children, the transverse diameter of whose heads amounted to full four inches, had been drawn forth with the forceps. I had always maintained that the loss of the children was occasioned by the preternatural energy of the uterine contractions, which, from the beginning to the end of the parturient effort, were of a character deserving truly to be called ergotic-the contractions of the uterus being permanent; and, as the children were large, the placental circulation was always suspended by the pressure of the after-birth against the child's body, so that, when born, it was born dead from asphyxia. The deep interest I took in the misfortunes of the parents, thus deprived of the hope and comfort of offspring, did not prevent me from resisting the proposition to bring on labor prematurely; and I felt prompted, from a desire I had to explain myself to the gentleman, to address him a letter, which I publish here, not as an argument against the induction in cases suitable for it, but as a caution to such as might feel tempted, unnecessarily, to resort to this method. I do not suppose I could make a better array of the motives for delaying the operation than I have here done. The following is the letter which I addressed to the gentleman, who, being himself a physician, had assisted at the very large consultation of physicians summoned for the purpose of deciding the question as to the induction of premature labor in the case. MY DEAR E.: Thursday, August 17, 1843. As you appeared yesterday to be at a loss to decide upon the steps proper to be taken in the approaching crisis, and, as I suppose, rather inclined in favor of the operation for the induction of premature labor, I think I shall feel better satisfied if I lay before you, in writing, the reasons which compel me to entertain an opinion perhaps wholly contrary to your own sentiments and wishes, yet maintained, as I think, for your real interest and happiness. I prefer that you should have this written statement both for your own greater satisfaction and also in order that I may not be at all misunderstood. Opinions thus deliberately expressed and defended are safer than those delivered vivâ voce. I am sure that you already know that I approve of the operation for inducing premature labor, in all cases where it is not performed too early to admit of the viability of the child, and where the withholding of it altogether, involves the mother in the certain necessity and risk of a severe embryotomy operation. If the antero-posterior diameter of the upper strait is below 31 inches, there is always the greatest probability that embryotomic instruments will be required; I say, the greatest probability; for it is certain that children have been born without their aid in cases of pelvic deformity even greater than this. Such a deformity, then, if it does not go too low, would warrant the operation, and recommend it as an act of professional duty. Now my opinion on this point is, I hope, very clear. But where the pelvis is of such magnitude as to admit of the transit of the foetal head, and further, renders the application of the forceps practicable, I hold that no man would be justified in inducing premature labor, without exigent necessity arising out of some well-understood, highly probable peril of the mother herself. In the case in question, we have seen delivery effected in a labor of four hours with a foetal head of dimensions which may, without exag. geration, be termed enormous; for a head of four and a quarter inches in the bi-parietal diameter is equal to the largest head I have ever seen at birth, and is just nine-twentieths of an inch above the average magnitude. The history of the past labors shows that the difficulty does not depend upon the smallness of the pelvis, either actual or relative. The history of hundreds of labors issuing happily will show that the foetus can bear longer and severer pressure of its cranium than ever has been borne in our case. In fact, the history of these labors, as I know that history, shows that the evil has been in the uterus, and not in the pelvis. This, perhaps, you may not admit. Peradventure, a premature labor might be marked by a character of uterine action different from those that have fallen at term: but shall a man feel justified to enter on an important operation, one admitted to be dangerous to the mother and uncertain for the child in the proportion of 50 per cent., upon the ground of a mere peradventure? I cannot think so. I am not much accustomed in my medical transactions to be guided by what are called authorities. In the first place, every case of dis ease, and every case of surgical disorder or accident, is a specialty. The action upon each case should be determined by judgment held upon the case, and not upon reported cases. Besides, I conceive myself to be capable, after the clinical experience I have had, of judg ing for myself; of making up my own opinion of what is my duty in every instance of disease submitted for my opinion. Were I, however, very readily inclined to follow the masters, I know not where I should look to find an authority for this operation. The only one that has the least resemblance of favoring it is that of Denman, who twice induced a premature labor successfully for women who had previously lost their fruit in utero in the seventh month. The cases, you see, are not parallel, and, if they were, I should not be moved by them; for I have seen a woman lose four children in successive pregnancies, from the sixth (or fifth) to the seventh month, who yet bore children afterwards at the full term, and in good health. Dr. Denman's patient might have done likewise, and I think he was not justified even by his good fortune in the dangerous operation he performed; I think he acted like a rash and injudicious man, whose success is no palliation of his error. To force or invite the womb to enter into action before term is to do violence to the organ by a voluntary interference with the law of its organism. It is a rule, universally accepted, that we must not do violence to the womb except upon urgent necessity; I adopt and teach this rule; and I can never feel myself justified in recommending such action, unless I can have very clear perception of the necessity for it, as relative both to the mother and foetus. So it is pretended that such exigency exists in relation to your lady. I believe you have taken too flattering a view of the operation, even as it relates to the child itself. A child is esteemed to be viable at the end of the seventh month. It is, I say, esteemed as viable, yet the facts show that a very large proportion of seven months children fail to live long. Indeed, it is understood that fifty per cent. of the whole sum of human progeny is lost at the end of the sixth year after birth: how much greater the percentage in the cases of premature parturition! If you will examine the results of the operation in Dr. Churchill, you will observe that he states in all 945 cases of the induction; I suppose that many of the 945 cases are restatements, i. e. they are cases stated over and over again; but, admitting that there have been 945 operations in fact, we still find that only 536 children lived. Lived, I say, but no man knows how long; and it is not uncharitable to say that, if we knew the whole truth, we should be obliged to make a very large subtraction from the number of 536. I have not the least belief that near one-half have been saved! and it is admitted that many of the operations were unnecessary, and even prepos terous. Dr. Chailly tells us that of the 211 cases collected by Stoltz, though more than one-half of the children were living, one in fifteen of the women died. Such a result proclaims the operation to be dangerous. It is true that we cannot here decide as to the difficulties and dangers of these 211 cases, and it may be true that the operation is less dangerous for a woman with an ample pelvis than for her who has a de and Dr. Denman relates the case of a lady of rank whom he attended with Dr. Savage, in consultation, in which the operation proved successful. Dr. Lee, in his Clinical Midwifery, 2d ed. p. 81, relates the history of the operation in the labors of Mrs. Ryan, æt. twenty-one, primipara: she lost the child after an embryotomy operation. In her second labor, Dr. Lee opened the membranes at the eighth month: he per forated the head. The third labor was brought on at seven months and a half; the feet presented; child lost. Fourth labor, induced st seven months; footling; child dead. Fifth labor, induced at the seventh month; the child born alive, died in sixteen days in convalsions. Seventh labor, induced at seven months and a half; the feet presented; child lost; great force required. Eighth labor, induced a seven months and a half; feet presented; child dead. Ninth labor, induced at the seventh month; the feet presented; child lost. Tenth labor, membranes perforated at the seventh month; child lost. Ele venth labor, induced at the end of the sixth month; child dead Twelfth labor, induced in the seventh month; child dead. labor; at the end of the sixth month, labor induced; child lost. Fourteenth labor, seventh month; child extracted alive, but soon died. Fifteenth labor, seventh month; child lost. I have cited this case of extraordinary perseverance, on the part of Dr. Lee, as much to show the resolute energy of that gentleman, as to show what may be ex pected in many of the cases of induction of premature labor. Thirteenth It is not to be doubted that the operation is legitimate, and that be who does it properly acts within professional rules and usages; but, inasmuch as every premature labor furnishes some just grounds of apprehension, both for the parent and child, I am clear in the belief that well-understood motives alone can justify the accoucheur who performs it. A woman may lose her child in one labor, and so on throughout a succession of labors, from faults not at all relative to the state of the pelvis. A lady was under my care in this city, who, in sixteen pregnancies, had given birth to only one living child; she subsequently gave birth to two children, of which the first was born a little past the eighth month, whereas the gestation of the last son continued until the close of the ninth month. There was never suspicion of the least fault in the dimensions of the pelvis. A lady of this city, out of eight children, lost seven in labor. It was proposed to her, previous to the birth of her ninth and last child, to submit to the induction of premature labor. I had been long convinced that the cause of the death of the children, in this person, was a cause relative to the action of the uterus and not to the resistance of the pelvis, because children, the transverse diameter of whose heads amounted to full four inches, had been drawn forth with the forceps. I had always maintained that the loss of the children was occasioned by the preternatural energy of the uterine contractions, which, from the beginning to the end of the parturient effort, were of a character deserving truly to be called ergotic-the contractions of the uterus being permanent; and, as the children were large, the placental circulation was always suspended by the pressure of the after-birth against the child's body, so that, when born, it was born dead from asphyxia. The deep interest I took in the misfortunes of the parents, thus deprived of the hope and comfort of offspring, did not prevent me from resisting the proposition to bring on labor prematurely; and I felt prompted, from a desire I had to explain myself to the gentleman, to address him a letter, which I publish here, not as an argument against the induction in cases suitable for it, but as a caution to such as might feel tempted, unnecessarily, to resort to this method. I do not suppose I could make a better array of the motives for delaying the operation than I have here done. The following is the letter which I addressed to the gentleman, who, being himself a physician, had assisted at the very large consultation of physicians summoned for the purpose of deciding the question as to the induction of premature labor in the case. MY DEAR E.: Thursday, August 17, 1843. As you appeared yesterday to be at a loss to decide upon the steps proper to be taken in the approaching crisis, and, as I suppose, rather inclined in favor of the operation for the induction of premature labor, I think I shall feel better satisfied if I lay before you, in writing, the reasons which compel me to entertain an opinion perhaps wholly contrary to your own sentiments and wishes, yet maintained, as I think, for your real interest and happiness. I prefer that you should have this written statement both for your own greater satisfaction and also in order that I may not be at all misunderstood. Opinions thus deliberately expressed and defended are safer than those delivered viva voce. I am sure that you already know that I approve of the operation for inducing premature labor, in all cases where it is not performed too early to admit of the viability of the child, and where the withholding of it altogether, involves the mother in the certain necessity and risk of a severe embryotomy operation. If the antero-posterior diameter of the upper strait is below 31 |