[Reprinted from The Medical News, October 20, 1894 ] 
ACCOUCHEMENT FORCE: REPORT OF A CASE. 
BY JOHN G. CECIL, B.S., M.D., 
PROFESSOR OF OBSTETRICS, KENTUCKY SCHOOL OF MEDICINE, 
LOUISVILLE, KY. 
On the morning of April 2, 1894, I was called by Dr. 
Atwood Smith to see a patient in consultation. Arriving 
about 9.30 A.M., I obtained the following history : Mrs. 
T., aged twenty-two, the wife of a policeman, had been 
left by her husband about 10 p.m., April 1st, in her usual 
health, that is, not complaining more than she had been 
for the preceding two or three weeks. For several weeks 
her feet and legs had been swollen ; she had not suffered 
or complained of headaches, disturbances of digestion, 
or vision ; there was not much swelling about the face or 
hands. 
Her husband returning from his watch at seven o'clock 
on the morning of the 2d, knocked, but receiving no 
response finally forced the door, and found his wife 
undressed and in bed entirely unconscious. Not being 
able to arouse her, he at once sent for Dr. Smith. The 
Doctor sent for counsel, and during the intervening time 
observed her in three or four convulsions. He at once 
commenced the administration of chloroform by inhala- 
tion during and at intervals between the convulsions, and 
gave drop-doses of croton-oil in emulsion. Upon exami- 
nation I found her in labored respiration-about twenty 
to the minute-the pulse 72, full, round, and hard; 
the temperature normal, the eyes staring, at times par- 
tially closed, the pupils not responsive to light; the feet 2 
and legs considerably swollen, some puffiness about the 
eyelids, restless, rolling from side to side and tossing her 
limbs about. She had been vomiting and purging. 
Digital examination revealed the vagina soft and dila- 
table, covered with abundant secretion, the cervix short- 
ened but firm, the os admitting the examining finger. 
She was within six weeks of the expected completion 
of her term of gestation, and from the periodic rest- 
lessness we thought it probable that she was having 
labor-pains, though little impression was being made on 
the cervix. The bag of waters was unbroken, and the 
presenting head could be felt, but it was not engaged. 
Fetal heart-sounds were heard in both hypochondriac 
regions, but more distinctly on the left. The uterus was 
large and irregular in outline. 
The diagnosis of multiple pregnancy, owing to the 
urgency of the condition, was not made out at this time, 
as it undoubtedly might have been easily done had more 
care been bestowed upon it. In consultation we deter- 
mined to control the convulsions with chloroform; to 
prevent recurrence by hourly doses of fifteen grains of 
chloral hydrate by the mouth, or thirty grains by the 
rectum ; to continue efforts at purgation by the croton-oil, 
and to let the labor for the time take care of itself. Dur- 
ing the next four hours she received six drops of croton- 
oil, which did not produce purgation until five or six 
hours later; also one hundred and twenty grains of 
chloral per rectum. Notwithstanding this and the ad- 
ministration of chloroform, she had two violent convul- 
sions, the last one being especially severe. 
I saw her again at 1.30 p.m., and, Dr. Smith con- 
curring, determined to deliver as rapidly as possible. 
Accordingly, she was placed in position, a vaginal 
douche given, put completely under the influence of 
chloroform, the urine drawn (which proved to be heavily 
laden with albumin), and cervical dilatation was begun 
with the fingers. Proceeding slowly, half of the hand, 
thoroughly cleansed and well oiled, was introduced into 3 
the vagina, and one finger into the os externum. In a few 
minutes a second finger was squeezed in alongside of 
the first. Then, at short intervals, the third and fourth 
fingers were inserted, and the four fingers, bunched into 
a cone, were used as the dilating wedge. The fingers 
were pushed as high as the presenting part would allow, 
care being taken not to rupture the amniotic sac ; they 
were then made to oppose each other, the index and 
sometimes the middle finger being hooked into the 
cervical ring, pulling it gently in different directions, the 
other fingers opposing. The cervical ring was thick and 
strong, and offered not a little resistance. The manipu- 
lations were continued for about forty minutes, when I 
had secured considerable thinning out of the cervix and 
a dilatation of from one-and-one-half to one-and-three- 
quarter inches. The head was now engaging, and the 
waters unbroken. I now had the choice between version 
(which might not have been an easy undertaking in view 
of the subsequent discovery of twins) and an effort to 
apply the forceps. Knowing the dangers incident to the 
delivery of a living child by the breech in a primipara 
under the most favorable surroundings, I determined to 
make an effort to apply the forceps ; in the event of fail- 
ure, I still had the alternative of version. Accordingly, the 
bag of waters was ruptured, and a small head in the right 
occipito-posterior position became partially engaged at the 
superior straight. The forceps was adjusted with some 
difficulty, the cervix being tightly stretched like a rubber 
band around the blades when they were locked. I now 
felt that I had control of the situation, and even though 
a laceration of the cervix should occur, I would be jus- 
tified in bringing the labor to a speedy termination. 
Intermittent tractions at intervals of two minutes were 
made very gently, and I soon had the satisfaction of 
seeing the cervical fibers dilate and retract over the 
forceps-blades and the descending head. The delivery 
was soon accomplished. The head being very small 
and the pelvis roomy, the former never rotated, but was 4 
delivered with the face looking to the symphysis. The 
child, weighing about five pounds, was in a state of con- 
gestive asphyxia. The cord was cut without ligature, 
and a small amount of blood permitted to escape; the 
infant was then quickly resuscitated. 
When this child was delivered it was at once ob- 
served that a second remained unborn, which presented 
by the head, in the left occipito-anterior position. It 
descended to the pelvic cavity in a little while, but the 
contractions being insufficient, the forceps was applied 
and delivery accomplished in a few minutes. The 
second child resisted efforts at resuscitation for a long 
while, but we were finally successful; though larger 
than the first, it was weaker, and was asphyxiated from 
a probable partially premature separation of the pla- 
centa. A single after-birth with the two cords attached 
was promptly delivered, and a firm uterine contraction 
followed. 
The time consumed from the commencement of the 
dilatation to the complete delivery was about two hours, 
and we had the satisfaction of having two living chil- 
dren, the mother still alive and in a better situation for 
the future to the credit of accouchement force. Owing to 
the small size of the fetal heads, notwithstanding the 
unfavorable position of the first, the perineum was pre- 
served entire, and if there was any cervical laceration, 
it was insignificant. There was no recurrence of convul- 
sions during the delivery. The mother was nowallowed 
to come out from under the influence of chloroform, and 
a close watch was instituted. In an hour or so she began 
to purge freely; the kidneys also secreted six or eight 
ounces of urine. 
I saw her again four hours afterward and found her 
breathing sixty-five times per minute; the pulse, 90; the 
temperature, 1020 F.; very restless, still unconscious, 
somewhat cyanosed, coarse mucous rales being heard 
over every part of both lungs. This condition, evidently 
one of acute edema, had come on suddenly, about three- 5 
and-one-half hours subsequent to the delivery. Mustard- 
plasters were freely applied to the chest in front and be- 
hind, a rectal injection of half an ounce of whiskey and 
fifteen grains of ammonium carbonate given, followed 
shortly after by the hypodermatic injection of morphin 
one-fourth grain and atropin grain. This brought 
relief, and she passed a reasonably quiet night. 
At eight o'clock the next morning, April 3d, she awoke 
to partial consciousness, and had a single slight convul- 
sion ; thirty grains of chloral by the rectum, and morphin 
and atropin were given. The edematous condition of the 
lungs still persisted; the temperature was 1010 F., and the 
pulse varying from 120 to 150 beats per minute. Later in 
the morning the morphia and atropin were repeated, and 
grain digitalin given hypodermatically. At four o'clock 
in the afternoon the woman had become semiconscious, 
the pupils responding promptly; the pulse was 120-better 
in volume and strength; she recognized her friends and 
was able to swallow teaspoonfuls of water, doses of whis- 
key, and ammonium carbonate. I directed that morphin 
and digitalis be continued during the night pro re nata. 
The temperature for the next two days was exceed- 
ingly erratic, varying from normal, or nearly so, to 
1050 F., making at times very rapid excursions, but the 
daily average became gradually higher toward the end, 
fluctuating from 103° to 1050 F. The condition of the 
lungs never materially improved, the coarse mucous 
rales persisting. I am inclined to think a condition 
identical with, or certainly very similar to, catarrhal 
pneumonia developed in the right lung. The urinary 
secretion from the time of delivery was satisfactory in 
quantity, showing daily improvement in the amount of 
albumin. The patient died early on the morning of the 
6th, or about four-and-one-half days after delivery, clearly 
from the pulmonary complication, there being at no time 
evidence of septic infection. It is probable that the 
edema was induced by intra-cranial interference with 
the functions of the pneumogastric nerve. 
No. 731 Fourth Avenue.