2. The pelvis measures between 3.5 and 2.3 inches in the conjugate.
A. At or near term. Here there are two subdivisions: a. The foetus is dead. In case of presentation of the vertex or the face, we should wait until dilatation is sufficient, rupture the membranes, and perforate. Then wait for complete dilatation, and if the head still does not descend, apply Bailly's cephalotribe and extract. In case the pelvic extremity presents, we should perform external version, and then proceed similarly. If ex ternal version fails, deliver the trunk' and perforate the after-coming head. If the shoulder presents, external version; if this fail, internal version, perforation, and extraction; decapitation if version is not possi ble. b. In case the child is alive, a further sub-division is necessary. c. The pelvis measures between 3.5 and 2.9 inches. In case of the vertex, the forceps should be tried, as also in case of the face, but traction should not be prolonged, and the foetus mutilated rather than injure the mother by ineffectual attempts at delivery. The pelvic extremity and shoulder also call for rapid intervention. d. Pelvis measuring from 2.9 to 2.3 inches. Here the interests of the mother are best served, as the lower limit is approached by resorting to mutilation of the foetus. Depaul favors the Caesarean section at 2.3 inches, but we can neither grant this, nor above all the Porro which deprives the woman at once of the chance of future delivery by resort to timely premature labor. We would await the death of the child, but we believe it should be the rule in these in stances to make up our minds to the sacrifice of the foetus, and that we should tell our patient that the induction of premature labor at her next pregnancy offers a chance of a living child.
B. The woman is not a term. There are a number of means at'ottr disposal. Depaul advocates debilitating measures and repeated venesec tion, and was thus able to obtain living fcetuses at the 'eighth month in pelves measuring 3.12 inches. Others have advised the administration of the iodide of potass. The capital method, however, is the induction of premature labor, sooner or later according to the degree of contraction. If labor is induced, must we resort to forceps or to version ? Champetier's researches and conclusions speak entirely in favor of the latter.
3. The pelvis measures from 2.3 inches and below. If the woman is at term we must distinguish the cases where the infant is alive or dead, and where the pelvis measures at least 1.5 inches, or below.
If the infant is dead and the measurement is at least 1.5 inches, we should resort to cephalotripsy. If the child is alive, the choice lies be tween cephalotripsy and the Caesarean section. In face of the risks to the mother involved in the Caesarean section, even as modified by Porro, we would prefer cephalotripsy and only resort to the former at the ex press request of the mother. Below 1.5 inches all authorities are agreed in regard to cephalotripsy in case the infant is dead. If it is alive, the Caesarean section is the choice of all but Pajot who advocates repeated cephalotripsy without traction even down to one inch contraction.
If the woman is not at term, miscarriage should be induced. Premature labor at seven months would avail nothing, since the foetus is too developed to pass with ease. Stoltz is about the only authority who advocates allow ing the woman to go to term and performing the Cxsarean section.
[The above deductions of Charpentier in regard to treatment will be generally accepted as just. It is, however, a question if in the not distant future these deductions will not suffer considerable modification. Day by day the results obtained from the modified Grsarean section are being bettered, and those yielded by laparo-elytrotomy will compare very favor ably, as regards the mother, with cephalotripsy, even after Pajot's method, in extreme degrees of pelvic deformity. If the time comes when the risk to the mother can be proved to be no greater by timely resort to operations which also consider the life of the foetus, most assuredly will it be our duty to reject absolutely all mutilating operations in case of a living child, other conditions necessary for the successful section, or laparo-elytrotomy, being present. The latest statistical data of these operations will be found under the subject of obstetric operations.—Ed.] We must now consider the proper course of action in case of deformity the result of other than rachitic cause. In osteomalacia the treatment is absolutely subordinated, not only to the degree of contraction, but also to the quality, so to speak, of the pelvic bones. We have seen that in one of the osteomalacic forms, the bones are so soft and supple that they may distend enough to allow the at first sight impossible delivery. The cus tomary procedure in these cases is version. These cases are exceptional, although proved by the instances recorded by Kilian, Robert, Olshausen, Hugenberger, Winckel, ete.
In the generally and regularly contracted pelvis, the vertex presentation is the most favorable of all, and version is absolutely contra-indicated. Forceps are required, and in case of failure, perforation and cephalotripsy.
In the oblique oval pelvis version is the most rational operation, the object being to bring the bead into the widest part of the pelvis.
In kyphotic pelves, perforation and cephalotripsy; in the spondylolis thetie and spondylizematic pelves, miscarriage before term, the Caesarean section at term; in pelves deformed from congenital luxation, with lordo sis or scoliosis, ordinarily labor at term is possible, and rarely is mutila tion requisite. Finally, in the pelves deformed by the presence of a tumor, all depends on its nature. If fluid, puncture; if solid, it is impossible to lay down fixed rules. In certain cases miscarriage, in others premature labor, in still others the Caesarean section, embryotomy, cephalotripsy, and finally in others even version or the forceps are called for.
We must never forget the fact noted by Ahlfeld and Simpson, that with successive pregnancies the fcetuses increase in size, and that hence a moderate contraction, allowing ready delivery at the first pregnancies, may call for operative interference in the later.