Fifty-nine cases of labor in contracted pelves of the first and second degrees in which version was performed, and 215 cases in which the expectant plan of treatment was adopted. As far as the mother is concerned, the result is the same in both methods; for the child the expectant plan is much more favorable. The advantages of the expectant method were most apparent in the most difficult cases,—that is, where there was the greatest disproportion between the size of the fmtal head and the capacity of the pelvis. In and of itself a contracted pelvis should never be regarded as an indication for version. Alatseevsky (St. Petersburg Univ. Thesis, '98).
"Version by the vertex within the pel vis”—a direct conversion, by flexion, of a face presentation into a normal vertex position—may be accomplished as fol lows: The patient beirg under full chloroform anesthesia, the hand is passed carefully in the vulva, with the outside hand seizing the body of the child. In the entire absence of uterine contraction the chest is pushed as much away from the pelvic brim as possible from the point toward which the chin is pointing in the direction of the occiput: that is, pushing obliquely from behind forward. At the same time the fingers of the vaginal hand are pushed up alongside of the head in one or other of the oblique diameters of the pelvis, so that they can reach the suboccipital portion of the head. The thumb at the moment steadies the brow, and, with a slight lifti ig motion im parted to the whole head it is caused to rotate on its axis as described, the chin passing upward above the sacro-ischiatic notch as the occiput is drawn down be low the pubis. Flexion may be consider ably hastened by pressing down the occi put by the outside hand as soon as the face is dislodged from its wrong position. Malcolm McLean (Sled. News, July 28, 1900).
Version was performed 196 times in 6000 eases of labor at the Charite Poly clinic. The maternal mortality of these versions was 5, or 2.6 per cent. The cause of death in these eases was as follows: Eclampsia, 1: anesthesia. 1; rupture of the uterus, 2; septic infection, 1. Death from rupture of the uterus or septic infection may properly, we think, be ascribed in some measure to the op eration itself. The mortality from sep sis in these cases was 0.5 of 1 per cent. The foetal mortality was 4S, or 24.5 per cent. The internal antero-posterior diam eter of the pelvis must be S centimetres. A slight contraction in the true con jugate gives a better prognosis than a considerable lessening to S V„ or S cen timetres. When the cervix is fully dilated and the membranes have not ruptured or have but very recently rupt ured. the chances are enhanced. Wolff (Archiv f. Gyniik., B. lxii. H. 3, 1901).
When it is thought that a version in the Walcher position will not result in the delivery of child for any reason, such as a tetanized uterus, or when the child cannot be turned, we are brought to consider symphysiotomy.
SYMPHYSIOTOMY.—This operation stands between version and the Cesarean operation. Accepting the lowest limit for version as 3 inches and allowing about inch for the increase which the Waleiter position gives us, this re duces the version limit to 3 inches, pro viding, of course, that the child is of average size. On the other hand, it is known that an absolute indication for the Caesarean section is one in which practically no opening in the pelvic inlet exists—up to 2 7, inches, which will not even allow the passage of a mutilated child. Comparing these fig ures, we must agree that the field of limitation for a symphysiotomy is a very small one.
Marx contends that, from the stand point of after-results (matemal lesions; large fcetal death-rate), the operation is both dangerous and uncertain.
It cannot compare in its immediate and remote results with the modern Cwsarean section as done by the technique-perfect obstetrical surgeon. The indications for the operation have been stated as well as possible in a negative fashion above. Its contra-indications are: too much pelvic contraction or too large a child; ankylosis of either sacro-iliac joints: a dead or dying foetus; and sepsis, the last being an absolute contra-indication for its performance.
Operative technique of symphystotonly: Full dilatation of the cervix is to be secured if possible without risk to the child. The urethra and bladder should be held to one side with a sound. The initial incision is made a little above the subpubic arch and under the ele vated clitoris. Then the left index fin ger is introduced within the vagina, against the posterior groove or ridge of the joint, up to the top and a narrow tenotomy-knife is passed with the point close to the joint., up to within a half inch of the top, and under the under lying soft tissues. A probe-pointed bis toury is substituted and the left index finger met with the probe over the top of the joint, and the blade is worked through the joint downward until sepa ration is felt by the posterior finger. An assistant should press the mouth of the wound and tissues lying over the joint with a small piece of gauze. Delivery is to be accomplished with forceps, if possible, refraining from suprapubie pressure, aiming to deliver the head through the cervix without drawing the latter down below the symphysis. The bladder is to be held well to one side NI bile pressing the pubic bones together. A small strip of gauze is then passed into the prepubic wound, and another against the cervix, after irrigating, leav ing both pieces exposed for easy removal, having refrained from stitching cervix or perineum. A soft-rubber catheter is introduced into the bladder and left until sure the patient can voluntarily mictura te.