Part 16 (1/2)
The whole process of introducing and fixing the forceps should be conducted in as gentle and gradual a manner as possible: no attempt should be made to proceed with the operation during a pain; and in no case is force either necessary or justifiable.
Every thing being now prepared for the extraction, we must endeavour to make this resemble as far as possible the natural expulsion. When a pain, therefore, comes on, we should grasp the handle firmly, and pull gently, at the same time giving them a rotatory motion. The direction of the handles, as before said, will depend upon the situation of the head in the pelvis: if it be at the outlet, it will point downwards and forwards; if in the cavity, nearly directly downwards. If the head makes but little or no advance with one or two efforts, it will be advisable to tie the handles firmly together, and thus keep up a continued pressure upon it, and dispose it the more to elongate and adapt itself to the pa.s.sages. As it advances and begins to press upon the perineum, we must be more than ever cautious not to hurry the expulsion, and give the soft parts time to dilate sufficiently. At this period it is desirable to make the extractive effort not so much forwards as the direction of the handles would seem to indicate: we thus avoid pressing too severely upon the urethra and neck of the bladder, which might otherwise suffer, and a.s.sist the dilatation of the perineum. When the head is on the point of pa.s.sing the os externum, all farther extractive efforts should cease; the perineum must be supported in the usual manner, and the head should be expelled if possible by the patient herself.[87]
In applying the curved forceps we must bear in mind another rule in addition to the one above-mentioned for selecting the first blade, viz.
the pelvic curvature must correspond with that of the sacrum. As with the straight, so also with the curved forceps, the extremity of the blade will be our best guide as to the direction in which we should hold the handle at the moment of introduction; it must be directed more or less forwards in proportion to the degree of the pelvic curvature of the blade. If, for instance, it be the upper blade which is to be introduced first, we pa.s.s it obliquely over the lower thigh or nates of the mother, making it glide closely round the convexity of the head, between it and the pelvis, without impinging either on the one or the other. As the position of the head is still more distinctly oblique at this earlier period of its progress through the pelvis, so will the blades require a more oblique direction, and also (as in the former case) they must be introduced in the contrary oblique diameter to that in which the head is.
As the blade pa.s.ses up between the head and pelvis, so does the handle gradually make a sweep backwards, until at length it approaches to the edge of the perineum. During the process of introduction, one or two fingers should press against the posterior edge of the blade to guide it up to the brim of the pelvis, and prevent its slipping too far backwards towards the hollow of the sacrum.
The second blade will be guided in its direction by that of the first: it must be introduced so that the inner surface of its handle corresponds exactly with that of the first. The locking must be performed under the same precautions as with the straight forceps: the more so, as in some cases it has to take place just within the os externum, and therefore requires the most careful attention to prevent the soft parts from being caught and pinched between the blades when they are brought together. In extracting the head we must bear in mind the part of the pelvis in which it is impacted, and make our effort in the direction of its axis; we must also recollect the curved form of the instrument, and that we must not pull in the direction in which the handles point, but rather hold them firmly with one hand, and, by pressing against the middle of the forceps with the other, guide the head downwards and backwards into the cavity of the pelvis. We shall thus make our extractive effort in the direction of the upper portion of the blades, or that part which has the chief hold upon the head: hence, therefore, as it descends, the handles are directed more and more forwards, so that when it has reached the perineum, the handles will not only point forwards, but considerably upwards. Whilst extracting we should, as with the straight forceps, slowly move the handles from side to side, and even make them describe a circle: we thus not only use the forceps as a simple extracting instrument, but make it act as a lever in every direction, and greatly facilitate the advance of the head, even under circ.u.mstances of considerable impaction. It is in these cases where keeping up a continued pressure upon the head by tying the handles tightly together, and tightening it after every successive effort, has such excellent effects in diminis.h.i.+ng the degree with which it is wedged against the pelvis and soft parts, and in disposing it by gradual elongation to a.s.sume a form which is better adapted for advancing through the pa.s.sages.
The slow and gradual pressure of the forceps thus exerted upon the head of a living foetus will have a very different result to that of the experiments by Baudelocque and others, in attempting to compress the head of a dead foetus by the application of a sudden and powerful force. Even if we were capable of effecting no greater diminution of its lateral diameter than a quarter, or at the most, three-eighths of an inch, as stated by Dr. Burns, we should, in most cases of impacted head, where the forceps is justifiable, find it quite sufficient to remove the obstructing causes.
The forceps is also occasionally required in presentations of the face and nates. In the first case we must pa.s.s up the blades on each side of the face, and along the side of the head, having previously ascertained to which side of the pelvis the chin is turned. In nates cases, the blades should also be pa.s.sed up along the sides of the child's pelvis, and here the advantages of a broad fenestra will be very evident, for otherwise our hold will not be firm enough without exerting an improper degree of pressure.
Cases every now and then occur, where from convulsions, &c., it is desirable to apply the forceps whilst the patient is lying upon her back, as is practised upon the continent. ”The patient is placed across the bed, propped up in a half-sitting posture, by pillows, &c., her pelvis resting upon the edge, her feet on two chairs, the knees supported by a.s.sistants.
Two, and generally three fingers are pa.s.sed, if possible, up to the os uteri, on the side where the blade is to be introduced: the index finger, is held a little behind the middle finger, so that this last, by projecting somewhat, forms a species of ledge upon which the blade slides, and which acts as a fulcrum to it. The handle is held at first nearly perpendicular; but as the blade advances, it gradually approaches the horizontal direction, being guided by the pelvic curve of the instrument.
The middle finger, along the ulnar surface of which the convex edge of the blade slides, prevents its extremity from pa.s.sing too far backwards, and directs it in the axis of the pelvis. When introduced to the full extent, the handle is inclined obliquely downwards, and is now grasped by an a.s.sistant pa.s.sing his hand below the patient's thigh. The other blade is introduced in the same way on the opposite side of the pelvis; and the locking, extraction, &c., conducted much in the same manner as in England.” (_British and Foreign Med. Rev._ vol. iii. April 1837, p. 419.)
_History of the forceps._ We have already mentioned some historical points connected with the improvements of the present French and English forceps; it will now be unnecessary to enter more fully into the history of this instrument. The earliest trace of the midwifery forceps which we possess is under the form of a secret in the hands of an English family, named Chamberlen. As to when and by whom it was first invented, this must probably remain for ever unknown; and at any rate there is no more reason to suppose that Dr. Hugh Chamberlen was the inventor than his father or brothers were. He was compelled to quit England on account of being involved in the political troubles of the time, and went to Paris in the beginning of the year 1770, and evidently had then been some time in possession of the secret. He returned to London, in August of the same year, having in vain attempted to sell it to the French government, after having entirely failed in a case of difficult labour which he had a.s.serted he could deliver in a few minutes, although Mauriceau had stated that the Caesarean operation would be required. Dr. H. Chamberlen published in 1772, a translation of Mauriceau's work, which had appeared four years previously, and in his preface he publicly alludes to this secret, and says, ”My father, brothers, and myself (though none else in Europe, as I know) have, by G.o.d's blessing and our industry, attained to, and long practised a way to deliver women in this case without any prejudice to them or their infants: though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy, one or both, with hooks.” He thus apologizes for not having divulged this secret: ”there being my father and two brothers living, that practice this art, I cannot esteem it my own to dispose of, nor publish it without injury to them.”
Whether a work, ent.i.tled _Midwife's Practice_, by Hugh Chamberlen, 1665, was by the translator of Mauriceau's work, or by his father, must now remain a matter of doubt: it was, however, in all probability by the latter, from what the translator says in his preface, viz. ”I designed a small manual to that purpose, but meeting some time after in France, with this treatise of Mauriceau, I changed my resolution into that of translating him.” On account of his being attached to the party of James II. he was again obliged to quit England, in 1688, and crossed over to Amsterdam, where he settled, and in five years after succeeded in selling his secret to three Dutch pract.i.tioners, viz. Roger Roonhuysen, Cornelius Bokelman, and Frederick Ruysch, the celebrated anatomist. In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it generally known. It turned out to be a flat bar of iron, somewhat curved at each end: this lever was stated to have been received from Roonhuysen, one of the original purchasers of the Chamberlen secret; but there is no reason to suppose that any such instrument had been communicated by Chamberlen either to him or the others, as we have distinct evidence that both Ruysch and Bokelman possessed _forceps_, the blades of which united at their lower end by means of a hinge and pin. It is known also that Roonhuysen used a double instrument consisting of two blades. The above-mentioned flat bar of iron, commonly called Roonhuysen's lever, was, without doubt, invented after his time, by Plaatman, who received the Chamberlen secret from him. (_Edin.
Med. and Surg. Journal_, Oct., 1833.)
[Ill.u.s.tration: Chamberlen's Forceps.]
Not many years ago a collection of obstetric instruments were found at Woodham, Mortimer Hall, near Mildon, in Ess.e.x, which formerly belonged to Dr. Peter Chamberlen, who, having purchased this estate ”some time previous to 1683,” was, in all probability, one of the brothers alluded to by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's work. This collection, (now in the possession of the Medico-Chirurgical Society, of London,) contains several forceps, two of which appear to have been used in actual practice: these differ from each other only in size, and present a great improvement upon the instrument possessed by Hugh Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well formed: the locks are the same as of a common pair of scissors, except that in one case the pivot is riveted into one lock, which pa.s.ses through a hole in the other when the blades are brought together. In the smaller forceps there is merely a hole in each lock through which a cord is pa.s.sed, and then wound round the shanks of the blades to fasten them together, an improvement in which Dr. Peter Chamberlen had evidently antic.i.p.ated Chapman, in making the first approach to the present English lock.
The earliest professors of the forceps, besides the Chamberlens, were Drinkwater, who commenced practice at Brentford, in 1668, and died in 1728; Giffard, who has given cases where he used his extractor as early as 1726; and Chapman, who possessed a similar instrument about the same time. These forceps correspond very nearly with the above-mentioned ones of Dr. Peter Chamberlen; and as it is well known that from those of Giffard and Chapman, the forceps of the present day are descended, we cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for these instruments, to which his bear so distant a resemblance, as to his relations, who, from living together in England, had doubtless a.s.sisted each other by their mutual inventions, and thus brought the instrument to that state of improvement in which it was found as above-mentioned.
For more detailed information respecting the history of the forceps we may refer our readers to Mulder's _Historia Forcipum_, &c., particularly, the German translation by Schlegel, to a similar work brought down to the present time, by Professor Edward von Siebold, to our own lectures on this subject, published in the _London Med. and Surg. Journal_, for March 28, 1835, vol. vii., and to the two papers already alluded to in the _London Med. Gazette_, Jan. 8, 1831, and _Edinburgh Med. and Surg. Journal_, October, 1833. [Also, _Researches on Operative Midwifery_, &c. By FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. _Dublin_, 1841.--ED.]
CHAPTER II.
TURNING.
_Turning.--Indications.--Circ.u.mstances most favourable for this operation.--Rules for finding the feet.--Extraction with the feet foremost.--Turning with the nates foremost.--Turning with the head foremost.--History of turning._
Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os uteri and v.a.g.i.n.a, and in this manner the child delivered. (Naegele, _MS.
Lectures_.)
Besides turning with the feet foremost as now described it has also been proposed, as being safer for the child, to bring down the nates or the head, but these operations, especially the former, have scarcely ever been practised, and in most cases are impracticable.
Turning, in the strict sense of the word, is that operation, by which, without danger to the mother or her child, the position of the latter is changed, either for the purpose of rendering the labour more favourable, or for adapting the position of the child for delivering it artificially.
The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the child, it has been very properly recommended by Deleurye, (_Traite des Accouchemens_, 1770,) Boer, (_Naturliche Geburtshulfe_, 1810,) Wigand, (_Geburt des Menschen_, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling powers; hence, therefore, under these circ.u.mstances, artificial extraction of the child with the feet foremost can scarcely be said to exist, the operation itself being confined to changing the position of the child.
Where, however, the circ.u.mstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation.
The artificially changing the child's position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty.