of the head; but such was not the opinion to be gathered from the actual phenomena.

"It has been seen that no great loss of time took place, after the softening of the tissues rendered it possible to break them up with some facility, whereas the process previously was exceedingly slow and tedious. The perforation was deferred as long as possible, which saved us from the dreadful and cruel operation of cephalotomy in a living foetus. The child died of long-continued pressure.'

"June 18th (Saturday), nine A. M. Our patient says she feels quite comfortable; had some sleep after we left; pulse one hundred and twelve, rather more feeble; skin moist; tongue slightly furred. Clean linen, &c., was put on her, and she was moved up in bed. The bladder was emptied by the catheter; fomentations with flaxseed mucilage directed to be applied to the vulva; the most perfect rest and quiet strictly enjoined; as diet, arrowroot and oatmeal gruel, tea and toast.

"Evening. Remains much the same; bladder again emptied; mucilages continued; an anodyne to be given at ten P. M., if at all restless.

“19th, nine A. M. Passed a comfortable night; pulse ninety-four; skin pleasant; tongue slightly furred; lochia almost natural; free from pain; slight soreness over pubes to left side; directed warm brandy to be applied over soreness, a Seidlitz powder to be given, and repeated, if necessary; continue other means.

'Evening. Medicine not having operated, an enema of warm flaxseed mucilage was directed, and an anodyne at bedtime.

"20. Rather restless in the early part of the night; enema operated freely; feels very comfortable; no pain; pulse seventy-six; skin pleasant; tongue continues slightly furred; countenance good; spirits cheerful; continue as before.

"23d. Our patient continues to do well, usually rests well at night; free from pain, although the soreness in uterine region continues; secretion of milk copious; feels so comfortable that she has taken an infant to nurse; pulse rather more frequent than natural; tongue clean and moist; bowels costive; passes urine without difficulty-the catheter was used three times daily till last evening, when it was found to be unnecessary; lochia serous; directed ol. ricini one ounce. Mucilages to vulva to be continued, mucilaginous injections per vagi nam; continue diet, and perfect rest in horizontal position.

"From this time our patient continued rapidly to improve; in three weeks from the time of her delivery, was so well as to be permitted

to go down stairs, and in a short time resumed her ordinary avocations.

"The subject of the preceding case is a native of Ireland, aged about twenty-two years, of small stature, not exceeding four feet and a half; is stated to have been a healthy child till her third year, when she received an injury by a fall, after which she was unable to stand or walk for two or three years; at the expiration of this time she regained her strength, and was subsequently considered an active child. Upon examination, we found the femur and tibia of each extremity very much curved, forming a considerable arch forward; at the lower part of the spine, there was a cavity sufficiently large to admit the hand corresponding with the promontory of the sacrum internally; the bones of each arm partook of the general disease. It was evident she had in early life labored under rickets."

Such is the history of Mrs. R.'s labor by my friend Dr. Fox. It was the most difficult case I have had during a long career. I hope the account above given may serve to instruct the Student better than any mere didactics could do. The case taught me one useful lesson, viz., that the crotchet, or uncus, which was for many centuries the woman's instrument, is a detestable thing; and that a better one was wanted. That better one I learned to supply; and in doing so, I have made a valuable contribution to our art.

In all cases where the diameters of the pelvis have been so much diminished by rachitis or mollities ossium as to render the descent of the foetal head impracticable, it has been the universal custom either to perform gastrotomy, or to lessen the size of the cranium by evacuating its contents, and then extract by means of the sharp crotchet. The method last spoken of is, perhaps, a good one, where the diminution of the pelvic passages is not too considerable: nevertheless, we find, upon reference to the records, that a great many women have been victims in such untoward labors, owing, measurably, to the violence done to the soft parts during the forcible extraction of the head, insufficiently reduced in size to admit of its transmission with safety to the mother-and probably in no less degree to the wounds that have been inflicted by the slipping of the crotchet.

The firm bony structure, composing the base of the foetal skull, is nearly two inches and a half in its transverse or smallest diameter; mere excerebration, therefore, cannot be regarded as furnishing a good security against fatal contusions from the forcible extraction of such a body from a pelvis whose smallest diameter is not exceeding two inches in length. Such a body as the base of the skull must, in order

to pass through such a pelvis, present itself in an inclined attitude, or with a dip; but this dip or inclination can be only imperfectly communicated to it whilst all the bones of the cranium retain their connection with each other. To enable such a base to pass downwards safely, the skull must be taken to pieces, and those pieces removed in succession. In some instances, this successive ablation of the cranial bones has been effected by the crotchet, the point of which was used to pick out the bones, sometimes in portions not larger than the finger nails; as, for example, in Elizabeth Sherwood's labor, impressively narrated by Dr. Osborne. Those who have perused that account will remember the extreme perplexity of that practitioner, and the infinite pains he took in his anxiety to avoid injuring her with the crotchet. He could not get the base of the cranium down until he had removed all the rest of the head.

Having had occasion to observe the difficulties and perplexities arising from labor in deformed pelvis, as they occurred in Mrs. M. R., the case above related, whom I have now delivered in two accouchements, I venture to lay before my professional brethren the impressions I derived from observing and conducting those two labors.

There is reason to believe that no other female has ever been safely delivered in this country, under the disadvantages of a pelvis measur ing only two inches from sacrum to pubis, which, by the judgment of persons of the highest claims to confidence, is the extent of Mrs. R.'s case. I speak this, however, under liability to correction. All the gentlemen then consulted, agreed that the diameter was as above mentioned.

Her second accouchement took place in the month of June, 1833, the child having reached the full term of utero-gestation, an event which I greatly deprecated, having vainly urged, with the concur rent advice of Dr. Dewees, the operation for inducing premature de livery.

The experience I had acquired in delivering her in the first labor convinced me that the crotchet was not to be relied upon in her case; not only because of the danger from contusion in extracting the skull, and from wounds made by the point of the crotchet, but also from the loss of time requisite for picking out the head bit by bit. The patient had almost fallen a victim to exhaustion in the first labor.

In reflecting upon the facts that had occurred in 1831, I found that the problem about to be solved in the second labor was not, a head being retained above a pelvis too small to transmit it, to extract said

head-but the question was, to extract said head with the smallest loss of time, and least possible risk to the mother. I had already ascertained that the Cæsarean operation would not be submitted to.

I supposed that the head might be four inches in its bi-parietal diameter, and I knew that the plane of the pelvis was only two inches. Under such circumstances, the vertex will not present, but the crown. of the head will be the presenting part: but since the cranium cannot recede farther than is necessary to bring it in close contact with the posterior part of the mother's abdomen, there will be two inches of the head lying upon the plane of the superior strait, and two other inches projecting in front of the symphysis pubis; or, in other words, the crown of the head will repose upon the top of the symphysis pubispart of the head being behind, and part in front of that bone.

There is a very important principle in the management of such a case, which is, that all that part of the cranium which lies in contact with the mother's back, is perpendicular to the opening of the strait, and may, when the skull has been opened, be seized with a straight forceps or pliers, like that represented in the engraving, Fig. 127;

whereas, all that part of the skull that lies horizontally over the opening, can be taken hold of with a curved forceps or pliers, Fig. 126. Long before the occurrence of Mrs. R.'s second labor, I caused the proper instruments, Figs. 126, 127, and 128, to be prepared by Mr. John Rorer, the eminent surgeon's instrument maker. Aided by means of this apparatus, I encountered but little difficulty in delivering this patient, whose first accouchement had cost me so much toil and anxiety. The invention is my own. I published it soon after the event spoken of, in the Baltimore Med. and Surg. Journ., and it is now known and used in this country as my embryotomy instruments. Neither Mulder nor any other author has described or proposed it. I look upon it as a most important contribution to the Operation in Midwifery. In a great majority of the cases, it wholly supersedes the crotchet, and mitigates the danger of the embryotomy operation in a remarkable manner. I am glad to believe that it has got into a very general use in this country, and I hope it will in the end entirely supersede the most detestable of instruments, the sharp crotchet.

I may properly be allowed to express the surprise which I experienced in finding my just claim to the invention of this most useful instrument treated without due regard, in quarters from whence the greatest liberality might have been hoped for in acknowledging the authors and inventors of things that contribute to the perfection of

our art.

I have found, upon applying the test of practice, that when the thin portions of the cranial structure are taken hold of, either with the straight or curved forceps, they can be broken up with great ease, and removed with sufficient celerity; so much, indeed, that a head may be reduced to a very small remainder in a short time. I believe that if early arrangements are made for delivering the patient by this method, no danger will exist of exhaustion or excessive constitutional irritation being produced before the extraction of the foetus can be completed.

From the foregoing remarks, it seems to be very clear that the practitioner, in undertaking to deliver a patient with excessive dis tortion of the pelvis, ought to proceed to his operation with a full understanding that, after perforation, he is to remove all the posterior parts of the presentation with the straight pliers, and all the anterior and lateral ones with the curved pliers; making attempts, from time to time, to draw the head down, as he finds reason to believe that it is sufficiently broken up and collapsed. Such are my views of the mode that ought to be adopted. I, at least, am fully of opinion that Mrs. R. could not have been rescued by me, had I relied only upon