It is contended by some that the delivery may be effected, under peculiarly favorable circumstances, when the passage measures only two and a half inches, and at all events the effort should be made; but for the sake of the mother such cases should not be left long, as the chance is so small, and the risk of delay so great. When the passage is less than two and a half inches, spontaneous or artificial delivery is allowed to be impossible, and the only alternatives then are to dismember the child or open the mother. Which of these should be done depends on circumstances. Whenever the child can be brought away by the natural passages, though it be piecemeal, it always is so brought, unless the danger to the mother be greater than by the cesarian operation, in which case that operation is resorted to. By means of an instrument called the Cephalotribe, which crushes the head, the child may be brought away, unless very large, when the pelvis only measures two inches. When the passage is less than two inches, the only resort is to the cesarean operation, which sometimes succeeds, and saves both mother and child, though more frequently the mother sinks.
The necessity for all these frightful operations is now much less than formerly, and may be done away with altogether. This important fact should be known universally, and also the means to be resorted to. In the first place, every young female should be examined, before marriage, by a competent person, if there be the slightest reason to suspect deformity; and in case the deformity is found to exist, the consequences if she becomes pregnant, must be laid before her. If, after being told this, she will marry, or has already done so, the means of avoiding conception should be placed at her disposal, so that she may not be made, of necessity, a helpless victim. These means need not be described here, though I have no hesitation in referring to them. When I know that the life, or life-long health, of a female, depends on her not becoming pregnant, I consider it my duty to put such means at her disposal, if she desires it. In many instances I have known females suffer, several times, the most frightful tortures, merely to bring into the world the mangled fragments of a dismembered child, with the greatest risk to their own lives; and in others I have known them in constant dread of becoming pregnant, because they were conscious it would be their death warrant. In such cases I leave it to humanity, and common sense, as to whether such information should be withheld? I could not reconcile it with my notions of duty to withhold it.
In case pregnancy has occurred before the deformity is discovered, and it is then found that a full grown child cannot be born, premature delivery must be brought on; or, in other words, the Uterus must be made to expel the child before the full term, while it is yet small enough to pass through the Pelvis. This operation is of course only allowable when needed to preserve life, or to escape great suffering and danger. It must always be decided upon by the medical man, and performed by him, so that a description of it is uncalled for here. In Europe it is quite common, and nothing has tended so much to do away with those disgusting and horrid operations, on mother and child, which were formerly absolutely necessary in cases of deformity. If it is found at the first delivery of a female, or before, that she cannot bear a living child at full term, artificial delivery is accomplished at seven or eight months, thus avoiding all the danger to the mother, and frequently preserving the child. In the case of the dwarf before referred to, when she became pregnant the second time, M. Dubois brought on premature delivery, and the child was born alive, with but little difficulty. According to statistics it appears that, when artificial premature delivery has been induced, in one hundred and sixty-one cases only eight mothers have died, and all but forty-six of the infants were born alive. Of the whole number of children seventy-three continued to live; and of the eight mothers five died from other causes, leaving but three whose death resulted from the operation. Now when the fearful number of deaths from instruments, and other operations, necessary at full term, is recollected, the advantage of this practice will be evident. In the Cesarian operation for instance, which is often the only remaining resort, but one female out of six recovers.
The delivery should be postponed as long as possible, so as to give the best chance for the child living. This must of course be decided upon after the size of the pelvis is ascertained. Seven months is the earliest time at which the fœtus is viable, and it is much better left till eight, if the size of the parts will allow of its birth then. In case they are so small that it cannot be born even at seven months, we have our choice, as M. Chailly remarks, between the dreadful Cesarian operation at full term, and producing early miscarriage.
M. Dubois seems to recommend premature delivery in nearly all cases, if the smallest diameter is under three inches; because, as he remarks, spontaneous delivery at full term is then a very rare exception, and the danger and suffering to the mother is so great. He also recommends it when there are tumors, and even when the female is afflicted with any acute disease. Of course it is always necessary, before operating, to be sure that the child is alive.
I knew a lady myself who had given birth, at full term, to seven children, all of which were torn from her with instruments, dead, owing to the smallness of the pelvis. When pregnant with the eighth, premature delivery was brought on, at my suggestion, at about seven months and a half. The fœtus was born with comparative ease, and lived. But for this operation she probably would never have been blessed with a living child at all. Since then she has avoided conception.
TUMORS IN THE PELVIS.
Tumors of various kinds are met with, both in the bones of the pelvis and attached to the soft parts. They frequently offer the most serious impediments to delivery, and baffle the skill of the most experienced obstetricians. In fact they differ so much in their structure, their size, and their situation, that but few general directions can be given as to their management. In every case where one exists pregnancy should never occur, if possible to be prevented, before it is removed; for though it may cause no inconvenience at other times, yet during delivery it may necessitate very serious operations, or even cause death. Some of these tumors are mere vesicles, or bags, filled with fluid, and may be punctured and their contents let out, so as to make them less. Others are more or less solid but moveable, and may often be supported above the upper strait till after the child is born. When they are so large as to block up the passage, and are either fixed or cannot be carried up into the Womb, there is often no other choice than to either cut them out or open the child's head; the practice being determined by the circumstances of the case. In some instances the bladder itself, distended with urine, has impeded delivery, and been mistaken for a tumor; and in other instances stones in the bladder have caused the same error.
A specimen of one of these tumors is represented in Plate XLVII, and one of a Polypus in Plate XLVIII.