that it holds the loop; the cord is fastened by the free ends of the tape, and by the catheter carried into the uterus as far as desirable, and the stylet withdrawn. Charpentier speaks favorably of the following method used by him successfully in one case : "The cord is encircled by a loop of silk, and the ends tied so that the cord will be firmly held but not compressed; the ends are now firmly fastened around the end of an olive-shaped elastic or wax bougie; the cord is now carried within the uterus until the lower end of the bougie is at the os. The bougie is left in the uterus, there is no tendency to recurrence of the prolapse, and the instrument excites uterine contractions, and thus hastens, which is always desirable, the termination of the labor."

Nearly two hundred years ago a famous Holland obstetrician, Deventer, advised the position on the knees and elbows in the treatment of prolapse of the umbilical cord: "The advantages of this position have been shown in later years, especially by Ritgen, Kiestra, Thomas, and Theopold." Playfair states that the success of this manœuvre is sometimes very great, but by no means always so, and that it is most likely to succeed when the membranes are unruptured. This position, if maintained for some time, is quite wearisome, and certainly causes the uterine force to act at a great disadvantage. Deventer also advised a lateral position in the treatment of prolapse of the cord; and Galabin states that if the patient cannot be readily induced to adopt the knee-elbow position, the semi-prone position may be used from the first with almost as much advantage.

Even when the pulsations in the cord are feeble and separated by long intervals, hope of saving the child should not be abandoned; the less near the end of pregnancy the longer the child survives interference with the circulation. But when no pulsation has been discovered for fifteen minutes, examinations being made in the intervals of contractions, it may be concluded the foetus is dead, and the delivery conducted without reference to its interests.

1 Schroeder.

CHAPTER VII.

ANOMALIES OF THE PELVIS.

[This chapter is contributed by Dr. HENRY MORRIS, Demonstrator of Obstetrics, Jefferson Medical College.]

Definition. It has been said that since the world began no two women have had pelves which exactly resembled each other in every particular; that in each case there has been some difference, more or less minute, by which any pelvis can be distinguished from all others. While this is probably an exaggeration, it is nevertheless true that the female pelvis is subject to many variations, both as regards its size and its shape. The "normal pelvis," therefore, is more of an ideal than of a reality-a pelvis conceived from the "good points" of many pelves, whose diameters are arrived at from averages derived from the measurements of thousands of specimens. The term "anomalies of the pelvis," then, does not refer to any slight variation from this perfect type, but to such changes in configuration or measurements-whether the result of disease or of arrested or of vicious development-as will present an obstacle, more or less insurmountable, to the passage of the products of conception, or otherwise modify the act of parturition.

Importance and Increasing Frequency. While it is not common to find American-born white women with pelves sufficiently deformed to offer serious obstruction to the passage of the child during labor, yet the constant stream of immigration, consisting in many instances of families who have been subjected to hard usage, and have lived under the worst possible hygienic conditions in their former homes-circumstances which, as will be seen, are powerful factors in the production of pelvic anomalies has caused such deformities to be more frequently observed, and more carefully studied in this country of late years. In proof of this may be adduced the increasing space devoted and prominence afforded to the consideration of this subject in American textbooks on obstetrics, the greater number of cases which are now reported in our journals, and papers read on the subject before our societies. As the country becomes more crowded, the conditions which produce these anomalies in other and older countries will probably act here also, and it is hardly to be hoped that the immunity at present enjoyed by American-born white women will continue to exist.

As regards anomalies of a lesser type, such as retard the second stage of labor without presenting a serious obstacle to the birth of the child, they probably exist more frequently than is generally supposed, and are overlooked by the medical attendant; indeed, many cases of

tedious labor, as well as many cases of mal-presentation, may be fairly attributed to this cause. As Lusk has said: "It is impossible to study the cases of vesico-vaginal fistulæ, reported by Dr. T. A. Emmet, without arriving at the conclusion that the existence of contracted pelvis is frequently overlooked." On account, then, of the increasing frequency of these conditions, it is necessary to study closely their varieties, causation and mode of production, diagnosis and treatment.

Varieties. Anomalies of the pelvis have been variously classified by different writers, according to the shape of the pelvic inlet and outlet; according to the supposed cause; or according to the diameters of the pelvis which are principally encroached upon by the abnormality.

Madam Lachapelle describes abnormal pelves under the various tities of reneform, triangular, rounded, oval, bilobed, cordiform, etc., according to the shape of the inlet and outlet. This classification has the effect of multiplying the varieties indefinitely, and, as she admits, leaves many varieties of these various orders yet undescribed. The classification according to cause, while apparently the best on account of its simplicity, is objectionable, because in certain cases the cause is yet sub judice, as in the case of Naegele's pelvis (obliqua ovata), while in other instances the same cause may produce totally different effects, according to circumstances; thus, rachitis, which usually gives rise to narrowing of the antero-posterior diameter of the inlet, may under other conditions produce deformities involving all of its diameters. The best classification, therefore, is that based upon the situation of the obstruction and the diameter with which it interferes, for when attending a parturient woman whose pelvis presents an obstacle to the descent of the child, the obstetrician is more desirous of knowing the situation of the obstruction than naming its cause; hence this classification appears the most natural as well as the most practical.

A. Anomalies involving the Entire Pelvis.-The pelvis itself may be perfect in shape, the diameters may bear the normal relation to each other, and yet, by deviating from the normal size, it may be an exceedingly bad one for purposes of parturition.

I. Pelvis Equabiliter Justo-Major.-In this abnormality, which is not very uncommon, the pelvis is equally enlarged in all its diameters, which still preserve the normal relation to each other. The result is simply a pelvis larger and more roomy than the normal. This variety of pelvis, although most commonly found in large, well-developed women with wide hips, is by no means confined to them, as it has frequently been seen in petite women also. It appears to be hereditary, as the women of some families seem always to have rapid labors and to be subject to the accidents enumerated below. It would be imagined at first thought that this would be a pelvis highly favorable for easy parturition, and perhaps as a rule this is the case, but its very spaciousness constitutes an objection, as from the large size of the cavity, the uterus does not rise up as it should about the third month of gestation, thus deranging the circulation of the parts, causing hemorrhoids, etc., and by pressure interfering with the function of the bladder and

1 Science and Art of Midwifery, 1885, p. 462.

rectum. It is also said that the gravid uterus is much more apt to be retroverted in a pelvis of this character. Again the pelvic inlet is so large that the inferior segment of the uterus toward the end of pregnancy presses constantly down into the cavity of the pelvis, giving rise to rectal and vesical tenesmus, and sometimes preventing entirely the passage of urine by pressing on the urethra. Obliquity of the uterus is more commonly seen as a concomitant to pregnancy in women with this anomaly, because the false pelvis is so large that the corpus uteri frequently falls toward one side or the other as it rests on the iliac fossa. During labor, also, the large size of the inlet, by not affording support to the head and inferior segment, allow them to pass down into the cavity before dilatation of the cervix is complete. Indeed, it is said that the uterus, not being supported below, may be torn from its attachment, or the lower segment from the body of the uterus, by the force of the abdominal contractions before dilatation is sufficiently advanced for the passage of the head; and that lacerations of the cervix are more frequent in these cases of large pelvis. If the child is of small or normal size and the contractions of the uterus of normal intensity the labor is always rapid, and the presenting part not meeting with much resistance is driven down against the pelvic floor before it has had time to become distended, and a rupture of the perineum is the consequence. Nor does the evil end with parturition, as the enlarged uterus, instead of ascending into the abdominal cavity, may remain in the cavity of the pelvis, and, the process of involution. being checked by the derangement to the venous circulation consequent upon its position, subinvolution, or various displacements may result.

II. Pelvis Equabiliter Justo-Minor.-This condition is the reverse of that which has just been considered, for in it, the pelvis which is normal in shape, is diminished in size, equally in all directions; its diameters, which bear almost the normal relation to each other, being decreased nearly proportionately. Two varieties of justo-minor pelvis are usually mentioned: (1) Those occurring in well-formed women, of any height, where nothing about them either as regards shape, size, or carriage lead to the suspicion of pelvic contraction; and (2) those occurring in dwarfs.

1. Of the first variety, Naegele says, the pelvis, with respect to the thickness, strength, texture, and indeed all the physical characters of the bones, size excepted, does not differ from a normal one. Litzmann, however, has called attention to certain differences in the relations of the various parts which are not found in the normal pelvis. Thus the sacrum is diminished in width, the alæ particularly being small; there is less pronounced forward rotation of the promontory and less curving of the lower extremity of the sacrum; the concavity

1 The writer attended a case of this kind in a young primipara, where the os uteri was felt resting on the perineal floor in the eighth month of pregnancy, and the pressure on the urethra was so great that the passage of a flexible catheter was impossible until the head contained in the lower segment of the uterus was pushed up. Catheterization had to be performed daily for two weeks prior to confinement.

2 Litzmann," Die Formen des Beckens," Berlin, p. 40.

of the sacrum in a transverse direction is increased; the posterior sacral surface is nearly on a level with the posterior superior spinous processes, instead of sinking forward between the ilia; the height of the anterior and lateral walls is proportionately lessened; and the angle formed by the symphysis pubis with the antero-posterior diameter is often increased. In spite of these differences the pelvis may be said to be of the feminine type.

The subjoined figure (Fig. 156), taken from "Holmes's System of Surgery," represents the normal pelvis in dotted outline, and a small

FIG. 156.

JUSTO-MINOR AND NORMAL PElvis Compared.

pelvis in bold outline, for sake of comparison. Both are drawn to the same scale. The latter was drawn from the pelvis of a woman who died a few days after a labor terminated by embryotomy. These pelves are evidently due to a premature arrest in growth, often occasioned by some disturbance of nutrition, occurring frequently in early life, as scrofula, rickets, and other diseases which tend to retard or suspend the growth of bone. In some cases this defect appears to be hereditary, while in others no cause can be assigned for the small size of the pelvis. This anomaly of form is rare, but is more common than the variety now to be considered.

2. The pelves of the second variety, that occurring in dwarfs, are not only small, but usually resemble the pelves of young girls at the age of puberty, both in configuration and in the mode of union of the different segments by cartilage. In these instances there has been not only an arrest of bone growth, but also of development, preventing the pelvis from attaining to the condition of maturity.

Where all the diameters are contracted equally, the obstacle pre

1 Cf. Holmes's System of Surgery, Am. ed., vol. iii. p. 896 et seq.