In 1871 Litzmann concluded that Spiegelberg had understated the in dication. He ranges himself, and we think justly, on the side of the mother's interest mainly. He divides pelves into three classes: 1. Pelvis generally and regularly contracted, diameter 3.9 to 3.5 inches; Pelvis simply flattened, or generally contracted from 3.7 to 3.19 inches. Here premature labor is only justifiable in case of complication.
2. Pelvis generally and regularly contracted, 3.5 inches at least. Pel vis simply flattened, or generally contracted and flattened, 3.19 to 2.8 inches. Operation is indicated, even in primipara.
3. Pelvis simply contracted, or generally contracted and flattened, about .29 of an inch. The operation is only exceptionally admitted.
Next comparing spontaneous premature labor, and induced from the side of the child, Litzmann gives the following table: In 1880, Maygrier in turn endeavored to estimate the value of prema ture labor (induced).
In 37 cases, in pelves 2.73 inches and below: Mothers saved 23, dead 11, mortality about 33.33 per cent. Infants saved 12, dead 22, mortality about 64.70 per cent.
Further, of these 12 living children eight died within the first week. From the standpoint of the infant, those figures may be arranged: Kunne, at Elberfeld, has induced labor fifteen times. All the mothers recovered, two only being sick; of the 15 infants, 12 were born alive and lived.
Naegele and Grenser place the limits between 2.73 and 3.7 inches. Schroeder gives no upper limit, the inferior limit is 2.63 inches. Jac quemier places it as low as 2.54 inches; Dubois 2.54 inches; Joulin 2.54 inches; Velpeau 2.63 inches; Cazeaux 2.34 inches; Depaul 2.34 inches; Tarnier 2.14 inches. According to the latter, if extraction of a living child is impossible, embryotomy offers a better chance, for the very rea son that the foetus is only partially developed.
Considering now the figures of Rigaud and of Stanesco, we have a total of 810 cases of pelvic contraction, where premature labor was induced. They may be divided as follows: We see, then, that underneath 2.34 inches premature labor has always been fatal to the infant. It is apparent that under this figure we must reject the operation, although a personal case, which we have already re lated, •where the pelvis was 2.14 inches, and the child, at seven months, was born alive and lived twenty-four hours, would lead us to place the limit at 2.14 inches. Such cases, however, are very exceptional, and we may say that below 2.34 to 2.14 inches there remains only the CEesarean section, or cephalotripsy with or without traction. Now, considering the
danger to the mother of both these methods, and considering the almost absolute fatality of induced premature labor to the infant in case of such pronounced contraction, it is really to induced miscarriage, that is to say, before viability, that we should have recourse.
These figures, be it remembered, are not at all absolute, being only means. We have seen that the foetal head was compressible to the extent of .39 inches without danger to the life of the child. It is evident, there fore, that below 2.34 inches the head might be delivered by the forceps, but at the expense of injury to it and to the mother. Whence the neces sity, in order to obtain a living child, of limiting the induction of prema ture labor at 2.34 inches; and although we have stated above that the limit might be 2.14 inches, it is because the head is at times more readily moulded, or the infant less developed, and hence may pass. Of course this lesser development means less chance of survival; nevertheless, encour aged by our one success, we would take the chances in analogous cases.
Further indications for premature labor are complications which threaten the life of the mother, whether these complications are deter mined by pregnancy, or aggravated by the presence of this condition. Such are: Uncontrollable vomiting, eclampsia (according to certain authorities, although we are, as stated under the subject, absolutely op posed to this), hemorrhages, acute or chronic diseases of the respiratory and circulatory organs, hydramnios, ascites, goitre (d'Outrepont,) prolap sus uteri, pernicious anaemia of the gravida (Gusserow), abdominal tumors, intercurrent or epidemic diseases. (See The Pathology of Pregnancy, Vol. II.) Here the question is a delicate one. We must not forget that the induction of labor by determining in the woman what Raymond has called the great puerperal state may aggravate her condition, and thus we may act directly against our aim. The case is somewhat analogous to what happens to a wounded man with a compound fracture requiring amputation. If this operation be done at once, he dies; if we allow him to recover from shock and then operate, his chances of life are greater. The state of affairs is about the same in the pregnant woman suffering from an acute disease. If in her already depressed condition, we add the shock of premature labor, we diminish her chances of recovery. Only as a last hope should we, hence, induce labor in this case, and then in order to diminish the gravity of the disease from which she is suffering.