ojst 
PROLAPSE OF THE UMBILICAL CORD 
ITS CAUSES AND TREATMENT, 
B Y 
GEO. J. ENGELMANN, A.M., M.D.. 
DIRECTOR OF THE BT. LOUIS SCHOOL OF MTO.WIVRS; 
MASTER IK OBSTETRICS OF THE UNIVERSITY OF VIENNA; FELLOW OF THE LONDON OBSTETRICAL SOCIETY: 
MEMBER OF THE LONDON PATHOLOGICAL SOCIETY, ETC. 
ReDriuted from American lonrnal of Obstetrics and Diseases ot women anil Gbildreii, 
August, 1874. 
WILLIAM WOOD & CO., 2 7 GREAT JONES STREET. 
NEWYORK: 
1874. ON 
PROLAPSE OE THE UMBILICAL CORD. 
ITS CAUSE AND TREATMENT. 
Master in Obstetrics of the University of Vienna; Fellow of the London Obstetrical Society; 
Member of the London Pathological Society, etc. 
\By GEO. J. ENGELMANN, A.M., M.D., St. Louis, Mo., 
INTRODUCTION. 
The subject of prolapse of the cord is of as great an 
importance to the practical obstetrician as it is of 
interest to the scientific accoucheur; its cause and 
treatment have as yet not been clearly defined. Though 
the literature devoted to this point is most extensive, 
the conclusions reached are by no means satisfactory, 
the results obtained by various authors differing in a 
number of points, and the cause of this disagreement 
seems to me to lie in the lack of sufficiently extensive 
and carefully compiled statistics. 
Upon the continent of North America this dystocia 
claims less attention than it does in Europe, where the 2 
Exgelmaxx : Prolapse of the 
deformed pelvis, which I look upon as the main cause 
of prolapse of the cord, is by far more frequent; for- 
tunately for our people they do not suffer from the 
wretched conditions which so often affect the frame of 
women of the lower classes in Europe—food poor and 
scanty, mostly vegetable, tenements narrow and close, 
with a damp climate, such as England and the North 
of Germany offer. 
In German hospital and policlinical (city poor) 
practice, prolapse is of comparatively frequent occur- 
rence, and the rather unsatisfactory and superficial way 
in which the subject has so far been treated, must lead 
to the favorable reception of an investigation based 
upon such extensive and valuable materials as that col- 
lected in the annals of the Berlin Lying-in House, which 
my worthy teacher and friend, Prof. Martin, the chief 
of that institution,, so kindly placed at my disposal. 
The large number of cases—the largest at the command 
of any one author—the careful notes, and the exact and 
complete measurements, permit the investigation of this 
question in a much more precise and methodical way 
than has yet been possible, and promise a satisfactory 
solution of the doubtful points. 
I deem it of prime importance carefully to consider 
the conditions under which the results here given have 
been obtained, and to gain a thorough knowledge of 
the material upon which our investigation is based ; 
this consists of the cases of prolapse of the funis ob- 
served in the royal Lying-in Hospital of the University 
of Berlin, and the policlinical (out-door) department 
of that institution from October, 1858, to August, 1871, Umbilical Cord. 
3 
two classes of cases between wliicli we must carefully 
distinguish. 
The records of the 63 cases observed in the Lying-in 
House are alone perfect in all their details, and decisive 
for all points under consideration. With the exception 
of 13 cases of most abnormal and complex labor, trans- 
ported inter partum from the city into the institution, 
these cases have been conscientiously observed from be- 
ginning to end; careful measurements of the pelvis 
were made in every case, and the treatment was con- 
ducted upon scientific principles throughout. 
Our out-door (policlinical) cases, on the contrary, 
were observed and treated under less favorable circum- 
stances. They are difficult or prolonged cases of labor 
among the poor of the city, to which the despairing 
midwife summons the aid of the Lying-in House staff. 
It is of necessity only at a later stage of parturition 
that these cases come under observation, mostly when 
the prolapse of the funis has already taken place, some- 
times even after it has ceased to pulsate, so that they 
are but imperfectly recorded. Among these out-door 
cases we find notes upon 302 prolapses; though the 
number of cases is large, they can aid us in solving but 
a few of the questions we propose to enter upon, such 
as the relative frequency of prolapse among primi- 
parse (Ip.) and multiparse (M.p.), or the position of the 
child. Of these 302 ont-door cases 98, however, have 
been carefully observed from beginning to end and 
measurements made, so that they may be considered 
equivalent to those observed in the Lying-in House, 
and have been classed together with them, making the 4 
En&elmann: Prolapse of the 
number of our prolapse cases with pelves measured, and 
deliveries carefully recorded, as high as 160.* 
As far as possible I shall refer to the total 365 cases 
from the Lying-in House and out-door department com- 
bined; this would be, as I have already mentioned 
with regard to the relative frequency of prolapse among 
Lp. and M.p., the position of the foetus, etc. 
With regard to treatment and prognosis the results 
achieved in the Lying-in House and in the out-door de- 
partment must be considered separately, the conditions 
under which the obstetrician labored being so very dif- 
ferent. 
A.—FREQUENCY OF PROLAPSE. 
However many obstetricians have given us their 
experience with regard to prolapse of the funis, the 
data we find as to the frequency of its occurrence vary 
very much, as it is natural that they should, being de- 
pendent upon country, climate, and class of population. 
The highest per cent, is that given by Michaelis, who 
finds that the Lying-in Institution of Kiel, which is sup- 
plied from a country where the rachitic pelvis abounds, 
produced 27 prolapses among 2,400 deliveries—l to 90 ; 
Scanzoni cites 178,043 cases, collected from the publi- 
cations of a large number of obstetricians, among which 
699 cases of prolapse occurred—1 prolapse to 254 de- 
liveries. As it is customary that the statements and 
figures of one authority, whether right or wrong, are 
Table L, containing the pelvic measurements and condensed history of these 
160 cases, will appear at the close of our article, in a later number of the 
American Journal of Obstetrics. Umbilical Cord. 
5 
faithfully copied in each successive work, and translated 
from language to* language, we find about the same 
statement made by Saxtorph, who gives 480 to 116,272 
—1 in 243, and Churchill, who finds 816 examples of 
prolapsed funis among 188,730 cases, or 1 to These 
are gathered from the obstetricians of all countries, the 
British having one prolapse to 232\ cases of labor; 
the French, 1 in 373 ; the German, 1 to 262f. 
Boivin finds but one prolapse to 521 cases. 
All these calculations, even if based upon large num- 
bers, are exceedingly superficial, and of value only so far 
as they approximately give us the relative frequency of 
the prolapse in lying-in institutions; and I myself am 
also unfortunately compelled to confine my calculations 
to the Lying-in Hospital, as we have no control over 
the relative number of normal deliveries to which the 
out-door cases of prolapse might be referred. 
I must simply state that, among the 5,900 deliveries 
observed in the Berlin Lying-in Hospital within the last 
twelve years, were 63 cases of prolapse of the funis, 
one prolapse to 94 deliveries, 1.07 per cent., a frequency 
which is exceeded only by the Lying-in Hospital of 
Kiel, the Rotunda in Dublin giving but 1 to 168. 
Even if we disregard the 13 cases which were brought 
interpartum to the Lying-in Hospital for more serious 
complication, 50 cases of prolapse still remain—l to 118, 
or 0.85 per cent.—a ratio similar to that found by 
Hagele—1 to 120. 
Should we desire to make general deductions, a wide 
margin must of course be given, in the consideration of 
these figures, to social and geographical conditions, to 6 
EiYGELMAisnsr: Prolapse of the 
the characteristics of the various countries and climates, 
and, above all, to the class of the population among 
whom the statistics are collected. 
As I have already stated, the prolapse is much more 
rare in this country, as well as among the higher classes 
—the better housed and fed abroad—where disease de- 
forming the pelvis, above all rachitis, seldom occurs; 
where we rarely find the flabby condition of the ab- 
dominal walls, or the early escape of the liquor amnii, 
so frequent among hardworking women, as the poorer 
of the Germans are. The class of women which frequent 
Lying-in Houses, often such as have before suffered from 
complicated labor, naturally make the frequency of 
prolapse in such institutions much greater than it is in 
general practice. On the contrary, the fact that there 
is a very large proportion of I.p. confined there, has no 
influence upon these figures, as we shall hereafter see, 
notwithstanding that great stress has been laid upon 
this point by many authorities. 
We must, in short, seek the true proportion between 
the various extremes given. 
Table ll.—Relative Frequency op the various Presentations; 
Presentations. 
Lying-in House 
Out-door cases. 
Total. 
No. 
p. c. 
No. 
p. c. 
No. 
p. c. 
Vertex 
Face 
Forehead 
Breech 
Foot 
Transverse...: 
Shoulder 
35 
1 
2 
16 
4 
5 
55.5 
'i'i 
3.0 
25.4 
6.4 
8.0 
167 
3 
2 
8 
53 
43 
26 
55.2 
1.0 
0.6 
2.6 
18.0 
14.0 
8.6 
202 
3 
10 
69 
47 
31 
55.8 
0.8 
0.8 
2.7 
19.0 
12.9 
8.5 
| 208 head presentations, 57 
[ P.c. , 
(157 head presentations, 43 
I P- c. 
J 
63 
802 
865 Umbilical Cord. 
7 
B. CAUSES OF PROLAPSE. 
I. PRESENTATIONS OE POSTAL PARTS. 
A.—Head Presentation.—The head presented in 208 
of the total number of 365 cases of prolapse, in 202 
the vertex presented, so that we see the number of 
these in excess of all other presentations combined. 
Although the prolapse is more frequently found com- 
plicating vertex presentations than any other, this is 
true only so far as absolute numbers go; compara- 
tively speaking, the prolapse but rarely occurs in this 
presentation, for among normal deliveries we find the 
vertex presenting in 94 per cent, of the cases, whilst 
deliveries complicated with prolapse give us but 55 
per cent, of vertex presentations; exactly what theory 
would lead us to expect, as the sufficiently resistant, 
well-rounded form of the presenting head fits upon the 
expanding os in its entire circumference, and closes it 
m°re perfectly than any other of the foetal parts, 
provided the conditions of the pelvis be approximately 
normal. 
Not so the presenting face (face and forehead presen- 
tation which usually emerge into face, considered to- 
gether). We find 6 such cases recorded—one face 
presentation among every 61 cases of prolapse of the 
funis, while under ordinary circumstances the face pre- 
sentations are much more rare, not over 1 in 170, which 
would naturally lead us to suppose that face presenta- 
tions tend toward causing prolapse of the funis. Yet 
this is not so; it is not the face presentation as such, it 
is the deformed pelvis which so frequently brings about Engelmaishst : Prolapse of the 
8 
a face presentation that we must look upon as causing 
the prolapse. In sof these 6 face presentations we have 
distortion of the maternal pelvis; of the sixth no record 
is given, so that this also may have been deformed. 
B.—Other Presentations.—So much for head presen- 
tation; that all other presentations—perfect breech 
presentations excepted—should tend more to prolapse 
of the funis is but natural, as size and shape of the 
presenting part prevents its thorough adaptation to the 
lower segment of the womb, thus leaving an open space 
through which the funis readily glides; moreover, in 
all these presentations the funis lies nearer the os. 
We need but refer to our table to see that facts verify 
these theoretical deductions, as 43 per cent, of the total 
number of cases of prolapse here recorded come under 
the latter class, while under normal condition at most 
but 6 per cent, of the children are delivered in one of 
these presentations, so that malpositions, as we might 
almost call them, are 7 times more frequent among 
cases complicated with prolapse. 
Breech Presentations.—Of all these presentations, so 
far contrasted in toto with the head presentation, the 
breech presentation is least often complicated with pro- 
lapse. The sum total of our cases giving us not more 
than one breech presentation to every 36 cases of pro- 
lapse—which but little exceeds the normal ratio—and 
seems but natural when we consider that size and shape 
of the breech, so similar to the cranium, permit a suit- 
able configuration of the lower segment of the uterus. 
Foot Presentations.—lt is far different with the near- 
ly allied foot presentations, the irregular small parts Umbilical Cord. 
9 
which first press downward through the yielding 
os do not permit the close adaptation of the cervix, 
and we find this presentation most frequently compli- 
cated with prolapse, yet I may incidentally add, it is 
fortunately in this very case that the prolapse is least 
dangerous; were this not so, foot presentations must be 
the terror of obstetricians; with but 2.7 per cent, of 
breech presentations we find 19 per cent, of foot presen- 
tations among our cases of prolapse. In the Lying-in 
Hospital they even reach 25.4 per cent, of all cases, much 
more than in the out-door department; in the former the 
number of in-door patients under treatment has been 
comparatively large—and the longitudinal position of 
the foetus as produced by the normal action of a healthy 
strong uterus naturally predominates. 
Transverse Presentations.—ln the out-door depart- 
ment, where we deal more largely with medical practice, 
the number of foot presentations (presentations in the 
normal axis of the uterus) is smaller, only 18 percent., 
the number of transverse position larger, 14 per cent, to 
6.4 per cent, in the Lying-in Hospital; this is due mainly 
to the laxity of the uterus, and abdominal wall 
m multipart; not so much to distortion of the pelvis. 
Of the total number of prolapses 12.9 per cent, oc- 
curred in transverse positions (47 cases—28 of the I. 
Class—the head of the foetus in the left side of the 
mother; 19 of the 11. Class, the head of the foetus in 
the mother’s right side). 
Shoulder Presentations.—Shoulder presentations, 
which are almost identical with transverse positions as 
a cause of prolapse, in so far as in both a presenting 10 
Engelmanx: Prolapse of the 
part, which closes the os, is lacking, constitute 8.5 per 
cent, of our cases—equally distributed in the Lying-in 
Hospital and out-door department. 
Summing up, we see that among head presentations 
the prolapse of the funis rarely complicates vertex pre- 
sentations, but is frequently found with face presenta- 
tions, caused, however, as I have proved, more by the 
deformed pelvis than the face presentation; as such 
breech presentations also are but rarely complicated 
with prolapse, transverse positions and shoulder presen- 
tations much more commonly, and foot presentations 
oftener than any other. 
Having seen what share the foetus in its various pre- 
sentations has in favoring or causing the prolapse, we 
shall now consider the foetal appendages in their casual 
relations; but in order that any results shall be as 
positive and as minutely exact as thorough notes enable 
me to give upon other points, I must here confine myself 
to much smaller numbers. 
11. FCETAIi APPENDAGES. 
1. Placenta.—Thus the place of insertion of the pla- 
centa is given in but 35 crises, in 16 of which it was 
found low down in the uterus—i.e., I consider all such 
cases as adherent unusually near the os, in which the 
rupture in the membranes is less than 4 centimetres 
distant from the margin of the placenta. Among these 
I have not enumerated the extreme cases in which the 
placenta presents; of such, 15 were under treatment— 
giving us one case of placenta proevia among every 24 
cases of prolapse, an unusual frequency; but disre- 
garding these and confining ourselves to the other 35 Umbilical Cord. 
11 
cases, it is certainly most striking that in 16 the ad- 
hesion of the placenta should have been so near the os, 
an uncommon occurrence, as in the very large number of 
autopsies upon women during gestation and‘shortly after 
confinement, which I have either witnessed or myself 
performed, I have but rarely observed these conditions; 
I have almost always found the seat of the placenta to- 
ward the fundus usually upon the posterior wall of the 
uterus, more often to the right than to the left. 
That this unusual location of the placenta favors the 
prolapse of the cord seems evident; but the reason of 
this is not, as the authorities state, because it brings the 
insertion of the cord so much nearer the os ; the reason 
is a totally different one—it is the passive, mechanical 
action of the large, though yielding mass of the placen- 
ta in preventing the normal course of the presenting 
part through the pelvic canal, and in making the close 
adaptation of the lower segment of the uterus to the 
foetal head impossible. I have laid some stress upon this 
point, as it is new, and I deem it of considerable impor- 
tance, certainly theoretically very interesting; at all 
events, I trust I have said enough to stimulate farther 
observation and investigation. 
In 
cases of placenta prsevia, complicated with pro- 
lapse of the funis, the prolapse becomes of secondary im- 
portance, the dangers threatening the life of the mother 
here claiming our attention; yet I may state that the 
placenta presenting the difficulties before mentioned, 
caused by its insertion upon the inferior zone of the ute- 
rus, are greatly augmented, and in addition we have the 
insertion of the funis so near the os, that the prolapse is 
made still easier. 12 
Ejstgelmajstn : Prolapse of the 
2. Funis.—Unfortunately, little attention lias been 
paid to the placental insertion of the funis, but among 
the few cases noted we find two in wfiicli the cord was 
attached to the lower margin of the placenta, the latter 
being in both cases situated near the internal os, and to 
these conspiring causes we should be led to attribute 
the prolapse, did we not find by far more serious com- 
plications in the one case (Lying-in Hospital, 20) in a 
deformed pelvis ; in the other (Lying-in Hospital, 34) a 
shoulder presentation, both of which I consider as most 
important and primary causes of the prolapse. 
It is not alone an analysis of the cases I find re- 
corded, a comparatively small number, but above all a 
careful consideration of the various points involved, 
which convince me that the insertion of the funis upon 
or near the lower margin of the placenta is a matter of 
very little bearing on the subject before us, notwith- 
standing that most authorities, each copying his prede- 
cessor, consider it a complication very favorable to the 
occurrence of prolapse. 
In the same way a great deal of stress is generally 
laid upon the length of the funis, with a vague idea, 
which seems sufficiently natural, that the longer the 
cord, the more readily will it come down. 
Length of the funis in 92 cases. 
In 20 cases, less than 56 c.m. 
“72 “ more than 56 cm. 
“37 “ betw. 56 and 70 c.m. 
“35 “ over 70 c.m. 
Average length, 65 c.m. Umbilical Cord, 
13 
We have the length of the cord in 92 cases, in which all 
other data are carefully ascertained, thus giving us not 
only this one fact which alone is worth very little, but 
enabling us to decide upon its importance by a com- 
parison with other complications. In 20 of these 92 
cases the length of the funis is less than the normal 
average of 56 c.m.; whilst in the other 72 it is above 
this, and in 35 of these cases the length is very consid- 
erable, over 70 c.m.; so that the average length of the 
cord in these 92 cases of prolapse is 65 c.m.—9 c.m. 
longer than the normal average I accept. This is an 
item which claims a careful consideration, and would 
seem to be of importance in the question before us. 
Tet this is not so, and I shall justify this apparently 
paradoxical assertion by an examination of the extreme 
cases of very long and very short funis which we find 
among our cases of prolapse. 
I may certainly call a funis of over 80 c.m. very long, 
of such we have 18; but in 10 of these cases we find a de- 
formed pelvis, and this, as I have repeatedly stated, I 
consider the primary and pre-eminent cause of the pro- 
lapse of the funis; in the other 8 cases in which the pro- 
lapse of an uncommonly long cord took place in a normal 
pelvis, we find in 5 instances footling and cross presenta- 
tions, which, as we have seen, greatly facilitate the pro- 
lapse—only 3 vertex presentations, and even these 3 
vertex presentations show other complications which 
tend very much toward producing a prolapse. In one 
case we have a very small foetus; in another, a premature 
rupture of the membranes while the head was still high 
in the pelvis, fast upon the brim; and in the third, a 14 
Exgelmaxx : Prolapse of the 
pathological condition of the uterus, as proven by the 
difficult labors which had preceded; we see that there 
is not a single instance of a prolapse which can be said 
to have been caused by an abnormal length of the cord, 
though this undoubtedly facilitates its occurrence. 
To these we must contrast the 6 cases with an un- 
usually short cord, of less than 45 c.m., among which 
we find 2 normal pelves both with vertex presentations ; 
in one instance the foetal head remained stationary in 
the higher strata of the pelvis for some time, which pre- 
vented a close adaptation of the cervix, and thus occa- 
sioned the prolapse ; in the other even a very short cord 
came down without any serious cause. 
This seems to me sufficient to prove, what I am 
thoroughly convinced of, i.e. that great length of the 
funis is by no reason to be classed among the causes, 
with a direct bearing upon the prolapse, but that, in 
connection with other circumstances, it may be looked 
upon as an item favorable to its occurrence. Although 
the average length of the funis in cases of prolapse is 
greater than usual, a short funis is by no means a con- 
tra-indication, and an uncommonly long cord will not by 
itself cause prolapse. 
An item which is frequently mentioned in connection 
with prolapse, is the coiling of the funis around the 
neck of the child; as one of the main reasons for this 
coiling is an undue length of the cord, which we have 
seen to be no rare occurrence in prolapse, we may ex- 
pect to find it more frequently than usual looped around 
the neck of the foetus, and this proves to be the case. 
Coiling of the cord is mentioned in a number of the Umbilical Cord. 
15 
Lying-in Hospital cases, Imt merely mentioned, without 
farther observations, so that the data are not sufficient 
for a proper consideration of the subject upon which 
the opinions of authorities are so divided. 
For the study of this point it would be necessary to 
know from a large number of cases in which a loop of 
the prolapsed cord was found coiled around the neck 
of the child, whether this loop was at the placental or 
at the foetal end of the funis; this is the all-important 
point, so far disregarded, which would explain and unite 
the differing views. 
They are in the right who claim that the coiling of 
the cord prevents prolapse, as it certainly does in a most 
effectual way (even if other circumstances are favor- 
able) if in a head presentation it is the foetal end of the 
cord which coils. So would also the observations of 
those be proved correct, who maintain that the coiling 
of the cord favors prolapse, as a long loop of funis re- 
mains between neck and navel, in close proximity to the 
os, and ready to descend if the slightest chance is given 
when a fold from the placental end of the cord coils 
around the neck of the child. 
3. Premature Rupture of Membranes.—A cause which 
we can discuss with more assurance, and which is not 
without weight, is the rupture of the membranes at an 
early period of labor, before the os is well dilated; this 
tends to prolapse, more especially if it occurs, as was 
frequently observed in the out-door cases, when the os 
is scarce permeable to the finger, in the very commence- 
ment of labor. Even if the position of the foetus corre- 
spond to the longitudinal axis of the uterus, let it be a 16 
Exgelmaxx ; Prolapse of the 
vertex presentation, yet the presenting part is still high 
up in the pelvis, and the lower segment of the womb so 
little conformed to it that the amniotic fluid, as it es- 
capes, drags down with it the funis. 
The rupture of the membranes is a dangerous moment, 
even at a time when the os is more fully dilated and 
the presenting part farther advanced, if the waters are 
abundant and escape suddenly. 
The cause of a premature bursting of the sack will 
be found either in the severe physical exertion to which 
women of the working classes are subjected up to the 
very commencement of labor, so rupturing the mem- 
branes by simple mechanical strain, or in chronic affec- 
tions of the vagina and cervix, which seem to corrode the 
membranes, as it were, by their secretion and make them 
less resistant. I have notes upon this point in 128 
cases, in 65 of which, over 50 per cent., the waters es- 
caped when the os was not dilated beyond the size of a 
silver half-dollar, or about 4 c.m., a very rare occurrence 
in normal labor. 
The greater part of these cases naturally belong to 
the out-door department, where circumstances are so 
favorable to the occurrence of these accidents. 
To review in a few words what has been said about 
the foetal appendages as causes of prolapse, we have seen 
that, disregarding placenta prsevia, the adhesion of 
the placenta to the inferior segment of the uterus— 
perhaps the insertion of the funis upon the lower margin 
of the placenta—and an unusual length of the cord, 
especially when concomitant, may tend to favor the 
prolapse of the cord, but by no means to cause it directly Umbilical Cord. 
17 
more dangerous than any of the circumstances here men- 
tioned, seems to be the rupture of the membranes at an 
early period of labor. 
The causes of prolapse which we have so far discussed, 
emanating from the foetus and its appendages, are either 
secondary or of minor importance; we now come to the 
chief and primary causes, due to the maternal parts. 
To begin with the less important, I shall first consider 
abnormities of the shape and position of the womb, as 
even these are in most cases only secondary changes ; as 
malposition of the uterus as produced by the venter pro- 
pendens, which was observed in a few instances among 
the M.p. of the poorer classes in the out-door department 
of the L.-in H. more frequently, in connection with a 
deformed pelvis. 
111. ABNORMITIES OF THE WOMB. 
The venter propendens, and the anteversio uteri 
gravidi, which mostly go hand in hand, aside from 
their most frequent cause, a deformed pelvis, in them- 
selves tend to cause prolapse in so far as they favor 
transverse and shoulder presentations, and even in ver- 
tex presentations retard the descent of the head. 
The repeated occurrence of the prolapse in the out- 
door department among multiparse, with normal pelvis 
and full-sized foetus in vertex presentations, proves to us 
that a flabbiness of the uterus itself, a diminution of its 
muscular power, may provoke this accident. 
They are cases in which the organ has been weakened 
by frequent child-bearing in laboring women who work 
to the last; unable to nurse themselves, they barely 18 
Exgelmaxx : Prolapse of the 
keep their bed for a few hours after delivery, and 
again take np work with a tender, impressible nterns, 
in the very beginning of involution. 
So also uterine diseases, of which endometritis colli 
is found most frequently among the out-door cases, 
destroy the elasticity and mnscnlar contractility of the 
organ, and render its close adaptation to the presenting 
part impossible,—the same effect as is produced by 
weakness or entire cessation of labor-pains. ' 
Labor-pains. One Hundred and Eighteen Cases. 
Normal in 62 cases; pathological in 58 cases. Pains 
weak or ceasing entirely in 40 cases; spasmodic, power- 
less contractions in 16 cases. 
Thus we find that in but 62 of the 118 cases in which 
the character of the labor-pains is given they were nor- 
mal, in a few instances of great intensity; the patholo- 
gical condition of the pains in the other 56 cases was 
mostly owing to deformed pelvis, malposition of the 
foetus, premature rupture of the membranes, or disease 
of the womb, so that we must consider this as a compli- 
cation—a concomitant—rarely as a primary cause of 
prolapse. Equally often with malposition, an abnor- 
mity in shape of the pregnant uterus is linked with 
prolapse of the cord; either the loss of the ovoid form 
by a cross or shoulder presentation, or the unusual 
expansion of the womb by a plurality of foetus or 
hydramnios. 
Twin cases are frequently complicated with prolapse; 
we find 15 upon our records, i.e., 1 twin case among 24 Umbilical Cord. 
19 
cases of prolapse, whereas the usual ratio is about 
1.80. 
In three of the four cases of twins treated in the Lying- 
in Hospital the mother was a lying-in patient; in all 
four we Lave a well-formed normal pelvis, without any 
of the pathological concomitants before mentioned; so 
that we may look upon the twin foetus as the uncompli- 
cated cause of prolapse, with the exception of the fourth 
case of a lying-in patient, in which we have other cir- 
cumstances favorable to the prolapse in the transverse 
position of one, and the breech presentation of the other 
child, and, if we will add in the length of the cords, 70 
and 7l c.m. respectively. 
Of the eleven twin-births among the out-door cases, 
only one was observed in a lying-in patient, and but one 
is complicated with a deformed pelvis; whilst in two 
instances the cords of both of the twin children pro- 
lapsed. 
The reason of the tendency to prolapse in twin births 
lies in the diminished action and power of the uterus, 
due to its unusual distention; we have in fact a twofold 
disproportion—on the one side the cavity of the uterus 
enlarged, on the other the foetus and its presenting part 
somewhat smaller than in single births. 
All this also holds true for cases of hyd/ramnios, in 
which we have farther complications, in the difficulty 
with which the presenting head finds its proper position, 
and in the ample space which the superabundance of 
amniotic fluid offers to the descent of the specifically 
heavier funis. 
I may, perhaps, add that not nnfreqnently hydram- 20 
Exgelmaxx : Prolapse of the 
nios is found conjointly with, twin foetus. Unfortunately 
we have but few cases of hydramnios recorded, as the 
out-door cases frequently did not come under observa- 
tion until after the escape of the waters; among the 
sixty-three cases of prolapse treated in the Lying-in 
Hospital we have three of hydramnios, but only in one 
of these cases does the superabundance of amniotic fluid 
seem to be the only circumstance leading to prolapse 
(Case 41. Healthy condition of abdominal parietes 
and of the womb, normal pelvis, vertex presentation of 
well-developed foetus, and an umbilical cord of 64 c.m. 
with normal insertion). 
IV. PREMATURE LABOR. 
I will finally mention the comparatively frequent 
occurrence of the prolapse in premature deliveries where 
both uterus and foetus are in an undeveloped state, unfit 
to enter upon the normal relation which they should 
sustain toward each other; we mostly find a premature 
rupture of the membranes and malposition of a fre- 
quently lifeless foetus, an interesting fact theoretically, 
but of little practical importance; thus of the premature 
births here enumerated, some were in the seventh, one 
even in the sixth month. 
Of the twenty-eight premature labors in which pro- 
lapse of the funis occurred, relatively by far the largest 
number (twelve) were observed in the Lying-in Hospi- 
tal, which is quite natural, as in many cases premature 
labor was induced on account of deformed pelvis, giving 
us a complication of circumstances. 
It is in part true of premature deliveries, as we have Umbilical Cord. 
21 
seen it to be of so many other complications of labor 
which have been accused of causing the prolapse of 
the funis, that in tracing the evil to its origin we find 
a pathological condition of the osseous part of the pel- 
vic canal as the primary cause of all trouble. 
V. PELVIS. 
That the pelvis and its abnormal deviations is of 
the highest importance in establishing our theories 
with regard to the prolapse, I have made evident 
enough, and it claims a most thorough and careful 
consideration, all the more as considerable impor- 
tance has always been attached to it in its causal 
relations to the prolapse, but in a vague and careless 
way—general statements without measurements or 
numbers to substantiate them. It is owing to the care- 
ful records of the Berlin Lying-in Asylum and the 
exact measurement of the pelvis so conscientiously 
taken in every single instance, that I am here enabled 
to deal with facts, and need not limit myself to 
theories. 
The laws here expounded are the well-weighed re- 
sult of the study of 160 cases of prolapse of the funis, 
concerning which we have all the desirable data—pelvic 
dimensions, etc.; 62 of these completely recorded 
cases were observed in the Lying-in Hospital, the re- 
maining 98 among the out-door cases. 
In determining the capacity of the pelvis, its exter- 
nal dimensions are here used, and I must necessarily 
say a few words in explanation of this, as, unfortunately 
for child-bearing women, pelvimetry is still in its 
infancy, and in this country almost untaught; to our 22 
Exgelmaxx : Prolapse of the 
shame be it said, that the average accoucheur is entirely 
innocent of a science upon which the life of mother or 
child not unfrequently depend. 
The exploration of the pelvic cavity with the finger 
is the method practised in this country and in England, 
whenever an attempt is made to ascertain its dimen- 
sions, to determine irregularities upon the inner surface, 
as well as the length of the diagonal conjugate. When 
properly executed, it gives the skilled examiner, and to 
him alone, a very good picture of the pelvis ; it is rarely 
definite, and is of little value to others; it cannot be 
concisely and precisely recorded; very different are the 
internal post-mortem measurements of the pelvis. 
Internal explorations have always been made ; but 
for a classification of the pelvis I have confined myself 
to external measurements, which can be more thoroughly 
made and recorded, and afford us a very good estimate 
of the cavity. 
The measurements given are : 
1. The distance between the spinse ilii anteriores su- 
periors, the inferior transverse diameter (inf, transv.) 
which in the standard pelvis is 25 c.m. or 
2. The distance between the cristse ilii at the widest 
part of the brim, the superior transverse diameter 
(sup. transv.), in the standard pelvis, 28 c.m. or 10 
3. The distance from the processus spinosus of the 
last lumbar vertebra to the symphysis, the* antero-pos- 
terior diameter (ant. post.), or external conjugate, 20 
c.m. or 
4. If possible to determine, the diagonal conjugate, Umbilical Cord. 
23 
from the pelvic arch to the promontory, is given 13 
c.m. or If" 
5. The external oblique diameters, the right from 
the spina ilii posterior superior of the right side to the 
spina anterior superior of the left (R. obi.) ; the left 
vice versa—22.s c.m. or 8*7/. 
6. The distance between both trochanters, 31. c.m. or 
11*". 
The pelvic circumference, taken beneath the spin® 
ilii and above the trochanters, 89 c.m. or 2>%". 
In order to facilitate a general insight into the ques- 
tion before us, it is necessary to classify the various 
kinds of malformations we are dealing with, and herein 
I must follow Michaelis and the German School; it is 
the only rational and scientific way of elucidating this 
point; the method in which it is treated by most English 
authorities, particularly by Ramsbotham, being so 
Table lll.—Classification of the pelvis. 
Antero-post. 
diam. in c.m. 
No. 
p.c. of the 160 pel- 
ves measured. 
p.c. of the 
contracted 
pelves. 
Normal 65 
41.p.c. 
16 
49 
Moderately 
enlarged. 
Standard. 
above 20 
19—20 
' 10. 
30.6 
Contracted 95 
59 p.c. 
69 
23 
1 
2 
Flattened. 
Simply con- 
tracted. 
Narrow. 
Oblique. 
j 17—19 
junder 17 
j 17—19 
i under 17 
60 
9 
22 
1 
37.5 ) 
5.6 f 
13.7 
0.6 f 
0.6 
1.3 
43.1 
14.8 
72.6 
24.1 
primitive and confused, that I would needlessly annoy 
the reader by any reference to them. Reference to 
Table 111. will show my method of classifying pelvic 24 
Exgelmaxx : Prolapse of the 
distortions, but I beg tlie reader not to remain satisfied 
with the general distinctions given in this table, but in 
each individual case to refer to the pelvic measurements 
in Table I. 
Of the 160 pelves, I regard 65 as normal, i.e. the 
external antero-posterior diameter being 19 c.m. or 
more, the inferior transverse above 25 c.m., the superior 
transverse above 28 c.m, both oblique 22.5 or over, 
Tab. 111. a. Pelyes classed according to their Antero-posterior 
Diameter. 
External antero-posterior diameter in o.m. 
No. of pelves. 
per cent. 
j (over 20 
19 and over -j 0q 
16 
54 
10.0 
33.8 
| 70 
= 43.8 p.c. 
Less than 19 l^7 1? 
80 
10 
50.0 
6.2 
j 90 
= 56.2 p.c. 
and the pelvic circumference 89 c.m.; 16 of these must, 
however, be grouped separately as moderately enlarged, 
the pelvis sequabiliter justa major, whose antero- 
posterior is above 20 c.m., with the transverse diameters 
especially enlarged. 
The way in which these moderately enlarged pelves 
are distributed among our cases of prolapse is character- 
istic, and I might almost say self-explaining. Only two 
belonged to primiparse, in whom we must expect the firm- 
ness and elasticity of the tissues to counteract the effect 
of a very spacious pelvis;—these two exceptional cases 
were twin births, which affords an explanation of the 
prolapse; among the remaining 14 cases of multiparse, 
many of them having very frequently borne, we mostly 
find cross and footling presentations; and here we have 
the simple explanation of the conflicting opinions ex- Umbilical Cord. 
25 
pressed by different authors—as is so often the case— 
both parties are partially right, the error being due 
to an incomplete study of the subject. If Scanzoni 
and others consider the moderately enlarged pelvis as 
a contra-indication to prolapse of the funis, they are 
right in so far as the preternaturally large, regularly 
formed pelvis affords the same advantage to the 
passage of the normal foetus in a vertex or breech 
presentation as the standard pelvis (yet it cannot 
be called a contra-indication) [if there is too great a 
disproportion between pelvis and cranium, as in cases 
of premature delivery—or unusually small foetus and 
enlarged pelvis]; on the other hand, the contrary 
opinion, that the moderately enlarged pelvis is one of 
the causes of prolapse, is justifiable, as in cases of cross 
and footling presentation, or an unusual extension of 
the uterine cavity (hydramnios or twins), then it is 
certainly a circumstance favorable to the occurrence of 
the prolapse, though I can by no means class it among 
the causes. 
As standard pelves, with an antero-posterior diameter 
between 19 c.m., 20 c.m., other dimensions corresponding, 
I have enumerated 49—less than a third—3l per cent., 
and even among these there are some which I have been 
forced to group under this head by reason of their ex- 
ternal dimensions, although I very much suspect some 
abnormity on account of difficult or lingering labor in 
the present or previous births; we must let this pass, 
as it is impossible for me now to determine the cause 
of the trouble. 
2. Contacted Pelves.—We now come to the consider- 26 
Ejstgelmajshs’ : Prolapse of the 
ation of the largest and most important class, the con- 
tacted pelvis / and under this general head I place all 
whose external dimensions are less than those of the stan- 
dard pelvis, whose antero-posterior is less than 19 can., 
be they distorted or simply (uniformly) contracted. 
59 per cent, of the 160 pelves measured are contracted ; 
among those observed in the L-in H., 52 per cent, are 
contracted (33 among the 62 births), whilst the out- 
door cases show 63 per cent, of contracted pelves (62 
in the 98 deliveries). 
Even if we bear in mind that of the 13 cases trans- 
ported inter partum, on account of most complex labor, 
into the L-in H., most every single one exhibits a highly 
contracted pelvis; even taking into account that of the 
out-door measurements, some were merely made on ac- 
count of an evidently deformed pelvis, nevertheless the 
number of contracted pelves remains a very large one, 
which we can only appreciate in recalling to mind the 
comparatively rare occurrence of the contracted pelvis. 
Michaelis, in his excellent work on the contracted j)elvis, 
describes 72 cases of this deformity which he has ob- 
served among 1,000 deliveries,—Lying-in Hospital de- 
liveries, be it remembered; this gives a contracted pelvis 
in about 7 per cent, of the cases—6 per cent., if we dis- 
regard cases brought inter par turn into the institution. 
Although the Lying-in Hospital of Kiel, which is 
supplied from a country suffering greatly from rickets, 
may even show a rather large number of contracted 
pelves, I think that I am justified in saying that about 
7 per cent, of the child-bearing women in the northern 
part of the European Continent possesses a pelvis Umbilical Cord. 
27 
varying so much from the standard as not to permit 
the ready delivery of a well-developed foetus at full 
term. 
About the same result is obtained by Dr. C. Martin 
(Zur ICenntniss der Engen-Beckens bei Gebdrenden), 
who finds among 2,034 pelves measured in the Berlin 
Lying-in Hospital, 135, somewhat less than 7 per cent., 
with an external antero-posterior of less than 19 c.m. If 
we add to these the oblique and narrow pelves with an 
antero-posterior diameter of over 19 c.m., the number of 
contracted pelves observed in the Berlin L-in H. will 
also reach 7 per cent. 
Notwithstanding the very rare occurrence of this 
malformation, we have, as our tables show, in labor 
complicated with prolapse, a contracted pelvis in 59 
per cent, of the cases (this gives us one case of prolapse 
of the funis to every 12 cases of labor complicated 
with contracted pelvis). 
I need say no more ; these facts suffice; they conclu- 
sively prove the contracted pelvis to be one of the main 
causes, directly as well as indirectly, of the prolapse ; a 
truth which, though often surmised, is here for the first 
time proven by the logic of numbers. 
According to the dates of the L-in H., the frequency 
of the prolapses is 16 times greater in the contracted 
than in the normal pelvis, and it is above all in vertex 
presentation, as we shall see, that the pathological 
pelvis asserts itself as a cause of the prolapse. 
We have so far only considered the contracted pelvis 
as contrasted with the standard; but in order to fully 
understand its bearing upon the dystocia in question— 28 
Exgelmaxx : Prolapse of the 
a purely mechanical one—we must study thefrequency 
of the various contractions and distortions to which the 
pelvis is subject, as the different forms affect the pro- 
cess of parturition in a very different way. Of the 95 
contracted pelves, by far the largest number, 69, or 72.6 
percent., are antero-posteriorly contracted, fattened pel- 
ves. 23, 24.2 percent., I have called simple contracted / 
these it is often difficult to separate from the flattened 
pelves, as but few of them are strictly uniformly simple 
contracted, the diminution in the antero-posterior being 
usually somewhat more than in the other diameters, 
and it is owing to this unusual scope which I give the 
simple contracted pelvis that its numbers here are so 
large. 
The oblique pelvis is a rare distortion; and among 
our number of contracted pelves we have but 2 which 
are distinctly characterized as such, i.e., which show~ a 
considerable difference in the dimensions of their ob- 
lique diameters. 
In a number of instances I find a lateral dislocation 
of the promontory noted. This was of course found 
in the digital exploration of the pelvic canal, made 
more especially for the determination of the diagonal 
conjugate; unfortunately the statements are too gen- 
eral, and as the external oblique diameters do not 
show sufficient variation, I am not justified in placing 
such pelves among the oblique, but have classed them 
according to their external diameters, mentioning the 
dislocation of the promontory. 
But one narrow—transversely compressed—pelvis 
was found complicating prolapse; this is clearly marked Umbilical Cord. 
29 
as sncli by the external dimensions, and the conditions 
of the present as well as the history of previous child- 
birth prove it to have been a serious obstacle. We 
have seen that the flattened pelvis is for us the most 
important of the contracted; not only is it the most 
common of the malformations of the pelvis which com- 
plicate prolapse, but also in a general average it is the 
most frequent of the pathological forms of the pelvis; 
this was first proved by Michaelis, who finds 70 per 
cent, of the 72 contracted pelves described by him to 
be antero-posteriorly contracted; my result is a very 
similar one. I have shown 72.6 per cent, of the 95 
contracted pelves complicated with prolapse to be flat- 
tened ; I have enumerated as flattened pelves only those 
which were very decidedly compressed antero-pos- 
tenorly, excluding those pelves which, diminished in 
all diameters, were somewhat more contracted antero- 
posteriorly, and notwithstanding placed by me among 
the simple contracted—which in their general features 
they resemble more than the flattened pelvis. We see 
that among contracted pelves complicated with pro- 
lapse, the per cent, of flattened pelves is greater than 
ordinary ; a fact which readily explains itself, as neither 
the narrow nor the simple contracted pelvis—provided 
that the diminution in their diameters is but moderate— 
cause as much obstruction to the normal descent of 
the presenting head as an antero-posterior shortening. 
Even if the disproportion between the transverse 
diameters of the foetal cranium and the conjugate of 
the pelvis is but slight, the head descends, the vertex 
presenting as usual, but with its longitudinal diameter 30 
Exgelmanx : Prolapse of the 
in the transverse of the brim ; in this position the head 
is held fast for some time before entering the cavity of 
the pelvis; it cannot descend upon the os and the cervix 
—though its elements be strong and active; cannot 
adapt itself and closely fit to the foetal part held fast 
so high up in the pelvis; the comparatively oval mass 
of the cranium, placed in the transverse axis of the 
brim or superior part of the cavity of a flattened pelvis, 
leaves the sacro-iliac fossse unoccupied, and this is the 
locus minoris resistentise in which the cord glides down. 
By far the larger number—60 of the 69 flattened 
pelves—have an external antero-posterior diameter of 
from 17 to 19 c.m.; the remaining 9 are so very much 
contracted, their antero-posterior being less than 17 
c.m., that they lose their importance for the prolapse 
of the cord—the life of the child being endangered by 
other and more serious complications. I should like to 
add, with regard to the cet iology of the flattened pelvis, 
though it is a question more of scientific than of practi- 
cal importance in this place, that among the 69 antero- 
posteriorly compressed pelves, in 28 the distortion is 
clearly the result of rachitis. This leads me to an 
opinion contrary to the one expressed by Michaelis, 
who takes the pelvis plana Deventeri to be more com- 
mon than the pelvis plana rachitica. The 28 flattened 
pelves which I have called rachitic, are either such as 
show the characteristics of the rachitic pelvis in a very 
marked way, or they are cases in which it is especially 
stated in the history of the mother that in her child- 
hood she suffered from the “English disease,” as this 
affection is popularly termed in the north of Germany. Umbilical Cord. 
31 
These 28 cases by no means cover the entire ground, 
and tliere is no doubt in my mind but tliat tlie greater 
number of the flattened pelves here observed are the 
result of rickets, a disease so very common in that por- 
tion of Europe, and more especially so among the class 
of people to whom we owe our cases. I have spoken of 
tbe direct relation which the contracted pelvis bears to 
the prolapse of the funis, and it now devolves upon me 
to show the effect it has, with regard to the dystocia in 
question, upon other circumstances connected with the 
progress of labor—so, first of all, upon the position of 
the foetus. 
Table IY.—Distribution of the Contracted Pelves among the 
Presentations. 
Normal. 
Contracted Pelves. 
•d 
a 
O »rH 
"5) 
ft 
a 
#o 
s 
Flattened Pelves. 
Simple 
P+ 
V 
+3 HS 
1 
a 
s 
o 
. 
£j o 
17-19 
-17 
Contracted 
* 
O 
d 
a 
O 
a a 
O .$5 
SB'S 
Ph 
£ 
g.2 
1 
cS Ot 
a 
W 
a i 
eS C5 
* 
r 
4-J 
-d 
*S *r| 
17-19 
-17 
c3 
3 
o 
*o 
d 
o > 
So 
& 6 
P5 
U 
3 
rt 
6 § 
P3 
O 
C3 
PH 
14 
No. 
p. c. 
Vertex 
Forehead.. 
3 
26 
27 
18 
1 
3 
3 
18 
1 
1 
98 
1 
71 
1 
72.5 
100 
, 101 head presen tat.; 
(_ 74 complicated 
f with contracted 
1 pelvis; 73.3 p. c. 
60 other presents 
( tions; £1 compli- 
j- cated with con- 
tracted pelvis; 35 
J p. c. 
Face 
1 
1 
2 
2 
100 
Breech .... 
a 
2 
2 
6 
2 
33 
Foot, 
3 
13 
6 
1 
i 
1 
25 
9 
36 
6 
8 
3 
4 
23 
9 
39 
Shoulder.. 
2 
3 
1 
6 
1 
16.5 
16 
(60)+ 
49 
36 
24 
5 
4 
22 
1 
(181)* 
160 
95 
59 
60 
9 
65 
69 
23 
- 
95 
i 
2 
Normal, 66; contracted, 95 = total 161. 
One normal pelvis being twice counted on account of twin-birth, with prolapse in both cases. 
Normal, 65; contracted, 95 = total 160, 32 
: Prolapse of the 
3. Pelations of the Pelvis to the Presentation.— 
Reference to Table IY. sliows us that by far the 
greater part, 78 per cent., of the contracted pelves 
occurs in combination with head presentation of the 
foetus; transverse shoulder and breech presentations 
together are found in the remaining 22 per cent. It 
must be distinctly understood that the cause of this 
combination is not to be looked for in an overpowering 
number of head presentations—it is not that we have 
more head presentations combined with contracted 
pelves, because we have so many more head presenta- 
tions. We have seen that a little over half, 57 per cent., 
of our cases of prolapse were with the head of the 
foetus presenting; the other presentations combined, 
almost equal them in number. If we lay the main 
stress upon the presentation, we shall find that of the 
101 head presentations observed among the 160 mea- 
sured pelves, 74—73.3 per cent.—occurred in combina- 
tion with contracted pelves, whilst of the 60 cases of all 
remaining presentations only 35 per cent, are linked with 
malformation of the pelvis. I have before shown that 
the contracted pelvis is found with unusual frequency 
in cases of prolapse, and we now see that it attains its 
highest importance as a primary cause of prolapse in 
head presentations ; a fact already known to Michaelis, 
who was led to the conclusion, by the study of 849 
head presentations treated by him, that prolapse of the 
cord in head presentations was ten times more frequent 
with contracted than with normal pelves; 7 cases of 
prolapse having been observed by him among 776 
cases of normal pelvis, and 7 among 73 contracted pelves. Umbilical Cord. 
33 
Here the distortion of the pelvis is in itself the direct 
cause of the prolapse; hut there are other cases still, in 
which it tends indirectly to bring about the same mis- 
hap. I refer to the venter propendens, to the malposi- 
tions and deformities of the uterus which so frequently 
complicate the contracted pelves, and in themselves 
again favor the occurrence of the prolapse. The fact 
that malposition of the foetus is so frequently engen- 
dered by contraction of the pelvis is of no great weight; 
we should be inclined to lay some stress upon this point, 
as it gives us a combination of two very important 
causes of prolapse. Though each is dangerous in itself, 
when concomitant they lose in effect. 
I must here diverge a moment from my subject to 
establish the point I have just touched upon, a disputed 
question in which I most thoroughly concur in the 
views of Michaelis, who says that malpositions of the 
foetus are by four times more frequent with contracted 
than with normal pelves ; this I have found to be the 
case, contrary to the ground held by INaegele, who main- 
tains that such positions are never brought about by 
distortion of the pelvis. 
4. Influence of the Contracted Pelvis upon the Pro- 
lapse in Ip. and M.p.-—-We must finally consider the 
distribution of the contracted pelves in cases of pro- 
lapse among primiparse and multiparse, as I must here 
again refute a theory which is quite freely accepted, 
namely, that the contracted pelvis has but little to do 
with causing the prolapse of the cord among I.parse, 
that it only attains its full importance in this respect 
upon the advent of the second child. Engelmann : Prolapse of the 
Now, we naturally inquire, how does this commonly 
accepted statement harmonize with our data ? What are 
the facts ? 
Per cent. Per cent. 
Among 44 Lp. we find 30 contr. pel. = 68.2 44 I.p. 80 contr. pel. = 68.2 
“ 51 ll.p. “ 30 “ = 58.8) nK u 
“ 65 M.p. “ 35 “ = 53.8 [ 116M-P- 60 -56 
Only 27.5 per cent, of the 160 women in labor (our 
cases of prolapse with measured pelves) are primiparse, 
and upon these come 31.5 per cent, of the contracted 
pelves, the same quantity which is distributed among a 
large number of secundiparse—32 per cent, of the 160 
prolapses; and in cases of prolapse among multi parse 
in general, the contracted pelvis is still more rare ; thus 
we have malformation of the pelvis in 56 per cent, of 
all cases of prolapse among multipart, whereas of 
primiparse 68.2 per cent, are so affected. 
As to the relative frequency of the prolapse among 
primiparse and multiparse, no average has as yet been 
accepted, the statements made by various investigators 
differing so very much ; that at least my results may be 
precise, I must, in the discussion of this point also, con- 
fine myself to the deliveries observed in the Lying-in 
House. 
Table V.—Relative Frequency of the Prolapse among Prtmiparhl 
and Multipart. 
Lying-in House. 
Out-door cases. 
35 cases of prolapse to 2,977 multiparas = 1 : 85 
37 “ “ “ “ 2,923 primiparae = 1: 108 
03 “ “ “ “ 5,900 deliveries = 1 ; 94 
243 prolapses among multipart 1 
57 “ “ primiparse 'j. 4 35.7 
300 J 
Prolapse 1.27 times more frequent among mul- 
tiparae than among primiparse. 
Relative frequency of prolapse among mul- 
4 26 
tiparse and primiparse = -1—- ; 1 = 1.4 ; 1 Umbilical Cord. 
35 
Among tlie 5,900 parturient women there waited 
upon we have 2,923 primiparse, in 27 of whom labor 
was complicated by prolapse of the cord ; compared 
with these we find an almost equal number of multi- 
parse, 2,977, with 35 cases of prolapse (21 of which 
occurred in secundiparse and 14 in pluriparse). 
So we see that the Lying-in House cases give us 1 pro- 
lapse to 108 parturient primiparse, whereas among the 
multiparse the ratio is as 1 : 85, making the occurrence 
of the prolapse somewhat more frequent among multi- 
parse than among primiparse (1.27 : 1). 
Though I have said that only the above compila- 
tion was to be thoroughly relied upon, I cannot refrain 
from giving the result of my calculations from the out- 
door cases, which are, to say the least, interesting, and 
claim a certain importance from their remarkable coin- 
cidence with the numbers obtained in the Lying-in 
House. 
Among the out-door cases of labor in which we have 
prolapse of the cord, multiparse were afflicted with this 
complication in 243 cases, whilst it occurred but 57 
times among primiparse, this being a ratio of 4.26 : 1. 
As I have no statistics which would give me the dis- 
tribution of primiparse and multiparse among cases of 
normal labor in Berlin during the same time, I must 
take the generally accepted statement that upon an 
average 3 of every 4 parturient women are multiparse; 
that cases of labor are 3 times more frequent among 
multiparse than among primiparse. We have found the 
prolapse in our out-door cases actually to occur 4.26 
times more frequently among multiparse, which would Exgelmaxx; Prolapse of the 
make the relative frequence of its occurrence among 
, . , . . 4.26 
multiparse and pnmiparse as : 1, or as 1.4 : 1, a 
ratio very similar to that obtained from the Lying-in 
House records. 
Our cases show that relatively the prolapse occurs as 
a complication of labor almost as often among primi- 
parse as among multiparse; I must acknowledge that 
when the contracted pelvis is excluded as a cause, 
the prolapse will become less frequent, but especially 
among primiparse, as those of the causes which we have 
traced more particularly to multiparse then become 
prominent. 
This is a point which I must discuss more at length, 
it being of great importance in the setiology of the 
prolapse. 
Among the first to combat the assertion made by 
most authors, that the prolapse of the cord was by fa-v 
more frequent among multiparse than among primi- 
parse, was Martin, then at Jena, who had observed its 
occurrence relatively almost as often in cases of first 
labor. It is this compilation of ours, of a very fair 
number of prolapses, justifying us in rather conclusive 
deductions, which has shown that the prolapse of the 
cord is almost as frequent an accident in the strong, rigid 
uterus of the primipara as in the more yielding womb 
of the multipara, and this is one of the urgent reasons 
which lead me to deny most positively that the main 
and primary cause of the prolapse is to be sought in the 
condition and action of the uterus. 
Hildebrandt (Beitrage zur Aetiologie und Behand- Umbilical Cord. 
37 
lung des Nabelscbnurvorfalls bei Kopflagen, Magazin 
fur Geburtsbiilfe, xxiii., p. 115), says that the most 
frequent and most important cause of tlie prolapse is 
found in a pathological condition of that organ, and 
not in any malformation of the pelvis. 
This view be bases upon bis observation of probably 
but a small number of cases in wbicb be found tbe 
prolapse of tbe cord a very rare occurrence among 
primiparse; a premise wbicb we bave seen is false— 
false even if we limit ourselves, as be bas done in bis 
article, to the cases of prolapse with bead-presentation 
of tbe foetus. He says that it is by far less often tbe 
contracted pelvis wbicb prevents tbe bead from de- 
scending upon tbe os than it is a deformity of tbe womb, 
or a malposition of tbe foetus, caused perhaps by a 
pathological condition of tbe pelvis. 
So much for bis data; ours differ. In tbe Lying-in 
House tbe relation of primiparse to multiparse in tbe 
prolapse cases is 1 : 1.27; and even if we consider our 
vertex presentations separately, we find that 15 of tbe 
36 occur in primiparse, and 21 in multiparse, wbicb is no 
great increase in tbe proportion of multiparse, tbe ratio 
here being 1 : 1.4. 
It is certainly true that in multiparse the occlusion of 
tbe os is more or less imperfect; dilatation takes place 
at a much earlier period of labor than in primiparse, 
whilst tbe presenting bead is still high in tbe pelvic 
canal, thus greatly favoring tbe occurrence of tbe pro- 
lapse by giving space through wbicb tbe cord may 
readily glide, if more potent causes are acting which 
lead to this mishap. Moreover, among multiparse we 38 
Exg-elman’jst : Prolapse oj trie 
more frequently have transverse and shoulder presenta- 
tions, and also the venter propendens, the result of re- 
peated labors—circumstances which indeed greatly 
favor the occurrence of the prolapse, and but rarely 
occur in primiparse. In these the contracted pelvis is 
the main cause of this dangerous accident; and we find 
this to be the case in 60 p. c. of all the primiparse ob- 
served in the Lying-in House whose labor was compli- 
cated with prolapse of the cord. 
As another argument to prove his theory that the 
prolapse is due mainly and primarily to a pathological 
action of the womb, Hildebrandt cites those cases in 
which the prolapse has been repeatedly observed in the 
same woman; he admits that a contracted pelvis fre- 
quently complicates these cases, but according to his rea- 
soning it is not this, but the always equally insufficient 
action of the uterus which causes the prolapse of the cord. 
I will not deny the possibility that the prolapse of the 
cord in several successive cases of labor may be in con- 
nection with, or dependent upon, a pathological condition 
of the uterus; yet I know of no single instance in which 
I could confidently assert this to have been the case. 
In all such labors, whether observed in the Lying-in 
House or among the out-door cases, we find a contracted 
pelvis, and this is certainly the primary cause of the pro- 
lapse ; how far the uterus may have suffered from this 
condition of the pelvis, and in what way its diseased state 
may have affected the prolapse, I, at least, cannot say. 
One case only (No. 11 of the out-door cases) is an 
exception: the pelvis is moderately enlarged; it was the 
sixteenth child; several of the last had come as footling Umbilical Cord. 
39 
cases, with prolapse of the cord in one. Here we must 
indeed admit that the laxness of the tissues of the womb 
and abdominal walls, with malposition of the foetus, 
were causes of the repeated accident. Another case in 
which prolapse was repeatedly observed (No. 17 of 
the out-door cases), I have placed among the normal 
pelves, as the measurements given show nothing de- 
cidedly abnormal, ant. post. 19 cm., inf. transv. 27.5, 
sup. transv. 28.5, oblicpie 21 cm. The somewhat in- 
sufficient length of the latter, but more particularly a 
consideration of the whole, lead me to look upon it as 
a somewhat contracted pelvis. 
Michaelis and others have also observed the repeated 
occurrence of the prolapse in the same woman, always 
in combination with contraction of the pelvis. This very 
fact, observed by eminent authorities, and thoroughly 
established by our own cases, is to my mind a most 
striking proof that the contracted pelvis is one of the 
main causes of the prolapse, primary and pre-eminent. 
It is interesting to study the various circumstances 
to which the different authors, each searching for some- 
thing new, have attributed the prolapse of the cord ; 
thus Hold accuses all such conditions which serve, 
temporarily or permanently, to change the normal and 
regular position of the foetus in ntero; he lays the 
main stress upon the position of the foetus, as others do 
upon the condition of the uterus. 
This is but an idle war of words. The difference 
between these various opinions is not an essential one, 
as all may be traced to the same fundamental cause. 40 
Engelmann : Prolapse of the 
C. APPEARANCE AND CONDITION OE THE PROLAPSED COED. 
The circumstances which complete the picture which 
the prolapse of the cord presents to us, the conditions 
under which it appears, the complications which sur- 
round it, are all of importance, more especially so for 
the treatment, and hence claim our attention. It is 
necessary that I should define the terms here employed, 
as they have heretofore been used indiscriminately, 
whereas I make a well-marked distinction between 
prolapse and presentation, and trust that it will be 
more universally adopted. 
Prolapse of the Cord.—So far I have always spoken 
of the prolapse of the cord, that is, the appearance of 
the cord in the os, or its descent through the os, after 
the rupture of the membranes, as this really is the point 
of clinical importance, the condition which threatens 
the life of the child and calls forth our most active 
efforts for its relief. 
Presentation of the Cord.—If the labor is under ob- 
servation from the very beginning, we may often, in its 
early stages, detect a presentation of the cord. By 
this term I understand its appearance in the os, within 
the still intact membranes, so that it may be reached 
by the examining finger. 
In the Lying-in House we have 7 cases recorded in 
which the funis was found presenting, 7 of the 50 cases 
observed throughout from the very commencement of 
labor; thus showing that among every 7 cases of pro- 
lapse the funis had been presenting in but one. In 
all such cases, prolapse inevitably follows the rupture Umbilical Cord. 
41 
of the membranes and the escape of the waters, unless 
active measures are taken and circumstances prove very 
favorable for treatment. 
Among the out-door cases the presentation of the 
cord was discovered in several instances, but these 
cases are useless to us for any comparison with regard 
to frequency of occurrence, as it was mostly the very 
fact of the cords having prolapsed which caused the 
attending midwife to summon medical aid; very few 
were observed from the commencement of labor. We 
see that the cases are rare in which the cord presents, 
where a loop of the soft, slippery, pulsating funis lies 
in the os, still enclosed within the foetal membranes. 
The life of the foetus is threatened in this situation, 
when the head presents, as the descending cranium may 
compress the cord notwithstanding the shielding pre- 
sence of the waters. 
It sometimes happens that the funis is not to be 
reached by digital examination, that we do not suspect 
it of presenting, and yet the foetal heart ceases to beat, 
and with the escape of the waters a pulseless funis 
prolapses, indicating that a small loop which had 
slipped down, though not far enough to present plainly, 
had been compressed by the descending head. 
Ordinarily the threatening danger is not suspected 
until the waters escape, and with these the cord is 
forced down. Rarely does the cord prolapse after the 
rupture of the membranes. Of such cases we have 
but 4 on record among our entire number of prolapses; 
they occur under peculiar circumstances, when the 
waters escape at an early period of labor, while the os 42 
Exoelmaxx : Prolapse of the 
is still imperfectly dilated and tlie foetal membranes 
tightly stretched across the small opening; the rupture 
in the membranes being but slight, and high above the 
os. Under such conditions it is impossible for the cord 
to prolapse until the os is more fully dilated and the 
membranes have been forced aside. 
Extent of the Prolapse.—Usually one loop lies in the 
os or descends through it into the vagina, yet the cord 
may prolapse to a much greater extent, and protrude 
from the genitals; in a very much contracted pelvis, or 
in foot and cross presentations ; several loops of the 
funis sometimes lie in the vagina; yet all these varying 
circumstances are of little interest and without impor- 
tance either for the prognosis or treatment. 
Table Yl.—Location of the Prolapsed Loop in 36 Oases op Vertex 
Presentation. 
Positions. 
I. 
II. 
III. 
IY. 
Left sacro-iliac fossa 
7 
3 
1 
Right sacro-iliac fossa 
5 
3 
1 
Left acetabular region 
3 
5 
Right acetabular region 
5 
1 
1 
Behind the symphysis pubis 
3 
1 
Location of the Prolapse.—l define the locality of 
the prolapse as that part of the pelvis in which, either 
by an irregularity in the configuration of the maternal 
parts, or by an abnormal position of the presenting foe- 
tal part, an unoccupied space is left between the two, 
through which the cord escapes. The determination of 
this point is of importance, as upon it depends to a 
great extent the pressure to which the funis will be 
subjected during the progress of labor. Umbilical Cord. 
43 
In the discussion of this subject I shall coniine my- 
self to vertex presentations. I merely mention, that in 
foot, cross, or shoulder presentations the locality of the 
prolapse is more difficult to determine and is of far 
less importance for the prognosis; the prolapse in these 
cases usually takes place in that part of the pelvis to 
which the foetal insertion of the funis, the abdominal 
front of the foetus, is directed; this mostly being the 
sacrum, the cord is thus thrown into the shelter of one 
or the other of the sacro-iliac fossae. 
In vertex presentations as well purely theoretical 
considerations lead us to suspect the sacroiliac fossae 
as the space in which the funis most frequently finds 
room to descend, and for the following reasons : 
The nerce of the pelvis in the sacro-iliac fossae is such 
as to leave one of these recesses unoccupied in any posi- 
tion the head may assume; moreover, those vertex pre- 
sentations predominate in which the face of the child 
looks towards one of the sacro-iliac synchondroses, 
placing the foetal insertion of the cord in the posterior 
part of the uterine cavity, where we also find its 
placental insertion in by far the greater number of 
cases ; this throws the mass of the funis into the pos- 
terior part of the cavity, everything tending to guide a 
descending loop into the sacro-iliac fossa. 
In the first vertex presentation in which the right 
oblique diameter * of the pelvis is occupied by the 
longitudinal axis of the foetal head, the occiput near 
* I have named the diameters right and left oblique, according to their pos- 
terior terminal point. 44 
Exg-elmajxn: Prolapse of the 
the left acetabulum, the forehead in the right sacro- 
iliac fossa, we would naturally seek the path of the 
prolapsed cord at one of the extremities of the unoccu- 
pied diameter, in the region of the right acetabulum, or 
of the left sacro-iliac synchondrosis. 
In a second vertex presentation we should expect the 
prolapse to take place in the right sacro-iliac fossa or in 
the region of the left acetabulum. 
Such are the theoretical deductions which have 
forced themselves upon me, and which, I am proud to 
say, I have been amply able to verify by a review of 
our cases. 
Notwithstanding that the prolapse of the cord in 
vertex presentations so often occurs while the fcetal 
head is still high in the pelvis, occupying the trans- 
verse diameter, or that a deformed pelvis complicates 
the case, somewhat changing the normal course and 
the relation of the various diameters of the foetal head 
to those of the pelvis, to a certain extent liberating the 
diameters theoretically occupied, we still find (Tab. VI.) 
that when the prolapse takes place in the first vertex 
presentation, the cord descends most frecpiently in the 
left sacro-iliac fossa and in the region of the right ace- 
tabulum. Among 12 cases with the foetus in second 
position, the cord was in 8 instances found where 
we should theoretically expect it—thrice in the right 
sacro-iliac fossa, and five times in the left acetabular 
region; in 2 cases the prolapse took place in the left 
sacro-iliac fossa, a place which may easily become the 
seat of the accident when the course of the foetal head 
is a somewhat abnormal one; in one instance the cord Umbilical Cord. 
45 
was found behind the symphysis, and in one case in the 
right acetabular region—a very rare occurrence. 
We see that in the 36 cases of vertex presenta- 
tion in which the location of the prolapsed loop is 
given, there are but three instances in which the pro- 
lapse took place in that section of the pelvis originally 
occupied by the occiput; one of these is the case just 
mentioned of a second position in which the cord pro- 
lapsed in the right acetabular region, which we may 
perhaps explain by the fact that in the very commence 
ment of labor the presenting head, which in a later 
stage assumes the second position, occupies the right 
diagonal diameter of the |>elvis, with the occiput in the 
right sacro-iliac fossa. Here the cord, subjected to 
pressure in a confined space, prolapsed pulseless; so also 
in one of the two cases of first position in which the 
prolapse occurred in the left acetabular region. The 
other case, in which a jmlsating cord prolapsed in the 
section of the pelvis occupied by the occiput, we can 
only explain by the fact that the head first presented 
in fourth position, with the occiput in the left sacro- 
iliac fossa, leaving the left acetabular region unoccu- 
pied; in this the cord descended, and was probably 
preserved from pressure by the rapid descent and 
delivery of the head after assuming a first position. 
As far as our cases go, facts prove my theory; and I 
am warranted in stating that the prolapse of the cord, in 
vertex presentations, as a rule, takes place in one of the 
terminal points of that diagonal diameter of the pelvis 
which is not occupied by the foetal head—the sacro- 
iliac fossa being the one which is most frequently the Exgelmaxx : Prolapse of the 
seat of the accident, on account of the formation of 
that section of the pelvis ; less often is it the acetabular 
region. Very rare, and in most instances fatal, is the 
occurrence of the prolapse in any region occupied by the 
occiput, as its rounded shape, adapted to the formation 
of the pelvis, leaves but little space for the cord to de- 
scend, and subjects it, once prolapsed, to an unavoid- 
able and fatal pressure. Equally dangerous, and not 
often met with, is the prolapse of the cord directly be- 
hind the symphysis pubis, where there are no soft parts 
to protect the funis, which must inevitably be crushed, 
forced between cranium and symphysis in the descent of 
the head. 
Pressure upon the Cord.—The prolapse of the 
cord imperils the life of the child, not, as has often 
been supposed, by the exposure of the prolapsed 
loop to the atmosphere, but by the pressure to which 
it is subjected; and this depends upon the condition 
of the maternal parts, the kind of pains, the foetal 
part which presents. In head-presentations where a 
hard unyielding part endangers the cord for a longer 
time, the location of the prolapsed loop, with regard to 
the pelvic diameter occupied by the foetal head, is 
the most important of all those points which determine 
the pressure to which the cord is subjected. 
In all other presentations less danger threatens the 
cord, as it is often not subjected to pressure until the 
very last stage of parturition, and then not for any 
length of time ; in many cases the pressure is so slight, 
scarce affecting the circulation in the umbilical vessels, 
that the powers of nature suffice to develop a living child, Umbilical Cord. 
unaided by the hand of the obstetrician. Several such 
cases were observed in the out-door department, some 
few in the Lying-in House ; one of these latter was even 
a case of vertex presentation, a first position, in which 
the cord was found presenting while the head was still 
in the brim, and the os not more than 1.5 cm. in di- 
ameter. The patient was placed upon her left side, the 
side occupied by the occiput, to hasten the descent of 
the head. The condition of the cord and the course of 
the labor were continually watched, and the patient 
directed how to assist its favorable progress by all 
means in her power; yet as there was no direct inter- 
ference by the hand of the obstetrician, we may still 
call it a case of natural labor. The patient was for- 
bidden to press with her abdominal muscles, and thus 
the membranes were preserved until the os was fully 
dilated. With the escape of the waters the cord came 
down in the right acetabular region, the anterior termi- 
nal point of the unoccupied pelvic diameter. The head 
being rapidly developed by a healthy action of the 
uterus and abdominal muscles, a strong, living child 
was born. 
The two other cases in which the cord escaped any 
serious compression were foot-presentations, in which 
no further assistance was rendered than is usual in such 
cases—manual delivery of the head. 
Unfortunately, these are but exceptional instances, as 
the prolapsed funis is inevitably subject to a pressure 
which is greater or less according to the relative condi- 
tion of the antagonistic powers; thus the compression 
of the cord may be but slight yet continued, or sudden 48 
Exgelmaxn Prolapse of the 
and severe, causing either a slow diminution, or a rapid 
cessation of the interchange between the foetus and its 
source of life, the placenta. The child no longer re- 
ceives the full amount of purified, oxygenized blood, 
necessary for its existence. The accumulation of car- 
bonic acid causes the foetus to seek its oxygen from 
other sources; intra-uterine inspirations are the result; 
but it is not oxygen, not air, it is meconium and liquor 
amnii which fill the expanding lung. As long as the 
medulla oblongata is still stimulated to increased action 
by the accumulating mass of C02, a morbidly increased 
activity of the heart, a few rapid, weak inspirations 
follow, and the foetus succumbs to the C02 intoxi- 
cation—perishes in an asphyctic state. 
Prolapse of Extremities.—Presentation, or prolapse 
of the superior or inferior extremities, not unfrequently 
complicates the prolapse of the cord, yet it is by no 
means to be considered as one of the causes, as Scanzoni 
takes it to be. The prolapse of the extremities is equiv- 
alent to that of the cord; both are brought about by 
the same causes, and those cases are exceedingly rare in 
which we are forced to look upon the one as the cause 
of the other. 
In 3 of our 63 prolapse cases, from the Lying-in 
House the descent of one or the other of the extrem- 
ities was noticed by the side of the presenting head, 
and in head-presentations alone is the prolapse of the 
extremities in combination with prolapse of the cord of 
interest. Among the out-door cases this combination is 
noticed much more frequently, as the conditions for its 
occurrence are by far more favorable in the greater Umbilical Cord. 
49 
number of multiparse. In 50 of the 302 cases of pro- 
lapse of the cord, one of the extremities, of course 
mostly an arm, had prolapsed with the funis on account 
of the irregularity of the pelvic canal, or its incomplete 
obstruction by an abnormity in the descent of the ad- 
vancing head. 
Saxtorph, in his compilation, obtains a similar result; 
he finds prolapse of an extremity complicating prolapse 
of the cord in head-presentations 41 times out of 253 
cases of prolapsus funiculi. 
D. POST-MOETEM APPEAEAXCE OF THE CHILD. 
We have seen in what way the prolapse of the cord 
endangers the life of the foetus, and we must next ask, 
What are the anatomical changes which a child pre- 
sents whose death has been caused inter-partum by 
compression of the prolapsed cord ? Is the post-mortem 
condition such that the pathological anatomist can with 
certainty point to prolapse of the cord as the cause of 
death ? These are questions of the utmost practical 
importance, which I can, unfortunately, answer in a but 
very indefinite way. 
Hoping to obtain some definite and positive results, 
I made very thorough post-mortem examinations of 
children whose death had been caused, during labor, 
by prolapse of the funis ; at the same time, as a check 
upon my investigation, I examined, with equal care, 
the bodies of those who had perished inter-jpartum 
from other causes. The result was a negative one, so 
that I desisted from farther pursuit of an investigation 
which looked so unpromising. 50 
Exgelmaxx : Prolapse of the 
I shall refer in my statements more particularly to 
the post-mortems of 13 thoroughly examined cases 
in which death had been caused by compression of the 
prolapsed cord. Some of the cases are taken from 
the books; the autopsies not having been made with 
special reference to the question now before us; the 
points here of importance have not always received the 
necessary consideration; yet the notes suffice to give us 
an understanding of the subject. 
The pathological conditions found in the different 
subjects vary considerably; we mostly find a more or 
less marked venous hypersemia of the internal organs, 
especially of the lungs, liver, and kidneys; the surface 
of the liver was frequently found to be very dark, con 
gested along the margin, and pale, sometimes marbled 
in the centre. In two cases the organs were found ex- 
quisitely anaemic. Among the most constant findings 
are numerous small ecchymoses; in only 3of the 13 
post-mortems none were discovered; in several instan- 
ces they were quite scarce, only a few small ones being 
found in the heart and in the kidneys. Ecchymoses 
most frequently occur in the lung and pleura, in the 
heart and pericardium, in the thymus gland as well as 
upon the liver; they &re more rarely found in the 
spleen and kidneys, and in the mucous membrane of 
the stomach. In a few of our cases small extravasa- 
tions had occurred in the galea, beneath the perios- 
teum, and in the brain. 
The serous membranes of the large cavities of the 
body principally are threatened with ecchymoses, above 
all the pleura, for with every intra-uterine inspiration, Umbilical Cord. 
51 
which is an expansion of the thorax without a corre- 
sponding expansion of the lung on account of the lack 
of air ; the external pressure upon the congested vessels, 
which counteracts the force of the blood from within, is 
diminished, the delicate walls of the capillaries can 
no longer resist, they burst, blood extravasates, and we 
have the ecchymosis. The oedema, which has been 
considered one of the most characteristic and most con- 
stant appearances in death caused by prolapse of the 
cord, we find in but 6 of our cases, and affecting very 
different localities, most frequently the scrotum, the 
umbilical vessels, the porta hepatis, and the lungs ; in 
5 cases the fact is especially mentioned that no oedema 
was found. 
Small extravasations, of blood, ecchymoses, occur, as 
wTe have seen, more frequently than the oedema; and 
this is to be expected, as in most instances where pres- 
sure is exercised upon the prolapsed cord, the circum- 
stances which favor the production of ecchymoses are 
given, whatever the individualities of the case may be, 
be it a slight and continuous or a sudden and severe 
<D > 
pressure which constricts the cord. The oedema, on the 
contrary, is dependent upon a slight but long-continued 
compression of the umbilical vessels, the increased pres- 
sure in the arterial system. Sudden and thorough com- 
pression prevents its appearance by the too rapid de- 
struction of life. 
The lungs are mostly found in a state of complete 
atelectasis; very rarely they contain a little air, and 
then only in but few of the alveoli. 
Meconium and liquor amnii were, in two cases, found 52 
Exg-elmaxx : Prolapse of the 
in the bronchi, probably not oftener because the air- 
passages were not in all cases carefully opened. Twice 
they contained a sero-hemorrhagic fluid, and twice they 
were found quite empty, normal. 
The stomach, in one case, contained meconium and 
amniotic fluid. 
The cavities of the pleura, pericardium, and peri- 
tonseum are in most cases more or less filled with a 
serous, slightly hemorrhagic fluid. 
We see that these various cases have, to a certain 
extent, some changes in common, yet not one which we 
find throughout, not one which we might call pathogno- 
monic ; and yet we must ask, Is there nothing which is 
characteristic for a death caused by prolapse of the cord ? 
the oedema ? the ecchymoses ? My own investigations, 
as well as the records of the Berlin Lying-in House, rec- 
ords of a large number of post-mortems, prove that the 
very same changes are also found in children who have 
perished from other causes during parturition. 
I have found the same oedema, even the oedema of 
the genitals, in head-presentations; in breech-presenta- 
tions it is, of course, a usual occurrence; ecchymoses 
are quite frequent, even in connection with complete 
atelectasis of the lungs, and they occur in the same 
places, upon the pleura, the pericardium, and the peri- 
tonseal covering of the liver. The exudations in the 
serous cavities are likewise found. This may at first seem 
strange, yet it is readily explained when we remember 
that the same conditions prevail in a breech-presenta- 
tion as in a prolapse of the cord; the same anatomical 
changes are called forth. But when the organs of a Umbilical Cord. 
53 
foetus winch has perished while passing the pelvic canal 
in a head-presentation display the same complication of 
symptoms—oedema, ecchymoses, meconium, and liquor 
amnii in the bronchi—we must naturally suppose, 
though no prolapse was observed, that a compression 
of the cord has taken place in utero, where it was 
more exposed, being coiled around the neck ; this seems 
to be proved by the post-mortem condition of two cases, 
which appeared very striking to me. 
Lying-in House, 22, 2, ’72. Child of Otilia H.; vertex 
presentation; cord coiled twice around the neck ; oede- 
ma scroti; lungs containing air; ecchymoses in all or- 
gans ; vernix caseosa and meconium in the bronchi; oede- 
matous condition of the umbilical vessels. 
Out-door cases, 26, 10, ’7l. Child of Agnes T.; ver- 
tex presentation; pressure upon the coiled cord; bloody 
serum in the abdominal cavity; atelectasis of the lungs; 
ecchymoses upon liver and lungs. 
The same anatomical changes are also produced by 
premature detachment (expulsion) of the placenta (out- 
door cases, Ferd. 11., 6, 2, ’72) ; yet they may even 
occur, and it is my duty to point out this fact, in simple 
cases of head presentations in which it is impossible for 
us to refer them to any of the above-mentioned compli- 
cations. 
I cannot concede that one of the umbilical vessels, 
veins or arteries, is more subject to pressure than the 
other on account of their anatomical conditions, as has 
been asserted by many; they are enveloped by the 
same protecting tissue, Wharton’s gelatine, and the 
difference in the structure of their walls is so slight, 54 
Engel Mann ; Prolapse of the 
that no theories can be based upon these circumstances; 
the one cannot resist compression more than the other. 
It is the position of the cord, the shape of the parts 
between which it is crowded, and the part of the cord 
which is most compressed, which causes the flow of 
blood through veins or arteries, or through both, to be 
checked. This gives us an explnation for the varying 
appearances of hypersemia and anaemia. 
To conclude, I must again state that the post-mortem 
examinations of the children whose death was caused 
by prolapse of the cord has given us but a negative re- 
sult, as it is nothing more than a death from asphyxia, 
which the foetus suffers from so many other causes; 
the circulation of the blood is hindered, checked, the all- 
important oxygen is no longer supplied, and the foetus 
perishes in a C02 intoxication. 
E. DIAGNOSIS. 
The prolapse of the cord is easily diagnosed, so also 
a simple presentation of the cord, provided it is a pul- 
sating loop we are dealing with, and not too high in 
the pelvis, at a very early stage of labor, or protected 
from touch by great tenseness of the foetal membranes. 
A possibility of a mistake in the diagnosis may arise if 
the presenting cord has ceased to pulsate and the os 
is but little dilated; but this will easily be rectified upon 
more perfect dilatation of the os. 
F. PROGNOSIS. 
The risk to the life of the child from the prolapse of 
the cord would seem great, according to our results from Umbilical Cord. 
55 
tlie Lying-in House and out-door cases; the mortality 
is indeed large in itself on account of the unfavorable 
circumstances under which the obstetrician is forced to 
act, but not large, on the contrary favorable, as com- 
pared with the results of others. 
Table VII.—: 
■Mortality. 
Presentations. 
Lying-in House. 
Out-door Cases. 
Total. 
Saved. 
+ 
Saved. 
t 
Saved. 
+ 
Number. 
Per cent. 
© 
& 
a 
p 
& 
Per cent. 
a> 
& 
a 
A 
Per cent. 
| Number. 
Per cent. 
.Q 
g 
£ 
1 
Per cent. 
Number. 
Per cent. 
Vertex presentation. 
11 
31.4 
24 
68,6 
65 
39. 
102 
61. 
76 
36.7 
126 
62 3 
Pace 
1 
100. 
0 
0. 
3 
60. 
2 
40. 
4 
66. 
2 
44. 
Breech “ 
2 
100. 
0 
0. 
2 
25. 
6 
75. 
4 
40. 
6 
60. 
Foot “ 
13 
81. 
3 
19. 
36 
68. 
17 
32. 
49 
71. 
20 
29. 
Transverse “ 
0 
0. 
4 
100. 
23 
54. 
20 
46. 
23 
50. 
24 
50. 
Shoulder “ 
4 
80. 
1 
20. 
11 
42. 
15 
58. 
15 
50. 
16 
50. 
81 
50. 
32 
50. 
140 
46.5 
162 
53.5 
171 
47.7 
194 
52.3 
Of the total number of 365 cases of prolapse 171 of 
the children, 47.7 per cent., were saved (Tab. VII.) ; in 
the Lying-in House the number saved is greater, a little 
over 50 per cent.; in the out-door department only 46.6 
per cent. 
This looks unfavorable, but the result is a very fair 
one for hospital practice, and very fair when com- 
pared with the average results of most obstetricians; 
thus, out of the 743 cases of prolapse of the cord com- 
piled from various authorities by Scanzoni, only 335 of 
the children were saved, 45 per cent.; even less fortunate 
than our out-door cases. Michaelis did not save over 26 
per cent. Churchill, in his work, has gathered a large 
number of cases of prolapse of the funis from all possible 
sources, and finds that 47.9 per cent, of the children 56 
Exgelmaxx : Prolapse of the 
were saved. To account for this favorable result, I 
need but state that Churchill has followed the good old 
custom and cited the cases of Mesdames Boivin and 
Lachapelle, which are so wonderfully successful. I 
for my part can place no faith in them, and deem it 
time that these myths be stricken from our roll of 
facts. 
Our results are least fortunate in cases of vertex pre- 
sentation / out of 202 such, the life of the child was 
saved in only 76, 36.7 per cent. This is accounted for, 
not only by the fact that the foetal part, which already 
threatens the cord at an early stage of labor, is large, 
hard, and unyielding, but also by the serious troubles 
which complicated these cases—the 22 craniotomies, 
and the cases of placenta prsevia. Then we have quite 
a number of the out-door cases in which assistance was 
asked after the cord had ceased to pulsate. Deducting 
all these, we have left 111 cases of vertex presentation 
complicated with prolapse of the cord, which were 
amenable to treatment, and which were treated for 
the prolapse and not for any complication. Out of 
these 111 simple cases, 65 per cent, of the children were 
saved—a result which, as we will soon see (Tab. IX.), 
was achieved in the out-door department as well as 
in the Lying-in House. 
The mortality among thq face-presentations is smaller, 
strange to say, than among vertex presentations; of 
the 6 face-presentations observed among our cases, 4 of 
the children were saved. 
The number of cases being so limited, I should not 
deem myself justified in making any general deduc- Umbilical Cord. 
57 
tions, more particularly sc as it does not seem rational 
tliat the face-presentation, dreaded under ordinary cir- 
cumstances, should, when complicated with prolapse of 
the cord, be less dangerous to the life of the child than 
the vertex presentation. The reason for this strange 
result is to be sought in the fact that in these cases medi- 
cal assistance is procured as soon as the face is found 
presenting, often long before the prolapse takes place. 
The case thus comes under observation in a much earlier 
stage of labor than a case of prolapse in an ordinary 
vertex presentation, thus giving greater promise of suc- 
cess to the efforts of the obstetrician in behalf of the 
threatened existence of the child. 
But few breech-presentations are recorded, and these 
remarkably unfortunate, the life of the child being 
saved in but 4 (40 per cent.) of the 10 cases which 
came under observation. The 2 cases treated in the 
Lying-in House, twin-children in each instance, were 
both successful. 
Foot-presentations are our most successful cases, and 
fortunate it is, as they are very frequent, ranking in 
number next to vertex presentations. Among our 
365 cases of prolapse, we have 69 foot-presentations, 
with 49 of the children, 71 per cent., saved; even in 
the out-door department 68 per cent, were saved—6B 
per cent, of all cases observed, including those in which 
the obstetrician found the prolapsed cord cold and 
pulseless upon his arrival. 
Of the foot-presentations complicated with prolapse, 
which were observed in the Lying-in House, 81 per cent, 
were saved, in fact 100 per cent., for among the 3 still- 58 
Exgelmaxn : Prolapse of the 
born in those 16 cases, we have 2 premature deliveries 
(foetus of not much over 6 months), and one child, 
probably syphilitic, already in process of maceration : 
these we can certainly exclude. In the remaining 13 
cases the children were all saved; so that in the Lying- 
in House not one of the viable children was lost in the 
cases of foot-presentation complicated with prolapse of 
the cord. 
The prognosis offered by transverse and shoulder 
presentations is very much the same, and more fortunate 
than we might expect it to be. In the 47 transverse 
as well as in the 31 shoulder presentations which we 
find among our total number of prolapses, 50 per cent, 
of the children were saved. This fortunate result I 
account for by the fact that in these cases the cord is 
less endangered by pressure, and that medical assistance 
is sought betimes. 
We see then that in the prolapse of the cord the prog- 
nosis is most favorable to the life of the child when the 
latter enters the pelvic canal with the feet presenting. 
Next to foot-presentations, but with by far more risk to 
the child, come transverse and shoulder presentations; 
the most dangerous are vertex presentations. 
The number of carefully observed breech-presenta- 
tions is so limited that I cannot accept the result they 
give us as a standard. The prognosis in breech-pre- 
sentations is at least equally favorable with that offered 
by transverse and shoulder presentations. 
So much for the risk to life as affected by the condi- 
tion of the child itself. The points most important 
for the prognosis, however, are those which we find on Umbilical Cord. 
59 
the side of the mother. A prolapse which takes place 
in a primipara gives a prognosis much less favorable to 
the life of the child than one which occurs in a multipara. 
To only 34 per cent, of deliveries complicated with pro- 
lapse of the cord in primipara), which terminated favor- 
ably for the child, we have 50 per cent, of the children 
of multiparse saved. 
That a first labor should be so much more dangerous 
to the child in cases of prolapse, is partially accounted 
for by circumstances already mentioned, which I here 
recapitulate : 
1. The contracted pelvis, which prolongs and en- 
dangers labor, is more frequent in primipara) than in 
multiparse: 68 per cent, of the primiparse showed 
a deformed pelvis, while only 56 per cent, of the 
multiparse were so affected. 
2. Vertex presentations, which render the prognosis 
more unfavorable, occur more frequently in primiparse 
than in multiparse. 
3. The rigidity of the parts in primiparse causes a 
prolongation of labor which greatly increases the risk 
to the child; the os but slowly dilates, and, being firm 
and rigid, renders any operation more tedious and diffi- 
cult. It is especially the greater laxness in the tissues 
of the uterus and the circular fibres of the os which 
makes the prolapse of the cord a much less dangerous 
accident when occurring in a multipara; labor goes on 
more rapidly, the cord, if compressed, is endangered 
for a shorter space of time; the os, being more yielding, 
not only dilates more readily, but causes less compres- 
sion, and, above all, gives ready entrance to the hand 60 
Engelmann : Prolapse of the 
of the obstetrician at a comparatively early period of 
labor. 
The contracted pelvis causes increased risk to the life 
of the child by making the labor more tedious and ren- 
dering any operation undertaken for the preservation 
of the child more difficult. In extreme cases it is of 
course the deformity of the pelvis in itself, and not the 
prolapse of the cord, which necessitates an operation 
mostly difficult and dangerous. 
Taking into account the various points considered, we 
must say that the prolapse of the cord, with all its com- 
plications,—the contracted pelvis and the operations 
consequent thereupon, the premature deliveries and pla- 
centa prseviae, the tardy arrival of the obstetrician, etc.,— 
make the prognosis for the life of the child an unfavor- 
able one, over 50 per cent, of the children having 
perished. If we consider the prolapse of the cord as 
such, theoretically, if we take those cases in which the 
prolapse is the only danger which threatens the child, 
and when obstetrical aid is at hand, we may call the 
prognosis a passably fair one. In cases of this kind, as 
observed in the Lying-in House, 72 per cent, of the 
children were saved. In foot-presentations the safety 
of the child can be predicted with an almost unfailing 
certainty. In transverse and shoulder presentations the 
result is but a trifle less favorable than it usually is in 
these presentations, when not complicated with prolapse 
of the cord. Vertex presentations are the most danger- 
ous, and even in pure cases of prolapse, free from any 
complication, they give a rather unfavorable prognosis. 
In cases of this kind (Tab. IX.) 65 per cent, were Umbilical Cord. 
61 
saved, and this I consider a true average per cent., as it is 
the result achieved in those 111 simple cases of vertex 
presentation, complicated with prolapse, excluding all 
cases in which the labors of the obstetrician were not 
confined to the preservation of the child. 
The prognosis in each individual case, of course, varies 
with the attending circumstances, position, presentation, 
stage of labor, pressure of the waters, size of the os, 
location of the prolapse, kind of pains, condition of the 
mother, etc. 
Finally, in view of the data here presented, we can 
give a somewhat better prognosis for the life of the 
child, in cases of prolapse of the cord, than most au- 
thorities have hitherto ventured to do. 
Among the large number of our cases we have not a 
single instance in which the life of the mother was in 
any way endangered by the prolapse of the cord as 
such; for instance, by hemorrhage occasioned through 
premature loosening of the placenta in cases where the 
cord is drawn over the head, as some authors relate 
them. 
That the death of the mother followed in a number of 
our cases, which include so many very much contracted 
pelves and placentae praeviae, is not surprising; but it 
was caused in every instance by the complication, and 
never by the prolapse itself. 
G. TREATMENT. 
The number of our cases is large, they are unusually success- 
ful, and I here propose to give the methods by which these 
favorable results have been achieved; to the discussion of these 62 
Engelmann : Prolapse of the 
methods I shall confine myself, avoiding theoretical specula- 
tions on treatment, which may be found elsewhere. 
I. Methods of Treatment in General.—There are cases of 
prolapse in which it is not desirable to leave the progress of 
labor wholly to the powers of nature, cases in which interfe- 
rence is necessary, yet no indications for operation exist: here the 
first and most simple assistance we can render is by properly 
directing the patient’s voluntary efforts; either, as the state of 
the case demands, to keep her quietly in one position, refrain- 
ing from pressure with the abdominal muscles, or, when labor 
is far advanced, to encourage her to aid the passage of the head 
by the exertion of all her energies. 
1. Postural Treatment.—Equally simple, and on that ac- 
count probably neglected in clinical teaching, as well as in the 
text-books, is the Treatment by Position, which is a valuable aid 
to the practitioner in conducting any case of labor, and the 
obstetrician who carefully follows the progress of his case can 
often, by this more elegant and delicate method, guide to a 
safe and natural termination a labor in which instrumental in- 
terference would otherwise have been unavoidable. 
By directing the patient to assume an appropriate position, 
and to carefully manage her voluntary efforts, we may, if cir- 
cumstances are favorable, save the child without reposition of 
the cord or any manual interference. 
By an appropriate position I mean the placing of the patient 
upon the side opposite to that in which the funis has prolapsed, 
so that the cord may be relieved from pressure, at least to such 
an extent as the influence of gravity in child and womb will 
permit, and may perhaps be so far released that, slippery and 
yielding as it is, it may glide back into the cavity of the womb. 
Thus when the prolapse takes place in one or the other of the 
sacro-iliac fossae, which is most commonly the case, as we have 
seen, we would naturally seek to throw the weight of the child 
forward upon the abdominal parietes, and this we accomplish 
by placing the patient on her hands and knees, in the knee- 
elbow position. I have achieved good results by this method, 
but the position is unfortunately very tiresome, and difficult to 
retain for any length of time, moreover cannot always be re- 
sorted to in private practice. In case we cannot make use of Umbilical Cord. 
63 
the knee-elbow position, or that it has proved too fatiguing, the 
patient must be placed in the corresponding side position, on 
the left side if the cord has prolapsed in the right sacro-iliac 
fossa. 
In some cases of prolapse we may succeed with this treat- 
ment alone, but we most frequently have recourse to it as a 
preliminary measure, and as such it is our main, I may say our 
only resort in the early stage of labor to relieve the cord from 
pressure, to preserve it well pulsating until the os is sufficiently 
dilated to undertake delivery. 
Thomas, in a paper in the New YorTc Journal of Medicine, as 
early as 1858, warmly advocates postural treatment in cases of 
prolapse ; great credit is due our eminent countryman, who was 
one of the first to have called attention to this method, and it 
would have been well had his teachings been more carefully 
followed. 
By postural treatment he, however, understands exclusively 
the knee-elbow position, which is an undue restriction of the 
term; his conclusions, too sweeping in some instances, were 
based upon only two successful cases, and were very properly 
modified in a later paper in which he says that “ position alone 
will rarely, if ever, cause the return of the cord without the 
aid of manipulation, unless the bag of water is unbroken, and 
even then it may not.” 
This is a very just delineation of the value of postural treat- 
ment, which is not so much a method of treatment in itself as 
an adjuvant necessary in the majority of cases—sometimes, in- 
deed, our only resort. 
3. Reposition of the Cord.—Reposition of the cord, the 
carrying back of the prolapsed loop into the cavity of the 
womb beyond the presenting part, is a treatment which has 
been given up as ineffective by some and is most warmly re- 
commended by others. 
In our cases the results achieved by this method are not the 
most favorable; reposition was accomplished in only 7of the 
11 cases in which it was attempted in the Lying-in House, and 
though apparently successful in these 7 cases, the cord not re- 
appearing, only 4of the children were saved. In the out-door 
department the result gained by this treatment was but little  : Prolapse of the 
better; reposition of the prolapsed loop having been practised 
in 32 cases, and. notwithstanding that the operation seemed to 
have succeeded in 26 of these, not more than 16 of the children 
were saved—in fact, by reposition of the cord alone only 13, as 
delivery was hastened by operation in the 3 other cases. 
The life of the child was saved in 50 per cent, of the cases in 
which reposition was apparently successful, and in 40 per cent, 
of all the cases in which it was attempted; bearing in mind 
that this treatment was only resorted to in the more favorable 
cases, with well-pulsating cord and normal pelvis, we must 
acknowledge that the results achieved were not such as to 
encourage us in giving it a more liberal trial. 
Reposition has been freely resorted to in the cases here 
treated wherever it seemed indicated ; it has perhaps been even 
too frequently tried because recommended by eminent obstetri- 
cians, and I must add by such, whose average results in cases of 
prolapsus funiculi are less favorable than those here achieved, 
but who, basing upon a small number of probably picked cases, 
have sought to prove reposition a most successful method of 
treatment. 
Thus Michaelis, in his main series of prolapse cases, saves but 
26 per cent, of the children, and in his treatise on the reposi- 
tion of the cord (Die Ursa die des Yorfalls der Rabelschnnr, 
nnd die Reposition derselben) cites 11 cases of prolapse, in 9 of 
which he practised reopsition with success; how is this to be 
explained % why was not this method equally successful in a 
larger number of cases'? 
Reposition is justifiable in many cases; in some it is prefer- 
able to any other mode of treatment; it has its strictly defined 
indications which I acknowledge and uphold, but at the same 
time I wish to see it restricted within these well-marked bounds, 
and not too freely resorted to. 
Should the cord have prolapsed and the labor still be in 
such a stage that delivery is out of the question, reposition will 
under certain circumstances be in place, but more frequently 
we must resort to postural treatment and to a strict control of 
the patient’s voluntary efforts. 
Reposition of the cord must, with very few exceptions, be 
confined to cases of prolapse with head presentation; only Umbilical Cord. 
65 
when the rounded and resistant head presents can we expect a 
successful reposition of the prolapsed loop, so that after the 
loop has been carried back into the womb, beyond the greatest 
circumference of the head, the uterus can adapt itself closely 
to the advancing foetal part, and by its firm contraction pre- 
vent the immediate return of the prolapse, and guide the head 
into the most favorable position. Often, when reposition 
has apparently been effected, the cord again descends as soon 
as the hand is removed; in such cases the efforts at repo- 
sition must not be too persistently continued, even if it be with 
the hand alone, which I consider preferable to any of the vari- 
ous instruments recommended. 
Not unfrequently a life is lost by too obstinate perseverance 
in this one method of treatment, as the cord is endangered dur- 
ing a forced reposition by compression and traction, so that 
when the obstetrician has finally accomplished his object with 
considerable labor, the cord he has replaced is pulseless; this 
is an accident which should not be permitted to occur. In 
other cases in which reposition appears to have been successful, 
a small loop, high in the brim of the pelvis, still remains ex- 
posed to pressure, and the operator who, deeming his object 
accomplished, permits labor quietly to progress, will be sur- 
prised to find the child born dead, notwithstanding all his en- 
deavors. We see with what care the reposition of the pro- 
lapsed cord must be attempted, and when presenting still 
greater circumspection is necessary in the treatment. 
Hueter (Ueber Reposition der Yorliegenden Nabelschnur 
bei unverletzten Eihauten. Zeitschr. filr Geburtsh. vi. p. 222, 
1831), who wishes to have reposition performed while the 
membranes are still intact, describes one successful case of this 
kind, and gives this method the preference over that of reposi- 
tion after rupture of the membranes, after prolapse has actually 
occurred. As the time most favorable for his operation he 
describes that period of labor when the os has attained the size 
of a silver half-dollar or dollar, and when the membranes are 
still lax in the interval between the pains. 
The chances for the success of the operation are certainly 
much smaller than those for a rupture of the membranes in 
the attempt; and the escape of the waters at this period of 66 
Engelmann : Prolapse of the 
labor, with presentation of the cord with the head, is an occur- 
rence so dangerous to the life of the child that I must rule out 
this doubtful and hazardous method. 
The reposition of a presenting cord should only be under- 
taken when the os is so far dilated that the escape of the waters 
is no longer to be feared, that, in case of necessity, delivery by 
forceps or turning can be immediately resorted to; in other 
words, this operation is superfluous; it is only to be attempted 
at a period of labor when there is no longer any danger from a 
rupture of the membranes, and delivery is possible and of 
course preferable. If the presentation of the cord is discovered 
at an early stage of labor we must endeavor to force its return 
by a favorable posture of the patient, and the gradually in- 
creasing contraction of the circular fibres in the lower segment 
of the womb; in addition to this the presenting loop may be 
gently pushed upward while the head is being pressed down 
into the pelvis; the parts all being rounded, smooth, and slip- 
pery, the cord glides upward into the more spacious cavity of 
the womb as it is forced aside by the slowly descending head; 
postural treatment alone may sometimes suffice to accomplish 
the result. 
Michaelis gives the following very excellent description of 
the condition of things in this early stage of labor: “In the 
commencement of labor the contractions of the lower seff- 
ment of the womb force the os toward the presenting foetal 
part. Tensely and closely it draws around this, and, if there 
be no abnormity, the presenting loop yields to the increasing 
pressure from beneath ; slowly receding, it glides upward away 
from the os.” Under unfavorable circumstances, in footling 
cases or abnormal position of the head (deformed pelvis), or if 
no part presents, the cord must retain its dangerous position. 
As labor progresses the os begins to dilate, and the labia, as the 
most tense part of the cervix, most firmly encircle the present- 
ing part; the more regular and round the foetal part, the closer 
do they affix themselves to it. 
This presenting part must of course be the head in order to 
secure perfect adaptation; it must be in normal position and 
sufficiently far down in the pelvis—conditions not easily ful- 
filled in a contracted pelvis. Umbilical Cord. 
67 
We therefore see that the reposition of the cord should not 
be attempted; that it would be useless and even dangerous in 
any case other than a vertex presentation with the head de- 
scending in the canal of a pelvis which must deviate but 
little from the normal dimensions. If the pelvis be any way 
contracted, deformed, the uterus cannot so readily adapt itself 
so closely to tbe descending head, the cavity having lost that 
symmetry of form to which all the parts have been moulded, 
and little or nothing is to be accomplished by the introduction 
of sponge or colpeurynter, by which some would simply close 
the space made by the irregularities of the pelvis, in which the 
cord threatens to descend. In transverse and shoulder presen- 
tations reposition is, as a rule, not to be undertaken; it is justi- 
fiable only if the funis descend in a region where it is more 
than usually endangered, for instance, behind the symphysis 
pubis; such cases, however, are rare; in the above as well as 
in vertex presentations we generally find the prolapsed loop in 
one of the sacro-iliac fossae, where it may be preserved intact by 
the proper postural treatment until delivery by turning can be 
accomplished. 
Reposition is by no means to be resorted to as the first at- 
tempt at treatment in a case of prolapsus funis, as has been 
vaguely recommended by some authorities ; we must be guided 
in our treatment by the circumstances of the case, the stage of 
labor, condition of the pelvis and the uterus, by the position 
which the presenting part occupies, and the cause which had 
brought about the prolapse; if a deformed pelvis, no time 
need be lost in futile attempts to return the prolapsed loop; if 
laxness of the tissues, a womb enfeebled by frequent preg- 
nancy, the cord may be returned without difficulty, the head 
forced downward well upon the os by external manipulation 
and there retained until the uterus, stimulated to action by the 
irritation of the operation and friction of the fundus, contracts 
more firmly, and the recurrence of the prolapse is no longer to 
be dreaded; as soon as the os is sufficiently dilated we should, 
however, resort to the more rapid and safe method of turning. 
The operation itself is sufficiently simple. The obstetrician 
introduces that hand which corresponds to the side of the 
patient in which the cord has prolapsed, well into the vagina, 68 
Engelmann : Prolapse of the 
and with two or three fingers carries the loop above the largest 
circumference of the head; with the other hand, manipulating 
externally, he presses the head down upon the os and retains 
both in place during at least one pain, taking care to force the 
head firmly down from without, while removing the hand from 
the vagina, and to continue the external pressure until the head 
has been so firmly grasped by the lower segment of the uterus 
that a return of the prolapse becomes impossible. 
The various instruments devised to aid in reposition are 
well known; the simplest and best adapted to the purpose is 
the catheter, with mandrin, which in Germany is known as 
Braun’s repositorium, in England as Robertson’s funis replacer ; 
yet this should only be resorted to in case of a very small and 
rigid, or retracted os, as the hand will generally be found more 
serviceable. Reposition accomplished, the foetal heart must be 
closely observed; auscultation must guide the obstetrician in 
those anxious moments in which the success or failure of the 
operation becomes apparent. 
It is by auscultation alone, when the pulsation of the foetal 
heart grows weaker and more faint, that we can diagnose those 
treacherous cases where reposition seems to have been accom- 
plished, yet a small loop remains compressed high in the pelvis, 
where it cannot be detected by the examining finger, and where 
speedy delivery is the only hope, if practicable, and if not, 
where postural treatment, our first and last resort, must be 
attempted. 
If the foetal pulse again becomes strong and regular, 
continuing so after several pains, we may be assured of suc- 
cess. 
3. Ancesthesia.—The use of chloroform was frequently re- 
sorted to, and proved a valuable adjuvant in achieving re- 
position of the cord. 
All more serious operations were, whenever at all practi- 
cable, performed under the influence of chloroform, and it is 
to a great extent to the careful and consistent use of this anges- 
thetic that I ascribe the successful results obtained. Chloro- 
form not only renders the operation painless, but above all, 
causes complete relaxation of the muscular fibres, voluntary as 
well as involuntary, and this is the important point. The Umbilical Cord. 
69 
patient well under the influence of the anaesthetic, the uterus 
and abdominal muscles are at rest and yielding; the womb 
no longer offers that intense resistance to the introduction of 
the hand ; the manipulation of hand or instrument in its cavity 
no longer causes irritation and reflex action, and the conditions 
are thus by far more favorable for a rapid and successful 
operation. 
In such cases only where pulsation of the cord had almost 
ceased and speedy delivery was necessitated, was version per- 
formed, or the forceps applied, without the use of chloroform. 
I have spoken of chloroform throughout, upholding the neces- 
sity and the advantages accruing from the use of au anaesthetic, 
without reference to the bitter strife now waging between the 
partisans of ether and of chloroform, which has remained 
comparatively remote from the field of obstetric operations. 
I myself give preference to chloroform, as in labor cases it 
is equally harmless with ether, and less liable to produce 
nausea. 
4. Forceps.—The forceps was not used as freely as we might 
expect; its application, as a means of saving the child, was 
resorted to about as often as the reposition of the cord. In 
15 of the 30 cases in which it was applied, the child was saved, 
which is about the same result as that achieved by reposition 
of the cord, if we deduct those cases in which manual or in- 
strumental delivery was resorted to after reposition had been 
made or attempted. 
Among our Lying-in House cases we find only two instances 
in which the forceps was used; both in a contracted pelvis, 
and both unsuccessfully. In one of these cases version had first 
been performed, but extraction by the feet being impossible, 
the forceps was used ; and this is the only instance we have of 
its application to the after-coming head, its use having been 
restricted to head presentations and to*such mal-positions as 
were reduced to normal vertex presentation during the progress 
of labor, either spontaneously or by external manipulation. 
5. Extraction by the Feet.■— Extraction by the feet simply 
(not following version) was practised in 65 cases, in 47 of 
which, 72.3 per cent., a living child was developed. The suc- 
cess of this operation naturally depends upon the favorable 70 
Engelmanjst : Prolapse of the 
prognosis offered by breech-first labors, in which alone it can 
be resorted to. 
The treatment in foot and breech presentations, as in all other 
cases, if presentation of the cord has been detected, is mainly 
a postural treatment, the patient being so placed that a return 
of the presenting loop may be facilitated ; all muscular strain 
must be avoided, the membranes must, if at all possible, be pre- 
served intact until the os is sufficiently dilated; when this is the 
case, the parts being yielding, we must not w’ait for threaten- 
ing signs on the part of the foetal pulse, but at once deliver. 
Extraction by the feet was practised in 14 of the Lying-in 
House cases, and in only one the child delivered dead, 
putrid; a case which should justly be excluded. We see that 
here the success of the operation is perfect, as might well be 
expected ; less favorable are the results among the out-door cases, 
where the accoucheur, not unfrequently being called in too late, 
was often forced to extract an already lifeless child, the indica- 
tion for the operation existing on the part of the mother. 
6. Version.—The operation which was most frequently re- 
sorted to, which proved, comparatively speaking, most successful, 
is turning by the feet, immediately followed by extraction. 
Of the 125 cases so operated, 72 were favorable, 57.6 per 
cent, of the children were saved, and this result holds good not 
only for transverse and shoulder presentations, but also for head 
presentations; with regard to the latter I shall make especial 
mention of the operation when we come to discuss more at 
length the treatment of head presentations complicated with 
prolapse of the cord. 
In transverse and shoulder presentations, turning, and, if the 
prolapse has already taken place, turning by the feet, is the 
treatment naturally followed; yet when the cord presents, or 
has prolapsed in the early stages of labor, the same rules must be 
adhered to in these as'in all other presentations :if the os is but 
beginning to dilate, and the cord threatened with compression, 
a change in the position of the prolapsed loop, an attempt at 
reposition, and postural treatment are called for; as soon as 
the hand can be readily introduced we must turn and extract 
if possible, with the assistance of full surgical anaesthesia. Umbilical Cord. 
71 
Table Vlll.—Treatment, 
Method of Treatment. 
Lying-in House. 
Out-door Cases. 
Total. 
Number 
Operated. 
Saved. 
t 
j Number 
Operated. 
j Saved. 
t 
Number 
Operated. 
Saved. 
t 
Turn ins. followed by Extraction 
16 
8 
8 
109 
64 
45 
125 
72 
53 
Extraction by the feet 
14 
13 
1 
51 
34 
17 
65 
47 
18 
Eorceps 
2 
0 
2 
28 
15 
13 
30 
15 
15 
Reposition of cord 
7 
4 
3 
26 
16 
10 
33 
20 
13 
Operations for saving the child 
39 
25 
14 
212 
129 
83 
251 
154 
97 
Perforation followed by Cephalo- 
tripsy 
10 
10 
15 
15 
25 
25 
Spontaneous, with postural treat- 
ment 
14 
6 
8 
2 
14 
6 
8 
7. Cejphalotripsy.—Craniotomy can certainly not be classed 
among the operations called for by prolapse of the funis, yet I 
cannot avoid making mention of this operation, as it was so often 
necessitated for the preservation of the mother, and as the large 
number of these operations, 25 among 365 deliveries, compli- 
cated with prolapse of the cord, most forcibly proves the fre- 
quency of the highly contracted and the distorted pelvis as cause 
of the prolapse. In all those cases in which the sacrifice of the 
child was demanded, the presenting part of the foetal head was 
perforated with the trepan-shaped perforator, the skull then 
crushed by the cephalotribe, and delivery completed by extrac- 
tion with the same instrument. 
In the Lying-in House cephalotripsy was resorted to in 10 of 
the 62 cases—17 per cent.—but less frequently, in only 5 per 
cent, of the out-door cases. 
Table 1X.—186 Cases of Head Presentation Complicated with Pro 
LAPSE OP THE CORD. 
Dying-in House. 
Out-Door Department. 
(Oases in which operation was resorted to.) 
Cases of Prolapse amenable to treat- 
ment 20 
Cases of Prolapse not amenable to treat- 
ment as such;— 
Highly contracted pelvis. Cephalo- 
tripsy 10 
Placenta praevia 2 
Child dead when received 3 
Prolapse of pulseless cord 1 
— 16 
36 
Cases of Prolapse amenable to treatment ... 91 
Cases of Prolapse not amenable to treatment 
as such :— 
(Cephalotripsy) 12 
103 72 
Engelmann : Prolapse of the 
11. Treatment of [lead Presentations.—Such were the op- 
erations employed in the treatment of our prolapse cases, and 
in transverse, shoulder, and breech-first presentations no choice 
is given ns as to the method of operation; the skill of the ac- 
coucheur is here shown by a careful preparatory treatment, 
and the judicious selection of the time of operation. 
In head presentations only is a wider range given to the treat- 
ment directed toward the preservation of the child, and it is in 
these cases that the course pursued in the Berlin Lying-in House 
and Out-door Department varies somewhat from that adopted by 
most German obstetricians, especially those of the present day. 
In order to demonstrate this more readily, I have compiled 
those uncomplicated cases of head presentation in which the 
treatment was confined to the prolapse of the cord, and directed 
solely to the preservation of the child. 
Table X. gives us 111 such cases, that may be considered 
pure and uncomplicated cases of prolapse of the funis; although 
they embody a number of moderately contracted pelves; it shows 
that the life of the child was saved in 65 per cent, of the cases, a 
very handsome result, being equally favorable among the 91 
out-door and the 20 lying-in house cases. 
Table X.—lll Cases of Prolapsus Funiculi with Head Presenta 
TIONS, UNCOMPLICATED AND AMENABLE TO TREATMENT. 
Treatment. 
20 Lying-in House 
Cases, 
91 Out-door Cases. 
Total 111 Cases. 
Number of 
Cases. 
Saved. 
t 
Number of 
Cases. 
Saved. 
+ 
O 
M $ 
'A 
Saved. 
t 
Postural treatment 
6 
5 
1 
6 
5 
1 
Reposition of cord 
6 
3 
3 
17 
12 
5 
23 
15 
8 
Forceps 
1 
1 
26 
13 
13 
27 
13 
14 
Version, with, extraction 
7 
5 
2 
48 
34 
14 
55 
39 
16 
65 per cent, saved. 
65 per cent, saved. 
65 per cent, saved. 
Here also turning truly proved “ the master-stroke of the 
obstetric practitioner,” being resorted to most frequently, and 
proving most successful, the child being saved in 70 per cent, 
of the cases. We see the forceps brought into requisition next, 
in 27 cases resulting less favorably, not more than 50 per cent. Umbilical Cord. 
73 
proving successful. Reposition of the cord gave an average 
result, preserving the child in 65 per cent, of the 23 cases in 
which it was resorted to. 
It is scarce necessary to state, what figures so plainly show, 
that version, preceded by judicious postural treatment, is the 
method to be followed which promises most for the life of the 
child in prolapse of the cord when complicating head presenta- 
tions ; of such cases we have so large a number, and so favora- 
bly developed, that the undeniable logic of facts and figures, far 
more than theoretical reasoning, sustain me in the high impor- 
tance I attach to this operation. At what period and to what 
extent reposition may be attempted, we have already seen, 
Hildebrandt, who greatly favors the latter operation, bases 
his theories on 195 cases compiled from those of Hold, Grenser, 
Elsaesser, Braun, and others, head presentations, in which 116 
of the children were saved, 51 per cent. He has, of course, only 
taken such cases in which the treatment was directed solely to 
the presentation of the child, and comparatively simple cases, 
as the frequency of reposition and of spontaneous delivery 
shows. These cases may be compared with our 111 simple 
cases of head presentation (Table X.) which proved far more 
successful, 65 per cent, of the children being saved. 
Cases Compiled by Hildebrandt. 
Number 
of cases. 
Saved. 
+ 
Reposition.. 
Ill 
78 
38 
Turning, with Extraction 
26 
12 
14 
Forceps... 
31 
8 
23 
Spontaneous delivery 
27 
15 
12' 
195 
108 
87 
In these cases of Hildebrandt’s, turning was but rarely re- 
sorted to, and with very unfortunate results. Equally unsatis- 
factory are the results of this operation as given by other au- 
thorities. So Michaelis, in discussing the treatment of pro- 
lapse of the cord as adopted in various lying-in institutions, 
points to the fatal results of turning in order to let the reposi- 
tion appear, by contrast, in so much fairer a light. 74 
Engelmann: Prolapse of the 
Number 
of cases. 
Saved. 
t ‘ 
Postural treatment 
10 
4 
6 
24 per cent. 
Turning-, followed by Extraction 
20 
4 
16 
saved. 
Forceps 
16 
3 
13 
46 
ii 
35 „ 
It seems indeed strange that the operation of turning by the 
feet, in head presentations complicated with prolapse, should be 
so disparagingly spoken of by most authorities, and should have 
given them such unhappy results, whereas in our cases it was 
mainly this very same operation which enabled us to save an 
unusually large number of the children imperilled by that dan- 
gerous accident. 
Hold, with his very unfavorable results, saving but 30 in 95 
cases of prolapse, speaks most discouragingly of the operation, 
directly asserting that by turning after escape of the wa- 
ters a living child was never delivered ; he would only turn 
when the membranes are still intact. Yery good, when possi- 
ble ; but under such favorable circumstances we must not turn 
by the feet unless the os is fully dilated, but by external man- 
ipulation, an operation as yet but little practised, which will 
yield most excellent results when more thoroughly studied and 
more freely applied. This method of turning is called for in 
head presentations when the cord is found presenting and the 
os but imperfectly dilated. 
Ho more do Hobbs results speak in favor of his theory of not 
operating while the pulsation of the cord is still unimpaired : 
such teachings are dangerous ; it is imperative upon us to oper- 
ate as soon as labor has so far advanced that we may expect to 
ojjerate successfully and deliver the child alive. 
I should deem it criminal neglect to hesitate until the very 
last moment, to wait until the pulsation of the foetal heart be- 
comes faint, and life is oozing away. In the 12 spontaneous 
head-first deliveries observed in the Lying-in House, reposition 
of the cord had been practised in 6, yet only 3 of the children 
were saved ; whereas of the other 6 cases, in which protection 
for the cord was sought by postural treatment alone, 5 escaped, a 
result which again admonishes us to devote more careful study 
to this method of treatment than is at present accorded to it. Umbilical Cord. 
The time of operation can bnt rarely be chosen by the ac- 
coucheur, the case being bnt too often given into bis hands at 
the very last moment, and he must act as the stage of labor and 
the condition of the child demand, and act at once; postural 
treatment with membranes still intact can therefore but rarely 
be practised. 
The patient usually comes under observation when advanced 
in labor, when the waters have escaped, and the cord has pro- 
lapsed, and now, if the os be sufficiently dilated, and the head 
unable to enter the brim, or still high in the pelvis, turning by 
the feet is in place, especially if the pelvis be a somewhat 
irregularly contracted one, as the occiput may then be guided 
through the more spacious part of the canal. Should the for- 
ceps be applicable, we must not wait until the pulsation of the 
foetal heart grows faint, but seize upon the auspicious time, 
while the child is still vigorous, and extract, administering 
chloroform to complete surgical anaesthesia, just as we would 
in turning. Worse still it is if the waters have escaped, the 
parts being still rigid, the os not dilatable; in this case, pro- 
vided the head present a normal position, reposition may be 
attempted ; if successful, it must be followed by postural treat- 
ment ; if not, it is equally postural treatment to which we must 
resort as our only chance to save the cord from compression 
until the forceps or turning is possible. 
H. RESUME. 
In conclusion, I will sum up in a few words the facts attained 
and the laws established by the examination of our prolapse 
cases. 
The causes of the prolapse of the umbilical cord have mainly 
proved to be such circumstances as prevent the complete filling 
of the pelvic brim, and the close adaptation of the lower seg- 
ment of the uterus to the presenting part. One of the more 
important of these circumstances is the shape of the presenting 
foetal part itself, and we thus find that foot presentations are 
most frequently complicated by prolapse, whereas vertex pre- 
sentations are least threatened. 
The foetal appendages are of secondary and minor importance; 
undue length of the cord, its marginal insertion or attachment 76 
Engelmann : Prolapse of the Umbilical Cord. 
of the placenta low down in the uterus can never be direct 
cause of the accident; excess of liquor amnii is alone to be 
feared. 
Some stress is to be laid on abnormity in shape and position 
of the womb, much more upon twin births. More dangerous 
than any of these is the contracted pelvis, which I have proved 
by measurements and numbers to be the main cause of prolapse 
of the funis, directly and indirectly; a fact hitherto generally 
accepted, but never as yet clearly established. Another such 
vague, general statement, that the prolapse is by far more fre- 
quent among multiparse than among primiparse, our cases dis- 
prove ; they show that primiparse are, comparatively speaking, 
almost as frequently afflicted as multiparse. 
The law governing the location of the prolapse is of impor- 
tance, and here for the first time touched upon; it will, I trust, 
be verified by the investigation of other observers. 
The post-mortem examinations revealed only the lesions due 
to death from asphyxia, nothing characteristic for death caused 
by prolapse of the cord. 
The prognosis we can give is somewhat better than generally 
allowed; most favorable for foot presentations, after these for 
shoulder and transverse presentations, while vertex presenta- 
tions are more dangerous than any; the case being, under all 
circumstances, more threatening when occurring in a primipara. 
In the treatment of our cases the high importance of the 
postural method has been developed, more as an adjuvant, how- 
ever, than as a method in itself of dealing with the prolapse. 
Yersion is comparatively the most successful of all operations, 
and should be more frequently resorted to when any choice of 
method is given, as in head presentations: the application of 
the forceps and reposition of the cord are less to be relied 
upon; but whatever may be the course determined upon, it 
must be borne in mind that the success of all operations, by 
which we seek the preservation of the child, whose life is 
threatened by compression of the prolapsed cord, is in a meas- 
ure dependent upon the judicious use of chloroform, its appli- 
cation to full surgical anaesthesia. TABLE 1.—160 CASES OF PROLAPSE OF THE CORD, WITH PELYIC MEASUREMENTS. 
A. Sixty-two Lying-in House Cases. 
CIRCUMSTANCES RELATING TO THE 
MOTHER. 
COURSE OF LABOR. 
TREATMENT. 
CHILD. 
d 
s 
I 
Size of the Os 
Prolapsed Portion of Cord. 
s 
a r/? 
| L.-in H. Case 
ti. 
£ 
o 
o 
d 
■S 
O 
- 
< 
o 
d 
£ 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
From the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
livery. 
Living 
or Dead 
B 
<D 
U 
O 
rO 
C3 
,rH o 
+3 B 
si 
® Jh 
>■ fcD 
Dimensions of 
the total Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child. 
Notes and 
Post-mor- 
tems. 
1 
22 
1 
Normal; antero-pos- 
terior contraction ; 
venter propendens. 
Inf. tr., 25. 
Sup. tr., 29. 
Ant.-post., 18.4 
7>£ months. 
I. Footling. 
One loop. 
Extraction of 
head. Bring- 
ing down of 
arms. 
Living. 
2,400 
Post, tr., 
9.2 
left foot in 
right side. 
Long., 
L. obi., 
11.5 
12.1 
2 
30 
1 
7 
Symphysis promin- 
ent. 
Simple contracted. 
Full term. 
10 days be- 
fore time. 
Partus prse- 
matur. arti- 
ficial. 
3 weeks be- 
fore time. 
Strong. 
Af nlpftlre 
Fully en- 
larged. 
Dilated. 
T -Pnntlin cr 
. 
Living; 
asphyc- 
tic. 
Living. 
? 
2,800 
2,400 
Post, tr., 
9.7 
3 
33 
Last labor, 
difficult; for- 
ceps ; previ- 
ous normal. 
of membr. 
Head and 
feet present- 
ing before 
rupture of 
membranes. 
of loops. 
One loop. 
right foot. 
By the side 
Version by the left 
by the feet 
at once. 
5 
Long., 
L, obi., 
Post, tr., 
11. 
12.8 
8.8 
Good. 
4 
25 
2 
Inf. tr., 
Sup. tr., 
Diag. coup, 
24.3 
27.7 
10.8 
Did not be- 
gin until 36 
hours after 
escape of 
Waters. 
Frequent, 
not intense. 
of membr. 
Os dilated. 
II. Foot. 
of the head. 
Coiled 
foot; extraction. 
heart growing 
faint imme- 
diately after 
prolapse. 
Extraction 
as pulsation 
grew faint. 
Perforation; 
with cepha- 
lotripsy. 
Living. 
9 
Long., 
L. obi., 
11.5 
12.1 
after birth. 
Asphyctic; 
survived. 
5 
23 
1 
Inf. tr., 22.9 
Sup. tr., 25.9 
Ant.-post., 19.6 
Rachitic; antero-post. 
cult; large, 
still-born 
child. 
At rupture 
of mem- 
brane. 
Dilated. 
Dilated. 
around the 
feet. 
In right 
Lay 7 hours with 
Dead. 
6 
3.000 
contraction. 
Inf. tr., 26.3 
Sup. tr., 27.7 
Ant. post., 18.2 
Diag. conj., 9. 
side; head 
left. 
pulseless cord. Ver- 
sion attempted. Ute- 
rus too firmly con- 
tracted. 
with- 
out 
the 
brain. 
rapidly. 
6 
22 
1 
i 
Normal. 
Intense, 
painful. 
Pound pre- 
senting with 
an os of 3 
cm. 
Dilated. 
To the side 
Extraction. 
Living. 
? 
2,000 
Ant. tr., 
7.4 
Inf. tr., 
Sup. tr., 
Ant.-post., 
26.5 
29. 
19.8 
before time. 
Head also 
present early 
in labor. 
of feet. 
Post, tr., 
Cong., 
L. obi., 
Short obi., 
8.3 
10.3 
11.5 
9.4 
7 
28 
2 
Moderate; 
antero- 
Malposition; 
version; 
child died. 
Full term. 
Dilated. 
Dilated. 
One loop in 
os. 
To the side 
Postural treatment. 
Version, with 
extraction. 
Living. 
4 
3,400 
Ant. tr., 
8.1 
Good. 
Good. 
post, contraction. 
Infr. tr., 25.6 
Sup. tr., 29. 
Ant. post., 18.9 
Superabun- 
dance of liq. 
amnii. 
of left arm. 
placed on left side. 
Post, tr., 
Long., 
Long obi., 
9.4 
11.5 
15.7 
8 
21 
2 
Moderate; 
antero- 
Full term. 
Full term. 
Partus pras- 
mat. mens. 
YI. 
Full term. 
4.0 cm. 
Dilated. 
Convolution 
of loops. 
Cord pulseless when 
Spontaneous 
delivery 7 
hours after 
Prolapse- 
Extraction two 
hours after 
prolapse- 
Dead. 
4 
3,510 
Ant. tr., 
6.1 
Good. 
Cord oede- 
matous; in- 
ternal or- 
gans con- 
gested. 
9 
27 
2 
post, contraction. 
Inf. tr., 26. 
Sup. tr., 28.4 
Ant. post., 18.7 
Normal, 
large child. 
Natural. 
Weak. 
2.5 cm. 
To the side 
prolapsed. 
Living. 
6 
3,500 
Post, tr., 
Long., 
Long obi., 
8.8 
10.8 
13.5 
10 
24 
1 
Probably normal, as 
not noted. 
Antero-post. contrac- 
plete foot. 
of left foot. 
11 
21 
2 
Natural. 
Strong. 
4.0 cm. 
mitting fin- 
ger. 
IV. Changed 
into I. Ver- 
tex. 
One large 
Near left 
Reposition attempted 
Dead. 
6 
3,330 
Ant. tr., 
8.5 
tion. 
Inf. tr., 
Sup. tr., 
Ant. post., 
Conj. diag., 
23.6 
27. 
16.0 
10.6 
twisted loop, 
pulsating. 
acetabular 
region. 
n right-side position, 
ailed; "then accom- 
plished in left-side 
Dosition ; total heart 
60 per minute. 
Post, tr., 
Long., 
Long obi., 
9. 
12.1 
13.5 
accomplish- 
ed ; the cord 
was still sub- 
ject to pres- 
sure between 
the head and 
the os uteri 
xz 
— 
i 
Painful. 
With rup- 
ture of mem- 
branes. 
Early in la- 
bor ; os very 
small. 
One largo 
In left side 
Child died when 
Perforation; 
cephalotripsy ; 
extraction. 
Dead. 
4 
Fair. 
int. 
montory, antero- 
post. contract. 
Head high in 
pelvis. 
loop. 
of swollen 
os. 
oatient was received 
in the institution. 
iut. tr., 25. 
Sup. tr., 25.4 
Inter, troch., 29.7 
Antero-post., 17.3 
Conj. diag., 9.4 
R. obi., 20.2 
L. obi., 20.2 
13 
31 
i 
Oblique. 
Full term. 
Painful. 
8.0 cm. 
I. Vertex. 
Loop of 5.0 
Left sacro- 
Reposition, with 
Spontaneous. 
3,340 
2,900 
4,459 
2,333 
2,370 
Ant. tr., 
7.4 
CEdema of ] 
scrotum; 
congestion 
of face and 
extremities. 
Putrid; p 
_syphilitic. ] 
Head was 
14 
22 
i 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Giro., 
11. obi., 
L. obi., 
Normal; 
24.3 
27.7 
20.2 
85. 
22.3 
20.2 
rachitic; 
Strong. 
Dilated. 
II. Foot. 
cm. 
A pulseless, 
iliac fossa. 
Between the 
funis replaced in left 
side xtosition under 
chloroform; foetal 
Peart faint; ceased 
beating one hour af- 
ter reposition. 
Pulseless when pro- 
lapsed. 
Unsuccessful at- 
Extraction. 
Dead. 
Post tr., 
Long., 
Long diag., 
9. 
12,8 
14.8 
15 
23 
i 
ant.-post. contract. 
Inf. tr., 27.9 
Sup. tr., 29.7 
Ant.-post., 18.9 
Full term. 
Very weak. 
3.0 cm. 
Cord to be 
felt through 
membranes. 
4.0 cm. 
Membrane 
retracted. 
Dilated. 
II. Vertex. 
Superabun- 
dance of li- 
quor amnii. 
1st child. 
discolored 
loop. 
One large 
feet. 
Version; os 
5.0 cm.; ute. 
riis firmly con- 
tracted ; ex_ 
traction by 
right foot de- 
layed by strio. 
ture of inter_ 
na-l os. 
Detraction. 
side, another 
loop trans- 
versely 
across head 
of child. 
In left side. 
for a long 
time firmly 
fixed on left 
ilium, but 
descended 
when pat. 
was placed 
on left side. 
16 
22 
i 
R. obi., 23.8 
Moderately enlarged. 
Full term. 
Scarce and 
weak. 
Scarce be- 
loop. 
One loop. 
tempt at reposition, 
with an os of 4.5 
cm. 
2 Liv’g. 
Sup. tr., 
Ant.-post., 
Circ., 
30.4 
20.9 
95. 
ginning to 
dilate. 
I. Breech. 
2d child. 
II. Vertex. 
Cord pro- 
lapsed with 
first twin 
child. 
29 
i 
Full term. 
Moderately 
2.5 cm. 
Almost fully 
One loop. 
Found pre- 
Reposition in left- 
Spontaneous. 
Living. 
ft 
3,233 
8.1 
Inf. tr., 
Sup. tr., 
Ant. post., 
Conj. diag. 
Circ., 
L. obi., 
R. obi., 
25.0 
26.8 
18.2 
11.2 
82.0 
20.9 
20.5 
dilated. 
senting in 
left side. 
side position ; foetal 
pulse improving! 
right-side position. 
Post, tr., 9.4 
Long.. 10.1 
Long diag., 13.5 
Short diag., 9.4 
18 
23 
2 
Normal. 
Tnf tr . 
27. 
Natural. 
Full term. 
Weak. 
Early in the 
labor. 
At rupture of 
membranes 
with head in 
brim. 
1.5 cm. 
I. Vertex. 
One loop. 
To right of 
Reposition under 
chloroform with os 
of 3.0 c. m.; funis re- 
placer used ; foetal 
pulse 86-90 after re- 
position ; left-side po- 
sition. 
Cord pulseless when 
received in the insti- 
tution. 
Spontaneous 
Dead. 
Dead. 
2,900 
8.1 
19 
41 
4 
Sup. tr., 28.4 
Ant.-post., 19.3 
Obi., 22.5 
Circ., 89. 
Uterine fibroids; ant. 
Last child 
Full term. 
Weak, at 
At a very 
I. Vertex. 
One loop 
head. 
Right aceta- 
bular region. 
In right 
Spontaneous. 
Post, tr., 
Long., 
Long diag. 
Short diag 
9.4 
11.5 
, 13.5 
, 9.4 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Conj. diag. 
Giro., 
Obi., 
27. 
29.7 
18.9 
10.8 
84. 
22.7 
spontaneous 
delivery; 
head com- 
pressed in 
passage of 
pelvis. 
yals. 
early stage. 
protruding 
from the 
vagina. 
sacro-iliac 
fossa. 
20 
36 
Normal. 
First deliv- 
Partus 
Found pre. 
senting two 
hours before 
rupture of 
membranes. 
yery small. 
II. Vertex. 
Only 
Spontaneous. 
24.3 
Dead. 
n 
Sup. tr., 
Ant.-post., 
Circ., 
Obi., 
27. 
19.8 
85. 
22.3 
ceps; others 
natural. 
mens. VIII. 
preevia late- 
ralis. 
presenting. 
bular region; 
.m internal 
os. 
21 
19 
1 
Rachitic; 
ant.-post. 
End of 9th 
4.0 cm. 
I. Vertex. 
Convolution 
Turning under chlo- 
roform in right-sia 
position by .right 
foot. 
Cephalotripsy. 
2,850 
Good 
Recovery. 
contraction. 
Inf. tr., 27. 
Sup. tr., 27,4 
Ant.-post., 17.1 
Diag. conj., 8.8 
R. obi., 20.0 
L. obi., 20.9 
Circ., 89. 
and begin- 
ning of 10th 
month. 
of loops. 
Dead. 
¥ 
22 
35 
1 
Normal. 
Full term. 
Strong. 
Over 
? 
Twins. 
One very 
In os; 
anterior to 
head. 
Operation soon aitev 
Vision; in 
Posi. 
t10Ih and ex- 
traction. 
2 Liv’g 
1,692 
2,050 
Ant. tr., 7.4 7.4 
Post, tr., 8.9 8.1 
Long., 10.1 10.1 
Long diag., 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Circ., 
26.3 
29.7 
20. 
92. 
5.0 cm. 
II. Vortex 
prolapse. 
I. Breech. 
small loop. 
$ 
23 27 
2 
Moderately large. 
Very easy. 
Full term. 
Strong. 
Dilated. 
I. Vertex. 
Anteriorly 
to side of 
head ; left 
acetab, reg. 
Passing over 
the left 
thigh,tow’rd 
the sacro- 
iliac fossa. 
Living. 
3,016 
4,216 
Ant. tr., 
Post, tr., 
Long., 
Long diag 
8.1 
24 
27 
2 
int. tr., 
Sup. tr., 
Ant.-post., 
Normal. 
26.3 
28.4 
22.3 
Very easy. 
Full term. 
Presenting 
with os; 
5.0 cm. 
pilated. 
I. Foot;,in- 
After left foot vas 
bom total pulse r 
duced to 96. 
hast b® 11 m to 
hasten expul_ 
,, sion. 
• iXtraction. 
9.4 
10.8 
, 12.8 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Giro., 
23.6 
28.4 
19.1 
92.0 
complete. 
¥ 
Post, tr., 10.1 
Long., 13.1 
Long diag., 13.5 
Short diag., 10.5 CIRCUMSTANCES RELATING TO THE MOTHER. 
COURSE OP LABOR. 
treatment. 
CHILD. 
d 
Cl 
s 
o 
o 
d 
1A 
* 
s 
Size of the Os 
Prolapsed Portion of Cord. 
l. 
Cl 
a 
a 
01 
O 
o 
o3 
a 
| L.-in H. Case 
d 
<1 
t 
3 
o 
d 
& 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length- 
Position. 
Prom the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
f livery. 
Living 
or Dead. 
,rH o 
■p jE| 
rC £ 
5 •§ 
Dimensions of 
the total Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child. 
Notes and 
Post-mor- 
tems. 
25 
32 
i 
Pull term. 
Intense in 
early stage 
of labor; 
disappeared 
later. 
Dilated. 
Waters 
escaped very 
early before 
pains set in. 
Unsuccessf’l attempt 
with forceps before 
being brought into 
the Ly’g-in-Houae. 
Perforation; 
Cephalotripsy. 
Dead. 
$ 
4,183 
Ruptura 
Patient was 
brought into 
the L.-in H. 
in a state of 
collapse; the 
foetal head 
firmly wedg- 
ed in the 
pelvis; tym- 
panitis uteri. 
• 
contraction. 
Inf. tr., 25.6 
Sup. tr., 27.7 
Ant.-post., 18.9 
Obi. 22.9 
Circ., 90. 
Post-mortem mea- 
surement. 
Diag. conj., 11.5 
True conj., 10.1 
Obi. d., 13.5 
Obi. s., 12.8 
uteri; peri- 
tonitis ; 
death. 
20 
31 
2 
i 
Rachitic; ant.-post. 
contraction. 
Inf. tr., 26.5 
Sup. tr., 25.8 
Ant.-post., 16.9 
Diag. conj., 9.7 
True conj., 7.6-7.9 
Obi., 20.9 
Craniotomy. 
Pull term. 
Weak at 
first; intense 
and painful 
after use of 
ergot. 
Soon after 
escape of 
waters. 
Waters 
escaped very 
early. 
I. Vertex. 
Behind the 
Reposition severo; 
Perforation 
Dead. 
3,250 
Recovery. 
loops. 
symphysis 
pubis. 
times attempted 
before patient was 
brought into the 
institution. 
when the os 
was only 4.0 
cm. large. 
27 
28 
0 
Natural. 
Pull term. 
Full term. 
5 0 i 
In right 
At rupture of mem 
Spontaneous; 
Living. 
3,533 
28 
22 
1 
Inf. tr., 24. 
Sup. tr., 27.5 
Ant.-post., 19.5 
Strong. 
Dilated after 
expulsion of 
first child. 
Dilated. 
sacro-iliac 
fossa; with 
head in brim 
Behind the 
branes cord returned 
and head forced 
down into pelvis. 
cord coiled 
tightly around 
neck. 
1,750 
1,683 
Post, tr.', 9.4 
Long., 12.1 
Long diag., 13.5 
Short diag., 10.8 
Ant tr 0 7 0.7 
Inf.tr., 26. 
Sup. tr,, 29. 
Ant.-post, 20. 
Circ., 86. 
complete; 
1st twin- 
child in II. 
Vertex. 
foot; de- 
scended with 
rupture of 
membrane. 
manual deliv- 
ery of head. 
Post, tr., 8.1 8.1 
Long., 10.1 10.1 
L. d., ‘12.1 j.2.1 
2!) 
37 
1 
Rachitic; simply con- 
tracted. 
Inf. tr., 23.4 
Sup. tr., 25.6 
Ant.-post., 17.S 
Diag. conj., 9.2 
R. obi., 19.6 
L. obi., 18.9 
Circ., 82. 
Pull term. 
3.0 cm. 
II. Vertex. 
Behind the 
Came into the Lying, 
in House with an os 
of 4.0 cm.; cervix 
swollen; ergot had 
been given before 
she was brought to 
the institution. 
Perforation; 
Dead. 
2,483 
Speedy re- 
painful, ir- 
regular. 
symphysis 
pubis. 
luxation of the 
bones of the 
head. 
with- 
out 
brain. 
covery. 
30 
23 
T>nrf 
p« 
To the side 
The abortus 
was caused 
by a fall. 
contracted. 
Inf.tr., 26.5 
Sup. tr., 28.5 
Ant.-post., 18. 
mens. VI. 
first. 
of waters. 
complete. 
side of va- 
gina. 
of the right 
foot. 
SI 
35 
3 
Ant.-post. contract. 
Diag. conj., 11. 
Pull term. 
2.0 cm. 
To the right 
Reposition in knee- 
Spontaneous. 
Living. 
3.133 
t 
of head 
(right sacro- 
iliac fossa ?). 
elbow position ; later 
left-side position. 
32 
33 
34 
24 
1 
Full term. 
Full term. 
Full term. 
Full term. 
Vigorous. 
Dilated. 
In right ace- 
3 070 
22 
1 
tabular re- 
gion. 
manual deliv- 
ery of head. 
Version; ex- 
traction. 
Version in 
right side posi- 
tion upon 
right foot. 
3 750 
28 
0 
contract. 
Inf. tr., 27. 
Sup. tr., 29.75 
Ant.-post., 18.5 
Diag. conj., 10. 
Circ., 83. 
Obi., 22. 
Normal. 
Simple contract. 
Inf. tr., 24.5 
Sup. tr., 26.5 
Ant.-post., 18. 
Conj. diag., 11.5 
Natural. 
senting with 
os dilated. 
with pro- 
lapse of right 
arm. 
loop. 
Version as soon as 
Living. 
Dead. 
? 
2,455 
3,570 
Post, tr., 8.5 
Long., 11. 
Long diag., 12. 
Ant. tr., 7.5 
Escape of 
waters at a 
very early 
period, 
caused by 
excessive 
hard work. 
22 
1 
Pains inef- 
fective ; 
ceased en- 
tirely for a 
time. 
lated. 
3.0; cord 
pulseless 
when receiv- 
ed in L.-i. H. 
At a very 
early stage 
of labor. 
II. Vertex, 
with pro- 
lapse of left 
hand. 
Behind the 
she reached the 
Lying-in House. 
Cord pulsele-s 
Post, tr., 9, 
Long., 10. 
Long diag., 12. 
Ant. tr., 7. 
right arm in 
right sacro- 
iliac fossa. 
- 
Sup. tr., 8. 
Long., 12. 
Long diag., 13. 
Short diag., 11. 
Obi., 21.5 
80 
29 
Slight; ant.-post. 
contract. 
Inf. tr., 25. 
Sup. tr., 28.8 
Ant.-post., 18.5 
Obi., 22.5 
Moderately large. 
Inf. tr., 28. 
Sup. tr., 80. 
Ant.-post., 19,2 
Inter, troch., 34. 
Obi,, 24. 
When the 
tampons 
were expel- 
led os di- 
lated. 
Dilated. 
Vagina several times 
Spontaneous. 
Extraction; 
patient under 
chloroform. 
Dead. 
3,240 
3,580 
Recovered. 
37 
23 
o 
Difficult, yet 
completed 
without for- 
ceps. 
Full term. 
Placenta 
preevia. 
II. Foot, 
Between the 
plugged with cotton 
tampons. 
Immediate delivery. 
Post, tr.', 9. 
Long., 12. 
Long diag. 13. 
Ant. tr., 8. 
pulseless 
when it pro- 
lapsed. Its 
insertion 
could readily 
be reached. 
faintly pul- 
sating loops. 
feet, which 
also descend- 
ed with 
escape of 
waters. 
Post, tr., 9.5 
Long., 11.5 
Long diag., 13. 
38 
26 
1 
Normal. 
Full term. 
Full term. 
Presenting 
with os di- 
lated. 
Dilated. 
II. Foot;in- 
complete. 
One loop 
presenting 
long before 
rupture of 
membrane. 
One pulse- 
less loop. 
Behind right 
foot. 
Immediate delivery. 
Extraction by 
right foot. 
Spontaneous. 
3 140 
39 
24 
1 
Inf. tr., 26. 
Sup. tr., 28.5 
Ant.-post., 19,5 
Inter, troch., 82. 
Normal. 
3,000 
3,170 
Post, tr., 9. 
Long., 11. 
Long diag., 12. 
Abdominal 
viscera con- 
gested; right 
lung did not 
sink in wa- 
ter ; left lung 
sank as a 
whole, some 
very bright 
red pieces 
swimming 
when sepa- 
.rated. 
40 
28 
2 
Inf. tr., 25. 
Sup. tr., 27.5 
Ant.-post., 19. 
Conj. diag., 12. 
Troch., 80.5 
Normal. 
Natural. 
ward the 
end. 
Almost fully 
dilated. 
tabular re- 
gion. 
Unsuccessful at- 
Dead. 
Post, tr., 8.5 
Long., 10.5 
Long diag., 13. 
Ant. tr., 7.5 
Inf. tr., 24. 
Sup. tr., 28. 
Ant.-post., 19. 
Obi., 23.4 
Circ., 94. 
verse. 
pulsating 
loops. 
prolapsed 
right arm. 
tempt at reposition 
with a funis replacer ; 
total heart growing 
faint; delivery. 
cult notwith- 
standing chlo- 
roform ; ex- 
traction. 
Post, tr., 8.8 
Long., 11. 
Long diag., 12.5 
41 
35 
3 
Natural. 
|Full term. 
Almost fully 
dilated. 
Dead. 
3,850 
Ant. tr., 8.5 
- 
Inf. tr., 25. 
Sup. tr., 30.5 
Ant.-post., 19,5 
superabund- 
ance of li- 
quor amnii. 
pulsating 
loops. 
head. 
tempts at reposition, 
followed by imme- 
diate delivery. 
traction. 
Post, tr., 10. 
Long., 12. 
Long diag., 13. 
42 
34 
3 
Rachitic ; ant.-post. 
contracted. 
Inf. tr., 26.5 
Sup. tr., 28.5 
Ant.-post., 17. 
Diag, conj., 8. 
R. obi., 22.2 
L. obi., 21.5 
1st labor, 
embryot’my. 
2d labor, 
cephalo- 
tripsy. 
Full term. 
Regular at 
first. 
1 
II. Vertex. 
Ferforation; 
cephalotripsy. 
Dead. 
2,790 
with- 
out 
brain. 
Recovered. 
prolapsed, 
pulsating. 
pulsating when pa- 
dent was brought in- 
to the L.-in H. 
43 
24 
1 
Full term. 
4.0 cm.; 
3.0 cm. 
I. Vertex. 
Protruding 
from the 
vagina. 
Cephalotripsy. 
Dead. 
3,440 
Recovered. 
- 
contracted. 
Inf. tr., 26.4 
Sup. tr., 27. 
Ant.-post., 17. 
Diag. conj., 10. 
R. obi., 19.9 
L. obi., 20.5 
Promontory to the 
left. 
when med. 
aid was sum- 
moned. 
of the head. 
total pulse growing 
faint. Version suc- 
cessful ; head resisted 
extraction. 
44 
36 
2 
Ant.-post. contracted 
Inf. tr., 24. 
Sup. tr., 28. 
Ant.-post., 17.5 
Diag. conj., 9.5 
R. obi., 20.5 
L. obi., 21.7 
Perforation; 
cephalo- 
tripsy. 
Partus prte- 
Dilated; 
membranes 
ruptured in 
narcosis. 
One loop. 
Extraction. 
2 120 
Ant. tr 7 5 
mat. artiflc. 
presenting. 
complete. 
dilated; chloroform; 
rupture of mem- 
branes ; delivery. 
Post, tr., 8.5 
Long., 10. 
Long diag., 12.2 
45 
24 
2 
Full term. 
Strong. 
8.0 cm. 
-J- 
T *11 
_ ... - , 
r • * 
Inf. tr., 26. 
Sup. tr., 30.2 
Ant.-post., 19. 
sation faint. 
acetabular 
region. 
with 2 fingers; head 
forced into the pelvis, 
and condition im- 
Post, tr., 9.2 
Long., 11.6 
Long diag., 13.1 
< 
46 
29 3 
Normal. 
Regular; 
Dilated. 
I. Vertex; 
placenta 
praevia lat- 
eralis sin- 
istra. 
One loop. 
Behind sym- 
physis pub.; 
as the head 
descended 
the feebly 
pulsating 
loop was 
forced back 
proved. 
Tampons necessi- 
tated for several days 
on account of hemor- 
rhage. 
Expulsion of 
head by pres- 
sure from 
without. 
Living. 
? 
Recovered. 
Asphyctic. 
Ant. post., 19. 
still-born ; 
version. 2d 
child, easy 
delivery. 
vigorous 
toward end 
of labor. 
47 
37 
2 
Ant.-post. contracted 
Inf. tr., 24.5 
Sup. tr., 27.3 
Ant.-post., 17. 
Diag. conj., 10. 
Obi., 21.5 
Rachitic; ant.-post. 
£ 
2.5 cm. 
Dilated. 
Dilated. 
I. Vertex. 
I. Foot; in- 
complete. 
One pulsat- 
ing loop. 
One feebly 
pulsating 
loop. 
in utero. 
Left-side position; 
refrain from all 
pressure on the ab- 
dominal muscle. 
Immediate delivery. 
3,520 
2,100 
Ant. tr., 7.6 
Post, tr., 9.1 
Long., 11-7 
Long diag., 13.8 
Ant. tr., 7.5 
4£ 
3C 
4 
INd I III til. 
Very difficult 
Partus pros- 
ward end of 
labor. 
Passable. 
In right 
acetabular 
region. 
To the side 
of the feet. 
bponlcintjuiis. 
Extraction. 
Living. 
? 
$ 
Very good. 
Asphyctic, 
On acc. of 
previous dif- 
ficult labors 
par. had been 
directed to 
come to the 
inst’n for 
prem. del.; 
labor was in - 
duced by 
warm 
douche. 
contracted, No. 42. 
mat. artiflc. 
Post, tr., 9. 
Long., 10.2 
Long diag., 11.8 CIRCUMSTANCES 
RELATING TO THE MOTHER. 
COURSE OE LABOR. 
TREATMENT. 
CHILD. 
I # 
d 
525 
| 
' 
Size of the Os 
Prolapsed Portion of Cord. 
q5 
7s 
L.-in H. Case 
d 
b£) 
2 
0 
«+-< 
0 
d 
6 
O. 
O 
d 
£ 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
From the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
livery. 
Living 
or Dead. 
id 
O 
t-1 
O 
7s 
i| 
tXi H 
■s g 
is to 
Dimensions of 
the fffital Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child. 
Notes and 
Post-mor- 
tems. 
49 
50 
51 
52 
29 
27 
29 
SO 
3 
Twice spon- 
taneous de- 
livery of a 
living child; 
prolapse of 
cord in 
sec’nd labor. 
Natural. 
Full term. 
Full term. 
J 
5.0 cm. 
? 
I. Vertex. 
I. Trans- 
verse. 
I. Vertex. 
One loop. 
One pulse- 
less loop. 
One large 
loop. 
One loop 
pulseless 
whenpatieni 
reached the 
Lying-in 
House. 
Pulsation had ceased 
Version by left 
foot: extrac- 
tion. 
Spontaneous 
evolution. 
Version in left- 
Dead. 
6 
4.32(1 'Ant. tr.. 
8.6 
Placenta 
Inf. tr., 35.5 
Sup. tr., 29. 
Ant.-post., 18.5 
True conj., 8.5 
R. obi. int., 11.5 
L. obi. sin. int., 12.5 
Large. 
Inf. tr., 30.5 
Sup. tr., 34.5 
Ant.-post., 21.5 
Troch., 83.8 
Ant.-post. contracted. 
Inf. tr., 27. 
Sup. tr., 28.75 
Ant.-post., 17.75 
Moderately large. 
Inf. tr., 28.5 
Sup. tr., 81. 
Ant.-post., 24, 
Troch.', 34.5 
Obi., 20.5 
In right side 
before the 
presenting 
shoulder. 
when medical assist- 
ance was summoned ; 
attempt with forceps; 
transported to Lying- 
in House. 
Dead. 
$ 
1,410 
3,514 
Post, tr., 
Long., 
Long diag. 
9.7 
11.8 
, 14. 
death. 
escaped into 
abdominal 
• cavity 
through rup- 
ture in ute- 
rus ; re- 
moved. 
Excess of 
2 
4 
Immediate delivery. 
Living. 
¥ 
Ant. tr.. 
7.75 
Good. 
Asphyctic; 
amniotic ft.; 
child affect- 
ed with 
hydrops san- 
guinolentus. 
Very easy; 
twice prema- 
ture labor. 
Full term. 
Membranes 
ruptured by 
careless 
hands early 
in the labor 
cord pro- 
lapsed. 
With rup- 
ture of mem- 
branes. 
II. Shoulder 
Version thrice at- 
side position 
under chloro- 
form ;by right 
foot extraot’n. 
Dead. 
$ 
3,020 
I’ost. tr., 9.5 
Long., 11.75 
Long diag., 13.5 
Recovered. 
revived. 
tempted before pa- 
tient was brought in- 
to the lying-in 
House. 
chloroform; 
extraction. 
53 
23 
3 
Simple contracted. 
Inf. tr., 28.5 
Sup. tr., 23.8 
Ant.-post., 17.8 
R. obi., 19.4 
L. obi., 19.2 
Pirst labor 
natural; 
second labor 
cephalotrip- 
sy. 
Ineffective ; 
painful. 
? 
I. Vertex. 
# 
Os = 4.0 cm.; cord 
pulseless when pa- 
tient first came under 
observation. 
Perforation: 
cephalotripsy. 
Dead. 
2,490 
with- 
out 
brain. 
54 
24 
1 
Ant.-post. contracted 
Inf. tr., 25.2 
Sup. tr., 27a 
Ant.-post., 18. 
Obi., 22. 
Circ., 88. 
Full term. 
Strong. 
4.5 cm. 
I. Trans- 
verse. 
Loop in va- 
gina. 
Delivery as soon as 
cord prolapsed. 
Version in left- 
side position ; 
extraction dif- 
ficult; forceps. 
Dead. 
4 
3,510 
Ant. tr.. 
7.2 
Post, tr., 9.5 
Long., 11. S 
Long diag., 12.E 
55 
29 
f- rfnr1 
Natural. 
Full term. 
Frequent; 
vigorous. 
Dilated soon 
after escape 
of waters. 
Dilated. 
II. Shoulder 
Immediate delivery. 
Version; ex- 
traction. 
Living. 
2,656 
6.8 
Inf. tr., 
Sup. tr., 
Ant. post., 
R. obi., 
L. obi., 
Circ., 
25. 
27. 
16.8 
20.3 
20.8 
74. 
Post, tr., 
Long., 
Long diag 
9.1 
11.2 
, 12.8 
56 
25 
1 
Full term. 
1.5 
II. Vertex. 
One pulse- 
less loop. 
Cephalotripsy had 
been attempted be- 
fore patient was 
brought, with pulse- 
less cord, into the Ly- 
ing-in House. 
Perforation; 
cephalotripsy. 
Dead. 
2,260 
Inf. tr., 
Snp. tr., 
Ant.-post., 
R. obi., 
L. obi., 
Circ., 
24.8 
26.2 
17." 
20. E 
19.« 
77. 
with- 
out 
brain. 
57 
5£ 
25 
31 
1 
Normal. 
Inf., tr., 
Sup. tr., 
Ant.-post. 
Inf. tr., 
Snp. tr., 
Ant.-post, 
Circ., 
Normal. 
Inf. tr., 
Sup. tr., 
Ant.-post. 
Full term. 
Full term. 
Strong. 
1st child. 
2d child. 
Vigorous. 
Dilated. 
Not fully 
dilated. 
IT. Shoul- 
In left side. 
Right side. 
Immediate delivery. 
Version under 
chloroform in 
left-side posi- 
tion ; extrac- 
tion. 
Extraction. 
Living. 
$ 
3,100 
Ant. tr.. 
8. 
26.' 
28.5 
20.2 
27.7 
29. 
19.2 
91. 
Natural. 
ruptured by 
operation. 
der; placenta 
praevia. 
I. Breech. 
Feebly pul- 
sating loop 
of 12 cm. 
One well- 
pulsating 
loop. 
1 
Delivery. 
2,230 
Post, tr., 9.5 
Long., 11. 
Long diag., 12.5 
Delivery. 
2,530 
50 
30 
6 
Natural. 
Full term. 
5.0 cm. 
artificially 
rrptured. 
verse. 
I. Vertex; 
left hand be- 
hind the 
head. 
In left sacro- 
Right-side position; 
reposition of cord and 
hand; cord held back 
until the head had 
passed through the 
os. 
Loop pulsating feebly 
when prolapsed ; de- 
livery. 
side position; 
extraction. 
Spontaneous, 
in side position 
Living. 
2,860 
8 
28. 
29. 
19.5 
iliac fossa. 
Post tr., 
Long., 
Long diag. 
8.8 
11. 
12. 
r 
Moderately large. 
Inf. tr., 26.5 
Sup. tr.. 30.25: 
Natural. 
Full term. 
6.0 cm.; 
presenting. 
3 
II. Foot; in- 
complete. 
Extraction 
under chloro- 
form. 
3,000 
A tvf' tr 
8.2 
DU 44 
1 
2 
Post, tr., 
Ihongr., 
Long diag. 
9.8 
n.s 
12.8 
Alii. 
Circ., 
97.5 
61 
31 
4 
Ant.-post. 
Inf. tr. 
Sup. tr., 
Ant.-post. 
Diag. conj 
R. obi., 
L. obi., 
Circ., 
contracted 
Difficult; 
Partus 
Dilated. 
II. Vertex. 
One pulsat- 
ing loop. 
Immediate delivery. 
Version; eX- 
traction under 
chloroform. 
Living. 
$ 
2,840 
Ant. tr., 
Post, tr., 
Long., 
Long diag. 
8.1 
Ecctal head 
27. 
29.3 
18.5 
9.5 
22. 
21.5 
87. 
1. Forceps 
2. Version 
3. Cephalo- 
tripsy. 
preematur. 
artific. 
iliac fossa. 
9.3 
11.6 
12.6 
was fixed on 
the right 
ilium when 
the waters 
escaped and 
the cord pro- 
lapsed. 
62 
24 
1 
Ant.-post. 
Inf. tr., 
Sup. tr., 
Ant.-post. 
Diag. conj 
R. obi., 
L. obi., 
Circ., 
Intense. 
Not entirely 
Dilated. 
I. Vertex. 
One loop. 
In left sacro- 
Knee-elbow position; 
foetal pulse growing 
faint; rupture of 
membrane; delivery. 
Forceps. 
Dead. 
2,880 
Ant. tr., 
Post, tr., 
Long., 
Long diag. 
8. 
28.5 
80.5 
10.5 
, 10.5 
20.5 
21.3 
82. 
dilated. 
iliac fossa ; 
during ex- 
traction be- 
hind sym- 
physis. 
8.5 
11. 
, 11.5 
B. Ninety-eight Out-door Cases. 
23 
a 
1. Difficult. 
Pull term. 
Regular; 
Dilated. 
II. Foot; in- 
Immediate delivery. 
Extraction. 
Living. 
Funis 73.0 
Inf. tr., 
Sup. tr., 
Ant.-post., 
L. obL, 
26. 
28. 
19. 
22.25 
2. Natural. 
vigorous. 
complete. 
cm. 
20 
30 
2 
Natural. 
Full term. 
Strong. 
5.0 cm. 
II. Vertex, 
One large 
loop. 
Protruding 
from vagina; 
pulseless 
when os was 
dilated. 
Protruding 
from vagina; 
pulseless 
while tones 
of foetal 
heart were 
still to be dis- 
tinguished. 
To the side 
of the right 
arm. 
Right-side position. 
Spontaneous. 
Extraction. 
Dead. 
Dead. 
¥ 
Circ., 33. 
Ant. tr., 
Post, tr., 
Circ., 
Funis 79 
3 
3 
Inf. tr., 
Sup. tr., 
Ant.-post., 
L. obi., 
28. 
31. 
19.75 
22. 
ant.-post. 
Natural. 
Vigorous at 
? 
Its early 
stage of 
labor. 
developed 
from 
III. Vertex. 
II. Breech : 
7.5 
1 
cm. 
contracted. 
Inf. tr., 25.5 
Sup. tr., 27.5 
Ant.-post., 17.3 
first; weak 
in later 
stage. 
prolapse in 
first of the 
twins. 
8.2 
33. 
4 
30 
8 
Rachitic; 
ant.-post. 
All very dif- 
Full term. 
Ineffective; 
Escape of 
I. Vertex. 
In right ace- 
tabular re- 
gion. 
Perforation • 
Dead. 
$ 
Recovered. 
Funis 82. 
! 
contracted. 
Inf. tr., 25.5 
Snp. tr., 26.5 
Ant.-post., 17.0 
Troch., 81.0 
R. obi., 21.0 
L. obi., 21. 
ficnlt; for- 
ceps in two. 
painful. 
waters. 
cephalotripsy. 
5 
28 
1 
Moderately large. 
Ceased after 
Dilated. 
II. Shoul- 
One loop. 
To side of 
foot. 
Rupture of mem- 
brane. 
Version; ex- 
traction. 
Living. 
4 
Good. 
Good. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
R. obi., 
L. obi., 
25. 
28. 
22. 
23. 
22.5 
delivery of 
first child. 
dor; second 
twin child. 
6 
28 
2 
Normal. 
26.75 
80.2 
19.7 
32. 
22.5 
Natural. 
Healthy; 
Dilated. 
Early to 
labor. 
I. Foot. 
Dead. 
Funis]60. 
Inf. tr., 
Snp. tr., 
Ant.-post., 
Troch., 
R. obi., 
weak toward 
the last. 
around left 
foot and 
thigh. 
7 
44 
1 
Ant.-post. contracted 
Inf. tr., 24. 
Sup. tr., 26.75 
Ant.-post., 18- 
Diag. conj., 10.5 
R. ob)., 21. 
L. obi., 21.7 
Venter propendens. 
Passable. 
Presenting; 
4.0 cm. 
5.0 cm- 
IV. Vertex. 
One loop 
Version; ex. 
traction; ex- 
traction dim. 
cult. 
Dead. 
? 
I 
Ant. tr., 
Post, tr., 
Long., 
Long diag. 
Circ., 
7.5 
Funis 76. 
prolapsed in 
escape of 
waters. 
8.7 
11. 
12. 
32. 
37 
5 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Diag. conj. 
True conj., 
ObL, 
Normal. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Diag. conj 
27. 
Difficult; 
Ceased 
1 
Early in 
labor. 
Dilated.] 
II. Vertex; 
Prolapsed 
in left side 
during at- 
tempt at 
version by 
an outside 
physician. 
In left side. 
Tympanitis uteri; 
version attempted. 
Postural treatment. 
perforation; 
cepUal°tripgy_ 
Version; ex. 
traction. 
Dead. 
Living, 
Died 24 
9: 
29. 
17. 
, 10. 
8. 
22. 
forceps in 
two. 
Prolonged. 
Full term. 
entirely. 
Passable. 
Presenting, 
almost di- 
lated. 
developed 
from III. 
vertex. 
II. Vertex. 
3,300 
8.5 
hours after 
delivery. 
Good, 
Good. 
25. 
28. 
, 12. 
$ 
Post, tr., 
Long., 
Long diag. 
Circ., 
10. 
11.5 
13. 
85.5 
10 
34 
8 
Normal. 
Inf. tr., 
Sup. tr., 
Ant.-post. 
R. obi 
L. obL, 
Full term. 
II. Breech. 
Left-side position. 
Extraction. 
Living. 
4 
Ant. tr., 
Post, tr., 
Long., _ 
Long diag., 
Circ., 
8.2 
Good.. 
Good. 
25.3 
28. 
20.2 
22.7 
22.7 
weak; for- 
ceps in two. 
9.5 
11.5 
14. 
35.5 CIRCUMSTANCES 
RELATING TO THE MOTHER.-. 
COURSE OP LABOR. 
TREATMENT. 
CHILD. 
d 
& 
C 
O 
S 
o 
Size of the Os 
Prolapsed Portion of Cord. 
o 
a 
D 
K 
,g 
d 
t c 
<i 
2 
2 
o 
o 
d 
£ 
o 
<1 
'o 
d 
£ 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
Prom the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
li very. 
or Dead 
s 
u 
to 
o 
"cS 
s 
a* 
■g a 
he S 
’S 
Dimensions of 
the fcetal Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child. 
Notes and 
Post-mor- 
tems. 
11 
30 
9 
7 
Moderately large. 
6 foot and 
Full term. 
Strong. 
Almost di- 
I. Trans- 
Several 
To the side 
Right-side position; 
Paipture of 
_Dead. 
s 
8. 
Good. 
Funis 140. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Troch., 
L. obi., 
28.5 
32. 
20.3 
33. 
24. 
transverse 
positions; 1 
prolapse of 
funis. 
lated. 
verse. 
loops. 
of elbow; 
pulsation 
108 at time 
of prolapse. 
refrain from pressure 
on abdominal 
muscle. 
membrane; 
version ; ex- 
traction. 
Post, tr.. 
Long., 
Long diag 
9. 
11. 
, 13. 
12 
20 
6 
Rachitic; 
ant.-post. 
d. 
20. 
20.2 
18.3 
9.3 
20. 
21. 
85. 
All still- 
[Strong. 
I. Vertex. 
One loop. 
Living. 
4 
Ant. tr., 
Post, tr., 
Long., 
Long diag. 
Circ., 
7.5 
9. 
11. 
, 12. 
34.5 
Good. 
Good. 
Funis 41. 
contracte 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Diag. conj. 
R. obi., 
L. obi., 
Giro., 
born; deli- 
vered by 
operation. 
iliac fossa. 
traction. 
13 
2G 
8 
Large. 
Easy. 
Pull term. 
Vigorous; 
ceased after 
escape of 
waters. 
4.0 cm; 
4.0 cm. 
I. Breech. 
Convolution 
In right 
Postural treatment. 
Extraction. 
Living. 
? 
4.000 
8 
Funis 65. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Troch., 
Circ., 
25. 
29.5 
22. 
34. 
99. 
of loops. 
sacro-iliac 
fossa. 
Post, tr.. 
Long., 
Long diag. 
Circ., 
10. 
12. 
13.2 
37. 
14 
31 
5 
2 
Normal. 
Forceps 
once. 
Pull term. 
Healthy. 
4.0 cm. 
II. Vertex. 
Porceps. 
Living. 
6 
Good. 
Good. 
Funis 85. 
1 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
Troch., 
27. 
29.5 
20. 
24. 
32. 
ular region. 
15 
31 
2 
Moderately large. 
Eorceps; 
large child. 
Premature. 
Ceased in 
second pe- 
riod of labor. 
Dilated. 
Version ; ex- 
traction. 
Dead. 
4 
Good. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
27. 
28.5 
21. 
22. 
averse. • 
1G 
24 
2 
Ant.-post. contracted 
With opera- 
Pull term. 
Weak. 
Before 
I. Vertex. 
In right side 
Left-side position. 
Spontaneous. 
Dead. 
s 
Good. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
R. obi., 
L. obi., 
27. 
28.5 
17.33 
21.5 
21.5 
tive assist- 
ance. 
assistance 
reached. 
17 
32 
4 
Normal. 
Normal ; 
prolapse of 
cord once. 
Pull term. 
Healthy. 
Very early in 
II. Vertex. 
One long 
Protruding 
Right-side position. 
Spontaneous. 
Dead. 
? 
7. 
Funis 48. 
Inf. tr., 
Sup. tr., 
Troch., 
Ant.-post., 
Obi., 
27.5 
28.5 
29. 
19. 
21, 
labor, before 
patient came 
under treat- 
ment. 
loop. 
from vagina. 
Post, tr., 
Long., 
Long diag. 
Circ., 
8.5 
11. 
12. 
35. 
18 
25 
3 
Moderately large. 
Natural. 
Pull term. 
Vigorous. 
Before pa- 
II. Foot. 
One long 
loop. 
Immediate delivery. 
Extraction. 
Living. 
4 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
27.5 
29.5 
21. 
23. 
tient came 
under treat- 
ment. 
19 
28 
5 
Normal. 
' Mostly 
premature 
deliveries. 
Premature. 
Weak. 
2.5 cm. 
I. Vertex. 
Version; ex- 
traction. 
Dead. 
Syphilis. 
1 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Troch., 
L. obi., 
24. 
20. 
20. 
80. 
23. 
20 
35 
5 
Simple contracted. 
Pull term. 
Healthy. 
Before pa- 
I. Vertex. 
In right side; 
Left-side position; 
Spontaneous. 
Dead. 
$ 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Conj. diag. 
R. obi., 
23.5 
20.2 
19.2 
10. 
21.5 
difficult; all 
natural. 
Went came 
under treat- 
ment. 
loop. 
head more 
to left. 
reposition attempt- 
ed. 
21 
27 
4 
Natural. 
Pull term. 
Healthy. 
One loop. 
In left side. 
Living. 
Good. 
Good. 
Funis 80. 
£ 
E 
2 
Inf. tr., 
Sup. tr., 
Ant.-post., 
v-'v-*!., 
28. 
29.5 
20. 
>i-i. 
verse. 
traction. 
22 
Rachitic; 
ant.-post. 
Porceps; 
Pull term. 
II. Paco. 
Perforation; 
oephalotripsy. 
Dead. 
. 
contracted. 
Inf. tr., 26. 
Sup. tr., 27. 
Ant.-post., 10.5 
Diag. conj., 9.5 
Obi., 21.4 
Circ,, 79. 
foetus of 
eight j 
months. 
23 
31 
6 
Normal. 
Natural. [ 
Natural. 
Natural. 
Natural. 
Pull term. 
Healthy. 
j At a Very 
early stage 
of labor. 
At an early 
stage of 
labor, 
One long 
loop. 
Convolution 
24 
34 
2 
Inf. tr., 20.5 
Sup. tr., 27.5 
Ant.-post., 19. 
Troch., 81.5 
L. obi., 21. 
Ant.-post. contracted 
I. Vertex; 
iliac fossa; 
head more to 
right. 
traction. 
Dead. 
Dead. 
Living. 
$ 
Promontori- 
um very pro- 
25 
27 
2 
Inf. tr., 
Snp. tr., 
Ant.-post., 
Diag. conj. 
Troch., 
L. obi., 
Normal. 
25. 
28. 
18.2 
10.4 
32. 
21.4 
Pull term. 
Pull term. 
Vigorous. 
Healthy. 
placenta 
prsevia late- 
ralis. 
of loops. 
iliac fossa. 
Vain attempts at op- 
eration before assist- 
ance of the institu- 
tion was summoned. 
Immediate delivery. 
traction. 
Perforation ; 
oephalotripsy. 
Extraction. 
death. 
rninent; la- 
cerated the 
womb, which 
was pressed 
against it 
during labor 
and delivery. 
26 
42 
8 
Inf. tr., 
Snp. tr., 
Ant.-post., 
R. obi., 
Oblique. 
26. 
28. 
19.5 
23. 
Dilated. 
with trans- 
verse posi- 
tion of head. 
I. Foot; in- 
covery. 
punis 69. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
R. obi., 
L. obi., 
25. 
30. 
19. 
23. 
21.5 
complete. 
27 
4 
Children 
syphilitic. 
Strong. 
Dilated. 
Extraction. 
Living. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
L. obi., 
25. 
2G.5 
19.5 
22. 
complete. 
hours after 
birth. 
28 
38 
9 
Natural. 
Pull term. 
Vigorous at 
first; weak 
toward 
close. 
II. Trans- 
To the side 
Living. 
Good. 
Good. 
Funis 66. 
‘ 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
Troch., 
Giro., 
27. 
29.5 
22. 
24.5 
34.5 
98. 
verse. 
loop. 
of left hand. 
traction. 
2!) 
4 
Natural. 
Full term. 
Vigorous. 
Almost fully 
dilated. 
I. Vertex. 
In left side; 
Living. 
Funis 44. 
Inf. tr., 
Ant.-post., 
Obi., 
Circ., 
25. 
20. 
23. 
95. 
head more 
to right. 
traction. 
SO 
43 
12 
Natural. 
Pull term. 
Strong. 
Early stage 
of labor. 
II. Vertex 
Forceps. 
Living. 
Good. 
Funis 58. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Troch., 
27. 
28.2 
21. 
33.3 
from shoul- 
der. 
right arm. 
31 
30 
1 
Ant.-post. contracted 
Full term. 
Strong. 
4-0 cm. 
I. Vertex. 
One loop. 
Left aceta- 
Cord pulseless when 
Forceps. 
Dead. 
Good. 
Funis 66. 
Inf. tr., 
Ant.-post., 
Obi., 
25. 
18.6 
23.0 
bular region. 
prolapsed. 
32 
30 
G 
Ant.-post. contracted 
Spurious ; 
painful. 
Early stage 
of labor. 
I. Vertex. 
Porceps. 
Dead. 
Funis 68. 
Inf. tr., 
Snp. tr., 
Ant.-post., 
Troch., 
R. obi., 
25.5 
27.- 
18.5 
31.3 
22. 
operation ; 
assistance. 
of loops. 
from variola 
S3 
28 
4 
Normal. 
Natural. 
Ceased after 
2.0 cm. 
Version; ex- 
traction. 
Dead. 
s 
Placentft 
firmly 
adherent. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
30. 
31.6 
19. 
24. 
rupture of 
membranes. 
verse: elon- 
gatio ‘ cervi- 
cis uteri, 
8 cm. 
death, c 
34 
31 
3 
Full term. 
Spurious; 
Early stage 
°f labor. 
r - 
... 
!••• 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Conj. diag. 
Obi., 
27. 
29.5 
17.5 
10. 
22. 
painful. 
sacro-iliac 
fossa. 
side position. 
Diving. 
’ / 
1 
35 
20 
3 
Normal. 
Full term. 
Spurious. 
Strong. 
Barly stage 
of labor. 
Funis 62. Q 
30 
20 
2 
Inf. tr., 27. 
Sup. tr., 29.3 
Obi., 23. 
Circ., 80. 
Natural. 
Full term. 
loop. 
In right 
sacro-iliac 
fossa. 
Morphine injection. 
Inf. tr., 
Sup. tr., 
Ant.-post., 
Obi., 
on 
20.7 
29.8 
21.2 
24. 
? 
of labor. 
II. Trans- 
verse. 
Protruding 
from vagina. 
Behind sym- 
physis. 
Version ; ex- 
traction. 
Dead. 
1 CIRCUMSTANCES RELATING TO THE MOTHER. 
COURSE OP LABOR. 
TREATMENT. 
CHILD. 
o 
fc 
& 
a 
W 
d 
o 
Size of the Os 
Prolapsed Portion of Cord. 
, 
< 
3 
o 
o 
§ 
Jh 
o 
,o 
<1 
o 
6 
525 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
* of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
From the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
livery. 
Living 
or Dead 
g 
o 
sa 
to a 
S g 
Dimensions of 
the foetal Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child. 
Notes and 
Post-mor- 
tems. 
31 
28 
2 
Rachitic; ant.-post. 
Somewhat 
Pull term. 
Cord pro- 
lapsed ; 
pulseless; 
with rup- 
ture of 
membranes. 
2.0 cm. 
II. Vertex. 
i 
Spontaneous. 
Dead. 
5 
Funis 114. 
contract. 
Inf. tr., 30.2 
Sup. tr., 31.5 
Ant.-post., 17.5 
Diag. conj., 10.5 
Troch., 32.2 
R. obi., 23.3 
L. obi., 23. 
difficult. 
spurious. 
38 
39 
10 
Without as- 
Full term. 
Suspended. 
I. Vertex. 
Large pulse- 
less loop. 
Cord pulseless when 
Forceps. 
Dead. 
4 
Ruptat* of 
uterus; 
death. 
Inf. tr., 24. 
Sup. tr., 88. 
Ant.-post., 19. 
Troch., 30. 
Obi., 22. 
sistance. 
assistance was sum- 
moned. 
30 
4 
Ant.-post. contract. 
Inf. tr., 25. 
Sup. tr., 27. 
Ant.-post., 17. 
Diag. conj., 10. 
2 Difficult 
Full term. 
Weak. 
3.0 cm. 
I. Foot. 
Ergot. 
Extraction. 
Living. 
4 
Funis 66. 
labors; still- 
born chil- 
dren. 
early stage 
of labor. 
40 33 
4 
Ant.-nost. contract. 
Difficult. 
4.0 cm. 
I. Vertex. 
One loop. 
Cephalotripsy. 
Dead. 
4 
Peritonitis; 
death. 
|Inf. tr., 25. 
ISup. tr., 28. 
lAnt.-post., 17.8 
iTroch., 82. 
R. obi., 22.2 
[L. obi., 22.7 
jCirc., • 95. 
iliac fossa. 
attempted. 
41 
32 
2 
.. .Normal. 
Natural. 
Full term. 
Strong. 
To the side 
Version ; ex- 
Living. 
¥ 
Funis 100. 
jlnf. tr., 23.8 
Sup. tr., 27.8 
Ant.-post., 19. 
iTroch., 81.8 
ill. obi., 22.8 
L. obi., 21.8 
,yerse. 
of right 
hand. 
traction. 
42 
23 
2 
Ant.-post. contract. 
Inf. tr., 27.5 
Sup. tr., 28.8 
Ant.-post., 18.5 
Troch., 32. 
Obi., 23. 
Natural. 
Full term. 
Strong. 
Dilated. 
Rupture of mem- 
brane. 
« 
Living. 
4 
hydramnios. 
forceps. 
tis. 
after birth. 
43 
37 
7 
Ant.-post. contract. 
Inf. tr., 27.2 
Sup. tr., 29. 
Ant.-post., 18.2 
Ding, conj., 10.2 
Troch., 31.4 
Obi., 22.2 
Weak. 
I. Vertex. 
Large loop. 
Living. 
¥ 
Good. 
Good. 
Funis 60. 
pains weak. 
of left hand 
and foot. 
traction. 
44 
24 
3 
Ant.-post. contract. 
Inf. tr., 25.5 
Sup. tr., 28.5 
Ant.-post., 17.7 
Troch., 31. 
R. obi., 23.7 
Diag. conj., 10. 
L. obi., 22.7 
1. Difficult. 
Strong. 
At an early 
stage of la- 
bor. 
I. Vertex. 
One long 
loop in va- 
gina. 
In right ace- 
tabular re- 
gion. 
Version; ex- 
traction. 
Living. 
$ 
Good. 
Good. 
2. Natural. 
45 
32 
4 
.. Ant.-post, contract. 
Natural. 
Full term. 
Strong ; 
weak toward 
end. 
II. Vertex. 
One loop. 
In left ace- 
tabular re- 
gion. 
Reposition of the re- 
Version ; ex- 
traction. 
Living. 
¥ 
Inf. tr., 27. 
Sup. tr., 28,2 
Ant.-post., 19. 
Diag. conj., 10.2 
iTroch., 32. 
Obi., 21.8 
lated. 
troverted uterus in 
the fourth month. 
46 
22 
1 
Full term. 
At an early 
stage of la- 
bor. 
I. Vertex. 
One pulse- 
less loop. 
In right sa- 
cro-iliac 
fossa. 
Left-side position. 
Spontaneous. 
Dead. 
6 
Inf. tr., 23.8 
Sup. tr., 27.5 
Ant.-post., 19. 
Troch., 30.5 
R. obi., 21. 
L. obi., 22. 
47 
31 
0 
Moderately lame. 
Irregular; 
weak. 
II. Vertex. 
Reposition. 
Spontaneous. 
Dead. 
4 
Inf. tr., 26. 
Sup. tr.; 28.5 
Ant.-post., 21. 
Troch., 31.7 
Obi., 23.2 
stage of la- 
bor. 
48 
29 
2 
Natural. 
Full term. 
Strong. 
Dilated. 
III. Vertex. 
Presenting 
when os 4.0 
cm. 
In right ace- 
tabular re- 
gion. 
Left-side position; 
attempt at reposi- 
tion. 
Living. 
¥ 
Good. 
Good. 
Inf. tr., 25.6 
Sup. tr., 28. 
Ant.-post., 19.3 
Troch., 31.4 
Obi., 22.4 
L traction. 
49 
27 
1 
Ant.-post. contract. 
Full term. 
Passable. 
I. Vertex. 
One loop. 
In right 
acetabular 
region. 
Left-side position; 
reposition. 
Spontaneous. 
Dead. 
Diphtheritis 
vaginae ; 
death. 
Inf. tr., 26.2 
Sup. tr., 23. 
Ant.-post., 18.5 
Diag. conj., 10.8 
Troch., 31. 
Obi., 22. 
50 
25 
2 
Simple contracted. 
Natural. 
Full term. 
Weak. 
1,5 cm. 
II. Vertex. 
In right 
sacro-iiiao 
fossa. 
Reposition through 
an os of 1.5 cm., 
without diminishing 
compression. 
Spontaneous. 
Dead. 
¥ 
Good. 
Inf. tr., 24.8 
Sup. tr., 27. 
Ant.-post., 17.8 
Diag. conj., 11. 
R. obi., 21.5 
Troch., 30.5 
51 
28 
2 
Ant.-post. contract. 
Normal. 
Full term. 
Spurious. 
Presenting 
Almost 
dilated. 
II. Vertex. 
Reposition vainly at- 
tempted. 
Forceps. 
Living. 
Good, 
Good. 
Funis 81. 1 
Inf. tr., 25.5 
Sup. tr., 28. 
Ant.-post., 18.8 
Obi., 21.8 
1.5 cm. 
sacro-iliac 
fossa. 
52 
27 
4 
Simple contracted. 
Prolapse of 
Full term. 
Moderate. 
At an early 
1. Vertex; 
right hand 
presenting. 
Living. 
4 
Good. 
Good. 
Funis 83. 
Inf. tr., 24.6 
Sup. tr., 27. 
Ant.-post., 19. 
Diag. conj., 11.4 
Troch., 30. 
R. obi., 21.5 
L. obi., 20.7 
funis in one 
case. 
stage of 
labor. 
traction. 
53 
d 
Normal; post-mor- 
Weak. 
Version attempted by 
outside physicians. 
Version; ex- 
traction. 
Dead. 
tem measurement. 
True conj., 14.5 
R. obi., 13. 
L. obi., 13.5 
Transv., 13.5 
verse. 
peritonitis; 
death. 
54 
34 
Moderately large. 
Inf. tr., 29. 
Sup. tr., 31.8 
Ant.-post., 20.1 
Troch., 81. 
Obi., 22.5 
Natural. 
Pull term. 
Strong. 
At an early 
II. Trans- 
Version; ex- 
traction. 
Living. 
? 
Good. 
Good. 
Funis 58, 
stage of 
labor. 
verse. 
55 
28 
2 
.. Ant.-post. contract. 
Natural. 
Pull term. 
Strong. 
Almost 
I. Vertex; 
One large 
Jn right 
Left-side position. 
Forceps. 
Living. 
Good. 
Good. 
Funis 70. 
Inf. tr., 26. 
Sup. tr.. 29. 
|Ant.-post., 17.5 
|Troch., 30. 
Obi., 20. 
dilated. 
from one 
shoulder. 
loop. 
acetabular 
region. 
50 
34 
7 
.. (Rachitic; ant.-post. 
Several very 
Full term. 
Weak to- 
At an early 
I. Trans- 
Version; ex- 
traction. 
Living. 
Good, 
Good. 
Funis 68. 
contract. 
Inf. tr., 26.5 
Sup. tr., 29.5 
Ant.-post., 18.5 
Diag. conj., 10.6 
True conj., 8.5 
Obi., 24. 
difficult. 
ward last. 
stage 
of labor. 
verse. 
57 
23 
2 
Normal. 
Natural. 
Passable. 
Cord pulseless. 
Dead. 
58 
20 
o 
Inf. tr., 24.5 
Sup. tr., 30. 
Ant.-post., 19. 
Troch.. 32.2 
Giro., 89. 
Normal. 
Natural. 
Full term. 
Moderate. 
Dilated. 
II. Vertex; 
acetabular 
region. 
Version; ex- 
traction. 
Perforation 
cephalotripsy* 
Eclampsia in 
childbed. 
Good. 
Funis 35. 
59 
38 
2 
Inf. tr., 25. 
Sup. tr., 28. 
Ant.-post., 19.5 
Troch., 31. 
Obi., 23. 
Simple contracted. 
Difficult. 
Painful. 
At an early 
second twin 
child. 
II. Vertex. 
To the side 
of right arm. 
Forceps . attempted 
by an ouside physi- 
cian. 
Dead. 
jlnf. tr., 23.4 
[Sup. tr., 26. 
j Ant.-post., 19. 
Troch., 29.5 
B, obi., 22. 
!l. obi., 21.5 
stage of 
labor. CIRCUMSTANCES RELATING- TO THE MOTHER. 
COURSE OP LABOR. 
TREATMENT. 
CHILD. 
d 
to 
1 g 
d 
Size of the Os 
Prolapsed Portion of Gord. 
jD 
g 
d 
"is 
e:<? 
►4 
u 
I'd 
id i 
i° , 
|*o : 
1 ©! 
H 
D 
<! | 
o 
d 
£ 1 
Sxternal Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
From the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
livery. 
Living 
or Dead. 
s 
O 
0) 
n 
a 
D 
■g 2 
fcc B 
> g 
Dimensions of 
the fcetal Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
of Child... 
?Notes and 
Post-mor- 
tems. 
eo 2 
S 1 
Simple contracted. 
Inf. tr., ' 25. 
Sup. tr., 26.5 
Ant.-post., 18.5 
Tr. cliag., 11.8 
Troch., 29. 
Full term. 
c 
2.2 cm. 
At a very 
early stage. 
I. Vertex 
from IV. 
vertex. 
Reposition. 
Spontaneous. 
Dead. 
? 
61 2 
) 2 
Rachitic ; ant.-post. 
contracted. 
Inf. tr., 27. 
Sup. tr., 28. 
Ant. -post., 17. 
Troch., 29. 
Obi., 23. 
Difficult. 
A few days 
beyond full 
term. 
Spurious. 
1.5 cm. 
I. Vertex. 
Bcposition at- 
Spontaneous. 
Dead. 
? 
tempted. 
62 2 
) 5 
Normal. 
Inf. tr., 26. 
Sup. tr., 29. 
Ant.-post., 21.2 
Troch., 31.9 
Obi., 23. 
Natural. 
Full term. 
Version ; ex- 
traction. 
Living. 
4 
Good. 
Death from 
Premature 
verse. 
trismus. 
loosening of 
placenta. 
63 2 
3 1 
Normal. 
Inf. tr., 28. 
Sup. tr., 80. 
Ant.-post., 19.4 
Troch., 81. 
Obi., 24. 
Full term. 
Strong. 
I. Foot. 
1 Extraction. 
Living. 
9 
Funis 82. 
legs. 
64 S 
3 2 
Rachitic; ant.-post. 
contracted. 
Inf. tr., 26. 
Sup. tr., 26. 
Ant.-post., 16.5 
Diag. conj., 9. 
Troch., 27. 
R. obi., 22. 
L. obi., 23. 
Instrumen- 
tal assist- 
ance. 
Eight 
months. 
Strong. 
Dilated. 
I. Vertex. 
Posteriorly 
(left sacro- 
iliac fossa). 
Rupture of mem- 
Version ; ex- 
traction. 
Dead. 
S 
Parametri- 
Funis 44. 
branes followed by 
delivery. 
tis; recov- 
ery. 
65 2 
7 1 
Rachitic; simple con- 
tracted. 
Inf. tr., 26. 
Sup. tr., 26. 
Ant.-post., 18. 
Diag. conj., 11.4 
Troch., 31, 
At an early 
stage .of 
labor. 
Living. 
s 
Good. 
Good. 
Funis 85. 
of loops. k 
traction. 
66 3 
4 1 
Rachitic ; ant.-post. 
contracted. 
Inf. tr., 26. 
Sup. tr., 27. 
Ant.-post., 17. 
Troch., 29.5 
Obi., ’ 22. 
Full term. 
At an early 
stage of 
labor. 
I. Vertex. 
Forceps. 
Dead. 
4 
Good. 
67 2 
6 1 
Normal. 
Inf. tr., 25. 
Sup. tr., 29. 
Ant.-post., 19. 
Troch., 31.5 
Obi., 22.5 
Full term. 
Suspended. 
At an early 
stage of 
labor. 
II. Vertex. 
One pulse- 
In right ace- 
tabular 
region. 
Opiates. 
Forceps. 
Dead. 
$ 
Good. 
less loop. 
68 4 
Ant.-post. contracted 
Inf. tr., 28. 
Sup. tr., 30. 
Ant.-post., 19. 
Diag. conj., 10.9 
Troch., 32. 
Obi., 23.8 
Giro., 87. 
Full term. 
Strong; later 
spurious. 
Dilated. 
At an early 
stage. 
IV. Vertex. 
Morphine injection. 
Living. 
Good. 
Good. 
Funis 72. 
traction. 
69 2 
3 1 
Ant.-post. contracted 
Inf. tr., 25. 
Sup. tr., 26. 
Ant.-post., 16.5 
Diag. con]., 9.5 
OhU 20. 
Strong. 
At an early 
stage of 
labor. 
I. Vertex. 
Cord pulse- 
Assistance summon- 
Spontaneous. 
4 
Funis C; 
less when 
discovered. 
ed too late. 
Troch., SI. 
— 
70 2 
8 4 
Simple contracted. 
Natural. 
Full term. 
Strong. 
I. Trans- 
; ex- 
traction. 
Living. 
$ 
Funis 70, 
Inf. tr., 23. 
Sup., tr., 25.5 
Ant.-post., 17.5 
Diag. conj., 10.8 
Troch., 33.3 
R. obi., 20. 
L. obi., 19. 
Giro., 84. 
verse. 
71 3 
2 1 
Rachitic; lordo-sco- 
Weak. 
I. Vertex. 
One pulse- 
Dead. 
$ 
Good. 
I 
liosis ; simple con- 
tracted. 
Inf. tr., 23. 
Sup. tr., 15. 
Ant.-post., 17. 
Troch., 80. 
R. obi., 21. 
L. obi., 22. 
less loop. 
of right 
hand. 
cephalotripsy. 
72 2 
3 1 
Strong. 
Presenting 
4.0 cm. 
Dilated. 
I. Vertex. 
Reposition attempt- 
ed ; knee-elbow posi- 
tion. 
Spontaneous. 
Dead. 
9 
Inf. tr., 23.8 
Sup. tr., 25. 
Ant.-post., 18. 
Diag. conj., 10. 
Troch., 80. 
Obi., 18.8 
73 2 
8 4 
Rachitic ; ant.-post. 
contracted. 
Inf. tr., 27. 
Sup. tr., 28.5 
Ant.-post., 17.3 
True conj., 8.5 
Tedious. 
Dilated. 
II. Vertex. 
Large loop 
Living. 
9 
Good. 
Good. 
Funis 77. 
presenting. 
traction. 
74 
Ant.-post. contract. 
Inf. tr., 25. 
Sup. tr., 28. 
Ant.-post., 19. 
Troch., 32. 
Obi., 20. 
Natural, 
Full term. 
Strong. 
Dilated. 
I. Foot. 
Rupture of mem- 
Extraction. 
Living. 
$ 
Funis 50. 
branes. 
i t 
75 3 
0 5 
Rachitic ; ant.-post. 
contracted. 
Inf. tr„ 27. 
Sup. tr., 28. 
Ant.-post., 17.5 
Diag. coni., 10.7 
Obi., 22. 
Circ., 81. 
Venter propendens. 
Tedious. 
' Full term. 
Reposition and for- 
Perforation; 
cephalotripsy. 
« 
Dead. 
6 
Good. 
ceps vainly attempt- 
ed. 
76 3 
5 1 
Ant.-post. contract. 
Inf. tr., 24. 
Sup. tr., 27. 
Ant.-post., 15. 
True conj., 7. 
Troch., 28. 
I. Vertex. 
Perforation ; 
cephalotripsy. 
Dead. 
4 
Good. 
773 
0 2 
Ant.-post. contract. 
Inf. tr., 24.8 
Sup. tr., 28.8 
Ant.-poet., 18.2 
Diag. conj., 11. 
Troch., 31.2 
Strong. 
II. Vertex. 
One loop. 
Version; ex- 
traction. 
TlPorl 
Funis 68. 
78 
6 2 
Rachitic ; ant.-post. 
Forceps. 
Full term. 
Weak. 
Presenting 
4.0 cm. 
Dilated. 
Version before rup- 
ture of membranes; 
os dilated. 
..Version; ex- 
traction. 
Living. 
9 
Good. 
Good. 
contracted. 
Inf. tr., 28.7 
Sup. tr., 30. 
Ant.-post., 17. 
Diag. conj., 10.5 
Troch., 31. 
R. obi., 22.5 
L. obi., • 21.5 
hydramnios. 
79 
29 3 
Ant.-post. contract. 
Inf. tr., 26. 
Sup. tr., 28.7 
Ant.-post., 18. 
Troch., 30. 
R. obi., 21. 
L. obi., 20.5 
C..rc., 81. 
Natural. 
Premature. 
Weak. 
Dilated. 
T t> i 1 
n i 
, 
Extraction. 
T * * 
n 
Between tlie 
feet. 
80 
24 
Rachitic; ant.-post 
Natural. 
Full term. 
Weak. 
Presenting. 
4.0 cm. a 
Dilated. 
I. Vertex. 
One large 
loop. 
Reposition attempt 
ed. 
Version; ex- 
traction. 
Dead. 
Good. 
Funis 81. 
contracted. 
Inf. tr., 26.8 
Sup. tr., 29. 
Ant.-post., 17. 
R. obi., 21.2 
L. obi., 23. 
Diag. conj., 8.5-‘ 
Double promontory. CIRCUMSTANCES RELATING TO THE 
MOTHER. 
COURSE 
OP LABOR 
TREATMENT. 
CHILD. 
d 
d 
o 
S 
o 
Size of the Os 
Prolapsed Portion of Cord. 
6 
PS rA 
o 
d 
O 
K 
•S 
Sj 
O 
o 
d 
£ 
+3 
o 
O 
d 
External Measure of 
the Pelvis. 
Previous 
Labors. 
Duration of 
Gestation. 
Quality of 
Pains. 
when the 
Prolapse was 
discovered. 
Diameter in 
Cm. 
at the time 
of Rupture 
of the 
Membranes. 
Presenta- 
tion. 
Length. 
Position. 
Prom the Discovery 
of the Prolapse up to 
Delivery. 
Mode of De- 
livery, 
Living 
or Dead 
o 
u 
o 
s 
" o 
+> g 
"S B 
g 
i Dimensions of 
the foetal Head. 
Condition 
after Birth 
of Mother. 
Condition 
after Birth 
j of Child. 
Noies and 
Post-mor- 
j terns. 
81 
38 
9 
Ant.-post, contract. 
Inf. tr., 25.5 
Sup. tr., 28. 
Ant.-post. 18.5 
Conj. diag. 11. 
Obi., 20. 
Tedious ; 
malpositions; 
prolapsus 
funis in four 
labors. 
Full term. 
Strong after 
ergot. 
Presenting, 
with os par- 
tially 
dilated. 
Dilated. 
IV. Vertex, 
Right-side position ; 
version by external 
manipulation. 
Spontaneous. 
Living. 
¥ 1 
Good. 
Good. 
from trans- 
verse. 
82 
SO 
2 
Rachitic; simple 
contracted. 
Inf. tr., 23. 
Sup. tr., 26. 
Troch., SO. 
Obi., 21. 
Ant.-post., 19.5 
Ant.-post. contract. 
Ant.-post., 17.5 
Diag. conj., 11.5 
True conj., 9.7 
Obi., 22.3 
Inf. tr., 28.1 
Sup. tr., 30.4 
Simple contracted. 
Inf. tr., 23.6 
Sup. tr., . 25.6 
Ant.-post., 19.6 
Obi., 21.6 
Circ., 70. 
Tedious. 
Prolapse of 
funis in one. 
Natural. 
Full term. 
Full term. 
Full term. 
Weak. 
Strong. 
At long in 
tervals. 
One long 
loop. 
Large, feebly 
pulsating 
loop. 
Reposition. 
Reposition; after 
which pulsation of 
foetal head ceased. 
Spontaneous. 
Living. 
¥ 
83 
84 
37 
81 
4 
iliac fossa. 
To the side 
of head. 
Spontaneous. 
Dead. 
Brain con- 
gestion ; me- 
conium in 
pharynx and 
bronchi ; 
lung contain- 
ing no air, 
with the ex- 
ception of 
some parts 
of lower lobe; 
eccbymosis; 
funis 80. 
2 
from III. 
vertex. 
Version : ex- 
Living. 
$ 
Good. 
Good. 
dilated. 
verse. 
of loops. 
traction. 
85 
33 
fi 
Rachitic; ant.-post. 
contract. 
Inf. tr., 27.7 
Sup. tr., 28.6 
Ant.-post., 17.1 
Diag. conj., 10.6 
Obi., 21.6 
Promontory to the 
left. 
Instrumen- 
tal assist- 
ance in four 
labors; one 
premature 
delivery. 
Full term. 
Strong. 
Version; ex- 
Living. 
i 
Good. 
Good. 
verse. 
traction. 
86 
35 
3 
Ant.-post. contract. 
Inf. tr., 26.8 
Sup. tr., 27.7 
Ant.-post., 16.9 
Obi., 19.6 
Natural. 
Weak. 
At a very 
early stage 
of labor. 
Version; ex- 
Dead. 
4 
Good. 
verse; first 
twin-child. 
traction. 
87 
31 
7 
Normal. 
Inf. tr., 29. 
Sup. tr., 31.7 
Ant.-post., 19.6 
R. obi., 24.3 
L. obi., 22.3 
Two last dif- 
ficult. 
Full term. 
Strong. 
I. Vertex. 
Version; ex- 
Living. 
Good. 
Good. 
Funis 90. 
of loop in 
vagina. 
traction. 
88 
r 
41 
3 
Rachitic; ant.-post. 
contract. 
Inf. tr., 27. 
Sup. tr., 28. 
Ant.-post., 18.2 
Diag. conj., 10.1 
Promontory to left. 
Very diffi- 
cult. 
Full term. 
Strong. 
Presenting 
4.0 cm. 
Almost 
Vertex. 
[Reposition. 
Spontaneous. 
Living. 
6 
dilated. 
89 
24 
1 
Simple contracted. 
Inf. tr., 24.7 
Sup. tr., 25.5 
Ant.-post., 19..3 
Diag. conj., 11.2 
L. obi., 21.1 
Full term. 
Weak; 
strong to- 
ward end. 
1.0 cm. 
I. Trans- 
Cord pulseless when 
assistance was sum- 
moned. 
Version; ex- 
Dead. 
4 
Good. 
verse; arm 
presenting. 
tons pulse- 
less loop. 
traction. 
bronchi. 
90 
24 
1 
Full term. 
Strong. 
4.0 cm. 
I. Vertex. 
One loop. 
In right 
sacro-iliac 
fossa. 
Reposition attempt- 
ed ; postural treat- 
ment. 
Version; ex- 
Dead. 
Good. 
contracted. 
Inf. tr., 26.3 
Sup. tr., 27. 
Ant.-post., 17.8 
Diag. conj., 10.3 
Obi., 20.9 
traction. 
91 
41 
5 
Ant.-post. contract. 
2d and 4th 
Full term. 
Spurious. 
Version; ex- 
tr»otio«v 
Dead. 
¥ 
? 
tis ; death 8 
days after 
delivery. 
Good. 
92 
29 
2 
1 
Sup. tr., 30.4 
Ant.-post., 18.9 
Obi., 22.9 
Simple contracted. 
Inf. tr., 24.8 
Sup. tr., 26.3 
Ant.-post., 18.9 
Obi., 22. 
Diag. conj., 11.2 
3d and 5th 
vertex pres,, 
with pro- 
lapse of cord. 
One abortus. 
Full term. 
Strong. 
4.0 cm. 
II. Vertex; 
arm present- 
ing. 
Version; ex- 
Living. 
4 
Good. 
traction. 
93 
30 
2 
Rachitic; simple con- 
tracted. 
Diag. conj., 8.1 
Inf. tr., 21.6 
Sup. tr., 21.6 
Full term. 
Strong. 
Perforation; 
Dead. 
¥ 
Recovered. 
position. 
head to 
right. 
cephalotripsy. 
94 
34 
4 
Rachitic ; ant.-post. 
contract. 
Inf.tr., 28.4 
Sup. tr., 27.7 
Ant.-post., 18. 
Diag. conj., 11.7 
Tedious. 
Full term. 
Strong. 
At a very 
Reposition attempt- 
ed. 
Version; ex- 
traction. 
Dead. 
? 
Good. 
early stage of 
labor. 
right hand 
presenting. 
95 
83 
5 
Rachitic ; ant.-post. 
contract. 
Inf. tr., 26.8 
Sup. tr., 26.3 
Ant.-post., 18.2 
Diag. conj., 8.8 
Oephalotrip- 
sy once; for- 
ceps twice. 
Presenting, 
Dilated. 
Version. 
Cephalotripsy- 
Dead. 
4 
Recovered. 
os almost di- 
lated. 
verse. 
of loops in 
vagina. 
96 
38 
i 
Simple contracted. 
Strong. 
Dead. 
t 
Inf. tr., 23.6 
Sup. tr., 25. 
Ant.-post., 18.2 
verse. 
traction. 
97 
41 
6 
Rachitic; simple con- 
tracted. 
Inf. tr., 22.9 
Sup. tr., 22.9 
Ant.-post., 18.2 
True conj., 8.8 
Difficult. 
Almost fully 
I. Vertex. 
Version; ex- 
Living. 
i 
Good. 
Good. 
dilated. 
of loops. 
traction. 
98 
35 
0 
Normal. 
Inf. tr., 26. 
Sup. tr., 29. 
Ant.-post., 20. 
Troch., S3. 
Obi., 22.5-23.5 
Giro., 87. 
Venter propendens. 
Full term. 
Presenting 
Dilated. 
I. Vertex. 
Forceps. 
9 
Dead. 
Good. 
4.0 cm.