ever, she became with child, and was admitted a patient into
Store-street Hospital. A vaginal examination was made, and
" immediately upon the introduction of the finger, I [Dr. Osborne]
perceived a tumour, equal in size, and not very unlike in feel, to
a child's head. However, it was instantly discovered that this
tumour was formed by the basis of the os sacrum, and last lumbar
vertebras, which, projecting into the cavity at the brim, barely
left room for one finger to pass between it and the symphysis
pubis, so that the space from bone to bone at that part could not
exceed three quarters of an inch. On the left side of the pro-
jection, quite to the ilium, which was about two inches and a half
in length, the space was certainly not wider, and, indeed, by
some of the gentlemen who examined her afterwards, it was
thought to be rather narrower. On the right side, the aperture
was somewhat more than two inches in length from the protuber-
ance to the ilium, and, as it admitted the points of three fingers
(lying over each other) in the widest part, it might, at the utmost,
be about an inch and three quarters from the hind to the fore
part, but it became gradually narrower, both towards the ilium
and towards the projection."* Such was the pelvis through which




Ovate Pelvis of Elizabeth Sherwood.

Dr. Osborne determined, after consultation with Drs. W. Hunter,
Denman, Bromfield, Walker, and Watson, to extract the child
with the crotchet. " It was my duty (he proceeds) to perform
the operation, which I began about eleven o'clock that night:
* Oshornc's Essays, p. 242.



CASE OF ELIZABETH SHERWOOD. 197

after placing her, in the usual manner, close to the edge of the
bed, on her left side, as the situation most commodious both for
the patient and myself. Even the first part of the operation,
which in general is sufficiently easy, was attended with consider-
able difficulty and some danger. The os uteri was but little
dilated, and was awkwardly situated in the centre and most
contracted part of the brim of the pelvis. The child's head lay
loose above the brim, and scarce within reach of the finger, nor
was there any suture directly opposite to the os uteri. Having
desired an assistant to compress the abdomen with sufficient
force .... I introduced them (the perforating scissors) with
the utmost caution through the os uteri, and, after repeated trials,
at length succeeded in fixing the point into the sagittal suture
near the posterior fontanelle. I very soon, and with great facility,
penetrated into the cavity of the head, destroyed the texture of
the cerebrum, with a common spoon extracted a considerable
quantity, and breaking down the parietal bones, made an opening
sufficient for the free discharge of what remained. In this state
we left her"* for thirty-six hours, when, " upon examination, a
small portion of the head was found squeezed into the pelvis ;
indeed, there were some little detached bits of the parietal bones
lying loose in the vagina. . . . Our intention, by delaying
the extraction of the child six-and-thirty hours after opening the
head, was, in the first instance, to allow the uterus opportunity,
by its continued contractions, to force the head as low and as
much within reach of the crotchet as the nature of the case
admitted, and afterwards, to induce as great a degree of putre-
faction as possible in the child's body, by which means it would
become soft and compressible, and afford the least possible
resistance in its extraction. ... I immediately determined
to begin to make an attempt to extract the child. / call it an
attempt^ for I was far from being satisfied in my own mind of
the itracticahility . . . . The os uteri being situated as be-
fore described, in the most contracted part of the brim of the
pelvis, where the space was incapable of permitting the intro-
duction of the curved point of the crotchet, without great diffi-
culty and danger, my first endeavours were bent to draw the os
uteri with my finger into the widest part of the brim of the
pelvis, and to dilate it as much as possible. Both the removal of
the OS uteri, and such dilatation of it as the bones admitted, were

* ())). cit p 247.



198 LECTURES ON PARTURITION.

effected without much trouble. I then introduced the crotchet,
through the perforation, into the head, and bj repeated efforts,
made in the slowest and most cautious manner, destroyed almost
the whole of the parietal and frontal bones, or the whole upper
or presenting part of the head : and as the bones became loose
and detached, they were extracted with a pair of small forceps,
to prevent, as much as possible, laceration of the vagina in their
passage through it. The great bulk of the head formed by the
base of the skull, still, however, remained above the brim of the
pelvis, and from the manner in which it lay, it was impossible to
enter without either diminishing the volume, or changing the
position : the former was the most obvious method, for it was a
continuation of the same process, and, I trusted, would be equally
easy in execution. I was, however, most egregiously mistaken
and disappointed, being repeatedly foiled in every endeavour to
break the solid bones which form the basis of the cranium, the
instrument at first invariably slipping as often and as soon as it
was fixed, or at least before I could exert sufficient force to break
the bone. At last, however, by changing the position of the instru-
ment, and applying the convex side to the pubis, I fixed the point,
I believe, into the great foramen, and by that means became master
of the most powerful purchase that the nature of the case admitted.
Of this I availed myself to the utmost extent, slowly, gradually,
but steadily, increasing my force till it arrived to that degree
of violence which nothing could justify but the extreme neces-
sity of the case, and the absolute inability, in repeated trials,
of succeeding by gentler means. But even this force was to no
purpose, for I could not perceive that I had made any impression
on that solid bone, or that it had been the least advanced by all
my exertions. I became fearful of renewing the same force in
the same way, and therefore abandoned altogether the first idea
of breaking the basis of the cranium, and determined to try the

second by endeavouring to change the position I

therefore again introduced the crotchet in the same manner, and
fixing it in the great foramen, got possession of my former pur-
chase; then, introducing two fingers of the left hand, I endea-
voured with them to raise one side of the fore part of the head,
and turn it a little edgeways. Immediately and easily succeeding
in this attempt, the two great objects wore at once accomplished,
for the position was changed, smd the volvune diminished. Con-
tinuing my exertions with the crotclict, I soon perceived the



DR. DAVIS S OSTEOTOMIST.



199



head advance, and, examining again, found a considerable portion
of it had been brought into the pelvis. Every difficulty was now
removed, and by a perseverance in the same means for a short
time, the remaining part of the head was brought down, and out
of the OS externum."*

We have detailed this case to you more at length, because it
accurately describes an operation with the crotchet, different
from what we have described — one by which the vault of the cra-
nium is quite broken up and removed, and the base of the skull
is drawn obliquely through the contracted brim of the pelvis, the
crotchet being fixed in the foramen magnum. It is also remark-
able — we might say singular — in the fact, that a child could by
any means be drawn through a pelvis so extremely distorted as to
have the antero-posterior measurement reduced to three-quarters
of an inch; and perhaps the most astonishing fact connected with
the case was, that the woman recovered without a bad symptom,
and sat up in seven days after such an operation. It is not sur-
prising, therefore, that a warm controversy should have arisen; the
advocates of the Csesarian section condemning the attempt, and
protesting against such a case being made a precedent for future
crotchet operations; while the supporters of craniotomy claimed
the case as a valuable proof of the superiority of perforation to hys-
terotomy, which latter was generally fatal to the parturient woman.




Di: l^dM^ s * KtLdtomist
Dr. D. Davis contrived several instruments to meet the dif-
ficulty of these cases — one was the osteotomist, a strong bone

* ( )]). fit. p. 2^!).



200 LECTURES ON PARTURITION.

forceps, intended to cut completely away the bones wHcli form the
vault, so as to leave the base of the cranium. Dr. Davis stated
that this also may be broken and removed by the instrument, so
as to prevent the necessity for that violent exertion which Dr.
Osborne was obliged to have recourse to in drawing the cranium
through the brim of the pelvis.*

Dr. Davis also contrived a double crotchet, for the purpose
of extracting the body of the child, after the head, in this muti-
lated state, has been brought through the pelvis, and thus he
anticipated that the osteotomist would "enable skilful operators
to effect deliveries in cases of moderate distortions with much
more facility to themselves, and proportionally less danger to their
patients, than heretofore, but it will also have the effect of re-
ducing almost to zero, the necessity of having recourse to that last
extremity of our art, and the forlorn hope of the unhappy patient
— the Csesarian operation."!

M. Baudeloque, jun., also, has invented an instrument for a
similar piu'pose to the osteotomist, to break uj) the head, not by
cutting it away, but by crushing it together. The cephalo-tribe
consists of two very strong blades, rough on the inside, and having
handles, through which a screw passes. The handles are brought
forcibly together by turning the screw, and the blades, by the
same power, crush the bones that lie between them (vide fig. 22,
p. 233).

Both these operations are intended to supersede the Cassarian
section, and both are liable to the same objection — viz., the ex-
treme difficulty of using them in those cases where they are chiefly
required, as well as the danger to which the passages would be
exposed in such an operation, especially with the cephalo-tribe.
In moderate distortions, where the crotchet or cranio tomy-forceps
may be used, the osteotomist and cephalo-tribe are unnecessary,
because they possess no advantages which would lead us to em-
ploy them in preference to the former instruments. But when
the distortion is extreme, and the alternative is the Caesarian
section, from the impossibility of delivery by the crotchet, they
would be invaluable, if, as Dr. Davis expected, they could reduce
hysterotomy to zero. Both instruments are new, and future

* Dr. Campbell has invented an instrument— the /iephakpsalis— tor a similar
purpose as Dr. Davis's osteotomist.

f Dr. Davis's Obstetric Medicine, p. 8.57.



OBJECTIONS TO THE CEPHALO-TRIBE AND OSTEOTOMIST. 201

experience must decide tlie question, but prima facie evidence
seenis against them. Look at the cephalo- tribe, and ask your-
selves, How could that instrument be used in Elizabeth Sher-
wood's case? To me it seems impossible. Again, with regard to
the osteotomist, it must be passed into the uterus, above the brim
of the pelvis, and that part of the head within reach of the instru-
ment cut away by it, until the bones are all removed. We ques-
tion very much whether this could be done under the circum-
stances supposed; but admitting it to be possible, the difficulty
of applying the crotchet to the broken cranium, lying loosely
above the brim, must be very great. And if we fail, how are we
to act? Are we, then, to have recourse to the Cssarian section,
for the purpose of delivering a mutilated child from the uterus?
It is true, we are assuming a mal-adroit performance of the opera-
tion, which might arise from want of skill. It is right, however,
to do so, and to consider the alternative in cases of failure, if we
would properly appreciate the value of the improvement. This
objection will, perhaps, appear with more force, from the caution
used by Dr. Osborne to avoid such a difficulty in his operation.
He first perforated the head, and then allowed his patient to
remain thirty-six hours in strong labour, in order that some part
of the head (then a putrid mass) might be driven into the brim of
the pelvis. He preferred leaving the patient so long in labour,
under such unfavourable circumstances, rather than operate, while
the head was yet above the brim of the pelvis. For these reasons
we very much doubt whether the sanguine expectations of Dr.
Davis will ever be realized.

Long before these instruments were invented, another opera-
tion was proposed, to supersede the Cassarian section, Avliich at
first was attended with some success, received the approval and
honours of the Academy of Medicine, Paris, excited the warmest
enthusiasm in its favour, and has now become only a part of
obstetric history. Sigault and Le Eoy proposed to divide the
symphysis pubis, and thus to force open the contracted brim.
It is sufficient to say that this operation failed in its object, and
proved to be so dangerous to the patient, that it has been dis-
carded from practice; we shall not, therefore, dwell upon it, but
proceed to the Caesarian section itself

This operation is based upon the third principle we have stated
to you — viz., when, from the circumstances of the case, the



202 LECTUKES ON PARTURITION.

safety of the motlier seems to be more than doubtful, if not hope-
less, the child must, if possible, be saved. The Casarian sec-
tion is therefore indicated in those extreme cases. In the case
of Elizabeth Sherwood, although the crotchet succeeded, its
success was the wonder of the professional world, and of none
more than Dr. Osborne himself. It cannot, therefore, be taken as
a rule to guide your practice. In order to decide upon the
Csesarian section, you should weigh carefully the probable result
to the mother if the operation be not performed ; and if it appear to
you that perforation is impracticable, or so diflELcult to perform
that the danger seems to be nearly as great to the patient as
opening the uterus, you are then authorized to undertake the
operation, because, if there be a probability that perforation will
not ensure safety to the mother, you are certainly bound to
consider the child, and to give it a reasonable chance for its
life. If, for instance, the ratio of mortality from hysterotomy as
compared with craniotomy, in these extreme cases, were equal,
or as four to three, this slight difference would not, it appears to
me, be sufficient to justify you in destroying the child. Taking
this view of the operation, it woxdd be desirable to ascertain by
statistical results its precise value, because no estimate of the
operation can be formed from individual cases. It is difficult,
however, to do so from reports, unless a careful attention is given
to the circumstances under which the operation was performed.
For instance, the results of the operation in Great Britain and on
the Continent differ exceedingly. In the former, more than
three-fourths of the patients died, and more than one-half the
children were lost. In the latter, the mortality of the mother was
much less, and more children were saved. But in Great Britain
the operation was performed, as a dernier ressort, after the patient
had been several days in labour, and under the most unfavourable
circumstances, while on the Continent, it was generally undertaken
in the first instance. The errors on the one side arose from imne-
cessary hesitation and delay, and I fear we must add that, on the
other, there have been also some mistakes from precipitancy, and
some needless operations performed.

Dr. Churchill has given the results of 409 cases of Caesarian
section : —

1st. Among British practitioners, in 40 cases, 11 mothers re-
covered, and 29 died, or nearly 3-4ths.



CiESARIAN SECTION. STATISTICS. 203

2nd. Oiit of 37 cases wliere tlie result to the cliild is mentioned,
22 were saved, and 15 were lost, or 1 in 2|-.*

3rd. Among Continental practitioners, out of 369 cases, 217
motliers recovered, and 152 died, or about 1 in 2^.

4th. Out of 187 cases where the result to the child is given,
138 were saved, and 49 were lost, or nearly 1 in 4.

5th. Taking the entire number, which amounts to 409, we find
that 228 mothers were saved, and 181 were lost, or about 1 in 2-|;
and that out of 224 children, 160 were saved, and 64 lost, or
1 in 3i.

More lately, Keyser, of Copenhagen, has applied himself to
the same question; he has carefully examined and checked the
accuracy of previous statistical researches on the Continent, and
has arrived at a result differing slightly from that of Dr. Churchill.
338 cases are collected, of which 128 proved successful, and 210
unsuccessfiil. The mortality of the mother is, therefore, 0-62.
The same data give 0*31 as the mortality of the children.
Keyser has taken great pains to classify the cases according
to the different circumstances under which the operations were
performed, and has thus ascertained a remarkable fact respecting
the degree of contraction in the pelvis: — " The mortality/ was
less in those cases in which it was extreme than in those in which it
was mo7'e limited. It was 0*47 in cases which were \^ (French)
inches and less than this, and 0'66 in cases which were If and
more than that measurement." f These latter cases are those in
which we have stated that the operation is called for, and there-
fore, in the Continental practice, where it is performed under the
most favourable circumstances, we may assume the mortality to
the mother to be about 1 in 2, to the child 1 in 3. I do not think
any fair conclusion can be drawn from British practice, because
there were so many causes in operation against its success ;
neither can we ascertain the proportionate mortality where per-
foration is performed in these extreme distortions. We cannot,
therefore, derive any rigid conclusion from a comparison of the
results of both operations. But if the circumstances of the case
be such that the risk to the patient is increased much beyond
ordinary perforation, I do not think we should venture upon that
operation in preference to the Caesarian section. In the former

* Churchill's Operative Midwifery, p. 221.

f London and Edinliurgh Monthly Jonrnal, No. LA^., p. .542.



204 LECTURES ON PARTURITION.

case, the cMld must be sacrificed for a very doubtful advantage.
In tlie latter, tbere is every reasonable cliance of preserving tlie
child, while the mother has at least an equal chance that she will
recover. For these reasons we are not disposed to look upon the
Caesarian section with that horror with Avhich some practitioners
view it; nevertheless, the serious nature of the operation should be
strongly impressed upon your minds, and every caution made use
of that is required in capital operations. The strictest antiphlo-
gistic measures should be previously used, to prevent inflamma-
tion, and the same means as to temperature, etc., adopted, that
have been found so useful in those ovarian operations which have
lately occupied public attention. The most essential point, per-
haps, to attend to is, the time at which the operation is under-
taken. It would be advisable to allow some time to elapse after
labour commences, to satisfy yourself that the head cannot enter
the brim of the pelvis, and thus to confirm your previous diag-
nosis. At the same time, it would be highly improper to allow
labour to proceed to such a length as to hazard either inflamma-
tion, exhaustion, or the death of the child. It is for this reason
that the operation has so often failed in British practice. In this
respect, each case must be considered separately; but you may
take it as a rule, admitting of many exceptions, that having pre-
viously ascertained, by examination per vaginam, the extreme
distortion of the pelvis, if after the first twenty-four hours the
head does not enter the brim, the operation may be performed.
We have Keyser s evidence on this point, also, to prove that such
delay would not be injurious to the patient: — " Kegarding the
time which intervened from the commencement of labour, M.
Keyser divides his tables into three categories. In the first, the
operation had been performed within the first twenty-four hours;
in the second, in the interval between the twenty-fifth and
seventy-second hour; in the third, more than seventy-two hours
after the commencement of labour. In the first category, the
mortality of the mothers was 0-67, that of the infant, 0'28. In the
second, the residt was respectively 0*55 and 0'33, and in the third,
the mortality amounted to 0-72 and 0-60."* From these tables it
appears that the middle period, between twenty-four and seventy-
two hours, was less fatal to the mother. An operation of so grave
a nature should never be imdertaken without the aid and assist-

*â–  London iiiid I<j(lii:l>iir,L;-li Monthly Joui'niil, ]). 542.



MODE OF OPERATING. 205

ance of at least two professional men of reputation, if it be at all
practicable to have their support.

The mode of operating we shall briefly explain. The rectum
and bladder must be carefully emptied ; the position of the pla-
centa ascertained with the stethoscope, and the exact direction of
the uterus observed. If it project forwards nearly in the middle
line of the body, and the placenta be in its usual position at the
back of the uterus, an incision may be made through the linea
alba for about seven inches, commencing above the umbilicus and
terminating about two inches above the pubis ; the uterus is thus
exposed, and the peritoneum along with it. An assistant should
press with both hands firmly on the uterus, at either side of the
wound, Avhile the uterus is being divided. This must be done by
cautious incisions, in the direction of the external wound, until
the membranes are seen. These should be raised, and a small
opening made in them to allow the liquor amnii to escape exter-
nally; the whole fluid may be removed by successive applications
of sponges to the opening. The membranes should then be divided
on a director the whole length of the wound, and while this is
being done, a second assistant should be prepared to grasp and
remove the child, while the first maintains pressure on the con-
tracting uterus, to prevent as much as possible protrusion of the
intestines or exposure of the peritoneum. The placenta then may
be easily removed, the intestines replaced (they always protrude),
and the wound united by several sutures; water-dressing and a
broad bandage may be applied over the whole.

Lauvergat advised us to puncture the membranes previous to
the operation, and this plan has certainly many advantages. The
placenta can be heard much more distinctly ; the size of the uterus
is reduced, and the calibre of its vessels diminished; the amount
of haemorrhage may thus be lessened, and the external wound
need not be so large. The peritoneum, also, is less likely to be
exposed when the uterus contracts after the child is removed.

The dangers you have to apprehend from this operation are : —

1st. The shock to the constitution, under which the patient
may sink ;

2nd. The haemorrhage which may result from the operation;
and

3rd. The inflammation of the peritoneum, in consequence of
the sac being opened.



206 LECTUEES ON PARTURITION.

Tlie subsequent treatment we shall consider, under these dif-
ferent heads, in another part of the course.

If we have pointed out to you with sufficient clearness the
different obstetric operations, the degrees of disproportion to
which they are applicable, from the slightest to the most extreme,
— from simple delivery by the vectis to the Caesarian section, — if
we have succeeded in defining the limits of each operation, we
would now direct your attention to a means of obviating the
necessity for those operations that involve the sacrifice of the
child.

In cases of contracted pelvis, which prevent the passage of the
full-grown child, if labour should take place at the seventh in
place of the ninth month, you can readily perceive the possibility
of the child (then much smaller) being safely delivered. The
child is quite capable of supporting respiration at that period;
therefore it has been proposed — and the practice is now very
generally adopted — to induce labour to take place at the seventh