There was a case at Riga in 1839 of a robust girl who conceived in February, and in consequence her menses ceased. In June she aborted, but, to her dismay, soon afterward the symptoms of advanced pregnancy appeared, and in November a full-grown child, doubtless the result of the same impregnation as the fetus, was expelled at the fourth month. In 1860 Schuh reported an instance before the Vienna Faculty of Medicine in which a fetus was discharged at the third month of pregnancy and the other twin retained until full term. The abortion was attended with much metrorrhagia, and ten weeks afterward the movements of the other child could be plainly felt and pregnancy continued its course uninterrupted. Bates mentions a twin pregnancy in which an abortion took place at the second month and was followed by a natural birth at full term. Hawkins gives a case of miscarriage, followed by a natural birth at full term; and Newnham cites a similar instance in which there was a miscarriage at the seventh month and a birth at full term.

Worms in the Uterus.—Haines speaks of a most curious case—that of a woman who had had a miscarriage three days previous; she suffered intense pain and a fetid discharge. A number of maggots were seen in the vagina, and the next day a mass about the size of an orange came away from the uterus, riddled with holes, and which contained a number of dead maggots, killed by the carbolic acid injection given soon after the miscarriage. The fact seems inexplicable, but after their expulsion the symptoms immediately ameliorated. This case recalls a somewhat similar one given by the older writers, in which a fetus was eaten by a worm. Analogous are those cases spoken of by Bidel of lumbricoides found in the uterus; by Hole, in which maggots were found in the vagina and uterus; and Simpson, in which the abortion was caused by worms in the womb—if the associate symptoms were trustworthy.

We can find fabulous parallels to all of these in some of the older writings. Pare mentions Lycosthenes' account of a woman in Cracovia in 1494 who bore a dead child which had attached to its back a live serpent, which had gnawed it to death. He gives an illustration showing the serpent in situ. He also quotes the case of a woman who conceived by a mariner, and who, after nine months, was delivered by a midwife of a shapeless mass, followed by an animal with a long neck, blazing eyes, and clawed feet. Ballantyne says that in the writings of Hippocrates there is in the work on "Diseases", which is not usually regarded as genuine, a some what curious statement with regard to worms in the fetus. It is affirmed that flat worms develop in the unborn infant, and the reason given is that the feces are expelled so soon after birth that there would not be sufficient time during extrauterine life for the formation of creatures of such a size. The same remark applies to round worms. The proof of these statements is to be found in the fact that many infants expel both these varieties of parasites with the first stool. It is difficult to know what to make of these opinions; for, with the exception of certain cases in some of the seventeenth and eighteenth century writers, there are no records in medicine of the occurrence of vermes in the infant at birth. It is possible that other things, such as dried pieces of mucus, may have been erroneously regarded as worms.



CHAPTER III.

OBSTETRIC ANOMALIES.

General Considerations.—In discussing obstetric anomalies we shall first consider those strange instances in which stages of parturition are unconscious and for some curious reason the pains of labor absent. Some women are anatomically constituted in a manner favorable to child-birth, and pass through the experience in a comparatively easy manner; but to the great majority the throes of labor are anticipated with extreme dread, particularly by the victims of the present fashion of tight lacing.

It seems strange that a physiologic process like parturition should be attended by so much pain and difficulty. Savages in their primitive and natural state seem to have difficulty in many cases, and even animals are not free from it. We read of the ancient wild Irish women breaking the pubic bones of their female children shortly after birth, and by some means preventing union subsequently, in order that these might have less trouble in child-birth—as it were, a modified and early form of symphysiotomy. In consequence of this custom the females of this race, to quote an old English authority, had a "waddling, lamish gesture in their going." These old writers said that for the same reason the women in some parts of Italy broke the coccyxes of their female children. This report is very likely not veracious, because this bone spontaneously repairs itself so quickly and easily. Rodet and Engelmunn, in their most extensive and interesting papers on the modes of accouchement among the primitive peoples, substantiate the fear, pain, and difficulty with which labor is attended, even in the lowest grades of society.

In view of the usual occurrence of pain and difficulty with labor, it seems natural that exceptions to the general rule should in all ages have attracted the attention of medical men, and that literature should be replete with such instances. Pechlin and Muas record instances of painless births. The Ephemerides records a birth as having occurred during asphyxia, and also one during an epileptic attack. Storok also speaks of birth during unconsciousness in an epileptic attack; and Haen and others describe cases occurring during the coma attending apoplectic attacks. King reports the histories of two married women, fond mothers and anticipating the event, who gave birth to children, apparently unconsciously. In the first case, the appearance of the woman verified the assertion; in the second, a transient suspension of the menstrual influence accounted for it. After some months epilepsy developed in this case. Crawford speaks of a Mrs. D., who gave birth to twins in her first confinement at full term, and who two years after aborted at three months. In December, 1868, a year after the abortion, she was delivered of a healthy, living fetus of about five or six months' growth in the following manner: While at stool, she discovered something of a shining, bluish appearance protruding through the external labia, but she also found that when she lay down the tumor disappeared. This tumor proved to be the child, which had been expelled from the uterus four days before, with the waters and membranes intact, but which had not been recognized; it had passed through the os without pain or symptoms, and had remained alive in the vagina over four days, from whence it was delivered, presenting by the foot.

The state of intoxication seems by record of several cases to render birth painless and unconscious, as well as serving as a means of anesthesia in the preanesthetic days.

The feasibility of practising hypnotism in child-birth has been discussed, and Fanton reports 12 cases of parturition under the hypnotic influence. He says that none of the subjects suffered any pain or were aware of the birth, and offers the suggestion that to facilitate the state of hypnosis it should be commenced before strong uterine contractions have occurred.

Instances of parturition or delivery during sleep, lethargies, trances, and similar conditions are by no means uncommon. Heister speaks of birth during a convulsive somnolence, and Osiander of a case during sleep. Montgomery relates the case of a lady, the mother of several children, who on one occasion was unconsciously delivered in sleep. Case relates the instance of a French woman residing in the town of Hopedale, who, though near confinement, attributed her symptoms to over-fatigue on the previous day. When summoned, the doctor found that she had severe lumbar pains, and that the os was dilated to the size of a half-dollar. At ten o'clock he suggested that everyone retire, and directed that if anything of import occurred he should be called. About 4 A.M. the husband of the girl, in great fright, summoned the physician, saying: "Monsieur le Medecin, il y a quelque chose entre les jambes de ma femme," and, to Dr. Case's surprise, he found the head of a child wholly expelled during a profound sleep of the mother. In twenty minutes the secundines followed. The patient, who was only twenty years old, said that she had dreamt that something was the matter with her, and awoke with a fright, at which instant, most probably, the head was expelled. She was afterward confined with the usual labor-pains.

Palfrey speaks of a woman, pregnant at term, who fell into a sleep about eleven o'clock, and dreamed that she was in great pain and in labor, and that sometime after a fine child was crawling over the bed. After sleeping for about four hours she awoke and noticed a discharge from the vagina. Her husband started for a light, but before he obtained it a child was born by a head-presentation. In a few minutes the labor-pains returned and the feet of a second child presented, and the child was expelled in three pains, followed in ten minutes by the placenta. Here is an authentic case in which labor progressed to the second stage during sleep.

Weill describes the case of a woman of twenty-three who gave birth to a robust boy on the 16th of June, 1877, and suckled him eleven months. This birth lasted one hour. She became pregnant again and was delivered under the following circumstances: She had been walking on the evening of September 5th and returned home about eleven o'clock to sleep. About 3 A.M. she awoke, feeling the necessity of passing urine. She arose and seated herself for the purpose. She at once uttered a cry and called her husband, telling him that a child was born and entreating him to send for a physician. Weill saw the woman in about ten minutes and she was in the same position, so he ordered her to be carried to bed. On examining the urinal he found a female child weighing 10 pounds. He tied the cord and cared for the child. The woman exhibited little hemorrhage and made a complete recovery. She had apparently slept soundly through the uterine contractions until the final strong pain, which awoke her, and which she imagined was a call for urination.

Samelson says that in 1844 he was sent for in Zabelsdorf, some 30 miles from Berlin, to attend Hannah Rhode in a case of labor. She had passed easily through eight parturitions. At about ten o'clock in the morning, after a partially unconscious night, there was a sudden gush of blood and water from the vagina; she screamed and lapsed into an unconscious condition. At 10.35 the face presented, soon followed by the body, after which came a great flow of blood, welling out in several waves. The child was a male middle-sized, and was some little time in making himself heard. Only by degrees did the woman's consciousness return. She felt weary and inclined to sleep, but soon after she awoke and was much surprised to know what had happened. She had seven or eight pains in all. Schultze speaks of a woman who, arriving at the period for delivery, went into an extraordinary state of somnolence, and in this condition on the third day bore a living male child.

Berthier in 1859 observed a case of melancholia with delirium which continued through pregnancy. The woman was apparently unconscious of her condition and was delivered without pain. Cripps mentions a case in which there was absence of pain in parturition. Depaul mentions a woman who fell in a public street and was delivered of a living child during a syncope which lasted four hours. Epley reports painless labor in a patient with paraplegia. Fahnestock speaks of the case of a woman who was delivered of a son while in a state of artificial somnambulism, without pain to herself or injury to the child. Among others mentioning painless or unconscious labor are Behrens (during profound sleep), Eger, Tempel, Panis, Agnoia, Blanckmeister, Whitehill, Gillette, Mattei, Murray, Lemoine, and Moglichkeit.

Rapid Parturition Without Usual Symptoms.—Births unattended by symptoms that are the usual precursors of labor often lead to speedy deliveries in awkward places. According to Willoughby, in Darby, February 9, 1667, a poor fool, Mary Baker, while wandering in an open, windy, and cold place, was delivered by the sole assistance of Nature, Eve's midwife, and freed of her afterbirth. The poor idiot had leaned against a wall, and dropped the child on the cold boards, where it lay for more than a quarter of an hour with its funis separated from the placenta. She was only discovered by the cries of the infant. In "Carpenter's Physiology" is described a remarkable case of instinct in an idiotic girl in Paris, who had been seduced by some miscreant; the girl had gnawed the funis in two, in the same manner as is practised by the lower animals. From her mental imbecility it can hardly be imagined that she had any idea of the object of this separation, and it must have been instinct that impelled her to do it. Sermon says the wife of Thomas James was delivered of a lusty child while in a wood by herself. She put the child in an apron with some oak leaves, marched stoutly to her husband's uncle's house a half mile distant, and after two hours' rest went on her journey one mile farther to her own house; despite all her exertions she returned the next day to thank her uncle for the two hours' accommodation. There is related the history of a case of a woman who was delivered of a child on a mountain during a hurricane, who took off her gown and wrapped the child up in it, together with the afterbirth, and walked two miles to her cottage, the funis being unruptured.

Harvey relates a case, which he learned from the President of Munster, Ireland, of a woman with child who followed her husband, a soldier in the army, in daily march. They were forced to a halt by reason of a river, and the woman, feeling the pains of labor approaching, retired to a thicket, and there alone brought forth twins. She carried them to the river, washed them herself, did them up in a cloth, tied them to her back, and that very day marched, barefooted, 12 miles with the soldiers, and was none the worse for her experience. The next day the Deputy of Ireland and the President of Munster, affected by the story, to repeat the words of Harvey, "did both vouchsafe to be godfathers of the infants."

Willoughby relates the account of a woman who, having a cramp while in bed with her sister, went to an outhouse, as if to stool, and was there delivered of a child. She quickly returned to bed, her going and her return not being noticed by her sleeping sister. She buried the child, "and afterward confessed her wickedness, and was executed in the Stafford Gaol, March 31, 1670." A similar instance is related by the same author of a servant in Darby in 1647. Nobody suspected her, and when delivered she was lying in the same room with her mistress. She arose without awakening anyone, and took the recently delivered child to a remote place, and hid it at the bottom of a feather tub, covering it with feathers; she returned without any suspicion on the part of her mistress. It so happened that it was the habit of the Darby soldiers to peep in at night where they saw a light, to ascertain if everything was all right, and they thus discovered her secret doings, which led to her trial at the next sessions at Darby.

Wagner relates the history of a case of great medicolegal interest. An unmarried servant, who was pregnant, persisted in denying it, and took every pains to conceal it. She slept in a room with two other maids, and, on examination, she stated that on the night in question she got up toward morning, thinking to relieve her bowels. For this purpose she secured a wooden tub in the room, and as she was sitting down the child passed rapidly into the empty vessel. It was only then that she became aware of the nature of her pains. She did not examine the child closely, but was certain it neither moved nor cried. The funis was no doubt torn, and she made an attempt to tie it. Regarding the event as a miscarriage, she took up the tub with its contents and carried it to a sand pit about 30 paces distant, and threw the child in a hole in the sand that she found already made. She covered it up with sand and packed it firmly so that the dogs could not get it. She returned to her bedroom, first calling up the man-servant at the stable. She awakened her fellow-servants, and feeling tired sat down on a stool. Seeing the blood on the floor, they asked her if she had made way with the child. She said: "Do you take me for an old sow?" But, having their suspicions aroused, they traced the blood spots to the sand pit. Fetching a spade, they dug up the child, which was about one foot below the surface. On the access of air, following the removal of the sand and turf, the child began to cry, and was immediately taken up and carried to its mother, who washed it and laid it on her bed and soon gave it the breast. The child was healthy with the exception of a club-foot, and must have been under ground at least fifteen minutes and no air could have reached it. It seems likely that the child was born asphyxiated and was buried in this state, and only began to assume independent vitality when for the second time exposed to the air. This curious case was verified to English correspondents by Dr. Wagner, and is of unquestionable authority; it became the subject of a thorough criminal investigation in Germany.

During the funeral procession of Marshal MacMahon in Paris an enormous crowd was assembled to see the cortege pass, and in this crowd was a woman almost at the time of delivery; the jostling which she received in her endeavors to obtain a place of vantage was sufficient to excite contraction, and, in an upright position, she gave birth to a fetus, which fell at her feet. The crowd pushed back and made way for the ambulance officials, and mother and child were carried off, the mother apparently experiencing little embarrassment. Quoted by Taylor, Anderson speaks of a woman accused of child murder, who walked a distance of 28 miles on a single day with her two-days-old child on her back.

There is also a case of a female servant named Jane May, who was frequently charged by her mistress with pregnancy but persistently denied it. On October 26th she was sent to market with some poultry. Returning home, she asked the boy who drove her to stop and allow her to get out. She went into a recess in a hedge. In five minutes she was seen to leave the hedge and follow the cart, walking home, a distance of a mile and a half. The following day she went to work as usual, and would not have been found out had not a boy, hearing feeble cries from the recess of the hedge, summoned a passer-by, but too late to save the child. At her trial she said she did not see her babe breathe nor cry, and she thought by the sudden birth that it must have been a still-born child.

Shortt says that one day, while crossing the esplanade at Villaire, between seven and eight o'clock in the morning, he perceived three Hindoo women with large baskets of cakes of "bratties" on their heads, coming from a village about four miles distant. Suddenly one of the women stood still for a minute, stooped, and to his surprise dropped a fully developed male child to the ground. One of her companions ran into the town, about 100 yards distant, for a knife to divide the cord. A few of the female passers-by formed a screen about the mother with their clothes, and the cord was divided. The after-birth came away, and the woman was removed to the town. It was afterward discovered that she was the mother of two children, was twenty-eight years old, had not the slightest sign of approaching labor, and was not aware of parturition until she actually felt the child between her thighs.

Smith of Madras, in 1862, says he was hastily summoned to see an English lady who had borne a child without the slightest warning. He found the child, which had been born ten minutes, lying close to the mother's body, with the funis uncut. The native female maid, at the lady's orders, had left the child untouched, lifting the bed-clothes to give it air. The lady said that she arose at 5.30 feeling well, and during the forenoon had walked down a long flight of steps across a walk to a small summer-house within the enclosure of her grounds. Feeling a little tired, she had lain down on her bed, and soon experienced a slight discomfort, and was under the impression that something solid and warm was lying in contact with her person. She directed the servant to look below the bed-clothes, and then a female child was discovered. Her other labors had extended over six hours, and were preceded by all the signs distinctive of childbirth, which fact attaches additional interest to the case. The ultimate fate of the child is not mentioned. Smith quotes Wilson, who said he was called to see a woman who was delivered without pain while walking about the house. He found the child on the floor with its umbilical cord torn across.

Langston mentions the case of a woman, twenty-three, who, between 4 and 5 A.M., felt griping pains in the abdomen. Knowing her condition she suspected labor, and determined to go to a friend's house where she could be confined in safety. She had a distance of about 600 yards to go, and when she was about half way she was delivered in an upright position of a child, which fell on the pavement and ruptured its funis in the fall. Shortly after, the placenta was expelled, and she proceeded on her journey, carrying the child in her arms. At 5.50 the physician saw the woman in bed, looking well and free from pain, but complaining of being cold. The child, which was her first, was healthy, well nourished, and normal, with the exception of a slight ecchymosis of the parietal bone on the left side. The funis was lacerated transversely four inches from the umbilicus. Both mother and child progressed favorably. Doubtless the intense cold had so contracted the blood-vessels as to prevent fatal hemorrhage to mother and child. This case has a legal bearing in the supposition that the child had been killed in the fall.

There is reported the case of a woman in Wales, who, while walking with her husband, was suddenly seized with pains, and would have been delivered by the wayside but for the timely help of Madame Patti, the celebrated diva, who was driving by, and who took the woman in her carriage to her palatial residence close by. It was to be christened in a few days with an appropriate name in remembrance of the occasion. Coleman met an instance in a married woman, who without the slightest warning was delivered of a child while standing near a window in her bedroom. The child fell to the floor and ruptured the cord about one inch from the umbilicus, but with speedy attention the happiest results were attained. Twitchell has an example in the case of a young woman of seventeen, who was suddenly delivered of a child while ironing some clothes. The cord in this case was also ruptured, but the child sustained no injury. Taylor quotes the description of a child who died from an injury to the head caused by dropping from the mother at an unexpected time, while she was in the erect position; he also speaks of a parallel case on record.

Unusual Places of Birth.—Besides those mentioned, the other awkward positions in which a child may be born are so numerous and diversified that mention of only a few can be made here. Colton tells of a painless labor in an Irish girl of twenty-three, who felt a desire to urinate, and while seated on the chamber dropped a child. She never felt a labor-pain, and twelve days afterward rode 20 miles over a rough road to go to her baby's funeral. Leonhard describes the case of a mother of thirty-seven, who had borne six children alive, who was pregnant for the tenth time, and who had miscalculated her pregnancy. During pregnancy she had an attack of small-pox and suffered all through pregnancy with constipation. She had taken a laxative, and when returning to bed from stool was surprised to find herself attached to the stool by a band. The child in the vessel began to cry and was separated from the woman, who returned to bed and suddenly died one-half hour later. The mother was entirely unconscious of the delivery. Westphal mentions a delivery in a water-closet.

Brown speaks of a woman of twenty-six who had a call of nature while in bed, and while sitting up she gave birth to a fine, full-grown child, which, falling on the floor, ruptured the funis. She took her child, lay down with it for some time, and feeling easier, hailed a cab, drove to a hospital with the child in her arms, and wanted to walk upstairs. She was put to bed and delivered of the placenta, there being but little hemorrhage from the cord; both she and her child made speedy recoveries. Thebault reports an instance of delivery in the erect position, with rupture of the funis at the placenta. There was recently a rumor, probably a newspaper fabrication, that a woman while at stool in a railway car gave birth to a child which was found alive on the track afterward.

There is a curious instance on record in which a child was born in a hip-bath and narrowly escaped drowning. The mother was a European woman aged forty, who had borne two children, the last nine years before. She was supposed to have dropsy of the abdomen, and among other treatments was the use of a speculum and caustic applications for inflammation of the womb. The escape of watery fluid for two days was considered evidence of the rupture of an ovarian cyst. At the end of two days, severe pains set in, and a warm hip-bath and an opiate were ordered. While in the bath she bore a fully-matured, living, male child, to the great surprise of herself and her friends. The child might have been drowned had not assistance been close at hand.

Birth by the Rectum.—In some cases in which there is some obstacle to the delivery of a child by the natural passages, the efforts of nature to expel the product of conception lead to an anomalous exit. There are some details of births by the rectum mentioned in the last century by Reta and others. Payne cites the instance of a woman of thirty-three, in labor thirty-six hours, in whom there was a congenital absence of the vaginal orifice. The finger, gliding along the perineum, arrived at a distended anus, just inside of which was felt a fetal head. He anesthetized the patient and delivered the child with forceps, and without perineal rupture. There was little hemorrhage, and the placenta was removed with slight difficulty. Five months later, Payne found an unaltered condition of the perineum and vicinity; there was absence of the vaginal orifice, and, on introducing the finger along the anterior wall of the rectum, a fistula was found, communicating with the vagina; above this point the arrangement and the situation of the parts were normal. The woman had given birth to three still-born children, and always menstruated easily. Coitus always seemed satisfactory, and no suspicion existed in the patient's mind, and had never been suggested to her, of her abnormality.

Harrison saw a fetus delivered by the anus after rupture of the uterus; the membranes came away by the same route. In this case the neck of the uterus was cartilaginous and firmly adherent to the adjacent parts. In seven days after the accouchement the woman had completely regained her health. Vallisneri reports the instance of a woman who possessed two uteruses, one communicating with the vagina, the other with the rectum. She had permitted rectal copulation and had become impregnated in this manner. Louis, the celebrated French surgeon, created a furore by a pamphlet entitled "De partium externarum generationi inservientium in mulieribus naturali vitiosa et morbosa dispositione, etc.," for which he was punished by the Sorbonne, but absolved by the Pope. He described a young lady who had no vaginal opening, but who regularly menstruated by the rectum. She allowed her lover to have connection with her in the only possible way, by the rectum, which, however, sufficed for impregnation, and at term she bore by the rectum a well-formed child. Hunter speaks of a case of pregnancy in a woman with a double vagina, who was delivered at the seventh month by the rectum. Mekeln and Andrews give instances of parturition through the anus. Morisani describes a case of extrauterine pregnancy with tubal rupture and discharge into the culdesac, in which there was delivery by the rectum. After an attack of severe abdominal pain, followed by hemorrhage, the woman experienced an urgent desire to empty the rectum. The fetal movements ceased, and a recurrence of these symptoms led the patient to go to stool, at which she passed blood and a seromucoid fluid. She attempted manually to remove the offending substances from the rectum, and in consequence grasped the leg of a fetus. She was removed to a hospital, where a fetus nine inches long was removed from the rectum. The rectal opening gradually cicatrized, the sac became obliterated, and the woman left the hospital well.

Birth Through Perineal Perforation.—Occasionally there is perineal perforation during labor, with birth of the child through the opening. Brown mentions a case of rupture of the perineum with birth of a child between the vaginal opening and the anus. Cassidy reports a case of child-birth through the perineum. A successful operation was performed fifteen days after the accident. Dupuytren speaks of the passage of an infant through a central opening of the perineum. Capuron, Gravis, and Lebrun all report accouchement through a perineal perforation, without alteration in the sphincter ani or the fourchet. In his "Diseases of Women" Simpson speaks of a fistula left by the passage of an infant through the perineum. Wilson, Toloshinoff, Stolz, Argles, Demarquay, Harley, Hernu, Martyn, Lamb, Morere, Pollock, and others record the birth of children through perineal perforations.

Birth Through the Abdominal Wall.—Hollerius gives a very peculiar instance in which the abdominal walls gave way from the pressure exerted by the fetus, and the uterus ruptured, allowing the child to be extracted by the hand from the umbilicus; the mother made a speedy recovery. In such cases delivery is usually by means of operative interference (which will be spoken of later), but rarely, as here, spontaneously. Farquharson and Ill both mention rupture of the abdominal parietes during labor.

There have been cases reported in which the recto-vaginal septum has been ruptured, as well as the perineum and the sphincter ani, giving all the appearance of a birth by the anus.

There is an account of a female who had a tumor projecting between the vagina and rectum, which was incised through the intestine, and proved to be a dead child. Saviard reported what he considered a rather unique case, in which the uterus was ruptured by external violence, the fetus being thrown forward into the abdomen and afterward extracted from an umbilical abscess.

Birth of the Fetus Enclosed in the Membranes.—Harvey says that an infant can rest in its membranes several hours after birth without loss of life. Schurig eventrated a pregnant bitch and her puppies lived in their membranes half an hour. Wrisberg cites three observations of infants born closed in their membranes; one lived seven minutes; the other two nine minutes; all breathed when the membranes were cut and air admitted. Willoughby recorded the history of a case which attracted much comment at the time. It was the birth of twins enclosed in their secundines. The sac was opened and, together with the afterbirth, was laid over some hot coals; there was, however, a happy issue, the children recovering and living. Since Willoughby's time several cases of similar interest have been noticed, one in a woman of forty, who had been married sixteen years, and who had had several pregnancies in her early married life and a recent abortion. Her last pregnancy lasted about twenty-eight or twenty-nine weeks, and terminated, after a short labor, by the expulsion of the ovum entire. The membranes had not been ruptured, and still enclosed the fetus and the liquor amnii. On breaking them, the fetus was seen floating on the waters, alive, and, though very diminutive, was perfectly formed. It continued to live, and a day afterward took the breast and began to cry feebly. At six weeks it weighed 2 pounds 2 ounces, and at ten months, 12 pounds, but was still very weak and ill-nourished. Evans has an instance of a fetus expelled enveloped in its membranes entire and unruptured. The membranes were opaque and preternaturally thickened, and were opened with a pair of scissors; strenuous efforts were made to save the child, but to no purpose. The mother, after a short convalescence, made a good recovery. Forman reports an instance of unruptured membranes at birth, the delivery following a single pain, in a woman of twenty-two, pregnant for a second time. Woodson speaks of a case of twins, one of which was born enveloped in its secundines.

Van Bibber was called in great haste to see a patient in labor. He reached the house in about fifteen minutes, and was told by the midwife, a woman of experience, that she had summoned him because of the expulsion from the womb of something the like of which she had never seen before. She thought it must have been some variety of false conception, and had wrapped it up in some flannel. It proved to be a fetus enclosed in its sac, with the placenta, all having been expelled together and intact. He told the nurse to rupture the membranes, and the child, which had been in the unruptured sac for over twenty minutes, began to cry. The infant lived for over a month, but eventually died of bronchitis.

Cowger reports labor at the end of the seventh month without rupture of the fetal sac. Macknus and Rootes speak of expulsion of the entire ovum at the full period of gestation. Roe mentions a case of parturition with unruptured membrane. Slusser describes the delivery of a full-grown fetus without rupture of the membrane.

"Dry Births."—The reverse of the foregoing are those cases in which, by reason of the deficiency of the waters, the birth is dry. Numerous causes can be stated for such occurrences, and the reader is referred elsewhere for them, the subject being an old one. The Ephemerides speaks of it, and Rudolph discusses its occurrence exhaustively and tells of the difficulties of such a labor. Burrall mentions a case of labor without apparent liquor amnii, delivery being effected by the forceps. Strong records an unusual obstetric case in which there was prolongation of the pregnancy, with a large child, and entire absence of liquor amnii. The case was also complicated with interstitial and subserous fibroids and a contracted pelvis, combined with a posterior position of the occiput and nonrotation of the head. Lente mentions a case of labor without liquor amnii; and Townsend records delivery without any sanguineous discharge. Cosentino mentions a case of the absence of liquor amnii associated with a fetal monstrosity.

Delivery After Death of the Mother.—Curious indeed are those anomalous cases in which the delivery is effected spontaneously after the death of the mother, or when, by manipulation, the child is saved after the maternal decease. Wegelin gives the account of a birth in which version was performed after death and the child successfully delivered. Bartholinus, Wolff, Schenck, Horstius, Hagendorn, Fabricius Hildanus, Valerius, Rolfinck, Cornarius, Boener, and other older writers cite cases of this kind. Pinard gives a most wonderful case. The patient was a woman of thirty-eight who had experienced five previous normal labors. On October 27th she fancied she had labor pains and went to the Lariboisiere Maternite, where, after a careful examination, three fetal poles were elicited, and she was told, to her surprise, of the probability of triplets. At 6 P.M., November 13th, the pains of labor commenced. Three hours later she was having great dyspnea with each pain. This soon assumed a fatal aspect and the midwife attempted to resuscitate the patient by artificial respiration, but failed in her efforts, and then she turned her attention to the fetuses, and, one by one, she extracted them in the short space of five minutes; the last one was born twelve minutes after the mother's death. They all lived (the first two being females), and they weighed from 4 1/4 to 6 1/2 pounds.

Considerable attention has been directed to the advisability of accelerated and forced labor in the dying, in order that the child may be saved. Belluzzi has presented several papers on this subject. Csurgay of Budapest mentions saving the child by forced labor in the death agonies of the mother. Devilliers considers this question from both the obstetric and medicolegal points of view. Hyneaux mentions forcible accouchement practised on both the dead and the dying. Rogowicz advocates artificial delivery by the natural channel in place of Cesarian section in cases of pending or recent death, and Thevenot discussed this question at length at the International Medico-Legal Congress in 1878. Duer presented the question of postmortem delivery in this country.

Kelly reports the history of a woman of forty who died in her eighth pregnancy, and who was delivered of a female child by version and artificial means. Artificial respiration was successfully practised on the child, although fifteen minutes had elapsed from the death of the mother to its extraction. Driver relates the history of a woman of thirty-five, who died in the eighth month of gestation, and who was delivered postmortem by the vagina, manual means only being used. The operator was about to perform Cesarean section when he heard the noise of the membranes rupturing. Thornton reports the extraction of a living child by version after the death of the mother. Aveling has compiled extensive statistics on all varieties of postmortem deliveries, collecting 44 cases of spontaneous expulsion of the fetus after death of the mother.

Aveling states that in 1820 the Council of Cologne sanctioned the placing of a gag in the mouth of a dead pregnant woman, thereby hoping to prevent suffocation of the infant, and there are numerous such laws on record, although most of them pertain to the performance of Cesarean section immediately after death.

Reiss records the death of a woman who was hastily buried while her husband was away, and on his return he ordered exhumation of her body, and on opening the coffin a child's cry was heard. The infant had evidently been born postmortem. It lived long afterward under the name of "Fils de la terre." Willoughby mentions the curious instance in which rumbling was heard from the coffin of a woman during her hasty burial. One of her neighbors returned to the grave, applied her ear to the ground, and was sure she heard a sighing noise. A soldier with her affirmed her tale, and together they went to a clergyman and a justice, begging that the grave be opened. When the coffin was opened it was found that a child had been born, which had descended to her knees. In Derbyshire, to this day, may be seen on the parish register: "April ye 20, 1650, was buried Emme, the wife of Thomas Toplace, who was found delivered of a child after she had lain two hours in the grave."

Johannes Matthaeus relates the case of a buried woman, and that some time afterward a noise was heard in the tomb. The coffin was immediately opened, and a living female child rolled to the feet of the corpse. Hagendorn mentions the birth of a living child some hours after the death of the mother. Dethardingius mentions a healthy child born one-half hour after the mother's death. In the Gentleman's Magazine there is a record of an instance, in 1759, in which a midwife, after the death of a woman whom she had failed to deliver, imagined that she saw a movement under the shroud and found a child between its mother's legs. It died soon after. Valerius Maximus says that while the body of the mother of Gorgia Epirotas was being carried to the grave, a loud noise was heard to come from the coffin and on examination a live child was found between the thighs,—whence arose the proverb: "Gorgiam prius ad funus elatum, quam natum fuisse."

Other cases of postmortem delivery are less successful, the delivery being delayed too late for the child to be viable. The first of Aveling's cases was that of a pregnant woman who was hanged by a Spanish Inquisitor in 1551 While still hanging, four hours later, two children were said to have dropped from her womb. The second case was of a woman of Madrid, who after death was shut in a sepulcher. Some months after, when the tomb was opened, a dead infant was found by the side of the corpse. Rolfinkius tells of a woman who died during parturition, and her body being placed in a cellar, five days later a dead boy and girl were found on the bier. Bartholinus is accredited with the following: Three midwives failing to deliver a woman, she died, and forty-eight hours after death her abdomen swelled to such an extent as to burst her grave-clothes, and a male child, dead, was seen issuing from the vagina. Bonet tells of a woman, who died in Brussels in 1633, who, undelivered, expired in convulsions on Thursday. On Friday abdominal movements in the corpse were seen, and on Sunday a dead child was found hanging between the thighs. According to Aveling, Herman of Berne reports the instance of a young lady whose body was far advanced in putrefaction, from which was expelled an unbroken ovum containing twins. Even the placenta showed signs of decomposition. Naumann relates the birth of a child on the second day after the death of the mother. Richter of Weissenfels, in 1861, reported the case of a woman who died in convulsions, and sixty hours after death an eight months' fetus came away. Stapedius writes to a friend of a fetus being found dead between the thighs of a woman who expired suddenly of an acute disease. Schenk mentions that of a woman, dying at 5 P.M., a child having two front teeth was born at 3 A.M. Veslingius tells of a woman dying of epilepsy on June 6, 1630, from whose body, two days later, issued a child. Wolfius relates the case of a woman dying in labor in 1677. Abdominal movements being seen six hours after death, Cesarean section was suggested, but its performance was delayed, and eighteen hours after a child was spontaneously born. Hoyer of Mulhausen tells of a child with its mouth open and tongue protruding, which was born while the mother was on the way to the grave. Bedford of Sydney, according to Aveling, relates the story of a case in which malpractice was suspected on a woman of thirty-seven, who died while pregnant with her seventh child. The body was exhumed, and a transverse rupture of the womb six inches long above the cervix was found, and the body of a dead male child lay between the thighs. In 1862, Lanigan tells of a woman who was laid out for funeral obsequies, and on removal of the covers for burial a child was found in bed with her. Swayne is credited with the description of the death of a woman whom a midwife failed to deliver. Desiring an inquest, the coroner had the body exhumed, when, on opening the coffin, a well-developed male infant was found parallel to and lying on the lower limbs, the cord and placenta being entirely unattached from the mother.

Some time after her decease Harvey found between the thighs of a dead woman a dead infant which had been expelled postmortem. Mayer relates the history of a case of a woman of forty-five who felt the movement of her child for the fourth time in the middle of November. In the following March she had hemoptysis, and serious symptoms of inflammation in the right lung following, led to her apparent death on the 31st of the month. For two days previous to her death she had failed to perceive the fetal movements. She was kept on her back in a room, covered up and undisturbed, for thirty-six hours, the members of the family occasionally visiting her to sprinkle holy water on her face. There was no remembrance of cadaveric distortion of the features or any odor. When the undertakers were drawing the shroud on they noticed a half-round, bright-red, smooth-looking body between the genitals which they mistook for a prolapsed uterus. Early on April 2d, a few hours before interment, the men thought to examine the swelling they had seen the day before. A second look showed it to be a dead female child, now lying between the thighs and connected with the mother by the umbilical cord. The interment was stopped, and Mayer was called to examine the body, but with negative results, though the signs of death were not plainly visible for a woman dead fifty-eight hours. By its development the body of the fetus confirmed the mother's account of a pregnancy of twenty-one weeks. Mayer satisfies himself at least that the mother was in a trance at the time of delivery and died soon afterward.

Moritz gives the instance of a woman dying in pregnancy, undelivered, who happened to be disinterred several days after burial. The body was in an advanced state of decomposition, and a fetus was found in the coffin. It was supposed that the pressure of gas in the mother's body had forced the fetus from the uterus. Ostmann speaks of a woman married five months, who was suddenly seized with rigors, headache, and vomiting. For a week she continued to do her daily work, and in addition was ill-treated by her husband. She died suddenly without having any abdominal pain or any symptoms indicative of abortion. The body was examined twenty-four hours after death and was seen to be dark, discolored, and the abdomen distended. There was no sanguineous discharge from the genitals, but at the time of raising the body to place it in the coffin, a fetus, with the umbilical cord, escaped from the vagina. There seemed to have been a rapid putrefaction in this ease, generating enough pressure of gas to expel the fetus as well as the uterus from the body. This at least is the view taken by Hoffman and others in the solution of these strange cases.

Antepartum Crying of the Child.—There are on record fabulous cases of children crying in the uterus during pregnancy, and all sorts of unbelievable stories have been constructed from these reported occurrences. Quite possible, however, and worthy of belief are the cases in which the child has been heard to cry during the progress of parturition—that is, during delivery. Jonston speaks of infants crying in the womb, and attempts a scientific explanation of the fact. He also quotes the following lines in reference to this subject:—

"Mirandum foetus nlaterna clausus in alvo Dicitur insuetos ore dedisse sonos. Causa subest; doluit se angusta sede telleri Et cupiit magnae cernere moliis opus. Aut quia quaerendi studio vis fessa parentum Aucupii aptas innuit esse manus."

The Ephemerides gives examples of the child hiccoughing in the uterus. Cases of crying before delivery, some in the vagina, some just before the complete expulsion of the head from the os uteri, are very numerous in the older writers; and it is quite possible that on auscultation of the pregnant abdomen fetal sounds may have been exaggerated into cries. Bartholinus, Borellus, Boyle, Buchner, Paullini, Mezger, Riolanus, Lentillus, Marcellus Donatus, and Wolff all speak of children crying before delivery; and Mazinus relates the instance of a puppy whose feeble cries could be heard before expulsion from the bitch. Osiander fully discusses the subject of infants crying during parturition.

McLean describes a case in which he positively states that a child cried lustily in utero during application of the forceps. He compared the sound as though from a voice in the cellar. This child was in the uterus, not in the vagina, and continued the crying during the whole of the five minutes occupied by delivery.

Cesarean Section.—Although the legendary history of Cesarean section is quite copious, it is very seldom that we find authentic records in the writings of the older medical observers. The works of Hippocrates, Aretxeus, Galen, Celsus, and Aetius contain nothing relative to records of successful Cesarean sections. However, Pliny says that Scipio Africanus was the first and Manlius the second of the Romans who owed their lives to the operation of Cesarean section; in his seventh book he says that Julius Caesar was born in this way, the fact giving origin to his name. Others deny this and say that his name came from the thick head of hair which he possessed. It is a frequent subject in old Roman sculpture, and there are many delineations of the birth of Bacchus by Cesarean section from the corpse of Semele. Greek mythology tells us of the birth of Bacchus in the following manner: After Zeus burnt the house of Semele, daughter of Cadmus, he sent Hermes in great haste with directions to take from the burnt body of the mother the fruit of seven months. This child, as we know, was Bacchus. Aesculapius, according to the legend of the Romans, had been excised from the belly of his dead mother, Corinis, who was already on the funeral pile, by his benefactor, Apollo; and from this legend all products of Cesarean sections were regarded as sacred to Apollo, and were thought to have been endowed with sagacity and bravery.

Old records tell us that one of the kings of Navarre was delivered in this way, and we also have records of the birth of the celebrated Doge, Andreas Doria, by this method. Jane Seymour was supposed to have been delivered of Edward VI by Cesarean section, the father, after the consultation of the physicians was announced to him, replying: "Save the child by all means, for I shall be able to get mothers enough." Robert II of Scotland was supposed to have been delivered in this way after the death of his mother, Margery Bruce, who was killed by being thrown from a horse. Shakespere's immortal citation of Macduff, "who was from his mother's womb untimely ripped," must have been such a case, possibly crudely done, perchance by cattle-horn. Pope Gregory XIV was said to have been taken from his mother's belly after her death. The Philosophical Transactions, in the last century contain accounts of Cesarean section performed by an ignorant butcher and also by a midwife; and there are many records of the celebrated case performed by Jacob Nufer, a cattle gelder, at the beginning of the sixteenth century.

By the advent of antisepsis and the improvements of Porro and others, Cesarean section has come to be a quite frequent event, and a record of the successful cases would hardly be considered a matter of extraordinary interest, and would be out of the province of this work, but a citation of anomalous cases will be given. Baldwin reports a case of Cesarean section on a typical rachitic dwarf of twenty-four, who weighed 100 pounds and was only 47 1/2 inches tall. It was the ninth American case, according to the calculation of Harris, only the third successful one, and the first successful one in Ohio. The woman had a uniformly contracted pelvis whose anteroposterior diameter was about 1 1/4 inches. The hygienic surroundings for the operation were not of the best, as the woman lived in a cellar. Tait's method of performing the operation was determined upon and successfully performed. Convalescence was prompt, and in three weeks the case was dismissed. The child was a female of 7 1/2 pounds which inherited the deformities of its mother. It thrived for nine and a half months, when it died of angina Ludovici. Figure 15 represents the mother and child.

Harris gives an account of an operation upon a rachitic dwarf who was impregnated by a large man, a baby weighing 14 pounds and measuring 20 inches being delivered by the knife. St. Braun gives the account of a Porro-Cesarean operation in the case of a rachitic dwarf 3 feet 10 inches tall, in which both the mother and child recovered. Munde speaks of twins being delivered by Cesarean section. Franklin gives the instance of a woman delivered at full term of a living child by this means, in whom was also found a dead fetus. It lay behind the stump of the amputated cervix, in the culdesac of Douglas. The patient died of hemorrhage.

Croston reports a case of Cesarean section on a primipara of twenty-four at full term, with the delivery of a double female monster weighing 12 1/2 pounds. This monster consisted of two females of about the same size, united from the sternal notch to the navel, having one cord and one placenta. It was stillborn. The diagnosis was made before operation by vaginal examination. In a communication to Croston, Harris remarked that this was the first successful Cesarean section for double monstrous conception in America, and added that in 1881 Collins and Leidy performed the same operation without success.

Instances of repeated Cesarean section were quite numerous, and the pride of the operators noteworthy, before the uterus was removed at the first operation, as is now generally done. Bacque reports two sections in the same woman, and Bertrandi speaks of a case in which the operation was successfully executed many times in the same woman. Rosenberg reports three cases repeated successfully by Leopold of Dresden. Skutsch reports a case in which it was twice performed on a woman with a rachitic pelvis, and who the second time was pregnant with twins; the children and mother recovered. Zweifel cites an instance in which two Cesarean sections were performed on a patient, both of the children delivered being in vigorous health. Stolz relates a similar case. Beck gives an account of a Cesarean operation twice on the same woman; in the first the child perished, but in the second it survived. Merinar cites an instance of a woman thrice opened. Parravini gives a similar instance. Charlton gives an account of the performance carried out successfully four times in the same woman; Chisholm mentions a case in which it was twice performed. Michaelis of Kiel gives an instance in which he performed the same operation on a woman four times, with successful issues to both mother and children, despite the presence of peritonitis the last time. He had operated in 1826, 1830, 1832, and 1836. Coe and Gueniot both mention cases in which Cesarean section had been twice performed with successful terminations as regards both mothers and children. Rosenberg tabulates a number of similar cases from medical literature.

Cases of Cesarean section by the patient herself are most curious, but may be readily believed if there is any truth in the reports of the operation being done in savage tribes. Felkin gives an account of a successful case performed in his presence, with preservation of the lives of both mother and child, by a native African in Kahura, Uganda Country. The young girl was operated on in the crudest manner, the hemorrhage being checked by a hot iron. The sutures were made by means of seven thin, hot iron spikes, resembling acupressure-needles, closing the peritoneum and skin. The wound healed in eleven days, and the mother made a complete recovery. Thomas Cowley describes the case of a negro woman who, being unable to bear the pains of labor any longer, took a sharp knife and made a deep incision in her belly—deep enough to wound the buttocks of her child, and extracted the child, placenta and all. A negro horse-doctor was called, who sewed the wound up in a manner similar to the way dead bodies are closed at the present time.

Barker gives the instance of a woman who, on being abused by her husband after a previous tedious labor, resolved to free herself of the child, and slyly made an incision five inches long on the left side of the abdomen with a weaver's knife. When Barker arrived the patient was literally drenched with blood and to all appearance dead. He extracted a dead child from the abdomen and bandaged the mother, who lived only forty hours. In his discourses on Tropical Diseases Moseley speaks of a young negress in Jamaica who opened her uterus and extracted therefrom a child which lived six days; the woman recovered. Barker relates another case in Rensselaer County, N.Y., in which the incision was made with the razor, the woman likewise recovering. There is an interesting account of a poor woman at Prischtina, near the Servian frontier, who, suffering greatly from the pains of labor, resolved to open her abdomen and uterus. She summoned a neighbor to sew up the incision after she had extracted the child, and at the time of report, several months later, both the mother and child were doing well.

Madigan cites the case of a woman of thirty-four, in her seventh confinement, who, while temporarily insane, laid open her abdomen with a razor, incised the uterus, and brought out a male child. The abdominal wound was five inches long, and extended from one inch above the umbilicus straight downward. There was little or no bleeding and the uterus was firmly contracted. She did not see a physician for three hours. The child was found dead and, with the placenta, was lying by her side. The neighbors were so frightened by the awful sight that they ran away, or possibly the child might have been saved by ligature of the funis. Not until the arrival of the clergyman was anything done, and death ultimately ensued.

A most wonderful case of endurance of pain and heroism was one occurring in Italy, which attracted much European comment at the time. A young woman, illegitimately pregnant, at full term, on March 28th, at dawn, opened her own abdomen on the left side with a common knife such as is generally used in kitchens. The wound measured five inches, and was directed obliquely outward and downward. She opened the uterus in the same direction, and endeavored to extract the fetus. To expedite the extraction, she drew out an arm and amputated it, and finding the extraction still difficult, she cut off the head and completely emptied the womb, including the placenta. She bound a tight bandage around her body and hid the fetus in a straw mattress. She then dressed herself and attended to her domestic duties. She afterward mounted a cart and went into the city of Viterbo, where she showed her sister a cloth bathed in blood as menstrual proof that she was not pregnant. On returning home, having walked five hours, she was seized with an attack of vomiting and fainted. The parents called Drs. Serpieri and Baliva, who relate the case. Thirteen hours had elapsed from the infliction of the wound, through which the bulk of the intestines had been protruding for the past six hours. The abdomen was irrigated, the toilet made, and after the eighteenth day the process of healing was well progressed, and the woman made a recovery after her plucky efforts to hide her shame.

Cases like the foregoing excite no more interest than those on record in which an abdominal section has been accidental, as, for instance, by cattle-horns, and the fetus born through the wound. Zuboldie speaks of a case in which a fetus was born from the wound made by a bull's horn in the mother's abdomen. Deneux describes a case in which the wound made by the horn was not sufficiently large to permit the child's escape, but it was subsequently brought through the opening. Pigne speaks of a woman of thirty-eight, who in the eighth month of her sixth pregnancy was gored by a bull, the horn effecting a transverse wound 27 inches long, running from one anterior spine to the other. The woman was found cold and insensible and with an imperceptible pulse. The small intestines were lying between the thighs and covered with coagulated blood. In the process of cleansing, a male child was expelled spontaneously through a rent in the uterus. The woman was treated with the usual precautions and was conscious at midday. In a month she was up. She lived twenty years without any inconvenience except that due to a slight hernia on the left side. The child died at the end of a fortnight.

In a very exhaustive article Harris of Philadelphia has collected nearly all the remaining cases on record, and brief extracts from some of them will be given below. In Zaandam, Holland, 1647, a farmer's wife was tossed by a furious bull. Her abdomen was ripped open, and the child and membranes escaped. The child suffered no injuries except a bruised upper lip and lived nine months. The mother died within forty hours of her injuries. Figure 19 taken from an engraving dated 1647, represents an accouchement by a mad bull, possibly the same case. In Dillenberg, Germany, in 1779, a multipara was gored by an ox at her sixth month of pregnancy; the horn entered the right epigastric region, three inches from the linea alba, and perforated the uterus. The right arm of the fetus protruded; the wound was enlarged and the fetus and placenta delivered. Thatcher speaks of a woman who was gored by a cow in King's Park, and both mother and child were safely delivered and survived.

In the Parish of Zecoytia, Spain, in 1785, Marie Gratien was gored by an ox in the superior portion of her epigastrium, making a wound eight inches long which wounded the uterus in the same direction. Dr. Antonio di Zubeldia and Don Martin Monaco were called to take charge of the case. While they were preparing to effect delivery by the vagina, the woman, in an attack of singultus, ruptured the line of laceration and expelled the fetus, dead. On the twenty-first day the patient was doing well. The wound closed at the end of the sixteenth week. The woman subsequently enjoyed excellent health and, although she had a small ventral hernia, bore and nursed two children.

Marsh cites the instance of a woman of forty-two, the mother of eight children, who when eight months pregnant was horned by a cow. Her clothes were not torn, but she felt that the child had slipped out, and she caught it in her dress. She was seen by some neighbors twelve yards from the place of accident, and was assisted to her house. The bowels protruded and the child was separated from the funis. A physician saw the woman three-quarters of an hour afterward and found her pulseless and thoroughly exhausted. There was considerable but not excessive loss of blood, and several feet of intestine protruded through the wound. The womb was partially inverted through the wound, and the placenta was still attached to the inverted portion. The wound in the uterus was Y-shaped. The mother died in one and a half hours from the reception of her injuries, but the child was uninjured.

Scott mentions the instance of a woman thirty-four years old who was gored by an infuriated ox while in the ninth month of her eighth pregnancy. The horn entered at the anterior superior spinous process of the ilium, involving the parietes and the uterus. The child was extruded through the wound about half an hour after the occurrence of the accident. The cord was cut and the child survived and thrived, though the mother soon died. Stalpart tells the almost incredible story of a soldier's wife who went to obtain water from a stream and was cut in two by a cannonball while stooping over. A passing soldier observed something to move in the water, which, on investigation, he found to be a living child in its membranes. It was christened by order of one Cordua and lived for some time after.

Postmortem Cesarean Section.—The possibility of delivering a child by Cesarean section after the death of the mother has been known for a long time to the students of medicine. In the olden times there were laws making compulsory the opening of the dead bodies of pregnant women shortly after death. Numa Pompilius established the first law, which was called "les regia," and in later times there were many such ordinances. A full description of these laws is on record. Life was believed possible after a gestation of six months or over, and, as stated, some famous men were supposed to have been born in this manner. Francois de Civile, who on great occasions signed himself "trois fois enterre et trois fois par le grace de Dieu ressucite," saw the light of the world by a happy Cesarean operation on his exhumed mother. Fabricius Hildanus and Boarton report similar instances. Bourton cites among others the case of an infant who was found living twelve hours after the death of his mother. Dufour and Mauriceau are two older French medical writers who discuss this subject. Flajani speaks of a case in which a child was delivered at the death of its mother, and some of the older Italian writers discuss the advisability of the operation in the moribund state before death actually ensues. Heister writes of the delivery of the child after the death of the mother by opening the abdomen and uterus.

Harris relates several interesting examples. In Peru in 1794 a Sambi woman was killed by lightning, and the next day the abdomen was opened by official command and a living child was extracted. The Princess von Swartzenberg, who was burned to death at a ball in Paris in 1810, was said to have had a living child removed from her body the next day. Like all similar instances, this was proved to be false, as her body was burned beyond the possibility of recognition, and, besides, she was only four months pregnant. Harris mentions another case of a young woman who threw herself from the Pont Neuf into the Seine. Her body was recovered, and a surgeon who was present seized a knife from a butcher standing by and extracted a living child in the presence of the curious spectators. Campbell discusses this subject most thoroughly, though he advances no new opinions upon it.

Duer tabulates the successful results of a number of cases of Cesarean section after death as follows:—

Children extracted between 1 and 5 minutes after death of the mother, 21 " " 10 and 15 " " " " " " 13 " " 15 and 30 " " " " " " 2 " " 1 hour " " " " " " 2 " " 2 hours " " " " " " 2

Garezky of St. Petersburg collected reports of 379 cases of Cesarean section after death with the following results: 308 were extracted dead; 37 showed signs of life; 34 were born alive. Of the 34, only 5 lived for any length of time. He concludes that if extracted within five or six minutes after death, they may be born alive; if from six to ten minutes, they may still be born alive, though asphyxiated; if from ten to twenty-six minutes, they will be highly asphyxiated. In a great number of these cases the infant was asphyxiated or dead in one minute. Of course, if the death is sudden, as by apoplexy, accident, or suicide, the child's chances are better. These statistics seem conscientious and reliable, and we are safe in taking them as indicative of the usual result, which discountenances the old reports of death as taking place some time before extraction.

Peuch is credited with statistics showing that in 453 operations 101 children gave signs of life, but only 45 survived.

During the Commune of Paris, Tarnier, one night at the Maternite, was called to an inmate who, while lying in bed near the end of pregnancy, had been killed by a ball which fractured the base of the skull and entered the brain. He removed the child by Cesarean section and it lived for several days. In another case a pregnant woman fell from a window for a distance of more than 30 feet, instant death resulting; thirty minutes at least after the death of the mother an infant was removed, which, after some difficulty, was resuscitated and lived for thirteen years. Tarnier states that delivery may take place three-quarters of an hour or even an hour after the death of the mother, and he also quotes an extraordinary case by Hubert of a successful Cesarean operation two hours after the mother's death; the woman, who was eight months pregnant, was instantly killed while crossing a railroad track.

Hoffman records the case of a successful Cesarean section done ten minutes after death. The patient was a woman of thirty-six, in her eighth month of pregnancy, who was suddenly seized with eclampsia, which terminated fatally in ten hours. Ten minutes after her last respiration the Cesarean section was performed and a living male child delivered. This infant was nourished with the aid of a spoon, but it died in twenty-five hours in consequence of its premature birth and enfeebled vitality.

Green speaks of a woman, nine months pregnant, who was run over by a heavily laden stage-coach in the streets of Southwark. She died in about twenty minutes, and in about twenty minutes more a living child was extracted from her by Cesarean section. There was a similar case in the Hopital St. Louis, in Paris, in 1829; but in this case the child was born alive five minutes after death. Squire tells of a case in which the mother died of dilatation of the aorta, and in from twenty to thirty minutes the child was saved. In comment on this case Aveling is quoted as saying that he believed it possible to save a child one hour after the death of the mother. No less an authority than Playfair speaks of a case in which a child was born half an hour after the death of the mother. Beckman relates the history of a woman who died suddenly in convulsions. The incision was made about five minutes after death, and a male child about four pounds in weight was extracted. The child exhibited feeble heart-contractions and was despaired of. Happily, after numerous and persistent means of resuscitation, applied for about two and a half hours, regular respirations were established and the child eventually recovered. Walter reports a successful instance of removal of the child after the death of the mother from apoplexy.

Cleveland gives an account of a woman of forty-seven which is of special interest. The mother had become impregnated five months after the cessation of menstruation, and a uterine sound had been used in ignorance of the impregnation at this late period. The mother died, and one hour later a living child was extracted by Cesarean section. There are two other recent cases recorded of extraction after an hour had expired from the death. One is cited by Veronden in which the extraction was two hours after death, a living child resulting, and the other by Blatner in which one hour had elapsed after death, when the child was taken out alive.

Cases of rupture of the uterus during pregnancy from the pressure of the contents and delivery of the fetus by some unnatural passage are found in profusion through medical literature, and seem to have been of special interest to the older observers. Benivenius saw a case in which the uterus ruptured and the intestines protruded from the vulva. An instance similar to the one recorded by Benivenius is also found in the last century in Germany. Bouillon and Desbois, two French physicians of the last century, both record examples of the uterus rupturing in the last stages of pregnancy and the mother recovering. Schreiber gives an instance of rupture of the uterus occasioned by the presence of a 13-pound fetus, and there is recorded the account of a rupture caused by a 20-pound fetus that made its way into the abdomen. We find old accounts of cases of rupture of the uterus with birth by the umbilicus and the recovery of the woman. Vespre describes a case in which the uterus was ruptured by the feet of the fetus.

Farquharson has an account of a singular case in midwifery in which abdomen ruptured from the pressure of the fetus; and quite recently Geoghegan illustrates the possibilities of uterine pressure in pregnancy by a postmortem examination after a fatal parturition, in which the stomach was found pushed through the diaphragm and lying under the left clavicle. Heywood Smith narrates the particulars of a case of premature labor at seven months in which rupture of the uterus occurred and, notwithstanding the fact that the case was complicated by placenta praevia, the patient recovered.

Rupture of the uterus and recovery does not necessarily prevent subsequent successful pregnancy and delivery by the natural channels. Whinery relates an instance of a ruptured uterus in a healthy Irish woman of thirty-seven from whom a dead child was extracted by abdominal section and who was safely delivered of a healthy female child about one year afterward. Analogous to this case is that of Lawrence, who details the instance of a woman who had been delivered five times of dead children; she had a very narrow pelvis and labor was always induced at the eighth month to assure delivery. In her sixth pregnancy she had miscalculated her time, and, in consequence, her uterus ruptured in an unexpected parturition, but she recovered and had several subsequent pregnancies.

Occasionally there is a spontaneous rupture of the vagina during the process of parturition, the uterus remaining intact. Wiltshire reports such a case in a woman who had a most prominent sacrum; the laceration was transverse and quite extensive, but the woman made a good recovery. Schauta pictures an exostosis on the promontory of the sacrum. Blenkinsop cites an instance in which the labor was neither protracted nor abnormally severe, yet the rupture of the vagina took place with the escape of the child into the abdomen of the mother, and was from thence extracted by Cesarean section. A peculiarity of this case was the easy expulsion from the uterus, no instrumental or other manual interference being attempted and the uterus remaining perfectly intact.

In some cases there is extensive sloughing of the genitals after parturition with recovery far beyond expectation. Gooch mentions a case in which the whole vagina sloughed, yet to his surprise the patient recovered. Aetius and Benivenius speak of recovery in such cases after loss of the whole uterus. Cazenave of Bordeaux relates a most marvelous case in which a primipara suffered in labor from an impacted head. She was twenty-five, of very diminutive stature, and was in labor a long time. After labor, sloughing of the parts commenced and progressed to such an extent that in one month there were no traces of the labia, nymphae, vagina, perineum, or anus. There was simply a large opening extending from the meatus urinarius to the coccyx. The rectovaginal septum, the lower portion of the rectum, and the neck of the bladder were obliterated. The woman survived, although she always experienced great difficulty in urination and in entirely emptying the rectum. A similar instance is reported in a woman of thirty who was thirty-six hours in labor. The fundus of the uterus descended into the vagina and the whole uterine apparatus was removed. The lower part of the rectum depended between the labia; in the presence of the physician the nurse drew this out and it separated at the sphincter ani. On examining the parts a single opening was seen, as in the preceding case, from the pubes to the coccyx. Some time afterward the end of the intestine descended several inches and hung loosely on the concave surface of the rectum. A sponge was introduced to support the rectum and prevent access of air. The destruction of the parts was so complete and the opening so large as to bring into view the whole inner surface of the pelvis, in spite of which, after prolonged suppuration, the wound cicatrized from behind forward and health returned, except as regards the inconvenience of feces and urine. Milk-secretion appeared late and lasted two months without influencing the other functions.

There are cases in which, through the ignorance of the midwife or the physician, prolapsed pelvic organs are mistaken for afterbirth and extracted. There have been instances in which the whole uterus and its appendages, not being recognized, have been dragged out. Walters cites the instance of a woman of twenty-two, who was in her third confinement. The midwife in attendance, finding the afterbirth did not come away, pulled at the funis, which broke at its attachment. She then introduced her hand and tore away what proved to be the whole of the uterus, with the right ovary and fallopian tube, a portion of the round ligament, and the left tube and ovarian ligament attached to it. A large quantity of omentum protruded from the vulva and upper part of the vagina, and an enormous rent was left. Walters saw the woman twenty-one hours afterward, and ligated and severed the protruding omentum. On the twenty-eighth day, after a marvelous recovery, she was able to drive to the Royal Berkshire Hospital, a distance of five miles. At the time of report, two years and six months after the mutilation, she was in perfect health. Walters looked into the statistics of such cases and found 36 accidental removals of the uterus in the puerperium with 14 recoveries. All but three of these were without a doubt attended by previous inversion of the uterus.

A medical man was tried for manslaughter in 1878 because he made a similar mistake. He had delivered a woman by means of the forceps, and, after delivery, brought away what he thought a tumor. This "tumor" consisted of the uterus, with the placenta attached to the fundus, the funis, a portion of the lateral ligament, containing one ovary and about three inches of vagina. The uterus was not inverted. A horrible case, with similar results, happened in France, and was reported by Tardieu. A brutal peasant, whose wife was pregnant, dragged out a fetus of seven months, together with the uterus and the whole intestinal canal, from within 50 cm. of the pylorus to within 8 cm. of the ileocecal valve. The woman was seen three-quarters of an hour after the intestines had been found in the yard (where the brute had thrown them), still alive and reproaching her murderer. Hoffman cites an instance in which a midwife, in her anxiety to extract the afterbirth, made traction on the cord, brought out the uterus, ovaries, and tubes, and tore the vulva and perineum as far as the anus.

Woodson tells the story of a negress who was four months pregnant, and who, on being seized with severe uterine pains in a bath, succeeded in seizing the fetus and dragging it out, but inverting the uterus in the operation. There is a case recorded of a girl of eighteen, near her labor, who, being driven from her house by her father, took refuge in a neighboring house, and soon felt the pains of child-birth. The accoucheur was summoned, pronounced them false pains, and went away. On his return he found the girl dying, with her uterus completely inverted and hanging between her legs. This unfortunate maiden had been delivered while standing upright, with her elbows on the back of a chair. The child suddenly escaped, bringing with it the uterus, but as the funis ruptured the child fell to the floor. Wagner pictures partial prolapse of the womb in labor.

It would too much extend this chapter to include the many accidents incident to labor, and only a few of especial interest will be given. Cases like rupture of an aneurysm during labor, extensive hemorrhage, the entrance of air into the uterine veins and sinuses, and common lacerations will be omitted, together with complicated births like those of double monsters, etc., but there are several other cases that deserve mention. Eldridge gives an instance of separation of the symphysis pubis during labor,—a natural symphysiotomy. A separation of 3/4 inch could be discerned at the symphysis, and in addition the sacroiliac synchondrosis was also quite movable. The woman had not been able to walk in the latter part of her pregnancy. The child weighed 10 1/2 pounds and had a large head in a remarkably advanced stage of ossification, with the fontanelles nearly closed. Delivery was effected, though during the passage of the head the pubes separated to such an extent that Eldridge placed two fingers between them. The mother recovered, and had perfect union and normal locomotion.

Sanders reports a case of the separation of the pubic bones in labor. Studley mentions a case of fracture of the pelvis during instrumental delivery. Humphreys cites a most curious instance. The patient, it appears, had a large exostosis on the body of the pubes which, during parturition, was forced through the walls of the uterus and bladder, resulting in death. Kilian reports four cases of death from perforation of the uterus in this manner. Schauta pictures such an exostosis.

Chandler relates an instance in which there was laceration of the liver during parturition; and Hubbard records a case of rupture of the spleen after labor.

Symphysiotomy is an operation consisting of division of the pubic symphysis in order to facilitate delivery in narrow pelves. This operation has undergone a most remarkable revival during the past two years. It originated in a suggestion by Pineau in his work on surgery in 1598, and in 1665 was first performed by La Courvee upon a dead body in order to save the child, and afterward by Plenk, in 1766, for the same purpose. In 1777 Sigault first proposed the operation on the living, and Ferrara was the one to carry out, practically, the proposition,—although Sigault is generally considered to be the first symphysiotormist, and the procedure is very generally known as the "Sigaultean operation." From Ferrara's time to 1858, when the operation had practically died out, it had been performed 85 times, with a recorded mortality of 33 per cent. In 1866 the Italians, under the leadership of Morisani of Naples, revived the operation, and in twenty years had performed it 70 times with a mortality of 24 per cent. Owing to rigid antiseptic technic, the last 38 of these operations (1886 to 1891) showed a mortality of only 50 per cent, while the infant-mortality was only 10 2/3 per cent. The modern history of this operation is quite interesting, and is very completely reviewed by Hirst and Dorland.

In November, 1893, Hirst reported 212 operations since 1887, with a maternal mortality of 12.73 per cent and a fetal mortality of 28 per cent. In his later statistics Morisani gives 55 cases with 2 maternal deaths and 1 infantile death, while Zweifel reports 14 cases from the Leipzig clinic with no maternal death and 2 fetal deaths, 1 from asphyxia and 1 from pneumonia, two days after birth. All the modern statistics are correspondingly encouraging.