THE TREATMENT OF PELVIC DEFORMITIES.
The prognosis is in a measure dependent on the treatment, and in re gard to this authorities are not at all in accord. In France it is to the forceps; in Germany and in England preference is given to version. We will, therefore, precede our remarks on treatment with a comparative study of the value of these two methods in cases of pelvic contraction, seeing that the partisans of version base their preference on the mechan ism of labor.
We have already noted how Otto de IIaselberg, Litzmann, Michaelis, and others explain this mechanism, and we have stated why Simpson be lieved that the after-coming head passed more readily than the before coming.
In 1865, Joulin stated that in order that an observation may throw light on this question of forceps or version: 1. The diameter of the pelvis and of the head should be indicated with care. 2. The form of the contrac tion should be stated, since one operation may in truth be indicated in one form of pelvic deformity, and contra-indicated in another. 3. That both forceps and version have been attempted on the same patient, since otherwise the doubt exists as to whether the operation not attempted would have not succeeded as well as the one which did. He then dis sects with care Simpson's monograph, and shows: 1. The vertex rela tively to the parietal protuberances forms the apex of a cone, shorter, it is true, than that bounded by the bi-mastoid diameter and the parietal protuberances, but not at all like the diverging branches of an A, and further the vertex has never been found flattened out by the pelvis. When labor has been long in progress, the head is greatly flexed, and then it is not the bregma which presents, but a point very near the occi put, which forms the apex of a cone, with the parietal protuberances as its base, and which is higher than, but not as thick as, the parieto-mas toidean cone at its apex. Simpson's theory, therefore, falls to the ground, for it is clear that if version only brings to the superior strait the same diameter that the forceps seizes, the operation does not compensate for the risks it involves. 2. The grasp which we have of the infant's body is net at all better than that which is furnished by the forceps, and if in slight contractions we obtain reduction of the head, may this not be at the expense of the fictus? 3. Not only is the head placed by the forceps oven
as by version, so that the small diameter, the bi-temporal, engages in the least diameter of the pelvis, but, further, the forceps engages the head by its sub-occipito-bregmatic circumference, while version engages it by the occipito-frontal. 4. Finally, when labor has been prolonged, the head is strongly flexed, hence it has no tendency to Rug-age by the bregma, but by the apex of the occipito-pariotal cone. Joulin further establishes by ex periments, that the total force necessary to engage the foetus by the after coming head is greater than when it comes before, and he naturally gives the preference to the forceps, except in case of oblique oval pelves.
In 1864, McClintock, as the result of clinical experience, pronounced in favor of version. His observations were based on 11 multiparm, and of the 63 infants, 16 were delivered by version and 9 lived. Of the re maining 47, born some without intervention, and others by forceps, 18 lived. Of the mothers delivered by version, but one died. In none of these cases was the contraction marked.
Martin prefers the forceps, and only resorts to version when, 1, the transverse diameter is long enough to allow the occiput, the thick part of the head, to lie alongside the promontory; and 2, in the oblique oval pelvis, when the contraction is to one side, when the promontory is devi ated laterally, etc.
Kristeller accepts Martin's teaching. Frank rejects version altogether. Scharlau is an earnest advocate of version. IIe has resorted to it in case of the following complications: Internal version was performed 61 times, and external 3. Of the 'chil dren, 14 were dead before operation. He obtained 43 living children. Of the mothers, 5 died, 2 of phlebitis, 1 of peritonitis, 2 of rupture of the uterus. In 12 cases the contraction was considerable. He draws the fol lowing conclusions: 1. Version allows us to save children which would otherwise die from prolonged labor. 2. The small diameter of the pelvis may be shortened to 2.9 inches, and still version is practicable, at term. and with resulting living children. 3. In version, in case of vertex pres entation, it is of advantage, although not indispensable, for the transverse pelvic diameter to be large enough to enable the larger Dart of the occiput to pass near to the promontory.