insufficiency of the expelling forces, and if their power cannot in a sufficiently short time be increased to the necessary degree the forces of nature must be replaced by others.

We have therefore only to consider the first two sections in the general obstetrical therapeutics.

When the expelling forces are too feeble, the most perfect treatment is to increase their activity, for which purpose there are external and internal remedies. If these do not succeed in strengthening the pains the necessary force is to be obtained from one or more other sources.

The effect of the pains consists in (1) dilating the soft parturient passages, (2) expelling the foetus, and (3) expelling the afterbirth. There is only one way of replacing the triple effect of the pains, namely, pressure applied to the fundus uteri, the so-called "method of pressure." (By means of the Cæsarean section, by which a new parturient canal is opened, the foetus and afterbirth are artificially extracted, and thus the expelling forces replaced in their triple effect). Pressure acts very uncertainly and slowly on the dilatation of the soft parts, somewhat better on the progress of the child, but with great certainty on the expulsion of the afterbirth. If this method is inapplicable, or what is more frequently the case insufficient, each individual effect of the expelling forces must be replaced by a definite operation with a view to that end. If the pains are unable to dilate the soft parts, artificial, manual, or instrumental dilatation of the os uteri is to be practised.. If the pains are insufficient to expel the fœtus, the wanting or insufficient vis à tergo is to be replaced by traction applied to the presenting part of the foetuswhen the head presents traction is, as a rule, made by means of the forceps (exceptionally also when the pains are weak, after the head has been perforated for other reasons, by means of the cephalotribe)-when the breech presents traction is made by means of the bent finger or the blunt hook-when one or both feet present traction is made on them. In some cases, especially when the head is high up and movable, the forceps cannot be used. Since no suitable traction can be applied to the head in any other way, another operation, turning by the feet, is to be performed. This is therefore done in order to extract by the feet. The third effect of the expelling forces, the expulsion of the afterbirth, can be replaced by artificial removal with the hand.

All these measures have already been said to be applicable, not only when the pains are absolutely feeble, and consequently the delivery too much delayed, but also when the pains are normal and accidents occur which, threatening the life of the mother or that of the child, urgently demand the rapid termination of labour. Treatment is then instituted, not because the pains are abnormal, but because they are insufficient to terminate labour with the rapidity desirable in the special case.

We shall now consider the measures to be employed when the obstacles are too great, and shall begin with those caused by the maternal passages.

If the obstacle is caused by the soft parts we shall have to employ the same means as when the pains are not strong enough to dilate the normally constituted soft parts. In this case the soft parts only

are altered, manual dilatation is as a rule useless, and it must be performed by means of instruments.

If the dystocia is due to too great narrowness of the hard passages their dilatation would be the most plausible treatment. This, of course, cannot be done without an operation, or only in very far advanced stages of osteomalacic softening of the pelvis, at the stage of the disease when the bony parts have just ceased to be hard. The contracted pelvic outlet may also be dilated in consequence of too great mobility of the pelvic joints; this has been observed in the case of a kyphotic, funnel-shaped, contracted pelvis. Independently of these extremely rare cases, attempts have been made to dilate the pelvis by dividing the joint of the symphysis pubis. This operation, however, though based on perfectly correct principles, has been entirely abandoned, because the dilatation of the pelvis by symphysiotomy is only very inconsiderable, and attended by great dangers and serious consequences to the

mother.

Thus, the bony pelvis cannot be sufficiently dilated without doing serious harm. It is therefore necessary to lessen the disproportion between the pelvis and the head by diminishing the size of the latter. The methods by which we endeavour to attain this object are principally determined by this fact-whether the life of the child can possibly be saved or whether it must be sacrificed. It is evident that the first method, if applicable, is to be preferred.

The diminution of the size of the child's head is usually accomplished by the strong pains gradually forcing the head through the narrow parts of the pelvis. We may try to produce this effect in cases of feeble pains by an artificial increase of the uterine action; this, however, rarely succeeds to a sufficient degree. Unfortunately, the natural process can only be imitated in extremely rare cases. The forceps certainly compresses the head of the child in that diameter in which it has been applied, and the compression is to a certain degree without harm to the child. One circumstance, however, is adverse to the general application of the forceps for this purpose. In the immense majority of contracted pelves it is the conjugate diameter of the inlet which is shortened, and the forceps can only be applied at the inlet in the transverse diameter. It is therefore inapplicable for the compression of the head contained in the conjugate diameter. In very rare instances, where, with sufficient length of the conjugate, the transverse diameters of the pelvis are too small, the forceps may occasionally be applied successfully, and without risk, to compress the head in that direction. Those cases are, however, extremely rare, and there are usually no means of compressing the head in its diameter corresponding to the conjugate.

Another mode of treatment has been proposed to avoid the disproportion. It is to prevent the head of the child acquiring its usual size by putting the mother on a debilitating diet. This plan is now abandoned, since we are fully persuaded that the desired object is not attained by it, and that the mother is debilitated in the highest degree at the time of her delivery.

The interruption of pregnancy at a time when the head has not yet attained its usual size and the child is viable, the induction of

premature labour, is based upon sound principles, and is therefore often and usefully applied in contractions of the parturient passages.

This last-mentioned measure is only prophylactic, and is no longer applicable when the physician is called to a parturient woman. Here all hope of saving the child has to be given up, and perforation is the only means by which the head of the child can be diminished. Ordinarily this operation will be resorted to when the child is already dead. In some cases cephalotripsy may be practised for that purpose even in a pelvis with a contracted conjugate diameter. For when this instrument has been applied in the transverse diameter and screwed up, it may be, owing to its small pelvic curve and its smaller size than the forceps, so turned that it, together with the compressed head, comes to lie within the contracted conjugate diameter. More frequently cephalotripsy is practised when, after previous perforation, the pains are insufficient to expel the head.

The obstacles opposed to the passage of the child may be so great that delivery per vias naturales is quite or at best almost impossible. A new way has to be opened up for the delivery of the child by dividing the abdominal walls and the uterus-the Cæsarean section.

The soft parts, too, when the pains are very slight, may also greatly impede labour. If by this the life of the child is brought into imminent danger, as long as the mother is alive the Cæsarean section will not be practised, because the operation is very dangerous to the mother and can rarely be performed in so short a time as to save the life of the child, which is already threatened. Matters are,

however, quite different when, after the death of the woman, no special regard need be paid her, and even then it is an exception that the life of the child is saved. We have already spoken above of performing the Cæsarean section on the dead.

Far more frequently the Cæsarean section is practised in cases of greatly contracted pelvis. It must be practised when the child can neither alive nor in pieces be delivered per vias naturales. If the accoucheur is fully convinced that the still living child cannot pass through the pelvis without fatal injuries, the Cæsarean section may be performed to save mother and child.

Anomalies of the ovum, and especially of the foetus, whilst the maternal passages themselves are perfectly normal, may also be the causes of considerable obstacle to delivery.

Those special manipulations required in certain anomalies of the fœtus or its appendages, and the treatment in diseases, malformations, faulty positions as prolapse of extremities of the fœtus, and the artificial rupture of the membranes, will be considered in the special pathology of parturition.

We shall here only mention the way in which we may help in faulty position of the foetus. Since, as a rule, the foetus can only pass through the pelvis when the cephalic or pelvic extremity presents, all deviations of those parts from the inlet, as well as complete transverse positions, require our aid unless nature herself rectifies the position.

It is evident that as long as it is possible to correct a position we must endeavour to do so. The position is rectified by turning the child so as to make head, breech, or one or both feet present.

If the correction of the position is impossible, the child in a transverse position cannot, as a rule, be extracted intact. The delivery of the mother per vias naturales is then only possible by cutting up the child (embryotomy).

The following will be a classification of the general treatment of parturition:

I. Treatment of (absolute or relative) insufficiency of the expelling forces.

1. By the increase of too feeble pains

a, by internal remedies;

b, by external manipulation.

2. By the replacement of too feeble pains—

a, by the method of pressure;

b, by imitating some of the effects of the pains;

a, artificial dilatation of the soft parts;

B, extraction of the child by traction on the presenting part

1. In head presentation by means of the forceps;

2. In breech presentation

a, by one or both feet;

b, by the breech;

y, artificial removal of the afterbirth.

II. Treatment of too great obstacles.

1. Anomalies of the maternal passages

a, of the soft, by incisions;

b, of the hard;

a, with the preservation of the foetal life by induction of premature labour;

B, without preserving the foetal life

1, by artificial abortion;

2, by craniotomy.

Appendix. Opening of a new passage by the Cæsarean section. 2. Anomalies of the foetus in its faulty position.

a, correction of the position

a, by turning by the head;

the breech;

the feet;

γ.

99

b, extraction of the foetus in faulty position rendered possible by embryotomy.

12

CHAPTER I

TREATMENT OF THE INSUFFICIENCY OF THE EXPELLING FORCE

I. INCREASE OF Too FEEBLE PAINS

A.-By Internal Remedies

ERGOT of rye undoubtedly occupies the foremost place amongst the medicines to which an influence on uterine action is attributed. Its action, however, upon the expulsion of the uterine contents is not the same as that of a normal pain. It rather causes a uniform persistent and rigid contraction of the uterus, uninterrupted by any relaxation.

Schatz has shown by means of the tokodynamometer that after the use of ergot the internal uterine pressure is continuously and greatly increased during the intervals, and that the pains become more frequent but less efficient, until at last they entirely cease.

It is known that it is just this persistent contraction which brings the child into danger, for during each contraction of the uterus, as during a normal pain, the diffusion of gases between the maternal and the foetal blood is not entirely stopped, but greatly limited, so that during a normal pain the sounds of the foetal heart are less frequent; in very powerful and rapidly succeeding pains the child cannot recover in the short relaxation, but becomes asphyxiated and dies.

This process is very similar to what takes place in the energetic action of ergot. By the uniform contraction of the uterus, interrupted by no pause, the diffusion of gases at the placental insertion is impeded, and thus asphyxia is produced.

Besides, the uniform tension of the uterus does not materially favour either the dilatation of the maternal soft parts or the progress of the ovum, and therefore ergot is useless for the expulsion of the child and may be in some cases even dangerous to it.

But the case is quite different in the afterbirth period. Here all depends upon the placenta being separated from the uterus, and that, immediately after the separation, the uterus should remain so contracted that not much blood is lost from the open vessels; the expulsion of the separated placenta is, as a rule, effected without difficulty.

We have learnt in the "Physiology of Parturition" that the placenta is separated from the inner surface of the uterus when the place of its insertion is greatly diminished by the contraction of the uterus. This effect, and still more the occlusion of the open vessels, is