Therefore, if miscarriage always sacrifices the infant, it saves the ma jority of women at least, and we do not think there is scope for hesitation.
Still, we must make a distinction between pelves deformed by rickets and by tumors and osteo-malacia. In the latter, indeed, the bones, in certain cases, are so flexible and supple, that, as is proven by the facts of Pagenstecher, Kilian, Schroeder, and others, even pelves with absolute contraction may yield to the pressure of the foetal body, and allow birth at term. We might, therefore, here, wait for the induction of prema ture labor.
Uncontrollable Vomittng.—This is one of the most frequent indications after contracted pelvis, and all authorities are in agreement. The inter ruption of pregnanby is the only means of saving the mother, and on one condition, that we do not interfere too late.
From the statistics which Gu(niot has collected, it is apparent that out of 118 cases 72 women recovered and 46 died. The 72 recoveries occurred: Without miscarriage, all grave cases and subjected to varied treat ment, 31. After spontaneous miscarriage, equally grave cases, 20. After induced miscarriage or labor, desperate cases, 21.
41 times, then, out of 72, cure resulted from premature labor, or mis carriage, artificial or spontaneous.
As for the deaths: Without miscarriage, 28. After miscarriage or spontaneous premature labors, 7. After induced miscarriage, 11.
McClintock reported to the Dublin Medical Society 36 observations of premature labor in case of uncontrollable vomiting, and of these 27 lived, and 9 died.
Cohnstein makes a distinction between multiparty and nulliparte, and does not counsel interference in the former: " after the expulsion of the foetus, vomiting ceases in 40% of the cases. But we must distinguish be tween provoked and spontaneous miscarriage, since the former is 25% of the 40%, and the latter 15%. The remaining 60% includes the cases where vomiting only partially ceased, 26%; those where it periiisted, 18%; those where it increased, 4%; and those where death occurred at once or shortly after miscarriage, 12%. He concludes that it is better to await spontane ous miscarriage."
We saw in the chapter on uncontrollable vomiting, that the selection of the time is of capital importance, and that it should be fixed at the end of the second period, without awaiting the third, the chances of recovery diminishing with waiting.
Finally, among the causes which justify miscarriage, we must cite re troversion of the uterus, hydramnios, molar pregnancies, and certain in stances where the life of the woman is seriously endangered, pregnancy being complicated by cardiac or pulmonary lesions, or by intercurrent diseases.
Miscarriage once decided upon, it remains to choose the time and the method.
If it be disease which calls for the operation, the time is, of course, sub ordinated to the condition of the patient. We can fix no precise date. We must neither act too soon, nor yet too late. The'same does not hold in case of pelvic deformity. Here the accoucheur, ordinarily, may choose his own time, but we must not forget that miscarriage is less grave at _ certain periods than at others. Although during the first two months, and generally from the fifth to the sixth month, miscarriage is simple and without complication, it is far otherwise from two and a half to four and a half months. It is usually, at this time, that we meet with serious hem orrhages, and miscarriage in two stages with retention of the secundines, and its sequelte. It is of advantage, then, to practise the induction of miscarriage in the first two months, or after the fifth.
We are not, however, always free to choose, because, on the one hand, the patients are rarely seen before the third month, and because later we must take into account the degree of contraction, the volume of the fcetus, and the size of its head. De Soyre insists, particularly, on this point. The figures in the following table represent the mean dimensions of the fcetal head before term: Up to this period, then, tho fcetal head, on account of the flexibility of the bones, is much more reducible than at term, a reducibility which is increased by the width of the fontanelles and the sutures. It is, there fore, the degree of contraction which should guide us.