Among the conditions and accidents which have been noted as retarding labor, impeding delivery, or otherwise presenting indications for the use of forceps, have been the following, in relative order of frequency of occurrence. It must be noted that several of these impediments have not seldom coexisted.

1st. Shortness of Funis.-Of this are noted 27 cases. This may have been absolute or accidental, by reason of circumvolutions about the child's neck or body. The shortest noted among these cases was but 10 inches in length, an exceedingly tedious, difficult and painful labor (No. 112 of table). The child was delivered safely, mother a primipara. There was another one of 12 inches, another of 14 and there were several cases of cords of 16 to 17 inches. One of 16 inches has been noted above in an eclampsic primipara in which the cord parted at the child's belly.

2d. Uterine Inertia in Second Stage.-Seventeen cases noted. In these cases, the os has become fully dilated, nothing requisite to complete the labor but continued uterine activity, when this has suddenly or sometimes gradually slackened and weakened and all advance stopped.

In one case under the care of an irregular, to which I was summoned, this condition was either caused by, or simply coincident with fainting fits (No. 52. In two cases, primiparæ, the women went into eclampsia at this stage, Nos. 146 and 170. The children of all three of the above born alive and well. One of the mothers (146) died afterwards of peritonitis. This condition has been observed as repeated in the same patient in subsequent labors. Nos. 30 and 43 are cases of this kind in the same woman, first and second labors, also 182 and 189 in same woman in first and second labors. It has also been observed as recurring in others.

The coincidence of this accident, inertia, with impeded and retarded labor by reason of brevity of the funis has been too common to be accidental, and I have

at times been enabled to foretell that I should find a short funis, or one with circumvolutions about the child from the course of the labor and the character of the pains. The cause can be readily understood, as I have shown in a paper before the State Medical Society on "Shortness of the Funis," as a cause of accidents and of retarded labor. The placenta being attached to a large portion of the surface covering the expulsive uterine fibres; for the attachment must be about the fundus to create a shortness; then the expulsive contraction of this large portion is neutralized by the dragging on the cord during pains, and not only this, but this portion of the uterus is placed between two forces, the expulsive force and the dragging force, which cause not only impeded labor, but very painful, tearing contractions; and this tearing, dragging feeling will often be located by the patient.

3d. Prolapse of the Funis.-Six cases of this noted. As brevity of the funis has been a frequent cause of indications for forceps, for the mother's sake, so prolapse of the funis, which can only happen from absolute or relative excess of length by reason of low-down attachment of placenta, has been an occasional indication for its use for the child's sake. Three of the children were still-born and three living. Of the still-born, all three cases were under care of others till a late stage, two of the three (Nos. 104 and 120) were lost by delay in sending for aid, and one (No. 124) in a case of eclampsia. The three living were delivered by reducing the cord in gunu-pectoral position of mother, then replacing woman on her back and delivering with forceps. Nos. 56 and 62 were in same woman in successive labors, seventh and eighth.

Face and Brow Presentation.-There were seven of these, three of brow and four of face. Two, both of face, were still-born. One was seen at a very late stage at a distance in the country, and after the forceps had been unsuccessfully applied by another physician and a skillful man. Two of the brow presentations were successive labors, her 14th and 15th, in same woman, who had passed through her thirteen previous labors under the care of women.

The three cases of brow presentation occurred in the practice of others, and to which I was summoned. I have never come across a case of the kind in my own practice, and the accident is regarded as rare. The January, 1886, number of the American Journal of the Medical Sciences speaks of Dr. E. Blanc, who studies and analyzes an interesting work by M. Devurs on delivery in brow presentation. He says, "Cases of brow presentations do not seem to be very common. Heinrich in the Maternity of Elsingfers, found only twelve instances out of 5,000 confinements; Mangragulli, during a period of five years, collected 64 cases, 17 of which occurred at the Maternity of Milan. Devurs examining the results of the Clinique d' Accouchement at Lyons

for the last five years, found five cases in 1,402 labors. Mr. Devurs says the prognosis is serious for both mother and child, but especially for the latter. He puts the extent of mortality at nearly 50 per cent., other authors make it only 20 or 24 in the 100. In nine cases recorded by M. Devurs, delivery occurred spontaneously in three, and in six forceps were used; in the three cases the mothers and the children died, while in the six only one infant succumbed. This reference is made because of the facts that of the three cases occurring under my observation, there were no difficulties of diagnosis or of delivery by the forceps, and no serious or unfortunate results to mother or child in any of them.

Prolonged Gestation and Large Children.-No. 60.— This, her sixth labor, June 29th, 1869, gives the following history. All her previous labors natural and easy. Last menstrual flow eleven months since. Has felt motion since January 1st, six months. Has a very large and pendulous belly. Indication of labor five weeks ago, at which time she expected it and has had pains every day since then. Child noted as very large, but weight not stated.

No. 185, 5th labor.-Attended by myself in each of her previous confinements, which were natural and easy. Expected to be confined six weeks ago, and has been awaiting it every day since. Labor unusually tedious notwithstanding regular and forcible contractions. Terminated by forceps delivery of a boy of 11 pounds.

Of other births of large children necessitating artificial aid by the forceps were the following:

the indications for terminating the labor as speedily as possible by forceps under chloroform.

Forceps to After-coming Head.-There were five cases: No. 118, 10th labor, breech presenting in sacropubic position, child dead; No. 150, 2d labor, hip and head presenting, version, child dead; No. 159, 9th labor, feet presenting, version, child dead; No. 176, 13th labor, arm and funis presenting, version, child living; No. 179, 7th labor, breech, eclampisa in 2d stage, child's weight 12 pounds, child living.

Miscellaneous Observations.-The youngest mother was 15 years old. Several were at the age of 16. The oldest case was 46. The oldest primipara was 43. She bore her second and last at 45.

Sex of Children.-Males have markedly exceeded in numbers. There were 111 males to 65 females, 10 cases being unnoted as to sex, or 59 per cent. males, to 35 per cent. females.

Ruptured Perineum.-Ten cases are noted of this accident. In the last three immediate stitching was done with good results.

Previous Histories of Labor.-No. 99, 7th labor, German, gives history of six difficult previous labors in Germany, in one of which she says the child was taken to pieces-probably craniotomy. No. 143, 3d labor, gives history of two previous labors in Germany, one by forceps, and the other a case of placenta prævia. Both children dead. No. 111, 3d labor, gives a history of two previous labors, 1st natural, child still-born; 2d by embryotomy. She was delivered successfully of a living child, and again subsequently (165) by myself.

Ergot. This was administered in 44 of these cases. It was almost invariably given in divided doses until ergotic contractions were produced, or at least until a reviving of the flagging pains was effected. It was only given by myself, at least, after full dilatation of os and when there was a distinctive inertia, and although it was disappointing in respect of failing to accomplish delivery as appears from the fact of the subsequent use of forceps, yet neither has it in this experience or in all my experience with it, merited that disfavor with which many writers regard it by reason of the injurious and dangerous effects upon the child of the tonic contractions produced by it. In only three of the cases in which it was administered was the child lost, and in each of these cases there were much more reasonable and probable causes of the death. These were No. 17, the first case of craniotomy, No. 36, in which there was prolonged delay in sending for aid at a distance in the country, and No. 96, a most difficult delivery of a face presentation of a large child in one of the smallest of women.

But

There were numbers of these women whose parturient histories are of interest and worthy of note. the paper has already so extended itself beyond anticipated limits, that I shall make but brief reference to only a few.

This

No. 11, 25, 29. Delivered in first five labors by forceps. First child only born living, and has survived; 2d and 3d under my care, both still-born; 4th and 5th by forceps, under care of another physician; same result. The labors all having been very difficult, the fatality was attributed to that fact, and she was persuaded to have induction of labor at from seven to eight months. course was persued in four successive pregnancies by me, by puncturing the membranes, with result of easy and speedy deliveries and quick recoveries, without drawback, but with the survival of the infant for only a few hours, one of which is noted as hydrocephalic. The parents were apparently healthy, but the woman small. Some pathological developments of the husband, of late years, have led me to suspect the cause of the fatality to the infants to be of specific nature.

Nos. 81, 94, 106, 122, 131, 142, 159, 179, all in same woman, eight successive and successful forceps deliveries in one woman, who was, after the first, always anxious and impatient for their application before the os was prepared, or I was so disposed. First four labors in Germany by nature's efforts alone and all still-born.

No. 164. This patient is the subject of twenty conceptions within a period of twenty-one years, bearing six children at term, and having had fourteen abortions, all attended with dangerous flooding, but one, a miscarriage at seven months, the others from third to fifth month. Her forceps delivery, and only instrumental one, was her nineteenth pregnancy and her fifth living child. The cause of the difficulty was a funis of but fourteen inches. There has been since, a living child at term, unaided, though the head and a hand came together. The cause of frequent abortions in this case, I have no doubt, from circumstances connected with the husband, is specific, but the notable feature is the fact of the subject giving birth to living and healthy children at intervals throughout the child-bearing period, followed and preceded by frequent abortions. The first and last to date were at full term, the other living children at varying intervals between abortions. The cause of her liability to abortion, as I have said, I believe to be specific, and these recurring, established what has been called the abortive habit, a term which, like many another in medicine, is simply expressive of medical agnosticism, and gives no explanation of causes. The cause of the establishment of the abortive habit is in the fact that repeated abortions, especially if speedily recurring, leave the uterus in a continuously subinvoluted condition, that is, enlarged, with unusual weight, patulous, and with relaxed ligaments. This condition leads to flexions and malpositions which obstruct circulation and creates irritation by pressure, and thereby promotes intolerance of contents. This patulous condition also leads to mal-attachment of the ovum to the uterine walls on its emergence from the fallopian tube; falling down by gravity, or carried down by secretions, it forms its attachment at a lower portion of the walls, and

the mal-attachment becomes a further predisposing cause, as we see in placenta prævia, however caused. The gradual development and expansion of the neck gives rise to slight separation with effusion of a small amount of blood. This acts as a further irritant and excitant of uterine contractions for its expulsion, and becomes, thereby, a further exciting cause. This patulous condition of the uterus, after frequent abortions, also aids ready conception, and thereby conception and abortion, abortion and conception follow each other in some women, with the regularity and frequency of the

seasons.

In conclusion, if, perchance, by the use of the forceps, an occasional child has been lost by excessive and too speedy compression of the head, or from other cause, that might otherwise have been born living; or one died after its birth from such cause, which might have otherwise survived; no such case is positively known, and on the other hand, that numbers of children have been saved which would otherwise have been lost, we have only to look over the histories of the cases, and previous parturitions in numbers of the women, to positively show. The saving of suffering to the mothers has been incomputable, and if rarely a perineum has been torn, not more than is known to have occurred, nor as many, as in the unaided labors in the practice of others; and no known case of vesico- or recto-vaginal fistula has occurred, and the mortality to children and mothers has been proportionately less than in unaided difficult labors with serious complications.

T IS WELL, I think, to consider occasionally the complications we are likely to meet with in the practice of midwifery. One of the worst, if not the very worst, of these complications is placenta prævia. Although it is of rare occurrence, when it does occur there is no other complication that requires more attention and prompt action on the part of the physician. Unavoidable hemorrhage always attends it, and is profuse in proportion to the implantation of the placenta around the os uteri.f

It is the severe and often sudden hemorrhage that makes this condition dangerous to the mother and child -especially the latter. The hemorrhage is unavoidable because the placenta is attached to that part of the uterus that expands during the first stage of labor. Consequent to this expansion the placenta is separated and stretched allowing the mouths of the blood-vessels to remain open and thereby permitting a free escape of blood.

The hemorrhage in placenta prævia may occur at any time during the pregnancy. Anything that occurs to disturb the normal position of the uterus is likely to start the flow of blood by disturbing the relation of the abnormally attached placenta. It is during the ninth month, however, that hemorrhage is most likely to occur. Nor does the danger cease here, for in these cases post | bartum hemorrhage may occur; this is due to the generally relaxed condition of the uterus. This relaxed condition is the source of another danger; it may allow the lochia to accumulate in the uterus, become decomposed and cause septic poisoning, or, by absorption into the circulation, pyæmia.

In the earlier months it is not at all unlikely that it

*Read before Detroit Academy of Medicine. +Churchill, Theory and Practice of Midwifery, p. 383.

is often the cause of abortion, the location of the placenta in these cases not being recognized.

The mortality in placenta prævia is very great. Muller* states that one mother in four dies during or shortly after labor. Including other puerperal disorders following this condition, he places the percentage of deaths at from thirty-six to forty. The mortality of the children born under these conditions is about sixty-six per cent. One-half of those that live die afterwards, making, according to this author, nearly eighty-five per cent. of deaths.

Fortunately, placenta prævia does not often occur. Muller found 813 cases in 876,422 births-nearly one case in one thousand. This is a somewhat higher percentage than some other authors give, still it is about the average.

Schwartz reports 332 cases of placenta prævia in 519,328 births, or 1 in 1564.

In the upper Rhei district, placenta prævia occurred 62 times in 52,792 births-1 in 852 cases. The average then, in these cases, would be nearly 1 in 1,000.

Beumer and Piepert give a very high percentage. In 2,517 births they report 15 cases of placenta prævia1 in 167 births. Of these 11 were placenta prævia lateralis, and 4 placenta prævia centralis. Of the 15 mothers eight survived and seven died-forty-six and one-half per cent. Of the 15 children, 10 died before, during, or soon after birth, and 5 lived.

Hospital and city cases result more favorably than those in country practice, where assistance generally arrives too late.

The mortality may, in general, be reckoned at thirty per cent. for the mothers.

Nægele and Grenser give twenty-one per cent.; Simpson twenty-seven and one-half per cent.; Burnes nine per cent.; Speigelberg sixteen per cent.; Schwartz twenty-five per cent.; and Churchill thirty-five per cent.

One fatal complication for the effectiveness of the pains in placenta prævia is the comparatively frequent abnormal position of the foetus. For, although head presentations considerably predominate, oblique positions. are frequent.

According to observations made at the Berlin clinic,§ there are about eighty-five per cent. of head, four per cent. of pelvis, and eleven per cent. of transverse presentations.

A great deal depends upon the good judgment and intelligence of the physician in charge. In country practice the danger lies in the sudden hæmorrhage that may occur; in city practice this is offset by the danger of septic infection. Where there is early hæmorrhage the chances of life for the child are very small, therefore the

* Lusk's Midwifery, p. 556.

+ Spiegelberg Geburtshülfe, 2d edition, 1882, p. 365. Arch. f. Gyn., vol. 23, p. 458.

§ Martin Operdio Geburtshülfe.