CYCLOP/EDIA 
" or 
OBSTETRICS AND GYNECOLOGY 
THE PATHOLOGY OF LABOR 
The Uses of Ergot 
BEING VOLUME THREE OF 
A PRACTICAL TREATISE ON 
OBSTETRICS 
BY 
DR. A. CHARPENTIER 
ADJUNCT PROFESSOR AT THE FACULTY OF MEDICINE, PARIS 
TRANSLA TED UNDER THE SUPERVISION OF, AND WITH NOTES AND ADDITIONS 
BY 
EGBERT H. GRANDIN, M.D. 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL ; INSTRUCTOR IN GYNECOLOGY AT THE 
NEW YORK POLYCLINIC; FELLOW OF THE OBSTETRICAL SOCIETY, ETC. 
jfour Volumes 
TWO HUNDRED FORTY-EIGHT FINE WOOD ENGRAVINGS 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887, 
WILLIAM WOOD & COMPANY. 
The Publishers' 
Book Composition and Electrotyping Co. 
157 and 159 William Street 
New York CONTENTS OF VOLUME III. 
CHAPTER I. 
Anomalies in the uterine contractions: exaggeration, feebleness, perversion; ano- 
malies in the contraction of the abdominal muscles; fractures of the ster- 
num; sub-cutaneous emphysema; pelvic deformities; pelves deformed by ex- 
cess in size; pelves deformed by diminution in size; the generally and regu- 
larly contracted pelvis, the irregularly contracted, the flattened, the ra- 
chitic, the pseudo-osteomalacic, the osteomalacic, the oblique-oval, the trans- 
versely contracted, the lordotic, kyphotic, ky pho -scoliotic, kypho-scolio-ra- 
chitic, the spondylezematic and spondylolisthetic; unilateral luxation of the 
femurs; double congenital luxation of the femurs; pelves obstructed by 
morbid growths; the diagnosis of pelvic deformity; mensuration, pelvimetry, 
pelvigraphy; pregnancy in case of pelvic deformity and delivery; physiologi- 
cal and mechanical phenomena of labor in case of pelvic deformity; the prog- 
nosis of labor in case of pelvic deformity-for the mother, for the infant; 
treatment in pelvic deformity-version, forceps, premature .labor; dystocia 
due to the maternal soft parts: narrowness and rigidity of vulva and of va- 
gina, laceration of the perineum, malformation of the genital organs, throm- 
bus of the vulva and the vagina, prolapse of the vagina, tumors of the vulva 
and the vagina, hernias; dystocia due to obstacles in the cervix: rigidity, ob- 
literation, deviation, cancer, fibrous tumors, ovarian tumors; ruptures of 
the uterus, of the vagina; puerperal hemorrhages: placenta praevia; artificial 
third stage of labor and its causes: inertia of the uterus, excessive size of the 
placenta, adhesions, spasmodic contraction of the uterus; inversion of the 
uterus; secondary puerperal hemorrhage, .... pages, 3 to 249. 
Dystocia due to the foetal annexes : anomalies of the cord, prolapse of the cord; 
dystocia due to the foetus itself; excess in size of the head or of the body 
without pathological alterations; hydrocephalus, encephalocele, hydrothorax, 
ascites of the foetus, diseases of the foetal urinary apparatus, retention of the 
urine in the foetus, tumors of the ano-perineal region, spina bifida; tera- 
tology: hermaphroditism, monstrosities; dystocia in case of twin-pregnan- 
cies; dystocia due to abnormal presentations or positions, pages, 250 to 335. 
CHAPTER II. 
The uses of Ergot: its physiological and its pathological action; its indications 
during labor and during the puerperium, .... pages, 336 to 348. 
CHAPTER HI. PART VI. 
The Pathology of Labor. CHAPTER I. 
MATERNAL DYSTOCIA. 
^^NDER tne term dystocia we include all the causes which may ren- 
der labor difficult, impossible, or dangerous for the mother and 
child, and which consequently require more or less active interference on 
the part of the obstetrician. These causes may be grouped under the five 
following heads: 
1. An abnormal condition of the expulsory forces, which may be exag- 
gerated, diminished, or perverted. 
2. Obstacles or malformations, that prevent the normal expulsion of 
the foetus, either of the bony pelvis, in the soft parts or parturient canal, 
or in the vicinity of this canal. 
3. Pathological conditions that render the labor dangerous for either 
mother or child. The foregoing are called maternal causes of dystocia. 
Under foetal dystocia are included: 
4. Dystocia from accidents directly connected with the foetus (prolapse 
of the funis or extremities, etc.) 
5. Abnormal size (partial or total) or malformation of the foetus or its 
attachments. 
6. Abnormal presentation or position; which may be complicated with 
prolapse of a limb, or of the cord. 
In this chapter we will consider simply the causes which emanate from 
the mother. 
Abnormal Uterine Contractions. 
The uterine contractions may be exaggerated, diminished, or irregular: 
and although the exaggeration of the pains does not, as a rule, produce 
any other result than too rapid termination of labor, it may on account of 
this very fact become a source of different accidents to the mother and 
child, which justify us in studying it under the head of dystocia. 4 
A TREATISE ON OBSTETRICS. 
Excessive Contractions. 
There may be actual exaggeration of the contractions, their intensity, 
duration, frequency, or the accompanying pain, being singly or collec- 
tively increased. It may be relative, that is to say, the contractions are 
of normal character, but really become too strong in consequence of the 
diminution of the normal resistance (large pelvis, or small foetus), or 
the relaxation of the soft parts forming the canal, or because the sensi- 
bility is lessened. It is only necessary to compare labor in a primipara 
with that in a multipara, in order to understand that the resistance 
offered by the perineum plays an important part in the expulsion of the 
foetus, since in cases where the perineum offers only a slight resistance, 
normal uterine contractions will, by reason of the absence of the usual 
barrier, become too violent, and under certain conditions cause precipitate 
labor with its consequences. Excessive contractions are especially ob- 
served near the time of complete dilatation, and they go on increasing 
until the end of the labor, leaving the woman no interval of rest. They 
are then frequent, violent, and prolonged, while there is an absence of 
the intermission between the pains that characterizes normal labor; the 
uterus appears to be in a state of tenesmus. The pains may be normal, 
but the os, vagina, perineum, and vulva may stretch so easily, or the 
child may be so small, that it is rapidly expelled. Excessive contractions 
are observed in delicate, as well as in robust women; they sometimes 
appear to be an hereditary peculiarity. They are due, in general, either 
to exaggeration of the contractility of the uterus, or to excessive hyper- 
trophy of its muscular fibres. 
In consequence of the too rapid expulsion of the foetus, rupture of the 
perineum, vagina, or even of the' uterus, (cervix,) may occur, while the 
latter organ is affected by a subsequent inertia, that leads to retention of 
the placenta, hemorrhage, and inversion. The foetal circulation may be 
fatally obstructed by excessive uterine contractions, or the child may be 
expelled upon the ground, and thus be injured; the cord may rupture, 
and the placenta be detached. Although the prognosis is not positively 
bad, it is far from being insignificant. 
Treatment.-This consists, in the first place, in confining the woman 
to her bed at the outset of labor, and insisting on absolute repose and 
no straining. If her condition permits, chloroform or chloral may be ad- 5 
MATERNAL DYSTOCIA. 
ministered. Some writers advise rupture of the membranes, of which we 
disapprove. Opium is useful, especially when administered subcutane- 
ously. If the lower uterine segment tends to become prolapsed, it should 
be held up with the fingers. If the entire organ is prolapsed, it must be 
supported by a bandage, and replaced immediately after delivery. At 
the time of delivery we should be very watchful in order to foresee, and 
to recognize when they appear, uterine inertia and hemorrhage, so as to 
treat them instantly. Finally, after a precipitate labor the woman should 
be kept in bed for a long time, and should not be allowed to rise until 
involution is well advanced; this process seems to take place more slowly 
in such cases. Puerperal troubles are also common. 
Feeble Contractions. 
Feeble contractions are more commonly met with than excessive, but, as 
Schroedei' has justly observed, it is difficult to establish a rule as to what 
constitutes feeble pains. Very slight pains may, in a given case, be 
sufficiently powerful to allow labor to terminate, while very strong contrac- 
tions may be too feeble to cause the expulsion of the foetus. On the 
other hand, normal pains are characterized by their increase in strength 
and duration as labor advances. Now this peculiarity may be absent, 
the pains are too feeble, short and infrequent, or are sometimes almost 
entirely absent. This constitutes feebleness of the uterine contractions. 
This deficiency may appear at any stage in the labor, and may persist 
throughout the entire period, or, it may be confined to a single stage, that 
of dilatation, expulsion, or delivery; all degrees may exist, from simple 
irregularity to complete and prolonged suspension of the entire contract- 
ing force of the uterus. Naegele and Grenser recognize three varieties 
of inefficient pains, viz.: 1. Uterine inertia, in which the pains are weak, 
and reappear after long intervals. 2. Atony of the uterus, where they 
grow more and more feeble, and finally disappear entirely. 3. Paralysis 
of the uterus, where the organ may be completely relaxed. Cazeaux 
divides them into: Pains that are feeble at the beginning of labor; those 
which begin strongly, but subsequently diminish, or disappear entirely; 
and pains which present marked irregularity in their duration, intensity 
and recurrence. Jacquemier defines inefficient pains as those which are 
" unable to overcome the normal resistance to the expulsion of the foetus. " 
The English expression " tedious labor" is peculiarly appropriate. 6 
A TREATISE OX OBSTETRICS. 
If feebleness of the contractions is present during the first stage, com- 
plete dilatation may require from twelve hours to several days. The 
women may have regular pains, but these are separated by very long in- 
tervals, or the pains recur frequently, but are brief and slightly marked; 
again, they may be irregular in their appearance, duration and intensity. 
Two or three pains rapidly succeed one another, then comes an inter- 
val of repose, a fresh pain occurs, and is succeeded by slight and short 
ones, dilatation being discouragingly slow. If dilatation is finally accom- 
plished, it seems as if the uterus had exhausted all its energy, the pains 
cease, the membranes do not rupture, and labor is prolonged. 
In another case the first stage proceeds regularly, but as soon as dilata- 
tion has been completed, the pains become infrequent and feeble, the 
stage of expulsion being indefinitely delayed. If the membranes have 
ruptured, the presenting part of the foetus becomes the seat of a con- 
siderable swelling, which may lead the attendant to think that the child 
has descended, when in reality it remains stationary. 
Although retarded labor is usually borne well during the first stage, it 
is not the case during the second. If the latter is prolonged, in addition 
to the fatigue produced by the length of the labor, there is often vomit- 
ing, fever, a hot and dry skin, uneasiness, anxiety, tremor, a dry tongue, 
hot vagina, etc. The foetus is also affected, as shown by disturbance of 
the heart, and may perish purely from the prolongation of the labor. 
The long contact of the foetal head with the same point in the pelvis may 
cause sloughing of the maternal tissues, with the subsequent formation of 
fistulas, not to speak of the favorable condition in which the exhausted 
woman is placed for the occurrence of future septic infection. 
Causes.-These are often obscure, and feeble pains may be observed in 
robust, as well as in delicate females, in the young, as well as in those 
more advanced in years. They seem to be of more frequent occurrence 
in primiparae than in multiparse, however, and are often seen in women 
of marked adipose development. Sometimes, the uterine inertia results 
from a condition of general debility, caused by previous diseases, hemor- 
rhages, or bad hygienic surroundings. The uterus may itself be inert, or 
the feebleness may be to a certain extent hereditary, or acquired in con- 
sequence of severe labors, repeated abortions, or chronic leucorrhoea. 
Other causes are premature rupture of the membranes, hyper-distension 
of the uterus (twin pregnancy, hydramnios, fibrous tumors, etc.), death MATERNAL DYSTOCIA. 
7 
of the foetus, prolongation of the first stage, and endometritis (Grenser). 
To these may be added uterine congestion and inflammation, biliousness, 
gastric irritation, distension of the bladder, and mental emotions (fright, 
anger). The arrival of the physician, or the presence of obnoxious per- 
sons, may produce the same effect, although in this case the cessation of 
the pains is only temporary. 
Prognosis.-1. For the Mother.-This is usually without gravity during 
the first stage, when the effects are limited to the fatigue, agitation, and 
impatience experienced by the patient; but the prognosis may become 
more serious if the period is so extended that she is deprived of sleep, 
loses her appetite, and becomes thoroughly exhausted. During the 
second stage it becomes still more serious, because, aside from the exhaus- 
tion of the mother, the pressure of the foetal head may cause sloughing, 
with resulting fistulas or other grave effects. All writers agree in regard- 
ing retarded labor as one of the most potent causes of the serious puer- 
peral sequelae, without mentioning primary accidents (hemorrhage, etc.), 
which may occur at the time of delivery. 
2. For the Child.-As long as the membranes remain intact, feeble pains 
seem to be innocuous no matter how prolonged the labor may be. Thus, 
among 133 cases collected by Tarnier and others, in which the first stage 
was prolonged from twenty-four to sixty hours, only eight children were 
dead-born. After the rupture of the membranes, however, and when 
dilatation is complete, the case is different. Although the foetus may 
not be affected for a long time, because of the relaxed condition of the 
uterus, if the stage of expulsion is prolonged beyond eight or ten hours 
the placental circulation is disturbed, the heart-beats become irregular, 
and the children perish in a considerable number of cases. This period, 
eight to ten hours, seems to us too long, although fixed by Jacquemier, 
and, in our opinion, we should apply the forceps when the head has been 
arrested for an hour or two after reaching the pelvic floor, and thus both 
snatch the child from the perils that threaten it, and relieve the woman 
of unnecessary suffering. 
Treatment.-As Grenser justly observes, we must see if the retardation 
of the labor is really due to the inefficient contractions of the uterus, and 
if so, we must ascertain the cause of the anomaly. The uterus may be 
simply reposing, and in endeavoring to awaken the contractions, we may 
exaggerate them. The main indication is to control the forces of the 8 
A TREATISE ON OBSTETRICS. 
uterus at the outset, so that they may be sufficient for each stage of the 
labor. Do not impose any arbitrary position upon the patient, but allow 
her to assume the one that is most agreeable to her. Some women have 
stronger pains when lying upon the back, others when standing. Give 
her a little light nourishment (tea, bouillon), and encourage her kindly, 
but do not fix any time for the termination of the labor. Avoid frequent 
examinations, as they are both useless and wearisome; note the condition 
of the bladder and rectum, and empty them if necessary. If the woman 
is weak, give light stimulants. If she is wearied by ineffectual pains, it 
is a good plan to give her fifteen or twenty drops of laudanum, or a 
drachm of chloral, by the rectum. Warm vaginal douches and baths will 
sometimes give great relief. Above all, wait; do not be in a hurry to 
interfere, but gain time by soothing the patient. If the pains continue, 
but are feeble and irregular, the membranes may be ruptured, but only 
under the following conditions: 1. The os must be dilated to some extent, 
and the cervix must not be rigid. 2. Both the position and presentation 
must be favorable. 3. The pelvis must be well-proportioned. 4. There 
must be no complications, such as prolapse of the cord, or of a limb. If 
accomplished with care, and with due regard to these conditions, the 
operation is often very useful. Do not act too hastily; rash interference 
is, in the great majority of cases, more dangerous than expectant treat- 
ment. 
For feeble pains during the second stage of labor, a number of reme- 
dies have been suggested; they may be described as mechanical and dynam- 
ical. Among the former is posture; the woman may be caused to stand 
and walk about, but this often increases her fatigue and effects nothing. 
The Germans have recommended the use of Braun's colpeurynter, and 
the introduction of a bougie into the uterine cavity; the latter method is 
often useful, but it is sometimes inconvenient to leave a foreign body in 
the cavity for several hours. Kristeller has suggested uterine expression, 
a manipulation which consists in grasping the uterus with both hands, in 
such a way that the ulnar border of each hand is turned toward the pelvis, 
while the palm encircles the fundus on each side, and exerting firm pres- 
sure downwards, at the same time squeezing the organ between the hands. 
The pressure is maintained from five to eight seconds, then the operator 
rests for half a minute (sometimes two or three minutes), when the same 
manoeuvre is repeated, and this is done from ten to twenty or forty times. MATERNAL DYSTOCIA. 
9 
If the patient is very sensitive it may be necessary to administer chloro- 
form. Suchard mentions the following indications for expression: 1. 
Arrest of labor from uterine inertia, when the os is not sufficiently dilated 
to allow the introduction of the forceps. 2. Spasmodic contractions of 
the os. 3. Arrest of the head, in breech presentations, after the trunk 
has been expelled, whether this arrest is due to contraction of the cervix 
or to resistance on the part of the perineum. 
We believe that these propositions are exactly opposed to all the prin- 
ciples of rational practice. If the uterine contractions are arrested at a 
period when the os is not sufficiently dilated to permit the introduction of 
forceps, it is better to wait if the indications are not urgent, or to dilate 
rapidly and apply forceps if they are. Kristeller's method seems to op- 
pose rather than to favor dilatation when the cervix is the seat of spas- 
modic contraction, because by exciting the uterus to fresh action we only 
increase the irritability of the circular muscular fibres. Finally, the for- 
ceps applied in practised hands are preferable to expression as a means of 
overcoming the resistance of the perineum. The hot vaginal douche, re- 
peated two or three times and continued for about ten minutes, is a use- 
ful agent. 
Among the dynamical means may be mentioned cinnamon, borax, ergot, 
especially the latter. The latter possesses advantages, but its use is dan- 
gerous for the mother, in that it produces tetanic contraction of the 
uterus, and for the foetus, since it causes profound disturbance of the 
placental circulation. Ergot should be absolutely rejected during labor, 
not only in the first stage, but in the second and during the third, its 
use being confined to the period after the expulsion of the placenta. 
This is the dictum of Pajot, who affirms that ergot should not be admin- 
istered until the uterus is entirely emptied of its contents, including the 
foetus, placenta, and blood-clots. Cannabis Indica, pulsatilla, uva ursi, 
and pilocarpine, have been recommended. Electricity was first proposed 
by Herder in 1803; was first employed by Henninger and Jacoby, and its 
use was revived by Saint Germain in 1869. The latter experimented with 
galvanism, employing the Ruhmkorff apparatus. He decided that the 
galvanic current caused a notable increase in the number and strength of 
the uterine contractions, that the os dilated steadily and. rapidly under its 
influence, and that neither the mother nor the child suffered harm, while 
file placenta was invariably expelled spontaneously and immediately after 10 
A TREATISE ON OBSTETRICS. 
the birth of the child. Apostoli stated to the Academy of Medicine, in 
1881, that he was accustomed to use the faradic current as soon as the 
child was delivered, introducing one pole into the uterine cavity. He 
claimed that involution was hastened in this way, while no bad results fol- 
lowed. It is precisely in the conditions described by Apostoli as favor- 
able for the employment of electricity, that we regard its use as unjusti- 
fiable. The woman should be kept absolutely quiet during the five or six 
days following delivery; such interference as he describes is not only use- 
less, but dangerous. 
The best way to accelerate labor during the second stage is to termi- 
nate it either by extraction or by the forceps, but we must not interfere 
too hastily. We wait from three to six hours after the rupture of the 
membranes, according to the condition of the mother and child, and the 
elevation of the presenting part. When the head has remained for two 
hours in the vagina, without making any progress, we do not wait longer, 
but deliver with the forceps, even when the child is in no danger, in order 
to spare the mother from unnecessary prolongation of the labor. If the 
child is in peril, we of course interfere sooner. This problem becomes 
one of the most difficult of solution, when the life of the child is threat- 
ened, before the os is dilated. In this case we should carefully try ex- 
pression, but if the latter was not immediately successful, and the disturb- 
ance of the foetal circulation increased, we should not hesitate to incise 
the cervix in one or two places, and to extract the child. But such cases 
are rare, because, as we have said, feebleness of the uterine contractions 
does not affect the foetus during the first stage, while during the second 
stage extraction and completion of the labor arc not, as a rule, attended 
with serious difficulties. 
[For ineffective pains during the first stage of labor, we know of noth- 
ing which will give better results than chloral. This drug regulates the 
pains, increases the interval between them, gives the mother rest, and 
thus restores her nervous force. We would administer the drug in fifteen 
grain doses every quarter of an hour, for four doses, or else give at once 
thirty grains per rectum, repeated in one half hour. 
For ineffective pains during the second stage, twenty grains of qui- 
nine have often increased the pains in our experience, and, in addition, 
we would strongly recommend the use of a mild faradic current, one elec- 
trode held by the patient, the other moved over the abdomen.--Ed.] 11 
MATERNAL DYSTOCIA. 
Abnormal Contractions. 
The uterine contractions may be misdirected (perverted) or irregular 
in their course, or partial, only one portion of the uterus contracting, or 
the fundus alone may contract, the inferior segment being quiescent. 
Sometimes the entire organ remains in a state of tetany, sometimes the 
fundus, the inferior segment, or one horn contracts at irregular intervals, 
when the organ presents a nodular shape.. No impulse is communicated 
to the foetus, and the membranes do not protrude during the pains, while 
the cervix remains hard, retracted and undilated, and is very sensitive. 
If this condition persists, and the contraction is confined to the region 
of the isthmus, hour-glass stricture results; if it involves the entire uterus, 
it is called tetanus uteri. As a rule, such spasmodic contractions only 
appear towards the end of the period of dilatation; they sometimes occur 
after the passage of the head, and are confined to the region of the os 
internum, where the foetus is grasped like a stud in a button-hole. The 
stricture may be at the os externum. When very violent, spasmodic con- 
tractions are attended with extreme pain, great agitation and fever; the 
genitals become hot and sensitive. The pain extends to the loins, thighs, 
and entire abdomen, the patients complain of cramps and reflex pains, 
while in some cases delirium and convulsions may occur. In spite of the 
violence of the pains, labor makes no progress. 
Causes.-- Although they may be due to some extent to the general 
condition of the patient, there are two agents that are particularly re- 
sponsible, ergot and unskillful excitation of the uterus, and especially of 
the cervix. How often does the injudicious use of ergot give rise to this 
spasmodic retraction, not only of the cervix, but of the entire uterus ? 
How often are frequent examinations, excessive friction of the uterus, and 
awkward attempts at version, applying the forceps, and hastening deliv- 
ery, followed by consequences extremely serious to the mother. 
Treatment.-Seek for thecause of the spasmodic contraction, and apply 
one of the following remedies, as it may be suitable: Dover's powder, 
laxatives, ipecac, in hourly doses of from f to If grains, enemata contain- 
ing antispasmodics or laudanum, valerian, and camomile, warm injec- 
tions or baths, and applications of belladonna ointment to the os. Lebert 
advises injections of morphine; Breslau injections of atropine; bleeding 
up to the point of syncope has been recommended. The best remedies 12 
A TREATISE ON OBSTETRICS. 
are chloral (by the rectum) during the first stage, and chloroform in the 
second. Do not practise manual dilatation, but incise the cervix if it be- 
comes necessary to interfere immmediately in the interest of the child. 
[Instead of incising the cervix we should be in favor of chloroforming 
the patient, and gently dilating the cervix by means first of one finger and 
then another. This method is warmly commended by Sinclair, of Bos- 
ton, Gillette, of New York, and others. It has answered us well.-Ed.] 
Irregular Contraction of the Abdominal Muscles.-Fracture of the Sternum. 
-Subcutaneo us Emphysema. 
The contractions of the abdominal muscles are partly subject to the 
patient's will, and it is common to see women making violent efforts, and 
exaggerating these contractions. Fracturf of the sternum may rarely re- 
sult from excessive straining; subcutaneous emphysema, following rupture 
of the pulmonary vesicles, is not so rare. It usually appears on the neck, 
face and chest. Haultcoeur reports 11 cases, and we have seen 2. This 
emphysema is usually of no significance when it extends to the medias- 
tinum and neck, but when it is confined to the pulmonary parenchyma, 
the result may be fatal. 
The abdominal contractions may be too feeble, either because of the 
severe pains, or because the women are weakened by pre-existing diseases 
(cardiac, pulmonary, etc.) Paraplegia sometimes plays an important 
part. Although feebleness of the abdominal contractions is insignificant 
in itself, when associated with ineffectual uterine contractions it may 
retard labor, and thus constitute an indication for artificial delivery. 
Malformation of the Pelvis. 
Whenever the pelvis varies from the normal type to such an extent as 
to render labor difficult or dangerous for the mother, the child, or both, 
it is said to be malformed. Deviations from the normal may exist in the 
form, structure, and dimensions of the pelvis, or in the direction of its 
planes and axes. There are accordingly three principal varieties, pelves 
that are too large, those that are too small, and those having an abnormal 
inclination. The second variety is by far the most important. MATERNAL DYSTOCIA. 
13 
Abnormally large Pelves. 
These preserve their relative proportions, their only striking features 
being the increase in theii' diameters, and the thickness and solidity of their 
Fig. 1.-Abnormally Large Pelvis. (Depaul.) 
walls. They are met with in females of large stature, also in those of 
small or medium size. Burns has described two pelves in which each of 
the diameters was increased about four-fifths of an inch; De la Tourette 
Fig. 2.-Large Pelvis (Diagrammatic.) (Pinard.) 
saw one in which the antero-posterior diameter at the brim measured 
nearly six inches, the transverse nearly seven inches, and the corre- 
sponding diameters of the inferior strait nearly six inches. Depaul gives 14 
A TREATISE ON OBSTETRICS. 
the following dimensions of a specimen in his collection: Antero-poste- 
rior diameters, 5.2, 4 and 5.8 inches, transverse, G.4, 4.8, and 5.4 inches, 
oblique, G, 4.7, and 5.4 inches. In this pelvis the distance between the 
antero-superior iliac spines was 11.2 inches, the bis-iliac diameter was 
12.8 inches, and the breadth of the symphysis, 2.4 inches. Sometimes 
the increase in size is confined to the upper portion (funnel-shaped pel- 
vis), or the inferior half alone may be enlarged either on both sides or 
on one alone (as a result of fractures or dislocation). Such pelves give rise 
Fig. 3.-Large Pelvis (Diagrammatic.) {Pinard..} 
to certain disadvantages, viz.: The non-gravid uterus is more liable to 
become displaced. During pregnancy the organ remains longer within 
the true pelvis, and may thus cause disturbances of the bladder and rec- 
tum; it is prone to become retroverted, and towards the end of preg- 
nancy, the head may descend so low as to affect the other viscera. The 
labor may be precipitate, and we may have in consequence rupture of 
the perineum and post-partuni hemorrhage. After delivery there is a 
tendency to displacement of the uterus, especially to prolapsus, most 
common in women who leave their beds too soon. 
Contracted Pelves. 
Frequency. -Narrowing of the pelvis is most common in countries in 
which diseases that affect the shape and development of the pelvis are MATERNAL DYSTOCIA. 
15 
most frequent, especially in Flanders. Michaelis found narrowing in 72 
women out of every 1000, Litzmann in 145, Schwartz in 140. Schroeder 
believes that the flattened, non-rachitic pelvis is quite frequent in Ger- 
many, being found more often than any other variety of deformity. Nar- 
rowing of the superior strait is much more common, then comes contrac- 
tion of the inferior strait, and, finally, of the cavity, the two latter being 
nearly always associated. A pelvis may be diminished in all its propor- 
Fig. 4.-Woman with Justo-Minor Pelvis. 
Fig. 5.-The same ; Posterior aspect. 
tions, or it may be unequally contracted-that is to say, the normal rela- 
tion between its diameters may be altered. 
1. Generally ancl Regularly contracted Pelvis.-This pelvis (justo-minor) 
is characterized by shortening of its diameters, which, at the same time 
maintain their proper proportion to one another. There are two varieties. 
In the more common the pelvis differs only in size from the normal. 
(Figs. 4, 5). Its presence is not suspected before a vaginal examina- 16 
A TREATISE ON OBSTETRICS. 
tion is made during labor. The second variety is very rare, being only 
met with in dwarfs; the bones present the infantile type, being imper- 
fectly ossified, the sacral segments and the three portions of the os inno- 
Fig. C.-Absolute Contraction with Normal Shape. (Depaul.) 
minatum are separated by cartilage. The relations of the diameters to 
one another, however, and to the pubic arch are the same as in a perfectly 
developed female. Figs. 10 and 11 represent a woman the antero-pos- 
Fig. 7.-Generally and Regularly Contracted Pelvis. (Spiegelberg.) 
terior diameter of whose pelvis measured 2.2 inches. She was delivered 
with forceps of a living seventh months' child. 
Naegele has described a third form in which both the bones and the MATERNAL DYSTOCIA. 
17 
pelvic diameters present an infantile character; the condition being due 
to arrested development of the genital organs, which arrest may involve 
the entire skeleton, and even the intellectual faculties. It possesses 
no interest obstetrically. Only thirteen instances have been recorded. 
Depaul says: 11 We must not take in too strict a sense the expressions 
Fig. 8.-Dwabf's Pelvis. (Spiegelberg.) 
' uniformly contracted/ and ' regularly narrowed/ employed by writers 
to describe this variety of deformity. I have several pelves in which the 
diameters are all shortened, and the entire pelvis is quite regular. Hut, 
while the transverse diameter of the brim is shortened by only three-fifths 
Fig. 9.-Justo-Minob Pelvis. (Stoltz.) 
of an inch, the shortening of the antero-posterior reaches one and three- 
fifth inches, so that the pelvis as a whole is evidently flattened from before 
backward, and may strictly, by reason of its regular shape, be included 
among the rachitic pelves." Those obstetricians who have affirmed that 
Vol. III.-2 18 
A TREATISE ON OBSTETRICS. 
such pelves resemble the male type are incorrect; they differ from the 
latter in the slight projection of thin, bony prominences, the slenderness 
of the bones, the divergence of the pelvic arch, the size and depth of the 
iliac fossae, and finally, by the relatively increased capacity of the true 
and false pelves. 
The cause of this deformity is still uncertain. Depaul regards it as "a 
Fig. 10.-Woman with Phocomelacia. 
Fig. 11.-Posterior aspect of same. 
freak of nature, the cause of which is as difficult to understand as is every 
other defect in proportion in the skeleton." 
Diagnosis.-This can be positively made only by the vaginal touch. 
Prognosis.-It is very grave, since in thirteen cases observed by Lubac, 
ten women died and only three infants survived. It is so much the more 
serious, as there is nothing in the woman's stature to point to contraction, 
and the deformity is only recognized during labor, in consequence of the 
obstacles that prevent its progress. The prognosis varies according to the 19 
MATERNAL DYSTOCIA. 
time at which we are summoned to interfere. In our two cases, both pa- 
tients survived, one being delivered spontaneously at the seventh month, 
while in the other artificial labor .was induced at the eighth. 
II. Irregularly contracted Pelvis 
In this, which is the most common form, the contraction may exist in 
one or all parts of the pelvis. Although the variations are numerous, 
three fundamental types exist, viz.: 
1. Shortening of the antero-posterior diameter, resulting in flattening 
from before backward. 
2. Shortening of the oblique diameters, causing sinking in of the antero- 
lateral walls. 
3. Shortening of the transverse diameter, producing flattening or com- 
pression of the sides. 
If the contraction is situated at the superior strait, it causes approxi- 
mation of the anterior and posterior walls, while the rest of the cavity 
may be of normal size, or even enlarged; or the inferior strait may be in- 
volved, or both together, so that pelves of various shapes may exist (cor- 
date, reniform, etc.). The deformity may be confined to the sacrum or 
symphysis. 
a. The Sacrum.-The sacral curve may be exaggerated, the base of 
the bone projecting so far forwards as to increase considerably the promi- 
nence of the sacro-vertebral angle; sometimes the sacrum is entirely flat, 
or its concavity is replaced by a convexity, the line of junction between 
the first and second vertebra being so marked as to resemble a second 
promontory, the entire sacrum appearing to be moved forwards. Or, on 
the other hand, the sacral curve is exaggerated to such a degree that the 
bone seems to be bent upon itself; as a result we have increased projec- 
tion of the promontory and base of the sacrum, narrowing of the superior 
and inferior straits, and enlargement of the cavity. Sometimes the sa- 
crum appears to rock upon itself in such a manner that the base approaches 
the symphysis, while the lower extremity recedes, causing narrowing of 
the superior strait, with enlargement of the lower portion of the cavity 
and the outlet. 
b. Symphysis Pubis.-Instead of being convex, it may be flattened, or 
even convex posteriorly, forming the " figure-of-8 " pelvis. The entire 20 
A TREATISE ON OBSTETRICS. 
pelvis is then contracted (flattened pelvis); or the symphysis may be 
broader than normal, being more inclined from before backwards, or from 
behind forwards. 
c. Coccyx.-Anchylosis of the coccyx may cause variations in the antero- 
posterior diameter of the outlet. 
There is another change which affects the superior strait, due to spondy- 
lolisthesis. The promontory is then formed, not by the sacrum, but 
by one of the lumbar vertebra?, and the brim is thus contracted, some- 
times to an extreme degree. In some instances the symphysis is flattened 
by reason of the compression of the horizontal rami of the pubes, so that 
the latter become parallel and juxta-posed. The symphysis assumes the 
shape of a duck's bill, and, since the gutter formed by the approximation 
of the pubic rami is useless during labor, there results very marked short- 
ening of the antero-posterior diameter of the pelvis, both at the brim, 
and in the cavity. (See Osteomalacia.) When the shortening of the 
oblique diameters is produced by compression of the antero-lateral walls, 
it may exist on one or both sides; this is due to flattening of the femur, 
and even projection of this bone into the pelvis, at a point correspond- 
ing to the bottom of the cotyloid cavity. As a result, the normal curve 
of the superior strait and cavity disappears, the hip-bone becomes flattened 
and straightened, the pelvic curve convex, and, when both sides are com- 
pressed, there is shortening of all the diameters of the brim and outlet, 
so that the pelvis assumes a trefoil shape. This compression is often 
confined to one side, at least the deformity is more marked on one than 
on the other (oval, or obliquely-oval pelvis). Rarely the transverse diame- 
ters are shortened, from atrophy or non-development of the ilium, or be- 
cause the latter is pressed towards the median line. The shortening is 
usually confined to the transverse diameters of the cavity and outlet (fun- 
nel-shaped pelvis). All these varieties may be combined, giving rise to 
complex forms; such pelves may, however, be classified according to the 
causes that have produced these deformities. But, in addition to those 
special causes, which we shall study a little later, there are three factors 
which affect the entire pathology of the pelvis, and these deserve some 
attention. As Schroeder says, in order to account for the deformities of 
the pelvis, we must go back to the new-born infant and study the agents 
that transform its pelvis into the adult form, because these will subse- 
quently produce the various malformations, whenever there exists soften- MATERNAL 
21 
DYSTOCIA. 
ing, or pathological changes in the pelvis. These causes are the pressure 
of the trunk, the mutual traction exerted upon each other by the iliac 
bones at the level of the symphysis pubis, and the counter-pressure of 
the femora. The weight of the trunk tends to force the sacrum down- 
wards into the pelvis, but since the centre of gravity of the trunk falls in 
front of the sacro-iliac articulation, the sacrum rotates about its axis, so 
that the promontory tends to sink into the pelvis, and the tip of the sa- 
crum to point directly backwards. But the extremity is firmly fixed by its 
ligaments, so that the sacrum is curved from above downward. On the 
other hand, while the sacrum has a tendency to sink into the pelvis, it 
produces, through the medium of the sacro-iliac ligaments, considerable 
Fig. 12.-High Pelvis. (Pinard.) 
traction upon the posterior superior iliac spines. As the latter, accord- 
ingly, approached each other behind, their pubic ends would be drawn 
apart in proportion to the amount of traction exerted posteriorly; hence 
there occurs an antagonism of forces, which results in the curving of the 
bones at the point of least resistance, that is to say, at the level of the 
articulation. This curve is a regular one according as the upward pres- 
sure of the femora upon the bottoms of the cotyloid cavities is added to 
the traction, in an opposite direction, made upon the anterior and posterior 
extremities of the iliac bones. If these three forces act regularly, simul- 
taneously, and in proper proportion, we shall have a normal pelvis; if one 
or the other force predominates, the result will be a deformity which cor- 
responds to the character and intensity of that force. 
Besides these principal types of pelvic deformity, some others should be 22 
A TREATISE ON OBSTETRICS. 
mentioned, which, as Depaul says, are only of importance so far as they 
are associated with the anomalies before-mentioned; these are abnor- 
malities in the height, weight, or structure of the pelvis. Lenoir has de- 
scribed a pelvis that was too high, and another that was too low, but De- 
paul believes that he was in error when he endeavored to represent these 
as special types. This deformity in itself could hardly impede to any 
serious extent the progress of labor, and, if the diameters are normal, it 
Fig. 13.-Low Pelvis. (Pinard.) 
is of no consequence. The same remark applies to variations in the 
thickness, resistance, weight, and structure of the ilia and sacrum; it is 
only when associated with other pathological conditions that they may 
under certain circumstances increase indirectly the complications already 
existing. There may be six instead of five sacral vertebrae, and the sym- 
physis may be 2 or 2| inches broad, or the coccyx may be anchylosed, all 
of which conditions may help to retard labor. 
III. Faulty Inclination of the Pelvis. 
The inclination of the pelvis may be increased or diminished, more often 
increased. Now, as Naegele and Grenser show, the head may be arrested 
at the level of the symphysis, and thus it may be slow in engaging. If 
in this case the other conditions of parturition are normal, this slight 
difficulty is soon surmounted. But if, as usually happens, there exists at 
the same time a greater or less disproportion between the head and the 
pelvis, the resistance offered by the anterior wall of the pelvis exerts a 
more unfavorable influence. In these cases Schultze and Naegele and MATERNAL DYSTOCIA. 
23 
Grenser advise that, whenever the head of the foetus impinges against the 
symphysis, at the brim of the pelvis, the woman should recline in such a 
way that the lumbar portion of her vertebral column is strongly flexed, 
-that is to say, that she should assume a semi-recumbent position. This 
bent attitude assists the entrance of the head into the true pelvis. 
The pelvis may be abnormally inclined forwards, backwards, or laterally. 
Forward inclination (anterior obliquity) consists in a more or less marked 
exaggeration of the normal inclination of the infe'rior strait, and is most 
common in rickets. In a case described by Naegele, the inferior strait 
was directed straight backwards, the symphysis pubis and the upper half 
of the sacrum were horizontal, and the right ramus of the pubic arch 
was less inclined than the left, so that intercourse could only take place 
in . a posture the reverse of the usual one. This did not cause contraction 
and the woman had seven children. Posterior obliquity is never as 
marked as anterior. In the most extreme degree of this deformity, the 
plane of the superior strait is horizontal, so that the axis of this plane 
is vertical and coincides with the axis of the body. Posterior obliquity 
may exist alone or be associated with other malformations. The vulva is 
often directed farther forward than normal, and the symphysis is more 
nearly vertical. The upper half of the sacrum is parallel with the axis 
of the body, and the lumbar curve is almost or quite absent. Finally, 
the tip of the coccyx in the erect posture is always either at a level with, 
or below the summit of the pubic arch, and the twelfth rib is generally 
nearer to the crest of the ilium than normally. In lateral inclination the 
pelvis is more or less inclined to the right or left. This incliryition is 
mostly observed in rachitic pelves, and in patients with shortening, or 
atrophy of one of the lower limbs, or dislocation of the hip. The most 
striking peculiarity is the difference in level of corresponding parts of the 
pelvis. This abnormality is more frequently associated with other more 
important deformities than are the two preceding forms. 
Forms and Types of Deformed Pelves. 
Although practically pelvic deformities may be divided into three classes, 
as viewed from an anatomical standpoint, there are several different varie- 
ties. Schroeder describes among the common forms: 
1. The generally and uniformly narrow pelvis. 24 
A TREATISE OX OBSTETRICS. 
2. The flattened pelvis, including the non-rachitic flattened, and the 
generally and irregularly contracted. 
3. The flattened rachitic, including the simple flattened, the uniformly 
and generally contracted, the pseudo-osteomalacic, the scoliotic, the ky- 
photic, and the kypho-scoliotic. 
4. The pelvis flattened by reason of double dislocation of the hip. 
5. The pelvis with congenital fissure of the symphysis. 
Among the rare forms he includes the following: The spondylolisthetic, 
kyphotic, funnel-shaped, obliquely-contracted, transversely contracted, 
osteomalacic, and the pelvis obstructed by foreign growths, etc. 
Spiegelberg recognizes only three varieties, viz.: The simple flattened 
pelvis, rachitic or non-rachitic, the uniformly narrow, and the uniformly 
contracted and flattened. 
Depaul distinguishes five prevailing conditions, rachitis, osteomalacia, 
abnormal development, deformities of other parts of the skeleton con- 
nected with the pelvis, and fractures, dislocations, exostoses, etc. 
Pinard also recognizes five principal types, as follows: 1. The rachitic 
pelvis, in which there is an exaggeration of the sacral curve, with descent 
of the promontory (pseudo-osteomalacic). 2. The rachitic pelvis, in 
which the promontory descends, while the sacrum is straight or even con- 
cave. 3. The rachitic pelvis, in which the relative lengths of the diame- 
ters is unchanged. 4. The pelvis in which the deformity is due to both 
rickets and some other pathological condition, as spinal disease. 5. The 
rachitic pelvis, in which there is extreme lateral deviation of the promon- 
tory. .He also describes other sub-varieties. 
The Flattened Pelvis. 
We have seen that the most common deformity consists in antero-pos- 
terior flattening, causing shortening of the conjugate diameters. Al- 
though this has until recently al ways been attributed to rachitis, Schroeder, 
Spiegelberg, and others, have observed it in women who presented no 
evidences of that disease. At first sight such a pelvis appears to be nor- 
mal, but, on measuring it, we find that the antero-posterior diameter of 
the brim is shortened, so that the pelvis is flattened from before back- 
wards. The other diameters are nearly normal, except the transverse, 
which is slightly increased, because of the.outward curve of the ilia. 25 
MATERNAL DYSTOCIA. 
The contraction is accordingly confined to the superior strait and cavity, 
but, as the sacrum does not revolve on its transverse axis, its anterior in- 
clination is very slight, so that the contraction is usually slightly marked 
Fig. 14.-Simply Flattened Pelvis. (Spiegelberg.) 
(never below 3.2 inches), and does not cause any seriout difficulty during 
labor. In some cases, however, the sacrum is inclined forwards to a 
greater degree, so that there appears to be a second promontory, which 
Fig. 15.-Pelvis Contracted from Before Backward. (Pinard) 
may be mistaken for the true one. The causes of this deformity are 
little known; they are due, perhaps, to carrying heavy burdens before 
puberty, as well as to retarded development. 
As the women present no characteristic external appearance, the diag- 26 
A TREATISE ON OBSTETRICS. 
nosis of this condition can only be established by measuring the pelvis. 
The distances between the iliac crests and spines are but little changed, 
but the external conjugate is always shortened. 
Schroeder has described a form of pelvis, to which he has given the 
name,''uniformly flattened and contracted pelvis." (Fig. 16.) It differs 
from the generally and regularly contracted type, only in the dispropor- 
Fig. 16.-Generally and Irregularly Contracted Non-Rachitic Pelvis. (Schroeder.) 
tion that exists between the conjugate and the other diameters. This 
sub-variety of the Germans seems to be more theoretical than practical, 
since flattened pelves are really rachitic pelves in which the rachitic ele- 
ment is but slightly marked. When the rachitis becomes more marked, 
we have the flattened rachitic pelvis of German writers. < 
The Rachitic Pelvis. 
Rachitis is a disease that attacks infants, usually at the age of from 
eighteen to twenty months-that is to say, at a time of life at which the 
osseous structure is developing rapidly; it is characterized by arrest of 
development, softening, and fragility and flexibility of the affected bones. 
The bones never regain their normal development after the disease has 
ceased to be active. The deformities occur from below upwards (tibia, 
femur, pelvis, etc.), especially in children who become rachitic after they 
have begun to walk. 
Rickets is not sufficient in itself to produce deformities; by softening 
the bones and rendering them more flexible, it renders them liable to 
become deformed, but this malformation is only due to the influence of 
external causes. Beside the three factors mentioned by Schroeder, the 
weight of the trunk, the traction of the ilia at the level of the symphysis, MATERNAL DYSTOCIA. 
27 
and the counter-pressure exercised from below upwards by the femora, 
we must, with Kehrer, consider muscular traction, and, with Depaul, 
accidental weights, independent of the body. 
Let us study the effects produced upon the pelvis by these different 
agencies. If the child remains absolutely in the dorsal position, the in- 
Fig. 17.-Rachitic Woman. Fig. 18.-Rachitic Woman. 
fluence of the first three factors will be nil, hence the form of the pelvis 
will not be changed. (Schroeder's " Liegbecken," the pelvis of the re- 
clining posture.) The weight of the body is the only one of these forces 
that can act alone, and it can only act in cases of congenital fissure ofdhe 
symphysis. Although the three forces are more or less concomitant, one 
may predominate, and thus cause characteristic deformities. If the child 
does not walk, the counter-pressure of the femora is absent, and the 
weight of the body and the traction at the symphysis result in antero- 
posterior flattening, with lengthening of the transverse diameter. 
(Schroeder's "pelvis of the sitting posture.") If the three forces act to- 28 
A TREATISE ON OBSTETRICS. 
gether upon a pelvis the bones of which are all softened, there results 
the osteomalacic form. 
But, aside from these agencies, there is another that is quite as impor- 
tant, the external pressure to which the pelvis is subjected, even in the 
dorsal recumbent posture, and still more when the child is carried on the 
arm. Being compressed between the trunk on one side and the femora 
on the other (acting on its antero-lateral wall), the pelvis becomes flat- 
Fig. 19.-Rachitic Woman. (Anterior Aspect.) Fig. 20.-The Same. (Posterior Aspect.) 
tened and deformed by the projection of the sacrum anteriorly, and by 
the flattening of the symphysis and the horizontal rami of the pubes. 
Hence there results shorteningof the conjugate diameter of the brim; the 
oblique diameters are but slightly changed, since the traction which is 
exerted posteriorly upon the iliac bones, is transmitted to the symphysis, 
and partly opposes the action of the femora. The cavity and the outlet 
are usually but slightly affected, indeed their dimensions may be in- 
creased, but if the sacrum is curved inwards strongly, the depth of the MATERNAL DYSTOCIA. 
29 
pelvis is diminished. As these forces are not equal, regular, or directed 
toward the same point, the pelvis may present various irregularities in 
its shape. The sacrum may have a lateral, as well as an anterior, devia- 
tion, or the pelvis may be more deformed on one side than on the other; 
finally, the change may affect the outlet, and sometimes deviation of the 
ischia, or the end of the sacrum and coccyx, may cause contraction of 
the inferior strait, either transversely or antero-posteriorly. 
Fig. 21.-Rachitic Woman. (Anterior Aspect.) Fig. 22.-The Same. (Posterior Aspect.) 
Aside from weight, we must also take into account traction, whether 
exercised by muscular or by fibrous tissue; the latter may cause deformity 
of the iliac crests, the ischio-pubic rami, and various apophyses and tuber- 
osities, to which muscles are attached. 
Finally, we must not forget that rickets is associated with arrest of de- 
velopment, that causes that smallness and slenderness of the bones so com- 
monly found in rachitic pelves. It is the exception to find the bones thick 
and massive. Rachitic females are usually of small stature, with short, 
slender limbs; there is often curvature of the spine, in consequence of 30 
A TREATISE ON OBSTETRICS. 
which they have a peculiar oscillating gait. The hips are large, the but- 
tocks prominent; the lower limbs present more or less marked curvatures, 
while the arms are short, slender, and occasionally curved inwards, the 
hands being small and. short. The thorax presents projections at the 
chondro-sternal articulations (rachitic rosary), while the head is large, 
the forehead prominent, and the lower jaw projects forward. Pajot has 
called attention to the asymmetry of the face, and the inequality of the 
eyes. 
Figs. 27 to 22 represent rachitic women, observed by my colleague, 
Bailly. 
The woman in Fig. 17 had a pelvis measuring 2.7 inches in the con- 
jugate, after deduction. One premature labor at eight months, one labor 
at term, delivery by forceps. Living child. 
In Fig. 18, the pelvis measured 3 inches. Two pregnancies. Issue the 
same as above. 
Figs. 19 and 20, a multipara, conjugate of 3.5 inches. Five labors at 
term, one at term with prolapse of cord. Five living children. 
Figs. 21 and 22, pelvis of 2 inches. Csesarean section at term. Living 
child, mother died on fourth day. 
The pelvis presents the following characteristics: 1. The bones as a 
whole, are abnormally small, the sacrum is short and straight. The iliac 
bones are so thin as to be almost transparent in some places. 
2. The sacrum is depressed and rotated on its transverse axis. Its con- 
cavity may disappear, the bone being straight or even convex. The pos- 
terior iliac spines project prominently over the posterior aspect of the sa- 
crum, the bodies of the vertebrae (especially that of the first) are much 
compressed posteriorly. 
3. The distance between the crests of the ilia is less than that between 
the anterior superior spines. 
4. The pubic arch is increased, the ischial tuberosities are more widely 
separated than normal, and the cotyloid cavities are directed more anterior- 
ly, the pubic symphysis is flattened (or is even convex posteriorly) and thus 
tends to approach the promontory. 
5. Since the pelvis is flattened in this manner, the conjugate diameter 
of the brim is always shortened, and this shortening is generally in pro- 
portion to the degree of malformation of the pelvis. 
6. The oblique diameters of the superior strait are also diminished in 
length, but this shortening is not constant. MATERNAL DYSTOCIA. 
31 
7. The transverse diameter may be of normal length, or even longer. 
8. The sacro-cotyloid measurements are considerably diminished. 
9. According to Schroeder, all the diameters in the cavity are length- 
ened; but Depaul states that the right oblique diameter is always shorter 
than normal. 
10. The diameters at the outlet are usually normal, or the transverse 
and conjugate may be slightly increased. 
Fig. 23.-Rachitic ItauKMrry. (Depaul.) 
11. The entire depth of the pelvis is diminished, as well as that of the 
sacrum and symphysis pubis. 
12. The anterior inclination of the pelvis is lessened in proportion to 
the depression of the sacrum. 32 
A TREATISE ON OBSTETRICS. 
13. The average weight of the pelvis is notably diminished (10 to 16 
ounces, the normal being 24 ounces.) 
14. Around the edge of the superior strait, especially in its anterior 
half, are sharp projections and spines, which may cause serious lesions of 
the soft parts, in consequence of prolonged pressure, during labor. The 
pubic crest and ilio-pectineal eminence may be the seat of these sharp 
knife-edged projections, which may be either unilateral or bilateral. In 
the living subject these edges are, of course, covered by the soft parts, 
Fig. 24.-Rachitic Pelvis, with Anterior Convexity of the Sacrum ; Antero-Posterior 
Contraction calling for the Cesarean Section. (Stoltz.) 
the spine of the pubes, in particular, being enclosed in such a thick cov- 
ering that it rarely does any harm. In certain cases, however, when 
the pelvis is contracted and labor is prolonged, if the head is compressed 
for a long time at the superior strait, a lesion may be produced in that 
part of the uterus which is caught between this sharp projection and the 
head, or between the promontory and the head, and the organ may even 
be perforated. MATERNAL DYSTOCIA 
33 
Pig. 25.-Rachitic Pelvis. Perforation in Two Labors. Premature Labor induced in the 
Third. Child Living. Mother Died. (Stoltz.) 
Fig. 26.-Pelvis, with Projections. 
Vol. ITI.- 3. A TREATISE ON OBSTETRICS. 
34 
The Pseudo-osteomalacic-rachitic Pelvis. 
In this variety the promontory is deeply depressed by reason of the 
tilting of the sacrum, the bone presents an exaggerated curve, which causes 
its two extremities to approach each other, the cotyloid cavities are ap- 
proximated, and the symphysis projects forwards: The superior strait 
has a triangular shape, the ilia curve inwards, and seem to be folded upon 
themselves. This deformity naturally results when infants are made to 
Fig. 27.-Rachitic, Pseudo-Osteomalacic Pelvis, where Cesarean Section was required. 
(Stoltz.) 
walk while their bones are still in a condition of rachitic softening. The 
sacrum is driven downwards into the pelvis by the weight of the trunk, 
while the acetabula are forced inwards by the counter-pressure exerted by 
the heads of the femora. MATERNAL DYSTOCIA. 
35 
An attempt has been made to include rachitic and osteomalacic pelves 
under a common head, the deformity in both cases being regarded as due 
to softening of the bones. But in rachitis the bones fail to harden, in 
osteomalacia they become softened after being hard; in the former case 
there is progressive metamorphosis, in the latter, retrograde degeneration. 
Fig. 28.-Rachitic Pelvis, with Exaggerated Sacral Curvature, and Lordosis of the last 
Lumbar Vertebra. (Pinard.) 
Pinard affirms that in the lesser degrees of -osteomalacia the shape of the 
pelvis is identical with that of the well-marked rachitic type. Spiegelberg 
describes two varieties of the pseudo-osteomalacic rachitic pelvis, in which 
the bones of an already rachitic pelvis undergo secondary softening, so that 
the same malformations are produced as in osteomalacia. A pelvis of 
Fig. 29.-Rachitic Pelvis, with Exaggerated Curvature. (Pinard.} 
this character is distinguished from a true osteomalacic pelvis, by the 
solidity of its bones, the smoothness of their surfaces, and by the fact 36 
A TREATISE ON OBSTETRICS. 
Different Curves in Rachitic Pelves. 
Fig. 30. Fig. 31. 
Fig. 32. 
Fig. 33. Fig. 34. MATERNAL DYSTOCIA. 
that their size is greater than normal; the distance between the anterior 
superior iliac spines is increased. The rest of the skeleton, moreover, 
presents the characteristic changes of rickets. " It is not very rare," says 
Depaul, " to find localized in a single bone changes that bear the mark 
of rickets. We can imagine how, in such cases, the pelvic deformity dif- 
Fig. 35.-Rachitic, Osteomalacic Pelvis. Five Normal Labors. (Spiegelberg.) 
fers from that which results from simultaneous malformation of all the 
bony parts." As a rule, there is in this instance only an unequal distri- 
bution of the rachitic changes, of which we find traces in other bones. 
This is the case in the pelvis here represented. (Fig. 36.) On examining 
it carefully, we note in the rest of the skeleton evidences of the disease, 
which is unequally distributed, and, by reason of its predominance in a 
single bone, appears at first sight to have been localized in that bone. 
Osteomalacic Pelvis. 
Osteomalacia is a disease of adult life. It rarely appears before twenty, 
generally developing between the ages of thirty and fifty; it is confined 
almost exclusively to poor women, who have been enfeebled by residence 
in damp, unhealthy dwellings, by insufficient nourishment, and repeated 
pregnancies. Osteomalacia does not attack women alone, but it is limited 
to adults. According to Ranvier, we must distinguish true osteomalacia 
in adults from the osteoporosis that occurs in old age. Kilian describes 
two varieties, osteomalacia psathyra (fracturosa), and osteomalacia apsa- 38 
TREATISE OX OBSTETRICS. 
thyros (cohserens); these are really only successive stages of the same dis- 
ease, so that both forms may be observed in the same subject. Some- 
times the bones are yellowish, compressible, and rugose on the surface, 
sometimes they are quite porous, and brittle, the weight of the entire pel- 
Fig. 36.-Unilateral Rachitis. 
vis being greatly diminished. The most characteristic feature of this 
pelvis, however, is the fact that it presents apparently normal dimensions, 
the bones being of the usual size and thickness; in short, there are no 
evidences of arrest of development as in the rachitic pelvis. 39 
MATERNAL DYSTOCIA. 
Pathologically the disease is to be regarded as an osteomyelitis and pro- 
gressive osteitis; the bone is deprived of its lime-salts, while at the same 
time all the other softened bone-tissues are compressed by the morbid 
proliferation of the marrow. When the women are in poor condition, 
the constant hyperaemia to which the bones are subject during the entire 
course of pregnancy, (especially when pregnancies follow one another in 
rapid succession), lead to the outbreak of the disease. Osteomyelitis is 
the initial process. The marrow is destroyed and is replaced by a young 
medullary substance of a reddish color, the small round cells of which 
proliferate under the influence of the excessive hyperaemia. The removal 
of the lime salts is effected through the agency of the Haversian canals, 
an osteoid tissue being formed, which in turn becomes dissolved, and is 
eventually replaced by the proliferated medullary tissue. This substitu- 
tion of medullary for osteoid tissue is observed along the Haversian canals, 
so that in the midst of the marrow there are found islands of intact osse- 
ous lamellae. Finally, the entire bone becomes soft, like wax, and cuts 
readily, though crackling in some spots. In extreme cases nothing is 
left but a membranous sac, formed by the periosteum, containing medul- 
lary substance and fat. No trace of glutin or chondrin remains in the 
bone, while the carbonate and phosphate of lime are greatly diminished 
in amount. 
Pagenstecher affirms that the disease is ushered in with pains in the 
affected bones, localized in one or both of the tuberosities of the femur. 
The pain extends successively to the symphysis and ischial spine, then to 
the sacrum and lumbar region; the hips, shoulders are next affected, and, 
in order to avoid the pain caused by movements of the joints, the women 
remain as nearly immovable as possible. As sitting is very painful, the 
patients lie on one side. Remissions and exacerbations may continue for 
months and years, when bronchial and gastric catarrh supervene, and be- 
come chronic. The patients become feeble and emaciated, and in some 
instances, the stature is appreciably diminished. The specific gravity of 
the urine is below the normal, but there is no increase in the amount of 
salts. According to Gusserow, women suffering from osteomalacia have 
a sullen, morose physiognomy, caused by theii* sufferings, and character- 
istic of the disease. 
The osseous deformities, and especially those of the pelvis, concern us 
most. The softened bones of the pelvis, being subjected to pressure from 40 
* 
the weight of the body, and to the counter-pressure of the femora, as well 
as to pressure from external causes, become malformed, bend inwards, 
fold upon themselves, and give to the pelvis a characteristic form. The 
deformity is as follows: The ilia become curved upon themselves and 
present a groove (sometimes bifurcated), directed from above forwards 
A TREATISE ON OBSTETRICS. 
Fig. 37.-Osteomalacic Pelvis, where the Cesarean Section was Performed. (Stoltz.) 
and inwards. Driven inwards by the pressure of the thigh bones, the 
cotyloid cavities are carried upwards, forwards, and inwards, approach- 
ing at the same time each other, and the promontory. The horizontal 
rami of the pubes become nearly parallel, leaving between them a mere 
cleft, narrow above, a little larger below, the symphysis having the shape 
of a duck's bill. The pubic arch disappears, and is replaced by a sort of 
deep, narrow fissure, through which the index finger can barely pass. 41 
.MATERNAL DYSTOCIA. 
The ischial tuberosities are driven inwards to an extreme degree, and 
thus narrow the inferior strait and cavity, while the posterior superior 
iliac spines are bent inwards, and are so small that they project but slightly 
behind the sacrum, and lie in the same plane as the spine of the last 
lumbar vertebra. The sacrum describes an excessive curve in such a way 
Fig. 38.-A Similar Pelvis, calling for the same Operation. (Stoltz.) 
that its middle portion projects posteriorly, wmie its upper end sinks 
deeply into the pelvis, and the lower end shows a marked tendency to ap- 
proach the upper. In place of the regular concavity, there is a sort of 
angular groove, surmounted at its upper extremity by the projecting 
promontory. By reason of the lowering of the latter, the lumbar ver- 
tebrae form at the upper part of the pelvis a projection above the superior 
strait, that also serves to narrow it. The pelvis assumes a peculiar ap- 42 
A TREATISE ON OBSTETRICS. 
pearance that has caused it to be compared to a trefoil. All the angles 
are well-marked, and it is deformed and altered in all its parts. The 
superior and inferior straits and cavity are all affected by the deformity, 
and often to such an extent that the diameters are reduced to a surprising 
degree. The conjugate at the brim may preserve entirely its normal 
length, while the transverse is so much shortened that there really re- 
Fig. 39.-Osteomalacic Pelvis of high Degree. The Woman died of the Disease. 
(.Collection of Stoltz.) 
mains no opening to be utilized for delivery. The distance between the 
anterior superioi' iliac spines is diminished, the breadth of the symphysis 
is increased, and the concavity of the sacrum is represented by a trans- 
verse groove. The pubic rami are nearly in contact, so that the arch be- 
comes merely a deep fissure. 
Osteomalacia is a protracted disease, and at the time of labor the pel- 
vic bones may be so soft as to yield to the pressure of the foetal head, and 
thus to allow of normal delivery, but these cases are extremely rare. MATERNAL DYSTOCIA. 
43 
Obliquely-oval Pelvis. 
Naegele (1829) was the first to call attention to the obstetrical impor- 
tance of this deformity, which he described as a shortening of one oblique 
diameter, with complete anchylosis of one of the sacro-iliac synchondroses, 
and imperfect development of the corresponding half of the sacrum and 
ilium. The characteristics of such a pelvis are, therefore: 
1. Complete anchylosis of one of the sacro-iliac joints. 
2. Arrest of development of the corresponding half of the sacrum. 
3. Diminished size of the femur on the same side. 
4. The sacrum is pushed over towards the anchylosed side, while, at the 
same time, the symphysis pubis is drawn towards the opposite side in such 
a way that it is no longer directly opposite to the sacro-vertebral angle. 
5. The lateral wall and corresponding half of the anterior wall of the 
pelvic cavity, on the anchylosed side, are smoother than normal. 
6. The other half of the pelvis is, of course, greatly deformed. The 
pelvis is obliquely contracted in the direction of the diameter that crosses 
the one extending from the point of anchylosis to the opposite cotyloid 
cavity. The distance between the promontory of the sacrum and the 
upper edge of either cotyloid cavity, as well as that between the top of 
the sacrum and either ischial spine, is less on the anchylosed side. The 
distance between the tuberosity of the ischium and the posterior superior 
iliac spine, on the anchylosed side, and that between the spine of the last 
lumbar vertebra and the anterior superior iliac spine, are less than those 
on the opposite side. The walls of the cavity converge in an oblique 
manner below, and the pubic arch is more or less contracted, while its 
shape approaches that of the male pelvis. The cotyloid cavity on the 
flattened side is directed more anteriorly than in a well-formed pelvis, 
while the opposite one looks almost directly outward. 
Frequency.-This deformity is not so very rare, and it often is unsus- 
pected, especially when the patient recovers. Women with such pelves 
are young, healthy, and otherwise well-formed, so that they present no 
appearance that would lead us to suspect the presence of the malforma- 
tion. 
Naegele believes that the condition is due to congenital causes, his 
theory being based upon the following facts: 1. The complete fusion of 
the sacrum with the femur, and the absence of all traces of secondary 44 
A TREATISE ON OBSTETRICS. 
Fig. 40.-Oblique-Oval Pelvis (Nichet de Lyon.) 1. Sound Side. 2. Synostotic Side 
Fig. 41. The Same. Posterior Aspect. 45 
MATERNAL DYSTOCIA. 
anchylosis. 2. Arrest of development of either lateral half of the sa- 
crum, diminution in the size of the corresponding innominate bone, and 
in the length of the synostosis, as compared with the synchondrosis on 
the opposite side. 3. The fact that synostoses and deformities in other 
bones may also be the result of congenital anomalies, and that congenital 
synostosis is usually added to a malformation of the united bones, which 
consists especially in arrest of development. 4. The close resemblance 
between pelves of this type. 5. The absence of every other cause or 
external influence which could have produced this deformity. 
Martin believes that there is first an inflammatory process, then fusion 
of the femur and sacrum occurs, with induration of the surrounding 
bone, and the anchylosis preventing the further development of adjacent 
parts would cause the deviation of the bones, in proportion as these con- 
tinue to grow. Hohl proved that there might be in these cases entire 
absence or imperfect development of the centre of ossification of the alee 
of the sacrum. Now if the centre is wanting only in the first sacral ver- 
tebra, the latter is supplied by the increased development of the centre 
in the second vertebra. If the centres for the second and third are want- 
ing, there results, necessarily, atrophy of the corresponding side of the 
sacrum, and in consequence, gradual formation of the obliquely-oval pel- 
vis, without our being able to recognize at any point in the pelvis patho- 
logical change. 
Simon-Thomas concludes as the result of a series of observations that: 
1. In every oblique-oval pelvis anchylosis should be regarded as the pri- 
mary change, the result of a previous inflammation, which may occur at 
any time, even in foetal life. 2. Inflammation may occur primarily in 
the sacro-iliac joint, in consequence either of internal causes or trauma- 
tism, or it may develop secondarily, in consequence of some affection of 
the neighboring joints (the articulations of the lumbar vertebrse or the 
hip). 3. If anchylosis occurs after puberty, when the pelvic bones have 
reached their complete development, simple atrophy of the adjacent bony 
parts results, the deformity becoming more complete according as the 
anchylosis takes place late. 4. After the original disease, which caused 
the anchylosis, has been cured, the traces of a pre-existing joint may be 
so completely effaced as no longer to be recognized on superficial exami- 
nation. 5. Other deformities, besides anchylosis, such as obliquity, and 
contraction of the pelvic canal, flattening of the lateral wall, diminished 46 
A TREATISE ON OBSTETRICS. 
size of the greater sacro-sciatic notch, scoliosis of the lumbar vertebrae, 
etc., are secondary lesions, which ought to be attributed, partly to atro- 
phy of the bones, partly to the unequal pressure supported by the two 
lateral halves of the pelvis, and partly to the necessity of re-establishing 
the lost equilibrium. 
Litzmann opposes these views, and tries to prove that the anchylosis 
is secondary, being the result of excessive pressure applied at the cotyloid 
cavity, when the weight of the body is thrown habitually upon one leg. 
Olshausen agrees with this writer. Schroeder believes that the anchylosis 
is secondary to inflammation of the joint. This inflammation may be of 
an acute suppurative form, often associated with caries of the neighbor- 
ing bones. If the inflammation takes place after the bones have fully 
developed, the shape of the pelvis is not changed; in these cases anchylo- 
sis is not generally complete, and we always see osseous bridges extend- 
ing between the bones. If the inflammation occurs in infants, before the 
alas of the sacrum are formed, the result of the synostosis is an arrest of 
development of the alae at the point which it had attained when the in- 
flammation occurred. When the other alae attains its normal size, the 
weight of the body is unequally distributed, so that the anchylosed side 
is exposed to more pressure than the healthy side. If the inflammation 
occurs during intra-uterine life, congenital anchylosis results, with marked 
contraction of the alae of the sacrum on the affected side, and, in conse- 
quence of this, arrested development and obliquity of the pelvis. This 
obliquity is not due to anchylosis alone, but solely to the contraction of 
the alae of the sacrum on the corresponding side, whereby the weight of 
the body is thrown more upon the femur of the affected side, so that the 
cotyloid cavity approaches the promontory, and the symphysis is displaced 
to the opposite side. It follows from the preceding that the synostosis 
does not necessarily result from atrophy of the alae, but is easily explained 
in other ways. Oblique deformity, not anchylosis, is the distinguishing 
feature of these pelves; this may result from hip-disease, amputation of 
the thigh, or old dislocation. Is anchylosis ever the primary condition ? 
Spiegelberg thinks not. He denies the existence of a congenital failure of 
development, because the sacro-iliac articulation is formed before any 
osseous centres exist in the sacral alae, and because all oblique pelves in 
which anchylosis exists are already more developed than in the foetus at 
term. If anchylosis occur early, it may prevent the growth of the bones 47 
MATERNAL DYSTOCIA. 
around the joint. When synostosis does not take place until after the 
complete development of the two bones, there is a partial, but not a 
complete, disappearance of the joint. 
What shall we infer from all these theories ? That the obliquely-oval 
pelvis of Naegele is not a single type, but presents several clearly-marked 
varieties, which may be reduced to three, viz.: 1. The most frequent form 
is distinguished by the fusion of the sacrum with the ilia, with conse- 
quent atrophy of the bones composing the articulation. (Naegele's pel- 
vis.) 2. The second variety is characterized by atrophy of the ilium and 
one-half of the sacrum, but without anchylosis. 3. In the third there is 
simply oblique contraction, without the other conditions. 
The Transversely-contracted Pelvis. 
This pelvis is characterized by anchylosis of both sacro-iliac articula- 
tions, with absence, or rudimentary development, of the alee of the sa- 
crum. The sacral vertebrae are straight and the sacrum presents a convex- 
ity transversely, instead of its usual concavity. The sacrum is deeply 
depressed in the pelvis, so that the posterior extremities of the iliac bones 
Fia. 42.-Transversely Contracted Pelvis, with Double Anchylosis. (Robert.) 
project prominently, and the posterior superior spines are closely approxi- 
mated. There is little, if any, curve to the os innominatum. The iliac 
bones are flattened anteriorly and unite at a very acute angle at the sym- 
physis. As a result, there is marked lateral contraction, so that the pelvis 
appears to be composed of the two halves of two obliquely-oval pelves. 
The principal alteration in these pelves consists in the transverse narrow- 48 
A TREATISE OX OBSTETRICS. 
ing, which increases from the superior to the inferior strait, so that the 
latter is in some cases represented only by a long narrow cleft. This 
variety of pelvis is not very common, only thirteen having been described. 
Fig. 43.-Transversely Contracted Pelvis, with Double^Anchylosis. (P. Dubois.) 
Fig. 44.-Transversely Contracted Pelvis, with Double Anchylosis. (Martin.) 
According to Schroeder, anchylosis is not the original lesion, but is pro- 
duced in consequence of the pressure of the trunk; as the sacrum is forced 
downward under the weight of the trunk friction occurs, which culmi- MATERNAL DYSTOCIA. 
49 
nates in adhesive inflammation of the sacro-iliac synchondroses, with re- 
sulting anchylosis. The pelvis preserves the infantile form, except that 
the sacrum sinks more deeply into the pelvis, and the ilia, on account of 
the pressure exerted through the femora, are more approximated, so that 
the transverse diameters are much shorter in proportion than in the new- 
Fig. 45.-Transversely Contracted Pelvis, with Double Anchylosis. (Depaul.) 
born. The sinking of the promontory shortens the conjugate diameter 
of the brim, but as there is no transverse widening of the pelvis, the 
symphysis not only does not approach the promontory, but even appears 
to be thrust forward; the conj'ugate is thus again increased, so that it 
generally varies very little from the normal length. 
Figs. 46-49 represent a very rare form, described by Naegele and 
Grenser. The woman died after the Cesarean section. 
Pelves altered by Deviation of the Vertebral Column.-(Lordosis, 
scoliosis, kyphosis, kypho-scoliosis, kypho-sciolio-rachitic, spondylizema, 
and spondylolisthesis.) 
It is only of late years that the influence of deviations of the spine has 
really been studied. Cazeaux says: " We must not think that non-rachitic 
spinal curvature has no influence on the direction and form of the pelvis; 
but, as a rule, it is only in old subjects that spinal curvatures, that have 
developed aftei' infancy, produce changes in the shape and direction of the 
pelvis, so that these possess but slight interest for the obstetrician." 
Although rachitic curvatures of the spine are not the principal cause of 
pelvic deformity, they exaggerate the narrowing and irregular shape of 
the pelvis. The main alteration consists in a curve from before backward, 
most marked at the lumbo-sacral junction, in consequence of which the 
Vol. Ill-4 50 
A TREATISE ON OBSTETRICS. 
Fig. 46.-Kyphotic Transversely Contracted Pelvis. (Lange.) 
Fig. 47.-The Same, Posteriorly. MATERNAL DYSTOCIA 
51 
Fig. 48.-The Same, Superiorly. 
Fig. 49.-The Same, Inferiorly. 52 
A TREATISE ON OBSTETRICS. 
pelvis resembles Naegel e's. Choisil, studying pelves with regard to the 
shortening of the transverse diameter of the outlet, divides them into the 
following varieties: 1. Pelves deformed by straightness of the vertebral 
column, by scoliosis, or kyphosis. 2. Obliquely-oval pelves, those de- 
formed by double anchylosis, simple luxation, amputation, arrest of de- 
velopment, and by osteomalacia. He believes, with Pinard, that every 
curvature of the spine in the young, whether due to scoliosis, or to ky- 
phosis, causes retrocession of the base of the sacrum, leading to lengthen- 
ing of the conjugate diameter of the brim, and proportional shortening 
of the transverse diameter of the outlet. 
Fig. 50.-Scoliotic, Non-Rachitic Woman. Fig. 51.-The Same, Posteriorly. 
A. Lordosis and Abnormal Straightness of the Pelvis. 
The normal dorsal and lumbar curves are absent. The S-curve seen 
in rickets is modified in lumbar lordosis, and disappears entirely in ab- 
normal straightness; in both instances the weight of the body is trans- 
mitted to new points, thus modifying the form of the pelvis. MATERNAL DYSTOCIA. 
53 
a. The Influence of Lordosis on the Shape of the Pelvis.-Increased in- 
clination of the pelvis is the initial change; the anterior part of the pelvis 
tilts downwards, while the posterior is thrown upwards, this being due 
to the fact that the patient, when standing, bends forward in order to 
bring the centre of gravity over a line joining the heads of the femora. 
When lordosis and rickets are associated the promontory projects more, 
causing shortening of the antero-posterior diameter. 
b. The Influence of Abnormal Straightness on the Shape of the Pelvis.- 
This causes forward displacement of the pelvis, the diameters of the brim 
not being affected, while those of the outlet are considerably shortened. 
Fig. 52.-Scoliotic, Rachitic Woman. 
Fig, 53.-The Same, Posteriorly. 
B. Scoliosis. 
This is a classic deformity of the vertebral column; but we must here 
make a distinction between rachitic and non-rachitic scoliosis. The lat- 
ter developes slowly, and affects only the spine (Figs. 50 and 51), while 
in the former the entire skeleton is involved, so that the pelvis and the 
limbs, as well as the vertebral column, are affected (Figs. 52 and 53), so 54 
A TREATISE ON OBSTETRICS. 
that women with these two deformities present appearances entirely dis- 
similar. In rachitis the limbs are short and curved inward, the women 
are not only of small stature, but, by reason of the affection of the tho- 
rax, are small in general. Moreover traces of rachitis will be found in 
the skeleton, such as are absent in non-rachitic scoliosis. The pelvic 
Fig. 54. Fig. 55. 
Fig. 54.-Skeleton of a Non-RachitIC ScoLIotic Woman. (Cazeaux-Tamier.) 
Fig. 55.-Skeleton of a Scolio-Rachitic Woman. (Leopold.) 
deformity is different in the two cases; it may be but slightly marked in 
the latter, and may occasion but little difficulty during parturition, while 
in the former the deformity may be sufficient to constitute a formidable 
complication to labor. Figures 54 and 55, from Tarnier and Leopold, 
will show the points of difference. 
a. N on-rachitic Scoliosis. 
The narrowing is rarely so great as to do any more than to somewhat 
retard labor; the women are usually delivered spontaneously at term. MATERNAL DYSTOCIA. 
55 
Hirigoyen notes the following points, based on an analysis of nineteen 
cases: 1. There is more or less marked flattening of that half of the pel- 
vis towards which the lumbar deviation inclines, or on which the weight 
of the trunk is thrown. 2. One of the oblique diameters, together with 
the corresponding sacro-cotyloid distance, is shortened. The symphysis 
may deviate slightly, so that there is a tendency to the obliquely-oval type. 
The contraction is confined to the brim, along the curve of the innominate 
bones, which is the centre of resistance between the trunk and the femora. 
b. Rachitic Scoliosis. 
Leopold has studied this subject most thoroughly; he has found that 
this influence is more marked when the individual is attacked with 
rachitis at an early age, and when she has used her lower limbs. Kehrer 
and Engel have shown that a certain number of the peculiarities of shape 
characteristic of the rachitic pelvis exist in the foetus, or in the infant 
who can neither walk nor stand; these peculiarities consist in longitudinal 
and transverse lengthening of the sacrum, in depression of the promon- 
tory forward and downward, curving in of the thigh bones, flattening of 
the ilia, a uniform or triangular shape of the superior strait, and broaden- 
ing of the symphysis. 
Three factors determine the characteristic shape of these pelves, viz.: 
The pressure and counter-pressure sustained by the pelvis, the traction 
of the ligaments, and that of the muscles. The degree of asymmetry 
of the pelvis depends on the degree of the scoliosis. The most 
striking feature in a scolio-rachitic pelvis is: 1. The forward in- 
clination of the promontory, and the marked shortening of the true 
conjugate, which varies from two to three and a half inches. 2. The 
evident shortening of the right oblique diameter of the outlet, which is 
always shorter than the true conjugate. In the scolio-rachitic the asym- 
metry is shown at the first by an increase of the distance that separates 
the anterior superior iliac spine from the ischial tuberosity of the same 
side; the distance between the anterior and posterior spines themselves is 
increased. The angle formed by the junction of the ischio-pubic rami is 
greater than normal. Consequently, the true conjugate is shortened as 
well as the oblique measurements, the symphysis pubis is displaced towards 
the side opposite to the lumbar scoliosis. As a result, on this side, the 56 
A TREATISE ON OBSTETRICS. 
distances which separate the superior and inferior borders of the symphy- 
sis from the posterior superior iliac spines are from one-tenth to four- 
tenths of an inch less than on the side of the lumbar scolioses. Finally, 
the transverse narrowing of the superior strait, and the inclination of 
the sacrum on the side of the lumbar scoliosis, cause a shortening of from 
Fig. 56.-Scolio-Rachitic Pelvis ; Curve to the Left. (Leopold.) 
12 to 2G per cent, in the distance between one extremity of the transverse 
diameter and the promontory, as well as that between the former point 
and the tip of the sacrum. 
Etiologically two questions are to be considered, viz.: Is the rachitic 
asymmetry primary, and the scoliosis only secondary ? May not the asym- 
metry be due to shortening of one of the lower limbs, and the scoliosis 
again be simply secondary ? Leopold believes that scoliosis is the original 
lesion, the pelvic deformity resulting in consequence. That does not 
mean, he explains, that there are not pelves in which arrest of development MATERNAL DYSTOCIA. 
57 
and atrophy of the sacrum may cause secondary deviation of the vertebrae 
and consequent modifications in their form. Scoliosis and shortening of 
the leg produce the same results, that is to say, unequal distribution of 
the weight of the trunk, so that more pressure is thrown upon one side 
of the pelvis than upon the other. Primary scoliosis causes more marked 
deformity than shortening of the lower extremity. Pickets is most apt to 
cause curvature in the dorsal region; the spine bends towards the right 
Fig. 57.-Scolio-Rachitic Pelvis ; Curve to the Right. (Leopold.) 
in the majority of cases, the lumbar curve being merely compensatory. 
As the latter becomes more marked, the pressure increases until the last 
lumbar vertebras are sometimes in contact with the posterior surface of 
the corresponding ilium; the deformity in this case is due directly to the 
pressure transmitted to the ilium through the spine, and in part, also, 
to the deviation of the sacrum, which shares in the lumbar curvature. 
Muscular contraction also influences the deformity. A number of power- 
ful muscles are attached to the pelvis, and, in consequence of the deviation 58 
A TREATISE ON OBSTETRICS. 
of the vertebral column, these act in a new direction, thus exaggerating 
the abnormal condition (so as to cause rotation of the ilium around its 
antero-posterior axis.) 
Schroeder does not admit the influence of scoliotic deviation of the spine, 
except in those cases (which he thinks are the rule) in which the sacrum 
shares in the compensatory lordosis. He affirms that the promontory is 
displaced towards one side of the pelvis, and that the iliac bone on the 
side corresponding to the scoliosis is turned upward, inwards, and back- 
wards, at the same time being straightened, especially in the neighborhood 
of the cotyloid cavity, while the tuberosity of the ischium is deflected out- 
wards, and the pubic arch is widened. The symphysis is slightly bent on 
the side opposite to the scoliosis, the line of the innominate bone on the 
contracted side is a little less curved than normal, while the sacro-cotyloid 
distance is much shortened. When the scoliosis is exaggerated, the coty- 
loid cavity may approach so near to the promontory, that the pelvis as- 
sumes to some extent the shape of the pseudo-osteomalacic type. 
C. Kyphosis.-Kyphotic Pelves. 
Kyphosis is characterized by anterior deviation of the vertebral column, 
which may include a large part of the spine, or may be quite circum- 
scribed (true angular curvature), and confined to the dorso-lumbar, lum- 
bar, or lumbo-sacral region. It may be due to localized diseases (caries, 
tuberculosis, etc.), or to rachitis, hence the following vareties of deform- 
ity: 1. The pure kyphotic pelvis. 2. The kypho-scoliotic. 3. Thekypho- 
scolio-rachitic. When Pott's disease occurs during childhood (especially 
in the dorsal lumbar and lumbo-sacral regions)* the pelvic deformity is 
most marked 
a. Pure Kyphosis. 
Herbiniaux (1785) was the first to clearly describe the deformity; 
Schroeder, Spiegelberg, Leopold, and others, have since studied it. 
A. Dorso-lumbar Kyphosis.-In this condition there is marked in- 
crease in the transverse measurement of the superior strait, as compared 
with that of the inferior. It seems as if the iliac bones had revolved about 
an axis passing through the centres of the cotyloid cavities. The spine 
has a posterior curvature, the angle of which is almost 90°. (Fig. 59.) MATERNAL DYSTOCIA. 
59 
The upper part of the sacrum is carried upwards and backwards, its an- 
terior surface forming with the last lumbar vertebrae a slight convexity; 
the lower sacral vertebrae unite with the coccyx to form a concavity. The 
anterior surface forms only a slight curve, as seen in profile. Its posterior 
aspect is nearly flat, as viewed longitudinally, and occupies a higher 
plane than the anterior. The sacrum is concave transversely, and the 
alae project forwards strongly. The coccyx is revolved around a trans- 
Fig. 58.-Pure Kyphosis, from Pott's Disease. 
Fig. 59.-Same Woman, Posterior Aspect. 
verse axis, and is directed backwards in such a way that the iliac fossae arc 
separated one from the other, while the ischial tuberosities, on the con- 
trary, are nearer together than usual. The pubic arch is narrowed and 
the angle is more acute than normal. The ilia are more elongated from 
before backwards, the lines of the ossa innominata are less curved, and 
the cotyloid cavities are situated more laterally, and incline downwards 
more than in the normal pelvis. The iliac fossae are flat, anterior inferior 
spines well developed, and the S-shape of the crests has nearly disappeared. 60 
A TREATISE OX OBSTETRICS. 
The pubic rami form an acute angle at their junction, they incline sharply 
backward; the ischial tuberosities are approximated. 
B. Lumbosacral Kyphosis.-The principal changes are seen in the sa- 
crum. It is diminished in size, the anterior borders of the auricular sur- 
Fig. 60.-Kyphotic Pelvis, of Moor of Zurich. (Spiegelberg.) 
faces project in front of the corresponding surfaces of the ilia; the trans- 
verse axis of the bone is shortened at the level of the upper foramina, and 
the concavity is more shallow, the former themselves are smaller and are 
Fig. 61.-Stadfeldt's Kyphotic Pelvis. (Spiegelberg.) 
separated by irregular intervals. The sacrum has a marked wedge-shape, 
especially at its lower end; instead of being largest at the level of the 
superior strait, its greatest breadth is at the first pair of foramina. MATERNAL DYSTOCIA. 
61 
The deformities of the ilium and pubic bone are similar to those in the 
dorsal-lumbar variety, but are more marked. The pelvis is funnel-shaped, 
by reason of the increased size of the false pelvis and superior strait, and 
the transverse contraction of the inferior strait. 
b. Complicated Kyphosis. 
Kyphosis rarely exists alone; it is usually associated with scoliosis or 
rachitis, or it may accompany sacro-iliac synostosis, luxation of the femur, 
etc. We shall describe, with Leopold, the non-rachitic kypho-scoliotic, 
and the kypho-scolio-rachitic pelves. 
1. The non-Rachitic Kypho-scoliotic Pelvis. (Figs. 62 and 63.)-When 
kyphosis and scoliosis are located in the lower dorsal region, kyphosis is 
Fia. 62.-Kypho-Scoliosis resulting from Lumbo-Sacral Caries. Anchylosis of the right 
Sacro-Iliac Symphysis. Funnel-Shaped Pelvis, Obliquely Contracted. (Leopold.) 
the more active factor, but it only affects the sacrum; scoliosis, on the 
other hand, only causes pelvic deformity when there is a lumbar com- 
pensatory curve. When the two lesions are situated lower down, they 
both influence the deformity, the character of the deformity depending 
upon the predominating factor. 
2. The Kypho-scolio-Rachitic Pelvis. (Figs. 64 and 65.)-Rickets and 
kyphosis act in precisely opposite directions, so that the deformity is 
often the resultant of two forces; the condition is often very complex, 
being modified by the different periods at which each of the forces began 62 
A TREATISE ON OBSTETRICS. 
to act (before ossification was complete). Leopold mentions the follow- 
ing features as characteristic of such pelves: The conjugate diameter of 
the brim is increased if the pelvis approaches the pure kyphotic type, 
varying from 3.2 to 4.8 inches, while in the scoliotic it does not exceed 
3.4 inches. The conjugate of the outlet is absolutely shortened (being 
at least in. less than normal). The sacrum is increased in length and 
Fig. 63.-Kypho-Scoliosis from Lumbar Caries. Pelvis Atrophied on the right, Contracted 
on the left, at the Superior Strait. Funnel-Pelvis, no Rickets. (Leopold.) 
is more elevated than in the rachitic pelvis. The distance between the 
anterior superior iliac spines is relatively increased, being equal to or 
greater than that between the crests. The transverse diameter of the 
brim is relatively greater, while that of the outlet is shorter; the oblique 
diameters are lengthened, as compared with those of the scolio-rachitic 
pelvis, and, in consequence of asymmetry of the pelvis, are unequal. 
The sacro-cotyloid distances are relatively increased, according to the 
amount of unilateral pressure. 63 
MATERNAL DYSTOCIA. 
The pelvis is accordingly funnel-shaped, that is to say, its form is ex- 
actly the opposite of the rachitic pelvis. The funnel, in the most sym- 
metrical formal decreases regularly from the brim to th a outlet; in the 
Fig. 64.-Kypho-Scolio Rachitic Pelvis. Superior Strait Contracted to the Right. Inferior 
Strait Contracted. Funnel-Shaped Pelvis. (Leopold.) 
asymmetrical, however, the contraction is confined more to the right ob- 
lique and transverse diameters. 
D. Spondylolisthesis. -Spondylizema. 
Kilian (1854) was the first to describe a peculiar deformity of the pel- 
vis, characterized by sinking of the vertebral column into the pelvic cav- 
ity; Ilergott (1877) showed that the condition was due to destruction of 
the bodies of one or more of the lumbar or sacral vertebrae, as a result of 64 
A TREATISE ON OBSTETRICS. 
Pott's disease, in consequence of which the support of the column was 
weakened, so that it sank downwards and forwards, obstructing the pel- 
vic entrance in such a manner as to prevent the engagement of the pre- 
senting part of the foetus-in short that the true condition was spondyli- 
zema, not spondylolisthesis. The difference between this form of pelvis 
and the normal is produced by the modified form of the sacrum, especially 
its manner of articulating with the lumbar vertebrae, and the consequent 
Fig. 65.-Kypho-Scolio-Rachitic Pelvis. Superior Strait Contracted to the Left. Inferior 
Strait Contracted. Funnel-Shaped Pelvis. (Leopold.) 
deviation of the lumbar spine. The sacrum is shortened in such a way 
that it appears to have been cut off at the upper third of the first vertebra 
in a plane parallel with the conjugate, so as to leave a projecting angle. 
Instead of the vertebral column forming with the sacrum the usual pro- 
jection, known as the promontory, it unites with the shortened bone in 
such a manner as to form an obtuse angle, opening anteriorly, thus pro- 
longing and exaggerating the sacral curve. There results, in consequence, 
a projection of the spine, so great that the upper part of the third verte- MATERNAL DYSTOCIA. 
65 
bra is separated from the pubes by a space of only 3.2 inches. This strik- 
ing change in the direction of the column is in consequence of the depres- 
sion of the sacrum and the almost complete disappearance of the fifth 
Fig. 66.-Stoltz's Spondylizematic Pelvis. Anterior View. (Didier.') 
lumoar vertebra; there remains of the latter bone only the arch and the 
spinous process, together with the transverse processes, and the surfaces 
Fig. 67.-The same, Posteriorly. 
that articulate with the sacrum and the fourth lumbar vertebra. The 
body of the fifth vertebra is represented merely by a wedge, join, broad 
at its base, and yV in. at its anterior border; the fourth vertebra articulates 
Vol. III.-5 66 
A TREATISE ON OBSTETRICS. 
directly with the sacrum. When the pelvis is held at its normal inclina- 
tion (so that the conjugate forms an angle of 55° with the horizon), and 
is brought to a level with the eyes, we see the upper surface of the third 
Fig. 68.-Right side of Stoltz's Pelvis. (Didier.) 
Fig. 69.-Section through Stoltz's Pelvis. (Didier.) 
vertebra covering the one beneath; we observe that the shortened spinal 
column conceals the upper half of the sacrum, and encroaches on the pel- 
vic cavity, while we also see the spinous and transverse processes of the MATERNAL DYSTOCIA. 
67 
third vertebra exactly covering the corresponding processes of the two 
vertebrae beneath. 
Fig. 70.-Section'through Stoltz's Pelvis, and through a Normal Pelvis, the one above the 
other (Herrgott.) 
2. Fehling's Pelvis.-The most striking feature in this variety is an 
Fig. 71.-Fehling's Spondylizematic Pelvis. (Herrgot t.) XI. and XII., Dorsal Vertebrae. 
I. and II., Lumbar Vertebrae. , 
anterior curvature of the spine, so excessive that it approaches within 
14 in. of the symphysis, while the angle that it forms with the conjugate, 68 
A TREATISE ON OBSTETRICS. 
is only 15.° Of the lumbar vertebrae, only the firstand second remain, 
while in the place of the other three is a small, irregular mass, thicker 
on the right than on the left side, forming a wedge which is broad be- 
hind and narrow in front, interposed between the sacrum and the body 
of the second lumbar vertebra. The important point to note is that the 
vertebral arches are preserved, since there are seven spinous, and seven 
pairs of transverse, processes. One-half of the first sacral vertebra is 
Fig. 72.-Spondylolisthesic Pelvis, at Prague. (Kiwisch.) 
absent, which explains the sinking of the column into the pelvic brim. 
This produces a true pelvis obtecta. 
3. Belloc's Pelvis.-The spinal column in this specimen was fused with 
the anterior surface of the sacrum at a right angle, so that when the 
woman was sitting, the posterior surface of that bone formed the base of 
support, instead of the ischial tuberosities. 
4. Gluge's Pelvis.-In this specimen the promontory was formed by 
the fourth lumbar vertebra; the sacrum was greatly shortened 69 
MATERNAL DYSTOCIA. 
5. Olshau sen's Pelvis.-Here the upper sacral vertebra was destroyed, 
and below the fourth lumbar vertebra there was a rudimentary one T|o 
in. broad, the upper border of which projected so far into the pelvis as 
to shorten the conjugate diameter to 3t8q inches. 
We see from the foregoing that it is the body of the vertebra that is 
destroyed, while the arches and articulating processes are more or less pre- 
served. The spine does not glide forward, but first sinks downward, and 
then rotates forward so as to cover more or less completely the superior 
Fig. 73.-Spondylonisthesic Pelvis of Paderborn. {Kilian.) 1. Fifth lumbar vertebra. 
2. First sacral vertebra. 
strait, the promontory being replaced by an acute angle, the narrowest 
part of the pelvis being the distance between the symphysis and the most 
projecting point of the lumbar spine, instead of the normal sacro-pubic 
measurement. 
In the pelvis at Prague (Fig. 72) only a trace of the arch of the fifth 
lumbar vertebra was found, but no spinous process. In Paderborn's speci- 
men (Fig. 73) the sacrum seemed to have executed a considerable move- 
ment of flexion; the summit of the exaggerated angle formed by that 
bone, corresponded to the junction of the second and third sacral verte- 70 
A TREATISE ON OBSTETRICS. 
brag. The body of the fifth lumbar vertebra presented a notch on its in- 
ferior surface, in which was received a corresponding projection on the 
anterior border of the first sacral vertebra; the spinous process of the 
former vertebra was represented by a small tubercle, and of the arch and 
Fig. 74.-Spondylolisthesic Pelvis. (Munich.) 
the articular processes only traces remained. In a specimen described 
by Spaeth, the first sacral vertebra had entirely disappeared, and only one- 
half of the fifth lumbar remained, the inferior border of which rested on 
Fig. 75.-Section of the Zurich Spondylolisthestc Pelvis, with normal Pelvis Superimposed 
the third segment of the sacrum. In the Munich pelvis the interverte- 
bral cartilage between the fifth lumbar and first sacral was absent, the 
two vertebrae being fused together and forming a projection. 
In Olshausen's pelvis the symphysis was on a level with the third lum- MATERNAL DYSTOCIA. 
71 
bar vertebra, the conjugate measuring 1T% in.; the fifth lumbar ver- 
tebra was united to the anterior surface of the sacrum, a small body being 
interposed between them, which Olshausen supposed to be the remains 
of the interarticular cartilage. Ebenhoff (of Prague) had two specimens. 
(Figs. 76 and 77.) In one the lower border of the anterior surface of 
Fig. 76.-Ebenhoff's First Pelvis. (Spiegelberq.) 
the fifth lumbar vertebra was anchylosed to the sacrum at a point oppo- 
site to the junction of the second and third segments. The anterior sur- 
face of the first sacral segment was fused with the first lumbar. In the 
other pelvis the bones were all light and spongy; the spinous process of 
the third lumbar was free, that of the fourth was closely applied to the 
process of the fifth and united to it by fibrous tissue. 
In DepauFs pelvis (Fig. 79) the sacrum was smaller than normal, its 72 
A TREATISE OX OBSTETRICS. 
anterior surface porous and the bone generally rough and uneven. The 
first segment was rudimentary, and was fused with the fifth lumbar; the 
fourth anchylosed with the fifth. The sacrum and last two lumbar ver- 
tebrae appeared to form a single bone; three large spinous processes ex- 
isted, the first two belonging to the last two lumbar, while the third pro- 
jected from the remains of the first sacral segment. In the pelvis described 
by Ilowitz, of Copenhagen, the lumbar vertebrae were inclined forwards, 
Fig. 77-Ebenhoff's second Pelvis. Vertical Section. 1, 2, 3, Spinous processes of the three 
last Lumbar Vertebras. 4, 5, 6, Bodies of the last Lumbar. 8, Anterior Border of superior 
surface of 1st Sacral Vertebrae, pushed forwards. 9, Portion of intervertebral Cartilage, 
pushed forwards. (Herrgott.) 
in consequence of the atrophy of the bodies of the fifth lumbar and first 
sacral and sinking of the body of the fourth into the sacral canal. 
(Fig. 80.) 
Van den Boschen's pelvis was asymmetrical, the right half being 
smaller than the left. The right ascending pubic ramus was a little 
more inclined than the left, its lower border being turned outwards. 
The bones, especially the sacrum, were quite light and porous. The fifth 
lumbar vertebra was alone preserved, so that the conjugate was repre- 
sented by a line drawn from the upper border of the symphysis pubis MATERNAL DYSTOCIA 
73 
Fig. 78.-Ebenhoff's First Pelvis, right side, Vertical Section. 1 to 5, Spinous processes of 
Lumbar Vertebrae. 7, 8, 9, Bodies of Lumbar Vertebrae. 6, 12, Sacral Canal. 15 
Projection of Spinous Process of Sacrum. 
Fig. 79.-Spondylizematic Pelvis. (Depaul.) 1, Anterior Surface of Sacrum. 2, Inferior Surface 
of the body of the last Lumbar Vertebra, and remains of the first Sacral. 3, Section of 
5th Lumbar. 4, Body of 4th Lumbar. 74 
A TREATISE OX OBSTETRICS. 
to the point of articulation between the second and third lumbar verte- 
bra?, its length being about two inches, while the distance between the 
most prominent part of the sacrum and the lower border of the sacrum 
was five inches. The first sacral segment, and a small portion of the 
second, were situated behind the fifth lumbar vertebra; the sacrum was 
rotated slightly on its transverse axis, so that its lower extremity was 
turned forwards and its base backwards. The fifth lumbar vertebra had 
sunk into the cavity, its anterior aspect having become inferior, and 
Fig. 80.-Spondylolisthesic Pelvis ok Howitz. (Herrgott.) 1Z to 51, Lumbar Vertebrae. 
2s to 5s, Sacral Vertebrae. 
almost horizontal; the upper surface looked almost exactly forwards, 
while the lower, which originally articulated with the base of the sacrum, 
had become posterior. The vertebral column united with the sacrum 
at a right angle, so that when the woman was seated, the posterior sur- 
face of the latter bone formed the base of support, instead of the ischial 
tnderosities, which were directed forwards and a little downwards. 75 
In a case observed by Perroulaz (1879), the existence of a spondylolis- 
thesic pelvis was demonstrated in a pregnant female, who was delivered 
three times with the forceps, once by version, and once by craniotomy. 
In this instance the fifth lumbar vertebra was displaced downwards and 
forwards into the true pelvis, and could be easily recognized by the touch. 
The spine was curved to the left, resulting in contraction of the corre- 
sponding half of the pelvis. The conjugate diameter of the brim was 
3T60 inches, that of the cavity Scinches, while the contraction at the out- 
let was confined to the right oblique and transverse diameters. 
The total number of spondylolisthesic, or spondylizematic, pelves 
amount to twenty-nine, so that this deformity is really very rare. What 
is the true cause of it ? While Kilian regards the deformity as caused by 
dislocation of the last lumbar vertebra forwards, due to the presence of a 
supplementary and rudimentary vertebra, which is sunk like a wedge in 
the posterior part of the sacro-lumbar articulation, and Braun thinks 
that it is due to the intercalation of an arch of one of the lumbar verte- 
brae, Lambl believes that the original cause is a lumbo-sacral meningo- 
cele. Spiegelberg adopts the latter theory, but Breslau opposes it. 
Schroeder affirms that the condition is due either to separation of the 
articular surfaces of the first sacral and last lumbar vertebrae, with glid- 
ing of the latter bone on the former, or to dislocation of the latter, or, 
finally, to solution of continuity of the articular processes (fracture or 
caries). Herrgott has proved that all of these writers are in error, the 
deformity being due in every case to Pott's disease. The following are 
his deductions: Disease of the lumbar spine and sacrum may produce two 
essentially different deformities, according as the body, or arch, of the 
vertebra is the seat of caries. If the former is destroyed, the support of 
the spinal column is weakened, it sinks downwards and forwards, block- 
ing up the pelvic brim (spondylizema, or sinking of the spine). If the 
arch is destroyed, the column glides downwards into the pelvic cavity 
(spondylolisthesis, or gliding of the spine). In the former case the nor- 
mal sacro-pubic diameter is either preserved, or even increased, but the 
diameter of the actual strait through which the foetus must pass is repre- 
sented by a line extending from the pubes to the body of the most pro- 
jecting lumbar or dorsal vertebra. In spondylolisthesis this distance is 
shortened, because, by reason of the gliding of the column, the body of a 
vertebra is interposed between the sacrum and the pubes. 
MATERNAL DYSTOCIA. 76 
A TREATISE ON OBSTETRICS. 
Pelves distorted by Reason of Deformity of the Lower Limbs. 
The lower limbs may be altered either in their relation to the pelvis, 
or in their length and direction. Moreover, these lesions may be pri- 
mary, dating from infancy, or they may be produced after the skeleton 
has attained to a great extent its normal development. There are two 
principal types, viz.: 1. Shortening in consequence of luxation of the 
femur. 2. Shortening where the head of the femur remains within the 
cotyloid cavity, as in atrophy of the leg, rickets, fractures, club-foot, 
knock-knee, flexion with anchylosis, and after amputations and resections. 
The Pelvis with Dislocated Femur. 
This may be unilateral or bilateral. Scdillot was the first to point out 
the modifications in the form of the pelvis caused by congenital luxation 
of the femur. He summarizes as follows: In double luxation the supe- 
rior strait is heart-shaped, the conjugate being slightly increased. The 
transverse diameter of the outlet is much longer than the antero-poste- 
rior, which is shortened, while the pubic arch is much enlarged. These 
changes are due to the traction of the muscles in a direction upwards and 
outwards. The depth of the pelvis is diminished. If the dislocation is 
unilateral, the deformity is confined to the corresponding side of the pelvis. 
a. Unilateral Dislocation. 
The pelvis is asymmetrical, the half corresponding to the dislocated 
limb being less developed, its pubic portion being slightly depressed, and 
turned backward, the corresponding oblique diameter is sensibly short- 
ened, as well as the sacro-pectineal distance. The sacro-iliac articulation 
on the dislocated side is situated more posteriorly than the other, the 
sacrum being deviated slightly towards the affected side. The pelvis is 
usually inclined on this side, and the lumbar spine presents in some in- 
stances a slight antero-lateral convexity in this direction. The pubes 
present a depression a few hundredths of an inch to one side of the 
symphysis, in consequence of which the depth of the sub-pubic arch is 
lessened; the length of one horizontal ramus is much increased, while the 
anterior border of the iliac wing is diminished. The tuber ischii is rotated 
outwards, the ischio-pubic ramus being slender, flattened, elongated, and 
straightened, the result being marked obliquity of the pubic symphysis on 
the affected side, widening of the pubic arch at the expense of its depth, with 
increase in the sub-pubic angle. The distance between the ischial tuber- MATERNAL DYSTOCIA. 
77 
G.PILlflSKl 
Fig. 81-Pelvis with Unilateral Luxation. (Depaul.) 
Fig. 82.-Woman with Unilateral Luxation. 
Fig. 83.-The same, Posterior View. 78 
A TREATISE ON OBSTETRICS. 
osity and the middle of the iliac crest is shorter on the affected side; the 
corresponding cotyloid cavity is shallow, contracted, and deformed. 
b. Double Congenital Dislocation. 
In this pelvis there is a striking symmetry in the deformity. The pel- 
vis is inclined forwards so far that the axis of the cavity sometimes be- 
comes horizontal, while the plane of the superior strait is vertical. The 
iliac wings are straightened, their anterior vertical borders are very thin, 
with small spines, flattened from without inwards; the iliac fossae are more 
shallow than normal. (Figs. 84, 85, 86.) The true pelvis resembles 
closely that in unilateral dislocation; the ischia, with their tuberosities, 
are rotated outwards, the transverse diameters of the cavity and Outlet 
being consequently lessened. The pelvis is shallow, the sacro-coccygeal 
curve is increased, as well as the anterior projection of the spine, and the 
original cotyloid cavities are contracted and deformed. The most impor- 
tant result of these deformities is the changed relation between the vari- 
ous pelvic diameters. The transverse diameters of the cavity and brim 
are often diminished, while that of the outlet is much increased; the pel- 
vis, as a whole, therefore, represents imperfectly a truncated cone, with 
the base at the perineum. 
As Scdillot observes, the foregoing deformities are explained by the 
abnormal relations which the femora bear to the iliac fossae. The latter 
are compressed from side to side, the result of which is shortening of the 
transverse diameter of the brim, without change in the conjugate. At 
the inferior strait, the effects are, as it were, inverse, since they are due 
chiefly to fibrous and muscular traction. The influence of the iliacus 
muscle is particularly important. 
c. Pelves in which the Head of the Femur preserves its normal Relations 
with the Cotyloid Cavity, although there is shortening of one or both of 
the Lower Limbs. 
The deformity is usually confined to the sound side, that is to say, the 
side which, in standing or walking, supports the greater weight. In con- 
sequence of this unequal pressure, transmitted through the head of the 
femur, the iliac curve on the corresponding side becomes more or less 
straightened, while the pelvis inclines toward the sound limb, all the cor- 
responding oblique diameters being shortened. This lateral compression 
is usually slight, and does not retard delivery at full term. Nine cases 
have been reported by various writers. MATERNAL DYSTOCIA. 
79 
Fig. 84.-Pelvis with Double Luxation. 
Fig. 85.-W oman with Double Luxation of the .Femurs. Fig. 86.-The same, Posterior View. 80 
A TREATISE ON OBSTETRICS. 
d. Pelvis with Congenital Separation of the Symphysis. 
Under the name " split pelvis " (bassin fendzi) Litzmann describes a pel- 
vis in which, as the result of arrested development, the two halves of the 
Fig. 87-Pelvis with Congenital Cleft at the Symphysis. (Litzmann.) 
symphysis have never been united. (Figs. 87 and 88.) As this con- 
dition is nearly always associated with congenital cleft of the abdominal 
Fig. 88.-The same seen Posteriorly. 
wall and. Ectopion vesicle, it possesses no obstetric interest. This pelvis 
is characterized bv increase in the transverse measurements in consequence MATERNAL DYSTOCIA. 
81 
of the sacrum being forced between the iliac bones, so that the latter are 
curved in such a way as to be nearly parallel. The pelvis is closed ante- 
riorly only by fibrous tissue. 
e. Pelvis obstructed by Morbid Growths. 
The tumors may be osseous (exostoses), cancerous, sarcomatous, etc., 
which spring from the pelvic bones, or even from the adjacent organs. 
Fig. 89.-Exostosis of the Pelvis. (Leydig.) 
Fig. 90.-Osteosarcoma of the Pelvis. (Lenoir.) 
Figs. 89, 90, 91 and 92 represent cases of exostosis, of osteosarcomata, 
of fractures, etc., and give sufficient idea of the gravity of these deform- 
ities. 
Vol. III.-6 82 
A TREATISE ON OBSTETRICS. 
Fig. 91.-Pelvis Deformed by Compression. 
Fig. 92.-Osteosteatome of the Pelvis. One child at seven months, still-born, in a N-Para. 83 
MATERNAL DYrSTOCIA. 
Diagnosis of Pelvic Deformity.-Measurements of the Pelvis.- 
Pelvimetry.-Pelvigraphy. 
The signs by which we may recognize pelvic deformity are of two kinds: 
Signs of probability; signs of certainty. 
Signs of Probability.-Deformities of the pelvis are due, as we have 
seen, with the exception of certain cases of congenital deformity, to either 
general diseases, rickets, osteomalacia, or to local affections of the verte- 
bral column, of the pelvis, or else, finally, to lesions of the inferior ex- 
tremities. 
Ordinarily, the history of the patient will give us a clue to the causal 
factor of the deformity, especially in case of rickets. A study of the 
writings of the older authors proves that they were familial' with this fact, 
and that they laid great stress on external examination of the patients. 
The external configuration, stature and symmetry of the patients, should, 
above all, attract our attention. It is usually women of small stature who 
present pelvic deformity, although, as we have seen, women of normal 
stature may also possess deformed pelves. In them, it is ordinarily from 
the history of antecedent labors that we obtain data pointing to pelvic de- 
formity. 
The form of the body calls for special attention. Women with broad 
hips and straight limbs rarely present pelvic deformity. Those of the 
reverse appearance are usually vitiated in the pelvis. Our suspicion of 
deformity will be the stronger in cases where the limbs are curved or 
shortened, or the spinal column is deviated. 
Rickets is the most common cause of pelvic deformity. It developes in 
the first years of infancy, and interferes with normal growth. We must 
inquire, therefore, into the age when the women began to walk, and if 
walking has been difficult. At times walking was not attempted till the 
age of three to four, and again the women simply remember that walk- 
ing was difficult, or that cod-liver oil was given them in infancy. 
Rickets is an affection characterized by the fact that its march is pro- 
gressive from below upwards. More or less pronounced deformities of 
the lower limbs will be found, as also of the vertebral column, but the 
pelvic deformity is not at all always proportionate to that of the limbs. 
Although, in general, deformity of the lower limbs and of the pelvis 84 
A TREATISE ON OBSTETRICS. 
march hand in hand, this is not the invariable rule. Women with pro- 
nounced pelvic deformity may offei' but little change in the limbs, and 
vice versa. These are the cases which are apt to deceive the accoucheur, 
and are unfortunate for the women in that no suspicion is evoked as to 
the gravity of the deformity until labor has set in. Hohl's theory, there- 
fore, which deduces the shape of the pelvis from the degree of deformity 
of the extremities, is a fallible one. The same holds true of Weber's 
theory, which supposes an accordance between the form and volume of 
the skull and the capacity of the pelvis. 
As for deviations of the vertebral column, the age at which they oc- 
curred is of great importance. If they date from infancy, they are due 
to rickets, and then the woman is usually small, the limbs short and slen- 
der, enlarged at their extremities, the thorax shows the characteristic 
chaplet, the head is large, the forehead and chin projecting. There has 
been, in a word, a true arrest of development. If, on the other hand, 
the spinal deviation is of later date, the changes are local. It is scoliosis, 
lordosis, kyphosis of the spine which are in the foreground. The limbs 
appear longer the more the thorax is diminished. The upper limbs reach 
the knees or lower, the legs are straight. Often then the pelvis is but 
little altered, but still such women should be carefully examined in re- 
gard to pelvic capacity. (See the sections on lordosis, scoliosis, kypho- 
sis.) 
In women who limp, whether this results from disease or from short- 
ening of one or other femur, there is almost always associated pelvic de- 
formity. We should always, hence, question the woman in regard to the 
cause of her limp. 
As a general rule, whatever the appearance or health of the woman, 
the pelvis should be examined with care. 
Palpation, at the seventh month, will ordinarily allow us, in primiparse, 
to judge as to the engagement of the foetal head. If engagement has not 
occurred, then should the pelvis be examined with care. In multiparse 
we possess the data furnished by previous deliveries. We know that 
deformity of the inferior strait and of the cavity is usually due to kypho- 
sis. The deviation of the spine, therefore, will arouse our suspicions. 
Signs of Certainty.-These are obtained from direct examination of the 
pelvis. The following are, according to Cazeaux, the normal dimensions 
of the pelvis. 85 
MATERNAL DYSTOCIA. 
Superior 
strait 
Antero-posterior . . . . . 4.29 
Oblique . . . . . . . 4.87 
Transverse . . . . . . 5.27 
Inches. 
Excavation.-All the diameters, about, . . . 4.68 
Inferior strait " " (mean) . . . 4.29 
From ant. and inf. iliac spine of one side, to opposite, 8.39 
From ant. and sup. " " " 9.36 
From centre iliac crest " " (i 10.5 
" to tuberosity of ischium, . 3.51 
From ant. and sup. part of pubic symph. to summit of 
first spine of sacrum (from which deduct thickness 
of sacrum and of symph.) . . . . . 7.05 
From isch. tuberosity of one side to post. sup. iliac spine 
of other, . . . . . . . . 6.8 
From ant. sup. spine, one side, to post. sup. spine of 
other (mean), . . . . . . . 8.19 
From spine of 2d. lumbar vertebra to ant. sup. iliac 
spine of one or other side (mean), . . . 6.8 
From great trochanter, one side, to post. sup. iliac spine 
of other, ........ 9.75 
From centre inferior border of symph. to post, iliac spine 
of one or other side, . . . . . . 6.6 
Instrumental Pelvimetry. 
Pelvimetry may be external, or internal. The number of instruments 
is great. In 1856, Killian, in his Armamentarium Lmcince, described 
20, and this number has greatly increased. The oldest instruments are 
those of Stein, 1770, and of Baudelocque, 1781. We mention simply the 
principal ones. For the description of each the curious reader is referred 
to Lenoir's monograph. 
Of external pelvimeters, we mention, Baudelocque's and Davis'; of in- 
ternal, Stark's, Kurzwich's, Koppe's, Simon's, Asdrubali's, Wigand's, 
Weidmann's, Ritgen's, Osiander's, etc., etc.; of the combined, Boivin's, 
Beck's, Amant's, Lazarevitch's, Kiwisch's, Veit's, Hubert's, Budin's, etc., 
etc. We will describe simply the pelvimeters of Baudelocque, Van Huevel, 
Depaul, Budin, Hubert, Kuestner, Crouzat. 86 
A TREATISE ON OBSTETRICS. 
Baudelocque'8 Pelvimeter.-It consists of two metal rods curved into 
a half circle so as to embrace, in their concavity, the greater part of the 
pelvis. The ends of the rods are furnished with lentil-shaped buttons, 
for application to the ends of the line we wish to measure. A graduated 
bar is fitted at the junction of the straight and curved portion of the in- 
strument, and thus the degree of separation of the extremities is measured. 
Fig. 93.-Baudelocque's Pelvimeter. 
Van HueveVs Pelvimeter.-Devised in 1841, modified in 1855, we de- 
seribe it as completed. It is a compass in shape, composed of two blades; 
the one fixed, the other movable. The first is internal or vaginal, and 
is eleven inches long, flattened like a spatula at its end, furnished at the 
centre with a ring below; this a graduated circle, and it articulates below, 
like a compass, with the second blade. This, in turn, may be shortened 
or lengthened at will, by sliding downward or upwards. (See Fig. 94.) 
Its upper extremity is traversed by a screw. When in use, the internal 
blade rests, at its extremity, at the sacro-vertebral angle, for internal 
measurements, and for external the extremities of the blades are used even, 
as in Baudelocque's instrument. The essential part and advantage of 
the instrument is the fact that the external blade is movable upward or 
downward with ease, and therefore the measurements may be very exactly 
obtained. The extremity of the internal blade may further be placed 
on the inner border of the symphysis, or indeed at any internal point, 
the outer blade resting wherever we please, and thus we may obtain the MATERNAL DYSTOCIA. 
87 
Fig. 94.-Universal Pelvimeter of Van Huevel. A, Vaginal blade. B, External blade, C, Hori- 
zontal screw. D, Arm of lever which compresses B at the graduated circle. 
Fig. 95.-Depaul s Pelvimeter. A, D, Articular Surface for third blade. E, This blade. 88 
A TREATISE ON OBSTETRICS. 
thickness of the symphysis, or any one of the diameters with a considera- 
ble degree of accuracy. 
Depaul's Pelvimeter.-This is simply Baudelocque's, modified so as to 
allow of its being used internally. The two blades of the instrument 
form, not a half circle, but a figure of eight, and further they may cross 
one another. (Fig. 95.) A supplementary movable blade allows of 
measuring the height of the uterus, one of the shorter blades resting on 
the cervix. 
Budin's Cephalometer. (Fig. 96.)-In principle it is simply Depaul's 
pelvimeter enlarged. It is 17.7 inches long; the two blades may be op- 
Fig. 96.-Budin's Cephalometer. 
posed and slide on one another, each being 9.75 inches long. One blade 
holds a graduated circle, the other terminates in an index. When the 
two extremities are in contact, the index points to 0, and as they separate 
this index marks the degree. 
Hubert's Pelvimeter. (Fig. 97.)-In shape like a widely open V, the 
long external blade is G.5 inches long, and curved at its lower extremity, 
at an angle of 45°, to join the second blade, which terminates in a 89 
spatula, 2 inches long, and 1 broad. To complete the instrument, take 
a piece of letter paper, and fold it 7 to 8 times on itself, and cut it to a 
point. (Figs. 98, 99.) 
MATERNAL DYSTOCIA. 
Fig. 97.-Hubert's Pelvimeter. 
Method of Using.-The highest point of the external surface of the 
pubes is marked. The vaginal blade is then guided to the sacral prom- 
Figs. 98 & 99.-Measurement of the Pelvis with Hubert's Instrument. 
ontory by the finger; the point of the paper is placed at the mark on the 
pubes, and the other end passed through and held in the second blade. 
Fig. 100.-Osteomalacic Pelvis. Slight 
degree. (Pinard.) 
Fig. 101.-Rachitic Pelvis, with lowering of 
Promontory. (Pinard.) 
To withdraw the instrument, it is tilted forwards, and the space which 
separates the point of the paper from the top of the spatula, is the sacro- 90 
A TREATISE ON OBSTETRICS. 
pubic interval, and to obtain this diameter we have simply to deduct the 
thickness of the pubes, and this may obviously readily be obtained by the 
instrument. 
Fig. 102.-Unilateral Luxation of left side. 
(Pinard.) 
Fig. 103.-Congenital Luxation of the Femurs. 
(Pinard.) 
Pinard has joined to pelvimetry, pelvigraphy, which enables us to re- 
produce on paper the measurements of dried pelves. According to him, 
" in normal as well as in pathological pelves, the shortest diameter is that 
Fig. 104.-Rachitic Pelvis, Dorso-Lumbar Kyphosis. 
(Pinard.) 
Fig. 105.-Rachitic Pelvis. Dorsal 
Kyphosis. (Pinard.) 
which extends from the promontory to a point situated .1 to .2 inches 
above the upper border of the symphysis, or a little higher, and not the 
sacro-pubic distance as is generally admitted in France. This diameter he calls the minimum or useful diameter. To attain his aim, Pinard uses 
two metallic blades, very supple, and yet capable of retaining the curve 
MATERNAL DYSTOCIA. 
91 
Fig. 106.-Non-Rachitic Scoliosis. {Pinard.) 
Fig. 107.-Funnel Pelvis. {Pinard.) 
given to them. They are .39 inches broad, and .039 inches thick. They 
suffice to obtain the contour of the posterior wall of the pelvis, from the 
Fig. 108.-Kypho-Scoliosis of Dorsal Region. 
{Pinard.) 
Fig. 109.-Kyphosis of Dorso-Lumbar Region. 
Anchylosis to right angle of right hip. {Pinard.) 
tip of the coccyx to the last lumbar vertebra, and also the imprint of the 
anterior and posterior surfaces of the pubes. By tracing the shapes thus 92 
A TREATISE ON OBSTETRICS. 
given to the blades on paper, if we have also by the compass taken the 
position of the sacrum and the pubes, we obtain graphic outlines, repre- 
senting the natural size of an antero-posterior section of the pelvis that 
is to say, giving both the sacro-sub-pubic, and the least diameter of the 
pelvis. The figures 100 to 109 represent a certain number of outlines 
thus obtained. " 
Scheffer, from measurements on dried pelves, draws the following con- 
clusions in regard to the dimensions of the transverse diameter of the 
superior strait. His measurements concern 252 pelves: 
1. The greater the distance of the iliac crests, the greater the neces- 
sary deduction in order to obtain the transverse diameter of the superior 
strait. The mean difference is 5.07 inches. 
2. The greater the distance of the iliac spines, the greater must be the 
deduction in order to obtain the transverse diameter of superior strait. 
The mean is about 4.70 inches. 
3. In non-flattened pelves, the distance between the iliac crests fur- 
nishes more precise information than that between the iliac spines. 
4. In flattened pelves, the distances between crests and spines are of 
about equal value. 
5. To obtain the transverse diameter, we must deduct from the distance 
between the crests 5.2 inches, in the dried not flattened pelvis, and 4.5 
inches in the flattened. 
6. The deduction from distance between iliac spines is about the same 
in both pelves, about 4.7 inches. 
Dohrn reminds us that if we consider as contracted pelves those where 
the conjugata vera is less than 3.6 inches, then: 
Michaelis found .... 13.1 per cent, at Kiel. 
Litzmann " . . . . 14.9 
Schwartz " 
20.3 at Marburg 
22 " Gottingen. 
Spiegelberg " . . . 13.9 at Breslau. 
Schroeder " . . . . 14.6 " Boun. 
With all authorities, Dohrn prefers digital mensuration, with two fin- 
gers, over all pelvimeters. On the living, to find the true conjugate, 4 
inches is to be deducted from the external, in the normal pelvis; 3.8 
inches, in the uniformly contracted pelvis; 4 inches in the flattened pelvis. 93 
MATERNAL DYSTOCIA. 
Litzmann usually measures only the external conjugate and the trans- 
verse. But, while Baudelocque deducted 3.12 inches in thin women, and 
3.32 in fat, Litzmann, in 30 cases, found a mean difference of 3.71 be- 
tween the internal and external conjugates, and he concludes that when- 
ever the external conjugate, in the living, is less than G.25 inches, there 
is contraction in the conjugata vera; and that with an external conju- 
gate of 7.05 inches, contraction will exist in 50 per cent.; between 7.05 
inches and 8.39 inches, scarcely in 10 per cent.; above 8.39 inches, 
almost never. 
As for the transverse diameters, he found in 200 women with large 
pelvis, distance between crests, 11.5 in.; in 200 women with large pelvis, 
distance between spines, 10.5 inches. 
The difference between the dried and living pelvis is about .4 inches. 
As for the oblique diameters, he could draw no exact conclusions. 
Kustner's Pelvimeter. (Fig. 110 and 111.)-This instrument is at the 
same time a kaligraph. It is composed of a solid plane curved in a half- 
Fig. 110.-Kestner's Pelvimeter. 
circle to rest on the iliac crests. It is furnished with a metallic half-circle 
divided into two portions of 90° each, the zero being at the centre. On 
this half-circle is fixed the arc of a circle (three-quarters) also divided into 
degrees. The half-circle is fixed, the three-quarter is movable around a 
vertical axis («.) Around the half-circle moves a lever (cl), furnished 
with an index (See Fig. 110) which registers the divisions of the three- 94 
A TREATISE OX OBSTETRICS. 
quarter circle. The lever is divided into two portions, between which is a 
circle of 90°. The free lever bar (y) is hinged at h so that it may bend at 
an angle of G0°. On the plane are two hooks, i, to which rubber bands 
may be attached, and at the two ends are two silk bands. Figure 110 
represents the apparatus | reduced. 
To apply the apparatus, the woman lies on her back, the thighs flexed, 
and abducted, the knees flexed. The plane is placed so that it rests at 
Fig. 111.-Kestner's Pelvimeter. 
its extremities on the anterior superior iliac spines, its centre being over 
the symphysis. (Fig. Ill •) The two rubber bands, passing behind the 
pelvis at the level of the crests, and tied together, hold the apparatus 
symmetrically in place. The free end of the pelvimeter is then inserted 
into the vagina and placed on one of the bony prominences which we de- 
sire to compare with the other, and then we read off the angles registered 
by the three circles. *To find the point of the symphysis nearest the 
promontory, the free arm of the lever is bent to 60°, and then we may 
touch this point with the lever.. We may thus obtain the extreme points 
in the pelvis, and from these the distances are calculated. (For the 
method, the curious reader is referred to Kustner's description.) 
Kiistner insists on the simplicity of this method. We are sorry we 
cannot agree with him. MATERNAL DYSTOCIA. 
95 
Crouzat's Pelvimeter.-In 1881, Crouzat proved that digital mensura- 
tion was open to serious error, that is to say, in the estimation of the least 
sacro-pubic diameter there might be an error of 1.5 to 2 inches in two 
cases out of three. To remedy this possibility he devised an instrument 
to be used as a direct pelvimeter. It is composed of two portions, a 
blade, and a graduator. (Figs. 112, 113, 114, 115.) 
Fig. 112.-Crouzat's Pelvimeter. 
The blade is of steel, round, 8 inches long, including the finger holder, 
and .2 inches thick. The nail rests at 0. The blade is graduated in 
hundredths of an inch, the zero being at 0. The graduator (CC') (Fig. 113) 
is 3.9 inches long, and at each end is a graduated arc of a circle. The 
larger arc (A) measures 1.5 inches in height, and the smaller (a) 1.1 
inches. The one or the other is used according to the elevation of the 
post-pubic point. The curvature of the two arcs is the same, belonging to 
Fig. 113.-Crouzat's Pelvimeter. 
Fig. 114,-Front View of Arc. 
an arc of a circle of 3.12 inches in diameter. In figure 114 it is seen that 
the arc is hollowed out in its centre to diminish the contact surface. Ou 
the horizontal rod of the graduator is the slide (G) 1 inch long. This 
may be placed at one or another end, and fixed there at i. 
Use of Instrument.-The bladder and rectum having been emptied, the 
woman is placed in the obstetrical position, the buttocks elevated, the 
thighs separated, the feet resting on two chairs. The operator stands 
between the patient's legs, and makes a careful vaginal examination, in 
order to locate the promontory, and to find the situation of the post-pubic 
point. According to the height of this point, he choses the smaller or 96 
A TREATISE ON OBSTETRICS. 
larger arc. The right index is then inserted into the holder, and is car- 
ried into the vagina to the promontory, the chosen arc being, at the same 
time, carefully placed behind the symphysis. The graduated distance is 
Fig. 115.-Measurement of Pelvis by means of Crouzat's Pelvimeter. 
then read off the horizontal bar, and this is the exact measurement of the 
least promonto-pubic diameter, inclusive of the soft parts. 
Digital Pelvimetry. 
As Depaul well says, "notwithstanding the partial advantages offered 
by the pelvimeters, they one and all are open to objections which render 
them useless in routine practice. Of all the methods of measurement, 
that by the hand is certainly the least uncertain, inconvenient, and most 
exact in its results. We may thus measure the conjugate, and appreciate 
with sufficient exactness the length of the transverse and of the oblique 
diameters of the superior strait. All the more readily, of course, in the 
cavity, and at the inferior strait. Further, thus exostoses and tumors 
may be readily recognized. This is the method of mensuration almost 
entirely used in France, and abroad the tendency is to return to it. We 
certainly do not thus attain mathematical results, but the expert obtains 
figures precise enough for practical purposes." 
While in Germany the left hand and two fingers are used for mensura- MATERNAL DYSTOCIA. 
97 
tion, in France the right and one finger are resorted to; only in exceptional 
cases is it customary to use two or more fingers, or the entire hand. 
The woman should occupy the dorsal position, the nates resting on a 
pillow. The index is carried upwards and backwards to the sacro-verte- 
bral angle, which is readily recognized by its projection, and the trans- 
verse depression at the sacro-lumbar articulation. (Fig. 116.) We must 
not confound with the promontory, the projection which the first sacral 
bone sometimes makes over the second, and to avoid this the finger should 
be carried as high as possible. The promontory once found, the end of 
the index is placed upon it, and the wrist is lifted upwards, until it rests 
under the inferior margin of the symphysis. The index of the other 
Fig. 116.-Measurement of the Conjugate with the Finger. 
hand is then placed against the first, just under the symphysis. The 
vaginal finger is then removed, with the other in place against it, and 
then the distance from the point of the index to the position of the 
second finger may be measured, and we have the exact sacro-sub-pubic 
diameter. 
Often, to reach the promontory, it is necessary to depress the elbow as 
much as possible and to elevate the nates excessively. 
Now the diameter we have thus obtained, is not the sacro-pubic, but 
the sacro-sub-pubic, that is to say, an oblique line longer than the antero- 
posterior diameter, and we must hence deduct a trifle, according to the 
depth, and the obliquity of the symphysis, in order to obtain the true 
diameter. (See Figs. 117 and 118.) Authorities do not agree as to the 
amount which should be deducted, varying from .2 to .6 of an inch, accord- 
ing to the pelvis. 
Vol. III.-7 98 
From his measurements Pinard concludes that: Although the height, 
thickness, and direction of the symphysis are the true causes of variation 
in the diameters, it is especially the height which is important, and then 
the direction, and finally the thickness; and he shows that, whenever 
A TREATISE ON OBSTETRICS. 
Fig. 117.-Measurement of the Pelvis. 
the symphysis measures 1.5 inches and above, we must deduct from .3 
of an inch to .7; and whenever it measures less, it will suffice to deduct 
about .4 of an inch. He agrees, therefore, with Depaul. 
Whenever the finger cannot reach the promontory, the presumption is 
allowable that labor may take place at term, although it does not neces- 
sarily follow that the pelvis is normal, as, for instance, in the oblique oval 
pelvis, where we cannot reach the promontory, and yet the pelvis is far 
from being normal. 
As for pelvimetry at the inferior strait, Breisky prefers external men- 
suration. We suggest, on the contrary, the following method: 
The woman is placed in the knee-elbow position, and an assistant pulls 
aside the skin of the nates, until the vulva opens. The internal border 
of each tuberosity is then found, and marked in ink. The distance be- 
tween the two points is now measured, and we possess the external trans- 
verse diameter. 
The finger is then inserted into the vagina to the internal border of the MATERNAL DYSTOCIA. 
99 
tuberosity of the ischium, and one of the blades of Depaul's pelvimeter 
is placed against it, and the other blade against the corresponding point 
on the other tuberosity. Reading off the distance on the scale, and com- 
paring the figure with that obtained above, we have the bi-ischiatic, or 
internal transverse diameter. 
Fig. 118.-Measurement of the Pelvis. 
We thus obtain, approximately it is true, but with sufficient accuracy, 
the dimensions of the transverse diameter. 
The methods of external mensuration in use, give exact enough figures, 
practically, for the transverse diameters of the inferior strait, as is proved 
by Frankenhauser's figures. His measurements were made with Osian- 
der's instrument, and in 9 cases the following were the results: 
During Life. 
After Death. 
1 case, 
4.3 inches 
4.3 inches. 
2 cases, 
4.3 " 
4.1 " 
3 " 
3.8 " 
3.7 " 
4 " 
4.2 " 
4.2 " 
5 " 
4.9 " 
4.7 " 
6 " 
3.7 " 
3.7 11 
a 
3.3 " 
3.3 11 
8 " 
3.9 " 
4. " 
9 " 
3.7 " 
3.7 u 
We see that the differences are slight. 100 
A TREATISE ON OBSTETRICS. 
Stocker lays great stress on the value of the measurement of the bi- 
ischial diameter, both from the standpoint of diagnosis, and of prognosis. 
He says: " 1. Increase in the bi-ischiatic diameter indicates either a 
rachitic pelvis, or else deformity due to double femoral luxation. 2. A 
bi-ischiatic diameter of less than 3.5 inches indicates, very nearly, a funnel- 
shaped pelvis, and these are, usually, also diminished at the superior strait. 
3. Diminution of the bi-ischiatic diameter in a rachitic pelvis, means a 
general and regular contraction. 4. If in a pelvis we find both diminu- 
tion in the antero-posterior, and the bis-ischiatic diameters, osteomalacia 
is suggested. 5. Exaggeration of the bis-ischiatic diameter suggests a 
diminution in the transverse of the superior strait. From a therapeutical 
standpoint, diminution in the inferior strait, exposes to laceration of the 
perineum, often renders recourse to the forceps necessary, gives the in- 
fant little chance in case of version, and calls for the early induction of 
premature labor. 
Diagnosis of the different Forms of Pelvic Deformity. 
A. Pelvis regularly and generally Contracted.-We notice, at the out- 
set, the slight forward projection of the sacrum. Mensuration enables 
us to determine a more or less regular and proportionate diminution in 
the external diameters, and in the general circumference of the pelvis. 
The external conjugate is least diminished, and the distance between the 
anterior iliac spines in the most, resulting in a greater difference between 
these and the crests than normally. Internal mensuration almost always 
gives a moderate diminution is the sacro-sub-pubic diameter (the diagonal 
conjugate.) We must usually deduct to obtain the true conjugate from 
.3 to .5 of an inch. The cause of this disproportion between the two 
conjugates is above all due to the lessened inclination of the symphysis. 
B. Flattened Pelvis.- Is characterized, in particular, by diminution 
in the antero-posterior diameter of the inlet, the other diameters suffering 
but little change. 
a. Flattened, not Rachitic Pelves.-This variety, according to German 
writers, is the most frequent of all, 35 to 25 in 100. The general con- 
figuration and the bones of such women are frail. The sacrum is usually 
deeply placed between the iliac bones, projecting forwards, and the pos- 
terior iliac spines jut out considerably beyond the sacrum. The inclina- MATERNAL DYSTOCIA. 
101 
tion of the sacrum, however, seems less, perhaps, than normal. Exter- 
nal mensuration gives figures a little below the normal. The external con- 
jugate is the most diminished, while the transverse are but little altered. 
The distance between the anterior and the posterior iliac spines is dimin- 
ished. The deduction to obtain the true conjugate is about the same as 
in the normal pelvis. This diameter is usually over three inches, and 
rarely below. Sometimes there exists a double promontory. 
b. Flattened, Rachitic Pelvis.-All the diameters are lessened, particu- 
larly the antero-posterior. This is the most frequent of all pelves. The 
diagnosis is easy. The hips are narrow, the distance between the crests 
and the spines is diminished. The sacrum has the rachitic shape, the 
anterior and posterior spines are near together, the external conjugate 
is notably diminished. The inclination of the symphysis is great, and 
therefore great deduction must be made to obtain the true conjugate. 
C. Oblique, Oval Pelvis.-The diagnosis has only exceptionally been 
made on the living. Its presence may be suspected by the greater ele- 
vation of one of the iliac crests, by the inequality of the distance between 
the anterior and posterior iliac .spines and the spinous process of the last 
lumbar vertebra. The posterior iliac spine is on the anchylosed side 
nearest the median line. The symphysis is found to be directed towards 
one of the sides, the ischiatic spines are at about the same distance from 
the sacrum, and one of the sacro-cotyloid diameters is shorter than its 
fellow. According to Naegele, the following measurements are obtained 
by Baudelocque's pelvimeter: 
Inches. 
From the isch. tuberosity one side to the post. ant. spine 
of the other, mean distance . . . . . 6.8 
From the ant. sup. spine of one side to the post. sup. 
spine of the other, . . . . . . 8.19 
From the spinous process of the last lumbar vertebra, 
to the ant. sup. spine of both sides, . . . 7.02 
From the trochanter of one side, to the post. sup. spine 
of the other, . . . . . . . 8.58 
From the centre of the inferior border of the symphysis 
to the post. sup. spine of each side, . . . 6.8 
The prognosis is very grave. Litzmann, found that of 28 women, 22 
died at first confinement, 5 at the second, and 1 at the sixth. Of 41 de- 102 
A TREATISE ON OBSTETRICS. 
liveries only 6 were normal, and of these 6, 5 were in the same woman. 
Of 41 children, only 10 were born alive, 6 from the same woman, and 2 
by the Cesarean section. Schroeder, however, in 3 cases, notes all the 
mothers and children living. 
Thomas lays down the following corollaries: "A. We must always 
think of the oval pelvis when: 1. Some mechanical cause seems to inter- 
fere with labor, even though we cannot reach the promontory; 2. When 
the iliac crests are not on the same level; 3. When the two postero- 
superior iliac spines are at unequal distances from the sacral crests; 4. 
When the history tells us that in infancy there was disease of the pelvic 
bones. B. When we suspect an oblique narrowing of the pelvis, we must 
endeavor to reach a diagnosis by: 1. Palpating the horizontal pubic rami, 
and the internal lateral walls of the pelvis; 2. Measuring the posterior 
stheno-cords. (Ritgen.); 3. External measurements, which often alone 
suffice. " 
D. Transversely contracted Pelvis.-The diagnosis is easy, since there 
exists marked narrowing of the inferior strait. The parallelism of the 
pubic rami is striking, the narrowness of the symphysis, the nearness of 
the ischiatic tuberosities. External mensuration allows us to determine 
notable diminution in the following diameters: 
1. Between the trochanters. 
2. Between the two iliac crests. 
3. Between the ant. sup. iliac spines. 
4. Between the ischiatic tuberosities. 
E. Scoliotic, Kyphotic Pelvis.-The deformity of the vertebral column 
will at once attract attention. 
F. Spondylolisthesic Pelvis.-The history will reveal an injury after 
infancy. The attitude is often characteristic, owing to the forward in- 
flection of the vertebral column. In Olshausen's case the woman walked 
like a quadruped; in Belloc's, the head and the upper part of the trunk 
were inclined forward to the level of the pelvis. The thorax is pushed 
backward, and the distance between it and the pelvis is notably diminished. 
Internal examination allows us to touch readily all the bony portions. 
Externally the spinal curve, with concavity backwards, is noticeable. 
G. As for pelves deformed by luxations, shortening of the inferior limbs, 
the nature of the lesion is apparent. We may, however, be deceived. 
We remember a case where there existed a congenital luxation of the MATERNAL DYSTOCIA. 
103 
right femur, and yet on vaginal examination very different characters 
were found. On close questioning we elicited the fact that, in childhood, 
the woman had suffered, in addition, from caries of the upper part of 
the sacrum and lower lumbar column. 
H. The osteomalacic pelvis does not entail any difficulty in diagnosis. 
The progressive march of this disease, its beginning after repeated preg- 
nancies, and the peculiar form of the deformity will put us on the right 
track. 
Pregnancy in Pelvic Deformity. 
At the outset, we would recall the fact of the frequency of miscarriage 
and of premature labor, in case of pelvic deformity, owing to the mechani- 
cal interference with the development of the uterus and of the foetus. 
When the uterus, in the course of its growth, endeavors to rise above 
the superior strait, it is evident how a projecting promontory will interfere, 
and how, furthermore, in case the uterus is a little tilted backwards, 
there will result retroversion, and, in case this displacement increases, we 
witness all the phenomena indicative of incarceration. (See Retrover- 
sion of the Uterus.) Happily, in the large proportion of cases, the uterus 
is able to pass by the obstacle, and to rise above the brim, and pregnancy 
may continue. What strikes us at once, in such cases, is the elevation of 
the fundus out of proportion to the age of the pregnancy, and, in addi- 
tion, the lower segment of the uterus, and if, in the latter months, it can 
be reached, the foetal parts are felt but indistinctly, if at all. This, ob- 
viously, is different from that which obtains in normal cases. Again, this 
elevation of the uterus is accompanied by greater mobility. The abdom- 
inal walls hang forwards, constituting the venter propendulus. The fall- 
ing forward of the uterus is further favored by the inclination of the 
pelvis. 
Pelvic deformities have a capital influence on the presentations and 
positions of the foetus. The fact of the frequency of mal-presentations 
has been noted by all accoucheurs, from the time of Mauriceau, and this 
is explained by the difficulty the foetus has in accommodating itself to the 
uterus and to the pelvis. The following data deduced from Litzmann, 
Spiegelberg, Schroeder and Stanesco, will give an approximative idea of 
the frequency of different presentations in pelvic deformity: 104 
A TREATISE ON OBSTETRICS. 
Vertex, . . 92 
Breech, . . 13 
Face, ... 2 
Shoulder, . 1 
In 108 cases where spontaneous labor occurred 
In 47 cases where labor was ended by version 
Shoulder, . 31 
Vertex, . . 11 
Vertex, . . 102 
Face, ... 5 
Breech, . . 1 
In 108 " " " " forceps 
In 16 " " " " craniotomy 
Vertex, . . 13 
Breech, . . 2 
Face, ... 1 
In 46 cases premature labor was induced 
Vertex, . . 34 
Breech, . . 8 
Shoulder, . 4 
Vertex, . . 82 
Face, ... 4 
Breech, . . 4 
In 90 where cephalotripsy was requisite . 
In 4 Caesarean sections . . . • 
Vertex, . . 2 
Not stated . 2 
In 414 cases, then: 
Vertex, ......... 336 
Face, .......... 12 
Breech, 28 
Shoulder, ......... 36 
Not stated, . 2 
Rigaud in 396 cases, with 404 children, gives the following figures 
O.L.A., . 352 
O.R.P., . • 100 
O.R.A., . . 6 
O.L.P., . . 2 
Presentations of vertex 
The position 0. L.A. includes the cases where the presentation was 
noted and the position not. 
Breech cases, 29 
Face, .......... 4 
Shoulder, 11 
Considering together the statistics of Rigaud and of Stanesco: 
Infants. 
Presentations of vertex, ...... 696 
" " Face, ...... 11 
" " Breech, 67 
" " Shoulder, ..... 47 
Unknown, ... .2 
Total, 829 MATERNAL DYSTOCIA. 
105 
It is evident, then, that presentations of the face, and of the shoul- 
der are much more frequent in case of pelvic deformity than in normal 
pelves. 
Spiegelberg and Schroeder have further noted that changes in presen- 
tation, both in pregnancy and at the beginning of labor, are very frequent. 
These changes may be explained by the greater motility of the foetus. 
Litzmann, Hecker, Crede, Schultze, all agree on this point. These 
mutations are infrequent in primiparae, since in them the uterus tends to 
retain its ovoid shape. They are met with, on the other hand, very fre- 
quently in multiparse, owing to the laxity and diminished resistance of 
the uterine and abdominal walls. 
It is particularly in premature labors that mal-presentations are met 
with. All authorities agree in the frequency with which there occurs 
prolapse of the limbs and of the cord. According to Spiegelberg, this 
frequency is 4 to 5 times greater than under normal conditions. 
In the cases collected by Rigaud and Stanesco, 810 in all, there was 
noted: 
Prolapse of cord alone, . . . . . . 71 
" 11 tl and limb, ..... 3 
" " arm, ....... 13 
" " foot, 2 
" li " and hand, ..... 1 
that is to say, 90 cases of prolapse in 810 cases, or 11.11 per cent. 
Aside from these local phenomena, women with pelvic deformity pre- 
sent certain general characteristics. 
When there exist coincidently spinal curvature and alteration of the 
thorax, there often result respiratory and circulatory troubles, as evi- 
denced by edema of the lower limbs, dyspnoea, gravido-cardiac disorders, 
pulmonary congestion, eclampsia, and these complications may of them- 
selves induce labor, even if they do not call for the induction. Usually, 
however, the general disturbances resulting from pelvic deformity are 
relatively well borne, and without disturbing pregnancy very much, which 
usually goes to term; it is generally only at labor that serious complica- 
tions supervene. Every variety of deformity, however, as we will see, 
/ • 
does not portend the same gravity. 106 
A TREATISE ON OBSTETRICS 
Labor in Case of Pelvic Deformity. 
At first we will study the general course of labor, and afterwards the 
march in special varieties of pelvic deformity. 
The phenomena of labor are divided, even as in normal cases, into 
physiological and mechanical. 
For the purposes of our study, we will divide pelvic deformity, with 
Naegele and Grenser, into three great classes: 
1. Although the pelvis is contracted, it allows of expulsion of the foetus 
by the efforts of nature. The risk to both mother and infant is, how- 
ever, increased. 
2. The contraction does not prevent engagement of the head at the 
superior strait, or in the cavity, but the head cannot entirely pass. 
3. The contraction is of such a degree that the head cannot enter the 
superior strait, and remains movable above it. 
In pelvic contraction, aside from the factors requisite in normal labor, 
regular and good contractions, there are two on which great stress must 
be laid: The degree of contraction, and the reducibility of the foetal 
head. 
Physiological Phenomena. 
a. Uterine Contractions.-In general, it may be said that these are 
proportionate to the resistance to be overcome. At first they are normal 
and regular, but it is not rare to see them assume an extreme intensity, 
yielding soon to feebleness and irregularity, merging finally into uterine 
inertia. These irregularities, of course, are most marked where the con- 
traction is considerable, and labor of long duration. 
The obstacle once overcome, not infrequently labor is speedily finished; 
in other cases, however, the uterus, tired out by its efforts, sinks into 
complete inertia. Whatever the case, both too energetic and too feeble 
contractions are fraught with danger. If they are too energetic, rupture 
of the uterus may result; if they are too feeble, the head does not engage, 
and labor is prolonged to the detriment of both the mother and the 
child. 
Whatever the nature of the contractions, what strikes us particularly 
is the tardiness with which the head engages, a tardiness dependent not 107 
MATERNAL DYSTOCIA. 
alone on the contraction, bnt on the overhanging abdomen, whence the 
head does not correspond to the pelvic inlet. This engagement of the head 
is exceptional before tabor, in case of deformed pelvis. Litzmann in 222 
women, found it only partially engaged 18 times during pregnancy; dur- 
ing labor in only about 24.1 per cent, of the cases; in 5G per cent, en- 
gagement only occurred after complete dilatation of the cervix. Vaginal 
touch, therefore, at the beginning of labor, does not allow us to reach 
the presenting part, which remains above the superior strait. Only by 
forcibly depressing from above, can the finger touch a small segment of 
the vertex. 
b. Dilatation of the Cervix.-This occurs slowly, often very slowly, 
on the one hand on account of the little intensity of the contrac- 
tions, and on the other because the membranes usually rupture 
prematurely, and, therefore, mechanical pressure is largely absent. 
As long as the membranes are intact dilatation proceeds regularly 
enough, but when these rupture, the cervix thickens and dilates very 
slowly. The cervix itself presents certain peculiar characteristics. 
Instead of being thin, as normally is the case, it remains thick; the 
os rarely exceeds in dilatation the size of a quarter, but we find that 
it is perfectly dilatable. This happens because the head has not pressed 
on the cervix, but has remained above the superior strait. Under the 
influence of the contractions, however, the head becomes more and more 
moulded and becomes partially pointed, and engages a trifle. At this 
part of the head the caput succedaneum forms, and projects the more the 
longer the duration of labor. The cervix is filled with this herniated, as 
it were, caput, and the cervix forms a ring around it, even where the 
head remains above, or nearly so, the superior strait. 
c. Membranes.-The head being retained above the superior strait, the 
liquor amnii may collect in front of it, and therefore the bag of waters 
is always voluminous. If the resistance of the membranes is considera- 
ble, it is an efficient factor in dilatation, until they rupture, and this usu- 
ally happens before the os is more than one-sixth dilated. It is at the 
moment of rupture, especially if the woman is in the erect position, that 
prolapse of the limb or the cord occurs, the presence of which, above the 
superior strait, we may occasionally recognize before rupture. When, 
however, the membranes are elastic, the appearance and sensation is 
different. The bag of waters does not form within the cervical canal, but 108 
A TREATISE ON OBSTETRICS. 
outside, and the projection is the more the greater the elasticity of the 
membranes. On touch, at first sight, it seems as though dilatation were 
completed, but on carrying the finger higher, the constricting cervix is 
felt. 
In each instance, however, the membranes rupture prematurely, and 
before dilatation has occurred, and, in consequence, labor is prolonged, 
and the foetus is exposed to the dangers resulting from interference with 
the uterine and placental circulations. t 
Occasionally, the membranes rupture even before the onset of labor, 
under the influence of the painless contractions. 
Rupture having occurred, the cervix retracts, although it remains dila- 
table to the same degree. Then either: 
1. The obstacle to delivery is insurmountable; the contractions become 
very energetic, and, if we do not interfere, the uterus, rarely, fortunately, 
ruptures, or the vagina is detached at the vaginal vault. There follows, 
usually, however, uterine inertia. 
2. The obstacle to delivery is not absolutely insurmountable, the head 
tends to engage, it moulds itself gradually, and sometimes passes the 
superior strait. Again, on the contrary, engagement may be only partial, 
and the head remains imprisoned, as it were, until art assists it. 
How now, and by what diameters does the head engage ? If we in- 
terfere, is forceps or version preferable ? These questions we will success- 
ively pass in review. 
Mechanism of Labor in Pelvic Contractions. 
General Mechanical Phenomena. 
The elements of the problem, as is readily apparent, are complex and 
multiple. In case of pelvic deformity, the head is not, as in the normal 
pelvis, engaged at the superior strait at the end of pregnancy. Often the 
only difficulty is this lack of engagement. That this may be effected, 
not only must the expulsory force be sufficient, but the obstacle to be 
overcome must not be too great, and the head must allow of considerable 
moulding, and its smaller diameters must adapt themselves to the smaller 
of the pelvis. Further, as we have seen, owing to the mobility of the 
foetal head, abnormal presentations are frequent, those of the face and 
the brow being relatively common. MATERNAL DYSTOCIA. 
109 
It is only since the time of Mauriceau and of Litzmann that a careful 
study has been made of the mechanical phenomena of labor in case of 
pelvic deformity, and latterly numerous works on this subject have been 
published. 
We have already seen that Budin's researches prove that, in normal ver- 
tex presentations, the occipito-mental and occipito-frontal diameters really 
diminish in length; that it is the sub-occipito-mental diameter which in- 
creases the most, and that the diameters which diminish the most are, in 
order, the sub-occipito-bregmatic, the bi-temporal, the bi-parietal-the 
latter, contrary to the generally accepted opinion, altering the least. 
Does the same happen in case of pelvic deformity? 
Otto de Haselberg divides deformed pelves into four categories: 
1. Pelves with Antero-posterior Diameter from 4.22 to 3.69 Inches.- 
The head lies transversely at the superior strait in all varieties of contrac- 
tion at this strait. This is necessary, seeing that the transverse diameter 
of the head, which is smaller than the oblique, occupies the conjugate of 
the pelvis, which is its least diameter. On the occurrence of contractions, 
the occiput descends, and since the conjugate is large enough to accommo- 
* date the bi-parietal, this engages, and the small fontanelle approaches the 
centre of the pelvis. In other words, the head flexes. The sagittal 
suture is at the same distance from the promontory and the symphysis, 
and the head is perpendicular to the plane of the superior strait. 
Naegele's obliquity is only apparently present. The head thus descends 
transversely to the pelvic floor. It is only at this level that the occiput 
rotates forwards. 
2. Antero-posterior Diameter from 3.69 to 3.16.-The head still lies 
transversely, but the bi-parietal diameter is too large for the conjugate, 
and this diameter cannot, therefore, engage. The head must flex, and 
this too, above the brim. This does not always happen, and then the 
occiput, lying between the promontory and the symphysis, becomes dis- 
placed, and the head beginning to extend, engages by its bi-temporal 
diameter. The sagittal sutures lie transversely across the centre of the 
pelvis; the larger fontanelle is nearer the centre than the smaller. It is 
readily apparent how a brow or face presentation may occur. 
3. Antero-posterior Diameter of 3.16 to 2.64 Inches.-Here even the bi- 
temporal diameter is too large for the conjugate, and lies well above the 
conjugate, the head being transverse. Since it cannot enter, the anterior 110 
A TREATISE ON OBSTETRICS. 
extremity, which encounters the least resistance, slips down. The head 
extending, the bi-temporal diameter descends, until it lies against the 
upper border of the symphysis. The sagittal suture, although remaining 
transverse, is no longer in the centre of the cavity; the large fontanelle 
is low down and very near the promontory; behind the symphysis the 
upper border of the ear is felt; the head, in other words, is inclined to 
the plane of the superior strait by the anterior parietal, which is lower 
and more accessible. This inclined engagement of the head, is the more 
likely to be found where the venter propendulus exists. We have here 
Naegele's obliquity. 
4. Antero-posterior Diameter below 2.64 Inches.-Engagement is abso- 
lutely impossible, either by flexion or extension. The head remains above 
the superior strait, either obliquely or transversely, and no caput succe- 
daneum is formed. 
We see, in this connection, the influence of solidity, volume, and com- 
pressibility of the head, since, for example, a pelvis of the second degree 
may be readily transformed into one of the third, if the head is large and 
well ossified. Otto, however, lays the greatest stress on the position of 
the head, and this situation allows us to predict if the head can or cannot 
pass the contracted part. 
As for the after-coming head, Otto say that, " once the trunk delivered, 
the head presents transversely at the superior strait, and this is normal, 
and the only position which will allow of engagement. Whatever the 
degree of contraction, we are obliged to interfere, and it is the bi-tem- 
poral diameter which is brought into the conjugate. The first effect of 
traction is to cause descent of the occiput and lessening of flexion. Con- 
sequently, the longitudinal diameter of the head, the occipito-frontal, 
coincides with the plane of the superior strait, the parietal protuberances 
slide laterally, and it is the transverse diameter anterior to these protu- 
berances which engages in the conjugate, and this must be the bi-temporal, 
since all others are too large." 
This mechanism, as we will see, is not that by which the head passes 
the conjugate, since the head must be flexed, instead of becoming ex- 
tended. As Otto says: 
" When the pelvis measures in the conjugate from 3.16 to 2.64 inches, 
the inclination of the head, which favored its engagement in vertex pres- 
entations, no longer exists where we are dealing with the after-coming MATERNAL DYSTOCIA. 
111 
head, and it is not necessary, since the head engages by its base, which 
presents no lateral projection, to stop it at the promontory or the symphy- 
sis. Only when the chin is anterior is the symphysis apt to interfere. 
Indeed, the whole difference between the before-coming and the after-com- 
ing head lies in its inclination, which exists in the first instance, and does not 
in the last." For Otto it is this inclination which retards labor in case 
of vertex presentation, and this is why he prefers version to forceps. 
" Spiegelberg believes with Otto in the transverse presentation of the 
head, but with Michaelis he grants great obliquity of this head to the 
superior strait. The sagittal suture is very near the promontory. Since 
the bi-parietal diameter cannot pass the conjugate, it deviates towards 
the side of the foetal back, and the occiput, therefore, is at or about the 
level of the linea innominata. It is here that the resistance is greater, 
and the temporal region sinks a little, and the bi-temporal diameter gains 
the conjugate; the anterior portion of the parietal bone, therefore, pre- 
sents. Thus the lambdoidal suture lies above the symphysis, and one of 
the small temporal fontanelles is near the promontory. The large 
fontanelle is a little lower than the small, nearer the promontory, and 
a trifle laterally. The finger may traverse the greater part of the 
anterior parietal bones. The head adapts itself to the superior strait as 
follows: The posterior parietal portion flattens against the promontory, 
Naegel e's obliquity becomes rectified, and this parietal portion slides 
backwards. The head flexes, the small fontanelle and the occiput descend, 
and the head rotates with ease." 
Dohrn rejects the mechanism of labor as described by Otto, or, at least, 
admits it only exceptionally. "In accord with Michaelis and Spiegel- 
berg, he states that the occiput and the forehead are relatively free to the 
right and to the left, and the force which brings about accommodation in 
the conjugate is expended in the lowering of the anterior part of the 
parietal, and in a notable flattening of the posterior part. The head ad- 
justs itself in the conjugate by its small oblique diameter. Thus the 
occiput descends, and it is not the parietal protuberance which slides un- 
der the promontory. This acts on the coronal suture, which it cuts from 
behind forwards. Either the promontory pushes the parietal in the di- 
rection of the ear, or else it acts from behind forwards and from above 
downwards, compressing the coronal suture. This last mechanism is the 
rule." Dohrn hence concludes that version offers no advantages, since 112 
A TREATISE ON OBSTETRICS. 
both in case of before and after-coming head disengagement occurs by the 
small oblique diameter. 
Both Simpson and Radford have studied the mechanism of labor in 
pelvic deformity, and they agree in the belief that the after-coming head 
passes more readily than the before-coming, and both prefer version to 
forceps. 
From Simpson's researches (V. Figs. 119 and 120), the following con- 
clusions are drawn: "1. The foetal head has the shape of a cone with base 
Fig. 119.-Effect of Pressure at the Summit of the Cranial Vault. 'When the head presents, 
the dotted line, c, b, b, c, is the vertical section. The line 1, 2, 2, shows the disadvantageous 
alteration in form caused by head presentation in deformed pelvis. 
upwards, and, when the trunk is first delivered, the smaller part of this 
cone may usually engage in the superior strait. (Fig. 121.) 2. The 
solid hold given by the body of the foetus when it-is delivered first allows 
us to use force enough to cause compression of the head, and to bring, if 
need be, the elastic and larger part of the cone into the greatest space 
Fig. 120.-Shape assumed by the Fcetal Skull in passing through the Contracted Superior 
Strait. A, Promontory of Sacrum. B, Pubic symphysis. C, Free space between the iliac bone 
and foetal forehead. D, Depression in skull, corresponding to sacral promontory. Anterior 
fontanelle. F, Posterior fontanelle. 
in the contracted pelvis; 3. The head, drawn through the contracted pel- 
vis, generally so adapts itself, or may be caused to adapt itself in such a 
manner as to bring its smallest diameter, the bi-temporal, instead of the MATERNAL DYSTOCIA. 
113 
bi-parietal, into the most contracted diameter of the pelvic strait; 4. The 
cranial vault is more readily compressed when the force is applied to its 
lateral surfaces, as it is in case of the after-coming head, and not, as in 
case of the before-coming head, partially to its lateral and partially to its 
superior surfaces." 
To justify this theory, Simpson states the following practical conclu- 
sions: " 1. The duration and hence the danger of labor is diminished by 
version. Therefore version should be resorted to as so.on as dilatation is 
complete, without waiting for engagement of the head, and, in conse- 
quence, before inertia can set in. 2. The compression of the foetal head 
Fig. 121.-Shape assumed by Skull under the influence of Lateral Compression of the Vault 
by the Contracted Superior Strait, in Delivery by After-Coming Head. The dotted line, ab, 
ab, represents vertical section of normal head. The contour, 1, 2, 1, shows the change in 
shape which occurs when the foetus is extracted by the feet in a contracted pelvis. 
is compatible with its life. 3. The traction to which the foetal neck is 
subjected is not incompatible with foetal life. 4. The risk of death from 
compression of the cord is not great enough to cause the rejection of ver- 
sion. 5. Energetic but rapid compression is less dangerous to mother 
and to infant than less but prolonged compression. 6. Local lesions of 
the vagina, fistulas, etc., are more likely to result from forceps than from 
version. 7. The risk of rupture of the uterus during version has been 
exaggerated. " 
Simpson gives the following figures in regard to comparative mortality. 
Forceps. Version. • 
Infants, ... 1 out of 3 . . 1 out of 3| 
Mothers, . . . 1 " 5 . . 1 " 15 
Schroeder also admits the transverse presentation of the head, but he 
believes that in contracted conjugate the greater resistance is much nearer 
the occiput than the forehead. The anterior part of the head, he says, 
Vol. Ill-8 114 
A TREATISE ON OBSTETRICS. 
descends, until the smaller transverse diameter, which is also more com- 
pressible than the greater transverse, engages in the conjugate. (See 
Figs. 122 and 123.) 
We see, therefore, that authorities are not absolutely in accord in regard 
to the manner after which the head engages. The endeavor has been 
made to prove by the deformity of the head that one or another diameter 
engaged in and passed through the conjugate. These deformities, how- 
ever, are not at all constant as to site. The only point which is at all ap- 
preciable is the degree and the form of the contraction. Labor will, of 
course, be all the more difficult, the greater the degree of contraction. 
Mechanical Phenomena in different Forms of Pelvic Contraction. 
Litzmann has studied this question with the greatest care, in particular 
the three classic forms of contraction: 1. Generally and regularly con- 
tracted pelvis. 2. Flattened pelvis. 3. Generally contracted flattened 
pelvis. 
1. These pelves measure ordinarily at least 3.5 inches in the conjugate, 
and Litzmann has never seen a case where the measurement was under 
3.12 inches. We have seen a case where the measurement was only 2.9 
inches, and we do not agree with Litzmann in classing such cases in the 
third category. The anomalies in shape and situation of the uterus are 
possibly less frequent in this form than in the others. The pendulous 
abdomen is uncommon, and abnormal presentations are relatively rare. 
But seeing that the contraction involves the entire pelvis, and not alone 
the superior strait, the difficulties in delivery are often very great, even 
to the extent of requiring cephalotripsy. 
In 1821, Mampe first called attention to the mechanism of labor in these 
cases, and Michaelis, agreeing with him entirely, insists on the fact that 
the head engages by its occipital portion. According to Litzmann, this 
descent of the occiput occurs in all pelves where the transverse diameter 
is shortened. In the regularly contracted pelvis, the lesser fontanelle is 
at a lower level than the greater, and remains so during the entire period 
of descent, until the brow reaches the promontory, when, as it descends, 
the occiput rises a little behind the pubes. Further, a very characteristic 
phenomenon according to Michaelis, the head remains mobile, and is not 
fixed in the sub-occipito-frontal diameter. The sagittal suture is at times MATERNAL DYSTOCIA. 
115 
transverse, again oblique, and sometimes antero-posterior with reference 
to the superior strait. Not infrequently, in these cases, the occiput now 
rotates anteriorly, now posteriorly, now descending and again rising. 
When the head presents transversely the two parietals are on the same 
level. When we find the sagittal suture near the promontory, this is not 
due to the contraction alone, but to the fact that Naegele's obliquity is 
very pronounced. This is rare, however, and ordinarily this suture is 
towards the front of the pelvis, and the anterior portion of the parietal 
presents. These irregularities in position soon correct themselves. 
Stein contends that rotation of the occiput occurs at the pelvic floor, 
while Litzmann says that it occurs earlier, as soon, indeed, as the descent 
of the occiput renders engagement possible; and he has at times already 
found the sagittal suture in the antero-posterior diameter of the pelvis, 
while the forehead was still above the superior strait. 
The gravest cases are those in which the head is extended instead of 
being flexed. 
While a number of authorities believe that, in the regularly and gener- 
ally contracted pelvis, presentations of the pelvic extremity offer greater 
difficulties than those of the vertex, Litzmann and Michaelis oppose this 
Fig. 122.-Engagement of the Head in case of Regularly and Generally Contracted 
Pelvis. (Schroeder.) 
view, and say that, on the contrary, when the chin has once descended, 
the head passes even more readily than in the flattened pelvis, and rotates 
with greater ease. According to them it is not the squamous suture, but 
the posterior part of the frontal which is subjected to pressure at the 
promontory. (Fig. 122.) 
Ruptures of the uterus and of the vagina do not seem to be more fre- 
quent in this variety of deformity, but owing to the pressure of the foetus 116 
A TREATISE ON OBSTETRICS. 
along the entire canal, sloughs oftener occur. The caput succedaneum is 
ordinarily large, but the impressions left on the skin of the skull are not 
especially marked. A characteristic of this variety of contraction is that 
the mark left by compression at the promontory is found on the pos- 
terior portion of the parietal bone, at equal distance from the coronal and 
the sagittal suture, extending, according to the degree of descent and 
the period of rotation, from the parietal protuberance to the external 
angle of the eye, or towards the cheek. Where, however, the head, 
through deep descent of the occiput, engages by its sub-occipito-frontal 
diameter in the conjugate, the depression due to the promontory is on 
the anterior part of the parietal, and extends nearly parallel to the frontal 
suture. The sutures generally overlap, the occipital bone being pushed 
under the parietals, one lateral part of the skull, in a word, overlaps the 
other. The posterior parietal is flattened, the frontal bone only when 
rotation occurs early. (V. Figs. 124 to 129.) In case of delivery by the 
breech, the depression is found on the posterior part of the frontal. This 
form of pelvis is of grave import both for the mother and the child. 
2. The simply flattened pelvis, rachitic, or not, is the most common 
form. The only difference lies in the fact that, in the rachitic, the flat- 
tening at the superior strait is more marked, since the conjugate is more 
contracted, the transverse diameters being not only relatively, but abso- 
lutely enlarged. We have already noted the complication of retroversion, 
pendulous abdomen, faulty presentations, and prolapse of limbs or cord. 
The obstacle to delivery is at the superior strait, and this once overcome, 
labor may be quickly terminated. 
Michaelis has given the most exact description of the mechanism of 
labor, and Litzmann's researches have confirmed the truth of the former's 
conclusions. "Asa general rule, the head is transverse at the superior 
strait, although, at the outset, the sagittal suture may be a trifle inclined 
obliquely. Rotation rarely begins until the two parietals are entirely en- 
gaged m the pelvis. The marks left by promontoric pressure, varying 
from a simple line to a depression, ordinarily extend from the sagittal 
suture along the coronal, towards the temple and the cheek. The more 
this mark deviates from this direction, in front of the external angle of 
the eye, the more likely it is that the pelvis is not only contracted in the 
conjugate, but also, more or less, m all the other diameters. Only excep- 
tionally does the head engage with its long diameter in one of the oblique 117 
MATERNAL DYSTOCIA. 
of the pelvis, and it is in these cases that we find deep descent and engage 
ment of the occiput. (V. Fig. 123.) Usually the anterior part of the 
head is the lowest. The larger fontanelle is in the centre of the cavity, 
while the smaller is almost inaccessible, and may be even above the su- 
perior strait. During engagement, the occiput descends still more, but 
usually, when the head is fixed in the conjugate, it remains transverse, 
and the greater fontanelle is felt to proceed gradually from the centre of 
the cavity toward one of the sides of the pelvis, while, on the other hand, 
the lesser fontanelle becomes more accessible. Sometimes engagement of 
the head occurs slowly, sometimes rapidly, until, flexion having been 
completed, rotation begins. The parietal tuberosities, meeting resistance 
Fig. 123.-Engagement of the Head in the flattened Pelvis. (Schroeder.) 
in the conjugate, slide to the side, supposing always that, between the 
wings of the sacrum and the pubic crests there exists space enough to 
admit of the bi-parietal diameter, and that the transverse of the pelvis is 
large enough to accommodate the occipito-frontal diameter. The two 
parietals rarely descend on the same level, only when the disproportion 
between the skull and the conjugate is not very pronounced. As a rule, 
the posterior parietal is the one which is stopped by the promontory, only 
exceptionally is the anterior parietal interfered with by the symphysis. 
(See Fig. 123.) In the first instance, Naegelc's obliquity is exaggerated, 
and the mechanism of engagement is as follows: While the border of the 
anterior parietal bone rests on the symphysis, the posterior parietal, situ- 
ated at the level of the promontory, flattens out, and describes an arc of 
a circle around the anterior point, which slowly brings the sagittal 
suture into the centre of *the pelvis. At the same time the head rotates 118 
A TREATISE ON OBSTETRICS. 
around its longitudinal axis, flexes, and the occiput descends. The two 
movements are combined, sometimes one, and again the other, being 
accentuated. In the second and rarer instance, it is the anterior parietal 
which rotates behind the symphysis. 
"In pelvic presentations, the head is always transverse; according to the 
degree of contraction, the head may be either engaged in, or else retained 
above the superior strait. In the first instance, flexion has already begun, 
and engagement takes place successively by the bi-temporal, and then by 
the bi-parietal, and while the squamous portion of the anterior parietal 
passes behind the symphysis, the posterior parietal rotates under the 
promontory. If the resistance offered by the pelvis is great, either the 
anterior inferior angle of the posterior parietal is simply depressed, or it 
is forced down towards the tuberosity. If the occiput has descended into 
the cavity at the same time as the chin, and this is very rare, if even it is 
lower than the chin, a line running the length of the coronal suture on 
the posterior parietal, indicates the pressure exerted by the promontory 
during the passage of the lateral region of the parietal protuberance along 
the promontory. Only exceptionally does such a degree of extension 
occur as will permit the descent first of the occiput along the promontory. 
The maternal lesions will be found at the promontory and the. symphysis, 
and may even be of the nature of sloughs. When the contraction is great, 
the markings on the foetal head are on the posterior parietal, between 
the tuberosity and the greater fontanelle, at a greater or less distance from 
the sagittal suture. 
" The overlapping of the sutures is much rarer than in the preceding 
degree of contraction, but the displacement of the two lateral halves of 
the skull is much more frequent. The posterior parietal is flattened. 
Grooved depressions are often found, cone or spoon-shaped seldom. (See 
Figs. 124 to 129.) 
"3. In the generally contracted flattened pelvis, at the beginning of 
labor, the head is almost always above the superior strait. It is still 
transverse, obliquity only being possible where the head is small and com- 
pressible, or the contraction slight. Whenever engagement is caused by 
the contractions alone, then it is by the occiput. Presentation of the an- 
terior parietal is sometimes seen, of the posterior rarely. In pelvic pre- 
sentations the head can only engage when markedly flexed. 
" The mechanism is then the same as in the simply flattened pelvis. The MATERNAL DYSTOCIA. 
119 
depressions are found between the middle and superior portion of the 
coronal suture and the parietal protuberance. These are situated nearer 
the suture, when the longitudinal diameter of the skull is near the antero- 
posterior diameter of the pelvis; they are the further from the sagittal 
suture the nearer the longitudinal of the head is to the transverse diame- 
ter of the pelvis. The maternal parts are liable to serious injury, and the 
risk for the mother and the child is great." 
Schroeder, from the study of deformity of the head in pelvic contrac- 
tion, reaches the following conclusions: " Aside from depressions and 
marks of compression, when the foetal head remains for long in a de- 
formed pelvis, it undergoes modifications in shape, persisting after delivery, 
which approach one of the two types, the dolychocephalic or the brachy- 
cephalic; sometimes there being a shortening in the transverse diameter, 
and again in the longitudinal of the head. ' ' 
Stadfeldt first called attention to the asymmetry of the head, involving 
particularly the occipital bone, the left side projecting more and being 
rounder than the right. Welker has found that the distance between the 
brow and the parietal protuberances is greater to the right than to the 
left, and attributes this fact to the greater frequency of left positions, 
and the pressure exercised by the pelvic bones during the last months of 
pregnancy. Dohrn, however, considers this lateral flattening the result 
of labor. (Fig. 125.) Schroeder, by measuring foetal heads, one half to 
one hour or more after delivery, found, in 30 cases, that the distance be- 
tween the parietal and the occipital protuberances was: 
Smaller from left to right, . . . . 11 times. 
Larger, ....... 17 " 
Equal, ........ 2 " 
From the eighth to the fourteenth day after delivery: 
Smaller from left to right, .... 18 times. 
Larger, ....... 7 lt 
Equal, . . . . . . . . . 5 " 
Congenital asymmetry of the skull, therefore, really exists, but Dohrn's 
researches are still of value. Ordinarily, the posterior parietal is pushed 
under the anterior, although there are many exceptions. When the 
conjugate is contracted, without or with general contraction, the anterior 
is at least as frequently pushed under the posterior, while in generally reg- 120 
A TREATISE ON OBSTETRICS. 
ularly contracted pelves the reverse is true. In contracted pelvis, over- 
lapping of the frontal bones is very frequent, and the frontal bones of the 
same side as the parietal overlap together. The occiput is pushed under 
the parietals, and is rarely above. (V. Figs. 124 to 129.) 
4. In the oblique oval pelvis the progress of labor depends, on the one 
hand, on the dimensions of the pelvis, and, on the other, on the degree 
of obliquity and of lateral displacement. If the lateral flattening is slight, 
the promontory deviated but little, the sagittal suture of the head, and 
this is ordinarily the case, may lie in the greatest oblique diameter, and 
labor may be terminated; but, if the sacro-cotyloid diameter is much de- 
creased, then the shape of the pelvis approaches that of the generally 
contracted and the mechanism is similar. In general, disengagement of 
the head is very easy when the sagittal suture occupies the shortened ob- 
lique diameter of the superior strait. Whence the advice to perform version 
in order to bring the occiput into the most capacious part of the pelvis. 
5. In the osteomalacic pelvis, only exceptionally is labor ended by the 
forces of nature. It is a deformity which generally calls for intervention, 
the Csesarean section, and therefore we can hardly describe a mechanism. 
Nevertheless, before resorting to this operation we should assure ourselves 
that the pelvis is not dilatable. Cases where labor has been completed, 
in this instance of deformity, have been recorded by Weichmann, Barlow, 
Hull, Lange, Feist, Olshausen, Kilian, Ilugen berger, Winckel, etc., etc. 
G. In the kyphotic pelvis, the head of the foetus does not assume an 
oblique situation as in the normal pelvis, or a transverse as in the rachitic, 
but a direct position in order to adapt itself to the greatest diameter, the 
antero-posterior. The head, indeed, meets with no obstacle to speak of 
until it reaches the inferior strait, but the prognosis, as we will see, is 
not very good. 
7. In the pelvis where there has been a single or double luxation, the 
obstacle resides in the exaggerated inclination of the pelvis, and on its 
flattening, for, once the head engaged, the size of the inferior strait, the 
little height of the'pelvis, the increase in the transverse diameter, these help 
the progress of the head, and labor is often spontaneous. It is then the 
primitive inclination of the head which is the real obstacle, and this once 
corrected, the head engages, and the mechanism is the same as in the 
flattened pelvis. Where the luxation is one-sided, the difficulty is some- 
times greater. MATERNAL DYSTOCIA. 
121 
Prognosis. 
Deformity of the pelvis always entails dangers both to the mother and 
the child. Even in the case where the contraction is slight, labor is pro- 
longed, and we know that both maternal and foetal mortality increases 
proportionately with the duration of labor. Happily by means of the 
premature induction of labor, we are able to diminish considerably the 
dangers run by both the mother and the child. 
The greatest risk which the mother runs is from injury to the soft 
parts, the greater, of course, the more prolonged the labor. Energetic 
and momentary pressure is less dangerous than feeble and prolonged, and 
hence a reason why version is advocated. As the result of pressure be- 
tween the head and the pelvis, this organ may rupture. Again, prolonged 
pressure may lead to sloughing, and the resulting fistulous openings from 
the vagina and uterus into the bladder and rectum. In rare instances, 
the passage of the head has caused rupture of the pelvic symphyses. 
Ahlfeld was able to collect twenty-one cases of this nature in osteomalacic 
pelves, and almost exclusively with vertex presentations. Ordinarily, 
however, as we will see, these lesions follow on manual or operative 
manoeuvres. Finally, the operations which we may be called upon to 
perform constitute an additional risk for the mother. Budin, in 1880, 
mentioned: lesions of the vulva and of the perineum, and tears of the 
vagina; ruptures of the cervix and uterus; fistulae; injury of the intestine, 
and hernia into the vagina or uterus; pelvic abscesses; traumatic paralyses; 
rupture or separation of the symphyses; fractures of the bones, already 
noted by Bailly. 
The consequences for the infant are not less. The prolongation of 
labor, the premature rupture of the membranes, the prolapse of the cord 
or limb, all seriously compromise its existence. Further still, the in- 
creased strength of the uterine contractions interferes with the foetal cir- 
culation, and occasionally induces premature separation of the placenta. 
Aside from these complications, vertex presentations expose the infant 
to special risks of varying gravity. 
We mention the caput succedaneum, which, although when limited, is 
of favorable nature, when it spreads beyond the scalp may be of serious 
nature; the modifications in shape of the foetal head; the impressions Fig. 457. 
Fig.. 458. Fig. 459. 
Fig. 460. Fig. 46 f. 
For description of above figures, see page 123. 123 
MATERNAL DYSTOCIA. 
superficial or deep; the deep overlapping of the sutures; true fractures- 
these, obviously, are of grave import to the health of the child. 
Pajot, in 1.853, classified these lesions as follows: 
" 1. Face and Head.-Wounds, contusions, edematous and bloody 
tumors, hemorrhages into the brain and the meninges, depressions of the 
bones with and without fracture, compression of the brain, facial paralysis. 
2. Neck.-Rupture of the vertebral column, tearing off of the head. 
3. Body.-Rupture of the vertebrae, contusions of the abdominal vis- 
cera, the liver in particular, rupture of the cord, lesions of the scrotum. 
4. Limbs.-Fractures, dislocations, separation of the epiphyses.'' We 
would add the traumatic paralyses of the new-born. 
In 26 infants Michaelis found compression marks on 15, in 5 of which 
there was sloughing. Ten were right positions, and sixteen left. The 
mean duration of labor had been 27 hours, and the duration after rupture 
of the membranes from 1 to 5 hours. 
In 27 cases Olshausen found: 
Simple impressions, . . . . . 19 times. 
Double " 5 " 
Triple, " 2 " 
Quadruple " ..... 1 " 
In 32 instances these marks were on the side of the head turned to the 
promontory; in 20, on the parietal bones; in 9 on the frontal; in 2 on the 
Figs. 124 and 120.-(Kehrer.) Left Parietal of a Young Cat, with deep Depression and Frac- 
ture of the Skull, persisting for four days after Birth. Cured at the end of eight days. Ani- 
mal killed and the bones examined, a, External surface, b, Internal surface, c, Depression site. 
Fig. 129.-Section at the Level of the Depression. Three fissures are seen projecting towards 
the dura mater, a, Fibrillar stratum of the pericranium, b, Dura mater, c, Compact tissue, 
deposited at the borders of the fracture, rich in connective tissue cells, d, Bony lamellae, e, 
Crenated borders of the fracture, f, Net-work of bone substance, forming in places a solid layer at 
the level of the fracture. 
Fig. 125.-Cranial Impressions and Depressions. (Dohrn.) Primipara. Flattened pelvis, slightly, 
generally and regularly contracted. Vertex presentation, O.L.A. Premature labor induced at 
thirty-fifth week; duration of labor 1% hours. Caput, diffuse, on right parietal. Entire left side of 
head flattened and displaced anteriorly, the parietal bone overlapping the frontal. On left parietal 
exists an impression extending from the greater fontanelle, along the parietal protuberance, and 
ending in a deep depression between the squamous portion and the frontal suture. The descent of 
the left parietal had been prevented by the promontory. 
Fig. 126.-Spoon-Shaped Depression. (Ruge.) Child Iqft hospital alive. Depth of depression 
about 1*4 of an inch. 
Fig. 127.-Depression of the Skull. (Martin.) About of an inch above the right parietal 
protuberance; a depression about .39 inches deep and .2 inches wide. 
Fig. 128.-Appearance of Depression on Left Side of Same Head as in Fig. 127. The 
length is about .7 inches. 124 
A TREATISE ON OBSTETRICS. 
coronal suture; in 1 on the temporal bone, in 1 at the centre of the sagit- 
tal suture, etc. Figures 124 to 129 represent various lesions which have 
been found on the foetal head, in cases of pelvic deformity. 
The Treatment of Pelvic Deformities. 
The prognosis is in a measure dependent on the treatment, and in re- 
gard to this authorities are not at all in accord. In France it is to the 
forceps; in Germany and in England preference is given to version. We 
will, therefore, precede our remarks on treatment with a comparative 
study of the value of these two methods in cases of pelvic contraction, 
seeing that the partisans of version base their preference on the mechan- 
ism of labor. 
We have already noted how Otto de Hasel berg, Litzmann, Michaelis, 
and others explain this mechanism, and we have stated why Simpson be- 
lieved that the after-coming head passed more readily than the before- 
coming. 
In 1865, Joulin stated that in order that an observation may throw light 
on this question of forceps or version: 1. The diameter of the pelvis and 
of the head should be indicated with care. 2. The form of the contrac- 
tion should be stated, since one operation may in truth be indicated in 
one form of pelvic deformity, and contra-indicated in another. 3. That 
both forceps and version have been attempted on the same patient, since 
otherwise the doubt exists as to whether the operation not attempted 
would have not succeeded as well as the one which did. He then dis- 
sects with care Simpson's monograph, and shows: 1. The vertex rela- 
tively to the parietal protuberances forms the apex of a cone, shorter, it 
is true, than that bounded by the bi-mastoid diameter and the parietal 
protuberances, but not at all like the diverging branches of an A, and 
further the vertex has never been found flattened out by the pelvis. 
When labor has been long in progress, the head is greatly flexed, and 
then it is not the bregma which presents, but a point very near the occi- 
put, which forms the apex of a cone, with the parietal protuberances as 
its base, and which is higher than, but not as thick as, the parieto-mas- 
toidean cone at its apex. Simpson's theory, therefore, falls to the ground, 
for it is clear that if version only brings to the* superior strait the same 
diameter that the forceps seizes, the operation does not compensate for 
the risks it involves. 2. The grasp which we have of the infant's body 125 
MATERNAL DYSTOCIA. 
is not at all better than that which is furnished by the forceps, and if in 
slight contractions we obtain reduction of the head, may this not be at the 
expense of the foetus? 3. Not only is the head placed by the forceps even 
as by version, so that the small diameter, the bi-temporal, engages in the 
least diameter of the pelvis, but, further, the forceps engages the head by 
its sub-occipito-bregmatic circumference, while version engages it by the 
occipito-frontal. 4. Finally, when labor has been prolonged, the head is 
strongly flexed, hence it has no tendency to engage by the bregma, but by 
the apex of the occipito-parietal cone. Joulin further establishes by ex- 
periments, that the total force necessary to engage the foetus by the after- 
coming head is greater than when it comes before, and he naturally gives 
the preference to the forceps, except in case of oblique oval pelves. 
In 1864, McClintock, as the result of clinical experience, pronounced 
in favor of version. His observations were based on 11 multipart, and 
of the 63 infants, 16 were delivered by version and 9 lived. Of the re- 
maining 47, born some without intervention, and others by forceps, 18 
lived. Of the mothers delivered by version, but one died. In none of 
these cases was the contraction marked. 
Martin prefers the forceps, and only resorts to version when, 1, the 
transverse diameter is long enough to allow the occiput, the thick part 
of the head, to lie alongside the promontory; and 2, in the oblique oval 
pelvis, when the contraction is to one side, when the promontory is devi- 
ated laterally, etc. 
Kristeller accepts Martin's teaching. Frank rejects version altogether. 
Scharlau is an earnest advocate of version. He has resorted to it in 
case of the following complications: 
Transverse presentations, podalic version, ... 44 
Premature attempts with forceps, podalic version . . 1 
Prolapse of the cord, vertex presenting, .... 8 
Rupture of the uterus, and passage of foetus into abd. cavity, 1 
Mal-presentations of the head, ..... 5 
" " vertex, prolapse of feet, . . 1 
" " " cord and hand, 2 
Placenta praevia, * . L 
Lateral presentation of head, (ear), .... 1 
64 126 
A TREATISE ON OBSTETRICS. 
Internal version was performed G1 times, and external 3. Of the chil- 
dren, 14 were dead before operation. He obtained 43 living children. 
Of the mothers, 5 died, 2 of phlebitis, 1 of peritonitis, 2 of rupture of the 
uterus. In 12 cases the contraction was considerable. He draws the fol- 
lowing conclusions: 1. Version allows us to save children which would 
otherwise die from prolonged labor. 2. The small diameter of the pelvis 
may be shortened to 2.9 inches, and still version is practicable, at term, 
and with resulting living children. 3. In version, in case of vertex pres- 
entation, it is of advantage, although not indispensable, for the transverse 
pelvic diameter to be large enough to enable the larger nart of the occiput 
to pass near to the promontory. 
Fuhrmann, in 1868, prefers version incase of partially contracted pelvis, 
but rejects it in other forms. 
Schroeder prefers version to forceps. He believes the operation indi- 
cated in contracted pelves whenever, dilatation being complete, the head 
remains movable above the superior strait. It is then inoffensive for the 
mother. In support of this opinion, he cites 36 cases of version, 5 chil- 
dren being dead before operation. Of the 31 remaining, 18 were living, 
3 lived but a few hours or days, 10 were delivered dead or dying. 
In 9 cases shoulder presentation, . . 9 living children 
In 1 case asphyxia before version, . . 1 dying child 
In 2 cases eclampsia and placenta prsevia, 1 living, 1 dead 
" 6 " prolapse of cord, ... 2 " 4 " 
" 13 " rachitic pelvis, 3.7 to 2.7 inches, 11 " 2 " 
" 1 case " " 3.4 " 1 living 
" 1 " " " 2.7 to 2.9 " 1 " 
" 1 " " " 2.8 " 2.5 " 1 
He concludes as follows: 1. Even in case of pronounced contraction we 
may hope for a living child by version. 2. Version is more favorable to 
the child than labor by the vertex. 3. It is more favorable for the 
mother than the forceps. 4. Energetic, momentary pressure is less 
grave for the mother and the child tiian continuous, persistent pressure. 
Strassmann, in 4 cases of irregularly contracted pelvis, saved 3 children, 
1 being dead before. In previous deliveries, twice perforation had been 
resorted to, and twice the forceps had extracted dead children. 
Otto de Haselberg, although a partisan of version, admits that we can- 
not always bring the occiput into the roomiest part of the pelvis. In 14 127 
MATEKNAL DYSTOCIA. 
cases practised by him 6 times the head engaged differently from what 
he desired. 
If now we add together the statistical tables, compiled by Stanesco, 
and by Rigaud, in connection with the results in various degrees of pelvic 
deformity, we obtain the following: 
Pelves measuring 3.9 and over in sacro-sub-pubic diameter, or at least 
3.5 in sacro-pubic:-301 cases: 
216 spontaneous labors 
Mothers, 13.88 per cent, died 
Infants, 15.74 " " 
21 versions, 
Mothers, 23.8 ' " " 
Infants, 66.60 " " 
Mothers, 35.29 " " 
Infants, 54.90 " " 
51 forceps, 
1 craniotomy, . . . Mother, 0 
3 premature labors,. . 33.33 " " 
7 cephalotripsies, . . 42.86 " 11 
2 forceps, cephalotripsy, 
craniotomy, version, . 50 " " 
Pelves measuring from 3.9 to 3.5 in sacro-sub-pubic diameter or from 
3.5 to 3.1 in sacro-pubic:-215 cases: 
84 spontaneous labors, 
Mothers, 9.52 per cent, died 
Infants, 36.90 " " 
15 versions, 
Mothers, 26.66 " " 
Infants, 80 " " 
60 forceps, 
Mothers, 28.33 
Infants, 31.66 
6 craniotomies,. 
25 cephalotripsies, 
Mothers, 33.33 " 
32 " 
Mothers, 17.66 " 
Infants, 47.05 
8 forceps, cephalotripsy, version, Mothers, 75 
Pelves measuring 3.9 to 3.5 in sacro-sub-pubic, 2.7 to 2.3 in sacro- 
pubic:-93 cases: 
17 premature labors, . 
11 spontaneous labors, 
Mothers, 9.09 per cent, died 
Infants, 45.45 " " 
20 forceps, . - 
Mothers, 10 
Infants, 60 " " 
3 versions, 
Mothers, 100 
Infants, 100 
2 craniotomies, 
38 cephalotripsies, 
Mothers, 0 
" 23.68 11 
Mothers, 27.77 
Infants, 66.66 
18 premature labors, 
Mothers, 100 
Infants, 100 
1 Caesarean section, 128 
Pelves measuring 3.5 to 2.7 in sacro-sub-pubic, or 2.7 to 2.3 sacro- 
pubic:-42 cases: 
A TREATISE ON OBSTETRICS. 
1 spontaneous labor, 
Mother, 100 per cent, died 
Infant, 100 " " 
4 versions, . . • . 
Mothers, 50 " 
Infants, 100 " " 
Mothers, 40 " " 
Infants, 40 " " 
5 forceps, 
2 craniotomies, 
Mothers, 50 " 
Mothers, 40 " 
Infants, 90 
20 cephalotripsies, . . Mothers, 40 " " 
Pelves measuring 2.7 to 2.3 in sacro-sub-pubic, or 2.3 to 1.9 in sacro- 
pubic: . 
10 premature labors, 
Spontaneous labor, . 
Mothers, 100 per cent, died 
Infants, 100 " 
. » 
1 forceps, 
Mother, 100 
Infant, 100 " " 
5 premature labors, . 
Mothers, 40 
Infants, 100 
5 cephalotripsies, 
Mothers, 20 
4 Caesarean sections, 
Mothers, 300 " 
Infants, 0 
We have ourselves delivered a child living, but dying in 24 hours, by 
the forceps, through a pelvis contracted to 2.1 inches. It was at seven 
months. 
Borinsky's statistics may be resumed as follows: 
Children. 
Spontaneous, 233 
Living. 
192 
Dead. 
41 
Delivery by vertex, . 322 •< 
Forceps, . 50 
36 
14 
Perforation, 39 
39 
Version, vertex presenting, 45 
j Not complicated, 16 
( Complicated, 29 
6 
15 
10 
14 
Reduced to percentages: 
Children. 
Living. 
Dead. 
Spontaneous labor. 
82.4 
17.6 
Forceps, .... 
72 
28 
Version, .... 
53 
53 
Borinsky prefers the forceps, and reserves version for the cases where 
there is abnormal deviation of the head, presentation of the face and 
brow, and procidence of the cord or limbs. In the face presentations 
which he has observed, he used the forceps twice out of 13 cases, and MATERNAL DYSTOCIA. 
129 
in both instances had living children. In 7 instances version was neces- 
sary, and 5 children were extracted dead. 
Shape 
of Pelvis. 
No. of Cases. 
Termination. 
No. of Cases. 
Infants. 
Without Complication. 
With Complication. 
Cases. 
Infants. 
Cases. 
Infants. 
Living 
Dead. 
Living 
Dead. 
Living 
Dead. 
Flattened, 
267 j 
Spont.Labor 
Forceps. 
Perforation. 
206 
33 
28 
170 
22 
36) 
11 b 
28 ) 
13 
6 
7 
22 
12 
10 
Generally 
contracted, 
814 
Spont.Labor 
Forceps. 
Perforation. 
14 
12 
5 
11 
9 
3) 
3 
5) 
Funnel- 
shaped, 
Spont.Labor 
Forceps. 
Perforation. 
3 
3 
1 
2 
3 
*1 
1) 
Generally 
flattened, 
contracted, 
Asymmetri- 
cal, 
H 
9! 
Spont.Labor 
Forceps. 
Perforation. 
Spont.Labor 
Forceps. 
Perforation. 
6 
1 
4 
4 
1 
1 
5 
1 
4 
1 
1} 
4 J 
11 
7 
3 
2 
1 wi^h 
perfora- 
tion. 
5 
2 
1 
2 
4 
(2 perfor 
ation.) 
Vertex Presentations-Delivery. 
Version. 
Barnes, 1873, after recalling the mechanism of labor, concludes that ver- 
sion is applicable to pelves of 3.1 to 3.5 inches. At 3.1 inches the forceps 
is equally applicable. Under 2.9 inches he absolutely rejects it. 
Otto de llaselberg, 1873, endeavors to justify his preference for version 
by a purely mechanical explanation. According to him, in presentation 
of the vertex, where the pelvis is relatively too narrow, the inclination of 
the head to the superior strait, instead of being disadvantageous, is in- 
dispensable, since it allows the head to engage. With the after-coming 
head, aside from the solid grasp which we have on the trunk, the head is 
in a still more favorable position. It is perpendicular to the plane of 
the superior strait, and two symmetrical points are between the promon- 
tory and the symphysis. The small transverse diameter is shortened by 
the compression of the head, and this diameter is already shorter than 
the great oblique, which is the one by which the before-coming head 
passes the superior strait. In this respect, then, he agrees with Mme. 
Lachapelle. 
Vol. III.-9 130 
A TREATISE ON OBSTETRICS. 
Schatz simply cites figures: He has practised version forty to fifty 
times in contracted pelves, and has usually obtained living children. The 
majority of the women had, in former labors, been delivered of dead chil- 
dren by forceps or perforation. Nevertheless, he has observed deep de- 
pressions, fractures of the skull, six times fracture of the clavicle, and 
once of the arm. According to him, the obstacle in case of forceps is 
Naegele's obliquity, which does not exist in case of version. The force 
used in version is less than with forceps. He never, however, resorts to 
version until dilatation is complete. An arm must always be brought 
down, but rotation of the back forwards is not always indispensable; the 
head must not be extracted quickly, but, before resorting to traction, two 
fingers should be inserted in the mouth to give the head a good position. 
The operation should be avoided in primiparae; he does not resort to 
Kristeller's expression. [A most valuable adjunct, nevertheless, for the 
delivery of the after-coming head.-Ed.] 
Ahlfeld rejects version. He awaits spontaneous labor as long as possi- 
ble, and resorts to the forceps as a last resort. 
Cohnstein, envisaging the question from the standpoint of compression 
•of the fretal head, concludes: 1. The after-coming head passes more 
readily than the before-coming, since in the former instance there is pro- 
duced a diminution in the cephalo-rachidian fluid, and, in consequence, a 
greater overlapping of the sutures, and greater reduction in size of the 
head. 2. In medium contractions, it passes more readily because its 
bony walls and the maternal parts are more closely in contact, and this 
favors accommodation, as well as evacuation of the cerebro-spinal fluid. 
3. Still, in case of the after-coming head, the life of the child is more 
compromised, because, on account of the above occurrence, the brain is 
more compressed. 
And yet Schatz, believing the life of the mother is of greater value 
than that of her child, and tractions with the forceps more dangerous for 
her than the traction on the trunk, resolutely favors version. 
Lowenhardt considers version and extraction as the heroic measures in 
case of pelvic deformity. He maintains that by version we cannot place 
the head symmetrically. He only succeeded twice in nine attempts, and 
in five cases he had to use forceps to extract the after-coming head. He 
is opposed, however, to waiting for spontaneous labor, and prefers the 
forceps only when: 1. The pelvis is large enough to admit the passage of MATERNAL DYSTOCIA. 
131 
the child without mutilation. 2. The child is living. 3. The child pre- 
sents by the vertex. But whether for forceps or version, the pelvis must 
be at least 2.9 inches. 
He endeavors to explain his preference for forceps by the data, on follow- 
ing page, which, however, are of little value, seeing that the degree of 
contraction is but vaguely indicated. 
Goodell, in two monographs, 1875, 1876, advocates version at term. 
"If the contraction is slight, he makes one or two attempts with the for- 
ceps. If the head cannot be thus engaged, version must be resorted to. 
In pelves where the conjugate measures from 2.7 to 3.1 inches version 
should ever have the preference. To vigorous tractions on the trunk 
he joins expression. In 10 cases, 4 living children, 2 from primipara, 2 
multipart, in whom at previous labors, delivery by forceps had been suc- 
cessful. There was always depression of the parietals. " 
Alexander Milne uses version, but combined with induction of prema- 
ture labor. Six women, with pelves ranging from 2.3 to 2.9 inches, had 
been delivered of 12 children, 11 of whom had died during extraction by 
forceps or craniotomy. In all the succeeding pregnancies, Milne induced 
labor and performed version. In 38 instances he obtained 35 living chil- 
dren, 7 of whom died in infancy, the lot of 11 being unknown, and 17 
reached adult age. 
Budin, Huge, and Matthews Duncan, have experimented on the head 
of the foetus before and at term, in regard to its compressibility, the force 
which may safely be exerted in traction, and the lesions which may re- 
sult. Champetier de Ribes has lately made new experiments in the same 
direction, and we may resume his studies and conclusions, as follows: 
1.- Mechanism of the Descent of the Head.-If, in a pelvis con- 
tracted in the conjugate, the head be left at the superior strait 
after the extraction of the trunk and the shoulders, it assumes 
ordinarily, a transverse position. The base of the skull,, although 
almost incompressible, may engage, without the influence of much force, 
in an opening smaller than itself, the posterior portion of the head rest- 
ing on the bodies of the vertebras above the promontory-the posterior 
border of the head descending first, instead of last, as it does in case of 
easy engagement. When the head descends either spontaneously, or in 
obedience to traction, it flexes, as Budin has pointed out, and the occiput 
rises. As this flexion occurs, its posterior portion moulds itself on the 132 
TREATISE ON OBSTETRICS. 
Application of Forceps in Deformed Pelves. 
No. of 
Cases. 
Infants. 
Mothers. 
Mortality, per cent. 
Morbidity 
of 
Mothers. 
Living. 
Dead. 
Recover'd 
Died. 
Mothers. 
Infants. 
Not difficult forceps 
95 
93 
2 
94 
1 
1% 
2$ 
Difficult forceps, 
65 
59 
6 
65 
9$ 
12.3$ 
Pelves contracted 
to 1st degree, . 
21 
16 
5 
24 
23$ 
33.33$ 
Pelves contracted 
to 2d degree, 
29 
8 
21 
26 
3 
10$ 
73.5$ 
65.5$ 
Pelves contracted 
to 3d degree, 
8 
8 
4 
4 * 
50$ 
w 
12.5$ 
Version and Extraction. 
Cases. 
Infants. 
Mothers. 
Mortality, per cent. 
Morbidity 
per cent, 
Living. 
Dead. 
Recover'd 
Died. 
Mothers. 
Infants. 
Versions taken together 
93 
56 
37 
90 
3 
3.2 
40 
7.5 
Shoulder presentation, 
56 
31 
25 
55 
1 
1.8 
44.6 
9 
Vertex presentation, 
37 
25 
12 
35 
2 
5.4 
32.5 
54 
Deformed pelves. 
Shoulder presentation, 
5 
2 
3 
5 
60 
20 
Cephalic end, . . . 
27 
17 
10 
26 
1 
3.7 
37 
7.4 
Pelves of 1st and 2d de- 
grees, 
20 
17 
3 
20 
15 
Comparative Table of Forceps and Version. Pelves large enough to permit 
Extraction of Non-mutilated Foetus. 
Forceps and Version. 
No. Cases. 
Infants. 
Mothers. 
Mortality per cent. 
Morbidity 
of 
Mothers. 
Living. 
Dead. 
Recover'd 
Died. 
Mothers. 
Infants. 
Forceps 
Pelves 1st 
degree. 
Pelves 2d 
degree. 
21 
24 
16 
8 
5 
16 
21 
21 
3 
12.5 
23.5 
66.6 
33.3 
58.2 
Total, 
45 
24 
21 
42 
• 3 
6.7 
46 5 
46.6 
Version & Extraction 
20 
17 
3 
20 
1 
15 MATERNAL DYSTOCIA. 
133 
part of the pelvis in contact with it, and the fronto-parietal suture ap- 
proaches the median line, or else the borders of the parietal or the fron- 
tal bone, which limit this suture. In addition to this flexion and displace- 
ment, the head turns on its axis, so that the occiput is brought in front 
or behind the corresponding extremity of the transverse diameter of the 
pelvis. According as the head is large or small, the occiput will rotate 
backward or forward. The posterior parietal protuberance is stopped be- 
hind above the ala of the promontory. If traction be made, the head is 
found to incline from behind forward. While the posterior portion re- 
mains motionless, the anterior describes the arc of a circle; the anterior 
parietal protuberance, which is on a higher level than the posterior, de- 
scends and passes by the superior strait. The cheek, which has cleared 
this same strait, is applied closely to the sacral concavity, and the posterior 
parietal protuberance descends either directly or else along the sacro-iliac 
synchondrosis. The end of the rotation movement brings the occiput 
behind the symphysis. 
The above description applies only to moderately contracted pelves. 
When the narrowing is considerable, extraction is not possible. 
In the asymmetrical pelvis, traction should be made in such a manner 
as to direct the occiput towards the widest pelvic half. 
2. Relative, Value of the Different Means employed to bring the Head 
into the Cavity.-The efficacy of flexion is indubitable. Traction on the 
neck and the lower extremities should, at the outset, be directed a little 
forward, and later, when the head is well flexed, backward, in order to 
disengage the anterior parietal protuberance. As for expression, it is only 
useful when it is made in the axis of the superior strait, and applied to 
the frontal region. It thus favors flexion and descent. 
3. The Force employed, the Lesions produced, the Results obtained.-Fif- 
teen times out of thirty-four, the head, at term, was brought through 
pelves measuring 2.9 inches by the use of a force varying from 45 to 66 
pounds. In a pelvis of 2.6 inches, 5 times the head was extracted by a 
force of 66 to 121 pounds, and 6 times it could not be moved, although a 
force of 176 pounds was applied. Before term the maximum force used 
was 55 pounds. As for the lesions, in all the cases before term except 
one, the parietals were fractured; at term, the same, whenever the trac- 
tion force exceeded 89 pounds. The maxillary bones were fractured in 
the foetus at term whenever the force exceeded 55 pounds; before term 134 
when it exceeded 4G pounds. Lesions of the vertebral column, before 
term, at 88 pounds, at term 110 pounds. 
Scanzoni, out of 10,557 women delivered at the Wurzbourg Maternity, 
from 1850 to 1881, found 198 with pelvic contractions. The following 
were the measurement in 194 of these cases: 
A TREATISE ON OBSTETRICS. 
1.56 inches, . . 1 case 
2.34 to 2.54 inches, . 3 cases 
2.54 to 2.7 " . 6 " 
2.7 to 2.9 " . 9 " 
2.9 to 3.1 " . 11 " 
3.1 to 3.3 " . 38 " 
3.3 to 3.5 . . 15 " 
3.5 to 3.7 . . 49 " 
3.7 to 3.9. . . 52 " 
3.9 to 4.1 . . 10 " 
Dimensions of the conjugate 
In the four remaining cases, two were scoliotic obliquely contracted, 
one kyphotic transversely contracted, one coxalgic. Of the 198 cases: 
Mothers saved, . . . . . . 91.4 per cent. 
Infants " ...... 65 " 
Mothers died, . . . . . . 8.5 " 
Infants " ...... 31 " 
Of the 17 mothers who died, in 11 the cause was sepsis in the 6 remain- 
ing, 2 of pulmonary oedema, and one each of inanition, rupture of uterus, 
post-partum hemorrhage, puerperal mania. 
In delivery, the forceps was used 38 times, and version 13. In 47.4 
per cent, of the cases, delivery was spontaneous with a maternal mortality 
of 4.2 per cent; in 52.5 per cent, delivery was instrumental (including 
forceps, version, etc.), and the maternal mortality was 10.5 per cent., of 
the infants born spontaneously, the mortality was 19.1 per cent.; of those 
extracted instrumentally (including the induction of premature labor) 
61 infants died. 
To compare the figures obtained by forceps and by version: 
Forceps. Version. 
Mothers saved, . 94.7 per cent. . 85.7 per cent. 
" died, . . 5.3 " . . 15. " 
Infants saved, . . 65.8 " . 31. 
" died, . . 34.2 " . . 69. " 
Scanzoni adds: " If we wTere, in general, to admit that, in cases of con- 
tracted pelvis, version is preferable to the forceps, it should always be re- MATERNAL DYSTOCIA. 
135 
sorted to at a relatively early period of labor, while the head is still freely 
movable. Now, in private practice, we are often called to our patient too 
late for version, and we must also remember that if we resort to version 
early, we may be unable to terminate delivery, in cases where often this 
will occur spontaneously when at first sight it seems impossible." He 
strongly favors, then, forceps to version, and says that where too great 
traction is requisite, perforation and cephalotripsy should be resorted to. 
Faithful to this opinion, in 198 cases of pelvic contraction he resorted to 
perforation 19 times. In 68.4 per cent, the mothers recovered, and in 
31.5 per cent, they died. 
[The practice of American accoucheurs in this connection is by no 
means settled. The general impression would appear to be that it is easier 
to pull the after-coming head through the contracted brim, than to bring 
the before-coming head down by the forceps. In other words, where the 
head is movable above the brim, or just engaged and the membranes not 
too long ruptured, version, we believe, offers a better chance to the child, 
and is less likely to damage the mother. In our own experience of the 
two operations, version and high forceps, the former is far easier of ap- 
plication under the conditions just outlined. We believe with Lusk, that 
the real intent of version is to save the life of the child, and that it is in- 
dicated, in particular, in contracted pelves li only where the child's heart 
beats with nearly unimpaired vigor, and in pelves measuring between two 
and three quarters and three and a half inches antero-posteriorly, with 
the contraction limited to the brim, and with sufficient amplitude in the 
transverse diameter." (Lusk.) 
As for the high forceps, we cannot do better than refer to the carefully 
prepared article published by Dr. Harold Williams, of Boston, in the 
Am. Journ. of Obstetrics, January, 1879. In 119 cases of high forceps, 
about 40 per cent, of the mothers, and 60 per cent, of the infants died. 
No one will question but that version will give far better results for the 
mother, and certainly for the child, if performed in time, and this is the 
sine qua non.-Ed.] 
We see then that the reasons given by different authorities in justifica- 
tion of their preference are practically identical. The capital deduc- 
tion is: In order that the head may pass the contraction, whether before- 
or after-coming, it must flex, and the parietal protuberances must lie to 
one side of the promontory, in the groove between it and the sacro-iliac 136 
A TREATISE ON OBSTETRICS. 
| Cases. 
Name of Observer. 
Degree of 
Contraction. 
Volume of 
Foetus. 
Operations. 
Result. 
Observations. 
Mother. 
Child. 
1 
G. Robert, (autopsy). 
1.8 in. 
Term. 
Cesarean section. 
Dead. 
Dead. 
Shoulder 
2 
H. Robert, (autopsy). 
2.3 " 
Living. 
( Conjugate of 
( brim .39. 
3 
Lambl, (Seyfert,) (autopsy.) 
2.1 " 
36th week. 
i Forceps, cranioclasty, cephalo- 
( tripsy. 
Dead. 
Vertex. 
4 
Spaeth, (autopsy). 
2.7 " 
Term. 
Forceps. 
5 
Frickhoffer. 
3.2 " 
Craniotomy, cephalotripsy. 
Recovery. 
6 
Hubner, (autopsy). 
3.2 " 
j 35th to 36th 
( week. 
( Induced premature labor, ver- 
•< sion, perforation of after- 
( coming head. 
| Dead. 
( Incomplete pel- 
( vic extremity. 
7 
Kirckhoffer. 
1.05" 
Term. 
Cesarean section. 
Living. 
8 
Grenser. 
2.3 " 
Craniotomy and Cephalotripsy. 
Recovery. 
Dead. 
( Necrosis of right 
) Ischium. 
9 
( Dupuytren. 
- Depaul. 
( Tramont. 
1.8 " 
2 " 
2.2 " 
Museum speci- 
mens. 
Transverse Contraction of Inferior Strait. 
(Double Oblique Oval Pelvis.) MATERNAL DYSTOCIA. 
137 
1 Cases. 
Name of Observer. 
Degree of 
Contraction. 
Volume of Foetus. 
Operations. 
Result. 
Observations. 
Mother. 
Child. 
1 
Moor, (Zurich), (autopsy.) 
- 
* 
1.8 in. 
to 
2.5 in. 
Term. 
35th week. 
Term. 
7 to 7| months. 
Forceps. 
Induced premature labor. 
Recovery. 
Dead. 
Living. 
Dead. 
Living. 
Dead. 
Vertex. 
Feet. 
Face. 
Brow. 
2 
Schmeidler, (Breslau). 
1.9 " 
Term. 
Perforation. 
Recovery. 
Vertex. 
3 
Birnbaum. 
Term. 
Forceps. 
Vertex, occiput posteri- 
or fracture of parietal. 
Vertex, O.L.A. (fissure 
of parietal.) 
4 
Hugenburger, (autopsy). 
r 
3.3 " 
Term. 
Term. 
Term. 
Forceps. 
Dead. 
Living. 
O.L.P. 
5 
Bailly. 
G 
6.8 " 
6| months. 
7 months. 
Induced miscarriage. 
Premature labor, induced. 
Recovery. 
Dead. 
Vertex. 
Breech. 
Vertex. 
6 
Jenny, (Lucerne), (autopsy.) 
3.5 " 
Term. 
Ces. section. 
Dead. 
Living. 
Uniformly contracted. 
7 
Depaul. 
64-5 lbs. 
Forceps. 
Recovery. 
Kyphotic Pelves. 
(Contraction of Transverse Diameter of Brim.) 138 
A TREATISE ON OBSTETRICS. 
synchondrosis, so that the bi-temporal, or a neighboring diameter, may 
substitute itself for the bi-parietal. Spontaneous termination, or by for- 
ceps, or by version, is only possible on this one condition. As for the 
choice of method, the experiments of Budin and of Champetier should 
to-day be our guide: Whenever the woman is at term, the forceps; be- 
fore term, version. The future, however, must decide the question. 
Prognosis.-The greater the contraction, the larger the infant, the 
graver the prognosis. The most common form of contraction, the rachitic, 
gives the best results; the osteomalacic, and the funnel-shaped pelves, 
give the worst results. The preceding tables, from Chantreuil and 
Choisil, (see pages 136, 137), show the gravity in case of the kyphotic 
and kypho-scolio-rachitic forms. 
Etiology and Treatment of Contracted Pelves. 
Rickets is the disease which most frequently causes pelvic deformity. 
We may avoid this deformity in a measure then by causing rachitic chil- 
dren to retain a horizontal position so long as the bones are soft, pliable, 
and likely to bend. 
The treatment is essentially based on the degree of contraction, and we 
must, therefore, at the outset, obtain an exact idea of this degree through 
mensuration. We must further endeavor to ascertain the cause of the de- 
formity, the correct period of gestation, and the volume, position, pres- 
entation, mobility, viability of the foetus. When labor has once begun, 
we should remember that the duration is always greater than in case of 
the normal pelvis, and we must never interfere unless this duration seems 
prejudicial to the mother or to the child. We should carefully, on the 
other hand, time our interference before the mother or the foetus becomes 
too greatly exhausted. The woman had better lie down from the outset, 
since premature rupture of the membranes is likely to occur, and, in con- 
sequence, prolapse of the limbs and of the cord. When the pains are fee- 
ble, and the head, at the superior strait, has but little tendency to en- 
gage, we do not hesitate at the end of about twelve hours to rupture the 
membranes, but always in the intervals of the contractions, and with the 
precaution of allowing the liquor amnii to flow out but slowly. We thus 
obtain fixation of the head, and the pains increasing in intensity the head 
engages more or less according to the degree of contraction, and the size MATERNAL DYSTOCIA. 
139 
of the foetus. If the head do not engage, then, after waiting a reason- 
able length of time,we must interfere,and the point is to choose the method. 
We have seen that abroad preference is given to version, and in France 
to the forceps, followed if need be by perforation. The recent experiments 
of Budin, Duncan, Milne and Champetier, would, however, seem to 
modify this practice, in that version is preferable before term and the for- 
ceps after. In case of transverse presentation at term, the endeavor 
should be made to bring the head by external manipulation over the su- 
perior strait, and similarly in case of presentation of the pelvic extrem- 
ity. But if the woman is not at term, should we interfere with a cepha- 
lic presentation by conversion into the breech by external manipulation, 
or, as Milne advises, induce labor and perform internal version? To 
induce labor is certainly our duty, but as to our second course of action 
this is a point which the future must decide. Finally, if the child pre- 
sent by the shoulder what should we do? Bring the head, by external 
version to the superior strait, or await complete dilatation and then per- 
form internal version ? Here again it is impossible as yet to dogmatize. 
Such are the general rules of treatment which we would lay down. We 
must now consider the special indications according to the degree of pel- 
vic contraction. 
1. The pelvis measures at least 3.5 inches in the conjugate.-a. The 
woman is at or near term. If the vertex presents wait as long as the 
condition of the mother and child will allow, and then apply the forceps. 
If the face presents, the indication will vary according as the chin is 
before or behind. In the former event, wait as long as possible, and then 
apply the forceps; in the latter event authorities are not in agreement. 
We must at the outset endeavor to transform the face into vertex by pro- 
moting flexion; but if this do not succeed ought we to turn or to apply 
the forceps? The forceps necessitates artificial rotation of the head in 
order to bring the chin forwards, but we have seen that, in a general way, 
version at term is less advantageous, and therefore we pronounce for the 
forceps, always provided that prolonged attempts at extraction are not 
made. If the pelvic extremity present, version by external manipulation 
to bring the vertex to the superior strait, and then the forceps. In case 
of the shoulder, external version, and, if this fail, internal, followed at 
once by the forceps to the after-coming head. b. Where pregnancy has 
not reached term delivery will always terminate spontaneously, and 140 
A TREATISE ON OBSTETRICS. 
we would only induce premature labor at 8| months in case the foe- 
tus was of excessive size or the mother had had difficulty in previous 
labors. 
2. The pelvis measures between 3.5 and 2.3 inches in the conjugate. 
A. At or near term. Here there are two subdivisions: a. The foetus is 
dead. In case of presentation of the vertex or the face, we should wait 
until dilatation is sufficient, rupture the membranes, and perforate. Then 
wait for complete dilatation, and if the head still does not descend, apply 
Bailly's cephalotribe and extract. In case the pelvic extremity presents, 
we should perform external version, and then proceed similarly. If ex- 
ternal version fails, deliver the trunk and perforate the after-coming 
head. If the shoulder presents, external version; if this fail, internal 
version, perforation, and extraction; decapitation if version is not possi- 
ble. b. In case the child is alive, a further sub-division is necessary, c. 
The pelvis measures between 3.5 and 2.9 inches. In case of the vertex, 
the forceps should be tried, as also in case of the face, but traction should 
not be prolonged, and the foetus mutilated rathei' than injure the mother 
by ineffectual attempts at delivery. The pelvic extremity and shoulder 
also call for rapid intervention, d. Pelvis measuring from 2.9 to 2.3 
inches. Here the interests of the mother are best served, as the lower 
limit is approached by resorting to mutilation of the foetus. Depaul 
favors the Csesarean section at 2.3 inches, but we can neither grant this, 
nor above all the Porro which deprives the woman at once of the chance 
of future delivery by resort to timely premature labor. We would await 
the death of the child, but we believe it should be the rule in these in- 
stances to make up our minds to the sacrifice of the foetus, and that we 
should tell our patient that the induction of premature labor at her next 
pregnancy offers a chance of a living child. 
B. The woman is not a term. There are a number of means at our 
disposal. Depaul advocates debilitating measures and repeated venesec- 
tion, and was thus able to obtain living foetuses at the eighth month in 
pelves measuring 3.12 inches. Others have advised the administration of 
the iodide of potass. The capital method, however, is the induction of 
premature labor, sooner or 'later according to the degree of contraction. 
If labor is induced, must we resort to forceps or to version ? Champetier's 
researches and conclusions speak entirely in favor of the latter. 
3. The pelvis measures from 2.3 inches and below. If the woman is at MATERNAL DYSTOCIA. 
141 
term we must distinguish the cases where the infant is alive or dead, and 
where the pelvis measures at least 1.5 inches, or below. 
If the infant is dead and the measurement is at least 1.5 inches, we 
should resort to cephalotripsy. If the child is alive, the choice lies be- 
tween cephalotripsy and the Csesarean section. In face of the risks to 
the mother involved in the Caesarean section, even as modified by Porro, 
we would prefer cephalotripsy and only resort to the f »rmer at the ex- 
press request of the mother. Below 1.5 inches all authorities are agreed 
in regard to cephalotripsy in case the infant is dead. If it is alive, the 
Caesarean section is the choice of all but Pajot who advocates repeated 
cephalotripsy without traction even down to one inch contraction. 
If the woman is not at term, miscarriage should be induced. Premature 
labor at seven months would avail nothing, since the foetus is too developed 
to pass with ease. Stoltz is about the only authority who advocates allow- 
ing the woman to go to term and performing the Caesarean section. 
[The above deductions of Charpentier in regard to treatment will be 
generally accepted as just. It is, however, a question if in the not distant 
future these deductions will not suffer considerable modification. Day 
by clay the results obtained from the modified Cesarean section are being 
bettered, and those yielded by laparo-elytrotomy will compare very favor- 
ably, as regards the mother, with cephalotripsy, even after Pajot's method, 
in extreme degrees of pelvic deformity. If the time comes when the risk 
to the mother can be proved to be no greater by timely resort to operations 
which also consider the life of the foetus, most assuredly will it be our 
duty to reject absolutely all mutilating operations in case of a living child, 
other conditions necessary for the successful section, or laparo-elytrotomy, 
being present. The latest statistical data of these operations will be 
found under the subject of obstetric operations.-Ed. J 
We must now consider the proper course of action in case of deformity 
the result of other than rachitic cause. In osteomalacia the treatment is 
absolutely subordinated, not only to the degree of contraction, but also to 
the quality, so to speak, of the pelvic bones. We have seen that in one 
of the osteomalacic forms, the bones are so soft and supple that they may 
distend enough to allow the at first sight impossible delivery. The cus- 
tomary procedure in these cases is version. These cases are exceptional, 
although proved possible by the instances recorded by Kilian, Bobert, 
Olshausen, Hugenberger, Winckel, etc. 142 
In the generally and regularly contracted pelvis, the vertex presentation 
is the most favorable of all, and version is absolutely contra-indicated. 
Forceps are required, and in case of failure, perforation and cephalotripsy. 
In the oblique oval pelvis version is the most rational operation, the 
object being to bring the head into the widest part of the pelvis. 
In kyphotic pelves, perforation and cephalotripsy; in the spondylolis- 
thetic and spondylizcmatic pelves, miscarriage before term, the Caesarean 
section at term; in pelves deformed from congenital luxation, with lordo- 
sis or scoliosis, ordinarily labor at term is possible, and rarely is mutila- 
tion requisite. Finally, in the pelves deformed by the presence of a tumor, 
all depends on its nature. If fluid, puncture; if solid, it is impossible to 
lay down fixed rules. In certain cases miscarriage, in others premature 
labor, in still others the Caesarean section, embryotomy, cephalotripsy, 
and finally in others even version or the forceps are called for. 
We must never forget the fact noted by Ahlfeld and Simpson, that with 
successive pregnancies the foetuses increase in size, and that hence a 
moderate contraction, allowing ready delivery at the first pregnancies, 
may call for operative interference in the later. 
A TREATISE ON OBSTETRICS. 
Dystocia Owing to the Condition of the Soft Parts. 
Contraction and Rigidity of the Vulva and Vagina.-In women who be- 
come pregnant late in life, or possess strong muscular development, the 
external genitals may be rigid and resist dilatation, thus retarding the 
progress of labor. The head succeeds in overcoming the obstacle only 
after violent efforts, and often after tearing the vulva and perineum. 
Budin has shown that the resistance is really not at the vulvar cleft, but 
at the lower extremity of the vagina. Olshausen has demonstrated the 
resistance offered by the constrictor cunni. The vulvo-vaginal opening 
may in some instances furnish an obstacle to delivery, but Budin believes 
that it is at the vaginal orifice, as he proved in a case where the head had 
been arrested for two hours at the vulva, and was delivered in a few 
seconds after incising the edge of the vaginal outlet. The latter only 
yields by tearing, and this occurs constantly at the first labor; the lacera- 
tion occurring at several points, one being in the median line posteriorly, 
and one or more on each side. The former may extend to the fourchette, 
and then involve the perineum, and is caused by the passage of cither the MATERNAL DYSTOCIA. 
143 
head or the shoulders. But the resistance and narrowness of the vulvar 
opening may constitute the real difficulty, and if the resistance is ex- 
treme, and the perineum is excessively thinned and distended, a central 
rupture may occur. It is in such cases that incision of the vulvar cleft 
has been recommended, and authorities differ as to the point at which it 
should be made, Michaelis preferring the median line, while others make 
two lateral incisions with the scissors or bistoury, the depth of which 
should not exceed j of an inch. Tarnier urges the following objections 
to lateral incisions: A large gaping wound is left on either side of the 
vulva, the edges of which cannot unite by first intention, and the result 
is long suppuration and cicatricial contraction. In a certain proportion of 
the cases the incisions do not prevent extensive laceration of the perineum. 
Tarnier recommends an incision beginning at the median raphe, and 
extending, not directly backwards, but obliquely outwards towards the 
anus. If rupture of the perineum occurs in spite of this, it will follow 
the direction of the incision, and the sphincter will be saved. 
Resistance and Laceration of the Perineum.-Resistance of the perine- 
um, especially in occipito-posterior positions with non-rotation, is unques- 
tionably the most frequent cause of dystocia in primiparae, and is due either 
to too vigorous contraction of the muscles that constitute the perineum, 
or to excess of adipose tissue in it. Two results may occur: Either the 
contractions of the uterus, which are at first exaggerated by reason of 
the resistance, gradually diminish in intensity, until the organ sinks into 
a condition of more or less complete atony, or, on the other hand, the 
pains continue to increase until rupture of the uterus or death of the 
foetus results; again, the head maybe driven through the perineum, caus- 
ing a central rupture. It is not by any means the thinnest perinea that 
are most liable to tear, but those in which the tissues are soft and oedema- 
tons. Whether the pains are weak or strong, says Cazeaux, we must ab- 
solutely proscribe ergot, and have recourse to the forceps. Kristeller's 
method of expression is sometimes of value. Lacerations may be com- 
plete, incomplete, or central. 
Frequency.-These are far more frequent than is generally admitted. 
As Cohen and Budin have shown, many lacerations extend from within 
outwards, the mucous membrane tearing first, then the muscles and fascia, 
and lastly the skin. Olshausen distinguishes two varieties, those which 
are inevitable, occurring in spite of the greatest precaution, and those 144 
A TREATISE ON OBSTETRICS. 
which are avoidable. The first (not including tears of the fourchctte,} 
occur in 15 per cent, of primiparae. The result of his observations, ex- 
tending over ten years, shows that the perineum is torn in 21.1 per cent, 
of primiparae, and in 4.7 per cent, in multiparse. Snow Beck saw 75 rup- 
tures in 112 primiparae, Schroeder 71 in 189 primiparae, but only 9 in 100 
multiparae. 
The following table, prepared by Schrenck, gives an idea of the 
frequency of rupture of the perineum. 
Cases. 
Proportion 
of 
Lacerations. 
Frequency. 
Primiparse. 
Multiparse. 
Hildebrandt, .... 
356 
7.2% 
19.7 
.18% 
Nippold 
1011 
11.5% 
18.7 
2.2% 
Olshausen, .... 
119 
21.1-4.7% 
4.7% 
Liebmann, .... 
1064 
15.9% 
30% 
4.2% 
Mewis, 
1095 
19«% 
31.8% 
5.8% 
Winckel, ..... 
20% 
Schrenck, 
847 
21.4% 
36.6% 
8% 
Fasbender, .... 
300 
22.3 
34% 
10.6% 
Schroeder, .... 
289 
27.7% 
34.5-37.6% 
9% 
Litzmann, .... 
27.6 
Causes.-Schrenck mentions as causes too slight inclination of the pel- 
vis. delivery in the dorsal position, want of experience on the part of the 
physicians or students who preside over the delivery. There are other 
more important factors, such as non-rotation of the head, rapid delivery 
with the forceps before the perineum has had time to dilate, or violent 
straining efforts on the part of the woman after the birth of the head. 
The slipping of the forceps is another cause, also the use of the cranioclast, 
the introduction of the hand, etc. There are, as Pajot says, some peri- 
nea that are bound to tear, especially such as are thick, narrow, and in- 
filtrated, or oedematous. The tear may involve the foil rchette only, a por- 
tion of the perineum, the edge of the sphincter, or the entire sphincter, 
and more or less of the recto-vaginal septum. As long as it does not ex- 
tend entirely through the sphincter, it may be regarded as incomplete MATERNAL DYSTOCIA. 
145 
Finally, the sphincter and commissure may remain, while the centre of 
the perineum is perforated, sometimes sufficiently to allow of the passage 
of the child. Among 181 cases of ruptured perineum, Schrenck has noted 
134 of the first degree, 41 of the second, and 1 of the third. Central 
rupture is rare; Morand (1869) collected 38 cases, in two of which for- 
ceps were applied to the non-rotated head. These tears generally heal 
readily, though in some instances a permanent fistula may remain. 
Lacerations through the sphincter are followed by serious consequences, 
the partition between the rectum and vagina being removed, so that the 
two canals form a true cloaca; gas and feces are passed involuntarily and 
the woman's condition is deplorable; the support of the vaginal wall being 
destroyed, prolapse of the same, as well as cystocele and prolapsus uteri, 
result. 
Treatment.-This is prophylactic and curative. 
1. Prophylaxis.-This consists in preventing the tear, or at least in 
limiting it to an incomplete rupture. The oldest method consists in sup- 
porting the perineum; to that end the palm of the hand was applied to the 
perineum, with the thumb on one side of the vulva, and the fingers on 
the other; but this did not always prevent rupture, since, although the 
head was indirectly supported, its rapid expulsion was not hindered. 
Hence we have now abandoned this method, and endeavor to apply force 
directly to the head, retarding its progress so that the perineum may 
gradually become distended. Some authorities press directly upon the 
head, others indirectly, or through the anterior portion of the perineum. 
Depaul applies pressure to both the head and the anterior commissure, 
the former being thus kept at the edge of the vulvo-vaginal outlet, until 
the perineum is gradually distended, thus avoiding a complete laceration. 
Hohl, in addition to retarding the head, advises making an attempt to 
increase its flexion by pushing up the occiput; this he also does during 
the intervals of traction with the forceps. Olshausen thinks that this 
manoeuvre is of slight value. Alt and Schroeder have advised placing the 
woman in the knee-elbow position, in order that gravity may assist in 
keeping the head under the pubic arch. The former writer states that 
in 100 wromen delivered in this posture the frenum was intact in 50, and 
that only 25 had actual lacerations. Since it was almost impossible to 
make patients assume this position, the lateral was substituted for it. 
Olshausen supports the perineum with one hand, with the woman on her 
Vol. III.-10 146 
A TREATISE ON OBSTETRICS. 
side, while with the four fingers of the other he supports and opposes the 
advance of the head. He does not use chloroform at this stage, because, 
in order to obtain complete relaxation of the abdominal muscles, it would 
be necessary to produce too profound anaesthesia; it is better, he thinks, 
to utilize the muscular contractions, rather than to eliminate them, in 
producing gradual distension of the perineum. He also recommends the 
introduction of two fingers into the rectum, so as to make pressure on 
the brow, while the thumb is pressed against the head at the anterior 
commissure; in this way too rapid expulsion can be prevented and a 
threatening tear be avoided, the head being slowly rolled out until it is 
entirely disengaged. Goodell describes a similar manoeuvre, but his ob- 
ject is to act, not upon the head, but upon the ano-perineal border, by 
drawing the entire perineum forwards, and thus relieving the tension 
upon it. Hunt raises the objection, very properly, that we thus defeat 
our own object, because in thus drawing the perineum forwards, we in- 
crease the chances of rupture; the perineum ought rather to be drawn 
backwards, so as to carry the vulvar cleft in the direction of the expulsive 
force, and thus to diminish the muscular resistance of the posterior half. 
It is better, when rupture is imminent, to perform episiotomy, or to incise 
the constrictor cunni. Simpson and Cohen have even advised sub-mu- 
cous division of the muscle. Olshausen does not believe that the use of 
the forceps prevents rupture, since in 244 cases in which they were ap- 
plied in the Halle Clinic, there were 76 lacerations, 36 being in primi- 
para, or one percent., while in spontaneous delivery the average was only 
six per cent. 
[The best way to prevent laceration of the perineum, is to prevent rapid 
termination of the second stage, and thus give the muscles an oppor- 
tunity to relax. As soon as the head reaches the perineal floor, it is to 
be carefully watched by the accoucheur, its advance being regulated by 
the fingers and flexion being maintained. When relaxation seems suffi- 
cient, administer chloroform to the surgical degree, and then, in the in- 
tervals between the pains, shell out the head, as it were. In this way the 
head will be prevented from tearing the perineum, and neither the 
shoulders nor the hips ought to do so. A point to be remembered is: 
After the completion of labor, not only look at the perineum, but test its 
integrity by the fingers. If this rule be followed, the statement will no MATERNAL DYSTOCIA. 
147 
longer be heard, as it frequently is-" In an extensive practice laceration 
of the perineum has never occurred."-Ed.] 
2. Curative Treatment.-In lacerations of the first degree, involving 
only the frenulum, or the anterior part of the perineum, no operative treat- 
ment is necessary. In those of the second degree, most writers advise 
immediate coaptation of the raw surfaces, by means of serre-fines or su- 
tures. We believe that these are unnecessary, since, as long as the 
sphincter is uninjured, primary union (at least of the posterior part of 
the wound) is the rule. Sutures and serre-fines are painful, and often 
become relaxed and displaced, while the same result is just as good if the 
limbs are simply approximated. The following is the treatment to which 
we confine ourselves: After carefully cleansing the wound, we place the 
woman on her back, and apply over the perineum a compress wet in a 
one-per-cent, solution of carbolic acid, and tie the legs together, the 
bowels being constipated with opium. The patient retains the dorsal 
posture for forty-eight hours, her urine being drawn, or passed in a bed- 
pan. The parts are washed with the carbolic acid solution, about four 
times in the twenty-four hours, a stream of water being allowed to fall 
upon them. After forty-eight hours the wound is examined, the patient 
being turned on her side. On the fourth day the bowels are moved with 
castor oil. In this way primary union is nearly always obtained. 
Surgical intervention is nearly always necessary in complete lacerations, 
since cases of spontaneous cure are rare. Shall we operate immediately, 
wait (with Nelaton) until the eighth or twelfth day, or until several months 
shall have elapsed ? We are strongly in favor of the latter alternative. 
Primary perineorrhaphy rarely succeeds; it is true that the wound is fresh 
and denudation is unnecessary, but, aside from the fact that the lochial 
discharge often prevents union, we must not forget that the perineum is 
not merely torn, but is contused and mangled, and that the previously 
oedematous and infiltrated tissues are predisposed to gangrene, and conse- 
quently are in the worst possible condition for immediate union. Nela- 
ton's method consists in trying to obtain union by second intention, by 
approximating the raw surfaces by means of deep and superficial sutures, 
without denuding; this has been successful in a few cases. It is better 
to wait until after the expiration of five or six months; we must not for- 
get that involution of the genital organs is not completed until the end 
of the third month, and there is no advantage in operating sooner. 148 
A TREATISE ON OBSTETRICS. 
[We are obliged to differ in toto from Charpentier. We would maintain 
that any laceration beyond the first degree should be immediately repaired, 
for the reason that thus a possible entrance site for septic matter is pre- 
vented, and also because the operation is a simple affair after delivery, 
and more complicated and extensive the longer we wait. Tying the legs 
together is an utterly useless procedure, as any one may prove by placing 
the woman in the dorsal posture, and separating her legs as much as he 
wishes, when he will find that the perineum is not stretched at all. 
The pain involved in the immediate operation is nothing to speak of; 
indeed, ordinarily, it may be performed while the patient is still under 
the influence of chloroform. Further, if the operation is carefully per- 
formed, primary union, in our experience, is certainly the rule. 
In case of laceration to the second degree only, one deep silk or wire 
suture, as recommended by Alloway, of Montreal, will amply suffice. 
If the rent be deeper, three to five sutures should be used. In any event, 
the patient should be placed on her side, a wad of absorbent cotton in- 
serted into the vagina to catch the discharges, the wound carefully washed 
and trimmed of jagged shreds, and then, guided by the finger in the 
rectum, the suture is passed deeply around, at | inch from the margins. 
The large curved needle, recommended by Mundo, answers admirably. 
The line of suture should be dusted with iodoform, and a narrow strip 
of cotton laid along the perineum and the posterior vaginal wall. The 
after treatment will consist in dusting with iodoform twice daily, and re- 
placing the strip of cotton by a fresh piece, till the sixth or seventh day, 
when the sutures may be removed.-Ed.] 
In connection with lacerations of the perineum, other lesions of the 
external genitals should be mentioned, and these are innumerable. Some- 
times they are confined to the vagina, sometimes to the nympha?, or the 
upper part of the vulva; they may be attended with profuse hemorrhage. 
Schroeder has noted seven cases of laceration in the vicinity of the clitoris, 
accompanied by much bleeding. The lateral incisions, made to prevent 
rupture of the perineum, may bleed freely; once we saw a small artery 
severed which required ligature. It is usually sufficient to apply to 
the bleeding parts a compress moistened in a solution of perchloride of 
iron. maternal dystocia. 
149 
Malformation of the Genital Organs. 
As Schroeder properly says, the only malformations of the female geni- 
tal organs that interest the obstetrician, are those which do not interfere 
with pregnancy. Now, conception is possible whenever normal ova are 
expelled from the ovary, and when the canal traversed by the ovum or 
the spermatozoa, from the ovary down to the vaginal outlet, is at no 
point absolutely impermeable. 
I. Malformations of the Uterus. 
Modern researches in embryology have shown that the genital organs 
are formed at the expense of the Wolffian body and its excretory canals, 
and Muller's ducts, the latter being transformed into the uterus and Fal- 
lopian tubes. Geoffroy Saint-Hilaire and others showed that there are 
three stages of development, viz.: 1. Separation and complete division. 
2. Approximation and reunion in the median line. 3. Complete fusion. 
Thiersch was the first to prove that the uterus and vagina are formed 
by the fusion of Muller's ducts, the upper portion becoming the tubes, 
the lower, the uterus and portio vaginalis. The rectum and bladder are 
eventually separated from the uro-genital canal by an anterior and poste- 
rior spur that, later, form the recto- and vesico-vaginal septa. The ex- 
ternal genitals are formed, after the internal have become partly developed, 
by the disappearance of the tissues placed between the rectal cul-de-sac, 
the vagina and the bladder on one side, and of the integument on the 
other, the three cavities communicating with the exterior of the body. 
This explains all the malformations that occur: for example, if the rectal 
oul-de-sac is not opened, imperforate anus results; if the tissue that closes 
the vaginal canal is not absorbed, more or less complete obliteration, or 
even absence, of the vagina is produced. 
1. Muller's ducts may remain in contact at their point of entrance into 
the cloaca, but remain separate above, forming two distinct uterine cavi- 
ties, each of which has a single tube connected with it; there are thus 
two uteri, each of which has its cervix, and a single tube and ovary at- 
tached to it (uterus duplex.] 
2. The ducts may unite below, but remain separated above (uterus 
bicornis.) 150 
A TREATISE ON OBSTETRICS. 
3. The junction may occur at the normal point, but the fundus may 
remain undeveloped, having a median cleft which gives to it the appear- 
ance of a heart {uterus cardiformis.) 
4. The ducts, instead of developing, may atrophy, resulting in the 
complete absence of the internal genital organs; this atrophy mav be 
Fig. 130.-Uterus Duplex. (Eisenmann.)-a, Double orifice of vagina, b, Meatus urinarius. 
c, Clitoris, d, Urethra, ee, Double vagina, ff, External orifices, gg, Cervices, hh, Corpora uteri. 
ii, Ovaries, kk, Tubes. Il, Round ligaments, mm, broad ligaments. 
limited to that portion of the ducts which is destined to form the body of 
the uterus, the appendages developing normally {uterus deficiens), or a 
single duct may atrophy, resulting in a deficiency of one horn of the 
uterus {uterus unicornis.) 
5. The septum which separates the united ducts may persist, so that 
the uterus contains two distinct cavities {uterus septus, bi'locularis, bi- 151 
MATERNAL DYSTOCIA. 
part this)', or, the septum may be absorbed below, but may persist at the 
fundus (uterus subseptus, semi-partitus.) 
6. The arrest of development may affect the vagina as well as the 
uterus, so that the canal may be wholly or partly double, or absent. 
It is evident that some of these malformations absolutely prevent con- 
ception, but that pregnancy may take place in a one-horned, or double, 
uterus. Pregnancy may occur either in the well-developed, or in the 
rudimentary horn, and that too although the neck of the latter is closed 
(Fig. 131). Schroeder explains this by supposing that the semen has 
Fig. 131.-Pregnancy in a Uterus Bicornis, mistaken for Tubal Pregnancy.-a, Uterus. 
h, Rudimentary cornu, g, Placenta and membranes, q, Placental villi. 2, Foetus. Hi, Muscular 
tissue uniting the cornua, k, Round ligament, n, Left tube, o, Left ovary, f, Right ovary, e, 
Right tube, c, vagina. 
been able to pass up the tube which connects with the well-developed 
horn, enters the peritoneal cavity, and crosses over to the opposite ovary, 
where it fecundates the ovum which has been grasped by the tube of the 
imperfect horn; or a fecundated ovum from the ovary corresponding to 
the normal cornu may cross to the opposite tube. According to Scanzoni 
and Schroeder, the course of the pregnancy in this case bears the closest 
analogy to the extra-uterine variety. The rupture of the foetal sac, with 
its fatal consequences, takes place at some time between the third and 
sixth month, the point at which the rupture occurs being the least de- 
veloped portion of the horn. The normal horn takes part in the forma- 152 
A TREATISE ON OBSTETRICS. 
tive activity, as shown by the hypertrophy and softening of the muscular 
tissue, the development of its vessels, and the growth of a decidua. The 
foetus may die and be transformed into a lithopaedion. The diagnosis is 
almost impossible in the living subject, and even in the cadaver it may 
be mistaken for tubal pregnancy (Fig. 131.) 
When pregnancy takes place in the well-developed horn it usually pro- 
ceeds normally; the uterus has a crescentic form, and by palpation a 
Fig. 132.-Uterus Bicornis with Double Vagina, in a young Girl of 17.-a, Vaginae, b, Os of 
left uterus, c, The two cervices, simulating one. dd, The cornua, ee, Round ligaments, ff, Tubes. 
gg, Ovaries. (Schroeder.) 
small tumor has been felt attached to the organ by a short pedicle. The 
eccentric attachment and abnormal shortness of the portio vaginalis serve 
to confirm the diagnosis. Gestation may likewise occur in a double uterus, 
but abortion is more likely to follow. Simultaneous development of a 
foetus in each half of the uterus has been observed several times, and this 
proves that in ordinary twin-pregnancies one ovule may come from each 
ovary, and not both from a single one. Labor usually proceeds normally, 
but rupture of the septum, or even of the uterus, may ensue. 153 
MATERNAL DYSTOCIA. 
G rinow has collected fifteen cases of pregnancy associated with malfor- 
mations of the uterus or vagina, two-thirds of the women being primi- 
parae. Eight reached full term, two nine months. In two instances labor 
Fig. 183.-Uterus Bipartitus with Double Vagina. (Cassan.)-a. Orifices of cervix. 
began with hemorrhage, as the placenta was attached to the septum. 
The uterine contractions were feeble, sometimes spasmodic, so that in- 
terference was frequently necessary. Five of the women died. 
II. Malformations of the Vagina. 
1. Abnormal Openings of the Vagina.-These may be arranged after 
Nelaton, under the five following varieties: a. Imperforate or open vagina, 
which communicates with the rectum; b. Imperforate rectum, opening 
into the vagina; c. Vagina opening into the urethra or bladder; d. The 154 
A TREATISE ON OBSTETRICS. 
bladder, rectum, and vagina may communicate and open into a true 
cloaca; e. The vagina may open through the anterior abdominal wall. 
2. Division of the Vagina. 
A. Complete Division, double Vagina. (Fig. 130).-The uterus may be 
single, or very rarely a double uterus may communicate with two va- 
ginae, one of which opens externally, while the other is imperforate at its 
vulvar extremity. 
B. Congenital Atresia of the Vagina. 
C. Obliteration of the Vagina.-Here we must distinguish between 
imperforate hymen and true obliteration of the vagina; the latter may 
Fig. 134.-Uterus in Fig. 133 laid open to show the Septum. 
take place at the vulva, being due to fusion of the nymphse, or the vagina 
may be closed by a transverse septum. 
D. Absence of the Vagina.-It may be entire or partial, may be lim- 
ited to the vagina, or may be associated with absence of the uterus. MATERNAL DYSTOCIA. 
155 
Three varieties are usually met with, viz.: 1. The external genitals are 
normal, but the uterus and vagina are entirely wanting. 2. There is no 
external opening to the vagina, but the uterus, and sometimes the por- 
Fig. 135.-Uterus Unicornis of a 10-para, and in whom the left Kidney was also absent. 
(Chaussier.)-a, Posterior wall of right, developed side of the uterus, b, Right tube, c, Right 
ovary, d, Right broad ligament, e, Tube, ovary, broad ligament of left side, atrophied. f, Vaginal 
portion of cervix, g, Vagina. 
tio vaginalis, are intact. 3. The vagina ends in a cul-de-sac, more or less 
extensive, the uterus being either entirely absent or atrophied. Men- 
struation is absent. 
III. Persistence of the Hymen. 
Among th? defects in original development is one that deserves our at- 
tention, because it may not only cause disturbances at the beginning of 
menstruation, but may give rise to dystocia; we refer to persistent hy- 
men. 
The hymen not only may resist the first conjugal approaches, but 
there are rare cases in which it may be multiple-that is, there are two, 
or even three, diaphragms at different heights in the canal, as described 
by Pajot and Nelaton. Sometimes the hymen is so relaxed that it does 
not rupture until the moment of delivery, when it arrests the head, so 
that interference is necessary on the part of the attendant. Cicatricial 
bands are usually due to former labors or caustics; it may be necessary to 
divide them. 156 
a treatise on obstetrics. 
Thrombus of the Vulva and Vagina. 
Under the name thrombus we designate an extravasation of blood into 
the cellular tissue surrounding the vulva and vagina. This extravasation 
may not be limited to these parts, but may extend high up on the abdo- 
men. We are then dealing with a true hemorrhage. This accident is 
rare, since Deneux, in a practice of forty years, only observed three cases, 
Dubois three cases in 1,400 deliveries, Winekel one in 1,600, while in our 
clinic only one case was noted in 1,800. It may occur in the non-preg- 
nant state, but is most common in the pregnant woman after delivery. 
Extravasations are most common at the vulva, the swelling being uni- 
lateral. In the vagina they are usually situated in the lateral and pos- 
terior walls, rarely in the anterior. The extravasation begins, as a rule, 
during labor, but does not actually appear until after delivery. Laborie 
has shown that the location of the swelling is determined by the anatomi- 
cal structure of the parts: thus, if it is beneath the skin of the perineal 
region, it may extend to the thighs or abdomen, but if beneath the super- 
ficial fascia, it does not spread beyond the nymphae. An extravasation 
beneath the deep layer of fascia may spread to the iliac fossae or sacro- 
sciatic notch; if effused between the pelvic fascia and peritoneum, blood 
may either collect in one spot or extend throughout the pelvis, in the 
broad ligaments and even to the mesentery and diaphragm. If the ex- 
travasation is in the vaginal wall, it is shut in by the fibrous layer and 
does not spread to surrounding parts. The causes may be predisposing 
or determining. 
1. Predisposing Causes.-These may be, according to Blot, either re- 
mote or direct. Pregnancy is the most important, since it results in 
general congestion and oedema of the genital tract. Pri mi paras seem to 
be predisposed to intra-pelvic extravasations, wh'ile thrombus, on the 
other hand, appears to be more frequent in multiparse. Narrowness of 
the vagina, pelvic deformities, and varices, have been regarded by all 
authorities as essential causes. Varices, however, do not seem to possess 
extreme importance, because Perret noted this condition only twice in 43 
cases of thrombus; they seem, indeed, to play a secondary part in the 
production of these hemorrhages. Disturbances of the circulation, and 
in the composition of the blood in pregnant women, are also included 
among the predisposing causes. 157 
MATERNAL DYSTOCIA. 
2. Determining Causes.-Among these are to be mentioned the bruis- 
ing caused by the foetal part, by instruments, or even by the hand, when 
it is necessary to introduce the latter into the canal to perform version; 
also unusual size of the foetus, repeated and awkward examinations, vio- 
lent expulsive efforts, or even coughing or vomiting. Finally, local in- 
juries, from falls, the jolting of a carriage, and external violence, are to 
be added. In few instances do thrombi appear after delivery without 
some appreciable cause. 
Mode of Occurrence.-In consequence of the venous obstruction, the 
veins become dilated and their walls thinned; under the influence of one 
of the above-mentioned causes, rupture occurs at some point in the vessel- 
wall, and the blood escapes into the cellular tissue, its spread being fa- 
vored by the looseness of the latter. When this accident takes place dur- 
ing pregnancy, it is almost al way due to external violence. During labor 
the congestion is increased by the pressure of the venous plexuses between 
the foetal head and the bony walls of the pelvis; hence the greater 
frequency of intra-pelvic thrombus. After delivery the mechanism is the 
same; it is even possible, as Dubois affirms, that the vessels may be so 
contused that necrosis of their walls results, rupture following when 
the sudden afflux of blood takes place after delivery. From the rapidity 
with which the tumor develops, it is probably due to arterial, as well as 
venous, hemorrhage. 
Symptoms.-The first is pain, which, however, is not invariably pre- 
sent; it usually precedes the formation of the thrombus by a brief inter- 
val, and is sharp and lancinating, radiating from the vulva and vagina 
to the loins and lower limbs. According to Perret, it is accompanied by 
a feeling of tenesmus and a bearing-down sensation. A tumor then ap- 
pears either at the vulva or in the vagina, the lattei' being recognized by 
the touch; it is smooth, circumscribed when small, but diffuse when it is 
very extensive, and imparts to the fingers an elastic feeling, with or with- 
out fluctuation. It is generally of a dark livid color, and, after an in- 
terval, ecchymoses appear, either in the vicinity of the tumor, or on the 
buttocks and upper part of the thigh. If the swelling appears before de- 
livery, it may offer a mechanical obstacle to the expulsioh of the foetus; 
it may at the same time cause symptoms of pressure, referable to the 
bladder or rectum, or may even displace the uterus. Finally, these 
tumors may retard expulsion of the placenta and cause later retention of 158 
A TREATISE ON OBSTETRICS. 
the lochia. If the tumor does not rupture, it may give rise to all the 
symptoms of grave internal hemorrhage; if it does rupture, external hem- 
orrhage, more or less profuse, may be added to the internal. The symp- 
toms are of course directly proportionate to the severity of the hemor- 
rhage; finally, symptoms of accompanying peritonitis, abdominal pains, 
nausea, vomiting, etc., may appear. 
Termination.-The thrombus may become absorbed, may rupture sub- 
sequently, may be cured by adhesion of its walls, by suppuration, or by 
gangrene. Suppuration may follow spontaneous rupture or artificial 
opening of the tumor. 
Diagnosis.-These tumors have sometimes escaped notice, or have 
been mistaken for other growths, the bag of water, the inverted or pro- 
lapsed uterus, or vagina, etc. These errors will be avoided by noting 
the phenomena which accompany the appearance of the enlargement. 
Prognosis.-This is extremely grave when the thrombi are intra-pelvic, 
less so (though still serious) in other cases. If they occur before delivery 
they almost always result fatally for mother and child if after delivery, 
the child is unharmed and the mother's risks are somewhat lessened. How- 
ever, the hemorrhage, and the possible occurrence of suppuration, ren- 
der the prognosis grave. 
Treatment.-This is preventive and curative; the former consists in 
relieving venous stasis (and the resulting varices) by insisting on the 
patients keeping a horizontal posture. The curative treatment varies ac- 
cording as the thrombus appears during pregnancy, labor, or after deliv- 
ery; but, in general, we may say that the primary indication is to wait, 
and be ready to interfere if accidents seem to be imminent. During 
pregnancy, interfere only when the thrombus ruptures spontaneously. 
To make an incision is only to give freer vent to the hemorrhage, while 
it does not prevent internal bleeding, while astringent injections only 
cause the clots to be detached, and thus set up fresh oozing. Wait until 
the thrombus ruptures, then tampon with cotton, dry, or soaked in as- 
tringent solution, pure alcohol being preferable to perchloride of iron, 
since the latter favors suppuration. If the accident occurs during labor, 
the latter should be terminated as rapidly as possible by the forceps, 
rather than by version, and we should resort to incision only when it is 
unavoidable. Most authorities, however, are in favor of immediate in- 
cision, urging in support of it: 1. The necessity of removing the obsta- MATERNAL DYSTOCIA. 
159 
cle to the passage of the child; 2. The danger of extension of the ex- 
tra vasate through the pelvic cellular tissue; 3. The fact that rapid 
delivery does not always prevent rupture; 4. Immediate incision prevents 
the formation of clots and the consequent dangers of suppuration. 
To these arguments we reply, with Hervieux: 1. The tumor is so soft 
that the foetal head can easily pass it when aided by the forceps; 2. 
Intra-pelvic thrombi are rare, and the fear of their possible occurrence is 
not sufficient to justify operative interference; 3. If we tampon immedi- 
ately after making' an incision, the effect will be the same as if the tumor 
was let alone; 4. Fatal hemorrhages have occurred more frequently 
after the operation than when nothing was done; 5. Sloughing is more 
likely to follow premature opening of the thrombus. 
After delivery operative interference is necessary after the hemorrhage 
has ceased, most of the blood has coagulated, and evidences of suppuration 
or gangrene are present. A free incision should be made, and the cavity 
should be thoroughly irrigated and drained. 
Cystocele or rectocele may exist before labor or may not appear until 
that period. The vagina is pushed before the foetal head, and forms a 
large, livid mass which retards delivery; gangrene may result. We 
must prevent, or at least remedy, this prolapsus by emptying the bladder 
and rectum, and then pushing up the tumor and holding it up with one 
finger until the termination of the labor. If the prolapsus continues, the 
bad results of compression may be avoided by applying forceps and deliv- 
ering as soon as possible. 
Prolapse of the Vagina. 
Tumors of the Vulva and Vagina. 
These are usually vegetations, abscesses, cysts, polypi and schirrous 
being rare. These tumors seldom cause serious trouble. (Edema of the 
vulva may be so excessive as to require scarification at the moment of de- 
livery; it may be due to awkward manipulation with the hand or instru- 
ments. 
Hernia. 
1. Hernia of the Bladder.-Cystocele.-Prolapse of the bladder and re- 
tention of urine is a frequent cause of dystocia, since it interferes with 160 
A TREATISE ON OBSTETRICS. 
the regularity and intensity of the uterine contractions. It is not by any 
means easy to pass the catheter, since the head is pressed against the 
neck of the bladder, and cannot be dislodged; wre should not hesitate to 
use a metallic instrument, although we may sometimes succeed with an 
elastic catheter, especially if the woman is placed in the knee-elbow posi- 
tion. In some instances, it is impossible to withdraw the urine in any 
way, and the distended bladder finally ruptures. Vaginal cystocele may 
Fig. 136.-Cystoceue. (Ramsbotham.)-A, Portion of the prolapsed bladder. 
apparently become a cause of serious obstruction, but this disappears 
on using the catheter. As soon as the bladder is emptied it may be held 
up by two fingers, while, if necessary, labor is terminated by forceps 
(Fig. 136). 
2. Hernia of the Intestine.-Enterocele.- Epiplocele.- The intestine, 
or mesentery, may become engaged in the anterior or posterior 
cul-de-sac and constitute a true vaginal hernia', they' may even 
descend as low as the perineum and form a perineal hernia. Finally, 
we designate under the name vagino-labial hernia a hernial tumor situated 
in the labium. These not only present a mechanical obstacle on account 
of their size, but they may become inflamed by reason of the pressure to 
which they are exposed, and strangulation may result. They must first 
of all be reduced, and kept so during the entire course of the labor. MATERNAL DYSTOCIA. 
161 
Vesical Calculi.-Vesical calculi have rarely been noted as complica- 
tions of pregnancy and delivery; they may, however, become a very seri- 
ous cause of dystocia. If discovered before labor, they should be lifted 
above the superior strait, and retained there until the head has descended 
below them; if they are not detected until the time of labor, and are 
firmly impacted between the head and the symphysis, it is necessary, if 
the head cannot possibly pass the obstacle, to extract them either through 
the previously dilated urethra, or through an incision in the vesico-vagi- 
nal septum, the wound being immediately closed. Ilugenberger (1875) 
reported 23 cases, in seven of which delivery occurred spontaneously; 
in eight interference was required. In seven instances the calculus was 
removed during labor. Winckel states that there are in all 29 recorded 
cases, in all of which the results were more or less serious. 
Dystocia due to Obstruction at the Cervix. 
The obstacles may be due to rigidity of the cervix, adhesion or oblit- 
eration of the same, or to lesions of various kinds, tumors, abscesses, 
etc., which prevent dilatation. 
Rigidity of the Cervix.-Under this expression we refer to a peculiar 
condition characterized by passive or active resistance to dilatation on the 
part of the cervix, which thus retards delivery. There are three varieties 
of rigidity, termed by writers anatomical, spasmodic, and pathological 
rigidity. 
A.-Anatomical Rigidity or the Mechanical Rigidity of Pajot.-This is 
often confused with that thickening of the cervix which is frequently 
noted in protracted labors; but in true anatomical rigidity the cervix has 
a peculiar feel, resembling oiled leather. Its border is firm, thick and 
resistant, but not painful; the cervix, although already dilated to a cer- 
tain degree, preserves, as in cases of abortion, a sort of relative length, so 
that it forms a more or less prominent projection in the vaginal roof, in 
the centre of which is an orifice of variable size. The cervix itself is not 
sensitive to pressure, nor is the vagina in any manner, or more sensitive 
than usual. The uterine contractions occur regularly and strongly, but 
are without effect; during the contraction the cervix does not become al- 
tered as the head presses upon it, and the stage of dilatation may be pro- 
longed for several days. It is only after labor has continued thus for a 
Vol. III.-11 A TREATISE ON OBSTETRICS. 
162 
certain length of time that we observe heat and sensitiveness of the va- 
gina, and often a little tenderness in the cervix. This condition is most 
common in primipane, and especially in premature labors. It is not se- 
rious, as a rule, as regards the foetus, but the woman may be deprived of 
rest and sleep, and is thus rendered especially susceptible to post-partum 
troubles. 
Baths, warm vaginal injections, and venesection are the best remedies 
in these cases. Opium and chloral enemata often act very beneficially. 
B.-Spasmodic Rigidity.-Here the phenomena are quite different; 
there is no longer passive, but active, contraction, which may occur dur- 
ing the second as well as during the first stage, or even at the moment 
of delivery. It may occur in either multipart or primiparae (especially 
the latter), of any variety of temperament, and is often due to frequent 
examinations, violent attempts at dilatation, and, above all, to ergot, and 
premature rupture of the membranes. 
When spasmodic retraction occurs during the first stage, the labor ap- 
pears to be progressing normally, when suddenly the cervix retracts, there 
being an actual spasm of the circular fibres surrounding the orifice. The 
pains are sometimes very severe, sometimes almost entirely absent, or 
separated by irregular intervals, and the uterus, in-stead of becoming re- 
laxed in the interval between the contractions, remains contracted and 
tender on pressure; this is especially the case when the membranes have 
ruptured, the cervix grasping the foetal parts immovably. 
To the touch the cervix appears thin, especially at the os, the edge of 
which is firm and unyielding, like a wire; the part is extremely sensitive 
to the slightest touch and feels hot. The vagina is also hot and sensitive. 
Vesical and rectal tenesmus, nausea, vomiting, great agitation and a 
more or less marked febrile reaction are frequently observed. 
Sometimes the spasm of the cervix occurs during the stage of expul- 
sion, as soon as the head is born, and may be situated at the internal, as 
well as at the external, os. This occurs above all in cases of version and 
extraction, and it is easy to understand how serious it may be for the 
child; the cervix, in fact, grasps the neck of the foetus, which is thus held 
like a stud in its button-hole, and if this continues long the child suc- 
cumbs. Finally, the spasm may occur during the third stage, as we shall 
see later. 
Treatment.-Spasmodic contraction of the cervix is transient; if it oc- MATERNAL DYSTOCIA. 
163 
curs during the first stage, the rule is to wait until it ceases spontaneously. 
But if it is prolonged for several hours, the obstetrician should interfere. 
Sitz, or full baths, emollient injections, fumigation with aromatics, 
venesection till syncope ensues, laudanum-enemata, and applications of 
belladonna to the cervix, have been recommended in turn. We have 
had some results from the application to the cervix of the watery extract 
of belladonna, but it often fails. Chloroform, pushed to the degree of 
complete anaesthesia, has been recommended, but in order to affect the 
uterine muscle it must be administered to a dangerous extent. Its prin- 
cipal action seems to be that of a nervous sedative; chloral accomplishes 
the same result without danger, and to it we give the preference. If 
chloral fails, and it becomes necessary to terminate the labor, we must 
resort to incision of the cervix. A long, blunt-pointed bistouri is passed 
along the left forefinger, and a small lateral incision is made at the sharp, 
rigid border of the os; one or two cuts are usually sufficient and dilatation 
then proceeds rapidly. Blot was once obliged to make eight incisions 
before the os would dilate. Such incisions are to be preferred to forced 
dilatation, after other remedies have failed. If the spasm is confined 
to the os internum, incision is absolutely contra-indicated, and we must 
try forced dilatation, although the latter should be regarded as an ex- 
treme measure, because it exposes the woman to extreme danger, and 
often leads to rupture of the uterus. If the spasm occurs after the birth 
of the head or trunk of the foetus, we must act quickly, and either incise 
or dilate forcibly, according as the contraction is at the external or in- 
ternal os. 
» 
C.-Pathological Rigidity.-This may be due to bands or cicatrices, 
tumors, or cancer of the cervix. It is to be distinguished from the other 
two varieties by the shape and peculiar character of the cervix. 
IT. Obliteration of the Cervix. 
When limited to the os externum, this has been termed by Naegele 
adhesion of the os externum. In tliis case the obstacle consists of a fi- 
brous tissue similar to peritoneal adhesions. The entire cervical canal 
may be affected, a condition called by Depaul complete obliteration of the 
cervix; this is much rarer than the partial forms. 
Causes.-Injuries during parturition, especially from the use of instru- 164 
A TREATISE ON OBSTETRICS. 
ments and cauterization of the cervix are among the causes. In closure of 
the os externum the finger seems to enter a cul-de-sac at the upper part 
of the vagina, no orifice being felt; or the cervix may be felt, but there is 
only a slight central depression. How shall we recognize complete oblit- 
eration ? 
1. Obliteration of the Os Internum.-A suspicion of the existence of 
this condition will be aroused when the uterine contractions have con- 
tinued for some time without producing the usual results. The finger 
passes through the os externum and meets at the level of the os internum, 
a complete septum without any opening. Through the speculum the 
condition will be recognized at once. 
2. Obliteration of the Os Externum.-On examination a smooth, 
rounded tumor will be felt at the upper part of the vagina, having a firm 
consistence (if the head presents), but without any projection, orifice, or 
depression, suggesting the cervix. The adhesion in this instance is be- 
tween the lips; sometimes a slight prominence may be felt, or a small de- 
pression, without any orifice, which indicates beyond doubt the site of 
the obliterated os. The vagina is dry, there being neither mucus, nor 
amniotic fluid. The uterine contractions produce no change in this con- 
dition. 
This alteration is not to be mistaken for deviation of the os, a malfor- 
mation of the portio vaginalis, atresia of the cervix, or cicatricial bands 
or septa in the vagina. 
Prognosis.-This is graver than would at first appear. When the ci- 
catricial tissue is old and dense, surgical interference may be necessary. 
Treatment.-Wait till you are sure that nature cannot overcome the 
obstacle, then try to dilate with the finger, and finally resort to incision, 
because eclampsia and rupture of the uterus may result from too long 
delay. We must always operate at the point of obliteration, which can 
easily be found when it is situated at the os internum, because the canal 
is a guide to it; when the os externum is closed, we must determine the 
point of least resistance, and then introduce the bistoury, dividing each 
layer of tissue in turn, and not by a single cut. The finger glides be- 
tween the uterine wall and the foetal part, and the opening is then en- 
larged by multiple incisions. Before operating, be sure that there is 
really an obliteration of the orifice and not merely a deviation of the same, 
because a fatal error has been made in this way. We should not confine 165 
MATERNAL DYSTOCIA. 
ourselves to an examination by the finger and speculum, but should chlo- 
roform the patient, and introduce the whole hand into the vagina, if nec- 
essary, before proceeding to make an incision. Hecker has reported a 
unique case of agglutination of the os uteri produced by its union with 
the membranes. 
III. Deviations of the Os. 
These follow displacements of the uterus, the cervix being carried back- 
wards or forwards, according as the organ is ante- or retro verted; the 
former is most common. As labor proceeds, the cervix will be carried so 
much farther backwards, according as the lower uterine segment projects 
farther into the vagina. The cervix dilates very slowly in these cases, 
since the contracting force is exercised upon its anterior and upper 
part. 
It is sufficient to draw the cervix forwards into the pelvic axis during 
the pain, and to keep the woman on her back, reversing the former ma- 
noeuvre if the cervix point forwards. In some cases this deviation of the 
cervix may be due to what Depaul has called "sacciform dilatation" of 
the uterus; the cervix is pushed up above the symphysis, so that it is ex- 
tremely difficult to reach it. This may become a very serious cause of 
dystocia. 
IV. Swelling and Elongation of the Anterior Lip of the Cervix. 
In this condition, which is most common in primiparae, the anterior 
lip is firmly wedged between the symphysis and the head, and if labor is 
not speedily terminated, especially if the pelvis is somewhat contracted, 
the lip forms a tumefaction below the head, that sometimes offers a se- 
rious obstacle to the expulsion of the foetus. The more the head tends 
to descend, the more the swelling increases, and the greatei- the obstacle. 
In some cases the lip can be pushed upwards, and retained during the 
pains until the head slips past it, but it is usually necessary to apply the 
forceps. As a result of pressure thrombi maybe formed in the lip, or the 
latter may tear and give rise to more or less serious hemorrhage. 
Cazeaux has also mentioned, as causes of dystocia, abscess of the cervix, 
fungoid tumors, vegetations, and simple hypertrophy. 166 
A TREATISE ON OBSTETRICS. 
V. Cancer of the Cervix. 
Theoretically, cancer of the uterus does not prevent fecundation, except 
as it depresses the general health of the woman; no obstacle is offered to 
the passage of the spermatozoa. Gueniot believes that pregnancy can 
only take place during the initial stage of cancer, since in the ulcerative 
stage not only are conjugal relations necessarily prevented, but numerous 
obstacles are presented to the union of the semen and the ovum. On the 
contrary, out of 127 cases observed by Cohnstein, in 21 the cancer had 
existed from several months to a year before pregnancy occurred; he 
even goes further and affirms that it favors the development of preg- 
nancy in women between certain ages. We do not accept this view. In 
21 cases Cohnstein was able to demonstrate that cancer existed for several 
months before pregnancy occurred, and in several instances it was not 
prevented by the presence of ulceration. Non-fungating epithelioma is the 
usual form, occurring 117 times in his 127 cases, the cauliflower appear- 
ance being noted only 10 times. 
The Mutual Influence of Pregnancy and Cancer.-The course of the 
pregnancy seems to depend essentially on the location, rather than on the 
extent, of the degeneration. It is less likely to be interrupted if the dis- 
ease is limited to the lips of the cervix, while as the cancer extends to 
the os internum, the chances of abortion increase. Lewes noted 40 per 
cent, of abortions in 120 cases, while Cohnstein saw 68 deliveries at term 
among 100 patients. Sometimes the pregnancy is prolonged past the 
usual time, or the foetus dies and is retained in the uterus. In 5 per cent, 
of the cases observed by Cohnstein the pregnancy pursued its usual course 
with very slight disturbances, but in all the rest there were various trou- 
bles, emaciation, slow fever, and oedema often appearing during the latter 
months, as well as neuralgic pains and psychical disturbances. 
The Influence of Pregnancy on Cancer.-Cohnstein says if cancer begins 
during pregnancy, it always develops more or less rapidly; if, on the con- 
trary, it existed for some time before pregnancy, the influence of this con- 
dition seems to be relatively favorable. Gusserow, however, mentions a 
number of cases, proving that the neoplasm develops with extreme rapidity. 
The favorable influence of pregnancy, according to Cohnstein, is shown 
by the marked diminution of the hemorrhages, at least during the early 167 
MATERNAL DYSTOCIA. 
months, the lessening of pain, and the improvement in the general con- 
dition. If breaking down of the tissues takes place at this time, the 
change is rather fatty degeneration than necrosis. Contrary to its course 
in the non-pregnant woman, the cancer very rarely extends to the body 
of the uterus, the bladder, or the vagina. 
Diagnosis.-The only difficulty, according to Gusserow, is at the outset 
of the disease; still many errors have been made. The hemorrhage may 
be mistaken for that due to placenta prasvia. 
When the cancer is confined to one lip of the cervix, spontaneous de- 
livery is the rule, the prognosis being more favorable for both mother and 
child when the posterior lip alone is affected. When both lips are dis- 
eased, or nearly the whole of the portio vaginalis, spontaneous delivery 
is more rare; the cervix may tear in several places, and rupture of the 
uterus may result from extension of the lacerations. Hemorrhage, sup- 
puration and death from peritonitis, or septicaemia, are common results. 
The delivery is more apt to be spontaneous when it is premature. When 
the cancer has extended to the body of the uterus and to the surrounding 
tissues, spontaneous delivery is impossible. If the contractions are violent 
the uterus may rupture, if they are feeble the foetus may be retained, and 
the patient may succumb to hemorrhage or septicaemia. 
If delivery is spontaneous, the woman may improve, and even become 
pregnant again, or she may succumb to the disease later; if labor has 
been long, the lesions of the cervix produced by the passage of the child 
are followed by gangrene of the diseased parts, septicaemia, and peritoni- 
tis, and\the mother succumbs to the puerperal complications. 
Prognosis.-This depends upon the character, location, and extent of 
the disease, but in general it is more grave for the child than for the 
mother. Chantreuil noted 25 deaths during and after labor among 68 
women; out of 70 children, 28 were born alive. Among 126 women ob- 
served by Cohnstein, 54 survived; 42 children out of 116 were born 
alive, while of the 74 who perished, 7 were delivered after embryotomy, 
14 were retained in the uterus, and 6 died from the effects of protracted 
labor and extraction. The total mortality was 38.8 per cent. 
Treatment.-The first question which presents itself with reference to 
cancer of the uterus is: Can we, and should we, operate upon the cancer 
during pregnancy? Should cauterization, amputation or extirpation 
of the diseased part be attempted ? A number of cases have been reported 168 
A TREATISE ON OBSTETRICS. 
in which the cancer was excised during pregnancy, not only without in- 
terrupting its course, but with the result of rendering labors less difficult, 
and causing the delivery of living children. 
We can not view the subject in this light; in the presence of a disease 
which is certain to destroy the mother sooner or later, we should think 
first of the child. Operations performed during pregnancy not only com- 
promise seriously the life of the mother, but almost inevitably interrupt 
gestation, and hence defeat the end which we propose, viz., the safety of 
the child. The treatment should be expectant, limited to controlling 
the hemorrhage by astringent and antiseptic injections. As soon as labor 
has begun we should be ready to incise the cervix and apply forceps if 
the interest of the child demands it; this applies also to cases in which 
the disease has extended to the os internum. Expectant treatment is 
far from being without danger, since out of 47 cases in which this was 
adopted, 12 terminated fatally in consequence of rupture of the uterus, 
and three from laceration of the cervix. Manual dilatation has been tried 
in vain, but incision of the cervix, as advised by Baudelocque, followed 
by the use of the forceps, version, or the cephalotribe, has been most 
generally adopted, the average results being 50 per cent, of recoveries for 
the mothers and 62.5 per cent, for the children. It seems as if the forceps 
should be much preferred to version, since we find that with the former 
75 per cent, of the mothers and 50 per cent, of the children were saved, 
while after version, only 18 per cent, of the mothers and 12.5 per cent, of 
the children survived. Cephalotripsydoes notappear to offer any advan- 
tages for the mother. Out of 6 cases collected by Cohnstein, 4 died. 
Incisions followed by the application of the forceps is really the best 
procedure, since dilatation with Barnes' bags, followed by version, has given 
much less favorable results. We believe that the induction of premature 
labor should be absolutely rejected, in view of the incurable nature of 
the mother's malady and the importance of saving the child; the same 
interference is necessary after the induction of artificial labor as in labor 
at term, hence there is no advantage in it. Csesarian section has been 
performed five times, two children being delivered alive, one of whom 
died immediately after the operation. These results are certainly dis- 
couraging; still, if the disease had invaded the lower segment of the uterus, 
if the pregnancy had reached full term, the foetal heart-beats were nor- 
mal , the membranes intact, and the cervix had not, for several hours, been 169 
MATERNAL DYSTOCIA. 
affected by the uterine contractions, we believe that we should hardly be 
justified in hesitating, and that we should have recourse to Caesarian sec- 
tion, which ought under these circumstances, to give a living child. 
VI. Fibroid Tumors of the Uterus. 
These are designated by various terms (fibroma, fibro-myoma, etc.) ac- 
cording to the relative predominance in them of fibrous or muscular tis- 
sue. They may be interstitial, sub-peritoneal, or sub-mucous, the intra- 
uterine growths being frequently polypoid. Their most common site is 
the posterior wall of the corpus uteri, fibromata of the cervix being rare. 
Out of 74 cases of fibroid in the non-pregnant woman, Chahbazian found 
only 4 in the cervix, Guyon 21 out of 111, and Sims 2 out of 114 cases; 
out of 380 cases in which pregnancy and labor were complicated by fi- 
broids, Chahbazian found 80 tumors in the cervix, 38 being sub-mucous 
polypi, 10 sub-mucous sessile growths, 29 interstitial, and 2 sub-periton- 
eal. They usually occupied the posterior lip of the cervix, and rarely 
involved both. 
Aside from the changes which pregnancy and parturition cause in myo- 
mata, they may become hypertrophied, atrophied, fatty degenerated, col- 
loidal {geodes of Cruveilhier), and vascular; in consequence of the latter, 
oedema, congestion, infiltration, extravasation of blood, or gangrene may 
be consecutive to this vascular dilatation. Each of these conditions may 
affect the general health and cause peritonitis, usually circumscribed, 
which results in the formation of adhesions between the myoma and neigh- 
boring parts. 
Myomata do not offer an insurmountable obstacle to pregnancy, and 
we must study in succession the relations which these tumors bear to fe- 
cundation, pregnancy and parturition. 
1. Fecundation.-Although this is not impossible, there is a connec- 
tion between sterility and the presence of these fibromata. While many 
writers believe that sterility is itself a direct cause of the development of 
fibroids, nearly all specialists in gynecology think fibroids cause sterility. 
We indorse the latter view, since it is easy to understand how the catarrh 
and hemorrhage due to the presence of these tumors (especially the sub- 
mucous variety) prevent conception. The modifications in the shape, 
situation, and cavity of the uterus, and the altered relations between the 
ovary and tube, are so many mechanical obstacles to fecundation. 170 
A TREATISE OX OBSTETRICS. 
In addition fibroids are more common in married than m single women, 
since ont of 1634 women 1192 were married and 442 single. Marion 
Sims found 119 cases of fibroids in G05 sterile women; among 255 women, 
observed by the same writer, who had had only one child, fibroids were 
detected in 38; among 250 who had never been pregnant, 57 had tumors; 
while in 100 young girls, suffering from pelvic troubles, 24 had fibromata. 
That the chances of fecundation are greatly lessened by the presence of 
fibroids will appear from the fact that among 1554 women with fibroids, 
observed by Winckel, Schroeder, Gusserow, and others, 476, or 1 in 3.05, 
were sterile. Now, on the authority of Courty, Simpson, and Spencer 
Wells, sterility is present in 1 marriage out of every 8 or 8.5. These 
tumors, indeed, really prevent the union of the male and female elements, 
by causing displacements of the uterus, obliterating the uterine cavity 
and the opening of the tubes, causing spasmodic contraction of the os in- 
ternum, etc.; also by leading to catarrh and hemorrhage, and to cir- 
cumscribed peritonitis, with the disturbances consequent upon the forma- 
tion of adhesions. 
The Influence of Pregnancy on Fibromata. - As the myoma is composed 
of tissue identical with that of the uterus it is not at all strange that it 
should be modified by pregnancy; but we must distinguish between fibro- 
mata, fibro-myomata, and myomata, since they undergo different changes. 
These changes depend, moreover, upon the seat of the tumor; the more 
intimate its relations to the uterus, the more will it share in the physio- 
logical phenomena which take place in that organ, and the more closely 
its structure approaches to that of the uterus the more profound will be 
these modifications. Thus, sub-peritoneal tumors undergo relatively 
fewer changes than the interstitial and sub-mucous variety. Fibromata, 
the tissue of which is denser and more compact, are less affected than 
myomata, in which muscular fibre is the predominating element. These 
changes are of several kinds, viz.: 
1. Fibroid tumors increase in volume during pregnancy, and after de- 
livery undergo a retrogression or involution, analogous to that of the 
uterus; this has been determined beyond doubt by numerous observers. 
The entire disappearance of a myoma is very rare, and as a rule it may 
be affirmed that although fibroid tumors do undergo involution, they 
are always a little larger than they were before the occurrence of pregnancy. 
2. At the same time that they increase in size, the fibroid growths 171 
MATERNAL DYSTOCIA. 
become actually softer. This softening may be due simply to the oedema 
which results from increase in the blood-supply, or it may be a pathologi- 
cal process. 
3. Finally, during the latter months, these tumors seem to undergo 
a peculiar change, that is due to true absorption of their tissue. Depaul 
says that neither hypertrophy nor softening is constantly observed, and 
that one condition might exist independently of the other. 
In many cases these tumors may become flattened, so that they can not 
be felt during pregnancy, and are not recognized until after delivery. 
This phenomenon is most often observed in pure interstitial myomata. 
The following table, which we take from Chahbazian's* monograph, 
shows the influence which pregnancy and labor exert in particular on 
fibromata of the cervix. In 39 cases:- 
Hypertrophy during pregnancy, .... 7 
Displacement, ........ 9 
Softening, ........ 10 
Expulsion, ........ 4 
Irritability, ........ 3 
Atrophy after labor, ...... 6 
The Influence of Fibrous Tumors on Pregnancy.-Lefour has found 
that a certain proportion of cases of extra-uterine foetation are associated 
Fig. 137.-Extra-uterine Pregnancy with Fibroid Tumor. (Gusserow) 
with fibroids; hence he believes that the ovum is prevented from travers- 
ing the tube that has become obliterated, in consequence of its being dis- 172 
A TREATISE ON OBSTETRICS. 
placed or compressed by the fibrous growth (Fig. 137). When the ovum 
has succeeded in reaching the uterine cavity, fibroid tumors tend to make 
it descend to the lower segment of the uterus; hence the relatively greatex- 
frequency of abnormal insertion of the placenta. 
Fig. 138.-Placenta partially inserted on a Fibroid. 
Thus Nauss found abnormal insertion once out of 49 cases, and Lefour 
once out of 23.71 cases. This frequency, indeed, is much greatex* thaxx 
aside from fibrous growths, as is proved by the following statistics cited 
by Lefour. 
Schwartz, . . . . . 1 in 1564 labors. 
Collins, ..... " 1492 " 
McClintock and Hardy, . . " 829 " 
Klein, ...... " 760 ie 
Arneth, (l 725 " 
Ramsbotham, . . . . " 665 " 
At Wurtzbourg Maternity, . . " 472 " 
At Paris Clinic, .... " 242 " 
Spiegelberg, .... " 1000 " 
It is a curious fact that the placenta may oe inserted not only at the 
inferior segment of the uterus, but even on the fibrous growth itself 
(Fig. 138). On the other hand, pregnancy may pursue its regular course, 
even in cases of multiple fibroids (Fig. 139). However, abortion and 
premature labor result in about once in 1.4 cases. Chahbazian found 
that in 114 cases of fibroid (especially of the cervix) there were 50 de- 
liveries at term (in 10 labor was very difficult), 10 premature births and 
8 abortions, 10 in which hemorrhage occurred during pregnancy, and 6 in MATERNAL DYSTOCIA 
173 
which it took place during, or after, delivery; rupture of the uterus 
resulted in 5 instances, prolapsus in 5, flattening of the foetus in 5, and 
retention of the same in 3. 
Fig. 139.-Gravid Uterus and Multiple Fibroids. 
The situation of the tumor is important. If it is outside of the true 
pelvis, it rises with the enlarging uterus, and only affects the progress of 
Fig. 140.-Fibroids of the Uterus. (Tarnier.) - s, Symphysis, v, Bladder, t, Small tumor. 
T, Large tumor, c, Cavity of tumor, r, Rectum, b, Douglass' fossa, p, Pedicle of tumor. . 174 
A TREATISE ON' OBSTETRICS. * 
pregnancy in so far as it gives rise to pressure-symptoms. If a sub- 
peritoneal fibroid with a long pedicle is situated between one side of the 
uterus and the corresponding pelvic wall, the pressure will be such as to 
diminish the chances of the pregnancy going on to term; if the tumor is 
situated merely between the walls of the pelvis, it ceases to press upon 
the uterus as soon as the latter has risen out of the pelvis (fourth month). 
The myoma may undergo morbid changes which exert an unfavorable 
influence on the general health, incompatible with the prolongation of 
pregnancy. Moreover, tumors in the posterior uterine wall may cause 
retroversion, with consequent incarceration and abortion. 
If the tumor is intra-uterine, it grows simultaneously with the foetus; 
if located between the pelvic wall and the lower two-thirds of the uterus 
these tumors, whether sessile or pediculated, are the most dangerous of 
all, as regards pregnancy, especially if they are in the posterior wall. 
Hemorrhage is less common than might be supposed, since it most often 
accompanies sub-mucous tumors which are rarely associated with preg- 
nancy as compared with sub-peritoneal. Finally, Gusserow has shown 
that the tumor may, during pregnancy, compress the foetus itself, and 
thus may cause abortion. 
Delivery in Case of Fibroid Tumors.-The location of the fibroids is of 
more importance than the number and size. If the tumor is situated at 
the cervix it may, by its size alone, become a cause of dystocia, but by 
enucleating it, the obstacle will usually be overcome. If the tumor is 
sub-mucous it is also proportionately less dangerous, because it is pedic- 
ulated, and if it is situated in the inferior segment of the uterus, it will 
often be expelled before the foetus, and then the pedicle will either 
rupture itself, or it may be divided, thus facilitating the expulsion of the 
child. 
If the tumor is situated higher up, delivery may be more difficult, and 
may necessitate interference with the forceps or even with the cephalo- 
tribe. But these cases are rare, and such tumors are usually not perceived 
until after delivery. Then they manifest their presence by hemorrhages 
and pain, and they are either expelled spontaneously, or are removed 
artificially. But, if the tumors are interstitial, and occupy the lower 
segment of the uterus, they may resemble sub-serous growths of the 
cervix, and may cause serious difficulties. 
When, on the contrary, they are higher still, they usually affect the MATERNAL DYSTOCIA. 
175 
delivery but slightly. If they are at first pushed into the pelvis in front 
of the child, they often ascend above the foetal part after the rupture of 
the membranes, under the influence of the uterine contraction, and thus 
allow its passage; or they are so softened that they are flattened out by 
the foetal part, and delivery takes place spontaneously, although it is 
retarded. This delay in labor has been observed by all authorities, who, 
aside from the difficulty which is inherent in the obstacle to be over- 
come, attribute it in great part to the feebleness of the uterine contrac- 
tions. Lefour believes that this feebleness is due to uterine inertia, 
following ineffectual attempts to overcome the obstacle. Sub-peritoneal 
fibroids complicate labor when they are situated at the inferior segment, 
and especially at the cervix. If there is a long pedicle, the tumor may 
descend into Douglass' pouch, and become impacted. When interstitial 
or sub-peritoneal fibroids are situated at the inferior segment or at the 
cervix, and thus more or less completely fill the pelvis, they oppose an 
enormous obstacle to delivery; however, this should not necessarily be 
regarded as insurmountable, because, in this case, delivery-may be effected 
either spontaneously or artificially. Here the size of the tumor, although 
it is an important element, is not the principal one, since it is rather the 
situation of the growth with reference to the pelvis; small tumors in a 
bad situation may be relatively more dangerous than those of much larger 
size. 
Delivery occurs in these cases by a special mechanism, which has been 
thoroughly studied by Depaul and Gucniot and more recently by Lefour. 
The tumor is not only compressed and softened, but it is displaced 
upwards into the abdominal cavity, so as to allow the passage of the 
foetus. Lefour affirms that this ascension may take place during preg- 
nancy, during the latter days of pregnancy, and at the beginning of labor, 
or during labor. 
1. During Pregnancy.-As the lower segment of the uterus develops 
at the expense of the anterior, rather than of the posterior wall, the latter 
extends upwards, carrying with it the sessile fibroid which is commonly 
attached here, or the ascent of the uterus as a whole tends to displace the 
tumor upwards. 
2. During the latter Days of Pregnancy, and at the beginning of Labor. 
-The tumor may be carried upwards by reason of the contraction of the 
longitudinal muscular fibres of the uterus; but these contractions are 176 
A TREATISE ON OBSTETRICS. 
not enough in themselves to elevate a large tumor above the superior 
strait; they merely dislodge it and render it somewhat movable, the eleva- 
tion being accomplished during the period of dilatation or expulsion. 
Fibromata often become adherent to the neighboring parts, and if these 
adhesions are firm, all the efforts of the uterus will be unavailing; if, on 
the contrary, these are loose, they will yield during the stage of dilata- 
tion. 
3. During Labor.-Large, sessile, sub-peritoneal tumors, with broad 
bases, are especially apt to ascend during labor, this ascension being due 
to three causes, the uterine contraction, the dilatation of the cervix, and 
the escape of the amniotic fluid. As the longitudinal fibres contract, 
they exert traction simultaneously upon the os uteri and the tumor; as 
the former dilates the latter is displaced upwards. When the membranes 
rupture the uterine walls retract, and consequently the lower segment is 
slightly elevated. Unfortunately, this ascension or displacement of the 
tumor, does not always take place, whence arise insurmountable obstacles, 
which may render Caesarian section necessary. But, aside from the 
difficulties attributable to fibroid tumors, there are others that come from 
mal-presentations of the foetus, which are much more frequent in preg- 
nancies complicated with fibroids; thus, in 22 cases observed by Tarnier, 
9 were breech-presentations; in 86 reported by Nauss, 18 were shoulder 
and 22 breech-presentations; in 48 reported by Toloczinow, in 10 the 
trunk presented, in 13 the breech; in 68 by Susserott, there were 12 of 
the former and 16 of the latter; in 102 by Lefour, 17 of the former and 
33 of the latter. According to the statistics of Dubois and Depaul, the 
average number of presentations of the trunk in normal labors is 0.04, 
of the breech, 4.2. Breech-presentations are regarded as the most favora- 
ble in cases of fibroid tumors, and vertex-presentations the most serious. 
Delivery is usually spontaneous, and presents no difficulties, although 
in some instances artificial delivery is necessary and is tedious. If the 
placenta is inserted on the tumor, the danger is extreme, six out of nine 
patients having perished from profuse hemorrhages. The prognosis is 
then very serious both for the child and the mother, but especially for 
the latter. In fact, aside from the dangers to which they may be exposed 
during pregnancy, by reason of the pathological changes which fibrous 
tumors may undergo, and the retroversion of the uterus, these growths 
may become impacted, and may then cause pressure-symptoms referable MATERNAL DYSTOCIA. 
177 
to the bladder, which may be so excessive as to exactly resemble those 
due to incarceration; we should mention also hemorrhages, retardation 
of labor, abnormal insertion of the placenta, mal-presentation of the 
foetus, inversion and rupture of the uterus, etc. To show the gravity of 
the prognosis, it may be mentioned that out of 287 women observed by 
Nauss, 123, or 53.92 per cent, succumbed, while out of 147 reported by 
Susserott, 88, or 53 per cent, died; the foetal mortality was in the former 
instance 57.2 per cent., in the latter, 66 per cent. Even when spontane- 
ous delivery takes place, the children may be compromised by the exist- 
ence of the tumor alone, the foetal head being compressed and flattened 
by the tumor. 
There was a case in our clinic, in which pregnancy was complicated by 
a larger fibroid tumor that was inserted at the junction of the cervix and 
body, and filled the entire pelvis; the child was living at the beginning 
of labor, and was delivered spontaneously on the day following the per- 
foration of its head. A second patient was brought to the clinic after 
having been in labor four days, her abdomen being enormously distended, 
and so painful that palpation was impossible. The os was partially dilated 
so that the foetal head could be felt; perforation was resorted to, but the 
child could not be extracted, and the woman died undelivered, the 
character of the obstruction not being recognized until the autopsy. 
Fig. 141 explains the condition which existed. 
Diagnosis.-In some cases this is quite easy, but in the majority it is 
very difficult and errors are frequent even among the most expert. 
Sometimes the presence of the tumor is recognized, but pregnancy is not 
suspected; sometimes, on the other hand, the latter condition is detected, 
as well as the fact that it is complicated, but the character of the growth 
is obscure. The rule is to wait, before giving a positive opinion, until 
the fact of pregnancy is established, and then to investigate the nature of 
the complication. In many cases women know that they have fibroids; 
the diagnosis is then complete. * 
Pregnancy complicated with fibroids has been mistaken for moles and 
hydatids, multiple pregnancy, hsematocele, etc.; the tumors have been 
taken for foetal parts (head, breech, or shoulder). The conditions most 
liable to be mistaken for it are extra-uterine pregnancy, hypertrophy of 
the uterus (especially of the lower segment), thrombus, or cancer of the 
cervix, tumors of the broad ligaments and ovaries, and, in fact, any ab- 
Vol. III.-12 178 
A TREATISE ON OBSTETRICS. 
dominal tumors that have descended into the posterior cul-de-sac. Three 
of these deserve particular attention, viz.: Retroversion, ovarian cyst, 
and extra-uterine pregnancy. 
1. Retroversion.-This may cause the same pressure-symptoms and pre- 
sent the same sensation to the examining finger; but, in retroversion, the 
symptoms are not so gradual in their onset as those produced by a fibroid; 
Fig. 141.-Interstitial Myoma invading the Body and the Cervix.-T, Uterine portion of 
tumor. T, Extrauterine portion of tumor. U, Vagina. U, Uterus opened in median line. 
the tumor appears smoother and more regular, and it is often possible to 
feel the foetal parts through the uterine wall. Retroversion always occurs 
in the fourth or fifth month of pregnancy, and all doubts are removed by 
the reduction of the organ, when this is possible. 
2. Ovarian Cysts.-The diagnosis is only really difficult when the cyst 
is contained within the pelvic cavity. We must then combine the rectal 
and vaginal touch with palpation, in order to appreciate the physical char- 
acteristics of the tumor. It will sometimes be possible, while holding the MATERNAL DYSTOCIA. 
179 
pregnant uterus, to displace the tumor which does not form a part of it. 
More frequently the cyst descends into the posterior cul-de-sac, and by 
the touch its rounded surface, resistance, mobility and fluctuation may 
be appreciated. But even fluctuation is not a positive sign, since it may 
be simulated by a softened fibroid. The differential diagnosis in the case 
of a solid tumor of the ovary, that had descended into the retro-uterine 
pouch, would be still more difficult, not to say impossible. 
3. Extra-uterine Pregnancy.-The tumors in the two cases are alike in 
their attachment to the uterus,their continuous growth, and in the fact that 
localized pains, spontaneous, and on making pressure, are common to 
both conditions; in both cases there may be hemorrhage. But an extra- 
uterine pregnancy is more elastic to the touch, the foetal parts seem to 
be situated just beneath the skin, and, above all, while in pregnancy 
complicated with fibroid, the uterus and the tumors develop simultane- 
ously, in cases of extra-uterine foetation the uterus developes much less, 
and it is sometimes easy to distinguish a distinct division between the two 
tumors. 
Complications.-During pregnancy, there are neuralgia, cramps, ob- 
struction of the circulation, oedema, vesical and rectal disturbances, ascites, 
etc., all of which are referable to mechanical pressure; morbid changes in 
the tumor ma^ lead to hemorrhage or peritonitis. During labor prolapse 
of the cord, or of foetal parts, rupture of the uterus, etc., may occur. 
Retention of the placenta, inversion of the uterus, and hemorrhage, fre- 
quently complicate the third stage. 
Treatment.-Forbid marriage and conception in every case. During 
pregnancy oppose the threatening abortion, and do everything to prolong 
the pregnancy until term. Surgical interference is limited to small ses- 
sile or pediculated growths, situated in the inferior segment and accessible 
through the vagina; the latter form being removed with the ecraseur, 
the former excised. Induced abortion, as well as Porro's operation, 
should be rejected, especially before term. During labor, allow nature 
as large an opportunity as is possible, then reduce the size of the foetus, 
or try to enucleate the tumor. Tarnier prefers version, Depaul the forceps. 
Susserott reports 20 forceps deliveries and 20 versions out of 147 cases, 
12 mothers and 7 children being saved by the former method, 8 mothers 
and 3 children by the latter. Out of 26 forceps deliveries, reported by 
Lefour, 19 mothers and 13 children were saved. The forceps seem, 180 
A TREATISE ON OBSTETRICS. 
then, to give better results than version. But, in some cases forceps or 
version do not avail, and we are obliged to have recourse either to the 
cephalotribe or to embryotomy. Finally, as a last resort, we have Caesa- 
rean section. Cazin noted 24 deaths in 28 operations, only 15 children 
being saved; hysterectomy has been performed 5 times with 5 deaths. 
Chahbazian resumes, in the following table, the results of treatment of 
fibroids of the cervix during pregnancy and labor: 
Mothers Died. Infants Died. 
8 Extirp. during pregnancy, 1 3 
32 Expectation, . . 9 (2 not noted) 14 (11 not noted) 
3 Pushed up during labor, 1 
12 Extirp. " " 1 . . 5(2"") 
5 Forceps, ... . . ( 2 " " ) 
3 Version, . . . 1 . . 1(1"") 
2 Manual Extraction . 1 
1 Blunt hook, 1 1 
5 Embryotomy, . . 3 5 
G Caes. section, . . 5 . . 3(1"") 
17 Extirp. after delivery, 4 
4. During the Puerperium.-Fibromata which have escaped detection 
during pregnancy by reason of their being flattened, often appear after de- 
livery, inconsequence of sub-involution. Interstitial or sub-serous tumors 
with broad bases then become pediculated and may be palpated, but, as 
a rule, the tumors undergo atrophy similar to that of the uterus, so that 
they may even disappear entirely. Sometimes it has been observed that 
fibroid tumors are enucleated and expelled from the uterine cavity; in 
other cases the tumor has sloughed away. Hemorrhage, retained placenta 
and consequent septic absorption, serious nervous troubles, syncope, peri- 
tonitis, inversion of the uterus, eclampsia, and rupture of the bladder, 
are among the resulting complications. Interference during convalescence 
depends upon the condition of the tumor, the nature of the complications, 
and the general state of the woman. 
VII. Her nice. 
It is extremely rare for the uterus to escape by one of the natural open- 
ings of the abdomen, such as the inguinal or crural, so as to form a true 
hernia. According to Schroeder, umbilical and ventral herniae are most 181 
MATERNAL DYSTOCIA. 
common. True ventral hernia of the gravid uterus is very rare; there 
are on record, however, a number of cases in which the uterus at an ad- 
vanced stage of pregnancy was situated in a hernial sac, formed by the 
dilatation of a large cicatrix in the abdominal wall. A few cases are on 
record in which pregnancy advanced to term in a uterus which formed a 
crural or inguinal hernia. The diagnosis of hysterocele is difficult dur- 
ing the first half of pregnancy, when the portio vaginalis is outside of 
the hernial sac; at a later stage the disturbance of micturition, the dis- 
placement of the urethra, and the movements of the foetus, help to clear 
up the diagnosis. 
The treatment consists in the reduction of the hernia, and, if this is 
unsuccessful, in the induction of abortion, and in the use of version or 
the forceps. But, in the majority of the known cases, the termination 
of the labor per vias naturales has been impossible, and it has been neces- 
sary to resort to Caesarean section. 
VIII. Ovarian Tumors. 
Although the possibility of conception is admissible a priori in cases in 
which only one ovary is affected, whatever may be the size of the tumor, 
it is difficult to understand how it can occur when both ovaries are dis- 
eased, and yet the facts reported by Atlee, Spiegelberg and others, prove the 
possibility of conception under these conditions, and with ovarian tumors 
of different kinds. The following statistics of Jetter show that any vari- 
ety of ovarian tumor may complicate pregnancy. Out of 166 cases, there 
were 97 ordinary cystomata, 31 dermoid cysts, 11 carcinomata and 27 un- 
certain. In most of the cases the tumors existed for some time before the 
occurrence of pregnancy; the latter has taken place where one, or even 
both, of the ovaries was diseased, and this proves that as long as a portion 
(no matter how small), of the ovary remains in a healthy condition, ovu- 
lation and conception are possible. 
The Influence of Pregnancy on ovarian Tumors.-Although this influ- 
ence is usually nil, or at least insignificant, in a number of cases the 
tumor undergoes marked changes. Spiegelberg affirms that under the 
influence of pregnancy, and the increased activity of the pelvic circula- 
tion, ovarian tumors often grow with extreme rapidity. Wernich not 
only adopts this view, but also believes that under the influence of preg- 182 
A TREATISE ON OBSTETRICS. 
nancy, a benign growth may become malignant, huge explains the lat- 
ter change by supposing that a malignant element was originally present. 
Doumairon has called attention to the frequency with which localized peri- 
tonitis developes in consequence of the friction of the cyst against the ab- 
dominal walls, the intestines, and uterus, as well as to the changes and 
inflammations that may take place within the cyst. He has even reported 
rupture of the cyst and escape of the contents into the abdominal cavity, 
and some rare cases in which, in consequence of inflammation, cysts have 
discharged spontaneously, either externally, or into one of the pelvic vis- 
cera. Simple cysts are most frequent, and dermoid the next; the latter 
are most influenced by pregnancy, since, on account of their relatively 
smaller size, they occupy the true pelvis. 
The Influence of Cysts on Pregnancy.-The size of the cyst does not 
usually have any considerable influence on pregnancy, as long as it is non- 
adherent, and has a pedicle sufficiently long to allow of its floating freely 
in the abdomen. If the tumor is small, it nearly always lodges in the 
posterior cul-de-sac, especially at one side; if not adherent, it rises into 
the abdomen with the uterus. If, on the contrary, it is a solid growth, 
and contracts adhesions that keep it within the pelvis, it gives rise to 
symptoms of incarceration on the part of the uterus, with compression 
of the bladder and rectum. When the cyst has risen out of the pelvis, 
it occupies one side of the abdomen, while the uterus occupies the other, 
so that two distinct tumors are felt on palpation, the character of each 
being so distinct as to allow of an exact diagnosis; the abdomen is then 
enormous, and oedema, ascites, varices, disturbances of respiration, etc., 
result. Again, the cyst may be situated in front of the uterus, so as to 
conceal the development of that organ, and thus to deceive the physician. 
The Influence of Cystic Tumors on Delivery.-They often cause dysto- 
cia, so that interference becomes necessary. If the cyst is small and fluid 
and non-adherent, with a pedicle more or less relaxed, it is generally 
pushed upwards above the superior strait, and does not descend into the 
pelvis again till aftei- delivery. If it is of large size, but is fixed in the 
abdomen, obstruction occurs only when a portion of the cyst is at the 
same time engaged in the pelvis; it is then imprisoned between the head 
of the foetus and the pelvic wall, and thus forms a direct impediment to 
the expulsion of the child. Ordinarily, these cysts act indirectly by caus- 
ing oblique deviation of the uterus and mal-presentation of the foetus. 183 
MATERNAL DYSTOCIA. 
and by interfering with the strength and regularity of the uterine con- 
tractions. If the cyst occupies the pelvis, the case is different; such cysts 
are originally located in the posterior cul-de-sac, and before they grow 
sufficiently to fill the entire pelvis, they are more or less fixed by adhe- 
sions, and thus form a more or less complete obstruction of the canal. 
Sometimes the foetal part will tend to push the tumor before it, but the 
Fig. 142.-Ovarian Cyst Obstructing Delivery. 
efforts of the uterus will be ineffectual; or the tumor may prevent tl» 
foetal part from engaging, and keep it above the superior strait, when 
compression will take place. (Fig. 142.) Hemorrhage, rupture of the 
cyst, etc., have occurred, as well as bruising and inflammation of its walls, 
but the patients in these cases have all recovered. 
The Influence of the Cyst on the Piierperium.-Cases are on record in 
which women have died of exhaustion from the length of the labor, some 184 
A TREATISE ON OBSTETRICS. 
(lays after delivery; incontinence or inflammation may occur. Rupture 
and inflammation of the ayst have been noted. 
Diagnosis.-When the existence of tumors is unknown before concep- 
tion, they may escape recognition after the uterus has become enlarged. 
If the cyst is small and is situated in the pelvis, the diagnosis may be es- 
tablished by the vaginal touch, as fluctuation will thus be detected. But, 
if the tumor is harder and more resistant, it may be mistaken for peri- 
uterine ha?matocele or a fibroid. It is only in the early months that it 
could be confounded with retroversion of the uterus. If pregnancy is 
recognized and is already advanced, the diagnosis in cases of intra-pelvic 
cysts may be very difficult. Such a cyst will distend the posterior fornix, 
rendering it so tense that the consistence of the tumor can only be im- 
perfectly made out; however, as a rule, there is more or less distinct fluc- 
tuation, so that an hsematocele alone could be mistaken for a cyst. But 
hsematocele has never been observed during pregnancy, so the diagnosis 
is simplified accordingly. If the tumor is above the superior strait, the 
distension of the vaginal walls sometimes renders palpation very difficult, 
and the touch does not give much information; if the growth is in the 
false pelvis, it may be situated in front, or at the side of the uterus, the 
organ being more or less displaced, according to the size of the tumor. 
In exceptional cases a groove of separation can be recognized between 
the two tumors. Even where fluctuation is not obtained, the peculiar 
elasticity of the tumor, and its location to one side of the uterus, throw 
light upon the diagnosis; moreover, with the exception of hydramnios, 
ovarian tumors alone cause such distension of the abdomen. In hydram- 
nios, prolonged palpation will usually establish the presence of uterine 
contractions, which are not present in the ovarian growth; puncture 
may be resorted to when a positive diagnosis is necessary. 
Prognosis.-This depends absolutely on the size, location, and character 
of the tumor, and the operative procedure. Doumairon reports 41 cases, 
25 mothers and 17 children surviving; Litzmann 56 cases with 24 mater- 
nal deaths; Jetter 215, with 64 deaths, and Playfair 56, with 23 deaths. 
During recent years the number of successful cases has somewhat in- 
creased. 
Treatment.-Lomer lays down the following rules: 1. In labors com- 
plicated with ovarian tumors, interference should not be long delayed. 
2. In all cases we should first try to reduce the tumor, resorting to punc- 185 
MATERNAL DYSTOCIA. 
ture if this fails. 3. When the cyst-contents is too thick to flow through 
the canula, the cyst-wall should be freely incised. 4. All other operative 
procedures employed instead of evacuation of the cyst should be regarded 
as too dangerous, and should be rejected. 5. In the case of solid ovarian 
tumors, we have the choice between Caesarean section and perforation. 
The decision will depend upon the peculiarities of the case and the con- 
science of the accoucheur. 
According to Olshausen, the indications for interference during preg- 
nancy are threatening asphyxia, intestinal obstruction, inflammation or 
rupture of the cyst, and twisting of the pedicle. Three courses are open 
to the obstetrician, premature delivery or abortion, puncture, and ovari- 
otomy. 
1. Premature Delivery.-This has been advised by Barnes, and has 
been adopted by Doumairon, but the latter only recommends it when the 
tumor is lodged in the pelvis, and has solid or semi-solid, contents, as in 
the case of dermoid cysts; if the growth is small, we should prefer pre- 
mature delivery to abortion. 
2 Puncture.-Spencer Wells greatly prefers this to the premature in- 
terruption of pregnancy, since by the latter method the child is sacrificed, 
and the mother's life is often jeopardized. When puncture is employed 
during the latter months or weeks of pregnancy, the relief experienced is 
often very marked; the procedure is usually free from the danger of 
wounding the uterus, which is only present when the pregnancy is unsus- 
pected. It is especially indicated in cases in which the excessive distension 
of the abdomen causes dyspnoea and threatening asphyxia, or where abor- 
tion is imminent by reason of the pressure on the uterus. .It may be 
necessary to repeat the puncture several times. 
3. Ovariotomy has been performed several times during pregnancy by 
Marion Sims, Atlee, Wells, and others (9 cases); in one instance Wells 
accidentally punctured the gravid uterus, the patient being saved by 
Caesarean section, and Hillas had a similar experience. Braun and 
Schroeder reported 14 cases, in 4 of which pregnancy was not suspected. 
In 9 or 10 cases the operation was performed in consequence of actual or 
threatening rupture or inflammation of the cyst. Pregnancy was inter- 
rupted in only four instances. [Quite recently, Mundt successfully per- 
formed ovariotomy at the fourth month of pregnancy without interrupting 
its course.-Ed.] 186 
A TREATISE ON OBSTETRICS. 
[Stratz has published a number of clinical observations in regard to 
the complication of pregnancy by tumors, the statistics of the Berlin 
Clinic for ten years being used. During this period there were nineteen 
cases of ovarian tumors, 14 of the women being saved by ovariotomy, and 
3 of these subsequently aborted. Among 84 cases of ovariotomy during 
pregnancy, the mortality was only 9.5 per cent. He advocates strongly 
this operation in every instance, since the induction of labor sacrifices the 
child, and does not free the mother from the subsequent risks of ovario- 
tomy, which are shown by the statistics quoted to be actually graver in the 
non-pregnant than in the pregnant female. Puncture of the cyst, he 
believes, offers no advantages over the radical operation, while it compli- 
cates the subsequent removal of the tumors. 
These views we believe will fairly represent the opinion held by the 
majority of obstetricians on this side of the Atlantic.-Ed.] 
In 1882 Cayla affirmed that ovariotomy may be performed during preg- 
nancy under two very different circumstances: 1. When the condition 
of the cyst is such as to render us fearful that some accident may occur. 
2. When some accident has occurred during gestation, sufficiently serious 
to make radical interference necessary. During pregnancy the accidents 
that may occur are rupture of the cyst, twisting of the pedicle, inflamma- 
tion and suppuration. During delivery the cyst may rupture in conse- 
quence of the uterine contractions, during the second stage; finally, dur- 
ing the puerperium, inflammation and suppuration of the cyst may take 
place. 
Heiberg divides the tumors, as regards treatment, into two classes, viz.: 
1. Those that occupy the pelvis. In this case we should endeavor to 
reduce it from the middle of pregnancy on; if not successful, we should 
puncture if fluctuation is present, or perform ovariotomy if the former 
procedure is contra-indicated, otherwise premature labor may be induced. 
2. When the tumor is abdominal, we should interfere if it developes rap- 
idly, and causes severe pain. Ovariotomy should be resorted to during 
the first half of pregnancy, puncture during the second half. Never 
induce premature labor in these cases. Among 52 cases of ovariotomy 
during pregnancy, the uterus was punctured six times; the mortality in 
the remaining 46 cases was 15 per cent, for the mothers, and 50 per cent, 
for the children. In 18 of the operations pregnancy was not suspected. 
Olshausen says that there is no indication for interference during preg- 187 
MATERNAL DYSTOCIA. 
nancy, when the tumor- is evidently a simple cyst of slow growth and not 
attended by much disturbance. A rapidly-growing cyst, which threatens 
to rupture, should be removed at once, unless it is firmly adherent, when 
it should be punctured. The pregnancy ought not to be interrupted ex- 
cept in those rare cases in which ovariotomy is impossible, puncture im- 
practicable, and in which the irreducible tumor becomes a serious obsta- 
cle to delivery, that is in almost all cases of irreducible solid and dermoid 
cysts, located in the true pelvis. 
During labor, we should also be guided by the same rule, to temporize 
as long as there is no immediate danger. But there is a method which 
we should always try, because it is very simple, and is generally free from 
danger-that is, the displacement of the tumor, especially when it is solid, 
to the side of the abdomen. If this does not succeed, we should try 
puncture through the vagina, or the rectum, the former being preferred. 
Ovariotomy during labor is not practicable, and the removal of the tumor 
through the vagina, as advised by Merrimann, would not give any better 
results; we must then resort to dilatation of the cervix, and interference 
with the forceps, version, cephalotripsy, and embryotomy, according to 
the cases, or the Caesarean operation. Olshausen rejects the forceps, on 
account of the danger of rupturing the cyst, and prefers version to it, as 
being a little less dangerous. Litzmann reports 5G deliveries, 32 mothers 
and 7 children saved; in 10 cases, in which delivery was spontaneous, 5 
mothers, and one child lived; in 7 in which the tumor was displaced, G 
mothers and 2 children survived. 13 out of 17 mothers were saved by 
embryotomy. Playfair has also collected 57 cases, in 13 of which delivery 
was spontaneous, resulting in the death of 6 mothers and 5 children; in 
all of the cases (9) in which puncture was resorted to, all of the mothers 
and two-thirds of the children were saved. 8 out of 15 women survived 
after embryotomy, 1 out of 5 after version, and 1 out of 2 in forceps de- 
liveries. 
IX. Tumors of Various Kinds. 
Carcinomata, fibromata, and ovarian tumors are not the only ones that 
may become causes of dystocia, and there are a certain number of other 
growths that have opposed serious obstacles to delivery by obstructing, more 
or less, the pelvi-genital canal. Among these are carcinoma of the vagina, 
tumors of the Fallopian tube,(hydro-salphinx), fibroma, carcinoma, etc., of 188 
A TREATISE ON OBSTETRICS. 
the pelvic cellular tissue, haematocele, hydatids, pelvic abscess, lithopsedia, 
enchondroma, vaginal cysts and tumors of the rectum. With regard to these 
different varieties of tumors, Naegele and Grenser remark, "these tumors 
have exactly the same influence on labor as ovarian cysts; their location 
is invariably the same, i.e., between the vagina and rectum, and it is often 
difficult, or even impossible, to distinguish between the two kinds of 
tumors. However, the differential diagnosis is of no practical impor- 
Fig. 143.-Osteosteatome of the Pelvic Cellular Tissue. (Lenoir.) 
tance, except in so far as regards the question of extirpation, because the 
other indications are precisely the same. We empty the cysts by punc- 
ture or incision, according to the consistency of the contents, then leave 
the delivery to nature, or, if necessary, terminate it artificially. Large solid 
tumors sometimes leave no choice between extirpation, embryotomy, or 
Caesarean section. Extirpation, although it is one of the gravest and 
most difficult of operations, is sometimes successful. 
X. Rupture of the Uterus. 
Rupture during pregnancy, and especially at the beginning, is rare; 
after the fourth month the uterus is exposed to injury through the ab- 
dominal wall, and rupture then becomes more frequent. Sometimes 
rupture occurs spontaneously, under the influence of recent and acute 
uterine lesions; the affected regions sometimes become so soft that they are 
less resistant than healthy tissue, and yield to the least muscular effort, 
or to external pressure exerted upon the uterus through the abdominal 
wall; cicatrices from former lesions may yield in like manner. Blows, 189 
MATERNAL DYSTOCIA. 
falls, etc., or even compression \>y contre-coup, are among the direct causes. 
Among recorded cases, we would note Corigue's case of wound of the 
uterus at the eighth month, Dionis at G months, Saxtorph at 7, Hohl 
at 5, Pigne at 8, Gueniot at 8, Geissler at 9. In 1868, Trask collected 
12 cases of rupture of the uterus during the first six months with recov- 
ery, and 26 after the sixth month with death in many of the instances. 
[Since Trask's report, the instances have multiplied to such an extent 
that it is impossible as well as unnecessary to cite them.-Ed.] 
The symptoms of rupture vary somewhat according as the accident takes 
place during the first four months of pregnancy, or after that time. In the 
former case the woman has a severe shooting pain in the lower part of 
the abdomen; at the same time a tearing sound is heard within the belly, 
the face becomes pale and is bathed in cold perspiration, the pulse is rapid 
and feeble; hiccough, vomiting, convulsions and syncope appear, the ab- 
domen becomes distended, hard and tender, the cervix is hard, and there 
is usually no external hemorrhage. The woman usually dies soon after 
the occurrence of the rupture, or she may succumb to subsequent peri- 
tonitis. From the fifth month on, the first symptoms after the accident 
are the same as in the former case, but, as the child often escapes into 
the abdominal cavity, special symptoms result. Aside from the fact that 
there is always hemorrhage in these cases, the shape of the abdomen be- 
comes altered, the foetal parts are felt, and the movements are often seen; 
by the touch changes are noted in the condition of the cervix and in the 
shape of the uterus. Finally, in wounds of the uterus, we find escaping 
from the wound blood and amniotic fluid, and in some instances the rent 
has been large enough to permit the escape of the entire foetus. Trask 
has only collected 12 cases of recovery. 
II. Ruptures during Labor. 
These may be complete or incomplete, according as they involve the 
entire thickness of the organ, or only extend to the peritoneal covering; 
they may extend to the vagina. It is only when they extend beyond the 
os internum that they become serious. They may be spontaneous or in 
consequence of obstetrical manipulations; the former are of most interest 
to the obstetrician, because the latter are nearly always preventable. 
Opinions vary regarding the frequency of this accident. The average* 190 
percentage, as estimated from the statistics of upwards of 30 different 
writers, and representing over 3,000,000 cases of labor, was 1 in from 
2000 to 4000. In 573 cases of rupture, Jolly found that 376 were spon- 
taneous, and 197 traumatic. 
Causes.-These are predisposing and determining. Most authors ad- 
mit the influence of multiparity. Among 1164 cases of rupture collected 
by various authorities, 616 occurred in multiparae. In consequence of 
child-bearing the uterine walls are softened, fatty degeneration resulting 
from repeated pregnancies, with consequent weakening of the power of 
the uterus, prolongation of the labor, and (according to Scanzoni), greater 
frequency of trunk-presentations. 
Duration of Labor.-Simpson's statistics show that when labor extended 
beyond twenty-four hours, there was one case of rupture in 38, but when 
it lasted only 6 hours, there was but one case in 2000. Trask found the 
mean duration of labor in 57 cases of rupture to be 21 hours and 6 min- 
utes. 
Contraction of the Pelvis.-Trask noted the presence of contraction in 
74 per cent, of 300 cases of rupture. The accident seems to be more 
common where the contraction is only moderate, as when the narrowing 
is excessive the cervix is always above the brim of the pelvis, and, as the 
foetal part can not engage, there is no chance for compression of the uterus 
against the bone. Rupture is said to occur more frequently with male 
infants. 
Thinning of the Uterine Wall.-This was noted by Trask in 14 out of 
49 ruptures; by Wilmart, in 21 out of 100. Softening from metritis, 
fatty degeneration, malignant disease, etc., is another cause. Cicatrices 
in the uterine walls, from former wounds, Caesarean section, etc., have 
been noted in some cases. Rigidity of the cervix, uterine tumors, etc., 
may be causes. Hydrocephalus in the foetus was noted as a cause by 
Keith in 16 cases out of 64, by Bandl in 2 out of 13, by Hohl in 5 out of 
77. Excessive size of the foetus was a cause in 10 out of 63 cases reported 
by Kormann. Presentations of the shoulder are especially unfavorable; 
they were observed 14 times in 84 cases. Unusual development of the 
fundus uteri, and malformations of the organ have given rise to the ac- 
cident. The immoderate use of ergot is a fruitful cause. 
Traumatic ruptures are mostly due to blows and to version. Among 
197 cases of traumatic rupture, 71 followed version, 37 the employment 
A TREATISE ON OBSTETRICS. 191 
MATERNAL DYSTOCIA. 
of the forceps, 10 cephalotripsy, and 30 other unwise manipulations. 
Many writers claim that rupture may take place before the membranes are 
ruptured. 
Pathological Anatomy.-Location.-The posterior wall of the inferior 
segment is the most common locality, and next to this the lateral walls, 
especially the left. The rupture is usually single, but may be multiple; 
Fig. 144.-Rupture of the Uterus. 
there may be simply a perforation of the uterine tissue, but more com- 
monly the lesion presents a considerable extent (3 inches and more); 
sometimes the uterus is almost completely detached from the vagina, or 
the rent may extend from the inferior segment to the fundus, involving 
also the cervix, vagina, rectum, or bladder. As a rule the peritoneal 
layer is not involved, being merely detached by the extravasated blood; 192 
A TREATISE ON OBSTETRICS. 
rarely the peritoneum is torn, while the other layers are intact. The 
foetus may remain in the uterus or escape into the cavity. The rent 
may be vertical, transverse, or oblique, generally with irregular edges. 
The blood escapes into the abdominal cavity, and spreads beneath the 
peritoneum. 
Mode of Production.-Three theories have been advanced: according 
to the first, the uterine contraction is the sole cause of the rupture, while 
the second refers the accident to obstetric manipulations, and according 
Fig. 145.-Disproportion between the Body of the Uterus and the Cervix in Presentation 
of the Vertex. Threatening Rupture to the Left. 
to the third rupture is due to the compression of the uterine tissues be- 
tween the foetal head and the pelvic wall, thus producing softening and 
gangrene. According to Bandl's theory the cervix retracts above the 
foetal head after complete dilatation, this retraction being produced by 
the combined muscular contraction and the elasticity of the tissue. In 
primiparae, during the stage of dilatation, there is the greatest develop- 
ment of the uterine force for the purpose of expelling the child. The 
external muscular layer in contracting both exerts a. concentric action on 
the contents of the uterus, and tends to draw the, uterine wall upwards 
over the foetal ovoid. The concentric pressure then tends to engage 
the child in the cervix, and it is only when the cervix is greatly distended MATERNAL DYSTOCIA. 
193 
by the fcetal part that the second factor becomes active, that is to say, 
the elasticity of the cervix, which causes it to retract above the head. 
When there is no obstacle offered to this ascension of the cervix, there 
occur in primiparae only those small, insignificant lateral tears which are 
observed in the portio vaginalis, and which may sometimes be entirely 
absent. When the relations between the head and the pelvis are not quite 
normal, delivery is somewhat more difficult, and the lacerations of the 
cervix are deeper. As a rule the anterior wall of the cervix is, so to speak, 
Fig. 146.-Disproportion between Body and Cervix of the Uterus in a Case of 
Hydrocephalus. 
imprisoned between the head and the pelvis, at a level more or less ele- 
vated, and the head in descending pushes the cervix downwards and dis- 
tends it at that point which we see appear at the vulva as a bluish or red- 
dish swelling. More extensive tears sometimes take place in this case, 
especially where small ones existed before, because, as the head is forced 
downward, and the muscular contraction acts in an upward direction, 
both forces act upon the cervix, the posterior wall of which is already re- 
tracted over the head, while the anterior is still impacted. Bandl has 
Vol. III.-13 194 
A TREATISE ON OBSTETRICS. 
often observed under these circumstances lacerations of the cervix, in- 
volving one-half of the cervix and the internal layers of the same, with- 
out causing the death of the women. These lacerations may also be pro- 
duced when the foetus is extracted after version, especially incases of con- 
tracted pelvis. 
Rupt/ure of the Cervix.-Fatal ruptures are usually spontaneous, and 
only result when by reason of the contraction of the pelvis, the excessive 
size of the head, or its failure to engage, delivery is retarded, and the cer- 
vix is greatly distended above the pelvic brim. Rupture takes place when 
Fig. 147.-Disproportion between Body and Cervix Uteri in Presentation of the Shoulder. 
the os internum is situated obliquely above the superior strait, or when it 
has ascended in such a marked manner that the uterus envelopes the 
foetus like a hood. (Figs. 145 to 148.) As soon as this condition of affairs 
exists, the uterus does not tear, as it is extremely difficult for it to rup- 
ture, no matter what operative manoeuvre may be undertaken. At any 
instant, however, the cervix may rupture in consequence of either a 
strong contraction or operative interference; but version is especially liable 
to lead to rupture, an accident that may happen to the most skillful 
accoucheur, if he fails to recognize the condition of affairs, or interfere in 
spite of them. In primipara?, as long as the head remains high up. the 
uterus contracts for many hours without deviating from its normal posi- MATERNAL DYSTOCIA. 
195 
tion. It is only when its force has been exercised for a long time to no 
purpose, that the abdominal muscles cease to contract, and can not in 
consequence fix the uterus at the level of the superior strait; all the effect 
of the contraction then becomes confined to the cervix. The body and 
fundus of the uterus tend to ascend higher and higher above the head 
and body of the foetus; the elastic cervix, consequently, becomes exces- 
sively distended and is impacted between the head and the brim. This 
condition is rare in primipara?, hence the infrequency of rupture. In 
multiparae the distension of the cervix will take place sooner, and in con- 
Fig. 148.-Disproportion between the Body and the Cervix in Presentation of the Shoulder. 
sequence the conditions will also be present that favor rupture. Bandl's 
theory can really be summarized as follows: Whenever a moderate ob- 
stacle (contracted pelvis, transverse presentation) is opposed to the expul- 
sion of the foetus, the uterine contractions, persisting in the body of the 
organ, and being no longer counterbalanced by the resistance of the sur- 
rounding parts and abdominal muscles, will act directly on the cervix. 
The os internum will be drawn above the superior strait, over the foetal 
part, and the uterus will be divided into two portions, the upper being 
formed by the fundus and body, and the lower by the cervix, in which 
the foetal part will be more or less engaged. These two portions will be 
separated by a groove, formed at the level of the os internum, which will 196 
A TREATISE ON OBSTETRICS. 
become more and more apparent at each contraction. While the body 
and fundus will tend to become thicker and smaller, the cervix, on the 
contrary, will become more and more distended, and will become thinner 
in proportion to this distension. It is evident, then, that the latter por- 
tion may become so thin that at a given time it may rupture, this rupture 
beginning at the cervix, and extending upwards until it affects the tissue 
of the corpus uteri. (Figs. 145 to 148.) 
Symptoms.-Rupture usually takes place suddenly during the expulsive 
stage, and without any previous warning. During a contraction, or some 
obstetric manoeuvre, the woman is seized with a sudden agonizing pain, 
which differs entirely from that which accompanies labor; the pain is 
accompanied by a sensation of tearing and sometimes by a dull sound, ap- 
preciable to the bystanders, as well as to the patient herself. If the wound 
is sufficiently large to permit the escape of the child into the abdominal 
cavity, she has a sensation of displacement. The uterine contractions 
cease, either at once or quickly, and the intermittent pains are succeeded 
by a steady pain in the lower part of the abdomen. At the same time the 
facies is altered, and becomes pale, the skin is bathed in cold perspiration, 
the pulse becomes small and imperceptible, and attacks of syncope en- 
sue, accompanied by nausea and vomiting. Then appear dyspnoea, ring- 
ing in the ears, and convulsions. The shape of the abdomen is changed, 
the uterus is extremely sensitive on pressure, and, if the child has escaped 
into the abdomen, the foetal parts are clearly felt through the abdominal 
wall. Then the belly becomes tympanitic, blood escapes from the vulva, 
either pure or sanious, according to the time that has elapsed since the 
occurrence of the accident. On examination it will be found that the 
part which presented at the superior strait has either disappeared or has 
been replaced by another, while on the introduction of the hand, or even 
the finger alone, the site of the rupture may be detected, and thus the 
diagnosis may be established directly. Sometimes a deceitful calm suc- 
ceeds this grave condition, while at the same time a mild sensation of heat 
is diffused throughout the abdomen, but the alarming symptoms soon re- 
appear, and death ensues either rapidly, or more slowly, from consecu- 
tive peritonitis. 
According to Jolly, among 580 cases of rupture, the contractions ceased 
in 256, there was external hemorrhage in 148, collapse in 179, vomiting 
in 147, retraction of the presenting part in 146, and abdominal pain in MATERNAL DYSTOCIA. 
197 
133; the foetal limbs could be felt through the abdominal wall in 77 
cases. 
There are certain other signs that deserve attention, viz.: a tearing 
sound, heard by the patient and bystanders, violent movements of the 
foetus, followed by sudden cessation of the heart-sounds, and change in 
the shape of the abdomen, the uterus and the escaped foetus each forming 
a tumor, with a furrow between them. Several writers have called atten- 
tion to the development of fluctuation and emphysema. Hemorrhage is 
constant, and may be internal, external, or mixed; if it is purely inter- 
nal, it sometimes escapes recognition. At other times the blood collects 
at one point, and forms a hypogastric tumor. According to Hervieux, 
the loss of blood will be slight when the distension is confined to the cer- 
vix and its vicinity, where there are few vessels, when the foetal part is 
so engaged in the wound as to compress the vessels, and when the entire 
contents of the uterus has escaped into the abdomen, thus allowing the 
organ to retract completely. The hemorrhage will be profuse if the rup- 
ture occurs at the placental site, so that the placenta is stripped off, and 
if the uterus is in a state of inertia. In some instances, symptoms are 
absent, and the rupture may not be recognized, as in 37 cases collected 
by Jolly. But there are unusual phenomena which awaken suspicion, 
such as fixed pain, vomiting, recession of the presenting part, and sud- 
den or gradual cessation of the contractions, that are not explained either 
by the course of the labor or by the general condition of the patient. But 
there are many cases in which the presentation is not altered, and the 
uterine contractions continue. Labor has sometimes proceeded, in spite 
of the rupture, until the child was expelled spontaneously. The persist- 
ence of the contractions has been explained in various ways, some believ- 
ing that the pressure of the foetus continues to irritate the uterus until it 
is expelled, after which the organ lapses into a condition of inertia, others 
affirming that the wound is the determining cause of the contraction, as 
long as it is not too extensive, while Tyler Smith thinks that the child is 
expelled by the same contraction that ruptures the uterus. The latter 
theory may apply to tears of the vagina and perineum, but not to those 
of the uterus. Bandl has given the true explanation of the mechanism in 
most cases, that is, where the rupture begins at the cervix and extends to 
the body. 
Prognosis.-This is extremely grave for both the mother and the child, 198 
A TREATISE ON OBSTETRICS. 
especially so for the latter, when it escapes into the abdomen. Franque 
reports 26 foetal deaths in 26 cases, Ramsbotham 217 deaths in 237 cases. 
Scanzoni explains the fatal result as due to the loss of blood, as well as to 
the severe nervous shock experienced by the mother, and by the strangu- 
lation of the cord or important parts of the foetus, in the retracting 
wound. The prognosis for the mother is less grave. 100 women recov- 
ered out of 580 cases collected by Jolly, 63 being saved out of 88 in which 
the child had escaped into the abdominal cavity. 
Treatment.-Three courses are presented to the obstetrician, expectation, 
extraction per vias naturales, and gastrotomy. 
1. Expectant Treatment.-This has been almost entirely abandoned at 
the present day, except in the case of rupture occurring during the early 
months of pregnancy; but, as soon as the pregnancy has advanced to the 
sixth month, the extraction of the foetus is positively indicated, especially 
if it is living. Out of 144 cases left to nature alone, 142 died, while out 
of 154 women "who were delivered by artificial means, 57 were saved. 
2. Extraction per vias naturales.-This is the usual procedure, and 
almost the only one adopted in France. If the child remains within the 
uterus, with the head presenting, delivery should be effected with the 
forceps or cephalotribe, according as the pelvis is normal or contracted; 
if these fail, version should be practised. In 75 forceps deliveries, with 
or without previous crushing of the head, 13 mothers were saved, in 85 
versions 15 were saved. If the child is partly or wholly outside of the 
uterus, Baudelocque advises the use of the forceps, if the wound is large 
and the pelvis normal; he reports 1 cure in 12 cases. Ramsbotham ad- 
vises version, and reports 45 cases with 33 deaths. If the wound is large 
and the pelvis narrow, we may resort to the forceps or to cephalotripsy; 
it is better to perform version and to puncture the head after it has been 
fixed. If the child is alive, gastrotomy is indicated; also when the child 
is partly outside of the uterus, and the wound has retracted, and extrac- 
tion can not be effected without employing great violence or enlarging the 
wound with a blunt-pointed bistoury. Gastrotomy is the only resource 
where the entire foetus has escaped into the abdominal cavity, and it is 
impossible to extract it per vias naturales, by reason of the contraction of 
the pelvis, the retraction of the wound, or uterus, or the resistance of the 
cervix; the foetus must first be extracted, then the clots and placenta. 
But if the extraction presents too many difficulties, it is better to leave 199 
.MATERNAL DYSTOCIA. 
the placenta to be detached spontaneously later. The statistics presented 
by Trask and Jolly appear to indicate that gastrotomy is the operation 
that gives the most successful results, the mortality, according to the 
former, being 24 per cent, as compared with 68 per cent, after version, 
and 38 per cent, after natural delivery. Jolly estimates the cures by gas- 
trotomy at 68.4 per cent., by version at 23 per cent., and after the use of 
the forceps 12 per cent. The time to interfere is as soon after the acci- 
dent as the condition of the woman permits, and we must afterward guard 
against peritonitis, by keeping the woman for some time under the influ- 
ence of opium, administered in full doses. 
[Dr. Malcolm McLean, of New York, has recently reported a case of 
partial rupture of the uterus, where he was able to perform podalic 
version. All of the child had escaped from the uterus except the head 
and one arm. The mother recovered, notwithstanding the formation of 
a large haematocele to the right of the uterus. 
McLean lays stress on the fact that in the above case the foetal envel- 
opes remained unruptured and thus protected the peritoneum from con- 
tact with liquor amnii, etc.-Ed.] 
XII. Ruptures and Lacerations of the Vagina. 
The vagina, as well as the uterus, may rupture spontaneously, or may 
be torn by the introduction of the hand, or by splinters and fragments of 
bone; the tears may be situated at the upper, middle, or lower part of the 
vagina. Those affecting the fornix, when very extensive, are often asso- 
ciated with rupture of the uterus, give rise to the same symptoms and 
call for the same treatment. Ruptures of the fornix, especially when 
spontaneous, are usually transverse, and the vagina may be entirely de- 
tached from the uterus. As in ruptures of the uterus, these tears may 
allow the complete or partial escape of the foetus into the abdominal cav- 
ity, but they are more frequently accompanied by prolapse of the intes- 
tine. When the tears occur at the middle or lower part of the canal, 
they often escape notice during labor, and are only recognized after the 
expulsion of the foetus. Although frequently fatal, they may, however, 
result favorably, even when the foetus has escaped into the abdomen. If 
not immediately fatal, they may cause para- and perimetritis, suppuration, 
more or less extensive gangrene, and consequent fistula?. Finally, lesions 200 
A TREATISE ON OBSTETRICS. 
of the vagina not infrequently result in consequence of prolonged pres- 
sure, whence vesico- and recto-vaginal fistulae. 
The child may usually be extracted per vias naturales, and hemorrhage 
becomes the accident that demands immediate attention. Injections and 
tamponing being naturally contra-indicated in these cases, we must be 
content with cold applications. In rare cases gastrotomy is advisable, as 
a last resort. Tears of the mucous membrane are usually of little impor- 
tance, and only require astringent and antiseptic injections. 
Ruptures of the vagina, although grave, are not by any means always 
fatal. Danyau records 4 recoveries in 17 cases, and McClintock in 51 
cases, 13 recoveries. 
Under this head are included all hemorrhages that may occur in the 
pregnant woman, from the cessation of the menses to their reappearance- 
in short, hemorrhages during pregnancy, labor, delivery, and the puer- 
peral state. The following varieties are to be distinguished: 
1. Hemorrhages during the first six months of pregnancy, or before 
the foetus is viable, which lead to abortion. 
2. Hemorrhages during the last three months, including those that 
occur during labor, which are invariably due to placenta praevia. They 
often compromise not only the existence of the pregnancy, but that of 
the mother and child. 
3. Hemorrhages during the third stage of labor. 
4. Secondary hemorrhages, occurring several hours, or days, after de- 
livery, and sometimes representing a return of the menses with too pro- 
fuse flow. 
1. Hemorrhages auring the first Six Months. 
We shall consider these briefly, referring the reader to the chapter on 
tc Abortion." 
. Causes.-The primary cause is pregnancy itself, which leads to general 
pelvic congestion, as well as to the various disturbances already mentioned 
at length. Two distinct conditions may exist, anaemia and plethora, both 
of which may lead to practically the same result; the former is really a 
serous plethora, while the latter, which is rare, is so to speak an active 
plethora. We must also bear in mind the peculiar alteration in the blood 
XIII. Puerperal Hemorrhages. MATERNAL DYSTOCIA. 
201 
that occurs during pregnancy. Under these different influences conges- 
tion may be produced, which leads to hemorrhage. But the menstrual 
congestion is also an active factor, especially during the early months of 
pregnancy; conception causes suppression of the monthly flow, but slight 
losses of blood are sometimes observed, especially during the first three 
months, which, on account of their coincidence with the usual time at 
which menstruation appears, seem to be related to that function. Nu- 
merous cases are on record in which women have menstruated through- 
out pregnancy; Elsaesser alone has collected 50 examples. This is not 
true menstruation, since the hemorrhage differs in quantity or quality, 
and would not be connected with the normal flow except for the coinci- 
dence in its appearance. 
Changes in the uterine mucous membrane or in the placenta constitute 
another cause of hemorrhage. The turgescence of the mucosa, which is 
present from the moment at which the ovum reaches the uterus, is in it- 
self a predisposing cause. During the third and fourth week the new 
utero-placenta vessels are so delicate that the slightest violence may sep- 
arate them and cause bleeding. After the second month the vessels are 
still larger, so that an injury or a sudden increase of the blood-pressure 
may cause rupture of a vessel and extensive extravasation. When the 
blood is effused in large quantities, it either collects about the seat of 
rupture, until the hemorrhage gradually ceases, or it extends to the os 
and escapes from it profusely and for a longer or shorter period. Again, 
the blood infiltrates the placenta and undergoes secondary changes (pla- 
cental apoplexy, or haematoma.) 
The hemorrhage may be of a venous nature, induced by obstruction 
of the vena cava inferior. 
The causes may be summarized as follows: menstrual congestion, ve- 
nous stasis (from general or local causes), mental shocks, straining, di- 
rect or indirect violence, imperfect development or attachment of the 
placenta, or separation of the same, inflammations or morbid growths of 
the uterus, acute febrile diseases, chronic toxic affections (syphilis, plum- 
bism), the use of abortifacients, diseases of the foetus or placenta, and 
finally abortion. [To these causes should be added the distinctive factors, 
erosions of the external os, lacerations of the cervix, mucous polypi, 
tumors of the cervix, intemperate coitus.-Ed. j 
Diagnosis.-As soon as we have ascertained the cause of the hemorrhage, 202 
A TREATISE ON OBSTETRICS. 
we have made the diagnosis. Erosion of the cervix is a very common 
cause of bleeding; it is usually confined to the posterior lip, and extends 
up the canal, and its origin is commonly referred to laceration of the cer- 
vix from a previous confinement, whether it terminated spontaneously or 
artificially. The discharge from the eroded surface is often hemorrhagic, 
but as these erosions often cause abortion, the apparent may give place 
to real bleeding. The important point to decide is, when does a hemor- 
rhage signify impending abortion, and when we are called to a case in 
which bleeding has continued for some time, does this bleeding result 
from a complete, or from an incomplete abortion? The treatment of 
these cases will be governed not only by our wish to preserve the ovum, 
but to guard the woman against both present and future harm. Abor- 
tion does not necessarily follow hemorrhage, and every obstetrician has 
observed cases in which neither the mother, nor the child, was injured 
by long and profuse bleeding. 
Treatment.-See chapter on Abortion. 
II. Hemorrhage during the last Three Months of Pregnancy, and during 
Labor.-Abnormal Insertion of the Placenta. 
What is abnormal insertion of the placenta? Portal (1685) was the 
first to show that the placenta might be inserted in the inferior segment, 
and over the os, and this was confirmed by numerous subsequent writers; 
but Baudelocque (1824) was really the first one to affirm that the fundus 
uteri was its normal site. Authorities differ as to its exact insertion, Scan- 
zoni placing it on the right postero-lateral wall, Naegele and Siebold on 
the left, Credo and Spiegelberg at the right upper angle of the uterine 
cavity, Carmichael at the inferior part of the posterior wall. Hegar 
affirms that it is attached most frequently to the posterior wall, and Gus- 
serow (from 188 observations) adopts the same view, in which he is joined 
by Schroeder and Bidder. Hennig (651 cases) found the placenta inserted 
in the superior uterine segment in 11 per cent. 
In order that its insertion maybe abnormal, the placenta must not only 
be attached to the lower segment, but it must be near the os, or rather, 
must partially, or entirely, cover it. Several varieties exist, viz.: 1. The 
placenta is inserted completely over the cervix, so that the os is entirely 
covered (total or central placenta prcevid). 2. The placenta is inserted at 
the lower segment, and over the cervix, so as to partially cover the os MATERNAL DYSTOCIA. 
203 
(partial). 3. It is inserted at the lower segment, so near to the cervix, 
that it slightly encroaches on it (marginal). Some authors (as Barnes) 
describe an intra-cervical insertion, which is rejected by Duncan and 
others. Marchal describes two varieties of "cervical pregnancy," one in 
which the ovum enters the cervix as soon as it reaches the uterus, and 
developes there, and the other in which the ovum developes in the cervi- 
cal cavity, and, after it has reached a certain size, passes into the cavity of 
the uterus, and there continues its growth; in the latter case the ovum is 
attached to the fundus by a pedicle sufficiently long to allow it to enter 
the cervix. Various local disturbance, hemorrhage and abortion, usually 
result from this abnormal condition. Several cases of this nature have 
been reported (five well authenticated). Marchal concludes: secondary 
cervical pregnancy is admissible, the ovum being attached to the fundus 
by a long pedicle formed from the decidua serotina, which allows its 
growth to continue; but no case is on record in which a new placenta has 
been formed in the cervical cavity. Primary cervical pregnancy is (foubt- 
less extremely rare. Wenzel has even sought to prove that complete cen- 
tral insertion of the placenta is impossible; it is certainly very rare, but 
well-authenticated cases have been reported. As a rule, only a portion 
(the smaller portion, according to Martin) of the placenta covers the os. 
Among 57 cases of this kind, it was inserted 44 times on the left and 19 
times on the right side; among 84 cases of marginal implantation, it was 
50 times on the right side and 34 on the left. Among 260 cases collected 
by various writers, 86 were examples of central and 165 of marginal inser- 
tion. Muller's statistics, founded on 1411 cases, are different, showing 
747 cases of central to 715 of marginal insertion, 31 of the women in the 
former and 59 in the latter case being primiparae. 
Pathological Anatomy.-Placenta praevia differs from the normally in- 
serted placenta in its form, as well as in the character of its tissue. While 
the latter has an average weight of between 16f and 20 ounces, a thick- 
ness of an inch, and measures about 7f inches in its greatest diameter, 
the former at term weighs hardly 16f ounces, and does not exceed 4 
inches in thickness. In most cases, a placenta praevia is extremely thin, 
and is elongated rather than oval in shape. The portion which presents 
is often dark red, and is thus distinguished from the rest of the placenta, 
which is pale and anaemic. As the placenta approaches the os the villi 
become small and scattered, and the portion corresponding to the cervix, 204 
A TREATISE ON OBSTETRICS. 
or its vicinity, is the softest of all. It is not rare to see part of it trans- 
formed into connective-tissue, or undergoing fatty degeneration, whence 
arise isolated cotyledons (placenta succenturiata); or it may spread out in 
such a way as to cover nearly the whole of the internal surface of the 
uterus. On examining the placenta, we usually find the cotyledons at 
the edge of the os flattened, and the placental tissue reduced to a sort of 
lamella, and heaped upon itself, as it were; under the microscope we rec- 
ognize fibrous metamorphosis and fatty degeneration of the cells of the 
villi. Apoplectic spots are frequently seen. The cord has usually a cen- 
tral, often a marginal insertion. Gendrin describes the changes in the 
placenta as consisting of a general softening of the tissue and its conver- 
sion into a homogeneous, reddish mass, which resembles the dependent 
portion of a congested lung, but is as fragile as the spleen. This change 
takes place when hemorrhage has occurred some time before, or during, 
parturition. In the zone adjacent to the central portion the placental tis- 
sue is condensed and is reduced to a dense, granular, homogeneous mass, 
of a yellow color, very fragile, and traversed by whitish filaments. In 
the midst of the tissue are small clots, which are intimately connected 
with the surrounding substance. The surface of the placenta, over the 
portions thus altered, often presents numbers of small, "white spots, slight- 
ly projecting, and resembling at first sight tubercles on the peritoneum in 
tuberculous peritonitis. The zone external to the one just described pre- 
sents a reddish tissue, in which is blood that has become coagulated and 
even incorporated with the placental tissue; this tissue itself is much 
softer and more friable than normal. The appearances differ according 
to the age of the changes, those near the centre of the placenta being 
most ancient and corresponding to the early hemorrhages. Aside from 
these alterations, lesions are produced in the placenta at the moment of 
expulsion; these appear as lacerations filled with coagulated blood, the 
ruptures radiating from a central point, as when a fragile body is crushed 
in the hand. 
Frequency.-Muller reports 813 cases of placenta prsevia among 876,432 
cases of confinement (1 to 1078), the greatest number occurring in patients 
between the ages of 30 and 35, the smallest between 13 and 19. 1347 out 
of 1574 women (observed by various authors) were multipart; among 691 
cases collected by Muller, 134 were primiparae, 114 II-parae, 70 Ill-parae, 78 
I V-parae, 54 V-para?, 42 Vl-parae, 48 VH-parae; 24 Xl-parse, 6 XIII-para?, MATERNAL DYSTOCIA. 
205 
etc. In general, causes that induce enlargement of the uterus favor ab- 
normal implantation. t 
Various explanations are offered to account for cervical implantation, 
such as the mobility of the uterus, the position of the woman during 
fecundation, the weight of the ovum (I), obliquity of the uterus, etc. 
Some affirm that the decidua developes at such a point in the cavity, that 
the ovule is attached abnormally when it reaches the cavity. Carmichael 
thinks that the placenta may become displaced from its normal position, 
through the general expansion of the uterus, and be pushed downwards 
and backwards. Schroeder admits that increased size of the uterine cav- 
ity, and an abnormally smooth condition of the mucosa, may favor abnor- 
mal insertion; increase in size is most frequent in multiparae, smoothness 
of the lining membrane is produced by previous leucorrhoeal discharges. 
Symptoms.-They almost never appear before the sixth or seventh 
month. Nearly all authorities agree on this point, that a hemorrhage 
which appears for the first time at this period, depends almost invariably 
on abnormal insertion, and, according to Naegele, it begins so much the 
sooner, according as the placenta covers the os more or less completely. 
When the implantation is marginal, hemorrhage may not occur until the 
end of pregnancy, or even the beginning of labor. Among 1,121 cases 
hemorrhage took place before the sixth month in 34, between the sixth 
and seventh in 53, during labor in upwards of 75. This hemorrhage ap- 
pears suddenly, without previous symptoms, often during the night, when 
the patient is asleep or perfectly quiet. Rarely she has colicky pains, or 
a feeling of discomfort in the loins for a few moments before the flow. 
The hemorrhage is always external, beginning gradually, and soon becom- 
ing more profuse, until a large amount is lost. It soon ceases, as it be- 
gan, without apparent cause. The blood has sometimes a venous, some- 
times an arterial hue, and has a marked tendency to coagulate. The flow 
ceases and may not return for from eight to fifteen days, or even longer; 
the patients have no special symptoms during the interval; then another 
hemorrhage occurs, as in the first instance, without appreciable cause, 
but more profuse and continuous than before. These phenomena may 
be repeated until labor begins, when the bleeding becomes so extensive as 
to place the woman's life in real danger. Intermittence is the distinguish- 
ing characteristic of the hemorrhage; anaemia, swelling of the face, gene- 
ral oedema, attacks of syncope, sometimes chills, fever and convulsions are 206 
A TREATISE ON OBSTETRICS. 
accompanying symptoms. The blood may collect to some extent in the 
interior of the uterus, but it is essentially external in character. Bal- 
lottement is absent in cases of placenta preevia, as the inferior segment is 
so much thickened by reason of the attachment of the placenta to it that 
the finger can not reach the foetal part. The presentation is often faulty. 
Thus Simpson records 21 transverse presentations among 90 cases of pla- 
centa prsevia, and Muller 272 among 1148. 
When labor begins and the cervix is sufficiently dilated to allow the 
finger to be inserted, the diagnosis is no longer doubtful. We feel at once 
the thick, rugose membranes, or even the edge of the placenta, easily 
recognized by its lobes and irregularities; great gentleness should be used 
during the examination, for fear of increasing the hemorrhage. Another 
sign is only observed after labor has begun, viz.: In accidental hemor- 
rhage the flow always stops during the contraction, but in abnormal in- 
sertion, on the contrary, it continues in the interval between the contrac- 
tions, and increases during each pain, as long as the membranes are intact. 
Mechanism.-Portal and Giffard attributed the hemorrhage to the dilata- 
tion of the cervix, and consequent laceration of the veins. Levret was 
the one who first advanced a true theory of this accident. The cervix, 
according to him, sharing during the latter months of pregnancy in the 
enlargement of the rest of the uterus, grows away from the placenta, 
which thus becomes detached, whence the early hemorrhages that inevita- 
bly recur during labor, because of the opening and dilatation of the cer- 
vix. This theory, though generally adopted, was based on erroneous ob- 
servations, and it was necessary to find another. Stoltz showed that the 
cervix remained absolutely intact up to the last weeks, or even days, of 
pregnancy, and could not by expanding give rise to the hemorrhage. 
Jacquemier affirmed that when the placenta was inserted over the os, its 
separation during the first half of pregnancy was prevented in part by its 
growth, which is at first very rapid, but later it becomes so stretched, that 
partial detachment occurs, whence the hemorrhage during the fourth, 
fifth and sixth months. But when the mechanical distension of the lower 
uterine segment is added to the enlargement of the placenta, causing it 
to project more or less into the pelvic cavity, the tearing increases to a 
very marked degree, and often results in separation of a portion of the 
placenta. Hence the increasing frequency of hemorrhage durihg the 
seventh, eighth, and a part of the ninth month, although the os is just MATERNAL DYSTOCIA. 
207 
as much closed as it was when bleeding first took place. Levret's ex- 
planation applies later after labor has begun; then dilatation of the cervix 
is the real, active cause. This theory has been attacked of late years by 
two authorities-Barnes, who admits that the blood comes from the uterus, 
and Simpson, who thinks that it is derived mostly from the placenta. 
The latter affirms that if the. exposed uterine vessels contribute to the 
hemorrhage, it is only to a limited extent, and that most of the blood is 
derived from the placenta. Hence, at each escape of blood, a portion of 
the placenta is obstructed, and prevents further access of the maternal 
blood at the detached side; the hemorrhage accordingly ceases as soon as 
the placenta is completely separated. This view is incorrect, since the 
blood comes from the uterus, and not from the placenta, as has been 
proved by all observers, in cases in which the bleeding continued after 
the expulsion of the placenta. 
Barnes offers the following explanation: In common with Stoltz, he be- 
lieves that the first hemorrhage is due to excessive development of the 
placenta, as compared with that of the cervix. Under the influence of 
the monthly congestion the uterus and plac.enta are engorged with blood, 
and the latter swells and becomes too large for the surface to which it is 
attached; it becomes separated at the edges of the os and the blood pours 
out. Then, in consequence of the irritation which this partial detach- 
ment produces, the uterus contracts, and thus a still larger portion of the 
placenta is separated, but this separation is always confined to the cervi- 
cal zone. The strong contraction of the uterus is the true cause of the 
cessation of the hemorrhage. Barnes divides the internal surface of the 
uterus into three zones (Fig. 149): The superior polar circle or fun- 
dus, which is free from danger; the middle zone, attachment of the pla- 
centa to which occasions risk of post-partum hemorrhage; and the inferior 
or cervical zone or region of danger. Any portion of the placenta inserted 
in the latter may be detached prematurely, because the os must enlarge 
to give passage to the child, and this enlargement does not allow the pla- 
centa to remain fixed. As long as the separation does not extend to the 
border of the cervical zone, the hemorrhage continues; as soon as this 
limit is reached it stops, if the uterus contracts strongly. Now, accord- 
ing to him, there are two things that prevent contraction, the fact that 
the uterus has not reached its full development, and the diminution of the 
vital force in consequence of loss of blood. Barnes affirms that the cer- 208 
A TREATISE ON OBSTETRICS. 
vix dilates slowly in these cases, but it is not because it is rigid and resist- 
ant, but rather because the uterine contractions continue for a long time 
to be feeble and irregular. In the 15 or 1G cases observed by me, I have 
never been able to demonstrate this so-called anatomical resistance of the 
cervix, which he describes. 
There are thus two theories: In the one the blood comes from the pla- 
centa and its vessels, and which is not admissible as an exclusive theory; 
in the other the blood comes from the uterus, according to certain authors 
during labor, and according to Barnes the hemorrhage necessarily ceases 
when labor has progressed to a certain extent. 
Legroux's conclusions (1855) express the same idea, viz.: Hemorrhage 
Fig. 149.-A, Fundal zone, a, Superior polar circle. B, Middle zone, b, Inferior polar circle. 
C, Inferior or cervical zone. 
due to separation of tlie placenta takes place during repose of the uterus, 
but ceases when the organ contracts, and does not recur if the contraction 
is permanent. The hemorrhage is almost entirely uterine, the placenta 
contributing only a small share of the loss, which may affect the life of 
the child, but not that of the mother. It becomes entirely uterine after 
the death of the foetus. 
Matthews Duncan believes that hemorrhages from placenta praevia dur- 
ing the last three months of pregnancy are often unaccompanied by sepa- 
ration of the placenta, although this doubtless takes place in some cases. 
Hemorrhage in his opinion may occur in four ways: 1. By the rupture of 
a utero-placental vessel, at the border of the os internum. 2. By the 
rupture of a marginal utero-placental sinus in the area of spontaneous 
detachment, in partial implantation. 3. By the partial separation of the MATERNAL DYSTOCIA. 
209 
placenta in consequence of traumatism. 4. By its partial separation from 
uterine contractions, which cause slight dilatation of the os. Spiegelberg 
adopts this view. 
4. Hemorrhages (hiring Labor. 
All authorities agree that hemorrhage during labor is inevitable in 
cases of abnormal insertion, and they attribute it to separation of the 
placenta. Jacquemiei* says if laboi' sometimes proceeds without accidents 
in these cases, it is because the placenta was either completely detached, 
or at least it was so attached that dilatation proceeded without sepa- 
rating it any further. Moreau's theory that hemorrhage ceases after the 
death of the foetus is negatived by many facts. Most writers believe 
that the hemorrhages increase at the return of each pain; Barnes, Jiidell 
and myself, adopt this opinion. Duncan says that the uterine contrac- 
tion diminishes the calibre of the vessels, and thus diminishes the hem- 
orrhage; Schroeder believes that the uterine wall glides away from the 
placenta during the dilatation of the cervix, as long as the membranes 
are intact, but after they are ruptured the placenta can follow the 
uterine wall in its movement of ascension, and there is no danger of sep- 
aration. 
What is the source of the hemorrhage ? According to Simpson it comes 
from the maternal vessels, according to Depaul and others from the uter- 
ine sinuses. According to Duncan there are four sources: 1. A gush 
of blood comes from the blood-sinuses of the maternal portion of the pla- 
centa, at the moment of separation. 2. It comes from the placental sur- 
face itself. 3. From the circular sinus which is at the border of the pla- 
centa. 4. From the open uterine sinuses. Mackenzie and Snow Beck 
affirm that the gaping arteries at the point of separation form another 
source of the hemorrhage. Coagulation, local and general anaemia, uterine 
contraction, separation of the placenta, etc., favor arrest of bleeding. 
3. Hemorrhage after Delivery. 
Hemorrhage from placenta praevia is very grave if it occurs after de- 
livery; it is due largely to uterine inertia, as well as to the extremely 
vascular condition of the inferior segment. 
Diagnosis.-This is without difficulty, if the previous history of the 
case is studied with special reference to the occurrence of bleeding dur- 
Vol. III.-14 210 
A TREATISE ON OBSTETRICS. 
ing pregnancy without known cause. After the placenta has been ex- 
pelled, it is easy to recognize the site of its insertion. When the placenta 
is inserted at the fundus, the membranes rupture at the most dependent 
point, that-is to say, at the part in contact with the os internum; hence 
the sac is at the opposite extremity from the placenta. But when the 
latter is inserted in the lower segment the membranes can with difficulty 
Fig. 150. Fig. 151. 
Fig. 150.-Rupture of the Membranes in Case of Normal Insertion of the Placenta. 
Fig. 151.-Rupture of the Membranes in Case of Abnormal Insertion of the Placenta. 
rupture spontaneously, so that the attendant must rupture them with the 
hand or an instrument. When the insertion is marginal, the membranes 
rupture at the most dependent part, which is near the edge of the pla- 
centa. 
Prognosis.-Placenta prsevia is one of the gravest complications of preg- 
nancy and labor. We would first call attention to €lie frequency of labor 
before term: 
3 months, 1 
4 '{ ........ 2 
5 " ... . . . 10 
6 " 21 
7 " 113 
8 " 234 
9 " 144 
\ 
End of pregnancy, . . . . . . 331 211 
MATERNAL DYSTOCIA. 
As to the variety of the placental insertion: 
5 months, 2 incomplete 5 complete. 
6 " 7 7 
7 " 33 " 39 " 
8 " 56 " 85 " 
9 " 40 " 55 
End of pregnancy, 153 " 113 " 
As to the maternal mortality, it varies from 32 per cent, to 25 per 
cent.; and as to the foetal mortality: Simpson of 106 children lost 73; 
Depaul of 63 lost 39; Muller of 853 lost 486. The mortality in general 
may be stated as 64.18 per cent. It varies considerably according to the 
month when labor sets in: thus at 7 months, 15 per cent., at 8, 29 per 
cent., at 9, 18 per cent., at term 35 per cent. 
It varies with the mode of insertion of the placenta. In 739 cases the 
mortality was 57 in marginal and 109 in central implantation. If the 
contractions are regular and strong, the labor will bo terminated sooner 
to the advantage of both mother and child. The prognosis for the 
mother becomes more favorable after the death of the child, as the hemor- 
rhage diminishes. The placenta may be adherent, as in 80 cases out of 
341, collected by Muller and others. 
The maternal mortality in cases of spontaneous delivery is from 11 to 
14 per cent., in artificial about 21.8 per cent. The foetal mortality in 
the former case is 32 per cent., in natural delivery preceded by a pre- 
liminary operation, 54.2, and in artificial delivery, 57.3 per cent. The 
following results were obtained by inducing premature labor: 
Hecker, out of 40 women, .... lost only 3 
Hoffmann, " 33 " 11 2 
Spiegelberg, " 74 " "4 
Treatment.-Different methods have been followed by different authori- 
ties, according to the diverse theories which have been adopted. One 
thing is to be remarked, most of them have made little account of the 
child's life as compared with that of the mother. We shall see if it is not 
possible to consult the safety of both. 
The prominent symptom is hemorrhage, and this must be treated ac- 
tively, and not with mere palliative means. There is one remedy which, 
although it may be of benefit in hemorrhages occurring during the first 212 
A TREATISE ON OBSTETRICS. 
six months of pregnancy, is certainly contra-indicated during the last three; 
we refer to venesection. It would only hasten the fatal issue if employed 
when a patient is already exhausted from loss of blood, and should be 
condemned in cases of placenta praavia. Opium tends to diminish the 
contractions, and may therefore do more harm than good; cold and astrin- 
gent injections are not sufficiently powerful; we are accordingly limited 
to a few other agents. These are ergot, forced delivery, the tampon, rup- 
ture of the membranes, and separation of the placenta and extraction of 
the same before the child, according to the plan recommended by Simp- 
son, Barnes, and other English writers. 
Forced Delivery.-Accouchement Force.-This is the most ancient 
method, which has been practised by many authorities; Levret recom- 
mended it only in cases of central insertion. It is a deplorable procedure, 
and ought not to be employed except when all other means have failed. 
The old obstetricians used to introduce one or two fingers through the os, 
and then the entire hand, after which they turned and extracted the 
child. This operation, no matter how gently it may be performed, al- 
ways results in contusions or tears of the cervix, sometimes with resulting 
gangrene. It is only possible to practise it after the cervix has become 
softened in consequence of the preceding hemorrhage; and besides, after 
the child has been turned and partially extracted, the cervix may grasp 
its neck so firmly, that it is impossible to extricate it. Now it is custom- 
ary to obtain more room by making multiple incisions, preliminary dilata- 
tion having been effected by introducing two fingers through the os; but, 
although such incisions are usually harmless, they may sometimes extend 
beyond the inferior segment. 
Rupture of the Membranes.-Puzos proposed this method, which still 
bears his name, although his claim to be its originator is not well founded. 
It consists in rupturing the membranes after the os has become moder- 
ately dilated, on the ground that this causes the pains to become stronger, 
and consequently checks the hemorrhage. One or two fingers are in- 
troduced into the os, and it is slowly dilated, pressure being suspended 
at intervals in order to allow the pains to recur. The membranes now 
protrude, and are freely ruptured. After some of the water has escaped, 
the inferior uterine segment can contract to greater advantage, so as to 
force the head downwards, and thus to compress the bleeding vessels. 
In this way both mother and child are saved, whereas they would inevita- 213 
MATERNAL DYSTOCIA. 
bly have been lost in a spontaneous delivery, and would have Deen seri- 
ously imperiled by forced delivery. This method is not applicable to all 
cases. When the os is completely covered by the placenta, some advise 
perforating the latter in order to rupture the membranes. Gendrin pre- 
fers to separate the placenta at one edge, until the membrane is reached, 
and then to puncture the latter. Dubois only resorts to rupture in cases 
of marginal implantation. We follow Gendrin at the Maternite wherever 
it is possible. Of course rupture of the membranes is contra-indicated in 
cases of faulty presentation; it does not always hasten labor, and we have 
then sought to aid it by employing other ecbolic means. 
Ergot.-Ergot occupies the front rank among these; but it is a remedy 
which is dangerous for the child, if not for the mother, and should there- 
fore be used with caution. Labor ought to be clearly advanced, and the 
head well engaged. In moderate doses it may be of great service in has- 
tening dilatation by increasing the contractions, and thus facilitating de- 
livery, as well as in preventing post-partum hemorrhage. It must never 
be given in cases of contracted pelvis, where there are organic lesions of 
the uterus, or where the presentation is faulty, because under these cir- 
cumstances we should be liable to produce results just the opposite of 
those at which we aimed, and, unfortunately there are only too many cases 
on record in which the unwise administration of ergot has produced rup- 
ture of the uterus. 
The Tampon.-This is the best means of controlling hemorrhage in 
placenta praevia, but, in order to obtain actual results with it, it is necessary 
to introduce it properly, and under proper conditions. Leroux (of Dijon) 
should be credited with popularizing this agent, which is now generally 
employed, except by Barnes, who has a special method of his own. The 
vaginal tampon is simply a dam, opposed to the stream of blood, which 
favors coagulation of that fluid, and obstruction of the openings of the 
vessels, and thus puts an end to the hemorrhage. Cotton and charpie 
make the best tampons, but any substance (tow, sponge) may be used in 
an emergency. As artificial tampons may be mentioned, GarieTs, Braun's 
colpeurynter, and Chassagny's balloon; but these act less perfectly than 
the classical tampon. This consists of pledgets of cotton, either united 
or single, the latter being preferable. The tampon must be sufficiently 
firm and resistant to close the vagina hermetically. The quantity of 
cotton necessary is enormous, a pound or a pound and a half not being 214 
A TREATISE ON OBSTETRICS. 
too much in some cases, especially in multipart. This amount is divided 
into three portions, one consisting of balls the size of small nuts (20 or 
30), with a long thread attached to each; the other of pledgets of the same 
size, without threads, the third portion not being thus separated; 5 or 6 
compresses and a T-bandage complete the apparatus. To introduce a tam- 
pon, place the woman on a couch, either transversely, or in the ordinary 
position, and give a vaginal injection of warm water, in order to wash 
away blood and clots; then empty the bladder, and the rectum also, if 
there is time. Some are accustomed to moisten the first tampon in a 
weak solution of perchloride of iron. I see no especial advantage in this, 
and I much prefer to anoint them with oil or cerate, so that they will 
glide in more easily. We do not aim at producing an astringent effect, 
but at making pure mechanical pressure. Having greased the pledgets, 
introduce them one by one, beginning with those to which threads are at- 
tached, and finally tie the latter together; press them in firmly, so that 
no space remains. Some insert the first tampon into the cervix, and then 
fill the fornix, others pack the culs-de-sac first, and then cover the cervix. 
After the tampons with threads have been introduced, the vagina is filled 
with the ordinary ones, which are packed into all the interstices, until 
the cavity is about three-fourths full. On arriving at the vulva, fill it 
out writh dry cotton, apply three or four compresses over this, and secure 
the whole with a T-bandage. If the tampon has been properly applied, 
it will remain nearly dry, that is, the outer layer will not be moistened. 
If a reddish fluid soaks through, do not hesitate to remove the tampon, 
and to insert another. The rule is to proceed slowly, pressing the tam- 
pons firmly against the cervix and the posterior part of the vagina; the 
whole success of the operation depends on this. The patient's life only 
depends upon the rapidity and dexterity with which we can practise it. 
After tamponing the patient, we keep her perfectly quiet, on liquid diet, 
administering small doses of ergot, if indicated. In order to be effective, 
the tampon should remain in situ from twelve to twenty-four hours. Now, 
Barnes advises that it be removed in an hour, but it is impossible to ob- 
tain good results in this way. Practitioners are always in too much of a 
hurry to remove it, and they thus lose all the advantage of it. In Ger- 
many the modus operandi is a little different. A speculum is introduced 
so as to expose the os, and through the instrument a cambric handker- 
chief is inserted, the interior of which is filled with pledgets of cotton. 215 
MATERNAL DYSTOCIA. 
the speculum being withdrawn as the vagina is distended. The entire 
tampon may be withdrawn by drawing out one corner of the handkerchief. 
The opponents of the tampon claim that it substitutes internal for exter- 
nal hemorrhage, brings on premature labor, and causes the patient pain, 
as well as disturbance of the bladder, etc. To the first objection it may 
be answered that it is impossible that there should be much internal 
hemorrhage, efen granting that it does occur, because the uterus is still 
occupied, and the membranes are intact; moreovei' the tendency is to co- 
agulation and arrest of the hemorrhage. After the membranes have 
ruptured, there are usually uterine contractions, which tend to diminish 
the size of the uterine cavity; moreover the foetus is still present to di- 
minish the space in which blood might accumulate. In reply to the ob- 
jection that the tampon tends to hasten labor, it should be stated that the 
hemorrhage usually appears after the seventh month (or thirtieth week), 
when the child is viable; but many observations prove that the tampon 
has, in some instances, remained in situ even as long as forty-eight hours 
without inducing labor, and even when this does occur, can we hesitate 
between this inconvenience and the danger which inevitably threatens 
mother and child if the hemorrhage is allowed to continue; and should 
we for this reason deprive ourselves of a resource which almost certainly 
saves the mother, and does not deprive the child of every chance of sur- 
viving ? It is very easy to remove a few tampons in order to catheterize 
a patient, and the rectum should be emptied before the cotton is intro- 
duced. How long shall we leave the tampon in place ? Pajot and Depaul 
would not disturb it, unless there is fresh bleeding, for twenty-four or 
thirty-six hours; but while the latter believes in terminating the labor as 
soon as possible, Pajot would leave entirely to Nature the successive ex- 
pulsion of the child and of the tampon. Depaul removes the tampon 
after the expiration of the time mentioned, and does not insert another 
unless the hemorrhage continues, but the patient is carefully watched, so 
that she can be at once tamponed in case of need. This treatment is 
usually sufficient if labor has not begun. If it has commenced, but dila- 
tation is slight, a fresh tampon is introduced, and a small dose of ergot is 
administered; the pains then increase, the cervix dilates, and in from eight 
to twelve hours the cotton is removed, and the membranes are punctured. 
As a rule, labor proceeds without much hemorrhage, and as soon as the 
os is sufficiently dilated, the child is extracted with the forceps, or after 216 
A TREATISE ON OBSTETRICS. 
version. If, on the contrary, profuse bleeding recurs, or the woman has 
been exhausted by the previous loss of blood, the tampon is not disturbed 
until dilatation is complete. The placenta is extracted immediately after 
the birth of the child. 
Bailly proposes to tampon, and instead of withdrawing the cotton when 
dilatation is supposed to be complete, not only to leave it in situ, but to 
prevent its expulsion by supporting it with the hand during the pains, 
and pushing back in the interval; then, when a portion of the tampon 
has been expelled by the natural efforts, fifteen or thirty grains of ergot 
are administered, to aid the uterine contractions, and to insure its con- 
traction after the expulsion of the child. If there is no bleeding, the 
after-birth is not extracted until after an interval. If fresh hemorrhage 
occurs, it is detached artificially. A fatal objection to this method lies 
in the fact that the foetal mortality is much greater when we wait for the 
natural termination of labor than it is when we empty the uterus at the 
proper moment. The following objections may be made to this method: 
1. It is only applicable to cases of normal presentation, whereas faulty 
presentations are especially common in placenta prtevia. 2. In some in- 
stances, where the tampon is applied after rupture of the membranes, a 
serious internal hemorrhage occurs. 3. In leaving the tampon to be ex- 
pelled by the uterine contractions, we assume that the latter are very 
powerful, whereas they are habitually feeble in these cases. We are usu- 
ally called to the patient after she has been already exhausted by loss of 
blood, and after the membranes are ruptured and the uterus is contract- 
ing feebly; the indication is to tampon at once, to restore the patient's 
strength with stimulants and broths, and, after the expiration of twenty- 
four or thirty-six hours, to interfere and terminate the labor. 
Finally, there is another objection to Bailly's method. He supposes 
that the os will be hermetically sealed as long as the tampon remains in 
the vagina; but, as the cervix dilates and retracts, it becomes removed 
from the tampon, so that a considerable space is formed between the two, 
in which a large amount of blood may accumulate. It is only excep- 
tionally that we can employ this method, in cases where we are called at 
the beginning of labor, and find the membranes intact, the presentation 
normal, the contractions sufficiently powerful, and the patient still in 
good condition. We may lose the child then, but we shall certainly save 
the mother. If, however, the conditions are the reverse, the woman be- 217 
MATERNAL DYSTOCIA. 
ing exhausted and the labor retarded, we should prefer Depaul's plan- 
tampon, wait until there is sufficient dilatation, rupture the membranes, 
tampon again if the hemorrhage recurs, and as soon as labor can be ter- 
minated without violence, terminate it. We shall then probably save the 
mother, and, if the child has still any chance of living, we shall have 
done all that we can to preserve it. 
Granting that the termination of the labor is indicated, and that this 
is possible, how should we act ? Two cases are presented, the insertion 
may be marginal or central. In the first instance, do not hesitate; the 
hand or instruments must be introduced where the path is open, that is, 
where the os is not covered by placenta. If the membranes are ruptured, 
enter by the natural passage, and search for a foot or apply the forceps. 
If the membranes are intact, rupture them, introduce the hand or in- 
struments, and deliver if the persistence of the hemorrhage indicates the 
necessity of so doing. But, if the bleeding is slight, and the head pre- 
sents so as to form an internal tampon, and if the contractions are suffi- 
ciently powerful-in short, if active interference is not called for-leave the 
labor to itself, and you will see it terminate rapidly and spontaneously. 
In central placenta praavia the method of procedure should be some- 
what different. Whether the membranes are ruptured or not, two courses 
are open to us: perforate the placenta, seek the feet of the child, and 
draw it through the opening thus made in the placenta, or, as Gendrin 
advises, detach the placenta completely at one side, enter by this artificial 
opening, seize a foot and extract. Both of these manoeuvres are ex- 
tremely dangerous for the child, whose vascular connections with the 
mother are cut off, but the second seems to me to be much preferable to 
the first, because it is easier of execution, and causes less disturbance of the 
utero-placental circulation. We thus give the child some chance of sur- 
viving, and do not imperil the mother. 
The choice of the hand or instruments, after the separation of the pla- 
centa has been effected, is governed by all the conditions (presentation, 
prolapse of a part, etc.) which regulate our conduct whenever the ques- 
tion of artificial delivery presents itself. Only, we must not forget that, 
in cases of abnormal insertion, every moment is precious both for the 
child and for the mother, and we must resort to the procedure which 
seems to afford us the means of terminating the labor most promptly. 
[The treatment of placenta praevia advocated by Charpentier, is, we 218 
A TREATISE ON OBSTETRICS. 
believe, faulty in many respects, and, like almost all methods, takes scarcely 
any account of the life of the child. The tampon is favored to an extent 
not warranted by contemporaneous opinion, and, we would strongly insist, 
ergot, in however small a dose, is distinctly contra-indicated. The prac- 
tice which we should favor may be outlined as follows: As soon as the 
diagnosis of placenta praevia has been reached, and this will ordinarily be 
the case on the occurrence of the first profuse hemorrhage, temporizing 
is out of the question, for the simple reason that the next hemorrhage 
may occur at any time, and might prove fatal before any of the indicated 
measures could be resorted to. In oui' opinion it is playing with two lives, 
certainly the maternal, to postpone active measures. As we have seen, 
the first hemorrhage from placenta prsevia ordinarily occurs after or at 
the seventh month, when the child is viable, and there can, therefore, be 
no reason for delay in the induction of premature labor. In case the 
seventh month had not been attained, we would only counsel delay in 
cases where the patient could be under the immediate, constant care of 
the medical attendant. Induce labor, then, on the occurrence of the 
first hemorrhage, would be our advice. 
One of the most efficient means of exciting uterine contractions is 
thorough tamponade of the vagina. In case of placenta praevia, before 
the membranes have ruptured and before dilatation is sufficiently ad- 
vanced for the purpose of the active method to which we will shortly re- 
fer, the tampon may be used without fear of concealed hemorrhage. It 
must, however, be rightly applied, and the sole way of accomplishing this 
efficiently is through Sims' speculum, in the lateral position. Where 
this speculum is not at hand, the woman should still be made to assume 
the lateral position, and two or more fingers of the hand may be used as 
a perineal retractor. The tampons, it is immaterial of what substance, 
provided it be clean, should be so inserted as to compress the lower uter- 
ine segment and the cervix, that is to say, they are placed first firmly in 
the posterior fornix, and then in the anterior, and finally a layer over 
all. They should not remain in place longer than twenty-four hours, and 
ordinarily less than this time is sufficient to enable one to resort to the 
active step which constitutes the modern treatment of placenta praevia, 
and the best, as well, for the reason that by means of it, not only are 
more mothers saved, but also no more children lost. 
In the "American Journal of Obstetrics," for December, 1884, will be MATERNAL DYSTOCIA. 
219 
found the most valuable contribution to the subject of the treatment of 
placenta praevia, which has ever been written. It was contributed by 
Lomer of Berlin, who, in a judicial manner, weighs the evidence in favor 
of the various methods of treatment heretofore advocated, and then proves 
that through resort to bi-manual version (the method of Braxton-Hicks), as 
soon as the cervix is sufficiently dilated to permit the procedure, the ma- 
ternal mortality is reduced to figures never even approximated by any 
other procedure, not excepting the method so ably advocated by the elder 
Barnes. 
The method consists, briefly, in performing bi-manual version as soon as 
possible, pulling down a leg and tamponing with it and the breech of the 
child, the ruptured placental vessels. " Do not extract the child then-, let 
it come by itself, or at least only assist its natural expulsion by gentle and 
rare tractions. Do away with the plug (tampon) as much as possible; it 
is a dangerous thing, for it favors infection, and valuable time is lost in 
its application. Turn as soon as you can pass one or two fingers through 
the cervix. If the placenta is in your way, try to rupture the membranes 
at its margin; but if this is not feasible, do not lose time; perforate the 
placenta with your finger, get hold of a leg as soon as possible and pull it 
down." By this method it may seem, at first sight, as though, after all, 
but little regard was shown for the infant's life, but, as the statistics we 
annex show, the results for the ch ild are certainly no worse than by other 
methods, and yet incomparably better for the mother. 
Up to the time of writing, Lomer was able to present the following re- 
sults from this method: 
Hoffmeier's cases, .... 37 with 1 death 
Behm's " . . . . 40 " 0 deaths 
Lomer's " .... 101 " 7 " 
that is, a maternal mortality of 4.5 per cent., while we have seen that the 
lowest mortality by any other method of treatment was 25 per cent., as 
given by Trask, 23 per cent, as given by Muller, and 22.5 per cent., as 
given by King (Indiana), taking cases collectively, and when taken singly, 
by operators, Spiegelberg 16 per cent., Hecker 10 per cent., Barnes 8.5 
per cent., Hecker and Murphy (30 cases) 0 per cent. These latter are 
selected results, and, to apply the same process to Hoffmeier's, Behm's 
and Lomer's personal cases, we have a series of 93 cases with 1 death. 220 
A TREATISE ON OBSTETRICS. 
As for the children, the mortality rate in the cases recorded by Lomer 
was 60 per cent., practically the same as by other methods, but in refer- 
ence to this question, Lomer draws the following conclusions, which are 
eminently just: 1. The average mortality of children born spontaneously 
after turning, is not superior to that of children extracted immediately 
after turning. The danger the child runs by not extracting it has there- 
fore been overrated. 2. In case of placenta preevia, a child's life is of so 
little practical value compared with that of the mother, that, should it be 
endangered by leaving it to be born by the natural powers, we are entitled to 
sacrifice it in cases in which we would endanger the mother by quick ex- 
traction. The only objection that could be made to the method is, there- 
fore, of no serious importance. 
For further information in regard to the method advocated, and the 
detailed analysis of the results obtained, we are forced to refer to the 
monograph itself. It will repay careful study, and will bear critical judg- 
ment.-Ed.] 
In regard to the results obtained by various methods the following sta- 
tistics are given by Weil: In 32 cases 15 mothers were saved, G out of 8 in 
which the tampon alone was used, and 9 out of 24 in which the tampon 
was employed with subsequent resort to rupture of the membranes, for- 
ceps, or version, or a combination of the same. Among 11 cases reported 
by Bailly, 3 out of 5 were saved by version, and 5 out of 6 by the use of 
the tampon alone. But the latter writer fails to state the conditions 
under which he acted. The results in the Clinique de la Faculte, were 
as follows: Among 10,613 cases of delivery which took place during the 
years 1852-1873 (the record for 1853 being defective) there were 65 of 
placenta praevia, 43 mothers and 23 children being saved; 53 women were 
multipart, and 12 primipara?; in 21 cases the insertion was central, in 44 
marginal. 33 patients were delivered spontaneously, with 8 maternal and 
19 foetal deaths, 22 by version, with 9 maternal, and 16 foetal deaths, and 
9 by the forceps, 4 mothers and 6 children succumbing. The conclusion 
to be> drawn from these statistics is opposed to that of Bailly, because, if 
spontaneous delivery was followed by such good results when the tampon 
was not allowed to remain indefinitely, it shows that his success was due 
not to the fact that he left it until expelled, but because delivery was 
spontaneous. In short, interference of any kind is undesirable, and we 
ought then to abstain from it. Unfortunately, this is not always possi- 221 
ble, and we are then compelled to resort to the only means that are left 
to us, that is to say, to delivery by the forceps or by version, and this is 
the plan followed at the Clinique. 
Muller gives the following statistics in connection with version in pla- 
centa praevia: 
MATERNAL DYSTOCIA. 
Authors. 
Cases of 
Version. 
Deaths. 
Mauriceau, 
14 
1 
Portal, . 
12 
1 
Giffard, 
18 
5 
Smellie, 
8 
3 
Rigby, . 
35 
9 
Clarke and Collins, 
7 
4 
Busch, . 
5 
2 
Schweighauser, 
46 
11 
Madame Lachapelle, 
13 
6 
S. Ramsbotham, 
86 
40 
F. Ramsbotham, 
96 
37 
Lever, . 
30 
7 
Lee, 
28 
10 
Wilson, . 
22 
8 
Harding, 
3 
2 
Jackson, 
1 
1 
Thompson, 
1 
1 
Roberts, 
2 
9 
Storer, . 
I 
1 
Hanks, . 
1 
1 
R. Thomas, 
2 
2 
Trask, . 
. 429 
104 
- 
-■ 
860 
258 
The mortality is 30 per cent. Comparing these results with those of 
version in cases of normal implantation, as given by Sickel, out of 3476 
versions there were 291 deaths, or 8.3 per cent. Of 416 children deliv- 
ered by version in case of placenta previa, 250 died (60 per cent.); in 
10,910 versions with normal implantation, 565.3 died (51.8 per cent.) 
Muller reports 92 cases of accouchement force followed by version, with 222 
A TREATISE ON OBSTETRICS. 
a maternal mortality of 47.8 per cent., and a foetal of 62.7 per cent.; in 
34 cases, in which the os was first dilated by the tampon or colpeurynter, 
35.2 per cent, of the mothers and 50 per cent, of the children perished. 
The same writer states that in 105 cases in which the tampon was ap- 
plied according to the German method, the hemorrhage was arrested in 
only 58; in 128 cases in which the influence of the tampon on uterine 
contractions was studied, in 55 the pains became vigorous in from 1 to 12 
hours. Out of 161 women with placenta praevia, in whom contractions were 
caused by the introduction of the tampon, 126 mothers and 64 children 
were saved, 6 of the latter dying soon after delivery. 
Chassagny uses his intra-uterine dilator to dilate the cervix and hasten 
delivery, but its haemostatic action is limited. Legroux ruptures the mem- 
branes, and then has the woman supported in a standing posture, with 
the.view of causing the descent of the head, so that it may act as a tam- 
pon. 
Separation of the Placenta.-This method, proposed by Radford, and 
ardently championed by Simpson, has been generally attacked in France 
and Germany, while in England it is especially advocated by Barnes. Hav- 
ing collected some 40 cases in which the placenta was expelled before the 
child, the hemorrhage being arrested, and -noting that this arrest was due 
to compression of the vessels by the head of the child, and also that the 
child was always born dead under these circumstances, he laid down the 
following nine propositions: 
1. Neither delivery nor detachment of the placenta should be at- 
tempted until the os is sufficiently dilated to allow the introduction of the 
hand. 2. If the foetus is certainly dead, we should detach the placenta 
completely, rupture the membranes, and leave the case to nature. 3. If 
the pelvis is narrow, extract the placenta, then perforate and extract the 
child with the crochet. 4. If the os admits the hand, detach the placenta, 
if the membranes are ruptured and the pains strong. 5. If there is an 
exhaustive hemorrhage in central placenta praevia, perforate the placenta 
at its centre, and use galvanism. 6. In cases of partial insertion rupture 
the membranes, and use galvanism if there is hemorrhage. 7. Remove 
the placenta if all other means fail to check the bleeding; also 8. When 
artificial delivery is dangerous or impossible. 9. When the death of the 
foetus renders the safety of the mother the only consideration, extract the 
foetus immediately. MATERNAL DYSTOCIA. 
223 
Now, Simpson's theory is false at the outset. The hemorrhage, as Lee 
and Ashwell have proved, comes from the uterus, and not from the pla- 
centa; moreover, Simpson would detach the placenta before the os is suffi- 
ciently dilated to allow version. Simpson reports 141 cases of extraction 
of the placenta before the birth of the child; in 47 cases there was an 
interval varying from ten hours to ten minutes between the expulsion of 
the placenta and the birth of the child, 44 mothers and only one child 
being saved; in 24, in which the child was born within ten minutes after 
the extraction of the placenta, 21 mothers and 11 children were saved. In 
30 cases the placenta came' away immediately before the child, or both 
were expelled together, 21 mothers and 11 children surviving; in 40 the 
exact time that elapsed between the separation of the placenta and the 
birth of the child was not known, but 36 mothers and 7 children were 
saved. To summarize, 129 mothers and 31 children out of 141 were 
saved. Other writers have not had the same success with Simpson's 
method, Walter having lost 10 mothers and 30 children in 33 cases, 
Hecker 27.5 per cent., and Trask, 13 mothersand 41 children in 61 cases. 
Finally Barnes proposes the following: If the pregnancy has only reached 
the fifth or sixth month, the os is not dilated, there are no pains, and the 
hemorrhage is moderate, we can wait; if there is considerable bleeding and 
the contractions are fair, no matter what may be the age of the pregnancy, 
we ought to act at once and hasten the labor by: 1. Puncturing the mem- 
brane. 2. Applying a tailed-bandage to the abdomen, so as to excite con- 
traction. 3. Introducing a tampon. 4. If the os is sufficiently dilated, 
and if there is hemorrhage, separate all that part of the placenta which is 
attached to the cervical zone. 5. If the os is not dilated, dilate by means 
of the dilators, and then detach the placenta from the cervical zone, by 
introducing the hand into the vagina, and sweeping two fingers around 
the os, so as to detach the placenta as high as they can reach. After di- 
lating, bi-polar version is practised. 
By the premature induction of labor, Thomas saved 10 out of 11 women 
and 6 children. However satisfactory these results may be, they are not, 
in our opinion, sufficiently numerous to induce us to abandon the 
tampon. 
Treatment after Delivery.-We should not forget that hemorrhage may 
recur after delivery, from uterine inertia, as the inferior segment does 
not always contract sufficiently to obliterate the utero-placental vessels. 224 
A TREATISE ON OBSTETRICS. 
Ergot, the introduction of the hand, or of ice, into the uterine cavity, 
douches on the abdomen, electricity, inassage of the uterus, intra-uterine 
injections, compression of the aorta, compression of the abdomen by an 
india-rubber bandage, and tamponing, have all been recommended. Per- 
chloride of iron applied to the cervical cavity and inferior uterine segment, 
will cause contraction and arrest the hemorrhage, after which the patient 
should be stimulated with hypodermic injections of ether, brandy and 
ergotin. [We object strongly to the sub-sulphate of iron, for reasons 
given later.-Ed.] 
3. Internal Hemorrhage. 
Hitherto we have been studying external uterine hemorrhage, but there 
is another form in which the blood is effused into the interior of the 
genital canal, and does not appear externally. During the early months 
of pregnancy, these extravasations take place in the midst of the decidua 
or placenta, constituting what was formerly called " placental apoplexy," 
but is now known as hsematoma of the placenta or decidua. This leads 
to abortion after the lapse of a certain interval. 
We shall, with Jacquemier, regard internal hemorrhage as one in which 
the blood is retained, wholly or partially, within the uterus, together 
with the product of conception; but this will include only hemorrhage 
that occurs before the beginning of labor. Hemorrhage from placenta 
praevia is usually external, but it may become internal, if a tampon is in- 
troduced after rupture of the membranes, but it is only hemorrhage which 
is internal from the first that really deserves this name. During the first 
months after conception, the blood accumulates between the uterus and 
the placenta, stripping off the latter more or less extensively, penetrating 
between its cotyledons, and infiltrating the tissue, being either circum- 
scribed in it, or extending beyond it, even making its way into the ovum 
in rare instances. This bleeding is of little consequence, and does not 
endanger the mother still there are cases on record in which the hemor- 
rhage has been so profuse that the patient succumbed in a short time. 
Internal hemorrhage occurs not infrequently before labor, when it gives 
rise to characteristic symptoms, such as lumbar pains, uterine colic, 
anaemia, and an increase in the size of the uterus, which is too sudden to 
be attributable to anything except intra-uterine hemorrhage. In rup- 
ture of the uterus, or the sac of an extra-uterine pregnancy, the extrava- MATERNAL DYSTOCIA. 
225 
sation takes place into the abdominal cavity, and the symptoms are quite 
different. Internal hemorrhage is called by some writers " accidental," in 
distinction from that which attends placenta praevia, which they term 
" unavoidable." When due to separation of the placenta, the hemor- 
rhage may be either internal, external, or mixed, it resulting, according 
to Jacquemierfrom: I. The uterine contractions, which disturb and sever 
the connections between the placenta and the uterus. 2. Excessive hy- 
peraemia of the uterus and placenta in consequence of violent emotions. 
3. Direct violence. 4. Acute diseases of a grave character, as small-pox, 
scarlet, or typhoid fever, acute yellow atrophy of the liver, etc. The 
hemorrhage may occur either before, or during labor, and may manifest 
itself by symptoms of external or internal bleeding. As to hemorrhage 
during labor, it may be said that women frequently lose a little blood at 
the beginning of labor, and also after the cervix is completely dilated, 
but this possesses no significance; moreover, in long labors, or when the 
perineum is quite resistant, blood may escape externally without causing 
alarm. In normal labor the placenta does not begin to separate until 
after the expulsion of the child, but sometimes it becomes detached pre- 
maturely, and thus gives rise to slight hemorrhage. This rarely assumes 
serious proportions, but we should observe carefully the condition of the 
woman and the foetal heart-beats, and interfere if necessary, employing 
the forceps or extraction, though this is rarely required. 
Slight oozing is observed in some cases in which the cord is abnormally 
short; this is also due to premature separation of the placenta. 
4. Hemorrhage from the Vessels of the Cord. 
This is due to rupture of the cord itself, or of its vessels, caused by: 1. 
Disease of the vessels, or a varicose condition of the umbilical vein. 2. 
Abnormal distribution of the umbilical vessels in cases of velamentous in- 
sertion. 3. Shortness of the cord. The indications are to terminate the 
labor as soon as the source of the hemorrhage is discovered. 
XIV. The Artificial Removal of the Placenta, and the Hemorrhages of the 
Third Stage of Labor. 
The factors which call for interference with the natural completion of 
the third stage of labor are: Inertia of the uterus, excessive size of the 
placenta, rupture of the umbilical cord, spasmodic contraction of the 
Vol. Ill-15 226 
A TREATISE ON OBSTETRICS. 
uterus, adhesion of the placenta, hemorrhage, inversion of the uterus, 
rupture of the uterus and eclampsia. The last two we have already 
studied. 
Inertia of the Uterus.-We have seen that the advent of the third stage 
of labor was ushered in by return of the uterine contractions, harden- 
ing of the uterus, slight bloody discharge from the vagina, and the appear- 
ance of the placenta within the cervical canal. In case these contractions 
do not return, or not sensibly, we are brought face to face with inertia 
of the uterus, and this organ instead of being hard and contracted, is felt 
to be soft, and pains are absent. In case the inertia is due to feebleness 
or to absence of uterine contractions, either the placenta has separated or 
not. In the first instance, there is no hemorrhage, and we must care- 
fully abstain from active intervention. Traction on the cord would only 
result in its rupture, or else in prolapse or inversion of the uterus. We 
should await the return of uterine contractions, and endeavor to promote 
these by friction of the fundus. If at the end of a half hour, contrac- 
tility do not return, then we should resort to Credo's method, to expres- 
sion. This is the only instance, in our opinion, where it is applicable. 
We much prefer it to titillation of the cervix, to the application of cold 
over the abdomen, as recommended by Cazeaux. Usually, under the in- 
fluence of stimulating drinks and friction over the fundus, contractility 
returns in the course of a half an hour. In the second instance, there is 
hemorrhage, and then we must not wait, but, as we will shortly see, re- 
move the placenta as quickly as possible. 
[Charpentier is eminently correct in the practice here advocated, but 
he is inconsistent. If Credo's method is of value here it is fully as valu- 
able in the natural third stage of labor, and yet he there rejects it. There 
are instances where even Crede's method fails to overcome the inertia, 
and then, in the absence of special indication calling for the manual re- 
moval of the placenta, we cannot too strongly recommend the faradic 
current. A small pocket battery is amply sufficient, and we believe that 
it should find a place in every obstetric bag. One prime point should be 
insisted upon here, and this is never to administer ergot to overcome the 
inertia until the placenta has been delivered. The reason is obvious. 
-Ed.] 
Excessive Size of the Placenta.-In such cases the uterus is found en- 
larged, soft, and the symptoms of internal hemorrhage are present. If 227 
MATERNAL DYSTOCIA. 
frictions over the fundus and tractions on the cord do not avail for deliv- 
ery, the hand must be inserted into the uterus and the placenta removed. 
[Here, as in every other instance, we are absolutely opposed to any trac- 
tion on the cord. It is never necessary, and may result in alarming com- 
plications and injury to the mother.-Ed.] 
Weakness and Rupture of the Cord.-Weakness of the cord may depend 
on the fact that the labor is premature, or because it is not inserted at the 
centre of the placenta, or else that the vessels divide within the mem- 
branes. Even moderate traction, in these cases, may cause rupture, but 
this, we are obliged to add, is usually due to the fact that traction is ex- 
erted before the placenta has entirely separated. In case of rupture, 
either there is no hemorrhage, when we should abstain from interference, 
or else there is, and then we must at once insert the hand into the uterus 
and deliver, when the uterus will contract and the hemorrhage cease. 
In every case where there exists what we may call simple retention of the 
placenta, intervention is easy, and it is here, as we have stated, that we 
may resort to the so-called Credo's method of expression. We should 
never, however, forget that the third stage of labor is a natural, physio- 
logical one, and that in the vast majority of cases it may be left entirely 
to nature, and that the complications of this period are often due to un- 
timely interference. For our part we apply pressure over the uterus only 
when the third stage drags, or else when we fear uterine hemorrhage or 
inertia. 
Adhesions of the Placenta.-We have already referred briefly to the dis- 
eases of the placenta, but we must dwell on them here further, because, 
as Gueniot says: " Very intimate union between the uterus and the pla- 
centa is one of the most formidable complications of the third stage, es- 
pecially when this adhesion is to the extent of fusion of the placental and 
the uterine tissue." These adhesions may be accompanied or not by 
hemorrhage, and by spasmodic contraction of the uterus. What is the 
cause? While the majority of authors agree with Hegar in the belief 
that adhesions are usually the result of inflammation of the uterus, of 
endometritis, of placentitis, of fibrous degeneration of the elements unit- 
ing the organ to the uterus, Gueniot, instead of seeing in these instances 
a lesion the result of pathological alteration, detects the absence of a 
physiological factor, which engenders the anomaly. " When," he says, 
" we find, aftei' labor at term, degeneration of the placenta, instead of 228 
A TREATISE ON OBSTETRICS. 
searching for a pathological cause, why not ask ourselves why these ad- 
hesions, which are normal at four months, have not progressively weak- 
ened during the second half of pregnancy ? why, in a word, the physio- 
logical labor, which leads to disunion, has not progressed ? " This query is 
purely speculative. The researches of Hegar, of Schroeder, of Spiegel- 
berg, point convincingly to pathological alterations, and Gueniot himself 
admits them in case of endometritis. 
Adhesions of the placenta are recognized by the following signs: When, 
notwithstanding energetic contractions, the placenta is not found in the 
cervix at the end of ten to fifteen minutes, we should suspect adhesions. 
This suspicion becomes certainty if, making traction on the cord, we feel 
it grow tense during the traction and abruptly retract on cessation. At 
the same time, during the traction, the woman complains of acute pain 
in the uterus, pain which increases with the intensity of the traction. In 
such cases if we persist we see rupture of the cord, [and exceptionally, 
perhaps, but still possibly, inversion of the uterus.-Ed.] If the adhesion 
be complete there is, generally, no hemorrhage, or it is insignificant, and 
the uterus, under the palpating hand, is hard and resistant, or soft and 
compressible. If the adhesion be partial, the finger feels a portion of the 
placenta, at a greater or less height, and there occurs hemorrhage which 
may be profuse. In this case, as Gueniot says, 11 the uterus cannot regu- 
larly contract, and the sinuses, which correspond to the detached portion 
of the placenta, remain open and give exit to the blood." 
The treatment consists in introducing the hand into the uterus, and re- 
moving the placenta. Intervention of this nature is subordinated to the 
hemorrhage. If it be not present, we may well wait one hour to one hour 
and a half; but if it exist, we must interfere at once. We must be care- 
ful not to administer ergot, which would only result in contraction of the 
uterus on the placenta, and closure of the internal os, when if the hand 
could be introduced it would be at imminent risk of rupture of the uterus. 
Where the adhesions are slight, it is not a very difficult matter to peel 
the placenta oil with the finger, but usually, unfortunately, the uterus 
rebels against the introduction of the hand, or the adhesions are very firm 
and resisting. In the last instance the placenta must be scraped off, and 
with the greatest care, in order to be sure of removing the entire portion 
of the placenta and membranes. (Fig. 152.) In case after extraction a 
portion is lacking, the hand must be re-introduced. If great difficulty is 229 
MATERNAL DYSTOCIA. 
met with it is better to desist, rather than by persisting injure the uterus. 
To say nothing of absorption of the placenta, which, although admitted 
by Velpeau and others, seems to us very problematical, we believe that 
the retention of a cotyledon or shred of the membranes is less dangerous 
than repeated attempts at extraction. From the observations of Hegar 
and many others, it is proven that often these cotyledons remain in the 
uterus a certain time without alteration, and are spontaneously expelled 
without much hemorrhage and without odor. Gueniot saw a fresh pla- 
centa expelled at the end of two days; I have seen the same occur at the 
Fig. 152.-Artificial Removal of the Placenta. 
end of five days. Usually, however, this is what occurs: A portion of 
the cotyledon breaks up and passes away in the discharges. Another por- 
tion putrefies and alters. This is either expelled at the end of a few days, 
(in a personal case at the end of thirty-seven days,) or else it becomes con- 
verted into a so-called placental polyp. The woman has but little fever, 
and tonic treatment as well as vaginal injections soon restore her to health. 
This, however, is not the rule. Under the influence of degeneration of 
the remnant, the woman is seized with chills, fever, and other symptoms 
of putrid infection, and, if we do not interfere, her life is greatly endan- 
gered. As to treatment, authorities are not in accord. While in England, 
and especially in Germany, active intervention is recommended, such as 230 
A TREATISE ON OBSTETRICS. 
dilatation of the cervix, curetting, etc., in France we are not so bold; and 
although Pajot uses the curette, and Depaul placental forceps, for our 
part, after having tried these means, we have rejected them, and we limit 
ourselves to intra-uterine injections twice, and vaginal eight to ten daily. 
In two cases we succeeded in saving septic women. To these measures, 
we add, of course, quinine, tonics, etc. The intra-uterine injections must 
be administered by the accoucheur, and with the double current catheter. 
[Under the subject of miscarriage (Vol. II.), we have given our reasons 
in favor of an entirely different action from that which Charpentier ad- 
vocates. It is unnecessary to repeat them here. We would simply lay 
stress on the following points, which are not emphasized as they should 
be in the text: Whenever the hand or instrument is introduced into the 
uterine cavity, give an intra-uterine injection of hot water (carbolized or 
sublimated, according to choice); and further, never fear injury to the 
uterus if manipulation is gentle, whether with the finger, dull curette, or 
placental forceps, half as much as the possible results from leaving a por- 
tion of the placenta or membranes in the uterus, to putrefy and poison 
the woman. Granting for a moment, even, that the chance of this oc- 
curring is slight, we would maintain that the accoucheur has no right to 
subject his patient to even this chance, when by prompt and timely action 
he can avert it without the least damage to her. We cannot repeat too 
often that the immediate removal of adherent placenta and membranes 
is, if done lege artis, not only not dangerous but salutary.-Ed.] 
Spasmodic Contraction of the Uterus.-Even as in labor, the contractions 
may become exaggerated, lessened, perverted, so, during the third stage, 
they may present the same anomalies, which Stoltz considers spasmodic, 
and divides into spasm of the external os, of the internal os, of the body, 
partial or total. Of these four varieties, that of the external os and total 
of the body are rare. The latter usually is seen in case of presentation 
of the shoulder, where the physician or midwife has prematurely ruptured 
the membranes, in order to make the diagnosis, and where ergot has been 
administered. It is then that tetanus results, rendering version impossi- 
ble, and calling for embryotomy. 
Spasm of the internal os is relatively common. The uterus is divided 
into two cavities, a superior portion, hard, rigid, contracted; an inferior 
portion, soft and relaxed. The uterus assumes the form of an hour-glass, 
whence the term hour-glass contraction. In this condition, the placenta 231 
MATERNAL DYSTOCIA. 
may: 1, be retained in the upper portion, the cord only passing through 
the os; or, 2, a small portion projects through the os; or, 3, one half of 
the placenta is above, and one half below the os; or, 4, the greater por- 
tion is below the internal os, and the remainder above. 
The complication is the graver the more the placenta lies above the 
constriction. The real danger, however, is the association of adhesions 
and of hemorrhage. As long as there is no loss of blood, we may wait, the 
constriction yielding at the end of a few hours or less, and, if the pla- 
centa be not adherent, it is expelled spontaneously. If it be adherent, 
once the constriction yields, the hand should be introduced into the uterus 
and the placenta peeled off. If, however, at the end of this interval the 
constriction does not yield, the patient must be anaesthetized, and first 
one finger and then another passed gently through the os, and extraction 
proceeded with, all the more urgently, of course, in case there is hemor- 
rhage. Stoltz recommends smearing the hand with extract of belladonna. 
In partial spasm of the body, the placenta is encysted in a portion of 
the uterine wall. In this case the constriction is above the internal os, 
and the uterus is divided into three cavities, the one as far as the internal 
os, the second between this and the constriction, the third above the lat- 
ter, where the placenta lies. The placenta may be encysted entirely or 
partially, or one or more cotyledons separately, the multilocular encyste- 
ment of Guillemot. 
On palpation the uterus is found irregularly contracted, the upper lobe 
being usually lateral, at a superior angle. Cases have been recorded by 
Riecke, d'Outrepont, Aschern, Payan and Scanzoni, where a portion of 
the placenta was inserted in the uterine end of the Fallopian tube. 
As for the etiology, the majority of authors attribute the condition to 
partial and irregular contractions of the uterus. Bubendorf, however, 
claims that it is due to a paralysis at the placental site, the remainder of 
the uterus being well contracted. 
As for the treatment, we must distinguish two categories: 
1. The incarceration is simple, and not complicated by hemorrhage. 
2. The incarceration is complicated by hemorrhage. 
In both instances, the placenta may be free or adherent. 
In the first instance, evidently, there is no call for haste, and yet we 
should not wait too long. Anti-spasmodics, opiate enemata, emollient 
injections, may be tried, but if at the end of a few hours matters do not 232 
A TREATISE ON OBSTETRICS. 
change, we believe it of advantage to pass the fingers, gently, one after 
another, through the neck of the sac, wherein lies the placenta, and ex- 
tract it, peeling it off if adherent. The woman, of course, should be 
chloroformed, not to relax spasm, for we believe that the uterus resists 
its action even after the heart, but to spare her pain, control her move- 
ments, and thus facilitate manipulation. (Fig. 153.) 
If this method doesnot succeed, then we may resort to Dubroca's, which 
consists in breaking up the placenta by means of one finger passed through 
Fig. 153.-Extraction of the Incarcerated Placenta. 
the constriction. After this manoeuvre, the uterus should be washed out 
several times daily for a number of days. 
In case the incarceration is complicated by hemorrhage, we must act 
immediately; overcome the obstacle, and extract the placenta whether 
adherent or not. Usually the obstacle is readily overcome. Ergot should 
then be given to maintain contraction of the uterus. 
In exceptional cases, where the placenta cannot be removed, and is not 
expelled spontaneously, we see develop septicaemia, with all its dangers, 
to which we will return at the end of this work. 
Post-partum Hemorrhage.-Under this term are included the hemor- 
rhages which occur after the birth of the child, during or after the ex- MATERNAL DYSTOCIA. 
233 
pulsion of the placenta, and they are of the gravest possible import, for 
they may assume such magnitude that in a few moments the woman may 
be dead. The accoucheur needs all his courage and all his experience. 
Practically, these hemorrhages may be divided into three varieties: 
1. Hemorrhage accompanied by retention of the placenta. 
2. Hemorrhage continuous or occurring after the expulsion of the pla- 
centa. 
3. Hemorrhage occurring a few days after delivery, which constitutes 
secondary puerperal hemorrhage. 
There is a prime cause for the two first varieties, and this is uterine in- 
ertia, which may be primitive or secondary. 
The normal separation of the placenta is accompanied by loss of blood, 
except in those cases where the foetus has been dead for some time. Con- 
tractions of the uterus, however, soon check this flow, and it is simply 
necessary to watch the woman in order to forestall relaxation and further 
hemorrhage. Occasionally this normal loss becomes abundant, owing to 
feebleness or irregularity in the uterine contractions, and then the pla- 
centa must be either partially or .entirely separated, and the uterus does 
not retract. 
Uterine inertia becomes, during the third stage of labor, a matter of 
extreme solicitude to the accoucheur. He should endeavor in every 
possible way to prevent it. When present, the uterine sinuses are wide 
open, the organ is capable of distension, a considerable amount of blood 
may accumulate in the cavity before appearing externally, and our inter- 
vention must not only be quick but certain. 
Causes.-Inertia is met with: 1. In women excessively fat, in those 
in whom the uterus is greatly distended, (by hydramnios, twins, etc.), 
in case of prolonged labor-in a word, in women in whom the fibres of the 
uterus would seem to have suffered exaggerated distension, and thus to 
have lost their contractile property. It is more frequent in primiparse, 
especially when they conceive late in life. 2. Where the onset of labor 
is sudden and its termination rapid, as though the muscular fibre had 
not had the time to develop its mode of action. 3. Where the course of 
labor is disturbed by emotion or fear, and where untimely traction is made 
on the cord, in order to hasten the third stage. 4. Finally, there are 
certain women who are apparently predisposed to hemorrhage of this 
nature in successive confinements. 234 
A TREATISE ON OBSTETRICS. 
Inertia may be local or partial, and thus the gravity of the accident and 
the difficulty of intervention vary. 
Symptoms. -In general, there are none of a precursory nature. The hem- 
orrhage appears suddenly. Certain authors attach importance, as a pre- 
cursory sign, to the absence of the chill or chilly sensations which usually 
follow the completion of labor. But this is fallacious, seeing that in per- 
fectly normal cases these sensations may be wanting. In a general way 
it may be said that there is danger of hemorrhage as long as the placenta 
and clots are within the uterus. The hemorrhage may be internal, ex- 
ternal or mixed, usually the latter. In case of internal hemorrhage the 
uterus increases rapidly in size, and is soft to the palpating hand. The 
woman feels that she is losing blood, and often first notifies the accou- 
cheur. Pallor, anxiety, tendency to syncope supervene; the pulse is 
frequent, small; convulsions, coma, set in, and death follows if the hem- 
orrhage be not arrested. The fundus of the uterus may rise above the 
umbilicus, and is filled with clots which may be expressed. 
The important point is to determine the cause of the hemorrhage, for 
on its localization depends the safety of the patient. Vaginal examina- 
tion will give the most certain information. We must assure ourselves at 
the outset if the placenta has separated or not, if a portion only remains, 
for the presence of this foreign body means increase in the hemorrhage. 
The indications for treatment consist in: 
1. To empty the uterus of the contained placenta and blood. 
2. To awaken contraction as speedily as possible. 
3. To check the afflux of blood to the uterus. 
4. To overcome the immediate and consecutive effects of the hemor- 
rhage. 
1. To fulfill the first indication, the woman must be placed flat on her 
back, the head low, and if there is retention of the placenta, it must be 
extracted at once. If the placenta has only partially separated and in- 
ertia is also present, common sense tells us to act against both at the same 
time, and fortunately the same measure suffices, and this is the introduc- 
tion of the hand into the uterus. The cavity must be emptied of placenta 
and clots, but the hand must not be withdrawn too soon. The uterus 
must be compressed by the external hand. Where adhesions exist, it is 
sometimes impossible to remove all of the' placenta. Indeed, in case of 
firm adhesions, the operation of removal is one of the most delicate and MATERNAL DYSTOCIA. 
235 
difficult in the whole range of operative obstetrics. Never should force 
be used, lest the uterus itself be injured, lliiter proposes scratching away 
the placenta piecemeal till every trace has been removed, but the French 
teachers are less bold and radical, and when the adhesions are too resisting, 
they prefer to leave the expulsion of a portion to nature. Usually this 
remnant passes away in a few days in the lochia. Vaginal injections 
prevent the sojourn of the debris in the genital passage. We are not as 
yet in France sufficiently accustomed to the use of intra-uterine injec- 
tions, and I believe that we are wrong in not resorting to them more fre- 
quently. 
In case the placenta has completely separated, nothing is simpler, seeing 
that a few tractions on the cord will suffice to complete the third stage. 
After the extraction of the placenta, the uterus must be watched with 
the greatest care, for often the organ relaxes and hemorrhage again sets 
in from what has been called'secondary inertia. 
In case the retention of the placenta is complicated by spasm of the 
uterus, and if there is hemorrhage, the manner of action is somewhat dif- 
ferent. If the spasm is at the internal os, it yields usually at the end of a 
few hours, unless it has been artificially produced by large doses of ergot. 
In this instance, however, there is no hemorrhage, foi' the entire uterus 
partakes of the spasm. In case there is hemorrhage, we must proceed 
rapidly to overcome the spasm. Sometimes enemata of laudanum, twenty 
to twenty-five drops, belladonna to the cervix, cause relaxation, and al- 
low of delivery of the placenta. If the hemorrhage is excessive, however, 
the hand must be passed boldly into the uterus. The same remark ap- 
plies to cases where the' placenta is encysted. 
At the same time as the placenta is removed, we must evoke uterine 
contraction. Frictions ovei' the uterus, irritation of the cervix, ergot, 
the introduction of the hand into the uterus, cold drinks, cold over the 
abdomen, [ice in the cavity of the uterus, the faradic current-Ed.], 
these are measures which suggest themselves. The English use opium, 
digitalis, turpentine, by the mouth, but these are means tardy in action. 
This does not hold true of intra-uterine injections. While in France we 
hardly dare use plain water, in England and Germany not only is cold 
water used, but also with vinegar or alcohol. Nowadays the belief is that 
the fear of penetration of fluid through the tubes into the abdominal 
cavity has been much exaggerated, especially since double catheters have 236 
been employed. In England and in Germany, obstetricians have even 
gone further, and injected into the uterine cavity styptic solutions, such 
as iron, where the hemorrhage cannot be controlled by other means. 
Outrepont was the first to resort to this, and he was followed by Scan- 
zoni and Kiwisch, who employed strong solution of the muriate of iron. 
Barnes, in England, lays down the following rules: He empties the uterus 
of clots and of placental debris, and then, by means of a Higginson 
syringe, he injects the iron solution directly into the cavity, with the pre- 
caution of first filling the syringe completely to avoid the injection of air. 
The fluid returns mixed with clots, and the perchloride of iron checks the 
hemorrhage by.coagulating the blood directly in the mouths of the vessels, 
by corrugating the mucous coat of the uterus, by causing contraction, fre- 
quently, of the muscular fibres. " The perchloride of iron comes to our 
aid, and saves the women often when their condition is most desperate. 
The hemorrhage rarely returns if the injection be made as I have out- 
lined, and in case it does, the process may be repeated. I grant that the 
perchloride may do harm, but we must remember that the hemorrhage, 
if it continue, may be fatal, and that the other means of checking it are 
not without danger. Our choice, then, must lie between unassured good, 
bought at a possible risk, and a certain ill which will probably result 
fatally. The following are the results which I have obtained by the use 
of the perchloride of iron: In many cases it has saved the patients when 
all other means were failures; in certain cases the hemorrhage has been 
instantly checked, and the women have had a phlemasia alba dolens. In 
a number of instances, where the women were in extremis, the hemor- 
rhage has been checked, but not soon enough to be of avail. The remedy 
was used too late. The lesson taught us is that the perchloride must not 
be left to the last, when even it will do no good. It should be used early 
before complete collapse. I lose no time in resorting to the measure, such 
is my confidence in it." (Barnes.) 
I have quoted thus at length from Barnes, because I wished to show 
how strongly he is in favor of the method. Personally I am not so en- 
thusiastic, and in face of the possible risks, I would leave it as the last 
resource. 
[We cannot fully coincide with the author in the treatment he advo- 
cates for post-partum hemorrhage. There is no emergency which calls 
for prompter action on the part of the accoucheur, and there is none 
A TREATISE ON OBSTETRICS. 237 
MATERNAL DYSTOCIA. 
which may be met more successfully, if met in time. In the face of pro- 
fuse hemorrhage from an inert uterus, it is simply fooling with life to 
waste time in giving laudanum enemata, ergot, or applying cold to the 
abdomen. The safety of the woman depends on our obtaining immediate 
uterine contractions, and these may almost infallibly be obtained by the 
injection directly into the uterus of ice water, hot water (115c F.), or a 
styptic such as vinegar or iodine. Iron we do not like, with due defer- 
ence to the opinion of Robert Barnes, for the reason that the clots which 
it forms are hard, and therefore irritating to the uterus, and readily de- 
compose. Our own preference is for ice water and vinegar, equal parts, 
or hot water, injected directly into the uterine cavity. These agents are 
always in the house. No one need fear the passage of fluid through the 
Fallopian tubes, for the reason that, in the cases of which we are speak- 
ing, the cervical canal is widely open, and the water will unquestionably 
flow out by the widest orifice. Besides, no force need be used. As for 
the syringe, we prefer the fountain to the Davidson, which is similar to 
the Higginson, although the recently introduced bulb syringe, called the 
" Alpha," is an excellent one, seeing that the outflow is continuous, and 
not intermittent, as in the Davidson. The uterine tube should have the 
terminal end closed, and the openings should be bevelled downwards. 
It should be passed well to the fundus. The Chamberlain glass tube 
is as good as any which has been devised. While the injection is 
being administered, it stands to reason that other measures should be 
used, but they are all subordinate to the former. The patient's head is 
to be lowered, the uterus compressed through the abdominal wall, ergot 
is to be given subcutaneously, and faradization resorted to. This meas- 
ure we have great faith in. Barnes, in his Obstetric Medicine and Sur- 
gery, thus expresses himself in regard to the interrupted current: "Of 
the remedies that present themselves, the most scientic is faradization. 
The experiments of Radford, Robert Barnes and Mackenzie, demonstrate, 
that under its power the uterus can be made to contract, even when it 
resists the influence of what may be called the diastaltic remedies." His 
only objection to it is that, except in hospital practice, the apparatus is 
not likely to be ready, or at hand. This objection should not hold, for 
in view of the great value of the faradic current in obstetrics, a battery 
should be carried in the obstetric bag, and the Gaiffe or similar pocket 
battery will answer perfectly, and not take up much space. 238 
A TREATISE OX OBSTETRICS. 
Ill case the measures outlined above succeed only when the patient is 
in collapse, the accoucheur should be prepared to resort to transfusion of 
blood direct, of milk, or a saline solution. A convenient formula for pre- 
paring the latter is: Chloride of sodium, 60 grains, chloride of potass, 
6 grains, phosphate of soda, 3 grains, carbonate of soda, 20 grains, dis- 
tilled water to 20 ounces, the whole heated to 90° F. 
In case of hemorrhage of moderate severity, and not calling for such 
stringent measures, it is a good plan to place the patient on her side, in- 
troduce Sims' speculum, and tampon the cavity of the uterus by means 
of Sims' slide applicator (see Vol. IL, under Miscarriage) the cotton being 
saturated with the compound tincture of iodine. The cotton plug, if not 
expelled spontaneously, should be removed at the end of twenty-four 
hours. -Ed.] 
In addition to the measures mentioned, Chassagny has advocated the 
tampon by means of a special instrument which he has devised. It con- 
sists of two balloons united by a narrow isthmus and each may be inflated 
independently of the other. The one is for insertion into the cervix, 
and the other into the vagina. When distended by fluid, the uterine 
balloon compresses directly, according to Chassagny, the uterine sinuses, 
and thus checks hemorrhage. The instrument, however, is open to the 
objection, that being in the uterus it prevents retraction, and it can hence 
be only of transitory utility. This instrument Chassagny has latterly re- 
placed by another, to which he gives the name elytro-pterigoide. In Fig- 
ure 154 this instrument is seen in profile and in action. The bladders 
adapted to it are from the pig, and are prepared with sulphur, which adds 
to their lasting properties. It is of use, according to the inventor, 1, in 
case of placenta praevia, 2, to induce labor, 3, to increase pains and bring 
about the rapid termination of labor in case of eclampsia, 4, to dilate the 
uterus, 5, to check, instantly, ante-and post-partum hemorrhages. 
The instrument consists of a speculum provided, internally, with two 
wings. As the bladder, inserted in the speculum, is distended, the wings 
separate and oppose the expulsion of the bladder. The inventor is still 
experimenting with it, and in his hands it has given good results.. 
There is a further means at our disposal in contending against post- 
partum hemorrhage, and this is the compression of the aorta. By this 
means we aim to prevent the afflux of blood to the uterus. According to 
Jacquemier, the first to practise it was Budiger, of Tubingen. He intro- MATERNAL DYSTOCIA. 
239 
duced his hand into the uterus and compressed the aorta through the pos- 
terior wall. Boer used the same procedure, but Max Saxtorph preferred 
to compress the vessel through the abdominal wall, and this was advocated, 
in 1825, by Ulsamer. It is the method in use to-day. Authorities, how- 
ever, are not at all agreed as to its efficacy, and Jacquemier is one of its 
decided opponents. Assuming that post-partum hemorrhage is largely 
venous, he contends that the effects will be different according to the level 
at which the vessel is compressed. " When compression is applied directly 
above the ovarian arteries, the slight amount of arterial blood furnished 
by the utero-placental arteries is cut off, but, at the same time, the stasis 
of the venous blood in the vena cava inferior is increased, and conse- 
quently in the veins of the uterus, and the situation is simply aggravated. 
The real way of checking provisionally, and more or less completely, the 
hemorrhage from the utero-placental vessels, is to compress at one and 
the same time the aorta and the vena cava." Jacquemier further adds 
that the advice everywhere given to administer ergot, while compression 
of the vessel is being made, is " both superfluous and irrational. How 
can this act when the arterial blood does not reach the uterus ? " 
Fig. 154.-Chassagny's Instrument for controlling Uterine Hemorrhage. 240 
A TREATISE ON OBSTETRICS. 
However much I respect the opinion of Jacquemier, whatever the value 
of his theoretical objections, this theory must yield to facts, and I believe 
that compression of the aorta is an excellent means of checking hemor- 
rhage, since it has succeeded well in three cases where I have resorted to 
it. I will not say that the result was due to compression alone, since 
others means were used, but it proved an excellent adjuvant. I resort to 
compression as follows: The woman lies on her back, the legs and thighs 
flexed, and the left hand depresses the abdominal wall above the fundus, 
a little to the left of the mid-line. As soon as the vessel is found, it is 
compressed against the vertebrae by three fingers, for about fifteen min- 
utes, when an assistant relieves the operator if his fingers are tired. The 
pressure exerted should be uniform, not forcible. To be of use, com- 
pression should be prolonged for fully one hour, until, in a word, the 
uterus is well and thoroughly contracted. 
The last method at our disposal, and which should be resorted to when 
all other means have failed, is transfusion. This has given satisfactory 
results. 
We have now passed in review the main cause of post-partum hemor- 
rhage-inertia of the uterus. For other causes, rupture of a thrombus, 
tumors, polypi, cancer, the reader is referred to the sections treating of 
them. We pass at once to a further prime cause, the 
Inversion of the Uterus. 
With William Newham, three degrees may be recognized: 1. Simple 
depression. 2. Partial inversion. 3. Complete inversion. 
Fig. 155.-Different Degrees of Uter.n-Z aversion.-a. Fundus, uteri inverting, b, Uterine 
cavity, c, Vagina, d, Upper border of the cup formed by the inversion. 
In simple depression the fundus sinks into the cavity, but forms no 
tumor in the vagina. Only by combined manipulation can we recognize MATERNAL DYSTOCIA. 
241 
this variety. In partial inversion, the fundus sinks into the vagina, 
forming a voluminous tumor, surrounded exactly by the orifice of the 
cervix. (Fig. 156.) In complete inversion, the uterus projects outside of 
the vagina and the vulva. The organ is detected no longer in the hypo- 
gastrium, and the os is felt at the upper part of the tumor surrounding it 
like a ring. (Fig. 157.) 
As Courty has well said, 11 a combination of varied conditions are neces- 
sary, in order that inversion may take place. Usually it occurs after laboi' 
Fig. 156.-Incomplete Inversion of the Uterus. (Denuc^.) 
at term, 350 times out of 400, according to Crosse, but also after miscar- 
riage and premature labor; cases of Spaeth at five months, of Brady at 
five months, of Woodson at four months. It may, however, be deter- 
mined by the presence of a fibroma or a polyp (Fig. 158), either during 
their spontaneous expulsion, or during efforts at removal. Inversion, 
however, compared with the other complications of the birth of the foetus, 
or the expulsion of tumors, is rare, and has doubtless, often, been mis- 
taken for prolapse." 
The conditions which favor inversion are, in general, uterine inertia, 
Vol. III.-16 242 
A TREATISE ON OBSTETRICS. 
sinking of the walls of the uterus, pressure on the organ from above or 
traction from below. Exceptionally, it may occur spontaneously, and 
although Depaul doubts this, the cases of Ruysch, Corvan, Saxtorph, 
Radford, Simpson and West are incontestable. 
In case of labor, Courtysays that the inversion may occur at two differ- 
ent periods: " 1. At the moment of the expulsion of the foetus, through 
inertia of the uterus, and traction exerted by the foetus on too short a 
cord, the parturient being erect. 2. During the third stage, owing to 
utero-placental adhesions. In these instances inversion may, at the out- 
set, be incomplete, and is rendered complete through the expulsive efforts 
of the woman, the pressure of the abdominal contents, etc." 
The majority of writers believe that there are certain factors indispen- 
sable to the production of inversion. Rokitansky lays stress on paralysis 
of the organ at the placental site. This site, not participating in the 
contraction of the remainder of the organ, terminates, as it were, in the 
uterine cavity, and palpation detects a cupping at this point. This is the 
first degree of inversion, and, once present, it tends to progress in part 
through the influence of uterine contractions, in part from the weight of 
the intestines, ovaries and tubes which sink into the depression. (V. 
Fig. 156.) Lazati contends that not only is partial uterine inertia pre- 
sent, but also total. Hunter insists on irregular contraction of the uterus, 
as the prime cause of inversion. The depressed portion becomes a foreign 
body in the cavity, and the uterus contracts, to get rid of it, even as hap- 
pens in inversion of the vagina. Henkel invokes after-pains; Siebold 
atony of the uterus, associated with precipitate delivery. Boivin and 
Duges inertia of the uterus, especially if, at the time, traction is made on 
the cord. Tyler Smith and Radford lay stress on the same causes. 
[In the American Journal of Obstetrics, October and November, 1885, 
Crampton of New York published a paper on inversion of the uterus 
after labor, and tabulated 120 cases of acute inversion, and 104 of chronic 
inversion, the line between the two classes being drawn at one month. 
Of the first series 87 recovered, 32 died, 1 remained unrelieved. In twelve 
instances, the patient was in extremis when first seen. Of the second 
series, 91 recovered, 7 died, 6 remained unrelieved. The average mor- 
tality from both series is nearly 20 per cent. The conclusions the writer 
reached from a study of these cases are, in brief: Inversion of the uterus 
is preceded by paresis of some portion of the uterine muscle, not neces- MATERNAL DYSTOCIA. 
243 
Fig. 157.-Complete Inversion of the Uterus.-(Boivin and Duges)-Caused by hasty extrac- 
tion of the placenta, a, Mons veneris, b, Labia majora. c, Labia minora, d, Clitoris, e, Meatus 
urinarius. /, External anterior surface of the vagina, g, External anterior border of the external 
os. h, Internal surface of the uterus which has become external. 
Fig. 158.-Partial Inversion due to a Sub-mucous Fibroid. (Lefour.') 244 
A TREATISE ON OBSTETRICS. 
sarily of the placental site, the main causes being too frequent child-bear- 
ing, tedious labor, repeated miscarriages, traumatism, emotions (especially 
in primiparse), precipitate labor. " It is a pure neurosis in its inception." 
Traction on the cord may cause prolapsus, but never alone inversion; 
for this to occur paresis must be present. Inversion is more likely to 
occur in first than in subsequent deliveries. Chronic inversion would 
rarely be met with if every physician adopted the custom of repeated 
and careful vaginal examinations after every labor within twenty-four 
hours. 
We would suggest that the routine palpation of the abdomen, at each 
visit, is an ample precautionary measure. We are opposed to vaginal ex- 
amination after labor, except in the presence of strict indication. 
For detailed analysis of the main causes of inversion we refer the reader 
to this interesting paper.-Ed.] 
For our part, we are inclined to side with Rokitansky's view, for we 
believe that, in the majority of instances, the cord will break before the 
uterus yields, in case inertia of the uterus is not present. 
The phenomena accompanying inversion are, at the outset, painless, 
to become intensified as the process increases, and the pains are the 
greater the more sudden the inversion. As a general thing, the hemor- 
rhage is not serious, although it may be profuse. Cases have been re- 
ported where there has been absolutely none, such as those of Brown, 
Chapman, Hamilton, Daillez, Burns and others. The chief symptoms 
are: Acute pain accompanied by the presence in the vagina of a more or 
less voluminous tumor, limited above by a ring formed by the cervix, de- 
pression or absence of the uterus from the hypogastrium, at times projec- 
tion at the vulva of a livid red tumor, to which the placenta or a fibroid 
may be adherent, hemorrhage, syncope, all these phenomena occurring 
so to speak, instantaneously. Such are the symptoms of recent inversion, 
with which alone we are here concerned. 
In case of inversion with the placenta still adherent, should we first 
remove the placenta or reinvert the uterus, with the latter adherent? 
The answer for us is self-evident. We should only reduce the inversion 
after the removal of the placenta. The hemorrhage will thus possibly 
be a trifle increased, but the volume of the uterus will be diminished. 
The prognosis depends on the rapidity of intervention. Reduction is 
the more difficult the greater the delay, and the greater the delay the 245 
MATERNAL DYSTOCIA. 
more serious becomes the condition of the woman. Finally, the intes- 
tine may lie in the depression, and is there subject to strangulation. 
If the uterus is in a condition of inertia, the whole hand should be in- 
serted into the vagina, and with the closed fist the projecting portion 
should be pushed up, the other hand externally taking account of the 
progress. Spiegelberg, with justice, lays stress on the point that pressure 
should be made particularly in the pelvic axis, to avoid impingement on 
the sacral promontory. If the cervix is contracted around the tumor, 
Kilian and MacClintock advise grasping it in the palm of the hand, so 
Fig. 159.-Reduction of the Inverted Uterus. {Barrier.) 
that the fingers lie at the constriction. The uterus is then to be com- 
pressed so as to push through the os first the portions which were inverted 
last, pressing up, at the same time, the fundus with the palm of the hand. 
Reduction once accomplished, the hand should remain in the uterus un- 
til the organ contracts regularly, and ergotine should be administered 
subcutaneously. 
Meissner recommends the following procedure: The tumor is grasped 
by four fingers of each hand, and the thumbs are applied to the lowest 
part of the fundus uteri. At this point the aim is to make a depression, 
and to increase this by gradual and moderate pressure. Courty and 246 
A TREATISE ON OBSTETRICS. 
others recommend section of the constricting ring. Longitudinal inci- 
sions are to be made so as to cut the circular fibres of the isthmus, one in 
front, and another posteriorly. Courty substitutes for Barrier's method 
the following: il The cervix is immobilized by two fingers in the rectum, 
while the fingers of the other hand endeavor to push the tumor through, 
pressure being made towards the pubes, (instead of towards the sacrum, 
as Barrier advised.) The fingers in the rectum hold the cervix towards 
the sacrum, being spread widely apait, between the utero-sacral liga- 
ments." Tate proceeds as follows: With the patient in the dorsal decu- 
bitus, the two thumbs are inserted into the vagina, two fingers of one 
hand into the rectum, and the index of the other into the bladder. These 
fingers aim at fixing and steadying the cervix, while the thumbs press on 
the tumor at its centre, and seek to push it through the cervix, which is 
distended by the fingers in the rectum and bladder. 
Finally various instruments have been devised as redressors, but all 
authorities agree in considering them more dangerous than useful, and 
in giving preference to the hand. 
[The best method, possibly, of overcoming a recent inversion, is that of 
Noeggerath. It has yielded the best results of any. It consists in plac- 
ing the index finger on one cornu of the uterus, and the thumb on the 
other, and in endeavors to push in first one and then the other. When 
this has been accomplished, pressure is made at the centre of the inverted 
mass, until it is reduced. The other hand, externally, makes counter- 
pressure. Whatever the method resorted to, anaesthesia is a pre-requisite 
to success. 
As for the methods of use for the reduction of chronic inversion, they 
do not belong here. Munde gives a succinct account in his Minor Sur- 
gical Gynecology.-Ed.] 
Secondary Puerperal Hemorrhage. 
Hemorrhages of this nature are less grave than those we have just de- 
scribed, but they may be serious in their complications. When primary 
inertia has been overcome, we piust not fall into the error of believing 
our patient safe, for frequently secondary inertia sets in. If we do not 
carefully watch our patient this may pass unnoticed, and all may be lost 
at a time when we thought all was gained. At the end of a variable 247 
MATERNAL DYSTOCIA. 
period, from a few minutes to a few hours, hemorrhage occasionally re- 
curs, and the patient is, of course, in a very bad. condition to withstand, 
this recurrent loss of blood. Whence the stringent rule, when once we 
have overcome a hemorrhage, not to leave our patient for some hours, 
and to keep her quiet in the bed. where she was confined, without at- 
tempting to change the sheets or to disturb her in any way. 
There are two symptoms which will foretell the impending hemor- 
rhage. The one from the side of the uterus, which, instead of being hard 
and globular, is soft, extends above the umbilicus, and on pressure gives 
exit to blood; the other, from the side of the pulse, which is very fre- 
quent and small. 
The explanation of this secondary hemorrhage is the following: Deliv- 
ery has been regular, the third stage normal, and the loss of blood moder- 
ate. Precisely because this loss is moderate, has it a tendency to coagulate, 
and there forms in the cavity a clot which keeps the uterus from con- 
tracting, and leads to deficiency in retractility. The uterus is kept at an 
increased size. Ordinarily, at the end of a variable time, the woman has 
a few after-pains, and expels the clot, but frequently there results pro- 
fuse hemorrhage, both internal and external. In such cases we must re- 
sort again to the treatment applicable to primary inertia. 
In order to forearm themselves against this late hemorrhage, certain 
accoucheurs are in the habit of giving ergot to all their patients. We be- 
lieve this practice more harmful than the reverse, for in such cases, we 
often see small clots, retained in the uterus, putrefy and become the start- 
ing-point of puerperal complications. [We have elsewhere given our 
reasons for disagreeing with the author. We simply repeat here that the 
routine administration of ergot, by keeping the uterus firmly contracted, 
prevents largely the formation of clots.-Ed.] 
In other instances, the puerperium progresses normally for forty-eight 
hours, and even longer, when hemorrhage occurs, without, at first sight, 
known cause. In the majority of cases, it is due to the neglect or error 
of the accoucheur. There has, perhaps, been left a portion of the after- 
birth in the uterus, which would not have happened had the placenta 
been carefully examined. If we examine these patients, indeed, there 
will often be found engaged in the cervix a shred of placenta or mem- 
brane, and when this has been extracted, the hemorrhage ceases. Some- 
times, however, the accoucheur is not at fault, where, for instance, the 248 
A TREATISE ON OBSTETRICS. 
placenta has been closely adherent, and it has been impossible, except at 
the risk of injury to the patient, to remove all. In such cases the hem- 
orrhage is really salutary, for it indicates the separation of these adherent 
portions, which might otherwise putrefy. Finally, in certain cases of 
supernumerary placentae, we meet with these hemorrhages, and yet the 
accoucheur could not have suspected the existence. 
There is still a further variety of secondary hemorrhage occurring 
towards the tiventy-fifth to the thirtieth day, even later. It occurs both 
in women who nurse, and in those who do not. In the first instance it 
seems as though the irritation of the breasts interferes with involution. 
If it become at all profuse, the indication is to stop lactation, and to give 
ergot. Hot injections sometimes cause the cessation of these hemorrhages. 
Hot general baths have yielded us the best results. (SeeVol. I, under the 
Puerperium.) 
In women who are not nursing, the uterus remains large and volumin- 
ous. Absolute rest, ergot, hot baths constitute the treatment. 
[In these late varieties of hemorrhage, the cause is almost invariably 
sub-involution, and the treatment called for is similar in nature. If the 
woman were otherwise in good condition, we would not put a stop to lac- 
tation, and we believe that the necessity for this is very exceptional. We 
would treat the case as follows: Place the woman in Sims's position, and 
through the speculum determine the cause of the hemorrhage. Often 
the prime cause is a lacerated cervix, frequently an erosion of the everted 
mucous membrane. Here, unless it seem appropriate to repair the cervix, 
applications of nitrate of silver 3 j to 5 j to the erosion, will temporarily 
check the flow. In case the hemorrhage comes from the uterine cavity, 
the dull curette should be passed over the endometrium to satisfy our- 
selves that there is no foreign body (polyp, shred of placenta, vegetation, 
etc.), and then, on a cotton-wrapped applicator, Sims's slide applicator 
may be used when we wish to temporarily tampon the cervix, a stypic solu- 
tion, (the compound tincture of iodine, or alum and glycerine, or iron and 
glycerin) should be applied to the endometrium. Rarely will the hemor- 
rhage of sub-involution pure and simple not yield to this measure. The 
best after-treatment is ergot and cannabis indica, five grains of the one 
and | grain of the other, by the mouth or rectum, or else ergot combined 
with the fluid extract of cotton root (gossypii radicis), and, every other 
day, for fifteen minutes, faradization of the uterus, or, what answers as MATERNAL DYSTOCIA. 
249 
well, the interrupted galvanic current. The hot douche, twice daily, is 
a valuable adjuvant. 
We plead, in particular, for non-interruption of lactation, except where 
these measures fail or there is other indication. 
As a not uncommon cause of secondary puerperal hemorrhage, we would 
note the premature resumption of sexual intercourse. We have in mind 
two cases, one on the fifteenth day the other on the twenty-sixth, where 
the congestion induced by copulation was the only possible cause for the 
hemorrhages. 
Munde, in a paper read before the Academy of Medicine in January, 
1883, on the subject of secondary hemorrhage, in his review of the causes, 
mentions, in addition to those which we have already noted: hemophilia, 
functional disease of the liver, malarial poisoning, and disease of the inner 
surface of the uterus.-Ed.] 
Finally, the mere presence of the husband in the wife's bed may pro- 
voke secondary hemorrhage, even as late as the fourth week. I have 
seen two instances in young hyperaesthetic women. The treatment, of 
course, consists in banishing the cause. 
At the end of six weeks, rarely earlier, the woman again has a flow, but 
this time it is physiological, being the return of the menses, and very fre- 
quently they are more profuse than was customary before conception, and 
ergot in small doses, with rest in bed, are called for. CHAPTER II. 
DYSTOCIA DUE TO THE FGETUS. 
J^YSTOCIA from the side of the foetus may depend on its annexes, in 
particular the cord, or on the foetus itself. 
Dystocia due to the Foetal Annexes. 
Anomalies of the Cord.-We have already studied the anomalies (See 
Vol. I.) of the cord, which may interfere directly or indirectly with the 
foetus. We will now pass in review the most frequent cause which ren- 
ders delivery dangerous to the infant, prolapse of the cord. 
Prolapse of the Cord.-Under the name procidentia, prolapsus, falling 
of the cord, we mean the engagement of a portion in front of or near the 
portion of the infant, which is presenting. Naegele and Schure make two 
divisions, according as the membranes are ruptured or not. In the first 
instance, the cord presents, in the second it is prolapsed. The first is 
inevitably converted into the second, unless it corrects itself spontane- 
ously. Jacquemier makes three divisions: Presentation before rupture of 
the membranes, incomplete prolapse when the cord lies in the vagina, 
complete prolapse when it hangs externally. As Depaul says, these sub- 
divisions are of no moment, for the danger and the indications are similar 
in each. Deneux says that procidentia of the cord may be met with at 
and before term, but usually it occurs only when the cervix is notably 
dilated. It is rare when the fcetal part reaches the excavation, and rarer 
still, of course, at the inferior strait. Naegele has recorded a case. It 
varies with the length of the cord, and it usually occurs in the neighbor- 
hood of the sacro-iliac synchondroses, infrequently in front of the sacrum, 
or behind the symphysis. The cord may be tense or loose. The descent 
may further be complicated by the presence of the foetal extremities, by 
knots, twists, placenta praevia. DYSTOCIA DUE TO THE FCETUS. 
251 
Frequency.-It is far from rare, and the figures given by the authori- 
ties vary infinitely. Thus:- 
Manzoni. . . found it in 1 out of 22 labors. 
Carus . . . " " 1 " 26 " 
Stoltz ... " " 1 " 69 " 
Hart . . " " 1 " 80 " 
Michaelis . . " " 1 " 92 " 
Clarke . . . " "1 " 156 " 
Richter ... " " 1 " 156 " 
Lachapelle ' " 1 " 592 " 
Mauriceau . . " " 1 11 18.1 " 
Schure ... " " 1 " 265 " 
Depaul ... " " 1 " 116 11 
Churchill . . 11 1 221 11 
Naegel e and Grenser " " 1 " 123 " 
Hildebrandt . . " " 1 11 148 " 
Etiology.-These have been well studied by Schure, who divides them 
into four groups. 
A. Every condition which renders the foetus more movable, a. 
Abundance of liquor amnii. b. Small size of foetus, c. Prolapse of a 
limb. 
B. All causes which give rise to space where the cord may engage. 
a. Naegele has insisted strongly, in this connection, on want of con- 
traction in the lower segment of the uterus, whence results lack of close 
approximation of this segment to the presenting part of the foetus, and 
hence space into which the cord may fall. b. Anomalous positions of the 
foetus which act either by making space for the cord, or else by bringing 
it nearer the cervix. In 124 cases recorded by Hecker, the cord was 
beyond the normal in length in 92 percent., having a mean length of 26^- 
inches. Multiparity would seem to have a notable influence. According 
to Hildebrandt in 100 cases only 15 occur in primiparae, and according to 
Hecker, in case of cephalic presentations, the proportion is 100 primiparae 
to 226 multiparae. c. Deformities of the pelvis and displacements of the 
uterus. 
C. All causes which bring the cord near the cervix. 252 
A TREATISE ON OBSTETRICS. 
D. Excessive length of the cord, premature rupture of the membranes, 
precipitate rupture, the woman being erect. 
E. Finally, Depaul adds attempts at version by the inexperienced. 
Diagnosis.-This is only difficult before the cervix is sufficiently dilated 
to allow the finger to reach the membranes. If the foetal part is deeply 
engaged, and the lower uterine segment very thin, we may, exceptionally, 
feel the pulsations of the cord through this segment. These pulsations 
may be differentiated from those which are normally felt at the utero- 
vaginal junction, by the fact that they are not isochronous with the ma- 
Fig. 160.-Prolapse of the Cord. 
ternal pulse. Where, on the other hand, the presenting part is elevated, 
the cervix dilated and a portion of the membranes accessible, the diag- 
nosis is possible. Then, either during the contractions, or in the inter- 
vals, a body is felt, not voluminous and floating, under the exploring fin- 
ger. The nature of this body is recognized by the fact that it pulsates 
isochronously with the foetal heart. If the foetus is dead, this sign of 
course fails, but then the diagnosis is of no importance. The membranes 
once ruptured, the diagnosis is a simple matter, when the cord is in the 
vagina. Its pulsations, the possibility of hooking the finger in a loop, 
clear away any doubt. The same does not hold true when the cord slips 
to one side of the head, and remains there during the first stage. Then 253 
DYSTOCIA. DUE TO THE F(ETUS. 
prolapse of the cord is often not diagnosticated, and Depaul says, with 
justice, that in certain cases where the foetus dies during labor without 
appreciable cause, this should be attributed to an unrecognized prolapse 
of the cord, aside from the compression to which it is subjected in the 
uterine cavity. 
When the cord presents at the vulva, it may appear normal, but often 
it is greenish, reddish, soft, as if withered. Pulsations may be present, 
or be lacking. From the absence, however, we cannot positively conclude 
that the infant is dead. In a case where the pulsation's had ceased ten 
minutes before our arrival, as attested by the attending physician, imme- 
diate version delivered an infant apparently dead, but which was resusci- 
tated by insufflation and survived. 
Prognosis.-If prolapse of the cord is of no moment as regards the 
mother, it is an accident which seriously compromises the life of the 
child. Thus: 
Scanzoni and Churchill place the mortality at 53 per cent 
Hecker " . " " " 37.6 " 
Lebmacher . . . in 50 cases had 49 deaths 
Hitter .... " 28 " " 21 " 
Michaelis . . . . " 27 " " 20 " 
Stoltz .... " 56 " 52 " 
Schweighauser . . . " 25 " " 25 " 
Depaul .... " 143 il " 96 " 
There are a number of circumstances which influence the prognosis. 
According to certain -writers, thick cords run less risk than thin. This is 
illusory, but it is different with the variety of prolapse, the position of the 
foetus, the part of the pelvis at which the prolapse occurs, the amount of 
the cord which is procident. Presentations of the head and breech are 
the most dangerous attendants on the prolapse, and when the prociden- 
tia occurs at the sides of the pelvis, it is less exposed to compression than 
at the anterior or posterior portion. Finally, the conformation of the 
pelvis, the duration of labor, the degree of the contractions, have an in- 
fluence. Every cause which retards labor, of course influences the prog- 
nosis for the child. Further, the nature of the interference modifies the 
prognosis. 
Results of the Prolapse.-Prolapse of the cord does not, of course, in- 254 
A TREATISE ON OBSTETRICS. 
fluence in the least the progress of labor, except in those very exceptional 
cases where the loop surrounds the head or the breech of the foetus, and 
opposes the descent of the presenting part. The consequence of prolapse 
is death of the infant. What is the cause of its death ? 
Smellie, Osiander, Schweighauser, Joerg, Hebenstreit, and others, laid 
stress on cooling of the cord, prolapsed outside of the vulva, and consecu- 
tive coagulation of the blood in the umbilical vessels; others, Mauriceau, 
Roederer, Baudelocque, Siebold, Carus, Meissner, admit refrigeration as 
an adjuvant cause, but insist, in particular, on compression of these ves- 
sels. All modern authors admit only compression as the cause of the in- 
fant's death. Kohlschuetter has proved that the theory of refrigeration 
was based on nothing at all positive, and that in the vagina the cord does 
not cool, and yet the infant dies if the cord be compressed. Difference 
of opinion only exists in regard to what vessels are compressed. Some 
say the vein, others the arteries, others both vein and arteries. Mittel- 
hauser, May, Wigand, Deneux, Bartscher, Baudelocque, who contend 
for compression of the umbilical vein alone, attribute the death of the 
foetus to hemorrhage, anemia, syncope. The foetal blood is carried to it 
by the arteries, but cannot return through the compressed vein. There 
results diminution in the amount of blood, and anemia of the foetus. 
Schure remarks, with justice, that the spiral arrangement of the vessels 
in the cord, will not permit of compression of the vein alone, and further 
that we ought to find the placenta gorged with blood, which is not the 
case. 
Ruhl and, Adolph, Faust, Gehler, contend for compression of the 
arteries only, and that there results congestion in the foetal viscera, and 
the infant dies of apoplexy. 
Finally, others contend for compression of all the vessels, and Heben- 
streit attributes death to the accumulation of blood in the heart, Adolph 
in the lungs; Waldkirsch believes in cerebral apoplexy, either primitive 
or secondary. Now in cases of foetuses dead from compression of the cord, 
we find neither anemia, nor hyperaemia, nor apoplexy, and therefore 
Schure and all accoucheurs are in accord in the belief that the foetus 
dies from asphyxia. Even as the adult has need of oxygen in order to 
live, so too the foetus. But whilst man gains his oxygen from the ex- 
ternal air, and his food from the intestine, the foetus acquires its oxygen 
from the maternal blood, through the placenta and the cord. The pro- DYSTOCIA DUE TO THE FOETUS. 
255 
ducts of retrograde metamorphosis return to the maternal blood from the 
foetal. If this interchange between the mother and the foetus is inter- 
rupted, the foetus asphyxiates and dies. In the normal state the foetus is 
in a condition of apnea, that is to say it does not need to respire, since it 
acquires otherwise a sufficiency of oxygen. Under normal conditions this 
state is only modified after the birth of the infant, and the infant only 
makes its first respiratory movement at birth. But if the cord is com- 
pressed, and if, in consequence, the regular supply of oxygen is suppressed, 
the infant ceases to be apneic, it makes an inspiratory movement, and 
the consequences of this first act are: 1. Suppression of the placental 
circulation, or at least notable diminution, lowering of the blood pressure 
in the right ventricle under the influence of the enormous sudden dilata- 
tion of the pulmonary arteries; 2. Suction into the respiratory passages 
of liquor amnii. The oxydation of the foetal blood does not occur, and 
the inspiratory acts recurring and drawing more and more into the thorax 
the blood from the right heart, and carbonic acid accumulating more and 
more in the blood, and the excitation of the medulla diminishing, paraly- 
sis of the heart ensues, and the infant dies. 
Asphyxia may, according as the compression is rapid or slow, occur 
rapidly or slowly, and hence the two conditions of apparent death in which 
the infant may appear. Post-mortem, indeed, congestion of the brain, 
heart and lungs have been found, as also anemia; but these differences 
are only apparent, and the same lesions are to be detected in the nervous, 
circulatory and respiratory centres. 
In case of compression of the cord, sudden death occurs but rarely, and 
usually the accoucheur may, so to speak, follow the progress of asphyxia 
by means of auscultation. 
Finally, compression may occur within the membranes before rupture, 
and in Depaul's opinion, which seems rational, where the liquor amnii is 
greenish and tinged with meconium, notwithstanding the integrity of the 
foetal heart, the explanation is probably to be found in transient compres- 
sion of the cord. 
Treatment.-The treatment varies with the case, and whilst in certain 
instances only rapid intervention can save the child, in others, on the 
contrary, haste would be only harmful, and expectancy is indicated. 
If the prolapsed cord is diagnosticated within the membranes, we must 
above all keep these intact as long as possible. The woman should lie 256 
A TREATISE OX OBSTETRICS. 
down, the buttocks elevated, and but few vaginal examinations should be 
made. The progress of labor should not be hastened, however prolonged. 
Birnbaum advocates the introduction of the colpeurynter to sustain the 
membranes. A Gariel pessary might be used for the like purpose. By 
means of the colpeurynter, according to Birnbaum, the vagina is dis- 
tended ; if the membranes rupture the waters can escape but slowly, the 
uterine contractions are intensified. Abegg approves this procedure, but 
we do not grant it any special advantage, for it is not in the vagina, or in 
the cervix, but at the level of the superior strait that the cord is subject 
to compression, and hence the tampon cannot relieve or moderate it. 
As soon as the membranes rupture, an examination should be made to 
gain whatever information is possible as to the state and the condition of 
the cord. 
When prolapse of the cord has been diagnosticated before rupture of 
the membranes, Ritgen has advocated placing the woman in the knee- 
chest position, or in the lateral position on the side opposed to that where 
the cord has prolapsed. Birnbaum, Ritgen's pupil, affirms that this 
manoeuvre alone has never resulted successfully. 
When the membranes rupture and we have assured ourselves of pulsa- 
tion in the cord, three methods are at our disposal: 1. Abandon the labor 
to nature, and simply direct and second hei' efforts; 2. End the labor as 
soon as possible; 3. Attempt reduction of the cord. 
Labor can only be left to the efforts of nature under the following 
circumstances: where the infant is dead, where the pains are good. We are 
dealing with a multipara, and where, consequently we may expect the end 
of labor in a few minutes. If, however, the pains are few and irregular, 
the pelvis is deformed, the foetal heart is troubled, the os is rigid, we must 
interfere. Where the cervix is dilated or dilatable, we should resort to 
the forceps or to version. Where such interference is impossible, we must 
try to reposit the cord and maintain it above the presenting part. 
Reduction of the cord may be attempted by the hand or by instruments. 
Manual reduction was employed by Mauriceau, Amand, Deventer, 
Roederer, Siebold, d'Outrepont, Busch, Kluge, Michaelis, and others. 
The latter in 35 cases succeeded 21 times, Lachapelle 14 out of 16. 
Lamotte, Smellie, Baudelocque, Boer, reject the method, whilst Ritgen, 
Kiestra, Leopold, Simpson, and others, recommend reposition by posture. 
The cord, grasped in the palm of the hand, is to be carried above the 257 
DYSTOCIA DUE TO THE F(ETUS. 
internal os and the presenting part, and held there until engagement of 
the foetus has taken place, and further descent prevented. Now, when 
the cervix is sufficiently dilated to allow this manoeuvre, it is much more 
simple to deliver at once by version. When the cervix is not sufficiently 
dilated then manual reposition of the cord becomes, as Boer has well ex- 
pressed it, a laboi- of the Danaids-it is carried*up by the fingers and it 
falls down again. As for the advice to sling the cord around one of the 
foetal limbs, it does not seem to us acceptable, for where the cervix is 
sufficiently dilated to allow of the procedure version is also possible, and 
this is preferable; in the event of the cervix not being dilated or dilatable, 
neither method is practicable. 
[We do not believe that Charpentier does justice to the method of re- 
position by posture. Thomas, of New York, in an article published in 
1858, amply demonstrates the value of the method, and it is as rational 
in theory as it is successful in practice. By posture we simply reverse the 
action of gravity, and in cases where the presenting part is not firmly 
engaged, the liquor amnii not entirely escaped-in short in cases where 
the foetus is still moveable-the cord will often slip back into the upper 
uterine segment, and will ordinarily remain there if care be taken to keep 
the patient in the semi-prone position until the presenting part has 
engaged. It is in the knee-chest position, furthermore, that manual 
and instrumental reposition should be tried, and the manipulation is in 
every way facilitated by working through the Sims' speculum. We 
would not be understood as meaning that reposition of the cord is a simple 
matter. We desire, purely, to lay stress on the fact that the postural 
method, under the given conditions, aided it may be by the hand or an 
instrument, is worthy of greater praise than Charpentier grants.-Ed.] 
Numerous instruments have been devised for reposition: the omphalosoter 
of Scholler, modified by Tarnier, (Fig. 161); the cord repositors of Braun 
(Fig. 162), Naegele and Scanzoni; the sponge repositors of Osiander, Sax- 
torph, and others; the slings, elastic rods, etc., of Eckhardt, Wellenbergh, 
Davis, Simon, and others; Murphy's repositor (Fig. 166), Lambert's (Figs. 
163 to 165), and others too numerous to mention. The oldest and simplest 
method is that of Dudan, modified by Dewees. Naegele and Grenser 
describe it as follows: " The cord is surrounded by a loop of ribbon, the 
ends of which are tied. A portion of the loop is passed through the eye 
of an elastic catheter armed with a stylet which retains the loop. (Figs. 
Vol. Ill-17 258 
A TREATISE ON OBSTETRICS. 
167, 168.) The catheter is guided by the finger into the uterus, and the 
stylet is withdrawn, and finally the catheter, leaving the ribbon and cord 
in the uterus. Of course, care is to be taken not to compress the cord 
by the ribbon loop." 
We have used the following procedure on one occasion, and it succeeded 
admirably. It is a modification of Dudan's. We surround the cord with 
Fig. 161.-Braun's Repositor. 
Fig. 162.-Scholler's Instrument. (Closed.) 
a silk loop and we tie this loop tight enough to prevent slipping, and yet 
not to compress. The terminal ends of the loop we next tie to an olivary 
elastic, or wax bougie. The cord is thus firmly held at the end of the 
bougie. We then pass the bougie into the uterus and leave it there, and 
tliis is wherein our method differs from others. The cord is not only held 
in place, but the bougie promotes what we desire, active contractions. 259 
DYSTOCIA DUE TO THE F(ETUS. 
[Without wishing to detract from Charpentier's claim to originality, 
this method, the best of all, was suggested by Roberton, and has been 
employed frequently with success. He passed a doubled piece of ordinary 
Fig. 163. Fig. 164. Fig. 165. 
Fig. 163.-Lambert's Repositor, (ready for use).-a, Double loop, b, Elastic stylet, c, End of 
stylet, e, Ring of stylet, f, Ends of loop. 
Fig. 164.-The same, with loop detached to receive the cord, or limb. 
Fig. 165.-Another Repositor, (without stylet).-a, b, e, Loop, c, End of loop sewed to the 
sound, to prevent slipping, d, Sound. 
twine through a catheter, and out at the eye. The cord is drawn through 
the twine loop, and the ends of the twine are tied to prevent slipping. 
The catheter is passed to the fundus with the cord and left there. 260 
A TREATISE ON OBSTETRICS. 
Ashford reported a case in the American Journal of Obstetrics, for 1878, 
where he attached the cord to a Gariel pessary, carried the pessary to the 
fundus, and inflated it. The method was successful.-Ed.] 
Fig. 166.-Murphy's Repositor.-A, Instrument with ring closed. B, With ring open. 
Fig. 167. Fig. 168. 
Fig. 167.-Dugan's Instrument. Ribbon fixed by the stylet. 
Fig. 168.-The Same, with the stylet withdrawn to allow the escape of ribbon. 
Dystocia from the Side of the Foetus. 
The causes may be divided into the six following classes: 1. Excess of 
volume without pathological alteration. 2. Excess of volume through 
pathological alteration. 3. Abnormal presentations and positions. 4. 
Prolapse and vicious position of the limbs. 5. Twin pregnancies. 6. 
Monstrosities. These wre proceed to consider separately. 
I. Excess in Volume without Pathological Alteration. 
This may be partial, limited to the head, or general. 
Excess in Volume of the Head.-This cause of dystocia is rare, and al- 
though Saxtorph, Voigtel, Credo, Hold, have reported cases of ossification 261 
DYSTOCIA DUE TO THE F(ETUS. 
of the sutures, with and without the presence of Wormian bones, Naegele 
and Grenser remark, justly, that there exists no authentic case of labor 
retarded by this cause alone. The two cases cited by Joulin from Mau- 
riceau and Delamotte, are open to doubt, and, as Cazeaux says, the 
method of action in such cases is doubtful, seeing that we can only ap- 
proximately estimate the size of the foetus while it is in the uterine 
cavity. 
Total Excess in Volume.-The majority of the reported cases are apocry- 
phal. Among the recorded cases we cite: Crantz's case where the foetus 
weighed 23 pounds; Cazeaux's and Riembault's, 18 pounds; Depaul's, 
12f; Ramsbotham's, 16; Martin's, 15 pounds. We have seen two. In 
the one, a boy, the weight was 12f pounds; in the other, a girl, 10 
pounds, If ounces. 
The age of the patient and the number of anterioi- labors combine to 
increase the weight of the child. This has been proved by the researches 
of Hecker, Veit, Frankenhauser, Wernich. Clarke and Simpson claim 
a notable difference in case of boys. Hecker and Schroeder admit this, 
but with greater reserve. Pfannkuch has shown that, the weights being 
equal, boys have always larger heads than girls, and Schroeder says that, 
while in young primiparae it is not exceptional to find a head with the 
transverse diameter measuring less than 3.7 inches, in old multiparae, if 
the child is a boy, the same diameter often measures 4 to 4.5 inches. 
The researches of Lumpe, Hecker, Ahlfeld, Bidder, in regard to the 
weight of successive infants, allow us to draw the following conclusions: 
1. The size of the child is greater in old primiparae than in young. 2. 
The reverse holds true in case of multiparae. 3. Boys predominate in 
very young women, and in those who have passed the age of thirty, 
whether primiparae or multiparae. 
It is apparent that when the foetus weighs as much as in the cases cited 
above, labor may be prolonged and difficult; but ordinarily it is only 
where pelvic deformity is associated with increased size that the obstacles 
to delivery become serious, and then the true cause of dystocia resides, 
as has been clearly pointed out by Jacquemier, in exaggerated size and ab- 
sence of rotation of the shoulders. 
This cause of dystocia has been mentioned, says Jacquemier, by the an- 
cient writers under two varieties: il In the first, it is supposed that, after 
the spontaneous or artificial birth of the foetal head, the large shoulders 262 
may present an obstacle to the birth of the body, which the uterine efforts 
singly, oi- aided by artificial means, cannot overcome. In the other, the 
shoulders are supposedly stopped at the brim or in the excavation. The 
head does not advance beyond the inferior strait, because the expul ^ory 
efforts are wasted on the shoulders, and not transmitted to the head. 
This constitutes Levret's imprisonment of the shoulders. " When we speak, 
Jacquemier further adds, of the volume of the shoulders, we really mean 
the volume of the thorax. Usually the above varieties of dystocia are 
conjoined. 
According to the same authority, arrest of the shoulders may depend: 
" 1. In four out of five cases exclusively on the exaggerated size of the 
thorax and the shoulders. 
112. On lack of proportion between the body of the foetus and the pelvis. 
" 3. On acephalic or anencephalic foetuses. 
"4. On absence of rotation of the shoulders, this in turn resulting 
from inertia uteri. 
" The indications for treatment vary, of course, with thecause. If the 
volume and not the position of the shoulders constitutes the obstacle, 
then the forceps. If this fails, mutilation of the head) in order to bring 
down an arm, and by traction on it, to deliver the trunk. If the head 
has been delivered, either traction on the head, which will often be of 
no avail, or else the insertion of the fingers in the axillae and traction. A 
better method is to first disengage one arm, and then the other, for thus 
the size of the thorax is diminished." 
This is the method which we advocate, but we must act quickly. We 
will often fracture an arm, or paralyze it, but both these lesions are re- 
covered from in a short space of time. 
A TREATISE on obstetrics. 
Excess of Volume through Pathological Alteration. 
I. Hydrocephalus. 
Under the term hydrocephalus are included all exudations of serum 
in the cavities of the brain and in its envelopes. We thus exclude the so- 
called external hydrocephalus, which consists in the collection of fluid 
between the skin and the cranial bones, and which is purely the result of 
the uterine contractions, of pressure, or of traction made by the ac- 
coucheur. " Under these influences, " says Herrgott, " internal hydro- 263 
DYSTOCIA DUE TO THE FCETUS. 
cephalus existing before labor, a small amount of the fluid contained with- 
in the cranium escapes through one of the sutures and spreads over the 
external surface of the skull, so as to form a tumor added to the head. 
This pouch or tumor is simply a diverticulum, so to speak." 
Hydrocephalus, then, as we understand it, is purely dropsy of the cere- 
bral ventricles, a dropsy which may spread into the substance of the brain, 
in the pia mater, into the sub-arachnoidean spaces, and finally between 
the cavity formed by the reflexion of the arachnoid on to the dura mater. 
Frequency.-Hydrocephalus is infrequent. Thus: 
Lachapelle ... in 43,553 labors saw 15 cases 
•Merriman a 900 " " 1 case 
Lever . ... " 4,666 " " 1 case 
Hohl .... tl li in cases 
McDonald 
Ramsbotham 
" 3,000 " " 1 case 
Kucher " 12,000 11 " 3 cases 
The above figures seem to us too low, for in our two years' service at 
the Clinique, in 2000 labors we saw three cases, and we have since seen 
four more in private practice. We believe that Merriman's figures, 1 out 
of 900, is near the truth. 
Causes.-The following causes, more or less hypothetical, have been 
invoked: Advanced age of the parents, alcoholism, excess in coitus, syph- 
ilis, chronic inflammations of the arachnoid and of the internal lining of 
the ventricle, interference with the venous circulation (Barrier), heredi- 
tary cretinism (Herrgott); of all these causes syphilis alone would seem to 
have a real influence, as proved by the cases of Osiander, Haase, Bayer, 
Gros, Lanceraux. Against these, however, we can oppose the numerous 
cases of syphilis without hydrocephalus. In certain women there seems 
to be a habit of giving birth to hydrocephalic infants, as noted by Franck, 
Underwood, Gelis, Castelli, Armstrong. Bouchacourt finally insists 
on the influence of consanguineous marriages. 
Pathological Anatomy.-The quantity of fluid in the cranial cavity may 
vary from a few spoonfuls to a number of quarts. The fluid is like that 
of dropsy elsewhere, clear, light yellow, containing .246 per cent, of 
albumin (Hilger), soda salts, and extractives. Where hydrocephalus is 
complicated by anencephalus, the amount of albumin is greatly increased. 264 
A TREATISE ON OBSTETRICS. 
This liquid, distending the cerebral ventricles, pushes the cerebral matter 
aside, and this atrophies, and tends to disappear with increase in the 
amount of fluid. In certain cases the brain is converted into a cyst with 
thin walls. It is apparent that the head may assume enormous propor- 
tions. Wrisberg has reported a case where the greatest diameter of the 
head was 9f inches, and the circumference 31 inches; Meckel a case 
Fig. 169.-Hydrocephalic Fietus.- Upper and lower limbs very short. Abdomen voluminous, 
without ascites. (Vrolik.) 
where the bi-parietal diameter was 16f inches, and Verdu (1846) a case 
where the head was 10 inches long and 30 in circumference. 
The bones are thinned out in accordance with the amount of distension, 
and sometimes they lose their consistency, and become as parchment. 
The fontanelles and the sutures, greatly enlarged, fluctuate, and through 
the intervals project pouches forming encephaloceles. Further, hydro- 
cephalus may be complicated by hydrorachis and other malformations. 
The physiognomy of hydrocephalus is always about the same. The 
face is small compared with the exaggerated development of the skull DYSTOCIA DUE TO THE F(ETUS. 
265 
(Fig. 169), and the skull may be asymmetrical according as the distension 
affects one ventricle more than another. Poullet insists on the persist- 
ence of the accessory sagittal suture. 
We are more particularly concerned with the affection in its relations 
to pregnancy and labor. 
Hydrocephalus during Pregnancy.-Ordinarily the affection is not 
recognized before the advent of labor. The symptoms during pregnancy 
are very vague. The size of the abdomen may be normal or increased; 
and sometimes, by conjoining the signs furnished by palpation, the touch, 
and auscultation, we may assume the presence of the affection. In the 
majority of cases, however, diagnosis during pregnancy is not possible. 
One striking factor marks hydrocephalus, and this is the association of 
presentation of the pelvic extremity. 
While, where the pelvis and foetus are of normal size, the vertex pre- 
sents in 19 cases out of 20, and the pelvic extremity once out of 70 or 80, 
in the 28 cases of hydrocephalus collected by Chassinat, there were seven 
presentations other than that of the vertex. Scanzoni, in 152 cases of 
hydrocephalus, found 30 other than the vertex. Poullet in 106 cases, 
found vertex in 65, face in 6, breech in 30, shoulder in 8, and in three 
cases, although not the vertex, not stated. There seems ground for error 
in these figures, for it is difficult to understand how'the face can present 
at all when we consider the shape of the head in hydrocephalus. 
Presentation of the Vertex before Labor. -Sometimes increased size of 
the abdomen will be noted; again considerable edema of the lower limbs. 
Again supra-pubic edema, which is also found in case of hydramnion and 
twin pregnancy. Palpation will often give us the most precise informa- 
tion. If the uterus does not contain much fluid, if it is soft and com- 
pressible, we may determine the disproportion existing between the large 
head and the breech. In two cases Blot made the diagnosis by ausculta- 
tion from the unusual height of the point where the foetal heart-sounds 
were heard. 
During Labor.-While the membranes are still intact, the diagnosis is 
often difficult, but when once ruptured, it becomes easy. The head rep- 
resents a fluctuating pouch, which might be mistaken for a second bag of 
waters, but the skin of the head is always thicker, and the hair may be 
felt. While the sutures and the fontanelles are scarcely recognizable, 
owing to their exaggerated dimensions, one or another bone of the skull 266 
A TREATISE ON OBSTETRICS. 
may always be reached, and this will frequently feel like parchment. The 
cases are not rare where, in the belief that there was a second bag of 
waters, the brain has been perforated. The caput succedaneum is 
a further source of error. Further still, where the foetus is dead and has 
been retained for some time, the changes determined by prolonged macer- 
ation might at first deceive us. The absence of the foetal heart and of 
the movements, for some time, and the character of the amniotic fluid, 
which is like wine-lees, will, however, in this instance, make the differen- 
tial diagnosis. 
As a general thing, labor progresses slowly, and uterine inertia often 
follows on energetic contractions. The influence of hydrocephalus on 
labor is, however, variable, and Spiegelberg makes three divisions: Labor 
is only slightly prolonged, the affection not very marked, and delivery 
occurs spontaneously. Delivery is still spontaneous, but it is prolonged 
and painful. Delivery is impossible, and it is here that rupture of the 
uterus may occur. 
In certain instances, where the distension was great, spontaneous deliv- 
ery has occurred, owing to the formation of a pouch containing the fluid, 
which enables the head to be compressed, and to pass through the pelvic 
canal. Sometimes, instead of forming a pouch, the fluid infiltrates the 
neck and thorax of the foetus, and even the abdomen, giving rise to a 
generalized edema, and enabling the bones of the skull to collapse. These 
cases are exceptional and usually accompany pelvic presentations. Finally 
where delivery is impossible, the uterus may, as we have stated, rupture. 
In 74 cases of hydrocephalus, this occurred 16 times. (Keith.) 
Presentation of the Pelvic Extremity before Labor.-The diagnosis has 
never been made. 
During Labor.-The progress of labor is characteristic. Everything is 
normal until the body has been delivered, and then the head does not 
engage, but is stopped above the superior strait, projecting above the 
symphysis. Traction is useless, and delivery is only possible through 
evacuation of the fluid, either artificially or spontaneously. 
Prognosis.-This is grave both for the mother and the infant. 
Chassinat, in 60 cases, noted the death of the foetus 41 times before or 
during labor, and of the 19 remaining, 8 lived less than four months, 5 
one year, 2 less than two years, and only 4 over two years. Further, it 
was only in the instances where delivery was spontaneous that the infants 
survived. Intervention is absolutely fatal. DYSTOCIA DUE TO THE F(ETUS. 
267 
Of Chassinat's 28 cases, .... all still-born. 
Of Ouvrier's 17 " " li 
Of Herrgott's 21 " . . . 20 " 
We have been more fortunate. True enough the affection was slight, 
but we delivered by the forceps an infant which lived 5^ months. 
Presentations of the pelvic extremity render the prognosis still more 
unfavorable. 
In case of the mother the prognosis depends purely on the conduct of 
the accoucheur. Early diagnosis and intervention are in her favor. 
In 106 cases Poullet noted 24 deaths 
In 94 " Spiegelberg " " " 
The mother usually dies from rupture of the uterus, or from trauma- 
tism during efforts at delivery. 
Treatment. -This varies according as the presentation is of the vertex 
or the pelvic extremity. 
In case of the vertex, as we have before stated, if the affection is slight, 
spontaneous labor is possible. If the affection is more pronounced, the 
forceps may be tried, but if after a number of prolonged tractions the 
head does not come down, we should at once perforate. Certain authors, 
in the hope of giving the infant a chance, have counselled puncture with 
a fine trocar. This hope is a vain one. The head must be extracted by 
the cephalotribe or the bone forceps. We prefer the former. Certain 
authorities have recommended version. This should never be attempted 
before diminution of the head, and afterwards we do not see what advan- 
tage it offers over the cephalotribe. 
In case of presentation of the pelvic extremity traction will sometimes 
deliver, but also sometimes result in separation of the trunk. Perforation, 
after one or another fashion, should be the rule. Lacroix and Van Huevel 
have advocated evacuation of the fluid through the vertebral canal. Tar- 
nier has done this a number of times. He makes an incision with a bis- 
touri down to the vertebrae, and then pushes a catheter through the 
rachidian canal into the cranial cavity. In 1878, Maggioli succeeded by 
this method. Indeed, it is so simple that it should be resorted to in 
every case of pelvic presentation with hydrocephalus. (Fig. 170.) 268 
A TREATISE ON OBSTETRICS. 
In certain rare cases, finally, the infants have presented transversely. 
Tarnier, Koscia, Gripat (1873) have recorded cases. After version, evacu- 
ate the fluid as indicated above. 
Fig. 170.-Hydrocephalus and Presentation of the Pelvic Extremity. Van HuevePs 
and Tarnier's Method. (Herrgott.) 
II. Encephalocele. 
Larger defines enceplialocele as a congenital tumor of the cranium and 
face, with concomitant lesions more or less pronounced of the brain, and 
consisting in a larger or smaller diverticulum of the meninges and the DYSTOCIA DUE TO THE F(ETUS. 
269 
brain, rarely the former alone, with or without serous fluid. He unites 
under this name the four varieties described by Spring, meningocele 
(Fig. 171), encephalocele (Fig. 172), hydrencephalocele, synencephalocele. 
Fig. 171.-Hydromeningocele. (Herrgott.) 
He admits three degrees: 1. Tumors in which the bones of the vault of 
the skull are almost ossified, and where there is simply a hole in the skull. 
These are the true surgical tumors. 2. Tumors in which almost all the 
Fig. 172.-Encephalocele. (Vrolik.y 
bones of the vault are ossified. 3. Where the skull is almost entirely 
membranous. 
According to the site of the tumor, he gives the following names: 
1st. degree. No special name for each region. 
2d. " Fronto-facial region . Proencephalocele. 
" " Occipital . . . Notencephalocele. 
" " Interparietal " . Podencephalocele. 
3d. " Complete exencephalocele. 
Frequency.-Although rare, Larger has been able to collect 98 cases. In 5000 labors, and over, Vines noted 1 exencephalocele; in 12,900 
Trelat noted 3. 
Girls are more subject to the lesion than boys: 
270 
A TREATISE ON OBSTETRICS. 
Larger in 28 cases 
Girls, 17. 
gOyS 
Girls, 35. 
Boys, 24. 
Spring in 59 cases 
Seat.-Wallmann in 44 cases found 24 posterior, and 20 anterior. 
Larger in 85 cases found 41 posterior, and 44 anterior. 
Anteriorly the site of election is the root of the nose; posteriorly it is 
sub-occipital. Encephaloceles are most frequent anteriorly, and hydren- 
cephaloceles and meningoceles posteriorly. 
Pathological Anatomy.-In case of exencephalocele the cavity in the 
bone is round or oval, more or less regular in border, always smooth. 
The dura mater is adherent to the walls of the sac, and, according to the 
majority of writers, the fluid is cephalo-rachidian. Larger, however, con- 
tends that since exencephaloceles are irreducible, it is difficult to admit 
that the fluid contents are in communication with the cephalo-rachidian 
fluid. These exencephaloceles may be accompanied by serous congenital 
cysts of the neck, by angiomata, lipomata, and other abnormalities of the 
body. While Spring and others attribute the lesion to hydrocephalus, 
Larger believes that the production is intimately connected with the de- 
velopment of the skull and the brain. 
Symptoms.-The tumor is always constricted at its base, and varies in 
size from a lentil to the foetal head at term. It is usually single, at times 
bi-lobed, is always irreducible, painless on pressure, and only accompanied 
by reflex action, cries, and convulsions, when it is complicated by me- 
ningo-encephalitis. It is translucent or opaque, according to the thick- 
ness of the tissues covering it; either solid or fluctuating. 
These tumors only complicate labor when voluminous, as in the cases 
of Ruysch, Deslandes, Tarnier. Labor is speedier when the head rather 
than when the pelvic extremity presents. If the obstacle to delivery is 
great, it suffices to puncture the tumor. 
III. Hydrothorax. 
Hohl has reported two cases, and Gottel one. Herrgott has investigated 
the latter case, and says it was really an ascites. It is indeed exceptional for hydrothorax to exist alone, and to be considerable enough to be a cause 
of dystocia. Ascites is almost always joined with it, and constitutes the 
real obstacle. Herrgott cites 8 case of ascites and hydrothorax, collected 
by Galetti and by Siebold. 
DYSTOCIA DUE TO THE F(ETUS. 
271 
IV. Ascites. 
Frequency.-Congenital ascites is very rare. The number of recorded 
cases amounts to about 50. Van Gelder ranges them under the following 
heads: 
1. Ascites, simple, 13 cases. 
2. " with hepatic lesions, with or without 
peritonitis, . . 3 " 
3. " 11 splenic lesions ... 1 case. 
4. " " inflammatory lesions . . 5 cases. 
5. " " retention of urine and hydrone- 
phrosis, complicated by per- 
itonitis, oi- not . . 4 " 
6. (l " retention of urine alone, with 
or without inflammatory 
lesions, . . . 6 " 
7. " " retention of urine and degenera- 
tion of the kidneys, . 3 " 
8. " " exudation into cellular tissue or 
serous cavities, . . 2 " 
9. " " hydrothorax, ... 1 case. 
10. (f complex cases, a. hypertrophy of liver, 
hydrocele, edema of th e scalp; 
b. hypertrophy of the liver 
and of the spleen, and peri- 
tonitis, ... 3 cases. 
Usually, hence, ascites is complicated by inflammatory lesions of the 
peritoneum, or by multiple lesions of the abdominal organs. The quan- 
tity of fluid varies from one-third of a pound to pints and over, and is 
ordinarily a yellow serum, sometimes clear and limpid, again greenish 
yellow, red, probably due to admixture with blood. The peritoneum has 272 
A TREATISE ON OBSTETRICS. 
been found inflamed, thickened, covered with reddish granulations. The 
intestines are bound together; the spleen occasionally hypertrophied; the 
liver frequently altered. Porak found an abscess in the liver. Retention 
of urine is a frequent complication. The bladder congested, thickened, 
with or without imperforate urethra. Sometimes hydronephrosis, de- 
generation of the kidneys by hydramnion, exaggerated development of 
the placenta, are found. Anomalies elsewhere in the body, imper- 
forate anus, absence of the scrotum, persistent urachus, absence of the 
caecum or colon, accompany the ascites. Syphilis is a frequent causal 
factor. 
During pregnancy the symptoms are about nil. The development of 
the abdomen, and the rapidity of this growth, edema, respiratory troubles, 
diminution in foetal movements, absence of ballottement, etc., which have 
been mentioned as signs, are met with in many other conditions, and we 
cannot, hence, establish a diagnosis by them. It is only during labor 
that we may suspect ascites. When, after delivery of the head or the 
breech, the trunk is arrested, we should introduce the hand along the ven- 
tral surface of the foetus. The exaggerated development of the abdomen 
and fluctuation may thus be determined. But the question will still re- 
main, are we dealing with simple ascites, or with retention of urine? The 
answer to this question can usually only be made after birth. 
The prognosis is always fatal for the infant and for the mothers; it de- 
pends on the method of intervention. 
The only way of ending labor is by puncture, by means of a trocar. In 
many cases the finger has served as perforator. 
V. Diseases of the Urinary System. 
a. Diseases of the Ureters and Cystic Degeneration of the Kidneys.- 
These affections are rare. 
b. Retention of Urine in the Fcetus.-The most frequent cause of dys- 
tocia from the side of the urinary apparatus is retention of urine. The 
first authentic case of this nature was reported by Portal in 1685. (Fig. 
173.) Depaul wrote a monograph on the subject in 1850. In the ma- 
jority of recorded cases, there has existed in addition to imperforate ure- 
thra other complications. Joulin, however, notesthat in certain instances 
the canal is not imperforate. Ordinarily, as shown by Herrgott, the ver- DYSTOCIA DUE TO THE F(ETUS. 
273 
tex presents, and puncture of the bladder is therefore rendered difficult. 
The infants are rarely born alive, and then usually die in from a few hours 
to a few days. 
Fig. 173.- -Retention of Urine in Foetus. 
The guide for puncture is the insertion of the cord. Often retention 
of urine is complicated by ascites. Both fluids must here be evacuated. 
VI. Diseases of other Organs. 
Haase and Noeggerath have recorded a case of dystocia, due to hyper- 
trophy of the liver; Letullea case of syphilis and hepatic tumor; Kollsch 
a case of hernia of the liver; Martin a case of hypertrophy of the pan- 
creas with ascites; Mangin a case of hypertrophy of the spleen with ascites, 
also Voss; Gervis a case of excessive distension of the foetal uterus; 
Rogers a case of cystic degeneration of an undescended testicle; Phenome- 
now a case of large aneurism of the aorta. 
We will see further on that foetal inclusion may become a cause of dys- 
tocia. 
VIL Tumors of the Ano-perineal Region. 
Writers have divided tumors of this nature into various classes. In 
1862 Braun stated the following divisions: 1. Tumors connected with 
Vol. in.-18 274 
A TREATISE ON OBSTETRICS. 
the spinal canal. 2. Degenerations of Luschka's gland. 3. Sacral hy- 
gromas. (Figs. 174 and 175.) 4. Coccygeal and sacral fibromas, cysto- 
fibromas, cysto-carcarcinomas, etc., (Figs. 176, 177.) 5. Hydrorrachis 
(Fig. 178. ) 6. Lipomata. 7. Tumors found in adults, and the congeni- 
tal nature of which has not been proved. (Figs. 179, 180. ) He has 
Fig. 174.-Tumor of the Coccygeal Region. 
(Hygroma.) 
Fig. 175.-Tumor of the Coccygeal Region. 
(Hygroma.) 
been able to collect 95 cases of the above varieties. In 1868, Molk col- 
lected 107 cases. 
Without attempting a further classification, we proceed to describe 
briefly the appearance of these tumors, referring to Braun's work for 
the details. 
In shape these tumors are, in general, either hemispherical or elon- 
gated; their surface is smooth, sometimes irregular, and they vary in size, 
occasionally reaching even to the heels. They usually project from the DYSTOCIA DUE TO THE FfETUS. 
275 
sacrum or the coccyx. In certain instances, a second tumor, within the 
abdomen, connects with the external. The external covering is formed 
by the skin, a fibrous membrane, and a mucous membrane. The skin is 
tense and traversed by dilated vessels. The contents are solid and liquid. 
The former consist of embryoplastic tissues (Depaul), and remnants of 
normal tissue (Molk, Duplay.) Fat and multiple serous cysts are also 
found. They are sometimes not attached to the bones, as in a personal 
Fig. 176.-Cysto-fibroma of the Coccy- 
geal Region. 
Fig. 177.-Cysto-carcinoma of the Coccygeal 
Region. 
case, and again adherent to the sacrum and coccyx. The pedicle may be 
long or short and is usually vascular. 
Alongside of the tumors which are evidently the result of foetal inclu- 
sion, we find tumors communicating with the rachidian canal, and con- 
sisting in either hydrorrachis with spina bifida (Fig. 178), or of hernia of 
the membranes or of the cord itself. Braun has described a tumor which 
he calls papillary, and which is made up of villous elements. 
In other instances, these tumors are absolutely independent of the spinal 
canal. Braun and Duplay have described cysts, sarcomata, cysto-sarco- 276 
A TREATISE ON OBSTETRICS. 
mata, fibromata, cysto-fibromata, lipomata, caudal tumors formed by 
supernumerary coccygeal vertebras. 
Fig. 178.-Coccygeal Tumor with Spina Bifida. Fig. 179.-Coccygeal Tumor. 
Fig. 180.-Coccygeal Tumor. 
These tumors may occasionally interfere with labor, and the course of 
action varies according as they are solid or liquid. If it is liquid, punc- 277 
DYSTOCIA DUE TO THE F(ETUS. 
ture; if it is solid, it must be broken up. Labor is more difficult when 
the pelvic extremity presents. 
VIII. Spina Bifida. 
Spina bifida appears as a tumor situated the length of the spine, in the 
median line (Fig. 181.) It is usually found in the lumbar region, then 
in the lumbo-sacral and sacral regions. It may be met with in the cer- 
Fig. 181.-Spina Bifida. 
vical region. The dorsal vertebras are rarely affected. Ordinarily it is 
no larger than an egg. It is usually round or oval, its greatest diameter 
being vertical. The cervico-dorsal region is the seat of predilection of ped- 
iculated tumors. The cavity communicates with the rachidian canal. In 
the dorsal region the tumor is almost always sessile. Generally, the cov- 
erings are the skin, the subcutaneous cellular tissue, the dura mater. 278 
A TREATISE ON OBSTETRICS 
The tumor may be perfectly transparent. At times the liquid escapes 
through an ulcerated spot in the skin. The contained liquid is the 
cephalo-rachidian fluid, and in the lumbar and lumbo-sacral regions either 
the marrow or nerves are included. When the marrow is inserted on the 
posterior wall of the tumor, a depression exists on which Virchow lays 
great stress. At times it is spread over the inner surface of the tumor, 
or floats freely in its cavity. The opening of the spinal canal is due to a 
defect in ossification of the bodies and spinous processes, involving usu- 
ally three to four vertebrae. 
Spina bifida, while frequently existing alone, is often complicated by 
other anomalies in development. The lesion does not seem to have an 
immediate effect on the life of the foetus, since it is born alive; ordinarily, 
however, death occurs during the first year. The tumor ulcerates, or 
ruptures, or it may inflame, and the natural result is death. 
IX. Tumors of varying Nature. 
In addition to the tumors mentioned, which are rare enough, there are 
others which are very exceptional. 
Tumors of the neck; general edema of the foetus (Hohl, Betschler, Osi- 
ander, Meissner, Tait, P. Smith, etc.); ankylosis of the foetus (Busch, 
Braun, Bird, Becourt, etc.); gibbous foetuses (Nivert, Montant, Stoltz, 
Hohl); emphysema of the foetus, which is rather more common. We 
have seen two cases. It is the result of post-mortem change. 
Teratology.-Hermaphrodites. -Monstrosities. 
[In order to render this subject as complete as possible, we have bor- 
rowed much additional matter from the elaborate description in Tarnier 
and Budin's Traite de l'Art des Accouchements. The subject of teratology 
is one to which but little space is devoted in the generality of obstetrical 
treatises, and yet which, from its peculiar interest, deserves somewhat 
extended reference.-Ed.] 
Certain writers have confounded all the anomalies of development under 
the single name u monstrosities." Bonnet, for instance, says " A monster 
is an organized production in which the shape, the arrangement or the 
number of certain of the constituent parts, do not follow ordinary rules." 279 
DYSTOCIA DUE TO THE F(ETUS. 
"We believe, however, that the word ''monster" should only be used to 
designate grave developmental anomalies which result in very apparent 
deformity. An individual with six fingers on one of its hands should not 
be called a monster. The definition of Geoffroy Saint-Hilaire seems 
to us preferable to Bonnet's: "Monstrosities present grave anomalies 
which render difficult, if not impossible, the performance of one or more 
Fig. 182.-Edema of the Fcetus. (Betschler.) 
of the vital functions, or produce in the individual a vicious conformation 
very different from that which it normally has." Thus we possess the 
following general classification: Hemiteric or half-monsters; heterotaxic 
monsters (where there exists displacement or inversion of the viscera); 
hermaphrodites. 
These constitute simple anomalies in development, and where the 
anomaly is more complex, the generic term monster is purely applicable. 
The following table makes cleai' the classification: 
Simple, 
1. Hemiterics. 
Anomalies 
in 
Development. 
Inversion of the 
viscera. 
2. Heterotaxics. 
Grave, 
Genital appa- 
ratus. 
3. Hermaphrodites. 
4. Monstrosities. 280 
This classification, although extremely artificial, and open to grave 
objections, is the best which has been proposed. 
A TREATISE ON OBSTETRICS. 
General Considerations bearing on the Genesis of 
Anomalies. 
Before the establishment of embryology on the basis of a science, the 
grave anomalies in development met with, and the cause of which could 
not be determined, were attributed to the will of the Almighty. Such 
in olden time was the established and not so unnatural belief in regard to 
the legendary Janus, Cyclops, Sirens, Chimeras, Centaurs, etc. This 
period of fable extended into the middle ages, and it was not until the 
XVIIth century that teratology began to be studied and to be understood. 
The various views in regard to the genesis of animals which have been 
held since the discovery of the microscope are most curious. For in- 
stance, Aromatari believed that the ovum contained the embryo already 
formed even before it had begun to develop; Swammerdam said that 11 in 
nature there is no such thing as generation, but only propagation, growth 
of parts and exclusion of all chance. Thus may be explained original sin, 
for all men who have since lived were contained in the beginning in 
Adam and Eve. When these germs are exhausted, the human race will 
cease to exist." This doctrine of the pre-existence of germs lasted into 
the XVIHth century and was advocated by Malpighi. It was not till the 
time of Wollf, who showed that primitively the ovule does not contain 
the embryo, that it was overthrown. 
Etienne and Geoffroy Saint-Hilaire, followed later by Dareste, first 
proved conclusively that all fecundated ovules are identical at the outset, 
and that some external cause, by interfering with their development, 
may determine the appearance of anomalies. Dareste in more than 9,000 
experiments was able to produce all the types of monstrosities from the 
eggs of the chick, and thus showed that physical external causes could 
modify the evolution of the fecundated germ. Whilst then it may be 
considered as proved that external causes influence the production of 
monstrosities, it is also true that other factors are powerful in the same 
direction, and certain ones must, in a measure, act by modifying the 
male or the female ovule before fecundation. How could we explain, 
else, those malformations which are hereditary in certain families ? We 281 
DYSTOCIA DUE TO THE FOETUS. 
would add that the influence of maternal impressions is very problematical, 
especially when we remember that exactly similar anomalies have been met 
with in certain animals in whom there can hardly be question of imagina- 
tion. 
/ 
[In reference to this point we would refer to the forthcoming volume 
(XI.) of the Trans. Am. Gyn. Society, where Fordyce Barker maintains, 
in a paper on 44 The Influence of Maternal Impressions on the Foetus," 
that the weight of authority must be conceded to be in favor of the 
doctrine that maternal impressions may affect the development, form and 
character of the foetus. In the discussion of this paper, Goodell related a 
remarkable case of the kind. There can be no question, we think, that 
there must exist some causal relation, although it is one of those hidden 
mysteries likely ever to remain beyond human ken.-Ed.] 
The varied causes of anomalies act by producing: 
1. Arrest of development; 2. Fusion of organs normally distinct. 
Genesis of Anomalies by Arrest of Development.-These may be grouped 
as under: 
A. An organ may not be formed at all, there being complete arrest in 
development. Acephalic foetuses, absence of uterus or ovaries, etc. 
B. An organ before attaining its definitive form stops short in a less 
advanced developmental phase. Bifid uterus or vagina. 
C. Certain organs normally only exist during intra-uterine life. These 
may persist after birth. 
D. Adhesions may form between the embryo and the membranes or 
between parts of the foetus itself. 
E. Anomalies may be consecutive to changes in the vascular or in the 
nervous system. 
Genesis of Anomalies by Fusion.-These result, in general, from the 
fusion of two blastemas which should remain separate. Usually homolo- 
gous parts unite. It seems as though the mid-portion of the body had 
disappeared, and the right portion had sunk into the left. When two 
homologous blastemas fuse, the result is symmetry in formation, and vice 
versa. 
In the following table are classified the simple anomalies (hemiteric) 
which may affect the foetus. Detailed study of all is impossible. Certain 
of the more important we have already referred to. 282 
A TREATISE ON OBSTETRICS. 
Principal Simple Anomalies. 
In height. 
Dwarfs-diminished growth. 
Giants-excessive growth. 
Diminished size of limbs. 
Faulty development of muscles. 
" " " mammae, thymus, etc. 
Large size of head. 
Increase of adipose tissue. 
Excessive size of breasts. 
In volume. 
Deformities of the head, etc. 
" " " stomach, uterus, vagina, pel- 
vis, etc. 
In form 
In color 
Albinism, complete, partial. 
Melanism, " " 
Abnormal ossification. 
Cartilaginous state of the bones. 
In structure 
In displacement of the 
splanchnic organs. 
Encephalocele, meningocele, etc. 
The heart, lungs, etc. 
Herniae of the viscera; extrophy of the bladder; 
late descent of the testicles, etc. 
In displacement of the 
non-splanchnic or- 
gans. 
Talipes, spinal curvature. 
The vessels, etc. 
In connection 
Bones, teeth, etc. 
Abnormal attachment of muscles, etc. 
Vessels of the heart. 
Vagina, rectum, ureters, urethra. 
In opening 
In perforation 
Rectum, vulva, urethra, mouth. 
(Esophagus, eyelids. 
In union 
Kidneys, testicles, fingers, toes, tongue to pal- 
ate, etc. 
In septum. 
Vagina. 
Uterus. 
Urachus. 
Foramen Botali. 
Hare-lip. 
Epispadias and hypospadias. 
Sternal fissures, etc. 
Spina bifida. 
In persistence or dis- 
junction. . . . 
Absence of muscular bundles. 
t( " vertebrae. 
" " fingers, toes. 
" kidney. 
" " uterus, vagina. 
In numerical diminu- 
tion DYSTOCIA DUE TO THE FCETUS. 
283 
In numerical increase. 
Supernumerary tendons, etc. 
" ribs, teeth, etc. 
" fingers, etc. 
" mammae. 
Many of these simple anomalies are treated of at length in treatises on 
surgery, and therefore we will not describe them here. Of the remainder 
the essential ones have already been noted by us in other portions of this 
work. We pass at once to a brief study of heterotaxy, or inversion of the 
viscera, and to hermaphroditism. 
Heterotaxy. 
Heterotaxy includes simple changes in the position of organs, and such 
changes often occur without real alteration in the relations and connec- 
tions; in other words they are complex and yet do not at all interfere with 
the function of the organs. (Saint-Hilaire.) This author recognizes two 
special divisions: In the one the external form of the individual is pre- 
served, the malformation being limited to the viscera; in the other the 
entire individual is affected, as well the external as the internal organs. 
This form is only met with in animals, and not in man, where the two 
halves of the body are symmetrical. It should not, therefore, detain us. 
Inversion of the internal viscera may be total or partial-total when 
all the abdominal thoracic viscera are affected, partial when only a few. 
Total Inversion of the Viscera.-The reported cases are numerous 
enough. All the viscera are displaced, although retaining their normal 
connections. Analogically, indeed, "the relation is as the wood-cut to 
the proof/' What is the cause of inversion? In the embryo the 
majority of the viscera are symmetrical, and if a certain number become 
later asymmetrical, this may depend on a number of causes. Of the 
organs which are double in the beginning and situated on each side of 
the median line, one may disappear and the other persist. If the organ 
which should atrophy persists, and the one which should persistatrophies, 
inversion will exist. For instance, hepatic inversion would result if the 
right lobe should atrophy and the left hypertrophy, these two lobes being 
considered as remnants of two livers. Again, normally, the digestive 
tube is single, situated in the mid-line, and its right and left halves are 
symmetrical. The tube may curve and its dimensions become modified, 284 
A TREATISE ON OBSTETRICS. 
the stomach forming a right angle with the oesophagus. Thus primitive 
symmetry would be destroyed. 
Partial Inversion of the Viscera.-This variety is rare. It may be 
limited to the lungs. As instances we note anomalies in distribution 
of the great vessels at the base of the heart, anomalies in position of the 
heart. 
Hermaphroditism. 
In times past, under the term hermaphrodite, were designated individuals 
who were supposed to possess the organs of generation of both the male 
and the female, and to be able to perform the functions of the two sexes. 
It is very questionable if from this standpoint there has ever existed in 
the human race an individual so constituted anatomically and physiologi- 
cally. 
It is to Saint-Hilaire that we are indebted for a fairly complete study 
of this subject, defective only because at the time he wrote embryology 
was as yet in its infancy. 
From a developmental point of view we may distinguish in the genital 
organs three segments. The first includes the external organs, and 
primitively these are neutral. As growth proceeds, the genital tubercle 
and folds are differentiated either into clitoris and labia or else into penis 
and scrotum; the second segment includes the vagina, uterus and tubes 
in the female, and the epididymis, the vasa deferentia, the seminal 
vesicles and the ejaculatory ducts in man. The development of this seg- 
ment differs from that of the preceding in that it does not result from 
the transformation of a single blastema into male or female organs. 
Sexal differentiation occurs by the continuous evolution of either Muller's 
ducts or Wolff's ducts. If the former develop and the latter atrophy a 
female is formed, and vice versa. At the outset, then, the embryo is 
bisexal. The third segment is formed by the ovaries in woman, the 
testicles in man. These organs are formed at the expense of the sexal 
eminence. The tissue from which the latter is formed contains at the 
outset both male and female elements. The atrophy of one or another 
element results in sexal differentiation. 
A prime law of development is that the formation of one of two sym- 
metrical organs necessitates that of the other. When a male gland ap- 
pears the rest of the excretory*apparatus must be male, and vice versa. 285 
DYSTOCIA DUE TO THE F(ETUS. 
There may, however, here as elsewhere in the body, result anomalies, 
and when two glands of opposite sexes are formed, we have herma- 
phroditism. Thus, in the third segment, a testicle may exist on one side 
and an ovary on the other, or an ovary and a testicle exist on the same 
side; in the second segment there may be present on the one side organs 
formed by Muller's ducts, and on the other organs formed by Wolfl's 
bodies, or on the same side both the ducts and the bodies may have simul- 
taneously developed; in the first segment, similarly, there may' exist 
clitoris and scrotum, or penis and labia. There result, therefore, many 
varieties of hermaphroditism. 
We must distinguish, in the first place, apparent hermaphroditism from 
the above different varieties. For instance, the testicles may not have 
descended into the scrotum, and the two halves of the scrotum have 
remained separate, and we have the external appearance of the female, 
and yet the individual is a male. If again, the clitoris is hypertrophied, 
the labia majora fused, the ovaries in the inguinal canal, the individual 
may be mistaken for a male. These are false hermaphrodites, for they 
do not possess both male and female organs. 
We will consider, in turn, hermaphroditism of the glands and herma- 
phroditism of the excretory canals and of the external organs of genera- 
tion. 
Hermaphroditism of the Glands.-This variety exists whenever one or 
more of the glands belonging to different sexes have simultaneously 
developed. There are three sub-varieties. 
1. Hermaphroditism through bilateral excess where two ovaries and two 
testicles exist. Schrell has recorded an instance; between the normal 
testicles and vasa deferentia there were two ovaries with tubes, one uterus 
and vagina. The male organs were developed, the female atrophied. 
2. Hermaphroditism by unilateral excess where there are two ovaries, 
two tubes, and a rudimentary uterus, a testicle, with vas deferens con- 
taining spermatozoa-as in the individual named Hoffmann, who men- 
struated regularly, and has been described by Rokitansky. 
3. Lateral hermaphroditism without excess, where there is an ovary on 
one side and a testicle on the other, has been very frequently observed. 
In Barkow's case there existed a uterus and tubes, an imperforate vagina 
passing through a prostate. The external genitals were those of a hypo- 
spadiac male. Of the glands, only one testicle was well developed. In 286 
A TREATISE ON OBSTETRICS. 
Berthold's case there existed on the right a testicle, an epididymis and a 
vas deferens opening into a vagina, and on the left side, an ovary, tube, 
uterus, and a vagina with hymen, opening into the uro-genital sinus. 
Hermaphroditism of the Excretory Apparatus.-The following divisions 
may be made: 
A. Hermaphroditism with two Testicles.- These instances are very 
numerous, and we may find the following varieties: 
a. There are twro testicles, but the external genital organs are female. 
Such wras the case with Madia Arsona, who was during life considered a 
woman. At the autopsy two atrophied testicles were found, as also vasa 
deferentia and vesicular seminales. The external genital organs were 
those of a female. 
b. In Giraldo's case, there were two labia majora and minora, a vesti- 
bule, urinary meatus, a vagina 3| inches deep. The testicles and. vasa 
deferentia wTere in the inguinal canal. 
c. In Steglehner's case, there were testicles, female external genitals, 
and in the middle segment both male and female excretory organs. 
d. The whole apparatus is male, and superadded, in the middle seg- 
ment, are female organs. In Petit's case, there "were testicles, with 
epididymis, vasa deferentia, vesicular seminales, male external genitals, 
tubes, uterus, and vagina opening into the urethra. 
B. Hermaphroditism with two Ovaries.-These instances are not so 
numerous: 
a. The case of Marto Joseph, where the external appearance and per- 
sonal habits were those of a male, is in point. The external organs ■were 
male except that the testicles had not descended. Post-mortem, two 
ovaries, tubes, a uterus and vagina opening into the prostatic portion of 
the urethra were found. 
b. The entire sexual apparatus may be female, and there may be 
superadded male organs. 
In the majority of the recorded cases many of the organs w'ere atro- 
phied. " There existed apparent anatomical wrealth by the side of physio- 
logical poverty." (Tarnier and Budin.) 
[A most singular instance of true hermaphroditism has been recorded 
by Fowler, of New York, into -whose possession had come a cast of the 
pelvic organs. The individual was aged twenty-seven at the time of his 
death, which resulted from congestion of the brain during menstruation. DYSTOCIA DUE TO THE FCETUS. 
287 
On the cast it was stated: "Was subject to monthly periods, epileptic fits, 
hysteria, and pains like those of dysmenorrhea. At the autopsy the 
vagina and male urethra contained a colored fluid like menstrual blood. 
Was remarkably fine looking and robust, more rotund in limb than is 
usual in male subjects. The bust and chest were that of a male; the 
pelvis broad; very light beard. His habits and mode of life were like 
Fig. 183.-Organs of a True Hermaphrodite. 
those of other males in his position in society." The cast was made from 
the organs themselves which came into the possession of Dr. Sayre, of 
New York. It represents (Fig. 183) the rectum, pubes, scrotum, penis 
with prepuce and. glans, vagina, uterus, ovaries, tubes and testicles. 
The individual both menstruated and urinated through the penis, the 
septum between the bladder and vagina having remained patent.-Ed.] 
Monstrosities. 
Monsters, as defined by Saint-IIilaiie, are deviations from the specific 
type, and are very complex in their nature. When they are made up of 
complete or incomplete elements of a single individual they are called 
simple; when they are made up of complete or incomplete elements of 288 
A TREATISE ON OBSTETRICS. 
more than one individual they constitute composite, double or triple 
monsters. Saint-Hilaire has divided monsters into two classes, which 
we will consider in turn. 
Simple Monsters. 
In case of these monstrosities either there is absence of a portion of 
the elements of the individual, or else all the elements are present, but 
they are modified variously in connection and in disposition. Saint- 
Hilaire has divided the simple monsters into three classes: The autosites; 
the omphalosites; the parasites. 
The autosites may exist outside of the uterus, not that their anomalies 
in conformation are compatible with long life, but because the cessation 
of the placental circulation does not mean immediate death. 
The omphalosites can only live in the uterus; they die as soon as the 
placental circulation ceases. 
The parasites are of such abnormal and irregular development that 
they are considered to-day as being simply morbid productions, having 
their seat in the uterus or ovaries (moles or dermoid cysts.) 
Autosites. 
The foetus is composed broadly of limbs, trunk, head and face, and 
each of these parts may be the seat of monstrosities, which we will con- 
sider in turn, following the classification of Saint-Hilaire. 
Ectromelic Foetuses.-These are characterized by the lack of develop- 
ment of one or more of the limbs, which is supposed by Dareste to 
depend on anomalous development of the amnion. Cases of intra- 
uterine amputation have frequently been confounded with these mon- 
strosities, but there is an essential difference, as is apparent. 
According as the lack of development affects one or another limb, 
ectromelic foetuses are divided into: 
Phocomeles.-Where the atrophy is limited to the middle segments of 
the limbs, the feet and the hands having continued to develop (Fig. 184); 
Hemimeles.-Where the feet or the hands, the forearms or the legs are 
rudimentary: 
Ectromeles.-Where the arrest in development includes all the segments 
to about an equal degree. (Fig. 185). 289 
DYSTOCIA DUE TO THE FCETUS. 
Fig. 184.-Phocomele Fcetus. {Mused Dupuytren.) 
Fig. 185.-Ectromele. 
Vol III-19 290 
A TREATISE ON OBSTETRICS. 
Symelic Foetuses.-These monsters are characterized by the union or 
median fusion of two limbs of the same kind. The lower limbs may be 
fused, and by their external surface instead of their internal. According 
as the fusion is more or less complete, these monsters are divided into: 
Sy metes.-Where the fusion being more or less complete there exists 
only a double foot: 
Fig. 186.-Symele. Anterior view. 
Uromeles.-Where the union is more complete and there exists only a 
single foot: 
Sirenomeles.-Where the fused limbs terminate in a point, the foot 
being lacking. According to Meckel this variety is only met with in 
case of female foetuses, but Saint-Hilaire has met with it in the male. 
Celosomic Foetuses.-These are characterized by a more or less complex 
Fig. 187.-Symele. Posterior view. 
eventration of the genito-urinary organs and various viscera. The entire 
contents of the abdominal cavity may be found in a pouch, the walls of 
which are formed by the cord. There are usually present in addition 
anomalies of the limbs, and the sex is usually female. We distinguish, 
with Saint-Hilaire, cases where the monstrosity is limited to the abdomen, 
and cases where it extends also to the thorax. The varieties are: DYSTOCIA DUE TO THE FCETUS. 
291 
Aspalosomes.-Where there exists lateral or median eventration at the 
lower part of the abdomen, the urinary, sexual, or intestinal system 
opening externally by three separate orifices. The situation of these 
orifices is not normal. The internal genital and urinary organs are atro- 
phied or lacking. Monsters of this variety, born alive, quickly die: 
Agenosomes.-Where the organs of generation and urination are lacking 
or rudimentary. The anus is found in front where the external genitals 
should be: 
Kellosomes.-Where there is lateral eventration at the inferior portion 
of the abdomen, and absence or lack of development of the pelvic limb 
of the same side: 
Schistosomes.-Lateral or median eventration throughout the entire 
extent of the abdomen, pelvic limbs lacking or imperfect. The abdominal 
wall is replaced by a thin membrane through which the viscera may be 
seen. This variety is very rare: 
Pleurosomes.-Where the fissure partially invades the thorax, and where 
there is atrophy or want of development of the thoracic limb of the same 
side as the eventration: 
Kelosomes.-Lateral or median eventration with fissure, atrophy or 
entire absence of the sternum, and hernia of the heart. The genito- 
urinary organs are normal. 
Exencephalic Festuses. 
These constitute a class characterized by the presence of a badly-formed 
brain, in part external to the skull which is itself imperfect. It is a 
transition stage, so to speak, between the celosomic and the acephalic 
monsters. Two varieties exist according as the fissure involves the verte- 
bral column or not, a fissure which must not, however, be confounded 
with that which is characteristic of spina bifida. 
Exencephalic foetuses without spinal fissure include the notencephalic, 
proencephalic, podencephalic, hyperencephalic foetuses of Saint-Hilaire. 
Exencephalic foetuses with spinal fissure include the iniencephalic and 
the exencephalic foetuses of the same authority. 
Notencephalic Foetuses.-Where the brain is almost entirely outside of 
the cranial cavity and posteriorly. The occipital portion of the skull is 
open, but there is no spinal fissure. At the level of the nucha is found a 292 
A TREATISE ON OBSTETRICS. 
tumor with a pedicle, reposing on the neck and upper portion of the back, 
but not adherent. The volume of the tumor depends on the amount of 
cerebral matter which it contains and the concomitant hydrocephalus. 
Fig. 188.-Notencephalic F<etus. (Bar.) 
The point of exit of the tumor is at the junction of the superior and 
posterior part of the occipital bone (Fig. 188). These foetuses usually 
die in a few days. 
Proencephalic Foetuses.-Where the brain herniates anteriorly through 
Fig. 189.-Notencephalic Fcetus. Antero- 
posterior section. (Bar.) 
Fig. 190.-Podencephalic Fcetus. 
(Beneke.) 
an opening in the frontal bone. It is rarer than the preceding. The 
monstrosity may exist alone, or be accompanied by deformities of the face, 
etc. The vault of the skull is flattened. 
Podencephalic Foetuses.-Where the hernia of the brain is from the 293 
DYSTOCIA DUE TO THE FOETUS. 
vault of the skull (Fig. 190). Ordinarily the tumor is circular, and may 
involve the sagittal, fronto-parietal sutures, etc. 
Hyperencephdlic Foetuses.-Where the upper portion of the skull is 
almost entirely lacking, the bones of this region existing only as rudimen- 
tary pieces. The frontal bones are long narrow shells, the parietal bones 
are stretched horizontally along the upper border of the temporals. The 
Fig. 191.-Iniencephale. (Budin.) 
entire portion of the occipital is rudimentary in its upper part, the basilar 
apophysis being well developed. It is in reality a highly exaggerated 
stage of the preceding variety. According to Saint-Hilaire, these foetuses 
are nearly always of the male sex, often premature, and are not viable. 
Iniencephalic Foetuses.-Consist in hernia of the brain at the occipital 
bone with vertebral fissure. (Fig. 191.) They are really hence noten- 
cephalic with fissure of the spine. The vertebral canal is open through- 294 
A TREATISE ON OBSTETRICS. 
out nearly its whole extent, and the malformation here is nearly if not 
equally as marked as that in the skull (Fig. 192.) 
As Duges says " the head is confounded with the thorax and thrown so 
Fig. 192.-Iniencephale. {Budin.) 
far forward that the occiput appears lost between the shoulders." The 
tumor contracts adhesions with the membranes which cover it. The 
quantity of cerebral matter outside of the skull varies. 
Fig. 193.-Exencephalic Fcetus. {Hildreth.) 
Exencephalic Faiuses, properly so called, are characterized by the fact 
that the brain is almost entirely external, and posteriorly associated with 
spinal fissure. They are similar to the hyperencephalic with the fissure 
of the vertebral canal superadded. The upper portion of the skull is en- DYSTOCIA DUE TO THE F(ETUS. 
295 
tirely lacking, whilst in iniencephalic foetuses there simply exists an 
opening in the occipital bone. (Fig. 192.) The herniated mass may be 
so large as to rest upon the back. 
Fig. 194.-Hernia involving the Base of the Skull. (Niemeyer.) 
In general, hernia of the brain at the base of the skull is rare. In 93 
cases collected by Houel only 9 were of this nature. The seat of the her- 
Fig. 195.-Hernia at the Base of the Skull. (Clar.) 
nia varies. Usually it is at the cribriform plate of the ethmoid; again at 
the sutures which unite the frontal bone to the nose or the superior max- 
illa. At times the mass fills both orbits, (Fig. 193). Again the opening 296 
A TREATISE ON OBSTETRICS. 
is at the sella turcica (Fig. 195.) In a case cited by Ahlfeld and in Vir- 
chow's, the tumor had perforated the base of the skull and the palate, and 
projected through the mouth. 
Pseudencephalic Foetuses.-These foetuses, according to Saint-Hilaire, 
do not possess any brain, properly speaking, since the nerve substance 
has almost entirely disappeared. The vault of the skull is almost en- 
tirely lacking. The tumor is deep red in color, and made up of interlac- 
ing small vessels filled with blood, and separated by debris Qi brain sub- 
stance. The mass has a similar texture to erectile tumors. These foetuses 
Fro. 196.-Pseudencephalic Fietus. {Lancereaux.) 
are eminently typical in appearance. " The head has neither forehead 
nor vertex, is sunk between the shoulders and surmounted by a blood 
tumor. The face is much developed, directed obliquely, almost always 
livid. The hair is scanty but long and encircling the tumor. The nose 
is large and flattened; the mouth usually open; the eyes large and pro- 
jecting, and at the top of the head; the ears deformed and often hanging 
down. These monsters have a truly hideous and unnatural appearance." 
(Saint-Hilaire.) 
The vertebral canal is only slightly altered or normal. The spinal 
marrow exists. These foetuses are usually of the male sex, and can hardly 
be considered as able to survive beyond a few hours. 
Pseudencephalic foetuses have been divided into two classes, according 
as there exists a vertebral fissure or not; nosencephalic, where the vascu- 
lar tumor occupies only the upper part of the head; tlilipsencephalic, 
where the anomaly is much more accentuated. The tumor projects so 
much backwards as to sometimes invade the first cervical vertebrae. It 
is a frequent monstrosity in the human raoe, but unknown in animals. 
Pseudencephalic foetuses, properly so-called, may be considered as thlip- 
sencephalic with the vertebral column largely open even down to the lumbar 
region. The disjointed vertebral bodies are widely separated, the spinal DYSTOCIA DUE TO THE F(ETUS. 
297 
marrow has disappeared, and may not have been replaced by a vascular 
tumor. The skin of the back along the fissure is lacking, and the exter- 
nal covering is represented by the meningeal membranes. 
Anencephalic Foetuses.-These may be considered as pseudencepha- 
lic without the fungous tumor. Other anomalies in development are fre- 
quently present. This variety is found almost exclusively in the human 
species, and usually in the female. According to Meckel, Saint-Hilaire 
and Dareste, the anomaly is the result of an arrest of development, due to 
Fig. 197.-Pseudencephalic Fietus. (Charpentier.) 
external pressure on the amnion. It may be subdivided into: Deren- 
cephalic foetuses, where the vault of the skull is largely open, all the bones 
having been pushed laterally, in a rudimentary state (Fig. 198); the occi- 
pital foramen is not recognizable. The upper cervical vertebrae are in- 
cluded in the arrest of development, as also, at times, the first dorsal. 
Throughout the fissure the nervous centres are completely lacking. 
This is a comparatively rare monstrosity. 
Anencephalic (true) Foetus.-Where the arrest in development extends 
throughout the entire vertebral canal, which is open and transformed into 298 
A TREATISE ON OBSTETRICS. 
a groove without special depth. The spinal marrow is lacking. Anen- 
cephalic foetuses are distinguished from derencephalic in that the fissure 
of the vertebral column is much more extensive. 
Such foetuses are often remarkable on account of their development. 
Fig. 198.-Derencephalic Fcetus. Front aspect. {Budin.) 
The liquor amnii is often profuse. The head is small, immediately on top 
of the trunk, the ears at the level of the shoulders, the face turned for- 
wards, the eyes projecting, the tongue often hanging from the mouth. 
Fig. 199.-Derencephalic Fcetus. Posterior aspect. (Budin.) 
(Fig, 200.) The chief diagnostic point before birth is the fact, to which 
Cazeaux calls attention, that, whenever the finger touches the presenting 
part, the foetus moves convulsively. These movements are probably due 
to direct excitation of the brain. 299 
DYSTOCIA DUE TO THE FCETUS. 
li Version is indicated. If it is not possible, the head is pulled down, by 
a finger or hook in the mouth." (Charpentier.) 
Cyclocephalic Foetuses.-These foetuses present the following character- 
istics: "Absence of nasal apparatus which is more or less atrophied; the 
visual apparatus of one or the other side badly-shaped, at times rudimen- 
tary, approaches the median line, one eye almost always being confounded 
with the other," (Saint-Hilaire.) 
Fig. 200.-Anencephalic Fcetus. (Charpentier.)- a, Remnant of brain. 
In the lower grades of these monstrosities, the maxillary region is 
always much deformed, but the inferior portions of the face are not much 
altered, and the ears are in their normal site. Cyclocephalicism is often 
complicated by other anomalies, in the limbs or trunk. The foetuses are 
usually female, and are usually born before term. When they are born 
alive, they soon die, which is the result rather of the difficulty of feeding 
them than of anomalies in the nervous system. According to Dareste, 
cyclocephalicism is due to an arrest of development of the anterior cere- 
bral vesicle. 300 
A TREATISE ON OBSTETRICS. 
Saint-Hilaire makes a division into five varieties: 
Ethnocephalic.-Where the nasal apparatus is not completely atrophied, 
but is present in a rudimentary state, with two imperfect nostrils, or a 
single one. There are two orbital cavities and eyes. 
Cebocephalic.-Where the nasal apparatus is completely atrophied, but 
two orbits and eyes are present. They resemble monkeys, whence the 
name. 
Rhinocephalic.-Where the nose has only partially disappeared, the two 
orbits are fused into one, which occupies the median line. (Figs. 201, 
Fig. 201. 
Fig. 203. 
Fig. 202. 
Figs. 201, 202 and 208.-Rhinocephalic Fcetus. (Budin.) Fig. 201.-Head in profile. Fig. 202. 
-Front view. Fig. 203.-The nose is lifted, and the single orbit is shown. 
202, 203.) The nose has usually one opening. In the orbit two united 
distinct eyes may often be seen, although every variety may prevail, from 
double cornea pupil and lens, down to one large eye, oval, large lens with 
wide transverse diameter. 
Cyclocephalic (true).-Where the atrophy of the nasal apparatus is more DYSTOCIA DUE TO THE FCETUS. 
301 
pronounced than in the rhinocephalic foetus, the nose disappears entirely, 
and the monster becomes cyclocephalic. (Fig. 204.) 
Stomocephalic.-Where the inferior portion of the face is very abnormal. 
The maxillary bones are lacking, and often the integument projects to 
such an extent as to look like an elephant's trunk. 
Otocephalic Foetuses.-These are derivatives of the cyclocephalic, but 
the tendency to atrophy is more marked, since it extends to a greater 
number of organs. They are characterized in particular by modifications 
from the side of the aural apparatus, the ears approaching the median 
line or even united there. Ordinarily there exists as well atrophy more 
Fig. 204.-Cyclocephalic Fcetus. (Budin.) 
or less marked of the inferior region of the skull, and also absence of the 
maxillae, and greater part of the face. The arrest in development having 
included the ethmoid as well as the inferior portion of the face, the ears 
are drawn inwards and downwards. The two lateral hemispheres of the 
brain are fused, imperfectly developed, and surrounded by a large amount 
of cephalo-rachidian fluid. The eyes may be separated, or united in the 
same orbit, distinct or fused. In the more advanced degree of monster, 
the atrophy extends to the complete absence of the organs of vision. 
Saint-Hilaire divides the otocephalic foetuses into five species: 
Sphenocephalic.-Where the two eyes are well separated, the two ears 
are united. The palate bone is bent so that the dental arches touch. 302 
There exists but one auditory meatus. The name of this variety is due 
to the fact that it resembles the sphenoid bone. 
Otocephalic (true).-The nose is atrophied, the eyes fused, the maxillae 
imperfect, the ears united or fused. 
Edocephalic.-So called because the nasal appendage resembles a penis. 
In these foetuses there exists a nose similar to that found in certain cyclo- 
cephalic foetuses. Above it a single eye. Below it a transverse opening 
which looks like a mouth, but which represents the auditory meati united 
in the median line. These foetuses have no mouth, and only rudimentary 
maxillae. A single orbit contains the eye or the two eyes. In a very 
pronounced instance, Tiedmann noted above the eye a snout, and below 
it the skin hung down like a second snout. 
Opocephalic.-Where there exists a single or two eyes in one orbit, two 
ears near together or united, two atrophied maxillae, but neither mouth 
noi' nasal appendage. The eye and its appendages form the greater part 
of the face, whence the name given to the species, which has frequently 
been found in animals, and only rarely in the human race. 
Triocephalic.-Where there is absence of eyes. All the anomalies de- 
scribed in the other varieties may be present. The entire head is only a 
little spheroidal swelling. This variety is very rare in man if it exists at 
all, but common enough in animals. 
Simple Omphalosite Monsters. 
These monsters lack many organs, and, therefore, they die as soon as 
the cord is cut. They live, in other words, by the umbilicus, whence 
their name. An interesting point in their history is that they result 
from a twin pregnancy, where one foetus is relatively well formed, while 
the other is a monstrosity, and has a heart very incomplete, even rudi- 
mentary. The twins have a single placenta, and, as Meckel and Cazeaux 
have shown, there exists in this placenta anastomosis between the um- 
bilical arteries and veins of the foetuses. In the omphalosite embryo the 
circulation is reversed. It is from the umbilical cord passing from the 
placenta to the normal foetus that the funis of the omphalosite is derived. 
The heart of the normal foetus sends its blood to the placenta by the um- 
bilical arteries, but a portion of this blood penetrates into the umbilical 
arteries of the omphalosite. The blood returns from it by the umbilical 
A TREATISE ON OBSTETRICS. DYSTOCIA DUE TO THE FOETUS. 
303 
vein, and passes through the cord of the normal foetus to the placenta. 
The circulation of the monster, hence, constitutes a species of diverticu- 
lum of the circulation of the normal foetus. The omphalosite, therefore, 
receives the blood which contains its nutritive elements, not by the um- 
bilical vein, like the normal foetus, but by the umbilical artery. 
The presence of a foetus with normal heart is hence essential to the 
'existence of an omphalosite. According to Claudius, gemellarity not only 
allows the development of the omphalosite during intra-uterine life, but 
it is the cause of the monstrosity. When two foetuses, of equal volume, 
develop simultaneously in the same uterus, each has its own life; but if 
one of them, well formed a£ the outset, is feebler than the other, the most 
vigorous heart will cause the blood pressure in the placenta to become too 
strong for the weaker. Little by little the heart of the latter will cease 
to be able to functionate, and the omphalosite is formed. This theory is 
purely hypothetical. We believe, with Dareste and Saint-Hilaire, that 
there is actually no proof that gemellarity is the cause of the monstrosity. 
Paraceplialic Foetuses.-" These monsters are peculiar in the shape of 
their bodies, which in almost every respect varies markedly from the nor- 
mal. Their limbs are imperfect not only in shape, but in the number 
of fingers. A great part of the thoracic and abdominal viscera may be 
absent. The head is very imperfect." (Saint-Hilaire.) The character- 
istic feature, indeed, about this monstrosity is the head, which is simply a 
mass at the upper part of the trunk. Both skull and the face are impli- 
cated in the atrophy. Theoretically this monstrosity constitutes an im- 
portant link uniting acephalic foetuses to those which we have just studied. 
The cervical vertebrae exist, although they may be atrophied so that the 
head can scarcely be differentiated from the trunk. The limbs are always 
very imperfect. The diaphragm is sometimes complete, but may be en- 
tirely wanting, so that the thoracic and abdominal cavities constitute a 
single one. The lungs are not present, or are represented only by a few 
vesicles; the heart may be only rudimentary, the circulatory system is 
very imperfect. Of all the organs, the genito-urinary are altered the least. 
The changes in the nervous centres are quite general. Saint-Hilaire 
says that these monsters have never been observed in animals. In the 
human race, such monsters have always been expelled in case of a twin 
pregnancy, where there were two sets of membranes, but only a single 
placenta. The foetuses are always of the same sex, usually female. 304 
A TREATISE ON OBSTETRICS. 
They are not viable, and in no case have they ever given sign of life. Sub- 
varieties are: Omocephalic, where the arrest of development is a trifle more 
accentuated. The thoracic limbs are lacking. Hemicephalic, where 
the head is still more imperfect. There is no mouth, the organs of sense 
are no longer distinct. A median superior mass is the only external trace 
of skull. 
Acephalic Foetuses.-These are distinguished from the paracephalic by 
the complete atrophy of the head, of which there exist only traces appre- 
ciable anatomically. The organs of sense are not even formed. There 
Fig. 205.-Acephalic Fcetus. 
is scarcely any projection above the trunk, which might be taken for a 
head. The upper extremity of the trunk is covered by a smooth skin like 
that of the rest of the body. The shape of the trunk is also abnormal. 
Its form is irregular and imperfectly symmetrical. The thoracic and 
abdominal viscera are badly formed or even absent. The thoracic viscera 
are particularly affected, the heart being lacking, or else only traces of the 
organ. Extra-uterine life is hence not possible. The genito-urinary 
apparatus is relatively developed. 
These monsters are likewise usually expelled after a twin pregnancy, 
the placenta being common to the twins. The fretuses are of the same 
sex, sometimes hermaphrodites. Often it is not possible to recognize the 
sex of the monster. 305 
Anidic Foetuses.-The form of these monsters is as abnormal as possi- 
ble without being indeterminate. It is ovoid, globular, pyriform. The 
term acardiac has been applied to them, but it is defective, for, although 
certain of them have no heart, in the higher degrees vestiges of this organ 
are found. These monsters, however, have no circulatory system, prop- 
erly so-called. The true heart is not in the monster, but in its brother, 
whose heart really works for both. The life of the monster ceases, hence, 
as soon as it is separated from its twin brother. It is a true parasite in 
intra-uterine life, and is not viable externally. 
DYSTOCIA DUE TO THE FOETUS. 
Fig. 206.-Acardiac. (Poppet.) 
Acardiacs then may be defined as the outcome of a twin pregnancy, 
where the foetuses are enclosed in a single amnion, and there is anastomo- 
sis of the two vascular systems. Now in one foetus the blood pressure 
becomes exaggerated and diminished in the other. One foetus developes 
normally, therefore, and the other atrophies. The stasis in the umbilical 
vein causes edema and hypertrophy of the subcutaneous cellular tissue. 
Spiegelberg and Ahlfeld describe four varieties of acardiacs: 1. Amorphi 
or mylacephali.-Spheroidal, covered with skin, without head or extremi- 
ties. Inside the mass are found a few rudimentary vertebras, muscles, 
rudiments of the intestine. 2. Acor mt. -Badly-shaped head, and very 
rudimentary trunk. The cord is attached at the neck. 3. Acephali.- 
Vol. III.-20 306 
A TREATISE ON OBSTETRICS. 
There exists no head. 4. Acardiaci anceps.- The head, body, pelvis, 
limbs, exist, as well as the heart, but these organs are atrophied. 
Dystocia in Twin Pregnancy. 
In twin pregnancy, dystocia may occur under two very different circum- 
stances: The twins are separate and well formed. The twins are more or 
less fused together. 
I. Isolated Twins. 
In 1877, Besson divided the causes into predisposing and determining. 
Among the first he noted: Excessive size of the pelvis, a single sac, small 
foetuses and faulty accommodation. Among the second, spasmodic and 
Fig. 207.-Twins Presenting by the Vertex. 
tetanic contraction of the uterus, the projection of the sac containing the 
superior foetus below the first presenting foetus, the premature rupture 
of the membranes of the second foetus. 
a. The Foetuses present by the Vertex. (Fig. 207.)-Usually the heads 
present successively at the superior strait, and there is no difficulty. 
Sometimes, however, the head of the second foetus is placed on the neck of 
the first, presenting together in the excavation. If the foetuses are small 
they may be expelled spontaneously, but otherwise intervention is neces- 
sary. DYSTOCIA DUE TO THE FCETUS. 
307 
b. One Foetus presents by the Breech, the other by the Head. (Fig. 208). 
-In case the legs are extended, the head of the second child may engage 
at the same time as the extremity of tile first. The head of the first may 
hook on to that of the second child, and drag it down. Delivery is only 
possible where the fcetuses are small, and the uterine contractions strong 
and sustained. In certain instances, it has been possible to push up the 
Fig. 208.-Presentation of Pelvic Extremity of one Fcetus, and of Head of the other. 
head, of the second child, and thus to deliver that of the first. (Cases of 
Budin (Fig. 208), Perrochaud, Sidney, Calise, Walter.) The forceps has 
been used by Hohl, Carriere, Balfour, Tellkampf, Eichorn, Braun, 
Genth, Depaul, and others. Craniotomy and decapitation have been 
practised by numerous others. 
c. The first Infant presents by the Head, the second by the Breech.-A 
case has been recorded by Mauriceau, where the sac of the second infant 
projected below the head of the first, and constituted the obstacle. 308 
A TREATISE ON OBSTETRICS. 
d. The Twins present by the Breech.-If the breeches are complete they 
cannot engage simultaneously; if the legs are extended the feet may de- 
scend together. (Cases of Amand, of Schultze, of Plessmann.) 
e. The first Foetus presents by the Head, the second by the Trunk.-Two 
cases have been reported: One of Morgagni (Fig. 209), one of Solayres. 
Fig. 209.-One Fcetus Presenting by the Vertex, the other by the Trunk. 
f. The -first Foetus p)resents by the Breech, the second by the Trunk.- 
One case of Baudelocque's, another of Dunal's. (Fig. 210.) 
g. The first Foetus presents by the Trunk, the other by the Breech.-A 
case has been recorded by Bartscher. 
Fro. 210.-One Fcetus Presenting by the Breech, the other by the Trunk. 
The above are the cases found in literature by Besson. In the major- 
ity the diagnosis was not made till labor. It is difficult to lay down rules 
for treatment. One rule should be absolute, and this is to abstain from the 309 
DYSTOCIA DUE TO THE FOETUS. 
administration of ergot, which can only compromise the life of the 
foetus, and complicate the necessary intervention. 
In the exceptional cases, where the twins occupy the same amniotic sac, 
the cords may intertwine and knot. Muller has collected eight cases, and 
to these we would add those of Ygonin, Fricker, Kleinwachter and 
Gueniot. 
Composite Monsters (Autosites). 
Autosite composite monsters include: Ensomphalic, monomphalic, 
sycephalic, monocephalic, sysomic, monosomic foetuses. 
Ensomphalic Fcehtses.-" These foetuses are each practically complete, 
although united together, and are able to accomplish independently 
Fig. 211.-Pygopagi. {Charpentier.) 
almost all the vital functions. Each has its own umbilicus, and, during 
intra-uterine life, its umbilical cord." (Saint-Hilaire.) Each is nor- 
mally constituted, except at the point of fusion; they are viable, and if 
they usually die, it is because they are born before term, or there is some 310 
A TREATISE ON OBSTETRICS. 
difficulty during delivery. They may be distinguished into: Pygopagi, 
inetopagi, and cephalopagi. 
Pygopagi..-Where the fusion is back to back. The sacrums are united 
from the first or the second sacral vertebra. The rectum is double 
above, and single below. They are viable, and a number have reached 
the adult age. (Helene Judith, Millie-Christine.) The union of the sa- 
crums is the reason why there has always been hesitancy in separating the 
two individuals. In one case where this was attempted, they quickly died. 
Fig. 212.-Metopagi. (Charpentier.) 
Fig. 213.-Cephalopagi. {De Baer.) 
Metopagi.-Where union is by the cephalic extremity, forehead to fore- 
head, vertex to vertex. They are normal except at the point of union. 
(Fig. 212.) The anterior and the posterior portions of the foetuses are in 
the same planes. 
Cephalopagi.-Are united also by the heads, but they look in opposite 
directions. (Fig. 213.) 
In the above two varieties, union of the foetuses may be by an extensive 
surface, or else by pedicle. In the first instance, the foetuses are end to 
end; in the second the two bodies may be more or less inclined, one to DYSTOCIA DUE TO THE F(ETUS. 
311 
the other, or even be parallel. We would add, further, that there exist 
transitional stages between the metopagi and the cephalopagi, where the 
anterior plane of one foetus is continuous with the lateral plane of the 
other. 
Monomphallc Foetuses.-These are characterized by the union of two 
complete individuals at a common umbilicus. Very few ever reach adult 
age. 
If the union is below the umbilicus, we have an ischiopage, if above 
the umbilicus a xyphopage, sternopage, ectopage, hemipage. 
Ischiopage.-Where two individuals are fused together at the umbilicus 
face to face. The bones of the pelvis of one foetus, instead of meeting in 
the median line, are separated to the right and the left to join those of 
Fig. 214.-Ischiopage. (Prochaska.) 
the other foetus. We thus find two lateral pubic joints. The external 
genital organs are similarly arranged, the right of one foetus being united 
to the left of the other, and vice versa. In addition, other anomalies may 
be noted bearing on other organs, such as extrophy of the bladder, or 
more or less intimate union of limbs. 312 
A TREATISE ON OBSTETRICS. 
Xyphopage.-Where the union of the individuals is above the umbili- 
cus, that is to say, begins there and extends above to include a portion of 
the thorax. (Fig. 216.) The fusion of the individuals is more or less 
deep, in certain instances only by the skin; in others the livers unite into 
Fig. 215.-Ischiopage. (Charpentier.) 
one vast hepatic gland. There may be two hearts contained in two peri- 
cardial sacs, or in one. The two diaphragms may be continuous, form- 
ing a single septum between the abdominal and thoracic cavities. 
Xyphopages are rarer than ischiopages. , 
Sternopage.-Where the two individuals are fused, face to face, from 
the umbilicus to the upper portion of the thorax. They are very similar 
to the preceding variety. The union of the two sternums is analogous to 
that of the pelves in case of the ischiopage. Each sternum is divided in 
the mid-line, and each half with its ribs opens outwardly like the 
leaves of a book. There is a single thoracic cavity, two vertebral 
columns, two sterno-costal walls, each wall being formed by half the 
sternum and ribs of one foetus, and half of the other. There is a single 
pericardial sac, containing two hearts near together or united. The large 
vessels of the heart are anomalous, the diaphragms are united, forming a DYSTOCIA DUE TO THE FtETUS. 
313 
single septum with two symmetrical halves. The lungs are four in num- 
ber, and but little altered. 
Fig. 216.-Xiphopage. (Pancoast.) The Siamese Twins. 
Fig. 217.-Sternopage. (Budin.') 
This monstrosity is not rare. They die shortly after birth, owing likely 
enough to anomalies in the hearts and great vessels. 314 
A TREATISE ON OBSTETRICS. 
Ectopage.-Characterized by inequality of the thoracic walls, or rather 
of the two costo-sternal walls of the double thorax, one well developed, 
the other more or less imperfect. The degree of atrophy of one thorax is 
Fig. 218.-Ectopage. (Regnauld.) 
variable. The vertebral columns are near together. The arms belong- 
ing to the atrophied side are near together, sometimes fused. The mon- 
Fig. 219-Ectopage. (Charpentier.')' 
ster may have three or more arms. It has four lungs, but the two on 
the atrophied side are very small. There are two hearts situated above a DYSTOCIA DUE TO THE FCETUS. 
315 
large diaphragm. The liver is often single, as also the stomach. Death 
has followed immediately after birth in all the known cases. 
Hemipage.-Is a very rare monstrosity. We find two bodies fused at 
Fig. 220.-Ectopage. (Charpentier.)} 
the thorax, with two very unequal thoracic walls, half of which belongs 
to each individual. There is this essential difference from the ectopage 
Fig. 221.-Hemipage. (Hartung.) 
-the fusion extends even to the mouths, which form a single cavity. 
(Fig. 221.) In other words, the two faces and the two necks are joined 316 
anteriorly and obliquely, the upper part of the faces and skulls being 
distinct. 
Sycephalic Foetuses.-Here there is no longer simply junction of the 
two heads, but intimate fusion. These monsters have been described 
under the various terms, janicephalic, janiformic, and have bodies com- 
pletely separated below the umbilicus, and fused above. There is a single 
head, with two faces, the one opposed to the other. "The two faces of 
janiform monsters are made up exactly as are the two pelves or thoraces 
of ischiopages and sternopages. The right half of the head of each 
foetus is separated from the left half, and the two half heads are disjointed, 
one from the other laterally, even as the leaves of a book may be divided, 
the back of the book not being displaced. The right half-face of one 
individual corresponds to that of the other, and unites with it, and in- 
versely, and so there are formed two faces which are lateral. Thus 
there exists on each side of the head a face, one half of which belongs to 
one individual, and the other half to the other, and which still, in size, 
may be scarcely beyond the normal. 
In these monsters all the anomalies may be formed which have been 
noted under the sternopagic foetuses. There are, however, two mouths, 
two pharynges, one of which may end in a cul-de-sac. Each foetus has 
its spinal cord, and the same is true of the medulla and the cerebral 
hemispheres, which are not fused, the two brains often being separated 
by a strong septum. These monsters are born at term, and are always 
unisexal. The varieties are: 
Jani ceps.-One large head with two complete faces, or nearly so, 
diametrically opposed, one large thorax with two sternal surfaces, one 
neck larger still than the double head and thorax which it separates, one 
umbilicus, below which the bodies are separated, two vertebral columns, 
two occiputs, eight normal limbs. Rarely there have been observed the 
anomalies belonging to the symelic, rhinocephalic, anencephalic foetuses. 
Miopes.-Where one face is normal, while the other does not really 
exist, but is represented by two ears very near one another, or perhaps 
only one median ear, and above it one orbit and an eye, more or less im- 
perfect. Each face looks outwards, and each occiput inwards. This 
monstrosity is exceedingly rare. 
Sy notes.-The monstrosity is still more accentuated. The eye has dis- 
appeared, and on the atrophied side only the ears are found close together 
A TREATISE ON OBSTETRICS. DYSTOCIA DUE TO THE FCETUS. 
317 
or fused, often only the meatuses. This variety is relatively rare in man, 
but frequent in animals. 
Monocephalic Fcetuses.-These include all the composite autosites in 
whom a double head without external trace of junction surmounts two 
Fig. 222.-Janiceps. {Bordenave.) In this case the lower limbs were anomalous. 
bodies joined in a more or less intimate manner, and more or less exten- 
sively. (Saint-Hilaire.) 
Monocephalic foetuses present two characteristics: " The first, apparent 
unity of the head, and secondly fusion of two bodies." (Saint-Hilaire.) 
When the bodies are separated below the umbilicus and united above, we 
Fig. 223.-Synote. {Meckel.) 
have the varieties deradelphe and thoradelphe; when the bodies are united 
also below the umbilicus, we have the ileadelphe and synadelphe. 
These monsters are very rare in the human race. Saint-Hilaire was 
able to find but two instances, and not a single instance in man of thora- 
delphic or synadelphic foetus. 318 
A TREATISE ON OBSTETRICS. 
Deradelphe.- Where the bodies are separated below the umbilicus, and 
united above. Four pelvic limbs, three or four thoracic limbs, a single 
Figs. 224 and 225.-Diprosope. (Charpentier.) 
Tlioradelphe.-Where the bodies are united above the umbilicus and 
separated below. Four pelvic limbs and only two thoracic; one head. 
lleadelphe.-One head, one neck, two thoracic limbs, one body below 
the umbilicus, bifurcating at the pelvis where there are four limbs. 
Figs. 226 and 227.-Cephalo-thoracopagi. (Charpentier.) 
Synadelphe.-Qne head, a single body including the pelvis, but there 
are eight limbs, four dorsal and superior. 
The above figures represent varieties of preceding groups. Sysomic Foetuses.-These are characterized by the more or less complete 
fusion of the two trunks, the two heads remaining distinct and separate. 
According to the degree of fusion, they are known as psodymes, xypho- 
dymes, derodymes. 
Psodymes.-Where there is a single pelvis with two lower limbs. The 
lower part of the abdominal cavity is single, as also the contained viscera. 
Above, the trunk seems to bifurcate, so that there are two thoraces, each 
DYSTOCIA DUE TO THE F(ETUS. 
319 
Fig. 228.-Psodymes. {Andreas Emmenius.) 
having two arms. The vertebral column is single below, in the lumbar 
region, and bifurcates at the dorsal. Sometimes a third rudimentary 
lower limb is seen, adherent by ligaments to the vertebral column. These 
monsters are very rare, and some have lived. 
Xyphodymes.-Where the fusion invades the lower part of the thoracic 
walls. There are two thoraces separated above, but not below. (Fig. 229.) 
" The vertebral columns, in certain cases at least, are entirely separate, 
and between them is a rudimentary pelvis usually formed of a single piece. 
There are two normal lower limbs. The two coxal bones are widely 
separated posteriorly, and between them are the sacrum and the two 
spinal columns. When a third rudimentary limb exists, it is attached to 
the centre, in front/' (Saint-Hilaire.) Throughout the united thoraces 
exists the same mechanism as in the sternopages. A few examples of 
xyphodymes have been seen in the human race. They may live, and the 
most celebrated case is that of Ritta-Christina, on whom Serres made an 
autopsy. (Fig. 229.) 320 
A TREATISE ON OBSTETRICS. 
Figs. 229 and 230. -Xyphodymes. (Serres.) 
Fig. 231-Derodyme. (Ahlfeld.) DYSTOCIA DUE TO THE FCETUS. 
321 
Derodymes.-WThere the body is fused throughout its entire length, 
although there are traces externally of union. The limbs may be normal 
in number, although there may exist certain rudimentary buds. At the 
neck the body divides into two heads. (Fig. 231.) 
They differ only from the xyphodymes in that the vertebral columns 
are near together and parallel. From their external borders extend the 
ribs, which are inserted in front into a wide sternum, while from the 
internal borders extend small short ribs, which unite in the median line. 
Monosomic Foetuses.-These are distinguished from those which we 
have studied, in that there is still more complete fusion of the bodies. 
There is in reality a single body surmounted by two heads. The varieties 
are: 
Fig. 282.-Miodymes. (Depaul.) 
Atlodymes.-Where there are two heads on a common body, but this 
body has really a truly single organization. Not a single example was 
found by Saint-Hilaire in the human species. 
Miodymes.-Where the two heads are not only contiguous, but are united 
laterally by the occiputs. (Fig. 232.) There maybe four ears or two, 
or even three. The neck is sometimes partially divided. 
Opodymes.-Where the fusion is still more accentuated. The ocular 
regions are near together, and there may be two eyes in two more or less 
Vol. III.-21 322 
A TREATISE OX OBSTETRICS. 
distinct orbits, two eyes in a single orbit, one orbit containing a single 
eye, often imperfect. (Fig. 233.) The middle parts present the anoma- 
lies which are found in case of the Cyclops. The mouths may be near 
together or separated; they may even form a single cavity. Whatever 
Fig. 233.-Opodyme. {Sammering.) 
the disposition of the mouths, there is always fusion of the posterior part, 
and while anteriorly the tongue is double, it is always single posteriorly. 
In the opodymes, anencephalus or microcephalus often coexist, and 
usually in both heads. 
Complex Parasite Monstrosities. 
In the case of all the monsters we have so far studied, the two indi- 
viduals, who by their union constitute the double monster, had about an 
equal volume. In those we are going to consider there is fusion of two 
beings, one of whom has undergone such arrest in development that it 
could not live independently of the other. 
Heteropage.-These are characterized by the presence of a parasite 
suspended to the anterior abdominal -wall of the principal subject. There DYSTOCIA DUE TO THE F(ETUS. 
323 
are two distinct sets of limbs and one head. This monstrosity is very 
rare. (Fig. 234.) 
Heteradelph.-If the parasite's head is lacking, so that the body, with 
or without the thoracic limbs, seems to implant itself by its upper portion 
at the level of the epigastrium of the autosite, we call it a heteradelph. 
(Fig. 235.) It is the least rare variety in the human species. 
Fig. 234.-Heteropages. (Licetus.) 
Fig. 235.-Heteradelph. (Bruckmann.) 
Heterodyne.-The parasite is represented only by a more or less imper- 
fect head implanted, by a very rudimentary neck and thorax, on the an- 
terior surface of the autosite. 
Heterotype.-This form, although named by Saint-Hilaire, was never 
described by him. 
Heteromorph.-The same remark applies to this as to the preceding. 
Heteralicus.-The parasite is inserted at a distance from the umbilicus 
of the autosite. It is constituted by a head implanted on that of the 
principal subject. There may be only a head, or vestiges of a trunk. 
The face of the parasite is usually turned towards the right lateral plane 
of the autosite. The epicome, which belongs in this class, may live a 
number of years. Saint-Hilaire speaks of one which lived over four 
years. This monstrosity is very rare. 324 
A TREATISE ON OBSTETRICS. 
Polignatlii.-These are very singular monsters. "If we imagine, at- 
tached and as though suspended from one of the maxillae of an otherwise 
regular being, deformed maxillae, or even a very irregular mass of amor- 
phous bone and cartilage, in which it is difficult to recognize the traces of 
Fig. 236.-Epicome. (De Baer.) 
a head, although the mass is covered with integument, partly cutaneous 
and partly mucous, then we will have an idea of the curious modifica- 
tions which characterize a polygnathic monster." (Saint-Hilaire.) 
The varieties are: 
Epignathus.-Where the parasite is inserted on the superior maxilla, 
usually on the palatine apophysis. (Fig. 23 7.) 
Fig. 237.-Epignathus. (Budin.) DYSTOCIA DUE TO THE FCETUS. 
325 
Hypognathus.-Where the parasite is implanted on the inferior maxilla. 
Augnatlms.-Very similar to the preceding, where the head of the 
parasite is so imperfect, that it is really simply a rudimentary maxilla, 
implanted on the inferior maxilla of the autosite. 
Polymelic Foetuses.-These are double monsters, where the parasite is 
reduced to one or two limbs, directly inserted on the autosite, and through 
the agency of a mass which represents the remaining part of the trunk. 
Fig. 238.-Pygomele. (Depaul.) 
Fig. 239.-Spina Bifida mistaken for 
Pygomele. (Charpentier.) 
Different varieties are distinguished according to the region of the auto- 
site on which the parasite is inserted. Thus: 
Pygomelic.-Where the autosite carries in the hypogastric region one 
or more supplementary limbs, which are inserted behind or between the 
normal limbs. (Fig. 238.) 
Ordinarily, the accessory limbs are inserted on a pelvis the bones of 
which articulate with those of the pelvis of the autosite, even as the pelvic 
bones articulate in the pygopage. The accessory limbs are always more 326 
A TREATISE ON OBSTETRICS. 
or less atrophied. The malformations of which they are the seat are 
most accentuated in the feet. If the accessory pelvis is atrophied it may 
close all connection with that of the autosite. In a more advanced degree 
the two limbs may be fused into a single. 
Gastromelic.-Are very rare. " They are characterized by the pres- 
ence of one or two accessory limbs inserted between the pelvic and the 
thoracic limbs." (Saint-Hilaire.) 
Notomelic.-Where there are one or two accessory limbs on the back. 
In the human race Saint-Hilaire never found a case. He saw it twice 
in cows. 
Cephalomelic.-Where the supplementary limb is inserted on the head. 
Melomelic.-Where one or more accessory limbs are inserted on one or 
more of the normal limbs. This variety is not so very uncommon. It 
may consist in the addition of a complete limb by a scapula or coxal bone 
near the normal limb; but often the scapula or coxal bone is lacking, 
and the accessory limb is confounded with the normal and has the same 
insertion. In certain instances, the superior segment of the limb is sin- 
gle, the division not beginning till the second segment, the forearm or 
the leg. Again, the excess in development includes only the hands, feet 
or fingers. 
The upper and the lower extremities may both be thus affected at the 
same time, and we may observe a certain symmetry in the malformation. 
Total doubling of the limbs is rarer. 
[A curious instance of this variety we recently had the pleasure of see- 
ing through the courtesy of Dr. W. J. Burnett of Long Island City, in 
whose practice the child was born. The following is the description 
which we wrote out at the time: Child, a female, aged thirteen months, 
with six teeth, and well-formed except as regards the right arm, forearm 
and hand. There are two humeri, each articulating with a radius and 
an ulna. In the forearm are three radii and three ulna), the central 
possibly articulating with the inner humerus. There are three hands, 
each can be moved separately. The inner hand has four fingers and one 
thumb, the latter always flexed in the hand from absence of the extensor 
muscle, and on its ulnar surface two rudimentary fingers; the middle hand 
has four fingers, always contracted, and no thumb; the outer hand has 
five perfect fingers. 327 
DYSTOCIA DUE TO THE F(ETUS. 
Thus then: Two humeri, three radii, three ulnae, sixteen fingers, two 
rudimentary. -Ed. ] 
Endocymic Foetuses.-The parasite is only represented by a mass in 
which traces of foetal structure may be found. They represent what the 
ancient writers described under the name of congenital pregnancy, and 
which to-day are classed among the dermoid cysts. 
These deep inclusions have been well described by Verneuil, according 
to whom there are three periods: 
1. A period of stagnation, where its presence is not revealed by any 
symptom physical or rational. This period is not of long duration. 2. 
Fig. 240.-Pygomele. (Burnett.) 
In the second period there are symptoms from the side of neighboring 
organs, although not suggestive of inclusion. 3. The third period is 
characterized by purulent inflammation, or by gangrene, and resulting 
elimination by the intestine, abdomen, etc. 
During labor perforation is called for. 
The prognosis is not, usually, grave for the mother. In 28 cases Paul 
noted 4 infantile deaths. In a number of instances, the infants have 
lived many years. Since the tumor may remain indolent, it is apparent 
that the real danger to the child depends on the site. 
Milliaresis reported a case where the included mass occupied the brain. 
Triple Monsters. 
Only a few instances have been recorded, and of these, some are in all 
probability apocryphal. The probability is that, in the future, observa- 328 
A TREATISE on obstetrics. 
tion will prove that even as there exist double monsters, so there also 
exist triple, only more rarely, even as triplets are rarer than twins. 
General Considerations on Double Monstrosities. 
Hohl, Kleinwachter and Veit have, in particular, studied this subject. 
The latter's monograph contains a resume of the majority of the reported 
cases. 
In 1850 Hohl had collected 96 cases, in 43 of which labor had termi- 
nated spontaneously, 4 with difficulty, and 49 by intervention. 
Playfair divides double monstrosities, from the standpoint of obstacles 
to delivery, into four varieties: 
1. Two almost distinct bodies, united anteriorly at the thorax or abdo- 
men, throughout a greater or less extent, 19 cases. 
2. Two almost distinct bodies, but united back to back in the sacral 
and inferior lumbar regions, 3 cases. 
3. Two heads, with a single body, 7 cases. 
4. Two bodies separated below, with two heads united by adhesions or 
completely fused, 2 cases. 
The following general facts may be stated in regard to these mon- 
strosities: 
1. As to frequency, they are met with four times in multiparge to once 
in primiparaj. 
2. Pregnancy rarely goes to term, and therefore, in volume, they are 
less even than separate twins. 
3. Presentations of the pelvic extremity are very frequent. 
These monstrosities may be divided into three groups in accordance with 
the difficulty which they offer to delivery. 
a. The obstacle depends purely on excess in volume of the entire body, 
or of one or another portion, (diprosopi, cephalothoracopagi, dipygi.) 
b. Where the fusion is at one or the other extremity of the body, and 
where, consequently, the monster may be straightened out (craniopagi, 
pygopagi, ischiopagi.) 
c. Where there exists mobility, ease of displacement of each constituent, 
during delivery, (different varieties of thoracopagi and dicephali). In 
xyphopagi this mobility is such during intra-uterine life that the two 
infants may present inversely at the moment of delivery. In case of 
thoracopagi, artificial displacement is possible. In both instances, par- DYSTOCIA DUE TO THE F(ETUS. 
329 
ticularly in the last, when the head presents, one body may be entirely 
delivered before the other without separation. (Fig. 241.) Only in case 
of very pronounced dicephali are we obliged to decapitate. 
In case of thoracopagi resort to version. 
Altogether, pelvic presentations are very favorable. They are indis- 
pensable in case of craniopagi, render delivery easier in case of diprosopi, 
cephalo-thoracopagi and thoracopagi, and still more so in case of the di- 
cephalus dibrachius. 
Fig. 241.-Dystocia in a Case of Thoracopagi. 
The craniopagi must present by one or the other extremity. Pygopagi 
and ischiopagi, when the head presents, require manual intervention for 
the delivery of the breeches, and when the latter present, one foot must 
be brought down to decompose the wedge, and allow of the successive de- 
livery of the head. 
Dicephalus dibrachius, where the accoucheur is skillful, when it presents 
by the pelvic extremity, will rarely require embryotomy, because the 
heads may successively be engaged. When the head presents it may be 
delivered by the forceps. Ordinarily, decapitation will be necessary. 
The dicephalus tribrachius and quadribrachius call for the same manage- 
ment as the thoracopagus when the head presents. In case of the di- 330 
A TREATISE ON OBSTETRICS. 
cephalus tripus, it is the third foot which constitutes the obstacle to 
spontaneous engagement of the breech. 
As a general rule, it is only aftei' delivery that the accoucheur is able 
to explain the cause of the difficult labor. The absolute rule for treat- 
ment should be: Concern yourself, above all, about the life of the 
mother. Leave the case to nature as long as the condition of the mother 
allows and then interfere in her interests, resorting to the means which, 
in the given case, seem likely to injure her the least. 
Dystocia due to Abnormal Presentations or Positions. 
I. Presentations of the Vertex. 
The vertex may not present regularly with reference to the axis of the 
superior strait, that is to say, it may be inclined. When slight, this may 
be considered normal, but when exaggerated, it becomes a cause of delay 
during the first stage of labor. 
If the inclined presentation does not correct itself, but persists, the 
forceps is indicated to terminate delivery. In case of the face, at times 
the forceps, at times version, are called for. In case of the breech, the 
foetus must be extracted, but intervention is absolutely dependent on the 
condition of the mother. 
The presentation may be normal, and the position abnormal. Es- 
pecially is this the case in posterior positions, whether of the face or the 
vertex, when rotation fails. 
We must further study in detail those instances where the extremities 
prolapse in connection with one or another presentation. 
a. Absence of Rotation.-Occipito-posterior Position.-Occipito-posterior 
positions, which we have studied at length under the mechanism of labor 
(vide Vol. I.), are far from being rarities, as is proved by the following 
figures which we take from Sen tex's monograph: 
Positions. 
P. Dubois and 
Naegele. 
Baudelocque. 
Boivin. 
Sentex. 
Occipito-iliac, left anterior, 
70$ 
82$ 
80$ 
88$ 
" " right " 
5$ 
17$ 
18$ 
13$ 
" " " posterior, 
27$ 
1$ 
2$ j 
2.03$ 
" " left 
1 in 160 
.95$ DYSTOCIA DUE TO THE FCETUS. 
331 
The observations of Dubois, Velpeau, Villeneuve, Sentex, Wilson, 
Pajot, prove sufficiently that spontaneous labor is possible in persistent 
occipito-posterior positions. We are entitled then to wait on nature. 
But ought we to do so ? 
Capuron and Macdonald argue for interference; Villeneuve, Sentex and 
the majority of authorities are guided by the condition of the mother and 
of the child, and we believe that this is the rule which should guide every 
accoucheur. 
What are the means of intervention at our disposal ? Portal, Leroux, 
Guillemot advise abdominal pressure during the contractions of the 
uterus. Aside from the fact that this pressure is painful, it will fail, we 
believe, in the majority of instances, and further it may cause metritis, etc. 
Smellie introduced the entire hand in the vagina, and endeavored to 
push up the head and to turn the face backwards, acting during the con- 
tractions. 
Burns recommends rupture of the membranes and pressure on the fore- 
head, during the contractions, to push it backwards. 
Tarnier has lately proposed to act on the occiput by placing two fingers 
behind the ear, and thus endeavoring to bring the occiput forward. 
Sentex is also a partisan of internal manipulations. 
In accord with Simpson, Burns, Cazeaux, Joulin, Depaul, we reject 
these internal manipulations as being inefficient and useless. Either 
rotation will occur spontaneously, and we must have the patience to wait 
a little for this-for we must remember that in many instances rotation is 
not effected until the head reaches the perineum-or else rotation will not 
take place, and then both external and internal manipulations will fail, 
and we must deliver by the forceps, which we much prefer to version. 
As to the forceps-for we would reject, with Tarnier, Leischmann and 
others, the lever-Millot, Levret, Astruc, Solayres, Capuron, Velpeau, 
Naegele, Cazeaux, Barnes, Grenser, Schroeder, Sentex, and many others, 
advise the delivery of the occiput by it posteriorly, without attempting 
artificial rotation, while Pajot, Smellie, Baudelocque, Simpson, Joulin, 
Jacquemier, Kamsbotham, Blot, Tarnier and his pupils, advocate artificial 
rotation. We agree with them, and only in case this is absolutely im- 
possible would we deliver with the occiput posterior. The objections 
raised against artificial rotation are not tenable, and the experiments of 
Tarnier and Blot prove that the occiput may be turned completely around 332 
A TREATISE ON OBSTETRICS. 
without any appreciable Jesion of the cord or of the foetus being produced. 
(See Vol. IV., under Forceps.) 
Unfortunately this rotation is not always possible, and then the occiput 
must be delivered posteriorly, at the great risk of the integrity of the 
perineum. 
[This subject is considered at length in the next volume under the 
Forceps. We would simply state here that in the majority of instances 
the absence of forward rotation is dependent on lack of flexion. Before 
resorting to artificial rotation, therefore, we would advocate an attempt 
at flexing the head either by the hand, or else by means of the valuable 
procedure advocated in particular by Richardson, of Boston, which con- 
sists in flexing the head through the forceps applied inversely to the 
ordinary method, and then removing the blades. In case, after an inter- 
val, varying according to the condition of the mother and the child, spon- 
taneous rotation and delivery do not occur, artificial delivery of the 
occiput posterior by means of the forceps (and here Isaac E. Taylor's 
slender-bladed instrument is very valuable should be resorted to.-Ed.] 
b. Mento-posterior Position.-In this case artificial rotation should 
always and absolutely be attempted. It often fails, however, and then 
our only resource is perforation, since version is not possible, unless the 
face is only slightly engaged, in which event, if it can be pushed up ver- 
sion is indicated. 
II. Presentation of the Trunk. 
We have already passed in review the signs and the treatment of pre- 
sentations of this nature, and we have pointed out that, while external 
version is easy during pregnancy, the presentation has always the ten- 
dency to recur. To prevent this recurrence numerous means have been 
suggested, and their very multiplicity proves their inefficacy. Convinced 
that the position of the foetus is, in these cases, due to lessened, resistance 
of the uterine and the abdominal walls, Pinard has endeavored to re- 
enforce this by means of the following bandage. (Figs. 242, 243.) It 
consists of three pieces, a right and a left forming the body of the bandage, 
aUd an intermediate completing the bandage anteriorly. "When at the 
eighth month the head is not engaged, the bandage should, be applied; 
when the presentation is of the breech or the shoulder, external version 
should be performed, and the bandage immediately applied. During the first day, compression should be moderate, and on the following days it 
should be increased by tightening the posterior buckles." 
We have used this bandage, even as has Pinard, Tarnier, Ribemont, 
DYSTOCIA DUE TO THE FCETUS. 
333 
Fig. 242.-Pinard's Abdominal Bandage. Profile. 
Budin, Chantreuil, Champetier de Ribes, but we are not so optimistic in 
regard to it as is Pinard. It has its disadvantages, such as the necessity 
■ * '' 
Fig. 243.-Pinard's Abdominal Bandage. Posterior. 
of removing it when palpation or auscultation is desired, the inability or 
unwillingness of many patients to wear it, the fact that, in many cases, 334 
A TREATISE ON OBSTETRICS. 
since it must be worn night and day, it produces erosions and abrasions 
of the skin, and becomes a source of torture instead of relief. We would 
limit its utility, therefore, to the few days which precede the onset of 
labor. 
III. Prolapse of the Limbs. 
Under the term prolapse, we understand the presence at and above the 
superior strait of a part of the foetus which does not belong to the pre- 
sentation, such as the cord and the extremities. Prolapse of the cord we 
have already studied. 
The above definition eliminates the presence of one or both feet in case 
of presentation of the pelvic extremity, and of the arms in case of the 
shoulder. In these instances there is not true prolapse, but only exten- 
sion of the limbs. 
Where prolapse exists, it is usually of an upper extremity. We may 
meet, by the side of the head, a hand, an arm, the two hands, a foot, 
and, by the side of the pelvic extremity, a hand or an arm. In certain 
cases a foot, the two hands, and the cord are found. Frequently, indeed, 
the cord is prolapsed with the extremities. Rarely, the feet prolapse in 
case of presentation of the shoulder, although usually this is due to inex- 
pert attempts at version. 
The causes are about the same as for prolapse of the cord, except that, 
while procidence of the latter favors prolapse of the extremities, the 
reverse does not hold true. They are not very rare. Depaul, in 17,613 
labors, noted prolapse of the extremities alone or with the cord 163 times; 
Lachapelle 45 times out of 15,652 labors, 11 of which were of the ex- 
tremities. The difference is notable, Depaul 1 in 102, Lachapelle 1 in 
1423. 
Diagnosis.-We must recognize the fact of prolapse, and then deter- 
mine which foetal part it is. The diagnosis is only difficult when the 
presenting part is above or at the level of the brim, and then careful ex- 
amination should be made to avoid errors. 
a. Prolapse of one or both Arms by the Head.-In this event very fre- 
quently there is no difficulty. If the liquor amnii escapes but slowly, the 
hand will ascend as the head descends. If the arm is prolapsed, labor 
may still terminate spontaneously if the pelvis is normal, if the foetus is 335 
DYSTOCIA DUE TO THE F(ETUS. 
not very large, if the contractions are energetic. According to Credo, 
all depends on the degree of prolapse. 
If the diagnosis is made before rupture of the membranes, the woman 
must stay in bed. After rupture, attempts at reduction must be made, 
and the prolapsed part held above until descent of the head. In case of 
prolapse of the arm reposition will often fail, and then, when dilatation 
is complete, the forceps should deliver, taking care not to grasp the arm 
in the blades. Where the pelvis is contracted, perforation may be re- 
quired. If the head is not at all, or only slightly engaged, version may 
be resorted to. 
b. Prolapse of one or of both Feet.-This is rarer than prolapse of the 
hand, although Depaul noted it 18 times in 278 cases. The attempt 
must be made to push up the foot, or else the head by traction on the 
foot, or else resort to the forceps. 
c. Simultaneous Prolapse of the Superior and Inferior Extremities. - 
These instances are very rare, and usually only observed in case of dead 
and macerated foetuses. Naegele, in a case where the right arm and the 
right foot were prolapsed, was able to push up the head, and by pulling 
on the foot, deliver a living child weighing 84- pounds. Monroe obtained 
a living child where one foot, the two arms and the cord were prolapsed. 
Hartmann succeeded where both feet and the right arm were down. 
d. Prolapse complicating Presentations of the Face.-These are very 
ominous. Cazeaux saw a case where the presentation was M.I.L.P., the 
conjugate of the pelvis measured 3 inches, and where the left foot was 
prolapsed. The forceps failed, as well as attempts to push up the foot. 
Embryotomy was requisite for delivery. 
In 1879 I saw two similar cases while substituting for Depaul at the 
Clinique d' Accoutrements. In the one case I perforated. The mother 
recovered. In the other I performed embryotomy. The woman died. 
The pelvis in this case was contracted. 
e. Prolapse of the Hand in Breech Presentations.-This is exceptional, 
and is not a complication of moment. We will consider it under version. 
(See Vol. IV.) It is much more common in these instances to see the 
arms extend over the head during extraction. 
Joulin has reported a number of cases of dystocia determined by these 
different varieties of procidentia. CHAPTER III. 
ERGOT AND ITS USES. 
the rainy season, says Jeannel, certain of the flowers com- 
posing the pistil of the rye (Fig. 245) undergo a peculiar alteration. 
A honey-like substance glues together the stamens, and this is the fungus 
sclerotium, which constitutes ergot. The fungus is the result of the ger- 
mination of a spore of the claviceps purpurea (Fig. 247.) The same fun- 
gus has been found on wheat by Mialhe. (Fig. 248.) 
Physiological Effects.-Without entering into special details, it seems 
advisable to state briefly our knowledge in regard to the physiological 
effects of this drug, which are constant, whether it be used as powder, 
aqueous extract, or as ergotine. Since the experiments of Holmes, in 
1869, much has been written on the subject of ergot, and it has been 
Fig. 244.-Ergot of Rye. 
proved over and over again that the drug acts with greatest intensity on 
the uterine system when gravid, and then on the circulatory, respiratory 
nervous and digestive systems. In our description we will follow Bailly, 
who has carefully studied the subject. 
The matrons of certain European countries and of America early de- 
termined the property of ergot of awakening uterine contractions, but it 
was first announced to the profession by Desgranges of Lyons (1818-1829), 
then by Sterns of New York (1818); although Prescott first, in 1815, 
studied the rapidity and duration of its action, and laid down the indica- 
tions for its employment. 
One of the indispensable conditions for the action of ergot is the de- 
velopment of the uterus and of its cavity under the influence of preg- 337 
nancy, or of the presence of a foreign body such as a polyp, blood, or 
vegetations. The uterine fibre must, indeed, be hypertrophied, the mus- 
cularis developed as well as the vessels, and therefore it is particularly at 
ERGOT AND ITS USES. 
Fig. 245. Fig. 246. 
Figs. 245 and 246.-Ergot of Rye. Mature, a, Sclerotium, b, Ergot, o, Mycelial filaments. 
full term that the drug acts best and most completely. The further 
from term, the less the effect of ergot on uterine contractility. 
A further point is that ergot has the property of over-exciting the mus- 
Fig. 247. Fig. 248. 
Fig. 247.-Claviceps Purpurea, er, Ergot bearing several fungi, a, The stem, b, The crown. 
Fig. 248.-Ergot of Wheat. 
cular fibre already in a state of action. All authorities do not agree that 
ergot may excite uterine contractions, that the drug is a true abortifa- 
cient. The general opinion to-day is that, while ergot may in a measure 
Vol. III.-22 338 
A TREATISE ON OBSTETRICS. 
excite contractions, it does not suffice of itself to determine labor, and. 
that it is simply an adjuvant to other means of provocation of labor. 
When, on the other hand, contractility is already present, its action is in- 
contestable; it re-inforces uterine contractions at every part of the uterus, 
as well the body as the cervix, with an intensity directly proportionate 
to the development of the uterine fibre. While Prescott denied abso- 
lutely the action of ergot on the empty uterus, Trousseau, Maisonneuve, 
Pidoux, C. Paul, Chapman, Muller, Peronnier, Joffi, Cabini, Pignocca, 
Bozzoni, Spargani, Laborde, Pitou, admit this, as well as, in a measure, 
P. Dubois. 
Together with this favorable action of ergot, there is another which is 
unfavorable. The drug, indeed, does not only re-enforce and prolong 
uterine contractions, but also changes their physiological character by 
suppressing those intervals of repose which separate the normal uterine 
contractions. As long as the uterus is under the influence of ergot, it 
remains in a state of retraction, of tension, tetanic so to speak, which 
induces uterine and foetal circulatory disturbances, which are dangerous 
to the foetus. Instead of suppleness and resiliency in the intervals of 
contractions, the uterus remains hard-in a word, as Bailly expresses it, 
from intermittency, we have remittency. 
The action of ergot varies with the different preparations used. When 
the powdered drug, or Bonjean's ergotine, is administered by the mouth, 
it is only at the expiration of ten to twenty minutes, as Prescott has ob- 
served, that we note the effect, while where the drug is administered 
subcutaneously, it is at the end of two to three minutes that it is effective. 
The duration of the action varies from one half hour to one hour and a 
half, according to the dosage. Yvon's solution has seemed to us to act 
the soonest, and to be the most transitory of all the preparations. 
We have seen that ergot may be dangerous to the foetus, and further, it 
may suffice to cause rupture of the uterus. As Jacquemier says, " spon- 
taneous rupture of the uterus is a rare occurrence, notwithstanding the 
frequent abuse of ergot, and the instances where it has been noted must 
be explained on the assumption of the presence of alterations in the struc- 
ture of the uterus, old cicatrices, etc., which weaken the natural resist- 
ance of its walls." (Bailly.) 
Finally, ergot acts on the urinary system by determining frequent mic- 339 
ERGOT AND ITS USES. 
turition, although the quantity of urine passed is small, accompanied by 
a sensation of pressure. 
It was formerly believed and sustained by Sauvage, Mialhe, Arnal, 
Hugues (1862), that ergot acted directly on the blood, but this theory is 
to-day abandoned. Levrat-Perroton, Pereira, Bailly, claim that ergot 
has a sedative effect on the circulation. The influence of the drug on 
the heart is not to be doubted. There is slowing of the beats, and Kohler 
and Eberty have shown that, after the absorption of large amounts, the 
heart stops in diastole, and remains insensible to all excitation. See has 
also established that the action of the heart becomes feebler, less frequent, 
at the same time that it becomes regular, in case of irregularity before 
the administration of the drug. Finally, Brown-Sequard claims that ergot 
causes contraction of the vessels of the spinal cord, and of its membranes, 
and so diminishes the amount of blood circulating in these organs. 
As Bernard has proved, the blood-vessels may be either contracted or 
dilated, the tissues around them either relaxed or compressed, and hence 
a modification in tension of the blood in the different parts of the vascu- 
lar system. 
In 1880, Bailly noted the direct action of ergot on the blood-vessels, 
and considered it the result of a paralysis of the muscular system of the 
large arteries. Schneider, Schrenck, Burghardt, Muller, Langius noticed 
the smallness of the pulse. Spargani, in 1830, claimed that this contrac- 
tion of the vessels was generalized throughout the entire vascular system. 
Admitted by Muller, Parola 1844, Boujean 1845, See 1846, Levret 1847, 
Villebrant 1858, Desprez 1860, and later by Gubler, Drasche, Loebel, 
Dobel, this retraction, this contraction, of the vessels was actually seen by 
Klebs in 1865, Holmes 1870, and afterwards by Brieseman, Potel, Eberty, 
Brown-Sequard, Wernich, Vogt, Laborde, Petou, who showed that the 
diminution in the calibre was due to contraction of the smooth muscular 
fibres contained within the coats of the vessels. Authorities, however, are 
not in accord as to the manner in which ergot acts on this smooth mus- 
cular fibre. Some claim that the action is a direct one, such as Holmes, 
Wernich, Laborde, Petou. Bernard claims that the action is on the 
vaso motor centres. On the other hand, Vogt, Kohler, Eberty, Vulpian, 
claim that the action on the vessels is secondary through the'nervous sys- 
tem. 
Since the capacity of the vascular system is diminished, there necessa- 340 
A TREATISE ON OBSTETRICS. 
rily results modification in tension. The blood tends to accumulate in 
the less contracted parts-that is to say, after the administration of ergot, 
there will be arterial ischaemia and venous congestion in the brain. "If," 
says Bernard, " we suppose ergo tine introduced directly into the vena 
cava superior or inferior, it will scarcely influence at all these large ves- 
sels, for the muscular fibres are few, and separated by a thick internal 
coat. After having passed through the right side of the heart and the 
pulmonary artery, the first elements likely to be influenced are the mus- 
cular fibres in the pulmonary arterioles. As these contract there will 
result: 1. Increase of tension in the pulmonary artery. 2. The disten- 
sion of the right ventricle will hence be more difficult, and the tension 
will be raised in the vena cava, which will empty themselves less readily. 
3. The pulmonary veins receiving less blood, the left heart receives less, 
and therefore less is transmitted to the aortal system, and there results 
diminution of tension in both kinds of vessels." 
To resume, then, there is increase of tension and congestion in the 
venous system, and diminution in the arterial. Shortly, however, the er- 
gotized blood will manifest its action on the arterioles of the aortic sys- 
tem; this will transmit less blood to the vena cava system, the tension 
will increase in the pulmonary veins, until the equilibrium is restored by 
the cessation of the action of the ergotine. 
This modification in tension explains the change in the pulse. Kohler, 
however, explains the slowing of the heart by an action of ergot on the 
pneumogastrics. 
Finally, ergot also acts on the vessels immediately, by influencing the 
perivascular tissue. It acts as well on the smooth fibres of the vessels, 
and on those of other organs, in particular the uterus. As for the mech- 
anism of the contraction, authorities explain it differently. According to 
Brown-Sequard uterine contractions are subordinate to the vascular con- 
traction. The nerves of the uterus are influenced by the anaemia of the 
medulla, an anaemia the result of constriction of its vessels. He accepts, 
hence, the opinion of Oser and of Schlesinger. Wernich also grants this 
primal medullary anaemia. 
Finally, ergot acts on the nervous centres, and See has noticed verti- 
go, pains in the limbs, cramps, feebleness in the lower limbs. 
As for the digestive system, the effects of ergot are, at times, nausea,, 
vomiting, great constipation. 341 
ERGOT AND ITS USES. 
Indications for the Administration of Ergot. 
Since ergot increases uterine contractility, Bailly has said, " Whenever, 
whether during labor or the puerperal state, it becomes necessary to in- 
crease the contractions of the uterus-that is to say, in uterine inertia 
during labor or after delivery-the use of ergot is strictly called for." 
We are in absolute opposition to this opinion of our colleague. While 
we may grant the use of ergot after delivery, we proscribe it before labor, 
during labor and before the termination of the third stage. We adopt in 
its entirety Pajot's law. As long as the uterus contains anything, be it 
child, placenta, membranes, clots, never administer ergot. We reserve it, 
therefore, purely for uterine inertia after the termination of the third 
stage of labor. First empty the uterus of its contents and then give ergot. 
The authorities who advocate the employment of ergot during labor 
formulate the following rules, and allow it under the following conditions: 
1. The cervix should be completely dilated. 2. The membranes be rup- 
tured. 3. The parturient canal be regular in size, or at least, large enough 
to permit the passage of the child. 4. The presentation of the foetus be 
such as to allow of the spontaneous termination of labor. 5. Moderate 
contraction only of the pelvis exists (Bailly alone believes this), and pos- 
sibly the presentation of the pelvic extremity. (Depaul and Grenser give 
ergot in case of pelvic presentations, when the breech is about to emerge.) 
6. Finally, in case of puerperal hemorrhage, placenta praevia, retention of 
clots. 
Tarnier, in his report to the Academy in 1872, only grants the use of 
ergot when the cervix is dilated or easily dilatable, the presentation favor- 
able, the pelvis not deformed. He neither advises nor rejects it in pelvic 
presentations, and decries it more especially in case of hemorrhage during 
the third stage. Blot says that li the disadvantages are greater than the 
advantages of using ergot during labor. Afterwards, in case of uterine 
inertia it is of great value, but it is not the only hemostatic. If we were 
to compare the cases where ergot has done harm, and those where it has 
done good, I believe that the first would be far more numerous." 
Our reasons, in agreement with Pajot, for rejecting ergot before the 
termination of labor, are: 
1. Ergot is dangerous for the foetus. The contraction of the uterus de- 342 
A TREATISE ON OBSTETRICS. 
termined by ergot is spasmodic, tetanic, maintaining the organ in a state 
of constant tension, which modifies profoundly the utero-placental circu- 
lation. The modification must endanger the foetus, the more so the more 
intense and prolonged the action of the drug. 
2. Ergot, by inducing uterine retraction, by applying hermetically, as 
it were, the uterine walls against the foetus, renders difficult, sometimes 
impossible, the extraction of the foetus where it might become necessary, 
and consequently will thus indirectly compromise the foetal existence. 
3. The action of ergot being exercised on every part of the uterus, on 
the body as well as on the cervix, may result in retraction of the cervix, 
and thus militate directly against the end aimed at. 
4. During labor the administration of ergot may induce retraction of 
the cervix on the foetus, and thus directly interfere with spontaneous ex- 
pulsion or extraction. 
5. For the mother, the tetanic retraction of the uterus, which too often 
follows the injudicious administration of ergot, means grave dangers by 
complicating the operations which may be called for to terminate labor. 
It renders version impossible, except at the risk of rupture of the uterus. 
6. Ergot administered before delivery of the placenta may lead to re- 
tention of this body, by causing retraction of the cervix. The same is 
true of clots in the uterus. 
7. Finally, ergot administered in case of placenta preevia is far inferior 
to the tampon, which is the heroic measure. 
In Germany, Schroeder " rejects the use of ergot before delivery. It 
only," he says, "causes spasmodic con tractions of the uterus and not normal 
pains. Further, Schatz, with his Toco-dynamometer, has determined that 
ergot induces an enormous and continuous elevation of the intra-uterine 
pressure during the intervals of the contractions, and that while the pains 
become more frequent, they are less efficient, until at length they cease 
altogether. Now, it is precisely this alternate relaxation and contraction 
which is the essential cause of the expulsion of the foetus, and if ergot defeats 
this alteration, it can scarcely be called a promoter of labor. Further still, 
the infant is compromised, for the uterus being in a state of permanent 
contraction, the interchange of gases cannot take place at the placenta, 
and the foetus asphyxiates." 
In a word; then, never give ergot until both child and placenta have been 
delivered. 343 
ERGOT AND ITS USES. 
If inertia uteri is present during labor, seeing that ergot is only allowa- 
ble where the cervix is dilated, the presentation favorable, and the pelvis 
well-formed, it is much better to use the forceps. In presentation of 
the pelvic extremity, we much prefei' pressure over the head after the 
method of Kristeller, and, if need be, the extraction of the foetus. 
During the third stage, least of all, should ergot be administered. The 
first thing to do in case of hemorrhage, is to empty the uterus of the pla- 
centa and the contained blood, and ergot, by causing retraction of the 
cervix, may oppose this. Therefore, again, never give ergot as long as 
the uterus contains anything. The rule is as absolute in case of hemor- 
rhage due to inertia after delivery, but here we give ergot, but only after 
the uterus has been emptied of clots. Finally, there is a further instance 
where we allow ergot, and this is in case of secondary puerperal hemor- 
rhage, the result of incomplete involution of the uterus. 
We limit thus the use of ergot to the hemorrhages of the puerperium. 
A number of accoucheurs, and we were once of this number, are accus- 
tomed to give ergot to their patients after delivery, with the end in view 
of assuring permanent contraction, and to avoid hemorrhage. We have 
for long relinquished this practice as being more harmful than useful. 
As for the use of ergot in case of after-pains, we do not grant it. By in- 
creasing uterine contractions, the after-pains are increased, and it is lau- 
danum, in high dose, to which we resort. Finally, ergot has been recom- 
mended as a prophylactic against the puerperal diseases. Jules Guerin 
has advocated it, but we reject it for the reason that ergot may cause the 
retention of small clots. 
[In the United States, it is safe to say that the great majority of ob- 
stetricians, in particular the older ones, will not accept Charpentier's 
views in regard to ergot. They have been in the habit of administering 
ergot at any and all times, and have never been able to satisfy themselves 
that it has ever done any harm, for very much the same reason, we be- 
lieve, that many of the same obstetricians will tell us that they have never 
seen a lacerated perineum in an extensive practice. Have they ever looked 
for the tear of the perineum? Have they ever stopped to consider if 
some difficulty in labor might not be traced to the ergot which they have 
given with unsparing hand? It is our belief that the rules laid down for 
the administration of ergot are golden ones, and our own practice and 
teaching are fully in accordance therewith. We can conceive of abso- 344 
A TREATISE ON OBSTETRICS. 
lutely no condition before the completion of the third stage of labor, 
where ergot conld be of greater service to the mother or child than other 
measures-massage, electricity, the forceps, version-which do not carry 
with them the risk that ergot unquestionably does. The real reason, we 
believe, why ergot is administered by many a practitioner is the hope of 
thereby saving personal time. Aside from the fact that this is a highly 
unworthy motive, we would contend that if there is any indication from 
the side of the mother, or of the child, calling for the saving of time, 
there is always some procedure at our disposal which will act to better 
advantage and with greater certainty, without risking the life of the lat- 
ter, and possibly also of the former. Ergot has been an instrument of 
greater harm than of good; and much as we prize it after the termination 
of the third stage, meaning thereby complete emptying of the uterus, 
and during the puerperium, we feel that rather than use it at other 
periods of labor, w7e would dispense with it altogether. 
Elsewhere, in these volumes, we have stated the slight points wherein 
we would disagree with Charpentier's views in regard to the use of ergot 
in case of placenta prtevia, and during the puerperium (Vol. I.). 
This work, however, would be incomplete without reference to the 
teaching and belief of many of the American accoucheurs who have ex- 
pressed their views in regard to the value and the proper sphere of ergot. 
The literature of the subject is vast, and we must content ourselves with 
recording here the latest expressions of opinion on this subject. Engel- 
mann, of St. Louis, and Johnson, of Washington, both claim that such 
has been and is the injudicious use of the drug, that it would be far bet- 
ter for the woman and her child were it not resorted to at all, if it cannot 
be used rationally. The late Albert II. Smith, of Philadelphia, thus ex- 
pressed his views in regard to ergot, in 1883: "I do not believe that it 
is ever needed under any circumstances, but that it is always capable of 
doing harm, and generally does harm. Its action is contrary to the ac- 
tion of the law of nature. The more nearly we come to the natural pro- 
cess, the more surely, effectually and safely shall we get our results. We 
know there is no law of nature more decided in the process of parturition, 
or more.important for the safety of the mother and the child, than that 
which establishes the remarkable intermittent contraction of the uterine 
fibre. Ergot, on the other hand, produces a persistent tonic contraction 
of the uterus, and therefore every practitioner who gives ergot to aid in 345 
ERGOT AND ITS USES. 
the expulsion of the child, outrages nature. In the first stage of labor 
it may be admissible, in extreme inertia and uterine relaxation with dila- 
table os, if from previous experience we know positively that there is no 
obstruction to be met with within the pelvic canal, that there is no varia- 
tion from a normal position or measurement of the foetus, and that its 
influence will be followed by immediate expulsion. But I maintain that 
it is very, very rarely, that we can know the presence of these conditions 
with sufficient positiveness to guarantee us against death to the child, 
and death or serious injury to the mother. In the second stage of labor 
we should never give ergot, because then we can use the forceps, an in- 
strument which is absolutely safe, and with which the intermittent action 
of nature can be imitated. In the third stage of labor I have seen the 
very worst effects produced by ergot, viz.: a spasmodic contraction of the 
internal os, with obstinate incarceration of the placenta. In postwar- 
turn hemorrhage it is an utterly worthless agent." 
The above represents fairly well the views of those who are opposed to 
the use of ergot, except under the condition where it can do no harm, and 
this is after the uterus has been emptied. Most American authorities 
favor the drug during the puerperium, for the beneficial action it has 
on uterine involution. Others, where they know the patient thoroughly, 
from attendance at previous confinements, do not hesitate to administer 
ergot in small repeated doses during any of the stages of labor, some to 
aid the expulsion of the placenta (Campbell of Georgia, Wilson of Phila- 
delphia, etc.), others place their reliance on it chiefly in case of post-par- 
tiim hemorrhage. W. T. Howard, of Baltimore, believes that ergot di- 
minishes to a certain extent the liability to some forms of puerperal fever, 
by preventing the retention of blood, etc., in the uterus; Reynolds, of 
Boston, claims that ergot is advantageously given, after delivery is com- 
plete, to lessen the liability to after-pains by insuring prompt and thorough 
uterine contractions, even though these contractions are made, at first, 
more sharp under its use. 
At the last meeting of the American Gynecological Society, Goodman of 
Kentucky read a paper on the use of ergot after labor, in which he claimed 
that it should be the invariable rule never to give ergot at the close of the 
third stage, unless the danger of hemorrhage was imminent, and then hypo- 
dermatic injection of ergotine was the preferable method. He stated that 
the purposes for which ergot was administered were three in number: 346 
A TREATISE ON OBSTETRICS. 
To prevent after-pains; to promote involution; to prevent post-part um 
hemorrhage. It was his belief that the only real benefit to be derived 
from the use of ergot was the prevention of hemorrhage, but that its use 
was attended with such risks that he did not believe there was warrant 
for administering it indiscriminately. He regarded the belief that ergot 
hastened involution as absurd, and although the drug unquestionably 
averted or arrested after-pains, it did so by setting up an action of the 
muscles which was not physiological. 
In the discussion of this paper, which in certain of its arguments must 
be considered over-drawn, Reamy, of Cincinnati, agreed practically with 
the author, stating that from his own observations he was satisfied that 
the natural state of the circulation in the uterine wall, after the placenta 
had been delivered, could not be reached if the normal intermittent con- 
tractions of the uterine muscle were made persistent. " Ergot not only 
closes up the uterus, but likewise interferes with the circulation within 
it, and therefore interferes with the process of involution and must lay 
the foundation for sepsis. He was perfectly satisfied that more evil is be- 
ing done to-day by this item in obstetric practice throughout the coun- 
try, than by any other one thing." 
It is thus apparent that there is no lack of variety in the views held in 
this country in regard to ergot, and yet in one respect there is more or 
less uniformity, and this is in regard to the fact that the drug adminis- 
tered before the uterus is emptied may be productive of harm. Such 
being the case, why, we would repeat, resort to it under any conditions 
where one or another more harmless agent is productive of the desired 
end?-Ed.] 
Method of Administration of Ergot. 
Ergot may be administered either in powder, or in infusion, [or in fluid 
extract.-Ed.] Thus given, however, it is sometimes not tolerated by 
the stomach, and therefore the attempt has been made to administer it 
subcutaneously. 
Dick, of Berne, has recently studied the comparative action of ergot 
and ergotine, and states: " 1. Ergot acts more rapidly than ergotine. 2. 
The only difference in regard to ergot by the mouth and ergotine subcu- 
taneously is that the effects of the latter are not so lasting. 3. Uterine 
tetanus has never been observed after ergotine." ERGOT AND ITS USES. 
347 
We believe, on the contrary, that ergotine subcutaneously acts more 
quickly'than ergot, and the duration of the action of ergotine is far 
longer than that of ergot. 
The following formulae for solutions of ergotine are given by Naegele 
and Grenser: 
Extract of ergot, ....... 3 j 
Glycerine, dilute alcohol aa 3 ij 
A Pravaz syringeful will contain 3| grains of ergotine. 
1> Bonjean's ergotine, ...... 3 ss 
Glycerine, distilled water . . . . . aa 3 ss 
II Bonjean's ergotine. . . . . . . 3 ss 
Glycerine, § j 
We believe that all the above solutions are likely to cause abscess, and 
we therefore use Yvon's solution, which has always answered us well. 
He prepares his solution so that fifteen minims shall contain exactly fif- 
teen grains of ergot, and we are thus absolutely certain of the dosage. 
From the use of this solution we have never seen abscess. There occurs 
simply a trifling induration of the cellular tissue at the injection site. 
Similarly does Herrgott maintain the efficacy and advantages of Yvon's 
solution administered subcutaneously. In promptness of action it is far 
superior to any other method of administration; it is perfectly innocuous 
when the solution has been carefully made. There is never consecutive 
pain or inflammation. Herrgott has never administered more than fifteen 
grains. We have given in urgent cases double this dose. We would 
add that Yvon's solution may as well be administered by the mouth, in 
the dose of thirty to forty drops, and that when we have used it subcu- 
taneously it has always been well borne, and has never excited either nau- 
sea or vomiting. 
[The tablet triturates of ergotine, or the hypodermic pellets, if reliable, 
are excellent forms for the administration of ergot. In case of an emer- 
gency, however, a drachm of the officinal fluid extract may be given 
hypodermatically, provided the precaution is taken to insert the needle 
deep into the muscles, without fear of resulting abscess. During the 
puerperium, ergot had better be administered as the aqueous extract, 
grains five, in suppository, twice oi' thrice daily, and it may advantageously 
be combined with a quarter to an eighth of a grain of cannabis indica. 
We would mention, finally, that of late years the fluid extract of cotton 348 
root (Gossypii radicis} has been used to some extent in place of ergot, 
for the reason that it is said to be just as effective an oxytocic, and yet 
not to possess the disadvantageous property of causing tetanic contrac- 
tion of the uterine muscular fibre. We can answer for its marked oxy- 
tocic property, but are not in a position to affirm that it is otherwise 
superior to ergot. We should be inclined to place absolutely the same 
limitations to its use, for the present, as we believe are applicable to 
ergot.-Ed.] 
A TREATISE ON OBSTETRICS.