Induction of Premature Labor. 
BY 
BYRON STANTON, M.D., 
CINCINNATI, OHIO. 
REPRINT FROM TRANSACTIONS, 
VOL. I, 1888. INDUCTION 
. OF 
PREMATURE LABOR. 
BY 
BYRON STANTON, M.D., 
CINCINNATI, OHIO. 
REPRINTED FROM TRANSACTIONS OF 
AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
SEPTEMBER, 1888. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1 8 89. INDUCTION OF PREMATURE LABOR. 
By BYRON STANTON, M.D., 
CINCINNATI, OHIO, 
Being impressed with a sense of the obligation which I, as one 
of the foundation members, owe to this Association, organized for 
the “ cultivation and promotion of knowledge in whatever relates 
to abdominal surgery, obstetrics, and gynecology,” I proceed to the 
discharge of my duty by submitting some remarks upon the subject 
of induced premature labor—a subject in regard to which an 
increased interest has been awakened in my mind by some recent 
experience. 
The distinction between induced premature labor and induced 
abortion is well understood, and what I have to say applies only to 
cases in which the fetus has reached the period of viability. In 
recent works on obstetrics this subject is treated of at full length. 
In older works it was disposed of in a few lines or passed by 
wholly unnoticed. 
The induction of premature labor was undoubtedly practised by 
the ancients, but by them its application was limited to cases of con- 
tracted pelvis. In later times its application has been extended to 
many other conditions. Two centuries ago it was resorted to in 
some cases of unavoidable hemorrhage, but there has always been a 
class who have strongly condemned it, regarding it as an unsafe 
and unjustifiable procedure. In the last century it was denounced 
as criminal and, according to Denman, it was not until 1756 that 
the English authorities decided upon its propriety and morality. 
As late as 1827 the Royal Academy of Medicine, of France, pro- 
nounced against it as immoral, and less than sixty years ago (1831) 
the operation was first performed in that country. Within the last 
half century it has been opposed by Osiander, Stein, Joerg, and 
others. Baudelocque opposed it strongly. The only cases in which 4 
STANTON, 
he admitted the propriety of its performance were those of great 
uterine hemorrhage, and then only when the child was probably 
destroyed and the safety of the mother compromised. The argu- 
ments which were used against this operation were based on the 
ground of its immorality as well as its uselessness, and would apply 
with equal or greater force to the use of forceps, turning, and all 
obstetric operations. Cesarean section is looked upon as a recog- 
nized and well-established operation ; yet its statistics as regards the 
result to the mother will bear no comparison with those of induced 
labor, and as regards the fate of the child it has but little advantage. 
Craniotomy had a stronger opposition and yet, fraught with danger 
as it is to the mother and fatal, of course, to the child, it has had 
the endorsement of the profession. If such an operation can be 
looked upon as a justifiable obstetric procedure, an operation which 
does not add materially to the risks of the mother and which has a 
record of half of the children saved, needs no defence. Indeed, 
like the resort to turning and the use of the obstetric forceps, the 
operation will do much to obviate the necessity of having to 
choose between craniotomy and Cesarean section. Its object being 
not only to save the life of the child, but to diminish the dangers to 
the mother, we may cordially agree with the late Dr. Bedford that 
“it is the most precious boon which science has yet bequeathed to 
suffering woman.” 
The morality of the procedure may, I think, be regarded as 
recognized. 
An argument against induced labor is that there are some risks 
incurred by the mother that she does not have to encounter at full 
time. The maternal passages have not fully undergone the changes 
which nature effects during pregnancy; the uterus is not in a condi- 
tion of best muscular development to effect delivery and expedite 
involution; the detachment of the placenta is more frequently de- 
layed, and malpresentations are of more frequent occurrence. On 
the other hand, it may be stated that malpositions in the last two 
months of pregnancy are not likely to be rectified, if there is pelvic 
deformity, at full time; that the child is of smaller size and the 
head more yielding and more easily adapts itself to the shape of the 
pelvis; that the mother escapes the dangers incident to protracted 
labor, and if craniotomy becomes necessary it is more easily and INDUCTION OF PREMATURE LABOR. 
5 
safely performed. The other dangers, such as fever, pelvic inflam- 
mation, etc., are no greater and no less than in labor at term. 
Statistics show that artificially induced labor is not attended with 
any more risk to the mother than accidental premature labor, not 
much more than normal labor at term, and is much less hazardous 
than the operations for which it is the alternative—craniotomy and 
Cesarean section. The propriety of the induction of labor has also 
been questioned on account of the high infant mortality attending 
it. Among the more recent writers Winckel, Litzmann, and Spiegel- 
berg have been quoted as holding that such intervention is danger- 
ous as compared with spontaneous labor. Strauck, of Moscow, in 
Archiv fur Gyndkology, Band .31, Heft 3, concludes that on account 
of the great infant mortality the induction of premature labor should 
give place to Cesarean section, since there is every reason to believe 
that the latter operation will lower its mortality as operators become 
more practised. Is there not reason to believe that with improved 
methods of inducing labor, and the greater care bestowed upon the 
infant after birth, induced labor will also lower its mortality? 
Strauck, in his estimate of the operation as relating to the child, 
bases his conclusions, I think, upon erroneous data. For instance, 
in twenty-one of his cases where labor was induced because of con- 
tracted pelvis, he gives the measurements of the conjugatce verce as 
from If to 31r inches. The induction of labor in a woman with a 
conjugate of If- inches, could but result fatally to the child, and such 
cases should be excluded from consideration, in determining the 
propriety of inducing labor after the seventh month. The choice 
would be between induced abortion and Cesarean section. But in 
Strauck’s own cases, of which he reports twenty-eight in all, 
twenty-one of the children lived, and eight were stillborn. 
Of the twenty-one living children, ten died in hospital, and 
eleven were discharged healthy. Whether the deaths were all due 
to conditions connected with premature birth, I do not know, but 
granting that they were, eleven healthy children is a good result in 
twenty-eight cases, in twenty-one of which the operation was per- 
formed because of contracted pelvis, with conjugates ranging from 
If to inches—better than would have followed the operative 
procedures that might have been required at term. 
In those conditions which jeopard the safety of the mother and 
child at full term, nothing will so greatly diminish mortality as 6 
STANTON, 
recourse to the induction of premature delivery. Its safety, then, 
may be regarded as established. 
The great number of cases in which it has been performed with 
success, when previous labors have been attended with loss of 
infant life, may be regarded as demonstrating its utility. 
That it is resorted to in cases in which it may not be necessary, is 
no doubt true. The same may be said of all the aids to labor. 
That many cases to which it is applicable are permitted to go to full 
term with loss of life of mother or child is, no doubt, also 
true. 
The morality, safety, and utility of the operation being generally 
admitted, the next thing for us to determine is to what classes of 
cases the artificial induction of labor is applicable. 
The points involved in determining this question are: 
1st. Whether the case is one in which delivery at term will in- 
volve the death of the infant, and subject the mother to much 
suffering and danger, and yet permit delivery at seven or eight 
months. 
2d. Whether the conditions are such that the life of the mother 
will be imperilled by continuance of pregnancy to the full period of 
gestation, by hemorrhage, or some intercurrent disease, or by aggra- 
vation of some chronic ailment which can be averted or removed by 
earlier delivery; and 
3d. Whether there is a history of infant fatality in several succes- 
sive pregnancies at some regular time after the age of viability. 
In the first case, delivery would be induced rather in the interest 
of the child than the mother; in the second, more in the interest of 
the mother; in the third, purely in the interest of the child. 
Reference has already been made to the fact that this operation 
was first resorted to only in cases of contracted pelvis, and ever 
since the operation was first suggested this has been the condition 
which has most frequently called for premature delivery. Dr. 
Merriman has laid it down as a rule that it should be strictly con- 
fined to such cases, but it now has a wider range of application. 
In the determination of the question as to what cases of contracted 
pelvis it is applicable, there are given two extremes of measurement 
which limit the operation. These extremes have been variously 
stated, the maximum ranging from 3 to 3.75 inches, and the mini- 
mum from 2.75 to 2.25 inches. Should there be a measurement INDUCTION OF PREMATURE LABOR. 
7 
in excess of the maximum stated, the operation is commonly regarded 
as uncalled for. I say commonly so regarded, for the reason that in 
exceptional cases a greater diameter may demand premature delivery, 
where for several successive pregnancies the child has attained such 
size that it could not be born alive. In such a case the propriety of 
the operation is to be determined more by this fact than by the 
diameter of the pelvis. 
Should there be a contraction below the minimum above named, 
the question to be determined is between induced abortion and 
Cesarean section. 
It is difficult to fix exact measurements within which the induc- 
tion of labor is justifiable. The difficulties of labor depend to some 
extent upon the character and location of the deformity. Delivery 
is more easily effected through a flat pelvis than through a generally 
contracted pelvis with the conjugate of the same measurement. 
Deliveries are also easier, cceteris paribus, when the narrowing is at 
the superior strait. Contraction of the same degree at the lower 
strait causes more delay, and more frequently calls for the applica- 
tion of forceps. If both straits are contracted, the difficulties are 
increased, for energetic uterine action might overcome the resistance 
of obstruction at one strait, but not be sufficient to overcome the 
resistance of a pelvis narrowed at both extremities. 
In some cases natural delivery has been successfully accomplished 
when there was a contraction to 3.75 inches, but with an ordinary 
sized fetus the labor is more difficult, and consequently more 
dangerous. A fetus of average size could seldom be delivered 
through such a pelvis, so that a maximum for our guidance in de- 
termining the propriety of induction of labor can only be approxi- 
mate. The same may be said in regard to a minimum. Children 
have been born through pelves measuring 2.25 inches (M. Depaul). 
The measurements, then, must vary with the size of the child, and 
the amount of compressibility of the fetal head, and these points 
cannot always be exactly determined. It is impossible to determine 
exactly the size of the fetal head, and in the determination of the 
diameters of the pelvis we can only make approximations. Even 
the most approved instruments do not-give exact measurements, and 
under all these uncertainties the question is to be determined for 
each case by itself. The circumstances of individual cases are so 
various, that it is impossible to lay down strict rules for their 8 
STANTON, 
management. We may agree upon general principles, but, at last, 
each case must be examined and decided on its own merits, under 
the lights of our experience. As the induction of premature labor 
is mostly called for in parous women, we have in a majority of the 
cases the history of previous deliveries to assist us. The induction 
of premature labor is seldom called for in primiparre. 
As approximations we may take for the extremes 3.5 and 2.5 
inches. Between these the interest of both mother and child will 
call for the operation before the full period of gestation. Spiegel- 
berg places the maximum at 8 c.m. (3.15 inches). He says that the 
resort to artificial induction of labor is of doubtful propriety when 
the contraction is not below that measurement, and even then it is 
not to be performed unless there is reason to suspect from the cir- 
cumstances of previous labors that the infant may be of large size, 
the cranium unyielding, and the presentation unfavorable. 
In some cases in which several previous deliveries have been 
attended with loss of life of the child because of its large size, labor 
should be induced before term, although the conjugate may measure 
more than the maximum above stated. In illustration of this class 
of cases, I give the following: 
Case I.—Mrs. is a woman of small stature and very small frame, 
about twenty-three years of age. She was a patient of Prof. Wm. B. Davis, 
of Cincinnati, by whom I was called in consultation in two labors preceding 
the one in which labor was induced. In the first confinement, at the time 
I was called, she had been in labor twenty hours. Uterine action had been 
vigorous for most of the time, but was beginning to fail. The membranes 
had been ruptured several hours, but the head, which presented by the 
vertex in the O. L. A. position, had made no descent into the pelvis. 
Chloroform was administered by Prof. Davis, and the Elliott forceps applied 
without a great deal of difficulty, but I was unable to advance the position 
of the head. It was then determined to resort to version, or, in the event of 
the child being dead, to perform craniotomy. On introducing the hand, it 
was found that the fetal pulsations had ceased, and the perforator was used. 
After a reduction of the size of the head, the forceps was again applied to 
the base, but the body could not be brought into the pelvis. I then turned 
and delivered an enormous child. Its exact weight was not determined, 
but I think it was as large a child as I ever saw. 
Eighteen months later she was again in labor, and I was again called to 
Prof. Davis’s assistance. The patient had been in active labor for several 
hours without making progress. The vertex presented in the O. L. P. 
position. The forceps was applied under anesthesia, but to no effect. 
Version was then performed, but it was with much difficulty that the head INDUCTION OF PREMATURE LABOR. 
9 
was brought into the pelvis. Forceps was reapplied and the head extracted 
but the child was dead. The weight of this child was less than the first 
but it was a iarge child. 
If a mistake was made in this case, it was in not resorting to version at 
first instead of applying the forceps. The delay was at the superior strait, 
and was due to the relative disproportion between the fetal head and the 
pelvic brim. The advantages of version in such a case are, first, that the 
soft parts of the child better prepare the maternal parts for delivery of the 
head ; second, that the after-coming head can be delivered through a nar- 
rower brim than the fore-coming head; third, that the forceps occupies a 
faulty position, being applied to the forehead and occiput; fourth, that the 
compression produced by the forceps increases the biparietal diameter, 
which corresponds with the contracted conjugate. These are criticisms 
easier made now than at the time, but with so large a child I doubt whether 
it could have been delivered alive through the pelvis by any means. 
The next year conception had again occurred and it was determined, in 
view of the experience in the first two pregnancies, to resort to induction 
of labor some time after the seventh month, the exact time to be determined 
by the estimated size of the fetus as the gestation continued. At about the 
thirty-thinl week of pregnancy, as nearly as we could determine, labor was 
induced by Krause’s method. At four o’clock in the afternoon an elastic 
bougie was introduced about seven inches into the uterus between the mem- 
branes and the posterior uterine wall, where it remained until labor was 
fully established. Labor pains began in sixteen hours, gradually increased 
in severity, and in six hours delivery was safely accomplished without very 
great difficulty. The weight of the child at birth was five and a half 
pounds. Lactation was soon established, and the child did well. It weighed 
nine pounds at six weeks of age, and twenty-two pounds at nine months. 
It is now a vigorous, healthy child. 
A possible criticism in this case might be that labor was induced 
slightly earlier than was necessary. We estimated the antero- 
posterior diameter of the pelvis to be a little over 3.5 inches, but 
with the history of the preceding deliveries of children of such 
unusual size we thought it not safe to defer action to a later period. 
The severe pains necessary to effect delivery, and the size of the 
child, so much beyond the average weight at that period of gesta- 
tion, lead me to believe that delivery could not have been success- 
fully accomplished if much longer deferred. 
The time at which labor should be induced will depend princi- 
pally upon the size of the pelvis. We must keep in mind the 
general fact that each day of intra-uterine life increases the chances 
of survival of the infant, and, therefore, we must not be too hasty 
in operating nor must we, on the other hand, postpone it until the 10 
STANTON, 
child is too large and the head too firmly ossified for safe delivery. 
Each day of delay, after the limit of safe delivery, adds to the 
danger to both mother and child—to the child because mutilation 
is more frequently required, and to the mother because the difficulties 
of mutilating operations increase with the increasing disproportion 
between the fetal head and the pelvis. Ritgen, M. Figueira, and 
others have made measurements of the fetal head at different 
periods of gestation, and, from these, tables have been prepared for 
our guidance in determining the time at which labor should be 
induced. 
Beginning at the seventh month, the earliest time at which labor 
should be induced, the biparietal diameter, which in cases of antero- 
posterior contraction must correspond with the conjugate, is 2.75 
inches. Allowing for some compression of the head inconsequence 
of incomplete ossification, a fetus at seven months could safely pass 
through a pelvis measuring 2.25 inches; hence, with that amonnt 
of contraction, the induction of labor should not be delayed much 
after the end of the seventh month. There seems to be a general 
consensus of opinion that if the conjugate is 2.5 inches, the time of 
election should be about the thirtieth week. Starting from this 
point, it might be stated in general terms that for each quarter of 
an inch increase in the size of the pelvis one week may be added to 
the time that gestation may be permitted to continue. 
This general estimate of the time as dependent upon the size of 
the pelvis does not exactly conform to the calculations of Ritgen, 
whose estimates would call for operation one week earlier. One 
writer, M. Busch, a number of years ago, fixed upon the end of 
the twenty-eighth week as the proper time for inducing labor when 
the conjugate is 2.75 inches. This is certainly unnecessarily early 
when the pelvis is of such dimensions. It might, with safety, be 
deferred three weeks. 
There are some exceptions to the rule given and to the tables 
published, fixing the time of operation in different degrees of de- 
formity. Primiparse generally bear smaller children and might be 
permitted to go a week or two longer. 
There are two difficulties in these cases. One is in determining 
the period to which gestation has advanced. But, counting from the 
date of last menstruation and from the period of quickening, a suffi- 
ciently accurate estimate can generally be made. In cases of doubt, INDUCTION OF PREMATURE LABOR. 
11 
when the pelvis is so contracted as to call for operation early in the 
seventh month, it is recommended that two weeks be added to the 
time that gestation may continue in order to prevent too early 
delivery of the child. The other difficulty is our iuability to deter- 
mine exactly the diameters of the pelvis in the living subject. 
Pelvimetry is not an exact science, but a well-practised finger will 
give sufficiently accurate information. 
What has been said in regard to the induction of labor in con- 
tracted pelvis, applies as well to cases where the genital canal is so 
narrowed by tumors connected with the pelvic organs or with the 
pelvic walls, that a child cannot be born at term. 
The induction of labor is called for in some conditions entirely 
unconnected with pelvic distortion. Cases occasionally occur in which 
pregnancy is associated with various constitutional diseases, in such 
a way as to render it incumbent upon the physician to induce pre- 
mature labor, with the view of saving the patient’s life or of miti- 
gating great suffering. It is difficult to specify all of the conditions 
in which the operation is justifiable. In general terms, it may be 
stated that when the life of the mother or child is imperilled by con- 
tinuance of pregnancy to term, by complications due to or aggravated 
by pregnancy that can be removed by delivery, the induction of 
labor is not only a justifiable operation, but is a duty of the physi- 
cian. A few of these conditions may be referred to. 
Unavoidable Hemorrhage.—A condition in regard to which 
there can be but little difference of opinion as to the propriety of 
resorting to induction of labor, is unavoidable hemorrhage. This 
is the second condition in point of time for which it was performed. 
This is the only condition in which Baudelocque made any excep- 
tion to his rule of condemnation of artificially induced labor. In 
the London Practice of Midwifery is the following aphorism in 
regard to unavoidable hemorrhage: “ He that determines to deliver 
early has determined that his patient shall not die.” Cases of 
accidental and unavoidable hemorrhage are often so urgent that 
labor must be induced for the sake of both mother and child. I 
think there is as general agreement in regard to resort to the opera- 
tion in these cases as in cases of contracted pelvis. Dr. Thomas 
urges rapid induction of labor in placenta previa, as we then have 
better chances of saving both mother and child, for we will then be 
dealing with a woman not exhausted by hemorrhage, the obste- 12 
STANTON, 
trician can be present at the beginning of labor and be better pre- 
pared to control flooding, while the pressure that controls the hem- 
orrhage dilates the os. The following is a case in point. 
Case II.—Mrs. B., a multipara, to whom I was called July 1, 1888. On 
my arrival at the house I found that she was bleeding profusely, hut labor 
pains had not been felt. She had not expected labor until the latter part 
of the month. It was her opinion that she had advanced about one week 
in the last month of pregnancy. She had had a hemorrhage six weeks 
before, but not so profuse as now. 
Recognizing the case as one of placenta previa, a vaginal tampon wras 
inserted, which arrested the bleeding. In two hours slight labor pains were 
felt. They gradually increased in severity, and at times it became necessary 
to introduce more cotton to control the bleeding. In seven hours, the pains 
becoming energetic, and the hemorrhage recurring, Prof. Mackenzie, who had 
been called to my assistance, gave an anesthetic, and I removed the tampon. 
Finding the os sufficiently dilated to permit version, I separated the placenta 
at its posterior border sufficiently to permit the introduction of the hand to 
the upper part of the uteius, when the membranes were ruptured and the 
feet brought down. Speedy delivery of a living child followed. The re- 
covery of the mother was slow, owing to the great loss of blood. 
In this case I was not called upon to induce labor, but to a 
woman bleeding before she had experienced any labor pains. The 
treatment which I regarded as best calculated to arrest flooding was 
that sometimes resorted to, to excite uterine action, and in this case 
a double indication was fulfilled by the tampon. The prompt 
action in this case and the delivery of a living child, were fortunate 
circumstances in a condition well calculated to excite the gravest 
fears. If labor had been induced before the occurrence of the 
second hemorrhage, much blood might have been saved to the 
mother and a source of danger to both mother and child avoided. 
Puerperal Convulsions.—In eclampsia, with or without 
albuminuria, when the attacks are so severe or frequently re- 
peated as to threaten life, and the means usually invoked to arrest 
the convulsions have failed, the operation is indicated. In regard 
to this, however, there have been and still are some differences 
of opinion. Some writers go so far as to advocate the induction of 
labor in cases of persistent albuminuria, although convulsions may 
not have occurred. Simpson reported to the Edinburgh Obstetrical 
Society that he had induced labor in a case of pregnancy, on account 
of extreme dropsy and dyspnea with albuminuria. The patient INDUCTION OF PREMATURE LABOR. 
13 
who was apparently dying at the time, made a speedy recovery. 
Chailly, Krause, Tarnier, and others have advised premature de- 
livery in these cases. Playfair says, “ I should not hesitate to adopt 
this resource in all cases in which the amount of albumen is con- 
siderable and increasing, and in which treatment has failed to lessen 
the amount; and, above all, in every case attended with threatening 
symptoms, such as headache, dizziness, or loss of sight. The risks of 
the operation are infinitesimal compared with those which the 
patient is running in the event of puerperal convulsions supervening, 
or chronic Bright’s disease becoming established. As the operation 
is seldom likely to be indicated until the child has reached a viable 
age, and as the albuminuria places the life of the child in danger, 
we are quite justified in considering the mother’s safety alone in de- 
termining on its performance” (Science and Practice of Midwifery, 
3d Amer. ed., p. 201). This is stronger advocacy of the operation 
than we generally find among American writers. Dr. Fordyce 
Barker, in an article in the American Journal of Obstetrics for July, 
1878, opposes the induction of labor in albuminuria until after 
appropriate treatment has been thoroughly and persistently tried 
without success, and the symptoms are so grave that there is strong 
probability of the death of the mother. Convulsions do not always 
occur when albuminuria is present, or, if they occur, they may not 
cease on completion of labor. Again, cases are recorded of sub- 
sidence of albuminuria and convulsions under treatment, and the 
women have gone to full time and been delivered without convul- 
sions returning. The occurrence of convulsions is not, in my 
opinion, a justification for resorting to induction of labor until all 
other means have been exhausted. If the labor can be deferred 
and treatment addressed to the renal disturbance which is present 
in almost all of these cases, the condition of the mother may be so 
far improved that delivery may take place with perfect safety and 
freedom from convulsions. To induce labor in such a case is often 
to add fuel to the flame. To the irritations which have excited 
the convulsive attacks are superadded the pains and exhaustion of 
labor. Cases in which induction of labor may be demanded by 
puerperal convulsions are of extremely rare occurrence. So expe- 
rienced an obstetrician as H. L. Hodge said, as late as 1866, that 
he had not yet seen one case. Still there are exceptional cases 
where pregnancy is so far advanced that the child would encounter 14 
STANTON, 
but little risk, in which the operation might be of advantage. It 
ought not to be absolutely discarded. 
Persistent Vomiting.—In the persistent vomiting of pregnancy 
there has not been general consent as to the propriety of the opera- 
tion. The weight of authority seems to be against it. It is cer- 
tainly seldom to be sanctioned. Fortunately, cases of continuance 
to the period of viability are of rare occurrence. So rarely does 
this condition prove fatal that, if the principle were sanctioned, the 
dangers to mother and child of artificially induced labor would 
result in the aggregate in greater loss of life than is occasioned by 
obstinate vomiting. So great is the distress of the patient and so 
urgent the solicitations of her friends, who are anxious only for her 
safety, that the physician may be tempted to yield his judgment to 
their importunities. If, however, all of our resources fail to give 
relief, and the life of the mother is threatened, premature labor 
may be induced. 
Acute and Chronic Diseases.—The operation has been recom- 
mended and performed in a number of acute and chronic diseases, 
where pregnancy has endangered the life of the mother and where 
the end of gestation would enhance her chances of recovery—as 
acute dropsy, alarming hemorrhage from the bowels, heart disease, 
severe chorea, mania dependent upon pregnancy, and some other 
nervous disorders. 
In some chronic affections which are necessarily fatal, sooner or 
later, to the mother, in which there are serious symptoms, the opera- 
tion has been resorted to, but, in my opinion, improperly unless the 
disease is so favorably affected by the termination of pregnancy that 
the mother’s life can be considerably prolonged. 
In hydramuios and abdominal tumors causing great distention, 
it is sometimes required. In these cases premature labor sometimes 
comes on spontaneously. 
In rapidly growing carcinoma and epithelioma of the uterus it 
may become necessary. 
My limits will not permit me to consider at full length the pro- 
priety of the procedure in all of the morbid conditions in which it 
may be required, nor is it necessary if we keep in mind the general 
statement already made, that when the condition of the mother or 
child renders the continuance of pregnancy to full term dangerous 
to both, or 10 either of them, and the danger can be removed by INDUCTION OF PREMATURE LABOR. 
15 
delivery in the seventh or eighth month without the substitution of 
a greater danger, the induction of labor is a justifiable procedure. 
If the operation is not indicated to save the life of the mother or 
child, it is criminal. 
Methods of Induction.—The propriety of resorting to induc- 
tion of labor and the time at which it should be done having been 
determined, the next question is: By what method can uterine 
action be started with greatest certainty and the least risk to the 
life of the mother and child? This is an important question. 
Upon its determination may depend the success or failure of the 
case. The operative procedure should be simple and safe, and the 
one that most surely induces uterine action without impairing the 
integrity of the ovum, is the one that will be safest for both mother 
and child. The more nearly artificial labor is made to correspond 
to natural labor the more likely is it to be successfully accom- 
plished. It should go on as quickly as compatible with safety to 
the patient, and after action is excited it should not be hastened 
by further artificial means, except when the interest of the mother or 
child demands them. The indications for interference or assistance 
in these cases would be the same as in labor at term, keeping in mind 
that we are dealing with a child of low vitality, and that the opera- 
tive procedures, such as version or use of forceps, would be more 
likely to result unfavorably than if the fetus had arrived at the 
full period of gestation. The physician who undertakes to induce 
labor owes to his patient his entire time, and the only attentions 
she should have at his hands should be those intended to conduct 
the labor most safely to a successful termination. 
There are numerous methods of inducing labor, and great im- 
provements have been made in them in the last few years. The 
choice of methods will, to some extent, depend upon the condition 
calling for the operation. A method applicable in contracted pelvis 
would not answer in a case of hemorrhage. The choice is not a 
matter of indifference. Some are safe but uncertain ; some are 
certain but unsafe. 
They may be divided into three general classes : 
1st. Those supposed to excite uterine contraction by acting 
through the general system. 
2d. Those acting by reflex irritation by excitation of some other 
organ, as the breasts, rectum, etc. 
3d. Those acting directly upon the uterus. 16 
STAXTON, 
Oxytocics.—Of the first class, ergot, cotton root, quinine, savin, 
rue, pilocarpine, and some other drugs, have been used. These are 
very uncertain, unpleasant, and unsafe. All oxytocic medicines 
are dangerous to the mother and child. If they have the power to 
excite uterine action, it is a tonic contraction not resembling uterine 
action in labor. Ergot was the medicine formerly most used, but 
its use is abandoned for exciting premature labor. Its use in labor 
at any time, is not, I think, admissible, except, perhaps, in the 
third stage,—certainly not until the maternal parts are in a condi- 
tion that delivery can be soon completed if the uterine contractions 
are not effective. Quinine has also been recommended, but while 
it has the power of increasing uterine action when started, it cannot 
awaken it. Pilocarpine, first recommended by Schauta, of Vienna, 
is the newest agent of this class, but it is very uncertain as a 
means of exciting action, is attended with great distress, and some- 
times gives rise to symptoms of poisoning. We may pass by 
all internal remedies that have yet been named as unsafe and 
uncertain. 
Of the second class, it may also be said that they are uncertain. 
Scanzoni was induced to try excitation of the breasts by blisters, 
rubber suction-bulbs, etc., to excite uterine action from observing 
the active sympathy between the breasts and the uterus. This 
method has failed much oftener than it has succeeded, is painful, 
has excited mammitis, and has been correctly classed as “ un- 
scientific.” 
Electricity.—Of the third class of agents, those acting directly 
upon the uterus, there have been many suggested. Some are slow 
in action, some uncertain, and some are attended with danger. Direct 
stimulation of the uterus by electricity—galvanism and faradism— 
has been recommended, and a certain measure of success has 
attended its use; but if used strong enough to be surely effective, 
it may be dangerous to the child. Killian, Schrieber, M. Dubois, 
and many others have used electricity without success. Schreiber 
has tried galvanism, Dorriugton and Simpson used electro-mag- 
netism, Henning used faradism, but the weight of testimony seems 
to be against their reliability. Baird speaks very highly of faradism 
as a stimulus in uterine inertia, but whether it will be found to 
start true labor pains is yet uncertain. Experience has not borne out 
the hopes at one time entertained for the various forms of electricity. INDUCTION OF PREMATURE LABOR. 
17 
Tampons.—Another method is by excitation of the cervix by 
means of tampons in the vagina. Cotton, bladders and rubber-bags 
filled with water, have been used, and this method has its advan- 
tages in some cases. They are especially useful in those cases in 
which labor is to be induced for arrest of hemorrhage, having the 
advantage of arresting bleeding at the same time that they excite 
uterine action and produce dilatation of the os. In cases of placenta 
previa they may be resorted to either alone or in connection with 
other methods of exciting labor. 
Kiwisch’s Method.—Hot water injections into the vagina were 
introduced into obstetric practice by Kiwisch. These douches were 
used somewhat warmer than the temperature of the body. They 
are very uncertain in the time required to excite uterine action, and 
sometimes fail altogether. They can be made more etfective by 
using alternately hot and cold water. 
Dilatation of the Cervix.—This has been resorted to by many 
obstetricians. It was first etfected by means of compressed sponge. 
Berninghausen was the first to suggest it, but Kluge first prac- 
tised it, and it is sometimes spoken of as Kluge’s method. Simp- 
son was the first to use this method in Great Britain. It has 
its advantages and disadvantages. It is speedy in action and keeps 
the membranes entire, but the introduction of the tents is not always 
easy, their action causes much pain, aud as they favor rapid decom- 
position of the secretions, and cause more or less abrasion of the 
mucous membrane, they are attended with risk of septic infection. 
Metallic dilators have been used, and by their use the last objection 
to sponge-tents has been avoided, but they are painful and liable to 
rupture the membranes. Barnes has recommended the dilatation 
of the cervix by means of rubber-bags introduced in the os, and 
distended with water by means of a syringe These instruments not 
only excite uterine action, but they dilate the os, and the process is 
made closely to resemble natural labor. While, perhaps, not the 
most desirable method of exciting labor, the dilators are of great 
service in dilating the os after the uterine action is set up, and they 
will find a place in many cases, more to accelerate than to initiate 
labor. 
Cohen’s Method.—A method first suggested by Schweighauser, 
of Strassburg, about 1820, but first tried about forty-two years ago, 
by Cohen, of Hamburg, whose name it bears, consists in the injec- 18 
STANTON, 
tion of a small amount of water, at about the temperature of the 
body, between the membranes and the uterus by means of a syringe 
holding about an ounce to an ounce and a half. This method 
possesses the advantage of exciting labor so gradually as to dilate the 
os before the membranes are ruptured, but it is not free from danger. 
It is prompt in action in most cases, but sometimes requires repeti- 
tion. It acts by separating the membranes, which awakens uterine 
contractions. The injection of air and carbonic acid has been 
resorted to for the same purpose. 
Hamilton's Method consists in detaching the membranes by pass- 
ing the linger through the os, and sweeping it around the lower 
portion of the uterus. 
In Mampe's Method a bougie is used instead of the finger. 
Lehmann, of Amsterdam, proposed and practised induction of 
labor by passing a bougie eight or ten inches iuto the uterus and 
immediately withdrawing it, the introduction being repeated if labor 
is not started within a day or two. 
The last three methods excite labor in the same manner as 
Cohen’s—by separating the membranes from the uterine walls. 
They are safe, if care is taken not to rupture the membranes, and are 
easy of execution, but they are not prompt in action. In one case 
I have known Lehmann’s method to fail where Cohen’s afterward 
succeeded. These methods are not adapted to cases in which the 
operation is done for hemorrhage. 
Krause's Method.—Krause, of Dorpat, has suggested the use 
of flexible catheters or bougies, to be introduced into the uterus 
between the membranes and uterine walls and permitted to remain 
there until the uterine action is excited. This is superior to Cohen’s 
method. It is more certain in its action, is not difficult of execution, 
but must be done with care lest the membranes be ruptured. It is 
not applicable to cases of hemorrhage unless associated with plug- 
ging the os or vagina. 
Scheele’s Method.—The method usually had recourse to fifty 
years ago, and on which great reliance was placed, was the sudden 
evacuation of the liquor amnii. It never failed to bring on labor, 
but the time varied from a few hours to a few days. Gradual 
evacuation of the water was also resorted to, but the former method 
was generally recommended for the reason that the sudden evacua- 
tion was more likely to excite brisk action. INDUCTION OF PREMATURE LABOR. 
19 
These methods are unsafe because of the increased difficulty and 
dauger in cases of too early rupture of the membranes. The danger 
of some of the other methods named, is their liability to interfere 
with the integrity of the ovum before the dilatation of the os has 
taken place. 
From this brief mention of the methods of exciting uterine action, 
we see that there are many of them. I have not named all, but I 
have referred to most of those that have at different times been 
most relied upon. 
The safest, and generally the simplest, methods are those by 
which the dilatation of the os uteri is effected slowly and gradually 
while the membranes are entire. Those methods that have for 
their object the rapid dilatation of the os and cervix are unsafe, 
and generally unnecessary. 
It is important to get the child to present at the superior strait by 
the head and have it delivered by a head presentation, if a natural 
delivery can take place. If assistance is required and a choice is to 
be made between forceps and version, the question must be deter- 
mined by the conditions of the particular case—conditions which it 
is not within the scope of this paper to consider. 
The method to which I would give preference, except in cases of 
hemorrhage, is that of Krause, a flexible bougie in the uterus, to be 
followed, if necessary, by dilatation of the os by Barnes’s dilator. In 
a case attended with hemorrhage, I would resort to plugging the 
vagina and after sufficient action has been excited, would introduce 
a Barnes’s dilator into the cervix. 
After labor, the child will demand especial attention. It must 
be kept warm contimiously by artificial means. Its circulation is 
feeble and the bath usually given to newborn children must be 
omitted. The body may be rubbed with warm lard, warmly clothed, 
and kept in a room the temperature of which is uniformly high. 
Early feeding should be resorted to, the mother’s milk, or that from 
some other woman, being drawn by a pump and fed to the child by 
means of a spoon until it has sufficient strength to nurse.