If the pelvis be not greatly deformed, the delivery may now soon be effected; if it be, we proceed to remove the bones piece-meal, taking care to guard each piece through the vagina, by laying the scabrous edges of it against the hand, which during the whole operation should be in the vagina. The sides of the two points of the perforator, which come against each other when the instrument is shut, are made rough, so that as with pair of pliers we may take hold of a bone which is too large to pass, and break. In this way we must bring away the frontal bane, and occipital bone ; the temporal bones, and the parietals; after which, in order to have a firm hold, we should lay the scalp as far over the parts within as we can, making a sort of flap to lay hold of. It is best to put on a glove well-greas ed in order to catch hold with. It will sometimes answer very well to carry up the blunt hook, with which we may occa sionally be able to catch hold somewhere, so as to have a good purchase; but it is very apt to slip, as it has no point. If it do slip, we can then only pass the crotchet, in the construction of which we should observe that the flat point, at its sharp extremity, looks inward ; so that if laid to a surface parallel to it in direction, it will not be able to peck into it, or wound it. When using the crotchet, we should be. gin with as little force as may be attend ed with a good effect ; since, if not suffi cient to bring down the head, it may be easily increased; recollecting that when ever this instrument is using, we must al ways keep that hand which is within the uterus directly opposite the beak of the instrument, so that in the event of the parts of the child giving way, no accident may happen to the uterus. We should use a force that we can command ; and if the pelvis be of sufficient dimensions, bring the body down without removing any more than the head ; for when once the head is delivered, the body will soon follow, as it is easily compressed Where the deformity is very great, and the passage very small, we should begin to open the head very early in labour, punct4ing whatever part we first reach, by a e drilled up to the stops. We should hen cease, and trust in some mea sure to that putrefaction which the mois ture and warmth of the parts will be sure to produce instantly. This putrefaction will proceed very rapidly; and the bones, and indeed the whole body, will come away easier, separating from each other with infinitely less force than before they could have done. When the patient can nut be left longer with propriety, after about thirty-six hours, we may proceed to bring away, piece-meal, the various bones of the cranium ; the temporal, frontal, occipital, and parietal bones ; after which the remaining part of the head will only be the basis of the skull, which admits of being placed in a more favourable posi tion for passing through the pelvis ; for the parietes being carefully laid over the bones whenever they may be felt expos ed, it will protect the uterus from injury, and then if the remains of the head be brought forward, and doubled down with the chin to the breast, it will, in this state, be frequently capable of being delivered. This sort of labour is very tedious; it lasts a very great length of time ; but it re quires no skill. We must be aware, that when we have brought the head down, we must not always expect the body to follow, as in other cases, but shall some times be obliged to bring away the whole child by pieces. It may be necessary, in order that the body may pass, to take out the heart and lungs, and every organ one after the other. All the caution that need be given is, to take care not to injure the woman in doing what we are about, nei ther in separating the parts, nor in bring ing them away.
On facilitating Labour by turning the Child. It will sometimes happen that, in spite of a slight deformity of the pelvis, we have a chance of saving the lives of both the mother and the child. And there are two modes of attempting to do this ; the first is by turning the child, which will also apply to other cases as well as deformity of the pelvis ; the second, by bringing on premature labour. Turning is not the best of the two resources; but many women will submit to this, who will not submit to the proposal of bringing on premature labour.
After turning a child, we may pull it through by the feet, while we never should have been able to have delivered it without, for the uterus would not have been able to push it through, in the com mon way of presenting with the head to the os uteri; and if we prove able to save the child's head, it is a grand point. If after we have brought the feet down, the head will not pass, even then we are only where we were at first, and can open it.
On bringing on Premature Labour. The operation that is certainly the best me thod of managing delivery, in deformities which admit of it, is premature labour, which is founded upon these positions ; that during pregnancy, the head of the child is increasing in size, to the time of so that if we take them in their gradual increase of size, it is pretty plain that one in the early months of pregnan cy would pass with ease through a pelvis that would not receive it at a later period; and in this way, by considering the case in all its parts, comparing the diameter of the pelvis with the size of the head at different periods of the pregnancy, we shall be able to calculate the time when we may bring on premature labour, fix ing either the seventh month, seventh and half, or eighth month, but never later ; for if we do, the head will be too much ossified to submit to the pressure it must sustain, with that ease which is ne cessary to the delivery being perfectly safe. It may, indeed, be brought away as early as five or six months, but the child then cannot be expected to live ;, and if it be produced later than eight months and a half, the labour will be as difficult as that at nine months.
The first step towards bringing on pre mature labour is, to carry up a male ca theter through the vagina to the os uteri. and to introduce it with care, in such a manner as that the point of the catheter shall be in contact with the sides of the uterus, using a gentle pressure only. When the extremity of the catheter is against the membranes, hut clear of the child, the instrument is to be thrust for ward so as to break the membranes ; and in this the catheter is preferable to a rod of silver, since as soon as the catheter en ters we know the object for which we introduce it is gained ; for while the in strument is still in our hand, we shall feel the waters passing off more or less; while if, a solid rod be employed, it may be necessary to introduce it a second time. In puncturiug or breaking the membranes, it is also preferable to get the instrument some way up the side of the uterus, instead of breaking them im mediately upon the os uteri, because, in the latter way, the child is most frequent ly born dead, which depends on the dif ferent effect with regard to the flowing off of the waters, produced by the mode of puncturing or breaking the mem branes.
The breaking the membranes at the side, only allows a partial escape of the waters, quite sufficient to produce a dis position to contract in the uterus, with out permitting any injurious effect to arise from pressure ; while, on the other hand, when they are broken in the front, the whole of the waters flow away, the uterus contracts very strongly round the child, and the circulation generally suf fers, and is either partially or completely interrupted. Delivery, by bringing on the action of the uterus prematurely, is for many reasons very estimable; a month or two before delivery naturally produc ed, the bead is not only smaller, but more compressible ; there is a less proportion of bone ; so that if we take two heads of the same absolute size, one being of eight months formation, and the other seven, still that at seven would have the advan tar in passing through a narrow pelvis. It is difficult for any one to determine the time which should apply to different pel ves ; but where the distance between the pubes and sacrum is under three, yet all but three inches, eight months may be al lowed ; where the distance is two and three quarters, seven months, and so on. Yet when a child is born at seven months it will rarely suck, and requires the ut most attention to be reared. By these means, then, we may be able to save two lives; by the Cesarean section we cer tainly lose one life, and by doing nothing we lose both.