A CONTRIBUTION TO THE RELATIVE VALUE 
—OF THE— 
DIFFERENT OPERATIONS 
—FOR— 
Delivery in Narrow Pelves; 
—WITH— 
THE HISTORY OF EIGHTEEN CASES. 
—BY— 
AUG. F. ERICH, M. D., 
Professor of Diseases of Women, College of Physicians and Surgeons, Baltimore 
Surgeon in Charge of the Maryland Woman’s Hospital, Etc., Etc. 
BALTIMORE, MD. 
| Reprint prom the Maryland Medical Journal, for October 1st and ijfC /. 
BALTIMORE, MD 
J. W. BURST & CO., PRINTERS, NO. 9 S. CHARLES ST. 
I880. A CONTRIBUTION TO THE RELATIVE VALUE 
—OF THE— 
DIFFERENT OPERATIONS 
—FOR— 
Delivery in Narrow Pelves; 
—WITH— 
THE HISTORY OF EIGHTEEN CASES. 
—BY— 
AUG. F. ERICH, M. D., 
Professor ok Diseases of Women, College of Physicians and Surgeons, Baltimore 
Surgeon in Charge of the Maryland Woman’s Hospital, Etc., Etc. 
BALTIMORE, MD. 
| Reprint from the Alary land Medical Journal, for October 1st and ijt/i, jS8u.\ 
BALTIMORE, MS. 
J. W. BORST & CO., PRINTERS, NO. 9 S. CHARLES ST. 
1880. A CONTRIBUTION TO THE RELATIVE VALUE OF THE 
DIFFERENT OPERATIONS FOR DELIVERY IN 
NARROW PELVES; WITH THE HISTORY 
OF EIGHTEEN CASES. 
AUG. F. ERICH, M. D., 
Professor 'of Diseases of Women, College of Physicians and Surgeons, Baltimore; 
Surgeon in charge of the Maryland Woman’s Hospital, etc., etc. 
Obstetricians are still divided in 
opinion as to the indications for the 
different operations devised to facili- 
tate delivery of the child in cases of 
narrow pelvis. Authorities of the 
highest standing in the profession are 
found upon both sides of the questions 
that are at present under such active 
discussion, and arguments of the most 
conflicting character are advanced by 
men of equally large experience. 
Under circumstances such as these, 
the truth cannot be reached by any 
method of a priori reasoning; nothing 
short of a careful sifting of our bed- 
side experiences will enable us to 
arrive at definite conclusions. 
The following eighteen cases bear- 
ing upon the points in dispute are 
offered as a basis for the arguments I 
propose to advance in favor of the 
views that appear to me to be true. 
Only one of these cases, (Case XII) 
occurred in my own practice; the 
other seventeen had been attended by 
midwives, or other practitioners and I 
was not called until a late stage of the 
labor; usually some time after the at- 
ten lants had despaired of delivering 
the child. 
The cases extend over a period of 
nine years, fiom 1871 to 1879, and are 
here given in their regular sequence : 
Case i. Mrs. J. McG, native of Ire- 
land, married, aged 42, multipara; 
was taken in labor on July 15th, 
1871, Drs. C. Edward Miller and R. 
W. Mansfield in attendance. Labor had 
progressed slowly until the head was 
firmly impacted in the cavity of the 
pelvis. Size of head out of propor- 
tion to the dimensions of the pelvic 
canal. Ergot had been used. Forceps 
were given a fair trial by all the at- 
tendants, but without success ; version 
was not attempted. After eighteen 
hours, perforation was performed 
under chloroform The entire roof 
of the skull had to be removed before 
delivery could be accomplished. Per- 
fect recovery of mother. 4 
The subsequent history of this 
patient could not be traced. 
Case 2. Mrs. L. W., native of Ire- 
land, aged 38, 1 para, married. In 
labor August 4th, 1871, attended 
by a midwife and Drs. Hamilton, J. 
R. Andre and C. M. Morfit. Head 
impacted in the cavity of the pelvis. 
Ergot had been used. Forceps 
tried fairly by all the attendants and 
by writer, but without success. Sixty- 
one hours after beginning of labor, 
the head was perforated with the tre- 
phine, and a large portion of the bones 
of the cranium removed before the 
foetus could be delivered. 
A vesico vaginal fistula resulted 
from sloughing of a portion of the 
anterior vaginal wall. 
The patient has had one abortion, 
but has not been confined at full term 
since the operation. 
Case 3, Mrs. I. A., mulatto, aged 
30, married, 2 para. Was taken in 
labor May 4th, 1873, Dr. R. W. Mans- 
field in attendance. Previous labor 
normal. After being in labor twelve 
hours, the head was impacted in the 
cavity of the pelvis on account of dis- 
proprotion between size of head and 
canal. Ergot had been used without 
result. Forceps fairly tried by Dr. Mans- 
field and the writer. Version was not 
attempted. Under chloroform, the 
head was perforated with the trephine. 
The entire roof of the skull had to be 
removed in order to deliver. 
A transverse rupture of the poste- 
rior wall of the vagina was produced 
during the efforts at delivery with the 
forceps. Perfect recovery without fis- 
tula resulted, The patient has since 
been delivered of a living child, after 
a normal labor. 
Case 4. Mrs. C. H., white, Ameri- 
can, aged 20, married, 1 para, in labor 
April 28, 1874, attended by Dr. James 
F. McShane. Ergot was not used 
during the labor. Head impacted in 
the cavity of the pelvis on account of 
disproportion of size of head to the 
pelvic cavity. Forceps applied and 
delivery attempted by Dr. McShane 
and the writer but without success. 
The case was unsuitable for version, 
the head being too low down in the 
cavity and the waters having long 
since drained off. Delivery of the 
head entire being manifestly impos- 
sible and the woman becoming rapidly 
exhausted, perforation with the tre- 
phine was resorted to and the child soon 
delivered. No anaesthetic was used. 
Perfect recovery of the mother with- 
out fistula or other injury. This 
patient has since borne three living 
children, the last one being delivered 
by forceps. 
Case 5. Mrs. G. F., white, Ameri- 
can, aged 24. married, 1 para, in labor 
May 17, 1874, attended by Dr. R. W. 
Mansfield. Duration of labor, twelve 
hours. Disproportion of head to 
pelvis, head impacted in cavity. Ergot 
used. After a fair trial of the forceps 
by both the attendant and the writer, 
craniotomy was done under chloro- 
form. Evacuation of the brain re- 
duced the size of the head sufficiently 
to permit delivery of the child. Ver- 
sion was not attempted. 
The mother recovered perfectly 
and has since been delivered of a 
living child. 
Case 6. Mrs C. B., German, mar 
ried, aged 28, 4 para, in labor October 
8, 1874, attended by a midwife. Ergot 
had been used by the midwife before 
writer was sent for. Antero- posterior 
contraction of the pelvis. Head 
arrested at the superior strait. High 
forceps operation tried without result. 
The forceps were difficult to apply, 
but were fairly tried without slip- 
ping. The patient’s first labor was 
normal, her second difficult; in the 
third she was delivered by version. 
In the present instance version was 
not attempted on account of dryness 
of the passages and exhaustion of the 
patient. The head was perforated 
with the trephine, and delivery rapidly 
completed. No anaesthetic was used. 
The mother soon recovered completely 
from the effects of the operation. 
In 4 subsequent labor a child was 5 
delivered by the high forceps opera- 
tion by another operator, from the 
effects of which she died. 
Case 7. Mrs. H., German, married, 
aged 40, multipara, previous labors 
generally difficult. In labor October 
25, 1874, attended by a midwife. 
Ergot had been used by the midwife 
during the labor. Disproportion in 
size between the head and cavity of 
the pelvis. Head impacted in the 
pelvic cavity. Forceps fairly tried 
but without success. Version was 
not attempted, the case being unsuit- 
able for this operation. Labor had 
lasted twenty-four hours, the vagina 
was hot and dry, and the strength of 
patient becoming rapidly exhausted. 
Perforation with the trephine was re 
sorted to without anaesthesia and de- 
livery easily accomplished. Recovery 
rapid and complete, without any in- 
tercurrent accidents. 
This patient has had no labor since. 
Case 8. Mrs. E S., German, aged 
21, married, 1 para, in labor with 
twins, March 20th, 1875, attended by 
a midwife. Ergot used by the mid- 
wife during the labor. Uniformly 
contracted pelvis ; head of presenting 
child impacted in the cavity. Forceps 
fairly tried without success. Version 
would have been difficult, or impossi- 
ble without great danger to the mother, 
and hence was not attempted. The 
head of the first child was perforated 
with the trephine and the foetus deliv 
ered. The second child was turned 
and delivered dead. The children 
were both males. No anaesthetic was 
used. Rapid recovery of mother 
without fistula or other bad accidents. 
This patient has been delivered of two 
living children, one male and one 
female, in normal labors since. 
Case 9. Mrs. R. C., native of Ire- 
land, aged 37, married. Was taken 
in her eleventh labor June 24, 1875, 
attended by Drs. M. J. Gately and John 
A. Conner. Her first labor was 
normal, child female; her second 
premature, male. In her third labor 
she was delivered of a boy, living ; in 
her fourth of a girl, living, by version; 
in her fifth of a girl, normal; sixth, 
seventh, eighth and ninth, boys, and 
tenth, a girl, all living and all normal 
labors. In her present confinement 
she was delivered of a dead female 
child easily, and another child 
discovered to be following, the head 
presenting. Twelve hours after the 
delivery of the first child, the head 
being impacted in the cavity of the 
pelvis, and the strength of the patient 
beconling rapidly exhausted, the he id 
was perforated and the foetus rapidly 
extracted. The forceps had been 
fairly tried, without success, by all the 
attendants. Version was not at- 
tempted. 
No anaesthetic was used. The 
patient recovered without fistula or 
other bad results, and eighteen months 
after the operation had another female 
child in normal labor. 
Case io. Mrs. M. D., German, mar- 
ried, aged 45. In labor for the elev- 
enth time, July 24, 1875, attended by 
a midwife. Her first labor was pre- 
mature, a female child at seven and a 
half months being born, which lived 
three weeks. Her second to sixth 
children were girls ; seventh, a boy; 
eighth, a girl, ninth and tenth, boy 
and girl (twins); all normal labors. 
Her eleventh child was a girl delivered 
alive by version, but died a few min- 
utes after birth. 
In her present labor ergot had 
been administered by the midwife. 
Disproportion between size of head 
and cavity of the pelvis, head impacted 
in the cavity. The labor having lasted 
twenty hours, with no prospect of 
terminating normally, and the forceps 
having been fairly tried without suc- 
cess, craniotomy was thought to 
offer .the best chance for the mother’s 
life, the case not being considered a 
suitable one for version. The head was 
perforated with the trephine, and a 
large male child delivered without 
much further difficulty. No anaes- 
thetic was used. 
The patient rapidly recovered with- 6 
out fistula or other accidents. She 
has had no labor since. 
Case ii. Mrs S. S., German, aged 
20, 1 para, married, in labor Nov 
13, 1875,attended by a midwife. Ergot 
used by the attendant before the 
writer was called. Considerable 
antero-posterior contraction of the 
pelvis. The head was arrested at the 
superior strait. The forceps were ap- 
plied, and traction made until all 
hopes of delivery in this manner had 
been rendered futile. Version was 
not attempted, on account of the ex- 
tent ot the contraction and the dryness 
of the passages, the membranes having 
been ruptured six hours previously. 
The head was perforated by the tre- 
phine without anaesthesia. A large 
portion of the skull was removed 
before delivery could be accomplished 
No fistula or other untoward results 
followed the operation and the patient 
made a rapid recovery. 
Two years later this woman again 
became pregnant and was again de- 
livered by craniotomy. (See below, 
case 14.) 
Case 12. Mrs. C. S., American, 
married, aged 23, 1 para, in labor 
August 15, 1876, attended by the 
writer. Ergot was not used previous 
to delivery. Head was very large 
and became impacted in the pelvic 
cavity. After a fair trial with the 
forceps without advancing the head, 
perforation by the trephine was re- 
sorted to, under chloroform, sixteen 
hours after the beginning of the labor. 
The patient rapidly recovered without 
fistula or other untoward results. 
The case was a more than usually 
interesting one from the fact that 
labor was delayed, to all appearances, 
two months beyond the full term of 
pregnancy. 
The patient was of small and deli- 
cate build. Being her first pregnancy 
every step of it was carefully watched 
by her family. When she had been 
pregnant nine months, according to 
the reckoning of the family, labor pains 
set in and the writer was sent for. 
Upon arrival at the house, the os was 
found undilated, and the pains gradu- 
ally diminishing in intensity. Patience 
was counseled, and it was decided to 
leave the case to nature. Fully two 
months elapsed before her confinement 
finally took place. The patient herself, 
her female relatives and her husband 
were positive in their assertions that 
she had been pregnant for eleven 
months. The size and appearance of 
the child were certainly calculated to 
support this view. It was as large as 
an infant two months old. The hair 
was unusually thick and long, and the 
nails were so long as to project con- 
siderably beyond the ends of the fin- 
gers. I was very reluctant at first to 
admit an eleven months pregnancy, 
but these evidences and the fact that 
I have since delivered the patient of a 
full-sized living child without version 
or the aid of instruments strengthen 
the presumption that the former diffi- 
cult labor was not due to any defect 
in the pelvic passages of the mother, 
but to the great size and unyielding 
hardness of the child’s head. The 
possibility of eleven month’s pregnan- 
cies is now generally admitted, and I 
believe the case just related to have 
been one. 
As stated above, the patient has 
since had a normal labor at full term, 
in which she was delivered of a living 
child. 
Case 13. Mrs. J. R., German, aged 
29, married, 4 para, in labor October 
29, 1876, attended by Dr. John A. 
Conner. In her first labor, the child 
was delivered by embryotomy, the 
operation being done by another prac- 
titioner. A vesico-vaginal fistula re- 
sulted from the operation. She was 
confined a second time at eight 
months, child still-born. In her third 
labor, a dead child was delivered with 
the forceps, the skull being crushed 
in. In the present labor the head was 
arrested at the superior strait, there 
being a decided antero posterior con- 
traction of the pelvis. Delivery by 
the high forceps operation was at- 7 
tempted by Dr. Conner and the writer, 
but without success. Version was 
not attempted. Ergot had been used 
to increase uterine contractions, but 
with no apparent good result. After 
labor had lasted thirty-six hours, and 
there being no prospect of natural de- 
livery, the head was perforated with 
the trephine. The whole arch of the 
skull had to be removed before the 
foetus could be delivered. A rapid 
recovery took place. 
This patient was delivered fourteen 
months later of a six months child, 
still-born. The labor in this instance 
was not difficult. 
Case 14 Mrs. S. S., (see above 
case 11), was again taken in labor, 
October 21, 1877, and attended by 
Dr. Pierre G. Dausch. As in her 
previous labor, the head was arrested 
at the superior strait. The forceps 
were thoroughly tried by both the at- 
tendant and the writer, but without 
success Perforation was finally re- 
sorted to and a large portion of the 
skull removed before the child could 
be delivered. No anaesthetic was 
used. Ergot was not used before the 
operation. The patient made a rapid 
and perfect recovery. 
After her first labor this patient was 
advised to have the induction of labor 
performed at the seventh month as 
furnishing the best chance for a living 
child with least risk to the mother. 
The advice was however declined, 
with the result given. In 1879 she 
again became pregnant. In this labor 
she was under the care of another 
practitioner who first attempted to de- 
liver with the forceps, and then by 
version, but without success. He was 
finally compelled to resort to crani- 
otomy. The child, according to the 
statement of eye-witnesses, was re- 
moved piece meal. The mother died 
on the day of the operation. 
Case 15. Miss A., colored.aged 20, 
unmarried, 1 para, in labor July 4th, 
1878, attended by Drs. B. F. Leonard 
and Albert Lyman. Ergot not used 
previous to delivery. Deformed pel- 
vis; head arrested at the superior strait. 
High forceps operation fairly tried, by 
all the attendants. Version was not 
attempted. After labor had lasted 
about twelve hours without apparent 
progress of the head, craniotomy was 
resorted to under chloroform. After 
perforation and breaking up of the 
brain, the head could be compressed 
sufficiently to permit delivery without 
removal of any of the bones of the 
skull. The patient made a rapid 
recovery without fistula or other acci- 
dents. She has since married, but has 
not borne any children. 
Case 16. Mrs. J. S., German, mar- 
ried, aged 22 years, i para, in labor 
April 8th, 1879, attended by a mid- 
wife. Ergot administered by midwife 
during the labor. Head arrested at 
the superior strait, contraction in the 
conjugate diameter of the pelvis. 
High forceps operation fairly tried by 
the writer without success. After 
labor had lasted about ten hours, the 
head was perforated with the trephine 
and delivery accomplished without 
removal of the cranial bones. No 
anaesthetic was used. Version was not 
attempted. After delivery she had an 
attack of parametritis from which she 
perfectly recovered. I have since de- 
livered her of a living child by the 
high forceps operation, preceded by 
the use of Barnes’ dilators and Braun’s 
Kolpeurynter. From this operation 
she has also entirely recovered, and is 
nowin excellent health. 
Case 17. Mrs. C. H., German, mar- 
ried, aged 22 years, 1 para, in labor 
June 25, 1879, attended by a midwife. 
Ergot administered by the midwife 
during the labor. Slight antero-pos- 
terior contraction of the pelvis, head 
arrested at the superior strait. After 
labor had continued over three days 
the writer was sent for to operate. 
The high forceps operation was first 
fairly tried, but without success. On 
account of the lingering labor, and the 
dryness of the pelvic passages of the 
mother, version was not attempted. 
Eighty hours after the commencement 8 
of the labor, the head was perforated 
with the trephine, and a portion of the 
cranium removed, before delivery 
could be accomplished. The child 
was a male The operation was done 
under chloroform. 
The patient made a perfect recovery, 
without any fistula; or other accidents 
which might have been anticipated 
from the delay in rendering her proper 
assistance. She has since been deliv- 
erhd of a female child in normal labor 
at full term. 
Case 18 Mrs. J. W., German, aged 
27, married, 1 para, in labor Novem- 
ber 2, 1879, attended by a midwife. 
Ergot had been administered by the 
midwife during the labor. Dispro- 
portion of size of head to cavity of the 
pelvis. Head impacted in the cavity. 
Forceps fairly tried without success. 
Labor having lasted nearly twenty 
four hours and the waters long since 
drained off, version was not attempted. 
Perforation with the trephine and con- 
sequent compression of the head re- 
sulted in rapid delivery. No anaes- 
thetic was used. 
Her first labor was a difficult one, 
and was terminated by the delivery of 
a still-born child with the forceps. 
The patient rapidly recovered with- 
out fistulae or other bad results. 
The practitioner called to a case of 
dystocia due to narrow pelvis, is re- 
quired to make a prompt choice be- 
tween the following means of delivery, 
viz: 1, the long forceps; 2, podalic 
version; 3, craniotomy; 4, laparo- 
elytrotomy; 5, gastro-hysterotomy, 
or its modification by Porro, gastro- 
hysterectomy. The discussion of the 
first two, the long forceps and podalic 
version, has been conducted with more 
bitterness than that of all the others 
combined. Next to the late Sir James 
Y. Simpson, who lent the great weight 
of his authority in favor of this opera- 
tion, one of the strongest advocates of 
podalic version in preference to the 
forceps, is Goodell, of Philadelphia. 
In a paper published a few years • 
ago,* he relates ten cases delivered in 
this manner, only one of which (case 
IX) can be considered as supporting his 
views, since in this case alone had the 
forceps been tried before version was 
attempted and a living child delivered 
by its means. Even this case loses 
some of its value by the confession of 
the author that he is “ a convert to,” 
and “ a warm partizan of podalic ver- 
sion.” Is it not possible that had he 
not been a partizan of delivery by 
version he might have continued his 
efforts with the forceps a little longer 
and perhaps finally succeeded with it? 
Dr. Alexander Milne, of Edinburg, 
another advocate of podalic version, 
says of the high forceps operation : f 
“The chief merit claimed for the high 
forceps operation is, that by it we 
may occassionally extract a child in 
cases of narrowed brim, where no 
other prospect is offered but the ‘sad 
and horrible ’ one of craniotomy. 
Now, granting that this happy result 
is obtained in some instances, and 
conceding further, for argument’s sake, 
that turning in these same cases could 
not have been accomplished, the ques- 
tion remains. Is the result worthy the 
price, or is the benefit obtained not 
outweighed by the attendant risks and 
dangers? Take the mother first, as 
the more important life, * * * 
What dangers threaten her, to what 
hazards is she exposed? In the first 
place, from the long delay * * * 
she may become exhausted and suffer 
from a train of well-known painful 
symptoms, or the protracted pressure 
may lead to inflammation, suppura- 
tion and sloughing; * * * or 
even rupture of the uterus, with its 
usually fatal termination may be 
induced.” 
This is indeed the language of “a 
partizan.” He pictures the dangers 
♦Clinical Memoir on Turning in Selves nar- 
rowed in the Conjugate Diameter. American 
Journal of Obstetrics, August, 1875. 
f On the Comparative Value of the Long For- 
ceps and Turning in Cases of Contracted Pelvic 
Brim. Eainburg Medical Journal. March, 1867. 9 
the womb.” What possible connec- 
tion the forceps can have with this 
physiological compression does not 
appear. He then continues : “ The 
compression to which the head is 
exposed during the high operation is 
doubtless severe ; and if, as is gener 
ally the case, the blades are applied 
obliquely, then the force is exerted in 
the antero-posterior axis of the head, 
which is believed to be the most dan- 
gerous direction,” and then he goes 
on to picture the sad results of bring- 
ing into the world an infant with per- 
manently injured brain, and “thus 
entail on a family a source of perpetual 
sorrow and compassion, and on the 
State a helpless and hapless member 
incapable alike of protecting himself 
or others.” The danger to the child 
from compression, as here described, 
is another proof of the fact that the 
author does not use the forceps as they 
should be used. What he says here 
may apply if the forceps are used as 
an instrument of compression. If the 
instrument is used in the interest of 
the child, as a means of traction 
merely, and with proper pauses for 
relaxation of its pressure to allow the 
circulation in the child’s tissues lying 
in contact with the blades to be re- 
sumed from time to time, not one of 
these dangers will be encountered. 
To what strange use statistics may 
be put, is illustrated in a paper pub- 
lished by Dr. Harold Williams, of 
Boston,* in which he furnished statis- 
tics, proving to his satisfaction, “ That 
the high forceps operation should be 
undertaken with the greatest hesitation, 
inasmuch as its results to the mother 
are more fatal than Caesarean sec- 
tion.” This is another proof of the 
utter unreliability of statistics of 
operations collected at random from 
the journals, leaving the compli- 
cations, time of performance and 
relative skill of the operators out 
of account. How much the dangers 
of the forceps operation are here ex- 
of delay as if that was inseparable 
from the high forceps operation, and as 
if a good obstetrician, provided with 
Barnes’ dilators and Braun’s kolpeu- 
rynter, would wait any longer in the 
one case than in the other, (see my 
16th case). The danger of rupturing 
the uterus is generally admitted to be 
greater in version than in forceps de- 
liveries. 
When portraying the dangers ac- 
companying the application of the 
long forceps, Dr. Milne proves con- 
clusively that he does not know how 
they should'be applied. He says the 
application of the forceps increases 
the dangers before recounted and con- 
tinues : “ For example, the vagina, 
tumefied by the delay, may be readily 
torn, or some part of the uterus may 
be lacerated. Indeed, no one can tell 
what injury the point of the blade 
may do as it travels its critical way 
within the cavity of the womb, any 
more than we can tell what lies at the 
bottom of a draw-well, or in a valley 
in the moon.” How can the vagina 
or uterus be lacerated by the point of 
the blade if that is preceded by the 
hand until it has entered the cervix? 
Should it fail to pass to its proper 
position by the application of such 
moderate force as could not possibly 
produce laceration, the hand should 
precede and guard the blade of the 
forceps until it has cleared the obsta- 
cle, however high that may be up. It 
may here be objected that there might 
be no room for the hand. This objec- 
tion cannot hold good in the cases 
under discussion where version is the 
alternative, since where there is room 
for version, there must also be room 
for the hand in the application of the 
forceps. 
Dr. Milne now puts in, what is evi- 
dently intended to be an eloquent plea 
for the child. He pictures the risks 
and dangers to which the child is first 
exposed from contractions of the 
uterus. “ Its brain ” he says, “ will 
not tolerate the prolonged compres- 
sion with impunity, even while within 
*Am. Journ. Obst., Jan., 1879. 10 
aggerated, will appear when we con- 
sider that the eighteen cases above 
reported constitute only the worst 
cases that I have encountered, and 
that after an hour’s faithful tugging at 
the forceps the risks of craniotomy, 
and in two of them the dangers of ver- 
sion were added without losing a 
single mother. In the light of this 
experience, I am forced to say, at the 
risk of appearing dogmatic, that if the 
high forceps operation becomes dang- 
erous to the mother, it is either a rare 
accident, or it is the fault of the ope- 
rator. In most cases of this operation 
ending fatally, this result should be 
attributed to the long delay and the 
previous use of ergot. If ergot had 
not been given, and the forceps had 
been earlier applied, the mother’s parts 
would not have become so hot, dry 
and adhesive as I have generally found 
them, and the probability is that in all 
those cases where the disproportion 
was small the delivery might have 
been effected without the use of the 
perforator.* In a case of shoulder- 
presentation to which I was called at 
“the eleventh hour’’ the stickiness of 
the maternal and foetal surfaces was so 
great that after I had brought down the 
feet and fastened strong bandages to 
them, it required my full strength and 
that of the midwife in attendance to 
deliver the hips and body of the child, 
although there was no narrowing of 
the pelvis. 
The other side of the question is 
strongly advocated by Byford, of Chi- 
cago ; Matthews Duncan, of London; 
Depaul, of Paris; Ellwood Wilson, of 
Philadelphia, and many other high 
authorities, McClintock, of Dublin, is 
opposed to version, and in favor of 
head-first delivery in contracted pelvis. 
Fleetwood Churchill* says that in a 
pelvis of 3.25" in the conjugate diam- 
eter, turning is unnecessary, as a living 
child may be delivered through it 
either with or without the forceps. If 
the conjugate is less than 2.75" turn- 
ing is unjustifiable, as a living child 
cannot be extracted. The limits of 
the operation then, are when the 
antero-posterior diameter is between 
2.75" and 3.25". Barnesf says that 
in cases where the antero-posterior 
diameter is less than 3." turning is 
not to be tried. 
Leishman| says that “ when the 
conjugate diameter is less than three 
inches, to attempt to turn would be 
to subject the woman to needless risk, 
while we may be confident that nothing 
but failure would attend our efforts.” 
He also says, that delivery with the 
forceps is a safer operation to the 
mother than turning. Cazeaux states 
that when version is performed in a pel- 
vis of three, or less than three inches, 
the result is almost always fatal to the 
child. Capuron affirms that the fa- 
tality to the children delivered by 
podalic version in contracted pelvis 
amounts to 70 or 75 per cent. This 
is endorsed by Cazeaux. Version is 
fatal to the mother according to Ca- 
zeaux in about ten per cent, of the 
cases, (1 in while the statistics 
of Churchill place it at 7 per cent. (1 
in 14). Chailly-Honore says § that 
“obstetricians up to 1866 are agreed 
to consider malformation of the pelvis 
as a motive for the exclusion of ver- 
sion,” and also that version should 
not be made where there is any dis- 
proportion between the head of the 
Child and the pelvis of the mother. 
Spiegelberg,|| perhaps the highest liv- 
ing German authority on obstetrics, 
restricts version to those cases where 
there is an unfavorable position of the 
head above the brim, preventing its 
engagement, or to inefficient pains. 
In these cases it is indicated when it 
can be performed at the proper time. 
The cases should likewise be selected. 
\ Med. Times and Gazette, Sept., 1868. 
| System of Midwifery, Am. Edition, p. 520-1. 
is Quoted by Wilson, Am Journal Obstetrics, 
VIII, p. 679. 
| Quoted on the authority of Dr. J. C. Reeve, 
Am. journal of Obstetrics, vol. IX, Review, 
♦Theory and Practice of Midwifery, Ed. of 
1866. 11 
It is only in fiat pelves that version 
should be undertaken; in the uni- 
formly contracted pelvis it is worse 
than useless. Dr. Angus McDonald * 
states it as his opinion “that turning 
does not present any proved advan- 
tages to the mother over long forceps 
in cases of contracted flat pelvis, and 
is undoubtedly more dangerous to the 
child. That it is entirely unsuitable 
when the contraction is general, being 
much more dangerous to the mother 
than long forceps or any of the higher 
operations ” 
The late Professor Hugh L. Hodge, 
perhaps the greatest master among 
American obstetricians, in a paper 
written just before his death, says: 
“ It has been said that success justifies 
the means; but how a practitioner can 
be justified, in a protracted case of de- 
livery, where the waters have long 
been evacuated and the body of the 
uterus firmly contracted upon the 
body of the child and placenta, and 
when a portion, if not the whole, of 
the presenting part has passed the 
circle of the os uteri, in attempting 
version, is inexplicable. A priori, it 
would seem to be impossible. The 
uterus is firmly contracted to a com- 
paratively small size, there is no room 
for the return of the presenting part, 
and every attempt to push up the head 
and to introduce the hand must be of 
the most imminent danger to the in- 
tegrity of the vagina and uterus, and 
we know that the operation is often 
impracticable and fatal. No latent 
hope that the child might possibly be 
saved under these circumstances can 
compensate for the immense risk to 
the mother.” f 
My eighth case furnishes pretty 
strong evidence that a living child can 
not be delivered by version after the 
forceps have been fairly tried and 
failed. It was a delivery of twins. 
The first-born having been delivered 
with comparative ease after perforation 
and partial evacuation of the contents 
of the cranium after failure to deliver 
by the forceps previous to the perfo- 
ration, I thought, here, if ever, was 
the case to test the merits of the ques- 
tion. Finding that after the most 
persistent efforts on my part, the 
second child also could not be deliv- 
ered with the forceps, I proceeded to 
deliver by version. Although I final- 
ly succeeded in delivering the head 
without perforating, the child perished 
before I could accomplish its delivery. 
The mother having refused to take 
chloroform, suffered much more from 
the delivery by version than from the 
previous one by craniotomy. In two 
other cases, not included in those 
above reported, I have tried version 
after the forceps had tailed. In the 
first of these, the delivery could not 
be accomplished without perforating, 
which was done by another operator. 
The mother died some hours after the 
delivery. In the second case, multi- 
para, disproportion in size of head to 
peivic canal, the mother being an edu- 
cated German midwife, requested a 
trial of version after the delivery by 
the forceps had been despaired of. I 
succeeded in delivering the head with 
out perforating, but not with sufficient 
rapidity to save the child. 
If our aim was simply to avoid 
craniotomy, version would olten en- 
able us to do that as was shown in 
these two cases, but the dangers to 
the mother and child after version are 
greater in consequence of the urgency 
for immediate delivery after it. The 
practitioner feels that every moment’s 
delay adds to the danger of the child. 
Rupture of the cervix or perineum of 
the mother, and fracture of the arms, 
clavicles or neck of the child are liable 
to result from it. 
Having failed to deliver by the 
forceps or version, and having conse- 
quently abandoned all hope of saving 
*On the Comparative Advantages of Forceps, 
of Turning and Premature Labor in Contracted 
Pelvis.—Obstet. Journal of Great Britain and Ire- 
landt Nov., 1873. 
f On Compression of tbe Foetal Head by the 
Forceps and Cephalotribe. Am. Journal of 
Obstetrics, May, 1875. 12 
the child, except under such serious 
risks to the mother as would not be 
justifiable ; it becomes a duty to choose 
of the remaining operations the one 
that promises the greatest safety to 
the mother, and that will, in my opin 
ion, necessarily be craniotomy. In a 
slightly contracted pelvis, this opera- 
tion when performed by an experi- 
enced operator, possessing ordinary 
dexterity may well be said to be 
almost free from danger to the mother. 
My eighteen cases, all delivered by 
craniotomy after a persistent trial of 
the forceps, and all ending in the re- 
covery of the mother, will, I think, 
justify this opinion. Most of the fatal 
cases reported are, I think, due to ex- 
haustion in consequence of delaying 
the operation too long. 
Taking such strong grounds in fa- 
vor of the comparative harmlessness 
of craniotomy as I have done in this 
paper, it may be necessary to account 
for the injuries some of the mothers 
sustained. In the second case, in 
which a vesico-vaginal fistula resulted, 
craniotomy could not possibly have 
contributed to the result, as the fistula 
was due to the sloughing, which 
would have been prevented, had the 
operation been resorted to earlier. In 
the third case, a transverse rupture of 
the posterior portion of the roof ot the 
vagina was probably produced by too 
forcible contraction of the uterus, pos- 
sibly due to the action of the ergot 
which had been administered long 
before even the forceps had been 
applied. The attack of parametritis 
occurring in the sixteenth case is too 
common a complication of parturition 
to hold craniotomy responsible for it. 
Wiener gives * statistics of the 
craniotomies in the clinic and poli- 
clinic at Breslau for the twelve years 
from 1865-77. There were during 
this time 101 craniotomies. The 
mortality of the mothers in these 
operations was twenty-five per cent. 
Thirty-nine of the operations took 
place in the clinic (lying-in hospital) 
with nine deaths, and sixty-two in the 
policlinic (out-patient department) 
with seventeen deaths. In the six 
years from 1872 to 1877, there were 
17 craniotomies in the clinic, with no 
deaths. During the same time there 
were in the policlinic 24 operations 
with 7 deaths. The larger mortality 
in the out-patient department is as- 
cribed to the late stages of labor in 
which the operation is done, the pa- 
tient being frequently entirely ex- 
hausted beiore the consulting accou- 
cheur is sent for. Spiegelberg states 
that after failure with the forceps, no 
more time is to be spent in temporis- 
ing. The time to operate having ar 
rived it is to be proceeded with at 
once. Dr. E Copeman in a report 
on cases of obstetrics in private prac- 
tice,* reports one death in 14 mothers 
delivered by craniotomy. By way of 
comparison it may be stated that the 
same writer reports five deaths in 22 
mothers delivered by version. 
Laparo-elytrotomy has recently 
been prominently mentioned as a sub- 
stitute for craniotomy, but Professor 
T. G. Thomas, who re-introduced the 
operation in 1870, being the second 
that ever performed it on the living 
subject, has expressed the opinion 
that “in uncomplicated cases of crani- 
otomy the operation of laparo-elytro- 
tomy would not be justifiable. Only 
in cases where the former operation 
would be especially dangerous to the 
mother would he give a decision in 
favor of laparo-elytrotomy.” f This 
operation holding out the hope of 
saving both mother and child should 
be resorted to whenever the diameter 
of the pelvis is so much contracted as 
to render craniotomy impracticable, 
that is, when the smallest diameter is 
below two inches. Of the eight cases 
hitherto reported, four women and six 
children have been saved. In exactly 
* Obst. Journal Great Britain and Ireland, June 
t874- 
f Trans. N. Y. Obstet’l Society; Am. Journal 
Obstetrics, April, 1880. 
* Arc hid fuer Gynakologie, bd. XI. 13 
one-half the cases, the bladder has 
been cut into or torn during the ope 
ration. It is probable however that 
with additional care this accident 
could in most cases be avoided. 
From these considerations it is evi- 
dent that the indications for gastro- 
hysterectomy (Porro’s modification of 
the Caesarean section) would dwindle 
down to cases of rupture of the uterus 
with escape of the child into the ab- 
dominal cavity, and cases of extensive 
carcinoma of the cervix This opera- 
tion, meeting all the indications for, 
and being less dangerous than gastro- 
hysterotomy, promises to supplant the 
latter operation entirely. 
The artificial induction of premature 
labor has been strongly urged of late, 
especially in Germany, as a proper and 
justifiable operation in contracted pel- 
vis. The foremost advocate and de- 
fender of this practice at present is 
Dohrn of Marburg.* He publishes 
an analysis of 42 cases with the fol- 
lowing results: Of the 42 cases, 11 
were primaparae, and 31 multiparae. 
Three of the mothers died. Of the 
children, 19 died during or shortly 
after birth, 23 remained alive. 
Nineteen ' multiparae, observed by 
Dohrn, in a succession of labors, were 
delivered at full term of 41 children, 
of which number 37 died during or 
shortly after birth, and only 4 lived. 
These same women were delivered by 
the induction of premature labor of 25 
children, of which 15 lived. In these 
cases the percentage of children saved 
is 60 per cent, in prematurely induced 
labor, and 9.7 per cent, in previous 
labors at full term. This would indi- 
cate a decided conservative influence 
of this operation. 
On the other hand, Spiegelberg,f 
Litzman,| MacDonald § and Landau || 
argue against the advisability of the 
operation. Spiegelberg seems to have 
somewhat modified his opposition 
however for the following statistics 
are reported by Wiener, * his assistant 
at the Breslau obstetrical clinic. Six- 
teen cases of premature labor artifi- 
cially induced in consequence of con- 
tracted pelvis, gave the following 
results: 
The mortality to the mothers was 
5.25 per cent., (one death in 16 
cases, from “ lymphatic septicaemia ”). 
62}4 per cent, of the children died 
either during, or shortly after birth. 
Wiener concludes, that within certain 
limist of pelvic narrowing (2.8" — 3.7") 
the artificial induction of premature 
labor is more favorable to the mother 
than labor at full term In a less de- 
gree the operation is also more favor- 
able to the life of the child. Wiener, 
however, points out that many child- 
ren delivered prematurely, die soon 
after birth, and that consequently the 
operation is not so favorable to the 
offspring as claimed by Dohrn. 
The conclusions that I have been 
able to draw from my experience and 
research in reference to the different 
methods of delivery in narrow pelves, 
are the following: 
1. The propriety of induction of 
premature labor is still questionable. 
2. That version, while it should 
never be the alternative of the forceps, 
should be tried in contracted flat pel- 
vis before resorting to craniotomy, 
but is worse than useless in a uni- 
formly contracted pelvis after the for- 
ceps have failed. 
3. The forceps, when properly ap- 
plied and used, are the safest means 
of delivery for both mother and child. 
After failure with them craniotomy is 
indicated, except in cases of narrow 
flat pelvis, where version should first 
be attempted. 
4. When there is not room enough 
for the application of the forceps, and 
when the smallest diameter of the pel- 
*Volkmann’s Sammlung Klin.Vortraege, 1875, 
und Archiv fuer Gynaekologie, bd 12. 
\ Archiv fuer Gyncckologie, Bd. I. 
| Ibid. Bd. II. 
§ Obstettical Journal Great Britain and Ireland, 
Nov. 1873. 
|Archiv fuer Gyncckologie, Bd. XI. 
* Archiv fuer Gytuekologie, Bd. XII. 14 
vis is less than two inches, laparo ely- 
trotomy is indicated. Our methods 
of measuring the diameters of the pel- 
vis and of estimating the size of the 
child’s head in utero are, however, so 
very inexact that it is amusing to see 
cases reported with diameters given 
down to one-twelfth of an inch. Con- 
sidering that these estimates are at 
best rough guesses, it will generally 
be well to give the child the ben- 
efit of the doubt and attempt to ap- 
ply the forceps whenever the small- 
est diameter of the pelvis seems 
to be somewhere above two inches. 
5. In cases of rupture of the uterus 
where the child has escaped into the 
abdominal cavity, and in cases of ex- 
tensive carcinoma of the cervix, 
Porro’s operation (gastro-hysterecto- 
my) should be performed in the in- 
terest of the child. 
6. The unmodified Caesarean sec- 
tion (gastro-hysterotomy), has been 
superseded by Porro’s operation, 
which meets all the indications, with 
less danger to the mother.