Part 17

THE reader will here please to observe, that in these cases of obliquity, almost every thing depends, as to the prognostication, and prevention of difficulties, as well as to the relief in actual labor, on the exploration of the touch, and consequently the manual function. The last is especially and palpably indispensable. What can supply the place of it? not surely those forcing medicines, which some ignorant men-practitioners obtrude on the unhappy patient, and which only serve to exasperate the pains in vain, and certainly not to accelerate that parturition, which is retarded by the purely local indisposition of the womb. An obstacle which a skillful, tender, experienced hand cannot but be the fittest to remove.

IN this case however it is, that Monsieur l’Accoucheur oftenest looks extremely silly and disconcerted. Though the throws redouble, the child is never the nearer coming out. On the contrary, till its passage is franked by the reduction of the uterus, it bears in vain upon any part, but that aperture, through which alone lies its issue: and, in fact, the harder it bears, the more it obstructs its own deliverance, and damages its mother. Monsieur l’Accoucheur stands by, does nothing, and can do nothing, or worse than nothing, if he should pretend to it: if he had the head, he has not the hand to give the patient any efficacious aid. Then it is, that where thus incapable by Nature, for the manual function, the men-practitioners abuse that excellent, that divine, but here mistimed and misplaced maxim, of leaving things to Nature, of trusting to Nature. The power of Nature is just then, all of a sudden, acknowledged to be self-sufficient, when she really wants human help to redress her wrong. She is then at her greatest need, left to shift for herself. The fruitless pangs increase. Monsieur l’Accoucheur stands by an idle spectator, or perhaps goes about his business. In the mean time both mother and child, exhausted by fruitless efforts, for perhaps four, five, or six days, perish for want of the proper and only relief. Thus the ignorant operators abstain from interfering, when interfering, if they were fit for it, might be of service, only because they cannot so well in this case employ their iron or steel instruments: and as to their hands, they would most probably indeed make sad bungling work of it. Their action, in short, is, if that can be imagined, yet worse than their inaction.

SOME of them, in this case, content themselves with saying, that the orifice is as yet too distant, and that nothing is urgent. They go away then, and leave the patient in the hope of some favorable change which is never to happen. They return, and find a strange disorder in the state of things, the child is too far engaged: it is too late to retrieve the damage, as they imagine, and I readily believe, when they have lapsed the due time of operation, of which it is not only probable they knew nothing, but, if they had known what to do, would have done it very ill. Then the vast knowledge and learning of these disconcerted instrumentarians can furnish them no better expedient, than that of murdering the child (as they pretend) to save the mother, though it is not always that the mother does not follow the fate of her poor infant.

I KNOW, by my own experience, that often to make a happy end of such deliveries, requires an extreme attention and indefatigable pains. But practitioners should resolve, either to go through with the undertaking as it should be, or not begin it, in such cases, especially where the lives of mother and child depend upon their doing their duty, as they will answer the contrary to God, to man, and to themselves.

THESE cases are but too frequent in England. I have myself met with several of them, and sometimes even in persons extremely well made, in which I have been obliged to perform this manual aid, for many hours together, ay, even for half-a-day and more by the clock; all my motions keeping time with those of Nature narrowly watched, so as to rectify and adjust the orifice and the uterus; constantly reducing any detortion, and keeping things in their due direction, without tiring, or without losing patience.

HERE I ask of my reader, is such work as this, naturally speaking, the work of a man, as Daventer would persuade us?

IF the Monsieur l’Accoucheur is an ignorant, or rather not a very intelligent one indeed, the mother, or the child, or perhaps both, will probably be his victims.

BUT you say, if he is an intelligent one all will be safe. No; he may perhaps know what to do, but will he have the woman’s faculty of acquitting himself of his duty? all the theory in the universe will not do here without the practical part; and will the hands of a man in that respect ever equal the suppleness, the dexterity, the tenderness of a woman’s? once more, is a man made for such work?

I SAY nothing here of the patience so remarkable in the true midwife on such trying occasions. I will grant, that Monsieur l’Accoucheur may, in the view of forty, fifty, or a hundred guineas perhaps, have enough of it not to slacken an attendance on his part, so dangerous, so insignificant, and often so pernicious; that it would be much better to pay him for his absence: I grant then, that he may employ his divine hippocratic fingers in such handy-work, for so many hours together, without stepping into the next room for refreshment; or, in short, without hazarding the lives of the mother and child, by a remission of actual attention and manual assistence. But granting all this, can any one, who has a respect for truth, a respect for his own knowledge and sense of things, a respect, in short, for two such precious lives, as those of mother and child, not, I may say, intuitively, perceive and feel, the impropriety and danger of the practice, in such cases, being committed to a man preferably to a woman?

BUT would a woman especially, who loves herself, who loves the child in her womb, and who is capable of thinking at all, sacrifice herself and child to so palpable an imposition, as that of the pretended superiority of the men to the women in this point? She cannot even, well, without repugnance, submit, nor but for the indispensable necessity probably would submit to receive such service even from one of her own sex, whose tender, soothing, congenial softness, must make it more easy and supportable. But what can she expect from a man’s clumsy, aukward, unnatural, disgustful operation, but increase of danger, or of pain, perhaps of both; while she and her child may not improbably be the victims of the rudiments in the art of a man by Nature condemned for ever to be a novice only, and who, for possibly a great hire to assist her, earns it only, as I have before observed, by excluding that due relief he is himself not capable of giving her; earns it by the not preventing enough her pains, and even by increasing her torments; till at length, not unfrequently, some infernal instrument is produced, like the dagger, in the fifth act of a tragedy, and forms the catastrophe of mother, or of child, or of both?

Of the EXTRACTION of the head of the FŒTUS, severed from the BODY, and which shall have remained in the UTERUS.

I AGREE with our modern writers, that there can hardly exist a more vexatious accident, than that of the head’s remaining in the uterus, after the extraction of the body. There are many causes of this effect. The death of the child for some time past, so that the waters may have had time to relax, to macerate the fibres, and thereby to render them incapable of resisting any efforts; there will result from thence a great difficulty of procuring the total issue of the dead fœtus, without dismembering it.

SOME mis-conformation of parts in the mother may also contribute to it, or the obliquity of the uterus, where the child is brought away by the feet.

INDEPENDENTLY of all these causes, this accident is almost always the effect of unskilfulness; it is, in truth, so rare, that it will scarce ever happen, where the delivery is conducted by an accurate and able practitioner of the art. If we have some examples, that even under skilful hands this case has come into existence, a thorough examination of it would shew, that it was only owing to the cruel necessity the practitioner may have been under, of being aided by persons not duly qualified to afford the least effectual help, or to conceive what they were directed to do.

BUT, however that may be, the damage is not absolutely without remedy. The great point is, without loss of time, to introduce the hand into the uterus, which does not proceed in its contraction, but gradually and leisurely enough, to give leave for the needful evacuation. It is true, that this operation requires a very nice skilful hand; with which, where it is found, surely no instrument, nor other invention, can come into competition.

THIS accident has appeared to occasion such severe labors, that many practitioners, and Peu, among others, (page 308) have advised abandoning the expulsion to Nature, rather than to fatigue the patient by fruitless and torturous attempts, to the success of which such obstacles presented themselves, as they looked upon to be unsurmountable.

MAURICEAU (Aphor. 240) is of the same opinion, which he thus expresses. “When the head of the fœtus shall have remained in the uterus, which is no longer open enough to give it passage forth, it is better to commit the expulsion to Nature, than to attempt the extraction with too much violence.”

THESE practitioners ground their opinion on that Nature, always wise and intent on self-preservation, taking more care to expel a superfluity, than even to attract the needful, often discharges herself, and that without violence, if she is but ever so little assisted, of all extraneous bodies, or other things retained in us against her intention.

MESSIEURS de la Motte, Peu, and Viardel adduce examples of Nature’s doing spontaneously, what some of our later moderns are for absolutely doing themselves by means of those curious instruments, in which they make such a parade of the rare inventiveness of their genius, particularly in the extraction of a head remaining detached in the uterus, on its contracting some hours after the unskilful operation of some deficient practitioners. In such cases, I say, those gentlemen furnish instances of Nature’s expelling the superfluous and extraneous incumbrance, with only the help of some glysters, and other remedies administered to the patient.

NOW though no one can be more intimately convinced than I am, that Nature, acting for ever upon surer principles than Art, possesses resources which she often displays in the most desperate exigencies; I own, that in this case I am not for totally relying upon her beneficence[32]. Here is a wrong to redress, not owing to her, but to deficient practice; and this wrong can hardly be repaired by her alone, unless something of a better practice contributes to relieve her. That practice is not, however, the less recommendable for being plain and obvious. The most gentle, the most guarded, but withal the most efficacious means must be tried, little by little, to insinuate the fingers and hand into the uterus, how closely contracted soever it may be; for yield it will; and then seize the head by the mouth, the occipital cavity, or whatever other part affords the least slippery hold, without waiting whole hours, as do certain ignorant or negligent practitioners with respect to the after-birth, who give time to the uterus to enter into too strong contraction.

SOME authors, and other persons of much that depth of practical merit, having learned solely by the experience of delaying to bring away the after-birth, that, to abandon thus the head of a child remaining in the uterus, was, at the same time, to expose the mother to the highest danger, judged it expedient to have recourse to auxiliary methods. They have therefore employed and directed for this purpose such edge-tools, as instruments and crotchets of different figures, some to incide and separate the bones of the skull; others to bring them away piece-meal, or all together, according as they should find the operation the easiest. [33] DYONIS and Mauriceau are of opinion, that the crotchet should be thrust into the most convenient place of the head, such as the mouth, one of the orbits of the eye, or the occipital cavity; after which, you are to endeavour to bring away the head by redoubled efforts. But if the crotchet slips, as the head is of a round figure, and may turn like a ball, they direct you to thrust the crotchet into the hole of the ear, then giving some one the handle to hold, you are to strike another crotchet of the same figure in the other ear, and so pulling with both crotchets at once, extract the head, that is to say, if possible.

AY, that “_if possible_,” is well added; for with infinite submission to those very _learned_ gentlemen, nothing appears to me more impracticable; and, I fancy, if they had ever made the experiment, they would have found it so. What a blind operation, with such instruments, and in such a place!

GUILLEMEAU (Treat. of Mid. Book II. chap. 17.) remarks, that, in such case, you should take the time that the woman has a labor-pain to accomplish the extraction by this method, that is to say, to snatch that moment to extract the head, when you BELIEVE you have got fast hold of it.

BUT if the woman is too badly conformed, Dyonis (Book II. page 287) advises the use of the edged crotchets to cut the head to pieces, and bring away, by parts, what you could not do whole.

MAURICEAU (Book II. page 287) would have it so, that this sort of crooked knife should have a long handle; and says, that Ambrose Paræus and Guillemeau are for a short one to it. Doctors will disagree. They all however give their respective reasons, and it is indeed hard to say which does not give the worst.

MR. De la Motte, in the like circumstances, made use of a bistory, or incision-knife inserted in a sheath, open at both ends; of which he gives the following account. (Observ. 259.)

“I INTRODUCED, said he, into the uterus, my left hand, over which I fixed the head; and with my right, I slipped in a sheath open at both ends, in which was an incision-knife, that I applied to this head, and made an opening in it capable of admitting my fingers. I widened it afterwards, as much as I thought proper, and scooped out a part of the brain; after which, I got hold sufficient to bring away the head, of which the volume was considerably diminished.”

AMBROSE PARÆUS (Book of Gener. chap. 33.) tells us he had, to his great regret, a case of this sort fall to his share, the head of a fœtus remaining in the uterus. To extricate himself from which, he proposes much the same methods I have described after Dyonis and Mauriceau; and advises, in the same case, that if they do not succeed, recourse should be had to an instrument, called _pied de griffon_, (Griffin’s claw) which he says he took from the French surgery of d’Alechamp. He gives two forms of one, one of two branches, another of four. These instruments, both the one and the other, are made on the principle of the _Speculum Matricis_[34], of which the use is at once, so detestably cruel, and so perfectly unavailing. The Griffin’s claw however differs from the _speculum matricis_, in that the latter has its branches elbowing in an angle, and that the former has its branches streight a-top and at bottom, and arched in the middle, and furnished with roughnesses to seize and keep hold of the head.

THOSE who will take the trouble to see the delineation of these instruments, in these authors, will, at the very first glance of the eye, be convinced of their unserviceableness. So would they be of that of another instrument of the like nature, invented some years ago, and attributed to a surgeon of Rouen, which is composed of two crotchets, of which the blades are arched, and their extremities claw-footed.

THE horror which these means of extraction naturally inspire, the damage and inconveniences inseparable from them, notwithstanding all the improvements pretended to have been made, have engaged several authors to imagine other less dangerous expedients. But before I mention them, I cannot well avoid taking notice of a suggestion of _Celsus_, if but to warn those whom it may concern, not to be too much carried away by the authority of a great _name_.

IN such a case the method Celsus recommends, is, for one of the robustest men that may be got, to press strongly upon the belly of the patient, with his heavy hands, inclining them downwards, so that such a pressure may force out the head that shall have remained in the uterus. Is not this a right _learned_, and especially a very tender expedient?

MAURICEAU and Amand giving a loose to their genius have proposed less perilous methods.

_THE_ first tells us, that it came into his head, in this case, that a fillet of soft linnen might be made, in from of a sling, to be slipped over the head, and so bring it away.

AMAND has imagined a silk caul, of net work, to wrap the head in. This caul is to be pursed up by means of a string, that gathers four ribbons fastened to four opposite points of the circumference, or opening of this kind of purse, by which the head so wrapped up is to be extracted.

MR. Walgrave professor at Copenhagen has improved on the first scheme of a fillet, by stitching together the two extremities of a fillet of linnen of about two yards long and four or five inches wide, in which he makes three slits lengthways, to seize the head more firmly, and hinder the fillet from slipping off the rounder parts of it. The figure of it may be seen in a Latin work intitled, _Dissertation upon the separated head of a child, and the different ways of extracting it from the mother’s womb_. By Mr. John Voigt, at Giessen, 1749.

MONSIEUR Gregoire, man-midwife at Paris, has disputed with Monsieur Amand the glory of this invention of the caul.

BUT if a reader will deign to consult his own reflexion, upon even these last, less however injurious means than those of iron and steel instruments, he will probably conclude, that if it is possible to come at the head, so as to fix, for example, a caul over it, the same liberty of access will serve to do all that can be necessary to secure a sufficient hold and purchase for the naked hand to bring it away, without such aids, as must necessarily suppose a free play of the hand in the uterus. I own this requires great shreudness of discernment by the touch, great expertness, great slight of hand and neat conveyance, but these are all points of excellence which midwives should be exhorted, encouraged, and even obliged to acquire: for acquire them they may; which is more than the men, generally speaking, ever can, and are therefore supplementally obliged to have recourse to such substitutes to hands, as those horrid instruments or silly inventions of theirs, with which, even at the best, they can never do so well as the women, who understand their business, can do without them.

LET it also be here remembered, what I observed at the beginning of this section, that this case of a separated head, I might almost say, never, no never comes into existence but through some previous neglect, error or failure of practice: so that surely the preventing it must be rather, preferable to the necessity of remedying it, either with crotchets, fillets, or even with but the hand alone; the trusting to any of which may make practitioners so often remiss, where remissness can hardly ever be but of bad consequence, where no fault, in short, can be other than a great one, and for which, the innocent patient it is that must most commonly be the sufferer, both in her own person, and in that of her child.

Of that labor in which the head of the fœtus remains hitched in the passage, the body being entirely come out of the uterus.

IT is here to be observed that though the body may be intirely free of the uterus, some of the causes deduced in the precedent section, may produce impediments or obstacles to the issue of the head. The head never detaches itself from the body but in that labor where the feet of the child come out first, and are too forcibly hauled by rash or unskilful hands, by such in short as do not know how to disingage or remove the let or obstacle to the issue of the head, with one hand, while with the other they properly support the body of the child. As it is then greatly to be wished that this accident might never happen, I shall, to the means I have already indicated for preventing or remedying it, add others coincidently with the design of this section, to prove the inutility of instruments in the case of the title prefixed to it. I shall then quote the practical tenets of the best authors upon this point, together with reflexions, which my own experience and practice have suggested to me.

MAURICEAU explains this case tolerably justly, where he treats of the footling-extraction.

“CARE (says he) should be taken that the child should have its face and belly directly downwards; to prevent, on their being turned upwards, the head of it being, towards the chin, stopped by the os pubis. If therefore it should not be so turned, it must be put into that posture. This will easily be done if, as soon as you begin drawing the child out by the feet, you incline and turn it little by little, in proportion as your extraction of it proceeds, till its heels bear in a direct line with the belly of the mother,”

[_Here I must beg leave to interrupt Mr. Mauriceau, to observe, that it is not enough to have hold of the child’s feet to begin turning it: but the breech must have come out: then, if it is not well turned, by placing one hand on the belly, and the other on the breech of the child, there will be time enough easily to turn it immediately and naturally, neither with too much precipitation, nor yet too leisurely, not little by little, or by slow degrees. This last precaution being of no use but to flag an operation, in which a delay may be fatal to the child, without any service to the mother, it only keeping her the longer in pain._]