a Cæsarean operation; those arguments were based chiefly upon the claims, or superior rights, of the child. In that case, as in all others, I was actuated in my opposition to the operation by the firm opinion that the child has no positive claims whatever, if they conflict at all with the rights of its more important parent; and I regard myself as not guilty of inhumanity in indulging or in expressing this sentiment -and I repeat a sentiment expressed upon page 531, in the quotation from Tertullian: “Atquin et in ipso adhuc utero, infans trucidatur necessaria crudelitate, quum in exitu obliquatus, denegat partum, matricidus qui moriturus.”

It appears to me an important matter that the medical profession should have just views as to the indications for these grave and direful operations. As I have great reason to think that many gentlemen, my brethren, have not given themselves time to reflect upon all the points of the indications, I am the more desirous to have an opportunity to state my own convictions in the matter, and I should be glad in the most emphatic manner to enter my protest upon the records of Obstetrics, against the Cæsarean operation being performed with any other views than those relative to the conservation of the mother, with the salvo always, that to save the child is a great additional good fortune. I believe that he who performs the Cæsarean section upon views relative chiefly to the conservation of the foetus flies in the face of the soundest doctrine; and I cannot understand how the conscience of such an operator should ever be appeased under the pungent reflections that must follow a fatal operation not rendered inevitable by the exigencies of his patient.

The number of cases of deformed pelvis met with in the United States, appears to be far less considerable than those met with in England or in the Continent of Europe.

CHAPTER XVI.

EMBRYOTOMY.

In

THE implements employed in Embryotomy, or those operations in which the body of the foetus is cut by the surgeon, are various. They may, however, be all comprised under the denominations of: 1st, the perforator; 2d, the crotchet; and 3d, the embryotomy forceps. cases, very rare ones, in which decapitation of the child is required, a knife of a peculiar form is to be used. I witnessed the decapitation of a foetus forty-six years ago, in 1813, and fortunately have seen no such operation since.

Perhaps there is nothing to be met with, in the very troublesome and anxious profession of an obstetrician, more painful to his feelings than the management of a labor in which it is required to mutilate the child, to extract it from the maternal organs. It is fortunate that this odious duty does not occur very frequently; and we are indebted to the inventor of the forceps, Chamberlen, for exemption from it in the present age, in numerous instances, in which, without the important uses of that instrument, we should be compelled to resort to the perforator and the hook, which comprised nearly the sum of the instrumental resources of the ancients. We are also in modern times highly favored by a knowledge of the stethoscope and of direct auscultation, in acquiring greater certainty relative to the life of the foetus, whose state of life or death can now be accurately determined by that means; thus relieving the mind of most painful solicitude by the certainty of its death, if that event should have happened, in cases where we are compelled to apply destructive instruments for its delivery.

When the foetal head is driven into the pelvis and arrested there in consequence of disproportion of its diameters to those of the bony canal, if the arrest cannot be obviated by the hand, the lever, or the forceps, the mother may suffer so much constitutional irritation from the fruitless efforts she makes, and the agonizing pain she endures, as to fall into exhaustion, and perish with the child still undelivered; and this, not only in the case of a cephalic presentation, but also in that of

the feet, or that of the breech-in short, in all situations where the child cannot be got away through the pelvis until after it shall have been reduced in its magnitude. But even in those instances in which the woman is not threatened with exhaustion, she is liable, from the pressure of the head, to suffer inflammation or gangrene of the soft parts, which are contused by it; or she is exposed to danger of laceration of the womb itself, or of the vagina, whose consequences are greatly to be feared, and if possible averted.

Exhaustion, manifested by cessation of the pains, smallness and great frequency of the pulse, a haggard and sunken countenance, anxiety, jactitation, coldness of the extremities, profuse viscous sweats, and delirium, may come on in labors that are drawn out too long from smallness of the pelvis, or from rigidity of the soft parts; cases in which we may clearly discern the necessity of immediate delivery, to rescue the woman from impending ruin. When such signs are present, and the child is known to be dead, if the ergot and the forceps are found, on trial, to be unavailing, recourse must be had to the most speedy means of relief, to wit, the opening of the head and discharge of its contents, with a view to the collapse of the cranium. We have less of the feeling of abhorrence above mentioned, when obliged to do this operation on the dead child; but, even in that case, we feel that our acts, as physicians, may be misconstrued by ignorant bystanders; so that, even here, embryulcia is a most unpleasant duty in practice. It ought therefore to be esteemed a duty to clearly state the condition of the child, and the urgent motives for lessening the size of its head in order that it may pass-or pass with safety to the

mother.

Lessening the volume of the head is effected by the introduction into one of the fontanels or sutures, of an instrument called Holmes' perforator, the blades of which being afterwards opened, make a free incision, through which, if enlarged by a crucial cut, the cerebral contents are either extracted at once, or allowed to escape slowly under the pressure of the pains. As soon as the opening is made, it is common to push the perforator deep into the cavity of the cranium, or introduce a crotchet so as to break up the textures within, and then, seizing the head by means of the sharp hook, which is applied to any convenient situation on the outside or in the inside of the skull, to draw it through the vulva, and deliver it; after which, if the woman has not suffered too severely, she soon recovers of the effects of her preceding fatigue and distressing pains.

This is the simplest and easiest case of embryulcia, and is one that any humane practitioner would or might perform without hesitation,

upon the proper grounds for the proceeding being fully set forth before him.

Yet, notwithstanding the facility with which the operation of embryulcia may be performed, it is one so unnatural, and so shocking to the feelings of all concerned, that it ought not to be done without very satisfactory reasons for it; and in general, not without consultation and agreement with a medical brother, for it is too grave and solemn a thing to exercise this professional authority as by the fint of an autocrat. In those instances in which it becomes necessary, during the life of the child, to resort to this mode of delivery, the most formal consultation ought to be regarded as indispensable; and no consultation can be supposed properly to result in such a proceeding, except upon the most urgent and clearly understood reasons for it. There are gentlemen in the profession who boast that they never have performed this operation. It may be very true; but the reason is that they resolutely decline to do their duty, which they throw upon some not more unfeeling, but more merciful and resolute brother.

There are cases of labor occurring in women with deformed pelvis, that are plainly impracticable with an unmutilated child. For example, if a woman have the pelvis occupied with an exostosis, or if the diameters of that canal are changed and spoiled by rachitis or by malacosteon, the child contained within her womb cannot escape whole per vias naturales. If the promontory of the sacrum comes within two inches and a half of the symphysis pubis, the child cannot pass the strait alive, because its own smallest diameter is more than three and a half inches; and, indeed, if the pelvis have three inches of antero-posterior diameter, it cannot be born alive, unless it be uncommonly small, and moreover possessed of a very incomplete ossification of the cranial bones, and great laxity of the suture lines that unite them: such a head might, by long pressure under a very powerful womb, be at length forced down through the strait, after it should have been moulded into the proper form by the force applied to it. we come to consider that the bi-parietal diameter is 3.88 inches, we shall entertain little hope of getting the head down, in a pelvis of three inches. Though it is true that Solayrés, and Dugés, and others have been fortunate enough to meet with cases in which the head at term has been born in a pelvis of two and a half inches from front to rear, it is not to be expected that success can attend labor in a female whose pelvic deformity even approaches to two inches and a half in its smallest line of diameter. The exceptions but prove the general rule. (See Monthly Journal Sci., July, 1847, for Dr. Simpson's case.) Such a pelvis is not fit for the forceps, since it is too small for them

Yet, when

to be withdrawn when locked. The question must always be, in such cases, as between the perforator and crotchet on the one hand, and the Cæsarean section on the other. But this can only be considered as relative to the living child, even by the warmest advocates of the hysterotomy. Of the dead child, no question can arise as to the mode of its delivery, except that by the perforator, and whether sooner or later. The dead child must always be withdrawn per vias naturales if there be space through which to extract it with equal safety: but even where the child is known to be dead, we may be compelled to perform the Cæsarean operation, if we would deliver the woman at all; since deformity may reach to the degree of shutting up the passage, even against the perforator. There is, in the museum of the University of Pennsylvania, a pelvis so distorted, that the hand could not possibly have directed an instrument to the head, in a manner to enable the surgeon to open and extract it. The woman from whose remains the pelvis was taken died in the almshouse, resolutely rejecting the Cæsarean operation, and preferring to it the death which she knew to be inevitable.

The practitioner who may be in charge of a case of labor where embryulcia is indicated, must be guided by his judgment and the counsel of his medical brother as to the signs which compel him to undertake the delivery. I have already enumerated them-and they are easy to be understood. There is, in general, far more danger of the operation being deferred too long, than of its being performed too soon; since, if it be not performed in time to save the life of the mother, it would be as well not to do it at all. I know that, in uttering this sentiment, I am liable to the imputation of wantonly encouraging the use of this dreadful operation, but I wish to disclaim such an intention. Any one possessed of a mere common humanity would instinctively recoil from the performance of such an office, and no man can have read the eloquent appeals of Alphonse Leroy on this subject without feeling that he was right in advocating the cause of mercy. I hope that no man living is reasonably more reluctant than I am to use any obstetric instrument whatever; and I fear that the resort to its employment is often had very unnecessarily and rashly. But I think that, when the case under consideration arises, we ought to act so promptly and so understandingly, that we may, on the one hand, derive a perfect success from it, and on the other stand acquitted, in our own judg ment and in that of others, as well as before God, from the charge of any rashness or precipitation. I shall strive, therefore, while I reiterate the opinion, to clear myself by repeating that all such cases require a medical consultation. To mutilate the child and then lose the mother,