ETIOLOGY AND TREATMENT OF CONTRACTED PELVES.
Rickets is the disease which most frequently causes pelvic deformity. We may avoid this deformity in a measure then by causing rachitic chil dren to retain a horizontal position so long as the bones are soft, pliable, and likely to bend.
The treatment is essentially based on the degree of contraction, and we must, therefore, at the outset, obtain an exact idea of this degree through mensuration. We must further endeavor to ascertain the cause of the de formity, the correct period of gestation, and the volume, position, pres entation, mobility, viability of the foetus. When labor has once begun, we should remember that the duration is always greater than in case of the normal pelvis, and we must never interfere unless this duration seems prejudicial to the mother or to the child. We should carefully, on the other hand, time our interference before the mother or the foetus becomes too greatly exhausted. The woman had better lie down from the outset, since premature rupture of the membranes is likely to occur, and, in con sequence, prolapse of the limbs and of the cord. When the pains are fee ble, and the head, at the superior strait, has but little tendency to en gage, we do not hesitate at the end of about twelve hours to rupture the membranes, but always in the intervals of the contractions, and with the precaution of allowing the liquor amnii to flow out but slowly. We thus obtain fixation of the head, and the pains increasing in intensity the head engages more or less according to the degree of contraction, and the size of the foetus. If the head do not engage, then, after waiting a reason able length of time,we must in terfere,and the point is to choose the method. We have seen that abroad preference is given to version, and in France to the forceps, followed if need be by perforation. The recent experiments of Budin, Duncan, Milne and Champetier, would, however, seem to modify this practice, in that version is preferable before term and the for ceps after. • In case of transverse presentation at term, the endeavor should be made to bring the head by external manipulation over the su perior strait, and similarly in case of presentation of the pelvic extrem ity. But if the woman is not at term, should we interfere with a cepha
lic presentation by conversion into the breech by external manipulation, or, as Milne advises, induce labor and perform internal version? To induce labor is certainly our duty, but as to our second course of action ads is a point which the future must decide. Finally, if the child pre ' sent by the shoulder what should we do? Bring the head, by external version to the superior strait, or await complete dilatation and then per form internal version? Here again it is impossible as yet to dogmatize.
Such are the general rules of treatment which we would lay down. We must now consider the special indications according to the degree of pel vic contraction.
1. The pelvis measures at least 3.5 inches in the conjugate.—a. The woman is at or near term. If the vertex presents wait as long as the condition of the mother and child will allow, and then apply the forceps. If the face presents, the indication will vary according as the chin is before or behind. In the former event, wait as long as possible, and then apply the forceps; in the latter event authorities are not in agreement. We must at the outset endeavor to transform the face into vertex by pro moting flexion; but if this do not succeed ought we to turn or to apply the 'forceps? The forceps necessitates artificial rotation of the head in 'order to bring the chin forwards, but we have seen that, in a general way, version at term is less advantageous, and therefore we pronounce for the forceps, always provided that prolonged attempts at extraction are not made. If the pelvic extremity present, version by external manipulation to bring the vertex to the superior strait, and then the forceps. In case of the shoulder, external version, and, if this fail, internal, followed at once by the forceps to the after-coming head. b. Where pregnancy has not reached term delivery will always terminate spontaneously, and we would only induce premature labor at 8i months in case the he tus was of excessive size or the mother had had difficulty iu previous labors.