REMARKS ON Dr. LEAKE's PAPER ON THE USE OF HIS FORCEPS.
REMARKS ON Dr. LEAKE's PAPER ON THE USE OF HIS FORCEPS.
TO prevent confusion, I shall examine the doctrine laid down in each paragraph, according to the order in which they arise.
I. The description of the Forceps is not correct. The Forceps ought to be considered as an Instrument consisting of two Levers, acting alternately from two centres, which are those parts of the child's head undergoing the greatest friction. It is true, that with respect to themselves, the centre of motion will be at that part where the blades unite; but when in the hands of the Operator, and containing a body within their Curve, the alternate motion necessary for the extraction of that body through a small space, changes the whole circumstance. Then all that part of the blades, not bearing upon the child's head, becomes an additional length of Lever.
II. Professors have generally misled us in the pursuit of practical knowledge, being too often of that order of men, who are the bane of real improvement.
"Inquirunt,
says Dr.
Harvey,
non quomodo res sunt, sed quid alii dicunt".
I believe there are reasons for suspecting that M.
Crantz
is but little qualified for laying down rules for the use of Instruments in Midwifery; and M.
Levrette
is not unexceptionable authority: The latter however set an example highly worthy of imitation, when he condemned the use of his Tire Tete, after having universally recommended it in the unexperienced part of his Life.
Dr.
Leake
says,
"When the Child's head is wedged within the bones of the Pelvis, it cannot be extracted by
Smellie
's Forceps, because of their shortness; and when the Hind-head is forced over the Symphysis of the Pubes, it cannot be got hold of, within the Curve of the Blades, because they are only curved in one direction, and being applied along the Ears, they are apt to slip over the Face, more especially as they are taper towards the point".
When the Head is
incuneatum, enclaveé,
or
wedged
in the Pelvis, it is a case in which Forceps of any kind cannot be used with prudence. If we did try them, we should happily miscarry in the attempt; for if we succeeded, dreadful would be the consequence to the soft parts of the Mother, crushed between the Child's head and Forceps on one hand and the bones of the Pelvis on the other.
It is supposed that the Hind-head is forced over the Symphysis of the Pubes. Whenever this is the case, it is not possible to apply Forceps of any kind with advantage, or without the utmost danger; and I call upon every Gentleman conversant in practice to confirm the truth of the assertion. This situation can only be occasioned by the projection of the Sacrum and last Vertebrae of the Loins. The Doctrine of applying Forceps before the bulk of the Head has passed the superior aperture of the Pelvis, carries great danger and unsurmountable difficulties on the face of it. Those who have endeavoured to reduce it to practice (for it is an old and obsolete doctrine) have in their accounts given us histories of their attempting it, of the difficulties they met with, of the mischief they did and a retraction of their errors.
The Censure on Dr.
Smellie
's Forceps is unprofitable. He was a man of great Candour, Industry and Ingenuity, and we are all indebted to him. Perhaps he pursued his favourite opinion too far, but let us attribute his errors to the common infirmity of Human Nature. Dr.
Smellie
's Forceps are not taper at the point.
The only possible advantage to be reaped from the third blade of the Forceps, is, the prevention of their slipping over the face, which does not happen once in a hundred times, if the Forceps are properly applied and the head of the child be low enough for their application.
III. Independent of the dimensions of the Pelvis, it is well known that there are many cases which require the use of the Forceps.
IV. Objections are made to the use of the Forceps, 'till the bulk of the head of a child has passed the superior aperture of the Pelvis, not only for the reason specified by Dr.
Leake,
but also because force cannot be exerted in a proper direction. It is true that terrible accidents have followed from the causes here mentioned; seldom of necessity however, but generally from mismanagement or innatention after delivery. They do not happen near so frequently when a Labor is wholly resigned to the efforts of Nature, as when the Forceps are injudiciously applied.
V. The largeness of the Head and the narrowness of the Pelvis are relative Terms. However desirable it might be to deliver a Woman under these circumstances, Facts prove, that if the bulk of the head is not descended through the superior aperture of the Pelvis, the attempt with Forceps would be fruitless with respect to the living Child and exceedingly pernicious with respect to the Mother.
No Practitioner who has a competent knowledge of
ever thinks of turning a Child when the head has entered the Pelvis and the Uterus is contracted. If the head is wedged in the Pelvis, this operation is absolutely impracticable.
VI. The case supposed in this paragraph, I believe never can happen at the upper part of the Pelvis; if it is meant at the lower part, the case requires no Instruments. For before it is perfectly turned, the Hind-head begins to emerge from under the arch of the Pubes. All presentations of the head, with regard to instrumental delivery, may be devided into two kinds;—with the face to the Sacrum;—or to the Pubes. Yet neither of these are exact at the time when it is judged necessary or proper to apply Instruments. At the superior aperture of the Pelvis the head descends with one ear to the Pubes, with the other to the Sacrum, or diagonally. As it progredes it necessarily turns to one of the general presentations, and it is compelled to this turn by the converging form of the internal surface of the Pelvis, and by the spinal processes of the Ischia. Now the Head is not placed with the Ears to each side, but diagonally, in all cases,
invariably,
when it is necessary to apply the Forceps. When they are applied, if the action be gentle with them, as it ought, the head will be turned, without our assistance, into the most favourable position, as in a natural Delivery. My reason for preferring the streight Forceps is a conviction that this opinion is true, and that under these circumstances the curvilinear Forceps become inconvenient, except with regard to the preservation of the Perinaeum. I do
not think any one case sufficient for the establishment of any practice.
VII. I know enough of the history of Vectes, in as able hands as
Roonhuysen
's, to convince a reasonable man that much mischief may be and has been done by them. It is not sufficient to know that Women have been delivered; we should be acquainted with the general events, or we cannot form any comparative judgement of the propriety of this or that Practice.
Roonhuysen
's Vectis changes it's centre of action, and though it may be first fixed against the Symphysis of the Pubes, the Ramus of the Ischium, near the obtuse process, must become the Fulcrum, or you will not be able to extract the head. I allow his Instrument to be very dangerous, but not to such a degree as the Forceps applied and acting before the bulk of the head has passed through the superior aperture of the Pelvis.
VIII. The application of a third blade is as free from danger as of either of the other blades.
IX. The resisting point is not particularly where the Hind-head presses against the Pubes;—the head is
wedged
and presses on many points.
X. The line of action will certainly be from the extremity of the curve. Without great caution, when the curved Forceps are introduced, we shall fix them on a part we do not mean, and when we act with them, we shall do it in a wrong direction.
The uniformity of the compressive force does not prevent the laceration of the Perinaeum; but slowness in acting and a recollection that the Vagina has an axis different from that of the Pelvis. Compressive force is not intended in the use of the Forceps, but it alway sis produced,
XI. There is a possibility of exerting insinitely more power with every kind of Forceps that has been contrived, than can be used, if we attend either to the safety of the Mother or Child. The designs of Nature are effected very slowly. The only method by which we can avoid every inconvenience which attends the use of the Forceps, is by imitating the progress of a Natural Delivery.
XII. Great advantages are said to be obtained by the use of Forceps curved, though of the common size. I object to the use of all curvilinear Forceps, because the head of the Child is
always
in a diagonal situation when it is proper or necessary to apply them The curve of M.
Levrette
's Forceps seems the most convenient, and Mr.
Osborn
has contrived a very elegant pair, by diminishing the size of
Levrette
's and very little alteration besides.
XIII. Allowing Dr.
Leake
the full force of his own reasoning, I cannot conceive the advantage arising from this complicated Instrument. But the case is really thus:
If we act with the Forceps, from handle to handle, the third blade can do no service, but must do much mischief by bruising the soft parts.
If we act with the Lever, the Forceps are useless or prejudicial.
I pay great regard to Dr.
Leake
's abilities, but being convinced that the Instrument which he has recommended will do great mischief, if the attempt to introduce it into practice should succeed, I have taken the trouble of writing these Remarks.
THO. DENMAN