776 BYFORD, NON-PUERPERAL HEMORRHAGES OF THE WOMB.

malarial hemorrhages; but we have found quinia a valuable means of controlling bleeding, as it contracts the uterus, and is otherwise of service to the system. I always use it in cases of hemorrhage from subinvolution, and do not think a merely local treatment all that is needful in such a condition. I have noticed the law of habit mentioned by Dr. Simpson, for hemorrhages will sometimes take place when the uterus is apparently healthy, not only independently of ovulation, but often after the climacteric period. These hemorrhages are largely attributable to regional attraction of blood to the uterus, for that organ is liable to regional hemorrhage, even when there is no disease of a local character. The treatment must be local or general, and sometimes it is necessary to resort to both. Topically, the best plan is to dilate the cervix and inject the perchloride of iron. Astringents by the mouth are of use at times, and, of these, I think with Dr. Goodell that gallic acid is the best. The heart-action often has an effect on the hemorrhage, and by using aconite and other remedies to reduce cardiac action, there will be a corresponding reduction in the flow of blood. In some cases in which the cause of hemorrhage could not be ascertained, I have used, with excellent results, the witch-hazel, which I believe to be a native of this country. Although the curette has undoubtedly been of service in many cases, yet I condemn its use, for it is often followed by furious bleeding, and the growth of small malignant excrescences is more rapid after using it. Besides, it is, at best, a dangerous instrument, and requires to be handled with the greatest care. In one year I lost two patients from its use.

Dr. BYFORD, in reply, said:-Quinia is only second to ergot in causing uterine contractions, and is an admirable remedy. I have known of miasmatic conditions producing hemorrhage in non-puerperal cases. Quinia is of use in these cases, especially in causing condensation of the uterus. In the vast majority of cases, hemorrhage from a non-puerperal womb is owing to one of two conditions, either hyperæmia or a vitiated state of the uterine mucous lining, from inflammation or from growths. For the former condition I use ergot and local remedies, such as the tincture of iodine, but not as intra-uterine injections. In my experience, uterine hyperæmia and hypertrophy need the application of a strong astringent to the neck of the womb alone, for the body of the uterus can be made to contract by applications to the external and internal surfaces of the cervix. Local remedies can be applied in many different ways. The other common cause of hemorrhage is a disorganization of the lining membrane of the uterus. Hemorrhage becomes more easy when this mucous coat is not firm, because it gives way more readily. Topical treatment is here indispensable. When bleeding has occurred after the menopause from a determination of blood to the womb, I have been able to do more with large doses of quinia and iron than with ergot or with anything else. I do not consider ergot particularly valuable in such cases. The vaginal plug is of great use when used properly and thoroughly. It should not simply be pressed against the os, but firmly packed in front and behind the cervix, in order to compress it. I have, in my own practice, been rather timid in regard to injecting fluids into the womb, probably too much so, but I avoid such treatment wherever it is possible to do so.

THE MECHANISM OF NATURAL AND OF ARTIFICIAL LABOR IN NARROW PELVES.

BY

WILLIAM GOODELL, A.M., M.D.,

CLINICAL PROFESSOR OF THE DISEASES OF WOMEN AND OF CHILDREN IN THE
UNIVERSITY OF PENNSYLVANIA.

"Opinionum commenta delet dies, naturæ judicia confirmat."

CICERO, De Naturâ Deorum.

IN studying the mechanism of natural and of artificial labor in narrow pelves, let us first inquire what is meant by a narrow pelvis, and what are its kinds.

A pelvis with a true conjugate (conjugata vera) measuring less than four inches constitutes a narrow pelvis. For, although the biparietal diameter of the average foetal head at term measures less than four inches, the working space between the promontory of the sacrum and the symphysis of the pubis is lessened by double the thickness of the uterine wall, and by double that of the vesical wall. While, therefore, the actual conjugate is ample for an average head to pass, the virtual conjugate may be too small. Thus, according to our best authorities, a standard head in a pelvis measuring in its conjugate 3.75 inches-viz., half an inch less than that of the average-sized pelvis-constitutes a difficult labor.

A spontaneous delivery is not impossible under such circumstances, but the forceps will usually be needed; sometimes, indeed, craniotomy. Every line below this measurement greatly increases the difficulties of parturition. For instance, out of thirteen vertex presentations in pelves measuring at the least 3.75 inches, Dubois had three cases of craniotomy or of cephalotripsy. In conjugate diameters between 3.75 and 3.1 inches, he had ten presentations at term of the vertex, and one of the face. Of these, two ended spontaneously, two were delivered by the forceps with the death of one child, and seven needed the cephalotribe.' Baudelocque contends that out of five hundred children at term and of average size, hardly one will be delivered alive through a pelvis of three inches. To this, Dezeimeris adds that one of 3.25 inches does not give much better results, and that one of 3.5 inches also offers to the child a very dangerous passage. Joseph Clarke gives, as the result of an experience of 14,077 cases of labor, that "three and a half inches is the least diameter" through

1 Management of Labor in Contracted Pelves. By Wm. H. Jones. This author, it is true, makes these cases occur respectively in pelves whose conjugates measured "over 3.5," and "between 3.5 and 3 inches." But since he has adopted the classification of Dubois, these figures seem to me incorrect. For Dubois's first and second categories of deformed pelves are those in which the conjugates measure respectively, at the least, 3 75 inches (au moins 9.5 centimètres), and between 3.75 and 3.1 inches (au plus 9.5 centimètres et 8 centimètres au moins). This information I get second-hand from Cazeaux, and not from Dubois, whose thesis is beyond my reach.

2 Dictionnaire en 30; Art. Accouchements Prématurées, p. 427.

3 Contributions to Midwifery; by T. E. Beatty, p. 23.

which he has known "a full-grown foetus to pass entire." Chailly-Honoré says, "The forceps will frequently extract a living child through a conjugate of over nine centimetres (3.54 inches), sometimes, indeed-although this is very rare-under this size." From these facts, the broad rule may be laid down that, when the short diameter of the brim does not exceed the biparietal diameter of the child's head, the unaided efforts of the mother will in general be inadequate to effect a safe delivery, and that even with instrumental aid the life of the child will be greatly imperilled. The most common kinds of narrow pelvis are three in number:(1) The simple, flat pelvis, or conjugate narrowing with correlative transverse widening.

(2) The generally and uniformly narrowed pelvis, in which all the pelvic diameters are symmetrically shortened.

(3) The generally narrowed, flat pelvis, which combines the bone-lesions of the other two, but in varying proportions.

Of these three varieties, the one most commonly met with is the simple, flat pelvis, in which the lesion is limited mainly to the brim and to its posterior half. Practically the obstruction is a marginal one, and is confined to the sacral pole of the conjugate diameter. In the second variety-or the generally and uniformly narrowed pelvis-the obstruction is not a marginal one, nor of limited area, but diffused over every plane of the pelvic canal. In the third variety, the obstruction depends upon the preponderance of conjugate or of transverse narrowing, and is, therefore, either mainly at the brim and marginal, or mainly in the pelvic canal and diffused.

Since "Art is the imitation of Nature, and those will best succeed in any science who closest watch her operations," let us next note the mechanism of an unaided head-first labor in these different kinds of narrow pelvis.

In the generally and uniformly narrowed pelvis, the mechanism is very analogous to that which takes place in the standard pelvis, but is of course attended with more delay. The head enters the brim synclitically and with the normal Solayrés obliquity-that is to say it engages in one of the oblique diameters of the brim, but without lateral (Nægele's) obliquity. It will also be strongly flexed (Roederer's obliquity), because the resistance at the brim is equal on all sides, and the shorter hind-arm of the head-lever must therefore descend. The head also begins to flex at a higher plane of the pelvic cavity than in the standard pelvis. For flexion in the latter is chiefly brought about by the resistance of the os uteri; in the former by the more highly situated brim. During the descent of the head, the synclitic movement is preserved except in so far as vertical or lateral shearing interferes with it. Since the absolute conjugate narrowing is rarely great, and the general narrowing is symmetrical in all directions, the furrows or the fractures of the cranium are by no means so common as in the other varieties of deformed pelvis. But, when present, they usually start from the boss of the parietal bone and run more or less parallel to the sagittal suture, as in cases of fracture reported by Lize and D'Outrepout, and one of depression of the skull by Danyau. It must, however, be borne in mind that, while the bone-furrow always

Accouchements; Paris, 1867, p. 649.

2 The Present State of Midwifery in Paris; by A. Tolver, 1770, p. 22.

3 Union Médicale, Fév. 1860, p. 295.

4 Journal de Chirurgie, par Malgaigne, 1843, p. 41.

5 Ibid.,

p. 49.

indicates the transit-line, the fractures do not, as they may radiate from it in every direction.

When left to the unaided efforts of nature, the typical mechanism of a head-first labor in the flat pelvis, or in one whose brim is narrowed mainly in its conjugate diameter, is as follows:-The hind-head offers its biparietal diameter at the conjugate, but cannot enter. The resistance being nearer to the occipital end of the head causes extension, and the fore-head dips. As the fore-head descends, the sagittal suture, losing its Solayrés and Roederer obliquities, becomes transverse in two senses-viz., it lies in the transverse diameter of the brim, and with the two fontanelles on the same plane. The shorter and more compressible bitemporal diameter-that is to say, the upper or vault portion of each temporal region near the coronal suture-reaches the conjugate, and is driven into it, by the changed direction of the propelling force, which, acting through the vertebral column, is now thrown out of its perpendicularity to the base of the skull, and so bears at an angle directed to the forehead. Thus the head is nipped, bent in on its sacral side, and moulded to the promontory. Sometimes it is the bicoronal (the bifrontotemporal) diameter which is nipped. Hence the frequency of face-presentations in narrow pelves-a frequency, according to Michaelis, eight times greater than in normal pelves. Hence, also, the ease with which the anterior fontanelle is reached, and the corresponding difficulty with which the finger touches the posterior fontanelle.

The resistance is now at a point nearer to the fore-head than to the hind-head, and the latter, therefore, begins to descend, but with the biparietal diameter to one side of the conjugate diameter. But the resistance of the iliac margin of the brim to the descent of the hind-head causes that portion of the cranium to expand and to mould itself to the corresponding sacro-iliac space. It also tends to shove the whole head over to the forehead side of the pelvis. In a generally narrowed, flat pelvis with absolute transverse shortening, this displacement in the direction of the occipito-frontal diameter may go on until stopped by the impact of the forehead on the opposite ilium. The head, therefore, passes the conjugate, not vertically in the bicoronal or the bitemporal diameter which first engaged, but along a transit-furrow running somewhat obliquely from that portion of the vault near the coronal suture to the base posteriorly, that is to say, in the resultant of three forcesflexion, uterine propulsion, and occipito-frontal displacement in the transverse (bisiliac) diameter of the brim. In proportion as the head descends, it becomes more and more flexed, and the biparietal diameter, which passed the brim to one side of the conjugate, will, at a later stage of labor, be found almost directly under the promontory. It must, how ever, be remembered that, since all the transverse diameters of the pelvic cavity are also lengthened out, the head usually descends to the floor of the pelvis with less flexion than in the normal pelvis, and anterior rotation of the vertex is proportionally delayed.

Thus, from the mechanism of natural labor in this kind of pelvis, it will be seen that the head enters the brim in a state of partial extension, or at least in a state midway between flexion and extension, and passes the short pelvic diameter by a short and most compressible cranial diameter. Further, the head usually passes the brim with also a lateral obliquity. Before the engagement of the head, the sagittal suture in a

1 Clinical Lectures by German Authors, New Sydenham Society, 1876, p. 302.

typical case will be found very close to the promontory. To engage, the head must cant over the edge of the promontory; and during the first stage of descent this suture approaches the pubis. Later on, it begins to return towards the sacrum. This last movement is owing partly to the moulding of the posterior side of the head, and partly to the greater resistance to descent at the sacro-vertebral angle, while the pubic margin of the brim offers a smooth and glib surface. The head, therefore, pivots on the promontory as a centre of motion, and, as it were, rolls over into the pelvic cavity. It "doubles the promontory," as our honored President, Dr. Barnes, so happily expresses it.

After such an unaided delivery, or after an artificial delivery in which the application of the forceps is delayed until the head has been driven past the brim, the cranium exhibits two very characteristic shears. In the one, there is a bending in of the sacral side of the head, and a bulging out of the pubic side-it is kidney-shaped. In the other, an equitation of one parietal bone over its fellow-usually the anterior over the pos terior. The site of the pressure-furrow, or of the bone-lesion, varies with the size and the position of the head, and with the shape of the pelvis. It is not found at one of the poles of the biparietal diameter, and more or less parallel to the sagittal suture, as in the uniformly narrowed pelvis in which the vertex dips ab initio, but at the forepart of one parietal bone, close to and more or less parallel to the coronal suture. Often it lies directly over this suture, overlapping both frontal and parietal bones, and sometimes on the frontal bone alone.

When the disproportion between the size of the head and that of the brim is relatively great, or when the conjugate is short and the head unduly ossified or bullet-shaped, engagement is often delayed. Under such conditions the head does not at once become fixed by the preliminary dip of the anterior fontanelle, but it coys at the brink of the brim without entering. Perched on the sacral shelf, it swings backward and forward, and see-saws with every foetal movement. The finger will find the sagit tal suture usually close to the sacrum, and the posterior fontanelle now in front and now behind the transverse diameter of the brim; now dipping into the inlet, anon tilting up out of it. It is momentarily fixed by each uterine contraction, and then is the time to take the position. This cranial play usually ends before long, and that by the adjustment and moulding of the bicoronal region to the conjugate, and by its conse quent engagement and descent. And this may be hastened, as the late Edward Martin has shown,' by turning the woman over on to the side towards which the forehead looks. The breech of the child then sags over to the same side, the hind-head is lifted out of the brim by the leverage of the spinal column, and the fore-head sinks in more deeply. Whenever this dipping of the fore-head does not happen, delivery without artificial aid will be indefinitely delayed.

In the foregoing description I do not pretend to have labelled all the natural processes involved, nor to have codified every law which governs the cranial movements in narrow pelves. Nor do I contend that the anterior fontanelle always dips, for the head may be a small one, or the cranium a yielding one, or other disturbing elements may intervene. But from a study of the writings of Schroeder, Spiegelberg, Martin, and Otto de Haselberg, and also from patient bedside observation, I believe that the above mechanism is in the main correct-it certainly best ex

Prager Vierteljahrsschrift, 1868, Band ii., Analect, S. 76.