lE]|[ijiJf Tin31TiH]fr^ i THE LIBRARIES COLUMBIA UNIVERSITY 1 HEALTH SCIENCES LIBRARY 1 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/operativemidwifeOOmunr OPERATIVE MIDWIFERY OPERATIVE MIDWIFERY A GUIDE TO THE DIFFICULTIES AND COMPLICATIONS OF MIDWIFERY PRACTICE BY J. M. MUNRO KERR, M.D., CM., Glas. FELLOW OF THE ROYAL FACULTY OF PHYSICIANS AND SURGEONS, GLASGOW PROFESSOR OF MIDWIFERV AND DISEASES OF WOMEN, ANDERSON'S COLLEGE MEDICAL SCHOOL OBSTETRIC PHYSICIAN, GLASGOW MATERNITY HOSPITAL ; GYNAECOLOGIST, WESTERN INFIRMARV ; EXAMINER IN MIDWIFERY AND GYNAECOLOGY, ST. ANDREWS UNIVERSITY; PAST PRESIDENT OF THE GLASGOW OBSTETRICAL AND GYNAECOLOGICAL SOCIETY ; LATE ASSISTANT TO THE REGIUS PROFESSOR OF MIDWIFERY, GLASGOW UNIVERSITY SECOND EDITION WITH 299 ILLUSTRATIONS IN THE TEXT NEW YORK WILLIAM WOOD & COMPANY MDCCCCXI TO THE MEMORY OF ROBERT BARNES, M.D., F.R C.P. PKEFACE TO THE SECOND EDITION Such a short time has elapsed since the First Edition was published that I have not considered it necessary to make many important alterations in the text. The slight changes and additions which have been made are in the chapters on Pubiotomy, Cesarean Section, Placenta Praevia, and Rupture of the Uterus. I desire to take this opportunity to thank those who reviewed the work when it first appeared for their kind criticism. Some critics referred to errors in style ; I am fully conscious of many such errors, and no one deplores them more than myself. As regards a certain discursiveness referred to by others, I feel this was almost unavoidable as I attempted to write each chapter as a separate article, while at the same time trying to preserve a continuity in the whole work. My best thanks are tendered to Dr. David Shannon for much help in correcting the proofs and index. J. M. K. 7,' Claremont Gardens, Glasgow. June, 1911. PREFACE TO THE FIRST EDITION Many years have elapsed since a treatise devoted entirely to Operative Midwifery has appeared in the English language. In venturing to consider the subject in these pages, I have constantly had before me two standard works. I refer to Barnes' ' Lectures on Obstetric Operations ' and Herman's ' Difficult Labour,' the former a classic in obstetric literature, the latter a most valuable companion at the bedside. As will be seen, I have followed very much the same lines as Barnes, whose ' Lectures 1 have always appeared to me nearly perfect. Much, however, has happened since the publication of the last edition in 1886. At that time antisepsis and asepsis in midwifery were only beginning to be discussed ; abdominal palpation for the diagnosis of presentations and positions of the foetus was practised by only a few ; the revival of symphysiotomy had newly begun ; the modern operation of Cesarean section had been described by Sanger only a year or two previously ; while operations upon the pregnant or parturient woman for abdominal and pelvic tumours were had recourse to only in the most desperate circumstances. Indeed, the changes that have taken place have their parallel only in the revival that followed the scientific teaching of Ambroise Pare. In considering the various pathological conditions causing dystocia and the methods of dealing with them, I have tried, as far as possible, to indicate what is becoming more apparent eveiy day, that the art of midwifery can no longer be considered a subdivision of medicine, but must be regarded as a branch of surgery requiring a thorough knowledge of surgical principles. I trust it shall be found that due credit has been given to those who have specially advanced the art of obstetrics in recent years. The names of many who have thus distinguished themselves in this and other countries are mentioned throughout the text, bat it is im- possible to avoid overlooking some, and to them I offer my apologies. x PREFACE For actual assistance rendered, I desire to thank especially Dr. •). W. Ballantyne, of Edinburgh, for kindly contributing the chapter on dystocia caused by doable monsters; J>r. Kiddell, of the Glasgow Royal Infirmary, for his note on pelvic radiography; and Dr. Dickie. my assistant at the Western Infirmary, for revising and correcting the proofs and rendering me much assistance in other ways. 1 am also indebted to my colleagues, Drs. Jardine and Russell ; Dr. W. L. Beid, Dr. Teacher, Dr. Lindsay. Dr. Dunlop, and Dr. -lames Scott, of Glasgow ; Dr. Adam of Hamilton, Dr. Hewetson of Birmingham, Dr. Lloyd Roberts and Dr. Donald of Manchester, 1 )r. Haultain of Edin- burgh ; Dr. Cullingworth, Dr. Herman, Dr. Spencer, and Mr. Bland- Sutton, of London ; Professors Bumm and Nagel of Berlin, Professor Barr of Paris, and Professor Edgar of Philadelphia, for permitting me to use illustrations and statements which have appeared in their published works. I must also thank the publishers of the Journal <>' Obstetrics and Gynaecology of the British Empire, the Practitioner, and the American Year-Book, for the loan of several valuable illustrations, and Messrs. Arnold and Sons, and Gardner and Son, for the blocks of the instruments here illustrated. Such of the illustrations of the pathological specimens as have not been lent me are, for the most part, from photographs and drawings of specimens in the Hunterian Museum, Glasgow University, in the Pathological Institute of the Western Infirmary, and in my own collection. The photographs of the different stages in the various operations were taken under my direction in the Glasgow Maternity Hospital. All the original drawings are by Mr. A. K. Maxwell, of Glasgow, to whom I am grateful for the trouble he has taken. I must also thank the publishers for the courtesy with which at all times they have met my wishes. J. M. MUNRO KERB. 7, Claremont Gardens, Glasgow, August, 1908. CONTENTS CHAPTER PAGE I. CONSIDERATION OF DYSTOCIA IN GENERAL CLASSIFICATION' OF DYSTOCIA ..---. 1 II. DYSTOCIA THE RESULT OF FAULTS IN THE FORCES : UNDUE STRENGTH OF THE FORCES PRECIPITATE LABOUR INEFFI- CIENCY' OF THE FORCES - - - - -5 III. DYSTOCIA THE RESULT OF FAULTS IN THE F(ETUS : ATTITUDE, POSITION, AND PRESENTATION ABDOMINAL PALPATION VAGINAL EXAMINATION AUSCULTATION OTHER METHODS OF EXAMINATION - - - - -15 IV. DYSTOCIA THE RESULT OF FAULTS IN THE FOETUS {continued) \ ABNORMAL ATTITUDE AND POSITION OF THE HEAD PROLAPSE OF LIMBS ASSOCIATED WITH PRESENTATIONS OF THE HEAD - 26 V. DYSTOCIA THE RESULT OF FAULTS IN THE FOETUS {continued) \ BREECH PRESENTATIONS - - - - - 50 VI. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FOETUS {continued) : transverse or oblique presentations - 86 VII. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FOETUS {continued) : malformation of the foetus - - 97 VIII. DYSTOCIA the result of ABNORMALITIES affecting THE FOETUS {continued): presence of more than one foetus - 113 IX. dystocia the result of abnormalities affecting the foetus {continued) : double monsters - 122 X. dystocia the result of abnormalities affecting the foetus {continued): cord — placenta — membranes - - 132 XI. DYSTOCIA THE RESULT of abnormalities affecting the par- turient CANAL : DEFORMITIES OF THE BONY CANAL CLASSIFICATION OF THESE DEFORMITIES AND CONSIDERATION OF THE DIFFERENT VARIETIES - 153 xii CONTENTS OHAl PAI I Mi. DYSTOCIA nil. RESULT OF ABNORMALITIES AFFECTING THI PARTURIENT CANAL (continued): DIAGNOSIS, PROGNOSIS, AND TREATMENT 01 PELVK DEFORMITY, MORE ESPECIALLY OF THE RACHITIC VARIETIES OF MALFORMATION - 177 Mil. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT (ANA I. (continued): ABNORMALITIES IS tin son parts: cervix — vagina — perineum - - 201 XIV. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL (continued) : CARCINOMA OF THE CERVIX - - - - - - 214 W. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING 'I'M I PARTURIENT (ANAL (continued): TUMOl Its OF THE OVARY 222 XVI. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL (continued ) : FIBRO-MYOMA OF THE UTERUS .-...- 235 XVII. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL (continued): TUMOURS OF THE BLADDEH AND RECTUM ------ 256 XViii. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL (continued) : SUPPURATIVE CONDITIONS IX PELVIS AND ABDOMEN .... 2(i() MX. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT < A\.\u(continued): ALTERATIONS IX THE AXIS OK THE CANAL — DISPLACEMENTS BACKWARD, FORWARD, AND DOWNWARD — DISPLACEMENTS THE RESULT OF VAGINAL AND ABDOMINAL FIXATION OF THE UTERUS - - 2ti" XX. DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL (continued) : MALFORMATIONS OF THE UTERUS AND VAGINA ... - 2!»4 XXI. PREPARATIONS FOR OPERATION — PREPARATION OF OPERATING- ROOM — INSTRUMENTS AND APPLIANCES — OPERATOR*^ HANDS — PATIENT — ANAESTHESIA .... 303 XXII. VERSION, on TURNING ----- 316 xxin. forceps- ._.... :;:!:; xxiv. FORCEPS (continued ): FORCEPS IX CONTRACTED PELVIS - 363 XXV. THE ENLARGEMENT OF THE PELVIC CAPACITY — SYMPHY- SIOTOMY AND HEBOSTEOTOMY (pUBIOTOMy) - - 374 XXVI. CESAREAN SECTION ----- 404 CONTENTS xiii CHAPTER l'AOE XXVII. [NDUCTION OF PREMATURE LABOUR ... 435 XXVIII. ACCOUCHEMENT FORCE, INCLUDING VAGINAL CESAREAN SECTION • - - - - - 456 XXIX. OPERATIONS INVOLVING DESTRUCTION OF THE CHILD : CRANIOTOMY DECAPITATION EVISCERATION CLEID- OTOMY --.-.- 478 XXX. MANUAL REMOVAL OE PLACENTA AND MEMBRANES - 508 XXXI. INTERRUPTED GESTATION ABORTION AND HYDATIDIFORM MOLE ------- 517 XXXII. ECTOPIC PREGNANCY PELVIC HEMATOCELE — PREGNANCY IN RUDIMENTARY HORN (CORNUAL PREGNANCY) - - 537 XXXIII. PLACENTA PREVIA — •ACCIDENTAL HEMORRHAGE - - 577 XXXIV. POST-PARTUM HEMORRHAGE - - - 607 XXXV. ACCIDENTS TO MOTHERS : LACERATION OF UTERUS, VAGINA, PERINEUM, SYMPHYSIS PUBIS - - - - 616 XXXVI. ACCIDENTS TO MOTHERS (conti)lUed) : INVERSION OF UTERUS PULMONARY EMBOLISM SUBCUTANEOUS EMPHYSEMA - 655 XXXVII. ACCIDENTS TO CHILD : INJURIES TO BONES, MUSCLES, NERVES, VISCERA, ETC. ; ASPHYXIA NEONATORUM - Q66 APPENDIX - - - 687 INDEX ------- 690 OPERATIVE MIDWIFERY CHAPTER I CONSIDERATION OF DYSTOCIA IN GENERAL- CLASSIFICATION OF DYSTOCIA When all the most distinguished writers of obstetric treatises in the past have failed to give an absolutely satisfactory definition of dystocia, it may be fairly assumed that the task is impossible. That this should be so is not to be wondered at when the other condition of normal labour or eutocia can only be described by cumbersome details of its phenomena. Fortunately, a definition is not essential to an under- standing of dystocia. One is not long in obstetric practice until one forms an idea of the condition ; indeed, it might prevent a full appre- ciation of the fact that Nature in parturition, although generally following a certain course, refuses to be trammelled by hard-and-fast rules. It is important for the accoucheur to remember this, and to appreciate within what limits she may be allowed a free hand. The mistake is too often made of forgetting this and of interfering with Nature, when, with a little patience, it would have been unnecessary. But if it is of great importance that the accoucheur should appreciate the natural variations of parturition, it is equally im- portant that he should recognize when Nature is at fault and requires assistance, and that he should do this as early as possible. He must never presume that a parturition is normal. He must not be content until he has satisfied himself that it is not abnormal. This attitude must be assumed in every labour. Again and again one sees how failure to do this results in complications being overlooked until they cannot be remedied, and the child's, and even, occasionally, the mother's, life is sacrificed or greatly endangered. Another matter which the accoucheur should ever bear in mind is the limitations of the different operative procedures. Repeatedly in the last few years cases have been admitted to the Glasgow l 2 OPEBATIVE M1DW IFKKY Maternity Hospital where the medical attendant has failed absolutely to appreciate this. Most of these cases have been examples of con- tracted pelvis or impacted shoulder presentation. It would appear as if the accoucheur considered it a disgrace not to be able to accompli sfa delivery by forceps or by version, and so he has recourse to unjustifiable force. As I shall point out in the following pages, the employment of extreme force is always wrong ; it may often be followed by no trouble — indeed, it may even appear to be quite successful — but in hundreds of cases it results in more or less serious consequences, and it is absolutely unscientific. It almost invariably means that the operation is unsuitable or is being badly performed. I cannot deny that occasionally one is compelled to exert considerable force in exceptional circumstances. These circumstances, however, will be referred to in their proper places. Here I would only remark that when an undue amount of force is employed in the extraction of the child it should only be exerted in the interests of the child. If the child is dead or dying, delivery should be completed by diminishing the bulk of the child by embryulcia. It is quite profitless to drag a dead child out of the parturient canal with difficulty, when by performing craniotomy one could extract it with great ease. In a difficult labour, therefore, the accoucheur must carefully observe the condition of the child. He must never sacrifice it, if, with safety to the mother, he can save it, but he must effect the delivery in the easiest manner should it succumb. Naturally, the relative claims of mother and child frequently require to be considered in cases of dystocia, and nothing taxes so much the judgment of the accoucheur as giving each its proper place, for their interests are often antagonistic. Let me illustrate this by two simple examples. In placenta praevia by rapidly dilating the cervix and extracting the child a large proportion of children will be saved, but by doing so one subjects the mother to very great danger ; on the other hand, by bringing down a foot, one does the safest thing for the mother, but not the best for the child. Again, take a case of contracted pelvis where labour has been allowed to proceed to an advanced stage and many vaginal examinations have been made. If the child is still alive, Cesarean section will almost certainly result in its life being saved, but the danger of sepsis to the mother will be enormous, while if craniotomy is performed the child will be sacrificed, but the mother probably rescued. Only experience and a quiet con- sideration of all the circumstances will teach the obstetrician how to act. No hard-and-fast rules can be laid down, and different obstetri- cians, of equal ability, knowledge, and experience, may act differently under the same circumstances. The obstetrician must ever avoid taking CLASSIFICATION OF DYSTOCIA 8 up an extreme position and becoming a partisan for or against any particular treatment. Progress in obstetrics has been much retarded in all ages by those who have unfortunately adopted such an attitude. "When one finds equally distinguished obstetricians holding absolutely different views, it is almost certain that the right is with none. Personally, I know of no recognized obstetric operation which has not its place and may not be practised with advantage under certain conditions, and I consider that obstetrics has been greatly advanced by the revival of symphysiotomy, by pubiotomy, and by vagimd Cesarean section. There are three factors which influence labour — the forces, the child, and the passage — and no attitude towards dystocia could be sounder than attempting to estimate in every case how far each of these factors is disturbed. This is often difficult, especially in the minor forms of dystocia, for sometimes more than one, and indeed all three, are at fault. The obstetrician, however, must carefully consider all, and relegate to each its proper place. The easiest explanation of a delay or difficulty is to blame the forces — the factor which is most indefinite and most difficult to exactly estimate. For this very reason, therefore, and because it is the least serious, the accoucheur should not rest satisfied with attributing the trouble to it until he has made certain that neither of the other two factors is disturbed. This matter will be more fully considered in the next chapter. But labour may be further disturbed by accidents to the parturient, such as rupture of the uterus ; by haemorrhage, such as that which is associated with placenta prsevia ; by displacements of the uterus, such as retroversion, all of which, and many other complications considered in these pages, the accoucheur must be alert to appre- ciate and deal with. Frequently he has to do this with all celerity under conditions not too favourable and with very inadequate assistance. Appreciating this fully, I have tried, in considering all complications, not only to describe the ideal treatment of the particular condition, but also, when such a treatment is impossible, to indicate the best course to follow under the circumstances. There remains, however, another group of cases where the factors of labour may or may not be disturbed, but where operative interfer- ence becomes necessary in the interests of the mother or child, because the vitality of mother or child shows signs of progressive weakness. In the case of the mother, where actual disease such as valvular disease of the heart, phthisis, hyperemesis, etc., are not present, it will be found almost without exception that one or more of the factors of labour is disturbed. In this connexion it must be remembered that women bear labour very differently, and that consequently, with some 4 OPERATIVE MIDWIFERY it is necessary to interfere earlier than with others. Generally speak- ing, the cardiac condition, as indicated by the pulse, is a fair guide. To have the full benefit of this guide, however, one must know before- hand the ordinary rate and character of the pulse, for I have found it by no means uncommon to get a pulse-rate of 1)0 or 100 quite early in labour — indeed, even during the later weeks of pregnancy. A steadily rising pulse-rate is of most value, and must always be looked upon as a danger-signal. The same applies to a steadily rising temperature and increasing restlessness. I have only referred to the early indications for interference, and have not mentioned tetanic contraction of the uterus, tenderness over the lower uterine segment, and the appearance of Bandl's ring. Without doubt, these also are indications for immediate delivery. As we shall see, when rupture of the uterus is being considered, they are symptoms of the very greatest seriousness. But they should never be allowed to develop ; the uterus should be emptied long before they make their appearance. As regards the child, a steady slowing of the fcetal heart, especially when the rate decreases to about 100, always points to the child's life being in danger. At such a time one finds the cardiac sounds much affected by the uterine contractions. At all times they are very much slower during the contractions, but if the child's vitality is undisturbed they quickly return to the ordinary rate as the contractions pass off. When they return slowly, and especially when they are irregular, there is no time to lose if the child is to be saved. The escape of meconium in all presentations other than the breech is another danger-signal on the side of the child. No doubt small quantities of meconium are discharged into the amnionic cavity even during pregnancy, but its free escape during labour, unless the child's cardiac condition is absolutely satisfactory, calls for speedy delivery. Strong and irregular foetal movements also frequently precede the death of the foetus during labour. With the mother very restless and suffering from the pains of labour, however, such a symptom is seldom of much practical value. We must depend, therefore, almost entirely upon the condition of the foetal heart. If the labour is at all protracted, the accoucheur must auscultate the foetal heart frequently ; he must note its rate and character, and how it is affected by the uterine contractions. CHAPTER II DYSTOCIA THE RESULT OF FAULTS IN THE FORCES Undue Strength of the Forces — Precipitate Labour — Inefficiency of the Forces. If the question were asked, What is the commonest cause of minor dystocia and delay in labour ? without doubt the answer would be — Faults in the expulsive forces. But, while such an answer is quite correct, all who have had much experience of obstetric practice must admit, that very frequently such an explanation is given too readily and without sufficient consideration. It is so simple and vague that one is tempted to be satisfied with it, whenever the cause of the dystocia is not strikingly apparent. I have frequently found the real cause some little departure from the normal in the pelvic cavity or in the position or attitude of the child, so much so that I think it a good rule to attribute delay and difficulty in labour only to faults in the forces, when one has absolutely satisfied oneself that the fault is not in the passage or passenger. In approaching this subject of the forces as a factor of dystocia, one is arrested at the very outset, by the fact that there is no standard for, or means of, estimating the forces. With dystocia associated with the passage and passenger, we shall see that it is quite otherwise, for by investigation and careful consideration the degree of difficulty may be fairly correctly surmised. I have said that there is no means of estimating the forces. By that, I mean, there is no practical method of doing so beyond the simple expedient of applying a hand over the abdomen and estimating the frequency, duration, and effect of the uterine contractions. One cannot measure the forces, and say that one has a force of so many millimetres of mercury too little or too much. There have been many attempts to measure the forces of labour. Duncan and Poppel, for example, estimated the resistance of the membranes to a bursting force. Others attempted to measure them by attaching a dynamometer to the forceps, and so estimating 5 Fig. L— Schatz's Tokodynamomete PRECIPITATE LABOUR 7 the amount of force required to extract the child. It is, however, unnecessary to discuss results obtained by such methods, for it is at once apparent that no exactness could possibly be obtained by such devices. The earliest and most scientifically constructed instrument for calculating the uterine force is the tokodynamometer of Schatz (Fig. 1), described some forty years ago. 1 By means of it, and its modifications, many interesting observations and tracings have been made by different observers, showing the features of normal and abnormal uterine contractions. In recent years Schaffer 2 has given this subject special consideration, and by means of his instrument has also made many tracings. Schaffer's instrument (Fig. 2) has the advantage of being more easily applied, although, of course, one Fig. 2.— Schaffer's Pelotte. cannot estimate the uterine contractions so accurately with it, as with Schatz's and similar instruments. Schaffer states that in the interval of the contractions the pressure is 5 millimetres of mercury, and during the contractions it varies from 80 to 220 millimetres. He also considers that the power of the uterine contractions and auxiliary forces is about equal. But although such instruments and investiga- tions are of decided scientific interest (Fig. 3), they are, at present, of no practical value. In practice one can only estimate the efficiency of the forces of labour by the progress made. The expulsive forces may be abnormal in three ways : they may be unusually strong, they may be unusually feeble and ineffective, and they may be irregular (tetanic). Precipitate Labour. — Although excessively strong uterine con- tractions and the resulting condition of precipitate labour does not, properly speaking, come under the head of dystocia, it is a subject, regarding which it is permissible to say a word. The first striking feature of precipitate labour as one encounters it in practice, is the 1 Archiv f. Gyn., Bds. iii. and xxvii. 2 ' Experimentelle Untersuchungen iiber Wehenthiitigkcit,' Berlin, 1896. 8 OPERATIVE MIIAYIKKHY fact that it is peculiar to certain individuals. This is due not only to the strength of the uterine contractions, but also, and even in greater part, to the slight resistance offered by the soft parts of the parturient canal. Very frequently such patients state that they have had only ' one or two pains,' which shows that the process of dilatation, usually accompanied by much suffering, occasionally does not set up nervous phenomena termed 'pain.' The ordinary dangers of precipitate labour are familiar to every one — rupture of the perineum, post-partum haemorrhage, injuries to the child. In addition, there has occasionally followed a subcutaneous emphysema, and still more rarely fracture of the sternum. Both these complications are considered in Chapter XXXVI. Walthard ' points out that emphysema is very rare in precipitate labour. Fig. 3. — Uterine Contractions registered by Schiifl'er's Instrument. Certainly, the two cases I have had experience of followed labours in which the bearing-down efforts were prolonged and of unusual severity. Uterine Inertia. — We are more concerned here, however, with the other condition, in which the expulsive forces are feeble and ineffective. As the expulsive forces consist of two component parts, the uterine contractions and the auxiliary forces, it is natural to expect that labour may be protracted sometimes by one, sometimes by the other, and occasionally by both being at fault. Uterine contractions, to be effective, should possess three character- istics. They should occur at regular but not too long intervals, they should be strong, and they should be sustained. As labour advances these features should become more decided. Sometimes all three are at fault, but the most frequent cause of delay is the weakening and cessation of the contractions just when they should continue. Uterine inertia may be primary or secondary. Primary uterine inertia is due to inherent weakness of the uterine muscle or to errors 1 Winckel's ' Handbuch,' 1905, Bd. ii., Teil iii., p. 2094. INEFFICIENCY OF THE FORCES 9 in its innervation. It may also be the result of some reflex irrita- tion inhibiting the action of the muscular contractions. Secondary uterine inertia, on the other hand, results from the muscle becoming tired and worn out. Primary uterine inertia ma}' be easy of explana- tion, as in cases where the uterus is known to be diseased from chronic metritis, or tumours ; is overdistended by an excessive quantity of liquor amnii or more than one fetus ; or has its con- tractions inhibited by some reflex irritation, such as retention of urine, premature rupture of membranes, etc. In very many cases it is extremely difficult to account for the inertia, and in such errors in development and innervation are vaguely spoken about. Although, however, one cannot always give a reason for the inertia, one can at least say that it is not necessarily found in cases of general debility. Nor is it a characteristic of individuals of feeble muscular develop- ment ; indeed, it has been my experience to find it more commonly in the strong and athletic than in those of poor muscular physique. It is often a feature of labour in young primiparse, and is not infre- quently seen in old primiparse. In the cases of decided uterine mal- formation which have been under my care it has not been a striking feature, although others have observed it in such cases. Secondary uterine inertia is quite different. Here, one has to deal with forces which up to a certain point were acting quite satis- factorily, but which for some reason gave out. If there has been a prolonged labour, and especially if there has been some abnormality in passage or foetus, one can readily understand this, for muscle cannot go on contracting indefinitely, it becomes exhausted. The time at which the uterine muscle becomes fatigued varies in different individuals ; sometimes it occurs early, sometimes late. Many speak vaguely of defective innervation in such cases, and claim that this results from congestion of the lower part of the uterus and cervix. Certainly it is not uncommon in cases of premature rupture of the membranes, and " generally contracted " pelves, in both of which the presenting head presses unduly on the lower part of the uterus. In the second stage of labour, when the expulsive forces are feeble, the uterus is often blamed, when, as a matter of fact, the fault is more in the auxiliary forces. One repeatedly sees regular, strong, and even frequent uterine contractions cease when they should continue. In such cases it will invariably be found that the auxiliary forces, the abdominal and other muscles concerned, are at fault. It is not uncommon in very stout individuals and in women with pendulous -abdomens, and feeble or widely separated recti. Again, it is very common in nervous 'and excitable women, and in those who bear pain badly or feel pain acutely. But the expulsive forces are some- 10 OPERATIVE MIDWII'KIIY times inhibited by such simple conditions as overdistension of bladder or rectum, and one Frequently sees strong bearing-down efforts follow the emptying of these viscera. It must not be forgotten, however, that a considerable amount of the strength of the uterine contractions and the auxiliary forces in the second stage is reflexly set up by the mechanical stimulus of the presenting part upon the pelvic floor. Feebleness of the forces is therefore not infrequently the result of non-descent of the presenting part. Every one is familiar with the effect which the introduction of the hand or a blade of the forceps has on the forces. Such treatment is seldom employed in the present day, although it was a common practice in ancient times. The recognition of uterine inertia is not difficult, provided one makes it a rule always to exclude the possibility of other pathological conditions being the cause, and only concluding that the forces are at fault when there is nothing else to account for the protraction of the labour. If this precaution is not taken mistakes will constantly be made. The operator, when it is a question of uterine inertia, should note the frequency and duration of the uterine contractions. Unfor- tunately, there is no standard for comparison. Every individual is a law unto herself, and sometimes, even the character of the parturi- tion, varies in different labours in the same individual. As labour progresses there should be an increase in the frequency, severity, and duration of the uterine contractions, and there should be a stead} 7 descent of the fretus. Frequently the uterine activity ceases for a time, and it will be found advantageous to encourage this by the administration of a full dose of opium or morphia. After such a lapse the uterus resumes its activity, and labour progresses rapidly. As regards the treatment of inertia of the uterus there is little to be said, and, unfortunately, not a great deal to be done. As protraction of the first stage of labour causes no concern, it will be found best not to interfere beyond removing any condition which may be reflexly inhibiting the uterine activity- Thus, it is important to keep the bladder and bowels empty, and to remove any irregular uterine contractions — the so-called ' false pains ' — by small doses of opium or morphia. Often a change in position is useful, and usually in this stage the most progress is made when the parturient keeps moving about. Many stimulants to uterine contraction have been suggested. Amongst them may be mentioned irritation of the breasts, massage of the uterus, electricity, hot vaginal douches, separation of the membranes, rupture of the membranes, dilatation of the cervix by means of the hand or metal dilators, and the administration of various drugs having a special effect upon uterine activity. Of great INEFFICIENCY OF THE FOKCES 11 antiquity are the two first methods, and certainly both, but especially the second, at fixed intervals, bring about uterine contractions. It is very questionable, however, if they advance labour to any great extent. From electricity little better results are obtained. The safest manner in which it can be employed is to apply one pole over the uterus and the other over the dorsal vertebra?. The introduction of an electrode into the vagina is undesirable. Some favour the con- tinuous and others the faradic current, but only a few electrical enthusiasts consider the treatment of any practical service. The various devices of irritating the uterus by stimulating the cervix are sometimes of value. Hot vaginal douches, especially if there is any undue resistance in the soft parts, are often of decided benefit. Separation of the membranes from the lower portion of the- uterus, the injection of glycerine, and manual or mechanical dilata- tion of the cervix, do not come into consideration here, for, properly speaking, they are methods of inducing labour. They will be con- sidered, therefore, when that subject is under discussion. As regards the drugs which have been recommended and employed for the purpose of stimulating uterine contractions, ergot and quinine are the most important. Some others, such as pilocarpin and ipecac- uanha, have a similar effect, but only the two first mentioned are now used. Of these the more important is ergot, in the form of the liquid extract, or ergotin. Ergot given in full doses produces uterine con- tractions of a tetanic nature. Every one knows this from clinical experience, and Schatz many years ago demonstrated it by means of his tokodynamometer. By one and all, therefore, it is condemned. That matter was settled long ago once and for all. The administration of ergot in small doses is another matter. Satisfactory results have been obtained by Schatz, Schaffer, and More Madden. In spite of the experience of these observers, however, it is generally condemned. Several writers have reported favourably of quinine sulphate, given in two or three doses of from 2 to 4 grains. Larger doses do not seem to give any better results. It is claimed that the uterine contractions produced by the drug do not present the unfavourable features which follow the administration of ergot. Personally, I have- been disappointed with the results. But of all methods of treatment the only really valuable one in my experience is the procuring for the ' tired ' uterus a period of rest. This is best accomplished by the administration of opium or chloral- After a varying interval the uterus refreshed begins once again to 3ontract strongly. When this recurrence of activity is established, ;he nature and effect of the uterine contractions should be carefully 12 OPERATIVE Ml I >\YIFEl:Y observed, and if they have any tendency to become ' tetanic ' the uterus should be immediately emptied. If after a short interval they still seem to be having little effect in advancing the labour, further delay is profitless. When the uterus is emptied after a period of rest and after active contractions have recurred, there is little danger of post-partum haemorrhage. All the methods of treatment which have been considered may be employed in both stages of labour. When, however, the second stage has been reached, other manauvres may be tried, for then the auxiliary forces have likewise to be stimulated. Amongst the devices to stimulate the latter may be mentioned mechanical irritation of the vagina and perineum by the colpeurynter or the hand. The latter of these is never employed at the present day. As regards the colpeurynter, however, it is frequently employed, especially on the Continent. Burger 1 refers to it favourably. The only form of mechanical stimulation extensively employed is massage of the uterus at regular intervals. I have never seen it do much good. Encouraging the patient to bear down, and removing any reflex condition which may be inhibiting the action of the forces, has often a very beneficial effect. Especially is this seen in cases where the parturient is very nervous and excitable, and complains greatly of the pain of the uterine contractions. Thus, it will be found that inhalations of small quantities of chloroform are of great service. It is surprising how such treatment is often followed by strong expul- sive efforts. But in other cases, when the symptoms mentioned are not present, chloroform retards the labour. Before leaving the subject of uterine inertia, an important question must be considered — viz., how far does inertia justify one in having recourse to artificial delivery ? As regards this matter there are two distinct opinions. There are those who maintain that inertia per se is never a sufficient indication, and that one must wait until the maternal pulse and temperature is disturbed, or until the fu-tal heart shows signs of being injuriously affected. On the other hand, there are those who recommend interference before these symptoms mani- fest themselves. They try to anticipate the symptoms. What are the facts of the case '? The effect of uterine inertia is to prolong labour, which in itself adds materially to the discomfort of the parturient. If it is only the first stage that is affected, nothing further results ; neither the mother nor the child is endangered except when the membranes rupture prematurely, and even in such cases there is a tendency to exaggerate the danger. As regards the second stage, the real trouble in private practice is that unusual delay is 1 Arcln'r f. Qyn., Bd. lxxvii., Heft >5., p. 54G. INEFFICIENCY OF THE FORCES 13 an inconvenience to the patient and those in attendance. The risk of infection in such cases is increased, largely because vaginal examina- tions are made at short intervals, with the object of ascertaining if any progress is being made. The dangers to the child and the soft parts of the parturient canal are not so great as is generally imagined. On theoretical grounds, therefore, non-interference is clearly the right attitude. It is an attitude which is logical, and serves as a good working rule for one's guidance, and I have every sympathy with those who adopt it. Still, in spite of that, I follow in practice those who consider that prolongation of the second stage to several hours is sufficient reason for operative interference in cases in which there is no disproportion between foetus and maternal pelvis. My position is that the human body is not a machine, and it cannot be treated as such. The temperature and pulse may be very considerably disturbed during labour, or even before labour commences, or they may respond slowly to the irritation of labour. As regards the child, my experience of a prolonged labour is, that if one waits until the foetus shows signs of circulatory disturbances, it will, when delivered, be more asphyxiated than was expected. I hope there is no misunderstanding regarding my attitude, or a belief that I favour early interference. Early interference in the second stage, unless there is some decided indication for it, in mother or child, cannot be too strongly condemned. Without doubt, it is responsible for many of the minor ailments which follow parturition, as it certainly is the cause of vaginal and perineal lacerations, which might have been avoided by allowing the pelvic floor to become gradually distended by the presenting part. Tetanic Contractions of Uterus. 1 — It sometimes happens that the uterine contractions are irregular in character. We meet with this in two forms — general tetanic contraction of the uterus, and spasmodic local contraction. Tetanic contraction of the uterus (tetanus uteri) is a condition seen in certain cases of extreme dystocia, when the uterus has been long trying to overcome the obstruction to the birth of the child. Thus, one sees it in marked degrees of pelvic deformity and in impacted trans- verse presentations. One also encounters it when ergot has been freely administered. Such a condition is to be distinguished from the ordinary form of retraction of the uterus found after the membranes have ruptured, by the fact that it is associated with great pain and iiscomfort, and a uterus uniformly convex and tender to pressure. 1 The most valuable paper on this subject in the English language is by Braxton Hicks, 'On the Condition of the Uterus in Obstructed Labour.' Trans- ictions Obstet. Soc. London, vol. ix., p. 207. 14 OPERATIVE MIDWIFERY This complication is one of extreme gravity, and as a matter of fact, is usually the result of mismanagement. A uterus should not he allowed to get into a condition of tetanus. AY hen this occurs, the first thing to do is to moderate the contractions hy inhalations of chloroform and a hypodermic injection of morphia. By such means the tetanic contractions can always be relieved. The delivery should be completed immediately in the safest manner possible, and here it may be remarked that, as the child will almost certainly be dead or dying, too much consideration need not be given it. If the tetanic •contractions have been present for some time, one must always be prepared for post-partum haemorrhage, and post-partum haemorrhage of a very troublesome character. If there is any suspicion of rupture of the uterus, the uterus must be carefully examined. Localized contractions of the uterus, the other form of irregular •contraction, are of interest both in pregnancy and labour. They are specially liable to occur in the three regions where the circular muscular fibres are pronounced — viz., the orifices, the os internum and externum, and the openings of the Fallopian tubes. In pregnancy such contractions about the Fallopian tubes have frequently led to errors in diagnosis, for on bimanual palpation the irregular swelling closely resembles an interstitial myoma or an extra-uterine pregnancy. Bar 1 has specially referred to these irregular contractions, and I have witnessed the occurrence on many occasions. During labour such localized spasmodic contractions often cause considerable discomfort, and when they occur about the retraction ring (strictura uteri), or about the external os (trismus uteri, spasmodic rigidity of the cervix), they may actually interfere with the birth of the child. Spasmodic contraction of the retraction ring usually follows a protracted labour in which the passage or passenger is at fault. The retraction ring may sometimes be so applied to the child as to arrest its expulsion, when the presentation is by the breech or by the head, while in the third stage retention of the placenta is a common sequela. These, like other varieties of irregular uterine contractions, are relieved by chloroform, opium or morphia. 1 Bulletin de la Soc. d'Obstet. de Paris, February 16, 1905. CHAPTER III DYSTOCIA THE RESULT OF FAULTS IN THE FCETUS Attitude, Position, and Presentation — Abdominal Palpation — Vaginal Examination — Auscultation — Other Methods of Examination. Amongst the commonest causes of dystocia attributable to the foetus are alterations in its attitude, position, and presentation. Each of these terms has its particular significance. Attitude is the relationship of the different parts of the child to one another. Presentation is the relationship of the long axis of the child to the long axis of the uterus. Position is the relationship which a particular part of the child bears to a particular part of the pelvic wall. Thus, we consider the child in the normal attitude when it lies flexed with its chin against the sternum and its upper and lower limbs folded across the upper and lower parts of its trunk; in the normal presentation when it lies longitudinally with its head lowermost ; and in the normal position when the long axis of its head lies in the right oblique diameter of the pelvis with the occiput anterior (Fig. 4). Abdominal Palpation. — To make out differences in attitude, position, and presentation is not always easy, and is especially difficult if one depends entirely on the older method of vaginal examination. Indeed, by such an examination, nothing can be made out so long as the os is undilated and the presenting part is high in the pelvis. Labour must have advanced some way before anj^thing can be affirmed regarding the presenting part. With the newer method of examination by abdominal palpation it is quite otherwise, for during pregnancy and early in labour, the presentation and position of the child can generally be defined without much difficulty. But abdominal examination possesses another advan- tage over the vaginal. It renders repeated vaginal examinations less necessary, and diminishes the risks of infection. Indeed, it is in great part because of this that it has come into such favour. 15 „ 16 OPKRATIYi: MIDWIlTJlY The two obstetricians whose names are especially connected with the perfecting of this method are Pinard in France and Leopold in (iermany. The most valuable monograph in the English language i& Fig. l — From a Dissection of a Uterus at Term, The Woman died of Eclampsia. (Photograph l>y Dr. James Scott.) one by McLennan, 1 of Glasgow, who has considered the subject most exhaustively and given a complete literature. To practice abdominal palpation with a view to making out the exact position and presentation of the fu-tus it is necessary to place 1 'Abdominal Manipulations in Pregnancy,' London, 1902. ABDOMINAL PALPATION 17 the patient to be examined on her back with the head slightly raised. The bladder must be emptied shortly before the examination, and the woman must be perfectly comfortable and breathe quite freely. The accoucheur, after heating his hands in warm water, should place them on the patient's abdomen. At first the pressure should be gentle, but it may be increased gradually. It is of great im- portance to avoid, as far as possible, setting up uterine contractions and spasms in the abdominal muscles. It will tend to relaxation of the abdominal wall if the patient's attention is diverted, and when moving the hands from one place to another if they are slid over the surface, not lifted and suddenly planted down again. It should be Fig. 5.— Palpation of the Fcetal Part situated at the Pelvic Brim. remembered, also, that it is not the tips of the fingers which are to be used, but their whole palmar surface, and that while one hand is making out what is beneath it, the other steadies the distended organ. The parts of the child which require to be located are the head, breech, limbs, and back. The first manoeuvre or 'grip,' which has for its object the location of the fcetal parts situated over the brim, is carried out by passing the two hands down along the sides of the uterus towards the brim of the pelvis. To do this the accoucheur should stand or sit at the right side of the patient (Fig. 5). In most cases the head will be 2 is o|'i:i;ativk midwiit.ky found at the brim, and will he recognized as a large, hard, globular mass. The beginner must make sure that it is really the pre senting head and not the pelvic brim he feels. The pelvic brim should therefore be defined, and then the fingers slipped over it on to the presenting part, when a depression will be found between the brim and the head, if the head has descended low into the pelvis, and especially if the uterus is very tense, it may be dillicult to feel the head, and the mistake may be made of thinking that there is no part of the child engaging. It will often be found that the head can be grasped better by making what is termed the ' Pawlik grip.' To carry this out the examiner should face the patient and grasp the Fig. 0. — ' Pawlik Grip.' presenting part between the thumb' and fingers of one hand, while steadying the child with the other (Fig. 6). Having made out the presenting part, and supposing it to be the head, while still facing the patient, the hands should be slid up to either side of the fundus (Fig. 7), where usually the breach is situated. This part is felt to be bulkier, but less globular, and to have a depres- sion between two prominences. The sides of the distended uterus are next examined (Fig. 8). They will be found occupied, the one by the trunk and the other by the limbs. On the side towards which the trunk is directed there is greater resistance, and the trunk is recognized as a long, smooth mass, curving round and running into the head and breech. A break in continuity can usually be recognized between trunk and head, and. unless the head is fixed at the brim, there is considerable mobility ABDOMINAL PALPATION 1«» between it and the trunk. At the pelvic extremity the back runs right into the breech without any break in continuity, and there is no mobility between the breech and the rest of the trunk. On the other side of the abdomen, and often more posterior, are the limbs. Here the resistance is very much less, and different members can be felt, sometimes at rest, but often gliding under- neath the hand or being pushed up by more violent movements of the foetus. From this brief description abdominal palpation seems very simple, but it is not always so. If the abdominal walls are thick or rigid, and if the uterus is very tense or irritable, contracting at the slightest F ig. 7. — Palpation of the Fretal Part situated at the Fundus. touch, it maybe extremely difficult, and sometimes impossible, to make out the foetal parts. Also, if the foetus is very small and the liquor amnii excessive, little can be felt. Still, with practice, it is surprising how much can be made out even when the conditions are by no means favourable. After the accoucheur has had some experience in abdominal palpa- tion, he will find that he can go a step further, and actually diagnose the position and attitude of the presenting head or breech. To some extent this may be done by the beginner from the position of the back and limbs, although in head presentation this does not permit of great exactness. The head must be fixed at the brim before one can pronounce definitely regarding its position. If one looks at the illustration (Fig. 9), it will be observed that in vertex positions, the 20 OPERATIVE MIDWIFERY occipital end of the head being lowermost, the fingers can be sunk deeper into the pelvis on that side, or, to put it differently, the Bide on which the fingers sink deepest is the side to which the occiput is directed. In face and brow presentations, as we shall see, it is quite otherwise. With them the occiput is higher, and is felt unusually prominent. These and other points, however, will be considered in connexion with the different positions and presentations. Similarly, the appreciation of the relative size of the foetal head and maternal pelvis, so important a guide to treatment, and the appreciation of the presence of more than one fcetus, will be considered when these subjects are under discussion. Vaginal Examination. — Cntil recent years the accoucheur made his diagnosis of the position, presentation, etc., of the fcetus entirely ] Fig. 8. — Palpation of the Fcetal Part situated at the Sides of the Uterus. by a digital examination per vaginam. If one looks at the obstetric textbooks of a comparatively few years ago, one finds this method of examination the only one seriously discussed, while even at the present moment a large majority of practitioners still employ it almost exclusively. The perfecting of abdominal palpation, but, above all, the demon- stration that every vaginal examination is a distinct danger to the parturient, has led the more enlightened and thoughtful to limit vaginal examinations as far as possible. Some enthusiasts would dispense with the latter altogether ; but it is perfectly evident that such an extreme position is untenable, for there are many conditions, both maternal and foetal, which can only be appreciated by vaginal examination. Amongst these may be mentioned small tumours in the pelvis, rigidity of the cervix, and, indeed, not infrequently, many VAGINAL EXAMINATION 21 slighter abnormal attitudes and positions of the foetus. Prolapse of the cord is another condition which can only be early appreciated by vaginal examination. Undoubtedly by careful auscultation one can tell when the child is in danger, but in cases of prolapse of the cord if one were to wait until the child showed symptoms of cardiac embarrass- ment there would be little chance of saving it. An early diagnosis •of the condition is only possible by vaginal examination. Having said so much in favour of vaginal examination, it must be Fig. 9. — The Occiput is located by the Hand — in this Particular Case the Left — sinking deeper into the Pelvis upon the Side towards which it is directed. clearly understood that the number of examinations should be as few as possible. Usually only two are necessary, one early in labour and the other after the membranes have ruptured. Again let me say that ^very vaginal examination during labour distinctly increases the risks of sepsis. One cannot get away from that fact ; it has been proved beyond all question. I have no intention, however, of discussing at this stage the question of septic infection and how to prevent it. That matter is fully considered in Chapter XXI. 2 2 OPERATIVE MIDWIFERY Prior to making a vaginal examination, it is always desirable, when possible, that the woman's bladder and rectum should be well emptied. The appearance of the abdomen when the bladder is over- distended is shown in the illustration (Fig. 10). The accoucher's band and the patient's vulva are thoroughly cleansed. In order to lessen still further the risks of infection, the fingers of one hand should hold apart the labia, so as to permit of one or two fingers of the other hand being introduced without any friction against the external genitals. The vulva should be fully exposed in making the examination. The position which the patient should assume is a matter entirely Fio. 10. — An Overdistended Bladder in a Parturient at Term of choice. We, in this country, favour the left lateral, but obstet- ricians in other countries generally prefer the dorsal. Whenever a thorough bimanual examination of the pelvis early in pregnancy is required, the dorsal is usually better, although I have occasionally found in stout women that the pelvic contents may he more exactly felt in a position midway between the dorsal and lateral. If the vaginal examination is being made for the first time upon th< parturient, the general formation of the bony pelvis and the condition of the soft parts should be investigated. It is most desirable in the case of a primipara and of a multipara, who has had any difficulty in her previous labours, that this examination should be made some few weeks before term, for now and again some abnormality will be dis- AUSCULTATION 28 covered which, if recognized for the first time during labour, might be difficult to treat. Personally, I examine vaginally every primi- para about the thirty-sixth week. At the same time I determine the presentation and position of the child by abdominal palpation. Having formed an opinion of the pelvis, the soft parts of the parturient canal, and the consistency of the cervix and the degree of its dilatation, the particular presentation is determined. The various landmarks of the foetal skull — the sutures, fontanelles, bony and other prominences — are familiar to all. I must admit that occasionally I have not been able to come to a diagnosis regarding the position, from them alone ; especially has this been so when there has been any defective ossification of the cranial bones, and the head has been situated high in the pelvis. In cases of doubt, therefore, and especially prior to any operative interference, I always feel for the ear. This landmark is not much employed at the present day, but the older obstetricians — Baudelocque, Smellie, and others — often made use of it, and I have found it of great service. The features of the different presentations are referred to elsewhere. In addition to determining the size, position, and presentation of the foetal head, the examining finger should always be swept round to make sure that there is no prolapsed loop of cord or other abnormal condition. Auscultation. — In the few remarks which are called for in con- nexion with the examination by auscultation I shall confine myself entirely to the foetal heart sounds. It is well known that other sounds may be heard with the stethoscope — the uterine souffle, the funic souffle, movement of the child, muscular susurrus, gas in the uterus, bruit of placental separation. None of them, however, is of any real practical importance. The careful and repeated auscultation of the foetal heart during labour, and especially when the second stage is protracted, cannot be too strongly commended. The child seldom dies quickly. Death occurs gradually, and so, as a rule, one has opportunities to interfere and save the child. Almost the only occasions upon which the child dies quickly during labour are where the cord becomes prolapsed and continuously pressed upon — say when the membranes rupture before full dilatation of the os. One knows that the child's life is in danger when the heart sounds become slower. Sometimes for a little they become faster, but before long, if the foetal heart is embarrassed, the sounds become slower and slower, and then intermittent, irregular, and still slower. Whenever they number less than 110 the child's life is decidedly in danger, and the sooner it is extracted the better. It is often difficult 21 OPERATIVE MIDWII l.l;V to count the fietal heart if it is registering 1 1<> to 160, hut when it comes down to 100 to 110 it is an easy matter. The only possible mistake is to confuse it with the maternal pulse. In a protracted lahour the foetal heart should he carefully noted every half-hour during the second stage. But there is valuahle information to be gained from the heart sounds regarding other conditions. The diagnosis of the presence of more than one fcutus is confirmed by hearing fcetal heart sounds of Fig. 11. — Areas of Maximum Intensity of the Foetal Heart Sounds in Pelvic and Vertex Positions. The line marks the uppermost limit for head presentations and the lowermost for breach. different rhythms. This, however, is considered in the chapter on Plural Pregnancy (Chapter VIII.). The fu'tal heart sounds are also of value in the diagnosis of the various presentations. The illustration (Fig. 11) shows the area of greatest intensity for the different presentations. It may generally be concluded that in all presentations except the face the sounds are heard best wherever the back of the child is situated. In face presentations, however, the sounds may be best heard over the thorax, and occasionally the foetal heart has been felt through the uterine wall in this presentation. RECTAL EXAMINATION 25 A rectal examination is rarely if ever called for in obstetric practice. With backward displacement of the gravid uterus and ■certain tumours complicating pregnancy, it is conceivable that it might be of service. For example, where a myoma happened to be •on the anterior uterine wall, and prevented palpation or auscultation of the fu'tus, as was my experience some time ago (Fig. 123), a rectal examination might permit one feeling the foetal parts. CHAPTER IV DYSTOCIA THE RESULT OF FAULTS IN THE FCETUS— Continued Abnormal Attitude and Position of the Head —Prolapse of Limbs associated with Presentations of the Head. ABNORMAL PEESENTATIONS OF THK VERTEX Oceipito-Posterior Positions of the Vertex. — The presentations of the vertex associated with dystocia are, with few exceptions, those in which the occiput is directed backwards (Fig. 12). It is of very frequent occurrence. I have found it in fully 20 per cent, of my private cases. As regards its etiology, nothing very definite is known. Theoreti- cally, the malrotation is more liable to occur if the pelvis is relatively large or the f anterior fontanelle or of the forehead, is pressed against the symphysis pubis, while the occiput is driven over the perineum. Stumph 1 refers to them as favourable and unfavourable forms respectively. The illustrations (Fig. 13) explain themselves. The accompanying outline Fig. 13. — Favourable aud Unfavourable Mechanism of Birth in Persistent Occipito-Posterior- Positions of Vertex. (Stumph.) Irawing (Fig. 14) of the fcetal head shows the manner in which the lead is moulded. But the practical point is : does this spontaneous lelivery of the head in a persistent occipito -posterior position often )ccur ? In my experience it is very uncommon. I am prepared, lowever, to admit that this may in part be due to the fact that I nterfere earlier than Continental operators. I have, however, in con- sequence, a lower fcetal mortality, for while the figures of those who Fig. 14. — Outline of Head Moulding in Persistent Occipito-Posterior Position. (Spiegel berg.) ■re advocates of extreme expectancy show a mortality of 10 to 12 per ent., 2 mine are 4 to 5 per cent. To bring about forward rotation of the occiput by manual interfer- nce, many devices have been recommended. Thus, with the object Jf favouring flexion, it has been suggested to press up the forehead uring a pain, pushing it at the same time towards the hollow of the acrum. Again, but directing attention to the other end of the fcetal 1 Winckel's ' Handbuch,' 1904, Bd. i., Heffc 2., p. 1078. 2 Hammerschlag; 'Lehrbuch der Operativen Geburtshulfc,' 1910, p. 407. 30 OPERATIVE MIDWIFERY head, pulling down the occiput with the fingers, the vectis, or on€ blade of the straight forceps, has heen advocated. Sniellie recommended a method which, in recent years, was revivt d by Tarnier. One or two ringers are passed into the vagina and laid along the side of the child's head, and during the uterine con- Fie. 15. — Correction of an Occipito-Posterior Position of Vertex. The internal hand rotates the occiput forwards, while the external drags round the shoulder ; the arrows indicate the direction of these manoeuvres. tractions the head is pressed upon and rotated in the direction desired. Doubtless these manipulations have sometimes been successful, but, although I have tried them all, I have but rarely found them so. The only manoeuvre I have found of real service is rotating the head •by means of the hand pressed into the vagina. The head is grasped ABNORMAL PRESENTATIONS OF THE VERTEX 81 between the fingers and thumb (Fig. 15), but before trying to bring about rotation the head must be flexed and raised out of the pelvis. The manoeuvre will only succeed, however, if the other hand, applied to the abdomen from the outside, brings the anterior shoidder forward. Although the fcetal head can stand very nearly a half-turn, the manual rotation of the head alone is attended with not a little risk to the child. Besides, if the shoulder is not brought forward, the head at once springs back into its old position. It is well, after having rotated the head and trunk, to apply forceps and extract the child. The manoeuvre is best carried out, I have found, with the patient lying upon her side. Taking my private and hospital cases I have found this manoeuvre succeed in 70 per cent., and sometimes even after attempts had been made to deliver the child with forceps. Opinions regarding the value of manual rotation vary. Speaking generally, the English school may be said to favour it, as may be seen from the writings of such modern authors as Herman, 1 Jardine, 2 and Eden. 3 Stumph, already quoted, gives it great praise, and such is the attitude of many German 4 writers. A few French operators, follow- ing Tarnier's lead, approve of rotation, but many refer to it as being unnecessary. Amongst American accoucheurs, it is coming to be looked upon with greater favour. It may happen sometimes that if one fails to bring about rotation in the manner described, the latter may be effected by passing one's hand into the uterus beyond the head and rotating the trunk by directly pulling on the anterior shoulder of the foetus. Quite recently I was called in consultation to a case in which two medical friends had been making fruitless attempts to deliver with forceps. Upon making a vaginal examination, I discovered that the child was of con- siderable size, and that the head, although in the cavity, was placed with the occiput posterior. Under deep anaesthesia I tried to rotate the head and body as described, but failed. I then passed my hand over the side of the child's head, seized hold of the anterior shoulder, and without much difficulty pushed it round. I then delivered the child, which weighed 9 pounds, with forceps. It was only slightly asphyxiated, although a good deal bruised about the head. Lamond Lackie 5 has recorded a case similarly treated. Some interesting cases are described by Von Weiss where, after pushing up the forehead, the child was delivered by expression. It 1 ' Difficult Labour,' new edition, 1910, p. 15. 2 ' Clinical Obstetrics,' 3rd edition, p. 342. 3 ' A Manual of Midwifery,' 1906, p. 223. 4 Fehling, ' Die Operative Geburtshiilfe,' 1908, p. 82. 3 Ed. Med. Joum., January, 1907. ° Op. cit., p. 614. 82 OPERATIVE MIDWIFERY is quite possible that this primitive method is employed too seldom nowadays,' and so it is interesting to read of these cases described by Aon Weiss. Rotating the head by means of forceps, either straight or curved, a method so strongly advocated by Tarnier, Edgar of New York, 1 and a few others, I have seldom tried, although occasionally, when extract- ing the child as an occipito-posterior, I have seen rotation occur with- out any attempts being made to bring it about. As, however, we have FlG. 16. — Posterior Fontanelle Presentation. not studied forceps delivery, I will postpone until later the consideration of the employment of the instrument in occipito-posterior positions. Anterior Fontanelle Presentation.— This presentation indicates a diminished amount of flexion. One meets with it most commonly in occipito-posterior presentations, which have just been considered, and in flat pelvis when the head engages in the transverse diameter of the brim with both fontanelles about the same level. But there is another condition in which the presentation is encountered — occipitoanterior presentations — where, owing to the smallness of the head or roominess of the pelvis, the head become* 1 ' Practice of Obstetrics,' 1903, p. 583. ABNORMAL PRESENTATIONS OE THE VERTEX 33 partly extended. As can be readily understood, if that happens a larger diameter of the head is thrown across the pelvis — indeed, the presentation approaches a brow, and the progress of the labour becomes retarded in consequence. In a case I saw some time ago this was -strikingly illustrated, and I was compelled, after the second stage had been allowed to go on for fully three hours without progress, to apply forceps. Even then considerable traction was required to bring away the child, although the pelvis was quite normal, because the head was too small to permit of the forceps getting a firm hold and so main- taining flexion. When the child was born it weighed only 5 pounds. FlG. 17. — Anterior Parietal Presentation. (After Bumm.) Posterior Fontanelle Presentation. — This presentation (Fig. 16) indicates greatly increased flexion, and is brought about by increased general obstruction to the passage of the head. Thus, one meets with it in generally contracted pelves and when the head is very large. The labour is always delayed, and frequently instrumental. The difficulties of delivery are referred to under the various operations. Anterior and Posterior Parietal Presentations. — It will be remembered that the head at the brim not infrequently assumes a lateral or biparietal obliquity, and comes to be directed towards one or other shoulder. As a result of this the sagittal suture, instead of running across the middle of the pelvis, comes to be situated some- times nearer the symphysis, sometimes nearer the promontory. Occasionally the obliquity becomes extremely marked, and then one 34 OPKUATIYK MIDWIFERY speaks of an anterior or posterior 'parietal presentation' (Figs. 17 and 18), according as one or other of the parietal bones occupies the pelvic brim. \>y the older writers such presentations were termed ' ear presentation-.' Prior to rupture of the membranes these presentations may alternate, but after rupture, as the head becomes fixed, one or other persists. Marked examples of the malpositions are rarely encountered when the pelvis is of normal size, although, with a pendulous abdomen, before the head is fixed, an anterior parietal presentation often exists if the parturient is standing or lying on her side and the abdominal In.. 18. — Posterior Parietal Presentation. (After Bamtn.) wall is not supported. The condition therefore is pre-eminently a feature of flat pelvis, and the mechanism of birth is referred to in connexion with that subject. The variety of obliquity influences greatly the birth, a posterior parietal presentation being much less favourable than an anterior. This is especially seen if delivery with forceps is attempted. "With the anterior parietal presentation traction brings the posterior parietal round the sacral promontory, while with the posterior parietal presentation the anterior parietal is pulled against the symphysis. I have found the anterior parietal presentation more common than the posterior in the slighter degrees of pelvic deformity, and the reverse to be the case where the malformation was very decided. Engagement of the Head in the Transverse Diameter of the Pelvis. — Early in labour one frequently finds the head in this position, ABNORMAL PRESENTATIONS OF THE VERTEX 35 even when the pelvis is of normal capacity. Usually, however, it changes into the oblique before labour has advanced very far. A persistent transverse position is the rule, however, in flat pelvis. Occasionally, even although the pelvis is normal, one meets with a persistent transverse position if the head is very small, and more than once I have seen the exit of the head arrested (Fig. 19) owing to this abnormal position. It is, as a rule, easily rectified by the hands or by forceps. Engagement of the Head in the Conjugate Diameter of the Brim. — I have had no experience of engagement of the head in the conjugate diameter, as a cause of dystocia. McKerron 1 in this country has referred to it. In his cases, however, there was general contraction Fig. 19. — Transverse Position of Vertex at Outlet. of the pelvis, and that appears to have been the real cause of the arrestment of the head at the brim. McKerron states that by rotating the head into the oblique diameter he was able to grasp it with forceps and deliver easily. Liepmann's 2 paper is the most recent that has some under my notice. PEESENTATIONS OF THE FACE. Facial presentations (Fig. 20) one is in the habit of looking upon is presentations of the vertex where, from some cause, such as con- racted pelvis, obliquity of the uterus, dolichocephalic shape of head, umours of the neck, etc., the head, instead of remaining flexed, )ecomes extended. This change of attitude in the head occurs, as 1 Lond. Obst. Trans., vol. xli., p. 142. 2 Zeit. Gel. u. Gnjn., Bd. lxv., Heft 2. 36 OPK1IATIYE MIDWIFE!^ a rule, at the commencement of labour, and the presentation resulting is often spoken of as " secondary" presentation of the face, to distinguish it from the " primary," which may exist for some time before labour. Specially interesting are the cases described by Croom, 1 Ahlfeld, 2 and others, in which the presentation has varied before labour, being sometimes vertex and sometimes face. The diagnosis of a facial presentation is not always easy. By careful palpation one searches for and locates the head, the back, the limbs, and the breech, just as in positions of the vertex. But while in vertex presentations this, as a rule, is a simple matter, in presentations Fir;. 20.— Third Position of tin- Face of the face considerable difficulty may be experienced, owing to the fact that the abdominal and uterine walls are often more resistant. In vertex presentations we saw that the back and occiput formed a curved surface with only a slight depression at the neck : in facial presentations, on the other hand, there is a marked depression between the back and the neck, and in conditions favourable for diagnosis, as where the child is lying dorso-anterior, this depression can be readily distinguished. Not infrequently, however, the child lies with its dorsum posterior (Fig. 20), when it is difficult to reach the depression mentioned. Some have referred to the inferior border of the chin forming a horseshoe-like rim, which dips into the cavity (McLennan), and I quite agree that this sometimes may be felt, but it is only when 1 ' Clinical Papers,' 1901. 2 ' Lchrbuch der Geburtshiilfe,' 1898, p. 387. PRESENTATIONS OF THE FACE 37 the conditions are very favourable for palpation, as the chin may easily be mistaken for the prominence of the occiput and the extended neck for the flexed back. This leads me to say that palpating the back in face cases is always difficult, because it runs more down the middle of the uterus, and is, consequently, out of reach. As regards the foetal heart sounds, one often hears them best high up over the chest of the child, especially in mento-anterior positions. Indeed, in such cases, if the uterine and abdominal walls are especially thin, the cardiac impulse has been felt occasionally. If a vaginal examination is hurriedly made, the face may be mistaken for the vertex, but the presentation most frequently confused with a face is a breech. Early in labour, with the os only slightly dilated and the presenting part high up, I must admit there is a considerable difficulty in distinguishing the two. Indeed, it is often impossible to say, from vaginal examination alone, which of them one has to deal with. This, further, illustrates the great importance of palpation. If the presenting face is within reach, it will be found that it does not so completely fill the pelvis at the vertex. It is less hard, and its outline is less smooth and uniform. The bony prominences of the orbital ridges, the malar bones, the chin, the ridge of the nose, the opening of the nares and the alveolar processes, can be felt, and the eyes and mouth can be distinguished. But although, in theory, these different parts may help one to a diagnosis of the presentation, in practice the landmarks that should be relied on are the alveolar processes and the nares. If one trusts to other landmarks one will certainly be led astray. Facial presentations occur about once in 200 labours. In the Glasgow Maternity Hospital in the last ten years we have found facial presentations in the proportion of 1 in 200. Pinard and Lepage, for the Clinique Baudelocque, found them in the proportion of 1 in 323. It is not so easy to decide the relative frequency of the different positions, but most authorities agree with Naegele that mento-posterior positions are more common that mento-anterior. For both mother and child the prognosis is less favourable than with vertex positions. The mother's life is placed in greater danger, because of the increased liability to lacerations and bruises of the soft parts, because of there being more vaginal examinations and manipula- tions, and, above all, because the conditions which caused the mal- attitude often still further delay and complicate the labour. If delivery is spontaneous, however, there is no additional risk. As regards the child, the labour being generally delayed, the face, especially on one side, becomes much swollen, sometimes, indeed, to 88 ulT.i;\Tl\ i: MIDWIFERY an alarming extent. Then, again, vaginal examinations, carelessly or excitedly made, may result in injuries to the mouth, nose, and especially the eyes, while, as the result of the great extension of the head (Fig. 21), injuries to the soft parts of the neck occasionally occur, especially if forceps is employed. In 69 cases of face presentation in the Clinique Baudelocque from LS90 to 1!)00 there were no maternal deaths ; in 52 the temperature was normal throughout, in 17 it was slightly raised ; 62 women were spontaneously delivered ; in 1 the face was converted into a head presentation ; in -1 primipara- 2 were delivered by forceps and 2 by symphysiotomy ; in 1 multipara, perforation (dead child) ; in 1 multipara, forceps (with fracture of the child's skull). Palotai, 1 for Kczmarszky's Clinique, Budapest, analyzing 108 cases, gives the following figures : In 50 to 00 per cent, the totus had originally lain in the first position ; duration of labour averaged fifty-two minutes Fig. 21. — Outline of Attitude and Moulding of Head in Face Presentations. (Spiegelberg.) more than in head presentations ; operative measures were required in only 4*85 per cent, of cases : maternal mortality. per cent. : fatal mortality, 8' 10 per cent. The author therefore believes that face presentations should be treated expectantly. Our results at the Glasgow Maternity Hospital have been very much worse. This, in great part, is due to early interference, which is undoubtedly a mistake, but also to the fact that so many cases are admitted to the hospital after attempts at delivery have been made outside. Treatment. — This presentation being less favourable to the mother and child than that of the vertex, the first question to be considered is whether or not one should convert it into the latter. Before taking up that important question, however, a word about another line of treatment that has been advocated by some — viz., the performance of version and bringing down the feet. Personally, I do not favour this in uncomplicated face presentations, because the total 1 Qyruekologia, 1902, No. 1, Ref. Joiu-n. Obst. and Qyn. Brit. Empire, vol. iv., p. 313. PRESENTATIONS OF THE FACE 39 mortality is greater when the head comes last. Only if there is some condition such as pelvic deformity, placenta previa, prolapse of cord, or some danger threatening the mother, calling for immediate delivery, would I have recourse to version. The first to describe clearly manipulations for the conversion of face presentations was Baudelocque. 1 There are two methods to which Baudelocque's name is attached, and they are generally referred to as I. and II. In Method I. that great obstetrician recommended the pushing up of the face with the fingers in the vagina, while the other hand from the outside pressed down the occiput. In Method II. he recommended the passing of the hand into the uterus and the pulling down of the occiput. Now, anyone who has tried either of these methods will have found that, while a face can often be changed into a vertex, the old presentation usually returns whenever the hands are removed. This is chiefly because the lordosis associated with a facial presentation remains, not being removed by the alteration in the attitude of the head. The results from Baudelocque's manipulations have therefore been disappointing. Some thirty-five years ago Schatz 2 made a most important con- tribution to the subject by describing certain manipulations directed to altering the lordosis, and which were carried out externally. To carry out Schatz's manipulations, the operator faces the patient, and, having palpated out the anterior shoulder and the breech, he raises the shoulder and back of the child. He then applies three fingers of the hand, that is raising the shoulder, against the chest, while with the other hand he pushes the breech in the opposite direction. With the hand over the breech, he then presses the child downwards. As can be imagined, considerable manipulative dexterity, mobility of the foetus in utero, and relaxation of the abdominal walls, are necessary before one can even hope to carry out the treatment successfully. Personally, I have always failed, and the experience of accoucheurs in this and other countries has been equally or nearly as unfavourable. It was very soon seen that a combination of the methods of Baudelocque and Schatz would be more efficacious than either, and so several operators suggested this. Thorn 3 probably deserves the greatest credit for perfecting the combined method of internal and external manipulations now favoured (Fig. 22). For the internal manipulations, Thorn favours Baudelocque I. — that is, pressing the face, then the forehead, upwards. Baudelocque II. — the pulling down of the occiput with the hand or fingers introduced into the uterus — may also be employed ; but Thorn does not consider this so safe. The 1 Heath's translation, 1790, vol. ii., p. 229. 2 Arcliiv f. Gyn., Bd. v. ■' Zeit. f. Gel. u. Gyn., Bd. xiii., 1886, and Bd. xxxi., Heft 1., p. 1, 189S. 40 OPERATIVE MimVII'KllY external hand of the operator presses against the protruding chest in the direction indicated in the illustration. An assistant, when avail- able, then drags the breech over in the opposite direction. The internal manuaivres may be varied slightly. For example, Fig. 22. — Thorn's Method for converting a Face into a Vertex Position. The arrows indicate the directions of pressure and traction. the head may be grasped antero-posteriorly by the thumb and fingers, as Opitz recommends, but one need not detail all the trifling varia- tions which have been suggested. To employ, however, the internal hand for correcting the lordosis by passing it into the uterus and PRESENTATIONS OF THE FACE 41 pressing upon the chest is undesirable and sometimes dangerous. Besides, it is usually unsuccessful, for, if it is necessary, the uterus is too firmly applied to the surface of the child. If an assistant is not available for dragging over the breech, the breech may fall over itself by placing the patient upon the opposite side to which it is directed. In the Glasgow Maternity Hospital during the years 1896 to 1906 the manipulations described were successful in about 65 per cent, of the cases. For the Berlin University ' Frauenklinik ' Olshausen states that from the years 1886 to 1900 they had 114 cases, with 79 successes — 70 per cent. 1 Weiss 2 and Thorn 3 give their successes as 50 per cent, and 75 per cent, respectively. Having corrected the mal-attitude of head and body, the foetal head should be pushed firmly down into the pelvis, and a pad and binder applied, or immediate delivery effected with forceps. For the employment of the manoeuvres described, it is of the greatest importance that the patient should be deeply anesthetized, the cercix /cell dilated, the uterine walls not applied too closely to the surface of the child, and the head not too firmly imparted in the -pelvis. Consequently, they must be carried out, as a rule, com- paratively early in labour, although occasionally I have seen them successful even when labour was far advanced. When attempts are made late in labour, the head must be dislodged from the pelvis, and that usually, by pushing the child against the uterus, stimulates the uterus to contract firmly, and prevents the external manoeuvres from being carried out. Besides, the head at this stage is much moulded, and so does not readily adapt itself to a new position in the pelvis. Judgment regarding the different methods of treatment in face presentations must be based on the foetal mortality, for the maternal mortality in hospital practice and in the hands of careful obstetricians has been reduced to a minimum. Failure to convert a face into a vertex presentation is of little moment, for very good results are obtained — in fact, many say better results — when one leaves the labour to Nature. It is entirely the attitude of the partisan for Thorn and others to explain away the good results obtained by purely expectant treatment, such as those given by Boer and Zeller — 120 cases with only six foetal deaths, a mortality of only 5 per cent. — and those recently given by Hammerschlag, 4 with a foetal mortality of only 6 per cent. (89 per cent. 1 ' Lehrbuch der Geburtshiilfe,' Olshausen and Yeit, 5th edition, 1902, p. 210. 2 Volkmann's Klin. Vortrdge, No. 74, 1893. 3 Ibid., No. 339, 1902. 4 ' Lehrbuch der Operativen Geburtshilfe,' 1910, p. 408. 42 OPERATIVE MIDWIFERY of the cases were treated expectantly). The best results, after correction, are those of Opitz Iot Olshausen's Klinik — 8*9 per cent. mortality. As far as can be judged at present, the best results are obtained by judicious expectancy. It appears to me, therefore, that the routine practice of correcting face presentations is not called for. I am quite prepared to admit that it is often successful, especially FlG. 23. — Persistent Mento-Postf rior Position ol Faoo. when Thorn's method is employed, but some experience and practice is required before the requisite amount of manual dexterity is obtained. In the meantime, therefore, I would advise the general practitioner to leave face presentations alone. If, however, he is anxious to try the method described, and he can choose his time, he will get the best results by operating when the os uteri is about three-quarters dilated, and when, in introducing his hand into the uterus, he requires to rupture the membranes. PRESENTATIONS OF THE FACE 43 But there is another matter which must be considered. What is ;o be done with those cases which one treats expectantly or fails to jonvert, and in which the chin remains directed posteriorly (Fig. 23) ? [n such cases it has been possible occasionally to dislodge the head md convert the presentation into a vertex, or, by manipulations, similar to those described for occipito - posterior positions of the /ertex, to bring the chin to the front. With a face firmly impacted n the pelvis, those manoeuvres have, as a rule, failed. It is usually ;aught that there is then nothing left but to perforate, but we nave had one or two cases where, with axis-traction forceps and by simply exerting traction, rotation of the chin has occurred. Lewers, 1 i few years ago, gave an interesting description of two such cases, tnd others have been recorded at odd times. Reed's 2 paper on this subject is most valuable ; seventy-five recorded cases, beginning with me by Smellie, are analyzed. It is very interesting, for the results lave not been nearly so bad as is generally indicated in textbooks. Here are some of Reed's conclusions : ' Rotation. — Manual succeeds, 4 (Yolland, 1) ; fails, 9 (Yolland, 4) ; orceps succeeds, 25 (33 per cent.) ; fails, 16 (21 per cent.). 'Manual Flexion. — Fails, 5 cases (Thorn, 1) ; succeeds, 12 (16 per :ent.). Vectis succeeded in 2 of the 3 cases tried. Version tried in rain in 4 cases. 'Delivery. — Unrotated, 17; spontaneous after correction, 10. forceps succeeded, 28 (37 per cent.) ; failed, 3 ; axis traction, forceps succeeded, 3 ; failed, ; craniotomy, 14. ' Mortality. — Mother : Live, 61 ; die, 8 ; not stated, 6. Babies : jive, 39; die, 30; not stated, 6.' It is evident, therefore, that attempts at rotation, and even tttempts at delivery, with forceps are quite justifiable, and frequently uccessful even in the most hopeless cases of mento-posterior posi- ions of the face. BROW PRESENTATIONS. I must now say a word or two about the most unfavourable of all lead presentations — viz., the brow (Fig. 24), the attitude between vertex and face. Fortunately, this unfavourable attitude is very rare, or it occurs only in about 1 in 2,000 cases. As regards etiology, the position may be looked upon as a variety >f face presentation, for the same factors influence the occurrence in »oth. When one has said that, however, the resemblance ceases. A •row is an infinitely more unfavourable presentation than a face. 1 Lond. Obst. Trans., 1899, vol. xli., p. 280. 2 Amer. Journ. Obst., 1905, vol. li., p. 615. 1! OPERATIVE MII>\Vlll.l;\ The diagnosis of the presentation is rarely made until the os is sufficiently dilated to permit one feeling such landmarks as the anterior fontanelle, and especially the supra-orhital ridges. True, if conditions are very favourable, one may make out by abdominal palpation the chin and the head less flexed than usual, but the deep depression between the occiput and the back, which can often be appreciated in face presentations, is not so marked. Even vaginal examination may leave one in doubt if the membranes have been long ruptured and a caput succedaneum has formed. Besides, the head is often high in the pelvis, for it engages in the occipito-mental diameter, FlG. 24. — Brow Presentation. the longest cranial diameter, and so finds great difficulty in entering the pelvis. Should there be any doubt about the presentation, the patient should be anaesthetized and a thorough examination made. In certain cases one may be deceived as regards the extent to which the head has descended, for the caput and elongated forehead may give the impression that the head is lower than it really is. Spontaneous delivery in brow presentations rarely occurs, except when the child is below and the pelvis above the normal. When it does occur, the face in the region of the base of the nose is fixed against the pubes, and the anterior fontanelle and rest of the head sweep over the perineum. If the chin remains posterior, spontaneous deliver} 7 is impossible. The moulding of the head is shown in the illustration (Fig. 25). BROW PRESENTATIONS 45 As already stated, the prognosis for both mother and child is by no means good, although, since rectification has become more general, the results for both have greatly improved. All manner of injuries to the mother are liable to occur, and Von Franque states that rupture of the uterus occurs in 3 per cent, of cases. In one brow presentation brought into the Maternity Hospital the uterus was ruptured. Tears of the perineum, fistulas in bowel and bladder, have frequently resulted. The long duration of the labour, and the injuries to the brain and soft part about the face, especially if the child is dragged through with forceps, account for the high foetal mortality. Brow presentations, therefore, cannot be treated expectantly, which many still consider the right course to pursue with face presentations. Fig. 25. — Two Forms of Moulding which the Head may undergo in Brow Presentations. (Spiegelberg.) Nor should they be treated with forceps and the child dragged through the pelvis, for such a procedure is attended with great risk to both the child and the mother. Version or rectification of the position are the only alternative treatments. Personally, I favour version when the presentation is recognized early, for, although the fcetal mortality is smaller after rectification, there is probably 20 to 30 per cent, in which rectification fails, and this, should it happen, is a very serious matter in brow presentations. When labour has advanced and version is consequently unsuitable, rectification after the manner of Thorn, already described in connexion with face presentations, should be practised. A year or two ago a woman, whose child presented by the brow, was admitted to the Glasgow Maternity Hospital advanced in labour. 16 OPKIIATIVH MIDWII'i:i;V Several fruitless attempts at delivery with forceps had been made before she was sent to the hospital. My assistant rectilied the mal-attitude, and without much difficulty delivered a living child weighing 12 pound.-. We have had three other such cases in recent years, and all have been] successful. As regards the cases delivered by forceps, in one the child was alive, in the other it was dead. The recent results from rectification have been very satisfactory. Von Franijiic 1 for 342 collected cases gives the following : Version ... ... ... 57 cases— 33*3 per cent, dead children. Forceps ... 77 ,, 27 „ ,, Alteration into a face ... 14 ,, 14 ,, ,, „ vertex ... 43 „ 7 „ „ When an alteration into a face or vertex fails, and the conditions are unfavourable for version, it has been recommended that sym- physiotomy should be performed. Wallich, for the Clinique Baude- locque, for several such cases gives a maternal mortality of 5 per cent, and a foetal of 28 per cent. I have once performed the operation for this condition. Both mother and child recovered and left the hospital well. I believe it is rarely indicated, and only if rectification fails and the child is in a thoroughly satisfactory condition. As a last resort, craniotomy is the only treatment. PROLAPSE OF LIMBS ASSOCIATED WITH PRESENTATION OF THE HEAD. Prolapse of an arm is a common occurrence in oblique presenta- tions. With head presentations (Fig. 26), however, it is very rare, a& it happens only about once in 400 cases. Naturally, any condition which hinders the engagement of the head predisposes to the accident. Thus, contracted pelvis, pelvic tumours, hydramnios, and sudden rupture of the membranes, are the most common causes on the side of the mother ; while prematurity, maceration, and abnormal positions of the head, such as those of the face, brow, and occipito-posterior positions of the vertex, may be men- tioned in connexion with the f(etus. The arm, of course, prolapses much more readily than the foot, and generally it is the anterior arm. Some extraordinary cases have been recorded where both arms and legs have presented. Broom 2 has related a very interesting one where the head and two feet became arrested at the brim. Yon Zumph describes one where there was pro- lapse of both feet and arms and the cord in a facial presentation. Hall 3 describes a very complicated condition where the head was impacted 1 Winckel's ' Handbuch,' Bd. ii., Teil iii., 1905, p. 1582. 2 Lancet, 1890, p. 1298. 3 Archiv f. Qyr *H lxiii., 1901. PROLAPSE OF LIMBS 47 between the legs of the child, and many odd and interesting cases are to be found scattered throughout the literature relative to the subject. When the foot or feet come down, the child is invariably premature or macerated, and the uterus is firmly retracted over the child's trunk. Fig. 26.— Prolapse of Ann in Vertex Presentations. (Bumm.) I have only once experienced difficulty in diagnosing the condition — when a foot came down beside the head and the tips of the toes felt exactly like the prolapsed cord. A careful examination under an anaesthetic should always be made in doubtful cases, when it will invariably clear matters up. 48 0PERAT1\ i: MIDWII'I.KV I'pon three occasions I have found the hand preventing the child's head engaging at the brim, but the arm was easily displaced, and tin- head immediately entered and descended. Naturally, considerable difficulty may be experienced in delivering the child if the prolapsed limb is not recognized, especially if the pelvis is deformed, and that accounts for the fact that not infrequently the mother and child have been seriously injured. The fu-tal mor- tality, however, is also increased by the fact that the children are often premature and badly nourished. In simple prolapse of the arm the latter can invariably be pushed up, and that should always be the treatment followed. To look upon Fig. '11- — Dorsal Displacement of the Arm. Hie condition as an oblique presentation and perform version is a mistake. When a foot comes down, however, especially if the uterus is very firmly retracted over the child, there may sometimes be not .a little difficulty in pushing the limb up. Here again version is a mistake, and it is usually very difficult. The course to pursue is to •deeply anaesthetize the patient and push up the leg. A peculiar but very rare displacement of the arm is the dorsal displacement (Fig. 27), which was first described by Sir J. Y. Simpson to the Edinburgh Obstetrical Society in 1850. l Since then many cases have been recorded. Sir A. R. Simpson in 1879- reviewed those recorded to date. Barbour 3 in 1887 recorded a case in which, after the birth of the head, in spite of extreme traction, the child 1 • Collected Works,' vol. i., p. 381. 2 Trans. Ed. Obst. Soc, Session 1878-1879, vol. 3 Eilin. Med. Joum., September, 1817, p. 216. p. 97. PROLAPSE OF LIMBS 49 could not be delivered. Finally, an arm was pulled down, and then it was discovered that the other was behind the occiput. It, too, was delivered with difficulty, and during the process was fractured. Wells 1 recently recorded an interesting case. In most cases — Simpson's, for example — the head is prevented from descending, but in others the difficulty may only occur after the head has been delivered. Apparently the arm catches upon the retraction ring, although it may sometimes be on the pelvic brim. Naturally, the condition is easily overlooked. It should, however, be suspected if there is difficulty in delivering the head or shoulders when the pelvis is of normal capacity, the foetus of normal size and in the ordinary position. By passing the hand up beyond the pre- senting part, the bent arm is felt. Replacement often succeeds, but is sometimes accomplished with great difficulty, so much so that version is recommended by several writers. With deep anaesthesia in the Sims position, however, I should imagine that reposition of the arm could usually be accomplished. 1 Lancet, January 19, 1907, p. 165. CHAPTEli V DYSTOCIA THE RESULT OF FAULTS IN THE FCETUS— Continued Breech Presentations. Pelvic presentations, as everyone is aware, are much less favourable than those of the vertex. The maternal mortality and morbidity Lfl greater because of the more frequent vaginal examinations and manipu- lations, while the foetal mortality is somewhere between 15 and 20 per cent. Many of the foetal deaths are unavoidable, but a great number are quite preventable, and are purely the result of unwise management. In detailing the treatment of the presentation and its varieties I have deemed it advisable to consider the subject in some detail. Diagnosis. — The diagnosis of a breech presentation by abdominal palpation is not always easy. Undoubtedly in many cases one can feel the breech at the pelvic brim, and recognize it as being softer and less globular than the head, and immobile apart from the trunk ; while at the fundus of the uterus the hard globular head is often distinguishable. Still, in many cases these features are not easy of recognition. The most characteristic feature, when it is present, is the ' ballotting ' of the head between the two hands placed on each side of the fundus. Such symptoms as undue fulness of the fundus uteri, and tenderness to pressure over that part, are not characteristic, and may be present in cranial presentations. By vaginal examination early in labour it is often impossible to determine the presenting part, as it is generally difficult to reach it. Later, when the os is dilated, and the soft, irregular breech can be distinguished, one feels two bony prominences with a depression between them, and sometimes the genitalia of the child. But the most important landmark is the spinous processes of the sacral vertebrae. Still later, and after the membranes have ruptured, these landmarks are even more distinct — the anus can be felt, and is distinguishable from the mouth by the absence of the alveolar processes. In addition, as the child descends and its abdomen is compressed, meconium is forced out, and escapes from the maternal passage with each uterine contraction. 50 BREECH PRESENTATIONS 51 THE BREECH ARRESTED AT THE PELVIC BRIM. An actual failure of the breech to engage and descend is observed •when there is distinct disproportion between the maternal canal and the lower part of the trunk of the child. On the maternal side may be mentioned such conditions as deformity of the bony pelvis, and tumours of the uterus or surrounding structures ; while on the foetal side the most important are unusual size of the child's pelvis, and tumours of its pelvis and abdomen. The maternal abnormalities referred to are not difficult of recog- nition — at least, pelvic deformity, if at all pronounced, should not be overlooked. In cases of contracted pelvis, when the deformity of the pelvis is only slight or moderate, most authorities recommend bring- ing down a leg in breech cases, and probably for ordinary practice that procedure is the best. It is, however, quite possible in many cases, as I have proved, to perform bipolar cephalic version, and bring the head to present. One is then able to accurately estimate the relative size of the foetal head and maternal pelvis. I refer to this again at the end of the chapter. Tumours, ovarian or uterine, are easily overlooked, especially if they are of medium size, for bimanual palpation of them is not always possible, owing to the presence of the distended uterus. Recently I had personal experience of this in a case of an ovarian cyst which was only distinguishable when the presenting part of the ■child was pushed out of the pelvis. With foetal abnormalities, such as a sacral tumour or enormous distension of the foetal abdomen, the diagnosis is always difficult. They can often only be appreciated by a process of exclusion and by introducing the whole hand into the uterus. Besides the conditions referred to, the engagement of the pre- senting part may be interfered with by alterations in the axis of the canal, such as are produced by a pendulous abdomen, or as a result of the operation of vaginal or abdominal fixation of the uterus (Chapter XIX.). But in addition to such abnormalities in mother or foetus, it is frequently necessary to bring dowm one or both feet for dangers threatening the life of the mother or child. In this connexion, on the mother's side, such conditions as placenta prsevia, severe eclampsia, phthisis pulmonalis, or cardiac disease, and on the child's prolapse of the cord may be mentioned. 52 OPKUATIYK MinWIFKl^ WRINGING DOWN A FOOT. Although it is comparatively easy to bring down a foot when the breech is arrested at the brim, and is indicated under certain circum- stances, it must not be forgotten that the risks to the mother and child are decidedly increased, especially if forcible extraction of the child follows. Traction, therefore, should only be exerted and delivery completed if there is distinct danger to the mother in delay, for if the breech is forcibly drawn upon, not only do the arms become extended, but the cervix, being insufficiently dilated, grasps the after- coming head with a force impossible to overcome, unless deep incisions are made in the cervix. In other conditions, such as placenta praevia, contracted pelvis, or large child, the case should be left to Nature until the whole breech is born. By so doing the maternal mortality will be reduced to a minimum, and the fu'tal mortality will be kept at the lowest possible figure. Before giving details as to how the operation should be performed, I must answer the question, Is it ever an advantage to bring down both feet ? The only circumstance, in my experience, under which it has appeared to have been an advantage was when rapid emptying of the uterus was deemed necessary. Often it is not easy to get hold of both feet. Besides, it increases the fcetal mortality ; consequently, it is only when rapid delivery for the sake of the mother is the first consideration, and the life of the child is of only secondary conse- quence, that both feet should be brought down. The bringing down of a foot is seldom a difficult manuuvre ; but occasionally, and especially if the membranes have ruptured early and the breech is fixed, it may give rise to a good deal of trouble. Until comparatively recent years the recommendation was to seize both legs, or whichever one presented ; but now the advice of all writers, with- out exception, is to bring down the one directed anteriorly. In this country we are largely indebted to Barnes for having clearly pointed out the advantage of such a procedure. By looking at the illustration (Fig. 28), it will be at once apparent why the anterior is better than the posterior. With the posterior leg down, the anterior buttock catches on the symphysis pubis, and the descent of the foetal pelvis is arrested. Even if traction is made on the limb matters are only made worse, for it is impossible to get the line of traction in the axis of the pelvis. But it is not always easy to get hold of the anterior leg, and it is especially difficult if the abdomen is pendulous, if the liquor amnii has drained away, or if the pelvis is contracted. Besides, the legs are often crossed, and confusion in consequence arises. Be the cause what it may, how is the unfavourable position to be BREECH PRESENTATIONS 53 overcome ? To push the limb back and seize the other is usually impracticable, even if it were worthy of consideration, while the bringing down of the other limb is not always possible. One is ■compelled in these cases, therefore, to make the best of matters. Flu. 28. — The posterior leg has been brought down, with the result that the anterior buttock catches upon the symphysis pubis. The arrows indicate the rotations of the trunk which result when traction is made on the leg. Now, if such a case is left to Nature, it will be seen that the posterior thigh comes to the front and becomes anterior by rotation. In doing this, however, it is apparent that the trunk may take either ■a long or a short rotation (Fig. 28 — the arrows indicate the two :,1 OPERATIVE MIDWIIT.IIY varieties). Most modern writers seem agreed that the long rotation is the more general. Here is the opinion of two who have given tin suhject special consideration. Faraboeuf and Varnier 1 write: ' La rotation abandoning a la spontaneity se fait toujour 8 par le eheniin le plus long': while Nagel 2 says: 'Die Drehung des Rumpfes um seine Langsachse geschieht desshalb auf dem langeren Wege,' etc. As a rule, however, if the posterior Leg is pulled upon, the foetal pelvis takes the long rotation in a dorso-anterior and the short in a dorso-posterior position. Occasionally a short rotation occurs even in dorso-anterior positions, according to Faraboeuf; but that is the exception, and certainly I have rarely seen it happen. Rotation may be greatly helped by the hand grasping the buttock between the thumb and finger, and encouraging the particular rotation the breech is tending to take. In carrying out the manipulation of bringing down a foot, the hand, with the fingers brought together in the form of a cone, is carefully insinuated into the uterus, through vulva, vagina, and cervix. I need not say that this must be done after the patient's genitalia and the operator's hands have been thoroughly cleansed. No hard-and-fast rule can be laid down as regards the hand to be employed and the position of the patient, for matters of that kind must be left to the judgment and experience of the operator. This only I would say, that the prospective obstetrician should train him- self to be ambidextrous. Personally, I prefer, when bringing down a foot, to have the patient upon her back, and I employ the hand which, introduced into the uterus, will most readily and most comfortably reach the limbs. Consequently, if the limbs are towards the mother's right side, I employ my left hand, and if they are to her left side, my right. Many, especially in this country, prefer the patient in the left lateral position, and, as I shall show, this is sometimes a distinct advantage. If such a position is employed, it will usually be found that the left hand is most suitable when the limbs are to the back, and the right when they are directed to the front of the mother. The cases in which it is a distinct advantage to have the patient in the left lateral position, and even to raise the pelvis with a pillow, are those difficult cases where the breech is impacted in the maternal pelvis (p. 80). Under such circumstances the lateral position allows the force of gravity to come into play, and so favours the dislodge- ment of the foetal pelvis, especially if in addition the patient is deeply anaesthetized. 1 'Introduction des Accout-hemcnts,' 1904, p. 165. 2 'Operative Geburtshulfe,' 1902, p. 42. BREECH PRESENTATIONS 55 Probably all operators — at least all English operators of any experience — have appreciated the advantage of the left lateral position in those conditions described where there is great difficulty in dis- lodging the fu'tal pelvis. Barnes speaks highly of it, Nagel does the FlG. 29. — The operator has passed his hand along the ventral aspect of the child, and is seizing the anterior leg. (Nagel.) same, while the older obstetricians in the days before anaesthetics often made use of the position, or even the genu-pectoral position ; see, for example, the recommendation of Smellie. 1 Having introduced the hand into the uterus, it should be passed 1 Smellie's ' Midwifery,' McClintock, vol. i., p. 317. 50 nl'KKATIYK MIDWII-'KUY along the ventral aspect of the child, over the thigh and lower part of the leg to the foot (Fig. 2!)), which is to he grasped hetween the lingers. It the legs are hent upon themselves, the foot is en- countered almost whenever the hand is introduced ; but if the legs are extended along the trunk, the hand will require to be passed Fig. 30. — Pinard's Manoeuvre for bringing the Foot within Reach. almost to the fundus before the foot can be seized. The manipula- tions must only be carried out in the intervals between the uterine contractions. During the pains the hand must lie passive against the child's body. Pinard has suggested a manoeuvre — no doubt employed from time immemorial, for one sees it hinted at in the writings of the old BREECH PRESENTATIONS 57 •obstetricians — for bringing the foot more readily within reach. As seen from the illustration (Fig. 30), the fore and middle ringers are applied over the thigh and press the latter against the trunk, with the result that the foot is brought lower, and can be more readily seized ; at the same time the external hand presses down the trunk. It is seldom of use, however, when the uterus is firmly applied to the child's body or the legs extended. Usually the lower leg can be readily bent on the thigh, but when one comes to draw down the thigh the knee catches on the uterine wall. In such cases the breech must be dislodged and pushed up, while the trunk is pulled over by the external hand applied over the fundus ; indeed, for a moment the j presentation is actually made oblique. IThe hand which is inside the uterus, and which, as I have already stated, is only moved during the intervals between the contractions, should, when possible, observe the character of the foetal pulsations in the cord, for the condition of the fcetal pulse naturally influences the further treatment. The operator, however, must not be surprised by a very decidedly intermittent and rapid pulse after any disturbance of the child, for this is the rule ; but it is only temporary, it soon quietens down after the manipulations cease, provided the condition of the child is satisfactory. Extraction of the Child by Traction on the Leg. — Having considered the indications for, and the methods of, bringing down a foot, and the advantage of bringing down the anterior one, we must proceed to the manner of extracting the child. Before doing so, I would once again warn my readers against such a proceeding with the os undilated, unless the indications are most pressing. It is no exaggeration to say that the risks to the mother are doubled, and those to the child trebled or quadrupled, by such a step. It is sometimes necessary, however, although almost the only indications are dangers threatening the life of the mother, when it is imperative that the uterus should be evacuated as quickly as possible. It might be thought that danger threatening the life of the child would also be a reason, but, as a matter of fact, in practice, that is only the case if the os is fully dilated. No fcetus, showing cardiac embarrassment, could be ex- tracted alive unless the parturient canal was, at the commencement of the operation, sufficiently dilated to allow of the child passing, or unless the operator was prepared to make deep incisions in the servix. The foot is to be grasped in the manner shown (Fig. 31), and if traction is made upon both feet they are best held with one finger between, to prevent them chafing. The attachment of a fillet is seldom necessary. The line of traction should be well back, so as to be 58 OPERATH E MIDWIFERY exerted as nearly as possible in the a\i.s of the brim. ( )nce t be knee is born, the operator's hand should be passed over the thigh so that the latter rests in his fingers, while his thumb is applied over it- dorsal aspect (Fig. ;{'2). When the posterior buttock distends the pelvic fl >or, the leg on which the traction is being made should be pulled upward-. I! need be a finger may be passed into the fold of the other thigh, so- <\ Fig. 31. — The Manner of grasping the Foot. that a little more traction can be exerted (Fig. 83). There should, however, be no attempt at pulling down the leg, which is still along the side of the trunk, until the foetal pelvis is completely born. Then it can be dislodged by passing the lingers up to the bend of the knee, and sweeping the lower part of the leg over the lower part of the trunk. All this time delivery of the breech may be much facilitated by BREECH PRESENTATIONS 5!r< a nurse or assistant exercising pressure on the uterus. This, however, must be done during the uterine contractions ; it is profitless to apply it in the intervals. Both legs being now down, traction on the trunk should be carried out by applying the thumbs over the dorsal aspect of the fatal pelvis, FlG. 32.— The Manner of grasping the Leg when Traction is being made upon it. (Nagel.) and the fingers over the ventral surface of the thighs (Fig. 34). The 3hild should on no account be grasped round the abdomen. While axerting traction at this stage the accoucheur must see that the cord is not dragged upon ; a loop should therefore be pulled down. So far the delivery is seldom troublesome, but the fact of having had to exert traction renders the rest of the operation, the disengage- <;o nl'KIIATIVE MIJ>\\ 1 1 KkY ment of the arms and head, a matter of considerable difficulty, for in a large proportion of cases they will be extended. Jt is just at this stage that quick delivery of the child is so important. Hough l_v speaking, once the child is born as far as the umbilicus it will nol survive if longer than eight minutes is taken for its extraction. I >f •course, in many cases, as we have seen, where the delivery is hastened,? Fis. 33. — The Forefinger of the Left Hand passed into the Groin/ Is order to help the Delivery of the Breech. (Nagel.) the child's life hardly comes into consideration, as the operation is performed in the mother's interests. In forcibly extracting a child by the feet the difficulty in bringing down the arms and head is frequently increased by the fact that the cervix, not being completely dilated, firmly grasps the body underneath the arms (Fig. 85). In such a condition, with a large child, unless ■one is prepared to forcibly dilate and tear the cervix, or to make BPE E CH PRE S E N T ATION S (\1 deep incisions into it, there is little chance of delivering a living child, and the hope of doing so should be abandoned. The necessity for bringing down the arms, prior to extracting the. FlG. 34. — The Maimer of Grasping the Breech when Traction has to be exerted upon it. head, has only been universally taught and practised since Baude- (ocque's time. Prior to that date some recommended leaving the arms alone, as Deventer; others bringing down one, as Pare. Mauriceau,. iiowever, recommended bringing down both, while Smellie advised 62 OPERATIVE MIDWIFERY bringing down the arm only if the pelvis was small and the child large. In disengaging the arms it is always an advantage to first bring down the one which is directed posteriorly, for there is more room for carrying out the manipulations in the hollow of the sacrum. In order to bring the arm well within reach, the child should be pulled up towards the abdomen of the mother and a little to one or Fig. 35.— Showing the Upper Pan of the Trunk caught by a Cervix not fully dilated. (Attn- 1'iuilin and Tarnier.) other side — if the back is to the right, to the left; if the back is to the left, to the right (Fig. 30). With a heavy child this is rather irksome, and so may be delegated to an assistant. The operator, however, usually finds it a distinct advantage to perform the manoeuvre himself. A mistake which is very commonly made, and one which renders the disengagement of the arms much more difficult, is pulling the trunk of the child too far down, for it has the effect of impacting the BREECH PRESENTATIONS 68 head and arms in the pelvis. Generally speaking, when one feels the lower angle of the anterior scapula just about the level of the lower margin of the symphysis pubis, one should proceed to bring down the aims. Indeed, in contracted pelvis, and with a very large child, it will sometimes be advantageous to do so earlier. Fig. 36. — Bringing down the Posterior Ann. (Nagel. The hand to be employed is the one which can be passed most con- veniently along the back of the child, so that while one hand is pulling the child forward the other is insinuated into the vagina and carried up the spinal column. If the child's arm is within easy reach, two angers inserted into the vagina and the thumb over the child's back [F ig. 36) is sufficient, but at other times the whole hand must be inserted. Having come to the shoulders, two fingers should be carried, or rather CI OPEEATIVB MIDWIFERY laid, along the upper arm as far us the bend of the elbow, and t In- arm pulled or pushed down over the child's face. One must never try Fig. 37. — Bringing down the Anterior Ann withonl rotating the Trunk. to bring the arm down by simply getting one or two fingers beyond the shoulder and pulling on the humerus, for that will almost certainly BREECH PRESENTATIONS 65 result in its fracture. If the arm cannot be reached, the trunk should be disengaged a little by pushing it up, and the whole hand, except the thumb, should be passed along the upper arm. Having brought down the posterior arm, one has the choice of bringing down the other, keeping it anterior or rotating the trunk until it becomes posterior. The former manoeuvre, most favoured by the French, is often quite possible, and, if so, should be adopted. It is carried out by pulling the child in a backward direction (Fig. 37) and passing the ringers over the shoulder on to the arm, as has just been described in connexion with the posterior arm. But it is sometimes impossible to bring down the anterior arm in that way. In such cases the trunk should be rotated, and the arm which was anterior carried round until it comes to be posterior. Some operators, indeed, make a practice of always employing this latter method. But rotation, although usually carried out quite easily, is not altogether free from risk, for if the chin is low and catches, the head is arrested, and torsion of the neck, beyond the point of safety, follows. When carrying out rotation, therefore, the trunk, grasped by the two hands with the thumbs placed over the back and the fingers round the body (Fig. 38), should be pushed up, and the head and remaining arm dislodged from the pelvis ; then, alternately rotating and pushing up the trunk, the latter is gradually brought round to the position which renders the arm accessible from the hollow of the sacrum. Rotation, however, may be made in the direction of either the black or the dotted arrow. If one makes it in the direction of the dotted arrow, the anterior arm comes posterior, and the head remains to be extracted occiput anterior, the best position for extracting the after-coming head. It seems, therefore, the most natural course, and, as a matter of fact, is the one generally recommended. It has, however, sometimes a distinct disadvantage, for in the process of rotation, the arm, becoming arrested by the friction against the uterine wall, comes to take up a position more or less behind the occiput. It has always seemed to me, therefore, better to follow the direction of the black arrow. In the particular position under consideration, the rotation must lot be stopped when the shoulder reaches the right sacro-iliac ■ynchondrosis, otherwise, although the arm could be brought do'jvj me would have to deal with an occipito-posterior position of the af oming head. Rotation, therefore, must be continued still furthe. ,nd the shoulder be carried to the other sacro-iliac synchondrosi g •efore the arm is brought down, for by so doing one will obtain whatl 3 desired, an occipitoanterior position of the head. But this long otation will be found of great advantage in another respect. All the c.ti OPERATIVE MlDWII'Km time the arm tends to come more over the face, and the last si of rotation aids this more than ;ill the rest, for the iirin catches on the projecting spinal column and becomes very accessible. Eaving placed the arm posterior, it is brought down as already described. Rotation may be aided by seizing the arm which is already down, and dragging or pushing the trunk by means of it (Fig. 39), but such Fig. 38. — Bringing down the Second Arm. (Nagel.) The posterior arm having been brought down, the operator is rotating the trunk to bring the anterior arm into the hollow of the sacrum, where it can be eaailj reached. The dark arrow is the right direction of rotation. a manoeuvre is not advisable, and the manipulations already described a/^ the best. It sometimes happens, owing to the large size of the child or the ,arrowness of the bony canal, that there is extreme difficulty in wringing down the arms. In such cases, under anaesthesia, the trunk of the child should be pushed well up, the hand passed along the ventral aspect of the child, and the anterior arm brought down. If such extreme difficulty is anticipated, it is well to do as Kiistner has BKEECH PKESENTATIONS 07 suggested, and bring down an arm immediately after the navel appears. When, after many and futile attempts, the arms cannot be brought down, a blunt hook must be used. I have only had to do this with a dead child where the maternal passage was deformed and the child was of Fig. 39. — Rotation of the Trunk by pulling or pushing the Trunk with the Ann already brought down — a Manoeuvre not recommended. extreme size. If recourse is had to a hook, it should be passed along the dorsal aspect of the child, over the elbow, and the arm pulled upon — it is invariably fractured. I have sometimes required to use i sharp hook for such cases. 68 OPERATIVE MIDWIFERY Occasionally it has even been necessary to perforate the head before bringing the arm down. Sometimes one of the arms gets displaced behind the occiput — Fig. 40. — Dorsal Displacement of the Arm, and the Manner in which the Trunk should be rotatcrl in Order to briny the Arm into the Hollow of t he Sacrum, and .so wit bin Easy Rcai-li. 'dorsal' or ' nuchal ' displacement of the arm. It has even happened that both have become so displaced — a malposition often extremely difficult to rectify. It is a matter of simplicity in the case where, BKEECH PRESENTATIONS 69. one arm being already clown, the other is discovered behind the neck (Fig. 40), for a simple rotation of the body in the direction of the arrow will result in the arm becoming arrested and the head slipping past the arm. Should, however, both arms be still alongside of the head, they must be brought down by the operator passing his whole hand into the uterus after the trunk of the child has been pushed up and disengaged, or they must be brought within reach by rotation. If rotation is chosen, it is at once evident that, as the trunk is rotated and the one displaced arm corrected, the malposition of the other is aggravated. The trunk is therefore rotated — the direction here does not matter — and the posterior arm, which is more easily reached, disengaged; then the child is rotated back again to allow of the other arm being brought down. In cases where the child's abdomen is forward at the stage when the arms have to be disengaged — a condition which need never occur if one favours rotation of the back forward as the breech is being born — some obstetricians recommend pulling the child backwards and passing the hand up along its ventral aspect, and disengaging the arms from that side ; while others favour approaching the arms from the dorsal aspect. It is impossible to detail all the little nianceuvres fvhich have been suggested. Fritsch's, however, seems good. It consists in passing one hand over the front of the child's shoulders, ind then pushing its trunk upwards with the other, the arms being ;hus dislodged by the movement of the trunk rather than by any lirect manipulation on the arms. EXTRACTION OF THE HEAD. Having delivered the arms, the operator now proceeds to the xtraction of the head. Should he have already lost much time n bringing down the arms, it is of the greatest importance, if the hild is to be born alive, that he extracts the head quickly. But while hat is fully appreciated by everyone, it is often forgotten that many hildren are lost, not so much by delay as by undue and misdirected faction on the trunk, causing fracture and dislocation of the upper art of the spinal column. It is a matter of extreme difficulty to give le relative proportion of cases lost by delay and those lost by injury d the spinal column, but I feel convinced that a much larger umber of cases are lost by the latter than is generally supposed. So npressed am I with this that it has become my practice in the ist few years always to deliver the after-coming head with forceps ?ig. 41), if moderate traction and suprapubic pressure, in the manner ) be described, fail to effect the delivery. Consequently, I always 70 OPERATIVE MIDWIFERY have forceps ready at hand in a breech presentation, or when I have brought down a foot ; not that I often employ the instrument, for thai is seldom necessary, but I prefer to have it ready in case it should be required. Since I have had recourse to forceps in all cases of the least difficulty, my results have been infinitely Fetter. This, it may be said, is a very prominent position for forceps to Fig. 11. — The Delivery of the After-coming Head with Forceps. occupy in the treatment of the after-coming head, and many, I know, will not agree with me, especially those who follow Continental teaching. Most English obstetricians of experience will side with me, however, for the treatment has always been in favour in this country, since our great Smellie recommended it. Barnes 1 wrote of it : ' It is 1 'Obstetric Operations,' p. 171. BREECH PRESENTATIONS 71 to be preferred to manual traction, because it avoids pulling upon the cervical articulations '; and again (p. 57) : ' But if there be any delay, the forceps will be safer for the child. The forceps, then, is the more scientific instrument. 1 Herman 1 says : ' This is the best waj' of delivering it (the head) when help is needed.' Obstetricians of other countries, taken as a whole, are either lukewarm or directly opposed to the employment of forceps. Zweifel, 2 for example, admits that the instrument is easy of application, but is opposed to its employment because it takes time, and because the results of forceps delivery are bad, and he quotes the statistics of Sickel. 3 But no time is lost if the forceps are ready to hand, as I have recommended they should be ; and it is not to the point to quote statistics of cases in which forceps were only had recourse to after many futile attempts at manual extraction. How can one expect good results with forceps in such cases? Williams 4 takes up a more pro- nouncedly antagonistic attitude, and writes : ' As a matter of fact, it is never necessary to resort to the forceps under such conditions.' There are indications, however, in quite recent years that the employment of forceps for the delivery of the aftercoming head is being looked upon with more favour. In both of two recent and most excellent German works on operative midwifery — I refer to those by Skutch and Nagel — and in Edgar's large text-book forceps is very favourably referred to, while in the recent and very important German work — Winckel's ' Handbuch der Geburtshiilfe ' — Wyder considers the subject very fairly, and although he does not advocate forceps so strongly as I have done, he writes favourably of the employment of the instrument. The only cases in which I believe forceps unwarrantable are those in which the maternal pelvis is too small or the fcetal head hydrocephalic. I would place the lowest limit as a conjugata vera of 3^ inches (8'7 centimetres). But, as I have already said, although always having forceps ready for use, I seldom require to employ them. Like most modern obstetricians, I believe that the best of the many methods of extract- ing the after-coming head is the method now generally associated with the names of Mauriceau, 5 Smellie, and Yeit. 1 ' Difficult Labour,' 5th edition, 1910, p. 57. 2 ' Lehrbuch dor Geburtshiilfe,' 1892, p. 705. 3 Schmidt's ' Jahrbucher,' Bd. lxxxviii., p. 112. 1 ' Obstetrics,' 1910, p. 419. 5 'Traite des Maladies des Femmes grosses," 4th edition, 1694, p. 284. The following brief summary of the various methods which have been from time to time suggested for dealing with the after-coming head may be of interest (Winckel's 'Lehrbuch,' translated by Edgar, 1890, p. 687) : ' The methods to deliver the after-coming head as rapidly and safely as possible 72 OPERATIVE MlhWII KKY Mauriceau 1 waa the first to lay down clearly instructions as to how the arms and after-coming head should lie delivered. Smellie- Beeme to have been quite unaware of them, for he does not refer to Mauriceau in his writings on the subject. Veit, who perfected the manoeuvre and described it most carefully, certainly deserves to have his name associated with the method. The illustration (Fig. 42) indicates how the manoeuvre is carried out. One linger of the right or left hand — whichever can most con- veniently be employed — is introduced into the mouth ; over the arm of this hand the child rides. By this means the head is maintained in an are very old, and have been often modified and combined in many ways. An historical retrospect is at this point especially interesting. We find the following methods : ' 1. Both hands are introduced, and with them the head only is grasped and retracted. — Hippocrates : " De Superfoetatione," Basel, 1546; ed. Cornarius, p. 66. ' 2. The severed head is pressed from without into the pelvis with both hands, and extracted from the vagina with hooks. — Celsus : Liber VII., 491. '3. The severed head is extracted with a finger introduced into the mouth and one or more hooks. — Paulus .Egenita : " De Foetus Imuiortui Extractione et Exsectione," cap. 74. ' 4. Traction on the body, sternutation of the parturient, and light compression of the lower portion of the abdomen. — Abulcasis : Liber II., "Exitus Embryonia super Pedes suas"; Jacob Rueff, 1580 (Hebammenbuch, s. 74 1. ' 5. Traction from the mouth on the lower jaw and the shoulders. — Mauriceau : " Traite des Maladies des Femmes grosses," Paris, 1668 ; Marguerite de la Marche, 1677; Paul Portal, 1685; Chapman, 1735; Levret, 1747: Boederer, 1759; Prange, 1760; Fries, 1769; Baudelocque, 1781; Stark, 1801; Lachapelle, 1821; G. Veit, 1863. Modification by Stein, 17S3 ; Steidele, 1784. '6. Traction on the lower jaw and the feet. — Peu : "Pratique des Aeeouch.," Paris, 1694. ' 7. Traction on the lower jaw and on the shoulders and the feet by an assistant. — Mauriceau : " Traite des Maladies des Femmes grosses," dernierc edition, Paris, 1683; Dionis, 1718; Puzos, 1759; Lachapelle, 1821 ("Pratique," etc., pp. 334, 335); Ahlfeld, 1875, Arc/Uv ./'. Gyn., viii. 360 (1887); " Ber. u. Arb. ana Marburg," 1887, p. 150. '8. Traction on the upper jaw internally and pressure on the head externally — L. Heister, 171s. '9. Traction on the lower jaw and pressure against the occiput internally. De la Motte : "Traite Compl.," 1725, p. 412; Mesnard, 1748; Poederer, 1759. '10. Traction on the lower jaw with two fingers and on the upper with one finger, and traction on the shoulder. — Giffars, 17:>4. '11. Traction on the upper jaw and pressure againsl the occiput internally. Smellie, 1752; Josephi, 1797; Busch, 1801; Froriep, 1818; Ritgen, Joerg. 1820; Wigand, 1820; Lachapelle, 1821. ' 12. Traction on the body and depression of the neck backward with the thumb of the other hand. — Japaner: Shauron von (lenjct: Kagama, 1751 or 17">l. 1 'Trait.' des Maladies des Femmes grosses,' 4th edition, 1694, p. 283. 2 Op. dt.f vol. i.. p. 311. BliEECH PRESENTATIONS 73 attitude of flexion. Two fingers of the other hand are applied over the child's shoulders, one finger on each side of the neck. Traction is now exerted in a downward and backward direction until the head is brought through the pelvis. The passage of the head down through the pelvis is greatly facilitated by an assistant or nurse pressing the head into the pelvis from above. It is a great advantage if this is done during a uterine contraction. Once the head has passed the brim and is well down in the cavity, and the nape of the neck appears below the symphysis — but on no account before then, otherwise dislocation of the neck will result — the child is carried well up on to the abdomen of the mother {Eig. 43). At this stage suprapubic pressure ceases, otherwise the ' 13. Traction on the body alone over the shoulders with both hands. — A. Petit, 1753. ' 14. Pressure from without on the head and traction on the shoulders. — Pugh, 1753; Kiwisch, 1846 ("Beitrage zur Geburtskunde," i., p. 69); Goodell, 1873. ' 15. Traction by the operator on the lower jaw and shoulders, and by an assistant on the body of the child, and pressure by a second assistant from with- out on the head.— Eschenbach : " Grundlage zum Unterricht einer Hebamme" (11 Aufl., Eostock, 1687). ' 16. Hooking the chin to flex it on the neck, expression of the head by pressure upon the occiput at the brow externally. — Wigand, 1800 ("Beitrage zur Theor. und prakt. Geburtshulfe," Heft 11, Hamburg, 1800, p. 118) ; Lachapelle (loc. cit., pp. 336-338) ; K. Euge (Zeitschr. f. Geburtsch. unci Frauenkrankheiten, von E. Martin, 1876, i. p. 82) ; Champetier de Eibes, 1879 (" Du Passage de la tete Foetale a travers le detroit Superieure Eetreci du Bassin," p. 78, Experience IX.); A. Martin, 1886 (Berl. JcUn. Wochenschrift, 1886, p. 660) ; Winckel : " Yerhand- lungen des 11 Gynak. Congress," Halle, 1888. ' 17. Pressure on the head from within and traction on the body.— Eitgen, 1820 (Monatsschrift f. Geburtskunde, viii. 233) ; Crede, 1854 (" Klinische Vortriige iiber Geburtshulfe, p. 763). ' 18. Traction on the trunk alone, by the shoulders and feet (the Prague manipulation). — Kiwisch, 1846 (compare No. 14); Scanzoni, 1851. ' 19. Traction on the upper jaw, pressure against the occiput internally, and pressure on the head by an assistant externally. — "Wigand, 1820 ; Eitgen, 1848 ; Crede, 1854 ; Ed. Martin, 1865 (Monatsschrift f. Geburtskunde, xxvi. 434). '20. Depression of the head into the small pelvis, and then extraction, com- bined with expression. — Kristeller, 1867 (ibid., xxix. 383). ' 21. Traction on the shoulders by the operator and an assistant ; lighter traction on the lower jaw. — Ahltield, 1887 ( ,l Ber. u. Arb. aus Marburg," 1887, p. 151). ' Of these twenty-one different methods, the action is — ' (1) By traction only and upon the head alone in Nos. 1 and 3; upon the body alone in Nos. 13 and 18 ; upon head and body in Nos. 5, 6, 7, and 10. '(2) By traction and pressure, and upon the head alone in Nos. 2, 8. 9, 11, 16, 19, and 20; upon head and body in Nos. 4, 12, 14, 15, and 21. ' (3) By pressure only in Nos. 16 and 17." 74 OPERATIVE MIDWIFERY head will be forced out too suddenly. The face and forehead are now carefully guided over the perineum, after which the occiput escapes and the delivery is completed. Fig. 42. — The First stage in the Delivery of the After-coming Head Manriceau-Smellie- Veil Method . Nagel.) The illustrations of two other methods — the Prague and the Wigand-Martin (Figs. 44 and 45) — explain sufficiently the manner of BREECH PRESENTATIONS !■> their employment. They are not much used, the former because there is great danger of injuring the spinal column, and the latter because one cannot exert so much traction. They are useful, however,, if the operator is single-handed. Another difficulty in connexion with the delivery of the after- coming head is its extraction in cases where the occiput is directed FlG. 43.— The Completion of the Delivery of the After-coming Head. The trunk is carried .up towards the mother's abdomen (Mauriceau-Smellie-Yeit Method). (Nagel.) backwards. Such a complication is very rarely encountered when the accoucheur has been in attendance from the first, for in all dorso- posterior cases, if a spontaneous rotation of the back to the front does not occur with the escape of the limbs, a very slight rotation of the ftetal pelvis is sufficient to bring it about. It occasionally happens, however, that the child's trunk is born before assistance arrives, or <<> OPERATIVE MIDWIFERY that the rotation manoeuvre referred to is not carried out, when of necessity one has to deal with a dorso-posterior position of the head. In such a position rotation may sometimes be accomplished by pressing the cheek or side of the jaw; but, better still, by passing a Fig. 11. The Delivery of the After-coming Head (Wigand-Martin Method). Nagel finger into the mouth. The head should be grasped in the ordinary way employed for delivering the after-coming head. The head is then pushed up a little and the occiput rotated forwards. If sue]) a manoeuvre is carried out, the head and trunk must be rotated to- gether ; there must be no attempt made to bring about the rotation BREECH PRESENTATIONS 77 of the bead by simply turning the trunk, for that may readily lead to fracture of the upper part of the spine. As stated before, I do not favour such a device as trying to bring about rotation by pulling or pushing on one arm. In some cases rotation is impossible, either because the head is- FlG. 45. — The Delivery of the After-coming Head when the Occiput is Posterior J (Prague Method). too firmly fixed in the pelvis, or because the chin has become caught above the symphysis pubis. If the chin is down, one may try the ordinary method of passing a finger into the mouth and grasping the shoulders with two fingers of the other hand. The child is now 7s OPERATIVE MIDWIFERY pulled backwards, and then, when the forehead is fixed against the posterior surface of the symphysis pubis, the trunk is pulled upwards on to the abdomen of the mother. In such cases, forceps and a deep incision laterally into the perineum will, I believe, give the child the best chance. In cases in which the chin slips up, and which will some- times require to be terminated by craniotomy, one should attempt to; deliver the head by the Prague rnanu'uvre (Fig. 45). Nagel describes a most interesting case where a woman delivered herself by pulling the child's limbs up on to her abdomen, as indicated in the illustra- tion. If the child is of any size, craniotomy will often require to be performed, and one has little hesitation in having recourse to it, as the child will generally be dead. There remains only one other matter to consider in connexion with the delivery of the after -coming head, and that is when the latter is arrested because of the cervix not being quite sufficiently dilated. Incidentally I referred to this, and pointed out the danger of its occurrence if one hastened the extraction of the child when the os was not sufficiently dilated. As such cases, however, occur, because labour has often to be accelerated, I will describe how this difficulty is to be overcome. In most cases, I believe, the best treat- ment is craniotomy, for in the vast majority of such cases the child is dead or hopelessly asphyxiated. There has usually been great delay with the arms, and very probably some maternal complication which has already seriously jeopardized the child. If, however, the child's •condition is still such that its life is worth considering, then the best procedure is to make two deep incisions into the cervix. It is abso- lutely profitless to try to dilate the cervix; there is not time for such a proceeding. THE BREECH ARRESTED AT THE PELVIC FLOOR- IMPACTION OF THE BREECH IN THE PELVIC CAVITV. This is by no means an uncommon occurrence in primiparse. In •most cases it is caused by uterine inertia ; but in others the size of •the breech, or the fact that there is some little pelvic narrowing, accounts for the condition. But there is another cause to which some writers have attached a good deal of importance — viz., an extended position of the legs along the body of the child (Fig. 46). The most important and interesting paper on the subject in the English language is by Griffith and Lea. 1 In this position the legs act like splints to the body, and prevent the lateral flexion of the trunk, >which must necessarily occur in the progress of the birth of the ] Trans. Lond. Obst. Soc, 189S, vol. xxxix., p. 13. BREECH PRESENTATIONS 79 breech. This extension of the legs may be primary or secondary to the descent of the breech, and one sees usually which it has been after birth by the attitude the child assumes, for on placing Fig. 46.— The Breech, with Extended Legs, impacted in the Pelvic Cavity. "the new-born infant on the bed its legs immediately take up the •extended position they occupied in utero if the condition was primary ; whereas, if it was secondary, the legs seldom become so completely ■extended. .so OPERATIVE MIDWIFERY The condition should he suspected when the hreech is found, early in labour, low down in the pelvis, and when the foetal heart sounds are heard below the umbilicus. As can be readily understood, the presentation by abdominal palpation closely resembles one of the vertex. No doubt abdominal palpation may reveal the exact position of the legs if the conditions are favourable for palpation, and certainly the head, if carefully searched for, will usually be felt up towards the fundus. A breech arrested in the pelvis is a condition which may cause the obstetrician much trouble. So far I have always succeeded in getting it delivered by one of the following devices : (a) Bringing down a foot ; {!>) traction with the fingers ; (c) traction with a fillet or hook ; (<1) forceps. These are the means to be employed if the child is alive. If the child is dead, the sharp hook or the cranioclast must be used. One usually succeeds with a finger in the groin, and, as a rule, one can reach the anterior groin more easily than the posterior. In order to get the forefinger into the groin, it is best to pass it up over the sacrum and to make traction more against the trunk, for there is the danger that, if one passes it over the thigh and exerts traction on the thigh, the force applied may fracture it. The fact, however, that one can only exert a moderate force usually saves one from doing this. Sometimes the posterior groin can be more easily reached, and occasionally in multipara? I have even managed to get a finger into each (Fig. 47). Only one finger should be employed for each groin. If two are used, there is greater danger of fracturing the thigh. The successful carrying out of the manipulations described is greatly facilitated by pressure from above. This should be carried out by a nurse or assistant, but only when the uterus is contracting firmly. The best plan is, just before the 'pain' comes on, to pass one finger into the groin, and so be ready for the uterus contracting; then, when the contraction is at its height, supplement it by external pressure. I have always found great difficulty in applying a fillet (Fig. 48), either by means of a carrier or catheter. Both the catheter and carrier are used in the same way. The instrument is passed up over the sacrum, and the hooked part is then rotated over the thigh : two fingers are then passed up between the buttocks, and the rubber tubing or silk ligature seized and a piece of gauze attached: this latter is then pulled over the groin. Nagel 1 recommends the carrying of the gauze over by means of a plain gold wedding-ring thoroughly sterilized, and passed up from behind into the groin. Jellett- 1 Op. rit., p. ;57. - ' Manual of Midwifery,' 2nd Edition, 1910, p. 1067. BlIEECH PRESENTATIONS 81 recommends employing a roll of gauze as follows : ' Take a small piece of double gauze about 18 inches long and 2 inches wide, and rolled like a bandage. The free end of this roll is held in the left hand, and the roll itself is pushed upwards between the thigh and the anterior pelvic wall in such a manner that as it advances it unrolls. As soon as it has been pushed above the angle of the groin it is pushed inwards across the latter until it comes to Fig. 47. — Impaction of the Breech — Delivery with a Finger inserted into Each Groin. (Nagel.) lie between the thighs. Then the fingers are pushed upwards from below between the thighs, and the roll of gauze caught and drawn downwards.' But a fillet is not altogether safe, for there is danger not only of bruising the soft parts, but of fracture and dislocation resulting, if the gauze is not passed exactly into the fold of the groin. The blunt hook is even worse, and although I have employed it once or twice without doing any injury, I have on one occasion fractured a limb. It must, 6 82 OPE I I AT | \ E3 MIDWIFERY however, be risked if it is impossible to deliver the breech by means of the fingers, forceps, or a fillet ; it should be passed along the dorsal Fig. 18. — Impaction of the Breech— Delivery by Means of the Fillet. aspect of the breech and then rotated into position, the point being guided over the thigh. BREECH PRESENTATIONS 83 Some obstetricians have expressed themselves in favour of forceps in impacted breech, although most writers are opposed tophe treat- Fig. 49. — Impaction of the Breech — Delivery by Means of Forceps. ment (Fig. 49). Various attempts have been made to devise forceps suitable for the breech, but they have always proved unsatisfactory. si OPERATIVE MIDWIFERY I'pon several occasions I have delivered the breech with forceps successfully when I have failed to do so with my fingers. I must also admit that I have frequently failed when the breech was firmly impacted. The great difficulty is getting a good grasp, for the two thighs are at different levels. I always try to grasp the breech transversely with a blade over each limb (Fig. 49). Naturally, one must be cautious in the amount of pressure and traction exerted, for if one compresses the blades too firmly injury may be done to the fu'tal pelvis, and if one pulls too strongly and the blades slip, the maternal parts may be seriously lacerated. Here, again, great help will be obtained by an assistant pressing the uterus daring a contraction. ^Vith increased experience of impacted breech presentations, 1 am more and more convinced that the best treatment, when one cannot pull down the breech with one's fingers, is to push the breech out of the maternal pelvis and bring down a leg. In almost all cases, even those which look hopeless, with deep anaesthesia and the patient in the left lateral position, the advantages of which position have been con- sidered, it will be found possible to dislodge the breech and bring down a leg. Barnes states that he has never failed in doing so ; while, going farther back, Smellie, La Motte, and others, describe cases where, even when the f octal pelvis was showing at the vulva, the former was pushed back and a leg brought down. It has been suggested in cases where the legs are extended not to try and bring down the limbs', but simply to bend them at the knee so as to allow the limb to take the natural flexion. I very much doubt if such a mameuvre will be successful with the impacted breech. A- I have already mentioned, it is often emploj'ed when the breech is movable. Should, however, it be impossible to deliver the child by these various devices mentioned, and the bringing down of a leg be also im- possible, there only remains extraction by means of the cranioclast. If this instrument is employed, the middle blade is introduced into the rectum of the child, and the two other blades applied outside its pelvis. Naturally, if one had ever to have recourse to such an instru- ment, the after-coming head should also be perforated, as otherwise the child might be born alive. There is one other course open — viz., symphysiotomy or pubiotomy. It is questionable if such a procedure is justifiable, for the foetal mor- tality, under the circumstances, must be very high indeed. It might be argued that, at the stage we are considering (a breech impacted in the pelvis), the child's life has not been much jeopardized ; conse- quently, although I would not care to have recourse to the operation. BREECH PRESENTATIONS 85 I can understand another taking up a different attitude, if the foetal heart sounds were satisfactory. Prophylactic Cephalic Version in Breech Presentations.— There is a matter in connexion with breech presentations which is worthy of consideration, but which I have not mentioned until now, as, properly speaking, it does not come into consideration in con- nexion with labour. I refer to prophylactic external cephalic version, which in this country has found so strong an advocate in Spencer. 1 Quite a number of accoucheurs, also, in other countries express themselves favourably regarding it. Personally, I entirely approve of the treatment, and have carried it out successfully upon one or two occasions. It is best performed a week or two before term, at the time of the examination, which all recommend should be made about the thirty - sixth week. Not infrequently in multipara it may be successfully performed early in labour. I have heard a University teacher of midwifery criticize the treatment, and refer to it as a return to the practice of Hippocrates. But such criticism is not to the point, for Hippocrates employed internal cephalic version, and the os had to be sufficiently dilated to admit of the introduction of the operator's hand. In the case of prophylactic version, recom- mended by Spencer and others, the manipulations are entirely external. Of equally little account is the other argument urged 'against the treatment, that in the case of failure a more unfavour- able — say an oblique — presentation is established. I have never found such a result in the cases in which I have failed. The objec- tion is purely theoretical, for an oblique presentation in which the head remains higher invariably becomes a breech presentation when labour starts. At the worst, therefore, one can do no harm. I was inclined to think so until quite recently, when I had rather an unfor- tunate experience. When carrying out, with a good deal of difficulty, cephalic version about the thirty-sixth week of pregnancy in order that I might alter a breech into a head presentation and test the relative size of the head and the pelvis (the pelvis was deformed), very sharp haemorrhage occurred, and I was compelled to plug the vagina. The child was shortly afterwards born dead. I had in this case actually caused a separation of the placenta, which was situated on the anterior uterine wall. Should the correction of the presentation succeed, the child is maintained in its new position by fixing the head in the pelvis and applying a binder or other abdominal support. i Brit. Med. Jourti., 1901, vol. i., p. 1192. CHAPTER VI DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FCETUS— Continued Transverse or Oblique Presentations. Of all presentations, oblique are the most unfavourable, for, except under the very rare conditions which will be referred to, spontaneous delivery is impossible. The presentation is often spoken of as trans- verse, but, as a matter of fact, the child lies obliquely in the uterus. A popular term for the presentation is ' cross-birth.' The frequency of the condition is, roughly, 1 in 125 births. Theoretically, any part of the trunk from head to breech may present, and the older writers were in the habit of distinguishing various presentations of back and abdomen ; but from the fact that an oblique presentation ultimately resolves itself into a shoulder, it is quite unnecessary to consider the refinements of the presentation. As the position of the child may be either dorso-anterior or dorso - posterior, with the head to either side, there are four transverse positions. The dorso-anterior are rather more frequent than the posterior, for in about three-fifths of the cases the back is to the front. The head is also rather oftener directed towards the left side, so that the first position is the most common (Fig. 50). Accord- ing to Raineri, 1 the right shoulder presented in 68 per cent., and the back of the child in 60 per cent, of cases. It is not possible to discuss here in detail the etiology of this presentation. I can only mention some of the factors which favour its occurrence. On the part of the mother multiparity (86 per cent.), a large and flabby uterus and a pendulous abdomen — consequently more common amongst the poorer classes — an overdistended cavity from excessive liquor amnii or plural pregnancy, the presence of placenta prarvia (7 per cent.), and a marked disproportion between the head and the pelvis, and especially a narrow pelvis (14 per cent.), are the most important. 1 Ep. Brit. Med. Journ., 1905, vol. xi., No. 9. 86 TRANSVERSE OR OBLIQUE PRESENTATIONS 87 An interesting group of cases, referred to by all writers, and one that may give rise to special trouble, is where malformation of the uterus exists, especially such slighter forms as uterus cordiformis, arcuatsu, or duplex subseptus. In such conditions one part of the child occupies one half, and the rest the other half of the uterus. Vogel, 1 writing especially upon transverse presentations in primipara;, states, that in eighty-six cases of transverse presentation a uterus arcuatus existed in nine, and in the eight cases in which the presentations occurred in primiparre, it was observed in as many as five. I am inclined to Fig. 50. — First Oblique Position. think, however, that in some of these cases the shape of the uterus was the result, not the cause. Very rarely ovarian and uterine tumours may influence the occur- rence of this presentation. On the part of the child may be mentioned prematurity, macera- tion, and deformity. The natural course of labour in an oblique presentation is for the shoulder to become pushed down into the pelvis, and if the malpres- entation is not corrected, for the labour to continue until the uterus becomes exhausted or ruptures. Very occasionally, however, spon- taneous delivery does occur, although one must never reckon upon such a termination. If it does, it takes place in one of the three following ways: («) Spontaneous version, (6) spontaneous evolution, i Zut still more may be diagnosed from the prolapsed arm, for if the hand is presenting, the thumb points to the head. In addition to the arm, one often finds that the cord prolapses in transverse presentations. Nor is this to be wondered at, as the umbilicus is brought so near the pelvic brim. In those rare cases of transverse presentation where the back or the front of the total thorax or abdomen are the presenting part-, there may be some difficulty in diagnosing the exact condition. Fig. 54.- -DiatiDguishing the Particular Hand which lias prolapsed by Shaking Hands with the Foetus. When it is the front of the trunk, this difficulty is not so great, for the ribs or umbilicus will be easily felt. When, however, it is the back, as in the case of partus conduplicato corpore, mistakes may readily occur if the arm has not prolapsed. In a case (Fig. 52) quite recently in the Maternity Hospital, the presentation was mistaken by the house-surgeon and nurse for a breech. Theoretically, by feeling the spinous processes of the vertebrae, the exact nature of the presentation should be recognized ; but in the case I refer to the TRANSVERSE OR OBLIQUE PRESENTATIONS 93 ^edematous swelling, which formed over the back, masked this land- mark entirely. Again let me say, always put the patient under an anaesthetic and make a thorough examination, rather than remain in the slightest doubt regarding the presentation. Prognosis. — The prognosis for both mother and child in oblique presentations is decidedly less favourable than in any other. As operative interference is always necessary, the dangers of sepsis and of injury to the parturient canal are very decidedly increased. As will be seen when considering rupture of the uterus, this accident is by no means uncommon. In my cases of rupture the presentation was transverse in 17 per cent., while in Ivanoff's 1 it was so in 32 per cent. It is needless to say that in oblique presenta- tions there is not the same proportion of raptures. The frequency of rupture of the uterus in transverse presentation is variously stated. As far as I can judge, however, it occurs about 1 in 100 to 150 cases. The rupture, although usually described as uterine, is very generally in the vaginal vault. The most important practical point in this connexion, however, is that the rupture is invariably violent — viz., is produced while attempts at rectification are being made. Spontaneous rupture is very uncommon, and occurs in only about 1 in 300 cases. The operator, therefore, must carry out his manipulations of version with great care, especially in cases where the membranes have ruptured some time previously, and the uterine wall is firmly grasping the child. The foetal mortality in oblique presentations is enormous, some- where about 40 per cent. Winckel for 883 transverse presentations found 8 - 3 per cent, born macerated, and 33 per cent, died during labour. Many factors contribute to this high death-rate, among which may be mentioned prematurity of the child, prolapse of the cord, and malformation of the maternal pelvis, rendering extraction of the child difficult. The prognosis is also unfavourably affected by prolapse of an arm. Treatment. — Were the question asked, What is the treatment of oblique presentation ? the immediate reply would be, rectification of the presentation by version. Such an answer is, however, not entirely correct. There are certain cases, where the shoulder has become im- pacted and the uterus is tetanically contracted, when version is abso- lutely contra-indicated, and it is because many fail to recognize this, and fail to appreciate the limitations of version, that I have introduced the consideration of treatment of oblique presentations in this some- what crude manner. Fortunately, the number of cases encountered in 1 Annal. de Gyn., 1903. :•! OPERATIVE MIDWII i;i:v practice where the shoulder is impacted and version is contra-indicated are not numerous, for they result, ;is a rule, from inattention and carelessness on the part of those in attendance. Having sounded this warning note regarding the dangers of version in certain cases, let us consider the treatment of oblique presentations under the following headings : 1. When the presentation is recognized during pregnancy. 2. When it is recognized during labour. 3. When the shoulder is impacted. 1. When the Presentation is recognized during- Pregnancy. — On several occasions I have emphasized the importance of examining a pregnant woman a week or two before labour. Here, again, will be seen the great advantage of doing this, for an opportunity of recognizing and correcting an oblique presentation will then occur. Since Pinard and Leopold perfected abdominal palpation, and this most valuable method of examination has become universal, the correction of oblique presentations during pregnancy has become the recognized treatment. Long ago, however, it was hinted at, and the postural treatment for the condition is of ancient date. The postural treatment consists in placing the patient on the side towards which the head is directed, so that when the breech falls over the head is pushed down towards the brim. This postural treatment is often successful up to about the thirty-fourth week, but later than that the presentation is so fixed that the foetus can seldom be dislodged by simple alterations in the position of the mother. Perfected external version is, as has been stated, of comparatively recent date. It is now very widely practised in all maternity hospitals, especially on the Continent, where pregnant women so often seek advice at the outdoor department of the hospitals. The argument still advanced against the treatment is that the child frequently slips back into its old position, even when the manipula- tions are successful. But even admitting that it was successful in only 2 or 3 per cent, of cases, that would be quite a sufficient argument in its favour. Besides, in cases which return to their old position matters are left no worse, and there is this great advantage, that the nature of the condition is known beforehand, and so the patient can be warned of the danger of the presentation and the necessity of seeking advice whenever labour commences. Unfortunately, in this country one has not many opportunities of correcting the position during pregnancy, for so few seek advice prior to the onset of labour. I can give no exact figures of the successes from the treatment, although I have noted a considerable number. The manner in which external version is carried out is detailed TRANSVERSE OR OBLIQUE PRESENTATIONS 95 lsewhere (Chapter XXII.). Having brought the child into a correct losition, the head should be seized between the two hands and pushed nto the pelvis ; pads should then be placed along the sides of the iterus, and a firm binder round the abdomen or Pinard's ceinture jfeocique should be applied. The patient is seen at intervals, and hould the foetus have slipped into its former malposition this is .gain corrected. Occasionally it has to be done many times, but isually there is less difficulty in carrying out the manipulations on ach succeeding occasion. 2. When the Malpresentation is recognized during- Labour. — 3y taking up the attitude of trying always to determine the presenta- ion during pregnancy, one increases enormously the chance of seeing iblique presentations early in labour. The importance of this to> uother and child, and especially to the child, cannot be overestimated. External version is still often possible early in labour, if the mem- >ranes are unruptured, and it is especially easy in those cases im vhich, prior to labour, corrections have been made. Should the external method fail, the question arises whether mmediate attempts by other methods should be employed, or the abour be allowed to proceed until the os is considerably dilated. \Iany, especially in this country, favour the immediate correction by nsans of the bipolar method of Braxton Hicks, and I, too, incline to his procedure. In many cases it can be carried out without rupturing he membranes. But even if the membranes do rupture the child is lot in danger, unless the cord prolapse. Impaction of the shoulder loes not occur until labour has been long in progress and the os well lilated. The mistake made by those who favour early bipolar version s to proceed to internal version if they find the membranes ruptured. t always increases the risks to the child to dilate forcibly the cervix .nd perform internal version. When rupture of the membranes occurs and bipolar version has lot succeeded, internal version should be delayed until the os is well lilated. With both varieties of version either the head or the breech may >e brought down, but while external and bipolar cephalic version are ■ften successful, internal cephalic version seldom is. Details regarding he operation of version are given in Chapter XXII. Having turned the child and brought down a foot, the progress of he case should be left to Nature, and the delivery hastened only if the •s is fully dilated, or the mother's or child's life is in danger from some ■dditional complication. A very large number of children are lost by tastening the delivery. No doubt, with the foot hanging out of the anal, one is very much tempted to drag upon it, but the result is 96 OPERATIVE MIDWIFERY always the same — the arms and after-coming head are caught hy the undilated os uteri. ;. When the Shoulder is Impacted. — The obstetrician of little experience will find it a difficult matter to decide when he should desist from making attempts at version in cases where the wal have drained away and the shoulder is impacted in the pelvis. To desist only after many fruitless attempts have been made is not a right attitude to assume, for during these attempts much injury may be done. Naturally, the greater the operator's experience, the more often will he be successful, but no matter how experienced he is, there are cases in which he cannot perform version with safety, and mast have recourse to decapitation. I have frequently found that medical practitioners consider it a disgrace if they fail to perform version. They forget that all operations have their limitations. In a case of impacted oblique presentation, one should first of all satisfy oneself regarding the condition of the child. In most cases the condition is unsatisfactory : the child is dead, or its vitality so low- that its life need not be considered ; consequently, one should •consider only the mother. The foetus should therefore be decapitated and delivered. But the reader may say, How is one to be sure of the death or impending death of the fcetus ? Auscultation of its heart sounds through the abdominal wall is difficult owing to the restless- ness of the parturient and the firm retraction of the uterus. Should that be so, the hand passed a little way into the uterus will usually encounter the umbilical cord and permit of an estimate being formed of the strength and frequency of the fcetal heart. It must not be forgotten that in passing a hand into the uterus for this purpose, and more especially for the purpose of performing version, the parturient must be deeply anesthetized. Internal manipulations are infinitely more dangerous and difficult when one attempts to perform them with the woman only partially anesthetized. Should by any chance the child's vitality be satisfactory, a little more may be risked, but, personally, I desist from making attempts at version, no matter what the condition of the child is, when I find a very much thinned out lower uterine segment with a well-marked retraction ring above the head. To pass the hand into the uterus and push back the retraction ring with the back of the hand and allow the fcetal head to slip up along the palm of the hand may sometimes be successful, but it is difficult and dangerous, unless the accoucheur has had considerable experience (Chapter XXIX.). CHAPTER VII DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FCETUS— Continued Malformation of the Foetus. Abnormal Size of the Foetus as a Whole. — Undue size of the foetus may be general or confined to certain parts — the head, the shoulders, the thorax, the abdomen, the pelvis. It is peculiar to certain women to have large children. I recently attended a patient where the first child weighed 12 pounds and the second weighed 11 pounds. Speaking generally, where the parents are of large stature the children are above the normal. This is most markedly seen in the case of giants. Next to heredity may be men- tioned prolongation of pregnancy. Jacoby, 1 in reviewing 6,976 labours, found that in 8*7 per cent, the foetus weighed 4,000 or more grammes; 20 per cent, were primiparse, 10 per cent, women who had more than one child, and 9'5 per cent, women who had borne several children. In 9 - 4 per cent, gestation was prolonged beyond 300 days, and in 1 69 per cent, beyond 280 days. The largest child delivered at the Maternity Hospital in recent years weighed 15 pounds. Craniotomy and cleidotomy had to be performed. Sheill 2 recorded a similar difficulty with one about the same size. If the maternal pelvis is roomy, labour, although tedious, is usually terminated without very great difficulty ; but if there is any pelvic malformation, no matter how slight, the labour may be both difficult and dangerous, and any of the major operations may require to be performed. As I have mentioned elsewhere, rachitic mothers have often relatively large children. The head of the child causes, as a rule, the most trouble, for, apart altogether from its size, the bones are often unduly ossified, and so the head does not mould well. Not infrequently, however, the shoulder girdle is the part of the foetus which has the greatest difficulty in passing through the pelvis. 1 Archiv f. Gijn., Bd. lxxiv., Heft 3., p. 556. 2 Dub. Journ. Med. Sciences, July, 1905. 97 7 98 OPERATIVE MIDWIFERY General Foetal Dropsy (Fig. 55) occasionally may cause con- siderable dystocia. Some time ago in the Maternity Hospital I had a case under my care, and although the delivery was not extremely difficult, it was somewhat trouhlesome, for the limhs tore off whenever any traction was made upon them. Fig. 55. — General Fcetal Dropsy. (From a photograph of a case in the practice of Dr. -lames Dmil<>]>.) A case of this kind was recently reported by Walther ' where there was considerable difficulty in getting the second twin away, as the limbs came off with the slightest traction, and, even although the tissues were torn, little fluid escaped. Ballantyne,- summing up the histories of the labours in such cases, 1 Frommel'fl ' Jahresbericht iiber Geb. u. ti.yn.,' 1904, p. 887. 8 'Antenatal Pathology and Hygiene,' p. 290. MALFORMATION OP THE FGETUS 99 writes : ' The birth of a dropsical infant was, if near the full term, a tedious and often an instrumental matter. Abnormal presentations were unusually common. The delay in labour was sometimes overcome by the natural efforts and sometimes by manual or instrumental traction ; but in certain instances the procedures which were finally adopted before birth (in fragments) was effected reached the utmost limits of embryulcia, evisceration, disruption, and dilaceration. In some cases the medical attendant seems to have lost all nerve, as first one limb and then another, and then a fragment of the trunk or the head, was dragged to light from the maternal passages. When, however, the fcetal abdomen, being within reach, was tapped, it was seldom found necessary to resort to such embryoclastic procedures. The third stage of labour was often rendered somewhat difficult on account of the large size and dropsical state of the placenta, and by reason of uterine inertia due to delay in the earlier stages. The puerperia, it is noteworthy, were generally quite normal ; in fact, the rapid disappearance of many of the maternal symptoms immediately after the emptying of the uterus suggested the conclusion that the fcetal condition was often the cause rather than the result of the mother's ill-health.' LOCALIZED ENLARGEMENT OF THE FOETUS. Hydrocephalus. — Amongst the enlargements of the fcetal head causing dystocia the most important is hydrocephalus, a malformation which is by no means uncommon (1 in 1,000), and which, by reason of the fact that it is so easily and so often overlooked, is frequently accompanied by very serious consequences to the mother. In this condition the ventricles are distended with fluid, and according to the amount of fluid the brain tissue is thinned oiat and destroyed. The quantity of fluid contained in a hydrocephalic sac may be as much as 17 to 20 pints (10 to 12 litres), and the circumference of the head may measure as much as 30 inches (75 centimetres) in extreme cases. The base of the skull and the face bones are well formed, although small, but those of the vault are very much separated, and although not always, still very frequently, defectively ossified. The trunk and limbs are usually small, and other abnormalities, such as spina bifida, talipes, etc., are not uncommon. A history of the previous birth of malformed children may some- times be obtained. The condition, as I have said, is not as a rule diagnosed until labour has been in progress for some time ; l indeed, often not until 1 Hammerschlag, Mbnatssch. f. Geb. u. Gyn., Bd. xxvii., Heft 4. 100 OPERATIVE MIJAYlI'Kn the accoucheur has failed to deliver the fore-coming head with forceps or the after-coming head by traction. That is the reason why rupture of the uterus occurs in somewhere about 1- per cent, of cases. The child almost invariably presents by the head or breech, transverse presentations being very rare indeed. Breech presentations an very common (25 per cent.), and us the diagnosis of the condition is most difficult in such cases, I will speak of them first. Theoretically, by abdominal palpation the enlarged and elastic head should be felt at the fundus, and without doubt in some cases this has been done. It is seldom, however, that even the most alert accoucheur makes this out, for prior to rupture of the membranes palpation of the head is difficult, because of the liquor amnii being often excessive; while after rupture the fatal parts cannot be defined, because the head and the rest of the- body are so pressed together, and the lower segment is so tensely distended. It may be assumed, therefore, that even with the highly ex- perienced, the condition will be but rarely recognized until the after- coming head has to be delivered (Fig. 5(5). But if it is excusable for the accoucheur to overlook the condition prior to this time, it i- quite reprehensible for him to do so later. It is true that the base of the hydrocephalic skull is well formed and ossified, and that if the fingers be passed along the trunk, with the object of getting them into the mouth of the child to aid its delivery, he may feel nothing of the enlarged head, but he should feel at once with his first traction effort that the head is too large to pass the brim. Especially should he be surprised at any difficulty when he looks at the child, usually puny and ill-nourished, and sometimes with a spina bifida or other malformation. Besides, the uterine swelling above the pubes is still of large dimensions. The mischief is done just at this stage ; the accoucheur pulls, and whoever is assisting presses on the uterus above, with the result that the uterus ruptures. He has again made the fatal mistake of trying to deliver by force. His first failure to effect delivery should have raised in his mind the possibility of the condition of hydro- cephalus being the cause of the difficulty. The only cases in which there is any excuse for the mistake are those where, in addition to the enlarged head, there is pelvic deformity, to which he attributes all the difficulty. With such he will be guided to the correct nature of the condition by appreciating the large swelling present above the pelvic brim. When the foetus affected by hydrocephalus presents by ///<■ head, the recognition of the condition is easier. Abdominal palpation,. 4l\fl. FlG. ">ti. — Hydrocephalus, showing how the After coming Head is caught at the Pelvic Brim. (After Bunini.) 102 OPERATIVE MIDWIFERY even with this presentation, does not always ^ r ive as much informa- tion as one might expect. The lower part of the uterus i.~ unduly distended, and the large head is freely movable: bnt, owing to the fact i hat the uterus so tensely grasps the head, the latter cannot be defined. Still, the condition is overlooked often, not because of its obscurity, but because the examination is made hurriedly. The presenting part, being high, is difficult to reach from the vagina, although I once saw a case where, the child being dead, a portion of the lax head projected down into the cavity, and felt exactly like a large caput succedaneum. Others have mistaken a similar condition for the bag of membranes. In most cases one can feel the gaping sutures and fontanelles, and although a caput succe- daneum might obscure them, it is long in forming in this condition. A crackling sensation on pressing the head is mentioned as being appreciable sometimes. The prognosis for the mother, if the condition is recognized and suitably treated, is not serious. Unfortunately, however, the con- dition is often overlooked, and many fatal attempts at delivery are made before the true nature of the complication is appreciated. As a result, bruises and tears of the soft parts, with subsequent septic manifestations, are not uncommon. Rupture of the uterus occurs in some 12 to 15 per cent, of cases. Keith found it occurred 1(5 times in 74 cases ; and in 159 cases reviewed by Hohl, Schuchard, and Veit, 21 ruptures were observed. In my own 17 cases of rupture of uterus hydrocephalus was present in 2. Although, as I have said, the accoucheur is usually to blame for this, it sometimes happens that he is not, for the rupture may be spontaneous, and may even occur early in labour, as recorded cases illustrate. Another danger to the parturient is post-part nm haemorrhage, the result of the overdistension of the lower segment and the feeble retractility and contractility of the uterus. Unfortunately, therefore, the maternal mortality is still very high, and is certainly not below 12 per cent., although, taking recent cases, such as those recorded by Hoffman and Bertino,- it works out at G - 6 per cent. My own results are one in six (16 per cent.). In certain cases, where the hydrocephalus is slight, delivery may be spontaneous or easily terminated by forceps or by traction on the lower limbs of the child. In such cases the condition will be appre- ciated only after the birth of the child. Even with a dead child, where the head is of some size, spontaneous delivery may result because of the laxness of the hydrocephalus. Rupture of the sac has occasionally occurred, the whole scalp giving way; but more 1 WinekePs ' Hundbueh der Geburtshulfe,' Bd. ii., Teil ill., p. 1646. MALFORMATION OF THE Freferab'ly the anterior. With a living child whose shoulders are so large that they prevent he descent of the trunk, one is in a very awkward predicament. Biter having failed to effect delivery by means of a finger inserted nto the armpit, it is safer to run the risks of the blunt hook than o make extreme traction upon the neck, for the danger to the child >f such a proceeding is very great. When the hook is employed, it hould be passed into the anterior axilla, if at all possible, for if one >asses it into the posterior, and the anterior is still above the brim, he latter will catch upon the brim, and the delivery of the shoulders endered more difficult. Should by any chance these devices fail, and I actually encountered iuch a case quite recently, the child's condition will have become Jmost hopeless. The clavicles should therefore be divided, and the sxtraction completed as if the child were dead. It has been suggested o perform symphysiotomy ; but few, I fancy, would favour such a reatment, as it would increase the maternal mortality, already very ligh, without much prospect of saving the child already endangered. A very similar dystocia — viz., a difficulty in extracting the ihoulders or even the head — may be caused by tumours of the neck on I by hydrothorax. Cystic and solid tumours of the neck are rarely )f a size sufficient to cause obstruction. The one figured in Winckel's Text-book' 1 is the largest I know of. One recently described by lewetson 2 in great detail is through the kindness of the author ■eproduced here (Fig. 59). Distension of the foetal thorax is of great rarity. Winckel 3 men- ions seven cases. Hydrothorax is invariably accompanied by ascites. 3allantyne 4 refers to such a case reported by Hardouin and Moreau. f there is much distension of the chest, the shoulders will always tave difficulty in engaging, and perforation of the chest is necessaiy. Tumours connected with the Abdomen and Pelvis. — The lext malformations we must consider are those connected with the -bdomen and pelvis. In certain cases these conditions may even 1 Edgar's translation, 1890, p. 430. 2 Journ. Obstet. and Gyn. Brit. Empire, 1903, vol. i\\, p. :!■"'■",. 3 Op. cit., p. 434. 4 Op. cit., p. 362. Fig. 59.— Congenital Adenomatous Bronchocele. (Hewetson.) MALFORMATION OF THE FOETUS 10!> tinder the engagement of the shoulders. As a rule, a diagnosis is >nly possible if the hand is passed into the vagina. Fig. 60.— Foetal Ascites. (Ballantyue.) Distension of the abdomen from ascites (Fig. 60) and tumours of the spleen, liver, testicles, ovaries, kidneys (Fig. 61), bladder, although 110 OPERATIVE MIDWIFERY rare, is not very uncommon. Each of these tumours is of pathologic! interest, but unfortunately they cannot be considered here. FroB the obstetric standpoint they all present the same feature. The difl tended abdomen prevents the descent of the foetus. I-,,. 61.— Congeoitally Enlarged Kidneys (Natural Size . (Ballantyne.) If the presentation is cranial, unless the abdominal distension is extreme, the shoulders can usually be delivered ; the trouble is in ♦ •xtracting the trunk. In these cases the diagnosis is simple, for the trunk of the child should always pass through the maternal pelvis MALFORMATION OF THE FCKTFS 111 iixsily. When, however, the shoulders also refuse to descend, there is , little more difficulty in appreciating the cause of the dystocia. The inusual distension of the mother's abdomen may arrest attention, but ometimes the hand has to be passed into the uterus before a diagnosis an be made. I had an illustration of this recently in a case of xtrerue ascites. Should the child present by the breech, one or both legs may be >ro light down, but further delivery is impossible. The other con- \L> Fig. 62. — Enormously Large Congenital Sacral Tumour. (Museum of the Pathological Institute, Glasgow University.) iitions which may give rise to a similar difficulty are tumours of the acrum and the arrest of the child by the retraction ring. The latter ondition — a very interesting one — is referred to elsewhere. Here, -gain, the passage of the hand into the uterus alone will clear natters up. In cases of distension of the foetal abdomen, the bulk of the child an usually be sufficiently diminished by withdrawing the fluid by an ispirator, as most of the conditions encountered are cystic. It some- imes happens, however, when the tumours are connected with liver, 112 OPERATIVE MlbYYIFKKY spleen, or kidney, that they cannot be sufficiently lessened by this simple device, and so a large abdominal opening has to be made, and the tumours broken up and removed by the hand. In cases of asci the foetua is usually born dead, but when the other tumours mentk>. are present it may be born alive. Should, therefore, any evisceration have been necessary in cases of breech presentation the after-coming head should be perforated. Sacral congenital tumours obstructing labour (Pig. 62) usually give most trouble when the child presents by the breech. With the fore-coming head, the legs and tumour slip through the pelvis more easily. In several eases — one, for example, recently recorded by Hewetson 1 and one by Frommel 2 — the child could only be extracted after the tumour was broken up. In the former case the child presented by the breech, and in the latter by the head. The diagnosis of the condition when the tumour presents may be very difficult, and is most likely to be confused with a submucous mvoma. A- I have repeatedly said, however, in all cases of doubt a manual exploration of the uterus should be made under anaesthesia. 1 Journ. Obstet. and Gyn. Brit. Empire, 1903, vol. iii., p. 203. 2 • Jahresberieht, iiber Geb. u. Gyn..' 1904, vol. xviii.. p. 886 CHAPTER VIII DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FCETUS— Continued Presence of More than One Foetus. We cannot discuss here the etiology or anatomy of plural pregnancy, the most interesting questions in connexion "with this subject, nor can we consider the effect the former has upon such complications as eclampsia, toxremia. etc. We are concerned with the condition only as it affects labour. The ease with which the diagnosis of plural pregnancy can be made depends very much on how the ova are placed. In the cases where they lie side by side (Fig. 63), or in the rare condition in which the one is above the other (Fig. 64), it is not difficult. When, however, both lie longitudinally and are placed the one behind the other (Fig. 65), there is, as a rule, considerable difficulty. As regards the diag- nosis, absolutely no reliance should be placed upon such subjective symptoms as a feeling of unusual size, the sensation of a great deal of foetal movement, etc. ; similarly, in palpating the abdomen, one must not conclude that there are twins simply because of the size of the abdomen or the apparently unusual number of limbs. I have been so often deceived that I only diagnose plural 113 8 Fig. 63. — Twins lying Side by Side. Ill OI'FJtATIVK MII>WI!T.l;Y Fig. 64.— Twins lying One Above the Other. pregnancy when I feel two foetal heads. Two breeches should make it quite as conclusive : but the breech is much more difficult to define, and I definitely decide upon plural pregnancy only when 1 feel two heads. I have purposely not referred to the outline of the abdominal swelling in the case of twins, for I have not found it of great service. "Without doubt, especially if the children are lying side by side, a sulcus may mark the division between the two sacs, but as often as not no such dividing mark is present. Very much the same applies to the foetal heart sounds. It is fre- quently stated that hear- ing these sounds over two areas, separated by an area in which they cannot be heard, should lead one to suspect plural pregnancy. It should not, however, do more, for I have several times observed the same when there was only one foetus. To be absolutely certain that there are two fcetal hearts beating, the accoucheur must make out the heart sounds to be of different rhythms over the two areas. They should therefore be counted simul- taneously by two observers, for it is surprising how quickly, and often after the slightest movement, the foetal heart rhythm becomes altered. Lastly, the feeling of two distinct sacs through the os is only FlG. 65. — Twins lying One in Front of the Other. PRESENCE OF MORE THAN ONE F(ETUS 11/ possible where the os is sufficiently dilated. Although not infre- quently with plural pregnancy the os is dilated for some time before labour, I have only been able to make out this feature on two occasions, and in both the foetuses were lying side by side. It is stated that even when they lie one in front of the other the two sacs may occasionally be felt ; but I fancy that is unusual, for in such cases the one is invariably higher than the other. The relative frequency of the positions of the foetuses is as follows I 1 Total Cases, 1840 (Leonhard). First child - head ; Second child - head - 38-5 361 cent »> head; n breech - 21-1 ii )> breech ; )> head - 14-3 ii >j breech ; 11 breech - 10-7 ii >> head ; >' transverse - 8-3 ii )> transverse ; )) head - 0-8 ii )> breech ; 11 transverse - 4-2 ii ,, transverse ; 11 breech - 0-7 ii »> transverse ; )5 transverse - 09 ii As regards the overlooking of plural pregnancy, or diagnosing it when it does not exist, both errors are common. Sometimes the co- existence of such conditions as hydramnios, cystic tumours, or mal- formation of the uterus may confuse matters, but as a rule that is not the reason of the mistakes. Most generally they result either from simply overlooking the condition altogether or from basing a diagnosis on insufficient evidence. As I said before, I always now withhold a diagnosis in a doubtful case, unless I can palpate from the abdomen two foetal heads or can feel two bags of membranes per vaginam. As a rule, the recognition of plural pregnancy prior to labour is a matter of no great practical importance. The exact state of matters is appreciated after the birth of the first child, and that is quite sufficient. I once, however, did find the correct diagnosis during pregnancy of importance, and others have had a similar experience. It was a question of inducing labour in a contracted pelvis in which the deformity was of the medium variety — viz., a conjugata vera of about 3} inches (7'8 centimetres). After a careful examination of the case and a diagnosis of twins I did not induce labour, because, presumably, the children would be smaller than usual, and so would pass through the pelvis more readily. My surmise proved correct, and the result was highly satisfactory, both children were born alive without any interference being necessary. The effect of more than one foetus being present is generally to 1 Strassmann (Winckel's ' Handbuch,' Bd. L, Heft 2, p. 1273). 116 OPERATIVE MIDWIFERY delay labour. The contractions, owing to the overdistension of the uterus, are weaker, and bearing down after rupture of the membranes is more feeble. The contractions, too, are often very painful. Against, and counteracting to some extent, these conditions is the smallness of the children. In cases left absolutely to Nature there is not a little delay between the birth of the two children. According to Strassmann, in seventy cases left to Nature the average duration of time between the birth of the two infants was twenty-eight minutes. In thirty-one, however, it was only ten, and in sixteen it was only fifteen minutes. The longest time was three hours. The other extreme of many hours and even days intervening will be found in the records of a few cases scattered throughout the relative literature. The general rule is that both placenta; follow the expulsion of the second child. I have never seen it otherwise, and Strassmann, in a series of 476 cases, found it occurred in all except three cases. When, however, there is a very long interval between the birth of the two children, it has happened that the placenta of the first has remained in the vagina and become septic. Futh 1 has referred to such cases, and pointed out the dangers to mother and child. Bearing in mind these few facts regarding the progress of labour in plural pregnancy, let us consider the treatment which should be followed. Speaking generally, labour should be interfered with as little as possible, and it should never be forgotten that there is always a period of uterine quiet after the first child is born. It may occasionally happen that rupture of the bag of membranes of the first child will help matters, for it will diminish the overdisten- sion, and therefore it is sometimes quite a wise course, even before) the os is fully dilated, to rupture the membranes. Then, again, the fact that the contractions are often feebler than normal will not infrequently compel one to assist delivery by forceps, or by traction on the lower limbs. It is inadvisable, however, to perform version upon the first child unless there is some coexisting complication, such as; placenta praevia, for there may be difficulty in extracting the after- coming head, especially as suprapubic pressure cannot be very effectively employed. The first child being born, and the cord tied both distally and proximally, one should wait for a little time unless there is some indication, such as ha?morrhage, for hastening the delivery. If the membranes do not rupture in fifteen or twenty minutes, that should be done artificially. At the same time the exact presentation ol 1 Zcnt.f. Qyn., 1901, p. 1055. PRESENCE OF MORE THAN ONE F(ETUS 117 he second child should be determined, for it occasionally happens hat after the birth of the first the second one changes its position. Although the change may be for the better, it is often for the worse, i, previously longitudinal lie being converted into an oblique. The nembranes being ruptured, the second child is, as a rule, soon ex- jelled ; if not, its delivery must be completed by artificial means. It s a mistake to hurry too much the delivery of the second child vith forceps, for in grasping a head which is still movable it will '■ery often be pulled into an unfavourable position. If possible, then, et the head engage before applying the instrument. Indeed, like nany others, I consider it better to employ version, for there will ieldom be any difficulty in performing it, and, the passage being ilready dilated, the second child passes readily, unless, of course, it is >f unusual size. It would be quite out of place to discuss further the dangers and complications of plural pregnancy. Everyone is aware that plural pregnancy throws a greater strain upon the mother, and that such complications as eclampsia, toxaemia, placenta prsevia, and post-partum hemorrhage, are more common. One can understand, therefore, why ,he maternal mortality and morbidity should be higher. The foetal mortality is also high. The fact that the children are 50 often premature, poorly developed, and malformed ; that the circulation in one or both is interfered with by the communication of heir bloodvessels and the faulty insertion of their cords ; and that luring their birth complications readily arise, explains why that should be so. Before leaving the subject, however, I must consider for a moment i most interesting accident which occasionally arises in connexion vith twin births — viz., ' locking.' I have purposely kept it quite ipart from my general remarks on the management of plural preg- lancy because it is such an extremely rare occurrence. According to {. Braun, it only occurred once in 90,000 cases in the two Vienna :liniques. Personally, I have seen it once in a case of premature abour, when both children were small. The condition may threaten when two foetal sacs appear together. In such cases it is well to avour the delivery by rupturing the sac which contains the child vith the head presenting, and following upon that, to place the voman, if possible, so that the force of gravity will tend to withdraw he other child from the pelvic inlet. There is here represented two forms of ' locking,' and, as can >e seen at a glance, the first locking of fore-coming and after-coming leads is much more serious than the other in which the two fore-coming leads become impacted. IIS OPERATIVE MIDWIFERY Taking the first variety (Fig. <'•<">>, where an after-coming head becomes caught by the fore-coming head of the second child, an attempt should first of all be made to push up the second, and under / Fig. 66.— Locking of After-coming Head of First Child with Fore-coming Head ol - (Bumm.) deep anaesthesia this may succeed. It did so in a case under my care. Should that manceuvre prove unsuccessful, it is inadvisable to do as has been suggested, even although it has been successfully carried LOCKE]) TWINS 11!) out — viz., apply forceps to the fore-coming head of the second child. The dangers to the second child are great and the risks to the mother not inconsiderable, as she will, almost certainly, have her parturient canal considerably lacerated. Consider the condition of matters. Flu. 67. — Locking of Two Fore-coming Heads. The chances of the first child being saved are almost nil. It has already had its circulation seriously interfered with, owing to pressure upon its cord. The second child, on the other hand, has not yet had its life in the least endangered. Of course, if it is known that the second child is dead, then everything must be done to try and save 120 OPERATIVE MIDWIFKIIY the first; but presuming that the second child is living, the onl\ course is to decapitate the first, apply forcep3 to the head of the second child and deliver it, and, finally, remove the severed head of the first with forceps or the cephalotribe. As regards the locking of two fore-coming heads (Fig. <">7), it is Fig. 68. — Locking of After-coming Sead of First Child with the Shonlder of the v (Bumin.) seldom of any consequence, for the second can usually be pushed out of the way. Failing that, attempts at extracting the first with forceps should be made, and if that still fails, craniotomy on the first child is preferable to craniotomy on the second, whose life so far is not at all endangered. LOCKED TWINS 121 A most hopeless condition is that in which an after-coming head ,nd a shoulder with a prolapsed arm become impacted (Fig. 68). 3audelocque accomplished delivery by decapitating the first child and Bfrforming version on the second, which would certainly appear to be he best course. Should it be quite impossible to reach the neck of ither child. Cesarean section might be the only alternative. CHAPTElt IX DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FCETUS— Continued Double Monsters. By J. W. BALLANTYNK, M.D., F.B.S.Ed., etc. Few medical men are called upon to conduct a case of labour in which the product consists of a double monster, and even obstetricians of considerable experience will see no more than two or three confine- ments so complicated in a lifetime. Nevertheless, any practitioner may any day find himself face to face with such an obstetric emergency, either in his own or in a brother practitioner's practice; and it is, therefore, necessary for him to know what has been the usual history of such cases, and in what way the difficulty in delivery can best be overcome. It is safe to say that in the past cases of difficult labour, in which the cause of the difficulty was the presence of united twins in the uterus, have generally been dealt with without any consideration for the life of the double monster. As a matter of fact, the only cases (two in number) with which the writer has had to do were ended after great difficulty by a sort of general dismemberment of the] foetuses. There are, however, certain circumstances which may now make it necessary for us to revise our views regarding such a mode of obstetric interference. In the first place, the profession regards with very different feelings the operation of craniotomy on the living foetus, and is striving to substitute methods of interference, such as •Cesarean section, symphysiotomy, and the induction of premature labour, which shall give a chance of survival to the infant. The life of united twins may not, perhaps, appear to have a high value : but it is a fact that some individuals thus congenitally fused have survived for a number of years, and not unhappily. The Siamese twins constitute an instance of this, for these brothers lived from 1811 till 1874, and begat normal children. In the second place, Caesarean section can now be performed with a much lower mortality than 1-2-2 DOUBLE MONSTERS L23 formerly, and gives an alternative method of delivery in cases which used always to be terminated by embryulcia. In the third place, united twins are not now condemned to pass their lifetime so fused together, for modern surgery has attempted, and in one or two instances has carried out with partial success, the separation of the two bodies. At the same time, while these new circumstances ought to make us take a different view of our responsibilities in the treat- ment of labours complicated by the presence of double monsters, it is doubtful whether it will be found possible as yet to apply them to the actual obstetric management of cases. There is still the difficulty of the ante-partum diagnosis of the existence in utero of such a mon- strosity. Although it may be possible for the more skilful diag- nostician to suspect abnormalities of the unborn infant as a result of his palpation of the uterus, it is the general rule that the malformation is not recognized till labour is in the second stage, and till, therefore, induction of premature labour is out of the question, and Csesarean section can only be performed under disadvantageous conditions. It must be borne in mind that the antenatal diagnosis of twins can rarely be made with certainty, the obstetrician being forced to content himself with intranatal recognition of this complication of labour. And I know of no way in which the nature of the twins can be foretold before their birth, for even if a radiogram could be made 3howing the presence of two foetuses, it would be useless for the diagnosis of the presence or absence of union of the twins, unless, indeed, the union were an osseous one. VAEIETIES OF DOUBLE MONSTEES. There are two great groups of united twins : in the first, the two foetuses are of almost equal size, and are symmetrically disposed and united by corresponding parts (e.g., chest to chest, head to head, gluteal regions to gluteal regions); in the second, the two foetuses are i of different sizes (often of markedly different sizes), are asymmetri- cally disposed, and are apparently united by unlike parts (e.g., head ; to chest). In the former group the united twins may be called symmetrical disomata, and in the latter asymmetrical disomata. In i the former group each twin has the same degree of formation and vitality, while in the latter one of them is obviously a parasite upon the other. It is not with the parasitic or asymmetrical disomata that the obstetrician has much to do. Labour may indeed be retarded, but ;fche degree of retardation, the means which require to be taken to iovercome it, and the effects produced upon the mother, do not differ 124 OPEEATIVE MIDWIFERY from those met with in cases of localized enlargement of the fa'tus from any cause whatever (e.g., fu-tal ascites, hydrocephalus, etc.). For instance, in a case of foetus in foetu (included fdtus) reported by Wright and Wylie 1 the labour was long and difficult on account of the large size of the infant's abdomen. Some time after her birth the infant was operated upon, and a mass removed from the cavity of the lesser peritoneum. This mass was sent to me for examination, and I reported that it was an included twin fcetus of the variety known as amorphus or anideus, and that by increasing the size of the abdomen of the co-twin it had led to the delay and difficulty in labour. Instances might be multiplied, but I pass to the consideration of the obstetrical relations of the symmetrical disomata or united twins in the ordinary sense of the term. There are three great subdivisions of the symmetrical disomata. For convenience and ease of description these groups may be called the chioid, the hypsiloid, and the lambdoid united twins, the names being given to them on account of their resemblance to the Greek letters Chi, Upsilon, and Lambda respectively. In other words, the united foetuses in these three subdivisions have the shape of an X, of a Y, and of a small Lambda or an inverted Y respectively. In text- books of teratology and antenatal pathology they are more often called thoracopagous, dicephalous, and syncephalous fused or united twins; but from the present obstetric standpoint I think it will be helpful to keep the general construction of the monstrosities before the mind's eye by means of these short descriptive names — X-shaped, Y-shaped, and inverted Y-shaped. The first group contains the cases in which there are two almost perfectly formed infants united more or less completely, thorax to thorax or back to back ; the second contains the two-headed monstrosities, in which the lower parts are more or less fused into one ; and the third includes the single-headed mon- strosities, which show duplication of the lower limbs and sometimes of the lower part of the trunk as well. LABOUR IN THE CASE OF THE CHIOID DOUBLE MONSTERS. When one looks at chioid united twins (Fig. (5!)), whether of the kind in which the place of union is situated anteriorly (region of thoraces or of abdomens), or of that in which the twins are fused in the gluteal regions, the first thought which comes into one's mind is that it must be impossible for such twins to pass alive and uninjured through the genital canal. Yet, as a matter of fact, records of the live birth of such monsters are found in obstetric literature, both old 1 Brit. Med, Jowrn., vol. ii., 1900, p. 142*. VARIETIES OF DOUBLE MONSTERS 125 ;ind recent. It is true that the confinement is occasionally stated to have been premature, and that the twins themselves are generally smaller than single foetuses of the same age, yet cases are not wanting in Fig. 69.— Chioid or Thoracopagous Monster. (Haultain.) which they have been of good size and born at full term. There is, of course, the well-known instance of the Siamese twins, and of late years Chapot-Prevost has recorded the case of Chinese brothers born L26 OPERATIVE MIDWIFKIlY alive, and surviving birth, at the full term. In the latter example it is further affirmed that the mother of the united twins was a priniipara. 1 From a scrutiny of the cases in which details of the confinement are given (not a very large number, it may be remarked) it would seem that the natural mechanism of delivery (if it may be so called) has been as follows : The united twins have presented by the feet, the bodies have descended parallel to each other through the vaginal canal, and then the obstetrician has carried the bodies well forward over the symphysis pubis, with the result that the posterior head has engaged in the pelvis and been born, while the anterior head has then been able to follow. This seems to have been the mechanism which proved effectual in the case recorded by ] )r. Haultain in the Transac- tions of the Edinburgh Obstetrical Society for 1901-1902. 2 When the obstetrician has been successful in the management of one of 1 these labours, it will generally be found that he has imitated as far as- 1 possible the natural mechanism indicated above. Version, therefore, ' gives the best results as a rule, for by its means the feet are made to present and the natural mechanism facilitated. The chief difficulty will arise in connexion with the birth of the heads. Here, a^ain, the rule is to imitate Nature, and get the posterior head to enter the pelvis, first, the bodies for this purpose being carried well forward over the symphysis pubis. Occasionally cases have been recorded in which delivery has taken place or been brought about without performing version, and in which, nevertheless, the heads have been the presenting parts. Such cases almost necessarily imply that the maternal pelvis has been large. In H. Hanks' case 3 the double foetuses presented by the heads. One head was born first, the other in the meantime occupying the space between the chin of the first twin and its chest ; then the second head was expelled with the help of traction on the first ; and then the two bodies came away simultaneously. But the two heads do not always come away together, as they did in Hanks' case. In an interesting record by P. Boulton 4 the following details are given. The mother was a small, weak woman, thirty-seven years of age, who had had eight pregnancies, all ending in normal confinements. In the present labour the first head presented as a face; forceps was applied and the first head extracted. Next, the shoulders, arms, and trunk of this child were brought down ; then the four feet and the trunk ; and finally the head of the second twin appeared at the vulva, and was born in that order. The labour was premature and the fused twins 1 • Chirurgie cles Teratopages,' Chapot-Pn'vost ; Paris, 1901. - Trims. Edirj. Obst. Soc, vol. xxvii., p. 176. :; Trans. Obst. Soc. Lond., 1862, vol. iii., p. 414. 4 Ibid., 1882, vol. xxiii.. p. 260. CHIOID OK THORACOPAGOUS MONSTERS 127 iixiall ; but for these facts it is doubtful whether such a mode of lelivery could have taken place. When a part of the fused twins has been expelled, and when no iirther progress takes place, or can be accomplished by ordinary )bstetric measures, the indication will be to reduce the size of the >roduct of conception by embryulcia; but it will be advisable to •egulate the plans of procedure as far as possible. If, for instance, he connecting band between the foetuses can be reached, and if it )e not of too solid a nature, the obstetrician will divide it, and then leliver the foetuses separately. If one head be at the vulva and the >ther be jammed in the pelvis, decapitation of the first head may nake it possible to complete the delivery. In almost any of the mpacted cases the performance of cleidotonry (division of one or both lavicles) will facilitate other obstetric manoeuvres, if it does not of tself make labour possible. Craniotomy of one or both heads may >e necessary ; and in a case in which the specimen afterwards came n to my possession for examination both heads as well as the two ibdomens had been opened into before the foetuses could be extracted. n all such cases the obstetrician will, of course, do his best to prevent :epsis, and will be well advised to wash out the interior of the uterus horoughly. One of the great dangers associated with the delivery of louble monsters of this type is the fact that not infrequently several nedical men have to do with the case, either as principal or con- stant or assistant, and that several different hands may thus be >assed into the uterus during the manipulations, each hand, of :ourse, increasing the risk of sepsis. Further, the labour is often a >rolonged, an anxious, and a disappointing one (dead-born infant), i,nd for these reasons the patient may be less able to resist septic nfection. LABOUR IN THE CASE OF HYPSILOID DOUBLE MONSTERS. The dicephalous or hypsiloid fused twins (Fig. 70) have two heads, hree or four upper limbs, two necks, a body showing some signs of luplicity, and (usually) only two legs, which belong one to each head. ^. classic case of this type of double monster is the S sottish brothers vho lived during the reigns of James III. and James IV., and attained to the age of twenty-eight years ; another instance is that >f Ritta-Christina, born in Sardinia in 1829, and living for a few nonths ; and yet another is that of the Tocci brothers, born in taly in 1877. It is, however, somewhat uncommon for fusei twins >f this type to survive birth, although, as a matter of fact, the -bstetrical conditions are not worse, but better, than those of the 128 OPERATIVE MIDWIFERY chioid type. In Dr. Pallaros' case of dicephalue which I reported some time ago 1 the cause of the futal death seems to have been the complication of the labour with a placenta pnevia. The obstetrical history of the hypsiloid twins closely resembles in its main outlines that of the chioid type. If the presentation be *'„;. 70.— Hypsiloid or Dicej'halous Monster. (Ihmteriaii Museum, Glasgow University.) breech or footling, the single body is born with perhaps some delay; then the first head enters the pelvis, and, if it be the posterior one of the two, is expelled by pulling the body well forward ; then the second or anterior head follows without further difficulty. It may, however, be necessary to decapitate. A fairly typical case is thus described by 1 • Teratologia,' 1895, ii. 210. LAMBDOID OB SYNCEPHALOUS MONSTERS 129 Horrocks : x ' The presentation was breech, and nothing abnormal was found until the child was born as far as the shoulders. Two necks and two chins were now made out. The left head was anterior and lower than the right, both faces looking towards the mother's right. The pains were strong, and presently the right head descended below the sacral promontory, got lower than the left head, swept over the perineum, and was born first, with the occiput posterior and to the left. The left head was born last.' In a case reported by Phillips 2 the anterior head was born first, but the labour was premature. When the heads present, delivery, if it can occur at all, takes place in the following way : One head is born and becomes fixed under the arch of the pubes ; then the body is driven past it by a sort of spontaneous evolution ; and finally the second head emerges. If, as is not uncommon, the delivery cannot be effected by this mechanism, it will be necessary to decapitate the first head and perform version. The same precautions must be taken, as regards asepsis and the avoidance of prolonged and purposeless traction, with the hypsiloid as with the chioid fused twins. 3 LABOUR IN THE CASE OF LAMBDOID DOUBLE MONSTERS. The cases are comparatively rare in which the fcetuses are fused in the region of the heads (Fig. 71) and upper part of the trunks, and separate in the lower parts and the lower limbs. The name lambdoid twins may be given to such monsters, although the more familiar ippellation is syncephalic (fused heads). The obstetrical difficulties ire in these cases usually associated with the large size of the single bead, for, although single, it represents two heads, indications of which are often forthcoming in the presence of two faces. The name Janus foetus ' has been given to it on account of the existence of the ;wo faces, which are sometimes placed side by side (with a common ientral eye) or back to back. If in such cases the lower extremities present first, it is quite likely that the two bodies may be born, with some delay, perhaps, but without any great difficulty ; but the after- ioming head will remain at the brim of the pelvis. The necessity vill then arise for perforation, and perhaps for basilysis, of that head, ;md in order to reach it easily it may be good practice to reduce the mlk of the shoulders by cleidotomy. If, on the other hand, the head 1 Trans. Obst. Soc Lond., 1885, vol. xxvL, p. 326. 2 Ibid., 1887, vol. xxviii., p. 278. 3 Interesting details (with a bibliography) of the birth of dicephalic double aonsters are given by Dr. J. Phillips (Edin. Med. Journ., 1888, vol. xxxiii., pp. 308. 04). 9 L80 OPERATIVE MIDWIFERY presents, the case will no doubt be treated by the usual methods, for the obstetrician will not guess that there are two bodies following ; in Fig. 71.— Lambdoid or Syncephaloua Monster. (Hunterian Museum, Glasgow Univerei™ other words, forceps will be applied, and will doubtless fail, and then recourse will be had to perforation. Probably it will be necessary to reinforce the perforation by considerable comminution of the head LAMBDOID OR SYNCEPHALOUS MONSTERS 131 (removal of large pieces of the cranial vault bones) and by basilysis. Since, however, these lambdoid double monsters have usually a very repulsive appearance, and little chance of surviving, there need be little hesitation in pursuing the line of treatment indicated above. There are some types of double monster which do not fall into any one of the three groups referred to ; but, as a rule, the obstetric diffi- culties they cause are no more than those which would be produced by separate twins. Thus, in the very rare cases of crcmiopagus (in which the two fee tuses are united by the vertices of the crania, and are separate in all the other regions) one twin is born by the feet, the two heads come one after the other, and finally the body and limbs of the second twin appear. The craniopagous fused twins may survive birth for months, even for years. . CHAPTKlf X DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE FCETUS — Continued Cord^Placenta— Membranes. COMPLICATIONS CONNECTED WITH THE CORD. Presentation and Prolapse of the Funis or Cord. — In considering this subject, it is still the custom of many to follow the classification of Naegele, and distinguish between 'presentation and prolapse of the funis, the former being a falling down of the cord in front of the presenting part before rupture of the membranes, and the latter being a similar occurrence after rupture. The distinction is useful, as the treatment for the two conditions is quite different. Doubtless, prolapse in most cases is a natural consequence of presentation, but in not a few it is only with rupture of the membranes and the escape of the liquor amnii that the former occurs, while occasionally the latter has disappeared during the course of labour. The frequency of the condition in the Glasgow Maternity Hospital is 1 in 150 cases. Speaking generally, the conditions favouring the occurrence of prolapse of the funis are those which interfere with the close applica- tion of the presenting part to the lower segment of the uterus. The head of the foetus best accommodates itself to the lower pole of the uterus ; consequently, prolapse of the cord is much less frequent with it than with pelvic and transverse presentations. Von Winckel 1 found transverse presentations twenty to twenty-five times and breech nine to ten times as often as head presentations. For the Glasgow Mater- nity Hospital the figures are : Head, 73 per cent. ; breech, 6 per cent.; transverse, 21 per cent. Malformations of the pelvis, and tumours of the uterus and sur- rounding parts, by hindering the engagement of the presenting part, also favour prolapse, while such conditions as low implantation of the placenta, marginal attachment of the cord, undue length of cord, sudden rupture of the membranes, especially if the parturient is in an 1 ' Handbuch der Geburtshiilfe,' Bd. ii., Teil iii., 1905, p. 1522. 132 COMPLICATIONS CONNECTED WITH THE CORD 183 tt'ect position, need only be mentioned. They are evident and impor- tant factors. The condition is found about five times as often in multipara? as n primiparse. But it is at once apparent that such a comparison does Fio. 72. — Prolapse of Cord. (Bumm.) not really give a correct idea of the relative frequency in primiparse, the practical bearing of which is that it is more common in the latter than is generally supposed. 134 OPERATIYK MIDWIFERY The position of the prolapsed funis depends chiefly upon the position of the foetus, for the cord tends to fall down on the side to which its abdomen is directed. It is, consequently, usually found to one or other side of the promontory (Fig. 72), rarely in front or at the sides of the pelvis. If it does prolapse in front, as in occipito-posterior positions, it will usually be found in the neighbourhood of the right ileo-pectineal eminence. The extent to which the cord prolapses varies. Sometimes only a small loop, but at other times many inches, fall down. Be the loop, which is compressed, large or small, the danger to the child is grave if the condition is left alone. A small loop is more easily replaced and kept up ; it is more readily overlooked, however. Few conditions simulate a prolapsed cord. None if pulsations in it can be felt. Sometimes, when there is great difficulty in reaching the presenting part, the tips of the child's toes or fingers resemble it, for they move away from the examining finger just as the cord does. It is commonly stated that the prolapsed intestines of the mother or child may be confused with it also ; and certainly in cases of ruptured uterus I have felt the prolapsed intestine very much like the funis, but only for a moment was there any doubt as to the real nature of the condition. Until recently I thought nothing could really simulate a prolapsed cord, but I was disabused of the idea, for in a patient I was attending, and in whom it was extremely difficult to reach the presenting part, owing to her stoutness, a flattened, pedunculated, submucous myoma exactly resembled the cord (Fig. 73). Indeed, I only came to a diagnosis after putting the patient under chloroform and inserting my hand into the vagina. From what has been said, it is evident that prolapse of the cord can only be diagnosed by vaginal examination, and, conse- quently, a labour must not be conducted by abdominal palpation alone, as some enthusiasts of abdominal palpation advocate. I am perfectly well aware that interference with the circulation of the cord, such as results from pressure upon it when prolapsed, produces alterations in the fatal pulse-rate and rhythm which can be recog- nized by auscultation. But the important point is, that by the time the alterations are distinct the child may have suffered considerable injury. Having ascertained that the prolapsed body is the cord, one must estimate the presence and strength of the pulsations. This can be done by pressing the cord against the fcctal head or maternal pelvis, or, better still, feeling it between the two examining fingers. The sources of error are the pulsations in the mother's vessels and in the COMPLICATIONS CONNECTED WITH THE COED 135 Fig. 73.— Flattened Submucous Myoma which simulated a Prolapsed Cord. (Author's Case.) examining fingers of the accoucheur, and I must admit, if the foetal pulsations are feeble and slow, it is sometimes not a little difficult to exclude these fallacies, unless one has the cord actually between one's ringers. 136 OPEBATIVE MIDWIFERY The child, it must be remembered, is not always dead, even although pulsations in its cord are absent. "When the cord is com- pletely compressed — during a uterine contraction, for example — the pulsations cease entirely, although they return again as the contrac- tion passes off. Again, as the child dies slowly, it is evident that the heart will continue beating some time after the pulsations cease to be appreciated. Everyone has had experience of the former condition, and I have once or twice had experience of the latter, but I have no recollection of ever having saved a child under the latter circum- stances. "When the pulsations are slow, and especially if they are feeble and irregular, one must extract the child quickly if it is to be saved. Prognosis. — In prolapse of the cord one has obviously to deal with a complication in which the chief danger is to the child. The mechanical obstruction of the cord to delivery is quite negligible, so that the mother can only be injuriously affected by the operative interference that may be had recourse to in the interests of the child. The foetal mortality is very high, but owing to the fact that the conditions which favour prolapse prevent engagement of the head, the cord often escapes pressure. It is more likely to be unfavourably pressed on when the presentation is a head and the pelvis is normal. Up to a certain point in the labour the condition is most favourable with transverse presentations, so much so that a temporary conver- sion into a transverse presentation while the os is dilating has been suggested. With a contracted pelvis, also, I have frequently seen the prolapsed cord but little pressed upon. In one of my cases of Cesarean section the cord was down in the vagina for an hour and a half after rupture of the membranes, and yet it continued pulsating quite normally. The child was extracted alive. As a rule, in a particular case the presence or absence of the intact membranes is the most important circumstance influencing the prognosis. Speaking generally, presentation of the cord — that is, falling down of the cord when the membranes are intact — is of little immediate consequence. It simply indicates that when the mem- branes rupture it will be endangered. Still, this is not always the case, for if there is little ' fore-water,' and the head is low in the pelvis, there will certainly be undue pressure on the cord, even although the membranes are intact. Next in importance is the degree of dilatation of the cervix, as it is self-evident that delivery or replacement are difficult in proportion to the expansion of the cervix. Then, again, the extent of the prolapse distinctly influences the prog- nosis, for the more cord down, the more difficult it is to get it replaced COMPLICATIONS CONNECTED WITH THE CORD 137 ,nd retained in a safe situation. Lastly, any coexisting complica- ions affect the outlook unfavourably. Treatment. — The treatment to be adopted in the complication inder consideration depends upon several circumstances. Chief of hese are, the condition of the membranes, the condition of the child, ,nd the extent to which the parturient canal is dilated. When the membranes are unruptured and the os only partially lilated, all one's energies must be directed to preserving the mem- •ranes intact, for except in those comparatively rare cases where the •resenting part is low in the pelvis, with little fore-water, the cord is afe from pressure. With that object in view, the patient is kept in ied, and all vaginal examinations and manipulations are desisted rom. In addition, an attempt is made to replace the cord by change f posture. The positions which are employed are the genu-pectoral r knee-elbow position, Sims', and Trendelenburg's. All act in the ame way. They raise the pelvis, and bring the cervix to a higher 3vel than the fundus, and so permit gravity to act on the prolapsed Dop. It is stated that ballotting the fundus with the hand favours he return of the cord. Theoretically, the treatment is sound, but, .nfortunately, it does not always prove successful in practice. Sims' position (Fig. 74) is quite as good as, and less irksome than, he knee-elbow or the Trendelenburg position. It also possesses this dvantage, that it lessens the risk of premature rupture of the mem- ran es. As a further preventative to this occurring, the employment f a hydrostatic dilator, introduced into the vagina, is recommended, 'ersonally, I have never employed the metreurynter at this stage and ith the object mentioned. The course to pursue, in cases of prolapse of the cord with uptured membranes, will depend upon the condition of the child nd the degree of dilatation of the cervix. It is perfectly evident that the pulsations in the cord have ceased, and the child is dead, othing need be done in its interest, and so the labour should be llowed to pursue its ordinary course. Any interference must be in ae direction of making the delivery as easy as possible for the lother. For example, in such a condition, if uterine contractions ail, and the extraction of the child is deemed necessary, the fore- oming head, delivered by forceps, or the after-coming head, delivered y traction on the trunk, may be perforated, so as to remove all hance of the head doing damage to the soft parts of the parturient anal. I have several times perforated the head already grasped by le forceps, and have always been satisfied that it lessened the bulk I the head, and did not render the instrument appreciably more able to slip. IMS ol'KKATIYK MlD\Yin:i;Y One must, however, be quite sure that the pulsations have ceased, and so the loop of prolapsed cord must he carefully felt, not only during the ' pains,' but also in the intervals between them. As I have pointed out elsewhere, the child usually dies slowly, and for a considerable time before its death pulsations may be quite good during the intervals, although they are entirely absent while the pains are in progress. One should also observe the condition of the fa-tal heart. If the os is fully dilated, the child should be extracted by forceps. In cases where the os is fairly dilated and the cord has been pressed Fit;. 74. — Sims' Position. The woman lies on left side, with right leg drawn up over It ft. upon, it may be not a little difficult to decide how far one is justified in forcibly delivering the child, with the object of saving it, knowing, as one does, that by such a course one appreciably endangers the mother. From my experience, I would say that when the foetal pulsations slowly return in the intervals between the uterine contrac- tions, and remain slow and intermittent and irregular, unless the child can be slipped out of the vagina immediately and with ease, it is profitless to add to the maternal risks by doing anything in the interests of the child. When, however, regular and strong pulsations return immediately after the uterine contractions have passed off, and COMPLICATIONS CONNECTED WITH THE CORD 139 ie is not pressed for time, manual dilatation or incision of the cervix ay be practised. One thing must never be done — viz., dragging the lild through the undilated cervix ; for with the after-coming head it absolutely profitless, as the child will certainly perish, owing to the faculty and delay in bringing down the arms and head, and with le fore-coming head it causes severe and irregular laceration of the irvix uteri. But in such cases hard-and-fast rules cannot be laid 3\vn. Experience, and a careful consideration of all the circum- ances, must be one's guide. We must now turn to prolapse of the cord when it is recognized irlier, and when there is still a possibility of replacing it, altering ie posture of the child, or introducing a hydrostatic dilator. As ated already, Louise Bourgeois (1609) suggested replacing the pro- psed cord. According to Fasbender, our latest obstetric historian, 1 ie recommended reposition and the maintaining of the cord in place v means of a tampon. Guillemeau and, later, Mauriceau also advo- ited reposition, although the latter fully appreciated the fact that it [ten proved unsuccessful. De la Motte opposed reposition. As forceps became perfected and more generally employed, and fraction by means of it was recommended by Levret, Smellie, and .hers, version and forceps came to be the only methods of treatment nployed. Writing in 1853, Eigby says : 2 ' Reposition has, neverthe- ss, met with so little success as to have fallen into complete disuse ntil the last few years.' A revival of the treatment of reposition was utiated by Michaelis. This great obstetrician, best known, of course > i connexion with his work upon deformities of the pelvis, wrote ^veral papers upon the subject of prolapse of the cord. Basing his pinions on his own results (22 per cent, foetal mortality), he became strong advocate of the treatment by reposition. The chief value of Lichaelis' work in connexion with reposition was the importance he ttached, and that very rightly, to pushing the cord above the retrac- on ring. About this time a great variety of repositors were devised y Braun, Martin, Murphy, and others. The results from manual reposition for the last five years in the lasgow Maternity Hospital show a fcetal mortality of 24 per cent., nd failure to effect reposition in 10 per cent. Beuter ;! has made most careful analysis of some 1,600 cases, and his figures go to apport the contention that the best results are now obtained by ^position. Regarding manual reposition, it must be remembered that the 1 Geschichte der Geburtshiilfe, 1906, p. 157. 2 ' A System of Midwifery,' p. 236. 3 Inaug. Dis., Bonn, 1894. 140 ( >ll : l:\ll \ i: MIDWIFERY results obtained before the clays of anesthesia, when the cord was not pushed up high enough, cannot be compared with those of to-day. Fig. 75. — Simple Devices for replacing the Cord. (After Edgar.) I have no hesitation in recommending replacement of the cord under anaesthesia. When the os is sufficiently dilated, the cord may be COMPLICATIONS CONNECTED WITH THE CORD 141 replaced, and at the same time hooked over a limb. When, however, the os is not sumciently dilated to permit of manual replacement, repositors may be employed. The earliest repositor used was gauze , and it and a large sponge have frequently proved of value. Of the various repositors, the most effective and the simplest is the catheter, employed as seen in the illustration (Fig. 75). A loop of a double thread of silk ligature or thin tape is brought out through the eye of a gum-elastic catheter. The prolapsed piece of cord is then inserted into the loop in one of the manners shown. The catheter and cord are then carried up into the uterus, and the silk thread loosened by moving the catheter about or removing the stilette. In the majority of our cases where the cord was replaced, delivery was completed by forceps. With the latter the results have been infinitely better than with version, which gave a fcetal mortality of 56 per cent. It must be admitted, however, that version was performed late, and in many of the cases the pelvis was decidedly deformed. My feeling with regard to the operation is that, if it is to prove successful, one would require to perform it prior to rupture of the membranes, or, at least, immediately rupture occurred. A& we have seen, however, everyone is agreed that it is the greatest possible mistake to rupture the membranes prior to full dilatation of the os externum ; and consequently I think version is unsuitable, except in tranverse presentations, or some coexisting complication, such as placenta prsevia. The metreurynter of Champetier de Eibes, or similar hydrostatic dilators, are favoured by only a few enthusiasts, for the cord may be compressed between the rubber bag and the uterine wall just as readily as between the foetal head and the uterine wall. Before leaving the subject, let me say that in certain cases of contracted pelvis I have seen the cord so little pressed upon, even with the membranes ruptured, that I have not interfered. I simply examined the condition of the cord from time to time, and auscultated the foetal heart regularly. In such cases the real danger to the child is when the head has passed the brim and is in the cavity. Consequently, all that is necessary is to direct the cord into one of the ' bays ' at the side of the promontory, and leave the case to Nature until the os is sumciently dilated and the head is moulded. The forceps are then applied, or any other operation had recourse to which is deemed suitable for the particular case. Shortness of the Umbilical Cord. — The umbilical cord may be actually short, or relatively short by reason of its being wound round some part of the foetus — most usually the neck. Actual shortness of the cord causing dystocia is very rare. I have only witnessed it on 112 OPEEATIVE MIDWIFERY, two occasions: once in the malformed fu.*tus shown in the illustration (Fig. 76), and once in an otherwise normal fntus, where it measured Fig. 7b'.— Adhesions between Amnion and Head; also Extreme shortness of tin- Cord in a Foetus horn Alive, and presenting many Recognizable Malformations. (Author's Collection.) about 8 inches (20 centimetres). In the latter case, during the extrac- tion of the trunk (the child presented by the vertex), I felt that the COMPLICATIONS CONNECTED WITH THE CORD 143 child was prevented from escaping owing to the shortness of the cord, and so divided the latter and completed the delivery. Similar cases have been recorded by many others. Among the most interesting was the one described by Braxton Hicks, 1 where actual shortness of both cords in a twin pregnancy was very marked. In the first child, which presented by the breech, the funis was exceedingly short, so that it scarcely could be tied and divided. The second child, dead and (.edematous, also presented by the breech. As the latter had been long delayed at the outlet, the author states : ' I hooked a crotchet into its abdomen ; some fluid escaped, which allowed more freedom of action. I now could feel the funis very tense, the umbilicus being stretched up. It was above the symphysis pubis. I determined to divide the funis, and having in my bag the osteotome of the late Sir James Simpson, I guided it up between two fingers of one hand and divided it. Upon using fair traction, the body came down. The funis was about 4 inches (10 centimetres) long altogether.' Bayer 2 describes a case where the cord measured 4*2 inches (10*5 centi- metres). The most extreme cases of shortness are found in associa- tion with malformations, more particularly exomphalos, as in the preceding illustration. It would appear that shortness below 10 inches (25 centimetres) usually gives rise to more or less dystocia. With relative shortening of the cord, the latter is usually found round the neck of the child, for the shoulders catch the cord. If it is simply round the body (Fig. 77), the child escapes through the loop as a rule. The child ' riding ' the cord — that is, ' astride of it ' — naturally only causes dystocia if there is actual shortness. With shortness of the cord, in addition to the birth of the child being retarded, rupture of the cord, separation of the placenta, and even inversion of the uterus, may follow. In the malformed fcetus seen in the illustration placenta and fcetus came away together. In Hicks's case a retroplacental haBinatoma formed, as also occurred in Mej'er's. 3 Matthews Duncan 4 experimented upon the power of the funis to resist a breaking strain, and found it averaged 8] pounds, while the extent of elongation before breaking averaged nearly 2 inches (5 centimetres) The rupture occurred some little way from the umbilicus. But although that is the rule, it sometimes happens that it occurs at the placenta, as in the case mentioned by Wynn Williams in the discussion which followed Duncan's paper. 1 Lond. Obst. Trans., vol. xxiii., p. 253. 2 Samml. Klin. Vortrdge, No. 265, 1900. 3 Prager Med. Wochenschrift, Nos. 48 and 49 ; ref. Winckel's ' Handbuch,' Bd. ii., Heft 3, p. 1498. 4 Lond. Obst. Trans., vol. xxiii., p. 244. 1 II OPERATIVE MIDWII T.IlY Fig. 77. —Cord twisted round Body and Neck of Child. (From Van Rhyrasdyke's drawing in tip Ennterian Minuih. Glasgow University.) The diagnosis of a short cord has occasionally been made before the aTtual delivery was in progress, as, for example, in McLennan's cases. COMPLICATIONS CONNECTED WITH THE CORD 145 McLennan, 1 quoting Weidemann, says the condition maybe diagnosed from the following : 1. The presence of the funic souffle. 2. The recession of the presenting part in the intervals between the pains. 3. One-sided pain in the abdomen (Wigand). 4. Variability of the position of the head within narrow limits (Rachel). 5. Discharge of some blood after each pain (Rachel). 6. Frequent emptying of the bladder in the pauses between the pains (Brickner). I can offer no opinion regarding these signs and symptoms. Theoretically, they are self-evident, and I doubt not are often present. How difficult, however, it must be to appreciate them ! In all proba- bility, in the future, as in the past, the condition will at earliest be appreciated when there is a difficulty in the extraction of the child, or when it is forcibly expelled with a ruptured cord, attached placenta, or inverted uterus. When actual shortness of the cord exists, the latter should be divided, the child quickly extracted, and the cut cord immediately secured. When the cord is round the neck, difficulty in extraction will only occur in head presentations. In such cases, if a loop cannot be slipped over the shoulder, it is futile to try to bring it over the head, as is the ordinary procedure ; the cord should be divided and the child at once delivered. It is unnecessary to waste time in clamp- ing the cord with pressure forceps or passing a ligature round it. The most exhaustive recent papers on the subject of shortness of the cord are by La Tor re. - Other abnormalities in the umbilical cord, such as undue length, twisting round the neck, trunk, or limbs, and knots, have little effect upon labour, and so need not be considered in any detail. Undue length of the cord — Gottschalk recently recorded one in which the length was 36*8 inches (92 centimetres) — naturally pre- disposes to prolapse, to twistings, and to the formation of knots. Prolapse has been considered already, and twistings round the neck may lead to relative shortening, as we have seen. Occasionally the cord has constricted the part round which it has been wound so tightly as to lead to the death of the child, or to interference with the development of a particular part. There are not a few cases on record where the neck of the child has been extremely constricted, where the trunk has been deeply indented, and where even a limb has been 1 ' Abdominal Manipulations in Pregnane}-,' 1902, p. 95. 2 La Clinica Ostetr., vol. vi., Nos. 1-9. 10 1 16 OPERATIVE MIDWIFERY amputated, although the latter condition probably more often results from amnionic bands and errors of development. The mosl interest- ing cases of knotting are those in which two or more knots have occurred in the cords of twin foetuses in one amnionic Bac. Such cases are very rare. An example is seen in the accompanying illus- tration (Fig. 78). Dr. Lindsay, of Glasgow, very kindly gave me the specimen. The knots, if they are tight, invariably lead to the death of the child. The condition naturally is only recognized after the expulsion of the placenta and membranes. Fig. 78. — Placenta and Knotted Cords, from a Case of Twin Pregnancy. (Specimen kindly given the Author by Dr. Lindsay.) The various anomalies in the number and relationship of the vessels in the umbilical cord cannot be considered here. It is other- wise, however, with the insertion of the cord to the placenta. The marginal insertion — often termed ' battledore ' placenta — is an abnor- mality occurring in about 5 per cent, of cases. To a slight extent it is a source of danger to the child. Much more serious, however, is the 'velamentous insertion' (Fig. 79), for in such cases the circulation is very readily interfered with. Rupture of the vessels and death of the child from haemorrhage have been noted on several occasions. COMPLICATIONS CONNECTED WITH THE COW) 147 The etiology of the condition has been discussed by Schultz, Kustner, Ahlfeld, and others, but, as it has no practical bearing, those interested in the matter are referred to the monographs on the subject by the authors mentioned. It is quite evident why the child should suffer in this condition, Fig. 79. — Yelamentous Insertion of Cord. Firi. i;.\tiyi: midwifery things being equal, a high false promontory is more serious than a low one. Passing from the brim to the cavity, one finds that the Latter ie usually shallow and roomy. In Hat rachitic pelvis, therefore, it may be safely said that once the head gets through the brim it is seldom arrested in the cavity. At the outlet there may be sometimes a little difficulty, for, although the transverse diameter is increased, the dragging of the coccyx inwards may diminish the conjugate to a Blight extent. In the mechanism of labour in flat pelvis, either rachitic or non- rachitic, there are three characteristic features : 1. The head engages in the transverse diameter. 2. The head is less flexed. 3. The biparietal obliquity is more marked. It is only natural that the head should pass through the brim in the transverse diameter, which is so much the largest. If examined at this stage, the anterior fontanelle can always be readily reached, and is usually lower, although occasionally it may be at the same level as the posterior. But the most striking alteration in attitude is the increased parietal obliquity. The head is tilted towards one or other shoulder, with the result that the anterior or posterior parietal bone presents. In the anterior parietal presentation (asynclitismus anterior, Fig. 94) the parietal bone, directed posteriorly, is arrested by the promontory of- the sacrum. It is an exaggerated degree of what is termed ' Naegele's obliquity.' The birth takes place by the anterior parietal bone becoming pressed against the anterior wall of the pelvis, and the posterior being driven down round the promontory. It is a very much more favourable position than the posterior ; indeed, in a large number of cases one sees spontaneous delivery occur. In the posterior parietal presentation (asynclitismus posterior, Fig. 95) Litzmann's obliquity is exaggerated, and it is the anterior parietal bone that is arrested at the symphysis, while the posterior engages at the brim. The mechanism, according to Litzmann, was for a gradual correction to take place, but Veit showed that the head might pass through the pelvis by the anterior parietal bone becoming much moulded and forced past the symphysis. Spontaneous delivery is difficult in such a presentation, unless the pelvis is only slightly deformed. A posterior parietal presentation should always arrest attention, for not only is the presentation particularly unfavourable, but the degree of pelvic deformity is usually considerable when the head assumes this attitude. DEFORMITIES OF THE BONY PELVIS 165 I have repeatedly tried to correct a posterior into an anterior parietal presentation after rupture of the membranes, but so far with little success ; and this is the general experience. If the pelvic deformity is not too great, version is recommended by many, and certainly it has always appeared to me sound treatment. The only Fig. 94. — Anterior Parietal Presentation. difficulty in pursuing such a course is that the position is often only recognized some time after the membranes have ruptured. When version is impossible, and the natural forces fail to overcome the difficulty, the forceps is of little value unless the head is well fixed and the pelvis only very slightly deformed. Craniotomy is then the only course open if the child is dead, and symphysiotomy, pubiotomy, or Cesarean section if it is alive. L66 OPERATIVE MIDWIFERY Generally Contractu]) Rachitic Pelvis. — The majority of the cases of marked pelvic deformity come under this beading. The hones are small and hard. In an absolutely typical example flattening is absent, hut in actual practice one invariably finds flattening, as well as general contraction. The explanation of the deformity is that the disease has arrested the pelvic development. The patients may he FlG. 95. — Posterior Parietal Presentation very small and much deformed in limbs, chest, etc. It has heen already explained that a general contraction of the pelvis is much more serious than simple flattening. Roughly, one calculates that a generally contracted pelvis of, say, 8| inches (8*1 centimetres) is equal to a. flat pelvis of 8 inches (7*5 centimetres), hut when the conjugate falls below that figure, the difference is even greater. DEFORMITIES OF THE BONY PELVIS 1(57 Pshudo-Malacosteon Rachitic Pelvis. — This variety of pelvic deformity is very rare. As far as I can remember, I have only seen two typical examples. Its features will be understood from the illustra- tion (Fig. 90). Presumably it occurs when the disease has run a long course, and when it has attacked the walking child. As a natural consequence, the weight of the child being supported by the femora, instead of the ischial tuberosities, the sides of the pelvis are pushed in, and the anterior wall projects in the form of a beak. A similar deformity is seen in the malacosteon pelvis, only to a more marked extent, and hence the term ' pseudo-malacosteon pelvis ' given to this variety of rachitic deformity. Osteomalacic Pelvis. — This is a deformity of the pelvis the result of the disease mollities ossium or malacosteon. The disease is Fig. 96. — Pseudo-Malacosteon Pelvis. one of adult life, and attacks both sexes, although women are affected ten or twelve times as often as men. In women it is confined almost entirely to multipara in the period of life when the reproductive organs are functionating. It is specially active during pregnancy and the puerperium. A most interesting feature of the disease is the fact that it is prevalent only in certain localities. In England, America, and France, for example, it is extremely seldom seen, whiif; in such areas as the Rhine Valley, the North of Italy, and certain districts of Switzerland and Hungary, it may be said to be endemic. Almost certainly it is a disease of unsatisfactory housing and improper and defective feeding, but one would think that there must be some- thing more than that, for similarly unhealthy conditions exist in all countries. A most important contribution to the etiology and treatment of the disease was made by Fehling in 1888, when he pointed out the great 168 OPERATIVE MIDWIFERY benefit that follows oophorectomy. To speak of the disease, however, as a ' trophoneurosis,' and caused by a pathological condition in the ovarian secretion, is somewhat premature, as our knowledge of the ovarian secretion is still very incomplete. At present only this fact is known — that oophorectomy does, in many cases, decidedly arrest the progress of the disease. The onset of the disease is, as a rule, gradual. During the course of a pregnancy, usually after one or two normal pregnancies, pains are complained of in the back and limbs, and walking becomes irksome. These symptoms may disappear after labour and lactation, to return again with increased severity in a subsequent pregnancy. With each pregnancy locomotion becomes more awkward, the patient's stature becomes less, from sinking of the trunk, and the Fig. 97. — Osteomalacic 1'elvis (Anterior View . labours become more and more difficult from the narrowing of the bony canal. The bones, as a result of the softening, bend, according to the direction of the forces transmitted through them. The illustrations (Figs. 97, 98) give a fairly good idea of the malformations that result from the disease, and it may be remarked that in no pathological condition of the pelvis does one meet with such extreme deformity as in osteomalacia. The promontory being pushed downwards and for- wards, and the lateral pelvic walls inwards, cause the anterior wall to be pushed out in the form of a beak, and the brim to assume a trifoliate shape. Hence the pelvis is often spoken of as the ' beaked,' 'rostrate,' or ' triradiate ' pelvis. The subpubic arch is very much narrowed, from the approximation of the ischial tuberosities. The acetabula look more forward, and the legs are brought closer together, so that the subjects of the disease have a peculiar swinging gait. From the muscles and ligaments dragging on their attachments, a marked curving of the iliac crests, and posterior parts of the in- DEFORMITIES OF THE BONY PELVIS 109- nominate bones, results, so that the posterior spinous processes may almost touch (Fig. 98). The diagnosis of this variety of pelvic defomiity is not difficult. The history of the disease and the deformities produced are absolutel v characteristic. Prior to Fehling's discovery that oophorectomy had such a bene- ficial effect upon the disease, the salts of lime and phosphorus in various forms were most strongly recommended. The results obtained from such drugs, however, were not very satisfactory. As a result of Fehling's discoveries, Csesarean section, with removal of uterus and ovaries, is the treatment to be adopted in all pronounced examples of the disease. In the slighter forms of the disease other simpler methods of treatment may prove sufficient, but owing to the Fig. 98. — Osteomalacic Pelvis (Posterior View). nature of the deformity it can be readily understood that it does not require any great malformation to render delivery j>er rias naturales- impossible. New Growths. — Small osteomata (pelvis spinosa), more especially about the symphysis, sacro-iliac synchondrosis, and the ilio-pectineal eminences, are not very uncommon. Such small growths, if the pelvis is contracted, may cause injuries to the foetal head, such as gutter-shaped indentations and fractures (Chapter XXXVIII.), or lacerations of the uterus from the pressure of the head. Larger tumours (Fig. 99) — osteomata, enchondromata, fibro- mata — are only very occasionally encountered. In the last six years, in the Maternity Hospital, we have only had one case, recorded by Jardine. 1 With the exception of the osteomata, they are frequently malignant, most commonly sarcomatous. They are usually situated on the posterior wall in the neighbourhood of thf* 1 Journ. Obst. and Gyn. Brit. Empire, vol. ii., 1902. p. 147. L70 Ol'KliATIVK .M 1 1 >\VJ I- 'EB V -aero-iliac synchondrosis. Naturally, such tumours prevent the passage' of the child through the pelvis, and so Cfflsarean section is invariably necessary. Fractures of Pelvis.— As can be readily understood, fractures, •either from the amount of callus, or from the irregular anion of the fractured portions, may occasionally produce a deformity of the pelvis, and cases of this nature have been described. The deformities Fig. 99. — Sacral Tumours. iBiinuu.) are very seldom encountered, for fractures of the pelvis generally result in death. Caries and Necrosis of the Pelvis. — In the rare cases in which the acetabulum becomes perforated in hip-joint disease, there may result an irregular bony formation, which may encroach upon the lateral pelvic wall. The effect of hip-joint disease on the pelvis we shall consider later. Caries of the sacro-iliac joint may result in an ankylosis of the joint, and the development of one sacral ala may be arrested in consequence. In such cases an obliquely contracted pelvis, resembling Naegele's, results. DEFORMITIES OF THE BONY PELVIS 171 Diseases of the Sacro-Iliac, Pubic, and Sacro-Coccygreal Joints. — 1 have referred already to the effect of disease and ankylosis of the sacro-iliac joint. Ankylosis of the pubic joint is by no means common, and some operators who have performed many symphysiotomies •question its occurrence. Reference will be made to this when sym- physiotomy is under discussion. As regards the coccygeal joint, premature ankylosis, or ankylosis following fracture, may cause obstruction to the escape of the child's head. Removal of the coccyx is the correct and most scientific treat- ment. The general course followed is to pull the child past the ■obstruction with forceps and refracture the bone. III. Deformities resulting from Disease in the SpiNx^l Column. Kyphosis. — The deformity of the pelvis found in kyphosis depends, in great part, upon the degree and situation of the curvature. It is also influenced by the age of the individual, and the disease, tubercu- losis or rickets, which causes the deformity. In cases where there is ■only a slight angular curvature little or no alteration in the pelvis is found. As regards situation, if the curvature is in the dorsal, especi- ally the upper dorsal, region, a compensatory lordosis develops, and the pelvis is little affected. If, however, the curvature is situated in the lower part of the spinal column and the lumbar, and especially the lumbo-sacral, region is involved, then very decided deformity of the pelvis almost always exists. The alteration in the pelvis (Fig. 100) consists in a tilting of the upper part of the sacrum backwards, and of the lower part and the coccyx forwards. As a result of this, the antero-posterior diameter at the brim is increased, and the same diameter at the outlet diminished. The inclination of the brim becomes lessened ; indeed, it may become almost parallel to the horizon. The sacrum is often found narrow and straightened. The transverse diameter of the pelvis gradually diminishes from above downwards. At the superior straight it is little altered, but the distances between the ischial spines and ischial tuberosities are decidedly diminished. The striking feature of the kyphotic pelvis is a diminution of all the diameters of the pelvic outlet; therefore, one finds difficulty in labour when the foetal head has reached the lower part of the cavity. It is somewhat curious that the head should so generally engage in the oblique or transverse diameter, for one would expect that it would engage in the conjugate, as that is the diameter which is increased. Another peculiarity is the frequency with which the occiput rotates L72 OPERATIVE MIDWIFKIIY backwards, Many writers have referred to this, and Klein's 1 in- 1 vestigations confirm those of such writers as Spiegelberg and| ( Mshausen. Until recently I had seen very little trouble in cases of kyphotic pelvis ; but within the last five years I have had five cases of extreme dystocia under my care. All who have collected a number of cases have had a similar experience. Champneys 2 gives the Fig. 100.- Kyphotic Pelvis. maternal mortality us 28 per cent, and the fu'tal as 40 per cent- Klein's figures for the mother are much better, but exactly the same for the child. Allowing for the fact that there is always a tendenc}- to report the graver cases, it must be admitted that the malformation is serious when the deformity involves the lower part of the spinal column. One thing that undoubtedly leads to the unsatisfactory results mentioned is the fact that, as the difficulty occurs late in parturition, the Archivf. Gyn., L896, Bd. 1. Trans, Obstet. Soc, vol. \w.. 1888. DEFORMITIES OE THE BONY PELVIS IT: 1 . necessity for serious operative interference is only appreciated after labour has been going on for some time. It is most important, there- fore, that the size of the pelvic outlet should be very carefully estimated during pregnancy or early in labour in all cases, but especially in low kyphosis. The index for treatment in kyphotic pelvis is the length of the trans- verse diameter of the outlet, the distance between the tuberosities. If it is 3 inches (7'5 centimetres), delivery should not be difficult, but below that figure it becomes increasingly difficult, and at 2£ inches Cesarean section or symphysiotomy if the child is living, and cranio- tomy if it is dead, is the treatment indicated. Klein advocates sym- physiotomy, and claims that a 2-inch separation at the symphysis gives an increase of fully 1} inches between the tuberosities. I have once performed pubiotomy for this condition, and am satisfied that it is sound treatment when the deformity is decided. Fig. 101.— Pelvis Obteota. (Fehling). Fehling has given the special name ' pelvis obtecta ' (Fig. 101) to a form of kyphosis in which the lumbar vertebrae overhang the brim and prevent the child engaging. Besides the ordinary kyphotic pelvis already described, one some- times encounters mixed forms — for instance, a rickety kyphotic pelvis. If the rachitis has been at all severe, the deformity follows more that type ; if, however, it has been slight and the curvature is situated high, then the one deformity may counteract the other. One cannot, however, generalize on such variations, nor upon the treatment. Scoliosis. — Lateral curvature of the spinal column, to any very marked extent, is usually a rachitic manifestation, and if the scoliosis is of non-rachitic origin it is quite negligible from the obstetric standpoint. The scolio-rachitic pelvis has been already mentioned (Fig. 93), and its importance as influencing the passage of the head through the brim has been referred to. A curvature of the spinal column high up will 17 1 OPERATIVE MIDWIFERY not have the same effect as one situated low down, for a compensat >v\ scoliosis occurs in the former. The malformation is similar to that Found in rickets, only the promontory is pushed over to the affected side, so that the pelvic brim is of extremely irregular outline. Spondylolisthesis. By this term is meant a slipping down of the last lumbar vertebra in front of the promontory (Fig. 102). In slight cases it only projects a little way over the promontory, but in extreme Fig. 102. — Spondylolisthetic Pelvis. (Bamm. cases it projects right down in front of the first sacral vertebra. The remaining lumbar vertebrae also sink down, and the fourth and third may actually project over the superior straight — not, however, to any- thing like the same extent as occurs in the ' pelvis obtecta.' It can be readily understood that the deformity causes great alteration in the pelvic capacity. The promontory is displaced back- wards, but the 'obstetrical conjugate,' the distance between the symphysis and the most projecting part of the vertebral column, is. DEFORMITIES OF THE BONY PELVIS 175 very much lessened. The sacrum being pushed backwards and the lower lumbar vertebrae downwards, the superior straight becomes more and more nearly parallel with the horizon. The pelvic outlet becomes diminished antero-posteriorly. The appearance of subjects with this deformity is quite character- istic ; the trunk seems to have sunk down into the pelvis, while behind there is often to be seen the projecting spine of the last lumbar vertebra. The diagnosis, therefore, should seldom be difficult,, although there are other conditions, such as mollities ossium and a low kyphosis, which produce a shrinking down of the trunk. By internal examination the projecting vertebra will be readily felt. The most generally accepted view of the etiology of this malforma- tion is that it results from maldevelopment of the interarticular processes of the last lumbar vertebra. A history of accidents, falls, etc., and the carrying of heavy weights, can rarely be obtained. The frequency of the condition is variously stated. Lane considers it by no means uncommon ; Olshausen and Yeit x mention seventy anato- mical recorded cases, but Breus and Kolisko maintain that in the various collections there exist only some twenty genuine specimens. The reason for this discrepancy is probably that Lane includes the slighter cases of projection of the last lumbar vertebra, while the others only accept extreme cases. As has been already stated, one sometimes finds the last lumbar vertebra pushed forwards and down- wards in the rachitic pelvis, and if one were to include such cases the frequency would certainly be much higher than even Olshausen and Yeit state. However, these are matters of anatomical interest. What is of real practical importance is that the deformity is a very serious one indeed. Only in the very slight degrees of the deformity is it possible to deliver the child -per vias naturales, either by forceps or symphysiotomy. Csesarean section if the child is alive and craniotomy if it is dead are, therefore, the operations to be considered. IV. Deformities from Diseases of the Lower Extremities. The deformities resulting from disease of the lower limbs are usually unilateral. Coxalgia, dislocation, and shortening of the leg from any cause, of which, perhaps, infantile paralysis is the most striking, are the chief affections encountered. The deformity resulting from each of these conditions is much the same, although in coxalgia it is usually most marked. In hip-joint disease, if the child is very young and the affected side 1 ' Lehrbuch,' 1902. L76 OPERATIVE MIDAVIFKKV is partly arrested in its development, an ankylosis of sacrum and ilium may result. As the child goes about, however, and most of the weight is thrown on the sound leg, an oblique distortion of that side of the pelvis follows. The deformity is seldom so great as to cause extreme distortion, such as would necessitate any of the major operations, although on one occasion I saw a case of double coxitis where the deformity was so decided as to necessitate the induction of premature labour. In the case of congenital dislocation of the femur, or a dislocation occurring in early life, the head of the bone is displaced on to the ilium, where a new joint forms. The affected leg being shortened, the greater part of the body-weight is borne by the sound leg, and conse- quently that side of the pelvis is pushed in. In congenital dislocation of both femurs both sides are pushed in, and so the brim is narrowed transversely. Similar, but less marked, deformities may follow shortening or absence of a limb from any cause, if it occurs in -early life. CHAPTER XII DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Continued Diagnosis, Prognosis, and Treatment of Pelvic Deformity, more especially of the Rachitic Varieties of Malformation. In considering the rarer forms of pelvic deformity, I briefly referred to the diagnosis, prognosis, and treatment of the particular one under consideration. With rachitic pelvis, however, I did not do so, for, being the commonest variety of deformity, and the one on which all discussions of diagnosis and treatment are based, I felt it required to be treated in a special chapter. The following remarks, therefore, have reference to the rachitic pelvis. It will be found, however, that the methods of examination and the principles which guide one in the choice of treatment apply, with certain alterations and reserva- tions, to the other deformities. I cannot commend too warmly the subject which is now to be considered, for I know of no pathological condition which calls for greater judgment than the treatment of contracted pelvis. Diagnosis. — A suspicion of pelvic deformity is aroused by smallness of a woman's stature, by a waddling gait, and by malformation of her limbs or spine ; also, in the case of a primipara, by a pendulous abdomen and by the foetal head not being fixed at the brim at the commencement of labour, and in a multipara by a history of previous tedious and instrumental labours. But while, undoubtedly, these features are commonly associated with pelvic deformity, one must not attach too much importance to their presence or absence. Cases occur in which all these peculiarities are distinct and yet the capacity of the pelvis is little diminished and parturition is but little disturbed ; while, on the other hand, many women showing no external deformities have a pelvic malformation, and in consequence a difficult parturition. It is highly desirable, therefore, that all primigravid.e be examined during pregnancy. This is done with greatest advantage about the thirty-fifth week, when any operative treatment deemed necessary can be arranged. Should the patient's appearance or history suggest, 177 " 12 L78 OPERATIVE MIJ'WIFKliY or Bhould tin- vaginal examination indicate, any pelvic deformity, an exact measurement of the capacity of the pelvis must be made. As regards the external measurements of the pelvis there i- do difficulty. They are taken with calipers, and it does not matter in the slightest which form is employed. The routine measure- ments taken are the intercristal, interspinous, and external conjugate diameters, which measure respectively 10f, 10, and 1\ inches 26*8, 25, and 18*7 centimetres). The exact terminal points of the inter- Fig. 103. — Measuring the Intercristal Diameter of the Pelvis. spinous diameter are easily defined — viz., the anterior superior spinous processes. With the intercristal diameter it is rather different. The terminal points of that diameter are the widest points on the crests. But the crest is a bony ridge of some thickness, and it makes a con- siderable difference if one measures from the outside or the inside of the ridge. Personally, I always measure from the middle, getting my thumb and middle finger on the inside and outside edge respectively of the bony ridge (Fig. 103). The' external conjugate, known as Baudelocque's diameter (Fig. 104) DIAGNOSIS OF CONTRACTED PELVIS 17!) — the distance between a point immediately below the projecting spine of the last lumbar vertebra and the symphysis pubis — is less easily determined because of the difficulty in marking off the posterior point. In certain individuals, however, the difficulty may be got over by taking the superior angle of a small rhomboid found often at the lower part of the vertebral column, and known as Michaelis' rhomboid (Fig. 105). This latter point very nearly corresponds to the point desired. There Fig. 104. — Measuring the External Conjugate, or Conjugate of Baudelocque. is, however, no very constant relationship between the external con- jugate and the internal or true conjugate of the brim, although, on an average, the difference is about 3 j inches (8*7 centimetres). Pelvic deformity should, however, always be suspected if it measures 7 inches (17*5 centimetres) or under. Lastly, the transverse diameter of the outlet (Fig. 106) — the distance between the ischial tuberosities — should be taken in all cases of kyphotic or funnel-shaped pelvis. On an average it measures 4| inches (11 centimetres). L80 OPERATIVE MIDWIFERY From these external measurements one can only approximately estimate the formation of the true pelvis. If one finds all the diameters about equally diminished, a generally contracted pelvis is surmised, while if the external conjugate only is altered, a Hat pelvi- is suspected. The measurements which should bo taken in the rarer forms of pelvic deformity are referred to in the previous chapter. In order to arrive at the exact internal measurements of the pelvis, endless devices and many forms of pelvimeter have been suggested. Without exception, these instruments have proved of little practical value, although many of them have seemed from a Fig. 105. — Michaelia' Rhomboid. The uppermost angle marks the posterior limit of the external conjugate diameter. theoretical standpoint most ingenious. One of the best is that of Skutsch (Eigs. 107 and 108), and fairly accurate measurements of both the conjugate and transverse diameters can be obtained by means of it. The conjugate diameter at the brim, or conjugata vera, is arrived at by measuring first the distance between the promontory and the anterior surface of the symphysis pubis, and then deducting from that the thickness of the symphysis (Fig. 107). The manner of measuring the transverse is explained in Figs. 103a and 108/'. But even with Skutsch's pelvimeter one cannot reckon on absolute accuracy, and it is evident that the results obtained are not satisfactory, for within the last few years new forms of pelvimeter have besn described DIAGNOSIS OF CONTRACTED PELVIS LSI by Zweifel 1 (Fig. 109) and Solowig. 2 These latter are to all intents and purposes old forms revived, and with absolute certainty will go the way of all others. From personal experience I believe Skutsch's pelvimeter is the best, although I have long ago given up attempting to measure the internal pelvic capacity with instruments. Quite a new principle characterizes the ingenious invention of Neuman and Ehrenfest. 3 The principle involved in the pelvigraph is that of parallel rulers. One arm localizes the various points within the pelvis, while the other has attached to it a dial. The various Fig. 106. — Measuring the Transverse Diameter of the Outlet. points are mapped out on a piece of paper, and the general pelvic formation in sagittal section is constructed. I understand that it has not come up to expectation. Certainly it is far too complicated for practical purposes, and this is the conclusion come to b} T Sonntag. 4 Radiography has not proved of practical value ; for although with X rays one can obtain an idea of the general pelvic formation, so far it has been impossible to make exact measurements of the pelvic diameters. i Zeit. f. Gyn., 1906, p. 763. -' Ibid., 1905, No. 24. 3 Monat.f. Geb. u. Gyn., vol. xi., p. 237. 4 Winckel, ' Lehrbuch,' Bd. ii., Teil ii., 1905, p. 1858. L82 <>l'i:i;\TlYK MIDWIFERY FlG. 107. — .Measuring the Conjugata Vera with Skutsch's Pelvimeter. First the distance between the promontory and the anterior surface of the symphysis pubis is taken, and then the distance between the posterior and anterior surface — viz., the thickness of the symphysis. The difference between these two measure- ments is naturally the true conjugate. FlG. 108«. — Pelvimetry with Skutsch's Instrument: tine Transverse Diameter of Brim. Measuring the distance between the great trochanter and the nearest point <>f the pelvic brim of the same side. DIAGNOSIS OF CONTRACTED PELVIS Is: i Owing, therefore, to the unsatisfactory results obtained by pelvi- meters, most obstetricians estimate the size of the pelvis manually. It need hardly be said that by such a method accuracy is also impossible. No doubt the skilled obstetrician, who has had an extensive experience of deformed pelves, can estimate fairly cor- rectly the pelvic capacity by means of his hand, and certainly the chances which the foetal head has of passing through, but he cannot Fig. 1086. — Pelvimetry with Skutsch's Instrument : the Transverse Diameter of Brim. Measuring the distance between the great trochanter and the most distant point of the pelvic brim of the other side. The difference between the measurements made after this and the previoxis figures is naturally the transverse diameter of the pelvic brim. tell the student, for example, nor can he put down on paper its exact measurements. The manual method most generally employed in practice is the taking of the oblique conjugate by means of the lingers (Fig. 110), and from that measurement calculating the conjugata vera. To do this the middle and forefinger of the right hand are passed into the vagina until the middle finger impinges on the promontory and the forefinger is pressed against the subpubic ligament. The forefinger of the other hand marks off the lower margin of the subpubic ligament. Both hands are then withdrawn, and the distance between the tip oi 1H-1 OPERATIVE MIDWIFERY the niidclle linger and point marked on the forefinger measured with a tape or calipers. In taking this measurement, it is hardly necessary to say that it should be done with the greatest care, it is D important that the linger be pressed against the true promontory , and not against a false one. and also that the lower margin of the Bubpubic ligament be marked off exactly. But here, again, conies a difficulty, for the difference between the oblique and true conjugate is most variable. AVe commonly reckon the true conjugate as between \ and | inch (1*2 and 1*9 centimetres) less than the oblique. But from measurements made post mortem on women whose pelves were examined during life I have frequently found this estimate of the conjugata vera entirely wrong — I have found it as far wrong as 'i inch (2 centimetres). The recent investigations of Fig. 109. — Zweilel's Pelvimeter. Sellheim 1 in this connexion are of great interest. He found that the difference between diagonal and true conjugate varied from to 8 centi- metres (0 to 1/2 inches). The older investigations of Skutsch were much the same — 0'5 centimetre to 2*9 centimetres (0*2 to 1 inch). For practical purposes, in estimating the true conjugate from the oblique, one must consider — 1. The height of the pubic symphysis. The higher it is, the more must be allowed. 2. The height of the promontory. The higher it is, the more must be allowed. 3. The angle of the pubic symphysis to the horizon. The more obtuse it is, the more must be allowed. Other methods of employing the fingers for measuring the pelvis Piamsbotham's method (Fig. Ill) is quite im- liave been suggested. 1 Zent.f. (1 !/»., 1904. p. :!4'.>. DIAGNOSIS OF CONTRACTED PELVIS 185 practicable. The passing of the whole hand into the vagina, however, and employing the closed fist or fingers, as is indicated in the illustra- Fig. 110.— Measuring the Oblique or Diagonal Conjugate. tion (Fig. 112), gives the skilled accoucheur a very good idea indeed of the general formation of the true pelvis, and I frequently make L86 OPERATIVE MIDWH'KUY use of the method. It can always be employed with success both in primipara and multipara; during labour, but only with difliculty and under anesthesia in primigravidffl. After delivery, when the abdominal wall is lax and the uterus can be pushed aside or has sunk down into the pelvis, the conjugata vera may be estimated externally by marking off with the fingers the distance between the internal surface of the symphysis pubis and the FlG. 111. — Ramsbotham's Method of measuring the Conjugata Vera. projecting promontory. Sometimes, even, by a similar manoeuvre, it can be estimated before delivery by pulling up the uterus ; but this is only possible in multipara? with lax abdominal walls, and, as a rule, only up to the thirty-second week. Ahlfeld, a few years ago, showed me wooden bars of various sizes which he employed for estimating the true conjugate externally. Calipers have also been used. All these devices are employed in the same way — one end of the bar DIAGNOSIS OF CONTRACTED PELVIS 1H7 or calipers is pressed against; the promontory and the other against the symphysis. It is perfectly evident, therefore, that neither by the hands nor by pelvimeters can one make an accurate measurement of the internal capacity of the pelvis, although with practice a fairly good idea, correct to about \ inch (0"6 centimetre), may be obtained. Generally such approximate accuracy is all that is necessary, but sometimes it is not so, as I shall have to point out later. But in contracted pelvis there is another very important factor influencing the parturition — viz., the size of the fcetal head. The fcetal head varies very much in size, but, what is perhaps of even Fir;. 112. — Johnson's Method of measuring the Conjugata Vera. greater importance, it varies very much in consistency. It is at once evident that a large or much ossified head will pass through a contracted pelvis less easily than a small and defectively ossified one. Attempts have been made to measure the fcetal head in utero (Fig. 113), but they have not proved very successful, while con- sistency is impossible to estimate until labour has advanced some way, for only then can the fontanelles and sutures be felt. Stone 1 has claimed great accuracy for his method, which consists in employing calipers applied to the head, whose position and attitude has been carefully palpated. We have, therefore, in practice to deal with a canal, the pelvis, and a hod;/ ivhich has to pass through that canal, the fcetal head, neither 1 Med. Bee, November 4, 1905. 188 OPERATIVE MIDWIFERY of which can be accurately gauged as regards size. This has been recently appreciated by Midler, Pinard, and a few others, who hav< advocated thai, after the pelvis is carefully measured, the relative Bize of the head and pelvis should be tested. Barbour stated this very succinctly when he said, ' The foetal head is the best pelvimeter.' There is here represented (Fig. 114) my method for estimating the relative size of head and pelvis. It is for the most part a combination of Mailer's and Pinard's methods slightly modified, and I believe improved. It is a bimanual method — the external hand pushes the head into the pelvis, while the internal fingers of the other estimate the relative size of pelvis and head. It may be employed with or without ana s- FlG. 113.— Cephalometer. (Ferret.) thesia, but greater accuracy is obtained if the woman is anaesthetized. The patient is placed in the ordinary position for a gynaecological examination, and the accoucheur stands at her side, facing her. The right hand seizes the head, and presses it into the superior straight. Two fingers of the left hand are passed into the vagina. These measure the consistency and manner of engagement of the head ; also, if it has not been done already, the nature and extent of the pelvic deformity. Further information, however, is obtained by utilizing the thumb, which is passed along the brim, and estimates the degree of overlapping. By this method I find the relative size of the foetal head and maternal pelvis can be very exactly estimated. There is onlv one detail which has to be watched — viz., TEEATMENT OF CONTRACTED PELVIS 189 the variety of parietal obliquity or asynclitism, which exists, or is produced by the external hand. To sum up, then, the manner in which one should approach a case of contracted pelvis is as follows : (1) The general appear- ance of the patient and the obstetric history, if she is a multipara,, is noted. (2) The external and internal pelvic capacity is carefully measured. (3) Finally, the relative size of the foetal head and the maternal pelvis is estimated. Having done all this — but not until then — one is in a position to consider the treatment. Fig. 114.— Author's Method for estimating Relative Size of Pcetal Head and Maternal Pelvis. Prognosis and Treatment. Everyone is aware that deformity of the pelvis, except it be of a slight degree, is a dangerous condition for mother and child. To give figures which would represent exactly how dangerous is quite impossible, for so much depends upon the extent of the deformity and the treatment adopted. Many times, too, the mother's and child's interests are directly opposed to one another, for the more the mother's life is considered, the greater is the child's endangered, and vice versa. Take induction of labour and Cesarean section. In the former the foetal mortality is enormous, but the maternal almost negligible ; in the latter the maternal is still considerable, but the foetal is small. 190 OPERATIVE MIDWIFERY It is not possible to consider here all the details of the treat- ment of contracted pelvis. These details will be found discussed elsewhere, chiefly in connexion with the various operations. My purpose at present is to treat the subject generally, and to point out the principles which should guide one in approaching a case of contracted pelvis and in coming to a decision regarding treat- ment. Many students and practitioners think — and they are encour to do so by the general teaching in all but a few of the modern text- books — that the treatment to be adopted in cases of contracted pelvis should be based upon the size of the conjugate diameter of the brim of the pelvis. No exception can be taken to such an attitude towards major and minor deformities, but it is an absolutely erroneous one to assume towards medium degrees of pelvic deformity, the class of deformity which is by far the most common. But, first of all, let me define these different degrees. By minor pelvic deformity I mean a conjugata vera of over 3f inches (9'3 centimetres), by major deformity where it is below 3 inches (7*5 centimetres), and by medium deformity where it is between 3| and 3 inches. In major and minor deformities the size of the pelvis alone determines the treatment, for in the latter spontaneous delivery or forceps always results in a satisfactory termination, while in the former, the major degrees of pelvic deformity, Cesarean section and craniotomy are practically the only alternatives. With medium degrees of pelvic deformity, however — that is to say, the deformities where the conjugate is from 3f to 3 inches (9'3 to 7 '5 centimetres) — it is quite otherwise, for in such cases there are several alternative treatments which have to be considered if the child is living. They are, leaving the case to Nature, version, forceps, induction of premature labour, symphysiotomy, and Cesarean section. No hard-and-fast lines can be laid down for cases of this group. Experience alone can teach one how to deal with these cases, which, more than all others, tax the obstetrician's skill and judgment. This I would say, however — it is absolutely essential to base the treatment upon the relative size of the foetal head and tin maternal pelvis, for in cases in which by pelvimetry the pelves ore tin- same sometimes one operation, sometimes another, will be found best. From 11)01 to 190<> inclusive, 1 had under my care in the Glasgow Maternity Hospital and private practice 230 cases in which the conjugata vera was 3.1 inches (8*7 centimetres) and under. Cases in which it was more than that figure are not included. TREATMENT OE CONTRACTED PELVIS UN In these cases the following are the results as regards mothers and children : Author's Cases of Contracted Pelvis 3^ Inches (8*7 Centimetres) and Under (1901-190G). Operation. Total Cases. Maternal Mortality. Immediate and Late Fcjetal mortality. > Per Cent. 30 37 100 1-8 Spontaneous delivery Forceps ... Induction of labour Craniotomy Symphysiotomy Caesarean section ... 7 76 23 63 8 53 Per Cent. 1-4 12-6 o 9-4 Spontaneous Delivery. — Naturally, up to a certain point, spon- taneous delivery gives the best results for mother and child. From that point, however, the prognosis becomes less favourable. The point, so far as I can judge, is 3 -J- inches (8*7 centimetres) for flat and 3| inches (9*3 centimetres) for generally contracted pelvis. During the last six years in the Glasgow Maternity Hospital we have had quite a number of women delivering themselves spontaneously whose pelves were of the size I mention ; but only once or twice has a full-time child been driven through a pelvis of 3 inches (7"5 centimetres). In the Queen Charlotte Hospital Report for 1905 a case is recorded of a primipara who delivered herself of a child weighing 5 pounds 12f ounces in ten hours, although she had a flat rachitic pelvis in which the C.Y. was only 2-f inches (7*1 centimetres). Peham' 2 mentions two cases. Here is an interesting table made up by Kronig for the Leipzig Klinik of Zweifel : Generally Contracted Pelvis. Flat Pelvis. C.Y. (4 10-9 cm. 'SI"). C.V.8-9-7-5cm. (:ii"-3"). C.V. 7-4 cm. and under (3" and under). C.V. 9 (31 5-S'5cm. '-3|"). C.V. S-4-7 cm. (3|"-2|"). C.V. 6*9 cm. and under (2| " and under). \ inches (8*7 centimetres) where the second stage lasts live, seven, even twelve hours, yet the children are living, and the mothers are none the worse. It is hardly necessary to repeat here that in all cases of prolonged labour the condition of both mother and foetus must be carefully watched. But another great advantage of spontaneous delivery is the low fcetal mortality. Boenninghausen gives the foetal mortality for spon- taneous delivery in generally contracted pelvis as 2-2 per cent., and for fiat rachitic pelvis 27 per cent., while in artificially terminated labours the mortality was 41 per cent, and 47 per cent., according as the pelvis was generally contracted or flat. Peham 1 gives the mortality as 3 per cent. In none of my recent cases has there been a fcetal death. Equally good results will be found in the recent reports of Queen Charlotte Hospital, London, and the Rotunda Hospital, Dublin. One naturally expects a much higher total mortality where operative interference is had recourse to ; but few, I feel convinced, are aware of how small the ftetal mortality is in suitable cases left to Nature. In medium degrees of pelvic deformity the following factors influence the passage of the head through the pelvis : (a) The extent and nature of the deformity ; (/;) the size and consistency of the head; (<■) the variety of biparietal obliquity present; (d) the posi- tion of the occiput ; (<•) the strength of the expulsive forces. I have already said sufficient regarding the degree of deformity. Without doubt it is the most important factor, although the two following have more influence than is generally admitted. It is perfectly obvious that the size and consistency of the head, being a very variable quantity, must be a factor of considerable importance, especially in cases where the deformity is on the border- line of being too much for the forces to overcome. Probably con- sistency is even more important than size, unless the latter is extreme. Personally, I have found the average weight and size of head of the children born of rachitic parents slightly higher than that of ordinary 1 ' Das enge Becken,' 1908. TREATMENT OF CONTEACTED PELVIS 193 children. Pinard 1 has remarked upon this also. The subject is fully discussed by Wilcke. 2 Of very great importance indeed in flat pelvis is the next factor, the variety of biparietal obliquity present. The posterior parietal presenta- tion is extremely unfavourable both as regards spontaneous and forceps deliveries. It is quite unnecessary to mention other writers in support of this view, for all are agreed that the posterior parietal presentation is infinitely less favourable than the anterior. One need not consider the subject again — -it is fully discussed in the previous chapter. In cases of scolio-rachitic pelvis — a variety of rachitic deformity which I have found not uncommon — the position of the occiput may influence the passage of the head through the brim, for it is at once apparent that the head will pass more readily if the occiput is directed towards the more roomy side. As regards the expulsive forces, the last important factor in- fluencing the labour, little need be said. Naturally, the stronger they are, the greater is the probability of the labour terminating spontaneously. In flat pelvis one usually finds them quite up to, and often even above, the normal, but in generally contracted pelvis of the non-rachitic variety they are not infrequently rather feeble. This has been already referred to in speaking of the expulsive forces as a cause of delay in labour. Turning now to the artificial methods of delivery in contracted pelvis, version and forceps are the only two I intend considering at present. The results from the other operations, induction of labour, symphysiotomy, craniotomy, and Csesarean section, will be considered in separate chapters. For the sake of continuity, however, I would say, in regard to symphysiotomy or pubiotomy, that my present attitude towards it is to employ it only in cases where, after two attempts with forceps, I fail to extract the child — where, in other words, I feel that a little more room in the pelvis is all that is necessaiw to permit of delivery per vias naturales. As regards induction of labour, my results have been so unsatisfactory that at present I perform this operation very seldom. Version. — Podalic version, early or late, was abandoned by us in the Glasgow Maternity Hospital some years ago, because we found the results to both mother and child were less satisfactory than when forceps was employed. So much was I impressed with the unsatisfactory results from podalic version that in presentations of the breech it has been my practice during the last few years to perform external cephalic version during pregnancy whenever that was possible, and the pelvis i Ann. de Gyn., 1898, p. 81. 2 Hegar, Beitr. Gel. u. Gyn., 1901, Bd. iv., p. 291. 13 l'.u OPERATIVE MH>\\ll'i:i;Y waa only moderately deformed. Such a procedure has this great advantage, that it permits the accoucheur testing the relative size of head and pelvis, so important a guide to treatment, and which other- wise he could not do if the presentation remained pelvic. The arguments advanced in favour of version as against forceps in flat pelvis are familiar. The most important are that the wedge- shaped head passes through more easily base first ; that the parietal bones overlap better with the after-coming than with the fore- coming head ; and that, as forceps must compress the head in the longitudinal diameter, it produces a compensatory increase in the biparietal diameter — the fcetal diameter which is engaging in the narrowest diameter of the pelvis, and which, in consequence, one wishes to remain as small as possible. Simpson usually gets the credit for having advanced the first of these three arguments in favour of version, although long before his time it was appreciated and taught. The last argument, however, was the one to which most weight was attached until Budin and Milne Murray disproved the truth of the statement. Long ago Baudelocque 1 proved by experiment that longitudinal compression of the head did not produce a compensatory increase of the biparietal diameter ; but he left the matter there, and his experi- ments were forgotten until Budin, and later Milne Murray,'- repeated them. These latter observers found that Baudelocque was correct in his observations, but they went a step farther, and found in their experiments that the compensatory increase occurred in the vertical diameter of the head, a measurement Baudelocque neglected to take. I have repeated the experiments of Budin and Murray, and have obtained similar results. Neither from practical experience nor on theoretical grounds, therefore, is version better than forceps, and this is the opinion of British obstetricians. Several obstetricians in France, (lermany, Italy, and America still favour prophylactic version. There is, however, not the same enthusiasm about the treatment now as formerly, and even those who approve of it only do so for the slighter forms of contracted pelvis. But having condemned version in general in rlat pelvis, I will make three exceptions — viz., cases of posterior parietal presentation, cases in which in scolio-rachitic pelvis the occiput is directed to the narrow side, and cases in which other complications requiring version, such as placenta prsevia, coexist. It is quite evident from what has been said why these exceptions should be admitted. 1 'A Svstem of Midwifery.' translated by Heath. 17VIU, vol. ii.. p. "-77. 2 Eilin. Med. Joum., lyss. vol. xxxiv., p. 417. TREATMENT OF CONTRACTED PELVIS 195 I have said that for many years the British school, in general, have been opposed to version. It is no small satisfaction, therefore, to find evidence that other schools are coming to a like opinion, but, be it noted, they are not coming to our opinion, because they favour forceps. Don't for a moment let us imagine that is the reason. They are opposed to version, because spontaneous delivery occurs more often than was supposed. Kronig writes as follows: 1 'Version on account of contracted pelvis, the so-called prophylactic version, cannot be recommended, for the prognosis for mother and child is less favourable than birth of the child by a head presentation.' Baisch 2 gives the results for the Tubingen Klinik, and his opinion regarding version is the same. In France neither forceps nor version is favoured by Pinard and his many followers. They hold that if spontaneous delivery does not occur, symphysiotomy should be had recourse to. The theory is quite logical — indeed, like so many other views of this great obstetrician, it is too logical. It appears to me too extreme, for there must be some cases in which the head requires just a little help through the brim, and surely this may be safely given with forceps. There is, however, another school in France which still favours version. Forceps. — Turning now to forceps, it is apparent from my table (p. 191) that the foetal mortality with it is very high — 30 per cent. It must not be forgotten, however, that I only include pelvic deformity when the vera is 3^ inches and under (8*7 to 7*5 centimetres), and that I include both the early and late mortality. But even allowing for that, the foetal mortality is greater than it should be. In recent years, however, I have improved this by giving the head a much longer time to mould. In 1909 I had no foetal death in my clinic. 3 As with spontaneous delivery, so with forceps, the results up to a certain point are quite satisfactory, the turning-point seeming to be 3\ inches. With a vera down to and including 3^ inches (8*7 centi- metres) the foetal mortality is 10 per cent., with a vera of 3| inches (8*1 centimetres) 25 per cent., with a vera of 3 inches (7"5 centimetres) 40 per cent. But apart from the foetal mortality, there is the foetal morbidity to be considered. Whenever one passes below 3i inches the foetal morbidity becomes greatly increased — in my cases by as much as four times. Indeed, indentation, severe bruising, and deep asphyxia, become comparatively common. It appears to me, therefore, that forceps should only be employed in exceptional eases when the cohjugata vera is below 3i- inches (8'7 centimetres), and seldom, if ever, when it is under 3] incites, and that the instrument should be had recourse to only 1 Op. cit., p. 100. 2 Monat.f. Geb. u. Gyn., 1905, vol. xx., p. 174. 3 'Clinical Report,' by Dr. David Shannon, Glasgow Medical Journal. March, 1910. 196 OPERATIVE MIDWIFERY when the head is well fixed at the brim and does not overlap, and only after considerable time has been given the head to mould, Finally, that only very moderate traction should be employed. The same factors influence forceps delivery as we have seen in- fluence spontaneous delivery. Posterior parietal presentations are extremely unfavourable. With few exceptions, obstetricians outside of Britain are opposed to the employment of forceps to pull the head past the obstruc- tion. They only countenance forceps after the greatest circum- ference of the head has passed the contraction. This is becoming the teaching also of a few in this country. With such a united opinion against the operation, it is at once evident that forceps, if employed at all, must be used with great caution. The promiscuous employment of the instrument for pulling the head through the brim and the use of brute force — a practice so common in this country — cannot be too strongly condemned. It is simply deplorable to see cases brought into hospital where for hours the medical attendant and his confreres have been making attempts to deliver with forceps, when such an operation should never have been contemplated. But having said so much against the employment of ill-advised force and the dragging of the child past an obstruction, the one extreme, I am not prepared to go to the other extreme and say that forceps should only be employed after the greatest circumference of the fcetal head has passed the obstruction, and never to help it past the obstruc- tion. Personally, I still practise and teach that in carefully selected cases forceps may be employed with most satisfactory results, even although the greatest circumference of the head has not passed the brim ; but the head must be fixed, and there must not be any appreciable overlapping at the brim. Besides, only one or two attempts with moderate force are to be made. If they fail, then some other treatment must be employed. For such cases axis-traction forceps is peculiarly suitable, and is much better than the ordinary double-curved instrument. It must not be forgotten, also, that in flat pelvis the Walcher position is often of great assistance. This subject, however, is referred to under Forceps Delivery in Contracted Pelvis (Chapter XXIV.). So far I have discussed the use of forceps from the standpoint of j the child — at least, the figures given had reference to foetal mortality and morbidity. I have done this purposely, because the maternal morbidity and mortality should, theoretically, be nil. As far as mortality goes, this is nearly the case. In my list there is one death, but the patient had been handled for long by a midwife before she was admitted to hospital. But what about morbidity ? Amongst the TREATMENT OF CONTRACTED PELVIS 11)7 cases of contracted pelvis which have been delivered by forceps in hospital during the last ten years, I know of three in which the uterus was ruptured in that part of the posterior wall situated over the promontory, and I know of several cases of severe bruisings and tears of the cervix and vagina. Amongst my own cases in one the cervix was extensively torn. Altogether there is a morbidity of 18 per cent. In my cases of spontaneous delivery the morbidity is nil. No doubt the morbidity in the forceps cases is due in great part to the fact that many of the patients were examined by midwives or careless practitioners before admission to hospital ; but, even allowing for that, it is too large. Let me now summarize the treatment I have sketched under the two following headings : 1. Cases in which the deformity is recognized during pregnancy. 2. Cases in which the deformity is recognized during labour. 1. Cases in which the Deformity is recognized during- Preg*- nancy. — It is of the very greatest importance to bring as many cases as possible into this group. Medical practitioners, therefore, whenever they have the opportunity, should make a point of satisfying them- selves of the pelvic capacity of all primigravidse, and of multigravidae who have had previous difficulty at their confinements. It is well that all pregnant women should appreciate this also, especially in cities such as Glasgow where pelvic deformities are common, and should go to their medical attendants during the later weeks of pregnancy. I need not enlarge upon this ; it is admitted by everyone. The accoucheur in a case of suspected deformity should measure the pelvis and estimate its capacity. He should then place the woman amongst those of slight, extreme, or moderate pelvic deformity. The exact limits of these different groups have been alread}^ given. Should the pelvis be of slight or extreme deformity, pregnancy is allowed to continue until near term. In the case of slight deformity labour is allowed to come on, as the delivery will be spontaneous, or at worst will be terminated by forceps. Should the deformity be extreme, however, preparations must be made so that the patient is prepared for either Csesarean section or craniotomy, should the child happen to be dead. If, however, the deformity of the pelvis is only moderate, a most careful examination of the relative size of the head and pelvis should be made under an anaesthetic in the thirty-fifth or thirty-sixth week of pregnancy. The object of this is to give an opportunity of judging if induction of labour should be had recourse to. If this operation is decided upon, it may be done at the time, or delayed a week to ten 198 OPERATIVE MIJAVI 1 I .l;Y days if deemed advisable. Should the case be considered unsuitable for induction of labour, pregnancy is allowed to continue. In most cases the examination will have shown the degree of disproportion between the head and pelvis, and, consequently, whether labour is likely to terminate spontaneously, with forceps, or with Cesarean section. If there is any doubt about this, it is well to examine again under an amesthetic at the very beginning of labour, for if Cesarean section is to be performed, it is undesirable that labour should be allowed to continue for any length of time. It will be observed that I have said nothing about symphysiotomy, and for the reason that I consider its place is when forceps just fails to effect delivery. When Cesarean section is deemed unnecessary, the patient must be allowed to continue in labour, and every opportunity given for spontaneous delivery. If that should fail, the accoucheur must be prepared for either forceps in the Walcher position (Fig. 155) or symphysiotomy (pubiotomy) if the child is living, and craniotomy if the child is dead. No rule can be laid down as to when one should choose Cesarean section and when one should allow labour to pursue its course ; only experience can teach one. I have found that, with only a slight degree of overlapping, the head usually moulds sufficiently to allow of delivery^'/- vias naturales. If, however, by pushing the head into the pelvis the latter cannot be made to catch, then there will seldom be sufficient moulding to permit of easy delivery per vias naturales, and consequently the accoucheur should choose Ca-sarean section. 2. Cases in which the Deformity is recognized during Labour. — In hospital and in the poorer districts of cities a large number of cases belong to this group. Here, again, the exact amount of deformity should be estimated, for in cases of extreme and slight deformity it will always guide one to the right treatment. Any difficulty in deciding will again be found amongst those cases in which the pelvis is only moderately deformed. But I have said enough on this subject. There is only one other point. A first labour is a trial labour, so with moderate pelvic deformity it is well to give nature every possible chance. One takes a great many risks for the child. Induction of labour and pubiotonry are seldom suitable operations, while, naturally, craniotomy is relatively more often necessary. In cases which come under one's care during labour, two other factors influence one's decision regarding treatment — viz., the time labour has been in progress, and the possibility of any infection of the parturient canal having occurred. The longer labour is in progress, TREATMENT OF CONTRACTED PELVIS V.)U the less is one inclined to risk the mother's life by such a major operation as Cesarean section. The same applies to cases in, which Fig. 115.— The Walcker Position. there is a possibility that infecting organisms have been introduced, as when the woman has been examined by a dirty midwife or careless practitioner. 200 <>ri:i: \tivk midwifes? As I have described it, the treatment of contracted pelvis is simplicity itself. It is the course I have followed in hospital and private practice for many years, and it has given me great satis- faction. The only results which have not pleased me have been those from forceps ; but during the last few years, since 1 have insisted that my assistants must never employ forceps unless they are absolutely sure that interference is indicated, and that they must give the second stage endless time, my results have been infinitely better. There should be no maternal nor foetal mortality beyond an occasional one, which no one can prevent. Such an ideal state of matters has almost been reached in maternity hospitals in cases which have not been interfered with prior to their admission. CHAPTER XIII DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Continued Abnormalities in the Soft Parts : Cervix— Vagina— Perineum. Pathological conditions of the cervical and vaginal canals are com- paratively rare. Doubtless their resistance to dilatation varies greatly, and imperceptibly influences the course of labour, but gross abnor- malities which one can appreciate are not common. Taking the cervical canal first, the commonest causes of dystocia are rigidity, stenosis, and atresia. Rigidity. — It is very general to classify rigidity of the cervix as follows : „ _ . f (a) Inflammatory. 1. Organic. -, /1A XT ,, & I. (o) New growths. _ t, .. ,('(«) Spasmodic (trismus uteri). 2. Functional - )' n L ... ,. . ( (b) Constitutional. The classification, on the whole, is good, although I am inclined to take exception to the group termed 'constitutional,' as will be seen later. One would expect that inflammatory affections of the cervix, which are often associated with great thickening and elongation of the canal, might readily cause rigidity and retard dilatation, yet in practice it is surprising how hypertrophied and elongated cervices yield. Even hard cicatrices soften to a wonderful extent during pregnancy and parturition. As far as my experience goes, the only interference called for has been pressing the lips of the cervix back over the presenting part, or making slight incisions into them. I have never required to amputate a hypertrophied cervix, but if necessary, I see no objection to doing it during labour. Even Cesarean section has been performed for this condition, as, for example, in the cases recorded by Ribemont-Dessaignes 1 and Rudaux. 2 Hansson 3 recom- 1 Anal de Gyn., 1905, p. 121. 2 Ibid., p. 124. 3 ' Festschrift,' Otto Engstrom, Berlin, 1903. 201 2o-J OPERATIVE MIDWIFERY mends the .imputation of the hypertrophied cervix daring pregnancy, and gives three cases; the pregnancy was interrupted in one, but in the oilier two continued undisturbed. Potocki 1 has also recorded a case which proved successful, and in which the pregnancy was not disturbed. It is interesting to know that this operation on the gravid uterus, in common with so many others, can be performed without the pregnancy being interfered with. I question, however, if such treatment is indicated, for it is surprising how the cervix yields, and, at the worst, the operation could be performed during labour. A very troublesome rigidity occasionally follows the use of caustics and the amputation of the cervix. Boissard and Coudert-and Pinard, Segond, and Couvelare 3 have described cases. In such if, after a reasonable amount of time, dilatation does not occur, then forcible stretching, or, better still, deep incisions of the cervix, become neces- sary. Indeed, Cesarean section may even be necessary, as in the case recorded by Studdiford. 4 The two other forms of rigidity, described as functional, are the most common. The spasmodic, which in its most marked form is known as ' trismus uteri,' is found in nervous primiparje often when there has been premature rupture of the membranes, or as the result of some reflex irritation — for example, overdistension of bowel or bladder. It occurs especially during the early stages of dilatation. No operative treatment is necessaiy, and manual dilatation, unless the patient is anaesthetized, only aggravates the condition. Any reflex irritation should be removed, and a full dose of opium given. I prefer Battley's solution (liquor opii sedativus) given by the mouth, but tincture of opium, by mouth or rectum, or a morphia suppository, may be sub- stituted. Chloral may also be employed, and often acts very well, although, in my experience, not so well as opium. Hot douches also often relieve this form of rigidity. The application of cocaine to the cervix sometimes acts well. The cervical surface may be painted over with a 10 per cent, solution of the chloride, or, better still, a plug of gauze soaked in 7 per cent, solution of the chloride may be inserted into the vagina. The injection of a '■> per cent, solution directly into the cervix by means of a long needle has also been recommended. I have never employed extract of belladonna as a substitute. But there is another form of rigidity very occasionally encountered which yields to no treatment. Cocaine maybe applied locally, opium, chloral, or any other drug may be administered internally, hot douches 1 Annul . dc (li/n., December, 1906, p. 709. - L'Obstetriqiu , January, 1004. 3 Annul, (h (iiju., December. lUUi'i. p. 70."i. 4 Amer. Journ. Obat., September, 1909. RIGIDITY OF THE CERVIX 203 and baths may be given, without producing the slightest effect upon the cervix. To this form the name of ' constitutional rigidity' is generally given. The term has always appeared to me a misnomer, as I do not believe it is functional, but rather the result of some pathological con- dition of the cervix. It is not peculiar to old primiparae, as is some- times stated ; indeed, the worst cases I have seen were in primiparae of little over twenty-five years of age. Nor is it found associated with any particular habit. The delay in dilatation in this form is some- times extreme. In one case recently seen the patient was four days in labour, with strong uterine contractions coming on every ten minutes ; finally, the labour had to be terminated by making incisions into the cervix. In such cases no medicinal treatment does any good. A sufficient time having been given, incisions or forcible dilatation of the cervix with the hands or a dilator, or, better still, the introduction of a hydrostatic bag, are the only means at one's disposal, and in such cases I would advise against too long delay. If the patient's tempera- ture or pulse begins to rise, or if the fcetal heart becomes affected, interfere immediately. Personally, in such cases I believe incisions are better than forcible dilatation. Both methods of treatment are discussed under Accouchement Force (Chapter XXVIII.). (Edema. — A very simple form of obstruction connected with the cervix is oedema of the anterior lip, which is produced by pressure of the lip between the presenting head and symphysis. I have occasion- ally seen a swelling as large as a Tangerine orange result. It is very seldom necessary to puncture the cedematous lip, for it is nearly always possible to push it back over the head. It very seldom fails if carried out during a uterine contraction, and if two fingers are employed. An acute cedema of the cervix and surrounding parts has been occasionally referred to. Geyl 1 considered the subject very fully, and Jolly 2 has discussed it recently. It is a condition which was first described by Gueniot. It generally occurs in pregnancy and in those cases where a prolapse of the uterus existed. A case of the kind was admitted to my ward recently. The woman had reached term. Shortly after some slight straining effort an enormous cedematous condition of the cervix developed. The swelling was the size of a Jaffa orange, and projected from the vulva. In a couple of days it had almost entirely disappeared, and she gave birth to a normal- sized child with- out an operative interference. An interesting case is described by Seitz 3 where the condition appears to have been produced by obstinate constipation. Sometimes an oedema affecting the whole cervix follows 1 Volkmann's Samml. Klin. Vortrage, 189-3, No. 128. - Zeit.f. Geb. u. Gyn., Bd. hi., Heft 3. 3 Zent.f. Gyn., 190,1, p. 289. 204 OPERATIVE MlhWIEKEY a prolonged labour. Especially 7 is this seen in cases of contracted pelvis. (Edema, which so often affects pregnant women, may occasionally be specially pronounced in the parts about the vulva, more par- ticularly the labia. Such a condition may occasionally interfere with parturition. If pressure does not remove it, multiple punctures should be made. New growths of the cervix are rarely found complicating labour, and practically the only two varieties met are myomata and carcino- mata. The whole subject of tumours complicating labour is con- sidered elsewhere. An extremely rare occurrence is hsematoma of the cervix. Barnes 1 describes a case in which he mistook such a tumour for an inverted uterus. The subject of hematoma is considered later in this chapter. Atresia. — Atresia of the whole cervix complicating labour must be extremely rare. Adhesion of the membranes to the lower part of the uterus, preventing dilatation of the internal os, is probably the commonest cause of atresia. In passing, let me remark that this condition has often appeared to me to be a cause of rupture of the membranes before or early in labour. Atresia of the external os (conglutinatio orificii externi) is not uncommon, and several cases have occurred in the Glasgow Maternity Hospital. In the simpler forms only the mucous membrane is agglutinated, although in some cases fibrous tissue is actually found present. The cause must, of course, have been some slight inflam- matory mischief during the pregnancy, although, as a rule, no history of such a condition can be elicited. Usually one can make out a slight dimple, which indicates the position of the os, but sometimes no trace of the latter can be detected. The obstruction may be so slight that the uterine contractions overcome the obstruction ; on the other hand, it may be so persis- tent that the thinned-out vaginal portion may be carried away by the presenting part. The condition is readily recognized if a careful examination is made. If, however, the examination is made casually, the thinned-out cervix may be overlooked, and, the landmarks of the head being so distinctly felt through the thinned cervix, the condition may be taken for a full dilatation of the os. Not very long ago a case was reported where this mistake was made, and forceps were applied, with great laceration to the vaginal vault, followed by the death of the patient. A colleague informed me that he was about to introduce the blades of the forceps in a case of the kind, when, finding that he could not feel the lips of the os, he made a more careful examination and 1 ' Obstetric Operations,' p. 472. ATRESIA OF THE CERVIX 205 discovered that the os was not dilated. In such cases one can trace the smooth vaginal surface over the head, and the fingers become arrested in the fornices. In treating this condition, all that is necessary is to make a crucial incision, and I prefer to do this after labour has been in progress and during a uterine contraction, when the part is on the stretch. If recognized during pregnancy, it is better not to interfere. It is sometimes not even necessary to make incisions ; the tips of the fingers or the point of a dilator is sufficient to remove the obstruction, after Fig. 116. — The Anterior Lip of the Cervix, very much thinned out, with the Os Externum but little dilated high up in the Posterior Fornix. which Nature completes the dilatation herself. It is surprising in these cases where incisions are made that there should be so little tearing of the cervix. In several cases I have carefully examined the cervix after delivery, and found wonderfully little laceration. Of course, if extensive tearing does result, the laceration must be carefully stitched. A condition somewhat similar is where the anterior lip becomes very thinned out, and where at first no os can be detected. On more careful examination it is found away up behind (Fig. 116). This condition is sometimes referred to as a backward displacement of the 206 OPERATIVE MIDWIFERY os, but the expression is incorrect, for it is really an undue stretch- ing of the anterior wall. A corresponding condition of the posterior wall with the os high up in front I have never seen ; it is, however, described. I'pon three occasions I have observed a cervix in which there was neither rigidity nor atresia of the os, and yet the cervix would not dilate. The curious feature in such cases (the women were all primi- gravidse) was that the os could be stretched with the greatest i It felt as if there was a circular thread preventing dilatation. It appeared to me like the open mouth of a muslin bag drawn in by a. tine thread ; break the thread, and the bag can be immediately opened. I was interested to find that Yon Bardeleben 1 refers to two similar cases where the os, from being very small, was dilated by the finger ' wie eine Irisblende ' in two and one and a half minutes respectively. Vaginal and Vulvar Obstruction. — Obstruction in the vagina is less common than obstruction in connexion with the cervix. Occasionally rigidity of the canal is encountered — more commonly, it is said, in old primiparze, but I have found it not infrequently an individual peculiarity, and quite independent of the age of the par- turient. A localized atresia, and still more a stenosis, is very rare. I have occasionally encountered the former where there had been severe laceration at a previous confinement; and I had in my hospital practice a case where there was only a small opening through a diaphragm situated about the junction of the middle and upper thirds of the vagina. Sometimes, as in a case reported by Heywood Smith, 2 no opening can be discovered, although a small opening must, of course, have existed prior to conception. Cicatrices and adhesions between the anterior and posterior walls of the vagina occasionally result from the application of caustic-, from the specific fevers, more especially diphtheria and scarlet fever, and syphilitic affections, and from previous injuries. Fournier 3 and Alontini 4 record cases of extreme vaginal obstruction following vesical fistula ; in both hysterectomy was necessary. Neugebauer 5 gives very complete summaries of the cases recorded to date. In a few the obstruction was congenital, and in them the atresia was very localized. i Archiv f. Gijn., 1905, Bd. lxxvi., Heft 1, p. 159. - Obstet. Trans., vol. xxiii., p. 117. 3 L'Obstetrique, 1904, No. 2. 4 'La Ginecologia,' Kef. Joitm. Obstet. and Qyn, Brit. Empire, April, 1906, p. 291. ■ " Zur Lehre von den angeborenen und erworbenen Verwachsungen und Verengerungen der Scheide,' Berlin, 1895. STENOSIS OF THE VAGINA 207 Some time ago I saw a case in consultation where a band obstructed labour. It proved to be the remains of the vaginal septum of a uterus didelphys. The foetal head had passed through the septum, but further progress was arrested by the shoulders being caught by it. After division of the band, delivery of the child was easily accom- plished. Similar cases have been recorded by Budin, Jacobs, and others. It sometimes happens that the hymen is not lacerated during intercourse, and remains more or less intact and obstructs the escape of the child. In one or two cases the hymen has been completely imperforate, the small opening which previously existed having become closed during pregnancy. Hard-and-fast rules cannot be laid down as regards treatment. In most cases cicatrices yield sufficiently, and, consequently, it is not advisable to interfere during pregnancy. When they are very exten- sive, or when bands or a diaphragm exist, incisions may be necessary. If the obstruction is very localized, incisions may be easily and safely made; but if extensive, and especially if cicatricial, they must be made very cautiously, and with due regard to the danger of injuring bladder or rectum. The incisions may be made on either the anterior or posterior walls, but those on the anterior must not be deep. Those on the posterior wall may be made much deeper, and it is well to pass two fingers high up into the rectum and cut to the side, in order to avoid the bladder and rectum as far as possible. Speaking generally, one should delay making incisions until the obstructing band or diaphragm is put on the stretch by the presenting part. As I have said already, it is surprising how even extensive cicatrices yield. Where the obstruction is so extreme as to render the extraction of the child impossible without extensive tearing occurring, Cesarean section is the only alternative, as in Fournier's case already referred to. Where the hymen remains intact, incisions must be made, after which it will often be found necessary to deliver the child with forceps. The most common site of obstruction in the soft parts, at least of primiparae, is the perineum and vulvar orifice. Where this is due to special development of the muscles of the pelvic floor, the obstruction is readily removed by opium or disappears under chloroform anaes- thesia, for it is only spasmodic rigidit}^. Where, however, the tissues are at fault, nothing is of any service. Fomenting the perineum by the application of hot cloths I have not found do any good. Indeed, I sometimes think it does harm, and renders the tissues more liable to tear. Nor do I think that manual dilatation of the vulvar orifice, although a method of great antiquity, is desirable or of any great service. As much time as possible should be given the head to 208 <>ri:i;\Ti\K midyvifkiiy distend the perineum. But if that is insufficient, a lateral incision of the perineum should he made (episiotomy). In some few cases I have seen the other extreme of the perineum relaxing too much and sagging, with the result that the head is not directed upwards round the symphysis. The trouble in such cases is at the vulvar orifice, which does not sufficiently dilate. ' Central ' perineal laceration is liable to occur. In such cases, if pressure on the FlG. 117. — Small Cyst of Vulva, which obstructed the Parturient Canal and had to be enucleated before the Child could be delivered. perineum is not sufficient, incision is the onty thing which will prevent an extensive perineal laceration. Tumours of Vagina and Vulva. — Although I have seen many cases of cysts of the vagina and vulva, and a few solid tumours of the vagina, only upon two occasions have I encountered them in pregnant women. Fig. 117 is an illustration of one case. In the other the tumour was smaller. In both the cysts were enucleated prior to the application of forceps. Solid tumours are easily shelled out, but cysts, as they have such thin walls, are more difficult to enucleate, HEMATOMA OF THE PAETUEEENT CANAL 209 and often rupture during the process. The tumours should always be removed prior to the extraction of the child. A very unfavourable condition is an abscess of the vulvar orifice, most commonly of Bartholin's glands. I have only had one case of the kind, and upon that occasion I excised the whole gland. In such cases there is a very great danger of the parturient canal being infected, as occurred upon two occasions in the Glasgow Maternity Hospital. I am not aware of any cases of dystocia from vesical calculus having occurred in the Hospital. The older writers frequently refer to it. One of the most interesting cases is recorded by Smellie, 1 where a large vesical calculus was discharged during labour. A permanent fistula followed. The subject of vesical calculus and other pathological conditions of the bladder, causing dystocia, are referred to elsewhere. The diagnosis of these different conditions is not difficult as a rule, and the determining as to whether a tumour is situated in the vaginal wall itself or in bladder or rectum should not cause much trouble. Occasionally, however, tumours situated posterior to the vaginal canal may really be intraperitoneal tumours of ovary or uterus pushed down into Douglas' pouch between vagina and rectum ; such cases are referred to in Chapter XV. Hsematoma of the Parturient Canal. All who have had an extensive experience of obstetric practice must have encountered hsematoma of the vulva as a complication of preg- nancy, labour, or the puerperium, for although not common, it occurs about once in 1,500 or 2,000 cases. But what is not fully appreciated is that sometimes the effusion of blood occurs higher up into the loose cellular tissue about the vagina and uterus, and gives rise to a con- dition serious by reason of the amount of blood effused and difficult of recognition. The extent of the effusion varies greatly, and does not always depend upon the disposition of the various layers of fascia. Certainly, if the haemorrhage occurs below the pelvic fascia, as it does in most cases, the amount will be comparatively small and localized to the vulva, lower part of the vagina, and rectum. On the other hand, if the effusion is above the pel\ic fascia, it usually remains localized to the lower part of the broad ligament and surrounds the upper part of the vagina. Occasionally, as there is no hindrance, the effusion extends up in front of uterus and bladder, as in Williams' - 1 Smellie's 'Midwifery,' McClintock, vol. ii., Case 60, p. 1000. 2 Trans. Amer. Gvn. Soc, 1904. 14 210 OPERATIVE Mll)\\Il'i:i;v case, where a fluctuating tumour appeared above the symphysis pubis, extended outwards into the broad Ligament and upwards towards the kidney. In some cases the pelvic fascia offers no harrier, and the effusion has heen found to extend from the labium up to and behind the kidney, and even over the lower anterior part of the abdomen. I hematoma of the vagina is most frequently recognized after delivery. In the seven cases which have heen under my care it has occurred twice during pregnancy, and five times it was only recognized after delivery. According to Perret, 1 in forty- three cases it happened twice during pregnancy, six times during labour, and thirty-live times during the puerperium. Of special interest is the case recorded by Sasanoff, 2 where a haematoma formed in the interval between the birth of twins. Sasanoff collected five similar cases. The general explanation given of the condition is that it results from the giving way of large varicose veins commonly found around the uterus, vagina, and vulva. That explanation, however, is ques- tioned by many, and long ago, Perret, in a case which terminated fatally, proved that it was capillary in origin by injecting first from the vein and then from the artery. Croom, 3 in recording three cases, considered the etiology of the condition, and came to the conclusion, which was practically that of Perret, that bruising and dragging on the tissue during labour resulted in tearing of the tissue and the fine capillaries. As Barnes 4 very naively puts it, ' There is a glacier-like movement of the mucous membrane upon the subjacent tissue.' It is generally stated, and one would expect that it should be so, that laborious and difficult labours favour the occurrence of hematoma. Nevertheless, in quite a number of cases those conditions have not been present, and, as my own two cases and many others prove, it is not very uncommon in pregnancy. Occasionally, in the ex- ternal variety, direct injuries, resulting from blows, falls, etc., may produce it. As regards the other variety, the subperitoneal ha?matoma, Williams, who recently described the case already referred to and analysed the records of thirty-three others collected from the literature, found the following conditions : In 63 per cent, the women were pregnant for the first time, and in NO per cent, the labour was spontaneous ; the weight of the children was somewhat below the normal. The symptoms of hematoma are severe pain of a tearing character and, in the superficial variety, bearing down and tenesmus of the 1 Tarnier and Budin, ' Train' d' Accouchement,' vol. iii. - Annal.de Ghyn., December, 1884. 3 Ef Vulva. (Author's Case.) One end of the piece of gauze Bhofl o has been pushed iuto the vagina. years ago (Fig. 118) ; the ha-matoma became infected, and the whole perineal body sloughing, a large suppurating cavity formed, into which the bowel and vagina opened. The treatment which has been sketched is that which has been generally recommended for many years. I am inclined to agree with HEMATOMA OF THE PARTURIENT CANAL 218 Walthard, 1 however, that we might now in many cases go a step farther and treat the condition surgically, without waiting for indications such as haemorrhage and suppuration — at least, in the cases which develop during or after delivery. The subperitoneal hematoma of an extensive nature is upon quite another footing. Expectancy in this variety may be fatal, and, indeed, in past years, often has been. The sac must be opened from the abdomen, the fluid and coagulated blood cleared out, and the cavity packed with gauze. The alternative of attacking the effusion from the vagina is less favoured, although there is no doubt that one obtains better drainage by such a route ; it should be adopted in those cases where the effusion involves chiefly the tissues of the pelvis. The case recorded by Walthard illustrates this. 1 Zent. f. Gyn., 1905, p. 919. CHAPTER XIV DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Contin Carcinoma of the Cervix. Another variety of tumour which is occasionally found complicating pregnancy or causing dystocia is carcinoma of the cervix. The complication is a rare one. In the Glasgow Maternity Hospital the frequency has been about 1 in 2,000. Sarwey puts the frequency at 1 in 2,000, and Glochner, for Zweifel's Klinik in Leipzig, at 1 in 1,500. The reasons for its comparative rarity are obvious. Carcinoma of the cervix, although not peculiar to the later years of reproductive life, more commonly appears then. Again, the growth itself, and the •harge which so frequently accompanies the disease when advanced, to some extent acts as a barrier to pregnancy, although I do not believe the disease in the early stages prevents conception. I know no one who supports the old view of Cohnstein 1 that the growth favours the occurrence of pregnancy. As regards the influence of pregnancy upon the tumour, and. vice versa, of the tumour on the pregnancy, only a word or two is necessary. Most authorities teach that the growth advances more rapidly in the gravid than in the non-gravid uterus. Recently, however, Pinard took exception to this view.- Personally, I have only one case to judge by — a woman with an inoperable carcinoma whom I watched during the last few months of her pregnancy. In her case I was not struck by any rapid increase of the tumour during that time. On the face of it, one would expect the disease to advance more rapidly if the uterus were gravid, for the parts are more vascular and the cellular tissue is looser. However, it is not a matter of very great importance, for it does not in any way affect the treatment. 1 Archiv f. Gyn.. Bd. v.. p. 336. 2 Annal. dc Gyn.. 1901. p. 309. 214 CAKCINOMA OF THE CERVIX -215 Most modern writers, including Bar 1 and Condamin 2 agree with the older statement of Cohnstein that the presence of malignant disease of the cervix predisposes to abortion ; not only so, but that the mortality amongst foetuses which have reached, or nearly reached, term is unusually high, according to Theilhaber as high as 47 per cent. My experience is one dead fcetus in five, and my colleague's results have been equally good, so that I cannot agree with Theilhaber. I cannot, however, go to the other extreme, as some have done, and say that the disease does not predispose to abortion or death of the fcetus. for it is inconceivable that the disease has no effect on these occurrences. But if. as almost all admit, the presence of carcinoma of the cervix affects pregnancy but little, there is not the least doubt that in many cases it influences labour very adversely. Naturally, the cases most affected are those in which the disease is far advanced, for then the dangers most dreaded — hemorrhage, rupture of the uterus, and septic infection — are liable to occur. The diagnosis of carcinoma cervicis (Fig. 119) seldom presents greater difficulty in the gravid than in the non-gravid. In both it is easy of recognition when at all advanced, and very difficult when the disaase is still at an early stage. The only reliable test is a care- ful microscopic examination of the cervical tissue. There is one point of great importance, however. The healthy cervix always becomes much softened during pregnancy, but the carcinomatous tissue does not altogether share in the softening. Consequently, the presence of any hard tissue in the cervix of a woman advanced in pregnancy, or in labour, should always arrest attention, and one should test its friability, either with the fingers or curette, and remove a small portion of the tissue. In a case recently placed under my care the medical practitioner who sent the patient to me correctly diagnosed the condition by the hardness of the cervix. This and the hemorrhage on touching the cervix were the only symptoms. As in carcinoma cervicis generally, the most difficult cases to diagnose are those in which the disease has originated in the cervical canal. In most of these, however, the disease is so far advanced that there is an ulcerated surface, and so the diagnosis is evident. Hemorrhage, if the disease has advanced to any extent, is always a symptom, and must never be neglected. No matter how slight the hemorrhage may be, its cause must always be searched for, because during pregnancy there should be absolutely no sanguineous dis- charge, and at the commencement of labour it should be very slight. Several writers have mentioned the frequency of pain and the early 1 These, Paris, 1889. - Annal. de Gyn., March, 1905, p. 129. 216 OPERATIVE MIDWIFERY appearance of it in the course of the disease ; in my five cases it was not a feature. A point of great interest, and one which, as far as J can gather from the literature of the suhject, has not been emphasized, is that Fig. 119. — Carcinoma Oervicis. (Author's Collection.) Child extracted l>y Cesarean section, ami uterus removed per vaginam. the proportion of operable cases amongst the gravid is much greater than amongst the non-gravid. The terms ' operable ' and ' inoperable ' as applied to carcinoma of the cervix, are presumably well understood. The former implies that the operator considers it possible to remove CARCINOMA OF THE CERVIX 217 the uterus and tumour, and the latter that he considers it impossible, or at least injudicious, to attempt it, because the disease has advanced too far. Naturally different operators hold different views as to when a case is operable and when inoperable. This is not the place to discuss this important question of * operability ' in carcinoma of the cervix. All I wish to point out is that, no matter upon what ground one bases one's decision as to whether a case is operable or not, it will be found that there are more operable cases amongst the pregnant than amongst the non- pregnant. Such a state of matters is highly satisfactory, and, if one thinks of it, it is not surprising. Advanced carcinoma must be a hindrance to conception, and, consequently, one encounters it in the pregnant •comparatively seldom. More important, however, than that is the fact that, if a woman the subject of carcinoma becomes pregnant, the haemorrhage causes her to seek advice early, for she is well aware of the danger of haemorrhage in pregnancy. Lastly, there is the labour which she is bound to go through, and which compels her to submit to a vaginal examination, and this gives her medical attendant the opportunity of recognizing any tumour. In discussing the treatment of carcinoma of the cervix in the pregnant or parturient, we shall first consider those cases in which the •disease is not too far advanced for removal, and later those where the •disease is inoperable. Cases of Carcinoma of the Cervix complicating' Pregnancy and Labour in which the Disease is not too far advanced for Removal. One would think that it would be admitted by all that whenever a carcinoma of the cervix is recognized, be it early or late in pregnancy, the uterus should be at once removed. Yet there are a few French obstetricians — Pinard, 1 the late Varnier, Bouilly, and others — who question the advisability of immediate operation in the later months of pregnancy, and advocate instead delaying the operation in the interests of the child. Such an attitude towards operable carcinoma •cervicis in pregnancy has been generally condemned, and by none more strongly than by Pinard's own countrymen, R. and A. Con- damin 2 and Pollosson. 3 Almost all are agreed, then, that the condition must be dealt with immediately it is recognized, and most approve of removing the 1 Annul cle Gyn., 1901. 2 Ibid., March, 1905, p. 129. :5 Ibid., August, 1905, p. 479. 218 OPERATH B MIDYVI l-Kl;Y diseased uterus along with the ovaries. The induction of premature labour or, if the pregnancy has only advanced to the earlier weeks, the induction of abortion prior to removing the uterus has nothing in its Favour. By adopting such a course one adds to the subsequent danger of the hysterectomy, which must ultimately be undertaken, all the immediate dangers of septic infection following the emptying of the uterus. In addition, all operators, with only one exception, as far as I am aware, recommend the removal of the whole uterus. The exception is Spencer. 1 The cases of Spencer are certainly interesting, but all operators who have lived through the time when high amputation of the cervix was practised could give similar experiences, if not in connexion with carcinoma of the gravid uterus, at least in connexion with the non-gravid. Would not an equally good result have followed hysterectomy in these cases? Spencer's answer is that it has not done so in the past, and he mentions how few permanent cures have followed ; indeed, he was able to find only two cases. E. and A. Con- damin, however, have collected quite a number of cases operated upon in pregnancy, eight of them late in pregnancy or after labour, and to which the term ' cure ' may be rightly applied, for it is four or more years since the operation ; besides, they mention several in which there is a good prospect of the cure being permanent. It appears to me unfortunate at this juncture, when the whole tendency is to favour radical measures in dealing with carcinoma, that this old treatment of high amputation should be revived. Without doubt, occasional successes will follow such treatment, but how is one to decide in a particular case when it should be employed and when hysterectomy is necessary? With our present knowledge of carcinoma of the cervix, be it in the pregnant or the non-pregnant, the only course is to remove the uterus and cellular tissue as early as possible, and to err rather on the side of operating too often. Whenever there is the least prospect of removing the uterus and tumour, an attempt should be made to do so, for, without doubt, occasional permanent cures follow even in apparently hopeless cases. In dealing with carcinoma of the cervix in the pregnant or par- turient, if one were to judge by current literature, the vaginal route is very much in favour. This is all the more striking when so many advocate the abdominal route for the condition in the non-gravid. The explanation, however, is simple. In recent years, since it has come to be appreciated that the gravid uterus even of four months and the post- partum uterus at term can be removed without difficulty per vaginam, it has become, for the time being, fashionable to adopt the vaginal 1 Trans. London Obst. Sue, 1905, vol. xlvi.. p. :S.V>. CARCINOMA OF THE CERVIX 219 route. There is evidence already that a reaction has set in. Sooner or later the abdominal route will be employed for all cases, both gravid and non-gravid. In the early months of pregnancy — indeed, up to about the end of the fourth — the ovum and uterus may be removed per vaginam entire. If the pregnancy has advanced beyond the fourth month, the uterus must first be emptied if it is to be removed by the vagina. Vaginal Cesarean section, followed by vaginal hysterectomy, is not to my mind a wise procedure. I believe the abdominal route is the best. In operable cases where the pregnancy has advanced beyond the early months or the patient is in labour, the following are the alterna- tive procedures. They indicate the evolution of operative treatment for this condition, and consequently I consider them in detail. (1) Cesarean section followed by supravaginal amputation of the uterus, with subsequent removal of the vaginal stump per vaginam. (2) Cesarean section, ligation and division of the ovarian and uterine vessels and other connexions, with removal of the whole uterus per vaginam. (3) Vaginal Cesarean section followed by vaginal hysterec- tomy. (4) Csesarean section followed by abdominal hysterectomy. Naturally, in all cases prior to proceeding to the removal of the uterus, the malignant mass is thoroughly scraped and the vagina disinfected. (1) Csesarean Section followed by Supravaginal Amputation of the Uterus, with Subsequent Removal of the Vaginal Stump per Vaginam. — This method was recommended by Zweifel. It possesses all the advantages of the abdominal route, and at the same time removes any risk of septic infection, as there is no dragging of the tumour through the abdomen. There is sometimes, however, some difficulty in removing the stump per vaginam if the disease has destroyed the cervix, and so the method is not much favoured. The same operation, only performed the reverse way — namely, the removal of the cervix per vaginam, and then attacking the uterus from the abdomen — has also been sometimes employed. It, however, possesses even greater disadvantages. Although I adopted the latter variation in one case, I do not favour either. (2) Csesarean Section, Lig-ation and Division of the Ovarian and Uterine Vessels and Other Connexions, with Removal of the Whole Uterus per Vaginam. — This method is specially associated with the name of Olshausen. It was devised with the object of getting over the danger of bringing up the septic cervix through the abdomen. I have upon one occasion employed this method, and was very satisfied with it. The uterus was readily removed, even although in the particular case I mention the pregnancy had 220 OPERATIVE MIDWIPERI reached term. I am inclined to think, however, that the method is unnecessarily complicated as compared with the most modern method of performing the operation from the abdomen, described under Method (4). (8) Vaginal Caesarean Section followed by Vaginal Hysterec- tomy. — This is the most recent method, and is specially associated with the name of Duhrssen. Several operators in Germany, more particularly Bumm and Orthmann, favour it, but it has few supporters in other countries. In Great Britain, "Wilson 1 of Birmingham has recently recorded two cases successfully operated upon at the eighth month. Orthmann puts the mortality at 17 per cent. The method of performing vaginal Caesarean section is described in Chapter WYIII. Although I have no experience of the operation for malignant disease, I have found it useful in other conditions. Personally, I am not in favour of the method for the condition we are considering, and Wilson informs me that he has now abandoned it. (4) Caesarean Section followed by Abdominal Hysterectomy. — This is the treatment most favoured. It was employed before the other methods were devised, but the results were then very unsatis- factory. The explanation given for this was that in pulling up the septic cervix the peritoneal cavity was infected. With more careful technique — packing off the intestines, carefully clumping off the vagina, and removing a good portion of the vaginal wall along with the uterus, much better results have been obtained. In the last few- years the more extensive Wertheim operation has been employed and recommended. An interesting contribution to this subject was recently made by Cuthbert Lockyer. 2 He points out how easity the uterus can be removed owing to the looseness of the connective tissue. Cases in which the Disease is too far advanced for Removal. Naturally, the treatment to be adopted in this class of case will depend upon how far pregnancy has advanced. When the disease is discovered in the early months, the child is the one to be considered ; the mother's sufferings must be relieved, but the pregnancy allowed to continue. It may be urged that this is some- times rather cruel to the woman, and I quite agree, so that had I a case in which I believed the woman's sufferings were extreme, and that they could only be relieved by emptying the uterus, I would do so. In none of our cases in hospital, however, has this been necessary. In none did the mothers suffer unduly during pregnancy, and in all they carried the child to near term, and were operated upon as I shall describe. 1 Lond. Obst. Trans., vol. xlvi., p. 378. - Brit. Med. Journ., October 9. 1909. CARCINOMA OF THE CERVIX 221 When it comes to the time, either at term or earlier, when it is deemed necessary to empty the uterus, the best method to pursue is to do Cesarean section and then perform supravaginal hysterectomy. Hysterectomy is performed because of the danger of the puerperal uterus being infected from the septic cervix. It is thus evident that it is a distinct advantage to operate before labour has commenced, while the cervix is still closed. The stump, after removal of the uterus, may be treated either intra- or extra-peritoneally. Few recommend the latter, although Spencer in this country and Fehling in Germany do so. The object in treating the stump extraperitoneally is to shut off the cervical canal from the abdominal cavity. In the cases operated upon in the Glasgow Maternity Hospital the cervical stumps were treated intraperitoneally. The women were delivered of living children, and recovered without any complications. The} 7 died five to seven months later. In the cases which come under one's notice for the first time during labour, the malignant mass should not be scraped and cauterized as is the general procedure in operating upon the non- gravid. The uterus should be removed by supravaginal amputation. As an alternative to such treatment, the labour may be allowed to pursue its natural course. The dangers of so doing are severe haemorrhage, rupture of uterus, and sepsis. Examples of each of these complications will be found recorded. It must be admitted, however, that a very large proportion of the cases escape the com- plications mentioned. Before leaving the subject I would just say that inoperable cases should always be examined a week or ten days after delivery. One or two writers have referred to the fact that these growths often assume a more hopeful appearance as the uterus diminishes in size. CHAPTEB XV DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Continued Tumours of the Ovary. Tumours of the ovary are such a common occurrence that it is not to be wondered at that they should be encountered now and again in the pregnant and parturient. My records show a frequency of about 1 in 1,500. It must be remembered, however, that those engaged as specialists have many more opportunities for encountering the com- plication than the general practitioner, so that statistics based on hospital records or the private practice of obstetric specialists give no correct idea of the frequency of the complication. All the different varieties of ovarian growths may be found. In the 862 cases collected by McKerron 1 the following were found : Simple and multilocular cysts (a few papillomatous) ... 594=68 per cent. Dermoids ... ... ... ... ... 204=28 ,, Fibromata or solid adenomata ... ... ... 19= 2 ,,. Malignant (carcinomatous or sarcomatous) ... ... 45= 5 862 Spencer 2 made an important contribution to the subject last year, and Marshall's 3 recently published paper contains many interesting cases and a very full bibliography. The tumours are of all shapes and sizes, but in a very large proportion of cases they are small, and occupy the pelvic cavity. There seems to be some difference of opinion as to whether or not ovarian tumours increase in size during pregnancy. Olshausen and Schauta believe they do, but Lohlein and Williams have denied this. I can give no personal experience, as I have never had cases under observation before and during pregnancy. I have always removed the tumour whenever I have recognized it. 1 • I'regnancy, Labour, and Childbed, with Ovarian Tumours,' 1903. 2 Surgery, Gynecology and Obstetrics, May, 1909. 3 Journ. Obst. and Gyn. Brit. Empire, February, 1910. 222 TUMOURS OF THE OVARY 223 Pregnancy associated with ovarian tumours is usually but little disturbed : and if any discomforts arise, they are, as a rule, of so slight a nature as to escape recognition altogether, both the patient and doctor attributing them to the ordinary disturbances of pregnancy. In only five of my eighteen cases was the condition appreciated during pregnancy. McKerron writes of the cases which come under observation : ' In over 80 per cent, no suspicion of its existence was entertained till its presence was revealed by vaginal examination in the course of delivery.' Occasionally, during pregnancy, some pain is complained of, and not infrequently disturbance of urination. This latter symptom was markedly present in a case of sacculation of the gravid uterus caused by a broad ligament cyst, fully detailed on p. 285. Again, reflex phenomena, such as morning sickness, are sometimes very much exaggerated, as I saw in a case of lateral flexion of the gravid uterus caused by a small dermoid. It occasionally happens that the great size of the abdomen, especially if it does not correspond to the age of the pregnancy, causes disturbance in the respiratory and circulatory systems, and arrests attention ; but these symptoms are much more frequent with myomata. Should, however, any of the accidents to which ovarian tumours are liable occur, attention is at once directed to the abdomen, and there is every chance of the condition being recognized. The most common accidents are rupture, torsion of the pedicle, incarceration, suppuration, and necrosis. I have not seen torsion of the pedicle during pregnancy, but in two of my cases it occurred immediately after delivery. McKerron states that in his collected cases it occurred in 12 per cent, during pregnancy, and in as many as 20 per cent, during the puerperium. He puts the condition apart from pregnancy at 8 per cent., a figure that exactly agrees with my own experience. 1 It is therefore evident that the accident is very much more frequent in the pregnant, and especially in the puerperal, condition. I am surprised, however, that McKerron has found it so common during pregnancy. One knows that it is very common during the puerperium, but I hardly thought it was as frequent as 12 per cent, in pregnancy. The symptoms of the accident are quite distinct if the torsion is acute — sudden and severe abdominal pain, with collapse more or less profound, distension and tenderness of the abdomen, and, if the tumour is palpable, increase of its size. When the torsion is more gradual, the pain and other symptoms are less severe. 1 'Complications and Difficulties in a Series of 250 Ovariotomies/ Journ. Obst. and Gijn. Brit. Empire, September, 1909. 224 OPERATIVE MIDWIKKKY I have only once encountered rupture of a cyst associated with pregnancy — viz., when removing a dead ovum in a case of abortion. The patient complained only of a little abdominal pain, and there was a slight rise of temperature and pulse. On opening the abdomen a few days later, the collapsed cyst was removed. McKerron puts the frequency at 2*8 per cent., but the older writers put it usually at double that figure. During labour it occurs in about IB per cent. As regards suppuration, it is very rare indeed during pregnancy, and it is often a question if the pregnant condition has had anything to do with it. The more likely explanation is that the tumours become infected quite independently of the gravid state, or that the condition existed before the pregnancy. On the other hand, suppuration readily occurs in the puerperium if there is any infection of the parturient canal during parturition. Dermoid tumours are specially liable to be infected. Necrosis of the tumour is likewise not uncommon, especially during the puerperium. It results from injuries inflicted b} r pressure, as in the very striking example of the accident recorded later (p. 232). A veiy rare accident is the forcing of the tumour down between the uterus and the vagina, and the final expulsion of the tumour per rectum or per vaginam. McKerron has collected thirteen cases. Walls, 1 Sutton,- and Haultain 3 have recorded cases. In most of them the accident occurred during forcible extraction with forceps, but in one or two it occurred during spontaneous delivery. In a considerable number, especially the earlier cases, death resulted. Another accident which has occurred in a few cases is rupture of the uterus. The diagnosis of ovarian tumours in pregnancy is usually not difficult. It is e&sy when the tumour is in the pelvis (Fig. L20) and the pregnancy is not far advanced, for then one can by bi- manual palpation differentiate the enlarged uterus and the tumour. Also during labour it is not difficult, for the tumour in the pelvis can be readily felt obstructing the parturient canal. Even when pregnancy has advanced to the later months, with the tumour above the brim, it is not difficult, provided the swelling is of some size. But if, as in two cases which were under my care, the tumour is placed behind the uterus to one or other side of the vertebral column, it may be impossible to reach it. In one of these (Fig. 121) I could only feel high up above the brim an indefinite fullness. I could not, even under an anaesthetic, get any tumour between nry hands. In the other case the tumour was not recognized until after delivery. Almost invariably — and this is a feature of great importance — the 1 Brit. M<;1. Journ., February 3, 1900. -' Lancet, February 9, 1901. :1 Tbid., January, 190*2. TUMOURS OF THE OVARY 225 position of the cervix is altered, and most commonly it is displaced forwards and to one side. If the tumour is large, it may also be FlG. 120. — Ovarian Cyst entirely in the Pelvis. (Author's Collection.) This tumour was pushed out of the pelvis in the second stage of labour, and the child extracted with forceps. The tumour was removed three weeks after the confinement by abdominal section. displaced upwards, although that is a much more common feature of myomatous growths. So far I have been considering the cases where pregnancy is a certainty, but the tumour is doubtful. Before the uterus has 226 OPERATIVE Mll>\\il T.liY increased in size, it is often difficult to make sure of pregnan with the pelvic organs in a normal condition. Much more is this tin- case with an ovarian tumour above the brim. The objective symptoms Fig. 121. — Ovarian Cyst which in Part projected into the Pelvis. (Author's Oolle stion. This tumour was removed by abdominal section during labour, the child being afterwards extracted with forceps. of pregnancy, however, the changes in the hreasts and cervix, and, above all, a steady increase in the size of the uterus, are the indications ITMOURS OF THE OVARY 227 one relies upon. In this connexion, it must not be forgotten that the subjective symptom of suppression of menstruation is by no means an uncommon feature of ovarian cystomata, quite apart from pregnancy. Even with a tumour in the pelvis the differential diagnosis may sometimes be difficult. This is seen in two conditions in particular — retrodisplacement of the gravid uterus and extra-uterine pregnancy. Both may simulate or be simulated by an ordinary uterine pregnancy complicated by an ovarian cyst. It is rarely, however, that a careful consideration fails to clear matters up. The absence of the fundus in front and, if the fundus is incarcerated, as in the case of retrodisplace- ment, the difficulty of urination, make the diagnosis easy. Softness and immobility of the tumour, abdominal pain, and irregular haemor- rhages are the features most to be relied on in the case of extra- uterine pregnancy. The prognosis when pregnancy or labour is complicated by ovarian tumours is very different to-day as compared to twenty or thirty years ago. The reason for this is obvious. Removal of the tumour during pregnancy has been substituted for expectancy, and displacement or removal during labour has been substituted for dragging the child past the obstruction with forceps or by traction on its legs. It is now generally accepted that when an ovarian tumour is discovered during pregnancy it should be removed at once, and this no matter what the size, nature, and position of the tumour may be. The extremely good results following abdominal section during pregnancy justify this decided attitude. McKerron, from his analysis of 480 cases, found a maternal mortality of only 5 per cent. In many of these cases, moreover, the injury which the tumour had undergone, and the general condition of the patient at the time of the operation, were really responsible for the death. He writes : 'During the last twelve years no fewer than 299 ovarian tumours during pregnancy have been recorded. Although in many of these acute symptoms existed at the time of operation, only ten of the patients died, or a mortality of 3*3 per cent.' My own experience is in entire agreement with these figures, for on the few occasions upon which I have operated all the patients made uninterrupted recoveries. On one occasion the operation was of extreme difficulty, for the cyst was a broad-ligament one which had burrowed away down into the cellular tissue behind the rectum. But the results are most satisfactory from another standpoint— viz., pregnancy in a very considerable number of cases is not disturbed. As regards my own six cases, two were aborting at the time they were placed under my care; in the other four the 228 OPERATIVE MIDWIFERY pregnancy continued undisturbed, liven in the ease quoted in which I removed the cyst from the broad ligament in the fourth month the pregnancy continued undisturbed. Curiously enough, of the recorded cases of removal of intraligamentary cysts during pregnancy, in very few has the pregnancy been disturbed. There are comparatively few cases recorded : but it stands to reason that the more difficult the operation, and the more extended the handling of the cyst and the abdominal and pelvic organs, the more likely will labour be induced. As far as can be judged, the pregnancy is less likely to be disturbed when the operation is performed in the early months, as can be seen from Mclverron's table : 1 Total Cases. Kccent Cases. M"llth of Pregnancy. Number of i Operations. Pregnancy inter- rupted and Child lost: Number of Operations. incy interrupted and Child lost. All Cases. Excluding Compli- cated 1 Second. Third. Fourth. Fifth. Sixth. Seventh. Eighth. Ninth. 39 102 84 55 22 23 14 7 10 = 25-6 19 = 18-6 12 = 14-2 14 = 25-4 11 = 34-3 9 = 39-1 6 = 42-8 1 = 14-2 28 60 60 38 22 15 7 6 6=20-7 9 = 15 7 = 11-6 8 = 21 8 = 36 5 = 33 4 = 57 0= 5=185 5= - - 3= 5-3 2= 6-2 4=22-2 3 = 200 4 = 57-1 0= Michin 2 gives for ten cases in the Maternity Department of the University of Charkow 100 per cent, maternal recovery and i)0 per cent, pregnancy uninterrupted. These figures correspond very closely to the latest statistics of Graefe. :! The latter author finds that in 215 cases performed since li)02 the maternal mortality was only 0'47 per cent., and the cases where labour was induced only 16 per cent. With results so good for mother and child, is an expectant attitude ever justifiable? As regards tumours recognized early in pregnancy, it must be a very rare case indeed in which one is justified in leaving matters to Nature, for early in pregnancy, the uterus being small, the cyst can be removed without difficulty, and with a com- paratively small abdominal incision. On the other hand, late in pregnancy, seeing that labour is more frequently induced, one may be justified in delaying operation for the sake of the child until shortly before term, when it matters little whether labour comes on or not. 1 Op. cit. p. 114. 2 Kef. Zcnt.f. Gytl., 1903, p. 318. 3 Zcit. f. Geb. u Gyn.. 1 Jd . hi., Heft 3; ref. Joitrn. Obst. and Gfyn., October, 1906. TUMOURS OF THE OVARY 22!) If such a course is decided upon, the patient should be kept under most careful observation. There is, however, one great objection to this course. Not infrequently ovariotomy late in pregnancy and during labour is rendered difficult by reason of the size of the uterus. Without doubt this difficulty may be overcome by bringing the uterus out of the abdomen, and replacing it after removing the tumour, but such a step is naturally undesirable, as it involves making a very long abdominal incision. But if the treatment to be adopted with ovarian tumours during pregnancy is self-evident, it is very different when these growths are discovered and have to be dealt with during labour. It is useless to say that abdominal or vaginal cceliotomy should always be performed, for that is not practicable. How could a country practitioner, for example, perform abdominal section in a farmhouse, many miles from his home, without appliances or assistants ? Yet any practitioner in the country may be placed in such a position, and, as a matter of fact, a friend of mine had exactly such an experience. It is perfectly apparent, therefore, that the treatment to be adopted depends largely upon whether or not one is within easy access of a hospital or nursing home, or can get assistants and appliances at short notice. Without doubt, theoretically, the ideal treatment is to remove the tumour by the abdomen or the vagina, and then to remove the child per vias naturales. Here is an example of this treatment : One morning, four years ago, I was asked by Dr. J. Wright, of Glasgow, to see a multipara, about eight months pregnant, who had been many hours in labour. The cause of the delay, he believed, was an abdominal tumour. When I examined her, I found labour was well advanced, but the head was prevented from entering the brim by reason of a tumour, the lower margin of which could be felt project- ing over the pelvic brim. This was even more clearly made out after emptying the bladder. She was removed to the Maternity Hospital, where I performed laparotomy. There was some little difficulty in reaching the tumour, but that was ultimately accomplished by turn- ing the uterus out of the abdomen. After removing the tumour, the uterus was replaced. The delivery of the child was completed by forceps. Considerable difficulty has been experienced in some cases in getting the tumour up out of the pelvis. In such cases it is often sufficient to turn out the uterus and then bring up the tumour ; but in a certain number, even when the abdomen is opened, and even after the uterus has been turned out, it is not possible to remove the tumour. In such, the only course open is to perform Cesarean section, extract the child, and then deal with the tumour. That 230 OPERATIC E MIDWIFERY Buch a treatment is occasionally necessary is quite certain, and it is absurd for 30me writers to say that Cesarean Bection is in necessary. What might be done in the case of broad-ligament cysts is simple puncture from the vagina, for one knows that such a treatment cu many of these cysts. Couvelaire 1 actually did this, and delivered the child per vaginam, and found, some years later, no trace of any tumour. Even if one did not diagnose the exact condition until the abdomen was opened, it might be quite sound treatment, instead of trying to enucleate the cyst, to tap it from below. Good results have also been obtained from vaginal ovariotomy during labour. The cases which are suitable for this treatment are small tumours low down in the pouch of Douglas, so that one can be sure of getting a pedicle long enough to allow of a ligature being applied. I have thrice had experience of this operation — twice for an ovarian tumour and once for a pedunculated myoma which bulged down into the vagina. I had no difficulty in removing the tumour first, and then the child, and finally stitching up the vaginal incision. In the case of the myoma, when tying the pedicle, the latter gave way, but as the tumour was a myoma, I did not think it necessary to open the abdomen, for the gauze which I pushed into the pouch of Douglas, uhen removed after the birth of the child, was quite dry. There had been no bleeding. Ranch 2 has recorded a similar accident in the case of vaginal ovariotomy. In that case — and this should always be done in the case of ovarian tumours — the abdomen was opened and the pedicle secured. Personally, I have no great liking for vaginal celiotomy, for in the cases referred to and in others which I have read of there has been some little difficulty in securing the pedicle. In theory the operation is very simple. An incision being made over the tumour, and the pouch of Douglas opened, the tumour is pulled out through the wound. The pedicle is then tied. In doing so it is well to pass the ligatures through its tissue, so that when the pedicle is cut and the tension upon it removed, the ligature will not slip. After the tumour has been removed, the wound in the vault of the vagina is stitched. No drainage is necessary. The child should then be extracted by forceps, or the delivery left to Nature. In some few cases, to be referred to later, the tumour, if it cannot be removed, may be evacuated of its contents, provided it is cystic, secured by a ligature, and removed after the delivery of the child, when the pedicle is relaxed, owing to the uterus being so much smaller. 1 Soc. d'Obat. de Qyn. et de V&A. dt Pom, July, 1902. -' [naug. I>is.. Leipzig, 190o. TUMOURS OF THE OVARY 231 As regards the results obtained from this method, they are fairly satisfactory. The strongest advocate of the vaginal route is Duhrssen; 1 but even he is forced to admit that there is sometimes difficulty with the pedicle, and that the patient must be prepared for the abdominal operation. But, as already stated, the ideal treatment of immediate ovari- otomy is not always possible, as, for example, in the two following cases : A patient was sent to me by Dr. Jackson, late of Sanquhar, a few months after her confinement, on account of a painful swelling, which could be felt low down in the left iliac fossa. She resided at a distant farm, several miles from the doctor, who arrived when labour was far advanced. On examination, he found that the child's head was prevented from descending by reason of a small ovarian tumour. He had only his ordinary obstetric instruments, and had no assistant beyond a neighbour, who had come in to lend a hand. He tried to displace the tumour, but failed. As he wrote to me, he had therefore no alternative, as far as he could see, but to puncture the tumour and deliver the child. This he did. The woman's recovery was uninter- rupted. After seeing the patient, I sent her into hospital, and was present when abdominal section was performed. The operator found the tumour most intimately attached to the bowel, and he had great difficulty in removing it. The patient died of sepsis a few days after the operation. Late one evening I was asked by Dr. Cooper, of Dennistoun, to see a multipara whose labour was protracted on account of a small tumour which he diagnosed as being of ovarian origin. The os was fully dilated and the tumour was pressed far down by the child's head. The surroundings being unsuitable for abdominal section, we decided to try to displace the tumour from the pelvis, and extract the child before having recourse to vaginal cceliotomy. Dr. Cooper put the patient deeply under chloroform. I only succeeded in dislodging the tumour, however, after I had pushed the foetal head out of the pelvis. A living child was extracted by forceps. Some weeks later I removed the tumour — a small dermoid — by abdominal section. The operation was very easy, and the patient made an uninterrupted recovery. Without doubt, when the surrounding conditions are not favour- able for abdominal or vaginal cceliotomy, the best course to pursue is to push the tumour out of the pelvis. In doing this, it should always be remembered that it is of great advantage to have the patient deeply anaesthetized ; also, when pushing up the tumour, to dislodge 1 Dent. Med. Woch., October 13 and 20, 1904. 232 OPERATIVE MIDWIEEI,^ tin' presenting part from the pelvis, as was done in the la described. The results obtained by this treatment show a mortality of 5*7 per cent., a mortality only slightly worse than those following ovariotomy. So far, the courses sketched — viz., removal or displacement of the tumour — are those which should be followed if possible. When, however, we come to the last group of cases in which these forme treatment are deemed unsuitable or impossible, we find at once differences of opinion. One thing, however, is certain — that it is never justifiable to pull the child past the obstruction, either by forceps or by traction on the legs. Craniotomy will help but little, and is not to be considered, even if the child is dead. The results of pulling a child past the obstruction are most disastrous — the maternal mortality is somewhere about 30 per cent. Rapture of the cyst or severe injury, with subsequent necrosis, are the usual accidents which follow. Here is a case which illustrates the danger of this treatment : A patient was admitted to the Western Infirmary, under my care, four days after a very difficult and tedious labour. She had an extremely rapid pulse, a temperature of 102° P., and looked and felt very ill indeed. On examination, I found a large soft tumour behind the uterus. I was informed that the delivery of the child, five days prior to the patient's admission, was accomplished with great difficulty by means of forceps, owing, the doctor said, to the presence of a tumour in the pouch of Douglas. Two or three days later I performed abdominal section, and removed a necrotic multilocular cyst. So necrosed was the tumour that it broke in pieces as I removed it. The woman died the following day. Brute force, in this as in all other obstetric operations, may there- fore be dismissed. There remains, consequently, only one course — to puncture or to incise the cyst. It must at once be admitted that many disapprove entirely of this treatment, and, rather than have recourse to it, advocate the removal of the patient to a home or hospital, or sending for an obstetric surgeon, even although such a course involves many hours' delay. I have great sympathy with such an attitude, but I cannot quite agree to so extreme a position, for 1 do think there are cases occasionally encountered when puncture or incision must be resorted to. To simply puncture the tumour, unless it is a broad-ligament cyst, is undesirable, for it is a haphazard treatment, and will result almost certainly in some of the contents of the cyst escaping into the abdomen ; and although the contents of ovarian cystomata are generally sterile, occasionally they are not. TUMOUliS OF THE OVAttY 233 A better course is the following : The vaginal walls being held back by retractors, an incision is made over the projecting tumour. The bleeding is seldom great, and can be easily controlled. When the peritoneum is reached, it should be opened with scissors. Two fingers are then introduced into the pouch of Douglas, and the tumour, if possible, pulled out. If the pedicle can be safely ligated and the tumour removed, this should be done. If not, the tumour should be freely incised and the contents evacuated. If then a loop of silk can be passed over the collapsed tumour, this should be done, the long ends being drawn outside the vagina. The tumour should then be packed with gauze, and a little strip of gauze pushed up beyond the tumour. By such a device one can keep the tumour well against the vaginal incision. The child should be extracted immediately if this is possible ; if not, the case should be left till the os is sufficiently dilated. After the child is extracted and the placenta expelled, the lips of the cervix should be grasped with volsellum forceps, and slight traction made on the uterus. The ligature which is round the ovary should then be pulled upon, and pressure made on the uterus from above. By these means the ovary may now be brought within reach, and its pedicle ligatured and tied. The vaginal wound should then be closed, or a little loose packing left in for twenty-four hours. Simpler than such a procedure is the suggestion of Fritsch, to stitch the sac to the edges of the vaginal wound ; but it is not always easy to pass sutures in the vagina, and the sac of all ovarian tumours is very friable. I agree with Spencer, therefore, that it is better to pack the sac with gauze. At any time in the puerperium one may be called upon to remove a tumour which has been displaced or punctured, for complications are very liable to follow labour. I have had experience of, or seen in the practice of colleagues, twisting of the pedicle, suppuration and necrosis, adhesions to the bowel, and even obstruction of the bowel. I have already detailed a case in which necrosis followed. Here is one in which the pedicle became twisted : Mrs. A , multipara, was admitted to the Western Infirmary, under my care, in September, 1906. She was in an extremely collapsed condition ; the pulse could hardly be counted, and she had a temperature of 101° F. Her abdomen was greatly distended and very tender. The history obtained from her medical practitioner was to the effect that ten days previously she had been delivered of a full- time child without any great difficulty. The practitioner was aware of the presence of a cystic tumour. Shortly after delivery she com- 284 OPERATIVE Mll»\\ ll'Kl;V plained of abdominal pain, which steadily increased. A diagnosis of an ovarian cyst with a twisted pedicle was made, and the abdomen opened. The tumour was found intimately adherent to the surround- ing structures. It was removed with no great difficulty. Two com- plete t\\i>ts from left to right were found in the pedicle. The patient died the day following the operation. All operators refer to the complications which 1 have mentioned. Doran says that in fifteen cases operated upon shortly after birth, there were no complications in only three, and Kynoch, 1 in three cases operated upon during the puerperium, found necrosis in one and sup- puration in another. Bearing in mind such records, it is always advisable to remove the tumour as soon as possible after delivery, and immediately any un- toward symptom appears. I have removed upon three occasions an ovarian cyst early in the puerperium. In the one case the operation was performed on the second day, and in two on the fourth day after the confinement. The results in all cases were highly satisfactory, and none of the patients were much disturbed. 1 Journ. o/Obst. and Gyn. Brit Empire, September. 1906, p. 270. CHAPTEE XVI DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT Q AS kL- Continued Fibro-Myoma of the Uterus. n considering the subject of fibro-myornata and parturition, I have ound it impossible to do so without also discussing these tumours as . FIBKO-MYOMA OF THE UTERUS 239 to tumours situated in the lower portion of the body and cervix. h\ such cases, from the summaries of various writers, Olshausen found vertex, breech, and transverse presentations 54 per cent., 24 per cent., and 19 per cent, respectively. Lastly, labour may be disturbed by uterine inertia and post-partum ]];i morrhage. The former has been vaguely referred to by one or two writers ; but it is very doubtful if it is much more common in women the subjects of uterine myomata than in those whose uteri are presumably healthy. Post-partum haemorrhage is a more serious matter, and is especially favoured by implantation of the placenta over the tumour. A case of the kind occurred in the Maternity Hospital a year or two ago. 2. The Effect of Pregnancy, Labour, and the Puerperium upon Fibro-Myomata of the Uterus. But while labour and the puerperium may be disturbed (as •described) by the tumours, the latter, in their turn, are liable to various alterations, and these we must now consider. The most evident effect pregnancy has upon fibro-myomata is to ■cause an increase in the size of the tumours. For the most part, it is only interstitial tumours which are affected, but even subserous growths may become enlarged if their attachment to the uterus is still ■extensive. The increase in size is very largely caused by cedema, although there also occurs a distinct, if varying, hypertrophy of the muscle cells, with the result that the tumour becomes more elastic. During the puerperium the size decreases with the involution of the uterus. It is very questionable if the tumour ever disappears, although a small nodule is sometimes all that remains of a large growth. This increase of the tumour during pregnancy and its atrophy during the puerperium has been often observed. A year or two ago, however, I had under my care a case in which the tumour did not decrease after pregnancy ; indeed, it steadily increased, the pregnancy appearing to start its active growth. But, besides being altered in size and consistency, the tumours often become altered in shape by the gravid uterus. Very often they become much flattened out, and if situated low down on the body wall or cervix, this may result in a portion of the tumour being dis- placed downwards into the pelvis. Piecently I saw a patient in whom the tumour was so evenly flattened out on the anterior uterine wall that I could not distinguish it from the anterior wall (Fig. 123). Indeed, it was not until after delivery that the large tumour was recognized. The peculiar feature was the impossibility of palpating 240 OPERATIVE MinwllT.HY the fu'tal purls, and the impossibility, on the most careful and repeated examination, of discovering any evidence of the foetal heart. The living child, which was lar^e, was delivered with forceps. Fi<: 128. — Large Fibro-Myoma in Anterior Wall flattened out. (Author's Case.) The fcetal parts could not lie felt, nor could the foetal heart sounds be heard. The child was delivered at term alive. The author had enucleated a large fibroid from the body of the uterus sonic six years before. FIBRO-MYOMA OF THE UTERUS 241 In tumours which become pedunculated, torsion of the pedicle has very occasionally occurred. The features of such a complication are the same as those which follow twisting of the pedicle of an ovarian cyst : severe and sudden pain, with tenderness over the tumour, and sometimes increase in its size, although the latter feature is not so marked in the case of a pedunculated myoma. At any time the tumour may become impacted in the pelvis, and give rise to all the symptoms characteristic of such a condition — great pain, nausea, dysuria, and difficult defalcation. Should such symptoms be present, and the tumour intimately connected with the uterus, it may be extremely difficult to say which part is tumour and which the gravid uterus. Until a few years ago, what has been said regarding the effect of pregnancy and labour upon fibro-myomata would have been sufficient, as the only recognized reasons for interfering with such growths were pressure symptoms or an obstruction in the parturient canal. Recently, however, another indication for operative treatment has been brought forward by some writers, and in this country more especially by Bland-Sutton — viz., degeneration of the tumours. This author claims that degeneration of fibro-myomata during and as a result of pregnancy is a common occurrence, and so far, indeed, has he gone that he recently published a paper entitled ' The Inimicality of Pregnancy and Uterine Fibroids.' 1 While obstetricians and gynaecologists are greatly indebted to Sutton for all he has done for gynaecology, and while they admire the cleverness of this title, they cannot but feel he has greatly exaggerated the danger, in all proba- bility because, being a general surgeon, he sees only the serious cases of fibro-myoma in pregnancy, but does not see the hundreds of cases which they see, and which never cause any trouble. A special feature of these fibro-myomata which undergo degenera- tion during pregnancy is pain and tenderness in the tumour. The degeneration is very generally the variety known as ' red degenera- tion,' in which the cut surface of the tumour resembles a raw beef- steak. I quite agree with Sutton that pain in fibro-myomata should always arrest attention ; but from my own experience I do not attach the same importance to pain in these tumours in pregnancy. I have seen in consultation several cases of myomata complicating preg- nancy in which pain in the tumour was a marked feature. In all the pregnancy was allowed to continue undisturbed, and no untoward symptoms arose either during parturition or the puerperium. I in- formed the medical attendants of the patients that I was prepared to operate at any time if any unfavourable symptoms developed, or if 1 ' Essays on Hysterectomy,' 1904. 16 242 OPERATIVE Mll>\\ IIT.KY the pain became excessive. In this connexion Stewart 1 described a case in which a myoma associated with pregnancy was removed hecause of the pain complained of. The tumour presented no unusual appearance. As hearing upon this Bubject, the remarks made by Pinard on two cases shown hy Lepage- are of special interest : 'I desire to add some further information about the two patients whose histories M. Lepage has just related to you. He has not laid sufficient stress on the condition of the women when they entered the Clinique Baudelocque, nor of the treatment which was there followed. These women, with the uterus crowded with fibroids, suffered terrible pain, and complained continuously. I believe that many surgeons, had they examined at that moment, would have thought, in view of the general bad condition of the patients, that the time had come for surgical interference, and would have performed extirpation of the uterus. I ordered these women complete rest in bed, a milk diet, and regulated the urinary and intestinal functions. Little by little the pain passed away ; there has been no haemorrhage, and in the uterus of these elderly primipane, crammed with fibroids, the children have developed sufficiently to be born, of average weight, at full term.' I have also found the pain in fibro-myomata greatly relieved by regulating diet and excretory functions. But apart from the subject of the degeneration of fibro-myomatous tumours during pregnancy, which, after all, is a matter no one can generalize upon with the evidence at present at our disposal, there is no doubt the tumours are occasionally injured during parturition. Here, again, situation is of more importance than size, for, naturally, tumours in the upper part of the uterus are more likely to escape injurious pressure than those situated in the lower areas of the body and cervix. Injuries were much more frequent when it was the practice to drag the child past the tumour, as then it was bruised and crushed between the foetal head and maternal pelvis. As in ovarian growths, the injuries to the tumours may not be immediately evident, the disturbances, such as pain, rise in temperature or pulse from infection, and other symptoms, only appearing a few days after delivery. Personally, I have been struck with the danger of infection. I have four cases in my mind, three of them seen by me in consultation after delivery, where serious septic disturbances followed parturition. In fact, one patient died, and two escaped only after weeks of illness. 1 Brit. Med. Jowrn., 1906, vol. i., p. 548. 2 Comptes Rendu* de la S<><-i>'t< : d'Obstit. de (rijn. et de Pid. de Paris, October, 1903 ; ref. Journ. Obst. Oyn. Brit. Empire, 1904, vol. v., p. 60. FIBEO-MYOMA OF THE I'TEIUS 243 In all the tumours were situated low down on the uterus, and, although no great force was used in delivering the child — for, as a matter of fact, only in one case was forceps used — -I have little doubt but that the tumours were injured during parturition. Hofmeir, writing in 189(5, says : ' I cannot deny that I have often contemplated the puerperium with great anxiety.' In a later paper 1 he speaks ess seriously of the condition. Olshausen, Winter, Wertheim, and many other Continental writers, express similar views. The practical bearing of this is that the puerperium should be carefully watched in all cases where the tumour has been compressed between the foetus and the bony canal, and the tumour, with or without the uterus, removed should any complication arise. Expulsion of the tumour from the uterus during or after delivery has been observed by several writers. A few years ago, when ex- amining a primipara who had been in labour some hours, I discovered a firm body within the os and slightly in front of the presenting head. At first I took it to be the cord, but on more careful examination under an anaesthetic I discovered it to be a flattened myoma, of about the size of a pigeon's egg. I removed the tumour, and allowed the labour to proceed (Fig. 73). A most interesting case is one reported by Seeligmann,' 2 in which that operator removed by ' morcellement ' a submucous myoma, the size of a foetal head, without disturbing an eight weeks' pregnancy. The tumour was forced through the os externum, and this was accompanied by severe pain and excessive bleeding. There are not a few records of such tumours being expelled during the puerperium. Many years ago Priestley 3 recorded a case in which he removed one on the fourteenth day of the puerperium. The tumour was deeply em- bedded in the uterus, and had retarded the delivery very much. Herman 4 showed one which presented at the os uteri ten days after delivery. Many similar cases have been described. Finally, inversion of the uterus may occasionally follow, and a few examples of that accident are recorded by Tarnier and others. Quite recently Mackenrodt reported one. 5 1 Zeit.f. Geb. u. Gyn., 1900, Bel. xlii., p. 383. 2 Zent. f. Gyn., 1902, No. 21, p. 547. 3 Lond. Obsfc. Soc. Trans., vol. i., p. 217. * Ibid., vol. xxxiii., p. 31, 1892. 5 Zeit.f. Geb. u. Gyn., 1903, Bd. xlix., Heft 1, p. 145. •ill OPERATIVE MIDWIFKHY 3. Diagnosis of Fibro-Myomata complicating Pregnancy and Labour. The diagnosis of a fibro-myonia in the wall of the gravid uterus may be easy or difficult, and the ease or difficulty will depend very much upon the form and situation of the tumour and the age of the pregnancy. The tumour, which is irregular in outline, projects laterally, is pedunculated, and pushes the uterus over to the opposite side or bulges down into the pelvis and displaces the uterus, so that it is almost impossible to reach the cervix, can be recognized by any- one. On the other hand, the tumour smooth in outline and moulded on the uterus, as in a case I have already referred to, may be im- possible to differentiate from the uterus. But there is the other diagnostic difficulty — the recognition of the pregnancy. If the pregnancy is still only of a month or two's dura- tion, it is, as a rule, impossible to be quite certain of its existence ; while, on the other hand, if it has advanced to mid-term or farther, one can usually, unless it is very much embedded in tumour tissue, be quite certain regarding it. At an early age, when the abdominal swelling is of comparatively small size — say, about the size of a sixteen to twenty weeks" pregnancy — mistakes may be made in several ways, and, to illustrate this, let me mention a very striking one made by myself. Several years ago my house-surgeon in the Glasgow Maternity Hospital and I diagnosed a subserous myoma complicating pregnancy in a patient who was sent to the Maternity Hospital as a case of extra- uterine pregnancy. She complained of great pain and tenderness over the uterus, which was distended by an eighteen to twenty weeks' pregnancy. On palpating the abdomen, an elastic swelling could be detected in the antero-lateral wall, and, presuming that the pain was caused by some change in the tumour which we were satisfied we felt, I opened the abdomen. Greatly to my chagrin, I discovered a normal gravid uterus, without the slightest trace of any tumour in its sub- stance or its neighbourhood. It seems extraordinary that such a mistake should occur. That it not infrequently happens, however, is evidenced by the fact that I have twice been asked to see similar cases. There are two explana- tions of such phantom uterine tumours during pregnancy. One is that portions of the uterus are seized between the palpating hands, and the other that areas of the gravid uterus contract, and sometimes remain contracted for some time. The latter peculiarity has been remarked on by several writers, but by none in so interesting a manner as by Bar, who calls attention especially to a partial contraction of FIBRO-MYOMA OF THE UTERUS 245 the anterior surface of the uterus associated with great pain — exactly the features my case presented. He mentions how sometimes it is only by repeated examinations that the phantom nature of the tumour can be recognized. Upon two occasions, with very unusual varieties of extra-uterine pregnancy, I have had difficulty in making up my mind as to whether the tumour was an ectopic sac or a myoma in a gravid uterus. One was a case of tubal pregnancy which had advanced to about the thirty-sixth week, when the body of the uterus felt like a myoma, and the sac like the ordinary gravid uterus. The other was an interstitial ectopic pregnancy of about the fifth month. In both cases, however, the history directed one to a correct appreciation of the nature of the swellings. They are referred to and figured in Chapter XXXII. Sometimes for a week or two one is in doubt as to whether the tumour one feels is a rapidly-growing myoma or a pregnancy. In many such cases it is both, as I experienced lately. A myoma seldom grows as rapidly as a gravid uterus, but I saw one recently which started growing very rapidly, and caused the patient's physician and myself to be in doubt about the case for a few weeks. Time, however, invariably clears up such cases, and unless there is some great urgency for operating it is as well to delay doing so. If the tumour is subserous, and has a distinct pedicle, the error may very easily be made, as happened to me in the case I have recorded (p. 251), of considering the neoplasm ovarian in origin. Likewise, if the tumour is submucous, and is projecting into the lower part of the uterine cavity, it may be mistaken for the child's head, or, if small, for the cord, which happened to me in a case also referred to (p. 243). Another mistake which has been made sometimes with abdominal tumours of this size, is confusing the gravid uterus with a pedunculated fibroid. As all are aware, in the gravid uterus about the sixteenth week there is great mobility between the body and cervix, owing to the softness of the tissue at the junction of these two parts. The illustration (Fig. 124) explains how the mistake may arise — viz., through the examiner pressing the cervix between his hands, and taking it for the entire uterus. Then, again, if the myoma is spread out over the surface of the uterus, the tumour or the pregnancy may be overlooked. If the tumour is on the posterior wall, the gravid sac is readily palpable ; but if the tumour is on the anterior wall, it may push the foetus altogether out of reach, as in the case illustrated (p. 240). In such cases a rectal examination is of great value. Rosthorn. 1 for example, 1 Ref. Olshausen, op. cit. 246 OPEKATIVE MIJ)W II \.\[\ was able to get ballottement through the rectum in u cum where he could not make out the Ecetus from the abdomen. A rectal examination may also be of value when the differential diagnosis is between a retroflexion of the gravid uterus and a myoma complicating pregnancy. The important symptoms of pregnancy — softening of the cervix, partial discoloration of the vagina, suppression of menstruation — are, with few exceptions, present. The softening of the cervix, however, especially when the tumour is situated low down on the uterus, is often not so characteristic as in an ordinary pregnancy, although it is seldom absent. Discharges of blood may occur, and may resemble Fig. 124. — Mistaking a Lateral Flexion of tin Uterus Gravid to Four Months for a Myoma. menstruation, but the} 7 are invariably slight, and are not common unless in cases of abortion. Still later, the foetal heart sounds, if present, make pregnancy a certainty, but their absence, even in the later months, does not exclude it. In the other class of cases, where it has been decided that a preg- nancy exists, and the uncertainty is regarding the myoma, onby careful palpation and consideration of the condition can decide matters, and my advice is, in all cases of doubt, to take time, and make one or two examinations before coming to a decision. It has occasionally happened that mistakes have occurred in con- fusing a myoma with a second fu-tus, not only during pregnancy, but even during labour. Indeed, once or twice an accoucheur has waited patiently for what he thought was the second child, when what he really had to deal with was a large myoma. The other mistake of confusing a second child, either during pregnancy or after the birth of the first, with a myoma is less excusable. FIBEO-MYOMA OF THE UTEUI S 247 4. Treatment of Fibro-Myomata complicating- Pregnancy, Labour, and the Puerperium. What has been said regarding the features of fibro-myomata in the pregnant and the parturient may have left the reader in some doubt as to the indications for surgically interfering with them. Before dis- cussing, therefore, the methods of operating, let me in a word or two summarize my previous remarks, and indicate the cases in which interference is necessary. 1. Tumours should only be removed during pregnancy if, on the one hand, they are distinctly endangering the life or seriously disturb- ing the functions and general health of a patient, and, on the other hand, if they are undergoing serious degeneration or injury. Also, in the interests of the child, when at all possible, interference should be delayed until the later weeks of pregnancy. 2. Speaking generally, whenever a tumour, at the end of pregnancy or during labour, is decidedly obstructing the parturient canal, and that tumour cannot be displaced out of the pelvis, it should be removed, with or without the uterus. 3. All tumours which have been injured during labour, or which show signs of undergoing marked degeneration, or have become infected after parturition, should be removed, with or without the uterus, as early as possible. One's attitude, therefore, to fibro-myoma in the pregnant is to operate only if interference is distinctly indicated. All gynaecologists who have had experience of obstetrics operate upon myomata in pregnancy as seldom and as late as possible. Pregnancy. — When a fibro-myoma causes such disturbances in pregnancy that interference becomes necessary, it will be found very often that the tumour is impacted in the pelvis. In certain cases, by digital pressure from the vagina, with the patient in the knee-elbow or Sims' position, the growth may be dislodged ; but in a very large proportion that simple treatment fails, and more radical methods have to be employed. In former years induction of abortion, or, if the pregnancy had advanced to the later weeks, induction of premature labour, was the treatment generally recommended and practised. Such treatment, however, has been entirely abandoned. For my part, I can conceive of few circumstances under which it is indicated, for, even if it is successfully carried out — and that is not always an easy matter, owing to the distortion of the uterus — one has in no way improved the condition of the woman, for the operation would require to be is Ol'KKATIVK MIDWIFERY repented should she again become pregnant. J have Baid there are few circumstances under which premature emptying of the uterus is indicated, and some may say there are none. I could, however, conceive it justifiable if the woman was suffering from some grave concurrent disease which rendered an abdominal operation a matter of extreme gravity. Even in such a case, however, the accoucheur would require to satisfy himself that the bringing on of abortion or labour would not be a greater tax upon the woman than abdominal section. In only a comparatively few cases is it possible to remove the tumour by the vagina. Small pedunculated myomata lodged in Douglas' pouch, pedunculated submucous tumours projecting from the os, and cervical myomata of small size, may. however, be removed by that route, and in many cases without disturbing the pregnancy. Enucleation of a cervical myoma from the vagina should only be attempted if the tumour is of moderate size and entirely in the pelvis. It is sometimes not easy to decide such a matter, for only a portion of the tumour may be projecting into the pelvis. One can usually tell, however, if there is any mass above, by pushing the uterus or child into the pelvis and observing how the tumour descends. Also, by making a rectal examination one may be able to define the tumour if it is situated behind the uterus. It is not wise to attempt to remove large myomata by enucleation through the vagina : nor are the extensive vaginal incisions recommended byDiihrssen suitable for such cases. By far the largest proportion of cases which require surgical inter- ference cannot be safely attacked from the vagina, but must be approached from the abdomen. When abdominal interference is deemed necessary in cases of myomata complicating pregnancy, the operator has two alternatives to choose from — removal of the tumours, and hysterectomy in some form or other. It will be admitted by all that, if a myoma is pedunculated, the rational treatment is to ligate and divide the pedicle, just as one would do in the case of an ovarian cyst. But of much greater interest are the results following myomectomy or enucleation. The operation of enucleation has come into great favour in recent years, and very rightly so, for, theoretically, it is the ideal operation. There is this also to be said in its favour when employed on the gravid uterus, that at such a time one sees the uterine tumours at their worst, for they are much enlarged, and if they happen to be multiple they are much more distinct. In two respects the operation is a most satisfactory one. The existing FIBRO-MYOMA OF THE UTEEUS 249 pregnancy is disturbed in less than a third of the cases, and the uterus is left for future pregnancies. In this country in recent years there have been many cases recorded, and a great many more which have never been reported. Djnald 1 and Sutton 2 have each referred to cases in which they had enucleated a fibro-myoma from the gravid uterus without disturbing the pregnancy; while Thring 3 has reported six cases, all of which recovered, and in five of which pregnancy was undisturbed. Equally good results have been described by Doran 4 and Routh. 5 It is evident, therefore, that the treatment of fibromyomata by enucleation is most encouraging, and, if the tumours were only single, would be the method invariably employed. In many cases, however, this variety of tumour is multiple, and the uterus is so extensively invaded that there is no possibility of removing all the tumours. As regards such cases, when many tumours exist, it is quite impossible to lay down any hard-and-fast rules regarding treatment. Emmett 6 removed nine myomata from a gravid uterus without disturbing the pregnancy. Another matter of satisfaction is that, even although the tumour is deep in the uterine wall, it may be enucleated with safety to the patient and the foetus. Several cases have been recorded where the operator actually exposed the decidua. Of such cases, one described by Mackenrodt is most interesting. A woman three months pregnant complained of pain and fever. Mackenrodt considered it to be arising from a uterine myoma undergoing degeneration. He enucleated the tumour, and in doing so exposed the decidua. The patient recovered and did not abort. The ease with which the tumour comes out of its bed during pregnancy, and especially during the puerperium, is well known to all operators, so that part of the operation is comparatively simple. The treatment of the raw surface left is of greater importance. Donald 7 recommends closing it in layers, and uses catgut. He attaches great importance to making very shallow layers, as other- wise too much tension is thrown on the uterine wall, and in that way he thinks abortion is favoured. Certainly, careful stitching of the uterine wound is of the greatest importance, for, apart altogether from the risk of abortion, which, after all, although disappointing, is not serious, there is the distinct danger of rupture of the uterus and 1 Lond. Obst. Trans., vol. xliii., p. 180. 2 ' Essays on Hysterectomy,' 1904. 3 Journ. Obst. and Gyn. Brit. Empire, September, 1906. 4 Brit. Med. Journ., 1906, vol. ii., p. 1446. 5 Clinical Journal, May 23, 1906. 6 Amer. Journ. of Obst., September, 1901. 7 Lond. Obst. Trans., vol. xliii. 250 OPERATIVE MIDWIFER1 hemorrhage. I can find no recorded case of rupture following. J>ut there have been several where haemorrhage from the uterine wound continued and necessitated the removal of the uterus. But more frequently the operator chooses hysterectomy. N" doubt the brilliant results obtained by operators in this and other countries will encourage others to consider fully the advantages of enucleation before having recourse to an operation which removes all chance of subsequent pregnancies. The two methods of hysterectomy, open to one before the child is viable, are supravaginal amputation and the removal of the entire uterus, or panhysterectomy. Naturally, if the child is viable, one would first perform Cesarean section. As all operators are agreed that panhysterectomy is a little more difficult and complicated than supravaginal hysterectomy, and as its mortality is slightly higher (although the statistics do not support the last contention), it is apparent that supravaginal amputation is the operation of choice, and panhysterectomy need only be had recourse to under special circumstances. The most obvious compelling circumstance is when the tumour or tumours have so altered the position and shape of the cervix as to render amputation through it wellnigh impossible. Another indication is infection of the cervical canal. The mortality in non-infected cases is not higher than 5 per cent. Labour. — Before considering in detail the different methods of treat- ment of fibro-myomata in labour, let me caution against dragging the child by force past a tumour. Such treatment is most unwise. Conse- quently, forceps, version, and craniotomy, be the child dead or alive, do not come into consideration at all, unless the obstruction is so slight as to be almost negligible. It is quite unnecessary for me to give figures to prove the disastrous results following such treatment as forcible extraction with forceps, version, craniotomy, induction of labour, and abortion ; and, indeed, I could only give old statistics, such as those of Siisserott and Lefour, published many years ago. Only if one were placed in some out-of-the-way country district would the treatment be justifiable. Under such circumstances, however, I would consider the risks of a long journey, even a very long journey, to a hospital or nursing home infinitely less grave than those involved in pulling a child by force past an obstructing fibro- myoma. Many of the tumours which project into the pelvis may be pushed up, and are even dragged up, by the contractions of the uterus. Tumours of the cervix, however, cannot, as a rule, be so dealt with. They must either be removed by the abdomen or by the vagina. FIBRO-MYOMA OF THE UTERUS 251 AVI i en possible they should be removed by enucleation. They can, as a rule, be easily shelled out after the capsule is split. Amongst the early recorded cases of vaginal enucleation of cervical fibroids is the one described by Braxton Hicks. 1 He tried to deliver with forceps, but failed. The tumour was easily enucleated, and he delivered a living child with forceps. A recent case of this nature is one described by Piobinson,' 2 where a large myoma growing from the posterior lip of the cervix was enucleated, and afterwards the child was delivered with forceps. The simplest of all myomata to remove are the pedunculated. They may be either subserous or submucous. An example of a submucous one which occurred in my practice, and was removed during labour, has been already referred to (p. 243). Here is a short report of a pedunculated and subserous myoma which obstructed labour, and was under my care a few years ago : Mrs. A , a multipara, was admitted to the Glasgow Maternity Hospital advanced in labour. The os was fully dilated, but the child, which presented by the vertex, could not be expelled because of a tumour which occupied the pouch of Douglas. The tumour was very tense, and was about the size of a closed fist. It could not be displaced from the pelvis, as it and the foetal head were firmly impacted in the cavity. I took the tumour for an ovarian cyst. As the case seemed peculiarly suited for vaginal cceliotomy, I made an incision over the tumour through the posterior fornix of the vagina. Without the least difficulty, and with little or no bleeding, the pouch of Douglas was opened into, and the tumour, which was evidently solid, seized with volsellum forceps. On pulling it through the vagina it was found to be a pedunculated myoma. Having transfixed the pedicle, I Avas proceeding to tie the ligatures when the pedicle tore across, as far as could be judged, at the point where it was attached to the uterus. Finding no vessel of any size in examining the pedicle, which came away with the tumour, I did not feel concerned about its having given way. As a precaution, however, I put a strip of gauze into the pouch of Douglas. I then proceeded to extract the child with forceps. That was very easily accomplished, and the child was alive. The placenta was expelled without difficulty. Finally, I removed the gauze from Douglas' pouch, and, finding it was not blood-stained, I closed the vaginal wound. The patient made an uninterrupted recover)'. One would, of course, only think of vaginal cceliotomy if the tumour projected into the pelvis and was of small size. Myomata with such a long pedicle are very uncommon, so that, although the operation described is one suited for ovarian tumours, it is seldom that myomata can be so treated. 1 Trans. Lond. Obst. Soc, vol. xii., p. 273. 2 Brit. Med. Journ., 1906, vol. ii., p. 1637. 252 OPERATIVE MIDWIFERY Although in many cases it is an advantage, when possible, to operate before Labour lias started, it is not always a wise proceeding, for there is a fair number of cases on record where, us the labour has progressed, the tumour has been drugged up. If, therefore, there is any prospect of such a termination — and 1 have already indicated the cases in which such an occurrence might he expected — it is advisable to delay operation until later. In those cases in which a more extensive operation, than simple removal of a pedunculated tumour is necessary, the following courses are open, and I mention them in the order in which they would com- mend themselves to one anxious to conserve the uterus as far as possihle, and at the same time do the best for the mother : 1. Myomectomy followed by extraction of the child per vias natural* *. 2. Cesarean section followed by myomectomy. 3. Hysterectomy. 4. Conservative Cesarean section. Not a great deal need be said regarding these methods. The conditions which guide one to choose enucleation during labour are the same as those which should influence one in choosing that method during pregnancy. Vaginal myomectomy during labour has already been referred to (p. 250). Abdominal myomectomy followed by extraction of the child per vaginam with forceps, version, etc., can only be resorted to when labour is far advanced and the os fully dilated, for no one would care to allow a uterus from which a myoma had been recently enucleated to have many hours expelling a child. True, one might incise the cervix, but it is a question if, by adopting such a course, one is not pushing a method beyond its rational limits. The same applies to delaying operation until the os is sufficiently dilated, for the tumour hinders dilatation. In this connexion, I find a case reported by Olshausen where a myoma was removed by the abdomen, and afterwards the dead child delivered by forceps. Calderini 1 records a case of enucleation and closure of the abdomen and delivery by version. The second method mentioned, Casarean section followed by myomectomy, is the course to be followed in those cases where the tumour cannot be enucleated until the uterus is emptied. "We have already seen that one is compelled sometimes to adopt a similar course with ovarian cystomata obstructing labour. If such a course is necessary, it is advisable to turn the uterus out and make the ( a sarean section wound in such a position that an extension of it wil 1 Zcnt.f. (1 ;/?>., 1890. FIBRO-MYOMA OF THE UTERUS 25$ permit of the removal of the tumour. Olshausen 1 mentions some good results from this method. It is the form of treatment which should be employed when the- Fig. 125. — Uterus with Fibro-Myomata, and containing a Full-time Child, removed by Panhysterectomy during Labour. (Bland-Suttun.1 tumour is single, but it is very questionable if it is advisable when there are several tumours. Without doubt the third method of treatment — hysterectomy — is the method generally favoured, and rightly so, for the uterus is 1 Yeit's ' Handbuck Gyn.,' 2nd edition, 1907. 254 OPERATIVE MIDWIFERY generally boo extensively < 1 1 - . . l - . < I to l>e ol much Future service, in most oases they are not many the child has first been removed by larean Bection, bat in an interesting ca ibed by Sutton (Fig. L25j the whole a terns was removed with the child in situ. The latter proceeding is only justifiable if the child ie dead. With a iving child, and, indeed, if there is the slightest possibility of its ueing alive, the uterus in u - 1 be opened into and the child extracted ■•re one proceeds to hysterectomy; for although there is one case on record where the uterus was opened into after its removal and yet the child was alive, that does not justify one in following ~uch a procedure. Sere, again, the choice is between supravaginal amputation and panhysterectomy. As in the case of hysterectomy during pregnancy, the position of the tumour is the chief influencing circumstance. But there comes in also the danger of septic infection from the cervix, so that if there is any reason to he suspicious of the parturient canal being infected, panhysterectomy should he chosen. Curiously, the results are rather better with panhysterectomy. Although I have always found panhysterectomy either during pregnancy or labour peculiarly easy, owing to the looseness of the cellular tissue, I cannot quite understand why the latter should give better results than supra- vaginal amputation, and I am inclined to think that the mortality of the two must be very much the same. The method of removing the uterus is described in connexion with the operation of Cesarean section (Chapter XXVI.). There is a large number of cases on record where conservative Cesarean section was performed. Personally, I think the simple con- servative operation incomplete, for the tumour or tumours are left behind, and although they usually diminish in size very decidedly after delivery, they seldom completely disappear, and they usually enlarge again in subsequent pregnancies. The conservative operation was the one employed until fifteen or twenty years ago, and Sanger in L882 wrote in its favour. 1 The results, however, have not been good, although it must he remembered that one is comparing figures of operations performed fifteen years ago with those performed to-day. The only advocate at the present time, as far as I know, of the simple conservative Cesarean section isLewers, 2 who recorded two successful cases a few years ago. Puerperium.— Before leaving this subject, let me say a word regard- ing myomata which give trouble during the puerperium. These are for the most part submucous and interstitial, although even the subserous 1 • 1'ir Kaiserschnitt bei Uterus-fibromen.' 2 Loncl. Obst. Trans.. 190.'., vol. xlvi.. p. 117. FIBRO-MYOMA OF THE I'TERUS 255 may occasionally be injuriously affected by the labour, as when the pedicle gets twisted or the tumour gets bruised. Some operators go the length of advising the removal of all fibroids immediately after delivery. But this is unnecessary, for many tumours, as every one admits, give rise to no trouble, and shrivel up and become very small indeed. The only variety which should always be removed, whether they are giving trouble or not, is the pedunculated submucous. But although it is quite unnecessary to operate upon all cases, from what I have seen, it is advisable to remove the tumour, either with or without the uterus, whenever there is evidence of any septic disturbance in the puerperium. When the tumour is submucous, the simplest proceeding is to shell out the tumour, and that is easily done as a rule. One trouble, how- ever, is that occasionally there is very profuse bleeding ; Martin, for example, lost two patients, although the tumours were removed a fortnight after parturition. Another danger is infection, particularly if one waits until there are distinct indications for operating. Speak- ing generally, hysterectomy is safer than simple myomectomy in cases where the tumour is infected, and panhysterectomy is the best method to employ, for in most cases the whole uterine and vaginal canal is infected. < hatti: l; \vn DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— < 'ontinued Tumours of the Bladder and Rectum. Tumours of the Bladder. — When speaking of tumours complicating parturition, I mentioned incidentally the case referred to by Smellie, where a vesical calculus obstructed labour, and was ultimately forced out of the bladder per vaginam. McLintock 1 refers to one in which a large stone was removed from a woman seven months pregnant without disturbing the pregnancy. Thomas - also recorded a case operated on during pregnancy. Hugenberger, in his monograph on the subject, written in 1875, collected twenty-three cases. In many of these great injury occurred, while sometimes the tumour was removed during labour or pushed out of the way. Personally, I have nothing to say regarding the condition, for I know of no case of the kind having occurred in the Glasgow Maternity Hospital. In recent years very few cases have been recorded. Rosenfeld 3 has described a case where lateral lithotomy was performed at the fifth month because of a urinary calculus and a septic condition of the urinary tract. Abortion occurred on the third day, and the patient died on the fourth. Tumours connected with the bladder are very rare at all times. In the few cases where they have arisen from the neck of the bladder they might well cause dystocia, but so far I have not encountered such a case, nor have I seen any reference to it in obstetric literature, although I doubt not the condition has been observed. Vander- linden ' describes a myxo-fibronia removed two months after labour at full time. During the patient's pregnancy there had been no bladder trouble beyond three slight attacks of hematuria. Labour was undisturbed, but on the sixth day of the puerperium, on pal- pating the uterus, a tumour of some size was discovered above the 1 Smellie's ' Midwifery, 1 vol. xi.. p. 101. 2 Lancet, 1888-89, vol. i., p. 58. ■■ Munch. Med. Woch., No. 89, 1895. ' B&LZeitf. Gyn., 1900, p. 887. TUMOURS OF THE BLADDER AND RECTUM 257 symphysis pubis. Some weeks later the tumour and a portion of the bladder were removed. Tumours of the Rectum. — The majority of tumours of the rectum encountered in practice are of a malignant nature. This is espe- cially seen in the cases where the rectal tumour has been found complicating pregnancy or labour. Odd cases will be found recorded where the tumours have been of a simple nature. Quite recently Alexandrow 1 reported one where a pedunculated fibroma of the rectum obstructed the delivery of the child. During extraction with forceps the tumour was pushed out of the anus. A somewhat similar case was described many years ago by Barnes. 2 Carcinoma of the rectum, however, is the chief tumour of interest. As, however, I have had no personal experience of the condition, I am indebted to such monographs as those of Hollander, 3 Krause, 4 A. "W. Russell, 5 and Nighoff. 6 The diagnosis of carcinoma of the rectum in pregnancy and labour, if the tumour is of any size, has usually presented no great difficulty, although, without doubt, there have been many cases in which the condition must have been overlooked. In most of the cases recorded a hard mass was felt pushing the posterior vaginal wall forward. Sometimes, however, this narrowing of the canal has been very slight, for the delivery was spontaneous, as in Kjelberg's 7 second case, where an inoperable carcinoma was discovered six weeks after a normal and spontaneous delivery, and Rossa's 8 case, where the delivery was also spontaneous at term. The symptoms of the condition are constipation, with occasional attacks of diarrhoea ; in a few cases, as Duncan's, 9 even intestinal obstruction. Generally, also, there has been pain in the sacrum, tenesmus, and irregular bleedings from the rectum. The effect of the tumour upon parturition has been variable. As already stated, some cases have terminated spontaneously, but in most there has been distinct obstruction — an obstruction which has sometimes been so great as to necessitate Cesarean section. In man} 7 of the cases, however, the child has been dragged past the tumour, sometimes without the growth being much injured; but on other occasions with considerable laceration to tissues. Speaking generally, the circumstances which should guide one in i Bull. Gen. de Therajp., April 30, 1905; ref. Zentral. f. Gyn., 1906, p. 1429. 2 Lond. Obst. Trans., vol. xxi., p. 28. 3 ArcUvf. Gyn., Bd. xliv. * Inaug. Dis., Bonn, 1900. 5 Scottish Med. and Surg. Joum., June, 1903. 6 Zent. f. Gyn., 1905, p. 881. 7 Op. cit. 8 Zent.f. Gyn., 1902, p. 1241. 9 Lancet, 1898, vol. L, p. 405. 17 OPERATIVE MlDWll'KliV tli.' treatment of carcinoma of the rectum complicating pregnancy and labour are very much the Bame ae those which, as we have already Been, guide one in dealing with carcinoma of the cervix. The older methods, such as induction of labour, if the disease is recognized in pregnancy, and the dragging of the child past the growth if the condition is Been for the firs! time during labour, are unsound in principle. Induction of premature labour might at first sight ap] correct enough treatment, hut why sacrifice the child, or run the risk of doing so? It is much better to allow the pregnancy to continue to term and perform Cesarean Bection. Taking first of all the cases recognized in pregnancy, one should decide whether the case is operable or inoperable. If operable, the tumour, with the necessary portion of bowel and surrounding structures, should be at once removed ; while, if the disease is inoperable, the pregnancy should be allowed to continue up to or as near term as possible. As far as I can find, Kjelberg's 1 first case is the only one in which the tumour was removed without disturbing the pregnancy, which had reached the fourth month. Spontaneous labour occurred at term. The modern surgical attitude towards car- cinoma affecting the uterus is to remove, not only the uterus, but also the cellular tissue around the uterus. Is it therefore sound surgically to simply remove the rectal growth, and allow the pregnant uterus to remain ? It is just possible that, owing to the presence of the enlarged uterus, there may be difficulty sometimes in deciding whether or not the tumour can be removed. If that should happen, the patient must have the benefit of the doubt. If need be, the abdomen must be opened and the uterus turned out. The condition of the rectal growth should then be examined, and, if operable, the pelvic contents removed. Should, however, the malignant disease he considered inoperable, the pregnant uterus is replaced in the abdomen and the pregnancy allowed to continue. Some may think that allowing the pregnancy to continue in inoperable cases is inhuman, and so should I if the woman's suffer- ings were great. In these cases, provided opium loses its effects, the patients' sufferings will usually he sufficiently relieved by performing an inguinal colotomy, as Duncan did in his case. The attitude assumed by this operator appears to me to be beyond doubt most sound. In cases of rectal carcinoma recognized during labour Cesarean » section is a much sounder treatment than pulling the child past the growth. The dragging of the child past the growth has proved i Ref. Zent ./'. Qyn., 1903, p. 1076. TUMOUES OF THE BLADDER AN]) RECTUM 259 disastrous upon several occasions,' as, for example, in the cases recorded by Herman 1 and Cruveilhier. 2 Quite a number of successful Cesarean sections have been performed ; and even in Duncan's case, where an inguinal colotomy had been performed previously, Cesarean section was most satisfactory, as the child and mother were both saved. The tumour, if operable, may be dealt with at the same time as the child is delivered ; but it is better practice to allow the woman to recover from the confinement, and to deal with the rectum a week or two later. i Lond. Obst. Trans., vol. xx., p. 191. 2 Ref. Hollander, op. cit. CHAPTER XVIII DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Continued Suppurative Conditions in Pelvis and Abdomen. Si i i i kative conditions connected with the reproductive and other pelvic organs complicating labour are more frequent than is generally supposed. In recent years, in the Glasgow Maternity Hospital and in private practice, I have had several cases under my care. Vulva. — Of abscesses about the vulva, those connected with the glands of Bartholin are the most common. I have seen two cases, one of which died of acute septicaemia. The other recovered, probably because the whole tissue, including the gland and surrounding parts, was removed and the vulva very thoroughly cleansed. These abscesses sometimes contain very virulent pus, although not infrequently the infecting organism is the gonococcus. Pelvic Cellular Tissue. — Some little time ago I performed a Cesarean section in a nursing home upon a woman at the end of her second pregnancy, who had had a very difficult craniotomy at her previous confinement owing to the smallness of her pelvis. There was a sinus discharging in the groin, connected, as was after- wards discovered, with the spinal column. The parts about the thighs and vulva were most thoroughly cleansed and isolated from the abdomen by means of wet dressings and bandages. The operation was performed at term and before labour had started. The whole uterus was removed. The woman made a most satisfactory recovery, but from the seventh to the seventeenth day there was slight febrile disturbance. Jardine has recorded two cases of retroperi- toneal abscess, one behind the kidney and the other behind the caecum. In one of the cases rupture occurred into the peritoneal cavity, and in both the women died. Freund 1 records a case where at the sixth parturition, which occurred prematurely, a para- metric exudation, which had developed after the previous labour, burst, 1 Ref. YVertheun, "Winckel's 'Handbuch der Geburtshulfe.' Bd. ii., Teil i.. p. 491. 260 SUPPURATIVE CONDITIONS IN PELVIS AND ABDOMEN 261 and was followed by the woman's death. Several interesting cases are referred to by Wertheim. 1 Tubes and Ovaries. — But more frequent than the conditions described are those in which the suppurative process has been connected with the ovaries and tubes. Quite a large number of such cases are on record. Personally, I have experience of two — one in which the diagnosis was confirmed at the post-mortem examination ; the other in which, unfortunately, there was no examination after death. The histories of both cases were very similar. The case in which the diagnosis was confirmed was a multipara whom I saw in consultation with Dr. Gardner Neill. The history was as follows : Seven days before she had been delivered without any difficulty of a living child. For three days she remained well, but early on the fourth the temperature rose and the pulse became more rapid. Abdominal pain also developed. When I saw her three days later she was extremely ill, with very rapid, irregular and feeble pulse, and great abdominal distension. She was evidently dying, and too feeble for operation. A few hours after I saw her she died. At the post- mortem examination there was general peritonitis, which had evidently arisen from an abscess connected with the tube. In Jardine's 2 case the temperature and pulse were also normal until the third day. The late Milne Murray 3 described an interesting case in which he saved the patient by laparotomy. The pus which escapes into the peritoneal cavity may come from the fimbriated ends of the Fallopian tubes or from a rupture of the sac. In some cases only one tube is affected, as in Murray's and the one I have just described, but generally both tubes are involved. Short of actual rupture or leakage from the tubes, the latter may become injured. I removed a single pyosalpinx some years ago in the fourth week of the puerperium from a woman who had had great abdominal pain since her confinement. The tube was very vascular. She made an excellent recovery. Early in the puerperium, when the uterus is large and soft, it is not easy to palpate the tubes, and once or twice I have been on the point of opening the abdomen, when the pain and fever have subsided with regular intra-uterine douching. Sudden and severe abdominal pain, with steady development of symptoms of general peritonitis, must immediately be dealt with by abdominal section. After removal of the sac, the question of vaginal drainage will arise. While I am quite in favour of such drainage under ordinary eir- 1 Winckel's ' Hanclbuch,' Bd. ii., Teil i., p. 490. 2 ' Clinical Obstetrics,' 3rd edition, 1910, p. 515. 3 Edin. Obst. Trans., vol. xxv., 1899-1900, p. 38. 262 OPERATIVE MIDWIFERY oumstanees in general septic pelvic peritonitis, it appears to me a mistake in cases early in the puerperium, for the discharge in the vagina may readily infect the uterus. Ordinary drainage through the abdominal wound I am very sceptical about, although some still look upon it with favour. If it La decided to drain, I think it best to make a counter-opening in the loin. Another condition, and one which closely simulates pyosalpinx, i- appendicitis. In the cases of this condition which 1 have seen, I have always obtained a history of previous attacks. The pain was extreme but local, and quieted down with rest and fomentations. Appendicitis in connexion with pregnancy is a subject which has aroused great interest amongst obstetricians and surgeons in recent years, and this is not to be wondered at considering how common the condition is. Cuthbert Lockyer referred to the subject in the dis- cussion on ' The Appendix and Pelvic Inflammation,' which took place at the annual meeting of the British Medical Association in Toronto, 1 and emphasized very strongly the dangers of the condition and the advisability of operating earl}'. Recent contributions to the subject, such as Filth's, 2 show that it is a condition of very great gravity, and that unfortunately it is often overlooked, the pain complained of being attributed to the enlarging uterus. A most useful paper is one by Meyer, 3 who considers 143 collected cases. He comes to very much the same conclusions as other writers, and he gives interesting statistics. It seems to be generally admitted that, although pregnancy does not predispose to a primary attack of appendicitis, if the woman is subject to appendi- citis she is more liable to have recurrences during pregnane}*. There is also greater risk of abscess formation. In all probability this is largely due to the obstinate constipation of pregnancy and the disturbance produced by the large uterus. In the cases in which there is no abscess formation, pregnancy is rarely disturbed b} 7 the removal of the appendix. In the suppurative cases, however, abortion or premature labour frequently follows, and the pregnant woman is then in special danger of septicemia. As can be readily understood, the diagnosis may be very difficult indeed. Suppose the woman complains of a little pain in the right iliac fossa, how readily one may attribute it to the disturbing effect of the growing uterus, or even to a threatening abortion. Theoretically, the condition of the pulse and temperature should guide one. but I need hardly remark that frequently in the very worst cases, where i Brit. Med. Journ., 1906, vol. i., p. 1709. 2 Archiv f. i., Bd. Ixxvi., Heft 8, p. 507. 3 Ami r Jou/rn. of Obst., 1906, vol. i. SUPPURATIVE CONDITIONS IN PELVIS AND ABDOMEN 263 there is an extensive collection of pus, these are only slightly disturbed. Itigidity, such a valuable sign, is often not available, owing to the presence of the distended uterus. The history of previous attacks, and the fact of the pain being localized and the part being tender to pressure, and, above all, the appearance of the woman and the blood - count, must be one's guides when there is little disturbance of pulse or temperature. Many conditions may simulate, or be simulated by, appendicitis — viz., ovarian tumour with twisted pedicle, painful myoma, extra- uterine pregnancy. But, after all, mistakes regarding this condition are not so serious, for operation is generally necessary in all of them. I have had once or twice under my care patients who complained of severe uterine pain, but in whom I could discover absolutely nothing abnormal. The pain in most of these cases was diffuse. As the women were multipara?, I looked upon the condition as being the result of chronic metritis. Should it happen that the pain is localized, as in one of my cases, the diagnosis is extremely difficult. Fortunately, in my case the pain was left-sided. During labour a chronic appendicitis may be lit up, or an old abscess burst, and a free escape of pus occur into the general peri- toneal cavity. In such cases the severe and acute pain persisting even during the intervals between the uterine contractions would arouse suspicion. In extreme cases the condition might simulate rupture of the uterus. Zalachos 1 records two cases where the two conditions coexisted. But in all probability the greatest diagnostic difficulties occur in the puerperium, for then any pain, tenderness, and rise in pulse and temperature are naturally put down to septic infection of the uterus. When, however, the labour has not been severe, and there has been no reason for sepsis occurring, and especially when the uterus is well retracted and the os firm and closed, then in all right-sided iliac pain one should think of appendicitis. All writers, without exception, are agreed that the same surgical principles should guide one in treating a case of appendicitis in the pregnant as in the non-pregnant. The appendicitis should be treated and the uterus left severely alone. If abortion or labour follows, the delivery must, of course, be completed, every possible care being taken to prevent infection of the uterus, for cases of this nature are the most serious. The condition of the parturient after delivery must be carefully watched, and the abdomen opened if it is deemed necessary. Should the latter become imperative, an attempt must be made to shut off the 1 Epitome, Brit. Med. Journ., November 11, 1905. 264 OPERATIVE Mll>Wll'Ki;Y vagina and vulva as far as possible from the field of tin; abdominal operation by carefully packing the vagina. Aiter the abdominal operation is completed, the vagina] packing should be removed. should it he iitrt-sui to drain tin- abdominal cavity, it Bhould be done through a counter-opening in the loin. All eases occurring in the puerperiuin must he promptly dealt with, and if there is any suspicion of abscess formation tin- abdomen must be immediately opened. The recent results in the cases associated with an extensive pufi formation have, as I have already said, been very satisfactory. Even some of the cases where general peritonitis has been present, ae in the most interesting one described by Mauchlaire, 1 have resulted in recovery. 1 A mini. (lr Qyn. t 190.";, p. '24:j. CHAPTER XIX DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— Continued Alterations in the Axis of the Canal— Displacements Backward, Forward, and Downward — Displacements the Result of Vaginal and Abdominal Fixation of the Uterus. Under this heading of alterations in the axis of the parturient canal, several very interesting conditions call for consideration. The one which naturally occurs to one's mind, and which we shall first discuss, is backward displacement of the gravid uterus. In addition to that, however, there is the forward displacement associated with a pendulous abdomen, and the alterations in the uterine axis which result from ventral and vaginal fixation. It is unnecessary, I think, to consider here the lateral deviations of the uterus so constantly present during pregnancy, and so generally directed to the right, for, beyond the fact that they favour occasionally malpositions and malpresentation, they disturb but little either preg- nancy or parturition. The late Milne Murray made an interesting contribution to this subject some years ago. 1 Backward Displacement of the Gravid Uterus. Of all the displacements of the gravid uterus this one is, without doubt, the most interesting. It is also the one most frequently encountered. Every obstetrician has met with it many times, and I doubt if there is any general practitioner of experience who has not had experience of it. The subject, therefore, is of very great importance to all who practise obstetrics. Of special interest is it to us in this country, for to William Hunter belongs the honour of having been the first to consider exhaustively the complication. Others before him, Gregoire in France and Kilmann in Germany, for example, knew of the condition and incidentally referred to it, but 1 Edin. Obst. Trans., vol. xxii., p 39. 265 266 OPERATIVE MIDWIFER1 all are agreed thai Eunter was the first to consider it in detail. The students of (llasgow I ni versify should take particular pride and interest in the matter, for the Bpecimen — the uterus was removed post mortem — upon which Eonter lectured on October 21, 1754, is still to l)e seen in all its beauty in the Hunterian Museum of our University. Here is a drawing of the Bpecimen (Pig. 126). Hunter seems to have taken peculiar pride in the specimen, for it is seen Fig. 126. — Drawing ol Specimen I s . i"' s . Bunterian Museum, Glasgow University. The specimen was obtained from the ease of retroversion of the gravid uterus which formed the text of Banter's historic lecture on the subject. resting upon the table in the portrait of him by Sir Joshua Reynolds. The history of the specimen appears to be of such interest as to warrant me inserting it here, especially as one can give it in Hunters L own words : 'A young woman, about four months advanced in her first pregnancy, after a frighl was taken ill, an I CO lid not with nit great difficulty go I" 1 'Medical Observations and Enquiries by a Society of Physicians in London.' '2nd edition, vol. x.. p. tOl. BACKWARD DISPLACEMENT OF THE GRAVID UTERUS 267 stool or make water. Her complaint grew worse daily, till on Saturday, October 12, both these evacuations were entirely suppressed. The sup pression of urine continued, without any relief being given, till Thursday. the 17th, when Mr. Walter Wall, surgeon, was called to her assistance lie drew off by the catheter about 7 or 8 quarts of urine. He then attempted to throw up a clyster; but very little passed up, and it had no manner of effect. In the afternoon about 3 quarts of water tinged with blood were drawn off by the catheter. ' In order to discover the cause of these symptoms, Mr. Wall introduced a finger into the vagina, which could not pass up on account of a large tumour that lay behind the vagina, and pressed it close to the inside of the ossa pubis. As there was not room to pass the finger, he could neither reach the extremity of the vagina nor could he discover anything like the os uteri. ' After this he examined the rectum, and found that the same tumour, which lay above and before the gut, pressed it so strongly against the gut inside of the os coccygis, etc., that the finger could only be passed a very little way. ' These circumstances made Mr. Wall recollect a case of retroverted uterus which M. Gregoire had given in his lectures at Paris. He then concluded that this was a case of the same nature, and attempted to reduce the uterus by laying the patient on her back, and by assisting with one finger in the vagina and another in the rectum, as M. Gregoire had directed, but without any success. The poor woman continuing in great pain, Mr. Wall came to me on Saturday, the 1 9th, gave me an account of what had passed, and desired me to visit her with him. We found her exceedingly weak and suffering great pain. She was lying upon her back. I passed my finger between the tumour and the inside of the os pubis, a little to one side of the urethra, upon which a considerable quantity of urine was discharged, as my finger removed the pressure upon the urethra. We then proposed a second attempt to reduce the uterus to its natural situation, for which purpose we placed her upon her knees and elbows, with her head and shoulders as low as possible. Then I introduced one hand into the vagina and two fingers of the other hand into the anus, and endeavoured to replace the uterus by pushing it up with the two fingers, and at the same time by trying to draw down the upper part of the vagina, which was considerably retracted from its natural situation. But these attempts were all in vain ; she became weaker every hour, and died on the Monday following. ' On Wednesday we were allowed to open the body. Upon cutting into the abdomen we found the bladder amazingly distended with urine, and filling up almost the whole anterior region of the abdomen, like the uterus in the last months of pregnancy. ' When urine was discharged by opening the bladder, we observed that the lower part of the bladder, which is united with the vagina and cervix uteri, and into which the ureters are inserted, was raised up as far as the brim of the pelvis by a large round tumour (viz., the uterus), which entirely filled up the whole cavity of the pelvis. We then passed a catheter up the vagina, and observed that it raised up the bladder at the top of the tumour — a demonstration that the upper end of the vagina, and consequently the os 268 OPERATIC E MlhW lli:i:Y uteri, was situated there ; and upon making a crucial incision through the bladder and vagina at that place, we found that it actually was so. The os uteri made the Bummit of the tumour upon which the bladder rested, and the fundus uteri \\.i> turned down towards the os coccygis and anus. The uterus in that retroverted state was grown bo large, and thence so wedged in the pelvis, that we could not take it out until we had cut through the symphysis of the ossa pubis, and torn these bones considerably asunder to enlarge the Bpace within the bones of the pelvis.' After Hunter's communication the subject seems to have given rise to a great deal of interest, for one finds in the ' Medical Observations and Inquiries,' vol. v., no fewer than four different communications. In addition, there seem to have been discussions regarding it, for Hunter speaks of ' the very existence of such a disease having been contradicted, till of late, at least, in a neighbouring enlightened country.' Varieties of Backward Displacement of the Gravid Uterus.— In backward displacement of the uterus in the non-pregnant it is customary to distinguish two varieties — viz., retroversion and retro- flexion ; for, although the two have much in common, each has a significance peculiarly its own. If this distinction is admitted to be useful and desirable in the non-pregnant, should it not also be adopted in the gravid '? In writing on this subject, Leishman 1 remarks: 'As the clinical history of the two classes of cases is essentially different, it is necessary that a clear distinction be drawn between them.' Such was the attitude of all writers in the middle of the last century, as may be seen from the descriptions by Burns. Rigby, and others. Towards the end of the century, however, less importance was attached to the matter, and the two terms were employed indiscriminately. In our country retroversion was, and still is, the term most favoured — in all probability because it was the one employed by Hunter. The same also applies to France. In Germany, on the other hand, retroflexion is the one in more general use. Quite recently, however, in such important monographs as those of Diihrssen- and Chrobak, 3 the essential differences between the clinical features of the two displacements have been again emphasized. Not content with the broad distinction between the two groups mentioned, some writers have subdivided retroversion into three different degrees — it is impossible to do this with retroflexion. This subdivision of retroversion goes back to Hunter's time, for in his last 1 ' System of Midwifery, 1 2nd edition, p. •27'.'. - Archvof. Gyn., Bd. Ivii., 1899. Samml. Klin. Vortrage, No. 377, 1904. BACKWARD DISPLACEMENT OF THE GRAVID UTERUS 269 paper on the subject, published in 1776 under the title ' Summary Remarks on the Retroverted Uterus,' he says: ' In this distressing state the uterus may be (1) fully retroverted, (2) half retroverted, (3) so far in its natural state that the body of the uterus shall be downwards.' One sees from this division how carefully Hunter had been observing the cases that had come under his notice ; indeed, so accurate is his classification that it practically is the same as the one given in the monographs already mentioned. Hunter, however, Fig. 127. — Sacculation and Partial Retroversion of the Gravid Uterus. (Dr. W. L. Reid.) did not recognize a retroflexion, although Lynn suggested the term in the case he reported. While agreeing in the main with the contention of Diihrssen and Chrobak, that the two varieties are distinct, I am inclined to side with Wertheim, 1 who thinks the distinction more of theoretical interest than of practical importance. It is perfectly true that with extreme retroversion symptoms appear later, and the replacement of the uterus is more difficult to effect than when the organ is retroflexed or only half retroverted. The essential features of the two conditions- are the same, however. 1 Winckel's ' Handbuch,' Bd. ii., Teil i., 1904. 270 OPERATIVE MIDWIFERY But there is yei another variety, and in some respects it is the most interesting, where u portion of tin; uterus remains imprisoned in the pelvis, while the anterior and upper pari o! the wall, as the organ enlarges, extends into the abdomen. It has been variously described as 'partial,' ' incomplete,' and 'spurious* retroflexion. In recent years, however, another term for the condition has come to be employed — viz., 'sacculation' of the uterus. The historical example of the variety, and the one generally quoted, is Oldham's, , although the condition was known long before Oldham described his case. The illustration (Fig. 127) given here is from a case described by Dr. W. L. Reid, 1 of Glasgow, who kindly lent me the block. Features and Progress of the Condition. — As has been already indicated, the condition is found almost without exception in women who have suffered from a backward displacement. It is stated to have followed once or twice some fall or jerk when the bladder was over- distended, but if such cases have occurred, they are very exceptional, as the overdistension of the bladder is the result, not the cause, of the complication. Very occasionally old adhesions, tumours, deformities of the pelvis, especially undue projection of the promontory, have been found. These conditions will be referred to later. At first the condition gives rise to little discomfort. As a rule the third month has almost been completed, and the uterus has become slightly incarcerated, before any symptoms present themselves. This statement, however, must be qualified, for occasionally reflex dis- turbances, such as hyperemesis, are more marked, and are immediately relieved if the displacement is recognized and corrected. It is the bladder which suffers in retrodisplacement of the uterus during pregnancy, for, beyond emptying itself, the uterus escapes as a rule. The first evidence of the displacement is in most cases a difficulty in urination, and, indeed, so characteristic of the condition is this symptom that dysuria in the early months of a pregnancy should alw r ays arouse in one's mind the suspicion of backward dis- placement. The time of its onset is, as a rule, the twelfth to the fourteenth week, but the size of the uterus, and especially the variety of dis- placement, influences this not a little. With retroversion of the second degree and retroflexion difficulties in urination appear earlier than with extreme retroversion. In these latter cases the fourteenth or fifteenth week, or even later, may be reached before symptoms manifest themselves. The difficulty in urination, at first slight, gradually increases, although it must not be forgotten that occa- sionally it may come on quite suddenly, and so simulate retention, 1 Kdin. Obst. Trans., vol. v., 1879. BACKWARD DISPLACEMENT OF THE GRAVID UTERUS 271 the result of an acute displacement. Finally, complete retention of urine occurs, or sometimes an incontinence, clue to an overflow ; and this has led a casual observer to overlook the real nature of the condition. Mechanical pressure upon the neck of the bladder by the displaced cervix is generally given as the reason for the retention, although, at first, the latter probably results from o j dema of the bladder wall, produced by the cervix pressing upon the veins and retarding the circulation about the neck of the bladder. Reed 1 discusses this matter in detail, and considers it due chiefly to pressure upon the nerves supplying the bladder. Several writers, including Barnes, describe and figure the bladder cavity becoming divided by the cervix into two unequal parts. This, however, as Duhrssen points out, can only occur in cases of extreme retroversion. I have certainly observed it in one case. As a result of the retention of urine, the bladder becomes enor- mously distended. Its wall becomes also much thickened ; in one case, at which I assisted Professor Murdoch Cameron, the wall was as thick as that of the gravid uterus. In part this increase in thickness is a true hypertrophy, but to a considerable extent, owing to pressure upon the veins about the neck of the bladder, the wall of the latter becomes cedematous and more or less extensively necrosed. Portions of mucous membrane, sometimes the whole mucous mem- brane, and occasionally, in exceptional cases, even the muscular and peritoneal coats of the bladder, become separated and expelled per urethram. The cases of this nature in which practically the whole bladder wall is shed are of extreme interest. In the English language Haultain's paper is very complete up to 1890. 2 Since then, Duhrssen, Chrobak, and others, have referred to a number of cases. One can understand how the mucous membrane may be shed, and even how a layer of the muscular tissue may come away, but how the whole muscular and even the greater part of the peritoneal coat may become detached is more difficult of comprehension. Such an occurrence, however, is now admitted by everyone. In the cases which recover, a new receptacle for urine forms. With the injuries to the bladder mentioned, conditions are most favourable for the invasion of septic organisms, with the result that all degrees of local inflammation follow, and neighbouring structures and organs become matted together. Although this, to a great extent, forms a protection against a general peritoneal infection, it may very decidedly prevent reduction of the uterus. At any time these pro- 1 Amer. Journ. of Obst., 1904, vol. xlix., p. 155. - Edin. Med. Journ., June, 1890. 272 OPERATIVE Mll'W M-KliY tecting adhesions may give way owing to the growth of the ovum or as a result of artificial attempts at n.luction. A general peritonitis naturally follows. llupture of the bladder, which may occur spontaneously or may follow manual attempts at rectification, is the most serious of all Fig. 128. — Fatal Septic Cystitis, with Rupture of the Bladder, following Retroversion of the Gravid Uterus. (Lloyd Roberts.) accidents, and is invariably fatal. Llo}-d Roberts 1 recently recorded a case, the illustration of which he has kindly allowed me to introduce here (Fig. 128). Gottschalk, 2 in his collected series of 1 Jowrn. Obst. and Qyn. Brit. Empire, vol. x., July, 1906, p. 51. - Archivf. Gyv., 1894, Bd. xlvii. BACKWARD DISPLACEMENT OE THE GRAVID UTERUS 273 seventy cases, found it occurred eleven times, while Berge, 1 in his collection of ninety fatal cases of incarceration of the gravid uterus, found that the cause of death proceeded from the bladder in 80 per cent. Following the overdistension of the bladder, the necrosis of its walls, and the infection of its contents, distension and infection of the ureters and kidneys — pyonephrosis and pyelitis — may supervene. Aery much less severe than the urinary complications described are disturbances of the bowels. Constipation is often very persistent, and Dienst 2 quite recently described a case of obstruction of the bowel, but, as far as I can gather, there is only one fatal case on record, that by Treub, 3 where, at the post-mortem examination, the compressed colon was found gangrenous. A still rarer complication is where the distended uterus has been pushed down between the vagina and rectum, and finally protrudes through one or other of these canals. The most striking example of this kind, where the fundus bulged into the vagina, is recorded by Grenser and quoted by Barnes. 4 Halbertsma 5 records one in which the uterus caused the rectal wall to bulge through the anus. The uterus itself, however, did not bulge through the anus, as some writers have stated. A very rare occurrence is rupture of the uterus; Main 6 has described such a case. As the disease advances and remains untreated, a variety of symptoms appear, such as rapid pulse, febrile temperature, furred tongue, and, shortly before death, great restlessness and delirium. These, however, are for the most part the results of septic infection. So far as we have considered the complication, its progress has been from bad to worse. But while such is the course run by many of the cases which come under observation, there is a very large number in which the displaced organ spontaneously rights itself, and an equally large number, probably, in which abortion occurs. The relative frequency of these two occurrences is difficult to estimate, but con- sidering how common backward displacement of the uterus is, and how frequently such a displacement is discovered when dealing with cases of abortion, one is justified in the conclusion that each of the terminations, spontaneous rectification and abortion, frequently happen. A most interesting paper by Herman 7 deals with this 1 Monat. f. Gel. u. Gyn., 1901, vol. xiii., p. 812. - Dent, Med. Woclu, November 16, 1905. 3 Journ. Obst. and Gyn. Brit. Empire, June, 1905. 4 ' Obstetric Operations,' p. 222. 5 Monat. f. Geb., vol. xxxiv., p. 414. 6 Archiv f. Gyn., Bd. lviii., p. 125. 7 Brit. Med, Jour?i., 1904, vol. i., p. 877. 18 -7 1 <;i:atiyi: midwifery i - - in the London B J85 tojj 8 inclusive, and those of Champneg 3 tholome 1 tall from 1881 1 392 there were 11". i in these only! _ . In ti - Herman llfcsi — 1 in 8 I in 17. Without doubt, when tl. - advanced to tl • symptoms of i: aboi ot nearly so frequent. Am • it writers who make! a distinction ;i retroversion and retroflexion it is gener agreed that with both abortion is liable to occur, and with bot: in the ease of extreme retroversion, spontaneous rectification otv infinitely more frequently than incarceration. The generally acce] .anation of spontaneous rectification, which, by the way, rarely occurs after any manifestation of in tion, is that the uterus, ..- _- the retroflexed part out of the pelvis. Under strong uterine contractions this may occur suddenly, but in many cases it is a gradual pi ■ --. Contractions of round ligament are not generally accepted as having much to do with spontaneous rectification. But there is the third group, in which a portion of the ute: - left behind in the pelvis. This is now referred to as partial retro- flexion or sacculation of the gravid uterus. It is quite possible in certain cases, where, for example, a tumour of the uterus or the ovary exists, that the retrodisplacement is really secondary, the tumour preventing the uterus from extending upwards in the abdomen, but in other cases it is certainly the result of adhesions. I once saw a case where a myoma of the uterus prevented the fundus from rising and caused sacculation, while a fe - ago a c - sent to me where a broad-ligam had a similar effect. Croom, 1 IHihrssen, 2 and others, have recorded similar cases. As examples sacculation, the result of a portion of the gravid uterus remaining behind, mention may be made of the -eribed by Oldham, 3 Merriman, 4 Barnes, 5 Hicks. Reid, 6 and Diihrssen. 7 A case of very great interest is one recorded by Macleod, 8 where pregnancy went on to term and the child was delivered .ean ion. When the abdomen was opened, a small fibroid • covered in the anterior uterine wall, and the fundus could not be raised because of the adhesions to the neighbouring struct . As -: :ed before, I do not consider that it serves any purp 1 • Clinical Papers,' 1901, p. 203. " 3 Lond. Obst. Trans., vol. i.. p. 317. 1 • A Synopsis of the Various Kinds of Difficult Parturiti' . eii., p. ■- Edin. Obst. Tr,. - vol. v.. p. 56. j . • '.. p. T ■ Brit. Med. Journ., 1901. vol. i.. p. I BACKWARD DISPLACEMENT OF THE GRAVID UTERUS 275 distinguish between sacculation and partial retroflexion, particularly as the features of both are in all essentials the same. Although bladder troubles occur with sacculation, they are seldom so extreme, and there is never the extensive destruction of the bladder walls which is so common an occurrence in the ordinary varieties of displacement. Abortion is common, but in not a few pregnancy has continued to term. Diagnosis. — The diagnosis of retrodisplacement of the gravid uterus is not. as a rule, difficult. Prior to incarceration there are generally no symptoms whatever, although on passing the examining linger into the vagina a large swelling is felt, and the vaginal canal is found to run directly upwards behind the symphysis. High up, sometimes higher than the finger can reach, is the cervix. A bimanual examination reveals the absence of the uterine body in front, ami presence in Douglas' pouch behind. Suppression of menstruation, alteration in the breasts, etc.. and enlargement of the uterus, decide one in favour of pregnancy, in addition to a backward displacement. It is unnecessary to explain that tumours of the ovary, myomata. and harmatocele may simulate or be simulated by a retrodisplaced uterus, and that each of these conditions, especially if there is a coexisting pregnancy, is only to be determined by a careful con- sideration of the case in all its aspects, and, above all, by a most careful bimanual examination. Later, when symptoms of incarceration exist, and especially if they have existed for some time, and the bladder wall has become much thickened, exact palpation of the pelvic and lower abdominal contents becomes most difficult. All are familiar with the error of mistaking a distended bladder for a tumour, and the simple means of preventing such an occurrence — viz., emptying the bladder by catheter. But in cases in which difficulty in urination has existed for some time, even after the bladder has been emptied and retracted, so thick are the walls of the latter that the organ can sometimes be felt above the symphysis, just like a uterus gravid to the third or fourth month; thus the retracted bladder may be mistaken for the gravid uterus, and the swelling in Douglas' pouch — the gravid uterus — for an ovarian or myomatous tumour. Such an error is made evident by passing a sound into the bladder and feeling it through the abdominal wall, high up, inside the swelling, that projects above the symphysis. There is a feature invariably present, and one which seldom exists to any extent in other conditions simulating incarceration of the retrodisplaced gravid uterus, and that is the great difficulty, often the inability, to pass urine. As far as I have seen, no tumour, be it uterine or ovarian, incarcerated in the pelvis and pressing upon 276 OPERATIVE Mll>\YIIT.l;Y the bladder and aterae ever gives rise to such extreme and persistent difficulty <>f micturition as does the incarcerated retrodisplaced litems. Certainly I have seen both ovarian cysts and myomata of the uta causing urinary trouble, once or twice to the extent of requiring catheterization, but never the persistenl obstruction one finds with the complication at present under discussion. There is one other condition which, occasionally, very closely resembles retroversion of the gravid uterus — viz., extra-uterine pregnancy, especially if the sac has ruptured and there is a pelvic hematocele. Curiously enough, in this condition also there is often some difficulty in micturition, although it is never so extreme as in retrodisplacement. Here is a case which was under my care : Extra-Uterine Pregnancy simulating: a Retroflexion of the Gravid Uterus. J. C , aged thirt} r , 3-para, was admitted to the Western Infirmary under my care on March LI, 1898. The patient complained of pain in the right side and difficulty of micturition and defalcation of four weeks' duration. She had had two children, the last eight years before. Menstruation had always been regular since the age of fifteen. Her last period was on November 12. About four weeks prior to admission she began to have pain in the lower part of her abdomen. A week later she took to bed, where she remained until trans- ferred to hospital. While confined to bed, she had considerable difficulty in passing urine and very obstinate constipation. On bimanual examination, the cervix was found pressed against the symphysis pubis and higher than normal. This was caused by a large tumour filling up the pouch of Douglas and extending slightly above the brim. There seemed to be a certain amount of mobility in the tumour. < >n careful palpation, the anterior wall of the uterus seemed to lie continuous with the upper part of the tumour, and the posterior lip of the cervix with the lowermost part. I had no hesitation in making the diagnosis of retroflexion of a gravid uterus, a diagnosis that the patient's medical attendant had made before sending her to hospital. Attempts at replacement under chloroform were made, but although the tumour could be raised, it was impossible to get it completely above the promontory of the sacrum. For some days after these manipulations there was bleeding and pain in the lower part of the abdomen. These symptoms, however, disappeared with rest and morphia suppositories. Ten days later she was again carefully examined under chloroform, when I began to be doubtful about the corn ness of the diagnosis. The condition of the parts was exactly the same as on her admission. On the day following the second examination, Professor M. Cameron having returned, we saw the case together, and he quite agreed that it had all the appearances of retroflexion of the gravid uterus. As, however, the BACKWARD DISPLACEMENT OF THE GRAVID UTERUS 277 patient's condition was not satisfactory, lie advised passing the sound, which was done. It passed into the uterus about 3 inches in the normal direction. The case was therefore cleared up. The following day the abdomen was opened, and a large sac of an extra uterine pregnancy moulded to the posterior wall of the uterus removed. It was adherent to the surrounding parts, and was situated exactly in the middle line deep in the pouch of Douglas. The pregnancy had advanced to almost the fourth month, to judge by the foetus contained in the sac. Many examples of this mistake have been described. Most of the text-books on midwifery mention it, and not a few monographs and communications to various societies exist on the subject. For example, Giles 1 records two cases, while Barbour 2 has made two communications on the subject. The more recent monographs of Diihrssen, Chrobak, and Wertheim, all refer to it in some detail. As illustrating the danger of a mistaken diagnosis, mention may be made of the case reported by Van der Haeven. 3 The woman was a primipara three months pregnant, where a diagnosis of retroversion of the gravid uterus was made. After the tumour in Douglas' pouch was apparently replaced, profound collapse came on and a retro-uterine hematocele formed, evidently from rupture of a gravid tube. An error of the opposite nature is a case recorded by Asterblum, 4 where the pouch of Douglas, and then the retroiiexed uterus gravid to four months, were opened, in the belief that the condition was a hematocele. Death followed from sepsis. When the abdomen was examined post mortem, an inflammatory exudation covered the retrofiexed uterus. Undoubtedly, the diagnosis between the two conditions is often difficult. Indeed, judging by the reported cases, the symptoms may be almost exactly similar. The fact, however, that with extra-uterine pregnancy one usually gets a history of attacks of pain and of irregular discharges of blood, that the retention of urine is seldom so complete, that the contour of the sac is less uniformly smooth, and that the cervix is seldom so much displaced upwards, will usually clear up the diagnosis. Barnes 5 lays special stress on the position of the cervix. He says : ' One general fact of great service in forming a diagnosis is this — almost all bodies which get into Douglas' pouch come from above, and so push the uterus, not only forwards, but at the same time downwards, thus bringing the os uteri within easy reach and pointing downwards. On the other hand, retroversion of the uterus lifts the os upwards and tends to throw it forwards.' 1 Lond. Obst. Trans., vol. xxxix. - Trans. Edin. Obst. Soc, vol. xix., p. 156. :! Epitome No. 318, Brit. Med. Journ., 1898, vol. i. 4 Zent. f. Gyn., 1905, p. 154. 5 Op. cit, p. 226. 278 OPERATD E MIDWIFERY Theoretically that may be correct, but in practice it is aot alwayt as witness Barbour's case, where the cervix was 'above reach,' and the case I have reported, where it was distinctly higher than usual. The irregular discharges of blood, so helpful in the differential diagnosis, as pointed out 1>\ Barbour, are not always present, as in my case they occurred only after manipulative attempts at replace- ment. On the other hand, in retroflexion they may occur if abortion threatens, as was illustrated by a rase recently under my care. In the case of partial retroflexion or sacculation, the diagnosis is often extremely difficult, and the records of almost all the cases already referred to show this. Indeed, in a number the true state of matters was only appreciated when the finger was introduced into the uterus. Besides, in many cases a tumour was also present. "What adds to the difficulty is the fact that the sacculation is often cedematous, and so simulates a tumour of ovary or uterus. Undouhtedly, in some few- cases the foetal head has heen felt through the thinned-out wall, hut this was not so in Reid's case (Fig. 127), for the placenta was implanted in the sacculation. Advanced extra-uterine pregnancy is stated to simulate the con- dition of sacculation, although in neither of the two cases of the condition which I have seen was there any very marked projection of the tumour into the pelvis. There are, of course, exceptions, as in Phillips' 1 case, but in a very large number of recorded cases of advanced ectopic pregnancy which I have consulted projection of the sac into the pelvis has not heen a feature. It is obvious, therefore, that no rule can be laid down for guidance in such cases. This, however, may be said, that a consideration of the history and a careful examination, repeated if necessary, will usually result in a correct appreciation of the nature of the condition. Treatment. — Before discussing the treatment of cases in which the retrodisplaced gravid uterus has hecome incarcerated, it is well that we consider for a moment the means that should he adopted to prevent the occurrence of this complication. As retrodisplacement of the uterus, without doubt, is occasionally a harrier to pregnancy, there is much to he said in favour of correcting all cases of backward displacement in the married prior to the meno- pause, even although no symptoms are present. Whatever view one takes as regards that matter, all are agreed that, whenever a dis- placement is discovered during pregnancy, it should be corrected, particularly if the case is one of extreme retroversion. In most cases such rectification is easy, and can he carried out by pressing the fundus upwards from the vagina. In a certain number, however — and 1 Obst. Tnms, 1900, vol. xlii.. p. 121. BACKWARD DISPLACEMENT OF THE GRAVID DTERUS 279 I had one of the kind recently under my care — the uterus cannot he replaced by such means, even although it is not fixed by adhesions behind. Under such circumstances, the other means at our disposal, which we shall consider later, may be tried, or the patient may be kepi in bed and spontaneous rectification allowed to occur. If the latter coarse is pursued, an examination should be made from time to time, and a little pressure exerted upon the fundus. It must be remembered, however, that examples of extreme retroversion are not suited for such expectant treatment. After the uterus is replaced, a vulcanite pessary of the Hodge or Albert Smith form should be inserted into the vagina, and retained there until about the fourteenth or fifteenth week. By that time the uterus has become so enlarged that the pessary may be safely removed without any risk of the uterus falling back into the hollow of the sacrum. In the early weeks of pregnancy, while the pessary is being worn, the patient should be very careful, and I always put such patients to bed at the times which would have been menstrual periods had pregnancy not existed. Whenever, upon examination, one finds a retrodisplacement pre- senting features of incarceration, replacement naturally becomes imperative. It must, however, be remembered, in the treatment of this condition, what has been frequently remarked regarding its symptomatology, that attention to the bladder is everything. So important is this that in many cases, if the patient is put to bed and the bladder kept empty by catheter, the malposition of the uterus will correct itself. It is therefore my rule to keep the bladder empty for a day or two before making any attempt at replacing the uterus, if there has been any great urinary difficulty. Particularly should this rule be followed if there are evidences of cystitis and extensive necrosis of the bladder wall, for during forcible attempts at replace- ment, under such circumstances, rupture of the bladder has occurred on several occasions. It has occasionally happened that difficulty has been experienced in passing the catheter, but if a gum-elastic one is used that is never serious, so that suprapubic puncture of the bladder need not be con- sidered. There are, of course, cases where there is difficulty in withdrawing the urine, owing to the necrosed portions of bladder wall blocking up the catheter. Such cases we shall consider immediately. When cystitis exists, the bladder should be regularly irrigated with a weak saline solution. In the extremely severe cases, where there is a large quantity of blood-clot, necrosed bladder wall, and stinking urine, much more radical treatment becomes necessary, or the debris cannot be washed out. The bladder must be emptied, therefore, through the dilated urethra, or if that is impossible it 280 OPERATIVE Mil >\\ I PERU must be opened int. i. The former proceeding is not much favoun for, under the circumstances, n Bafficient dilatation of the urethra is hardly possible. One is left, therefore, to choose between making the <>l>cninu r from above or from below. Sinclair and Pinard have recorded cases iii which the bladder was opened and washed out from below. A most interesting case ie recorded by Cameron, 1 where the bladder v opened into from ahove, all blood-clot and debris cleared out. and 1 finally stitched, after which the uterus was replaced and the abdoi closed. The patient not only recovered, but pregnancy was uninter- rupted, and she was delivered of a living child at term. Having attended to the bladder in the manner indicated, one is in a position to attempt replacement of the uterus. In mosl of the cases simple manual manipulations are all that is necessary. After having placed the patient in the knee-elbow position, or, what i- equally efficacious, the Sims position, two fingers are passed into the vagina. and steady pressure exerted upon the fundus. The advantage of the Sims position is that it does not preclude the administration of an anaesthetic, while attempts at replacement are being made. "When pushing up the uterus in order to avoid the promontory, pressure should be made more to one side, and preferably to the right of the pelvis, for the fundus is most commonly directed to that side, and there is a little more room there. I do not favour carrying out the manipulations from the rectum, as Hunter suggested and a few operators have since advocated, notably Herman, 2 who claims that one can exert pressure higher up. If, after several attempts, success does not follow, one should desist, and leave the patient for twenty-four hours, as there are many cases on record where, after fruitless attempts at manual replacement, the organ has spontaneously righted itself. Here is an example from my own practice : Incarcerated Retroflexed Gravid Uterus which after Several Fruitless Attempts at Replacement righted Itself. H. H , aged thirty-one, 3-para, came under my car.' at the Western Infirmary, Glasgow, in August, 1894. She stated she was about four months pregnant. She complained of great pain in the abdomen and difficulty of micturition, witli an almost constant dribbling of urine, of about four weeks' duration. Her first pregnancy was normal in every respect, but her last, in 1887, terminated in a miscarriage at the third month, she last menstruated on April 28, just about four months before her admission to hospital. The symptoms of dysuria, etc., came on, therefore, at the end of the third month of the pregnancy. On examination, the abdomen was much distended and tender to pressure. 1 Brit. Mr,l. Jaunt.. Octoher ">1. ls'.lti - Ibid., 1904, vol. i., p. *77. BACKWARD DISPLACEMENT OF THE GKAVID UTEBUS 281 The bladder being emptied (GO ounces of mine were drawn off), the distension and tenderness of the abdomen disappeared. On bimanual examination, the cervix was found raised and pressed against the symphysis pubis by the very much enlarged body, situated in Douglas' pouch. The diagnosis of retroflexion of the gravid uterus made by her medical attendant prior to admission was confirmed. Attempts were made to replace the organ, but failed, even when she was placed in the genu-pectoral position. 1 therefore advised the house-surgeon to keep the bladder empty by passing the catheter every eight hours, to see that the bowels were thoroughly emptied, and to prepare the patient for chloroform on the following day, when further attempts would be made to rectify the displacement. The woman was told to lie well round on her face, and to sometimes assume the genu-pectoral position. After my attempts at replacement she ex- pressed herself as feeling much relieved, and she was able to pass urine quite freely a few hours after. On examination the following morning, prior to giving her chloroform, great was my surprise to find the uterus in normal position. .She was dismissed a few days later feeling perfectly well. When, after repeated attempts at short intervals, manual reposition proves unsuccessful, there are several manoeuvres which should be tried. Amongst the simplest is pulling down the cervix with volsellum forceps while pressure is exerted upon the fundus by the fingers (Fig. 129). I have, however, always found, and other operators have had a similar experience, that the cervix of the gravid uterus very readily tears, and that one cannot, therefore, put much traction upon it ; besides, one often cannot reach the cervix. Much better is the device of employing a colpeurynter distended with water or quicksilver, as Albert 1 and Funke have advocated. The safest way of employing the colpeurynter is to leave it distended in the vagina, and allow the steady pressure of it to gradually push up the fundus. One can, however — and, if I mistake not, Olshausen advocates the method — place the colpeurynter in the vagina and distend it while the patient is in the lithotomy position, and then allow the legs to fall down as in the Walcher position. A similar device, recommended by Sinclair 2 and others, is the employment of a watch-spring pessary of such a size that when intro- duced into the vagina it maintains an oval shape, and so exerts a steady and constant pressure upon the displaced fundus. It is quite obvious that the colpeurynter or watch-spring pessary can only be employed if there is room in the vagina. In Sinclair's most interesting case this could only be attained after the bladder had been cleared of the debris it contained, and the cervix had been pulled down by volsellum forceps. 1 Miinch. Med. Woch., 1903, No. 12. Trans. Lond. Obst. Soc, vol. xlii. , p. 338. 282 OPERATIVE MlhWIl'KllY Such arc the devices to be tried for the correction of an incarcerate. 1 retrodisplaced gravid uterus. Tiny almost invariably Bucceed, and, indeed, Borne operators go the length of Baying that they never fail. Siu-li a position, however, is too extreme. It is certainly very striking that many accoucheurs <»f wide experience have never encountered a case of irredncible retrodisplacement of the gravid uterus, a fact which should always lead one to pause before pronouncing the displacement Fig. 129.— Replacement of Incarcerated Retroflexed Uterus. [After Bumm.) irreducible, and to question the judgment of such an operator as Jacobs, who has described twelve cases in which he had to perform abdominal section. Admitting, then, that although rare cases are now and then encountered in which replacement by the ordinary methods already described is impossible, let us consider for a moment the means at our disposal for treating such very troublesome cases. There are two courses open to one in dealing with cases of irre- BACKWARD DISPLACEMENT OF THE GRAVID UTERUS ducible retrodisplacement of the gravid uterus ; one is to empty the uterus from below, and the other to open the abdominal cavity and replace the uterus by pulling the fundus up while an assistant pushes it from the vagina. The former alternative was the only method employed until recent years, and induction of abortion by passing a sound or elastic bougie was the proceeding most favoured. But in not a few cases, particu- larly if the condition was one of retroversion, it was found impossible to introduce the instrument. In such cases puncture of the uterus from the vagina or rectum was recommended, and as recently as 188ft we find Barnes writing : x ' If it be found impossible to pass an instru- ment through the os uteri, if induction be also impossible, and the symptoms urgent, it is justifiable to puncture the uterus by the vagina or rectum.' Barnes preferred puncture from the rectum. He says : ' The rectum is to be preferred, because puncture there is more certain to tap the body of the uterus and to keep clear of the cervix.' Some years later Sanger 2 suggested incision and emptying the uterus from the vagina, and this proceeding was successfully carried out quite recently by Wennerstrom. 3 Olshausen, in a case in which the uterus was irredu- cible because of pelvic deformity, removed the whole organ per vaginam. In recent years, however, the possibility of replacing the uterus from the abdomen without sacrificing the child has become more evident every day. Laparotomy for the condition under consideration was suggested years ago. Burns, for example, in the tenth edition of his text-book, published in 1863, writes (p. 298) : ' It has also been asked whether it would not be allowable to make an incision into the abdomen and push up the uterus. Section of the symphysis has also been proposed.' The latter treatment — symphysiotomy — has been suggested from time to time, and is of special interest, for it will be remembered in Hunter's historical case that, at the post-mortem examination, it was only after the symphysis was divided that the displaced uterus could be raised from the pelvis. The successful results obtained by laparotonry have brought that treatment more and more into favour, and many cases are now on record. One of the earliest was Cameron's, already referred to. Jacobs, 4 Mann, 5 MacLean, 6 Mouchet, 7 and Handfield Jones, 8 are a few 1 Op. cit, p. 228. - Zent. f. Gyn., 1894, p. 175. 3 Zent. f. Gyn. , 1903, p. 302. * Joum. d' Accouchement, April, 1898 ; and Epitome, Brit. Med. Journ., June 4, 1898. 5 A, tier. Journ. Obst., July, 1898. fi Ibid., August, 1898. 7 Annal. de Gyn. et d'Obst., December, 1901. 5 Journ. Obst. and Gyn. Brit. Empire, October, 1903. 284 OPERATIC E MII)\\ll'i:i;V operators who have recorded cases so treated I ig. L80 ■ Jacobs has operated upon as many as twelve cases, and in four of these he found adhesions of the litem- to Burrounding tissues. Handfield .lone-' is of special interest, for lie found the adhesions so intimate that owing to the patient- collapsed condition he could not proceed to their complete separation. Fig. 130. --Incarceration of the Retrofiexed Uterus. After Wertheim. In front the Madder is being dragged forward, thua permitting tin- uteri - J)i>tinct adhesions can be Been on the posterior surface of the uterus. Here, perhaps, it is well to mention that adhesions between fundus and surrounding tissues may be primary and the cause of the displacement, or secondary and the result of inflammation follow- ing septic infection from the bladder. In the former the adhesions will probably be very difficult, and sometimes impossible, to break BACKWARD DISPLACEMENT OF THE GRAVID UTERI'S 285 down, as in Macleod's case, but in the latter they will readily give way. In a few no adhesions existed. In a number where tumours were the cause, the removal of the latter allowed of replacement. The following case, which occurred in my practice, illustrates this (Fig. 131) : Incarceration of the Retroflexed Gravid Uterus with Broad Ligament Cyst— Laparotomy — Removal of Cyst — Replace- ment of Uterus — Continuance of Pregnancy. The patient, a fairly robust multipara, aged twenty-seven, was sent to me by Dr. Armstrong, of Kirkintilloch. She had had one child three years before. Fig. 131. — Retroflexion of Uterus caused by Large Broad Ligament Cyst. (Author's Case.)> The retractors are holding apart the edges of the abdominal wound while the hand is pulling the cyst over, thus permitting the retroflexed uterus being seen. The period prior to her present pregnancy was about December 27, 1903. I saw her first on April 28, 1904, when she told me that for six weeks she had been troubled with her urine — during four with frequency of micturition, but during the last two with retention. For two days Dr. Armstrong drew off the urine with catheter. Diagnosing the condition as an incarcerated retroflexed gravid uterus, he sent her to me. I examined her under chloro- form with him, and agreed that such was the condition, and that the cause 286 OPERATD E Ml l>\\ I IT.KY was probably a tuiiH.ur preventing the uterus from rising up. < m. May l, 1 opened the abdomen, and removed with Bome difficulty a cystic tumour about th<' size of a foetal bead from the lefl broad ligament. 1 then pushed up the uterus fr the vagina. The patienl made an excellent recovery, and the pregnancy was undisturbed until seven and a half months were reached. The difficulty in micturition, which disappeared after the operation, returned slightly for a week or two before delivery. She was delivered of a small seven and a half months child withoul trouble. 1 1 is specialty pleasing and encouraging that in a large number of! cases not only was the uterus replaced, but pregnancy continued. In all Jacobs' cases except one pregnancy continued; this also happened in the cases recorded by Cameron, Mouchet, Mann, and myself. In operating upon such cases, steady pressure from the vagina by an assistant is of the greatest help, and there is no don lit that it is an advantage to place the patient in the Trendelenburg position. If, in spite of such devices, I still found it impossible to raise the uterus, I would seize the organ with volsellum forceps, and try to get my fingers down behind the fundus, not only for the purpose of breaking down adhesions, but to allow air to get into the pouch of Douglas. Should it still be impossible, I would perform Cesarean section, empty the uterus, stitch it up, and perform ventro-fixation. But a word must be said regarding those rare cases of sacculation of the gravid uterus in which the pregnancy continues to term, llecently, as we have already seen, Macleod had to perform abdominal section for such a condition, and naturally such a proceeding is the onty course open to one, if the sacculation cannot be removed or the child extracted. As Merriman and others have shown, however, the uterine contractions of labour are sometimes sufficient to remove the sacculation, and in Reid's case delivery was completed by bringing down a leg. Sometimes the sacculation may be removed by pulling the abdominal portion of the uterus downwards and forwards, and push- ing the sacculation upwards and backwards. Olshausen and Barnes record successes after such manipulations. If laparotomy is necessary, one should only proceed to Csesarean section if there are other indications for that operation, or if one failed, as did Macleod, to pull up the sacculation. If the sacculation can be relieved, it appears to me desirable that the child be delivered, if possible, per vias naturales, although it might be considered wiser to perform Cesarean section if the uterus was the seat of myomatous tumours, and if the condition of the patient was such that a Cesarean section would disturb her less than a prolonged labour. FORWARD DISPLACEMENT OF THE UTERUS 287 Forward Displacement of the Uterus during- Pregnancy and Labour. All are aware that a feature of the early weeks of pregnancy, and one which sometimes assists the obstetrician in coming to a diagnosis of pregnancy in doubtful cases, is an increased degree of anteflexion. The reason for this occurrence is the increased weight of the fundus and the softening of the tissues at the upper part of the cervix. As a result of this increase of normal flexion and version, frequency of micturition results in not a few cases ; indeed, in the early weeks of pregnancy it is a very general complaint. There should never be, however, any confusion of such a system with ischuria paradoxica, which, as we have seen, is a feature of the incarcerated retrodisplaced uterus ; for, if the story of the patient leaves any doubt, a careful •examination of the condition of the pelvic organ will clear up any obscurity. In addition to this ' irritability of the bladder,' constipation may be aggravated, although I have never seen it more pronounced than one ordinarily finds it during pregnancy. Another feature emphasized by G-raily Hewitt and others is an aggravation of the sickness of the early weeks. Without attaching too much importance to anteflexion as a cause of hyperemesis, I must admit that on several occasions I have seen the latter condition associated with an undue forward displacement of the uterus. It might only be a coincidence, but it has been too frequently remarked by others to justify such an explanation. Besides, I have seen the sickness relieved, and only relieved, by correcting the displace- ment. There is no evidence that an undue forward displacement is associated with a tendency to abortion, but pelvic uneasiness, aching over the symphysis and down the thighs, and difficulty in locomotion, are features that have occasionally been found associated with the malposition. The diagnosis of the condition of exaggerated anteflexion or anteversion — it is unnecessary to distinguish between the two, although they both occur — is not difficult. On vaginal examination, the cervix is discovered tilted back and higher in the pelvis than usual- sometimes very markedly so — while at the same time the fundus is unusually low. On bimanual examination, it is readily made out that the swelling in part is the elastic anteflexed uterus. Occasionally, I must admit, it has felt very much like a myoma in the anterior uterine wall, but a myoma is harder. Incarceration of the antedisplaced uterus is never of any serious moment ; indeed, it is questionable if, properly speaking, it can occur. '.Should symptoms arise, and it is believed that the displacement is 288 OPERATIVE BilDWIFERl the cause, occasional pushing up ol the fundus, with the patient in the dorsal decubitus and the pelvis raised, and a tampon or col- peurynter, have proved successful. Later in pregnancy all are familiar with the falling forwards of the uterus in cases where the anterior abdominal wall is much weakened, where the uterine cavity i- unusually distended, and where the vertebral column and pelvis are deformed by disease. The cases with which we are really concerned here are those in which the anterior abdominal wall is at fault. A pendulous abdomen, especially amongst multiparous women of the working class, is not uncommon. This condition allows the uterus to project forwards and hang over the symphysis when the woman is in the erect position. The most marked examples of tho condition are found associated with distinct separation of the recti muscles. The worst case of the kind that has come under my care was where the cicatrix of an abdominal wound had given way. The displacement was so extreme that the uterus hung down over the patient's tin when she stood up, while, on vaginal examination, the cervix could hardly be reached. Eosner 1 has described a case where the gravid uterus became incarcerated in a ventral hernia. Abdominal section, and then Cesarean section, were necessary. The uterus was finally removed, because there was complete occlusion of the os externum. Extreme anteflexion of the uterus, besides being a source of great discomfort to the patient during the later weeks of pregnancy, may be the cause of considerable trouble in parturition. Malpresentations, especially breech and footling presentations, are very common. The uterine axis during labour being altered, and the resistance of the abdominal wall being lost, labour is retarded until the firm support of a binder is supplied. It is a great mistake to attempt to employ the left lateral position in these cases, as the heavy uterus falls over and the presenting part is prevented from engaging. This is especially the case if forceps is employed. The patient should be made to assume the dorsal decubitus throughout the labour. During the puerperium, also, anteflexion occasionally prevents the escape of the lochia, and a condition arises sometimes termed lochiometra. I have only once seen a typical example of this condition. "When I removed the ante- flexion and passed in an intra-uterine douche-tube, I was surprised at the quantity of pent-up lochia which escaped. The treatment of the condition is obvious — a firm abdominal belt. The material to be used is of no great importance, although a broad i Zent.f. Gyn., 1904, p. I486. PROLAPSE OF THE UTERIS 2s«> strip of flannel, over which is applied an elastic binder, is probably the best. ft will often be found in such cases as we are considering, especially amongst women of the poorer classes, that there is con- siderable irritation of the skin over the lower part of the abdomen and pubes, owing to chafing between the two surfaces. This is a distinct source of danger to the patient, for the irritated areas and the skin about the pubes harbour innumerable micro-organisms. Every pre- caution must therefore be taken to cleanse the part, and, if possible, have the raw surfaces healed before labour comes on. Prolapse of the Uterus. Prolapse of the pregnant uterus is sometimes observed in multi- paras who have suffered from prolapse for some time. The most extreme case of the kind which has come under my observation was an elderly multipara, four months pregnant, who, after some slight strain, had a complete procidentia of the gravid uterus, associated with complete urinary obstruction. On emptying the bladder, the uterus was easily replaced, and maintained in position with the help of a pessary. Slighter degrees of the displacement, where the os uteri has appeared or even projected beyond the vulvar orifice, I have, on a few occasions, observed, and in these cases there was generally also difficulty in micturition. As far as I can find, there is no case on record in which pregnancy has continued until term in a uterus completely outside the vagina, but there are one or two recorded where a considerable portion of the uterus, with limbs of the contained foetus, have projected behind the external orifice. The older writers frequently referred to acute prolapse during labour. Mauriceau and Smellie, for example, refer to such cases ; recent writers, however, rarely do so. I have once or twice seen the presenting head covered with the undilated cervix just within the vulvar orifice, and during extraction with forceps have even found the edges of the cervix appear outside. A case such as Jentzen's, 1 where there projected a portion of the head completely covered with the thinned-out cervix, is extremely rare. In that particular case the author incised the cervix and delivered a dead child with forceps. The patient was a primipara, and he states that before labour there was neither prolapse nor hypertrophy of the cervix. Naturally, the condition that is most likely to be mistaken for prolapse of the uterus is hypertrophy of the cervix, and, as a matter 1 Arch, de Tocol, Paris, 1890, vol. xvi., p. 268. 19 290 OPERATIVE .Ml l>\\ II'KltV of fact, the two conditions often coexist. Confusion is esp< -cialM liable to arise if acute odema of the cervix occurs. This condition, which has been referred to recently by several writers, is considered in Chapter XIII. The treatment of prolapse of the uterus is to replace the organ, and maintain it in position, if need be, by means of a support. If, however, the ordinary support— namely, ;i vulcanite or watch-spring pessary — is not sufficient, the patient should be kept in bed until the uterus is of such a size that it can no longer fall down. The replacement of the prolapsed uterus is seldom difficult. It might, I however, happen that, owing to adhesions or a tumour, replacement is impossihie, and although 1 am not aware of any such case. I see no reason why it might not occur, seeing that an irreducible prolapse in the non-gravid has been more than once described, for example, one recorded by Barbour Simpson. 1 In the event of such a condi- tion, two courses would naturally be open to one — namely, to empty the uterus or to perform abdominal section and remove the condition producing the prolapse. By adopting the latter means, one would hope that the pregnancy might continue. The cases in which there has been difficulty in reducing the prolapse have invariably been successfully treated by keeping the patient in bed and emptying the bladder at regular intervals, and, from time to time, pushing the cervix and lower part of the body upwards, for in these cases difficulty in replacement arises partly from the overdistension of the bladder, and partly from the a-dematous condition of the cervix. Displacements of Uterus the Result of Vaginal and Abdominal Fixation. In recent years many operations have been devised for correcting backward and downward displacement of the uterus. The three most important have been shortening of the round ligaments (Alexander- Adam operation) ; incising the vaginal wall, pushing aside the bladder, and fixing the anterior wall of uterus to the vaginal wound (vaginal fixation) ; opening the abdomen and fixing the uterus to the anterior abdominal wall (hysteropexy or abdominal or ventral fixation). With the relative merits of these different methods we are not concerned, except in so far as they affect, disturb, or complicate subsequent pregnancies and parturitions. The one which undoubtedly does this least — in fact, I have never heard of it causing any trouble whatever — is the ' Alexander-Adam operation.' 1 Edin. Obst. Trans., 1904-05, vol. xxx., p. 94. DYSTOCIA FROM VAGINAL FIXATION •291 ( t )uite otherwise is it with ' vaginal fixation,' an operation which has been practised but little in this country, but which was for some time much favoured in Germany. After the introduction of the operation, some twenty years ago, it was universally advocated. Very Fig. 132. — Showing the Distortion of the Gravid Uterus which may result from Abdominal Fixation. (Edgar.) The arrow points to the adhesion between uterus and abdominal wall. I had a case recently almost similar. The adhesions to the abdominal wall were more intimate. soon, however, it was found that parturition was often very difficult, and that even Cesarean section was sometimes necessary as a result 292 OPERATIVE Ml I»W1I'KI;Y of the operation. Some few yearn ago we had, in the Glasgow Maternity Hospital. an illustration of the extreme dystocia that mighl result from vaginal fixation. A patient upon whom the opera- tion had been performed by one of our staff was brought into hospital in labour. On admission, the os was found displaced upwards and backwards. As it dilated, the presenting part refused to engage, and a leg was with difficulty brought down. As it was still found impos- sible to deliver the child, the operator performed Cesarean section. Similar cases have been recorded by Strassrnan, Martin, Wertheim, and others. In recent years, however, since it was appreciated that the dystocia in great part resulted from passing the ligatures too high up on the uterine wall, one reads of few cases of difficulty. In Stahler's case, 1 in which great dystocia followed a low fixation, it must be remembered that at the time of the vaginal fixation two myomata were enucleated from the body of the uterus, and conse- quently the adhesions to the tissues in front were very intimate. Both Martin and Diihrssen, in their recent writings, state that no dystocia follows a low stitching of the uterus (vesical fixation). The effect of hysteropexy or ventral fixation of the uterus on subsequent pregnancy and labour is a matter which is causing a good deal of interest amongst obstetricians at the present time. The matter is still sub judice, but it must be admitted, I think, that dystocia results somewhat more frequently than was at first imagined. There are now many contributions to the subject, and several writers in addition have collected and analysed the recorded cases. Noble, in 1896, discussed the subject from 206 collected cases, while recently Andrews- did the same from 395 cases which he had gathered from English, American, French, German, and Italian literature. The paper of the latter is a very useful one, for it contains not only a table of the cases, but also a very full bibliography. The following are Andrews' conclusions : 1. Ventral fixation may be the cause of great difficulties in labour. 2. These difficulties are due to too rigid fixation of the uterus. Eigid fixation of the anterior wall is not followed by so much difficulty as is fixation of the fundus or posterior wall. 3. The method of fixation involving least difficulty in labour is that in which the uterus is attached only to the parietal peritoneum, or peritoneum and subperitoneal connective tissue. 4. In women who may become pregnant after the operation it ia not advisable to anchor the fundus or posterior wall of the uterus by firm adhesions, such as would be useful in cases of prolapse in 1 Zent.f. dun., 1902, p. 176. 2 Journ. Obst. and Gyn. Brit. Empire, 190.3, vol. viii.. p. 97. DYSTOCIA FROM ABDOMINAL FIXATION ±m older women ; in other words, ' suspension ' should be performed in women who may subsequently become pregnant, fixation in older women. Since Andrews' paper several important contributions have ap- peared — one by Seegert, 1 and two in English, by Herman 2 and Giles. :{ Herman states (p. 11): 'If the operation is properly performed, subsequent difficulty in labour need not be feared ; by " properly performed " I mean that the anterior half of the fundus uteri is stitched to the muscle about half-way between the symphysis pubis and the umbilicus.' I am specially interested in Herman's remarks, as I have for several years performed hysteropexy in the manner he describes, although I have not been in the habit of stitching the fundus quite so high. Up to the present I have had one case of such very decided dystocia that I was compelled to perform Cesarean section. 4 In two of the cases abortion occurred, but later they, in common with the others, carried children to full time. One of the patients complained of very great pain during the early months of pregnancy. Giles' method of operating is more simple. Three silk-worm gut sutures are passed through the whole thickness of the abdominal wall, then through the anterior wall of the uterus, and out through the abdominal wall on the other side. He says : ' It is advisable that the sutures be passed low down in the anterior uterine wall in women of child-bearing age.' In his cases twelve became pregnant, five mis- carried, seven went to term, and of these latter five had normal confinements and two were delivered with forceps. Amongst the cases of dystocia may be mentioned those of Clark and Lee 5 and Caiman. 6 Cameron and Hocheisen 7 described a case of dystocia at the Gesellschaft fur Geburtshiilfe und Gynsekologie ; and Bumm, Nagel, Olshausen, Brose, all referred to difficulties that they had experienced. It is perfectly evident, therefore, that ventral fixation may occa- sionally cause dystocia. Roughly, somewhere about 1*5 per cent, represents the frequency. 1 Festschrift f. Olshausen, 1905. 2 Journ. Obst. and Gyn. Brit. Empire, January, 1906. 3 Brit. Med. Journ., vol. ii., 1906, p. 1188. 4 In this case the abdomen was twice opened before the Cesarean section was performed. 5 Johns Hopkins Hospital, 1905, p. 168. 6 Zent.f. Gyn., 1906, No. 6. 7 Ibid., 1906, No. 31, p. 80. < ii \iTi:i; x\ DYSTOCIA THE RESULT OF ABNORMALITIES AFFECTING THE PARTURIENT CANAL— ( 'ontinued Malformations of the Uterus and Vagina. It is only within quite recent years that special interest has attached to the occurrence of pregnancy in malformed uteri. In great part, no doubt, this is because the conditions were not appreciated, and because the general and erroneous idea prevailed that malformation of the uterus precluded pregnancy. Many interesting cases are now recorded, however, and every day their number is being added to. As giving an idea of the frequency of the malformation, I may mention that seven cases have been under my personal super- vision — three cases of uterus didelphys, one case of uterus bicornis unicollis, one case of uterus subseptus, and two cases of uterus cordiformis. Naturally, it is quite impossible to discuss in detail the various malformations of the uterus and vagina which may disturb preg- nane} 7 . I can only give an outline of the general course these cases run, and illustrate some of the difficulties which have been recorded and are likely to arise. It will be remembered that the tubes, uterus, and vagina are developed from the Miillerian ducts, and that these two ducts become fused, except the uppermost parts, which go to form the Fallopian tubes. The varieties of malformation encountered, therefore, are very numerous, and depend upon the extent to which development and fusion of the two parts, which should become blended, fail. The illustrations in Figs. 188 and 184 diagrammatically represent the various malformations which may be encountered. As one would expect, pregnancy in a uterus unicornis is of extreme rarity. Molderhauer's 1 is the only case I know of. although I doubt not others have been recorded. As regards uterus bicornis with a rudimentary horn, it is quite 1 Arch. f. Oyn., 1'xl. \ii., p. 175. 294 MALFORMATIONS OF THE UTERUS AND VAGINA 295 otherwise. Many cases of this malformation have been found where the normal half was pregnant, and many others where the rudi- mentary horn was gravid. Very rarely indeed is there an external communication with the rudimentary horn. Werth, 1 in his hundred collected cases, found a communication in nineteen. Interesting isolated cases have been recorded in this country by Galabin, 2 Targett, 3 Cameron, 4 etc. Fertilization in most cases takes place in the following way : The spermatozoa, which pass up the normal side and out of the Fallopian tubes, wander over to the other tube, and pass into it and impregnate the ovum. A common termination is rupture of the sac. This, according to Kehrer, 5 occurred in 47 per cent., and according to Werth in 45 per cent. Rarely does pregnancy continue to the later months ; but Becker 6 has described such a case. A correct appreciation of the nature of the condition is seldom come to until the abdomen is opened, for the round ligament and tube running from the distal margin of the sac — the feature which distinguishes the condition — are usually impossible to palpate. Targett, however, recognized the condition in his case prior to operation. The treatment is to remove the sac, which as a rule can be easily carried out, as Galabin, Targett, Doran, and others, have shown ; but I cannot linger over such cases, for clinically they present features more nearly resembling tubal pregnancy, and are therefore considered in Chapter XXXII. The simpler forms of malformation, such as uterus cordiformis and uterus subseptus, are of comparatively little consequence, except in so far that they favour the occurrence of oblique presentations, as we have already seen in Chapter VI. In the malformations where there are two distinct cavities the disturbances of pregnancy are less frequent than one might expect. In the two cases of uterus didelphys which have been under my care pregnancy continued until term. Labour was but little disturbed. The child was delivered with forceps when its head had reached the outlet. In both cases the vaginal septum was torn. The cases are briefly described on p. 298. 1 Winckel's ' Handbuch,' Bd. ii., Teil ii., 1904, p. 978, and Arch. f. Gyn. vol. lxxvi., p. 48. 2 Lond. Obst. Trans., 1895, p. 225. 3 Ibid., 1900, p. 276. 4 Journ. Obst. and Gyn. Brit. Empire, 1902, p. 67. 5 ' Das Nebenhorn der Doppelten Uterus,' Inaug. Dis., 1899. e Monat.f. Gel. u. Gyn., 1905, vol. xxii., p. 587. 296 ()I'i;i;\TI\ !•: MIDWIFERY Uterus Unicornis (with rudimentary Uterus Unicornis, horn). Uterus Subseptus. Uterus Septus. Fig. 133. — Malformations of Uterus. MALFORMATIONS OF THE UTEEUS AND VAGINA 297 In the English language the most important paper is by Giles. 1 Since Giles' paper several others have appeared, one of the most interesting being by Guerin-Valmale. 2 This author reviews 46 cases of uterus didelphys. In the 104 pregnancies which occurred in these women, abortion occurred in 19, premature labour in 8, or a total interruption of pregnancy once in 4 cases. Complications, the result of auto-intoxication, seem more frequent than usual, for there were 3 cases of eclampsia in the 104 pregnancies. Uterus Cordiformis. ¥ Uterus Bicornis Unicollis. Uterus Didelphys. Fig. 134. — Malformations of Uterus. The labour is rarely complicated. He writes : ' En somme la delivrance s'effective habituellement avec la plus grande simplicite, sans accidents ou complications serieuses.' Trapet 3 has reviewed 186 collected cases. He found that the com- plications and difficulties were not frequent. Menstruation from the non-gravid half was not common, although it occasionally occurred 1 Trans. Lond. Obst. Soc, 1895, vol. xxxvii., p. 301. 2 L'Obstetrique, May, 1904, p. 209. 3 Inaug. Dis., Bonn, 1905 ; ref. Zent. f. Gyn., 1906, p. 671. 298 OPERATIVE MIDVYIIT.KY quite regularly. The decidua which formed in the aon-gravid half was usually expelled at or ahout the time of the delivery of the lotus but occasionally it was expelled during pregnancy. With all varieties of double uterus difficulties may arise. Some of these 1 will now refer to. I have already mentioned that even the sLijilc form, uterus cordiformis, may he associated with mal- presentations, hemorrhage, retention of the placenta, i An extraordinary case is that described by Jakesch. 1 where the total head must have been pushed through the septum. Halhan reports a case where the birth occurred through the cervical canal of the non-gravid side. But although it must be of extreme rarity to have the uterine septum give way, it is by no means uncommon for the vaginal one to be torn. This occurred in two cases under my care. Case 1.— The following notes regarding this case have kindly been furnished to me by Dr. Baird, with whom I saw the patient in consultation : ' In August, 1904, about •"> p.m., I was called to Mrs. A— . a primipara, who had nearly reached term. On vaginal examination, I found that tin' vagina was divided antero-posteriorly by a septum, which extended from immediately above the meatus urinarius to the centre of the perineum and upwards to the cervix. On passing the finger on each side, I judged by the feel that it would be about £ inch in thickness. The septum was complete, and I could not get nry fingers to meet, not even at the cervix. The two passages were completely separate. The right half seemed to become wider and more roomy as the finger passed upwards, while the left got narrower. They both had a vaginal portion projecting into them. On both sides the cervix was obliterated, and the os about the size of a sixpence. < >n seeing her six hours later, the left os had dilated to about the size of a crown piece. The presenting head by this time had detached the uppermost end of the vaginal septum. A little later the head was found to have projected through the opening into the right vagina. The child descended through the right vagina, but was prevented from escaping by the remains of the vaginal septum. At this stage I asked Dr. Munro Kerr to see the case with me. ' After putting the patient under chloroform, Dr. Kerr divided the septum and extracted a living child with forceps. The placenta was soon after expelled. A vaginal examination was made thereafter, and two distinct uterine bodies were felt. The remains of the vaginal septum were then removed. ' Case 2. — J. McW , 1-para, was admitted bo the Glasgow Maternity Hospital under my care on duly 28, L904, in labour. The pelvis was of normal dimensions. A curious condition was discovered, however— a double vagina and uterus of the variety uterus duplex separatus cum vagina separata. Labour was allowed to proceed. The foetal head in its descent tore tie- vaginal septum. No great bleeding took place, however, so nothing was done until the tearing process threatened the parts ahout the clitoris, when an incision 1 Zenhf. Oyn., L897, 729. MALFORMATIONS OF THE UTERUS AND VAGINA 299* with a knife freed the last | inch of the anterior attachment of the septum. Spontaneous delivery took place without any rupture of the perineum. As I have already said, the septum frequently tears during the birth, but for the torn septum to act as a barrier to the head or shoulders, as in the above cases, is not common. Strauch ' has recorded a case. Lukowicz's case 2 is of special interest, where the presenting breech rode on the vaginal septum. A similar case has also been recorded by Gardini. 3 A very rare complication is for the non-gravid half to act as an obstruction. Ranken Lyle 4 has recorded a case where the non- gravid half of a uterus duplex separatus cum vagina separata, and affected by fibroids, necessitated Cesarean section at term. Both mother and child were saved. V. Braun 5 described one where Cesarean section was performed because of a tumour impacted in the pelvis, which obstructed delivery and could not be dislodged. Upon remov- ing the tumour, it was found to be the non-gravid half of a uterus bicornis. Wendling has recorded a case where a haematocolpos, previously incised, formed again, and acted as a barrier to delivery f until an incision was again made and the accumulated blood allowed to escape. Backer's case 7 is of interest, for although a hrematometra had been present for some years, the woman had had no trouble at four previous births. At the fifth confinement — the one described by the author — laparotomy was performed, on account of the tumour mentioned obstructing the parturient canal. Abortion is not infrequent, but rarely gives trouble. Gusserow's 8 experience is most peculiar. A three months ovum became retained in a closed vagina of a uterus didelphys, and could only be removed by dividing the septum. Plural pregnancy has been observed frequently. Nowikow 9 has described three most interesting cases : (1) A multipara delivered of a premature child was discovered to have a swelling towards the left of the abdomen, which was diagnosed as a pregnancy of seven months in the one half of a double uterus. Two months after a full-time living child was born. (2) A multipara had a full-time child. Soon after its birth a three months ovum was discharged. (3) A multipara was delivered of two full-time children at an interval of forty-seven days. Paulin 10 records 1 Zent. f. Gyn., 1887, No. 43, p. 684. 2 Ibid,, 1886, No. 85, p. 572. 3 Anal. cVObst. et Gyn., September, 1899. 4 Journ. Obst. and Gyn. Brit, Empire, December, 1904, p. 438. 5 Zent, f. Gyn., 1895, p. 579. 6 Wien. Klin. Woch., 1896, No. 2. ■ Zent.f. Gyn., 1896, p. 883. s Charitr Annal, 1900, p. 618. 9 Eef. Zent.f. Gtjn., 1902, p. 861. 111 lief. Epit., Brit. Med, Journ., 1905, No. SO, vol. i. \ 800 OPERATIVE MIDW1I in a twin labour, bhe children being born at seventeen days' interval. Daring the interval there was no lochia, nor any active secretion of milk. Both children were alive, and were suckled by the mother. A distinct Beptnm divided the uterus into two compartments, but there was no .-ulcus at the fundus. Trapet 1 has added to the cases collected by WI1T.I;Y Ligatures and Sutures. Silk.— Silk should he loosely wound on glass spools or plates; there Bhoald oot be too much on «>ne spool. It is readily sterilized l>y boiling in water for twenty to thirty minutes. It may then he preserved in a solution of carbolic, 1 in 80, or, hetter, bin iodide of mercury and 70 per cent, alcohol 1 in 1,000. Before use it may be washed, hut it is more conveniently manipulated when taken directly from the alcohol solution. It is advisahle when using silk to employ the finest variety that will serve the purpose. Personally, I try to use silk as little as possible ; indeed, for the last year or more I have used nothing hut catgut. Several operators speak highly of Pagenstecher's celluloid thread. Moynihan, for example, prefers it to silk. We used it for a short time in the Glasgow Maternity Hospital, but did not find it possessed any advantages over silk. It Is sterilized by boiling in the same way as silk. In an emergency, and when neither of these materials mentioned is available, sterilized linen thread is quite a useful material. Silk-worm Gut. — Silk-worm gut is readihy sterilized by boiling for twenty to thirty minutes. It maybe kept in either the carbolic biniodide solutions already mentioned. But it must be washed well in water, otherwise it breaks very readily. It is a most useful suture, and I employ it always for the abdominal wound and the perineum in the manner I will describe when considering these wounds. Catg^ut. — The sterilization of catgut is too big a subject to discuss in detail. Much has been written regarding it, and there are a great number of methods recommended. At the present time the one most favoured is by means of iodine. Claudius some three or four years ago recommended this method. The ordinary coninierei.il catgut is steeped for eight days in a solution of iodine, 1 part ; potassium iodide. 1 part ; and water, 100 parts. Before use,. Claudius recommends its being thoroughly well washed to remove the excess of iodine. Several operators have recently advocated the addition of alcohol. Scott Piiddell 1 contributed an interesting article on the subject, and reported certain investigations carried out by McDonald where a solution of tincture of iodine 1 part and proof spirit 15 parts was employed. It appears that this solution is an excellent germicide, and that anthrax spores and ]>ap and water, taking care that all the crevices about the labia and clitoris are thoroughly cleansed, and then finally swab the parts with 1 in 30 carbolic solution, or 1 in 1,000 biniodide of mercury and alcohol. But while it must be admitted that a thorough cleansing of the vulva is as important in obstetric practice as is the thorough cleansing of the abdominal wall in surgical work, one cannot say the same regarding the cleansing of the vagina. In recent years very extensive investigations regarding the organisms that infest the vagina have been made by a number of different observers, Kronig, Menge, Doder- lein, and Williams being specially worthy of mention. It certainly would appear that the healthy vagina of pregnant and parturient women is free of pyogenic organisms, and that in consequence auto- infection does not occur. But the practical point is how to know that the vagina is healthy. Undoubtedly, when a purulent abundant dis- charge is present one can say it is not so, but there are quite a number of cases in which no one could tell, except b}^ bacteriological examina- tion, whether or not pyogenic organisms were present. While I am certainly not an advocate of the universal ante-partum douching of parturient women, I do think it is a wise proceeding to wash out the vagina carefully in all cases of operative interference, except those simple cases where the head is at the outlet and has simply to be helped through the vulvar orifice. For cleansing the vagina it is not sufficient to simply introduce the nozzle and wash out the canal. The operator must, with his ringers, go all over the mucous membrane, and this naturall} 7 is best done with the hand protected by a rubber glove. Soft soap and lysol, I per cent. PREPARATION OF THE PATIENT 313 is the best material for doing this, -for. it is not possible to scrub the mucous membrane of the vagina with rough gauze. In quite recent years ;i number of obstetricians, including Ahlfeld, Hofmeier, Pinard, and Schauta, have been favouring the more general cleansing of the vagina by douching in labour, and their results do not seem to indicate that infection is more frequent. Indeed, their figures, as compared with those of others who have not adopted such a course, are better, as can be seen by the table given by Herff. 1 Doderlein's recent investigations support the view that the morbidity is lower in the cases not douched. Post-partum douching I only employ in cases of haemorrhage, and where the placenta or membranes have been removed manually, and as far as can be judged at present that is the general attitude assumed towards douching after delivery. The preparation of the abdominal wall, when the peritoneal cavity has to be opened, is a much simpler matter than the cleansing of the vagina and vulva, and there is no question regarding the necessity of its being thorough. In the Glasgow Maternity Hospital, and in private, I prepare the abdomen as follows : If immediate operation is necessary, it is washed with soap and water and a soft nail-brush for five or six minutes, and then with turpentine and 70 per cent, alcohol. After the alcohol has been removed, a large compress, soaked in 1 in 20 carbolic, is applied for a quarter of an hour. This is removed, and the skin again cleansed with soap and water and alcohol immediately before the operation begins. When two or three days are available for preparing the patient, the skin is treated differently, and I rely then upon frequent washings of the abdomen with soap and water and alcohol, a dry sterilized dressing being applied in the intervals. Some hours before the operation a compress of 1 in 40 carbolic is applied, and on the operating-table, before proceeding to open the abdomen, my assistant goes over the skin again with soap and water and alcohol. Since I adopted these methods of cleansing the skin and of cleansing the hands, and since I and my assistants and nurses have used gloves, it is most exceptional to get any stitch abscess in cases in which the operation was undertaken for non-septic conditions. I must admit, the patient has once or twice suffered from carboluria. 2 In addition to all the precautions taken against infection which have been already detailed, the lower bowel and bladder should be 1 Winckel's 'Handbuch,' 1906, Bd. iii., Teil ii., 792. 2 In a series of hospital cases Dr. Dickie and I employed acetone and iodide for skin preparation. The results were not altogether satisfactory, so that I have returned to the carbolic dressings mentioned. 31 l OPERATIVE MIDWIl'KliV evacuated. The bladder, <>f course, is easily emptied by a catheter if the patient cannot evacuate it herself. It is a good rule, however, to use the catheter as little as possible, for, in spite of every precaution taken against conveying organisms into the bladder, these latter are sometimes carried in and slight cystitis set up. It is my custom, therefore, in all cases where the catheter has to be frequently pa>- after operation, to put the patient on small doses of urotropin and to run into the bladder 2 or 8 ounces of weak boracic solution after each catheterization. 1 feel sure that since J have adopted these prophy- lactic measures vesical catarrh has been less frequent. When time permits, the bowels should be thoroughly evacuated by a full dose of castor oil or some other laxative, but in obstetric prac- tice one frequently has not time to do this, and so has to be content with clearing out the lower bowel by means of a soap and water enema. Prior to any operation necessitating the administration of chloro- form the diet of the patient should be restricted, but in obstetric practice this is seldom practicable. There is no doubt that careful dieting, and especially the establishment of a good diuresis before the administration of chloroform, lessens the sickness which so commonly follows the administration of an anaesthetic. Anaesthetics in Parturition. The anaesthetic employed in obstetric practice in this country is almost exclusively chloroform. It is very easily administered, and. - every one admits, is most safe in pregnancy and parturition. In spite, however, of what may be said to the contrary, chloroform does favour post-partum haemorrhage, and very decidedly so if the administration has been continued for any length of time, and surgical anaesthesia has been induced. In my experience chloroform distinctly inhibits retrac- tion of the uterus after the birth of the child. The amount of haemor- rhage may not be of any consequence, but the ballooning up of the ut< with blood- clot accumulating between the membranes and placenta and uterine wall interferes with the natural separation and expulsion of the placenta, and so favours laceration and retention of portions of the membranes. Some may say that this latter complication is the result of the accoucheur hastening the delivery of the placenta, which he is probably tempted to do in cases where anaesthesia has been prolonged. I am quite satisfied, however, that is not the full explanation, for I have given the placenta infinite time to separate and be expelled, and yet have had trouble with retained membranes. The effect of chloroform upon the parturient varies ; sometimes it AN/ESTHETICS IN PARTURITION 315 distinctly inhibits the uterine contractions even when given in small amount, but on other occasions, especially if the parturient is nervous and excited, small doses, by quieting her or by removing some reflex irritation, act as a stimulant to the uterus. Every one is familiar with the relaxation that follows the administration of chloral or chloroform if the soft parts are unduly rigid. As regards the child, there is only danger to it when the anaesthesia is very prolonged. It is quite certain, however, that a considerable amount of the anaesthetic gets into the child's circulation, for it is frequently very drowsy for some time after its birth. Spinal Anaesthesia. — Since the introduction of spinal anaesthesia secured by the injection of 1 to 12 grammes of a sterilized 2 per cent. solution of cocaine into the spinal cavity, other preparations, such as eucaine, stovaine, novocaine, etc., are under experimental trial. The following is Bier's formula : Stovaine - 04 gramme. Adrenalin 0-00013 „ Sodium chloride 0-0011 „ Distilled water 2-0 grammes. Thus, each dose contains 4 centigrammes of stovaine. The skin being sterilized, a long, hollow needle is introduced into the spinal cavity at a point between the third and fourth lumbar vertebrae, half an inch to either side of the middle line. The needle is pushed in an upward and inward direction, and the escape of a few drops of cerebro-spinal fluid indicates that the spinal cavity has been reached. The syringe containing the solution is now attached to the needle, and about 1 c.c. of cerebro-spinal fluid allowed to mix with the stovaine solution. The fluid is then slowly injected. The puncture is sealed with sterilized collodion. In the few cases in which I have employed spinal anaesthesia I have been thoroughly satisfied. Scopolamine and Morphine. — In the last few years hypodermic injections of scopolamine and morphine have been extensively employed in parturition. Speaking generally, the results have been fairly satisfactory. Some writers have referred to the injurious effect on the foetus, and nearly all are agreed that they slightly retard the progress of labour. As far as one can judge, they do not very appreciably predispose to post-partum haemorrhage. Although the injections may be employed during any stage of labour, in most cases it is preferable to use them only in the second stage ; but in a very prolonged first stage I have seen no ill effect follow the administration of the drugs. Speaking generally, the most suitable initial dose is inyo- grain of scopolamine, with J grain of morphine ; if need be, this can be repeated. The amount of the second dose should be gauged by the general and mental condition of the patient. CHAPTEIi XXII VERSION, OR TURNING In this chapter I will only discuss the methods of performing version, us the manner of extracting the child and the difficulties in doing this have been already considered in Chapter V. The operation of version has for its object the substitution of the head or the feet for some other presenting part. If the head is brought to present, we speak of 'cephalic' version: while if a lower limb is brought down we speak of ' podalic ' version. It is of extreme lv ancient date, and was extensively practised by Hippocrates, who recommended cephalic version for all presentations other than those of the head. .Etius, Celsus and others, at different times, pointed out the fallacies of the Hippocratic teaching and the advantages of podalic version ; but, supported by Galen, it, for the most part, continued in favour till the sixteenth century, the one ever famous in obstetrics by reason of the great revival in midwifery initiated by Ambrose Pare. Pare was the first to clearly describe and point out the possibilities and advantages of podalic version, and from his time until the obstetric forceps became common property podalic version was widely practised in cases where immediate delivery was deemed necessary. About a hundred years later an alteration in the technique of the operation was suggested by Portal — viz., the bringing down of one leg instead of both, as was the custom up till then; but, apart from that, there was no great modification of the operation until 1807, when Wigand described and recommended version by external manipulations. But even such a brief reference, as this one is, to the history of version would be incomplete did I not mention the name of Braxton Hicks, who will ever be honoured on account of his method of version by combined internal and external manipulations, which he described in 18G0. 1 Full details of the operation are also to be found in the London Obstetrical Society's Transactions, 2 in the Appendix to which paper Hicks justifies his claim to having first clearly described this 1 Lancet, July 14, 1860. - Vol. v., p. 219. 316 VERSION, OR TUENING 317 method of version. It is perfectly true -Wigand suggested the employ- ment of one hand internally, but his reference to that hand is so casual that it is impossible to believe that he really meant it to be much used. Hohl, Wright, Schmidt, Lee, and others, referred to similar manipulations ; but Hicks, by reason of the clear manner in which he described all details, really deserves the greatest credit. In certain conditions the operation of version is one of choice : in others, it is the only course open. In transverse presentations, for instance, it is the only treatment to be considered ; but in placenta prsevia, accidental haemorrhage, contracted pelvis, accouchement force" for any danger threatening the mother, it may be said to be an opera- tion of choice. The position it occupies in the treatment of these conditions is discussed in detail when each is being considered. Here I shall simply summarize the matter. The indications for the operation of version may be placed in the following groups : 1. Malpositions and Malpresentations of the Child. — In all transverse presentations, and in brow and face presentations under certain conditions, version is indicated. Mento-posterior face and brow presentations, recognized early in labour, are considered by many to be best treated by version, although a few favour the altera- tion of the presentation into an ordinary vertex by the method of Thorn (p. 39). In recent years quite a number of obstetricians (Pinard, Hegar, Spencer) have expressed themselves in favour of converting a breech into a vertex presentation by external version. I have frequently done this in the last two weeks of pregnancy, and, personally, am of opinion that it is sound treatment. It is incorrect to say that one makes the presentation worse and brings about a transverse if one fails, for when the foetus cannot be completely turned it can always be pushed back into its old presentation. The object of the treatment is to lessen the foetal mortality, which, in primiparse especially, is very high. It is quite absurd for those who are opposed to this treatment to say that it is a reversion to the treat- ment of Hippocrates, for Hippocrates performed the operation during labour, and with his hand in the uterus. 2. Flat Pelvis. — Personally, I do not consider a flat pelvis an indication for version, except in cases of scolio-rachitic pelvis where the occipital end of the head is towards the small side of the pelvis, and in posterior parietal presentations. The subject is fully con- sidered in connexion with contracted pelvis (Chapter XII.). 3. Dangers threatening- the Mother. — Amongst these the most striking are placenta prasvia and accidental hemorrhage. As a step in the operation of accouchement force it is also frequently performed. 318 OPERATIVE MihVYll Ki;Y \ ery occasionally fche operation is necessary in displacements of the uterus and in doable monsters (Chapters XIX. and J\.). 1. Dangers threatening- the Child. Prolapse of the cord is the most important indication under this head. The subject, however, discussed under Prolapse of the Cord (Chapter XX.). There are three methods of performing version, by any one of which the head (cephalic version) or the lower limhs (podalic version) may he brought to present. These are : (1) JJv purely internal manipula- tions—Internal version: (2) by purely external manipulations — I ternal version : (8) by combined internal and external manipulations — Bipolar version, or version after the method of Braxton Hicks. Each of these methods we must now consider, hut before doing so a word regarding the relative merits of cephalic and podalic version. As previously stated, until the middle of the sixteenth century cephalic version was almost exclusively practised. As a result of Fare's teaching, podalic version came into favour, and completely replaced cephalic. Following, however, the great improvements of Wigand, Hicks, and others, cephalic version has once again come more into favour. The method is suitable for rectifying oblique presentations, and even breech presentations, recognized early in labour. It is, however, not suitable for cases of hamorrhage, and the majority of obstetricians would also say that it was not suitable for cases of contracted pelvis. Personally, however, I have frequently changed a breech into a head in cases of moderate pelvic deformity, for I believe the chances to the child are infinitely better if it comes head first. Internal Version. This is, as we have seen, the oldest method. For its performance the os must be sufficiently dilated to allow of the introduction of the hand. The vulva, lower abdomen, and upper parts of the thighs, having been thoroughly cleansed, and the bladder and rectum emptied, the patient is ready for operation. She should then be brought to the edge of the operating-table or bed, and have the vagina thoroughly washed out. The position of the patient during the operation may be either the dorsal or the left lateral, but on the whole the lateral position is better : at least, that is so in cases where the child lies dorso-posterior in the uterus. When the child lies dorso-anterior, the left lateral position is of slight advantage only if the operator is ambidextrous and can use his left hand, which adapts itself better than the right to the curve of the sacrum (Fig. 18(1). Another advantage of the lateral position, especially if the patient is rolled well round on her breast, is VERSION, OR TURNING 319 that the presenting part slips away by gravity from the brim ; this allows the hand to be passed into the uterus more readily. After the foot has been seized, and extraction has to be proceeded with, the dorsal position is more suitable, as one can employ the external hand better in conjunction with the internal when the patient is in that position. If one employs the dorsal position from the first, it is better to seize the limb or limbs with the hand which corresponds to the side the limbs are on. That is to say, if the limbs are on the left side, one employs the right hand ; if they are on the right, the left hand. Fig. 136. — Internal Version, showing the Advantage of using the Left Hand, as it accommodates itself better than the Right to the Curve of the Sacrum. But much more important than the position of the patient, which, after all, is very much a matter of choice, is that the patient be anaesthetized before any attempts at version are made. Especially does this apply to the operation of internal version when the waters have drained away. Much injury is done by the operator getting excited and pushing his hand into the parturient canal when the patient is only half under the anaesthetic. When the operator has determined that his whole hand is to be introduced into the uterus, he should separate the labia with the fingers of the one hand, and cautiously pass the other hand in the form of a cone up towards the feet, keeping the back of the hand 320 OPERATIVE Mll>\VII'i;i;Y directed against the uterine wall. The hand should be passed right through the membranes if they are -'ill intact: the forearm dams back the liquor amnii. Thia is much better than passing the hand up between the membranes and uterine wall until the limb is reached, used tu be the teaching, because by so doing there is greater danger of infection, seeing that any organisms present are implanted upon the raw uterine surface instead of inside the amnionic Bac. From tim< time during uterine contractions all manipulations musl be desisted from, and the open hand allowed to lie passively against the surl of the child. There is seldom much difficulty in getting hold of a foot ; indeed, it only occurs when the waters have drained away, and the child is grasped and doubled up by the contracting uterus. In such cases it will generally be found best, instead of getting mixed up with limbs all huddled together, to pass the hand right up to the breech, and come back along a thigh and seize one or both feet. It sometimes happens, in cases in which the waters have long drained away and the uterine wall is closely applied to the child, that the child is more readily turned if both feet are seized. The difficulty of differentiating a foot from a hand is not great. A foot is always to he distinguished from a hand b} 7 the presence of the heel ; other differences, such as the length of fingers, mobility of thumb, etc., are not to be relied upon. The heel is the landmark one should search for ; never bring down a limb until the heel is felt. Having reached the lower limbs, one foot is seized, or both. A.fl stated elsewhere, Pare and Guillemeau recommended the bringing down of both feet, and that continued to be the practice for nearly two centuries, even although Portal, in the middle of the seventeenth century, clearly demonstrated the advantage of bringing down only one. It is only in comparatively recent times that it has been the general practice to bring down one foot. I have already pointed out the advantages of doing so (Chapter V.), and have recommended that only when the delivery has to be completed with all speed should both be seized. Theoretically, it is not altogether a matter of indifference which foot one takes, although in practice I must admit it is a good enough rule to grasp the first foot one encounters. In all cranial presentations the anterior leg is the one to seize. This holds good also in transverse presentations when the back of the child is anterior, hut not in dorso- posterior positions: then the posterior or superior leg is preferable. A good working rule, therefore, is : Seize the nearest foot in (til cases except oblique dorso-posterior positions. The advantage of following •this rule is that the anterior leg is brought down against the VERSION, OR TURNING 321 symphysis, whereas if one took the other foot, one would bring down the posterior leg, and the anterior buttock would catch on the symphysis, which we have already seen (Fig. 28) is a great dis- advantage and causes delay in extracting the breech. The foot, being seized, should be brought down through the cervix. Fig. 137. — Internal Version. Version is Vicing completed. The accoucheur is pulling down the leg, while his assistant is pulling up the head. It will be observed that he has seized the leg farthest away, because the position is an oblique dorso-posterior one. The carrying of this out is often facilitated by an assistant pushing or pulling up the head (Fig. 137). The operator may himself do this, but his spare hand is better employed steadying and pushing down the breech, for the external hand should always act in consort with the internal. The operation of version is seldom difficult if the membranes are •21 322 Ol'KIIATIVK MIDWIFERY intact or have only recently ruptured. It becomes increasingly difficult and dangerous, however, after the liquor iimnii has drained away, and great caution must be exercised in attempting the operation in such cases. It must never be performed in head presentations if Mm FlG. 138. — Internal Version. A fillet has been passed round the prolapsed arm, in order to prevent it slipping up after version is completed. The accoucheur is seizing hold of a foot — the wrong one in this particular position of the foetus (see text). the retraction ring is well defined, nor in cases of impacted transverse presentation ; forceps or craniotomy in the former and decapitation in the latter are the operations which should be had recourse to. In transverse or oblique presentations the lower arm not in- VERSION, OR TURNING 323 frequently prolapses. The particular arm can always be recognized by shaking hands with the child (Fig. 54). When the arm has prolapsed, it may sometimes be pushed up, but this is often impossible and quite unnecessary, for the arm slips up as the leg is pulled down. A. very useful manoeuvre is to apply a loop of gauze round the wrist of the foetus (Fig. 138). In doing so care must be taken not to fasten it too tightly. This loop of gauze or fillet so applied is of great service later in the labour in preventing the arm from slipping up along side of the head. It must only be used to prevent the arm slipping up. If, however, in spite of all one's efforts, the arm should slip up, it must be brought down in the ordinary way and not by pulling upon the gauze, for that might result in its fracture. It sometimes happens, especially when the waters have drained away, and there is difficulty in turning the child, that version is facilitated by a manoeuvre generally ascribed to Siegemundin. It consists in passing a fillet over the foot and then exerting traction on the fillet with the one hand, while the other hand is passed into the vagina and pushes up the presenting shoulder or head (Fig. 139). "When such a manipulation is necessary, it usually means that the uterus is firmly retracted over the child, and so the operation is not free of danger. An alternative to this method is the bringing down of the other foot, which will usually be found behind the one already brought down. In attempting to bring down the second foot the hand must be passed cautiously into the uterus behind or in front of the leg already down, according as it is the anterior or posterior one which is present- ing. In cases of doubt one can readily determine which foot is down from the position of the great toe. With the two feet together the great toes are in apposition. Both feet being seized and steady trac- tion made upon them, version can generally be completed, unless the uterus is grasping the child very firmly. As can readily be understood, a great strain is put upon that part of the uterus against which the head rests during these manoeuvres, and especially is this the case when, labour having been long in progress, the lower uterine segment is much thinned out. Either of the manoeuvres, if carried out very cautiously, will result in the safe delivery of the child without any damage being done to the mother, provided the head is within the body of the uterus. Should, however, the head be in the lower segment below the retraction ring, there is the greatest possible danger in employing either of them, but more especially the second. Indeed, I would almost go to the length of saying that they are never justifiable, because of the great danger of the uterus and vagina being ruptured. Besides, they are almost profit- 324 OPERATIN E MIDWIFERY ess, as tlif child is dead, or on the point of dying in the vast majority of cases. I am well aware that Binlin and others have reconini> inl«-l.-t in.u. version. A fillet has been passed round the leg which has been broughl down. The accoucheur pulls upon this, while with his < >t lier hand he pushes up the head 01 shonldi r. cases, when the head is helow the retraction ring, that the hand should be passed up between the uterine wall and the child's head, the retraction ring pushed back and the child's head allowed to glide VERSION, OB TUKNING 825 out of the lower segment. I have succeeded in doing this under deep anaesthesia, but it is a mamcuvre very often impossible, and, unless one has had extensive practice in difficult obstetric operations, is attended with considerable danger. Internal cephalic version, the operation of Hippocrates and his disciples, has practically been given up. If by any chance it should be deemed advisable to have recourse to it, the head should be grasped and pulled down while the breech is pushed up to the fundus by the external hand. Fig. 140. — External Cephalic Version. The accoucheur has located the head with the right and the breech with the left hand. External Version. Following strictly in chronological order, we have now to consider the method of version known as External Version. To Wigand, as we have seen, is due the credit of first describing this method, although others had undoubtedly long before casually referred to it. It is an operation possible only under favourable conditions. If the membranes have ruptured, if the liquor amnii is very scant} 7 , and if the uterine wall is so rigid that the foetal parts cannot be grasped, external version is impossible. After some experience of the opera- tion, however, it is surprising how comparatively seldom such con- ditions are encountered in pregnancy. Even at term in multiparas one can often perform it ; but in prinriparae it is always difficult 826 OPERATIVE MIDWIFERY and often impossible. The operation has this advantage — it can be performed early in lahour or even during pregnancy before the cervix is obliterated, and I have apon several occasions convened breech into cranial presentations at the thirty-sixth or thirtli-seventh week by this method. So niiicd), indeed, am 1 in favour of this form of version that in many ca>es in which version by Braxton [licks' method might be chosen — as, for example, in placenta pra via — I actually perform the operation by external manipulations, and only employ the fingers in the vagina to pull down a foot after the breecfa has been brought over the os. Fig. 141. — External Cephalic Version. The accoucheur is pushing the foetal head downwards with his right hand, while he is pulling the breech upwards with his left. In some women, more especially multipara?, the operation may he performed without an anaesthetic ; but if the patient is a primipara, has rigid abdominal and uterine walls, and has reached term, an anaesthetic is usually necessary. It will generally be found best to have the patient lying upon her back, with the shoulders slightly raised, although sometimes lying upon one or other side helps a little the rotation, and certainly favours dislodgment of the lower pole. This postural treatment, the principle of which is to place the mother on the side to which the head or the breech is directed, according as one wishes a head or a breech presentation, is occasionally of value. VERSION, OK TURNING :>>-±l The first step in the operation after the patient has been anaesthetized is to carefully palpate the position of the different parts of the child (Fig. 140). After that has been done, occasionally all one has to do to alter the presentation is to grasp one end of the fcetal ovoid with each hand, and pull one pole and push the other in the direction wanted (Fig. 141). To succeed in turning the child as easily as that is exceptional. As a rule, an assistant is necessary. The operator and assistant stand facing each other, and it is an advantage that they should be on different sides of the patient. Fig. 142. — External Cephalic Version. In cases of difficulty the accoucheur uses his two hands to drag the one fcetal pole upwards, while his assistant pulls down the other pole. Each takes an end of the fcetal ovoid and pulls it towards himself (Fig. 142). Sometimes, however, the child is turned best by reversing this and pushing the part away, or even by operator and assistant facing the patient and pulling down and pushing up the end each is responsible for. The position of the child will usually indicate the direction in which pressure is to be exerted. In transverse presenta- tion always, and generally in all cases where one pole is substituted for another, it will be found that the child slides round best when pushed in the shortest way to the desired position. Once or twice, however, I have found the child go round better when rotated in the longest way. One thing, of course, must be remembered — no 828 OPERATIVE MIDWIFERY manipulations must be made which would tend to extend the child. Saving turned the child, one must try to maintain it in the favourable position in which it 1ms been placed. Unfortunately, how- ever, this is not always possible, especially if the previous presenta- tion has been transverse. Where ii has been Longitudinal, it is not so V Fig. 143. — Bipolar Version. The accoucheur, with one or two fingers of the one hand through the cervix, is poshing th< head away from the pelvic brim, while with Ids other hand he is pushing down the breech. difficult. If it is the head which has been made to present, then it should be pushed down into the pelvis and a firm binder applied. If the patient is in labour, it is well to rupture the membranes. A very interesting paper on the subject of External Version was delivered recently by Pollock to the London Obstetrical Society. 1 1 Lond. Ohstet. Trans., vol. xlviii., for 1906. VERSION, Oil TURNING 329 This author, although admitting the difficulties and frequent failures of external version, referred to the method in very favourable terms, and stated that he had found the Trendelenburg position of great advantage. Carried out in this position, he referred to the method as ' fundal external version.' As Spencer pointed out in the discussion which followed, postural treatment is of great antiquity. I have Fig. 144. — Bipolar Version. A further step in the operation. The head and shoulder of the fetus are being pushed away with the internal hand, while the breech is being pushed dowu with the external. repeatedly referred to the advantages of the Sims position in certain cases, where, for example, one wishes to dislodge the presenting part from the pelvis. Bipolar Version. This method, as we have seen, was elaborated and perfected by the late Braxton Hicks, and the operation is very rightly referred to under his name. One may bring either the head or the breech to present. The illustrations indicate the manner in which the 880 OPERATIVE MIDWIFERY manipulations are carried oat. It is better to have the patient upon ber back and anfesthetized. The parte about the vulva having been thoroughly cleansed, the suitable hand is introduced into the vagina and two lingers arc passed through the cervix (Fig. 148). These push the presenting part away, while the external hand presses or pulls down the other total pole (Fig. 111). It is important to employ the suitable hand internally, so that the arms are not crossed during Fig. 145.— Bipolar Version. The feet of the foetus having been brought over the os, the accoucheur is now able to sei: ■ the manipulations. An assistant can often render great help by pulling up the pole which is being pushed away by the operator's internal hand. In order to carry out the operation, the foetus must be fairly movable in the uterine cavity ; consequently, the membranes must be unruptured, or only recently ruptured, and the os must be dilated to permit at least one finger being passed through the cervix. It is surprising how occasionally, long after rupture of the membranes, it is still possible to perform version by Hicks' method. When the VERSION, OR TURNING :■$:!! feet are brought over the os, one should be pulled down into the vagina (Fig. 145). There is sometimes a little difficulty in getting hold of the foot, but the external hand, by steadying and pushing the leg down, will generally bring it within reach of the internal fingers (Fig. 146). Personally, I do not care to bring down the leg by hooking my finger into the bend of the knee, for, if the presenta- tion has been originally cranial, it is not easy to make sure that it is Fig. 146. — Bipolar Version. The accoucheur, having seized the foot, is bringing it down through the vulva. the leg which is over the internal finger. I never like to bring down a limb in such cases until I feel the heel. With one finger only through the cervix, the foot is not easily brought down, but by getting it over the os, then suddenly withdrawing the finger in the cervix, it will sometimes slip down. Not infrequently I have succeeded in bringing down the foot by grasping it with long pressure or vulsellum forceps. Of course, if the cervix admits two or more fingers, there is no great difficulty in seizing the foot. 882 OPERATIVE MII>WII'Kl;Y At one time I employed this method to the exclusion of the external, but in recent years I have had recourse to it only when external version has failed. On many occasion e one accomplishes as much by purely external manipulations, and with less chance of rupturing the membranes. Naturally, after the membrane- have ruptured, the method of Braxton Eicks will succeed for some time after external version is impossible. The indications for the opera- tion are many, but placenta pra via is one of the most im- portant. Its value in that complication is fully discussed elsewhere I (Chapter XXXIII.). CHAPTER XXIII FORCEPS A treatise on practical obstetrics is not the place to detail the history of the forceps. It is quite fitting, however, that I should consider how axis-traction rods came to be added to the instrument, and should attempt to estimate the value of this last modification. History and Mechanism of Axis-Traction Forceps. Tarnier will ever be honoured as the inventor of axis-traction forceps, and deservedly so. But long before Tarnier described his Fig. 147. — Tamier's Axis-Traction Forceps. instrument in 1877 (Fig. 147), it had been fully appreciated that, even with the long double-curved forceps, traction in the axis of the pelvis was impossible, and that a great deal of the force exerted by the operator was lost by the head being pulled against the anterior 333 384 ol'KKATlVK MIDWIFERY pelvic wall. Levret, Smellie, and Baudelocque, for (••.ample, in order to obviate this, gave directions how traction was to be made as far back as possible. With the object of obtaining traction in the axis of the pelvis, many alterations and additions to the ordinary double-curved forceps have been suggested. One of the earliest — that of Saxtorph and his pupil Stein — was bands through the fenestra' of the blades. A century later this suggestion reappeared in the recommendation of Poullet to pass cords through holes made immediately below the Flu. 148. — Pajot's Manoeuvre. The accoucheur pulls on the handles of the forceps with his right hand, while with his left lie [>ulls on the shanks. fenestras The manoeuvre commonly known as Pajot's (Fig. 1 18 was described by Osiander, a pupil and assistant of Stein, although it was really first suggested by Saxtorph. Until quite recently it was very generally employed, and is still made use of by some of the older obstetricians. As far as can be ascertained, the suggestion of having special traction handles was first made by Hermann of Berne in 1844 (Fig. 149). But, as Milne Murray very rightly pointed out, the rods in Hermann's forceps were employed on the same principle as Osiander and Pajot effected their manoeuvres. Hermann's device FORCEPS 335 seems to have been forgotten, if, indeed, it ever became very generally known. An important step in the evolution of the instrument was Hubert's Fig. 149. — Hermann's Forceps. traction bar, described in 1860, for, undoubtedly, by it traction could be exerted in the axis of the pelvis. Still later, curving the ends of Fiu. 150. — Defects of Ordinary Forceps (Tarnier.) A, E, C, Line of traction ; A, D, B, ideal line of traction, and very nearly obtained in the best form of axis-traction forceps ; A, S, F, force wasted against the symphysis pubis. the handles, and a detachable traction handle applied either to the upper or lower ends of the handles, were recommended, and some- times employed. 886 OPERATIVE MIDWIFERY The mechanics ol axis-traction Forceps was very carefully con- sidered by Tarnier 1 and Milne Murray. 8 To those interested in the Bubjecl 1 would hcitrtily commend the writings of those two authorities. Here I will only say a word or two about the matter. It is perfectly evident to every one employing the ordinary forceps, with the head high in the cavity, that a large amount of force is lost against the anterior pelvic wall. Tarnier (Fig. 150) estimated that nearly half the traction force is lost. With axis- traction forceps this is in great part saved. Another important point, de- monstrated by Murray more espe- cially, was that the ideal attachment of the traction rods is just below the fenestra; of the blades (Fig. 151 . Thus, such forms as Neville's (Fig. 152), where they are attached to the upper part of the handles, and the older forms in which there is a pelvic curve connected with the lower end of the handles, although better than forceps with no traction rods, are less satisfactory than Tarnier's and its modifications. That this should have been proved mathematically is very interesting, for it agrees with the practical experi- ence of my colleagues and myself in the Maternity Hospital. For several years I used exclusively Neville's forceps, but I found it much less efficient than such forms as Murray's and Simpson's. On many occasions, when I was in the habit of employing forceps above the brim, I failed to deliver with Neville's forceps, and succeeded with Murray's. Of all varieties of axis-traction forceps, then, Tarnier's and the various modifications of it — Simpson's, Murray's, Culling- worth's, and Bonnet's, etc. — are the best, theoretically and practically. The English modifications of Tarnier's forceps, excepting Bonnet's, have the traction rods attached to the outside of the blades. In 1 Trans. Inter. Med. Congress, London, 1881, vol. iv. 2 Trans. Edin. Obst. Soc, vol. xvi., etc. Fig. 151. Mechanical Construction of Tarnier's Forceps. (Milne Murray. X, Centre point of blade tip : V, junc- tion of blade and shank ; X, Y, cord of arc of blade; E, F, bisects cord at right angles; \\ II l'.l;V of the bladder is of the greatest importance. I am perfectly certain that many of the cases of partial incontinence following parturition — cases by no means uncommon — are the result of pulling the child out of the vagina with the bladder still containing a considerable quantity of urine. The bladder should be emptied hy catheter just In -fore the introduction of the blades, for only hy that means can one be perfectly sure that it is thoroughly evacuated. This is an easy matter, except in those cases where the head is low in the vagina and actually press- ing upon the urethra. In the latter the head must he pushed up a little way to allow the catheter to pass. The emptying of the howel is also necessary, not only hecause it is extremely disagreeable to the operator to have fa-ces escaping while he is delivering the child, but because their escape while vaginal manipula- tions are being carried out is an actual danger to the parturient. It is also desirable to have the patient under an anesthetic. In the case of a primipara, at the time the head is escaping surgical anaesthesia is an advantage, for a patient half under struggles and tosses about so much that it is very difficult to control her and prevent perineal rupture. In this country the common position for the patient to assume is the left lateral. In simple forceps delivery I employ this decubitus. It is, however, advisable that the accoucheur should also accustom himself to operate with the patient on her back, the position preferred in all other countries except Great Britain. It is largely a matter of custom which position is chosen in the simpler cases of forceps delivery ; but when the instrument has to be applied with the head at the brim, and especially with the pelvis deformed, the dorsal decubitus is better, not because the operation is easier in that position, but because the blades can be applied more exactly, and the head does not slip out of the pelvis. Besides, in contracted pelvis it is often an advantage to drop the legs, and put the patient in what is known as the Walcher or ' hanging-leg ' position (Fig. 171). A very exhaustive discussion regarding the value of this position took place at the Inter- national Congress in Amsterdam in 1899. 1 It was generally admitted by all, with the exception of Bar, that an increase of about 1 centi- metre (0*4 inch) resulted. Those interested in the subject will find it fully considered by Fothergill.- In the Walcher position the weight of the hanging legs depresses the fore-part of the pelvis, when there of necessity results an increase in the conjugata vera. The conjugate at the outlet is diminished, however ; consequently, after the head has passed the brim the position 1 Zent. f. Gijn., No. 35, 1899. - Brit. Mr,/. Jnuni.. 1896, vol. ii., p. 1290. F011CEPS :;i should be changed to the lithotomy one- Apart altogether from actual measurements made on the cadaver, practical experience confirms the advantage of the position. Upon several occasions I have delivered with forceps in the Walcher position after failing in the lateral or dorsal. My colleagues in the Maternity Hospital have had similar experiences. There is another distinct advantage which the dorsal decubitus possesses in cases of ' high forceps.' If a patient deeply anesthetized is rolled round on her side, the head, although well engaged, slips out of the brim, because the body of the child falls over to the more dependent side. The operator has, therefore, to apply the instrument to a movable head, and may pull it into a position other than that in which it was moulding and trying to pass. Fig. 155. — The Ideal Position of the Blades with respect to the Foetal Head. We must now consider an important question — the relationship of the blades to the maternal pelvis and foetal head. Should the blades be applied relatively to the pelvis or relatively to the foetal head? The blades of any of the ordinary varieties of forceps are so constructed that they are in perfect position when they grasp the head transversely (Fig. 155) and are placed transversely in the pelvis (Fig. 15G). If the head of the child always lay in the pelvis, with its antero-posterior diameter in the antero-posterior diameter of the pelvis, this would be readily secured ; but the long or antero- posterior diameter of the head does not always occupy the conjugate — indeed, only at the lower part of the cavity does it do so. At the brim it is in the oblique or transverse diameter of the pelvis ; consequently, in such cases the blades cannot grasp the head transversely and lie transversely in the pelvis. 848 OPERATIVE MIDWIFERY If one applies the forceps to a dried pelvis it ifl at once evident that each blade has a certain range of what may be called 'safe movement/ and that the limits of this are the ilio-pectineal eminence and the sacro-iliac synchondrosis on each side (Fig. L57). With the head lying in the Oblique diameter, therefore, it is still possible to a transverse grasp by applying one blade over these two points. Hence the old rule in such cases: 'Apply the blades in the oppoe oblique diameter to that in which the head lies.* When, however, the long axis of the head occupies the transverse diameter of the brim, as in flat pelvis, it is obviously impossible to apply the blades Fis. 156.— The Ideal Position of the Blades relatively to the Maternal Pelvis. (I'mmni.) transversely to the head, unless, of course, one moves them beyond the ilio-pectineal eminence and the sacro-iliac synchondrosis, and places them in the conjugate diameter of the pelvis. I shall refer to such cases when speaking of contracted pelvis. In advocating a deliberate grasping of the child's head and the placing of the blades against the head, I am simply returning to the teaching of the older obstetricians, Levret, Smellie, and Baudelocque. Pushing in the blades to the side of the pelvis and trusting to the grasp being satisfactory is of quite recent date, and although it is very generally followed, and is the method of application recommended by such writers as Barnes, Galabin, and Playfair, I have always taken FORCEPS 349 exception to it. 1 I need only mention the cases where, by applying the blades in the casual way mentioned, the instrument repeatedly slips off the head, until finally a satisfactory grasp is obtained. Would such a satisfactory grasp not be more likely to be obtained if the blades from the first were applied deliberately to the child's head in the direction deemed best ? I am not alone in advocating a more careful and deliberate grasp of the head ; some of the most distinguished obstetricians of the present day — as, for example, the late Milne Murray, Clarence Webster, Whitridge Williams, Pinard, the late Varnier, and Nagel — do so. Fir;. 157. — Showing the Range of Safe Movement of the Blades relatively to the Pelvis. (Bumni.) We have now reached the stage when I may describe how the forceps are to be applied, and in so doing I shall first take a simple case where the head is low down in the pelvis, and afterwards consider the more difficult and complicated cases in detail. With the woman in the left lateral position, I believe it best to use the left hand internally for guiding both blades, and the right for holding and introducing them. When, however, the dorsal decubitus is employed, each blade is best guided into position by the hand which most naturally applies itself to the side of the maternal pelvis ; 1 Lancet, September 24, 1898. 850 OPERATIVE MIDWIFERY thus, (or the right blade the operator's left hand is b< -;. and for the left his right. Having determined the exact relationship of the long axis of the head to the bony pelvis, the left blade is introduced by passing it o the fingers of the left hand, which is in the vagina (Fig. L58 . blade must be kept closely applied to the Bide of the total head, and carefully guided inside the os externum. Having done this, the handle is depressed and carried well hack. This has the effec bringing the blade over the most suitable part of the child's head. It Fig. 158. — The Application of tlie Lower or Left Blade. The blade and traction rod are held as indi also takes the blade out of the operator's way, especially if there is an assistant available to steady it. It is evident from the illustration that the traction rod is not the least in the way, being held along with the handle by the right hand. The second blade may be introduced as was the first, only above and to the right side of the pelvis, opposite to the other. But thai method is not nearly so satisfactory as the one generally employed Fig. 159). In the latter the blade is passed first into the hollow of the sacrum, and is then rotated into position opposite the first. Some operators introduce the first blade in this way also. The operator FORCEPS 351 holds it with the traction handle well out of the way and resting on the dorsum of his hand. By neglecting this little precaution all the trouble with the axis-traction forceps arises. He grasps then the handle with the traction rod resting on the dorsum of his hand, and under the guidance of his other hand he slips the blade into the hollow of the sacrum. Having placed it over the forehead of the child, he rotates it round into the position desired, opposite the first (Fig. 160), and he finds that without any difficulty the blades lock (Fig. 1(31). Difficulties with locking hardly ever occur when the head is low down. If by any chance they should, a little gentle manoeuvring Fig. 159.— The Introduction of the Upper or Right Blade. The lower or left blade is held well back while the right or upper is carried into the hollow of the sacrum. The traction rod, it will be observed, is not in the way; it rests on the dorsum of the operator's right hand. or reintroducing the blades will right the matter. The instrument being locked, he then brings the traction rod of the right blade, which until now has been in front, into position alongside of its fellow by pushing it back over the shank of the blade. The butterfly screw is then tightened, and the traction handle attached to the bars (Fig. 162). As I have said before, the butterfly screw must be slackened from time to time, as a continuous pressure endangers the child. One knows when a good grasp has been obtained by the blades of the forceps being applied to the head in the manner already illustrated (Fig. 155). Bat if the operator has not troubled about how they lie relatively to the head — as is unfortunately the custom with so many — it will be evidenced by the blades locking readily, and by 852 OPERATIVE MII>\Vll'i:i;Y there being very little separation between the ends of the handles. In high forceps, with the head in the transverse or oblique diameter, separation of the handles is unavoidable; but with the head low down it always means that the forceps is wrongly applied, or that the child's head is lying in a different position than was supposed. If the handles are widely separated, the blades should be removed, and a careful examination of the position and attitude of the head again made before they are reapplied. In delivering with forceps, one should do so with the expenditure of the minimum of force, and to accomplish this one should always Fig. 160.— The Rotation of tin- Right or Upper Blade from the Hollow of the Sacrum mi to the Pari of the Child's Head desired. Observe the traction rod is not causing the operator any inconveniena ■ try to pull the head in the direction it would be driven naturally. In a normal delivery the occiput is pushed lower and lower down, and slowly rounds the symphysis pubis. The occiput does not become arrested at the symphysis pubis, and if it does, premature extension of the head occurs, with the result that a larger circumference of the head is brought across the vulvar orifice, and rupture of the perineum follows. Now, with forceps, especially the ordinary variety, such a mistake is very liable to occur if traction is directed too soon forwards. With axis-traction forceps this is not so likely if one allows the handles to guide one as to the direction in which to pull. The traction FORCEPS :;:,:; rods should be kept close to the handles as the latter come farther and farther forwards (Fig. 168). They must not actually touch the handles, otherwise they might press them forwards. In such a way the head is slowly guided over the perineum (Fig. 1(54). Traction, however, must not be continuous, but must be exerted during the uterine contractions, or, if they are very infrequent, at regular intervals. I have sometimes found that the head, if small, moves within the blades, and when one pulls upon the forceps, the handles pass at once Fir;. 161. The Mades are now locked. The traction rod of the right blade is still in front, carried back over the shanks beside the left one. It is now forwards. In such cases, were one to follow the handles, traction would be made too soon forwards, with the result that the occipito- frontal circumference would be brought through the vulvar orifice and the perineum ruptured. The best course in such a condition is to help the occiput down with one's fingers, or retard the forehead by pressing it from behind. In most cases I do not remove the blades before the head escapes. The advantage of leaving the blades on while the head is escaping is that by means of them the too rapid birth of the head can be controlled. The only objection to keeping them applied — the amount of room they take up may be neglected — is that, if the head is im- perfectly grasped, or if it slips within the forceps, a longer diameter than the suboccipito-frontal is thrown across the vulvar orifice. 23 ::;,1 OPERATIVE MIDWIFERY The Edinburgh school attach great importance to keeping the blades on when extracting a child, and their teachers have frequently "i referred to the advantages of axis-traction forceps in preserving the I perineum from rupture. Glasgow and other British schools do no< attach so much importance to this. If delivery is completed without the blades, the head must never be pushed out with the hands, unless the occiput is prevented from catching on the symphysis. Also, the mistake must not be made of J taking the blades off too soon, and so allowing the head to slip back. Fig. 162, The blades are locked and the traction rods are in position. The blades are slightly gaping, and the butterfly screw is not more than just biting. Details regarding the management of the escape of the head and the preservation of the perineum will be found in the chapter on Perineal Rupture. During the extraction the nurse should hold up the woman's right leg. As can be seen from the illustration (Fig. 164), the leg is maintained extended, so as to relax the perineum to the greatest possible extent. The Head High in the Cavity, but lying* in the Oblique Diameter. When forceps have to be employed with the head high in the pelvic cavity, without doubt there is something to be said in favour FORCEPS 355 of placing the patient in the lithotomy position. As I have already mentioned, in that position the blades can be more exactly applied to the head, if necessary, the Walcher or hanging-leg position can be made use of, and the weight of the trunk maintains the child's head fixed in the pelvic brim. Barnes says : ' Placing the woman in the dorsal position facilitates extraction.' In order that the head, situated high in the pelvis, may be grasped laterally, the blades must lie in the opposite oblique diameter to that occupied by the long axis of the head (Fig. 157). To accomplish this Fig. 163. — Traction Downwards and Backwards. The traction rods are all but touching the handles, which guide one as to the direction in which traction should be made. ;he blades must be carefully placed over the sides of the head, not ust casually pushed in at the sides of the pelvis. With the patient in the lateral position one proceeds as follows : An issistant steadies the child by pressing upon the fundus uteri. The )perator then passes his left hand into the vagina and determines the 3xact position of the head. The fingers here must be placed well nside the margin of the cervix, and the blades carefully guided through ■he os. The left or under blade is passed either directly up towards .he sacro-iliac synchondrosis, or carried into the hollow of the sacrum md rotated on to the side of the child's head. It is then held in position by an assistant. The second, upper, or right blade is best ntroduced if passed into the hollow of the sacrum and rotated into 856 OPERATIVE MIDWII'KIIV position. One must make sure that it is carried well forward opposii the ilio-pectineal eminence. The handles are then locked, sometimei] with a little difficulty, bat usually fairly easily, if tho first is heh in position and hoth are pressed well back. If the difficulty iij extreme, it is advisable to remove the blades and reintroduce them The traction bars are applied as already described. I must admit that in the 'high operation' the traction rod.- an sometimes a little trouble, but if the rule I have laid down is followed of keeping the rod of the right or upper blade well forwards until th( Fir;. Hil. The head is being extracted. The traction rods follow tin- handles as the latter pass forwards and upwards between the parturient's thighs. blades are locked, a very little practice will render the manipulations easy. Before proceeding to traction it is a wise precaution to make surf that the cervix is quite free, and that the blades are in the position desired. One or two tentative efforts at traction having then been made, the delivery should be proceeded with. Traction must be in the right direction — viz., in the axis of the pelvis. As T have already described, the handles, as the head descends, are one's guide. Traction must also be made during the uterine con- tractions, or, if they are absent, at short intervals. FORCEPS 357 If the patient is a primipara, some time will be required to bring the head down through the whole length of the canal. This may have an injurious effect on the child, especially if the mistake is made of keeping the butterfly screw tight. Occasionally I have found it advisable to remove the blades at the outlet and reapply them, for although theoretically delivery may be completed with the grasp first obtained, in practice, when the head reaches the floor, a better grasp may often be secured by removing and then reapplying the blades. Oceipito-Posterior Position of the Vertex. This position of the vertex was considered in detail when mal- positions of the child as a cause of dystocia was being discussed (Chapter IV.). I gave it then as my experience that rotation by means of the hand could be effected in somewhere about 70 per cent, of cases, and that it was a most desirable proceeding, as it rendered the delivery of the head infinitely easier and safer for mother and child. It sometimes happens, however, that rotation is not possible, or that the malposition is overlooked until forceps has been applied. I have already referred to this, and indicated how one must suspect the position if there is much difficulty in delivering a head at the outlet, and especially if the vulvar orifice gapes without the perineum distending. I cannot agree with Barnes when he writes 1 against manual rotation of the head, nor when he states with regard to forceps that ' delivery is nearly as easy as when the instrument is applied to an occipito-anterior position.' My experience in delivering primiparse where the occiput remains persistently posterior is that a considerable amount of force is required, and that frequently a very extensive tearing of the perineum results. When rotation fails there is nothing for it but the employment of forceps. In this position of the head, and in this position alone, straight forceps may be of use, and there are some of my colleagues who carry that instrument solely for the cases under consideration. The ordinary forceps, however, with or without the traction handles, is quite suitable, for if rotation does occur it is a simple matter to remove the blades and reapply them. It has been recommended to apply the blades with the pelvic curve directed backwards, so that if rotation occurs the blades are in proper position. Seldom do I try to rotate with the forceps, but if I feel the instru- ment slipping round and the occiput coming to the front, as it some- 1 Op. cit., p. 60. 858 OPERATIVE MlhYYU l.l;\ times does, I encourage it to do so. Williams, Edgar, and many others, speak very highly of actually rotating the instrument uftei having pulled the head down and encouraged flexion. In occipito-posterior positions the blades are introduced in tin manner already detailed. It is most important that the blades Bhoufl lie about equidistant from the occiput and sinciput, otherwise tln-\ are liable to slip off suddenly when traction is exerted. In persistent occipito-posterior positions, the head should U delivered in the same way as nature effects delivery. The sinciput in the region between the anterior fontanelle and the glabella is pressed Fig. 165. — Forceps in Persistent Occipito-Post< rior Position of Vertex. against the symphysis, while the occiput distends and finally swi i pe over the perineum (Fig. 165). The producing of flexion has the great ;i d vantage that it gives the head a chance of rotating up to the last, and once or twice when I thought all hope of rotation was past I have found it occur. It is a mistake to bring the occiput too far down before bringing it over the perineum. Traction should therefore be made downwards and backwards, then more and more forwards, until the occiput is born. The face then slips down from behind the sym- physis. Very frequently I make a lateral incision through the margin of the vaginal orifice, in order to avoid perineal tearing. FOIICEPS 359 Face Presentations. Forceps may be employed in face presentations, and with very satisfactory results, provided the head has passed the pelvic brim and the chin is forwards. With a normal pelvis the indications for the operation and the conditions which must be fulfilled before the instrument is applied are in the main identical to those which obtain in vertex positions If, however, the pelvis is deformed, forceps is not a suitable instru- JFig. 166. — Forceps in Face Presentation. ment. Nor, indeed, is it advisable to attempt manual correction of the position. Version, if that is still possible and the pelvis is not too deformed, is probably the most suitable treatment. The position of the blades in a facial presentation is as the illustra- tion indicates (Fig. 166). The manner in which the blades are inserted and placed over the sides of the face is, for the most part, as has been already described. Special care must, however, be taken not to injure the face, and to see that the blades lie over the sides of the head in a direction approaching the occipito-mental diameter. Consequently, the handles must not be pushed too far back. In delivering the head one must prevent too early descent of the occiput, for if that occurs before the chin comes below the pubes the head becomes impacted in the pelvis. Traction is directed, therefore, to bringing the chin below and then round the symphysis. In cases 860 Ol'KKATIN ]■; MlhW \l\.\l\ where the pelvis is normal, or only slightly deformed, our results from forceps delivery in facial presentations have been very satisfactory to both mother and child. Turning now to mento-poaterior cases, 1 must differ from Williams and Edgar and many French and German operators who refer to forceps as being unsuitable and profitless. A little time ago we had a case which proved that, although theoretically such an opinion may be correct, in practice it is not so. The patient had been in the second stage for some hours, and it was necessary, both in the interests of mother and child, that the delivery should be completed. Having had previous experience of the face rotating under the influence of traction, my house-surgeon made traction under my direction, with the result that the chin came round to the front and a living child was delivered without difficulty. Lewers 1 some years ago described a similar experience in two cases, and in the discussion which followed Spencer mentioned three in his practice. A most valuable paper by Reed on the subject recently appeared in the American Journal of Obstetrics. If one fails to deliver the head in a persistent mento-posterior position with forceps, recourse to symphysiotomy is not commendable, even if the pelvis is of a normal capacity, for the child's chances of surviving are not good. In such cases, if I could not rotate the chin forwards, I would without hesitation perforate the head. The subject of mento-posterior position of the face is fully considered in Chapter IV. Brow Presentations. I consider forceps unsuitable in brow presentations. In two cases in my own practice in which such treatment was employed, on one occasion by myself many years ago, and on the other by my house- surgeon recently, the results were most unsatisfactory. After very severe traction the children were delivered, but both were dead. Contrast that with the result obtained in another case, where the brow was converted into a vertex position, and a child weighing 12 pounds was delivered alive after several fruitless attempts had been made with forceps outside the hospital (Chapter IV. t. After-comingr Head. It is my practice always to have forceps ready in breech pre- sentations, and to apply them if after two attempts with traction and suprapubic pressure I fail to deliver the after-coming head. My reasons for pursuing such a course have been already given when 1 Trans. Lond. Obst. Soc, 1899, vol xli.. p. '2*0. FORCEPS 361 considering breech presentations. I never employ the axis-traction forceps, as the rods are apt to get in the way, especially the one belonging to the right or upper blade. In carrying out the operation it is an advantage, if an assistant is available, to get him to hold the trunk of the child a little forwards, so that it may be out of the way. The introduction of the blades is Fig. 167. — The Delivery of the After-coming Head with Forceps. carried out precisely as in other cases of forceps delivery. The trunk of the child being pulled forwards out of the way, the left or lower blade is passed along the side of the child's head. The right or upper blade is then passed into the hollow of the sacrum, and rotated round into position over the other side of the head. The blades must always lie along the ventral aspect of the child, so as to promote 862 OPERATIVE MIDWIFERY flexion (Pig. 1»»7). If they are placed along the dorsal aspect, any fcraotion extends the head. Traction should be made first downwards and backwards, then the forceps and child should be carried upwards towards the mother's abdomen. Impacted Breech. 1 have once or twice delivered the impacted breech with forceps when I have been unable to get my lingers into the groin, but 1 have more often failed owing to the forceps slipping. To get a proper hold of the fo?tal pelvis the blades must be applied to the side of the breech, with the tips placed between the thigh and abdomen of the child (Fig. 49). That, however, is not always possible, especially if the thighs are at different levels. I cannot, therefore, give the treat- ment a very hearty recommendation, although it is a method I would always try before attempting to apply the fillet or blunt hook. The introduction of the blades is quite simple, and is carried out as already described for other presentations. The treatment of impacted breech is fully considered in Chapter V. CHAPTER XXIV FORCEPS— Continued Forceps in Contracted Pelvis. In the last chapter I considered the general principles that should guide one in the employment of forceps under ordinary conditions. There now remains the very important question of the employment of the instrument in contracted pelvis., which I have thought advisable to discuss in a separate chapter. Few subjects in midwifery have given rise to so much discussion, or to such differences of opinion, as the employment of forceps in contracted pelvis. Even at the present time differences of opinion exist. As illustrating this, let me give very briefly the views of a few representative Continental and American obstetricians regarding the matter. In Winckel's large work on obstetrics Wyder says : ' The applica- tion of forceps is contra-indicated so long as the head has not passed the obstruction, and in general contracted pelvis so long as the head has not moulded itself to the pelvic deformity.' Proceeding further, however, the writer admits that where the life of the mother or child is in danger an attempt may be made with forceps even before these conditions are fulfilled. Olshausen and Veit x take a slightly broader view, for they consider the application justifiable if the greatest circumference of the head is already engaged in the brim. Ribemont-Dessaignes and Lepage 2 write : ' This operation, which during certain times has been the subject of numerous discussions, has lost in great part its interest, by reason of the introduction of symphysiotomy and the almost complete abandonment of forceps in contracted pelvis.' These writers recommend the application of forceps only when symphysiotomy is contra-indicated — for example, when the child is already on the point of dying. Faraboeuf, Pinard, 1 ' Lehrbuch der Geburtshulfe,' 5th edition, 1902, p. 530. 2 ' Precis d'Obstetrique,' 6th edition, 1904, p. 1122. 863 864 OPERATIVE MII>\\ Il'KkY and French obstetricians generally, are opposed to pulling the head past the obstruction. Bdgar of New York 1 writes: ' The greatest circumference of the head roust have passed the inlet, and the head must he fixed in the pelvis'; but when speaking of forceps in contracted pelvis he says: 2 4 Forceps application is applicable to those cases in which the head is engaged, or in which it can be made to engage by suprapubic pressure, or in which it is possible to be sure that there is no disproportion between the head and the pelvis.' Williams 3 says: 'Generally speaking, contracted pelvis presents an absolute contra-indication to the application of forceps, for if the contraction be marked it will be impossible to drag the head through the pelvis, and if brute force be employed it will result in the death of the child, and severe injuries to the soft parts of the mother, and occasionally cause her death. On the other hand, when the contraction is slight — and especially when the head is already engaged in the upper part of the pelvic cavity — a tentative application with forceps may be justifiable. Under such circumstances a few tractions of moderate intensity should be made ; if the head follows them, they should be continued, but if not the forceps should be removed, and delivery effected in some other manner.' Of these writers, Williams is undoubtedly the most explicit, and his attitude towards this subject is clear and well defined. The others, with the exception of a certain school in France, who condemn entirely the application of forceps before the greatest circumference of the head has passed the brim, evade the real question at issue. "While condemning the pulling of the head past the obstruction, they are forced to admit that it must be done under certain circumstances. Personally, I am in entire agreement with Williams, and I think his summing-up of the matter in the few words already quoted is excellent. In recent years one or two German writers have expressed similar views. Both Skutsch 4 and Nagel 5 recommend the bringing of the head past the obstruction with moderate traction. Nagel 6 writes: * Only those can term the high forceps barbarous who have had little practice with, and have incompletely mastered, the operation. In truth it is now the most skilful of all the obstetric operations.' Wenczel 7 and T6th s have made two important contributions on the subject of high forceps in contracted pelvis. The attitude that it 1 ' Practice of Obstetrics,' 1903, p. 1016. - Ibid., p. 698. 3 ' Obstetrics,' 1903, p. 358. 4 'GeburtshiilHiche Operationslehere,' Jena, 1901. 5 'Operative Geburtshiilfe,' Berlin, 1902. ' Ibid., p. 221. " Archiv f. Gyn., 1904, lxxiii., p. 673. - Ibid., J5d. lv.. p. 11. FORCEPS 365. is permissible to pull the child's head past the obstruction appears to me the only rational one, for otherwise how can one avoid performing symphysiotomy, pubiotomy, or Cesarean section unnecessarily ? Every one knows that there are many cases in which only a little traction is required to bring the head through the brim. Is one to perform, symphysiotomy, pubiotomy, or Cesarean section in such cases '? So much for the extreme position that forceps is not to be applied until the child's head has passed the obstruction. But there is the other extreme position of those who employ brute force to bring the child through the contracted brim. Admitting that it is sometimes permissible to pull the head past a bony obstruc- tion of the pelvis with forceps, it must be clearly understood that this obstruction must be slight, and that the amount of force employed must be very moderate. Unfortunately, at present this is not fully appreciated. Practitioners drag at the child's head with forceps, and proudly boast how, with their feet against the bed or couch, or even- against the pelvis of the mother, they have pulled children through the most contracted brims. Practitioners not infrequently say to me that they have never seen cases of contracted pelvis in which they could not deliver the child with forceps. Every week we receive into the Glasgow Maternity Hospital cases of contracted pelvis in which practitioners have failed to deliver with forceps. "What are the reasons for this state of matters ? and who are to blame for this unfortunate, but far too common, practice ? In great part obstetric teachers have been to blame. Let me indicate what I mean by a specific example. An important discussion on the employment of forceps in contracted pelvis took place at the annual meeting of the British Medical Association m Carlisle in August, 1896. 1 The discussion was introduced by the late Milne Murray, who was then recognized as a great British authority on forceps. Milne Murray then said : ' During the last eight years I have delivered living children in several cases where the brim was not more than 3| inches, and in one case, already on record, I delivered a living child where accurate measurements of the pelvis made post- mortem and under chloroform showed that the conjugate was not more than 2 - 75 inches. In this case the head was quite free when the forceps were applied — indeed, it had to be steadied by an assistant during their application.' The harm which has followed such teaching is incalculable. It will be many years before it is generally recognized as being unsound and unscientific. Speaking for myself, it is only from the experience 1 Brit. Med. Journ., October 31, 1896, vol. ii., p. 1282. 866 OPERATIVE MIDWIFERY gained in the last few years in the Glasgow Maternity Hospital that I have rcali/cd it — indeed, J have only fully done so since I examined our results from the treatment and discovered how very unsatisfactory they are. Let me give these results. Here is a table, which includes all cases of pelvic deformity, where the conjugata vera measured 3k to 3 inches (H-7 to 75 centimetres), delivered by forceps in the •Glasgow Maternity Hospital during the years 18'J'J to 1906 inclusive. The cases number 130 in all. Table of 130 Casks, whkuk Conjugata Vera measured 3J i" :; [scuba 3*7 i" 7*5 Centimetres), delivered bt Forceps in Glasgow Maternity Bospital, 1899 TO 1906. In. (7*5 cm.), 80 Oases. C.V. S\ In. (8. cm.] I C.V. Alive, 21. Dead, 18. Alive, 40. Dead, 12 Alive. 33. Dead, 6. tVetal mortality, 46 %. Foetal mortality, 23 %. Foetal mortality I need hardly say that these results are far from satisfactory. Many of the cases, without doubt, were interfered with before admis- sion to hospital, but excluding the fatal cases that we in the hospital were not responsible for, the fcetal mortality is far too high. If such are the results obtained by my colleagues and myself in the hospital, who have had so much experience with forceps in contracted pelvis, and have every convenience for performing the operation, it may safely be concluded that worse results will follow a similar treat- ment practised by those who only occasionally encounter cases of pelvic deformity. In employing forceps in contracted pelvis two great mistakes are made : (1) Insufficient time is given the head to mould ; (2) forceps is employed in degrees of pelvic deformity in which it is quite profitless to employ the instrument. I have said sufficient about the first mistake elsewhere. I have pointed out that the second stage should be allowed to continue three, four, five, six, or even more hours, and that the condition of the mother and child should be watched, and inter- ference had recourse to only when there are decided indications for doing so. The second mistake is well illustrated by the table. As shown, the foetal mortality is as high as 46 per cent, with a conjugata vera of 3 inches (7'5 centimetres). It must be admitted, therefore, that with such a degree of deformity it is unwise, except in very exceptional circumstances, to employ forceps. I am perfectly well aware that there are cases on record where living children have been delivered through a pelvis of 2| inches (7 centimetres). Milne Murray and FOltCEPS 367 others have recorded cases, and in the hospital we have had such cases ; but they are of great rarity, and should not come into ■consideration or influence one in favour of forceps. I have stated that under exceptional circumstances the operation may be justifiable with the degree of deformity we are considering — viz., 3 inches. If, for example, the head is found well engaged and moulded, and seems only very slightly larger than the pelvic brim, and provided the type of pelvis is of the fiat variety, one may make an attempt in the Walcher position with the forceps prior to performing pubiotomy or craniotomy ; but, let me again remark, rarely will one succeed in such cases with moderate traction. Flu. 168. — Oblique Grasp of the Head, showing the Position of the Blade situated over the Face. Take now pelves less deformed. As might naturally be expected, with increasing pelvic capacity the fcetal mortality proportionately ■decreases. Thus from the table it will be seen that at 3] inches it is 23 per cent., and at 3|- inches it is 15 per cent. No hard-and-fast rules can be laid down regarding the employment of forceps in such degrees of medium deformity ; the only guide must be the relative size of the head and the pelvis. In certain cases with a pelvis of 3^ inches it may be absolutely sound treatment to employ forceps, while in other cases with a deformity of Sh inches it may be equally unsound. When is one justified in such cases in using forceps? It is easier to answer this by stating under what conditions one is not justified. 1. One is not justified in applying the instrument until the head 368 OPERATIVE MIDWIFERY has been given the utmost limit of time to mould. By the utmost limit of lime 1 mean until symptoms of disturbance in the mother or embarrassment in the foetal circulation arise. -. One is not justified in applying forceps if the head is freely movable above the brim and if there is distinct overlapping after the head has been allowed this long time to mould. :'.. One is not justified, or at least one will find it profitless, to apply forceps in posterior parietal (Litzmann's obliquity) presentations (p. 163). 4. One is not justified in continuing attempts at forceps delivery after two failures with a moderate degree of traction and the patient in the "Walcher position. Fl.: 169. — Oblique Grasp of the Head, showing the Position of the Blah:i;ati\ i: midwjfkiiy of thu Long axis of the head (Pig. 170). Tlie placing of the hlades exactly in position is by no means easy, and I must candidly admit that I have frequently failed, and got a slightly oblique instead of an exact antero-posterior grip of the head. It hus always appeared to me, however, even in the cases in which I have failed to get the blades applied exactly as I wished, that I secured a better grasp of the head than if 1 had simply casually slipped in the instrument and trusted to the hold obtained. The locking of the hlades is sometimes attended with a little difficulty, as the handles gape very widely. It is necessary to tighten the butterfly screw firmly. The blades being locked, traction should now be made to if the instrument is holding; this being considered satisfactory, it FlG. 170.— Application of Blades of Forceps, with One Blade over the Face and the other over the Occiput. is advisable to place the patient in the Walcher position. The operator now sits upon the floor (Fig. 171). That I have found absolutely necessary if the full benefit of the axis-traction forceps in the Walcher position is to be obtained. He then pulls directly in the axis of the brim. One or two attempts at pulling the head past the obstruction is all that is permissible, and the amount of force that the operator exerts must not be extreme ; it must not be more than can be exerted by his forearms. In the majority of cases, if one has carefully estimated the relative size of the head and the pelvis and conformed to all the conditions already laid down, the head will | through. In flat pelvis it does so sometimes with a sudden jerk, FORCEPS 871 which, on the first occasion the sensation is experienced, may alarm the operator ; but it is of no consequence, and simply means that the head has passed into the roomy part of the pelvis. The forceps is now removed. To continue the extraction with it still in the antero-posterior diameter of the head would be a distinct error in technique, for one would then be dragging the longest diameter of the head through the narrowest diameter of the pelvis. The blades must, therefore, be reapplied in the ordinary way. I have Fig. 171. — Axis-Traction Forceps with Head fixed at the Brim. The patient is in the Walcher position, and the operator is sitting on the floor. sometimes found that if I reapplied the blades immediately, I obtained ■the same grip of the head, for it had not rotated. It is, I think, better, therefore, after removing the blades, to stimulate the uterus to contract, to exert firm pressure upon the uterus when it does so, and to rotate the head into the conjugate diameter with the hand in the vagina before reapplying the instrument. Delivery is then completed in the ordinary way. 372 OPERATIVE MIDWIFERY 3. The Deliberate Application of the Blades Antero-Posteriorly as regards the Pelvis— One Blade in front of the Promontory and the Other behind the Symphysis. — This is the method em- ployed by the old obstetricians, and careful instructions regarding such an application will be found in the writings of Baudelocque, Smellie, etc. At the present time it is still employed by a few obstetricians in France, but in all other countries it has been entirely abandoned, the previous methods described being preferred. Several obstetricians — for example, Sloan, Reid, and Cameron of Glasgow, and Fry in America — have invented forceps the blades of which lie antero-posteriorly as regards the maternal pelvis. The object of such forms of antero-posterior forceps is, of course, to obtain a transverse grasp of the child's head. Here is an illustration of Cameron's forceps (Fig. 172). It is at once evident, that the position Fig. 172. — Cameron's Forceps. of the blades antero-posteriorly must be a source of considerable danger to the parturient during extraction, and especially must there be great danger to the soft parts situated over the promontory. Antero-posterior forceps, therefore, has not been received with any favour, and is not likely to become more popular in the future. An instrument somewhat similar in principle to Cameron's forceps, but much more complicated, is the prehenseur-levier-mensurateur of Farabceuf (Fig. 173). Forceps in Generally Contracted Pelvis. — In suitable cases forceps is most useful. In this variety of pelvic deformity it must never be employed unless the head is well fixed at the brim and there is no overlapping. The presence of an unusually large caput may sometimes render it difficult to say how much of the head has really passed the brim, but by careful palpation along the brim one can always tell the relative size of head and pelvis. It must be FORCEPS 373 remembered, however, that a relatively less amount of disproportion can be overcome in a generally contracted pelvis than in a flat pelvis. In a generally contracted pelvis we have seen that the head engages in the oblique diameter of the pelvis and is very much flexed. The application of the blades is, as has been already described, for cases where the head is high in the cavity, except that the blades must be brought well forward, otherwise they are very apt to slip off. The Walcher position is of no advantage in the pure varieties of generally contracted pelvis. Maternal and FoGtal Mortality and Morbidity. — The maternal mortality in my cases was l - 4 per cent., which does not appear a very Fig. 173. — Prehenseur-levier-mensurateur. (Farabceuf.) high figure. I would remark, however, that several of the fatal cases of craniotomy, which are mentioned in connexion with that operation, were really the result of injudicious use of forceps. The same remark also applies to the maternal morbidity, which works out at 20 per cent. That figure in no way represents the proportion of cases in which injuries to the parturient canal resulted from the injudicious use of forceps. I have already said sufficient about the festal mortality (Chapter XII.). The morbidity also is very high ; bruises and lacera- tions of the soft parts, indentations and fractures of the bones, and injuries to eyes, ears, nerves, are by no means uncommon. These injuries are considered in Chapter XXXVII. CHAPTER XXV THE ENLARGEMENT OF THE PELVIC CAPACITY— SYMPHYSIOTOMY AND HEBOSTEOTOMY (PUBIOTOMY) The operation of symphysiotomy has had a most chequered history. Although performed upon the dead as an alternative to post-mortem Cesarean section by Claude de la Courvee in 1655, it is invariablv associated with the name of Sigault, who suggested it in 1768, and performed it for the first time in 1777. The result of Sigault's operation was in the main satisfactory, for the child was born alive. The woman had previously given birth to four stillborn children. She suffered for the remainder of her life from a urinary fistula. 1 In the succeeding years symphysiotomy was performed many times. Baudelocque, 2 a strong opponent of it, wrote : ' It was performed more times in the space of four or five years than the Cesarean operation had been in the course of twenty or thirty, or perhaps in half an age.' Its popularity was short-lived, however. In France it was soon entirely abandoned, although in Italy it lingered on, and was occasionally performed. After an interval of about one hundred years interest was again aroused in it, and, as might be expected, Italy furnished the prime movers in the revival. The obstetrician most prominently associated with this revival was Morisani. Encouraged by Morisani's results, it soon met with the support of many distinguished obstetricians in other countries, chief amongst these being Pinard, Yarnier, and Bar, in France, and Zweifel in Germany. Little wonder, therefore, that in a few years symphysi- otomy once again came to be the most burning question in obstetrics. In France and Germany during the last decade of the nineteenth 1 Zweifel, 'Die Symphyseotonrie,' 1893; and Fasbender, ' Geschichte der Geburtshulfe,' 1906. 2 Heath's translation, vol. in., p. 241. 374 THE ENLARGEMENT OF THE PELVIC CAPACITY 375 century it was constantly being discussed, and at the International Medical Congress in 1894, and again in 1897, it was the principal subject under consideration in the Obstetrical Section. The operation never has aroused much interest in this country or in America. Valuable communications have been made by Herman, 1 Buist, 2 Jewett, 3 and others, but there have been no enthusiastic partisans, as in France and Germany. We have for the most part been onlookers. A year or two ago it appeared as if history were going to repeat itself, and the operation were again to be forgotten. Quite suddenly, however, interest was aroused by the introduction by Van der Velde and Gigli of pubiotomy, or as it is often termed hebosteotomy. This opera- tion is considered later (p. 398). General Considerations. — The object of both symphysiotomy and pubiotomy is to enlarge the pelvic capacity, so that a living child may be delivered without any great difficulty per vias naturales. Their indication, therefore, is a certain degree of pelvic deformity ; the exact degree we shall consider later. It has been claimed that these opera- tions might occasionally be of value in persistent mento-posterior positions of the face and in brow presentations. Everyone is agreed that it would be unwise to make a routine practice of the operations in such conditions, but recently I was forced to admit to myself that occasionally they were justifiable. The case which converted me to this view was a brow presentation admitted to hospital advanced in labour which I could not convert to a vertex or deliver with forceps without using brute force. The child's heart sounds were regular and strong, and so I proceeded to perform pubiotomy. The result was most satisfactory both as regards mother and child. As a result of division of the symphysis or pubes, all the pelvic diameters are increased. 4 Formerly it was thought that this occurred by a simple rotation of the bones outwards ; it is now known, however, that the innominate bones, when separated, rotate, not only outwards, but downwards, for the sacro-iliac joints — the hinges, if we compare the innominate bones to two folding doors — do not lie parallel to the divided ends of the pubic joint. All recent writers have referred to this, and the general opinion is that with 3 centimetres of pubic separation there is a descent of 2 centimetres. The most valuable paper on this subject in the English language is by Sandstein, 5 who 1 Trans. Lond. Obst. Soc, 1900, vol. xlii., 1900, p. 282. 2 Trans. Edin. Obst. Soc, vol. xxvii., p. 112. 3 Amer. Journ. Obst., vol. xliv., 1901. 4 The pelvic capacity is increased to an equal extent in both operations. 6 Trans. Edin. Obst. Soc, 1902, p. 68. 876 OPERATIC E M 1 1 >\\ 1 1 i:i;V made careful measurements of the pelves of twenty-eight female cadavers upon whom he performed symphysiotomy. Bandetein believes that the increase of the pelvic capacity results more from the movement downwards than from the rotation outwards. As regards the amount of gain in the conjugata vera, Sandstein says: 'Roughly speaking, (J centimetres (2-:*4 inches) of pubic separation gives an increase of 1 centimetre (0*89 inch'. Morisani found with (5 centimetres separation a gain of 1*8 to 1*5 centimetres.' Jewett ' writes : ' With a pubic separation of 7 centimetres the total gain in the antero-posterior diameter is about 1*8 centimetres ; in the transverse the gain is 1*5 centimetres ; and in the oblique about twice as much as in the conjugate.' Doderlein, from his experiments, 2 states that he found the pelvic ring increased from 105 .jcm. to 155 qcm., with centimetres of separation (the conjugata vera was 10"2 centimetres;. Wehle :! considers that with a separation of 6 centimetres there is an increase of 1*2 centimetres, and with a separation of 7 centimetres an increase of 1*5 centimetres. Generally speaking, these different observers are pretty well agreed as regards the amount of separation necessary to obtain a gain of 1 centimetre in the conjugata vera. Curiously enough, however, Farabceuf and Sandstein arrived at exactly opposite conclusions when the initial size of the pelvis is considered, for Farabu-uf found that the larger the pelvis the less was the increase, while Sandstein states ' The larger the true conjugate, the greater the increase for each centimetre of separation.' In this matter I attach more importance to Farabceuf s results, for Sandstein seems to have experimented only upon cases where the pelvis was normal. He says, ' The conjugata vera averaged 11*28 centimetres ' (4*5 inches). But there is another factor besides the increase of the pelvic capacity which favours the passage of the head after symphysiotomy, and, with the exception of Sandstein, all writers are agreed regarding its importance. It is the bulging of the anterior parietal bone into the gap between the separated pubic bones. In certain cases of obliquely deformed pelvis this cannot occur ; but such cases are not common. 1 ' Practice of Obstetrics,' 1902, p. 747. * Zent.f. Gyn., 1893, No. 23, p. 490. Arbeit, aus Her Kiiniylichcn Fnmenldinik in Dresden, 1892, vol. i., p. :;7 I. THE ENLARGEMENT OF THE PELVIC CAPACITY 377 Conditions which must be Fulfilled before Symphysiotomy or Pubiotomy is Contemplated. Before the operation of symphysiotomy or pubiotomy is contem- plated the following conditions must be fulfilled : 1. The child must be alive. 2. The pelvis must be of sufficient size, and there must not be too great a disproportion between it and the fcetal head. 3. The passage must be well dilated. 4. The parturient canal must not be infected. 1. The Child must be Alive. — Not only must the child be alive, but the foetal heart sounds should be regular, strong, and of normal frequency. To subject a woman whose child's vitality is already very decidedly impaired to the risks of symphysiotomy or pubiotomy serves no purpose, for the child will very probably not be saved, and the mother's life will be much more endangered than if one performed craniotomy. If the pelvic deformity is such as to permit of sym- physiotomy or pubiotomy, craniotomy can be carried out with the greatest ease, and with little risk to the patient's life or her future comfort and health. Consequently, it is clearly the operation which should be chosen. Some obstetricians refuse to perforate a living child under any circumstances, but I have no sympathy with such an extreme attitude. As I shall explain in connexion with Cesarean section and craniotomy, it is occasionally better for the individual, the family, and the State to perforate a living child, especially if its life has been decidedly endangered. In difficult craniotomies it has been suggested that the delivery of the child might be facilitated by performing symphysiotomy or pubi- otomy. Although such a procedure is extremely undesirable, it is conceivable that an operator might be justified in having recourse to it. Suppose, for example, the accoucheur performs craniotomy and cannot get the child extracted ; such a misfortune might happen if he had not appreciated the real extent of the pelvic deformity. The operator in such a plight, with a perforated child he cannot extract, has nothing left but to perform symphysiotomy (pubiotomy) or Cesarean section, and I can quite understand that he might prefer symphysiotomy. Before adopting such a course, however, he must make very sure that the pelvic capacity is such as to allow the perforated head to pass. Some time ago I read of a case in point where the accoucheur, after performing craniotomy and symphysi- otomy, had finally to have recourse to Cesarean section ! 378 OPERATIVE MlhWllT.KY Here, also, Lei me Bay that it is undesirable to combine symphysi- otomy or pubiotomy with induction of premature Labour, as has been once or twice BUggested. If the premature infant cannot be extracted with forceps, it is injudicious to subject the mother to the risks of symphysiotomy or pubiotorny for the sake of a premature child, whieh, even under the most favourable conditions, has but a feeble hold of life. 2. The Pelvis must be of Sufficient Size, and there must not be too great a Disproportion between it and the Foetal Head. In discussing this most important matter, let me first of all indicate the extreme limit of pelvic deformity at which the operations may be performed with safety. Personally, I believe this to be 3 inches (7'5 centimetres), unless the foetal head is abnormally small. Pinard, 1 Bar,'- Zweifel, Jewett, Herman, and Buist, as regards symphysiotomy, are of the same opinion. All of them admit that a slightly lower figure than 3 inches (7"5 centimetres) need not necessarily contra- indicate the operation, but in their recorded cases, with few exceptions, that has been the figure. In the cases in the Glasgow Maternity Hospital the operation was performed on two occasions with a vera of 2| inches (6*8 centimetres), and in both there was considerable lacera- tion of the soft parts. In none of our recent cases has the vera been less than 3 inches (7'5 centimetres). My colleagues and I have come, therefore, to the same conclusions as our British and Continental confreres regarding the lowest limit of pelvic deformity at which symphysiotomy is advisable. Exactly the same figures apply to pubiotomy. With regard to the upper limit, however, no definite figure can be stated, for it entirely depends upon the size and position of the child's head relative to the pelvis and the favour in which forceps is held by the operator. I have already stated, when considering forceps delivery, that with a vera of 3 inches (7*5 centimetres) the foetal mortality in the Glasgow Maternity Hospital with forceps was 46 per cent. This mortalit}', I said, was so high that I did not consider one was justified in trying to deliver with forceps alone. But, while I make such a statement with all confidence, I cannot, unfortunately, make the other — that symphysi- otomy or pubiotomy should always be employed with a conjugata vera of 3 inches (7*5 centimetres), for the operation may be a wise or a foolish choice in that degree of pelvic deformity. What must decide the question is the disproportion between the head and the pelvis. If this is pronounced, Cesarean section is indicated ; if. on 1 Ann. de Gyn., 1896, 1897, 1899. 2 'Lecons de Pathologie Obstetrical,' 1900. THE ENLARGEMENT OF THE PELVIC CAPACITY 379 the other hand, the disproportion is not very marked, then symphysi- otomy or pubiotomy may be chosen. Where the pelvis is a little larger than 3 inches (7"5 centimetres), I do not believe that, in a particular case, one can decide before labour that symphysiotomy or pubiotomy is the correct operation. One may go the length of thinking it possible that the operation may ultimately be necessary ; but one cannot be certain, for in such cases labour may terminate spontaneously or be easily completed by forceps. If an operator says to me before or early in labour, ' This is a case for symphysiotomy or pubiotomy,' I invariably think that he does not quite appreciate the refinements in the choice of operation for pelvic deformity ; and, secondly, that if, on account of the extent of the pelvic deformity, he has come to the conclusion that one of them is necessary, he would be better to choose Cesarean section. As far as I have been able to judge, they are justifiable — I would even say indicated — when, after the second stage has been allowed to go on as long as possible, and after two attempts at moderate traction, with the patient in the Walcher position should the pelvis be flat, it is found that forceps just fails to bring the child down through the pelvis. The pelvis may be 3^ inches (8*1 centimetres), or even 3£ inches (8'7 centimetres), but that should in no way influence the choice. It is, therefore, apparent that I would limit symphysiotomy and hebosteotomy to a very few cases. As illustrating this, I may mention that while I have performed Cesarean section over eighty times, I have only chosen symphysiotomy upon ten occasions, and pubiotomy upon four occasions. I am perfectly well aware that, although Olshausen, Schauta, Jewett, and English operators generally, favour a trial with forceps, many, and amongst them the most distinguished obstetricians, are opposed to such practice. Personally, I cannot conceive how it is possible to avoid doing symphysiotomy or pubiotomy unnecessarily in certain cases if forceps is not tried. On several occasions I have had under my care a patient, the size of whose pelvis and the head of whose fcetus were most carefully estimated, prepared for possible pubiotomy, and yet I have delivered her with no great difficulty of a healthy living child with forceps. Again, let me repeat, the obstet- rician of experience can always say if a head will pass through a pelvis after symphysiotomy or pubiotomy, but he cannot always say that it will not pass with a little assistance from forceps. Naturally, those who only employ forceps after the head has passed the con- tracted brim, employ pubiotomy much more frequently than I do. While I am quite prepared to admit that up till a few years ago I have delivered with forceps when I should have performed symphysi- 380 OPERATIVE MIDWIFERY otomy or pubiotomy, I am equally certain that they have had recourse to these operations upon many occasions when I would have succeeded with forceps alone. '.). The Parturient Canal must be well Dilated. — It is perfectly -obvious that the os must be fully dilated if one intends extracting the child immediately after dividing the symphysis or pubis — the pro- cedure most favoured. We shall have to return, however, to this subject later, when considering the extraction of the child. But not only must the cervix be fully dilated : the vaginal canal must also be sufficiently relaxed. In multipara this invariably exists. But in primiparae it is quite otherwise. Amongst my cases in the Maternity Hospital, both the examples of severe lacerations to vagina, vestibule, and urethra occurred in prirnipara?. This was not because the dis- proportion between head and pelvis was greater in them than in the multipara?, but simply because the soft parts had not been previously stretched. When the ends of the pubis are separated, and the support of the anterior pelvic wall is removed, the vagina and parts about the vestibule are very liable to be torn or burst during the extraction of the child. Nearly all operators, therefore, emphasize the special danger to primiparre, and make it a sine qua non that the patient must have already borne children. To overcome the danger from an undilated vaginal canal in primi- para?, a large colpeurynter may be inserted into the vagina. Bar and others speak very highly of the benefit to be derived from this pro- cedure. Traction may be made upon the colpeurynter either by pulling upon it from time to time or by attaching a weight to the ond of it. In the case of prirnipane, deep incisions into the lower part of the vaginal wall and the perineum prevent lacerations of the vestibule and vagina, and may be had recourse to if the vulvar orifice is very narrow. Some operators have recommended the performance of the opera- tion early in labour. That is a mistake, as one cannot tell beforehand that a head will not mould sufficiently to pass the brim without division of the symphysis or pubis. 4. The Parturient Canal must not be Infected. — If the patient has been infected, or has been presumably infected, by those in attendance, it is undesirable to subject her to the risk of symphysi- otomy or pubiotomy — especially as in most cases when the canal is infected several attempts at delivery with forceps have been made, and the child's vitality has been distinctly reduced. This, of course, as already indicated, does not apply to failure to deliver with forceps, carefully employed. What I am opposed to is subjecting a woman, probably infected, to the dangers of symphysiotomy or pubiotomy THE ENLARGEMENT OF THE PELVIC CAPACITY 381 when the child has already been much injured and it is very question- able if it will survive. Naturally, the only alternative in such cases is craniotomy. Anatomy of the Parts concerned in Symphysiotomy and Pubiotomy. Before proceeding to discuss the surgical procedure in symphysi- otomy and pubiotomy, a knowledge of the anatomy of the parts is- Dorsal Vein of Clitoris. Fibro-cartilagc. Subpubic Ligament. \ Ischium. \ y Arteries of Clitoris. Transverse Perineal. Ligament. Pudic Vessels. Triangular Ligament Fig. 174. — Dissection to show Anatomy of the Symphysis Pubis. necessary. The articulation between the pubic bones is an amphi- arthrodial joint formed by the juncture of the two oval articular surfaces of the ossa pubis. This joint consists of a disc of fibro- cartiiage connecting the surfaces of the pubic bones in front, and contains a cavity in its centre, caused by the absorption of the fibro-cartilage, and is lined by synovial membrane. Each pubic symphysis is covered by a thin layer of hyaline car- tilage, which is connected to the bone by a series of nipple-like processes. This cartilage may catch the knife of the unskilled 382 OPERATIVE MIDWIFERY operator, although there is, in reality, ample room ; hence, pre- samably, is the reason of incorrect statements concerning hony ankylosis and the diihculties they may cause in the operation of dividing the joint. Fig. 175. — Dee]) Dissection of Female Perineum to show Structures likely to be injured in the Operations of Symphysiotomy and Pubiotomy. ". < 'i us clitoridis ; b, olitoris ; c. suspensory ligament of clitoris ; d, meatus urinarius ; ■ to clitoris ;/, artery to cms clitoridis; g, left cms divided and retracted to show#J h, internal pudic artery; i, vagina; /, sphincter vagina? ; m, levator ani; h, anus: o, sphincter ani ; p, border of gluteus maximus : q, artery to lmlb : r, internal pudic artery more superficial than /< ; ••>, ischium. The stability of the symphysis depends less on this fibro-cartilage than on the fibrous investment which it receives from the anterior, posterior, superior and inferior pubic ligaments. The ligament THE ENLARGEMENT OF THE PELVIC CAPACITY 388 of greatest importance, anatomically and surgically, is the inferior or subpubic ligament (Fig. 171). This ligament is of considerable thickness and strength. It forms the upper boundary of the pubic arch, and is attached above to the interpubic disc and laterally to the adjacent sides of the descending rami of the pubes. Its lower border is free, and is separated from the triangular ligament by a transverse oval interval, through which the dorsal vein of the clitoris passes backwards to the interior of the pelvis. The arterial supply to the structures of importance in the opera- tion of symphysiotomy and pubiotomy is derived chiefly from the Fig. 176. — Symphysis Pubis from behind, to show Main Trunks forming Venous Plexus. (Farabceuf.) internal pudic artery. The obturator and deep epigastric arteries send small twigs to the thickened periosteum of the symphysis pubis. Each crus clitoridis receives a branch from the internal pudic artery, while the glans clitoridis is supplied by its terminal branches (dorsal arteries of the clitoris — Fig. 175). The main source of bleeding, on which much stress is laid by some operators, is venous, chiefly from tearing of the loose unsup- ported plexus of veins which surrounds the upper part of urethra and neck of bladder — viz., the inferior vesical plexus (Figs. 176 and 177). The dorsal vein of the clitoris in its course backwards to the inferior 884 OPERATIVE MlhWIIT.n vesical plexus is apt to cause trouble when the clitoris La detached, if the vessel has not been previously clamped. Another source of hemorrhage, upon which little stress has been laid, is tearing of the bulbus vestibuli and roof of vagina. The bulbut vestibuli is composed of minute convoluted bloodvessels held together by a very small amount of connective tissue — a particularly difficult tissue in which to check haemorrhage. Its arterial supply is derived Anterior \V;ill of Bladder. Inferior Vesical Plexus. I ii real Vein of Clitoris in Inferior Vesi- cal Plexus. Dorsal Vein of Clitoris. Fie. 177.— One Half of Symphysis Pubis removed to show Bladder and Venous Plexus. (Farabceuf.) on each side from a branch (arteria bulba vestibuli) of the internal pudic. The bleeding from tearing of the bulba vacf'nue is mainly venous, arising from rupture of the large veins of the vaginal plexuses, which, in sympathy with the general increased calibre of vessels during pregnancy, have become enormously dilated and tortuous. Methods of Performing- Symphysiotomy. — Having briefly de- scribed the anatonry, we must now turn to the different methods of performing the operation of symphysiotomy. The woman being anaesthetized, the pubes shaved, and the parts about the vulva THE ENLARGEMENT OF THE PELVIC CAPACITY 385 thoroughly cleansed, the pelvis should' be brought to the edge of the operating table or couch, and the legs supported by two assistants. Zweifel allows the legs to hang down, and if the accoucheur is short of Fig. 178. — Division of Suspensory Ligament of Clitoris. (Faraboeuf.) assistants it is all right, for in that position the pubic bones will not spring so widely apart as they would do if the legs lay abducted. As regards the actual method of performing the operation, there are certain differences in detail in different countries. Let me take the French method first — the method perfected by Faraboeuf, and without doubt the most exact. 25 386 OPERATIVK MiI)\VIFi:i;V An incision is made over the symphysis of about 3 inches 7*5 centimetres) in Length, and extending from about l'. inches above the pubis to the line which the operator has made with tincture of iodine to mark off the lower limit of the triangular ligament. Should the clitoris be placed higher than usual, a ' lambda' incision is made round it. The clitoris must then he pulled downwards, and its sus- Fig. 179. — Stages in the Division of Recti Abdominis. (Farabceuf.) The skin lias already been divided, and is held apart by retractors. pensory ligament divided (Fig. 178), all bleeding being suitably con- trolled. This being done, the lower margin of the triangular ligament is defined. The operator now turns to the upper part of the wound, and makes a longitudinal incision through the linea alba (Fig. L791 It is desirable to keep the incision longitudinal, but if it is not possible to get the fingers in through the opening, the assistant should flex THE ENLARGEMENT OF THE PELVIC CAPACITY 387 the legs, and the operator make slight cuts laterally. A finger and then a grooved director (Fig. 180) is pushed behind the puljes into the so-called space of Retzius, between the bladder and the posterior Fig. 180.— Division of Symphysis Pubis. (Farabceuf.) surface of the pubic bones. Having done this, the director is with- drawn and introduced under the triangular ligament from below upwards. The operator then cuts upon the director from behind forwards with the point of a short-bladed knife (Fig. 180). ::ss OPE It ATI VK M 1 1 »\V1 l-T.UY In recent years the operation has been much simplified, and the following is the method I have always employed: Eaving made an incision over the Bympbysis pubis, and pushed my finger down behind the joint as already described, I divide the joint from before hack- wards and above downwards with a Btrong small-bladed bistoury. I then divide the triangular ligament, keening well to the leftside. I do not believe there is much danger to the urethra at this stage ; the real danger to the urethra is during the extraction of the child. Con- sequently, I do not introduce a sound into the bladder and drag the urethra over towards the other side. Morisani, and Italian operators in general, make a small incision, longitudinal or transverse, above the symphysis, then push the fore- finger down behind the pubic joint, and divide the latter from behind forwards and from below upwards with a special curved knife. There are various forms devised by Galbiati, Spinelli, Novi, etc. Zweifel, the great advocate of the operation in Germany, operates in very much the same manner as the Italians. After a transverse or longitudinal incision over the pubes, he passes his forefinger behind the joint. If there is any difficulty in defining the joint, an assistant moves the leg. With a probe-pointed knife the joint is divided from behind forwards. The triangular ligament is then exposed, and care- fully divided from above downwards. Any danger of injuring the urethra is avoided by directing the urethra over to the right with a sound in the bladder. Immediately after the division of the joint and of the triangular ligament, but only then, the pubic bones spring apart. Only once have I had any difficulty in dividing the joint, and that was when it was irregularly formed. Such is the experience of all other operators. Ankylosis of the joint is practically unknown. Zweifel, Morisani, Bar, and Pinard are all of that opinion. Irregularities in direction are not infrequent, and sometimes trouble arises from the operator not noting the exact position of the joint and cutting into the fibro- cartilage. A condition which has occasionally prevented a sufficient separation of the pubic bones is an ankylosis of the sacro-iliac joint. It is quite unnecessary, therefore, to employ any instrument to forcibly separate the pubic joint : that can be done b} r those in charge abducting the legs according to the instructions of the operator. After complete division of the symphysis pubis, an important point for consideration now arises : Should the child be extracted with forceps immediately after the division of the symphysis, or should time be given the natural forces to bring about the expulsion '? Just as might be expected, seeing that a good deal can be said for both courses, THE ENLARGEMENT OF THE PELVIC CAPACITY 389 each has its supporters, but the majority of operators now favour immediate delivery by forceps or version. In the Glasgow Maternity Hospital the delivery has always been completed with forceps. Without doubt, artificial delivery increases the risks of laceration of the soft parts ; but if the patient is a multipara, and the case carefully selected, careful extraction should not be followed by much injury to vagina or urethra. If the case is left to Nature, a temporary dressing is put over the wound, and a bandage applied round the pelvis so as to support it. If such a course is followed delay in expulsion of the head is not in- frequent. If not caused by simple uterine inertia, it is generally the result of the head continuing to lie with its long axis in the transverse diameter of the pelvis. This arises from widening of the pelvis and lessening of the resistance of the pelvic floor. If artificial extraction is proceeded with, the blades of the forceps are carefully applied and slow and steady traction made. When previous attempts to deliver with forceps have been made, it is ad- visable to leave the instrument loosely applied to the head while the symphysis is divided. The pelvis during extraction must be supported. This is best done by an assistant on either side holding the leg in one hand and pressing on the trochanter with the other. Should the operator have insufficient assistance, a binder should be applied round the pelvis and the legs allowed to hang down. It is very important that the pelvis should be properly supported, and that the amount of separa- tion should be controlled ; and, not only that, but the separation should be equal, otherwise there will be a greater strain thrown upon one sacro- iliac joint than upon the other. In the Glasgow Maternity Hospital we have very generally placed the patient in the Walcher position, and without any harm resulting. Some operators, however, are opposed to such a procedure, for they believe that if there is any difficulty in extracting the child the danger of injuring the sacro-iliac joints will be increased. It is, I take it, quite unnecessary to discuss another method of delivery — viz., version — for almost no one is in favour of it in this country. Several French operators, however, recommend it. Bar discusses the method, and, although his results are quite as good with it as with forceps, he gives it very little support. After the delivery of the child there is sometimes fairly free bleed- ing, which should be controlled by packing some gauze down behind the pubes and pressing down the uterus from above. It is futile to try and catch the bleeding-points. The third stage should be managed in the same way as in a normal 890 OPERATIVE MIDWIFEM labour. If desired, a temporary binder may be applied round the pelvis. Some prefer to give five or seven minutes for placental separation, and then express or remove the placenta manually. There now remains only the stitching of the wound to complete the operation. Before describing (his, however, there is one question which must he considered, and that is, Should the space of Retziue be drained? "Without douht, in many cases, hlood collects there, and, not obtaining a free exit, is a source of danger should it become in- fected. Zweif el is a strong advocate of draining; Pinard also approves of it, but Bar looks upon it unfavourably. Drainage from above is unsatisfactory. I have found Zweifel's suggestion x of draining through an opening in the left labium minor very useful. I employ a loose packing of gauze and push it well down behind the joint : the end of the gauze I pull out through an opening in the left labium. If, however, there happens to he any wound into the vagina, J drain through it. In closing the joint, pegging or wiring the bones is quite un- necessary ; stitching of the wound as shown (Fig. ]H1) is all that is required to obtain satisfactory union. Personally, I employ three chromicized catgut sutures for the periosteum, ordinary catgut for the fascia, and silkworm for the skin. Before introducing the sutures, the edges of the pubic bones must he brought exactly together, and for holding them together the forceps of Farabeeuf (Fig. 181) are very useful. Failing that instrument, a strong, single-pronged vulsellum forceps may be employed. I find, however, that no special instru- ment is necessary if the edges of the bones are brought well together by the assistants. The stitching is very simple. In bringing the edges together, care must be taken that the bladder and gauze packing, which is left in to drain the lietzius pouch, are not caught between them. On one occasion the latter accident happened to me, and I had great difficulty in getting the gauze out of the wound. Should post-partum haemorrhage occur from the uterus, it is to be treated by the ordinary means ; personally, I have never required to- pack the uterus, having always found that ergot and hot douching controlled the bleeding. The after-treatment of cases of symphysiotomy is exceedingly troublesome ; indeed, that to my mind is the great objection to the operation. The following is the method employed in the Glasgow Maternity Hospital : A simple dressing is applied over the wound, and kept in position by bands of adhesive plaster which are applied right round the pelvis. A large pad of absorbent cotton is then plaa d 1 Zent.f. Gyn., 1902, No. 18, p. 821. THE ENLARGEMENT OF THE PELVIC CAPACITY 891 over the part, and a firm binder applied round the pelvis. The patient is then put to bed, and two long sand-bags are placed and maintained in position against the pelvis and thighs. In order to facilitate the sponging of the vulva and the toilet of bowel and bladder, the charge Sister of the hospital devised a mattress which consists of three portions, the middle part being a narrow strip which can be easily slipped out. This allows the nurse to reach the parts very conveniently without disturbing the patient. The gauze drain in the Eetzius pouch is removed in twenty-four hours, and replaced or not as is deemed advisable. The bowels are Fig. 181. — Uniting divided Symphysis. Figure on the right shows Farabceuf's forceps for coapting the severed joint. (Farabceuf.) moved on the third day, and then every second day. The stitches are removed on the twelfth day, and the patient is allowed up about the twenty-fourth day. I need hardly say that, should any lacerations occur to the soft parts as the result of the operation, these should be carefully repaired. Any tearing of the vagina should be stitched, and, above all, one should make sure that every care is taken in making good any injury to the urethra. The Subcutaneous Method of Performing' the Operation. — As an alternative to the methods of performing symphysiotomy already described, several operators have recommended subcutaneous division o£ the symphysis. The Americans, and I think with right, claim this 892 OPERATIVE MlhWll i:i;Y as their method, for undoubtedly Ayr.- deserve.- the credit of having brought ii prominently forward. In England Eerman and Buist have each detailed series of cases in which the operation was easilv and successfully carried out. \yres' 1 method is described by Edgar 2 as follows: 'The left index finger is introduced within the vagina, and held against^the posterior aspect of the joint (Fig. 182). A narrow teno- tomy knife is then passed up to a point within \ inch of the summit of the joint beneath the overlaying soft tissues. A probe-pointed bistoury is then substituted for the tenotomy knife, and carried to the top of the joint, where it meets the index finger: it is then carried downwards through the joint until the latter is felt by the index Fig. 182. — Subcutaneous Symphysiotomy- Ayres' Method. (Edgar.) finger behind to give way. An assistant now presses a small gauze compress against the incision beneath the clitoris. If possible, the child is then delivered with forceps.' Herman's method 3 is even simpler : ' Take the tenotomy knife and press its point through the mucous membrane opposite the middle of the symphysis'pubis. It will easily penetrate the symphysis. If you have not hit the middle line and the point impinges on bone, the difference of resistance will inform you of the fact ; if so, shift the point a little to the right or left, and it will come upon the symphysis. When the knife has penetrated the symphysis, cut downwards until you have reached and divided the ligamentum arcuatum. Then turn the blade so that the cutting edge is upwards, and divide the rest of the symphysis. There may be a little difficulty in dividing the last 1 Amer. Journ. Obst., July, 1897. - ' Text-book,' 190:$, p. 969. 3 ' Difficult Labour,' 1910, p. 467. THE ENLARGEMENT OF THE PELVIC CAPACITY 3«)3 ligamentous fibres at the top and lower part of the symphysis, because there is a little tendency for the knife to push these fibres before it, instead of cutting quickly through them. You will overcome this tendency by pressing, with the finger applied externally, these fibres against the knife. When you have divided all the fibres which unite the two pubic bones, they will, at once, spring about \ inch apart ; then seize the foetal head with forceps and deliver.' Personally, I can offer no opinion about either of these methods. Buist 1 and Herman, 2 however, speak very highly of the operation, and many successful cases so treated have been recorded in this country and in America. Zweifel has written 3 in support of subcutaneous symphysiotomy. His method can hardly be described as subcutaneous, as that term is generally understood. An opening is made above and below the pubis, the bladder is pushed away, and a needle is passed behind the joint. The saw is then pulled through, and the joint divided by means of it. Zweifel makes no reference to the methods just described, although they may be much more correctly termed subcutaneous, and have been known and practised for years in this country and America. Prognosis. The results from symphysiotomy in the hands of those who have had experience of the operation are highly satisfactory ; indeed, I can- not understand how anyone would wish to do away with the operation. I am well aware that some teachers of obstetrics are opposed to the operation. In not a few cases, however, their opposition is negligible, for they have had absolutely no experience of it. Some time ago I heard a prominent teacher of obstetrics condemn the opera- tion — to my certain knowledge he had never performed the operation. Without doubt there have been cases of disaster, but many of these •could have been avoided if greater care had been taken in selecting the cases. If the obstetric surgeon thoroughly understands what he has to do and chooses his cases carefully, the operation performed upon patients brought to hospital in labour will be followed by much ■better results than Cesarean section. I challenge any opponent of symphysiotomy to refute that statement. I do not consider, however, that the operation is suited for domestic practice. The general practitioner, unless he has had very special training in obstetrics, does better to choose Cesarean section or craniotomy. 1 Trans. Edin. Obst. Soc, vol. xxvii., p. 112. 2 Trans. Lond. Obst. Soc, 1900, vol. xlii., p. 282. 3 Zent.f. Gyn., 1906, p. 737. 394 OPERATIVE MIDWIFERY I give here a table, compiled a year or two ago, showing the maternal and foetal mortality <>f ;i number of the advocates of symphysiotomy. Table of Symphysiotomy ('asks. Bar lot .1 Cases. 28 Maternal I ■• Postal i>. ttba. 6 l'ii 1.1 id 100 12 12 Moiisuni 55 2 8 Zweifel / 52 (open) \ 12 (subcu- taneous) 8 I Herman K Jewett... 8 1 1 Buist ... 8 2 Munro Kerr ... 9 The mortality is obviously most satisfactory, but what about the morbidity? Let us consider this aspect of the subject in some detail. The dangers to the patient are : (a) Injuries to the sacro-iliac and pubic joints, and resulting interference with locomotion ; (b) severe haemorrhage from laceration of the parts in front and behind the symphysis ; (c) injuries to urethra and bladder ; (d) septic infection. The injuries to the sacro-iliac joint result from too great separation of the pubic bones, for, although the ossa innominata may be com- pared to two folding doors whose hinges are the sacro-iliac joints, these hinges permit of only a very limited movement. As might be expected, it is the superior and anterior ligaments of the sacro-iliac joint which are specially put on the stretch : the strong posterior sup- ports escape almost entirely. This is extremely fortunate, and explains why it is that disturbance of locomotion is so very infrequent. Sandstein states that in the cadavers experimented upon, in 44 per cent, the rupture of the anterior ligaments began below 6 centi- metres of pubic separation, while in ;>6 per cent, it began above that point. In two it only began at 8 centimetres, and in one not even at 8 centimetres. These observations of Sandstein are, on the whole, in agreement with those of others, although 2 or 3 centimetres of separation has occasionally been found to be sufficient to produce injury to the sacro-iliac ligaments. The extreme limit of safe pubic separation is generally stated to be 7 centimetres, but personally I agree with Morisani, Pinard, Bar, Zweifel, and others, that it is inadvisable to exceed 6 centimetres. The injuries result from exceed- ing this limit, or from allowing one side to be more separated than the other. In those who survive the operation, one can only judge of THE ENLARGEMENT OF THE PELVIC CAPACITY 395 injury to the joint by disturbance of locomotion or pains in the joints. Doubtless, if one could examine the sacro-iliac joint in all cases, one would find rupture of part of the ligaments in not a few, for it has been noted at several autopsies of cases which have died shortly after operation. The fact, however, remains that few patients have their locomotion disturbed. Pain they sometimes complain of for a few days after the operation, but our experience is in agreement with Bar's, that such pain is almost always transitory. Suppuration of the joint, observed in one or two cases, has only occurred where there was general septic infection. There is no permanent injury done to the pubic joint. Faraboeuf, Bar, and others, by means of X rays, have been able to demonstrate that there is, as a rule, a permanent separation between the bones. Even without the aid of X rays, one can in many cases, with the fingers in the vagina, make out a distinct separation between them. In my cases the separation that persisted has been very slight, due, I have no doubt, to careful nursing. But even although a little persists, it is of no great moment, for there is very little disturbance of locomotion, provided the sacro-iliac joints are not seriously injured. Nor is this to be wondered at, for in cases of split pelvis there is no great difficulty in walking. Disturbances of locomotion following symphysiotomy are always- referred to by the general medical public, and believed by them to be frequent. That, however, is an extremely erroneous idea ; not one of my patients has had her locomotion impaired in the slightest degree. I am quite convinced that the disturbance has been grossly exaggerated. Without doubt, defect in walking has occasionally followed, but such cases are extremely rare, as the results of Morisani, Pinard, Bar r Zweifel, Jewett, Herman, Buist, etc., show. More serious, and infinitely more frequent, are injuries to the soft parts, especially to the bladder, urethra, and vestibule. The worst bleeding arises from tearing of the corpora cavernosa and the venous plexuses behind and in front of the symphysis. In cases where there exists a varicose condition of the veins underneath the integument in front, haemorrhage is naturally liable to occur when dividing the skin : such bleeding, however, is very easily controlled by the ordinary means. The bleeding, however, which occurs after division of the joint, from tearing of the vascular tissue behind and to the side, is often very profuse. It can only be arrested by plugging with gauze, and by applying firm pressure on the uterus from above. Undoubtedly Zweifel is correct, that excessive haemorrhage is, as a rule, the result of faulty technique, although, as I have already remarked, not so much in dividing the tissues as in extracting the child. 896 OPERATIVE MIDWIFERY So far I have escaped Injuring the bladder. Morisani rathe] makes light of the accident, as he has never Been it occur: Bar. likewise, has not observed it. Pinard, however, mentions it as having happened in two of his hundred cases, and Zweifel also has had experience of it. In one of Pinard's cases the injury was very exten- sive, and followed a difficult extraction of the child with forceps. Very much more frequent are injuries to the urethra. In one of my cases the urethra was torn completely from the surrounding tissues, and in the other it was split almost up to the bladder. In the former case the tissues were brought together round it, and perfect union resulted: hut in the other the stitched urethra did not heal, and the patient left the hospital with practically no urethra. She had, however, almost complete control of the bladder, except when she strained, coughed, or sneezed. All operators have bad experience of injuries to the urethra: still, Pinard, Varnier, Zweifel, and Bar have had singularly few cases. Varnier says, ' One ought tc be able to prevent these injuries by perfecting the extraction.' 1 I entirely agree with him. Both my cases were primiparae, and I believe the lacerations might have been prevented by incising the vulvar orifice. Symphysiotomy Repeated. — I have on one occasion performed the operation twice upon the same patient, but with a very highly unsatisfactory result. I divided the symphysis pubis, but could not get any separation of the bones, because there was a firm mass of tissue behind uniting the bladder to the posterior surface of the joint. Applying forceps with the patient in the Walcher position, 1 extracted the child with a little difficulty. During the extraction my assistants kept up pressure upon the sides of the pelvis, and the pubic bones separated only about 2 centimetres (f inch). I feared the bladder might be torn. The mother escaped without injury, but the child was not so fortunate. There was a deep indentation over the frontal bone, with evulsion of the eye. The indentation I corrected by compression {Chapter XXXVII.) ; the eye, unfortunately, had to be removed. Both Bar and Pinard refer to similar difficulties as I experienced. Bar, in one of his cases, removed the cicatricial tissue after dividing the joint. Nor is it to be wondered at that it should be so when the ordinary method is employed, for there is bound to form a very firm •cicatrix. Buist and Herman have not experienced any difficulty in the cases in which they employed the subcutaneous method. An important question arises at this stage: How far is the pelvis permanently enlarged by symphysiotomy ? It is generally stated that 1 Corn/pies rendu8 des XII Congria International de Medecin, Moscow, L897. THE ENLARGEMENT OF THE PELVIC CAPACITY 397 it is permanently enlarged. This conclusion is come to because, in quite a number of cases, subsequent labours have terminated spon- taneously or with only a slight assistance with forceps. Such reasoning is apt to be misleading. Without doubt the pelvis is increased ; skiagrams of cases where the symphysis has been divided show a separation of the bones and a distinct bridge of fibrous tissue, but the increase is infinitesimal unless there is a great permanent separation of the divided ends. There is practically no ' give ' in the fibrous tissue. The real explanation why subsequent labours terminate without much difficulty is, in all probability, because the vagina has been previously dilated, the size, shape and consistency, or position of the foetal head is more favourable, and the head has been given more time to mould. I do not believe that the pelvis is permanently enlarged to any practical extent after symphysiotomy. The bearing Fig. 183. — Fiith's Flastic Operation for permanently enlarging the Pelvic Girdle. of this is that one must be prepared to repeat symphysiotomy, or have recourse to some other operation, at subsequent labours. Several plastic operations have been suggested for permanently enlarging the bony pelvis, but they have not proved of any practical value. Fiith's suggestion 1 is probably the best. He has performed the operation successfully several times, and Varnier referred to a case at the International Congress at Moscow in 1897. The operation consists in removing an anterior layer of the pubic bones and joint, then dividing the joint posteriorly and placing the separated anterior layer between. It will be readily understood from the illustration (Fig. 183). Quite recently this same author has suggested the trans- planting of the xiphoid cartilage between the ends of the bones.' 2 This subject of plastic operations was fully discussed and severely criticized by Varnier years ago in connexion with a paper by Phenomenon and Kotchckoff. 3 It has very recently been considered again by Klien 4 in connexion with a very wild method suggested by Crede. 5 1 Monat.f. Geb. u. Gyn., 1896, vol. iii., p. 491. 2 Zent.f. Gyn., 1907, p. 692. 3 Ann. de Gyn., 1894. 4 Zent.f. Gyn., 1906, p. 846. 5 Ibid., 1906, p. 617. 898 oI'KHativk Mii'Wii t.ky Pubiotomy, Hebotomy (Hebosteotomy). Within the last few years much baa been written, especially in the Italian and German obstetric journals, regarding the enlargement of the pelvis by dividing the pubic hone instead of the symphysis. Bonardi, Van der Velde, Gigli, Doderlein, and Bumm have been especially prominent in advocating this method. The credit, however, of first recommending it, as an alternative to symphysiotomy, is undoubtedly due to Stol/., 1 who described in 1814 the operation which is being practised to-day, even to the use of a saw. Nearly twenty Fig. 184. — The Symphysis Pubis bom the Front. The lines A and B represent the directions in which the pubes may be divided in the operation of pubiotomy. A is the direction recommended by Van der Velde ; 15. that recommended by Gigli. years ago Sir William Macewen, of Glasgow, made a communication on the subject at the International Congress in Berlin. But the symphysis is not a joint in the ordinary sense, nor is it, when opened, subject to the same dangers as, say, the knee-joint; consequently, the claim that there is greater danger in opening and dividing the symphysis than in dividing the pubic bone is purely theoretical. As far as one can judge there is slightly less risk of injuring the urethra, but Zweifel and Doderlein indicated at the Deutschen Gyniikologen Kongress in Dresden in 1!I07, 2 that the bladder is not 1 Fasbender, 'Geschichte der Geburtschiilfe,' 1906, p. 872. 2 Zent.f. Gyn., L907, No. 24. THE ENLARGEMENT OF THE PELVIC CAPACITY 399 a little endangered, especially if the subcutaneous method of Bumm is employed. It has always been admitted that the chief danger to the urethra, bladder, and vagina arises during the extraction of the child, so that to justify the choice of pubiotomy it must be proved that the danger of injuring these structures is really less during extraction. liar 1 doubts it, but Baisch- thinks otherwise. On anatomical grounds there should be more bleeding with pubiotomy, unless the corpus cavernosum is carefully stripped off and pushed well out of the way. As a matter of fact, Zweifel has abandoned pubiotomy because of this hemorrhage. This bleeding may not only .M Fig. 185. — Pubiotomy, after the Method recommended by Doderlein. occur at the time of operation, but a slow oozing may continue, with the formation of a hematoma. Several important communications have been made regarding the primary and permanent enlargement of the pelvis resulting from the respective operations. One of the most interesting is by Sellheim, 3 who has gone into the subject most carefully. He states : ' Hebotomy and symphysiotomy bring about the same alterations in the birth canal.' It would appear also with both there is a slight permanent increase in the pelvic capacity. After symphy- 1 ' L'Obstetrique,' 1905, p. 245. 2 ' Keforinen in der Therapie des engen Becken,' Leipzig, 1907, p. 181. 3 Monat.f. Geb. u. Gyn., 1906, Bd. xxiii., p. 362. 10(1 OPERATIVE MIDW l!'Kl;Y siotomy the union is naturally fibrous, hut after pubiotomy bony. lloeheisen 1 has recorded sixteen eases operated on in Bumm'a Klinik ; skiagraphs accompany the paper. Me states that after a few months bony union is always present. Having followed very carefully the discussions in this and other countries regarding symphysiotomy and pubiotomy, I am inclined to think that, if anything, puhiotomy is the safer operation : but it is only very slightly safer, and so I can quite understand the attitude of Fig. 186. — Subcutaneous Pubiotomy. Herman, who stated recently that he was still a supporter of sym- physiotomy. In performing pubiotomy, division of the hone is best made with a Gigli saw (Fig. 185), the direction being either as Van der Yelde or Gigli has suggested (Fig. 184). Van der Yelde's incision certainly is less likely to cause injury to the internal pudic artery and the corpus cavernosum. It is not possible to avoid the latter altogether, however, unless it is first separated and pushed aside. An objection to adopt- ing Gigli's line is, as I found on one occasion, that if the symphysis is oblique one may come right down upon it. Doderlein had a similar 1 Archivf. Gyn., 1906. Bd. lxxx.. Heft 1., p. 99. THE ENLARGEMENT OF THE PELVIC CAPACITY 401 experience. 1 There is a great variety of carriers for the saw, and some operators pass them from above downwards and some from below upwards. Undoubtedly the safest plan is to make an incision a little external to the pubic spine, and introduce the forefinger behind the pubis and push the bladder aside. This method of J)6derlein (Fig. 185) cannot, of course, be termed subcutaneous. Bumm's method, however, is subcutaneous (Fig. 18G). He passes a curved saw-carrier close under the pubic arch, entering it between the larger Fig. 187. — Dividing Pubes with Saw. and lesser labia. The clitoris and labium minor are pulled over to the other side. The carrier is then pushed round the bone, the point of the instrument being kept hard against the bone. It is brought out close by the inner margin of the spine of the pubis. The saw is then pulled through, and the bone divided (Fig. 187). The child is then delivered artificially by forceps or version. After the delivery is completed, and all blood has been squeezed out of the wound, the small openings in the skin above and below are closed with stitches. 1 Archivf. Gyn., 1904, Bd. lxxii., p. 287. 26 402 OPERATIVE MIDWIFERY A dressing is then applied over the wounds and the pelvis, supported hy a binder. It has been found in recent years that a moderate support of the pelvis is all that is necessary. A still more lateral division of the pelvis was carried out by Faralm iuf and Pinard ! in a case of obliquely contracted pelvis. The pubes and ischium were divided about 4 centimetres from the middle line. This operation has been termed ' ischio-pubiotomy.' The result was most satisfactory. The child was saved, and the mother made an excellent recovery. Bony union is reported to have followed. A similar operation was suggested by Aitken - of Edinburgh in 1784. Mortality and Morbidity of Pubiotomy. — During the last two years I have performed pubiotomy four times. In one case death followed from sepsis, and in another the wound became infected, while in the other two the patients made perfectly satisfactory recoveries. In the fatal case the woman had been in labour and the membranes had been ruptured long before she was admitted to hospital, and it was rather against my better judgment that I performed the operation. Craniotomy was the operation I should have chosen. As regards the results in Germany, where pubiotomy is most favoured, Hammerschlag in his recent work, 3 states that in 77 cases operated on by the open method, the mortality was 10*4 per cent., while in 700 cases operated on by the subcutaneous method (Bumm and Doderlein), it was 4*4 per cent. The total mortality was 9 per cent. If the reader refers back to p. 304 he will see that in 245 cases of symphysiotomy performed by representative operators in this and other countries the maternal mortality was 7 per cent., and the fietal mortality was 10 per cent. With improved technique, and above all more careful selection of cases submitted to pubiotomy, both the maternal and foetal mortality will greatly improve. This is well illustrated in the latest report of Schauta 4 — fifty cases with no maternal mortality and a foetal mortality of only 6 per cent. Equally good results were recorded recently by Williams of Baltimore in a series of twenty-five cases. Conclusions regarding- Symphysiotomy and Pubiotomy. 1. The operation of symphysiotomy or pubiotomy has a distinct and valuable place in certain well-chosen cases. The cases suitable 1 Ann. dc Oyn., 1892. 2 Fasbender, ' Geschichte dcr Gcburtshilfe,' 1900, p. 872. 3 ' Lehrbuch der Operativcn Geburtsbilfe,' 1910. 4 Monat. f. Geb. u. Qyn. y January, 1910, p. 21. THE ENLAEGEMENT OF THE PELVIC CAPACITY 403 for the operation are few in number, and have already been described in connexion with symphysiotomy. 2. Neither of these operations should ever be performed on a primipara. 3. Neither of these operations is suitable for domestic practice. It requires very great experience indeed of contracted pelves to be able to determine the cases suitable for either operation, and if a mistake is made in choosing either of them, most disastrous results may follow. The mortality will be as high as Cesarean section, and the morbidity (injuries to bladder, urethra, etc.) infinitely greater. 4. There is very little to choose between symphysiotomy and pubiotomy, but upon the whole the latter is the better. In conclusion I would earnestly request all obstetricians in this and other countries to be most careful in their selection of cases for symphysiotomy or pubiotomy, otherwise they will undoubtedly bring into disrepute a most valuable means at our disposal for dealing with certain cases of contracted pelvis. CHAPTER XXVI CESAREAN SECTION Indications for the Operation. As the results from Cesarean section have improved, its limitations have become less restricted, so that the operation is now had recourse to for conditions which would not have been considered justifiable ten or fifteen years ago. The conditions for which Caesarean section is most generally per- formed are deformity of the bony pelvis and myomatous and carci- nomatous tumours of the uterus. In recent years, however, there have arisen advocates for the operation in certain cases of eclampsia, concealed accidental haemorrhage, and even placenta prsevia. In contracted pelvis Cesarean section is called for when a living child cannot be born per vias naturales, and, in the case of a dead child, when the risks of craniotomy are greater than those of Cesarean section. From the previous chapters upon contracted pelvis and forceps we have seen that it is almost impossible to deliver with forceps a full-time child alive when the conjugata vera is less than 3 inches (7*5 centimetres), and that even at 3 inches about half of the children are either born dead or succumb shortly to the injuries inflicted on them during their extraction. Unless a child is very small, forceps delivery should not be attempted under 3£ inches. Even at 3 \ inches Caesarean section must be considered if there is a distinct disproportion between the head of the child and the maternal pelvis, and especially if the pelvis is generally contracted. As regards symphysiotomy and pubiotomy, I expressed myself as very much opposed to those who take up an extreme position either for or against these operations. I tried to make it clear that I con- sidered it most desirable that symphysiotomy or pubiotomy should retain a place amongst obstetric operations, and that, to put it briefly, they were indicated in the case of a living child when our just failed to effect delivery after our or two attempts with forceps. I do not consider that symphysiotomy or pubiotomy comes into competition with Cesarean section, for if the disproportion between the head and 404 CESAREAN SECTION 405 the maternal pelvis is so great as to lead an operator, before labour or at an early stage of labour, to consider symphysiotomy, pubiofcomy, or Cesarean section necessary, then, without doubt, Caesarean section is the safer operation, and will be attended with better results for mother and child. Turning now to the cases of extreme pelvic deformity, Caesarean section is indicated whenever the conjugata vera is below 2£ inches, for craniotomy in cases of such extreme pelvic deformity is an opera- tion of great difficulty, and attended with a very high maternal mortality. Even at 2\ to 2i inches (5'6 to 6'2 centimetres), especially if there is a general contraction of the pelvis, the operation is one requiring both experience and patience. Under such circumstances, I have spent as long as two and a half hours in extracting the child. My results from craniotomy performed under favourable conditions, even in these difficult cases, when the vera is 2^ to 2| inches (5-6 to 6-2 centimetres), have been slightly better than those ob- tained from Caesarean section, and so, if the child is dead, I prefer craniotomy to Cesarean section. Here, probably, is the most suitable place for considering the question as to whether or not one must always perform Caesarean section if the child is alive and the deformity such that the only alternative is craniotomy. We are constantly receiving into hospital cases in which labour is far advanced, in which many examinations, and even attempts at delivery, have been made by midwives and practitioners whose hands have not been thoroughly cleansed. In such cases, if the child is alive, must one choose Caesarean section ? Personally, I am quite convinced that one considers the best interests of the mother and of the State in deciding against Caesarean section and in favour of craniotomy, if it is at all possible to deliver the child by such means. The general results in the Glasgow Maternity Hospital from Caesarean section performed upon women admitted advanced in labour, and previously interfered with, have been disastrous. Even supravaginal hysterectomy, the operation generally had recourse to in these cases, is attended with a very high maternal mortality. I agree with Galabin x when he says : ' In such cases the argument still holds good which was used while the mortality of Caesarean section was very high — that to perforate a living child may conduce to the interest even of foetal life if it saves the mother to bear more children.' Still more does this argument hold good when one thinks that in many of these cases the life of the foetus has already been endangered, and that in a considerable number the child is extracted dead or dies soon after. 1 Brit. Med. Journ., October 11, 1902, p. 1124. 406 OPERATIVE Ml hWIl- Ki;Y In recent years I have very seldom performed Cesarean section in cases which have heen interfered with prior to their coming under the care of myself or my assistants, unless the deformity of the pelvis was so extreme as to render craniotomy impossible, or more dangerous to the mother than Ca-sarean section. I am compelled, therefore, not infrequently to perforate a living child. 1 am well aware that such an attitude is condemned by some operators ; but each operator must satisfy himself as to the attitude he should assume towards such cases. It is always with extreme regret that I perforate a living child ; but I am perfectly convinced I save more mothers and probably, indirectly, more children. I do not take upon myself the blame of destroying the children ; that rests with those who send the cases too late to hospital. In this class of cases it is very striking that Pinard, who is absolutely opposed to perforating a living child, has a very high maternal death-rate — 20 per cent. 1 Indeed, in the four cases where he performed total hysterectomy he had three maternal and two fcetal deaths. Theoreti- cally it is sound to take up the attitude that no living child should be perforated, but practically it is not. Routh, 2 in his most valuable contribution to this aspect of the subject, points out that the mortality in such cases is fully 30 per cent, (vide p. 431). The indications for Cesarean section when labour is obstructed by tumours of the uterus and neighbouring structures, deformities and displacements of the uterus, and cicatrical contractions of the vagina, are considered in the chapters devoted to these special subjects. As regards eclampsia, there is now a general consensus of opinion that in certain cases — they are, of course, few in number — Cesarean section is not only permissible, but is actually the treatment indicated. Van den Akker is credited as being the first to perform the operation in 1875. The patient was not only an eclamptic, but suffered from slight pelvic deformity. A hundred years previously Lauverjat recom- mended the operation." Halbertsma performed his first operation in 1878, but did not report it till 1889. In recent years all obstetric writers have referred to the subject, and several monographs with collections of cases have appeared in obstetric journals, more especially in Germany. Among the more important are those by Hillman, 4 Streckeisen, 5 and Croom. 1 Ann. de Gyn. et d'Obst., September, 1907. p. 529. 2 Journ. of Obst. and Gyn. of Brit. Empire, January, 1911. :i Fasbender, ' Geschichte der Geburtshiilfe," 1906, p. 804. * Monat.f Geb. u. Gyn., Bd. x., Heft 2. 6 Cent./. Gyn., 190:5, p. 1072. 6 Trans. Edin. Obst. Soc, vol. xxix., p. 194. CESAREAN SECTION 407 The cases in which the operation is indicated are when the eclamptic seizures are of great severity and frequency in the later weeks of pregnancy, and, above all, when the cervix is not taken up and is very rigid and undilatuble. This is not the place to discuss the treatment of eclampsia. I would only say that, with my present experience, I am strongly opposed to radical operative interference until saline transfusion and the administration of chloral or morphia have been given a full trial. On many occasions I have seen eclampsia arrested by such treatment. If, however, after two hours the progress of the disease is not arrested by these measures, I consider emptying of the uterus not only justifiable, but absolutely indicated. Caesarean section in eclampsia comes into competition with ' Vaginal Ca j sarean Section ' and forcible dilatation of the cervix by means of metal dilators. Metal dilators in most cases at term are quite unsuit- able if the cervix is not taken up. Vaginal Caesarean section in the case of a primipara at term is an operation attended with consider- able difficulty ; I would therefore confine it to cases in the earlier months of pregnancy. In the later months the abdominal operation is more easily carried out. This whole subject is fully considered in Chapter XXVIII. As regards the results from abdominal Cesarean section, all are agreed that the maternal mortality is extremely high. It must, how- ever, be remembered that only the very worst cases are treated by this method, and that, consequently, one cannot expect other than a high death-rate. Berkeley 1 puts the mortality at 47 per cent. Caesarean section in accidental haemorrhage and placenta praevia is considered in connexion with the treatment of these conditions. I would only remark here that, while many are in favour of Caesarean section followed by hysterectomy in severe cases of concealed acci- dental haemorrhage, very few approve of such radical treatment for placenta praevia. In addition to the conditions mentioned, Gemmell 2 and Kohn 3 refer to the performance of the operation in myasthenia gravis. Preparation of the Patient. — In all abdominal operations the great danger is septic infection, and in few is this more likely to occur than in Caesarean section. In addition to the ordinary risks through the abdominal wound, there are all the dangers through the par- turient canal. The uterus left behind, and containing as it does debris of decidua and blood-clot, with large dilated veins and lym- phatics running from it, furnishes a most suitable soil for the growth 1 Jour?i. of Obst. and Gijn. of Brit. Empire, December, 1904, p. 476. 2 Prag. Med. Woch., May 14, 1903, p. 242. 3 Journ. of Obst. and Gyn. of Brit. Empire, March. 1904, p. 271. 40H OPERATIVE MIDWIFERY and di>semination of any micro-organisms which may be introduced into it either through the abdominal wound or the vagina. Then, the operation has frequently to be performed upon women hurriedly prepared. ' But, even worse than that, not infrequently the patients sent into hospital are advanced in labour, and in very many cases have been previously examined by midwives and practitioners whose hands have not been thoroughly cleansed. So serious is this latter factor, and so unsatisfactory are the results from Ca-sarean section, that many of us now are disinclined to perform the operation in such cases unless there is absolutely no alternative. As I have already said, some of us even go the length of perforating and destroying a living child, for in such cases one cannot reckon upon a maternal mortality of less than 20 per cent. One is confronted, therefore, by this unfortunate state of matters — that Cesarean section, the simplest of all abdominal operations, is attended with a higher mortality than ovariotomy or hysterectomy for myomata, for example. This can only be remedied by the medical practitioners appreciating the limitations of forceps, doing everything to prevent infection, and, if they are not prepared to perform Cesarean section, sending their patients into hospital in the last days of pregnancy or very early in labour. It is a distinct advantage to have the patient in hospital for some days before the operation. To arrange this is not always easy, for the onset of labour is not a date one can fix with exactness. My own practice is to bring the patient into hospital or nursing home a week before labour is expected. If she delays going into the institution until the last moment, she may be taken in labour before she can get there. There is another advantage of having a patient in hospital for some time before Cesarean section. Many of the cases of severe rickets when they are admitted to hospital show signs of considerable bronchitis, and if a severe operation with a prolonged anaesthesia is performed immediately after their admission, the bronchitis often becomes extreme. On one or two occasions I have been very anxious indeed regarding patients in this respect. The preparation of the abdominal wall prior to operation is fully considered in Chapter XXI. Until recently it was my custom to cleanse the vagina very carefully prior to operation. During the last two years I have abandoned this procedure except in those rare cases in which I perform Casarean section, although the vaginal canal has possibly become infected. Time for Operating 1 . — At this point it is advisable that I refer to the time for operating. It was the custom until a few years ago, and is still the recommendation of some surgeons, to operate only after CESAREAN SECTION 409 labour has been in progress some Httle time. Those who advocate this claim that, if the cervix is dilated, any blood-clot forming in the uterus is more readily expelled ; in other words, that drainage is better, and that post-partum hemorrhage is less likely to occur. Others maintain that it is better, when one has the choice, to operate prior to the onset of labour, because one can choose the most suitable time in the day, and quietly make every preparation. These latter ■claim that the uterus finds no difficulty in expelling any clots that may form in its cavity, and that the danger of post-partum hemor- rhage is theoretical. Personally, I think there is much to be said in favour of operating before labour has commenced. In multipara; I always do so if possible, and I have never seen any trouble result. On two occasions, however, in primigravide considerable disturbance from after-pains followed. In consequence of this, I delay operating upon them until labour has begun. wnav: Operating before labour has commenced is naturally only suitable for those cases in which there is absolutely no doubt that Cesarean section is necessary. If there is any doubt about this, and any probability of the labour being terminated spontaneously by forceps, symphysiotomy, or pubiotomy, the patient must be allowed to go into labour, and possibly, indeed, the latter must be allowed to continue for some time before Cesarean section is performed. There is a danger in operating before the onset of labour that one may occasionally perform the operation before term has been reached, and so deliver a child distinctly premature. Hospital patients are often so uncertain regarding the onset of pregnancy, and the abdo- men in the rachitic becomes early so prominent, that it is impossible by palpation to estimate the size of the child. It was once my experience to deliver a child which, as far as could be judged after delivery, was not more than thirty-six weeks old. "When, however, the patient's statements regarding the duration of her pregnancy are reliable, the likelihood of performing the operation much before term is reduced almost to the vanishing-point. The actual operation is just as easy in the pregnant as in the parturient, and the uterus, I find, contracts equally well in both. If one has to remove the uterus, it is a distinct advantage to operate before labour, for there is a much smaller stump to stitch, as the calibre of the cervical canal is much narrower. When, therefore, hysterectomy is called for, the operation should always be performed, if possible, before labour has started. Immediately before commencing the operation a full dose of ergotin should be given hypodermically. It is a mistake to give it too soon, especially if the labour has been going on for long, as there may be some little trouble in extracting the child. 110 UPKUAT1YE MIDWII i:i:V The Operation. The Abdominal Incision. — The abdominal incision should be high and sufficiently long. It should be high, because one can open into the uterus high up on the fundus. My rule is to make an incision 8 to 10 inches ('20 to 25 centimetres) in length, the length depending upon whether or not I intend to turn the uterus out of the abdomen before opening into it. Two-thirds of this incision is made above and one-third below the level of the umbilicus (Fig. 188). If it is the Fig. 188. — The Abdominal Incision — Two-thhds above and One-third below the Umbilicus. operator's intention to remove the uterus the incision should be made lower. Having opened into the abdominal cavity, one has to decide whether or not the uterus should be turned out of the abdomen. There is no doubt that if the uterus is not turned out before it is emptied, the abdominal incision may be kept about 2 inches (5 centi- metres) shorter, and that, of course, is a slight advantage. On the other hand, the abdominal cavity can be kept cleaner by turning the uterus out. On theoretical grounds the advantages are in favour of turning out the uterus, and personally I prefer it. Others — as, for CESAREAN SECTION 411 example, Schauta 1 — prefer not to turn out the uterus. It is really a. matter of no very great importance, except in those cases where the membranes have ruptured some time before, for then there is a danger that the uterus may have become infected through the vagina. Consequently, in such cases the uterus should always be turned out before being opened into. If it is decided to open the uterus while it still remains in the abdomen, the hand should be passed round to the right side of the abdomen and the uterus rotated to the left so as to correct the torsion to the right so commonly present. By so doing the uterus can be opened in the middle line, which is always an advantage. The uterus should then be surrounded by large sterilized swabs, to prevent as far as possible blood and liquor amnii getting into the abdominal cavity. If, on the other hand, it is decided to turn the uterus out before opening into it, the hand should be passed up over the fundus, when, if the abdominal incision has been long enough and high enough, there is no difficulty in bringing the uterus out. After having turned it out, the abdominal wound above should be temporarily closed by means of pressure forceps, and the uterus surrounded by sterilized swabs or towels. The Uterine Incision. — The recognized uterine incision is a longitudinal one running down the middle of the anterior wall of the uterus. It should be limited to the active contractile portion of the organ, and should not extend into the lower uterine segment. There are several objections to cutting into the lower uterine segment, and of these the most important are : that the wall is very thin ; that the wound is brought nearer to the vagina, and so there is greater risk of infection ; and that in extracting the child the lower end of the wound is very apt to tear. Another disadvantage is that, in stitchin g the lower segment, if thick silk ligatures are employed, they may find their way into the bladder. Several cases of this kind have been reported. Especially interesting was one described by Cameron, in which three large stones were removed from the bladder of a patient upon whom he had performed Caesarean section some few years before. The nucleus of each stone was a silk ligature. The longitudinal incision is not the only one which has been advocated. Kehrer recommended a low transverse incision ; Johan- nowsky a posterior longitudinal ; Cohnheim a posterior longitudinal one with drainage through Douglas' pouch into the vagina ; Caruso and Miiller a sagittal fundal incision; and Fritsch' 2 a transverse fundal one. 1 Archivf. Gyn., 1906, Bd. lxxix., Heft 1. 2 Zentraiblait f. Gyn., 1897, p. 561. 412 OPERATIVE MIDWIFER1 But the incision which in recent years has been most discussed is the extraperitoneal one associated more particularly with the names of Sellheim and Latzko. It will he referred to at the end of this chapter in some detail. In 1S97 Fritech 1 recommended a transverse fundal incision, and claimed that it possessed the following advantages: (a) The abdomen being opened into high, there is less risk of subse- quent hernia ; (/<) by pulling forward the fundus the escape of blood and liquor amnii into the abdominal cavity is better prevented ; (c) the child is more easily extracted; (rf) the placenta is less frequently cut down upon; (c) there is less bleeding; (/J there is greater diminution of the wound and less stitching required. After employing the incision in some nine cases, I discussed the matter in detail in two papers. 2 My conclusions were that the first two advantages mentioned would be obtained with the ordinary incision if the abdomen were opened into high enough, and the uterus turned out before opening into it. The third advantage, that the child is more easily extracted, I was inclined to admit, for when the waters have drained away there is occasionally slight difficulty in •extracting the child through a longitudinal incision. The difficulty, however, is only slight, although on two occasions I have seen difficulty in extracting the head, which was firmly grasped below the retraction ring. Curiously enough, Steinthal 3 reported a case of the same difficulty where a fundal incision was employed, and so firm was the grasp of the head that he was forced to make a longitudinal incision through the retraction ring before he could get the head removed. The fourth advantage claimed, that the placenta is less frequently cut down upon, I did not find was the case, for 1 encoun- tered it in 40 per cent, of my cases. Others have had a similar experience. Schroeder 4 encountered the placenta in 35 per cent., Hiibl 5 in 41 per cent., V. Braun-Fernwald 6 in 54 per cent. It certainly is preferable not to cut down upon the placenta, for there is always more bleeding when one encounters it, and the stitching of the uterus is not so satisfactory ; besides, risks of infection are slightly increased. The other advantages, that there is less bleeding and greater diminution of the wound, did not impress me, although I was disposed to think that the transverse incision contracted more than the longitudinal. 1 Zentralblatt f. Gyn., 1897, p. 561. 2 Journ. of Olsf. and Gyn. of Brit. Empire, vol. ii.. 1802, p. 21 ; or.d Bi it. Med. Jvwrn., vol. ii., 1902, p. 1129. 3 Zent.f. Gyn., 1898, p. 345. * Monat.f Geb. it. G-yn., P.d. xiii., 1901. p. 22. 6 Ibid., Ed. xii., 1900, p. 480. 6 Archivf. Gyn., Bd. lix., 1899, p. 820. CESAREAN SECTION 41S- The objections urged against the incision, that the fundus uteri contracts adhesions to the bowels, that a high attachment of the fundus to the abdominal wall results, and that involution of the uterus is in consequence interfered with, are not of much importance. I admit, however, that rupture of the uterus at a subsequent preg- nancy is more liable to occur with a fundal than with a longitudinal incision. As a matter of fact, rupture of the fundal cicatrix did occur in one of my cases at a subsequent pregnancy. The case is described and the uterus figured in Chapter XXXY. Fig. 189. — Showing bulging of Membranes through Uterine Incision. One could not but feel that the excitement in Germany regard- ing Fritsch's incision was out of all proportion to the importance of the subject, I quite agree with Bar when he wrote regarding it : ' Je regarde la modification de Fritsch pour peu importante et je m'en tiens encore a l'incision longitudinale pratiqnee aussi haut que possible. n The longitudinal incision should be from 6 to 7 inches (15 to 18 centimetres) in length, and, as I have already stated, should be placed high on the anterior wall in the middle line. In cutting through the wall, very free bleeding occurs, especially if the placenta is situated 1 ' Le./ons de Pathologie Obstctricale,' 1900, p. 20. -114 OPERATIVE MIDWIFERY anteriorly. The slight inconvenience of this may be lessened by the operator and his assistant pressing on the uterus with a swab just outside the incision. This has the effect of controlling the haemor- rhage, except when the placenta is situated underneath the incision. The operator, when opening the uterus, cuts down carefully upon the membranes, which when reached bulge out through the incision (Fig. 189). Two lingers are then inserted between the membranes and the uterine wall, and the incision is quickly enlarged upwards to the extent required (Fig. 190). The membranes are then ruptured, Fig. 190.— Enlarging the Uterine Incision. 1 and the child seized and extracted. In cutting down upon the mem- branes one often punctures them, but this is of no consequence. The placenta is encountered in some 40 per cent, of cases. In such cases the operator on reaching the placenta slips his fingers up between it and the uterine wall, enlarges the incision, and extracts the placenta quickly; or, better still, pushes his hand through the placenta and seizes hold of the child, just as he would do in perform- ing version in a case of ' central placenta pra via.' To open the uterus, as Olshausen 1 has suggested, in the part where the placenta is not situated has not been found practical, for it is not always possible 1 Zent.f. Gyn., No. 1, 1900. p. 1. CESAREAN SECTION lir- to make sure of its position, and valuable time is lost in trying to do so. Olshausen claims that the area where the placenta is situated has visibly dilated vessels. I have not been able to confirm the observation of Bayer, Leopold, and Palm, that when the placenta is situated anteriorly the distance between the tubes anteriorly is increased, and when situated posteriorly the distance between them posteriorly is increased. Holzapfel, Koblanck, 1 and Olshausen also question the correctness of the observation. Fig. 191. — The Hand has been pushed through the Membranes and a Foot seized. The extraction of the child is best accomplished by seizing one or both feet (Fig. 191), for with a high uterine incision, except in cases of breech presentation, the head is more difficult to reach. There is almost never any difficulty in extracting the head. The cases in which I have found difficulty are where the waters have drained away, and the uterus is firmly applied to the surface of the child. I have twice seen the neck grasped by the retraction ring ; but in both cases the difficulty was overcome without cutting through the retraction ring, as Steinthal 2 required to do. If too small an incision has been made, the uterus may contract 1 Zeitschrift f. Geb. u. Gijn., Bd. xlvi., Heft 1, 1901, p. 99. 2 Zent.f. Gyn., 1898, p. 345. •lie OPERATIVE MIDWIFERY firinly round the head ; but a slight extension of the incision up wards- overcomes this difficulty. It is a mistake to try and drag the child through a small incision, for the uterus is very apt to be torn, and if this occurs downwards, as it generally does, an irregular and ragged tear is made in the lower segment. Whenever delivery is completed, the umbilical cord should be clamped with forceps and cut, and the child handed over to the assistant who is ready to look after it. The child cries very soon (Chapter XXXVII.), but the apnoea may continue for some seconds. FlG. 192. — The Removal of the Secuudines. As the child is extracted, the assistant seizes the uterus, and if it is- not already outside the abdomen, brings it out and surrounds it with large swabs. He then kneads it firmly, which causes it to contract and arrests all haemorrhage. There remains now only the removal of the placenta and mem- branes, and it is of the greatest importance, if the uterus is left behind, that these should be completely removed (Fig. 192). When the membranes have bulged down into the vagina, there is a risk of infection in pulling them back up through the uterus. If the os is sufficiently dilated, this difficulty may be overcome by separating the placenta and membranes, and pushing them down through the cervix, by means of a large swab. CESAREAN SECTION 417 The Treatment of the Uterus. — There are three different courses open to one after extracting the child : (a) Removal of the uterus by supravaginal hysterectomy, formerly known as Porro's operation, when the stump was treated extraperitoneally ; (b) panhysterectomy ; (c) retention of the uterus without sterilization, the true conservative Cesarean section ; (d) retention of the uterus and the sterilization of the patient by removing a portion of the tubes. Each of these methods has its advantages, and must be considered in some detail. (a) Removal of the Uterus by Supravaginal Hysterectomy, formerly known as Porro's Operation, when the Stump was treated Extra- peritoneally. — The removal of the uterus after the extraction of the child is indicated in cases where there is a probability that the parturient canal is infected, when myomatous tumours are too extensive or too numerous to permit of simple myomectomy ; when post-partum haemorrhage cannot be controlled ; when the uterus has been too much injured by rupture or previous Cesarean sections to justify one leaving it behind ; and in women the subjects of osteomalacia. All the indications are self-evident and need no elaboration, with the exception of post-partum haemorrhage. This condition I have only once observed. The patient had been long in labour, and was driven some twenty miles before operation. All other operators of experience have remarked upon the infrequency of post-partum haemorrhage. Every one admits that Porro's operation for some years after its introduction gave the best results. It was introduced by him in 1876, but was suggested many years before by Cavallini and Blundell, 1 the latter Professor of Obstetric Medicine in Guy's Hospital. Each suggested the operation after making experiments upon the lower animals. Blundell did the operation upon four rabbits, three of which recovered. 1 The true Porro operation consisted in a supravaginal amputation of the uterus, the pulling of the stump up through the lower part of the abdominal wound, the fixing of the stump there with long pins, and the passing round it of a serre-noeud, which was slowly tightened until it cut through the stump. The abdominal wound was closed in the ordinary way. The method was a very crude one, and suppuration often occurred about the stump and lower part of the wound, so that the healing was very protracted and the mortality was high. Improvements soon began to be made, such as opening of the uterus only after it had been turned out of the abdomen, and con- trolling haemorrhage by the application of the tourniquet. The greatest improvement, however, arose as a result of Hegar's method 1 ' Obstetric Medicine,' p. 367. 27 •118 OPERATIVE MimYIFERY of treating the stump in hysterectomy for myoma. Hegar separated the peritoneum, stitched it to the wound, and then dealt with the stump entirely extraperitoneal^. This method was perfected by Fehling and others on the Continent, and by Lawson Tait in this country. While the extra-abdominal treatment of the stump was being perfected, others were engaged in trying to devise a suitable method of treating it intra-abdominally. The earliest device suggested, and carried out in a few cases — it now seems a very primitive one — was to invert the stump or the whole uterus into the vagina. Again, the great advance, although it was somewhat slow in being appre- ciated, came as a result of improvements in the technique of hyster- ectomy for myoma. With greater experience and attention to aseptic precautions, Schroder's method of stitching the stump and dropping it back into the abdomen gave such satisfactory results that obstetricians came to adopt it also. At the present time, with the peritoneum carefully stitched over the stump, it is the method generally employed when the uterus is removed by supravaginal amputation. The extra-abdominal treatment of the stump is still favoured by a few operators in septic cases, for they claim that by that method infection is better prevented. Should it be had recourse to, the uterus is turned out of the abdomen and amputated, the peritoneum turned back and stitched to the abdominal wound, and two pins introduced at right angles to prevent the stump being retracted. The modern method, which is still erroneously referred to as Porro's operation, consists in securing the uterine and ovarian vessels on both sides by ligatures, amputating the uterus supravaginal!}*, stitch- ing the stump, and finally bringing the peritoneum by a continuous suture over the stump — a method which is correctly described as retroperitoneal or subperitoneal treatment of the stump. The details of the operation are briefly as follows : The patient is placed in the Trendelenburg position, and the intestines are carefully walled off with swabs. The uterus, being pulled out of the abdomen, is dragged over towards one side by the assistant, so as to allow the operator to reach the broad ligament of the opposite side. The haemorrhage from the wound in the uterus is controlled by a long clamp, or by rapidly stitching up the uterine wound (Fig. 193). Clamps are now applied, first to the round ligaments and then to the ovarian vessels, either beyond or on the uterine side of the ovary, according as one decides to remove or leave the latter behind. A clamp is then applied close down the side of the uterus, to control any bleeding from the ovarian vessels on the uterine side. The tubes and ovarian vessels are CESAREAN SECTION 4V.) then divided. Any vessels which have not been included should be clamped. The securing of the uterine vessels — the next step — is the only troublesome one in the operation. Prior to attempting to secure them, however, the peritoneum on the anterior uterine wall should Fig. 193. — Supravaginal Amputation of Uterus. be divided transversely, just above where it is reflected on to the bladder. In doing this the peritoneum alone should be seized with dissecting or pressure forceps and cut across. If one catches it care- lessly, the subjacent cellular tissue, which contains numerous dilated vessels, will be injured, and profuse bleeding will result. The bladder is then pushed down out of the way with a gauze swab. The peri- 120 OPERATIVE MIDWIFERY toneum behind the uterus is also divided. < >ne has now opened up the lower part of the broad ligament, and tin- uterine vessels of each side can be readily seen and felt. The vessels are secured by clamp- applied close to the cervix in case of injuring the ureters, although there is really not much chance of doing this if the bladder has been Fig. 194. — Stitching Stump of Dilated Cervix. pushed well out of the way. . Having secured both uterine vessels, they are divided close by the uterus. Having grasped the cervix with vulsellum forceps below the level at which it is to be divided, the cervix is cut across and the body of the uterus removed. The vessels which have been clamped must now be ligated, and this I prefer to do by ' under-stitching.' There now remains only the stitching of the stump, which is steadied by the CESAREAN SECTION 421 vulsellum forceps. Prior to doing this, however, I am in the habit of swabbing out the cervical canal with pure carbolic ; others use the Pacquelio cautery, or dissect out the mucous membrane. I do not attach great importance to these steps, and many operators dispense with them altogether. The actual stitching of the cervix Fig. 195. — Covering the Stump with Peritoneum. must be done with care. I usually do it in two layers (Fig. 194). The sutures, which are of catgut, are passed through the anterior and posterior walls of the cervix, but do not include the mucous membrane. The amount of stitching that is necessary depends upon the width of the cervix. In the case of a dilated cervix the stump to be stitched is very broad, so that five deep and two or three superficial sutures are required, while, on the other hand, if the cervix has not been dilated 422 OPERATIVE MIDW1 1T.I;Y and the stump is quite small, two deep and one or two superficial sutures are sufficient. Having again satisfied oneself that there is no bleeding -point un- Fn:. 196. — Panhysterectomy. Upper part of vagina is clamped across, and the operator is pushing gauze into lower part of vagina. secured, the peritoneum is carefully stitched over the stump, and the raw surface of the broad ligament brought together with a continuous CESAREAN SECTION 423 catgut suture (Fig. 195). All blood-clot is now removed, and if the patient is at all collapsed, 1 or 2 pints of normal saline solution are poured into the abdomen. The closing of the abdomen is considered later. (1>) Panhysterectomy. — When the uterus has to be removed, a few operators prefer total hysterectomy, especially in septic cases ; it is also indicated in carcinoma of the cervix, and in certain cases of uterine myoma and rupture. The steps in the operation are, up to the point of clamping the uterine vessels, the same as those followed in supravaginal amputa- tion. The bladder must now be pushed farther down, and the tissues around separated from the cervix and the upper part of the vagina. Fig. 197. — Conservative Cesarean Section. The assistant controlling the bleeding and bringing the edges of the wound together. prior to the operator introducing the sutures. The latter is then clamped with forceps curved at the ends (Fig. 196). The vagina is then divided below and gauze is packed into the canal. This prevents any of the uterine discharges contaminating the peri- toneum. The anterior and posterior vaginal walls are then stitched together, special care being taken at the corners, for there is apt to be a little venous oozing there. The gauze is then withdrawn through the vagina. In septic or suspected septic cases many prefer to leave in a gauze drain, and only partially close the vagina. (c) Retention of the Uterus without Sterilization — ■ Conservative Cesarean Section. — This is the ideal operation. It is carried out as follows : After the placenta and membranes have been care- fully removed from the uterus — this must be done very completely — the organ is grasped by the assistant as represented in the illus- 424 M'KKATIYK MlDWIFKliY tration (Fig. 1!)7). I have tried other methods of holding the uterus while the sutures are being inserted, and these other methods are shown (Figs. 198 and 199); hut they are not so satisfactory, for they prevent the escape of blood into the vagina. The application of a tourniquet round the cervix to control haemorrhage is, I think, undesirable, as it has a paralysing effect upon the uterine muscle. It is true the method I have indicated as being the best is rather irksome for the assistant, but with a little practice, and by not grasping the uterus too firmly at first, this will be lessened. As may be seen in Fio. 198. — Another Method of controlling Bseniorrhage. The assistant grasps the uterus and ovarian vessels between his thumb and fore and middle fingers. the illustration, the assistant applies the thumb and forefinger of each hand to the sides of the incision, and brings the two inner edges of the w r ound exactly into apposition ; this is of the very greatest importance, because, in order to get a firm cicatrix in the uterus, the stitches must be inserted through the entire uterine wall up to the m :cous membrane (Fig. 199). I agree with the late Cullingworth, Zweifel, and Fritsch that no harm results from stitching through the whole thickness of the uterine wall. Indeed, if the placenta has been situated on the anterior wall under the incision, I think it is a distinct advantage, for in such cases CESAREAN SECTION 125 the deeper portions of the uterine wound, heing occupied by large sinuses, are very friable ; consequently, in tightening the sutures they are apt to tear through the deeper parts of the wall, and only the superficial parts are brought into apposition. The mistake is often made of only stitching the superficial layers of the uterine wound, and unless one is very careful this mistake is easily made, for the internal part is often retracted, and, the whole internal surface of the uterus being raw, it is difficult exactly to define the internal edges of the Fig. 199. — The Uterine Sutures inserted. It also shows another method for controlling haemorrhage. The assistant compresses the vessels against the uterus by grasping the uterus with one hand. This method of controlling haemorrhage is practically the same as the application of a tourniquet round the cervix. wound. The only possible objection to stitching through the whole thickness of the uterus is that a portion of the suture, being situated in the uterine cavity, is liable to become infected, and this infection may spread along the sutures. If infection of the uterus does occur, however, it is very questionable if the patient's chances would be any better had the stitches not included the mucous membrane. For many years I used catgut for suturing the uterus, but recently I have returned to fine silk. The reason I abandoned silk some years ago was because in septic cases, if the silk became infected, a most troublesome sinus resulted. Since I have given up Cesarean section 126 OPERATIVE Mii>\\in:n in infective cases the objection to the use of silk has been got over, and so I have returned to it in this operation. From eight to twelve sutures are usually required, and these are placed ut a distance of about '. inch apart (Fig. 200). In addition, a few tine superficial stitches are also inserted between the others, wherever the edges of the wound are not in perfect apposition. In tying catgut sutures a double knot is always desirable, and the superfluous portion of the suture must not be cut off too near the knot, for the uterus being an organ that does not remain passive, but Fig. 200.— The Uterine Sutures tied. is frequently contracting and retracting, the knots are apt to come undone. This is no theoretical danger, for it actually occurred in one of my cases. This patient some eight hours after the operation showed signs of collapse. I'nfortunately, I could not get to see her. and those who were in charge, not appreciating fully the probability of internal haemorrhage, did not care to open up the abdominal wound. At the post-mortem examination about 40 ounces of blood were found in the abdominal cavity, and two or three of the catgut sutures were untied. The uterus is now ready to be replaced in the abdominal cavity, but prior to doing this it is firmly compressed with warm swabs, and all blood-clot, etc., is removed from the abdominal cavity. Such CESAREAN SECTION 427 debris is usually found in front, of the broad ligaments in the utero-vesical pouch, although some may also find its way down into Douglas' pouch. Having replaced the organ, the abdominal wound is closed. The stitching of the abdominal wall in layers is, I am convinced, the best method of closing the wound. In Cesarean section, however, the abdominal parietes are sometimes so thin that this is occasionally unnecessary. My usual practice is to stitch in three layers. I first stitch the peritoneum with a continuous catgut suture, then I place silkworm gut interrupted sutures through the whole thickness of the abdominal wall except the peritoneum. Before tying these latter, I carefully bring together the rectus sheath with interrupted catgut sutures. This careful closing of the abdominal wound takes ten minutes longer than simple through and through stitching. It is, however, worth the time expended upon it. Before the wound is closed it should be washed with normal saline solution and well dried. After the sutures have been tied, the wound is washed with 70 per cent, alcohol, and a simple dressing of sterilized gauze and gamgee applied. The dressing is not, as a rule, changed until the twelfth day, when the stitches are removed. (d) Retention of the Uterus and the Sterilization of the Patient bi/ Removal of a Portion of the Tubes. — This method is the one most frequently employed when it is deemed necessary to sterilize the patient. It has this advantage, that it is an easier operation than hysterectomy, and consequently is specially suited for practitioners who have not had experience of abdominal surgery, and who are suddenly called upon to perform the operation of Cesarean section in out-of-the-way country districts and without efficient assistants. The method adopted in the Glasgow Maternity Hospital is to tie the tubes in two places, and remove the small portion between the ligatures. If one is not satisfied with this procedure — and there are a few recorded cases where pregnancy has followed — it is a simple matter to cut and tie the tubes close to the uterus, and bring a fold of peritoneum over the uterine stump of the tube. There is one reason which may be advanced in favour of this method of sterilization, as here described, and it is that if at a future date the woman wishes to have a chance of another pregnancy one might perform abdominal section, and unite the two ends of the tubes together again. Here are two cases to illustrate what I mean : A patient who had been sterilized as described came to me in great distress because her child had died. I told her that I could do nothing for her, but it occurred to me afterwards that the procedure 128 (H'KIIATIYK Mil >\\ II J.UY mentioned might have been suggested to her. Some months later I did suggest it to another patient who had been sterilized and who had also lost her child, but she would not consent to the operation. Such a procedure as I have suggested is quite feasible, provided one simply cuts and ties the tubes, for in two cases in which I saw the abdomen opened some years after because of the presence of an ovarian tumour, the ends of the tubes were patent, and could have been easily reunited. This is perhaps the most suitable place for considering the question of sterilization after Cesarean section — a subject of great interest, and regarding which very different views are held at present. With regard to this subject there appears to me to be three matters for considera- tion : (1) The ethical question ; (2) the danger to the patient of the repetition of the operation ; (8) the danger of rupture of the uterus during a subsequent pregnancy. From the ethical standpoint the question of sterilization is a very subtle and difficult one. A most interesting discussion on the subject took place at a meeting of the American Gynaecological Society. 1 It followed the reading of a paper by Green on ' Eepetition of Cesarean Section on the same Patient : the Experience at Boston Lying-in Hospital.' Green took up a very strong position, a3 can be judged from the following quotation : ' I venture to assert that the only safe and moral ground for the medical profession is that based upon modern medical science uninfluenced by sociological considerations. If a woman comes to Cesarean section and recovers, she and her husband, if she has one, should be informed of her condition, and of the prognosis and treatment in the event of future pregnancy ; if subsequent pregnancy ensues, the responsibility of treatment rests with the obstetric surgeon, but the responsibility for the condition rests elsewhere.' In the same discussion, Whitridge Williams distinguished between 'pauper patients' and 'women in the upper walks of life.' As regards the former, he is reported to have said : ' I do not believe we are justified in allowing pauper patients to be subjected to repeated Cesarean section unless they particularly desire it.' As regards the others, he continued : ' They should be made to share the responsi- bility with the physician. In such cases the husband and wife have the right to demand sterilization, though I should earnestly dissuade them from it after the first operation, and point out to them the possibility of the subsequent death of the child and the absolute impossibility of having another after such an operation. If, however, the patient requires a second operation, the matter should be left 1 Trans. Ainer. Gyn. Soc, 1903, vol. xxviii., p. 128. CESAREAN SECTION 429' almost entirely in her hands ; but my advice would tend in the direc- tion of rendering her sterile at that time, as, no matter how favour- able our results may be, an occasional death is bound to occur. A similar discussion followed a paper read by me before the London Obstetrical Society. 1 Spencer, who has for many years con- sistently recommended the conservative operation, said : ' The matter was an ethical one, to be decided entirely by the doctor, and that his duty was to deliver the woman and restore her as nearly as possible to a natural condition, a result obtained by the conservative operation without sterilization, and not by the mutilating operation of hyster- ectomy, nor by the unreliable and dangerous one of tying the tubes. If the patient became pregnant again, the responsibility was not the doctor's, whose duty was to repeat the Cesarean section, which experience had shown to be very safe.' Herman, on the other hand, is reported to have said : ' It was for the patient to decide whether she would be sterilized or not.' Culling- worth sided with Spencer, and Routh with Herman. The danger of repeated Cesarean section was gone into very fully by Wallace 2 some years ago. Since his contribution many cases have been reported, and the mortality has fallen to a very low figure. It has fallen below the mortality of Cesarean section performed for the first time. This is to be accounted for in several ways. The chief reason is that if the operation is to be repeated the woman is watched carefully during the later weeks of her pregnancy and is taken into hospital or private home before labour is expected, and so is well pre- pared for the repeated operation. Another reason given for the lower mortality is the presence of extensive adhesions, which, it is claimed, shut off the general peritoneal cavity so that the uterus may be evacuated without opening into the general peritoneal cavity. Now, while I admit that adhesions are often found at a subsequent operation, they are rarely so extensive as to permit of the second operation being performed outside the general peritoneal cavity. I have performed the operation twice on the same patient upon nine occasions, and in another case I have had to open the abdomen because of the rupture through the cicatrix of a previous Cesarean section wound in a woman who had nearly reached term. In the latter case there were absolutely no adhesions. In only two would it have been possible to open the uterus without opening the peritoneal cavity. Naturally, with each operation the adhesions between uterus and abdominal parietes become more intimate. It has been my practice, up to the present, to sterilize the woman 1 Trans. Lond. Obst. Soc, 1905, vol. xlvi., p. 309. 2 Journ. Obst. and Gyn. Brit. Empire, December, 1902. 180 OPERATIVE MIDWIFER1 after a second Cesarean section, either by tying the tubes or, more generally, by removing the uterus. I have made an exception to this rule in two cases. I find myself in agreement, therefore, with Whit- ridge Williams, for I feel that a woman who has twice subjected her- self to Cesarean section has done sufficient for her family and the State. Others, however, have acted differently, and have repeated the operation three, four, five, and even seven times. I do not say that I will not ultimately follow their example, but at present I am not convinced it is the right treatment. The danger of the uterine cicatrix giving way at a subsequent pregnancy or parturition is the chief argument advanced by those who are opposed to the conservative operation. Relatively speaking, there is a fair proportion of cases in which rupture has occurred. For example, ruptures have been recorded by myself, 1 Guillaume,- Kob- lanck, :J Woyer, 4 Target, 5 Galabin, Everke, 7 Meyer," Eckstein, 9 Prusmann, 10 Convelaire, 11 Werth, 12 and a few others. The most important monograph on this subject is by Singer. 1:; In connexion with these cases, it is an interesting fact that in a large proportion the placenta was situated over the cicatrix of the previous Cesarean section wound. Without doubt, in many cases the rupture has resulted from imper- fect suturing of the uterine wound. As I have already pointed out, this mistake is very easily made, for the inner part of the wound tends to retract, and so the two surfaces are not completely and exactly brought together. But there is another factor no less important- viz.. infection of the wound. It is of prime importance, therefore, that the wound is most carefully stitched and heals by first intention, if the conservative operation is employed. Results to Mother and Child. As regards the results to mother and child from Cesarean section, I shall only consider cases of contracted pelvis, for one can hardly estimate the mortality from the operation in cases of eclampsia, accidental haemorrhage, etc. Taking my own results, I and my assistants have performed the 1 Journ. Olst. and Gyn. Brit. Empire, November, 1904. 2 Zent. f, Gyn., 1896, p. 1286. 3 ' Uterus Bupture,' 1896. 4 Monat.f. Gel. u. Gyn., 1897, Bd. vL, p. 192. " J Trans. Lond. Obst. Soc, vol. \lii., 1900, p. 262. ,; Ibid., p. 248. 7 Monat. f. < i<'li. a. Gyn., 1901, Bd. xiv., p. 637. a Zent.f. Gyn., L903, p. 1416. '■' Ibid.. 1904, p. 1802. 111 Zentf. (lib. a. Gyn., 1905, Bd. lv., p. 415. 11 Zent. de Gyn., 1906, p. 148. 12 Zent.f. Gyn., 1D00. p. 565. 13 ' Des Cicatrices Cesariennes Abdonrinales Classiques,' Paris, 1909. CESAREAN SECTION 431 operation eighty times. Seven of the mothers died — a maternal mortality of 8'7 per cent. One of the deaths I have already referred to: it resulted from haemorrhage. The sutures of the uterine wound came undone. Another resulted from acute pneumonia on the fourth day after operation. A large window in the ward in which she was placed was blown in, and she was transferred to another ward. A few hours after she had a rigor. The other five died from sepsis. The results of Continental operators are very similar. Olshausen 1 for 91 cases had a mortality of 9"8 per cent.; Schauta 2 for 158 cases a mortality of 5 per cent. ; and Leopold"' for 188 cases a mortality of 7*5 per cent. Some particularly good results have been obtained in this country, notably, by Gow, Barber, and Russell. But much more important than the bare narration of percentage mortalities are the results obtained from the operation performed under different conditions. This aspect of the subject has been gone into most fully by Amand Routh. 4 One of the most interesting tables in his monograph is Table IV. (p. 48) : Table showing the Mortality of Cesarean Operations for Contracted Pelvis where Details are given as to Possible Infectivity (1901-1910). Condition. Cases. Maternal Deaths. Percentage. A. Not in labour ... ... ... i 245).™ B. In labour, membranes unruptured 224/ C. In labour, membranes ruptured ... 1661 D. Frequent examinations or attempts -230 at delivery ... ... ... 64 j 18 | Uo 22J 11} ™ 10-8) -173 34-3J These figures demonstrate conclusively that Cesarean section per- formed upon women ' when frequent examinations or attempts at delivery have been made ' is a most dangerous operation for the mother. That being admitted, let us consider what are the alterna- tives : (1) Craniotomy — this treatment has been fully considered; (2) Extraperitoneal Cesarean Section. During the last two years much has been written on this subject in the German obstetrical journals. The history of the evolution and development of the opera- tion will be found in such monographs as those of Jeannin 5 and Doderlein. 6 But it is quite impossible to consider this aspect of the 1 Zent.fiir Gxjn., 1906. 2 Neumann, Arcliiv filr Gyn., 1906, Bd. lxxix., Heft 1, p. 1. 3 Arcliiv fiir Gyn., 1907, Bd. lxxxi., Heft 1. 4 Jov/rn. Obst. and Gyn. Brit. Empire, January, 1911. 6 L'Obstetrique, August, 1909. 6 Monat. f. Geb. u. Gyn., January, 1911. 182 OPERATIVE Mii'W mt:i;y subject here. As far a- my personal reading goes (I have no practical experience of the operation), the best procedure is that recommended by Doderlein. 1 This is really a modification of Latzko'e operation, hoderlein, instead of employing a Phannen.-teil's incision, makes an inciBion parallel to 1'oupart's ligament from the symphysis pubis to the anterior superior spine. He cuts through skin, fascia, and muscles, securing and tying any bleeding vessels. Having reached the lower cellular tissue, he pushes it aside and defines the lateral limit of attachment of the bladder, which he pushes over towards the middle line. The lower limit of peritoneum is not observed. He then renders the surface of the uterus (lower segment) clear by separating off the loose cellular tissue and securing any bleeding vessels. Having done this, he makes an incision into the uterus two fingers' breadth from the margin of the bladder. The child is extracted with forceps if the head is the presenting part, or by traction on the limbs if the breech presents. The placenta is expressed or removed by hand. The stitching of the uterine wound is very simple as the wall is so thin. A continuous catgut suture is employed. Doderlein employs a second layer of continuous suture, by means of which he brings some cellular tissue over the wound. He then closes the abdominal wound, having previously inserted a drain into the cellular tissue. Personally, I very much doubt if this method of extraperitoneal section will ever meet with much support, and this for several reasons : (1) It is a much more complicated operation. (2) It has not been proved that the maternal mortality is lower in infected or possibly infected cases. (3) It has not been proved that the uterine cicatrix, after this operation, is stronger than the cicatrix after the ordinary longitudinal incision. I I feel convinced that extraperitoneal Cesarean section will never give better results than the ordinary operation in infected cases, but I can imagine that there is a possibility that the uterine cicatrix may be sounder when made in the lower segment than on the active con- tractile portion of the uterus. If the advocates of this operation can prove that to be the case, then I will at once become a convert to the extraperitoneal section. (4) It has been suggested by Sellheim to establish a utero - abdominal fistula for drainage purposes, but few favour such a procedure. (5) Total or sub-total hysterectomy is certainly the soundest procedure ; but if the woman is young, it is surely a most unfortunate proceeding to remove her uterus. (6) Improvement in the technique of the operation. This is merely a personal suggestion. In these infected or ' suspect ' cases, I feel sure the uterus is often infected by dragging up the placenta, and more particularly the ruptured membranes, through the uterine wound. I 1 Monat. f. Oeb. n. Oyn. t January, 1911. CESAREAN SECTION 433 would suggest that in all cases, where the labour is advanced, and especially in possibly infected cases, the operator, after removing the child, should put on fresh gloves and separate the placenta ; and, instead of removing it by the wound, should push it down through the cervix. It might be quite useful to fasten the end of the roll of gauze to the umbilical cord and push the gauze down into the vagina, and by means of it drag the placenta out of the vagina. I have only carried out this procedure in two cases, but I believe that, with a high uterine incision and this suggested method of removing the placenta, it is possible that better results might be obtained, and the uterus might be saved. Post-mortem Caesarean Section. The performance of Cesarean section upon women who die during parturition or late in pregnancy is an operation of great antiquity ; indeed, its beginning is lost in mythology. According to the Lex Regia instituted by Numa Pompilius, it was decreed that the opera- tion was to be performed should the mother die during the later weeks of pregnancy or parturition. From the very earliest times, therefore, it has been appreciated that an attempt should be made to save the child, provided the child is viable, in all cases where the mother dies. Owing to the fact that, comparatively speaking, so few children are saved by post-mortem Cesarean section, it has been recommended at different times that the operation should be performed before the death of the mother actually occurs. According to Fasbender, this was first mentioned by Rodericus a Castro in 1603. The operation upon the dying has always been so repugnant, however, to both the friends and medical attendants that it has been performed com- paratively seldom. Apart from sentiment, there is everything to be said in its favour, so that it is not surprising that from time to time it should have been advocated. Kleinhans, 1 who discusses the subject very fairly, gives the following as the conditions which must be fulfilled before an operation is proceeded with : 1. ' The death of the pregnant woman must be imminent. It is essential that several doctors give a unanimous verdict to that effect. 2. ' There must be proof that the child is alive. Here also it is essential to have the examination and opinion of several doctors. 3. ' The Cassarean section, which is quickest and least dangerous for the child, is the operation indicated.' 1 Winckel's ' Handbuch,' 1906, Bel. iii., Teil i., p. 844. 28 [84 0PE1IATIVK MIDWIFF.KY Two comparatively recent papers on fche subject are those by I ►ohrn 1 and Fiith.'-' ln recent years ;i aumber of children have been saved by post- mortem Csesarean section, and that, too, after a considerable interval from the death of the mother. For instance. Weisswange described a case where the child was delivered alive nineteen minutes after the death of the mother. Very valuable experiments on rabbits were made by Kunge 4 many years ago. My own experience of post-mortem Cesarean section is limited to two cases — one done by an assistant in hospital, and the other by the practitioner who called me to the case in consultation. Neither of the children were saved, although in the latter case, where the mother died of heart disease, the child's heart was still beating feebly when it was extracted. As one would expect, the cases in which there is the greatest chance of saving the child are where the mother dies suddenly, and the operation is performed immediately. 1 Samml. Klin. Vortrdge, 1900, No. 274. 2 Zcnt.f. Gyn., 1905, p. 714. 3 Ibid., 1903, p. 298. 4 Zeit.f. Geb. u. Gyn., Bd. ix., Heft 2. CHAPTER XXVII INDUCTION OF PREMATURE LABOUR To whom belongs the honour of first suggesting the operation of induction of premature labour is uncertain, and the difficulty of dis- covering this is rendered all the greater by the fact that induction of abortion for grave conditions threatening the mother was performed in very early times. But from the beginning of the Christian era, discouraged by the Church, it ceased to be practised almost entirely amongst Christian peoples. With the revival in midwifery, and the placing of the latter once again upon a scientific basis by Pare and his pupils, artificial inter- ruption of pregnancy for conditions threatening the mother came to be recommended. For example, in certain severe cases of haBinor- rhage Guillemeau recommended and practised emptying the uterus. Earlier than that, even, we have in Germany the distinguished mid- wife Siegemundin recommending rupture of the membranes through the placenta in placenta prama. For other complications, such as valvular disease of the heart, nephritis, etc., the operation is of recent date. But there is a condition which interests us above all others, as furnishing an indication for the induction of premature labour — viz., a medium degree of pelvic deformity. The history of the operation in this connexion is well known. In the year 1756 there was a meeting in London of the most distinguished obstetricians of the day to discuss the morality of induction of premature labour in contracted pelvis. The finding of the meeting was in favour of the operation, and shortly afterwards Macaulay performed it for the first time. Doubtless it had been talked about prior to that gathering, not only in Great Britain, but also in France, Germany, and Italy. Be that as it may, it was first performed in Great Britain, and, what is more, for many years it was only in our country that it was practised. In France, owing to the opposition chiefly of Baudelocque, the treatment was condemned ; and so strong was his and his pupils' antagonism 435 186 OPERATIVE M1I>YYI1T.I;Y that it was not until 1881 that it was performed there. In Germany it was accepted earlier, for Wenzel performed it in 1809. Indications for Induction of Premature Labour. What strikes one in reading the literature on this subject is the greal differences of opinion held by obstetricians, especially the extreme position so many of them take up with regard to each of the several indications, and how often apparent inconsistency is evidenced, extreme licence being allowed in one condition, and equally extreme restrictions being laid down in another. The indications for induction of premature labour or abortion may, for convenience' sake, be divided into obstetrical and medical. Tnder obstetrical I would place all pathological conditions in the mother or child which render delivery at term dangerous, or necessitate the adoption of an operation of greater seriousness than the one we are considering. Thus, in this group I place contracted pelvis and undue size of the fcetus. It will be observed that I have not included con- tractions and malformations of the soft parts, nor tumours of the uterus, ovary, etc., for all accoucheurs are agreed that induction of labour in such conditions is rarely, if ever, advisable. But let us consider the medical indications first. These I would say are conditions in which, owing to disease, it is felt that the pregnant condition is endangering the life of the mother or child. On the maternal side there are in this division an enormous number of diseases, but they may be arranged in three groups: (1) Acute diseases occurring during pregnancy ; (2) chronic diseases associated with pregnancy ; (3) diseases peculiar to pregnancy. On the fcetal side, its habitual death in the later weeks of preg- nancy, and the protraction of pregnancy beyond the normal ten lunar months and unusual size of the fcetus are the conditions which call for consideration. 1. Acute Diseases occurring- during: Pregnancy. — The induction of premature labour or abortion is almost never indicated in acute febrile conditions. Doubtless, in many of these acute diseases, especially if the type is severe and the temperature runs high, an early induction of labour would result in some children being saved, but it would also with equal certainty be followed by a higher maternal mortality. It is, therefore, the universal opinion of both physicians and obstetricians that the interfering with pregnancy, except in most exceptional cir- cumstances, is decidedly contra-indicated. But it is just regarding these exceptional circumstances that an opinion is desirable. Speaking in a very general way, I would say that induction of labour is indicated under the following circumstances — if with a dead child in utero there INDUCTION OF PREMATURE LABOUR 437 is evidence of septic absorption occurring from it. This, of course, is very rare if the membranes are intact ; indeed, as far as I can remember, I have seen only one case. Again, if the size of the dis- tended uterus is interfering with the cardiac and respiratory functions, the operation must be considered. In this connexion, however, it must not be forgotten that a labour puts a very severe strain upon a heart embarrassed by an acute febrile condition, especially if one forcibly dilates the cervix. In such cases, therefore — and they must be very few in which labour has to be induced — I feel inclined to favour the more rapid method of emptying the uterus by incising the ■cervix. Should the woman not be able to stand such an operation, simple rupture of the membranes might give partial relief. There is one other matter which comes for consideration here. In the case of a viable child, should labour be induced in the interests of the child if the mother is evidently dying ? It is hardly necessary to say that it is extremely trying to an operator's feelings and senti- ments to operate upon a dying woman when he is not performing the operation in her interests. In spite of that, however, I think it is his duty to do the best for the child, and consequently to empty the uterus before the mother's death rather than wait and do it post mortem, when there will be very little chance of saving the child. This same question was also considered in connexion with Cesarean section on the dying (Chapter XXVI.). It is hardly necessary to say that acute conditions such as appendicitis and intestinal obstruction must be dealt with in exactly the same way in the pregnant as in the non-pregnant. One would never think of inducing labour in such conditions. 2. Chronic Diseases complicated by Pregnancy. — As might be expected, induction of labour or abortion is more often called for in cases belonging to this group. But while that is so, we find great differences of opinion amongst writers regarding the indications for such radical treatment. In the next group to be considered, 'diseases peculiar to the pregnant condition,' we shall find much greater uniformity of opinion, for there labour is induced when all other means fail to arrest the downward progress of the patient. With chronic diseases, however, the same downward progress is not as easily appreciated, and so the difficulty of deciding is greater, and •taxes more the operator's judgment. The chronic diseases most commonly found associated with preg- nancy are renal cirrhosis and valvular disease of the heart. Although it is universally agreed that neither of these conditions per se is a sufficient indication for the induction of either premature labour or abortion, with each of them the operation may be necessary, when, in 188 <>n:i:.\T!\ k mii>\\ n r.i;v spite of the ordinary treatment, rest in bed. dieting, and the adminis- tration of suitable drugs, the patient's condition does not sufficiently improve. With chronic nephritis one is inclined to interfere earlier, and not to give the child so much consideration, seeing that its life i- 80 very precarious and its death and premature expulsion so frequent. Therefore, when pronounced symptoms, such as severe headache, disturbance of vision, etc., develop in spite of treatment, labour should be induced without delay. Even prior to these symptoms developing a progressive diminution in the quantity of urine and in the output of urea call for the operation. In this connexion must be mentioned ' retinitis albuminuria/ which in the chronic variety is a serious complication. 1 understand, however, that the prognosis from the ophthalrnological point of view is very good in such cases, and that induction of labour is seldom necessary on account of any permanent damage to vision resulting. As regards chronic valvular disease of the heart it is different, for in that condition there is a great danger during and after parturition of pronounced cardiac failure. I have several times induced labour for cardiac disease, but always with considerable anxiety, for although the patients, with one exception, have stood the labour well, one or two have died a few days later. Often for the first twenty-four or thirty-six hours in such cases there is marked improvement, to be followed in a few days by an aggravation of all the symptoms of cardiac failure, which steadily increases in spite of all one's efforts to arrest it. I am, therefore, very loath to induce labour in valvular disease, unless I am compelled to do so owing to the patient becoming steadily worse in spite of treatment. Most recent obstetric writers of experience are also of this opinion. Many of them refer to the greater safety of emptying the uterus in the early months, and I am at one with them in that. It is an advantage in this condition to empty the uterus rapidly, with as little shock as possible to the patient. Consequently, this is distinctly one of the conditions in which I believe vaginal Cesarean section has a place. In recent years several monographs have appeared on the various anaemias and other blood diseases in pregnancy, and the indications for the induction of premature labour in such conditions have been fully discussed. Herman, 1 for example, considered leukaemia and pregnancy, and came to the conclusion ' that in leukaemia with preg- nancy the induction of premature labour or abortion is indicated as a therapeutic measure.' Many years ago Gusserow and Graefe referred to the great danger of pregnancy in women the subjects of pernicious 1 Trans. Lond. Obst. Soc, 1901. INDUCTION OF PREMATURE LABOUR 439 anemia. Recently, however, Schauta has insisted that little benefit results from emptying the uterus in these cases. Another disease which, along with others, I have found very seriously aggravated by pregnancy is Graves' disease, and I certainly agree with those who would induce labour if this complication is pro- nounced, particularly as the disease is very intractable after pregnancy. Williamson 1 has recorded a case where labour or abortion was induced four times. Many obstetricians have been disappointed, however, with the benefit derived from emptying the uterus. Chorea gravidarum is another condition which occasionally necessi- tates the operation. Amongst the most valuable contributions in the English language are those of Buist, 2 Dyce Duckworth, 3 Wall and Andrews, 4 and Shand. 5 With the exception of Wall and Andrews, Shand, and a few others, most authorities are agreed that induction of labour should be resorted to when the movements are extremely violent, and are uninfluenced by treatment, and when extreme sleep- lessness, and especially mania, supervene. In this disease, as in others presently to be considered, the operation must not be too long delayed, a mistake which is so often made. 3. Diseases Peculiar to Pregnancy. — The large proportion of such diseases are toxaemias, and one can generalize to this extent, and say that the induction of labour or abortion becomes necessary if, in spite of treatment, the patient steadily loses ground and her life is seriously endangered. The usual mistake in practice is for the medical attendant to postpone the operation too long. This is especially the case with hyperemesis, the most common of all the conditions calling for this radical treatment. It is quite impossible to lay down hard-and-fast rules as to when abortion should be induced in hyperemesis. If, however, after general and local treat- ment, and complete rest to the stomach by rectal feeding, the retching continues, or returns whenever any food is taken by the mouth, and if the pulse becomes progressively more rapid, the time for emptying the uterus has arrived. Pinard is more definite, and relies chiefly upon the pulse, and recommends induction if it rises above 100. But such a simple and exact rule cannot be followed. How far the increase in the ' ammonia coefficient ' (percentage of nitrogen put out as ammonia compared with the total nitrogen of the urine) is of value as indicating the seriousness of the condition one cannot at present say, but Williams 6 believes 10 per cent, indicates danger. 1 Trans. Lond. Obst. Soc, 1904, p. 95. 2 Trans. Edin. Obst. Soc, vol. xx. 3 St. Bartholomew's Hospital Reports, 1903. 4 Journ. Obst. and Gyn. Brit. Empire, June, 1903. 5 Ibid., April, 1907. 6 Amer. Journ. Med. Sciences, September, 1906, p. 343. 110 OPERATIVE MIDWIFERY With hydramnios, another condition which often causes the preg- nant woman great discomfort, one has less hesitation in bringing on Labour, for the child or children (plural pregnancy is common) are often very weakly. It must not he forgotten, however, that when hydramnios develops in the later weeks of pregnancy, the children may he horn quite healthy and strong. Early and acute hydramnios usually calls for interference, and at all times the pregnancy must be interrupted if the condition is causing severe general disturbance and impairment of the respiratory, circulatory, and digestive functions of the mother. As regards affections of the kidneys in pregnancy, one meets with them in several different forms. Chronic cirrhosis has been already referred to. What, to all intents and purposes, is an acute nephritis may attack the pregnant woman. The features of it are its sudden onset and the presence of large quantities of albumin and blood in the urine. Then there are the cases of ' pregnancy kidney,' with often only a slight amount of albumin, but an amount which is very variable, and often suddenly increases. In many of these cases the albumin disappears soon after delivery ; sometimes in two or three days it is entirely gone. In a certain number, however, it continues for long after parturition, sometimes for weeks and months. Indeed, I know of two cases in which it has never disappeared, and the women are now the subjects of chronic nephritis. With each of the varieties mentioned eclampsia may develop, and with the two first it may develop very suddenly. If, however, the patients are under observation, and are suitably treated, it can generally be wardeo off. Not infrequently the foetus dies, and labour supervenes. "When eclampsia does threaten, as is evidenced by severe headache, epigastric pain, and amaurosis, and the ordinary means to avert it do not avail, induction of labour must be had recourse to. In connexion with the subject of induction of labour and albu- minuria, to my mind the most difficult cases to come to a decision upon are those in which, in spite of treatment, albumin continues in considerable amount. These are the cases when it often continues for long after labour, and sometimes even becomes chronic. In such cases one has to consider induction, not so much because of the danger of eclampsia, which, although sometimes occurring, can generally be averted by suitable treatment, as the danger of a chronic cirrhosis of the kidney being established. I cannot express a decided opinion upon these cases, but I have once or twice seen such slow recovery — months of albuminuria after delivery, and in two cases chronic cirrhosis established — that a few INDUCTION OF PREMATURE LABOUR 441 more similar experiences would decide me in favour of induction of labour whenever the child was viable. The difficulty, of course, in such cases is that one does not know beforehand whether or not the albumin will be slow in disappearing. Personally, I have always found it slow in going if it continues in distinct amount for some time before labour. Another condition which calls for induction of lahour or abortion is icterus, when it becomes pronounced and is attended with progres- sive general disturbance. Habitual Death of the Foetus in Later Weeks of Pregnancy — Protraction of Pregnancy and Unusual Size of Foetus. In these conditions one often obtains satisfactory results from the operation of induction of labour. With habitual death of the foetus in the later weeks of pregnancy, induction shortly before the date at which the foetus usually dies (be syphilis the cause or not), often proves very satisfactory. With our present knowledge there is no exact means of diagnosing when the life of the foetus is in danger. We trust to arriving at the date from previous experience, and we make sure of not inducing after the death of the child by auscultating the foetal heart. In this connexion I would mention one case in which the slow death of the child in utero was observed, although I was unaware at the time I was doing so. The mother had been most unfortunate in her pregnancies, for two ■ended in dead-born children in the later weeks of pregnancy and two in abortion. Syphilis could be entirely excluded. During the preg- nancy under consideration I insisted upon almost complete rest in bed, and administered chlorate of potash. One day, about four weeks from term, on listening to the foetal heart, I found that its character had quite altered. One sound had become very much accentuated, and, indeed, it very closely resembled the accentuation of the second sound which occurs in chronic Bright's disease. I made this out on a Monday, and on the Wednesday and Friday it was even more marked. •On the following Monday, when I listened, no sounds could be heard, the child was dead. Labour came on about a week later, when a macerated child was expelled. This is the only case of the kind I have had an opportunity of observing, nor do I recollect of having read any similar observation, so that I can offer no opinion as to the frequency or value of accentuation of one of the foetal heart sounds as indicating embarrassment of the foetal circulation in pregnancy. In protracted gestation, without doubt, the child frequently suffers, 142 OPEEATIVE Ml DWIFERI and even dies. It is desirable to induce labour, therefore, if protrac- tion of pregnancy has occurred in a previous gestation, or if in any protracted pregnancy the child shows signs of having its circulation embarrassed. Und/ue size of the child is sometimes an indication for induction of labour. As a rule, if there has been a previous experience of difficulty, one is perfectly justified in having recourse to such treatment at a subsequent pregnancy, for each individual bears a fairly constant type of child, and it is a peculiarity of some women to have very large children. Prochownik has claimed that he is able to keep down the size of the child by carefully dieting the mother in the later weeks of pregnancy. This is questioned by later observers. As every one is aware this is a very ancient idea. In the cases where I have had to consider the advisability .of inducing labour because of the large size of the child, I have always tested the relative size of the fcetal head and maternal pelvis in the thirty-sixth or thirty-seventh week. If at that time I found the head too large for the pelvic brim, I have induced labour : if not, I have allowed the pregnancy to continue for another fortnight and again examined. Induction of Labour in Contracted Pelvis. As I have already said, the greatest differences of opinion exist re- garding the value of induction of labour in contracted pelvis. It may seem strange that this should be so, for the results of many thousands of cases upon which to base a judgment of the operation are now available. But, as in so many other conditions, the difficulty in allocating the treatment its exact value is rendered impossible by the attitude of extremists and partisans. The advantages of induction of labour are that it is an operation very easily performed, and, if carried out carefully, is associated with a very small maternal mortality. Indeed, theoretically, the maternal mortality should be nil : but, in spite of all care, occasionally infec- tion occurs, and now and then a death from septicaemia follows. This, however, I would place at not higher than 0'6 per cent. Among my twenty-two cases in private and hospital practice in the years 11)01 to 1!)0(), inclusive, there was no death. The great objec- tion to the operation is the high fcetal mortality. In my twenty-two cases I had a fa'tal mortality, immediate and late, of 36 per cent., and that in spite of the fact that I took every possible care in selecting my cases. In judging of the value of induction of labour, one must take the late as well as the immediate mortality. The terms explain INDUCTION OF PREMATURE LABOUR 443 themselves. Immediate implies that the children are born dead ; late, that they die within two or three weeks of their birth. If one only thinks of it, many circumstances favour a high foetal mortality. First and foremost is the fact that the child is premature, and so is more delicate and difficult to rear. Especially is this the case amongst the poorer classes, who are unable to give the premature child the necessary amount of care and attention it requires. Then there is the great difficulty in determining the age of the child in utero. This, also, is especially seen in hospital patients, who have only a vague recollection of such dates as the last menstruation, the onset of morning sickness, quickening, etc., from which one estimates the age of a pregnancy. It is no uncommon occurrence for women to come to hospital with the statement that they have reached ' full time,' and yet to find that they are only in the eighth month ; or to give the story that they are only eight months pregnant, and a day or two after they are delivered of full-time children. In private practice, however, this difficulty does not arise so often. If conditions are favourable, and the different parts of the foetus can be palpated, one can form a rough estimate of the size of the child. One i may even measure the length of the foetal ovoid, which works out about half the length of the child, and from that determine the age of the ! foetus. But it is a very approximate estimate that can be made by such a rough-and-ready calculation, and it is really of no practical value. It is generally stated that twenty-eight weeks is the viable age, and it would appear from recorded cases that children have been reared born at that age. It has been found by all, however, that below the age of thirty-four weeks the chances of the child surviving are very small indeed ; and, after all, it is upon that that we must base our estimate of the value of the operation. I feel convinced, from my own experience and from the records of others, that induc- tion should be performed not earlier than the thirty-fifth or thirty- sixth week. The statistics of the Glasgow Maternity Hospital bear this out. Until a few years ago it was the custom in the hospital to induce labour even earlier than the thirty-fourth week, the date which by almost general consent is now admitted as the earliest at which the operation should be performed. We have given that practice up, however, and personally I have never intentionally induced labour before the thirty-fifth week. It will be seen at once from Black's paper on ' Induction of Labour ' in the Glasgow Maternity Hospital, 1896 to 1898, 1 how fatal as regards the interests of the child induction earlier than the thirty -fourth week 1 Trans. Glas. Obst. and Gyn. Soc, vol. ii., p. 121. 441 OPERATIVE MIDWIFERY is. Taking Black's cases, where the pelvis was 3 J to 3 inches, the foetal mortality when induction was performed before the thirty-fourth week was 80 per cent., and after 40 per cent. Here arises a point of practical importance. In looking over the older reports in the ward journals of the hospital, it is often not a little difficult to tell what the exact age of the fo-tus was when labour was induced, for the operation is generally stated as having been performed at such and such a month. It is most undesirable to speak of months in pregnancy; one must reckon by weeks — for when months are mentioned, who knows whether lunar or calendar months are meant, or whether the beginning or the end of the month is referred to ? As influencing the results of induction of premature labour for pelvic deformity, we must now consider another all-important factor — the pelvic capacity. It is perfectly evident that as one passes from the slighter to the more pronounced degrees of pelvic deformity the foetal mortality must gradually increase, until it becomes so high that the operation is futile, and should not be considered. It is seldom necessary to induce labour when the pelvic deformity is very slight, say a conjugata vera of 3f inches (8'3 centimetres), unless the foetal head is of unusual size. That is determined by estimating the relative size of foetal head and maternal pelvis. As regards the lowermost limit let us see how matters stand. Bar 1 states that in fourteen cases where the conjugate was from 7 centimetres or under, and labour was induced, the fo-tal mortality was 85*7 per cent. Black, in his record of fifty-two cases, mentions fourteen in which the conjugate was from 2h to 2| inches (6*2 to 7*2 centimetres). In these cases the early and late mortality amounted to 78*5 per cent., a mortality very comparable to that given by Bar. These figures are sufficient to prove how hopeless the operation is when the pelvis is below 3 inches (7*5 centimetres). So convinced of this have obstetricians become that, without exception, all are agreed that induction should not be performed in pelves of such small dimensions. Induction of labour should not be considered, therefore, if a patient has a pelvis with a conjugata vera of less than 3 inches (7*5 centimetres), except in the extremely rare cases where, after carefully estimating the size of the head and the pelvis, the head is found so unusually small that it will pass through the pelvis without much difficulty at the thirty-sixth week. Let us now turn to cases in which the pelvis is a little larger, and where there is some prospect of the operation being successful. Here is a table of my twenty-two cases, showing the immediate and 1 ' Le<;ons cle Pathologie Obstetricale,' 1900, p. 147. INDUCTION OF PREMATURE LABOUR 445 late fcetal mortality in the different 'degrees of pelvic deformity : the terms early and late have been already explained (p. 443). Table of Author's Cases of Induction of Labour in Contracted Pelvis, 1901-1906. Conjugata Vera, 3" (7-5 era.). Conjugate Vera, Z\" (S-l cm.). Conjugate Vera, 3J" (S7 cm.). Total cases, 9. Fcetal mortality (early and late), 44 per cent. Total cases, 9. Total cases, 4. Fcetal mortality (early Fcetal mortality (early and late), 33 per cent. and late), 25 per cent. My experience with a pelvis of 3 to 3 -J- inches (7 - 5 Co 7*8 centi- metres) is a foetal mortality of 44 per cent. Bar 1 found in fourteen cases with a conjugate of 7"1 to 8 centimetres that the mortality, (early and late) was 53*3 per cent. Pinard, 2 for the same deformity gives for sixteen cases an immediate and late mortality of only 33*3 per cent. Kronig, 3 for Zvveifel's Klinik, puts it at 57'4 per cent. Taking Leopold's 4 two groups, which together nearly correspond to those of Bar and Pinard, we find in his twenty-one cases an immediate and late mortality of 57 per cent. Black's figures for practically the same measurements give 61 per cent. ; but, then, in two cases which died the labour was induced decidedly before the thirty-fourth week. If these two cases are excluded, so as to bring the conditions as nearly as possible comparable with the others, Black's results work out in eleven cases at 54 - 5 per cent, mortality, a figure almost identical with those of Bar, Leopold, and Kronig. Every one, I think, must admit that these results are very dis- appointing. Even Pinard's of 33 3 per cent., so much better than the others, is a huge fcetal mortality. So much has this impressed Bar that he states he has now given up inducing labour if the pelvis is less than 8 centimetres (3J inches). Kronig points out a most interesting fact, that with pelves of the deformity mentioned the foetal mortality was only 63 per cent, where the labour was allowed to go on to term. Recently Baisch 5 has come to a similar conclusion. Taking, now, cases where the pelvis is slightly larger, one finds, where the conjugata vera is 3| to 3h inches (8'1 to 8'7 centimetres), a distinct improvement as regards the foetal mortality. My results for 1 Op. cit. 2 Arm. de Gyn. et cVObst., 1902, Bd. xxxv. " ' Die Tnerapie beirn engen Becken,' Leipzig, 1901. 4 ' Arbeit aus der Koniglichen Frauenklinik,' Dresden, Bd. i., p. 95. 5 'Reformen der Therapie des engen Becken,' Leipzig, 1907, p. 120. in; OPERATIVE MIDWIFERY :;] inches (8'1 centimetres) arc 88 per cent., and for 3J inches (8*7 centimetres) 25 per cent. Bar found that, with a conjugata vera of h-1 to 8*5 centimetres, the foetal mortality was 31*5 per cent. Leopold for the same figures gives his as 25 per cent. But even these results are not very encouraging ; indeed, if I compare them with my results from forceps (23 per cent, and 15 per cent, respectively), it is at once evident that the child has a much better chance <>i surviving in this particular degree of "pelvic deformity it the pregnancy is left alone ami labour allowed to terminate spontaneously, <r. P . Acute mania. Dilatation with fingers, followed by version and extraction. Operation took fifty minutes. Kecovery complete. These have been casually chosen from amongst my cases of manual dilatation. In my experience the shortest time taken to dilate manually, and deliver a woman not in labour, has been fifteen minutes. This was a case of contracted pelvis, in which I intended to induce labour, but finding the cervix ver/y soft, I dilated and extracted the child. The longest time was fully two hours. Taking my cases, I would sa} r that, on an average, to dilate and deliver a multipara not in labour, and with the cervix not obliterated, an hour at least is required : and to do the same in a primipara about an hour and a half. I do not include, of course, cases of abortion. In such cases a very considerable time is often necessary to dilate the cervix manually ; indeed, it is sometimes quite impossible, as I indicated in the previous chapter. As I shall point out later, when speaking of expanding metal dilators, dilatation is distinctly more difficult and more liable to be complicated with laceration in the early months of pregnancy and if the cervical canal is unobliterated. Dilatation by Means of Expanding" Tents. — Dilatation by means of expanding tents is a slow process, and occupies hours instead of minutes. It is suitable for cases in which there is no hurry to empty the uterus. Laminaria tents are the only variety now employed (Fig. 203). They may be sterilized by dry heat or by soaking in 1 in 1,000 perchloride of mercury and alcohol for forty-eight hours. Hartmann's tents in sealed glass tubes are the most convenient. The method of proceeding when tents are employed is as follows : The patient, having been anaesthetized, should have a further thorough disinfection of the external parts. The pubes should be shaved, and the vagina washed out with some soapy disinfectant, such as lysol. ACCOUCHEMENT FORCE 1 01 The cervix is then seized with a pair of vulsellum forceps, the anterior and posterior vaginal walls being retracted if necessary. Before introducing the tent I have usually employed the ordinary dilators of Hegar, which must be pushed in until one feels the point has passed beyond the internal os. No great force should be used ; if that is necessary, one should desist. The largest tent which can be introduced is placed in the cervix. In doing this care must be taken that the tent is not pushed in too far. This is especially apt to occur when the gauze packing is being placed in the vagina. In order to prevent this accident a loop of strong silk should be passed through the tent in place of the thin cord generally found there. Through this loop is passed a piece of gauze about half a yard long, which, pushed into the fornices, anchors the tent and prevents its displacement. The rest of the vagina is packed firmly with gauze. Sometimes there is not a tent large enough for the cervix ; in such cases one can usually dilate with the fingers, but if this should be impossible, two or more tents can be Fig. 203. — Laminaria Tent. used together. Larger tents made of several pieces of laminaria glued together cannot be recommended. Tents should be left in for twelve hours at least. On their removal, the cervix should be sufficiently dilated to permit of the fingers being introduced, and the further dilatation and extraction of the child being proceeded with. If that is still impossible, several tents may be again inserted, and left for another twelve hours; or a metreurynter may be introduced. Dilatation with Hydrostatic Dilators — Metreurynter. — At the present time ' metreurysis ' is much in favour, and many important contributions to the subject will be found in recent Continental and American literature. Rubber bags, like tents, dilate the cervix very slowly. Another objection is that they can only he used after the cervix has been sufficiently dilated to allow of their introduction. The method is consequently quite unsuitable for cases in which rapid delivery is of primary importance, and for those cases of difficult dilatation to which I have already referred. Without doubt, the hydrostatic dilator of Champetier de Ribes or Muller is the best. Most modern English writers, such as Herman, 162 OPKIIATIYK MIDWIFERY Jellett, and Tweedy, favour it. Barnes's rubber bage Pig. 204) 1 have always found of little real service when the cervix is at all rigid, for they simply balloon up inside the uterus. In the Maternity Hos- pital, therefore, we have ceased using bhem. A more complicated metreurynter is that of Pomeroy (Fig. 205). The metreurynter of ("hanipetier de Ribes is the mosl serviceable Pig. 206). It is pear-shaped, and made of waterproof silk. From the apex a rubber tube passes, and through this the bag is tilled with sterile solution. Before use it should he thoroughly tested by firm pressure hetween the hands, as it is liable to hurst if at all old. Only the other day one burst in my hands when I tested it. Bursting of Fig. 204. — Barnes's Hydrostatic Dilator. the bag after its introduction into the uterus has been recorded by several writers. The mode of procedure in employing a Champetier de Ribes hydrostatic dilator is as follows : The patient, being anesthetized, is brought to the edge of the bed and placed in the lithotomy position. The pubes, vulva, and vagina are then thoroughly cleansed. If necessary, the cervix is steadied by vulsellum forceps. Having grasped the bag with a long pair of clamp forceps, or the special forceps for the purpose (Fig. 207), the bag is carried up into the uterus and the forceps withdrawn. I have occasionally found it easier to insert the bag without employing the forceps, simply using my fingers. The bag is then slowly filled with sterilized solution. The tubing is then wrapped up in gauze, and the patient is put back to bed. Generally one allows the natural forces to expel the bag ; but if it is deemed necessary to hasten the dilata- tion, traction may be exerted on the tubing through a cord attached ACCOUCHEMENT FORCE If,:', to a weight brought over the foot of the bed. A very light weight is all that is necessary, say a couple of pounds. I have already referred (p. 451) to the question whether or not the membranes should be ruptured before the bag is inserted. When a large Chanipetier de Ribes bag has been expelled, the os is sufficiently dilated to allow the passage of an average-sized child. If, however, the child is larger than normal, the cervix will require to be more widely dilated with the hand. In my experience it is usually about twelve hours before the bag is expelled. Naturally, in a multipara, wdiose cervix is soft and dilatable, it occurs sooner than in a primipara. Dilatation with Expansile Metal Dilators. — Of all methods of dilating the cervix, none is so rapid as that carried out by means of expansile metal dilators. Pronged dilators are of ancient date, and at different times have Fig. 205. — Pomeroy's Metreurynter. been brought forward and advocated. The most recent revival of the instrument occurred in 1890, when Bossi introduced the one which in the last three or four years has been so much discussed. Bossi's instrument consisted of three prongs, but later a fourth was added (Fig. 208). Frommer's modification of the instrument consists of eight prongs, which theoretically was considered a distinct improve- ment, for it allowed of pressure being more equally distributed round the margin of the os. In practice, however, in common with others, I found it inferior, for it did not allow the operator to get his fingers between the prongs to feel how the cervix was stretching. The only real improvement in Bossi's latest pattern is De Seigneux's instru- ment, 1 with its graduated caps and pelvic curve (Fig. 209). A very 1 Zent. f. Gyn., 1905, p. 717. m OPERATIVE MIDWIFER1 simple dilator is the eoarteur of Tarnier (Fig. 210), which slowly expands by the steady compression of the elastic hands at the end of the handles. The operation of dilating the cervix with expansile metal dilators is not difficult. There is, however, great danger of tearing the cervix, and it is upon the extent and frequency of this occurrence, as we shall see, that criticism must be based. Fig. 206. — Champeticr de Ribes' Bag fully expanded. The preparation of the patient is as for any vaginal operation. She should be deeply anaesthetized, otherwise the shock is consider- able. The blades of the instrument should then be passed through the os. The os must, therefore, be sufficiently dilated to allow of this being done. I would not advise employing the instrument with- out the caps unless there are no Hegar's dilators at hand. "When the FlG. 207. — Cliampetier de Ribes' Metreurynter (collapsed), with Forceps for introducing it. cervix is obliterated there is no difficulty in getting the instrument introduced ; but when it is still not taken up there is considerable difficulty. Most operators are now agreed that the instrument is unsuitable in these latter cases. If it is employed, especial care must be taken to have the edge of the flange on the cap well beyond the internal os. I do not advise the seizing of the cervix with vulsellum ACCOrCJIKMKXT KOIiCK Um forceps while the blades are being introduced, for by pulling on the cervix one elongates it, and so renders the introduction of the flanges beyond the os internum difficult. By pressing the instrument well back against the perineum, the prongs slip into their places more readily. Having placed the instrument in position, as described, the handle ^^^ fes^ fe^X- >-^££j Fig. 208.— Bossi Fronged Dilator (Open). which expands the blades should be turned. This must be done very slowly, and only in the intervals between the pains. I usually turn the handle not more than a sixth of a circle at a time, and at the later stages even less than that. One should always desist during a uterine contraction, and even sometimes turn the handle backwards, to take the strain off the cervix for a moment or two. Every now and again, also, one should feel between the prongs how the cervix is Fig. 209. — De Seigneux's Uterine Dilator. yielding, both on the cervical and vaginal surfaces. In my experience, when tears have occurred, they hare always taken place in the lateral walls, and usually first on the cervical, not on the vaginal surface. I remember one case in which a bad laceration occurred, when I suddenly felt the resistance of the cervix disappear. I found no tear in the vaginal surface, but a moment or two afterwards it was also 30 mi; Ol'KHATIYE MIDWIFERY found torn. The graduated caps of Seigneux's instrument without doubt give a wide surface of pressure, and to some extent lessen the risk of tearing. The time taken to screw up the instrument to the required amount depends upon the condition of the cervix. If it is a flabby cervix, twenty minutes may suffice ; but if it is hard, and especially if it is not taken up, more than twice that amount of time may be necessary. It is only after some experience that one can gauge this properly ; at first one is liable to be in too great a hurry. I have not said any- thing about changing the position of the instrument so as to alter the points at which the caps press on the cervix, as has been recommended by some writers, for the latest instruments have a pelvic curve. The extent of dilatation required depends entirely upon the size Fig. 210. — Ecarteur of Tarnier. of the foetus. When the index is at 10, one may usually stop, unwind the handle, and remove the instrument, for such dilatation will permit a small child readily passing through. After removal of the instrument, one should note very carefully ij there are any lacerations, for there is no doubt that main/ of the tears which follow this method of accouchement force' result, not from the dilatation, but from the subsequent extraction of the child. Such, briefly, is the method of employing expansile metal dilators. Many have found them "most valuable. Doubtless the more enthu- siastic have been inclined to overestimate their importance, and to practically place no restriction upon their employment, just as others condemn them utterly. Amongst those who have tried to take an unbiassed view, and who have had some considerable experience of the different varieties of dilators, opinions are pretty uniform regard- ACCOUCHEMENT FORCE 467 ing the dangers, and how these are to be avoided. The principal danger is laceration of the cervix. Writing on the subject in November, 1903, x I mentioned four factors which influenced the occurrence of laceration : (a) The manner in which the dilatation is carried out. (b) The number of the pregnancy. (c) The degree to which the cervix has been taken up. (d) The age of the pregnancy. At the present time, with a very much more extensive experience of cases from hospital and private practice, I still am of opinion that these are the most important factors. I am now inclined to dilate much more slowly, and the most recent experience of obstetricians is the same. It should always be remembered that Bossi recommended twenty minutes up to one and a half hours. Then, again, although as a rule the cervix of a multipara yields better than that of a primi- para, if there are deep cervical lacerations from former labours, these tear very rapidly, and often before much dilatation. On two occasions I have witnessed this. On one occasion the laceration which resulted while I was dilating extended into the lower segment, and had to be packed with gauze before the haemorrhage could be arrested. But the other two factors are the most important — the degree of dilatation of the cervix and the age of the pregnancy. With a patient in labour and the cervix ' taken up,' dilatation with Bossi's or any other metal dilator is not difficult, and lacerations should be very infrequent and very slight. Some say, Why not use the hands in such cases ? Of course, there is no possible objection to doing so ; but it is infinitely more fatiguing for the operator, and is much slower. When the cervix is closed, and not taken up, it is a very different matter, and there is a general opinion now that metal dilators are unsuitable in such cases. Even if care and time be taken, the danger of severe lacerations is very great ; besides, the extraction of the child is often difficult, for the cervix grasps the child whenever traction is made upon it. The condition of the cervix should guide one. If it is soft and dilatable, then Bossi's instrument may in a few cases be employed safely. If, on the other hand, it is hard and rigid, and the uterus must be emptied quickly, I would strongly advise against employing it. But quite as important, although not as a rule so much appre- ciated, is the age of the pregnancy. The earlier the pregnancy, the greater the difficulty in dilating the cervix ; so much so that unless it 1 Trans. Glas. Obst. Soc, vol. iv., p. 167. 168 OPERATIC E M1DW1I i:i;V happens bo be abnormally soft, I have given up using metal dilators in the earlier months, and have chosen instead vaginal ('a san ion. The results obtained with metal dilators in this country— tb tor example, of Fothergill, Haultain, Ballantyne, Jardine, Armstrong, and others — are very satisfactory, especially in cases where they are employed when the cervix has heen taken up. The later figures from Leopold's Clinic in Dresden — those furnished by Ehrlich 1 — are also good. He puts severe laceration as only occurring in 1 per cent. <>f cases. There were, however, five not included where the laceration w T as quite decided, although not severe. A most interesting paper by Lichtenstein, 2 taking up the later effects of dilatation with metal dilators in Leopold's Clinic, appeared a few years ago. It was an answer to Bardelehen's unfavourahle criticism of the treatment. Lichtenstein succeeded in getting eighteen of the old cases to come hack and be most carefully examined. The two cases in which there had heen a severe laceration had healed fairly satisfactorily. "With few excep- tions, the women were remarkahly well. Some had slight catarrh, and one had retroflexion ; but such occurrences may follow even normal labours. There was n<> evidence t<> show that expansile dilators judiciously employed caused future uterine disturbances. In the discussions on the subject, which took place at the Ver- sammlung der deutschen Gessellschaft fur Gynaecologie in 1907, and at the annual meeting of the British Medical Association in the same year, all who favoured metal dilators restricted them to cases in the later weeks of pregnancy where the cervix had heen already taken up. Enlarging 1 the Cervical Canal by Means of Incisions. Incisions of the Cervix. — Before considering the latest and most extensive method of incising the cervix, known as vaginal Cesarean section, I must refer briefly to the small incisions of the cervix which have been employed from early times in certain conditions, as, for example, rigidity of the cervix, and atresia of the cervix. It is a matter of historical interest that such incisions were recommended by Simpson 3 and others for uterine and vaginal carcinoma obstructing the parturient canal. In atresia of the os externum we have seen that a cervical incision should he made over the os, and labour allowed to proceed. In rigidity of the cervix, when that condition does not yield to opium or chloral, or the local application of cocaine, multiple 1 Archivf. Gyn., 1904, Bd. Ixxiii., Heft :;, p. 439. - Ibid., 1905, Bd. Ixxv., Heft 1, p. 1. 3 'Obstetric Works,' vol. i., p. 198. ACCOUCHEMENT FORCE 469 small incisions with scissors are .usually recommended. Sometimes these are sufficient, but on other occasions they are not, and deeper FlG. 211. — Incision of the Cervix where the latter is taken up, but the Os Externum is only slightly dilated. Dark lines show direction in which incisions should he made. incisions have to be made. These, however, should only be employed if the cervix is completely taken up. The illustration (Fig. 211) 470 OPERATIVE MIDWIFERY explains the direction of the incisions. Prior to employing them, the vagina and vulva are cleansed, as has been described, and the patient placed in the lithotomy position, and brought over to the edge of the conch. The advantage of this method of operation is that the uterus can be rapidly emptied, and with less shock than when a metal dilator or FlG. 212.— The Two Vulsellum Forceps applied to the Cervix. The dotted lines show direction of incisions. (The Year- Book Publishers.) the hands is employed. In certain cases — e.g., valvular disease of the heart — this question of shock is a very important one. Vaginal Caesarean Section. — Within the last few years incisions of 'a very much more extensive nature have been under consideration. The names of two obstetricians are connected with the subject — Diihrssen and Acconci. I do not intend considering who should have priority. Those interested in the question will find it fully discussed by Diihrssen. 1 Since Acconci's death, Di'ihrssen's name has come to i Winckel'a ' Handbuch/ 1900, lid. iii., Teil ii., p. 609. ACCOUCHEMENT FORCE 471 be almost universally associated with the operation. He first described it in 1895. His monograph, entitled ' Der Vaginale Kaiserschnitt,' appeared the following year. Since then he has published other papers, and made many communications on the subject. The operation is commonly known as vaginal Cesarean section, and certainly, from Diihrssen's description of the extensive incisions he Fig. 213.— Pushing the Bladder from Anterior Uterine "Wall. (The Year-Book Publishers.) makes, it must be admitted that the name given to it is not out of keeping with the magnitude of the operation. 1 The ease or difficulty in performing the operation of vaginal Cesarean section depends chiefly upon the size of the uterus and the age of the pregnancy. In the first half of pregnancy the uterus can be pulled down, and the uterine contents removed through a much smaller opening than is necessary if the pregnancy is more advanced. 1 The terra 'vaginal Cesarean section' is an old one; it was considered unsuit- able by Baudelocque (Heath's translation, vol. iii., p. 351). 472 OPERATE i: Mll-WH Kl;Y I will first describe the operation for the simpler cases, and then inchoate the more extensive incisions which may he necessary when the fu'tus has to he removed in the later weeks of pregnancy. The patient is placed in the lithotomy position, and the vulva and vagina thoroughly cleansed. With a retractor the assistant pulls Lack the posterior vaginal wall. The cervix is then seized laterally by two vulsellum forceps, which are replaced hy two ligatures, as the Fig. 214. — Edges of Uterus being drawn down and Scissors cutting the Lower Uterine Segment. (The fear-Book Publishers. latter take up less room. A transverse incision is now made across the cervix immediately below the reflection of the bladder. This trans- verse incision should embrace the anterior half of the cervix (Fig. 212). It is well also to make a longitudinal incision when operating in the later weeks of pregnancy. The bladder is then pushed out of the way with the fingers (Fig. 213), both in the middle line and at the sides. It is most important to separate the bladder completely. The anterior cervical wall, now bare, is split up the middle line by means of scissors ACCOUCHE Mi; NT FORCE 473 to the extent of permitting the^ fingers being introduced into the uterus (Fig. 214). The membranes now protrude, and if the opening into the uterus is of sufficient extent, these are ruptured, and the child seized by a foot and extracted. Even with a f\\ 1IT.I;Y As regards the indications for craniotomy in other conditions than contracted pelvis, little need be said. Obstruction of the parturient canal by cystic tumours of the ovary, myoma of the uterus, carcinoma of the cervix, is seldom an indication for this operation. It is almost always wrong to drag ;t child, even after craniotomy, past obstructions produced by such growths. It sometimes happens, however, where the rapid emptying of the uterus is of importance to the mother — as in certain cases of eclampsia, heart disease, etc. — that perforating the child facilitates the delivery. In these cases the operation should only be performed if the child is dead or dying, or is BO premature that there is no possibility of it living. I need not discuss — for it is referred to elsewhere — the operation of craniotomy in such conditions as ' locked twins,' ' double monsters,' or hydrocephalus. Prognosis. — The prognosis of the operation of craniotomy depends upon several circumstances, but the two conditions which influence it most are the degree of pelvic deformit}', and the previous operative interference and probable infection. As can readily he understood, the mortality becomes higher as the pelvis becomes smaller, and where frequent examinations and attempts at delivery with forceps have been made before the patient is subjected to the operation. During the years 11)01 to 1906 inclusive, in the Glasgow Maternity Hospital, I and my assistants performed the operation of crani- otomy sixt} T -three times with eight deaths, a mortality of 12 6 per cent. This is 4 per cent, higher than my mortality for Cesarean section. It is entirely to be accounted for by the fact that in most of the fatal cases the parturient canal was very much injured and invariably infected before the patient was admitted to the hospital. It is interesting to find that not a single death occurred in cases which had been brought into my wards uninterfered with. Galabin, for Guy's Hospital, states that from 1891 to 1901 the mortality was 9 per cent. ; in the Rotunda Hospital, 1896 to 1900, the mortality was 16 per cent. Pinard, from the years 1892 to 1899, places it at 11*5 per cent. Liermberger, in 1902, referring to 232 craniotomies in Chrobak's Clinic in Vienna, puts the mortality at 7 "7 per cent. Bretschneider, 1 Zweifel's Clinic, Leipzig, for 182 cases, places it at 7 per cent. But, as these two latter operators mention, in many cases the fatal terminations were not really attributable to the operation. Although these figures show a high maternal death-rate, the ultimate results are even worse, for the morbidity is naturally very great. In Chrobak's Clinic, for instance, according to Lierm- 1 Arrhivf. Gyn., Bd. lxiii., Heft 1, 2, p. 225. OPERATIONS INVOLVING DESTRUCTION OF CHILI) 183 berger, it was 22 per cent., and in the Leipziger Clinic 28 per cent. ; in my sixty- three cases the morbidity was fully 30 per cent. Operation. — The preparation of the patient for this operation must be most thorough, for in many cases, unfortunately, the operation is had recourse to only after many vaginal examinations and attempts at delivering with forceps. In a large proportion of the cases sent into the Maternity Hospital the cervix, vagina, and perineum are already lacerated. Sepsis being so very common after craniotomy (in my sixty-three cases the mortality was 12 per cent, and the morbidity 30 per cent.) the parts about the vulva and vagina must be most thoroughly cleansed. The first step in the operation is perforation. This is carried out by the perforator, of which there are two different types — the scissors form and the trephine form. In this country the only perforators now employed are of the scissors variety, but in some Continental clinics the trephine is still occasionally used. The advantages claimed for the trephine are that it does not slip so easily off thefcetal Fig. 216. — Smellie's Perforator. skull, and that consequently there is less danger to the soft parts of the mother ; also that the opening made allows a more free escape of the brain contents. It is questionable, however, if these slight advantages compensate for the inconvenience of the instrument. Be that as it may, the instrument is now hardly ever employed. The earliest form of scissors perforator was devised by Levret. Smellie (Fig. 216) altered the instrument slightly, and improved it by adding a shoulder to each blade, so that the blades might be prevented from passing completely into the skull. In these two early forms of scissors perforator the opening in the skull is made by separating the handles. Obviously, such an arrangement in time was found unsuitable, and the more modern instrument, by which the opening is made by compressing the separated handles, became gradually perfected. There are many different forms of scissors perforator, but the two most generally employed at the present day are those of Naegele and Simpson (Fig. 217), although Oldham's (Fig. 218) is quite a suitable instrument. As seen in the illustrations, the perforator has two 484 OPERATIVE MIDWIFERY cutting-blades, each being Limited by a shoulder. The handles, when the blades are in apposition, are wide apart, and held firmly there by a hinged crossbar lixed to the ends of the handles. This crossbar is so hinged that it only permits of separation of the handles when the two sides of the bar are pulled together. The steps in perforating are as follows: The handles are fixed by means of the crossbar. The instrument is then grasped in the right hand, and carried into the vagina protected by two fingers of the left Fig. 217. — Simpson's Perforator. hand. The head of the child, if it is not sufficiently fixed, is steadied by an assistant grasping the head from the outside. Under protection of the fingers of the left hand, the perforator is then pushed through the skull (Fig. 219). The situation of the opening made in the skull will be considered in a moment. Sometimes it will be found necessary to move the perforator from side to side so as to bore the point of the instrument through the bone. In pushing or boring the instrument through the skull, the direction of the instrument should be, as far as Fig. 218.— Oldham's Perforator. possible, at right angles to the surface of the child's head, otherwise there is danger of the instrument glancing off the skull and doing injury to the soft parts of the mother. And here I may remark that it is of the greatest importance to have the perforator sharp ; with a sharp perforator there is almost no danger, but when the points of the instrument are blunt a greater amount of force is required to push the instrument through, and naturally there is greater danger of it slipping. In most cases it will be found necessary, in order to OPERATIONS INVOLVING DESTRUCTION OF CHILD 485 get the perforator at right angles to the surface of the skull, to depress the handles of the instrument against the perineum. The blades of the instrument, having been pushed through the skull as far as the shoulders, should then be separated, and this is done by unlocking the crossbar and pressing the handles together (Fig. 220). A large tear in the skull having now been made in one direction, the instru- ment should be turned round and a similar tear made at right Fig. 219. — The Perforator, having been carried up the Vagina under Protection of the Fingers of the Operator's Left Hand, is being pushed into the Skull iu the Neighbourhood of the Anterior Fontanelle. angles. The handles are again fixed by the crossbar. This having been done, the points of the instrument should be pushed into the skull and the brain broken up in all directions. The instrument is now withdrawn under protection of the left hand. I have referred to the danger of the perforator slipping, a danger which is practically nil if the instrument is sharp and the operator is 486 OPERATIVE M1DWI l'Kl;V at all careful. There is another danger which it seems almost un- necessary to mention did I not know that once or twice it has heen made ; it is mistaking the projecting promontory for the foetal skull. Such an unfortunate mistake cannot occur unless the operator 18 careless or excited. An important matter is the situation of the opening made in Fid. 220. —Tin' Blades are being separated }h;ilotribe. In the Maternity Hospital we employ Auvard's instrument, in which the blades and shanks are of more than usual length. This lengthening of the blades is in order to avoid having the lock in the vagina. We have found it a most useful instrument. It has simplified the operation of craniotomy immensely, for in place of taking an hour or two, as was the case with the crotchet and the bone forceps, it seldom takes more than one-third or one- fourth of that time. I ■cannot speak too highly of the three-bladed instrument. In the three-bladed instrument one blade is passed through the •opening in the skull, and the other two are applied over the external •surface of the head. They are brought together by a strong screw, and when approximated and the head crushed, are kept in their place hy the two shoulders, which are pulled down into position, and serve -as a means of exerting traction. The instrument is straight ; it has no pelvic curve. It is employed as follows : The opening having been made with a perforator, the middle Wade is pushed through the opening up to the base of the skull. OPERATIONS INVOLVING DESTRUCTION OF CHILD 495 This middle blade is not employed as a perforator. In some instru- ments the middle blade is screwed into the base of the skull — preferably into the foramen magnum. This is not altogether free from risk, unless the hand is passed into the uterus and applied to the base of the skull, so as to ensure that the point of the instrument is actually being bored into the base. Having passed the point of the instrument well up to the base of the skull, one of the external blades is now applied. It will be found best, when at all possible, that the first external blade should be applied over the surface of the face. If the occiput is first grasped by the external blade, and the screw applied, there will result an increase of flexion (unless the head is perforated very far forwards), and the second blade, which is to be passed over the face, will not extend far enough down over that part. The blade is placed in position by first carrying it upwards, under protection of the left hand, to the side of the promontory, and rotating it into position, as one does with forceps. While this is being done, it is of great service if an assistant steadies the head externally and keeps it extended, for seldom does the inner blade hold it sufficiently firmly in position. The handle of the instrument should be pushed well backwards against the perineum, so that the blade will be brought as far forwards as possible. The external blade being brought into position over the face, the screw is now turned, and the front part of the head crushed. One can always tell at this stage that a good grasp of the head has been obtained when there is considerable resistance to approximating the blades. If they are easily brought together with the screw, one can be perfectly certain the grasp is defective. It will be found very undesirable to apply the other blade, and attempt to crush the head, when the grasp of the instrument is unsatisfactory, for once the head has been crushed in a wrong direction, it is not easy to apply the instrument in a proper direction, as the blades always tend to slip into the first position. The other external blade is now introduced from the opposite side of the pelvis, usually in the neighbourhood of the sacro-iliac synchondrosis, and rotated into its proper position over the occiput. In doing this it is sometimes easier to place the third blade into its proper position, and at other times to keep the third blade fixed, and rotate the occiput on to it with the other two blades. The third blade is now locked, the screw applied (Fig. 230), and the head again crushed. The position of the blades and the appearance of the crushed skull are, as in the illustration, already given (Fig. 222), and if this ideal grasp is obtained I have never seen this instrument slip during the process of extraction. The instrument having been applied as described, the operator 496 OPERATIVE MIDWIFERY now proceeds to extract, the crashed head. In doing thin the blades Bhould be encouraged to rotate into the smallest diameter, which, in the deformed pelvis most commonly encountered, is the antero- posterior. Usually, by Bimply pulling upon the head, the instrument will rotate spontaneously, sometimes towards one side, sometimes to Fig. 230. — The Blade applied over the Fair has been fixed, and the Other Blade p] over the Occiput is being screwed np so that the Head is completely crushed. the other; but if it does not do so, the operator may carefully en- courage rotation. Very frequently one sees the beginner forgetting this, with the result that the crushed head catches on the brim. He must remember, also, to direct his traction well back. In the ordinary rachitic pelvis, once the head has passed the brim, the further extraction of the child is easy ; but in other deformities of the OPERATIONS INVOLVING DESTRUCTION OF CHILD 497 pelvis, where the whole cavity is contracted, as in extreme degrees of general contraction, or where the outlet is narrowed, as in kyphotic pelvis, there may be difficulties down through the whole pelvis, and even at the outlet. By steady traction, directed as far back as possible, the head is slowly pulled down through the pelvis. As a rule, unless the deformity is extreme, a slight amount of force is sufficient to accomplish the delivery of the head. When, however, the deformity is great, or when the grasp of the head is not satisfactory, a more than usual amount of force is required. In these latter cases the danger of the instrument slipping is greatly increased. The operator should therefore watch carefully for this, and during traction should keep the fingers of the left hand against the head, and make sure that, while he is pulling, the head is descending along with the instrument. These fingers in the vagina, which inform him as to how the head is descending, serve the other purpose of protecting any splinters of bone from injuring the soft parts. With the modern instrument, this danger of laceration of the soft parts by splinters is reduced to a minimum, for the scalp being still intact, except for the perforation hole, prevents the broken bones from doing any injury. Having extracted the head, the trunk is removed without difficulty. Sometimes the shoulders give trouble when the child is of unusual size. In such cases the division of the clavicles is necessary to facilitate extraction. This operation, termed cleidotomy, will be referred to later. After the shoulders are born, the rest of the trunk is easily delivered. I have never required to employ the cranioclast or cephalotribe in breech presentations ; but if it should be necessary, the middle blade should be passed into the rectum, and the two others over the pelvic walls of the foetus. Craniotomy on the After-coming 1 Head.— As the operation of craniotomy upon the after-coming head differs considerably from the operation upon the fore-coming head, it is necessary that we consider its details. In some circumstances it is easier ; in others it is more difficult. Provided the pelvis is not too deformed, the operation can readily be performed, and the extraction is easier ; but in extreme degrees of deformity it is more difficult, as the head is far out of reach, the brain substance does not readily escape, and the cephalo- tribe is difficult of application. Some years ago Donald published a very interesting paper, 1 in which he pointed out the advantages of craniotomy on the after- coming head, and in which he recommended, when craniotomy was decided upon, and the child could still be easily turned, that version 1 Lond. Obst. Trans., vol. xxxi., p. 28. 32 198 Ol'EKATIVK Mll'WII KltY should be first performed. His paper was freely discussed, but the majority of those who spoke were rather sceptical of the advanta claimed by bhe author. The operation is carried out as follows: The arms of the child having been brought down, the assistant grasps the feet, and directs Pig. 231. — Perforating the After-coming Head through the Postero-lateral Fontanelle. traction upon them, in the direction desired by the operator. The operator carries the perforator, protected by the two fingers of the left hand, along the dorsal aspect of the trunk, until he reaches the skull. He then pushes the instrument through the skull, in the neighbourhood of the postero-lateral fontanelle (Fig. 281). Some- times this point is difficult to reach, and he can only perforate OPEEATIONS INVOLVING DESTRUCTION OF CHILD 499 through the occipital bone in the middle line. In these cases he must make sure that he really perforates the skull, and not the uppermost part of the vertebral column ; for if this mistake is made not only will he find it difficult to gain entrance to the skull, but, having fractured the vertebral column, he will have rendered extrac- tion of the head more difficult. Fig. 232. — Extracting the After-coming Head with the Crotchet. The perforator is pushed through the skull, and an opening made in the manner already described for perforation of the fore-coming head. The brain matter having been broken up and washed out, extrac- tion is now proceeded with. It will be found in many cases this can readily be accomplished with the crotchet, the point of which should be turned towards the vertebral column. With this instrument a 500 OPERATIVE MII'WIIKIIY very firm hold of the skull can he obtained, seeing that the hones at the base of the skull are so strong. The illustration (Fig. 232) shows the manner in which the operator protects the soft parts of bhe mother with his lingers, while he exerts traction with 1 1 1 « - crotchet. The traction should he steady and gradual, so as to permit of the hones of the cranial vault collapsing. If with moderate traction the head does not collapse, it is not safe to exert an undue amount of force, for the hody may he dragged from the head and the latter left in the uterus. Should one fail to deliver with the crotchet, the cephalotrihe must he employed. This, however, is sometimes difficult, especially if there is general deformity of the pelvis, for there is so little room for the instrument and the neck of the child in a deformed pelvic canal. It is claimed hy some that the roof of the mouth is a hetter site for perforating the skull, as the brain suhstance escapes morel freely through such an opening. It is, however, difficult to reach! that part in some cases, and the hold one obtains with the crotchet is very feeble, as the bones are so soft. Occasionally it might be a quite useful procedure to make two perforations, one through the occipital bone and the other through the palate. Decapitation. The operation of decapitation consists in the severing of the head from the trunk, followed by the extraction of the trunk and then of the head. It is an operation of considerable antiquity, for we find it recommended by Celsus. The operation has always been looked upon as one of great difficulty. I cannot say that it is easily carried out, but in most cases it may be performed without much difficulty, and my colleagues and I in the Maternity Hospital prefer this operation to the much slower one of evisceration. Personally I have only once found the operation impossible, and that was in the case of an impacted trans- verse presentation with a contracted pelvis, where the child's arm was prolapsed, and owing to the size of the child the neck could not be reached. I therefore perforated the chest, divided the trunk, extracted the lower part of the trunk, removed the arms, and finally extracted the head after perforating it (evisceration, spondylotomy, and craniotomy). I find decapitation is very seldom performed by practitioner^ in this country. This is most unfortunate, for there are a number of cases in which it is the only safe treatment. There have been in recent years a considerable number of patients sent into the hospital in OPERATIONS INVOLVING DESTRUCTION OF CHILD 501 which practitioners have made fruitless attempts at version, and where with very little difficulty we have decapitated and terminated the labour. The indication for the operation is an impacted transverse pre- sentation, where the uterus is grasping the child so firmly that version is dangerous. It is not a little difficult to decide when one should desist from making attempts at version, for even when the waters have 1PK Fiu. 233. — Decapitating Hook (Ramsbotham's). drained away, and the uterus is closely applied to the surface of the child, by deeply anaesthetizing the patient the uterus relaxes to a surprising extent, and version is sometimes more easily per- formed than one expected. It is my custom, therefore, before proceeding to decapitation, to try and estimate the relative danger of performing version. I decide to desist from version and have recourse to decapitation in all cases if the child is dead Fig. 234. — Decapitating Hook (Jardine's). or dying (judged by the pulsations of the umbilical cord) ; and, if it is living, where the lower uterine segment is very much thinned out, the head is below the retraction ring, and the uterus still grasps the child even although the patient is deeply anaesthetized. The reason why I apparently sacrifice the child in these latter cases is because, if a transverse presentation has become impacted, the prospect of the child surviving a difficult version and extraction is so small as to be almost negligible. This matter is considered in Chapters VI. and XXII. 502 ol'HRATIVE MIDWIFERY The severing ol the head of the child from the trunk may be carried out with a variety of instruments; it has been done with cord, wire, chains, ecraseurs, and scissors, but the two more common instruments employed are the decapitating knife, of which the best- known form is that of Ramsbotham (Fig. 233), and the hook devised by Braun. In recent years both of these have been much modified ; Sclmltze and Jardine have modified the former, Zweifel and others have modified the latter. The objection to Ramsbotham's knife is that it is too large, and is often difficult to manipulate ; and the objection to Braun's hook is that owing to narrowness of the curve it is not always easy to get it over the child's neck. Besides, the method of twisting the head off with a hook is crude as compared to dividing Fig. 235. — Showing the Manner in which the Decapitating Hook or Knife is employed. the neck with a knife. Schultze's knife is a distinct improvement on Ramsbotham's, but, I think, even better than the latter is the com- bined hook and knife of Jardine (Fig. 234). The operation of decapitation is carried out as follows : The exact position of the neck having been determined, the decapitating instrument, protected by the palm of the left hand, is passed up over the child's shoulder (Fig. 235). The point is then turned over the neck. Generally the neck can be reached most easily from the front, as seen in the illustration, but occasionally it will be found easier to pass the hook round from behind. In a great number of cases the arm is prolapsed, and this is usually an advantage, unless the arm and shoulders of the child are unusually OPERATIONS INVOLVING DESTRUCTION OF CHILD 503 large, for by traction on the arm the neck can be brought more readily within reach (Fig. 236). If the knife is used, by a backward and forward movement it is carried through the neck, but if Braun's hook is the instrument employed, then it is twisted round and round until the neck is completely severed, the head being steadied from the outside. By this latter method, which I have indicated is very crude, Fig. 236. — The Assistant pulls upon the Prolapsed Arm so as to steady the Fcetus and bring its Neck within reach. The Operator then passes the Decapitating Hook over the Neck under Protection of his Left Hand. He is here dividing the Neck. the bones of the spinal column are shattered. There is then only a band of skin to be divided with scissors. After the head is completely severed, the trunk is removed by making traction on the prolapsed arm. There now remains the removal of the severed head, and this is easily accomplished manually or with forceps, unless the pelvis is deformed. Should the pelvis be contracted, the head is steadied by suprapubic pressure, perforated, 504 OPERATIVE MIDWIFKIIY and then removed with the cranioclast, crotchet, etc. (Fig. 237 . Care must he taken in extracting the head that the ragged neck does not injure the soft parts, for usually, when the head is severed, the greater part of the neck is left attached to the head, the line of cleavage heing close to the shoulders. The operation of decapitation has heen attended with excellent Fig. 237. — Removing the Detached Head with the Crotchet. results in the Maternity Hospital. Since 1901 inclusive it was per- formed twenty-five times without any maternal deaths, although in all cases the women were very ill when brought into the hospital. Evisceration. The operation of evisceration consists in the removal of the abdominal and thoracic contents, with the object of diminishing the bulk of the child, and so permitting of its being extracted. The most common indication is an impacted shoulder presentation OPERATIONS INVOLVING DESTRUCTION OF CHILD 505 in which decapitation is impossible owing to the neck being out of reach. The operation is also occasionally necessary in monsters, and where the abdomen or thorax of the child is distended with fluid or new growths. The operation is performed by first making a large opening with a perforator into the abdomen or thorax ; the viscera are then broken up and removed manually. During these manipulations, if the pre- sentation is transverse, the trunk of the child may be steadied by means of the prolapsed arm. As the abdominal contents are the most bulky, the removal of them diminishes most the bulk of the child. Where the opening is made into the thorax, the abdominal contents can be reached through the diaphragm. After evisceration the child can often be extracted in a doubled-up condition, provided the pelvis is of normal size and the child is small or macerated ; but where the pelvis is deformed, or the foetus large, the vertebral column has to be divided. The term ' spondylotomy * was given by Simpson 1 to this division of the vertebral column. It can be done best with scissors, but it is often a very tedious operation. In cases where the presentation is transverse, and the trunk has been divided, the lower part of the trunk is first extracted by making traction on the legs. The extraction of the other half of the child must be carried out with great care if there is much of the trunk left, because when pulling upon the trunk the ragged edges of bone may injure the parturient canal. In the simpler cases where the child has to be eviscerated on account of the bulk of its abdominal or thoracic contents, the opera- tion is more simple. The abdomen, if the presentation is a breech, can be easily reached when the legs are brought down. In head pre- sentations there may be a little more difficulty, for the abdomen may sometimes require to be opened through the diaphragm, although in all cases in which I have required to perform the operation I have been able to perforate the abdomen direct. Cleidotomy. The operation of cleidotomy, or division of the clavicles, has for its object the reducing of the bulk of the shoulder girdle. In all probability the operation was performed in times past, but attention was first directly drawn to the advantages of the operation by Spencer, in a paper entitled, ' On Delivery of Certain Cases of Impaction of the 1 ' Obstetric Works,' vol. i., p. 502. 50(5 OPERATIVE Mim\IFEl;Y Trunk of the Foetus.' 1 Pie says: ' It may be necessary to reduce the width of the child's shoulder. With this object I have found it a useful plan to snip through the clavicles with scissors.' A few weeks Fig. 238. — Showing the Collapsed Shoulder (Jirdle after Cleidotomy. The child was a very large one, and had to be extracted with the cephalotrilu-. later Phenomenon 2 made a contribution under the title, ' Zur Frage iiber Embryotomie. Uber die P)urchschneidung des Schlusselbeins (Cleidotomia).' Knorr and Strassman in Germany, Bonnaire in France, 1 Brit. Med. Journ., April 13, 1895, p. 808. 2 Zent.f. Gyn., June 1, 1895, p. 5s:,. OPERATIONS INVOLVING DESTRUCTION OF CHILD 507 and Ballantyne in this country, have drawn special attention to the operation. Ballantyne's paper 1 is the most complete on the subject in the English language. I have performed the operation frequently in the Glasgow Maternity Hospital, and I entirely agree with all that has been written in its favour. The operation is a very simple one. The clavicles are divided either by a pair of strong, straight scissors, or a symphysiotomy knife, such as Pinard's. The two fingers of the left hand are passed along the ventral aspect of the child, and under the protection of these the knife or scissors is introduced and the clavicle divided. The other clavicle is divided in a similar manner. The illustration (Fig. 238) shows a case in which both clavicles have been divided. The only danger is injuring the soft parts of the mother, but if the operator takes care to protect the soft parts with the fingers of his •other hand when he introduces the knife this cannot occur. 1 Edin. Obst. Trans., vol. xxvi., p. 24. CHAPTER XXX MANUAL REMOVAL OF PLACENTA AND MEMBRANES It sometimes happens that the placenta and membranes, instead of being expelled some little time after the birth of the child, are retained in the uterus. In most cases they are separated, and are merely ' retained,' but in a few they are actually ' adherent.' According to the figures of a number of different writers who have collected series of cases, the operation of manual removal of the placenta was neces- sary about once in 200 cases. Adherent Placenta. — This is the result of pathological changes in the uterus and placenta, most commonly a chronic inflammation of the uterus. It is a rare complication — much rarer than is generally supposed. It is more frequent in pregnancies which terminate pre- maturely than in those at full time. The recognition of adherent placenta is not difficult. The uterus remains of the same size and shape, the ligature which was applied round the cord at the vulvar orifice to mark any descent of placenta remains in the same situation, and expression of the placenta is impossible. Strassmann has pointed out that as long as the placenta is adherent a thrill is felt in the umbilical cord whenever pressure is made on the fundus. Naturally, if there is a ligature applied at the vulvar orifice, the thrill will be arrested there. With a partially separated placenta this sensation is not experienced. A placenta which is adherent to any extent cannot be expressed, and so, after waiting for a certain time, the hand must be introduced into the uterus and the placenta and membranes removed. It may be very rightly asked — How long should one wait ? As there is no definite time for placental separation, this cannot be stated. In my experi- ence the placenta takes on an average fifteen to twenty minutes to separate, and so, if separation has not occurred after half an hour longer, I look upon the condition as abnormal, and I proceed to remove the placenta manually. Of extreme importance in performing the operation is surgical 508 MANUAL REMOVAL OF PLACENTA AND MEMBRANES 509 cleanliness, for the mortality and morbidity from it are very high. Collected cases of a variety of writers show a mortality of 7 to 10 per cent. There are several reasons for this. The operator's hand not only comes in contact with, but is rubbed repeatedly over, the raw placental site. (Prior to delivery all manipulations were carried on within the protecting bag of membranes.) Further, he is called upon to perform the operation after a prolonged and often difficult delivery, when he is tired, and consequently not so careful in the precautions taken against infection. Lastly, in many cases the parturient is extremely exhausted by a difficult parturition and an abnormal loss of blood, and in consequence her resistance to infection is lowered. Before proceeding to remove a placenta manually, the operator's hand and the patient's vulva must be thoroughly cleansed over again. When the whole placenta has to be removed, as in the condition we are at present considering, rubber gloves may be worn with advantage, but when it is a matter of removing small portions of membrane or placenta I have found it necessary to remove the gloves. One can, of course, as some operators do, employ cotton gloves for the purpose ; the naked hand, however, is much the best. The operation of removing the placenta is not difficult, provided the patient is anaesthetized, which should always be done. To attempt the operation without an anaesthetic has several disadvantages. In the first place, it is very painful ; but even more serious than that is the fact that it is more difficult to introduce the hand, and more force is required to push it through the vulvar orifice ; thus there is greater danger of carrying in organisms. Lastly, there is the danger of injuring the parturient canal. Quite recently a case was brought into hospital where the medical attendant ruptured the uterus while manually detaching a very adherent placenta. It was recently suggested by Peters 1 that the cervix should be pulled down by means of vulsellum forceps while the assistant pushed down the fundus. By this means the os externum can be brought right down to the vulvar orifice and surrounded with gauze, and the accoucheur can pass his hand into the uterus without his hand coming in contact with the vaginal wall. In removing a placenta that is adherent, the fingers should be passed up between the uterine wall and the placenta, and the latter stripped off. Wide sweeps should be made until the whole placenta is separated. It should then be grasped in the hand (Fig. 239), and the uterus made to force out the hand and placenta together. During the whole process of removing either placenta or membranes the 1 Zmt.fwr. Gyn., Nr. 7, 1910, p. 225. .10 Ol'KKATIVK MIDWIFIJIV external hand must steady the uterus and work along with the internal. The uterine surface after detachment of the placenta is always ragged; it can never be made smooth, even by scraping; so that it is unwise to do this, for there is a distinct danger that by scraping the placental site too energetically injury may be done to the uterine Fig. 239. — Manual Removal of the Placenta. wall. As I shall point out when considering rupture of the uterus, -cases of weakening of the wall and rupture at a subsequent pregnancy have followed such a procedure. After the removal of the placenta or membranes, it is advisable to give an intra-uterine douche of boiled water at a temperature of 116° to 118° F. The object of this douche is to wash out any debris and to stimulate the uterus, which is usually in a condition of inertia MANUAL REMOVAL OF PLACENTA AND MEMBRANES 511 after these manipulations and the deep chloroform anaesthesia. It is also well to give an intracellular injection of ergotine. Retained Placenta and Membranes. — While the abnormal ' adhesion ' of placenta to uterine wall is a condition quite beyond one's control, it is not so with ' retention ' of the membranes and placenta in whole or in part. In most cases — there are, of course, many exceptions — this complication is the result of improper manage- ment of the third stage, especially hurrying it unduly. That being so, it is well that we consider what occurs normally after the child is born. If one observes a case of normal delivery, one finds that the uterus remains retracted and quiescent, just as it does after the birth of a first child in a twin pregnancy. After a time, varying from five to fifteen minutes, active contractions begin, and these go on at regular intervals, as they did during the first and second stages. During the period of quiescence, and especially during contractions, separation of the placenta occurs. I do not propose discussing here how this separation occurs. As is well known, many different views are held regarding the matter, some attributing it to retraction of the placental site, others to relaxation of the uterine wall after contraction, while many still support Schultze's view of the formation of a retro- placental hematoma. These are all still disputed points, and not questions that can suitably be considered here. What we do know is that the placenta takes time to separate, the uterus does not attempt actively to expel it for some little time, and the expulsion of the placenta is very generally followed by the escape of a considerable quantity of blood. 1 Without doubt, theoretically, the ideal course to pursue would be to leave the expulsion of the placenta entirely to Nature ; but in practice such a course is hardly possible, for, from statistics in which such a course has been followed, the placenta has often not been expelled for many hours. It is, therefore, universally admitted that some assistance should be given to the uterus to expel the secundines. To put a time limit upon what should be the duration of the third stage is quite impossible, for, like every other stage, it must vary in duration. It is quite unnecessary for me to say that the other extreme of forcing the placenta out immediately after the child is born is a highly reprehensible practice. But even when that is appreciated, and a considerable time is allowed to elapse before the placenta is expelled, portions of membrane are often retained. In great part I am convinced this results from the erroneous practice of 1 It must not be forgotten that the placenta is often retained because the bladder is over-distended. ;i2 OPERATIVE M1KWII IKY early kneading the uterus. The intelligent mid careful accoucheur knows that lie slmuM keep his band upon the uterus during the third stage; but the mistake he makes is, instead of allowing his hand to lie quietly on the uterus and watch that it does not become over-distended with blood, he begins to knead it immediately, with the result that he Fig. 240. — Method of expressing the Placenta. (After Bumm.) sets up a tetanic contraction of the uterus, especially of the lower part of the body ; he forgets the fact that the uterus must have a period of rest before it begins to contract. Personally, I believe, although this is a debated question and opposed to the views of many •distinguished writers, that the early kneading and compression of the MANUAL. REMOVAL OF PLACENTA AND MEMBRANES 513 uterus destroys the quiet formation of the retroplacental hematoma, which, to my mind, is a most important factor in normal placental separation and expulsion. The course to pursue is as follows : Keep the hand quietly resting upon the uterus, wait for fifteen minutes or so until contractions commence ; if they do not occur, establish periodic contractions by kneading the uterus at intervals of three to five minutes. Do not attempt to expel the placenta until it has passed from the body into the lower uterine segment. This is indicated by the altered shape of the uterus ; the fundus rises up higher, and the shape comes to be less globular. In addition, more of the cord slips out of the vulvar orifice, ' v x Fig. 241. — Removing the Membranes by twisting the Placenta so that the Mem- branes are formed into a Twisted Cord. Fig. 242. — Removing the Membranes by- Direct Traction upon them. and traction upon the cord indicates that the placenta is not as intimately connected with the uterus as it was. By the end of thirty minutes or so, if the placenta has passed out of the body of the uterus, pressure may be exerted on the fundus, and the placenta slowly forced out of the vagina. The method of expressing the placenta generally employed is associated with Crede's name, although there is no doubt that the Rotunda School rightly claims priority. The operation is carried out as follows : The uterus is kneaded firmly by the hand until it actively con- tracts — the fingers are passed behind and the thumb in front of the uterus (Fig. 240). Not only is it profitless to try and express 33 514 OPERATIVE MIDWIFERY the placenta before a contraction is established, but there is even the danger that by trying to do so an inversion of the uterus may be pro- duced. Having secured an active contraction, the uterus is squeezed between the thumb and fingers, and the placenta is slowly forced out of the vagina. No great force is required, as a rule — indeed, if it is necessary, it is evidence that the placenta is not yet ready to be forced out. As I have already indicated, the passage of the placenta is often retarded by contraction of the lower part of the body (Bandl's ring). This, as stated, often results from too early kneading of the uterus. Special care must be taken that the after -birth is not expelled too rapidly, for then the membranes are very liable to be torn and retained. As the placenta appears at the vulvar orifice it should be received by the hand of the accoucheur, and the membranes should be care- fully removed by traction. It is frequently recommended that as the placenta is removed it should be twisted so that the membranes are formed into a cord (Fig. 241). Personally, I am very doubtful about the wisdom of this common procedure, and certainly I think it unwise when the membranes show signs of tearing along the edge of the placenta. It is better, I think, if there is any difficulty with the membranes, to grasp them and exert gentle traction upon them (Eig. 242). I have sometimes sat holding them for many minutes, until the spasm of the uterine muscle has quite passed off. Occasionally, when there is a little difficulty in removing the mem- branes, the sudden withdrawal of the hand that is pressing down the fundus allows the latter to spring back a little, with the result that the membranes come away easily. Manual Removal of Portions of Placenta and Membranes. — Should it happen that a portion of the membranes is retained in the uterus, the question will naturally arise as to whether or not the hand should be introduced into the uterus for their removal. The answer is sometimes a little difficult. I certainly think the mem- branes should be removed manually if the bulk of them is retained ; but when only small portions are left behind, or when one is doubtful as to whether or not any is retained, I think the wiser course is not to insert the hand, because of the great danger of introducing in- fection. The statistics of all maternity hospitals prove that this danger is very great, and my personal experience in private practice is the same. If one removes any portion of membrane that may be in or projecting into the vagina, the expulsion of the remainder may safely be left to Nature, as it will come away in a few days in the lochial discharge. Should there arise, by any chance, in such cases MANUAL EEMOVAL OF PLACENTA AND MEMBRANES 515 a rise of temperature of any other symptom of infection, intra-uterine douches must be given. I need hardly remind my readers that in examining the membranes both the chorion and amnion must be Fig. 243. — Placenta Succenturiata. (Author's Collection.; looked at. Very frequently the amnion comes away without the chorion — indeed, this is most commonly the case where portions of membranes are retained. So far I have purposely not mentioned the retention of portions 516 OL'EUATIYK MIDWIFERY of placenta, for thai condition is on quite a different footing to reten- tion of small portions of membranes. No portion of placenta should ever be left behind; consequently, even in cases of doubt with regard to the placenta, the hand should be introduced. It may sometimes happen that a placenta succenturiata (Fig. 248) is left behind in the uterus. Such a condition is impossible of recognition, for, although in such cases a portion of the membranes is wanting, the operator naturally thinks that only membranes are retained. In removing the whole placenta, adherent or retained, I advise using a rubber glove. I have found, however, that it is quite im- possible to remove small portions of placenta or membranes with the gloved hand. One should try to remove the membranes with the first introduc- tion of the hand, for each succeeding introduction of the hand increases the risk of infection. The later effects of retained portions of placenta, and also to a slight extent of retained membranes, are saprsemia, secondary post- partum haemorrhage, subinvolution of the uterus, and placental polypus with menorrhagia. CHAPTER XXXI INTERRUPTED GESTATION— ABORTION AND HYDATIDIFORM MOLE In considering interrupted gestation, it is customary to distinguish two distinct groups, according as the pregnancy is interrupted before or after the foetus is viable, interruption before the viable age being termed ' abortion ' and after that time ' premature labour.' The viable age generally fixed is twenty-eight weeks, or seven lunar months. Abortion. Abortion, or miscarriage, may be defined as interruption of preg- nancy before the fostus is viable — that is, before the twenty-eighth week. In some text-books a distinction is drawn between ' abortion ' and ' miscarriage,' abortion being the term applied up to the end of the sixteenth week and miscarriage from that time until the twenty- eighth week. Such a distinction has been very generally given up, for clinically the two are the same, so that the two terms are used indiscriminately, with the exception, perhaps, that abortion is the more technical and miscarriage the more popular. It is an extremely common occurrence, this interruption of gesta- tion. Certainly half, if not more, of all married women abort at least once, or, to put it in another way, at least one in every seven preg- nancies terminates in abortion. But abortions are more frequent than even these figures would suggest, for many of the cases occurring early in pregnancy are never recognized, either by the women them- selves or by their medical attendants. The small ovum is expelled with some blood, which is considered that of a delayed or a premature menstrual period. Abortions come under our notice most generally in the third and fourth lunar months, because at that time the attachment of the ovum to the uterus is not very firm, and because if they occur before that time they pass by unrecognized or without any attention being 517 518 OPERATIVE MIDWIFERI given them. Criminal abortions are usually induced at this time also, as before the third month there is always some uncertainty as to whether pregnancy exists or not; while after the fourth month, concealment of the condition being impossible, it is considered neces- Bary not to delay longer. The time that would have been a menstrual period had pregnancy not existed is especially dangerous, for although menstruation is suppressed during pregnancy, it is not uncommon to find loc;il and general disturbances periodically manifesting themselves. Again, if a miscarriage has once occurred, it is liable to recur, because the pathological condition causing the abortion remains so often uncor- rected ; indeed, it is sometimes aggravated by the miscarriage, for women, more particularly amongst the poorer classes, do not take anything like the same care of themselves after an abortion as after a labour at full time. Etiology. In discussing this subject I shall be very brief. The conditions which bring about abortions are both numerous and varied. They all, however, act in two ways : they stimulate the uterus to contract and they interfere with the utero-placental circulation. In most abortions the separation precedes the contractions, but in a few that is not so ; the contractions first occur, and they bring about the separation. The conditions on the side of the foetus which give rise to abortion are for the most part disease of itself and its membranes. The most important disease is, of course, syphilis. In most cases of disease of the ovum the circulation on the fcetal side of the placenta becomes disturbed, placental haemorrhage occurs, and finally the circulation is arrested. The dead ovum then becomes a foreign body, which remains for a variable time, until uterine contractions are set up and bring about its expulsion. The maternal causes are so numerous and varied that I have thought it well to divide them into the following groups : [a) Diseased Conditions in the Reproductive Organs, especially such conditions as endometritis, metritis, retro-displacement of the uterus, and tumours of the uterus. These varied diseases all act in the same way : they favour pathological changes in and separation of the placenta. Of them all, by far the most important is endo- metritis, and I have no hesitation in saying that at least 70 per cent. of all cases of abortion are caused by this. (b) Diseased Conditions in the Other Systems of the Body — for example, in the alimentary, diarrhoea and vomiting ; in the INTEKKUPTED GESTATION 519 nervous, chorea and epilepsy ; in the respiratory, bronchitis and pneumonia ; in the vascular, valvular disease of the heart ; in the urinary, nephritis and cystitis. Such conditions act differently in bringing about miscarriage. For instance, in severe coughing or excessive vomiting the uterus may be directly stimulated to contract, or in diarrhoea it may be reflexly stimulated to do so. In chronic valvular disease of the heart passive congestion and haemorrhage into the placenta are liable to occur, and the uterus is stimulated to contract by the excessive carbonic acid in the blood, the result of defective aeration. (c) Poisons circulating- in the Blood. — In some these are the poisons of the specific fevers. The poison of syphilis is far the most striking example, and it is undoubtedly accountable for a very large number of abortions ; but, besides syphilis, there are others, such as those of small-pox, typhus, enteric, malaria, etc. Some of these poisons directly kill the child, but many bring about abortion, because the waste material produced by the high temperature stimulates the uterus to contract, and favours passive congestion of the placenta. In another group of cases the poisons are simply the result of defective metabolism and elimination. Eclampsia, icterus, and many cases of hyperemesis gravidarum, are good examples. In yet another class the poisons are metallic, slowly absorbed into the system. Examples of this are found in lead and mercury workers. Lastly, in certain cases the poison is some drug, such as ergot, savin, etc., taken intentionally or accidentally. Each of these causes abortion by stimulating the uterus to contract either directly or through the nervous system. {d) Accidental Conditions, such as Falls, Blows, and Injuries. — These, acting directly or indirectly through the nervous system, set up uterine contractions. Also sudden emotion may occasionally bring about a miscarriage. In this connexion, however, I would remark that the healthy uterus can stand a great deal, and that abortions are comparatively rarely caused by accidents. There is usually some disease of the uterus. (e) Criminal Abortions.— The abortion is induced by the passage of instruments into the uterine cavity, by the taking of oxytocic drugs, by jumping from a height, etc. (/) But, besides all these causes, there yet remains a number of cases where, as far as one can discover, no cause exists beyond an irritability on the part of the uterus which allows the pregnancy to advance only a certain stage, and then time and again throws off the product of conception. This has led some to speak of the uterus as having contracted the habit of aborting. Eepeated abortions, how- •>:.'<» OPERATIVE MIDWIFERY ever, are more usually tlie result of special diseased conditions, which, if carefully searched for, will lit- discovered. It, therefore, Leads to errors of treatment if one contents oneself with a diagnosis of ' habit abortion.' Still, in spite of the most careful examination, there are cases where a peculiar irritability of the uterus seems to he the only cause. That this is probably s satisfactory enough explanation in such cases is evidenced hy the fact that the irritability of the uterus varies in different individuals. One does encounter cases where women abort on slight emotional disturbance or trivial accident. Again, in cases of induction of premature labour — one finds that labour is brought about with the greatest ease in some, while in others it is most difficult — I have seen the cervix dilated and bougies inserted without avail. Symptomatology and Diagnosis. The symptoms of abortion are pains or uterine contractions, haemorrhage, and dilatation of the cervix. Occasionally there are certain discomforts, spoken of as prodromal symptoms, such as a feeling of weight in the pelvis, irritability of the bladder, a mucous or sero-mucous discharge ; but they are really of no importance or value from a diagnostic point of view. The first symptom may be haemorrhage or pain ; most commonly it is haemorrhage. The extent of the haemorrhage varies greatly, and is sometimes quite alarming. Following the haemorrhage, and, as I have said, sometimes before it, are ' pains ' referred to the back and hypogastrium. By multiparas they are described as resembling labour pains, but by primigravidae they are often described as resembling intestinal colic. In abortion in the earlier months the pains are much less severe than in abortions which occur later ; indeed, the ovum may in the first and second month be expelled with little or no pain. Dilatation always follows the haemorrhage and pains, and its extent depends on the size of the ovum to be expelled. The diagnosis of abortion in most cases is not difficult. The history of suppression of one or more menstrual periods and other symptoms of pregnancy, the haemorrhage, and the pains, make it clear generally that one has to deal with this condition. Before definitely deciding upon abortion, one must exclude the possibility of extra- uterine pregnancy, for at an early stage they may have every symptom in common. Many may think I am laying undue stress upon this danger, and may say extra-uterine pregnancy is such a rare occurrence it may be put out of account ; but that is not so : it is now known to be by no means uncommon. As evidence of the INTERRUPTED GESTATION 521 necessity of emphasizing this danger of overlooking an extra- uterine pregnancy and diagnosing an ordinary abortion, I may mention that in fully 30 per cent, of the cases of extra-uterine pregnancy which I have had to deal with the mistake has been made. In most cases- a careful bimanual examination reveals which of the two conditions exists. I shall go into this matter more fully in the succeeding chapter, when discussing extra-uterine pregnancy. But other conditions besides extra-uterine pregnancy may simulate abortion — for example, ulcerative conditions of the cervix, polypi of the cervix, and sometimes even menstruation during pregnancy, call for mention. In these conditions there are no ' pains,' the bleeding is very rarely profuse, and there is no dilatation of the cervix. Still, each may resemble ' threatened abortion,' and only a careful examina- tion will settle which it is. Malignant disease or a polypus of the cervix should not be difficult of recognition, but menstruation during pregnancy may be very confusing. In the cases which I have seen this periodic dis- charge has occurred at the usual regular intervals, has always been scanty, and has never continued after the third month. There are, however, cases on record where it has continued during pregnancy. I have never seen such cases; I believe they are very rare indeed. In all eases where haemorrhage recurs during pregnancy the possi- bility of placenta praavia should be considered. The cases in which I have had greatest difficulty are where, shortly after delivery and when menstruation is suppressed, a decision has to- be come to between post-partum metritis and endometritis and an early miscarriage — indeed, I have once or twice found it impossible to decide in such cases. Fortunately, the treatment in both is much the same, for if the bleeding continues after rest, etc., the uterus must be explored with the fingers or the curette. I would sum up the matter of diagnosis in cases of supposed abortion by advising every one to satisfy himself on the following points : (1) Is the woman really pregnant '? (2) Is the pregnancy intra- or extra-uterine? (3) If intra-uterine, is abortion inevitable, or is it only threatened ? Varieties of Abortion and their Differentiations. Having satisfied oneself that the pregnancy is intra-uterine, the next thing to decide is whether the abortion is threatening or in- evitable. To decide this question is not always easy, especially if all blood-clots, etc., have been thrown out and are not available for inspection. If the bleeding is at all pronounced, the pains very 522 OPERATIVE MIDWIFKllV severe, and the os distinctly dilated, one always considers the abortion inevitable ; but if there is only moderate pain and hemorrhage, the miscarriage may often be prevented by suitable treatment. In all cases of doubt one must temporize and treat the abortion as only threatening. This not infrequently involves keeping the patient under observation in bed for some time. In these cases one may sometimes be uncertain as to whether or not the pregnancy is going to continue on account of a slight discharge persisting. If it is con- tinuous and of a brownish character, in spite of rest in bed, the ovum is generally dead ; but if there are occasional slight bright hemorrhages, I have often seen the pregnancy continue, and ultimately terminate quite satisfactorily. The patient must be kept in bed until all hemorrhage ceases. Let me once \\ III i;V there had been practically no discharge for -mum. daw-, and the uterus appeared of about normal size. In spite of that, however. I explored the uterus, and removed a large piece of placenta. 1 alwaye explore the uterus unless I am absolutely certain from what 1 have seen that everything has come away. In cases of incomplete abortion, when only a small portion of tissue is left behind, it may he some time before there is any evidence that such is the case. Sooner or later it will manifest itself by monorrhagia, abdominal uneasiness, and Blight sapraemia. There remains another variety, termed missed abortion. In it the ovum dies, the pains and hemorrhage cease, and the ovum is Fig. 245. — Fleshy, Carneous, or Hemorrhagic Mole, from a case of Missed Abortion. (Author's Collection.) retained for weeks or months. In such cases the symptoms of pregnancy, such as swelling of the breasts and morning sickness, dis- appear, the uterus remains of the same size, and menstruation'con- tinues suppressed, although there is occasionally a slight brownish discharge. The diagnosis of this form of abortion is by no means easy. There is not usually any difficulty in recognizing the existence of pregnancy, but there is in deciding whether the ovum is alive or dead. Time clears matters up, for if the ovum is alive the uterus steadily increases, while if it is dead it remains stationary. The ovum expelled in such cases (fleshy, carneous, tuberose, or hemorrhagic mole) presents peculiar appearances (Fig. 245). The fu-tus may entirely (lis- INTERRUPTED GESTATION 525 •appear, or only a trace of it may remain ; but if it has developed some weeks before its death occurred, it becomes mummified. The length of time an ovum or part of an ovum can be retained in the uterus is variable, but very often it is retained until such time as, had pregnancy continued, normal labour would have come on. Occasionally it is retained eleven months. Berry Hart 1 pointed this out several years ago. He wrote : ' It looks, therefore, as if the uterus were occasionally cheated by the mole, which forms at or about the second or third month, and may be retained for the nine months given to a normal pregnancy.' Hart, in the same paper, remarks : ' So far as my reading goes, no case has gone beyond eleven months. There are, however, one or two which have been recorded where the dead ovum was retained for years. They are considered by Graefe.' 2 Treatment. Prophylactic. — "Where previous abortion has occurred the patient should be carefully examined, and the cause of the abortion deter- mined, if possible. Diseased conditions, such as chronic inflammation of the uterus or appendages, should be treated, displacements cor- rected, and any reflex irritation removed. Above all, the possibility of syphilis should be considered, and if there is the slightest suspicion of this poison being present, both parents should undergo a course of -antisyphilitic treatment for twelve months at least before another pregnancy is permitted. In very troublesome cases, where no distinct cause can be dis- covered, it is well to begin treatment by advising a cessation of all marital intercourse for some months, and this is best accomplished by sending the patient from home. During these months of absence the general health should be improved with suitable exercise, massage, and general tonics, such as iron, quinine, or strychnine. It is often advisable to curette the uterus before permitting another pregnancy. "Whenever pregnancy occurs all intercourse must be again stopped. If syphilis was the suspected cause, antisyphilitic treatment must be continued during the whole of the pregnancy. In other cases chlorate of potash (5 grains thrice daily) is recommended. It is supposed that this drug has a beneficial effect, because it parts so readily with its oxygen ; the amount of oxygen given up, however, must be very small indeed. I usually prescribe the drug, and continue it throughout the pregnancy, 1 Brit. Med. Joztrn., October 24, 1896, p. 1189. 2 ' Festschrift Carl Ruge,' Berlin, 1896. 526 Ol'KliATlYE MIDWIFERY unless it causes gastric irritation. The bowels must be most carefully regulated. A diet which gives the least amount of waste should be prescribed. The patient should be encouraged to drink considerable quantities of fluids between meals, for it is most important to keep up elimination. Fresh vegetables, if the digestion is good, and fruit- juice should be recommended. It is, of course, impossible to say how far such treatment does good, for, in addition to it, I have always insisted that my patients remained absolutely at rest in bed throughout the greater part of the pregnancy. The importance of this absolute rest in bed cannot be too strongly emphasized. It is very irksome for the patient. J//< r a few months, she may be allowed a little more liberty ; for it is in the earlier months, when the placenta is being formed, that it is so extremely important to maintain a quiet circulation in the uterus. Threatened Abortion. — -A threatening of abortion should be treated by at once confining the woman to bed and giving some sedative. Personally, I always give opium or morphia. Laudanum or Battley's solution by the mouth, or a morphia suppository, are the best ; morphia given hypodermically is not so good. Liquid extract of Viburnum prunifolium, twice daily, is strongly recommended by American obstetricians. Williams 1 recommends the following suppository : Codi* sulphat., gr. ss. ; ext. hyoscyami, gr. i. ; ext. viburni prunifolii, gr. v. ; ol. theobroma?, q.s. This is to be ad- ministered every four hours. Chloral, with or without bromide of potash, is also recommended, but personally I have found morphia or opium do most good. Ergot, in small doses, is said to be bene- ficial. Given in that way, it is claimed that it arrests bleeding, without setting up uterine contractions. For my part, I believe that the cases which terminate satisfactorily do so in spite of the ergot. The diet should be very simple, only cold fluids being given. The patient should be kept in bed until the bleeding has ceased for some time. The great difficulty is to know when the abortion has ceased to be threatening and has become unavoidable. In the early months a continuation of the bleeding, even if the pains are absent, usually means that the fcetus is dead, and, consequently, the sooner it is removed the better. In many cases one can only decide by examining the uterus from time to time, and seeing if it is enlarging. This, as I have already indicated, involves weeks of suspense to the patient. When pregnancy is more advanced, repeated auscultations may be of service, as giving information regarding the life of the foetus. 1 'Obstetrics,' 1910, p. 618. INTERRUPTED GESTATION 527 Inevitable Abortion. — When the abortion is inevitable, the sooner the uterus is emptied the better. The ease with which this can be done depends upon the degree of dilatation of the cervix. In emptying the uterus in cases of abortion, the very greatest care must be taken in thoroughly cleansing the vagina and vulva, because, with the continuous hemorrhagic discharge, those parts are generally septic. In the early months, if two fingers can be passed into the uterus, the ovum can usually be separated completely, especially if the other Fig. 246. — Method of expressing the Ovum. hand presses down the uterus from the abdomen. Sometimes, although separated, the ovum slips round the fingers, and cannot be caught hold of. It should then be removed by ' expression ' or by ovum forceps. Expression (Fig. 246) is carried out by compressing the body of the uterus between the two hands. The internal fingers press the body from the anterior fornix and the external press it from the abdomen. One must only express with the internal fingers in the anterior fornix. If an attempt is made to do it from the posterior, there is danger of lacerating the vault of the vagina. This accident actually occurred some years ago in the hands of a prac- titioner of wide experience. He asked me to see the case in con- 528 OPEIIATIYE MIl^VIFKIiY saltation with him, and I discovered that, although the vault of the vagina was torn, bhe peritoneal cavity w r as not opened into. The wound was plugged, and the patient made quite ;i satisfactory recovery. A very convenient way of removing the ovum when it i> detached is by means of the ovum forceps (Fig. 247). If the os is not dilated, this must be done before the ovum can be removed. It may be carried out in various ways. The one generally employed is to plug the cervix and vagina with sterilized gauze. This operation should always, when possible, be carried out under an anaesthetic, for one can then perform it much more thoroughly and aseptically. The very greatest care must be taken in cleansing the part about the vulva and vagina. The cervix is seized with vulsellum forceps, great care being taken not to put too Fig. 217. — Ovum Forceps. much traction on the instrument, as the cervix, being so soft, readily tears. A retractor is then introduced, and the posterior vaginal wall pulled back. It is always well to use retractors when packing the vagina or cervix, because if they are not used, the gauze, when being pushed in, abrades the mucous surface. The gauze is carefully pushed in through the cervix, and the vagina is firmly packed (Fig. 248). The plug is left for twenty-four hours, when, on removal, the os is often sufficiently dilated to allow of the ovum being removed ; indeed, it sometimes comes away with the plug. Plugging is most efficacious when there are active uterine contractions going on. If uterine activity is feeble, one may get very little dilatation from the plug. If, on removing the gauze, dilatation is not sufficient, the plugging may be repeated. The objection to this method is that it necessitates repeating the anaesthesia, and involves much vaginal manipulation. If plugging is not sufficient, I proceed, therefore, to more rapid dilatation with dilators or expanding tents. In using metal dilators one must take care not to drag too hard on the cervix, which is grasped with the vulsellum forceps ; and, indeed, I have often found it better to push down the uterus over the dilator with the external hand rather than try to push the dilator into the uterus. The cervix also is very liable to be torn by the dilator, so that I prefer INTERRUPTED GESTATION 529 the more gradual method of dilating with tents. This tearing always begins on the inside. These matters are especially referred to in Chapter XXVIII. After the cervix is dilated, the uterus must be thoroughly ex- plored, to see how much of the ovum is left behind ; and let me again Fig. 248.— Plugging the Cervix with Gauze. (Bumm. say, in a case of abortion, if there is the least doubt of anything having been left, the uterus should always be explored with the fingers. I do not favour the curette, except in very early abortions. Apart altogether from the danger of the curette when the uterus is soft, as it is in pregnancy, there is the difficulty of removing the whole ovum with it, for it slips round the ovum, and merely breaks 34 580 OPERATIVE MIDW IFEB.Y it up. There is nothing bo good ae the fingers tor removing an in- complete abortion. I frequently run over the uterine Burface with ;l curette after I have removed the ovum. The douche cur< (Fig. •-!!!») is very suitable. The operation is carried out as follows: Having lixed tlie cervix with vulsellum forceps, the curette i- 'are- 3 ■.<:i. l ,.».a.v..,:K«.i.i.:,- fc ^-^- Fig. 249 Douche I lorette. fully passed into the uterus, until one feels it against the fundus. Long sweeps, from fundus to cervix, are made, and the whole surface is carefully scraped. After removing the remains of an abortion, it is always well to I give an intra-uterine douche of sterilized water, at a temperature of Fig. 250. — Bozemann-Fritsch Intra-uterine Nozzle. 118° F., to wash away all debris and to stimulate the uterus to contraction. This is best done with a Bozemann-Fritsch nozzle (Fig. 250). Budin's nozzle is also a useful form (Fig. 251). Great care must he taken that the water is not introduced at too high a pressure. I use an antiseptic douche of 1 in 3,000 biniodide of mercury only if Fig. 251. — Budin's Intra-uterine Nozzle. the uterine contents are septic. I ma_y here remark that the Rotunda siphon douche tube (Fig. 252^ is much more convenient and more easily sterilized than a douche can. A septic ovum should always be removed, if possible, without the curette. In two septic incomplete abortions recently curetted an anterior pelvic cellulitis followed — I believe as a result of the treatment employed. When the os is sufficiently dilated there is no difficulty ; the ovum is removed with the lingers. When, however, INTERRUPTED GESTATION 5:51 the os is closed and difficult to "dilate, one has to choose between plugging with gauze, the insertion of a sea-tangle tent, immediate dilatation with metal dilators, and incising the cervix, before one can clear out the uterine contents. When a diagnosis of missed abortion has been made, the only question to settle is, Should the uterus be emptied immediately, or should one wait until the ovum is expelled ? Of course, there can be Fig. 252. — Rotunda Siphon Douche Tube. no question of waiting if there are any disturbing symptoms; but even if there are not, many believe in emptying the uterus, as they consider a dead body in the uterus is a constant source of danger. Others, however, hold a different view, and would wait until uterine contractions come on spontaneously. My own attitude is to remove the ovum if there is the slightest discharge or discomfort, and if the knowledge of its presence is an irritation to the patient. Otherwise I leave the ovum to be expelled spontaneously. >82 OI'EKATIYK MII>WII'K1;Y Hydatidiform Mole (Vesicular Mole, Dropsy of Chorion, Cystic Degeneration of Chorion, Myxoma of Chorion). This disease of the chorion is a cystic degeneration of the terminal villi. It may occur at any time of reproductive life, although Fig. 253. — Portion of Hydatidiform Mole. (Author's Collection.) it is a little more common between the ages of thirty and forty than before or after these years. In general appearance the mole resembles a large bunch of small grapes ; consequently the Germans speak of it as a ' Traubenmole ' (Fig. 253). On examining one of these affected INTERRUPTED GESTATION 533 villi, it will be observed that the villus is not altered throughout its entire course, but that swellings occur here and there along its wall. These cysts vary in size, but they are rarely much larger than a hazel-nut. As a rule, the disease attacks the ovum at an early period of its existence, and invades the greater part of the chorion. In the more marked cases of the disease early death of the embryo occurs, so that often no trace of it is to be discovered. In other cases only a small portion of the chorion is affected. Should this be very slight in amount, the general nutrition of the foetus may be little interfered with, and pregnancy may continue undisturbed. Fig. 254. — Microscopic Section of a Portion of Uterine Wall invaded by the Villus of a Hydatid Mole. The microscopic changes consist in a destruction of the stroma of the villi, more particularly in those parts where the vesicles are present. It is generally stated that the bloodvessels are also to a large extent obliterated. In the more marked cases of the disease, however, it is probable that no vessels have ever existed; the villi are really nourished from the maternal tissues. As regards the epithelium covering the villi, it is found that both layers undergo proliferation of a very irregular character. The syncytium is very irregularly developed, and the nuclei are large and vesicular. Numerous vacuoles are present in the protoplasm. Here and there great proliferation of Langhan's layer is observed. All these features may be seen in the accompanying illustration (Fig. 254) from my third case of chorion- epithelioma. The tumour followed a hydatidiform mole. The uterus 534 OPERATIVE MIDWIFERY was removed. The operation was performed four years ago, and the woman is still in perfect health. In recent years attempts have heen made to differentiate what might be termed malignanl and benign forms of vesicular mole. Observations, however, in this direction have heen very disappointing. There is no means of telling by microscopically examining a portion of a mole removed whether the proliferation of the epithelium is ol a Fig. 255.— Chorion-Epithelioma. (Author's Collection.) benign or malignant character. All moles are potentially malignant. The development of a chorion-epithelioma would appear to depend chiefly upon the completeness with which the mole is expelled or removed. Some moles penetrate the uterine wall much more than others ; indeed, there are a few cases on record — as, for example, one by Martin — where rupture of the uterus occurred through the mole penetrating the wall. In these cases, where the wall is much eroded. INTERRUPTED GESTATION 535 it is more difficult to remove the diseased chorion completely; con- sequently chorion-epithelioma is more likely to follow. As regards chorion-epithelioma, I need not remind my readers that a vesicular mole is not necessary for the development of this disease ; it may follow any pregnancy. There are cases — as, for example, Schlagenhaufer's 1 — where metastatic deposits formed during preg- nancy, although the uterine contents were apparently perfectly normal. I cannot, however, further discuss here this most interesting tumour. Symptoms. — In cases where only a very small part of the chorion is affected there are no symptoms, and pregnancy continues undisturbed. When, however, the disease is at all extensive, well-marked and char- acteristic symptoms exist. There are the ordinary early subjective symptoms, such as sickness, pain in the breasts, and suppression of menstruation ; in addition the woman, as a rule, feels out of sorts, and is often very anemic. There is usually great enlargement of the uterus: indeed, the must striking feature is that the distension is out oj all proportion to the age of the pregnancy. In a case which was recently under my care the woman thought herself three months pregnant, but when I examined her, I found the fundus two inches above the level of the umbilicus. On palpating the distended uterus, it is found to be globular in form and tensely elastic to the touch. It is commonly stated that the uterus feels soft and boggy ; this sensation was only experienced in one of the six cases which have been under my care. Pain is often complained of over the uterus, and this is usually increased by pressure. Another striking and absolutely characteristic symptom is a sero-sanguineous discharge, with some of the vesicles floating in it. This, however, is not always present. Not infrequently the discharge takes the form of irregular hemorrhages, which in no way differ from those occurring in an ordinary abortion. When the chorion is extensively affected, abortion usually occurs about the fifth or sixth month ; very rarely indeed is the ovum retained longer. The hydatidiform mole in its typical form — that is to say, where there is rapid distension of the abdomen, and the characteristic discharge containing the vesicles — is easy of diagnosis ; but where the menstrual history is vague, and the discharge is simply sanguineous, the diagnosis may be very difficult until the os is dilated, the finger inserted, and the shaggy chorionic villi felt. Even then, if the vesicles do not come away, the accoucheur may think at first that he has to deal with a placenta previa. That mistake was actuallj 7 made in one of my six cases. A prognosis in this disease must be given with considerable 1 Wien. Klin. Woch., 1899, No. 2, p. 18. 586 OPERATE E MIDWIFERY caution, for not only is there immediate danger of rupture of the uterus, haemorrhage, and septic infection, bu1 there is also the latex danger of chorion-epithelioma (Fig. 255). (In my six cases of hydatidiform mole two developed chorion-epithelioma, while in my four cases of chorion-epithelioma the abortion was only once a vesicular mole.) Treatment. — Whenever thecondition is recognized, the uterus mast be carefully and thoroughly emptied. If the os is sufficiently dilated, no difficulty will be found in doing this ; but if the cervix is not sufficiently patent, the cervical and vaginal canals should be plugged with sterilized gauze until there is sufficient dilatation. For the removal of the mole the fingers should be employed. It is of great importance that the uterine cavity should be thoroughly evacuated, as any portion of the mole left behind may form the nidus for a chorion-epithelioma. The most difficult cases are naturally those in which the degenerated villi penetrate deeply into the uterine wall. In these cases great care must be exercised in scraping with the fingers, as the uterus may be very readily perforated. While the wall is being scraped with the fingers the external hand should steady the uterus, and should always be applied over the part that is being scraped. The operator who has extensive experience of curetting the uterus may employ a blunt curette with extreme caution, but I would advise the general practitioner not to employ the curette, but to trust entirely to his fingers. After removing the mole a hot intra-uterine douche should be given, with the object of washing away all debris and stimulating the uterus to retract. It is advisable after douching to go over the uterine surface once again with the fingers, paying special attention to any areas in which the uterine wall has been deeply eroded. A second douche should then be given. A patient from whom a vesicular mole has been removed must be very carefully watched. Should any septic mischief arise, a weak antiseptic douche should be given night and morning till the tem- perature subsides. For some months, too, the woman must be seen at short intervals, in case chorion -epithelioma should develop. This will manifest itself by a recurrence of hamorrhage. Should such a condition arise, the uterus must be extirpated immediately. In addition the general health of the patient should be attended to, and tonics, especially iron and strychnine, should be administered. It is advisable to caution the patient against becoming pregnant until a considerable time has elapsed. CHAPTER XXXII ECTOPIC PREGNANCY— PELVIC HEMATOCELE— PREGNANCY IN RUDIMENTARY HORN (CORNUAL PREGNANCY) In considering extra-uterine pregnancy I shall confine my remarks almost entirely to the clinical and operative aspects of the subject. The etiology and the minute pathology of this most interesting condition I do not intend to discuss, as they would necessarily take up a large amount of space, and are outside the province of the present work. I must, however, refer to the grosser changes which occur in the tissues as a result of extra-uterine pregnancy, so that I purpose considering the subject under the three following headings : (1) Pathological Anatomy. (2) Clinical Features. (3) Treatment. Pathological Anatomy. Although it is possible for the ovum to become implanted anywhere between the ovary and uterus, it is found with few exceptions that it is to the interior of the tube it becomes attached in the first instance- Until recently the old idea of ' ovarian ' and ' abdominal ' pregnancy was doubted by every one, and absolutely denied by not a few. In the face of recently recorded cases that extreme position has been abandoned, and every one now admits the possibility, not only of primary ovarian, but even of primary abdominal pregnancy. With our increasing knowledge of tubal pregnancy, it has been found that the ovum may attach itself to different parts of the tube, and that these different situations vary in point of frequency. Not only that, but the course the pregnancy runs is very consider- ably influenced by the site of the implantation. I shall consider ectopic pregnancy, therefore, in the following situations, and the order in which they are mentioned is the order of their frequency : (1) Ampulla ; (2) isthmus ; (3) infundibulum : (4) interstitial portion of the tube ; (5) ovary ; (G) bowel, omentum, mesentery, etc. (primary abdominal pregnancy). 537 538 Ol'KllATIVK MIDWIFERY (1) Implantation in the Ampulla. — This is much the commonest munition — in all probability because it is the widest part of the tube, in id the ovum situated then; obtains the best vascular supply. Although I do not intend to discuss the microscopic pathology of ectopic pregnancy, I must refer in a word or two to what happens when the fertilized ovum becomes implanted in the tube. I shall be as brief as possible, and shall point out only the features that have a bearing upon the subject from the practical side. There is no specimen of tubal pregnancy so early as Peters and Leopold's youngest uterine ovum, but there have been several young enough — especially Filth's — to satisfy every one that what takes place in a uterine pregnancy takes place also in an extra-uterine. The fertilized ovum buries itself in the wall of the tube. This occurs uo matter whether the ovum primarily becomes attached to a crest or a trough of the wavy mucous membrane (so-called columnar and inter- columnar insertions). It does this by means of its trophoblast, and illustrations showing this may be seen in such papers as those of Berkeley and Bonney 1 and Fiith. 2 All the tissues are affected — muscular, connective tissue, blood- vessels. A decidua capsularis (reflexa) is sometimes found, but in many cases the ovum is so deeply embedded in the tube wall that there is hardly any bulging of the sac into the lumen of the tube. The connective tissue cells become altered and take on the appearance of decidual cells to a varying extent. Sometimes the tube away from the sac and even the other tube share in this change. There is, however, no well-formed decidua, as in the uterine pregnancy. From the practical standpoint the damage done to the bloodvessels is the most important. These have their walls eroded by the trophoblast, just as occurs in the uterine vessels in the formation of the inter- villous space. In the uterus there is the support of a thick, dense muscle wall, but in the tube there is nothing of this : the thin sheets of circular and longitudinal fibres are, therefore, soon broken up and destroyed. Sooner or later the tendency is for the ovum to have its connexions with the tube wall disturbed, by reason of minute intra- mural hemorrhages. With the ovum embedded in the ampulla several terminations are possible: (a) Tubal abortion, complete or incomplete; (M tubal rupture ; (c) formation of a mole, with subsequent changes — atrophy or disintegration of it ; (d) continuance of the pregnancy to the later months or even term. (a) Abortion. — As Werth has very rightly pointed out, this may be 1 Journ. Obst. cmd Oyn. Brit. Empire, February, L905. '-' ArcMvf. Qyn., Bd. Ixiii., p. 97. ECTOPIC PREGNANCY 539 described as an internal rupture of the gestation sac, just as the second termination of rupture of the tube may be termed ' external rupture.' The whole ovum may be shed from the tube, or only part may be separated, when the abortion, comparing it with a uterine one, is incomplete. With this termination there is some bleeding into the peritoneal cavity, but it is seldom great, and ceases after the ovum is completely expelled. When, however, the abortion is incomplete, a ' drip-drop ' of blood continues from the end of the tube, and this blood gradually accumulating, forms a hematocele more marked on one side of the pelvis, and often made up of blood of different ages. (Pelvic hema- tocele is considered later, p. 571.) The tube, after complete abortion, very soon resumes its normal appearance, just as the uterus does after expelling its contents prematurely. Everything then quietens down, and the hematocele that forms in time disappears. With incomplete abortion, however, there are recurrences of abdominal pain and hemorrhage, the symptoms which we shall see are the features of ectopic pregnancy. (b) Rupture of the Tube. — At one time this was considered the commonest termination, but it is now known to be less frequent than tubal abortion. I have explained how it is sometimes termed ' external rupture ' of the gestation sac. There is another variety of rupture, according to Berkeley and Bonney 1 — namely, 'intramural' — which these writers compare to the change occurring when a sacculated aneuiysm becomes diffuse. In many cases, no doubt, this is a stage prior to ' internal ' and ' external ' rupture about to be referred to. When rupture occurs, it takes place as a rule between the sixth and tenth weeks, although it may occur much earlier than that date. The rupture and accompanying hemorrhage may take place into the general peritoneal cavity (intraperitoneal), or between the layers of the broad ligament (extraperitoneal), for the tube is not completely surrounded by peritoneum, being uncovered along the lower part of its wall, where the layers of the broad ligament come together. Bupture directly into the peritoneal cavity is much the most frequent termination, and, as might be expected, is the more serious, for there is no let or hindrance to the effusion of blood. With the extraperitoneal, the layers of the broad ligament limit the hemorrhage, although, it must be remembered that they do not always do so. I have, for example, seen an effusion of blood into the broad ligament so extensive that the hematoma extended up as high as the umbilicus, although the gestation sac was only two months old. Paipture of the gestation sac may be sudden, a large quantity of 1 Journ. Obst. and Gyn. Brit. Empire, June, 1906, p. 446. 540 OPERATIVE .MIJ)\VIli:i;V blood being poured out into the peritoneal cavity, and the patient becoming profoundly collapsed in a very few minutes. More commonly, however, the rupture is gradual (Fig. '25);). The sac wall is eroded by the cells of the trophohlast, and later by the chorionic Fig. 256.— Ruptured Tubal Pregnancy. The body below the tube is the ovary ; the body above is the ovum turned upwards fiom where it was attached to the tube ; the point "f the probe is projecting through t lie rapture in the tube. (Author's Collection.) villi. In such cases there may be recurrent attacks of bleeding, abdominal pain, and syncope. When the whole ovum is suddenly expelled into the peritoneal cavity, it usually dies ; it is questionable if it can re-ingraft itself on a peritoneal surface. Sometimes, however, where the pregnancy has ECTOPIC PREGNANCY 541 idvanced farther and the rupture is gradual, the placenta remains ittached in the tube, and develops there and in the surrounding iissues, while the ovum goes on growing in the free abdominal cavity. For such an occurrence it is usually necessary that the foetal membranes •emain intact, but it is now known from one or two specimens that the ['cetus may continue to grow, although its membranes have ruptured. The condition is comparable to what sometimes occurs in an intra- uterine pregnancy (Grossesse, ' Extra-Membraneuse,' p. 148). Sooner or later, however, the foetus dies in these cases. Rupture of the tube between the layers of the broad ligament is, as I have already said, of rare occurrence. In fifty-four cases it occurred in five, but that is a very much higher proportion than is usually found. Here, again, death of the ovum usually results, and a hematoma forms of varying size. Later, a secondary rupture into the peritoneal cavity may take place. Quite recently I had an example of this, where I enucleated from the left broad ligament an ectopic sac, which, from the history, had first ruptured into the broad ligament and later into the peritoneal cavity. In a few cases the growth of the ovum continues in the broad ligament, and the two layers become more and more separated ; in fact, many of the cases of extra-uterine pregnancy which advance to the later months are of this variety. The form is spoken of by various names — ' extraperitoneal,' ' subperitoneal,' ' pelvic,' or ' broad- ligament ' gestation. As the pregnancy advances the layers of the broad ligament become still farther separated, the peritoneum becomes stripped off the bladder and rectum, and pushed up by the enlarging gestation sac, which displaces all organs in its growth. This advanced variety is spoken of as ' subperitoneal abdominal pregnancy.' When it has reached the later weeks the sac seldom ruptures. If it should advance to term, a spurious labour occurs, with painful uterine con- tractions and the shedding of a uterine decidua. The fcetus at this time, if not extracted by abdominal section, soon dies. If retained, as it has been in not a few cases, it becomes mummified, altered into a lithopedion, or disintegrated and expelled through bowel, abdominal wall, bladder, etc. (c) Tubal Mole. — In this variety the ovum is surrounded by layers of blood-clot (Fig. 257). Rupture may arise, or if it is retained it shrivels up, or, its tissues becoming disintegrated, a hematosalpinx forms. Suppurative changes may even occur and the sac become infected. In such cases the patient seldom continues absolutely free from symptoms of abdominal discomfort ; there is usually a dragging pain, irregular menstruation, and a general feeling of abdominal uneasiness. 542 OPERATIVE MIDWIFERY (il) Pregnancy may advance to Full Term without Rupturi of the Sac. — Such cases .ire extremely rare, but bhey do sometimes occur. The growing sac usually contracts adhesions to the surrounding structures, and displaces these to a greater or less extent. But oc sionally the sac may be free, as in a most interesting case described by Amos, 1 where there were only adhesions in the neighbourhood of a small perforation of the sac wall. The placenta was situated at that point. (2) Implantation of the Ovum in the Isthmus of the Tube. — It is only within recent years that implantation in the isthmus of the tube has been recognized to present features different from the variety previously described, where the ovum is lodged in the ampulla. "While Fig. 257. — Tubal Mole. (Author's Collection.) theoretically the different terminations already described for the previous form may also occur in this one, it is found in practice that rupture is peculiar!;/ frequent, and occurs generally at a very early date — often, indeed, as early as the second or third week — and often before any menstrual period is missed. The explanation of this early rupture is that the muscular fibres are peculiarly scanty and poorly developed, so that the ovum readily perforates the tube wall. (3) Implantation of the Ovum on the Infundibulum. This implantation may be directly on the infundibulum, or on the elongated ovarian fimbria. The occurrence is a very rare one. The ovum 1 Zeit.f. Geb. u. Qyn., Bel. liv., Heft 1, p. 169. ECTOPIC PREGNANCY 543 either becomes separated, or, contracting adhesions to the surrounding parts, continues to develop. (4) Implantation of the Ovum on the Interstitial Portion of the Tube. — In this form of extra-uterine pregnancy the uterus is found much enlarged in one corner. As giving an idea of its rarity, I would mention that Werth l states that in 120 operations for ectopic pregnancy he had not met an example of this form. Personally, I have had one case in my series of fifty-four. Subdivisions are sometimes made of interstitial pregnancy — the one tubo-uterine, where the sac extends into the uterine cavity, and the other utero-tubal, where it extends into the tube, and really is a variety of implantation in the isthmus. In its typical form the ovum, attached between the uterine and abdominal openings, grows in the wall of the uterus and dissects up the muscular layers. The corner of the uterus is pushed upwards, the sac enlarging especially in that direction. Sooner or later rupture takes place, occasionally into the uterine cavity, but most commonly into the peritoneal cavity. It is attended with very profuse haemor- rhage, as large vessels are usually torn. It is generally stated that rupture is a late occurrence, often not taking place until the fifteenth or sixteenth week, but from the following table given by Werth 2 it will be seen that rupture not infrequently occurs early. Here is his list : First month ... 1 Third to fourth month ... 2 First to second month ... 3 Fourth month ... 4 Second month ... 4 Fourth to fifth month ... 4 Second to third month ... 6 Fifth month ... 3 Third month ... 4 Fifth to sixth month ... ... 1 The following is a brief history of my own case (Fig. 258) : Mrs. X was sent to me by Dr. Rennie, of Coatbridge, on account of an abdominal swelling, which he considered to be an ectopic sac. The history was as follows : The woman, a multipara, was suddenly seized, when about seventeen weeks pregnant, with severe abdominal pain. Within a very short time she was profoundly collapsed — indeed, so collapsed was she that her doctor did not think she could possibly recover. With restoratives and transfusion, however, she slowly rallied, and ultimately became quite well. When I saw her I could distinguish a swelling elongated vertically, of about the size of an ostrich egg, occupying the hypogastric and right iliac areas, and extending up to about the level of the umbilicus. On bimanual palpation this swelling was intimately connected with the uterus. The uterus could not be distinguished from the swelling, but on the left side there was a little knob, from which the lqft appendages seemed to run off'. In writing to Dr. Rennie I pointed out to him that if the case was one of extra-uterine 1 Winckel's ' Handbuch der Geb.,' Bd. ii., Teil ii., p. 739. - Op. cit. 5 l l Ol'KltATIVK MIDWIFERY pregnancy, it must bo of the interstitial variety. A few days later, in the Alexandria Cottage Hospital, Coatbridge, I operated upon the patient. I must here thank l>rs. Etennie, Macphail, and Wilson for their trainable assistance. ( ta opening the abdomen I found the tumour as described, most intimately associated and adherent to the Burrounding intestine,. With Gravid Baa Uterus. Fig. 258. — Interstitial Ectopic Pregnancy. (Author's Collection.) great difficulty I separated these adhesions, and then found the sac. which had given way at one part, and through which a foetal limb could be seen. So intimately was the sac connected with the uterus that I decided the easiest course to pursue would be to remove that organ along with the tumour. This I did, and the specimen is seen in the illustration. The patient, although very much collapsed after the operation, which was a prolonged one, made an uninterrupted recovery. ECTOPIC PREGNANCY 545 The diagnosis of this variety of ectopic pregnancy is often very difficult. It closely resembles angular pregnancy (p. 502), pregnancy in a rudimentary horn (p. 574), and pregnancy in a septate uterus (p. 800). (5) Implantation in the Ovary (Ovarian Pregnancy). — Every one now admits the possibility of ovarian pregnancy. There are several well-authenticated cases — for example, those of Kouwer and Fig. 259. — Ovarian Pregnancy. (Author's Case.) A, Tube ; B, ovary ; C, ovum projecting from ovary ; D, rupture. Katherine van Tussenbroek, 1 Thomson, 2 Anning and Littlewood, 3 Mendes de Leon and Holleman. 4 My own case is here illustrated (Fig. 259). It is fully described, along with an extremely early ovum, in a work entitled ' A Contribution to the Early Embedding of the Human Ovum,' by Professor Bryce, of Glasgow University, Dr. Teacher, of the Pathological Institute of the Royal Infirmary, and myself. 1 Annal. de Gyn., December, 1899. 2 American Gyncecoloyy, 1902, p. 1. 3 Lond. Obst. Trans., vol. xliii., p. 14. 4 Bev. de Gyn., June, 1902, p. 387. 35 546 OPERATIVE MIDWIFERY Ovarian Pregnancy associated with an Intro-Uterine Pregnan Mra MoD — -, a patienl of Dr. Wilson's, of Greenock, came to Glasgow to spend the Christmas holidays of L902. She delayed going home, however, on account of one or two attacks of abdominal pain, which she attributed to errors in diet. She supplied me with the following details : Sheistwenty- seveu years of age, has been married for two years, and has one child, now eleven months old. She nursed the child for a few months, bul then gave it up, as the supply of milk was not sufficient. During the whole time of lactation she menstruated regularly. <)n November 20 -lie became unwell for the last time, and as she had no period in December, she considered herself pregnant. There was no sickness or vomiting, however. On New Year's Day, 1903, she felt a little backache and pain in the lower part of the abdomen ; this pain was in the form of spasms, hut did not quite resemble intestinal colic, although she thought that was the cause of her discomfort. She had a second severe attack of pain on the night of .January 8. I saw her on January 9, 1903, when I found her in bed, with a pulse of 90 and a temperature of 100'4°. She had had some sickness and vomiting during tin- night ; there was no vaginal discharge. On examining the abdomen it was found slightly distended and rigid, more especially over the light iliac region. On bimanual examination the uterus was freely movable, enlarged, ami pushed forward to the left by a soft elastic swelling behind and to the right of the uterus. The diagnosis of extra-uterine pregnancy was made. Tin- patient was removed to a nursing-home. On January 13 I opened the abdomen. The operation presented no great difficulties. On opening the abdomen a considerable quantity of blood welled up ; in all about two pints of black blood were removed from the abdominal cavity. When I pulled up the right appendages I was expecting simply to find a ruptured tube. I was surprised to find the tube was quite free and undisturbed, and had no blood- clot attached to it; indeed, to the naked eye it appeared perfectly normal. On looking at the ovary, however, the thought of ovarian pregnancy at once occurred to me, for projecting from the inner margin of the ovary was a hemorrhagic mass about the size of a walnut. With great care I removed the tube and ovary, and placed the specimen in a weak solution of formalin. The completion of the operation presented nothing of note ; all blood-clot was carefully removed, and the abdominal wound closed in layers. The uterus was unusually large and soft; I was very suspicious that there existed also a uterine pregnancy, and I informed the husband of this. The recovery of the patient was absolutely uneventful, and she returned home in about four weeks. On the 274th day from the first day of the last menstrual period — viz., August 19 — the patient gave birth to a full-time healthy child, so that my surmise that the uterus was pregnant at the time of the operation turned out to be correct, and I had, therefore, the unique example of a coexisting ovarian and uterine pregnancy, the latter being undisturbed by the removal of the sac of the former. ECTOPIC PREGNANCY 547 In the specimens of ovarian pregnancy which have been described within the last few years, rupture has occurred at a comparatively early date. In my case it occurred about the fifth week. Some of the other specimens, however, are older. A specially interesting one is that described by Menge, 1 an ovarian pregnancy of nearly full time, with a coexisting uterine pregnancy. The diagnosis of a tumour obstructing labour was made. When the tumour was opened it was found to contain a fully-developed living foetus. In regard to ovarian pregnancy, round which so much discussion has taken place in recent years, it has been generally admitted that the following conditions, laid down by Spiegelberg, must be fulfilled before an ectopic pregnancy can be pronounced truly ovarian : (1) Absence of ovary of corresponding side ; (2) elements of ovarian tissue in the wall of the sac ; (3) attachment of the sac to the uterus by the ovarian ligament ; (4) no part taken in the formation of the sac by the tube, and a topographical relationship similar to that found in large ovarian tumours. Lawson Tait, 2 always a sceptic as regards ovarian pregnancy, wrote : ' The uterus and both tubes would have to be recorded as intact, and we should have one ovary present and the other not to be accounted for, save by its existence on the cyst of the ovum ; and in the cyst wall of such a case microscopic evidence of the presence of the ovarian tissues would be required.' Primary Abdominal Pregnancy. — When one excludes all the older cases of so-called abdominal pregnancy, most of which are examples of secondary abdominal pregnancy, or primary implantation on the ovarian fimbria, there are very few cases indeed in which one can say the ovum was primarily attached to the peritoneum. Par- ticularly difficult is this if one admits the possibility of a tube aborting or even rupturing, and the expelled ovum re-ingrafting itself upon the peritoneum and then developing. Amongst the most interesting cases recorded is that of Galabin, 3 whose specimen was carefully examined by a committee of the Obstetrical Society of London. In that case the only thing against its being an example of primary abdominal pregnancy was the possi- bility of its being a tubal abortion, where the ovum had re-ingrafted itself on the peritoneum and then developed. The committee favoured the idea that the case was a genuine one of abdominal pregnancy. Of course, the possibility of re-implantation could not be excluded ; that will never be possible until it has been proved that an ovum cannot be detached and re-ingraft itself elsewhere. 1 Munch. Med. Woch., 1907, p. 2452. 2 ' Diseases of Women,' 1889, vol i., p. 444. 3 Trans. Lond. Soc, vol. xxxviii., p. 88. 548 OPERATIVE MIDWIFERY \ incenzo 1 recently reported a case where the sac was quite free, and felt like an ovarian cyst. Tpon opening the ahdomen the sue had adhesions only to the bowel and omentum. The uterus and append- ages were normal in appearance and position, and the sac had no connexion with them. Changes in the Uterus and Surrounding- Tissues as the Result of Ectopic Pregnancy.— As a result of extra-uterine preg- nancy the uterus becomes altered in size, shape, and consistency. r« ■ f. A rl+ Fig. 260. —Ruptured Tubal Pregnancy, with Decidual Formation in Uterus. (Hunterian Museum, R. R. 376, Teacher's Catalogue, vol. ii.. p. 757.) At first the ectopic sac is too small to affect the position, but later the uterus may be displaced forwards, backwards, or to the side. It is also displaced upwards, but downwards hardly ever, for even with a large sac, such as a pregnancy that advances to the later weeks, the uterus is dragged up, not pushed down. In size it steadily increases, sometimes as much as one or two inches. In shape also it becomes slightly more globular, and in consistency softer. These two latter features, however, are not uniformly prominent. 1 Gynecologia, 1905, fasc 6; ref. Zcnt. f. Gyn., 1906, p. 412. ECTOPIC PREGNANCY J49 Apart from the increase in size, the most striking change occurring in the uterus is the alteration of its mucous membrane into a decidua {Fig. 2G0). The formation of this decidua takes some little time, so Fig. 261. — Uterine Decidual Cast from a Case of Ectopic Pregnancy. (Author's Collection.) that in those rare cases in which rupture of the tube occurs in the early weeks, a properly-formed decidua may not exist. Both macro- PWF^-^I' '■■ ■■'■ ■VI'. ' I'.' 1 f\ <■ '■'■J 1 '' I'' '■•'' v' fa. } i "tn^ j M-'-: : .yy\ .'■■:■ ^■■>.,,.^.: ■■■■■■ ■ '>i'V'S W . '■." i't ;■ %■""■ K> " • /''•- 'si- "' '<:'. ■?■''• •• Fig. 262. — Uterine Decidua in a Case of Uterine Abortion. (Teacher.) scopically (Fig. 261) and microscopically the decidua of extra-uterine pregnancy resembles the decidua that forms in the uterus in an ordinary pregnancy. 550 Ol'KKATIYE MIDWIFERY \ stratum compactum and spongiosum can be distinguished, tin- glands in the deeper part may he observed compressed and oblique, and the epithelial cells flattened (Figs. 262 and 268). The whole interglandular stroma becomes oedematous, and the typical decidual cells are everywhere evident. The shedding of the decidua, which ifl generally stated to be so characteristic a feature of ectopic pregnancy. is not by any means constantly observed. It usually takes place at %sm Fig. 263. — Uterine Decidua in a Case of Ectopic Pregnancy. (Teacher.) the time the tube ruptures or aborts. Very generally it comes away entire ; and once shed, no new one forms, should by any chance the pregnancy continue. It need hardly be mentioned that the enlarging sac disturbs the relationship of all the surrounding structures. Clinical Features. Having considered the macroscopic appearances of the tissues affected in ectopic pregnancy, it would be very satisfactory if, under the present heading of clinical features, I could present to my readers simple pictures of the symptomatology of each of the varieties which have been described. Many writers have attempted to do this. I have always felt, however, that while that was a thoroughly scientific method of approaching the subject of symptomatology, it led to confusion in the reader's mind, unless he was very familiar with ectopic pregnancy and had encountered examples of the complication in practice. I will leave, therefore, what I have already written as a separate entity, and try now to present ectopic pregnancy as one sees it in practice at the bedside. It is very interesting when the operator has ECTOPIC PEEGNANCY 551 removed the sac to know where the latter was situated, whether it was a tubal abortion or a tubal rupture, and whether the rupture occurred into the layers of the broad ligament, or into the general peritoneal cavity ; but such questions have really no practical bearing on the treatment, and cannot be more than suspected until the abdomen is opened. As far as my personal experience of this condition goes, I would say that cases of ectopic pregnancy may be placed, at the bedside, in the four following groups : (1) The woman is struck down suddenly with abdominal pain and profound collapse. (2) The woman suffers for some time from abdominal uneasiness, pain, occasional faintings, and hemorrhagic vaginal discharge. (3) The woman advances in her pregnancy to the later weeks. (4) The woman suffers from a pelvic hematocele. The cases belonging to Group 2 are the most important, and very much the most numerous ; they, however, are often overlooked until they pass into Group 1, or very occasionally into Group 3. Group 4 always passes through 1 or 2. (1) The woman is struck down suddenly with abdominal pain and profound collapse. This type of acute tubal rupture is by no means common. It is seen in its most typical form when the ovum is in the isthmus of the tube, although it may also occur even when the situation is the ampulla. If one questions the patient regarding menstruation, there may or may not be the history of a period missed. It all depends upon the age of the pregnancy, and what might be termed the ' malignancy of the ovum.' There are no premonitory attacks of abdominal pain or sanguineous vaginal discharge ; the woman is perfectly well one minute, and is suddenly seized with abdominal pain, the feeling of something giving way, and then collapses. Here is a case : A young married lady, aged twenty-five, the mother of one child, born three years previously, was seized one afternoon, while going about her ordinary household duties, with severe abdominal pain ; she fainted and fell. The housemaid, who happened to be on the same landing, heard her fall and rushed into the bedroom. With considerable difficulty she lifted her mistress on to the bed, and immediately sent for a doctor. The doctor, on his arrival, fifteen minutes later, found the patient conscious, but very pale, and with a small thready pulse of about 150 or 160. Appreciating fully the gravity of the condition, he called in a surgeon. When they questioned the patient, there was no history of any previous illness, and there had been no menstrual period missed. Both, however, were convinced that some abdominal viscus had given way, and they decided that the abdomen must be opened. This 552 OPERATIVE MIDWIFERY was done as soon as preparations could be made. The upper part of t lie abdomen was explored first, but nothing abnormal could be detected there. The operator then passed his hand down into the pelvis, and immediately blood welled up. The nature of the condition was then apparent— an early tubal pregnancy had ruptured. The tube was removed, and ;i rupture was dis- covered in tlie isthmus close by the uterus. The history is so striking in this type of case that there should never he any difficulty in coming to a diagnosis. The diagnosis, how- ever, must he based upon the history and appearance of the patient, for in these cases of early rupture nothing may he felt on hiinanual examination. The tube which has ruptured is soft and collapsed, and the blood which is poured into the abdominal cavity may take some time to make itself distinctly felt as an effusion in the pouch of Douglas. Later the blood collects, and is felt behind and around the uterus as a pelvic hematocele. The conditions which simulate this variety of what may be called ' acute ' or ' fulminating tubal rupture ' are : (a) rupture of a gastric or duodenal ulcer; (6) a fulminating appendicitis; (c) torsion of a pedunculated tumour, most generally of the ovary. In none of these conditions, however, is the collapse so profound or so rapid. There may be faintings, which blanch the face and disturb the pulse, but whenever these pass off there is recovery for a time, followed, of course, by progressive abdominal symptoms. In the case of a perfor- ating gastric ulcer there may be a history of old-standing disturbance, and in palpating over that region there is tenderness and rigidity. (Confusion arises sometimes from the fact that occasionally in cases of acute rupture of a tube the pain is referred to the upper part of the abdomen.) With a fulminating appendicitis there will always be tenderness and rigidity over the region of the appendix. I need not remind my readers that the pain following a ruptured duodenal ulcer is sometimes referred to the region of the appendix. The third condition which may simulate a sudden rupture of the tube is torsion of the pedicle of an ovarian cyst. The resemblance becomes marked if, in addition to the severe pain complained of, there is a hemorrhagic discharge. This is not uncommon with a twisted pedicle. Should the case be seen shortly after the attack of pain and collapse, the diagnosis will be easy if a distinct tumour is felt from the vagina. With intraperitoneal hemorrhages no tumour (hematocele) is felt, for, as I have said, the effusion of blood takes some time to collect and coagulate. With an ovarian tumour, on the other hand, if the tumour projects into the pelvis it can always be felt. When, however, it does not project into the pelvis it may be difficult to define, as the abdomen is so rigid. ECTOPIC PREGNANCY 558 I do not purpose taking up any longer time with this type of case, for there is really no danger of its being overlooked ; the woman is so ill that operative interference is obviously necessary. Naturally, mistakes in exact diagnosis are most often made by the general surgeon, who not infrequently loses a little time in searching for the mischief in the region of the stomach or duodenum, because he most frequently meets with these cases. Should he approach the appendix first of all, no time will really be lost, because he will find the effusion of blood whenever he passes his fingers down towards the pelvis. (2) The woman suffers for some time from abdominal uneasi- ness, pain, and occasional faintings and haemorrhage vaginal discharge. This type is much the most common. I may mention that all except two of my fifty-four cases presented at one time the clinical features of this group. Some of them had passed into the first group and one into the third before I saw them, but all of them except two had premonitory symptoms for some time before the severe collapse. It is of the greatest importance that the medical practitioner appreciates this, and remembers that the subjects of ectopic pregnancy are not, as a rule, struck down suddenly without warning, but that they have premonitory symptoms or warnings, generally of so marked a character as to cause them to call in medical assistance. I feel sure this is not fully appreciated. Most practitioners, if they think of ectopic pregnancy, picture a woman suddenly pros- trated by internal hemorrhage. Certainly such cases occur, as we have seen, but they are very much the exception. Anyone can recognize them, for the extreme collapse is apparent, but for the full appreciation of those of the group we are now to consider, a knowledge of the condition and an alert and judicial mind are necessary. In this group of cases of the very first importance is the clinical history. In no disease that I know of is a careful consideration of the history more important than in ectopic pregnancy. To illustrate my point that there are usually abdominal disturbances and discomforts for some time before the collapse, let me give notes of a few of the cases which have been under my care in recent years. CASE I. — Seen in consultation with Dr. B ■ and Dr. D , of a neighbouring town. Patient blanched, pulse 140. Swelling of lower part of abdomen, extending on right side to the level of the crest of the ileum. On bimanual examination pouch of Douglas filled with hematocele ; uterus pushed forwards and upwards. Diagnosis : Ruptured ectopic pregnancy. The following history was obtained : Patient is thirty-seven, has had four children, last four years ago. No miscarriages. Last menstrual period ended on October 17. Remained well until November 15, when she was seized with a violent shivering. Fortnight later (November 30) seized with severe 554 OPERATIVE MII>Wll-i:i;Y 'cramps' in left iliac region. Seven days later (December 7) seized with similar attacks, followed by faintness. Sanguineous paginal discharge firel appeared on December I I, when there was aunt her attack of abdominal pain. At this time a tender abdominal swelling was detected in the ovarian region by her medical attendant. Twelve days later (December 22) another Bevi attack of abdominal pain, followed by profound collapse. I saw patient two • lays later ( I December 24). Abdominal section was performed in patient's house. A large quantity of blood and the ruptured right tube, were removed. With Btimulants and transfusion patient rallied, and ultimately made a complete recovery. Cask II. — A young married lady, the mother of two children, was placed in a nursing-home under my care. She was sent to me by l>r. It , ol neighbouring town, who diagnosed the condition as a ruptured ectopic pregnancy. She had been seized the previous day by a severe attack of abdominal pain and collapse. Upon bimanual examination I discovered a diffuse swelling behind and to the right of the uterus, which was pushed forward. Upon inquiry I discovered that the patient was about three months pregnant, but that she had had several attacks of abdominal pain for some four weeks previous to the severe one which ended in collapse and caused her to be sent to Glasgow for operation. A sanguineous vaginal discharge appeared after the severe attack of abdominal pain, and a decidua was expelled the day before she came under my care. When I opened the abdomen, I discovered a ruptured ampullarv preg- nancy, with a very considerable amount of free blood in the peritoneum. 1 removed the tube and blood-clot. The patient made an excellent recovery. Case III. — Mrs. C , aged forty years, 7-para, was admitted into the Western Infirmary, under my care, complaining of pain in left iliac region, and hemorrhagic vaginal discharge of six weeks' duration. A swelling] about the size of a goose's egg, could be felt in left broad ligament, displacing the uterus over to the right. From the history and bimanual examination a diagnosis of a tubal pregnancy, which had ruptured into the broad ligament, was made. The following history was obtained : Patient altered last about the end of May. Seven weeks later she was seized with irregular abdominal pains. At irregular intervals these attacks recurred, and were associated with feelings of faintness. A fortnight before admission she was seized with a specially severe attack, which was followed by collapse. A vaginal discharge appeared then for the first time. An ectopic sac was removed from the left broad ligament. The recovery of the patient was uninterrupted. Case IV. — Mrs. I) , aged thirty-six, 11 -para, was admitted to the Maternity Hospital under my care, complaining of abdominal pains and vaginal discharge. I had seen her earlier in the day, and from the history, and the fact that there was an indefinite swelling, about the size of a hen - egg, behind and to the right of the uterus, I diagnosed ectopic pregnancy. and sent her into the Maternity Hospital. ECTOPIC PREGNANCY 555 The history obtained was as follows': Her last child was born eighteen months previously. Menstruation reappeared, and was perfectly regular until September 1, when she had her last period. The period lasted from September 1 to 4. On October 24 abdominal pain began, and lasted more or less for twenty-four hours. Two days later a hemorrhagic vaginal discharge appeared. The discharge was not abundant, and consisted chiefly of dark clots. There followed a brownish-black discharge, which continued until patient's admission. From October 26 to November G patient had several severe attacks of pain and faintings. She was treated with poultices for inflammation of the womb. On opening the abdomen the right tube was found ruptured. There was a fair quantity of blood free in the abdomen and surrounding the tube (para-tubal hematocele). The gravid tube and blood were removed. Recovery was excellent. Case V. — Mrs. D was seen by me one evening in May, 1906, in consultation with Dr. N . She was in a collapsed condition. The history of the case was as follows : She had always been delicate, and had one child seven years before. Six weeks after a missed period she began to complain of abdominal discomfort, especially marked in the left iliac- region, and referred to the region of the colon. The pain was irregular, and after about ten days was associated with a slight brownish vaginal discharge. After a severe attack of pain an abdominal examination under chloroform was decided upon, but before it could be made another attack occurred, followed by profound collapse. An elastic swelling could then be felt behind and to the left of the uterus. So collapsed was the patient that the opera- tion was delayed until a fortnight later, when a ruptured gravid tube was removed. It was encysted and closely adherent to the intestines. The decidual cast was shed a few days before operation. The patient made an excellent recovery. It is at once apparent, from a consideration of the cases described, that each of them conforms to a certain type — period of amenorrhea, recurrent attacks of abdominal pain and uneasiness, hemorrhagic vaginal discharge, and feelings of faintness. But while the picture is so realistic, and can be so readily interpreted after the abdomen is opened and the sac removed, it is often a little difficult to fully appreciate the significance and gravity of the symptoms at the patient's bedside. The hemorrhage is apt to be attributed to a threatening abortion, and the pain to intestinal colic. Let us consider these symptoms seriatim, and first abdominal pain and uneasiness. The pain is caused by the intramural hemorrhages which I have described as so constantly occurring. It is also due, no doubt, to a colic in the tube, and sometimes in the uterus. Naturally, if the pregnancy advances, the muscular fibres become destroyed, and spasmodic contraction of the tube becomes almost impossible. Later, 556 OPERATIVE MIDWIFERY when blood has been effused into the peritoneal cavity, tin: pain is due in part to irritation of the peritoneum. The importance of abdominal pain cannot be too strongly empha- sized; it is always a symptom that should arrest attention. In the case of ectopic pregnancy, it is generally situated low down in the abdomen, and very often is more marked on one side, although it may extend over the whole lower quadrant of the abdomen. Very generally it is of a common aching, with more or less severe exacerbations. Along with the pain there is also rigidity more marked on the affected side. Pressure, however, does not relieve this pain .is ii docs an intestinal colic. Another point of difference between tubal and intes- tinal colic is that the abdominal uneasiness continues with tubal pregnancy, whereas with intestinal colic the woman feels perfectly well whenever the spasm passes off. In some cases, especially if the sac is on the left side, the pain is specially referred to the bowel. When there is constipation, as is the case so often, there is considerable excuse for the medical attendant considering the pain as due to irritation and colic of the bowel. Later, if there is a large effusion of blood in Douglas' pouch, great un- easiness in the rectum, with a frequent inclination to go to stool, is often complained of. I shall refer to this again in speaking of pelvic hematocele. In the cases that I have detailed it will be seen that the patients had severe attacks of pain, with intervals in which there was only a little abdominal uneasiness. It is, of course, entirely a matter of accident how frequent these attacks of pain are, or how many occur before rupture or tubal abortion. Amenorrhcea, the next symptom of importance, is usually present in cases of this group, although occasionally the abdominal pain and uneasiness may come on before there is time for a menstrual period to be missed. Again, the symptom may not be available if tubal preg- nancy occurs during lactation, or wdien there is some pathological condition associated w 7 ith amenorrhcea, such as anasmia or chlorosis. The number of periods missed varies; but in the cases here described — and I find my own cases are very similar to those described by others — the abdominal pain and discomfort come on before the second period ; that is to say, one period is missed before symptoms present them- selves. In only five of my cases was the abdominal pain delayed until after the second missed period. Naturally, amenorrhcea is a symptom of very great importance, for it at once directs the attention of the physician to pregnancy, and in association with abdominal pain to some complication of pregnancy. ECTOPIC PEEGNANCY 557 It sometimes happens that the next symptom, hemorrhagic vaginal discharge, may lead to confusion, and may be mistaken for a men- strual period, particularly if the discharge comes on at or about the time a menstrual period is expected or would have occurred had pregnancy not existed. If, however, this symptom is inquired into, it will usually be found that the hemorrhagic discharge has been pre- ceded by abdominal pain and discomfort, that it is irregular in its time of appearance, and that it is seldom very abundant. The quantity is very rarely profuse ; I have only once seen it so. On the other hand, it is very generally preceded by one or more attacks of abdominal pain and discomfort. Taking the five cases I have given in illustration of this group, it will be found that in Case I. it occurred four weeks after the first attack of pain ; in Case II. it occurred four weeks after the first attack of pain ; in Case III. two weeks after the first attack of pain ; in Case IV. two days after the first attack of pain ; and in Case V. ten days after the first attack of pain. In 80 per cent, of my cases the pain has preceded the haemorrhage. That, however, is not the experience of all writers. Bell, 1 in his analysis of eighty-eight cases treated in St. Thomas's Hospital, gives a definite statement regarding this point in sixty-eight cases. From an examination of his table, it will be found that pain was the first symptom in 58 per cent, and haemorrhage in 41 per cent. Very often the discharge is attributed to a threatened abortion, especially if one or two periods have been missed. The differential diagnosis between these conditions is fully considered later. The fourth feature of cases belonging to this group is occasional feelings of faintness, nausea, and sickness, amounting sometimes even to syncope. It is due to reflex irritation of the peritoneum, to the intramural haemorrhages which tensely distend the sac wall, and to tubal colic. It may be said that the faintness is due to haemorrhage, and, of course, that is so if the amount of haemorrhage is abundant ; but I have operated upon many cases in which there had been a distinct syncope, and yet the internal bleeding was very slight, and, yer se, could not have produced the collapse. Besides, the patients get over the syncopal attacks very quickly, unless, of course, the internal haemorrhage is profuse and the case has really passed into Group 1. In referring to the hemorrhagic discharge, I purposely did not mention the expulsion of a uterine decidua, because I did not wish to give the impression that this was a symptom that should be waited for. Undoubtedly, when present, it is a feature of very great value ; but it is very generally a late sign, frequently not appearing until 1 Journ. Obst. and Gyn. Brit. Empire, December, 1906. OPERATIVE Mll»\VII'i:i;V there have been several attacks of pain and tin tube has aborted or raptured. In a number of my cases the cast has not been Bhed until after operation. Very often, indeed, it is never seen. In my o I it was observed in 27 per cent., in Haultain's 1 in 80 per cent., and in Bell's in 1!) per cent. I may mention that in a number of my cases the uterus had been curetted before I saw the patient, and in the ovarian pregnancy there was a coexisting uterine gestation. Taking aeries of cases reported by different operators, a decidual cust is noted in not more than 30 per cent, of cases. Without doubt the decide often lost in the discharge, especially at such times as the bowels and bladder are evacuated. Besides, as I have already pointed out, early in pregnancy there is practically no decidua present. The presence or absence of the ordinary subjective and objective si^ns of pregnancy, such as morning sickness, pain in the breasts, and other mammary changes, cannot be relied upon in ectopic pregnancy in the early months. Naturally, if they are present, they confirm the diagnosis of pregnancy ; but they are very often absent, and, indeed, appear to be less constant in extra-uterine than in intra-uterine gestation. Irritation of the bladder, amounting frequently to dysuria, is a common symptom, especially if there is a large sac or collection of blood in Douglas' pouch pushing the uterus forward against the bladder. This is referred to in connexion with pelvic hematocele (p. 572). Constipation is very frequent, but that is so general with women, especially during pregnancy, that it is of no value from a diagnostic point of view ; indeed, from recorded cases, and from those which I have seen in my practice, it has often confused the medical attendant, and led him to think that the abdominal pain or uneasiness com- plained of by the patient had its origin in the bowel, and was caused by constipation. Having impressed upon my readers the extreme importance of carefully considering the history in this disease, I must now refer to the bimanual examination. In carrying out a bimanual examination in a doubtful case of ectopic pregnancy, the greatest care must be exercised, for a gravid very readily gives way if carelessly handled. This has frequently happened, and, as a matter of fact, occurred in one of my cases, with a most disastrous result. My house-surgeon was examining the patient when the sac ruptured, and the contents being septic, and escaping into the general peritoneal cavity, a general septic peritonitis resulted. Especial care must be taken when the examination is made under an anesthetic, for then, the patient being unconscious, there is 1 Journ. Ubst. and Qyn. Brit. E»ij)irc. June, 1906, p. 409. ECTOPIC PKEGNANCY 559 nothing to warn the examiner of the danger he runs from pressing too firmly. The sac which is felt in cases of ectopic pregnancy varies greatly as regards size, consistency, and position. Its size depends in great part upon the age of the pregnancy, but also not a little upon the amount of haemorrhage which has occurred. Besides, sooner or later the sac contracts adhesions to the surrounding intestines, ovary, broad ligament, etc., and there is thus formed a mass of variable dimensions and of very indefinite outline. The consistency, too, is not constant. Theoretically it is soft and elastic, but, as a matter of fact, especially after any effusion of blood into the wall, it may feel just as firm and hard as any solid tumour. Pulsation over its surface is frequently referred to as being a feature of some diagnostic importance. Personally, I do not attach great importance to this feature, for in inflammatory conditions of the appendages it is also well marked. The sac is very generally tender to the touch. The sac in the early weeks is commonly situated on one side, and rather behind the uterus, and as it increases it very generally extends farther and farther backwards. As it does so it pushes the uterus forwards and upwards. It is very much less common to find the sac in front of the uterus, although after intraperitoneal hemorrhage some blood may collect in the utero-vesical pouch. When the rupture occurs into the broad ligament, the tumour may be distinctly lateral, and the uterus markedly pushed over towards the opposite side. The cases in which the sac is most difficult to define are where the uterus is backwardly displaced and is lying over the sac, and where the sac is situated far out in the ampulla, is very soft, and is closely surrounded by the intestines. The history, the localized rigidity, and pain may then sometimes he the only symptoms, and on them alone it may be necessary to act. It occasionally happens, in spite of a history so typical as the one we have seen is generally associated with ectopic pregnancy, that the diagnosis is not so simple, and that other conditions may simulate or be simulated by it. Amongst the most important of these conditions may be mentioned salpingitis, appendicitis, and tumours of the ovary and uterus, especially when these are associated with intra- uterine abortion. Let me give a few examples from my case-book : Case 1. Simple Ovarian Cystoma behind the Uterus associated with "» Intro- Uterine Abortion of Tiv<> Months — Diagnosis: Ectopic Pregnancy — Abdominal Section — Recovery. — A young married lady, with three of a family, about the 560 OPERATE i: MIDWIFER1 time of a second missed period, was seized one afternoon with abdominal pain, especially marked in the right iliac fossa. There also existed a red vaginal discharge. The pain complained of was distinctly paroxysmal. Dr. I'-- . her family doctor, asked me to see her in consultation. Upon bimanual examination I found the uterus enlarged, and a swelling about tin- size of a walnut, which was fixed and tender, close to the Bide of the uterus. I diagnosed extra uterine pregnancy, and advised her immediate removal to a nursing-home. Upon opening the abdomen I discovered that the tumour was a small cystic ovary. A day or two later I removed the remains of a uterine abortion. I have upon one or two occasions opened the abdomen in cases of salpingitis, suspecting that I had to deal with an ectopic pregnancy. The differential diagnosis between the two conditions must be based generally on the history ; but occasionally the histories are so much alike as regards pain and irregular bleedings that one is left in uncer- tainty regarding which one has to deal with. In connexion with the bimanual examination, in most cases of salpingitis both tubes are affected, but very often one is more decidedty affected than the other, and masks the other. Upon one occasion I made the diagnosis of extra- uterine preg- nancy when I had really to deal with a case of appendicitis with an intra-uterine abortion. As a decidual cast came away in this case, it will be readily understood that there was sufficient excuse for the mistake. Appendicitis with Intro-Uterine Abortion. — Mrs. 8 , a young married lady, a fortnight after a period missed was seized with severe abdominal pain. Dr. E , who was summoned, found the pain very severe ; it extended over the whole lower quadrant of the abdomen, but was especially marked on the right side, where there was distinct rigidity. There was also a red vaginal discharge. Upon bimanual examination a small swelling could be felt to the right of the uterus. Very naturally he made a diagnosis of extra-uterine pregnancy, and the following day, when I saw her in consultation, I had no hesitation in agreeing with him, especially as there had been expelled in the meantime a portion of decidua. The patient was immediately removed to a nursing-home. When I opened the abdomen, I found an elongated and inflamed appendix adherent to the tube and ovary, both of which showed signs of recent inflammation. As, how- ever, I believed the inflammation was from the appendix, I only removed it and a portion of ovary. The patient made an excellent recovery, and ten days after the abdominal operation I curetted the uterus. Another mistake which sometimes arises is the confusing of an extra-uterine pregnancy with a backward displacement of the gravid uterus. A most interesting example of this mistake has been already ECTOPIC PREGNANCY 561 recorded in the chapter on Backward Displacement of the Gravid Uterus, where the differential diagnosis of these two conditions is fully considered. But the most common mistake is to diagnose uterine abortion when what really exists is an extra-uterine pregnancy. Here is a case of this nature, where the doctor, imagining he had to deal with an incomplete abortion, curetted the uterus, and while doing so ruptured an ectopic sac : Extra-Uterine Pregnancy mistaken for Intra- Uterine Abortion — Curettage — Rvptwe of the Sac — Death. — Mrs. M , aged thirty, 3-para, was brought into the Maternity Hospital under my care, in November, 1907, in a condition of collapse. Her doctor who accompanied her gave the following- history : Three weeks before he was called to see her on account of abdominal pain and vaginal haemorrhage. As she had missed a period the doctor thought an abortion was threatened, and prescribed the usual remedies for arresting this condition. When he saw her again three weeks later she was still having haemorrhage. He therefore decided to curette the uterus, which he did under chloroform. After the operation he noticed the patient was collapsed, and this collapse increased in spite of strychnine, saline transfusion, and stimulants. When he brought her into the hospital, he informed me that he thought he had ruptured the uterus with his curette. On bimanual examination I could detect nothing definite, as the abdomen was so rigid and the uterus seemed displaced back- wards. I suspected, however, that there must have been something more serious than a simple laceration with the curette, and I hazarded the diagnosis of a ruptured extra-uterine pregnancy. As she was steadily sinking, and the only possible hope of saving her seemed abdominal section, I opened the abdomen. When I did so, I found it full of blood. On passing my hand clown to the pelvis, I pulled up a large ruptured tubal sac ; this I quickly removed along with the other tube, which was also distended with blood. I then flushed out the abdomen with saline, and rapidly closed it. The patient sank, and died a few hours after the operation. Veiy frequently this mistake is made ; indeed, in a large proportion of the cases that have been under my care I have been asked to see the patients, because the doctor imagined he was dealing with an incomplete abortion. Consequently, my practice and teaching are in all cases of abortion to exclude the possibility of extra-uterine pregnancy, and I advise my students always to approach the case in the following way, and to answer the following questions : (1) Is the woman pregnant ? (2) Is the pregnancy uterine or extra-uterine ? (3) If uterine, is the abortion threatened, complete, or incomplete? I make no exception, and always decide these three questions. I feel convinced that mistakes can only be avoided by doing this. Quite recently I was discussing this subject with my students when a patient 36 562 OPERATIVE MIDWIl'KllY came to consul) me at the Western Infirmary, and gave the following history : Mrs. X stated Bhe was twenty-five years oi age, and had bad five children. She also said thai she had not altered for six weeks ; that theday before she had some pain in the lower part of the abdomen, nausea, and vomiting. She had a slight hemorrhagic vaginal discharge. I asked the nurse in prepare her for examination, ami pointed out to the student* that it was not likely that we had to deal with a case of extra-uterine pregnancy ; most probably it was a simple threatened abortion, as the latter was a far more coi in occurrence, bul that we must exclude in this and in .ill eases the possibility of extra-uterine pregnancy. When I examined her, 1 was greatly pleased to find an elastic swelling behind and to the left of the uterus, for it was such a valuable lesson t<> the Btudents. Two days later I removed the gravid tube ; it was an example of an incomplete tubal abortion. The other mistake of considering the condition extra-uterine when it is really an intra-uterine pregnancy has also been occasionally made, and to illustrate this let me briefly detail the following case : Angular Pre gnu n rii resulting in Abortion mistaken for Extra-Uterim Preg- nancy. — Four years ago I was asked by a medical friend to see his wife, as he feared she was threatened with an abortion. I hail attended the lady at her two previous confinements — one seven and the other four years previously. When I visited her, she gave me the history of a period missed. In addition, she told me that ten days after the period was expected abdominal pain and hemorrhagic vaginal discharge appeared. The discharge was not great, hut the pain was sometimes pretty severe, and was more marked towards the left iliac fossa. Upon making a vaginal examination I discovered the uterus Avas enlarged, and at the left corner in the neighbourhood of the tube I could detect a small localized bulging. I told her husband of my fear that there might be an extra-uterine pregnancy, and that I was chiefly alarmed because it was so close beside the uterus. My fear appeared to be fully justified when, two days later, the cast shown in the illustration (Fig. -64) was expelled. As may beobserved, the cast is complete except at the right corner. I thought I would have to open the abdomen at this stage, but my friend requested me to delay doing so. We were, however, prepared for any possible sudden call to operate; the patient was watched very carefully, and all discharges kept. Four days later a small piece of membrane, which just completed the sac that was expelled, came away in the vaginal discharge. Attached to this little piece of decidua was the ovum. In the case just described I had to deal with the very interesting condition of what is known as 'angular pregnancy,' which has been especially referred to by Budin, Bar, Kelly, and others. It is the implantation of the ovum in the corner of the uterus over the tubal ostium. Naturally, it very closely resembles interstitial and isthmal ectopic pregnancy. ECTOPIC PEEGNANCY 563 Other errors of diagnosis which' occasionally are made are mistaking interstitial fibroids, ovarian tumours, and lateral flexions of the gravid uterus for an ectopic sac. The latter condition — flexion of the gravid uterus — may simulate very closely an extra-uterine pregnancy. In all cases of doubt an examination under anaesthesia is necessary. Mistakes in diagnosis, such as taking an ovarian tumour or myoma for a gravid sac, or, vice versa, taking a gravid sac for one of these tumours, is seldom likely if one carefully considers the history. I Fig. 264. — Cast of Uterine Decidua in a Case of ' Angular Pregnancy.' At the right corner there is a small piece wanting ; that piece came away a few days after the cast was expelled. The ovum was attached to it. (Author's collection.) have referred already to how closely these tumours may simulate an ectopic sac if there is a coexisting intra-uterine abortion. In cases of great doubt, where the diagnosis is especially difficult, it used to be the custom to recommend the exploration of the uterus with the sound, and even with the curette. As regards the uterine sound, I am quite prepared to admit that sometimes it is of real practical value. I have once or twice had to employ it. If the accoucheur makes use of the instrument, he must do so with great caution, as several cases are on record where the uterus was injured. Not only must he introduce and move it about with great care, but he 564 OPERATIVE MIDWIFERY must make absolutely sure that the vaginal canal is thoroughly dis- infected, for where there has been a vaginal discharge going on for -Mine time there are sure to be present many organisms of greater or less virulence. Still more careful must he be with the curette, as he may very readily set up violent contractions in the sac, and injure and infect the uterine tissues. I am doubtful if the curette is often of much value. From the scrapings removed and examined microscopically one could generally give an opinion as to whether or not pregnancy existed, but one could not say whether the pregnancy was uterine or extra-uterine. Only if chorionic villi were found present could one say it was uterine, for, as we have seen, the deciduse in uterine and extra-uterine pregnancy are indistinguishable either macroscopically or microscopically. (3) Cases in which the woman advances in her pregnancy to the later months. Cases of this group are not very common, although there are now a large number recorded. In this, as in the previous groups, the history is generally of the greatest importance. For example, one very generally finds on questioning the patient that she has passed through Group 2; she has at one time of her pregnancy had attacks of pain, faintness, etc. In some cases, however — they are very much the exception — there is nothing unusual, and the pregnancy advances without disturbing the patient to any extent. The ultimate termination of cases of this group is very varied. At any time during pregnancy the peculiarity of the sensations felt by the mother or the discomforts she experiences may induce her to seek medical advice. The discomforts are chierly those produced by the large sac displacing the structures from their normal position. Obstinate constipation is frequent, disturbances of the bladder not uncommon. Uneasiness and even pain in the abdomen may be complained of, but the symptoms are often so vague that the medical attendant, when he comes to examine the patient, attributes them to the ordinary disturbances that are frequently associated with pregnancy in the later months, when the growing uterus displaces and disturbs the surrounding organs. Even the situation of the gravid sac becomes very much like the normal. Abdominal distension is usually more marked on one side than the other, but one sees this in normal pregnancy, in which, as a rule, the uterus is displaced to the right side. The gravid uterus, however, can be pulled over to the middle line, while a large gravid sac is generally fixed. Should the physician make a vaginal examination, there is then every likelihood that he will have his attention arrested by the condition of matters. The cervix will not be so soft, and it will often be displaced. He may be fortunate enough in feeling the uterus a - ECTOPIC PREGNANCY 565 whole displaced, but very frequently the extra-uterine sac is so closely applied and fixed to the uterus that he cannot distinguish the one from the other. A rectal examination may be of service, but the accoucheur must have had his suspicions very strongly aroused before he would resort to this method of examination. In the case of advanced extra-uterine pregnancy figured (p. 569), I at first mistook the body of the uterus, which was displaced behind and to the right, for a fibroid, although later, when the patient came into hospital, I appreciated the mistake. I found that the tumour that I thought was a fibroid was the body of the uterus, and the sac which I thought was the enlarged body was an ectopic pregnancy. In cases of doubt the passage of the uterine sound is of service, but not infrequently when this has been employed injury to the sac has resulted. This was so in my case : the sound had been forced along a false passage several times, and the sac wall and its contents had been infected. Of course, if every possible care is taken in passing the sound, and if the hands of the operator and the vulva of the patient are thoroughly cleansed, there is little risk of doing any harm. At any time during pregnancy the patient's attention may be arrested by the cessation of the foetal movements, and she may seek medical advice because of this. Naturally, the farther the pregnancy has advanced and the more energetic the movements, the more likely is she to have her suspicions aroused and to consult her medical attendant. In cases of extra -uterine pregnancy which advance to term, phenomena occur which are referred to as ' spurious labour.' There is severe abdominal pain and often expulsion of the uterine decidua, with a hamaorrhagic vaginal discharge. The foetus, if it is alive, gives evidence of very great disturbance in its circulation, its movements become extremely active, then quieten down and cease altogether. After death of the foetus a number of changes may take place in the sac and its contents. The liquor amnii is absorbed and shrinking of the sac occurs, so that the abdominal tumour gradually diminishes in size. The foetus itself may become altered in different ways — most commonly it becomes mummified. In this process the foetus, mem- branes, and placenta become shrivelled up by the absorption of the fluid in their tissues. Occasionally an adipocereous transformation occurs, the tissues of the foetus becoming altered into a soapy-like yellow substance. Calcification is yet another variety of change. In most cases it does not amount to more than a deposit of lime in the membranes and placenta, and a scattered deposit in the foetus. Occasionally, however, the foetus is chiefly affected, and one gets the 566 OPERATIVE MIDWIFERY true lithopedion. In .such cases the superficial tissues of the I are affected, although the deeper ones maj also be impregnated with the lime salts. These shrunken Baca are often retained for man;. years in the uhdominal cavity, and are stowed away in a marvellous manner. 1 recently noticed a case described where the woman hud had several pregnancies after a supposed ectopic one many y< before. At her death the abdomen was opened, and an old shrunken ectopic sac was discovered. ( t »uite a number of similar cases have been described. An interesting review of such cases is given by Bovee. 1 Should by any chance the sac become infected, a suppura- tion and breaking down of its contents may occur. In most of these cases the pus and disintegrated contents of the sac find an outlet through bowel, vagina, abdominal wall, or even bladder. This process is often very slow if the foetus is of some age, as the bones have diliiculty in passing through the sinuses formed. Fortunately, in these cases a rupture seldom occurs into the general peritoneal cavity. As a result of inflammation the surrounding intestines become adherent, and completely shut off the general peritoneal cavity. Treatment. I purpose discussing the treatment of each of the groups of cases that I have already described in connexion with ' clinical features ' of ectopic pregnancy. After doing so, I will consider those cases of marked hematocele, as one's attitude towards that condition is some- what different than towards any other variety of ectopic pregnancy one encounters in practice. 1. The Woman is struck down suddenly with Abdominal Pain and Profound Collapse. — In such cases the all-important question for consideration is, When should one operate ? Should one, no matter how collapsed the patient is, open the abdomen, remove the sac, and arrest bleeding, or should one give the patient time to recover from her profound condition of shock ? There are advocates of both courses. Personally, I believe the safer procedure is immediate operation in all cases. After all, if the patient is extremely collapsed, the immediate operation adds very little to the shock already present, for the operation can be performed quickly and with light anaesthesia. It is most important to appreciate that fact. "When immediate opera- tion is undertaken for sudden collapse, the abdominal route is the only one to be considered. The operation is performed as follows : The abdominal wall is 1 George Washington University Bulletin, vol. v.. No. 3 ; ref. Jmtrn. Obst. and Gyn. Brit. Empire, June, 1907, p. 504. ECTOPIC PREGNANCY 567 thoroughly cleansed. The patient is then placed in the Trendelenburg position. An incision is made in the middle line, the hand passed down into the pelvis, and the affected tube and corresponding ovary brought up to view. If desired, a pair of pressure forceps is applied to the infundibulo-pelvic ligament beyond the ruptured tube, and another pair is applied to the uterine end of the tube. The tubal sac is removed, the ovary being, if possible, left behind, provided it is quite healthy. Ligatures are then applied to the two cut ends of the broad ligament, and the raw edge covered with peritoneum. The pelvic and abdominal cavities are then irrigated with normal saline solution, or simply swabbed out with dry gauze. Before closing the abdomen the other tube and ovary should be examined. I have seven times in my fifty-four cases found the other tube the seat of a hamiato- salpinx, in one case the result of a previous extra-uterine pregnancy. I would remove the other tube and ovary only if they were grossly diseased and could not possibly be conserved. During the operation, but not before it, an assistant introduces one or two pints of normal saline solution underneath the breast or into a vein. The patient is then put back to bed and the foot of the bed raised. If deemed advisable, she is given some brandy by the rectum. I would strongly caution, however, against the danger of over- stimulation. I have often found my house - surgeons make this mistake. 2. The Woman suffers for Some Time from Abdominal Uneasiness and Hemorrhagic Vaginal Discharge. — In this group immediate opera- tion is always advisable, for one can never tell when all danger is past. Some years ago I saw a case, along with a well-known gynaecologist, which illustrated very well the danger of leaving such cases unoperated upon. The gynaecologist referred to had quite recognized that the condition was one of extra-uterine pregnancy, but he considered that all danger was passed, as the sac was small and hard. He advised against operation. A few weeks later I heard that the patient had been seized with severe abdominal pain, and had collapsed and died. The operation in cases of this group is a very simple one. Usually there are slight adhesions between the tube and surrounding parts, but these are readily broken down, and the sac — be it an aborting tube or be it a ruptured tube— is removed as I have already described in Group 1. Should the rupture have occurred into the broad ligament and a hematoma exist, the general recommendation is tu split open the broad ligament, clear out all blood-clot, and pack the cavity with gauze. The broad ligament is then stitched over, and the end of the gauze brought out through the vagina. It is undesirable, if it can be avoided, to bring out the gauze through the abdominal OPKi;.\Ti\ i: midwii i:i;v wound, tor drainage in thai direction is unsatisfactory, as it weakens the lower pari ol the wound. In these cases it is quite sound to proceed as Kelly and others have recom mended, and deal with the sac entirely from the vagina, and then close the abdomen. \n cases where tlic ovum is situated in the interstitial portion of the tube, it may sometimes he found impossible to satisfactorily cdose the ragged cavity of the uterine wall, mid bo it is often necessary to remove the entire uterus Bupravaginally. This was found necessary in my case already deserihed and figured (p. 544). If possible. however, the uterus should always he saved, and that will usually be possible if the pregnancy is still early, and the sac has projected out from the uterus rather than developed in the uterine wall. In recent years several operators have suggested a conservative- treatment of the tubes in cases of tubal pregnancy. Some, for example, have dilated the abdominal end of the tube and pressed out the ovum ; others have split open the tube and shelled out the ovum from its wall. In the latter case the wound in the tubal wall is carefully sutured. I have twice tried this treatment, but as the bleeding from the tube continued, I was ultimately compelled to remove the tube. 3. Ectopic Pregnancy in the Later Months. — Before considering details regarding the operative treatment of such cases, one must consider the question as to whether or not it is ever advisable to delay operating for the sake of the child. Personally, I would decidedly answer in the negative. I am fully aware that a number of children have been saved, but I think the dangers of delaying are greater than the chances of obtaining a healthy child. If delay is decided upon, it is only permissible if the patient is placed under such conditions that immediate operation can be performed should that become necessary. The chief difficulty in operating upon cases of advanced extra- uterine pregnancy is the treatment of the placenta. There is never any difficulty in opening into the sac or in removing the foetus, but there may be considerable difficulty in dealing with the sac, and especially with the placenta. The ideal treatment is to remove the sac entire — fcetus, placenta, and membranes — as was done in the case figured in the illustration (Fig. 265), where I had simply to separate some adhesions and tie off the lower part of the sac. This is generally possible when the child has been dead for some time, for a 'dead' placenta is easily stripped off, and any little bleeding that occurs is readily controlled with gauze packing. But the placental site of a ' living ' placenta bleeds very freely when the latter is separated ; and besides in the process of separation, especially if the placenta has been attached to the mesentery, serious injury may be ECTOPIC PREGNANCY 569 clone to the blood-supply of a portion of the intestines. \n such cases, with a view to obtaining a 'dead' placenta, and one thai may be safely detached, it has been recommended that the operation should be delayed until some time after the* death of the child. In many cases this is perfectly safe, and the dead placenta can be easily and safely separated. But by such treatment the child is sacrificed, and there is no guarantee that in the interval the sac, with its dead Fig. '265. — Ectopic Pregnancy which had advanced to Term. (Author's collection.) contents, may not become infected. It is a treatment, therefore, quite out of harmony with modern obstetric surgery. In recent years the successes attending immediate removal of the ' living ' placenta have been increasing in number. There are two most interesting papers on the subject by Sittner, 1 who has carefully collected a large number of recorded cases from the obstetric literature of different countries. From his figures it is evident how much better the results are from immediate removal than from any other method, for where the placenta was left behind the mortality was 57 per cent., and where it was removed it was 18 per cent. 1 Zcnt.f. Gyn. t 1903, No. 2, p. 33, and Deut. Med. Woch, 1906, Nr. 30, p. 1200. .-,70 OPERATIVE MIDWIFER1 In dealing with some of these eases, it has been found that occasionally the arterial blood-supply may be cut off by ligaturing the ovarian and uterine vessels before proceeding to separation. In others, separation of the Bac by degrees and careful ' understitching ' of the wall have proved successful. Sometimes the hemorrhage from the raw placental site lias heen so great as to necessitate compressing the aorta until the bleeding was controlled. The worst cases to deal with are those where the placenta is attached to some vei\ vascular and freely movable viscus, such as the bowel. Winn the attachment is in the pelvis, bleeding can usually be controlled by simply packing. Occasionally the operator has deemed it advisable to remove the uterus, but that is unfortunate in a young woman, and should be rarely necessary. When it is deemed inadvisable to separate the living placenta, the best course to pursue is to cut the umbilical cord short, stitch the sac wall to the abdominal parietes, and pack the cavity with gauze. If the sac is well down in the pelvis, the end of the gauze may be brought out through the vagina, and the sac wall closed above. The gauze should be removed in a few days and the sac repacked. After ten or twelve days the placenta should be removed. If that is not done, the ' dead ' placenta disintegrates, and a discharge continues, which sooner or later becomes secondarily infected by pyogenic organisms, and is a constant source of danger to the patient. One has only to read the records of such cases to see how extremely unsatisfactory this termination is. Closing the abdomen and neglecting the placenta, leaving the latter to take care of itself in the abdominal cavity, has proved absolutely unsatisfactory, and has now no advocates. It is occasionally possible to remove the child and deal with the placenta entirely from the vagina. It is generally stated that the cases suitable for this treatment are where the lower pole of the f centimetres. This band is usually attached to the normal horn about the level of the internal os, although its lower margin may be as low as the os externum. In the great majority of cases no canal is found, and in many when it exists it is incomplete. Werth 1 found in his hundred collected cases a canal in nineteen, but only in two was there an opening into both parts of the uterus. It is possible that occasionally the canal becomes closed during pregnancy. As there is so seldom b canal, impregnation occurs usually by the spermatozoa passing through 1 Winckel's ' Handbuch der Geburtshulfe,' 1904, Bd. ii.. Teil ii., p. 998. ECTOPIC PREGNANCY 575 the healthy half of the uterus and tube, and impregnating an ovum which has been shed from the ovary connected with the rudimentary horn. In some few cases, however, an ovum from the other ovary has been impregnated, as the corpus luteum was discovered in the ovary connected with the normal horn. The course of pregnancy in a rudimentary horn is variable. In a large proportion of cases rupture occurs because of the poorly-developed muscular and mucous coats. The trophoblast, meeting with little resistance, burrows into the wall and erodes it. This will be seen in the figures accompanying a recent paper by Hoff. 1 According to Werth, rupture occurred in forty-five of his hundred collected cases. The fourth and fifth months are the most usual time for this occurrence, but quite a number occurred earlier, and a few even later than that time. In the cases in which rupture occurs it will be found that the clinical features usually resemble those found in extra-uterine pregnancy, described under Group 2 — recurrent attacks of abdominal pain, tenderness, faintings, often vaginal discharge, and expulsion of the decidual from the normal uterine horn. In some cases the rupture and collapse occur suddenly without any premonitory symptoms, such cases being comparable to those belonging to Group 1. In quite a number of cases, however, the pregnancy continues to term. In this country Galabin, 2 Targett, 3 Murdoch Cameron, 4 Bland- Sutton, 5 and Roberts 6 have recorded such cases, and there are a considerable number recorded by different foreign writers. In these cases the striking clinical fact is that there were so generally attacks of abdominal pain and vaginal haemorrhage, etc., during pregnancy. Late in pregnancy, often about the time labour was expected, a ' spurious labour ' occurred in many of the cases. A foetus retained after its death may undergo all the changes that have been described already in connexion with extra-uterine pregnancy. Of the rare complications which are associated with a gravid rudimentary horn may be mentioned torsion of the pedicle, prolapse of the tumour behind the uterus, and infection of the sac. The condition is theoretically not difficult of diagnosis, but in practice it is comparatively seldom that it is fully appreciated before the abdomen is opened. Extra-uterine pregnancy is the usual diagnosis. Targett, Bland- Sutton, and a few others, recognized the 1 Archie f. Gyn., Bd. Ixxx., Heft 2, p. 352. 2 Trans. Lond. Obst. Soc, vol. xxxvii., p. 225. 3 Ibid., vol. xlii., p. 276. 4 Jouni. Obst. and Gyn. Brit. J'Ju/jdrc. vol. i., p. 67. 5 Trans. Lond. Obst. Soc, vol. xliv., p. 316. 11 Jouni. Obst. and Gyn. Brit. Empire, December, 1905. 576 OPERATIVE MIDWIFERY condition exactly before operation. The position of the round ligament and the separation of the tumour from the uterus are important features, especially in the early months, but later the sac is so large that these landmarks are often difficult to distinguish. In the early months an interstitial ectopic pregnancy is somewhat similar, only in that condition the tumour and uterus form one body. Later in pregnancy, when the gravid horn is of large size, the latter may be mistaken for the pregnant uterus, and the non-gravid normal horn mistaken for a myoma or an ovarian tumour. In such cases of difficulty the uterine sound, employed with great caution, may be of assistance in coming to a conclusion regarding the exact nature of the condition. The treatment of this condition is to remove the gravid horn. In two cases recorded by Doran 1 normal pregnancy has occurred in the horn left. In most cases the removal of the gravid horn is not difficult. The ovarian vessels are ligatured in the infundibulo-pelvic ligament, and then the band connecting the horn with the other half of the uterus is secured. Special care must be taken in ligating the latter, for there may be veiy free bleeding if it is not carefully tied. But not infrequently adhesions to the surrounding parts exist, so that, as in Targett's and Bland- Sutton's cases, considerable difficulty may be experienced in separating them and in securing all the bleed- ing points. It may occasionally happen that the association of the sac and the other horn of the uterus is so intimate that total extirpation is deemed advisable. Should it be suspected that the contents of the sac are septic, and should it be found, when the abdomen is opened, that the sac wall lias very intimate connexions with the surrounding structures, it is well not to try and extirpate the sac, but to open it from the vagina and empty and drain it for some time. The sac may be removed later. If it is quite impossible to remove the sac — a very rare con- tingency to judge by recorded cases — the sac may be emptied from the abdomen, and the Fallopian tube belonging to the rudimentary horn removed, or divided and ligatured, so as to prevent the horn again becoming gravid. Cameron pursued this course in his case. He took the further precaution of packing the cavity, and bringing out the gauze through the vaginal vault. 2 1 Journ. Obst. and Gyn. Brit. Umpire, June, 1906, vol. ix.. p. 443. - As it would serve no practical purpose, I have not considered eases of repeated ectopic pregnancy, pregnancy in both tubes, plural pregnancy in one tube, and of coexisting tubal and uterine pregnancy. I nave, however, detailed in connexion with rny case of ovarian pregnancy this most rare condition — a coexisting ovarian and uterine pregnancy. CHAPTER XXXIII PLACENTA PREVIA— ACCIDENTAL HEMORRHAGE By placenta previa is meant an implantation of part of the placenta over the lower uterine segment. The complication is very serious, as, owing to the situation, separation of it must take place before the child is born. This fact led Rigby to term the bleeding that occurs ' unavoidable haemorrhage.' Until Portal in 1685, but more especially Schacher in 1709, clearly described the anatomical relationship of placenta to uterus, it was believed that the condition was produced by separation and prolapse of the placenta. Schacher demonstrated, on the dead body of a woman with placenta previa, the exact relationship of the placenta to the uterus. Since then the teaching has been that the condition arises from the ovum becoming attached low down, and, as it grows, coming to cover the os or projects down towards it. The illustration (Fig. 267), from a specimen of "William Hunter's in the Hunterian Museum, shows this low implantation very well. It is generally supposed that this low implantation is the result of the uterine cavity being enlarged, and the endometrium being the seat Of an old- standing inflammation. In support of such a view there is the fact that the complication is found to occur more frequently in multiparas than in priniipare, and that in many cases of the complication a history of old-standing uterine trouble may be elicited. In the Glasgow Maternity Hospital the proportion of primipare and multiparas was 1 to 26 ; in Strassmann's 1 recent figures it was 1 to 5. The tendency to placenta previa increases with each pregnancy, and especially is it liable to occur when the pregnancies occur in rapid succession. It has also been suggested that the low implanta- tion may sometimes be the result of low implantation of the tubes, or of impregnation occurring when the ovum is just about to escape from the uterus. As, however, we do not yet know where the meeting-place of the ovum and spermatozoa normally is, these sugges- 1 Arcliiv f. Gijn., Bd. lxvii.. p. 112. 577 37 578 OPERATIVE MIDWIFERY t ions are pure speculations. So also is the view that the coverin the ovum is altered, and that it doc- not ingraft itself until it reaches the lower part of the uterus. Occasionally the placenta becomes previa purely by reason of its size. Thus, placenta preevia occurs oftener with plural than with Bingle pregnancies. In my forty cases it occurred twice. Strassmann in 281 cases found it fifteen times. Fig. 207. — Implantation of the Ovum over Os Internum. Glasgow University.) (Hunterian Museum, But one not infrequently finds an unusually large placenta apart altogether from plural pregnancy. Strassmann explains this by saying that there is a defective blood-supply, and in consequence the placenta must become large to cope with the demands of the foetus; but does this explanation not beg the question ? In recent times the theory advanced by Hofmeier 1 and confirmed 1 'Die Menschliche Placenta.' Wiesbaden, 1890. PLACENTA PILEYIA— ACCIDENTAL HAEMORRHAGE 579 by Kaltenbach, that the condition arises from a development of placenta from the ' decidua reflcxa,' which, as pregnancy advances, comes to cover the os internum, has met with considerable support. There are now a sufficient number of specimens confirming this view. In most cases, however, a low implantation is present from the first. This is apparent in Webster's 1 specimens, which were shown in support of Hofmeier's and Kaltenbach's views. The frequency of placenta previa in the Glasgow Maternity Hospital has been 1 in 300 cases ; but naturally the percentage is higher in hospital practice, for the complicated cases tend to gravitate there. Hofmeier puts it at 1 in 500 to 600; Strassmann,'- Fig. 268. — Showing the Different Varieties of Placenta Pnevia. for the Berlin Charite, found it 1 in 220 for the Klinik and 1 in 300 for the Poliklinik. The extent of the implantation varies greatly, so that it is customary to divide examples of this complication into a ' central or complete,'' a ' marginal ' and a 'lateral' variety, according as the placenta completely covers the os internum, reaches up to its margin, or dips into the lower uterine segment. This will be clearly understood from the illustration (Fig. 268). In almost all cases of central implantation the placenta is attached more to one side of the uterus than the other ; very rarely does the middle of the placenta correspond exactly to the os internum (Fig. 269). Again, as dilatation occurs in a case where only a small portion of the placenta covers the os, this 1 Webster, ' Text-book of Obstetrics,' 1903, p. 543. - Wrnckel's ' Handbuch,' Bd. ii., Teil ii., p. 1202. iso OPERATIVE MIDWIFERY Fig. 269. — Complete or Central Placenta Pnevia. (Photographed from Van Rymsdyk's drawing in the Hunterian Museum, Glasj l Iniversity. small part becomes separated, and feels to the examining finger like a tongue hanging over, or projecting into, the cervix. It was origin- PLACENTA PREVIA— ACCIDENTAL HAEMORRHAGE 581 ally, nevertheless, an example of the central or complete variety. There are objections to all classifications, but, as it is almost necessary to have a classification, I think the one given is as good as any other. Clinical Features and Diagnosis. The condition first makes itself known by haemorrhage. The bleeding may occur without warning when the woman is at rest, although it often follows straining efforts, such as straining at stool, lifting weights, or after severe fits of coughing, sneezing, etc. As a rule, the first hemorrhage occurs during the last ten weeks of pregnancy, but sometimes not until term. Occasionally it manifests itself very early, as can be judged from the accompanying table. Table to show Time of Onset of Hemorrhage in Placenta Pr.eyia. Mouth. Pinard. Dorantk (Klinik Chrobak). Cases. Cases. First ... 25 4 Second... 11 4 Third ... 18 5 Fourth... 7 4 Fifth ... 10 5 Sixth ... 27 14 Seventh 23 17 Eighth... 20 40 Ninth ... — 40 Tenth ... — 21 Term ... 11 43 Commencement of labour Total 17 — 169 197 Not a few abortions are the result of the condition. As regards this, Strassmann gives the following figures : Abortion, 18 per cent. ; premature birth, 42 per cent. ; full-time birth, 39 per cent. The blood comes, of course, from the portion of the uterine surface from which the placenta is detached, and, to a very slight extent, from the separated portion of placenta. In addition, on one or two occasions very profuse bleeding has occurred from rupture of the circular sinus of the placenta (Fig. 270). Matthews Duncan x refers to this specially. Budin 2 has reported several cases of this nature. 1 'Mechanism of Natural and Morbid Parturition,' 1875, p. 387. 2 Societe d'Obstet. et Gyn., June, 1893. J82 OPERATIC E MIDWIFER1 Beemorrhage occurring during Labour is easily understood; the os as it dilates, and the lower uterine segment as it develops, bring about the separation of the placenta. When hemorrhage occurs during pregnancy, the explanation is that the bleeding is produced by the same conditions that bring about 'accidental htemorrha That this is probably the correct explanation is supported by the Fig. 270. — Showing Portion of Uterine "Wall and Attached Placenta. The circular sinus is very distinctly seen. (Drawing from a specimen in the Hunteriau Museum, Glasgow University.) fact that both varieties of hemorrhage result from similar diseased conditions of the uterus. In this connexion one must not forget that, besides the active and rapid development of the lower uterine segment which occurs during labour, there is a slow increase of the segment ^in the later weeks of pregnancy. Yon Franque found the upper limit of the lower segment from the second to the fourth months 2*5 centimetres, from the fifth to the sixth months 4 centi- PLACENTA PR/EVIA— ACCIDENTAL HAEMORRHAGE 583 metres, and from the seventh to the tenth months 6 centimetres, above the os internum. At the first attack the bleeding is often slight, so that assistance is unfortunately not requested until several attacks have occurred. Recurrent attacks of haemorrhage, becoming gradually more severe, is the usual history. Although one would expect the central variety to be associated with earlier and more severe hemorrhages than the lateral, this is not always so. On several occasions I have observed cases of central attachment where term was reached, and no bleeding occurred until labour actually commenced. This has been frequently remarked. Naturally, in cases of the lateral variety there is often no bleeding until labour occurs. In some few cases of central attachment the placenta has been expelled before the child, and in one or two the child has been born through the placenta. These are extremely rare occurrences, for usually uterine action is not very strong, and the profuse bleeding leads to collapse of the woman and inhibition of the uterine contractions. Placenta previa is not, as a rule, difficult of diagnosis ; indeed, the only other condition which really resembles it is ' accidental haemorrhage.' It should always be suspected with any haemorrhage during pregnancy, especially during the later weeks. On two occasions I have been able, by abdominal palpation, to locate a placenta situated on the anterolateral wall. The head in the lower pole of the uterus could be made out on one side, but on the other was obscurely felt as if through a doughy swelling. Palpation of the placenta, however, is seldom possible, and it is questionable in these two cases if I would have recognized the abnormal position of the placenta had my attention not been arrested by the hemorrhage. In coming to a diagnosis one must depend on the vaginal examina- tion, and actually feel the placenta with the examining fingers. If one feels the placenta one calls the condition placenta previa, if one does not feel it one diagnoses it ' accidental hemorrhage.' If the os is sufficiently dilated to allow of the finger being passed through — and that is usually the case — the placenta is easily recognized, for almost the only thing that can be mistaken for it is blood-clot. The latter is soft, smooth, and breaks up under the pressure of the finger, while the placenta feels firm and rough. I once saw a case of hydatidiform mole, in which the ragged mass, which was felt through the cervix with the tip of the examining finger, exactly resembled a placenta. I could also conceive of a submucous myoma such as the one figured on page 135 resembling the placenta. The cases in which :,si OPERATIVE MII)\\ll-'i:i;V difficulty is found are the lateral forms, for sometimes, with them, only a very small portion of the placenta dips into the lower uterine segment, and cannot he reached by the examining finger unless the hand is introduced into the vagina and the linger is pushed well into the uterus. Not a few of these cases are never recognized : bleeding occurs, but with the separation of the small portion of the placenta attached to the lower segment it soon ceases, and the child is born. Ij the membranes are examined after birth, it will bt found that the rent is close to the margin of the placenta. It is generally stated that the vault of the vagina feels boggy, that there is difficulty in making out the presenting part through the placenta, and that ballottement is more difficult to appreciate. In cases of central implantation all that is quite true ; but in many cases of lateral and marginal implantation these features are not apparent ; it is only by getting a ringer in through the os internum and feeling a portion of placenta that one can make sure of the condition. The degree of collapse is proportionate to the extent of the bleeding. The symptoms of such a condition are small, rapid pulse, clammy sweats, with, in extreme cases, dimness of vision, air hunger, faintings, convulsions, etc. I have already said the first attack of bleeding is usually not excessive ; indeed, so slight is it sometimes that the woman does not give any information regarding it. But there are many exceptions to this rule, and Edgar 1 has reported a case where death followed the first attack of haemorrhage at the fourth month of pregnancy. Prognosis for Mother and Child. The prognosis for both mother and child is serious, and is most serious with the central variety. As regards the mother, in the Maternity Hospital our mortality has been about 10 per cent, for some years. If all care is taken against septic infection, and the delivery of the child is not unreasonably hurried, the mortality should not rise above 8 per cent. Amongst the very poor, however, where the surroundings are unfavourable for operating, and where the women are ignorant and delay sending for assistance, and are first of all attended by dirty ' handy-women,' the mortality will always be greater. But apart from the actual mortality, the morbidity is naturally high ; tears of the cervix, cellulitis, and later phlegmasia alba dolens, are not infrequent, while profound anaemia and general debility are occasional late complications. 1 ' Practice of Obstetrics,' 1903, p. 230. PLACENTA PEiEVIA— ACCIDENTAL H/EMOKRHAGB 585 As regards the children, the results are very much more unfavour- able. In great part this is due to the fact that the children are born prematurely. Taking my cases, this was so in fully 60 per cent. The method of treatment employed is another most important factor in the prognosis. Next to the age of the fcetus the foetal mortality is most affected by the treatment employed. In this connexion we shall see that the lives of mother and child are often antagonistic. Take, for example, accouchement force and version. The former gives the best fcetal results, but the worst maternal ; while the latter gives better maternal results, but worse foetal. With this complication, however, we must not be too concerned about the child. The child must always be given proper consideration if it is mature, but we must never risk the mother's life unduly, especially if the child is premature. The outlook is infinitely more serious for the child with a central than with a marginal or lateral variety, for with the former so much of the placenta becomes separated in the progress of the delivery. Treatment. It is interesting to remember that it was in this complication Guillemeau recommended podalic version, and that by such a treatment he saved the daughter of Ambrose Pare, the master who had taught him the new method of turning. This was the first really scientific treatment of the condition, and it was followed and amplified by Mauriceau and others. But accouchement force fell into disfavour, for the results were not satisfactory, and there was a return to the old treatment of removing the placenta. Gradually it came to be appreciated that rupture of the membranes or version without forcible extraction was sufficient to arrest the bleeding. As regards the treatment by simply rupturing the mem- branes, this was recommended by Siegemundin, 1 who was born about 100 years before Puzos, so that the latter's claim to priority cannot be admitted. The most important advance in the treatment of this condition resulted from the introduction of bipolar version by Braxton Hicks some fifty years ago. By this method forcible dilatation of the cervix prior to turning, with all its dangers, became unnecessary. Of much less importance was the introduction of hydrostatic dilators. But even in a brief consideration of the treatment of placenta praevia, we must never forget the great service rendered by Barnes 1 Siebold, ' Versuch einer Geschichte der Geburtshiilfe,' Bd. ii., p. 203, Berlin, 1845. 586 OPEKATIVE MIDWIFERY who recommended partial separation of the placenta, separation from what he termed the ' dangerous zone,' which later investigations have proved to be the lower uterine segment. Neither should we forget the extraordinary mistake made by Sir -lames V. Simpson, of believing that the blood came from the separated placenta, and that, con- sequently, the treatment for the condition was to remove the placenta. 1 Before Onset of Labour. — In considering the modern treatment of placenta pr.evia, the first question that naturally arises is that of expectant treatment. Is one justified in temporizing when one kn one is dealing with a case of placenta prsevia ? Personally, I have no sympathy with such a treatment in private practice, for I have repeatedly seen how unsatisfactory, dangerous, and even fatal it may be. Only if a skilled medical attendant is living under the same roof, and in constant attendance should such treatment be considered, and even then I am not in favour of it, except in very particular cases. When a placenta praevia has been diagnosed, the uterus should be emptied. I am quite aware others, including Pinard and mam- distinguished obstetricians, take up a different position, and prescribe rest, sedatives, and hot douches until the child is viable. Having considered the question of temporizing, and believing that the only safety to the mother is in emptying the uterus, let us consider the means at our disposal for bringing about the delivery of the child. Xow, it is at once apparent that the ease or difficulty with which this can be accomplished will depend largely upon the condition of the cervix, and whether or not labour is in progress. At present, and, indeed, for a quarter of a century, the routine treatment in this, as in many other countries, has been the vaginal tampon (Fig. 271), when the cervix is closed and bipolar version after the manner of Braxton Hicks, whenever the cervix is sufficiently dilated. For many years I have employed these methods of treatment in private and hospital practice, and upon the whole I have been well satisfied with the results. At the present time many obstetricians in England, Germany, France, Italy, etc., are opposed to the tampon, as they believe it possesses many disadvantages. In the first place, they say it does not always arrest the bleeding, although they admit that it does so usually if the membranes are still unruptured. They object to it. in the second place, because it does not always bring on labour, and so has to be repeated ; and, in the third place, because there is a considerable risk of infection, no matter how carefully it is employed. Thej' would make use of the tampon only in cases of emergency, as, 1 ' Obstetric Works,' vol. i., p. 68. PLACENTA PB.EVIA— ACCIDENTAL H.KMOllKHAGE 587 for example, when preparations are not complete for delivery, or the patient has to be removed to a hospital or nursing-home. Let us take a few writers on the subject. Pinard disapproves of it, and states that he gave up employing it as far back as 1885. The late Varnier was also opposed to it ; Nagel and Strassmann condemn it. Fig. 271. — Cervical and Vaginal Tampon in Placenta Prsevia. But Herman, Eden, Hofmeier, Edgar, and Williams, recommend it employed properly. As regards my own experience, 1 believe it is the best treatment when bleeding lias to be arrested before labour has begun, and when the cervix is not taken up; but both cervix and vagina must be plugged properly. OPERATIVE MIDWIFERY What is the alternative treatment to the tampon when the cervix is undilated '? There are two courses one may pursue : Rupture of the membranes: (6) partial dilatation, followed by bipolar version, or the introduction of a Champeth-r de Kibes or some other metreurynter. As we have seen already, simple rupture of the membranes is an old method of treatment. Puzos advocated it towards the end of the eighteenth century, and Siegemundin suggested it, if she did not practice it, nearly a century earlier. The objection usually raised to the treatment is that not infrequently it does not completely arrest the haemorrhage ; and that if it is insufficient and the bleeding con- tinues, one is very awkwardly placed, for plugging is valueless after rupturing the membranes, and version is difficult or impossible, as the waters have drained away. Within recent years, however, the introduction of the various rubber bags has greatly altered matters, for supposing haemorrhage does continue after rupture of the membranes, a Champetier de Ribes bag or some other metreurynter maj" be introduced. 1 Naturally it will be asked, Is the cervix ever so rigid that it is impossible to introduce two fingers, perform version, or insert a metreurynter ? In my experience it is sometimes most difficult to get the cervix dilated sufficiently. I admit such cases are not numerous, for the haemorrhage always brings about a degree of softening and dilatation ; still, they may be encountered. When the Cervix is Dilated or Dilatable. — When the cervix is dilated or dilatable to the extent of permitting two fingers being passed through it, I feel convinced that the general practitioner will be well advised to continue the treatment which has been most favoured during the last thirty years — viz., version according to the manner of Braxton Hicks (Fig. 272). When the cervix is dilated to any extent, version is an easy matter. Personally, I have found it an advantage to perform external version, and then seize hold of a foot when the child has been turned. I find Strassmann and several other writers recommend this. In most cases I have found external version easy, but if after one or two attempts it is impossible, then the ordinary method of bipolar version must be employed. "When rupturing the membranes, this should be done to the side of the placenta; but in some cases of central or 1 If labour has advanced considerably by the time the patient comes under treatment, rupture of the membranes is quite sufficient if the placenta is lateral, or even marginal. In such cases the pressure of the head arrests the bleeding. Besides, by this treatment one will save most children, for when the os is fully dilated one can, if necessary, deliver with forceps. PLACENTA PB/EVIA— ACCIDENTAL ILEMOBBHAGE 589 complete placenta pnevia this is not possible, for the edge cannot be reached. In such cases the fingers should be pushed through the placental tissues. The foot having been seized and brought down in the manner described (p. 55), a loop of gauze should be attached to Fig. 272. — Bipolar Version in Placenta Prrevia. (Bumm.) it, so that slight traction may occasionally be applied to it should it be deemed necessary. It is of the greatest importance that no attempts at hurried extraction of the child be made. The child's thigh and breach must be pushed through the cervix by the uterine contractions, not dragged through, otherwise serious laceration of 590 OPERATIVE Mll>\\ Il'KliY the cervix and great difficulty with the arms and after-coming head may result. Should the uterine contractions be feeble and infrequent, occasional traction on the limb may be indulged in, but only with the ohject of stimulating uterine action. By this method the bleeding, in my experience, has always been arrested. It is not surprising, therefore, that so many operators favour this treatment, and that the results obtained from it should l)e so satisfactory. In my hospital and private practice during the years 1901 to 1906 I had forty cases with a maternal mortality of 7*5 per cent. Nagel 1 had forty-two consecutive case- without a death, Hofmeier thirty-seven cases with one death, and there are many others showing a mortality of only 4"5 per cent, or 6 per cent. Whenever attempts at dilatation and rapid extraction are made with the object of improving the fcetal mortality, the maternal is at once raised, and that is the reason why my results show a higher death-rate. This also explains Klein's figures for the Chrobak Klinik in Vienna, where there was a maternal mortality of 9'4 per cent. Olshausen, Leopold, and Noble, all emphasize this point, and Strassmann, in his most excellent monograph, shows by his figures that extraction improves the prognosis for the child by 285 per cent., but makes it worse for the mother by 1T-A per cent. As regards the mother, then, I am convinced that, taking everything into consideration, bipolar version is the safe.-t and best treatment for the general practitioner. Strassmann says it continues to be the simplest and safest, and Bumm, 2 Zweifel, 3 and most English obstetricians are of the same opinion. The disappointing feature about version is that the fcetal mortality is so high. Total Cases of Placenta Pr.eyia in* my Hospital and Private Practice, 1901-1906— Forty Cases in all. Relative Maternal Total Percentages. Deaths. I • it be. Foetus macerated. Central ... 42 per cent. 1 i _ _ 66 per cent. Marginal ... -21 „ proper 5Q ^ 3-75 per cent. Lateral ... 36 „ 1) cent ' 41 There were two cases of twins ; in one case both children were born alive, in the other both were born dead. In 75 per cent, of cases bipolar version was the treatment ; in four C'hampetier de Ribes bags were inserted, and in four accouchement force was employed. 1 'Operative Geburtshiilfe.' L902. - ' Grundriss Studium der Geburtshiilfe,' 1902, p. 603. 3 Munch. Med. Woch., 1907, Nr. 48. PLACENTA PREVIA— ACCIDENTAL HEMORRHAGE 59J To all intents and purposes, therefore, the figures here given represent the results from bipolar version. My results in forty cases show a fatal mortality of 52 per cent. Of recent writers who favour version may be mentioned Sonnenfeld, 1 who gives his foetal mortality as 62 per cent., and Berger and Graf, 2 who give a fcetal mortality for Schauta's Klinik in Vienna of 54'9 per cent. It is owing to the fact that the fcetal mortality is so very high — not because of the maternal mortality, which can hardly be improved upon — that other modes of treatment than version have been advocated. The first we will consider is the comparatively recent treatment with the metreurynter (Fig. 273). It is not of much importance which of the various forms of this instrument is employed, but in speaking of it and describing how it is introduced (p. 464) I have indicated a preference for the one devised by Champetier de Ribes. Used in cases of placenta previa, this instrument compresses the placenta against the uterine wall and so arrests the haemorrhage, and, at the same time, dilates the cervix and allows of the easy expulsion of the child afterwards. It must, of course, be introduced after the membranes are 'ruptured; for if, as has sometimes been done, the bag is pushed in against the unruptured membranes, the result must be that more of the placenta is stripped off. Zimmermann 3 recom- mends maintaining the membranes intact ; I feel sure this is unwise. As regards the results from the metreurynter, Hofmeier, Strass- mann, and Nagel are satisfied it has not reduced the fcetal mortality to any very great extent, but other equally distinguished writers hold the opposite view. Without doubt Pinard's results are very good, for with rupture of the membranes and the metreurynter the foetal mortality was 31 per cent. Zimmermann gives for 116 cases a maternal mortality of 5 per cent, and a fcetal of 37 per cent., and Hannes, 4 for a series of 112 cases, a fcetal mortality of 30 per cent. I am satisfied that for hospital practice, or where the conditions are favour- able in private practice, the metreurynter is suitable, and gives the slightly better results as regards the child. As regards the dangers of this method of treatment I need say little. There are all the ordinary dangers attendant upon all forms of treatment in placenta prrevia — infection, laceration of cervix, etc. Lea, Braun von Fernwald, and others, have recorded cases of rupture of the uterus, and Strassmann has pointed out that after the expulsion of the metreurynter there may be a very profuse discharge of blood. 1 Monat. f. Geb. u. Gyn., 1901, Bd. xx., p. 1096. 2 Ibid., January, 1907, Bd. xxv., p. 49. 3 Ibid., 1902, Bd. xvi., p. 37. 4 Zcnt.f. Gyn., Nr. 3, 1909. 592 OPERATIVE MIDWIFE I; Y On several occasions the metreurynter lias burst, but that accident should not happen if the hag is tested beforehand. With the object of lowering the fu-tal mortality still farther, much more active and heroic methods of treatment have been suggested Fig. 273.— Metreurynter in Placenta Prsevia. (Bunmi.) in recent years. Thus, forcible dilatation of the cervix, either by the fingers or by metal dilators, vaginal Cesarean section, and even the classical Cesarean section have been recommended. Piegarding accouchement force, I very much question the wisdom of employing it in such a condition as placenta prsevia. And in PLACENTA PR.EVIA— ACCIDENTAL HAEMORRHAGE 593 support of this view I would refer my readers to the attitude of Treub of Amsterdam, who, until recently, strongly recommended this treatment. Within the last two years, however, he has abandoned it. But at the present day there are those who recommend vaginal and abdominal Cesarean section for this condition. Under no circumstance whatever is it conceivable that vaginal Cesarean section is a suitable operation for placenta previa in the later months of pregnancy. I dismiss, therefore, this treatment without doing more than absolutely condemning it, and in writing so strongly I feel sure I have the support of all unprejudiced obstetricians. Abdominal Cesarean section, however, I place in quite another position. Suggested many years ago by Lawson Tait, it was received with derision. In recent years, however, there has been growing up la slowly increasing body of obstetricians who, while not inclined to advocate the treatment, are disposed in certain exceptional cases to adopt a less antagonistic attitude towards it than formerly. I admit I am one of this number. I have once performed the operation for placenta prawia with a successful result for both mother and child, and in thinking over a large number of cases of this condition which have been under my care, I can remember two others in which it would have been the soundest treatment. It is needless to say that the cases of placenta previa in which such a radical operation as Cesarean section is contemplated must be chosen with the very greatest care and judgment, and with a mind absolutely unbiased. Let us consider the cases that possibly might be suitable for this operation. As we have seen, placenta previa has a maternal mortality of 8 per cent., and a fcetal mortality of 50 to 60 per cent. The best figures give 4 per cent, and 35 per cent, respectively, and they are as low as one can ever expect to reach with the present recognized methods of treatment. Looking at the fcetal mortality, it must, I think, be admitted that, provided the pregnancy is at or near full time, [Cesarean section would undoubtedly be better for the child, for by means of it one could make sure of reducing the mortality to 5 per cent, or 7 per cent, at worst. We will dismiss the consideration of the child for the moment, and consider the mother. Taking the cases of placenta pmevia as a whole, better than 4 per cent, to 8 per cent, maternal mortality cannot possibly be attained by the ordinary methods (version, metreurynter, etc.) ; but are there not certain cases where that mortality of 4 per cent, to 8 per cent., which is the best average, cannot be attained by the ordinary recognized methods of treatment, when, in other words, these treatments would 38 594 OPERATIVE MIDWIFER1 coiiitj to have a higher mortality than ( ;tsarean section/ The cases which 1 refer to are old primiparae, where the haemorrhage occurs at full time and before labour has started, and where, to judge by the condition of the parturient canal and the size of the child, delivery would be tedious and difficult. I pat the question in connexion with such cases — Is it not possible to get as low a mortality from Cesarean section as from the recognized treatments in such cases, provided the women have not been interfered with and infected'.' It will be observed I do not say a ' lower,' but ' as low " a mortality. If the answer is in the affirmative, then in such cases Caesarean section is the right treatment, for there will be an enormously larger number of children saved. Before leaving the subject of the treatment of placenta prsevia, I must warn my readers to be always prepared for post-partum haemor- rhage. This haemorrhage is said to occur because the placental site does not retract satisfactorily, situated as it is in a less actively contractile portion of the uterus. In my experience severe post- partum haemorrhage rarely follows this variety of ante-partum haemorrhage. Without doubt, if the more rapid methods of emptying the uterus come to be generally employed, post-partum haemorrhage will be much more common. ACCIDENTAL HEMORRHAGE— ABLATIO PLACENTAE. By accidental haemorrhage is meant haemorrhage that results from the partial or complete detachment of a normally-situated placenta in the later weeks of pregnancy — say after the child is viable. The similar condition, prior to that time, is abortion. The name ' accidental haemorrhage ' was given to the condition by Rigby, to distinguish it from ' unavoidable haemorrhage,' the hemor- rhage from placenta praevia, which we have just considered. These two terms have been very generally employed since Rigby's time. There are, doubtless, certain objections, particularly to ' accidental ha-mor- rhage,' for it might be, and often is, understood as meaning ha-morrhage of any kind the result of an accident, whereas, as the definition says, it is haemorrhage resulting from the detachment of a normally-situated placenta. But the terms, as far as one can judge, are likely to continue to be employed ; at least, the attempt of Holmes 1 to call the condition of accidental hamorrhage ' ablatio placenta- ' has not met with much support. The etiology of this complication may, with a few reservations, be said to be that of abortion. Frights, falls, injuries, and diseases of 1 Amcr. Jowrn. of Obst., 1901, xliv., p. 758. ACCIDENTAL HEMORRHAGE— ABLATIO PLACENT.E 595 the various systems — nervous, digestive, etc. — furnish doubtless occa- sionally causes for the placental separation ; but, without a diseased condition of the endometrium, it is surprising how harmless such disturbances are. Without the least doubt, the great cause of 'accidental hemorrhage,' as it is the great cause of abortion, is a chronic inflammatory condition of the uterine mucosa. Thus we meet with the complication most commonly in the poorer classes, in multipara?, and in those who have suffered from uterine troubles. In the severe cases of the disease which I have seen, the general condition of the women has been most unsatisfactory ; very often they have been ailing for some time, and many of them have been very decidedly anaemic. I have not often found them the subjects of chronic renal disease, although, of course, one often finds albumen present in the urine. Winter and many others have laid great stress upon this. Personally, I am inclined to think that the albuminuria often present is, in many cases, the result of the patient's general ill- health, and is not the cause of the condition. How far actual diseases of the placenta plays a part as an etiological factor in this complication it is impossible to state, seeing that the placental pathology is in such a confused state at present. Clinical Features and Diagnosis. This all-important complication presents itself in two distinct forms, according as the haemorrhage escapes externally and is evident, or becomes pent up inside the uterus between the placenta or mem- branes and uterine wall, when it is spoken of as ' concealed,' a term given to the condition by Baudelocque. The bleeding is at times so slight as to be almost negligible, at other times so profuse as to place the woman's life in the greatest jeopardy. The blood may come away quite bright red, but if retained for any length of time it is dark and coagulated, and sometimes is expelled in the form of large, flat clots. If at all profuse, labour comes on spontaneously, or the means employed to arrest the bleed- ing result in its onset. In slighter degrees one meets with recurrent attacks of bleeding, as in placenta previa. Once or twice I have seen cases where, after a moderate degree of active bleeding, a dark brownish discharge continued until labour came on spontaneously or was induced. I have said there are two distinct varieties ; I should have added a third or a ' mixed ' variety, which includes a large number of cases, where the bleeding is partly external and partly internal. 596 Ol'KKATIYE MIDWIFERY Both the apparent and concealed varieties are serious, but the concealed is especially so, as it is generally associated with a more diseased condition of the uterine wall, and is apt, from the absence of hamorrhage, to be overlooked. Indeed, it is no exaggeration to say that it is one of the most serious complications of parturition. As the different forms present features quite distinct, we shall consider them separately. Apparent Accidental Haemorrhage. — The bleeding, although often following some strain, stress, or injurj 7 , not infrequently comes on without any exciting cause. The quantity of 1 the haemorrhage varies. Sometimes a feeling of weight and tension in the abdomen is complained of, but' until labour comes on such discomforts are usually slight. Sensations, such as feelings of faintness and sickness, and evidences of anaemia, such as pallor, rapid pulse, etc., soon supervene if the haemorrhage is at all profuse. A diagnosis of the condition is not difficult, although it is by no means always easy to say whether or not in a particular case an internal as well as an external bleeding is going on (Fig. 274). I always conclude that there is a decided internal haemorrhage if the anaemia and general symptoms are out of proportion to the amount of blood lost, and if there is decided uterine tenseness. It is of the greatest importance that these mixed forms should be recognized. In my experience they are very apt to be disregarded, for the medical attendant is apt to gauge the seriousness of the case by the amount of evident bleeding, whereas he must always gauge it by the general condition of the patient and the state of the uterus. Let me give a case in illustration : Case of Accidental Hcemorrhage of the ' Mixed' Type not fully appreciated until the Parturient was extremely collapsed. — Some little time ago a patient, a 4-para, was admitted into my wards in the Maternity Hospital in a con- dition of extreme collapse. Early in the day she had sent for her medical attendant on account of some vaginal haemorrhage which alarmed her. He, seeing that the haemorrhage was slight, advised absolute rest in bed, and prescribed some sedative to relieve the uterine pain. Later in the day he was again summoned to her because of her collapsed condition. There had been very little external bleeding in the interval. The doctor, of course, now diagnosed the nature of the condition — concealed accidental haemorrhage — and immediately sent her into hospital. So ill was the patient when she came under my care that I deemed it advisable to perform abdominal hysterectomy. She survived only a few hours. Behind the placenta and membranes there was a large quantity of coagulated blood, and even the uterine wall contained in its substance numerous and extensive lj;emorrha<'es. ACCIDENTAL HEMORRHAGE— ABLATIO PLACENTAE 597 There is only one other condition that is likely to be mistaken for apparent accidental hemorrhage, and that is the hemorrhage that occurs from placenta previa. Profuse bleeding from polypi, malignant tumours of the cervix, and from torn vaginal vessels, is extremely 1 Fig. 274. — Accidental Haemorrhage in which the Bleeding is partly Concealed aud partly Apparent. Mixed Variety. rare, and may be disregarded, although quite recently my house- surgeon mistook a case of concealed accidental hemorrhage, where there was a little external bleeding and the cervix was a little thickened, for a carcinoma of the cervix complicating pregnancy. As regards OPERATIVE MIDWIFERY placenta previa, the placenta can be felt, as a rule, by carefully Bweeping the fingers round the lower uterine Begment inside the os internum. Undoubtedly blood-clots may simulate the placenta very closely, but they are smoother on the surface and more friable. As we have seen when considering placenta previa, a small portion of placenta attached to the lower segment may be overlooked very easily, and there is not the least doubt that many cases of hemorrhage are of this nature. Fortunately, treatment differs but little in the two conditions, and in carrying it out, as in performing version, one has an opportunity of making a more exact diagnosis. After delivery also, an examination of the placenta and membranes may give important information, for in placenta previa the rupture in the membranes will be near the margin of the placenta, while in accidental hemorrhage it will be some distance from it. Concealed Accidental Haemorrhage. — Turning now to the more serious form, the ' concealed,' one may find external bleeding entirely absent (Fig. 275). That, however, is very uncommon. In fifty cases in the Maternity Hospital, in the years 1901 to 1906, it was only noted four times. Colclough, 1 in his analysis of eighty-two cases in the Rotunda Hospital, found it in six cases, while Holmes in 200 collected cases found it fort3 T -one times. Not infrequently, although there is no external bleeding, there is a serous discharge from the vagina. It sometimes happens that one gets a history of the woman having had a sensation of something having given way, and this, especially when external bleeding is absent, may give rise to considerable un- certainty as to what exactly is the condition one has to deal with. Rupture of the uterus is the other complication that most naturally comes to one's mind, but rupture of the uterus during pregnancy or early in labour is very rare, although it does occur occasionally. Theoretically the rapidity and extent of the collapse, the sudden onset of pain, and the alteration in the outline of the abdominal swelling, would lead one to suspect rupture ; but, as I shall show in Chapter XXXV., rupture may occur and yet these symptoms may not be present. In practice it may occasionally happen that the differential diagnosis of the two conditions is not easy. A sub peritoneal hematoma referred to in Chapter XIII. (p. 208) may also closely resemble concealed accidental hemorrhage. If the hematoma is of any size, it may be distinguished as a distinct tumour, although in some cases that has not been possible. The all-important feature of concealed accidental hcemorrhage is tenseness and tenderness of the uterus. In addition, there is collapse out of all proportion to the amount of blood lost. 1 Journ. OW. ami Gyn. Brit. Empire, 1902, vol. ii., p. 1"> ;; . ACCIDENTAL HAEMORRHAGE— ABLATIO PLACENT/E 599 The blood that becomes pent up in the uterus collects between the placenta and membranes and uterine wall. Occasionally one finds the whole placenta separated except at its margin, but at other times, and more commonly, some blood accumulates also behind the membranes. Fig. 275. — Concealed Accidental Haemorrhage. Very rarely indeed the effusion of blood ruptures into the amniotic cavity, and still more rarely does the uterine wall give way. As a result of the bleeding, there are all the symptoms character- istic of hemorrhage and shock — pallor, faintness, cold, clammy sweats, and small, rapid pulse. The amount of collapse, however, is out of 600 OPERATIVE MIDWIFEBI proportion to the quantity of blood effused, and is due, therefore, not altogether to the anemia, but also to the shock produced by the uterus being so tensely distended. In bad cases one always finds, in addition, extreme restlessness, great pain, distension, and tenderness of the abdomen. Sometimes the tenderness and distension are confined more especially to one part, where presumably the separated placenta is. On palpating the uterus it is always found very hard and globular ; person- ally I can never remember having found it boggy. It is, as a rule, im- possible to make out the fcetal parts. By vaginal examination the membranes can be felt through the os more than usually tense. Prognosis for Mother and Child. In most of the cases where the haemorrhage is slight the outlook is not serious. Whenever the bleeding is at all pronounced, however, and especially if it is concealed, the dangers to mother and child are very great. As regards the mother there is probably no complication, w 7 ith the exception of rupture of the uterus, in which her life is placed in greater danger. Statistics are unreliable, for if the slight cases are included in a series, then the mortality will appear comparatively small. In the grave cases there is a mortality of 40 to GO per cent. Ae regards the children, unless the placental separation is very slight indeed, they always perish. Treatment. Before discussing such a contentious subject as the treatment of accidental haemorrhage, let me remark that this complication is on quite a different footing as regards treatment to the other form of haemorrhage which we have just considered — namely, placenta praevia. Accidental haemorrhage almost invariably results in the death of the child, so that its life, except where the haemorrhage is very slight, need not be considered. The treatment is entirely directed, therefore, to saving of the mother. As the clinical features and severity in the different varieties of accidental haemorrhage differ, so also should the treatment. Let us first of all consider the cases where the ha-morrhage is apparent, and where, as far as can be j udged from the clinical features, there is little concealed. All, I think, will agree that in the slight cases of this variety, which occur during labour in a uterus contracting satisfac- torily, the simple procedure of rupturing the membranes is all that is required. It is not even necessary in most cases to perform version, which has the objection of complicating the delivery, and diminishing ACCIDENTAL HEMORRHAGE— ABLATIO PLACENTAE 601 the chances of obtaining a living child, for in this variety one occasion- ally is fortunate enough in saving the child. When the haemorrhage occurs before labour has started, or only just at its commencement, the procedure to be followed is quite different. In such cases there are three distinct methods of treat- ment : (a) Plugging the cervix and vagina ; (l>) rupturing the membranes ; (c) dilating the cervix and extracting the child (accouchement force). Treatment by Plugging". — In recent years in this country the treatment first initiated by Leroux, in 1776, of plugging the vagina has been revived, and has been very strongly recommended, more especially by the past and present masters of the Rotunda Hospital. In the discussion on this subject at the British Medical Association in 1904, Macan and other Irish obstetricians, without a dissentient voice, supported this treatment, inaugurated some years previously in the Rotunda Hospital by Smyly. Certainly the results obtained by this method in the practice of the Rotunda Hospital have been of a highly satisfactory nature, as can be judged from the valuable paper on the subject by Colclough, in which he showed a mortality by the treatment of slightly under 5 per cent. At the same meeting Champneys supported the treatment in certain cases. Galabin also half-heartedly favoured it, but pointed out that in the old statistics of Sinclair and Johnston, of about fifty years ago, where the treatment was rupture of the membranes and acceleration of delivery, the mortality was only slightly greater. In Germany, with the exception of Veit, 1 Hofmeier, 2 and Nagel, 3 there are few who favour the treatment by plugging ; the same also applies to France and America. Amongst those who condemn the treatment may be mentioned Herman, 4 who writes : ' The only way in which it does good is by irritating the cervix, and so stimulating the uterus to contract ; it is a clumsy and painful way of doing this.' Webster : 5 ' The tampon treatment is most pernicious ; it has no scientific basis whatever, although it may have in a certain class of cases of placenta previa.' Holmes: 6 'The tampon should have no place in the treatment of ablatio placenta?.' We have here, then, as in so many other conditions, two absolutely opposite opinions by equally distinguished obstetricians on the treat- ment by plugging. It is, consequently, not a little difficult to decide 1 ' Handbuch ftir Geburtshulfe,' ii., p. 86. 2 'Handbuch der Geburtshiilfe,' Bd. ii., Teil ii., p. 1195. 3 ' Operative Geburtshiilfe,' 1902, p. 299. 4 ' Difficult Labour,' revised edition, 1900, p. 301. 5 American Journal of Obstetrics, 1901, vol. iv., p. 861. t; Op. cit. 602 OPERATIVE MIDWIFERY who is in the right, or, what is more important, whether or not plugging is of value in the treatment of accidental haemorrh There are two conditions in which it is agreed by every one thai plugging is unsuitable — viz.. when the membranes are ruptured, and when the haemorrhage is concealed, and it is self-evident why thai should he so. These cases, therefore, may he dismissed from con- sideration at present. Personally, I favour the treatment by plugging in certain cases, and for the simple reason that it is the only method of imitating Nature's cure. On several occasions I have watched the progress of a case of accidental haemorrhage which has been left entirely to Nature, and I have found that by the formation of clots the further progress of the haemorrhage becomes arrested. But during such a time the woman loses a considerable amount of blood, and sometimes Nature cannot control the condition, and so, with the object of favouring clotting, the tampon is sound treatment. It also, of course, has the effect of damming back the blood, stimulating the uterus to contract, and dilating the os. There is another action claimed for the plug by Tweedy — that it compresses the uterine arteries when there is a tight abdominal bandage pressing down the uterus from above. If the contention is correct, a very large supply of blood must be cut off from the uterus. In other words, as Tweedy says, arrestment of bleeding results in the same way as occurs in post-partum haemor- rhage if the abdominal aorta is compressed. It is incorrect to say that the plugging of an external haemorrhage simply converts it into a concealed or internal one, for this will only happen if the uterine wall is unable to withstand the pressure from within. "We have had in the Maternity Hospital, and I have had in private practice, some highly satisfactory results in cases of apparent accidental haemorrhage by plugging. But when I have said this in support of the plug, used as I shall describe it immediately, I feel that I have said all I can in support of it; for there are certain cases — those in which, although the haemorrhage is apparent, it is also to a large extent concealed — in which the treatment by plugging must be used with great care. The patient must be watched constantly as regards her general condition, more especially as regards her pulse and the effect that the distension of the uterus is having upon her. In these cases the experience and judgment of the operator will be tested to the utmost, and he must be prepared, if symptoms of the more serious form of concealed hemorrhage develop, to adopt the more energetic treatment we shall consider later. In plugging for accidental haemorrhage the operation should be carried out as follows : The woman is placed in the lithotomy position. ACCIDENTAL HEMORRHAGE— ABLATIO PLACENTAE G03 1 The external genitals are then thoroughly cleansed and the pubes ! shaved, as there is great danger of sepsis. The vagina also should be carefully washed out with a weak solution of lysol, so as to remove any loose blood-clot which maybe present in its upper part. The material used for plugging is not of any great moment, although, without doubt, plugs of absorbent cotton-wool, about the size of a walnut, fit into the ■fornices better than larger tampons. Sterilized gauze does very well if tampons are not available, and, of course, at a pinch, any linen or cotton boiled will do. If the material used for plugging is soaked in an antiseptic, it must be a very weak solution, as otherwise con- siderable damage will be done the vaginal mucous membrane. As such a weak solution can have no germicidal value, it is quite unnecessary to employ it. If retractors are at hand, they should be employed ; although it is easy to use one hand as a vaginal retractor, while pushing in the plug with the other, the vaginal wall is much more likely to be damaged. Having packed the gauze firmly round the cervix and filled up the vagina completely, a firm abdominal binder is applied over the uterus. The binder is fastened from above downwards. Last of all, a perineal pad and bandage are applied, the latter being pinned to the abdominal binder. Rupture of the Membranes. — It is perfectly true, as has been already stated, that in a certain number of cases rupture of the membranes, and so taking off the strain on the uterus, and allowing its walls to retract over the child, is sufficient. As Barnes 1 says, ' Nature will do the rest.' In a very large number of cases, however, and these the most serious, rupture of the membranes is not sufficient, and even the strongest supporters of this treatment admit this in their writings, for they all, as witness Barnes and Herman, refer to what should be done should hemorrhage continue. Rupturing the membranes is usually quite sufficient in cases where labour has been in progress for some time and the uterus is contracting well. But should one adopt this simple procedure where the cervix is still undilated and the uterine contractions are not active, one is very awkwardly placed indeed if the hemorrhage continues ; a foot cannot be brought down, and there will be difficulty even in introducing the metreurynter. Both the older results, such as those of Goodell and Hicks, and the more recent results of Smyly — an opponent to the treatment by rupture of the membranes — are far from satisfactory, and were it not for the dernier ressort of the metreurynter no present- day obstetrician would favour the treatment. Hofmeier,' 2 writing on this subject, says : ' Rupture of the membranes should only be 1 ' Obstetric Operations,' p. 426. 2 Op. cit. 604 OPERATIVE MII>\YJIT.I;Y employed when the bleeding is not very strong, when the pains are good, and when labour has advanced so far that rapid delivery is -ihle should it hecome necessary. 1 Practically all other modern writers express themselves in similar terms. Dilatation of the Cervix— Extraction of the Child— Accouche- ment Force. — At the present moment on the Continent of Kurope and America the treatment by the metreurynter is probably the one most favoured; in Jlolmes' paper this is the treatment recom- mended for severe cases not in labour. Others in America, such as Jewett, 1 Hirst, 2 and Williams, 3 all favour this method. In this country Herman, Eden, and most recent writers, with the exception of the liotunda school, favour the treatment, and trust to it rather than the plug. Without doubt this treatment has its place, and the cases in which personally I believe it is suitable are where there is a moderately severe internal haemorrhage, in which one is not quite prepared to adopt the very radical treatment that is now recommended for the very grave forms of concealed accidental haemorrhage. To my mind, therefore, it is the most suitable treatment in cases unsuitable for plugging, but not severe enough for hysterectomy. As regards treatment by more active dilatation, such as that carried out by means of Bossrs dilators, obstetricians one and all are opposed to such a procedure. Our results in the Maternity Hospital by this treatment have been most unsatisfactory. The shock produced to the patient — and it must be remembered she is already very much shocked — is very great, the danger of laceration of the cervix is not inconsiderable, and the probability of post-partum haemorrhage by no means remote. Abdominal and Vaginal Caesarean Section. — I have dealt suffici- ently exhaustively, and above all, clearly, I hope, with the treatment of accidental haemorrhage as one meets with it generally. I have pointed out how in slight bleeding during labour simple rupture of the membranes is sufficient ; how in the apparent hemorrhage during pregnancy or early in labour, the best results are obtained by plugging ; how in the mixed, especially those in which a large quantity of blood is concealed, the metreurynter should be employed, and after its expulsion the child extracted by forceps or version. There now only remain to be considered those severe cases of concealed accidental haemorrhage, which are fortunately not common. It is a very striking fact that, as regards this, the most 1 ' Tracticc of Obstetrics,' 2nd edition, 1902, p. 528. - ' Text-] look of Obstetrics,' 1899, p. 536. 3 'Obstetrics,' 2nd edition, 1907, p. 808. ACCIDENTAL HEMORRHAGE— ABLATIO PLACENTA 605 serious group of cases, there is gradually coming to be a greater uniformity of opinion. Year by year one finds the active treat- ment, which I shall refer to, more and more advocated. At the British Medical Association at Oxford, in 190-1, when this subject of accidental hemorrhage was discussed, all the speakers without exception, held more or less the same opinion regarding the treatment of these most serious and fatal cases now under con- sideration. The results obtained from all the ordinary forms of treatment in cases of severe accidental hemorrhage have been so unsatisfactory that modern obstetricians have been forced to adopt most radical measures in the hope of lessening the maternal mortality. The treatment consists in emptying the uterus, and in most cases removing that organ. This may be done either by the abdomen or by the vagina. The reason why the uterus is removed is that it has been found that, after emptying it, hemorrhage often continues, and that there is great difficulty in controlling this post-partum haemorrhage even by plugging. I entirely agree with this attitude towards this condition. In the grave cases of concealed accidental haemorrhage the uterus is in a state of atony, and cannot possibly be aroused from that state by massage, douche, etc.- One finds advocates both of the abdominal and vaginal route, and there is much to be said for each. The advantages of the abdominal route are that the operation is easier, that there is less risk of injuring the bladder, and that the subsequent removal of the uterus is not difficult. The advantages of the vaginal route, on the other hand, are that the risks of infection are less. Quite a number of successful cases have been recorded by both methods. In the two cases in which I have adopted hysterectomy I chose the abdominal route. In neither of the cases did the treatment prove successful. One died almost immediately after the operation, while the other succumbed to sepsis on the fifth day. In the latter case it was specially disappointing that this happened, as her progress after hysterectomy for the first two days was extremely satisfactory. Both these patients were admitted into the Maternity Hospital pro- foundly collapsed, and I am perfectly certain no other treatment would have been more successful. Targett 1 has reported a success- ful case, and scattered through the literature of the various countries are to be found not a few successes. The form of abdominal hysterectomy to be performed in these cases is supravaginal amputa- tion of the uterus, with a retroperitoneal treatment of the stump, an operation described on p. 418. The vaginal Cesarean section, so 1 Trans. Lond. Obst. Soc, vol. xlvii., p. 147. 006 OPERATIVE MIDWIFKKY strongly recommended by Puhrssen, Bumm, and others is fully detailed on p. 170. In (Icrniany several successful cases have been recorded by this method, and it may be that it will be more extensively employed in the future. The objection to the vaginal Caesarean section, with the subsequent extraction of the uterus by the vagina, that there would be a difficulty in removing the large uterus, has not been found to be the case. The objection is purely theoretical. Several operators, including Wilson of Birmingham and myself, have described cases where the full-time uterus has been removed without difficulty through the vaginal canal. The uterus becomes so relaxed and stretched out that by steady traction it is readily dragged down. As I have already stated, 'If vaginal Cesarean section is to have a permanent place amongst the recognized obstetric operations of the later months of pregnancy, there is no condition more suited for this method of treatment than severe concealed accidental hemorrhage.' And I say this for two reasons — (1) The child, as we have seen, is negligible ; it is always dead, and so the after-coming head may be perforated always and easily extracted. (2) The uterus is negligible ; it should be removed, and, consequently, it does not matter how it is incised or torn. When speaking of vaginal Ca?sarean section in Chapter XXVIII., where the operation is described, I pointed out that my objection to the operation in the later months of pregnancy was the danger of injuring the lower uterine segment. Naturally that objection cannot be raised if the uterus is removed. The accoucheur who is accustomed to vaginal operations will have no difficulty in removing the full-time uterus by the vagina. The quickest way of dealing with the vessels is by securing the broad ligaments with clamps, and in cases where this route is chosen I would advise this method of treatment, for the operation can be per- formed in a few minutes. It is all-important that the clamps should have the ridges on the blades running longitudinally, otherwise they are apt to slip. They should be removed at the end of forty-eight hours. CHAPTER XXXIV POST-PARTUM HEMORRHAGE Post-partum haemorrhage is commonly divided into primary and secondary ; ' primary ' is the haemorrhage that occurs during the first twenty-four hours after delivery, and ' secondary,' or puerperal hemorrhage, that which occurs later. Primary Post-Partum Haemorrhage Post-partum haemorrhage of a severe type is a complication which one now sees comparatively seldom in hospital and private practice. The explanation of this satisfactory state of affairs is that the second and third stages of labour are managed much more carefully than in former years. It is no exaggeration to state that the all-important preventive against post-partum haemorrhage is a proper management of these stages of labour. It does happen occasionally, however, in spite of the utmost care, that severe haemorrhage follows the expulsion of the child, so that in a very short time the woman may be so exsanguinated that death results ; but that is not the most common type of post-partum haemorrhage. More generally the haemorrhage is less severe, and there is some slight attempt at uterine retraction and contraction. Post-partum bleeding may occur from the placental site, or from tears and lacerations in cervix, vagina, and vulva. Haemorrhage from the placental site is the most important, but it is well not to forget that occasionally severe haemorrhage occurs from tears in the situations I have mentioned. I quite agree with Herman 1 that lacerations of the cervix are very rarely associated with severe haemorrhage. Herman writes : ' One cannot say it is impossible for a torn cervix to cause dangerous post-partum haemorrhage, but I doubt if it ever does.' Personally, I have only seen it in two eases, where the lacera- tion extended into the broad ligament. These cases are considered in Chapter XXXV. Tears of the vaginal wall and lacerations of the 1 Practitioner, April, 1907. 607 608 <>!T.l;.\TI\ E MIDWIFERY perineum may also be associated with a considerable amount of bleeding, but I have Been the worst bleeding of all occur from tears of the vestibule in the neighbourhood of the clitoris. Haemorrhage from lacerations of the parturient canal is to be distinguished from hamorrhage from the placental site by the fact that with the former the uterus is firmly retracted, although bleeding still goes on. The repairing of lacerations of the cervix and the perineum is described in Chapter WW. Tears of the vestibule are only to In- dealt with by deeply understitching the part. A needle is passed down to the bone wide of the bleeding-point, and a ligature carried round the bleeding centre (purse-string suture). "We must now turn to the ordinary post-partum haemorrhage — that is, the haemorrhage which occurs from the placental site. The im- mediate causes of post-partum hemorrhage of this variety are primary and secondary uterine inertia or exhaustion. The former is favoured by overdistension of the uterus, from hydramnios or plural pregnancy, tumours of the uterine wall, etc., but most of all by a diseased condition of the uterus, seen so commonly in multiparas the subjects of chronic metritis. The latter, secondary inertia or exhaustion of the uterus, also results from the conditions already mentioned, but it is seen in its most typical form in cases of prolonged parturition where there is a disproportion between the parturient canal and ftetus or some malposition of the fcetus. It will be observed that I have not mentioned precipitate labour, for I have seldom seen grave post-partum haemorrhage in that condition. In cases of Cesarean section, for example, where the child is rapidly extracted, it seldom occurs, and when it has occurred the uterus was invariably exhausted. Neither have I mentioned pathological con- ditions of the blood, as found in haemophilia, anaemia, and general debility, for I believe that these conditions are of comparatively little account. But there is one thing which I feel convinced favours post- partum hemorrhage, and that is the long-continued administration of chloroform. In private practice amongst the wealthier classes a light anesthesia is often kept up for many hours. In such cases I have often found the retractility of the uterus greatly impaired. The diagnosis of post-partum hemorrhage is simple when the uterus remains absolutely flaccid and blood is gushing from it. The condition may not, however, be fully appreciated when there is a slow oozing of blood, and the uterus contracts slightly from time to time. In these cases the blood often becomes pent up in the uterus, and only a small quantity escapes, so that the uterus slowly distends, and the condition is only recognized when the accoucheur, on pressing POST-PARTUM H/EMORRHAGE 609 it, forces out a large quantity of blood-clot, and finds the patient un- expectedly becoming collapsed. The latter type is the more common, but the least serious. Cases belonging to it can always be saved, for there is a certain degree of activity left in the muscle-fibres of the uterus. Cases of the former type are naturally much more grave, and must be dealt with promptly and energetically if the patients are to be rescued. Treatment. Prophylactic. — Before discussing the treatment of post-partum haemorrhage, I must say a word or two about the prevention of this ■condition. Although the patient who has had experience of post-partum haemorrhage need not at a subsequent labour be again afflicted with this complication, there is no doubt that it is to her advantage to have any pathological condition of the uterus corrected, and to have her general health kept at as high a level as possible during her preg- nancy, in case of the complication recurring. The particular patho- logical condition of the uterus that should be suspected, and if possible remedied, is a chronic metritis. Unfortunately, however, it does not yield very readily to treatment. The administration of small •doses of ergot and strychnine during the later weeks of pregnancy is generally recommended in such cases, with the object of improving the muscular contractility and innervation of the uterus. I am in the habit of giving these drugs, but I cannot say if they have done good. One thing is certain — they cannot do any harm. In recent years the exhibition of chloride of calcium has been recommended because of its property of favouring coagulation of the blood. As I have already indicated, however, post-partum haemorrhage is only to be prevented by securing uterine retractility and contractility. The greatest factor in preventing post-partum haemorrhage is the proper management of the second and third stages of labour. It is quite impossible to discuss here the whole management of the second stage of labour, so I will only refer to the one all-important point — namely, the danger of extracting the child while the uterus is in a condi- tion of secondary inertia. The uterus in that condition is tired and worn out ; it requires rest : opium is the drug to give. When the uterine contractions recur and do not complete the delivery, then extraction may be performed with absolute safety. The management of the third stage has been considered in Chapter XXX., so that I need not refer to the subject here. Active. — Post-partum haemorrhage can only be controlled by ■establishing retraction and contraction of the uterus. It is never 39 010 OPERATIVE MIDWIFERY encountered when the uterus is firmly retracted, nor will it ever fail to occur when the uterus is flabby and in a condition of atony. There has been a great deal of discussion about the meaning of these two terms ' retraction ' and ' contraction.' For a simple explanation of them I cannot do better than refer my readers to Herman's recent remarks on the subject. 1 Herman says : ' I will not discuss definitions, but I will describe. Anyone who puts his hand on the abdomen of a woman who has just been naturally delivered will feel the uterus. It is firm ; its shape is definite ; its inner wall is applied to the placenta ; its muscular fibres are grasping and con- stricting the vessels, and in this condition it remains. This is retraction. Every few minutes the uterus becomes smaller and harder ; it grasps the vessels more tightly, and it squeezes the placenta ; and if the placenta is loose, it squeezes it out. This is contraction. The patient is not safe in the third stage of labour until this condition of retraction with intermittent contraction has come to stay.' The first thing to do in order to try and secure this condition of retractility and contractility is to massage the uterus. The uterus is seized between the fingers and thumb and rubbed firmly. If the placenta has not been delivered, it should be expressed. In the slighter degrees of post-partum haemorrhage the expression of the placenta and of blood-clot ends one's anxiety about the condition ; bnt in the graver cases, where the uterus does not respond to massage, the hand must be immediately introduced into the uterus, and the placenta, if it is still there, and all blood-clot removed. Before doing this it is well to pull on a sterilized glove, for one seldom has time to resterilize the hand, which has become contaminated to a slight extent. I have discussed the advantages and disadvan- tages of gloves elsewhere. If the accoucheur has not gloves, he should cleanse his hands once again, provided there is time for doing so. If there is not time, then he must run the risk of introducing his hand soiled as it is. Provided he has previously thoroughly disinfected his hands before delivering the child, the risk is not great. Very generally the removal of all blood-clot and the manipulations of the hand in the uterus bring about uterine contractions. Whether or not that occurs, an intra-uterine douche of sterilized water at a temperature of about 118° (water at this temperature is uncomfort- ably hot, but not more than that, to the skin of the forearm) should be given. In addition to the douche ergotin should be injected into the buttock : 10 to 20 minims of the aseptic ergotin supplied in little 1 Op. cit., p. 447. POST-PARTUM HEMORRHAGE Gil glass capsules is the best preparation ; liquid extract given by the mouth (2 drachms) is much slower in its action. If these means are ineffective in producing satisfactory retraction of the uterus, the hand should be again introduced, the uterus stimulated, and the surface again gone over with the fingers, in case there may still be some membrane or placenta left behind, and another douche given. I have only twice seen this treatment fail to arrest the bleeding, and in both of these cases I packed the uterus with gauze, which I believe is the best course to follow. One should always carry a quantity of broad iodoform gauze, sufficient to pack the uterus and vagina. Supplied in the tins of Diihrssen, it can be carried about Fig. 276. — The left-hand figure shows a Uterus carefully plugged with Gauze; the right- hand one a Uterus in which only the Lower Uterine Segment is packed. A, Retraction ring ; B, cavity of uterus unpacked. (Bumm.) very conveniently. In order to arrest the bleeding the packing must be thorough. It is best performed by pulling down and steadying the cervix with vulsellum forceps, and stuffing in the gauze with the hand. Gauze forceps are not nearly so good. After the uterus is thoroughly packed, the vagina should be plugged, a pad should be placed round the fundus, and a firm abdominal binder applied. B)i this means tlie bleeding can be absolutely controlled. The illustration (Fig. 276) shows a mistake often made of packing Dnly the lower uterine segment. Such plugging is naturally quite ineffectual in arresting haemorrhage. 012 OPERATIVE MIDWIFERY I am quite aware that many operators, especially in this country, are opposed to plugging the uterus. Herman, for instance, is opposed, to it, and Eden 1 gives it a very half-hearted support. Tweedy,* 2 how- ever, approves of it, and many American and German accoucheurs recommend it. The alternative to plugging is bimanual compression of the uterus ; Fig. 277. — Bimanual Compression of Uterus for the Purpose of arresting Postpartum Haemorrhage. (Bumm.) that is to say, the whole fist is introduced into the uterine cavity, and the uterine wall is squeezed between the fist and the external hand- It is claimed that this is a better method of compressing the uterus than the one illustrated, where the hand in the vagina grasps the cervix, and the external hand grasps the fundus and doubles the body on the cervix (Fig 277). I very much question if this manual com- 1 ' Manual of Midwifery, 1 1906. 2 ' Potunda Practical Midwifery,' 1908, p. 291. POST-PARTUM HAEMORRHAGE 613 pression is better than plugging, and in any case one cannot keep it up for any length of time. In desperate cases, as a temporary measure, manual compression of the abdominal aorta by the fist may be employed. In carrying out this treatment the accoucheur or his assistant should stand above the patient, place his fist over the aorta, and lean the whole weight of his body on his straightened-out arm. By that means he can keep up pressure for an indefinite period, but if he tries to do the same by pressure with the arm bent, he will soon become exhausted. More radical suggestions have been made for dealing with desperate cases of post-partum haemorrhage. It has been recom- mended that the uterine vessels should be clamped, and that the uterus should be removed. It has even been suggested that the uterus should be artificially inverted. I will not discuss such methods, however, for I do not believe that they are ever necessary. In the text-books of twenty or thirty years ago the swabbing of the uterine cavity with a styptic solution was recommended, the idea being that the bleeding could be controlled by producing thrombosis of the vessels. For this purpose such substances as perchloride of iron and vinegar were employed. I could hardly have believed that such measures were still in use, yet a case came under my notice some few years ago where a practitioner packed the vagina and uterus with gauze soaked in vinegar ; the consequences were very serious, for the entire mucous membrane sloughed. In recent years swabbing with a weak solution of adrenalin, 1 in 1,000 to 1 in 2,000, or soaking a portion of the gauze in such a solution, has been recom- mended. I feel sure it is unsound treatment for this kind of haenior- rhage, and if employed is bound to result in destruction of tissue, which naturally favours the invasion of saprophytic organisms. Treatment of Collapse from Haemorrhage. So far in discussing the different varieties of haemorrhage I have only incidentally referred to the manner in which the collapse should be overcome. Certainly it is all-important to arrest the bleeding, but it has also been abundantly proved in recent 3 T ears that, unless fluid is added to the circulation to take the place of the blood lost, the patient may die even although the bleeding has been stopped. After arresting the haemorrhage, of first importance is maintaining the vital organs of the body, such as the brain and abdominal viscera well supplied with blood. This is done by raising the foot of the patient's bed, and, if thought desirable, although it is of less 614 OPERATIVE MIDWIFERY importance, applying bandages round the limbs (auto-transfusion). Secondly, an amount of fluid should be added to the circulation to take the place of the blood lost. This may be done in a variety of ways. Fluid ma} 7 be introduced into the rectum, the subcutaneous connective tissue, or directly into a vein. Rectal injections of warm saline solution (temperature 102°) is the simplest method of introducing the fluid, but, owing to the enfeebled circulation, absorption is often too slow. Should, however, it be the only possible and convenient method of giving the fluid, it is hest given with a syphon-douche. In recent years it has been found that great benefit follows a continuous saline rectal infusion. About a pint per two hours is allowed to flow slowly into the rectum. This continuous infusion is most valuable in cases of profound shock following severe abdominal operations. In the case of shock following haemorrhage the fluid must be introduced into the circulation more rapidly, and so intracellular or intravenous infusion is better. Intracellular transfusion is more rapid in its action. The fluid may be injected into the loose connective tissue over the abdominal wall or back, but it is even better to inject it into the loose tissue underneath the breasts. All that is required for this operation is a filler, a piece of rubber tubing, and a large trocar and cannula. This simple apparatus should always be carried by the obstetrician. The solution employed consists of boiled water at a temperature of 101°, to which is added common salt (sterilized common salt or, better, salt tabloids) in the proportion of a drachm to the pint. One or two pints of fluid are injected. If the breast is chosen, a very convenient method is to introduce simultaneously by means of a double tube a pint into each breast. The tissue underneath the breasts cannot usually contain comfortably more than about a pint. During the operation the tissues should be gently massaged to hasten the absorp- tion of the fluid. After the trocar is withdrawn, a collodion dressing is applied, and two pieces of adherent plaster placed over it. The most rapid method of introducing fluid into the circulation is through a vein. The median basilic is the one generally chosen. This simple operation is carried out without an anaesthetic, seeing that the patient is so extremely collapsed. The steps are as follows : A bandage is applied round the lower part of the upper arm : this makes the veins of the forearm stand out. An incision is made over the vein for about 1 inch. The vein is separated from the tissues, and a loop of fine silk applied underneath it. An opening is made into the vein and a blunt needle introduced. Care must be taken that no air is allowed to enter. The ligature is tied over the needle. One or two pints of fluid is allowed to enter slowly POST-PARTUM HEMORRHAGE 615 from a filler held not more than about 1 foot above the patient's arm. The needle is removed and the vein tied in two places and divided. Lastly, the skin wound is sutured and a collodion dressing applied. In addition to the means described, judicious cardiac stimulation is of value. Brandy or whisky (2 or 3 ounces) should be given by the bowel, and strychnine or digitalin should be injected hypodermi- cally. Care must be taken not to overstimulate the heart at this stage. The recovery of the patient is often surprisingly rapid, but in some cases it is very protracted. It should not be unduly hastened, for there are late dangers, such as crural and pulmonary thrombosis. Last of all, there is the danger of a pernicious anaemia being established. Secondary Post-Partum Haemorrhage. By secondary post-partum haemorrhage we understand haemorrhage which occurs any time in the puerperium after the first ten hours. The most common cause of this complication is the retention in the uterus of blood-clot, pieces of membrane, but especially pieces of placenta. Sometimes it is purely the result of subinvolution, but in such cases the amount of haemorrhage is usually slight. In two cases I have seen a very profuse haemorrhage occurring in the third and fourth weeks of the puerperium, when the patients were going about, and where apparently the only cause was a backward displace- ment of the uterus. Submucous myoma calls also for mention as a cause of post-partum haemorrhage, and lastly, chorion epithelioma must not be forgotten. With this latter tumour the bleeding usually does not come on until three or four weeks after parturition. The treatment of secondary post-partum haemorrhage is simple- If the haemorrhage is only slight, ergot (liquid extract, a teaspoonful morning and evening) should be given for a week, the patient kept at rest in bed, and hot intra-uterine douches given. If this does not control the bleeding, the uterus should be explored. If at all possible, this exploration should be done by the finger, and it is often possible, as the cervix is still dilatable. Any displacement of the uterus should be corrected, while a submucous myoma should be removed. In the cases of chorion epithelioma the uterus should be removed entire. CHAPTER XXXV ACCIDENTS TO MOTHERS— LACERATIONS OF UTERUS, VAGINA, PERINEUM, SYMPHYSIS PUBIS Rupture of the Uterus. To anyone acquainted, however slightly, with obstetrics the mention of rupture of the uterus at once suggests a labour badly managed. Such a view is in the main correct, for without doubt, in the majority of instances, the accident must be considered a disgrace to the obstetric art, and to the individual who has had charge of the parturient. There are, however, exceptional cases in which the accident is quite unavoidable, even cases when it occurs during pregnancy. I purpose considering rupture at three distinct periods : (a) During pregnancy ; (b) early in labour ; (c) after labour has been protracted. Rupture of the Uterus during- Pregnancy. Of cases belonging to this group the most numerous are those in which the uterus has been previously injured. Naturally, the injury which first occurs to one's mind is a previous Cesarean section wound. There are quite a number of cases in which such a wound has given way. I have myself described one 1 in which the cicatrix of a fundal incision gave way ; similar cases have been reported by Eckstein 2 and Meyer, 3 while cases of rupture through the scar of the ordinary longitudinal incision have been reported by Targett, Galabin, Guillaume Woyer, Koblanck, Everke, Backhaus, etc., and recently by Couvelaire, 1 who gives a review of several of the recorded cases. But other injuries, such as perforation of the uterus with the 1 Journ. Obstct. and Gyn. Brit. Enqrire, 1904, vol. vi., p. 378. 2 Zent.f. Gyn,, 1904, p. 1302. 3 Ibid., 1903, p. 1416. 4 Ann. de Gyn., 1906, p. 148. 616 RUPTURE OF THE UTERUS 617 curette or uterine sound, etc., have been followed by rupture at a subsequent pregnancy, as in the cases of Herzfeld 1 and Staude. 2 In this connexion the observations of Jellinghaus, 3 that previous removal of an adherent placenta predisposes to rupture, are of particular interest. The probability is, that in such cases the operator actually tears the uterus with his fingers in removing the after -birth, and blood being effused, the wound heals by granula- tion. Very similar to the above are those in which a previous rupture gives way. Several cases of this nature are referred to in Peham's monograph, 4 and by Lahhardt. 5 Lastly, there is a group in which injuries, falls, blows, etc., during pregnancy have been the cause. Reusing describes a case of his own and several others previously recorded. In most of them the women were multiparas, but in Reusing's and Plenio's cases they were young primiparre. The injury to the uterus was in some cases direct, but in others it was indirect, the women having fallen upon their sides or buttocks. In such cases the laceration is generally in the upper part of the uterus, and is very extensive. As is well known, it occasionally happens that the interstitial portion of the tube becomes gravid, and ruptures, as a rule, about the sixteenth week. Such cases, literally speaking, are examples of uterine ruptures, but they are considered in Chapter XXXII. in con- nexion with ectopic pregnancy. The same applies also to pregnancy in a rudimentary horn of a double uterus. The cases of rupture of an infantile uterus in which pregnancy occurs are somewhat different, however. Such an occurrence is very rare, for the women are almost invariably sterile, but there have been described one or two cases in recent years. The two most interesting are those of Freund 7 (Fig. 278) and Schickele, s referred to very specially by Wertheim. 9 Freund considered his case one of pregnancy in an infantile uterus, but Schickele looked upon his as possibly a pregnancy in a diverticulum. Similar are the cases, such as Donald's, 10 already figured (p. 301), where a double uterus gave way. By putting aside all such cases, which are, after all, easily 1 Zent. f. Gyn., 1901, p. 1219. 2 Ibid., 1903, p. 706. 3 Archivf. Gyn., 1897, Bd. liv., p. 103. * Zent.f. Gyn., 1902, p. 87. 5 Zeit.f. Geb. u. Gyn., Bd. liii., p. 478. 6 Zent.f. Gyn., 1895, p. 41. 7 Hegar's ' Beitrage,' iv., p. 1. 8 Ibid., 1904, viii., Heft 2. 3 Winckel's 'Handbuch,' Bd. ii., Teil i., p. 408. 10 Practitioner, June, 1903. 618 OPERATIVE MIDWIFBKY explained, and also those such as Martin's, 1 where a hydatidiform mole perforated the uterine wall, there yet remains a number in which the cause of rupture is still unknown. Hound such cases there is much interesting speculation. As, however, the suhject belongs still to the region of speculation, I do not intend to do more than mention some of the views which have been expressed. Fig. 278.— Fundal Rupture of Infantile Uterus. (After Freund.) Fatty degeneration has been freely spoken of in the past, but in recent years grave doubts have been expressed regarding the frequency of its occurrence : Herman, 2 Gebhard, :i and other modern writers, are very sceptical regarding it. Further investigations are necessary 1 Trans. Edin. Obst. Soc, vol. xxi., p. 63. 2 Trans. Lond. Obst. Soc, 1901, vol. xliii., p. 220. 3 ' Pathologische Anatomie TVeiblichen Sexualorganen,' 1899, p. 239. RUPTURE OF THE UTERUS 619 before this matter is decided. The same also applies to hyaline degeneration, although in this connexion a case recently recorded by Meyer 1 is of great importance and interest. He found in the neigh- bourhood of the tear, which had occurred during pregnancy, that the uterine tissue and muscle showed signs of hyaline degeneration. The exact effect of pregnancy on a uterus affected by chronic metritis is also unknown, although this disease has been mentioned repeatedly by writers as favouring rupture, nor is it to be wondered at that it should. Personally, I feel convinced that degeneration of the wall is frequently present and predisposes to the accident, for a slight fall or cough, or a more than usually violent movement by the child, have been the only apparent exciting causes in some cases. The recent investigations of Pick, 2 Ivanoff, 3 Schaper, 4 and many others, have not confirmed the theory of Dawidoff and Poroschin, 5 that the rupture is due to a deficiency of elastic fibres in the tissue of the uterus in the neighbourhood of the rupture. Several, including Martin and Diihrssen, have, however, found the elastic fibres diminish as age advances, and it is quite probable that they, in common with other tissues, become altered with each succeeding pregnancy. The situation of the placenta has an influence in different ways. There are not a few recorded cases of rupture of the uterus associated with placenta prcevia. Again, the tubal orifice being a weak spot, as Gebhard points out, \ implantation there is favourable to rupture. Lastly, in a considerable number of cases of rupture during preg- nancy of a cicatrix of a previous Cesarean section wound, the placenta has been situated over the cicatrix, and it is just possible that under certain conditions the chorionic villi have a specially destructive effect, and burrow unusually deeply into the wall. Be that as it may, not a few authors have referred to the fact, as, for example, Alexandroff, 6 Meyer, Couvelaire, and Eckstein. I also refer to it in recording my own case (p. 631). Rupture of the Uterus after a Protracted Labour. It might appear a natural sequence that, having discussed rupture during pregnancy, one should turn to those cases where the accident happens early in labour. Personally, I think otherwise, however, for I am disposed to look upon the latter group from the etiological point 1 Hegar's 'Beitrage,' Bd. ix., p. 45. 2 Berlin. Klinih WochenscJirift, 1900, xxiii. 3 Annal. de Gijn., August, September, October, 1904. 4 ' Diss. Wurtzburg,' 1901. 5 Zent. f. Gijn., 1898, p. 183. 6 Monat.f. Gel. u. Gyn., Bd. xii., 1900, p. 447. 620 OPEBATIVE MIDWIFERY of view, as standing midway between the group where rupture occurs during pregnancy and the one in which it follows a prolon. parturition; consequently, it will be beet understood after these groups have been considered. llupture of the uterus following a complex and protracted labour is a subject which has come to be understood only in recent } r ears. Although Guilleineau. Uaudelocque, and, later, Michaelis, appreciated in great part the nature of the accident, it is only since Bandl's writings on the ' Lower Uterine Segment ' that any clear conception of the pathological anatomy of the subject has arisen. For a correct comprehension of rupture of the uterus in labour one must appreciate the different anatomical features of the uterus, and especially of the lower segment, during parturition. That being so, I must consider them for a moment. Since Bandl's paper appeared in 1875 the number of contributions to the subject of the lower uterine segment have been legion, but although many matters regarding it have from time to time been settled, there are still many details upon which differences of opinion exist, and these differences have not been lessened by the latest frozen section of Bumm and Blumreich. This is not the place to discuss these in detail, and so I have thought it best to give the principal conclusions of one of the most recent writers. Von Bosthorn, writing in YVinckel's 'Handbook of Midwifery,' 1 comes to the following con- clusions regarding the lower uterine segment : 1. There already exists during pregnancy a lower uterine segment. 2. This segment is covered by decidual altered mucous mem- brane. 3. The arrangement of the muscle in the wall of the segment is lamellar, and it is to a moderate extent distinct from the wall of the corpus uteri, and very different from that of the part below. 4. The upper part of the lower segment is marked by the firm attachment of the peritoneum, and in the inside, when uterine contractions have already been in existence by the so-called contrac- tion ring. 5. The lower limit is the essentially different cervical tissue. 6. The mucous membrane appears to vary. In the majority of cases there is sharp differentiation — on the one side distinct cervical mucous membrane. The illustration represents (Fig. 279) the relationship of the different parts of the uterus during parturition. This is a very old diagram- matic figure of Schroeder, but for practical purposes it is still useful. I do not suppose it is correct, but who can say what exactly is the 1 Bd. i., Heft 1., p. 5r,:\. RUPTURE OF THE UTERI'S 021 lower uterine segment ? The upper part or body, the active contrac- tile portion, the middle or lower uterine segment, and the lower part, the dilated cervix, are represented. Daring labour the upper part, the body, is the only really active part of the uterus — it alone forces the child down through the parturient canal ; the lower uterine segment Fig. 279. — Diagrammatic Representation of Parturient Canal at End of First Stage. (Schroeder.) and cervix play an entirely passive role. As labour progresses the body becomes diminished in a vertical direction because the retraction, or Bandl's, ring, which marks the lower limit of the body and the upper limit of the lower segment, becomes farther and farther drawn up ; it can be appreciated sometimes by abdominal palpation as high as, or even above, the umbilicus. But the active contractions of the 622 OPERATIVE .MII>\VI J'Kl:V uterus would do more than pull up Bandl's ring ; they would also pull up the cervix, were it not that the latter is more or less fixed by its attachments. As a result, therefore, of the upper part being increasingly retracted and the lower fixed, one finds, in a protracted labour, that the area between — viz., the lower uterine segment — becomes more and more stretched and thinned out. It is not surprising, therefore, that there is a stage at which, not being able to stretch any farther, and with its tissues bruised by pressure between the head and the pelvis, it gives way, either spontaneously or as a result of operative interference. For many years after Bandl's papers great importance was attached to this fixation of the lower part of the uterus, more particularly by the presenting head, as in cases of contracted pelvis and hydrocephalus. Freund, at the present time, is the strongest supporter of this view, and gives emphatic expression to it in his chapter in Winckel's 'Handbuch.' 1 But few go as far as Freund. Olshausen and Veit (in the last edition of their text-book) and Ivanoff do not attach the same importance to this factor. Personally, my experience leads me, in common with most others, to side with the authorities last mentioned. "Without doubt a good deal of misunderstanding has arisen from the erroneous idea that the cervix is drawn up or retracted over the head during labour. From clinical observation I have not found that to be the case to any great extent, and the records of frozen sections support that view. Barbour' 2 points this out when he says : ' The dilatation of the cervix can only, to a very slight degree, result from stretching through traction on its ring by the contracting uterine walls, but must be almost entirely due to dilatation through expansion of the ring by the bag of membranes or presenting part.' When I mentioned before that the cervix was fixed, I meant that it was fixed by its attachments, not by the presenting part. What happens is that the cervix and lower part of the lower uterine segment become unduly pressed upon, bmised, and lacerated. It is not so much that the cervix is held down and cannot retract over the head. But let us now consider the conditions which chiefly favour the occurrence of rupture of the uterus — pelvic deformity, malpresenta- tions and malpositions of the child, and hydrocephalus — and let us see how they act and the nature of the injuries they produce. The importance of pelvic deformity as a cause of rupture of the uterus is well illustrated by the large percentage of cases in which bony deformity of the canal exists. In seventeen cases which have 1 Bd. ii., Teil iii.. p. '21 L6. 2 'Anatomy of Labour,' p. 47. EUPTUEE OF THE UTEEUS 623 been under my care in recent years pelvic deformity was present in 50 per cent. ; others have had a similar experience. Merz 1 found it in 30 per cent., and Ivanoff in 40 per cent, of their collected cases. The pelvic deformity is not, as a rule, of the extreme type, for when the deformity is great the danger of the condition is early appreciated, and labour is not allowed to be indefinitely protracted. Almost without exception the women have borne children, and many of them have had several. Naturally, the danger increases with each succeeding pregnancy. This is often attributed to degeneration of the uterus, and rightly so in many cases ; but in recent years it has come to be recognized that in some cases cicatrices from previous labours have given way, cicatrices of wounds often only slight and never appreciated. The nature of the lesion in the different forms of contracted pelvis has been most carefully investigated by Ivanoff; no one has gone into this subject so particularly. Personally, however, I am not in a position to express any opinion regarding his conclusions, for although, in common with others, I have found the lesions in cases of contracted pelvis are in general as he has described, I cannot give exact state- ments. He is the first who has so exactly distinguished the lesions which are found in flat pelvis from those which arise in generally contracted pelvis. He believes tha^the tears are produced by injury of the soft parts. The extension of the rupture may occur spontane- ously, or be produced by violence. With these lacerations, which occur in the progress of labour transverse commonly in front or behind in the case of flat pelvis, and lateral in the case of generally contracted pelvis, extension of the tear readily occurs, especially if the child is forcibly extracted. In such cases, as with violent rupture in general, the extension of the lacera- tion is often longitudinal, and very usually passes into the broad liga- ment. In the Glasgow Maternity Hospital during the last twelve years, amongst the cases of flat pelvis where rupture occurred there were four in which the child was delivered with forceps, and the tear pre- sented the appearance shown in the illustration (Fig. 280). In these cases the rupture was complete. Next in order of frequency as a cause of rupture are malpresenta- tions of the child, and especially transverse presentation. Amongst my cases such a condition existed in 16 per cent., and taking the authorities already referred to, one finds that Koblanck found it in 25 per cent., Merz in 11 per cent., and Ivanoff in 32 per cent. As might be expected, the rupture in most cases results when version is attempted after the waters have drained away and the shoulders have become impacted. But in a certain number of cases this has not i Archivf. Gyn., 1894, Bd. xlv., Heft 2., p. 181. 624 OPERATIVE MIDWIEEllY been so : the rupture has .occurred spontaneously. Spontaneous rupture in transverse presentations, however, is rare. In most cases the laceration is longitudinal and to one or other FlG. 280, — Laceration of the Posterior Uterine Wall in a Case of Flat Pelvis. side (Fig. 281). It tends to be extensive, as one would expect, and to run up into the body. The cervix is invariably torn, and the vaginal vault in many cases also suffers. In this condition there is no RUPTURE OF THE UTERUS 625 difficulty in understanding how the accident occurs; indeed, it is Surprising that it does not occur oftener. Other nialpresentations, such as face and brow presentations, are Dccasionally found associated with rupture. A brow presentation is Fig. 281. — Laceration of the Lateral and Posterior Uterine "Wall. jertainly a very unfavourable attitude, for the long diameter is thrown icross the pelvic brim (p. 44). It is dangerous, therefore, to attempt ,o deliver the child by forceps. Indeed, should such a course be persisted in after one or two futile attempts, the risks of rupture are :onsiderable. Very much less likely to cause injury are face and 40 626 OPERATIVE MIDWIFERY occipito-posterior vertex presentations ; when they are associated with rupture, the cause has usually been some coexisting condition, or the manipulations have been badly carried out. The other important cause of rupture is hydrocephalus. In my seventeen cases it occurred once (6 per cent.), while Merz found it in 7*5 per cent., and Ivanoff in 3 per cent. In most cases of rupture pro- duced by hydrocephalus, however, the hydrocephalus has not really been the cause : either the condition has not been recognized — and it must not be forgotten how easy it is to overlook the condition — or the proper treatment — craniotomy — has not been practised ; attempts have been made with forceps, as in my case, or some other method of delivery has been tried. As a cause of rupture in this condition, Freund attaches great importance to the fixation of the cervix by the enlarged head. He believes this occurs more frequently when the hydro- cephalus is of medium dimensions, as when it is very large the head cannot engage, and so the cervix slips over the head. Ivanoff attaches more importance to bruising of the tissues. The lacerations are, as a rule, very extensive and longitudinal. In my case the whole lateral wall was torn longitudinally. Other conditions, such as tumours, cicatrices and adhesions, etc., obstructing the parturient canal, may naturally predispose to, and may be occasionally associated with, rupture. Old cicatrices, es- pecially about the cervix, are liable to tear, although sometimes the cicatricial tissue withstands the strain, and the tissues, not involved formerly, give way. With tumours the accident should not occur, as it is now recognized that it is quite inexcusable to drag a child past a tumour by brute force. In a certain number of cases rupture has followed the removal of the placenta. Schwendener 1 has recorded one as a result of expelling the placenta after Crede's method. Fraenkel 1 has recorded another. Oswald 2 has collected thirty-eight cases from obstetric literature where it w T as produced while manually removing the placenta. Twice while removing an adherent placenta situated at the fundus I have found my fingers almost through the uterine wall, an experience which has led me to exert the greatest possible care in performing this simple operation. I have referred elsewhere to the dangers of rupture in subsequent pregnancies when the uterine wall has been injured by the fingers, curette, or uterine sound. 1 Zent.f. Gyn., 1903, p. 907. 2 Beitrdg. z. Geb. u. Gyn., Bd. viii., Heft 1; ref. Zent.f. Gyn., 1904, p. 336. RUPTURE OF THE UTERUS 627 Rupture of Uterus Early in Labour. We must now turn to the last and most interesting group of cases — viz., those in which rupture occurs early in labour. This group, as regards etiology, stands midway between the two others, for rupture results partly from disease of the uterine wall, and partly from the conditions mentioned in connexion with the previous group. Personally, I cannot but feel that disease of the uterine wall, and probably unrecognized lacerations at previous labours, play the most important part, for looking at the recorded cases one is struck with the frequency of previous difficult labours, injuries, or disease. Take the case described by the late Milne Murray, 1 where there had been protracted parturitions and possibly the wall seriously injured. The various diseased conditions which may exist have already been referred to when rupture during pregnancy was under considera- tion. But there is another condition which specially comes into play in ruptures of this group, and it was mentioned years ago by Bandl. The lower segment may have been overstretched at a previous labour, and consequently very early in a subsequent one reaches the same condition. Some of the records would lead one to attach some importance to this view ; naturally, it will always be very difficult to distinguish rupture caused by such a condition and rupture caused by the giving way of a previous cicatrix. Freund considers that even rigidity of the os externum may bring it about. But in order to prove that rigidity per se could cause rupture, one would require to satisfy oneself that there did not also exist de- generation of the uterine muscle. It is not to be wondered at that occasionally rupture of the uterus should be associated more or less directly with placenta praevia, for a placental implantation weakens the lower uterine segment, and manipulations to arrest haemorrhage, such as turning, which en- danger the lower uterine segment, have generally to be had recourse to. All authors refer to the occasional association of the two com- plications : in my list there was one case, in Ivanoffs twelve. Ivanoff very rightly, it seems to me, emphasizes the fact that in the vast majority of the cases rupture was violent. Taking twenty cases from his own and collected cases, sixteen were certainly violent, two probably violent, and only two spontaneous. In the majority of these cases the laceration was lateral, longitudinal, and incomplete. However, spontaneous rupture does occasionally occur, and a case 1 Edin. Obst. Trans., 1901, vol. xxvii., p. 39. 028 OPERATIVE MIDWIFERY was recently recorded where the accident occurred in a primipara. Absolutely nothing was done to interfere with the birth of the child except to rupture the membranes when the os was about three-quarters dilated. The birth of the child quickly followed. The rupture was through the posterior wall of the uterus, and was apparently incomplete. Varieties of Rupture of the Uterus. Complete and Incomplete Rupture. — Clinically, it is customary to speak of 'complete' and 'incomplete' rupture of the uterus. By the former condition we mean that the laceration extends into the peritoneal cavity, and by the latter that it stops short of the peritoneum. This distinction is very useful, for we shall find that the treatment differs in the two groups. As regards the relative frequency of the two varieties, it appears from most series of cases that complete rupture is more common than incomplete. It must not be forgotten, however, that there is a very large number of ca.ses of incomplete rupture never reported, nor indeed appreciated, while few of the cases of complete rupture escape notice, seeing that the symptoms are more grave. Of the 17 cases of rupture under my care in private and hospital practice, in only 5 has the rupture been incomplete. Braun gives it as 4 incomplete and 15 complete ; Merz as 46 incom- plete and 181 complete; Ivanoff as 43 incomplete and 58 complete. As would be expected, the lower down in the uterus and the more lateral the tea]', the more likely will the rupture remain incomplete. The cases of laceration during pregnancy or early in labour are, with few exceptions, complete. Amongst the cases which have been under my care, in one only have I found the bladder involved. 1 In Braun' s nineteen cases there was only one in which the bladder was injured. Neither in Merz's nor Ivanoff' s collected cases can I find any evidence of laceration of the bladder. In Murray's most interesting case the bladder was torn and had to be stitched. There is a veiy interesting group of cases in which the mucous membrane of the uterus remains intact, although the muscular wall 1 Rupture of bladder, apart from rupture of uterus and retrodisplacenient of the gravid uterus, is very rare. Grhnsdale (Journ. Obst. ami Gyn. Brit. Empire, May, 1905) has referred to a most interesting case in which the bladder was injured in the first stage of labour. On opening the abdomen a large quantity of blood was found in the peritoneal cavity. This had escaped from the bladder through a small opening in its upper part. The opening was closed, and the patient made an excellent recovery. RUPTURE OF THE UTERI'S 629 is torn. The point of importance in these cases is that there are all the symptoms of collapse from internal haemorrhage without any appreciable lesion of the uterus or vagina. Knauer has drawn atten- tion to the subject recently. 1 In such cases the tears, starting in the muscle, may extend either outwards or inwards. Slight tears of the peritoneum (fissures of the peritoneum) over the surface of the upper part of the uterus have long been known to occur, and have been frequently referred to by different obstetric writers. This laceration of the muscular tissue, however, has not had attention directed to it. Of especial interest are Knauer's observations in con- nexion with concealed accidental haemorrhage. In several of these cases he observed laceration of the muscular wall with considerable intramural haemorrhage. I observed the same condition of matters in a fatal case of concealed haemorrhage which was under my care in the Maternity Hospital. Rupture of the Vaginal Vault (Colporrhexis). — In recent years the subject of rupture of the vaginal vault (colporrhexis — Fig. 282), as distinguished from rupture of the uterus, has been much discussed. This lesion is no new discovery ; indeed, before Bandl's papers lesions of this nature were understood better than lacerations of the uterus. But after Bandl's papers lacerations of the vaginal vault were neglected for uterine rupture, until Freund 2 reawakened interest in the subject. In recent years the most important paper is one by Kaufman, 3 who discusses the subject very fully. Specially liable to this form of rupture are cases of transverse presentation and pendulous abdomen. Generally the rupture is violent, and often occurs when the hand is being forced into the uterus. But Kaufman, in his collected cases, quotes many that were not violent, and were the result of a diseased condition of the tissues, and of other factors. Where only the vaginal vault is torn there may be no symptoms of consequence. Plugging is generally the best treatment. Symptomatology and Diagnosis. The clinical features of rupture of the uterus differ greatly according as the rupture occurs in pregnancy, early in labour, or after labour has been in progress for some time. In the two former there is seldom much warning of the accident, while in the latter very 1 Zent.f. Gyn., 1903, p. 647. 2 Zeit.f. Geb. u Gyn., 1S92, Ed. xxiii., Heft 2. 3 Archivf. Gyn., 1908, Bd. lxviii., Heft 1, p. 152. 630 OPERATIVE MIDWIFEKY frequently, for some little time before, there are premonitory symp- toms, which if properly interpreted by the accoucheur should lead him to dread rupture, and, consequently, to take every precaution to prevent it. Taking first the cases where the rupture occurs early in labour or during pregnancy, one Mould naturally expect, as with rupture of any other viscus, that the giving way of the uterus would be followed Fig. 282. — Laceration of the Lower Part of the Uterus and the Vaginal Vault. The uterus is turned over to the right to show the laceration. immediately by severe abdominal pain, decided collapse, and other symptoms of internal haemorrhage, small thready pulse, cold sweats, etc. "Without doubt, in many cases these symptoms are present, and the nature of the condition is self-evident, but what is not fully appreciated is that sometimes they are not evident and the accident is overlooked. Here is a case from my own practice which illustrates how very gradual the onset of the symptoms may be : KUPTUEE OF THE UTERUS 631 Spontaneous Rupture of the Uterus chiving Pregnancy through the Cicatrix of a Ccesarean Section Wound. — Mrs. M , 3-para, was admitted on October 28, 1901, to the Glasgow Maternity Hospital. In both the previous labours the children were extracted with difficulty, and were dead. On the last occasion craniotomy had to be performed. The pelvis was of the flat rachitic type, the diagonal conjugate being 3f inches. I therefore chose Csesarean section, and employed the ' fundal incision ' of Fritsch. I came right down on the placenta, which I removed before extracting the child. The child, which weighed eight pounds, was extracted very easily, and the uterine wound stitched with little trouble or bleeding. She was not sterilized. The temperature was never above normal, and the pulse, after the first three days, was not accelerated. The abdominal wound healed by first intention, the stitches being taken out on the fourteenth day. The patient left hospital on November 30, both she and her baby being perfectly well. The following note was made on her admission for the second Csesarean section on January 26, 1904 : As far as can be judged the patient is now in her thirty-seventh week of pregnancy ; she has been in good health, and has suffered no special discomfort since she became pregnant. She is well nourished and of good colour ; her pulse is of good tension, regular in force and rhythm, and numbers' 84 per minute. The abdomen is irregularly enlarged, the bulk of the swelling being to the right side. There is a median firm scar of the previous Cesarean section. Foetal movements are active. The cervix is not taken up, but admits the tip of one finger. After an enema, given about midnight, the patient complained of abdominal discomfort — slight pain in the epigastrium ; this extended upwards and to the right. She mentioned this to the night-nurse, but as she did not complain further and fell asleep, the nurse did not think it necessary to report the fact to the house-surgeon. She slept from about 12.30 till 5 a.m., at which time a sanguineous discharge from the vagina was noticed, and slight pain in the right iliac region was complained of. At 7 a.m. the temperature was 97*6° F., and the pulse 80 ; the pain, which had now spread over the abdomen, was not very great, so it was taken for painful uterine contractions. There was no sickness or vomiting. At 11 a.m., on making my ward visit, I spoke to the patient quite by chance, for no one considered her condition serious. I then found that there was considerable abdominal tenderness, and suggested to those present the possibility that the old uterine cicatrix had given way. As, however, the pulse was 84, regular, and of good tension, I simply advised my house- surgeon, Dr. Rodgers, to go into the case and note the patient's condition carefully. An hour afterwards I was summoned by him, as the abdominal tenderness was now more marked, the pulse 90, the temperature sub- normal, and the breathing more rapid. At this time the condition of the abdomen was as follows : She lay with her feet slightly drawn up ; on palpation there was considerable tenderness over the whole abdomen, more marked to the right and below the umbilicus ; the pain also extended up to the right shoulder. On placing the hand over the abdomen one was struck by the readiness with which the fcetal parts could be defined ; above the 682 o|'i:i;ati\j; midyyii-kky umbilicus, and slightly to the left of the middle line, a limb could be made outj while the head lay towards the left iliac fossa. Two tumours could not be differentiated; percussion gave a slightly dull note in the Banks. On vagina] examination the tip of one finger could be pushed through the cervix, but the presenting pari could not be felt ; on withdrawing the finger it was blood-stained. The pulse numbered < v >s • Strychnine .,',, grain was given, and the patient prepared for laparotomy. She was anaesthetized, and the abdomen opened along the side of the / Fig. 283. — Rupture of Uterus through the Cicatrix of a Previous Csesarean Section "Wound. (Author's Case.) previous incision. Immediately that was done a large quantity of dark- coloured blood escaped, and the intact membranes and placenta with the enclosed foetus presented. The uterus lay retracted behind and down towards the pelvis. The membranes were opened into and a well-formed dead child extracted. The uterus was then examined and a transverse rupture was found extending over the highest part of the fundus (Fig. 283), evidently through the cicatrix of the wound of the previous Csesarean RUPTURE OF THE UTERUS 633 section. There were only two slight uterine adhesions, one to the omentum and one to the abdominal wall. The uterus was removed by supravaginal hysterectomy, the peritoneum being carefully brought over the stump. Finally, all blood-clot was removed, and fully 2 pints of saline solution Avere introduced into the peritoneal cavity. After the operation the patient was considerably collapsed ; the lips, cheeks, and extremities were blanched ; the pulse was 126, small, easily obliterated, but regular. She soon im- proved, however ; the following day the pulse was 1 20 and the tempera- ture 98° F. She was dismissed a month after the operation perfectly well. Sooner or later in almost all cases symptoms arise : the woman complains of increasing abdominal pain. She assumes more decidedly the ' abdominal facies,' while a most important feature is the steady increase in the pulse-rate. As far as I have been able to find from records of cases, this ' quiet : rupture rarely occurs in cases of spontaneous rupture early in labour ; in all such cases the classical symptoms of rupture are present. and there is no difficulty in diagnosing the fact that the uterus has given way. The same also applies, although not quite so universally, to rupture in pregnancy when that accident follows any fall or strain. The cases in which the quiet rupture occasionally takes place are where the uterus is diseased or has been previously injured. In such the •ovum seems to pass gradually through the uterine tear. Not in- frequently the placenta is situated over the tear ; quite a number of writers have called attention to this fact. An interesting case in which rupture was found in progress was the one recorded by Staude. 1 Early in labour a small elastic tumour developed over the anterior wall of the uterus during the pains. The condition was diagnosed as a rupture, the abdomen was opened, and the diagnosis confirmed. But after all, rupture of the uterus during pregnancy or early in labour is not a condition which is often encountered, and is, con- sequently, not a subject upon which one is justified in lingering. We must therefore turn to the cases which form the bulk of the examples of rupture of the uterus — those in which the tear occurs late in labour or during attempts at delivery. In considering cases of this nature it is customary to discuss the symptomatology before and after rupture. This is a wise procedure, for in a large proportion of cases there are distinct premonitory symptoms. After a prolonged second stage, where the expulsive forces are not at fault, the patient becomes restless and complains of constant pain over the lower part of the uterus, while the uterine contractions tend i Zent.f. Gyn., 1904, p. 781. 634 OPERATIVE Mll>\\ I l'KHY to become more and more tetanic. Id addition, the pulse becomes more rapid and the temperature possibly rises slightly. Along with these symptoms there is a steady increase of the lower uterine segment. This can be easily appreciated, for the retraction or Bandl's ring can be felt to rise higher and higher. There is seldom any difficulty in palpating the ring, for it can be appreciated as a hard ridge round the uterus. I have seen it as high as the umbilicus. It is not always at the same level all round ; especially is this seen in cases of transverse presentation, where one part is subjected to greater strain than the other. One can often appreciate that the wall of the segment is very thin, but as a rule it is so tense and tender that the foetal parts cannot be differentiated. With a uterus in such a state rupture may occur at any time. How general such symptoms are prior to rupture I have not had opportunities of judging, for, w T ith one exception, the patients have come under my care after the rupture has occurred. From what I have been able to gather, however, in many cases they were present, and I have frequently seen them and feared rupture. "When a patient in such a condition comes under one's care, no attempts to deliver by version or forceps should be made ; decapitation or craniotomy should be immediately performed. Turning now to the symptoms which follow rupture, it is a very striking fact that in a large number of cases the rupture has not been recognized until after the birth of the child. The classical symptoms of a sudden feeling of something giving way, of cessation of the uterine contractions, of alteration in the shape of the abdominal swelling, of haemorrhage and collapse, are very frequently absent ; nor is this to be wondered at, for in many cases the rupture takes place during the delivery. Let us consider these symptoms seriatim. In very few indeed of my cases or those reported by Ivanoff and others has the symptom of a sudden feeling of something having given way been present, and naturally it cannot be expected to be appreciated in the cases of rupture from violence, for the patient is then, usually, under the influence of the anaesthetic. "When it is present the laceration is extensive, and the child, in whole or in part, generally escapes into the peritoneal cavity. The same remarks apply to cessation of the uterine contractions. This symptom is again most pronounced where the child escapes into the abdominal cavity. It must not, of course, be confused with the uterine inertia which follows exhaustion of the uterine muscle ; the latter is gradual in its onset. It is hardly necessary to say that an alteration in the shape of the abdominal swelling can only occur if the child passes in whole or in EUPTUEE OF THE UTEEUS 635 part outside of the uterus, and this, we have seen, does not occur so often as is supposed. When it does occur, two abdominal swellings can be differentiated, the one representing the parts of the child that have escaped and the other the retracted uterus. Naturally, it is most distinct when the child and uterus lie side by side ; for if the retracted uterus is placed behind, as in one of my cases, it is impossible to distin- guish the two swellings. When present this alteration in the shape of the abdominal swelling is a symptom of great importance, especially if the accoucheur has observed the uterine outline beforehand. Occasionally this sign is present in other conditions than rupture. Quite recently I saw a case of dystocia from pelvic deformity in a patient with a bipartite uterus. The double swelling of the uterus and the collapse of the patient led me, on seeing the case for the first time, to think of rupture of the organ. It was a case of accidental haemorrhage. Similarly, in cases of plural pregnancy, the uterine outline being often irregular and double, a suspicion of rupture of the uterus may arise if the patient shows any evidence of collapse during labour. Again, in cases where there is a coexisting tumour, either ovarian or uterine, a differential diagnosis has occasionally to be made between such a condition and rupture of the uterus. But a difficulty in differential diagnosis may occur in a much simpler and more common condition — viz., in an impacted oblique presentation, for then there are two swellings with a sulcus between. Sometimes, when such cases are brought into hospital in a markedly collapsed condition, we have great difficulty in deciding if rupture has occurred or not. Indeed, often it is only possible to decide by an intra-uterine examination under deep anaesthesia. In addition to an alteration in the outline of the uterus, the foetal parts become much more easily palpated, after the child has escaped into the peritoneal cavity. One must be very careful in deciding upon rupture on such grounds, for sometimes the uterine wall is so soft and thin that the fcetal members are felt as if underneath the thin abdominal parietes. In advanced extra-uterine pregnancy the child can also be very easily palpated. The amount of haemorrhage which occurs as a result of rupture of the uterus varies very greatly. Amongst my own cases I have only had three in which it was extremely severe. Ivanoff, in his long series of 124 collected cases, found only 53 in which the haemor- rhage proved fatal, and in half of them not until many hours after the accident. One may be deceived in respect to the actual quantity of blood lost, for a considerable amount may escape into the peritoneal cavity, or 636 OPERATIVE MIDWIFERY into the cellular tissue around the uterus, and remain concealed. Sometimes the bleeding is BurprisiDgly small in amount. The reasons for this are the relative situation of the tear to the larger vessels and the fact that the latter do not tear readily. In one of the cases of rupture upon which I operated — the case is here briefly detailed — the tear was along the side of the large uterine artery, which could be seen pulsating, but only the smaller veins were torn. of Complete Rupture of the Uterus with Escape oj //'<< Fcetm into the Peritoneal Cavity -Panhysterectomy Recovery. 1 — Mrs. X ■, 2-para, - twenty-four, had been delivered by craniotomy four year* before her admission to the Maternity Hospital on March- 18, 11)07. Present labour came on at term. Attempts at delivery with forceps failed, after which she was .sent into the Maternity Hospital under my care. When I saw her a little time after her admission her pulse was 140, and she was evidently ill, but not seriously collapsed. My house-surgeon informed me that she was worse than when she was admitted. There was no history of sudden pain, or of anything having 'given way.' She was not very blanched. I could feel the child free in the abdominal cavity. From the vagina I could feel an extensive tear on the right side of the uterus and vaginal vault. There was no profuse vaginal hemorrhage. Upon opening the abdomen I found the foetus free in the abdominal cavity, which also contained meconium, vernix easeosa, liquor amnii, and a little blood. After removing the child and placenta I examined the rupture, and found that it extended vertically through the right lateral wall of the lower segment and transversely in front, so that only a small portion of cervix remained attached to the bladder. The bladder itself was not injured. I clamped and then divided all the uterine attachments and removed the entire uterus. I then packed the lower part of the pelvis with gauze and closed the abdomen. The whole operation did not take twenty-five minutes. The patient soon got over the shock. The gauze was removed by the vagina on the fourth day. She made an uninter- rupted recovery. I have already emoted IvanofT's experience and my own, which agrees with it. Eversmann 2 states that only in some 12 to 15 per cent, of cases does the blood come from the ruptured uterine vessels. It is a very erroneous idea, therefore, but one generally expressed by those with little experience of this complication, that rupture of the uterus is followed immediately by profuse bleeding. Infinitely more common is a slow but steady haemorrhage. The pulse-rate in such cases slowly rises, and uneasiness and general abdominal pain and the ordinary symptoms of collapse become gradually more pronounced. The case already recorded is an illustration of this, as was also one i Brit. Med. Journ., August 24, 1907. 2 Arch.f. Gyn., 1905, Bd. lxxvi.. Heft 3, p. 601. EUPTUEE OF THE UTEEUS 637 brought to me from the country some years ago. This patient, although driven some eight miles, had absolutely no symptoms of collapse, and her pulse was not more than 80. She was found to have a complete rupture of her uterus. I removed the uterus, and she made a most satisfactory recovery. When all the classical symptoms are present, there is very little difficulty in coming to a diagnosis. There are few other conditions associated with similar symptoms. Accidental hemorrhage and placenta previa are undoubtedly attended with all the symptoms of collapse and hemorrhage, but a vaginal examination, at least in the case of placenta previa, reveals the condition. With accidental hemorrhage, either apparent or concealed, it occasionally happens that the diagnosis is rendered difficult, and scattered through obstetric literature are several recorded cases of mistaken diagnosis. In such cases the history and the presence or absence of tenseness and tenderness of the uterus will usually clear matters up. Besides, in most cases of uterine rupture one can feel the tear. The diagnosis between complete and incomplete rupture can only be arrived at by a vaginal examination, except in the cases where the child is evidently free in the peritoneal cavity. When the rupture is complete, one feels the intestines distinctly ; when it is incomplete, that is not possible. In theory, that is simple enough, but once or twice I have had a little difficulty in deciding, for the peritoneum is very thin. Prognosis. The prognosis of rupture of the uterus is much more favourable to-day than it was when the condition was treated expectantly. When the latter treatment was in vogue many cases were, of course, never appreciated. But even amongst those which were recognized occa- sional recoveries followed. A former physician of the Maternity Hospital told me of one in which after delivery of the child he had pushed his hand through an extensive and complete rupture, and had easily felt the bowels. The patient made an uninterrupted recovery without an} T treatment. Scattered through obstetric litera- ture are many extraordinary cases, but certainly amongst the most wonderful is one recorded by Leopold, 1 in which rupture occurred at the fourth month, and yet pregnancy continued to term, when the child died. On opening the abdomen three months later the child was removed. Its umbilical cord was found to run through an open- ing in the posterior wall of the uterus. But it is profitless to consider such rarities. 1 Arcluvf. Gyn., 1896, Bd. Hi., p. 376. 688 Ol'KKATIYE MIDWIFERY Various estimates have been given of the mortality from the ex- pectant treatment, hut it appears to have been 90 per cent, at l< amongst recognized cases of complete rupture. Naturally, it was much lower in the incomplete variety. In recent years, with a more exact understanding of the condition and with the adoption of active treatment, the mortality has fallen fully a third. It is still, however, 50 to GO per cent., being a little higher than that figure for complete, and a little lower for incomplete, rupture. This question, however, will be more carefully considered when the different methods of treatment are being discussed. Treatment. As rupture of the uterus is so often a preventable accident, it is necessary that I should say a word or two about its prophylaxis. As regards those cases where the uterus has been previously injured, either by tears, incisions, curettage, or disease, subsequent pregnancies should be watched, and especially should the patient be under careful observation during the later weeks, so that, should rupture occur, an operation could be immediately undertaken. The same applies to cases in which previous labours have been difficult and protracted, owing to malformations of the pelvis, or undue size of the children ; for, as we have seen, previous lacerations are often passed unrecog- nized, and a lower segment which has once been overstretched yields and tears more readily. As the danger of rupture during the first stage is practically nil, excepting in cases where there have been previous lacerations or injuries to the uterus, there is nothing to be done. In the second stage, however, if any of the premonitory symptoms of rupture arise, delivery must be carefully completed. In contracted pelvis the degree of deformity and the relative size of fcetal head and pelvis must be carefully calculated, and the safest treatment adopted. As rupture of the uterus occurs so commonly in neglected transverse presentations, it is of the greatest importance that such a malposition of the child should be early recognized and corrected. Again, if, for any reason, the presentation has not been appreciated, or the accoucheur has not seen the case until after labour is far advanced, attempts at version must on no account be made, unless there is every prospect of the child being easily turned. The treatment of cases of impacted transverse presentation has been already discussed (Chapter VI.). I would commend to my readers the remarks there made. The disastrous results that follow RUPTUBE OF THE UTEBI S 639 attempts at version in such cases are greatly to the discredit of the obstetric art. Hydrocephalus, another condition, as we have seen, occasionally followed by rupture, is much more difficult to recognize, especially if the child presents by the breech. Its diagnosis and treatment have been considered elsewhere (Chapter YIL). Before leaving the subject of prophylaxis I must again warn the accoucheur against the danger of performing vaginal operations, such as turning, etc., with the woman only partly anaesthetized. Strong contractions of the abdominal and pelvic muscles and of the uterus are set up by the introduction of the hand, and in consequence many cases of rupture, especially of rupture of the vaginal vault, are brought about by the operator requiring to employ undue force in overcoming the resistance of the tissues. Active Treatment. — The treatment of rupture of the uterus is a subject regarding which there are still considerable differences of opinion, and in all probability it will continue in this position for some time to come. Before, however, the active treatment of rupture can be discussed, we must consider what is to be done with the child if it is still undelivered when the rupture is recognized. In certain cases this is easy to decide, in others it is difficult. If the head is presenting and can easily be reached, it should be extracted with forceps. Often it will be necessary to perforate it, for in many such cases the pelvis is deformed, the head is of unusual size or in an unfavourable position, and the child is dead or dying. Similarly, if the breech is accessible and one or both legs can be seized, the child should be extracted by traction, and if there is any difficulty with the after-coming head it should be perforated. Another group of cases in which the course of treatment is obvious are those in which the child has entirely escaped into the abdominal cavity. In such cases the uterus has retracted, and extraction per raginam is evidently impossible ; consequently the foetus must be removed by abdominal section. The cases which present the greatest difficulty are those where the child has partly escaped through the rent. In many of these the presentation was originally transverse, but in some the head was the presenting part. Whatever the presentation was, the head is the part which is generally through the rupture. In such cases the course to be pursued will depend on whether one intends to continue the further treatment of the case one's self, or to place the patient in the hands of another, be it in the woman's own home, a hospital, or a nursing home. The reason for this is obvious : the child is acting 640 OPERATIVi: MI I »\VI l'KKY plug. It should only be removed, therefore, when the operator is ready to proceed with the further treatment. Whoever takes chi of the further care of the patient will have to decide between removing the child per vaginam or per abdomen. If possible, he should do it per vaginam, because if he drags it up through the abdominal wound he will carry up infection. Usually the vaginal delivery will be best accomplished by bringing down one or both feet ; rarely will it be possible to complete it by craniotomy or decapitation of the fore- coming head. The abdominal route should be chosen when the child's shoulders are beyond the tear. The treatment of the lacerated uterus after the child has been delivered depends largely upon the variety of rupture. In cases of incomplete rupture, plugging the tear is the best course. There are two ways of plugging the tear — it may be done tightly or loosely. The former method must be employed if the bleeding is at all severe, but the latter, especially if a drainage-tube is inserted along with the gauze, gives better drainage. It is not necessary to douche out the tear before plugging. The gauze should be inserted with the cervix steadied by means of vulsellum forceps, and should not be removed until forty-eight hours have elapsed. In cases of incomplete rupture, in which the abdomen is opened under the suspicion that the rupture is complete, it is usually advisable to leave the uterus, plug the cervix from the vagina, and then close the abdomen. A very pertinent question in connexion with this method of dealing with a ruptured uterus is the subsequent treatment of the organ, for the danger of rupture at a succeeding pregnancy is con- siderable, as recorded cases show. A ragged tear treated by plugging must always be followed by a cicatrix, which is liable to give way in a succeeding pregnancy, and not only in the later weeks, but even as early as the fourth or fifth months. Probably the safest course to pursue in such cases is to remove the uterus some time after the patient has recovered from the accident. If the accoucheur deems it safe enough to permit another pregnancy, he must make sure that the patient is kept under observation during the later weeks, in case the old tear gives way. With the great improvement in technique and the results of abdominal surgery, it is not surprising that good results were expected from opening the abdomen and removing the uterus or stitching the tear. But I fancy most of us who have adopted such a course have been a little disappointed with the results, for the mortality is still high, because of the collapsed condition of the patient at the time of operation and the sepsis that so frequently follows. Of my EUPTUEE OF THE UTEEUS 641 fatal cases, two died of shock very shortly after the operation, and four of sepsis. One is not disheartened by death from shock, for in this condition it is often impossible to prevent it ; but it is very disappointing when a patient recovers from the shock and dies of septicaemia. In the cases which died of sepsis the patients died on the fourth, fifth, eleventh, and thirteenth days respectively. It is not to be wondered at that septicaemia so frequently follows. Many of the cases have been carelessly handled ; the tissues have been much bruised ; micro-organisms have been introduced, and actually rubbed into the tissues during the various manipulations carried out ; and the patients are exhausted by prolonged labour and loss of blood. Nothing could be more favourable for the occurrence of infection. Table of Author's Cases. Number of Cases. Maternal Deaths. Died unoperated upon (complete) ... ... o 3 Plugging (all incomplete) ... ... ... ... "> Hysterectomy (Porro's) (incomplete) 1 1 , , retroperitoneal treatment of stump (all complete) ... ... ... ... ... 5 3 Panhysterectomy (all complete) ... 5 2 Total maternal mortality in cases treated ... ... ... 43 per cent. Mortality for hysterectomy (11 cases, 6 deaths) ... ... 54 „ When the abdomen has been opened for the purpose of extracting Che child, or when abdominal section is decided upon after the child has been removed by the vagina, there are several modes of dealing with the uterus. (a) Complete removal of the organ — panhysterectomy. (b) Supravaginal amputation, with retroperitoneal treatment of the stump. (c) Amputation of the uterus after Porro's method. (d) Stitching the laceration and plugging. Panhysterectomy is the most radical treatment. My own results show a mortality of 40 per cent. The method of carrying out the operation is detailed elsewhere ;p. 423). It is the operation which I think will ultimately give the best results. The only treatment which I think may come into jompetition with it is simple stitching of the peritoneum and draining. [ shall refer to this treatment later. 41 642 OPERATIVE MIDWIFERY Panhysterectomy is the soundest treatment, because by this method one removes the uterus (body and cervix I, both of which are infected. If the eases of ruptured uterus which die of sepsis are examined, it will be found that the sepsis is generally local. That being so, the best thing to do is not only to remove the entire uterus, but to pack the pelvis with iodoform gauze, bring the end out through the vagina, and leave the gauze in for three to four days. In the last two cases I have employed a rubber drainage-tube surrounded with gauze. The operation which is favoured by many when hysterectomy is performed is supravaginal amputation of the uterus, with retro- peritoneal treatment of the stump. In other words, the peritoneum is stitched over the stump. The steps of the operation have been already fully described. The advantages claimed for this method are that it is easier than total hysterectomy, takes less time, and so is attended with less shock. I think these advantages are theoretical, and I feel sure are more than counterbalanced by the ill-effects which result from leaving the ragged infected stump of the cervix behind. My own personal experience from this method has not been very fortunate. I have adopted it five times, but have only had two successes — a mortality of GO per cent. One died of shock a few hours after the operation, and the others of sepsis on the fourth and eleventh days respectively. This is the great danger. In reading over the recorded cases it appears that the best results are obtained by simply bringing the peritoneum over the stump, not carefully stitching the latter. The late Milne Murray 1 specially referred to this in a case he recorded shortly before his death. In addition to giving good drainage, it saves time, so that the operation can easily be carried out in twenty minutes. The cellular tissue should also be drained by gauze loosely packed round a rubber drainage-tube. Formerly the removal of the uterus and the treatment of the stump after Porro's method was most favoured, but in recent years it has almost been given up, so that in cases collected from the literature 1903- 1005 I found only ten reported, with 50 per cent, mortality. Porro's method is a very crude method of treating the stump. Spencer, Fehling, and a few others, advocate its employment in certain cases of Cesarean section where the uterine cavity is infected ; but its employment in rupture of the uterus is of no advantage, for the cervix, the vaginal vault, and the cellular tissue are infected. It is possible that the last method, stitching the peritoneum, may 1 Trans. Edin. Obst. Soc, vol. xxvii., p. 39. RUPTURE OF THE UTERUS G43 come into favour, as it has been recently advocated by no less an authority than Zweifel, whose results from hysterectomy have been so insatisfactory. 1 He advocates a very careful abdominal toilet, stitch- ing the peritoneal coat, but is opposed to draining from the vagina. The method has this great advantage, that it can be easily performed ind may be carried out in the patient's own dwelling, as witness a most interesting case recently recorded by Down, 2 who not only saved the mother, but saved the child. It is a mistake, however, not to drain, for there must be some infected material left in the peritoneum. Eversmann's figures indicate that the results are better when drainage is employed. It is very questionable if stitching the whole thickness of the torn 3dges of the wound is advisable, for it is not sound surgery to stitch i lacerated infected wound (in Zweifel's recent recommendation of stitching it is only the peritoneum that is stitched). Plugging and draining the tear, even although the laceration is complete, is favoured by several operators, and in this country has i strong advocate in Spencer. It certainly gives surprisingly good •esults. In one respect this is highly satisfactory, for it is the simplest treatment for the practitioner who has no experience of abdominal surgery. Naturally in all cases where this conservative nethod is employed the accoucheur must make sure that all bleeding s arrested. Laceration of the Cervix. Slight laceration of the cervix is unavoidable in a primipara lelivered at term of a normal-sized child. In most cases the lacera- ion is slight, and in some can hardly be appreciated. The laceration most commonly occurs on the left side of the ervix. The explanations generally given for this are, that the .terus being usually displaced to the right, there is a greater strain on he left side of the cervix, and that in so many cases the head comes hrough the cervix with the occiput directed towards the left side. Intil recent years I was of opinion that extensive lacerations of the ervix only occurred in cases that were interfered with, either by ragging the child through the undilated cervix or by administering rgot. I have, however, seen cases, in both my hospital and private ractice, in which extensive lacerations occurred where labour was pontaneous ; nor is this to be wondered at, for the forces and resist- nce of the parts are seldom absolutely normal. But although the 1 Hegar's Beitrage, Bd. vii., p. 1. - Lancet, 1904, vol. ii., p. 755. en OPERATIVE MII>U II1.1;V obstetrician cannot be blamed for extensive lacerations of the cervix in all cases, it must be admitted that in the va.-t majority of cases the tearing results from too early extraction of the child with forceps, or dragging on the breech. It is highly undesirable, therefore, unless thf life of the mother or child is in great danger, to forcibly drag the Fig. 284. — Stitches applied in Suturing a Lacerated Cervix. child through an incompletely dilated os. In considering forcible dilatation of the cervix and the methods for carrying out this opera- tion, I referred to the dangers of lacerating the cervix, particularly in cases where the cervix was unobliterated and the pregnancy was still of an early date. Details regarding the prevention of cervical injury in such cases will be found in Chapter XXVIII. LACERATION OF THE CERVIX 645 In but few cases does laceration of the cervix manifest itself by iny particular signs or symptoms. True, in certain cases there is haemorrhage of a more or less profuse character, which, as I said jefore, was to be distinguished from haemorrhage from the placental site by the fact that the uterus was well contracted, but in not a few 3ases the haemorrhage is slight. It is undesirable to introduce the fingers into the parturient canal unless, after a difficult accouchement, there is the probability that the cervix is injured ; it is undesirable to search for any laceration ; when, however, it is suspected, either from the haemorrhage or by reason of the operative interference, it is well to examine the cervix. This is best done by attaching vulsellum forceps to the anterior and posterior lips and pulling the cervix down. In doing this it must not be forgotten that the tissue is very friable and easily torn, so too great traction must not be applied with the forceps. The uterus should also be pressed down from above. Should a tear in the cervix be discovered, it must be carefully stitched with catgut, and as far as possible the whole thickness of the cervical wall embraced in the ligature. The illustration shows how the stitches are introduced (Fig. 284). It will often be found best to introduce the lowermost one first, and, using it as a tractor on the cervix, insert the others. For stitching the cervix a medium-sized half-circle needle is the best one to employ ; also it will be found that a needle-holder is of distinct advantage. When the sutures are inserted they should be tied and cut short. Laceration of the Perineum. In ordinary obstetric practice this is, in all probability, the commonest accident that occurs. Left to nature, lacerations of the perineum, more or less extensive, frequently occur — indeed, they are the rule. I have always carefully examined the perineum after delivery in cases of primiparoe, where the birth occurred spontaneously without any attention from nurse or doctor, and I have usually found lacerations. Undoubtedly, in certain cases the perineum has entirely escaped, but that, in my experience, is the exception ; indeed, in some cases I have seen very extensive laceration of the perineum result. On the other hand, in most cases conducted by an accoucheur of experience only slight tears are the rule, and, indeed, in a great number of cases practically no tearing at all results ; there is a slight tear of the fourchette, but that is all. From these two facts it is evident that a very great deal can be done by the intelligent and practised obstetrician in preventing lacerations of the perineum and 646 OPERATIVE MlhW 1FK1;Y it is most important that the young obstetrician should give this matter his most careful consideration and attention. He will require to attend a large number of deliveries before he gains the requisite amount of skill and dexterity in guiding the head safely over the perineum. I need not impress upon my readers the importance of preserving the perineum, and should it rupture, as rupture it will in certain cases, of repairing it carefully. The future comfort of the woman depends in great part on the preservation of this all-important pelvic support. Every one is familiar with the chronic catarrhs, displace- ments, dragging pains, etc., complained of by women where the perineum has been destroyed and has not been carefully repaired. Many conditions favour laceration of the perineum. Amongst these may be mentioned a large head, and especially a much ossified head incompletely moulded ; unfavourable presentations of the head, especially occipito-posterior presentations ; rapid extraction of the unmoulded after-coming head ; and large shoulders. On the side of the mother, we have a narrow pelvic outlet, which necessitates especial distension of the perineum before the head can round the symphysis. One very frequently hears the accoucheur blame the consistency of the perineum for the laceration, and although he is often simply excusing himself, in not a few cases he is justified in his contention, because the tissues are sometimes so soft that the} 7 tear on the slightest distension, or so rigid that they refuse to distend. In the former condition of the perineum nothing can be done to prevent laceration ; all that one can aim at is to control the tear as far as possible. In the latter condition, however, laceration of any extent may be prevented by the administration of opium or chloroform, which relaxes the part sufficiently to permit of a more complete dis- tension. In these cases, when the perineum is rigid, fomenting the perineum or smearing it with a lubricant has been recommended : neither of these devices is of any value. Apart from these conditions referred to, laceration of the perineum not infrequently occurs through a faulty manual or instrumental delivery. In difficult deliveries the accoucheur, in his anxiety to extract the child, tears the perineum with his hand or with the instrument. I have riot infrequently seen cases in consultation or brought into hospital where the perineum has been destroyed before the head has been brought down to the pelvic Moor. Lacerations of this nature should not occur if the operator is careful and does not excitedly carry out his manipulations. In ordinary cases there are three points to attend to in preserving the perineum : (a) The presenting part should be allowed to distend LACERATION OF THE PERINEUM '117 he perineum when that is at all possible ; (/>) the head should be maintained in an attidude of flexion when it is delivered ; (c) the head should be allowed to escape slowly through the vulvar orifice. It is most desirable, when at all possible, to allow the perineum to become slowly stretched by the presenting part. Of course, in certain cases, where the life of the child or the mother is in danger, this cannot be permitted ; but these cases are fewer than is generally supposed, and if a little more patience were exercised by the medical attendant, they would become much less frequent. When it is necessary to drag a child from the pelvic cavity, this should be done slowly and cautiously, so as to permit of gradual stretching of the Fig. 285. — The Prevention of Perineal Laceration. The accoucheur is controlling the passage of the head through the vulvar orifice. pelvic floor. An anaesthetic should always be employed in order that the parts may be as relaxed as possible. Next to allowing the perineum to be distended, it is of the greatest importance that the head should escape flexed. In that attitude the smallest circumference of the head — the suboccipito-bregmatic — passes through the vulvar orifice. Lastly, the head must be allowed to escape slowly so that the vaginal outlet is gradually distended. There are many methods described for guiding the head over the perineum, but the differences in detail are of comparatively little moment, provided the three important points already mentioned are attended to. I will, therefore, only describe the method which I have found the best, and which is employed in the Glasgow Maternity Hospital. When the head appears through the vulvar orifice, its 648 OPERATIVE MIDWIFERY progress is very carefully watched, and the patient and accoucheur lake up positions as indicated in the illustration (Fig. 285). The patient, lying in the left lateral position (I helieve one has better control over the patient in tbie than in the dorsal decubitus), is placed across the I •s Beilrage, 1907, Bd. xi., p. 200. 3 Journ. Ob-st. and Gyn. Brit. Emjrire, November, 1910. CHAPTER XXXYI OCCIDENTS TO MOTHER— Continued ; INVERSION OF UTERUS- PULMONARY EMBOLISM— SUBCUTANEOUS EMPHYSEMA is the present work is devoted entirely to operative midwifery, I do .lot deem it suitable to consider in any detail the complications which : ollow parturition. I feel, however, that I must refer to three which occasionally manifest themselves immediately after labour. These ihree are : inversion of the uterus, pulmonary embolism, and sub- cutaneous emphysema. Inversion of the Uterus. We are here only concerned with this accident as it occurs mmediately or shortly after the birth of the child, so-called ' acute inversion.' I do not intend considering cases of chronic inversion, or chose which result from the presence of tumours, etc. The frequency of this condition is variously stated. -Jardine, for ;he Glasgow Maternity Hospital, found that it occurred three times in 51,290 cases. Naturally, there are different degrees of inversion — from the simplest, where there is only a depression over the fundus, to the nost extreme, where the uterus is turned inside out and the vaginal walls are also everted (Fig. 293). Etiology. — As regards the etiology of the condition opinions liffer, for while some consider that a localized atony, more particu- arly of the placental site, along with active contractions of the rest of the uterus, is all that is necessary, others hold that the accident results from pure atony, the inversion being produced by pressure from ibove, by the hand, or by the contraction of the abdominal muscles, Di' dragging on the cord from below. The latter, without doubt, in a arge proportion of cases, seems to be the correct explanation of the 3ccurrence ; but it is quite conceivable that the former view may also be correct, for once an indentation has occurred, it is evident that complete inversion may be produced by uterine contractions alone. 655 OPERATIVE MIDWIFERY The most valuable and original contributions to the etiology and treatment of this condition in recent years are those made by Bar. 1 Bar has pointed out how little the anterior vaginal and uterine walls are supported, and how, therefore, they fall down and drag the rest of the uterus after them. Apart from uterine retraction, the chief supports against inversion are the infundibulo-pelvic ligaments (Pig. 294). Although, as one would expect, multipara' are more liable to this complication than primipara , still, there are quite a number of the FlG. 293. — Complete Inversion ol' Uterus and Vagina. < Buniiu.) latter ; in my series of collected cases the proportion of primiparse to multipara is as 9 to 12. "Without attempting to make an exhaustive table of the recorded cases, I collected, for the years 1903 to 1905 inclusive, twenty-three cases from English and Continental literature. In examining them it was evident that the occurrence followed pressure from above or traction from below in the majority of the cases. In looking over the series I was not a little surprised at the large 1 Bull, de la Soc. d'Ubst. de Paris, 1901, 1902. INVERSION OF Till-: UTERUS 657 roportion of cases in which traction on the cord was the cause. Vith few exceptions, in these cases mid wives had charge oi the atients. Of course one must not forget that in recording cases f inversion of the uterus, the tendency is for the practitioner to scord those cases in which he has not been to blame, still, even llowing for that, traction on the cord appears to be a very im- ortant cause of inversion, a much more important cause than I upposed. In this connexion an interesting case is recorded by fighton and Collins, 1 where the inversion followed the birth of a Fig. 294.— Partial Inversion of Uterus. (Bar.) lild with an unusually short cord ; the cord was wound round the eck and trunk of the child several times. Similar cases where the 3rd was actually short, or short by reason of being wound round the lild, have been recorded by several writers. Then, again, inversion as followed a precipitate labour in which the child has been born ith the woman sitting in an erect posture, the child in its fall ragging on the cord. Next in frequency to dragging on the cord comes increased xlominal pressure, such as is produced by straining, coughing, leezing. In two cases, those reported by Pompe 2 and Falk, :i the 1 Journ. Obstet. and Gyn. Brit. Empire, October, 1905, p. 250. 2 Zent.f. Gyn., 1903, p. 612. 3 Ibid., 1904. p. 1441. 42 OPERATIVE MII'WII i:i:v inversion appears to have been produced by injudicious employment o! Cred6'fi method of expressing the placenta. On more than one occasion I have produced daring the third stage slight indentations by pressing upon the fundus of an atonic uterus, in such cas if pressure had been continued, without doubt complete inversion could easily have been brought about. Credo's method of express- ing the placenta should never be employed until the uterus is in a state of contraction. It has occasionally happened that inversion has followed the manual removal of a placenta, either by reason of the external hand pressing firmly upon an atonic uterus, or the internal hand being withdrawn and establishing a negative pressure. Symptoms, Diagnosis, and Prognosis. — As a rule, the symptoms of this accident are very pronounced. Generally there is a feeling of something coming down, quickly followed by more or less pronounced collapse and haemorrhage. That is true, at least, of those cases where inversion is complete. Where it is only of a slighter degree, and the fundus does not come beyond the os externum, only pain and hainor- rhage may be present. Very seldom indeed are symptoms entirely absent, but Galabin has recorded a case in which there were no symptoms whatever, either immediately after the delivery or during the puerperium ; the condition was only recognized after lactation had ceased and when irregular hemorrhages occurred. Similar cases have been described by several other writers. Careful vaginal and bimanual examination will at once reveal the nature of the condition where there exists a complete inversion, for a large body will be evident projecting from the vaginal canal, and there will be no trace of the enlarged uterus above. Sometimes the indentation can be made out from the abdomen. The only condition that simulates inversion of the uterus is a submucous myoma projecting down through the os, but in such a case there would still be present the enlarged uterus above the pubes. Theoretically, the contractility of the inverted uterus is a diagnostic feature of importance. I question, however, if it is of real value in practice. Even in the cases where there is only slight inversion a careful bimanual examination will reveal a depression, and, if the fingers are inserted through the os to confirm the diagnosis, a projecting body will be felt. It must not be forgotten, however, that these remarks regarding the diagnosis only apply to acute inversion ; chronic inversion may be more difficult of recognition. One of the most extraordinary cases of mistaken diagnosi- is a case described a few years ago by Hickson Smith, 1 where a midwife 1 Brit Mel. Journ., 1S97, vol. i., p. 1476. INVERSION OF THE UTERUS 659 .hinking she had to deal with a second ehild, pulled upon the inverted items, and after three-quarters of an hour succeeded in removing it. vVhen Dr. Smith arrived, the inverted uterus was examined by him. Sven more extraordinary is the fact that the hemorrhage was slight, ind that the patient made an excellent recovery. The treatment idopted by Dr. Smith was simple vaginal plugging. Another very extraordinary case is one described by Henkel. 1 In ihis case an inverted horn of a double uterus (uterus bicornis unicollis) ,vas taken first for an inverted uterus, and then, because a uterine sound passed in 6 centimetres, it was deemed to be a polypus. The iumour was removed, when it was found that an opening had been aiade into the peritoneal cavity, proving that the condition was an inverted horn of a double uterus. Prognosis. — The prognosis for inversion of the uterus is very much better now than formerly, for it is less likely to be overlooked ind sepsis is less likely to follow. Still, the number of fatal cases is not inconsiderable. Nor is this to be wondered at, as the accident Dccurs most commonly amongst those who are attended b} T midwives. [t is difficult to explain some of the deaths, for the amount of blood ^ost is not sufficient to account for them. The shock, however, is }ften very considerable. Of the twenty-three collected cases, the omplication proved fatal in six (28 per cent.). Treatment. — Before considering the treatment of inversion when it has occurred, let me say a word regarding prophylaxis. On no xccount should the cord be dragged upon ; on no account should >ede's method be injudiciously employed ; and on no account should a ivoman be left whose uterus is not firmly retracted. As regards the ast point, a hot intra-uterine douche and ergot will generally cause irm retraction. Personally, I am entirely opposed to the employ- ment of a pad underneath the binder, as was very commonly the practice in this country until recently, for should the uterus become itonic and any increased abdominal pressure occur, the pad will ictually favour the occurrence of inversion. The reduction of an acutely inverted uterus is usually accomplished without much difficulty. In my twenty-three collected cases it is stated to have failed in three, and to have been accomplished with difficulty in four. It is commonly recommended to replace first the part that became last inverted, and Bar especially recommends, in difficult cases, attacking the anterior part first. In those cases where the whole uterus is relaxed there is seldom any difficulty, but where Bandl's ring remains firmly contracted an incomplete reduction — viz., the removal of the inverted cervical and lower uterine segment 1 Zent.f. Gyn., 1905, p. 751. 660 OPEEATIVE MIDWIFERY — is all thai can be accomplished. It is very important to remember that it is generally Bandi's ring thai prevents reduction, not the c< rvix, which is flaccid after delivery. In such cases the employment (if much force is not a little dangerous, for the lower segment being so thinned out and non-resistant, there is no point d'apjmi : the hand must be applied externally in order to supply the resistance necessary. Many recommend pushing the fingers into the depression through the abdominal wall and stretching the constriction. They claim that they have succeeded in doing this ; but in all probability they have not dilated the ring; they have only supplied a point d'appui. In such cases, undoubtedly, deep anaesthesia, and especially chloroform anaes- thesia, is of great advantage, and although I cannot speak from personal experience, I imagine that a full dose of morphia would be beneficial. In all cases, and especially when chloroform and morphia have been freely given, there is a distinct danger of post-partum haemorrhage. One should therefore have ready to hand ergot, a hot douche, and packing, in case haemorrhage occurs. In not a few cases the placenta has remained attached to the inverted uterus, and in such it is generally recommended to first attempt replacement with this body attached, as it is a certain protec- tion to the uterus. Should, however, replacement be impossible, the placenta and membranes must be carefully stripped off. As regards those cases where reduction entirely fails, various methods of treatment have been advocated : the most radical is abdominal section and replacement of the uterus by various methods, such as Kustner's and others, or hysterectomy. Very few, however, favour such procedures, and certainly the results from abdominal section have been highly unsatisfactory. In a certain number of cases where reposition has failed, a spontaneous rectification has occurred. Boxall 1 records a most interesting case, and Spencer and Galabin, in the discussion which followed, referred to similar experiences. In fact, it seems to be quite a recognized occasional occurrence, for the older writers in obstetrics refer to it also. In Boxall's case the patient had had continuous douches, and the author believed ' that the constant douching may have very materially assisted the process of reposition.' How such a spontaneous reposition occurs is a little difficult to explain, but if one reads the careful description of the anatomy of this complication given by Bar, 2 it does not cause one so much surprise. We all know how frequently a retro verted gravid uterua spontaneously rights itself, and so it is no wonder that occasionally the inverted uterus should do the same. In those cases, then, where 1 Trans. Lond. Obst. Soc, 1904, vol. xlvi., p. 292. 2 0/>. cit. INVERSION OF THE UTERUS 661 one fails, the part should be carefully washed, some aseptic gauze applied round the organ, douches given twice daily, and subsequent attempts made at replacement. In this class of case the various repositors, such as Aveling's, which are so useful in chronic inversion, are rather difficult to apply because of the large size of the uterus. There have been several cases of successful reduction where the cup has been constructed to suit the size of the uterus, and especially where the repositor has been used a week or ten days after the delivery. Galabin 1 refers to such a case. The various metreurynters may also be tried ; Pinard' 2 mentions several successful cases where Champetier de Ribes' bag was employed. By adopting the conservative treatment just sketched, one will without doubt succeed in getting the organ replaced in almost all cases, and even should one fail and require ultimately to have recourse to abdominal section, the chances of a successful result will be much greater than if one had hurriedly opened the abdomen because in the first attempts reduction failed. Recently Tate 3 described a most interesting case where he removed per vaginam a septic inverted uterus. Pulmonary Embolism. Amongst the most fatal accidents following on parturition is pulmonary embolism. This complication is due to the dislodgment of a portion of thrombus from some of the pelvic veins. It usually occurs in the third week of the puerperium, but occasionally it takes place immediately after delivery. No matter Avhen the accident occurs, the condition is an extremely grave one, and the vast majority of patients attacked die. The disease will be best illustrated b} T recording two cases from my practice. In the first the accident happened at the end of the second week, and in the second immedi- ately after delivery. Case 1. — Case of Death on the Fourteenth Day of the Puerperium from Pulmonary Embolism. — Mrs. B , aged thirty-four, 4-para, had been a patient of mine for several years. She first came under my care in her second pregnancy, which terminated in a miscarriage at the fourth month. Her first pregnancy, she informed me, had ended at full time, when she was delivered with forceps of a large male stillborn child. Her third pregnancy also terminated in an abortion at the fourth month. During her fourth pregnancy she was troubled greatly with digestive disturbances, and 1 Trans. Lond. Obst. Soc, vol. xlvi., p. 206. - Anal de Gun. et cVObst., May, 1906, p. 25. 3 Journ. Obst. and Gyn. Brit. Empire, March, 1907, p. 24s. 662 OPERATIVE MIDWIFERI towards the end by albuminuria, and even a threatening of eclampsia. With suitable treatment, however, Bhe escaped the latter, and her pregnancy allowed to continue until full time, when Bhe was delivered with forceps living child. During the whole of her pregnancy she was taken great of. The puerperium was a little unsatisfactory. The pulse wae alwj rapid, usually about 90, ami the temperature always a little raised — '•''•''•">° to 100° F. < )u several occasions the uterus was douched with mercuric chloride. Gradually the temperature and pulse subsided, but never quite returned to the normal. At the end of the second week she complained of a little pain in the left iliac region, and she was warned not t<> rise. On the thirteenth day, however, contrary to my instructions, she insisted upon being lifted into an arm-chair, and the same thing was done on the four- teenth day. On the hitter day she felt so well sitting in the chair that she actually tried to walk a little. After going a few steps she was suddenly seized with great precordial pain and dyspneea. She was immediately lifted into bed by her husband and the nurse, but the breathlessness and pain continued. I reached her house about half an hour after the occurrence. She was, however, dead before I reached her — at least, she gave one last gasp as I entered her bedroom. At the post-mortem examination both pulmonary arteries contained large Hood-clots; the left iliac vessels were thrombosed. Both kidneys were extensively diseased, the right being replaced almost entirely by cysts : the left also contained many cysts, and was much enlarged. Case 2. — Pulmonary Embolism immediately after Delivery — Recovery. — This patient complained of pain and breathlessness shortly after her delivery. She was a primipara with a slight justo-minor pelvis. On examining her under chloroform about the thirty-sixth week, it was deemed advisable, because of the relative size of the head and the pelvis, to induce labour. This was done with a bougie. Labour came on in a few hours, and terminated spontaneously within a very short period. After giving the placenta fully an hour to separate, I introduced my hand into the uterus and found it slightly adherent. I removed the placenta without much difficulty. When the patient recovered from the anaesthesia, she complained of precordial pain and breathlessness. This became steadily worse, and the pulse became more rapid. After a hypodermic injection of ] grain of morphia the pain was relieved, but she still remained very breathless, and could not lie down comfortably in bed. Inhalations of oxygen from time to time gave her some relief. She made a somewhat slow recovery, but there were no further complications. The temperature was normal throughout the whole puerperium. A severe case of pulmonary embolism can hardly be mistaken for any other condition. The sudden onset, the severe precordial pain, the great dyspnoea, and the increasing lividity, render the diagnosis self-evident. In the slighter forms of the accident, however, there may be some doubt. For instance, I have twice seen patients seized with hysterical attacks of dyspnoea which very closely resembled the PULMONARY EMBOLISM 663 lyspncea of pulmonary embolism. It is always, of course, open to loubt whether these attacks were really hysterical. In one case, aowever, they were quite certainly of this nature, as the patient had several, one some weeks after her confinement, when she received the news that her husband was suddenly ordered abroad with his regiment. The other patient was undoubtedly neurotic also, and has had peculiar nervous symptoms at different times while she has been under my care. Very occasionally the embolus consists not of blood-clot, but of air. The symptoms are analogous. The air is introduced during intra- uterine manipulations, as in cases of placenta praevia, version, and especially in removing an adherent placenta. Serious, and even fatal, dyspncea may also follow the insufflation of vomited material. A very grave condition indeed, and one which may give rise to sudden death, is acute oedema of the lungs. Some little time ago I was asked to see such a case in consultation, but the patient was dead before I reached her house. The quantities of frothy mucus from the respiratory passages is a very striking feature of this condition. The treatment of this most serious accident of pulmonary embolism consists in keeping the patient at absolute rest. She must on no account be allowed to move ; everything must be done for her. The pain complained of over the pericordial region is best relieved by the administration of morphia hypodermically. Inhalations of oxygen are also of value, although there is often not time to obtain cylinders, as death frequently takes place within a few minutes. Intracellular saline transfusion to dilute the blood is recommended by many writers, but none now attach much value to the liquor ammonia or the alkalis formerly advocated. If the patient at any time shows signs of collapse, stimulants must be given by the mouth and strych- nine hypodermically. Subcutaneous Emphysema. This complication is one of considerable rarity, although it is probable that slighter examples of the condition are often overlooked. Many interesting monographs have appeared since Depaul published the first exhaustive memoir on the subject in 1842. In recent years Klots, 1 Hergott, 2 Stevens, 3 and Kosmak, 4 amongst others, have made 1 Zeit.f. Gel. u, Gyn., 1899, Bd. xli., Heft 3. 2 Ann. de Gyn. et cVObst., 1904, p. 641. 3 Trans. Med.-Chir. Soc, Glasgow, vol. iii., p. 99. 4 Bulletin, L/ying-in Hospital, New York. 1907, vol. iii. 664 OPERATIVE MIDWIFERY interesting communications. Klote has collected forty cases and ELosmak seventy-seven. The genera] view held is that the condition arises from rupture of the air vesicles at the root of the lung, air, therefore, escapes underneath the pulmonary pleura into tin- anterior mediastinum, and bo underneath the cervical fascia up over the neck and chest. Their are, however, some who believe that the condition is due to injuries to the respiratory tract higher up — for example, in the mouth and trachea. Judging by the published cases, the patients wire invariably primiparsB. In all there were considerable straining efforts made during the second stage. In many the labours terminated spontaneously. The condition is undoubtedly favoured where resistance is inert owing to the child being of exceptionally large size, or the pelvis being unusually small, and the soft parts unduly rigid. In a considerable number of cases pain is complained of, and is very often situated about the region of the seventh or eighth rib. The outlook is good, the patients invariably recovering. No very special treatment is required, but if the pain is excessive during breathing, the affected side should be firmly strapped, as is done in cases of fractured ribs. The following two cases illustrate this condition : Case 1. — Mrs. X was delivered of a first child in October, 1902. Distinct labour pains began about 10 p.m., and the child was born six hours later. The first stage was of short duration. Soon after the second - ; _ began the pains became very severe, with strong expulsive efforts. About three hours before delivery a slight swelling of the neck was noticed, and increased until the birth of the child, which occurred spontaneously. Shortly after delivery the patient complained of severe pain over the right side, in the region of the seventh and eighth ribs, about 2 inches outside the nipple-line. The swelling in the neck had by this time increased, and had extended up the sides of the head and down over the chest, back and front. Over this whole puffy area crepitation could be elicited. The pain in the side continued for several days, and the emphysema entirely disappeared within a week. There was no cough nor expectoration, and the patient made an uninterrupted recovery. Case 2. — A. M , aged twenty-nine, a primipara, was a patient in my wards in September, 1905. The presentation was normal and the birth spontaneous. The first stage lasted some thirty-six hours, but was not unduly severe. The second stage was not specially delayed, but the patient earned excessively, and for half an hour before her child was born had extremely severe pains. About half an hour before delivery Bhe noticed a swelling in the neck, and had a choking sensation. This swelling in the neck extended upwards over her cheek and eyelid-, and downwards over her chest. She complained of slight pain in her left side, she directed the SUBCUTANEOUS EMPHYSEMA 665 house-surgeon's attention to the swelling after her delivery. It was then found that over the swollen area there was distinct emphysema. The swelling disappeared in a few days, and the patient made an uninterrupted recovery. In cases of rupture of the uterus there is a variety of subcutaneous emphysema occasionally encountered. The air in such cases gets into the cellular tissue of the broad ligament and abdominal wall. < BAPTEB XXXVII ACCIDENTS TO CHILD : INJURIES TO BONES, MUSCLES, NERVES, VISCERA, ETC. ; ASPHYXIA NEONATORUM All manner of injuries may follow a difficult delivery terminated by forceps, or by traction on the breech and after-coming head. Amongst the least serious are bruises and lacerations of the scalp, face, and other soft parts. Caput Succedaneum and Cephalo-Haematoma. These simple conditions are familiar to everyone. The caput succedaneum forms over the presenting part. It is an a-dematous swelling of the superficial tissues which arises in most of the cases after the membranes have ruptured, and increases in size the longer the second stage continues. The swelling is a harmless one, and disappears in a few days. A cephalo-hamatoma, on the other hand, is a collection of blood underneath the pericranium. It is to be distinguished from the caput succedaneum by the fact that it generally does not appear until a day or two after delivery, is limited to particular bones by the attachment of the periosteum, and is most common when parturition is easy and rapid. In most cases it forms over one parietal bone, but sometimes both are affected, and occasionally it is found on the occipital and frontal bones. The swelling is a fluctuant one and often takes weeks to disappear. At the edges of the swelling an irregular ossification occurs, so that a round, hard, raised edge may be felt. Occasionally a more diffuse ossification occurs, so that crepitation may be elicited over the tumour. Very occasionally the swelling becomes infected. Some writers have recommended puncture, aspiration of the blood, and the application of a firm binder or strapping. The effusion need not be interfered with, however, unless suppuration occurs, when the sac should be freely opened and packed with gauze. Injuries to Nose, Ear, and Eyes. More serious injuries are fractures of the nose, lacerations, and even complete removal, of the ear, and injuries to the eyeball. These 666 i ACCIDENTS TO CHILD 667 a variably result from forcible extraction of the child with forceps in ■ontracted pelvis. Fracture of the nose may possibly occur even in ■pontaneous delivery, but tearing or removal of an ear only results in a orceps delivery when one of the blades slips. These accidents are ixtremely rare. Injuries to the eye are often very serious ; slight lacerations of the syelid are not of much consequence, but sometimes it happens that he eyeball is burst or even completely evulsed. Several interesting irticles have been written by Buchanan and Thomson 1 on the subject if corneal opacity following forceps deliveries. They have pointed out hat a general cloudiness of the cornea often occurs, which finally ■ettles down into a linear cicatrix. Undoubtedly, in many cases the njuries to the eye are directly produced by a blade of the forceps ; >ut in not a few cases, especially those in which evulsion of the eye >ccurs, the accident results from extreme compression of the head, as vhen a child is dragged through a deformed pelvis. Injuries to the Bones. Fracture of the Skull. — Injuries of the bones of the skull almost nvariably occur during parturition, and most commonly when there las been difficulty in extracting the fore-coming head by forceps or he after-coming head by traction. Very occasionally it happens that ractures of the skull occur during pregnancy as a result of falls or •lows sustained by the mother. In such cases the head of the child, till movable in the uterus, is suddenly driven against the brim of he pelvis or the vertebral column. The child may be killed by the ■ccident, which is often so severe as to bring on premature labour : ut in not a few cases the pregnancy has continued undisturbed and he child has recovered, the injuries having healed in utero. In most cases, when injuries occur during parturition, the labour ias been protracted owing to the disproportion between the foatal head nd the maternal pelvis. In some the force of the uterine contractions as been sufficient to overcome this obstruction in the parturient canal, nd the injuries, therefore, may be described as spontaneous. In most ases, however, the delivery has been artificially terminated by forceps r traction on the lower limbs, and the injuries are, therefore, of a iolent nature. I have seen occasionally very extensive fractures irectly produced by the blades of the forceps. In such cases the hild's head has usually been grasped obliquely, and the tips of the lades have been the cause of the injuries. The occipital and frontal ones then suffer most. Sometimes, however, although fractures 1 Trans. Ophthal. Soc, vol. xxiii. OPEBATIVE MlhWll i:i;V occur, the forceps Le not primarily to blame; fche injury really ari from dragging the child past the projecting promontory. In t - the parietal and frontal bones are those usually injured. A most serious injury is separation of the condyloid process of the occipital bone. It usually occurs when there is difficulty in extracting the ufter-coming head. In this condition death may result from intra- cranial hemorrhage or from direct injury to the medulla. Another very serious and fatal accident is dislocation of the upper cervical vertebra. Indentations of Skull. — Indentations of the skull are either furrow-shaped or spoon-shaped. The furrow-shaped variety are less serious, and seldom give rise to much immediate disturbance. They may be of various forms. They are sometimes confined to the parietal or frontal bones, but very often involve both. Much more serious are the spoon-shaped indentations, for, in many cases, they are associated with fracture of the indented portion of bone. The subject of indentations of the skull of the new-born has been frequently written about, more particularly by French obstetrician-. I considered the subject in some detail a few j r ears ago. 1 The injury is usually situated on one or other of the parietal or frontal bones in the neighbourhood of the anterior fontanelle. "With few exceptions, it occurs where there is deformity of the maternal pelvis, most commonly a deformity of only a moderate degree. The indentation is usually caused by the head being pressed or pulled against the projecting sacral promontory. Apart from bony deformity, it would appear that the condition has occasionally been produced by tetanic contractions I of the uterus, contractions of the muscles of the pelvic floor, ankylosis of the coccyx, and tumours of the bones and soft parts of the pelvis. On the foetal side, Budin has recorded a case of twins where the after- coming head of the first child, which presented by the breech, was arrested by the presenting head of the second ; both the children were born dead, with depressions of their skulls. Braune- reported a case where the depression was caused by an arm prolapsed at the side of the head. Occasionally the accident has recurred in succeeding labours. Strassmann 3 has recorded a case where a woman gave birth on five different occasions to children with depressions of their skulls. No doubt defective ossification of the skull predisposes to the accident. Experimenting on stillborn infants I found I could produce 1 Brit. Med. Jouni., January 19, 1901, and Edin. Obst. Trans., vol. xwi.. p. 12. - Zentf. Gyn., 1896, p. 225. 3 Zcit.f. Geb. u. Gyn., 1900, Bd. xlii., Heft 8, p. 615. ACCIDENTS TO CHILD 669 epression with little pressure in some cases, but in others I could nake no impression on the bones at all, even although I used onsiderable force. In the majority of forceps deliveries, as I have already indicated, t is the pressure of the head against the promontory, not the blades, hat causes the injury. The effect of these injuries upon the child varies. In some cases hey cause death. When the children are born alive, the indentations ometimes disappear spontaneous!}' in a week or ten days. In such ases there has probably been no real fracture of the bone ; it has been simple indentation. Most commonly the depressions remain, but ause no immediate or late disturbance. On other occasions they give ise to more or less severe nervous phenomena, and later in life to >ermanent mental -weakness. Here are two illustrative cases : (ask 1. — Some years ago I delivered a mature child with forceps hrough a slightly flat rachitic pelvis. The child was born with a spoon- haped depression over the right frontal bone ; it seemed otherwise well, t did not thrive, however, and about a fortnight after its birth took a few onvulsive seizures and died. Case 2. — Some months after the above case occurred, Dr. Malcolm Black, Consulting Physician to the Maternity Hospital, told me of a case in vhich he had great difficult}' in extracting the head with forceps, owing to a leformity of the pelvis. There was a large spoon-shaped depression over he left frontal bone ; the child's heart was beating very slightly, and artificial espiration brought about little improvement in its condition. Recollecting ay request, he tried compression of the skull, with the result that the adentation came up suddenly with a jerk, the child immediately began to nake attempts at respiration, the heart commenced to beat more strongly, aid before long the child was quite out of danger. Removal of Indentation. — At one time I was not in the habit of nterfering with cases of spoon-shaped indentations, but in recent /ears I have almost invariably operated upon them. When I made .he contribution already referred to, I suggested a simple treatment vhich I had found successful — viz., very firm antero-posterior com- pression of the head (Fig. 295). This simple procedure, which often succeeds, I discovered accidentally at a confinement of a private )atient. This briefly is a history of the case : A child which was of average size and full time was extracted with orceps, the indication for the latter being a persistent oecipito-posterior n-esentation. On extracting the child I discovered a deep spoon-shaped ndentation on its right frontal bone. The child was only slightly isphyxiated, and soon cried and seemed little disturbed by the deformity. 670 OPERATIVE Mlh\VIIKl;Y While looking at the indentation, it occurred tome that by firmly compn ing the head antero-posteriorly, sufficient pressure might be exerted on the depressed bone to cause it to spring up. I hardly expected the simple manoeuvre to be bo successful, but one, left exophthalmos, and right facial paralysis. The child cried Fig. 296. — Indentation of Skull removed by Operation. /ery feebly. M. Millard bored through the skull and raised the lepressed bone, with the result that the child cried immediately. The convulsions ceased, the exophthalmos gradually disappeared, and on ;he following day only a trace of the facial paralysis remained. In -ecent years a number of successful cases have been recorded. In some the operator has trephined over the depression, in others ae |_has incised the skull along the margin of the depression. All nanner of instruments have been used for raising the bone. In most 3ases, when the operation is undertaken immediately, the bone is very easily raised, but after a few days it becomes increasingly more lifficult. 1 'Rotunda Practical Midwifery,' 1908, p. 311. 2 ' Lelievre's These,' Paris, 1892. 672 OPERATIVE MIDWIFER1 The method 1 have employed in the Maternity Hospital is the making of an incision through the Bcalp and pericranium along the margin of the depression, cutting the hone with Bharp Bcissors, and then inserting a fiat elevator between the dura mater and skull. In the illustration (Fig. 296) is seen the result from such an operation. There is no Hap turned down ; if this is necessary, then the incision would be made along the upper margin of indentation. For cases seen some time after the occurrence of the accident an ingenious device is that suggested by Nicoll. 1 A flap of the scalp and pericranium is turned down, and the indented portion of the bone is cut out with a trephine. The excised portion of the bone is reversed and then replaced. The scalp and pericranium are then brought over the bone and stitched. Injuries to Other Bones. — I have only once observed fracture of the lower jaw ; it was caused by the tip of the blade of the forceps. The bones which are most liable to be fractured are the clavicle, humerus, and femur. The accident most generally occurs in bringing down the limbs in breech presentations. It would appear from the investigation of Eiether 2 and Muus 3 that fracture of the clavicle is bj T no means uncommon. As it frequentl}* causes little discomfort to the patient and does not prevent its moving its arms, the condition is often overlooked. Occasionally it occurs in spontaneous births, but usually it follows difficult extraction of the shoulders, when the child is large in size or the passage is narrow. The clavicle fractures are generally incomplete, but those of the humerus and thigh are often complete, for the bone is broken right across. In dealing with fractures of the clavicle and the humerus the child's arm should be firnily bound against the trunk. Fractures of the lower limbs are more difficult to treat, as Jones 4 of Liverpool has recently pointed out. Injuries to Muscles. Although tears and lacerations of any of the muscles may occur in difficult deliveries, more especially difficult breech deliveries, the only one which requires special mention is that of the sterno-mastoid. Injuries to this muscle are followed by the development in its substance of a hematoma. This accident may occur in head-first and in head- last deliveries. In head-first deliveries it is produced in very much the same manner as 'birth paralysis' (p. 077). The hematoma i- 1 Trans. Glas. Med.-Chir. Soc, vol. iv., p. 421. - Wien. Kim. Woch., .tune 12, 1902. No. 21. Zentf. (iijn., 1903, No. 23. i Brit. Med. Jowrn., 1908, vol. i.. p. 1 ACCIDENTS TO CHILD 673 ften not noticed for some little time after the birth. It usually takes ■me to disappear, but clears up completely and leaves no bad effects, •ccasionally it is the cause of torticollis. Injuries to Brain, Spinal Cord, Nerves. Haemorrhage into the Cranial Cavity. — As might be expected, itracranial haemorrhages are most frequently the result of difficult nd artificial deliveries. It occasionally happens, however, that these :aemorrhages take place in easy and spontaneous births. All writers, lcluding Gowers, 1 refer to the fact that in not a few cases labour was ■recipitate. According to Seitz, 2 in 20 per cent, of cases this was so. lS might be expected, the occurrence is more frequent with boys than /ith girls. Haemorrhages into the substance of the brain are not common. For he most part they are meningeal, and are generally situated over the urface of the convexity of the brain, although not infrequently they re found also at the base. According to Gowers, when the haenior- hage is over the convexity of the brain, it is generally bilateral, ,nd is most considerable over the central region and towards the aiddle line. This is in agreement with Spencer's findings. 3 Gushing 4 tates, although evidently it is only an impression, not a conviction rom observations made : ' I am of opinion that the extravasation is isually limited to one side of the falx, though, indeed, a bilateral esion is common enough, as the many patients with diplegia would adicate.' It will be observed that in two of the four cases described y dishing there was extensive haemorrhage over both hemispheres, ,nd it is very possible in Case 1 that this was so also. Seitz also says hey are mostly unilateral, but he only speaks from six cases. This uestion, as to whether the haemorrhages are generally unilateral >r bilateral, has become a matter of practical importance since perative treatment has been advocated by Cushing, Carmichael, 5 teitz, and others. I shall refer to this later. In a very large proportion of cases the haemorrhage is associated nth asphyxia neonatorum. No doubt in many the haemorrhages are he result of the asphyxia, for in a very large proportion of cases the laemorrhages are not limited to the cranium, but are found in kidneys, 1 ' Diseases of Nervous System,' vol. ii., p. 414. 2 Zent.f. Gyn., 1907, No. 26, p. 780. 3 ' Visceral Haemorrhages in Stillborn Children : an Analysis of 130 Autopsies.' ]rans. Lond. Obst. Soc., 1892, vol. xxxiii. 4 ' Concerning Surgical Intervention for the Intracranial Hemorrhages of the Jew-born,' Amer. Journ. Med. Sciences, October, 1905. 6 Trans. Edin. Obst. Soc, xxxi., p. 105. 43 674 OPERATIVE MIDWll K1;Y liver, spleen, intestines, uterus, etc. It must, however, lje admitted, I think, that in a certain number the hemorrhages are the cause of the asphyxia. Without doubt, as has been indicated already, in a very large pro- portion of cases direct external violence has been the cause of the haemorrhage ; but apart from this cause, there are other factors than violence, such as the delicacy of the vessel walls, and the mobility between the different bones of the fcetal skull. This latter factor is a matter of extreme importance. "When the head moulds, the parietal bones overlap and are pushed over or under the frontal and occipital bones. Both Gowers and Cushing explain the frequency of these haemorrhages over the upper aspect of the hemispheres by the over- lapping of the parietal bones. By this overlapping the veins which ascend over the cortex and open into the longitudinal sinus are torn before their entrance into the latter ; it may even happen that some- times the sinus itself is torn. Spencer 1 says: 'There are, however, two conditions to which I wish to draw special attention as determining causes of meningeal haemorrhage — namely, softness of the skull bones and increased mobility of the bones from laxity of the sutures, and particularly of the lower edge of the parietal bone. . . . ' As stated above, in eleven instances the ha?morrhage was found limited to the parietal region of the Sylvian fissure — that is, to the part drawn by the great anastomotic vein. In many of these cases it was obvious that the effusion was due to the clamping of the vein from the pressure of the lower anterior corner of the parietal bone, which immediately overlies the main trunk of the vessel. In other cases, where the haemorrhage was more diffuse, it is more than probable that the depressibility of this part of the bone was an important factor in the causation of the haemorrhage, though it was- less demonstrable than in the cases just mentioned. ' The above observation leads me to regard the part occupied by the lower anterior portion of the parietal bone as the most vulnerable part of the child's head.' The symptoms of cerebral haemorrhage are by no means constant. If the haemorrhage is very extensive, symptoms may show themselves immediately after birth, but in not a few cases symptoms have not appeared till some days after delivery. Where the intracranial pressure is great the anterior fontanelle is very tense, the bony outline of the space cannot be defined, and pulsation is absent. The eye- balls often protrude and the lids are cedematous. Convulsions are frequent, but rarely appear until some time after delivery. These 1 Op. cit., p. 268. ACCIDENTS TO CHILD G75 onvulsions are often accompanied by rigidity of the limbs. If the :hild recovers, they usually cease after a week or two. With great ncrease of intracranial pressure the child becomes progressively vorse. It refuses to take its food, becomes increasingly listless and Irowsy, and finally sinks into a condition of coma. The history of a lifficult delivery will often help the diagnosis, but, let me again remark, he occurrence may take place in precipitate labours. A valuable lid to diagnosis is lumbar puncture, for with intracranial haemorrhage he fluid withdrawn will be blood-stained. In recent years several writers, as I have already stated, have ecommended operative treatment for cerebral haemorrhage, and ;vithout doubt, if the haemorrhage is slight and is limited to one aemisphere, the results will be highly satisfactory, and the operation should be undertaken. There is often a difficulty, however, in making mre that haemorrhage exists, and in determining whether or not the laemorrhage is bilateral. This is well indicated in Cushing's cases, md especially in Case 3, where first the one and then the other mrietal bone was turned down, and blood-clot washed away from each Hemisphere. I am in entire agreement with those operators who point out how vvell the child bears these operations, for in the cases which I have seen operated upon, or have operated upon myself, the children were ingularly little disturbed. In dealing with cases of cerebral disturbance immediately follow- ing parturition, it must not be forgotten that in a considerable number }f cases the disturbances are not produced by gross intracranial aaemorrhage. In two cases which were under my care where there ivas evidently increased intracranial pressure, and where convul- sive seizures appeared a few days after delivery, more especially narked on the one side, I was disappointed to find when the skull was opened that there was no haemorrhage to speak of. In one there was i very small blood-clot, about the size of a split pea, which I could not relieve was sufficient to cause the disturbance. The children in these ;wo cases were born spontaneously ; indeed, the births might almost je termed precipitate. In one of the cases there was no history of lervous disturbances in the family, in the other the father and a )aternal grand-uncle both had infantile paralytic affections. The nothers were both particularly healthy during pregnancy. They had 10 disturbances whatever and had no albuminuria. One of the jhildren was very much better after the operation — the convulsions, itc, ceased — but it now presents nervous phenomena. It is six years )ld. Its mental development has been very slow, and it was nearly .wo years old before it could walk. In the other case both parietal 676 OPERATIVE MII>WJFKI;Y bones were turned down in the hope that a hemorrhage might be discovered, but no blood-clot whatever was found. The child died some twelve hours after the operation. In these cases where nervous phenomena appear in very early infancy and childhood, there is a tendency to attach too much impor- tance to the injuries at birth. It must not be forgotten that in many cases there has been no cerebral haemorrhage. The disease is tin- result of hereditary weakness and of a toxaemia. For example, in not a few of the cases there has been a history that the mothers suffered from eclampsia. I have repeatedly seen the children born of eclamptic mothers seized with convulsions shortly after their birth, and in almost all children born of eclamptics albumen will be found in the urine. It is quite probable also that the poisons in the other toxemias, such as pernicious vomiting, may also have an injurious effect upon the fine tissue of the brain of the fotus. Last of all, asphyxia, apart from that produced by extreme dystocia and operative interference, very decidedly favours the con- dition, as can be judged by the writings of all who have investigated this subject. Late nervous manifestations, such as Little's 1 disease, etc., cannot be considered here. The practical question in connexion with these cases, which show cerebral disturbances shortly after delivery, is — I Under what circumstances should the skull be opened ? Certainly, if there is extreme intracranial pressure and blood-stained cerebro- spinal fluid, it should be done ; but where there are no such certain signs of intracranial haemorrhage, it is much more difficult to decide when surgical interference is advisable. Facial Paralysis. — The most frequently injured nerve is the seventh cranial (facial), but happily the ultimate results are not usually serious. From its anatomical situation one can easily understand how exposed it is. Thus it happens that the tip of the blade of the forceps frequently presses on the nerve-trunk at its point of exit from the skull. This accident is most likely to happen when the grip is not the ' ideal,' and the head is grasped more or less obliquely. On account of the obstruction to labour which deformity of the pelvis offers (flat rachitic), facial paralysis is distinctly more frequent in this type. The lesion, as a rule, is unilateral : occasionally, although extremely rarely, it may be bilateral. The prognosis is good. As a rule, the paralysis, which at first is very noticeable, begins to improve within a very short time after delivery, and at the end of ten days is almost entirely gone. This is the usual type. Another variety of facial paralysis is of central origin. This form is much less commonly 1 Trans. Lond. Obst. Soc, vol. iii., p. '293. ACCIDENTS TO CHILD 677 encountered. It is of a gradually deepening character, but usually if the child survives it also entirely disappears. 'Birth Paralysis,' or Duchenne's Paralysis. — This form of paralysis in the new-born is especially associated with Duchenne's name. He described, in 1872, four cases of paralysis of certain muscles of the shoulder and arm, under the title of ' Paralysies obstetricales infantiles du Membre superieur.' These cases pre- sented identical symptoms, and in each the same muscles were involved — viz., the deltoid, infraspinatus, biceps, and brachialis anticus. In all but one of the cases the electrical reactions were abolished and cutaneous sensation still remained. The arm hung powerless by the side and could not be abducted ; the forearm was extended and could not be flexed ; and the hand, in consequence of the inward rotation of the humerus, could not be completely supinated. From the distribution of the paralysis Duchenne came to the conclu- sion that the lesion was one of rupture or compression of nerve fibres in the brachial plexus before they enter the main nerve trunks of the arm. Erb, in 187-1, from his investigations on a form of paralysis in adults presenting almost similar characters to that previously reported by Duchenne, located the injury. This he found to be an injury of the anterior primary divisions of the fifth and sixth cervical nerves, where they unite to contribute to the brachial plexus. Subsequent researches have proved this fact, as it has been shown that the motor nerve fibres in the anterior divisions of the fifth or sixth cervical nerves at their point of junction are those which supply the muscles affected. Such being the explanation of this form of paralysis, let us see what is its causation. The nerves involved are so definitely demarcated that one must try and find a reason for their specific selection. However the injury is produced, either by compression or stretching of the upper part of the brachial plexus, the fifth and sixth nerves have their con- ductivity destroyed. Different opinions are held as to the true cause. Some say that the nerves are injured by their compression between the clavicle and the transverse processes of the vertebrae ; others affirm that the nerves are damaged by compression between the clavicle and the first rib. Kennedy of Glasgow, 1 to whose writings I am indebted for the above remarks, and whose name is specially associated with the surgical treatment of this accident, affirms ' that the chief factor in producing the lesion is forcible depression of the shoulder, while the head is bent to the opposite side and rotated.' In this position Kennedy has shown that the junction of the fifth and sixth cervical nerves suffers maximum tension, the lower cords being scarcely affected 1 Brit. Med. Jour)!., 1903, vol. i., p. 298. 678 OPERATIVE MIDWIFERY at all. Harris and Lowe 1 state that only the lifth nerve is invol and in proof of this assertion show that traction of the neck, as in pulling to one side, is more likely to injure the more delicate lifth nerve than the stronger junction of the sixth. From such an explana- tion it is clear that this type of injury is likely to occur when, for some reason, considerable force is required to deliver the child. While occurring most commonly in head-first cases (on account of their frequency), the injury may follow any presentation. In breech pre- sentations or transverse presentations, followed by version, the injury results in delivering the arms and after-coming head. In vertex presentations it results from forcibly pulling upon the head when delivering the shoulders. The prognosis is variable. Some cases recover rapidly : others make only a partial recovery after a year or more : many others are permanently injured. In all cases the opinion of a surgeon should be taken, as operative interference offers most gratifying results in many cases. Asphyxia Neonatorum. Much theorizing and speculation has been occasioned in the attempts to find an adequate reason for the genesis of the first respira- tory attempts of the child. From experiments upon the lower animals, it would appear that the gradual accumulation of carbonic acid in the blood stimulates the respiratory centre and is the chief cause, although it is likewise true that peripheral stimulation does independently excite respiratory action. Clinically, this last factor is well known. One is quite familiar with the sight of newdy-born children in a moderate degree of asphyxia, only made to breathe by external stimuli (slapping, dash- ing cold water on chest, etc.). But we have proof clinically of the other factor also, for in cases where the children are rapidly extracted by Csesarean section they are frequently in a condition of apncea. In these cases there has been no gradual accumulation of carbonic acid. The application of these foregoing facts to practical midwifery is easy. After the membranes rupture and labour proceeds to the termination of the second stage, the placental circulation is being repeatedly interfered with by the uterine contractions; the child, especially its head, is being subjected to external pressure in its passage through the utero-vaginal tract, and finally there is a change of environment from liquid medium at !)i)° to the air at 65°. The combination of the accumulated carbonic acid in the blood and the 1 Brit. Med. Joitrn., 1903, vol. ii., p. 1085. ACCIDENTS TO CHILD 679 external stimulus results in a gasp or cry and the establishment of respiration and the pulmonary circulation. The causes of asphyxia neonatorum are numerous, and I purpose dividing them into three main groups : 1. Traumatism. 2. Interference with the placental circulation. 3. Interference with pulmonary circulation. 1. Traumatism. — As examples of this group we have — (a) Badly- applied forceps, (b) Undue prolongation of ' moulding of head,' either where the pelvic canal is narrowed by the presence of bony malforma- tions, tumours, etc., or where there is a great disproportion between the head and the pelvis because of undue size of the fcetus. In this group, called by Barnes 'paralytic asphyxia,' the condition is pro- duced by compression or injury to the brain, especially compression or injury to the medulla oblongata. Spencer 1 showed, in his most valuable paper on the post-mortem examination of newly-born children, that injuries to the brain and its membranes are far from infrequent, and that although slighter haemorrhages are found even in spontaneous deliveries, these haemorrhages are much more frequent and extensive in cases of dystocia. In these cases one finds meningeal effusions, congestion, and small haemorrhages into the pons and medulla : less frequently gross intracranial haemorrhages. Thus the cause of death in these cases would seem to be due to direct and in- direct injury to the brain and respiratory and cardiac centres. The fcetus in most of such cases dies without ever making any respiratory efforts. 2. Interference with the Placental Circulation. — This interference with the placental circulation may be due to several causes : (a) Pre- mature separation of the placenta, as in placenta praevia or accidental haemorrhage, (b) Direct pressure on, or constriction of, the umbilical vessels by knots, twists, or prolapse of the cord. (N.B. — Occasionally the asphyxia results when a cord twisted round the neck of the child gets pressed against the symphysis pubis while the child is being born. This cause is often overlooked, for the accoucheur has auscultated the fcetal heart and found it quite satisfactory before proceeding to deliver the child.) (c) In cases of prolonged labour after rupture of the membranes, accompanied by undue prolongation of the uterine contrac- tions, thereby causing temporary interferences of the placental circula- tion, {d) Grave diseases of the mother, in which, for various reasons, her circulation is impeded or interfered with — e.g., heart and lung diseases, anaemia, haemorrhage, or the moribund state, {e) Poisons 1 Trans. Lond. Obst. Soc, 1891, vol. xxxiii., p. 203. 680 o|'i.l;\TI\ i: MIDWIFERI circulating in the maternal system — syphilis, uraemia, etc (/) With undilated or rigid cervix, where the child makes premature attempts at respiration, or where the cervix is so closely applied to its neck as to obstruct the circulation altogether. In this type of asphyxia the apnosa of the fu-tus is usually pre- ceded by intra-uterine attempts at respiration, the result of the accumu- lation of carbonic acid in the blood. The respiratory centre in tin- medulla is excited, and (except where the mouth of the child is closely applied to its own body or to the uterine wall), with the expansion of the chest, meconium, amniotic fluid, and mucus are aspirated. As a result of this, a condition of grave venous congestion occurs in the lungs, and the cardiac action is inhibited. As the carbonic acid accumulates, the medulla becomes more deeply poisoned, and death re- sults. The heart cavities, especially on the right side, are found tilled with venous blood, and hemorrhage occurs into the cranium, liver, spleen, etc. This is the commonest type of fy an arm and thigh and rolled over until the chest looks a little downwards ; at the same time the chest is compressed. The child is then rolled back to its original position. The movements are repeated twelve times per minute. In this method air is forced out of the chest when the child is rolled on to its side, and inspired when it is rolled on to its back. Personally, I do not favour the employment of Schultze's method of artificial respiration. I am well aware that many obstetricians approve of it, and I have not the least doubt that air is drawn in and Fie 299. — Byrd's Method of Performing Artificial Respiration. forced out very effectively by means of it. There is no doubt also that the heart is mechanically stimulated by it. In severe cases of asphyxia pallida, however, it has always appeared to me too violent. "We have seen in those cases that hemorrhages into the brain and abdominal viscera are very common ; surely, therefore, violent mechanical movements are undesirable, as they will tend to increase the haemorrhages already present. In the slighter forms of asphyxia it is quite unnecessary. It has been my custom, therefore, to remove all mucus from the air-passages, immerse the child in warm water, and employ rhythmic traction of the tongue and compression of the chest. I believe that by such quiet methods better results will be obtained than by the violent movements employed in Schultze's manreuvres. APPENDIX MEASUREMENT OF PELVIC DIAMETERS BY THE ROENTGEN RAYS By J. K. RIDDELL, L.R.C.P. & S.(Edix.), L.F.P.S.(Glas.), Medical Electrician, Royal Infirmary, Glasgow. The main difficulties to the accurate measurement of the brim of the pelvis by means of the Roentgen rays are : 1. The picture is made by a shadow of the object. 2. The plane of the pelvic brim and the surface of the plate on which the shadow is cast are not parallel, but lie at a certain angle to each other. 3. The plate cannot be got close to the brim, nor can it be always placed at the same distance from it. Of the various methods employed, none is more accurate and simple than that used by us — namely, to make a radiogram of the inlet, under certain definite conditions and eliminate the error by calculation. In applying it, the following facts have to be borne in mind : 1. A plate can always be so placed as to rest on the most posterior part of the sacrum and on the tuberosities of the ischium at the same time. 2. The plane of this plate will be at a certain angle with that of the pelvic inlet, and this angle will be nearly the same in all cases. 3. The distance between the plate so placed and the centre of the plane of the pelvic brim is about 3f inches, and never exceeds ih inches. Technique. Place the patient face downwards on a canvas-topped couch, with the tube underneath it in a movable carrier. Place a small air bladder between the patient's abdomen and the couch, just above the symphysis pubis. Place the screen on the patient's back, darken the room, and excite the tube. The outline of the pelvic brim will now be visible, and the tube can be moved 687 OPERATIVE M1I>\\11 Kl;Y into such a position that the normal ray falls perpendicularly on the plane of the inlet. Thai the tube is in the correct position is judged by the appearance on the screen, and, more exactly, by arranging that the normal ray falls practically vertically on the plate when placed in position. The tube is brought to a point 21 inches distant from the screen ; a plate in its ;w INDEX (51)1 Anaesthesia, spinal, 315 Angular pregnancy, 562 Annular detachment of cervix, 202 Anteflexion, cause of dystocia after vaginal fixation, 290 cause of dystocia after ventral fixation, 292 in contracted pelvis, 177 of gravid uterus, 287 Ante-partum hemorrhage. See Hemorrhage Vnteversion. See Anteflexion ^.nus, laceration of sphincter, 646 repair of sphincter, 653 Appendicitis during pregnancy and labour, 262 simulating extra-uterine pregnancy, 552, 560 Arm, diagnosis from leg, 90 diagnosis of particular, 91 dorsal displacement of, in head pre- sentations, 48 in breech presentations, 67 fracture of, 672 prolapse of, in bead presentations, 47 in transverse presentations, 89, 323 Artificial respiration. See Asphyxia neona- torum, 684 iscites of foetus, dystocia from, 108 ispbyxia neonatorum, 678 etiology of, 679 haemorrhages in fojtus associated with, 673, 679 livida, 680 pallida, 681 prognosis, 682 treatment, 682 ; .ssimilation pelvis, 159 stringents in post-partum hemorrhage, 613 i tony of uterus. See Uterine inertia tresia of cervix, cause of dystocia, 204 of vagina, 206 of vulva, 206 ttitude of foetus, 15 uscultation, diagnosis of presentation and position of child from, 24 foetal heart, 23 " importance of, during labour, 4, 23 in multiple pregnancy, 114 uterine souffle, 23 xis of pelvis, variations in, 337 traction forceps. See Forceps, 333 yres' method of performing symphysio- tomy, 392 ickward displacement of gravid uterus (see Retroflexion of gravid uterus), 265 icteriology of vaginal secretion, 312 ig of membranes confused with caput succedaneum, macerated fretal bead, cedematous scrotum, cystocele, 150 premature rupture of, 148 illottement of head in diagnosis of breech presentations, 50 mdl's ring. See Retraction ring imes' hydrostatic dilator, 462 Bartholin's glands, abscess of, complicating labour, 260 Basilyst, 494 Baudelocque's omphalotribe, 493 diameter, measurement of, 178 Bichloride and biniodide of mercury as antiseptics, 308 Bicornuate uterus, cause of dystocia, 295 pregnancy in, 294 rupture of, 300 Binder, abdominal, in correcting mal- presentations, 95, 328 in pendulous abdomen, 288 in plugging for accidental haemor- rhage, 603 Biparietal obliquity, 164 Bipolar version, 329 in placenta previa, 589 Bladder, ectopia of, in split pelvis, 159 irritation of, in anteflexion of uterus, 287 in ectopic pregnancy, 558 in short umbilical cord, 145 rupture of, in backward displacement of gravid uterus, 272 in rupture of uterus, 628 stone in, 256 tumour of, complicating labour, 256 Blood, diseases of, induction of labour for, 438 mole, 524 Blunt hook, 492 Bougie for induction of premature labour (Krause's method), 448 Brain, injuries to fcetal, 673 Braun's decapitating hook, 502 cranioclast, 492 Braxton Hicks' method of version (see Bipolar version), 329 Breech presentations, 50 arms, difficulty in bringing down, 62 auscultation in, 24 cephalic version during pregnancy, 85 complicated by contracted pelvis, 51 extended legs, 78 fillet in, 81 foot, bringing down, 52 forceps in, 83 head, after-coming, extraction of, 69 impacted, extraction of, 78 in hydrocephalus, 100 liberation of arms in, 62 nuchal or dorsal displacement of arm, 6S treatment of, during labour, 50 during pregnancy, 85 Broad ligament, hematoma, 209-21 1 simulating accidental haemorrhage, 598 pregnancy, 541 rupture of uterus, 617 Brow presentations, 43 couversion of, into face or vertex, 39 frequency of, 43 moulding of head in, 45 prognosis in, 44 symphysiotomy in, 46, 375 692 OPERATIVE MlDWIFEllY presentations, treatment ol • >n in. ir» Byrd'a method of resnsoitation, I ■ otion for accidental haemorrhage, 604 conservative, 410 contra-indications, 106 following vagino-fixation, 291 rentro-fixation, 292 For carcinoma of cervix, 21 7 of rectum, 258 for contracted pelvis, 192, 401 for eclampsia, 406 bypertrophied cervix, 201 for myasthenia gravis, 107 for myoma of uterus, 252 for ovarian tumour, 229 for placenta previa, 407, 593 for vaginal cicatrices. 207 hysterectomy after, 417 indications for, 404 mortality from, 430 on the dead or dying, 133 Porro's operation, 417 post-mortem. 433 preparation for, 407 prognosis of, 430 repeated, 429 results to mother and child, 430 sterilization of patients after. 427 symphysiotomy contrasted, 379, 403 technique of, 410 time for operating, 408 vaginal (see Vaginal Cesarean section), 470 Calcification of fcetus in extra-uterine preg- nancy, 565 Cancer. See Carcinoma Caput succedaneum, cause of, 666 diagnosis from bag of membranes, 150 Carbolic acid as antiseptic, 308 Carcinoma of cervix, complicating preg- nancy and labour, 214 proportion of operable cases, 216 treatment, 219 Carcinoma of rectum complicating preg- nancy and labour, 257 Cardiac disease. See Heart disease, maternal Carneous mole, 524 Catgut, sterilization of, 306 Catheterization before operation, 314, 345 danger of infection, 314 Caul, danger to child born with, 680 ' lephalic version, 316 in breech presentations, 85 methods of performing, 325 Cephalometer, 187 < lephaletribe, 493 combined cranioclast and cephalotribe, 494 Ceivix, acute (edema of, 203 amputation of, for hypertrophy, 201 for carcinoma of cervix, 218 annular detachment of, 202 ( !ervix, atresia ol - carcinoma ol Bee I iarcinoma ol 21 I changes in, during labour, ''>2l dilatation ol see Dilatation "i cervix), 156 hypertrophy of, complicating labour, 201 incision of see Vaginal Caesarean sec- tion laceration of, 6 !■! oedema ol rigidity ol see Rigidity of cervi stenosis of 204 ( !hild, relative claims of mother and child, 2 Chioid (thoracopagons monster, 128 Chloroform in labour (see Anaesthesia , 314 Chorea, induction of labour for. Chorion, disease of see Hydatidi form n 532 retention of, 514 Chorion-epithelioma, 534 Circular sinus of placenta, rupture of, 147 Clavicle, fracture of, 072 Cleidotomy, 505 Cocaine in spinal anaesthesia, 315 Cohen's method of inducing labour, 152 Collapse following haemorrhage, treatment of, 613 Colpeurynter. See Metreurynter Colporrhexis, 629 Concealed haemorrhage (see Accidental haemorrhage . 598 Conglutiuatio orificii externi, 204 Conjugate diameter of 1 irim (Conjugata 180 Baudelocque's, 178 diagonal (oblique conjugate), 183 external, 178 measurements of, 180 of outlet, 179 tnie, 180 Constrictor vaginae, importance of pic— i v- iug, 650 Contracted pelvis, Ca-sarean section in 193, 404 causes of. 153 classification of, 154 craniotomy in, 480 diagnosis of, 177 forceps in, 194, 363 induction of premature labour for. 199 442 mechanism of labour in flat pelvis. 164 in generally contracted pelvis, 155 pelvimetry in, 17'.' prognosis of labour in. 189 size of foetus in, 192 spontaneous delivery in, 191 symphysiotomy in, 193, 375 treatment of labour complicate! hv, 189 X rays in diagnosis of, 181. See Appen- dix INDEX 61)3 Contraction, uterine, 5 definition of uterine, 610 hour-glass uterine, 14 in dystocia, due to contracted pelvis, 193 in threatened rupture of uterus, 633 irregular uterine, 13 tetanic, 13, 633 Convulsions. See Eclampsia of new-born child, 676 Cord. See Umbilical cord Cornual pregnancy, 574 Corrosive sublimate and biniodide of mercury as antiseptics, 309 Cranioclast, 492 Craniotomy, 478 after-coming head. 497 in double monsters, 127 in hydrocephalus, 102, 479 in mento-posterior face presentations 43, 360 in threatened rupture of uterus, 634 indications for, 479 limitations in contracted pelvis, 480 living child, 405, 479 prognosis of, 4S2 technique of, 483 Crede's method of expressing placenta, 513 rupture of uterus from, 626 Criminal abortion, 519 Crotchet, 492 Curettage in abortion, 529 diagnostic purposes in ectopic pregnancy, 563 Cystitis from catheterization, 314 Cystocele, complicating labour, 289 mistaken for membranes, 150 Cysts of ovary (see Ovarian tumour causing dystocia), 222 of vagiua and vulva, causing dystocia, 208 Death of fcetus during pregnancy, 440 repeated induction of labour for, 441 of mother during labour, 661 Decapitation, 500 in locked twins, 120 in transverse presentations, 96, 501 Decapitating instruments, 502 Decidua in ovary in ovarian pregnancy, 544 in tube in tubal pregnancy, 538 retention of, in abortion, 522 shedding of, a sign of ectopic preg- nancy, 550, 557 uterine, in ectopic pregnancy, 549 Deciduoma malignum (see Chorion-epithe- lioma), 534 Deformed pelvis. See Contracted pelvis Dermoid cysts of ovary. See Ovarian tumours, 222 Diameters of pelvis, measurements of, 178 of fcetal head, alterations result of compression, 194, 343 Dicephalous monster, 127 Dilatation of cervix, artificial, 156 manual, 459 with forceps, 34 1 with metal dilators, 463 with metreurynter, 461 with tents, 460 Disinfection of abdominal wall before lapar- otomy, 313 of hands, 307 of instruments, etc., 304 of vagina, 312 of vulva, 311 Displacement of arms in head presentations, 46 of uterus (see Uterus, displacements of), 265 Dolichocephalic head, cause of face presen- tation, 35 Double monsters, dystocia from, 122 Double uterus and vagina, 294 Douche, intra -uterine, for post-partuni haemorrhage, 610 for retained membranes and placenta, 510, 530 routine post-partum, 313 vaginal, lie fore labour, 312 before Cesarean section, 408 Douglas' cul-de-sac, drainage through, 573 incising, in ectopic pregnancy, 573 perforation of, in expressing ovum in abortion, 527 Drainage, abdominal, disadvantages of, 567 vaginal, in extra-uterine pregnancy, 570, 573 in rupture of uterus, 641, 643, 645 Dropsy, general fcetal, 98 Dry labour, 148 Duchenne's paralysis (birth paralysis), 677 Dwarf pelvis, 155 Dyspncea during pregnancy, induction of labour for, 437, 438, 440 after delivery, 662 Dystocia, classification of, 3 definition of, 1 result of different abnormal conditions of forces, fcetus, and parturient canal. See Contents Dysuria in extra-uterine pregnancy, 276, 558, 572 from retrodisplaced gravid uterus, 270 Ecarteur of Tarnier, 464 Eclampsia, accouchement force in, 457 bleeding in, 405 Cxesarean section in, 406 saline infusion in, 405 Ectopic pregnancy. See Extra - uterine pregnancy, 537 Embolism, air, 663 pulmonary, immediately after labour, 661 Embryotomy, 478 Emphysema, subcutaneous, in labour, 663 of abdominal walls, following rupture of uterus, 665 r,!H OPERATIVE MIDYYIFEKY Enoephal le, cause ol dystocia, 104 Endometritis, cause of abortion, 518 cause of placenta pnevia, 577 cause <>i premature separation of pla- centa, 595 Enteropto8is. See Pendulous abdomen Episiotomy, 649 Ergotin. See Ergot Ergot in abortion (threatened . 526 in po8t-partum luemorrhage, 610 in uterine inertia, 1 1 Estimation of age of child, difficulty of, in induction of labour, 1 10 Eucaine in spinal anaesthesia, B15 Evisceration, ".04 Evolution, spontaneous, 88 Examination, abdominal, 15 bimanual, in estimating relative size of pelvis and foetal head, 187 rectal, 25 vaginal, few weeks before labour, importance of, 22 in lection from, 21 limitating number of, 20 Exostosis, causing injuries to foetal head, 067 producing pelvic deformities, 169 Expression of ovum in abortion, 527 of placenta (Crede's method), 513 External version (see Version, external), 325 Extraction of after-coming head, 69 of breech, 57 Extra-uterine pregnancy, 537 abdominal (primary), 547 adipocerous change in foetus, 565 advanced, 564 ampulla, implantation in, 538 associated with intra -uterine, 576 classification of, 537 clinical features, 550 decidua, tubal, 538 uterine, 549 differential diagnosis, 552, 559 dysuria in. 276, 558, 572 hematocele following, 571 interstitial, 543 isthmic, 542 lithopii-dion formation in, 565 ovarian, 545 pain in, 555 pathological anatomy of, 537 repeated, 576 rupture of, 539, 551, 555 symptoms of, 550 terminations of, 538 treatment of, 566 tube wall, changes in, 538 vaginal haemorrhage in, 557 varieties of. 537 Face presentations, causes of dystocia, 35 causation of, 35 complicated by contracted pelvis, 39 conversion of, into vertex, 39 Pace presentations, craniotomy in, 187 diagnosis of, 36 forceps in frequency of, 37 injuries to child, 87 mento-postei ior position of, 12 prognosis, 87 symphysiotomy in, li treatment of, 88 version in • facial paralysis following forceps 676 Factors influencing labour, 3 Faraboeufs prebenseur-levier-mensurateur, 372 Fascia, pelvic, limiting effusion of 1 209 Fatty degeneration of uterine wall ca . rupture ot uterus, 618 Fevers, specific, causes of abortion, 519 induction of labour in, 436 Fibro • myomata causing dyst Myoma), 235 Fillet in impacted breech, M J Flat non-rachitic pelvis, 157 rachitic pelvis, 160 diagnosis of, 177 factors influencing birth, 192 features of, 160 forceps in, 195, 363 mechanism of labour in. 104 prognosis, 188 treatment (see Contracted pelvis . 189 Foetus, abdomen, enlargement of, 107 abnormalities of, obstructing labour, '.'7 ascites of, cause of dystocia, 109 attitude of, in utt ro, 15 in face presentation, 35 bladder, distension of, 109 calcification of, in advanced extra- uterine pregnancy, 565 circulation of, disturbances of, Foetus, heart sounds cystic kidneys of. 110 death, signs of impending, 4, 23,441. 689 estimation of age of, difficulty of, 443 excessive size, 97. 1 12 fracture of bones of. in uter ' general dropsy of, 98 habitual death of, induction of labour for, 441 head. See Head, foetal heart -sounds, auscultation, importance of, 23 in prolonged labour, 4, 682 in twin pregnancy, 114 hydrocephalus of, 99 injuries to, during labour, 666 length of, measurement in utero, 44:; malformations of, cause of dystocia. 97 movements, excessive, before death, I, 682 mummification of, in extra - uterine pregnancy. 565 INDEX 695 Foetus, over-development of, induction of labour for, 44 2 position of, alterations in cause of dystocia, 26 pressure marks on, 668 size of, in contracted pelvis, 192 tumours of body of, cause of dystocia, 106 Fontanelle presentations, 32, 33 Foot, bringing down, in breech eases, 52 choice of, to bring down, 52, 320 diagnosis from hand, 90 Forceps, 333 action of, 339 adjustable axis - traction forceps of Milne Murray, 337 anteroposterior, 372 application of, 347 as dilator of cervix, 344 axis-traction, 336 Cameron's forceps, 372 cephalic application of, 347 choice of, 336 compression, amount of, exercised by forceps, 310 conditions necessary before application of, 344 facial paralysis following, 676 foetal mortality in contracted pelvis, 195, 366 head movable above brim, 345, 364 high in cavity, 354 condemnation of, with head mov- able, 363 history of axis- traction, 333 indications for, 341 in after-coming head, 69, 360 in breech, impacted, 83, 362 in brow presentations, 45, 360 in contracted pelvis, 195, 363 in face presentations, 43, 359 in flat pelvis, 195, 363 in generally contracted pelvis, 195, 372 in mento-posterior position of face, 360 in occipito-posterior presentations, 32, 357 in posterior parietal presentations, 165, 195, 368 in prolapse of cord, 137 in protracted second stage of labour, 12, 342 limitations in contracted pelvis, 195, 338, 366 low, 350 mechanics of axis-traction, 333 Mdne Murray's forceps, 337 Neville's forceps, 337 operation, ordinary, 349 ovum, 527 Pajot's manoeuvre, 334 pelvic application of, 348 perineal tears, prevention of, with forceps, 353. 646 position of patient, 346 preparations for operation, 345 Forceps, prognosis of, in contracted pelvis, 190, 195, 373 Tarnier's, 333 tr.ui ion, amount to be employed, 196, 339, 390 version contrast. -.1, 193 Walcher position in forceps delivery, 346, 371 Forces concerned in labour, 3, 5 dystocia due to faults in, 5 Fornix, rupture of, during labour (colpor- rhexis), 629 rupture in manual removal of ovum, 527 Fractures of fcetal bones ui utero, 667 of fcetal skull during labour, 667 of pelvis, 170 Fundus incision in Cesarean section, 411 Funic souffle with short cord, 145 Funis. See Umbilical cord Generally contracted pelvis (justo- minor pelvis), 155 mechanism of labour in, 33, 155 prognosis and treatment. See Con- tracted pelvis Glycerine, inducing labour by injection of, 452 Graves' disease in pregnancy, induction of labour for, 439 Grossesse extramembraneuse, 150 Habit of abortion, 520 Habitual death of fcetus, 441, 519 induction of labour for, 441 Htematocele, pelvic, 571 treatment of, 573 Hsematoma of broad ligament, in extra- uterine pregnancy, 541, 567 of sterno-mastoid muscle of new-born, 672 of vagina and vulva, 209 subperitoneal, 210, 598 Hematosalpinx (see Mole, tubal), 541 Haemorrhage, accidental (see Accidental haemorrhage), 594 of placenta prsevia (see Placenta previa), 577 in abortion, 520 intracranial (fcetus), 673 intraperitoneal in extra-uterine preg- nancy, 539 in rupture of uterus, 635 post-partum (see Post-partum haemor- rhage), 607 secondary post-partum, 615 transfusion in, 614 unavoidable (see Placenta previa), 577 vaginal, in extra-uterine pregnancy, 557 Hand disinfection, 307 fcetal, diagnosis of, 90-91 Head, after-coming. See After-coming head consistency of influencing labour, 187, 192 diameters, alterations, from compres- sion, 193, 341 696 OPERATIVE MIDWIFERY Read, foetal changes in shape of, in brow presentations, 15 in face presentations, :; 7 in oooipito posterior positi f vertex, 29 injuries to, during labour, 666 measuring fcBtal bead in utero, i vs size influencing labour, '.'7, 192 size relative to maternal pelvis, impor- tance of estimating, 187 Heart, diseases maternal, induction of labour for, 438 foetal, alterations in protracted labour, 4, 343. 682 auscultation of, 23 face presentation. -i7 in twin pregnancy, 24, 111 situation of maximum intensity in- dicating position of child, 24 Hebotomy (hebosteotomy), 398 Hegar's sign of pregnancy, "244 Herman's method of symphysiotomy, 392 Hermann's forceps, 335 Hernia of pregnant uterus, 288 High forceps (see Forceps, high), 354 Hook, blunt, 492 use of, for bringing down impacted breech, 81 Hour-glass contraction of uterus, 14 Hydatidiform mole, 532 benign, 534 destructive, 534 malignant, 534 pathology of, 533 relation of, to chorion-epithelioma, 533 rupture of uterus from, 536, 618 symptoms of, 535 treatment of, 536 Hydramnios, induction of labour for, 440 malpresentations resulting from, 86 Hydrocephalus, cause of dystocia, 99 cause of rupture of uterus, 102, 626 craniotomy in, 103, 479 diagnosis of, 100 presentations in, 100 prognosis, 102 spinal tapping, 104 treatment, 103 Hydrorrhcea gravidarum, diagnosis of, from rupture of membranes, 149 caused by grossesse cxtramembraneusc, 150 Hymen, atresia of, cause of dystocia, 207 Hyperemesis gravidarum, accouchement force in, 456 induction of labour in, 439 vaginal Ca-sarean section in, 475 Hypertrophy of cervix, cause of dystocia, 201 C'resarean section for, 201 Hypsiloid (dicephalous) monster, 127 Hysterectomy for accidental haemorrhage, 604 for carcinoma, 218 for myomata, 250 Hysterectomy, for rupture ol uterus, 641 supravaginal, after Cesarean section, 417 total, after • taeean an section, 128 ii. il. in i aroinoma ol oen ix, 219 in accidental hemorrhage, <>')\ Hysb Luse ol dystocia, 290 Icterus gravidarum, induction ol labour for, ill Incarceration of prolapsed gravid utei u of retroflexed gravid uterus, 270 Inclination of pelvis, vai iations ol Incomplete abortion, 522 Induction of abortion (see Abortion, induc- tion ol), 458 of prematun- labour (see Premature labour, induction of , 135 Inertia uteri (see Uterine inertia . Inevitable abortion, 527 Infant. See New-born child Infantile paralysis, effect upon pelvis, 175 pelvis. 155 Infundibuliun implantation of ovum on, ">42 Injuries to birth canal, 616 following forceps delivery, 195 to child in "'< ro, 667 during parturition, 667 Insufflation of lungs in asphyxia m torum, 684 Internal version, 318 Interstitial pregnancy, 543 Intracranial haemorrhage (foetal), 673 Intrauterine douche. See Douche Inversion of uterus, causes of, 655 hysterectomy for, 660 repositor for, 661 spontaneous reposition, 660 symptoms, diagnosis, and prognosis, 658 treatment. 659 Ischio-pubiotomy, 402 Isthmic, pregnancy in, 542 Jardine's decapitating hook, 502 .Jaundice of mother. See Icterus Johnson's method of measuring conjugata vera, 185 Joint, pubic, anatomy of, 381 Justo-major pelvis, 155 Justo-minor pelvis, 155 Kerr, method of estimating relative size of fcetal head and maternal pelvis, 188 Kidney, changes in, induction of labour for. See Albuminuria cystic, of fo lit\ cause of dystocia, 111 Knee presentation. See Breech presentation Knots of umbilical cord, 1 15 Krause's method of inducing labour, 1 19 Kyphotic pelvis, 171 symphysiotomy in, 173 Labium majus, oedema of, 204 Labour, anaesthesia during, 314 asepsis and antisepsis, 307, 311 INDEX (597 Labour, auxiliary forces of, 9 complicated. Sec Dystocia death during, GUI dry, 148 ergot during, 11 examination in, limiting of, 21 factors influencing, 3 Mat pelvis, 164 force exerted, 7 forces, 5 generally contracted pelvis, 155 haemorrhage during. See Haemorrhage in elderly primiparae, 203 obstructed. See Dystocia pains of. See Forces precipitate, 7 premature, induction of (see Induction of labour), 435 preparations of patient for, 311 of room, bed, etc., 303 prolonged, cause for interference, 12, 342 spinal anaesthesia, 315 third stage, management of, 508 uterine contractions. See Forces vaginal examination during, 21 Lambdoid (syncephalous) monster, 129 Langhan's layer of chorion in hydatidiform mole, 533 in chorion-epithelioma, 534 Laparotomy during pregnancy, safety of, 227 for extra-uterine pregnancy, 566 for nbro-myomata, 247 for ovarian tumours, 227 for rupture of uterus, 641 for retroflexed gravid uterus, 283 for suppurative conditions in pelvis, 261 preparation for, 304 Lateral curvature of spine (see Pelvis, scoliotic), 173 displacement of gravid uterus, 265 simulating extra-uterine pregnancy, 563 simulating fibro-myoma, 245 placenta pnevia, 579 position of patient in parturition (see Sims' position), 137 disadvantage in high forceps, 346, 347 Lead-poisoning, cause of abortion, 519 Leucocytosis in diagnosis of appendicitis, 263 Leukaemia, cause for induction of labour, 438 Levator ani, injuries to, during labour, 645 Life, prospect of, for foetus, 2, 404, 442, 457 Limitations, general remarks on, limitations of different operative procedures, 1 Lithoptedion, 565 Litzmann's obliquity, 164 contra- indication to forceps, 367, 368 Liver, acute yellow atrophy of, cause for induction of labour, 441 Lochiometra (retention of lochia), 288 Locked twins, 116 Loops in umbilical cord. See Umbilical cord Lower uterine segment, 620 injury of, in vaginal Cresarean section, 477 rupture of, 620 Malformations of fetus causing dystocia, '.'7 of uterus and vagina causing dystocia, 294 Manual dilatation of cervix, 459 removal of placenta, 508 Masculine pelvis, 156 Mauriceau's method of delivering the after- coming head, 72 Meconium, escape of, sign of fetus in danger, 4, 682 Membranes, adhesion to lower part of uterus cause of dystocia, 151, 204 bag of, resistance to bursting force, 148 fetal, premature rupture of, 148 retention of, 514 rupture of, method of inducing labour, 448 delayed rupture of, 150 premature rupture, 148 Meningocele cause of dystocia, 104 Menses, persistence of, in pregnancy, 297, 521, 557 Menstrual molimen during pregnancy, 518 Mercurial poisoning, cause of abortion, 519 Metreurynter in accidental haemorrhage, 603 in accouchement force, 461 in induction of labour, 450 in placenta praevia, 591 in prolapse of funis, 141 in rigidity of cervix, 203 method of inserting, 462 of Champetier de Ribes, 462 of Pomeroy, 462 rupture of, 462 rupture of uterus, 591 Metritis, cause of post-partum haemorrhage, 608 rupture of uterus, 619 Michaelis' rhomboid in contracted pelvis, 179 Miscarriage. See Abortion Missed abortion, 524 labour in extra- uterine pregnancy, 565 Mole, blood, carneous, fleshy, tuberose, 524 hydatidiform, 532 tubal, 541 Mollities ossium (see Osteomalacic pelvis), 167 Monsters, double, cause of dystocia, 122 Morning sickness in extra-uterine pregnancy, 558 Moulding of head, importance of, 366 Movements, foetal, excessive, sign of danger to child, 4, 682 Midler's method of estimating size of head and pelvis, 188 Multiple pregnancy, 113 complications, 117 course of labour in, 116 diagnosis of, 113 management of, 116 position of each child, 115 698 0PERAT1VK MlhWIl'KKY Myoma of uterus, Cesarean section in, 263 complicating labour and pregnancy, 285 puerperiam, 25 1 diagnosis of, 244 effect of, - :; "' treatment, 217 of vagina, 208 Myomectomy during pregnancy, 248 Myxoma chorti (see Hydatidiform moli jele's obliquity, 18 1 \ a< gele's pelvis, l~>7 Natural delivery, variations in, 1 Neck, tumours of, in foetus causing dystocia, 106 Nephritis, induction of labour for. 4:37. i 10 New-born child, accidents to the, 666 asphyxia neonatorum, 678 birth paralysis, »J72 bones, injuries to, 667 cephalo-bsematoma of, 666 cerebral hemorrhage. 673 convulsions, 67 , r > Duchenne's paralysis, 077 facial paralysis, 676 head of, injuries to, 666 muscles, injury to, 672 skull, fractures of, 667 indentations of, 668 Nuchal or dorsal displacement of arm, 48, 68 Obliquely contracted pelvis, 156 Obstructed labour. Sec Dystocia Occipito-posterior presentations, diagnosis of, 26 forceps in, 357 rectification of, 30 treatment of, 28 Gidema, acute, of cervix, 203 of fcetus, 98 of labium, 204 of lungs, cause of death, 663 Oligo-hydramnios, cause of amniotic bands, 142 Operations. See Particular operations limitations of, general remarks regard- ing. 1 Os externum, backward displacement of, 205 occlusion of, 204 Osteomalacia, pelvis, 167 deformities resulting from, 168 ovariotomy for, 169 pathology of, 168 Ovarian pregnancy, 545 tumours, Cesarean section in, 229 complicating labour and pregnancy, 222 the puerperium, 233 Ovariotomy during labour, 229 pregnancy, 227 for osteomalacia, 169 Ovum, Fiith tubal, 538 site of. in ectopic pregnancy, 537 trophoblast of, in ectopic pregnancy, 540 Oxytocic-, in criminal abortion, lor bringing on labour, 448 lor uterine inertia, 1 1 Pajot's manoeuvre, ; Palpation, abdominal importance 1 breech presentations, 50 brow presentations, 14 contraction ring in threatened rupture of titerus, 63 1 face presentation foetal heart-beat in (ace presentations, 8? occiput, indicating positii occipito-posterior position placenta in placenta previ 1 position an<( attitude, diagnosis of, by, 18 round ligaments in diagnosis < tion of placenta, 115 transverse presentations, 90 twins, 118 Paralysis, birth (Duchenne's), 877 facial, following forceps, 676 obstetrical (Duchenne's paralysis Parturition. See Labour Partus conduplicato corpore, 90 PawHkgrip, 18 Pelvic abscess, complicating labour, 260 lluor, importance of preserving, 646 Pelvigraph, 181 Pelvimeters, forms of, 180 Pelvimetry, by use of X rays. See Appendix and 181 external, 178 internal, 180 Pelvis, assimilation, 159 axis, variations of, Milne Murray's forceps for, 337 classification of deformities, 154 contracted. See Contracted pelvis coxalgic, 175 deformities, classification of, 154 etiology of, 154 frequency of, 153 development, arrestment of, cause of deformity, 154 diameters, alteration of, in tlat pelvis, 161 dislocation of femora, 176 double Xaegele (see Roberts), 158 dwarf, 156 etiology of deformities, ] 5 I exostosis of, 169 figure of eight, 162 Hat non-rachitic, 157 fiat rachitic, 160 fractures of, 170 funnel-shaped, 156 generally contracted, 155 rachitic, 160 enlarged, 155 infantile, 156 paralysis, cause of deformity, 175 joints of, injury of, after symphysio- tomy, 394 INDEX 099 Pelvis, justo-major, 155 justo-minor, 155 kyphoscoliotic, 173 kyphotic, 171 masculine, 156 measurements, alterations in contrac- tion, 178 movements of, in connexion with sym- physiotomy, 375 NTaegele's, 157 obliquely contracted (Xaegele), 157 obtecta, 174 ossification of, faults of, cause of de- formity, 161 osteomalacic, 167 outlet of, measurement of, 179 pseudo- osteomalacic, pseudo -malacos- teon, 167 reniform, 162 rachitic, 160 Roberts', 15S rostrate (see Osteomalacia), 168 scolio-rachitic, 163 scoliotic, 173 spinosa, 169 split, 159 spondylolisthetic, 174 transversely contracted, 158 trifoliate (see Osteomalacia), 168 tumours of, 169 Pendulous abdomen, cause of dystocia, 288 malposition of foetus, 86 rupture of uterus, 629 Perforators, cranial, 483, 484 Perineum, lacerations of, 645 central, 208 prevention of, 646 repair of, 650 rigidity of, 207 Pernicious anemia, cause for induction of labour, 438 vomiting of pregnancy (see Hyper- emesis gravidarum), 439 Pessary in treatment of retroflexed gravid uterus, 279 Miantom tumour of uterus, 244 Phlebitis following haemorrhage, 615 'lacenta, abnormalities of, 148 adherent, 508 battledore, 146 bipartita, 148 circular sinus, rupture of, 148, 581 diagnosis of position by palpation, 583 expression of, by Crede's method, 513 in extra-uterine pregnancy, 568 in multiple pregnancy, 116, 146 manual removal of, 509 mechanism of, separation of, 511 • edema of, 148 previa, 577 accouchement force in, 457, 592 Cesarean section in, 407, 593 central and complete, 579 clinical features, 581 developed from decidua reflexa, 579 Placenta previa, diagnosis of, 683 etiology of, 577 frequency of, 579 induction of labour for, 586 lateral, 579 marginal. 579 metreurynter in, 591 plugging in. 586 prognosis of, 584 symptoms of, 581 treatment of, 585 varieties, 579 version in, 588 premature separation of (see Accidental hemorrhage from short cord), 143 prolapse of, 577 removal of, 513 retention of, cause of haemorrhage, 610 site of, as shown by Cesarean sections, 412 succenturiata, 148, 516 velamentous, 146 vessels of, abnormalities of, 146 Placental forceps, 528 polypus, 521 Plugging. See Tampon Plural pregnancy. See Multiple pregnancy Podalic version, 318 dangers in impacted shoulder, 96, 323 foot to seize, 320 position of patient, 318 technique of, 318 Pomeroy's metreurynter, 462 Porro's operation, 417 Position of foetus, diagnosis by palpation, 17 Post-mortem Cesarean section, 433 Post-partum hemorrhage, 607 diagnosis of, 608 etiology of, 607, 608 primary, 607 secondary, 615 treatment of, 609 Postural treatment of malposition, 94, 329 Prague method of delivering after-coming head, 78 Precipitate labour, 7 Pregnancy, abdominal, primary. 547 accidents during. See Abortion, Acci- dental haemorrhage, Rupture of uterus examination, preliminary, during, 23, 177 extra-uterine (see Extrauterine preg- nancy), 537 multiple (see Multiple pregnancy), 113 ovarian, 545 protracted, danger to child from, 152. 441 induction of labour for, 442 signs of, 152 rudimentary horn, 296, 574 rupture of uterus during, 616 surgical operations during, 199, 213, 221, 234] 256, 261 tubal. See Extra-uterine pregnancy -<>(> OPERATIVE MIDWIFERY I ' t < • I u ■ 1 1 s. u r - K- v i i- r - r 1 1 < • 1 1 n 1 1 1 .i i < 1 1 1 of Faraboeuf, 372 Premature labour, indications for Lndui for carcinoma oi cen i\. 2] 3 fur ohorea, 139 foi contracted pelvis, 1 12 foetal prognosis in, i IS indications for, 142 Limitations, 1 16 maternal prognosis, I 12 methods, 4 18 for excessive size of child, 1 12 fur habitual death of fotus, 441 for heart disease, 438 for hydramnios, 1 10 for hyperemesis gravidarum, 439 for icterus gravidarum, 441 for nephritis, 437, 438 for pernicious ana-niia, 13.* for placenta prsevia, 586 for protraction of pregnancy, 441 methods of, 448 Premature rupture of membranes, 148 separation of placenta (see Accidental haemorrhage), 594 Preparations for operations (patient, accou- cheur, etc.), 303 Presentation : breech, knee, foot, 50 brow, 43 definition of, 15 diagnosis of, by palpation, 15 ear, diagnosis of position from, 23 face, 35 fontanelle, anterior and posterior, 32, 33 funic, 132 occipito-posterior, 26 oblique, shoulder, transverse, 86 parietal, anterior and posterior, 33, 164 Frolapse of gravid uterus, 289 of placenta, 577 of umbilical cord, 132 Promontory, false, 163 injury to, in craniotomy, 486 Protracted labour, forceps in, 342 pregnancy, induction of labour, 441 Pseudo-osteomalacic pelvis, 167 Pubiotomy, 398 Puerperium, appendicitis, 263 myomatous tumours in, 254 ovarian tumours in, 233 salpingitis, 261 Pulmonary embolism, 661 Quinine as an oxytocic, 11 Rachitic pelvis, 160 diagnosis of, 177 mode of production of pelvic deformity in, 160 treatment of labour in, 1S9 varieties of, 160 Rectum, carcinoma of, complicating preg- nancy and labour, 257 simple tumours of, 257 Repositor for inverted uterus, 661 foi prolapsed umbilical cord, 1 10 Reposition ol prolapsed arm in tram presentations, S23 funis, 137 limbs in head presentation Respiration, artificial, ol child, 682 R< tained Lochia, 28 - membranes, •". 1 1 placenta, 508 removal of, "'1 1 Retinil is. albuminuric, 438 Retraction ring. See Bandl'e ring Retroflexion, cause of abortion, 518 of bicornuate uterus, 299 of gravid uterus, 265 diagnosis of, 275 differential, from extra-uterine preguancy, -7 7 J featun-s and progress, 270 laparotomy for, 283 treatment. 278 varieties of, 268 Retroplacental luematoina, 511 Rhomboid ofMichaelis, 179 Rigidity of cervix, 201 treatment of, 203 varieties of, 201 of perineum, 207, 646 Roberts' pelvis, 158 Roentgen ray in determining size of pelvis. See Appendix Rotation with forceps in mento-posterior positions, 43, 360 in oceipito. posterior positions, 32, 357 Round ligaments, indicating position of placenta, 415 Rubber gloves, use of, 310 Rubber instruments and gloves, steriliza- tion of, 305 Rudimentary horn, pregnancy in, 295, 574 Rupture of cervix, 643 of perineum, 645 of symphysis pubis, 654 of tube in extra-uterine pregnancy, 539 of umbilical cord, 143 of uterus, 616 diagnosis of, 629 during pregnancy, 616 etiology of, 617 early in labour, 627 in contracted pelvis, 622 in infantile uterus, 617 in hydatidiform mole, 534 in hydrocephalus, 626 in neglected transverse presenta- tions, 623 in protracted labour, 619 in pregnancy in bicornuate uterus, 301, 617 in removing placenta, 626 in scar of Cesarean section wound, 616 plugging in, 640, 643 INDEX 701 Rupture of uterus, prognosis, 637 prophylaxis, lilis repeated, 617 spontaneous, 617, 627 symptoms of, 629 threatened rupture, 633 treatment of, 638 varieties of, 628 Sacculation of uterus, 269 Sacro-iliac synchondrosis, injury in symphy- siotomy, 394 Sacrum, tumour of foetal, cause of dystocia, 112 Saline transfusion (see Transfusion), 614 Salpingitis, diagnosis from extra-uterine pregnancy, 560 in puerperium, 261 Sehafer's pelotte, 7 Schatz'a tokodynamometer, 6 School's method of inducing labour, 448 Schultze's method of separation and extru- sion of placenta, 511 method of rcsussitation, 684 Scolio-rachitic pelvis, 163 Scoliotic pelvis, 173 Secondary post-partum haemorrhage, 615 uterine inertia, 9, 608 Septum, vaginal, cause of dystocia, 298 Shoulder presentation (see Transverse pre- sentation), 86 diagnosis of, 90 large shoulder girdle, cause of dystocia, 106 cause of rupture of perineum, 649 Simpson's basilyst, 494 cephalotribe, 493 forceps, 336 perforator, 483, 4S4 Sims' position, 137 advantage in impacted breech, 84 in difficult version, 319 in replacing umbilical cord, 137 Skull, ftetal, injuries (see jSTew-born child), 666 Skutsch's pelvimeter, 182 Srnellie's scissors perforator, 483 Souffle, funic, 23, 145 uterine, 23 Sphincter ani, laceration of, 645 repair of, 653 vaginae, importance of preserving, 650 Spinal anaesthesia, 315 Spinal tapping in hydrocephalus, 104 Split pelvis, 159 Spondylolisthetic pelvis, 174 Spondylotomy, 505 Sponges, preparation of, 305 Spontaneous delivery in contracted pelvis, 191 evolution, 88 rupture of uterus, 617, 627 version, 88 Spurious labour in extra-uterine pregnancy, 565 Sterilization of hands, instruments, etc., -;'>l of patient after Cresarean Bection, 127 Sterno-mastoid, baematoma of, in new-born, 672 Streptococcus in vagina of pregnant, 312 Stovaine for spinal anaesthesia, 315 Subinvolution of uterus from retention of membranes, 516 Succenturiate placenta, 148, 516 Sudden death during labour, 661 Suppurative conditions in pelvis and abdo- men, complicating pregnancy and labour, 260 Sutures, method of sterilizing, 306 Symphysiotomy, after-treatment, 390 anatomy of parts concerned in, 381 forceps and relative position of, 193, 367, 378, 379 history of, 374 Cesarean section contrasted, 379, 404 dangers and injuries resulting from, 394 drainage after, 390 delivery after, 388 enlargement of pelvis, 376 permanent, 397 general considerations regarding, 375 in face and brow presentations, 46, 375 in kyphotic pelvis, 173 indications for, 377 pelvic measurements, effect on, 375 prognosis of, 393 puliiotomy contrasted, 400 repeated, 396 results, 391 subcutaneous, 391 technique of, 384 Symphysis pubis, rupture of, in labour, 654 Syncephalous monster, 129 Synchondrosis, sacro iliac, injury to, by symphysiotomy, 394 Synclitism, 164 Syphilis, cause of aboition, 518 Tampon in abortion, 528 accidentil haemorrhage, 601 in placenta pi\evia, 586 in post-partum hemorrhage, 611 in rupture of uterus, 640, 643 Tamier's basiotribe, 493 ecarteur uterin, 466 forceps, 333 Tetanic contraction of uterus, 13 prior to rupture, 633 Third stage of labour, physiology of, 511 Thoracopagous monster, 123 Threatened abortion, 521, 526 Thrombosis after haemorrhage, 615 Thyroid, tumours of, cause of dystocia, 107 Tokodynamometer, 6 Transfusion of salt solution in eclampsia, 407, 457 for haemorrhage, 613 intracellular, 614 rectal, til 1 venous, 61-1 702 OPERATIVE MIDWIFE m Transverse presentations, dystocia in, 86 oephalio version in, 94 course ol labour in, s 7 decapitation in, 96, ! diagnosis of, '• ii| impacted, 96 poualic version in, 95 rupture of uterus in, <'■- treatment of, 98 Transversely itraeted pelvis, 158 Trephining akull for intracranial hemor- rhage, indentations of skull, 671, 072, 673, 675 Tubal abortion, 538 pregnancy (sec Extra -uterine preg- nancy), 537 Tuberose mole, 52 1 Tumours, abdominal, diagnosis of, in preg- nancy, '224, 244 - of bladder, complicating pregnancy and labour, 256 of fcetus, 98, 104, 106, 107, 109, 110 of ovary, 222 of pelvis, 169 of rectum, 257 of uterus, 235 of vagina, 20S Turning (see Version), 316 Twin pregnancy (see Multiple pregnancy), 113 Twins, locked, 117 Umbilical cord, causing dystocia, 132 abnormalities of, 145 coils of, about neck and body of child, 143 knots of, 146 long, 145 loops of, about neck and body, 1 13 marginal insertion of, 146 prolapse of, 132 reposition of, 137, 139 rupture of, 143 short, cause of dystocia, 141, 657 treatment of, 145 shortness of, cause of inversion of uterus, 657 souffle in short cord, 145 strangulation of, bv amniotic adhesions, 143 torsion of, 145 variations in insertion of, 146 in length of, 145 velamentous, insertion of, 146 Unavoidable haemorrhage (see Placenta previa), 577 Urine. See Dysuria Uterine inertia, 8 cause of post-partum haemorrhage, 608 diagnosis of, 10 reason for interfering, 12, 342 treatment of, 10 souffle, auscultation of, 23 Uterus, anteflexion of, cause of dystocia, 287. 290 Uterus, atony o if posl partum Demon h bioornis, 297, 800 bipartite, 297 carcinoma of, 21 1 cordiformis, 297 causing transverse presentation, - resembling rapture of uterus, I contractions, irregular, 9, 1 1 displacements of, 265 double complication- of. 2'.'- diagnosis of, 300 rupture of, 300 treat ment, 802 varieties, 296 with rudimentary horn, 294, 57 l didelphys, 297, 298 hour-glass contractions of, 14 incarceration of retroflexed, 270 inertia, cause of dystocia, 3, 8 inversion of, 655 lateral displacements of, 215. 265, malformations of, 294 myoma of, 234 perforation of, 530, 536 prolapse of, 289 retroflexion of, 265 retroversion of, 208 rupture of, 616 sacculation of, 269, 279 septus, 296, 298 subseptus, 296 tumours of, complicating pregnancy, 235 unicornis, 296 Vagina, atresia of, 206 bands and cicatrices, 206 diaphragm in, 207 double, 298 fornix, laceration of, 527, 62!) hematoma of, 209 laceration of, during labour, 652 malformation of, 298 septa in, 207, 298 sphincter, preservation of, 650 stenosis of, 206 tumours of, 208 Vaginal Cesarean section, 470 douche, 312 drainage, 573 examination during pregnaucy, limita- tion of, 21 fixation, cause of dystocia, 290 hysterectomy for carcinoma of cervix, 219 in accidental haemorrhage, 604 septum, cause of dystocia, 207. 2 18 ' Vagitus uterinus,' 682 Velamentous insertion of cord, 146 Venous transfusion, 614 Veutro-nxation, cause of dystocia, 292 Version, 316 after symphysiotomy, 389 bipolar. 329 in plaeenti previa, 588 INDEX 703 Version, Braxton Hicks (see Bipolar version), 329 cephalic, 85, 316, 326 dangers of, in impacted shoulder presen- tation, 96, 325, 501 external, 325 history of, 316 indications for, 317 in breech presentation during preg- nancy, 85 in brow presentations, 45 in contracted pelvis, 193 in face presentation, 38 in posterior parietal presentation, 193 in transverse presentations, 93 indications for, 317 podalic (see Podalic version), 318 spontaneous, 88 Vertex presentations, abnormalities of, c uising dystocia, 26 Vesical calculus complicating labour, 256 Vesicular mole, 532 Vestibular bulbs, injury to, in symyliysio- tomy, 383 Vestibule, laceration of, 384, 608 Vomiting, excessive, of pregnancy. See Eyperemesis gravidarum Vulva, abscess of Bartholin's gland, 209, 260 hematoma of, 20'.' injuries of, during labour, 607, 645 oidema of, 204 tumours of, 208 Walcher's position, 156, 199, 370 association with forceps, 371 symphysiotomy, 389 X rays in determining size of pelvis. See Appendix Zweifel's pelvimeter, 184 symphysiotomy, method of performing, 38S, 393 THE END BAILLIERE, TINDALL AND COX, 8, HENRIETTA STREET, COVENT GARDEN DATE DUE *,*»" — 1 ti.bR 'i II m X*.r%\ v A 1007 j.v - 5 urn APR I ** {IV zhi J tf .- : ■■ r ' ^# Demco. Inc. 38-293 COLUMBIA UNIVERSITY LIBRARIES 0043058094 Kerr Operative midwifery. RG725 Kk6 1911