Part 20

“FIFTHLY, these same blades should, in their expansion, go a little depth in the vagina.

“IF the man-midwife, (says Levret) perceive, that _any_ of these favorable signs should be _wanting_, he ought to _mistrust_ the _success_, and to have recourse to his _sagacity_ for the remedying it.”

THUS far as to the handling this forceps of Levret’s, to whom the defectiveness of the English and French forceps had inspired an idea of providing such a supplement to it, from the richness of his own invention.

I DO not wonder however at no instrument pleasing Mr. Levret so well as his own. Nothing is more common among the instrumentarians, than their disagreement about the make of their instruments. Some will have their forceps long, others short, some strait and flat, others curve: in short, there is no adapting the mechanism of it to their various fancies, so apt too as they are to change. Levret complains bitterly of the inability or injustice of the instrument-makers; but by what I believe of them, very unjustly. The gift of the fault is not in the instrument; it is in the use to which they are so often put of attempting impossibilities.

BUT now let us examine, what surely very competent judges have thought of this famous new forceps of Mr. Levret, which he calls _his_ instrument.

WHEN the book and instrument were presented the Royal Society at London, it appears by a quotation inserted by Mr. Levret himself, that his instrument was allowed to be ingenious enough, but that “there was _nothing extraordinary in it_.”

PAGE the 10th of his preface, he has the candor to own, that he does not absolutely pretend that success will always attend its application, even in the cases he points out.

PAGE the 36th, and seq. of his observations, after having exploded the forceps, and other instruments of the authors who have preceded him; and after having described the alterations and corrections made in the English and French tire-têtes, he gives us indeed the better opinion of his, by a fair confession of the insufficiency of them all without exception, and even of his own: by which, however, it is plain, he can mean no more than that, imperfect as they are, they all are still preferable to the hands alone; but the question of this superiority is as constantly as it is shamelessly begged by him, and all his fraternity of instrumentarians.

THUS however he expresses himself as to his own instruments. “This instrument is actually, to all appearance, now at the very utmost degree of perfection, to which it is possible for it to arrive, without however having all the perfection that might be wished, for the most expert practitioners in the use of it, agree in the opinion.

“FIRST, of the difficulty of its introduction in certain cases.

“SECONDLY, of its stubbornness as to the crossing of the blades.

“THIRDLY, of its contributing to _tear_ the _fourchette_, or _frænum labiorum_.”

[OUR author is very angry, that Boëhmer, who, in his critical objections, opposes those his own words to him, has not added the subsequent lines.]

“THE correction I have made in this instrument (continues Levret) by means of the shifting axis, has rendered the difficulty of crossing the blades _less_ considerable, and the two following reflexions may serve _greatly_ to overcome the other two inconveniences.”

BUT should it be granted to Levret, that the shifting axis somewhat lessens the difficulty of crossing the blades of this instrument, it would still remain too great an one, for all that correction. The reflexions he adds, for the overcoming the other two inconveniences, carry no conviction with them; and indeed he himself seems to think so, by his adding afterwards (p. 99.)

“TO obviate this inconvenience of tearing the _fourchette_, or the perinæum, I caused to be made a _curve_ forceps, as to any thing else not differing, in its dimensions, from the first. I took the idea of it from the curve pinchers used in the operations of lithotomy. It will be easier to conceive, than for me to describe the advantage it must gain by it. That was not however the only end I proposed by it, as all the good practitioners at present agree on the _small_ efficacy of the common forceps, in the case of a head stuck in the passage when the face is turned upwards.”

IT is in consequence of this opinion that Levret, in the sequel to his observations, p. 301, tells us.

“I COULD (says he) answer Mr. Boëhmer, that all the most eminent men-midwives are convinced, that when the child presents with the face upwards, or turned forwards, that is to say, towards the os pubis, and that in this position, the head sticks, the forceps commonly used can be of _no_ service: I do not (adds he) even except the one I have had made with a shifting axis. The defectiveness of these instruments, in these particular cases, sufficiently proves, I should think on one hand, that the English forceps is not so good as Mr. Boëhmer seems to believe; and on the other, I presume, he will be convinced, that I am not more servilely attached to my own productions, than those of others.”

THIS insufficiency then of the common forceps has given rise to the curve forceps of our author. Here follows what he further adds to what I have above (p. 427) quoted from page 99 of his work.

“THE form I have given to my forceps, renders it then very useful, since, by means of the curve, it lays holds of the head with all the efficaciousness that can be found in the use of the common forceps, employed on the most advantageous position that the head can be imagined.... Notwithstanding all the corrections made in the English and French forceps (continues the other practitioners) if my instrument is compared to all the other forceps it will appear;

“FIRST, that it has none of their faults.

“SECONDLY, that it is very feasible with it to extract the head of a child separated from the body and remaining in the uterus. This is so possible, that all those who have seen my instrument, are unanimously of opinion, that no other forceps can do as much.

“THIRDLY, with my instrument it appears to me possible to assist powerfully the getting out the head of a child that shall have remained in the uterus, the body being entirely come out, but of which a part is still in the vagina.

“FOURTHLY, my instrument has this in common with the ordinary forceps, that it can extract a child by the head, when this part shall be stuck in the passage.”

IT may well be said here, that Mr. Levret attributes such excellent qualities, and marvellous properties, to that same new forceps of his, as ought to immortalize his memory, and render his forceps universal over the whole earth,—if they were but proved. Ay! there lies the difficulty. Messieurs Rathlaw, Boëhmer, Janckius, and the most notable practitioners in England, do not believe a syllable of the matter. Even Dr. Smellie, though I think he approves the crooked part of the forceps, speaks slightly enough of it, and has even dared to falsify the inventor’s assertion of the ne-plus-ultra of it, by altering the form, as he tells us, p. 370. “in a manner that renders it more simple, more convenient, and less expensive.” Mr. Levret cannot then expect we shall take these advantages for granted upon his own bare assertion, in the blind enthusiasm he manifests for this rare production of his genius. I do not so much as believe, that he was even himself, at times, clearly persuaded of its excellence. At least he, in several places, appears to contradict himself. As it is then greatly of use to show into what a maze of errors these are capable of falling, who neglecting the guidance of judgment in the road of truth, wander into the wilds of imagination, I shall just point out here some of Levret’s, at least, to me, seeming inconsistencies with himself, but especially with plain reason and common-sense. The reader will find the notice I take of them far from digressive, serving as they do even for connexion, as well as enforcement of my arguments.

MR. Levret, p. 161, concludes the first part of his observation thus.

“NOTA, some very intelligent persons have been pleased to charge me with an opinion, which I have never had as to CURVE FORCEPS: they think, that I believe it capable of going into the uterus in search of the child’s head when it is not ingaged in the orifice: and yet I do not advise the use of it, unless in those cases where the other (the common forceps) is employed, over which it has essential advantages.”

HERE the reader will please to observe, that all the wonders, just before quoted from himself, are reduced only to the cases in which it may be advantageously substituted to the common forceps. This, by the by, is reducing it to less than nothing. But how is this consistent with those same marvellous excellencies he displayed to us a little before, to wit? “_It is very feasible with it to extract the head of a child separate from the body, and remaining in the uterus._”——And again, “_with my instrument it appears to me possible, to assist powerfully the getting out the head of a child that shall have remained in the uterus, the body being entirely come out, but of which a part is still in the vagina_.”

NOW these two cases clearly imply, that Mr. Levret’s curve forceps is capable of going into the uterus in search of the child’s head, even when it is not engaged in the orifice: for here the case meant, is either that of a head remaining detachedly in the uterus, after having been severed or torn away from its body: or of a head not separated, but remaining in the uterus after the body shall have come out, and part of it is still in the vagina.

IF therefore Mr. Levret’s forceps had the advantage over the common forceps, confessedly insignificant in these cases, of being able to lay hold of these heads, he might be somewhat in the right to exalt it as he has done. But at present he must be wrong, which ever side he takes. The dilemma is self-evident. He is in the wrong to deny what he had certainly said. He is in the wrong to complain of being taxed with an opinion, which his own allegations prove he had entertained. I therefore refer Mr. Levret from himself to himself. If he did not believe, that his curve forceps had over all the rest the properties he sets forth, why has he so confidently affirmed them? and after affirming them, why would he hinder us from thinking that he believed what he affirmed?

I AM here to observe, that if I have made use of the terms of “a head not _separated but remaining in the uterus after the body shall have come out, and part of it is still in the vagina_,” it is purely because I would not change any thing in the expression of this celebrated instrumentarian. It is this exactness of quotation, that has made me conform myself to his manner of speaking, in my answer upon this difficulty. Otherwise, I own, I do not apprehend the propriety of his description of the case. It surprized me too the more, in so intelligent a writer as Mr. Levret, that he should represent to us a body come out of the uterus, and yet remaining in the vagina; as if, on such an occasion, the vagina could be distinguished from the orifice of the uterus. It is even stranger to me yet in Mr. Levret, for that he himself, in a note, p. 106, of his observations (by me before quoted) expressly says, that “when you are for using this forceps, it is absolutely necessary that the orifice of the uterus should be, as it were, totally erased or defaced;” so that the vagina and orifice should be laid into one. (See p. 420.)

HERE follows a much more material contradiction, rather however to common sense than to Levret himself, to which I intreat the reader’s particular attention.

OBSERVATIONS, part the 2d, p. 160. Levret gives us the following preliminary general precept.

“THERE is, says he, a general precept by which it is established, that a surgeon ought never to thrust instruments into deep places, without guiding or conducting them with the hand, or with the extremity of the fingers of that hand that does not hold the instrument.”

IT is then to this general axiom strongly dictated by reason, and surely in no case more obviously so, than where the exquisitely tender texture of the uterus protests against committing its safety from the cruellest injuries, to the necessarily blind random agency of an iron or steel instrument, so palpably ungovernable in so remote, intricate, and slippery a place by even the most skilful hand[40]; it is, I say, in exception to this so salutary general precept, that Mr. Levret will have it that there are exceptions, and in favor of what, do you think, not surely of the poor woman who, is to be the subject, or rather the victim of the experiment, but of——his most egregiously silly CURVE FORCEPS! Yes; it is by way of trying practices with that same instrument, that the patient is liable to be _spread out_, in that delicate attitude which I have above, (p. 237) described from Levret, to the perusal of whom, for a thorough conviction of the perfect insignificance of that instrument, or indeed of any of that sort, I would recommend even the most sanguine in favor of instruments, if they would but grant, to their own reason, its just prerogative of a previous suspence of prejudice.

IN these cases, however, for the which being exceptions to that excellent general rule, Levret contends; and, to do him justice, contends so auckwardly, that he rather provokes pity than indignation, at his endeavouring to establish even so pernicious an error; let the reader consider within himself the part into which this forceps is to be thus blindly thrust, at the risque of so many almost inevitable dangers. And for what?——In those cases it is either possible or not possible to introduce the fingers. Where they absolutely cannot be insinuated, the introduction of those instruments is in all human probability big with the worst of mischiefs, where neither hand nor fingers can controul the effects of the iron or steel: which, consequently, endanger more than they can help, and are therefore not to be used. But if the hand or the fingers can be insinuated, the hand or the fingers well conducted will do the work without the help of instruments, which in this second supposition become also useless.

THIS brings me to this case particularly, the title of which is prefixed to this section, that of a head stuck in the passage, which the gentlemen-midwives may perhaps second Levret, in maintaining to be an exception to that admirable axiom above quoted, and maintain it purely, in evasion of the conclusion against their miserable instruments, which I aver need never be resorted to, nor never are, but for want of sufficient skill in the manual function to terminate such labors without them.

I ANSWER then to these instrumentarians, that an instrument, even, no more dangerous than a probe, would in so tender a place as I am treating of, not perhaps be quite enough exempt from a possibility of doing mischief, to deserve an exception: but as to those instruments, which are so palpably likely to hurt both mother and child, to injure, in short, or even to destroy both the mould and the cast, they are all of them within the case of exception, or rather exclusion. It is then, in knowing what to do, and in the faculty of operating with the hand according to that knowledge, that the art of midwifery principally consists. If instruments are deemed ingenious, the doing without them is surely not less so.

NOW as to the case proposed in this section, that of a child’s head stuck in the passage, I aver, that it is not absolutely impossible to terminate this delivery by the hand.

I AM even ready to demonstrate this before any competent judges. I speak by experience. I have hitherto executed with all desirable success this operation without any aid but that of the hand, with a little patience and proper assiduity. I have many and many a time seen it practised at the Hôtel Dieu, and elsewhere. I never in my whole course of practice saw sufficient reason for attempting so hazardous an extraction, as that which is executed by means of a tire-tête. Why then those needless terrors, those superfluous tortures with instruments, to women already in too much pain and anguish? care enough could not be taken to spare those of the weaker-nerved sex in that condition such horrors, the very idea of which, to say no more, is enough to put them into imminent peril of their lives. All the forceps, and the rest of the chirurgical apparatus, especially the more complex instruments, very justly frighten the women, and their friends and assistents for them. Their introduction requires at once a painful, a shocking, and a needless devarication. The patients are put into attitudes capable of making them die with apprehension, if not with shame, from that native modesty of theirs, which, in these cases, may however be pronounced rather a wise instinct than a virtue.

HOW much preferable is the true midwife’s practice, who will have oftenest prevented, by her knowledge and skill, this very situation! That is to say, if she has been called in time. She knows how to predispose the passages, and by gentle reductions to restore Nature to her right road, where she has been through mispractice driven out of it, or through negligence suffered to deviate from it, or not preventively watched.

I HAVE never but seen, with respect to the uterus in this case, that it was possible to insinuate first one finger, then another, and little by little the whole hand, not indeed a hard hand, as big as a shoulder of mutton, the hand of some lusty he-midwife, but of a midwife, such as it is commonly seen.

WHEN Nature does not proceed as could be wished in her labor-pains, the point is then to husband well the strength of the patient, to restore it where it fails, by giving her good broths and corroboratives, that do not heat, or cooling things, where heating ones have been injudiciously administered. She is then to lie as composed and tranquil as possible; to be cherished, comforted, inheartened. There is, humanly speaking, no fear but her strength will return; her pains must not be irritated, nor herself harrassed with ineffectual interference. Nature will come to herself again: the situation will, by her benign energy, change for the better, and become favorable enough, for the midwife to be able to assist her in the due time with a manual operation, that will terminate happily her delivery. It is at least, with this success, that I have delivered many, who, by the unskilfulness of those who had attended them, at the beginning of their pains, had been reduced to a deplorable condition, by their labor lingering some for upwards of six days.

IN short, it is extremely rare that this case of a head stuck in the passage ever happens, unless under the hands of unskilful practitioners, or of over-dilatory or neglectful midwives, who will not have duly attended to the prognostics of this event; who will not have watched and taken the benefit of the favorable critical moment; who give the head time to engage itself, or get fast jammed, for want of their removing the impediments to Nature’s doing the rest, or when help has been called or come too late. It may also be owing to those who hasten too much, who precipitate the women’s labor by forcing draughts, that heat, burn them up, exhaust their strength, and prematurate the coming on of the labor-pains. Some practitioners fatigue them, with making them walk, or keep them up too much.

BUT when the membranes are not too soon pierced and the waters let out, when the pains are not provoked, when time is given to Nature to form to herself a passage, not omitting the precautions I have summarily intimated; when due care is taken to procure all possible ease of body and mind to the patient; who may vary her posture, sometimes lying along, sometimes sitting up, or well supported when she walks: little by little the head will frank itself a passage with the weight of the body acting by an innate energy, and with a little due assistence of the midwife’s art: and with this practical advertence, that, in these arduous cases, much may be safely left to Nature, but not every thing. There are times in which she cannot bear neglect, but there are none in which she can bear extreme violence.

HERE the reader will not expect I should in a treatise, purely calculated to expose the abuses of midwifery, attempt to particularize either all the contingent cases, or all the modes of operation in them. That would require a work a-part. I shall only then, to the four principal cases, in which instruments are so falsely supposed necessary, add a summary account of that of a _pendulous belly_, which is not without its difficulty.

AS to a PENDULOUS BELLY, madam Justine, midwife to the Electress of Brandenbourg, remarks, in her Treatise of the Art, that she knows, by experience, that some children turn upon their heads with their feet upwards, in women who have a large and prominent abdomen; because, says she, they are pitched too much into the fore-part of the belly, that is become pendulous. But she does not explain the consequence of this situation, which however does not fail of causing a severe and troublesome labor; in that the uterus being fallen into the capacity of the hypogastrium, and the child being got above the os pubis, there it sticks, and the labor-pains are ineffectual, if proper assistence is not given to Nature.

THE practice which my success on experience encourages me to propose is, to have the patient lye on her back, the belly to be braced upwards with a large linnen-fold or roller, to reduce the uterus and fœtus to its better position in the capacity of the pelvis; but if, notwithstanding that help, the head of the child continues to rest on the os pubis, the finger must be insinuated between those bones and the head, in order to make, it, little by little, retrograde into the pelvis towards the coccyx.

IN every case then that can be imagined, so far as my own experience and observation have reached, I am authorized to aver, that the gentleness of the manual assistence to women is at once more agreeable to Nature, and more salutary than the violence of the instrumental practice; which not only conveys the idea, but the very reality of a butchery. While its being sheltered under the plausible pretext of tenderness and pious regard to the safety of the poor women and children, cannot but provoke the greater indignation, at seeing vile interest trifling thus wantonly with their lives, and add to the cruel outrages on the human person, the greatest of insults on the human understanding.