The above description applies only to moderately contracted pelves. When the narrowing is considerable, extraction is not possible.
In the asymmetrical pelvis, traction should be made in such a manner as to direct the occiput towards the widest pelvic half.
2. Relative Value of the Different Means employed to bring the Head into the efficacy of flexion is indubitable. Traction on the neck and the lower extremities should, at the outset, be directed a little forward, and later, when the head is well flexed, backward, in order to disengage the anterior parietal protuberance. As for expression, it is only useful when it is made in the axis of the superior strait, and applied to the frontal region. It thus favors flexion and descent.
3. The Force employed. the Lesions produced, the Results teen times out of thirty-four, the head, at term, was brought through pelves measuring 2.9 inches by the use of a force varying from 45 to 66 pounds. In a pelvis of 2.6 inches, 5 times the head was extracted by a force of 66 to 121 pounds, and 6 times it could not be moved, although a force of 176 pounds was applied. Before term the maximum force used was 55 pounds. As for the lesions, in all the cases before term except one, the parietals were fractured; at term, the same, whenever the trac tion force exceeded 89 pounds. The maxillary bones were fractured in the fo•tus at term whenever the force exceeded 55 pounds; before tern' when it exceeded 46 pounds. Lesions of the vertebral column, before term, at 88 pounds, at term 110 pounds.
Scanzoni, out of 10,557 women delivered at the Wurzbourg Maternity, from 1850 to 1881, found 198 with pelvic contractions. The following were the measurement in 194 of these cases: In the four remaining cases, two were scoliotic obliquely contracted, one kyphotic transversely contracted, one coxalgic. Of the 198 cases: Of the 17 mothers who died, in 11 the cause was sepsis in the 6 remain ing, 2 of pulmonary oedema, and one each of inanition, rupture of uterus, postpartum hemorrhage, puerperal mania.
In delivery, the forceps was used 38 times, and version 13. In 47.4 per cent. of the cases, delivery was spontaneous with a maternal mortality of 4.2 per cent; in 52.5 per cent. delivery was instrumental (including forceps, version, etc.), and the maternal mortality was 10.5 per cent., of the infants born spontaneously, the mortality was 19.1 per cent.; of those extracted instrumentally (including the induction of premature labor) 61 infants died.
Scanzoni adds: " If we were, in general, to admit that, in cases of con tracted pelvis, version is preferable to the forceps, it should always be re sorted to at a relatively early period of labor, while the head is still freely movable. Now, in private practice, we are often called to our patient too late for version, and we must also remember that if we resort to version early, we may be unable to terminate delivery, in cases where often this will occur spontaneously when at first sight it seems impossible." He
strongly favors, then, forceps to version, and says that where too great traction is requisite, perforation and cephalotripsy should be resorted to. Faithful to this opinion, in 198 cases of pelvic contraction he resorted to perforation 19 times. In 68.4 per cent. the mothers recovered, and in 31.5 per cent. they died.
[The practice of American accoucheurs in this connection is by no means settled. The general impression would appear to be that it is easier to pull the after-coming head through the contracted brim, than to bring the before-coming head down by the forceps. In other words, where the head is movable above the brim, or just engaged and the membranes not too long ruptured, version, we believe, offers a better chance to the child, and is less likely to damage the mother. In our own experience of the two operations, version and high forceps, the former is far easier of ap plication under the conditions just outlined. We believe with Lusk, that the real intent of version is to save the life of the child, and that it is in dicated, in particular, in contracted pelves " only where the child's heart beats with nearly unimpaired vigor, and in pelves measuring between two and three quarters and three and a half inches antero-posteriorly, with the contraction limited to the brim, and with sufficient amplitude in the transverse diameter." (Lusk.) As for the high forceps, we cannot do better than refer to the carefully prepared article published by Dr. Harold Williams, of Boston, in the Am. Journ. of Obstetrics, January, 1879. In 119 cases of high forceps, about 40 per cent. of the mothers, and 60 per cent. of the infants died. No one will question but that version will give far better results for the mother, and certainly for the child, if performed in time, and this is the *int qua We see then that the reasons given by different authorities in justifica tion of their preference are practically identical. The capital deduc tion is: In order that the head may pass the contraction, whether before or after-coming, it must flex, and the parietal protuberantes must lie to one side of the promontory, in the groove between it and the sacro-iliac synehondrosis, so that the bi-temporal, or a neighboring diameter, may substitute itself for the bi-parietal. Spontaneous termination, or by for ceps, or by version, is only possible on this one condition. As for the choice of method, the experiments of Budin and of Champetier should to-day be our guide: Whenever the woman is at term, the forceps; be fore term, version. The future, however, must decide the question.
Prognosis.—The greater the contraction, the larger the infant, the graver the prognosis. The most common form of contraction, the rachitic, gives the best results; the osteomalacic, and the funnel-shaped pelves, give the worst results. The preceding tables, from Chautreuil and Choisil, (see pages 136, 137), show the gravity in case of the kyphotic and kypho-scolio-rachitic forms.