In such a pelvis as this, the pregnant woman ought to be advised to submit to an early abortion, whereby she might be preserved from an ultimate direful necessity to undergo a Cæsarean operation; for when the antero-posterior diameter of the pelvis is only an inch and a half in length, it is impossible to extract a nine months foetus, except that foetus be either of an under size, or else in a state of absolute decomposition, circumstances not to be expected, and, therefore, not to be relied upon, nor scarcely to be hoped for. Dr. Simpson's late case, published in an English journal, might serve rather to mislead the practitioner with vain hopes of an unparalleled good fortune like that which his patient enjoyed, than as a precept to be generally followed.

Fig. 113.

I annex the figure of another pelvis (Fig. 113), in which the distortion has attacked the sacrum itself, as well as the pubes and ischia, and partially the left ilium. In such a pelvis as this, provided the antero-posterior diameter should not be reduced below three inches, good hope might be entertained of extracting a living child by means of dexterous and patient use of the forceps, especially should the child be rather under size, and one in which the progress of ossification had not gone so far as to render the bones of the

cranium very firm and resisting. But as a child's head, in its biparietal diameter, according to my measurements, will average 3.88, and as, in a series of three hundred heads, I found but one under 3.50, there will be in general but faint prospect here of extracting a full-grown child alive. The records, however, contain abundant examples of cases in which the foetus at term was spontaneously expelled in pelves reduced as low as 2.50. In the treatment of such a case as the one now under consideration, the least reflecting Student must perceive that, in adjusting the position of the head, it would be desirable for him to bring the bi-parietal diameter, which is the smallest diameter of the head, into coincidence with the antero-posterior, which is the smallest diameter of such a pelvis; and further, that in any attempt to assist the natural powers by means of the forceps, it would

be preposterous to think of adjusting the blades upon the sides of the head in that direction. The pelvis is already perhaps fatally small. To apply the blades of the forceps, then, would be considerably to increase the necessity for some reduction in the transverse diameter of the head. Common sense, therefore, would teach him that if he must apply the additional force, it must be applied to the face and occiput of the child. The blades of Davis's forceps, even when the handles are perfectly shut, are 3.9 asunder. It would be impossible, therefore, to extract the forceps in that direction, much less the head contained within them.

I believe the practitioners of midwifery in England are less familiar with the use of the forceps than those of the continent or of the United States. I think them quite too prone to refer to the aid of the crotchet and perforator, and cannot but indulge a disposition to dissent from their almost invariable practice of adjusting the blades upon the sides of the head, much preferring the practice of the continental physician and those of the United States, who seize the head upon the sides of the pelvis, a practice as to the safety of which I confidently speak from multiplied opportunities in my clinical expe rience.

This is a case, also, in which, perhaps, more properly than in other cases, the precept should be observed of attempting to deliver by turning. Those who, in restricted pelvic diameters, propose the resort to turning as a means of saving the child, and at the same time of preserving the woman from much pain and great danger, insist upon it that the chance of preservation is greater because when the child has been turned and drawn away, so as to allow the head to come to the narrowest part of the pelvis, the cranium yields, allows its diameters to be reduced, and may be disengaged from within a narrow strait, through which it could not be driven if the head were the presenting part. The idea is this: when the head is drawn through by means of traction exerted upon its neck, it undergoes a process which, as I take it, is not wholly unlike that called wire-drawing; whereas, when the head presents, such a process of wire-drawing cannot be supposed readily to take effect. A portion of metal can readily be drawn through the apertures of a wire-plate, which no art could drive through it from the other side.

I am not prepared in this place to go so far as Professor Simpson, of Edinburgh, in recommending a resort to version in bad pelves; and my hesitation arises from this, that the mensuration of the pel vis being an inaccurate operation, there is reason to fear that the

inexperienced accoucheur might be led to institute this method in cases where excerebration is indispensable for the delivery of the head. I admit it is possible to effect excerebration in the footling case; but in a case of badly deformed pelvis, the operation implies a great risk of detruncation, an accident the most to be deprecated, for what occasion can arise for embarrassment and vexation greater than that which he experiences who is condemned to the task of extracting a detruncated head through a very much reduced superior strait of the pelvis!

In Dr. Lee's 3d Report, Clinical Midwifery, p. 74, 3d ed., he gives accounts of several cases of footling labors occurring in deformed pelves, in which he was obliged to diminish the head by opening the cranium through the occipital bone. In conducting those cases, that able practitioner frequently found himself greatly embarrassed in effecting the operation. To read his accounts of the cases, would be sufficient to put the Student upon his guard against the risk of encountering such embarrassments from version.

Here is another pelvis, Fig. 114, in which the rachitis has attacked the whole organ; the last

lumbar vertebra, as well as the ilia, ischia, and pubes, being changed in shape. The horizontal portions of the pubes have become almost parallel, narrowing, of course, the antero-posterior diameter, and approximating the extremities of the transverse as well as the oblique diameters, so as to render hopeless any

attempts to extract the child through it alive.

Fig. 114.

It appears to me needless to follow the example of writers who have reduced the deformities of the pelvis into a sort of classification. It is evident that softening of the bones, which may attack the whole or any part of the osseous structure of the basin, may yield any conceivable irregularity of form; and those that I have already spoken of in this article being sufficient to show the Student what is the nature of these deformities; and as he is already acquainted with the mean dimensions of the foetus, he may be considered qualified to give judgment on questions of obstetrical operations arising under pelvic deviations.

It is necessary that he should be aware of the methods which are adopted for ascertaining the dimensions of the pelvis. As a general rule, the indicator finger of the accoucheur will scarcely be found capable of extending further than three and a quarter inches or three and a half inches beyond the crown of the pubal arch. It is true that, by the introduction of half the hand, the palp of the indicator finger can be made to explore a region four and a half inches distant from the crown of the arch; but, as the introduction of half the hand in the woman not in labor or affected only with the earliest stages of labor, is so painful as to excite repugnance and resistance on the part of the patient, the vaginal taxis alone is generally preferred. Suppose there should be some suspicion of a deviation of the pelvis -one in which the pubis has retreated towards the sacrum, or one in which the promontorium has descended towards the symphysis. If he should carry his indicator finger as in the annexed figure, directing it towards the promontory of the sacrum, and in vain endeavor to touch the sacrovertebral angle, his exploration will teach him at once and clearly that his patient has nothing to fear on this head; but if he can readily touch it, as in the figure, then she has a deformed pelvis, proportional to the facility of the touch.

Fig. 115.

If, again, the point of the coccyx, which can always be touched with the indicator finger, is

found not to approach too close to the crown of the pubal arch, uneasy apprehensions on this head are at once set aside. As for the mensu ration of the transverse diameters of the inferior strait of the pelvis, the least tact, with but little experience, would show that that strait is or is not normal, and to what degree deviated, if at all.

If, however, upon introducing the index finger, it should at once encounter the sacro-vertebral angle, by pressing the point of the finger against the protuberance, and lifting its radial edge up to the crown of the arch, he can mark the point of contact with the top of the arch, and then, measuring the distance to the point of the finger, he will have an accurate report of the antero-posterior diameter.

It appears to me that there is no necessity to trouble one's self to make a provision of callipers to measure the pelvis externally, to get a report of the internal diameters of it; nor need one procure an intropelvimeter, which is more apt to mislead him than the hand, and which, moreover, is both inconvenient and painful in its application.

Nevertheless, if he should be inclined to avail himself of the use of the callipers, he may learn in the annexed figure the mode of its application. Applying one of the buttons of the calliper to the symphysis pubis, and the other to the spinous process of the fifth lumbar vertebra, the scale will mark the space by which the buttons are divided. Let him subtract from that space half an inch for the thickness of the symphysis pubis, and two and a half inches for the space between the sacro-vertebral angle and the spinous process on which the button rests, and he will have three inches to deduct from the

Fig. 116.

whole sum; the remainder is to be taken as the antero-posterior diameter of the plane of the superior strait. If he will refer to Fig. 114, in which the pubis projects in consequence of the parallelism of its horizontal rami, he will at once perceive the futility of an attempt to deduce the internal capacity of that pelvis from an external measure

ment.

The great matter for him is to determine the indication of treatment in the case, and that must clearly arise from a consideration of the actual state and wants of the patient, and not from any rules or precepts that can be set down in any book whatever. A gentleman might, for example, be impressed with the propriety of trusting to the unassisted powers of nature a patient whose antero-posterior diameter at the superior strait is three or even less than three inches, and he would be led to do so from an opinion he should form of the ability of the woman to support for a long time the efforts and the irritation of a most laborious labor; whereas, in another patient, having a pelvis of precisely the same dimensions, he might find the most urgent necessity to deliver immediately, to preserve her from otherwise ine

vitable death.

Besides deformities of the pelvis from mollities ossium and rachitis, there are other affections of the capacity of the basin, which are produced by bad arrangement of the form of the pubic arch-cases in which the arch is Saracenic, and not Roman; the descending rami of the pubes, instead of divaricating so considerably as to allow the rounded occiput to rise quite up into contact with the triangular liga