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He speaks also of fraudulent tendencies in life, in pseudo-science, etc.; warns against advertising quacks and nostrums, and does not fail to give a rap at such tendencies in the profession.

We cannot follow the author farther here, but it is fortunate that one of his eminence should devote himself to the instruction of the public upon matters of vital importance, for which his special studies and pursuits as well as his rich experience and ripe judgment so well qualify him. PHILIP ZENNER.

The Practice of Obstetrics. By American Authors. Edited by CHAS. JEWETT, M.D. Third edition, revised and enlarged, 785 pp. Lea Bros. & Co., publishers, Philadelphia.

The third edition of this work is handed us for review, a task which gives us both pleasure and pain. It is a pleasure to call attention to the strong features of the work and painful to be compelled to point out the shortcomings which prevent it from being the best of modern text-books. An unusual amount of information will be found between its covers, and most of it has been utilized in such a way that one can hardly afford to be without the work. The publisher's part of the work is well done, the illustrations good, and no fault can be found, except that typographical errors are a little more numerous than they should be in a scientific work.

The section on anatomy of the female pelvic organs is superior to that in any text-book with which I am acquainted. We must, however, doubt the truth of the proposition that "carunculæ myrtiformes are undeniable evidence of a former parturition. The medico-legal importance of this subject is grave enough to render it unfortunate for such a mistake to receive authoritative expression.

The physiology of pregnancy is fully and ably presented. The development of the ovum is considered ably, and, so far as we are capable of judging, with great accuracy. The same may be said of the discussion of the changes in the maternal organism caused by pregnancy.

The diagnosis of pregnancy and differential diagnosis of pregnancy are unusually able. When it comes to predicting the probable date of confinement the language is somewhat ambiguous. While granting that by computing the probable date of confinement, either from the last menstruation or from the time of quickening, we will be frequently in error, we can hardly subscribe to the doctrine that an examination of the abdomen gives the most accurate data. The general configuration of the woman, the width of the brim, the size of the child, the amount of liquor amnii, and many other elements enter into the problem and rob a conclusion thus formed of any very great accuracy. That the relative size of the head and brim may be ascertained by examination through the abdominal wall we grant, but this does not give the period of gestation, for some heads are larger at seven months than others are at term.

The mechanical elements of labor are presented with unusual clearness and fullness. We cannot, however, subscribe to the position taken under the title "Changes in the Shape and Position of the Uterus." To consider the fundus as the active and the zone of dilatation as the passive portion of the organ is, we think, untenable. That which opposes an antagonistic force, and yields only under compulsion, cannot with propriety be termed passive. That the os uteri and lower zone of the uterus contract with vigor and yield only to a superior force can be demonstrated any time an examination is made during a uterine contraction. In the field of mechanics, progress can only come from accuracy of expression, and in describing the mechanical phenomena of labor

language is not only the symbols for communicating our thoughts, but is a medium for thought as well. An error is none the less an error because supported by ancient authority.

Nor can we subscribe to the doctrine that the fetal ovoid elongates as a result of uterine contraction when a proper appreciation of some of the most interesting and important phenomena of labor depend for their explanation upon the opposite of this proposition. If the liquor amnii is still retained the uterine wall will hardly exert a straightening effect upon the fetal ovoid, for any force applied upon the convex back will only serve to push the child toward the opposite side of the uterus. If the waters have been discharged, the breech of the child will be in contact with the fundus while the head is against the lower uterine zone, and any force exerted by the uterus will tend to increase the curve of the spine rather than to straighten it. This mechanical error is of itself trivial, but he who attempts to tread the tangled maze of obstetric mechanics must start right or arrive at false conclusions.

That the elevation of the fundus during contraction results from contraction of the round ligaments would require a good deal of credulity to accept. Any hollow muscular organ will, upon contraction, tend to become globular in outline. If during its flaccid state it has yielded to surrounding forces, and become distorted, its axis will tend to straighten under uterine contraction. The cervical portion being fixed, it is the fundus which is elevated, and by the contraction of the uterus itself.

A desire for completeness often leads a writer to mention things without discussing them. If experiments of others are introduced into the text without adverse criticism, the reader will naturally infer that the writer concurs. On page 210 you will find an account of the experiments of Dubois showing the mechanism of anterior rotation of the occiput upon the pelvic floor and those of Edgar purporting to prove in another way the same proposition. Dubois, by pushing the fetus through the pelvis of a woman who died in delivery, applies his force as nearly as possible like the natural force of uterus and abdominal muscles. Edgar's experiments imitated nature not at all; he applied his force posterior to the small fontanelle and pulled at right angles to the line of the parturient forces. There is not a single mechanical element in his experiments which resembles the natural mechanism, and the fact that the "answer came out right" is no proof of correctness, but is due to the fact that there is such a thing in mechanics as compensatory error. When the head has arrived upon the pelvic floor moulding has occurred until, in some instances, the occipital arm of the head lever has become longer than the anterior. In addition to this, flexion has occurred until the chin is in firm contact with the sternum, and the force of the uterus is distributed between the spine and chin. swivel should, therefore, to be mechanically honest, be placed considerably anterior rather than posterior to the smaller fontanelle. Applying his traction with a string, he must pull upward almost parallel to the plane of the pelvic floor. If his experiments had been undertaken with the child laying on a table, and the feet held by an assistant, traction on the string would have effected rotation. These experiments demonstrate nothing except that if traction is made by a string attached to a movable object the object will have a tendency to follow the string. We do not thus call attention to this error in a spirit of levity, but to do what we can to prevent this, like similar errors, from being copied from text-book to text-book, until it becomes hallowed by constant repetition.

His

On pages 431 and 432 we find a new cause of precipitate labor, namely, oblique presentation. We had always labored under the impression that this was one of the most frequent causes of slow progress in labor, and had frequently secured rapid progress by correcting the obliquity. Equally astonishing is the attributing of the delay caused by a full bladder to its changing the axis of the uterus and making its contraction painful. That such a phenomenon should be thus interpreted certainly shows lack of digestion of the material collected. That a full bladder may tend to displace the full-term uterus we do not doubt, but that it should actually accomplish the displacement seems as ridiculous as the complaint of the elephant that he had been jostled by the ant. A full bladder will frequently suspend labor, and any one observing such a case must, it seems to us, arrive at the conclusion that the inhibitory influence comes entirely through the nervous system.

In this same section we find ergot suggested for inefficient pains-in small doses, it is true, but yet seriously suggested. If this is intended simply that the chapter may be complete it might have been well to call attention to the fact that good obstetricians usually find some mechanical cause for inefficient uterine contractions. The dosage of morphia suggested is too small to be effective, and it is a well demonstracted fact among those accustomed to employ it that it will not stop true labor. This whole section of the book, pages 429 to 519 inclusive, is unsatisfactory. It contains a great deal of valuable material, but not very systematically arranged and frequently badly interpreted. It seems a pity for such a wealth of material to be wasted by not being logically arranged and judicially applied. Defective though it be, the experienced man may yet profit by its perusal, but the student will do best to avoid it.

It is a pleasure to turn from this to some other parts of the book which remain to be considered. The chapter on eclampsia is full, well written, and eminently satisfactory. It is a little surprising to find veratrum viride ranked second to chloroform as an agent for controlling convulsions, but when we find the author attempting to formulate rules for limiting its emetic effects, we can readily see the reason for its being thus assigned. When pushed to the point of copious bitious vomiting, lasting several hours, in the belief that in no other way can such an elimination of toxins be secured, it leaves a very narrow field for either chloroform or chloral. If thus given we think that the arguments used in favor of forced delivery will also be found to have lost most of their force.

The contribution to the subject of puerperal infection is the work of a master, and although many will disagree with him on some points, none can criticise seriously his facts, nor the masterly way in which he marshals them to the support of his opinions. There is nothing ambiguous and no necessity for several readings to make his meaning plain. It is rare good fortune to find a writer at once possessed of the qualities essential for the strictly scientific study of the subject, for the clinical application of the facts thus secured, and a master of the English language.

While standing uncovered in the presence of genius may we respectfully suggest, however, that prolonged labor predisposes to infection in other ways than by increasing the number of examinations required? Long before the age of antisepsis and asepsis it was demonstrated that the dangers to the mother were in direct proportion to the length of labor; and we are satisfied from personal experience that, in spite of aseptic precautions, this is still true. Prolonged bruising devitalizes the tissues much more than clean tears, while exhaustion lowers the consti

tutional resistance of the woman. While granting that a certain amount of danger attends vaginal examinations, we hold that the information thus gained will, if properly utilized, result in a lessening of puerperal infection by preventing the loss of local and constitutional vital resistance. The discussion of immediate repair of lacerations is clear and concise, being well calculated for the instruction of those who have not had gynecological training. The same author has a good article on abortion.

The article on forceps is a little less full than it should be, and shares the weakness of similar articles in other text-books, viz., no one will be able to understand the technique of the application from its perusal. Why the operation with forceps should not be described with as much accuracy and detail as Cæsarean section we never could comprehend. Th article on version is good but hardly as complete as we expected at the beginning of the section. There are several criticisms which should be made, however. It is strange to see space given to rules detailing which foot to secure in various positions in order to insure anterior rotation of the dorsal surface of the child and no space given to Simpson's rule how to secure version without violence. The rules given are of secondary importance, because, if the outside hand does not interfere too actively, the back of the child will, under traction, come anterior whether the rule is followed or not. If Simpson's rule, to pass the hand over the anterior surface of the child and secure the farthest knee, be followed, the violent shoving of the impacted shoulder toward the cephalic portion of the uterus will be avoided, and version will be accomplished by effecting a retreat of the child from every point of special resistance. Without this rule, we are not equipped for the management of impacted cases of shoulder presentation, and, as the author ignores the rule, we are not suprised to see him place such emphasis upon the dangers of uterine rupture, and evince a readiness to resort to destructive operations. Equally surprising is the ignoring of the rule which foot to turn by in order to bring the occiput into the more roomy side of the pelvis; and, having ignored this rule and Goodell's rules for extracting the after-coming head, we are not surprised to see axis traction instruments applied to occiput and forehead. The mechanical proof that all the diameters of the head are thus diminished does not answer the objection that by driving the occipital bone under the parietals serious damage to the brain will result. Throughout the work we find the advantages of Walcher's position spoken of, but have looked in vain for a hint at the mechanical facts which rob it of any great advantage, viz., that by increasing the sacro-vertebral angle we compel the forces attempting delivery, whether working from above or below, to act at a mechanical disadvantage.

If the student will ignore the suggestion of the author about having the assistant maintain flexion, and being certain to place the head transversely in the brim, in case of contracted conjugate, he will escape most of the complications discussed. The arms are stripped up because the elbows catch upon the brim, and the larger the child, in proportion to the pelvis, the more impossible is it to prevent. By desisting from following the suggestions made, and by only making supra-pubic pressure after the head has been nipped by the brim, the operator will escape both extension of the head and rotation backward, for well-defined mechanical reasons which lack of space does not permit us to discuss.

If the work was not of an unusually high character these criticisms might not have been made, but weaknesses are the more noticeable if placed in contrast with strength.

W. G.

VOLUME LXXXXVIII
NUMBER 5.

A Weekly Journal of Medicine and Surgery

PUBLISHED BY THE LANCET-CLINIC PUBLISHING COMPANY

CINCINNATI, AUGUST 3, 1907.

ANNUAL SUBSCRIPTION
THREE DOLLARS.

A CONSIDERATION OF RETRO-VERSIO-FLEXIONS OF THE UTERUS IN THEIR
RELATIONS TO PREGNANCY.*

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Gynecologist to Chicago Polyclinic School and Hospital; Adjunct Professor of Gynecology, University of
Illinois Medical School; Surgeon and Gynecologist Marion Sims Hospital;
Obstetrician to Cook County Hospital.

There is a sense in which every retrodisplacement in a child-bearing woman bears a relation to future pregnancy, but I wish more particularly to direct my remarks to the co-existence of the two conditions. There is evidence that incarceration of the uterus was recognized as long ago as the time of Hippocrates; Gregoire, of Paris, in an unpublished lecture, also dealt with the subject. We are indebted, however, to John Hunter for much of our early information upon this subject, as on many other subjects. In 1754 he delivered a lecture upon incarceration of the pregnant uterus, and instituted the use of the term "retroversion." In 1776, in "Medical Observations and Inquiries," he deals with the cause or the condition and lays stress upon a roomy lower portion of the pelvis lacking adipose tissue and a constricted inlet, together with over-distension of the bladder from some cause, as etiological factors. This is known as Hunter's theory, and his opinion that the condition was secondary to bladder distension was credited and maintained by such men as Denman, Ramsbotham, Robert Lee, Meigs and others, as shown by W. Tyler Smith in his quotations from their writings. He also quotes Rigby as believing that retrodisplacement precedes bladder distension, and is a cause of it. Smith reports several cases showing that the displacement is primary, therefore combating Hunter's theory. This is now a matter of history. That a previously retrodisplaced uterus frequently becomes pregnant cannot now be doubted. This may be a boon ro the patient suffering from retrodisplacement, or it may multiply the evils of the displacement several fold. Williams states that displacements and pathology resulting therefrom are among the most frequent causes of spontaneous abortion.

When we remember the causes of retrodisplacement, which may be said to be, first, anything which increases the weight of the uterus; second, anything which decreases the carrying power of its supports (ligaments, pelvic floor, cellular tissue, etc.); and third, anything which makes traction or exerts force in the wrong direction, we will readily see that retrodisplacement may be favored during the early months of pregnancy by reason of the congestion and extra weight of the uterus and other pelvic organs. In some cases the downward displacement of the uterus is only slight and in others it is extensive. In normal cases the extent is not so great as to cause great inconvenience, and the uterus soon ascends as the result of growth. Displacement of the non-pregnant uterus and its accompanying pathology may cause more or less distressing symptoms, but seldom imperils life. The accompanying diseases of retrodisplacement may cause sterility, but this is by no means constant. What may we expect from those cases in which pregnancy takes place, or in which retrodisplacement follows pregnancy? There is apt to be an increased displacement with aggravation of the symptoms. Then one of four things may take place:

First, the uterus may return to normal position and the symptoms be relieved or disappear. This frequently occurs even in spite of some adhesion.

Second, abortion may and frequently does follow. This is undoubtedly due at times to the endometritis and other complications, but, as stated by Williams, it is unquestionably due at times to the retrodisplacement.

Third, incarceration may take place, causing abortion, retention of the urine, sloughing of portions of the bladder, peritonitis, etc. Fourth, pregnancy may continue to term, * Read before the Thirty-second Annual Meeting of the Mississippi Valley Medical Association, at Hot Springs, Ark., November 6-8, 1906.

with the uterus still retroflexed, causing only moderate, mild or almost no symptoms. This condition, as shown by Oldham, may become a complication of labor.

Fortunately, the first claas furnish a large number, and the third and fourth only a small number. Unfortunately, however, a large number of the second class are found. The outcome depends on the complications and the tolerance of the uterus. Abortion is favored by the presence of endometritis, septic conditions, adhesions, etc. Incarceration is favored by extensive adhesions, a deformed pelvis with an overhanging promontory. Sinclair has denied the possibility of pregnancy existing with adhesions of any extent, but the findings of almost every other operator contradict this.

It would seem that the continuance of a retroflexed or retroverted uterus to full-term pregnancy must be accompanied with a great degree of tolerance on the part of the uterus, the bladder and the patient herself.

TREATMENT.

The treatment to be advised is to be based on the present conception of the value of different methods of treatment of retrodisplacement, of the danger or absence of danger of radical cure, of the tolerance of pregnant women for an operation, of the value of the life of the child, and lastly, the method of operation. It must not be based upon the conception of these matters fifteen, ten, or even five years ago.

If a laparotomy is considered dangerous, and the same operation upon a pregnant woman much more dangerous, the life of the fetus of little value, and there is no method of permanently curing the retrodisplacement, then abortion, incarceration and death will be the rule. If we can make a laparotomy fairly safe, if this danger is only slightly increased in the pregnant woman, if the rights of the child are recognized and an operation can be performed that prevents the possibility or probability of a return of the displacement after delivery, then these cases will be operated on early. Last-resort surgery in this, as in other conditions, will be less popular.

Most of us agree, no doubt, that a judicious correction of the displacement before pregnancy would be a good prophylactic measure, yet this proposition would find dissenters. I do not wish to make that the bur

den of this paper. When pregnancy and retrodisplacement exist together I think we could further agree that an effort to replace the uterus should be made. This is sometimes accomplished with ease and sometimes

with great difficulty, and it is sometimes found impossible. The knee-chest position should be assumed by the patient at the time of replacement, and also at other times; and in those cases in which efforts at replacement fail, an anesthetic is sometimes desirable.

If the uterus is replaced it can be held in position by means of a pessary. In those cases in which efforts at replacement fail, the case may be watched, the knee-chest position advised frequently and mild efforts made at intervals to get the growing uterus in front of the promontory. Frequently the uterus will be righted with these efforts. Sinclair claims great success in replacing retroverted pregnant uteri by means of the watch-spring pessary, but others have not found it so successful. I have had no experience with pessaries except to hold the uterus after it has been replaced. Cases are recorded where sacculation of the wall of the uterus in the abdomen has drawn the rest of the uterus out of the pelvis, even after considerable incarceration has taken place.

With the first signs of intolerance on the part of the uterus, abortion or incarceration should not be waited for. With the bladder and rectum empty, a moderate yet thorough effort may be made to replace the organ by the means suggested. This failing, some have advised emptying the uterus, and as a means to that end in cases of incarceration, puncture of the uterus through the vaginal wall has been advised in cases where the uterus could not be readily emptied. The latter procedure is to be condemned in the interest of the mother. The puncture may be so located as to be equivalent to a rupture of the uterus into the peritoneal cavity. The emptying of the uterus is to be condemned in the interest of the child.

In the light of our present aseptic technique, the tolerance of the pregnant woman to operations, and our present methods of permanently curing retrodisplacements without creating new pathology, I wish to enter a plea for earlier and more efficient treatment of these cases. I see no reason why we should advise or wait for abortion. If abortion is already inevitable, the uterus, of course, must be emptied. But with the uterus intolerant, with abortion only threatening, or with incarceration, other means failing, the abdomen should be opened and the uterus returned to position, complications dealt with, and if conditions are such as to warrant it, a radical operation should be performed for the retrodisplacement. In the days of ventro-suspensio-fixation, the radical cure could not well be advised, although Fry

pleads for earlier treatment in these cases, with ventro-suspension for the radical cure. There are few who would be so bold, or, I might say, injudicious, as to fix or suspend a pregnant uterus, and yet Lapthorne Smith and others, as well as Fry, have used this method, and some of these cases have gone to term. Kelly, after a long effort to justify "suspensio uteri," in his new edition of "Operative Gynecology," cautions against suspending this organ if pregnancy exists, even during the early weeks. He argues that fixation, instead of suspension, may result, and in order to avoid such a possibility, he advises routine curettage, saying that "it would seem better to do an unwitting abortion on a woman whom we did not suspect to be pregnant than to occasion a fixation in a pregnant uterus." To this I would say that we must have a better reason for curettage. If pregnancy does not exist the curettage for this purpose is unnecessary, and if it does exist, the curettage is unjustifiable.

No argument is necessary to prove that this is not the operation in cases in which the abdomen must be opened, much less the operation which will encourage the early attention that these cases deserve, before abortion is in progress or the uterus incarcerated. We scarcely feel justified in opening the abdomen to replace a retroverted pregnant uterus without the most urgent symptoms, if the patient is not to be given the benefit of the radical cure. To operate upon these cases when most advantageous to mother and child, the operation must offer the following safeguards and advantages:

First, it must be safe for the mother. Second, it must decrease fetal mortality. Third, it must insure or promise a permanent cure of the retrodisplacement.

With these conditions secured, instead of pregnancy being a bar to an operation it may at times furnish an earnest argument for an operation. Time was when we were inclined to look upon the pregnant woman as exempt from surgery. The time is now coming when, under some circumstances, we will say: "This woman needs an operation because she is pregnant." Then a large number of abortions and incarcerations will be prevented. I have laid some stress upon the inadvisability of using ventro-suspensio-fixation.

The method of operating has much to do with the betterment of conditions, and I therefore crave the indulgence of the society while I call attention to an operation described by myself in 1905. This operation was fully described, and I will therefore only briefly review the main points:

First, the round ligaments are picked up about two-thirds the distance from the uterus to the internal ring, and control ligatures put around them.

Second, a special long-curved ligature-carrier is carried outward from the lower angle of the abdominal incision, under the external oblique fascia, over the rectus muscle, until its point reaches the region of the internal ring, when it is pushed into the abdominal cavity through the ring.

Third, the control ligature is grasped with this forceps and drawn through the internal ring and to the abdominal incision along the course taken by the ligature-carrier.

Fourth, the loops of round ligament are sewed to the underside of the aponeurosis of the external oblique muscle, and then, if long enough, are sewed together over the recti muscles.

This operation offers for these cases under consideration the following advantages:

1. It may be performed through a very small incision.

2. It does no sewing to the uterus. 3. It permanently holds the uterus, yet allows normal mobility.

4. It takes the ligament out of the abdomen at the proper place-the internal ringand so creates no false ligament or false placing of the ligament, as was the case in former operations.

This, then, offers a manner of dealing with retro-versio-flexion during pregnancy earlier and with less marked symptoms than formerly, and yet being entirely within the bounds of rational conservative surgery.

Of course, I am well aware that some will say, "Yes, the treatment advised may do all right for places which offer proper advantages, but here in the country I would prefer to empty the uterus, puncture it if necessary -anything to avoid laparotomy." In answer I will say that I have not heard of any community in the Mississippi Valley so isolated, with transportation so poor that they kill their insane rather than transfer them to an asylum. Then why should we advise the killing of these more useful members of society?

I wish to insert a brief report of a case, not because it verifies the position taken, but because it presents features of interest in this connection.

Mrs. P., referred to me by Dr. S., of Wisconsin, gave the following history: Well until a few weeks previous, when patient, who considered herself about three and one-half months pregnant, began to suffer with bladder irritability. This was followed by retention, at which time Dr. S. was called. A large amount of urine was drawn with the catheter, and a deceptive mass was found in the pelvis. As the pa

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