| Germany | once in every | 1944 | labors; |
| Paris | ” ” | 1628 | labors; |
| France, at large | ” ” | 1200 | labors; |
| Vienna | ” ” | 688 | labors; |
| England | ” ” | 220 | labors; |
| Ireland, formerly | ” ” | 128 | labors;[141] |
| ” at present, Dublin Hospital, 1854, | ” ” | 105.7 | labors.[142] |
The remarkable difference between the practice on the continent and in England, so suggestive to us in this country, is undoubtedly owing to the fact that in Catholic States greater value is attached to the life of the child than “in Protestant States, as Britain, where the child is always sacrificed to save the mother.”[143] The immense excess of embryotomy cases in Catholic Dublin furnishes no exception to this rule, drawn as they are from hospital practice under Protestant control.
So far proof by deduction. In many cases involving the question of craniotomy, that operation is not required; in some of them, not even the induction of premature labor.
Two classes of cases remain, each affording more direct evidence; those where craniotomy being absolutely indicated if the patient were allowed to go her full time, that operation is, and those where it is not performed.
Craniotomy, being necessarily fatal to the fœtus, is indicated only to save the mother’s life; to be avoided when any other alternative giving the fœtus a chance of life, and not more than equally hazardous to the mother, can be resorted to. Especially is this the case when it is compared with the induction of premature labor, attended as is the latter, despite a certain amount of danger of its own, with great probability of saving the child, and with decidedly lessened risk to the mother; for craniotomy not merely requires the use of murderous instruments, dangerous to all tissues they may approach or be in contact with, but the operation is usually, though often very improperly, delayed till late in labor, and therefore till the mother’s chances of recovery have been proportionally lessened. Premature labor, on the other hand, though of course involving some risk to the child, is not necessarily fatal to it; nor is it usually so, when properly performed. That there is a choice in this respect between the means employed, will hereafter be shown.
Craniotomy, when absolutely indicated at the close of pregnancy, must be for one of two reasons: that the fœtus cannot pass through the pelvis at the full time alive, though it may do so unmutilated, the operation being performed to save the mother the greater risks of protracted labor; or that it cannot pass at the full time unmutilated, even when dead. We defer the consideration of another supposable instance, where the fœtus in the outset of its viability may pass, but not alive, for this pertains to the consideration of the mother’s safety alone, no alternative availing for the child. In the other cases, if the necessity could be learned in season, from the previous history of the patient or by pelvic exploration, labor should most certainly be prematurely induced, as affording some positive chance of life to the child, and as less dangerous to the mother. It were here worse than foolish, if not criminal, blindly to imitate nature, when, her course being obstructed, she would kill the child.
I have alluded for a double reason to cases, fortunately few, where craniotomy, and much more decidedly premature labor being indicated, the practitioner decides from the outset to perform neither, to give his patient or her child no aid. Such conduct is as cruel and wicked as it is unprofessional, and were not instances occasionally reported, its existence could hardly be believed. We acknowledge with Blundell the evils of meddlesome midwifery, but there are extremes to all things; certainly to the powers of nature and the limits of justifiable delay.
I am aware that I have referred to a reported case, which might in this connection be quoted against the opinion now expressed; but even by its exceptions do we prove the rule. Where chances are so greatly against both mother and child as in these cases if left unaided, it would be the office of the physician, were there no better procedure, by craniotomy to save the one;[144] but at the present day it is no less plainly his duty, where possible, to anticipate labor, and thus save both. I have elsewhere discussed this question at some length,[145] and can only repeat, as is indeed allowed by Churchill,[146] that this is no matter on which to select one’s words; the deliberately sacrificing an unborn, but still living child, in cases where statistics go to prove that the adoption of another mode of delivery, nothing counter-indicating, would give that child a good chance of successful birth, is nothing short of wilful murder, no matter by what schools or by what eminent men it may be sanctioned, and it should be branded as such by the profession.
But, undertaken for the child’s sake, not merely should premature labor be resorted to for the purpose of preventing craniotomy, but often in cases of incurable disease, acute and chronic, of the mother, where it is evident that she must inevitably, or even probably, perish before the full period of pregnancy has been attained. Instances of such acute disease will readily suggest themselves. The question here is merely between the operation under consideration, the Cæsarean section, and doing nothing. The last, suppose the fœtus viable and to be still living, would in many instances be decidedly unprofessional and unjustifiable. Cæsarean section after the mother’s death is comparatively unsuccessful; and before it, is so much more severe and in all probability so much more quickly fatal, that the other should be preferred, unless death be already close at hand.