This document discusses two operations - symphysiotomy and mechanical dilation of the pelvis - that have been proposed as alternatives to cesarean section when childbirth is obstructed. The author argues that these operations are not adequate to significantly increase pelvic diameter and could result in dangerous injuries to the bones. While the pelvis may sometimes soften during difficult labors, this effect is temporary and unpredictable. Preferentially destroying the infant's life in order to save the mother's requires fully considering all relative circumstances, not just abstract reasoning or feelings.
This document discusses two operations - symphysiotomy and mechanical dilation of the pelvis - that have been proposed as alternatives to cesarean section when childbirth is obstructed. The author argues that these operations are not adequate to significantly increase pelvic diameter and could result in dangerous injuries to the bones. While the pelvis may sometimes soften during difficult labors, this effect is temporary and unpredictable. Preferentially destroying the infant's life in order to save the mother's requires fully considering all relative circumstances, not just abstract reasoning or feelings.
This document discusses two operations - symphysiotomy and mechanical dilation of the pelvis - that have been proposed as alternatives to cesarean section when childbirth is obstructed. The author argues that these operations are not adequate to significantly increase pelvic diameter and could result in dangerous injuries to the bones. While the pelvis may sometimes soften during difficult labors, this effect is temporary and unpredictable. Preferentially destroying the infant's life in order to save the mother's requires fully considering all relative circumstances, not just abstract reasoning or feelings.
This document discusses two operations - symphysiotomy and mechanical dilation of the pelvis - that have been proposed as alternatives to cesarean section when childbirth is obstructed. The author argues that these operations are not adequate to significantly increase pelvic diameter and could result in dangerous injuries to the bones. While the pelvis may sometimes soften during difficult labors, this effect is temporary and unpredictable. Preferentially destroying the infant's life in order to save the mother's requires fully considering all relative circumstances, not just abstract reasoning or feelings.
April 15, 1865.] DR. RADFORD ON CESAREAN SECTION. [British Medical Journal.
fore mentioned, may be partially dilated by the me-
chanical influence of the elastic bag, yet, in my opinion, practical rules cannot be based on such an ON THE uncertain event where life is concerned. CSESAREAN SECTION AND ON OTHER Before such a change can be safely effected, a very considerable and an uniform softening must OBSTETRIC OPERATIONS. have taken place in the greater number, if not in BY all, the bones of the pelvis which are subjected to the TIIOMAS RADFORD, M.D., influence of pressure, whether it be produced by the F.R.C.P.EDIN. AND F.R.C.S.ENG., ETC., child or by artificial means. We know very well nIONORARY CONSULTING PHYSICIAN TO ST. MARY'S HOSPITAL, that this uniform change is found to happen in very MANCHESTER. few cases. Some of the bones sometimes become very soft, whilst others are comparatively unchanged. CHAPTER VIII. In other cases, some of the bones become very soft; Syinphyseotomy and Ifechanical Dilatation. whilst others become very hard and brittle. Some- times, the pelvis becomes very highly distorted, and I HAVE now to speak of two propositions intended all its bones are extremely brittle and fragile, as hap- to supersede the Cesarean section, and which cannot pened in Dr. Murphy's case. be included under either of the former divisions. In a pelvis thus changed by disease, what would I.-Symphyseotomy. Symphyseotomy, or a divi- be the result (supposing it possible to accomplish it) sion of the cartilages constituting the symphysis of dragging a full grown mutilated child through pubis, was advocated by Sigault, and his suggestion its cavity, or of attempting, by artificial and mechani- was received with enthusiastic approval. A medal cal force, to dilate the pelvis for the purpose of accom- was struck off in honour of him. plishing the delivery? The bones must be smashed, British obstetricians have discountenanced this or at least so much broken, that irreparable injury operation, because it is not only inadequate to in- must be produced. Even assuming that the bones crease the diameters of the pelvis, so as in any way are so uniformly softened as to yield to the pressure, to facilitate delivery when this bony cavity is so it is quite certain that the increased capacity would contracted as to require the Caesarean section, but only be temporary, as the bones would immediately because it would be attended by most dangerous and most likely completely return to their former po- results. sition as soon as the pressure was removed. British medical literature has only once been dis- graced by the record of the performance of this oper- CHAPTER IX. ation. I have already adverted to Mr. Simmons's The Comparative Value of Mfaternal and Infantile proposed compound operation of symphyseotomy and Life. craniotoiny. The British obstetric principle, which admits the II.-Mechanical Dilatation of the Pelvis. At a preferential use of the crotchet, or the induction of late discussion on a case of Caesarean section at the abortion, is based on a calculation made as to the Royal Medical and Chirurgical Society, which was relative value of the life of the mother and of that reported in the Lancet, it was stated that a pelvis of the infant or of the embryo. which was distorted from mollities ossium might be It is said, and no doubt truly, that the social rela- dilated by means of bags introduced within its cavity, tions of the woman are greater than those of the and distended by either water or air. It was asserted, infant. She is endeared to her husband, it may be that this practice had been adopted in one case with to her children, and perhaps to her brothers and the effect of widening the pelvic space. The Presi- sisters, besides other kindred and friends. In the dent stated that he had found the bones affected abstract, these are weighty considerations, and are with this disease yield during the extraction of the calculated to bring conviction to the mind, that her child after craniotomy. claims for the preservation of life greatly pre- From my own practical knowledge, I can truly ponderate over those of the infant or of the embryo. affirm the truth of the last statement. Some years It may be stated that these beings are unequal to the ago, I made the fact known to the profession. mother in organisation, having no moral or religious In a case, at some distance from Manchester, in responsibility, no social ties, no anticipation of their which the pelvic space at the brim was about two future doom; and further, as regards the latter (the inches and a quarter, it was deemed right to cranio- embryo), that it is at the very time drawing its nou- tomise the child. After fixing the crotchet, and ad- rishment from the mother's existence, that it has justing the head in the most favourable position, never had a distinct or separate life, and that it is force was cautiously used, and, after a few extractive little more than a member of the mother. These ar- efforts had been made, the head gradually descended, guments, when only abstractedly considered, appear during which time the pelvic bones yielded to the to be true; and to warrant the deduction that the pressure, and ultimately delivery was accomplished. life of the infant or embryo is of little value when Immediately afterwards the pelvis was examined, compared with that of the mother. and found to have regained its former dimensions. The impulse of natural feeling would probably- Other cases of this kind have come within my nay, nearly to a certainty-induce a man to decide knowledge. One of great interest is briefly related in favour of this proposition. But, in the settle- in the Provin. Med. and Surg. Journ., vol. ii, page ment of a question which involves the preservation 706, 1847. Although it is true that the pelvic bones, or destruction of a human being, neither abstract when affected with mollities ossium, do sometimes reasoning nor feeling should be allowed to influence yield to the pressure of the child when drawn the obstetrician ;-conscience, reason, and judgment, through the cavity; and although the pelvis, as be- ought to actuate him, after having fully and 365 British Medical Journal.] DR. RADFORD ON CA3 SAREAN SECTION. [April 15 1865. deliberately considered all the relative and contingent Dr. I)enman had aversions to repeated clotchet- circumstances which either now or in future apper- operations. He says: " Suppose, for instance, a tain to the case. woman, married, who was so unfortunately framed The unfounded and unwise opinions of Dr. that she could not possibly bear a living child by any Osborne primarily and mainly led a large section of method hitherto known. The first timne of her being the profession to estimate the life of the infant in in labour, no reasonable m4n could hesitate to afford utero at a very low value. Hle conisidered it nearly relief at the expense of the child. Even a second or as a nonentity; as devoid of sensation, ancd also as a third trial might be justifiable to ascertain the fact nearly deprived of motion. But I thinik I am assert- of the impossibility." This eminent writer most ing the truth when I say that there are few, if decidedly erred in even conditionally sanctioning a any, members of our profession who now entertain repetition of this operation. In such cases, the im- such opinions. possibility of delivery of an unmutilated infant per According, to British practice, the destructioni of vias natmrales can and ought to be proved by a single the infant is not limited to one; but if the cause case as clearly as by twenty, and when so shown, the which required its sacrifice in the first instance be Caesarean section should be performed. permanent, then in each successive labour, no matter It is by no means to be understood that the life of what number, the same operation must be performed. the infant must never be sacrificed to save the Henice in the end there must be a fearful sacrifice of mother. On the contrary, I have already enumer- human life. ated cases in which craniotomy ought to be performed The repeated necessity of craniotomy in the same as an operation of election; but it is not right to woman demands from the obstetrician serious con- destroy the infant on the unfounded assumption that sideration. In some cases, from one to twelve in- the mother could alone be saved by it; a deduction fants have been destroyed. Can such a procedure altogether untrue, and unsanctioned by statistical be justifiable? The obstetrician should pause; he evidence. should reflect. It is a dreadful position to be placed The life of the woman is not, either relatively or in, to have one's hands imbrued with innocent comparatively, always of the same value. If she be blood. afflicted with a serious disease, or labouring under The woman is ipso facto one party, and indeed the some incurable malady, being unfit and unable to ,chief party, who has brought into existence the inno- discharge her domestic and her social duties, which cent being whose life the practitioner is employed to performance can alone render her life desirable to take away. It may be argued, as a plea for her jus- herself or to her friends, then, under such circum- tification, that the wife is subject to her husband; stances, the infant's life ought not to be sacrificed for and there can be no doubt that she has engaged to be the mere ideal chance of prolonging her miserable so in the matrimonial contract, which was mutual. existence, which is a positive evil to herself. But if it be considered right (which in such a case Again, in our estimate of the comparative value of as this could only be so conditionally) strictly to ob- the two lives, we should especially consider whether serve this promise, it must be equally imperative the cause of difficulty is temporary only or perma- upon both parties to obey the law of nature and nent. If it be of the latter character, then the infant's fulfil their mutuial pledge to procreate (and without life (except as aforesaid conditionally) ought to be doubt preserve) the species, both of which vows are considered higher; and if of the former kind, then broken by the employment of the crotchet. we should invariably decide in favour of the mother. It may again be urged, that both the parties were The obstetrician should, therefore, endeavour, as far alike ignorant of any cause (otherwise they were as is compatible with the safety of the mother, to solemnly called upon at the altar to avow it) which preserve the infant; for I know no case in which an would interfere with the great object of matrimony. intention or a desire to sacrifice her can ever be en- Therefore, the woman, unacquainted with her phy- tertained, as the especial object of the practitioner sical organic defect, would be entitled to have those should always be to try to save both lives. measures adopted for her first delivery which would When the contingent hazards of craniotomy, and expose her life to the least hazard. Although the the risk of its abuse are considered, and as we know comparative safety of delivery by the only two avail- that the act is the sacrifice of life, and that this awful able methods is unsettled by either positive or correct catastrophe must be often repeated in order to carry statistical evidence, yet, if she or her husband desire out the abstract proposition "1 to save the life of the that craniotomy should be performed, then the obste- woman by destroyilng the infant"-when we remem- trician would probably act correctly in perform- ber the difficulty which in extreme cases is experi- ing it. enced in performing it, the cruelty it inflicts, and But, in a second pregnancy, when they are fully many other evils consequent upon it-we may truly acquainted that an unmutilated infant cannot be wonder that professional men should allow their born, the question stands on very different social and minds to be haunted by an imaginary Camsarean moral grounds. The practitioner is here placed in a spectre, and be so obscured to their own moral and most responsible and trying position when called social responsibility. Why should the obstetrician upon to decide whether he ought, time after time, or stand in such an unenviable position, not only as an thus repeatedly, be made the agent to take away life. accessory, but ipso facto the agent ? Again, I ask, I entertain the fullest conviction that a great propor- ought he to be called upon, and ought he to consent, tion of our profession have most conscientious to victimise poor helpless infants in successive pre- scruples to repeat this revolting operation in the same gnancies, in numbers which make one shudder to re- woman. This destruction of infants, in my humble count'? Does this remorseless sacrifice of human opinion, can be justified on no principle, and is life correspond with those high moral principles only sanctioned by the dogma of the schools or by which the members of our noble profession ought usage. to posess ? 366 April 115, 1865.] ORIGINAL COMMUNICATIONS. [British Medical Journal. The eminent Professor of Midwifery in Edinburgh makes the following pertinent remarks. He says: " Formerly medical practitioners seem to have thought little, and medical writers said little, regard- ing the very repulsive and revolting character of the (originaJ dommxrniutirnxs operation of craniotomy, when performed, as it fre- RETROSPECTIVE NOTES ON OUT- quently was, when the child was still living. Appa- PATIENT PRACTICE. rently, some obstetric practitioners and writers of the present day continue to look upon the practice of By C. M. DURRANT, M.D., Physician to the East craniotoimny as one that should not unfrequently be Suffolk and Ipswich Hospital. adopted, and one which it is quite justifiable to [Concluded from page 818.1 adopt. Obstetric reports and collections of cases MISCELLANEOUs AFFECTIONS. have been published within the last few years de- The list of those diseases that could be grouped scribing craniotomy as performed forty or fifty times, according to their regional situation have been com- or oftener, by the hand of the same practitioner. pleted; it remains only to enumerate those affec- But, perhaps, ere long, it will become a question in tions which are of a miscellaneous character, and professional ethics, whether a professional man is, which cannot be included in the preceding classifica- under the name of a so-called operation, justified in tion. deliberately destroying the life of a living human 1. Anrcmia. The first on the list, as having afforded the largest number of cases, is anmmia. This is a being." blood-disease, and of very common occurrence among Woman naturally is mild, kind, and humane. She the out-patients of a hospital. is endowed with great fortitude and undaunted The chief causes of this affection among the poor courage. She has generally a great desire for off- are insufficient diet, too close confinement, and the spring, and has a great love for children. Then how existence of those diseases which drain the blood of its can we suppose that any woman with a well regulated red corpuscles, as hemorrhoids, menorrhagia, carci- mind, if fully aware of her responsibility, could wil- noma, or any other exhausting discharge. lingly be a consenting party to the repeated destruc- Among the middle and upper classes, another, and tion of her unborn infants? According to my own a very rife cause obtains,which is too much overlooked, knowledge, the case isotherwise. I feel convinced inmy and too often unheeded, both by practitioner and own mind that there would scarcely be a woman to patient. I allude to the overworking of the brain, which is becoming daily in this age of competition be found, who would not suffer any amount of bodily an increasing cause of disease. An exhausted ner- pain to save her infant. vous system will as certainly produce an impover- Every woman in whom there exists organic impedi- ished condition of the blood as insufficient food, or ment to the passage of a mature or full-grown too powerful and prolonged muscular exertion; and infant, ought to be at proper time fully informed of cases arising from the former cause, will be found to the nature and as to the degree of the obstacle. She be more resisting and more unsatisfactory to treat, should also be made acquainted with the alternative than those originating in physical disturbance operations which are suitable to meet her case. If merely. the obstruction be moderate in degree, then the for- A few words on the condition of the heart, to which ceps, turning, or the induction of premature labour, the attention of the patient is so mainly and so will be proper; but if these means are not available, distressingly directed, may not be out of place. The irritable action of the organ itself, and the vascular or if the cause of difficulty is great in degree, then murmurs peculiar to anaemia, are too well known to the performance of the Caesarean section will be re- require comment; but one point, I believe, is not suf- quired. ficiently attended to, viz.: the importance of making such a thoroughexaminationof the heart and vessels as THE NEW DISEASE ! Telegrams received from Sir will enable the practitioner to assure the patient and A. Buchanan, St. Petersburg, report that the fevers friends that no disease of the organ exists. I refer to in that city are believed to have no affinity with the this circumstance from having been so frequently told plague, but are attributed to over-crowded lodgings by aneemic persons that they have been informed that of the labouring classes, spoiled vegetables, and bad "their heart is not quite right," or "that the heart water. This is, indeed, only what most sensible per- is slightly amiss." Now all this unnecessarily alarms sons had already concluded. The member of fever the patient, aggravates the functional disturbance, cases admitted into the hospitals varies from 100 to and might be entirely prevented by a careful exa- 150 a day, of which the average mortality has been mination, and a faithful explanation of the precise 25 or 30 a day, and the highest mortality 60. The cause of the disturbed action. The vascular mur- Paris Moniteur of Saturday published a note, stating murs which are sometimes temporarily heard in an- that the Government had made inquiry into the con- mmic cases, both in the subclavian regions and also dition of St. Petersburg; and found that, although over the cartilage of the third rib on the left side, deplorable some weeks ago, it is now greatly im- are quite distinct from the functional souffle and the proved, and shows no epidemic beyond the ordinary bruit de diabie, which is so common an attendant sickness of the season. upon this condition of the blood. TAPEWORM IN ABYSSINIA. A recent traveller in Dr. Richardson, in his Asclepiad essay upon the Abyssinia, Mgr. Van den Deck, has sent to the Bel- former murmur, believes it to arise either from a gian Royal Society an interesting account of the tape- peculiar condition of the subelavian muscle affecting worm which so commonly afflicts the inhabitants ol the artery, or from pressure from behind the vessel that country. They take small doses of kousso only caused by local tuberculous deposit. In highly anve- to get rid of the body, when the worm gets of an in- mic subjects, I imagine that it may arise from a convenient size; but they are anxious to retain the portion of condensed lung, not necessarily tubercu- head, for they are terrible gluttons, and having a lous, temporarily pressing upon a highly irritated tenia enables them to eat so much more. The tenia artery, and causing a murmur by disturbing the cur- common in Abyssinia is T. vtediocanleUata. rent of blood through the vessel; or it may arise from 367