Part 18
“THERE are (he goes on) however children with so large a head, that it remains stopped in the passage after the body is intirely got out, notwithstanding all the precautions that can be used to avoid it. In this case, you must not stand amusing yourself with so much as attempting to bring the child away by the shoulders, for sometimes you will sooner part the body from the neck, than get the child out by this means. But while some other person shall pull it by the two feet or beneath the knees,” [_here Monsieur Mauriceau is much out: great care should be taken not to have it pulled by any one, but purely to give the body of the child to be supported by some discret person, while the delivery proceeds as the author goes on to describe_] “the operator will disingage little by little the head from between the bones of the passage, which he may do by sliding softly one or two fingers of his left hand into the mouth of the child, to disingage the chin in the first place, and with his right hand, he will embrace the back of the child’s neck, above the shoulders, to draw it afterwards, with the help of one of the fingers of his left hand, employed, as I have just observed, in disingaging the chin. For it is this part which the most contributes to detain the head in the passage, whence it cannot be drawn out before the chin shall have been intirely disingaged. Observe also, that this is to be done with all possible dispatch for fear the child should be suffocated, as would indubitably happen, were he to remain any time thus held and stopped: because the umbilical chord, which will have come out, being turned cold, and strongly compressed by the body or by the head of the child, remaining too long in the passage, the child cannot then be kept alive by means of the mother’s blood, whose motion is stopped in that chord, as well by its cooling which coagulates it, as by the compression which hinders it from circulating, for want of which it is a necessity for the child to breathe, which he cannot do till his head shall be intirely out of the uterus: therefore when once you have begun the extraction of the child, you must try to procure the total issue of it as quick as possible.”
MONSIEUR Levret, who has wrote for no end on earth but to recommend his _tire-tête_, seizes the occasion of the foregoing passage extracted from Mauriceau to tell us, page 51, of the first part of his work.
“MAURICEAU acknowledges here, that there are children who have the head so large, as for it to remain stopped in the passage, after the body shall have been wholly got out, notwithstanding all the precautions that can be taken to avoid it.”
FROM whence this zealous instrumentarian draws the following conclusion. “Here (says he) is one of those cases, in which my _instrument_ may be of great service.”
THIS conclusion however does not to me at all appear a just one.
FIRST, because Mauriceau, after those lines of his, just above quoted by Levret, adds immediately the method of practice pursuable in this case, to give a good account of it without the help of instruments.
SECONDLY, because we are not at all to be concluded by what any author says, any farther than the truth of things bears him out. Mauriceau[35] might have explained himself better: he might have said, that, in this case, the child should be pushed back a little into the uterus, to have the freer play for its being more easily disingaged: he might have advised, as I have before observed, rather a safer method of proceeding than what he has done. Mr. Levret himself allows this p. 56. Then, still with a view to recommend his forceps, his _tire-tête_, as being absolutely necessary, he continues thus (p. 58.)
“THOUGH every thing should apparently have been done that is above set forth, still we are not always so happy as to accomplish the delivery. It sometimes happens, that we cannot get the head of the child out of the uterus. There are of this two examples in the treatise of M. De la Motte, of which I do not think it here out of place to furnish an extract.
“MR. De la Motte, in his 253d. Observation, (goes on M. Levret) relates, that in a case in which he was obliged to turn the child, in order the better to finish the delivery, he turned it very easily; that having brought it out as far as to the thighs ... it being alive, he gave its body a half turn, so as to put its face downwards which it had upwards, and that then he continued drawing out the child as far as to the shoulders and neck.
“AFTER that (says M. De la Motte) I gave it some gentle shakes, and even pulled it pretty hard, and had several tugs at it, to make an end of a delivery I had so happily begun; but all was in vain. This obliged me, according to my usual method, to put my finger into its mouth. I was mistaken, for what I took to be the mouth, I found to be the nape of the neck, and that the neck, not having followed the motion of the body, was twisted round, and consequently the face still remained turned upwards, so that the chin it was that, being hitched at the os pubis, was the obstacle to have been conquered to terminate the delivery.”
MR. LEVRET here observes, there being a great probability that, when la Motte turned the body of the child, he was pulling it towards him, and that the mother was in a labor-throw: for it is well known, that then the uterus contracts itself in all directions round the body it contains: she was then compressing exactly the head of the child, which must render it immoveable, while he was turning the body. These two co-incidences must have contributed to twist the neck of the child, consequently to make it lose its life. And to clench the misfortune, he gave its little body to be held by the husband of the mother, while he was pushing back the head with one hand, and with the other disingaging the chin. He told the husband at the same time to pull softly; “but he hauled with such violence, in the hope of easing his wife, that he fell with a jerk six foot off the bed, with the body of the child, of which the head had remained in the uterus.”
LET us proceed to the second example. This is the fact. M. De la Motte tells us, that he was called to assist a poor woman in labor, in which she had been lingering for two days, that this patient was a very little woman, and of about forty five years of age; the arm of a very small child had come out the day before.
“I SLIPPED (said he) my hand along this little arm, to go in quest of the feet, which I presently found, and after having closed them together, I brought them away out of the uterus. The body followed till it came to the neck. The patient being on the edge of the bed, which was very high from the ground, and where there was not room enough left to support the child in proportion as I drew it out, I was obliged to give it a woman to hold, while I proceeded gently to disengage the head which was stopped in the passage. This was no wonder, considering the streightness of it, being correspondent to the littleness of her size; considering withal the advanced age of the patient, the length of time since the discharge of the waters, during which the uterus being irritated by the lingeringness of the labor, the presence of the arm in the passage had caused an inflammation, consequently some induration, all these joined to the time that the fœtus had been dead, which as before observed was a very small creature, were reasons more than sufficient to manage very tenderly with the child, so as to bring it away whole. This (says M. De la Motte) induced me to introduce my hand flat towards the _frænum labiorum_, and to put my middle finger into the child’s mouth, while my other hand was over its neck. My measures being thus taken, I desired the midwife, while I should disingage the parts, to pull softly, for fear of an accident. But she nevertheless, senselessly and foolishly, gave it much such a pull, as the woman’s husband I have before mentioned. This indeed forced out the body of the child, but severed from the head, which remained in the uterus.”
HERE it may be observed that Monsieur Levret, by this preamble, on the one hand prepares us for the necessity of his instrument, by a constant supposition of cases, in which, notwithstanding all the precautions that may be taken, it happens sometimes (as he says) “that it is not possible to terminate happily the delivery, nor get the child’s head out of the uterus;” to support which opinion he produces the two examples from De la Motte, which I have just before quoted.
ON the other hand, he owns, as it were, _en passant_, that there are means, which he even explains of accomplishing successfully the deliveries, in such labors, by solely the operation of the hands, avoiding the faults committed by M. De la Motte, after which, as if those faults were any proof in favor of his instrument, he concludes, that, “if through any cause whatever, this case was not to be got over, the child should be given to some one to be held, with the precautions before set forth, and that then the operator was to proceed with his instruments.”
IN the first example we see that De la Motte was guilty of three grievous errors. The first, in taking the nape of the neck for the mouth: the second, in having taken the time of the mother’s throw, in which the uterus must have contracted round the neck in all directions, to turn the body of the child, which contributed to twist its neck: thirdly, in having given the body of the child to the husband to hold, with direction to pull it, even tho’ he cautioned him to do it gently. He ought rather not to have trusted him with the body at all, or have absolutely forbid him to make the least motion, his part being only to support it.
IN the second example, De la Motte committed no more than the last fault, in trusting a midwife, of whom he might not know all the stupidity: but this was sufficient to produce that accident; an accident which it will not even be hard to avoid, with due management, or hands skilfully conducted.
WITH Mons. Levret’s leave (whom I ought to honor, since it is from him I have chiefly taken what he has said against all instruments but his own) I shall then say, that it is against the laws of candor, or of common sense, to seek, from the faults which may be committed in the manual practice, either through ignorance, inadvertence, or want of circumspection, to infer the necessity of instruments.
THE point here under discussion turns intirely upon a child extracted by the feet. Now it is extremely rare, that in this case, the head does not follow the body. But if, in exception to this general rule, the head should be stopped in the passage, upon proceeding to disengage it, with all the proper measures and precautions which I have added to those above specified from Mauriceau, the sole aid of the hands will be full sufficient to accomplish the total delivery. But if they were to be ill managed, the risk would be evidently great of detaching the body from the head; and this would change the case from that of the head stuck in the passage, to the one of the head separated from the body, of which I have treated in the preceding section. Without then multiplying cases without necessity, as the reader will easily see, that the first is but the consequence of a mis-treatment of the last, so that, by the same rule, the right management of the last case is a sure prevention of the first, I shall only observe, that it might be shewn, that capable, well-conducted hands are sufficient to guard against both dangers, and shewn, even by Mons. Levret’s own confession, which he so inconsistently contradicts, in favor of his own instrument, without offering any thing like a reason for such a contradiction.
BUT if the damage in these cases resulting from an unskilful use of the hands should be urged against me: I answer, in the first place, that I am not arguing for any thing but what is to be effectuated by good practice: my point, is only to establish the superiority of skilful hands to the use of instruments: and in these cases, I aver, that even the damages done by the mispractice of defective hands, may be better repaired by sufficient ones, than by a recourse to instruments. How often too are instruments used by such men-operators, as are to the full as unfit to manage such instruments, bad as they are, as some women may be to use their hands! But if I could give no better reason for the rejection of instruments, than the abuse of them, even by the numbers of ignorant superficial men-practitioners that employ them, I should not expect to be heard; and yet the great argument against midwives is the ignorance of a few of them: though that ignorance of theirs could never produce such a multiplicity of horrors, of murders, injuries, tortures of mothers, such mutilations and massacres of children, as the deep learning of the instrumentarians!
MY plea then is much more fair. The reader will be pleased to consider, and decide upon his own reflexions, whether, it is not at least probable, from what has been shewn in the cases of the obliquity of the uterus, of a head separate from the body of the fœtus, or even of that reputed most dangerous extremity, the head being hitched in the passage, when the whole body shall have come out, that every thing may be at least as hopefully attempted with the hands alone, as with those instruments, the use of which forms the sole reason for a recourse to men-practitioners; tho’, well considered, nothing could be a stronger reason against such a recourse than their using them. But let us proceed to the next case;
When the head of the fœtus presents itself foremost, but sticks in the passage.
FOR this section it is, that I have reserved to treat incidentally and more at large of the objections to be made in general to all instruments, and in particular to the principal ones.
AMONG the severe labors, which give much trouble, and exact much patience from all parties, from the patient, the midwife, and all the assistence, this case may challenge a place. It is that, in which the head of the child having presented itself foremost, and having ingaged itself half way, or thereabouts, in the streight of the bones of the pelvis, and of the orifice of the uterus, the labor-pains remit, languish, and the progress of the labor becomes suspended. Whether there be any mis-conformation of the bones of the pelvis, or whether (as our practitioners are pleased to express it,) the head of the fœtus be too large for the passage, or whether, in short, both these causes concur to the formation of this obstacle, or exist in complication with other circumstances; it is, in this case, we may say the head is hitched, stuck or ingaged in the passage.
MR. De la Motte, book the 3d. chapter the 20th, describes this state of the fœtus.
“WHEN (says he) the head has struck into the streight of the passage which, at first, affords a great deal less room than were to be wished, for its letting it pass, the head ingages itself as much forward as possible, from the continual and violent pains the woman suffers, which act upon the child, whose head lengthens and flattens, in such a manner, to adjust and mould itself to the passage, that the hairy scalp becomes quite tumefied, so as to make the head look almost like a double head, which however remains stuck fast between the bones, without being able to get out, and only ingages itself the more the more it advances ... but growing larger as it advances, and the aperture which it obliged to force diminishing more and more, makes it so that the head remains at length so jammed in, that it cannot be drawn out without diminishing its volume, which (as this author says) cannot be executed without instruments: as I was obliged to do, to accomplish the following delivery.”
MR. De la Motte then proceeds to tell us, that he was called to lay the wife of a laborer, the head of whose child was hitched in the passage. After having well examined the state of the mother and child, and ascertained as much as it is possible to ascertain the death of the latter——“I determined, (says he) to finish the delivery, which I did by opening the head of the child with my incision-knife, and scooped out therewith part of the brain. After which, I made use of my hand, with which I got hold of the inside of the skull, and in an instant drew the child out, who appeared to have been dead a long time.”
IT is not here that, in answer to M. De la Motte, I shall stop to propose a more gentle and more natural method of giving a good account of this case of a hitched head, than the cruel and dangerous expedients suggested by the instrumentarians: I reserve the submission to better judgment of my own ideas of practice, in this point, till after I shall have quoted the notions of more authors.
DAVENTER, p. 343, of his observations, supposes to us the case of a head stuck in the passage, when the difficulty of the labor shall have been increased, as well by the ignorance, as by the negligence of the practitioner, male or female, that may not have given the proper aid in due time, or not have foreseen the danger; he moreover supposes a complication of obliquity, caused by the mis-conformation of the bones in the patient. If this embarrassment then should not have been foreseen or guarded against, he advises the opening of the head of the child.
“THERE is, for this no occasion (says he) for any instruments of a particular make; a common knife guarded as far as the point, a pair of scissors, a pointed spatula do the business. The opening they make may be dilated with the fingers, and the brain taken out; after which, you seize the head with your hand, or with a linnen cloth, and try, in this manner, to bring away the body. When I say you may draw the head out with a linnen cloth, I mean a broad strip or fillet cut lengthways of the cloth, and hemmed in the borders, or any piece of linnen that is fine and strong, to be passed round the back of the head, and bringing in under the chin, you twist the fillet, and draw out the child.”——He then adds, that he much esteems this method; that those, whose hands are _small_ enough to pass this linnen round the back of the head, without opening it, are not obliged to open it, and have therein a great advantage over others.
THIS last method proposed by Daventer ought doubtless to be preferably pursued, as being the less cruel. But, in the first place, it is utterly impracticable. A head represented to be hitched or jammed, does not leave the least hands that can be imagined room or liberty to pass a fillet round the back of the head, in order to bring it under the chin. But were it even practicable, it would be useless, and dangerous: useless, in that the hands alone, so introduced, might of themselves, little by little, disingage this head; dangerous, for that this fillet might most likely produce the effect that fillets commonly do, strangle the child.
MAURICEAU, to conquer this obstacle of the head so stuck, proposes several kinds of crotchets, to apply various ways, to the head of the child, after having scooped out the brain, by means of an opening made in the skull. He gives us several examples in his observations, but as they are absolutely fit for nothing but to inspire horror, I shall refrain from specifying them. Dyonis is of the same opinion with Mauriceau.
THOSE who will give themselves the trouble to peruse the authors who have preceded thus, will find, that their method differs very little from that of la Motte and Mauriceau, which most assuredly kills the child if it is not dead: and the ascertainment of the death of a child stuck in the passage is so difficult, that the ablest practitioners cannot answer for not being mistaken in it. The reader will please to apply here what I set forth, p. 139, and following, to which I beg leave to refer.
MAURICEAU, at length, imagined, that he had out-done all others, in his invention of an instrument he calls a _tire-tête_. He specifies it in his 26th observation. But it is as dangerous as the crotchets, since, in order to use it, you must begin by opening the skull with an incision-knife, or with a sort of steel spike, double-edged, which he invented on purpose for the use of piercing the child’s scull at the _fontanelle_, to admit a little round plate of steel of another instrument.
MONSIEUR Soumain, and other celebrated practitioners, have acknowledged the insufficiency of this instrument of Mauriceau; but were it good for any thing, as to drawing out the head so stuck, it would for ever be fatal to those poor unfortunates, since it could not fail of killing them if they were still alive.
AFTER this we have the tire-tête of Mr. Fried, but it is as murderous as that of Mauriceau, nor answers the intentions which its author had proposed to himself. He has therefore himself had the candor to condemn it, as may be seen p. 154. in a treatise of midwifery, published in 1746, by the care of Mr. Boëhmer, who has added two dissertations to the treatise on this art by Dr. Manningham.
MR. Menard, in his preface, p. 24, gives the figure of an instrument, of which the idea seems to have been taken from a twibill, with a ducks beak. Mr. Menard has endeavoured at perfecting it, by having it made angular, shortened, and grooved. He has given it a figure of dented pinchers, with curve claws. He gives us also the figure of an instrument pointed and edged, made like the head of a spear, which he uses for opening the scull, and introducing the pinchers, by means of which he draws the child out by the head, as he keeps pinching the bones of the scull and teguments. By this it is easy to conceive, that this instrument has no advantage over that of Mauriceau, and has all its inconveniences.
MANY other modern practitioners advise the use of one or two crotchets, be the child dead or alive, or of a tire-tête, made in form of strait blades, with spoon-bills, to introduce them one after another into the uterus; and after having placed them on each side of the child’s head, and made them meet together, to try the extraction with them.
THIS last contrivance, as ingenious as it may appear, does not save the child’s life, as all these authors would insinuate. For these instruments, wherever they are applied, must pierce to get a solid hold; without which they could serve for nothing but to crush or lacerate the teguments; so that they should not be used where the child is a live one: and even when it’s dead, the mother is not absolutely safe from the damage they may do, whatever precaution the operator may take, or whatever may be his dexterity of hand. If one of the blades should slip, which frequently happens, it will be difficult for him not to do the mother a mischief. For as to the child, it is very rare that the crotchet does not instantly destroy it.
MENARD has again given us another figure of an instrument, to appearance less dangerous; but the make of it sufficiently denotes its want of power in the operation, which is also confirmed by the testimony of the most celebrated practitioners.