Treatment must also be prompt in those cases in which a partial degen eration of one lip prevents dilatation from taking place regularly. Only two methods of dilatation are available in these cases, either the application of Barnes's dilators, (laminaria and sponge-tents not being sufficiently active,) or incisions into the affected tissues. At the same time both procedures are efficient only when the pains are powerful and the area of the disease is so small that we may at least hope that nature will be able to complete delivery. In other cases the above-mentioned procedure may render possible the employment of other operative measures. Thus Savory' dilated the os with Barnes's dilators only sufficiently to allow him to turn a seven months' foetus. The latter, however, died during the operation, and the mother succumbed on the thirteenth day of childbed. A. Edis' dilated the os with the same instruments until he was able to apply the forceps, and succeeded in extracting a fully developed, living child. The mother died of pytemia two weeks later.
Spiegelberg' was more fortunate: after incising the os he delivered a living child with the forceps, while the mother passed safely through childbed. Other favorable cases have been reported by Ganiot and de the latter after dilatation of the os with sponge tents, and subsequent application of the forceps. On the other hand it not seldom happens that incisions do not suffice to allow delivery to be accomplished quickly, and both mother and child perish. (Malgaigne, Chantreuil, 1. c., p. 75.) Cohnstein collected nine cases in which incisions had been made, one of them without any additional operative interference. Fifty per cent. of the mothers survived labor, and 62.5 per cent. of the children were born alive. Naturally the incisions easily lead to further crushing and laceration of the diseased lower segment of the uterus, and cannot, there fore, act as sure preventives of rupture of the uterus or of peritonitis.
When incisions into the os do not suffice to bring about the desired re sult, it is advisable to remove with the scoop or scissors as much as possi ble of the cancerous masses, and to follow this up by delivery with forceps or by turning. Bischoff' practised this method in four cases, saving all the mothers as well as their offspring. C. Braun' also favors this proced ure, particularly as it permits a more radical operation after delivery.
The forceps will be very serviceable in all cases in which the os is suffi ciently dilated to render its application feasible, and the foetal head has descended low snough into the pelvis to allow of extraction. Although the use of the instrument may be attended with extensive lacerations of the maternal tissue, the thereby induced abridgement of labor certainly inures to the benefit of the child.
Herman (1. c.) states that out of nine cases of this kind the mothers died four times.
Version and extraction ought, I think, to be restricted to those cases in which they are indicated by a malposition of the child, such as trans verse or breech presentations. (Danyau, Depaul.) The prognosis is always very bad for the child in these cases on account of the difficulty of freeing the head and arms, and it does not, therefore, seem appropriate to perform version when the head presents, as has been recommended by Simpson, although the latter in one instance executed it with a favorable result for both mother and child. It was also successful in the hands of Galabin.' A similar case of Godson's' terminated very unfavorably. Cohnstein found that, in eleven cases of the operation but 18.1 per cent. of the mothers and 12.5 per cent. of the children survived.
Craniotomy and embryotomy offer scarcely any advantage in cancerous disease of the lower segment of the uterus, for the fcetus must, of course, be sacrificed, while the result for the mother is unfavorable. According to Cohnstein four mothers died in six operations of this kind, two of rup ture of the uterus, one undelivered, and.one during childbed. Chantreuil records three instances of craniotomy, in two of which the mothers died, and two instances of embryotomy, in one of which the mother expired during the operation. Galabin reports a case in which he performed cephalotripsy through an os which admitted only three fingers, and then, not succeeding in extracting the child during the next three hours, he was compelled to resort to version before delivery could be effected. Valenta' lost a patient from the same operation from a laceration extend ing to the peritoneum. Freund' had a somewhat similar experience.
Now, although induced abortioh offers a better prognosis for the mother than does labor at full term, yet the opinion is universally accepted that in view of the undeniably incurable disease of the mother, the former operation should be rejected, in order to save, if possible, the life of the infant. It has already been demonstrated that abortion is not to be feared in those cases in which there is a prospect of cure, or of long-continued improvement for the mother. When, however, the disease is so far ad vanced as to forbid this hope, the induction of premature labor is entirely out of the question, since it does not guarantee any noteworthy benefit to the mother, while it materially impairs the prognosis as far as the child is concerned.