Theuse of instruments in effecting delivery is a last resort to save life, and ought to be intrusted only to persons of skill; it may therefore be thought unnecessary to treat of them in the present work, and indeed I should not have done so but for the purpose of satisfying the natural curiosity of females themselves. The greater part of the dread they now experience where instruments are needed, arises from ignorance of their nature and mode of action. At the present time nearly all the instruments used, in competent hands, are comparatively safe and harmless, and if females generally understood how they operated, much less fear would be excited by their use. Years ago, when cutting and tearing instruments were employed, in nearly every case of difficulty, the lamentable results which followed fully justified the fears experienced, but at the present day such things are seldom seen, except in medical museums, the same purpose being much better effected by simpler and more harmless apparatus. I wish therefore simply to give a brief explanation of the structure, and mode of action, of the instruments now chiefly employed, and to show the extent of their application and the results which have followed from it.
The forceps are intended to take hold of the fœtus, and assist us to draw it into the world when the naturalforces are inadequate, and no hold can be obtained by the hands. They were first invented about the year 1650, by an English surgeon named Chamberlin, who made a secret of his invention and realized a large fortune from it. Since that time they have been modified in various ways, by different practitioners, but still remain essentially the same as when first used.
The most usual form, and probably the best, is that represented below:
PLATE L.Fig. 1.Fig. 2.forcepsIt consists of two blades articulated by a button, or screw joint, so that they can be easily separated and again adjusted,—Fig. 1. Each blade is cut out in the middle, and curved, as seen in Fig. 2.
PLATE L.
PLATE L.
Fig. 1.Fig. 2.
Fig. 1.
Fig. 2.
forceps
It consists of two blades articulated by a button, or screw joint, so that they can be easily separated and again adjusted,—Fig. 1. Each blade is cut out in the middle, and curved, as seen in Fig. 2.
It consists of two blades articulated by a button, or screw joint, so that they can be easily separated and again adjusted,—Fig. 1. Each blade is cut out in the middle, and curved, as seen in Fig. 2.
The only part to which the forceps are intended to be applied is the head, to the dimensions and form of which they are specially adapted. Some practitioners have used them on the breech, but the practice is not generally sanctioned, because they seldom retain their hold on this part and are nearly sure to seriously injure the child when so applied. With properly constructed forceps, rightly applied to the head, there is but little danger either to the mother or the child; but in the hands of an unskillful or careless person the consequences of their use may be deplorable to both.
It is scarcely necessary to remark that the forceps are neithercuttingnorcrushinginstruments, but are simply intended tolay hold, like the hand itself, and enable us to draw down the head, or change its position. Most usually they are made long and curved, as shown in the above plate, but sometimes they are made much shorter and straight. They may be used upon the head when it is either at the upper or the lower straits, or while it is in the passage; but on no account should they be applied till the parts are fully dilated, and everything indicates that the childcanpass. Thus they should never be used when the head is too large, or the pelvis too small, nor when there are tumors in the way. In short no attempt should be made with them toforcethe fœtus through a passage which will not admit it by reasonable efforts. M. Dubois says they should never be used when the pelvic diameter is less thanthree inches, because with such dimensions the child is nearly certain to be crushed to death, and the mother can scarcely escape serious bruises and lacerations. In like manner, if they are thrust into the womb before the mouth of it is naturally dilated they are sure to tear and injure it.
It is not necessary here to give directions for using the forceps in every variety of presentation and position, but simply to show the mode of applying them as they are most frequently required. The two blades are adjusted separately, one to each side of the head, and then locked together, so that the head is firmly inclosed between them, but not crushed. Dr. Denman gives perhaps the best and simplest directions on this point, and I therefore quote from his work.
"The first part of the operation consists in passing the forefinger of the right hand behind the ossa pubis and the head of the child to the ear; then taking the part of the forceps to be first introduced by the handle in the left hand, the point of the blade is to be slowly conducted between the head of the child and the finger till the instrument touches the ear: there can be no difficulty or hazard in carrying the instrument thus far, because it will be guided, and in some measure shielded, by the finger. But the further introduction must be made with a slow semi-rotatory motion, keeping the point of the blade not rigidly, yet closely, to the head of the child, by raising the handle toward the pubes. In this manner the blade must be carried gently along the head till the lock reaches the external parts near the anterior angle of the pudendum. The point of the blade, while introducing, sometimes hitches upon the ear of the child, and it then requires a little elevation. But when it has passed the ear, and is beyond the guidance of the finger, should there be any check to the introduction either of this or the other blade, it should be withdrawn a little, to give us an opportunity of discovering the cause of the obstacle, which we mustnever strive to overcome by violence, though we must proceed with firmness. When the first blade is properly introduced, it must be held steadily in its place by pressing the handle towards the pubes, and it will be a guide in the introduction and application of the second blade. Let the second blade be introduced in this manner. Keep the blade first introduced in its place with the two lesser fingers of the left hand, and carry the fore-finger of the same hand between the perineum and head of the child as high as you can reach. Then take the second blade of the forceps by the handle in the right hand, and, conveying the point between the finger placed within the perineum and the head of the child, conduct the instrument, with the precautions before mentioned, so far that the lock shall touch the interior part of the perineum, or even press it a little backwards. In order to fix the two blades thus introduced, that which was placed towards the pubes must be slowly withdrawn, and carried so far backwards that it can be locked with the second blade retained in its first position; and care must be taken that nothing be entangled in the lock, by passing the finger round it. When the forceps are locked, it will be convenient to tie the handles together with sufficient firmness to prevent them from sliding or changing their position when they are not held in the hand, but not in such a manner as to increase the compression upon the head of the child. Should the blades of the forceps be introduced so as not to be opposite each other, they could not be locked; or if, when applied, the handles should come close together, or be at a great distance from each other, they would probably slip, or there would be a failure of some kind in the operation, as the bulk of the head would not be included,or they would be fixed on some improper part of the head; though allowance is to be made for the difference in the size of the heads of children. But if a case be proper for the forceps, if they be well applied, and we were to act slowly with them, there would not be much risk of failure or disappointment. The difficulty of applying the forceps is most frequently occasioned by attempting to apply them too soon, or by passing them in a wrong direction, or by entangling the soft parts of the mother between the instrument and the head of the child, against all which accidents we are to be on our guard."When the forceps are first locked, they are placed backwards, with the lock close to, or just within, the internal surface of the perineum; and they can have no support backwards, except the little which is afforded by the soft parts. The first action with them should therefore be made by bringing the handles, grasped firmly in one or both hands, to prevent the instrument from playing upon the head of the child, slowly towards the pubes till they come to a full rest. Having waited a short interval with them in that situation, the handles must be carried back in the same slow but steady manner to the perineum, exerting, as they are carried in the different situations, a certain degree of extracting force; and after waiting another interval, they are again to be carried towards the pubes, according to the direction of the handles. Throughout the operation, especially the first part, the action of that blade of the forceps originally applied towards the pubes must be stronger and more extensive than the action with the other blade, this having no fulcrum to support it, and chiefly answering the purpose of regulating the action of the other blade. If there were any laborpains when the operation was begun, or should they come on in the course of it, the forceps should only be acted with during the continuance of the pains; the intention being, not only to supply the want or insufficiency of the pains, but to follow them, and imitate also the manner in which they return. By a few repetitions of this alternate action and rest before described, we shall soon be sensible of the descent of the head; and it will be proper to examine very frequently, to know the progress made, that we may not use more force than needful, nor go on with more haste than may be expedient or safe. In every case we ought to proceed slowly and circumspectly, not forgetting that a small degree of force, continued for a long time, will in general be equivalent to a greater force hastily exerted, and with infinitely less detriment to the mother or child. But after some time, should we not perceive the head to descend, the force hitherto used must be gradually increased, till it be sufficient to overcome the obstacles to the delivery of the patient. It was before observed, as the head of the child descended, that the face would be accordingly turned towards the hollow of the sacrum, without any aim or assistance on our part. Of course the position of the handles of the forceps, and the direction in which we ought to act with them, should alter; for they becoming first more diagonal or oblique with respect to the pelvis, and then more and more lateral, every change in their position will require a differently directed action, because the handles should ever be antagonists to each other. In proportion also to the descent of the head the handles of the forceps should approach nearer to the pubes; so that, in the beginning of the operation, though we acted in the direction of the cavity of thepelvis, towards the conclusion we should act in that of the vagina. When we feel that we have the command of the head, by its being cleared of the pelvis, and the external parts begin to be distended, we ought to act yet more slowly, especially in the case of a first child, or there would be great danger of a laceration of the soft parts; and this can only be prevented by acting very deliberately in the direction of the vagina—by giving the parts time to distend—by duly supporting the perineum, which is the part chiefly in danger, with the palm of the hand—by soothing and moderating the hurry and efforts of the patient—and, in some cases, by absolutely resisting for a certain time the passage of the head through the external parts."
"The first part of the operation consists in passing the forefinger of the right hand behind the ossa pubis and the head of the child to the ear; then taking the part of the forceps to be first introduced by the handle in the left hand, the point of the blade is to be slowly conducted between the head of the child and the finger till the instrument touches the ear: there can be no difficulty or hazard in carrying the instrument thus far, because it will be guided, and in some measure shielded, by the finger. But the further introduction must be made with a slow semi-rotatory motion, keeping the point of the blade not rigidly, yet closely, to the head of the child, by raising the handle toward the pubes. In this manner the blade must be carried gently along the head till the lock reaches the external parts near the anterior angle of the pudendum. The point of the blade, while introducing, sometimes hitches upon the ear of the child, and it then requires a little elevation. But when it has passed the ear, and is beyond the guidance of the finger, should there be any check to the introduction either of this or the other blade, it should be withdrawn a little, to give us an opportunity of discovering the cause of the obstacle, which we mustnever strive to overcome by violence, though we must proceed with firmness. When the first blade is properly introduced, it must be held steadily in its place by pressing the handle towards the pubes, and it will be a guide in the introduction and application of the second blade. Let the second blade be introduced in this manner. Keep the blade first introduced in its place with the two lesser fingers of the left hand, and carry the fore-finger of the same hand between the perineum and head of the child as high as you can reach. Then take the second blade of the forceps by the handle in the right hand, and, conveying the point between the finger placed within the perineum and the head of the child, conduct the instrument, with the precautions before mentioned, so far that the lock shall touch the interior part of the perineum, or even press it a little backwards. In order to fix the two blades thus introduced, that which was placed towards the pubes must be slowly withdrawn, and carried so far backwards that it can be locked with the second blade retained in its first position; and care must be taken that nothing be entangled in the lock, by passing the finger round it. When the forceps are locked, it will be convenient to tie the handles together with sufficient firmness to prevent them from sliding or changing their position when they are not held in the hand, but not in such a manner as to increase the compression upon the head of the child. Should the blades of the forceps be introduced so as not to be opposite each other, they could not be locked; or if, when applied, the handles should come close together, or be at a great distance from each other, they would probably slip, or there would be a failure of some kind in the operation, as the bulk of the head would not be included,or they would be fixed on some improper part of the head; though allowance is to be made for the difference in the size of the heads of children. But if a case be proper for the forceps, if they be well applied, and we were to act slowly with them, there would not be much risk of failure or disappointment. The difficulty of applying the forceps is most frequently occasioned by attempting to apply them too soon, or by passing them in a wrong direction, or by entangling the soft parts of the mother between the instrument and the head of the child, against all which accidents we are to be on our guard.
"When the forceps are first locked, they are placed backwards, with the lock close to, or just within, the internal surface of the perineum; and they can have no support backwards, except the little which is afforded by the soft parts. The first action with them should therefore be made by bringing the handles, grasped firmly in one or both hands, to prevent the instrument from playing upon the head of the child, slowly towards the pubes till they come to a full rest. Having waited a short interval with them in that situation, the handles must be carried back in the same slow but steady manner to the perineum, exerting, as they are carried in the different situations, a certain degree of extracting force; and after waiting another interval, they are again to be carried towards the pubes, according to the direction of the handles. Throughout the operation, especially the first part, the action of that blade of the forceps originally applied towards the pubes must be stronger and more extensive than the action with the other blade, this having no fulcrum to support it, and chiefly answering the purpose of regulating the action of the other blade. If there were any laborpains when the operation was begun, or should they come on in the course of it, the forceps should only be acted with during the continuance of the pains; the intention being, not only to supply the want or insufficiency of the pains, but to follow them, and imitate also the manner in which they return. By a few repetitions of this alternate action and rest before described, we shall soon be sensible of the descent of the head; and it will be proper to examine very frequently, to know the progress made, that we may not use more force than needful, nor go on with more haste than may be expedient or safe. In every case we ought to proceed slowly and circumspectly, not forgetting that a small degree of force, continued for a long time, will in general be equivalent to a greater force hastily exerted, and with infinitely less detriment to the mother or child. But after some time, should we not perceive the head to descend, the force hitherto used must be gradually increased, till it be sufficient to overcome the obstacles to the delivery of the patient. It was before observed, as the head of the child descended, that the face would be accordingly turned towards the hollow of the sacrum, without any aim or assistance on our part. Of course the position of the handles of the forceps, and the direction in which we ought to act with them, should alter; for they becoming first more diagonal or oblique with respect to the pelvis, and then more and more lateral, every change in their position will require a differently directed action, because the handles should ever be antagonists to each other. In proportion also to the descent of the head the handles of the forceps should approach nearer to the pubes; so that, in the beginning of the operation, though we acted in the direction of the cavity of thepelvis, towards the conclusion we should act in that of the vagina. When we feel that we have the command of the head, by its being cleared of the pelvis, and the external parts begin to be distended, we ought to act yet more slowly, especially in the case of a first child, or there would be great danger of a laceration of the soft parts; and this can only be prevented by acting very deliberately in the direction of the vagina—by giving the parts time to distend—by duly supporting the perineum, which is the part chiefly in danger, with the palm of the hand—by soothing and moderating the hurry and efforts of the patient—and, in some cases, by absolutely resisting for a certain time the passage of the head through the external parts."
PLATE LI.The head being drawn through a narrow Pelvis by the Forceps.use of forcepsThe manner in which the forceps draw the head is well shown in the above plate, and also the compression of the head itself, which is seen to be squeezed almost to a point at its presenting part. This compression, however, is not likely to do serious injury, unless it be excessive. The child may be convulsed a little from it, but usually recovers, and suffers nothing afterwards.
PLATE LI.The head being drawn through a narrow Pelvis by the Forceps.
PLATE LI.
The head being drawn through a narrow Pelvis by the Forceps.
use of forceps
The manner in which the forceps draw the head is well shown in the above plate, and also the compression of the head itself, which is seen to be squeezed almost to a point at its presenting part. This compression, however, is not likely to do serious injury, unless it be excessive. The child may be convulsed a little from it, but usually recovers, and suffers nothing afterwards.
The manner in which the forceps draw the head is well shown in the above plate, and also the compression of the head itself, which is seen to be squeezed almost to a point at its presenting part. This compression, however, is not likely to do serious injury, unless it be excessive. The child may be convulsed a little from it, but usually recovers, and suffers nothing afterwards.
It is merely necessary to remark, in conclusion, that the forceps should never be used till it is manifestly impossible for the child to be born without them; and it should be remembered that nature alone frequently effects delivery under the most unfavorable circumstances, by giving her time. We should wait therefore as long as the safety of the mother will allow, but never delay a moment when that safety is compromised.
The accidents which have followed from the use of the forceps are numerous and terrible, and I could give a most horrifying account of them if it were necessary. It must be recollected however, that these accidents have chiefly followed from want of skill in managing the instrument, or from its being used under improper circumstances. It is true that there is always more or less of pain and injury to be dreaded from the forceps, even in the most favorable cases, and with the most competent operators, but this is no argument against their employment altogether. In every case where they are really called for, the female would, most probably, die undelivered, or have to be cut open, so that it is simply a choice of evils, of which the forceps are the least.
The cases in which the forceps are absolutely necessary however, areVERY RARE, much more so in fact than many people suppose.Patience, and the persevering use of ordinary assistance, would probably succeed alone in half the cases where they are now employed.
In Murphy's lectures ondifficult Labors, he gives us some valuable statistics on this subject. He tells us that inseventy-five thousand nine hundred and eleven labors, the forceps were used onlyone hundred and thirty-eight times, or once in everyfive hundredand fiftylabors. In these one hundred and thirty-eight casesthirty-fiveof the children died, andtenof the mothers. Dr. Murphy however, thinks that the general results, to both mother and child, would be equally favorable if the forceps werenot used at all, and he gives the tables of Dr. Collins to support his opinions. From these tables it really appears that, when all the difficult labors were left entirely to nature, the number of deaths wasjust about the same as when the forceps are used, in factrather less, while the accidents, and subsequent evils, were not nearly so great. Dr. M. therefore thinks that the forceps shouldneverbe used, except in a few cases where everything is quite favorable to the passage of the fœtus; and the uteruscannotbe made, in a reasonable time, to contract and expel it; and also whenimmediatedelivery is needed to save the mother's life, as in flooding. In cases of mere ordinary difficulty or delay, he decries their use entirely; and he evidently thinks that when the labor isfitto be terminated by the forceps, nature can and will terminate it herself if left alone. There is no doubt but that they are now used a great dealtoo much, either from a desire tooperate, or fromwant of patience; and I have no hesitation in expressing my opinion that more have beenkilledthansavedby them.
Respecting other instruments, such as theCrotchet, theVectis, and theCephalotribe, orcrushing forceps, it is not necessary to say anything here, as their use, when imperatively needed, must necessarily be confined to the surgeon; and fortunately may now be dispensed with altogether. The recently introducedpractice of bringing onpremature labor, in all cases of deformity or smallness of the pelvis, entirely obviates the necessity for any of these dreadful resorts, if the difficulty be known in time, which it is sure to be when a sufficient degree of knowledge is disseminated.
TheCesarian operation, or cutting open the womb externally; andCephalotomy, or the opening of the child's head, may also be dismissed with the same observations.They can always be avoided, if the real condition of the patient is known in time; and if from neglect nothing else can be done, they must always be performed by a skillful surgeon.