FIRST 
ANNUAL ADDRESS 
OF THE PRESIDENT, 
/ 
SAMUEL C. BUSEY, M.D., LL.D., 
DELIVERED BEFORE THE 
Washington Obstetrical and Gynecological Society, 
OCTOBER 5, 1SS3. 
Reprinted from The American Joirnal of Obstetrics and Dis- 
eases of Women and Children, Vol. A'VII., No. 2, 1884 ; and 
Reprinted under the auspices of St. Mary's Seminary. 
WASHINGTON: ! 
Wsi. II. IyEPLEY, Bookseller and Publisher, 725 15th St., N. W. 
1888. FI RST 
ANNUAL ADDRESS 
OF THE PRESIDENT, 
SAMUEL C. BUSBY, M.D., LL.D., 
DELIVERED BEFORE THE 
Washington Obstetrical and Gynecological Society, 
OCTOBER 5, 1883. 
Reprinted from The American Journal of Obstetrics Dis- 
eases of Women and Children. Vol. XVII., No. 2, 1884/ and 
Reprinted under the auspice* of St. Mary's Seminary. 
WASHINGTON : 
Wm. H. iApley, Bookseller and Publisher, 725 15th St., N. W. 
1888. CRANIOTOMY UPON THE LIVING FETUS IS 
NOT JUSTIFIABLE. 
Gentlemen : The meeting to-night completes the first year of the 
existence of this society, and it gives me pleasure to congratulate you 
upon the success attained. 
The duties of the presiding officer have been exceedingly light and 
pleasant. During the entire session there has not occurred a single 
infraction of the rules and courtesies of deportment, or of parliament- 
ary order or decorum, and there has been but one failure to comply 
with the individual obligations of the members. The attendance has 
been prompt and the average unusually large. 
The essays and discussions have exhibited study, thought, and a 
high order of professional and scientific attainment. There has not 
been one indifferent paper submitted. The zeal and enthusiasm dis- 
played by the essayists should command the admiration of the entire 
membership, and every member must acknowledge the value of the 
instruction derived from the efforts of his colaborers in this field of 
obstetric, gynecic, and pediatric study. 
This young and vigorous society has not, however, been permitted 
to complete its first year's existence without a sorrow. The memory 
of the lamented Ashford lingers in the freshness of commingled affec- 
tion and grief. We who knew him so well, who had learned to value 
the qualities of his heart and mind, and had so often listened to his 
terse and cogent utterances, will not soon forget our friend, compan- 
ion, counsellor, and co-worker. He died at the early age of forty-two, 
yet had made for himself a reputation which but few can hope to 
attain, and he has left to his friends and family the heritage of an 
untarnished name and unsullied character. 
Medical societies with limited memberships, for the mutual instruc- 
tion of their members in special departments of the science of medi- 
cine, have become quite common in the larger cities, both abroad and 
at home. Societies similar to our own have been established during 
the last decade in many cities no larger than Washington. The time 
had surely come when it was the duty of those who were specially 
interested in the study and practice of obstetrics and the diseases of 
women and children to unite and concentrate their individual efforts 
for their common good. The results in other places have demon- 
strated the literary and scientific advantages of similar organizations, 
and it cannot be doubted that this city possesses professional talent 4 
TRANSACTIONS OF THE OBSTETRICAL AND 
which will cone with the highest order of medical intellect. This 
position cannot, however, be won if individual capacities and acquire- 
ments are confined to the privacy and isolation of the sick room. 
Enlarged thought and advanced study demand the broader field of 
intellectual comparison, analysis, and trituration. These desiderata 
can only be secured by organized effort, systematic piesentation of 
well-considered opinions, clinical experience and observation, and the 
examination and discussion of these by men engaged in the same field 
of scientific labor. The success of the past year gives assurance of 
the complete fulfilment of the paramount objects of the association. 
The first being mutual improvement in scientific knowledge and prac- 
tical skill, and the second a more intimate mutual acquaintance and 
personal intercourse. 
A careful record of the proceedings and the publication of its trans- 
actions constitute the chief incentives to intelligent, systematic, and 
persistent work. No medical society prospers long.and continuously 
without these aids. Upon the Recording Secretary and Committee of 
Publication important duties are devolved, to the complete and 
impartial discharge of which the continued existence and success of 
this society mainly depends. The committee should be clothed with 
full and necessary powers, and the society should hold it to a strict 
responsibility. The duties, though very onerous, are too important 
to be neglected, and the committee should feel that the life, useful- 
ness, and standing of the society will be the measure of a careful and 
exact observance of its duty. 
It would be invidious in me to select any one of the papers read 
before this society for special commendation or criticism, ft will, 
however, he pardonable to recall your attention to a subject which, 
in somewhat different aspects, was discussed on several occasions. 
I am induced to again refer to the justifiability of the operation of 
craniotomy upon the living fetus because of the great importance of 
the subject and the increasing interest which it is now exciting, hop- 
ing that with the re-examination now in progress there will result a 
modification of the extreme views which have been held by a large 
majority of the ablest and most renowned obstetricians of the past, 
and, perhaps, of those living of equal ability. 
IS CRANIOTOMY UPON THE LIVING FETUS A JUSTIFIABLE OPERATION ? 
It is, probably, the most ancient of obstetric operations, and the 
hook and perforator are, perhaps, the most antique of obstetric in- 
struments. The operation means death and mutilation of the fetus, 
and is performed solely in the interest of the mother. When the fetus 
is already dead it is an accepted procedure, within certain well defined 
limits, to effect delivery. But then, as well as when the fetus is liv- 
ing, it demands skill and dexterity. In a large percentage of eases it 
is attended with serious dangers to the woman, and, according to 
Churchill and Tyler Smith, with a mortality in the proportion of one GYNECOLOGICAL SOCIETY OF WASHINGTON. 
5 
to five. Many other authors claim a higher death-rate, and a few a 
lower one. When performed upon the living fetus it necessarily in- 
volves the deliberate killing and mutilation of a human being. In 
every case of labor two lives are more or less in danger. Fortunately, 
in a vast majority of cases both lives are conducted safely through 
and past the perils of parturition. For the comparatively few cases 
in which delivery cannot be accomplished without artificial aid, the 
operation of craniotomy was originally devised in the interest of the 
mother, and from the times of Hippocrates and Celsus it has been 
recognized as a justifiable procedure, even when the fetus was 
alive. 
In the remote periods of antiquity many pregnant women must 
have perished in the travail of labor undelivered, but even after the 
invention of the hook and perforator, and through all subsequent 
time down to the present, with the progressive improvements in in- 
struments, advances in obstetric knowledge and science, and the 
acquisition of manual dexterity, no operator has ever yet assured the 
life of the mother, even after the life of the fetus had been sacrificed, 
and the best result that can be offered is, according to the standard * 
of Churchill and Smith, the saving of the lives of four mothers out of 
five, or, in other words, the saving of four lives out of ten, imperilled. 
In the earlier times, when obstetric operations had their beginning 
and were at best performed with rude appliances in a bungling and 
unscientific manner by operators lacking knowledge and experience, 
the preservation of four lives out of ten which would certainly have 
perished must be cherished as a blessing to humanity, and the means 
by which it was accomplished must be regarded as a great advance 
in the obstetric art. But as yet there is no proof that Hippocrates, 
Celsus, or the Arabian physicians ever deliberately destroyed the life 
of the fetus preliminary to the extraction of the mutilated body of 
the unborn child. It may be that their mortality of mothers was 
greater, perhaps far greater, than it is to day, but when Baudeloque 
and Kluge rated it at more than fifty per centum, Rokitanski at forty- 
one, and Hemming, Jones, Churchill, and Smith at twenty, the com- 
parison of our later-known results with the unknown of the remote 
past does not conduce to a verv high appreciation of the progressive 
improvement in the operation of craniotomy. If, however, the ques- 
tion of mortality be studied chronologically, it will appear that the 
death rate of mothers has diminished with the lapse of time and ad- 
vance of obstetric science, and that it is now less than at any former 
period. It must, nevertheless be admitted that whilst the mortality 
of mothers has been diminished by the more dexterous performance 
of the operation and the better management of the eases, the relative 
proportion of fecticides has greatly increased, and the sum-total of 
* fn view of the advantages of antiseptics in surgical operations, this standard may 
be unfavorable to craniotomy, but as the oby ct is to illustrate the fact that It is at- 
tended with a mortality, not now possible to ascertain, it answers the purpose. 6 
TRANSACTIONS OF THE OBSTETRICAL AND 
lives lost and sacrificed has been greater during the present than 
during any previous century since the operation was devised. The 
more frequently the operation is performed on the living fetus the 
greater the number destroyed, for half of the lives imperilled must 
necessarily be sacrificed, and the chances of saving the remaining 
half can only be enhanced by a percentage equal to the death-rate of 
the mothers, whatever that may be. The most expert and experi- 
enced operator cannot save more than half the lives at risk, and the 
more dexterous the greater the number of ventures, consequently the 
greater the loss and sacrifice of life. No one has or can hope to attain 
the success of saving a possible fifty per centum of the lives at 
stake. 
Just here I will be confronted with the statement of those who have 
performed one, two, three, four, or five craniotomies without the death 
of a mother. The assertion of such a fact is probable proof that the 
operations were hasty and unnecessary. The successful craniotomist, 
more often influenced by ambition than judgment, and dazzled by the 
desire to gain an additional success, precipitates the death of the 
fetus that the dangers of delay may be avoided. If it is justifiable 
during the lifetime of the fetus, it is best to proceed to its execution 
before the exhaustion of the patient by ineffectual efforts, and before 
the contusion of the soft parts incident to attempts to effect delivery 
by the more conservative intrapelvic methods. But if such a rule 
should become the established practice, it is only the exceptional few 
who can avoid the guilty killing of a human being in cases where de- 
livery of a living child might have been accomplished per vias natur- 
ales. Even so distinguished an obstetrician as Albert Smith ~ relates 
a case where a living child was born while the messenger had gone 
for the instruments of death, and more than once the shocking illus- 
tration of bungling haste has been exhibited in the cries of a mangled 
infant. 
Craniotomy offers no hope, not even a ray of the promised life to the 
unborn, but proclaims from the altar of professional justification death 
by violence to the fetuses of women who are physically incapacitated 
to give birth to a living child. Nay, more, it offers immunity from 
the travail of labor, and protection from the annoyances of maternity 
to those who have accepted the pleasures of concubinage or wedlock, 
and have become copartners in the creation of a new being and a new 
soul to live forever, but who cannot complete the highest and noblest 
purpose of woman's creation. So repulsive does it present itself in 
this aspect, that many who have advocated and performed it recoil 
from its repetition upon the same woman. The renowned Meigs f, who 
had twice successfully delivered Mrs. Reybold, refused to incur the 
responsibility of a third operation ; Gibson subsequently twice de- 
livered her by Cesarean section of a living child, and she lives to day 
*Med. Times, March 10, 1883, p. 412. 
f Prof. Charles D. Mieg's. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
7 
in the ripeness of a happy old age in the en joyment of two children 
and six grandchildren.* 
With such a showing it must follow that the operation is detestable 
where a living child is at stake. If so, is it entitled to a place among 
the scientific surgical procedures of the present time ? Does the fact 
that in a limited number of those cases where the mother's life only 
is in peril, an early and skilful performance secures a reasonable 
prospect of recovery, give it such a place? Must this one fact, the 
only one in justification, and always embarrassed by the probability 
of repetition, and the consequent variations in the chances of success, 
counterbalance the enormity of deliberately taking the life of the 
unborn ? To admit this in the fulness of its import is to concede that 
intrauterine life forms no part of the heritage of human existence, 
and that the violent destruction of a new being just at the moment 
when nature has completed the processes which fit it for an inde- 
pendent life, is a matter of such trivial concern that it can be deter- 
mined upon the probabilities of enhancing the prospects of the wo- 
man's recovery. 
If craniotomy is justifiable, science and the good of mankind demand 
that the limits of its application should be definitely fixed. This 
question is now engrossing the attention of some of the ablest and 
most conscientious members of the profession. It cannot be disposed 
of by words or sentiment, but must be settled by an examination of 
the facts derived from an intelligent experience, and an impartial 
study of the complications of labor and the methods of relief. 
It matters not whether craniotomy is, or is not, the most ancient of 
obstetric operations ; in a scientific aspect all the other methods and 
procedures, which have for their purpose the saving of the lives of 
both the mother and child, must be regarded as its substitutes. 
These may be divided into intra and extra-pelvic. Under the first 
must be classed delivery by the forceps, by turning, the induction of 
premature labor, and symphysiotomy ; under the latter, the Cesarean 
' section and its substitutes, laparo-elytrotomy, the utero-ovarian 
amputation, and the total extirpation of the uterus, in all eight. The 
mere enumeration of this number of obstetric devices, and the con- 
stant and persistent efforts to improve and popularize them, consti- 
tute a. reasonable presumption of a widespread detestation of craniot- 
omy, and the present revival of interest in, and discussion of the 
relative merits of the extra pelvic methods, and their advantages over 
craniotomy, would seem to be conclusive against its continued ac- 
ceptance as a scientific procedure, and relegate it to the class of des- 
perate expedients, of doubtful propriety under any circumstances. 
* Several of the subjects of Cesarean delivery have reached advanced life in the 
United States, the oldest known being sixty-eight and seventy-four years respectively. 
Several of the children have been heads of families, and one in this citv [Philadelphia] 
is now forty-eight years old, and has given birth to eight children, three of whom 
have grown up. Medical News, October 13, 1883, p. 411. 8 
TRANSACTIONS OF THE OBSTETRICAL AND 
According to Tyler Smith, about half of the cases of craniotomy are 
occasioned by contraction of the pelvis. This estimate is too low. 
The great improvement in the forceps, and greater dexterity acquired 
in the execution of the intra-pelvic substitutes, have vastly lessened 
the field of application formerly claimed for it, other than in cases of 
pelvic deformity. This. I believe, is now universally conceded by 
competent authority. And, even in very many cases of faulty pelvis 
to which, until recently, it was applicable, the better result to mothers, 
now obtained by other methods, have entirely excluded it. 
In the justo-minor or equally contracted pelvis, it is inadmissible. 
In support of this statement, I need only quote two recent authors. 
Lusk, in 1879, reported* a case in which the conjugate diameter 
measured, in the dried specimen, three and one-sixth inches, crani- 
otomy proved fatal. In his review of the subject, he could find but 
five recorded cases of " generally contracted pelves, in which the con- 
jugate ranged from three to three and a quarter inches, and all died 
as a consequence of delivery through the natural passages." In the 
same paper he refers to the case of Korman, nearly identical with his 
own. in which, "after more than three days' labor, the head adapted 
itself to the pelvis, and the child was delivered alive by forceps. The 
mother died of peritonitis." Even in cases of such extreme general 
contraction, nature and the timely application of the forceps have 
yielded better results than craniotomy. In discussing the proper 
management of such cases, he says that laparo-elytrotomy, which had 
been recently revived by the "genius of Thomas and the daring of 
Skene." is peculiarly fitted to such conditions, and concludes with the 
assertion that, after a careful study, he is convinced that " where 
there is a diminution of nearly an inch in all the diameters, Cesarean 
section or, probably, laparo-elytrotomy holds out the best chances of 
success." 
Professor Isaac E. Taylor, in a masterly paper on the equally faulty 
or justo-minor pelvis, recently published,} asserts that "in almost all 
the cases recorded of equally faulty or contracted pelvis, when the 
diminution is from three-fourths to one inch, both mother and child 
are lost." In considering fhe treatment he declares, with marked 
emphasis, that the loss of lives of mothers by craniotomy and cepha- 
lotripsy in such cases, when the diminution is from three-fourths to 
one inch (and the total loss of life to the child even in the minor de- 
gree of lessening of from one-third to one-half inch) is so disastrous 
that a conscientious discharge of duty demands the substitution of 
Cesarean section or some of its modifications, or symphysiotomy even 
in the minor degree of one half inch. In the higher grades of contrac- 
tion a more appalling presentation than by either of these operations 
could not exist. In the justo-minor pelves craniotomy is inadmissible. 
The most common form of deformed pelvis is the simple flat, rickety 
or non-rickety, in which the faulty condition is mainly in the conju- 
* Gynecological Transactions, vol. iv., p. 358. 
+ Am. Joub. Obst., Aug., 1883, p. 811. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
9 
gate diameter, hence it is usual to discuss the relative applicability of 
the various methods of treatment with special reference to the meas- 
urements of the conjugate. There is not, perhaps, living to-day a 
single obstetric authority of accepted repute who will claim the prac- 
ticability of craniotomy in cases where the conjugate is one and a 
half inches or less. Indeed, but few hold it justifiable when the con- 
jugate is two and one-half inches or less. Parry, as early as 1878,* 
demonstrated that in pelves with a conjugate of two and one-half 
inches or less, craniotomy gave no better results to mothers than 
Cesarean section. When the total number of lives at stake is consid- 
ered, the results are vastly less favorable than from Cesarean section, 
even when performed under disadvantageous conditions, for one-half 
of the lives are certainly sacrificed by the murderous operation, and 
in those pelves where the conjugate is less than two and one-half 
inches Cesarean section is preferable whether the fetus is dead or 
alive. "As much as I have advocated," says Taylor, " craniotomy in 
preference to Cesarean section, in simple flat pelves, in my former 
papers on craniotomy and cephalotripsy, I am constrained to believe 
that one of the external operations, as the Cesarean section, or 
laparo-elytrotomy, early performed, or symphysiotomy when the 
labor is more advanced and the head w'edged in the cavity, should be 
selected." In fact, in the light of recent experience and the improved 
results obtained from the intra and extra pelvic substitutes, profes- 
sional opinion seems to be rapidly approaching the definite conclu- 
sion, that when the conjugate is less than two and one half or two 
and live-eighths inches, craniotomy is absolutely inadmissible. 
"As we have," says Montgomery, in a very able paper read before 
the Philadelphia County Medical Society.! but three-fourths of an 
inch between three and twenty-five-hundredth inches, the maximum 
diameter at which craniotomy is supposed to be necessary, and two 
and one-half inches, the minimum diameter, in which it is safer for 
the mother than Cesarean section, we have certainly reached a period 
when we are justified in abolishing the murderous operation of crani- 
otomy from the list of elective operations when the fetus is still alive." 
In the same paper, with equal ability and fairness, he discusses the 
relative advantages and merits of other alternatives, and reaches the 
following conclusions, which I accept in their entirety. These meth- 
ods are equally safe to the mother, and afford the child a chance for 
life. They are suggested in the following order : Where the conjugate 
measures three and one fourth inches or over, the forceps; two and 
three-fourths or over, version ; two and three eighths or over, symphy- 
siotomy, followed if necessary by the forceps. In all subsequent 
pregnancies, and in the first, when distortion is discovered sufficiently 
early, premature labor should be induced." 
I need not pause to portray the value of the forceps. Perhaps no 
* Amer. Jour. Med. Sei., vol. Ixxiv.', 1878, p. 323. 
+ E. E. Montgomery, Medical Times, March 10, 1883. p. 387. 10 
TRANSACTIONS OF THE OBSTETRICAL AND 
other instrument ever invented has contributed as much toward the 
alleviation of suffering, and saved so many lives. It is almost univer- 
sally recognized as both a mother's and a child's instrument, and it is 
a significant fact that those who most frequently use forceps have 
least occasion to resort to either of the deadly expedients. The dan- 
ger, if any, is not the result of their application, but of delay in using 
them. 
When the conjugate measures between three and one fourth and 
two and three-fourths inches,* version offers greater prospect of 
success than craniotomy. The mortality of version has been gener- 
ally estimated at one in sixteen of mothers and one in three of chil- 
dren. This is believed to be too high ; but whatever it may be it is 
in marked contrast to that of craniotomy, even when the latter is 
limited to like conditions of pelvic deformity or other causes of ob- 
struction in which either is claimed to be admissible. The mortality 
in cases of version is not, however, due wholly to the method, but 
quite as often to the causes which indicate it, as in placenta previa 
and rupture of the uterus, which may make it speedily imperative. 
The induction of premature labor offers a more decided antagonism 
to craniotomy, because it is specially applicable in those conditions 
of pelvic distortion in which the craniotomist insist the latter opera- 
tion is the proper elective proceduie. Its application lies within the 
limit of two and one-half inches minimum, and three and one-half 
inches maximum measurement of the antero posterior diameter. It 
is conceded that a viable child cannot be extracted through a pelvis 
with a conjugate less than the minimum, and that a living child at 
full term can be delivered through the natural passages with a pelvis 
measuring not less than three and one-half inches antero posteriorly. 
Ritgen has constructed from the various measurements of the size of 
the head (quoted from Montgomery), at different periods of utero- 
gestation the following table showing the application of induced 
premature labor after the period of viability, to various grades of 
pelvic deformity. He says labor may be induced at the 
29th week, when ant. post, diameter of pelvis is 2ZZ 7ZZZ 
f 30th " " " " " " " 2ZZ 8/zz 
31st " " " " " " 2ZZ 9ZZZ 
35th " " " 11 " " " 2ZZ 10zzz 
36th " 2/z JJZZZ 
- 37th U U " U " U 3,z 0ZZZ 
From statistics of artificially induced premature labor, in cases of 
pelvic deformity, which J collated some years ago, when studying the 
value of the procedure in aggravated uremia, I determined the mater- 
* In pelves whose conjugate ranges from 2.75 to 3.25 inches, turning should be the 
initial step.-Goodell Amer. Jour. Obstets., vol. viii., p. 215. 
+ Kiwisch says 2i inches conjugate is necessary for a viable fetus at 30th week to pass 
safely. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
11 
nal mortality at five and twenty-seven hundredths per cent., and that 
of children at forty per cent. In these figures were included a large 
number of operations performed in the interest of the mother and 
under conditions which necessarily sacrificed the life of the fetus. 
With the improvement in the management of such cases greater 
safety has been secured to mother and child. 
It thus appears that the induction of premature labor covers the 
exact limits of pelvic obstruction, and offers better results than crani- 
otomy. It will, however, be said that, as a rule, it can only apply to 
second and subsequent pregnancies, because the incapacity will not 
have been discovered until labor has begun. This, unfortunately, is 
too true ; but it is not an argument against the induction of prema- 
ture labor, or in favor of the practice of craniotomy. It is simply proof 
of failure or neglect to ascertain the fitness of the pregnant woman to 
give birth to a living child per vias naturales, before it is too late to 
advise her, and to adopt the means science offers for the better pro- 
tection of herself and her offspring from the dangers incident to her 
condition.* 
I must express my detestation and abhorrence of the widespread- 
ing vice of criminal abortion. I hold with that most eminent man 
and pious physician, the elder Hodge, that conception brings into ex- 
istence a new being and an immortal soul, and that it is alike criminal 
in the mother and in the physician to employ means to destroy that 
being that sin and shame may be concealed or pride maintained. No 
reputable and conscientious physician wiil engage in or connive at 
the criminal production of abortion. Does the crime consist in the 
performance of the operation, in the effort to conceal vice, hide shame, 
prevent disgrace, obviate the discomforts of maternity, or in the de- 
liberate act of killing ? If in the latter, then tell me where the obliga- 
tions of professional duty cease and crime begins ? To me abortion 
as a substitute is equally as reprehensible as craniotomy. It cannot, 
however, occupy a place among the conservative methods, for in those 
cases in which pelvic deformity will not afford a chance to a viable 
fetus, craniotomy is conceded to be inapplicable. 
The revival of the invention of Sigault, by Professors Morisani and 
Novi in the Neapolitan hospital for incurables has supplied another 
conservative"procedure, which promises most favorable results. Har- 
ris! informs me that in the last twenty one years seventy-one opera- 
tions have saved fifty-three women and fifty-five children. This 
result "is equal to that of early performed Cesarean section under 
favorable circumstances 11 It has been alleged that symphysiotomy, 
even when the pubic joint " was opened to the extent of three inches, 
* There have been as many as sixteen children sacrificed in the successive labors of 
•one lady in this city [Philadelphia], each head having been locked in her pelvis, which 
was small but not deformed; a seventeenth was saved, by an accident inducing labor, 
when she was eight months pregnant.-Harris, Amer, Jour. Med. Sei., vol. Ixxxv.., p. 31, 
+ Personal communication, Dec. 22,1-887. 12 
TRANSACTIONS OF THE OBSTETRICAL AND 
without impairing or injuring the sacro-iliac joint, only three or four 
lines at most could be gained." This is true in regard to the antero- 
posterior diameter, but the transverse and oblique diameters (Taylor, 
Harris) " are increased to the extent of one inch for the cavity and in- 
ferior strait." If the conjugate is not materially lengthened, the cav- 
ity is greatly amplified.* This amplification is what is needed to 
effect delivery in the class of pelvic distortions which have been con- 
sidered. If necessary, delivery may be facilitated by the forceps.f 
In fact, symphysiotomy, premature labor, and the forceps may be 
combined, and the delivery of a living fetus accomplished without 
detriment to the mother. The pubic section is not. however, recom- 
mended when the conjugate is less than two and five-eighths inches,j: 
and consequently does not cover the precise limits of three-fourths of 
an inch between two and one-half and three and one-fourth, in which 
its advocates claim that craniotomy is, par excellence, the elective 
operation. 
If I should rest the argument here, it might be maintained that 
version, the induction of premature labor and symphysiotomy failed 
to supply sufficient opportunities for delivery between those limits 
only separated by a fraction of an inch, and that craniotomy would 
be equally preferable in conditions of pelvic obstruction other than 
those caused by bony deformity, as in those cases where version or the 
forceps had proved ineffective. Its advocates cannot be permitted 
to cover retreat even under such ambiguous assumptions. The im- 
portant and substantial improvements in the external methods leave 
it without justification even as an ultimate resort in these debatable 
conditions. 
The Cesarean section and its substitutes offer additional preferable 
procedures. The weight of the later and more recent authorities, 
other than the British, is vastly in favor of this operation when the 
conjugate is one and one-half inches or less. In fact, it cannot be said 
that craniotomy competes with it when the conjugate is two inches 
or less, and even when the measurement reaches two and one-half 
its performance is considered by some of its warmest adherents of 
* In Naples, the section is made subcutaneously with the probe-pointed and sickle- 
shaped bistoury of Galbiati. An incision is made above the pubis, and the knife slowly 
passed behind the symphysis until it reaches the pubic arch, when the ligaments are 
divided from below upwards. The pelvis is not forced open, neither is the fetus turned 
or dragged upon, but when the head presents, the case is left mainly to nature. Tn 
about one case out of four the forceps are applied. The incised part is treated anti- 
septically, and by Irrigation if in warm weather. And as soon as convenient the ossa 
pubis are kept in apposition by an immovable apparatus, to secure an early union of 
the severed parts.-Harris, loc. cit.. p. 27. 
tin the new symphysiotomy of Naples, version is never used, hence the escape of 
pelvic injury, and the diminished fatal death rate. 
Jin the cases reported, the conjugate ranged between three and one-quarter and two 
and one-half inches. Raffaele reports for Morisani a case operated on at the beginning 
of the eighth month in which the conjugate measured only two and three-sixteenths. 
The patient, forty days after the operation, walked without inconvenience. Labor 
was artificially induced, and the woman delivered herself. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
13 
doubtful propriety.* If the relative merits of the two methods are to 
be studied with impartiality, they ought to be measured by their re- 
spective results in like conditions of pelvic obstruction below the 
maximum conjugate at which either is admissible, and not by exclud- 
ing from the mortality of craniotomy its disastrous results to mothers 
in the higher grades of diminution of the conjugate and the total loss 
of children at all grades. It does not subserve the purposes of science 
to limit one to an elective sphere of very narrow proportions, where 
even its best results will not save fifty per centum of the lives im- 
perilled, and compare such percentage of maternal recoveries with 
those obtained from Cesarean section and its substitutes extended 
over a far larger field, and applied to less favorable conditions. But 
even this method of investigation does not present the external opera- 
tions performed during the past five years in a less advantageous 
aspect than craniotomy. Harris has shown that when Cesarean sec- 
tion has been performed during the first twenty-four hours after labor 
has begun, seventy-four per cent, of women f were saved and eighty- 
one per cent, of children delivered alive. Deufeillay (Lusk) has shown 
that in timely operations eighty-one per cent, of mothers are saved. 
In the Santa Caterina of Milan, and the Krankenhaus of Vienna 
(Harris), the Porro-Cesarean operation has saved seventy-three per 
cent, of women and all the children. The application of antisepsis 
has so greatly improved the results in other abdominal operations 
that no one can doubt that it will prove equally beneficial in these. 
This seems to have been already demonstrated by the immensely 
(Eustache) more favorable results to both mother and child which 
have been achieved in recent years. "The effects of antiseptic (Har- 
ris) measures and greater cleanliness have been shown by the results 
of the Porro and other capital operations in large lying-in institutions, 
and in nothing more than the entire change of results in the two mat 
ternities of Naples, in which the old and the new pubic sections have 
been performed. Perhaps no tabular record of Italian surgery is so 
much to the point in exhibiting the possible variation of results from 
unfavorable to favorable as that prepared upon the first, second, and 
third hundred ovariotomies by Dr. Peruzzi. From having lost nine 
of the first operations in succession before achieving one success, they 
have gradually improved in results until now the mortality is reduced 
to a moderate percentage." 
Even when limited to the narrow area of its chosen field of election, 
craniotomy can never save the percentage of lives already obtained 
* According to the investigations of Parry, whose decision I have verified by my own 
researches, craniotomy has scarcely a fractional advantage in saving life over gastro- 
hysterotomy in cases where the conjugate diameter of the superior strait measures two 
and one-half Inches or less, and not even this claim when the latter is performed, as it 
should be, very early in labor.-Harris, Amer. Jour. Med. Set, vol. Ixxvii., p. 46. 
+ Of the one hundred and thirty-two operations performed in North America prior to 
July, 1882, forty-five and five-elevenths per cent, of women were saved.-Harris, Amer. 
Jour. Med. Sci., vol. xxxiv., p. 155. 14 
TRANSACTIONS OF THE OBSTETRICAL AND 
by gastro-hysterotomy and its modifications, nor can it ever attain 
the brilliant results of the Porro substitute, which for the whole num- 
ber of operations has saved forty-five and five-eighths per cent, of 
mothers and seventy-seven and one-twelfth per cent, of children. In 
fact, from a later classification by Harris (Amer. Jour. Med. Sei., Oct., 
1883, p. 438), it appears that the Porro operation, carried out as origi- 
nally designed, has saved 46 14-41 per cent, of the cases, the Porro- 
.Miiller method, unmodified, has saved 52 16-17 per cent., and the two 
combined 48 8-29 per cent, of women, and 90 out of 118 children.* In 
view, then, of the greater number of lives saved, and. in fact, when 
all the conditions and circumstances are impartially considered, the 
greater number of mothers saved, the classical Cesarean section and 
its modifications and substitutes must be regarded as conservators of 
life. But this is not all; Cesarean section may restore to women in- 
capacitated by pelvic deformity the privilege and power of giving 
birth to an indefinite number of living children. Lungrenf has shown 
that in one hundred and nineteen multiple operations upon forty- 
eight women, there were only eight mothers lost. In three of these 
cases, the operation was performed seven times, in two six times, in 
one five times, in three four times, and in three three times, all of 
which recovered. The Porro modification has not only saved a larger 
percentage of lives, but prevents subsequent pregnancies, and there- 
fore in such cases there cannot occur such successive repetitions of 
craniotomy as related in the case before cited. In the face of such 
facts, can the most enthusiastic craniotomist continue to class the 
operation among the elective procedures ? J It has been alleged that 
in occasional instances women have after one craniotomy given birth 
per vias naturales to living children, and such is probably true ; but 
it only proves that either the operation was hasty and unnecessary in 
the first pregnancy, or that the obstruction was due to disproportion 
of the fetal head, or to impaction of the foetus in a transverse posi- 
tion. The rule is that each subsequent fetus has been killed and mu- 
tilated, as in the case cited by Harris (see note, page 11), or one of the 
external operations has been finally resorted to, as in the ease of Mrs. 
Reybold, with equally satisfactory results.g 
It is not necessary in this connection to discuss the relative merits 
of the classical Cesarean section and its substitutes, nor to point out 
* The Sanger operation in Europe saved forty women and forty-eight children out of 
the first fifty, in chronological order, and the Porro twenty-one in fifty.-Harris, per- 
sonal communication, Dec. 22.1887. 
+ Amer. Jour. Obstet., vol. xiv., p. 78. 
7 Keyser estimates the mortality from second operations on the same woman at 
twenty-nine per cent.; in the United States it has been twenty-five.-Harris, Amer. 
Jour. Med. Sci., vol. Ixxli., p. 61. 
§ We have had women in this country who have endured several hours of suffering 
under craniotomy, and narrowly ascaped with their lives, who were afterwards deliv- 
ered safely of living children by gastro-hysterotomy.-Amer. Jour. Med. Sci., vol. 
Ixxvii, p. 59. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
15 
the indications which should give one or the other the preference. 
Garrigues,* Harris, and others have so fairly and ably reviewed these 
questions that, even if relevant to the present issue, I could afford to 
pass them with this reference. 
Nor is it necessary that I should review in detail the comparative 
merits of craniotomy and its alternatives in the minor and rarer forms 
of obstruction to labor. In the very rare forms of pelvic distortion, 
as in the oblique-ovate, the Cesarean section is generally most strongly 
advocated. The time has probably passed when any one would hold 
craniotomy on the living fetus justifiable in cases of cancer of the 
cervix uteri or advanced phthisis. The results in either case are 
equally, if not more, favorable when left to nature unaided, or, at 
most, assisted by the forceps or version. In transverse positions, Har- 
ris has shown that in the United States twelve Cesarean sections have 
yielded nine successes. But neither cancer, malacosteon, exostoses, 
or uterine fibroids contraindicate Cesarean section or its substitute. 
In pregnancy complicated with fibroid tumors of the uterus, it has, 
however, proven very unfavorable in this country, because of the at- 
tending exhausting hemorrhage ; yet in some it is not only the best 
but the only possible operation (Garrigues), as in Sanger's case, where 
a fibroid as large as a child's head sprang from the posterior wall of 
the cervix. 
Prof. G. Eustache (Lille, Belgium) concludes a paper on the " Par- 
allel between Embryotomy and the Cesarean Section," read before 
the London International Congress, as follows : " Considering, on the 
one hand, (1) the recent results of ovariotomy and of all other abdom- 
inal sections, (2) the improvement in the prognosis of all surgical in- 
juries under antiseptic treatment. (3) the successor Porro'soperation, 
(4) the immensely favorable results both to mother and child after the 
Cesarean section, which have been published during recent years." 
"And considering, on the other hand, that embryotomy while it 
always sacrifices the child, exposes the mother to as grave dangers as 
the Cesarean section ; that it is inapplicable in many cases of de- 
formed pelvis, e. (/., when the conjugate is five centimeters and 
under." 
" I. When the child is living at the beginning of labor, and when 
the pelvic strait is under seventy-eight mm.-the extreme limit for the 
application of the forceps-the Cesarean operation should be per- 
formed earlv, that is to say, as soon as labor has really set in, and with 
antiseptic precautions." 
" II. When the child is dead and the superior strait measures five 
centimeters recourse should be had to embryotomy. Below five cen- 
timeters the Cesarean section becomes an operation of necessity." 
" To sum up, the Cesarean section should be the method of election, 
embryotomy that of exception." f 
* Amer. Jour. Obstet., vol. xvi., p. 337. 
+ Amer. Jour. Obstet., vol. xiv., pp. 944-5 16 
TRANSACTIONS OF THE OBSTETRICAL AND 
Harris * struck the keynote of success when he wrote "that the first 
and most important step is to make the operation one of anticipation 
and choice rather than one of dire necessity and last resort." The 
largely increased percentage of recoveries in the timely operations has 
demonstrated beyond dispute that delay is the chief factor of danger. 
The exhaustion of the patient and bruising of the soft parts by long 
continued ineffectual efforts to accomplish delivery through the nat- 
ural passages have, in very many cases, destroyed every prospect of 
recovery before the operation was begun. "A very early operation 
(Harris) in the United States will save three out of four women and 
as many children ; a moderately late one will lose about two out of 
three, and one-half the children ; and a very late operation, that is 
from three to fifteen days or more aftec the commencement of labor, 
will lose three, four or five to one, according to citcumstances." j- The 
application of antisepsis,j: improvements in the method of operating, 
management of the uterine wound, and subsequent treatment of the 
patient have contributed largely to the better success. And to-day 
the prospect is so encouraging that even the most skeptical will soon 
be compelled to accept the results as conclusive. 
So much for the obstetric and surgical substitutes for craniotomy. 
There is another plan of treatment even more conservative than 
either of the procedures heretofore considered. Nature, says Lusk,§ 
will, under favorable circumstances, in all but the extreme forms of 
pelvic contraction, "do her own work with the least expense of in- 
fant life, and with a relative small maternal mortality." He cites the 
fact that, in cases of contracted pelvis in the Dresden, Leipsic and 
Breslau Maternities, "four hundred and seven spontaneous deliver- 
ies took place with the loss of fifty-three children, and, from puer- 
peral diseases, of twelve mothers, the latter representing very nearly 
the usual mortality in lying-in hospitals." By favorable circum- 
stances he means a "presentation and position of the child's head 
suited to the form of the pelvis, and a sufficient degree of uterine ac- 
tivity." I have previously incidentally referred to unnecessary and 
hasty craniotomies and to the dangers of delay in the performance of 
its substitutes. These can only be avoided by a careful and accurate 
study of the existing conditions, based upon a complete knowledge of 
the obstacles presented and applicability of the methods of procedure. 
The wisest course will always yield the best results, but where to in- 
terfere and how to proceed are not always either easily or quickly 
determined. Human judgment, even when supported by intelligent 
experience and the highest scientific attainments, is not infallible. 
The expectant plan of treatment is not mere guess-work, or the hap- 
hazard conclusion of the tyro, but the deliberate judgment of one who 
* Amer. Jour. Med. Sei., vol. Ixxxiii., p. 374. 
+ Amer. Jour. Med. Sei., vol. Ixxvil., p. 62. 
$Garrigues, Amer. Jour. Obstet., vol. xvi., p. 508. 
§ The Science and Art of Midwifery, p. 476. GYNECOLOGICAL SOCIETY OF WASHINGTON. 
17 
knows what not to do, as well as what to do, and when to do it. It is 
not the sloth of idle expectations, but the masterly inactivity of ex- 
perience, discretion, and knowledge. 
But, after all, the question hangs upon the right of election between 
two lives at stake. Just so long as this right is maintained just so 
long craniotomy will have its advocates and operators. The law of 
justification will always be invoked to cover the plea of necessity. If 
the life of the mother could certainly and only be saved by the killing 
of her fetus, and the death of both was otherwise inevitable, the exe- 
cution of the child might be justifiable as the only alternative. But 
no such relation of conditions ever did or can exist. Unless delivery 
is accomplished, both lives will be sacrificed, but the killing of the 
fetus is not necessary to, and does not guarantee, the recovery of the 
mother. Neither are the two lives in equal danger. Either may be 
saved with or without the saving of the other. Craniotomy offers no 
chance to the fetus, but a reasonable prospect of recovery to the 
mother. Its substitutes offer three out of four chances to the fetus, 
and quite equal, or, at most, but slightly lessened chances to the 
mother. Then it must follow that this right of election subordinates 
the life of the fetus and the larger number of lives to the possible en- 
hancement of the chances of life to the mothers, and relegates the 
resources of obstetric science, which offer in the aggregate largely 
more favorable results, to the category of methods of dire necessity 
and almost hopeless resort. It is not then the greatest good to the 
greatest number, but the offer of possibly improved prospects to the 
chosen few. Is that the humanity which the science of medicine 
should espouse and proclaim to the world as an illustration of its be- 
neficence ? 
This right of election is furthermore based upon the alleged greater 
value of the life of an adult woman than that of her unborn child. 
By whom, and in what manner, is this valuation to be estimated ? Is 
it a mere matter of trade and business to be determined always in 
favor of one because the future and possibilities of the other cannot 
be known? Are social position, personal qualities and domestic re- 
lations commodities of value to be purchased at the cost of the life of 
the unborn ? But it so happens that one such life would rarely liqui- 
date such indebtedness. If the right to take life on such a pretext is 
indisputable, the number of such sacrifices can only be determined 
by the number of subsequent pregnancies, and the breeding and kill- 
ing may go on at the pleasure of the woman and will of the execu- 
tioner. Even the most uncompromising advocate of the murderous 
operation could not view such a picture without the utmost abhor- 
rence. 
The relative value of two lives cannot be the only arbiter, for every 
life is of equal value to every holder. It is true that the fetus has not 
gained an independent existence. It is, nevertheless, true also that 
in these cases it is the life of a woman who cannot give birth to a liv- 
ing child per vias naturales. And such incapacity is the one and only 18 
TRANSACTIONS OF THE OBSTETRICAL AND 
claim of right to destroy the fetus. Can such a right rest exclusively 
upon such a basis, when it is established that other procedures offer 
almost, if not quite, equal chances of the mother's recovery, and res- 
cue the larger number of children imperilled ? 
It is, moreover, claimed that a mother's life is above and beyond 
any and every consideration of a fetus in utero. A specious subter- 
fuge ! But very few, if any, such women could ever become mothers, 
unless the delivery of a living child is accomplished by one of the con- 
servative methods. Not one of the forty women cited by Lungren 
could ever have had a child to foster, or could ever have experienced 
the first pleasure of a realized maternity, but for the Cesarean section 
or one of its substitutes ; and the woman who had submitted sixteen 
fetuses to destruction might have added one or more but for the timely 
accident which Providence interposed as its expression of abhorrence. 
It is also alleged that the law of moral responsibility imposes the 
obligation of professional duty to destroy the fetus that the chances 
of the woman's recovery may be improved. In timely Cesarean sec- 
tions seventy-four per cent, of women, and eighty per cent, of chil- 
dren ; in the recent Porro-Cesarean operation seventy-three per 
cent, of mothers and all the children have been saved; and in 
the first fifty Sanger operations eighty per cent, of mothers and 
ninety-six per cent, of children have been saved. These results 
are comparable with eighty per cent, of recoveries of women and loss 
of all the children after craniotomy. It may be that if the comparison 
were based upon the results of craniotomy during the last few years, 
it would be less unfavorable. Surely such a law or duty cannot find 
its vindication in such data, and its supporters must seek some other 
defence than results. If such a law or rule of conduct has any founda- 
tion at all, it is the unwritten ipse dixit of by-gone periods-the out- 
growth and excuse of a dire necessity, which science never did accept 
and can no longer tolerate. 
The beneficence of medical science consists in the alleviation of suf- 
fering, and the prolongation and saving of life. In the face of the 
facts hereinbefore presented, there can be no rule of morals or of 
duty which clothes it with the prerogative to take life as a mere choice 
of obstetric or surgical procedures, and this too when such choice in- 
curs the responsibility of its repetition, whilst another operation 
might have either prevented any subsequent pregnancy, or fitted her 
to bear living children independent of her physical incapacity. 
If more attention were paid to the saving and more regard held for 
the life of the fetus, more women would be saved. The dangers of 
delay would be avoided, and the life of the fetus would not be lost in 
ineffectual and unskilful efforts to accomplish delivery of a living 
child through the natural passages, when the obstruction precluded 
its possibility. It would demand an early diagnosis of the condition, 
and invoke a more minute and more general study of the causes of 
obstructive labor and the proper methods of procedure. The senti- 
ment of a higher responsibility would be infused, and the pride and GYNECOLOGICAL SOCIETY OF WASHINGTON. 
19 
glory of saving two lives would oftentimes supplant the detestable act 
of killing one and possibly losing both. 
In conclusion, I disclaim any assault upon individual opinion or 
practice. I have endeavored to consider the question in its scientific 
aspect, and entirely free from the influence of ecclesiastical doctrines. 
I fully realize the embarrassment of individual cases when a profes- 
sional brother may be dizzied by the emotional appeals of a false and 
sentimental humanity, and his judgment made to swerve from a 
sound discretion and logical conclusions to the adoption of a plan of 
treatment which the experience of past ages has handed down to us, 
and vindicated by the assertion of the right to take one life rather 
than leave two to die. But, in the interest of a broader humanity 
and a far wider field of usefulness, I would follow the pathway illu- 
mined by science and supported by the results of recent progress, and 
offer chances to two lives rather than take the one which cannot as- 
sure the safety of the other.