A System of Midwifery Part 17

During all this time the other hand placed externally will be of great service, not only in supporting the uterus, but in fixing the child and rendering the different parts of it more attainable. Where the feet are at some distance, we frequently come first to an arm or thigh, which soon leads us to the elbow or knee; if the introduction of the hand has been attended with some difficulty, it will not be very easy to distinguish these joints from each other, without bearing in mind the following diagnostic points:--the knee present two rounded prominences (condyles of the femur) with a depression between them, whereas, the elbow presents also two rounded prominences, but with a sharp projection (olecranon) between.

If the foot is not easily reached, there will be no need of forcing up the hand farther to gain it: it will be much better and safer to hook the finger into the bend of the knee and hold by it for a pain or two: this will generally be sufficient to bring it within reach; or during an interval of the pains, the leg may be gently disengaged and brought down.

Not unfrequently we can only feel the toes with the extremities of our fingers, and therefore cannot maintain a sufficient hold upon the foot so as to bring it down: here again the same rule will be applicable, for by keeping but a slight hold upon it during a pain, it will be found to have approached nearer when the pain has gone off; in fact our first attempt to move the child must be done in this cautious manner, and we shall effect our object with greater certainty by merely holding the feet still during the pain, not allowing them to recede from that position in which we had placed them during the intervals, than by using considerable efforts to bring them to the os uteri. By the time we have got one foot fairly within grasp, the other is seldom very distant and should always be brought down if possible: by bringing down both feet we cause the hips of the child to enter the brim of the pelvis more equally; whereas, if one leg only is brought down, the pelvis of the child comes more or less awry, and the ischium of the other side is apt to lodge against the brim of its mother's pelvis.[92] This practice has been recommended on the grounds that, by bring down only one leg, we make the presentation rather resemble a breech case, which is known to be more favourable for reasons already mentioned, and that by having the other leg turned upon the abdomen it will protect the cord from undue pressure. As far as the abdomen is concerned this may possibly be the case, but the pressure of the head upon the cord, which is the real source of danger to the child in turning, can in no wise be influenced by this position.

In bringing down the feet it must be done with the articulation, that is, the child must be turned forwards; at the same time the hand upon the abdomen, externally, will be of great service in a.s.sisting us to move the child, and in preventing the change of its position from taking place in too sudden and violent a manner, a circ.u.mstance which is apt to paralyze the uterus considerably, and even produce alarming symptoms from the shock it occasions.

_Extraction._ When once we have brought the feet into the v.a.g.i.n.a, the first part of the operation, viz. the changing the position of the child, is completed: it has now become a presentation of the feet, and as such ought to be treated, unless some source of danger be present which requires that the delivery should be hastened. The value of this practice in footling cases was first pointed out by Deleurye,[93] and particularly applied to the second act of turning by Wigand. "I have made it," says he, "a strict rule in turning, from the moment that I have brought a foot of the child as far into the v.a.g.i.n.a as I can without force, to do nothing beyond patiently waiting for the return of the pains, even if this did not take place for many hours, and leaving the rest of the labour entirely to nature. I have found by doing so that when the pains at length began to expel the child, they did it with so much force and activity as was not even seen in the most natural case of head presentation." (_Geburt des Menschen_, vol. ii. p. 130.)

As the feet descend towards the os uteri, the presenting part, particularly if the arm has been prolapsed into the v.a.g.i.n.a, begins to recede, the hand externally will a.s.sist in moving the child round, and we should perform this step of the operation so gradually as to be a.s.sured that the presenting part has quitted the pelvis before the feet have entered. Without attention to this point, the child may easily be fixed across the upper part of the pelvis, or even the body brought down, while the head is wedged into the cavitas iliaca of the ilium, and produce a serious obstacle to its farther advance. This is a sort of mishap which can rarely happen except to young pract.i.tioners. If the process be slowly and carefully conducted, we doubt much if it be ever necessary to disengage the presenting part as has been so frequently recommended: the uterus in fact will move the child round with very little a.s.sistance on our part, and we shall find that after every pain the advance of the feet and recession of the part has increased considerably. From our own observations we would say that in all difficult cases, of turning especially, it is desirable for the patient to have several pains between the moment of gaining the feet and bringing them fairly into the v.a.g.i.n.a: very little force is required to bring them down, and the uterus does not appear to suffer; but where the position of the child has been rapidly changed, its contractile power seems to be injured, and it is ill able to make those exertions during the last stage, which will be required of it in order to save the child's life.

Not less necessary is it that we should proceed with the second stage as cautiously as possible: the grand principle is the same, viz. to conduct the expulsion as gradually as possible: there is no use whatever in hurrying this part of the operation, for if the child be alive, we place it in imminent danger of its life; and if it be dead, as will easily be known by the cord not pulsating, we are putting the mother to a great deal of suffering for no reason. Now that it has become a footling case, it must be managed according to rules already given for this species of presentation: the uterus must be emptied as slowly as possible, the anterior part of the child must be directed more or less backward, and the funis guided into the vicinity of one or other sacro-iliac synchondroses.

By r.e.t.a.r.ding the advance of the child, we resist the action of the uterus somewhat, and thus excite it to contract more actively, the head enters the pelvis in the most favourable position, and as the pains are still brisk, it pa.s.ses through so quickly as to subject the child to little or no danger by pressing upon the cord. Where however the pa.s.sage of the head through the pelvis threatens to be delayed, we would strongly recommend the application of the forceps in order to terminate the delivery before the child has begun to suffer: it is to this mode of practice that Professor Busch, of Berlin, attributes the extraordinary success of turning in his hands; of forty-four cases where turning was deemed necessary only three children are stated to have lost their lives from the effects of the operation, a result which is by far the most favourable known.

_Turning with the nates foremost._ It has been proposed by several authors of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (_L'Art des Accouchemens_, -- 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,[94] also by some other continental authors; but the difficulty in bringing down a part of the child's body, upon which we can exert so little hold, will always be very considerable, wherever the circ.u.mstances under which the operation is undertaken is at all unfavourable. Schmitt recommends that as soon as we reach the nates we should apply the hand flat upon them; while in order to turn the child, active pressure is kept up from without by the other hand: when once we have succeeded in moving the breech somewhat downwards, its farther descent is very easy.

A still more recent modification of turning the child in arm and shoulder presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists in raising the presenting part, and at the same time turning the child upon its long axis, as the hand placed in the axilla carries the shoulder to the upper parts of the uterus, after which, as the hand descends, it brings the feet along with it into the v.a.g.i.n.a.

_Turning with the head foremost._ In former times, as the head was considered the only natural presentation of the child, every deviation of its position from this was looked upon as unnatural, and, therefore, the operation of turning only applied to bringing down the head, which had not presented: as, however, the difficulties already mentioned, in turning with the nates, would apply still more forcibly to bringing down the head, it is plain that this mode of turning would rarely be practicable. "Were it practicable at all times," says Dr. Smellie, vol. i. book iii. chap.

iv. sect. iv. number v., "to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he, therefore, ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels by the touch that the face, ear, or any of the upper parts present." Still, however, he confesses that the usual method of turning by the feet is the safest. In his first volume of cases, (collection 16, number 6, case 5,) he has given a description of this mode of turning. Dr. Spence also turned with the head foremost, as is shown by his thirty-second case, where the hand and cord were prolapsed into the v.a.g.i.n.a. "I introduced my hand into the v.a.g.i.n.a, and in the intervals between the pains reduced both the arm and the cord: but as I found they were like to return again upon my withdrawing my hand, I therefore continued to support them till such time as, by the strength of the pains, the child's head was so far forced down as to prevent any danger of their returning, the happy consequence of which, was, that she was delivered of a live child in about half an hour after: both mother and child did well."

(Spence's _System of Midwifery_, p. 465.) Dr. Merriman has recorded a similar case in his own practice: "The arm was returned at two o'clock; there was afterwards no occurrence of pain till six, after which, they became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six." (_Synopsis of Difficult Parturition_, 1838, p. 250.) Still more recently turning with the head foremost has been tried by Dr. Michaelis, of Kiel, (_Neue Zeitschrift fur Geburtskunde_, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty.

_History of turning._ Turning, as it is generally practised at the present day, viz. changing the position of a living child so that the feet are brought down foremost into the v.a.g.i.n.a, was unknown to the ancients. There is little doubt, however, that if they could have been induced to have looked upon presentations of the nates and feet as natural labours, they would have been in possession of this valuable means of effecting artificial delivery; as it is, we meet with detached allusions to it in their writings, although applying only to cases where the child is dead.

In the writings of Aspasia and Philumenus, which, but for the quotations of Oetius, would have been entirely lost to us, we find directions for turning the child. Thus, Philumenus states, "Si caput foets loc.u.m obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur." At a still later period, Celsus gave similar directions, but to all appearance they also merely apply to a dead child. "Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est;" and again he says, "Sed in pedes quoque conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas ma.n.u.s commode educitur." (Celsus, _de Medicina_, lib. vii. cap. 29.)

From this time the whole subject seemed to sink into oblivion, until Pierre Franco, in his work on surgery[95] proposed the extraction of the child with the feet foremost: this was put into practice by the celebrated French surgeon, Ambrose Pare, (Ambr. Paraeus, _Opera Chirurgia_, 1594,) who, nevertheless, recommended turning with the head foremost, where it was possible. His work was afterwards translated into Latin by Guillemeau, who, although he still adhered to the old plan of bringing down the head, showed the value of Pare's mode of turning in haemorrhages and convulsions.

To Francis Mauriceau, a man of great learning and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William Manquest de la Motte, in 1721, to whom the merit is due of having pointed out the value of two great laws in turning--the one of not rupturing the membranes as already mentioned, the other of not attempting to push back the arm which presents.[96]

CHAPTER III.

CaeSAREAN OPERATION.

_Indications.--Different modes of performing the operation.--History of the Caesarean operation._

The next operation in Midwifery for delivering the full-grown foetus alive is that of _Hysterotomy_, commonly called the Caesarean operation, viz.

where the foetus is extracted through an artificial opening made through the parietes of the abdomen and uterus.

The _indications_ for performing the operation are so different in this country to what they are elsewhere that they require especial mention: in England the operation is never performed upon the living subject except where the child cannot be delivered by the natural pa.s.sage; under these circ.u.mstances it is scarcely undertaken in this country for the purpose of saving the child's life, but merely that of the mother, it being considered preferable to deliver the child by perforation or embryotomy, even when known to be alive, than to expose the mother to so much suffering and danger.

On the Continent and also in America, it has not been considered in so dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother's life, it is performed for the purpose of saving the child's life in cases where, by using the perforator, the child might be brought through the natural pa.s.sages. The results of the Caesarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to pract.i.tioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former times, viz. Ambrose Pare, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr.

Osborn, &c.)

There is no doubt that in England it has been peculiarly unsuccessful. Dr.

Merriman has collected the results of 26 cases of Caesarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90 terminated favourably; and Dr. Hull, in his _Defence of the Caesarean Operation_, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few women, "some of them having submitted to it three or four times, others five or six, and even as far as seven times, which if they were all true, would superabundantly prove that it is not essentially mortal." (_Baudelocque_, transl. by Heath, -- 2095.)

During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German pract.i.tioners, so that there has been scarcely a journal of late from that part of the Continent which has not contained favourable cases of it. One of the most interesting instances of later years is that recorded by Dr. Michaelis, of Kiel, where the patient, a diminutive and very deformed woman, was operated upon four times:[97] the second operation was performed by the celebrated Wiedemann, and is stated to have been completed in less than five minutes, and without any extraordinary suffering on the part of the patient, who complained most when sutures were made for bringing the lips of the wound together. The uterus became adherent to the anterior wall of the abdomen, so that in the fourth operation the abdominal cavity was not even opened, the incision being made through the common cicatrix into the uterus.

There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. "In France and some other nations upon the European Continent," says Dr. Hull, "the Caesarean Operation has been and continues to be performed where British pract.i.tioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repet.i.tion of tormenting, though unavailing pains, and before her life is endangered by the accession of inflammation of the abdominal cavity. From this view of the matter we may reasonably expect that recoveries will be more frequent in France than in England and Scotland, where the reverse practice obtains. And it is from such cases as these, in which it is employed in France, that the value of the operation ought to be appreciated. Who could be sanguine in his expectation of a recovery under such circ.u.mstances as it has generally been resorted to in this country, namely, where the female has laboured for years under _malacosteon_ (_mollities ossium_,) a disease hitherto in itself incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominal cavity, or been exhausted by labour of a week's continuance or even longer."

(Hull's _Defence of the Caesarean Operation_.)[98]

The difficulty of deciding upon the operation according to the indications of the Continental pract.i.tioners, is much more perplexing than according to that which is followed in this country: the question here is, can the child under any circ.u.mstances be made to pa.s.s _per vias naturales_ with safety to the mother? The impossibility of effecting this object is the sole guide for our decision. In using the operation as a means for preserving also the life of the child, we must not only feel certain that the child _is_ alive, but that it is also capable of supporting life, before we can conscientiously undertake the operation upon such indications. This uncertainty as to the life or death of the child greatly increases the difficulty of deciding. Under circ.u.mstances where there is reason to believe that, although the child may be alive, it is nevertheless unable to prolong its existence for any time, and the pelvis so narrow that it can only be brought through the natural pa.s.sage piecemeal, we are certainly not authorized in putting an adult and otherwise healthy mother into such imminent danger of her life for the sake of a child which is too weak to support existence. Circ.u.mstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural pa.s.sage: in this case, even if the child be dead, the operation becomes unavoidable.

Under the above-mentioned circ.u.mstances, it is the duty of the surgeon to perform the operation; and he can do it with the more confidence from the knowledge of many cases upon record where it has succeeded even under very unfavourable circ.u.mstances, and where it has been performed very awkwardly: moreover, it seems highly probable that the unfavourable results of this operation cannot often be attributed to the operation itself, but to other circ.u.mstances. Not unfrequently the uterus has been so bruised, irritated, and injured by the violent and repeated attempts to deliver by turning or the forceps, and the patient so exhausted, and brought into such a spasmodic and feverish state by the fruitless pains and vehement efforts, together with the anxiety and restlessness which must occur under such circ.u.mstances, that it is impossible for the operation to prove successful. Here it is an important rule that we should decide as soon as possible, whether she can be delivered by the natural pa.s.sages or not: we should allow of no useless or forcible attempts to deliver her; and if these have been made, we should carefully examine whether the pa.s.sages, &c. have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural pa.s.sages.

(Richter, _Anfangsgrunde der Wundarztneikunst_, band vii. chap. 5.)

Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has commenced to any extent; for unless the os uteri has undergone a certain degree of dilatation, it will not afford a sufficiently free exit for liquor amnii, blood, lochia, which, by stagnating in the uterus after the operation, would soon become irritating and putrid, in which case they would be apt to drain through the wound into the abdominal cavity and create much mischief.[99]

_Different modes of operating._ The incision has been recommended to be made in different ways by different authors; but the highest authorities, as also later experience, combine in favour of that in the linea alba.

Richter states, that one great advantage from making it in this direction is, that when the uterus contracts and sinks down into the pelvis, the incision in it still corresponds with that through the abdominal parietes, and therefore admits of a free discharge of pus, &c. through the external wound; whereas, if it have been made to one side, viz. at the outer edge of the rectus abdominis muscle, as recommended by Levret for the purpose of avoiding the placenta, the wound in the uterus when contracted ceases to correspond with it, and the discharge escapes into the abdominal cavity. Besides this the abdomen is usually more distended at the linea alba; the uterus here lies immediately beneath the integuments; the intestines are usually pressed towards each side; and therefore when the incision is made on one side they frequently protrude, a circ.u.mstance which rarely happens when it is made in the linea alba, except perhaps towards the end of the operation. In the linea alba we have only to cut through the external integuments in order to reach the uterus, while at the side, we have to cut through considerable layers of muscle.

Previous to operating, the r.e.c.t.u.m and the bladder should be emptied, particularly the latter, because it is desirable to carry the incision of the abdominal integuments, for reasons just given, as near as possible to the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent a.s.sistants are necessary, "two to prevent the protrusion of the intestines, and a third to remove the placenta and foetus." (_Neue Zeitschrift fur Geburtskunde_, band iii. heft 1. 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air than upon any other cause, for by this means alone can we save the patient from the dangerous peritonitis which is so apt to follow. The two a.s.sistants, whose duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to this that the great success of the Caesarean operation in later years is chiefly owing.

The incision in point of length varies from five to six, seven, or more inches, beginning at about two to four inches below the navel, and terminating at rather less than that distance above the symphysis pubis.

The peritoneum is usually divided with a bistoury and director, and the wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the uterus rapidly contracts, and thus prevents all fear of haemorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when pa.s.sing through the wound, and thus retain it. It is desirable to remove the membranes as far as possible, especially from the os uteri, to allow of a free discharge from the uterus per v.a.g.i.n.am. No sutures are needed for the uterine incision: the contractions of the organ not only diminish its length, but generally bring its edges into sufficiently close contact.

Some discrepancy of opinion has existed respecting the treatment of the external wound: sutures are of course the most secure means of retaining the edges in apposition, but they produce great suffering, and, from taking up a good deal of time, delay the closing of the abdominal wound more or less; whereas, straps of sticking plaster are applied much quicker and without any suffering to the patient. To do this most effectually it will be advisable to arrange them under the loins previous to the operation: they should be from five to six feet long, and the ends may be rolled up until wanted; the wound can thus be instantly closed and in the most secure manner. Where the operator finds it necessary to use sutures, he must avoid puncturing the peritoneum as far as possible: the lower inch of the wound should be left open to allow any matter to drain out, and the whole dressed according to the common rules of surgery. The patient should be placed upon her side with the knees bent to relax the abdominal parietes. A grain of the hydrochlorate of morphia has been given in these cases with the best effects, having procured sleep and allayed the disposition to spasmodic coughing and vomiting, which so frequently exists after the operation.

One of the greatest triumphs of modern surgery is the performance of this dangerous operation four times successively on the same patient. The first operation was performed in June 1826, the woman being then in her twenty-ninth year, the second in January 1830, the third in March 1832, and the fourth on the 27th June, 1836. The second operation was performed by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it appear that the patient's sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.[100]

_History._ Although the early records of the Caesarean operation are not very distinct, still we possess sufficient data to p.r.o.nounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed.

The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: these were the birth of Bacchus and aesculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circ.u.mstance, however, connected with the birth of Bacchus is curious, viz. that his mother Semele died in the seventh month of her pregnancy.

The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, B. C. 508. Scipio Africa.n.u.s, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius Caesar was born by this operation, or still less that it derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor Naegele, viz. that one of the Julian family at Rome had been delivered _ex caeso matris utero_, and had been named Caesar from this circ.u.mstance, so that the name was derived from the operation, not the operation from the name.

"The earliest account of it in any medical work is that in the _Chirurgia Guidonis de Cauliaco_, published about the middle of the fourteenth century. Here, however, the practise is only spoken of as proper after the death of the mother." (Cooper's _Surg. Dict._) Among the Jews, however, it appears to have been performed on the _living_ mother at a very early period; a description of it is given in the _Mischnejoth_, "which is the oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In the _Talmud_ of the Jews, also, their next book in point of antiquity, the Caesarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In the _Mischnejoth_ there is the following pa.s.sage, 'In the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen, nor the second, can receive the rights of primogeniture, either as regards the office of priest or succession to property.' In a publication called the _Nidda_, an appendix to the _Talmud_, there is the following remarkable direction: 'It is not necessary for women to observe the days of purification after the removal of the child through the parietes of the abdomen.'" (_Introduction to the Study and Practice of Midwifery_, by W. Campbell, M. D. p. 260.)

The first authentic operation upon a living woman in later times was the celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, owing to its fatal character and the strong feeling against it, it was performed but rarely: still, however, sufficient evidence existed to mark its occasional success and urge its repet.i.tion in similar cases; and from what we have already stated, the history of the last twenty years shows that its results have rapidly become more and more favourable, so that in the present day it can be no longer looked upon as an operation of such extreme danger and almost certain fatality, as it was in former times.[101]

CHAPTER IV.

ARTIFICIAL PREMATURE LABOUR.

_History of the operation.--Period of pregnancy most favourable for performing it.--Description of the operation._

Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circ.u.mstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the Caesarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of pa.s.sing through the contracted pelvis of its mother.

_History._ Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English pract.i.tioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute.

To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. "A great number of instances," says he, "have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly. He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rect.i.tude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living." (Denman's _Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few pract.i.tioners, (_Sue_,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and a.s.sign it a totally different object to that which is intended: the very name which they have given to it of _Avortement artificiel_, plainly shows how little they have understood of its real character.