tion. One case is recorded by Dr. Ash well, in which the os uteri
was absent; nor could the first stage proceed, until an artificial
opening was made to allow the head to pass. These are, however,
very rare cases; a more common eflect is the alteration produced
in the vagina.
Sometimes a hand is found crossing the vagina and
preventing the advance of the head. The walls of the vagina are
occasionally united for a certain distance, and, again, a stricture
may be formed in the vagina, just as in the urethra. It is very
necessary to make the most careful examination when a case of
this kind presents itself, because the extent of the injury done
is not always confined to the part which obstructs the head;
partial sloughs of the vagina are just as likely to be the result of
the previous inflammation, and when these have separated, the
portions that have been thus partially destroyed must have been
164 LECTURES ON PARTURITION.
left extremely thin, and badly calculated to resist any extreme
pressure. Thus the vagina may be very easily lacerated if labour
is suffered to continue for any great length of time.* When a
band is formed in this manner, it may easily be divided by a
guarded bistoury, and the obstruction removed ; but when a
stricture is the cause of difficulty, more care is necessary. The
head should be pressed back in the interval of the pains, and
the portion of the vagina above the stricture accurately examined ;
if it be of the visual strength and thickness, or if its density
be increased, it is better to allow labour to proceed, in order
that the head may gradually dilate the stricture ; but if, on the
contrary, the vagina be felt unusually thin, it would be extremely
dangerous to do so, because the head may force its way through
* In a very interesting paper on this subject in the Dublin Journal, vol. xxiii.,
Dr. Doherty states some facts worthy of attention. He mentions one instance of a
" slough of the entire inner surface of the vagina. From the vulva to the os uteri,
not a point escaped; and to prove how care and attention can prevent ill-conse-
quences, even in such a case as this, I would remark, that the patient who suffered
this loss of substance, left the hospital Avith the passage almost as capacious as
before delivery " (p. 67). In another case, where there was occlusion, " There
was no direct communication between the vagina and iiterus; an orifice below the
occlusion admitted the finger into the cavity of the bladder, into which the os uteri
could be felt to project, owing to the destruction of the vesico-vaginal septum also
above the adhesion." This patient was not pregnant.
The advantage of nauseating doses of tartarised antimony in relaxing a rigid vagina.
Dr. D. illustrates by the case of a middle-aged Avoman, who was admitted into the
Dublin Lying-in Hospital in labour of her first child. " On examination, the finger
could be passed up the vagina only with the greatest difiiculty, and Avhen introduced,
felt as if it were surrounded by a cylinder of iron, so thick and hard Avere the Avails of
the canal and perinceum. They seemed in truth not to possess the slightest elasticity ;
so much so, indeed, that I was some time before I could persuade myself that it was
not one of those hard, encysted tumours surrounding the rectum that my finger came
in contact with. And yet all this rigidity disappeared in less than six hours, under
the use of tartar emetic, and the child was expelled Avithout any difiiculty " (p. 69).
" While I deprecate the rashness of operating Avithout a well-marked necessity, I
would at the same time beg to dAvell on the fatal consequences Avhich may ensue
fi'om postponing the use of the knife beyond the moment at Avliich it becomes neces-
sary. Every additional instant then adds to the risk of laceration, and of course
increases the chance of a lamentable termination to both mother and child ; a fact
which was forcibly impressed upon me by a case Avherein the attendant, Avhile sit-
ting at the bed-side Avith the scalpel in his hand, delayed employing it, in order to
afford another practitioner Avho Avas pi'esent, an opportunity of examining the part ;
meanwhile a strong pain suddenly came on, and the vagina was extensively torn (p.
72). In a case of face-presentation, a thick band surrounded the upper portion of
the vagina. This band was nicked in one or two places, the pains continuing of
natural strength and frequency; the face gradually descended, and as it progressed
the remainder of the band appeared to relax, and CA^ery hope Avas entertained of a
fortunate issue, till about tAvo o'clock, p.m., when rupture took place" (p. 73).
the attenuated portion, and perliaps convert tlie rectum and
vagina into one common cloaca. It would be preferable to
divide tire stricture in different places, so that it may yield to
tbe head more readily. When the walls of the vagina cohere,
the case becomes very embarrassing, because they must be
separated ; and yet there is a danger that the vagina may be cut
through, if great caution be not exercised. You have also the
additional difficulty, that it is almost impossible to ascertain
the condition of the vagina behind the portion that is united.
Some risk must therefore be encountered. It is better to allow
the labour to proceed sufficiently far to determine the extent to
which the head may separate the parts adlierent, employing every
necessary means to counteract any inflammation that may arise.
The head may overcome the resistance to a certain extent, so as
to render the division of the remaining portion much safer and
more easy ; but if this cannot be accompUshed, the walls of the
vagina must be dilated, so as to expose perfectly the adhesion
which it is necessary to divide by cautious and frequently re-
peated incisions with the knife.
Ovaviau Tmnouv. — IMerrinian.
Ovarian tumours sometimes descend into the pelvic cavity, and
obstruct the head of the child. If the tumour consist of several
166 LECTURES ON PARTURITION.
cjsts, the smallest may pass down between tlie vagina and rec-
tum; cases are also recorded where very large tumours are
found in the same situation. One of these cases is given by Dr.
Merriman, along with a very accurate drawing of the tumour.
Their contents vary so very much in their consistence and density,
that they are not always easily recognised; but if there be any
sense of fluctuation, or even if the tumour be very elastic, the
probability is, that it is an ovarian cyst, containing fluid more or
less deeply seated. Unless the size be great, it is possible that
the head may press the cyst against the sides of the pelvis, and
pass below it; a small tumour also may be pushed back towards
the brim of the pelvis, when the pains are absent, and perhaps
be prevented from again descending when the action of the uterus
returns; if by neither of these modes the removal of the obstacle
can be accomplished, the only resource left is to puncture the
tumour and allow the fluid to escape. This may be done,
although there be no distinct sense of fluctuation, because the
fluid is often thick, like honey, and may be deep-seated, which
will communicate to the fingers an elastic feel rather than that of
fluctuation. Besides, if a mistake be made, and you should
puncture a polypus or a fibrous tumour, no great injury is done.
It is when the sense of fluctuation is distinct that caution is re-
quired, especially if the tumour should appear towards the pubic
side of the pelvis. The bladder has sometimes prolapsed before
the head of the child, and presented a fluctuating tumour. It is
not necessary to tell you that this should not be punctured. But
the danger of these cases does not generally arise from the deli-
very being obstructed, but from the effect which labour produces
on the disease; the tumour is necessarily exposed to a great deal
of irritation; the patient is weakened if not exhausted by the
struggle which takes place; and, when labour is concluded, she
is quite unequal to combat the effects of that irritation. Dr.
Merriman has collected the history of eighteen cases of ovarian
tumours obstructing parturition. One half the mothers died,
three recovered very imperfectly, and six only may be said to
have escaped; sixteen of the children were still-born, and four
were born alive. I shall quote from Dr. Merriman's work the
results of these cases as he has given them, from which it appears
that the greatest success attended those cases where the tumour
was opened: —
" From the enumeration of tlie cases already referred to, it
" Twice, the labour was effected by the pains, unassisted by the
art of the accoucheur ; but one of these women lost her life, and
one of the children was still-born.
" Five times, the perforator was used after a longer or shorter
duration of labour. Three of these women died, another reco-
vered very imperfectly, and one got well.
" Five times, the labour was terminated by turning the child;
all the children were lost, and only one mother recovered.
" Three times, the tumours having been opened, the labour was
afterwards trusted to nature. Two of these women recovered,
but the other remained for a long time in an ill state of health.
Two only of the children were preserved. In three cases, the
tumours being opened, it was still found necessary to have recourse
to the perforator. One of these women died, one remained in an
ill state of health for eighteen months, and then sunk under her
sufferings; the third recovered."
Dr. Merriman remarks, " Upon the whole, the evidence we at
present possess is more in favour of opening tumours when they
contain a fluid, than of any other mode of procedure, for of the
nine women who recovered more or less perfectly, five appear to
owe their safety to this operation^ and of the children born alive,
two were preserved by the same means."* '
Polypus. — Ramshotham.
Polypus has been found sometimes to interfere with delivery.
An interesting case of this kind is given in Dr. F. Ramsbotham's
* Merriman on Difficult Partiu'ition.
168 LECTUKES ON PARTURITION.
" Midwifery,"* in wliicli the polypus nearly filled tlie pelvic
cavity. However, " tlie moutli of tlie womb dilated rapidly, the
membranes burst speedily, and in less than an hour after my
[Dr. Ramsbotham's] arrival, the head, under the action of
powerful throes, forced the principal bulk of the tumour external
to the vulva (which still, nevertheless, retained its attachment
to the uterus by the stem), and itself instantly followed." f Thus
it is possible that a moveable tumour of this kind, although very
large, may be driven down before the head. If it be small, and
detected early in labour, it might also be in your power to
prevent the tumour descending. It might be pressed back when
the pain ceases, and so retained until the head passes beyond it.
But if neither can be accomplished, if the tumour remain an im-
passable barrier, it should be removed, not by ligature, but by
excision ; the polypus shordd be drawn down as much as possible
by a forceps proper for the purpose, a temporary Hgature applied,
and the stem cut through.
We shall not here enter into a discussion of the comparative
merits of the treatment of polypus by ligature and by excision ;
this must be reserved for another opportunity. But in reference
to the present case, we would only observe that the risk of dan-
gerous haemorrhage after excision is not so great as to justify the
adoption of the only alternative — destroying the child. You
will have little difficulty in recognizing polypus when it descends
so low into the vagina as to interfere with labour. Beside the
firm, fleshy feel of the tumour, it is extremely moveable, and
when the head is pressed back in the interval of the pains, its
pyriform shape and long narrow stem will be more obvious. It
is not Hkely that the ovum could be brought to maturity if a
large polypus occupied the cavity of the uterus; it is, therefore,
fair to assume, that when a polypus is found to impede partu-
rition, it must be attached to the mouth of the uterus, and there-
fore it can be the more easily traced to its origin, so that you
have every facility to assist your diagnosis.
Another cause of obstruction may arise from a fibrous tumour
of the uterus. A remarkable and very interesting case of this
kind is recorded by Dr. Beatty,| in which the tumour was so large
* Ramsbotham's Principles and Practice, etc., p. 237.
t Op. cit. p. 237-8.
'I Dublin Medical Journal, vol. xvii. p. 411.
and apparently so attaclied, as it was tliouglit would render the
Cassarian section necessary. It was agreed, however, to wait, and
to observe the action of the uterus, as long as it might be done
with safety. After some time, and to the surprise of those in
attendance, the tumour appeared to retreat from its situation,
while the child began to occupy its place, and to present its foot :
this was seized, and the dehvery with great difficulty completed.
The child was still-born, but the mother recovered.
OSTEO-SAECOMA sometimes grows from the sacrum. The bony
tumour may be so large as to render delivery per vias naturales
impossible, and therefore the Cassarian section must be had re-
course to. But it may be small enough to prevent this necessity,
although it may be difficult to save the child. A case of this
kind came under my own observation, where a tumour, about the
size of an orange, was connected to the middle of the sacrum; it
was perfectly immovable, and of bony hardness; the head of the
child could not pass it, nor was there the least hope that it could
be drawn by the forceps through the narrow space left in the
pelvic cavity; the head was therefore perforated, and the child
removed: the mother perfectly recovered.
Beside these more usual causes of obstruction to delivery. Dr.
Drew had detailed, many years ago,* two very remarkable cases
of tumours in the pelvis. The first patient, who was not pregnant,
* Edinburgh Medical and Surgical .Tuurual, vol. i. 1805, p. 20.
170 LECTURES ON PARTURITION".
died in consequence of it. An examination was made after death ;
tliere seemed to grow from tlie left sacro-sciatic ligament a
tumour, wliicli " was perfectly round, about sixteen inclies in
circumference, of a fat, gristly substance, without any appearance
of circulation in it." The root seemed to be its principal attach-
ment, because when that was cut through it came away quite
easily. The result of this inspection satisfied Dr. Drew of the
practicability of removing it by operation; and, although a rare
variety of tumour, it so happened that very soon after (as is often
the case) a similar tumour came under his notice when the patient
was in labour.
Dr. Drew states, " It was exactly the same. The tumour
grew out of the right side, and occupied the whole cavity of the
pelvis so completely as to admit of passing only one finger between
it and the pubes, by which I could scarcely reach the head of the
child." Dr. Drew proposed to remove it, which was assented to.
An incision was made through the perinseum, at the right side;
the tumour was exposed, the finger passed before and behind its
root, which was easily divided with a knife, and brought away.
The wound being dressed, labour proceeded, and in six hoiu's, the
head being within reach of the forceps, was delivered safely. The
patient recovered rapidly. These rare cases may present them-
selves : if such should happen, you have sufficient encouragement
not to despair altogether of giving relief.
We have now concluded the consideration of difficult labours,
so far as their causes, symptoms, and general treatment, are con-
cerned. We have directed your attention to cases where the aid
of the vectis, the forceps, or the perforator, is called for. It re-
mains to us, therefore, to consider the mode of applying these
OBSTETRIC OPERATIONS. — THE FORCEPS.
Instruments employed for preserving the Lives of the Mother and the Child — The
Vectis — Of limited Application — Mr. Gaitsldll's manner of using it — Proposed
mode of Operation — Objection to use it as a Lever — The Forceps — Operation with
the Short Forceps when the Head is resting on the Perinasum — Operation when the
Head is in the Pelvic Cavity — Operation when the Head is fixed in the Brim of
In tlie three preceding lectures, we endeavoured to point out to
you tlie situations at wliicli tlie head may be impeded in its pro-
gress through the pelvis, and the varieties in the degree to which
it may be compressed; we were also desirous to place before you
the evidence upon which the conclusions therein stated were
founded, in reference to disputed questions as to the rule of
practice in certain cases of difficult labour. Turning from those
controversial subjects, and, leaving the questions when instru-
mental aid is called for, and what kind of instruments should
be employed, your attention must now be directed to an equally
important subject — obstetric operations.
The instruments employed in operative midwifery may be
arranged into three classes. 1st. Those calculated to preserve the
lives both of mother and child, as the vectis, the forceps. The fillet
was formerly used for the same purpose, but is now discarded
from practice. 2nd. When the preservation of both lives is im-
possible, those intended to preserve the life of the mother by
sacrificing the child. These include, the perforator and crotchet,
the craniotomy forceps, the osteotomist, the cephalotribe. 3rd. When
the delivery of the child cannot be effected even by such means,
and the safety of the mother is more than doubtful, there still re-
mains the operation of opening the uterus through the abdomen, and
172 LECTURES ON PARTURITION.
tlius removing the cliild, witli some cliance, at least, tliat it may-
The rules, therefore, which govern the application of instru-
ments, are founded upon these three principles: — 1st, to preserve
the lives of the mother and the child; if this be doubtful, 2nd,
to preserve the life of the mother, without reference to the child;
and when this cannot be done, or, at least, seems so from the cir-
cumstances, 3rd, to save the child, if possible.
The vectis and forceps belong to the first class. The vectis
consists of a single blade, shaped like a blade of the forceps, only
more abruptly curved, and when used in the manner we have
recommended, it is intended to act as an extractor, to assist the
feeble action of the uterus, to correct malpositions of the head, or
to overcome any unusual resistance of the perinaaum. It is not,
therefore, an instrument of much power, and its use is limited
to the removal of slight impediments to the passage of the head.
The advocates for this instrument do not, however, confine them-
selves to such a restricted application. They employ it as a
substitute for the forceps, and even claim for it a superiority over
the long forceps, in those cases in which the head is arrested in
the brim of the pelvis. We must dissent from such a view of the
utility of the vectis : in order to give to it the same power which
the forceps acquires by the counter-pressure of the blades, an
amount of force must be employed which might be very •
dangerous to the j)atient. Imagine the head fixed in the brim
of the pelvis, the vectis applied to the occiput, the practitioner
using all his strength to extract, and at the same time to keep
the vectis in its position, and the instrument slipping from its
situation into the vagina; by supposing such a case, you can
readily understand our objection. Nevertheless, as the operation
of delivery by the vectis at the brim of the pelvis has received
the support of Dr. Blundell, who recommends the instrument
improved by Mr. Gaitskill, and his mode of iising it, we shall
briefly quote Mr. Gaitskill's rules for applying it in such cases.
After giving directions as to placing the patient, etc., he proceeds,
" The preliminaries being settled, the next thing is, the safe intro-
duction of the instrument. To do this with facility and safety,
the accoucheur should kneel on a pillow by the side of the bed,
and introduce all the fingers into the vagina as far as the brim of
the pelvis, at the side of the sacral promontory (either right or
ME. gaitskill's vectis opekation. 173
left, according to the situation of tlie occiput) ; as lie passes up tlie
instrument the fingers should be gradually withdrawn. The in-
strument is to be pressed up into the cavity of the uterus, being
careful that it is in the inside and not on the outside, gliding it over
the parietal bone till the screw part of the handle presses on the
fourchette of the os externum. This attained, the handle should
now be held firmly in the right hand, while the index and middle
finger of the left, fixed about two inches from the screw part
within the vagina, become a fulcrum. On this fulcrum, or point
of support, the instrmnent is made to move from the sacro-ihac
symphysis towards the hollow of the ilium, by the action of the
right hand on the handle. In this way it describes the section of
a circle, and glides on the occiput. Should the occiput point to
the right ilium , the left hand must be employed ; if to the left
ilium, the right hand must be used. When a labour pain takes
place, the accoucheur should gently aid it by drawing down in the
line of the axis of the pelvis — i. e., an imaginary line, directed
from the umbilicus through the centre of the axis of the pelvis.
In this way the occiput is depressed, while the chin approaches
the child's breast, and its head is reduced to the smallest compass,
and is thus enabled to pass through the cavity of the pelvis. As
soon as the occiput is brought so low as to press on the perinseum,
the instrument should be withdrawn, and re-introduced with the
usual precautions. The object now in view is, to place the in-
strument over the face of the child. To effect this, the hand
must be passed up, as at first directed, to the right or left sacro-
ihac symphysis, according to the situation of the face. When the
instrument gets above the brim of the pelvis, a finger or two must
be inserted by the side of the instrument, and pressed on till it
(the instrument) passes over the forehead on to the face, so as to
embrace the chin. An imaginary line drawn through the centre
of the child's mouth, ear, and occiput, is the present situation of
the instrument, and quite the reverse of what it was before. The
practitioner has now nothing to do but to draw down during the
time of pain, increasing the power according to the degree of
Such is the mode in which Mr. Gaitskill applied it when the
head was high up within the cavity, or in the brim of the pelvis ;
but we confess our fears to recommend to you such a manner of
* London Medical Kepositoiy, 1823, p. 379—381.
174 LECTURES ON PARTURITION.
employing the vectis. The cases in which it may be used with
most advantage, are those in which the head is arrested at the
outlet, in consequence of the uterus being unable to overcome the
resistance of the perinseum. So long as the pains continue with
any regularity and strength, you should not interfere, except for
the purpose of preventing inflammation ; but when the pains be-
come feeble, suspended, or return at long and irregular intervals,
then the vectis may be applied with even more advantage than
the forceps, because there is less risk of injuring the perinasum.
We shall proceed to describe to you the manner of performing
such an operation.
You must first observe those preliminary measures necessary
in all obstetric operations. The urine should be withdrawn from
the bladder by an elastic gum catheter, of rather a large size (No.
10), and without a stilette. It is always safer to use a catheter of
this kind, because there is less risk of injuring the urethra, if it
should be compressed, than if the unyielding silver catheter were
employed. An enema should also be administered, to relieve the
large intestines : and when these points are secured, the patient,
lying on her left side, should be drawn as near to the edge of the
bedstead as possible. The pelvis must be raised more than usual,
and if the patient has been lying on a bed, and not on a mattress,
it would be advisable to place a hair cushion under the hips.
Adopting Mr. Gaitskill's position, you may kneel with one knee
on a pillow, and in the interval of the pains, introduce the first