendulum-movement.'" By an abuse
of metaphorical license one may liken combined traction and swaying action  to
gravitation-force. But the gravitation that moves the pendulum does not act in the
ease of a woman lying in the horizontal posture. 
32
OBSTETRIC OPERATIONS.
in a case of arrest of the head  in the pelvis, thus enabling the prac-
titioner to rescue his patient and himself from a trying situation.
   A similar principle of leverage may be applied by the  two blades of
the short forceps.   But in this case the leverage is  applied more to
the transverse  diameter of the head.  The lever can in like manner
be applied to the side of the  head if  necessary.   When the blades
are crossed and locked, the common  fulcrum is at  the  lock.  Then,
by gently bearing upon either handle  alternately, swaying the instru-
ment backwards and forwards, avoiding  all pressure against the pelvic
walls, you  cause the head-globe to rotate to a small extent alternately

                              Fig.  10.
SHOWING LEVERAGE ACTION OP FORCEPS. (r. B.J
in opposite  directions  upon its own  centre.  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 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. 10, 11.
In Fig. 10, the head grasped transversely, the handles  are first carried
to the left.  The right or pubic hemisphere descends.
  In Fig. 11, the handles are  carried across to the right.   The left or
sacral hemisphere descends. 
ACTION  OF  FORCEPS.
33
  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 advances by a series of alternate side-move-
ments, 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, however, dis-
approved of by some  authorities, who  enjoin traction alone.  But I

                              Fig. 11.
SHOWING LEVERAGE ACTION OF FORCEPS.
believe  that  pure traction is almost  impossible, 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.
  This  leverage-action on  the transverse diameter of the head is, in
truth, an imitation of Nature.   Under the natural forces, the careful
observer may note that the head descends by an oscillating movement.
D 
LECTUBE   IV.
THE  APPLICATION OF  THE SHOBT FORCEPS—HEAD IN  FIRST POSITION
     —HEAD IN  SECOND POSITION—OBJECTIONS TO SHORT  FORCEPS—
     THE APPLICATION OF THE LONG OR  DOUBLE-CURVED  FORCEPS—
     INTRODUCTION  OF THE  BLADES—USE OF LONG FORCEPS--LOCK-
     ING--CAUSES  OF  FAILURE IN  LOCKINGS--EXTRACTION—HOW  TO
     MEASURE  THE ADVANCE  OF   THE  HEAD--THE  MANOEUVRE  OF
     "SHELLING OUT"  THE  HEAD  DELAYED AT THE  OUTLET--RE-
     LOCKING--THE HEAD IS SEIZED OBLIQUELY  BY THE  FORCEPS—
     TIME REQUIRED FOR EXTRACTION.

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,
occiput forwards.  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 which are not necessary, but favourable.   1. The mem-
branes must be ruptured.  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 pelvis is simply drawn
to the edge of the  bed, the patient  lying on her left side.   I think it
needless  to enter into controversy  upon the relative advantages of the
two  positions.   We  shall probably adhere  to custom.  The EngHsh
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.   Certainly in the  last stage of
extraction, when the handles have  to be carried round the symphysis,
the dorsal position gives more  power and precision.   And  in cases of
convulsions, where the patient  is unconscious or  unmanageable, it is
at times  necessary to  apply  the forceps in the dorsal position.
  The operation may be divided into four stages or acts.  1. Introduc-
tion  of the  blades ; 2. Locking; 3.  Traction,  sometimes compression,
and leverage ;  4. Bemoval of the instrument.
  1. Which blade do you pass first ?—In the case of the  single-curved
forceps,  both blades being alike, you cannot  take up  the wrong one. 
USE OF FORCEPS.
35
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
directed forwards,  so  that  the  blade  shall  cross  the mother's right
thigh obliquely,  the point will  be guided  over  the perinaeum  by two

                                Fig. 12.
         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 down-
wards and backwards, to get the point of the blade round the head and up into side of the pelvis
in the line a b. At b the blade is in sitd.

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
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
                                                             d 2 
36
OBSTETRIC OPERATIONS.
follow this convexity.   This is  done by lowering the handle and draw-
ing it backwards, 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 manipu-
lation of the second or pubic blade.
  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  forwards, crossing

                               Fig. 13.
           INTRODUCTION OF THE SHORT FORCEPS—THE SECOND OR PUBIC BLADE.
  A, the first stage.  As the blade passes up the pelvis and round the head, the handle travels in
the direction of the line a b. At b the blade is in sittl.  The two blades of Figs. 12 and 13, therefore
correspond at b, and will lock.

the mother's left  thigh obliquely.    Kunning  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 backwards, 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 
USE OF FORCEPS.
37
 overcome, you are going wrong; and, vice versa, if the blades are slip-
 ping 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 spact
 where there is most  room—that is,  one blade will  go  nearly opposite
 the  sacro-iliac synchondrosis, the  other  will go  opposite the foramen
 ovale.*
   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  careful 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  single-curved forceps.
   Then  come, thirdly, traction, compression, and leverage.   Traction
 must be  exerted in the  direction of  the  pelvic axis.  Thus at first the
 traction  will be  backwards in a line drawn from the umbilicus to the
 coccyx.   Gradually,  as the head descends, the handles will come more
 forwards, and  the face turning a  little backwards into the hollow of
 the  sacrum, the handles will also rotate, so that the instrument will
 approach the transverse diameter of  the  pelvis.   As the head emerges,
 the  vertex appearing under the pubic arch in the genital fissure, the
 handles,  following the extension movement of the head,  will describe
 a circle  round  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,  so  as  to
 unlock, seize the handle of the pubic blade, draw  it downwards and
 backwards off the head, then, taking  the  sacral blade, draw it upwards
 and a little backwards.
   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 governed 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 nought  the refinements of theory,

  * Some  adherents of the short forceps 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, Dublin, and Edinburgh now follow the method
 recommended in the text—namely, of passing the lower or sacral blade first. 
38
OBSTETRIC OPERATIONS.
 and clears  out for  herself a straight  and simple  path through the
 intricacies woven in the closet.   Dr. Eamsbotham says : *  " In em-
 ploying 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 injuring the soft parts
 during  extraction.   But  I confess  that I  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 to examine the head
 in every case after delivery.  I have thus many times seen the stamp of
 the fenestra  on the  brow and side of the occiput.   This is as clear to
 read as the impression 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 towards 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.  Roberton, an operator like
 Ramsbotham, trained in the field of obstetric difficulties, says : " There
 is  some haziness of mind about position of  the foetal head—about the
 necessity of  feeling  for the ear."   The terms  "sacral" and " pubal"
 are misleading.   He, too,  applied the blades  in  the  sides of the
 pelvis.
   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 rotation on  its axis so as to bring the occiput  forwards.  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 sacrum, and the head is released.  In two
 cases  of this kind  I thus easily succeeded in delivering after failing
 with my long  forceps, the blades of which,  lying  in  the  transverse
 diameter of the pelvis, grasped the head in  its  long  or fronto-occipital
 diameter.  These are the only two cases in which I have ever found
 the short forceps preferable to the long.   And  the simple  lever would,
perhaps, have answered as well.
  There  are objections to the  single-curved forceps, short or long :__
  1. One objection is in the introduction ; others  in  the injuries likely
to  be inflicted on mother  or child.  To  introduce the second or upper
                  * "Medical Times and Gazette," 1862. 
USE OF FORCEPS.
39
blade, the handle must be much depressed, nearly at right angles with
the mother's left dliigh, 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.
  2. In extraction,  the handles,  nearly to the last  moment, must be
directed more  backwards  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
                               Fig. 14.
             SHOWING THE SINGLE AND DOUBLE-CURVED FORCEPS IN SITU.
 The single-curved forceps presses back upon the perinaeum, putting this structure on the
stretch.  The shanks  of the double-curved forceps keep clear of the perinseum, the whole
instrument approximating to Carus' curve.

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 always
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 instrument have confessed to me that this  objection is a real
one.
  The best single-curved forceps is that  of Dr. Beatty, of Dublin.  I
used it for some time, but gave it up because of these two faults, and of 
40
OBSTETRIC OPERATIONS.
 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  blades be applied as usually  taught—i.e., nearly 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.
   5.  If applied, as usually inculcated,  the anterior blade will often go
 directly behind the pubes.   The edge will bruise the urethra.   Hence
 vesico-vaginal fistula.
   From all these objections the long forceps I  recommend is nearly
 altogether  free.  I  have described  the short single-curved forceps in
 deference  to a still common prejudice, and because many men possess
 only this instrument; but this description may be conveniently passed
 over by those who are ready to adopt the double-curved forceps.

              THE  LONG OB DOUBLE-CUEVED FORCEPS.

   The application of this instrument is governed by a different  law
 from  that  which governs the use  of the short forceps.   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 therefore be passed as nearly as
may be in the transverse diameter 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 instrument.  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;  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 
THE LONG FORCEPS.
41
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 practice 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 conical  bullet.  But even then the com-
parison  is not complete, for the pelvis, unlike a gun, is  a bent tube.
Now, just as the head must traverse  the  pelvis in a helicine course,

                              Fig.  15.
SHOWING THE FIRST STAGE OF INTRODUCTION OF THE FIRST BLADE.
determined  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  intro-
duction 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 patient should lie
on her left side, the knees  drawn up towards 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  facilitate  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 hang over 
42
OBSTETRIC OPERATIONS.
the edge of the  bed.   Exposure of the patient  is unnecessary.  The
whole operation is  conducted under the bed-clothes, or a sheet.  You
trust to touch, not to sight.  Pass  the  catheter.


            FIRST  ACT—INTRODUCTION OF THE BLADES.

  Selection of the blades.—Dip  them  in warm  water, wipe dry, and
lubricate them with carbolized vaseline.  Join them, and holding the
instrument with the concavity of the pelvic  curve forwards,  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.

                             Fig.  16.
SHOWING SECOND STAGE OF INTRODUCTION OF FIRST BLADE.
  First stage.—One or two fingers of the left hand are passed 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 backwards towards the  hollow of the
sacrum (see Fig. 15).
  Second  stage.—The  handle is now raised so as to throw the point 
APPLICATION  OF  FORCEPS.
43
downwards upon the left side of the head.   As the 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
forwards in the direction of Carus' curve,  so as  to  reach the  brim of
the pelvis, the handle  rises, goes backwards,  and  partly rotates  on
its axis  (see Fig.  16).
  Third  stage.—The handle  is now  carried backwards  and down-
wards  to complete  the  course of the point  around the 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
 SHOWING LAST STAGE OF INTRODUCTION OF THE FIRST BLADE AND THE CROSSING THE SHANK OK
     THE FIRST BLADE BY THE SECOND BLADE IN THE FIRST STAGE OF ITS INTRODUCTION.
 situ; the shank is to be pressed against the coccyx by the back of the
 operator's left  hand  whilst he  is introducing  the second blade.   Its
 weight aids in maintaining it  in situ (see Fig.  17).

               INTRODUCTION OF THE SECOND BLADE.

  First Stage.—Two  fingers  of the left  hand, the  back of  which  is
 supporting the first blade against the perinaeum, are  passed into the
 pelvis between the os  uteri and the side of the  head which lies  nearest
 to 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  sHpped along the palmar  aspect  of
the  fingers in the vagina, across the shank of the first blade  in sitii,
inside the perinaeum towards the hollow of the sacrum  (see Fig. 17). 
44
OBSTETRIC  OPERATIONS.
   Second stage.—As the  point has to describe  a helicine curve to get
round the head-globe and forwards in the direction  of Carus'  curve,
the handle is now depressed and  carried backwards until the blade lies
in the right ilium.   When it has  reached this position the handle will
be found near the coccyx, nearly in opposition to the first blade.

                                  Fig. 18.
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 towards 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 sM, the shank near the coccyx,  where it is held by the back or the  operator's
left hand, whilst the point of the second blade is passed over and across it inside the perinseum,
as seen in the next figure.


   The   application  of the long forceps  is further  illustrated  in  the

diagrams (Figs. 18,  19).
   The locking.—This is effected by  a slight movement of adaptation. 
APPLICATION OF FORCEPS.
45
A handle is  seized  in each hand.  The handle  of the first  blade is
brought a little forwards 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 backwards 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  (see Fig.  20).
Fig.  19.
         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 in situ, a, the
handle at the moment of passing c, the point, inside  the perinseum into the hollow of the sacru m,
across x, the first blade; the handle then drops and goes backwards to b, the point c travelling
round the head, and advancing into the right ilium in the direction of the axis of the brim to d ;
when it has reached this position, it will be found nearly opposed to the first blade, x ; the locking
is effected by bringing the handle x over the handle b.

   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 
46
OBSTETRIC OPERATIONS.
their  not being properly introduced,  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 second
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  re-
adjusted.
  In the second case, that of pelvic unfitness, the locking is prevented
by the  projecting promontory or other  deformity 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  towards its  fellow, but towards  the

                             Fig.  20.
SHOWING THE LONG FORCEPS LOCKED, AND GRASPED BY THE TWO HANDS.
                The head being at the brim, traction is backwards.

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
ivill lock  without force, it may be reasonably concluded that the case is
a fit one for the trial of this instrument; and a  reasonable attempt 
APPLICATION OF FORCEPS.
47
should  be  made  to  deliver by its aid before passing on  to turning or
perforation.
   The Extraction.—Get  an assistant to press  upon the  right hip and
support the back.   Grasp  the handles with one hand, and apply the

                               Fig. 21.
                  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.
 fingers of the other hand to the ring  or shoulders at  the lock.  Draw
 at first backwards 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 (see Fig.  20).
  It is further extremely useful, if you have a competent  assistant, to
 get him to support and press upon the fundus daring extraction.   This
 helps to keep the axis of the uterus and of the child in proper relation
to the axis of the pelvis; and in proportion to the aid  thus given
a tergo, you lessen the amount of extracting force required.   Placing
the woman in the dorsal position also  facilitates extraction. 
48
OBSTETRIC OPERATIONS.
   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 circumference 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 diameter,  you  may be
certain that the head is descending.  Further  evidence is found in  the
rotation of the forceps.  As the  head can hardly turn upon its cervico-
vertical axis without 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 slipping, 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 is the principal force in
maintaining the grasp 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 necessary 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 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  is put 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 the head is  advancing.   To some extent
the increasing scalp-swelling or caput succedaneum may give a false
impression that the  cranium itself is descending.  But a little practice
and attention will correct this error.  When 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.  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.
During traction the  hafidles may now be directed more forwards.  The
shanks thus avoid stretching the perinaeum, and the traction is in the
axis of the outlet.  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' curve.   Here it  is often  convenient  to push 
APPLICATION  OF FORCEPS.
49
 the handles forwards  rather than to pull.   This action is  seen  in
 Fig.  21.
   In the last stage of extraction it is often useful to turn the patient
 on her  back.   In this  position  you get  the  aid  of  gravity; your
 assistant can support the uterus better in the axis of the pelvis, and
 even exert direct expression-force ; and the handles  of  the forceps
 travel more easily round the symphysis.
   The forward  direction of the handles, or the  revolution in Carus'
 orbit, must not begin until the occiput is well under the pubic arch.
   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 effect  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 towards  the  perinaeum, when
 they  will re-lock.
   If  the head is in the genital fissure, and  there is  sufficient uterine
 energy, you may proceed to the
   ith 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 apply 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 backwards, whilst the  head  is
 pushed forwards towards the pubic arch, the head is, as it were, shelled
 out by being made to  complete its movement 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.   By this combination
 of perinaeal squeezing  and of compression of the fundus and  body of
 the uterus, I once  extricated myself and my patient from an awkward
 predicament.  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 labour, the  head on the perinaeum, and no
 pains. The lever or the forceps  would have delivered  her in a minute.
 Neither was to be had.  But the manoeuvre I have described perfectly
 succeeded, 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 pressure upon the fore-
 head. In this way it is sometimes possible to bring the face downwards,
to start the extension movement, 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 Lecture II.,
                                                            E 
50
OBSTETRIC OPERATIONS.
the force propagated through the spine will aid materially in giving the
extension movement.  This combination 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  diameters,  will tend to throw off  the
blades towards 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 fenestrae left on the scalp.   The  blades  naturally find their way
into this position if they are introduced gently.   One tendency of this
oblique  seizure is to assist the head in its  axial rotation, face sacrum-
wards, 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 bi-parietal
diameter bulge out, thus increasing the difficulty  of passing the  small
or conjugate diameter of the  pelvis.   In most cases  the objection is
theoretical  only—it is mainly based  upon experiments made on  the
dead foetus.
  Elongation or  moulding  of the head, we have  seen, is the result of
gradual  compression of  the equatorial zone.   Now the pelvis 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 under-
stood 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  longi-
tudinal diameter.  An  exception occurs in the case of  the  very flat
pelvis, in which  there  is conjugate contraction with very little pro-
jection  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 hindrance  on the part of either the
anterior or posterior valve, it is generally sufficient to use slight traction
and oscillation for  a few minutes.  As soon as the head is started by 
APPLICATION  OF  FORCEPS.
51
the forceps, the uterus takes up its work, helps the operator, and the
labour is  quickly over.
  If the uterine and perinaeal valves obstruct the passage  of the head,
a little more  time and caution  are  required.   (See  Lecture V.,
Figs. 22,  23.)
  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, and getting the  aid of gravitation, will
greatly facilitate the entry of the 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 labour.
  In the event, however, of arrest from pelvic contraction or from want
of dilatability  of  the soft  parts,  time  is a necessary 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, and if the handles of the forceps  maintain  a marked  degree
of divergence,  the question whether the forceps must not  be laid aside
for turning or perforation  will have to be  considered.
e 2 
LECTURE  V.
CAUSES  OF  ARREST  IN  FIRST  LABOURS—DISTURBED OR DIVERTED
     NERVE-FORCE — THE  UTERINE  AND  PERINEAL   VALVES--THE
     PONDING-UP OF  LIQUOR AMNII—THE  FORCEPS TO DELIVER  THE
     AFTER-COMING HEAD—THE  LONG FORCEPS  (continued)--APPLICA-
     TION  IN  OCCIPITO-POSTERIOR POSITIONS  OF  THE   HEAD--THE
     MECHANISM BY WHICH  FRONTO-ANTERIOR,  FOREHEAD, AND  FACE
     POSITIONS GENERALLY,  ARE PRODUCED—FRICTION IN LABOUR--
     THE  MANAGEMENT OF  THESE  CASES.

A very large proportion of cases that  call  for the forceps are  first
labours.  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  labours the
difficulty does not arise from disproportion.   The frequency of  an easy
second labour proves this.   The difficulty, then, lies in  the soft  parts of
the parturient canal, or in faulty position of the head.   And this  may
be  either from want  of contractile  energy   of the uterus, or  from
excessive resistance of the os uteri, vagina,  or vulva.  I will endeavour
to  explain  the nature of  these  cases.   First,  let us consider 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 labour, as Dr. Power called it. Emotion,
fear, the shrinking before pain, will frequently cause such a derivation
of nerve-force that all  labour 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 labour  is  frequently resumed and
carried out to a successful termination.   It is not a figure of speech to
say that here chloroform or ether acts like a charm.  It may even save
the necessity of resorting to instruments.
  Arrest or delay in the second stage of  labour, from whatever cause,
is a source  of danger to  the  mother  and  child.    The procrasti-
nating school insists  upon  the  dogma that we  should wait four, six,
or  more  hours from the  commencement, or  after  an   ear  is  felt 
               UTERINE  AND PERINEAL  VALVES.            53

before interfering.   This course is full of peril.  Whilst we are waiting
the woman is suffering—suffering needlessly—her nervous energy is
being used up, she is drifting into exliaustion.  Often aid is imperiously
indicated  long before the os is fully dilated or an ear can be felt.  If
there is conjugate contraction the head  cannot descend  enough  to
stretch  the cervix;  and in primiparae  the anterior or uterine valve
remains capping the head down to the very floor of the pelvis.  (See
Fig. 22.)   It  comes out very clearly from the  histories of the cases
in  the  Dublin  Lying-in Hospital, that the  maternal  mortality has
decreased  since the forceps has been  more frequently, that is,  earlier,
resorted to. Upon this point, the evidence of Dr.  Johnston, the Master,
is very  decided.   Delay in the second  stage is  eminently a case for
help as soon as it is clearly ascertained that the natural powers  are not
efficient.  It is often for want of driving-power that the head rests on
the floor  of the pelvis in a transverse position, so that a double cause
of delay arises.  This is almost instantly  relieved by the forceps.
   In no respect has modern midwifery given more satisfactory evidence
of progress than in the  extending  practice of applying the forceps  to
obviate  delay in the second  stage of labour.
   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 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 backwards
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 pluriparae  it commonly does so early. When this anterior valve
has retreated, 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 forwards  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-quarter axial turn, occiput  forwards, 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;  but as patience on
the part of the physician may involve  agony and  danger to the woman,
this should not be overstrained.  Sometimes one or two fingers may
be insinuated  between the valve and the head in the intervals of pain, 
54
OBSTETRIC OPERATIONS.
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 whilst the head
descends 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  Hquor amnii behind, and impeding the full  action  of the uterus
by over-distending it.  The lever  or forceps opens  a channel for the

                              Fig. 22.
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.

escape of  the  pent-up fluid.  The  uterus then acts immediately, and
the labour proceeds.   I have often used the forceps successfully for no
other purpose  than this.  One blade will sometimes suffice.
  Well, we have  now  disposed of the uterine valve.  The  perinaeal
valve and the vulva oppose another  barrier, all the more troublesome
because it has to be encountered by  diminished  force.  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 the head, may answer.   But the forceps is to be preferred.
  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 
THE  AFTER-COMING-  HEAD.
55
sensitive structures of the vulva, it cause  intolerable pain.   The con-
sequence 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.

                               Fig. 23.
               SHOWING THE LOWER OR PERINEAL VALVE.

a. Anus.  i. Bladder, e. Coccyx retropulsed. s p. Symphysis pubis,  u u. Uterus.
                       p v. Perinteal valve.
  Another cause of delay may, of course, reside in the mechanical con-
dition  of the resisting structures: rigidity of the cervix uteri, of the
perinaeum  or  vulva,  may be added to other unfavourable conditions.
Rigidity may be due to thickening, oedema, hypertrophy of the tissues,
or there may be rigidity without  discoverable alteration  of  texture;
and there are  the more  serious cases of  partial or complete occlusion
from cicatricial tissue, the result  of previous  injury, or from disease,
as cancer.  Obstruction  from these causes demands  special treatment,
which  will be discussed hereafter.
  Most authors  describe the application  of the forceps to the after- 
56
OBSTETRIC OPERATIONS.
coming head—that is, when the head is delayed after the birth of the
trunk in breech, footling, or  turning  labours.  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 prompti-
tude 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 recover; for within that time
the head must generally be extricated in order  to save life.   The  time
is certainly very brief.   Here it may truly be said that "horae momento
cita mors venit, aut victoria laeta."   The data are necessarily wanting in
precision.   Hugh Carmichael* in two cases removed the foetus from the
uterus within  fifteen minutes from 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 Caesarian section was
performed,  and a live  child was  extracted.   The interval was  here
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 carried  to the  Hospital.   She died at 7.55.
Mr.  Green opened the  abdomen at 8.8, and the child was withdrawn
by Dr. Blundell, asphyxiated.   Its lungs were  inflated, and it survived
thirty-four  hours. J   Here, then, we  have  an instance  of partial reco-
very at the end of thirteen minutes from the mother's death.   Dr.
Pingler relates  a case in which a live child was extracted by Caesarian
section about  fifteen minutes  after the mother's death; and another
case in which it was established that the mother had been dead twenty-
three minutes. §   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  com-
pression of the cord during labour.  Numerous 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 stoppage  of  the placental  respiration.  I think it  must be
accepted as a general law that if the head compress the cord, the  child
should be extracted within three minutes.   Even if this be done, there
will  commonly be considerable asphyxia and cerebral congestion, and
restorative  means will be required.

  * " Dublin Journal of Medicine," vol. xiv.
  t "Med.-Chir. Trans.," 1822.
  + It is worthy of remark  that in the history of this case Mr. Green especially calls
attention to  the depressing effect of the warm-bath—a point  since  enforced by
Milne-Edwards and Marshall Hall.
  §  " Monatsschr. f. Geburtsk.," 1869. 
HEAD-LAST  LABOUR.
57
  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 some cases  in which
the head comes easily 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.   But if there be
any hitch or delay the  forceps will be safer for the child.  The forceps
then is the more  scientific instrument.  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 traverses 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 forwards over  the symphysis in the direction of
Cams' curve, and held there by  an assistant, so as to leave the outlet
clear for manipulation.  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 proceeding is 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 by hooking
two fingers of the right hand over the back of the neck, on the shoulders,
whilst the left hand seizes the feet above the ankles, a napkin interposed.
You then draw in the axis of  the outlet.
  Extraction with the forceps.—(See Fig. 24, p.  58.)   You find  the
face turned towards the sacral hollow  when the head  has cleared the
brim ; the forceps, following this, rotates a little in your hands.  When
the occiput is appearing under  the pubic arch, carry the handles well
forwards,  so  as to bring the face  over the perinaeum  with  the least
possible strain  upon this structure.  The face and forehead sweep the
perinaeum, describing a curve round the occiput resting upon the pubes.
The use of the forceps  in this case was strongly inculcated 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.   The traction-force being applied to  the  head itself,  you
avoid the dangerous traction upon  the neck  incidental to delivery by
the hands pulling upon the  shoulders and trunk.  Later  experience of
myself and Fancourt Barnes with the axis-traction forceps is  decidedly
in favour of this proceeding.
  We return to  the story of the  long  forceps applied to  the head 
58                  OBSTETRIC OPERATIONS.
presenting  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 downwards—i.e., to the mother's left
thigh,—for if through inadvertence you turn the face upwards 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.

                              Fig. 24.
     ILLUSTRATES THE APPLICATION OF THE LONG FORCEPS TO THE AFTER-COMING HEAD.

  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 backwards, 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 forwards, or  an attempt made to  turn it back into the hollow
of the sacrum.
   The cause of arrest of labour,  of difficulty, when the position is
occipito-posterior, is,  I  believe, this : The  occiput has  revolved round
the lumbo-sacral or Barnes' curve, turning up under the promontory,
just as it does in normal labour around  the symphysis pubis in Carus' 
OCCIPITO-POSTERIOR POSITIONS.
59
curve.   The head thus imprisoned in the pelvis  is not able to take
its normal extension movement.  In  occipito-anterior positions, the
propelling 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 positions, 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 promontory.   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 movement  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 fore-
head is fixed, whilst 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 occipito-posterior
position is, whether we can  hope for the change,  spontaneously  or by
art, to  an occipito-anterior position ?
  Smellie accomplished this  change by the forceps.  Clarke and Burns
said the rectification could be made by the fingers.  Dr. R. U. West*
has proved  the practicability of procuring the rotation face backwards
by artificial  means.  He applied his fingers  to  the  frontal bones,
turning this  part  backwards,  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 doing it.  The  evidence of
Dr. Millar  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  laboured  assiduously  to  promote it  after the
manner recommended  by Baudelocque and Dewees.   ...   I  have
since experimentally allowed Nature  to take  her course in a con-
siderable number of such cases, and  I find that the desired mutation
is generally  accomplished  about  as  well  without  as with my
assistance."
  Dr. Leishman saysf :  " We may succeed in amending the position
in two  classes of cases.  In the first, the head  is free at the brim,
or at least has not encountered any serious  pelvic resistance ; and
                   * " Glasgow Medical Journal," 1856.
                   t "System of Midwifery," 1873. 
60
OBSTETRIC OPERATIONS.
here rotation may be effected by the forceps.  ...  In the second,
the head has reached  the  floor of the pelvis, where we have natural
rotatory forces operating in our aid ; but no attempt, while the head
is in a position intermediate between these two, is likely to be attended
with success.  ...  In  the second class of  cases  the forceps  is
quite  inapplicable.  Simple rotation  must not be attempted.  We
must employ our whole efforts in promoting the  preliminary flexion
of the head.   This is  done most  effectively by bringing  two fingers
to bear upon it, and pressing in the direction indicated during a pain.
This, in the first instance, will probably have little  effect in displacing
the forehead, but  if we can  only succeed  in  preventing its further
descent we  thus transfer  the  propulsive  force  to the occiput, and
encourage the essential movement of  flexion."   Should this fail, the
occiput may be pulled down by the vectis as R.  U. West describes.
  I  have  found that the  occiput must be brought down below the
edge of the sacro-sciatic ligament in order to  permit of the rotation
face backwards.
  It is judicious,  I think, to  make a reasonable  attempt, after the
methods of Leishman and  R. U. West, to bring the occiput down and
forwards.   But it will  be seen that Leishman's  manoeuvre postulates
a driving  force.  This  is  often wanting.   The  " pains "  commonly
flag when the head is arrested on the  floor of the pelvis.
  The leverage  may be applied  by the forceps.    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 backwards 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.  Professor Elliot,  in  his  admirable  practical work
(Obstetric Clinic, New  York, 1868), gives cases  in which  he rotated
the occiput  forwards by the forceps with success.
  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.  Indeed I  think this  occurs more frequently than Naegele
represents.   Nor does  the case call for any  amount of  force.  By
aid of  the forceps  the  delivery is  nearly as easy as when  this instru-
ment 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 position.   Extraction,
then, simply, without troubling yourselves  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 forwards
and you will feel the handles of the forceps  turn upon their axis.  But 
OCCIPITO-POSTERIOR POSITIONS.
61
in a large proportion  of  cases  Nature will not insist  upon bringing
the occiput forwards ;  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  relation, the
handles will turn with the head.   It is labour 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.
                               Fig. 25.
  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 trans-
verse diameter.  The symphysis, c, is the centre of rotation.  The vertex and occiput sweep the
perineeum, producing a movement of flexion.

  In  this latter  case there  are  two things  to  be observed: first,  the
perinaeum is put  more  upon the stretch,  and therefore requires more
care; secondly, if  the  handles of the  forceps  are carried forward
towards the mother's  abdomen too  soon, the blades will be  apt to
sHp off.  The superiority of the long forceps in saving the perinaeum
is very marked.
  The propriety of not attempting  to turn the face backwards is even 
62
OBSTETRIC OPERATIONS.
more decided in those more  marked  cases of fronto-anterior positions
in which the forehead looks  nearly directly forwards.  It appears to
me that  this position is sometimes due  to unusual  flatness  of the
promontory—a  very slight  projection  of this part.    A pronounced
projection of the promontory 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.  The connection between a particular form of pelvis and occipito-
posterior positions  seems proved by  the frequent recurrence of these
positions in the  same subjects.  Thus, I have  delivered the same lady
three times successively by forceps  on this account.
   Upon this point  I am glad to quote the  authority of Dr. Rams-
botham,—" 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 embraced 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  forwards.  In this  case the fillet or lever
seizing  the occiput would find its most scientific application.
   When the head is delivered, if the child is of large  size, there  may
still  remain considerable difficulty in extracting the shoulders and
trunk.  And during the delay the child may die of asphyxia.  The
shoulders will be lying nearly in the transverse diameter just above the
outlet, breast forwards—an unfavourable position, since the shoulders
will hitch on the ischial tuberosities.  To liberate the child it may be
necessary to rotate the shoulders so as to bring the dorsum forwards,
or at least to bring one  shoulder under the pubic  arch.  This may be
done  by a bi-polar  manoeuvre, pressing  one shoulder backward  with
one hand, and the other shoulder forward with the  other hand. As  soon
as a little movement is effected in the desired direction, uterine action,
or in its default firm compression of the  uterus to  impart  onward
movement, will complete the  necessary rotation.   The deHvery is  then
easy.   The manoeuvre is in strict accordance with  the law that dictates
the conversion of abdomino-anterior into dorso-anterior positions.
  The case is, however, more  severe if it is a complete face-presentation.
You can hardly, by aid of the forceps, so far  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 yourself
left with no alternative but to perforate.  It is very true  that a large
proportion of face-labours end happily without assistance.   It is equally
true that face-presentations supply some  of the most difficult cases in
practice. 
FACE-PRESENTATIONS.
63
   It is convenient in this place to examine how brow-presentations and
face-presentations are produced.   Dr.  Carl  Hecker  attributes  face-
presentations to an  original dolico-cephalic condition.  He supposes
that the increased power of the occipital  arm of the lever throws the
face down.   I  have taken  photographs and outline-tracings of heads
born after face and other varieties of labour, and think I am entitled to
affirm that Dr. Hecker's hypothesis is drawn from  an erroneous inter-
pretation of facts.  It is true that in face-labours the head is found
elongated; but it is easy to trace this  altered form  to the compression
undergone during labour.   There is no evidence to show that it exists
before labour.   Fig. 2, p. 25,  represents  the  common globular shape
of the head before it enters  the pelvis ;  in Fig. 28, p. 68, the head,
taken  from  a  photograph of an  actual  case, represents  the dolico-
cephalic condition produced during its compression  in  the pelvis.
   Brow-presentations may be regarded as transitional between vertex
and face-presentations ; and by analysing  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 diame-
ter or axis represents the lever ; the atlanto-occipital articulation is the
seat of the power.   Riding upon this  point, the head moves in see-saw
backwards and forwards.   A force which  is  generally unnoticed  in
obstetrics 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, whilst at the
opposite point it will advance to a greater extent;  or resistance at one
point may quite arrest the head at that point.   In either case it 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, whilst 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.   A condition  that  singularly favours this
excess of occipital  friction, and  consequent rotation in extension,  is
lateral obliquity of the  uterus.  The want of coincidence between the
axis of the uterus and child and  of the axis of the  pelvis, disturbs the
equilibrium of resistance and friction.
   Now, if we  can transpose the greatest friction or resistance to the
forehead, and  still maintain the  propelling  force,  it is  clear that the
occiput must descend, and  that the normal condition may be restored. 
64
OBSTETRIC  OPERATIONS.
In practice this  is actually done.  When at an early stage of labour
we  find  the  forehead  presenting,   we  can,  by applying  the  tips
of  two  fingers  to  it,  during  a pain,  retard  its  descent,  and  the
occiput comes down.   This  effected, the  rest  will probably  go  on
naturally,  because,  the atlanto-occipital joint  being somewhat nearer
the occipital than the  frontal  end of the lever, the shorter or occi-
pital  arm of the lever will  keep lowest.   But if there  should  still
be  excess of resistance at the occipital 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  Fig. 26.   It  is  at the
same time desirable to restore the due relations between the axis  of the

                               Fig. 26.
 THE FINGERS APPLIED TO THE FOREHEAD AT P TRANSPOSE THE GREATEST RESISTANCE TO THIS
                                 POINT.
 The force propagated from e to c will therefore drive down b, the occipital 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 applying the palm of the right hand externaUy and pressing the
occiput downwards.

uterus and the axis  of the pelvis.   This is  best done by placing the
patient on her back, and supporting the  uterus in the median line by
the hands.
   The mechanism  of face-presentation  must detain us a few minutes.
As in the case of the cranial presentation, there are four positions ;  and
these may be described as  conversions  or accidental departures  from
the respective cranial positions.  Thus, take the first  cranial position at
the  brim, in which, as we know, the  occiput is directed to the left 
FACE-PRESENTATIONS.
65
foramen ovale.  Imagine that the occiput, instead of descending into
the pelvic cavity,  hitches  against the edge of the brim, or is kept up
from some other cause, whilst, the  driving-force  continuing, the head
will  rotate  on  its  transverse axis, and the  forehead and face will
successively come  lowermost.  Thus is formed the first face-position.
The  second face-position is formed in  a precisely similar manner, the

                               Fig. 27.
SHOWS THE LONG FORCEPS APPLIED TO THE HEAD IN FACE-PRESENTATION DELAYED IN THE PELVIS.
   The curve of Carus—the dotted circle—indicates the direction of traction, restoring flexion.

forehead coming to the right foramen ovale, and the fronto-mental line
of the face lying  in the second oblique diameter of the pelvis.  The
third and  fourth face-positions  may, in like manner,  be traced to the
third  and fourth  cranial positions.   In all the  cases the  forehead
represents the occiput.   And in this position the head might very well
proceed through the pelvic cavity and outlet, following corresponding
rotations to those observed in cranial positions, if the head only had to
be transmitted.   But the child's  trunk must follow ; and it  is this
which causes the difficulty, and which compels a change.  If you look
at diagram 27,  you  will see that if the head get into the  cavity of
the pelvis,  face-presenting, the  occiput will be jammed between  the
shoulders,  which, entering the pelvis along with it,  make  a  wedge
whose  base is  too  large  for the  space.   Hence impaction,  unless
rotation is effected.   This is usually accomplished.  The chin comes
F 
66
OBSTETRIC OPERATIONS.
forward,  getting under  the  nearest pubic  ramus, as in diagram 27.
The pelvis here being shaUow, the chin emerges, and, the whole  head
rotatnig  upon its transverse axis in the curve of Carus, the occiput
quits the shoulders ; the wedge is decomposed;  the  difficulty is over-
come ;  the trunk foUows.  The sum and object of all this mechanism
is to restore  flexion.
  But the face may enter the pelvis, take its turn forwards, and  then
be arrested,  just as the  head in cranial presentation may be arrested.
In such  a  case the forceps  may be useful.   The  application is as
follows.  Assume that it is the first face-position ; remember that the
object to be  accompHshed 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 obhquity in relation to the pelvis.  The  first or  sacral blade, there-
fore, must pass up the left  side of the  pelvis,  somewhere between the
sacro-iHac joint and the left extremity of the transverse diameter.  The
second or pubic blade wiU pass in the opposite point of the pelvis, that
is, between the foramen ovale and the right extremity of the transverse
diameter.  When locked, traction is at  first directed downwards, to get
the chin fairly under the pubic  arch.  Then the traction is  directed
gradually more and more forwards and upwards, 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
weU forwards, so  that  the shanks are out of the way; but not too
soon,  lest the blades slip  off.  Extract gently.
   But  we shall  not always be  so fortunate even as this.   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 Hkely to seize beyond the jaw and compress the
neck, bruising the  trachea.   If the attempt be made to seize the head
by applying the  blades in the obHque  diameter,  they must be passed
very high,  and even then may slip.  If firmly grasped 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, extraction may  have  to be completed by perforation.
Turning can be  effected with infinitely less trouble,  and with a better
prospect for the child.
   In the second order of cases, the face has descended into the cavity.
The birth of a full-grown Hving or recently dead child, with  the fore-
head maintaining  its direction forwards,   is almost impossible.   The
extension of the neck is extreme, the  head being doubled  back  upon
the nucha.   The  chin  represents the  apex of a wedge, a b c, the base 
FACE-PRESENTATIONS.
67
of which is formed by the forehead, the entire length of the head, and the
thickness of the neck and chest (see Fig. 28, p. 68).  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.   Compres-
sion,  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 forwards 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, restoring flexion,
and so to bring the cranium down ?  This may be accompHshed whilst
the head is  above the  brim, but scarcely when it is squeezed into the
cavity.
   2.  Can the turn of the chin forwards  be  effected by the  hand, the
lever, or  the  forceps ?  This is  sometimes possible, and  should be
tried.  It is thus described by  SmelHe : " 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  afterwards brought  down  to the
inferior part of the last-mentioned bone.  This done, the operator must
pull  the forceps with  one  hand, whilst 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 wiU easily be extracted."
   3.  Can the head be brought down by the forceps  without turning
 the chin forwards ? This is a practice against Nature.  If  the forceps
 grasp, and it will  generaUy sHp,  it will bring more of the  base of the
 wedge into the brim.   The head  must be smaU, or the pelvis large,
 to admit of success by this mode.
   1. 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  forwards 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  perinaeum  by drawing the  chin
 forwards by forceps, and pulling the perinaeum backwards (see Fig. 28).
 The chin thus outside, the forceps or lever  may be applied to draw the
 occiput down under the pubes and  backwards, so as to make the head
 revolve  on its transverse  axis,  thus restoring  flexion.   You  are in
 fact  decomposing the base of the wedge.  You deliver by a  process the
                                                           f 2 
68
OBSTETRIC  OPERATIONS.
reverse  of that of  ordinary occipito-anterior  labour.   In  this, the
occiput  escapes by  a process  of extension.   In the mento-sacral
position you deliver by promoting  flexion.   The perinaeal or Aveling's
curve is here the analogue of Cams' curve.   Or, to take our illustration
from the mechanism of face-labour, you obtain flexion by causing the

                                  Fig. 28.
  AN EXTREME CASE OF FACE-PRESENTATION IN WHICH THE ROTATION CHIN-FORWARDS WILL NOT
                                 TAKE PLACE.
  The face, much swollen by pressure, is near vulva ;  the cranium, although flattened on vertex,
cannot descend, because the occiput, rolled back upon the nucha between the shoulders, forms,
with the thickness of the chest, the base of a wedge abc much longer than the conjugate or
oblique diameters of the pelvis. If traction in the axis of the outlet be made by forceps, this will
only increase the stretching of the neck, and  jam the head and chest more strongly in the brim.
It will be seen that, if the head can be grasped by the forceps, and drawn down in Aveling's curve
d e round the coccyx as a centre,  the chin riding over the perinaeum, the wedge abc will be
decomposed, and flexion being restored, the head may be delivered.

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. 
LECTURE  VI.
THE FORCEPS  IN DISPROPORTION  OF THE PELVIS :  DEGREES OF DIS-
     PROPORTION :  INDICATIONS IN  PRACTICE--THE  MECHANISM  OF
     LABOUR IN  CONTRACTION  FROM PROJECTING  PROMONTORY :  THE
     CURVE OF THE  FALSE  PROMONTORY--DEBATABLE  TERRITORY ON
     THE   CONFINES  OF  THE  SEVERAL  OPERATIONS -- PENDULOUS
     ABDOMEN : THE CAUSE  OF DIFFICULTY  IN  PENDULOUS ABDOMEN :
     SUSPENDED  LABOUR ; THE MODE OF MANAGEMENT.

Now we have to  consider what the forceps can do in  cases of dispro-
portion ; 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  compressibility of  the head  under the  forceps, and  the com-
parison of the  advantages of the  forceps with those of turning.   The
degrees of contraction of the brim may be classified approximately in
the following manner :—
 Scheme of Relations of Pelvic Contractions to Modes  of  Delivery at
              Term ;  Child's Head  assumed to be Normal.
     Conjugate diameter        Operations at term.      Operations at seven months.
        reduced to
    4 to 4*25 in.  may end in natural labour
    4 to 375 in.    ,,    ,,   forceps or turning    .  Natural labour
    3 75 to 3*50 in.  ,,    ,,   turning   .    .    .  Forceps
    3-50 to 2-25 in.  ,,    ,,   craniotomy.    .    .  Turning
    „ „- *.  ,  -- •          f craniotomy doubtful, 1  n   ■ .
    2-25 to lv5 m.  ,,    ,, \        .J   A.  ' Y  Craniotomy
                        I   Caesarian section  J
                                             Caesarian section eliminated

  Taking the same measurements  in labour at seven  months, by sliding
down the scale of operations,  we find that natural labour  takes  the
place of forceps,  forceps of turning,  turning of craniotomy, craniotomy
of Caesarian section ; and thus the  Caesarian section  is  eliminated.
  In this table there is seen  some  overlapping in the  application of the
various operations.    It  is  obviously  impossible  to construct  rigid,
absolute rules.   Other factors  besides  that  of  mere pelvic narrowing
commonly enter  into the case, amongst which  are the  skill of  the
operator and the quality of his instruments. 
70
OBSTETRIC  OPERATIONS.
   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 labour.  Now, this is a gradual, even a slow process.  The
head is seized by  the  long forceps in the  way already described.  The
handles are firmly grasped with both hands, and especial care is required
to extract well backwards in the axis of  the  brim, so as to make the
head revolve round and under  the projecting,  overhanging promontory

                                Fig. 29.
NORMAL PELVIS.
  s, the symphysis pubis, the centre of Carus' 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' curve, at once.

as a centre.  Here I may pause to show that, in labour 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
possesses 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 Carus  described, has its counterpart in a curve round
the promontory.*  In  ordinary labour, with  a well-constructed pelvis,

  * In Barnes' "Obstetric  Medicine and Surgery" the importance of  this curve in
natural labour is demonstrated.  It is there called " Barnes' curve."  The projecting
promontory in the  contracted pelvis exaggerates this curve, and becomes what in
former editions of this work I called the "curve of the  false promontory." This name
is retained here. 
CURVE  OF FALSE  PROMONTORY.
71
the  head  enters the  pelvis,  describing only the  gentle lumbo-sacral
curve.   It thus quickly enters the  orbit  of Carus' curve.
  But  a  projecting promontory,  involving, as  it  commonly does,  a
scooped-out sacrum below, disturbs this course.   The  promontory must
be doubled.  The. head must move  round  this, the curve of the false
promontory, before  it  can strike  into Carus' curve.

                                 Fig.  30.
      PELVIS CONTRACTED BY RICKETS TO SHOW THE CURVE OF THE FALSE PROMONTORY.

  s, the symphysis, the centre of Carus' curve c d ; f p, the false promontory, the centre of the false
curve e o ; o, 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 head is thrown over the pubic symphysis by the projecting promon-
tory. The forceps draw backwards in the line a h to bring the head under the promontory in the
orbit of the false promontory before it can enter at g the true or Carus' orbit c d.
  This diagram should be contrasted with Fig. 29.  It weU be seen how remarkably the axis of the
pelvic brim a h, is altered in relation to the datum-line a b. It is brought nearer to the horizon,
forming a more acute angle. It thus throws the uterus more forwards, and becomes the chief
cause of the pendulous belly, so marked a feature in cases of contracted pelvis.


   This curve  of the false promontory is the chart by which to steer in

turning on account  of contracted pelvis.   Bearing  this in mind, and

assuming that the head is seized nearly in  its transverse diameter, the

blade  corresponding to the  anterior or  pubic side  of the head  must

describe a large circle, whilst the sacral side of the head, and  the blade

in  relation with it,  move 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'  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 
72
OBSTETRIC  OPERATIONS.
the forceps, and sudden  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 labour.
   It happens, however, in these cases of contracted conjugate diameter,
that the head commonly presents at the  brim with its long diameter
very  nearly,  if  not  quite,  in  correspondence  with  the  transverse
diameter of the pelvis.   The blades of the forceps, also finding most
room in this diameter, will grasp the head in its longitudinal diameter.
In extraction, therefore, both blades will move equally around the false

                               Fig. 31.
  a b, datum-line ; c d, Carus' curve; e f, curve of the false promontory ; f p, false promontory;
g, point of intersection of the two curves where the head passes from the false to the true orbit.
The forceps now draws the head in the direction of the outlet in Carus' curve.

promontory,  so that when the head  has doubled the promontory, and
entered the  cavity, it  will  be useful  to remove  the forceps, and  to
readjust the blades on the sides of the head, should traction-force still
be necessary.
  What  is the extreme  degree  of narrowing  that will admit  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 
PENDULOUS UTERUS.                    73
as we cannot know with sufficient precision what the properties of the
head still above the  brim are, we are justified in making 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 between the head and the pelvis, compels us to leave a range
or border-land of debatable territory between the more  clearly recog-
nized or conventional limits assigned to the several operations.   This
debatable territory is further liable to invasion from either side, accord-
ing  to  the  relative skill with which  the  competing  operations are
carried  out.   And herein lies the source of the great controversies in
obstetric practice.  Thus one operator, possessing a good long forceps,
and confident in his skill in handling it, will use this instrument with
success where  the  contraction is  three  and a quarter inches, whilst
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 unfortun-
ately 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.
  There is a condition causing dystocia called the pendulous abdomen.
It is most frequent—First, in women  who have borne  many children,
and in whom the abdominal walls are much relaxed.  Secondly, where
the pelvis is contracted.   Thirdly, when there is separation of the recti
muscles, constituting hernia of the gravid uterus.  When it exists, the
uterus, hanging down in front of  the  pubes, is out of the axis of the
brim, and, if it contracted,  would only direct the child over the brim,
backwards 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 upwards and backwards.  This will
restore  the  relation between the axis of the uterus and  that of the
pelvic  brim.  But  if contractile  energy  be  still insufficient, the long
forceps  will come  into 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 forwards, but swags downwards to
the  dependent side, constituting  a further  deviation,  and increasing
the obstacle to parturition.
  How to determine the choice between forceps and turning ?  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 
74
OBSTETRIC OPERATIONS.
the blades:  here  turning may be preferable.   I have several times
rescued a living child by turning under  these circumstances.
  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  one blade of the
forceps.  Having accomplished this, the  uterus,  under  the combined
advantages of restoration 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.

                              Fig. 32.
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' curve.

  In the diagrams (Figs.  32, 33), the mechanism of labour obstructed
by this form of malposition of the uterus is illustrated.
  Until the uterus is  brought back to its normal position, it is clear
that two causes concur to render  labour  difficult.  First,  the uterus
being thrown forwards, its fundus is carried away from the diaphragm
and upper  part of  the abdominal  walls.   It loses, therefore, the  aid
which  the  expiratory  muscles, acting powerfully when the glottis is
closed and 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 labour, the uterus remaining  quite  passive.
When  the  uterus is  thrown  forwards across  the pubes, any force 
PENDULOUS  UTERUS.
75
propagated  downwards  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  contents down  upon  the  symphysis, or even  more forwards  still,
shice the body of the child, which lies in front of the symphysis, forms
the longer arm of a lever,  and the force is expended upon it.
  Secondly,  the uterus  itself, if not paralysed, acts in a  wrong direc-
tion.   It loses the  stimulus to  action which the normal  pressure and
support of the diaphragm and  abdominal  walls supply, and  therefore
                               Fig.  33.
              SHOWING THE MECHANISM OF LABOUR IN PENDULOUS BELLY.
  a b, datum-line determining position of the pelvis; c d, Carus' curve; h i, axis of uterus and of
child directed towards the promontory; f a, line of force of expiratory muscles cutting the axis of
the uterus and of child; a e, normal axis of pelvis; u u', the umbilicus.

acts  languidly.  Its independent  power is also weakened by another
circumstance.   It is a law, of which the patient observer will not fail
to discover  many  proofs  in the  progress of  difficult labour,  that,
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 
76
OBSTETRIC OPERATIONS.
can  act with  advantage.   This provision  protects, for a long time,
against exhaustion from protracted labour.   Indeed, what appears to
be protracted labour is often simply suspended labour.
  The remedy is obviously to restore the uterus to its normal position.
In Fig.  33,  the uterus and child  are  represented lying across  the
symphysis pubis, like a sack across a  saddle, " Vuterus en besace."
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 behind and 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
outline, 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.
  In the case of pendulous belly from  contracted pelvic  brim,  the
restoration of the axis of the uterus  to its proper relation with  that of
the  pelvis  can rarely be  effected  until the  head is brought into  the
pelvic cavity ;  and this has  to  be  done after  craniotomy.   Then  the
dorsal decubitus, and upward support of the  abdomen and uterus, come
in effectively. 
LECTURE   VII.
DYSTOCIA FROM FAULTY  CONDITION  OF  THE SOFT PAETS—CONTRAC-
     TION OF THE  CERVIX  UTERI--RIGIDITY--SPASM--DEVIATION--
     HYPERTROPHY--CICATRIX--CLOSURE --CEDEMA--THROMBUS--
     CANCER--FIBROID TUMOURS--THE  NATURAL FORCES THAT DILATE
     THE  CERVIX--THE  ARTIFICIAL DILATING  AGENTS--THE  HYDRO-
     STATIC DILATOR—AGENTS WHICH MODERATE  UTERINE ACTION OR
     RESISTANCE--CHLOROFORM--CHLORAL--OPIUM--NITRITE OF AMYL
     --PHYSOSTIGMA--TARTAR  EMETIC--BLEEDING--VAGINAL  IRRIGA-
     TION--ERGOT--DILATATION BY HAND : BY  WATER-PRESSURE :  BY
     INCISION--RESISTANCE OFFERED  BY THE  VAGINA, VULVA, AND
     PERINEUM.

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, however, makes  it  convenient  to
discuss the question in  this place.
   The cervix uteri, the vagina, or the vulva, including the perineum,
may refuse to yield a passage to the child, and  to permit the applica-
tion 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 contraction.  2. Thickening from oedema.  3. The cervix may
have an abnormal direction and  position.  The cervix is not  in  the
fine  of the  axis of extrusion.  Perhaps it is  bent  down at  a more
or less acute angle upon the body. A more frequent condition is  the
pointing of the os  uteri backwards towards the promontory, and very
high up, so  that it is difficult  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, 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 
78
OBSTETRIC OPERATIONS.
cervix rends.  4. From contraction of the brim, or from the presenta-
tion of some part of the child—as the arm, face, or feet—not  adapted
to descend  easily and  fairly upon  the cervix,  there  is  insufficient
dilatation.   5.  The cervix may  be  organically diseased.   The most
marked  causes of this kind are hypertrophy, occlusion from  false
membrane, described  by Naegele, fibroid tumour, or cancer.   In one
case  to  which  I  was called, although the lips of the os could be
distinguished, a thick membrane was continuous with  the  circum-
ference of the os, completely occluding it.   In this case  I arrived at
the opinion that  the  occluding membrane was formed by amnion and
chorion, which had become closely adherent to the lower zone of the
uterus.   6.  In  another case,  that   of  a Maternity  patient  of St.
Thomas's,  the os was completely  closed by cicatricial  tissue  con-
tracting concentrically.   Severe labour-pains  had no effect in opening
it. The pulse rose to  120.  I pushed a hernia-knife through the centre,
and  nicked freely all round.  The  cervix expanded  with wonderful
rapidity as soon  as the  unhealthy tissue was divided.   Mother  and
child did well.
   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 cervix  must be  treated as one that is rigid or other-
wise diseased.   It obstructs labour, 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 present-
ing part of the child cannot come  down  upon it.  But if the mem-
branes  are ruptured 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 contraction.
   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 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 towards the
 fundus, thus draw it open.   No doubt this is an important factor ; but
 it is ineffectual alone.
   It is a matter of observation that the os uteri does not expand in any
 marked degree until either  the  bag of membranes 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 
RESISTANCE  OF  CERVIX.
79
propelled by the contractions of the uterus and the abdominal muscles.
Under this distending force, the circular fibres of the cervix yield, just
as the sphincter ani or the sphincter vesicae 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.  Sometimes the normal harmony between this preponderance
and the 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 frequently arises from  an  inversion in
time, in the order of  succession 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 irregular 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 congested 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 fcetus driven into it, is found in the
equivalent action  of my hydrostatic cervical dilator.  This instrument
is inserted in a collapsed state within the cervix, and  then gradually
distended with water,  as seen in  Fig.  34, p.  82.   This very nearly
represents the normal action of the  liquor amnii distending  the  sac
of the  minion.   Under this  pressure, the cervix yields  smoothly and
gradually, just as in natural labour; 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 labour, completely within
the control of skill.
   How shall we  restore the due  relation between  the expulsive 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  prin-
cipal ways.  We  may increase  the power of the body of the uterus,
 so as to  restore its  preponderance 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
between these two courses.  Before deciding in favour 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 administer.   To  give ergot, for example, when the frame 
80                  OBSTETRIC OPERATIONS.
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
favourable  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  indication is to  soothe, to subdue nervous
irritability.  Belladonna in the form of extract has been smeared upon
the part.  One sees the action of this  drug in expanding the  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 expedient  for  passing time.
  Chloroform  is often of  signal  service.    It acts  by annulling the
sense of pain and the fear of pain, and by restoring  the equilibrium
of the nervous  system  by removing disturbing 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 labour proceeds.
  A remedy sometimes of equal value to chloroform is opium.  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 harmony of the distribution of nerve-force ; and if
not in itself sufficient, it will aid in the carrying out of other measures.
  Chloral is  sometimes superior to opium.  It produces  unconscious-
ness,  without  stopping uterine contraction.   It is especially useful in
the first  stage of labour.
  Tartar  emetic in small doses  to provoke nausea has been recom-
mended.   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.  It certain  cases, as of  con-
vulsions,  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 labour.  Nor can bleeding be depended upon, as  may be frequently
seen, in cases  of placenta  praevia, where  even flooding ad deliquium
will  sometimes 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 labour into it  must often be insurmountable.
  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  induction  of labour.  And  it is  obviously 
RESISTANCE  OF  CERVIX.
81
 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  labour that  has begun.   In many cases this irrigation 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  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 minutes at a time, and repeated after an equal interval.
   To accelerate labour-pains, Valenta (Wien. Med. Presse, 1870) extols
 the plan of placing an  elastic bougie in the uterus,  without rupturing
 the membranes,—another application of the labour-provoking agents to
 the task of accelerating labour.
   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.  You have evoked a  power  which you cannot
 control.   Ergotism, like strychnism,  will run its course.  If it act too
 long or too intensely, you cannot help it. You may try "epichontocics,"
 as chloral or nitrite of amyl, or possibly physostigma.  But  these may
 fail.  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 be not  quickly born!  I very  much prefer  to  use 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 gradually pushed forward 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  it is
 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 already  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 appli-
 cation is limited;  and, I think, what is called manual dilatation 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
                                                             G 
82
OBSTETRIC OPERATIONS.
such a case, the steady onward pressure of the hand-wedge, aided by
chloroform,  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 introduction 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,  lubricate it with vaseline  or soap, then pass it

                              Fig. 34.
 THIS FIGURE SHOWS THE HYDROSTATIC DILATOR DISTENDED IN SITU WITHIN THE CERVIX UTERI.

into the cervix, guided by the forefinger of the left hand, which is kept
on the os uteri; or sometimes it  is easier to roll  up the bag, and to
seize it by a long speculum-forceps.  When  the bag is passed so far
that the narrow or middle part is fairly embraced by the cervical ring,
withdraw the sound or forceps, keeping  the guiding finger on the os to
insure the preservation  of  the bag in situ.   Then 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 distend  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 
INCISION OF THE  UTERUS.
83
capable of giving, remove it, and introduce No. 3, which is  larger and
more powerful.  The dilatation No. 3 will give is commonly 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  the 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 the child does not bear upon it.   But in certain
cases  where  there is rigidity from  alteration  of tissue,  as  oedema,
hypertrophy, 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,  Velpeau, Hohl, Scanzoni,
indeed all  the  most  eminent Continental  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 :  exliaustion,
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 Caesarian section to  give birth to a
child which cannot be delivered by the natural passages.  Indeed, it
would be far more absurd, for the Caesarian section is a most dangerous
operation, whilst vaginal hysterotomy of the kind under discussion is
comparatively  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 subsequently closed by a false
membrane or by cicatricial contraction.   You will rarely fail to feel  a
nipple  or depression where the os ought to be.   It is generally very
high up  and far backwards, 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  lecture.  This is long and straight, probe-blunted at the end,
having a  cutting edge of about three-quarters of an inch near the end.
                                                           G 2 
84
OBSTETRIC OPERATIONS.
The forefinger of the left hand is kept on or in the os uteri, as a guide.
(See Fig. 35.)  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 considerable ;  and the effect  in allaying
spasm  is remarkable.  It matters not  much at  what points  of the
circumference of the  os these nicks  are made ; perhaps the  two sides
are to be preferred.
THIS FIGURE SHOWS THE OPERATION OF DILATING THE RIGID OR HYPERTROPHIED CERVIX UTERI BY
                               INCISION.
  Before extending or repeating these incisions, it is proper to observe
the effect of  uterine  action  in continuing  the dilatation.   And if
nothing is gained in  this way, introduce the hydrostatic  dilator ; dis-
tend this gently, carefully testing its  action by the  finger.  This  plan
of combining the water-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.
  When the forceps will pass—and it is quite possible to apply it when
the os will allow the three fingers to pass as far  as  the  knuckles—this 
OBSTRUCTION OF THE  VULVA.               85
instrument may serve to dilate further.  The head being 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 the head to pass, and thus to save the child's
life.   But this must be done with great caution, and not be persevered
in unless  the  cervix yield readily.   If this resist long, the continuous
pressure upon the child's head is very likely to prove fatal.   Moreover,
this  mode of dilating  the  cervix  is not  free from  danger  to the
mother.
   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 mischief.  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 consequence 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 labour. Atresia
from cicatrices presents a more formidable obstacle.  I have found the
passage constricted  by dense  cartilaginous  tissue, so as  to permit no
more than a  probe to  pass.   In such a  case,  a careful process of
incisions,  multiplied in all points of the circumference, alternating with
water-pressure, is necessary ; and it is, after all, probable that you will
have to meet the difficulty half-way  by perforating the head.
   Lastly,  obstruction may  occur  at  the  vulva and perinaeum.   In
primiparae, especially, the vulva may form  a small  rigid oblong ring
scarcely permitting the scalp  of the presenting 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, the perinaeum 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 not yield, something else must.   The uterus will cease
to act;  or, struggling in vain, it may burst itself or the vagina.   These
dangers you may avoid by incisions.   The forefinger is passed between
the head and the edge of the vulva, and two or  three small nicks are
made on  either side, nearer to the posterior commissure than to the
anterior.   The relief sometimes gained in this  way  is  surprising.
Spasm,  irritation, pain  subside ; the vulva  dilates, and labour is soon
happily  at an end.  The  bleeding is insignificant;  and the minute
wounds  left when the parts have contracted quickly heal.   How labour
may be  obstructed  successively by the first  or  uterine  valve,  and
secondly, by the perinaeal valve, is  illustrated by reference to Figs. 22,
28, pp. 54, 55, Lecture  V. 
86
OBSTETRIC OPERATIONS.
  Sometimes  the  vulva,  including  the  labia  majora,  is  so greatly
swollen by serous infiltration, as to offer  a serious obstacle to labour.
This condition is commonly associated with albuminuria and convul-
sions.   And out of this association contending difficulties arise.   The
convulsions  urge to the acceleration of labour;  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 labour, 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  sub-mucous infiltration of blood—the
so-called thrombus.  I have  seen a large tumour formed in this  way
on the os uteri; but the more common seat is  the labia of the vulva.
If the obstacle be so great that the head, in passing, threatens to burst
and rend the tumour, it is better to open it with a 4ancet.   As soon as
the child  is born, the part should be carefully examined to see  if it
bleeds; and pressure upon it by compresses soaked  in perchloride of
iron should be applied.   The nature and treatment of thrombus will be
further  discussed under " Haemorrhage."
  In cases of formidable obstacle  from cancerous or fibrous growth,
recourse to the ultima ratio—the Caesarian section—may be indicated. 
LECTURE  VIII.
TURNING--DEFINITION — THE CONDITIONS  WHICH  DETERMINE  THE
    NORMAL POSITION OF FCETUS—PROPERTIES OF THE FCETUS, LIVING
    AND  DEAD—CAUSES OF  MALPOSITION—FREQUENCY  OF  CHANGE
    OF POSITION  OF FCETUS  IN UTERO—THE  POWERS OF NATURE IN
    DEALING   WITH   UNFAVOURABLE POSITIONS  OF  THE CHILD —
    DENMAN'S ACCOUNT  OF  THE  SPONTANEOUS  EVOLUTION  OF THE
    CHILD—THE  MECHANISM OF  HEAD  LABOUR, THE TYPE OF THAT
    OF LABOUR WITH SHOULDER-PRESENTATION.

                              Turning.

If  we were restricted  to  one operation in  midwifery  as our  sole
resource, I think the choice must fall upon turning.   Probably no other
operation  is  capable of extricating patient  and practitioner  from so
many  and so  various difficulties.   In almost every kind of difficult
labour 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 exaggerate 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 fcetus in utero depends ;  the various modes
by  which the  fcetus may be made  to  change its position ;  and the
applications of this knowledge to the practice  of turning,  embodying
the teaching  of  Wigand, D'Outrepont, Radford,  Simpson,  Esterle,
Lazzati,  Braxton  Hicks, myself, and others.
  Having regard to the various allied operations which it is convenient 
88
OBSTETRIC OPERATIONS.
to class under  a general description, I  would  define  Turning  as
including all  those proceedings  by which  the position of the child is
changed in order to produce one more favourable  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 fcetus in utero ?
  2. What 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  unfavourable  positions of the fcetus ?
1.—The  Conditions that determine the Normal Position of the Fcetus
                             in  Utero.

  It would be idle to do more  than glance  at the  fanciful  ideas upon
this  subject that have obtained currency at various 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  fcetus made its way
into the world by its own independent exertions.   Dubois endeavoured
in a long  argument to  show that  the  fcetus  has instinctive power,
which  determines it  to take the head-position.    Simpson,  rightly
concluding that the maintenance of normal position  depends  very
much upon the life of the fcetus, observes that it  has no power of
motion except muscular motion, and infers that  the fcetus 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 physiological doctrines.   First, the fcetus 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  am  disposed to  estimate at a still
lower point the influence of the fcetus as an active agent in maintaining
its position during pregnancy or labour.  It is incontrovertibly true
that the normal position of  the foetus  and the course of labour are
intimately  dependent  upon  the life  of the  fcetus.  But I think I am
enabled to affirm from very close  observation that the foetus, if full-
grown and only recently dead—that is, for a few hours—may be nearly
as well able to maintain its  position,  and to  conduce to a healthy
labour, 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 fcetus.  Whilst 
PROPERTIES  OF  THE CHILD.
89
alive, or only  recently dead, the spine is firmly supported in a slight
curve, the limbs are flexed  upon the trunk, the whole fcetus 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  contact with the opposite
point of the uterus ;  head  and breech  will move  simultaneously in
opposite  directions.  In labour, 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 furthest from  the  direct force,  is pushed along
hi the direction of least resistance, turning  at those  points  where it
receives the  guiding impact of the walls of  the canal.
  When the fcetus 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, it
is very imperfectly  so; the  long axis  bends,  doubles up 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 towards  the  opposite side of the uterus. And  if labour 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
pelvis.  The head—the cervical spine having  lost its  resiliency—will
not take the  rotation and extension turns.  It  will run into the pelvis
like plaster into a mould.  Or, at an earlier 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  present-
ations.  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.  A dead child  is so efficient a cause of
dystocia that it may even lead to rupture of the  uterus.*
  Another property of the dead child which it is useful to bear in mind,
is its extreme  ductility.  If any degree of decomposition have taken
place, it easily  elongates under traction,  and may  be drawn through a
very narrow  pelvis.
  Still another property to remember is fragility.  According to the
degree of change the  body has undergone,  will  be the  facility with
which its parts give way and separate  under traction.  Thus, the head
being arrested on the brim,  and traction-force applied to the trunk, the
  * See ''A Memoir on Pelvic Hematocele,"  by the Author, in "St. Thomas's
Hospital Reports," 1870. 
90
OBSTETRIC OPERATIONS.
amount of force required to separate  trunk from  head is  much less in
the dead child than in the living.
  Other factors  besides the  child have to be considered.  Scanzoni
correctly observes that the frequency of head-presentation is dependent
on the operation of various cases.  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 contractions of the uterus
during pregnancy and the first stage of labour ; 6. The coincidence of
the uterine and pelvic axes.  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  pregnancy the fcetus
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 fcetus—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 fcetus has become
too long to find room for its long diameter in the transverse diameter of
the uterus.   Mutual adaptation requires  that the long  diameters of
fcetus 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-pregnant uterus, the  cavity of  the  body—the true and  only
gestation-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 anterior superficies lies  flat  against  the posterior
superficies, touching it  as  if the two were squeezed together.   When
pregnancy supervenes, these  surfaces are  necessarily separated 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
backwards than from side to side.  This is proved by direct observation
if the fingers are introduced  after abortion, or the hand after labour 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 fcetus takes a position with either its back or belly directed forwards.
The fcetus 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 physiological design that dictates the downward
position of the head.  The fundus is  the part designed for  the implanta-
tion of the  placenta, where  it can  grow  undisturbed, and continue its
function during the expulsion  of the  child.  The  lower part of the 
           FORCES THAT  CHANGE CHILD'S  POSITION.         91

cavity is therefore left  free for the development of the embryo.  Why
the back is commonly  directed forwards  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 moveable,
it  is its back that recedes, turning forwards.
   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 favours  malposition.   The
principal disturbing conditions  may be stated as follows:—An excess of
liquor amnii acts in two ways :  first, it favours increased mobility of
the fcetus ;  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 fcetus
is no longer kept in a vertical position,  for want of  the proper relation
between its form and size and those of the  uterus.
   Obliquity of the uterus was considered by Deventer  to  be  a main
cause of malposition.  It   is  now very  much  discredited,  but  I
am disposed  to  believe that  it has,  not seldom, a real  influence.
Dubois  and Pajot showed that in one hundred women the uterus in
seventy-six exhibited a marked lateral obliquity to the right, in four to
the left, and in twenty an anterior obliquity.  Wigand had shown that
deviations of the uterus to the right and forwards  were far the most
frequent.   The normal direction  of the non-pregnant uterus is nearly
that of the axis of the  pelvic  brim.   As the uterus  grows  during
pregnancy, rising above the brim, the  projecting lumbo-sacral 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 forwards.  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
fcetus to present.  The probability  of  this will be increased  by the
irregular contractions of the uterus  likely to be excited 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 further off
the brim on to the edge, where, if it find a point cVajypui, it will rotate
on its  transverse axis,  producing forehead or face-presentation,  and
favouring the  descent of the  shoulder.   Wigand  explains  how a too 
92
OBSTETRIC OPERATIONS.
loose and shifting relation of the uterus to the pelvis disposes to cross-
birth.  In this condition it  is observed that the head is found now in
one place, now in another, and now not felt at all.
   He further * says that any obliquity of the uterus exceeding an angle
of 25° is unfavourable ;  and that even a lesser obliquity, with excess of
liquor amnii or a small  child, is likely to cause the presenting head to
be displaced, and to bring a shoulder into the  brim, especially if strong
pains or bearing-down efforts be made early in labour.
   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 direction, thus  putting in
practice  the principle of acting  simultaneously upon the two poles of
the uterus.
   Deformity  of  the pelvis  or  lumbar  vertebra  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  malposition than  extreme degrees.   In these latter, mal-
positions are rarely observed.  In marked deformity, the head cannot
enter the pelvic  brim,  but  floats free above  it, and therefore is  not
influenced by hitching on the edge.
   The attachment of the placenta to the lower  segment of the uterus is,
as Levret has clearly  shown,  a cause of malposition, 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-presentation in cases of partial placenta  praevia.  But  there  are
numerous cases  in  which  the placenta dips into  the lower  zone,
growing  downwards from the posterior and lateral walls of the uterus,
without leading to haemorrhage,  and thus not  suspected to be cases of
placenta praevia, which,  nevertheless, form an  inclined plane behind or
on one  side, and  produce malposition.
  Then there is the influence of external  forces, as of pressure 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 movements 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 fcetus an
oblique position, throwing the head out of the pelvic axis.  Pluriparae
should do the reverse of this.   They  should  wear an abdominal belt,
which supports  the fundus  of the  uterus from below  upwards.
  Want  of  tone in the  uterus, which implies inability  to preserve its
elliptical form, and a tendency to  fall into rotundity,  a form which
         *  "Die Geburt des Menschen," Berlin, 1820, vol. ii. p. 137. 
           FORCES  THAT  CHANGE CHILD'S  POSITION.        93

evidently favours malposition.   Scanzoni says laxity of uterus is a chief
cause.   As soon as contraction begins, the uterus tends to resume its
ovoid form.
  Excess of liquor amnii is an efficient factor : first, by impairing the
tone of the uterus ; secondly, by giving it  a spherical form ;  thirdly,
by  permitting  the  fcetus to  float  too  freely.    A very  slight force
applied to  either pole will  cause the head to deviate from the axis of
the brim ;  and if,  at such a moment, the membranes burst, the fcetus
may be fixed in its unfavourable position  by the contracting uterus.
  Hcening (Scanzoni1 s  Beitrdge,  1870)  calls special attention to  the
development  of the  foetus in the later  months as a factor.   A large
foetus cannot so easily change position.  The cranial presentations have
the greatest stability.  A 1st cranial changes to a 2nd, and vice versa,
but the cranial rarely changes to a breech.   Cranial  and breech pre-
sentations  are  most stable in primiparae;  oblique presentations  in
pluriparae.
  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.   Heyerdahl says contractions of the
uterus are a chief factor, and  these are often caused by palpations.
This,  no doubt,  accounts  for a large proportion of  the changes of
position encountered by the too industrious  German observers.  They
produced the changes  they observed.
  Crede, Hecker,  Valenta,* Gassner, Heyerdahl, Schultze, have made
repeated observations, and found change of position even more  frequent
than  did other observers.   They establish  the fact  that the foetus
changes its  position with  remarkable frequency.   Valenta examined
363 multiparas and 325 primiparae in the latter months of pregnancy.
He found that  a change of position took place in 42 per cent.    Change
was more  frequent  in  multiparae, 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 proposition.    It is interesting to observe that the
general tendency  of changes of position is towards those which are
most propitious.  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 external manipulations.   Valenta 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 his fingers
as suddenly  as possible towards the cavity of the uterus, against the
                  * "Monatsschr. f. Geburtsk.," 1866. 
94
OBSTETRIC OPERATIONS.
 part of  the  child  lying  at the  fundus.   By  this manoeuvre he  has
 always succeeded in recognizing the head, if lying at the fundus, by its
 peculiar  hardness and evenness.   He detects the head in oblique  and
 cross-positions in the same manner.  P. Miiller* relates a case in which,
 within five days,  a complete  version  of the  fcetus  was effected six
 times.
   Esterle 1 gives abundant evidence to the same effect.
   Yet  the fact of the " spontaneous evolution " of a living child, as
 described by Denman from actual observation,  has been doubted !
   We have now to  study—


 3.—The  Powers of  Nature, or rather the Methods employed by Nature,
         in dealing with unfavourable 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
 approaches coincidence with the axis of the pelvic brim.   With  some
 additional  difficulty,  Nature  is in most of these  cases  able to  effect
 delivery without 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 sceptics,
 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 rigorously 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 scepticism to an
 irrational degree.   There  are  subjects,  and  this is one, which are not
 questions of opinion, but of evidence.   Shall we reject  the testimony of
 Denman  ?  Whose shall we, then,  accept 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
     * " Monatsschr. f. Geburtsk.," 1865.
     t " Sul rivolgimento esterno,"—" AnnaliUniversali di Medicina," 1859. 
              HOW  CHILD'S POSITION  IS CHANGED.           95

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 impossibility
of turning the child had,  to the apprehension of writers  and prac-
titioners, left the woman without any hope  of  relief.  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 evolution 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 presume that, after the  long-continued action of the uterus, the
body of the child is brought into such a  compacted state as to 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 gradually 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  calculated 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 from  that we are now describing."
   Denman  cited, in  confirmation, the evidence  of  Dr. Garthshore,
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, similar cases had been observed, although not understood.   Thus,
Perfect:  " The arm  presented ; and after endeavours 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, Loffler,  Christoph  von  Siebold,
             * " Abhandlungen nnd Beitrage,"  "Wiirzburg, 1822. 
96
OBSTETRIC OPERATIONS.
Wilhelm  Schmitt,  Wiedemann, Vogler, Saccombe, Ficker,  Simons,
Elias von Siebold, Hagen,  Wigand, as  all having  witnessed  self-
turning,  chiefly,  indeed, by the head.  He says he himself has fre-
quently witnessed it.
   Since Denman's  time, evidence has accumulated.  Professor Boer,
of Vienna, a name of the first rank  of the  illustrious in  Medicine,
described, in 1801, a case of arm-presentation, the fingers having been
seen at the vulva.   He was preparing to turn, when he  found the hand
higher than when he had examined  before.  As the pains continued,
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.  Velpeau, a man remarkable for the precision of his observa-
tions, 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 impeached ?  There are two grounds.
In the  first  place,  there is the observation  of  a fact, of a  different
method of spontaneous  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 premature
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 Medical
Journal in 1784, Denman  relates several cases  of  spontaneous  birth
with arm-presentation—some  observed by himself, some communi-
cated to him.  In  these the  child was born dead, and the shoulder
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 sharp
distinction which he  afterwards drew  (1805, see fifth  edition Intro-
duction 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  collateral testimony.   The
observation of Denman, so far from being incredible  or  improbable,
is  in entire  harmony with  the phenomena of gestation and labour. ' 
SPONTANEOUS VERSION.                   97
  We will now endeavour to trace, with more precision,  the modes
employed  by Nature in  dealing with  shoulder-presentations.   The
mechanism of labour with shoulder-presentation is  strictly analogous
to that of ordhiary  labour.   It is,  therefore,  desirable to set before
our minds the picture of an ordinary head-labour.  For  this  purpose
reference  is made back to Lecture  III.
  Labour  with shoulder-presentation  must  obey the  same laws  as
labour with head-presentation.
  Shoulder-presentations  may be primitive or secondary.   The primi-
tive  exist before labour  has set in,  and are almost necessarily asso-
ciated with obliquity of the uterus.   The secondary  are formed during
the  initiatory  stage  of labour,  under 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  position, 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 forwards,
and  the  left shoulder will descend when the child's belly is  directed
forwards.  Li the case of the second or right cephalo-iliac position, the
right shoulder will descend when the child's belly is turned forwards,
and the left shoulder when the child's back is turned forwards.*

                              * Fig.  36.
  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 repre-
sents the brim and the space beneath the symphysis pubis. The above figure will
serve as a model.  Cut out the dark parts.  A small lay-figure of corresponding size
must be procured.
                                                               H 
LECTURE  IX.
DEFINITION OF SPONTANEOUS VERSION AND SPONTANEOUS EVOLUTION
    — SHOULDER-PRESENTATION,  HOW  PRODUCED -- VARIETIES  OF
    SPONTANEOUS VERSION—MECHANISM OF  SPONTANEOUS  VERSION
    BY  THE  BREECH—SPONTANEOUS  EVOLUTION--MECHANISM  OF,
    IN  THE  FIRST  SHOULDER-PRESENTATION,  DORSO-ANTERIOR —
    MECHANISM  IN  ABDOMINO-ANTERIOR  POSITION -- SPONTANEOUS
    EVOLUTION  BY  THE  HEAD—MECHANISM  OF  SPONTANEOUS  VER-
    SION  AND SPONTANEOUS  EVOLUTION   FURTHER  ILLUSTRATED—
    THE  CONDITIONS  REQUISITE   FOR   SPONTANEOUS   VERSION —
    EXAMPLES OF SPONTANEOUS VERSION  BY  HEAD.

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 "  spon-
taneous evolution " 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 turning.   The  position  of  the child is  changed.   All
French, German, Italian,  and Dutch authors  apply to this process
the term "spontaneous version"—"versio spontanea."  It might  be
called natural version, to distinguish  it from artificial version effected
by the hand of the obstetrician.  All  Continental authors likewise call
Douglas's process by the name, " spontaneous evolution," the process
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 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
" version " and " evolution " in the correct  sense. 
SPONTANEOUS VERSION.
99
  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.
                                Fig. 37.
                           -^    D
             THE BEGINNING OF SHOULDER-PRESENTATION, DORSO-ANTERIOR.
  a b is the horizontal line of the pelvic brim;  c Dthe axis of pelvic brim;  e p the axis of foetus
and  uterus inclined  obliquely, so that the head projects a little over the pelvic edge; o h, the
direction of the force sent by diaphragm and abdominal muscles striking the fundus uteri on one
side.
  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.  37 I have endeavoured  to represent the very earliest 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 labour
                                                              h  2 
100
OBSTETRIC OPERATIONS.
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.

                                Fig. 38.
\ J	c
YCV 0	f '
         SHOWING FURTHER STAGE OF SHOULDER-PRESENTATION, DORSO-ANTERIOR.
  The letters have the same significance as in Fig. 37.  The force g h bearing more still on the side
of the uterus, throws it and the fcetus more nearly into transverse position.

Wigand insists that  transverse  positions  are   rare.    Esterle  and
Lazzati  say  the   same,  and  maintain  that the  oblique  position is
favourable  to spontaneous  version.*   I venture  to  say that,  except
in cases of dead,  monstrous, or small  children,  or with  loss of  form

  * It has been my habit, when making notes of cases coming under my observation,
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 are taken. 
SPONTANEOUS  VERSION.
101
 of the uterus, through excess of liquor amnii, a true cross-birth, such
 as is commonly pictured and generally accepted, does not exist at the
 commencement of labour.  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-presentations, and to discard  the terms " cross-
 birth " and  "transverse presentation" altogether.   In  shoulder-pre-
 sentation, an oblique position of the child becomes  transverse in the
 course of labour;  but the presentation is not transverse  ab initio.
   The neglect of  this  fact  has been a main cause  of the errors that
 prevail in the doctrine and practice of turning.
   In the  diagram (Fig. 37), the  child  and the uterus, E F, stand
 obliquely, at an angle of about 15° or 20° to a perpendicular  c D drawn
 upon the plane a b of the  pelvic brim.   The child's head is nearly
 in a  straight line with its spine.  It stands  partly over the brim, and
 partly projecting beyond into the left iliac  fossa.   That is  the first act.
 This act may  pass into natural  head-labour.   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 pheno-
 menon is, in fact, a form of self-turning  or  natural  rectification.   If
 this attempt  at rectification  fail, 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  fundus.  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 direction 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 came round to the
 spot abandoned by the  breech,  performing, in fact,  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. 38 represents this
 second position of the fcetus.   ab is the  plane of the brim;  c d the
perpendicular to the plane, representing the axis of entry to the pelvis;
e f is the axis of the child's trunk;  and G  h shows the direction of the 
102
OBSTETRIC OPERATIONS.
downward force, which now strikes the uterus and breech at a greater
angle with the perpendicular.
  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 forwards, the palm  back-
wards, the  thumb to the  left.   All this tells  plainly that the  head is
in the left iliac fossa, and that  the child's back is turned forwards 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
Fig. 39.
                   THIRD STAGE OF SHOULDER-PRESENTATION.
      The head is high in left iliac fossa.  The body is undergoing flexion upon its side.

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;
whilst the belly  and legs  of the child, turned towards 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 continuing, the breech is driven lower
down ; the trunk bends upon its side ; the curve  thus assumed by the 
SPONTANEOUS  VERSION.
103
long axis carries 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 upwards  a little
out of  the  pelvis.  The third  act, one of  increased lateral flexion
of the  child's body, and of movement across  the pelvic brim, is repre-
sented in Fig. 39.
  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
driven 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

                              Fig. 40.
         SHOWING DIFFICULTY OF BIRTH IN ADVANCED SHOULDER-PRESENTATION.
k r represents transverse diameter of pelvic brim; a b c triangle formed of child's body, whose
                 apex is a, and whose base b c much exceeds e f.

reception of the trunk.  This  enters in the  following mamier:—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 sacral promontory—a movement of rotation
takes  place analogous  to the  rotation which the head  takes  in  head-
labour.  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 head  yields  somewhat to  the
altered direction of the spine  by coming more forward.*
  When this  rotation-movement  is effected, or rather  simultaneously

  *  This part of the mechanism of spontaneous version will be illustrated further on. 
104
OBSTETRIC OPERATIONS.
with it, a movement of descent or progress in an arc of a circle round
the pubic centre  goes  on.   The flexion  of the  spine is now reversed.
Above the brim the trunk  was concave  on its  left side, as  seen in
Figs. 39 and 40.   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 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. 40), 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.
   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; therefore b and c 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.
   One result of the great compression exerted by the concentric con-
traction  of the uterus is  to cause such pressure upon the  chest and
abdomen of the  child,  and so to compress  the placenta and  cord, that
the child is asphyxiated and killed.  The death of the child, leading
to the loss  of resiliency, 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.   This process I
have described as " balling of the fcetus."
   Spontaneous evolution, therefore, almost surely involves the death of
the child.  If  not already dead at the commencement, 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 spontaneous version.   A  living  child is favourable to
version, a dead one to evolution. 
SPONTANEOUS EVOLUTION.
105
  Spontaneous evolution from the first position proceeds as follows :—
At first, we have the oblique position  of foetus and uterus represented
in Figs. 37 and 38.  Secondly, strong flexion of  the  head upon  the
trunk, and descent of the shoulder into the pelvis (see Figs. 39 and 40);
the head is in one iliac fossa, the trunk and breech in the other.  At
this stage, commonly, the membranes burst, and the arm falls into the
vagina, the hand appearing externally.  Thirdly, 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
inclined planes  of the ischia direct  the breech backwards  into  the
sacral hollow ; this backward  movement  of the trunk throws the head
forwards over the symphysis  pubis; from transverse, as the child was
above the brim,  it now  approaches  the fore-and-aft  direction;  the

                             Fig.  41.
RIGHT SHOULDER—FIRST POSITION AFTER ROTATION.
right side of the head, near its base,  is forcibly jammed against the
symphysis;  the  side  of  the neck  corresponding  to the presenting
shoulder 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, the shoulder
being absolutely fixed ; the trunk bends more and more upon its  side,
the balling is more complete, the presenting chest-wall bulges out, and
makes its appearance under  the pubic  arch.  Then, lastly, the move-
ment in a circle of the  body round the fixed  shoulder  is executed.
The  side  of the  trunk and  of  the  breech  sweep the perinasum and
concavity of the sacrum ; the legs follow.  When the whole trunk is
born, the movement  of  restitution is effected, the  back  turning
forwards, the belly backwards.  The uterus rights itself.   The head
escapes  from its fixed position  above  the  symphysis, the chin  turns 
106
OBSTETRIC OPERATIONS.
downwards, the occiput  looks upwards 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 circle is  exe-
cuted.   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 subjec-
tion throughout this process to the laws which govern the mechanism
of ordinary labour, that Lazzati* does not hesitate to describe spon-
taneous evolution as  the natural  delivery by the shoulder.

                              Fig. 42.
EVOLUTION IN PROCESS : RIGHT SHOULDER, FIRST POSITION J STAGE OF COMPLETE BALLING J  DURING
       MOVEMENT IN CIRCLE AROUND SYMPHYSIS. BULGING OF RIGHT SIDE OF CHEST.

  The case we have just described is the most common form  of  spon-
taneous 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 forwards or backwards.   In  the first case, we have exactly the
counterpart  of the process  described.   It  would  be superfluous  to
repeat the description, when all is  told by  simply substituting the
words "right" for "left," and "left"  for  "right."  It is, however,
useful to  trace the course of a labour  in which  the child's belly is
                   * " Del parto per la Spalla," 1867. 
SPONTANEOUS  EVOLUTION.
107
directed  forwards.  Let us take  the  second position—head in 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 towards the  breech, shortening the opposing base
by bending the head upon the chest and the trunk upon itself.   This
is the movement of flexion.   This movement continuing is combined
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

                              Fig.  43.
SECOND POSITION  OF SECOND SHOULDER-PRESENTATION (ABDOMINO-ANTERIOR) 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.

symphysis ;  the breech rolls into the sacral  hollow.   The right side
of the chest  emerges through the  vulva;  the trunk and breech sweep
the perinasum; the left arm follows, and lastly the head,  the occiput
taking up its fixed point 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 ; the sternum is directed forwards ; the thumb of the prolapsed
arm is turned to the left, the back of the hand looks backwards, the 
108
OBSTETRIC OPERATIONS.
palm towards 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 pelvic cavity, the rotation-move-
ment 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 anterior part of the brim ;  the  sternum will turn to the right, the
dorsum to the left and backwards.   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 performed—the back will be directed  to the left and
forwards.   The head will be above the brim, with the nucha turned to
the left and forwards 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-labour.

                              Fig. 44.
EVOLUTION IN PROCESS : RIGHT SHOULDER ABDOMINO-ANTERIOR—SECOND POSITION AFTER ROTATION.

  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,  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 labour in shoulder-presentation.  Were
it more  often  justifiable to wait and watch the efforts of Nature, we 
SPONTANEOUS EVOLUTION.
109
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
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, whenever 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 that spontaneous evolution may be effected
by the head traversing the  pelvis first.  The case is indeed  rare, but
                              Fig.  45.
 EVOLUTION IN PROCESS : BALLING COMPLETE J LEFT SHOULDER—FIRST POSITION AFTER ROTATION.
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, should 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
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.
Pezerat *  relates a case that seems free  from ambiguity.   The child
                 * " Journ. Complementaire," tome xxix. 
110
OBSTETRIC OPERATIONS.
was large, the shoulder presenting.  Pezerat tried to push it up, but
could not.   A violent pain drove the head down.  Fichet de Flichy *
gives  two cases.  In both  the midwife  had  pulled  upon  the arm.
Balocchi relates  a case.t   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-presentation.  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.  Monteggia J  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.

                              Fig. 46.
   EVOLUTION IN PROCESS : BALLING IN PELVIS COMPLETE J LEFT SHOULDER—SECOND POSITION
                           AFTER ROTATION.

  Fielding Ould (1742) relates the  following: He was called to assist
a midwife, who had been pulling  at the child's arm, which came along
with the head, yet she could not  bring  it forth.   The head was so far
advanced that it could not be put back, in order to come at  the  feet.
However, after an hour of excessive toil, he brought forth a living
child, with a depression of the parietal and temporal bones proportional
to the thickness of the arm.   Next  morning  the  bones had recovered.
Child and mother did well.
  It is so important, as a guide to the artificial means of extricating a
patient from the dangers of  shoulder-presentation, to possess accurate

            *  "Observ. Med. Chir."
            t  " Manuale Completo di Ostetricia."  Milano, 1859.
            X  "Traduzione dell' Arte Ostetricia di Stein," 1796. 
SPONTANEOUS  EVOLUTION.
Ill
ideas  of the mechanism of spontaneous  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 elastic, 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 movable, receives the impulse  of the force, and is
driven downwards.   This rod, or spine, therefore bends.   But the rod,
being elastic, constantly tends to straighten  itself.  This  effort will, if
the head  is  not immovably  fixed,  lift the  head off the edge of the
pelvis, and carry it  higher  into the  iliac fossa.    The force  con-
tinuing  to press upon a,  will  drive it still lower, and the  rod still
bending, and  tending to  recover its straightness,  the  head will rise
Fig. 47.
         REPRESENTS FURTHER STAGE OF SPONTANEOUS VERSION AFTF.R ROTATION.
        b, head has risen from symphysis, the rod straightening, a, breech escapes;

further from the edge of the  pelvis.  At last (see Fig. 47) 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
hke manner.   Let us represent  the child's body by a rod, flexible, but
almost without elasticity.   In Diagram  48,  one end  of the rod,  b,
is  fixed against the  edge of  the pelvis;  the other end, a, being mov-
able, 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 
112                 OBSTETRIC  OPERATIONS.
forms a strong curve, with  its convexity downwards, 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  49.)
  In illustrating spontaneous version, as well as spontaneous evolution,
it  is necessary  to  exhibit first a pelvis seen  from the front, then  a
section  as  seen from  the  side;  because 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  forwards.
  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

                              Fig. 48.
         ILLUSTRATING MECHANISM OF SPONTANEOUS EVOLUTION (OR EXPULSION').
a b, flexible inelastic rod, as is body of dead child, bending so that b rests on edge of pelvis, whilst
                          a is driven into pelvis.

to predicate in any  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  overwhelming.   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
opportunities for discovering  the  resources of  Nature, and  how  she
acts in  turning  them  to  account?   The principal conditions  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 
SPONTANEOUS  VERSION.
113
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 grasping the fcetus  in every part,
bending  its long axis  by  approximating the head  and breech.  It is
not likely to take place when the head has advanced towards a position
above the symphysis pubis, that is, when the movement of rotation has
commenced.
  But the practical question will arise, Is  spontaneous version ever
so likely to occur,  that we shall be justified  in trusting to  Nature ?
Ample  experience  justifies an  answer  in  the affirmative.   But it
Fig. 49.
         ILLUSTRATING END OF SPONTANEOUS EVOLUTION, ROTATION COMPLETED.
      b, the head is fixed above symphysis; a escapes from pelvis after doubling of rod.

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 accomplish 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.  Examples of spontaneous version
by the pelvis have been given in  Lecture VIII.   I will  give two
examples  of  spontaneous  turning  by the head.
  Velpeau* relates the^following case of cephalic version:—A woman
was  in labour at the  Ecole  de Medecine (1825).  The os was little
            * " Traite complet de l'Art des Accouchements," 1835.
                                                             I 
114
OBSTETRIC OPERATIONS.
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 Denman" Velpeau  did not  search  for the  feet.  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  labour ended  naturally.
  The late Dr. E. Copeman, of Norwich, records the following case* :—
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 endeavoured to pass
his hand over the right  side of the child towards the pubes, but hi so
doing he felt the child recede, and therefore confined himself to raising
the child's  pelvis with  his flat hand and fingers;  whilst the pains
forced down the occiput, the  head descended, and delivery was quickly
completed.  Dr.  C. thinks,  if he had  waited a  little  longer, spon-
taneous  evolution would have occurred,  and  the child would have
been  born even without manual  interference.   The  child was  a full-
grown male, lively and  vigorous.
               * J. G. Crosse's " Cases in Midwifery," 1851. 
LECTUBE  X.
APPLICATIONS  OF THE KNOWLEDGE  OF THE MECHANISM OF  SPONTA-
    NEOUS 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--REASON  WHY VERSION  BY  THE  BREECH  IS
    COMMONLY  PREFERRED--ILLUSTRATIONS OF HEAD-TURNING, OR
    CORRECTION OF THE PRESENTATION, BEFORE AND DURING LABOUR
    IN  OBLIQUITY  OF THE  UTERUS AND  FC3TUS--SHOULDER-PRESEN-
    TATION--FOREHEAD  AND  FACE  PRESENTATIONS--DESCENT OF
    HAND  WITH HEAD--DESCENT OF UMBILICAL  CORD.

From the  observation  of the spontaneous  or  accidental changes of
position of the fcetus  in  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  position with  remarkable facility.  It follows
that the judicious application  of very moderate forces  may, under
favourable  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.
  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, whilst
                                                           i 2 
116
OBSTETRIC OPERATIONS.
the other works internally through the os uteri.  The first method—
that practised by Wigand, D'Outrepont, Esterle, and others—has been
called the bi-manual  proper.   The  second, which  was  first  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 fcetus.   It would  be more correct to describe
them both as forms of the bi-polar method of turning;  and by this
designation, proposed  by me in  the first edition of these Lectures, they
are now generally  known.   It is  an accident, not a  fundamental
difference, if, in  one case, it  is more convenient 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 applica-
tions to practice.
   I have found the bi-polar method serviceable, adjuvant in every kind
of labour 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
favourable 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
requires, in its special  uses, if not  the presence of liquor amnii, at any
rate a uterus not yet closely contracted upon  the fcetus. But I am in  a
position to state that amongst more than 200 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 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  principle, 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, more-
over,  successfully applied that theory  in  practice.  They had applied
it  to  the purpose of altering the position  of the  child before labour,
chiefly by bringing the head over the centre of the pelvis, restoring
at the  same  time the uterus and fcetus from an oblique to  a right
inclination.   This  they did generally by  external manipulation ;  but
not exclusively, for sometimes one or two  fingers introduced into the
os uteri served to  drag the lower  segment or pole of the uterus to  a 
BI-POLAR VERSION.
117
central position, v/hilst the hand outside 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 hereafter.  It is
enough to say in the present place that it consists in holding down the
leg that has been seized,  whilst a hand or a crutch introduced into the
pelvis pushes up the head and chest.   Li this operation it  will be
observed that both hands work below  the pubes,  whilst  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  principle  of bi-polar turning.  They simply
indicate the  principle of supporting  the uterus, so as to  prevent the
risk  of laceration of the cervix whilst pushing  the hand through the
uterus and  up towards 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 Rigby  (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 downwards against the hand which  is now advancing
through the os uteri.  Li 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 liability there must be  to lacera-
tion  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 J. Y. Simpson*:
—"Use both your hands," he says, "for the operation  of turning.
In making this  observation,  I mean that  whilst we have  one  hand
internally in the uterus, we  derive the greatest possible aid in most
cases from manipulating  the  uterus and infant with the  other hand
      *  "Lond. and Edin. Monthly Journal of Med. Science," Feb., 1845. 
118                 OBSTETRIC OPERATIONS.
placed externally on the surface of the  abdomen.   Each hand assists
the other to a degree which  it would not be easy to appreciate except
you  yourselves were actually performing the operation.  It would be
extremely  difficult,  if  not  impossible, 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 fcetus
in situ while we attempt to  seize the necessary limbs, or it assists in
moving those parts where required towards the introduced hand, and it
often aids us vastly in promoting 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 described.  But
the bi-polar principle is  at best but dimly foreshadowed.
  Dr. Robert  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 towards 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.  His is a manoeuvre of limited appli-
cation.  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 by the
light of experience  in practice, might construct out of the elements
thus contributed by Wigand and his followers, by Rigby, Simpson, and
Robert 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
myself of having in this manner evolved that theory, and applied  it in
practice.   Dr. Rigby'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 Professor
Simpson, from which the passage above quoted is drawn, at the  time
of its appearance.   Since  then I have turned  more than two hundred
times.   In  no case have I failed to observe  the precept of using both
hands ; and gradually I found out that  the  external 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 
BI-POLAR VERSION.
119
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 pro-
fessional brethren who have honoured me by seeking my assistance can
bear witness to the fact,  that  it was by the application 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
contributions 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  reference to the
forceps  be true—namely, that  the  carrying  to 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
lectures, 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 labour, it follows that to
obtain a head-presentation is the great end  to be contemplated by art.
It seems enough to state this proposition 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  favourable
for an  unfavourable 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 instances, 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 experience of one order of events is apt so to  fill the  mind
as to exclude the recognition of events  that are  observed but  rarely.
Many truths  in Medicine escape  recognition because  the mind  is
preoccupied by  dogmas  and  narrowed by  an arbitrary and enslaving
empiricism.   Many things  are not  observed because  they are not
sought for with an intelligent  and  instructed eye.  And then, reasoning
in a  vicious  circle, some men  will  boldly  deny the  existence of that 
120
OBSTETRIC OPERATIONS.
which their untrained faculties cannot perceive.  They go further : by
doggedly and consistently following a practice which arrests Nature in
her course, substituting a violent proceeding of their  own, they never
give Nature a chance of vindicating her powers, and they consequently
never give themselves a chance of learning what those powers  are, or
of realizing the imperfection of their own knowledge.   They close the
shutters  at  noon-day, and say the sun does not shine.
  Li the seventeenth and in the beginning of the eighteenth 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 necessary 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 a ready means of extraction.
  Flamant appears to have been almost 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'Outrepont 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  towards the fundus
uteri.   The head, thus made to descend, was seized by the hand.   The
liquor amnii had long escaped.  He worked in these cases entirely by
internal  manipulation.   Wigand accomplished the  same object by
external  manipulation, saving the children.  D'Outrepont had a  case
of a woman who had lost three children  by  foot-turning.  In  her
fourth labour  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 right thumb and the right side of four fingers on its
left side ; then he pushed it to the left and upwards ; then he released
the back, and seized the neck, whilst 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 the 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 afterwards practised  with  success Wigand's method of
head-turning by external  manipulation.
  Here is a case  of bi-manual  and bi-polar head-turning by D'Outre-
pont :  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 
HEAD-TURNING.
121
side  where the head lay, directing  it towards 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.
  Professor  E.  Martin* has carefully  described  the operation, and
practised it  with great success.
  Hohl! says turning by the head is much less esteemed than it ought
to be, and 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 Labour.—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.  When Labour has Begun.—1. When the  uterus  and fcetus are
placed obliquely in  relation  to  the  pelvic  brim,  which  obliquity
may be preparatory to the complete substitution  of  the shoulder for
the head.
  2. In some cases of shoulder-presentation, the membranes being 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 the 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 Labour.—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 occur-
rence of spontaneous version in the eighth and ninth months of gestation
that led this  eminent obstetrician to practise external bi-polar version.!
He observed that a large number of shoulder-presentations in the last
two months,  if left to themselves, were converted into natural presenta-
tions, either  on the approach of labour or after the beginning of  labour.
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  com-
bined action of the movements of  the  fcetus 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 follows :—
      * " Froriep's Notizen," 1850.
      t " Lehrbuch der Geburtshiilfe," 1862.
      I " Sul  Rivolgimento Esterno."—" Annali Universali di Medicina," 1859. 
122
OBSTETRIC OPERATIONS.
  The patient  must be placed in such  a  posture as to produce  the
greatest  possible muscular relaxation.   Bearing  in  mind the  con-
ditions  which  take  part  in  spontaneous  version, it  is  necessary to
imitate  them  as much as possible.   Amongst  these  is  the  lateral
and  partial contraction of the uterus, which diminishes the transverse
diameter, and  which  exerts a  convenient pressure upon the  ovoid
extremities of  the fcetus ;  and the movements of the foetus,  the re-
percussion of its head, and its descent when the centre of gravity of
the foetal body favours its fall.   To imitate this, the lateral contrac-
tions must be  replaced by lateral pressure.   This is  applied towards
the fundus or the neck, according to the situation of the part which
it is sought  to raise or to depress.   This pressure is assisted greatly
by  gentle strokes or  succussions  made by  the  palm  of  the  hand
alternately towards  either ovoid extremity.  These strokes are then
made, in  rapid succession, simultaneously upon the two extremities,
one giving a movement of ascent, the other a movement of descent;
or we may act  upon  the  head alone, whilst the other hand  makes
a steady  pressure  on  the  contrary  side, the more to  diminish  the
transverse  diameter.    The  desired  position being  effected,  it  is
necessary to maintain it.   This may  be done   by the  adaptation
of a  suitable bandage.
  Lazzati operated in a similar manner.  He maintained the  uterus
and  foetus in due position by the adaptation of cushions or of pads
to the sides  of the opposite poles of the foetal ovoid.
  B.  1,  2, and  3.—Head-turning or correction  of the presentation
may be  attempted in  cases of moderate obliquity, where the liquor
amnii is still present  or has only recently escaped.  It  is also neces-
sary that the action of the  uterus be  moderate.    Correction,  as we
have seen, consists in  restoring 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 ex-
ternal manipulation.   Supposing the case be one in  which the head
is  deviated to  the left ilium, and the fundus, with  the breech,  are
directed to the right of the mother's spine, the first  step  is to place
the patient in a favourable  position.   Now, by laying her on her  left
side, the  fundus of  the uterus, loaded  with the breech,  and  being
movable,  will  tend  to fall towards  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  recommends  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  pelvis.    When this is found,  the  sooner
the membranes are  ruptured  the better.   The patient  must  thence-
forward  be  kept carefully  in the same  posture,  the  uterus  being 
BI-POLAR VERSION.
123
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 towards the median line of the
mother, both at its  fmidus and  at  the lower  part, which contains the
head.  The head will thus be pushed  by  one  hand to the right, whilst
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 labour has begun, we may combine internal with external manipu-
lation.  We may press upon the fundus  with one hand, whilst with a
finger in the os uteri we pull this over  the centre  of the brim (Wigand).
External pressure by a cushion or pillow placed in the hollow of the ilium
in which the head lies will aid this manoeuVre.   Then, having got the
head into proper position, and whilst 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  due  relation.  If by this contraction the head should happily
become  fixed in the brim, the manoeuvre has succeeded ; the labour has
become  natural.  Velpeau and Meigs  relate instances of the successful
application of this practice.   But if the head still show 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.
   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 Lecture V.
   Sometimes correction  of  these  presentations may be effected  by
restoring the equilibrium of resistance  to the anterior 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 necessary.
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 upwards, 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 restoration of a
lost head-position.*  In one case,  feeling the face  presenting through
                *  "Cases and Observations," vol.  ii.,  1754. 
124
OBSTETRIC OPERATIONS.
the membranes, he raised the forehead ; then letting the waters escape,
the head was fixed in  its proper  position,  and the labour 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 this accident
occurs, it is apt to proceed to shoulder-presentation, the hand and arm
slipping down and wedging the head off the brim to one or other iliac
fossa.  Hence the importance of correcting this presentation as early as
possible.  Whilst the parts  are still movable, it is commonly possible
to push  up the presenting hand  by means of your  left fingers in
the vagina:  and at the same time, by pressing down the head by the
external hand towards 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 timbilical cord by the side of the head may some-
times be managed  successfully in  a similar  manner,  having  first
replaced  the cord above the presenting head.  In the next lecture we
may conveniently examine  the mode of dealing with prolapse  of the
umbilical cord, and discuss  the  subject of asphyxia generally. 
LECTURE  XL
PROLAPSE OF UMBILICAL  CORD—HOW PRODUCED--HOW  TREATED--
    THE  CORD  ROUND  THE  NECK--SIGNS  OF  DEATH OF CHILD--
    ASPHYXIA OF  CHILD, PARALYTIC  AND  SIMPLE--INFLUENCE  OF
    PLACENTAL  AND AERIAL RESPIRATION COMPARED--TREATMENT OF
    ASPHYXIA : BY REFLEX IRRITATION ; BY  ARTIFICIAL  RESPIRATION;
    MARSHALL HALL, SYLVESTEU,  PACINI, BAIN, HOWARD, RICHARDSON.

Most of the causes which favour the production of malposition of the
child,  such  as  pelvic distortion, placenta  praevia, excess  of liquor
amnii, also  favour prolapse  of the  umbilical cord.  All  causes that
hinder the complete filling of the lower segment of the uterus and the
pelvic brim by the presenting part of the child, of course leave room
for the falling through of a loop of cord.   And  the cord is  especially
apt to be hooked down if it be over-long, if it take its origin near the
orificial zone  of the uterus from the lower margin of the placenta, and
if  there  be  a copious   or  sudden rush  of liquor amnii when  the
membranes  burst.  In  healthy  labour,  the lower  segment  of  the
uterus,  which contains  the presenting  head, sinks down  at the very
earliest stage into  the pelvic brim.  Thus, when the cervix dilates  and
the membranes  burst, the head instantly descends into contact with
the uterine orifice, and  closes  it like a ball-valve.   So perfect is  this
action, that usually a portion of liquor amnii is even retained until the
child's body is born.  Whenever the cord  falls through, something has
prevented this sinking of the  lower segment of  the  uterus into the
pelvis.   One  thing deserves  attention.   Prolapse of  the  funis  has
frequently happened when the  patient  has been  sitting  or standing
up at the time the membranes have burst.  Hence it  is  desirable to
keep the patient on her  bed when this event is expected; and then,
should the funis come down, you will  have the further advantage of
detecting the  accident at the earliest moment—a point of paramount
importance.
  There are  two  periods  of prolapse of the cord ;  and the management
must be modified accordingly. 
126
OBSTETRIC OPERATIONS.
   The first case is when the cord is felt below the  presenting part of
the child whilst  the membranes  are  still entire.  The liquor  amnii
being of course preserved, the risk of pressure upon the cord is but
small.  It is rarely necessary to interfere before the membranes  burst.
But when the cord is felt through the membranes, we must be prepared
for the coming difficulty.   The moment the membranes burst, the cord
will probably be carried down by the torrent of liquor amnii and the
expulsive force.  If the cervix  uteri is freely  open at the  moment of
bursting of the membranes, the condition will  be so far favourable for
immediate efforts to replace the cord or to deliver.  But  should the
cervix be only moderately open, the risk  is greater. In this case we
should do well to dilate the cervix, before the membranes burst, by the
water-bags,  so  as  to insure the desirable freedom for  manipulation.
We must be ready to act the moment the membranes burst, according
to the indications of danger to  the child and the presentation.
   Since, during the passage  of the child,  the prolapsed  cord must
undergo protracted compression, the child's life is in imminent danger.
Rescue from this danger will depend upon one  of two conditions : first,
upon the re-position of the prolapsed cord above the presenting part of
the child, and its retention there ; or secondly, upon the speedy delivery
of the child, before  fatal  asphyxia has taken  place.   Sometimes we
have a choice in the method of proceeding ; sometimes the course of
action is imperatively dictated by circumstances.  For example, if
there is a shoulder-presentation, there is  obviously a major reason for
turning.   If there is placenta praevia  with profuse haemorrhage, to
secure the safety  of the  mother must be our first object;  for this,
turning may be indicated : indeed that  which is best for the mother is
often here the best chance for  the  child also.   In the case where the
cord springs from the margin of the placenta, and this margin descends
to near  the  orifice  of  the  womb—and the two things  commonly go
together—it is  clear that  there is not  much hope  of keeping up the
cord even if you  succeed in putting it back  into the  uterine  cavity.
The next pain will expel  it again.  The  prospect of saving the child
depends  upon  prompt delivery.   If  the head present, put on  the
forceps at once.  If the  os is  not sufficiently  dilated,  use  the water-
bags.  Or, if you think  delivery  can be effected more quickly by
turning, adopt this operation.
  If there be contraction of the conjugate diameter of the pelvis, so that
the cord slips down on one side of the  promontory where the brim
cannot be occluded by the head, you may try to replace the  cord before
proceeding to expedite delivery.  The  same course should be adopted
when there is no deformity and when the cord springs from the higher
zones of the  uterus.
  As to the mode of re-position of the umbilical cord.  Much ingenuity
has been brought to bear upon this problem.   You may  occasionally— 
PROLAPSE OF FUNIS.
127
rarely, it is true—take the prolapsed  loop in the fingers of your left
hand, and, in the absence of uterine  contraction, carry it up into the
uterus above the presenting head, and even hang it over  the child's
knee or foot.   Unless you  succeed in thus finding a peg for it, it will
almost certainly  follow your hand  down again as you withdraw it.
And whenever you have succeeded in carrying the cord into the uterus,
in whatever way, you must immediately try to fill up the pelvic brim
with the child's head  so  as to  obviate a recurrence of the prolapse.
This may be done, sometimes by external pressure by the hands, or a
bandage so applied as to fix the head in the brim, or better still by the
forceps.  Where  the cord comes down  in feet-presentation, you may do
as Wigand did: carry up  the cord with your hand,  and immediately
bring down a leg into the os uteri.

                              Fig. 50.
ROBERTOX'S FUNIS-REPLACER.
  Another mode of replacing the funis is by help of the so-called knee-
elbow posture.  By placing the woman on her elbows and knees, the
pelvis is necessarily raised above the level of the fundus of the uterus.
Gravity,  therefore, favours the descent of the child from the pelvic
brim, thus giving  room  for  the  cord  to  fall back  too,  and for the
obstetric hand to help to replace it.   This is  an excellent plan.  But
even here, you must not neglect to bring the head into the brim either
before  or  immediately after  allowing  the  patient to  resume the hori-
zontal  posture.   The resort to the knee-elbow position is not altogether 
128
OBSTETRIC OPERATIONS.
new.  I was taught it by the late Dr. Bloxam more  than thirty years
ago.   But it has lately been enforced, and successfully applied,  by Dr.
Thomas, of New York,  under the name of the  "Postural Method"
(Transactions of the New York Academy of Medicine, 1858); by W. '
Theopold (Deutsche Klinik, 1860);  by Dr.  Wilson (Glasgow Medical
Journal, 1867); and  others.   You  may, as these  practitioners  have
done, succeed by the  elbow posture, aided by your hand alone.  But
it may be useful to employ a special instrument to  replace the cord.
A  multitude of instruments for  this  purpose have  been invented.
None surpass in simplicity and effectiveness the contrivance  of  Dr.
Roberton.  This is nothing more  than a large catheter of vulcanized
india-rubber, mounted on a  stilet.  It should be fifteen inches long,
of large calibre, with an eyelet-hole near  the  blind  end.   Fig. 50
represents it prepared for use.   A loop of coarse  soft silk, or worsted,
is carried through the tube and brought out at the eyelet;  or you may
simply tie a bit of worsted in form  of a loop round the end of the 
PROLAPSE  OF FUNIS.
129
catheter.  The prolapsed cord is caught in this loop.  The tube is then
carried, by means of the  stilet, past  the  presenting part of the child
until the cord is fairly lodged in the uterus.   Then, applying a finger
of one hand to the lower end of the tube, you withdraw the stilet with
the other hand, leaving the tube in sitfi.  Being perfectly smooth and
flexible, it gives rise to no sort of  inconvenience.  It comes away with
the placenta when the child is born.
   Efficient as this little contrivance often is, I, however, advise  you to
combine the advantages offered by the knee-elbow posture, as repre-
sented in Fig. 51.
   It is well to keep  the tube always ready armed with the silk-loop.
If not at hand, you will find an ordinary  elastic catheter an excellent
extemporaneous  substitute.
   If the cord  is quite flaccid and pulseless, and especially if a loop
outside the vulva is also cold;  and  if tickling of the child's feet excite no
reflex  movement, it may be presumed that the child is dead.  If known
to be dead, the obvious indication is to turn our attention  exclusively
to the interest of the mother.   But mere absence of pulsation  in  the
cord must not hastily be taken as  certain  evidence of  the child's death.
It is proper, in doubtful cases, to auscultate the  abdomen for the foetal
heart; and if the hand is passed into the uterus we should take  the
opportunity of feeling the child's chest for  the heart-beat.
   Observations on the signs of impending asphyxia will be made when
describing  breech-labour.
   Allied to prolapsus is the entanglement of  the cord round the child's
neck.  In this case,  the cord  being, perhaps, of excessive length, and
the child's head being prevented from filling the lower segment of  the
uterus, a loop of  cord lodges there, so that when the  cervix opens,  the
head passes through the loop.   I  have no doubt this is the common
way in which the accident  arises.   But there is reason to believe that
it is sometimes due  to versions of the child during or  before labour.
Occasionally, the cord forms two coils, or even  three, round the neck.
The effect of the accident  is that, as the child descends through  the
pelvis, the cord tightens round the neck, tending to  strangle it, and at
the same time the circulation through the cord  is interrupted.  And
there is, moreover, likely  to  be arrest of the  labour from the child
being held back by the cord dragging upon the  uterus.  It  is obvious
that the child  is  in imminent peril.   It is, therefore, a good rule,  the
moment the head is born, to pass your finger round the neck to feel if
the cord encircles it.  If it be found loose, and the body is advancing,
so that you have no time to bring the loop of cord over the head, open
the loop and let the child's body pass  through it.  But if the head is
not advancing; if you observe that after every pain the head seems to
be retracted; and especially if you see the face becoming  congested,
and you feel the cord tight and pulseless round the neck,  lose not a
                                                             E 
130
OBSTETRIC OPERATIONS.
moment in passing a finger under the cord, and sever it.   Dr. Haake
(Zeitschr. fur Med. Chir. u. Geburtsk., 1865) suggests that  this com-
plication may be detected by examining by the rectum. Thus the finger
can be easily, he says, carried above the head, so as to feel the umbilical
cord and its pulsation.  This may give timely indication of the child's
position, and  tell when it is necessary to accelerate labour.   Then
accelerate the birth of the body;  and tie the cord at the  usual distance
from the navel.   If you fear that the child may bleed, you may secure
both ends of the cord by tying, before the body is expelled or extracted.
But this is not really necessary.
  Asphyxia  of  the  new-born child.  In  cases of  labour  with pro-
lapsus of the cord, and  when the cord has tightly embraced the neck,
we  should always  be prepared  with means  of exciting  respiration.
Asphyxia in the new-born is a large and interesting subject, which I
cannot fully discuss in this place.  Asphyxia from prolapse of the cord
is one of the most simple cases.   It is generally entirely due to pressure
upon the cord interrupting the circulation between the  foetus and the
pelvis.  There is not so  often as  in other causes  of  asphyxia—for
example, in head-last labour, contraction of the brim, difficult labour,
or forceps-delivery—complication with compression of the child's brain.
Where this occurs there is often injury to the brain-tissues,  meningeal
effusion of blood, or at least congestion of the pons Varolii and medulla
oblongata.   These conditions may be so severe as to be incompatible with
recovery.   The child cannot breathe; the lesion of the nervous centres
renders this act impossible.  This we may call paralytic asphyxia.
  But in simple asphyxia there is  hope.   The  great indication is
obviously to  establish aerial respiration  to  compensate for the loss of
the placental circulation.   How is this  best done ?   In  minor degrees
of asphyxia, where the excitability of the medulla  oblongata remains,
you may work upon the reflex function.  Irritation of the respiratory
nerves will often succeed.  Cold aspersion on the face and chest, gentle
friction of the chest, dipping the child for a moment in warm water,
may be enough to excite respiration. But  if the nervous  centres  will
not  respond to  peripheral irritation, what next ?   Here comes the
question as to the absolute and relative  merits  of the various methods
of artificial respiration.   The  object of  all is to get  some  air into the
lungs.  The oldest method is by  direct insufflation by mouth to mouth,
or by a tracheal tube.   An objection to  it is that it is difficult to avoid
rupturing the delicate air-cells.
  In discussing the principles of dealing with asphyxia  in the  new-
born infant, it  is necessary  to consider  how  it is  produced and the
phenomena which attend it.   We  may start with the  undisputed
proposition that  aerial  or lung-respiration  is the necessary substitute
for  placental  respiration.  If the  child  is to live,  the lung-respira-
tion  must quickly take the place  of  arrested placental respiration. 
ASPHYXIA OF  NEW-BORN.
131
Usually, this  substitution takes  place immediately the child is born.
What  is the  cause of the first inspiration ?  The following  events
may be observed.   The child commonly breathes the moment its chest
emerges from the mother's pelvis.   Here, two conditions  conspire to
set up breathing :  first, the elasticity of the  chest-walls causes them
to expand  when  external pressure is taken off; secondly, the impres-
sion of cold air,  or the  cold produced  by the evaporation of the fluid
on the surface of the  face and chest, acts as an  excitor of the respi-
ratory nerves, which,  acting on  the medulla oblongata, excites reflex
action of the  inspiratory muscles.
  Another event  is not uncommon.  Breathing begins as soon as the
head is born, and before the chest is expelled.  In this case the elasticity
of the chest enters as a factor in a modified degree only; the impression
on the respiratory nerves of the  face still acts.  But the researches of
Hecker, Krahmer, Schwartz, and others prove that an attempt at inspira-
tion may take place even before the face comes into the external world.
We must, therefore, seek further  back for the essential cause of aerial
respiration.  We find evidences  of this  attempt  whenever there  has
been interruption of the  placental circulation.  These evidences are :
the presence of liquor amnii, foetal  epithelial scales, meconium in the
air-passages, and ecchymoses of puncta or blood under the pleura  and
pericardium.  Now, the  fluid  in which the foetus floats can only be
drawn into its trachea by  an inspiratory effort.   This  effort  is  the
result  of the  accumulation of carbonic acid in the child's  blood from
the  interruption of the placental circulation.   There is an immediate
want of oxygen, and the inspiratory act is excited to supply it.  There
can  be no  doubt  generally, that  complete cutting-off of the  placental
communication with  the child is a sufficient  provocative of the act of
inspiration. This complete breaking off commonly takes place with the
powerful contractions  which drive the head  into  the  world.   But  it
has  been further  contended that every uterine contraction during the
second stage  of labour, since it must partially interrupt the  placental
circulation, by constricting  the  uterine  placental  vessels, must also
provoke an effort  to respire.   If  this proposition  were true, we  ought
constantly  to find extraneous fluids in the child's air-passages, and the
risk of asphyxia would  be much higher than it is actually found to be.  I
cannot therefore admit, that in ordinary labours the partial and periodical
interruptions to the placental circulation provoke inspiratory efforts.
  Nor must it be concluded that even complete placental interruption
is necessarily provocative of an inspiratory effort.   In cases where the
brain  has  been  long  compressed,  and  probably from other  causes,
the  medulla  oblongata  may be insensible to the stimulus—there  is
paralytic asphyxia.
  A circumstance observed in asphyxia is that the heart continues for
a time to pulsate.   I do not know, indeed, that  recovery has ever been
                                                           k 2 
132
OBSTETRIC OPERATIONS.
established when the heart has ceased to beat.  To maintain the pulsa-
tion of  the heart, purification of  the  blood circulating in the vessels
must be effected.   This must be done either by means of  the placenta
or of the lungs.  If both these organs are idle, the heart's action will
gradually  flag,  and soon cease. The  experiments of Brodie long ago
demonstrated that artificial respiration would keep up the action of the
heart.   But I am not aware of any observations quite so apposite  to
the present question as some made by  myself.  (See London Hospital
Reports, vol. i.)  I induced labour, at the seventh month,  in a woman
who had  a contracted pelvis, chiefly by  galvanism.   The cord came
down, and by holding it I had accurate information of the variations of
the fcetal pulse.  In the absence of uterine action, the pulsations in the
cord numbered eighty in the minute.   Galvanism being applied during
contractions, these were sensibly increased in power, and the pulsations
became  intermitting,  and  occasionally stopped.  As  the  contractions
relaxed, the pulsations resumed their strength and regularity.  I also
initiated contractions by galvanism, and then, too, intermittences  of
the fcetal  pulse ensued.   The same  effect  upon the pulse was  also
observed  under the  influence of normal  contractions.    There  was
never any pressure upon  the  cord.
  In the course of a case of placenta praevia I had an excellent oppor-
tunity of observing and comparing  the respective influences of placental
and aerial respiration upon the foetal  circulation.  The gestation was
between six and seven months.   The  feet presented.   By stethoscope
I heard the  fcetal  heart beating  ninety  times  in  the minute.   The
mother's  pulse was eighty.   During  uterine  contractions the  fcetal
pulse fell to sixty.   I presently seized  the feet to aid expulsion.   The
child when born  gave  a  feeble  gasp, followed by  an emissive cry.
Heart and cord both pulsating.  I did  not sever the cord,  but en-
deavoured to  excite  more  perfect respiration  by  stimulating the
respiratory nerves.  The gasp and emissive  cry recurred every  minute.
The pulsations were sixty in the minute  only ; but they increased  to
ninety immediately after every inspiration, and then sank again  to
sixty.   The same  phenomena were observed for some time after the
cord was severed.   We here  see that placental and aerial respirations
were of equivalent value in  maintaining the  fcetal pulse  at ninety.
  We have it, then, clearly  established :  1. That the  uterine con-
tractions  of labour, whether occurring  spontaneously, or artificially
produced,  lower  the heart's  action;  2.  That placental or  aerial
respiration raises and sustains the heart's action; and 3.  That unless
aerial respiration be kept up in the new-born child, the heart's action
will speedily fail  altogether.   Here, then, we find the scientific basis
for resorting to artificial respiration when  natural respiration cannot
be  provoked.
  Is it  worth  while  to defer cutting  the cord when  a child is born 
ASPHYXIA OF  NEW-BORN.
133
asphyxiated ?   Can we depend upon the placental circulation fulfilling,
for a time, the function of breathing until the lungs will take up the
work ?  It is not easy to answer this question absolutely.  Tying the
cord sometimes seems to be an immediate stimulus to respiration.  On
the other hand, as it is possible the heart's action may be sustained  to
a moderate extent by the limited placental circulation, it may be wise
to avail ourselves of this help.   Generally it is better to wait a minute
before severing the cord.
  The course recommended is this :—
  1. Place the child on a flannel on its  back in a position  favourable
for respiration.
  2. See that its mouth, nostrils, and trachea are clear.   If obstructed
by mucus or in-drawn fluids, remove them before attempting to set up
respiration.  B. S. Schultze* describes a method of rejecting in-drawn
fluids,  which  embraces a  method of producing artificial respiration.
He  seizes  the child by the  shoulders in such fashion that his thumbs
are  applied on  either side to  the anterior surface  of the thorax, his
index fingers in the axillae, and the other fingers to  the child's back ;
the head  is supported  by the ulnar edges  of  his  palms.   He then
swings the depending  child upwards about 45° above the horizon,  so
that the lower  end of the child and its weight rests on his thumbs
applied to the thorax.   The chest in this way is compressed upwards
by the abdominal cavity, and the in-drawn fluids are driven out.  This
being effected, the body is allowed to fall back to its original position,
when the chest being relieved from pressure, it expands by its own
elasticity and  draws in air.  This may be repeated several times.  I
cite this method  because  Schultze speaks  highly of its  efficacy.  But
I should use it no further than to get rid of the tracheal obstruction,
not as a method of inducing artificial inspiration.   It  is too violent,
and certainly inferior to other  methods of artificial respiration.  The
late Dr. J. G. Wilson, of Glasgow, contrived a convenient  apparatus,
consisting of a tracheal tube attached to an elastic  ball, by which, he
says, mucus is readily sucked up and removed.   His  instrument  is
designed for insufflation;  it is very simple, and is certainly preferable
to the ordinary tracheal tube. By working one ball only of Richardson's
bellows, that one unconnected with the secondary ampulla, b (Fig. 52,
p. 136), you have an aspirator  which  will suck mucus out  of the
air-passages.
  3. Try  if the medulla  oblongata will respond to reflex excitation.
Blow upon the face; dash  cold water on the face and chest;  sprinkle
a little brandy on the chest, and use gentle friction on the chest; flick
the  chest or buttocks with the corner of a wet towel; dip the child for
a moment in warm water, say at 90° F.
  4. Reflex irritation failing, turn to artificial respiration.  This may
               * " Jenaische Ztschr. fur Medicin," iii. Band. 
134                 OBSTETRIC OPERATIONS.
 be practised by one of two principal methods—first, by direct insuffla-
 tion into the lungs ; or secondly, by expanding the chest-walls, creating
 a vacuum  which draws  air into the lungs.   The first method is the
 most ancient.   It was first practised by blowing from mouth to mouth,
 with or without the  intervention of a piece  of linen.  It was found
 that the air often passed over the trachea and went into the stomach.
 A tube was therefore passed into the trachea,  to serve for  insufflation.
 It has been objected to this plan, first, that the air from the surgeon's
 lungs must itself be  charged with carbonic acid, and,  secondly, that it
 is difficult  to  moderate the force  of  the  insufflation so  as to avoid
 rupturing  the  tender air-vesicles and  causing emphysema.  The first
 objection is not of much force.   If, before operating,  you fill  and
 empty your lungs fully  several times  in succession,  and then having
 well filled them, blow into the tube gently  the air with  which  your
 mouth is filled, very little carbonic acid will go into the child's lungs.
 The second objection is more valid.  With a  tracheal  tube it must be
 difficult to regulate very nicely the force of the current of air.
   This objection, and the fame of Marshall Hall, led in  this country
 to the extensive use of the " Ready Method."   There  are five methods
 of practising artificial respiration by manipulation of the body.   The
first, Marshall Hall's, is effected in this way :—First lay the child on
 its back, the head  slightly  raised; then roll the  trunk over  a little
 more than a quarter turn, on its side,  until the  chest looks  a little
 downwards ; then roll the trunk back to its  original  position;  repeat
 this movement twelve to sixteen times a minute.   The weight  of the
 trunk upon the chest compresses it, and  the elasticity of the chest
 when the weight is taken off opens it,  and air is drawn in.
   2. The same  object is effected by Sylvester's method.   To practise
 this, place the child on its back, the head slightly elevated; seize the
hands or fore-arms, one in each of your hands, and  extending them
outwards so as to bring the child's hands above the level of its head ;
then bring  the  arms down again to the  sides ; repeat this manoeuvre
twelve to sixteen times in the minute.  The chest  is thus pulled open
by the attachment of  the pectoral muscles, and it collapses  again when
the arms come  down.
  3. Pacini's method.—Place  the  child on  its back, and standing
behind the  patient's head, insert your hands in the  axillaa on the dorsal
aspect, then  pull the shoulders towards you  with an upward  move-
ment;  then let  them fall again.  This manoeuvre is  repeated twelve
or sixteen times in the  minute.
  4. Bain's method is a modification of Sylvester's and Pacini's.   The
child laying on  its back, place your fingers in the axillae in their front
aspect, with  your thumbs over the outer ends  of the clavicles,  and
draw the shoulders towards you.  On relaxing your hold, the shoulders
and chest return to their former position. 
ARTIFICIAL RESPIRATION.
135
  5. Howard's method.—The child is held on its back in the operator's
left arm,  the head hanging back  a little.   This attitude  opens the
larynx.   Then, with the right hand, the chest-walls and abdomen are
alternately compressed and relaxed twelve or sixteen times in the
minute.
  In appreciating the relative value of  these methods,  I can appeal  to
my own  experience of each.  Under each,  asphyxiated children have
recovered.  I prefer Sylvester's  and Bain's, because  they are  more
easily practised on the infant.   The rolling about  of the head' under
Marshall  Hall's  method  is awkward.    In using  Sylvester's,  it  is
convenient to get the child's feet  steadied, so as  to  counteract the
dragging  on  the arms.   Dr.  Bain's  method  has  been  admitted by
a committee  of the Medical and Chirurgical Society,  on which Dr.
Burdon-Sanderson  and Mr.  Savory served, to draw in more air than
the other methods;  it certainly is  more  easy to carry out, involving
less disturbance of the  body;  and Dr. Bain  informs me that he
succeeded  in restoring a child by  it, after  Hall's  and  Sylvester's
plans had  been tried ineffectually.   Howard's  method is perhaps the
best.
   A signal advantage, common to these five methods,  is that they are
independent  of all apparatus,  and can be applied under all  circum-
stances without loss of time.   A  drawback, also  common to all, but
applying in least degree to Bain's method, is the protracted disturbance
of the patient.   I  have seen reason to conclude, in some  cases, that
the extensive movements imparted  did more harm than good ;  that,  in
short, they helped to extinguish the latent scintillula  which required
the most gentle treatment to  fan  into life.
   I therefore, to a great extent, abandoned these methods, and  where
means of  exciting  reflex  action  failed, I thought it best to wrap the
infant in  a  warm  flannel, and get  it  nursed before the fire.   In
this way,  by  inaction—deliberate, if not masterly—the  flickering
spark will sometimes gather strength, and respiration be established.
But lookers-on are rarely competent to appreciate  inaction.  Inaction
may be the best practice, but it bears the outward likeness  of neglect.
Many a man  has earned  high credit for  strenuous exertions which
were really injurious.  Of  course,  this should not  lead us to do what
we ought not to do.   But where inaction  fails, we should anxiously
seek  for means of acting beneficially.  Dr. B.  W.  Richardson has
lately returned to  the old idea of insufflation, and  has devised  an
apparatus  at once  scientific and  practical for  applying  it.   It  is
represented  in  Fig.  52.    It  consists of  a double bellows of  india-
rubber.   The nozzle  is introduced into  a  nostril.   Both bellows are
grasped  in the hand, and compressed twenty times  in the  minute.
Since one of the balls acts for insufflation and the other for expiration,
it is scarcely necessary to  compress the chest after insufflation, as is 
136
OBSTETRIC  OPERATIONS.
done in insufflation  by an ordinary tracheal tube.  This  supplies  the
quantity of air that is required.  To make sure that the  air goes into
the lungs  you may close the other nostril.   If  it be feared that the
force of insufflation may injure the air-vesicles, leave the nostril  open.
This will act as a safety-valve, the air returning  by it from the lungs,
avoiding undue tension.  But I think the instrument is so constructed
that the force of the  air-current is  not likely to  do  injury.   Dr.
Richardson insists that warm dry air  be used;  moist air frustrates
attempts at artificial respiration.  Let  the child, then,  be held in  a
blanket before the fire during the  proceeding.
Fig-. 52.
            dr. Richardson's dottble-bellows for artificial respiration.
a takes air from without, and, on compression, propels it along the tube into the lungs, b draws
                  back from the lungs, and discharges externally.

  There would  be no  difficulty in  using this instrument in cases of
head-last labour,  where the head is delayed, and the child is in danger
from  compression of the  cord.  The nozzle  can  be slipped into  a
nostril;  and, if the chest  be tolerably free from pressure, respiration
can be thus kept up until the head is born.
  An excellent insufflator  is  that of Ribemont-Dessaigne.   It consists
of a curved tube for  passing  into the  trachea, and of an elastic  ball,
which acts as an aspirator and insufflator.
  There is  a class of cases  of asphyxia in  which the face is  livid, 
ARTIFICIAL RESPIRATION.
137
indicating congestion of the brain.   This is especially apt to occur
when the cord is round  the  child's neck, or where  the  head being
born, the neck is gripped by the vulva.   Under these  conditions, the
face is seen to rapidly become  purple and bloated from compression of
the veins in the neck.  In  such cases, it is  generally advised, I think
rightly, to let a teaspoonful or  so of blood  escape from the  cut cord
before tying it.  It  is one of  the  most remarkable  and gratifying
illustrations of  the  phenomena  of  respiration and   circulation, to
observe how quickly the bloated cyanosed  aspect of the face vanishes,
giving place to a healthy hue, when a good  respiration has taken
place. 
LECTURE   XII.
turning  (continued) :  the  management  op  certain  difficult
    BREECH-PRESENTATIONS—THE  MANAGEMENT  OF  TWIN-LABOUR—
    LOCKED  TWINS—DORSAL DISPLACEMENT OF  THE ARM--DOUBLE
    MONSTERS—SINGLE MONSTERS.

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 favourable  to
delivery."
  Now, the cases  of  breech-presentation to which I  refer cannot  be
brought to a satisfactory 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 encountered in the most
severe forms of shoulder-presentation.
  In a considerable proportion of breech cases, the labour is premature.
In  these generally there  is no  difficulty.   Indeed, I  have  commonly
observed in these  premature breech-labours a remarkably active, even
stormy character in the uterine contractions, driving the child through
with  unexpected rapidity.  But when  the  child  is mature and well
developed, a breech-labour is by no means easy.
   Although breech-presentations fall  within the accepted  definition  of
natural, inasmuch as the  long axis  of the  child's body coincides with
the long axis of the uterus and with the axis of the  pelvic brim, they
are less favourable to mother and child than head-presentations.   The 
DIFFICULT BREECH.
139
risk to the child is serious  if there is any delay in the transit of the
trunk  and head through the pelvis.   The chief  cause  of danger is
compression of the funis, or interruption of the placental circulation in
some other way.  Danger may arise before as well as during the transit
of the child  through the pelvis.   The breech plugging the os uteri
imperfectly lets all or nearly all  the liquor amnii drain off.  Thus the
child, placenta, and cord are liable to be deprived of the usual protection
from pressure during the contractions of the uterus.  This is dangerous
in several ways : 1st,  the cord may be compressed between the child's
body and the uterine wall;  2nd, the placenta may  be squeezed against

                               Fig. 53.
the child's head,  so  that its vascular  system is  obstructed ; 3rd, the
more persistent and closer contraction of the uterus may so contract the
uterine arteries and sinuses as to involve want of supply and stagnation
of blood in the placenta.
   When the trunk and head  are traversing the pelvic canal, the  danger
of direct  compression of the cord is increased. Perhaps the moment of
greatest peril is when the head is arrested at the os uteri.   The os uteri
is  probably imperfectly dilated, so that  the head  does not pass readily.
The os uteri then encircles the neck  like a ring, compressing the cord.
Or the cord may be jammed against the edge of the brim.   If the  cord
be found, or be placed, on one side of the sacral promontory, it may lie
in the recess comparatively protected.
  If delivery be hurried by traction, the cord may be retained by friction,
so that it is put on the stretch, pulling upon the umbilicus.  To obviate 
140
OBSTETRIC  OPERATIONS.
this, it is a good plan in every case, as soon as the way is cleared by the
birth of the  breech and  legs, to pass the hand up along  the child's
abdominal surface to the umbilicus, and gently to draw down a sufficient
loop of funis  to allow of the progress of the trunk without pulling upon
the umbilicus.  We may at the same time take the opportunity to direct
the funis into a sacro-iliac recess.
  The probability of this dragging upon the umbilicus, and the not less
serious  one of the running up  of  the arms by the sides of the head,
warn against precipitate delivery by traction.  The reasons for traction
are: 1st, impending danger to the child from interruption of placental
circulation; 2nd, arrest of the labour from inertia; 3rd, arrest of labour
from impaction.  The last two conditions involve danger to the mother
as well.
                              Fig. 54.
   THE POSITION OF THE FCETUS 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
turning forwards 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.

  How, then, do we know—1st, when the child is  in danger ?   If the
placental circulation be materially interrupted, an attempt is excited to
substitute aerial respiration.  The child makes an effort to expand the
chest.   In correspondence  with  this reflex act the legs often twitch
convulsively ; the sphincters relax,  and meconium is  often voided, and
recognized by its green slimy character ; the pulsation in the cord is felt
to flag and cease.   These three signs together indicate extreme peril;
but the escape of meconium, I know from frequent observation, is not
in itself of much  importance.   The child's vitality may  be  experi-
mentally tested by tickling  its feet, thus  producing reflex retraction of
the legs; by feeling the beating  of the heart  by direct  application of
your hand to  the  child's chest, which  can  generally be reached ; and, 
DIFFICULT BREECH.
141
especially, by  tracing the  cord up to its insertion in the navel, and
feeling if there is any  pulsation at this  point.   If the  heart is still
beating, its impulse is generaUy felt here, even long after it has ceased
to be transmitted to the cord.
  There  are two  principal conditions of  breech-presentation under
which labour may become arrested or  difficult.  Whether the position
of the  fcetus be dorso-anterior or abdomino-anterior, 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
the os  uteri (Fig. 53, p.  139).   Secondly,  tne legs may be extended
so that the  toes  are pointed close to the face (Fig. 54).

                              Fig. 55.
  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 pelvis.

  In  this  second  case 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  forwards under  the pubic  arch, the breech tends to  bend
backwards in the hollow of the  sacrum.  The  spine, tending to curve
in a  sigmoid form  (Fig. 55), is not so 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, hi addition, there  is an  impediment to 
142
OBSTETRIC OPERATIONS.
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 condition  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. 54 I have endeavoured to depict
some of the conditions described.
  Sometimes the cause of arrest is simple inertia :  a little vis a froute
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 account 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 a  foot  in the first instance.  Then, traction, if
still indicated,  can be  exerted  by aid of the leg with safety and with
increased  power, and under  the most favourable  conditions  for the
descent and rotation of the  child.
  I  have  seen fruitless  and injurious attempts made  to extract  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 considered in our text-books—condemn the use
of hooks  and  forceps.   Chiari, Braun,  and  Spaeth,"  Ramsbotham,
H. F. Naegele, are decided in their reprobation; Hohl f says 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 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 bom alive.   Now hooks and forceps will, in all
                   * " Klinik der Geburtshiilfe," 1855.
                   t " Lehrbuch der Geburtshiilfe," 1862. 
DIFFICULT BREECH.
143
UkeHhood,  either destroy the child  or  involve its  death through the
delay arising out of their inefficiency, 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 forceps
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. 55.
  The clear  indication  is to break  up  or decompose the obstructing
wedge (Fig.  56).  This is done by  bringing down one foot  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 ;

                              Fig.  56.
REPRESENTS A BREECH-PRESENTATION WITH THE LEGS FLEXED UPON THE THIGHS, AND THE MODE
                           OF SEIZING A FOOT.
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.
  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 has chiefly to be
distinguished. There are four principal diagnostic points in the breech:
the sacrum and anus behind,  the  genitals  in front, an ischiatic pro- 
144
OBSTETRIC OPERATIONS.
tuberance on either side.   The sacrum is distinguished by its uneven
spinous processes from anything 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 them-
selves ; 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 question now comes,
which foot to bring down ?   I believe the one  nearest to the pubic arch
                             Fig. 57.
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 back-
wards to  clear the symphysis pubis.  When the leg is extended outside
the vulva, it will be  found that  traction upon it wiU cause the half-
breech to descend, and the child's sacrum  to rotate forwards.  The
further progress of the case falls within the ordinary laws of breech-
labour.
  The second case—that  in which the  feet  He  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. 54 ;  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 
DIFFICULT BREECH.
145
operator's hand to pass ; 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 :—Place the patient on her
left side.  Produce anaesthesia  to the surgical degree;  support the
fundus of the uterus with  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 towards  the child's abdomen,
until you reach a foot (Fig. 57)—the  anterior foot is still  the best to

                              Fig. 98.
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
(Fig. 58). The main obstacle is thus removed, and you have the leg to
exert  traction upon, if more assistance is required.   One  caution is
necessary in  performing 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 cavity sometimes, by the breech,
render  the operation  one of considerable  difficulty, demanding great
                                                            L 
146
OBSTETRIC OPERATIONS.
steadiness and gentleness.   I have brought a live child into the world
by this proceeding on  several  occasions,  where  forceps,  hooks,  and
various other  means had  been tried  in  vain  for many hours.   The
reason of the operation, you will see, is analogous to that which indi-
cates turning in arm-presentation.  The further management of podalic
or feet-first labours will be described under " Turning."
  Fielding Ould (1742) seems to have clearly understood these cases.
When the  feet, he says, are near the outlet, seize  them ; and at the
same time that they are  drawn forwards, the buttocks must be propor-
tionately  thrust into the womb  by the fingers of the left hand ; for
want of this precaution  the thigh-bone of many  an infant has been
                             Fig. 59.
broken.  " Both legs  and thighs may  be extended along the child's
body, so as to have a foot over  each shoulder, which much increases
the difficulty.   In this case each leg must be taken separately,  and
the knee bent."  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 tractile force may
be  enough to  bring  the wedge through  without  decomposing  it.
Various 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 down each groin alternately.  (See Fig. 59.)
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.   The left
buttock presented.  Giffard, not being  able with the forefinger of each 
DYSTOCIA FROM TWINS.
147
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 a 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 out, and thus extracted, being aided by the
pains.   An apparatus, having  a curved flexible spring, might be  used
to carry the string over the hips; or the object might be accomplished
by a catheter first carried across,  and then, having tied  the string to
the end,  it could be drawn  through—the proceeding resembling that
adopted to plug the posterior nares for epistaxis.   (See Fig. 59.)   The
true mode of action, when there is a reasonable prospect of the breech
coming through without  decomposing the wedge, is that  practised by
Fancourt Barnes.   He draws steadily upon one groin, at the same time
rotating the breech.  The combined leverage and traction thus made
brings the breech into the most favourable relations.  This  manoeuvre
has proved easy  and successful.  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, will
generally be the  proper thing to do  in the  first instance.
   Whenever traction is performed, and especially when rotation of the
child on  its axis is made by the operator,  there  is great risk of the
arms hitching on the edge of the pelvic brim, and thus running up by
the  sides of  the head.  The way to remedy this  difficulty will be
explained in Lecture XIV.,  p. 172.  When the breech and trunk are
delivered, the arms and head may follow with the aid of slight guiding
force;  and it is important in the interest of the child that the slightest
possible  traction-force be used.   If, however, we feel no pulsation in
the cord,  and there be convulsive twitching of the legs, with spasmodic
heaving  of the chest, there  is no  time to lose.  The delivery must be
accelerated.  This  may be. done  in  one of  two  ways:—1st,  we may
hook two fingers of one hand over the shoulders, whilst, the other hand
holding the legs, we exert traction in the direction of the axis of the
pelvis ;  but if this  manoeuvre do not succeed readily, it is better, 2nd,
to apply  the forceps in the manner described in Lecture V., on the use
of the forceps  to the after-coming head.   The forceps  obviates the
danger of pulling upon the neck.
   Twins.—Amongst  the  most puzzling and difficult cases requiring
operative interference are certain cases  of twins.   Commonly, when
twins are found, the embryos are lodged each in its own bag of amnion
and chorion, apart from each other, and so packed in the uterus that,
when labour occurs, one presents at  a time in the brim, and traverses
the  pelvis before the bag of liquor amnii  of the other is ruptured.
Under such circumstances, labour is apt to be tedious, because the
uterus,  being  over-distended,  acts at a  great  disadvantage.
   There is another cause  for this  lingering,  imperfect action, which I
                                                          l  2 
148
OBSTETRIC OPERATIONS.
have not seen noticed:  it is that uterine force is lost because it can
only be transmitted to the first child  through the fluid contained in
the membranes of the second.  But in this case there is no mechanical
interference  of  the  children with  each other.   All  that  may  be
necessary is to supply a little vis a froute by  means of the forceps, to
make up for the defective or wasted vis a tergo.  The question arises,
Shall we expedite the delivery of the second child, or leave it for the
natural powers  to expel?   When expectation has  been the course
adopted, hours, even days, have elapsed before the second child was
born.   The  conditions of the case commonly declare  that  want of
power is  the  cause  of delay.  And want of power is a  cogent reason
for giving help in labour.   It is not wise to leave an  inert uterus and
an exhausted system to  struggle alone.  Dr.  David Davis  says  he
frequently saw flooding ensue in the practice of those who waited after
the birth  of the first child.  The  judicious course, then, is to allow a
moderate time, say half an hour, for the system to rally  from the first
labour, and  then to help the second  labour.  Immediately  after the
expulsion of the first child,  apply the binder firmly to support the
uterus.  If the membranes bulge in the os uteri, rupture them ; whilst,
at the same time, you increase the pressure on the fundus uteri so as
to fill the space left by the escape of liquor amnii.   If effective uterine
action arise,  let the uterus  do its  work, aiding  only  by  external
support.   But, if deficient, apply the forceps if the head present.  Be
careful to follow down  the child  by external pressure, squeezing the
child out, as it were.  It is especially necessary in twin-labour to help
the uterus to the utmost.   That the risk of haemorrhage is far greater
after twin-labour than after single  labour, is well known.   Not only is
the  uterus weakened by excessive distension, but  there is a greatly-
increased area whence blood may flow.   I have ascertained that the
superficies of an ordinary single placenta is about  sixty square inches.
If the uterine walls  are  relaxed, an equivalent surface may pour out
blood. In twin-pregnancy, this bleeding area may equal one  hundred
square inches  or more.  Thus there is  a vastly larger bleeding surface,
and  less contractile energy to close it.
   When the embryos are both lodged in the  same sac, that is, in one
common chorion and amnion, an awkward complication may  arise.
Before or during labour, the limbs  and heads may become so entangled
or locked as to  form virtually one body, which is  too  large to pass
through the pelvis.  The embryos may perform the most remarkable
evolutions.  Cases have  been observed where  one embryo has dived
through  a loop  in the  other's umbilical cord; and knots have  been
formed involving the two cords.
   In the more ordinary and favourable course  of twin-labour,  the first
child presents  by the head, and is  entirely expelled before any part of
the second becomes engaged in  the pelvis.   Indeed, the membranes of 
TWINS:  HEAD-LOCKING.
149
the second do not  burst until  after the first is wholly born.  This
second child may present either by the feet, or breech, or by the head.
  The most common form of locking  occurs through  the hitching of
one head under  the chin of the other;  and this may happen whether
both children present head first, or one by the breech, the other by the
                               Fig. 60.
 >-n<JWS HKAIJ-LOCKIXO, FIRST CHILD COMING FEET FIRST ; IMPACTION OF HEADS FROM WEDGING IX
                                 BRIM.
    d apex of wedge, e c base of wedge which cannot enter brim, a b line of decapitation to
        decompose wedge, and enable trunk of first child and head of second to pass.
head.   The latter  case appears to be the more  frequent.  A child
presents by the feet or  breech; and when  born as far  as the trunk or
arms, it is  found  that  the labour does not proceed, and on making
traction to accelerate the delivery, unexpected resistance is encountered.
You pull, but the child sticks fast in the pelvis.  The first  surmise is,
probably, that the head is too large,  from hydrocephalus, or that the 
150
OBSTETRIC OPERATIONS.
arms  have run up  by the sides of the head, wedging it in the brim.
You liberate the arms, and pull again, and still the  head refuses to
move.   And now you must explore fully.  You may get information m
two ways.  First, produce anaesthesia, and pass your left hand into the
cavity of the pelvis, so as to reach  above the child's breast, feeling for
its chin or mouth.  Instead of feeling this first, you may be  surprised
at meeting a hard, rounded mass (see Fig. 60), jammed in the neck
and chest of the presenting child, which can hardly be anything else
than the head of  another child, which  has got in the way of the first.
Secondly, by  external palpation, you  may succeed  in making out
through the abdominal walls the head of a child above the symphysis
pubis, inclined to one or other side, in  a position which its relation
to the trunk partly born, and to the head you have felt whilst exploring
the interior of the pelvis, will satisfy  you is the head of the first child.
   If the children are small, they may, with more or less  difficulty,
come through  the  pelvis  together in this fashion.
   Sometimes  it  has  been possible  to seize the second head by the
forceps, and to extract it and the embryo to which it belongs without
disturbing the first child.   But if the  children be at all large, this
proceeding is not likely to  save them.   The pressure to which both
must be subjected is too hazardous.   Even with  children of the
average size, the head of the  second child, resting  on the neck and
chest of the first, form a wedge too  large to clear the brim.  You get
the state of things represented in Fig. 60.   d is the apex of the wedge
driven  into the pelvis; e c is the base, too large to enter ;  a b is the
point at  which the wedge  may be  decomposed, by  detruncating  the
first  child at  the neck.
   The  apex of  the  wedge, formed by  the trunk  of one child, has
 traversed the  pelvis ; the  base,  formed  by the  head  of  one child
 pressed against the neck of the other, is too large to  enter the  pelvis ;
 and if  traction is exerted  on the apex,  the only effect  is to jam the
 head tighter  against the  neck,  hooking the  two heads more  firmly
 together.  The problem is, how to extricate one head from  the other,
 so as to allow one  child to pass at a time.   There are several methods
 of accomplishing  this.  But, before deciding  upon  one, it is  well to
 study how the children are affected  by the  complication.  Is one child
 in greater jeopardy than the  other ?  If so, which ?  If we find that
 the situation involves extreme peril  or death to one  child, we shall, of
 course, not hesitate  to mutilate this one, if, by so doing, we can pro-
 mote the safety of the other.
   The first thing you will try to  accomplish is, to disentangle  the
 heads  without mutilating  either  child.   It is  still possible that both
 may be born alive.  The  patient being rendered insensible, you press
 back the trunk  into the pelvis as much as possible, so  as to lift the
 heads  off the brim,  and so  to weaken the lock.   Then by external 
TWINS:  HEAD-LOCKING.
151
manipulation, aided  by a hand in the pelvis, you try to push the heads
apart in  opposite directions.   If  you  succeed in  unlocking them,
support the head of the second child out  of the way, whilst you  or
an assistant draw down the body of the first child and engage its head
in the pelvis.  If you can manage this, the  difficulty is over.
  Now, experience  and reflection  concur  in showing that the  first
child whose  trunk  is  partly born incurs by far the  greater  danger.
Its  umbilical cord is likely to be compressed;  its neck and chest are
forcibly squeezed.   On the other hand, the umbilical  cord  of the
second child is comparatively safe, and the pressure  upon its  neck  is
less severe.   You may, moreover, find, by feeling the cord of the first

                              Fig. 61.
SHOWING HEAD-LOCKING, BOTH PRESENTING HEAD FIRST.
child, that it is pulseless and flaccid, and that tickling its  feet excites
no reflex action.  Having thus  determined that  there is no hope for
the first child, you turn to  the  best  means  of  rescuing the  second.
You may decompose the wedge, formed by the two heads, by detaching
the head of the first child.   This is done by drawing the body of the
child well backwards, so as to bring its neck within reach.  Being  held
in this position by an assistant,  you pass the fingers of the left hand
into the pelvis, so as  to hook them over the neck, and serve as  a guide
to Ramsbotham's or Braun's decapitator,  or the  wire-ecraseur.    If
these are not at hand, the task can be accomplished by strong scissors,
or  even by a penknife.*  (See  Fig. 60; a b represents the  line  of
decapitation.)
             * See a case by H. Raynes, "Obst. Trans.."  1863. 
152
OBSTETRIC OPERATIONS.
  As soon as the neck is severed, the trunk will be  extracted easily
enough.   The head  of the first child will then slip up or on one side,
or you may make it  do  so by passing  your hand inside  the  uterus.
If the head  of the  second child  do  not descend by the spontaneous
action of  the  uterus, you  may either  seize it  by the long  double-
curved forceps,  or seize a leg and turn.  The first head will MIoav last
of all.  If it offer any difficulty, it may be dealt with  as described in
Lecture XVI.
  If there be reason to  conclude that  the second child is  dead, it
would be justifiable to perforate its head, and  lessen its bulk  by help
of the crotchet.   This is  another  mode of breaking up the base of the
wedge.  The head will then flatten in, and permit the trunk and head
of the second child to be delivered.
  In  the  other  case, where the head of the first child presents, and
gets locked by the head of the second, as  in (Fig. 61,  a similar rule of
action will apply.  You  may  disentangle  the  heads by external  and
internal manipulation.  Failing this,  you may  seize the foremost head
by the forceps ;  and whilst an  assistant pushes away the second head,
you  can  extract the first  child.   A good case, in which this plan
succeeded,  is related by  Dr.  Graham Weir.*   Hohl  recommends to
apply forceps to the second head.
  Dr. Elliot (Obstetric Clinic)  relates an interesting case of twins
with contracted pelvis, in which imminent locking of the heads was
prevented by placing his hand on the abdominal wall over that head
which was superior and  to  the  left, and forcing it into the pelvis in
advance of the other.
  Another rule  should be observed.   When the first child  is born,
do not pull upon the cord, or you may do mischief in two ways.  It
is possible that the  cord may be  entangled round the neck  or limb
of the child  still in utero, or the cord of the child in utero  may be
entangled in it, so that by pulling  on the first  cord you may strangle
the second  child, or  arrest the circulation in its  cord; or you may
detach the placenta prematurely, thus giving rise to haemorrhage, and,
in the probable event of the placenta being united or common, again
imperilling the  child  in utero.  It would be better, if  the cord become
tight, so as to drag on the umbilicus, to divide it, without attempting
to tie the cut ends.


                 Dorsal  Displacement of the  Arm.

  There is a curious cause of  dystocia resulting from the locking of an
arm behind the  neck, to  which special attention has been drawn by
Sir James Simpson t and Caseaux. As the difficulty is to  be  met by
      *  "Eclin. Journ. of Med.," 1860.     f  " Obstetric Works," vol. i. 
                DORSAL  DISPLACEMENT OF  ARM.            153

altering the  position  of the  displaced  limb,  it  comes  under our
definition of Turning.
  Fig. 62 represents this position  of  the  arm.   This  displacement
more  commonly occurs in cases of podalic or breech-labour, as after
turning ; and  I am  very much disposed to think  it is  then  most
frequently produced by unskilful manipulation.  I have already insisted
upon  the importance of avoiding the error of rotating the  child upon
its axis during extraction.  If you commit  this fault, this is what  is
likely to happen :  the trunk revolving  under your manipulation, the
arm is caught against the wall of the uterus, and does not move round

                              Fig. 62.
SHOWING DORSAL OR NUCHAL HITCHING OF THE ARM.
with the trunk, but  comes to be  applied to the nape  of  the  neck.
Duges  and Caseaux explain that this  may  happen in  two different
ways.  First, the arm may cross  behind the  nucha after having been
raised above the head;  the crossing then takes place from above down-
wards and from before backwards  relatively to the foetus.   Secondly, it
may take place from  below upwards, the  arm rising on the  back of
the foetus, and stopping below the occiput.  This last method requires
a little explanation.   The arms are habitually placed by the sides of
the chest.  In  rotating, the attempt is  made to  carry the abdominal
aspect of the child towards  the loins of the mother; the trunk only 
154
OBSTETRIC OPERATIONS.
 moves; the arm, therefore, remains  behind;  the operator, in perform-
 ing extraction,  draws the trunk down ;   the  arm is caught  by the
 symphysis pubis, where  it is detained  until the  nucha  comes down
 to clench it.   It is obvious, therefore, that  this dorsal displacement of
 the arm  is manufactured by too great diligence  on the part of the
 obstetrician.   Those who anticipate  Nature, thwarting her operations,
 must be  prepared for the  penalty.  I am entitled to say,  that by
 observing the  rules I have laid down for version, this accident will not
 occur.
   But to extract light from  our  errors is true wisdom.  By reflecting
 on the mode in which  the displacement is  produced,  we shall see how
 to remedy it.  You must retrace your  steps.  By rotating the child
 back in the contrary direction, so as to restore the  original  position,
 you may possibly liberate the arm.  At any rate, you  will render more
 easy the further proceeding  that  may be necessary.   You carry the
 trunk well backwards, so as  to give room to pass your forefinger in
 between the symphysis pubis  and  the child's shoulder ; and hooking on
 the elbow, draw this downwards,  and then forwards.  It may be useful,
 as a preliminary step, to gain room by first  liberating the other arm.
   If the  arm cannot be liberated,  you may  be driven to perform
 craniotomy.
   In Sir  J. Simpson's case the head  presented.  It is not  easy to
 imagine how the arm of a living child can  get  behind the neck when
 the  head presents.   Simpson throws out the suggestion that  this
 occurs more frequently than is  suspected;  and that it accounts for
 many cases of  arrest of the head  where  there is no disproportion, and
 which resist even traction by  the  forceps.   Simpson  recommended to
 bring down the hand and arm  forward over  the side  of the head,
 converting the case into  one  of simple presentation  of the head and
 arm.  Or recourse might be had to turning, as was done successfully
 in a case related by J. Jardine Murray.*


                    The Delivery of Monsters.

  We may here consider  the mode of delivery of monsters.   Double
 monsters may  give rise to the same kinds of difficulty that sometimes
 occur in the case  of twins.  In  many cases,  Nature is able  to  deal
 with them.  They  are most frequently born dead, or possessed of little
 vitality—a circumstance  not  usually  much regretted.  The death is
 often the result of  the mode of birth, one part of the monster pressing
injuriously upon another.   If,  in any present case of obstructed delivery,
it could be with certainty diagnosed that the  cause of obstruction was
 a monstrous embryo, the indication would  be clear to do our best to
                  * " Medical  Times and Gazette," 1861. 
DELIVERY OF  MONSTERS.
155
spare the mother, even at the cost of mutilating the  embryo.  But
this cannot  always be  known in  time to  influence  our  choice  of
proceeding.   As in the case of locked twins, we  are  therefore led to
postpone mutilation, in the hope that  the  delivery may be  accom-
plished without.  Dr. W.  Playfair  has discussed this  subject in an
excellent memoir.*  He divides  monsters, according to  their obstetric
relations, into four  classes.
   A.  Two  nearly separate bodies  are united in  front to a  varying
extent by the  thorax  or abdomen.
   In this case the feet or heads  may present.  The most favourable
presentation  appears to be that of the feet.  The trunks come down
nearly parallel.  The  arms  can be  liberated without much  trouble.
It  is when the  heads come to the brim  that the  difficulty arises.
The object, then, is  to get one head at a time to engage in the brim.
This  has been  done successfully,  after turning, by  Drs. Brief  and
Molas,| in the following manner:—When the shoulders  were born, the
bodies were  carried strongly  forwards over the  mother's  abdomen.
This  manoeuvre has the  effect of placing the two heads on a different
level, bringing the posterior head lower than the  anterior one, which
for the time is fixed  above  the  symphysis.  When the posterior head
is in  the pelvis,  traction then will  bring it through, and the  second
head  will follow.   If not,  either  the  first  or  second  head  can be
detruncated  by Bamsbotham's hook, or by scissors or  knife.
   The command thus  obtained  over the course  of labour in podalic
presentations renders it desirable to turn if  the  heads  present.
   But sometimes, when the heads present, a  mutual adaptation takes
place, which  permits them to pass without  mutilation.  As  in a  case
reported  by  Mr. Hanks, §  one head got packed between the  shoulder
and head of the other body, so that both passed without great difficulty.
One head is born first, either by aid of forceps  or spontaneously, and
the corresponding body may be expelled by a process of doubling up,
or  spontaneous  evolution.   If  this  does not proceed with sufficient
readiness, decapitation or craniotomy of either the first or second child
must be practised.
   B.  Two nearly separate bodies are united nearly back to  back by the
sacrum, or lower part of the spinal column.
   In this case the mode of  delivery is essentially the same as in A.
   C. Dicephalous monsters, the bodies being fused together.
   One head  will come down first.   The body follows, by  doubling or
spontaneous evolution.   If this does  not take place, decapitate the first
head,  and bring down the feet.
  D. The bodies are  separate below,  but the heads are partially united.
                * "Obstetrical Transactions," vol. viii.
                t " Bulletin de la Faculty de Med.," vol. iv.
  X "Memoires de l'Acad.," vol. i.         §  " Obstetrical Transactions,"  vol. iii. 
156
OBSTETRIC OPERATIONS.
   Whether  the head or feet present, if there be obstruction, perforate
the head.
   In the case of dystocia from excessive size  of  the abdomen  of the
foetus, as happens sometimes  from dropsy, from enlarged kidneys or
liver, perforation and evisceration may be indicated.  In some of these
cases the abdomen may burst, or be  originally defective, so  that the
intestines will prolapse.  Such a condition, if not produced deliberately
by the surgeon, may puzzle extremely.   The procident  intestines may
be taken to be those of the  mother, and lead  to  the  conclusion that
there is rupture of the uterus.   Or, on the other hand, where there has
actually  been rupture of the  uterus  or vagina,  with protrusion of
intestines, these  may, under  circumstances disturbing the  surgeon's
judgment, be  assumed  to belong  to the child,  and cut away.
   Labour with single monsters, especially the acephalous monsters, is
not only at times puzzling, but is apt to be protracted.  Mr. Curtis, of
Melbourne  (Australian Medical Gazette, 1870), appears  to have  had
unusual experience in cases of this kind.  The diagnosis, of course, is
apt  to perplex.   We  are not accustomed  to feel a head divested of
cranial bones.   He points out  that labour with  an acephalous fcetus is
always protracted, and that there is more haemorrhage.   He attributes
the  protraction to the absence of the fully-developed skull.   As the
uterus presses upon the child,  the child's body doubles upon itself, the
back of the  neck becoming the presenting part.  He had to deliver all
his cases by the forceps : and says resort to this instrument or turning
is necessary.  In fact,  an acephalous fcetus acts like a dead  fcetus in
retarding labour.
   A full description of the varieties of monsters, and of the difficulties
into which they may lead the obstetric practitioner, would fill a con-
siderable volume.  They  are  carefully described in the  systematic
work,  Obstetric Medicine and Surgery, by Bobert and Fancourt Barnes.
They may simulate almost every complication.   Tumours as big as the
head itself may be attached to the head or to the sacrum.  The limbs
may be  double or truncated.  Such  anomalies  may defy diagnosis
before delivery.
   Hernia,  inguinal or  femoral,  complicating pregnancy,  may not
seriously obstruct the progress of labour, but  may prove a source  of
danger to  the mother.   A  coil  of  intestine  might  get compressed
against the pelvis by the descending  child.  A similar danger might
also arise from vaginal hernia.  Beduction should  always be effected
during pregnancy.  The same  observations apply  to umbilical hernia,
generally the result of  separation of the recti muscles  in  a  former
labour.  A well-adjusted abdominal  belt  should  be  worn  during
pregnancy and during labour, to  compensate for the deficiency in the
normal support and action of the abdominal  muscles, as well as  to
guard against the protrusion and  injury of the intestines. 
LECTUBE  XIII.
 PODALIC BI-POLAE  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.

 The conditions indicating podalic  turning are :—
   1. Generally, those which are not suited for head-turning, 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 prolapsed.
   4. Most  cases  in which  the cord has  prolapsed with  the arm  or
 hand ;  some  cases  where the cord alone is  prolapsed, and  cannot  be
 returned or maintained above the presenting part of the child.
   5. Cases  of shoulder-presentation in  which  the  liquor  amnii has
 drained off, and the uterus has contracted so much as to impede the
 mobility of the fcetus.
   6. Certain cases in  which it is desirable to expedite labour 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.   But the forceps would  be
 preferred if promising equal expedition.
   7.  Some cases of inertia,  the head presenting, as in pendulous belly
 and  uterus,  where the head cannot well be grasped by the forceps.
   8.  Certain cases of face-presentation.   (See Lecture IV.)
   9.  Certain cases of minor contraction  of the pelvis, or of the second
degree (see Lecture V.), which  are beyond the power of the forceps, and
ought not to be  given over to craniotomy.
   10. Certain cases  of morbid contraction of the  soft parts. 
158
OBSTETRIC OPERATIONS.
   11. As a part of the operation for the induction of premature labour
in certain cases in which the pelvis is contracted, or other circumstances
do not permit the spontaneous  transit of the fcetus with sufficient ease
and quickness to secure a live birth.
   12. Some cases after craniotomy, as the readiest mode of extracting
the foetus.
   13. Certain cases of rupture of the uterus, the child being still in the
uterine cavity.
   14. Certain cases of monstrosity in the foetus.  (See Lecture XII.)
   15. Certain cases of dystocia from tumours encroaching on the pelvis.
(See Lecture XIX.)
   16. Certain cases of death of the mother during  labour, in the hope
of rescuing the child,  when Caesarian section cannot be performed.
   We will now discuss what are the conditions necessary or favourable
to turning in imitation of the spontaneous podalic version ?
   These  are :  1st. The pelvis must be capacious enough to permit the
passage of the foetus without  mutilation.  2nd. The parturient canal
must be  dilated, or sufficiently dilatable  to permit  of the  necessary
manipulations and  of the passage of the fcetus.  3rd. The presenting
part must not be deeply engaged in the pelvic cavity.  4th. The uterus
must not be contracted to such an extent that the fcetus has  been in
great part expelled from its cavity, which is hence so diminished that
the presenting shoulder or head  cannot be 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 shoulder is movable, even if the hand has fallen into the vagina,
the operation is practicable,  often not even difficult.
  If, on the other hand, the shoulder has been driven low doiun 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  impossible  without
extreme danger to the mother.  This  is the indication for imitation of
the natural  spontaneous evolution.
  Let us, first of all, take the more simple order of cases, where  turning
is resorted to on account of symptoms indicating 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 turning—that is,
the changing the position of the child in order to produce  one more
favourable 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. 
                    OPERATION  OF  TURNING.                 159

  It will, however, give a more complete  exposition of the subject to
describe  the two  operations of turning and  extraction continuously,
assuming a case in  which  both  are necessary.
  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.
  2nd Act.—The seizure of a knee.
  3rd 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.
  2nd Act.—The Uberation of the arms.
  3rd Act.—The extraction of the head.
  Before  commencing the  operation,  there  are  certain  preparatory
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 or ether as an aid  in turning.  I will do no more than
glance at  the principal points.
  Anaesthetics are resorted to in the hope of  accomplishing  two
objects :—The first is to  save the patient pain ; the second 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
anaesthesia 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 the patient's self-control.  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 are
not, indeed, always  obtained without  drawbacks.   A perfectly flaccid
uterus indicates considerable general  prostration, and  predisposes to
flooding.
  Here  we want agents  that  will  produce the opposite effect to
oxytocics.  It  is probable that nitrite of amyl or  physostigma will be
found more valuable, in  such a  case  as  that under discussion,  than 
160
OBSTETRIC OPERATIONS.
chloroform, ether, or  chloral, which are apt to cause vomiting, and to
excite instead of allaying muscular irritability.
  To facilitate the passage of the hand is the first great object.  The
hand is opposed, first, by the  muscles of the vulva and vagina,  the
levator  ani and the  sphincter.  These contract  spasmodically when
the attempt is made to introduce the hand.   Secondly, the cervix uteri
may resist in like manner.   The  difficulty is overcome by anaesthetics
and by free lubrication.  Place a large lump of vaseline in the vagina
before attempting to  turn.
  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  shoulder will not  dilate the cervix  properly.  The same
may be said of many cases where turning is indicated by danger to
the mother, as from convulsions or haemorrhage.   To wait for  a well-
dilated cervix might be to wait  till the child or the mother is dead.   It
follows, therefore, that we must be prepared to undertake the operation
at a stage when the cervix uteri is only imperfectly dilated.
  What is the  degree  of  dilatation necessary ?  If the  question 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.
  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 Lecture VII.  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 labour
has begun at term, will commonly produce an adequate opening within
an  hour.   Sometimes the fingers  alone will succeed as quickly.  In a
case where the head presenting could not bear upon the cervix to dilate
it because of slight conjugate contraction, in a few minutes I expanded
it by the fingers  sufficiently to admit the narrow  blades of Beatty's
forceps.   The instrument, however, was not powerful enough to bring
the head through.  I 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 cannot  always proceed so  quickly.
Nor is it commonly possible to  effect by artificial  means  that  complete
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
labours, as in head-first labours, the head must  generally open up the 
POSITION  OF PATIENT.
161
passages for itself.  What we have to do is to take care  that the parts
shall be so far prepared 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  widely  as  to admit  of three fingers  manoeuvring
without inconvenience 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  generally
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 preparations.
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 unavoidable.  There is another position also, in some
cases useful—the knee-elbow  position.   But this generally precludes
the use  of chloroform.   We may obtain all the necessary facilities 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 towards 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 obstruct or fatigue the
operator's right hand, which has to pass between the  thighs  to work
on  the surface  of the abdomen.
  The presence or absence of liquor amnii in the uterus is a matter of
accident.  If water 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 revolve 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 ruptured. What
is the best time to do this ?  If you are proceeding 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 Peu, of
slipping the hand up  between the uterine wall  and the membranes
until you feel the feet, and then to break through and  seize them.
During  this operation  the  arm, plugging  the  os uteri, retains  the
liquor amnii, and on drawing down the legs, the body revolves with
perfect  facility.
                                                            M 
162
OBSTETRIC OPERATIONS.
  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 accomplish the first act in
version—that  is, of removing the head or shoulder from the brim, and
of bringing the knees over the  os, whilst  the membranes are  intact.
This  you  can try first, only rupturing the membranes when you  are
ready to 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 amnii to run off.   While doing this you should keep
your fingers 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 active agent in the
operation.   The left  hand in most  people is smaller than the right.
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  patient lying on her  left
side, the left hand follows the curve of the sacrum  far more naturally
than  the  right.  It  meets the right hand  outside, the  two working
consentaneously with comfort,  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
towards the right sacro-iliac joint—that is, inclining backwards and to
the right, so that the left hand passed up in  the  hollow of the sacrum
will reach  the legs with the utmost 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
exercises 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  razor  in  the left hand;  use
your  toothbrush with the left hand;  and if you now and then  come to
grief through lefthandedness, think how  much less is this evil than
injuring a woman or breaking down 'in an  operation.
   Well, all things being  ready, we will proceed  to the operation.   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.
The preparations necessary have been  made.  One thing more I have 
BI-POLAR TURNING.
163
to insist upon :  it is to avoid all parade or fuss in your conduct.  Make
your preparations as quietly and  miostentatiously as possible.   Do aU
that is essential, and no  more.   Tell the  patient and  her attendants
that you find it  necessary  to help the labour.   But let  your help be so
given as to involve the least possible changes from the usual proceedings
in ordinary labour.
   When the patient is in position, and in anaesthesia, slip off your coat,
turn up the shirt-sleeves  above [the elbows, anoint  with  carbolized
vaseline the back of the left hand and  all round the  wrist; insinuate
vaseline into the vulva.
                               Fig. 63.
             REPRESENTS THE FIRST STAGE OF BI-POLAR PODALIC VERSION.
  The right hand on the fundus uteri pushes the breech to the right and backwards, bending
the trunk on itself.  The left-hand fingers on the vertex push the head to the left ilium, away
from the brim.  The arrows show the direction of the movements given to the two poles of the
child.
  The Introduction of the Hand.—Bring the fingers  together in the
form of a cone;  pass in the apex of this cone, gently pressing  back-
wards  upon the perinseum, and pointing to  the  hollow of the sacrum.
If you find any difficulty—as you probably will if the  case be a first
labour—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 by expulsive action will partly
mask  that  caused by the manoeuvre; and expulsive  action tends to
                                                            m  2 
164
OBSTETRIC OPERATIONS.
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 inwards before  the  fingers.   This is counteracted  by
drawing the labia open by the thumb of the right hand, by 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 extracted a mature child without passing in more than two fingers,
without even turning back or soiling  the  cuff  of my  coat; but the
circumstances must  be  favourable to  admit of this.

                              Fig.  64.
REPRESF.NTS 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, whilst the left hand pushes the shoulder across the brim towards the left iliac fossa.

  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 passing 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.  (Fig. 63.)   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 woman's 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 towards the left ilium,  the hand 
BI- POLAR TURNING.
165
outside pressing the breech across to the right  side and downwards
towards the right ilium.  The movements by which this is effected are
a combination of continuous pressure and gentle 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.   (Fig. 64.)  Commonly,
you may feel the firm breech through  the abdominal walls under  the
palm, and this supplies a point to press against.  A minute sometimes,
seldom 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.
                              Fig. 65.
REPRESENTS THE SECOND ACT OF BI-POLAR PODALIC TURNING.
  The trunk being well flexed upon itself, the knees are brought over the brim; the forefinger of
 *e left hand hooks the ham of the further knee, and draws it down, at the same time that the
 right hand, shifted from the fundus and breech, is upplied, palm to the head-globe, in the ilium,
 and pushes it upwards. The arrows show the opposite directions imparted to the two poles by
 the two hands.

   Now, it is important to keep the breech well  pressed down, so as to
 have it steady whilst you attempt to seize  a  knee (see  Fig. 64).  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 further one is, on the  whole,  to be preferred.
 You will observe in the  diagrams, Figs. 64,  65, that the legs, doubled
 up on the abdomen, bring the knees near the chest, so that, as soon as
 the head and shoulder are pushed on one side, the knees come near the
 os uteri.
  The knee  being seized, the  further progress of the case is under your
command.  By simply drawing down upon the part seized, you may 
166
OBSTETRIC  OPERATIONS.
often complete version.   But it will greatly facilitate the  operation to
continue to apply force to the two poles.  You will observe in  Fig. 65
that the hands have changed places in relation to the two  poles of  the
fcetal 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 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 upwards
in response to, and in aid of, the downward traction  exerted on  the
child's leg.   This outside manoeuvre  singularly facilitates  the  com-

                               Fig. 66.
REPRESENTS THE THIRD ACT IN PROGRESS.
  The right hand continues to push up the head out of the iliac fossa ; the left hand has seized
the further leg, and draws it down in the axis of the brim. Version is now nearly complete.
The arrows show the opposite directions given to the two poles of the child by the hands.

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.
  The Third Act.  (Fig. 66.)   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 the front of 
BI-POLAR  TURNING.
167
the mother's pelvis.   This  rotation  depends  upon a natural  law  of
adaptation  of the two parts.  You  are  not 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 oniuard 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

                                Fig. 67.
          REPRESENTS THE COMPLETION OF THE THIRD ACT OF PODALIC TURNING.

  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 long axis of the child is now coincident with the axis of the pelvis. If extraction is
necessary, the forces of both hands, traction and pushing, are exerted in the same line as shown
by the arrows.

to tl^e pelvis as to enable it to pass  with the greatest facility.   So it is

when we  supply 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 drawmg upon the leg, and

Nature will do the rest.  You will feel the leg rotate in your  grasp,

and the back  will gradually come forward. 
168
OBSTETRIC OPERATIONS.
  I have said that, upon the whole, the farther knee is the  better one
to seize; but if you compare Figs. 65  and 66, you will see that, by
drawing the nearer or anterior  knee, you  would directly  secure the
rotation of the child's back forwards ; 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 more easy to seize.  But in  cases where the
liquor amnii has long been lost, and the child is fixed, "balled-up,"
by  the   contracted  uterus,  the  farther  knee is the best to  seize.
Drawing  upon  this, exerts diagonal leverage  upon  the  trunk, and
therefore lifts the  presenting shoulder more surely  from  the pelvic
brim.   (-See Lecture XV.)
  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  wiU proceed to this operation. 
LECTURE   XIV.
 THE OPERATION  OF EXTRACTION  AFTER  PODALIC  VERSION, OR  OTHER
     BREECH-FIRST LABOURS—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 labour  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 favourable breech-first labours, whether  the breech or feet have
 originally presented, or have been brought to present by art, care on
 the  part of the  practitioner 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 podahc
 extraction will embrace,  and apply  to,   all the cases  in which  this
 operation is called for.   We will  begin with the most simple case—
 that in which there  is  no serious complication,  in the shape of  pelvic
 contraction, excessive size of the child, or resistance by the  soft  parts.
 It is either a case  of inertia, or one in which  prompt  delivery or  the
 acceleration of  labour is  indicated in the interest 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.   Li
this  security consists one  of the main arguments in  favour  of podalic
version.  We have divided the operation of extraction into three acts : 
170                 OBSTETRIC OPERATIONS.
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.   (Fig. 68.)  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 rotation will

                              Fig. 68.
REPRESENTS THE FIRST ACT OF EXTRACTION.
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 extracting force  forwards  in the axis of the
outlet.
  When the  breech has come to the outlet, the extracting force is
directed a little forwards, 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 prepara- 
EXTRACTION AFTER TURNING.
171
tion for the easy passage 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 forwards across the child's
abdomen, you  may facilitate the liberation of the leg.  When both
legs and breech are outside the vulva, you  have acquired a consider-
able 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 the thumb of one hand.  It is generally
desirable to interpose a thin soft napkin between and around the ankles.
It gives a better hold, and lessens the risk of contusion.
   And if you still want  more power,  you can grasp the child's body
just above the hips  with the  other hand.
   Traction  may now be greatly aided by pressure upon the fundus
uteri, pushing  the  child down.
   Traction  must now again be directed in the axis of the brim, in
order to bring the  shoulders through that aperture.   The shoulders
will enter in the same  oblique  diameter, back forwards, 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 friction 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—that is, generally,
on one side  of the  promontory of the  sacrum; and you must further
take care to keep  off the  pressure of the vulvar sphincter upon it by
guarding it  with your fingers.  From time to time feel the cord, to
ascertain if  it continues to pulsate.  If you find the pulsations getting
feeble or intermittent, you have an indication to accelerate extraction.
   The observations of May and Wigand upon this point are worthy of
attention.   Seasoning that the pressure suffered  by the cord affects
the vein more than the arteries,  and  hence that  the  access of blood
to the fcetus is hindered,  whilst  the  removal  of  the  blood from the
foetus is little obstructed, so that  a fatal anaemia results, they advise to
fie 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.   Von  Bitgen says  he  has often done
this,  and   affirms  that  when  done  there is little  need  to  hurry
extraction.
   The second act comprises the liberation of the arms.   In the normal
position of  the fcetus the  arms  are  folded upon   the breast, and if
the trunk and shoulders  are  expelled through  a normal  pelvis by the
natural efforts,  they will  commonly be born in this position.  But if 
172                 OBSTETRIC OPERATIONS.
ever so little traction-force  be put upon the trunk, the arms, being
freely movable, encountering 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 fcetus,  increased by
the thickness of the arms, forms a wedge which is very apt to stick in
the brim.   This is one great reason 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 observed.  What are these
rules ?
                             Fig. 69.
REPRESENTS THE MODE OF LIBERATING THE POSTERIOR OB SACRAL ARM.
  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  downwards,
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 downwards 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.  (See Fig. 69.)
  The cardinal rule to  follow is to observe  the natural flexions of the
limbs, always to bend them in  the direction of  their natural move-
ments.   The arms, therefore, must  always be brought forwards 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 
LIBERATION OF ARMS.
173
the shoulder between the acromion and the neck; then slide the fingers
forwards, 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 forwards the forearm follows.  Your fingers continuing
to glide down will reach the bend of the  elbow, and, still continuing
the same downward  and forward movement across the child's breast
and abdomen, 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;  therefore it is best to  take the posterior
arm first.
                              Fig. 70.
REPRESHNTS THE MODE OF LIBERATING THE ANTERIOR OR PUBIC ARM.
  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 of your finger.   Carry the child's body well
forwards, bending it over the symphysis pubis.  (Fig. 69.)   The effect
of this is a  twofold advantage.  Space is gained  between  the child's
body and the sacrum for manipulation;  and  as the child's body revolves
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 backwards over
the coccyx as a  centre.   This brings down the pubic arm.  (Fig. 70.) 
174
OBSTETRIC OPERATIONS.
  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 rotation  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.   (Fig. 71.)  Then,  your object
being accomplished so far, you call to your  aid the  first  manoeuvre,
and  bring  this arm  completely down.   This done,  you reverse  the

                              Fig. 71.
                 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.

action and rotate the trunk in the  opposite direction.   The  sacral arm
is thus brought to  the front of 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 circumstances  of  difficulty it
is  exceedingly valuable.   The rotation 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 lessened.
  A paramount reason why you  should be careful in imparting rotation 
EXTRACTION OF HEAD.
175
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.   The  atlas forms with the  axis a rotatory
joint, so constructed that if the movement of rotation of the head be
carried  beyond  a quarter of  a circle, the  articulating surfaces part
immediately, and the spinal cord is compressed or torn.   Thus, if the
chin  of the  fcetus  pass the shoulder  in  turning backwards, instant
death results.  I have no  doubt  that many children have been lost
through oblivion of this fact.
                               Fig. 72.
            REPRESENTS THE RESULT OF THE MANOSUVRE BEGUN IN FIG. 71.
       By rotating the trunk from right to left, the left arm is thrown across the face.

  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 under its chin, running  your finger down as near
the  elbow as possible, so  as  to lift  this  part, as it were,  over the
obstruction.
  The arms liberated, now begins the third act, the extraction of the
head, often a task of considerable difficulty, and always demanding the
strictest  observance  of  the  laws which govern  the mechanism of 
176
OBSTETRIC OPERATIONS.
labour.   This act  differs  from  the  two  first in that,  whilst  these
are sometimes effected by Nature, the liberation of the  head must
often  be conducted by art.  When the head is  last, and has entered
the brim, it is very much removed from  the influence  of expulsive
Fig. 73.
                  REPRESENTS THE EXTRACTION OF THE HEAD.
 The dotted line is the curve of Carus, which indicates the direction to be observed in extraction.

action.   The uterus can with  difficulty follow it into the pelvis,  and
the trunk, unless supported  by the hands,  would, by  its mere vis
inertia 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 
                      EXTRACTION OF HEAD.                  177

 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  per-
 formed—namely, the child's life.  Let us suppose 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,  whilst you lift  up and hold  back the perinaeum,  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  of  artificial  trachea, communication  with  the
 external air ; or better  still, Richardson's bellows.  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.  The application of the forceps to  the after-coming head is
 described  and figured.   (See Lecture V.)   It has been advocated  by
 Busch,  Meigs, Bigby,  and others.  It  is to be  preferred to manual
 traction, because it avoids pulling upon the cervical  articulations.
 If you  decide upon  manual extraction, remember that the head  has
 to perform a treble  movement in  its progress.  It must  first revolve
 around the promontory; secondly,  around the symphysis ;  and thirdly,
 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 extract-
 ing, 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 curves of Barnes and 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,
 whilst 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 whilst force will  never compensate for want of skill, it
 is  astonishing how far skill will carry a very moderate force, especially
 if  firm pressure upon the fundus uteri  be  made to aid traction.   To
 practise this with the greatest advantage, the patient should be on her
 back.   The modes of extricating  the  head  under circumstances of
 unusual difficulty will be discussed  hereafter.  But before passing on I
must refer to one  practice commonly taught, which is, I believe, based
                                                             N 
178
OBSTETRIC OPERATIONS.
on  erroneous  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 in correspondence
with the axis of the pelvis.  Now this  is a piece of truly "meddlesome
midwifery," because it  is  perfectly unnecessary.   The  chin  is  not
likely to be caught on the edge of the pelvis or elsewhere, unless by a
previous piece  of  "meddlesome midwifery,"  you have  been busy in
" giving the turns."   The truth is, Nature has taken care to arrange
the convenient adaptation of means to end in head-last  labour as in
head-first.  It  is true that the occipito-spinal joint  is seated behind the
centre.  It might, prima facie, appear that the occiput, forming 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 upwards, is surely  caught by
the walls  of the parturient  canal as the head descends.   The  greater
friction thus experienced by a larger  superficies  favourably disposed
virtually converts the shorter arm of the lever into the more powerful
one ; it is  more retarded in its course (Fig. 72); and  therefore the
chin is kept down near  the breast, and therefore, again, there is no
need for the obstetrist to meddle  in the matter. 
LECTURE   XV.
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  ILLUS-
     TRATED.

So long as there is any liquor amnii present in  the uterus, and often
for some considerable time afterwards, the bi-polar  method  of turning
is applicable.   But a period arrives when it becomes necessary to pass
a 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, naturally concentric or centripetal,
tends to  shorten  the  long axis of the  child's  body.   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—that is, "balling  the
foetus."   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 preparatory measures.
It is only necessary here to  call to  mind that chloroform, ether, 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 in  Lecture XIII. some of the reasons why
the left hand should be preferred.  In the majority  of cases the child's
back is directed forwards.  To reach the legs, which  lie on the abdomen,
your hand must  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  proceeding 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 towards the mother's  spine, and then
                                                          n 2 
180                 OBSTETRIC OPERATIONS.
to drag them down over the child's back.   If you  attempted this, you
would probably get into a difficulty.  The child, perhaps, 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.
   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.
   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 mother's 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
liand into the vagina, along the  inside of the child's arm.  The passage
of the brim,  filled with the child's shoulder, is often difficult.  Proceed
gently, stopping when the pains come on.   At  the same time support
the  uterus externally with your  right  hand.   Sometimes  you  may
facilitate the passage of the brim by applying the palm of the right
hand in the groin, so as to get below the head and to push it up.  This
will  lift the  shoulder a little out  of the brim.  Or you may adopt  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 forwards, 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. 
OPERATION  OF  TURNING.
181
  Sometimes advantage is to be gained by placing the patient  on her
elbows and knees.   In this position you are favoured by gravity, for the
weight of the foetus and uterus tends to  draw the impacted shoulder
out of the brim.
  The brim being cleared, your hand passes onwards into the cavity of
the uterus.   This  often excites spasmodic contraction, which  cramps
the hand and impedes its working.   Spread the hand out flat,  and let
it rest until the contraction  is subdued.   In  your progress you must
pass the umbilicus, or a loop of umbilical cord may 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 transmitted 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 ivould you seize ?  It is still not uncommon
to teach that the feet should be grasped.   You will see pictures copied
from  one text-book to  another,  representing this  very unscientific
proceeding.  There ought to be some good reason for going past the
knees to  the feet, which  are further 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 reasons :—The child's life  is more frequently preserved
 where  the  breech presents 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 leg being down, is  eleven to
 twelve and a  half inches, whilst 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  Sir J. 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, which,
 representing the opposite pole, cannot be moved without directly acting
 upon the presenting shoulder.  If the opposite knee be drawn down, 
1.S2
OBSTETRIC OPERATIONS.
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 complete, 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. 74 from Scanzoni
(Lehrbuch der Geburtshiilfe, 4th  edition, 1867),  in order to show you
the error in practice which I wish you to avoid.  It represents a dorso-
anterior  position,  the right shoulder  presenting,  and  the method
recommended by Scanzoni.  The operator's left hand is seizing and
drawing down the right leg.   I have introduced  the  arrows to indicate
the direction of the movements sought to be imparted.  You want the

                              Fig. 74.
                            After Scanzoni.
 TO SHOW THE ERROR OF ATTEMPTING TO TURN BY SEIZING THE LEG OF THE SAME SIDE AS THAT
                       OF THE PROLAPSED SHOULDER.

shoulder to run up whilst you draw down the leg.  Now, drawing on
the right  leg necessarily tends to bring it  towards  the shoulder, the
line of motion 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. 75 and 76, which  I have designed
to show the true method and  principle of turning.   The arrows as
before, indicate the  direction of  the movements.  By drawing  upon
the opposite  knee  to  the presenting  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 causinc
the whole trunk to revolve; and the right shoulder  will necessarily 
                         ERROR  IN  TURNING.                     183

rise.   To turn  effectively,  the  child must  revolve  upon its long  or
spinal  axis,  as well  as upon  its  transverse  axis.   Turning, in short,

                                  Fig. 75.
 SHOWING THE PRINCIPLE OF TURNING BY BRINGING DOWN THE KNEE OF THE OPPOSITE SIDE 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.

                                  Fig. 76.
                          SHOWS TURNING IN PROGRESS.
As the left knee descends, the trunk revolves on its transverse as well as on its long axis, and
                      the right shoulder rises out of the pelvis.

is a compound or oblique movement between rolling over  on the  side
and the somersault. 
184
OBSTETRIC OPERATIONS.
  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 maintaining 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 opposition 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. 77 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 in-
                  genious 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
these I think the simple apparatus of Braun or  Boberton,   which
also  serve  for the reposition  of the umbilical cord, are  as efficient as
any.  The wire-ecraseur forms  an excellent  snare  to seize a foot.
A loop just large enough for the purpose is made, and  guided over
the ankle.  It can be  slightly drawn  in to fix the  grasp, avoiding,.
of course, cutting  into  the limb.
BRAUN S SLING-CARRIER,
TO APPLY A LOOP ROUND
THE FOOT, OR TO REPLACE
THE UMBILICAL CORD. 
LECTUBE  XVI.
TURNING IN THE ABDOMINO-ANTERIOR POSITION—INCOMPLETE VERSION,
    THE  HEAD  REMAINING  IN  ILIAC  FOSSA, CAUSES  OF--COMPRES-
    SION  OF  UTERUS,  TREATMENT  OF--BI-MANUAL  OR  BI-POLAR
    TURNING WHEN SHOULDER  IS  IMPACTED  IN  BRIM OF  PELVIS--
    IMITATION  OR FACILITATION OF DELIVERY  BY PROCESS  OF SPON-
    TANEOUS  EVOLUTION--EVISCERATION--DECAPITATION--EXTRAC-
    TION  OF A DETRUNCATED HEAD FROM THE UTERUS.

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,
whilst you pass your right hand along the inner aspect of the child's
arm and behind the symphysis pubis ; it proceeds across the child's
belly to seize the  opposite knee.  Drawing this down in the direction
of the arrow in Fig. 78, 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 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.
  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 manipulation is carefully pursued, and unless the opposite
knee  be seized.   The  head may commonly be felt throughout the
entire process  nearly fixed in the iliac  fossa, and  sometimes the fore-
arm 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 between spontaneous version  and spontaneous evolution.
The diagrams Figs. 79 and 80, taken from memoranda  made of a case 
186
OBSTETRIC OPERATIONS.
which occurred to me, will serve to illustrate both this feature of incom-
plete turning and the importance of the principle of drawing upon the
leg opposite to the presenting shoulder.
  If the head and shoulders  rise enough to permit the breech to enter
the brim, delivery will not be seriously obstructed.   But it not uncom-
monly 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  bi-polar
principle must be  called into action.  It is obvious that if you draw
down upon the  leg, whilst you push up the shoulder, you would act at
a great advantage.   But you  cannot get both  your hands  into the

                              Fig.  78.
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.

pelvis.  Sometimes you may release the shoulder by external mani-
pulation, pressing up  the head by the palm of your hand insinuated
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 admit 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 or bowline 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.  (See Fig. 81.)
Often you will have to act with one hand only in the vagina, the hand
outside holding  on the  free  end of the  tape ready to tighten the
noose as soon as it  has got hold.   Or, whilst holding the foot with one 
TURNING.
187
hand, you  may carry the noose  by help of Braun's instrument.  (See
Fig. 77.)   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 room that, whenever  you push, there is  a tendency to carry
the leg up as well.  The most effective movement is as follows :—Pull
and push alternately.  Presently you wiU find  the leg will come lower,
and the prolapsed arm will rise.
        REPRESENTS AN ABDOMINO-ANTBRIOR 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.
   In pushing the chest and shoulder, it is  not unimportant in what
direction  you push.  You  cannot push backwards, or  even directly
upwards.   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 Von Deutsch.  Push the shoulder and adjacent part of  the chest
well forwards, so as  to make them describe  a  circle round  the pro-
montory as  a centre.   The reviewer of the first edition of this work
in the American  Journal  of Medical Sciences  calls  attention to the
practice of pulling upon the opposite arm to produce rotation on the
spinal  axis.  I  have  never tried it,  but it is  clearly a resource to be
borne in mind. 
188
OBSTETRIC  OPERATIONS.
  Various 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 instrument, 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.
  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.

                               Fig. 80.
           REPRESENTS THE CORRECTION OF THE ERROR COMMITTED IN FIG. 79.
 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.

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, consequently, 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  labour—a condition,
especially if  the child were also of small size, most favourable to  the
carrying out of this process of spontaneous evolution—or the child  has 
EVISCERATION.
189
been destroyed under the long-continued centripetal 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 observation will  soon enable  us to
determine how far this desirable solution of the difficulty is probable,
and when we ought to interpose.  If the pelvis be roomy in proportion
to the child ; if  the  child be dead, small, and very  flaccid ; if we find
the side of the chest making progress in descent under the influence of
                               Fig. 81.
UEPRESF.NTS THE BI-POLAR METHOD OF LIFTING  AN  IMPACTED SHOULDER FROM THE  BRIM  OF
                   THE PELVIS, SO AS TO EFFECT VERSION.
strong uterine  action  possessing an expulsive  character, 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 have
ceased to act expulsively, and the  patient's strength  be failing, her
pulse rising, we must  help.   Then comes the second question :  In
what manner ?   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. 
190
OBSTETRIC OPERATIONS.
  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' curve, will commonly
effect delivery  without  difficulty.  This  operation  is represented  in
Fig. 82.
                              Fig. 82.
  REPRESENTS EXTRACTION AFTER PERFORATION OF THE CHEST, AND DELIVERY IN IMITATION OF
                         SPONTANEOUS EVOLUTION.

   Sometimes  perforation  and  evisceration  are  insufficient in  them-
selves, 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
Von Hoorn.
   The recognition, or at least the application,  of this proceeding is  so
inadequate, that I think it useful to state the arguments in favour of it
with some fulness. 
BISECTION  OF  CHILD.
191
   The  late Professor Davis, in his great work,* a  work too much
neglected by  his  successors, 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 of the
child at the neck."  Again, he  says:  "It ought to be an established
rule in practice to decapitate in arm-presentations not admitting of the
safer  performance of turning."
   Dr. Bamsbothamj  also  says :—" It appears to me better  practice
either to eviscerate  or decapitate  the  fcetus, than to endeavour to
deliver  by turning, in  all cases where the uterus is so strongly con-
tracted  round the child's body as  to  cause apprehension  of its being
lacerated by the introduction of the hand ; because if such a degree of
pressure is exerted on  it as to render 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."
   The  justness of the rule thus distinctly expressed by Davis  and
Bamsbotham  is  attested by  the practice  of  the  most  eminent Con-
tinental practitioners.  Decollation has been  advocated and practised
by l'Asdrubali (1812), by Paletta,| by Braun of Vienna, by Dubois, by
Lazzati of Milan,§ and by many others.
   When in presence of a case such as that described we may select one
of two  modes of  delivery.   Passing by the imitation  of  spontaneous
evolution just described, we  may (1)  bisect or break down the spinal
column at the most bulging part.  This  is  called " Spondylotomy."
(2) We may bisect at the neck—that is, decapitate.   There is a third
plan  which it is well to  know, although it is less scientific than  the
two preceding.  It is to cut off both arms  at  the  shoulder.  We  may
thus  gain space to get at the feet and turn.
   1.  Spondylotomy, or bisection of the trunk.—The principle of this
operation is to facilitate the complete doubling of the body.  It may be
likened  to  breaking  a bent stick in the middle,  thus destroying  the
bow or arc, and allowing the two pieces into  which the stick has been
resolved, to come through parallel and close to each other.  It is to be
preferred when the head is retained above the brim, and access to the
neck is rendered difficult by the bulging of the chest and trunk.   The
spine  is to be divided at the most prominent part.   This may  be done
by strong scissors, by the  craniotomy-perforator, by a knife, or some-
times by getting a strong cord round the body and cutting through the
whole trunk  by a sawing movement.  Extraction  when the  trunk is
thus  broken is generally not difficult.  The  base of the obstructing

              * "Obstetric Medicine."
              t " Medical Times and Gazette," December, 1862.
              X " Del Parto per il Biaccio," Bologna, 1808.
              § " Del Parto per la Spalla," 1867. 
192
OBSTETRIC OPERATIONS.
wedge is  materially reduced, and  still greater facility  is gained for
compression.  But it may still  become necessary to extract  the two
parts of the severed body separately.   In this case we should take  the
lower  extremity  first, seizing  it  by the  craniotomy-forceps.  This
extracted, the other end, to  which the head is attached, may be dealt
with in like manner.
   2. Decapitation, or bisection at the neck.—Various  instruments
have  been designed to effect decapitation.   Bamsbotham's  hook  is
perhaps best known in this  country, and  it  has  served  as  a model
for several  modifications  made  abroad.   It is named after the first
Bamsbotham.  It was described and recommended by Professor Davis.
It consists of a curved hook, having a cutting edge on  the  concave
part,  supported on a  strong straight stem,  mounted on  a  wooden
handle.  Professor Davis also  used another intrument, 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
neck, and then, by a to-and-fro or sawing movement, effected by cross-
bars of wood on the ends to serve as  handles, to cut through the parts.
Dr. C. Bell suggested the use of  an instrument like that for plugging
the nares  in epistaxis,  to  carry a cord.   Dr. Bitchie designed an
instrument  like an ecraseur, with  a perpetual  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 some-
times 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 divided 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  Wharn-
cliffe blade.
   The favourite instrument in  Germany and Italy is Braun's blunt
hook or " decollator."   Dr. Garthshore 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,  including  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 described  as con-
sisting of  three stages.   The  first  stage  is the   application of  the 
DECAPITATION.
193
decapitator  and the bisection of the neck;  the  second is  the extrac-
tion of the trunk ;  the third,  the extraction of the head.
   The First Stage.—The patient may lie on her left side or on her
back.  Take Kamsbotham'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
                               Fig.  83.
             REPRESENTS THE FIRST STAGE OF DELIVERY BY DECAPITATION'.
  The dotted outline shows how the hook (Ramsbotham's) is introduced, lying flat upon the back
of the child's neck, the beak being then turned over the neck, and meeting the lingers of the left
hand on the anterior aspect.
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 relations of the prolapsed arm and
exploration  with  the hand internally  will inform  us as to these par-
ticulars.   The next  step is to  get  an assistant to pull down  the
prolapsed arm, so  as to bring  down the shoulder and  fix  it well.
This  brings the  neck nearer within reach.   Should the assistant in
this duty be in the way, you may seize the prolapsed arm by a clove-
hitch on  cord or tape, upon which the assistant may pull, keeping
                                                              o 
194
OBSTETRIC OPERATIONS.
quite clear of the operator.   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 dotted outline in Fig. 83, 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  received,
guided, and adjusted by the fingers of the left hand.   The instrument
being in situ, whilst cutting  or breaking  through the neck, it is still
desirable to keep up traction  on the prolapsed arm.   In using Bams-
                              Fig. 84.
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.

botham's  hook,  a  sawing  movement  must  be  executed,  carefully
regulating  your action by aid  of the fingers applied to the beak.  If
Braun's decollator be  used,  the movement employed is  rotatory,  from
right to left, and at  the same time, of course, tractile.   The instru-
ment crushes or breaks through the vertebrae.   When the vertebrae
are cut through, some shreds of soft parts may remain.  These  may
be divided by scissors, or be left to  be torn in the second stage of the
operation.
   The Second Stage:  The Extraction  of the Trunk.—The wedge
widening above the brim, that hitherto obstructed delivery, is  now
bisected, divided into  two lesser masses, each of  which  separately can 
EXTRACTION OF DETRUNCATED  HEAD.          195
readily  be  brought through  the pelvis.   By  continuing to pull upon
the prolapsed arm the trunk will easily come through, the head being
pushed  on  one side  out of the  way by  the advancing  body.   (See
Fig. 84.)   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.
  The Third Stage :  The Extraction of the Head.—The problem, how
to get away a detruncated head left behind in 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 connections  of the bones are  broken  down by decomposition, and
the whole becomes a  plastic  mass, easily  compressible.  Such  a head
                              Fig. 85.
        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' curve.
 will sometimes be expelled spontaneously.  I have taken away a head,
 in the circumstances under  discussion, 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 four modes of action.
 The crotchet, the forceps, the craniotomy-forceps, or  the cephalotribe
 may be used.  If the crotchet can be passed  into an orbit,  or into the
 cranial cavity, getting a good hold, this plan may answer.   The objec-
 tion to it is the difficulty of getting such 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  crotchet.
                                                          o  2 
196
OBSTETRIC  OPERATIONS.
    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,—extraction 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.
    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 per-
  forate.  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  the soft parts  of the  mother.   To obviate this diffi-
  culty, 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 drilUng, screwing, boring  motion, partly by pushing,  perforates
 the  cranium.  The drilling  movement  avoids the necessity of using
 much pushing force, and thus  lessens  the  risk  of the instrument
 slipping.*   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' 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 regulating the force and direction
 of traction.
   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, having first performed craniotomy, is invaluable.

   * 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 per-
 pendicular, and the  point is almost certain to glide off.  They  are not fitted to
 economize pushing-force, by drilling or boring, as  a good straight perforator is.
 Indeed, almost all the ordinary perforators sold in the shops are wretched instru-
 ments.  They will serve in those easy cases  where it may  be  doubted whether
 craniotomy is necessary or justifiable ; they will fail in cases  of serious difficulty.
 The superiority of a straight powerful perforator like Oldham's will not be disputed
 by any one who has  had to perforate  under difficulties;  The trephine-perforators
 are not applicable to the case under discussion,  owing to the difficulty of fixing the
 head.   It may be interesting to mention that  Celsus  distinctly points  to the
 necessity of fixing  the head left in utero, by firmly compressing the uterus with
 two hands, so as to push the head down upon the os; extraction was  then made
with hooks. 
LECTUBE   XVII.
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
     —THE  INDICATIONS  FOR  TURNING IN CONTRACTED PELVIS—THE
     OPERATION.

We  now  come  to  a long-contested and still undecided  question in
obstetric practice—Is turning ever justifiable as a  means of  delivery in
labour obstructed by pelvic deformity ?
  The next  alternative in  the descending scale of operations is a
transition from conservative to what may be distinguished 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, which must otherwise be condemned to
the perforator, without injury or danger to the mother ?  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  application of turning
to them ?  And if  we err by turning in mifitting cases, what  is  the
penalty incurred ?—how can we retrieve our error  ?
  These questions I will endeavour 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 perfection of these operations, and by the 
198
OBSTETRIC OPERATIONS.
 relative skill in them possessed by the individual operator.   And in
 estimating the arguments of different authors, we must bear this law in
 mind.
   The operation of extracting a child  through a contracted  brim has
 no doubt often been performed as a matter of assumed necessity, as,
 for example, when the shoulder has presented ;   and contraction of the
 pelvis is certainly a cause of  shoulder-presentation.  The observation
 of such cases, a certain proportion 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 labour.   Thus Deventer, who  wrote in 1715, as well as
 La Motte, declaimed against the use of instruments, and recommended
 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 me evident
 that,  in the early part of the  last century, turning was better under-
 stood 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 instrument,  feeble and  imperfect as  it  was.  He   failed  igno-
miniously.  As science advanced, 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 mutilation.
  It is, then, from the time of Smellie and  Levret, who perfected and
used the long forceps, that the real interest of the inquiry  dates.  It is
not a little remarkable that amongst 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 
                 TURNING  IN NARROW  PELVIS.              199

Smellie in 1752,  chaUenge  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
when it is impossible to turn or to deliver with the forceps ; and this
is seldom the case  but when  the pelvis is too narrow,  or the head too
large to pass, and  therefore rests above  the brim."
  Pugh, of Chelmsford (1754), who advocated the long forceps, says:—
" When the pelvis is too smaU 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 result of these two
modes, " I have never opened one head for upwards 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 first three
having  been  extracted after  perforation.  La ChapeUe (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  amongst those who reject the
long forceps that  the  strongest opponents of  turning in contracted
pelvis are to be found.   This is the more astonishing  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 relates a striking  case in
illustration of  its  advantages.   He  delivered a woman  of  her  eighth
child, alive, at  the fuU period, all her  other  children  having been
stillborn.   " The success of  such attempts," he says,  "to preserve the
life of a child is very precarious, and the operation of turning a child
under the circumstances before stated is rather to be considered  among
those things  of  which an  experienced man  may  sometimes 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 teaching,  obstructed the
progress of knowledge, and  enforced a slavishly  timid, yet barbarous
practice, which still persists  in some degree down to the present time. 
200
OBSTETRIC OPERATIONS.
That the precepts and practice of Smellie and his immediate disciples
were infinitely 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.   Thirty years ago, or less, craniotomy was
still  frightfully rife in this town and  in  many  parts of the country.
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  would 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, not less than medicine or surgery, steadiness yet promptitude
in judgment, courage under difficulties, 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,
whilst 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 powerful forceps.  It is  accordingly
in Germany,  France, and  America, especially that  the claim  for the
superiority of the forceps is contended for.
   Stein  (1773) and Osiander the  elder (1799)  preferred the forceps ;
Boer was opposed to  turning.   In France, Baudelocque  maintained
the same doctrine as Stein and the elder  Osiander ;  and the recent
experiments  of Joulin,  Chassagny, and  Delore  with  the  " appareils
a traction,"  by  which a  powerful  extracting  force is added   to
the  forceps,  enabling it to  bring a head through  a greatly con-
tracted passage,  seem to strengthen  the comparative claim  of this
instrument.
   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 ?  Undoubtedly,  the patient will
have to  go through a second operation.   We are driven  to perforate
after all.   We have tried to save the child, and have  failed.   Is  the
mother imperilled by  this attempt and failure? This also  must be
answered 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 
TURNING IN NARROW PELVIS.
201
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 Lecture V. for an
illustration and description of the mechanism of labour in contraction
of the  pelvis from projection of  the promontory.   This  projecting
promontory forms the centre of  rotation around which the head must
revolve in order to enter the  pelvic cavity.  The side  of  the head
applied to this point scarcely moves at aU.   The promontory catches
the foetal skull  in  the fronto-temporal region.   If the coarctation be
decided, the  skull  where  it is caught bends  in.   Nearly  all the
onward movement  is  effected by  the opposite'or  pubic  side  of the
skull sweeping in a circle,  "the curve  of the  false promontory," or
"Barnes' curve," until the equator or greatest circumference has passed
the plane of  the brim, when the whole  head slips into the cavity with
a jerk.   Now, injurious pressure is  avoided on the pubic side by the
smoothness 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. Lijurious 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 cephalhematoma 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 is sufficient to kill the child.
   What follows ?  This obvious corollary  : that the mother will safely
bear that lesser degree of pressure which is required 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 passage of a dead child.  We have here,
 perhaps, carried the  experiment to the  verge of what  is justifiable.
 Beyond this, there being no  possibility  of getting a  child by this
 means, 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, whilst
 calculating upon an  average or  standard head, we may encounter a
 head  above  the standard  in  size or hardness,  and  thus,  in our
 endeavour to  save the  child,  we may find ourselves 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  reject the
 operation accomplish, namely, the  safety of the  mother.   We have
 tried to do more :  to save the child as well. 
202
OBSTETRIC OPERATIONS.
  Is there any great difficulty or danger in perforating after turning ?
I have found none.   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 head.   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 recourse 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  labour—that is, before  the liquor amnii has all
drained away, whilst  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 principle,  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 performed in good time.   In short,
the safety of the mother is secured by carrying through both operations
whilst 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 diameters 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  submitting the decision
of this or any other question in  obstetric practice to a priori argu-
ments drawn from statistics.  It would not be difficult to prove that
the  statistics employed  by  Dr. Churchill and others are a  confused
heap of incongruous  facts, and that rules to guide practice drawn from
them  must  be stultified by  endless 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 
TURNING  IN NARROW  PELA'IS.
203
reasonable care in the selection of cases, and skill in execution, more
than one-half of the children may be saved.   And  to save even one
child   out of twenty is  something  to  set  against  the  deliberate
sacrifice of all.
  Experience here again corrects the foregone conclusion deduced from
statistical reasoning.   The risk to the child is considerably less than
might  be fairly anticipated.  It is a matter of observation 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 towards which the face looks,  and there it is protected
in the  recess formed by the side of the  jutting promontory (see Fig. 86);
so that if  the soft parts are dilated sufficiently to avoid compression of
the cord against the  child's  face, and if the labour can be completed
under  five minutes, or even  a little more, the child has  a  very good
chance indeed.   This proposition is  especially true in  the  case  of
premature labour  with contracted pelvis.   In this case  the  child
may, in the 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 labour 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
" meconium  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.  And even  these would
appear not to be absolute.   Thus, D.  M. Williams relates (Brit. Med.
Journ., 1875) the case of a woman who, when eight months pregnant,
took scarlatina.   Her child  was  born alive at term, the skin desqua-
mating.  Dr. Edis relates (ibid.) a case  of a child weighing  eight
pounds born  alive, all its epidermis peeling off, either from  scarlatina
or syphilis.
  So long as there is tonicity, rigidity, or firmness  of the limbs, life 
204
OBSTETRIC OPERATIONS.
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 suspended  placental  circulation.   When this
is  felt,  it is a  warning to accelerate  delivery, and  to  excite  aerial
respiration.
   The value of turning in moderate degrees of pelvic contraction rests
greatly upon the truth of the  following proposition:—The head will
come through the pelvis more easily if drawn through base first than
if by the crown first.   Baudelocque  affirmed  this proposition.   He
saia :—" The  structure  of the head  is such that it collapses more
easily  in its width, and enters more  easily 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 labours
with much ingenuity.   The proposition has, however, been disputed
by Dr. M'Clintock.*
   It is also contested by Professor  E.  Martin. \   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  observations
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  labour 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 labour again
 is delivered breech first;  the  head exhibits the model globular shape,
 having  slipped through  the  brim without . appreciable  obstruction.
 For examples  see my outlines of heads.}
   In  the  second place,  I have on several  occasions been called  to
 an  obstructed  labour,  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 compressive power, aided by  con-
 siderable and sustained traction, 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
                 * "Obstetrical Transactions," vol. iv., 1863.
                 t "Monatsschr. f. Geburtsk.," 1867.
                 X "Obstetrical Transactions," 1866. 
TURNING IN  NARROW  PELVIS.
205
illustrated by  diagrams how the  head, caught  in the  conjugate at
a point below its  bi-parietal  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,  acquired
by pulling on  the legs and trunk is  as  great as can be exerted  by
any ordinary forceps.   But  there is  another  circumstance  in  the
clinical history of head-last labours in narrow conjugate which  affords
a remarkable illustration  of  this  proposition.   The  head is  rarely,
or never,  seized in its widest  transverse  diameter;  it  is seized  by
the conjugate at  a point  anterior to its greatest  width—that is,  in
Fig.
           REPRESENTS THE HEAD ENTERING A COXTRACTED BRIM, BASE FIP.ST.
 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.
 the  bi-temporal  diameter;  the  bi-parietal and occiput  commonly
 finding ample opportunity for moulding in the freer space left in the
 sides 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.*   Moreover,  the head is  disposed with  a certain obliquity of its
 transverse diameter to the  plane of the brim—Naegele's  obliquity—
 or in its oblique subparieto-superparietal diameter, which is less than
the bi-parietal.   I  think, therefore, it may be taken  as  demonstrated,
                    * " Obstetrical Transactions," 18bo'. 
206
OBSTETRIC OPERATIONS.
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 expected 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 element of the problem—namely, the degree of
contraction of the pelvis.   The other element, the relative size and
hardness 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 limit of  pelvic
contraction justifying the  attempt to  deliver by turning ?  In  other
words, this means :  What  is the narrowest pelvis  that admits  of the
safe passage  of  a normal head ?  This is answered chiefly by experi-
ence.   It is not to be answered by a priori reasoning like that urged
by  Dr. Fleetwood Churchill, who says :*—" The bi-mastoid diameter
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 forceps.  With a pelvis
of this  size,  then, the  operation  is unnecessary ;  and if the antero-
posterior  diameter be less than 2| 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 would be
unjustifiable."
   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  considerable 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 sustained, is not great—rarely
great enough  to reduce a bi-parietal diameter of 4*00" to 3-50" without
killing  the child.   My  opinion,  then,  is  that   a  standard  head,
especially if it happen 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
                * "Theory and Practice of Midwifery," 1866. 
                  TURNING IN  NARROW PELVIS.             207

competition with  the forceps.   I believe  no one advocates resort to
turning when the conjugate measures less than 3", miless the  child
be premature.
  A correlative  proposition  to  the  foregoing  is  the following:—
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 Badford,  Bamsbotham,
and Simpson.   It is confirmed by the observation of the form which
the head assumes under moulding in natural labour, which, as I have
shown, is effected by the lengthening  of the fronto-occipital diameter
and the  shortening  of  the transverse diameter  (Obstetrical  Trans-
actions, 1866).'
  Now, it  is  an almost necessary  consequence that  when the head,
arrested  on a contracted brim,  is seized  by the forceps, 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
narrow conjugate caused by the lateral bulging.
                 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, although canting a little in Naegele's obliquity, must be exposed
in nearly its full width to the narrowed strait.   Even if the side of the
head be indented by the promontory, no important degree of  canting
of the  base can be counted upon.  But if the head should fortunately
be undersized or unusually plastic, there is a fair prospect of  the  child
being drawn alive through a conjugate diameter measuring 3-00".
  Generally,  however, from  3-25" to 3-50",  or even a little more, is
the working range for a child at term.    The great majority 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 ilio-pectineal margin of  the brim  incline
rapidly backwards,  the  occiput  will not find  room.
  The operation is also indicated if, the conjugate  diameter being
3*50" or more, the  forceps  have failed.
  Velpeau (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. 
208
OBSTETRIC OPERATIONS.
  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  ichenever there has  been
obstruction  in delivery.  It  follows,  then, that for  the  operation to
be successful 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  labour 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 presumption 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 readiness  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 admit of the ready version of the child.
  The contra-indications 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.
  It must be remembered that the sudden emptying of the uterus of a
woman far gone in prostration, acting as  a new shock, is apt to increase
the collapsus post 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  necessary 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.
  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 towards the right with the
right hand externally ;  push the head across to the left iliac fossa with 
TURNING IN NARROW PELVIS.
209
the fingers of the left hand passed through the os uteri, and seize the
further knee.   Extraction must be performed at first slowly, so as  to
allow the half-breech to dilate the cervix.  This is especially a case
where hurry is misplaced.    The  extraction should go on slowly whilst
the trunk is passing.   As  soon as the  funis is felt, draw down a loop,
and  direct it towards  the  posterior  wall of the pelvis.  So long as it
pulsates freely, do not hurry.  But if the pulsations flag, lose no time in
liberating the arms.   The  pelvic contraction makes this a  little more
difficult  than under  ordinary circumstances.   (See Figs. 69,  70, 71.)

                                Fig.  87.
  SHOWS THE MODE OF EXTRACTION AFTER TURNING WHEN HEAD IS .JAMMED IN THE CONJUGATE
                                DIAMETER.
  The right forehead fixed against the jutting promontory is the centre of revolution.  The left
side of the head, resting on the pubes, sweeps round in the orbit of the false promontory a b.  To
favour this first movement, traction is made well backwards.  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.

As  soon  as  the arms are liberated,  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
complication, 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
                                                                 p 
210
OBSTETRIC OPERATIONS.
to draw at first as much backwards 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 handkerchief over the neck,  and bringing
the ends in front of the chest, and drawing upon them, as in Fig. 87.
  Great assistance in extraction  may  be gained,  and  traction-force
economized, by  getting an assistant to press firmly upon  the vault
of the head through the abdominal  walls, thus helping to push  the
head  through the  strait.   This  proceeding was advised  by Pugh
and Wigand.   It should be practised  in all cases of  head-last labour.
It economizes  traction-force and lessens dragging on the child's neck.
  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.   Professor E. Martin  describes  three modes
of accomplishing this.
  1. A  suitable position of the ivoman.   Let  her  lie on  that  side
towards  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  towards the brim.   Martin refers  to a  case in
which he  successfuUy 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-presentation, 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  vioe versa.  If, therefore, the right
half of 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,  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 
                  TURNING  IN NARROW PELVIS.            211

into the narrower half of the pelvis.  I have saved children when this
has happened, and Strassmami  relates* some  striking cases  in proof
of this proposition.
  To  determine which side  of the  pelvis is the  more  contracted,
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 the  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-circumferences 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.

               * "Monatsschr. fiir Geburtskunde," June, 1868.
p 2 
LECTURE  XVIII.
MECHANICAL COMPLICATIONS OF PREGNANCY AND  LABOUR :  DYSTOCIA
     PROM  DISPLACEMENT  OF  THE  WOMB :  RETROVERSION--HISTORY
     OF RETROVERSION AND RETROFLEXION OF  THE  GRAVID WOMB—
     ORIGIN  OF RETROVERSION AND RETROFLEXION  IN  THE EARLY
     MONTHS, COMPLETE   AND  INCOMPLETE -- INCOMPLETE  RETRO-
     FLEXION AT THE END OF GESTATION—DIAGNOSIS FROM EXTRA-
     UTERINE GESTATION—FROM PELVIC  CELLULITIS—FROM  RETRO-
     UTERINE HEMATOCELE — PROLAPSUS  AND  PROCIDENTIA  UTERI
     AND  HYPERTROPHIC   ELONGATION   OF  THE   CERVIX  UTERI --
     TREATMENT.

To determine the choice of operations, it is desirable here to study
certain  complications  which  may  impede labour,  presenting great
varieties of difficulty, and demanding a corresponding  range of treat-
ment.   The  uterus itself  may present  abnormalities of development.
Tumours may exist  in its walls, or  in its neighbourhood,  so as to
block the pelvic  canal.   Both kinds of  complications may exert an
injurious influence before the  natural term of gestation, and compel
the physician to weigh the question, whether to deal with the  intruding
complication or to terminate the gestation.  And, if the term of gesta-
tion is  reached, the question, how  the delivery  can  be  most safely
effected, must be solved—and that without much time for  deliberation.
These cases being comparatively rare, no man can expect  to have such
an amount of personal experience as will enable him to form alone safe
rules of practice.   The danger, perhaps  unsuspected until  the crisis is
at hand, culminates quickly.   We can only hope to meet it successfully
by  careful  study of groups of cases, scanning closely in  what the
danger consists, and the success of  the treatment opposed  to it.
  By pursuing this  course, I hope we shall arrive at certain definite
principles which will help  us through most  particular  emergencies.
The first order of cases I propose to  discuss includes certain  abnormal
conditions of the uterus.  These I will class in order:—1.  Retroversion
and Retroflexion of the gravid uterus.  2. Hypertrophy  of  the cervix 
               RETROFLEXION  OF  GRAVID  WOMB.           213

uteri.  3. Prolapsus and Procidentia of the gravid uterus.   4.  Preg-
nancy in one horn of a double uterus.
  The second order includes mechanical obstructions to the development
of the pregnant  uterus, or to the accomplishment of labour, which
arise either in the walls of the uterus or external to it.  We may class
them in the following order:—1.  Tumours in  the walls of the uterus,
including polypi projecting from the walls into the cavity.  2. Descent
of bladder  before the head.   3.  Tumours in  the vagina,  including
hematoceles.  4. Abdominal tumours, including extra-uterine gestation,
ovarian  tumours, retro-uterine hematocele, hydatid tumours of the
liver, cystic disease of  the kidneys.  5. Pelvic tumours, including bony,
cartilaginous, and sarcomatous tumours attached to the  walls of the
pelvis ;  ovarian tumours dipping into the  true pelvis.


                    Retroversion of the  Uterus.

  The relations  of  retroversion to  pregnancy and labour  are very
imperfectly  related  in most text-books.  Indeed, many  of  the  most
important features are scarcely referred to, or are quite misunderstood,
I need  do no more than glance at the  doctrine of Denman,  which
attributes retroversion  of the gravid womb to distension of the bladder.
It is undoubtedly erroneous ; an instance  of to varepov irporepov.   It  is
true,  the severe  symptoms of retention  of  urine, intolerable  pain,
straining efforts, and tenesmus appear more or less suddenly ;  but  it
does  not follow  that  the displacement of the  womb was  produced
suddenly.   So long as the retroverted womb is comparatively small, it
does not press upon the rectum  and bladder  so as greatly to obstruct
the function of these organs.   But  when, in the course of develop-
ment,  the  eccentric  pressure  gradually  increasing,  at last   com-
presses  the  structures  outside the uterus  against the unyielding walls
of the pel Tis, then the distress arises, the bladder is jammed against
the pubes,  and retention  ensues.  It is  an  epiphenomenon—a con-
sequence, not a cause of the retroversion.
  Retroversion and retroflexion are frequent conditions of the non-
gravid womb.  They are frequent in  single women, still more frequent
after child-birth.   In many cases these displacements offer no impedi-
ment to  conception.   And having  begun under  this  condition, so
pregnancy goes on.  I have observed  retroversion or retroflexion of the
gravid womb under all the following circumstances.   First, there  is
the condition of primitive retroversion or retroflexion with prolapsus
persisting during pregnancy ; secondly, it may be a  continuation  of
retroversion or retroflexion  existing  before the  actual pregnancy, the
result  of a  previous  labour.  W. J. Schmitt (1820) affirmed that
retroversion  of the gravid, as well  as of the non-gravid womb,  was a 
214
OBSTETRIC OPERATIONS.
gradual process.  He uses the term " reclination."  He says it may
be overlooked in  the earlier stages, and  until the  severe  symptoms
arise.  This has also been pointed out by Dr. Tyler Smith (Obstetrical
Transactions, vol. ii.), and adopted by Scanzoni.   Thirdly,  the retro-
flexion may have been caused by a tumour in the posterior wall of the
uterus, or by adhesion dragging the fundus backwards.  In the case of
prior retroversion with prolapsus, the heavy fundus is gradually forced
back by the intestines, and being caught under the sacral promontory,
the cervix is tilted  forwards by a persistent leverage action.  Li all
                              Fig. 88.
                      RETROVERSION OF GRAVID WOMB.
The fundus, thrown back, bulges out the perinaeum, flattens the vagina, throws forward the
               cervix uteri, and drags up and compresses the urethra.
these cases the gestation during the early months may be called pelvic
gestation.  The uterus grows within the cavity of the true pelvis, and
becomes locked there when it ought to find room by emerging into the
abdominal cavity.  In several  cases (Bailly, Callisen,  Boivin), narrow-
ing  of  the conjugate diameter  of the pelvis  has been noted  as a
predisposing  cause.
  It must not, however, be concluded that retroversion  of the gravid
womb is always of gradual formation.  It may arise, fourthly, suddenly. 
INCOMPLETE RETROFLEXION.
215
If, for example, a woman pregnant three or four months be subjected
to great and sudden exertion, as by lifting heavy weights, whilst the
bladder is, perhaps, somewhat distended, and thus directing the fundus
uteri  backwards, the  superincumbent  pressure of the intestines will
bear  upon the anterior  surface of the  fundus, and  the uterus, acting
like a lever under  the force applied to one extremity, will roll back,
and may get locked under the promontory. Being there, tenesmus, un-
controllable efforts at defaecation and micturition are produced, and the
pressure of the intestines then acts more directly upon the anterior wall
of the uterus, tending to maintain  and increase the retroversion.  In
this fourth case there may have been  originally no flexion ;  and the
accidental displacement will  be the typical  retroversion  of  Hunter
and Denman, the only form at one  time recognized.  Severe repeated
vomiting  at this  stage of gestation  may also  increase  or  produce
retroversion.
   There is still a distinction to be made—one of extreme  importance.
Retroversion or retroflexion  may be  complete or  incomplete.  This
distinction  is hardly  yet understood.   It has  often  been observed
that  retroversion  of  the  gravid womb  tends  to spontaneous  cure.
This  is  generally  supposed to arise from the uterus liberating itself
suddenly or gradually, as  it enlarges, from the  pelvic  cavity.   Now,
this is true only in  a  certain proportion of cases, possibly not  in the
majority.  What really  takes place in  many  cases  is this : Down to
the end of three or four months of pregnancy, there is pelvic gestation
with retroflexion or retroversion.   At this stage the effects of eccentric
pressure upon the  organs surrounding the growing uterus are  often
felt ;  they may gradually subside ; but  examination  still reveals exist-
ence of the retroflexion.  How, then, has relief been obtained ?  The
ovum continuing to grow, pushes  out that portion of  the uterine wall
which looks upwards  and forwards to  the  abdominal cavity.  This
part is free; and it gradually enlarges to form a secondary sac or pouch
accommodating  the main bulk of the foetus perhaps  to  the  normal
term  of  gestation.   This secondary pouch, or diverticulum,  expands
in the  abdominal  cavity just as  the  whole uterus does in  normal
gestation, whilst the posterior portion and fundus are  retained in the
pelvis throughout.   Towards the end of pregnancy the  predominance
in rate of growth and of  bulk  of the  abdominal diverticulum  is so
great  as to draw the pelvic portion partly out of its lodgment there,
producing  a partial rectification  of the form  and  relations of the
uterus: the os comes nearer to the centre of the pelvis, and  there
is no obvious obstruction  to  labour.   The phenomena  described  I
have distinctly traced and recorded in several  instances ;  and I regard
the process as  an  ordinary  one by  which  Nature releases  herself
from the danger of a  locked retroflexed uterus.   But  sometimes the
course of events is not so favourable.   The development goes on as 
216
OBSTETRIC OPERATIONS.
described, in the two pouches, one  pelvic, one  abdominal;  but the
pelvic  part  of the gestation  remains so  considerable that the  os  is
kept fixed  behind  and  above the  symphysis, so  that  when labour
comes  on it is found that the pelvic cavity is filled with  the uterine
pouch,  containing, perhaps,  the child's  head,  whilst  it is almost
impossible  to  bring  the cervix and os down  into relation with the
axis of the pelvis, so as to  afford  a channel  for the passage of the
foetus.   (See Fig. 89.)   Merriman relates two  cases which appear  to
have been  of  this  kind.  One  of them he  attended with  Denman.
They found the os come down gradually during  the  pains of labour,
as if the uterus were  rolling round to its natural  position.   Merriman

                               Fig. 89.
INCOMPLETE RETROFLEXION OF GRAVID UTERUS.
 o u, os uteri, bent downwards above symphysis pubis;  b, bladder; r, rectum.  One part of
bi-lobed uterus locked in the pelvis contains the head; the  other part, developed in the abdomen,
contains the body of the fcetus.

believed  that  retroversion might continue  to  the end  of gestation.
He did not seize the fact that  retroversion so continued could only
be incomplete.   Scanzoni  {Lchrbuch  d.  Geburtsk., 1867)  says  the
"partial"  retroversion  is rather  a fault  of  form than of position.
It  is always  caused by  the pressure  of the part of the child upon
the posterior  lower  wall of the uterus;  and  is especially observed
when with  slight pelvic inclination the  fundus of the  uterus  falls
down through the relaxed abdominal walls.  The trunk of the child
thus sinking forwards, the presenting head pushes the relaxed  hinder
wall into the  sacral hollow in  form of a sac.   The vaginal portion 
PARTIAL RETROFLEXION.
217
(cervix) is pushed forward.  This form, he says, is only seen in  the
last  two months.   It causes no  interruption to pregnancy.
  Hecker describes a remarkable  case (Monatssch. f. Geburtsk., 1858),
observed in the sixth month.  A pluripara had suffered repeated attacks
of dysuria, at times  threatening abortion ;  at last she took to bed with
crampy pains.  The fundus was  felt about the level of the  navel, the
uterus contracting; the os  uteri  was felt,  with much difficulty, above
the symphysis ; the cavity of the  sacrum was filled by a smooth, elastic
swelling, which compressed the vagina forwards.  This was violently
pressed down with every pain, so that rupture was feared.  After failing
to push the tumour out of the pelvis, it at length rose, and at the same
time another round elastic swelling—the membranes—came down from
behind  the symphysis.   The  child was then delivered.  Dr. Oldham
relates (Obstetrical Transactions,  I860) a still more striking case.  The
patient, a primipara, was at term.  The  head was contained in  the
pelvis, whilst the trunk and breech of the child  were contained in
the abdominal portion of  the uterus ;  the  os pointed downwards,  but
was high behind the symphysis ;  the vagina, of course, was flattened
against the symphysis.  Oldham  contrived  to deliver by pulling down
the cervix, by pressing the breech down by a hand outside, and pushing
up the  pelvic mass.  A sort of rotation took place, the  child  being
delivered by seizing a foot.   Oldham had seen this woman three years
before,  when single ; she  was then  suffering from dysuria and  retro-
flexion  of the womb.
  The following is a condensed account of an interesting case of this
kind, which I saw in conjunction  with Drs. Hilliard and  Brunton.
A lady, a week before term of gestation, complained of headache and
oedema of the face and legs.   The urine was found to contain albumen,
blood-discs, and casts.  Taken in labour, no os uteri  could be  found
until we produced anaesthesia.  I felt the posterior wall of the vagina
closely compressed against the anterior by a rounded, firm mass filling
the cavity of the pelvis. Following the vagina, I felt the os uteri soft and
patulous above the upper edge of the symphysis pubis.  Through  the
os I could feel a hard rounded mass, which I concluded to be a foetal
head covered  by the membranes.  This head came close to the rounded
mass  in the pelvis, giving  the idea  of two heads interlocking.  This
intra-pelvic mass presented a hard  ridge, unlike the  head, and  Dr.
Brunton, on careful auscultation, could only hear one fcetal heart.  The
abdomen was irregular in shape ;  the enlargement was  transverse and
bi-lobed, suggesting twins.   I determined first to try to push up into
the abdomen the mass that occupied  the  pelvis, so as to enable me to
seize the head which lay above the pelvis with the forceps.  This I
succeeded in  doing.  When the mass was  lifted into the abdomen the
os uteri came down into the centre of the pelvis.  The cervix was
then dilated to some extent by bags until I could get the  blades of 
218
OBSTETRIC OPERATIONS.
my long forceps over the head.  Delivery was completed by traction,
extending over an hour and a half.  The child, small, but mature, was
born alive.  The placenta was cast.  Next day child and mother were
doing well.  The case proved to be one of incomplete retroversion;  a
pelvic pouch contained the breech, an abdominal pouch contained  the
head.  The pressure upon the pelvic and  abdominal vessels and upon
the bladder was probably a contributory cause of the albuminuria.
  The  terminations  of  retroversion  of  the  gravid womb  are :—1.
Recovery  by  reposition,  spontaneous  or chirurgical, is, perhaps,  the
most frequent termination.   2. Recovery is also occasionally effected
by the  safety-valve  process  of partial  outgrowth of the uterus  up-
wards  into  the abdominal  cavity.   3. Abortion  is not uncommon.
The immediate  diminution  in bulk of the uterus, and  the  cessation
of the  attraction of blood to the  pelvis,  bring quick relief.   Arthur
Farre says::|:—"The sequelae, when reposition cannot be effected, are
usually premature expulsion of the ovum, or sloughing of the  uterine
parietes, and  slow  discharge of the contents by fistulous  openings
into the vagina, rectum, or bladder."  Some of these cases were most
probably not cases of  retroversion,  but of  extra-uterine gestation. I   4.
Death  by blood-poisoning, the matters which should be excreted by
the kidneys being retained in  the system.   This I believe to be  the
most  frequent cause  of a fatal termination.  It was  the chief cause
in four  fatal cases observed by myself.  5.  C. Braun relates I a case
which  ended  in death under eclamptic attacks  in  consequence  of
Bright's degeneration of kidneys,  and secondary  uraemia.  In many
cases, conjoined with urinaemia, there is  disease of the  bladder, such
as intense congestion, inflammation,  even sloughing  of the mucous
coat.§   Dr. Schatz || relates and figures a well-marked case, in which
not only the mucous coat, but also the muscular coat became necrosed
and entirely separated. Dr. Moldenhauer relates (Arch. f. Gynakologie,
1874) a similar case. A pluripara,  after complaining  eight  days of
dysuria, had complete retention. The bladder was  emptied by catheter,
and reposition  repeatedly tried.  The woman  emaciated rapidly, had
general prostration, and was taken into hospital on the 9th October.
The catheter drew off 100 grammes of  strongly ammoniacal turbid
urine.   In spite of many attempts  the bladder could not  be completely
emptied.  The last  portion drawn  was slimy and purulent, and mixed
with gangrenous shreds, and so thick that it would barely pass through
the catheter.   An impacted retroflexion of the gravid uterus was made
out.  Reposition was effected in the knee-elbow position.  The woman

           *  " Cyclopedia of Anatomy."
           f See a case by Guichard, "Rev. Therap. du Midi," 1857.
           J  " Clin, der Geburtsk."
           §  Haussmann :  "Monatssch. f. Geburtsk.," 1868.
           ||  "Arch. f. Gynakol.," 1870. 
ISSUES OF RETROVERSION.
219-
seemed relieved.   Urine flowed involuntarily.  On the 15th October
she was delivered of a  fresh fcetus  nine inches  long.  The uterus
contracted  to normal size.  Vomiting and collapse set in, and death
took place  on the 17th.  Autopsy:  No mark of recent  peritonitis.
There  were old  adhesions  binding the fundus of  the  bladder to the*
colon and small intestines, forming a bridge which completely obstructed
the rise of the uterus out of the pelvis.  The contracted  uterus  was.

                              Fig. 90.
                        Dr. Chambers' Case.

PARTIAL RETROFLEXION OF UTERUS, CERVIX COMPRESSING NECK OF BLADDER.  DRAWN FROM
         NATURE (HALF-SIZE), FROM SPECIMEN IN ST. THOMAS'S HOSPITAL.
found retroverted.   The bladder, distended beyond the size of a child's-
head, contained  a grey-yellow sac, which was the mucous membrane,.
with a part  of the  muscular  coat, cast  off by necrosis.  The ureters
were not much dilated.  The pyramids of the kidneys were very full of
blood.   G. Death by rupture of the bladder.  This is extremely rare.
Lynn,  of Woodbridge (1771), published  a case ending fatally through
this  cause ;  Van Doeveren,  of Groningen (Specimen Observationum 
220
OBSTETRIC OPERATIONS.
Academicarum, etc., artem obstetriciam pracipue  spectantium, 1765),
gives two similar cases.  I have not noted any recent case.  There are
three compensating factors  which  retard or  prevent  bursting—1st,
dribbling, or overflow; 2nd, stretching of the bladder, to accommodate
a great  accumulation;  3rd,  absorption  from  the bladder.  A fourth
factor  is probable:  oozing through the walls  of the  over-stretched
bladder.   Moreove^ when the retrograde pressure  upon the  kidneys  is
great there is diminished secretion of urine, and a diversion  is effected
to the skin, which throws off abundant perspiration.   Death will occur
from  urinaemia, shock,  and  exhaustion  long before  the  bladder will
burst.   The quantity of  urine that gathers varies from four to ten or
twelve pints.  In Dr. Chambers' case (see Fig. 90) the accumulation  of
urine was enormous.  The woman measured  thirty-nine inches round
the abdomen.   The case was at first supposed  to be ovarian.  Twelve
pints of  urine  charged  with blood,  and having scarcely any urinous
odour, were drawn off.   A foetus of  four or five months' gestation was
removed.   The uterus was fixed  in the pelvis.   At  the autopsy the
bladder was found to contain two  pounds by weight of black  clot.
There was no trace of peritonitis.  7. Death by gangrene of  the uterus
or other parts  compressed.   This is also  extremely rare.  Burns says
inflammation and gangrene of the vagina and external parts have been
produced.   8. Peritonitis,  which may be fatal, or  which may  end
in adhesions.   In none of five fatal cases seen by myself was there
peritonitis.  Death  by  urinaemia and  the   shock of  pain  usually
anticipate the outbreak of peritonitis.   Peritonitis  is  a later event.
Mr.  Misley relates (Med.  Times  and  Gaz.,  1855) a case  in  which,
after  reposition,  the patient died  twenty days  later  of peritonitis.
Adhesions  of intestines  were found, and  the  ureters were distended
fourfold.   In some cases, no doubt, where no post-mortem examina-
tion has been  made, peritonitis has been inferred from the intense
pain suffered during life.  But this sign is  fallacious, since in cases
where peritonitis had been  so  diagnosed, post-mortem  examination
refuted the diagnosis.  9. Shock and exhaustion enter into every case,
but they may be the chief fatal factors.  10.  Rupture of the posterior
wall of the vagina, caused by violence  of the expulsive effort, has been
noted.
  If abortion do not occur during the acute stage it may still follow
reposition,  some days or weeks later.   But  in a large  proportion  of
cases, after  reposition, gestation  goes  on to term.   After labour the
uterus is very liable to fall  back, either immediately or in a few days,
disposing to haemorrhage, primary or secondary.  Amongst the remote
effects, vesico-vaginal fistula, cystitis, chronic catarrh of the  bladder,
disease  of  the  kidneys,  chronic inflammation of the uterus, may be
observed.
  The Diagnosis.—Seeing that the development of the dangerous state 
                 DIAGNOSIS OF  RETROVERSION.              221

is often gradual, it becomes a question of practical interest to study
the early  or premonitory symptoms.   The early subjective  signs  are
those of retroversion or retroflexion of the womb in  a more  or less
aggravated degree, preceded  by the signs of  pregnancy : a sense of
dragging, of bearing-down, lumbo-sacral pain, pressure upon the bowel,
and, above all, bladder-distress evinced in frequent desire to pass water,
with occasional partial retention or dysuria.  I think the rule I have
submitted elsewhere  (Lancet, 1875), to examine the state of  the pelvic
organs whenever there is severe bladder-distress, should  be imperative,
and especially  so  when  pregnancy is  known or  suspected to  exist.
Retroversion, when gestation is but two or three months advanced, is
very apt to lead to abortion; and  if this  danger be escaped from, the
more formidable, perhaps fatal, complications  may ensue.   Thus,  I
have known a  case  in which a woman had been attending a surgeon
for several weeks on account of partial retention ; complete retention
supervened suddenly, and she died from impaction of the retroverted
gravid womb at the fourth month.  Now, these catastrophes can almost
certainly be averted by maintaining the  uterus in  its proper place during
the second and third months by a Hodge-pessary.  At the end of this
time the uterus, having  been kept with its fundus pointing forwards,
will grow into the abdominal cavity,  and henceforward will  support
itself.
   When the  stage of impaction or incarceration has arrived, that  is,
when the uterus is so large as to press injuriously upon the surrounding
structures, the  subjective symptoms are commonly too urgent  to  be
neglected.   The signs are—1.  Those  of pressure; severe pelvic and
abdominal pain.  2.  Shock, the result  of pain, interruption of bladder
and bowel function,  and the  local  violence due to the displacement of
the  womb.  3.  Reflex phenomena, straining or bearing-down,  caused
by the fulness of the bladder, and the pressure of the fundus uteri
upon the rectum.   4. The secondary  or constitutional symptoms, as
urinamia and exhaustion.  In some cases albuminuria has been ob-
served ; the legs may swell.  5.  Numbness  of  the  legs,  suggesting
paraplegia, has  been described by Bedford.
   The objective signs of retroversion of the gravid ivomb ought to lead
to a positive conclusion.   1.  The abdomen, if  the bladder is distended,
is peculiarly prominent; intensely painful to touch ; and percussion
will map out a tense fluctuating tumour occupying the position of the
gravid womb at the sixth or seventh month.   Besonance will be made
out above it, and in either flank.  2. The finger passed into the vagina,
instead of going back towards the hollow of the  sacrum,  is  guided
forward close behind the symphysis pubis, because the posterior wall
of the vagina is compressed  forward  by a firm rounded mass which
fills the sacral  hollow.   Feeling  for the  os  uteri, it is found  to  be
difficult or impossible to reach ;  it is dragged up into the displaced 
222
OBSTETRIC OPERATIONS.
roof of the vagina, perhaps high above the  symphysis.   (See Fig. 88.)
The finger being in the vagina, we ought, by passing the fingers of the
tother hand in above the pubes, to meet it and feel it: but the distended
and painful  bladder prevents this approximation.   3.  This leads at
once to  exploration  by catheter.   And now  a  characteristic sign is
revealed.   The base of the bladder and the urethra attached to the
anterior  wall of the cervix uteri are pulled up, and so  stretched that
the  anterior  wall of  the vagina with the urethra is smoothed out, the
meatus urinarius is  dragged up from its  place, and so  stretched out
that it is sometimes  difficult to  feel, and how  to pass up the catheter
may be  extremely puzzling.   (See Fig. 88.)  This  important  sign,
which I believe distinguishes retroversion of the gravid womb  from
every other condition, was particularly pointed out by Dr. Roper, in a
discussion at the Obstetrical  Society, in 1874.  In the typical  cases
there is complete capsizing of the  uterus without flexion ; the  os  looks
upwards and forwards towards the umbilicus, whilst the fundus points
backwards and downwards towards the coccyx or anus.   This position
of the uterus brings about another symptom scarcely less  character-
istic, to which my attention was drawn by an old pupil, Mr. Max Simon.
 This is: 4.  The bulging of the anus and perineum,  caused by the
 enlarged uterus, especially manifest if  tenesmus and expulsive action
 are set  up.   Under this action  the bulging of  the  perinaeum and
 protrusion  with eversion of the  anus remind  one of  the  stage  of
labour when the head is bearing on the  perinaeum.  This  symptom has
 been several times  observed.   In simple  retroversion it is probably
 seldom altogether wanting.  Halbertsma, of Utrecht, relates a case in
 which the fundus uteri projected through the anus, which was widely
 (opened.  In Dr. Chambers' case the posterior wall of the vagina was
 protruded  through the  vulva.    But  occasionally,  if  certain  cases
 j-elated are not erroneously interpreted, the pressure exerted under the
 stormy  reflex expulsion excited is so great that actual bursting  of the
 posterior tvall of the vagina may  occur. This accident is so important
 that the cases must be briefly cited.  Grenser relates (Monatsschr. f.
 ^Geburtsk., 1857) that  a  midwife  was  called  to  a woman, whom she
 found  forcing down strongly and complaining  of  sacral pains  and
 (obstruction of the bowels.  She found a swelling like a  lump of flesh
 projecting from the vulva.   A physician who was sent  for found the
 woman in collapse.  Thinking the mass might be a mole, he concluded
 he must drag  it away, and so pulled in various directions.   He felt
 compelled to give  in.  Another physician arriving, recognized retro-
  version of the womb.   The woman died in four or five hours.   At the
  autopsy, a  swelling the size of  a child's head  projected outside the
  vulva : this was the  uterus, containing an ovum the size of a hen's
  egg, and the ovaries.  At the back  part of the vagina was  a rent,
  through which the uterus and ovaries were hanging forth, so that tlie 
DIAGNOSIS OF RETROFLEXION.
223
cervix was  still in  the  pelvic cavity.   The case was  submitted to
Grenser for report.  He concluded that the  rupture was spontaneous.
Dubois relates (Presse Midicale, t.  i.) a similar  case.  The gravid
retroverted  uterus came through a vaginal rent.   The woman died a
few minutes after reduction.   This case is related  in detail by Moreau
(Traite prat,  des  Accouch.).  The doubt may be entertained that a
lenient judgment covered ignorant malapraxis.  But it seems irrational
to deny the probability that the accomplished reporters were right.
   When the bladder has been emptied, auscultation in the groins may
reveal the uterine  souffle.  And in some cases the double touch may
bring  out a sense of ballottement.
   Retroflexion of  the  gravid  uterus  is not usually attended by such
marked symptoms as is retroversion;  and thus the diagnosis is not so
easy.  It has been said that in most,  if not in all cases, retroversion is
the first stage of  retroflexion; that  is, that as the cervix rises, the
dragging of the vagina and bladder upon  its anterior wall bends it
down.  To  a  certain extent this is true; but I am satisfied that the
statement  in  its  general  application is based  upon  theory  or very
limited observation.   In the majority of cases  the flexion exists ab
origine, although it may become aggravated as the body of the uterus
enlarges, and as, therefore, the fundus grows  downwards.  The subjec-
tive  early   signs  are  irritation  of the  bladder, dyschezia,  sense of
bearing down, and of weight in the pelvis.   Retention is less common
than  in pure  retroversion.   The objective  signs also  differ.   The
posterior wall  of  the vagina  is driven forward  by the displaced  and
enlarged body of the uterus.   But since the cervix uteri is not thrown
up, the roof of the vagina is  not  dragged up into an elongated cone to
the same degree as in retroversion.  For the same reason the urethra
is not so much pulled up, the meatus is not displaced, and retention of
urine is not nearly so frequent.  The os uteri points downwards ; it is
closely jammed against the symphysis pubis, and flattened transversely
by the pressure.  The finger, pressed into the angle between the cervix
and  body of the uterus, may trace the continuity  of the  organ.  The
bulging of the anus and perinaeum will also be less marked  than in
retroversion proper.   (See Figs. 89 and 90.)
   Up to this point the objective signs are nearly the same as those of
retro-uterine hematocele,  or  of  extra-uterine gestation  in Douglas'
pouch.  The first  condition is that for which I have most often known
it to  be mistaken.   The distinction  is  made by remembering that in
retro-uterine haematocele the uterus  is pushed bodily forward by the
mass behind,  preserving its normal axis, so  that when the  bladder is
emptied, the finger  of the left hand  applied behind the os  uteri,  and
the fingers of the  right hand pressed down above the pubes, the body
of the uterus  is felt between.  The position of the uterus is clearly
demonstrated  by the sound, which will easily pass up to the  fundus 
224
OBSTETRIC OPERATIONS.
for the normal length or more ; and thus held supported on the sound,
the uterus may be plainly felt  close behind the abdominal wall rising
above the symphysis  pubis.   In this  case, then, it follows  that  the
mass protruding the posterior wall of the vagina is not the displaced
uterus.   The os uteri, often flattened as in retroflexion, is generally
much loiuer  down.   Again, haematocele  is not  often  limited to  the
pelvic cavity;  a portion  rises into the abdomen.   It rarely  fills  the
lower part  of the  sacral hollow so  completely as  retroversion  or
retroflexion.   If of recent formation, it  is  softer  as  felt from  the
rectum.   It fixes tlie  uterus in one  mass with itself.   (See Fig. 91.)
                               Fig. 91.
    ENCYSTED RETRO-UTERINE HEMATOCELE, FROM A SPECIMEN IN ST. THOMVs's HOSPITAL.
a, the haematocele, pushing u, the uterus, forward upon the bladder. The os uteri points
                      downwards, and is easily reached.
  A small ovarian tumour locked under  the sacral promontory may
push the  uterus  forward like  a haematocele.  Here, again, the sound
defines  the position of the uterus.  The tumour is made out by its
firm elastic feel; by its globular shape; by its being generally mobile
and capable of being isolated from the uterus.
  Pelvic cellulitis or peritonitis has some features in common.  But the
os uteri is usually lower down and  nearer  tlie middle of the pelvis;
the peri- or retro-uterine masses are harder, not so uniformly rounded;
they embrace the cervix not behind only, but generally on one or both
sides as well, fixing  it;  they rarely fill the retro-uterine pouch  so
evenly  or  centrally as the displaced uterus or  a haematocele.   The 
                  DIAGNOSIS OF RETROFLEXION.              225

 disease may usually be coimected by history with labour,  abortion,
 interrupted menstruation,  or  surgical or other local injury.
   A retro-uterine  abscess may displace  the  uterus, causing  retention
 of urine, and produce many  of the subjective and objective  signs of
 retroversion  or retroflexion.  The sound  wiU reveal the position of
 the  uterus.   The more obvious fluctuation wiU  distinguish it  from
 haematocele ; and  the aspirator-trocar, by drawing off pus, and greatly
 reducing the tumour, or causing it to disappear, will remove all doubt.
   An  extra-uterine gestation-cyst will  sometimes get  in part  into
 Douglas' pouch, and push the uterus forwards.  The aspirator-trocar
 will be of sendee here.   In a case in which I was  at first misled, the
 woman was calculated to be seven months pregnant  when she began
 to suffer from incontinence of  urine, then pain, and a red erysipelatous
 suffusion spread over the abdomen.  The vagina was compressed  from
 behhid forward by a  round  elastic tense tumour partly filling the cavity
 of the sacrum, and coming from above.   The os uteri was close behind
 the symphysis pubis, pointing downwards; it admitted the finger freely,
 but  I  could  not reach the os internum or  feel  any part of  a child.
 The sound went readily towards the  umbilicus several inches.  There
 were symptoms of peritonitis and prostration.  I punctured the elastic
 swelling in the vagina with a fine trocar, and drew off eight ounces
 of turbid  fluid mixed  with blood.  This reheved  the tension of the
 tumour and  of the  abdomen; and the  erysipelatous  blush vanished
 almost immediately.   I then felt parts of a foetus through the flaccid
 walls of the  cyst.   She  died two  days after this.   Autopsy:  Exten-
 sive recent adhesions glued  the  abdominal wall  to the intestines.
 Breaking through  the adhesions, we came  to an irregular cavity from
 which  flowed dirty  turbid  fluid,  with some  blood.  In front of  this
 cavity was the uterus, singularly elongated in its cervical portion, so  that
 the fundus reached nearly to the umbilicus, as ascertained by the sound
 during life. The body of the uterus contained a pultaceous membranous
 investment (decidua ?).   The Fallopian tubes and  ovaries were undis-
 tinguishable in the confused mass of adhesions.  Behhid the uterus was
 a cavity, bounded below  by Douglas' pouch, behhid by the mesentery
 and  vertebral column, above  and in  front  by the Uver, intestines,
 omentum, and abdominal wall.  It contained a foetus of seven months'
 development, cuticle peeUng,  and decomposition so far  advanced as
 to suggest  that death  had taken place a fortnight  previously.   The
 placenta grew to the iliac fossa.  The case figured (Fig.  92)  is a fair
 parallel to  this case.  I  have related it  in some  detail  because   the
retention of  urine  and  the  pelvic objective signs  closely simulated
those of retroversion  of the gravid womb, and these comciding with a
history of pregnancy rendered the diagnosis  stiU more embarrassing.
It is well known that extra-uterine gestation-cysts commonly encroach
in part into  Douglas'  pouch.   The important differences here were
                                                            Q 
226
OBSTETRIC OPERATIONS.
the determination of the  position of the uterus by the sound, the os
being low down, the freer elasticity of the  retro-uterine  tumour, and
the escape of  fluid on tapping, with the consequent ability  to  feel
foetal  bones.
  One general fact  of great  service in forming a diagnosis  is this:
Almost all bodies which get into  Douglas' pouch come  from above,
and so push the uterus not only forwards, but at the same time down-
wards, thus  bringing the os uteri within easy  reach, and pointing
downwards.  On the other hand, retroversions  of the uterus lift the
os upwards and  tend to  throw it  forward.
Fig. 92.
      CASE OF RETRO-UTERINE GESTATION, FROM A SPECIMEN IN ST. THOMAS'S HOSPITAL.
b, bowels; u, uterus; v, vagina; r, rectum, forming boundary of gestation-sac, which is opened
                      to expose the foetus and placenta.

  In  connection  with this  question  I refer to a most valuable series
of cases  of  extra-uterine gestation by M. Depaul, in the Archives de
Tocologie, 1874.  In  the  same journal is  a history by Dr. Bailly  of
a case of partial or bi-lobed retroverted  gravid  uterus,  which  was
taken by the most able  observers for  extra-uterine gestation.   The
sound passed three inches  close behind the pubes, and could be felt
through  the abdominal walls.   It  had  passed  into  the  upper or
abdominal pouch of the uterus.   The uterine  souffle was heard.  In 
RETROVERSION  OF GRAVID  UTERUS.          227
the case figured  (Fig. 90), which I saw with  Dr. Chambers,  also I
was  at  first deceived by the  sound passing three  inches.
  In the cases of partial retroversion, with outgrowth of the  uterus
into  the abdominal  cavity, there is not so often  actual retention of
urine.   The os uteri will be carried above the symphysis pubis, and it
may point downwards or forwards.   When the bladder is emptied, the
part of  the uterus which grows up into the  abdomen  will be made out
by palpation and percussion.  The symptoms rarely become  urgent
until the natural term of gestation.  Then the trouble consists mainly
in the  difficulty  of labour.   This, no  doubt, is the  reason why these
cases, which,  I believe,  are not uncommon, have been so long over-
looked.
   The question of treatment must first be considered in relation to the
intercurrence of urgent symptoms in early pregnancy.  It will first of
all be  directed to the relief of the imperatively urgent symptoms—
retention of urine, and pain.   The first object, and to some extent the
second, will have been accomplished by passing  the catheter for the
purpose of diagnosis.  1. Passing  the catheter is  not always an easy
matter; and,  in anticipation of difficulty, it will  generally be wise to
induce  anaesthesia.  The first difficulty consists in finding the meatus,
which,  in retroversion proper (see Fig. 88), is drawn up and flattened
out behind the symphysis.   The point of the catheter—a flexible male
one, No. 9 or  10, should be selected,—instead of being directed a little
backwards under the pubic arch, must  be directed close up behind the
symphysis.   The second difficulty is sometimes found in emptying the
bladder, even  when the catheter has entered it.  It should, in the first
instance, be passed in as far as it will go;  and then, when urine has
ceased  to flow, withdrawn by slow degrees, when more urine will  often
flow, as if the  catheter tapped fresh pouches of bladder. A very singular
phenomenon  sometimes observed—one which I cannot satisfactorily
account for—is that, when you have apparently drawn off all the urine,
a copious gush  will  spurt  out when the uterus  is reduced.   This
shows,  at least, that the obstruction was mechanical, not simply from
paralysis.  In some cases,  when retention has been  severe, the flow of
urine is at times  stopped by shreds of cast necrosed mucous membrane,
or plugs of mucus and blood.   2.  The reduction  of the uterus.   The
bladder being emptied, and  the state of anaesthesia  being maintained,
careful  trial  should be  made  to restore the uterus.   Two  kinds of
difficulty  may oppose  restoration.   First, there may  be adhesions
binding down the fundus.  These  are  not common  ; but should they
be present, attempts to push up the uterus might be  fatal.  Blundell
relates  a remarkable case:;: of a young lady who had an ovarian cyst,
which burst from a fall;  peritonitis followed. On recovery she married;
and becoming pregnant, died  with an irredi ible retroversion of the
                        * "Obstetric Surgery."
                                                          Q  2 
228                 OBSTETRIC OPERATIONS.
uterus.  Inflammatory adhesions had  fixed the uterus in the pelvis.
(See Moldenhauer's case, p. 218, for another example.)  Meigs relates a
case in which  the  retroverted  uterus  was bound  down  by adhesions
connected with a Fallopian gestation.
  Secondly, reduction may  be impeded by the  tumefaction of the
parts.   The  uterus is  locked  in the pelvis by  its bulk.   In such
cases, and indeed in all  cases where it is very difficult to reduce the
uterus, the proper course is to induce  abortion.   By merely lessening
the bulk of the womb, certain relief is obtained, the pressure  is taken
off, and the stimulus of developmental attraction being arrested, con-
traction and involution  of the  uterus set in.   Beduction then will
generally be easy;  and  if not  effected, the diminished  uterus  ceases
to be a source of danger.  The induction of abortion, however, is not
always  easy.  The os  uteri may  be not  only  high up  above the
symphysis,  but  it  may  also be directed forwards and upwards  so
that it is hard to reach ;  and  it becomes  difficult, if not impossible, to
pass an instrument  through it into the uterus.  This is  especially the
case in pure retroversion.   In the  case of retroflexion  the  os uteri
points downwards,  and  is more easy to reach.   In  either  case  an
attempt may  be made  to pass a curved sound or an elastic bougie
into the uterine cavity, to rupture the membranes, or at least to disturb
the connections of  the ovum.   This done, the patient should rest in
the  prone  position, the bladder being  emptied every  six hours  by
catheter.  If it be found  impossible to pass an instrument through the
os  uteri, if reduction be also  impossible, and the symptoms urgent,
it is justifiable to puncture the  uterus by the vagina or rectum.  The
risk of piercing the placenta,  which  is likely to be attached to the
posterior wall of the uterus, should not deter, but must be encountered
as a lesser evil.  The best instrument is Dieulafoy's aspirator-trocar,
which is perfectly safe.   The forefinger of the left hand applied inside
the vagina or rectum determines the most bulging part of the uterus ;
and the trocar, guided by it,  is  pushed into the uterus, taking special
care  to enter the  uterine wall  perpendicularly.  The rectum is to be
preferred, because puncture  there is  more  certain to  tap the body of
the uterus, and to keep clear  of the  cervix.   Under  the influence of
air-exhaustion,  liquor amnii should  run out  of the  canula.    Some
diminution  of bulk is immediately  gained, and abortion  will follow
in a few hours.  This suggestion, made in  the  second edition of this
work, has been successfully carried out by Anthony Bell.  The fcetus
was expelled in thirty-six hours.  The woman made a good recovery.
   Where it  has been found impossible  to pass a catheter, reduction
being also  impossible, the question  has arisen between supra-pubic
puncture of the bladder and puncture of the uterus by rectum.   A case
of  this kind  occurred to Dr.  Head  at the London  Hospital."   He
                   * See " London Hosp. Rep.," 1867. 
RETROVERSION OF UTERUS.               229
punctured the uterus; it then became possible to empty the bladder;
a shrivelled foetus of five months was passed, and, after a very severe
illness, the woman recovered.  The decision  to  puncture the  uterus
first was judicious, since it might still have been necessary to do it after
having punctured the bladder.  On the other hand, Dr. Munchmeyer
relates:::  a  case in which he  punctured the bladder; the  uterus  was
then reduced, and recovery followed.  And Dr. Schatz  relates! a  case
in  which  he tapped  both  uterus and  bladder  with  success.    The
aspirator-trocar, moreover, greatly lessens  the  objection to puncturing
bladder or uterus.   By its use the urine can be drawn off with complete
safety.   The puncture should be  made  about three inches above the
symphysis, so as to allow for the descent of the bladder as it becomes
empty.
                               Fin.  93.
REDUCTION OF A RETROVERTED GRAVID UTERUS BY BI-POLAR DIAGONAL TAXIS.
  p, Promontory of sacrum locking f, fundus of uterus;  o, os uteri behind symphysis.  The
arrows show the direction of the force applied by the fingers to bring the uterus into an oblique
diameter represented by dotted line, in which it is clear of the promontory, and can then rise out
of the pelvis.
  Reduction may  be attempted,  either leaving the ovum  intact, or
after abortion.   In a  fair proportion of cases,  if  seen  early, simply
keeping  the  bladder  and rectum empty, and rest in the prone or semi-
prone  posture,  are enough to  obtain restoration of the uterus;  and
unless very urgent distress continue, time should be afforded for  this
spontaneous  cure.   When it has been decided  to  try reduction,  the
plan to  be pursued  is  as follows:—Empty the bladder and rectum;
induce anaesthesia to  the surgical degree ;  place the patient in  the
prone  or semi-prone  position with the nates elevated;  pass two or
three fingers, or  even the  whole hand,  into  the rectum ;  apply  the
tips  of them to one  side  of, and  under, the  uterine globe;  push  the
     * " Mon. f. Geburtsk.," 1860.         t " Archiv f. Gynakol.," 1870. 
230
OBSTETRIC OPERATIONS.
globe upwards and to one side of the promontory of the sacrum, so as
to clear this projection.  This oblique direction of the reducing force is
a point of great importance.  It was insisted upon  by Dr. Skinner
(Brit. Med.  Journal, 1860).  You adapt the bi-polar principle to the
reduction.   First,  by  finger in the vagina, pull the cervix  uteri
backwards towards the  right acetabulum, so as to bring the uterus into
the left oblique diameter of the  pelvis ; then,  the fingers in the rectum
push the fundus towards the  left sacro-iliac  synchondrosis.  (See Fig.
93.)  If the patient is not  under  chloroform, pressure should  be
exerted during expiration  only.   I have with comparative facility, by
attention to this rule, reduced  an impacted  retroverted gravid uterus
which had resisted many previous efforts.  If it  be found awkward to
work with one hand in the vagina, and the  other in the rectum, the
cervix  uteri may be drawn down by help of a  hook.
  Various methods have been suggested and tried to facilitate reduction.
Halpin  applied a sheep's bladder, dilated with air or water, with the
view of so lifting up the uterus.  Desgranges took up  the same idea.
Dr. Playfair relates a case in which fluid-pressure by my bags sustained
for twenty-four hours in the vagina replaced the uterus.  I succeeded in
like manner in two cases in St. George's Hospital.   In one case I failed.
In fact, a point d'appui is wanted below, which the perinaeum  is ill-
adapted to give : the distensibility of the floor of the pelvis allows the
bag to expand downwards.  And in most cases it would be difficult to
get a bag into the vagina.  But since it is impossible to govern with
accuracy the  direction of the  force, the  bag, expanding, presses the
fundus  uteri directly upwards  under the promontory, thus in reality
calling for more force than would be  necessary if the hand—a sentient
and intelligent instrument—were used in the  manner already described.
It would be better to place the bag  in  the rectum as  I did.   Thus it
gets more command over  the  uterus,  and  the  lateral course  of the
rectum will  direct the pressure to one side of  the promontory.   Again,
position has been much insisted upon.  Blundell recommended the
knee-elbow  position, that  is,  upon all-fours.   The knee-elbow position
was tried by Hunter.  Moreau says this was the method commonly
tried, but that it was  bad because the woman could not bear it.  It
has been supposed  to help by gravitation ; but  this is  illusory.  The
semi-prone position gives all  the requisite facility.  Godefroy (Gazette
cles Hopitaux, 1859) placed the patient on the edge of the bed, so that
her head and chest were  hanging down on the  floor, the  legs  and
pelvis only being on the bed.  In this  position  there is no resistance
from the abdominal walls.  Then, two  or more  fingers in the rectum
act at  greater  advantage.  Negrier,  of  Angers,  introduced the  whole
hand into the vagina, turned it  in supination, and pressed forcibly by
the flat surface  made by the backs of the first phalanges and by the
thumb  brought  level with them.  This he   calls " reduction  a poing 
RETROVERSION  OF UTERUS.
231
fermeV'  He succeeded by it in four cases.  It is useful, whUst pushing
the uterus from  below, to exert counter-pressure by the other hand
applied above the symphysis  pubis.  Professor Halbertsma  relates  a
case in which a woman died; the uterus was found retroflexed and
retroverted.  There was no peritonitis.  On pressing up the fundus,
the uterus immediately rose like a feather into its place.  This post-
mortem  demonstration is especiaUy valuable.  E. Rigby and Dewees
advised bleeding  to facilitate reduction.   Where there is great con-
gestion this may be useful.   But the commonly existing  exhaustion
and  the impetus given to absorption by bleeding  would be  strong
contra-indications.
   The management of the case after reduction is  important.  Richter,
Baudelocque, and Simpson recommended to apply a pessary to prevent
the uterus falling back again.   The best pessary for this is a large
Hodge's lever.
   Looking to the history of retroversion and retroflexion, regarding it
as a condition existing before pregnancy and continuing with advanc-
ing pregnancy, the prophylactic treatment should have  prominent
attention.  I have on many occasions used Hodge's pessary to support
the uterus when retroverted during the first three months of pregnancy,
as a precaution against impaction.  This  precaution should  never be
omitted in the case of pregnancy occurring in  a  woman  who has
once suffered from retroversion or retroflexion, especially  if she has
had  abortions.
   Other points are, absolute rest, encouraged by opium ; keeping the
bladder empty—retention may persist from paralysis even after pressure
is removed ;  and medicines,  such as mineral acids, are  useful.  The
bladder requires  the most careful attention.    The liability  of the
mucous coat to undergo necrosis must be borne  in  mind.   Shreds of
mucous  membrane or of fibrinous cast  may  become detached and
occlude the urethra.
   The treatment of incomplete retroflexion, that is, when  the  gestation
is partly abdominal, must be  mainly expectative.  When labour has
arrived, should the pelvic portion  of  the uterus not  rise  into the
abdomen, we must endeavour to push it up by fingers in the rectum,
whilst the patient is  on all-fours.
   If reduction cannot be effected, imitate the practice  of  Oldham,
described in the case I have quoted.  Draw down the cervix uteri, push
down the abdominal mass, push up the pelvic  mass, so as to effect a
rotation of the uterus forwards.
   Retroversion, or rather retroflexion, may occasion  difficulty even
after delivery at term.  The uterus imperfectly contracted, and there-
fore  enlarged and flaccid, may bend back and become  locked in the
pelvis.   Retention  of  urine  may result.   This  accident, Merriman
says, has principally occurred on the second day after delivery ; but he 
232            •     OBSTETRIC OPERATIONS.
gives a case in which retention of urine  happened from this cause on
the ninth day.  E. Martin says post-partum retroflexion is due to the
placenta having been attached to the anterior wall  of  the uterus, the
effect of  which is to keep this wall longer than the posterior, and  thus
to throw the fundus back; and conversely that anteflexion is due to the
placenta having been attached to  the posterior wall.
   But reduction  should not  be looked  upon  as  the object to be
accomplished  at all hazards.  One cannot  think without a shudder
upon the description given by Amussat of his supplementing his own
strength by that of one or two assistants who helped him in pushing
the uterus into its place.   When the uterus has shrunk after  tapping
and abortion, it is  no  longer the chief  source of mischief.   Indeed,
I  have known death to ensue after an  easy reduction of the uterus.
The woman died  from  the shock  already  sustained, the continuing
urinaemia, and the injury  done to the  urinary apparatus.
   The general rules, then, may be thus summed up:—1. Empty the
bladder :  2. Make a gentle attempt at reposition :  3.  If this fail, be
governed by  the  urgency of the  case;  if there be  great  distress,
induce abortion or puncture the  uterus  by the aspirator-trocar, and
wait:  4. When  abortion has  taken place, make  further  cautious
attempts to reduce :  5. If there be still difficulty, wait again: 6. When
the  uterus is reduced,  support  it in position  by a suitable  Hodge-
pessary.   This should be done  in every case after  labour in women
who have been  the subjects of retroversion in the non-pregnant state.

          Prolapsus or Procidentia of the Gravid  Uterus.

   This,  like  retroversion, may be primitive, or may occur suddenly
during the course of pregnancy.   Conception may occur in a prolapsed
or even in a procident uterus ; and continuing to grow, it may retain
its vicious position.  The simple prolapsus becomes  a pelvic gestation,
the  uterus growing in  the pelvis  proper.   In this case,  unless  it
become retroverted, it is pretty certain to grow up into the abdominal
cavity in the fourth or fifth month ; and then it is generally too large
to sink bodily  through the brim again.  But, in the case of procident
uterus, it is quite possible for the enlargement  to  go  on external to
the vulva.  The pregnant uterus then, covered by the inverted vagina,
forms an enormous  mass between the  thighs.   It has been said also
that the entire uterus containing the child has been driven through the
vulva during labour.  I have no  doubt that in some of the instances
recorded  as of this nature  there  was a defect of observation, and  that
the real condition was simply protrusion of the lower segment  of the
uterus, or the hypertrophied cervix, to be described presently.
  A curious case which  comes under this head  is cited  by Moreau,*
              * " Traite pratique des Accouehements," 1838. 
PROLAPSUS  OF  GRAVID  UTERUS.
233
 from Chopart.   A young woman  had procidentia uteri, the result of
 violence before marriage.   This was never reduced ; but after twenty
 years  the cervix becoming gradually  opened,  conception  took place.
 Labour  at term went on for twenty-four hours without progress, when
 the child was dead  and the woman seemed expiring.  The surgeon,
 Marrigue, divided the cervix by incision, and thus was able to extract
 the child.  The mother recovered.  It is  not  clearly stated that the
 entire uterus and child were external to  the vulva at the  time of
 labour.   There  is a  figure in  Siebold's  Journal filr  Geburtshiilfe
 (1826)  of a large mass  outside  the vulva with  a foot projecting; but
 it is not certain that the whole uterus was outside.  A more probable
 case is that of Portal, treated  in  conjunction with the first Moreau.
 A primipara had long  suffered from  prolapsus, but the  uterus  had
 gone up during pregnancy, and only  came  outside  under  violent
 straining in aid of slight  labour-pains.  The  orifice was  artificially
 dilated, and a living child extracted.
   Harvey relates a  case of conception taking place in  a procident
 uterus.   A  dead premature child  was expelled.
   The Treatment.—Labour with simple prolapse is generally tedious,
 from the fundus  wanting the full support and impact of the  abdominal
 muscles.  If the cervix is  slow in dilating, and  the  expulsive power
 deficient, the cervix  should be  dilated artificially by the water-bags,
 and the  forceps put on the head, care being  taken  to support  the
 perinaeum and vulva well,  lest  the  lower  segment of the uterus be
 drawn through.   In  the case of complete  procidentia the difficulty
 is aggravated : the uterus is away from all  its auxiliary forces.  Still,
 its inherent  power may possibly expel its contents.  First  of all  you
 should  try  to carry the  uterus up  into  the pelvis.   If this fail,
 delivery must be ended  outside  the pelvis.  Whether the  uterus  act
 by itself, or  you find it necessary to extract the child by forceps or
 turning,   it  is desirable  to support  the lower segment carefully by
 means of a  square cloth, having  a  hole cut out of its middle large
 enough to afford exit to the  child.   This opening is applied  over
 the  os uteri, and the four corners are held up around the uterus, so
 as  to  counteract the downward traction  exerted  upon   the  child.
 Scanzoni says,  the  long-continued  bruising  of the uterine  walls
 against the  pelvis  may  cause metritis or  sloughing.
   I have not seen a complete procidentia of the gravid uterus at term ;
 but  I  have  several times been  called in to see  it.  This  is what I
 actually saw:  an enormous  fleshy mass protruded beyond the vulva, of
 livid colour, and  presenting an  opening—the os uteri—in  its  centre.
 On feeling the abdomen, however,  I  have found at least  a portion of
 the uterus, containing part of the fcetus, there.  It was clear,  then,
 that although the os  uteri and cervix might be completely outside  the
vulva, the whole  uterus  was not.  In  one  case, in which the midwife 
234                 OBSTETRIC OPERATIONS.

said the labour-pains were forcing the whole  body out, I found  the
os uteri outside :  and, on examining, my finger passed three inches up
along the cervical canal till it was arrested by the os internum uteri,
above which was the child's head.    This condition is  represented
in Fig.  94.
  It is  simply  a case of hypertrophic elongation of the cervix  uteri.

                              Fig. 94.
          LABOUR OBSTRUCTED BY HYPERTROPHIC ELONGATION OF THE CERVIX.
The head rests upon the os internum;  the os externum is outside the vulva. The figure also
           shows the down-dragging of the bladder and distortion of urethra.

Iii a subsequent labour she was  seen  by Dr. Roper, then my colleague
in the  Royal  Maternity  Charity.   He  found  the same  condition.
There  can be no doubt  that the elongated  cervix was a  persistent
condition.  (See  Obstetrical Transactions, vol. vii.)  In  another case
I found the head had passed  along the hypertrophied  cervix, and  was
protruding the  os   externum  outside the vulva.   In  another,  the 
                   HYPERTROPHY  OF  CERVIX.               235

hypertrophied cervix  was enormously  distended  with  extravasated
blood—cervical  thrombus,—a  condition  to  which  the  hypertrophied
cervix  is  especially exposed.   One cause of dystocia  in  these  cases
is  the  hardened state of the os  and cervix  uteri.
  Dr.  Boper relates (Obstetrical Transactions, vol. xv.) another case
which iUustrates the influence of labour upon the hypertrophied cervix.
The subject was a primipara, aged  twenty-two.   In labour the  cervix
protruded through  the vulva about three inches,  forming a mass  in
circumference equal  to a man's wrist.   After reducing  the  cervix
within the vagina, the  head  could be felt.   The cervix  had a firm,
Fig. 95.
                            AFTER OLDHAM.
     Representing pregnancy in one uterus, a second uterus unimpregnated by the side.

gristly feel.   I  saw  her in consultation,  and  we  agreed  that free
incisions in the os externum were necessary.  These were practised, so
that the  os  externum  was freely  opened  up to meet the  natural
expansion  of the  os  internum.   She  was  then delivered, after an
anxious labour of fifty-two hours; both mother and child doing well.
It is important, in similar cases, to wait until expansion takes place
above, and then to meet it by incisions from below.  Two months after
delivery, the cervix hung down in the vagina like a shrivelled piece of
skin.  It was amputated. 
236                 OBSTETRIC OPERATIONS.
  It may be necessary to dilate the cervix by means of the water-bags,
or even by incision ; and to apply the forceps, or to turn.
  A considerable number  of cases are  now  recorded  where labour
has been obstructed by  the hymen.  Where this is found the remedy
is incision.
  Pregnancy in one compartment of a two-homed uterus is a rare and,
therefore, perplexing complication.  I  was called to a case  of severe
puerperal convulsions with albuminuria, in which  it was considered
desirable to expedite delivery.  There  had been strong pains but no
progress.  Mr.  Garlick,  who was in attendance, could touch the pre-
senting head ; but when I tried I found a dense fleshy septum between
my finger and  the head, although it  was quite clear that my finger
passed into  the os uteri.   At last, following my friend's guidance,  I
got my  finger  also on  the head;  and thus  I ascertained that  there
were two ora, each leading to distinct uterine cavities, one of which
contained the child, whilst the  other  was empty.   It was  necessary
to deliver by craniotomy.  Oldham  describes  a similar  case (Guy's
Hosp. Reports).  Fig. 95  is taken from  his illustration.  Lefort cites
a case from F. Tiedmann,* who says there is in the Heidelberg Museum
a double uterus  with double vagina, taken from a  woman who died
after labour.   At her labour two  distinguished physicians  attended;
one declared the woman was not pregnant, the other that the head was
in the os uteri.  One had examined the left vagina, the other the  right.
The same thing happened  to two  midwives at the Maternite in 1824.
My difficulty, therefore, is not without precedent.  Lawson Tait related
a similar case (British Gynecological Society, 1885).
  Birnbaum relates (Monatsschr. fur Geburtsk., 1863) a case of twin-
pregnancy,  a child in  each  side  of  a two-horned  uterus.   A very
distinct saddle-like depression was observed near the umbilicus,  the
upper boundary between the  two horns of the uterus.   The summits
of these rose to  an unequal height.   There  was one placenta.  He
relates another case of  single gestation in one horn of a two-horned
uterus.   There is a valuable collection  of cases illustrating this subject
in Kussmaul, and the subject is discussed in my work on Diseases of
Women.
  In some cases the septum is continued all the way down the vagina.
There is then a double vagina  as  well as a double  uterus.   In these
cases one vagina  only is generally  used in copulation.   If labour were
found obstructed  by such  a septum, there should be no hesitation in
dividing  it  longitudinally with  a hernia-knife.
* 'Mourn. Complem. du Diction.," t. iv. 
LECTURE  XIX.
MECHANICAL COMPLICATIONS  OF LABOUR CONTINUED—DYSTOCIA FROM
    TUMOURS :   FIBROID  OR MYOMA — POLYPUS — OVARIAN — EXTRA-
    UTERINE   GESTATION-CYST — CONDYLOMATA — RETRO-UTERINE
    HEMATOCELE.

        Pregnancy and Labour complicated  tuith Tumours.

There  are few complications of pregnancy and  labour productive of
more  perplexity, difficulty, and danger than tumours.   They present
great  variety of form, size, consistence, position,  origin, and relations,
entailing corresponding  interference with the due course of pregnancy
and labour.
  First, we will discuss the  influence of tumours in the walls of the
uterus.   These will include polypi projecting  from the  walls into the
cavity.
  Happily, in a great number of instances, fibroid tumour or myoma
imbedded in the walls of the uterus operates  as  a bar  to  conception;
but when pregnancy does supervene, the result is often disastrous.
The tumour interferes  with  the equable development  of  the uterus;
and, therefore, frequently determines haemorrhage and abortion.   And,
perhaps, this is the  most fortunate  event; for  delivery in the latter
months brings additional danger.  The haemorrhage of abortion can
be stayed by injection of hot water or swabbing with  perchloride or
persulphate of  iron.  It  is not often that the tumour is so injured
that inflammation  ensues ;  but looking  to  future probabilities,  we
should  deprecate incurring the  risk of another pregnancy.  I believe
every experienced obstetrician  would  advise  a single  woman known
to have fibroid  tumours  in  the uterus to avoid marriage;  with the
doubtful exception  of tumours seated in  the fundus.   There  is  an
alternative in  extirpation of the ovaries.   But this belongs, perhaps,
to the surgery  of the future, when it may be  so  advanced as to  over-
ride the ethical objections. 
238
OBSTETRIC OPERATIONS.
  Compression of the bladder and rectum  may be caused by the com-
bined growth and eccentric pressure of the  tumour and uterus, causing
symptoms resembling those arising  from retroversion of the  gravid
womb.  These may be  developed early  in  pregnancy,  and  compel
prompt  intervention.  In some  cases, indeed, a  tumour  has  caused
retroversion.
  After five  months there is  less risk of intra-pelvic compression,
because the  uterus  and foetus  will  have grown out of the   pelvis.
There is some danger of haemorrhage, but generally danger is hence-
forth  in suspense until  the  advent of labour.
  A myoma growing in the uterine wall'induces effects upon the uterus
analogous to those of pregnancy.  It acts  as  a cause of development;
it attracts blood; it may be said that there  is tumour-gestation.   If
to this be added  true embryonic gestation, there  is commensurate in-
crease of uterine vascularity and growth.  The tumour, or the cellular
capsule  around it, may undergo  inflammation, or  a kind of  degenera-
tive softening.  Pain  and even  suppuration  may result.  At  least, I
think I have  observed these  events.   Dr. Lee relates* a case proving
fatal at five months  from inflammation and suppuration of the tumour,
with peritonitis.   I  must refer to B. and F. Barnes' Obstetric Medicine
and Surgery (1884-5) for fuller discussion of  the relations of tumours
to gestation.
  The dangers attending labour are of the most serious kind.   First,
there  may be obstruction to  labour requiring  .dangerous operations to
overcome  it.   Secondly,  the uterus  may  be  rent from  the unequal
strain of the  contracting muscular  tissues, or from dragging  on the
tumour by the advancing child.  Thirdly, if the tumour be  in the
anterior  wall of  the  uterus, so as  to be compressed between the
advancing head  and the symphysis  pubis, rupture of the bladder or
vesico-vaginal fistula may occur.  I have known  two cases  of this
accident, one of which was  fatal.  Fourthly, the solid masses  in the
walls  prevent the equable contraction of  the uterine muscles  during
and after labour, and thus give rise to dangerous haemorrhage, scarcely
controllable by the ordinary means.  Fifthly, the placenta may be
attached to the tumour, and lead to  inversion of the uterus.   Inver-
sion has even occurred where the placenta was not known to have so
adhered.  Sixthly, the bruising to which  the tumour and the  uterine
wall are subjected, by being jammed  between  the  head and the  pelvis,
is commonly  followed by a low form of inflammation in the tumour,
tending to necrosis,  and giving rise to  peritonitis  and septicaemic
puerperal fever.   There  seems little  doubt that myoma, being  consti-
tuted  of analogous  tissues to those  of the uterus in  which it  arises,
grows with the  uterus  during pregnancy;  and  hence,  at  the time
when labour comes,  the tumour is unusually  vascular  and more prone
                     * " Clinical Midwifery," 1842. 
TUMOURS  OF  UTERUS.
239
to suffer from violence.  It also undergoes a process of involution after
labour, like the uterine tissue proper.
  Myomas,  it is known,  occasionally get driven  outwards, so as to
hang  loosely in  the  abdominal cavity by a slender pedicle to the ex-
ternal surface  of the uterus.   Li this position they are  shut off from
the influence of the  changes going on in the uterus, and may be out
of the way of mechanical mischief.  I have  attended a lady through
several labours,  who had a tumour which I  could grasp  in my hand
through the abdominal walls ; she never suffered in any way in  conse-
quence.  These  tumours have been  known to get detached altogether,
so as  to roll free in the abdomen.  In this case they would gravitate
into the retro-uterine sac, where they might  obstruct labour.   The
danger and the prognosis  are influenced by  the region of the  uterus
in which the tumours are seated.  Those  occupying the lower region,
and which are, therefore, most exposed to injury during labour, are the
most  dangerous  ; whilst those seated in the fundus above the child are
comparatively free from mechanical injury.  They are  not, however,
altogether free from the danger  of inflammation, and are  not unlikely
to cause haemorrhage.
   In  not  a few instances a  myoma has  been  spontaneously expelled
some  days  or  weeks  after  labour.   I   exhibited a tumour  to the
Obstetrical  Society,  expelled  in this way some  weeks  after  labour.
It seems  that  during labour a  process   of loosening  of the  attach-
ments, favouring enucleation, takes place.  Danyau and M. Duncan
each  relate a  case  in which partial enucleation thus effected was
easily completed surgically.   The great decrease in size of the  uterus
after  delivery,  and  the  persistent  contractions, tend to  cast off the
tumour.
   Sometimes the tumour disintegrates, or undergoes atrophy, and dis-
appears, wholly  or in part, after labour, or at least to such an extent
as to  escape detection.  Dr. Pagan  relates a  striking case in which a
tumour was mistaken for a second child.   The  woman recovering, the
tumour rapidly  diminished and disappeared below the pubes.   She
had observed  the same  phenomenon in  preceding pregnancies.  Dr.
Leonard  Sedgwick relates (St. Thomas's  Hospital Reports, 1870) two
cases  in which  uterine tumours entirely disappeared after delivery.
Montgomery cites similar cases.  I have watched a case of the kind
to cure.  Hence we see pregnancy may cure uterine myoma.   A most
important feature occasionally attending  this complication is the ex-
treme difficulty  in establishing  a correct diagnosis.  The pelvis  may
be so blocked, the vagina  and cervix  uteri  so distorted, that  access
for the examining finger  below may be  impossible, and  at the same
time  abdominal exploration  may be  equally unsatisfactory.   The
mystery may, however, be cleared  up by making repeated examina-
tions  at  sufficient  intervals.   The  comparative  observations  may 
240
OBSTETRIC OPERATIONS.
reveal changes  of form,  size,  and relation, and possibly auscultatory
signs due to the progress of gestation.
  Closely allied to the muscular tumour  in the uterine wall is the
muscular polypus, which, attached by a stalk, projects into the uterine
cavity, or through the os uteri into the vagina.   Such  a polypus may
impede labour by getting out of the uterus before the head  and filling
the vagina.   A case of this kind occurred in  St. Thomas's Hospital
Maternity, in 1868.   A solid  polypus, as large as a full-sized cocoa-
nut, blocked the vagina.  It adhered to the  os and whole circumference
of the cervix.  My then colleague, Dr. Gerv-is, being  sent for,  found
that some laceration of the surface of the polypus had occurred, and
with every  pain  it became  extremely tense and  elastic.  The child
was delivered by craniotomy.   A second child  was delivered by turn-
ing.  The tumour, after labour, protruded  through the vulva.  It was
removed by the ecraseur  five  days  afterwards.   The woman died on
the thirteenth day, symptoms of peritonitis having set  in.  Peritonitis
was found on post-mortem examination.   The tumour, which is pre-
served in St. Thomas's Museum, and figured in  the Obstetrical Trans-
actions  (1869),  was a myoma  enveloped in a capsule  of true uterine
tissue.   Low necrotic inflammation was progressing in its substance.
In St. Bartholomew's Museum is  a specimen (32.22) of a large polypus
removed by excision ; it was five inches long;  its base of attachment
nearly 1^ inches in diameter.   The subject was  twenty  years old.  The
polypus  was first discovered  after labour,  and was excised ten days
afterwards.   The woman recovered speedily.
   Again, the polypus may be above the child's  head in utero, and  not
appear until the child is born, as in a remarkable  case  recorded by Dr.
Crisp.  The placenta  being retained, Dr.  Crisp introduced  his hand
and removed it.  He thought he felt another child, but it was found to
be a large polypus, causing violent expulsive pains and greatly exhaust-
ing the patient.  The energetic action of the womb forced the polypus
so  low down in the vagina as to interfere with the passage  of the
catheter.  The  patient  died  collapsed,  worn  out  with the constant
uterine action; there was no haemorrhage.  This symptom—violent
expulsive action continuing after  the birth of the child—seems  one of
the dangers attending leaving the polypus attached.  It was enough,
we see, in Dr.  Crisp's case to cause death.   Ingleby and Gooch relate
fatal cases.   It was very severe in other cases, namely, in  one related
by Mr.  Freeman,'1'  and in one by Dr. Priestley.!  It  is important to
remember another point  in connection with labour complicated with
tumour.  It is that the tumour  has  been  mistaken, as in Dr. Pagan's
case, for the head  of a child.   Such a mistake, leading  as it might
to  attempts to  deliver by hand, by forceps, or by perforation, might be
fatal.   In this way the uterus might even be torn away. And yet how
         * " Obstetrical Transactions," vol. v.           t Ibid., vol. i. 
             OVARIAN  TUMOURS AND  PREGNANCY.          241

easy the  error !  It is so natural  to conclude that any firm rounded
mass, like in size to the foetal head, is a foetal head ;  and so rare, and
therefore unthought  of, is a tumour, that even experienced men  may
be deceived.  I  know of no way of ascertaining the  exact  conditions,
but that  of passing the  whole hand above the  tumour, and tracing
deliberately its attachments.   Then the question,  an anxious one, not
free from doubt, arises : how to  deal with  it ?  Whether  left alone or
removed  by operation, death may  follow.   Experience is not decisive
enough to justify the laying down of an absolute law. My opinion would
be generally in favour of immediate removal by the wire  ecraseur, the
galvanic  cautery, or  enucleation ; but in any given case, the surgeon
must be governed by circumstances and the means  at his disposal.
  In a case under my care some years ago, the subject complained of foul
discharges  and symptoms of chronic pyaemia three months after labour.
I found a large polypoid myoma in a state of decomposition growing
from the fundus of the  uterus.   I removed it  by the wire-ecraseur.
The uterus then underwent normal involution, and the woman  made
a good recovery.
  Since  it may  be difficult  or impossible to make out the nature and
attachments of some of the things  that may present in the passages by
the mere sensation they impart to the touch, it is a good  rule in  every
case of doubt to put the patient  in anaesthesia, and to explore with the
whole  hand.  In this  way,  if we  succeed  in tracing the walls of the
vagina and uterus, getting  all round the  presenting mass as far as
possible, and  above it,  we  can hardly fail to  determine  whether  it
belongs to a foetus or be attached to the uterus.
  The sources of danger,  then, in polypus, are similar to  those in
tumour of  the  uterine wall.  The mass  gets bruised and undergoes
necrotic  inflammation  leading  to  metro-peritonitis  and septicaemia;
imperfect contraction may lead  to haemorrhage ; uterine tenesmus or
tetanus may cause collapse from  exhaustion;  and inversion may be
produced, as in a case of Dr. Beatty's.
  We  will further discuss  the treatment of  these  cases when we
have gone  through  the history of complication with other kinds  of
tumours.
  The relation of cancer of the uterus and vagina to pregnancy will
receive incidental  illustration in  the Lectures  on " Rupture of the
Uterus " and  " Caesarian Section."
  The next class  includes  tumours external to the  structure of the
uterus.  First, ovarian tumours.  These are movable  or immovable;
they may be solid or fluid; be seated below the uterus in  the pelvis, or
to one side, behind it, or above  it; and the  issue of the  case will
depend very much upon which of these  conditions  is present.   The
diagnosis is sometimes very difficult, only to  be clearly  made out by
repeated comparative observations.
                                                            R 
242
OBSTETRIC OPERATIONS.
   The influence of ovarian tumours on the course of pregnancy is the
first subject of study.   It is generally the case that the ovarian tumour
exists  and has attained a certain size when the pregnancy  begins ;
and as ovarian tumours mostly rise out of the pelvis, the gravid uterus
enlarging,  finds the tumour  above  it, probably a little to one side.
The tumour being  movable,  is lifted up  by  the growing uterus, and
pushed aside.   If of moderate size, the pregnancy may go on to term,
and delivery be accomplished without difficulty.  Such a case is  not
uncommon.  I have seen several, and some  in which a woman with
ovarian tumour has been delivered two or three times.  But we shall
not be always so fortunate.  Another issue is abortion or premature
labour.  Sooner  or later the  tumour  presses  against the growing
uterus, or the  double growth becomes too much for the system to bear,
and the uterus is driven to expel its contents.   When this happens the
danger is usually over for a time.  But if  the danger is not averted by
the spontaneous or artificial reduction  of the uterus,  it  is but  too
probable that  the  tumour must  give way.   There  is  a limit to  the
distensibility of the abdomen ; there is a  limit to the pressure which
the abdominal viscera,  the vessels, and the thoracic organs  can  endure.
In ordinary gestation, provision is made for the accommodation of  the
uterus.  But the system can ill  tolerate the simultaneous growth of
two masses in the abdomen.  To be  effected safely,  distension and
accommodation must proceed at  a  given moderate  rate.   When  an
ovarian tumour is  added  to  pregnancy,  the  distension is rapid and
beyond measure.   The tumour grows as  well as the uterus.  It  not
only oppresses by  its  bulk,  but it drains the system of part of  the
supplies wanted for healthy purposes.  We may, therefore, find towards
the end of gestation such a degree of suffering and exhaustion, that  the
patient will sink either before or soon after delivery.
  Or  a remarkable  circumstance  may  happen.  The uterus growing
upwards underneath the tumour, not only lifts it up, but rolls it round
on its  axis, elongating and twisting the pedicle.  The consequence of
this is  strangulation of the vessels which feed  the tumour.  They burst
and pour out blood into the cysts  of the tumour, or externally into  the
peritoneum.   Death speedily follows under the  shock of the injury,
from haemorrhage or peritonitis.   I have seen cases  of this kind; one
is  recorded in St.  Thomas's  Hospital Reports, 1870.  Dr. St. John
Edwards,  of  Malta, records  another  (Lancet,  1861).   Or the axial
twisting may occur under the expulsive efforts of labour.  Bokitansky
relates more cases  in illustration of  this  accident.
  Another  event, more  common,  is simple rupture of the  cyst.  This
may happen at any period  of  pregnancy, but is most frequent after  the
sixth  month.  The accident  is not  always fatal.   The effused fluid
may be absorbed,  and  the pregnancy may even go on.   But  more
frequently the shock is followed  by  fatal collapse; or,  if the patient 
OVARIAN TUMOURS AND PREGNANCY.         243
live to the point of reaction, fatal peritonitis ensues.   In cases of this
nature which I have seen, death took place  from shock, and although
intense pain was complained of, there was no evidence of peritonitis on
dissection.  Whether it  be by  bursting  as above mentioned,  or by
some other  process, there  is  evidence to  show that  ovarian  tumours
may  vanish  under  the  influence  of pregnancy.   Montgomery  and
Hamilton give examples.
   If the patient escape  the perilous period of pregnancy, she has to
run the gauntlet of even  greater perils during and after delivery.   The
tumour may burst  or become  strangulated  under  the  straining of
labour.  It may be otherwise injured, so that  a fatal result follows in
a short time.   All  this may occur even when  the tumour has offered
no material obstruction  to the passage  of the child.   But where the
tumour is lodged wholly  or partly in the pelvis, unless  it be movable, it
can  hardly escape injury, and by encroaching on the pelvic  space  it
obstructs  the birth of the child.   Rupture is  more likely to  happen;
the dragging or stretching of the structures to which it is  attached
may set up  inflammation; and the bruising its own  structure under-
goes may also prove fatal.
   I  have referred  to the familiar  fact  that many women  have gone
through  several  labours without  accident  under complication with
ovarian tumour.   Let  me insist  upon  another fact,  necessary to
moderate  the confidence  in future immunity which undue consideration
of these fortunate  cases may inspire :  not  a few women, after thus
escaping once or oftener,  have in the end fallen victims to one or other
of the catastrophes recited.
   Mr. Berry, late of Birmingham, relates (Obstetrical Trans., vol. viii.)
an extraordinary case, showing what narrow escapes  sometimes occur.
Labour had been obstructed by an ovarian tumour, and the child had
been  extracted with considerable force  by  forceps.   Next  day,  after
coughing, the patient felt  something come  down.   Mr. Berry being
called  in,  found it to be  an ovarian tumour, the pedicle of  which was
traced through  a rent in the upper part of the vagina.   Mr. Berry was
of opinion that the rent had been  caused by  the forceps.  But it is
quite possible that in such a  case the rupture might  occur  spon-
taneously.   A  ligature   was  put on, and the tumour was  cut  off.
The  woman recovered.    The preparation is in St.  Bartholomew's
Museum.
  Dermoid tumours, containing hair and  fat, may get  into the  retro-
uterine pouch  and  obstruct labour.  They may feel  so hard  as to
suggest solidity.  But on puncture fat may run out, as  in a case of
Ramsbotham's (Path. Trans., vol. iv.), and in others related by Ingleby
and myself.  Hence, Ramsbotham says all tumours obstructing labour
should be punctured.  Denman cites a case where  labour was  ob-
structed by a dermoid cyst between the vagina  and rectum.  The head
                                                         k 2 
244
OBSTETRIC OPERATIONS.
was  perforated;  but the woman died from the injury to the tumour
and  surrounding parts.  It would probably have been better to follow
Ramsbotham's rule.  In a case which occurred in the British Lying-in
Hospital, Fancourt Barnes resorted to Porro's operation.   The tumour
could not be moved.
  Amongst the most remarkable and dangerous forms of tumour that
may complicate pregnancy is the tumour formed by an extra-uterine
gestation.   It  must be  very  difficult to diagnose this with  certainty
during the uterine  pregnancy.   The extra-uterine  cyst  is  in  great
danger of  bursting at this time.   If it endure to the term of gestation,
it may burst  under the violence of labour, or become the centre  of
inflammation that may  prove fatal.  A case of recovery is related by
Perfect.  It was communicated by  Mr. John  Bard, of New York,  to
Dr. John Fothergill.  A woman, aet. twenty-eight, had had one child
and thought she  was pregnant again.  At the end of nine months she
had  some pains  which  went  off, and the swelling grew less.  A hard
indolent tumour  remained in the right side.  Menstruation returned;
she conceived again  ; at the end of nine months she was delivered of a
healthy child.  The tumour  still felt as before.   Five days afterwards,
violent fever, purging, pain in the tumour, profuse foetid sweats set in.
These subsided into hectic and diarrhoea.  After nine weeks, fluctuation
was  manifest  in the tumour ; it was opened; a vast quantity of foetid
matter and a  foetus of common size were extracted  through the inci-
sion.   It was  imagined the  placenta had dissolved into  pus.   The
woman recovered and  suckled.
  Two cases  are recorded by Dr. Greenhalgh.*  One  of these is also
reported at length by Mr. Cooke, i  A tumour was found  in the pelvis
obstructing labour ;  it was pushed up with some force out of the pelvis,
and  the child was delivered  by turning, dead.  The woman  died two
days after the  labour.   A full-grown fcetus, contained in its membranes
unruptured, was  found  in the peritoneal cavity.   Beneath the tumour
the uterus was  seen partially contracted, and unruptured.   The pla-
centa of the extra-uterine foetus was found attached to the fimbriated
■extremity of the right  Fallopian tube.   Dr. Greenhalgh's second case
is briefly as follows :—A twin extra-uterine fcetation obstructed labour ;
the forceps was  applied to  the uterine child.   The woman recovered,
with  subsequent discharge of fcetal bones.  Montgomery  has collected
some cases of women bearing uterine children several times success-
fully, an extra-uterine  gestation persisting throughout.
  Obstruction by hydatid  tumour of the  liver and by cystic disease
of tlie kidneys occasionally occurs.   It  would be  better to puncture
these before labour than to  incur the risk of  their bursting into the
abdomen.
              * "St. Bartholomew's Hosp. Reports," 1865.
              + "Obstetrical Transactions," vol. v. 
             OVARIAN TUMOURS  AND PREGNANCY.          245

  Sometimes the distended bladder is carried down before  the head,
and presents a tense  fluctuating tumour at the vulva.  The diagnosis
and the  treatment offer no difficulty if we have  observed the good
obstetric  rule of passing the catheter in every case of tedious labour.
A  distended bladder complicating pregnancy has  been  mistaken for
dropsy.   Lowder mentions a case  where tapping was performed.   The
trocar traversed the  bladder, penetrated the  uterus, and pierced  the
child's head.  Death ensued.
  The obstruction offered by tumours in the vagina and vulva may be
great; but these cases are generally less serious, because they are more
within reach of operative measures for removal.  If they stand in the
way, they should be  removed before the child comes down.   Fibroid
tumours  may spring  from the  vaginal walls.  Condylomatous or  can-
cerous growths may  form large tumours at the vulva.  If these are
left until labour supervenes they  must undergo severe laceration,  and
may cause rending of the vagina.  A young woman was in the London
Hospital, several months advanced in pregnancy, having an enormous
growth  of syphilitic condylomata around the vulva.  It was removed
with  the knife, under my advice, by Mr. Curling.  The haemorrhage
was controlled without  much  difficulty, and  the  pregnancy went on
undisturbed.   We should now  remove such excrescences by  the
galvano-cautery wire or  knife.
  Another form of tumour which I have known to co-exist with preg-
nancy is  retro-uterine hematocele.   The mass  was expelled by the
rectum.   Where such a tumour is suspected, it may be punctured by
the rectum.   Blood-tumours  may  also form in the os uteri, at  any
point of  the vagina,  and in the vulva.  If they obstruct labour, it is
best to open them before the head comes to pass, otherwise increased
laceration  and bleeding may  result.  The diagnosis of retro-uterine
haematocele and other retro-uterine tumours  is discussed in  the  pre-
ceding lecture  on " Betroversion."   (See Figs. 91 and  92.)
   The diagnosis of ovarian tumours.   In some cases the presence of
ovarian disease  will be  known before the pregnancy has begun.   But
it is remarkable that, in a considerable number, no tumour is suspected
until symptoms of distress come on at an advanced period of gestation.
Then we are led to examine.  The symptoms are mainly those which
result from mechanical  pressure.   Dyspnoea, accelerated pulse, hectic,
accompany excessive abdominal tension.  This may be  due to excess
of liquor amnii, to twin-pregnancy, to complication with ascites.  With
care the  two tumours,  ovarian  and  uterine,  can generally be  dis-
tinguished.
  By referring to Fig. 96 we see the general outlines of the two masses
are preserved.  Even through the  abdominal walls, the groove or furrow
between  the two may be felt: it gives the idea of a bi-lobed tumour;
the distension  of the abdomen is greater transversely,  in  the flanks, 
246
OBSTETRIC OPERATIONS.
than in simple  pregnancy ;  and the foetal heart is heard very much
on  one side,  and generally lower  than it  should be.  And I  have
observed that the spot  of greatest intensity of this sound  shifts its
place  as  the gestation advances and the  uterus  is  pushed more and
more  aside.   It may  or may not  happen that  the os uteri  is  dis-
placed, and  that a portion  of the  tumour may be felt  in the brim of
the pelvis.
                              Fig.  96.
                 PREGNANCY COMPLICATED WITH OVARIAN TUMOUR.
  o t, the tumour lifted out of the pelvis by the uterus, u, which is pushed over to the side and
          over the brim of the pelvis; f h spot where fcetal heart may be heard.
  A small ovarian  tumour, or an early Fallopian  gestation-cyst, may
be diagnosed by the feeling a tense elastic swelling in  the  roof of the
pelvis, stretching the posterior wall  of the vagina, and carrying the
uterine neck forwards, and  the fundus to  one side.   The  diagnosis
is made clearer,  and a good  therapeutical indication is fulfilled, by
puncturing  the swelling with an aspirator-trocar.
  The uterus deformed by  myoma  has been  mistaken for a uterus
bicornis.   Nor is  the diagnosis easy,  even  after the embryo  and
secundines  have  been expelled.
  The placenta adhering to a polypus  may simulate inversion of the
uterus.  We must be careful, therefore,  to put in practice all the tests
for  inversion.   These I have described under " Inversion." 
               OVARIAN  TUMOURS AND  PREGNANCY.         247

   The treatment or management of pregnancy and labour complicated
 with ovarian tumour will be indicated by the  compendious  history
 I have traced of the events which have been observed under this com-
 plication.  The rule of conduct should be based upon the general law
 of giving primary consideration to the  safety  of the mother, regarding
 the  fate  of  the  child  as  of secondary importance.  Indeed,  a rigid
 analysis will show that the best hope of rescuing the  child will, in
 many cases, depend  upon our  success in saving the mother.
   The fact which stands most  prominently out is, that  a main source
 of danger is  the injury the tumour undergoes, especially during labour.
 During pregnancy even,  this danger is great in  the  case  of ovarian
 tumours.  The risk of bursting, of strangulation of the tumour, and
 of consequent shock,  haemorrhage, and peritonitis,  is so serious, and
 the  catastrophe  comes with  so little warning, that  the question
 whether it is ever prudent to let pregnancy  and ovarian tumour pro-
 ceed together without interference compels attention.  To do nothing,
 because pregnancy has often been completed without mishap, is simply
 trusting to chance ;  it is a surrender  of  judgment but too likely to
 entail unavailing regret.   We have  no means of telling whether any
 particular tumour will  burst or become strangulated under  pregnancy
 or labour.  The fluid tumours are more likely to burst;  but the solid
 ones are  liable to twisting and strangulation and perforation.   Both
 may give rise  to unexpected obstruction  to labour, and  undergo fatal
 injury during  the  process.   The double  burthen  itself, apart  from
 mechanical injury, may prove too much for the system  to  bear.  On
 the  other hand, judicious  interference does  not involve any  serious
 danger.
   At one time the observation  of a considerable number of cases of
 severe constitutional or organic disease complicating pregnancy, and
 of ovarian tumours progressing simultaneously,  had led me  to the
 general conclusion that it was better to  bring the pregnancy  to an end
 in the first instance, and  then  to deal  with the disease  or  tumour in
 its simple state according to its particular indications.  This  conclusion
 was  based on three different orders of observation, all converging to
 the same point.  1st. In a large proportion of cases, Nature solves the
 problem, takes the case into her  own hands, and finds  relief  by the
 spontaneous  induction of premature labour.   2ndly. In another series
 of cases, where labour  has been induced  artificially, immediate  relief
 and  safety have been attained.   3rdly.  In another series,  where labour
 hart  not  occurred  spontaneously, or been  induced by art, formidable
 catastrophes,  and even death, have happened.   The  point  to which
 reasoning converged,  then, appeared to be to reduce  the case  to its
 simplest  expression by eliminating one or other  of the  complicating
elements.
  Which  shall be eliminated ?  We may tap  the cyst and  so  reduce 
248
OBSTETRIC OPERATIONS.
the bulk  of the tumour that it will be brought within tolerance ;  and
even should premature labour  not follow the tapping, and  it is very
likely to follow, what remains of the tumour may not  impede delivery
at term.  But there are considerations which weigh strongly in favour
of eliminating the tumour altogether.   The  propriety of selecting
extirpation  has been  ably  discussed by  Mr. Goddard (Obst. Trans.,
vol. xiii.), and illustrated by the history  of a case in which Spencer
Wells performed ovariotomy on a woman  about two  months pregnant.
She recovered, and was delivered at term.
   Another question must be considered.  Take the case  where we are
surprised by the bursting or strangulation of the cyst, and  death by
shock, haemorrhage, or inflammation threatens.   If we do nothing, or
trust simply  to ordinary  means, the  woman dies.   One such case
appears to  have been saved by  decisive  action.   Spencer Wells per-
formed gastrotomy, removed the burst tumour, and  cleared out the
effused fluids  (Obst.  Trans.,  vol. xi.).  The  woman made a  good
recovery, pregnancy being uninterrupted.   I am disposed to think that
where  severe  and  sudden peritonitis  occurs during  pregnancy,  it is
frequently due to rupture of an ovarian  cyst.  Under these circum-
stances recovery is  scarcely probable.   But, as Wells' case shows, the
probability is increased by removing the offending cause.   We should,
therefore, not hesitate to practise laparotomy.
   The  aspirator-trocar is likely  to prove  of great service  in cases of
small fluid ovarian cysts,  and of early  extra-uterine gestation-cysts.
These cysts may be tapped by the vagina, and the contents drawn off
with ease and -safety.   Professor Thomas  operated successfully upon
an extra-uterine gestation by opening the  cyst through the vagina with
the galvanic  cautery, and removing a foetus of  four months' growth
(New York Med. Journ., 1875).
   Next we  have to discuss  how to act when  labour  is  obstructed by
tumour.  Up  to a certain point the principles of action are the same
whether  the tumour be ovarian or fibroid.  We have to  bear in mind
that our  duty is, first, to deliver the woman safely; secondly, to secure
the safety of the child, if possible.
   The  first  question  to determine is, Can the obstructing tumour be
pushed out of the way ?  Many cases  of  ovarian tumour, and some of
fibroid, are movable, and admit of being  lifted  above  the pelvic brim,
so that the diild can find  room to pass.  This may be  done by the
hand.   The  operation will generally be  facilitated  by  placing  the
patient.on all-fours.   Now and then the tumour rises out of the pelvis
in the course of labour, under the unaided action  of the descending
uterus  and child.   Beatty and Depaul relate cases  in point.  In one
case, Dr. G. Kidd carried a tumour out of the way by the pressure of
one of my bags distended below it in the rectum (Dublin Quart. Journ.
of Med.,  1870).  As soon as the pelvic brim is clear, endeavour to seize 
             OVARIAN  TUMOURS AND  PREGNANCY.          249

the child's head with the forceps.  Three excellent reasons persuade to
this practice:  first, the  head being made to occupy  the  pelvis,  the
tumour cannot fall in again ;  secondly,  you save the forces  of  the
mother, by lessening the  need of uterine action—you lessen the  risk of
rupture of  the tumour and  of the uterus ;   thirdly, you improve  the
chances of securing a live child.
  This, then,  is  the  simplest  course:  put  aside the  tumour  if  you
can.
  The second  question, one which arises in the event of the first being
decided in the  negative, is, Can we diminish the  bulk of the tumour so
as to give room for the child to pass ?  We might greatly simplify  this
difficult question by deciding at once that we ought not  to  puncture
solid tumours.  Little or  nothing can be gained in the way of  lessening
bulk by this procedure, whilst the injury is  very likely to be followed
by low  necrotic inflammation and death.  Dr. Charles West has  dis-
cussed and  illustrated this point."'   In a fatal case he attributed  the
death to an  attempt to puncture the tumour before trying to carry it
above  the  pelvic brim.   There was no  general peritonitis, but  the
wound in the tumour " was gaping widely, the tissue around  it was of
a black colour, and this discoloration extended thence inwards towards
the centre of the tumour."   But this rule requires  a  qualification.
The best test of solidity  is sometimes puncture.  The  aspirator-trocar
is not open to  the objection urged by West.
   I would  submit this proposition as the rule in dealing with solid
tumours :  if they cannot  be pushed up and aside, puncture by aspirator,
but do not incise them  unless  you  see your way clearly to  removing
them altogether.   To enucleate a fibroid  tumour from  the  uterus,
during  labour, is a hazardous  undertaking.  But circumstances may
occasionally be favourable.  Thus, Dr. Hicks relates a  caset in which,
finding the head  arrested by a firm  tumour  so  filling  the  vagina  that
delivery by forceps, turning, or embryotomy seemed doubtful, he made
a  small incision  in the  lower  part  of the tumour, which, under  dis-
tension, permitted its  enucleation  and removal.   There was   no
bleeding.   The woman  did  well.   The decision is clearer when  the
tumour is  of  polypoid form.  If a  polypus  protrude  into the vagina
before the child, I strongly advise that it  be  removed  before the child
is allowed to pass over it.  You may do this by the ecraseur directly,
or you may apply a whipcord ligature round  the pedicle  first, and cut
off the tumour below.  A better plan still is removal  by the galvanic
cautery-wire.
   In the  case of fluid  tumours, as ovarian cysts, the  propriety of
puncturing  is established.  How shall we proceed?  The first thing
to  do  is to rupture the  foetal membranes,  and  let the liquor amnii
                 * "Diseases of Women."  Edition,  1856.
                 t "Obstetrical Transactions," 1870. 
250
OBSTETRIC OPERATIONS.
drain off.  This at once reduces bulk and takes off  some amount of
tension.  Then puncture the  cyst.  The  best place,  if the cyst pro-
trude into the pelvis  and fluctuation be felt there, will  generally be
the most prominent part of the tumour behind the os  uteri in the
roof of the vagina, or by the  rectum.   But if fluctuation be  not felt
in the vagina, it will  be  better to puncture in the  most prominent
part of the cyst in the abdominal walls, carefully  determining the
position  of  the  uterus by  the  foetal  heart  and  palpation.   Use  a
moderate-sized trocar or the aspirator  first.   The  cyst, if punctured
by  the abdomen, will probably collapse  more completely;  and you
are more likely  to  avoid the solid basis  which  is  so often found at
the lower part  of ovarian tumours.
 LABOUR OBSTRUCTED BY A FLUID OVARIAN TUMOUR, T, FIXED IN THE HOLLOW OF THE SACRUM,
                AND PUSHING THE UTERUS FORWARD AND UPWARD.
  I am  disposed to think that  even where the ovarian cyst  does  not
materially obstruct  labour, it should be tapped.   It  is a remarkable
circumstance that in not a few cases the cyst has  ruptured—or, at
least, the evidence of rupture has become manifest—days after labour,
causing  death.  Dr. Clay relates an instance of this."  In such a case
as that  sketched in  Fig.  97,  puncture of the tumour by vagina or
rectum  would at once permit the uterus and child to descend.
  Dr. Playfair has examined the question how to deal  with ovarian
tumours by comparing the histories of nearly  fifty  instances (Obst.
Trans.,  vol.  vii.) of  labour complicated with ovarian tumour.   He
found that of the cases delivered by craniotomy more than  half  had
terminated fatally.  It might, he urges, be fairly assumed that had the
Caesarian section been performed in these cases at an early period the
mortality of mothers would not have been greater, whilst some of the
                  *  '' Obstetrical Transactions," vol. i. 
                   TUMOURS  AND PREGNANCY.               251

children would have been saved.  This reasoning is difficult to resist;
but it clearly does not justify a uniform mode of proceeding.   The
facts, however, prove  the extreme danger of dragging a child past an
ovarian tumour;  and that, in some cases at least, the Caesarian section
is  the safer proceeding.   When gastrotomy has been performed with
the view to Caesarian section, it may be found  that the best solution
is  to proceed  to extirpate the tumour;  and if this cannot be done,
then  to proceed  to Caesarian  section  on Porro's method.   Indeed,
looking at the fair prospect of a radical cure  of a threatening disease,
as well as at the solution of  the  difficulty of  effecting delivery, the
propriety  of conjoint Caesarian  section and  ovariotomy  should be
carefully weighed when  discussing the treatment of these  cases.
   The third question arises in the event of the  tumour being immov-
able,  and incapable of reduction of  bulk.   The danger now rises  high.
There is obstruction to labour; there is the almost unavoidable risk of
injuring the tumour.  Malignant ovarian cysts may be firmly attached
to the pelvic  walls, sarcomatous or bony tumours  may spring  from
the pelvic walls,  and fibroid tumours  of the  uterus may be impacted
in the pelvis.  Our decision as to  the course to be adopted  must be
governed by a careful survey  of all the conditions of the particular
case.   It  is  assumed that we cannot act  upon  the  tumour.   The
alternative is  that  we must act upon  the child.  The mode of action
will depend upon the degree to which the pelvis is contracted, and
upon the estimate  we may form  of the nature  of the tumour and its
liability to be  injured by  the  passage  of the child.  If there remain
three inches, or perhaps  even less, of space in the conjugate diameter,
and the tumour be of a yielding substance, we may possibly deliver by
the forceps, but turning is generally to be preferred ;  if the  space be
very  small,  say under two inches,  and the possibility of the tumour
being seriously bruised  is great,  we  must be  prepared, whether we
have  applied the  forceps or have turned, to perforate the child's head
to lessen  its bulk  and  solidity.   A perforated  head will flatten and
mould itself in its passage,  especially if the  cephalotribe be  applied:
thus  plastic and yielding,  pressure  against  the tumour is greatly
lessened.   In  the case of  a solid or  comparatively  firm  tumour,
leaving barely an inch  or so of pelvic space,  it may  be difficult  to
reach the  head  to perforate,  or, if perforation be  accomplished,  it
may  be impossible to pursue the further steps of crushing the head
by cephalotribe,  of picking  off  pieces of the   cranial vault, and  of
seizing the face by the craniotomy-forceps.  It  will, however, be  seen
in the lecture  devoted to  Craniotomy, that this operation admits  of
being successfully performed in  a  far narrower space than  is  com-
monly deemed possible.
   This is especially a case where my operation of reducing the head
by making  sections  of  it  by  the  wire-ecraseur  promises to be 
252
OBSTETRIC OPERATIONS.
useful.  We should exhaust all means of acting  upon the child  before
deciding upon the Caesarian section.  The case should be well studied
in all its bearings.  If we are of opinion that no amount of mutilation
of the child that can be effected will ensure delivery with a reasonable
prospect of saving the mother,  then we should spare  the child and
deliver  it  by  the Caesarian section.   Great  as is the peril of this
operation  to the mother, there  comes a point at  which  it holds out
the best chance. And  to give  the best chance we should endeavour
to perform the operation as the  first step, that is,  by  election, without
having previously damaged the prospect of success by fruitless efforts
to deliver  by other means.  If the obstructing tumour be extra-uterine,
bony  or semi-solid, and encroaching to an extreme  degree upon the
pelvic space, the argument for Caesarian section  will  be strengthened.
If the tumour be uterine myoma, the Caesarian section  offers  but a
slender  hope  unless conducted  on Porro's method.
   Dr. E. J. Lambert, in his valuable Etude sur les grossesses compli-
quees de Myomes uterins, 1870, has collected fifteen cases in which
the Caesarian  section was performed.  Two women recovered:  one
operated upon by Mayor, of Geneva, and one by  Duclos, whose case
is cited by Tarnier.
   In the case of complication with an extra-uterine  gestation, it appears
to me that we should  first of all determine  whether  the extra-uterine
tumour can be pushed out of the way so as to  secure it against violence.
This is  scarcely likely, for these cysts almost always contract adhesions
with the viscera in the lower abdomen.   We  are then  driven to elect
between mutilation  of the child  and  gastrotomy.  If  by means of the
former proceeding we  can ensure delivery of the uterine child without
doing violence to the  extra-uterine cyst,  we may adopt it.  But I
should  be disposed, more than in any other complication,  to  resort
to gastrotomy.  In  this  case it  would be  proper to remove the  extra-
uterine  child in the  first instance,  avoiding opening the uterus unless
the passage of the uterine child per vias naturales should still prove
impracticable.
   What is best to do n the case  of a myoma in utero after labour ?
It has probably been injured;  and inflammatory process of a  low type,
leading to metro-peritonitis and blood-infection,  is  likely to set in ;
and the uterus, still  in a state of active muscular  development and
reflex irritability, resents the presence of the tumour as a foreign body.
The expulsive pains set  up  are  so severe and exhausting as to be in
themselves a  source of  danger.  This I have seen strikingly marked
in a case in  which I was consulted by Mr.  Corner.   Cases  in  which
spontaneous  or operative enucleation  has  been  effected soon after
labour,  have  done well.  The general indication, then, to get  rid of
the  tumour  early,  seems clear.  The  mode of proceeding must be
determined by  the  characters  of the  case in  hand.   The  cervix 
TUMOURS  COMPLICATING PREGNANCY.         253
should  be well dilated  by introducing a faggot of laminaria tents,
so as to give  free space for  examination and manipulation.   Then a
hernia,  or other convenient  knife, carried into  the uterus,  may be
used to  divide  the  capsule  of the  tumour  freely.  If the  tumour
project  much into  the  uterine  cavity, it may then be  possible to
shell  it  out,  partly  by  the  fingers,  and  partly by  a vulsellum
dragging  upon it.:::  If the tumour do not project  much, and imme-
diate  enucleation  be too difficult,  further proceedings may be  post-
poned.   The  uterus continuing to contract may  drive the  tumour
further  into  the cavity,  and in a day or two  its removal may be
easier.  This  process may be aided by frequent  doses of ergot, or by
the  subcutaneous injection  of  ergotine.  Haemorrhage, if it occur,
may be controlled by pledgets  of lint steeped in perchloride of iron;
and foetor may be obviated by lint plugs  soaked in carbolic  acid oil.
   We may sum up the argument in the following propositions, rising
from the simplest cases to those of  extremest difficulty.
   A.—In the case of tumours complicating pregnancy :—
     1.  Induce premature labour.
     2.  Or remove the tumour by laparotomy.
     3.  If ovarian tumour burst or become strangulated during preg-
          nancy, remove it quam primum by laparotomy.
   B.—In the case of tumours obstructing labour,  that is, presenting
before the child :—
     1.  Push  the tumour aside, if possible.
     2.  If the tumour be fluid, lessen its bulk by  puncture.
     3.  If solid,  puncture by aspirator-trocar; and  if still  not dimin-
          ished in bulk, remove it by enucleation or by wire.
     4.  If the tumour cannot be  advantageously acted upon, reduce
          the  bulk of the child.   Turn, perforate,  crush the head by
          cephalotribe, break up the cranial vault, remove it in sections
          by wire-ecraseur.
     5.  If neither tumour nor child can be advantageously acted  upon,
          have recourse to the Caesarian section.
   C.—When the tumours present after the birth of  child :—
     1.  If polypoid, remove early after  labour by wire-ecraseur  or
          galvanic cautery-wire.
     2.  If sessile or projecting  in a marked  degree from  the  inner
          surface of  the uterus, more especially if seated in the cervix,
          or lower zone of the uterus, so  that they have been bruised
          by the passage of the child, remove if possible by enucleation.
     3. If they cannot  be so  removed, try to promote  expulsion by
          quinine, by subcutaneous injection of ergotine,  and watch
          to counteract septicaemia.
   * I have contrived a powerful axis-traction vulsellum,  which works well in cases
 of this kind. 
LECTURE   XX.
mechanical complications of pregnancy and labour (continued):
    DEFORMITIES  OF  THE  SKELETON--THE  RACHITIC  PELVIS--THE
    KYPHOTIC PELVIS--THE  OSTEOMALACIC PELVIS—THE SPONDYLO-
    LISTHETIC PELVIS--DISEASE  OF THE PELVIC  ARTICULATIONS--
    NAEGELE'S  PELVIS--FRACTURES OF  THE  PELVIC   BONES--THE
    "THORNY"  PELVIS — DIAGNOSIS OF PELVIC DEFORMITY—PECU-
    LIARITIES OF  LABOUR IN  DEFORMED PELVIS.

         The Principal Abnormal Conditions of the Skeleton

which offer impediments to labour are the following:—
  1. Those  arising from rickets.   These affect  the pelvis most fre-
quently ; but  often the  spinal column is  also  implicated in  such a
manner as to  influence labour.
  2. Those arising from osteomalacia.   These commonly affect  both
pelvis and spine.
  3. Those arising from disease or injury  of  the vertebre or the ver-
tebral joints.   These,  when   leading to  dislocation of the  lumbar
vertebrae, produce the deformity called spondylolisthesis.
  4. Those arising from scrofula, syphilis, or some other less under-
stood diseases which lead to osteophytic growths, producing nodular or
pointed  excrescences from the pelvic bones.
  Stein, the younger, enunciated the important law, that like causative
diseases always produce like forms of  pelvis.   Hence there is a rickety
pelvis, an osteomalacic pelvis,  and so  on.
  It would carry me far beyond the scope  of  this essentially practical
work, were I to attempt a full account of all the varieties and degrees
of skeleton-deformities in their obstetric relations.  I limit myself to
giving a concise description and  figures  of the leading typical forms,
which  exercise the most marked  influence upon child-bearing, and
which determine us in the choice of operative proceedings.
  Fig. 98  may  serve as a healthy  standard pelvis.  Like Figs.  99,
100, 101, 102, 103, it  is reduced to one-third of the natural size for  the
sake of  more precise comparison. 
DEFORMITIES  OF  PELVIS.
255
  1. Rickets.   This disease,  beginning  as  it  does  before  maturity,
influences not only the shape, but also the development of the skeleton.
A rickety skeleton is commonly deformed, and below the average size.
This double abnormality  intensifies the  evils which pertain to each
separately.
  A-—The most  common deformity produced in the pelvis tells most
seriously upon the brim.   This  is compressed antero-posteriorly ; the
promontory of the sacrum is  protruded forwards,  and the symphysis
pubis is flattened  in; the conjugate diameter is shortened, absolutely,
and also relatively, to the other diameters.   From  cordate, the outline
STANDARD NORMAL PELVIS: AD NAT., ONE-THIRD NATURAL SIZE.
of the brim has become transversely oval or reniform.  Lordosis, or
arching forwards of the lumbar vertebrae,  often accompanies the pelvic
deformity.   This spinal curvature is at times so great that  the lumbar
vertebrae overhang the pelvic  brim, impeding the entry of the  uterus
and  foetus, virtually  closing the pelvis.   When this occurs, the  pro-
trusion  forwards of  the uterus causes extreme prominence or over-
hanging  of  the abdomen.  There is  a remarkable example of  this
deformity in St. George's Museum.  The woman died after craniotomy.
Sometimes the spine is curved laterally—scoliosis.   When  this  occurs
there is usually oblique distortion  of the  brim as well as flattening.
A  perpendicular drawn from the symphysis pubis will strike on one
side of the promontory.  The general effect  upon the pelvis below the 
256
OBSTETRIC OPERATIONS.
brim, that is, in the cavity and outlet, is to expand it.   Not that there
is absolute increase of room, but the relative dimensions compared with
those of the  brim are larger.  There is often narrowing of the  pubic
arch, approximation  of the tubera ischii, and sometimes incurving of
the lower part of the sacrum and coccyx.   Still, as a rule, in rickety
pelves, the  bones at  the  outlet diverge; there is  room  for the intro-
duction of the  obstetric hand, and therefore for operations  upon the
child.
  B.—Rickets occurring in earliest infancy, before the component parts
of the innominate bones have become fused, may lead to the triangular
or trefoil deformity similar to that produced by  osteomalacia in the
adult.   Indeed, Hohl  contends that rickets and osteomalacia  are the

                             Fig.  99.
EXTREME RACHITIC PELVIS : AD NAT., ONE-THIRD NATURAL SIZE.
same disease.   There is a tendency, as development proceeds, to gain
the normal form.   Hence we rarely find in the adult rickety pelvis a
well-marked triangular distortion.
  Fig. 99 is an extreme example of rachitic pelvis.  The specimen
comes from a  dwarf upon whom I performed the Caesarian section,
after fruitless  attempts at  embryotomy, and irremediable injury had
been inflicted.  The pelvis is  in St. Thomas's Museum.
  The specimen shows the tendency of this deformity to divide the
brim into two parts, one on either  side of the much-projecting pro-
montory, so that the available space is reduced  to one  of the loops  of
the figure x>.
  Deformities  and  contractions  from rickets vary  greatly in degree.
The " simple  flat  rachitic  pelvis " of Litzmann,  the most  common
form, is often  said  to have its transverse diameter absolutely length-
ened.  In some specimens the basis of the  sacrum actually exceeds 
RACHITIC PELVIS.
257
the normal width.  If I may trust the general conclusion drawn from
large personal observation in the quarter of London where deformities
are most rife, I should say that actual excess of transverse diameter is
extremely rare.   The rickety pelvis is small generally ;  the narrowing
bearing principally upon the conjugate, but affecting in some degree the
other diameters also.  Dr. Hicks has formed a similar opinion ;  and he
has kindly had  measurements  made  for me of ten  rickety pelves in
Guy's Museum.   Two  only of these measure 5'00" in transverse
diameter—that is, attain the ordinary dimension, whilst four measure
4*75", three 4*50", and one 4-25" only.
   It  is quite probable that deformities vary  in kind  and degree in
different countries, as they certainly do in frequency.  In England the

                              Fiu. 100.
      KYPHOTIC' TRANSVERSELY-CONTRACTED PELVIS, AFTER HUGENBERtJER; ONE-THIRD
                            NATURAL SIZE.

poorer classes  are  better  fed, clothed,  and  housed  than in most
countries  on the Continent;  and our sanitary condition is generaUy
superior.  In some districts on the Rhine, and around Milan, osteo-
malacia is a frequent result of the miserable  circumstances  under
which the labouring classes exist ;  whilst  in England the disease is so
rare that many men in large practice have never seen a case.   On the
Continent rachitis also seems far more frequent than with us.  It may,
therefore,  well be that what we look upon here as rare exceptions may
be so  common abroad as to justify an important place in a  systematic
classification.
  Narroiuing of  the pubic arch is not  uncommon  in London.  By 
258
OBSTETRIC OPERATIONS.
throwing the  child's  head backwards, it is apt to cause  laceration  of
the perinaeum.  I  have often found  it hinder the descent of the head
and call for forceps.
   Spinal  kyphosis induces a peculiar deformity of the  pelvis, called
by Breisky* and Hugenbergerf the "Kyphotic transversely-contracted
pelvis."  The illustration Fig. 100 I have borrowed from Hugenberger.
   Robert, of  Coblentz,  described another  form of the  transversely-
contracted pelvis or the two-sided synostotic, or double ankylotic.  This
appears to be  due to defective development of the alae of the sacrum.
These forms of pelvis resemble the pelvis  of  the  lower mammalia,  of
the infant, and of the Bushmen and Malayans of Java.  The dimensions
of the inlet are reversed, the antero-posterior  diameters being  length-
ened, and the transverse shortened.   The effect of this reversal of the
normal diameters would be to reverse the position of the head.  It would
enter more easily  with its long  diameter  in  the  conjugate direction.
   The funnel-shaped pelvis, the  peculiarity of which consists in the
convergence of the tuberosities of the ischia and of the sacrum, whilst
the brim and cavity are little affected, is not, according to my observa-
tion, of frequent occurrence in London.  I have, however, seen examples
of it in the  practice of  the Royal Maternity  Charity, amongst the
weavers of Bethnal Green, and others who, from childhood, spent a great
portion of their lives working in a sitting posture.  Imperfect nutrition,
no  doubt, disposes to it.   It is  frequently referred to by the  Dublin
school;  so much so that I am disposed to call it the " Irish pelvis."
But the most marked case I know is that of a lady who shows no other
sign of  having suffered  in health.   Two  of  her  children have been
sacrificed by craniotomy; in the  third pregnancy  labour  was induced
at seven months, the forceps was applied and brought the head without
difficulty to the outlet, when the disproportion  became too manifest  to
admit a hope of its passing in this way; I therefore turned, and thus
succeeded in bringing through the child, which survives.
  In some cases the sacro-coccygeal joint is ankylosed.  This will
produce an effect similar to the funnel-shaped  pelvis.  In such a case
we may  have to choose  between perforating the head  and  forcible
fracture of the ankylosis, so  as  to allow the  coccyx  to revolve  back-
wards.
  2. Osteomalacia.—This disease, occurring after maturity, does not
involve general diminution of size of  the bones.  It produces  remark-
able deformity.  It bears chiefly upon  the spine and  pelvis, the long
bones being  comparatively less affected.    The  bones  losing  their
mineral constituents, become soft and yield under  pressure.   The
pelvis and lumbar vertebrae forming a compressible centre between the
upper part  of the body and the legs, give way ; all the bones sink
                  *  "Mod. Jahvb.  Wien.," 1865.
                  t "St. Petorsli. Med  Ztsohr.,"  1868. 
OSTEOMALACIC PELVIS.
25D
inwards, collapsing together ; the spine falls downwards and  forwards,
squatting,  the  patient losing stature.   In many  instances the lower
lumbar  vertebrae dip into  the pelvic  cavity  (there  is  a remarkable
example of this in  St. Bartholomew's Museum).  The heads of the
femora drive in the acetabula and sides of the pelvis; there is universal
centripetal falling-in.  In  some cases the ilia are bent up, distorted
like  wet pasteboard,  as in a characteristic specimen in  St. George's
Museum.   The  pubic bones are  flattened  together by their posterior
surfaces so as to form a beak  or rostrum,  so  distinct that the  finger
and thumb can seize it through the living structures.  The effect upon

                             Fio.  101.
     OSTEOMALACIC PELVIS: AD NAT., FROM A SPECIMEN IN ST. THOMAS' HOSPITAL MUSEUM,
                         ONE-THIRD NATURAL SIZE.

the brim is to produce the extreme cordate  shape, sometimes approach-
ing  the letter Y,  as in Fig.  101.  The cavity  and outlet share the
concentric compression.  There is  really no pubic  arch; the tuberosities
are closely approximated ; the sacrum  is curved forwards ; the outlet
is almost  closed.   The  obstetric  result is  that, in marked cases, it  is
scarcely possible  to introduce two  fingers ; there is little room for
manipulation  or for working instruments ; we are often compelled  to
get at the child from above, through the abdomen.   It must not, how-
ever, be forgotten that the plastic condition of the bones  may admit  of
the pelvis being opened out again under eccentric pressure ; and that
if labour be brought on before the seventh month by embryotomy, we
may secure  a  foetus so lessened  in  bulk and  so ductile,  that  it  will
traverse even  extreme degrees of distortion.
                                                          s  2 
260                  OBSTETRIC  OPERATIONS.
  3. Disease of the Vertebra.—Under various diseases, as scrofula, or
injury inducing caries or  softening, the articulations gave way, and,
the lumbar vertebrae slipping forward, a dislocation results.  Hence
the name  " Spondylolisthesis."   This gliding down  throws two or
more  lumbar vertebrae into the cavity of the  pelvis, producing a new
and false promontory in front of, and lower  than the true one ;  it not
only contracts the conjugate diameter, but by partly filling the pelvis,
prevents the uterus and  child from entering.   Some of the cases appear
to have been congenital;  but in others certainly the condition arose
after  maturity.   It  was first described by  Kilian.   I have  discussed
Fig. 102.
          SPONDYLOLISTHETIC PELVIS, AFTER KILIAN;  ONE-THIRD NATURAL SIZE.
4. Fourth lumbar vertebra; 5. Fifth lumbar vertebra. The virtual conjugate is indicated by the
                              dotted line.

the subject in  some detail in the  Obstetrical  Transactions,  vol. vi.
The general obstetric  effect is similar to that  produced by  a  large
osteosarcoma in the pelvis.  Most of the  cases  required the  Caesarian
section.
   The illustration, Fig. 102, is  taken from Kilian.  It is called  the
" Prague Pelvis." . The  original is  in  the Prague  Museum.*  In
another  specimen described by  Kilian,  the  virtual  conjugate starts
from  the second lumbar vertebra, the third, fourth,  and fifth having
all sunk into the pelvis.   Becently Franz Neugebauer has richly
  * "De Spoulylolisthosi  gvavissimae  pelvangustise, causa nuper detecta."  Bonn,
1853. 
OBLIQUELY-DISTORTED PELVIS.
261
illustrated  this  subject   (1884).   I  must  refer  to  the  Obstetric
Medicine  and  Surgery, vol. i.,  1885,  for  fuller  description of this
and  other  forms of distortion.
  4. Disease of the Pelvic Articulations.—Inflammation, softening,
caries, especially of the sacro-iliac synchondrosis,  induce oblique dis-
tortion  of  the  pelvis.  This is  the  deformity described  by Naegele
under  the names  " Schragverengte Becken" and "pelvis  oblique-
ovata."  The disease affecting one joint, the nutrition of the  corre-
sponding side is modified,  the relative action of the muscles attached
to the  two sides, and the pressure  bearing upon the  two sides, are
disturbed.   Frequently, also, there  is  defective  development of  one

                              Fig. 103.
OBLIQUELY-DISTORTED PELVIS, AFTER NAEGELE ; ONE-THIRD NATURAL SIZE.
side  of the sacrum.   Hence the symphysis pubis is thrown across
towards the sound side;  and  the affected side is  diminished.   This
condition  may arise from congenital causes ; but it also undoubtedly
arises  in childhood and maturity.
  Less marked, but stiU distinct degrees of pelvic obliquity, or asym-
metry  of the two sides of the pelvis, are produced by lateral curvatures
of the spine,  and by  shortening  of one leg, especially  if these occur
before  maturity.
  In its obstetric relations we find it preventing the due adaptation of
the head,  and impeding its  descent  into the pelvis.   The forceps will
suffice in the minor degrees : turning,  taking care to bring the occiput
into  the larger  or sound side  of the  pelvis, may answer in cases of 
262
OBSTETRIC OPERATIONS.
somewhat greater severity;  and embryotomy with cephalotripsy ought
to effect delivery in the most extreme cases known.   Caesarian  section
can very rarely be necessary.
   It is usual to describe a pelvis  equabiliter justo major, and a pelvis
aquabiliter justo minor.  The  first requires no  description.  It is
simply a  large pelvis.  The existence of the second,  as  a product
of disease, may be doubted.  Disease  will almost invariably induce
deformity,  although  the  degree may  be slight.   The  term  might
usefully be discarded.  A  perfectly  proportioned  pelvis,  uniformly
reduced in  all its  dimensions, must  be regarded as  an infantile or
immature pelvis, or as a general result of small stature.
   Fractures  of the pelvic bones  from injury may leave various forms
of distortion.   Cases of the kind are extremely rare,  and methodical
description of them is scarcely possible.

                              Fig. 104.
REPRESENTS SECTIONAL VIEWS OF THE NORMAL PELVIS (THE STRONG LINE) CONTRASTED WITH THE
       OSTEOMALACIC PELVIS (FIXE LINE) AND THE RICKETY PELVIS (DOTTED LINE).

  Certain diseases affecting the osseous system cause sharp ridges, or
needle-like projections.  If these occur on the  linea ileo-pectinea, they
will  obviously endanger  the  uterus,  cutting or  stabbing its  walls.
They often occur  in the rickety pelvis.  A form of pelvis is described
by Kilian  under the name " Acanthopelys," " das Stachelbecken ;"
Anglice, the " thorny pelvis."
  In connection  with pelvic  disease we  may  most conveniently refer
to osseous, fibrous, and sarcomatous outgrowths from the pelvic walls.
These are of various sizes  and origin.  Perhaps they most frequently
spring from the sacrum.   Growing, they gradually encroach upon the
pelvic space ; and in  some cases,  as in  one recorded by Dr. Shekle-
ton,   of Dublin,  whose  drawing is  copied  into  most  text-books, so
nearly filling the  cavity that delivery by the natural passages became 
               DIAGNOSIS OF  DEFORMED PELVIS.           26b

impossible.   This  was  the  motive  of a  Caesarian section  at  St.
Bartholomew's which I witnessed and assented to, having myself
vainly  endeavoured to deliver by turning,  after Dr. Greenhalgh had
failed.   We both succeeded in touching a  foot.   The operation was
performed by Mr. Skey.  The woman died,  and  the  pelvis was found
nearly  blocked by a sarcomatous  tumour.   These tumours sometimes
grow  quickly, so that as  in Shekleton's  case,  the  labours  become
increasingly difficult.   In others,  they remain stationary, or grow very
slowly, as in a case to which I  was  called by Dr.  Bogers, once my
Besident Accoucheur at the London Hospital, for the express  purpose
of performing the Caesarian section.  I, however, succeeded in deliver-
ing by my craniotomy forceps.  The subject recovered, and was  seen
by me  occasionally for  several years afterwards.
  Mr.  Berry  relates  an instructive case (Obst.  Trans., vol.  vii.) of
obstruction  from medullary  cancer springing from  the bones of the
sacrum.   As it  felt  fluctuating it  was  punctured, when  a  large
quantity of florid blood flowed.   After great exertions, the child was
delivered by craniotomy and turning ;  but the woman died in  an hour.
The uterus and vagina were found lacerated.
  It is clear from  the comparison of  the  various kinds  of deformity
that no definite universal rules as to choice of mode of delivery can be
drawn  from the simple element  of dimensions.   Shape  of pelvis and
the nature of the  obstruction must also be considered.   Still, in the
rickety, which embraces by far the larger number of cases of deformity
leading to obstructed  labour, the space given in the antero-posterior
diameter  of the brim will generally  determine  our  proceedings.  A
scheme of the relations  of operations  to  pelvic contractions,  in  con-
formity with the improved  methods of operating described in this book,
is given in Lecture VI., p.  69.
  The diagnosis of the kind and degree of  pelvic deformity is easy in
proportion to its severity.  The  rickety pelvis  may be suspected  from
the low stature and ungraceful gait of the subject.  It is often attended
by  marks  of imperfect  development,  and  by  spinal deviation.    In
marked degrees there is a peculiar form and expression of the features.
In advanced pregnancy the  abdomen overhangs the pubes.  The sacrum
is remarkably flat externally.  On  internal examination nothing unusual
may be noticed at the outlet; but, on pressing the finger backwards, it
strikes the sacrum  or  its promontory, whilst the knuckle is, perhaps,
applied to the arch of the  pubes.  In a healthy pelvis this cannot be
done.   An experienced hand  will, from this examination, form a very
close estimate of the length of the conjugate, and the mode of delivery
that must be adopted.  Much ingenuity has been expended in the con-
struction of instruments that shall give the pelvic measurements  with
absolute precision.   Nothing surpasses  in this respect Van Huevel's
pelvimeter.   Its  application is often of great  scientific value.  But I 
264
OBSTETRIC OPERATIONS.
imagine few obstetric surgeons of experience rely upon any instrument
but the hand.  This  gives information that can be obtained in no other
way.   When there is obstruction, or retarded labour, or other cause
to suspect pelvic contraction,  the most  practical  course  is to induce
anaesthesia and to pass the hand into the vagina.   In this way you can
explore the whole pelvis, take  note of the various dimensions,  and
ascertain the relations of the foetus.
  The oblique pelvis  may be made out by the same method, and verified
by external measurement from the spinous process  of  the  upper sacral
vertebrae to the symphysis pubis on either side.
  The osteomalacic pelvis may be suspected by the extreme closure of
the outlet making it  difficult for  the fingers to  pass, and verified by the
rostrated condition of the ossa pubis.
  It was at one  time thought  that there was a fixed relation  between
the external  and the internal conjugates, and that by measuring the
external  we  might  read off the internal diameter.   No one  would
venture to act  solely upon the  estimate thus deduced.   Taking the
standard external conjugate to be 7", it does not follow that, where this
is found, we can depend upon an internal conjugate of 4".   Taking two
pelves both  measuring externally 6",  we may find that  one has an
internal conjugate of 3", the other one of 3-50".  There is, in  short,
no substitute for internal exploration by the hand,  and all other modes
may be dispensed with.   But where the question is as to the induction
of labour, we shall  hardly be wrong  if,  on finding an external con-
jugate of 0", or even of 6-50",  we advise the induction  of labour at
seven  or eight months.


           Mechanism  of Labour with Deformed Pelvis.

   Pelvic deformity may generally be recognized by the  characters it
imposes  on the  course of labour.  As a natural pelvis  governs the
process of labour according to certain  definite laws, so do the various
forms  of abnormal pelvis, each in its own manner, control the process.
   The presenting position and the progress of the child  are  liable to
characteristic modifications.   In the case of the moderately contracted,
flat, or rickety pelvis, the conjugate diameter  being narrowed, and the
promontory projecting, the head can hardly enter the brim in an oblique
diameter ;  it must almost necessarily present  with its long diameter in
relation  with the  long or  transverse  diameter  of  the pelvic brim.
The anterior side of the head will, in the early stage of labour, overlap,
more  or less according  to  the  degree  of conjugate  contraction,  the
symphysis pubis. The broader expanse of the occiput not  so easily
entering the pelvis  as the narrow sinciput, is delayed a little on the
edge of the brim; thus the  forehead will be  at first  driven lowest in 
                LABOUR IN CONTRACTED PELVIS.            26-3

the pelvic cavity.  The driving force increasing  up to a certain  point
with the resistance, the head is gradually moulded by being flattened
in its transverse or bi-parietal diameter, inducing great overlapping of
the frontal and parietal bones, so as to adapt itself to the flattened
brim  of the  pelvis.  The projecting promontory virtually alters  the
direction of the axis of the brim, depressing it so as to bring it nearer to
the horizon;  that is, it is made to form with the  horizontal datum-line
(see Figs.  29,  30) an  angle less than 30°.   The lower end of this*
imaginary line would fall, not upon the coccyx, but higher up at some
point in the  concavity of the sacrum, whilst the upper  end would be
brought below the umbilicus.   There  is increased inclination of  the
pelvis.  The consequence of this is  that  the  head must travel  more
directly backwards under the  projecting promontory than when  the
pelvis  is  normal.  It  must, in fact, travel round  the  promontory,
doubling it, in order to get  into the  cavity.  The anterior side of  the
head  at first occupies nearly all  the brim of the pelvis, the sagittal
suture running across the brim being much nearer to the promontory
than  to the  pubes.   The posterior side of the head is comparatively
fixed  against the  promontory,  the vertex pointing backwards towards
the sacral hollow.  The head describes the first curve, that to which I
have, given the name  of the  "false promontory"  (see  Fig. 30), an
exaggeration of the lumbo-sacral or " Barnes' curve." Having got  so
far, the occiput usually descends and comes forwards, and  enters  the
normal curve of Carus  (see Fig. 30).  I may refer back to Lecture VI.
for an exposition of the mechanism of labour under this condition.
   If the conjugate contraction be more marked—that is, to abput 3*50"
—the first stage of labour will  be more protracted still; the presenting
part will remain  for a longer  time above  the  brim ;  the os   uteri,
wanting the dilating force of the liquor amnii  and head, will  be  more
slow  in opening;  perhaps  the cord will come down,  and this  is
especially liable to be the  case if the membranes  break early, since  the
head cannot  block the  brim.  At length violent pains may force  the
head into the strait.   The conditions already described will be observed
in a more exaggerated degree.  It is in these cases and in the preceding
class that some additional vis a froute by  the aid of the forceps is often
valuable by aiding and economizing the struggling vis a tergo.
   In the still more contracted conjugate,  where it is  reduced to  3" or
below,  the head can hardly enter  at  all;  it rests  upon  the   brim,
touching at  two  or  three  points only,  therefore perfectly  movable
except when fixed by  the  driving power ;  and there it will remain
unless its bulk be reduced.  In these  cases a marked  indentation, even
fracture, of the frontal or parietal bone,  caused  by the long and violent
pressure against  the  projecting promontory, has  been noticed.   This
injury is not necessarily fatal.  It is useful to bear it in mind, because
in the event of  the forceps having been used, this might be assigned as 
206
OBSTETRIC OPERATIONS.
the cause.  I have several  times  known actions for damages  threat-
ened on  this ground, even  although  the child and  the mother  have
done well.
  In the osteomalacic pelvis the  head will  rest upon  the  brim in a
similar manner.
  The following circumstances should provoke the suspicion that there
is pelvic  deformity:—A protracted first stage of labour;  slow dilatation
of the cervix; premature rupture  of the membranes ; prolapse of the
cord ; an unduly transverse  position of the head, the forehead being as
low or lower than the occiput;  an abnormal presentation; failure of
the presenting part to enter the pelvic  cavity, although  the cervix may
be dilated ;  approach  to a pendulous  belly, the fundus uteri being
apparently lower, pointing more forwards  than  usual.
  As after-effects of severe  pressure concentrated upon limited areas
or points of the soft  parts, fistula,  or rupture of the uterus or  vagina
may arise ;  and from  the local injury,  combined with the systemic
exhaustion and absorption  of effete matter, there  is greater  risk of
puerperal fever. 
LECTURE
XXI.
RUPTURE  OF THE UTERUS,  VAGINA, AND PERINEUM—DEFINITION  OF
     LACERATION,  RUPTURE, AND  PERFORATION--PREMONITORY SIGNS
     AND  PROPHYLAXIS--THE  CONDITIONS UNDER  WHICH  RUPTURE
     OCCURS :   IN  NON-PREGNANT  UTERUS ;   DURING   PREGNANCY ;
     DURING  LABOUR--LACERATIONS  FROM  OBSTRUCTION TO LABOUR
     — LACERATION OF THE VAGINA--TRAUMATIC LACERATIONS--THE
     SYMPTOMS  AND  COURSE OF CASES  OF LACERATION--THE TREAT-
     MENT--DIFFICULTIES FROM  DIFFICULTIES  IN  DIAGNOSIS--ILLUS-
     TRATIONS  OF SOURCES  OF ERROR--DESCENT OF INTESTINE.

Rupture of the uterus  has this  affinity to the Caesarian section, in
that it is sometimes  produced by conditions  similar to those which
determine us to perform the Caesarian section.   Indeed, a great motive
for this operation is to avoid rupture.   And when rupture has occurred,
it  is commonly necessary to open the abdomen in order to remove the
fcetus.  There  are, in fact,  cases of dystocia where Nature, unable to
effect delivery per vias naturates, seems, by rending open the uterus
and extruding  the child  into  the  abdominal  cavity, to  endeavour to
accomplish that which the  surgeon accomplishes by cutting open the
uterus after laying open  the abdomen.  It rests with the surgeon in
these cases to meet Nature half way, by performing abdominal section,
to get at the child cast out into the abdominal cavity.
   There are few  subjects in obstetric  practice more  interesting, or
possessing a wider range  of relations, than rupture  of the uterus.   A
full knowledge  of  the  conditions under which  the accident may arise,
of the symptoms and terminations,  is  of the  highest importance in
medical and  in medico-legal relations.  The accident rarely  or never
happens without  some imputation or suspicion of  malapraxis falling
upon the  medical practitioner.  It is  of the last importance  to know
what to do, and what not to do, not alone in the interest  of the patient,
but also, reflecting on the fearful penalties  under which Ave practise, in
our  own.   It is of the very nature of the accident that it commonly
happens suddenly, without warning, and therefore precludes the medi- 
268
OBSTETRIC OPERATIONS.
cal  attendant  from using means to obviate it.   I  have been  more
frequently consulted in criminal charges connected with  rupture  of
the uterus  than with any other obstetric casualty.  In» almost  every
instance  the conclusion that the  accident  arose  from unavoidable
causes proved to be the best  founded.
  The following general propositions may be affirmed.
  1. The non-pregnant uterus may burst.
  2. The uterus may burst at any period of gestation independently of
labour proper.
  3. Any part of the parturient canal may be lacerated during labour.
  4. By  far the greater number of cases occur during labour at term.
  5. The uterus  will not burst unless it  be in a certain  degree  of
tension,  from  containing something in its cavity.
  6. The uterus  may burst in child-bearing women of all ages ;  in
women pregnant for the first time, or in women who have  borne one
or more children ;  the greater risk being in primiparae and  in women
who have borne many children.
  It is desirable to attach definite meanings  to certain terms.   By so
doing, we shall at  once effect a natural classification of cases that will
much simplify our inquiry.
  1. Rent, tearing, or laceration, occurs when a breech begins at the
edge of the os uteri, or  perinaeum,  and extends, under  the action of
labour ;  or when the structures are torn by the hand or instruments.
  2. Rupture, or bursting, occurs in the body of the uterus, or at the
junction  of the vagina and uterus, or in the middle of the  perinaeum.
Rupture  of the uterus may occur at any period of pregnancy  or labour.
This is generally the result of spontaneous uterine action.
  3. Perforation,  or boring-through, occurs when the tissues give way
from change of structure, as from disease, or long-continued compres-
sion of one part,  or continued attrition.  In these cases the  wearing of
tissue is  the first stage ; but the same  forces may act as in  " rent" or
"rupture,"  and cause extension  of the  lesion.  Rent and rupture are
generally produced  suddenly, although  they  may subsequently  be
extended gradually.  Perforation  is  a  slow, gradual process.  It may
occur from disease in the non-pregnant uterus.  Ruptures, then, may
be instantaneous  or progressive.  They may also be  spontaneous  or
traumatic.
  Before discussing particularly  the causes  of rupture, we may here
conveniently dispose  of the important  questions : 1.  What  are the
premonitory symptoms ?  2.  What is the  prophylactic treatment ?
Since, in a large proportion of cases, the injury occurs without warning,
there is no opportunity of preventing it.  And  although, starting from
the general  fact that  the uterus  may give way if there be impediment
to the progress  of labour, we may,  in  some cases, hope by removing
recognized impediments, to obviate rupture, there will still remain other 
RUPTURE  OF  UTERUS.                  269
cases in which it will not be possible to discover impediments, or even,
if discovered, to remove  them.  As Denman  well observes, " Some of
the causes are unavoidable, for it is not within the  sphere of human
abilities to give to some part the principle by which it has the disposition
or power to perform any function."   The tissues, for example, may be
diseased or degenerated.
   The explanation commonly given of rupture of the uterus is that it is
produced by obstruction to labour.  The histories  of the great majority
of reported cases prove  that obstruction to  labour was the immediate
antecedent.  But this  explanation can scarcely  apply to those cases
where  the uterus suddenly bursts during pregnancy when there was no
labour.  The immediate cause is, I think, more comprehensively  stated
in the  following proposition :—The uterus ruptures because there is a
loss of balance  and of due relation between the expelling power of the
body of the uterus and the resisting power of the parturient canal,  the
resisting power  being in excess.
   Trask, discussing the 417 cases he had collected, says :  " Inordinate
voluntary  exertion deserves  to  be enumerated among the causes of
rupture.  We believe no case of rupture has  yet (1856) been published
in  which chloroform  was used, which may be  due to the fact  that
voluntary effort is greatly suspended under its influence."  Tyler  Smith
says:  "In ordinary  labour, some  amount  of voluntary  or instinctive
action of  the muscular system,  and particularly  of the  expiratory
muscles, is quite natural during the stages of propulsion and expulsion.
In acute or severe labour, these voluntary exertions are productive of
great mischief, as lacerations  of the uterus and  perinaeum, and exhaus-
tion."
   In many cases no decisive symptoms precede.  This uncertainty is a
cogent reason  for watching closely in every case for the signs of
obstructed labour, and for removing any cause of obstruction that may be
detected.   Obstruction, allowed to persist, leads either to exhaustion or
to rupture.  In a case of occlusion of the cervix uteri, the pulse  rose to
 140 ; crampy, painful contractions of the uterus set in ; rupture seemed
imminent.  Incision of the  cervix,  allowing expulsion of the  fcetus,
almost immediately  brought relief.   This  rule must especially be
observed in weakly, exhausted subjects.  The case is well stated  by Dr.
Ewing Whittle.  When we are attending a patient from whose antece-
dents  and constitution, and from the slow and unsatisfactory progress
of whose labour we have reason to fear that we have a feeble, flabby
uterus to deal with, our first  care  should be to soothe the patient, and
keep her quiet  until  the os  is  fully relaxed.  Opiates  will here be of
service.   This  sedative treatment should, however,  not  be trusted too
long.   The cervix should be  dilated by the hydrostatic bags.  In these
 subjects avoid ergot.   There  is serious danger in  goading an exhausted
 system to put out strength it cannot spare.   When  the os is dilated, 
270
OBSTETRIC OPERATIONS.
rupture the membranes, and, if labour does not proceed satisfactorily,
deliver with the long forceps.   Since Roberton has  shown  that when
rupture occurs from faulty pelvis, it generaUy does so within twelve
hours, the indication is clear to watch closely, and to act betimes where
the signs of obstruction are present.
  Commonly, when the resisting power is in excess, the uterus becomes
exhausted, or from other causes ceases to struggle against the resistance.
In this way rupture is  averted.  We may then look upon obstructed or
retarded labour, or the signs of it, as summed up in Lecture I., as the
premonitory  signs of rupture.  We shall  rarely  get  anything more
precise.  But the following  summary by  Crantz is valuable : " When a
woman  is threatened with rupture of the womb in difficult labour, the
abdomen is very  high  and  tense, the vagina is retracted, and the os
uteri  very high;  the pains  are strong, leave but  short intervals, and
are without effect."
  We might, then,  in  cases  where we  see  the uterus  struggling
impotently against an obstacle, avert rupture by one of  two ways.
First, we may endeavour to restore  the  proper preponderance of the
uterine  force, by  lessening the resistance;  or, secondly, we may avert
or postpone danger by subduing the excessive action of the uterus.
  We will dispose of the latter alternative first.  Can we persuade the
uterus to  be passive  for a time ?   If  we can command  temporary
quiescence, we  may gain time and opportunity for the diminution or
removal of the resistance.   We possess in ergot a great, a dangerous
power of augmenting the force of the  uterus. Indeed, this agent has too
frequently, by goading  the uterus  beyond  measure, caused  it to burst
itself.  We want  an agent endowed  with the opposite effect, that will
control and suppress uterine action.  An agent that could be depended
upon  to do this would  extend,  and—if considered  in association with
the powers we now possess  of  accelerating labour, namely,  the means
of provoking labour, the uterine dilator, the forceps, turning, ergot—
complete our command over the course  of pregnancy and  labour.  I
consulted  Dr.  Richardson on  this  point.   He  tells me the  desired
power exists  in the nitrite  of amyl.  Three minims of this added to
one drachm of ether taken by inhalation is the form he recommends.
It does not produce unconsciousness, but it is an anaesthetic as well as
a sedative of muscular  action.   It is the antidote or opposite force to
ergot.   In it we have the desiderated " epechontocic agent."
  We have long been accustomed  to give opium with  the view of
allaying muscular action and postponing labour.   Its use in this way
is often  valuable in gaining  time.  Chloroform  has of late years been
frequently  resorted to.   But  it has  the disadvantageous  property,
derived  from the  chlorine in its composition, of exciting vomiting and
muscular spasm.   It is only when pushed  to extreme  anaesthesia that
muscular resolution  is obtained.   I think, therefore,  that  the nitrite 
                 RUPTURE  DURING  PREGNANCY.             271

of amyl should  have a  fair trial.   Since the foregoing statement,
published in the third edition of this work, we have had  satisfactory
experience  of  the  value of nitrite of amyl.
  A most  interesting narrative of a cure of tetanus  by the Calabar
bean, by  Dr. Ringer (see  Practitioner, Nov.,  1874),  suggests  the
probability that this agent might control  undue energy of  the  uterus.
The patient was a physician.   He  took  §-grain of the  extract every
fifteen minutes.  The remedy is hazardous. Much smaller doses, say the
y^-grain every twenty minutes, might first be tried.  Chloral has been
extolled for its " amyosthenic " property by Martineau (Gaz. des Hop.,
1873).   A woman  seven months  pregnant took  quinine.   Uterine
action quickly followed.   Laudanum  had  no effect  in  stilling  it.
Chloral in fifteen-grain doses allayed all action, and averted  abortion.
Chloral would be safer than physostigma.
  In stormy, tetanoid,  or   spasmodic action  of the  uterus,  where
rupture  or exhaustion is threatened,  the first indication is  clearly
to subdue this dangerous activity ;  and the second is to  remove the
obstacle  against which the  uterus is struggling.

           The Conditions under which Rupture  occurs.

  1. Rupture may  take place  in the non-gravid uterus.  Duparcque
cites cases  (Maladies de la Matrice,  tome ii., 1839).  But disease of its
tissues, as thinning,  softening,  abscess,  appears  to  be a necessary
condition.  Other factors are :  closing  of the os and accumulation of
fluid in the  body.   Perforation by  cancer—a distinct  event  from
bursting—is  not  infrequent.
  We need not dwell in this place upon the cases of direct injury to
the  uterus by wounds or blows.  Such may, of course, occur at  any
time.  It is well to remember that blows inflicted upon the  pregnant
womb may wound, even kill the child, without  causing rupture  of the
womb.   Duparcque gives an example.
  It  has been  stated  that  sudden violent  efforts of the child have
caused rupture.   The cases  cited in support of this  proposition are
not convincing.   It is more  probable that the uterus ruptured itself, or
that some violence external to the uterus was concerned.
  2. The history of rupture or bursting of the uterus during pregnancy
more immediately concerns us.   This  event  is rare, but well authen-
ticated.   Indeed, it is not more  surprising than spontaneous rupture
of the heart.   It is  known  to have occurred as early as the third
month.   H.  Cooper  (Brit.  Med.  Journ.,  1850)  saw a pluripara of
thirty, who was taken with collapse  after dancing, and died next day.
The uterus was  found torn at  the left side  of the fundus, a three
months'  fcetus projecting through the  rent.  The  tissue at  the part
was  thin, pulpy,  cheesy.  There was tubercular degeneration. 
272                 OBSTETRIC  OPERATIONS.

  It has occurred in the fourth month.   Dr. McKinlay relates a case
(Glasgow Med. Journ., 1861). Without any exertion or injury a woman
died after being taken ill the previous night.  The uterus was ruptured
across the fundus.   Its tissue was apparently healthy.
  Dr. Harrison (Amer. Journ. of  Med. Sc, vol. viii.) relates the case
of a pluripara, who in the fifth month, after a long walk, felt a sudden
and severe  pain "as if something had  given way within her."  She
died  in  a few hours.  Blood  and the foetus  in its membranes  were
found in the peritoneal  cavity.   There was a transverse  rent from one
Fallopian tube to the other.  There was no thinning or any appearance
of disease.   Collins relates a fatal case at five months.
  Mr. Scott, of Bromley, relates (Med. Repository, vol. viii.) the case
of a  woman in the sixth month who was awakened  from  sleep by a
sudden pain about  the umbilicus.   Rupture was found  at the fundus,
through which the foetus, enveloped in its membranes, had  escaped
into the abdominal cavity.
  Mr. Mitchell relates (Obst. Trans., 1870) the case of a woman in the
seventh month, who died after sudden abdominal pain caused by terror
from lightning.  The uterus had burst apparently under  contraction
upon the projecting  knee of the foetus.
  Other cases will be found in Trask's " Memoirs " (Amer. Journ. of
Med.  Sc, 1848  and 1856).
  In the eighth and ninth months spontaneous ruptures are less  rare.
From the cases above referred to, and others, the following conclusions
flow : first, spontaneous bursting of the uterus may occur  from weak-
ening of the uterine tissue  from thinning, from disease, as tubercular,
fibrous, or fatty degeneration.  Second, under emotional excitement to
uterine contraction where the  tissue  appears sound.  The influence of
emotion in determining uterine contraction and  haemorrhage is well
known.   The cases of Mr. Scott and Mr. Mitchell  just cited are
examples of rupture from this cause.  Francis White (Dublin Journ.
of Med. Sc.) gives  another, that of a  woman near the end of gestation.
She fainted under terror, was  delivered a week after, and died almost
immediately.  A large  quantity of blood was found in the abdomen.
Two rents were found in the anterior part of the  womb involving the
peritoneal coat  and some  muscular fibres.    Thirdly, after violent
exertion  and fatigue, or injury, as a blow or a  fall, or from severe
vomiting.   Duparcque  cites  a case of rupture  attributed to vomiting.
The subject was between two and three months pregnant.  The uterus
at the seat of rupture, near a tubal angle,  was thinner  than else-
where.  Another case is cited by  Duparcque to show the influence of
effort.  A woman was carrying a weight on her head, when symptoms
of internal injury set in; but she rallied for a time, had  another attack,
and  died.   The uterine cavity contained a foetus of  three or four
months.  There was a fissure in the  fundus uteri near the right  tube. 
RUPTURE  DURING LABOUR.
27-'3
Fourthly, there is  another order of cases  in which the pregnancy
deviates from the normal kind.   For example, Canestrini relates a case
in which there was  a double uterus.  One of the uteri, after some pains
in the  fourth  month,  burst.   The ovum  was found entire in  the
abdomen.  Goupil  cites a case, from Payan,  of a woman who died
under symptoms  of shock, causing suspicion of abortion having been
procured.  Above the proper cavity of the uterus was another cavity
formed  in  the  wall.  This interstitial cavity had  become  thinned by
the growth of the ovum, and burst.   Goupil cites a similar case
from Duverney, and several  others are recorded.   Indeed, interstitial
gestations  mostly end in fatal rupture before the fourth month.   The
rupture is nearly always close to the opening of a  Fallopian tube.
   By these last cases we touch  upon another order which may, and no
doubt often have, given  rise to  error.  The  symptoms cannot be dis-
tinguished from those of rupture of a tubal-gestation cyst, and, without
dissection, there  may be no means of proving  what  it was that rup-
tured.   The inference that the case is one of extra-uterine gestation is
strengthened whenever  foetal structures  make  their escape externally
by abscess and  fistulae.
   Spontaneous rupture  of the uterus early in pregnancy is so rare that
suspicion of foul play  is easily excited.  No  doubt the vagina and
uterus  have been frequently  wounded by instruments  used to procure
abortion.   The characters of the wounds may differ from those due to
spontaneous  rupture.    Spontaneous bursting most frequently  occurs
in the body of the womb.   Criminal wounds  are generally inflicted
upon the os, cervix, and  lower part  of  the uterus.   They will show
evidence of cutting, puncture, or bruising, according  to the nature of
the instrument  used.   A  careful microscopical examination of  the
tissues, especially at  the  seat  of injury, should be made.
   3. Rupture or bursting of  the uterus at term or on  the advent
of labour.—In this order of cases the reversal of the normal relation
between  active uterine  force and passive resistance is more obvious.
In a large  number of  cases there is decided mechanical resistance
to the  expulsion of the fcetus.  But it  is  remarkable that bursting
has frequently  happened  long  before obstruction  to  labour  could be
encountered.  These cases are  similar  in their mode of  production
to those which  occur  early in pregnancy.  There is one striking point
of resemblance: namely,  the frequency  with which  the entire  ovum
is cast out of the uterus  into  the abdominal .cavity.  In this respect
they differ from the lacerations  which occur  during obstructed labour,
in which the child, or  at  any  rate the placenta,  is  more commonly
retained  in the  uterus.   The explanation of these early  ruptures
appears to me  to be  that the  uterus is  excited to contract suddenly.
The resistance is hydrostatic.   The contents of the uterus  are incom-
pressible.   The  conditions are analogous to  those  of the  famous
                                                            T 
274
OBSTETRIC OPERATIONS.
Florentine experiment  to  test  the  compressibility of  water:  the
water exuded through the metal globe.   There is no  provision for
diminution of the bulk of  the contents by the opening of the os uteri
and  discharge  of the liquor amnii.  Under  these  circumstances  a
moderate  contracting force may result  in  bursting.  There can  be
no doubt that in many cases this catastrophe is averted by the facility
with which the membranes burst.  Thus abortion may be looked upon
as an alternative of rupture.  On the other hand, the uterus will often
stretch, and in this way bursting is also averted.  But stretching is  a
process that requires time.   A sudden contraction,  such as is induced
by emotion, gives no opportunity for this, and so the tissue gives way.
Belonging to this order are cases of over-distension of the uterus from
excess of  liquor amnii, and  from the presence of twins or triplets.
Under any one of these conditions, although the uterus grows in some
measure in  proportion to the increasing bulk of its contents, the rate
of accommodation is liable to be outstripped by the distending force.
The  uterus  becomes  thinned out, stretched, therefore  weakened.  If
the thinning happen to  be more marked at one part, rupture at that
part  is  very likely to happen  if  a  sudden contraction occur.   And
especially is this likely if the tissues have undergone morbid change.
   This is the more likely to happen because distension  of the uterine
fibre is very apt to cause vomiting;  and vomiting has been  noted as
a factor in  the production of rupture.   That  the expulsive  action of
the auxiliary muscles  may conduce  to  rupture, the following con-
siderations show.
   Tyler Smith says: "In  cases where the  uterus is feebly developed
or weakened by disease and  exhausted action, the contractions  of the
abdominal muscles must contribute  to  the rupture of the  organ, by
urging the head or presenting part of the child through the  os uteri."
In the Lecture on " Retroversion " (see p. 222) cases are cited showing
that the vagina may be ruptured by the pressure upon it of  the retro-
verted uterus,  gravid  or after  labour.   And so an ovarian tumour,
as in Mr. Berry's case  already referred to, and in Dr. Dunn's (see
p. 306), may be so driven into Douglas' pouch  as to tear through the
posterior wall of the vagina.
   Reasoning from the  observation of some  cases in which the uterine
tissue was altered by disease, and partly from the  analogy of rupture
of the heart, the opinion has lately found favour that disease of tissue
is a necessary condition to rupture of the  uterus.   It  is urged that
a  healthy uterus will not rupture.   It is scarcely necessary to  point
out that the supposed  analogy of the heart  is  faUacious.  The  uterus
tears itself  by  pulling upon a fixed point, as where the head jams the
lower segment of the  uterus in the  pelvic  ring.   There is no similar
condition in rupture of the heart.  There is, no doubt, a class of cases
in which  the uterine  tissue gives way from disease, like the  heart. 
DISEASE  OF  UTERINE TISSUE.
275
But  to affirm the universal presence  of  disease  as  a factor is to
sacrifice  experience  on  the  shrine  of theory.  The   opinion  that
alteration of tissue led to rupture was  first clearly insisted upon  by
Murphy.  He described a  softening of the tissue as   the  result of
inflammation  during pregnancy, as an  indication  of which there is
frequently pain in a  particular spot.   Another condition which  has
been many  times observed is extreme  thinness of the uterine wall.
This thinness may be general,  or  limited to a part.
  Bandl has shown that the lower segment of the uterus below Bandl's
ring, or Barnes' physiological  boundary  between the upper two-thirds
and  the lower third  of  the  uterus,  commonly  undergoes extreme
thinning during labour, and contends that thinning is the condition of
rupture (see  Fig. 105, from Bandl).   This explains  the  very common
laceration of the vaginal-portion  during  the passage of the head. This
laceration leaves evidence after it, in the fissure or split, which  White-
head and Emmet have shown to be likely to entail hypertrophy of the
vaginal-portion, perimetritis, and other evils.   To remedy this, Emmet
pares the edges and unites by suture.  I  believe I was the first in this
country to adopt his practice.
  But  apparent thinness may occur at  the fundus, more especially at
the presumed origin  of a Fallopian  tube.   In some  of these cases,
there can hardly be a doubt  that  there was gestation  in one horn
of an  imperfectly developed  uterus.  This  seems  to   me to  be  the
explanation  of an " Obscure Uterine Disease " in which fatal rupture
took place,  published  by E.  C. Ling   (Lancet, 1872).  Other cases
are cited  and figured  in my work on the " Diseases of Women."
Thinness  may be the result  of distension during pregnancy, as from
multiple gestation, excess of liquor amnii, or it may be produced during
the labour.   In this latter  case, the thinning  will take place  at  the
point of resistance from  the  muscles  constantly dragging upon this
part.   Thinning may be the  result of  disease, as in a  case related by
E. Whittle (Liverpool Med.  and Surg. Reports). The child had passed
through a rent near the junction of the body and neck anteriorly.  For
two or three inches on either  side of the rent the uterus was thin and
soft.   The edges  of the rent  were not more than  0-25" in thickness.
The woman was affected with  secondary  syphilis, and Whittle beheved
the degeneracy and atrophy  were due to this condition.   Collins relates
a marked case of this kind.
  Fatty degeneration  is the  change most  frequently  described.   In
confirmation, reference is made to  the normal process of involution of
the uterus, in which, at the end of pregnancy, some  molecular granular
change occurs in the muscular  ceUs.   If it  be held that the ordinary
kind and degree of granular  change is sufficient to impair the strength
of the  tissue to the extent of  causing it to rupture, it must be  enough
to point out the extreme  improbability of Nature's so  bungling as to
                                                          t 2 
276
OBSTETRIC OPERATIONS.
weaken the uterine tissues at the moment when the greatest vigour and
resisting power are required.  If it  be urged that this physiological
condition may pass into a  pathological excess, an argument is used
more  difficult to refute ; the  more so because in some cases direct
observation seems to prove that excessive fatty degeneration did exist.
But to prove that a particular factor existed  in a limited number of
cases is very different from establishing it as a general or universal law.
And there is abundant  evidence to prove that in  a very considerable
number of cases no such excess did exist.  In the first place, many
ruptures have occurred during pregnancy, at  a period  when even the
physiological change is rare ; in some of these the healthy condition of
the tissue was established by competent observers.  Secondly, a large
Fig. 105.
          SHOWING THINNING OP THE LOWER SEGMENT OF THE UTERUS (BANDL).

proportion of the cases occurring in labour at term were in primiparae,
in whom  the  presumption is strong against morbid change of tissue.
Thirdly, in many  cases of rupture at term in pluriparae the tissue was
found healthy. In four  cases examined by myself, this was the case.
In one  of these my conclusion  was verified by Dr. Bristowe and Dr.
Montgomery.   Fourthly,  in not  a few cases recovery  with perfect
healing of the uterine  wound has occurred.  Experiments made upon
small pieces of uterus are useless in their application to the problem of
the power required to burst the  living uterus.   Ln the  living uterus
various  parts may vary greatly in thickness and strength ;  and, like a
chain, the uterus is only as strong as its weakest part. 
               RUPTURE  FROM  DISEASED  TISSUE.            277

  On the other hand, the frequency of rupture in pluriparae, in women
about forty years  of  age, who  have led a hard life, whose system is
generally enfeebled, makes it reasonable to infer that the uterus partakes
of the general feebleness or degradation of tissue.  In two of the cases
I refer to, the muscular fibres of the heart exliibited marked  granular
change.  I found a similar condition in the heart of a woman who died
of accidental haemorrhage ; she was also a pluripara, aged about forty,
much worn by poverty and labour.   In fact, accidental haemorrhage and
rupture are apt to  occur in the same class of subjects. In another case,
which was the subject of a criminal charge, it was stated by the medical
witnesses for the  prosecution,  that the heart and other organs showed
fatty  change.   In another case which came under my knowledge, a
pluripara had albuminuria at the end of pregnancy ; the kidneys were
found in an advanced stage of Bright's disease.
  Klob, however, distinctly says *  that he has, in several cases of spon-
taneous rupture, observed fatty  degeneration of the muscular wall at the
place of rent.
  Dr. E. L. Ormerod,! who  minutely examined a case, says : "As far
as I  have seen,  a ruptured uterus does not give  way from  rupture
of fibres which have undergone fatty degeneration ; indeed, I am not
aware that  this form of disease occurs at aU in the pregnant uterus.
The torn edges display strong  fibrous tissue, not  degenerated fibres."
The subject  was  in  her  fourteenth  pregnancy.   The rent extended
from cervix to fundus.  He found follicular disease about  the cervix,
and fibrous degeneration  of  the adjacent muscular structure.
  C.  Braun describes a peculiar hyperplasia  of the uterus, in which
the body and cervix lose all relation to each other.
  Cancerous degeneration has led to rupture.  Dubreuhl relates (Lyon
Medical, 1871) a case where  the uterus burst along its whole anterior
surface  from encephaloid degeneration  of its  walls.  In the museums
of St. George's and  Guy's Hospitals may be seen  specimens of  fatal
laceration  from a similar  condition.   Rigidity  of the  cervix from
cicatricial  tissue may also cause  rupture.
  In  one case  related by H. Cooper,\ a pluripara in the third month,
aged thirty, died in  collapse the day after  dancing.  The uterus was
found  torn at the  left  side  of the fundus, a three  months' foetus
projecting  through the rent.  The wall of the fundus was  thinned,
the tissue was pulpy, soft, cheesy.   It  is  probably  an instance of
tubercular degeneration.
  Alteration of tissue produced during labour is a factor, the frequent
existence of which cannot be doubted.   Where the lower segment of
the uterus is long  compressed between the pelvis and the child's head,
                * "Pathol. Anat. d. Weibl. Sexualogane."
                t " St. Bartholomew's Hospital Reports," 1868.
                X " British Medical Journal,'" 1850. 
278
OBSTETRIC OPERATIONS.
the circulation gets stopped, intense congestion of the parts above and
below  the  compressed ring  ensues,  the  part compressed  becomes
friable,  softened,  and may yield.  If delivery be effected before this,
we see the effect at a later period in sloughing, forming vesico-vaginal
fistulae, and  perhaps even gangrene.  The points at which this bruising
or rubbing-through of the uterus  is liable to occur, are chiefly those
opposite the promontory of the sacrum, and the symphysis  pubis  in
rickety pelvis.  (See Figs. 106,107,108.)  The pectineal ridge may  be
sharp  enough to  cut through;  sometimes  the pubic  portion of this
ridge folded  back as in osteomalacia, gives points of  resistance against
which  the head may be jammed.  Unnatural sharpness of the edge
of the pelvic brim, or spinous  projections  are even more dangerous
than  simple narrowing.   (See  Lecture XX.)   Unhappily,  the  two
conditions are sometimes combined, as in a case seen by myself.   The
specimen  is  preserved in  St.  Thomas's Museum.   Duparcque cites a
case in which "the anterior part of the neck  of the womb separated
from one side to the other, and the child passed immediately  into the
abdomen.  The pelvis was a little narrow; the point of the os sacrum
passed  through  the posterior part of  the  womb.   The inner  and
prominent edge of the pubic  symphysis and ilia resembled an  ivory
paper-knife."  In  deformed  pelves there is  often found  at the joints
an excrescence or exuberant growth of bone projecting inwards, so that
when the foetus  presses the uterus against  the pelvic ring, laceration
easily occurs.  I have found this condition frequently.   It is  a reason
why, in all  examinations of contracted pelves, we  should sweep the
finger carefully all round the brim, when taking note of the kind and
degree of the deformity.   This bony  excrescence is very common  at
the pubic symphysis behind, and  is especially dangerous;  but it  is
also found at the line of the sacro-iliac joints.  The direction of the
lesion in these  cases  of rubbing-through,  or perforation, is  usually
transverse, corresponding to the direction of the pelvic  brim.
  A  fibrous  tumour in the  wall  of the uterus has caused  rupture.
There  is  a   specimen  illustrating this in  the  Middlesex  Hospital
Museum.  In a  case  I  examined  with reference to a charge  of mala-
praxis, a tumour in the anterior wall had got compressed between the
head and the pelvis, causing perforation of the uterus  and bladder.
Probably no care  could have averted this catastrophe.   The  accused,
an iUegitimate practitioner, was discharged.
  A  stone in the  bladder has caused a similar injury.  Guillemeau
relates a case.   Vesico-vaginal fistula resulted.
  Rupture has  several times  occurred  in women who had been the
subjects of  Caesarian  section.  In some of  these the  laceration  took
place in the seat  of the cicatrix of the wound.
  The uterus may be torn after  delivery of  the child.   One lip, most
frequently the anterior one,  may hang  down in a large loose  flap, and 
HOW  RUPTURE IS  CAUSED.
279
even protrude at the vulva.   This  has been mistaken for the placenta,
supposed to  be adherent;  and being pulled upon has  been actually
torn away.   Duparcque relates a case where this error occurred.
  Laceration from  obstruction to  labour.—It  is not  necessary to do
more than refer to the familiar causes of obstructed labour;  that is, to
narrowing and distortion of the pelvis, tumours blocking the pelvis,
rigidity or other diseased conditions of the cervix and vagina, obliquity
of the uterus, excessive  size of the child, hydrocephalus, to monsters,
locking of twins, or malpositions, producing a wedge the base of which
is too large to enter the brim, or to traverse the pelvic canal.

                               Fig.  106.
RUPTURE OF UTERUS.
  From a preparation GG2 in St. Thomas's Hospital; half-size.  "The rupture"  (or rather
rubbing-through) " is in a transverse direction, from four to five inches in extent, and situated at
the lower part of the anterior wall.  The peritoneal surface is coated with recent lymph. From
a woman who had a slight deformity of the pelvis. She had previously borne four children at the
full period.  The uterus is at the eighth month of gestation.  Death in five days. Dr. Waller's
case."—M»stum Catalogue.

  We  may assume, in  the first place, that the uterus, like the  heart,
ruptures itself.   The mode in which rupture  is  brought  about during
pregnancy or  independently of labour  has been  pointed out.   When
laceration occurs during obstructed- labour, the conditions differ.  The 
280
OBSTETRIC OPERATIONS.
liquor  amnii has  almost always been discharged.  The uterus  has
contracted upon the child.   There is no longer the  equable hydrostatic
pressure.  The necessary condition now is, that some part of the uterus
be fixed, whilst the rest of the organ is pulling from that fixed point.
It is this point which generally gives way.   Duparcque says, " Uterine
contractions alone are the most frequent causes of  transverse ruptures
of the  uterine neck."   A muscle  in active contraction  will not tear its
own contracting fibres.  It tears  at its attachments, or at the point it
is pulling upon, just as the tendo Achillis  gives way  rather than  the
muscles  which pull  upon  it.  If a muscle is  not strong enough to
accomplish the object for which  it  contracts, it becomes  fatigued and
relaxes.  It is only when a sudden increased strain or injury is inflicted
at the  moment of  contraction that the muscular fibres  are liable to be
torn.  The uterus is no exception to this law.  We see how it acts in
ordinary labour.  It contracts in  the direction of its long  axis, tending
to shorten itself, pulling the os towards the fundus.  So acting, the os
uteri is partly pulled open, partly dilated by the hydrostatic pressure of
the liquor amnii, or of the protruding part of the foetus.  The effect of
the hydrostatic pressure in dilating the os is  marked in  ordinary healthy
labour.  If it fail through too early discharge of the liquor amnii, and
there be  obstruction, so that the foetus  is  slow in engaging in  the
cervix,  and  in descending  into  the pelvis,  dilatation  is  slow, and is
ultimately effected mainly by the continuous pulling-up of the cervix,
by the  action  of the longitudinal uterine muscles.   In either case, so
long as the cervix, the part pulled upon or stretched, yields, there is no
fear of laceration.  But, if  the cervix will  not dilate, and the uterus
continue to  contract, as it will do under excito-motory  stimulus, the
foetus being  driven down violently upon  its lower segment, the uterus
will lacerate here.  In such a case usually the laceration begins at the
edge of the os uteri, and extends upwards  longitudinally.  Or, if the
fcetus be dead, or presentation be  abnormal, so that it  cannot traverse
the  os, a limb, as  a  knee or elbow, forming an angular  projection at
some part of the  body of the uterus,  may  render this particular  part
the fixed point upon which the  uterine muscles pull; and, this point
gradually softening and weakening, gives way.  In this case  the  rent
may be longitudinal or transverse, and at any part of the  uterine wall.
But the direction of the rent is usually determined by the drag of the
muscular fibres.  Hence, if the rent occur  in the sides of the uterus,
the rent is longitudinal;  if at the fundus, or on the front  or back, it is
transverse.  I  have, however, known a case  in which the uterus was
rent along its  whole length in the middle  of the posterior wall.
   A similar explanation holds in  the greater number of cases of rupture
from contraction of the pelvis.   The proneness to rupture is not in
proportion to the  degree of pelvic  contraction.  If the contraction at
the brim be so great that the foetus and inferior segment  of the uterus 
HOW  RUPTURE  IS CAUSED.
281
cannot enter, the risk of laceration is less than when there is just that
degree of contraction which permits of the descent of the head into the
pelvic cavity, but impedes its progress.   This point has been weU made
out by Radford (Obst. Trans., 1867) and others.  In nine cases out of
eighteen reported by Radford there was slight contraction of the brim.
In  these cases, when the head is  forced down, the uterine neck and
vagina become fixed between the head and pelvic  walls.  The uterine
muscles continuing to contract, and not being able to propel the fcetus,

                               Fir;.  107.
                           RUPTURE OF UTERUS.
  From a preparation in St. Thomas's Museum, one-third size, GG2'. Anterior aspect. There is
a boring-through of the anterior wall of the cervix into the bladder.  The result of long-protracted
compression against the symphysis pubis.  Dr. Barnes's case.

pull upon the tissues forming the fixed ring, which either directly tear,
or being first contused and softened, yield.  Hence it  is that in these
cases the rent is usually transverse or circular.  (See Fig. 106.)   In
some instances, even where there  has been  no pelvic  contraction, but
the os  has been rigid, the cervix has been torn  through all round, or
has  gradually sloughed off, and been  cast as a ring.  Not to mention
other cases usually cited,  I will refer to one related by  Dr.  Herbert 
282
OBSTETRIC OPERATIONS.
Barker  (Obst. Trans., vol.  ii.) under the title, "Annular Laceration
of the Cervix," and to another referred to me by  Dr. Hague.  In
these cases the peritoneum is not involved;  and the danger  is not
great.
  But where the lower segment of the uterus is nipped in the ring of
the pelvic  brim, the laceration commonly involves all the  tissues,  at
least  in some  part  of the  circumference.  We  then  have a  direct
opening into the peritoneum through which the child may pass out
of the uterus.
                              Fro. 108.
RUPTURE OF UTERUS.
Posterior aspect of same uterus as that represented in the preceding figure.  The posterior wall of
 the cervix is bored through by long compression against the jutting promontory of the sacrum.
  In some cases of great pelvic contraction, where the head has been
long compressed upon  the brim, the soft  tissues are worn down by
rubbing and  necrosis, and  give way transversely at the two  points of
greatest pressure,  viz., at  the  anterior wall and  bladder opposite the
symphysis pubis, and  at the posterior wall opposite the jutting pro-
montory of the  sacrum.   In these cases the lesion is always  trans-
verse.   This  is well illustrated  in  Figs. 107,  108.   The subject was a
very deformed  dwarf,  to  deliver whom I was  called to one of the 
CAUSES OF RUPTURE.
283
 workhouses.   She had  been long in labour, and  great  efforts had
 been made to  deliver after craniotomy.
   In another class of cases, strictly  analogous to the preceding, the
 head of the fcetus has traversed the  os  uteri and entered the pelvis,
 when, owing  to  impaction,  a  zone  of  the vagina is nipped.  The
 uterus still striving to drive the  child on, pulls upon this fixed vaginal
 ring, and  a transverse or circular laceration occurs.  Of this there
 are  many  examples.   Duparcque thus describes the  process: " The
 child's head arrested on, or more or less  engaged in the pelvic brim,
 the womb  continuing to contract pulls itself, so to speak, away from
 the  child.  The borders of the  uterine  orifice drawn towards  the
 fundus of the organ,  therefore rise and abandon gradually and some-
 times completely the fixed  head.   It  results  that  the vagina  is
 subjected  to an  active  traction proportioned to the  energy  of  the
 uterine contractions, and  that,  opposing only  a  passive  resistance
 gradually becoming weaker by  stretching, it  ends by giving way by
 bursting."  Once begun, these  ruptures  may, by  the continuing  or
 the renewal of the uterine contractions, separate  the uterus from  the
 vagina almost completely.  Velpeau says he has met  with this twice
 (Tocologie, 2 ed., t. ii., p. 194).  But the forceps or hand had been
 used  in both cases.  " It will be easily understood how the lifting-up
 of  the uterus, by ill-directed efforts, as  when  the woman  throws
 up her stomach  by suddenly throwing the trunk back, by vomiting,
 or  convulsions, may  determine  a  vaginal rupture  which  was only
 imminent.  Abdominal  compression  so  directed as  to  lift  up  the
 womb when the dilatation of the orifice is  complete, may in the same
 manner provoke rupture of the vagina.  The same  thing may happen
 from  pushing back the child,  as  this act adds to the state of tension
 the canal is already suffering ; and this is not one of the least common
 causes of rupture of this kind."
   The unskilful  introduction of the forceps, the  blades being pushed
 behind the os, may cause rupture.
   In  transverse  vaginal ruptures  the  head rarely  escapes  into the
 abdominal cavity ;  but the body may easily do  so, since the uterus,
 after  the rupture, is  drawn up  away from the child.
   When the whole child goes  into the  abdomen, it may be because
 the head has  been pushed back by attempts to manipulate.
   I was consulted in  a  case in which the circular laceration was com-
 plete, so that the entire uterus  containing the placenta came away
 from  the  body.  Malapraxis was charged, but the facts  seemed  to
refute the accusation.   The uterus was not inverted ; it seemed diffi-
cult  for  the attendant  so to grasp  the  uterus  as  to tear  it away.
Th^  case  is consistent with experience  of the mechanism  of spon-
taneous injuries.   Ingleby  says,::: " The  rent  is usually more or less
                          *  "Obstet. Med." 
284
OBSTETRIC OPERATIONS.
oblique, sometimes including nearly the  entire circumference,  and
thus virtually  dissevering  its  connection with  the  uterus."  Dr.
Collins  relates  a case where the uterus was almost  torn  from the
vagina.   Moulin and  Elkington relate similar instances.   I have
known  another  case  of  the  kind.  Dr. Roberton relates  a  case  in
which the cervix was separated from the vagina except by a shred.   In
the case to  which  reference is  first made, it was objected  that the
Uterus could not have rent its ligaments ;  that these must have been
torn by  manual violence.   But there is no doubt  that these ligaments,
the round and  broad, have been torn during inversion (Casper).   In
women who have borne many children, all whose tissues are  degraded,
the ligaments at the time of  labour are not capable of much resistance.
When the vagina has given  way, the  whole strain will fall  on them.
A little  accidental force, then—as introducing the hand to remove the
placenta, the application  of  the  forceps, vomiting—might easily com-
plete the detachment.   Such is a summary of the arguments in favour
of spontaneous  circular  laceration  of the vagina, which led  to the
acquittal of the  prisoner.  Shortly afterwards a singular confirmation
of their truth occurred in a strikingly  similar case  recorded by the
late Thomas Paget, of Leicester (Brit.  Med. Journ., 1861).   A pluri-
para had a not  severe labour lasting three hours.  The placenta was
removed with but little traction in twenty minutes.  To this, however,
was attached a large fibrous  mass, which was found to be the uterus,
with Fallopian  tubes  and ovaries.   The vaginal-portion hung loose,
and was jagged by laceration.  She died in forty-five minutes.   It was
the decided opinion of Mr.  Paget  that the accident  occurred spon-
taneously.   He says :  " For  the  exertion of the detrusive power of the
uterus  there is  no point d'appui,  no  purchase, except  the  slender
moorings, the  round  ligaments and sheet-like  attachments of the
vagina.   Who shall wonder  that they occasionally give way?"  Boer
(Medic. Obstetr.), in  chapter  " De fluxu quodam  sanguinis, etc.,"
describes a  most extensive  separation of  the vagina from its attach-
ments in consequence of an immense effusion of blood into the cellular
substance.   The uterus was  not  inverted.
  Dr. Miller, in A Memoir on Inversion  of the Uterus, relates a case in
which  the  whole uterus, placenta included  in it, was  torn away by a
midwife inserting her  fingers inside the cervix.  There was very little
haemorrhage, and the  woman recovered.
  These cases of separation by laceration  must be distinguished from
the entire  separation completed after labour by sphacelus,  as in  the
instance recorded by Dr. More Madden  (Brit. Med. Journ., 1874).  A
primipara,  aged 33, was  admitted  into  the  Rotunda  Hospital; when
admitted she had been eight hours in labour, the os was  about  the
size of a shilling, and the head low down in the pelvis, pressing on the
cervix uteri.  The pains in the second stage were weak.  A stimulating 
CIRCULAR LACERATION.
285
enema and a dose of ergot having been tried, she was delivered under
chloroform by forceps.   No force was required, a child weighing 6 lbs.
was born alive in two minutes.   She became suddenly coUapsed  on
the fourth day, and died.   Autopsy revealed advanced peritonitis.  The
uterus was intensely  inflamed in  the  cervical-portion, which  was
actually  in a state  of sphacelus.   The ulceration  had extended com-
pletely through the cervix, so as to have  entirely separated the uterus
from the vagina;  the line of separation being as sharp and clear as if
effected by the knife.  The vagina, particularly near the vulva, was also
in a state of intense inflammation, and had sloughed considerably on its
anterior wall.  Dr.  Jamieson (Edin. Med. Journ.,  1872)  relates a case
in illustration.   The woman's  spine  was short, so that the last ribs
squatted below the iliac crests.   There was marked anteversion of the
uterus, which, therefore, acted  at  great disadvantage.   Continuing to
contract  violently, it tore itself away from the vaginal attachments.
   In St. Bartholomew's Museum are two specimens illustrative of this
point.   " No. 32*46.  Uterus  and  vagina.   During parturition  the
vagina was torn through half its  circumference close to  the  part
connected with the uterus."  " No. 32-47.   Uterus, the  neck of which
was torn through two-thirds of its  circumference during parturition.
Child hydrocephalic."
   The argument that  the uterus ruptured  itself, as  described,  is
enforced by Roberton, who draws the conclusion that, in the majority
of those instances of rupture of the uterus, caused by faultiness in the
brim, the accident  occurs within twelve hours  after labour has com-
menced.   This implies unimpaired vigour of contractile force.
   But we must  not forget that,  although complete separation  may
occur spontaneously, a transverse laceration of the vagina near the
uterus having begun,  very moderate force  may  cause  it to extend.
This  is  adverted to by Denman, who says :  " I was called to a  case
of a very extraordinary kind, in which that part where the vagina and
uterus are united was ruptured ; the  child remaining in the cavity of
the uterus, the os uteri  being little dilated.   Here my advice was not
to attempt to deliver, because so much  force would be required  for
dilating, that it was feared the uterus would be completely torn from
the vagina before the hand could be passed into  the uterus, at least
before the child could  be extracted,  and then  the case would have
been  more horrible."   The woman would, in all  probability, have
had a better  chance if left in the hands  of a bolder man, who would
have done what  Denman  dared not to do.  But he  would have done
it  at  the risk of his own reputation, and  of a conviction for man-
slaughter,  with imprisonment as a felon !
   In another class of cases there may be no fixing of the lower seg-
ment  of the uterus,  buo the cervix rends,  beginning at the edge of the
os. In  almost every first  labour this takes place to  some extent, and 
286
OBSTETRIC OPERATIONS.
the trace is found in the cicatrices of the os, which tell that the subjects
have borne a child.   If the os be unusually indisposed to  dilate, if the
head be large, if the liquor amnii have escaped  early, if the os have
been carried down into the pelvis  capping the head, and if the pains
be severe—especially if stimulated  by ergot—an initiatory rent of this
ordinary kind may easily extend upwards  into  the uterus, and  down-
wards  into the vagina.   In these  cases, the direction of the rent  is
longitudinal, and usually in one side.  The particular side is deter-
mined by  the inclination of  the  uterus.  Dubois says the  habitual
direction of the uterine neck to the left, and the left occipital position
of the foetus, account for the greater frequency of lacerations in the
left side.
   The most frequent seat of rupture is at the junction of cervix and
vagina.  It is almost the exclusive region  of perforation from pressure,
and from external violence.  But it is also the most common for spon-
taneous rent;  and in many cases  where rupture has been observed in
the body  of the  uterus,  it probably extended from  the cervix.  (See
Bandl, p. 275.)   Collins and Clarke never saw rupture at  the fundus ;
and there is good reason to doubt  whether  some  cases reported as
such were  not really examples of the giving way of a sac of a mural
gestation, or of one formed in one horn of a one-sided uterus.
   Apart from any detected abnormality of pelvis or of obstructed labour,
the uterus has given way under a suddenly excited increase  of contractile
energy.  Dr. Tyler Smith particularly insists that the irritation caused
by manual examination  of the os uteri is sometimes  enough to cause
rupture.  Several cases lend confirmation to this view. In one I have
recorded (St. Thomas's Hospital Reports,  1870), " when examined, the
uterus was felt contracting ; the os uteri was not reached,  but the head
was just felt.  Whilst under examination the pains stopped ; the woman
said she felt something  give  way.  She  walked across the room after
this, but collapse followed in five minutes."  We may,  then, admit that
rupture may be  caused through the excito-motory  system.   But the
centric stimulus to inordinate uterine action is more  frequent.  In  a
very  large  proportion of cases, ergot had been  given.   It is to  be
remarked that in this order of cases, the action of the uterus is excessive,
and suddenly evoked, and  probably disorderly in character; in this
respect resembling those which occur before labour, in the circumstance
that there is no adequate safety-valve process of cervical dilatation to
meet the  sudden contraction of the body  of the uterus upon its incom-
pressible  contents.
   Rupture has on many occasions  taken place, or been extended, during
 straining at stool.   This was observed in  one of my  cases.
   Lacerations of the vaginal-portion do not always extend through the
 peritoneum.  At the lower segment, the  connection of the peritoneum
 is looser.   Rent  beginning at  the  mucous surface  and  involving the 
PARTIAL RUPTURE.
287
fibro-muscular tissue may terminate by stretching the connective tissue,
so that the peritoneum is dissected off from the utero-vaginal surface.
Another  condition favouring this immunity of the peritoneum is the
great distensibility of this membrane.  The cavity of the abdomen is
thus preserved.  During labour some stretching of the connective tissue
around the cervix always takes place, often with some amount of blood-
effusion,  always with serous  effusion.   When there  is  considerable
laceration of the cervix, haemorrhage takes place into this loose tissue,
forming peri-uterine haematocele, which, when intra-abdominal inspec-
tion is  made, may be  seen forming  a bluish tumour  composed of
coagulated and fluid blood, in a sac formed of the peritoneal investment
of the uterus and the broad  ligaments.  The peritoneum is, in  fact,
undermined by the effused blood.  This may burrow even as far as the
lumbar vertebrae upwards, and in the pelvic cellular tissue as far as the
labia vulvae downwards.   It cannot be rare, since Collins observes that
in nine out of his thirty-four cases, the peritoneal covering did not give
way.  " Yet," he adds, " death  ensued equally speedily, showing that
the free admission of air into  the abdominal cavity, is not necessarily
followed by any increase of danger."  The part  where  the  blood is
effused forms a bulging prominence on the outer surface of the uterus,
and the peritoneum  may crack.  Simpson  has seen  it  produced  by
injecting water into the uterus to induce labour. This variety is some-
times called "partial rupture."  When moderate in extent, the injury
and shock are much less severe than in complete  ruptures.   Haemor-
rhage externally commonly attends.  The collapse and ominous change
of countenance, the  sensation as if something had snapped, may be
wanting.  Hecker has  drawn  attention to a sign*  depending on the
extra-peritoneal  thrombus.  The pulse, he says, always  falls, even at
the beginning of the rupture ; it is quick and small.  Then a haematocele
forms in the cellular tissue between the bladder and  the uterus.  The
swelling thus formed is smooth, elastic, and quickly-growing.  They
differ from  rents in the body in that they do not readily close ;  they
remain gaping.  The deficiency of muscular fibres in the lower segment
accounts for this.  The rapidity  and extent of the blood-effusion is
accounted for by the great vascularity  of the parts wounded.   Collins
narrates cases that illustrate this point.  In one he says, " The peri-
toneum was not injured, but was  raised up  and distended with blood
underneath,  resembling  a bladder."   Recovery is not infrequent.
   Another form of incomplete rupture is that in which the peritoneal
coat is alone or chiefly  torn.   Over the body of the uterus the con-
nection of the serous membrane with the muscular wall is so  intimate
that it  is scarcely possible for rent of the  peritoneum  to  take place
without involving the muscular wall to some extent.   When it occurs,
some blood is often effused into the peritoneal cavity, where it may
                   * " Monatssch. f. Geburtsk'.," 1868. 
288
OBSTETRIC OPERATIONS.
 excite inflammation.   Jacquemier  describes  splits and scars in the
 neighbourhood of the Fallopian tubes and round ligaments, the result
 of mechanical distension.   These, say Dubois and Pajot, do not appear
 to give  rise to  perceptible symptoms.   They may be likened to the
 lesions of the skin from distension of the abdominal walls.  But in the
 more severe cases of peritoneal laceration death may occur from shock,
 as in a case narrated by Clarke (Trans, of the Soc. for Improvement of
 Med. and Surg. Knowledge), where only an ounce of  blood was found
 in the abdomen; and in another by Collins.   A more frequent cause
 of death seems  to  be haemorrhage, as in cases by Ramsbotham and
 Francis White.
   There is  a preparation  in Middlesex Hospital Museum presented by
 Dr. Hall Davis.   The subject fell heavily on her  back, being near the
 end of gestation.  The under  surface of the liver and the opposite
 surface of the uterus were lacerated.  Copious effusion of blood was
 found in the abdomen.  It did not appear that any direct violence was
 inflicted  on the womb.
   Rupture may ensue from obstruction caused  by the child—namely,
 from excessive size and want of elasticity—hence the explanation of the
 fact, that rupture is more frequent in labour with boys than with girls.
 Thus Collins says of thirty-four cases seen by him, twenty-three were
 with  boys ;  and  McKeever, out  of  twenty,  says fifteen  were boys.
 From  hydrocephalus :  this  was the  cause in one of  my cases ; from
 malposition: the child lying so  as to form a wedge, the base of which
 cannot enter or traverse the pelvis ; from death of the  foetus, as in two
 cases observed by myself.   I am disposed to think that this last cause,
 hitherto unsuspected or overlooked, is not infrequent.  Where the foetus
 has been dead some  few hours, all its  elasticity is lost; force  bearing
 upon its  breech is not propagated through its spine so as to drive on
 the head as in a live child, but  the trunk collapses, doubles up, the
 head bends upon the chest, the whole foetus tends  to mould into a ball.
 It thus  offers resistance  as effectual as does  an ordinary  shoulder-
 presentation.
   Lacerations of the vagina have been carefully described by McClintock
 (Dubl. Quart. Journ. of Med., 1868) and Scanzoni.  There are incom-
plete  lacerations.  Tearings of the mucous membrane and of the
 sub-mucous  connective  tissue  may happen.  Bleeding  occurs if the
 mucous membrane is torn.  Thrombus forms if the connective tissue
 is torn, whilst the mucous  membrane remains whole.
   Circular laceration of the upper zone of the vagina  under the action
 of the uterus  has been described.   Spontaneous lacerations of the
 upper part of the vagina are often the result of extension of laceration
 of the lower segment of the uterus.  The peritoneum behind, or the
 bladder in front,  may be  involved.   (See Figs. 107, 108.)
   Ingleby says : " The  contractions of the  uterus  will act  upon the 
RUPTURE  OF  THE VAG-INA.
289
 child, even to the laceration of the vagina, without producing a breach
 of its own surface."   But we must not  forget that similar injury may
 be  inflicted  by the hand or by  instruments in  attempts  to deliver.
 Thus,  Ingleby says: "In very difficult  turning  cases, the extensive
 separation of the vagina from the uterus has  occurred whilst the
 practitioner was  engaged in  changing the position of the child, the
 uterus instantly  passing  into the abdomen out of his reach.  I am
 acquainted with two such instances.  From these and several others
 of a similar  kind, which have been reported  to  me,  it appears that
 a laceration of the superior portion of  the vagina, including nearly its
 whole  circumference,  is  an  occurrence  by no  means unfrequent."
 And we must also bear in mind that transverse rupture of the posterior
 wall of the vagina has been caused by the sheer force of the expulsive
 efforts  driving an ovarian tumour upon it (Berry and Dunn's cases);
 or  the  retroverted uterus in early pregnancy  (Martin's,  Dubois',
 Sclmakenberg's, Grenser's cases,  and Fehling's), in which the  non-
 pregnant prolapsed uterus was thus protruded.   In the same way an
 extra-uterine gestation-cyst has burst  its  way through the vagina at
 the retro-uterine pouch, as in the  case of Dr. Thormann (Wien. Med.
 Wochenschr., 1853).  Under expulsive efforts a rent was made in the
 posterior vaginal  wall, and an arm of the foetus  protruded.
   As to the  consequences of such injuries, Ingleby  says: " The
 absolute separation of the whole uterus  from  the vagina, as the result
 of laceration or  sloughing, would seem quite incompatible with the
 preservation of life; but an  instance of this  kind, which terminated
 favourably, has been recorded  by Mr. Cook, of Coventry.  The separa-
 tion took place the second day after  delivery, and the specimen, which
 embraces  the  uterus  in a  state  of  inversion,  together  with  its
 ligaments, has just been  deposited in the  anatomical museum in this
 place "  (Birmingham).
   Rupture of the middle part of  the vagina is rare.   It can  scarcely
 take  place through  its%wn contractions, as the contractile power of
 the vagina distended during labour is not great.  It commonly occurs
 when the head is in the pelvis: and is therefore  probably caused by
 the action of the uterus either dragging  the canal upwards from the
 impacted head, or  driving  the  head  through the  distended walls.
 A dead  flaccid child would  favour this accident, so would  a face-
 presentation,  or an occipito-posterior  presentation, in aU  of which
 there is a tendency to delay in labour, and to rolling back of the head
 in extension, stretching and bruising inordinately the posterior wall of
 the vagina.
  Vaginal  lacerations mostly take  a  circular form;  they  remain
patulous ; and if the posterior waU is torn, the escape of the fcetus into
the peritoneal cavity is frequent;  prolapse of the intestine is also not
uncommon.
                                                             u 
290
OBSTETRIC OPERATIONS.
   Laceration of the inferior third of the vagina almost always takes
 place  in the  posterior wall, and merges in laceration of the perineum.
 This may  be  central or vulvo-perinaeal.  In a considerable proportion
 of cases I believe the rent begins in the centre of the perinaeum, then
 extends backwards  and upwards into  the  recto-vaginal septum, and
 forwards  through  the  commissure.   There  is,  in fact,  rent  of the
 posterior valve (see Fig.  23, p. 55), the  final obstacle to the expulsion
 of the head.   In almost every first labour more or less laceration of the
 commissure or  fourchette takes  place.   This is  usually insignificant.
 But it is not uncommon to find  lacerations  an inch in length.  As the
 parts recover from distension these are reduced,  and granulation often
 substantially repairs the injury.   Occasionally, in spite of every care,
 the  rent extends through the sphincter.   There is a  form of pelvis
 that seems to predispose to this  accident.   The symphysis pubis  is
 unusually  deep, the arch narrowed  so that  the head is necessarily
 directed backwards, and in  some women the  vulva is extremely smaU
 and rigid.   Then,  again, in  lingering  labour, the  parts  may lose a
 portion of their expansibility, and  the forceps  becoming necessary,
 under  the  strain the perinaeum will  be more likely to  give way.  No
 doubt, if unskilfully used, the forceps  may increase the risk of rupture:
 and that  in some  cases skilfully used, it may lessen this risk.  But
 still, on the assumption that the use of the forceps is indicated to
 avoid the dangers to mother and child of  retarded labour, the lesser
 danger of injury to the  perinaeum must be  encountered.  Rupture of
 the perinaeum, whether it  occur under spontaneous or instrumental
 delivery, is not evidence of want of skiU.  Under instrumental delivery,
 which  presupposes unusual difficulty,  rent is a fortiori more  probable.
 This is important to remember, because threats of legal  proceedings to
 extort  money have been based upon accidents of this  kind.  Sometimes
 the rupture is  limited to the central perforation.   Duparcque measured
 the perinaeum as distended  by  the  head.   The  length was  3-50" to
 4-00", the breadth 6*00", being more than twice its ordinary  dimensions.
 It is,  besides, excessively  thinned.   If the head be large, firm, the
 perinaeum at all  rigid from obstruction to its circulation, or unyielding
 as in primiparae, and especially if the coccyx retreat  backwards, or the
 pubic arch be narrow so as to  throw  the  head  backwards, opposing
 extension  round the symphysis, the perinaeum  becomes  enormously
 distended centrally, and  is very  apt to be perforated.   The child has
 several  times  been driven through this perinaeal opening, the  com-
 missure being  preserved intact;  but more commonly the rent forwards
is  completed.  Occipito-posterior  or  face-presentations  are. especially
liable to cause perinaeal lacerations.  The structures may also give way
before stormy tetanic uterine contractions.   I have sometimes seen the
central  opening  produced  in the way  described, but  the head has
 ultimately passed through the vulva.   In one case a fistulous hole in 
TRAUMATIC LACERATIONS.
291
the perinaeum remained for some time.   The perinaeum is not  seldom
torn by instruments.  I have, when discussing the use of forceps, dwelt
upon  this  subject.   The  structures also give way after undergoing a
stage  of  mortification from  compression, bruising, and stagnation of
circulation,  the  result of protracted labour.  They then become  as
lacerable as wet brown paper, literally rotten.
  Rent sometimes  begins at the  vulvar edge from extreme rigidity.
This  may  be prevented  by timely incisions.   Laceration  may take
place  at  the anterior edge  of  the vulva (see Tyler  Smith, Manual,
1858, quoting my authority; and P. Miiller, of  Wiirzburg, Scanzoni's
Beitrdge, 1870, on ruptures  between the clitoris  and meatus).   In one
case fatal haemorrhage ensued.
  Regarding the process  by  which perinaeal  laceration commonly
occurs, the mode of guarding against it  seems clear.  The  perineum
requires support.  It is necessary to obviate the initiatory tendency to
central perforation by giving an artificial  firm flooring to  this part  by
the palm of  the hand, which resting behind  upon the end  of the
sacrum prolongs the pelvic floor,  and guides  the head forward in ex-
tension.   Abundant lubrication is  useful.   And occasionally the long
double-curved forceps, by carrying the head well forwards, may preserve
the perinaeum.   The short straight forceps is more likely to split it.
  When  laceration  of the perinaeum occurs, it is commonly advised to
stitch it up at once  whilst the edges are fresh.   This may  be done even
as late as the next day; but it is better  done at the time.   Fancourt
Barnes, who has had considerable experience in perinaeorrhaphy, con-
tends that the immediate  suture is bad;  and that it is better to  defer
the restoration until after  the period of involution.  Abroad it is usual
to employ  serres-fines for the purpose.   Sutures are better.  If the
opportunity for  doing  this  be lost, endeavour should  be  made  to
promote  closure by granulation and cicatrization.  This often takes
place  spontaneously.  But  the process is  much promoted by  placing
a strip of lint steeped in  solution  of carbolic acid or chloride  of lime
between the lips of the wound, taking care to  press  it  well back to
the fork of  the wound.   This should be renewed twice a day.  It
preserves perfect cleanliness,  and  stimulates healthy granulation.
  Traumatic  lacerations.—These  may  result  from  injury inflicted
through  the abdominal walls  or through  the vagina.  Injuries from
without are of endless  diversity.
  The injuries  inflicted  from within are of more  special obstetric
interest.   These may arise from-the use of instruments or the hand.
During pregnancy,  wounds of the vagina and uterus are mostly the
consequence of  attempts  to  procure abortion.   Various  stilets  or
pointed instruments have been used for this  purpose.  If unskilfully
used,  as  is commonly the case, puncture or laceration of the vagina
or cervix uteri often occurs in the attempt to pass the os.  In other
                                                          u 2 
292
OBSTETRIC OPERATIONS.
cases, punctures have been found penetrating the cervix and the wall
of the uterus, opening into the peritoneal  cavity.   In these cases
effusion into the peritoneum, and  the  injury,  may result  in death ;
in minor  injury, perimetritis and pelvic peritonitis of an acute type
is very common, and may also  be  fatal.   The symptoms of abortion
of course  attend.
   Injuries inflicted during labour may or may not be the consequence
of unskilful obstetric manoeuvres.  Not seldom is  it very difficult to
determine, even in the presence  of the most  severe and extraordinary
injuries, whether accident, avoidable or  unavoidable, or direct  violence
was  the cause.   They may have begun spontaneously, and have been
extended  by attempts, perfectly  legitimate  and perhaps not unskilful,
to complete delivery  of child or placenta or to return prolapsed intes-
tine.  It requires the greatest circumspection not to commit one's self
to an opinion  which subsequent evidence  may prove to  be erroneous.
It must sometimes be impossible to  discover in the wound unequivocal
proofs as to the mode of its formation.
   Beginning with the perinaeum, we of  course  conclude that  severe
injury in  this part,  if noticed before the descent of the child,  is the
result of  external violence.  If known to have occurred during the
delivery of the child, it would be  difficult to  prove that it was  due
to criminal malapraxis, however strong the suspicion might be that
it was due to unskilful treatment.  Injuries of the vagina mostly occur
at the upper part. They may arise from unskilful use of the forceps or
perforator.  The blade of the forceps may be thrust through the roof
of the vagina at the angle of reflection  from  the  cervix uteri;  it may
thus penetrate the peritoneum,  and partially detach the uterus from
the vagina.   Wounds made in this  way are almost always transverse.
But so are most of the lacerations of this region which occur under the
natural forces.   Possibly the edges  of the wound may show marks of
bruising  if  made by the forceps.   The roof of the vagina has been
pierced  by the perforator, and  this accident is  really not  so utterly
inexcusable as may be supposed.  A very projecting sacral promontory,
occupying, as it does, exactly the place where  the head ought to be, and
presenting physical characters very similar to the touch to those of the
fcetal head, may easily deceive the inexperienced.   Strict observance of
the rules given in describing the operation of  craniotomy will  secure
against this error.  I believe the accident has also happened from the
use of bad perforators.  Indeed,  it must require an amount of skill  far
beyond the average so to use some of the vile instruments still in vogue,
as to avoid their slipping and doing  mischief, under some circumstances
of difficulty.
   Injuries may be inflicted by the hand, first, in attempts to turn when
the child is  tightly compressed by the contracting uterus or impacted
in the pelvis;  secondly, in detaching an  adherent placenta.   I have 
TRAUMATIC LACERATIONS.
293
known the uterus to be perforated  during  an attempt to separate a
placenta  which  had  undergone  hydatidiform degeneration,  and  so
had penetrated into the uterine wall.  The woman recovered.
  The first danger in turning is encountered in the endeavour to get
the hand past the  presenting part of the foetus.   If this be  roughly
made,  the uterus may be  partially torn from the vagina.  If this
danger be overcome,  the uterus may be  perforated in the body by the
projection of the knuckles,  or  by violent  thrusting  forward of the
fingers.  I must refer  to the  minute instructions  given in  Lecture
XVI.  as to the modes of turning under difficulties, as  the best means
of avoiding lacerating the uterus.   I would especially insist upon the
importance of the operation of decapitation where the child  is dead,
as the most certain way of  saving  the mother from further suffering
and  danger.   Upon  this subject Denman says:  "If the uterus be
strongly  contracted, it may be ruptured  by attempts to pass the hand
for the purpose of turning a child ; but in this case a rupture could
only happen when the force with which  the hand was introduced was
combined with the proper action of the uterus; for the strongest person
has not the power  to force  his hand through a healthy and unacting
uterus."   This,  I believe, is true.   But we must  admit that it is very
possible  to tear  through  the vagina, and also to rend the os uteri,
whence the lesion  might easily extend  into the walls  of the body of
the uterus, especially if the tissue be abnormaUy weak.
  When the placenta is adherent, there is sometimes disease of the
uterine tissue,  and  it may be impossible to detach all  the placenta
without  injuring the uterine wall.  The operation should be  done
with  great gentleness.  It is better to leave portions adherent, than
to persist too strenuously in tearing  them off.  This  subject  is  dealt
with  under "Haemorrhage."  Dr.  Dunn relates*  a  case in which
rupture occurred with an adherent placenta.   There is a preparation
in University College Museum showing the same combination.  The
caution required in removing the placenta is well enforced by Denman:
" I have known  two cases  in  which it  appeared that the uterus was
ruptured by the very  effort which expelled the child.  If  the placenta
be afterwards retained, and  it should be thought  necessary to extract
it, on  passing the hand for that purpose, this would be more likely,
without  the  greatest circumspection, to pass through  the ruptured
part into the cavity of the abdomen than into the uterus, the os uteri
being  more contracted.  It  might then be possible to mistake  some
of the viscera for the detached placenta.  This mistake  was  actually
made with very aggravated  circumstances in  a late unfortunate case;
and the immediate loss  of the patient's Ufe, and the irreparable destruc-
tion of the attendant's character,  were the natural and miavoidable
consequences."
                  *  "Obstetrical Transactions," 1868. 
294                 OBSTETRIC OPERATIONS.
  The crotchet, again, may slip  and tear the  uterine wall, especially
near  the  cervix.   Jagged  pieces  of cranial  bone detached  by  the
crotchet may  inflict similar mischief.  The obvious way of avoiding
these accidents is to discard the crotchet, and substitute the craniotomy-
forceps or cephalotribe.   Injuries of this kind are not necessarily fatal.
  Besides lacerations from more or less excusable want of skill,  the
most  frightful injuries have been inflicted under the influence of ignor-
ance, terror, or intoxication.   The inverted uterus  has  been seized by
both hands and literally torn away from the body.   A specimen of this
land  is  preserved  in the Museum  at  Birmingham  (Ingleby).   The
woman recovered.   Dr. Walters (Obstet. Trans., 1883) collected fifteen
cases of recovery after avulsion.  Several feet, even yards, of intestine
have protruded or been pulled through  the vagina  and  cut  away.  In
a case of the last kind in which I was  called to give evidence, it was
suggested  on behalf of the prisoner  that he might  have mistaken  the
intestine  for  umbilical cord.   The  difficulties associated  with this
question will  be discussed further  on.
  The attempt to determine, by examination of the  subject after death,
how a rupture was produced is surrounded with difficulties.   To invoke
the history of the case, in order to explain the post-mortem appearances,
seems like begging the question.  And too often the history wiU be so
defective, drawn from imperfect or unskilled observations, essential facts
being overlooked or suppressed, that it  will rather mislead than help
investigation.   The great practical question will generally be, to decide
whether  the injury was caused spontaneously or by  violence  from
without.  But even, if we arrive at the  conclusion  that the injury was
caused by the medical attendant, it  will not necessarily follow that it.
was done  through unskilfulness.
  There are, however, certain points that may help to form  a  conclu-
sion :—First, it ought not to  be difficult  to  affirm or to negative the
healthiness of the tissues  of  the uterus.   For  this purpose a careful
inspection of the uterine tissues at different parts, remote from as weU
as at, the  seat of rupture should be made.   They should be tested as to
then power  of resisting traction;  and  especially as to their intimate
structure, by the microscope.   And  to  throw additional light upon the
question of degeneration, it is  desirable  that a similar inspection should
be made of the tissues  of the heart, kidneys, and  liver.  It should be
remembered that pregnancy itself occasionally causes  organic  changes
in these organs.  Hence it may weU be that  a similar change may
involve the uterus.
   Such an  examination  would reveal, if present, cicatricial, fibrous,
cancerous, fatty degeneration  or  tumours;   softening,  ecchymosis,
breaking-down,  necrosis  from long-continued  pressure and  friction;
the relative thickness of the waUs at the seat of injury and elsewhere;
the marks of internal or external pressure, friction or dragging.   And 
RUPTURE  DURING  PREGNANCY.
295
these indications should be studied  in connection with the pelvis in
its  dimensions and other characters, and in connection with  those
of  the child and  placenta.   The pelvic cavity and lower abdomen
should be  searched for tumours or  other abnormalities.
  In some cases  inspection of the seat of injury  alone  will throw
decisive light upon the cause of injury.   Thus,  where boring-through
has occurred from obstruction to labour, the marks of injured tissue
may be much more obvious and extensive, and the breach of continuity
may be considerably greater externally than  internally (See Fig. 106).
So  again where  there are breaches  of surface at different parts of the
circumference of the lower zone of  the  uterus  or upper zone of the
vagina, the inference that the cause was obstruction  at the pelvic brim
wiU generally be correct. As an example  of the first proposition, I may
refer to  a  preparation in University College Museum (No. 2872) in
which it seems obvious that  the lesion was the result of grinding
against the pelvic brim ;  and, as an example of the second proposition,
to the case  (Figs. 107, 108) in which the rectum  and  bladder were both
perforated  by long jamming and grinding against the narrow pelvis.
  On the other hand, injury inflicted by  the hand or by instruments
may be expected to show more  extensive  marks  on  the inner aspect of
the uterus  or vagina ; and these marks will consist of bruising, ecchy-
mosis, punctures, rents, or incisions  ; and if marks of the kind are seen
in  healthy tissue  the  presumption  that violence from without is the
cause will be increased.
  I hardly think it would be justifiable to give an absolute opinion as
to the manner in which a lesion of the  uterus was produced,  where a
close examination  of this kind has been neglected.
  The symptoms and course will naturally vary with the cause, extent,
and seat of rupture.    The common signs  are  those of " abdominal
shock," indicating sudden severe  intra-abdominal injury.
  Rupture of the uterus during early pregnancy can hardly be  distin-
guished from rupture of a tubal gestation-cyst.  The subjective symp-
toms will be almost identical.  We  may arrive at a diagnosis after the
accident by exploring the uterus with the sound, especially after dilating
the cervix with laminaria tents.  We may thus  find the uterus intact,
and if its size be not much increased, we have additional evidence that
the pregnancy was not uterine.   There may be external haemorrhage in
both cases, but there will probably be more in uterine rupture.
  The symptoms of spontaneous rupture or laceration early in labour,
as commonly described, and as they occur in a great number of instances,
are  : sudden acute pain with a sense  of rending in the beUy, sometimes
attended  with an  audible snap, it is said; quick coUapse, marked by
pallor, fainting, extinct pulse; vomiting ;  some haemorrhage externally,
and the signs of anaemia from greater  loss internally; cessation of
uterine contraction ; if the child be cast  wholly or  in part out of the 
296
OBSTETRIC OPERATIONS.
 womb, the abdomen sinks in, there is retreat of the presenting part of the
 child from the os uteri; occasionally prolapse of intestine in the vagina
 or beyond the vulva;  great pain,  especially  on palpation,  over  the
 abdomen, where irregular, hard projections, which may be identified as
 parts of the foetus, when the foetus has been extruded from the womb.
 If the effusion of blood be great there is increased and  distressing
 tension of the abdominal walls.  Cramp-like or spasmodic pains foUow.
 The flushed  face becomes  suddenly deadly pale ; the  eyes lose their
 brilliancy;  the  whole  surface is covered with a  clammy  sweat;
 tremblings of the limbs or repeated faintings announce a profuse
 internal  haemorrhage.   Presently, when reaction comes,  the patient
 complains of feeling a warm fluid pouring out in  the neighbourhood of
 the groins and loins.   She  sometimes feels the movements of the child
 when it has escaped into the abdomen; but usuaUy the child quickly dies.
   It has  often been observed that the symptoms are not  so  strongly
 marked.  Sometimes very little pain is complained of at the time when
 it was presumed  the  laceration took place ;  the collapse creeps on
 gradually, the patient being capable  of walking  about  for some time.
 Denman  says : " I have seen one case in which there was reason  to
 believe that the woman walked a considerable distance, and lived several
 days after the uterus was ruptured before her labour could be properly
 said to commence."
  But sooner or later, almost always within two or three hours, collapse
 becomes pronounced, and pain is severe.  The  gradual development of
 the symptoms, is explained in some cases by the gradual progress of the
 injury.  The rent does not, at one stroke, attain its maximum.  There
 is first a moderate rent, possibly not through the peritoneum at first,
 without much effusion of blood  into the abdominal  cavity;  the rent
 extends, and blood, and perhaps the foetus, are extruded.  We must not
 then expect uniformity in the symptoms.   They vary considerably,
 according to  the nature  and seat  of the injury.  Thus in  vaginal
 laceration there may be no retreat of the head or  other presenting part
 of the child, although the body may escape into the abdominal cavity.
  The symptoms of partial  rupture,  or where the peritoneum has
remained intact, have already been described.
  The diagnosis of laceration early in labour is generally distinct enough
if the fcetus have been  extruded  into the abdominal cavity.  Parts of
the child are felt  by external palpation.  This  palpation gives great
pain.   The contour of the abdomen is  distorted; it presents irregular
prominences.  The uterus  may  be  felt  contracted and shrunk  down
towards the symphysis  pubis.  But  the  most certain  sign is  obtained
by passing the hand into  the uterus, where  possibly intestine may
be felt coming down into its cavity, or  even  into the vagina, and the
hole may be felt.  In one case where the rent was anterior, I could feel
my finger, protruded through the rent, by the hand on the abdomen. 
SYMPTOMS  OF RUPTURE.
297
  Where the  foetus  is  still  retained in utero,  the diagnosis  is less
obvious.   But here  also there is generaUy  some  recession  of  the
presenting  part.
  The symptoms of boring-through under long pressure  and friction
can hardly be distinguished  from  the extreme collapse and  irritative
fever  which follow upon long-protracted  labour.  The perforation of
the uterine tissue is only the climax, the last  stage, of long-preceding
injury.  The symptoms  are  mostly continuous.  The patient  dies of
prolonged shock, exhaustion, and  deteriorated blood.
  Haemorrhage varies greatly in different  cases.  In some fatal cases
scarcely any blood has  been lost.   This  may be partly explained by
the rupture having traversed parts  distant from the cervix and sides of
the uterus, and  from the placental attachment;  from  the  placenta
itself  not  being  detached, and from  the  uterus  having quickly con-
tracted.  There  is usually  little  or  no haemorrhage in the cases of
gradual perforation or separation  resulting from long compression.
  The symptoms also vary  according to the seat  and degree of the
injury.  Laceration of the cervix  uteri not extending to the  uterus or
vagina may give rise  to no marked symptoms.  It is,  moreover,  a
cause of secondary haemorrhage.
  The symptoms of laceration of the vagina are usually less severe
than  where the uterus  suffers.  Premonitory symptoms are rare;  the
shock is moderate ; vomiting occasionally occurs ; escape of the fcetus
and placenta into the  peritoneal cavity is more frequent (McClintock)
than in uterine rupture.   Prolapse of the  intestine is not uncommon.
But  simple  laceration  without  expulsion  of the  child  into  the
abdomen, or prolapse  of intestine may be  fatal from  shock, as in
a  case  communicated  to  me  (1875)  by  Professor  John  Clay,  of
Birmingham.
  The prognosis, it is needless to say, is in a high degree unfavourable.
The successive risks which the subject of rupture of the uterus has to
run are—1. Shock.  This may kiU in a few minutes.  2. Hemorrhage.
This  acts more  slowly.   But shock and haemorrhage are often com-
bined, and act quickly : and secondary haemorrhage may occur.  3.
Metritis,  gangrene,  perimetritis,  peritonitis,  diffuse  suppuration,
leading to 4.  Thrombosis   and  5.  Blood-infection,  prove  fatal at
variable  intervals,  extending  to  days or  even  weeks.  6.  In  the
perforative injuries,  there may be sloughing  or gangrene, especiaUy
when the  bladder is also involved.   Rokitansky mentions  that  the
uterine artery has been  opened by sloughs in  the cervix, giving rise to
fatal  haemorrhage.   7.  The agglutinations from inflammation may
obstruct the intestine and cause fatal ileus.  8. Psoas abscess was the
cause of death in one or more of Collins's cases.
  It is worthy of remark that in  several  fatal cases, masses of blood
decomposing were found in  the abdominal cavity. 
298                 OBSTETRIC OPERATIONS.
   The most formidable cases, however, do not exclude hope. Numerous
instances are recorded  of recovery even after the child, extruded into
the  abdomen,  has been  extracted  by turning through  the uterus.
Some cases have been reported in which recovery followed,  although
the child was left in the abdomen.  It may fairly be doubted whether
some of  these were not cases of extra-uterine gestation.   On the other
hand, it  is  possible that the child may have become  encapsulated by
inflammatory deposits, and subsequently discharged on disintegration.
Recovery where the child is not cast  into the abdominal cavity is more
frequent.  A moderate quantity of blood in the peritoneum may form a
haematocele, and the uterine wound may heal.  Perimetritis in such a
case becomes  a conservative  process;  and the uterus may contract
adhesions with the abdominal  walls.   The uterus contracting retreats
into the  pelvis; the wound either closes by a scar, or it has remained
unclosed in part, but the  opening shut off from the peritoneal cavity
by adhesions to the abdominal wall.
  It is  a gross error  to suppose that  the uterus  and  the  auxiliary
muscles necessarily cease to contract after the shock of rupture.  Yet
I have heard this unhesitatingly affirmed by medical men in a court of
law, their theory being that, since intestine  was found protruding, it
must have been dragged out by the medical attendant.   First,  as to the
power of the uterus.   Leclerc, cited  by Duparcque, tells a case  of  a
woman who had had six children.  The body of the child escaped into
the peritoneal cavity, whilst the head descended into the pelvis.   The
edges of the rent  were firmly contracted about the neck.  She  died
undelivered in  twenty-four hours.  The fact is that in a considerable
proportion  of cases the uterus contracts forcibly, just as it does after
the analogous injury inflicted  by the  Caesarian section.  In not a few
cases the child is expelled either  by the natural passages, or through
the rent into  the  abdominal  cavity.   Even after the expulsion  or
removal  of the child,  contraction has been  ascertained  by the hand
in utero as  weU as  by external  manipulation.   This I have felt myself.
In fatal  cases  the uterus  has  often  been seen, on  post-mortem
examination, so contracted that a rent  through which the child had
passed into the peritoneal cavity,  was reduced to the length of two  or
three inches.  And if the uterus did not sometimes contract, how are
we  to account for  the cases  of  recovery?   It is  because the uterus
contracts that prolapse of intestine is not more frequent.   The uterus,
like the heart, has a certain independent power.  It has been known
to contract  after being  almost  entirely separated.from its attachments,
and  even after death.
  Then as to the diaphragm and  abdominal muscles.   That  expulsive
efforts generally cease under the collapse of shock may be true.  But
there is nothing so dangerous as that fatal tendency of smaU experience
to rush  to  the absolute ■" Never " or "Always."   If expulsive effort 
TREATMENT.
299
always ceased, how can prolapse  of intestine be accounted for in any
case ?   Yet there are many  examples of protrusion where  manual
interference was out of the  question.  I can vouch  for  one from
personal observation.  A frequent  consequence of shock is vomiting.
What does the act of vomiting imply ?  Does it not involve expulsive
action of the  abdominal  muscles?  The  strain of vomiting has even
caused rupture of the uterus.
   An observation by Prof. R. H. Thomas (Trask, Amer. Journ.  of Med.
Sc, 1856) is precise.  He found >a woman in collapse, and  felt  the
child's limbs through the abdominal  walls.   He introduced  his  left
hand into the vagina, and discovering a large rent on the left and upper
part of its connection with the uterus, passed his hand into the peri-
toneal cavity, seized the  feet and brought them into the  vagina.
" Some bearing-down pains (abdominal  muscles)  now  came  to  my
assistance, and  a large  dead child was delivered.    The uterus was
found to  be contracted."   The  contracted uterus  was  also seen on
post-mortem examination.
   It may appear superfluous to point out to medical men of ordinary
education that it is  not  the uterus, but the diaphragm and abdominal
muscles, that force out intestine.  But for want of knowledge  of this
simple physiological fact, excusable in a  lawyer, and for want of due
regard to skilled evidence, not excusable  in  a  judge, Lord Coleridge,
in the case of the Queen v.  Peacock (Warwick Assizes, 1875), found
fault with  me  for   citing  Dr. Fehling's case (referred to,  p. 304)
as  a proof that a  large mass of  intestine could be  spontaneously
protruded through a rent in the vagina.   Lord Coleridge was unable
to understand that the uterus being quite passive in this matter, it
could not signify quoad this point  whether the woman were pregnant
or not.
   The Treatment.—The general principle, one not, however,  universally
assented to, is thus stated by Duparcque :—
   " Whatever be the cause, seat, and direction of the rupture produced
in the womb during labour, one first principle  and fundamental indi-
cation presents itself: this is to deliver.   This  is necessary to obviate
the passage of the child into the abdomen, if this has not already taken
place.  It is indispensable in every case, in order to  save  it, and at the
same time to rescue the  mother from the formidable dangers which
threaten  her.  Time  presses : a moment's delay may accumulate  ob-
stacles, may render them insurmomitable, or allow accidents inevitably
fatal to both mother and child to arise.   It is especially in these cir-
cumstances that the physician  must be equal to his mission.   Success
depends  upon his  accuracy of perception, upon rapid  appreciation,
upon action quick, bold,  even rough,  but always calm and reasoned
out."
  The  prophylactic  treatment has been  already referred  to.   The 
300
OBSTETRIC OPERATIONS.
remedial measures will be dictated by the nature of the case.   Where
there is  spontaneous rupture during pregnancy, and  at  the onset of
labour before the os uteri is expanded,  first of all  dilate this part, and
then explore the cavity of the uterus.   This may be done by incisions,
if necessary, but certainly by the hydrostatic bags.   This proceeding
will enable you to extract the foetus per vias naturales,  if it  be not
extruded into the abdominal cavity ;  and will, at any rate, afford outlet
for blood and  liquor  amnii.   If the head  is within  reach apply the
long forceps, if you  are  called early and there is hope  of the child
being alive; but if the accident has happened more than thirty minutes,
if prostration be great,  in  all probability the child  is dead.  If by
perforating it seem likely to extract the child with less distress to the
mother, this method should be preferred.  If the head do  not present,
or be beyond reach of forceps, turn.
   1. Take the first case:  that where the child, or at least the presenting
part, remains in the uterus  or vagina.  Assuming, and I assent,  with
only that qualified reserve which  a prophetic sense of unforeseen com-
plications dictates, to the dictum of  Duparcque, that quick delivery is
indicated, we have but to  decide upon the best  mode of delivering.
Our choice will here be limited to the forceps, craniotomy, and cephalo-
tripsy, and turning, or laparotomy.   If  the head present, if the cervix
be expanded, and there be no marked obstruction from pelvic deformity,
or from the child, the forceps will naturally be  selected.   Anaesthesia
should be  induced, I  think, notwithstanding the influence of shock.
The introduction of the blades will demand extreme care.   The points
must be carefully kept close to the child's head.   An assistant  should
grasp the  uterus  on either side between his  two hands  during the
extraction.  When the child is delivered, even greater care, if possible,
is required in the removal of the  placenta.   The cord must be tracked
up to the placenta ; and  the greatest possible circumspection will be
necessary in order not to mistake this body for anything else, and to
avoid drawing down intestine  along with it.   Although the presenting
part of the child may not have escaped into the abdominal cavity, yet
the placenta may have done so, either soon after the occurrence of the
rent, or  during the uterine  contraction attending  the extraction or
expulsion of  the child.    The cord then  may guide you  into the
abdominal cavity, where the  placenta will be surrounded  by floating
intestines.   You will, holding  the free  end  of the cord by one hand,
and fixing the fingers of  the hand which is in the woman's body round
the insertion of  the  cord in  the placenta,  draw  it gently down  and
extract it,  if detached.  If it does not come easily, carefully, gentlv
feel  all.round  the margin  of the placenta, and  try  to ascertain the
cause of retention.  If the  placenta be in  the  abdominal cavity, the
difficulty may be due to  contraction of the  opening of the rent,  more
especially if the rent  be  in the uterine  wall.   In this case the  utmost 
TREATMENT.
301
care will be required to avoid breaking the  cord  off at the root, and
thus leaving the placenta  loose among the  intestines.
  What shall be done if this accident happens ?  The best course here
certainly, and probably  in most cases, will be to open the abdomen as
for  Caesarian section ;  and to remove the child, placenta, and blood;
and  generally the  injured uterus also, as will be  described under the
head, " Porro's  Operation."
  Doing nothing has high authority;  but the balance of recent opinion
is  in favour of gastrotomy.  The placenta is an offending foreign
substance likely  to set up irritation and inflammation in any case, and
since air may get access to the rent, to putrefy.  It should therefore be
removed.   And  the argument for gastrotomy is strengthened by the
fact, that blood in considerable quantity has been also  poured into the
abdominal  cavity, and can  be removed  at the same time.  If the rent
be a large one  in the  posterior vaginal wall, there is, of course, less
liability to  closure by contraction,  and there will consequently be little
difficulty in  extracting  the  placenta,  although  entanglement with
intestines may equally  embarrass.
  If the pelvis be narrowed, or the child be of excessive size, it will be
better to perforate the head, to crush it down by cephalotribe, and then
to extract.   In  perforating, the rule  laid down in Lecture XXIII., to
have the uterus  well supported upon the pelvic brim by an assistant, is
specially to be observed, lest  pushing force  applied to  the head below
increase the laceration.   If the child present transversely, decapitation
or bisection at the trunk should be preferred to turning, as involving
less  strain upon the injured maternal parts.
  2. Take  the second case, that where the whole child, with or without
the placenta, has been cast into the abdominal cavity.   Sometimes the
entire ovum, unruptured, has been cast out of the uterus, as in  one of
my cases.  If the rent be  in the vagina, it may not be difficult to
remove  the child by the hand passed through  the rent;  and success
has several times followed the removal when the rent was in the uterine
wall. Ingleby relates  a successful case.  A case related by Danyau
(Mem. de la Soc de Chir.,  1851), and another by Dr. Bell, of Bradford,
were instances  of extraction through a vaginal rent.   Generally, the
attempt at  removal, to offer  any prospect of success, must be done at
once : but Duparcque relates  a case in  which the foetus was extracted
putrid through a transverse  rent at the union  of the cervix with the
body of  the uterus eight days after the rupture, the woman recovering.
If, however, the rent be  in the body of the uterus the chances of success
by operating by  this route are much diminished.  You may succeed in
passing the hand through and in seizing the child ; you may even have
brought the child back into the uterus as far as the head, only to find it
strangled in the  opening, and resisting  all further effort at extraction,
unless at the expense of so much force as may destroy the little chance 
302
OBSTETRIC OPERATIONS.
 left of Ufe.   Unless, then, the hand pass easily, unless the child's feet
 —for you must seize both feet—be  easily grasped, and unless you feel
 pretty confident that the child can be brought back without difficulty,
 it is better not to make an attempt, which if not successful, will be
 sure to make matters worse.  Precise contra-indications are, large size
 of, the child, hydrocephalus, cancerous or other disease of the uterine
 neck, contraction  of  the uterus, narrowing of the pelvis.
   In the cases where the fcetus and placenta cannot be brought out by
 the  natural passages, we have a  resource in gastrotomy.   The opera-
 tion is described in the Lecture on the Caesarian Section.   It is very
 simple.  In  two  cases in which I  performed  it,  although  death
 followed,  very sensible immediate  reUef appeared to  be  gained; the
 shock seemed diminished; the pulse recovered, and  I was  satisfied
 that  Ufe  was prolonged.  In both cases the operation was delayed
 some hours.  Had the  opportunity been offered  of  operating at  an
 earlier period, the prospect of recovery would have been  better.   In
 other cases a fair proportion of success  has been  attained.  Where
 death  follows, it  must  be difficult or impossible to  assign  to  the
 original  injury and to the operation their  respective shares in  the
 result.  But, looking to  the history of ovariotomy, to the  exploratory
 incisions made without  completing ovariotomy, we  are  justified  in
 regarding the operation  in  itself as of comparatively  small moment.
 It is the original injury that kills.   If we fail to save the  subject
 from her extreme peril, we must find comfort  in the reflection that
 we have done the best  that art  and humanity suggest.  Not to  cite
 cases more or less known, I may  refer  to one published  by  Dr.
 Crighton (Edinb.  Med.  Journ., 1864).
   Gastrotomy offers the  great advantage over all other  proceedings
 of enabling us to clear the abdominal cavity of placenta and of blood,
 and the best chance of saving the child.
   ShaU any attempt be made to  close the uterine wound ?   I am not
 aware that it has ever been done in  any case of gastrotomy for rupture
 of the womb.  The fact is certain that women  have recovered after
 gastrotomy.   Therefore  the operative closure of  the uterine wound
 is not in all cases necessary.  But it may be true, notwithstanding,
 that some cases that  proved fatal would  have had a better chance
 of recovery had the uterine wound been stitched up.  In the successful
 cases, no  doubt  the wound was closed  more  or less  completely  by
 the  muscular contraction  of  the womb.   It  may be  that in some
 of the unsuccessful cases the womb  did  not contract,  so that the
 opening  remained gaping.  Might  not then closure by suture com-
pensate for want  of natural  contraction ?  The affirmative is not a
necessary sequence.  Contraction is proof of vital power ;  flaccidity, of
prostration from injury that struck deeply.  Mere closure of the wound
cannot give vital power.  The advantages  to be  gained from  closure 
EXTRUSION  OF  INTESTINE.
303
are : security  against protrusion of intestine,  and the prevention of
the escape of blood or noxious discharges from  the womb into the
abdominal cavity.  When the  uterus  is  flaccid  it would be  better
to sew  up the  opening;  or  better  stiU, to remove the  uterus  by
Porro's  method.
  Take  the case where intestine  protrudes through  the  rent.  The
following  propositions may be  stated :—Intestine may be protruded
by the natural expeUing forces, or it may be dragged  out accidentaUy,
or through recklessness, or by getting entangled  in the limbs of the
child.   We may next inquire how much, and  what portions  of the
intestine can be  protruded spontaneously ?  The  question is not easy
to answer.  The histories of cases given  are  wanting in precision
on this  point.   But looking to what we see in  operations  for  ovario-
tomy ;  to the  analogy  of hernial protrusions  where there  is  no
rupture in the sense of rent; and to  the few cases of rupture of the
uterus  or vagina where the  length of  intestine protruded has  been
more or less precisely adverted  to, we may conclude with  confidence
that more than  six feet  may be  thus driven out;  and we  are not
entitled to  deny that  very  much  more  may  be driven  out.  The
force required to drive  out intestine is really very smaU.  The intes-
tines are retained  in sitil by  being packed  in  a closed bag;  the
mesentery is not wanted to  suspend them, and Nature does nothing
in  vain;  the mesentery is  a delicate membrane, the chief  use of
which is  to carry vessels and nerves to the intestine.  Any one who
observes what takes place when  the intestines are handled in  a post-
mortem examination, must have  been struck with the facility with
which the body may be  disembowelled.   I have instituted an  experi-
ment to  determine  the  force required to draw  out intestine.  The
mesentery being detached at one point of the small  intestine, a two-
pound  weight was  attached to the coil;  it quickly ran down  to the
ground  carrying intestine with it, the mesentery offering  but slight
resistance.*   Now,  the  expulsive force  of the  abdominal muscles
much exceeds  two  pounds.   It is  incontestable  that it must equal
the weight of the child, for  the abdominal muscles  alone may expel
the child and the uterus with it.  The child commonly weighs seven
pounds, and  may weigh  twelve or  more.  Moreover, this weight is
propelled  against considerable friction.  An approximate  idea of the
power of  the  abdominal muscles,  even in a delicate woman,  may be
obtained when we attempt to  grasp the uterus  through them  to cast
the placenta.   Not  seldom,  contraction  so powerful is excited that
the hands of a strong man  using his utmost  strength, and  putting
his  weight into the effort, are thrown up from  the uterus.  In a case
of ovariotomy  I  performed  (June,  1875) a  solid tumour weighing
  *  Dr.  Braxton Hicks and Dr.  Gobdhart have since made experiments with
similar results at Guy's Hospital* 
304
OBSTETRIC OPERATIONS.
 twenty-eight pounds was thrown  out  of the abdomen  by the mere
 force of the diaphragm under vomiting.   Without insisting upon  the
 experiments and calculations of Dr. Haughton, I am satisfied that
 the  expulsive  force is  not  overstated at  fifty pounds.  A case related
 by Dr. Fehling  (Arch. f. Gynak., 1874)  is a distinct illustration of
 the  simple action of the expiratory muscles in expelling intestine,
 the  more valuable as it occurred in  a non-pregnant woman.   The
 subject, a  pluripara aged  sixty-three,  had suffered from a reducible
 prolapsus vaginae for  thirty years, latterly about as  large as a  foetal
 head.  Carrying  a bucket of water up  four steep steps, the  womb
 came down.   She  tried to  replace  it, using some force.  She  felt
 something  give way,  and intestine protruded, forming a mass  as
 large as a man's head.   The intestine was followed into the abdominal
 cavity through a large rent in the  posterior vaginal wall.   An attempt
 was  made to replace the bowel, but it was unsuccessful; F. punctured
 the inflated bowel, but with  no  good result.   She died eleven hours
 after the accident from shock.  There could be no doubt, says Fehling,
 as to the diagnosis of  rupture  of the  peritoneum.  The parts removed
 from the body showed  that  the posterior wall of the vagina formed
 a  large tumour, into  which  the  rectum  protruded  (rectocele).  In
 this  cavity probably  a large part of  the small intestines had also
 lain.   The  obstacle  to complete reposition was attributed  to  the
 diminished space  in the abdomen from long-standing prolapse, and
 to the  string-like  stretched  mesentery  of  the protruded  intestines
 which drew them back  into the vagina.   What was the amount of
 intestine expelled in  this  case ?   The account is  not precise;  but
 Dr. Fehling tells me  it  was  probably  over twelve feet;   and a  mass
 "as  big as  a man's head"  could not be  much less.   No  doubt  there
 was predisposition to  protrusion from the old hernial state; but that
 the main bulk of intestine had never been  down  before the injury
 is proved by the facts that the hernia was  "  as big as a child's head,"
 and the protruded mass " as big as a man's head."
  In Cooper's  Surgical Dictionary (Art. Wounds of Abdomen)  a case
 is  related where the whole of the intestines, except  the duodenum and
 the arch of the stomach, had escaped through a wound four inches long
 on the  side of the upper abdomen.    The intestines had  not  been
 dragged out.
   What may happen if protruding intestine be not returned ?  1st. It.
 may  be gradually reduced by spontaneous processes.   The peristaltic
 action probably, or the passage of air  along it, may draw the prolapsed
 coil,  if this be of moderate length, back into its place.  Examples of
 this are not rare.   I observed one myself.  2nd. It may get strangled
in the  uterine  wound,  inflammation  and   gangrene  supervening.
 Deneux quotes a case from Percy.  But recovery has been known.   In
the case of Dr. M'Keever four feet  of intestine sloughed away, and 
SOURCES  OF  ERROR.
305
recovery ensued.   An artificial anus may form, as in a case seen by
Roux.  (See Duparcque.)  It appeared that the surgeon had nipped a
loop of intestine along with one lip of  the os uteri between his forceps
and the child's head, and this  sloughing, a communication with the
vagina  was formed.
   As it is a matter of great  practical interest  to  know  the possible
sources of error in diagnosis, and  consequent  error in practice, I will
enumerate those which by  experience or reading have been brought
under my notice.
   1.  The Placenta.  A child may have been delivered, and a placenta
has followed.   Another  placenta  may be  felt  in vagina or uterus.
This would naturally lead to the  conclusion  that  there was another
child; and  as none might be found in the uterus, it would suggest
the inference that there was rupture,  and escape  of  a child into the
abdominal cavity.  I have  been called to such a case.   The  second
placenta was a placenta succenturiata.  There was no rupture and no
second  child.
   2.  A rupture may have taken  place.  The child  may  have  been
delivered naturally or artificially,  the  cord  tied; and in searching for
placenta, tracking the cord, the hand may be- guided through the rent
into the abdominal cavity where the placenta may have been cast by
the uterus.  Dr. John M. Cottle communicated to me a case to which
he was called after death.  He " found the body of the child, excepting
the head and the neck—the head being fixed low down in the pelvis—
and also the placenta were  amongst the  intestines, having  passed
through a large rent at  the  back of the vagina.  Had the child  been
delivered, the placenta might either have been driven out along with the
intestines, or the attendant tracing the cord would have  got amongst
intestines, and  very moderate  traction upon the cord  would  have
drawn intestine along with the placenta."
   3.  A more or  less solid  blood-mass  may present or be felt in utero
after  the  birth of the child.   Such a mass may easily be mistaken for
placenta,  although no  cord be attached to  it.   And  such a mass
surrounded  by membranes  or layers of fibrin may even  to the eye
resemble the placenta.   And  such a mass  may come, as in a case I
published in St. Thomas's Hospital Reports, from the abdominal  cavity.
   4.  Substances other than a child or placenta may be protruded from
the uterus.  Thus a fibroid tumour or polypus may be thrust out after
the child has been born.  It may be taken for the placenta or  a firm
clot.  It is a most puzzling complication.  And it is not unlikely to be
attended by rupture.
   5. An abnormality of the fcetus, which might be seriously embarrass-
ing, is figured (Fig. 109) from  a  specimen in  St. Thomas's Hospital.
It might  easily  be taken for placenta.  It  is a tumour of the sacro-
coccygeal gland.
                                                            x 
306
OBSTETRIC  OPERATIONS.
   6. In the Virginia Medical Monthly, for December, 1874, a remark-
able case is related by Dr. Dunn, in essential features the counterpart
of Mr. Berry's.   He was called to a woman suffering from " shock " in
labour.   On " placing his  hand  on  the  abdomen, the fundus of  the
womb felt as if it  had separated from the right and right anterior
half.  The perinaeum was enormously distended, so as  to make  the
impression that the  child's  head  was  in the vulva."    He felt a
fluctuating tumour in Douglas' pouch.   The foetal head, emerged from
the os uteri, was pressing firmly upon the upper surface of the tumour.
This pressure had caused it to tear an opening of two inches in length
Fig. 109.
through the upper portion of the posterior vaginal wall.  The elevation
of the womb due to the resistance to the exit of the head, and the
elongated  distension  of the perinaeum caused by the pressure  of the
tumour upon it, gave the vagina a length of eleven inches as measured
along its posterior wall.   Dr. D. enlarged the rent in the vaginal wall,
and bore firmly upon the perinaeum during  a " pain," which forced the
tumour through the enlarged rent into the vaginal cavity;  the pedicle
of the tumour was ruptured by the same pain.  It was now easy to
extract the tumour lying loose in the vagina by forceps.   The  con-
traction of the abdominal muscles during the extraction of the tumour 
RUPTURE:  SOURCES  OF ERROR.
307
through the vulva, forced the foetus into the abdominal cavity through
the opening in the posterior wall of  the  vagina.   He  immediately
passed his hand  through the rent,  turned, and  delivered the child.
The expelled tumour was found to be an ovary which had undergone
multilocular cystic degeneration.  It weighed thirty-three ounces.  The
fundus of the uterus  resumed its  normal position soon after delivery.
The haemorrhage did not exceed three pints.   The woman was treated
by  repeated  doses  of  morphia, and after  protracted convalescence
recovered.   In a narration otherwise  precise  and  consistent,  no
mention  is made of the placenta.
  7. Omentum may be mistaken for  placenta or the membranes.  Dr.
Hicks relates a case (Lancet, 1875).  He " was called to  see a woman
in whom  there was  considerable prolapse  of  the  omentum from the
vulva.   He was told a curious modification of the  placenta existed,
but the medical man, fearing all was  not  right, asked him to assist.
Turning was accomplished  when this mass came down to the vulva.
During examination and manipulation it came outside three  or four
inches, where  it  was  seen."  Had, he  observes,  this omentum not
been looked  at, but treated as  a portion  of  the  membranes (a not
difficult mistake to make), dragged down, and very possibly endea-
voured to be peeled off as the membranes sometimes require, the case
would  not have been without many points of resemblance to that tried
at Warwick.  (Queen  v. Peacock, 1875.)  See page 299.
  8. Intestine may come down into the vagina or outside.   But this is
not necessarily proof of rupture.  The intestines may belong to a child
in utero, malformed, having no abdominal wall, as in a case (Brit. Med.
Journ., 1875) reported by Dr. Sheehy, in one by Dr. Meadows (Obst.
Trans., vol.  vii.), and as  in a  specimen in St. George's Hospital
Museum ; or the abdomen  having burst from decomposition, or from
over-distension from ascites, the intestines may have fallen through.
Foetal  intestines will be smaller than those of the  mother ; but the
difference may well escape  detection  by one who in all probability has
never felt one or the other before.
  9. Maternal intestine, then, may be mistaken for fcetal intestine. And
for  what else ?  It has been mistaken for umbilical cord.  This, it is
said, ought  not to occur.  It is easy to be wise after the event.  We
are all under the  dominion of  habit.   We believe the sun will rise
to-morrow because it has done so every day hitherto.  The obstetrist
who has never felt anything else but  placenta or cord in the vagina, is
instinctively led to conclude that anything he feels there which bears
to the touch any resemblance to them is placenta or cord.  A mass  of
omentum  consolidated  by inflammatory deposit, intestine  adhering  to
it, would  hardly be  distinguished  from  placenta.    Then, as to the
resemblances between intestine and  cord.  First,  what  are the cha-
racters of umbilical cord after division from the born child ?  It is a
                                                         x 2 
308
OBSTETRIC OPERATIONS.
 single string; there is the cut end outside ;  it has no mesentery ;  it is
 tolerably firm, not inflated by air ; traced up, it leads to its insertion m
 the placenta.  What are  the characters of  intestine ?  It is a hoUow
 tube, forming loops or coils ; to its inner  border is attached a  thin
 membrane, the  mesentery; it  has an  elastic feel less solid than the
 cord;  traced up to its source, it does not lead to the placenta, but
 through a  rent into  the abdominal cavity.   These  differences  are
 marked  enough to enable any skiUed person under  ordinary circum-
 stances, in  the full  possession of  his  faculties, and retaining  his
 delicacy of touch,  aided by sight, to distinguish one  from the other.
 But the circumstances are generally, ex necessitate rei, extraordinary;
 and the  characters of cord and  intestine are not always so peculiar as
 above stated.  The cord, even  after  being divided, may form loops  in
 the vagina, the  cord being carried  back into the vagina  in  searching
 for the placenta  or lost in clots of blood.  If tbe cord be long—it has
 been recorded as being five feet long, and I have heard  a surgeon declare
 in a court of law that he had known one fifteen feet long !—there is no
 difficulty in the  formation of loops and coils ;  and a cord  of  a  second,
 or even  of a third  child may come down in a coil, there being no free
 end.   Then as to the feel: some cords are very thick, pulpy, as  in a
 specimen in St. George's Museum, so resembling intestine as to deceive
 even the eye as weU as the touch, especially resembling intestine which
 has been a little stretched, possibly separated from its mesentery, as it
 is very likely to be when protruded  through  a rent.  Intestine  so
 stretched loses  its  distinctive character  of a hoUow  elastic tube : it
 becomes a thickish cord; so that, as  Tyler Smith  showed me,  and
 demonstrated to  a  judge, it would require no small coolness and  skill
 to distinguish them.  Moderate tension upon the intestine will displace
 the air in it, reduce it to  the semblance of  a cord, and may detach it
 from its mesentery.  Practised men have  been  deceived, at least for a
 time.   Thus Duparcque :  " examining  I found  in the  vagina  a  body
 which  at first I took for the umbilical cord."  I have  experienced the
 same difficulty, and in the  same case two other surgeons were in like
 manner puzzled.  In a very interesting case narrated by Mr. 0. Lowsly,
 of Beading, the  cord  gave way  in  attempt to extract the  placenta.
 " Being  obliged  to  pass his hand into the uterus, there finding some-
 thing like a portion of placenta, he brought it down,  and to  his great
 surprise  discovered  it was  a loop of intestine."  It was  immediately
returned.  The  woman recovered, and dying fourteen months after-
 wards  of phthisis, a post-mortem examination  showed a  star-shaped
 cicatrix in the posterior wall of the body of the uterus.   The way in
which  doubt has been cleared up was by gently drawing down a loop of
the presenting body, and inspecting it by the eye.
  Dr. Hicks calls attention (Lancet,  1875) to the singularly elongated
state in which the vagina is often found at  the  time  of labour.   " In 
            RUPTURE: PROTRUSION OF INTESTINE.         309

removing the placenta," he says, " one has had to pass the hand as far
as the ribs before the  os  uteri could be reached ; that is, the uterus
receded  so readily, that till it  was caught and fixed by the external
hand, which is not always easy, the internal hand has reached so high.
But  in  most cases  the hand will reach to the umbilicus very readily.
This is just about the centre of the mesentery, and therefore if a rent
exist behind  at  its upper end there is  an opportunity afforded for  a
prolapse of magnitude.  If, therefore, in searching for the insertion of
the funis,  a coil or two of intestine have protruded through, the entan-
glement of them in the fingers, and the  movements of the latter  to
avoid them and find the funis, would be sufficient to bring through a
large amount, especially if aided by the straining of the woman and
much pressure outside."
   What are the motives, or rather the excuses, for cutting off intestine ?
I do  not think that any adequate surgical reason has been shown for
cutting-off protruding intestine in a  recent  case of  rupture  of the
uterus or vagina.  Where  a  coil  has been partially separated  by gan-
grene it may with propriety be  removed.  But it  is a remarkable fact
that in several, probably in many cases, the protruding mass has been
cut away by scissors.  Cases of the kind are referred to in aU countries.
Instinct  and  reason alike  are  shocked  when such a  case  occurs.
Indignation is not  unnaturally excited.   The actor is presumed  to
have been drunk, ignorant, or reckless.  But now and then a case has
occurred where the  actor has been  neither drunk nor ignorant, and
where recklessness  was not, at least, an attribute of his known cha-
racter.  On what principle then are we to explain such conduct ? Two
hypotheses may be invoked.  1st. He has been appalled by  the sudden
appearance of a mass  of intestine; his distress has been increased by
inability to return it; under the  mental shock his judgment and his
power of accurate manipulation are paralysed ;  in ill-directed efforts
more intestine comes  down, and very slight force  will cause this.
Terror succeeds—first alarm for the  danger of his patient,  then dread
of the consequences to  himself.   Under this temporary mental disorder
he may do the most desperate things.  He gives the woman up for lost;
and, vaguely hoping to  escape  censure, he may seek  to conceal what
has,  perhaps from  no  fault of his,  taken place.   Thus the intestine
has  been cut away, thrown behind  the  fire or buried  or  thrown
into  a privy.
   2ndly. More or less  disturbed by an occurrence altogether beyond
common experience, he may mistake the protruding intestine for some-
thing else : and acting on  the broad  general rule,  that whatever  is
expelled from the vulva during labour is to be removed, he may remove
it  in the readiest way.  Thus intestine has been cut, thus  the uterus
itself, inverted or detached, has been dragged away.
   I  do  not urge  these reflections,  founded though they be upon 
310                 OBSTETRIC OPERATIONS.
experience, to excuse drunkenness or gross ignorance, or to advance a
plea for  professional  irresponsibility.   But it deserves  consideration
whether  it is  reasonable to expect from every practitioner, no matter
how young, how necessarily limited his knowledge  and experience,
unaided  by counsel, harassed by the  bewildering emotions  of those
around him, under emergencies sudden and terrible, exhausted by long
watching, and beyond ordinary experience, the calmness of judgment
and the skill in action which rarely come but with maturity in years
and familiarity with difficulties.   If the  object of punishment be not
vengeance for a particular crime, but the prevention of crime for the
common protection, it may well  be doubted whether criminal prosecu-
tions  for surgical  casualties  or  blunders really conduce to the public
interest.   A young man entering on practice will hardly be encouraged
under difficulties that may compromise  his reputation and his liberty,
by the feeling that he is working with a halter round his neck, to keep
a cool head and a steady hand.  Will not this feeling rather terrify him
into the attempt to conceal a mishap, than encourage him to an effort
to repair it?
  If intestine protrude through a rupture  in the uterus, attempts should
be made to return it.   This is sometimes extremely difficult,  even
impossible.  As fast as you  push up one part another comes down.
Expulsive reflex action may be set up, so that the very effort you make
to replace  intestine, excites to the  expulsion of more.   It would be
advisable, I think, to administer  large doses of opium, chloral, chloro-
form,  or  ether, to  lessen reflex irritability, if  this is  found  to oppose
reduction.  The attempt must not, however, be persisted in  too  long,
lest we increase the prostration and perhaps the injury.   If we succeed
in reducing, we may next endeavour to excite uterine contraction by
keeping the hand in contact with the uterine  wall, and in this way to
close the opening and prevent recurrent protrusion.
  When  the rent is in the posterior wall  of the vagina, the difficulty in
returning the intestine and in preventing it from coming down again is
much greater.   The opening remains gaping, and  all expulsive action
bears directly upon it.  It has occurred to some that the opening might
be stitched up.   Of course this presupposes that the intestine has been
first reduced.  I know of no instance of this proceeding being executed.
I have heard of its  having been done, but the cases are not published.
Even if one were fully prepared  for  the  operation with all appliances
and adequate assistance, the carrying  it out would be so  difficult,
tedious, and dangerous to the patient, that it will generally be wiser not
to make  the attempt.
  An  easier proceeding, one which might fairly be justified, would  be to
open the abdomen by an incision large enough to admit of manipulation;
to draw back the intestines, taking the opportunity of removing blood-
clots,  and then to  stitch up the  wound by operating from above.   But 
RUPTURE :  TREATMENT.
311
the courage of the operator might not be appreciated ; and there are not
many men possessing nerve and skill enough to execute it without the
countenance and assistance of a professional brother.  A more effective
proceeding may be adopted, if stitching  the uterine  wound  after
laparotomy be unadvisable;  that is, to carry  out Porro's  operation
of amputation  of the uterus.
  To lessen haemorrhage there are  two principal resources :—1st, to
induce contraction of the uterus ; 2nd, the topical application of styptics.
The  first object  may be promoted  by grasping the uterus ;  by the
application of ice to the uterus.  But the injury involves shock ; and
so long as shock endures it  may be impossible to obtain contraction.
We are then driven to styptics.  A solution of persulphate, chloroxide,
or perchloride of iron may be  applied by a- swab  to the wound.  A
most interesting case is related by Dr. More Madden (Brit.  Med.
Journ., 1874).  There was a rent so large  that his " hand passed into
the  abdominal cavity.   There  was little  external  haemorrhage, but
a considerable effusion of blood was  going on into the peritoneal cavity
from the open uterine  vessels.   The patient was now  pale  and col-
lapsed, and  it was evident  that any further  loss of blood must be
fatal;  therefore, with Dr. White's  sanction, I saturated a  sponge in
the strong solution of perchloride of iron, and applied it freely to  every
part of the rent.   The effect was instantaneous.  The  woman  com-
plained of intense  pain, but the haemorrhage ceased completely, and
the  lacerated  gaping wound  in the vagina  and uterus  contracted
sensibly under the stimulus.  The  woman  was still cold,  pulseless,
and  apparently moribund.   Brandy and  Uquor opii were thrown up
into the rectum.   I  left her, firmly expecting to  hear of her death."
She was kept under the influence  of opium,  and recovered.
   During  collapse, and  indeed for long  after,  perfect rest is all-
important.    Give   occasional  stimulants,  as  brandy,  ether,  and
ammonia.  When reaction  takes place,  or even before, give opium
freely by mouth, rectum, or by  subcutaneous  injection.  If peritonitis
arise,  leeches to the abdomen may be useful. 
LECTURE  XXII.
INVERSION  OF  THE  UTERUS—DEFINITION—ACUTE  AND   CHBONIC—
     SPONTANEOUS  OR  PRODUCED BY EXTERNAL  FORCE--CONDITIONS
     OF ITS OCCURRENCE :  JOHN HUNTER'S THEORY—CROSSE'S THREE
     DEGREES--SYMPTOMS  AND  DIAGNOSIS--TERMINATIONS :   SHOCK
     —HAEMORRHAGE—DEATH—GANGRENE—TRANSITION--TO CHRONIC
     FORM—SPONTANEOUS  REDUCTION—TREATMENT:  MODES  OF RE-
     DUCTION.

Inversion of the uterus is  an accidental complication of labour which
may  most  usefully be studied in connection with  rupture.  In the
suddenness of its  occurrence;  in its instant danger;  in  the  call for
prompt recognition and remedy ; and in its medico-legal consequences,
it has many points  of analogy.
  Definition.—Inversion may be  simply  defined as  a  turning inside-
out of the  womb.   The fundus falls through the cervix, coming out at
the os, so as to form a new cavity, the lining of which  is the external
or peritoneal coat of  the uterus.
  Inversion may   be  complete  or partial.  Crosse describes  three
degrees (see Fig. 110) :—1, depression ;  2, introversion ;  3,  perver-
sion,  or complete  inversion.
  Inversion is acute or chronic.   In my  article on this accident  in
Samuel Lane's  edition of  Samuel  Cooper's Surgical  Dictionary,  I
defined acute  inversion as  ending with  the completion of the invo-
lution of the  uterus.  When this process  is complete,  the  case  is
chronic.  The distinction is based upon  the important physiological
fact  that whilst involution  is going  on, the muscular  fibres are stiU
possessed of some  active property, the organ is larger, and the cervix
less rigid.  During this stage the  parts are more yielding, and reduc-
tion  is comparatively easy.   The  history of  the  chronic form  is
traced with care in  my work on the  Clinical History of the Diseases
of Women.   Our  present concern is limited to the recent or  acute
form  of the accident.
  Inversion, again, may be spontaneous or produced by external violence. 
INVERSION OF  UTERUS.
313
   Frequency of the  accident.   It  is  so rare  that many men  of large
experience  have  never  seen  it.   In  former years the accident was
not uncommon; and  this may still be  said  to be  the  case in  those
                 1.                   2.                   3.
             DEPRESSION.          INTROVERSION.       COMPLETE INVERSIOX.
                                 After Crosse.
a, Inverted outer surface of uterus; b b, cavity of uterus, disappearing in 1 and 2, gone in 3;
                                  c, vagina.

countries where  obstetric practice  is largely  in the  hands of women.
Like other of the great catastrophes of midwifery, it has become rare

                                  Fig.  111.
        DR. CHAMBERS' CASE OP INVERSION OF UTERUS : ONE-THIRD OF NATI7RAL SIZE.
  The Fallopian tubes and round ligaments are  seen hanging out of the infundibulum formed
by the inversion.  The rough surface at the  lower part is the placental site.  A secundipara
set. twenty-seven. Half an hour after child's  birth haemorrhage set in, the placenta being not
yet expelled.  The midwife exerted traction upon the  cord; the patient had severe abdominal
contraction;  uttered a violent shriek of pain; and a round ovoid body protruded from the vulva.
The patient was seen moribund.  There was no  opportunity for replacement.

in proportion as the art has  improved.   Thus it is aU but unexampled

in the records  of the Dublin Lying-in Hospital.*   In  the  practice

  * Dr. Speedy  relates a case which occurred  outside  the hospital during Dr.
Denham's   mastership.    The  woman  died,  although  the uterus  was  quickly
returned. 
314                 OBSTETRIC OPERATIONS.
of the  London Royal Maternity Charity, from 1857 to 1874 inclusive,
during which time 61,906 women were delivered, only one  case  of
inversion occurred ; whilst Ruysch tells us that it was not uncommon
in Holland in his day,  when  midwives  were  generally  employed.
But although as a general conclusion it may be true that the frequent
occurrence of  inversion  is indicative of  bad  practice, it  would be
wrong  to  apply this  conclusion  absolutely to every  particular case.
Now and  then instances  occur,  and will occur  under  skilful  hands,
and  when  approved  principles  of conduct  have  been  sedulously
observed.   These general facts lead  us to  study  the  modes in which
inversion,  spontaneous or induced by external force, is brought about.
  The  following  circumstances  have  been noticed  in the  histories
of cases of inversion  associated with labour:—1.  It has  occurred
almost always, if not invariably, immediately after  the completion
of the second stage  of  labour, that  is, after  the expulsion  of the
child, and during the delivery of the placenta.   2.  In a  large pro-
portion of  cases, the accident followed puUing  upon the  cord,  or
other forcible attempts to deliver the placenta.   3.  In other  cases,
the cord is noted as  having  been unusually  short, or  twisted  round
the child's  body so that undue traction  would  be  exerted  on the
placenta during the expulsion of the child.   These  cases, although
resembling  in mechanism those  in  which  inversion  is  caused by
dragging  on the  cord,  differ  in  being spontaneous  and presumably
unavoidable.  4.  In some cases there was adhesion  of the placenta,
and  efforts to detach it have  been  followed by inversion.   5.  In
some cases where there  is no mention of the placenta having been
meddled with, the delivery was very rapid.   6.  In  some  cases  the
labour  was natural but  slow,  characterized by inertia or want  of
power.  7.  It has occurred in primiparas  as well as  in women who
have borne many children.   8. It has  been caused  by compression
of the  uterus by the hand  to  cast  the  placenta.   Delivery in the
upright position  has  in  several  cases  been  an  attendant  condition.
It has happened  after delivery by forceps and ergot.
  Dr. Woodson relates a case  in which inversion followed abortion at
four months (Amer. Journ. of Med. Sc, 1860).  Dr. John A. Brady
(New York Med.  Times,  1856) relates a case following abortion at five
months.  Both these recovered after reposition.
  It has  occurred in non-pregnant  women, always,  so far as I can
ascertain, from the dragging or expulsion of a  polypus  or  tumour,
except in  one case related by E. Clemenson (Hospital Tidende, 1865),
who attributed the inversion to an altered texture of the organ  result-
ing from  fatty regression after  labour.  But it is quite possible that
this case was not exceptional.   The history is defective; and the inver-
sion may  have taken place at the usual time  of labour, and have been
overlooked. 
INVERSION :  CAUSES OF.
315
   The fact of inversion has not seldom escaped detection at the time of
labour.  Hence some have  supposed that  the  uterus might undergo
spontaneous inversion hours, or days even, after labour.   Ane, Baude-
locque, and Dubois cite cases.  The evidence upon which this rests is
mainly the negative fact that no inversion was observed  at the time of
labour ; and then upon the positive fact  that an  inverted uterus was
found at some subsequent date.   This kind  of evidence is rarely satis-
factory.  The doubt will naturally  arise that the inversion had been
produced at the time of labour, and been  overlooked.
   The essential conditions for the production of inversion are, on  the
one  hand,  relaxation  of some part  or  the  whole of the walls of  the
uterus ;  and on  the  other, considerable enlargement  of  its cavity.
When the uterus has contracted, its walls are so thick, and the cavity
is so reduced—the  anterior wall  being  flattened close in contact with
the  posterior wall—that  inversion  cannot  take place.  The extreme
flaccidity of the uterus has been distinctly described by many observers.
Thus  Smellie relates a case told  him by Lucas of a  woman whose
uterus, after inversion, was immediately reinverted.  It was  "like a
piece of tripe."  The uterus has even been inverted after post-mortem
delivery, under circumstances which  preclude the  idea  that active
contraction of the  organ  was an efficient factor.   In Guy's Hospital
Reports (1864), Dr. A. S. Taylor relates  a  case, the details of which
were supplied by Mr. Bedford, of Sydney.  A woman set. thirty-seven
died  in  labour undelivered with  her  seventh child.   She  had had
violent pains, but  it was  clearly ascertained that the  head, although
low  down,  had not been extracted.   Inspection of the exhumed body
was  made  a week  after death.  The abdomen was much  distended
from decomposition.   A male child was found between the woman's
thighs.  The uterus was inverted, and, with the placenta attached to
it, was lying also between the thighs.   There was also a  rupture of
the uterus  a little  above the cervix, transverse, and about six inches
long.  The conclusion arrived at, which  the  history seems to justify,
was  that the rupture occurred during life, and was the cause of death ;
and  that the expulsion of the child  and inversion of the uterus were
caused by  the  pressure of gases in the abdomen.   The  uterus  was
found  flaccid.
   Haemorrhage, again, is known to be a disposing cause.   Whoever
has had his hand in the cavity of a uterus, powerless through loss of
blood, who has felt  its flaccid wall yielding to every pressure, internal
or external, like "tripe"  or wet brown  paper, will understand how
easy it would  be for such a uterus to be  inverted.  Indeed, I have
often felt partial inversion taking place  whilst endeavouring to detach
adherent placenta by  the  fingers.    Lazzati  precisely  says  that the
uterus was  inert  at the time  of inversion.  Whilst in this state it
is not difficult to understand that dragging upon  the placenta by the 
316
OBSTETRIC OPERATIONS.
cord may easily pull down the fundus  and turn  the  uterus  inside
out;  or  that pressure exerted upon the fundus from without, as by
the hand forcing it  down  with  the design of provoking  contraction,
or by the expulsive action of the abdominal muscles, voluntary, reflex,
or  in  the  act  of vomiting,  may drive  the fundus down, and even
through  the  os  uteri;  and,  as  we  have seen,  delivery of the child
and inversion of the  uterus may be effected after the woman's death
by  the pressure  of the  gases accumulating in the abdomen.  I have
had a case in St. George's Hospital, in which  inversion was caused
by  squeezing the uterus to expel  the placenta.
  We may, then, have spontaneous and artificial inversion in an entirely
passive state of the uterus.
  It is, however, certain that the  uterus may be inverted by a spon-
taneous active self-inversion, the uterus being, of course, active.   The
first distinct enunciation of this process is given  by John Hunter.  In
the Museum of the College  of  Surgeons (No. 2654, see Pathological
Catalogue) is a specimen of an inverted  uterus with a fibroid polypus
detached, which had caused the  inversion.   The  accident  occurred
independently of pregnancy.  The  polypus had grown from the fundus.
A ligature had  been  applied near  the attachment.  The tumour had
sloughed off  just before the  patient died.   Hunter described the case
under the  title  of " Intussusception," to which he likens inversion.
" The uterus," he says, " is liable to inversion from two causes : one is
immediately after labour, when it is so large as to admit of its containing
itself, and which is commonly from an imprudent mode of disengaging
and bringing away the placenta when that substance has been attached
to the fundus of the  uterus.  .   .   .  The second is somewhat similar,
namely, the expulsion of an adventitious body, although of another kind,
and at a very different period in  the state of this viscus.   It begins to
take place when this viscus  is smaU,  but becoming gradually large
enough (by the very disease that produces it) to  admit of an inversion;
so that in the first cause, the uterus is first large, so as to admit of an
inversion, and by its contraction to its natural state it, as  it were, fixes
it.   This is done immediately, because its  cause is  immediate, for this
enlarged state  of the parts  is of  short duration ;  but the  second  is
gradual, because it is to produce itself by the  very action  of the uterus
in expelling an unnatural body (such as a polypus).   The  polypus as it
grows will gradually fill the cavity of the uterus,  and the uterus wiU be
constantly endeavouring to remove it.   The action of the uterus  wiU
be  downwards,  and as the body of the uterus acts on this substance it
will be gradually squeezed  down towards the os  tincae, and the fundus
will, of course, be gradually  drawn into its own cavity, and as the polypus
is squeezed down so will the  fmidus follow.  When  the whole of the
polypus has got  into the vagina,  if it has no length of neck, then  wiU
the fmidus uteri be as low down as the os tinea?, the upper half of the 
INVERSION: CAUSES OF.
317
uterus just filling the lower half; but I conceive it does not stop here.
I conceive the contained or inverted becomes an adventitious or extra-
neous body to the containing, and it continues its action to get rid of
the inverted part, similar to an introsusception of an intestine."  It is
remarkable that in the  subject of this case an introsusception of the
small intestine coexisted.
  A similar theory was set forth by Crosse.  He says, the most powerful
predisposing condition to the  commencement of inversion (depressio),
and without  which  the greater  degrees  cannot transpire, is partial
inertia.   He also points  out that  one of the most constant conditions is
attachment of the placenta to the fundus uteri.  Then, again, the action
of the uterus in increasing an inversion, when once this has commenced,
has been admitted and indicated  by  many authorities,  but by none
more pointedly than by Denman, who observes that " if a disposition to
an  inversion be first  given by  the force in pulling the funis, it  may be
completed by the action of the uterus." Crosse then states the  modern
doctrine in distinct terms : " I cannot conceive that the organ itself has
any power to commence the displacement, and to cause simple depressio.
.   .  .   .  But when a commencement  has been made, and the case
goes on to introversio,  bringing  the  fundus within the  grasp and
influence of the uninverted body  of the uterus, this organ will, by the
natural powers called into action by its sensibility, regard the inverted
part as  an extraneous mass, and  proceed to  act upon it instinctively by
successive and suitable  efforts of its muscular coat, to propel it down-
ward ;  whilst the  os and  cervix will, by consent, and as transpires in
the regular process of delivery,  become dilated, and thus a part of the
uterus will act on the  rest, and carry on  the  displacement  even to
perversio extrema.....The nisus depressorius of the abdomen
awakened  will  assist the expulsion."
  Tyler Smith  has  seized the  same  idea,  and expounded  it with
unmatched felicity und  terseness of language.
  An important factor  in the  process  has been  insisted upon by
Rokitansky.   Inversion begins  at the placental  site.    This  part is
liable,  says the great pathologist, to paralysis, and being thicker than
the other parts  of the uterine walls, forms a projection into the cavity.
That  is the first  step;  the first postulate   of Hunter.  Then if the
placenta adhere, and be dragged upon by the cord from below, or if the
diaphragm and abdominal walls  act, as in  a bearing-down effort, the
part already disposed to fall inwards  is forced further down into the
cavity.   The external cup-like depression formed  by paralysis of the
placental site may be  felt by examination through the abdominal walls ;
and especially is this the case  if you drag upon the cord, the placenta
adhering.  When things have gone thus far, further pressure or dragging
brings the fundus down upon the cervix.  If this part be contracted it
may prevent the fundus  from  coming  through; or,  the pressure con- 
318
OBSTETRIC OPERATIONS.
 tinuing, the os may yield, and allow it to slip through (as it does in the
 converse case of artificial reposition) ; or the advancing fundus may find
 the cervix relaxed and offering no opposition.  Indeed the cervix is very
 liable to temporary  paralysis after labour, and more especially is this
 the  case when,  as  is not uncommon,  it  is lacerated.   Accordingly,
 it has been observed that some cases have occurred graduaUy; others
 suddenly.
  It may be supposed that the uterine ligaments would offer sufficient
 resistance to obviate  spontaneous  inversion ; and  the  inference from
 this assumption  would  be  that inversion must be the consequence
 of  direct violence.   But in reality the anatomical  conditions  are
 easily  overcome.   During gestation the ligaments become elongated,
 so as to be easily drawn into the hollow or cup  formed by the invert-
 ing  body of the  uterus.  The moorings of the fundus are too slack
 to  keep  this  part  up;  but  the  connections  of the  cervix  to  its
 ligaments,  and to  the  bladder and vagina, hinder the inversion  of
 this part for a time.   Casper (Forensic Med.,  N. Syd. Soc Transl.,
 vol. hi.) says laceration  of  the pelvic ligaments may attend spon-
 taneous inversion of  the uterus.   Hence one explanation of the
 greater  frequency of  the two  first  stages  of  inversion than of the
 third.
  The symptoms and diagnosis of recent inversion.  The symptoms
 are  chiefly those of  shock,  indicating sudden  severe  injury.   They
 vary with the degree  and progress of  the inversion.   Thus  the  first
 degree,  or  simple depression, may be  unattended by pain, and be
 indicated solely by haemorrhage  and  a corresponding depression  of
 the  vital powers.  The  haemorrhage comes from the  relaxed intro-
 cedent part.   As  the descent proceeds,  and  becomes  introversion,
 urgent symptoms arise,  according  to the  degree of compression
 exercised by  the  uninverted portion  upon  the  inverted portion.   A
 sense of fulness, weight, as of something to be expelled,  is  felt.
 The woman  has  thought  another  child  was  passing.  Expulsive
 efforts, both uterine  and  abdominal, sometimes very violent, follow.
 Haemorrhage  is  not  constant.  It seems  that when  the inverted
 portion  is  firmly compressed the  haemorrhage  is arrested, and  that
 bleeding is a mark of inertia.  When the inversion is complete, pain
 and collapse are aggravated.   Clammy sweats, cold extremities, vomit-
ing,  alarming distress, restlessness, extinction of pulse,  occur.
  During the  expulsion  the woman has often exclaimed  that  " her
body has come  out," or that the attendant  " is tearing away her
inside; " and  this even  although  no one  may have  been  touching
her.   Perhaps convulsions  set in;  but  generally  consciousness  is
retained.  The second sign  is probably hamorrhage.   This is  often
profuse and continuous.
  In the recent  state, retention of urine, owing to the. distortion and 
INVERSION OF  UTERUS.
319
compression of the neck of the bladder and urethra, is not uncommon.
This  has been  relieved when the uterus was restored.   But con-
gestion- of the mucous membrane of the bladder, and even retrograde
kidney trouble may ensue, as in retroversion.
  Examination made, the appearance of an unusual mass is observed
outside the vulva.   This may be as big as a chUd's head or bigger.
In Middlesex  Hospital Museum is a specimen  as large as  the adult
head  hanging down from the vulva; there was also rupture: both
said  to be produced by the midwife  pulling  on the cord.  In  cases
of this kind the depending mass is fleshy, more or less firm, rounded
or pyriform,  dark red,  bleeding, probably partly obscured by blood-
clots.  The  cord, if  the placenta had  not previously come away, and
if the cord  had not been  torn  off, will be hanging from the mass,
and  being traced up to its root in the placenta, may give the impres-
sion  that it  is placenta and nothing  more.   Under  the influence  of
this impression, the natural impulse is to seize the mass and try  to
remove it, and to this  the attendant  will be the more impelled by
the  profuse flooding,  which  seems   to  admit  of  no  delay.  But
deliberate examination will show that the  hand cannot be  passed
up beyond the presenting mass or presumed placenta into a cavity
like  the vagina and uterus, but  is arrested all round the root of the
mass by a groove low down in the pelvis, or even outside the vulva ;
feeling above  the pubes for the uterus, it is not found where it ought
to be, but the hand sinks in, carrying the flaccid abdominal walls
before it  quite back to the spine, and even  into the  pelvic cavity.   The
uterus, then,  is not  where it ought  to be,  and there is a body  of
corresponding bulk and shape in a place where no such body is usually
found.  The  inference is  strong, if not conclusive, that this body in a
strange place  is the uterus inverted.
  If the  placenta still remains attached,  the mass will be correspond-
ingly larger.   It ought  to be  known  whether the placenta  has come
away or not.  If it  has not come away, it will naturally be sought for.
The  cord will  afford  a ready clue,  if it has not been torn off.  In all
cases of difficulty the doubtful body should be inspected by the eye, if
possible,  as well as by the touch.  The ramifications of the umbilical
vessels over the surface of the mass, and the torn  membranes, wUl
reveal the placenta.   A  placenta in  this  position  is  presumably
detached, and removable without further force.  If it be found that it
cannot be so removed, the reason  of the resistance must be carefully
sought.  The  membranes  should be drawn forward so as to bare the
edge of the placenta; it will then be felt, and seen to be attached to a
spherical body, which is almost certainly the  uterus  inverted.   I say
almost certainly, because cases are known where the  placenta has
grown to the  child's head, or to a polypoid tumour projecting from
the uterine  cavity.   The second  case is one of real difficulty,—the 
320
OBSTETRIC OPERATIONS.
more so  since the polypus may have caused inversion of the uterus.
There will then be three masses in very unusual connection : placenta,
tumour,  inverted uterus.   Whilst we are making all  this  out,  the
patient  may be dying of  shock and haemorrhage.  Still, howsoever
urgent the need of help, there is more danger in precipitate unreasoned
efforts than in the procrastination necessary  to take an accurate survey
of the situation, and to deliberate on the proper course of action.   If
you  take time you  will probably do what is right.
  The recently-inverted uterus has a remarkable  property  which dis-
tinguishes it from every other tumour.  Contractility is a vital attribute
that no polypus possesses.  If the tumour, then, hardens  and relaxes
alternately, we know it is the uterus.
  The recently-inverted uterus is also  usually very much  larger than
a polypus.  And the polypus traced up to its root or origin will lead to
a cavity—the cavity of the uterus, which cannot be felt in the wholly
inverted  uterus.   The case of incomplete  inversion, that is, in  the
stages  of depression or  introsusception,  may be very  difficult  to
diagnose  from polypus.  There is a tumour above or engaging in the
cervix uteri.   The finger  or sound will pass into the uterine cavity
around the base  or  neck  of the presenting  tumour, very much  as in
the case of a polypus springing from the fundus.   The diagnosis will
depend upon our being able to  feel the  inverted  cup of the fundus
through the abdominal wall, whilst a finger of the other hand is in the
uterus.   If the  womb be  inverted, we find on passing  a finger  or
a bougie upwards to the  root of  the tumour, that  it is arrested  by
a groove  or cul-de-sac all  round, about an inch or  half an inch within
the os uteri.  The depth of this groove will  depend upon the degree of
inversion.  The greater this is, the shallower will be the cul-de-sac.
It is even possible there may be no such cul-de-sac, the os uteri being
entirely obliterated;  in this case the outline  or  surface of the  tumour
will  be quite  continuous with  the vagina  all round.  The distinctive
character between inversion and polypus is that in the first the tumour
is all below the groove or cul-de-sac ; whereas, in  the second,  there is
still  a mass,  the uterus  itself,  above and  beyond  the tumour,  the
polypus.   These facts are  determined by bi-manual palpation, and  by
the sound.  In the case of inversion, a finger applied to the root  of the
tumour may feel the point of a sound passed into the bladder.   The
two  meet above the inverted uterus.
  Should the placenta have come away  the  case, although so far
simplified, is  by no means free from danger of mistake.   There is a
large, rounded,  fleshy,  roughish  mass,  bleeding, hanging  perhaps
between  the  thighs.  It  may be  mistaken  for a placenta, for  some
part of a child, normal or abnormal, for a  polypus or other  tumour,
or even for a mass of coagulated blood.   If you  have been following
the uterus down during the extrusion of the placenta, or afterwards to 
                     INVERSION  OF  UTERUS.                 321

ensure contraction, and suddenly feel the uterus retreat into the pelvis,
a firm mass appearing simultaneously in the vagina or externally, you
have, with the symptoms of shock, strong presumptive evidence  that
the uterus has become inverted.  You may make this sure by pressing
the tumour back a little up the vagina with one hand, whilst you press
in  the  flaccid abdominal  wall with  your other hand  behind the
symphysis;  you may thus feel  the  cup-shaped depression  or funnel
formed by  the introcedent fundus uteri.
  If there be  any possibility of  getting the  aid and counsel  of a
professional brother, for  your own sake, as well  as  for that  of your
patient, get  it.  But whilst waiting, your patient may be dying—time
is life ; you must be prepared to act decisively on your  own judgment.
And here it may be well to say a few words upon the  use of consult-
ations in difficult cases.   I will  state as a leading proposition, that in
most difficult cases, two, if not  more, skilled practitioners are wanted
to execute, to  carry out the treatment.   The cases are many in which
one man, no matter what his skill, can hardly do all that is necessary;
and the  cases  are more numerous still in which what has to be done
will be done much better with efficient help.   Nor  does the benefit
stop here.   For two men to act in concert there must necessarily be
interchange of thought;  both must verify the circumstances ; and this
implies deliberation, the only security for judicious action.   These two
conditions,  conjoint deliberation and skilled manual help, contribute
largely to the apparent superior  efficiency of the consulting physician.
This I have often felt.  And often have I felt  that an undue share of
the credit of a successful operation has been awarded to me,  which I
could hardly have performed alone.
  These considerations  apply most emphatically to emergencies  com-
parable to that under  discussion.  Where the best energies of two men,
one of them bringing a fresh mind and a steady hand, may be tasked
to the uttermost, it is not a matter for  surprise that any one man  may
prove unequal to the occasion.
  Terminations.—1. The patient  almost  immediately, or  very soon
after the accident, dies from pure shock.  The  shock attending simple
depression has proved fatal.  2.  More frequently death occurs rapidly
from  shock and haemorrhage combined, that is, within twelve hours.
3. The inverted uterus may be  strangled by its own  cervix, or by the
vulva.  This induces, first, continuous or  secondary  shock ;  and in
some cases, if  the patient survive long enough, and it  need not be long,
gangrene ensues.  This  may, or may  not, be fatal.   The uterus has
sloughed  off:   Saxtorph  (in  Actis.  Soc  Med., Hav.);  Deboirier
(Richtefs  Chir. Bibl.);  Radford  (Dublin Journ.  of Med., 1835).
E. Clemenson relates (see my work on Diseases of Women, p. 719) a
case of gangrene following spontaneous inversion in a woman aet. fifty,
independently  of pregnancy or  polypus.  In other cases the strangu-
                                                           Y 
322
OBSTETRIC OPERATIONS.
 lation caused  by the cervix has ended fatally before there was time for
 sloughing (Velpeau).
   Death has  ensued from strangulation of intestine  in  the  uterus.
 Gerard de Beauvais relates a case (Arch. Acad, de Med., 1843).
   In some cases, and these not uncommon, the shock and haemorrhage
 are not very severe, or at  any rate the woman survives the immediate
 effects, rallies, and  is thought  to be all right.   Tolerance,  more or
 less complete, may ensue.  But  generally metrorrhagia continues,
 interrupted perhaps at intervals, but  always  liable to recur at the
 menstrual  epochs.   The  losses thus induced  may prove  fatal at no
 distant date.
   Where the case  is  not fatal,  and the uterus is not reduced, the
 symptoms of chronic inversion succeed.  First, the tumour by its bulk
 causes distress of the bladder and rectum.  Then it is probably forced
 externally.  I must refer  to my work on Diseases  of Women  for the
 further history of this condition.
   Meigs and others affirm that spontaneous reduction has occurred.
 But Crosse says,  " There is not a shadow of evidence of total inversion
 in the strict sense replacing itself spontaneously."   It is not difficult to
 imagine that partial inversion, that is, where the fundus has not come
 through the os, may be restored spontaneously.
   To make good  the fact  of  spontaneous reposition it is  necessary to
 start with  clear evidence  that inversion actually existed, and then to
 verify the return of the uterus to its normal condition.   In  some of the
 cases as they stand recorded, there is the possibility of fallacy attaching
 to one or the other of these postulates.
   A fibroid tumour may  have  simulated the uterus  and have either
 retreated into the uterine cavity, or have  been cast  off.   But  the
 possibility  of  spontaneous reposition seems to be  established  by the
 following case of Spiegelberg (Arch, filr Gynak.,  vol. v., part 1).   In
 a woman aet. forty, in her  twelfth  labour, inversion followed attempts
 of the midwife to hasten delivery by pulling on the body and umbilical
 cord of the child.  Attempts at replacement failed.   At the end of six
 weeks a rather copious haemorrhage occurred; the uterus was found to
 be still inverted  and  cou  d not  be replaced.   Two and a half weeks
 afterwards  the patient came  into hospital.  The inverted portion was
 closely  embraced by the os uteri;  the part which was not inverted
 measured scarcely § inch.   As the woman had  a  severe attack of
 diarrhoea soon after admission,  a fortnight elapsed  before a  second
 examination was  made with a view to reduction.  Now, however, the
uterus was  found  to be completely reduced.  According to the  explan-
 ation offered by  Schatz,  with which Spiegelberg agrees,  the  uterus
was  raised by the continued lying in bed, the round and  broad  liga-
ments accommodating themselves to the new position : and during the
diarrhoeal evacuations the vagina, with the vaginal-portion of the  uterus, 
INVERSION OF UTERUS.
323
 was pressed  down, whilst the ligaments being unable to follow this
 movement raised  the  fundus.
   Dr. Denham relates (Dublin Quart. Journ. of Med. Sc, 1866) a case
 of  partial spontaneous  reduction.   A  primipara,  aet.  twenty-three,
 suffered inversion  from pulling on the cord and pressure on the fundus
 of the  uterus.  She was admitted to hospital  eleven days afterwards.
 Under steady pressure the uterus gradually diminished, and was felt to
 yield, so that the fundus alone remained unreduced; "no amount of
 force compatible with the safety of the organ could  enable us to com-
 plete the operation."    " On the  third morning we were agreeably
 surprised to  find that  the fundus had spontaneously returned."   The
 woman made a good  recovery.
   Treatment.—When  we find  inversion,  the  indication is  clear to
 reduce it, and that as soon as possible.  The presence  of the  uterus
 grasped in its own neck excites contraction, the  part gets strangled,
 swollen, and it becomes more and more difficult to return it.   In most
 cases, probably, the mass might be pressed back with comparative ease,
 if the  attempt were  made immediately after  the occurrence of the
 accident,  whilst the cervix was still paralysed, and the uterus itself
 flaccid.   But this  opportunity is rarely found.  The  first question that
 arises is  as  to detaching the  placenta  first or not.  To detach the
 placenta is  to lose a  little time, to risk flooding and  irritating the
 uterus  to contract: if we leave  it, there is the greater bulk to pass
 back through the os uteri.   If  you have  the good  fortune to recognize
 the accident  at the moment, you may be  able to take advantage of the
 flaccidity  of  the cervix, and return uterus and placenta at once ;  but if
 this favourable moment is lost, it will be better to detach the  placenta
 first.  Look  for the  margin  of the  placenta ;  insinuate one or two
 fingers  between it  and  the globe of the uterus;  supporting this organ
 by the other  hand, continue to  peel off  the placenta by sweeping the
 fingers  along.  When it is wholly  detached,  proceed to reduction.
 The mode of manipulation  must vary according to circumstances.  If
 the uterus is large, flabby,  and the cervix dilated, it may be quickly
 replaced by  depressing the fundus with the fingers gathered into a
 cone, and carrying the hand onwards  through the os. Lazzati says it
 is better to apply  the closed fist to the  fundus ; this acts better, and
 we avoid the risk—by no means  a slight one—of  perforating  the soft
 structure  of  the uterus.   In executing this, two  things must on no
 account be omitted: one  is  to support the uterus by the other hand,
 pressing firmly down upon it from above  the symphysis pubis, lest we
 lacerate the vagina.  This is a real danger, and to  avoid it  is  better
 than  to turn to account the aid midoubtedly acquired  by  the full
stretching of  the vagina,  which tends to  pull down the  os  and cervix
over the inverted  body.
  It is remarkable how extensile the vagina is after labour.  It  some-
                                                          y  2 
324
OBSTETRIC OPERATIONS.
times elongates under pushing so readily that we may easily fail to
realize whether it is stretching or rending.  The other thing to observe
is  the course of  the  pelvic axes, and  the  form  of the pelvic brim.
Pressure will first be made a little backwards towards the  hollow of
the sacrum ;  then the direction must be towards the brim, and at the
same time to one  side, so  as to avoid the sacral promontory.   As in
attempts to reduce a retroverted gravid uterus, failure has often ensued
from  not understanding this  latter point.    It was first,  I believe,
insisted upon by Dr. Skinner, of Liverpool.   I can testify to  the value
of the rule from personal experience.  By attention to it mainly, I was
enabled to reduce an uterus in fifteen minutes, which had been inverted
for ten days, defying repeated efforts by  other practitioners.
   When reduction has been completed, the hand following the receding
fundus  will occupy the cavity of the uterus, and the organ will be
grasped  between  the hand inside and  the  hand  supporting outside.
The opportunity  should be taken to induce  contraction by pressure
externally and by excitation internally.  But I would not  withdraw
the hand from the cavity, lest re-inversion take place, until I had taken
the following further security.   Pass up along the  palm of the hand an
uterine  tube connected with a Higginson's injecting syringe ;  throw up
by means of this  six or eight ounces of a mixture composed of equal
parts of the strong solution of perchloride  of iron and water, so as to
bathe the whole inner surface  of the uterus ;  or  you may  apply  the
styptic  by  means of  a swab.   The  effects of  this are,  instantly to
                   constringe  the  mouths of the  vessels, to  stop
                   bleeding,  to excite uterine  contraction, and to
                   corrugate  the  tissues  and narrow the os uteri.
                   When this state is  induced there is safety.  This
                   is all  the more important, because at the moment
                  ' of reduction there  is likely to be considerable col-
                   lapse and  uterine inertia.
                      If  uterine action be  present, especially if the
                   cervix and os  are  constringing the inverted part,
                   contracting spasmodically, the difficulty is  greater,
                   and it is no longer  judicious to commence by push-
                   ing in  the fundus.   As  Dr.  McClintock has well
                    shown (Diseases of Women, 1863), to do this is to
                   double the inflexion of  the uterine walls, and thus
                   to double the thickness of the mass that has to pass
                   through the os.  He advocates the method practised
                   by Montgomery, which consists in regarding the
                   inversion as a hernia,  and in replacing that part
first which came down last.  The  tumour  must be grasped in  its cir-
cumference near  the constricting os;  firmly compressing it towards the
centre, and at the same time pushing it upwards, forwards,  and to one
Fir;. 112.
   After McClintock.

 a v, cervix uteri; c, in-
verted fundus, the dotted
line  showing  effect of
doubling in the fundus to
reduce it. 
                     INVERSION OF UTERUS.                 325

side.   The  pressure  must be  steadily kept up,  as it  is  sustained
pressure that wears out the resistance of the os.  After a time the os
is felt to relax, the part nearest is pushed through, and then, generally
suddenly,  the body and fundus spring into position (Dr. J. G. Wilson,
Glasgow Med. Journ.).  Two things facilitate this operation: anaesthesia
and  a  semi-prone position of the patient.   McClintock compares the
process to that  of  treating  a  paraphimosis.   Two movements are
required:  1,  to squeeze the uterus;  2, to press the  uterus slowly up.
  If the opportunity of reducing within a few hours be lost, the difficulty
increases through advancing contraction  and involution of the uterus,
and  especially contraction of the os.   But you are not to be discouraged
by the teaching, only till recently held, that after a few hours, inversion
of the uterus is all but irreducible.  Beduction is simply a question of
time :  keep up  pressure  long enough, and the constricting os  must
yield.  Re-inversion, however, does not always ensure recovery.   Many
patients have died soon after re-inversion.  In some instances, perhaps,
further injury has been inflicted during  the  operation.   But it must
not  be  forgotten that laceration of the vagina or uterus may have been
spontaneously  produced at the same time  as the inversion.  And in
some fatal cases, it is certain  that  the reposition  has  been accom-
plished without  any  such injury.
  The after-treatment will consist in absolute rest; opiate suppositories,
one  or two  grains ;   or chloral enemata,  containing  one drachm of
chloral; ice,  oxalate of cerium, hydrocyanic acid, bismuth, to restrain
vomiting  ; and  light  diet, with sparing use  of stimulants.   As soon as
the process of involution has begun, there is reasonable security against
return of the inversion.  In  subsequent labours increased disposition
to inversion  may be  anticipated.  There are several  cases in  which
inversion has happened in successive labours. 
LECTUBE  XXIII.
CRANIOTOMY--THE INDICATIONS  FOR THE OPERATION--THE OPERATION
    --TWO  ORDERS  OF  CASES--PERFORATION  SIMPLE;  AND FOL-
    LOWED  BY  BREAKING-UP  OR  CRUSHING  THE   CRANIUM,  AND
    EXTRACTION--EXPLORATION —- PERFORATION--EXTRACTION  BY
    CROTCHET,  BY  TURNING -- DELIVERY  BY  THE  CRANIOTOMY-
    FORCEPS J USE OF,  AS AN EXTRACTOR, AS A MEANS OF BREAKING-
    UP  THE  CRANIUM ;  USE IN  EXTREME  CASES OF CONTRACTION--
    DELIVERY  BY  THE CEPHALOTRIBE--POWERS  OF  THE CEPHALO-
    TRIBE ; COMPARISON WITH CRANIOTOMY-FORCEPS--THE OPERATION
    --DR. D.  DAVIS'S  OSTEOTOMIST--LAMINATION :  VAN  HUEVEL'S
    FORCEPS-SAW—DELIVERY BY THE  AUTHOR'S  NEW  METHOD OF
    EMBRYOTOMY  BY THE  WIRE-ECRASEUR--TARNIER'S  METHOD--
    INJURIES THAT MAY RESULT FROM  CRANIOTOMY.

We have lingered  long  on the border-land between Conservative 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 enable 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  preserve 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 behoves us  to exhaust every  effort in
perfecting the means of removing a dead child, in order to rescue the
mother  from the  Caesarian  section, that  operation  which Professor
Davis called  "the last  extremity of our art, and the forlorn  hope of
the patient."   But we  may strive to  modify this dictum. 
                          CRANIOTOMY.                      327


                 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 tumours, bony, malignant, 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 labour at term is obstructed from disproportion,
the pelvic contraction ranging from 3-25" as a maximum, to 1*50" as a
minimum.  If  labour  occur  at  seven months, these means  may
certainly be applied to contraction measuring less than 1-50".   F. H.
Bamsbotham  considered that a full-grown child might be extracted
through a pelvis measuring 3 in. in the lateral,  and 2 in. or even  If in.
in the conjugate diameter.   Ingleby, representing a school possessing
imperfect  instruments, and unexercised skill in these operations, dis-
sented, saying, " it was  no easy matter to fix the instruments so as
to ensure the naso-mental diameter passing first."
  We are not  hastily to  assume, because a woman has been  delivered
on  previous  occasions  by natural  powers or by forceps, that  it is
therefore  unnecessary to resort to craniotomy.  It  is,  indeed,  ample
reason  to pause  and  to examine  anxiously.  But  it is  a matter of
experience that some women bear children with a constantly increas-
ing 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 histories of many women whose first labours may have been
natural, and whose subsequent ones exliibited difficulties increasing in
a kind of accelerated ratio, rising  from  the forceps to turning and
craniotomy.  The second cause may be independent of, or aggravate,
the first.  Thus D'Outrepont says he has  constantly observed that in
fruitful women whose first  children were small,   subsequent  ones
become bigger and bigger.
  Professor Elliot makes the apposite observation,  that  " the same
degree  of  deformity  admits  of varying  results in  successive  preg-
nancies."   For example, the child may  at  the  time of labour have
attained a different degree of development;  it may present differently ;
there  may be  accurate  dip  of the  head  in one labour,  and not in
another.
  2.  Certain  cases  where obstruction to delivery is due to  the child
—as some cases of face-presentation ;  some cases  of locked  twins, 
328
OBSTETRIC OPERATIONS.
in which the lessening  one head  is necessary to release  the  other;
some cases of double monsters ;  excessive  size  of  head,  as from
hydrocephalus;  cases where there is obstructed labour,  the  head
presenting, and the child is dead.
  3. Conditions of danger  to  the  woman, rendering  it  expedient  to
deliver  her as  speedily as  possible,  and where craniotomy is  the
quickest way, involving the least violence.   Amongst 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 indicated, the  cervix uteri is  not sufficiently dilated
to admit of other operations.
  An important question is—at what stage of labour shall we begin ?
As  most of the dangers flow from exliaustion, 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
to distinguish  between directly  destroying a  child,  and deliberately
leaving  it  exposed  to  circumstances  which  must inevitably destroy
it;  and it is risking the very object of our art  to wait for this linger-
ing death of  the child until the  mother's  life is  also  imperilled.   If,
then, we  see the woman  drifting into the dangers of " lingering  or
obstructed labour," and we have  clearly  determined  by our  know-
ledge 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  labour.  We  should not wait  long after  the  rupture  of
the membranes.  It  would, in  many cases, be  useless to  wait  for
complete dilatation of the cervix uteri.   It is one of the necessary
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 then
yields gradually.
  Although it is a good general rule to  perform every operation  as
early as the indication for it is clearly recognized, it is not desirable,
in minor degrees pf  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 
CRANIOTOMY.
329
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  shall  be  broken down.   Until
this is done, you may  obtain,  with considerable expenditure of time
and force, some amount of  moulding or  alteration of form, but no
diminution of bulk.  It is astonishing what resistance to compression
the unopened head possesses.   The most powerful  forceps, and even
cephalotribes, 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.
Besides, more  room is  required if  we apply the  cephalotribe to the
whole head.   It is remarkable  that  not a  few Continental obstetrists
practise cephalotripsy without  perforating.
  Craniotomy,  being used  as a general term to include all the pro-
ceedings for reducing the bulk of the head, may be divided into three
principal  orders :—
  The first includes those  cases of  minor  disproportion in  which
perforation is enough to allow of such an amount  of collapse  of the
head under  the natural forces  as will effect delivery.
  The second  order includes those  cases of major disproportion in
which perforation must be  supplemented by brealdng up, removal of
parts  of the cranium,  or by crushing  down,  and followed or not by
extraction.
  The third includes those  cases of extreme disproportion  in  which
the head has to be removed  in  sections by lamination, as by my New
Method of Embryotomy.
  The preparatory steps 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 towards the middle  of the bed ;  or  if the
bed is  sufficiently  high, she may  be placed  on  her back,  the legs
being supported by  assistants.
  Exploration.—The left hand of the operator is introduced, if  neces-
sary,  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 promontory,  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 circumference  of   the  head,  taking note  of  the outline  of the
brim. 
330
OBSTETRIC OPERATIONS.
  Perforation.—The point to be selected for perforation is that which
presents  most  centrally.  It is easier  to strike;  it  offers  a better
resistance to the point of the  instrument; the  opening made allows
a free exit to the contents of the skull;  and it 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, pressing them firmly  down  towards the pelvis, so
as to  fix the head  upon the brim,  and  obviate  the  retreat or roUing

                             Fio. 113.
OLDHAM'S PERFORATOR.
of the  head under the impact of the instrument.   The other thing
is, to take care that the instrument shall strike  the  head perpen-
dicularly.   If  it strike  at  an angle,  the  point  will be  apt  to  fly off
at a tangent, or to make the head roll over, at  the risk of wounding
the mother.   I have seen so many wretched perforators, and knowing
that  they are  not  only liable to fail in doing what  they ought  to  do,
but to  do mischief, that I here introduce a figure of the best and
most  efficient  instrument  I have ever handled.  Those usually  sold
as Naegele's,  Holmes's,  Smellie's, etc.,  are  almost  all bad.   The 
CRANIOTOMY.
331
curved point is especially vicious.   They answer, perhaps, well enough
in slight cases where it may be  doubted whether craniotomy is neces-
sary.   They deceive and fail in cases of real difficulty.
  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 aUow 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 having 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 handles 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
of the cranium; allows  free discharge of brain, and ample entry for
the crotchet or craniotomy-forceps.
  Now  you may wait a little,  to  afford opportunity for spontaneous
compression and collapse ;  or you may at once pass in the crotchet.
This  should be  carried in as  deeply  as  possible,  and moved freely
round in all directions, to break up the tentoria and the brain.  This
proceeding greatly facilitates 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 pro-
pulsion 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 to artificial compression of the
skull.
  Extraction may be accomplished in  several  ways.
  1. By  the Crotchet.—This instrument  was  long  preferred by the
Dublin  school.   It was very naturally resorted to in preference to
bad craniotomy-forceps ; and some practitioners of  great experience,
who have acquired exceptional  skill in the management of it, accom-
plish  delivery by its aid in cases of great disproportion.  Until I had
contrived a good craniotomy-forceps,  I myself trusted to it  entirely.
But for safety and expeditiousness it is very inferior to the craniotomy-
forceps, or  the  cephalotribe.    The way of  using the crotchet  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 important,
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 
332
OBSTETRIC OPERATIONS.
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.  This may be  generally done with the
fingers.  By-and-by—for the process is apt to be tedious—when the
cranial vault is much broken up, if a good hold can be obtained in the
occipital bone  or in the foramen magnum, collapse or falling-in of the
skull takes place, and  extraction is successful.   In very difficult cases,
when the vault is well broken up,  it is  better to take hold in the
orbital region, 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 edgewise 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 decomposition had  to take place before the
bones  would collapse sufficiently,  and exhaustion, or even inflamma-
tion of the uterus,  and fatal prostration would sometimes ensue.  The
late Professor  Davis records  that, even 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 conse-
quences.  Indeed,  when it  is  considered that  craniotomy is not  often
performed except  at  an advanced  period  of  labour, 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.   This plan of waiting  upon
Providence was no doubt imposed by the wretched instruments in use.
This necessity is now gone.   Operations which  formerly lasted twelve
hours or more, requiring several sittings, exhausting alike the patient
and operator,  are now accomplished with safety and comparative ease
in an hour or less.
   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 during  extraction is drawn over
the aperture made by  perforation,  and  sheaths the jagged edges  of
the bones.   But this 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 excep-
tional 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 
CRANIOTOMY.                       333
portions of the bones of the cranial vault.   The first use is adapted to
minor degrees of disproportion.
  What part is  best to seize ?  If the head  is found to  collapse 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
presenting,  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 narrow passage formed

                              Fig. 114.
SHOWS THE BONES OF THE CALVARIUM REMOVED, AND THE BASE OF THE SKULL, GRASPED BY THE
    CRANIOTOMY-FORCEPS, DRAWN THROUGH THE CONTRACTED BRIM EDGEWISE, FACE FIRST.

by the soft parts supported by the pelvis.  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 remarkable advantage.
  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 
334
OBSTETRIC OPERATIONS.
only.   His contention was hotly  disputed  by Dr.  Hull.   Dr. Burns
came  to the same conclusion as  Dr.  Osborn, 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.   (See Fig. 114.)  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  Caesarian section, are rare  indeed.   This question has

                              Fib. 115.
 SHOWS THE REMAINS OF THE SKULL DRAWN  THROUGH  THE CHINK OF THE BRIM, FLATTENS
                             LIKE  A  CAKE.
     The calvarium being removed, the head resembles that of an anencephalous foetus.
                a, projecting promontory of the sacrum; c, coccyx.

been investigated  and illustrated anew by Dr. Braxton Hicks.*   He
describes very fully the mechanism of the proceeding.  Having removed
the calvarium, he grapples 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 forwards, as
occurs in ordinary face-labour.  A fresh  hold, in the mouth or under

                *  " Obstetrical Transactions," vol. vi., 1865. 
CEPHALOTRIPSY.
335
 the jaw, is then taken for traction.   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 occipital 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
 extreme, it may be enough to break away  two or three pieces, say an
 angle of each  parietal and of the occipital.   This destroys the arch of
 the  calvarium, so that the remains of the walls easily fall in upon the
 base, forming a flat  cake, when the head comes to be compressed in
 the chink of the brim.  When enough has been taken away to admit of
 this flattening 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  unyielding hold.   (See
 Fig. 115.)   The craniotomy-forceps, in  fact, here acts like, and fulfils
 the  chief function of, the cephalotribe, possessing the  advantage of
 taking up less room.   Then  traction is made, carefully backwards at
 first, in the course of the circle round the false promontory.  As the
 face descends it tends to turn chin forwards, and this 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 between
 the  shoulders.   The  head comes  through  flatwise like a disc  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.
  The late Professor Davis, relying upon his  method  of embryotomy,
 used these  words :—" There are few pelves  with superior  apertures
 so small as not to furnish frqni 1"  to 1^-" in the conjugate diameter,
 or at least of antero-posterior diameters across some part of the brim.
 In any such cases it would be the practitioner's duty to avail himself
 of the use of the osteotomist, and to undertake delivery by the natural
 passages.    It will have  the effect  of  reducing  almost to  zero  the
 necessity of having  recourse  to the  Caesarian section."
  4. Delivery by  Cephalotripsy.—What are the relative powers  of
 cephalotripsy and of craniotomy as  just  described?   I  doubt much
 whether  cephalotripsy can carry the possibility of safe delivery at aU
 beyond  the  point  attained  by craniotomy.   The craniotomy-forceps
 takes less room than the cephalotribe, and it effects the same object—
 by a different process it is true—i.e., of bringing the base of the skull
 through  the contracted brim edgewise  like a disc.    Cephalotripsy
nevertheless  possesses  considerable  independent  advantages under
many circumstances, and may lend much help to other proceedings. 
336
OBSTETRIC OPERATIONS.
   The Powers of the Cephalotribe.—The all-essential  point is that
it shall  be able to  compress and crush down the  remains of the
calvarium upon the base of the skull, so as to bring the flattened skull
into relation  with the  chink of  the  inlet.    A  secondary property
which it is desirable to possess is  that of holding during extraction.
The crushing power can be obtained 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 Continental  cephalotribes.
The best  known modifications made in this  country are Sir James
Simpson's,  Kidd's,  and Braxton  Hicks'.   Simpson  insists upon a
pelvic  curve in  the blades, as being  less likely to slip  than straight
blades.   Kidd insists strongly upon the advantages  of  long straight
blades, on the following three grounds :  First, straight blades  admit
better  of the head  being rotated whilst in the grasp; secondly, they
are easier to introduce ; and lastly, they hold more securely.  Braxton
Hicks has modified Sir James Simpson's cephalotribe,  producing a
very handy and efficient  instrument.  He preserves a moderate  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 neces-
sarily  the case where crushing  is required, the blades should be
curved;  but this  curve should be very slight, otherwise the incon-
venience in rotating or shifting the relation of the instrument to the
pelvis referred to by Dr. Kidd will be felt.   I think the blades of Dr.
Hicks' instrument are too short, and  a little  too much curved.
   The best  cephalotribe I  have used is that designed by Dr.  Fancourt
Barnes.  It is  figured.  It is longer  than Hicks',  and  can  seize the
head arrested  on the brim ; it has a  moderate curve, and  it is  also
provided with a moderate perineal curve, on the principle of  the axis-
traction forceps.   The advantage  of this  third curve  is very striking
in practice.   The  amount of traction-force   required  is materially
diminished,  and by so much is the  compression and  contusion of the
mother's structures averted.  It combines effectively the three powers
of crushing, holding, and extraction.
   When the instrument is applied to the perforated head,  it may be
made to partly crush the base, imparting great plasticity;  then the
base is tilted edgewise, and the skull is  flattened down by pressing the
squamous and parietal bones on to the base.
   This  is the true action of the  cephalotribe.  The  base  is canted,
not crushed.  But  Goyon, Tarnier, A. B. Simpson,  and others have
worked  upon the different principle of breaking up the base by special
instruments.  These are called basilysts or  basiotribes.  Simpson's
basilyst is figured.
   It is made to perforate the  cranial  vault, and then to traverse the
cranial  cavity, and perforate  the  base.    Tarnier's  basiotribe is a
combination of the perforator and the cephalotribe.  After perforating 
CEPHALOTRIPSY.
337
the base of the skull, the blades  seize and compress.   In perforating
the base there is some danger of traversing the part, and  of wounding
the mother; and an objection to Tarnier's instrument is its complexity
and the  space it  occupies in cases where the very conditions which
call for operation  imply want  of space.
   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 disproportion.   But what is
the least amount  of  space admitting  of its use ?  This  must depend
somewhat upon the form and size of the particular  model adopted.  In
a  discussion held at Berlin, the majority of the  speakers thought a
minimum  of  5*4  mm. = 2-0"  conjugate diameter,  was  necessary.
Lautlr'" says the application begins at 8 mm., or about 3-00", at which
point the forceps and turning are not  available, and ends at 5*0 mm.,
or a little under 2*0".   But Pajot goes beyond  this, and contends that
it ought  to  be applied  where there is only 1-25" conjugate diameter.
Crede thinks  it, should be used  if only there is room enough to apply
it.   I have used  it with  perfect success in a case of extreme rickety
deformity, at St. Luke's Workhouse, aided by Messrs. Harris, Rogers,
and Sison, 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 Caesarian section.
   Other conditions are—
   The os  uteri must be sufficiently  dilated; but  this can be readily
effected  by the caoutchouc  water-bags.
   The head must be previously perforated.   Abroad, sometimes the
ordinary forceps is put on to  hold the  head during  perforation; or the
blades of the cephalotribe are first adjusted, and  then  perforation is
effected.   But this  is sometimes not feasible for want of room, and is
never necessary.
   Position.—The patient may  lie on her left side;  or  on her back, the
breech brought well to the edge of the bed, and the legs flexed, held by
an assistant on either side.
   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 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,
       * "De la Cephalotripsie."  Par J. F. Ed. Lauth.  Strasbourg, 1863.
                                                             Z 
338
OBSTETRIC OPERATIONS.
when the handle is raised, and the point, turning 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 intro-
duced 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 backwards, 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.  (See Fig. 116.)  If spicula crop out  of  the scalp,  they should
                              Fir. 116.
fancoup.t barnes's axis-traction cephalotribe, applied.
be picked away by the fingers or the craniotomy-forceps.  Indeed, the
removal  of portions  of the cranial vault in this way  much facilitates
the subsequent transit of the head.  When  the base is crushed in the
direction first seized, you may use the instrument as a tractor.  If
there be any marked resistance, it is better  to  take off the blades, to
re-apply them in the opposite  oblique diameter, and repeat the crushing;
then, rotate the head by turning the handles about a quarter of a circle!
to bring the flattened head into relation with the transverse  diameter
of the brim before extraction, so as  to bring the head, flattened like a
disc,  to  correspond  with the  chink of  the pelvic  brim.   It  is not,
indeed, always necessary to give this rotation.  I found, in the extreme
case referred to above, that the necessary adaptation took place  almost. 
CEPHALOTRIPSY.                      339
 spontaneously.  Extraction may be made by the cephalotribe, taking
 care to allow time for the dilatation of the cervix uteri and vulva.
   Pajot (Arch. Gen. de Med.,  1863, and preface to French  edition of
 this work) has practised a method analogous to that formerly employed
 in  this country in  craniotomy.   He  performs  what  he describes  as
 " cephalotripsie repetee sans tractions "—that is, he first crushes the
 base by one operation ; 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 two or three hours to  Nature.   One or two  crushings
 suffice  for  the  trunk.   (See also Osservazioni di  Cefalotrissia, by
 Dr. Chiara, Turin, 1867, for a good case in illustration.)  Pajot places
 this method  in distinct competition with the Caesarian  section.   The
 cases related by him lend weight to his recommendation; but I cannot
 help thinking  that the operation may and generally ought to be finished
 at one sitting.  The great extent to which the head compressed in  the
 cephalotribe will expand again when the compression  is removed  is a
 point to remember.   The resiliency retained is  considerable.  A head
 flattened in the grasp of the cephalotribe may not measure more than
 one and a half inches, yet, on taking off the blades, it will spring out
 to more than two inches.   Why not, then, keep the blades on ?
   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 anterior to the  other.
 By keeping up traction on the  head backwards, this anterior shoulder
 will be brought a little  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 forwards, 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  the  chest  with  the
 cephalotribe.
  In extreme  cases it is sometimes  convenient to use both cephalotribe
 and craniotomy-forceps.  For example, the cephalotribe having crushed
 and seized the presenting part,  and served to draw it down to a certain
 extent, the instrument may slip a  little, or the foetus  may show signs
 of giving  way  above  the  point gripped.  The  craniotomy-forceps may
 then be made to take a  fresh  hold at  a  higher point.  In  a case of
 extreme contraction, in a dwarf, which I saw (1874) with Dr. Corbet,
 of Surbiton, where the shoulders offered great resistance, I thus renewed
 the hold several times, and  succeeded  in  extracting without  injury to
the woman, who  made a good recovery.
  If turning has been practised after  perforating or cephalotripsy the
arms fall in upon the crushed head  and offer no serious obstruction.
                                                          z 2 
340
OBSTETRIC OPERATIONS.
  To save the assistants the ghastly sight  of the mangled head, wrap
a napkin round it as soon as it  is born.  If traction is necessary in
delivering the trunk,  it is  easier to  hold when so treated.
  5. Lamination.—(a.) Delivery by the Forceps-saw.—This instrument,
introduced  by Van Huevel in 1842, may  be said to be the distinctive
feature of the Belgian school.  It is figured in the Obstetrical Society's
Catalogue of Instruments, 1867.   Dr. Hyemaux, who had been assist-
ant to Dr. Van Huevel  at  the Maternite"  of Brussels, in  his Manuel
Pratique de  VArt des Accouchements (Bruxelles, 1857), rejects in its
favour all crotchets and  cephalotribes as comparatively dangerous and
inefficient.    It is therefore used in all  cases where  embryotomy 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 Van  Huevel contrived a pair  of forceps
toothed on one blade to seize the most convenient part of the child.
Notwithstanding the formidable and complex appearance of the forceps-
saw, it seems  to  have  made  its  way into  use.  Professor Faye, of
Christiania, a man of singular judgment and ability, says it is the only
instrument fitted to cut  through any part of the fcetus ; but he appears
not to be aware of the power of the wire-ecraseur.   He has simplified
Van Huevel's instrument considerably, and extols  it as safe, easy, and
effectual.  It is used in  Germany ; and in Italy, Dr. Billi has modified
it and introduced it into practice.   We cannot  refuse to lend favourable
consideration to an instrument so recommended.   It is certainly a new
power ; and  its claims to compete with  or displace other methods of
facilitating delivery by embryotomy  should  be tested  in  practice.  It
appears  to me, however, 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  craniotomy-
forceps ; and that in extreme cases, where the conjugate 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.
   (b.) Delivery  by the Author's Neiu  Method  of  Embryotomy.__I
have   now to  describe  a  new method  of  embryotomy,  designed by
 myself,  to effect delivery  in the  most extreme  cases  of pelvic  con-
 traction.  It had long appeared  to me  that, if  the  problem, how to
 break up  and extract  such a body as  the  mature  foetus  through a 
EMBRYOTOMY  BY  ECRASEUR.
341
chink measuring an  inch wide  and three or four inches long, were
proposed to a  skilful engineer, he would find a  solution.   The  chief
difficulty seemed to be in finding an instrument that  occupied  little
space.   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
tumour, 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 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.*
  As in cephalotripsy, but not  so urgently, it is  desirable, first of all,
to perforate the head.   It  further facilitates the  operation to twist off
a portion of the parietal  bones  by the  craniotomy-forceps, so  as to
destroy the sphericity of  the head.  The wire-loop thus buries  itself
more readily  in the  skull, a smaller loop  is  required, and  it cuts
through the base more readily.  If the  sphericity of the head is not
first destroyed,  the  wire-loop  is apt to  glide  off  the  head-globe,
seizing  only the scalp  when  the  screw  is  worked.   (See Fig.  117.)
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 right side of the uterus, where the face  lies.   The
compression being removed, the  loop springs open to form its original
ring, which is guided over the anterior part of the head, as in Fig. 117.
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 manoeuvres  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  cephalotribe, 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 intervening soft
parts being liable  to be bruised, crushed,  and even perforated.   And
this  danger, obviously rising in proportion to the extent  of the pelvic
contraction, together with the bulk of the instruments used, deprives
the mother, in some cases of  extreme contraction, of the benefit  of
  *  I also demonstrated this operation at the meeting of the Obstetrical Society on
the 2nd  June, 1869, and, at Newcastle, to the Obstetrical Section of the British
Medical Association. 
342
OBSTETRIC OPERATIONS.
embryotomy, leaving her only the terrible  prospect  of  the Caesarian
section.  When  the anterior  or  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  one 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 re-applying 
CRANIOTOMY.
343
the loop over the occipital end of the head,  as  seen  in a, Fig. 117.
It thus accomplishes what the  cephalotribe does not,  viz., it breaks
up the base of the skull.
  The small part of the head still remaining attached to the trunk
offers no obstacle.   It  is useful  as a hold for traction.  The  crani-
otomy-forceps now seizes this firmly, and  you proceed to  deliver the
trunk.  If  the child be  well developed, this part  of the operation
will  require  considerable  skill  and  patience.   An assistant  draws
steadily on the  craniotomy-forceps,  directing traction to one  side,
so as to bring a shoulder into the brim.  The operator  then  hooks
the crotchet  into the axiUa, draws it down, and with  strong scissors
amputates the arm at the shoulder.  This proceeding is then repeated
on the other arm.  Boom is  thus gained to deal with  the thorax.
You  perforate  the thorax, introduce  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, moderate
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 Bamsbotham's hook,
may be made to  carry  a strong  wire  under  the  axilla, and  the end
being brought out, and the tube removed,  the wire can be attached
to the ecraseur,  which then cuts through the limb  with  ease and
security.  Decapitation may be  conveniently  performed in the  same
way.
  (c)  Tarnier's Method of Lamination is carried  out by an apparatus
similar in principle to Van Huevel's, but much lighter, and taking up
less  room.   It consists of two  branches  or  stems, one  of which is
curved  to  correspond with  the sacral  curve;  the other is nearly
straight.  These  branches carry  a travelling chain-saw,  which, like
Van Huevel's, works from below upwards,  so  that the  division  of the
skull begins below.  Having cut  as  far as  the  base, one can begin
again, and  so take out a wedge-shaped slice or section.   I saw heads
and sections so treated at the Matemite, which illustrate the  method.
  Certain  dangers attend  the operation  of  craniotomy.   What are
these ?  Certain  injuries  may  be  inflicted  upon  or result  to the
mother.
  1. The perforator  has been known  to strike the promontory of the
sacrum, or to lacerate the cervix uteri.
  2.  Spicula of cranial bones resulting from perforation may scratch or
tear the soft parts.
  3.  The crotchet may  slip and lacerate the soft parts.
  The above, of course, may be avoided with care.
  4.  But serious  evil is likely to result from  deferring the operation
too long—i.e.,  until after exhaustion has  set in—and under  a too 
344
OBSTETRIC OPERATIONS.
protracted operation in an unsuitable case.   Long-continued dragging
of the head  upon  a brim which  it  cannot pass, jamming  the s'oft
parts, more especiaUy at the two points of greatest projection, the
promontory and the symphysis, ends  by stopping the circulation in
the parts compressed, bruising them, actually grinding through them.
In this  way, after  severe operations, it has been found  that  a large
hole has been  made through the posterior cervix uteri.   Such injury,
added to the shock and exhaustion of the system, may be fatal.   Under
such circumstances  I have noticed that the soft parts, i.e., the vulva
and perinaeum,  greatly deprived of vitality, lose elasticity and power of
resisting distension.  They are deep brown  or black from congestion,
they break down, or tear like wet brown paper.   When the tissues
have arrived at this point, I doubt  if the patient ever  recovers.  It is
the result of operations which,  by forcing the child against the mother's
soft parts, arrest the circulation in them.  It is a form of acute necrosis.
Proper modes of delivery, as  removal of cranial vault, cephalotripsy,
and the wire-ecraseur, acting  on the  foetus, if timely  used, avoid this
serious danger.
  5. If the  immediate injury above  described do not occur, the long-
continued pressure  may cause mortification of a limited portion of the
neck of the uterus.   Thus, in the course of a few  days,  a slough is
formed between the vagina and bladder, resulting in vesico-vaginal
fistula.
  In the possibility of attendant danger, craniotomy differs essentially
from the forceps.   Whilst under craniotomy, mischief or  death  may
ensue; the forceps, if used rightly and in suitable cases, is an innocuous
instrument.  Statistics, professing to show that the mortality from the
use of the forceps is at the rate of 1 in 20, are flagrant examples of the
fallacy of arguing "post  hoc,  ergo propter  hoc."   Properly speaking,
the mortality from the forceps  is nil.  Women die because  the instru-
ment is used too late. 
LECTURE   XXIV.
THE CAESARIAN SECTION—THE INDICATIONS FOR—THE MORAL ASPECT
     OF  THE  OPERATION  AS  BETWEEN  MOTHER  AND  CHILD--THE
     CONDITIONS THAT RENDER THE OPERATION NECESSARY--QUESTION
     BETWEEN  C^SARIAN  SECTION  AND  TURNING  IN  DYING  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--
     SYMPHYSIOTOMY.

The Casarian  section occupies a doubtful  place between Conservative
and Sacrificial  Midwifery.   It  is conservative in its  design, in  its
ambition ;  it is too often sacrificial in fact.  It is resorted to with a
feeling  akin  to despair for  the  fate of the mother, which is  scarcely
tempered by the hope of rescuing the child.  It is looked upon by the
great majority  of obstetricians as the last desperate  resource, as the
most forcible example of that  kind of surgery  which John Hunter
regarded as the reproach of surgeons, being a confession that their  art
was baffled.  On  the other  hand, it is regarded by some enthusiastic
practitioners, dazzled perhaps by its  false brilliancy, as an operation
deserving to  be raised  into  competition with turning, craniotomy, or
cephalotripsy.  At different times and in different countries it has been
looked upon  with favour, because  promising  salvation to  the  child.
The child  is weighed against its mother ; and conscience is  silenced
with  the reflection  that the  possible  or probable rescue of the  child
may  rightly  be  purchased  by  subjecting the mother to  the  most
imminent peril.   It  is held that this double chance, made up of odds in
favour of the child  and against  the mother,  is to be preferred to the
single chance afforded by an operation which  gives up the child for the
sake of odds in favour of the mother.
  The situation is painful,  and may well perplex those who  are not
steady in their allegiance to those moral laws which ought to rule over
all professions,  and which certainly recognize  no exception here.
  None of us will claim exemption from  these  laws ;  but  some may 
346
OBSTETRIC OPERATIONS.
interpret them differently.   And here, again, we must call to mind a
lesser law to which reference has before been made—namely, that the
choice between two operations will be influenced  by the comparative
skill in them which the operator happens to possess.   Under this
influence the favoured operation will  be more and more cultivated, and
its competitor more and more neglected.  Thus, to apply this law to
the present discussion : the man confident in his skill in the extraction
of a dead child by the natural passages  with  safety to the mother will
be disposed to assign the  narrowest possible limits to  the  Caesarian
section; and,  on the other hand, the man who has not this confidence
will be disposed to prefer the Caesarian section, an operation easy and
dazzling.
  The operation  must be  studied  under  two aspects—first,  as one
imposed by necessity, as the only means of effecting delivery;  secondly,
as one of election,  deliberately chosen as the best means of effecting
delivery.
  The distinction  is very important  to be borne in mind; for, under
that fatal fascination which  seems to oppress the reasoning faculty in
statisticians,  conclusions drawn from figures representing the most
dissimilar facts are accepted and put forth as the legitimate deductions
from experience.   With our  present materials, I believe it is the most
idle and  unprofitable waste of intellect and  of time to  seek to draw
rules  for  practice  from  statistical   calculations.    It  seems to me
impossible in a great number of cases to distinguish or to estimate the
relative shares in causing death that  arise from causes  antecedent to
the labour,  from  causes  arising  during and in consequence of the
labour, and from the operation itself.  All cases, therefore,  which were
not selected—that is, deliberately operated upon, under simple con-
ditions, especially freedom from dangerous disease and from protracted
labour—must  be  put aside or considered apart.   How many simple
cases  of this kind do we possess ?   Certainly not enough to deduce
a law  of  mortality to  estimate the risk to  life  from  the  Cassarian
section.   M.  Pihan-Dufeillay,* indeed, declared  that the  operation
performed under favourable circumstances, as early as the impossibility
of delivery per vias naturales  is recognized, gives nearly 75 per cent.
of recoveries.   But what assurance have we that an undue proportion
of successful  cases  are  not recorded, unsuccessful ones  remaining
m the dark?  Pajot, in the  preface with which  he  has  honoured
the French  edition  of my work on  the  Diseases of Women (1875),
affirms that  " this operation has cost the lives of all  the  unhappy,
ignorant  women who have undergone it, in Paris, since  the beginning
of this century.  And,"  he adds, "it is  still practised!"
  And if this element of the comparison, the risk to life from Caesarian
section, is so defective,  vague, and  uncertain, it  foUows  that  com-
                    * "Archives Gen. de Med.," 1861. 
CJESARIAX SECTION.
347
parison, or  ponderation in the statistical scales, is  impossible, even
assuming  that  the  other  element, the risk to life under craniotomy,
were determined.  But  do we know more of this  second element, the
risk  to life  in  cases of exactly similar pelvic deformity under other
modes of delivery ?  Obviously, we cannot  recognize fatal  cases of
craniotomy in extreme deformity, say of conjugate diameter reduced to
2" or to 1#75", unless the  operation was begun under selected circum-
stances—that is, before exhaustion had  set in—and conducted with
due skill, and after  the  most approved methods.   We are fairly called
upon to reject all fatal  cases in which craniotomy was performed with
bad  instruments, in which  the skull was either not  crushed down
by the  cephalotribe,  or  the calvarium not  removed,  so as to leave
nothing but the base to bring  through the brim, edge on, or the head
and  trunk not reduced by sections,  as by my  method.   The  point
to determine is, what is  the limit  of contraction that  admits of this
proceeding,  or  some better proceeding,  being  carried out  with  a
reasonable  presumption  of  safety ?   When that  is  determined,  it
follows, as a logical necessity, that this proceeding ought to be adopted
in cases falling within that limit.
   To dispute this proposition—and it has been disputed, the disputants
not  seeing  the  dilemma  prepared  for themselves—is  to dispute the
propriety of performing  craniotomy in any  case.   For, why  do we
perform craniotomy or  cephalotripsy in the case  of a pelvis contracted
to 3" or  3-50"?   Is it  not because, possessing means  of extracting
a  dead child through  such a pelvis  with a reasonable prospect  of
safety to the mother, we  acknowledge it  to be our  duty to  use  those
means?   Now, assume  that we also possess means of extracting a
dead child  through a  pelvis  narrowed  to 2-00" or  1-50",  with  a
reasonable  prospect of safety  to  the mother,  who will  venture  to
dispute,  whether as a  matter  of logic or of  morals, that the mother
shall be denied that prospect?
   The case, then,  as   far as relates  to pelvic contraction, stands on
the  old ground.  It may be stated broadly as follows :—Embryotomy
stands first, and must be  adopted in every case where it  can be carried
out  without injuring the mother.   The Cassarian section comes last,
and must be resorted  to in those  cases  where embryotomy is either
impracticable, or cannot  be carried out without  risk of fatal injury to
the mother.  There is, therefore, no  election.  The law is defined and
clear.  The Caesarian  section  is the last  refuge of stern necessity.
   Certainly, those  who advocate the Caesarian section in cases of con-
traction below  2-25",  may deny the  possibility  of extracting a  dead
child through the natural passages with a reasonable  prospect of safety
to the mother.  But this denial, of course, applies  only to the expe-
rience of  those who   deny.   I can  but refer  to  the  testimony  of
Bamsbotham and  a host  of  English teachers,  to  Pajot  and  many 
348
OBSTETRIC OPERATIONS.
Continental authorities, as to the positive fact as regards cephalotripsy.
(See Lecture XXIII.)   It is right, however, to state that Scanzoni"
declares the limit generally adoptedin Germany to be  2-50".  But I
repeat, with all the emphasis that conviction  based upon experience
dictates, that delivery by the natural passages, either by cephalotripsy,
by the craniotomy-forceps, or by my new method of embryotomy, if
the conjugate  diameter measures  1-50", is perfectly practicable,  and
with a presumption of safety to the mother much greater than that
attending  the  Caesarian section.  I am  even confident that the same
may be predicated  with a conjugate  diameter  reduced to 1*25".

         Infant Mortality attending  the Cesarian Section.

  The probability of saving the child must obviously vary according to
circumstances.  Sometimes the operation is determined  upon without
any consideration for the child, simply as a means of delivering the
woman.   The child may be  known to be dead.  The most practical
question is—What is  the  probability of saving the child when the
operation  is performed under the most favourable selected circum-
stances ?   Statistics, even upon this point, are  not conclusive.  But it
may be assumed that the prospect of the child  is less than in the case
of ordinary labour.   The experience of the Boyal Maternity Charity
gives rather more than 3 per cent, of still-born children to the total
births.  Dr. Badford says the risk to the infant of delivery by Caesarian
section is  not much greater than that which  is  contingent on  natural
labour.  Scanzoni + ascertained the fate of 81 children out  of 120
operations performed between  1841 and 1853;  53 children, or 60 per
cent.,  were born alive.  Keyser says the infant mortality is 30 per
cent.   The mortality, then, is  probably  greater  than in  ordinary
labour.
  But assuming the probability of  saving the child to be ever so high,
are we justified by law, or by religion, the basis  of law, in taking the
woman's life as it were into our own hands, and deliberately subjecting
it to the  most imminent  hazard for the sake of probably saving her
child ?  It has been urged  that, the  woman  having a prospect of a
miserable existence for a few months or weeks only, whilst the child
is likely to be saved and live to maturity, the  child's life is the more
valuable, and  ought therefore to be preferred.   But this only applies to
a limited number of cases.
   Or,  taking  the case  of a woman who cannot give birth to a  living
child by the natural passages, calling upon the obstetrician time after
time to deliver her by craniotomy, it is asked, Ought we not at length
to refuse craniotomy and insist upon the Caesarian section ?
                   * " Lehrbuch der Geburtshiilfe," 1867.
                   t Ibid. 
C^SARIAN SECTION.
349
  Dr. Denman" states the question perspicuously thus:-—"I cannot,
however, relinquish the subject without mentioning another statement
of this question, which  has often employed my mind, especially when
the subject  has been actually passing before  me.  Suppose, for in-
stance, a woman  married,  who was so unfortunately framed that she
could not have a living child.   The first time of her being in labour,
no reasonable person could hesitate to afford relief at the expense of
her child;  even  a second and  a third trial  might be  justifiable, to
ascertain the  fact of the impossibility.  But it might be doubted hi
morals whether children should be begotten under such circumstances;
or whether,  after a determination that she cannot bear a living child, a
woman be entitled to have  a number of children  (more than ten  have
sometimes been sacrificed with this view) destroyed for the purpose of
saving her life ; or whether, after many trials, she ought  not to submit
to the Caesarian operation,  as the means of preserving the child at the
risk of her own life.   This  thing ought to be considered."
   The question is indeed  a trying one.  We may easily go astray in
the labyrinth of casuistry, unless  we  hold  steadily to  the clue laid
down by the moral law.  I think it will not  be disputed that, in law,
he who accelerates death is held responsible for having  caused death.
We  are  not justified in regarding a life as less  sacred because we
believe that, in the  ordinary course of  disease, it will not last beyond
a very short time.  We are,  therefore, not justified in preferring the
Caesarian section  to craniotomy in a case where the latter  operation
offers a fair prospect of safe delivery,  because the  woman is suffering
from  osteomalacia, which is commonly, but not always,  a progressive
and fatal disease.  We have no right to lessen the woman's chance of
life because  it is already small.  We cannot, even in the  case of osteo-
malacia or cancer, be certain of our prognosis.  I have known women
live for many years with osteomalacia, and even recover.
   Then take the case put by Denman.   The  conduct of  the woman is
assumed to  be culpable, and we are assumed to  be in the position of
accomplices or abettors  in her fault  if we repeatedly relieve  her by
craniotomy.   But are we entitled to take upon ourselves the office of
the Judge ?   Are we to  make  ourselves the  ministers of Justice  ?
Vengeance,  punishment, is not ours.  When  did Medicine ever  with-
hold  her merciful hand from the degraded,  the  sinful, the criminal  ?
Shall we dare to put a mere vegetative life—that of an unborn child—
into the scale against that of a being like ourselves accountable to the
Almighty ?   Can we take upon ourselves the  awful weight of deciding
that the wretched woman was  wrong—criminal, in becoming a mother?
She is subject to her husband.   If punishment is due, must it fall upon
her ? and are we to inflict it ?   I cannot, therefore,  hesitate in express-
ing my conviction that we should be traitors to our  trust  if we were to
                     * " Introduction to Midwifery." 
350                 OBSTETRIC OPERATIONS.
perform the Caesarian section when craniotomy is safer for the woman,
because in our judgment she was culpable  in  becoming a  mother.
The final argument is that it is the  mother's inalienable right to be
rescued, even if that involve the  sacrifice of her child.

    The  Conditions  that render the Cesarian Section necessary.

  The most frequent condition  is  deformity with contraction of the
pelvis.  The operation  is justified whenever the contraction is  such
as to render it impossible to extract a dead child through the natural
passages.   This may be stated at 1-50" conjugate diameter and below,
at the higher limit of 1*50" coming into competition with craniotomy.
But I think we may reasonably hope to  carry the minimum to l'OO".
Cases may also occur in which a conjugate diameter of 2-00" may
call for Caesarian section if the pelvis is  much distorted, so that the
diagonal and transverse diameters offer insufficient compensation for
the narrow  conjugate.  This is more especially the case when, as in
osteomalacia, the outlet of the pelvis is  also so  contracted and  rigid
as  to render the necessary introduction  and manipulation of instru-
ments  impossible.
  The most frequent form of distortion calling for the Caesarian section
is that which arises from  osteomalacia.   In this  disease the sides of
the triangle forming the brim of the pelvis are all pressed inwards, and
are more  or  less convex.  The  result is  that the  brim is practically
divided into two  parts,  neither of which is available for the passage
of the head.   Rickets, also, will sometimes produce a  pelvis that will
leave no  alternative.  The  slipping down of the lumbar  vertebrae—
spondylolisthesis—into the pelvic cavity, if to any great  extent, leaves
no other resource.
  The next most frequent causes are tumours of various kinds growing
into the pelvis,  such as bony or malignant  tumours  springing  from
the  wall  of  the  pelvis  ; tumours of the  ovary descending into the
pelvic  cavity,  and getting  fixed there.   Dr.  Sadler, of  Bamsley, has
recorded a case * in which the operation  became  necessary from the
pelvis being filled up with an enormous  hydatid cyst  springing  from
the liver.  Other exceptional causes, chiefly remarkable on account
of their  extreme rarity, have been  observed.  Atresia  of the cervix
uteri and  vagina  from disease, as from cancer or cicatrix, may be so
extensive  and  unyielding  that  the  Caesarian section  may  be  less
hazardous than the attempt to  open a canal through the contracted
tissues.
  We are sometimes driven to  the operation after having exhausted
other modes of proceeding—for example, when craniotomy may have
failed to deliver.
                  * " Medical Times and Gazette," 1864. 
                CAESARIAN  SECTION:  CASES  FOR.            3ol

  The Caesarian section, or simple abdominal section, is indicated hi
certain cases of rupture  of  the uterus, when  the child cannot  be
extracted with  advantage through  the pelvis, and in  some cases of
extra-uterine gestation.
  It is resorted to when the mother has  died undelivered, in the hope
of rescuing the child.  In this way several children have been  saved.
The success, of course, will depend greatly upon opening the  uterus
very soon after  the  mother's  death.   How soon ?  It is  difficult to
assign a  precise limit  beyond which the child's  life  may be regarded
as lost.   Harvey said,  " Children have been  frequently taken out of
the womb  alive hours after  the death of the mother."   I am not
aware of instances to justify this statement.   But Burns says,  " The
uterus may live longer than the body ; and after the mother has been
quite dead the  child still  continues its functions."  The foetus  in the
lower animals  will live  some  time if the ovum is  not opened.  It
seems not  improbable that  a  modified  degree  of  placental  circu-
lation may continue for some little time after the mother's general
circulation  has stopped ; and  it is, further, even  more probable that
the child may  survive for some little time  in a  state of asphyxia,
capable  of  restoration on  being brought into  the  air.    Certainly
children  have  been extracted  alive  ten minutes  after the mother's
death.  Wrisberg  cites three cases of  infants  born enclosed in the
membranes ; they lived,  one  seven  minutes, and  the  two   others
nine  minutes,  whilst  thus enveloped.   Dr.  Brunton relates  a case
(Obst. Trans.,  vol. xiii.) of a  seven months'  child expelled in  intact
membranes,  from  which  it was taken  out  alive after an estimated
lapse of fifteen minutes.  Dr.  George Harley  relates (Med. Times,
1850) a case in which he performed  post-mortem  section,  and with-
drew a live child  " three or four minutes " after the woman's  death.
It  was  saved with  difficulty  by artificial respiration.  Dr. Hoschek
(Arch. f. Gyndkol.,  1871)  relates an interesting case in point.  A
woman  about eight  months pregnant, dying  of phthisis, begged him
to  save  her child by Cassarian section. The  child  was  extracted
about ten minutes after the poor woman's death.   It  cried lustily, and
survived  about four months, dying of small-pox.   On  the other hand,
children  have  been extracted  dead  when the  operation  has  been
delayed  fifteen minutes.   This has  occurred  twice  in  my own
experience.   The chance  of  preserving the  child by the  Cassarian
section post  mortem  will  be  much influenced  by the circumstances
of the mother's death.  If she dies by sudden injury, the  child may
survive a little  longer.  If she  dies from hasmorrhage or rupture of
the uterus, the  child's death is likely to have preceded that  of the
mother.  If  she dies from  phthisis  or other gradually exhausting
disease, the child may  survive  some minutes.
  The probability of  the child in utero  surviving its mother for a 
352                 OBSTETRIC OPERATIONS.
short time  seems to have been impressed  upon  the  popular mind
from  the remotest  ages.   Mythical, pagan,  Jewish,  and  Christian
creeds have  alike sanctioned  attempts to  rescue the  unborn child
from  its dead  mother.  The operation is indeed associated from  its
origin with  the history of Medicine.  When Coronis  had died  by
the hand  of Apollo, and was laid  on  the  funeral  pyre,  the  poet
says :—
             '' Non tulit in cineres labi sua Phoebus eosdem
               Semina, sed natum flammis uteroque parentis
               Eripuit, geminique tulit Chironis in antrum."

The offspring  so  rescued was /Esculapius.
  The Caesarian  section after death comes  into  competition  with
forced delivery per  vias   naturales.  Sometimes,  if  the  cervix is
dilated,  the  child may be extracted by turning  as  quickly as  by
Caesarian section; and it  has this advantage—that, being less likely
to shock the friends, it  may be practised when the  Caesarian  section
would be rejected, or resisted until too  late.
  This view  has recently found favour in the Italian schools.  Professor
Bizzoli proposed to  deliver in this manner as soon as the woman was
dead.  The late Professor  Esterle* related a  case  occurring in 1858,
in which he successfully executed this proceeding  in a woman dying of
cerebral  apoplexy. One argument he adduced in support was the fact that
in similar cases the child  survives its mother's death so short a time
that to save it delivery must be effected whilst the mother is still living.
He says  that, in his  judgment, this is the proper course to adopt—of
course requiring  that all possible gentleness  shall be practised,  and
that,  if  necessary, the plug and  vaginal  douche  be used beforehand.
  Cases  in support of this practice are recorded by Belluzzi,t Ferratini,
and others.  Out of three cases, Belluzzi saved two children.   FerratiniJ
saved the child of a  woman  dying of phthisis.   The subject  is also
referred  to by  Dr. Hyernaux,  of  Brussels, in the  second edition of his
Treatise on  Obstetrics.
  A condition  which has several  times led to the Caesarian section has
been  disease, mostly  malignant, of the  lower segment of the  uterus,
preventing its due dilatation, and  involving the  danger of laceration.
In this case, the opportunity is commonly presented of inducing labour
or abortion.  Or in some cases it is possible to remove the greater part
of the obstructing diseased mass by the galvanic cautery-wire.   The
conditions of choice are  often  perplexing.  If labour be induced before
seven months,  the prospect of a  viable  child  is small,  but  the uterus

  * " Annali Universali di Medicina," 1861.
  t " Nuovi fatti in appoggio dell' estrazione del feto col  parto forzato durante
I'agonia delle donne incinte, onde salvare piu facilmente il feto stesso in sostituzione
a tale operazione, o al taglio cesareo post mortem."  Bologna, 1867.
  X " Un nuovo fatto in appoggio," etc.  Genova, 1868. 
              C.ESARIAN SECTION:  THE OPERATION.         353

 may be able to dilate sufficiently without injury.  On the other hand,
 the life of the mother is probably doomed to be of short duration from
 the progress of her disease.   Any injury to the diseased structures, as
 even  by premature labour, is liable to accelerate her death.  Is it not
 then better, both in her interest and in that of the infant, to let things
 go on to the natural  term of gestation ?   She  may live two or three
 months longer, and the child will undoubtedly have a better chance.
   What is the best time to choose for the operation ?
   1.  Sometimes, of course, all choice is denied us, or the range of time
 offered is extremely limited.  If called to a woman in labour at term,
 and under the conditions assumed  to require the operation, it ought to
 be performed without delay.  There is, if possible, greater reason than
 in conditions requiring other less formidable proceedings, to anticipate
 the exliaustion and local injury  that follow upon protracted labour.  It
 is a misfortune, tending fatally  to compromise success, to be obliged to
 operate when the system is prostrated;  when the structures that have
 to be  wounded are so worn and injured that the power of reaction and
 repair is  seriously reduced;  and when the  blood is  deteriorated by
 the products of nervous and muscular  overwork.   It is, then, a clear
 indication  to operate  early in labour.
   2. If the  patient come under observation  early in pregnancy, we
 have the double  opportunity of considering the propriety of inducing
 labour, with the  object of avoiding the  operation, and of selecting the
 time for its performance should it  be unavoidable.  Is it an advantage
 to operate during labour ?—that is, does the process of labour conduce
 to the success of the  Caesarian  section ?  Amongst Continental practi-
 tioners, and indeed generally here, the Caesarian section being regarded
 as a mode of delivery, it is held to be a primary indication to respect
 the laws of parturition, and to enlist the natural powers in our aid as
 much as possible. It has been, therefore, almost universally considered
 proper, in  cases  where  the ultimate  necessity of resorting to the
 Caesarian  section  is  recognized, to postpone the  operation until the
 advent of labour.  It is presumed that  the epoch which Nature fixes for
 labour is  that when  the  most  favourable conditions for  the  process
 and for the recovery are present.  The whole organization is better
 prepared ;  and the uterine muscles having acquired their highest stage
 of development,  and  contraction  having  actually  set in, it  seems
 reasonable  to anticipate that the wound made in the uterus  will close
 better, and that the necessary changes attending delivery will be more
 safely  carried out.
   Dr.  Ludwig Winckel,*  whose experience in this operation  is the
greatest, says the most favourable time is the  end of the second  stage
of labour, when the membranes  are ready to burst.   He advises not to.
rupture the membranes.   The escape of liquor amnii into the abdomen
                * " Monatsschrift fur Geburtskunde," 1863.
                                                           A A 
354
OBSTETRIC OPERATIONS.
does no  harm, and  the  extraction of the  child  is more easy  if the
membranes are kept  entire until the moment of seizing the child.
  But admitting spontaneous labour  at  term to  be a favouring con-
dition, may  not labour induced artificially before term  be an equally
favourable condition  ?   The arguments in support of the affirmative
deserve attention.  Dr. Braxton Hicks brought on  labour a fortnight
before term as a preparation  for the Caesarian section, influenced  by
the opinion that by so doing, the uterus, taken at  a period prior to the
highest degree of degeneration of its muscular fibres,  would  heal
better.  I think this is  a physiological error.   The degree of fatty
change observed in the mature uterus  is no impediment  to reparation.
There are, at any rate,  too many examples  of complete repair after
section by the knife,  and  even after rupture, to  admit of a doubt that
the mature uterus  is  in a condition not unfavourable for the  operation.
On  the other hand, it cannot  be  doubted that  the  uterus at seven or
eight months is also  capable of complete repair after injury.  We may,
then, very properly consider  whether, assuming  things to  be equal,
quoad the uterus, there may not be other  circumstances  that  may
rightly turn the scale in favour  of premature delivery.   Such, I think,
do exist.   For  example,  if we wait for the advent  of natural labour,
we  may be  called upon  to  operate in  the middle of the night, and
surrounded by many difficulties, all concurring to lessen  the prospect
of success.  By selecting our  own time, we  may have daylight, the
assistance of colleagues,  and  every appliance  that  may be thought
useful.
  The best time to select, then, would be as near the natural term of
gestation as possible, and this may be determined approximately  by
taking some day in the estimated last  fortnight of gestation.
  Then comes the question, Shall we  start labour before operating, or
proceed to the operation at once without  exciting  any preparatory
action of the uterus ? I think the preponderance of reason is in favour
of operating upon a uterus already in the act of  labour.  The first step
will be to pass up an elastic bougie  into the uterus overnight.   This
will excite some  degree  of uterine action.  Next day,  the hour of
operating being fixed, say, for 1 p.m., we may  in the morning ascertain
to what extent labour has proceeded.  If the os uteri is  not open more
than enough to allow a finger  to pass, it will be  useful to dilate it a
little more with the caoutchouc bag No. 2.  This  will probably induce
further contraction of the uterus,  and  secure one most desirable  object
—namely, a free outlet for liquor amnii and other discharges by the
natural passages.  But  we will avoid rupturing  the  membranes.
  The instruments required are :—1. A sharp bistoury.   2.  A bistoury
having a  blunt  end.  3.  A director  such as is  used in ovariotomy.
4. A large probang armed with sponge.  5. Artery-forceps and ligatures
in case of  bleeding  from the  abdominal wound.   6. Clean sponges, 
             CESAREAN SECTION:  THE  OPERATION.         355

wrung out with solution of carbolic acid or iodine.  7.  Ice.  8.  Needles.
9. Silver or silk sutures for uterine and abdominal wounds.   10.  Lint.
11.  Many-tailed  bandage  and  adhesive  plaster.   12.  Carbohzed
vaseline.
  Assistants.—Skilled assistants  should stand one on each side of the
patient.   Another should be  free to hand  instruments and assist in
sponging, etc.   A nurse or  two  to  help  will complete the necessary
staff.
  Preparation.—The  bowels  should be emptied by  castor-oil or by
enema on  the  morning of the operation.
   The Operation.—Position.—The patient  is laid on  a  table on her
back, with  the head and shoulders slightly raised.  The operator stands
on the patient's right or in front.   Anaesthesia is induced.
  The catheter is introduced to empty the bladder.  If the case be one
of osteomalacia, explore for the last  time carefully to ascertain if the
pelvis can be  opened up by  dilatation by the  hand.  In this  way,
several  times,  the operation has been  avoided.   It  is related that a
young surgeon, burning with  the ambition to perform the Caesarian
section, invited his confreres  to  assist.  Everything  was ready,  when
Osiander  requested  permission  to examine.   He opened  the pelvis,
turned, and extracted a live child ;  and thus, says he, " I saved the
woman from the Caesarian section, and  from death."   Dr. Tyler Smith
has related a case in which he was  able to dilate the pelvis with his
hand, and  deliver after craniotomy.   Olshausen relates a similar case
(Berl. Klin.  Wochenschrift,  1869).   I have  already adverted to the
testimony of Professor  Lazzati, the late distinguished Director of the
Lying-in Hospital of Milan,  who informed me  that, although osteo-
malacia  is very  frequently  observed there, he did  not  often find  it
necessary to resort  to Caesarian section, even  in cases of great de-
formity.   The common  practice is to turn, and  the bones yield to
admit the child, either mutilated  or not.  When  the  child has passed,
the bones collapse again.  He has more  frequently been called  on to
perform  the Caesarian section on account of extreme  distortion from
rickets.
   In cases of  great  distortion,  the uterus  is not  seldom  found con-
siderably displaced.   Where there is great prominence of the sacral
promontory, and squatting of the chest  down upon the  flanks, the
uterus is necessarily thrown much forward, sometimes so as to  over-
hang the symphysis.   With this there is occasionally marked lateral
obliquity;  and, what is less common, but still likely,  a twisting of the
uterus on its long axis, bringing one  of its  sides to look  more or less
forward.
  It  is also desirable  to take note, by  auscultation, of the seat  of
attachment of  the placenta.   Assistance may  also  be obtained by
laying the hand flat  on the  uterus, when, if  the walls are  thin, a
                                                         a a 2 
356
OBSTETRIC OPERATIONS.
 peculiar thrill or vibration marks  the  seat  of the placenta, which is
 confirmed by feeling the  part bulging a  little, as if a segment of a
 smaller globe were seated on a large spheroid.  This  has been  pointed
 out by Dr. Pfeiffer (Monatsschr. fur Geburtsk., 1868).
   The uterus is then brought into proper  relation with the  linea alba,
 so that the two incisions may correspond, unless  it be found that  the
 placenta can be avoided by cutting a little on one side of the median
 line.  The abdominal incision is best made  in the linea alba,  extend-
 ing from below  the umbilicus to within about  three inches  of  the
 symphysis pubis.   When nearly through it is desirable to get a finger
 through a small  opening, and, using this as a director,  to cut from
 within outwards, so as to avoid scratching the uterus.   The assistants
 support the abdominal wall on either side, looking out to prevent  the
 escape of intestine.  The uterine incision is  made in the middle line,
 sparing the fundus  and lower segment as much as possible, as  these
 parts are not well adapted to close by contraction, and large  vessels  are
 more  likely to be divided.   Circular fibres predominating near  the
 cervix  tend to make the  wound gape.   A manoeuvre described  by
 Winckel, and forced upon him by his being often called upon to  operate
 with insufficient  assistance,  here  deserves  attention.   An assistant
 hooks the forefinger of each hand in the upper and lower angle of  the
 uterine wound, and, lifting them up, fixes them in  contact with  the
 corresponding angles of the abdominal wound.   This shuts out the
 intestine effectually, and tends to prevent  the blood from running into
 the abdominal cavity.
   If the placenta is found directly behind the wound, the hand of  the
 operator is  insinuated  between the placenta and the uterine  wall,
 detaching it until the edge is felt, when the membranes  are pierced,
 and the child is seized by the feet.  This point obstetricians will pardon
 me for prominently emphasizing, because I have seen  a surgeon pull at
 the arm and fail to extract the child.   Sometimes the neck is  tightly
 grasped by the uterine wound.  If the constriction does not soon yield,
 it is better, says Scanzoni, to  extend  the  incision than to drag  over-
 much, lest the womb be torn.
  When the child and placenta are removed, attention is required to
 watch the bleeding ; this may take  place from the  cut  sinuses in the
 uterine walls, and from the inner  surface from which  the placenta has
 been separated.  Haemorrhage is best checked by direct compression of
 the uterus with the hand,  but the cut edges may be effectually com-
 pressed by Sydney Jones' ovariotomy clamps.  If the uterus contracts
 well, the haemorrhage ceases.  Ice may be applied to the wound, and a
piece placed in the uterine cavity.  If haemorrhage persist from the
placental site, it will be  necessary to swab it  with perchloride of iron.
Dr. Hall Davis  and Mr.  de Morgan  induced  contraction of  the uterus
by galvanism. 
              C.ESAR1AN  SECTION:  THE OPERATION.         357

   Before closing the uterine wound, thrust the probang through the os
uteri ami vagina, to make sure that the natural passages are clear for
the discharges from the uterus.
   Tlie Closure of the Wound.—When the bleeding has ceased, and any
blood that may have found its way  into the abdomen is removed, we
have to consider the question of applying sutures to the uterine wound.
It is a matter of observation that in many fatal cases the edges of this
wound have been found flaccid and  gaping.  But in the  majority of, if
not in all, these cases  the operation  had been performed on women
exhausted  by protracted  labour;  and, on the other hand, in women
operated upon at a selected time, when the powers are unimpaired, the
uterus commonly contracts well.  But we must remember  that just as
we find it in post-partum haemorrhage, the uterus may relax again after
having been apparently well contracted.  Winckel  says  he has never
lost a case from haemorrhage,  and has not stitched the uterine wound.
The history of closure of the  uterine wound by  suture is traced by
Dr. Bodenstein  (Amer. Journ.  of Obstetrics,  1871).  He was present
at a  case in  which haemorrhage was stopped by sutures.   He cites
Lauverjat as  stating that  Lebas  de  Mouilleron applied the " suture
sanglante "  to close the uterine wound in  a successful Caesarian section
in 1769.  Kilian condemned  it as  a most rash proceeding.  In the
Gazette Medicate, 1840, Godefroy reports  a successful case in which he
used  sutures to the uterus.  In 1863, Sir James  Simpson used three
iron sutures to control an " immense haemorrhage."   The patient died.
In the same year, Spencer Wells reported a  case (Obstet. Soc).  He
used a long piece of silk  as an uninterrupted suture, leaving one end
hanging  out through the vagina; by  pulling on this end the suture was
removed after several days. In Dr.  Grigg's case, performed  at Queen
Charlotte's Hospital in  1875, at which I  was  present, Wells put in  a
continuous silken suture, not tying it at either end.   It was found after
death that the suture had worked its way out at the upper  half.   This
was probably effected under the disturbance of severe vomiting and the
relaxation of the uterine  wall.
   Greater, if not complete, security against effusion into the  peritoneum
is attained by stitching the uterus, and uniting it by the  sutures to the
abdominal walls.  In this  way the formation of adhesions  is favoured.
Dr. Hicks and M. Tarnier have each treated  a case on this principle,
and effusion was prevented. In the carrying out, it is necessary to bear
in mind the contraction of the  uterus, which, going on for several days,
causes the organ to retreat towards  the pelvis, gradually sliding down
aAvay  from the  abdominal Avound.   If, then, the uterine Avound  were
united to the abdominal Avound exactly on the same level, and tightly,
there  Avould soon be dragging upon  the uterus, Avhich might  interfere
with its in\Tolution, and excite  inflammation.  I think,  lioAveA'er, this
difficulty can  be obA'iated. 
358
OBSTETRIC OPERATIONS.
  Uterine suture should meet the following conditions :—1st, it should
stop haemorrhage from the cut surfaces of the uterus ; 2nd, it should
secure fair apposition of  the two lips of the uterine wound ; 3rd, it
should keep  the anterior  Avail of the  uterus in  apposition with  the
abdominal  wall, so as to  favour  adhesion without causing dragging ;
4th, it should admit of the easy removal of the sutures when they have
done their duty; or better still, catgut, which does  not require remoAral,
may be used.  I have designed a method of suture calculated to answer
all  indications.   The  method is described and figured in the  third
edition.  It is not  repeated here, because I now  think Porro's opera-
tion, presently to be described,  is  generally preferable.
  The dressing  is the same as  after ovariotomy. Over the ordinary
dressing  a many-tailed bandage is adjusted,  to  secure rest of  the
AA'ound.
  After-treatment.—A full dose of opium should be given immediately,
either in  form of pill or suppository.  Light nourishment and perfect
repose are  the things  to  be observed.  The dressings  should not be
remoAred  for  five or six days.  To  obviate foulness, sprinkling  with
Condy's fluid or weak carbolic acid  may be resorted to.  The  sutures
may be  removed on the  seventh or eighth day.  The bowels may
be relieved by enema on  the fourth or fifth day. It  is desirable to
wear  a  well-adjusted  abdominal  belt  for  some months after  the
operation.

           The Dangers  of the Operation;  the Prognosis.

  What is  the risk to life  attending  the Cesarian section, numerically
expressed?   I  have  already made some  remarks upon this,  the
statistical aspect of  the question.   I doubt if any satisfactory answer
can be given.  Can any quasi-analogical deduction be drawn from the
mortality attending ovariotomy :   Take this to be  one death to nine or
ten recoveries ;  may we  expect a  similar result  from the Caesarian
section—I  mean, of course, Avhen  performed at a selected time ?  It
Avould be rash to expect an equal  success ; and there is  a consideration
which I think is generally neglected by statisticians.  It is this : we are
not justified  in treating a  given patient as an  abstract entity, a mere
arithmetical  unit.  Her fate is not to  be decided by what are called
statistical laAvs, but which are in reality too often  nothing better than
the accidental issues of blind gropings.  We must study case by case ;
compare  them; analyse clinically.  "Non numerandae, sed perpendendae
sunt observationes."   We must weigh carefully all the conditions of
the patient who is before us.
  The principal risks run are as folloAVS :—
  1. If the operation is performed  as the last resource  after protracted
attempts to deliver by other means, the woman is liable to sink from 
CAESARIAN SECTION.
359
shock and exliaustion within a feAv hours ;  or if she survive beyond
a feAv hours, there is the risk of haemorrhage, of metritis, of peritonitis,
and of puerperal fever.  It may be said that  the prospect  of recovery,
when the operation is  performed under  these  circumstances, is  very
small.
  2. If the operation  is  performed at a selected  time,  the woman
escapes the shock attendant upon tlie protracted labour, and encounters
the shock of the operation with unimpaired strength.  Still, the shock
is very great, and is  not seldom fatal  per se.   This  is the first and
most  pressing danger.  Could it be in any Avay modified or controlled,
the Caesarian section might be undertaken with  more confidence.  But
shock  necessarily  attends  all seA-ere  abdominal injury.    It  affects
different persons in different  degrees.   We cannot predicate of any
given person that  she  Avill bear shock Avell or badly.  It is an un-
certain  element, and  must probably  eATer perplex all  calculation  as
to the result  of the Caesarian section  in any particular case.
  3. The next  danger  is  hemorrhage,  and as haemorrhage is often
associated AATith prostration as cause  and as effect, the danger is serious.
This  may come on Avithin a feAv hours.  It might be  expected that
haemorrhage Avould be liable to come from the inner uterine surface,
as after ordinary labour, but the more common source  is  probably from
the sinuses divided in  the uterine Avound.    The  quantity lost  may
be enough to cause a  fatal anaemia.   But the more common  eAdl is
from  the  irritation caused by the blood collecting in the abdominal
caAdty.  This Avas the  probable  cause of death in  a  case I  saAV at
the Hopital de  la  Faculte, at Paris, in  1843, performed by Danyau
and Malgaigne.   There Avas no contraction of the uterus.   It reached
to the umbilicus.   This may,  to a great extent, be obviated by closing
the uterine Avound by  suture, and  uniting  the uterus  closely to the
abdominal Avail.   By averting this  danger Ave  avert one  cause of
  4. Secondary  shock and peritonitis.   That secondary shock precedes
peritonitis I have no doubt.   Intense  pain, even tenderness on pres-
sure,  rapid small  pulse, accelerated and impeded breathing, suggest
the diagnosis of  peritonitis.   This condition  I  have  described  as
" Abdominal Shock."    If at  this  stage the  patient die and  be ex-
amined,  probably no trace of peritonitis, as  revealed  by redness  or
effusion, is discovered.  Peritonitis may come on the day folloAving the
operation.  It may be met by fomentations to the abdomen, by opiate
suppositories ;  and the  prostration  soon ensuing must be  combated
Avith  Avine, brandy, beef-tea, chicken-broth.   Salines are often  useful,
especially at first.
  5. If the patient escape the preceding dangers, there is still the risk
of septic infection, of septicemic puerperal fever.  The  source  of this
is the absorption of septic matter from  the caAdty of the  Avomb or from
the edges  of the Avound; or it  may arise  from general blood-dyscrasia 
360
OBSTETRIC OPERATIONS.
resulting from the accumulation in the circulation of effete matters
which the  excreting organs  are  unable to dispose  of.
  6. In addition to the  dangers incident to  the  operation and to
the puerperal state, there is the danger inherent to the disease  which
rendered the operation necessary, liable in some cases, as  in cancer,
to be aggraATated  by  the operation, Avhich  may accelerate  the fatal
issue.
  Winckel says that  osteomalacia is much  more  unfavourable than
rickets  in  connection  Avith  Caesarian  section.   Still,  osteomalacic
patients bear  Avounds  AA*ell, and  the poAver of repair is often great.
  The uterus  often  contracts  adhesions  with the abdominal wall
during repair.   These adhesions do not appear to  entail any serious
incoirvenieiice; and should pregnancy  again  occur, and the Caesarian
section  be  again necessary, they render the  operation less  dangerous

                              Fig. 118.
          DR. NEWMAN'S CASE OF C/ESARIAN SUCTION'.  HALF-SIZE.

Deep sulcated cicatrix remained seven years after the operation. Tlie preparation is in
                   St. Thomas's Hospital Museum.
(Meigs).   The peritoneal cavity is  shut off; the  incision through the
abdominal wall  leads directly through the adhesions  to  the uterus.
Thus the dangers of haemorrhage, of effusions into  the abdomen, are
eliminated, and it is even probable that the shock is less.   This most
desirable  result  would  be  favoured by  uniting the  uterus to the
abdominal Avail at the time of the operation.   On the other hand, no
adhesions may be found, and the Avound  in  the uterus may heal  so
completely  that  years   afterwards  no  trace   of cicatrix  is  found.
(Badford).  Again, there may remain a marked cicatrix, Avith freedom
from adhesions,  as in Dr. Newman's case.   (See Fig. 118.)
   Several cases  are iioav known in  Avhich the Caesarian  section has
been performed  tAvice,  thrice,  and  e\Ten  four  times  on the  same
woman. 
C.ESARIAN SECTION.
361
   These cases of repeated success  Avould seem to indicate a special
 tolerance of  severe  injury  in the  subjects,  and cannot Avisely  be
 taken  as evidence, absolute or cumulative and statistical, in reduction
 of  the danger of the  operation.  This  is further illustrated in  the
 following history :—Dr. Freericks (Nederl. Tijdschr.-v. Geneeskunde,
 1858)  performed the section  on account of contracted pelvis.   Mother
 and child  recovered.   When again pregnant, premature labour was
 induced about the eighth month.  When labour had  begun, collapse
 set  in; the  uterus  had  ruptured.  The  child  Avas  removed   by
 abdominal section.  Vomiting  caused  extrusion   of  the intestines.
 To effect reposition, numerous pricks Avere made  in them to let  gas
 escape, Avithout effect, until  an incision was  made with a bistoury,
 and much thin pappy matter  escaped.   The intestines Avere  then
 replaced,  and the wound was closed.   The  patient recovered  com-
 pletely.  How many women  would be as tolerant ?
   Such is  the description  of the  old or simple Caesarian section.
 I  must now briefly  describe  the  modifications  recently made  or
 revived.
   Porro's Operation.—The most remarkable fact in the history of  the
 Caesarian section is the introduction of the method known as Porro's.
 It consists in the removal of  the uterus and appendages by ampu-
 tation  through the  cervix after  extracting the  child.  It is claimed
 for it  that it  giAres  greater security against haemorrhage ; there is no
 uterine wound to heal, there is  less risk of septicaemia, and  there
 is security against further pregnancy.   The operation is performed
 by  (1) making an abdominal incision;  (2)  laying open  the uterus ;
 (3) and extracting  the  child  as in  the ordinary Caesarian  section;
 then (4) drawing  the emptied uterus  out of the abdomen; (5) trans-
 fixing  and ligating the uterus  just beloAV  the os internum by Cintrat's
 or Koeberle's serre-nceud ; (6) amputating the  uterus with the ovaries
 and tubes just above the serre-nceud; \1) securing the stump outside
 the abdominal wound  by transfixing-needles.   The general  rules  of
 antiseptic surgery are  observed.   (8) The abdominal wound is closed
 as in ovariotomy.
  In  a case  performed  by  Fancourt  Barnes, all  haemorrhage  from
 the wound of the uterus was  effectually controlled by  seizing the
 cut edges with Sydney Jones'  ovariotomy-clamps,  so that very little
 blood need be lost.
  Dr.  Godson collected 138 cases.  These gave 77  deaths against 61
recoveries—a very formidable result.  We are unable to say whether
this  contrasts favourably  or  not with that of the simple Caesarian
 section.  The indications for the operation  are generally the  same.
In Godson's   case, Avhich ended  in  recovery, the pelvis had  been
smashed in   childhood.   In Fancourt Barnes'  case, the operation
Avas called for  by the blocking of the pelvis by an immovable  dermoid 
362
OBSTETRIC OPERATIONS.
cyst.   The patient  liAred four days, and would probably have survived
but for the changes  undergone in the  tumour, which  was fixed to
the pelvic Avail, and could not be removed.
  One question not yet settled is whether it is  better to secure the
stump outside  the abdomen  or to drop  it  inside.   Dr. Goode, of
Sydney,  had a successful issue after  the   intra-peritoneal  method.
But  the  results  of  this plan in  ordinary hysterotomy  are  not
encouraging.
  Midler's modification of Porro consists  in drawing out the Avhole
uterus,  Avith  its  contents, through  the  abdominal  wound.   Thus
drawn out,  the  ligature is  secured  round  the stump  before  the
uterus is opened and the child  extracted.  This operation does not,
in my  opinion,  offer any  advantage  OArer  Porro's.  It  is open to
the objection that a much larger abdominal Avound is necessary.
  The operation of laparo-elytrotomy  (Xcnrdpa, the flanks ; eXvrpov,
the vagina ; and rofirj,  a cutting),  reviAred by  Dr.  Gaillard  Thomas,
Avas originally  performed by Von Bitgen and Baudelocque.  It  con-
sists in an incision, usually on the right side, through the abdominal
Avail from above the spine of the pubes to above the anterior superior
spine  of the ilium—that is, along Poupart's  ligament.   The   peri-
toneum is then  raised, the fundus uteri is tilted down to the opposite
side, the os uteri tilted up, and  an incision made through  the vaginal
Avail on to a probe or  staff in the vagina.  The child is then  extracted
through  the  os  uteri and  the vaginal wound.   The Avound in the
flank  is  then  united  by  sutures.   Dr. Garrigues states that for the
performance of  this operation fiATe assistants  are desirable, four  indis-
pensable.   The operation has been done eight times.   Of these  cases,
six  Avere done  in America by three operators : Drs. Thomas, Skene,
and Gillette.   In England, up  to the  present time, Drs. Hime and
Edis alone have resorted to the  operation—in both instances un-
successfully.  Of Dr.  Thomas's two  cases,  one recovered.  Of Dr.
Skene's three cases, two recovered.   Dr. Gillett's one  case recovered.
The mortality  has therefore  been four  in  eight  cases.  The  chief
draAvback to  the operation is the  difficulty—Ave were almost  saying
the impossibility—of preventing injury to  the bladder  during the
delivery of the  child.   In Dr.  Edis's  case,  in the British  Lying-in
Hospital, the  child weighed  7 lbs. 10 oz.,  and yet the  bladder was
ruptured.   In four out of the eight cases just  mentioned the bladder
was injured.   The  epigastric artery may be  wounded ;  this, however,
is easily ligated.  An important  objection  to the  operation is  that
the mother may again become pregnant, and have  to undergo similar
dangers.
  Cesarian Section plus Removal of  the Ovaries.—The removal of
the ovaries  obviates  the risk  of future pregnancy.  It appears  to be
the natural complement  of the Caesarian section.   It is desirable to 
                       CiKSARIAN  SECTION.                   363

remo\'e the Fallopian tubes at the same time.   The parts are embraced
in a clamp, and the  stumps secured by ligatures.  In other  respects
the operation is the  same as the simple section.


                          Symphysiotomy.

  Symphysiotomy is  the operation by which the pubic joint is diA'ided,
so as to permit of the enlargement of the pelvic brim and caA'ity, by
forcibly separating the bones.  Its rationale rests upon the assumption
that the joints soften and yield under the influence of pregnancy.  We
find the natural analogue of this proceeding in the guinea-pig, Avhose
pubic joint opens  widely during parturition.   The operation  is never
mentioned in English works, unless to be condemned.  The subject
is Avell discussed by Scanzoni and by Lovati (Del parto  meccanico).
Sigault, who gave his name to  the  operation, said that an inch Avas
gained by it.  Leroy gained two and a half inches.  Baudelocque
and Desgranges,  in  their  experiments, gained a  space betAveen the
pubic  surfaces of two and a half inches.   They  say  that every
half-inch  of  distance  between the pubic  surfaces  gives  one line of
conjugate diameter; therefore tAvo  inches  gives  four  lines ;  then,  if
the parietal protuberance is made to  project into the space  betAveen
the pubic bones, you get two lines more ;  the oblique  diameters gain
eight lines ; the transverse gains half  the distance between the pubic
bones, that is, one inch.   The operation might therefore be available
in cases where a gain of six lines will enable a live child to pass, or
Avhere  a  head impacted in  the  pelvis might be liberated Avithout
perforation.   In   either case  extraction  by  forceps  would  still be
necessary.
  The operation has in recent years been revived in Italy.  Morisani
gives statistics of fifty cases performed on forty-eight women  between
1868  and  1881 ;  the principal  operators  being  Novi, Martini, and
Morisani.  Forty  mothers and forty-one children  survived.   He con-
siders  that it is  less dangerous than embryotomy.   The deaths of
mothers are  not  more numerous, and the  children saATed are a clear
gain.   It may be objected that the maternal deaths from embryotomy
are much OATerstated.  His method  is  as folloAvs :—He uses  a small
crotchet-shaped knife, curved, and cutting on its concaATe  edge ; it is
blown as the falcetta di Galbiati.  An incision of  from 3 to 5 centim.
is made just  aboA'e the symphysis pubis.  The articulation  is gradually
reached, the falcetta is slipped along the  posterior  surface of the
symphysis, and when the lower  edge of the symphysis  is  reached,
the cutting concaAdty of the instrument is hooked  under the inter-
pubic cartilage,  which  is then  cut through from beloAv upwards.  If
the uterine  contractions are strong,  the expulsion of the  child is 
364
OBSTETRIC OPERATIONS.
allowed to take place spontaneously.   If  they are feeble, the forceps
is  applied.  Lastly, the  wound  is  dressed, and immobility of  the
pelvis is secured by an appropriate bandage.
  Symphysiotomy,  notwithstanding this favourable report, will  prob-
ably not  make  way in practice  as  an alternative for the Caesarian
section  or for  embryotomy.   Scanzoni says the only case  in Avhich
it is justifiable is where the  mother dies in labour,  the child  being
partly  born, and extrication  difficult Avithout  enlargement of  the
pelvis.
 \The  mother  will probably remain lame. 
L E C T U B E  XXV.
THE  INDUCTION  OF  PREMATURE LABOUE--THE  MOEAL BEARING  OF
     THE  OPERATION—THE  FITNESS  OF THE  SYSTEM AND  OF THE
     GENITAL ORGANS  FOR PREMATURE LABOUR--THE  INSUFFICIENCY
     OF  SIMPLY  PROVOCATIVE  MEANS--TWO STAGES  OF  PREMATURE
     LABOUR ARTIFICIALLY INDUCED : THE PROVOCATIVE ;   THE  AC-
     CELERATIVE--DISCUSSION OF THE VARIOUS PROVOCATIVE AGENTS:
     DANGER OF  THE DOUCHE--ACTION OF  THE VARIOUS  DILATORS--
     THE  MODE  OF PROCEEDING--PROVOCATION  OVERNIGHT—ACCEL-
     ERATION AND CONCLUSION OF  LABOUR NEXT DAY—DESCRIPTION
     OF  CASES  DEMANDING  INDUCTION  OF  LABOUR--QUESTION  OF
     STARVING THE  MOTHER--MODE  OF   DETERMINING  EPOCH  OF
     GESTATION--PROCEEDING  IN   CONTRACTED   PELVIS  OR  OTHER
     MECHANICAL  OBSTRUCTIONS--IN  CASES OF  URGENT DISTRESS  OF
     MOTHER, AS CONVULSIONS, HEART  DISEASE,  PHTHISIS--IN  CASES
     WHERE  THE CHILD IS DEAD--MISSED   LABOUR—CARE  OF  CHILD
     WHEN BORN ALIVE.

We now come to an operation Avhich carries us fairly back within the
domains of  Conservative  Midwifery.   The induction of  premature
labour is designed to save the mother and child, or at least the mother,
from those  perils which one or both  Avould  have to encounter  at
or before the natural  term of gestation.  In many cases those perils
increase in  an accelerated  ratio with  the  advance of gestation.  By
anticipating the ordinary epoch of delivery,  by  selecting a time when
these perils have  either not yet arisen or are still  comparatively small,
Ave may make the labour auspicious, indeed, natural in everything but
in the moment of its occurrence.  In many  other cases Ave may obtain
an equally auspicious result by commanding the  entire course of the
labour,  overcoming certain  difficulties  by appropriate proceedings.   I
shall sIioav that it has been too much the custom  to consider that our
resources are limited to the first order of cases, to leave too much  to
accident; and that, by taking the whole conduct of labour into our own
hands, Ave may greatly extend the application of  this most  beneficent 
366
OBSTETRIC OPERATIONS.
operation, save much suffering, and greatly add  to the probability of
preserving the  lives of mother and  child.
  We  have  thus three great conservative  operations :  turning,  the
forceps, and the induction of labour.  The  tAVO latter  have been
contributed  by  the  London school.
  Denman tells us that he learned from Dr. C. Kelly, that " about the
year 1756 there was a consultation of the  most  eminent  men at that
time in London to consider  the  moral rectitude of, and  advantages
Avhich  might be expected  from,  this practice."  It met with their
general approbation; and under this sanction the operation was resorted
to with success in  many  instances.
  It is happily no longer  necessary to prove the moral rectitude of the
practice.  Its justification rests upon  the same basis as that from which
the whole  art  of Medicine derives its authority.  Its design  and  its
general effect are to save  life, in many cases the lives of both mother
and child;  and in  the rest,  where  the child cannot be  rescued, to
increase  at  least the chances of  safety  to  the mother.   The moral
aspect  of the question is now reversed; the  accuser and defendant have
changed places  : it  rests with those avIio neglect that which will rescue
a woman and  her offspring from  impending  danger, who thus suffer
one or both to drift to destruction,  to justify their neglect.
  We  may therefore proceed at once to discuss what are the advantages
to be  derived from  the practice.
  A preliminary question  arises, the solution  of  which is necessary to
the  right appreciation  of what  can  be  gained  by  inducing  labour
prematurely, and of the means  of accomplishing this purpose.  This
question, one which has  been almost Avholly neglected hitherto, is—
What  is  the  condition  of the  uterus  and  the system  generally in
reference to its  fitness to assume the Avork of parturition prematurely ?
  First,  as  to  the fitness of the general system to enter upon labour
and the puerperal state.   Upon this point little need be said, since we
must be  content to  accept the conditions as  they exist at the time of
our selection for the operation.   We  cannot  materially modify them.
Experience,  moreover,  has amply  shown  that  the  system is fairly
competent to assume the  duties cast upon it  at any time after the end
of seven  months.   To apply the physiological formula of the Genesial
Cycle  so beautifully described by Tyler Smith, Ave observe that when
gestation is brought to a term, the breasts  enter  upon their office, milk
is secreted for  the  nourishment of the infant, and the uterus,  thrown
out of work, undergoes involution.  These processes are usually carried
on Avith scarcely less efficiency Avhen labour occurs prematurely.
   Almost all the consequences of labour at term may follow premature
labour and  even abortion : inflammation  and  abscess of the breast;
peritonitis, including pelvic peritonitis  and pelvic  cellulitis ; thrombosis,
including phlegmasia dolens ; and  all the forms of puerperal fever. 
INDUCTION OF LABOUR.
367
 But experience does not seem to indicate that these complications are
 in any sensible degree more likely to attend premature labour.
   Secondly, as to the fitness of the parturient organs.  Here the case
 is Avidely different; for, any lack of efficiency in these must be made up
 by art.  When labour comes prematurely, the uterus is overtaken in an
 imperfect state of development.  It is taken by surprise.  This implies
 imperfection in  the contractile poAver of the body of the uterus,  and
 greater resistance in the cervix.  And the normal supply of nervous
 energy stored up  in  preparation for the  Avork of labour is not  yet
 complete.   (See my  " Lumleian Lectures," Lancet, 1874.)   Hence
 there is another source of difficulty in provoking contraction. It is true
 that the child, the body to be expelled, is smaller, and that in this Avay
 the balance betAveen power and resistance  is to  some extent restored.
 But this is  certainly not always  so.  It frequently, nay  commonly,
 happens that the uterus is slow to respond to the unexpected call made
 upon it.  It is  but reasonable to anticipate that help Avill often be
 useful.   And  help  can be given both to facilitate the dilatation of the
 cervix,  and to  supplement  the contractile energy, if this cannot be
 brought into  play.
   Now, the expediency of giving this help, and the means of doing it,
 have been almost  entirely overlooked.    Action has been limited to
 attempts at provoking the  uterus to expel its contents, leaAdng the rest
 very much to chance.  The consequence too frequently has been that the
 child has been born at some unforeseen, inopportune time, before aid
 could be procured, and it has perished from one of those accidents, such
 as preternatural presentation or descent of the cord, which are so likely
 to occur in premature labour.  Thus, supposing it Avas  determined to
 bring on labour  at  the eighth  month by detaching the membranes, by
 puncturing them, or by inserting a bougie in the uterus : this done, it
 has been considered that there Avas nothing to do but to wait patiently
 until active labour should set in, Avhen the medical attendant should be
 sent for.   Now, this may come to pass in tAvelve hours, in twenty-four
 hours, or in two, three, four  days, or  even later.  There is no certainty
 about it.  When labour comes the child is expelled with little warning,
 almost  suddenly, and before the  medical attendant  can  be fetched.
 And it has to run the gauntlet  of  all  those perils Avhich especially
 surround  premature labour unaided.
  Does it not follow that it is desirable to  keep a  control over  the
 Avhole course of labour, to  take care that  nothing adverse to mother or
 child shall happen in our absence, to substitute,  in short, skill and
 foresight  for  accident ?  FeAv, perhaps,  will  hesitate to answer  this
 question in the affirmative.   But another question must follow.   Can
 Ave so regulate a provoked labour throughout as to limit and define  the
time expended ; and to conduct the delivery so as to give more security
to the child and to the mother '? This also I am prepared to answer in 
368
OBSTETRIC OPERATIONS.
 the affirmative.  Repeated experience justifies the declaration made by
 me in 18(52, " That it is just as feasible to make an appointment at any
 distance from home to carry out at one sitting the induction of labour,
 as it is to cut for the  stone."   The operation may be brought entirely
 within the  control of the  operator.  Instead  of being the slave of
 circumstances, Avaiting anxiously for the response of Nature  to his
 provocations, he should be master of the position.
   Assuming, then, that it is both desirable and  possible to control  and
 regulate the entire course of  a labour  prematurely induced, let me
 describe the method after Avhich the  proceeding should be conducted.
   The act  of artificial labour  may be  divided  into tAvo  stages.
   The first stage is provocative and preparatory.  This includes some
 amount of dilatation of the  cervix uteri, and implies a  certain amount
 of uterine  action, and lubrication of the cervix and vagina.
   The second stage is the accelerative or concluding  stage.  It consists
 in the expulsion or extraction of the foetus and placenta.
   The ordinary modes of conducting  an induced labour almost ignore
 the last stage, or the means of accelerating delivery.
   Dividing the agents at our  command for effecting  delivery at will
 into the provocative and the accelerative, let us first examine the means
 we possess  of provoking labour. These are numerous.  In a course of
 lectures designed to  be practical rather than historical, it is  not
 desirable to discuss them in detail.   I  have endeavoured to do this in
 memoirs " On the Indications and  Operations for the  Liduction of
 Premature Labour, and for the Acceleration of Labour " (Obstetrical
 Trans., 1862, and St.  George's Hospital Reports).  It may be stated, as
 a  general  fact, that all the  means  employed act by stimulating  the
 spinal  centre to exert  itself in causing contraction of the uterus.  Some
 of these agents act directly upon the  spinal marrow, being carried
 thither in  the  blood.   Such are ergot of rye,  borax,  cinnamon, and
 other   drugs.   Quinine will provoke labour.   Dr. Lewis  A. Sayre
 [American  Practitioner, 1871)  says he brought on labour by it.   Dr.
 Angelo Monteverdi  says Peruvian  bark  is superior  to ergot.   Quinine
 in five-grain doses  every half-hour provokes uterine contractions and
 labour.  The diastaltic  system  is  probably  more actiA<e in Europeans
 in hot  climates.   We  seldom find  quinine efficient in provoking labour
 in this country ;  but Surgeon-General  Cockburn,  who has had long
 experience  in India, says it  is  very unsafe to give quinine to pregnant
 Avomen there.  It is a  popular belief, shared by some  medical men, that
iron will provoke labour, and charges of attempt  to procure  abortion
have been founded upon the  administration of this metal to pregnant
women.  Sound clinical observation does not support this belief; and
certainly iron cannot be depended upon to provoke  labour.   Some
agents   evoke  the energies  of  the diastaltic system  by  stimulating
various peripheral  nerves.    Such are  rectal injections, the vaginal 
INDUCTION OF LABOUR.
369
douche,  the  colpeurynter,  the carbonic-acid  douche,  probably the
irritation  of  the  breasts by sinapism and the air-pump, the cervical
plug, the  separation of the  membranes,  the  placing a flexible bougie
in the  uterus, the intra-uterine injection, the evacuation of the liquor
amnii, and galvanism.
   The artificial dilatation  of the cervix, the evacuation of the liquor
amnii, and the  intra-uterine  injection  act  in  a  more complicated
manner, and  not simply through the diastaltic system.  Some of the
above agents  are altogether uncertain and untrustworthy; some are in
a high degree dangerous ; and some are both efficient and safe.  Ergot,
borax,  cinnamon, and all other drugs may be dismissed on  account of
their uselessness or uncertainty.   Ergot is  not only uncertain, but
when it  acts it is liable to prove fatal  to the  child.   Rectal  injec-
tions may be harmless, but cannot be relied upon.   Irritation of the
breasts often  fails, and it is liable to  be folloAved by inflammation and
abscess.   The  vaginal  douche (Kiwisch's  plan), which  consists in
playing a  stream  of water against the cerAdx uteri, is often tedious, and
is not free from danger.  It requires to be repeated at intervals during
one, tAVO,  or more days.  It is liable to cause congestion of the lower
segment  of  the  uterus.   Serious  shock,  metritis, and death  have
followed.  It was advocated by Tyler Smith  in this country, until he
encountered  a  fatal  result,  which he communicated  to  me.
   The intra-uterine douche, sometimes  described as KiAvisch's  plan,
Avas in reality recommended by Schweighauser  in 1825,  and practised
by Cohen in  1846.*  It is known in Germany as  Cohen's method.  It
was recommended by  Schweighauser as a better means of detaching
the  membranes  than  the  use  of  the  finger  or sound adopted  by
Hamilton. Cohen thought  the injected  fluid acted, not by detaching
the membranes, but  through its being absorbed by the  surface of the
uterus.  Professor Simpson f says  that  he at first used the vaginal
douche of Kiwisch, but "he soon found  it a simpler  and more direct
plan to introduce the end of the syringe through the uterine orifice ; "
he became convinced  that  the douche was  liable  to fail,  unless the
injected fluid accumulated in, and distended the vagina, so as to expand
that canal and  enter the os uteri; and that its  efficiency was  great in
proportion to the extent to which it separated the membranes.
   The intra-uterine douche,  although  more certain,  is  even  more
dangerous than the  vaginal douche.  Lazzati relates two fatal  cases.
Taurin saw, in  January,  1860,   in Dubois'  clinique, such  grave
symptoms follow, that  death was apprehended.   Salmon, of Chartres,
related to the Academie de Medecine (July, 1862) a fatal case.  Depaul
communicated to the Parisian Surgical Society (1860) a  case of death
occurring suddenly from the  uterine  douche.  A gurgling noise attended
           *  "  Neue Zeitschrift fur Geburtskunde," Band xxi.
           t  "  Obstetric Memoirs and Contributions," vol. i., 1855.
                                                           B B 
370
OBSTETRIC OPERATIONS.
 the use of the instrument.   Air escaped on cutting into the uterus for
 the purpose of extracting the  child by post-mortem Caesarian section.
 The  uterine tissue  was bright red ;  the blood frothy.   Blot had to
 deplore a similar accident in the Clinique d'Accouchements.  Tarnier
 relates tAvo  similar cases.   Esterle relates  a case* in Avhich serious
 obstruction to the cardiac circulation, ending in death, occurred.  It
 may be asked, Hoav is it  that  the injection of a stream of water into
 the vagina  or uterus can prove fatal ?  The cases cited, and  they are
 by no means all that are known, leave no  doubt as to the fact.  It
 seems to me that danger results in three ways.   The first is by shock.
 When Avater is injected into the gravid uterus, it can only find room by
 stretching the tissues of the uterus.  This sudden tension is the cause
 of  shock.   It has been supposed that  some  of the fluid finds  its Avay
 through the Fallopian tubes into the peritoneum.  And the following
 case,  related by Ulrich,f suggests another solution :—
   " H. W.,  aged  twenty-nine, was, at the end of her second pregnancy,
 carrying twins.   Three vaginal douches were used to accelerate labour,
 the last one by a midAvife.   The temperature of the Avater Avas 30° R.
 The 'clysopompe'  was used.  Eight  hours  after  the injections had
 been  going on, the patient got  up in bed, and instantly  fell  down
 senseless, and died in a minute at most, with convulsive respiration-
 movements  and  distortion of the  face.   Five minutes afterwards,
 crepitation was felt  on touching the body.   Venesection was  tried in
 the median vein.  Only a  few  drops of blood came.  On section, the
 cerebral sinuses were found full of dark fluid blood ; the membranes
 not very hyperaemic;  the  brain normal.   The  heart was lying quite
 transversely, the  left  ventricle  strongly contracted, the right ventricle
 quite flaccid ;  the coronary vessels contained  a quantity of air-bubbles.
 The left heart contained scarcely any blood ;  the right had a little ; it
 was quite frothy."
  This is illustrated by a case told by J. C. Dalton (Brit. Med. Journ.y
 1860).  A gutta-percha tube  was used to  puncture the membranes
 and procure abortion.  The woman fell back  and died.  Air was found
in the veins and  heart.  It was believed  by Mr. Dalton that  air was
blown -in.
  It is probable, then, that air  may get into the  uterine sinuses.
  Sir  J. Simpson  relates the  following:\—"He had been  greatly
alarmed by  seeing a  patient faint  under an injection, probably from
some  of the  fluid getting into the circulation.   And  he had seen two
more alarming cases still,  where both the patients died.  In both, only
a feAv ounces of water Avere  injected;  and yet  rupture  of the uterus
took place.   The  occurrence of  the rupture was to be explained by the
             * " Annali Universalidi Medicina," March, 1858.
            t " Monatsschrift fur Geburtskunde,"  1858.
            X " Edinburgh Medical Journal," 1862. 
INDUCTION OF LABOUR.                371
 fact  that the uterus, being already fully distended, could not  admit a
 few  ounces  of  fluid  Avithout  being stretched  and  fissured to some
 extent; and during labour these slight fissures might easily be con-
 verted into fatal ruptures.  In one case the patient  died before labour
 was  completed ;  in the other, in twelve hours after its termination."
   Another objection  urged by J. Y. Simpson is, that  in injecting water
 we have no control over the direction it will take in the uterine cavity,
 and that the placenta may be detached.  Cohen's cases sIioav that this
 accident may happen.
   It is also apt to  displace the head, and cause transverse presen-
 tation.
   Of course no degree of efficiency could justify the use of a method
 fraught with such terrible danger.  But the douche does not possess
 even the merit of certainty.  It has been repeated many times during
 several days before labour ensued.   Lazzati, having tried it in thirty-
 six  cases, found that the number of injections required ranged from
 one to twelve ; the quantity used was about forty pints ; the duration
 of the injections was  from ten to fifteen minutes  at  a time; the tem-
 perature of  the water 28° to 30° R.  The time expended from the first
 injection to labour varied from one to fourteen days, the average being
 four days.
   It  has  also been found that a large proportion of  the children were
 lost.
   The douche, therefore,  Avhether vaginal or intra-uterine, ought to be
 absolutely condemned as a  means of inducing labour.   I think it
 necessary to repeat this  emphatically,  because, notAAdthstanding the
 warnings conveyed by many fatal catastrophes, I find that  the use  of
 the method  is still taught and practised.
   Mr. James, formerly surgeon to the City of London Lying-in Hospital,
 described (Lancet, 1861) a plan of intra-uterine injection which he had
 practised since 1848.   He passes an elastic male catheter to the extent
 of four or five inches through the os,  between the uterine wall  and
 the  membranes,  and  then injects  about eight ounces  of cold  water.
 Of eight children, only two were  still-born.  Professor Lazarewitch
 (Obst. Trans.,  1868)  has  explained, modified,  and  given  more pre-
 cision to this method. He proves, by observations and experiments,
 that the nearer to the fundus of the uterus the irritation acts, the more
 sure and speedy is the result, and  vice versa.  He contends that the
 frequent failure of the douche Avas due to the stream not being carried
 much beyond the os.   He found that when the stream was  carried up
to the fundus, one injection  was  commonly enough.   He therefore
introduces a tube as near to the  fundus as  possible, and then injects
several ounces  of water.   The  cases he relates (twelve in number)
sufficiently establish  his  proposition, that  this method is more sure
than  other modes of applying the douche ;  but they are too few to
                                                        B b 2 
372                OBSTETRIC OPERATIONS.
prove that it is  more safe.   I feel very sure  that, if it  be at all fre-
quently adopted, fatal catastrophes  will ensue.
  It may, moreover, be doubted whether, in cases managed according
to the principle of James and Lazarewitch, the injection of water Avas
not really superfluous.   The  passage of a catheter fiATe  or six  inches
into the uterus detaches the  membranes along its course, and this, it
has been seen, is usually quite enough to provoke  labour.  Why not,
then, rest satisfied Avith that  portion of the proceeding  which  is
efficient and safe, and discard that Avhich is superfluous and dangerous?
  It is  instructive to  compare  the  histories  of some cases of intra-
uterine injection with those of accidental or intra-uterine haemorrhage
depending  upon  detachment  of  the placenta.   Sudden severe pain
in the abdomen  at the  seat of effusion, shivering, vomiting,  collapse,
are all observed  in  both cases.  In the case of  haemorrhage,  these
are certainly not  in proportion to, or due alone to, the  loss of blood.
They seem to be  the direct effect of  injury to  the  uterus from sudden
distension of fibre.  The uterus will grow to  keep pace with develop-
mental  stimulus of a  body  contained  in it;  but  it will not stretch
to  accommodate several cubic inches of fluid suddenly thrust  into
it.  Yet  this is  what it  is called upon to do Avhen water is  injected.
If the water escape as fast  as  it enters, the  shock  may be  avoided,
but then  the  operation  is  liable to  fail in inducing labour.
  The injection  of carbonic acid gas or even  common air seems more
dangerous still than the  injection of fluids.  Scanzoni has related two
fatal  cases  from  the  injection of carbonic  acid, and  Sir  James
Simpson relates  one Avhere  the patient  died  in a few minutes after
the injection of common air.
  Another agent is galvanism.  Herder suggested  this  as  a direct
stimulant, to  cause the uterus  to  expel  its  contents,  in 1803.   In
1844, Horninger and Jacoby brought  on  labour  by this  agent.  Dr.
Radford  showed  the value of galvanism in labour and  in  controlling
haemorrhage.  In 1853, I published*  a memoir  on this  subject.   I
succeeded, in three cases, in inducing  labour by it.  But the method
is tedious, and  sometimes distressing  to the patient.   I have, there-
fore,  abandoned  it.  But Faradism, as recently practised by Kilmer t
and others, seems  more certain.  It deserves further trial.
   Another  exciting or provoking agent consists in the  insertion  of
some form of plug  or expanding  body in  the  os  or  cervix  uteri.
A great  variety  of contrivances  for  this purpose  have  been  proposed
and tried.   It is unnecessary  to describe the greater part of them.
Those most in  use are  the  sponge-tent, the  laminaria-tent,  and the
elastic air or waster dilator.   There is no doubt labour  can be induced
by  these agents.  But  it appears  to  me  that their use  to provoke
                   * "Lancet" and " L'Union Medicale."
                  t See " Obstetrical Transactions," 1884. 
INDUCTION  OF  LABOUR.
373
labour is  not based on a rational A'iew of the physiological or clinical
history  of the  process.  I  agree  Avith Lazarewitch,  that  irritants
applied  to the cervix are slow and uncertain.  In  most cases some
further  means, such  as  rupturing  the  membranes, will be necessary.
The laminaria-tent is,  however,  extremely useful in  expediting  the
dilatation and eA'acuation of the uterus  in some cases of abortion.
   The  method  knoAvn  as  Professor  Hamilton's, Avhich consists in
detaching, by means of the finger or sound, the membranes  of  the
ovum from the loAver segment  of the uterus, has the recommendation
of safety ; but it is uncertain in its operation.
   The success that commonly attends the plan of introducing a bougie
into the uterus, between  the  ovum and the  uterine AArall, is  perhaps
eAddence  of  the truth   of LazareAvitch's proposition,  that irritation
should  be applied to the fundus.   I find that the bougie should be
passed  at least  six or seven inches through the os uteri in order to
ensure  action.   Probably,  in  many  cases where  it  has failed,  the
bougie  has  only penetrated  a  short  way.  By  passing the  bougie
gently,  letting it worm its oavh way, as  it AATere, it will  naturally run
betAveen the membranes and the uterus Avhere  there  is least resist-
ance, turning round the edge  of   the placenta, if  this  organ lie in
its course.
   Some use  an  elastic  catheter supported in its  stilet,  and withdraAv
the stilet when the catheter has  been passed.  The stilet converts
the catheter into  a rigid instrument,  Avhich  is  objectionable.  An
elastic  bougie answers perfectly.
   If a  rigid  instrument  be used, there  is great likelihood of rupturing
the membranes ; and, although this  may happen at  some  distance
from the os  uteri, premature  escape  of the  liquor amnii may follow.
 The bougie  OAves  part of its efficacy, no  doubt, to the necessary
 detachment  of the  membranes from  the uterus ; but  not all,  since
 it  is found that labour more  surely supervenes if the bougie be left
 in situ for several hours.  (Krause, 1855.)
   I believe this  method is now the one most generally adopted.  No
 other method combines safety and certainty in an  equal degree.
   Puncturing the  membranes as a provocate  of labour is practised
 in  two ways.   The direct  puncture  at  the point opposite  the os
 uteri is probably the oldest  method  of  inducing labour.  It is the
 surest.   The immediate effect  of  draining off the liquor amnii is to
 cause concentric collapse of the uterine walls,  diminishing its cavity
 in adaptation to the diminished bulk of its contents.  This involves
 some  disturbance, probably,  in the utero-placental circulation.   The
 parts of  the  fcetus come into contact with the uterine wall.   Hence
 uterine contraction is promoted both by diastaltic excitation and by the
 impulse given by  the concentric collapse, or " form-restitution."
   In certain cases the  puncture of the membranes is the most  con- 
374
OBSTETRIC OPERATIONS.
venient, as where the object is to lessen the bulk of the uterus, and
ensure labour quickly.  But it is  open to the following objection :—It
is an inversion of the natural order of parturient events.  Some uterine
action, lubrication, and expansion of the  cervix ought to  precede the
evacuation of liquor amnii.  If this order  be not observed, the child is
apt to be driven  doAvn  upon the unyielding cervix, and the uterus, still
contracting concentrically, compresses the child and kills it.  And this
is all the more likely to happen in premature labour  from the greater
liability to shoulder-presentation and descent of the funis.
  This objection is to some extent obviated by a  modification of this
method.   Hopkins* recommended to pass the sound some  distance
between the ovum and the uterine Avails, and then to tap the amniotic
sac at a point remote from the os.   By this mode  it was sought  to
provide for the gradual escape of the liquor amnii.  This operation may
be regarded as  a compromise  between the direct evacuation of the
liquor amnii and Hamilton's method of detaching the membranes.   It
is an important  improvement,  and is  still successfully adopted in this
country and  in  Germany.
   Vaginal Dilatation.—In 1842, t Dr. Hiiter described  a method for
exciting labour by placing a calf s bladder, smeared with oil of hyoscy-
amus,  in the vagina, and distending it with  Avarm  water.   This
proceeding he repeated every day until labour set in, Avhich  usually
happened in from three to seven days.   Professor BraunJ substituted a
caoutchouc  bladder,  to which,  from the  purpose  to  which  it was
devoted, he gave the name of colpeurynter.   Von Siebold, Von Bitgen,
Germann, Birnbaum, and others,  adopted this modification.   Another
form of vaginal  dilator is the  air-pessary  of Gariel.   The earlier trials
with this instrument seem to  have been  especially unfortunate, since
six mothers  died out  of fourteen  ; and Breit saw inflammation of the
genitals and death caused by it.   I do not  think these  dangers  are
inherent in the method, if carefully pursued; but the principle of vaginal
dilatation and excitation  is certainly untrustworthy.
   Direct  Cervical Dilatation.—For the last sixty years various con-
trivances  for  mechanically dilating the cervix have  been tried.
   The idea of dilating the cervix by sponge-tents was announced by
Brunninghausen in 1820.   This was again advocated  in  1841  by
Scholler.   It has since been  in  constant  employment at home  and
abroad.   From  personal  observation I am  in a position to affirm that
this method  is very uncertain as to time.  Symptoms like  those of
pyaemia have ensued from the absorption of the foul discharges caused.
This accident may possibly be obviated by the use  of tents charged Avith
antiseptic agents.
       *" Accoucheur's Vade Mecum."  Fourth edition.   London, 1826.
       t  " Neue Zeitschrift fur Geburtskunde," 1843.
       X  " Zeitschrift fiir Wiener Aerzte," 1851. 
INDUCTION  OF  LABOUR.
375
  Osiander, Von Busch, Krause, Jobert, Dr. Graham Weir,  Bigby,
invented other forms of dilatatoria more or less resembling the urethral
dilators which have lately come into use.   These numerous  contrivances
attest the strength and prevalence of the  opinion  that it was desirable
to possess a power of dilating the  os and cervix uteri at will.  The
subject attracted the attention of Dr. Keiller, in Edinburgh, early in
1859 ;  and  in March of that  year  he,  Dr. Graham  Weir  assisting,
accelerated  a  labour which had  been provoked by other means, by
introducing Avithin the uterus the simple caoutchouc bag, and gently
distending it.
  The  case of Mr. Jardine  Murray* is  the first  published case I am
acquainted Avith in which fluid  pressure  was used to dilate the uterus
to accelerate labour.   It was a case of placenta praevia.  Mr. Murray
first detached  the placenta from the cervical zone after my method,
then introduced a flattened air-pessary betAveen the wall of the uterus
and the presenting surface of the placenta, and inflated by means of a
syringe.
  Dr.  Storer published  a case in 1859,1 in Avhich he introduced "the
uterine dilator " within the cavity of the uterus.  He especially insisted
that the  dilatation  " was from above downwards."   I saw inconve-
niences in the use of elastic bags,  expanding inside the  uterus, even
more serious  than those attending  the vaginal dilator or colpeurynter
of  Braun.   The  cervix it was  .that required  dilating,  and  a bag
expanding below it in the vagina, or above it in the uterus, could only
act upon  it indirectly,  imperfectly, and  uncertainly.    Besides, the
uterine dilator seemed unsafe ; during dilatation it must distend, stretch
the uterine walls at the  risk of injury and shock,  and it Avas very likely
to  displace the head  from the os uteri.
  I had long felt the desirability of bringing the  further progress  of
labour with placenta praevia, after having arrested  the haemorrhage by
detaching the  placenta  from the cervical  zone, under  more complete
control.  I had always  strongly insisted upon  the danger of forcibly
dilating the cervix with  the hand,  and before Mr. Murray's case was
published I was  engaged  in  devising  an elastic dilator  capable  of
expanding the cervix with safety.   The first form I  deAdsed was an
elastic bag, with a long tube mounted on  a permanent flexible metal
tube, having  apertures  at the end  inside the bag.  The metal  tube
served as a stem to introduce the  bag inside the cervix, to  keep it there,
and to carry  the water  for distension.   This form was  modified and
adopted by Tarnier,  of  Paris,  and  others, when I had abandoned it.
I at length realized my idea by perfecting the fiddle-shaped bags, which
are now in general use, and I have never yet seen any bags for cervical
dilatation but  those of my own contrivance.  The constriction in the
            * " Medical Times and Gazette," 1859.
            t " American Journal of Medical Science," July, 1859. 
376
OBSTETRIC OPERATIONS.
middle is seized by the cervix, whilst the two ends expanding serve to
prevent the instrument from  slipping up or down.   This instrument
imitates  very  closely the natural action  of the bag of membranes.
By its aid it  is very  possible, in many  cases, to expand the cervix
sufficiently to  admit of delivery  within an hour, although generally
it is desirable to expend more time.   I have completed delivery in five
hours, in four hours, and even in one hour from the commencement of
any proceedings.   In many cases of placenta praevia where there Avas
scarcely any cervical dilatation, I have effected full dilatation in half an
hour.   And there  is now accumulated  a  large body  of evidence from
numerous practitioners who  have  had  equal success  by aid  of my
instruments.
  In the paper in the Edinburgh Medical  Journal (1862) I proposed
that the first step in the induction of labour should be the full dilatation
of the cervix uteri, and after that to proceed to further provocation and
acceleration.  I related cases in which I began with dilating the cervix,
afterwards  rupturing the  membranes, further  dilating,  and turning.
I am  now convinced that, although this rapid method is Arery feasible,
and is even proper under some circumstances Avhere prompt delivery
is  urgently indicated,  it is desirable, under  ordinary  conditions, to
prepare the  uterus by  some preliminary excitation.
  Barnes' Method.—Having discussed the various methods of provoking
labour which have been practised, Ave are now in a position to select
the most safe, convenient, and efficient.   The plan I  ha\re successfully
practised for  some years is the following :—First,  overnight pass an
elastic bougie, No. 9 or 10, as  far as it will go into the uterus, and coil
up the remainder of the instrument in the fundus of the vagina; it will
thus keep in situ.   Next morning some uterine action will have set in.
The uterine neck  and  vagina  will be found soft, and freely lubricated
with mucus, and  some degree of cervical  expansion will have taken
place.  The bougie should be kept in its place until the child is ready
to pass.   In the  afternoon, at an  appointed  time, you may proceed,
if desirable, to accelerative measures.
  Before rupturing the membranes, adapt  a  binder  to the  abdomen,
and let this be tightened, so as to keep  the  head in close apposition to
the cervix.   This  will  often prevent the cord from being washed down
by the rush of liquor amnii.  Dilate  the cervix by the medium  or large
bag, until the cervix will admit  three or four fingers.   Then  rupture
the membranes, and, before all the liquor amnii has escaped, introduce
the dilator  again, and  expand  until the uterus is open for the  passage
of the child.   If the presentation is  natural,  if there is  room, and if
there  are pains, leave  the rest to Nature, watching the progress of the
labour.   If these conditions are not present, and one or other is  very
likely to be wanting, proceed  with accelerative  methods,—that is, to
the forceps or turning ; or, in  cases where the passage of a live child is 
                      INDUCTION OF LABOUR.                 377

 hopeless,  to  craniotomy.  By pursuing this method we may predicate
 with  great accuracy  the term of the labour.   Twenty-four hours in
 all—counting from the insertion  of the bougie—should  see  the  com-
 pletion of the labour.  The personal attendance of the physician during
 two hours is  generally enough.  But the mode of proceeding must vary
 according to  the conditions of the  case.*  In many cases it is desirable,
 being clear that the child is not imperilled by delay, to allow dilatation
 and expulsion to be effected as far  as possible spontaneously.  We must
 recollect that the safety of the child is best seemed by obtaining such
 full dilatation  of  the soft parts that  it may pass through easily  and
 quickly.
    What are  the conditions that call for the induction of labour ?
   Gestation  may be  divided arbitrarily into  two parts.   During  the
 first  part, terminating at 6£ or 7 months, or at the end of 180 or
 200 days, it  is  scarcely probable that  a viable foetus will be expelled.
 To induce labour within this period is really to  bring about  abortion.
 It  is, therefore, only  done under the pressure of conditions that pre-
 clude waiting till the child is viable,  and out of regard solely to the
 safety of the  mother.  BetAveen 200 and 230 days is a stage of  very
 doubtful viability,  and the physician will still endeavour to  postpone
 interference   until  after  the  latter  date,  when  the  operation  may
 be  undertaken  with  more  confidence of  saving both  mother  and
 offspring.
   In a large proportion  of cases we  are  able, within certain limits,
 to  select our time.   For example, where there is  moderate pelvic
 contraction,  admitting of the safe passage of a child a little below
 the full  size, we may be justified in  waiting until the  end of eight
 months—say 250  days.   The  difficulty is  to determine the starting
 point  of  pregnancy.  There is a  very probable  range of  error of  at
 least  15 days.  If  Ave count  15 days too many,  Ave reduce the dura-
 tion of pregnancy to 235 days—that is, Ave run the  risk of falling
 within the first part, when the child  is of doubtful  viability.  If, on
 the other hand, we count 15 days too few, we run the contrary risk
 of approaching  too near the natural  term of gestation, and of having
 a child too large to pass the narrow pehds alive.
  The best Avay, perhaps, of avoiding these two rocks is to reckon the
 pregnancy from  the day after the cessation of the last menstrual period,
 the most probable time  of  conception.   Count  230 days  from that
 epoch, and add 20 days  for a margin of safety.  This  will leave a
 full month, or  30 days,  to complete  the  deA^elopment of the  child.
 The cases  are few,  if all  the resources in the acceleration of labour
 are  turned  to account, in Avhich a child of  250 days  may not be
 deliA^ered alive.  But if we fall upon a child of 215 days or less, the
  *  For a series of cases illustrative of this  practice, see  "St. George's Hospital
Reports," 1868. 
378
OBSTETRIC OPERATIONS.
chances of its  surviving are very slight.   I regard ,the error  of pro-
crastination as  being generally  of  less moment  than the error  of
anticipation.   Of course, if the pelvic contraction is great—say  to
2-50"—it will be prudent not to calculate beyond 240 days, but rather
to incur the risk of bringing a non-viable child.
  In every case the first question to weigh is, whether you can
postpone interfering until  the child  is viable.   The  cases  of pelvic
contraction which do not permit of  this postponement are extremely
rare in this  country.   The answer is more difficult in  those cases
where the expediency of inducing labour  conies  under consideration
on  account of local and  constitutional disease of the mother.  In the
first case, by waiting too long, the mother encounters greater  danger,
and we may have to sacrifice  the child.   In the second case the  risk
of sacrificing the mother is even greater.
  It will be convenient to  enumerate first those conditions which,  in
the interest of the mother, and disregarding the child,  demand the
interruption of gestation during  the first part.
  These are,  A. Certain cases of extreme  contraction in  the bony  or
soft parts—e.g., distortion  and narrowing  of the  pelvis beloAv 2-00";
the  encroachment  of  considerable  tumours, especially  if  they  are
unyielding, upon the pelvic canal; some cases of advancing and exten-
sive cystic disease of the ovary ; great contraction from  cicatrices  of
the os uteri and vagina, not admitting of free dilatation ;  retroversion
or retroflexion of the uterus not admitting of reduction ; some cases  of
carcinoma of the uterus or vagina; some of tumours of the uterus.
  B.  Certain cases  of urgent  disease of the mother, depending upon
and complicating pregnancy—e.g., obstinate vomiting, with progressive
emaciation, and a  pulse persistent  for some days  above 120; some
cases of advancing jaundice, with  diarrhoea; some cases of  albuminuria,
convulsions being present  or apprehended;  some cases  of insanity
or  of chorea ;  haemorrhages producing marked anaemia,  especially if
depending upon commencing abortion or placenta  praevia  ; some cases
of disease  of the heart and lungs,  attended with extreme dyspnoea ;
such are aneurism, great hypertrophy, valvular disease, oedema of the
lungs, pleurisy.
  If, in the presence of any of  the  foregoing complications, Ave have
been  fortunate  enough to carry the  patient over the first  part of preg-
nancy, reaching the period when the child is viable, we  may still  be
compelled to induce labour.  The indications from disease beginning
in  the  first  part,   as  hasmorrhage,  convulsions, cardiac  distress,
vomiting, jaundice,  may grow more  urgent, or they may arise during
the second part.
  My experience leads me to conclude that in  cases of urgent disease
there is more frequent occasion to regret having delayed the operation
too long, than having had recourse to it too  soon.   When through 
INDUCTION  OF  LABOUR.
379
obstinate vomiting, for example, nutrition  has long been arrested, the
starved tissues craving for supplies, and falling into disintegration, feed
the blood with degraded and noxious materials ; the system feeds upon
itself and  poisons itself;   the  poisoned  blood  irritates the  nervous
centres,  and  these  centres, Avrought to  a  state of  extreme morbid
irritability, respond to  the  slightest peripheral, uterine,  or emotional
excitation.    All nervous  energy is thus  diverted  from  its natural
destination, and exhausted in destructive morbid action.    Irritative
fever ensues ;  the pulse rises to 140 or more.   No organ in the body is
capable of discharging its functions, for the pabulum of life is cut off at
the very source.   At this point, labour, whether it occur spontaneously,
as it often does,  or be induced artificially,  comes too late.   The tissues
are altered, the powers  are impaired beyond recovery, and  death  soon
follows delivery.
   The most  generally recognized indication is the presence of such a
degree of pelvic contraction as  to forbid the birth of a live child at
term.
   It was long thought that the  end of inducing labour prematurely,
namely, that of  securing a child whose size should be kept within the
capacity of the pelvis, might be attained by starving the patient, in order
to arrest the  development of the  child.   The  question has been  even
recently discussed in Italy.  Experience sIioavs that little reliance can
be placed upon this method.  Leonard  Sedgwick relates (St. Thomas's
Hospital  Reports, 1870)  a case of  obstinate  vomiting,  in which
nutrition was reduced to the lowest point compatible with life.  Preg-
nancy  ended in labour at term, when  a healthy child was born, quite
unaffected  by the severe regimen of its  mother.   It  seems that the
organism in  utero will attract to itself  all  it can  get, even at the
sacrifice  of the  parent.  This is often illustrated in phthisical women,
who, almost  dying of exhaustion, emaciated  to the  last degree, bring
forth plump  children.
   No one, I believe, disputes that where Ave have the choice, induction
of labour should be  performed where  the ultimate  alternative is the
C;esarian section ; and  this rule  should hold  whether the proceeding
hold out a hope of saving  the child or not.  It should also be resorted
to for  the  sake  of avoiding craniotomy.
   In the  great  majority of cases we are led to  determine upon the
expediency of inducing labour by the  history of  antecedent  labours.
Where craniotomy has been performed on account of contracted pelvis
clearly recognized, there can be little  ground for doubt.  But  why
should one or  more children  be sacrificed  in  order to  teach  the
physician that the pelvis is too small ?   Is there no other gauge of the
capacity  of  the  pelvis  than a child's  head?  Of course  it will  be
admitted that a  Avoman pregnant  for the  first time is equally entitled
to the benefit of the premature induction of labour, if it be known that 
380
OBSTETRIC OPERATIONS.
her pelvis is  too small.    The difficulty  is to  know this.   In this
country, and generally in private  practice, the opportunity of making
an obstetric estimate of the pelvis before labour is very rarely afforded.
The first labour at term is, therefore, the common practical  test of a
woman's  aptitude for child-bearing.   But on the Continent, where
a very  large proportion of women are delivered in hospitals, Avhere
they are  received one or  tAVO months before  the end of  pregnancy,
examination of the pelvis is  made on admission, and thus  they and
their children  come within the benefit of  this  proceeding.
  The object to be attained is the reduction  of  one of the factors of
labour  into due relation Avith the  other.   The  pelvis being a fixed
quantity,  the alternative is to bring the child through it at an early
stage of  its development.   By  referring  to  the  tables  giving  the
relations  of  the different  degrees  of  contraction to the  different
operations at term and at  seA^en  months  (see p. 69),  it will  be  seen
how the scale  of operations,  arranged  in  the  order of their severity,
may be  slid doAvn so that, when applied  to labour at seven months,
spontaneous  labour  supersedes  the   forceps,  the forceps  turning,
turning  craniotomy,   craniotomy  the  Caesarian  section  ;  so  that
nothing remains for the  Caesarian section.
  The modifications  proper to be adopted in different  cases are  as
follows  :—
  1. In the case of  pelvic deformity  not  admitting  the birth of  a
live child at term.
  There  are three degrees of contraction to  be considered.  The
first or least   degree, say, giving a  conjugate diameter  of 3*50".
In such a case a child of  seven  or eight  months' development will
probably pass  Avithout difficulty.  Here it may be enough  to provoke
the labour, and Avatch its  course, as in ordinary labour.
  The  second  degree, giving,  say, a conjugate  of 3-00".   In such  a
case,  unless  the child prove very small or timely aid be given, its
head may be delayed  so long  at the brim that it will be lost.  Here
it Avill be proper to provoke the labour by inserting the elastic bougie
overnight; to accelerate the  labour by dilating  the  cervix, rupturing
the membranes, applying the forceps, or turning.
  The  third degree,  giving, say, a conjugate beloAv 3-00", may admit
the forceps, but it  may be  necessary to  accelerate  the  labour  by
turning, or possibly by craniotomy.
  A double advantage is  gained  by bringing  on labour prematurely
when the pelvis is  greatly contracted. We not only secure a fcetal
head  that  is   smaller, but  also  one that  is more compressible.
During  the  last month  of  gestation, ossification   of  the  cranial
bones proceeds rapidly.   Taking  two heads, the one  at eight months
and the other  at the  full term of gestation, of equal size,  the  head
of eight months' gestation will, on account  of  its less perfect  bony 
INDUCTION  OF LABOUR.
381
development, come through the  same contracted pelvis  with more
ease, or may even come through alive, when the  equal-sized  head at
term would have  to  be  perforated.  This is  especially seen in those
cases  Avhere  turning  is resorted to as an  accelerative proceeding.
  The course to pursue is  as  follows:—If the uterus act Avith suffi-
cient power, and the  pelvic contraction be not so great  as to  impede
the passage  of  the child's  head, and the cord do  not  fall through,
watch, and let Nature do her  work.   But if  the  head be delayed or
the cord fall  through, we must intervene.  There are two alternatiATes.
We may first  try the  forceps.  But  if the conjugate is reduced to
3-00",  or beloAv, turning is the true  accelerate means.  If I may
trust my own  experience, I should, without hesitation, say the pros-
pect of  a child being  born alive under the  conditions  postulated
is much  better than under any other mode of delivery, and  even
better  than is  the prospect under turning in ordinary circumstances
at  the  full period  of  gestation.  The  explanation is  this:—The
smaller and more plastic head is caught at the smaller or bi-temporal
diameter between the  projecting  promontory  and the  symphysis
pubis ;  the jutting promontory leaves  abundant room on either side
in the  sacro-iliac region of the brim  for the cord to  lie  protected
from   pressure;  and, if  care  be  taken  that  the  cervix  uteri  be
adequately expanded, the  head  comes through  so  quickly that  the
danger of asphyxia  is  not great.  The  mode  of  turning  deserves
attention.   The object  being  to  secure  a quick  delivery,  the  soft
passages must be  well  prepared.  We might  turn by  the  bi-polar
method, without passing more  than twq fingers through the os uteri.
But I  have  found that, although it is ahvays well  to avail ourselves
more or less of the bi-polar  principle, it is  desirable, in this case,
to pass  the  greater  part of the hand through the cendx to grasp
the further  knee.  The reason is this :—The cervix that will admit
the hand will,  in all  probability, permit the ready transit of the
child.   We thus  secure adequate dilatation.
  When the turning  is completed, extraction  must  follow.  It should
be performed gently, drawing upon the one leg until the breech has
passed the outlet; the extraction of the trunk should be slow;  and
a loop  of cord should  be drawn  down  to take off tension.   If the arms
run up by the sides of the  head they must be quickly liberated.  The
rules given for  this operation  (see p. 171) are here of extreme import-
ance.  By observing them,  if the cervix is fairly dilated, the arms can
be brought doAvn  in a minute or two.   When the arms  are  liberated,
another  difficulty arises: the neck of the child is in danger  of being
nipped in the circle of the cervix.  This is the moment for acceleration.
The two legs  are held at the ankles  by the left  hand, whilst the
right-hand fingers are crutched over the back of the  neck  (see p. 176).
The head is sure to enter the contracted brim in the transverse diameter. 
382
OBSTETRIC OPERATIONS.
 It has then to describe the circle round the point of the jutting promon-
 tory, which I have defined (see Figs. 30, 31, pp. 71, 72) as the " curve
 of the false promontory," or Barnes' curve.  Traction must, therefore,
 be at first exerted in the direction of this curve or orbit—that is, well
 backAvards—so as to bring the head round and under the promontory.
 When  it has  cleared the  strait, and  is in the pelvis, the occiput
 commonly comes forward, and traction is changed to the direction of
 Carus'  curve,  to bring the head through the outlet.   Unless rigorous
 attention be paid to the above  rule for bringing the  head through
 the brim, so much time may be lost as  to imperil the  success of the
 operation.
   In cases of extreme deformity, in which it is difficult or  impossible
 to perforate or to seize a leg, if we have induced labour at six months,
 the foetus may still pass, if we give  time.  After making a  reasonable
 attempt to snare a foot, by manipulation and the Avire-ecraseur, if Ave
 leave the uterus to act for twelve or twenty-four hours, the child having
 perished and become moulded, some part of it, a foot or  shoulder, will
 come Avithin reach.   This can be  draAvn down ; the head can be per-
 forated, and then traction will deliver.   The placenta should also, if
 not following readily, be left for tAVO or three hours to be expelled.  By
 adopting this method,  I delivered,  in St. Thomas's  Hospital,  a six-
 months foetus, in  a case of great  osteomalacic  deformity, in which it
 was impossible to get two fingers through the brim.   By thus calling
 Nature  to our aid,  and practising  a little "masterly inaction,"  we
 avoided the Caesarian section, and  saved the woman.   This course
 applies  especially to cases of  osteomalacia in which  some amount  of
 yielding or unfolding of the pelvic bones may be generally obtained.
  In  dealing  with cases in which  the  induction of labour  is  indi-
 cated by urgent distress in  the mother, we must again be governed
 by a  careful estimate of the circumstances.    There is  no common
 rule.
  Take first the case of convulsions.  It has been seen over and over
 again that the convulsions have ceased soon after the uterus has been
 emptied.  Everything conspires to prove that  the  coiwulsioiis are due
 to conditions arising out of the pregnancy.  What, then, more logical
 than to terminate the pregnancy as soon as possible ?  Yet experience
 suggests caution  as  to the  mode  of acting.   In not a few cases the
 completion of labour has failed to put an end to the  convulsions.  In
 other cases death has followed labour,  whether  this have  occurred
 spontaneously or have  been induced.  Is the unfortunate  issue the
 consequence of procrastination in inducing labour, or of  over-haste or
 want  of precaution  in the mode of proceeding ?  I  believe it is due
 sometimes  to  one  cause and sometimes  to  the  other.
  The question of inducing labour before the actual  outbreak of con-
vulsions—that is, during the conditions that lead up to convulsions__ 
INDUCTION  OF  LABOUR.
383
does not often come practically before us.   We have, therefore, mainly
to do Avith the question Iioav best to  carry out a labour the indication
for inducing which is clear.   Is it to be done citissime ?  Is it to be
done  sloAvly and  deliberately ?   I  believe  the  latter principle is the
more judicious.   The  proceedings should involve the least possible
manual  or  other  operative  interference.    The  detachment  of  the
membranes or the insertion  of a  bougie is  too  sIoav in results.   It
is better to puncture the membranes.  This  at once  lessens the bulk
of the uterus, and diminishes the pressure upon the abdominal vessels.
If the convulsions remit, we may leave the labour  to  Nature.   If
urgent  symptoms persist, we may dilate the cervix carefully by the
cervical  dilators,  and accelerate by forceps, by  turning, or even  by
craniotomy,  according  to the special indications.  Before proceeding
to any operation, even making an examination or passing the catheter,
it will be wise to induce  anaesthesia.  In  uraemic eclampsia the dia-
staltic susceptibility is so inordinately increased that this precaution is
of extreme importance.
   A similar rule applies in  almost all cases where  the  induction of
labour is indicated  by urgent distress of  the mother, such as heart
disease,  or chorea.   In the case of dangerous vomiting  in  the early
months, it  will be  useful,  as a  preliminary measure, to insert  a
laminaria-bougie as far as it will  readily pass into the uterus.   This
will ansAver the  double purpose of detaching the ovum and dilating the
cervix.
   In retroversion of the uterus, irreducible, and with urgent symptoms,
the puncture of  the membranes is the proper  course.   We immediately
gain relief by permitting the concentric  diminution of the volume of
the uterus.
   There is a series of cases in which  the indication is  simply or
primarily to save the child.   There are certain conditions which tend
to destroy foetal  life before the term of gestation.   If we can bring the
child into the world before the anticipated period  of its death in utero,
we may hope,  by  bringing it  under  fresh influences, to save  it.
Denman gives the case of a woman avIio lost her children about the
eighth  month,  a rigor preceding.   He suggested  the induction  of
labour.   There are various diseases which are known to endanger the
child as they advance.   Such are hydrocephalus, syphilis of the child,
fatty  degeneration,  hypertrophy,  dropsy of  the  placenta.   In cases
where there has been no sufficient  opportunity of treating the mother
before  or during pregnancy, and where there is  a history of labours
ending  in  the  birth of dead children,  the  induction  of labour  is
indicated.
   There are cases in Avhich the wisest medical and ethical judgment is
required.   A Avonian  pregnant about six  months  is dying of phthisis.
Would it prolong her  life or improve  her  condition if labour were 
384
OBSTETRIC OPERATIONS.
 induced ? and should we be justified in sacrificing the child with that
 object ?
   A woman pregnant about  seven months is dying of phthisis.  The
 child is assumed to be viable ;  its life hangs  upon the fragile  thread of
 its mother's life, which may snap before the natural term of gestation
 is accomplished.   Are  we justified in inducing labour to rescue the
 child, disregarding the mother ? or is  such a course likely to prolong
 her life, or to accelerate her  death ?
   The decision in such cases is both perplexing and painful.
   Observation of the course of things when pregnancy is complicated
 with phthisis, lends material help in arriving  at  a  solution.  It  was
 long thought, and  I believe  some people still think, that pregnancy is
 antagonistic to the advance of phthisis.  If this Avere true, the decision
 would be obvious.  Let the pregnancy alone. But experience, I think,
 is adverse to the opinion that pregnancy exerts any beneficial influence
 upon phthisis.   I am sure I have seen, in numerous instances, phthisis
 advance with accelerated speed towards a fatal issue when complicated
 Avith pregnancy, the sufferer either dying before the term, or sinking
 rapidly after labour.
   It  is an  idea founded more, I am afraid, on imagination than  on
 facts, that Nature,  in her solicitude to perpetuate species, will struggle
 with unwonted energy to sustain the life of  the  expectant parent until
 the embryo is  matured.  Faith  in this hypothesis would  lead us to
 procrastinate.
   Putting aside  poetry not  supported by facts,  there are two con-
 siderations that offer material aid in arriving at a decision.    First,
 pregnancy is commonly less trying to a phthisical patient than  labour
 and childbed.   The puerperal state especially throws such an increase
 of work  upon the  circulation, that the system  often  breaks  down at
 this period.   It is  therefore desirable,  in the interest  of the mother,
 to postpone labour as long as possible.
   Secondly, the prognosis  in phthisis, even in cases  apparently  the
 most  desperate,  is  often open to grave fallacy.  Who has not seen
 patients whose days, whose hours almost, were counted, survive for
 months and years ?  In the interest of the mother and child, then,  it
 is not wise to take precipitately the irrevocable step.
  Fixing of the uterus by peritonitic adhesions, so that laceration or
 other mischief is apprehended  during the development of the uterus,
may necessitate induction of labour.  There is a  case in illustration
 which occurred  at  St. Bartholomew's,  reported in the Lancet  (May,
 1871).  But it is surprising how these adhesions may disappear  under
gradual stretching.   Their vitality is quickly destroyed, and they
undergo rapid atrophy.
  Lastly, there are cases in which the induction of labour is indicated
 to remove a dead child retained in utero. Usually, expulsive  action wiU 
INDUCTION OF LABOUR.
385
set in spontaneously  within two  or  three  days of the death of the
fcetus.  It Avill rarely be postponed beyond three weeks ;  but cases are
known where a much longer time has  elapsed.   There is a tendency to
postpone the act of labour, no matter  at what period the embryo may
have perished, until the expiration  of nine months.   And in some rare
cases of so-called " missed labour," one remarkable example of which
came under my care,* labour may be indefinitely postponed.  In these
cases the uterus will commonly have lost much of its active contractility
and other properties peculiar to the pregnant state. Simple provocative
means may be totally inefficient.  The cervix may have to be dilated by
fagots of laminaria-tents, and the child be extracted piecemeal,  perhaps
at several  sittings.
   Care of the Child.—Where we expect to deliver a live child we must
be prepared with means of rescue  from asphyxia.  (See Lecture XL)
And if we have the good fortune  to secure a living child, special care
AAdU commonly be necessary to rear it.   Born before its time, its
development is  necessarily  imperfect.   It  has a diminished power
of resistance  to  external  impressions.   Its  heat-producing  capacity
especially  is defective.  It  will depend very  much  more than  the
mature infant upon a supply of warmth from  without.  It should be
carefully surrounded with good non-conductors of heat;  kept in bed by
the side of its mother or nurse,  or by the fire;  care  should be taken
that the air it breathes should be warm—not less than 70° Fahr.   If it
must  be kept in a cot, put a hot bottle by its  side, and do not let
the nurse expose its surface to the  cooling influence of evaporation by
washing  it  too  soon or in  the  usual  way.   The experience of  the
couveuse, a  contrivance for keeping the child immersed in  water kept
at a uniform heat, is very successful at  the Paris  Maternite.
  I Avill conclude this subject by recalling attention to the  rule urged
by  Denman  and  his  contemporaries, namely, that  the artificial
induction  of  labour should only be undertaken after deliberate con-
sultation.   When Ave consider  the many and weighty medical, legal,
and moral questions involved in the arbitrary interruption of pregnancy,
we  shall  see abundant  reasons for  seeking  assistance in avoiding
possible clinical error, and for  sharing serious professional  and social
responsibility.
                     * "Med.-Chir. Trans.," 1882.
C C 
L E C T U B E  XXVI.
UTERINE HAEMORRHAGE—VARIETIES:  CLASSIFICATION OF—FROM ABOR-
    TION--CAUSES  OF ABORTION : MATERNAL,  OVULINE, AND FCETAL
    --COURSE  AND  SYMPTOMS  OF  ABORTION :  TREATMENT--THE
    PLACENTAL  POLYPUS--THE  BLOOD-POLYPUS--THE  PLUG--HOT
    WATER--PERCHLORIDE  OF IRON--PROPHYLAXIS--HYDATIDIFORM
    DEGENERATION OF THE OVUM.

The management  of  flooding involves so much operative treatment,
that a course of lectures on obstetric  operations cannot be  complete
Avithout a history of this subject.   Haemorrhage is  certainly one of the
most  frequent and most perilous of all the accidents that  threaten
the pregnant woman.   Often-occurring without warning, in impetuous
torrents, quick death  from shock and exhaustion  may ensue.  If not
immediately  fatal, the drained and  enfeebled  system, ill  adapted to
resist injurious influences, may sink in a few days from some form of
puerperal fever, from  thrombosis, or other complication.  And, if these
secondary dangers be escaped from,  there are  still to be encountered
the remote effects, sapping the strength,  perverting nutrition,  and
predisposing the patient to various  protracted diseases.  I have seen
almost complete blindness,  deafness, hemiplegia,  and other  forms of
paralysis persist as consequences of haemorrhage.
   The  action of the  physician must obviously, in the first  place, be
fixed on the endeavour to save life from the imminent peril.   But his
duty is far from ending here.  He has to take measures to prevent the
return of the flooding ; to rally the patient from the depression already
present;  and to secure  her against the  secondary and  remote  con-
sequences.   He will  draw the most valuable  indications in practice
from a  careful  clinical study of the  various  conditions upon  which
uterine haemorrhage depends. He must act on the aphorism that every
ounce, every dftrp  of blood that he can save, will be useful in averting
subsequent evil.  I insist upon this, because I have observed that many
men, perhaps most, are more afraid  lest the energetic use of the most
efficient agent in  stopping  bleeding may be more hazardous than the 
HAEMORRHAGE.
387
continuance of the bleeding itself.  This dread, I believe, I know, is
overstrained ;  and I earnestly beg those who feel it, and whose hands
are thereby paralysed, to reflect that the dangers  of haemorrhage are
great and certain, that the time for action is brief, that lost opportunity
is irretrievable ;  whilst the dangers apprehended from  the prompt use
of the great haemostatic agent, salts of iron,  are at  most problematical.
Whilst we are hesitating,  the  woman dies.  The  emergency justifies
some risk.   Even those who distrust the remedy should remember the
Celsian maxim :  " Anceps remedium melius quam nullum."   It is
eminently applicable here.   We should not  choose to  founder against
Scylla because Charybdis lay beyond.   We should  try and clear Scylla
at all hazards, trusting to skill and Providence  to clear Charybdis too.
If,  therefore,  means  be  pointed out  of almost infallible efficacy in
stopping haemorrhage, thus avoiding  the first rock, is it rational to
withhold those means for  fear of shock, air in  the veins, thrombosis,
septicaemia—rocks ahead  indeed,  but not necessarily  in  our course ?
  For  clinical purposes, haemorrhages  may  be  most  conveniently
divided into those Avhich  occur during  pregnancy,  and those which
occur during  and after labour.
  The first  order  of cases, those occurring before labour, includes
these three principal forms :—
  1. The haemorrhages during pregnancy, including  those of abortion.
  2. The haemorrhages from placenta praevia.
  3. The  haemorrhages,   so-called  " accidental,"  from premature
detachment* of the placenta, when not praevia.
                 1. The  Hemorrhage  of Abortion.

  Haemorrhage occurring  during early pregnancy is both a cause and a
symptom of abortion.
  Under normal conditions, the  relations between the ovum and the
uterus, both  in structure  and function, are so harmoniously balanced,
that the abundant  supply of blood attracted to the uterine vessels by
the developmental stimulus of the embryo finds its natural employment.
The demand keeps  pace  with the supply, and, the  structures being
healthy,  there is no extravasation.  But if this  healthy correlation be
in  any  way disturbed, haemorrhage is likely  to  occur.   Whatever
produces a state of  hyperaemia  predisposes to haemorrhage.   In preg-
nancy this hyperaemia exists in  a  high degree.   The developmental
nisus acts as a vis a froute, attracting blood  powerfully to  the vessels
of the uterus.  The  hyperaemia is  so great that a flaw anywhere will
.almost certainly  lead to a leakage of blood.
  The following  defect is the  most frequently  observed:—A morbid
                                                        cc 2 
388
OBSTETRIC OPERATIONS.
condition of the  mucous membrane, combined or not  Avith a morbid
condition of the muscular Avail of the uterus, and frequently attended
by abrasion or loss of epithelium.   The part thus affected is commonly
the  vaginal-portion of the cervix uteri.   The morbid action here is
aggravated  by the physiological  developmental stimulus ; and at  the
menstrual epochs, the additional stimulus of ovulation attracting still
more blood, the vessels, ill  protected by  the  diseased tissues,  break
down, and haemorrhage results.  Simple emotion,  or physical shock,
will often act in like manner, by directing a sudden  excess of blood to
the  uterus,  and taking  off the inhibitory action of the pelvic  vessels.
So  long as the blood only comes  from the os and cervix uteri,  the
embryo may be safe ; but  the haemorrhage itself may be injurious, and
a remedy should be applied.   In such  cases,  lightly touching  the
abraded congested surface with nitrate of silver a few times at intervals
of a week will commonly effect  a  cure.   It may be feared that such
local treatment will provoke abortion instead of preventing it.   Expe-
rience, however,  corroborates what physiological reasoning suggests,
namely, that the  cure of a diseased  action  in the organs of parturition
Avill contribute to the security of the pregnancy.   It is not desirable to
let  disease go  on because a  woman is pregnant.
  An analogous  form of haemorrhage is that  which arises from  the
decidual cavity during  the  first  six weeks of pregnancy, i.e., before
the decidua reflexa and decidua vera have  coalesced.    The  mucous
membrane of the  uterine  cavity, being unhealthy, pours out blood,
which escapes externally.   This involves far more  danger  to  the
embryo, because the extravasation is not likely to be strictly limited to
the free surface of the decidua ; it will probably  spread to  parts  in
connection with the chorion and young placenta.   The embryo then
perishes ;  and blood being retained in the substance of the placenta,
and some insinuating itself between the decidua and the uterine wall,
the uterine  fibre, put suddenly on  the stretch, is irritated, and spas-
modic  contractions, tending  to expel the contents, are set up.  This
spasmodic action, itself a new source of local  hyperaemia, adds  to and
keeps up the haemorrhage.
  There are, of course, many causes  of abortion;  but whatever  the
primary or  predisposing cause, the immediate or  efficient cause  of
abortion is  extravasation of  blood  into the decidua, and  between  the
decidua and uterine wall, leading to partial separation of the ovum.
When  things  have gone so far that  the integrity of the ovum is
impaired by extravasation of blood into the structure  of the  decidua
and  placenta, abortion is commonly inevitable.
  I  cannot  in this place discuss  minutely  the  numerous  causes,
maternal and ovuline, which lead to abortion;  they are described and
illustrated in Barnes' Obstetric Medicine and Surgery, vol. i.  In dealing
with threatening or present abortion, whatsoever the cause, the course 
HAEMORRHAGE.
389
of action is very much the same.   But,  as a guide  to prophylaxis, a
knoAvledge  of these causes  is  important.   They  may  be classified as
follows :—
                     A.  Maternal Causes of Abortion.
                               [ a. Communicated = Heterogenetic :   malaria,
                                    fevers, syphilis, various gases,  as  CO, CO>,
   I. Poisons circulating in the       lead> C0PPer' mercm'?> and certaiu  ™Setable
       mother's blood.          \     P0?0™'         , -,    •
                                /3. Products  of morbid action = Autogenntic :
                                    as bile-matters, albuminuria,  carbonic  acid
                               \     from asphyxia, and in the moribund, etc.
  II. Diseases  degrading  the  1 Anaemia,  obstinate vomiting, over-suckling, albu-
       mother's blood.          /     minuria, lithiasis, cholamiia.
 III. Diseases disturbing the circulation dynamically :  as liver-disease, heart-disease,
      lung-disease, excess  of vascular tension  (the vessels  of the uterine mucous
      membrane most naturally give way), engorgement of the portal system.
                             I a. Some nervous diseases, as epilepsy, chorea.
                                §. Mental shock, physical or emotional excite-
                                    ment.
       nervous system.          \ y. Diversion or exhaustion of  nerve-force : as
                                    from obstinate vomiting or convulsion.
                                5. Excess of nervous tension.
V. Local disease.
                                  ,  Uterine disease: as fibroid tumours, inflam-
                                     mation,  hypertrophy,  imperfect involution,
                                     diseased decidua.
                                  , Mechanical  anomalies :  as versions, flexions,
                                     pressure of  tumours  external to  uterus,
                                     adhesions  of uterus.
 VI. Abortion artificially induced,  Blows, squeezing, wounds,  direct interference
      with  the ovum.  Generally, the causes which  produce rupture ; abortion is
      an  escape from  rupture.
VII. Adolescent and climacteric abortion.

                     B. The Fcetal Causes of Abortion.
 I. Diseases of the membranes of  the ovum,  primary or secondary upon diseases of
      the maternal structures or blood, as—
    Fatty degeneration of the chorion or placenta.
    Hydatidiform degeneration of  ,,         ,,
    Inflammation, congestion of   ,,         ,,
    Apoplexy of                 ,,         , >
    Fibrinous deposits in          ,,         ,,
    Vicious attachment of the ovum, as in placenta praevia.
II. Diseases of the embryo : Faults of development—
    a.  Malformation.
    /3.  Inflammation of serous membranes.
    y.  Diseases of nervous system.
    8.     ,,    of kidney, liver, etc.
    e.  Mechanical, as from torsion of the cord.
In short, anything causing the death of the embryo.   Often the  causes are  compli-
cated, arising partly from  the maternal, partly from the fcetal side, and often it is
difficult to unravel these, or to discover the efficient cause. 
390
OBSTETRIC OPERATIONS.
  The careful study of the  etiology of abortion  has a use beyond  that
of guiding prophylaxis.  In a  given  case of threatening abortion, it
will  often furnish  important indications.  For instance, in some cases
it is  desirable to endeavour to avert the abortion, to arrest the process ;
but where certain diseases, as fever, severe blood-change, or conditions
causing dynamical disturbance  of the circulation  exist, abortion  is a
means by which Nature seeks relief from the double burthen.   We see
then that, in some cases, abortion is a conservative process.
  The double burthen may  overwhelm the powers of the system.   By
eliminating one burthen, the pregnancy, the case is reduced to its most
simple expression ; and the patient may successfully struggle through
the uncomplicated disease.   In such a case, the indication is to second
Nature by accelerating the accomplishment of the abortion.
  A  similar  indication  arises  in those  cases in which there  is local
disease rendering the continuance of  pregnancy hazardous or impos-
sible, as  retroversion, tumours,  etc.
  Also in  certain cases of  embryonic  disease,  where  the  previous
history, or our  knowledge  of the state  of the uterus or its contents,
establishes a strong presumption that  the embryo  is either dead or is
not likely to survive.
  Bearing these things in  mind, let us trace the ordinary course and
symptoms of abortion.  These  will vary somewhat,  according to the
cause and condition of the ovum and uterus.  The two great symptoms
are pain and haemorrhage.  There is reason to apprehend abortion if,
after a woman has missed one or more monthly periods, she complains,
about a  menstrual epoch,  of unusual  heavy  aching lumbar pains,
followed  by spasmodic  or  colicky pains in  the lower  abdomen  and
pelvis; and still more if a discharge of blood takes place.  But these
symptoms may pass away under rest, and the pregnancy go on.  When
this  occurs, we  may  infer that  there is no disease of the foetus or its
membranes incompatible with its life ; and that the symptoms are due
to  the recurrence  of the ovarian stimulus which is  the physiological
cause of  menstruation.
  The hyperaemia attending  the menstrual nisus may be the cause
of extravasations of  blood into  the  decidua  and between the  villi.
There, coagulating and hardening, through the removal of the watery
part  of the  blood, it may help  to form a solid mass, which may retain
connection with the uterus for some time longer, and be eventually
expelled as a fleshy mole.  No trace  of an embryo  may be discovered ;
but a  careful microscopical examination will reveal  the  elementary
constituents  of the  ovum,  especially   chorion-villi.   This  minute
examination  is  of great importance.    The  naked  eye may fail  to
distinguish a compressed ovum infiltrated with blood from  a fibroid
tumour or polypus, or from a compressed blood-clot.   I have known a
fibroid expelled spontaneously to be mistaken for an abortion.   It is 
ABORTION.
391
needless to point out how grave might be the social  consequences of
such an error.
  If things are going on to abortion, the haemorrhage will continue,
perhaps in  great  abundance.   Blot observes  that  where  there is
albuminuria the haemorrhage is greater.   The plasticity of the blood is
probably impaired.  Pains of a forcing or expulsive character persist
until, amongst  the discharges,  the  embryo, enclosed or riot in the
amnion and chorion  and decidua, is  found.    In  early  abortions,
occurring at from six weeks to two months, the embryo will  often pass,
enveloped in the chorion. The  decidua, or  mucous membrane of the
uterus, may adhere for some  time longer;  and so long as  it remains,
the haemorrhage and pain and the danger last.
  In abortions occurring at three or four months the  embryo is some-
times expelled alone in the first instance, the ovum  being burst under
the contractions  of the uterus.   Then,  the  membranes,  amnion,
chorion and decidua, and placenta follow.   But it may happen that the
ovum is not burst, and  then the  whole ovum will come away in one
mass.   This is more  likely to  be the  case  when the embryo has
perished some  time before its  expulsion, and  when the  process of
retrogression of the  media between uterus and placenta has  made
some progress.   Some diseased ova are the most liable  to be thrown
off in this entire form.   But if the abortion be the result of hydatidi-
form  degeneration  of the chorion, it is likely that  only a  part of the
diseased structure will come at a time.   Then, haemorrhage  AviU still
continue.   You must  carefully examine what  has passed, to see if
there is any appearance of parts being torn off, giving reason to infer
that more  remains behind.  You must also, in  every case, examine
per vaginam to ascertain if there is anything  in the uterus.
  The first question of a practical nature is,  Can  the abortion be
averted ?   Can gestation continue ?
  If you  think abortion may  be averted,  the methods of- allaying
nervous excitement must be called into exercise.  I must refer to the
lecture on "Bupture"  (Lecture XXI.) for a discussion on the value of
" epichontocics"  or " amyosthenics."   These agents may here find
useful  application.
  If you have found any portion of the embryo or membranes in the
matters expelled, you  must give up the hope of this.
  If you find very active expulsive pains, attended with free haemor-
rhage, affecting the patient's strength, and if the os uteri is opening so
as to admit the finger freely, you may, even if no portion  of the  ovum
has been expelled, give  up the hope of  averting abortion.
  The sooner the ovum, or the remains of it, are  voided, the sooner
the patient will be out  of danger.  This, then, is the first indication.
Empty the uterus.  How ?  Sometimes you will feel the ovum project-
ing partly  through the os.  It feels like  a polypus.  In this case it is 
392
OBSTETRIC OPERATIONS.
probably detached, and under proper manipulation it will come away.
The method  of proceeding is as  follows :—The patient placed on her
back or on her side, with the thighs flexed so as  to relax the abdominal
walls, you press with the palm of  one hand above the symphysis pubis
upon the fundus of the uterus, so  as to  depress the organ well into the
pelvic  cavity.  By this  manoeuvre  you  carry  the  os lower  down,
making it more accessible to the finger  passed internally, and  you
support the  organ  by providing  counter-pressure.  This  singularly
facilitates the penetration of the cavity by the finger,  which must
generally pass to  the fundus, in  order  to get hold of  the  ovum  and
scoop it out.
  Generally,  the  uterus,  in abortion, is low in the pelvis;  and the
vagina being  relaxed, it is not difficult to reach the os.   There is a
characteristic dilatation of the  fundus  vaginae  present whenever the
uterus  is acting to expel  something with haemorrhage.   This is of
importance in diagnosis.    But not seldorif, although the  os can be
reached, it may be necessary, in order to command the uterus and its
contents, to pass  the hand into  the vagina.  This is  a very painful
proceeding, and calls for anaesthetics.   This is more especially the case
if the ovum adheres; then, the fingers must be swept  Avell round the
cavity of the uterus—even at the  fundus.   The  decidua may thus be
broken up, and only pieces will come  at  a time.
  Various ovum-forceps have been  devised  for the purpose of seizing
the ovum and bringing it away.  Levret  and Hohl, amongst others,
invented forceps of this kind, and  Stark  contrived a form  of spoon.  I
have used several of these instruments ;  but,  after trial of them, I
prefer  the hand.   The hand gives you information  of Avhat you  are
doing as you go on ; and it acts by insinuating the  finger between the
ovum and the uterus,  peeling one from the other, not  by avulsion,
as the forceps must do.  Besides, you know, if you  use your fingers,
exactly what has  been accomplished,  if  any part of  the  ovum  has
been left behind,  and you avoid the  risk of injuring the uterus.   But
where  the vulva  is small, and the ovum is projecting through the
os externum, forceps  guided by the  finger may be useful.
  I have said that there is no security  against  return of haemorrhage
whilst the ovum  or  a portion  remains  behind.   But  there  is an
exception to this  rule.  I have frequently observed, in cases  where it
was not possible  to bring away the whole ovum, that the remains, if
much  broken up, did no harm, and  that  the haemorrhage ceased.
The debris gradually become disintegrated; and  involution goes on
unimpeded.
  Sometimes a portion of  decidua and placenta adheres so intimately
that it cannot be removed by the fingers.  Projecting into the uterine
cavity, it forms the placental polypus.   If haemorrhage continue, this
may be removed by the wire-ecraseur, which will shave it off smoothly 
ABORTION.
393
from the  surface of the uterus.   I  believe this is the best and safest
way of dealing Avith these masses.  There is another  condition to be
considered here.   Sometimes, blood collecting in the cavity of the
uterus  gets  compressed, so that  the  fluid portion being squeezed out,
the fibrin forms  a firm body, which may adhere to  the wall of the
uterus.   This  is the blood or fibrin polypus.   Kiwisch thought  it
might arise from a kind of uterine apoplexy, independent of conception.
But  Scanzoni  is probably right  in  regarding it as consequent  on
abortion.   The stalk  is commonly  formed  of  a shred  of decidua
adhering to the uterine wall.   Just like an ovum or bit of decidua, it is
a cause  of haemorrhage by irritating the uterus, inducing  spasm or
colic.  It can commonly be scooped out  by the finger, although pre-
liminary dilatation  of the cervix  by laminaria-tents may be necessary.
  When the embryo has been expelled, the uterus  Avill often  close
upon the membranes; the cervix  contracts, imprisoning them; and the
uterus in its imperfectly developed state having little  expulsive power,
there is retention of the membranes.  Betention is often complicated
Avith adhesion.   Then  I have often found fibrinous  deposits in the
placenta.  These tAvo conditions sometimes require time to overcome.
The  consulting practitioner here occasionally reaps  credit  which  is
scarcely his due.   He is called in, perhaps, on the third day, or  later,
when the adhesion of the decidua to the uterus is breaking down.  He
passes  in his fingers and extracts at once.  But  had he tried the day
before he might  have failed,  like the medical attendant  in  charge.
  1.  The first difficulty to overcome is the narrowing of the cervix.
Whilst using means to  dilate the cervix, you may use the  ordinary
means  to control the  haemorrhage.   There are  medicines,  as  ergot,
cinchona, strychnine, turpentine, hamamelis, which are to  a certain
extent  useful.  The most frequent  resource is  cold, either in the
form of  cold  water applied  to  the  abdomen and vulva, or in the
form of ice  in the vagina.  But  hot Avater is  far more efficient and
safe.  A stream of water at  110° F. Avill often act like a charm.
  The  most efficient  internal  remedy  is  turpentine;  but, like  all
others, it  is apt to fail.  It is better not to  rely upon these agents,
but to  proceed at once,
  2.  To  plug.—The usual plan  is to plug the  vagina;  but this  is
really unscientific and  illusory.   In a  short  time,  the vagina con-
tracting, squeezes the plug, compressing it to a calibre that no longer
fits the canal; blood flows freely past it or collects about  it.   The
proper  way to plug was pointed out to me some  years  ago by Dr.
Henry  Bennet.   You must plug the  cervix uteri itself.   This may
be done through  a speculum, pushing small portions  of lint  or sponge
into  the  cavity by means of a sound.  It is well to tie a bit of string
round each  bit of  plug, to  facilitate removal.  This  is a true plug ;
it arrests haemorrhage  and favours  the  dilatation of  the cervix. 
394
OBSTETRIC OPERATIONS.
  But  in the  sea-tangle,  or laminaria digitata, introduced by  Dr.
Sloan,  of Ayr, we  possess an agent  that surpasses all  others for the
purpose.
  The  tangle may be used either perforated as  a tube two or three
inches  long, or  solid.   For  ordinary purposes, especially in the non-
pregnant state, where  the os and cervix are very small, the tubular
form is most convenient.  To introduce a plug  of this kind,  it may
be mounted on a wire attached to a  stem provided with a canula.
Thus mounted, the plug is carried into  the  uterus like a sound;  and
when in,  the  wire is Avithdrawn, and  leaves the plug in situ.   The
instrument-makers sell  an instrument of this kind designed by  me.
But a flexible catheter, cut down at the end, so as to leave about two
inches  of the wire  stilet bare, upon  which  the tangle-tube can be
mounted,  answers very Avell.  If desirable, three  or four  tubes  can
be introduced together, forming  a fagot.   By this means more rapid
and  complete dilatation  of  the cervix can  be  obtained.   In cases
of abortion, however, I have  found it more  convenient  to take a solid,
smooth piece  of  laminaria  about four  inches long,  the calibre of a
No. 8 or No. 9 bougie, and to  give it a slight curvature at one end.
This curve very much  facilitates  introduction, and the length  of the
plug enables one to pass it  as easily as a sound.  It  may be passed
as far as it will go Avithout  obstruction, that is, generally about three
inches  within the os  uteri, leaving an inch  projecting into the vagina.
Thus it is maintained  in situ.  In  a few hours  it vsdll have swollen,
so that,  if  passed  overnight,  next morning,  on removing  it,  the
finger will be  admitted Avith  ease.  During its expansion, the haemor-
rhage will have stopped ; and on its removal you will  generally find
the ovum fit  to  be  detached.   During the  stretching of the  cervix
by the laminaria,  vomiting  occasionally occurs.   For  this it  is  well
to be prepared.  Whether  sponge-tents or  laminaria  be used, they
should be impregnated with iodine to obviate  foulness.   My caout-
chouc  water-dilators are sometimes  used for  this purpose ;  but they
are hardly adapted for the early stages of pregnancy.  The laminaria
is far more convenient.
  3. When  the cervix has been well dilated, and the uterus has been
emptied  of  its contents,  there is rarely any more  hasmorrhage; the
patient is then generally safe.  But if there should be  any return,
I strongly urge, if  injecting hot water  fails, the  application of an
iron styptic to the inner surface of the uterus.   This  acts as a direct
styptic, and may be  relied upon to  check  any further  bleeding.  The
mode I prefer  in  these cases, where the cervix  is widely open, is  to
soak a piece of sponge, fixed on a  whalebone stem, in a mixture of
one part of the strong liquor ferri perchloridi of the British Pharma-
copoeia Avith three of  water, and to pass  this into  the  cavity of the
uterus as a swab.  A  difficulty sometimes  experienced is, that the 
ABORTION.
395
moment the charged  swab touches the cervix, the constriction caused
arrests its further  progress.   Where this is  the case, it is necessary
to pass a small tube like a catheter, and  to inject very slowly a small
quantity,  say half an ounce, of  the solution  through it.  I  have
recently contrived  a  more  convenient instrument.   It  consists  of  a
large tube of vulcanite, having large holes  at the  uterine end.  At
this  end  it  is charged Avith pieces  of sponge soaked in the  styptic
solution.   The styptic is  thus carried  quite into the uterine  caAdty,
none escaping by the way.   When in  sitH, the fluid is  squeezed out
by ramming down the  sponge with a piston-rod.   In  this  Avay aU
injecting force is obviated.
  I must  caution you not to rely upon the topical use of perchloride
of iron before the  uterus is cleared.   There is  no  substitute  for, no
evasion of, this primary duty.
  It must be remembered  that  a patient who has suffered abortion
is liable  to all  the puerperal affections that assail  women who  have
been deliArered at term.  To most  of  these affections  loss of blood
strongly predisposes ;  hence  the  importance  of stopping the  haemor-
rhage as  quickly as we can.
  The after-treatment  of  abortion  is:—1.   Immediate, directed  to
obviate  or mitigate the  concomitants or consequences of abortion,
that  is,   anaemia,  the risk  of  inflammation, and other puerperal
accidents.
  The first kind of treatment is restorative, and the great condition
of restoration is rest.   The woman who has suffered abortion should
be kept  for  ten days in bed, and made to  conform to  all the  rules
that govern  the lying-in chamber.   The neglect of  this precaution
is the source of much immediate danger, and of many  ulterior affec-
tions that sap the health, and lead to protracted misery.  Women are
apt  to think lightly of a miscarriage ;  and many medical practitioners
who have not seen the more severe  cases   countenance this  error.
They can scarcely  be  persuaded  that  abortion may  cause death.  It
is a  common belief that the haemorrhage, however  profuse, will stop
in time,  and  that  the patient is sure to rally; but  this is  not the
experience of those who are largely  consulted  in  difficult cases.  I
have biOAvn not a feAv deaths from primary haemorrhage and shock,
not a few from septicaemia, some  from inflammation, and I  have seen
many women who have, indeed, escaped with  their lives, but only
to suffer  for years afterAvards from  anaemia, and other  disastrous
consequences.
  2.  Curative and prophylactic, that  is, aimed at  the  causes which
led to the abortion.   This  is  much neglected  in practice.  In every
case there is an efficient cause.   The hope of preventing recurrence
of abortions depends upon  our  tracing  it   out.  Do not sit down
disarmed  and passive under the influence  of  that ignorant  dogma 
396                 OBSTETRIC OPERATIONS.
which  asserts that women  have a habit of aborting,  that  they  are
labouring under  an "abortive  diathesis."   This  is no more than
saying that  women abort  because  they abort,  which  is  not very
instructive.   The " habit of aborting"  is real thus far : quick recur-
ring impregnations find  and keep  the  uterus in a state  of chronic
sub-involution.   But, then, this  is the efficient  cause of the abortions.
  The management of  haemorrhage  from  hydatidiform degeneration
of the  ovum requires a little special consideration.  As I have already
said, haemorrhage may recur in repeated  attacks, alternating with
watery discharges, and  only portions of the ovum may come away.
The discharges, if carefully examined, will show shreds of membranes
having the characteristic cystic  enlargements.  Sometimes these can
scarcely  be recognized without  a magnifying  glass.  Whenever they
are recognized, the indication is  clear to proceed to empty the uterus.
A strong presumption  that the case is  one of hydatidiform, or of
some  other degeneration of  the  ovum, is justified when such a degree
of enlargement of the  uterus is verified  as  does  not  correspond with
the  calculated  date  of the  pregnancy.  The uterus  is  commonly
smaller than it  should be, and  it is  often  softer, more pulpy  to  the
feel.  There  is  little or no prospect of a live foetus when cystic
disease has  once begun.   In the majority of cases, no  embryo at all
is found.  But  it is an  error to suppose, with Mikschik and Graily
Hewitt, that  this disease is  ahvays secondary upon the death of the
embryo.   Many instances of  living  foetuses with  a cystic  placenta
have  been  recorded,  for  example,  by Perfect, Martin  of Berlin,
Villers, and Krieger.  There is  every reason to believe that, in many
cases  at  least, it is the advancing  cystic degeneration  of the chorion
that destroys the embryo.   In  many cases  the cause of the chorion-
change must be sought in a primary disease  of the  decidua.  Virchow
and others describe the decidua as hypertrophied.  There is  hyper-
plasia with intimate adhesion of the mucous membrane to the uterine
wall.   In this state the  chorion-villi shoot  into the substance of the
morbid decidua ;  and not only that, but may actually penetrate deeply
into the waU of the uterus itself.   When this  happens, there is such
continuity of structure  that complete detachment of  the  ovum is
impossible.   Volkmann relates (Virchow's Archiv, 1868) a case of this
kind.   In consultation  with the  late Dr. Hassall, of Bichmond, I saw
a remarkable example.  These  extreme cases are, of  course, excep-
tional ; but they illustrate the common condition, that there is disease,
hypertrophy, and more or less intimate adhesion of the decidua.  The
lesson in practice is this : although we ought always to endeavour to
detach the whole ovum  by passing the fingers, or the hand, if necessary,
into the  uterus, we must  not persevere  too pertinaciously in this
attempt, lest  we inflict injury upon the uterus.  Take aAvay all that will
come readily, and then, if haemorrhage return, inject hot  Avater, and, 
ABORTION.
397
that failing, apply the perchloride of iron.  Sometimes the diseased OAorm
Avill come aAvay in one mass, moulded to the shape of the cavity of the
uterus.   Still,  in these cases the decidua will show  evidence  of being
hypertrophied.   The surface will  be covered with thick shreds;  and
decidua may be traced into  the substance  of the diseased mass.
  In  every case of abortion, I think it is  important  to  apply a  firm
bandage to the abdomen  afterwards.  This, by depressing the fundus
of the uterus and promoting contraction, lessens the danger of sucking
in air,  and consequent septicaemia.  It  is desirable,  also, when the
discharges are at all offensive, to Avash  out  the  vagina with weak iodic
solution or carbolic acid.
  But I Avould submit it  as a rule, that whensoever the discharges are
offensive, the presumption is that there is something in the uterus  that
ought to be removed.  To clear  up this point, never fail to  make a
thorough exploration.   You  may be  satisfied that the uterus  is clear
if—1. There is no  offensive discharge ;  2. If the os  uteri is closed ;
3. If the sound shows the uterine  cavity to be only 2-50" long, i.e.,  that
involution has proceeded to its normal extent. 
LECTUBE  XXVII.
PLACENTA PREVIA—HISTORICAL  REFERENCES :  MAURICEAU,  PORTAL,
    LEVRET,  AND  RIGBY -- MODERN  DOCTRINES  EXPRESSED  BY
    DENMAN,  INGLEBY,  CHURCHILL,  AND  SIMPSON — THE OLD  AND
    THE AUTHOR'S  THEORIES OF  THE  CAUSE  OF  HEMORRHAGE IN
    PLACENTA   PREVIA — THE  PRACTICE  OF  FORCED   DELIVERY,
    DANGERS OF—THEORY OF PLACENTAL SOURCE OF  HEMORRHAGE,
    AND  METHOD  OF  TOTALLY  DETACHING  THE  PLACENTA--THE
    COURSE, SYMPTOMS, AND PROGNOSIS  OF  PLACENTA  PREVIA —
    THE AUTHOR'S  THEORY  OF PLACENTA PREVIA,  AND  TREATMENT
    —THE PLUG—PUNCTURE OF THE MEMBRANES—DETACHMENT OF
    PLACENTA  FROM CERVICAL  ZONE--DILATATION  OF  CERVIX  BY
    WATER-PRESSURE — DELIVERY--SERIES  OF PHYSIOLOGICAL PRO-
    POSITIONS  IN  REFERENCE  TO  PLACENTA  PREVIA--SERIES  OF
    THERAPEUTICAL  PROPOSITIONS--THE SO-CALLED "ACCIDENTAL
    HEMORRHAGE."

                         Placenta Previa.

Greatly extended personal  experience, and the  testimony  of many
excellent observers in this country and abroad, confirm the soundness
of the theory of placenta praevia which I first enunciated in the Lancet
of* 1847, more fully unfolded in the Lettsomian  Lectures  of  1857,
illustrated in various subsequent publications, in the preceding editions
of this  work,  and in the second volume  of Obstetric Medicine and
Surgery, by Bobert  and Fancourt  Barnes, 1885.   From  this theory,
as from  preceding theories, distinct rules  of practice logically follow.
To obtain a clear appreciation of the principles which should  govern
us in the difficult task of managing  a  case of placenta praevia, it is
therefore desirable to begin Avith a statement of the physiology of the
subject.  This I will make as brief as possible, bearing chiefly in mind
the practical purpose before us.
   Before the time of Levret  and Bigby there could scarcely be  said to
be a  clearly-reasoned-out theory of placenta praevia.   The treatment 
PLACENTA  PREVIA.
399
was purely empirical, using the Avord in the Celsian sense.   Although
it  was known to  obstetricians, especially to Giffard and  Portal, that
the placenta might be implanted over the cervix uteri, the distinction
between haemorrhages depending upon  this and upon other conditions
was not accurately defined.   In all haemorrhages of a severe character
occurring during pregnancy, the indiscriminate practice inculcated by
Guillemeau, Mauriceau, and their successors, of emptying the uterus,
was  blindly followed.   This practice, rightly called the accouchement
force, consists in  forcing the  hand, if necessary, through the cervix,
in seizing and extracting the  child, and in removing  the secundines
as quickly as  possible.  The guiding theory Avas very  simple:  it was
a rough  deduction from  observations  shoAving that the haemorrhage
generally  stopped when the delivery Avas  complete, and that  unless
delivery Avere effected the haemorrhage went on.
   LeATret  and  Bigby, observing Nature more closely, grasped with more
precision  the  special bearing of the  implantation  of the placenta over
the cervix as  a cause of haemorrhage.  They believed that so long as
the labour  continued the haemorrhage would  go on, even increasing.
The logical conclusion again was, that it was necessary to empty the
uterus as quickly as  possible.   Bigby at one  time drew a broad dis-
tinction  between  the  management  of haemorrhage  depending on
placenta  praevia,  which he called  " unavoidable," and haemorrhage
arising  on  detachment of placenta  growing at its normal site, which
he called " accidental."  In the first, he says, " manual extraction of
the foetus by the feet is absolutely necessary to save  the life  of the
mother;  in  the  second species such  practice  is  never required."
Later, hoAveATer, he admitted  that "assistance might  be required  in
accidental haemorrhages."
   Almost all  subsequent authorities concurred in accepting the doc-
trines, and in adopting the practice of Levret and Bigby.
   This is Denman's opinion : " It is a practice established by high and
multiplied authority, and sanctioned by success, to deliver women by
art, in all cases  of dangerous haemorrhage, Avithout confiding  in the
resources of the constitution.   This practice is no longer a  matter of
partial opinion, on the propriety of which we  may think ourselves  at
liberty to debate ;  it has for near two  centuries met the consent and
approbation of every practitioner of judgment and reputation in this
and many other countries."
   The folloAving quotation from Ingleby may be taken as expressing
the theory almost uniATersally  recognized until recently :—" And thus
the placenta Avill undergo a  continuous separation, corresponding to the
successive expansion  of the neck, until nearly  the whole of the surface
is dissevered from its uterine connection.  From this it is evident that
when the placenta is affixed either  to the cervix  or os uteri, whether
wholly or partially, the vessels will  become exposed on  each successive 
400
OBSTETRIC OPERATIONS.
detachment, and  the  ultimate  safety of the patient will depend upon
delivery by  turning the  child, excepting,  perhaps,  in two  peculiar
states, in Avhich rupture of membranes is the only treatment offered to
us in  one  case, and the safest,  and therefore the most  eligible, in the
other.   Pain, efficacious as it is in the accidental form of haemorrhage,
unless adequate to the expulsion of the child, is  neither to be expected
nor to be desired, to any material  extent, in the unavoidable form, as
it  only  renders  the effusion more abundant;  for though a  certain
degree of relaxation is necessary, it must be remembered that in exact
ratio as  the cervix uteri is successively developed, and the  os internum
progressively dilated, will  an additional mass  of placenta be detached
from  its connecting  medium,  and haemorrhage  necessarily  be re-
newed."'"
  Churchill t speaks no less distinctly : " The flooding is the necessary
consequence of the dilatation of the os uteri, by which the connection
between the  placenta and uterus is separated, and the more the labour
advances, the greater the disruption and the more excessive the haemor-
rhage. From this very circumstance it follows that the danger is much
greater than in the former cases (of accidental haemorrhage), and also
that what  in them was the natural mode of relief is here  an aggra-
vation of the evil, and  cannot  be  employed as  a remedy."
  What theory can be more hopeless ?   Pain, that is,  contraction, is
the thing wanted, but if it comes it brings danger with it!  Expansion
of the cervix uteri is a necessary  condition of labour,  but the cervix
cannot expand without causing  more  haemorrhage !   Nature is utterly
at fault.  She is condemned  Avithout appeal.   Art must  take  her
place.
  Those, therefore, who accepted the theory of Levret and Bigby, were
confirmed in the old practice of delivering at once at all  hazards.  The
accouchement force received the  sanction of modern  science.  But
absolute laws seldom endure long without  question  or mitigation in
practice.  Mauriceau had long  ago discoA-ered  that, in  some  cases of
partial placental presentation, rupture of the membranes and evacua-
tion of the Uquor amnii was enough to arrest the hasmorrhage.   Sub-
sequently, Puzos  defined with more precision the  cases in  which
rupture  of the membranes might be practised.   Wigand and d'Outre-
pont avoided the accouchement  force  as much as possible, trusting to
the plug and rupture of the  membranes.   Dr. Bobert  Lee J  says :
" The operation  of turning, which is required in all cases of complete
presentation, is not necessary in the greater number  of  cases in which
the edge of the placenta, passing into the membranes, can be distinctly
felt through the os uteri.  If  the os uteri is  not much  dilated or
         * " Uterine Hemorrhage," 1832.
         t "Theory and Practice of Midwifery," 1855.
         + " Lectures on the Theory and Practice of Midwifery," 1844. 
PLACENTA  P1LEVIA.
401
 dilatable, the best practice  is  to  rupture  the membranes, to excite
 the uterus to contract vigorously,  by the binder, ergot, and all other
 means,  and to leave the case  to Nature."
    Since the time of Levret, says Caseaux, the insertion of the placenta
 over the neck of the uterus has been considered as an  inevitable cause
 of hasmorrhage during the last three months of pregnancy and  during
 labour.   The loss is  then, says Gardien, of the very essence of preg-
 nancy, and especially of labour.   The current opinions apply  to the
 separate conditions of pregnancy and of labour.  The explanation  of
 haemorrhage during  pregnancy is  as  follows :—Until  the fifth  month
 the body only of the uterus  undergoes any considerable change ; but
 from that date the neck participates.   The shortening it undergoes is
 attended by enlargement of its base,  at the head of the os internum.
 The placenta, fixed  and immovable on the spot where it is  planted,
 cannot folloAv the expansion of the  upper part of the neck; hence the
 connections between  placenta  and uterus are torn, and haemorrhage
 necessarily results.
   This doctrine, passed on traditionally, and accepted  almost without
 question, is undoubtedly founded on  an anatomical and physiological
 error.  Stoltz clearly shoAved that the cervix proper contributes in  no
 Avay to the  reception  of the ovum.   I have repeatedly felt the cervical
 canal entirely closed above by the narrow os uteri internum at the end
 of pregnancy.  The  freedom of the cervix  has also been  ascertained
 by dissection of women  dying  after labour.   And  if the explanation
 referred  to  Avere true, haemorrhage  would be  far more frequent; for
 the rapid expansion  of the cervix,  if physiological, should  be a con-
 stant condition, and  the uterus must infallibly always  grow  aAvay
 from the placenta.
   Then, as to the haemorrhage occurring at the time of labour,  Avhich
 is attributed to the active expansion of the cervix, casting off placenta.
 Is this consistent Avith clinical observation ?   If you reflect upon what
 is observed, you will see that  it can be  only  partly true.   It  is an
 indisputable fact that haemorrhage, frequently at least, and I believe
 commonly,  begins before there  is any expansion of the cervix at all.
 The true  explanation is,  I  submit,  the  very reverse of that generally
 accepted.  What is the part  endowed with  the most active groAvth ?
 Is it not the ovum,  the placenta ?  The growth  of  the  uterus  is
 secondary;  it is the result of the  stimulus of the ovum.   The first
 detachment of placenta, then, arises from an excess in  rate of groAvth
 of the placenta over that of the lower zone, a structure which was not
 designed for placental attachment, and which is not fitted to keep pace
 Avith the  placenta.  Hence loss of relation; the placenta shoots beyond
 its  site, and hasmorrhage  results.   Hasmorrhage is most common at
the  menstrual epochs,  and has not necessarily anything  to  do with
labour.   At  the menstrual nisus there  is an increased flux of  blood
                                                          D D 
402
OBSTETRIC OPERATIONS.
 to the uterus and  to the placenta.   This over-filling of the placenta
 makes it too big to fit the  area of its  attachment; it breaks aAvay at
 the margin of the os, and blood escapes.  Under the irritation of this
 partial detachment, the infiltration of some blood into the substance of
 the placenta, which increases the  bulk  of the organ, and the insinua-
 tion of some blood,  perhaps clotting,  between the placenta and  the
 uterine wall, active contraction of the  uterus  may be excited.   Then
 the retracting  lower zone  may detach more  placenta.  But this is
 secondary.   And what  I  shall  presently set  forth will abundantly
 prove the error of the theory that  "the placenta will undergo separa-
 tion corresponding to the successive expansion of the neck, until nearly
 the whole of the surface is dissevered from its uterine  connection."
 The severance will never go beyond the lower zone.
   The vieAv  just enunciated, that the first loss of relation  betAveen
 the  placenta  and  uterus is due  to the excess  in  rate of  growth
 and  periodical hyperaemia  of  the placenta, is strengthened  by the
 analogous case of Fallopian  gestation.   Like tubal  gestation, gestation
 in the lower segment of the uterus is an example of error loci; both are
 alike in being instances of ectopic gestation.   In both cases  the ovum
 grows to a structure not adapted to harbour  it.  This want of adapta-
 tion consists in unfitness to grow with the  advancing groAvth of the
 ovum.  Hence, in the case of tubal or interstitial gestation, there comes
 a time when  the growth of the  ovum is so rapid that the sac, not able
 to keep pace with it, bursts.  This catastrophe,  too, commonly happens
 near a menstrual period, when  increased  growth is  aggravated  by
 increased afflux of blood.  I have  drawn  attention to the fact (Clin.
 History of Diseases of Women), that before the rupture of a  Fallopian
 sac, a discharge of blood by  vagina often takes place.  This is eAidence
 of the ovum outstripping its habitat, and getting partially detached.   It
 is exactly what happens in placenta praevia.
   To return to our history.  Still  the prevalent practice was  to deliver
 at once ;  and this was, and  is, often  done without much regard to the
 fitness of the parts to undergo this severe operation.   So imperious is
 the dogma of "unavoidable " persistent  haemorrhage, that the difficulty
 presented by  an undilated os uteri is overcome by a special hypothesis,
 which assumes that in  these cases of flooding, the os uteri  is, by the
 flooding,  always rendered easily dilatable.  Unfortunately, this is not
true.   Proofs of  laceration, of  fatal  traumatic hasmorrhage  from the
injured  cervix,  as  the  penalty  for  forcing  the   hand through the
presumed  dilatable  cervix, abound; but the error is so prevalent, that
I think it useful to  adduce some evidence upon the subject.  Leroux
says (Edition, 1810): " Before  Puzos' time, the < accouchement force'
was generally performed. The operation was difficult, very laborious,
and often followed by a fatal issue."  The late Professor D. Davis says
he had met with  many examples  of even  fatal  hasmorrhage unaccom- 
PLACENTA  PREVIA.
403
panied  by any  amount  of dilatation of the orifice of the Avomb.  He
relates  a  case where very profuse hasmorrhage had occurred, yet the
orifice of the uterus was  but slightly dilated, and as rigid as if no
haemorrhage had been sustained.  Labour was induced, taking four or
five hours to expand  the  os.   Living tAvins Avere delivered. .On the
fifth day  after the labour, profuse flooding  set in, and caused death.
No rupture was found ;  but the long-continued bearing incident to the
introduction of  the hand had produced contusion, inflammation,  and
suppuration  of  the os uteri,  and a portion of  its  tissue,  about  the
diameter  of  a sixpence, had sloughed  off, and left behind it a deepish
ulcer ; several branches of arteries were found in the depth of it,  and
thus Avas  rendered evident the cause  of the fatal haemorrhage.   The
preparation is in  Middlesex Hospital Museum.
   Dr. EdAvard Bigby says :* " Cases have occurred where the os uteri
has been artificially dilated, where the  child was  turned and delivered
with  perfect  safety, and the  uterus  contracted  into  a hard  ball;  a
continued dribbling of blood has remained after labour ; the patient has
gradually become exhausted, and  at last died.  On  examination after
death, Professor Naegele has invariably found the os uteri more or  less
torn."
   Collins and others relate examples in point.   The truth is, that so
far from the os uteri in placenta praevia being in  a state favourable to
dilatation, the conditions are often the reverse.   The  implantation of
the placenta involves an enormous increase of vascularity of the parts,
and this, added  to  the imperfect muscular development attained  Avhen
labour comes on  prematurely,  renders the dilatation of  the  cervix   *
especially difficult  and  dangerous.   Haemorrhage from  laceration is
not  the only danger.   One,  a little more  remote, but  scarcely less
formidable, is that of inflammation, of septicasmia.  Some of the worst
cases of puerperal fever I  have  seen, have, in my opinion, been  the
direct consequences of the bruising of the vascular tissues of the ceiwix,
caused by forcible  delivery for placenta praevia.   I will  show presently
hoAv this  injury to  the  uterus can almost always be averted.
   What is tlie source  of the blood ?  Next there  came a new theory,
based upon a presumed physiological basis.   Levret believed that in
this form of uterine haemorrhage the placenta supplied a portion of the
blood.  Rawlins, of Oxford,! says : " The blood proceeds more from  the
vessels of the detached portion of  the placenta than from the denuded
vessels of the uterus."   The late  Professor Hamilton entertained  the
same opinion.   Kinder  Wood,  Radford, and  Simpson adopted  this
opinion ; but they did not  agree in their reasoning from it.  Simpson
dreAv from it the practical conclusion, that  to stop the hasmorrhage we
should completely detach the placenta.   Radford, who  had previously
             * "System of Midwifery," 1844.
             t " Dissertation on the Obstetric Forceps," 1793.
                                                         DD  2 
  404                 OBSTETRIC OPERATIONS.

  adopted this practice, was led to it mainly by the clinical observation
  that  the haemorrhage had ceased on  the spontaneous separation and
  expulsion of the placenta.
    I do not think this hypothesis of the placental source of the blood is
  now entertained by any one of authority.   The little evidence adduced
  in its support is entirely fallacious.   In my Lettsomian Lectures I
  pointed  out  that  where flooding  ceased  on  the  spontaneous  total
  detachment of the placenta, it was because the detachment Avas effected
  by contraction of the  uterus;  and this contraction  closes the utero-
  placental vessels just  as it does  in postpartum haemorrhage.   And
  then again there  are cases in which the haemorrhage did not stop on
  total detachment of the  placenta effected spontaneously or artificially.
  This  Avas because  the  uterus  did not  contract.    That any  great
  amount  of blood cannot  Aoav  quickly and in gushes  through  the
  placenta, was  proved by the Hunters,  who  showed that the cavernous
  structure of the maternal placenta could only permit of a slow uniform
  current back from the utero-placental arteries to the sinuses.  Legroux
  relates (Arch.  Gen.  de Med., 1855) two cases of fatal  haemorrhage from
  placenta praevia,  in Avhich dissection shoAved that the foetus had long
  been dead.   In these,  he reasoned, the placental  circulation must
  have ceased, and the  source  of  bleeding must  have been  the uterus.
  The late  Dr.  Mackenzie  made experiments bearing directly  on  this
  question.   1.  Having  opened the uterus  of a pregnant  bitch,  and
 detached the  placenta, he observed that the blood flowed freely from
 the uterus, and that it was arterial.  2. Having partially detached the
 placenta in a woman, he injected defibrinated blood into the hypogastric
 arteries.  He again observed that the blood flowed exclusively from the
 uterus, and from the utero-placental  arteries.   3.   He adduces  the
 recorded  observations  of many practitioners to show that the blood in
 women flooding from placenta praevia  is arterial in  colour.
   The blood has often been seen flowing direct from the uterine  surface
 in cases of Caesarian section and of inverted uterus, both in  partial and
 complete separation of placenta.   The late  Dr. Chowne  collected  a
 mass of evidence of this  kind.  I may further observe that the languid
 current through the  placenta must be quickly stopped by coagulation.
 The detached part of the placenta  is nearly ahvays found hard and
 impermeable from this  cause.
  Disregarding all this evidence, Simpson, dAvelling  exclusively upon
 the placental hypothesis, thought he Avas imitating Nature by  totally
 detaching the placenta, so as to prevent  blood from getting into  it, and
 therefore  out of it.
  How  is  the total  detachment of the  placenta accomplished ? The
 method prescribed is to pass the hand, if necessary,  into the vagina,
 then to pass two  fingers  through the cervix uteri, and  with them to
separate the placenta. 
PLACENTA  PREVIA.
405
  The fatal objection I urged  against this proceeding, false in theory,
was that it Avas impracticable.  In by far the greater number of cases
the placenta extends higher than  the equator of the uterus,  often
reaching the fundus.  The fingers are  not long enough to reach even
half-way toAvards the further margin of the placenta.  The diameter of
the placenta is nine or ten inches;  the fingers will barely reach three
inches.   In the greater  number of  cases,  therefore,  in  Avhich  the
directions prescribed  have been  followed, the placenta has not been
Avholly detached ; and the result,  when successful, cannot be attributed
to an operation which was not performed.   This is further proved by
the history of some of the  cases narrated as examples of this practice.
The child was born alive.  Is it  consistent Avith our biowledge of the
conditions  upon  which the  child's  life  depends, to  suppose that  the
child  will survive if the whole placenta be detached, unless the birth
follow the detachment  immediately ?  And  this condition, under  the
postulates  of the hypothesis, is  wanting.   This objection, so obA'ious
when simply stated, was not suspected by Professor  Simpson and  his
disciples until it was formally set  forth by me. I am not aware that
the Professor ever  published an  acknowledgment  of the  error  of
his theory and  practice;  but  I  have been informed that  he latterly
recognized the accuracy of my views.
   The  entire detachment of  the  placenta  has been  urged, on  the
ground that it can  be executed at a stage when the dilatation of  the
cervix is insufficient to admit of turning.  But if it cannot be executed
Avithout passing the whole hand  into the  uterus, that is,  Avithout
forcing the hand through the undilated cervix, in what respect is the
operation less severe than that  of delivery  by turning ?   Is it  not
reasonable to conclude that, since the forcible entry has been effected,
the seizure and extraction of the child, as well as the  detachment of
the placenta, had better, to give the child a chance, be completed at
the same time ?
   If so, the special character of the proceeding  vanishes; it is even
more severe than  turning,  which does not  require the  hand  to  be
passed  through  the cervix.
   But clinical observations, it is contended, prove that haemorrhage
has stopped on the total detachment of the placenta.   These obseiwa-
tions  are partly  true, partly fallacious.   The true  observations  are
those in which the  placenta  has  been spontaneously cast  off and
expelled before the birth of the child.   These cases are  not numerous.
They do  not justify  the conclusion drawn,  that  the  artificial total
detachment of  the  placenta will  be  equally  followed by arrest of
hasmorrhage.    There  is  a fundamental  physiological  distinction
betAveen the two cases.   When the  placenta is cast off  spontaneously,
it is because the uterus contracts powerfully.   This  contraction stops
the bleeding.   When the  placenta  is detached artificially, there may 
406
OBSTETRIC OPERATIONS.
be, and probably is, defective uterine contraction.   The bleeding will
be  likely  to  continue.  There is  no independent virtue in the mere
detachment of the  placenta, as post-partum haemorrhage abundantly
proves.
  Here, then, we have true observations erroneously interpreted.   The
fallacious  observations  are  of the following nature.  The physician,
seeking to imitate  the  spontaneous detachment, obeys the precept  to
pass two fingers into the uterus,  and  concludes that  he  has wholly
detached the  placenta.  In this he has, in all  probability,  deceived
himself.   The fingers  can only detach as far as  they will reach, that
is, for an area of two or three inches from the os  uteri.   The  operator
has unconsciously  failed in doing  Avhat he tried to do;  he has un-
wittingly done very nearly Avhat he ought  to  do.   The haemorrhage
stops ; he sees in his  success a proof of the truth of the  theory that
total detachment of the placenta is the security against haemorrhage.
But he has not wholly detached  the placenta ;  he  is  unconsciously
giving proof of the truth of a very  different theory : namely,  that the
haemorrhage  ceases when that part of the placenta which had grown
within the lower zone  of the uterus has been detached.
  The memoir  in  the Lancet (1847)  contains  the earliest  distinct
enunciation of the  physiological  theory  that  there  is   a  natural
spontaneous arrest of the haemorrhage attained Avhen that  part of the
placenta which had groAvn  within the  lower  zone had been detached,
provided uterine contraction concurred; and of the correlative law  of
treatment by the artificial detachment of this part of the placenta,
supplemented by means for ensuring uterine contraction.   In  1855
(Arch. Gen. de Med.), Legroux, in  a memoir  of signal merit, pointed
out that the haemorrhage is diastolic,  and hasmostasis systolic; and
hence he concluded that the proper course Avas " to  provoke fearlessly
an energetic action  of the uterus."
  I will now endeavour to give a succinct view of my theory of placenta
praevia, and of the principles that should guide us in the treatment of
this complication.
  The chief points in the  physiology  of  placental  attachment are
expressed  in the diagram (Fig. 119), modified from  one contained  in
my Lettsomian  Lectures (1857):—
  The inner surface of the uterus may be divided into  three  zones  or
regions, by two latitudinal  circles.   The  upper  circle may be called
the upper polar circle.  Above this is the fundus of the uterus.   This
is the seat of fundal  placenta, the most natural position.   It is the
zone or region of safe attachment.  The loAver circle is  the lower polar
circle.   It divides the cervical zone or region from the equatorial zone.
The equatorial space comprised betAveen the tAVo circles is the region of
lateral placenta.  This  placenta is not  liable to  previous detachment.
Attachment here may, hoAvever, cause  obliquity of the uterus, oblique 
PLACENTA PR.EVIA.
407
position of the child, lingering labour, and  dispose  to  retention of the
placenta and post-partum hasmorrhage.
  BeloAv the  lower circle is the lower zone,  the  region of dangerous
placental  attachment.   All placenta fixed here, whether it consist in a
flap encroaching downwards from the equatorial zone, or whether it  be
the entire placenta, is liable  to  previous detachment.  The mouth of
the Avomb must open to give passage  to the child.   This opening,
which imphes retraction  or shortening  of the lower zone, is  incom-
patible with the preservation of the adhesion of the placenta within its
scope.  In  every other part  of  the womb there  is an easy relation

                               Fig.  119.
DIAUKAM TO ILLUSTRATE THE AUTHOR'S THEORY OF PLACENTA Pr..EVIA.
  A B, upper polar circle;  C D, lower polar circle, or Barnes' physiological boundary between
equatorial and lower zones.  F. PI., fundal placenta; E. PI., equatorial placenta;  PL Pr. L.,
placenta prsevia lateralis ; PI. Pr. C, placenta preevia centralis ; f.z., fundal zone ; e.z., equatorial
zone ; l.x., lower zone ; E F, circle of os internum; Ox, os externum.

betAveen the contractile limits of the muscular structure and that of the
cohering placenta.  Within the lower region this relation is lost.   The
diminution in surface of the uterine tissue is in excess.
   The loAver polar circle is, then, the physiological line of demarcation
between prasvial  and lateral placenta.  It  is the boundary line  below
which you have spontaneous placental  detachment and hasmorrhage;
above which spontaneous placental detachment and hasmorrhage cease,
   When the dilatation of the cervix has reached the stage  at which the
head  can  pass,  and  all that  part of  the  placenta Avhich had been 
408
OBSTETRIC OPERATIONS.
originally adherent Avithin the cervical zone is  detached, and  if, as is
the constant  tendency of Nature to effect, the  intermitting active
uterine  contractions arrest the haemorrhage, a stage  is reached  Avhen
the labour is freed from all prasvial placental complication ; the  equa-
torial and fundal  portion of placenta retains its connection, supporting
the child's life ; the labour is, in all respects, a natural labour.
  This  is the course  which  Nature  strives to accomplish.   I have
verified  it frequently at the bedside.   Many cases are recorded by old
and recent authors in which this course was successfully accomplished,
although the narrators failed to  interpret  the  phenomena correctly.
If observations in point are  not  more abundant, it is  simply  because
men, acting servilely under the thraldom of the  " unavoidable  haemor-
rhage"  theory, fear to let Nature have a chance  of Adndicating her
powers.   The  instant resort to the accouchement force interrupts the
physiological process;  we can see no  more.
  Mercier seems to have been  so struck with the occasional absence  of
haemorrhage, that he wrote an essay under the title, " Les accouche-
ments ou le placenta  se trouve appose sur le col de la matrice  sont-ils
constamment  accompagnes de l'hemorrhagie ?" :;:    He thought the
exhalant vessels  were  in a state of constriction  which  opposed the
passage  of blood.  Moreau and Simpson thought the  preA'ious death of
the foetus, and the consequent  diversion of blood from  the  uterus,
explained the  absence  of haemorrhage.   This to  a certain extent  is
true;  but I am in a position to affirm, from repeated obsenatioii, two
things:  first, that hasmorrhage occurs when the child has long been
dead (I have cited two from Legroux); secondly, that there may be no
hasmorrhage although it is born alive.
  Caseauxf also  says: "The hasmorrhage  which has  been generally
regarded as inevitable under these circumstances may nevertheless not
occur, not even during  labour; and the dilatation of  the neck  may be
effected  without the escape of a drop of blood."
  In an appendix to  my  work  on Placenta Prtevia  (1858),  I have
related the histories of  several cases, some quoted from various  authors
and some occurring under my own observation, illustrating this point.
Indeed,  it was the reflection upon a case of this kind,  which I saAv in
1845, that led to the  working  out of my theory.   The  cases in the
appendix  referred to,  prove   the  fallacy of the explanations before
offered  as to  the cause of the cessation or absence of haemorrhage.
They  show that it is not accounted for by the death of the child; nor
by the pressure of the head or other part of the child upon the bleeding
surface.   They afford strong presumption, at least, that  the  hasmor-
rhage ceases when  the physiological limit I have  described has  been
reached, tonic  or  active contraction of.the uterus concurring.  I am far
    *  "Journal  de Medecine," vol. 1\\
    t " Traite theor. et prat, de l'Art des Accouchements."  6erne ed., 1862. 
PLACENTA PR.EVIA.
409
from affirming that Nature is generally equal to the carrying out of this
process.   Not seldom she is utterly unequal to the task.  It is import-
ant to  knoAV what are the causes of her break-down ;  knoAving these, Ave
may know Iioav to help her.
  There are two conditions commonly present in flooding from placenta
praevia.   The first is an immature uterus.   Flooding frequently occurs
before  the term of gestation is complete.  The uterus is therefore taken
by  surprise, before  its tissue is  developed, before  it has  acquired its
normal contractile  poAver.   Besides this, the tissue is ill-adapted  to
expand.   The second is  the loss  of blood itself, impairing the vital
Via. 120.
   SHOWING A LATERAL PLACENTA DESCENDING TO A A, THE BOUNDARY-LINE BETWEEN THE
                       EQUATORIAL AND CERVICAL ZONES.

  The placenta descends to the very fullest expansion of the os, and therefore remains just within
the limit of safe attachment. The space between a a and b b is the range of expansion necessary
to permit the passage of the head.  (The uterus is adapted from one of William Hunter's
engravings.)

power,  causing shock and prostration.   The several or joint action of
these conditions is often a powerless  labour, the absence of contraction.
Hence  the  continuance  of  haemorrhage.   We feel  we cannot depend
upon contractile force Avhen all  force  is  ebbing aAvay with the blood.
We  are compelled  to act,  to  assist  Nature in her extremity. 
410
OBSTETRIC  OPERATIONS.
  Let us iioav endeavour to determine the exact position of the loAver
polar circle or boundary-line between haemorrhage and  safety.  This
can be  done with considerable accuracy.
  The  lower  segment of the womb must open  to  an  extent corre-
sponding to the circumference of the  child's head in  order to permit
its extrusion.   By noting, therefore,  the amount of necessary recession
or shortening of the loAver segment  of the Avomb to reach this extent
of expansion, we shall obtain the exact measure of the original depth
of the  cervical  zone, the region  of prasvial  placental  attachment.
Fig. 120 will  serve  to illustrate this position.
  This  point may be further demonstrated  by the folloAving simple
proceeding:—Take  a  foetal  skull, and marking the left parietal pro-
Fig. 121.
        SECTION OF UTERUS AND CERVIX IN EIGHTH MONTH OK GESTATION (BANDL).
  UC, body of uterus;  a, Bandl's ring; b, os internum; oe, os externum;  17/, vagina; UI, lower
uterine segment;  C, cervical mucous membrane ; d, connective tissue; c, muscular layer; b, seat
of Muller's os internum; n, seat of Braune's os internum.

tuberance for a centre, stretch a vulcanized india-rubber ring over the
circle of greatest circumference of the  skull,  preserving  it at equal
distance from the centre.  This ring will represent exactly  the os uteri
at the stage of utmost expansion necessary for the passage of the head.
To this extent the os uteri must  expand ; beyond this  it need not, and
will  not expand.   It therefore marks the limit betAveen the orificial and
equatorial portions of the uterus.   And this limit, thus fixed by clinical 
PLACENTA  PREVIA.
411
 observations and physiological deduction, is coincident with Bandl's
 anatomical demonstration.  It is interesting to  note Iioav closely this
 discovery, flowing from clinical and physiological study  by me in 1847,
 and that subsequently made by anatomical study  by  Bandl, confirm
 each other, and  demonstrate what really constitutes placenta  praevia.
 The studies of Spiegelberg and MattheAvs Duncan further confirm  the
 truth of my theory.
   The drawing from Bandl shows in section the seat of this boundary
 line.
   If Ave now measure the distance between the  presenting parietal
 protuberance  of  the foetal head and any part of the line of greatest
 circumference, we shall have the utmost extent of the cervical zone.
 In a full-sized foetal head  this is about three inches.   If Ave noAv
 describe a circle within the womb at three inches  distance from  the
 undilated os internum, we shall have drawn the lower  polar circle (or
 Bandl's  ring).   This  is  nearly  exactly what the fingers  introduced
 inside the womb can do.
   There  is another demonstration of the  extent  of the lower polar
 zone, derived  from examination  of the state of the placenta after its
 delivery.   The part which came nearest to the os internum  uteri, and
 which may have  been felt during labour, is exactly indicated  by  the
 rent in  the membranes  being close to it;  it being obvious, as was
 pointed  out by Levret, Hugh  Carmichael,"  and Von Bitgen,! that  as
 the membranes must  burst or be  ruptured  at the  os  uteri Avhen  the
 child passes, so, by measuring the distance of this rent  from the lower
 edge of  the  placenta,  we  shall obtain exactly  the elevation  of  the
 placenta from  the os  uteri.
   This  part  of the placenta, which had been detached during labour,
 is found infiltrated with extravasated blood, making a thick, firm, and
 black flap, quite distinct in appearance from the rest of the placenta,
 which, growing above  the lower polar circle, had preserved its adhesion
 in the ordinary way until after the expulsion of the child.   The area
 of this ecchymosed portion corresponds to the area of the loAver zone.
   I  believe, however, that the boundary line of safety is often prac-
 tically reached before  the expansion of the mouth  of  the womb has
 reached the full  diameter of the child's head.  I ha\re observed that
 the haemorrhage  has completely stopped Avhen the os uteri had opened
 to the size of the rim of a Avine-glass, or even less.
   We may now consider—
   The Course and Symptoms of Placenta Previa.  When the placenta
grows wholly or in part within the  cervical zone, its  relation  to the
uterine Avail at this part is always liable to be disturbed.  At any time
during the course of pregnancy, haemorrhage from this  cause is  apt to
                * "Dublin Quarterly Journal,"  1839-40.
                t " Monatsschr. f. Geburtsk.," 1855. 
412
OBSTETRIC OPERATIONS.
take place.  It is most probable that some cases of presumed ordinary
abortion at the third or fourth month are in reality due to this cause.
At least, in aborted ova of this period, I have frequently verified the
fact  that  there was placental  structure Avithin  the lower zone;  but,
usually, placenta praevia is not recognized as such  earlier than the end
of the fifth month.  At and after this time, the woman may be  over-
taken without warning by a  smart flooding of fresh florid blood.  This
often occurs  Avhen  the patient is at rest, in  the  night, even  asleep;
sometimes when she is out of doors, or away from home, so little  is
she  prepared  for any  accident.  Sometimes it  comes after unusual
exertion, on  emotion,  or coitus.  These attacks  of haemorrhage are
usually quite independent of labour  or  of uterine contraction.  They
occur most  frequently at the menstrual epochs ; thus it is not un-
common to observe a recurrence of these hasmorrhages at intervals  of
about a month.  It cannot be doubted that the disturbance of relation
between placenta and  uterus is brought about by the increased afflux
of blood brought to the uterus and placenta at those periods.  Some-
times the bleeding subsides, and the patient is  reprieved for a time.
It is even possible that she may go the full term of pregnancy, after
ha\diig  suffered  several  attacks  of hasmorrhage,  and  be  deliA^ered
naturally with little loss.  But most frequently, premature labour will
be excited either at the first  or second attack.  The seventh and eighth
months are frequent critical  epochs.  The bleeding having begun, some
blood is extravasated between  the uterine and placental surfaces, the
lower part of the placenta  gets  thickened  and  hardened with extra-
vasated blood, and  thus the uterus  is excited to contraction.   When
once the uterus  is set in action, the termination  in labour  is highly
probable.
  The Diagnosis.—The os uteri internum is often found scarcely, if  at
all, dilated more than is usual in pluriparae—and  it is  in  pluriparae
that placenta  praevia most frequently occurs—if examination is made
early during the flooding ;  but the cervix or  vaginal-portion is  com-
monly thicker than ordinary.  The finger passed into the os will miss
the head or other presenting part of  the child, especially if the case  be
one  of placenta centralis.   In  this case,  also,  ballottement  will  be
difficult or not  made  out;   but, instead, you may feel  the quaggy,
spongy placenta, or a blood-clot.   The cervix is generally more tender
to the  touch, and pain  is  often  felt  during gestation at  the loAver
segment of the uterus and  on the side  to which  the  placenta groAvs.
Levret  says,  the  uterus,  instead  of  being  rounded  or pointed,  is
flattened,  as if divided into two  parts as in tAvin-pregnancy, but the
division is more  on one side, causing oblique irregularity of form; and
in the first months the patient  has been conscious  of a swelling,  with
pain and  hardness, in one side.  Gendrin says, a pulsation, not  syn-
chronous  with the mother's pulse, may  be  felt at the os uteri.   The 
PLACENTA  PREVIA.
418
stethoscope Avill, as Hardy and McClintock * have shown, often deter-
mine the seat of the placenta at once.   But these points are sometimes
difficult to realize, and are therefore of  doubtful value.
  It is usual to teach that in  accidental haemorrhage  the bleeding is
arrested  during a  pain, Avhilst in placenta prasvia the haemorrhage,
although  continuing during the intervals,  is greatly increased  during
the pain.  Nothing, I believe, can be  more illusory than trusting to
this distinction.  As Legroux  pointed out, the  hasmorrhagic act is
diastolic; the apparent  hasmorrhage is systolic, the blood previously
effused being then expelled; the haemostatic act is systolic.  Certainly,
at the onset, there is often  no pain in placenta  prasvia; and, as the
case proceeds, active pains will often stop the hasmorrhage.
   Varieties of Placenta Previa.—The precise physiological definition
of placenta prasvia  I submit is : attachment of any portion of placenta
Avithin the lower zone of the  uterus.' Any portion,  or the  Avhole of
the loAver  zone, may be covered by placenta.   The placenta  may dip
doAvn to the edge of the os uteri  internum :  this is partial  placenta
previa; or  it may  cover the os  uteri internum : this is  complete
placenta previa,  or placenta centralis.
   The Prognosis.—It is  often  repeated that  partial  placenta  praevia
is much less formidable than  the complete  form.  This may be so
sometimes.  But  I am sure no  rule  of prognosis or treatment can
safely be  based upon this  assumption.  Collins  says  : "I have  seen
the haemorrhage as  profuse where there was  merely a portion of the
edge detached, as  where the great bulk was  separated." My  experi-
ence entirely confirms this statement.   The prognosis applies to three
principal  questions :  1. What is the immediate danger of the patient ?
2. What  is  the ultimate  danger ?  3. Will the case go on at  once
to the completion  of delivery, or wiU the symptoms  subside ?
   1. The immediate danger to life from  shock and loss of blood is
serious, if the hasmorrhage be profuse,  if the cervix remain unex-
panded, and  if delivery and  contraction of the uterus  be not secured
Avithin a short time.  Whenever the loss is rapid and  great, and the
patient is clearly affected  by the loss of blood, the indication  is strong
to abandon at once the  prospect of postponing labour, and to proceed
immediately  to accelerate delivery.
  2. The ultimate dangers, supposing immediate sinking from haemor-
rhage is cleared, arise from  anaemia.   The  secondary  dangers  are :
malnutrition ; nervous disorders;  the local injury to  the cervix  uteri
during  labour; the  contusion, laceration, dispose to  inflammation,
and blood-infection  from the necrosis  of tissue and decomposition of
clots about the mouths of the  utero-placental vessels ; phlegmasia
dolens  is  not uncommon, and is sometimes severe, even fatal, being
complicated with more than the usual degree of blood-infection; all
                      *  " Practical Observations." 
414
OBSTETRIC OPERATIONS.
 the  other forms of puerperal  fever are more common after placenta
 prasvia;  secondary haemorrhage from laceration  of the  cervix ;  and
 lastly, there is the  prospect  of  imperfect  involution of  the  uterus,
 and of chronic endocervicitis.
   In 1864, I had occasion to review my experience of the terminations
 in 69 cases of placenta praevia.  The  deaths were six, i.e., 1 in 11|,
 a  proportion  much  smaller  than  that  usually  given  in  statistical
 tables.   But upon this  point  I  think it idle  to dAvell,  for general
 statistical tables, drawn  from miscellaneous sources,  are  utterly un-
 trustworthy in this matter.   Of the six fatal cases, one  died, three
 Aveeks after labour, of septicaemia :  one died in a few days, of septi-
 caemia  following forced  delivery,  performed by  a  practitioner Avho
 prided'himself  on his promptitude  in  the treatment of these cases ;
 two  were  moribund  when  first seen ;  one died  of  exhaustion (she
 had  had  eleven children), one died of  puerperal  fever, aggravated  by
 ill-usage.  I feel very  sure that  if we  could always  see these cases
 at the earliest  stage  of haemorrhage, and  if they were treated  on the
 principles I have laid down, the mortality would be brought very much
 below anything hitherto known.  In the cases above referred to, there
 occurred an unbroken series of 29 successful cases.  My subsequent ex-
 perience is not less favourable.   Dr. Murphy (Med. Press, 1885)  gives a
 series of 25 cases without a death, conducted closely  on my principles.
  3. Will the case go on to delivery? If the hasmorrhage is moderate,
 if the os does not dilate, if there is little or no sign of uterine  action,
 there is the probability of the  utero-placental relations being so little
 disturbed that  the  pregnancy may go on.   But this question is often
 practically settled  by the  physician, who,  governed by  his  estimate
 of the strength  of the patient, the stage  of pregnancy, and the urgency,
 absolute and relative, of the symptoms, may resolve  to accelerate the
 labour.   If the pregnancy have advanced beyond the seventh month,
 it will, as a general rule, I think, be wise to proceed to delivery, for
 the next  haemorrhage may be fatal; Ave cannot  foretell the time  or
 the extent of its occurrence,  and Avhen it  occurs, all, perhaps, that
 Ave shall have the opportunity of doing will be  to regret that Ave did
 not act when Ave had the chance.
  The Prognosis as  to  the Child.—This will depend very much upon
 the conduct of  the  case.  But under  any method  of treatment  the
risk to the child is great—so great, indeed, that Simpson and Churchill
have expressed the opinion, that the hope  of saving the child ought
 scarcely to influence  the  treatment.  In this view I cannot concur.
It  is true  that in many cases the child is dead  before  there is any
opportunity for  treatment.  The child dies from  asphyxia, the result
of  the mother's loss of blood ; this blood, which  is the  means  of
aeration  of the  child's  blood,  comes in too  small quantity and too
feebly to effect  the  necessary change.   Again, the child  is frequently 
PLACENTA PREVIA.                   415
premature, sometimes not even viable ;  frequently there is  transverse
presentation;  frequently the cord is prolapsed; and then the  child
has to run the gauntlet of  artificial modes of delivery.  Exposed to
these perils, it is not  surprising that  the  child  Avill  often  perish.
But  still  the broad  fact remains,  that a considerable  proportion of
children are born  alive; and nothing can be  more  certain than that
some of the sources of peril to the child may be lessened  or  alto-
gether avoided, and  that not only without adding  to  the  danger of
the mother, but even increasing her security.  Out of sixty-two  cases
of placenta prasvia which had been noted in reference to this point,
but which had not all been treated after my method, or under favour-
able circumstances, twenty-three children were born alive.  I am con-
fident  that a better result  than  this may be obtained, if the' proper
principles of  treatment are  applied, beginning  at  the  onset of the
flooding.
   The total  detachment of  the  placenta  before the birth of the  child
is almost necessarily fatal  to it.  The  precipitate  forcible  delivery of
the child is  scarcely less hazardous.   Once granted or assumed that
all cases  must be treated  in this Avay, the  surgeon easUy persuades
himself that the child is doomed.   He has  excluded by his  oavii act
the possibility of saving it.   The method I recommend  is  calculated
to give the child every possible chance, and  at the same  time con-
duces in  the highest degree to  the  safety of the mother.


                   Treatment of Placenta Previa.

   The treatment must  vary according to the nature of the  case  ; and
cases of placenta prasvia vary greatly.   I  have already adverted to the
distinction draAvn by  many authors  between  partial and complete
placental  presentation,  and to the fact that a different rule of treatment
applies in the two cases.  It is generally taught that in partial pre-
sentation  there is  less danger, and that  less active treatment  is called
for.   As  a  general  proposition, this  is  true.  But I have frequently
seen the most seA^ere  flooding attend partial presentation, so as to call
for action as energfetic as in any flooding from central placenta.   I
think a more practical division of cases is into—
   A.  Cases of  placenta prasvia, Avhether partial  or  complete, in which
there is active contractile power  in the  uterus, with spontaneous dila-
tation.
   B.  Cases in Avhich  the contractile poAver of the uterus  is absent,
with or Avithout dilatation.
   The first question,  Ave haA'e seen, is to decide whether the pregnancy
can  be allowed to go  on.   If the pregnancy is only of five or  six
months, the os not dilated,  all pain absent, and the hasmorrhage very 
416
OBSTETRIC OPERATIONS.
 moderate,  we  may  temporize ; watching,  hoAvever, most vigilantly.
 But if the haemorrhage  be at all profuse,  and there be any signs of
 uterine action, no matter what  the  stage of pregnancy,  act at  once;
 accelerate  the  labour.  Above all,  do not  trust to the Aveak conven-
 tional means  of keeping the patient in the recumbent  posture, in a
 cool room, with cold cloths to the vulva, to mineral acids, and acetate
 of lead.   This is but trifling in the presence  of a great emergency.
 Commonly, they do  no good whatever ; always,  they lose  precious
 time.
   The great haemostatic agent is contraction of the uterine fibre.  To
 obtain contraction is, therefore, the end to be sought.  Although the
 poAvers of the  system may still be good, the uterus will not always act
 well, especially in premature  labour, whilst it is fully distended.  To
 evoke contractile energy, it is often enough to puncture the membranes.
 This done, some liquor amnii  runs off; the uterus collapsing, is excited
 to contract,  and being diminished  in bulk,  it  acts at  advantage.
 Labour being  actiA'e, the cervix expands promptly, the placenta gets
 detached from the orificial zone, the bared uterine vessels get closed by
 the retracting tissue and by the pressure of the advancing head ; the
 haemorrhage ceases spontaneously.
   1.  The puncture of the membranes is the first  thing to be done in all
 cases of  flooding sufficient to cause anxiety before labour.  It is the
 most generally  efficacious remedy, and it can always be applied.   The
 patient lying  on her side, a finger  is  passed  up into the os  uteri,
 guiding a  stilet,  quill-pen, or porcupine's  quill to  the  membranes,
 Avhilst the uterus is supported externally.
   2.  At  the same time  apply a firm  binder over  the uterus.   This
 further promotes  contraction ; and by propelling the child towards the
 os uteri, it accelerates  the  expansion of the  os and  moderates  the
 hasmorrhage.
   3. Puncture  of the membranes is in many  cases  enough of itself.
 But  if the haemorrhage  continue, and especially if the patient  shows
 signs of exhaustion, the os uteri being undilated, the plug may be tried.
 Leroux, Dubois, Chailly, extol the plug.   It has been extensively used
 on their authority.  It often renders great  service.   The best plan is
 to plug the os uteri itself with laminaria-tents.   This will expand the
 os, and prepare for further proceedings.  The various forms of A-aginal-
plugs, such as the  silk-handkerchief,  toAv,  lint, even Braun's colpeu-
 rynter, are treacherous aids, requiring the most  vigilant Avatching.  Do
not  go to  sleep  in the false  security that,  because you  have tightly
packed the vagina,  the bleeding  will cease.    The plug you  have
introduced with so much pain to the patient soon becomes compressed,
blood flows past it or accumulates above or around it, and the tide of
life ebbs away  unsuspected.   Never  leave a patient more than an hour,
trusting  to the  plug.  Feel  her  pulse frequently; watch her face 
PLACENTA  PREVIA.
417
attentively ; examine to see if any blood  is oozing.  BemoA^e the plug
in an hour, and feel if the  os uteri is  dilating.  If it be dilating, and
the haemorrhage have stopped, you may trust Nature a little farther,
AA'atching her  closely.   The labour may now go on spontaneously,
probably issuing in the birth of a living child.
   4. You must not, however, be surprised to find that the haemorrhage
continues, that the os uteri  does not expand, and that there is no active
labour.  Expectancy  has  its  limits ;  the  time has  come  for  more
decided measures.  Will you force your hand in and turn ? Bemember
Avhat I have  said  of the dangers of this proceeding.  There are tAvo
means of accomplishing the end in view, Avithout violence, wdth more
certainty and with  more safety  to  the patient and her child.
   Consider, what are the ends to be attained ?
   We  want to check the haemorrhage at once ;
   We  want security against the  renewal of  hasmorrhage.
   To attain  these ends, the uterus must  be placed in a condition to
contract.   The essential steps towards this consummation are—first,
the free dilatation of the cervix;  secondly, the  completion of the labour.
   The first difficulty is to  effect the dilatation of  the cervix.   Under
any process, this must take a little time.  Can anything be done in the
meantime  to  moderate the bleeding ?
   Something  very effectual  may be done.  If the physiology of placenta
prasvia, Avhich I have laid down, be correct, it may be expected that by
accelerating the  completion of the  necessary process of separating all
the placenta  which adheres icithin the  lower zone, Ave  shall, at any
rate, get over  the period of danger more quickly.  If we can do this, we
shall gain other advantages  : we remove an obstacle to the dilatation of
the cerA'ix, for the adherent  placenta acts as a mechanical impediment;
and Ave lessen the risk of laceration of the placenta, an accident very
likely to happen in the ordinary  course  and under turning, and which,
by rupturing  the foetal vessels, adds to the  peril  of the child.
   Tlie operation is this : Pass one or two fingers as far as they will go
through the os uteri, the hand being passed into the vagina, if necessary;
feeling the placenta, insinuate the finger between  it  and the uterine
Avail; sweep the finger round in  a circle, so as to separate the placenta
as far  as the finger can  reach; if you feel the edge of  the  placenta
Avhere the membranes begin, tear open the membranes freely, especially
if these have not been previously ruptured ;  ascertain, if you can, what
is the presentation of the  child,  before withdrawing your hand.  Com-
monly, some  amount of retraction of the cervix takes place after this
operation, and often the hemorrhage ceases.   You have  gained  time.
You have given the patient the  precious opportunity of rallying from
the shock of  previous loss, and  of gathering up strength for further
proceedings.
  If, the cervix  being iioav liberated,  under  the pressure of a  firm
                                                           E E 
418
OBSTETRIC OPERATIONS.
 binder, ergot, or stimulants, uterine action returns so as to drive doAvn
 the head, it is pretty certain there will be no  more hasmorrhage ; you
 may leave Nature to expand the cervix and to complete the delivery.
 The  labour,  freed  from  the  placental  complication,  has  become
 natural.
   5. If, on the other hand, the uterus continue inert, the haemorrhage
 may not stop; and  you must proceed  to the  next  step, the  artificial
 dilatation of the  cervix.   This is accomplished by  the  use of  my
 hydrostatic dilators.  Insert the middle or largest-sized bag into the os;
 distend Avith  Avater  gently and gradually,  feeling the effect of  the
 eccentric  strain upon the edge  of the os.  When  the  bag  is fully
 distended, keep it  in sitil for half-an-hour  or an hour if necessary.
 During this time, the haemorrhage is commonly suspended ;  probably
 the intra-uterine portion of the bag presses upon the mouths of the bared
 vessels ; certainly retraction or shortening of the loAver segment of the
 uterus goes on, Avhich is the direct means of closing these A^essels ; and
 under  the combined  effect of pressure from  below by the  dilator, and
 from above by the binder, the  contents  of the uterus are kept in close
 contact with its inner surface, thus  keeping  pressure on the vessels of
 the cervix, and stimulating the  entire organ  to  contract.   Legroux,
 guided by his observation  that hasmorrhage  occurs  during uterine
 diastole, puts  the patient in the vertical position during uterine relaxa-
 tion, so as to maintain the pressure of the contents of the  uterus upon
 the cervix.  He relates a case where this practice perfectly succeeded.
 But it  is obvious that this position disposes to  the danger  of syncope.
 The bags accomplish the purpose better and more safely.   When you
 find the cervix freely open, you may withdraw the bag.
   Again, you  may wait and observe if  Nature  is  able  to carry on the
 work.   If  contraction persist, if the head present, the labour  is hence-
 forth essentially normal, and may be allowed to go on spontaneously.
 You must nevertheless watch attentively.
   If contraction is inefficient, if haemorrhage  goes  on, if another part
 than the  head is  presenting—a condition very frequent  in  placenta
 praevia—Ave must  carry  our help further.  We must do what Nature
 cannot do : we must deliver.  This is  done by seizing the child's leg,
 and extracting.  Now, this can almost always be accomplished Avithout
 passing the hand into  the  uterus.   The bi-polar method of turning
 here finds one of its  most valuable applications.  It avoids  the danger
 and difficulty  of forcing the hand through an imperfectly-expanded os,
 through imperfectly-developed  and  abnormally-vascular  structures.
 Having seized a leg, it must be draAvn down gently, so as to bring the
 half-breech into the cervix.  Traction must be  so  regulated as to bring
 the trunk  through with the least amount of  force necessary for  the
 purpose.   Whilst delivery is  going on, the  haemorrhage  is generally
arrested.   Hicks  points  out  that the child's  breech compresses  the 
PLACENTA P1LEVIA.
419
bleeding  surface.   Extract gently.    This gives the cervix time to
dilate  gradually, and  avoids mischief.
   As soon as the child is born, re-adjust the pressure upon the uterus ;
and if there is no haemorrhage, allow  three or  four minutes for the
system to rally, before attempting  to remove the  placenta.  If hasmor-
rhage occurs, and the placenta does not come on moderate compression
of the uterus and traction, you must  pass the hand into the uterus to
detach it.  The portion growing to the equatorial zone is not always
readily cast.   Examine the placenta carefully on its uterine surface, to
see if  it is  entire.
   In every labour,  the  cervix, having to  suffer great distension and
contusion under the passage of  the child, and possessing less contrac-
tile elements in its structure  than the  rest of  the uterus, is liable to
paralysis  for a time.  This  state is  more likely to occur in labour
with placenta  prasvia, and it is doubly dangerous because the cervix
is so near  the placental site.   Here is  another reason  for sparing
the cervix to  the  utmost.  Hence it  may be  desirable to inject hot
water, and sAvab the part freely  with a  solution  of  perchloride of
iron.
   The chief facts in relation to placenta praevia  may be  summed up
in the following series of physiological and pathological propositions.
In  the Obstetrical  Transactions  and elsewhere,  I have published
the histories of cases in illustration  and proof;  and it may be said
that the medical journals of recent years  abound with  similar  cases
recorded  by many  practitioners  avIio  have  adopted the principles
expounded by  me.

              A.—Series of Physiological  Propositions.

   1. That in the progress of a labour Avith  placenta  prasvia, there is a
period or  stage Avhen the  flooding becomes spontaneously arrested.
   2. That this haemostatic process does not depend upon total detach-
ment of the placenta ; upon death of the  child;  upon syncope in the
mother;   nor upon  pressure on the cervix bared of placenta, by the
presenting part of the child, or distended membranes.
  3. That the one constant condition of this physiological arrest of the
flooding is contraction, active or tonic,  of the muscular structure of the
uterus.
  ■4. That this physiological arrest of flooding is neither permanent
nor secure until the Avhole  of that portion of the placenta Avhich had
adhered within the  loAver zone  of  the  uterus is detached—that being
the portion which is liable to be separated during the opening of the
loAver segment of the uterus to the extent necessary to give passage to
the child.
  5. That, Avhen this  stage of detachment has been reached, there is
                                                         E E 2 
420
OBSTETRIC OPERATIONS.
no physiological reason why any further detachment or flooding should
take place until after the expulsion of the child, when, and not till then,
the remainder of the placenta, Avhich adheres to the middle and fundal
zones of the uterus, is cast off, as in normal labour.
  6. That the rent made in the sac of the amnion to give passage to
the child, being necessarily at the part opposite  to the os uteri, marks
the spot at  which the placenta Avas attached to the uterus; thus, in
cases of partial placental  presentation,  the rent is  commonly found
close to the  edge of the placenta.   (Levret.)
  7. That  attachment of  the  placenta to  the  loAver segment of  the
uterus  at the posterior  part is a frequent  cause of transverse  presenta-
tions.   (LeA-ret.)
  8. That, in the case  of partial placental presentation, where an edge
of the placenta dips down to  near the  edge of the os uteri internum,
the umbilical cord commonly springs from that edge; and that thus
is explained the liability to prolapsus of the funis  in  cases of placenta
praevia.  (Levret.)
  9. That adhesion of  the placenta to the os uteri internum impedes
the  regular  dilatation of  the  part, and, consequently,  Avhilst  such
adhesion lasts, the proper course of labour is hindered.
  10. That inflammation of the uterine structures, particularly of  the
cervix, is especially likely to supervene  upon delivery  attended  by
placental presentation.   That one of the purposes intended by Nature
in fixing the seat of the placenta at the fundal and middle zones of  the
uterus, is the preservation of the  parts  rendered highly  vascular by
connection  Avith the placenta, from the distension, pressure, and con-
tusion  attending  the passage of the child.
             B.—Series of Therapeutical Propositions.


  1. That  the  greatest amount of  flooding generally  takes  place  at
the commencement of the labour, when the os is beginning to expand.
That the os is  always, from its being near the  seat of the placental
attachment, highly vascular,  and is frequently, at  this  stage, very
rigid.    That any attempt  to  force the hand  through  this structure,
at this stage, either for the purpose of wholly detaching the placenta,
or of turning the child, must be made at the risk of injuring the womb;
and that the dragging the child through the os when  in this condition
—even when it has not been necessary to pass the hand  into the uterus
—is a proceeding  affording slender  chance of  life to  the  child, and
dangerous to the mother.
  2. That  the  entire detachment  of the placenta is not necessary  to
ensure the arrest of the haemorrhage ; and that, therefore, it  is not 
PLACENTA PILE VIA.
421
necessary either to wholly detach  the placenta before the birth of the
child, or, in cases uncomplicated Avith cross-presentation, to proceed to
forced delivery, Avith a view to wholly detach the placenta after the
birth of the  child.
  3. That, since  the dilatation of the  cervical  portion of  the  womb
must take place  in  order  to give passage to the  child, and  since,
during  the earlier stages of this  necessary  dilatation, haemorrhage is
liable to occur, it is desirable to expedite this stage of labour as much
as possible.
  4. That, in cases where labour  appears imminent, with considerable
flooding, whilst the os internum uteri is still closed, the arrest  of the
flooding and  the expansion of the os  may be favoured by plugging the
vagina, and especially the cervix, and by the use of ergot.
  5. That, since  a cross-presentation,  or other  unfavourable position
of the child at the os internum uteri, is apt to impede or destroy the
regular contractions of  the uterus which are necessary to the arrest of
flooding, it is mostly  desirable,  in cases  complicated with unfavourable
positions of the child, to deliver as soon as the condition of the os uteri
will permit.
  6. That, in some cases, the simple  use of means to excite contraction
of the uterus, such as ergot, rupturing the membranes, the administra-
tion of a purgative,  or  the  employment of galvanism, will  suffice to
arrest the hasmorrhage.
  7. That, in  some cases, where  it is  observed  that the os  uteri has
moderately expanded—namely, to the size of a crown-piece, or  less—
the placenta being felt to be detached  from the cervical zone, and the
hasmorrhage having  ceased, it is not necessary  to interfere Avith the
course  of the  labour, now  become normal.
  8. That,  at the critical period, when the total detachment of the
placenta or forcible delivery is a dangerous or impracticable operation,
the introduction of the index-finger through the os, and the artificial
separation of that portion of the  placenta which  lies within  the lower
or orificial zone of the uterus, is a safe and feasible operation.
  9. That the artificial detachment of all that portion of the placenta
which  adheres within  the  cervical  zone of the uterus  will at once
liberate the  os internum uteri from those  adhesions  which  impede
its  equable dilatation;  and,  by facilitating  the regular contraction of
this segment  of  the uterus, will favour  the arrest of hasmorrhage,
and convert  a labour complicated Avith placental presentation  into a
natural  labour.
  10.  That  the immature  uterus, partly paralysed by loss  of  blood,
cannot always be trusted to  assume the vigorous action necessary to
effect delivery; that  it is, therefore,  often desirable  to  aid by dilating
the cervix artificially ; that this can be  done safely and quickly  by the
caoutchouc water-dilators. 
422
OBSTETRIC OPERATIONS.
  The management of the case after the removal of the placenta  falls
Avithin the  subject of post-partum haemorrhage, and will be discussed
in the next lecture.


           C.—The  so-called  "■Accidental Hemorrhage."

  The placenta  growing within the normal  regions, that is, in  the
fundal or equatorial zones, haemorrhage  may break out at  any time.
The haemorrhages which occur during the first six months of preg-
nancy  have been discussed under the head of abortion; but several
of the causes which  lead to abortion  may act during the latter three
months of  pregnancy.   The haemorrhages of the latter three months
have  been  divided   by the elder  Bigby into " Unavoidable"  and
"Accidental," in order to  contrast those depending upon growth of
the  placenta over the cervix  uteri from the other cases.  The  dis-
tinction is  arbitrary and unphilosophical; but it has been generally
adopted  in  this  country because of  its  convenience.   Convenience,
however, is here, as is too often  the case, purchased at the cost of
truth.   I have  shown that the  Avord "unavoidable"  is  much  too
absolute.   The  word  "accidental"  is  even  more unfortunate.   It
may be doubted  whether, with placenta prasvia, haemorrhage  be more
unavoidable than it is in  the so-called  accidental  cases.  And  why-
should a haemorrhage arising from spontaneous detachment of placenta,
brought about by disease or emotion, of which we often  know nothing
—that is, nothing more than we knoAV  of the existence of placenta
praevia—until its  consequence,  haemorrhage, has  broken  out,  be
specially characterized as "accidental"?
  If, then,  we retain the word, we must be careful to  use it  simply as
an arbitrary formula to exclude haemorrhage from placenta prasvia.
  There is, however, sound clinical reason for studying the hasmor-
rhages  that  occur  during  the latter three   months  of pregnancy,
distinguishing those which depend upon placenta praevia, apart from
the  haemorrhages of early  pregnancy. As we approach the term of
gestation, the relations of the placenta to the uterus differ essentially.
The adhesion becomes less intimate  ; slighter  causes  determine  its
premature detachment; and one circumstance, that which lends special
significance and gravity to the haemorrhages of this period, the liability
to partial or complete retention  or concealment of  the extravasated
blood in the uterus, is almost unknown  in the first half of  gestation.
This important practical distinction we undoubtedly  owe to Dr. Bigby's
definitions.  This pathological  distinction and the  outflowing clinical
indications  are scarcely apprehended by French and  German authors.
  Haemorrhage in the latter months  depends essentially upon detach-
ment of placenta, so that  blood  Aoavs from the ruptured and bared 
" ACCIDENTAL  HEMORRHAGE."
423
utero-placental vessels.   This general proposition is no less true of the
hemorrhages which arise when the placenta grows to the fundus than
it is Avhere the placenta grows to the loAver zone.
  The immediate causes of detachment  of  the placenta are—1. Con-
tractions  of  the uterus, which disturb and  break the  relations of
surface betAveen  uterus  and placenta ;  2.  Undue,  especially sudden,
determination  of  blood  to  the uterus  and placenta;  3. External
violence.
  1. Towards the  end  of gestation,  the muscular fibre of the uterus
becomes rapidly  developed, and  contractility becomes more and more
pronounced.   Hence it  is that  detachment of  the  placenta is more
frequent at this period.  Causes  that  heretofore Avould  have been
harmless, may noAv excite active contraction.   Some degree of con-
traction analogous to  the peristaltic movement of the intestines may
commonly be  felt by the hand, especially if it  be applied  cold,  on the
abdomen.  If this contraction  be  excessive or  sudden,  the placenta
may be partially loosened.  The smallest extravasation between uterus
and placenta will excite further contraction;  the separation is increased,
and more blood is effused.   This disposition to  separation is much
facilitated by any morbid  condition of the placenta, such as  fatty
degeneration, calcareous degeneration, fibrinous  masses, which  impair
the uniformity of its structure.   A morbid placenta will not folloAv and
adapt itself to the varying movements and superficial area of the uterus,
so easily as a healthy one.:;:   A dead foetus may lead to detachment in
two ways.  First, through retrogression of tissue the attachment of
the placenta  is loosened ;  secondly, the contraction of  the  uterus is
excited as by  the  presence of a foreign body.
   Gendrin gives the following explanation of the mechanism of detach-
ment of the placenta.  The muscular structure of the uterus is disposed
in two layers, an external and an internal.   The relations of these tAvo
layers Avith the vascular layer  account for  the  influence they exercise
in the production of haemorrhage.   When  spasmodic contractions are
excited, the intra-uterine vascular  plexus being pressed irregularly by
these  muscular contractions, blood must flow  in  some  points of the
placental disc ; hence, a partial congestion, which may cause a rupture
of  the weak  venous ramifications.   These contractions, by causing
circumscribed  puckerings on segments  of  the uterine  globe, neces-
sarily drag  upon  the placental connections,  and may  cause  their
rupture.
   2.  The second  cause may act independently  of  the first, but  it will
act with especial force Avhen the first exists.  Emotion will cause con-
traction of the uterus ;  it is also a poAverful agent in directing a sudden
floAV of blood to the uterus.  The sudden tension of the  A^essels, aided
  * Sec the Author's memoirs on "Fatty Degeneration of  the Placenta "—" Med.-
Chir. Trans.," 1851,  1853. 
424
OBSTETRIC OPERATIONS.
 or not by contraction of the muscular wall, is relieved by extra\rasation
 of blood between uterus and placenta.   It has been observed (Kiwisch)
 that detachment does not always at once ensue upon the nervous shock,
 and that flooding may not set in until after some hours, even days,
 have passed.  I would explain such cases by supposing that a slight
 extravasation  takes place at the time,  which, acting as an irritant to
 the uterus, occasions extended contraction a little later.   The utero-
 placental vessels are of extreme delicacy ; they form the weakest point
 of  the  circulating  system.  Sometimes  extravasation takes  place in
 the placenta itself:  this is placental apoplexy ;  it will probably lead
 to detachment.
  3.  Violence in many forms may  produce similar results.   Direct
 violence, usually assigned as the most common cause, acts in an obvious
 manner.  A blow, even if  not bearing  immediately upon that part of
 the uterus to which the placenta is attached, may, by re-percussion, or
 contre-coup, throwing the uterine  wall into agitation, or making it
 contract, cast off the  placenta.   The  movements of the  foetus  may
 excite sufficient contraction.   In some cases  I have  suspected  that
 coitus has been the  cause.   Detachment of the placenta has been
 known  to folloAV severe vomiting,  straining at  stool, or coughing,
 lifting heavy weights, standing at hard work at the wash-tub, and so
 on.   These  may act  not only by the  violent succussion, but also by
 producing uterine hyperaemia.  But the frequency of violence as a
 cause is, I believe, much exaggerated.   Duparcque suggests that com-
 pression of the uterus by the abdominal muscles, as under the strain of
 vomiting, may detach the placenta.  But probably the emotional con-
 traction of the uterus participates in this effect.
  Predisposing Causes.—This premature  separation  of  placenta rarely
 occurs in the young and robust.   It  is most  common in women about
 forty years of  age, who have borne many children, whose constitutions
 are worn by sickness and  poverty, and  whose  tissues are therefore
 badly nourished, wanting in tone, tending to atrophy or degeneration ;
 in short, in the same class  of persons who are most liable to rupture of
 the uterus.  In one case, I found fatty degeneration of the heart.
  A thin, watery, degraded blood is a frequent factor.  Certain dis-
 eases dispose to haemorrhage  and detachment  of placenta; such  are
 variola, scarlatina,  or  typhoid, albuminuria (Blot), leucocythaeruia,*
 acute atrophy of the liver.  Should one of these  affect  a pregnant
 Avoman—and the three last are especially liable  to arise in  connection
 Avith pregnancy—the risk of extravasation at the weakest point  of  the
A-ascular system, namely, the utero-placental vessels, will be great.
  In  these predisposing causes lies one source of the great danger
 attending these cases.   A second  is,  that the blood is  often AAholly or
partially "concealed."  The detachment taking place at  a  distance
                 * Paterson : " Edin. Med. Journ.," 1870. 
ACCIDENTAL HEMORRHAGE."
425
from the cervix, the blood accumulates in the cavity of the uterus ;  Ave
lose, therefore, the ordinary evidence of flooding.   Thirdly, this sudden
irruption  of blood into the cavity of the uterus  stretches the uterine
fibre, producing shock, perhaps collapse.  The peritoneal coat has even
been known to be torn by this sudden  stretching.  This is illustrated
by the  fact observed by  Sir J. Y. Simpson, that forcible  injection of
water or  air into the uterus, for the purpose of inducing labour, has
caused similar laceration.  Indeed, fatal mischief is often  done before
the physician  is summoned, or has the opportunity of acting.
  It must not, however,  be concluded that all cases are of this extreme
severity.   There is  an  order  of  cases in which  the symptoms  are
comparatively slight.  There is no mark of tension of the uterus, and
but  slight shock or pain.  In  this order  it will be remarked that
the blood  escapes externally;  and it  is  to  this  condition that  the
mildness  of the symptoms is due.  These are the  cases  in  Avhich
simple rupture  of the membranes,  or  even expectancy,  is sufficient
treatment.  There being little shock or exhaustion, the uterus quickly
re-asserts its  power.   I  believe they truly are chiefly cases in which
the placenta encroaches upon  the cervical zone.   This I have often
demonstrated  by showing that  the rent in the membranes  Avas near
the margin of the placenta.  This fact must be accepted as circum-
scribing the number of  cases  of "accidental''  haemorrhage.  Many
cases described under  this designation  are, in  reality, cases  of partial
placenta prasvia.  It must at the same time be borne in mind that  the
same causes produce premature separation of  the placenta, Avhatever
be the  seat of its attachment.
  The Diagnosis and Symptoms.—We must seek  for other symptoms
than  haemorrhage to guide  our diagnosis.  The most characteristic
are—first, acute pain in  some part, generally the fundus, of the uterus,
increased on pressure ; second, collapse; third, great distension of  the
fundus  of the uterus;  fourth,  loss of  regularity of form of icterus;
it protrudes more than naturally into the  epigastric region, and com-
municates a doughy feel, the form of the foetus being lost at  this part.
These signs are the result  of the stretching  of the uterus by  the
accumulation  of blood in a circumscribed part.   The histories of cases
show that the detachment almost always begins in the middle  of  the
placenta,  and  proceeds toAvards the margin under the pressure of blood
accumulating.   A cavity is formed  for the reception  of  the  blood,
partly by inward compression  of the  placenta,  Avhich  tends  to be
separated, and  partly  by the  bulging  outwards of the uterine Avail.
The placenta  examined  after  expulsion, instead  of being  convex on
its maternal surface, is cup-shaped.  Dr. Oldham described * a typical
case, in which the placenta retained its  adhesion all round the margin
only, a  large  mass of blood being imprisoned  in  the hollow formed
                       * "Guy's Reports," 1S56 
426
OBSTETRIC OPERATIONS.
betAveen uterus and  placenta.   The  placenta is  in  Guy's  Museum.
A fifth result  of the  sudden shock  and uterine injury is commonly
absence of all true labour-pains.
  It is interesting to note the analogy between these cases and rupture
of the uterus.   The  symptoms  often  bear a striking resemblance.  In
both cases there is sudden injury to the uterus.  Accidental hasmorrhage
may, in some  cases, be regarded as an  alternative  of  rupture of the
uterus.  We have  seen that emotion, by producing sudden concentric
pressure, may  cause rupture.  This catastrophe may be averted if the
ovum or its attachments give  Avay.
  There  are indeed  the general  signs  of loss of blood:  fainting,
blanching, agitation, perhaps deafness or blindness.   The  skin is cold
and  clammy, the pulse feeble, dicrotous,  or  almost extinguished; the
features  are  pinched ;  the whole   aspect  indicates  suffering  and
depression.  The  intensity of these symptoms is greater than can be
accounted for by the amount of blood Avhich  escapes externally.   There
is a characteristic indication of concealed  hasmorrhage.  In these cases
the clot or crassamentum is retained.  Under compression the serum
is squeezed out and escapes.  Hence, when Ave see a thin watery blood,
we  may suspect retention of clot from " accidental " or "  concealed "
haemorrhage.  When the child is born,  placenta and black clots come
aAvay with a rush.
  Prognosis.—Cases of this nature, occurring as they mostly do under
conditions  of  debility, if not of disease, Avhere there is little inherent
poAver of resistance or of recuperation, must always be looked upon with
anxiety.  Death may occur in a few hours,  even before delivery; and
sometimes  the additional shock of delivery  induces  fatal prostration ;
and  sometimes, further  hasmorrhage following the birth of the child,
extinguishes Avhat little  strength and hope remained.  Safety  often
depends upon  early  recognition of the nature of  the  case.
  Treatment.—The first  thing to be done is  to rupture the  membranes.
This, by  letting off  the  liquor amnii, takes off the strain  upon the
uterine fibre, allows  the  walls to resume their natural condition, and
provokes  labour.   This done, it is desirable  to  watch  and  give
opportunity to rally.  In some cases,  where  prostration is not marked,
this is enough. Nature will do the rest.  To proceed quickly to forcible
delivery, might prove fatal by adding to the  shock.  Ergot, I think, is
not very useful.  If there be great depression, the drug is either not
absorbed,  and is  therefore  inert; or, if absorbed, it is injurious by
adding to  the prostration.   Stimulants internally,  warmth to the
extremities, and friction,  are  useful in promoting reaction.   This
effected, the uterus may be  able to contract, and labour  may go on
spontaneously.  If not, the next thing is to  dilate the cervix gradually
by means  of the water-dilators.  Formerly, it was necessary to incur
the danger of letting the  patient sink from exhaustion,  unless we were 
"ACCIDENTAL  HEMORRHAGE."
427
prepared to encounter the greater  danger of forcing the hand through
the  cervix  and  turning  the child.   Collins says, "I knoAV  of  no
operation more  truly  dangerous both to  mother  and child than the
artificial dilatation of the os uteri and turning the child."  He relates a
case in Avhich laceration of the uterus was thus caused.  If the hydro-
static bags are used, there is no operation more safe.  When  there is
sufficient dilatation, you may deliver by the forceps  if the head present;
by bi-polar turning if any other  part present.  The ruling principle
should be, to proceed with as little precipitation and force as possible,
economizing the woman's strength.   With  this view  it is sometimes
desirable  to  deliver  by  craniotomy ;  and  especially  if  the  child is
dead.
  When the child is delivered, the placenta comes aAvay Avith a mass of
clotted and  fluid blood; and often the prostration is increased, death
sometimes quickly following.   As soon as  the  placenta  is extracted,
I strongly advise to inject luith hot water (110° F.), and then  to swab
the  uterus  with perchloride of iron,  instead  of  trusting to cold or
kneading, both of which are injurious.  The great depression contra-
indicates  the resort  to any agents that depend for  their  efficacy
upon a reserve of power in the system.   The paralysed, injured uterine
fibre predisposes to fresh haemorrhage.   It  is all-important to secure
the patient  against further loss by the most prompt and trustAvorthy
means.
  In these cases the child is almost always  born dead.  It perishes of
asphyxia, arising from  the mother's loss of blood and collapse, and the
partial or complete  detachment of the placenta. 
L E C T U B E  XXVIII.
HEMORRHAGE AFTER THE BIRTH OF  THE  CHILD—CASES  IN  WHICH
    THE PLACENTA  IS RETAINED—CONSEQUENCES OF RETENTION  OF
    PLACENTA—THE  PROPHYLAXIS OF  HEMORRHAGE—CASES  AFTER
    THE REMOVAL  OF THE  PLACENTA—SECONDARY  HEMORRHAGE—
    CAUSES  OF  RETENTION  OF  PLACENTA—MODE  OF CONDUCTING
    THIRD STAGE OF LABOUR—ENCYSTED OR INCARCERATED PLACENTA
    —APPARENT  ENCYSTMENT  FROM GROWTH  IN ONE HORN  OF  A
    TWO-HORNED  UTERUS--HOUR-GLASS CONTRACTION--MEANS  OF
    EFFECTING DETACHMENT  AND EXPULSION OF PLACENTA—ADHESION
    OF  THE  PLACENTA — CAUSES--TREATMENT--PLACENTA SUCCEN-
    TURIATA—PLACENTA DUPLEX--PLACENTA  VELAMENTOSA.

We have now to discuss the nature and management of the hemor-
rhages which occur during and after labour—that is, after the birth of
the child.  These may be usefully divided into
  a. Cases in which the placenta is retained.
  b. Cases in which bleeding persists, or occurs after the removal of
the placenta : post-partum hasmorrhage.
  c. Cases in which bleeding  persists, or occurs some days after labour:
the so-called " secondary puerperal haemorrhage."
        a. Hemorrhage in which the Placenta  is retained.

  In the most healthy labour, the supreme effort of expelling the child
is commonly attended by so much pain and expenditure of nervous
force, that a period of rest, the result of temporary exhaustion, follows.
Probably the placenta is in great measure detached  during the final
contractions which expel the child.   Soon,  sufficient nerve-force is
reproduced; the uterus contracts again,  and completes the detachment
of the placenta.  If the placenta has been adherent to the fundal or
equatorial zones of the uterus, its connection is preserved entire until 
POST-PARTUM HEMORRHAGE.              429
these final expulsive contractions take place, when it is cast en masse.
In the case of fundal attachment, the separation begins  at the centre of
the placenta and extends to the  circumference.
  But if a portion of the placenta has dipped down within the lower zone,
this part  may have been detached during the expulsion  of  the child,
and hasmorrhage will continue afterwards ; or, which  is  as frequent,
the part of the  placenta which had  grown  to  the  upper part of the
orificial zone has not been detached during the second stage  of  labour,
and thus, when  the uterus contracts, it is only the fundal  and equa-
torial regions of the organ which contract so  uniformly as to throw
off  the placenta; the lower region not contracting to the same extent,
the placenta correspondent to it  remains adherent, and again haemor-
rhage results.  In either of  these cases,  separation begins  at  the
margin.
  If, from any other cause than the foregoing, the nervous force neces-
sary for  complete uterine contraction be wanting, so that the uterus
is affected unequally,  even  if the placenta be normally attached, this
unequal contraction Avill cause partial detachment of the placenta and
haemorrhage.
  It is not to be forgotten that weakness during expulsion of the child
commonly  continues  into  the  stage of  placental  expulsion.  This
disturbance is the more  extensive, the greater the degree of weakness
of the pains, the longer the labour, and the more rapid the artificial
delivery.  Hence the axiom: in delivery by forceps proceed deliberately,
so as to give the uterus opportunity to act and help.  Help the  uterus;
do  not supplant it.  In all  labours, let  the  uterus expel the body and
legs of the child.
   Or, again, if  after the placenta has been Avholly detached, it  remain
in the uterus, and inertia come on, hasmorrhage will also folloAv.
   Dr. Graily  Hewitt* has drawn attention to  a remarkable cause of
hasmorrhage,  namely,  the  presence of peritoneal  adhesions  on the
surface of the uterus,  the  effect of Avhich  is to prevent the  regular
contraction and descent of the uterus.  This  cause  is  rare, but  it
should not be  lost sight of.  It is especially a case for the topical
use of  perchloride of iron.
   Not only does the presence of the placenta excite irregular spasmodic
action, but, so long as it remains,  the full, equable contraction neces-
sary  to  completely close the  uterine sinuses  cannot  take place.  It
follows as  a  corollary,  that the removal of the placenta is the first
great end to  be attained as a security against haemorrhage.
   How is this best effected ?   There is  error both in precipitation and
in delay.   If,  immediately after the birth of the  child, you begin to pull
upon the  cord,  you irritate the  uterus  at the moment of temporary
exliaustion,  you  make  that  temporary  exhaustion  persistent,  you
                   *  '' Obstetrical  Transactions," vol. xi. 
430                 OBSTETRIC OPERATIONS.
induce irregular spasmodic  contraction.  This will rarely  have any
other effect  than to cause partial detachment, prolonged retention of
the placenta, and haemorrhage.
  Hunter and Denman encouraged the practice of leaving the extru-
sion of the  placenta to  the natural  efforts, even  for  several hours.
This practice had already been tried  in Holland, under  the authority
of  Buysch,  and  abandoned.  Hasmorrhage  and puerperal fever  so
frequently followed, that  it was  abandoned  here  also.  But this sort
of moral handcuffing for an arbitrary time  can only be applicable to
persons Avho cannot  be trusted to observe and interpret accurately the
condition of the  patient.  The uterus will  often, indeed, detach  the
placenta and extrude it into the vagina ; but there it will  lie for  an
indefinite time,  for the vagina has rarely the power  to expel it.   What
useful  purpose  can it answer to  leave it there ?  The prevalent prac-
tice in this country seems  to me  the  most reasonable.  It is to Avatch
for  contraction  of the uterus, Avhich  is ascertained by the hand, and
by the consciousness of expulsive pain by the patient.  If the uterus
is felt  hard, and  of  the size of a child's head, behind the symphysis,
and if, on using the  cord for a clue, you can feel the insertion of the
cord without passing your hand into the uterus, you know the placenta
is cast and  partially extruded  into the vagina.  Once beyond  the
action  of the uterus, the spongy mass of  the placenta will fill  the
vagina, adapting itself to  the  cavity of  the pelvis.  The  vagina,
recently distended, has little contractile power,  and  in it the placenta
will be retained.   The indication clearly  is  to complete  what  the
uterus and vagina cannot do, by gently removing it.   This you may
do sometimes in five minutes ; and it is rarely desirable to  wait more
than ten or fifteen  minutes.  If not expelled spontaneously, put  on
vim a tergo.
  The consequences  of retention of the placenta are these :—
  1. Commonly,  hasmorrhage and  spasmodic pain.   The alternate
contractions  and  relaxations  characteristic  of uterine  action  are
repeated.
  2. Sometimes,  no  haemorrhage, but expulsion after  an  indefinite
number of  hours  or days.
  3. Decomposition  of  blood in the cavity of the  uterus, and  im-
prisonment  of the products, by the  placenta blocking up the  orifice,
constituting physometra.    In  this  condition  the  uterus sometimes
enlarges, becoming  tympanitic.   The most  horribly  offensive dis-
charges escape.
  4. Septicaemia, from the  absorption of the foul  products.
  5. Inflammation of the uterus  and peritoneum,  from the presence
of foul stuff in the veins and lymphatics, and possibly from escape of
foul stuff by the Fallopian  tubes into the  peritoneal cavity.
  6. Disappearance  of  the  placenta  by  disintegration,  liquefaction, 
POST-PARTUM HEMORRHAGE.
431
or absorption.  I very much doubt Avhether absorption of the placenta
can be established on good eAddence.  I feel disposed to  regard it in
the same light as Velpeau  regarded  " Vagitus uterinus."   Since men
of credit affirm that  they have seen it,  so  I believe it; but if I  had
seen it myself I should doubt.
                 The Prophylaxis of Hemorrhage.

  The prophylaxis  may begin  during pregnancy,  or  even before.
Experience has  proved that certain women are prone to bleeding in
labour.   This  proclivity may depend upon one  of tAvo  conditions
especially,  namely:  an  altered   state  of  the  blood;  or  defective
muscular tone combined with low nervous  power.   With albuminuria
it has been remarked (Blot) that the  disposition to haemorrhage  is
greatly increased.  Women addicted  to drink,  whose  liA7er,  kidneys,
and  heart  are  probably  affected, are especially prone to bleed.   In
anaemia from  any  cause,  and  Avhenever  there is  evidence of the
blood being  reduced in  quality,  care  should  be taken  to restore  it
to its due standard.  Iron under  conditions  of this kind is often useful.
Under the action of this remedy, abortion even may in many cases be
averted.  For abortion is often the immediate consequence  of hasmor-
rhage, and therefore, remotely,  of the conditions that  predispose  to
haemorrhage.
  Coming  to the time  of  actual labour, Ave  again sometimes  find
indications in the character of the labour  of the liability to  flooding.
Where the uterus is largely distended ; where  the parts of the foetus
are  easily  felt,  showing that the walls  are  thin; where  there  is
generally  want  of  tone,  Avith flaccid  muscles,  and  hyperaesthesia,
excessive anxiety of mind, approaching to terror, it  may be  expected
that the uterus will  act feebly, and that haemorrhage will occur.  Dr.
EAving Whittle has  given  the folloAving description  of the signs  that
threaten hasmorrhage  (British Medical Journal,  1875) : " The pains
are strong and quick ;  they do not culminate into a strong pain and
subside again, but they are sharp, quick, and cease almost suddenly ;
and  the  intervals between the  pains  are  long in proportion to the
length of the pains.   After the child is born a relaxation folloAvs : one
or tAvo sharp pains  expel  the placenta with a gush  of blood, and the
uterus again relaxes,  continuing  the same tendency Avhich existed
before the delivery  of  the child."   When  the uterus acts in  this
manner, Dr.  Whittle gives, as soon  as the  os  uteri  is Avell dilated, a
dose of ergot.  Indeed, the use of ergot at this time  has long been
relied upon by many practitioners of eminence.
  The principle  is to study the natural action  of the uterus ; to take 
432
OBSTETRIC OPERATIONS.
note  of  any deviation from  the course of  healthy  action;  and  to
endeavour to restore  healthy  action.   Irregular feeble contractions
sometimes depend upon  loaded boAvels.  A dose of castor-oil, Avith
ten  minims  of laudanum  or  an enema, will in such a  case  often
quickly be folloAved by efficient  pains.  Emotion may disturb or  quite
suspend uterine action.  In such a case, the induction of anaesthesia,
or a draught composed of thirty minims of Hoffman's anodyne with
fifteen minims of the sedate liquor  of opium, will act with surprising
benefit.
  Continuing to  observe  the  same  principle,  we  must  be  careful  to
respect the great  law of labour, that  the  uterus should   as far  as
possible be aUowed to do its own Avork.  Since the time of Smellie,
all good authorities have recognized the importance of avoiding quick
delivery.  When  you  hurry a  labour by pulling  upon the  child, you
disturb the sequence  and  correlation of  the  factors of labours.   The
uterus resents  this  meddling,  acts  irregularly and imperfectly,  and
hasmorrhage is  the  consequence.  Another form of interference allied
to precipitate manipulations, to be avoided, is the practice  too  often
urged  by nurses  and  officious friends, of bearing-down, of straining
violently, fixing the chest, by  pulling upon a toAvel fastened to the
bed, in order " to help the pains."  Voluntary effort should  wait
upon the reflex stimulus ;  it should not be called into untimely action,
as it is Avhen it is made to anticipate the spontaneous  reflex contrac-
tion of the uterus.
  The practice, so  general, of removing  the  placenta by pulling  upon
the cord, is liable to invert  the placenta, so  that  it comes  aAvay Avith
the membranes covering the maternal aspect.   This is  described as the
natural relation by Baudelocque.  But Caseaux, Lemser, and MattheAvs
Duncan have taken pains to  show  that this  is  not  the  disposition
when things are allowed to  take their natural  course.  The placenta,
they say, presents by its edge at the os ; and if expelled or withdrawn,
so as not to disturb the relation of the parts, it comes away edgewise,
the membranes covering  the fcetal  surface and  the cord,  as during
pregnancy.  But  there are  two sides of the shield.  In the  System
of Obstetric Surgery and  Medicine (vol.  ii., 1885), I have shoAvn Iioav
both descriptions are true.  I  have  there, by  illustrations,  explained
that Avhen the placenta  has  been  attached to the fundus,  Baude-
locque's statement that the foetal surface presents,  the placenta turning
inside  out, holds  good;  and that when the placenta  has  grown  to
the side  of the uterus, it  may  come aAvay edge first, as described by
Caseaux.
  This may be laid down as  an axiom in obstetrics: by the proper
management  of labour, including the delivery of the placenta, you
greatly secure  the patient against hemorrhage and many  other
dangers. 
POST-PARTUM HEMORRHAGE.
433
  In  Avhat  does this management consist?   To  some extent this
question is already answered.
  The rule laid  down by the  late Dr.  Joseph Clarke, of Dublin, and
endorsed by  Collins  and Beatty,  is the one I recommend  for  your
adoption :—When the head and trunk  of the child are expelled, follow
doAvn the fundus uteri in its contraction by your hand on the abdomen,
until the foetus is entirely expelled, and continue this pressure for some
time afterwards, to keep  the  uterus in a contracted  state.  When you
are satisfied  of  this,  tighten  the  binder.  I always apply the binder
during the labour ;  the support  thus given to the uterus  is invaluable;
it tends to preserve the due relation between the axis of the uterus and
that of the brim, thus obviating  the most serious objection made to the
English obstetric position on the left side.
  This plan  of  causing  the uterus to contract and  expel the placenta
by manual compression has within the last few years been introduced
into Germany,  as  a discovery, by  Dr. Crede, without  a  suspicion,
apparently, that it  has long been a familiar practice in this country.
It  is  insisted upon Avith  detail  by Hardy  and McClintock."
  The great point is,  to let or  make the uterus cast the placenta by its
own efforts; not to  pull the placenta away.   The " expression " or
squeezing out the placenta should not then  be always resorted to.  It
is  "meddlesome"  and injurious to practise it immediately after the
delivery of the child.  A few minutes must be allowed for  the uterus and
the nervous system to rally from the supreme  effort and shock of the
second stage.  There is commonly a temporary inertia from exhaustion.
If,  during this primary inertia,  you squeeze  the uterus too resolutely,
you might even cause inversion of the uterus—as occurred to Schnorr
(Monatsschr. f.  Geburtsk., 1867), and in a  case which came under my
care at St. George's Hospital.   Timely applied, " expression " aids and
is  aided by  natural contractile  efforts.  In this  lies security.
  Where there  is special reason  to fear hasmorrhage, as from great
laxity of muscular fibre,  a mobile  emotional  or nervous  temperament,
or  a history of  liability to flooding, you should be  on your  guard to
command the uterus from the  moment of the expulsion of the child.
The proper  mode of expressing the placenta is as follows.   Place
the patient on her back.   This gives more power to the operator, and
places the uterus in more favourable relation to the  axis of the pelvis.
Place the palms of  both hands on the fundus of the  uterus ;  compress
the fundus  steadily  downwards, and  from side to  side between the
hands, and thus prevent  it from relaxing.   The  pressure should not
bear unduly  upon the fundus, but be so applied  as to  compress the
anterior  wall of the  body against the posterior  Avail.   The pressure
should be exerted by preference  during an effort at uterine contraction.
Another person should feel if the  placenta is detached, and Avhen  it
                     * "Practical Midwifery," 134S.
                                                           F F 
434
OBSTETRIC OPERATIONS.
is so, remove it.   Frequently under pressure the placenta and  mem-
branes are cast entire into the bed.  The pressure should be maintained
some time  after the removal.   By this plan,  I have knoAvn delicate
women, who in previous labours seemed likely to bleed to death, saAred
from all loss and make excellent recoveries.   It is in this class of cases
that a full dose of  ergot, given just before or during the expulsion of
the child, acts with peculiar advantage.
  A retahied  placenta  may become  "encysted," or  "incarcerated,"
that is, locked up in the fundus of the uterus by contraction of the part
below.  A form of this retention is familiarly spoken of as " hour-glass
contraction."   It is described and figured as a  ring-like  contraction of
the middle part of the uterus, dividing  it into tAvo spaces.   By others,
more accurately,  it is  described  as due to contraction of the  loAver
segment  and neck of the uterus.  It is  agreed by most authors of
experience,  that hour-glass contraction is very  rare.   The  varieties
of irregular contraction of the uterus  might be deduced a priori from
consideration of the arrangement of the  muscular fibres.  If all  the
muscular bundles  of the uterus contract harmoniously together, there
will be the much-desired  normal uniform contraction,  closing  the
cavity, and necessarily expelling anything that may happen to be in it.
But it is a matter  of observation, that occasionally parts of the uterus
contract, whilst other parts remain passive.   Now, which are  the parts
most disposed  to contract, and  which to remain passive ?   Naturally,
those parts  in  which muscle is most  abundantly provided, Avill have
the greater power of contracting.   Two parts are especially rich in this
respect—that is, each corner around the entrance of the Fallopian tubes.
At the lower part of the body of the uterus the  bundles  of fibres from
either side assume a transverse or circular direction.
  Now, there are two parts which are  specially exposed to conditions
that weaken their contractile power, producing  even temporary para-
lysis.  These are,  the placental site and the cervix.   The attachment
of the placenta involves a great development  of vascular structure;
and hoAvever it be  explained, the fact is  certain, that the placental  site
is very liable to inertia.   The paralysis of the cervix is accounted for
by the great distension  and bruising to which it is exposed  during the
passage of  the child.   After delivery it is constantly felt to be quite
flaccid, as if it  had lost all  power of recovering  its  former shape  and
tone.  Levret  points out  the necessity  of distinguishing  from  the
contractile  neck  of the womb,  that  kind  of  elongation  resembling
the truncated  end of a large intestine which  is sometimes met with
in the vagina  after labour.  This  is  the  lower  part of the neck.
The placental  site and the cervix then are the two great sources of
hasmorrhage.
  If the placental site  be at the fundus, extending into  the area of
Buysch's muscle on either side, the fundus  generally will  be  liable to 
                   POST-PART CM HEMORRHAGE.             435

 paralysis ; and the part  below being excited to action, there may arise
 hour-glass contraction—i.e., contraction of the  loAver part, or equator,
 of the uterus.
   If the placental site  be  in  one angle of the uterus, occupying the
 area of one of Buysch's muscles, the central part of that area will be
 liable to paralysis, and the circular bundles on the margin of that area,
 being excited to action, will close in upon the placenta, forming a sac.
 Clinical  observation  confirms this.  If you feel through the relaxed
 abdominal wall a spasmodically-acting uterus, you  will often find it of
 irregular shape, and you will perceive a marked prominence at one side
 of the  fundus, caused  by  the  contraction  of one  circular muscle.
 Again, if you pass your  hand into a uterus contracting irregularly, you
 Avill come to  the constriction,  the  seat  of which you will be able
 exactly to determine, between the two hands, to be  Avhere I  have
 described it.
   It is generally admitted that these forms of irregular contraction
 are most frequently  induced by injudicious  meddling, by precipitate
 artificial delivery,  by making too early attempts to bring away the
 placenta, by  pulling  on the cord, thus irritating, teasing the uterus.
 You must remember the  precept: Make the uterus cast out  the
 placenta;  do not drag  it out.
   Some  cases of  apparent encysted  placenta may be due to  the
 placenta having grown  in one horn of  a  partially  duplex uterus (See
 Kussmaul, p. 187).
   A method  of  exciting the  uterus  to contract and  throw off the
 placenta is the injection of cold  water into the vein  of the umbilical
 cord.   This Avas proposed by Mojon.*  By this means cold is applied
 directly to the placental  site, so that the very part of the uterus with
 which  the placenta  is  connected is  stimulated to contract.  I have
 no personal experience  of this method; but Scanzoni speaks  highly
 of it.
   If the  uterus cannot be made to contract, or  if pressure fail to cast
 off the placenta, it will  be necessary to pass the hand into the uterus
 to remove the placenta.   For this purpose the patient  may lie  either
 on her b?^k or  left  side.   Support the  uterus firmly, pressing the
 fundus backwards and downwards towards the pelvis with one hand;
 at the same  time  pass  the  other  hand, guided by the cord, into the
 cavity of the  uterus.  Feel for the lower edge of the placenta,  and with
 the fingers flattened  out between the placenta  and  uterine  wall,
 insinuate them by a light waving movement upwards, so as  to peel off
 the placenta from the uterine  surface ;  all  the while  be  careful  to
support the uterus by the hand  outside; you gain  from this consen-
taneous  action  more command  over  the internal  manoeuvre, and
 wonderfully facilitate  the accomplishment  of your object.   When the
                 * " Annali Universal! di Medicina," 1826.
                                                         FF  2 
436
OBSTETRIC OPERATIONS.
placenta is entirely separate, seize  it well, endeavouring, by outAvard
pressure, to induce the uterus to expel the placenta and hand together.
When the  placenta is extruded, proceed in like manner to clear the
uterine  cavity perfectly of clots.  Apply the binder firmly, aided by a
compress, if necessary.
  The  whole organ is sometimes affected, assuming the character of
tetanus, the contractions are so rigid and persistent.   This is especially
apt to occur after ergot.  To overcome  them,  you must  depend  upon
steady  continuous pressure  with the  hand or the water-bag;  opium,
ether, chloral, chloroform, especially nitrite of amyl, Avill often assist.
Pass the hand in a conical  shape into the constriction, carefully push-
ing the  fundus uteri doAvn  upon  the inside hand by the other  hand
on the abdomen.   You must trust to  time to  tire out  the spasm, not
to force.   Your  hand may very  likely be cramped,  but  you  must
persevere, or  you will only  have  irritated the uterus,  and be  obliged
to begin again.   When you have succeeded in passing  the constric-
tion, grasp the placenta, remove it, and keep up  steady pressure  upon
the uterus externally.   When the placenta  is removed,  the harmony
of action of the uterus will be restored.
   The  object is to restore the  due relation  of  contractile energy
in the different parts of the uterus.   The greater contractile energy
should  be exerted by  the fundus.    We  must  then seek—1, means
to  relax the crampy constriction of  the  lower  segment;  and, 2,
means  to  evoke the supremacy of  contraction of the  fundus  and
body.
   The cases  we  have  been considering comprise those in  which the
placenta is retained simply from want of uterine energy to detach and
expel it.  These are by far the most common cases.  But the placenta
may be retained by morbid adhesion to the uterus.   Cases of this kind
are comparatively rare.  They  most frequently occur to  students and
young practitioners.   Many cases, in fact, are purely subjective. When
real, they are more  troublesome  and  dangerous than the first, and
require more  decided treatment.
   True  adhesion of the placenta commonly depends upon  a diseased
condition of the decidual element.   The most  frequent is some form of
inflammation with thickening—hyperplasia.   This, in all probability,
began  in the mucous membrane before  pregnancy.  It is liable to
aggravation when the mucous membrane is  developed  into  decidua.
Sometimes there is distinct fibrinous deposit on the uterine surface of
the  placenta;  sometimes  the decidua is  studded  with  calcareous
patches.   The  maternal  origin  of  the  forms  of  diseased  placenta
leading  to adhesion is proved  often  by the history of previous  endo-
metritis or other disease, and  by the frequent recurrence of adherent
placenta in successive pregnancies.
   I have adverted to  this  subject  under "Abortion."  (See p.  892.) 
POST-PARTUM  HEMORRHAGE.
437
Further  information will be found in memoirs by myself,* Fromont,t
Hiiter,;]  and Hegar.§
  Diagnosis of Placental Adhesion.—You may suspect morbid adhesion
if there  have been unusual difficulty in removing the placenta in pre-
vious labours ;  if,  during the  third  stage, the uterus contract at
intervals firmly, each contraction being accompanied by blood, and yet,
on following up the cord, you feel the placenta  still  in utero; if, on
pulling on the cord, two fingers  being pressed into the placenta at the
root, you feel the placenta and the uterus descend in one mass, a sense
of dragging  pain being elicited;  if, during a pain, the uterine tumour do
not present  a globular form, but  be more prominent than usual at the
place of placental attachment.
  The removal of a morbidly adherent placenta must be effected in the
same manner  as  that just described for retained placenta;  but you
must be prepared to encounter  more difficulty.  The peeling process
must be  effected very gently and steadily, keeping carefully in the same
plane during your progress, being very careful to avoid digging your
finger-nails  into the  substance of the uterus.  In  some  cases the
structures of the uterus and of the placenta are so intimately connected,
seeming, in fact, to be continuous parts of one organization,  that you
cannot tell  where placenta ends and uterus begins.  In endeavouring
to detach the placenta,  portions tear aAvay, leaving irregular portions
projecting on the surface of the uterus.  In trying to take away these
adherent portions you must proceed with the utmost  caution.  The
connected uterine tissue is, perhaps, morbidly  soft and  lacerable.  It
is very easy to push a  finger  into it, to the  extent of producing fatal
mischief.  A very  serious  practical  question now arises.   To  what
extent must you persevere in trying to pick off the firmly adherent
portions  of placenta ?  If you  leave any portions, haemorrhage, imme-
diate or  secondary, is  very  likely to folloAV;  in decomposing  and
breaking-up, septicaemia is  likely to  follow;  and there is, besides, the
liability to metritis.  If  a fatal result ensue, and a portion  of placenta
be found after death in the uterus,  it is but too probable that blame
Avill  be  cast upon  the  medical  practitioner.  The nurse and all the
anility of the neighbourhood  will be sure to cry out,  " Mrs. A. died
because Dr. Z. did not take away all the after-birth."   The position is
a very painful one.  The true rule to observe is, simply to do your best;
make reasonable effort to remove what adheres.   It is safer for the
Avoman to do too little than too much.  You cannot repair grave injury
to the uterus.  To save your own reputation, you must fully explain the
nature of the case at the time.  You may lessen the risk of haemorrhage
       * "Brit, and For. Med.-Chir. Rev.," 1854.
       t " Mem. sur la Retention du Placenta."  Bruges, 1857.
       X "Die Mutterkuchenreste,"—" Monatsschr. f.  Geburtsk.," 1857.
       § " Die Pathol, und Therap. der Placentarretention."  Berlin, 1862. 
438                 OBSTETRIC OPERATIONS.
and septicaemia by injecting first hot Avater, then perchloride of iron.
In a few days the process of disintegration may loosen  the attachment
of the placental masses, and they may come away easily.  The safest
way, if it can be done, of removing these " placental polypi," is to pass
a wire-ecraseur over them.  As this instrument can  only  shave the
uterine surface  smoothly, you  are  secure against injuring the uterus.
To obviate septicaemia, inject daily a solution of carbolic  acid, 1 in 60.
  As  a  warning against attempting too  much, and as ammunition to
repel an unjust charge of having done too little, remember the folloAving
passage  from Dr. Bamsbotham, the  truth of Avhich I  can attest from
my own experience:—"Instances are sometimes met with in Avhich a
portion  of the placenta is so closely cemented to the  uterine surface
that  it cannot by any  means be detached;  nay, I  have  opened more
than one body where a part was left adherent to the uterus, and Avhere,
on making a longitudinal section of the organs, and examining the cut
edges, I could not determine the boundary-line between the uterus and
the placenta, so intimate a union had  taken place betAveen them."
Smellie, Morgagni, Portal, Simpson, Capuron, relate similar  instances;
and there is an instructive case reported by Dr. B. T. Corbett, in the
Edinburgh Monthly  Journal,  1850.
  A very soft placenta, especially if it be thin, of large superficies, so
as to be diffused over a considerable portion of the surface of the
uterus, is frequently associated with adhesion.  The contracting uterus
does not easily throw off such a placenta—that is, completely.  To be
cast easily, a placenta must have a certain degree of firmness, and not
be too large.  Perhaps a large part may be expelled or withdraAvn, and
appear to be all; but  a portion of a cotyledon remains behind; bleeding
and  irregular  action of the uterus  are  kept  up, until  the  hand is
introduced, and the  offending substance  removed.
  A very rare—but on that account the more likely to be overlooked—
event is the leaving behind a lobe of a placenta succenturiata.  I  have
seen some  singular examples of this.  At a distance  from  the main
body of  the placenta, perhaps three or four inches or more from the
margin, a mass of chorion-villi will be developed into true placental
structure, and connected with the main body of placenta by a few Aressels
only.  It resembles a lobe or cotyledon which has grown far  away from
the rest by itself.  Such an accidental or supernumerary  placenta may
very easily remain attached after the  main body, which is complete in
itself, has been  removed.  These placentas succenturiatae rarely exceed
in size that of a single cotyledon, i.e., they measure about two or three
inches in diameter.  But I was once called by a midwife of the Boyal
Maternity Charity to a case of a different kind,  at first very puzzling.
The child was born, the cord tied,  and the placenta, apparently entire,
removed, when there followed a second placenta.  Both were of nearly
similar size and form.  The first and natural conclusion of the midAvife 
ABNORMAL PLACENTAS.
439
was that there was a second child stiU in utero; but she could not feel
it, so sent for me.   I  passed my hand into the uterus, ascertained that
it Avas empty, and made it contract.  The second placental mass  was
developed on the same chorion as the chief placenta ; vessels ran from
it  across the  intervening bald space  of  chorion  to join the  single
umbilical cord which  sprang from the chief placenta.  Dr. Hall Davis
exhibited a similar double placenta to the Obstetrical  Society.
  Another form of placenta associated with haemorrhage is where the
cord is  velamentous.   In this case, the umbihcal vessels, instead of
meeting on the surface of the  placenta to form the cord, run for some
distance along  the  membranes, uniting perhaps several inches beyond
the margin to form the cord.  This part of the membranes containing
the umbilical vessels spread out fan-like, may be placed  over the cervix
uteri.   These  vessels must be torn  during  the passage of the child.
The haemorrhage thus resulting comes from the placenta, and of course
endangers the  child.  Dr.  V. Hiiter describes this formation of the
placenta fully.*  Two  cases of  this kind  are related by Caseaux.   Joerg,
quoted  by Hegar,  describes a case in  which bundles of vessels Avere
found over the  greater  part of the chorion, but no proper parenchy-
matous placenta; thus resembling the diffused placenta of the  pig.
Most of the unusual forms of placental development and  of arrangement
of the vessels in the placenta are beautifully illustrated  in Dr.  Jos.
Hyrtl's splendid work, Die Blutgefdsse der menschlichen Nachgeburt,
Wien,  1870.
                 * " Monatssch. fur Geburtskunde," 1866. 
                      LECTUBE   XXIX.

HEMORRHAGE  AFTER THE  REMOVAL  OF  THE  PLACENTA — THREE
     FORMS:  IMMEDIATE, PAULO-POST,  AND "SECONDARY"  OR REMOTE
     — TWO SOURCES: THE  PLACENTAL SITE;  THE  CERVIX UTERI —
     THE NATURAL  LOSS  OF BLOOD — NATURAL AGENTS IN ARRESTING
     HEMORRHAGE—SYMPTOMS, DIAGNOSIS, AND PROGNOSIS OF HEMOR-
     RHAGE  FROM  INERTIA,  FROM   TUMOURS  OR  POLYPUS, FROM
     RETROFLEXION—ARTIFICIAL  MEANS OF ARRESTING HEMORRHAGE
     —MEANS DESIGNED  TO  CAUSE  UTERINE  CONTRACTION :  PASSING
     THE  HAND  INTO THE   UTERUS,  ERGOT,  TURPENTINE,  COLD,
     KNEADING THE UTERUS, COMPRESSION  OF THE AORTA, COMPRES-
     SION  OF  THE  UTERUS,  BINDER AND  COMPRESS, PLUGGING  THE
     UTERUS — INDICATIONS  HOW  FAR TO  TRUST   THE  FOREGOING
     AGENTS--THE DANGERS  ATTENDING THEM--MEANS  DESIGNED TO
     CLOSE  THE  BLEEDING  VESSELS:  STYPTICS,  HOT  WATER,  THE
     PERCHLORIDE  OF IRON--HISTORY;  DANGERS  OF,  DISCUSSED-
     SHOCK—SEPTICEMIA—MODE  OF APPLYING  THE IRON—RESTORA-
     TIVE  MEANS : OPIUM, CORDIALS, SALINES, REST, IODINE.

The general or systemic conditions Avhich lead to "Accidental  Hasmor-
rhage " also  predispose to  post-partum haemorrhage.
  Some of the conditions which lead to hasmorrhage before the removal
of the placenta may  also persist and keep up  haemorrhage  after its
removal.  Of these  the most formidable is inertia.   When the uterus
is perfectly relaxed, it may be said that  the flood-gates are  opened,
and  that the blood issues in torrents.   In a feAv minutes  life  may be
extinguished.   In short, the accumulation  of  blood in  the  uterus,
especially  if coagulated, reproduces  very closely the same symptoms
as those which attend retention  of  the placenta from inertia.
  We may usefully distinguish the hasmorrhages which occur after the
removal of the placenta into three  forms, differentiated by the time of
their appearance.   The first may  be  called primary or  immediate.
The  haemorrhage folloAvs immediately  upon  the removal  of the  pla-
centa ; the uterus failing to contract in any degree.  The  second may 
POST-PARTUM HEMORRHAGE.
441
be called paulo-post, in order to distinguish it from the remote haemor-
rhage to which the term  secondary is more especially assigned, and
which is the third form.  The haemorrhage breaks out after apparently
satisfactory contraction of the  uterus.  An  hour or more after the
delivery  of the  child, after the bandage has  been applied, when all
things seem to be  secure,  when  congratulations have been exchanged,
the woman complains  of pain, feels faint, says something is floAving
from her.  You examine, and find  the  uterus has relaxed, is perhaps
irregular in shape, tender  to the touch.
  Hasmorrhage  after  the  removal of the placenta may arise from two
sources.   The first is from the gaping vessels on the placental site.
  The second source is from lesion  of the cervix or other part  of the
uterine  structure.   In the case of severe  rupture of the  uterus, this
source of haemorrhage is obvious enough ;  but minor lacerations of the
cervix, especially after  forcible  delivery, although far more common,
are seldom recognized.  Contraction of  the uterus is less  effectiA7e in
arresting haemorrhage of  this kind than that from the placental site ;
indeed, it persists  when the uterus is well contracted. I have no doubt
that laceration of the cervix is the true  explanation of some of those
cases of haemorrhage which Gooch described as due to an over-distended
circulation, driving blood  through the contracted uterus.
  If, then, we find oozing or trickling of bright blood  going on after
labour, and with a well-contracted  uterus, Ave may suspect this injury
to be the cause.
  It may ;be  useful, at starting, to acquire as accurate an idea  as
possible  of what  may be considered the natural loss of blood.  This
standard is very difficult  to fix by  quantity.  Women vary greatly in
this respect.   Some lose  very freely, without appearing to be any the
worse;   whereas  others  cannot bear the loss  of even  a moderate
amount  Avithout exhibiting alarming  prostration.   When  the  uterus
contracts normally, its  substance is compressed, so that  the blood  in
its vessels  is squeezed out, much as we squeeze Avater out of a sponge.
The quantity of blood so held in the uterus  at the moment of separation
of the placenta may be regarded as superfluous quoad the Avants of the
system.   It may amount to one  pound; but it is  often less, and
occasionally more.   This  I call  "physiological  haemorrhage."   A
further quantity drains slowly, constituting the lochia, for several days.
  What  are  the  means  which Nature  employs to  arrest  uterine
hemorrhage ?
  1. The first is the turning off the current  of blood from the uterus,
brought about by the abrupt cessation of the utero-placental circulation
when the child is born.  This cutting-off of the utero-placental system
is a physiological necessity ; but it  is greatly secured by
  2. the most efficient factor, Avhich is active contraction of the mus-
cular wall  of the uterus.  This constricts,  with the force of a ligature, 
442
OBSTETRIC OPERATIONS.
the mouths of the arteries and veins on the placental site.  So long as
firm contraction holds, no blood can escape.  To obtain this  firm con-
traction is the great end of the obstetrician.   Active contraction settles
into what may be caUed passive or  tonic contraction, by Avhich the
volume of the uterus is permanently reduced.   This seems due to a kind
of elastic contraction, likened by Leroux to a spring (" ressort").  It is
sometimes called the force of "form-restitution."  When this tonic con-
traction is effected, the patient is secure against a return of haemorrhage.
   3. The uterine arteries have a certain retractile property.  Shrinking
inwards, their mouths become narrowed,  and the formation of thrombi
is favoured.
   4. The veins or sinuses of the uterus  running obliquely or in strata
in the uterine wall, and opening obliquely on the  surface,  are  most
favourably disposed for closure, by the approximation of their walls,
and the valve-like arrangement where  the sinuses  pass  from  one
stratum to another.  Even moderate tonic  contraction of the uterus
will so close the  uterine  sinuses  as to stop bleeding, provided the
circulation is not  unduly excited.
   5. If the stream of blood through  the uterine vessels be stopped for
a short time, and diverted into the systemic circulation, so that there is
temporary rest in the uterus, the opportunity is given for the formation
of clots, thrombi, in the vessels.   Under great  losses  of  blood, the
property of coagulating is increased.   Andral found the highest  pro-
portion of fibrin,  10-2  per 1,000,  after  a fourth bleeding.  Many
women are thus rescued, to all appearance from imminent death, after
the  most profuse  and uncontrollable  floodings.  Under syncope, or a
state approaching to  it, the heart beats  so feebly that the circulation
is almost suspended ; there is suspension of  circulation in the uterus ;
and if ever so slight tonic contraction of  the uterus goes on, the \ressels
get plugged  by coagula.   The  probability of this  event should encou-
rage us never to despair  of a case of haemorrhage.
   The symptoms,  diagnosis, and prognosis of hemorrhage from atony
of the uterus.   The effects  of bleeding are—1. To modify the balance
between the circulating  and respiratory systems.  2.  To promote the
influx of fluids from all parts of  the body into the venous system.
3.  To promote the tendency to the separation of fibrin.   4. Syncope.
5.  Convulsion of the muscles   from  the removal of  nervous control,
muscular irritability being retained.   6. Fall of animal temperature.
The first warning generally is  the complaint of the patient that she
feels blood  flowing  from her.  Never  disregard this.  Examine the
linen  and the parts immediately.   You will often  see a  thin stream
of florid blood  trickling down across the  nates.   This  may  seem
insignificant  in amount; but  there  should  be none; and  this  "thin
 red line " is too often the indication of a greater loss, Avhich is filling
 and stretching the uterus. 
                  POST-PARTUM HEMORRHAGE.              443

  You feel  the uterus,  and find it  has risen  above the symphysis,
perhaps above the umbilicus, that it is  flaccid, or presents irregular
hard prominences which shift  their  position.   On compressing its
fundus firmly, perhaps blood and clots will be forced out of the vulva.
If the uterus is not brought to contract by this  compression, you  pass
your hand into the cavity, and feel that it is full of blood partly clotted;
you feel the enlarged cavity;  you feel the flaccid flabby waUs. When the
inertia is complete, it is sometimes difficult, by  external manipulation,
to make  out the uterus at  all.  You miss the hard globe ; and this
negatiAre sign  is all.  When the uterus has reached its full measure  of
distension, spasmodic contraction is sometimes  excited, and a furious
rush of blood is poured out.  Often again, emotion, the dread of flooding,
determines blood to the uterus, and a large quantity of blood is poured
forth in  a gush.   Alternate contractions and relaxations, the  uterus
getting smaller, then larger, a pain attending, and tenderness on grasp-
ing,  are  certain  signs  of hasmorrhage from atony.  These are the
local signs.
  The general signs are scarcely less marked.  Bleeding often goes on
very insidiously, the woman not complaining.  She may  even  feel  at
ease.  But this calm may be illusory.   She feels that her eyes darken ;
that there are strange noises, singing in the ears ; that she " is sinking
through the  bed," that she is unable to move  her limbs  without dif-
ficulty.  She may feel an  uncontrollable desire to get up or sit up.
This is due to that disturbance  of relation betAveen the circulatory and
respiratory  systems already indicated.   The pulse is  feeble.   Hence
every Avoman should be keenly watched  for some  hours after labour.
Undoubtedly  life has  ebbed away under unsuspected  bleeding,  from
exliaustion  or  syncope.
  Blood  may issue in a considerable stream, or by gushes.  Or it may
simply ooze out in a thin stream.  In this latter case, the discharge is
often more watery.  It indicates retention  of clot in  utero.  When
hasmorrhage is copious enough to affect the system, a feeling of faint-
ness, sometimes passing  into actual syncope, comes on ;  irrepressible
anxiety, a  sense  of fear, depression, are early symptoms ; a degree  of
shock, of  collapse,  is  conspicuous  ; the  face  is pale and cold; the
whole  surface is cold ;  the pulse is almost or quite imperceptible; the
heart-beat  is  feeble and  frequent; there is an  indescribable sense  of
oppression on the  chest; the  patient  calls  out for air, will have the
windows open; insists upon sitting up, sometimes would even get out of
bed; the respirations rise to 36, 40, or more in the minute; the breathing
is noisy and laborious; she tosses her arms  about, says she is sinking
through the bed, is more or less delirious ; her perception of external
objects is  dulled, or her appreciation of  them is distorted;  partial
blindness,  double vision, sometimes complete  amaurosis, set in, the
pupils  dilate, the iris seems paralysed ;  she ceases to recognize at times 
444
OBSTETRIC OPERATIONS.
the people about her;  she complains of intense headache, noises in the
ears, sometimes is manifestly deaf;  she can hardly swallow, unless the
fluid given  be poured into the back of the mouth.  Brandy, beef-tea,
medicines,  lie inert in the stomach, until rejected by  vomiting.   So
great is the loss  of nen^ous force, that every organ, every tissue seems
paralysed ;  the uterus refuses to act under any stimulant; perhaps the
sphincters  relax, fasces and  urine  being  voided.  There  is  general
muscular paralysis.  She rejects help ; by word or sign entreats to be
let alone ; she Avould willingly die undisturbed.
  From  these symptoms, desperate as  they look, the patient may
recover.  If  the bleeding stop for aAvhile, slowly there  is gathered
up a little  neiwe-force ;  life that seemed ready to  flit,  holds its seat,
with feeble and doubtful grasp, it is  true, but gradually strengthening,
if no fresh loss or accident occur.
  But  if  these  signs  are folloAved  by  marked collapse,  contracting
features, by short gasps or sobbing inspirations, which indicate that
the chest-walls, unable to expand, make  but an imperfect attempt to
take in air, then quickly collapse,  by convulsions, the  case is  indeed
desperate.  All poAver to respond  to any remedy is exhausted.   To
persist in applying  remedies  now, except the hypodermic injection of
ether, and  transfusion, is to  harass the  last moments of the  patient
in vain.  At  this stage, or even earlier, the slightest  operation may
be fatal.
  The favourable signs  are,  returning warmth and  moisture  of the
surface, disposition  to swallow, steady pulsation at the  wrist, evidence
of  contraction of the  uterus, a more tranquil respiration, a   feeling
of  hopefulness  and  courage,  a  clearer perception of surrounding
circumstances, a more  accurate and steadier judgment.
  Internal  haemorrhage is promoted by any cause that obstructs the
escape of the blood externally.  Thus,  obliquity,  or  bagging  of the
uterus to the side—very likely to occur when the patient  lies  on one
side, or even  tending to  the prone position with the  pelvis raised—
will form  a  depending sac in which blood will  readily accumulate.
Another condition  promoting internal haemorrhage is  retroflexion  of
the uterus.   This also is not  very uncommon after labour AAdth  inertia.
It was noticed by Burns.  Boivin relates a good case.  I haA7e seen it
several times myself,  the haemorrhage ceasing Avhen the fundus Avas
lifted  into  its proper  position.  Betroflexion is even  more common
as  a cause of secondary haemorrhage.   The  best way of restoring
the  uterus in the  primary cases  is to pass  a hand into  the cavity,
and by it to lift the  fundus  forwards.
   Hasmorrhage post par turn  sometimes depends upon a fibroid tumour
imbedded in the wall of the uterus, or a  fibroid polypus projecting
into the caArity.  No  complication  can  Avell be  more serious.  The
tumour disposes to hasmorrhage in tAvo Avays.  In the first place, by 
POST-PARTUM HEMORRHAGE.
445
its  density  and  form,  it  destroys  the uniformity of thickness and
density of the uterine wall.  This  impairs the poAver of the uterus
to contract equally, and  to  maintain its  contraction.  Secondly,  by
its  independent  vitality,  it  attracts blood  in  abnormal quantity  to
the uterus,  and  besides  acting as  a foreign  body, it  irritates the
uterus, exciting to irregular spasmodic action.   The ordinary means of
stimulating contraction are apt either to act badly or to  fail.  Knead-
ing is especially dangerous,  from  the liability  to  bruise  and injure
the  tumour, and even to lacerate  the uterine tissue in which it is
imbedded.  Some amount of injury of this kind will probably have
been  endured under the  force of labour.  These  cases, then, require
the most gentle manipulation.  The safest and most  effectual plan
is, the placenta being removed, at once to inject hot water, and this
failing, to apply the perchloride of iron.  This will arrest the flooding,
even where it is difficult to induce the uterus to contract.
   The  fibroid  polypus  also requires special management.   This
form of   tumour, too, is commonly influenced  by the developmental
stimulus  in the  pregnant uterus;  it enlarges  considerably;  when  the
child and placenta  are expelled, it is  liable to  be  extruded from  the
uterus, and, if of large size, it may even  be  projected outside  the
vulva.    Hasmorrhage  almost constantly  follows, partly,   perhaps,
from uterine  paralysis, partly from the attraction of blood.   Another
pressing  danger, besides haemorrhage, calls for decisive action.  The
polypus,  like  the intramural fibroid tumour,  is copiously infiltrated
with fluid and new tissue ; it has suffered  contusion, probably, during
the  passage  of  the child;   it is  fatally disposed  to a low form of
inflammation, tending  to necrosis;  this is a  cause  of  constitutional
infection replete with danger.  The double question is before us, Iioav
to  suppress the  hasmorrhage, and  how to deal with  the polypus  so
as to avoid the too probable ulterior mischief ?  The most immediate
difficulty is the  haemorrhage.  Excite contraction by hot water,  by
friction on  the uterus, by ergot, if you can.  But lose not much time
upon  these uncertain remedies.   Inject perchloride of  iron  before
much blood  has been lost.   The  polypus itself  should be  remoA7ed
by wire-ecraseur without delay.   If the  pedicle is thick  it  is  better
to  use the galvanic wire cautery.   It can scarcely be  doubted that
the necessity  of supporting a large  parasitic growth  of  this kind
must,  as  the least evil,  impede  the  healthy  involution of  the
uterus.
   One or  two general  rules should be observed, whatever the par-
ticular method we may choose to rely upon to restrain the haemorrhage.
   1. Place the Patient on  her Back.—The value  of this rule is very
great.   Gravitation helps to let the uterus sink into the  pelvis, instead
of bagging over, as when  the patient  is on  her side; the face is
open to observation, to  access of air, to administration  of stimulants 
446
OBSTETRIC OPERATIONS.
and food;  the  chest-Avails can expand for  better  respiration ;  the
uterus and  aorta  are  under more easy control by  the hand  of  the
physician.
   2.  Pass the  Catheter.—A  full  bladder  diverts the  nervous force
from the uterus, inducing irregular contractions, and  impedes manipu-
lation on the abdomen.
   The indications  in  practice  are drawn from our  knoAvledge of the
sources and natural modes of arrest  of hasmorrhage, and observation
of the symptoms.
   In haemorrhage, after the removal  of the placenta, Ave have, first, a
class of remedies whose power  is  limited by one imperative condition.
These remedies act by exciting contraction of the  uterine muscular
fibre.  To  effect this, there must  exist a certain degree of nervous
force,  able  to respond  to centric or  peripheral irritation.  All  the
remedies  commonly  relied upon  postulate  this  condition.   Ergot,
compression of the uterus, cold,  lieat, all  depend upon their power
of  inducing  uterine  contraction.   If the nervous  exhaustion  be so
great that irritability is  lost, these  agents are useless or injurious.
The patient may indeed rally after syncope, but it may be truly said
that at this point  the art of the  physician fails.
   It  fails  unless,  secondly, he has  the courage to call  to  his  aid
another haemostatic power, which  acts even  when to  evoke contrac-
tion is impossible.  When this is  gone he may still  stop bleeding by
the  direct  application of powerful styptics  to the  bleeding  surface.
The most useful of these  agents is the perchloride or persulphate of
iron, the obstetric  application  of  which I shall presently  describe.
   Passing  the  Hand into the Uterus to  Clear  out  the  Cavity.-—
Although  this proceeding is deprecated by many,  and looked upon
by most  men as hazardous, I  am satisfied that  it  is the  first thing
to be done whenever there is  hasmorrhage with  an enlarged uterus,
and a suspicion that clots or other  substances  are retained  in  the
cavity.  If the enlarged uterus refuse to contract on external pressure,
so  as to expel  its contents completely, I  think  there is  no rule in
obstetrics more imperative than  to pass in the hand.   If  the patient
be lying on her back, you can support the uterus externally by  one
hand whilst  you introduce the other, without  admitting  much   air
into the cavity; you gain certain knowledge as  to what  is  in  the
uterus : if there is nothing, the hand will  act as  a  stimulus to con-
traction ; if there  are  placental remains or clots, you have the oppor-
tunity of removing at once one of  the most  certain causes of flooding,
primary and  secondary,  and of   averting a  very frequent  cause of
puerperal disease.   In many cases this operation  is followed by  im-
mediate success, little else  being wanted.  Often have I, when  called
in to a bad  case of puerperal  fever, Avished that I could be fully
assured there  Avas nothing in the  uterus.   I  perfectly agree with 
POST-PARTUM HEMORRHAGE.
447
Collins and others, who insist upon the importance of this proceeding.
I do  not hesitate to repeat it tAvo or  three  times  if the uterus fills
again ; and  in this latter  case, the hand is ready to carry up  the
uterine tube for the injection of hot water or of perchloride  of iron.
It is needless to insist that  the operation should be performed gently.
The shirt-sleeves  should be  rolled up to the shoulder ;  the back of
the hand and the arm be well lubricated; the hand  should be directed
in the axes of the pelvis ;  the other hand must support the uterus
externally.  It cannot,  however, be  denied that  passing  the  hand
into the  uterus has been followed by  quick death.
  Ergot, we  know, possesses the property of causing uterine  contrac-
tion.  But how often does  it fail  to arrest uterine hasmorrhage!  It
is best  given before the expulsion of  the  child.  The subcutaneous
injection of ergotine is  extolled by some.  The caution I would urge
in respect to ergot is  this: if the first dose be not quickly folloAved
by contraction, trust it  no  longer ; do not lose all-precious time in
repeating it.   If  it fail to  act at  once, it is  probably  because the
nervous  power is too much  exhausted to respond to the excitation.
I am sure I have seen  the administration of ergot, when the system
was much prostrated by loss of blood,  cause further depression, doing
harm instead of good;  and if it does no harm, it is  inert.   In states
of great depression, no absorption goes on in the stomach.  Ergotr
brandy, beef-tea, all alike simply load  the stomach, until rejected by
vomiting.
   Vomiting is, indeed,  often beneficial.   It  seems to check flooding.
On this  indication some practitioners give an  emetic dose  of  ipeca-
cuanha.   Turpentine, if the  stomach Avill tolerate it, is a very efficient
haemostatic.
   Cold is very much relied  upon.   How does  it act ?   Producing a
kind of  shock, it  excites  reflex action, inducing contraction of the
uterine muscles.  The essential condition, therefore, of its action is,
that there be sufficient nervous power to respond to the excitation.   If
this poAver be deficient, then the shock of cold only  adds to the general
depression; no contraction  follows, or it is only momentary, the uterus
quickly  relaxing again.  Nor does the harm cease  here.   The con-
tinuous application of ice and cold water will often  cause congestion of
the  internal  organs, and even lead to pleurisy, broncho-pneumonia, or
peritonitis.   I have seen cases of these forms of  puerperal fever  Avhich
I have no doubt were due to  the patients  being  deluged in water, and
being left for an hour or more chilled in wet clothes, because extreme
prostration made it dangerous to change.  Velpeau  bears  testimony to
the same effect.
   The rule, then, in the application  of cold should be, not to trust to
it, if it be not quickly successful in  evoking  uterine contraction.   The
best form of using it,  if the case is slight, if the nervous  energy  is 
448
OBSTETRIC OPERATIONS.
good, is to apply the cold hand, or a lump of ice, or a plate taken out
of ice-Avater, to the abdomen  or back  of the neck.  Taking a draught
of cold  water  into the stomach will sometimes excite uterine action.
  The douche method,  practised by Gooch and extolled  by Collins,
of pouring a  stream of Avater from a height upon the  abdomen,  is
the most certain to evoke contraction, if any degree of contractility
remain.  It is open  to  the  objection that it swamps  the bed, and
exposes the patient to the danger of subsequent chill and inflammation.
A very efficient plan, and free from the foregoing  objection, is to flap
the abdomen smartly with the corner of a wet towel.  A good plan is
to inject cold Avater  into the rectum.  Cold is  more effectual if applied
internally.  Levret  Avas,  I believe, the  first who used ice in this Avay.
Perfect says Levret  " hit upon a very odd and  ingenious expedient; he
introduced  a piece  of ice into the uterus, which being struck with a
sudden  chill, immediately contracted and put a stop  to the haemor-
rhage."  Some years ago, it was a frequent practice to inject cold Avater
into the uterus.   I knoAv it is often effectual.  It has the advantage of
washing out clots, as Avell as of exciting contraction; but I am not sure
that it is free from danger.   Levret's plan of placing a lump of ice  in
the uterus is the safest and  best mode of applying  cold.  Ice also has
the power, if  continued  long enough,  of condensing the tissues, and
thus  of diminishing the calibre  of the  vessels.   But I  must  repeat
the  warning,  that  unless  there  exist in  the patient  the poAver  of
reaction, cold  will  do  harm  instead  of good.   Unless  it  ansAver
quickly, give it  up.  The necessary effect of great loss of  blood  is
to reduce animal temperature.  Cold can  only increase this injurious
effect.  At this stage, warmth,  not cold, is  often necessary, as was
well observed  by Crosse.
   Hot water  injections  have lately come into use.   The  method is
commonly  very  efficacious, and it is free from the objections AAdiich
apply to cold.   Its use should always precede that of iron.
   Kneading the uterus,  or  compressing  it firmly with the hand,  is
a means of exciting the uterus to contract, much trusted to, and often
useful.  Even gentle friction or compression will often cause the uterus
to contract and expel the placenta.  A similar force applied Avhen the
uterus remains  flaccid,  or contracting spasmodically, will commonly
induce firm, equable contraction.  In states of greater exhaustion, with
profuse flooding, even firm  grasping  is  apt to  fail.  Whilst  a strong
hand is powerfully compressing the uterus, the haemorrhage is  certainly
checked.  But who can long keep up the requisite grasp ?   As soon as
the tired hand relaxes, the haemorrhage  returns.  Another hand takes
the place of the first,  and is in its turn exhausted ; and so on,  until the
condition of the  operator is  almost as pitiable as that of the  patient.
   In resorting to this manoeuvre, it is all-important to economize your
own strength.  You may do this greatly by placing the patient on her 
POST-PARTUM HEMORRHAGE.
449
back near the side of the bed, so that you can stand well over her, and
aid direct manual  compression by the Aveight of your body.  This
manoeuvre is often rewarded by  success.   If the hasmorrhage can  be
restrained for a  few minutes,  the strength   will  rally,  and  tonic
contraction may  return.
   On the other hand, where there is deficient power,  the uterus relaxes
again and again; each  renewal of flooding makes it more difficult  to
excite permanent contraction.  Clots form again in  the cavity, excite
spasmodic action,  and  compel repeated introduction of the hand  to
remove  them, for  squeezing out will not answer  well unless  it  be
backed  up by  firm uterine contraction.   Alternate  relaxation and
contraction of  the uterus acts thus : expanding, it sucks  up  more
blood from the aorta and  vena cava; contracting, this will escape
again on the uterine  surface ;  and so the uterus  goes  on relaxing
and  contracting,  drawing blood  from  the  system, and  discharging it
into  the uterine  cavity.  Thus,  the  uterus  acts  like  a  Higginson's
syringe  pumping blood out of the body.
   Not only  is  kneading uncertain, most painful to the patient, and
exhausting to  the physician,  but  it entails a special  danger.   This
severe handling of the uterus, attended by bruising of the tissues, is
liable to cause metritis.  I have seen cases of metritic puerperal fever
which I could only assign to this cause.
   The  compression of  the  abdominal aorta is a plan that  deserves
attention.  It  is  practised in two  ways.   Ploucquet,  who was  the
first to  insist upon the method, compressed the aorta by the  hand in
the  uterus.   Baudelocque  and Ulsamer  compressed it through  the
flaccid  abdominal  walls.  This  is the plan most generally followed.
It is recommended by  Chailly, Caseaux, Jacquemier, and others.   By
it you  may arrest the  flooding, gaining a respite  and time for the
preparation of other means.  It is performed in the following manner;
—The  patient lies on  her  back near  the  edge of the bed, the thighs
drawn  up.   The  physician stands at the  right side ;  he presses the
three middle fingers of his left  hand gently into the abdominal wall
near the umbilicus, curving them so as to fall obliquely upon the aorta,
compressing  it equally with all three fingers.   The  aorta is thus fixed
upon the left side of the spinal column, avoiding the vena cava.  The
right hand can be used to aid  the left, by supporting it.   Compression
kept up for  a  minute  will  often control the bleeding, giving time  for
the reproduction  of nervous poAver and the contraction of the uterus.
Faye relies mainly upon  this  method;  Kiwisch objects to it, that
compression  on  the aorta will simply compel the blood to  go  round
by the  spermatic arteries, and that the compression of the vena cava
being unavoidable, the blood gets to the uterus  by  the numerous
anastomoses of the pelvic  circulation.  The  good  resulting, he  says,
is due to the compression of the  uterus.  Boer and  Hohl take similar
                                                           G6 
450
OBSTETRIC OPEKATK )NS.
 objections.   I  have occasionally derived advantage from it,  and look
 upon it as a momentary resource.
   A form of pressure sometimes preferable to outward grasping of the
 uterus, is one  recommended by Dr. G. Hamilton (Edin. Med. Journ.,
 1861).   The fingers of  one hand introduced into the vagina are placed
 under the uterus, which the  relaxed state of the parts usually allows;
 then,  Avith the other hand  upon the uterus externally, the  organ is
 firmly compressed  between the two  hands.  The cavity is closed  by
 the anterior  and  posterior  surfaces  being  flattened together.   This
 manoeuvre involves less violence,  and is, for the time  at least  of  its
 application, quite  as effectual as  external kneading.
   Another form of applying pressure is by means of the binder, Avith
 or Avithout a compress.   I am a decided advocate for the binder after
 labour.  That  it is  a source of comfort to the patient, almost  every
 Avoman testifies; that it offers some  security against haemorrhage,  by
 exciting contraction of the uterus and  preventing accumulation of blood
 in the uterine  cavity, scarcely  any practitioner of experience doubts.
 It has another advantage: in severe flooding from inertia, if the woman
 be lying on her side or prone, the bulky flaccid uterus falls towards the
 diaphragm and forwards, encountering no support or resistance from
 the distended and  paralysed abdominal walls; this  falling fonvards,
 creating a vacuum, draws air into the vagina and cavity  of the uterus,
 supplying the conditions for decomposition of clots, and thus favouring
 septicaemia.  If the  hand be introduced into the uterus, as it is  likely
 to be in these  emergencies,  to remove placental remains or  clots, air
 may often be felt and  heard rushing in.   Another  urgent reason is
 this:  just as after tapping an ovarian cyst, the sudden  release of the
 abdominal vessels from pressure, by  diminishing the tension under
 Avhich the heart acts, disposes  to  syncope.   A  well-applied  bandage
 is a security against these possibly  fatal accidents.   But it should
 not be applied  until the uterus is contracted.  Its  use is rather  to
 maintain contraction than to produce it.
  Plugging has been practised in various ways.  Paul of iEgina placed
 a sponge, soaked in vinegar, in the vagina and uterus.  In later times,
 Leroux (1810) Avas a warm advocate of this method.   D. D.  DaA'is also
 advocated it.   Bouget  (1810) advised the introduction  of  a sheep's
 or pig's bladder into the uterus, and then distending it.  Diday (1850)
 used a vulcanized caoutchouc bladder  in this way.   If there is nervous
 force enough  to respond to the irritation provoked by the presence  of
 these foreign  bodies, the plan may  be useful.   But as  excitants to con-
 traction they  are inferior to other means; and, as  plugs, I am sure they
 cannot be trusted.
  Noav, let us assume that the means AAdiich act by inducing uterine
contraction have failed.   Some men, indeed, affirm that they never fail
to induce contraction.   This is simply evidence that their experience is 
STYPTIC  INJECTIONS.
451
limited.   No one largely engaged in difficult midwifery has ever made
such a statement.   The haemorrhage  goes on.  Must Ave  abandon the
patient  to a too probable death ?    Is there no other condition  for
stopping the stream of blood from the open vessels than  contraction ?
There are styptics powerful enough.   Why should Ave not use them ?
If they  Avill act precisely Avhen other means fail, is it not unreasonable
to reject their aid ?
   This  is the place to  discuss the application of the styptic salts of
iron.  Until after the publication of this work, this remedy was not
mentioned in English or French text-books ;  it is still feared by many
practitioners as a dangerous innovation.   These men should ask them-
selves whether  haemorrhage to extreme degrees is not  more certainly
dangerous ?  To withhold this remedy, then, from a woman bleeding to
death, because  it may do some immediate or ulterior harm, is at once
illogical and Avrong.   The first pressing duty is to  save the woman
from dying.  The case is, that, other means  being exhausted, she Avill
die unless local styptics  be applied.   Where, then, is the force  of  the
objection that  these styptics may work ulterior harm ?  They cannot
harm the dead.  Is not this a legitimate reductio ad absurdum ?■
   As I am mainly responsible for the introduction of iron styptics into
obstetric practice, at least in this country, it is desirable that I should
give a more connected account of the matter than has hitherto been done.
   The styptic virtue of the perchloride and other salts of iron has long
been known.   These salts have  been applied to bleeding surfaces by
swabs by many surgeons. The idea of applying styptics to the bleeding
uterus   is also  not new;  but until  recent  times there  prevailed an
unreasonable dread of touching the  inner surface of the uterus with
styptics.  Yet  from time to  time they have been used with a success
that might have encouraged us to look upon them  with more confidence.
Perfect  says he stuffed the vagina with tow and  oxycrate (vinegar and
Avater).   Hoffman  succeeded  in  stopping  a profuse hasmorrhage  by
passing pledgets of lint dipped in a solution of " colcothar of vitriol"—
a mixture of sulphate and oxide of  iron—as high  into the vagina as
possible.
   Smellie says  : " Others order ligatures for compressing the returning
veins at the hams, arms, and neck to retain as much blood as possible
in the  extremities  and  head.  Besides these applications, the vagina
may be  filled with toAV or rags  dipped in  oxycrate, etc., in  which a
little alum, or  saccharum saturni,  hath been  dissolved;  nay,  some
practitioners inject  proof spirits warmed, or, soaking them up in a rag
or sponge, introduce or squeeze them in  the uterus, in order to con-
stringe  the  vessels."
  It appears from  Hohl that the injection of perchloride of iron was
first used by D'Outrepont; but reference to the subject  in those of his
Avorks which I  have read has escaped me.   It  is strongly praised  by
                                                        g  a  2 
452
OBSTETRIC OPERATIONS.
Kiwigch,* avIio used a solution of t\vo drachms of the muriate of iron
in eight ounces of Avater.   Professor  Faye, of Christiania (Obstetrical
Journal, 1874), says he has used  it  since D'Outrepont's time in his
Maternity Hospital.
  The first  idea of  using this  means in uterine haemorrhage Avas
suggested to my mind on reading  that perchloride of iron had been
injected into an  aneurysmal  sac.  If the salt  could thus be thrown
almost into  the stream of the circulation with  safety,  a fortiori the
open mouths of the sinuses on a free  surface  might be bathed Avith it;
and surely the often irresistible and desperate course of uterine haemor-
rhage  Avas motive  enough to try even  a doubtful  remedy.  In the
Lettsomian  Lectures  on Placenta PrasAda, delivered  by  me in  1857,1
I recommended this practice.  In a lecture on " The Obstetric  Bag,"
published in the Lancet, in 1862,1 again recommended that perchloride
of iron should be  carried for the purpose  of arresting hasmorrhage.
Again, at the Obstetrical Society's meeting, in February, 1865, I made
the following remarks, Avhich were  soon afterAvards reported  in the
medical journals.|  The subject under discussion Avas puerperal fever.
"As  a means  of preventing  the loss of blood—as hasmorrhage un-
doubtedly predisposes to  puerperal  fever—I have found  nothing  of
equal efficacy to the  injection of a solution of perchloride o iron into
the uterus after clearing out the cavity of placental remains and clots.
I have used  this plan  for several years, and in a large number of cases
after labour  and abortion, and have ahvays had reason to congratulate
myself upon the result.  The  perchloride had the further advantage  of
being antiseptic.   It  instantly coagulated the blood  in the mouths  of
the uterine vessels."   As  many of the cases referred to had occurred  in
consultation, of course my practice had been obseiwed by many profes-
sional brethren.  Dr. Mendenhall, of Cincinnati, published (Cincinnati
Lancet,  1860)  a successful case  of  injection  of persulphate of iron.
Scanzoni,  in  his  systematic  Avork  on Obstetrics (edition   1867),
recommends it  to  be used in the  most desperate cases,  and  quotes
D'Outrepont and Kiwisch as advising it.   Since  the  publication of the
first edition of this work,  in 1869, the practice there recommended has
been Avidely adopted;  and it may fairly be said that an overAvhelming
mass of evidence has established its value.  This evidence is iioav far
too copious  to admit of even comprehensive analysis.  I shall therefore
limit the discussion to the objections  that have been urged, and to some
of the cases relied upon in support of  those objections. It is incumbent,
hoAvever, upon me to state the accidents  that have attended the use of
the remedy.
  * " Beitrage zur Geburtskunde," 1846.
  + "Lancet," 1857,  vol. ii., and "The  Physiology and Treatment of Placenta
Prsevia," 1858.
  X " Obstetrical Transactions," 1866, vol.  vii. 
STYPTIC  INJECTIONS.
453
  Reasoning from general knoAvledge,  it may be  apprehended  that
the injection of perchloride of  iron into the uterus is  not  free from
danger.
  May not some of the fluid  penetrate  into the circulation,  and cause
thrombi  in  the blood-vessels  or heart ?   This  risk  is met by  the
property the iron possesses of instantly  coagulating the blood it comes
in contact with  at the mouths of the  vessels.  The  thrombi there
formed  protect the circulation  beyond.   Thrombi,  indeed,  abways or
nearly so form  in  the  mouths  of the uterine vessels  under ordinary
circumstances.   These artificially-produced thrombi  break doAvn  in  a
few days, and, under the contraction and involution of the uterus, get
extruded  into the  cavity.  For some days  the debris, small coagula
formed  by free blood, and serous oozing, come aAvay.   The  discharge
is black; it is apt to stain linen ; and the nurse  should be warned
of this, lest she should take alarm at the unusual appearance.  The
discharge sometimes becomes  a  little offensive.  This may be corrected
by washing the vagina with  weak carbolic acid or weak solution of
iodine.   But the  perchloride of iron  is a valuable antiseptic; and I
believe this property is useful  as a preservative against the septicaemia
to which women who have gone through a labour with placenta praevia
are so prone.
   Several disastrous accidents  have happened from the injection of
minute quantities  of a solution of iron into nasvi.   The veins  about
the face and neck present peculiar facilities to the entry of injected
air or fluid.  Most of the recorded  accidents in  this region  have
occurred during operations where the veins come within the range of
the aspiration  or suction-force  of the chest, no injection being used.
Poiseuille denies that there is a suction-power in  the abdominal veins.
In this he is possibly wrong.   But  certainly the conditions  are unlike
those of the chest-walls.
   May not air be carried into the uterine sinuses, and  thence into the
heart ?  Possibly.  The only case knoAvn to me in which  symptoms
causing a suspicion of this accident arose, was one of abortion, in Avhich
an injection Avas  made by means of  a  clumsy india-rubber bottle.
Symptoms  like  those  described  as  following  on air entering  the
circulation,  and death, ensued.   In the  face of these catastrophes, Ave
cannot regard the application of the perchloride to the uterus Avithout
some misgiving. Why  should not the styptic be carried in like manner
along the sinuses  into the iliac veins and vena cava inferior, and so to
the heart ?  But there are reassuring considerations.   The small, rigid
uterus, with an imperfectly dilated os, as in abortion, is different from
the large, flaccid  uterus, with  widely expanded  os, after labour.  In
abortion, I have already insisted that it is better to swab than to inject.
   May not some of the injected fluid run along the Fallopian tubes,
and escape into the peritoneal cavity ?  Three  cases  are  known to 
454
OBSTETRIC OPERATIONS.
  me in  which this accident  happened.   The  first  is  related by  Dr.
  V. Haselberg, and reported in full by me in the British and Foreign
  Medico-Chirurgical Review, 1870.  The second  Avas reported to me
  by Dr. Herman.   It occurred at the London Hospital.  The third is
  reported in Joulin's  Journal, 1873.   All  these  subjects were in tlie
  non-pregnant state.   The tAvo first  cases  are related in detail in the
  second  edition of this Avork, and in my  work  on the Diseases of
  Women.   In the  latter work I have  discussed the  conditions under
  which injected fluids run along the Fallopian tubes in the non-pregnant
  woman.   In the lecture on " Induction of Labour " I haA-e  referred to
  cases  of sudden death  from injecting water into the  graA7id Avomb.
  These facts must  be  considered in relation  to the subject.
   Is there any other styptic equally efficacious and more safe than the
  salts  of iron ?   The  agent that comes most prominently  into  com-
 petition is iodine.   In  1857 there appeared in  the  North  American
 Medico-Chirurgical Review a communication  by M. Dupierris,  con-
 taining   the  histories  of  three  cases  in  Avhich  iodine   Avas used
 successfully  to  control post-partum  haemorrhage.    The   injection
 consisted  of  half an ounce  of tincture of  iodine.  In 1871  (Bull, de
 Therap.) Dupierris collected tAventy-four cases, in Avhich iodine had
 been  resorted to.   In all the result  was successful, no accident
 occurring.  Dr. Trask informs us that  strong injections  of iodine have
 been lately used in NeAv York.  But  the amount of evidence is still too
 small  to justify  a  decided opinion.  And  Dr. Trask's estimate of the
 dangers  of perchloride of iron is based upon statements which, although
 publicly challenged, have  never been substantiated.
   I have always held it as  an open question, whether  perchloride of
 iron Avas  the  best  styptic  for intra-uterine application.   That  the
 contact of this substance with the inner surface  of the  uterus is not
 seldom attended  by acute severe pain  is certain.  And  although  this
 may be affirmed of many other substances, and even of cold water, or a
 clot  of blood, I am satisfied from  observation that the  perchloride of
 iron is especially  apt to produce this pain.   It is probable that the pain
 is in  some measure due to the great  excess of free  acid in the per-
 chloride.   To obviate  this  objection, Piazza  (see Braun on  the use of
 " Acid-free Iron-solutions in Gynecology," Wiener Med. Wochenschr.,
 1867)  suggests  neutralization  by carbonate of  soda,  Avhich  forms
 common  salt, and he  says increases  the styptic action.   The per-
 sulphate of iron has been preferred by  many practitioners in America.
 I believe it is not less efficacious than the perchloride, and it may prove
 to be less irritating.  A form  of iron that deserves further trial is the
 liquor  ferri dialysati.  It is almost neutral.   A promising styptic is the
 extract of hamamelis—one or two ounces to half a pint of hot Avater.
  Too  great injecting force may be  a cause of pain.   To obviate this,
only the gentlest propelling force should be used.   Associated Avith the 
STYPTIC  INJECTIONS.
455
pain occasionally  caused  by the iron-injection arises  the  question of
shock.   The truth  of the following propositions, as  expressed  by
Legroux, has been affirmed by many of the highest authorities.  " 1st,
acute anemia (that  is, succeeding to repeated hasmorrhages) lays the
subjects under  the imminence of instant, unexpected  death, and calls
for  all  the  solicitude  of  the  physician ;  2nd, that the most trifling
obstetrical manoeuvres may add to  this debility a fatal perturbation."
Noav, this is exactly  the condition which  exists in those cases where
haemorrhage urges to give prompt assistance.  I have  seen the simple
introduction  of the  hand into the  uterus  followed  by almost sudden
death.   I have seen the same thing from  the injection  of cold water
into the uterus.   I  have seen it from the  injection of perchloride of
iron.   Sometimes death occurs more slowly, as in a case which I saAV
Avith tAvo  medical friends in  Camden Town.   The patient  had been
delivered of  her eleventh child.   Hasmorrhage set in four hours after -
Avards.  Dr.  A. introduced  his  hand,  and removed clot and a bit of
placenta.  On  the third day he  injected a  warm solution of perman-
ganate of potash.   At the  time the pulse Avas 120,  the respiration
ordinary.  Immediately afterwards the pulse rose to 160 or more, and
the respirations to 60, attended by great pain  in the abdomen.  He
feared  instant death under the shock.  She rallied someAvhat, but died
tAvo days later.
  I met Dr. Arthur  Farre on the case of a lady of exaggerated nervous
susceptibility.  Ergot had been given, and the utmost pains  taken to
prevent haemorrhage.   NotAvithstanding, some haemorrhage occurred.
Dr. F. injected perchloride,  feeling that in so delicate a woman even a
moderate loss might prove  fatal.  She remained very prostrate.   The
injection Avas repeated; and the haemorrhage Avas arrested.   She was
so Ioav, that  resorting  to transfusion was anxiously  discussed.   The
proposition  Avas  abandoned,  under the fear that  the  most trifling
disturbance  might extinguish  her.  Under  absolute  rest she  sIoavIv
recoA-ered.
  The case Avhich has made  the  most impression upon me is that
described  by Dr. Bantock (Obstetr. Trans., 1873).   There  had been
considerable loss  from  " accidental hasmorrhage," occurring a fortnight
before term.  There  was marked prostration from anaemia.  I delivered
by forceps.  Acting  on  the experience that in  these  cases atony of the
uterus  is especially  to  be feared, I  injected some perchloride of iron.
It Avas  attended by severe pain in the hypogastrium.  A fluid  drachm
of nepenthe  Avas  given, but the pain increased  in severity, and the
patient died seven or eight hours afterwards.   I am disposed to concur
in Dr. Bantock's  opinion, that  the  iron-injection Avas the  immediate
cause of death.   The case is an illustration of the influence of shock
in persons already depressed  by hasmorrhage  and labour.
  One of the most accomplished practitioners in the proAdnces sent me 
456
OBSTETRIC OPERATIONS.
the folloAving history:—A lady whom he had attended before pregnancy
for pulmonary hasmorrhage and albuminuria, who, to use his expression,
" at her best had but a slender hold on life," having pale lips and a
faint aortic bruit, came under his care in her fifth labour.  She  Avas
delivered of twins.  " Enormous hasmorrhage "  ensued.   She eventu-
ally recovered.   In her next labour, the uterus was carefully supported
throughout the labour.  She had several doses of ergot.   The uterus
was steadily compressed until after  the  placenta was  removed.   But
grasping it expelled a pint  of  blood and clot at one  gush ; the flow
continued.   The patient became pulseless,  blanched, unconscious.  A
stream of  ice-cold water was  injected into the uterus ;  contraction
ensued, she rallied, the binder was applied.   About three  hours after
the labour, flooding reappeared.  The patient  was again blanched;
unconscious, breathing heavily,  in cold sweat, with little or no pulse.
There was no external Aoav.   The uterus contained about four ounces
of firm coagula ; the vagina was full of blood and soft coagula.  All this
Dr. X. at once expelled; but  " this time no contraction followed the irri-
tation of the internal surface of the uterus."  Death seemed imminent.
A little more than  an ounce of liquor ferri was mixed with eight ounces
of water.  " There were  still tails and  shreds  of coagula lining the
uterus, which were rubbed off with a last hope of inducing contraction;
but instead, Avarm blood Avas  felt running along  the IioUoav of the
hand."   The syringe-tube Avas passed up  to the fundus uteri, air having
been previously expelled, and the fluid was injected.  Some blackened
coagula  came  away,  but the latter  part of the  injection came out
uncoloured  by blood.   The hasmorrhage  ceased from that moment.
The patient cried out, " Oh, my legs, oh, my back!  don't press me so ;
let me die in peace.  I am getting blind, I can't see."   She threAV her
arms  about.   She died in  an  hour.  I have quoted  this account in
some detail, because it presents a vivid picture of the effects of haemor-
rhage, drawn by a trustworthy  observer  and skilful practitioner.  Did
the injection cause death ?  Possibly the shock attending the operation
might have turned the trembling scale against life.  But the symptoms
that followed the injection are those of haemorrhage.   At any rate, we
here see an example of  ergot,  compression, and cold-water injection
failing to prevent or to stop haemorrhage.  We see a uterus refusing to
contract under irritation ; Ave see haemorrhage stopped  under this inex-
citable condition by a small injection of perchloride  of iron.   Had the
styptic been used at  an  earlier stage, before extreme exhaustion, the
result  might have been  more  favourable.
   It has been urged  that  the  perchloride of iron may  give rise  to
scpticamia.   The evidence  upon  this  point  is not  conclusive.  In
Dr. Bouth's case  (Obstetr. Trans., 1873) of post-partum hasmorrhage,
I injected a solution of equal parts of the weak tincture  of steel and
water.   "  On the third or fourth clay puerperal fever set in," and ended 
STYPTIC  INJECTIONS.                  457
fatally.  There  Avas  no such  continuity of  symptoms as  might  be
expected, had  the  septicaemia been  started  by the injection.  The
history differed  in no respect from a multitude of cases of septicasmia,
in Avhich no injections had been used.  And hasmorrhage is a condition
which poAverfully predisposes to septicasmia.
   Another case  cited at the discussion at the Obstetrical Society is open
to still graver doubt.  A solution of one in four of the  tincture was
used.  The hasmorrhage Avas restrained.  After three days pain set in,
the lochia became arrested, and the patient died from  puerperal peri-
tonitis and other grave complications five weeks after delivery. In this
case it transpired  that the  uterus  had  not  been cleared out before
injecting.  A large clot Avas found which had been condensed by the
injection.  The  subsequent decomposition of this probably  set up the
inflammation and septicaemia.
   Dr. Heywood  Smith's case (Obstetr. Trans., 1873) cannot be admitted
as telling against the judicious use  of perchloride.   The subject com-
plained of severe pain in the hypogastrium on the third day, no injection
having yet been made.  On  the tenth day hasmorrhage occurred, and
continuing on the  eleventh, an injection of one part of  strong liquor
ferri to  eight of water was made.   On the sixteenth, bleeding con-
tinuing, the injection was repeated ; and  again on the  " eighteenth
day with iron one in four ;  and  again  on the  twentieth with  equal
parts of the solution of iron  and water.  On the  twenty-first  day a
strong  solution  of iron was injected into  the uterus  with an  intra-
uterine syringe  holding about two  drachms.    This produced severe
pain, but completely stopped the  hasmorrhage."   On the twenty-third
day the patient Avas delirious, and the discharge offensive and broAvn.
On the tAventy-eighth  day she died.  Autopsy  shoAved  a depression
stained black, near the junction of the upper  third with  the  loAver
two-thirds of the uterus.   Near the centre of this depression an artery
hung out more  than an eighth  of an  inch, and close to it Avas " a
rounded mass of placenta the  size of a small filbert."  " The anterior
and posterior surfaces of the  uterus Avere marked with black streaks."
The  case is  in  several respects remarkable.   Injections of increasing
strength Avere used, ending Avith the concentrated liquor, Avhich  is
highly caustic.   Although continuous bleeding lasted for several days,
no attempt was  made to dilate the cervix, to  explore the cavity of the
uterus for the cause of  the hasmorrhage.  Had this  been done, the bit
of placenta might have been removed, and in all probability the artery
which  it is presumed yielded the blood Avould  have retracted.   Had
some  perchloride been applied  to the  spot immediately  after  the
removal of the bit of placenta, the Avoman's  life might have been saved.
  Faye, who has used the iron-injections  freely, says: " The theory
about blood-poisoning and septicemia is a mere phantom " (Obstetr.
Journ., 1874). 
45S                OBSTETRIC  OPERATIONS.

  I am not prepared to express so absolute a negative.  But there are
several considerations which, if fairly  Aveighed, Avould moderate the
confidence with Avhich the  affirmative is held by  some  men  Avhose
personal  knowledge of  the  subject  is  very  limited.   1st. I  have
probably resorted  to iron-injections  in  severe post-partum haemor-
rhages as frequently as any one in this  country ; and I declare  that
I have seen no case in which septicasmia could reasonably be  traced
to the practice ; and I am not aware that any one  avIio has had  con-
siderable experience, looks upon the remote risk of septicaemia  as a
sufficient reason for Avithholding  the  use of iron  when death is
threatened by haemorrhage.   2nd.  The cases reported,  even assuming
them to be  correctly interpreted, are  very few in  number.  It is
doubtful  Avhether  they  exceed or equal the  proportion  in  Avhich
septicasmia occurs  in  cases  of seA^ere  hasmorrhage in  which iron-
injections had  not been  used, or in those in which ergot, cold Avater,
or kneading the uterus had  been  trusted to.  3rdly.  It must  not be
forgotten that haemorrhage predisposes to septicaemia ; and that quite
independently   of  all treatment.   The  consequent relaxed state of
the uterine tissue favours the collection of small clots  in  the uterus ;
the thrombi that form in the sinuses  not being readily squeezed out
into the uterine cavity and expelled, linger in situ, undergo decompo-
sition ; Avhilst the increased activity of the absorptive process, brought
about by the empty state of  the circulatory apparatus, and the  need
of restorative nutrition, promotes the entry of septic matters into the
blood.   4thly.  Iron is a  powerful  antiseptic.   For a  Avhile, at least,
blood coagulated by it will be less  liable to  enter into decomposition
than blood spontaneously coagulated.   5thly.  The conditions  that
favour septicasmia  are to  a great extent under control.   No one  who
throAvs iron into a  uterus full of blood is entitled to say that the iron
caused septicasmia.  The plain duty is to clear the uterus  first.   No
one  who throws repeated injections  of iron,  ending  with  a  caustic
solution, into  the  uterus  whilst placenta  adheres,  is  entitled  to say
that septicasmia was  caused  by the iron.  The placenta  should  first
be removed.  But  Avhen  these  things  have  been  done,  small  clots
may still remain ;  and  if contraction  of the  uterus  do  not   follow,
may give rise  to septicasmia.  Thus, Dr. Hicks said (Obstetr. Trans.,
1873),  " The only case in which he had seen  any trouble was  one of
severe  flooding  after twins.   The  injection was used  with complete
success.  Twenty-four hours after, pains arose, and it was found that
the  uterus contained  hard  blackened  coagula which  it  could   not
expel.  These  were broken up and washed  out, and the  patient did
Avell."
  But, even on the hypothesis  that  shock  and septicasmia are  real
clangers,  do those who insist upon them to the extent  of rejecting
the perchloride  of  iron  in extreme danger from haemorrhage  hold a 
STYPTIC  INJECTIONS.
459
very logical position ?   Certainly, women avIio are  alloAved to die out-
right of hasmorrhage will escape shock and septicasmia.  And, if shock
and septicaemia are dangers that must in any case be aA'oided, we should
equally be called upon not to  pass the hand into the uterus, not to inject
cold Avater, not to give ergot.   In short, Ave should, by this reasoning,
be compelled to give up all treatment, since shock and septicasmia and
death have followed every mode of treatment.
  It may be affirmed, as a  general fact, that wherever  the practice
has  been largely  used, the  greatest confidence  in  its  efficacy and
safety has  been established;  and  that  the condemnation  of it  is
absolutely in proportion to the smallness of the experience of those
who condemn.   Thus it is largely adopted in London, in the provinces,
in our Colonies, in the United States, in Dublin, in Christiania, in
Vienna.   In Edinburgh  the  experience  is limited.  In a discussion
at the Edinburgh  Obstetrical Society  (December, 1874), the  prevail-
ing  opinion was  one  of suspense  or opposition.  It  Avas doubted
whether  the remedy was necessary, since haemorrhage  could  always
be averted or arrested  by other means.   A most distinguished member
stated that  "in  the Maternity Hospital  there, he believed a  death
from  post-partum haemorrhage  had never occurred."   There is some-
times  a  difficulty  in  assigning  a death to  its  main  cause,  Avhere
several causes have acted concurrently or consecutiA-ely.  But cases
of fatal haemorrhage cannot  be unknoAvn in Edinburgh.  I  am in-
formed in  a  letter from a  former pupil and resident-assistant  at
St. Thomas's Hospital, written during  his  residence in  Edinburgh
(February, 1874), that "Professor Simpson's assistant,  up to within
four Aveeks ago,  invariably told the  clinical class  that it Avas  always
possible  to  stop post-partum hasmorrhage by compression, etc., and
that  it Avas the  fault of the  practitioner if death occurred.  But
during the  last  month, and  within a  feAv days,  he has had  in his
own practice tAvo deaths  arising in this Avay, and in  spite of every
means usually adArocated.  As a last resort he injected  the iron ; but
not having it by him, valuable time  being lost, the injection Avas used
too late.  The  haemorrhage, however, immediately stopped  in  both
cases, directly the remedy Avas used ; and  this practitioner states that
he shall  be more careful  in the future to have the iron by him.   In
neither case does  he attribute death to the injection, but is confident
that, had it been  used earlier, life would  have been saved.  The first
case Avas absolutely dying when the injection Avas made, and died
shortly after ;  the other  one, although  gasping,  lived  on until the
next eA'ening."
  Let us noAV endeavour to lay down precise  rules for using the iron-
styptics.
  In  the case  of haemorrhage  from abortion, it  is proper, first,  to
dilate the cervix well with laminaria-tents; secondly, to pass a finger 
460
OBSTETRIC OPERATIONS.
into the uterus to remove all placental debris ; thirdly, if haemorrhage
still persist, to inject hot water (110° F.),  then apply the styptic  on
a swab of sponge  or  cotton-wool attached to  a piece of whalebone,
or by  the  tubes to be described in the next  paragraph.  Injection
is rarely necessary.
  In the  case of hasmorrhage from  the  non-pregnant  uterus,  the
same method  of dilatation  and swabbing will commonly be the best.
Where injection is  thought necessary, a tube should be used provided
Avith small  holes at  the  extremity, directed backwards, so  that  the
fluid Avill emerge with  moderated force  in fine streams running down-
Avards toAvards the os uteri.   An excellent tube is that of Burkhardt, of
Bremen.  It is made of glass, Avith an open channel, so that the fluid
readily  escapes.  I  have also  used silver or vulcanite tubes, haA'ing
large slits at the uterine end, in which pieces of sponge, soaked Avith
the iron-solution, are  packed.  When the tube is in situ the sponge
is compressed by a piston-rod, and the styptic oozes out.  I have these
tubes of different sizes, so as to meet cases where the uterus is small,
as in cases of abortion, and even after ordinary labour.  By this means
all injecting force is obviated.
  I believe  also that  greater  security  is obtained  by using a strong
solution, not less than  one part of perchloride of iron to ten of Avater.
The constringing effect is greater, and thus  there is a greater tendency
to corrugate the inner surface of the uterus and to close the Fallopian
tubes.
  To sIioav the effect of a concentrated solution, the following case is
cited.   Dr.  Tissier  (Gaz. des Hopitaux, 1869), in a case  of profuse
flooding, non-puerperal, introduced into the vagina  a plug of charpie
dipped in strong perchloride of iron.   The plug was removed in forty-
eight hours.   On the  seventeenth  day a piece  of mucous  membrane
Avas discharged.  The patient had a slow convalescence ;  and a great
contraction  of  the vagina   followed.    The perchloride  acted as  a
powerful caustic, producing  a slough of the mucous  membrane.  The
case is valuable as an example of the greatest local injury that caustic
perchloride of iron can  cause.  Bouchacourt  relates a similar case (Lyon
Medical, 1875).   Atthill has used successfully the solid perchloride.
  The  case of the uterus  after labour at term differs essentially from
that of  the non-pregnant  uterus ; and  it appears to me  that the  dif-
ference  is  in  favour of increased safety.  The free opening  of  the
cervix, permitting a hand  to pass, is a  security against retention of
injected fluid.   The ragged  state of the lining membrane from decidual
shreds  and clots must serve  as a  great protection against the entry of
injected fluid  into  the tubes or uterine tissues.  The muscular con-
traction which  is  also generally  provoked,  is  a further protecting
condition.
  The  mode of using tlie perchloride of iron in post-partum flooding. 
STYPTIC  INJECTIONS.
461
—An important preliminary step is to clear  the uterus of placental
remains  and clots,  so  that the fluid, Avhen injected, may come into
immediate contact with  the  walls  of the caA-ity.
  Place  the  woman  on her back.   Get an assistant to press  firmly
with a hand on  either side of the  uterus, Avhilst you inject.
  You have the Higginson's syringe adapted Avith an uterine tube eight
or nine inches long.  Have two basins charged: one Avith Avater at
110° F.,  the  other with  a mixture of four ounces of the liquor ferri
perchloridi fortior of the British Pharmacopoeia  and twelve ounces of
water, or dissolve half an ounce of solid perchloride or persulphate
of iron  in ten ounces  of water.  The suction-tube of the syringe
should  first  be placed  in the hot-Avater  basin,  taking  care that the
in-draught end reach to  the  bottom  of  the vessel.  Pump through
the delivery-tube  tAvo or  three  times to  expel air, and to  ensure the
filling of the apparatus with the fluid before passing the uterine tube
into the uterus.   This, guided by the fingers of the left hand  in the
os uteri, should be passed quite up to the  fundus.  Then inject  slowly
and gently during  two or three minutes.   If the haemorrhage con-
tinues, transfer the suction-tube to the iron-solution.   Again inject
slowly and gently.  A  few strokes  are often enough.
   The haemostatic effect of the iron is produced in  three Avays  : first,
there is  its  direct action in coagulating  the blood  in  the mouths of
the  vessels ; secondly, it acts as a  poAverful  astringent  on the inner
membrane of  the uterus,  strongly corrugating! the surface, and thus
constringing the  mouths of the vessels ; thirdly,  it  often proA'okes
some amount  of  contractile  action  of  the muscular Avail.   This con-
traction,  if  accompanied by  constriction closing the  os  uteri, may
prevent the escape of the styptic fluid.  The  concentric  contraction of
the uterine globe  upon its fluid contents  will then  tend to driA^e the
fluid along the Fallopian tubes.  It is  therefore imperative to observe
the rule to pass one or two fingers through the cervix along Avith the
tube.  The fingers in this position further act as sentinels, informing
you of the operation of the styptic in checking the hasmorrhage and in
corrugating  the  inner surface of the uterus.
   It is rare to find any renewal  of haemorrhage after the injection  has
been made as described.   If there  should  be  any return, the injection
may be repeated, first taking  care that there  is no clot in the  uterus.
If the discharge prove offensive, especially if the temperature and pulse
rise, if there be uterine colic, or shivering, wash out the uterus with a
weak solution of iodine,  or of  carbolic acid.
   The  injection  of the perchloride to arrest  hasmorrhage has been
followed :—1st. In many cases  in  which flooding persisted, in spite of
the use of ordinary means, i.e., ergot, compression, cold and hot-water
injections, iodine injections, and after refusal of the uterus to respond
to any excitation, by instant arrest of the bleeding and steady recovery. 
462
OBSTETRIC OPERATIONS.
In a large proportion of these cases the patients have borne children
subsequently.
  2ndly. In several cases where profuse bleeding had taken place, it
was also instantly arrested ; phlegmasia dolens appeared.  All the cases
known to me  recovered well in the end.  One had  had phlegmasia
dolens after a  previous labour, Avith profuse flooding, the injection not
having been resorted to.
  3rdly.  In several cases Avhere the  patients were already in extremis,
from loss of blood, the  injection stopped further bleeding; but  death
ensued.  In these cases I Avas unable to see that the injection in any
way contributed to the fatal issue.  The patients were moribund ; the
remedy was used too late.
  One fact is  important.   Haemorrhage  often returns  after all the
other remedies ; rarely or  never after iron.   The commentary Avhich
I would  offer  upon these three classes of cases is, that, of  the first
class, some Avomen would clearly have died but for the remedy ; Avhilst
others Avere clearly spared an amount of blood which secured  them
against the severe secondary effects of flooding.  In  making this  state-
ment, I make full allowance  for the difficulty that  not seldom occurs
in satisfying oneself that some of the women  who recovered would not
equally have recovered if they had been let alone.
  That the supervention of phlegmasia dolens  may possibly, in some
cases, have  been due to the  extension of the thrombi formed in the
mouths of the uterine  sinuses  by the action  of the  perchloride; but
that, on the other  hand, we cannot regard this thrombotic process  as
altogether  injurious.  It is  undoubtedly often a conservative process,
cutting off from the  general circulation noxious  matter  generated
on the surface of the uterus.  And, again, phlegmasia dolens is not
uncommon after flooding, where iron-injection  is  not used.  Finally,
some of these patients Avould probably  have died  without the  iron.
It was surely  better to run  the hazard  of phlegmasia  dolens.
  That, in the last 'class of cases, those in which death ensued after the
injection,  the cause being collapse from loss of blood, recovery Avas not
to be expected from  anything less than  the  supply  of that which was
lost.  Here the remedy is  transfusion.    The  practical lesson  to  be
deduced from  these unfortunate cases is, not  to defer  resort to the
injection too long.   It will, at almost any stage, stop the bleeding, but
it cannot  restore the blood which has been lost.  It cannot recall the
life that is ebbing away.  Two remarkable illustrations of the combined
use of the styptic injections  and  transfusion  are related in the section
on " Transfusion."   Although, therefore, the injection of perchloride of
iron will not seldom rescue women from death  by flooding after other
means have failed, it is  important to use it betimes,  before the stage of
utter collapse, Avhilst there is  still inherent in the system tlie poAArer of
reaction. 
               THREE  STAGES OF HAEMORRHAGE.           463

  This end will be secured if the warning I have given as to the extent
to Avhich ergot, compression, cold and hot water should be trusted, be
regarded.   If these  agents be  abandoned  the moment Ave observe that
the expected  response in uterine contraction is not given, Ave may then
count upon the best results from  injecting perchloride of iron.  One
more emphatic reason  I Avould plead in  favour of early resort to this
treatment, is, that it is  not enough to save bare life; we  must save all
the blood  Ave can.   For this reason, and having acquired confidence in
the efficacy and safety of this crowning  remedy, I  never now lose time
by persisting in other means that  may  fail, and which, having failed,
even partially, leave the patient  the  worse by the quantity of blood
lost.
  We have,  then, three stages of hasmorrhage to deal Avith:—
  First, there is haemorrhage  Avith active contractility of the uterus.
Here the diastaltic function may be relied upon ;  excitants of contrac-
tion find  their application.
  Secondly,  there is a stage  beyond the first, Avhen contractility  is
seriously  impaired,  or  even lost.  Here  excitants of contraction are
useless.  Our reliance must be upon the  direct application  of styptics to
the bleeding surface.
  Thirdly, there is the stage beyond the tAvo first, when not only con-
tractility,  but all vital force is spent—when no remedy holds out a hope
unless it be transfusion ;  and when even this Avill probably be too late.
  In these cases,  and pending the  preparation  for  transfusion,  Ave
should put in practice the method  of restoration proposed by Nelaton
in collapse from chloroform, namely, raising the body so that the head
depending may receive  by  gravitation  Avhat blood there  is left in the
Aressels.
  A few Avords upon the restorative treatment.  The great  physiological
principle  of rest must  govern all  treatment.  The system, drained of
blood, and therefore barely nourished  enough  to keep  the ordinary
functions  going on the most  reduced scale compatible with life, can ill
tolerate any  unnecessary call.  The  first effort must be directed to
produce  reaction  from the  stage of  collapse.  This  is  especially
necessary if  the patient have  been much prostrated by the persistent
use of cold.   And to prostration from this cause is added that from the
rapid cooling influence of accelerated respiration.   Since cold  is so
universally trusted  to, and is pushed  so far, it requires some firmness
to insist upon resort to its opposite—Avarmth. But  unless you Avould see
your patient  sink under collapse, you must restore  the circulation.   To
this end,  hot bottles should be applied to the feet; wet, cold  linen
removed,  if possible, Avithout disturbing the patient;  if not, Avarm dry
clothes must be Avrapped around her; gentle friction  of the hands and
feet  may  be  used.   Cordials  and  stimulants  must be given in small
quantities, warm.   It is the common  practice to give everything cold, 
 464                 OBSTETRIC  OPERATIONS.

 under the fear that Avarmth in any form is likely to cause a renewal of
 the bleeding.  But we are iioav dealing with a state of A'ital depression
 greatly  caused by  cold.  You will not cure by  making  the patient
 colder.   Cordials are,  no doubt, increased in efficacy if taken Avarm.
 What are the best cordials ?   The  best of all, undoubtedly, is cognac.
 Give  it at first  in  small sips, diluted AAdth equal parts of hot Avater.
 A good mull of claret and cinnamon or nutmeg is often useful.  Watch-
 fulness is required lest  over-anxiety  ply the wealv, all  but paralysed
 stomach  too freely.   The power of imbibition is very feeble ; if you
 pour  in any quantity, it simply accumulates, loads the stomach, until
 it is  forced  to reject the whole by vomiting.
   It  is at this stage, or when the system  is rallying, that opium is
 so  valuable.  Opium is, in  my  opinion,  decidedly contra-indicated
 during the flooding.  It then tends to relax the uterus.   But Avhen the
 object is  to support the system, to allay nervous irritability, there is no
 remedy like  opium.  It may be given in doses of thirty or forty drops
 of laudanum or  Battley's solution,  every two or three hours.  In con-
 firmation, I  cannot help quoting the conclusion of the late Dr. Beatty :
 " That opium is capable of inducing haemorrhage AAdien given  soon
 after  delivery, I  once learned to my cost.   Opium given prematurely
 must  do mischief.  Ergot is our sheet-anchor at first, when we Avant to
 arrest the hasmorrhage ; and opium  aftenvards, when we Avish to restore
 exhausted vital  action."  If the stomach will not bear it, it  may be
 given in  an enema.  It  may be worth Avhile to try the subcutaneous
 injection of ^ to  \ grain of morphia ; but this must be done cautiously.
   When  a little strength has been gathered up, you must  think of
 nutrition.  "Little and  often" is a good maxim.  What  you gi\re, if
 it be  absorbed,  is soon  used  up ; but if you give much it is lost by
 vomiting;  therefore, the supplies  must  be  frequent and moderate.
 When the  stomach will  not tolerate  even  small  quantities, the
 difficulty may be tided  over by  enemata, consisting  of  six ounces of
beef-tea or milk,  an ounce of wine  or  brandy, and ten or tAventy drops
of laudanum.  A state of atonic dyspepsia  lasts for  some time; and
during this  the  stomach must be most  sedulously studied.
   When  reaction has  set in, the heart beats painfully, the  temples
throb, agonizing headache follows.  Then salines, of which the best
is the fresh-made acetate  of  ammonia, are  most sendceable.  The
opium can be combined with it.   Nothing  tranquillizes the  hasmor-
rhagic excitation like  salines;  and  it is  more than  probable that
salines supply a pabulum the circulation  Avants.  Salines continue
to be useful  for many  days  during Avhat has  been  aptly called the
 "hemorrhagic fever."   Ice will  iioav be useful; it  quenches thirst,
and acts  as a  sedative.  Do not be  in  a hurry to  give iron.  If
given  prematurely, it parches the mucous membranes, increases head-
ache and fever.  In short, it  cannot be borne at this stage; it comes 
                  POST-PARTUM  HAEMORRHAGE.             465

in usefully at a more advanced period of convalescence.   Five  or ten-
drop doses of tincture of digitalis, or a minim  of hydrocyanic acid,. •
added to the saline, are often of great service in calming the irritability
of the heart.
   In cases of great exhaustion  from haemorrhage, do  not  suffer  the
patient to rise on any pretext;  linen can be changed  Avithout quitting
the recumbent posture;  and it  is  better to use the catheter  tAAro or
three times a day than to  incur the  risk  of  sitting  up.  In fine, all
depends  upon constant  attention to the smallest details, upon good,
noiseless, gentle nursing.  Guard your patient  against all excitement,
even from the effort of talking.   Bar the  hall-door against officious,
sympathizing friends.  After labour with flooding, there  is great danger
of defective contraction of the uterus.  This state  disposes to secondary
haemorrhage, and lays the circulation open to the invasion of septic
matter.   To  counteract this, give,  three times a  day,  a mixture of
quinine tAvo grains,  dilute sulphuric acid ten  minims, liquor of ergot
twenty minims, or some equivalent medicine.   Fordyce Barker insists
much upon this.   I  can attest the value of the practice.
H H 
                       LECTUBE  XXX.

SECONDARY  OB REMOTE PUERPERAL HAEMORRHAGE—CAUSES :  LOCAL
     AND  CONSTITUTIONAL—RETENTION  OF  PLACENTA--BLOOD-CLOT
     --LACERATION  OF  CERVIX  OR  OTHER  PARTS--THROMBUS  OR
     HEMATOMA--RETROFLEXION--FIXING OF  UTERUS  BY PERIMETRIC
     DEPOSIT.
                Secondary Puerperal Hamorrhage.

When the immediate perils of childbirth seem to have been Aveathered;
when the patient has been deemed safe from hasmorrhage ; at any rate,
at a period more or less remote from labour, varying from a feAv hours
to two  or  three Aveeks, this  terrible  complication  may yet make its
appearance.  But  if we have  taken  due care in the conduct of  the
labour,  and especially  in  the  management of the  placenta  and any
primary hasmorrhage,  we shall rarely experience  the  mortification of
seeing secondary haemorrhage.  This  will  be evident  if Ave  examine
the principal ascertained causes of this  catastrophe.  They are :
   A. Local.—1.  A portion  of  placenta  or  membranes  may have
remained in utero.
   2. Clots of blood may have formed and been retained.
   3. Laceration or abrasion of the  cervix, vagina, or perinaeum, or  a
vesico-vaginal or recto-vaginal fistula.
   4. Haematocele  or  thrombus  of  the  cervix,   vagina,  vulva,   or
perinaeum.
   5. Chronic hypertrophy, congestion or ulceration of  the cervix uteri.
   6. General relaxation of the uterine tissues.
   7. Fibroid tumours and polypi.
   8. Inversion of the uterus.
   9. Betroflexion or retroversion of the uterus.
  10. Pelvic cellulitis or peritonitis  fixing the uterus.
   B. Constitutional or  remote conditions causing disturbance of  the
vascular system.
   1. Emotions.
   2. Sexual intercourse. 
SECONDARY HEMORRHAGE.
467
   3. Beturning ovarian action, manifested commonly at the end of one
month from labour.
   3a. Ovarian action, favoured  by failure to  suckle, and  imperfect
involution of the uterus.
   4. Heart disease, including imperfect involution.
   5. Liver disease, Bright's disease.
   ('». Leucocythaemia.
   7. General debility  of tissue,  malnutrition of nervous system, and
irritable heart from anasmia.
   A. 1. Retention of Placenta.—-This  is, perhaps, the most common
cause.   It is that which I have most frequently met with;  it is that
which may be most surely  avoided.  Since it has become  a recognized
practice not  to allow  the  placenta to remain  more  than an hour, it
must be very rare to find secondary haemorrhage occurring from reten-
tion of the entire placenta,  or even the greater  part of it.   But I have
been called in to such cases.   In these the flooding has  usually come
on within twenty-four hours of labour.  The explanation has been that
rigidity of the  cervix uteri rendered it  impossible to get  the placenta
aAvay.   I  have removed the whole placenta several days, even a AA-eek
after labour.   In all these cases there  was not only  flooding—indeed,
flooding Avas  not ahvays the  urgent symptom—but there  Avere unmis-
takable marks of septicaemia : a pallid straw-coloured  complexion, Avith
hectic  flush ; rigors ; quick  pulse,  running over 100, to 120 or 130;
temperature  rising to  102° or 103°; often foul breath, suggesting the
odour of  decomposing lochia ; thirst;  distressing  perspirations alter-
nating with hot skin ;  vomiting ; general prostration.  The local signs
were:  some  distension of  the abdomen ; tenderness  on  pressure over
the uterus, which could be  felt rising perhaps as high  as the umbilicus;
on examination by vagina, the uterus  Avas felt enlarged ; the  cervix
more  or  less  open, at  least admitting  one or tAvo  fingers, and  on
withdrawing  the  finger it Avas found  smeared Avith muco-purulent
sanguineous fluid, generally of peculiarly offensive  odour ; and, some-
times,  retention  of urine.
   These symptoms are enough to justify, even  to demand, exploration
of the cavity  of the uterus.  The tenderness of the uterus and  abdomen,
and the partial closure of the  cervix, render the introduction  of the
hand, or even a finger, a very distressing operation.   You may some-
times acquire information  to  guide further proceedings by passing in
the uterine sound.  This will give you the exact measure of the cavity;
and you may be able by it  to  make out the presence of a  foreign body
in the  cavity.  If the  sound  goes four  inches  or more beyond the  os,
you may infer that the uterus is of abnormal size, and that it contains
something solid.   If you perceive any fluid issuing  from it, or feel any
substance  in  it, you must make up your mind to pass your finger fairly
into the cavity, so as to explore fully, and to bring away whatever is in
                                                        h h  2 
46S
OBSTETRIC OPERATIONS.
it.  At an early period, that is, within t\vo or three days after labour,
you may squeeze  out  placenta or clot, by grasping the uterus firmly
above the symphysis.
  It Avill be next to impossible to remove an entire  placenta  Avithout
passing your hand into the uterus;  and this is  an operation  of no
small difficulty.   If the cervix be so contracted as not to admit more
than a finger, it will be Avise to introduce a fagot of three or four large
laminaria-tents, and to leave the patient for a  feAv hours to let them
expand.  The next step may be to  introduce the  medium or largest
sized  caoutchouc bag, and distend Avith AArater  until  there  is room to
pass three or four fingers.   When you can do  this, the patient  being
anaesthetized, by steady pressure,  supporting and pushing  the fundus
doAvn upon  the inside hand by the  hand outside, you will succeed in
getting your left hand  into the cavity.   This done, take care to  grasp
Avell the  Avliole mass  of the placenta, and  withdraw it.   When  you
have got  it out, you will be glad to get rid of it  as  quickly as possible.
There is, perhaps,  no  stench  more  offensiA7e than  that  of  a  placenta
that has decomposed in utero.
  This being so, what  must be the condition of the uterus itself ?  It
clearly Avants disinfecting.   It should be Avashed out  Avith  chlorine
Avater, Aveak solution  of carbolic  acid,  creasote, Aveak iodic solution,
or perchloride  of  iron ;  and if none  of these  are at hand, Avith hot
water.  The uterine  tube  should be  carried  fairly  into  the uterus.
The operation should be repeated tAvo or three times a day for some
days.   An excellent plan is to irrigate  the parts by means  of such an
apparatus as that contrived by Dr. Basch.  The fluid is carried into the
uterus by a syphon, and runs out by a discharge-tube, Avhich  empties
itself  into a vessel by the side of the bed.
  More common is the retention  of a portion  of placenta.   This may
be either adherent or loose.  It is  more  likely to have adhered at the
time  of the removal of the bulk of the placenta.  In this  case the
uterus remains large; there is  constantly tenderness on pressure;
often  there  is  an  offensive discharge attending or  alternating  with
haemorrhage.   Comparing  a considerable number of observations, I
find that, where portions of placenta  are retained, the secondary haemor-
rhage commonly appears at the end  of seven or eight days.  At about
this period  the  progress of involution  brings  the  Avails of the uterus
into closer  contact with  the foreign  body in  its  cavity, which then
becomes  a more active source of  irritation.
  The same proceedings must be adopted as in the  case of retention of
the Avliole  placenta.  But  there may be  great  difficulty in separating
all the adherent portions  from the  surface of  the  uterus.  You  must
take pains  to break off all that  Avill  readily come, carefully avoiding
digging your nails into the substance of the uterus.  It often answers,
as in the case of early abortion, to break up  any adherent masses if 
SECONDARY HAEMORRHAGE.
469
you cannot detach them.  It is far better to be content with this than
to err by excess of pertinacity.  If a portion project at all prominently
in a polypoid form, I strongly advise removing it by the Avire-ecraseur,
which does it cleanly, and Avithout injuring the uterus.  Having done
your best in removing debris, wash out with disinfecting fluid.
   You  may  generally  infer that the  uterus  is free from  placental
remains if, at the  end  of ten days—1, there is no  bleeding; 2, the os
uteri closes ; 3, the  uterine sound goes not more  than three inches.
   2. A  blood-clot may form  in the uterine cavity from  imperfect
contraction  after  labour;   it  grows by  receiving  accretions  on its
surface  ; and being compressed by the uterus, it becomes condensed
into a mass having the shape of the cavity.  This  acts as a foreign
body.   It excites  spasmodic action; it  attracts  blood to  the  uterus;
and the congestion is relieved by oozing of blood  and serum from the
uterine  Avail.   Some  of this  escapes externally,  but not always in
sufficient quantity to arrest  attention as " flooding."   The napkins are
sodden  Avith a serous  fluid  streaked  Avith  blood, and often someAvhat
offensive to the smell.   This serous discharge is  indicative of retained
clot.
   Sometimes, when the uterus remains flaccid, the clot is not moulded
and compressed, but more blood collects, and forms a number of dark,
loose clots, mixed with fluid blood.
   In either case the uterus  must be emptied.  It is advisable, first, to
try to  empty  the uterus by squeezing.   If this is not  satisfactory,
the fingers or hand must be  passed into the cavity.  Here, again,
irrigation by disinfectants  is advisable.
   I ought to mention,  for the benefit of those who are led by authority
more than by  reason,  that the  immortal  Harvey  used  the  sound for
diagnosis,  and intra-uterine injections as a remedy, in cases  of this
kind.   His knoAvledge  of  uterine pathology, and his practice,  were
indeed vastly superior to those of the  great bulk of our modern English
physicians.   He was superior in freedom from prejudice, and therefore
in diagnostic and therapeutical success.
   3. Laceration  or abrasion of  the cervix  is more frequent  than is
commonly suspected.    Haemorrhage  from  this cause  is sometimes
protracted and serious in  quantity.   We arrive at  the diagnosis by
a  method of  exclusion.   If we find the body  of  the uterus firmly
contracted, of  size corresponding to  the date after  delivery—a point
accurately determinable by  bi-manual examination and the intro-
duction of the uterine  sound—our attention is fixed upon the state of
the cervix.   A rent here  may then be felt, and even  seen  by the
speculum.   The blood  is usually florid.  The treatment is to apply a
solution of perchloride of iron to the wound by a swab, carried through
the speculum, or on pledgets of lint, in the form of  a  compress or plug.
Dr. Boper Avas called to a patient of the Boyal Maternity Charity eight 
470
OBSTETRIC OPERATIONS.
hours after delivery.   The pains had been very violent.   The placenta
had been  expelled.   There had been much haemorrhage;  but it had
stopped.   The uterus Avas well contracted.   On  the sixth day very
profuse  flooding occurred;  life seemed  in jeopardy.  Dr. B.  found
a large  ragged laceration extending  the whole length of the ceiwix
uteri on the left side as far as the reflection of the vagina.   The uterus
Avas Avell  contracted.   Dr. B. passed dry cotton-wool into  the gaping
cervix, and filled the vagina too.   Next day I saw the woman Avith
Dr. B., and SAvabbed the  rent Avith  perchloride of  iron.  Fifteen days
after delivery there was another severe flooding.  Dry cotton-wool Avas
again used.   Tavo months after deliATery a Avide red cicatrix remained.
The healing  Avas perfect, without  deformity.  If seen in the recent
stage, the Avound should be  stitched up.
  Laceration of the  Vagina or Perineum.—Any  part of  the vagina
may be torn during labour.   Laceration of the upper part is,  com-
monly, an extension of rupture of  the loAver  part of the uterus : and
symptoms indicating the  gravity of the injury will  be apparent at the
time of labour.  Laceration  of the middle part of the vagina  is rare ;
but laceration of the loAver  part, merging  in rent  of the perinaeum, is
common.   This  may become a source of secondary bleeding.  Digital
and visual examination will  reveal it.   If not discovered for  some
days,  the better course  will be to stop  the bleeding by  compresses
steeped in perchloride of iron, if necessary, and to leave restoration to
future consideration.  But the practice of immediate reunion by suture
is coming into use.   If undertaken,  it should be done thoroughly, with
the same care that is used in the ordinary operation.
  A little bleeding may also continue  from -vesicovaginal or  recto-
vaginal  rents or fistulas; but the quantity is  rarely enough to  cause
anxiety  as to haemorrhage.
  4. Thrombus.—A  collection  of blood  may  form before, during,  or
after labour, in the sub-mucous tissue of  the cervix uteri, some part of
the vagina,  or  of the perinaeum or vulva.  Thrombus of the cervix
uteri is apt to occur in connection Avith hypertrophic elongation of that
part.  The part most exposed to the formation of  blood-tumour is the
vulva,  especially  the labia majora.  The folds of  skin and  mucous
membrane which constitute the labia, enclose a copious arrangement of
veins, arteries, and cellular filaments.  The vessels anastomose freely.
Bupture at any part gives free vent  to blood, which finds ample space
to accumulate.   In pregnancy the veins  are frequently varicose, always
excessiAely full of blood, Avith a disposition to  stagnation; they easily
rupture, sometimes under external  Adolence, sometimes spontaneously.
Most frequently, one labium only is affected.   Thrombus may occur at
any period of pregnancy ;  is more frequent as the term  of gestation
approaches ;  and most common during labour.    The blood-tumour
mostly forms when the head is  about to  clear the  vulva.  The rupture 
THROMBUS.
471
of the vessels is thus the result of the excessive distension to AAdiich they
are subjected by the pressure upon the soft parts above.   I have knoAvn
a large thrombus dissecting the vagina away from the rectum following
the administration of ergot.   Occasionally the tumour is developed
rapidly before the head comes down to the outlet, forming a mechanical
obstacle  to the completion of labour.   The distension is  at times so
rapid and  great  that  the walls burst,  and considerable haemorrhage
of an arterial  character takes place.*   But more often, although the
rupture of the vessels may occur  before the  passage of the child, the
tumour is  developed  gradually after its birth.   The passage of the
head, carrying before  it the inner  layer of the labium, increases the
lesion of the vessels.   There is a glacier-like movement of the mucous
membrane upon  the  subjacent tissues.   These post-partum thrombi
are especially dangerous, because they are more liable to be overlooked.
They may burst;  their Avails may undergo mortification: they may
lead to septicasmia.
  Acute pain generally marks the beginning of thrombus, due probably
(Caseaux) to the  rupture of the vessels.  The  effusion may be  limited
to the loose tissue of the  vulva ;  but it may be very extended.  Thus
Caseaux relates  a case  in which  he traced the blood dissecting the
peritoneum all up the iliac fossa, Avhere it formed a large  coagulated
mass;  it extended, still behind the peritoneum, up the left and posterior
part of the abdomen, as high as the right hypochondrium, bathing all
the cellular tissue surrounding the kidney, and even to  the attachments
of the diaphragm.
  If the tumour burst,  the haemorrhage may be so  great and rapid as
to prove quickly fatal.  If it fail to burst, it  may become  so large as
to close the vagina,  and  lead to retention of lochia  (Lachapelle);  it
may also cause  retention of urine,  or fasces.
   The diagnosis  is not always easy.  When the tumour has acquired a
moderate size, it presents a shining aspect of purple  or bluish-black
colour.  It tends to occlude the entry  to the vagina, Avhilst the finger,
passed above it, defines its extent and  relations.   Its  rapid formation
Avith pain, the hardness  of the tumour  if the blood has coagulated, and
its  fluctuation if the blood remains fluid, are characteristic.
   The prognosis  is serious.  Deneux collected  sixty-tAvo cases, of which
twenty-tAvo were fatal.  In twenty-one  of these the child also Avas lost.
The cause  of death  is  usually loss of blood, internal  or external.
Gangrene  or suppuration may prove  fatal at a later period.   Other
cases have ended by resolution, suppuration, bursting, peritonitis, or
septicemia.
   Hugenberger f summarizes  the  issues of the puerperal  effusions of
  * See an excellent lecture on this  subject by Fordyce Barker, " Medical Record,"
1S70 ; also, this author's " Puerperal Diseases," 1874.
  f " St. Petersburg Medical Zeitung," 1867>. 
472                 OBSTETRIC OPERATIONS.
blood into the cellular tissue, observed by him—1. Perinasal haematoma
before labour,  consecutive abscess,  perforation of rectum,  recovery.
2. Labial haematoma, apparently arising during labour ;  suppuration
of the burst blood-gathering, pyaemia,  death.   3. Labial  haematoma
before labour;  suppuration of the burst  gathering during childbed ;
fatal metro-peritonitis and pyaemia.  4. Labial haematoma,  bursting,
recovery.   5. Labial haematoma, incision, recovery.  6. Labial haema-
toma,  incision,  recovery.  7. Labial haematoma, incision,  recovery.
8. Peri-vaginal after labour, bursting, recovery.  9. Peri-vaginal after
labour, bursting, recovery.   10.  Peri-uterine  during  labour;  violent
labour-pains, fatal  hasmorrhage.   11. Peri-uterine after labour, Avith
cross-birth and turning; bursting of the  sac, and death  by bleeding
into the abdominal cavity.
  The two following  cases illustrate some of the features of haema-
tocele  or thrombus:—
  B. M. Charity, 31st  Oct., 1859.   Primipara:  ordinary labour.   After
it, midwife observed a mass  protruding externally, which she took to
be bladder  and vagina prolapsed.  I saw her two  hours after labour.
There was a soft tumour, the size of a child's head, projecting from
pubes  to anus.   In front it seemed  tense, shining, translucent; fluc-
tuating ; its sides presented similar characters ; the circumference, the
base, was continuous  with the skin of labia and thighs.   Posteriorly
was an inflexion of the  tumour, having an anterior  lip much  ecchy-
mosed,  and posterior lip forming  a  sharp crescent,  the Avliole  much
resembling the os uteri after labour.  Pursuing examination up this
orifice, I found that  the swelling was caused by the enormous distension
of the labia vulvae, especially the left, by blood and serum.   On  the
internal aspect of left labium,  about one inch from the orifice, Avas  a
jagged hole which communicated Avith the sac formed by the effusion
in the labium.  Through this some sanious matter escaped on pressing
the swelling.  It was a  rent made in the mucous membrane  by the
head in the birth.   Fomentations were used.  During the tAvo succeed-
ing days the tumour much diminished.  She did well.
  B.  M. Charity, June, 1863.  Hypertrophy; procidentia;  hema-
toma  of cervix.—Sent for by midwife in great alarm, she thinking the
whole uterus had come out after  child and  placenta.   I found patient
prostrate, cold, agitated; a  large mass lay forth beyond the  vul\-a, of
dark colour, like  coagulated blood, resembling in bulk  and colour the
placenta.  I next thought it  was the inverted  uterus.  Some haemor-
rhage from  it.   The  mass was  soft, its covering easily lacerating on
slight  pressure; it  was found to  consist  of tAvo lobes,  and betAveen
them  was an opening admitting  two or three fingers some  distance.
This was the os uteri; the two lobes  were the lips of the cervix uteri,
enormously enlarged by infiltration with serum and blood.  On pressing
the mass to reduce it, the  mucous membrane easily  tore, and blood 
SECONDARY HEMORRHAGE.               473
 oozed out.   To guard against this, I covered the Avliole Avith a napkin ;
 then by careful and gradual compression  it was  returned within the
 vagina.   A good  perineal compress was  applied  to  prevent  descent.
 Patient  did  Avell.
   This Avas  a  most aggravated example of the contusions and injury
 which the cervix  undergoes  during labour.  It was hypertrophied and
 elongated.
   It is probable that a varicose condition of the cervix, similar to that
 which so  frequently exists  in  the  labia vulvae, may be the cause  of
 thrombus  of the  cervix.  Dr.  Murray relates (Obst. Journ., 1873) a
 case in which  severe haemorrhage occurred in tAvo successive  labours
 before the passage  of the  head.   The  source  appeared  to  be the
 bursting of  a  mass of varicose veins—a form  of  hasmatocele—just
 Avithin the cervical zone.   On  one occasion  haemorrhage recurred a
 fortnight after labour.
   The treatment will vary according to the time  of the appearance  of
 the  tumour.   If it form before the descent of the child, Ave may first
 endeavour to restrain the effusion by ice and  pressure; if this is not
 successful, whether the tumour by  its  bulk impede  labour or not, I
 believe it is better to open it by the lancet, and to deliver by forceps.
 Thus the danger of further  injury under the  attrition of the head  is
 lessened.  If the tumour have burst, and haemorrhage be at all profuse,
 the  first  effort should be to deliver by forceps,  if the head  present.
 Then we can employ means  to arrest the bleeding.   F. Barker  adA-ises
 to enlarge the opening by  incision, to  clear out the clots,  and  to
 compress the cavity Avith lint  soaked in  solution  of iron.   When the
 haemorrhage is fairly arrested,  care is required to  avoid sloughing and
 septicaemia from decomposition of the clots.   The styptic plug should
 be replaced  by dressings Avith carbolic acid oil, and  syringing Avith a
 solution  of  carbolic acid or  iodine.  It  is well to remember that
 haemorrhage may arise  from  laceration  of  the vulva  apart  from
 thrombus.                                                                  •
  5. Chronic hypertrophy, congestion or  ulceration of the  cervix, will
 be detected  by touch and by speculum.   The parts  may  be  touched
 lightly Avith  nitrate  of silver every  third day.  Astringent lotipns are
 also  useful.
  6. General relaxation of the uterine tissues is mostly associated vrith
 systemic debility and malnutrition.    Constitutional treatment  is here
 especially  serviceable.   Iron,  strychnine, phosphoric acid, cinchona,
 ergot,  are  particularly  valuable.
  7. The complication of fibroid tumours and polypi has been pre-
 viously discussed.   If  first  discovered  some  days  after labour, the
 treatment is  still the same  as  that  recommended when found  at the
 time of labour.  In  the case of fibroid tumours, Ave must first restrain
hiemorrhage  by the topical  application of  perchloride of iron ;  some- 
474
OBSTETRIC OPERATIONS.
times the tumours can be removed by enucleation.   Polypi should be
removed by the Avire-ecraseur.
  8. InversionhsiS been already discussed.  (See Lecture XXII., p. 312.)
  9. Retroflexion  of the uterus is, in my experience, a frequent cause
of secondary haemorrhage.  The displacement no doubt  occurs soon
after the labour, the heavy fundus falling backwards, Avhilst the tissues
are still in  a relaxed  state.   In some  cases, I ascertained that there
had been retroflexion in the non-pregnant state.   It is highly probable
that there has frequently been antecedent retroflexion, and also, that
occurring for the first time after a labour, the condition becomes per-
manent.  Ed. Martin says retroflexion and anteflexion after labour are
caused by non-involution of the placental site.   Thus, if the anterior
Avail be the placental site, it will remain larger than the posterior Avail,
and so throw the fundus  backwards.  When  it occurs, the free return
of blood from the body of the  uterus is  impeded  by the flexion  at the
neck ;  the involution  of the fundus and body is arrested, these parts
become congested and relaxed, the body is found bulky, and the pressure
upon the pelvic organs no doubt also favours  local hyperaemia.
   The diagnosis is made out by the finger  in the Aragina feeling the
rounded mass of the fundus of the uterus behind the os uteri, bulging
doAviiAvards and forwards the  posterior  and  upper part of  the vagina;
by the finger in the rectum, which determines the rounded mass of the
fundus even more accurately;  by the finger in the vagina passing up in
front of the  os uteri  to meet the hand pressed down from above the
symphysis, revealing the  absence of the uterus between them ;  and still
more absolutely, by the  uterine sound, the  point  of which must be
turned back to enter the  body  of the uterus.
   The treatment is, first, to restore the uterus.   This may be done by
the pressure of the finger in the vagina or rectum beloAv on the fundus.
It may be maintained in  position by an air pessary placed in the fundus-
of  the vagina, or better still, by a  large Hodge's pessary.
   If  bleeding  continue  after  restoration, the interior of the  uterus
should  be injected with hot water, then swabbed Avith perchloride  of
iron.  The constringing effect of this application, by lessening the bulk
of the fundus, tends still further to correct the retroflexion.  At a later
stage, the insertion of a  five-grain stick  of sulphate of zinc inside the
uterus every fourth day will help to bring about a healthy condition.
   10.  Perimetritis fixing  the Uterus.—When  this condition  arises,
involution is  impeded ;  the  uterus is liable to  engorgement, the cir-
culation being difficult; and  as there is commonly  some shedding of
epithelium from the   cervical cavity and os externum, bleedings  are
frequent.  Best and quinine best promote absorption of effused fibrin.
The bared surface may be touched occasionally Avith nitrate of sihTer or
nitric acid, if the  bleeding is troublesome.
   B. The management  of secondary haemorrhage depending upon the 
SECONDARY HAEMORRHAGE.
475
constitutional or remote  causes must obAdously consist in aA'oiding or
lessening the influence of those causes, and in pursuing the treatment
indicated for the cure or  mitigation of the diseases disposing to uterine
haemorrhage.
   Some women are so excitable that the mere application of the child
to the breast will cause haemorrhage.  Here we haAre an example of
the  influence of breast-irritation  acting unfavourably.   The normal
influence of suckling promotes uterine contraction, and thus may be
regarded as a provision against haemorrhage.
   We  may  observe  the influence  of  ovarian  irritation in  the  not
infrequent  occurrence of haemorrhage  exactly a month  after labour.
This is more especially the case where suckling has not been instituted.
The ovaries then more readily assert their power, and, resuming active
Avork,  excite the  menstrual Aoav, Avhich  easily exceeds the normal
quantity,  assuming  the  proportions of  haemorrhage.    I  have  also
noted  several cases in Avhich hasmorrhage broke out a fortnight after
labour.
   The enumeration  of the conditions  which predispose to, or  cause,
haemorrhage (see  the Table, p. 466) will, in many cases, suggest the
indications, prophylactic or  curative, of treatment. 
LECTUBE  XXXI.
                           TRANSFUSION.

When the patient has  sunk to the  last extremity from loss of blood,
the hope  that springs  eternal  in the human  breast  under severest
trials, is still justified by the remarkable recoveries  that have folloAved
the operation of transfusion.
  This hope will  be strengthened by the reflection that the reco\'eries
—resuscitations they may fairly be called—have occurred under  the
most desperate circumstances.   The operation appears terrible to  the
bystanders; the  conditions of success are not  yet  established;  there
are practical difficulties attending it;  but  there seems no reason to
doubt that every difficulty may be  overcome, and  that we shall  not
long have to regret that the operation occupies  an equivocal position
amongst the resources  of obstetric  medicine.
  Under extreme prostration  from haemorrhage the  stomach  either
rejects nutriment, or the faculty of  absorption and  conversion is lost.
Nor can the bowel be  trusted  to.   In  this conjuncture,  assimilation
being either too  slow or altogether  at a standstill, what  remains but
to throw aliment directly  into  the  circulation?  It is the last hope.
  Tavo  great  questions  to  settle  are—first, the form in Avhich  the
renovating fluid  shall  be  prepared;  secondly, the apparatus  to be
used.  It is obviously  essential that the fluid be in a  condition to
ansAver  the great end  of rallying the powers of the  system,  that it
enter as an  harmonious constituent  into   the  body  of  the  patient.
It is also essential that the apparatus  be  simple,  and of coiiA'enieiit
manipulation.
  Three kinds of fluid have been  used for the purpose :  1st,  whole
blood, as it flows  from the veins of the giver ; 2nd, defibrinated blood ;
3rdly,  fluids  artificially prepared,  chiefly  saline  solutions to  Avhich
alcohol  may be added, or milk.
  The most animated  contest has  been raised  between the advocates
of Avhole blood on the one side, and  of defibrinated  blood on the other.
  But in truth, exclusive merit does not rest Avith  either.   Both have 
TRANSFUSION.
477
been  used with  success,  and accidental circumstances  attending a
particular case may fairly  determine Avhich is  to be  preferred.
  1. We Avill first discuss the question of whole blood.  Prima facie,
it seems most natural to conclude that pure blood Avould be the best.
Many cases are on record in which the transfusion of pure blood has
been  attended with  complete  success.  The  objection to it  is its
tendency to coagulate.  This property has often baffled the operator, by
plugging the apparatus  or the vein near the  point  of injection; and
sometimes by the  blood clotting in  the heart.  The blood of  many
animals begins to coagulate  almost immediately on  escaping from the
vein.   Human blood sometimes begins to coagulate in a minute ; and
Avithin  a feAv  minutes, four  or  five,  there is no security  against this
event.  Can  coagulation be  in  any way averted?  Ore  sIioavs that
cold,  and  preventing contact of  air,  retard  coagulation.  HeAvson
sliOAved  that  various  salts  prevent  coagulation.  Dr.  Bichardson
(Cause  of  Coagulation of  the Blood) proved that ammonia preA7ented
fibrillation, and he used  it  for this purpose in transfusion.
  We may, then, preserve the fluidity of the blood by keeping it cool,
from  contact with  the  air; or by  the addition  of various salts or
ammonia.   To obviate contact  with  air,  we must  adopt the  im-
mediate or vein-to-vein system.   This is the plan adopted  by  Ore
and Aveling.   Aveling's apparatus is simple.   It  may be described
as  a  small Higginson's syringe Avithout valves, and  armed  at each
end Avith  a silver canula to enter the vessels.   It is, in truth, a con-
tinuous tube with  a dilatation  in  the  middle.   This  dilated part
holds tAvo drachms.  It may be used to propel the blood, if floAving
sloAvly.  By pinching the tube on either side of the  expanded portion,
valves  are dispensed with.  If a  bit of glass tube be interpolated, the
operator can  see if the  blood is  flowing.   In  animals  the apparatus
answers perfectly.   It has been  doubted whether a sufficient  supply
could be  drawn by it from the human giver.  But  numerous  experi-
ments  of  Bichardson and  Ore answer this  objection.  Air  may be
got rid of by first pumping water through the instrument, or better
still,  a saline  solution.  But  although  avoiding  contact with air
retards coagulation, it  does not give security against  it.
   Some form of  injecting apparatus  has been most  generally  used.
The blood has been collected as  it  flows from the vein  of the giver
in  a  reservoir, generally  a funnel communicating  directly with the
pipe of the syringe, so that the blood is propelled partly by gravitation.
An excellent instrument  of this kind  is Mr. Higginson's,  who by  it
saved ten lives out of fifteen, using whole blood (see Liverpool Med.-
Chir.  Journ., 1857,  and Obst.  Journ.,  1873).   In  this apparatus
there is no piston ;  gravitation is aided by squeezing the barrel, which
is  made  of  vulcanized  india-rubber.   The apparatus  of Dr.  Little,
figured and described in  the London Hospital  Reports,  1866, has 
478
OBSTETRIC OPERATIONS.
 answered in practice.  Dr.  Bichardson,  avIio prefers  mediate trans-
 fusion, uses a glass syringe, holding about eight ounces, to  which is
 attached an  elastic delivery-tube.  The  syringe has a piston Avith a
jointed rod.  Where the rod is united to  the piston, this is perforated,
 so that on pulling up the rod fluid will run through, getting below.
 On pushing  the rod down, this  opening is  closed, and the fluid is
 propelled.  A little water  is first put in the  syringe.   The blood is
 received  direct from  the giver into the  syringe, the jointed rod and
 perforated  piston  admitting of this without any difficulty.   Coagu-
 lation is prevented by adding about  three drops  of ammonia to every
 ounce of blood.   This enables  the  operator  to  proceed  leisurely and
 without fear of  obstruction.
  2. Defibrinated blood  is by  some preferred, on the grounds  that it
 obviates  the inconveniences and danger of  coagulation;  that the
fibrin is  really useless as a  renovating ingredient; and that the use
of defibrinated blood renders it unnecessary to bring the giver into the
 sick-room.   All the preparations can be made  in an adjoining room.
  The fluid thus prepared may be poured into Little's or McDonnell's
apparatus, or pumped directly from the basin by Aveling's syringe.   If
human blood cannot be procured, a lamb may  be  used.  This has been
successfully done (see Hasse, Allg. Wiener Med.  Zeitung, 1873).   To
supply an  answer to  a vulgar  dread that with  the blood of animals
some noxious vital principle may be imparted,  it ought to  be enough  to
remember that man lives upon the  flesh and blood  of animals ; and
that it cannot  matter whether lamb's blood be taken first  into the
stomach  or directly into the  veins.   Moreover, F.  Galton put the
doctrine of pangenesis to the  test by breeding from rabbits of a pure
variety,  into  whose circulation blood  taken from other  varieties had
previously been largely injected.  The results  were absolutely opposed
to the idea of pangenesis; for  the animals continued to maintain  in
their offspring the purity of the breed.  Blood is mere nutriment. It is
not the  seat  of the original  developmental or formative  force.
  When respiration is going on, the  natural suction-power is consider-
able.  It is a moving  force in the circulation; and for the time being
the fluid  supplied and the vessel Avhich connects it with  the patient's
vein form part  of the circulation.  A priori,  it is desirable to  let the
operation proceed as far as possible on this principle.   In  the course of
one of Mr. Wagstaffe's cases, it Avas observed that " during inspiration
the flow Avas rapid; Avhen she  Avas crying out, there Avas some regur-
gitation of fluid."  Mr. Wagstaffe used milk  as the  renovating fluid.
  An  apparatus, the value  of Avhich in transfusing  defibrinated blood
has been proved by successful experience, is that of Dr. McDonnell
(Trans,  of Dubl.  Obst.  Soc,  1871).   It consists of  a  strong glass
pipette,  capable  of  holding  about seven  ounces, to the  loAver  end  of
which is attached an elastic  tube, and to the end  of this the nozzle for 
                          TRANSFUSION.                      479

insertion into the patient's vein.  It acts primarily by gravitation ; but,
this  being insufficient, propulsion is gained by strongly  bloAving into
the pipette.  The apparatus is extremely simple ;  but I would suggest
that  it might be improved by being made double  the  size.   It would
thus gain  in hydraulic pressure.
  3.  Saline Fluids.—But it  will not rarely  happen that  to procure
blood is  impossible, or entails too much loss of time.  In such cases
I Avould  strenuously urge the expediency of giving the sinking woman
the chance of recovery promised by  saline alcoholic injections or milk.
If such injections will restore a patient  dying from a disease such as
cholera, which to extreme draining of the circulating fluid adds a dire
poisonous influence, it may fairly be expected that they will act not  less
effectually where there is nothing but the loss of blood to contend with.
Dr. Hodder, of Toronto (Practitioner, 1873), in tAvo patients moribund
from cholera injected fourteen and twenty-eight ounces  of pure milk.
Both recovered.
   An  argument  in favour of saline  fluids lies in the  fact that  the
drained  circulatory system labours  not alone  under the loss of the
vivifying  element,  but also under the purely mechanical difficulty of
vacuity.   The heart and arteries have nothing to contract upon.   Noav
the  simple injection of  ten or twelve  ounces  of fluid restores, to a
certain extent, the dynamic  condition  of  the  circulation.  And it is
proved by Little's experience that  saline solution is well  tolerated.
The case of Dr. Henderson cited (see p.  483)  shows the value of saline
injection, and also  the importance of supplementing it by the addition
of defibrinated blood.  Probably  further observations  will prove that
the  best  fluid is  a mixture of saline solution  and defibrinated blood.
I have referred to the  dynamic relations of venous injections in con-
nection Avith the history of a case in which I resorted  to the  mixed
saline and blood (Lancet, 1874).
   The method of saline injections has the incontestable  advantages of
being always available at short notice ;  of avoiding risk of failure from
coagulation ; of enabling us to use simple forms of apparatus; and of
being  a  more  simple proceeding.
   If, then, it be determined to employ saline injections,  we have first
to prepare the fluid.  This may be either Mr. Little's fluid, adding tAvo
drachms of pure alcohol to the pint, or a similar solution, omitting the
chloride of potassium.   Three or four  pints  of this may be prepared
in a basin,  and kept at a temperature of 98° to 100°.   Mr. Little's
solution is composed of—
       Chloride of sodium  .                   -60 grains.
       Chloride of potassium
       Phosphate of  soda
       Carbonate of soda
       Distilled Avater .
	6	>»
	. o	>)
	. 20	))
	. 20	ounces
 
480
OBSTETRIC OPERATIONS.
 If these ingredients  cannot be  procured,  a suitable  saline may be
 improvised  by dissolving a  teaspoonful of  common salt and half the
 quantity of carbonate of soda in  a pint of Avater, at the temperature of
 98° to 100° Fahr., or a solution  of phosphate of soda  alone, or water
 with  a feAv  drops  of ammonia  in it.   The  solution should be of about
 equal  specific gravity  to that of blood.   It should be filtered.
   The  apparatus may be Mr. Little's, figured in the London Hospital
 Reports, 1866.
   With this apparatus, the whole  operation can be performed  by one
 person.  The vessel holds forty ounces ; a lamp  underneath  and a
 thermometer in it regulate the temperature ;  from the tap near the
 bottom proceeds a thick india-rubber tube four feet long, AArith a silver
 nozzle at the end.  When this  instrument Avas placed at the bedside,
 about on a level with the patient's head, and the nozzle inserted into a
 A'ein at the  bend of the elbow, its contents flowed into the vein in
 about ten minutes.   The instrument might  be made to contain  eighty
 ounces.  In Mr. Little's more successful  cases, eighty ounces Avere
 introduced at a time, generally  in betAveen tAventy minutes and half an
 hour.   These were cases of  cholera.
   Such an apparatus cannot  conveniently enter  into the obstetric  bag,
 but it might  very well  be  a part of the armamentarium of lying-in
 hospitals.
   But a small Higginson's syringe armed Avith an appropriate nozzle,
 as used by  Dr. Woodman and Mr. Heckford,  should be carried for
 emergencies of this kind; or Aveling's little instrument might serve for
 the saline injections as well as for immediate transfusion.
   Dr.  Woodman informed me that he examined the blood-globules in
 a  patient who  had undergone  saline  injection;  he found them quite
 unaltered.   Pure water,  we know, Avill affect the globules.
   Whichever the  method preferred,  it is  well  to obviate  the fatal
 tendency arising from  the rapid cooling of the body, by keeping warm
 bottles to the feet and  chest; and to raise the body above the level of
 the head, as advised by Nelaton in cases  of  asphyxia from chloroform.
   The  Operation.—The  instruments  required in addition to the in-
jecting apparatus  are—1.  An  ordinary bleeding-lancet, or what  is
 better,  a fine-pointed  small  knife  mounted on  a handle.   2.  A pair
 of dissecting-forceps.   3.  A  silver probe.
   Failing a  special apparatus ad hoc, you need  not therefore abandon
 the operation.   Almost any injecting apparatus  may be  made to
 ansAver.  Thus I have found an aspirator-syringe, adapted to work
 as a stomach-pump, do perfectly.  One of the  aspirator-trocars  was
made  to do duty  for a canula  by filing off the sharp point  before
inserting it  into the vein.
  The proceedings will, of course, be modified by the method selected.
If Ave  determine on the use  of defibrinated blood  or  saline solution, 
TRANSFUSION.
481
two distinct  operations have to be  performed.   First,  there  is the
renovating fluid to prepare; secondly, there is the injection itself  to
be done.
  Let  us first  prepare the  fluid and the apparatus.  This should  be
done in an adjoining room.   The best subject we can get to give the
blood is bled in the ordinary way, about ten or tAvelve ounces of blood
being received in a clean basin.   This is whipped with a silver fork  or
a glass rod to separate the fibrin.  It is then  filtered through muslin,
to free it from small coagula and air-bubbles.  To the filtrate may  be
added  an equal quantity of  Little's saline solution ; and  this addition
is especially  important when the quantity of blood  at our  disposal is
small.  The apparatus is then  charged with  the fluid, and worked  so
that we are sure there is no hitch or defect, and that air  is expelled
from it.   The fluid is kept at about 98° Fahr.
   We  then prepare for the injection.   Expose a vein at the bend of the
patient's elbow.  To do this, pinch up a fold of skin ;  transfix it trans-
versely to the course of the vein ;  and, if  necessary,  dissect down
gently to the vein,  so as fairly to  bare it for a quarter of an inch.
Seize the vein with forceps; open it by a longitudinal  slit.  It  may
be useful to pass a fine  probe under  it  to secure  it.
   Noav,  having first allowed some  of the  renovating  fluid  to  flow
through the tube and  canula, insert  the  canula  in  the vein, directing
its point towards the heart.
   The fluid may now be allowed to flow into  the patient's system.
This   should  be done very gently and  slowly.   If McDonnell's  or
Wagstaffe's apparatus be used, the natural suction-force, aided perhaps
by a moderate and regulated gra\Titation-force, Avill  carry the fluid on.
If a syringe, as Higginson's, Aveling's, or Bichardson's, be used, more
especially  the two  latter, a little propelling  force may be  required.
And  here great delicacy  is essential.  Propulsion by squeezing the
barrel, or by driving a piston,  is inferior in smoothness to the  force
of  gravitation.   Sudden jerks or  too rapid propulsion  are  to  be
avoided.
   Watch the effect upon  the patient.   When ten or  twelve ounces of
fluid have been taken in, the operation is usually completed.
   The canula  is then removed, whilst  you compress  the wounded
vein with your thumb.   Over the spot, apply a small compress of lint
or rags, and bind  up the arm secundum artem, that is, according to  an
almost lost  art, which many of you  may never  have seen, and may
never see.   A  broad  piece  of  tape is placed by its  middle over  the
compress, the tAvo  heads are carried, one above the elbow-joint,  the
other  below; they are then  brought forward in the opposite direction,
so as to form a figure of 8 round the elbow; they are then crossed just
over the compress, and tied.
   If we determine  on direct or vein-to-vein transfusion, you still first
                                                             u 
482
OBSTETRIC OPERATIONS.
 get your apparatus  in  order.  Aveling's apparatus is the most  con-
 venient for the purpose.  It should be charged with saline fluid, and
 so Avorked as to expel all  air.   Next prepare the patient.   Expose
 and open a vein  as  already described.   Commonly a little thin serous
 blood escapes.  Let an assistant compress the vein with  his thumb
 whilst you open  the vein of the giver.  Into this insert  the canula
 in the distal direction, that is, towards the giver's hand.  Keeping it in
 situ, insert the other canula in the patient's vein, directing its point
 towards the heart.   All being arranged, the blood may be allowed to
 flow.   Sometimes the natural suction-force of the patient, aided by the
 natural driving-force of the  giver's heart, will give movement enough.
 But if the current flags, movement is imparted by squeezing the barrel
 or ball of the instrument.   To send the blood in, you  close the tube
 by compressing it Avith  finger and thumb  between  the barrel  and
 the giver; then, squeezing the barrel, the contents must go on into
 the patient's  vein.   This  done, to replenish the barrel, you let go the
 giver's side of the  tube  and close  the patient's side;  the barrel
 expanding, draAvs  in  blood from the giver.  Thus charged  again,  you
 repeat  the  proceeding  described  as often as  necessary.   The barrel
 holds about tAvo drachms,  so that the charges being  counted, you know
 very nearly the quantity  injected.
   Before connecting the veins of giver and receiver,  I think it better to
 inject two or three ounces  of the saline fluid.
   In this mode of proceeding Ave have in the saline fluid an  additional
 security against  fibrillation ;  at  the same  time,  additional security
 against the entry of air ;  and, further,  what is almost certainly  an
 advantage, a  quantity of  saline fluid  injected as  well as  blood.   A
 reservoir containing  saline fluid might be so adapted to the tube as to
 give a further supply to mix with the blood as desired; or we might
 throw into the barrel or expanded portion of the tube a drop or two of
 ammonia by  means  of the hair-trocar or  a  subcutaneous injecting
 syringe, from time to time,  so as to ensure liquidity  of the blood.
   Whole blood may also be transfused by Higginson's  apparatus.   In
 using this also, it would, I  think, be advisable  to secure against coagu-
 lation by putting some saline or a little ammonia in the apparatus.
   A very small quantity  of blood  will  sometimes suffice.  Patients
 have rallied and recovered  in a marked manner after the injection of
 six or  eight ounces- of blood, whole or defibrinated.
   The Indications  for the Operation.—The quantity of blood lost is no
 criterion.   We must look to  the state of the system.   Absence of
 pulse, sinking of the features, gasping for air, jactitation, unwillingness
 to be disturbed, arrest of absorption, are signs of threatening dissolu-
 tion.   It should be our endeavour to act before these are far advanced.
We shall  come, by-and-by, I  have little doubt, to  regard transfusion
and venous  injection as much less formidable operations than they 
TRANSFUSION.
483
now seem ; we shall then take courage to act earlier, before the case is
desperate, and the results will be proportionately better.
  As to Re-injection.—If the patient flag again, showing symptoms of
sinking, the operation should be repeated.
  Transfusion has been performed before delivery in cases of placenta
prasvia, Avhere the patient  Avas  too  prostrated to be able to survive
delivery unless  previously rallied.   Many  patients perish under  the
attempt to deliver them Avhen  in a  state of extreme  depression.  If
rallied first,  they may bear artificial delivery,  and recoA'er.
  In cases of hasmorrhage  during and after labour, it has been appre-
hended that  the new blood transferred might again  escape on  the
uterine surface.  This source of failure may be overcome  by the local
application of perchloride  of iron.   The two methods of arrest by
styptics, and of replenishing by transfusion, should be  thoughtfully
studied together.   In most  cases the timely use of the styptic will
render resort to transfusion unnecessary.  But in some AATe should be
prepared to folloAV up the  styptic by transfusion.
  This suggestion has  been successfully carried out  since  the pub-
lication of  the  second edition  of this  work, by my friends, Drs.
Henderson, Johnston, and Little, of Shanghai.   The  case is one of
the most interesting in the records of obstetric medicine.  It  is related
in detail in the Lancet (1874).  Mrs.  A. had had five  children.  She
Avas very  anaemic from protracted lactation and  long residence in the
East.   The labour being sIoav,  Dr. H. ruptured the membranes, gave
ergot, and  the  nurse followed  the  fundus uteri down  during  the
expulsion of  the child.  The placenta not  being cast, the patient Avas
put  upon her back, when the first flooding  took place.   Dr. H. had to
detach the placenta, which  he  found closely adherent to the fundus.
The womb Avas  then felt to  contract,  but it soon  relaxed, and flooding
recurred.   The situation was  " sufficiently  alarming."   Ergot Avas
again  giATen.    The  uterus  continued to  contract  feebly and relax
alternately.   After a hurried consultation it was  decided, in the first
instance,  to  try the effect  of external and internal cold.  The long
elastic mount  of Higginson's  syringe was passed fairly to the fundus,
and iced Avater  Avas freely injected into the cavity.  On  withdrawing-
the syringe, a piece of ice was placed in the uterus, and  other  pieces
in the vagina.   By these means, and by compression, the bleeding Avas
at  last arrested,  the uterus contracting fairly.   She  was then left,
Drs. H. and  J. " congratulating  themselves  on the successful issue of
the  treatment by cold.   But the bleeding  returned.   The uterus Avas
found full of  blood,  and oozing was  going on.   The  patient Avas
blanched ; her surface and extremities cold; the breathing sighing and
interrupted;   the pulse feeble and intermitting."  After  immediately
emptying the uterus, twelve ounces of  the  iron-solution,  prepared
according to Dr. Barnes's directions, was injected.  As "he  withdrew
                                                          n  2 
484
OBSTETRIC OPERATIONS.
the pipes the uterus contracted,  and the hamorrhage ceased, never
again to recur.  So far reason for satisfaction; but Mrs. A.'s appearance
was ghastly in the extreme,  and I feared that Dr. Barnes's powerful
remedy had been used too late  to save life."  It Avas then decided to
resort to transfusion.  Mr. Little assisted.  The operation was delayed
for some time, as she appeared to  rally a little under the use of  some
soup prepared  out of raAv meat  and  hydrochloric  acid.   But she
became Avorse, and " appeared to  be sinking rapidly."  Little's fluid
was accordingly used.  " The change in the patient's condition which
followed  the operation was no less rapid than wonderful; the marked
improvement in breathing, pulse, and general appearance, leading us to
form a much more favourable opinion as to the ultimate result.  This was
at 4 p.m.  At 6 p.m. her condition was, if possible, worse than before.
TAvelve ounces of blood Avere  taken from the husband, defibrinated and
strained.  The apparatus  (Little's) being adjusted, some  saline fluid
was first injected, then some of the defibrinated blood was added to the
saline  fluid when it was  ascertained  that the  first fluid  was  satis-
factorily  entering the circulation."   The result  of this last transfusion
Avas favourable beyond the most sanguine anticipations.  " The  pulse
once more filled and steadied; the breathing became full and regular;
and by slow degrees warmth returned to the  extremities."   She made
a perfect recovery.
   One of Dr. Bingland's  cases  is scarcely less interesting as  illus-
trating the propositions I  have so  much insisted upon, that, although
styptic injection  may stop haemorrhage,  death may follow from the
loss sustained; and that the  hope of rescue lies  in transfusion.   The
subject,  in her tAvo previous labours, had  flooded; " her life  had,
moreover,  been  on  tAATo  occasions placed in  imminent jeopardy by
hasmorrhage  connected  with miscarriage."
   In  her third  labour, Avhich  Avas under  Dr. Bingland's  care, the
secundines were expelled  entire Avithin ten minutes after the birth of
the child.  In consequence of her hasmorrhagic diathesis, Dr. B. gave
two doses of  ergot, and retained a grasp of the uterus for an unusually
long time.  This pressure was continued even after the pad and binder
Avere applied.  After some time, notwithstanding, severe haemorrhage
set in.  The uterus responded to the grasp of the cold  hand, but
almost  immediately  relaxed, and  the haemorrhage  returned  with
renewed  violence.  Brandy  and  ergot  were given Avith   temporary
benefit.   Injection of cold water into the uterus, and the introduction
of the hand  in its cavity, Avere had recourse to, but  with no  better
result, contraction following  the application, but relaxation instantly
succeeding.  Dr. George Johnston assenting, a solution of perchloride
of iron was injected into  the uterus.  Subsequent to its employment,
not  one  drop  of blood was lost.  She  had  brandy,  cold beef-tea,
ammonia; but still the  pulse indicated excessive prostration,  being 
ADDENDUM  TO  PAGE   483.
  In  cases of  great  exhaustion, the  first  indication  before proceeding  to the
injection of perchloride of iron, or to transfusion, whilst waiting for  the  necessary
preparations,  is to rally the  patient.    This is best done by  the  subcutaneous
injection of a drachm  of ether.  The effect is  often  striking.  Power is regained,
and the patient is thereby enabled to bear the operations for arresting haemorrhage
and  restoring  blood.    The  injection  may be repeated  several  times at  short
intervals if necessary. 
 
TRANSFUSION.
485
easily quite extinguished.   She became very restless, sighed frequently,
and  respiration became very laboured.  It Avas  felt that  transfusion
Avas  the only  hope.   Dr. McDonnell came.  During the necessary
preparations  the patient's  state  became   materially worse.   About
tAvelve ounces  of defibrinated blood was injected.  Marked improA'e-
ment was  immediately  manifest.  She made  a  perfect  recovery.
Dr.  B.  gave an anodyne  soon after.   This lady  having come to
reside in London, was by Dr. Bingland recommended to  my care in
her next labour.  Impressed by her history, the utmost  pains were
taken before  and throughout her labour to counteract her tendency to
haemorrhage.   She had ergot.  Aided by the same nurse whom she
had  brought  from Ireland—and a more  efficient  assistant I never had
—the uterus was kept under constant  control.   The  placenta  was
expeUed, not taken away.   The uterus contracted.   It  was  firmly
compressed by  pad and binder; and Ave thought she  would this time
escape all serious loss.  But the  old diathesis  asserted itself.   The
uterus relaxed; rather free  haemorrhage occurred.   I felt it Avas not a
case to  dally Avith.   Dr.  Bingland's experience proved that although
one might obtain contraction, it would only be temporary.  I therefore
at once injected about  eight  ounces of a solution of iron.  This stopped
the  haemorrhage.   There Avas no  return.   The puerperal state  Avas
perfectly physiological.
  These cases  of Dr. Henderson  and  Dr. Bingland form the  best
possible  commentary  upon  the principles  advocated in  this  work.
Had they not proceeded  to transfusion,  the women would in all  pro-
bability have perished, and it might  have  been concluded that the
iron-styptic which stopped the bleeding  had been the cause of  death.
  I would further urge the expediency of extending the application of
transfusion of  blood, or of  the injection of saline fluid, to other  con-
ditions  of  great emergency as well  as to hcemorrhage.    In three
conditions  the  indication  is especially  strong.  I mean puerperal
convulsions,  extreme  prostration  from  uncontrollable  vomiting in
pregnancy, and puerperal fever.   In convulsions  with albuminuria
the  blood is undoubtedly poisoned ; most  men  of experience in  this
disease  still  recognize that  venesection is beneficial;  that the benefit
thus derived  is  partly due to the abstraction of a portion of the poison,
it seems reasonable to believe ; and there seems to be ground  for hope
that the injection  of healthy blood or saline fluids, to replace the
poisoned blood  abstracted, may be useful in diluting the poison  still
circulating and in rallying the  system from  the prostration  that
threatens to  be  fatal.   I  believe one successful case  of this  kind has
been published.
  With regard  to the application in cases of extreme  exhaustion from
obstinate  Aromiting, I  have  even  less hesitation.  Here there  is un-
doubtedly not  only a high degree of anaemia,  but  the little blood
< 
486
OBSTETRIC OPERATIONS.
circulating is degraded by admixture with the  products  of diseased
action.   The source of nutrition is stopped up ; there is no other door
open for the admission of fresh supplies than through the veins.
  Dr. Tyler Smith narrated * the case of a woman  seemingly dying of
puerperal fever, in which he  injected a  solution of one part of liquor
ammonias to three of water, to the  extent of half a drachm, into one
of the veins of the forearm.  Becovery ensued.  Here, as in other cases
where  strong ammonia has been injected, considerable inflammation
arose at the  point  of injection.  The practice here Avas  suggested by
that of  Dr. Halford, of Melbourne, who injects ammonia as a  remedy
in snake-bites.   I am much inclined  to think that the injection of a
saline fluid, after the formula  of Dr. Little,  to the  extent  of six or
eight ounces, AviU be found more practicable and  useful.
  After-treatment.—When transfusion has been performed, great care
is still required to economize and to increase the  little  store  of heat
and strength  the system may retain.  Take care that warm dry linen
surround the patient's body; apply hot bottles to the feet, legs, and
sides of the body ; when opportunity offers, throw an enema of half a
pint of  warm gruel  or beef-tea,  containing an ounce or two of brandy
and twenty minims  of laudanum, into the rectum.  When  the woman
can swallow,  give small quantities of hot brandy-and-water.
  To encourage resort  to transfusion,  even  in extreme collapse, the
experiments of  Brown-Sequard may  be cited.   He  made the foUowing
observations  on decapitated  criminals.   Decapitation took place  at
8 a.m.   Eleven hours later all trace of irritability had disappeared.
Injection was then made of blood draAvn from the veins of the subject
into the radial artery.  It went in vermilion, and returned  dark as in
life.   In ten minutes irritability had  returned;   movements in the
muscles could be excited.
  Is it not strange that in these days, Avhen blood is looked upon as so
precious, when  venesection is almost gone out of use, when the dread
of losing a pint  of blood  by an operation is  too often an  obstacle  to
relief, that restoring this vital fluid  to a patient dying for the want  of
it should be still struggling for  a settled place in obstetric medicine ?
  I think it ought to be an accepted  aphorism in medicine,  that no one
should be permitted to die of hatmorrhage.  It may be long before this
aphorism will be realized in practice.  But we should  never rest until
the  means of preventing  dangerous losses of blood, and of restoring
those who are  in  danger  from such  losses,  shall  be  brought  to
perfection.
                 * " Obstetrical Transactions," 1870.
* 
INDEX  OF   SUBJECTS.
Abdomen, pendulous, 74
Abortion, causes of, 389
      inversion after, 314
      treatment of, 395
Abscess,  retro-uterine, 225
"Accidental" haemorrhage, 422
"Accouchement force " in placenta praevia,
  400
Air, death from injection of, 370
Albuminuria in pregnancy, 86
      in retroversion, 217
      cause of abortion, 389
      cause of hemorrhage, 431
Ambidexterity, value of, 162
Amnion  (see Liquor amnii)
Amyl, nitrite of,  12, 81, 270
" Amyosthemics," 271
Anaemia, acute, 464
Anaesthesia in obstetrics, 159
Antimony,  use of potassic tartrate, 80
Anus, protrusion in retroversion, 222
Aorta,  compression  of, in  haemorrhage,
   449
Apoplexy and pregnancy, 352
Arm, dorsal displacement of, 152
       liberation of, 174
Armamentarium obstetricium,  11
Arms, amputation of, 343
Asphyxia, hoAV long may the child survive
   temporary ?  56
       of new-born child, 130,  385
       paralytic,  130
       simple,  130
       attempt to breathe in utero, 131
       treatment of, 133
       reflex excitation,  133
       artificial respiration, 134
       from congestion of brain, 137
 Aspirator-trocar, 22, 248
 Auscultation, uses of, 129, 203

 Bag, the obstetric, 11, 12
 Basilyst, 15              . '
 Baths, warm, in rigid cervix, 80
 Belladonna in rigidity of cervix, 9, 80
 Bellows for artificial respiration, 136
 Binder,  uses of, in twin labours, 148
      in abortion, 397
      in haemorrhage, 433, 450
Bi-polar version (see Turning)
Bi-section of child, 190
Bladder,  in labour—
      displacement of, 218, 223
      puncture of, 229
      prolapsus of, 234
      rupture of, 219
Bleeding (see Hiemorrhage)
      in rigid cervix, 80
Blood (see Clots, Coagulation)
      transfusion of,  476
Blood-mass in utero, 305
      polypus, 393
Blunt hook for decapitation, 16
Bougie in uterus to induce labour, 373
Breech-labours, 138
      two kinds  of difficult, 141
      fcetus forms a wedge in, 140
      management of difficult, 142
      forceps in, 142
Brow-presentations, 63

Caesarian section, 342
      by necessity or election, 346
      compared with craniotomy, 347
      indications for, 350
      post-mortem, 351
      time for operation,  353
      instruments, 355
      the operation, 355
      suture of uterus, 357
       Porro's method, 361
      plus removal of ovariis, 362
      dangers of operation, 358
Calabar  bean (see Physostigma)
Cancer of uterus and pregnancy, 241, 350
       a cause of rupture,  277
Caput succedaneum, 48
Carbonic acid,  dangers  of injection  of,
   372
Catheter, a male flexible,  best, 11
       in retroversion, 218
       haemorrhage, 446
Cellulitis, pelvic, 220
 Cephalic version  (see Version) 
SUBJECTS.
 488                     INDEX  OF

 Cephalotribe, varieties of, 16, 336
       m detruncated head, 196
       powers of, 336
       mode of using, 336
 " Cephalotripsie repetee," 339
       by laparo-elytrotomy, 362
 Cephalotripsy, 335
       limits of, 337
       the operation, 337
 Cervix uteri, diseases of, causing dystocia, 77
       the forces that dilate it, 78
       author's hydrostatic dilators, 82
       rigidity of,  9, 78
       incision in, 83
       hypertrophy, 234
       annular laceration of, 282
       dilatation of, 76,  374, 418
       lesion of, 403, 469
 Child (see Foetus)
 Chloral hydrate, 12, 80,  271
 Chloroform, its use in obstetrics, 80
 Chorea in pregnancy, 383
 Cicatrices, atresia  from, treatment of, 78
 " Circle " movement in labour, 21
 Clots of blood in utero after delivery, 469
 Coagulation of blood in transfusion, 477
 Cold in haemorrhage, 447
 Collapsus, post-partum, or syncope, 450
 Colpeurynter, Braun's, 374
 Compressibility of head, experiments on,
  25
 Compression of head, where least injurious,
  204
 Compression of uterus, 8, 450
       of aorta, 449
 Condylomata cause dystocia, 245
 Conservative midwifery,  364
 Consultations, on, 321, 385
 Convulsions in pregnancy, 86, 382
       in haemorrhage, 444
 Cord, umbilical (see Funis)
 Cranioclast, 15
 Craniotomy, 326
       indications  for, 327
       three orders of cases,  329
       dangers attending, 343
       delivery by turning after, 332
       by craniotomy-forceps,  332
       in face-presentations, 67
       dystocia from tumours, 251
 Craniotomy-forceps, description and essen-
  tials of, 15
       use of, 196, 332
       after bi-section, 196
 Crotchet, best form of, 15
       use of, 331
 Crutches, use in turning, 188
 Curve of false promontory,  70
 Curves,  the  three,  Barnes', Carus', Ave-
  ling's,  19, 20
       parturient curve, 20

Decapitation, instruments for, 16,  190
Decollation (see Decapitation), 191
Depressio uteri, 313
Desquamation of child's skin, significance
  of,  203
Diaphragm in labour, 5
Dilatation  (see  Cervix,   Hydrostatic,
  Vaginal, etc.)
Dilators, cervical, 17, 82, 374
       the author's, 11, 82, 375
Disinfectants, 253
Disproportion, forceps in, 69
       degrees of, 69
Dorsal displacement of arm, 153
Douche,  intra-uterine and vaginal, 369
       sometimes fatal, 369
       abdominal, 448
Dynamometric forceps (Dr. Kristeller's), 8
Dystocia, definition of, 1, 2 (see Labour)

Ecraseur (wire), use of, in embryotomy, 16,
       192
Embryotomy, author's mode, 340
       scissors, 16
Emetics in rigid cervix, 80
Emotion, cause  of contraction of uterus,
  423
"Epechontocics," 81, 270
Ergot, 81
       in haemorrhage, 446
Ergotine, 447
Ergotism, 81
Ether to allay spasm, 80
Eutocia,  definition of, 1, 2
Evisceration in impaction of fetus, 190
Evolution, spontaneous, 98
       definition of, 98
       mechanism of,  104
       imitation of, 158,  190
" Expression," 8
       of placenta, 433
Extraction of child after version, 169, 176
       in "jammed"  head, etc., 177
       of head detached in utero, 195
       after craniotomy, 331
       in placenta praevia, 418
Extra-uterine gestation, 244, 252
       diagnosis from retroversion, 223
       rupture of, 402

Face-presentations, Iioav produced, 64
       management of, 66
       long forceps in, 67
       version preferable sometimes, 67
Face,  mento-posterior position of, 68
Factors in labour, 2
Fallopian tubes, dilatation of, and  per-
  meability to injections, 453
       gestation in, 402
Fever, haemorrhagic, 464
Fibroid tumours (see Tumours)
Fillet, use of, 31
First labours, when to interfere in, 52
Fistula,  vesico-vaginal, 344
Fcetus, survival after detachment of pla-
  centa or mother's death, 56,  351 
INDEX  OF SUBJECTS.
489
Fcetus, position of, 88
      A'olition in, 88
      instinctive power of, 88
      reflex muscular power of,  88
      cause of normal position of, 88
      properties of dead, 89
      ductility, 89
      fragility, 89
      death of, cause of malposition, 89
                         dystocia, 89
      reason for inducing labour, 382
      changes its position frequently, 91
      causes of malposition,  91
           deformity of pelvis, 92
           Ioav attachment of placenta, 92
           external forces, 92
           want of tone in uterus, 92
           excess  of liquor amnii,  93
           irregular  contractions  of ute-
             rus, 93
      Iioav Nature  deals  with  unfavour-
         able  positions of, 94
      tumours of coccyx, 305
      signs of death of, 203
      mortality after Caesarian section, 348
      in placenta praevia, 414
      viability of, 377
Foot, how to seize, in turning, 144,  184
Force  required for  natural  labour,  esti-
  mates of, 8
       traction by forceps, 23
       expulsion  of  abdominal  muscles,
         299,  303
Forced delivery, 400
Forceps, description of, 12
      powers of, 22, 37
       three types of,  13
       short, 22
      v. Craniotomy, 27
      how it holds, 23
       Assalini's, 24
       French, 24
       Lazarewitch's,  24
       Simpson's, 24
       tractile, 23
       how blades are held in  apposition,
         23
       compressive power,  24, 37
       leverage, 37
       traction, 37
       dynamometric,  8
       rules for traction, 27
       oscillation  or lever action, 27, 31
       cases suited for, 52
       it is a lever, 22
       "short,"  application of,  35
       "long or double-curved," 40
       application, position of patient in,
         41
       which  blade to apply first, 42
       is it necessary to feel the ears ?  38
       the long should be applied in rela-
         tion to pelvis, 40
       mode of using, 41
Forceps, locking of, a presumption of tlieir
        suitability, 45
      extraction by, 47
      how advance of head is measured, 4S
      removal of blades, 49
      how long should they be tried ? 50
      applied   to  the   "after-coming"
        head,  58
      in occipito-posterior positions, 61
      in disproportion, 69
      limits of usefulness,  70
      in pendulous belly, 73
      not adapted to breech cases, 142
      in detached head, 196
Forceps-saw, 340
Friction, force  of, in obstetrics, 63
Fronto-anterior, forehead and face present-
  ation, 61, 65
Funis, instruments for replacing prolapsed,
  11, 127
      prolapse of, 125
      postural or "knee-elbow" method
         in prolapse of, 128
      round child's neck, 129
      how  to protect it  in  extraction, 171
      when to tie, 132
      may be  tied before birth, 129
      compression of, 171
       mistaken for intestine,  307
      injection of cold water into,  435


Gangrene after rupture,  297
Galvanism induces uterine action, 132
Gastrotomy, 356
      in  rupture of uterus, 302
Genesial cycle, the, 366
Gestation, term of,  377
       pelvic, 214
       extra-uterine, 223, 225

Haematocele, retro-uterine, cause of dys-
  tocia, 223, 245, 287
Haemorrhage, varieties of, 387
       of abortion,  387
       rupture of uterus, 287
       laceration of cervix, 469
       in Caesarian section, 359
       "unavoidable," 399
       "accidental,"  422
       "concealed," 424
       natural powers in controlling, 441
       placenta retained, 429,  433
       peritoneal adhesions, 429
       post-partum, 428, 440
       physiological, 441
       paulo-post-partum, 441
       causes of, 431
       sources  of, 441
       atony, 443
       internal, from obliquity, 444
       tumours and polypi, 238, 444, 473
       retroflexion of uterus, 474
       perchloride of iron in, 451 
490
INDEX OF  SUBJECTS.
Haemorrhage, three stages of, 463
      treatment, restorative, 463
      ought never to be fatal, 486
      prophylaxis of, 431
      secondary puerperal, 466
Haemostatics, Nature's,  441
      artificial, 446
Hand, the master instrument in obstetric
  practice,  17
      as a  uterine dilator, 81
      by side of head, descent of the, 124
      use of left hand,  162
      which to use in version, 162
      removal  of placenta  and clots by,
         446
Head, before action of labour, 25
      "after-coming,"  labour with, 57
      moulding of, by labour, 25, 50
      dolicho-cephalic form, 63
      by forceps, 25
      compressibility of, 25, 204, 207
      locking, in twins, 149
      rarely seized by  forceps  in  longi-
         tudinal diameter, 24, 205
      delivery  of  "after-coming,"  in
         podalic presentations, 58
      delivery of detruncated, 196
      extraction of perforated, 331
" Head-turning," 119
Hook, Ramsbotham's, 16, 193
      blunt, 17
      Braun's, 16
"Hour-glass" contraction, 434
Hydatid cyst of liver, cause of dystocia, 350
Hydatidiform placenta,  391, 396
Hydrostatic dilators, the author's, 11,  82,
  418, 426
Hypodermic injection of ergotine, 447
Hysterotomy, vaginal, 83
Hymen,  a cause of dystocia, 236
Hypertrophy of cervix, dystocia, 234

Ice, uses in haemorrhage, 448
Ileus in rupture of uterus, 297
Incision  of rigid cervix uteri, 84
Induction of premature  labour, 365
Injections,  intra-uterine, 453, 461, 468
      intra-venous, 483
Instinctive power of foetus, 88
Instruments, obstetric, 11
Intestines,  protrusion of, 299, 304, 307
      diagnosis of, 305
      cutting off,  294
      mistaken for funis, 307
Introversion of uterus, 313
Inversion of uterus, 313
      acute and chronic, 312
      after abortion, 314
      post-mortem, 315
      spontaneous, 316
      gangrene from, 321
      three degrees, 313
      reduction of, 323
      terminations of, 321
Inversion of uterus, diagnosis and  treat-
  ment of chronic, 323
      caused by "expression," 433
Iodine in haemorrhage, 454
Ipecacuanha in haemorrhage, 447
Iron, perchloride and persulphate of, uses
  of, in  haemorrhage, 311, 394, 451
      in inversion, 324
      in Caesarian section, 356
      accidents attending, 453
      effect of concentrated solution, 460
      mode of using, 460
      author's instruments for, 460
      use as restorative after haemorrhage,
         464
Irrigation in rigidity of cervix, 80

Kneading uterus in haemorrhage, 445, 448
Knee, which to seize in turning, 165
      better to seize than foot in turning,
         181
Knee-elbow position in turning, 181
      in funis prolapse, 128
      to reduce retroverted uterus, 230
Kyphotic pelvis, 257

Labia vulvae, oedema of, 86
      thrombus of, 86
Labour, a problem in dynamics, 2
      three factors of, 2, 7
      force required in, 8
      propitious characters of, 4
     ■ unpropitious characters of, 5
      head-first, mechanism of, 19
      causes of arrest in, 52
       delayed by nervous disturbance, 53
           by uterine and perinaeal valves,
             54
           occipito-posterior position, 61
           fronto-pubic position, 62
       metastatic,  52
       in after-coming head, 56
       with pendulous belly,  74
Labour delayed by faulty condition of soft
  parts,  77, 81
       with shoulder-presentation, 99
       management of third stage, 430
       with descent  of hand by side  of
         head, 124
       with descent of funis,  124, 125
       with breech, 138
       with head-locking, 129
       with displacement of womb, 212
       monsters, 154
       ascites  of fcetus, 156
       retroversion of uterus,  213
       ovarian tumour, 242,  245
       extra-uterine gestation-cyst, 244
       dermoid cysts, 243
       Avith hernia, 156
       tumours, 237
       polypi, 240
       prolapsus of bladder,  245
       tumours in vagina, 245 
                             INDEX  OF

 Labour with condyloma vulvae, 245
        cancer of vagina, 245
        retro-uterine haematocele, 245
        deformed pelvis, 69, 264
        protracted, 5
        with twins, 147
        in tAvo-horned uterus,  235
        head-locking, 149
        dorsal displacement of arm, 152
        premature (see Premature labour),
         365
 Laceration (sec Uterus, Vagina)
 Laminaria-tents, 394
        author's instrument for, 394
 Lamination, 16, 340
 Laparo-elytrotomy,  362
 Left hand,  importance of  skill  in use
   of, 162
 Lever,  11
        action of, 28
 Liquor amnii best dilator  of  cervix uteri,
         79
        ponding-up of the,  54, 125
        excess of, 93, 125
       facilitates turning,  161
       turning after it has run off,  179
 Liver,  hydatid  of, necessitated  Caesarian
   section,  350
       acute atrophy of, 424
 Leucocythaemia and haemorrhage, 424
 Locked heads (sec Twins)
 Lumbo-sacral curve, 20, 71

 Malpositions, causes of, 91
 Manreuvrrs to liberate arms, 172
       of Levret and Van  Deutsch, 187
       for  delivering  head  delayed  at
         outlet,  53
 Mechanism of head-labours, 19
 " Meddlesome midwifery," 178, 433
 Medicines required in obstetric bag, 12
 Membranes,  rent in the, shows  placental
  site,  411
       force necessary to burst, 8
       detachment of, to  provoke labour,
         373
       puncture  of, 373, 416
 "Metastatic labour," 52
 Metritis from tumours, 238
 "Missed labour," 385
 Mole, fleshy, 390
       hydatid, 396
 Mollities ossium (see Osteomalacia)
 Monsters, varieties and delivery of,  154
 Museums, use of, 7
 Myoma utei i, cause of dystocia, 237

 Nrcvi,  death from injection of, 453
 Neck,   danger  of  twisting  the  child's,
  58,'66
 Nitrite  of amyl, 159, 270
 Noose   of   tape,  use  of,  in  impacted
  shoulder,  186
Nuchal hitching of arm, 153
SUBJECTS.                       491

 Obliquity of uterus, 63, 73, 91
 Obstetric operations, relation to degree of
   pelvic  deformity at  seven and nine
   months, 68
 Occipito-posterior positions, 58
 (Edema of cervix and vulva, 77, 86
 Omentum mistaken for placenta, 307
 Opium, uses in obstetrics, 9, 269
       in haemorrhage, 464
 Oscillation-movement of forceps, 31, 51
 Osteomalacia, 258
 Osteomalacic pelvis can be opened   up,
   355
 Osteotomists (Professor Davis), 195
 Ovum, extraction of, 392
 Ovum forceps and spoon, 392
 Ovarian tumours (sec Tumour)
 Ovariotomy during pregnancy, 248
 Oxytocic remedies,  8, 159

 Pains, 3
 Paralysis of facial muscles  of fcetus from
   forceps, 40
       of leg of mother from ditto, 40
 Pelvimeters, 263
 Pelvic cellulitis, 224
       version,  spontaneous, 99
 Pelvis, cardboard model of normal, 97
       compared to  a screw and rifled gun,
         41
       contraction,  degrees  of, in relation
        •to  operations, 69
       deformity causes malposition, 92
       causes of dystocia, 77
       varieties of, 77
       standard normal, 255
       rickety,  256
       kyphotic, 257
       osteomalacic, 259
       funnel-shaped, 258
       spondylolisthetic, 260
       fracture of, 262
       the " Prague," 260
       articulations, disease  of, 261
       obliquely  distorted   (Naegele's),
         261
       infantile, or  immature,  262
       thorny, 262
       outgrowths from, 262, 263
Pendulum-movement of forceps, 31
Pendulous  abdomen a  cause of dystocia,
  73
Perchloride of iron  (sec  Iron)
Perforation after turning, 200
       in craniotomy,  200, 330
       of uterus, 286
Perforators, description of, 14, 196,  330
Perimetritis cause of haemorrhage, 474
       after rupture, 297
Perinaeum, incision of the, 85
      protrusion of, in retroversion, 222
      distensibility of,  291
      rupture of, 291
      traumatic lacerations, 291 
492
INDEX OF  SUBJECTS.
Peritonitic adhesions  and  induction  of
  labour,  384
Peritonitis, 220, 224
      in Caesarian section, 359
" Perversio uteri," 313
Pessaries,  use of, 221, 231
Phlegmasia   dolens  after  haemorrhage,
  413, 462
Phthisis and pregnancy, 384
Physostigma, uses of, 81,  159
Placenta,  area  of,  amongst  intestines
  305
      adherent, leading to rupture, 293,
        393, 437
      removal of, 437
      inferior  attachment  of,  leads   to
        malposition, 92
      mistaken for viscera, 293
      Iioav to determine seat of, 411
      diseases of decidua, 423
      hydatidiform  degeneration of, 396
      retained,  430, 467
      management of third stage, 430
      squeezing  out,  or  " expression,"
        433
      encysted or incarcerated, 434
      disappearance of, 430
      how to  remove  retained  or  ad-
        herent, 437
      adhesion of, 437
      soft, 438
      succenturiata, 305,  438
      velamentosa, 439
      diffused, 439
Placenta praevia, 398
      history of doctrines of, 399
      source of blood, 403
      total detachment of placenta, 404
      author's theory, 405
      what constitutes ? 411
      identity  of Barnes'  physiological
         boundary and Bandl's ring, 410
      prognosis and dangers, 413
      treatment of, 415
      varieties of, 413
      author's operation of detachment
        from cervical zone, 417
      physiological propositions relating
         to, 419
      therapeutical propositions relating
         to, 420
      retained, 467
      seat of, found by auscultation, 355
                     placental thrill, 355
Placental polypus, 392
Plug for inducing labour,  372
      in  abortion, 393
      in  placenta praevia, 416
      in  haemorrhage, 450
Podalic turning, 157
Polar circles of uterus, 407
Polypus,  cause of dystocia, muscular or
         fibroid, 240
       blood or fibrin, 393
Polypus, placental, 392
Porte-lacs,  Braun's and Hyernaux's, 18 4
" Position " of child in labour, defined, 19
      of patient in forceps, 34
                   version, 161
Post-partum haemorrhage, 428
Practice  often deterndned by  degrees of
  skill, or of perfection of instruments, 18
Pregnancy  with tumours, 237
      in tAvo-horned uterus, 236
Premature  labour,  induction of, 365
      fitness of the system, 366
           parturient organs, 367
      operation, two stages, 368
      provocation, acceleration, 368
      douche, vaginal and uterine, 369
      galvanism in, 372
      cervical plug, 372
      detaching membranes, 373
      insertion of bougie, 373
      puncturing  membranes,  373
      vaginal dilatation,  374
      cervical dilatation,  374
      author's proceeding, 376
      conditions requiring, 377
      in deformed pelvis, 378
      v. Caesarian section, 379
      in convulsions,  382
      in urgent distress of mother, 383
      ethical questions, 384
      fixing of uterus by  adhesions, 384
      to remove a dead child, 384
      care of  child, 385
      not  to be done  without a consult-
         ation, 385
"Presentation" in labour, defined, 19
      transverse,  100
Pressure, economy of,  33
      instead of  extraction,  on delivery
         by means of, 8
Primiparae, why  dystocia most common
  in, 53
Probang, use of, in Caesarian section, 357
"Progression " movement in labour,  21
Prolapsus uteri, cause  of dystocia,  232
Promontory of sacrum, projection of, 70,
  256, 265
       " curve of false," 70
Propositions,  physiological    and thera-
  peutical, on placenta praevia, 419
Puerperal fever, 359, 430, 446
Pubic arch, narrowing of, 257
Pushing-out child, 8

Quill of porcupine, to rupture. the mem-
  branes, 11
Quinia, to provoke labour, 368

Rectum, in labour, 48
Reflex theory of fcetal position, 88
       actions, sign of life, 140
Repellers,  use of,  in version, 188
'' Restitution  " movement in labour,  21
Retention  of urine, 213 
INDEX OF  SUBJECTS.
493
Retroflexion and retroversion of uterus in
  pregnancy, incomplete, 215
      causes haemorrhage, 444, 474
      terminations of, 218
      post-partum, 231
      reduction of, 227
      "partial," 216
Retro-uterine haematocele,  245
Rickets, description of, 256
Rigidity of soft parts, treatment of, 9, 81
" Rotation" movement in labour, 21
Rotation of the head, on artificial, 59, 60
      often spontaneous, 60
Rupture  of  uterus,  etc.  (see  Uterus,
  Vagina)


Sacrificial midwifery, 327
Salines, beneficial effects  of, after haemor-
  rhage, 464
Saline injections into veins, 476
Scarlatina causes haemorrhage,  424
Sea-tangle, tents of, 394
Septicaemia from tumours, 238
      Caesarian section,  359
      after rupture of uterus, 297
      retention of placenta, 430
      abortion, 395
      after haemorrhage, 453,  456
 " Shelling out" the head, manoeuvre, 49
Shock in  Caesarian section, 359
Shoulder-presentations, mechanism of, 99
      primitive and secondary, 97
Sigaultian operation, 363
Skeleton, abnormal conditions of, cause of
  dystocia, 254
Sling-carrier to seize foot, *184
Small-pox causes haemorrhage, 424
Spasmodic contractions cause malposition,
  93
Spondylolisthesis, 260
Spondylotomy, 191
Sponge tents, 372
 Statistics, fallacy of, 344, 346, 35?
 Stone in  bladder, 278
Strychnism, 81
 Stvptics in haemorrhage,  394, 451
 Sutures in Caesarian section, 357
 Swabbing the uterus, 394
 Symphysiotomy, 363
 Syringe,  with uterine tube, 17

Table of  pelvic contractions in relation to
   modes  of labour, 69
 Tartar  emetic in rigid cervix, 80
 Tetanus,  uteri,  81
 Thrombosis, 297
 Thrombus of uterus, vagina,  vulva, So,
   287,  470
 Transfusion,  476
       whole or defibrinated blood, 4/6
       milk or saline fluids, 476
       indications for, 482
       in convulsions, 485
Transfusion in exliaustion from  obstinate
      vomiting, 485
      in puerperal fever, 485
Tumours, cause of dystocia, 237
      in wall of uterus, 237
      in abdomen, 241
      in pelvis, 243
      ovarian,  224, 241
      axial rotation,  242
      rupture,  242, 250
      protruded  through  vagina,  243,
         289
      dermoid, 243
      spontaneous expulsion of, 243
      disappearance  of, 243
      formed by extra-uterine  gestation,
         244
       in vagina, 245
       condylomatous and cancerous,  245
       retro-uterine haematocele, 245
       obstructing labour, 350
 Turning (see also Version), 87
       in face-presentations, 67
       definition of, 98, 138
       bi-manual, bi-polar, 117
       two-finger, 118, 123
       podalic bi-polar, conditions indicat-
          ing, 157
       conditions favourable to, 158
       the operation,  160, et seq.
       extraction after, 169
       liberation of arms after, 172
       extraction of head after,  176
       when liquor amnii has run off, 179
       which hand to use in, 162
       positions of patient in, 180
       what part of child to seize, 181
       how to seize a foot, 181, 184
       in dorso-anterior positions, 180
       in abdomino-anterior positions, 186
       incomplete, 185
       imitation of spontaneous evolution,
          190
       delivery by bi-section or decapita-
          tion,  191
       in deformed pelvis, indications and
          contra-indications for,  197, 207
       hoAV head is caught at brim, 177
       limits of application, 197
       indications for, 207
       the operation,  208
       after craniotomy, 332
       after Caesarian section, 300
       after death of mother, 352
       in placenta praevia, 400,  418
 Turpentine, use of, in flooding, 447
 Twins, cause of dystocia, 147
       locked,  treatment of,  149
       in two-horned uterus, 236
 Typhoid causes haemorrhage, 424


 Umbilical vein,  cold injections into,  435
 Umbilical cord,  prolapse of,  125 
494
INDEX OF  SUBJECTS.
Urethra, displacement ofj in retroversion,
  222
Urine, retention of,  in retroversion, 221,
  231
Urinaemia, 221
Uterus (sec Inversion, Retroversion, Pro-
  lapsus)
       "uUrus en besace," 76
       contractions of, 4
       obliquity of, 91, 355
       hernia of, 73
       twisting of,  355
       retroflexion of, 213, 474
       flattened form of its cavity, 90
       laxity of, 92
       pregnancy in double,  235
       gangrene of> 297
       cicatrix of, after Caesarian section,
        360
       duplex, 235, 236
       chronic hypertrophy of, 234
       rupture of, 267, 296
           spontaneous, 272
           causes of,  271
      rent, laceration, bursting, perfora-
        tion,  boring-through, 268,  470
      impaction of retroverted, 221
           symptoms of,  268
       mechanism of rupture of, 273
      fatty degeneration of, 275
      powers of, 298, 442
      protruded through anus, 222
      rupture from child, 89, 288
      complete separation of, 289
      disease of tissue, 276
      cancer,  277
      tubercular disease, 277
      softening during labour,  277
      tumours in, 278
      contracted pelvis, 278
      division into zones, 407
Uterus, paralysis of, 317, 434
       inversion oi(scc Inversion)
       compression of, in haemorrhage, 446
       air in, 450

Vagina, dystocia from contracted,  85
       bursting of,  in retroversion, 222
       tumours in,  dystocia from, 245
       dilatation of,  to  provoke  labour,
         374
       laceration of, 288, 470
Vagitus uterinus, 431
Valves, the uterine and perinaeal, obstruc-
  tions to labour, 55
Version, spontaneous,  95, 99
       definition of (see Turning), 98
       varieties of,  99
       mechanism of, 100
       cephalic, 121
       bi-polar, 157
Vertebrae, disease of, cause of dystocia, 261
Vertex, defined, 19
Violence,  result of struggling feebleness,
  13
Vomiting, obstinate, may call for delivery,
  378
       in haemorrhage, 447
Vulva, oedema  of, 86
       dystocia from contracted,  85
           from tumours in, 245
       rent of,  290
       thrombus of, 86

Warm-bath, depressing  effects of  the, on
  child, 56
       in rigidity, 80
Water, cold, injections, 435, 448
       hot, use in flooding, 393, 448, 461
Wire-ecraseur,  16

Zones of uterus, 407 
INDEX   OF
AUTHOEITIES.
Andral on blood after haemorrhage, 442
Ane" on inversion of uterus, 315
Asdrubali on decollation, 191
Assalini's trepan, 14
      forceps, 24
Atthill, use of solid perchloride,  460
Aveling, forceps, 13
      immediate transfusion, 477
Aveling's curve, 13, 19

Bailly, retroversion of gravid womb, 214,
  226
Bain's method in asphyxia, 134
Balocchi, case  of spontaneous  evolution,
  110
Bandl's ring, 410
Bantock, death after perchl. iron,  455
Bard, John, uterine with   extra-uterine
  pregnancy, 244
Barker,  Herbert, circular  laceration  of
  cervix, 282
Barker,  Fordyce, on thrombus, 471
Barnes,  Fancourt, his cephalotribe, 16
      on forceps to  after-coming head, 57
      on breech cases, 147
      on labour with dermoid cyst, 244
      on perinaeorrhaphy, 291
      on cephalotribe, 336, 338
      on case of Porro's operation, 361
Barnes' curve, 19
      physiological boundary, 410
      on rupture of uterus, 276
Barnes,  R.,  how placenta presents, 432
      uterine water dilators, 375
Bassett on haemorrhage, 431
Baudelocque on compression of head, 25,
  26, 204
      on anterior rotation of head, 59
      on laparotomy, 362
      on inversion of uterus, 315
      symphysiotomy, 363
      how placenta presents, 432
      on compression of abdominal aorta,
         449
Beatty, his single-curved forceps, 39
Beatty, labour with polypus and inversion,
        241
       on opium after labour, 464
       labour with ovarian tumour, 248
       on third stage of labour, 433
Beauvais, G.  de, inversion of uterus, 322
Bedford, Dr., paraplegia from retroversion,
  221
Bedford (of Sydney), inversion  of uterus
  after death, 315
Bell, Dr. C,  on decapitation, 192
Bell, Dr., of Bradford, on rupture of uterus,
  301
Bell,  Anthony,  retroversion  of  gravid
  womb, 228
Belluzzi on post-mortem version, 352
Bennet, Henry, method of plugging, 393
Berry,  Mr., labour with ovarian tumour
  expelled through vagina,  243
       medullary cancer of sacrum, 263
Billi, modification of forceps-saw, 340
Birnbaum,  twin-pregnancy  in two-horned
  uterus, 236
Blot, uterine  douche  proves fatal, 370
    on haemorrhage from albuminuria, 391
Bloxam on replacing funis, 128
Blundell, Dr., case of Caesarian section, 56
       on retroversion, 227, 230
Boer, Prof., on spontaneous evolution, 96
       turning v. forceps, 200
Boivin, retroversion of gravid womb, 214
      haemorrhage from retroflexion,  444
Bouchacourt,  effect of strong iron injection,
  460
Braun, C,  on rupture of uterus, 277
      on retroversion of gravid uterus, 218
       on iron  injections in haemorrhage,
        454
Braun, G.,  condemns breech-forceps, 142
      sling-carrier or foot snare,  184, 187
      decapitator, 11, 151,  191,  192
      colpeurynter, 374
Breisky on  kyphotic  pelvis, 258
Breit,  bad effects of distending vagina,
  374 
496
INDEX OF  AUTHORITIES.
Bristowe  and  Montgomery,  rupture  of
  uterus, 276
Brie, case of monster, 155
Brodie, on artificial respiration, 132
Brown-Sequard, on transfusion, 486
Briininghausen's cervical  sponge-dilators,
  374
Brunton, retroflexion of gravid womb, 217
      post-mortem Caesarian section, 351
Burns on occipito-post-position, 59
      on live-birth after death of mother,
         351
      on removal of calvarium, 334
      haemorrhage from retroflexion, 444
Busch (of Berlin) on forceps after version,
  177

Callisen, retroversion of gravid womb, 214
Canestrini, rupture of uterus, 273
Capuron on adherent placenta, 438
Carmichael,  Hugh,  removes  fcetus  after
  death of mother, 56
      on seat of placenta, 411
Carus, the curve of, 19, etc.
Caseaux's diagrams of version, 117
      on dorsal displacement of arm, 152
      on placenta praevia, 401, 408
      how placenta presents, 432
      on velamentous placenta, 439
      on compression of aorta, 449
      on thrombus, 471
Casper, rupture of uterine ligaments from
  inversion, 318
Celsus on decapitation, 190
      delivery by external compression, 8
Chailly, version in narrow pelvis,  207
      on compression of abdominal aorta,
         449
Chamberlen's discovery of forceps, 24
      accepts Mauriceau's challenge, 198
Chambers, retroversion of gravid womb,
  220
      case of inversion of womb,  313
Chassagny on compression of  fcetal head,
  26
      forceps v. turning, 200
Chiari condemns breech-forceps, 142
Chiara on repeated cephalotripsy, 339
Chopart, procidentia uteri, 233
Chowne,  source  of  blood  in  placenta
  praevia, 404
Churchill, Dr., diagrams of version, 117
       statistics, 206
       turning v. craniotomy,  202
       on placenta praevia, 400
Clarke, Joseph, on third stage of labour, 433
       occipito-posterior positions, 59
       rupture of uterus, 288
Clay, Dr., labour and ovarian tumour, 250
Clay, John, rupture of uterus, 297
Clemenson, inversion of uterus, 314, 321
Cockburn, quinine in pregnancy, 368
Cohen's intra-uterine douche,  369
Collins on rupture of uterus, 284, 287
Collins on laceration of cervix, 403, 427
      on placenta praevia, 413
      on haemorrhage, 446
      and Beatty on third stage of labour,
        433
Cook (of Coventry) rupture of vagina, 289
Cooke,  uterine  with  extra-uterine  ges-
  tation, 244
Cooper,  H., on rupture of uterus,  271, 277
Cooper, Samuel, extrusion of intestine, 304
      inversion, 312
Copeman, Dr. E., on cephalic version, 114
Corbet, case of cephalotripsy, 339
Corbett, R., on adherent placenta, 438
Corner,  Mr.,  labour with fibroid  tumour,
  252
Cottle, rupture of uterus, 305
Coutouly on incisions of cervix, 83
Crede on changes of fcetal position, 93
      on expulsion of placenta, 433
Crighton, rupture of uterus, 302
Crisp's,  E., case of labour  with  polypus,
  240
Crosse on inversion, 312
      heat v. cold in haemorrhage, 448
Curtis on monstrous-births, 156

Dalton, J. C, injecting air in veins, 370
Danyau, labour with fibroid tumour, 239
      on Caesarian section, 359
      rupture of vagina, 301
Davis, Professor D.,  on twin-labour, 148
      condemns version in still-birth, 191
      on decapitation, 191
      guarded embryotome,  195
      on craniotomy, 326, 332, 335
      laceration  of cervix,  402
      astringents in haemorrhage, 450
Davis, Dr. Hall, case of double placenta, 439
      case of rupture of uterus, 288
      Caesarian section,  356
Deboirier, inversion of uterus, 321
Delore's experiments  on compression, 200
Deneux on protruded intestine, 304
      thrombus, 471
Denham, inversion of uterus, 323
Denman's short forceps, 22
      on spontaneous evolution, 95, 98,
         111
       on turning v. craniotomy,  199
       on retroversion of gravid womb, 215
      labour with dermoid cyst,  243
       on morality of craniotomy, 349
       on premature labour, 366
       placenta praevia, 399
       on management of placenta, 430
       rupture of uterus, 269, 285
       on consultations,  385
 Depaul, fatal cases of intra-uterine douche,
   369
       labour with ovarian tumour, 248
       extra-uterine gestation, 226
 Desgranges,  retroversion of gravid womb
   230 
INDEX OF  AUTHORITIES.
497
Dcsgrauges on symphysiotomy, 363
Deventer on obliquity of uterus, 91
       on version, 198
Dewees on anterior rotation of head, 59
Diday's  caoutchouc bladder plug in flood-
  ing, 450
Dieulafoy's aspirator trocar, 228
D'Outrepont on spontaneous evolution, 95
       on obliquity of f<etus,101
       on bi-manual version, 87, 116
       cases of version, 120
       increasing size of head, 327
       on perchloride  of iron in floodin",
         451
Douglas v. Denman on spontaneous version
  and expulsion, 96
Dubois' spinal cervical scissors, 17
       theory of instinctive power in fcetus.
         88
       on lateral obliquity  of uterus, 91,
         2S6
       on decapitation, 191
       retroversion of gravid womb, 223
       on rupture of uterus,  286, 288
      *on inversion of uterus,  315
       on plugging in haemorrhage, 416
Dubreuhl, rupture of uterus, 277
Duclos, labour with fibroid  tumour, 252
Duges on dorsal  displacement of arms,
  153
Duncan, Dr.  Matthews, on  labour  with
  fibroid tumour, 239
       on placenta praevia, 411
       how placenta presents,  432
Dunn, rupture of uterus, 293, 306
Duparcque, distensibility of  perinaeum, 290
       rupture of uterus, 271,  278,  2S0.
         283, 299, 308
       on  detachment  of  placenta  by
         vomiting,  124
Dupierris on injection of iodine,  454
Duverney on rupture of uterus, 273
Edis,  desquamation of live child at birth,
  203
      laparo-elytrotomy,  362
Edwards, Milne, on effect of warm bath, 50
Edwards,  St.  John,  twisting  of ovarian
  tumour, 242
Elkington on rupture of uterus, 284
Elliot, Prof., on rotation of head, 60
       on locked twins, 152
Emmet's operation, 275
Esterle on head turning, 116, 121
      on bi-manual head-version, 87,  121
      mobility of fmtus, 87
      changes of lutal position, 94
      on transverse positions, 100
      on  rectification of position  before
        labour,  121
      on post-mortem turning, 352
      on fatal case of intra-uterine douche,
        370
Farre, A., on retroversion of gravid uterus
  218
      on perchloride of iron in haemor-
         rhage, 455
Faye, Prof., on forceps-saw, 340
      on compression of aorta, 449
      on perchloride of iron in haemor-
         rhage, 452
Fehling, rupture of vagina,  289
      expulsive   powers   of abdominal
         muscles, 304
Ferratini on post-mortem Version, 352
Fii.-ker on sjwutaneous evolution, 96
Flamant on cephalic version,  120
Flichy,  Fichet de,  cases of spontaneous
  evolution, 110
Fothergill, John, labour with  extra-uterine
  cyst, 244
Freeman, labour with polypus, 240
Freericks, Caesarian section, 361
Fromont on retained placenta, 437
 Galton, F.,  on pangenesis, 478
 Gardien on placenta praevia, 401
 Gariel's air-dilator, 374
 Gartlisliore on spontaneous evolution, 95
       on blunt decapitator, 192
 Garlick, W., case of two-horned uterus.
   labour in,  236
 Garrigues laparo-elytrotomy,  362
 Gassner on changes of fcetal position, 93
 Gendrin on placental pulse,  412
       mechanism of  detachment of pla-
         centa, 423
 (Hermann on  dilating vagina, 374
 Gervis, Dr., labour  complicated  with
   polypus, 240
 GiHard's loop for  breech cases, 146
       on placenta praevia, 399
 Gillette, laparo-elytrotomy, 362
 Goddard,  ovariotomy during  pregnancy,
   248
 Godefroy on retroversion,  230
       on suture of uterus, 357
 Godson,  statistics  of Porro's operation,
   361
 Goodhart, expulsive power  of abdominal
   muscles, 303
 Gooch, labour with polypus, 240
       on h.emorrhage, 441
       cold douche in hiemorrhage, 44S
 Goupil on rupture of uterus, 273
 Goyon on cephalotripsy, 336
 Green, J. H., Caesarian section by, 56
       depressing effects  of warm baths,
        56
 Greenhalgh, Dr.,uterine with extra-uterine
  gestation, 244
       tumour growing from pelvis, Caesa-
        rian section, 263
Grenser, retroflexion of gravid womb, 222
       on rupture of uterus, 289
Grigg,  Caesarian section, 357
                              K K 
498
INDEX OF  AUTHORITIES.
 Guillemeau, manual skill of,  18
        on placenta praevia, 399
 Guyon, basilyst, 15

 Haake, entanglement of funis, 130
 Ilagen on spontaneous evolution, 96
 Hague, rupture of uterus, 282
 Halbertsma, retroversion of gravid  womb,
   222, 231
 Halford on venous  injection in snake-bites,
   4S6
 Hall, Marshall, on warm bath, 56
        "ready method," 134
 Halpin on retroversion,  230
 Hamilton,  G., pregnancy with ovarian
   tumour, 243
        on compression of uterus, 450
 Hamilton, Prof.,  on use of sound  in  in-
   ducing labour, 373
        on source   of  blood  in  placenta
          praevia, 403
 Hanks, Mr., case of monstrosity, 155
 Hardy and McClintock  on auscultation of
   placenta, 413
       on third stage of  labour, 433
 Ilarley, G., Caesarian section, 351
 Harris, Rogers, and Sisson, case  of cepha-
   lotripsy, 337
 Harrison on rupture of uterus. 272
 Harvey believed in fcetal volition, 88
       dystocia, defined, 2
       believed  in  survival of fcetus after
          mother's death, 351
       on Caesarian section, 351
       intra-uterine injections, 469
 Haselberg, Y.,  death after injecting per-
   chloride of iron, 454
 Hassall  and  Barnes, case of hydatidiform
   placenta, 396
 Huighton, expulsive power of abdominal
   muscles, 304
 Head on retroversion of gravid uterus, 228
 Hecker on production of face-presentation,
   63
       on changes of fcetal position, 93
       on asphyxia, 131
       on retroversion of gravid uterus, 217
       signs of rupture of uterus,  287
 flcekford and Woodman's saline injection,
   480
 Hcgar, retained placenta, 437
 Heister on decapitation,  190
 Henderson on saline  injection and  trans-
   fusion,  479
 Herder on galvanism to induce labour, 372
 Herman,  Dr..  death  after injecting per-
   chloride of iron, 454
 Hewitt, Grailv, on hydatidiform placenta,
   396
      peritoneal adhesion cause of hiemor-
         rhage, 429
Hcwson, salts prevent coagulation of blood,
   ■177
lleverdald, position of fcetus, 93
 Hicks, Braxton, cephalotribe,  16, 336
       on  combined internal and external
         version, 87, 116
       labour with tumour, 249
       on rickets, 257
       expulsive   force   of   abdominal
         muscles,  303
       elongation of vagina,  309
       on delivery by base of skull, 33 4
       case of Caesarian section, 354
       suture of uterus in C;esarian section,
         357
       on rupture of uterus, 308
       on  perchloride of iron  in haemor-
         rhage, 458
 Higginson's transfusion apparatus, 477
 Hilliard, retroflexion of gravid womb, 217
 Hime, laparo-elytrotomy, 362
 Hippocrates  compares  fcetus  to  olive in
   bottle, 94
       dystocia, 1
 Hodge's pessary, 231
 Hoening, Dr.,  delivery by extraction, 8
       forces that change child's position,
         93
 Hofmann's anodyne, 12
       colcothar lint-plugs in flooding, 451
 Hold on incision of cervix, 83
       on cephalic version, 121
       condemns breech-forceps, 142
       on locked twins, 152
       turning in narrow pelvis, 210
       rickets and osteomalacia, 256
       on compression of  fcetal head,  204
       ovum forceps, 392
       on perchloride of iron, 451
 Holmes's perforator, 14
 Hopkins, use of sound to induce labour, 374
 Hcirninger and Jacoby on galvanism,  372
 Hoschek, post-mortem Caesarian  section,
   351
 Howard's method in asphyxia,  135
 Hubert, basilyst, 15
 Hugenberger on kyphotic pelvis, 258
       on thrombus, 471
 Hull, Dr.,  disputes with Dr.  Osborn,  331
 Hunter, W., and Denman, on  removal of
  placenta, 430
 Hunter, John,  opprobrium chirurgicorum,
   345
       on inversion, 316
 Hunter, William, on retroversion of gravid
  uterus, 215, 230
       on management of placenta, 430
 Hunters, J. and W., on structure of pla-
  centa,  404
 Hiiter on induction of  premature labour,
  374
       on retained placenta, 437
       on velamentous placenta, 43;i
Hyernaux, porte-lacs, 184
       on forceps-saw, 340
       on post-mortem version, 352
Hyrtl on forms of placenta, 431' 
INDEX OF  AUTHORITIES.
499
Ingleby, case of labour with polypus,  240
       labour with dermoid cyst,  243
       on rupture of uterus, 283, 294
             of vagina, 288
       on placenta praevia, 399
Inglis  (of Aberdeen), his forceps, 24
Ireland, Dr., case of Caesarian section, 56


Jacquemier's decapitator,  17
       on rupture of uterus, 288
       on compression  of the  abdominal
         aorta, 449
James' method of induction of labour,  371
Jamieson, rupture of uterus, 285
Jobert's cervical dilators,  375
Johnston (of Dublin), forceps in arrested
  labours, 53
       Ringland's case of transfusion, 484
Johnston (of Shanghai), case of saline in-
  jection and transfusion, 483
Jorg on oblique position of fcetus, 101
       on diffused placenta, 439
Joulin on compression of head, 26
       forceps t\ craniotomy, 240


Keiller on uterine dilators, 375
Kelly,  C, on induction of labour, 366
Keyser,  infant mortality  in   Caesarian
  section, 348
Kidd,  Dr. (of Dublin), his  cephalotribe,
  16, 336
       labour with ovarian tumour, 248
Kilian on spondylolisthesis, 260
       on acanthopelys, 262
       on the  " suture sanglante," 357
Kilner, galvanism in labour, 372
Kiwisch's vaginal douche  for induction of
  labour, 369
       on compression  of abdominal aorta,
         449
       on perchloride  of iron  in  flooding,
         452
Klob on rupture of the uterus, 277
Krahmer on asphyxia, 131
Ivrause on cervical dilators,  375
Krieger, live  birth in  hydatidiform pla-
  centa, 396
Kristeller's dynamometric force]is, 8
Kussmaul on two-horned uteri, 236


La Chapelle, Madame, on long forceps, 199
       on turning in narrow pelvis, 199
       occlusion of uterus from thrombus,
         471
Lambert on labour with myoma,  252
La Motte preferred version to forceps,  198
Lauth  on limits of cephalotripsy, 337
Lauverjat, the "suture sanglante," 357
Lazarcwitch's, Prof., forceps, 24
       induction of  premature labour,  371
Lazzati, rarity of transverse presentations,
  100
Lazzati on version, 122
       on spontaneous evolution, 100,  106,
        110
       on bi-polar version and use of pads,
        122
       on decapitation, 191, 192
       dilatability  of osteomalacic pelvis.
        355
       fatal  case of intra-uterine douche,
        369
       on inversion, 315
Leclerc, rupture of uterus,  298
Lee, Robert, on version with fingers, 118
       labour with fibroid tumour, 238
       on placenta praevia, 400
Lefort on double uterus,  236
Legroux on placenta pnevia, 404
       on acute anaemia,  455
Leishman, Dr., on rotation of head, 60
Lemser, how placenta presents, 432
Leroux on placenta praevia, 402
       on  plugging in haemorrhage,  416,
        450
Leroy on symphysiotomy, 363
Levret  on  malposition   from  placenta
  praevia, 92
       on turning, 187, 198
       ovum forceps, 392
       defines labour, 6
       on placenta praevia, 399, 401, 411
       on ice in uterus, 448
Levret and Von Deutsch's manoeuvre,  ] 80.
  187
Ling, rupture of uterus,  275
Little, Dr.,  on  saline alcoholic injections
  into veins, 477
Little, L. S.,  on  intra-venous saline in-
  jections, 479
Litzmann, rickety pelvis, 256
Loffler on spontaneous  evolution,  95
Lovati, symphysiotomy,  363
Lowder, labour  with  distended  bladder,
  245
Lowsly, rupture of uterus, 308
Lucas, inversion of uterus, 315
Lynn,  rupture of bladder, 219
Mackenzie, E. W., on source of blood in
  placenta praevia, 404
Madden, More, rupture of uterus, 284, 311
Malgaigne, Caesarian section, 359
Marrigue, procidentia uteri,  233
Martin's, Prof., trepan, 14
      on bi-manual head-version, 121
      on compression of fcetal head,  204
      on turning v. craniotomy, 207
      hydatidiform degeneration, 396
      on haemorrhage  from  versions of
         uterus, 474
      post-partum retroflexion, 232
      rupture of uterus, 289
Martineau  (of  Norwich)  on spontaneous
  evolution, 95 
500
INDEX OF  AUTHORITIES.
Martineau (of Paris) on chloral, 271
Martini on symphysiotomy, 363
Mattel's vertebral scissors, 192
Mauriceau and Chamberlen, 198
      on uterine haemorrhage, 399
May and Wigand on  ligature of funis be-
  fore birth, 171
Mayor, labour with fibroid tumour, 252
McClintock  on . turning  in contracted
  pelvis, 204
      on compression of fcetal head, 204
      laceration of vagina, 288
      on auscultation of placenta, 413
      on inverted uterus, 324
      on expulsion of placenta,  433
McDonnell on transfusion, 478
McKeever, protruded  intestine, 304
McKinlay on rupture  of uterus, 272
Meadows, rupture  of  uterus,  307
Meigs, Dr., on forceps  after version, 57, 177
      on-retroversion, 228
      external bi-polar version,  123
      inversion of uterus, 322
      Caesarian section,  360
Mendenhall on  salts  of iron in flooding,
  452
Merrier  on   placenta   praevia  Avithout
  haemorrhage, 408
Merriman on retroversion of gravid uterus,
  216, 231
Mikschik on hydatidiform  degeneration,
  396
Millar on artificial rotation of head, 59
Miller, inversion of uterus, 284
Milne-Edwards on warm bath in asphyxia,
  56
Misley  on retroversion of gravid uterus,
  220
Mitchell on rupture of uterus, 272
Mojon injects umbilical vein, 435
Molas, Dr., case of monstrosity, 155
Moldenhauer,  sloughing of inner coat of
  bladder, 218, 228
Monteggia on  spontaneous evolution, 110
Monteverdi, bark an  ecbolic, 368
Montgomery on reducing inversion,  324
       pregnancy with uterine tumour, 239
       pregnancy with ovarian tumour, 243
           uterine with  extra-uterine ges-
             tation,  244
Moreau, diagrams of  version, 117
       on placenta praevia, 408
       retroverted gravid uterus, 223, 230
       procidentia uteri, 233
Morgagni on adherent placenta, 43S
Morgan, de, Caesarian section, 356
 Morisani on symphysiotomy, 363
 Mouilleron, de, " suture sanglante," 357
Moulin on rupture of uterus, 284
 Midler, P., on frequent changes  of fcetal
   position, 94
       rupture of vagina, 291
       modification of Porro, 362
 Miinchmeyer on retroversion, 229
Murphy, Dr., on rupture of uterus, 275
Murphy  (of  Sunderland)  on  placenta
  pnevia, 414
Murray,  J.  J., on  version  in  dorsal dis-
  placement of arm, 154
      dilatation  of uterus  by fluid pres-
         sure, 375
Murray,   Gustavus,  haemorrhage  from
  varicdse vein in cervix uteri,  473

Naegele's perforator, 14
      on 3rd and 4th position, 58
      occlusion of os uteri,  78
      laceration of os uteri, 403
      on malposition from  irregular con-
         traction, 93
      oblique-ovate pelvis,  261
Naegele, H. F., condemns breech-forceps,
  142
Negrier on retroversion, 230
Nelaton, restoration from asphyxia, 463
Neugebauer, Franz,  on  spondylolisthesis.
  260
Newman, case  of Caesarian section, 360
Novi on symphysiotomy, 363

Oldham, Dr., his perforator, 14, 196,  330
      on retroversion  of gravid  uterus,
         217, 231
      labour with double uterus, 235
      case  of accidental haemorrhage, 425
Olshausen,  dilatability of pelvis in osteo-
  malacia,  355
Ore on transfusion, 477
Ormerod on rupture of uterus,  277
Osborn,  Dr., on delivery by base of skull,
   333
Osiander on compression of head, 25, 204
       cephalic version,  120
       on forceps v. turning, 200
       dilatation of pelvis in osteomalacia,
         355
       on cervical dilators,  375
Ould, Fielding, on transverse presentation,
   110
       on breech cases, 146

 Pacini's method in asphyxia,  134
 Pagan, labour with fibroid  tumour, 239
 Paget  (of  Leicester)   on   " rupture  of
   uterus,"  284
 Pajot on lateral obliquity of uterus, 91
       decapitating cord, 17
       limits of cephalotripsy, 337
       repeated cephalotripsy, 337, 339
       rupture of uterus, 288
       Caesarian section, 346
 Palctta on  decapitation, 191
 Palfyn's lever-forceps,  24
 Pare, Ambroise, manual skill of, 18
       on turning, 198
        on fcetal volition, 88
 Paul (of iEgina) used  vinegar  and sponge
 t  tents in  flooding, 450 
INDEX  OF  AUTHORITIES.
501
I'avan on rupture of uterus, 273
Percy, protruded intestine, 304
Perfect on spontaneous evolution, 95
      long forceps, 27
      turning in narrow pelvis, 199
      live birth in hydatidiform placenta.
        396
      tow and oxycrate plugs in flooding,
        451
      ice inside the uterus, 448
Peu's proceeding in spontaneous evolution,
  189
Pezerat, case of spontaneous evolution, 109
Pfeiffer, Dr., on placental thrill, 356
Piazza  on  injection   of  iron-solutions,
  454
Pihan-Dufeillay on Cicsarian section, 346
1'ingler on survival of fcetus after mother's
  death, 56
Playtair, Dr. W., on monstrosities, 155
       on retroversion,  230
       labour complicated  with tumours,
         250
 Ploucquet on  compression of  abdominal
  aorta, 449
 Poiseuille, suction-force of abdomen, 453
 PoppcTs experiments on uterine force,  8
 Porro's method of Caesarian section, 361
 Portal on placenta praevia, 399
       on procidentia uteri, 233
       on adherent placenta, 438
 Power, Dr., on metastatic labour,  52
 Priestley, labour with polypus, 240
 Pugh (Chelmsford) on version,  199, 210
       delivery by expression, 8
 Puzos on placenta praevia, 402

 liadford,  Dr., on  turning, 87
       on turning by one foot, 181
       mobility of fetus in utero,  87
       on risk to child  in Caesarian section,
          348
       compression of fcetal head,  207
       uterine  cicatrix   after   Cicsarian
          section,  360
       on rupture of uterus, 281
       on galvanism to uterus,  372
       on   source  of  blood  in   placenta
          pnevia,  403
       on inversion, 321
 Kainsbotham's decapitating hook, 11, 16,
    151, 192
       mode of applying  forceps, 38
        on fronto-anterior position, 62
        condemns breech-forceps, 142
        on breech  cases, 142
        on decapitation, 191
        compression of fcetal head, 207
        labour with dermoid cyst,  243
        on craniotomy,  327
        on placental adhesion, 438
 Kitsch, apparatus for irrigation, 468
 Rawlins  (Oxford) on  source  of  blood  in
    placenta pnevia,  403
Kay nes on twin-labour, 151
Rilicinont's insufflator, 11. 136
Richardson,  Dr.  B.  W.,   bellows  for
  asphyxia, 11,  135
      on nitrite of amyl, 270
      on ammonia in transfusion, 477
Rigbv, Dr.  E.,  on forceps  after version,
  57,' 177
      on version,  117
      on retroversion, 231
      on placenta pr:evia,  403
Rigby on placenta praevia, 399
Ringer, S., on Calabar bean, 271
Ringland, case of transfusion, 484
Ritchie on decapitation,  192
Ritgeu, von, on delivery by pressure, 8
       ligature of cord before birth, 171
       on dilatation  of vagina, 374
Rizzoli on post-mortem version, 352
Robert on synostotic pelvis, 258
Roberton's  tube for prolapsed funis, 14,
   127
       mode of applying forceps, 38
       on rupture  of uterus, 270, 284
Rodenstein,  Cicsarian section, 357
Rogers," case of pelvic tumour, 263
Rokitansky on rupture of uterus, 317
       axial  rotation of ovarian tumours,
         242
 Roper,  labour  with elongation  of cervix
   uteri, 234
       retroversion of gravid womb, 222
 Rouget used bladders as plugs in flooding,
   450
 Routh,  Dr., death after  perchloride  of
   iron, 456
 Ruysch on management of placenta,  430
       on inversion of uterus, 314
       muscle, 435
Saccombe on spontaneous evolution, 96
Sai htleben on spontaneous evolution, 95
Sadler, labour impeded bv hydatids of the
  liver, 350
Salmon, fatal intra-uterine douche. 369
Savory  and Sanderson  on methods  of
  treating asphyxia, 135
Sayre.  L. A., quinine as an ecbolic, 368
Saxtorph, inversion of uterus, 321
Scanzoni on incision of cervix, 83
       causes of head-presentation, 90
       retroversion of gravid uterus,  214,
         216
       Cicsarian section, 348
       on symphysiotomy,  363
       injection into umbilical vein, 435
       laxity of uterus as a cause of mal-
         position, 93
       method  of turning erroneous, 182
       labour with procidentia, 233
       risk  to  child in Caesarian section,
         318
       laceration of vagina, 288 
502
INDEX OF  AUTHORITIES.
Scanzoni, fatality of injections of carbonic
         acid, 372
      on perchloride of iron, 452
Schatz on retroversion of gravid uterus,
  218, 229
      on inversion, 322
Schmitt, Wilhelm,  on spontaneous evolu-
  tion, 96
      on retroversion of gravid womb, 213
Schnakenberg, rupture of uterus, 289
Schnorr,  inversion of uterus, 433
Scholler's use of sponge-tents, 374
Schultze, treatment of asphyxia, 133
      on change of fetal  position, 93
Schwartz on asphyxia, 131
Schweighauser's intra-uterine douche, 369
Scott, on rupture of uterus, 272
Sedgwick, L., labour with fibroid tumours,
  239
      obstinate vomiting, 379
Shekleton, osseous growth in pelvis,  262
Siebold, on compression of head, 25
      on spontaneous evolution, 96
      procidentia uteri, 233
      used the colpeuryliter, 374
Siebold,  Elias von,  on spontaneous evolu-
  tion, 96
Sigault, symphysiotomy, 363
Simon, Max, retroversion  of gravid womb,
  222
Simons on spontaneous evolution, 96
Simpson, Sir James, his forceps, 13
      cephalotribe, 336
      theory  of reflex  muscular  move-
         ments of fetus, 88
      on version, 87, 117, 181
      on dorsal  displacement  of  arm,
         152
      on compression of fetal head, 204,
         207
      on rupture of uterus, 287
      on retroversion, 231
      on Caesarian section, 357   ' .  •  \
      on intra-uterine douche, 369
      fatal  cases of injection of air, 370
      on source  of  blood in  placenta
         pnevia, 403
      on adherent placenta,- 438
Simpson, A. R., basilyst,  15, 336
Skene, laparo-elytrotomy, 362
Skinner,  Dr., on retroversion, 230
      on reducing inversion, 324
Sloan (of Ayr), his laminaria-tents, 394
Smellie's long forceps,  27
      on occipito-posterior positions, 59
      on rotation in face-presentation, 67
      restores head position, 123
      on limits of craniotomy, 199
      inversion of uterus, 315
      craniotomy scissors, 330
      on  ligation  of  extremities  and
         styptics in haemorrhage, 451
Smith, Heywood, death after injection of
  perchloride of iron, 457
Smith,  Tyler,  on retroflexion  of  gravid
  uterus, 214
      on version, 118
      on retroversion, 214
      on inversion, 317
      on rupture of uterus, 274, 286, 308
      on rupture of perinaeum, 291
      on  vaginal  douche in pregnancy.
        369
      on  dilatation of  pelvis  in   osteo-
        malacia, 355
      genesial cycle, 366
      on  venous injection in  puerperal
        fever, 486
Spaeth condemns breech-forceps, 142
Speedy, inversion of uterus, 313
Spiegelberg  on inversion of uterus,  322
      on placenta praevia, 411
Stein, forceps v. craniotomy, 200
      law of deformities,  254
Stoltz on cervix uteri  in pregnancy,  401
Storer, Dr.,  dilatation  of uterus, 375
Strassman,  Dr.,  on  turning in  narrow
  pelvis, 210
Sylvester's method of treating  asphyxia,
 ' 134
Tait,  Lawson,  pregnancy  with   double
  uterus, 236
Tarnier's forceps, 14
      labour with fibroid tumour, 252
      basiotribe, 336
      lamination, 343
      uterine suture  in  Caesarian section,
         357
      fatal cases of intra-uterine douche,
         370
      uterine dilators, 375
Taurin, fatal case of intra-uterine douche,
  369
Taylor,  A.  S., inversio uteri post-mortem,
  315
Theopold on  knee-elbow position for  re-
  placing funis, 128
Thomas  on knee-elbow  position  lor  re-
  placing funis, 128
      tumours in pregnancy, 248
      laparo-elytrotomy, 362
Thomas, R. H., rupture  of uterus, 299
Thorniann,  rupture of vagina, 289
Tiedmann,  pregnancy and  double uterus,
  236
Tissier,  effect of strong perchloride of iron
  460
Trask, rupture of uterus, 269, 272
      injections of iodine in haemorrhage.
         454
Ulrich, fatal case of intra-uterine douche,
  370
Ulsamer  on  ompression  of  abdominal
  aorta, 449 
INDEX  OF  AUTHORITIES.
503
Valenta on changes of fetal position, 93
      mode of accelerating labour, 81
Van Doeveren, rupture of bladder, 219
Van Hucvel's pelvimeter,  263
      forceps-saw,  340
      on lamination, 340
Velpeau on compression of head, 25
      on incision of cervix, 83
      on spontaneous version, 96, 113
      external bi-polar version, 120
      rupture of uterus, 2S3
      inversion of  uterus, 322
       on cold  as  a cause of puerperal
         trouble, 447
      on cephalic version, 123
      advises version in  distorted pelvis,
         207
      on vagitus uterinus,  431
V ill ens  on  hydatidiform   degeneration,
  396
Virchow on hypertrophy of decidua, 396
Vogler on spontaneous evolution, 96
Volkmann's case of hydatidiform degene-
  ration, 396
Von Buseh on cervical dilators, 375
Von Deutsch  on turning,  180, 187
Von Hoorn on decapitation, 190
Von Ritgen on seat of placenta, 411
       on " expression," 8
       on the  colpeurynter, 374
Wagstaffc on transfusion, 478
Weir, Dr. Graham, on locked heads, 152
      cervical dilaiors, 375
Wells, Spencer,  ovariotomy during preg-
  nancy, 248
       on uterine suture, 357
West, C, pregnancy with tumour, 249
West,  R. U.. on  artificial rotation of head,
  59, 60
White, F..  rupture of uterus, 272, 311
Whittle, E.. on  rupture of uterus, 275
       signs of haemorrhage, 431
Wiedemann on spontaneous evolution, 96
Wigand on uterine deviation, 92, 101
       mobility of fetus,  87
       rectification of face-presentations,
         123
       on spontaneous evolution, 96
       on external bi-polar version,  116,
         120,  ct  seq.
       on compression of the funis, 171
       prolapsus of funis. 127
       on turning, 167,  210
Williams, D.  M..  live fetus desquamating
  at birth, 203
Wilson, J. G., on knee-elbow position for
  replacing funis, 128
       on inverted uterus, 325
       tracheal tubes for asphyxia,  133
Winckel, Dr.  Ludwig,  time for  Caesarian
  section, 353, 357
       on osteomalacia,  360
Wood, Kinder, on source of blood in pla-
  centa pnevia, 403
Woodman  on blood-discs after  saline in-
  jections into veins, 480
Woodson,  inversion of uterus after abor-
  tion, 314
 
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