Part 16

HAPPY! thrice happy it is for the midwives, that, at least, if avarice should tempt any of them to the injustice of hurrying a poor patient’s delivery, in order to attend a rich one; a circumstance which, I fancy however, does not more often occur to the female than to the male-practitioners; the woman cannot, at least, use towards precipitating such deliveries means so violent as the men. They appear only in guise of peaceable simple seconds to Nature: the men take the field, armed as combatants against her. The women can but prematurate things by excitation of the hand; they may be guilty of reprehensible negligence, they may be over curious in their bandages, by way of smoothing wrinkles after delivery; in short, they may commit many faults, which I am far from justifying, or even extenuating; but at the very worst, I defy them to equal the instrumentarians in mischief; nor can their practice abound with those horrors, of which a man-midwife tells us he could furnish VOLUMES (p. 298.) horrors which must be so greatly multiplied since his time, as the recourse to instruments is more than ever pursued, in practice, though so fallaciously disowned in the theory; under which disavowal the gentlemen midwives figuratively conceal their bag of hard-ware, just as Dr. Smellie directs them literally to do in their visits to patients.

BUT to resume the subject of TOUCHING, I am to observe, that among its essential services on many occasions, both during the pregnancy, and in the actual labor-pains, there is one case, which, for its frequency and importance, deserves a separate consideration: it is that of the obliquity of the uterus, of which touching not only serves to inform, but to rectify it. I shall therefore dedicate a section to the treating of it.

Of the OBLIQUITY of the UTERUS.

BY the obliquity of the uterus I mean its untoward situation. For either the uterus preserves its natural direction, or does not preserve it. Where the uterus preserves it, I call it well placed: the point of it is turned directly to the cavity of the pelvis, and the _fundus uteri_ is suspended in the space between the umbilical region and the vertebræ: if the uterus does not preserve its natural direction, if it inclines too much forwards, backwards, or towards either the right or the left side, I call it oblique, or untowardly placed. All the other situations of the uterus are reducible to these four, from which they differ no otherwise than as its line that should naturally be perpendicular to that of the vagina deviates more or less from it towards any of them. It is from this obliquity, greater or less, that proceeds, by much the most often, the greater or the less difficulty of the lyings-in.

IT would be superfluous here to analise all the causes of such obliquity, because, being mostly natural ones, there is no preventing them. But there are some causes of it, or at least, that appear to me to be sometimes the causes of it, that it cannot be improper for me to premise here, for precaution-sake.

I HAVE then some reason to think, that both here and in Holland the stays contribute much to the obliquity of the uterus. For though women, during their pregnancy, may perhaps wear them looser than at other times; yet their natural hardness pressing on the belly, with the stiff whalebones, always too many if there are any at all, cramp the fœtus and the womb, to which the stays too often give a bad situation, according to their motion or swagging more to one side than to the other, in their state of looseness; and if they were laced tighter, that would be yet more dangerous.

I COULD wish then, that women with child would either content themselves with wearing a bodice only, or stays without any whalebone, but at the back just to serve the loins, and even those not to come so low down as I have seen some. The obliquity of the uterus is much rarer in France than it is here, for which I cannot account otherwise, than from the women there avoiding any prejudice from their stays, during their pregnancy. There is another cause, as I apprehend it, of the lateral byass, which is the lying too constantly on either side, whence the uterus contracts a habit of inclination to that side. The probability of such an effect I submit to the anatomists, as I speak here only conjecturally, and not with the presumption of certainty.

THE obliquity of the uterus may be discerned from the difficulty there will be, in touching, to come at its orifice. And it is by touching alone that you can hope to discover which way its deviation points, whether it is placed too high towards the _os pubis_, too much turned towards the curve of the vertebræ, or in a lateral direction, towards either the right or left _ilion_. But which ever way that mis-direction points, the difficulty of the delivery is proportionable to the degree of it: and the skill and knowledge of the midwife in not only the reduction, but the keeping of the uterus to its due position, till the delivery is accomplished, form one of those principal branches of the art, for which the gentlemen-midwives must be naturally so unfit.

THERE are very few authors who have treated of this obliquity of the uterus. Some do not mention it at all, others speak of it, but so slightly as to escape attention.

DR. Smellie in his enumeration of the cases, by which laborious labors are occasioned, which he ranges under seven heads, has intirely omitted this case of obliquity. He has bestowed indeed a whole chapter on the distortion of the pelvis, a case I take to be comparatively infinitely rarer than an obliquity of the uterus. He might as well suppose a frequent vitious conformation of the cheek-bones, as of those that form the pelvis: which, were it so, must necessarily imply a constant recurrence of hard labors in the same woman, which is not often the case. Whereas the liableness of the uterus to an obliquity from various accidents, principally accounts for the easiness of one labor in a woman, being no argument for her not having a hard one in future, or convertibly. I dare aver then, that in the course of my practice, which is not the least extensive one, this very case of obliquity has occurred to me oftener than all the others put together, and indeed caused me the most pain to remedy or conquer. Why then such an omission by these writers? I cannot conceive, unless that they were aware of the consequence, obvious to be drawn from thence, that women, by the superior fitness of their hands, must be the properest to apply the topical remedy; and that their iron and steel instruments could not so well be set to work in such a case, at least in due time. This is absolutely so true, that in the case of this very obliquity, which occasions most of the very lingering labors, for which the midwives, who have not preventively exerted themselves to reduce it, and thereby to clear the passage for the fœtus, have no remedy but patience; those very lingering labors, I say, which shall have thus arisen from the want of skill or prevention, furnish the men-practitioners with a pretence to dispatch them with their instruments. Thus they, often murderously for the child, and injuriously to the mother, terminate many a delivery, which a gentle and constant reduction of the uterus would have so much more safely and less painfully accomplished. And how accomplished? evidently not by any violence to Nature, but purely by redressing the wrong she is in, oftenest not by her own fault, but by some adventitious cause, in which she has been rather a passive sufferer than originally herself deficient. A justice this of distinction too often refused her, and from which too many errors of practice arise, perhaps in more cases than this.

HOWEVER, this is certain, that this case of the obliquity of the uterus deserves much more notice and attention than have been paid to it. It is one of the most important difficulties of the art.

HE who treats the most at large of this matter is Daventer, who, I have strong reasons for believing, first took the hint from some midwife: but a hint, which the usual imperfection of the manual function in men hindered him from duly improving. For in the way he sets forth the different inclinations of the uterus, and the methods of rectifying them, instead of throwing a practical light upon the subject, he has obscured it with errors, absurdities, and repetitions without number or excuse.

BUT that I may not appear to treat this author dogmatically, and especially as he furnishes me with an occasion of further elucidating a point of such great importance to the art of which I am treating, I must here intreat the attention of those readers, especially who deign to peruse me rather in the search of useful truth, than of amusement, of which indeed so serious a matter is so little susceptible.

LET us then examine some of Daventer’s methods of practice, so inconsequential to so just a theory as that of the mis-direction incident to the uterus.

DAVENTER, chap. xlvi. p. 288, French edition, treating of the rectification of an obliquity of the uterus fallen forwards, goes on thus. “When the membrane is broke, and the vertex of the head partly come forth, there is no longer occasion to support, as before, the orifice of the uterus. It should be let fall with the head beyond the curvature of the os sacrum. The head will make its way much more easily than if it was still wrapped up in the uterus (_indeed!_) Now to make the fœtus come forth, the midwife must, as she did at the beginning, employ both her hands; the one internally applied, the other externally; but take care so to do judiciously. Neither must she wait till the labor-pains are over, before she sets her hands to work, as I have just before observed. On the contrary, it is in the time of the throws that she must operate, and when they are on the decline, terminate the delivery. The midwife therefore should not barely content herself with watching the time of the pains, but should also admonish, at every one of them, her patient to second them with all her strength, in order that the child may advance the more under their stronger protrusion. During which, the midwife having her hand in the vagina, the back turned towards the rectum is to advance the tip of her fingers, the most she can, under the head of the child, taking care however not to overpress them; and in this posture, she is to keep her hands unmoveable, till she feels the labor-pains come on. The other hand she is to put on the hypogastrium, nearly over the place answering to the _fundus uteri_; and when the pains shall begin, she is to give her hands such action, that that which is in the vagina shall push back the coccyx, and the other applied externally shall push up gently the _fundus uteri_, and at the same time determine its orifice towards the pelvis. I say gently. But this is to be understood of the beginning of the throws, for in proportion as they increase, the midwife must press the harder.

“CARE must, in the mean time, be taken, that the pression made on the belly must not be too violent but _very_ moderate: whereas that made on the coccyx must be with the midwife’s whole strength, with this attention however, _first_, that this great effort must not be made but when the force of the throws obliges the woman strongly to contract the muscles of the hypogastrium, and must cease with those throws. _Secondly_, that the hand must be laid flat on the coccyx, not with the fingers half-bent, least the joints should hurt the woman. _Thirdly_, that the hand may be as much expanded as possible, that the pression may be equal on all parts. Observing these three conditions, the midwife may employ her _whole_ strength, without _fear_ of doing any harm to the woman. On the contrary, she will greatly relieve her.”

TO the which I have to say, that I should greatly pity a woman that should fall under the hands of a woman that should receive such directions from Monsieur l’Accoucheur, and much more yet, if she was to be under his. A midwife to operate thus! with one hand in and the other out, over the lower part of the belly, “gently” says Daventer, and yet stronger in proportion as the throws increase: and a little after he says, this pression on the belly must not be too violent, but _very_ moderate. I confess, I do not understand, but that may be my fault, how a pression can be stronger and stronger as the pains increase, without ceasing to be gentle or very moderate.

BESIDES; as to the pression of the midwife’s hand on the coccyx of the patient, so violent as he advises it, with the whole strength of the midwife, can this be executed without causing to the vagina or rectum a contusion, very capable of bringing on a gangrene, of causing a mortification, or, in short, the laceration of the frænum labiorum, whatever he may say to the contrary?

I OBSERVE, by the way, that in this very chapter Daventer supposes the heads of children breaking themselves, sometimes against the os pubis, or the vertebræ, as if these were bare bones, at least he is to me, in these points, unintelligible.

HE goes on to object, that if, through ignorance, Nature has been so far left to herself, that the point of the uterus should be fallen into the pelvis, that its orifice, and the head of the child, should be fallen into the lower curve of the _os sacrum_, that the membrane should be broke, and the child’s head a little discovered, and withal, the woman’s strength much exhausted,

“TO change, (says Daventer) this situation, thus you must proceed. The woman must rest upon her knees and elbows, with her head low. And what (adds he) determines the placing a woman in this posture, is, that the weight of the uterus may impel it to the side of the diaphragma, and consequently withdraw it from the sinuosity of the coccyx.”

TO me it appears impossible, that a woman, whose strength shall have been exhausted, or but much diminished, can put herself into such a posture, which could only serve to make her lose any little strength she might have left.

AT the end of the said chap. xlvi. Daventer concludes in the following terms.

“HOWEVER, to say the truth, of whatever kind the obliquity of the uterus may be, I hold, that the safest, the easiest, and the least painful expedient, is the footling-extraction of the child, from the very beginning of the labor, before or immediately after the discharge of the waters, as soon as one can be assured that the pains the woman feels are the labor-pains. If this method should be followed, which I hope (adds he) it will one day be, it would preserve an incredible number of women and children, the unhappy victims of a contrary practice.”

HERE I must confess the shallowness of my understanding. Such a reasoning as Daventer’s in this case passes my conception. He allows, that in all the obliquities of the uterus, it is extremely difficult to find the orifice, to come at it, and to introduce the fingers into it: nay, he owns, that it is not without a great deal of trouble, that you can get to touch but the surface of that orifice; and after that confession, he tells you very gravely that, in such cases, you must deliver the child by the feet, in the very beginning of the labor, before even the discharge of the waters, or at least soon after.

OUGHT then the translator of Daventer, who is at the same time his apologist, in good conscience, boast so much the discoveries of this author upon the obliquity of the uterus? is it possible for common sense to give the approbation that he does to those easiest, safest, and least painful methods, that he recommends for relieving the mother and child in those cases of obliquity?

I AM then too much prepared to be surprized, in the chapter following that from which I have quoted, to find him, where treating of an uterus too much inclined towards the vertebræ, not scruple to reason as follows.

“BUT if the child is too much compressed, or has a head over large, so that it is not without much difficulty to the midwife, and pain to the woman, that it can be hoped to bring the child into the pelvis, a state of things which does not unseldom happen, I judge that, to prevent the danger, the best method is the footling-extraction. But (adds our author by way of reflexion) this work is more _befitting_ a _man_ than a _woman_, unless she has a _quick_ judgment, and an _alert_ hand: a man-midwife should therefore be called (_Doubtless!_) and he must lay his account with having work enough, for it is not without a great deal of trouble and difficulty, that he will accomplish the turning the child, and that for _three_ reasons.

“THE FIRST. Commonly, the orifice of the uterus in this situation is but little open: it must be _violently_ dilated, that is to say, in _forcing_ Nature, or _doing violence_ to her. Yet this must be done slowly, for too much precipitation would cause to the woman _very acute pains_. (_To be sure, a slow violence would not hurt her._)

“REASON the SECOND. It is not more easy to penetrate to the bottom of the uterus, of which the orifice already, narrow as it must be, is moreover occupied by the head of the child, than to open the orifice. No wonder then, that so much trouble and patience should be required to get at the child’s feet.

“THIRDLY, It will be found, that the distance there is between the orifice of the vagina to the bottom of the uterus, must render the _man-midwife’s_ work so much the more difficult for the sinuosity of it, and his being forced to operate in a part so narrow and close, and in which the hand is much cramped for room. It is obvious to sense, that a place so oblique and streight must deny the liberty of passage.”

THE advice which Daventer gives here of extracting the child by the feet in the case he supposes, and, for that purpose, violently to dilate the orifice of the uterus, appears to my weak mind such mad, such frantic doctrine, as to be beneath refutation. The bare recital of his own reasons, and of the difficulties there are to surmount, which he himself confesses, abundantly demonstrate the impossibility and absurdity of the method he proposes.

BUT after taking the liberty of dissenting from that celebrated man-midwife in cases of obliquity, as to the practical part, which I take indeed to be his _own_ discovery, it is but just I should offer what I conceive to be the true midwife’s practice, for terminating happily the labor of a woman in the case of obliquity of the uterus: submitting the same to better judgment.

ALL the deflexions or byasses of the uterus, whatever they are, are to be known by the touch. An expert and knowing hand will never fail of ascertaining the discovery of them. I say, an expert and knowing hand, for without an exact knowledge of the figure of the whole pelvis, the situation of the bladder, of the rectum, the vagina, and the uterus, before and after pregnancy, the situation of the orifice with respect to the pelvis, there is no distinguishing for example, an over-elevated orifice from one too low, nor a direct from an oblique one. In vain would one conceive clearly what those terms signify, or have some knowledge of the distinctive parts of the female sex, without one has at the same time sufficient experience, and fineness of sense in the touching part. Without these qualifications there is no proceeding but darkling, and in danger of deception.

THE orifice of the uterus is always diametrically opposite to the fundus of it. When then you know what the situation of the orifice of the uterus is, when in its due place, you may, if well versed in _touching_, calculate any aberration from the right line, and by the situation of the orifice giving that of the fundus, know how the rest is disposed.

WHEN, by _touching_, I perceive, there is an obliquity of the uterus in the case, in the proper time, I desire the patient to lay on her back, and introducing my finger, endeavour to come at the orifice of the uterus. Upon getting hold of it, I support it so long as the labor-throw continues, and I take care the child should not engage itself too much.

I AM obliged, with my hand, continually to repeat this service; and after resting a little from the fatigue, whenever I can snatch a moment safely for such relaxation, I re-introduce my finger, as before, in order to prevent the pains, and hinder the orifice from falling, that is to say, from sinking, so as to turn too much backwards, or from rising too high, or, in short, from deviating towards the right or the left, according to the circumstances or kinds of inclination that may present themselves. I also take great care, that the child may not engage itself too far under the os pubis. I do not discontinue these cares, these attentions, until, whatever assiduity, length of time, or trouble it may cost me, I shall have arrived at rectifying the wrong direction, by thus constantly supporting the internal orifice, till, in short, I have brought it, little by little, to turn and come directly on a line with the external orifice. By this management of the hand, I procure the child a fair opening, and its falling forward, without being wrapped up or embarrassed in the uterus.

AND yet, in certain cases of obliquity I sometimes find so great an inversion of order, such an intanglement, that the child presents itself in the vagina with the body of the uterus covering it wholly, and by its volume totally impeding the coming at the orifice.

I HAVE before observed, that I required my patients, in these cases, to lye upon their backs, and this, because, if they set up straight, the uterus would overset, and render the obstacle, if not invincible, at least, much more hard to remove.

HOWEVER, both to ease my patients, and to prevent the child’s ingaging itself too far in the pelvis, I get them, according to the circumstances, to keep still lain down, but to turn sometimes to one side, sometimes to the other, without ceasing my attentions, without discontinuing to rectify the turn of the internal orifice from over the summit of the child’s head, and to uphold the said orifice, if it should tend to turn backwards, to depress it downward, by a gentle pressure, if it is inclined to rise towards the os pubis. This operation, this support, this depression, ought always to be managed with as much tenderness as skill, and there cannot be too much of both.

CERTAIN it is, that the bad situation of the uterus often occasions a severe and difficult labor. A midwife therefore, from the very first of the labor-pains, cannot bestow too much attention to the giving such preventive or actual aid as I have proposed. Nothing, on these occasions, is more dangerous than delay. The pretious moments of operation must not be lost, least the child, coming to engage itself, should throw us into an embarrassment yet greater than the first.

IN the beginning of the labor, it is no very great matter, to know exactly, what part the child presents to the orifice of an oblique uterus. It is enough to know, that it is not the head, in order to determine you, in due time, to the footling-extraction. What I mean is, that as soon as a good position shall have been procured to the orifice of the uterus; if it is any other part but the head that presents itself at that orifice, and that it is sufficiently dilated for the hand to get by gentle degrees introduced, dilated, in short, to about the diameter of a crown-piece, then, if the membranes do not break of themselves, the midwife should pierce them, and search for the feet of the child, to bring it away. But if the head it is that presents at the orifice, there is no need of any hurry: it is even better to wait till the membranes burst of themselves, unless they should be come out of the vagina, in which case they are to be opened, in order to terminate the delivery, not with scissors, but with the fingers alone.