the crotchet for her delivery: with my embryotomy forceps, I should not hesitate to promise to deliver speedily in a pelvis of two inches.

It is proper to observe that the female constitution suffers less in the first hours of labor, in which the head cannot engage, than in those wherein the head sinks low into the excavation. This depends, in part, upon the well-known principle, that the contractions of the womb are violent and powerful in proportion as that organ becomes smaller or more condensed. If the head becomes arrested in the excavation, and particularly after having wholly escaped from the uterine cavity, it is urged with great power upon the tissues, which resist its further descent. Under such circumstances, constitutional irritation is rapidly developed; whereas, under the more lenient exertions of the uterus, while the entire fœtus is still contained within its cavity, not only is the impulsion of the head against the resisting tissues far more moderate, but during the intervals between the pains the pressure is suspended. Hence a woman remains long in labor with little constitutional disturbance, in the kind of cases I am discussing. These observations are illustrated, and their truth confirmed, by reference to some of the most celebrated examples of such labors which are recorded in the books.

Whenever, therefore, a woman who is known to have an impracticable pelvis, has fallen into labor, and in whom the Cæsarean operation is rejected-if the perforator is to be resorted to, it should be applied as soon as possible, in order that, the child having ceased to exist, all the facilities derivable from the incipient decomposition of the foetus may be enjoyed. The firmness and cohesion of its soft parts are so much lessened by maceration in an elevated temperature, equal probably to 99°, that the extraction of the pieces of bone becomes comparatively easy. I should, therefore, in such difficult cases, recommend that all attempts to deliver should be delayed, if possible, for many hours after the perforation of the head. This recommendation is founded on what I have experienced of difficulty in getting out the portions of bone after I had broken them up, when I made the attempt antecedently to the occurrence of signs of decomposition. The patient can meanwhile be quieted with anodynes, and supported with light nourishment, and, if needful, may, by venesection and cold drinks, be kept tolerably free from vascular disturbance during the whole period of such delay as may be deemed advisable.

The engraving, Fig. 128, shows the form of the perforator that I employed in Mrs. R.'s case. It is a trocar or drill, ten inches in length from the handle to the point. I recommend it to the attention of the Student as a good instrument for making the perforation in

those cases where he can by no means find a fontanel or suture. He ought to notice that, in very great deformity of the pelvis, the lips of the os uteri, which will descend lower than the plane of the superior strait, will be brought so close together as quite to touch each other, and, therefore, he will not be able safely to use the ordinary perforator as a drill-the rotatory motion would wound the mutually touching lips. But such a drill as Fig. 128 is devoid of this objection. I was obliged to make use of such means of penetrating the skull in Mrs. R.'s case, since no suture was discoverable, and the common Smellie's scissors could not be made to perforate the solid bone; any direct pressure causing the head to roll or move upwards, and any rotatory or drill-like motion with it, being impossible without great danger of wounding the lips of the os uteri. The same cut exhibits both the straight and curved pliers. They are eleven inches in length; the gripe is serrated, and the sides of the mandibles are rounded, in order that they may not pinch any tissues except those intended to be included in the bite, which, on account of the serræ, is very sure and strong.

I learned, after the events above described, that this patient again became pregnant; that the child presented the breech, which would make delivery per vias naturales absolutely impossible; that she was under the care of Dr. Nancrede, of this city, and was safely delivered of a living child by means of the Cæsarean operation, performed by Professor Gibson, of the University of Pennsylvania, assisted by the late Dr. Beattie, Dr. Nancrede, and others. In a subsequent or fourth pregnancy, I saw her, the history of which case was again drawn up and given to the public, in the American Journal of the Medical Sciences, by Dr. George Fox, to whom I am indebted for the relation already above given to my readers, and from whose interesting "Account of a Case in which the Caesarean Section, performed by Dr. Gibson, was a second time successful in saving both mother and child," I here cite a portion of the account, with a view to make it more extensively known by means of this volume.

As Dr. Fox's paper is partly occupied with the preceding histories, I shall commence at p. 17 of his statement:

"Toward the latter end of August last, Mrs. R. called on me, and stated she had nearly completed the seventh month of pregnancy, and was desirous that I should again attend her: this I agreed to, upon condition that she would consent to the performance of any operation which should be deemed most advisable. Dr. Meigs kindly consented to attend with me.

"Premature labor, in her then advanced state of pregnancy, we

considered would be attended with as much difficulty, and much greater danger to the patient, than at the full period.

"Under the impression that the Cæsarean section would be most proper, we endeavored to prepare her system for this operation, should it be concluded upon, by a regulated diet, such as would be least stimulating, attention to her bowels, &c.: accordingly, for some weeks previous to labor, her diet was restricted chiefly to milk and farinaceous articles.

"On Sunday, November 5, 1837, I was sent for by Mrs. R. about five o'clock A. M. On my way to her house, I stopped for Dr. Meigs. We found her laboring under a good deal of mental excitement, with a pulse of 116; countenance anxious and pallid; and apparently in a much more unfavorable situation than in either her first or second accouchement. Her pains had commenced about three hours previous to calling upon us; they were slight, recurring at an interval of about ten minutes; upon an examination per vaginam, the os uteri was found pretty well dilated, swollen, and succulent, as in previous labors; the head presenting to the left side of the pelvis; the membranes had been ruptured. Upon inquiry, we learned that on the evening of the Friday previous there had been a considerable discharge of water from the vagina, which continued throughout the following day; but, as it was unattended with pain, she had not thought it requisite to send for us; this discharge was not produced by any exertion on her part. After remaining with her some time, finding that her pains were not urgent, we concluded to meet at nine o'clock, and invite Professors Gibson and Hodge to join us in consultation.

"9 A. M. Met Drs. Meigs, Gibson and Hodge. We found our patient much the same as when we left her, excepting that the pains were rather more urgent and frequent. Upon an examination of the case in all its bearings, we determined to advise the Cæsarean section, as best under the circumstances. I accordingly stated to the patient our views of her case, and after some little hesitation obtained her consent to the performance of this operation: previous to which, upon an examination of the abdomen, we were struck with the complete anteversion of the uterus; the old cicatrix was dark-colored, hard, and puckered, about five inches in extent; adhesion had apparently united the integuments and uterus for a space of four or five inches, from near the pubis up towards the umbilicus.

"We now ascertained, by applying the ear to the uterine region, that the child was living. Our patient's bowels having been opened by an enema, and her bladder emptied, she was placed upon a table protected by a mattress, on her back, with her hips at the edge, and

the operation immediately performed by Dr. Gibson, in the presence of Drs. Meigs, Hodge, Norris, C. Bell Gibson, and myself. Dr. Norris and myself making firm pressure upon the sides of the abdomen to prevent protrusion of the intestines, Dr. Gibson commenced by making his incision with a scalpel, through the integuments, muscles, &c., extending from an inch and a half below the umbilicus, nearly down to the pubis, directly through the old cicatrix: the uterus was found connected with the integuments by strong adhesions, for a space of about four inches; the incision into this organ was made near the fundus, and extended down five or six inches; that portion which was adherent was much attenuated, being scarcely one-fourth of an inch in thickness. To ascertain the extent of these adhesions, Dr. Gibson with his scalpel dissected up the integuments on one side, until a knuckle of intestine protruding satisfied him of their extent, which might be about half an inch.

"When the section of the uterus was completed, the placenta was seen immediately under the line of incision, and partially detached by the separation of the lips of the wound. Dr. Meigs, standing on the left of the patient, now introduced his left hand towards the right side of the womb, displacing the placenta no more than was necessary dur ing the exploration, yet detaching a considerable portion of it, as it filled the wound in the organ; he first extricated the left foot and hand, which were found near each other; the breech soon followed, suc ceeded immediately by the shoulders, and lastly by the head, after a few moments of resistance, by the contracting edges of the cut, which grasped the neck of the child, and the hand of the operator, with great force. The placenta was soon after removed through the incision, and the cord tied and cut: the hemorrhage from the uterus was at first considerable, but ceased upon the contraction of that organ, after the removal of the child and placenta. The external wound was brought together by six sutures (introduced from within outward), and adhesive strips, and a compress placed over it; a broad band, to support the abdomen, was now applied around it; the pressure of its sides, to prevent protrusion of the intestines, was continued until the external wound was closed.

"The child thus born was a boy of good size, but in an extremely feeble state: some time elapsed before perfect respiration was estab lished, but happily the efforts of Dr. Meigs were completely successful, and all anxiety on its account ceased.

"Our patient bore the operation well, scarcely murmuring; in fact, she says, she suffered but little more than with one labor pain, her pains usually being uncommonly severe. Her position was not al

tered, excepting that her lower limbs were now supported by another table. The pulse immediately after the operation was 96, just before 112. She is enjoined to lie perfectly still, not on any account to move; to be permitted to take nothing but small portions of barley water; and, in case there is much pain, a teaspoonful of the following: R. Sulph. morphiæ gr. ij; aquæ 3i. M. ft. sol.

"Soon after the operation, Messrs. J. Forsyth Meigs and Skelton arrived; these gentlemen assiduously devoted themselves to our patient during the first five days and nights, so that, had any unfavorable symptom appeared, we should have had immediate notice.

"13 P. M. Feels quite comfortable; after-pains very slight; pulse 80.

"4 P. M. Pulse 88; has taken one teaspoonful of morphia solution. 10 P. M. Met Dr. Meigs. Pulse 88; skin pleasant; gentle moisture; tongue clean and moist; some flatulence; not much soreness; afterpains moderate; urine drawn off by the catheter, six ounces; directed solut. morphiæ to be given every three hours if there is much pain, and a small portion of lime-water occasionally for the flatulence.

"6th, 10 A. M. Met Drs. Meigs, Gibson, and Hodge. Mrs. R. passed a restless, uneasy night; was unable to sleep, though not in pain; took a dose of morphia at 11 P. M., and another at 5 A. M., also lime-water twice. Her pulse is 85, and soft; skin pleasant; slight distension of abdomen, without any increase of soreness; urine by catheter five ounces, of natural appearance. 1 P. M. Symptoms all favorable; pulse 88. 4 P. M. Pulse 92. 8 P. M. Met Dr. Meigs. Pulse 94; skin and tongue moist and pleasant; countenance good; no expression of anxiety; considerable tympanitis; complains much of flatulence; no after-pains; lochia free and natural; urine by catheter ten ounces. At this time, a catheter was introduced into the rectum, which caused the discharge of a large quantity of gas, rendering her much easier, and completely relieving the tympanitis. Directed a tablespoonful of the following mixture to be given every two or three hours: R. Bicarb. potassæ 3ij; sulph. morphiæ gr. ss; aquæ menthe p. 3vj. M. ft. sol.

"7th, 10 A. M. Met Drs. Meigs and Gibson. Our patient had a very good night; slept comfortably, without an opiate; pulse 78, and soft; countenance good; respiration natural; skin pleasant; tongue slightly furred, but moist; urine by catheter eight ounces. 4 P. M. Pulse 82; no pain or tenderness; has slept through the day; expresses herself as feeling comfortable. 8 P. M. Pulse 84; no return of tympanitis since the introduction of the catheter into the rectum last evening; urine by catheter eight ounces; continued mixture.