OBSTETRICAL OPERATIONS. 483 



BOOK III. 



OBSTETKICAL OPEKATIONS. 



In the various malpresentations and malpositions, as well as for the 

 other causes of dystokia already enumerated, the indications for recti- 

 fication and extraction were alluded to and described at sullicient 

 length, and the nieans to be adopted for carrying them out were like- 

 wise mentioned. It was shown that, in many cases, it is sufficient to 

 correct the abnormal presentation or position, and rectify the deviation 

 of limbs, neck, or liead, to effect delivery in the ordinary manner by 

 means of the hand alone. For, as has well been said, the practised 

 hand is the best and most perfect of all instruments, and it can effect 

 in obstetrical operations what no instrument is competent to achieve. 

 Therefore it is that an operator with a long and powerful arm, and a 

 small hand with strong fingers, possesses many advantages as an 

 obstetrist, and is in a better position to afford relief than one with a 

 short arm and large hand — especially in the correction of those devia- 

 tions which are so frequent, and oftentimes so baffling. 



Extraction by the hand alone may be effected in many cases of 

 difficult parturition, when these rectifications have been made ; though 

 even then it is essential that the os uteri be fully dilated, the vagina 

 and vulva dilatable, and sutliciently prepared to allow the young 

 creature to pass througli ; it is likewise necessary that such a relation- 

 ship in proportions should exist between the volume of the fcetus and 

 the capacity of the pelvis, that extraction can be accomplished without 

 much difficulty. Finally, it is particularly desirable that the uterus 

 retain its contractile power, and that its regular contractions should 

 second the efforts of the operator. 



In only too many cases of dystokia,. however, one or more of these 

 conditions are absent, and the unaided hand — no matter whether it be 

 ever so well endowed and practised — fails to effect delivery ; so that, 

 in order to overcome the dilficulties, recourse must bo had to various 

 surgical instruments and appliances, and there must be performed, 

 either on the mother or fcetus, more or less complicated and serious 

 •operations which demand strength, expertness, and an accurate know- 

 ledge of anatomy and physiology, and even of meciianics, in addition 

 to a thorough acijuaintance with surgical pathology. Some of the 

 obstetrical operations have been alluded to ; but it is necessary to study 

 them as a whole, in order to master their special features, and par- 

 ticularly the manner in which they are to be performed, as upon the 

 exactness of our knowledge with regard to them will generally depend 

 their successful results. 



These operations have for their object either to supplement the 

 forces of Nature, which are insufficient to secure the birth of the young 

 creature ; to rectify its presentation or position ; to diminish its size 

 when it is cither too large, too deformed, or too deviated or distorted, 

 to pass through the maternal passages ; to enlarge the latter, or to 

 extract the foetus by an artificial passage when these last do not admit 

 of extraction. This leads to a consideration of : (1) Preliminary 

 precautions and operations ; (2) Rectification of presentations and posi- 

 tions of the fcetus ; (3) Mechanical means for the extraction of the fcetus ; 

 (4) Embryotomy ; (5) Vaginal hysterotomy ; (6) Ccesarian section ; 



