Thisis one of the most useful operations that the accoucheur can perform, in many cases, and has the advantage of being altogether accomplishedby the hand. Its object is to change the presentation, when unfavorable, and to facilitate delivery. Most usually the hand is introduced into the uterus, and thefeetare brought down. This is calledpelvic version; but sometimes the head is brought to the mouth of the womb, particularly in shoulder presentations, and this is calledcephalic version.
Cephalic Version.—This can seldom be performed, and not often attempted with safety. In some cases however, when it is ascertained that the shoulder presents, and before the membranes are broken, an effort may be made to remove it and bring the head in its place. To do this the position of the head must be ascertained externally, and one hand placed upon it; then with the two forefingers of the other raise up the shoulder from within, as in ballotment, and endeavor to push the head into its place. If the child be very moveable this may sometimes be done, and will be highly advantageous; but most frequently the substitution cannot be accomplished, and the attempt ruptures the membranes, after which it is still more difficult, and even becomes dangerous. Even if the head be brought down there is always danger of its becoming displaced, and the shoulderagain presented, owing to the tendency which any presentation has to be reproduced. To prevent this the hand should be firmly pressed on the fœtus, externally, as soon as the head is brought down, to fix it; and the membranes should be ruptured so that it may begin to descend, after which there is no danger of a change.
Cephalic version can be so seldom performed however, and is so difficult, and sometimes dangerous, that it is seldom or never attempted; more particularly as pelvic version can always be substituted, and is more easy and safe. It is true that presentations of the head are the most favorable, providing they occur before the rupture of the membranes, but after that event they may not be so favorable as those of the lower extremities, and certainly are not so easy or safe to induce.
Pelvic Version.—Turning to bring down the feet is performed for various reasons, and under many different circumstances. As a general principle we may say that it is done either to change the presentation, when unfavorable, or to terminate the labor when it is lingering, or when it is desirable to have it over as quickly as possible. The feet may be drawn through the mouth of the Womb when it is but little opened, and when they have once passed, the limbs and body soon follow, and the head seldom remains long behind. The fœtus may in fact be compared to awedge, of which the feet are the point, and if they enter the passage the rest part is gradually driven after by the uterine contractions.
The chief contingencies which call for the operation of turning are, a protracted labor, a presentation of the placenta, causing hemorrhage, and a wrong presentation, particularly one of the shoulder.
The operation of turning is very clearly explained by Dr. Lee, and I know from experience that his directions can be safely relied upon. It very frequently happens however, that there will be some peculiar circumstances in a case, which will necessitate more or less change in the manner of proceeding, so that the practitioner must after all be guided, to a great extent, by the requirements and conditions then existing. Dr. Lee's directions therefore, must merely be considered asgeneralones, to be modified as occasion may require:—
"When the operation of turning is required before the membranes are ruptured, and when the orifice of the uterus is widely dilated, and there are long intervals between the pains, it is accompanied with little difficulty and danger. Having explained to the patient and her relatives the nature of the case, let her lie on the left side near the edge of the bed, with the knees drawn up to the abdomen. Sit down by the side of the bed, and quietly take off your coat; lay bare your right arm by turning up the shirt above the elbow, and cover the back of the hand and the whole forearm with cold cream, lard, or a solution of soap. Introduce one finger after another into the vagina, and slowly and effectually dilate its orifice. The hand, in a conical form, and in a state of half supination, must then be pressed steadily forward with a semi-rotatory motion against the perineum and sides of the passage, till it clears the orifice of the vagina. This should always be done very slowly and gently, as it is accompanied with great pain. Let the hand remain some time in the orifice of the vagina, that it may be fully dilated, and offer no resistance in thesubsequent steps of the operation of turning. When the hand has dilated the vagina sufficiently, in the absence of pain gently insinuate the points of the fingers and thumb into the os uteri in a conical form; and if it is not sufficiently open to allow the hand to pass, you must proceed next to use artificial dilatation here also, very gently and slowly, always stopping as soon as a pain comes on, but not withdrawing the fingers altogether at the time from the os uteri. Having succeeded in dilating the part without rupturing the membranes, slide the hand up between the membranes and the anterior part of the uterus into the cavity, and grasp the feet when the membranes give way. Most frequently the membranes burst as the hand is entering the uterus, before it reaches the feet, and the liquor amnii rushes out and is lost, if it is not prevented by pressing the hand forward firmly into the orifice. Never be contented with one foot when it is possible to grasp both; and this can always be done when the liquor amnii has not escaped, and the uterus is not closely contracted round the body of the child. Seize both feet and legs, and when there is no pain, draw them down into the vagina; and as the nates descend through the os uteri, the shoulder and arm will gradually recede or be retracted, and will offer no obstacle to the remaining part of the operation, which should be completed as if the nates and inferior extremities had originally presented, and which has already been very fully described. In actual practice, except in twin cases, the membranes have been ruptured and the liquor amnii is gone, in a great proportion of cases—in about ten to one—long before we are called upon to deliver by turning, and the operation is then a much more serious affair. Sometimes, when theos uteri is half dilated, there is an interval of freedom from pain for several hours after the rupture of the membranes, and partial escape of the liquor amnii. Here it is advisable to turn without delay; and the hand can be passed up into the uterus and the feet brought down with little more difficulty than if the membranes had not been ruptured."
"When the operation of turning is required before the membranes are ruptured, and when the orifice of the uterus is widely dilated, and there are long intervals between the pains, it is accompanied with little difficulty and danger. Having explained to the patient and her relatives the nature of the case, let her lie on the left side near the edge of the bed, with the knees drawn up to the abdomen. Sit down by the side of the bed, and quietly take off your coat; lay bare your right arm by turning up the shirt above the elbow, and cover the back of the hand and the whole forearm with cold cream, lard, or a solution of soap. Introduce one finger after another into the vagina, and slowly and effectually dilate its orifice. The hand, in a conical form, and in a state of half supination, must then be pressed steadily forward with a semi-rotatory motion against the perineum and sides of the passage, till it clears the orifice of the vagina. This should always be done very slowly and gently, as it is accompanied with great pain. Let the hand remain some time in the orifice of the vagina, that it may be fully dilated, and offer no resistance in thesubsequent steps of the operation of turning. When the hand has dilated the vagina sufficiently, in the absence of pain gently insinuate the points of the fingers and thumb into the os uteri in a conical form; and if it is not sufficiently open to allow the hand to pass, you must proceed next to use artificial dilatation here also, very gently and slowly, always stopping as soon as a pain comes on, but not withdrawing the fingers altogether at the time from the os uteri. Having succeeded in dilating the part without rupturing the membranes, slide the hand up between the membranes and the anterior part of the uterus into the cavity, and grasp the feet when the membranes give way. Most frequently the membranes burst as the hand is entering the uterus, before it reaches the feet, and the liquor amnii rushes out and is lost, if it is not prevented by pressing the hand forward firmly into the orifice. Never be contented with one foot when it is possible to grasp both; and this can always be done when the liquor amnii has not escaped, and the uterus is not closely contracted round the body of the child. Seize both feet and legs, and when there is no pain, draw them down into the vagina; and as the nates descend through the os uteri, the shoulder and arm will gradually recede or be retracted, and will offer no obstacle to the remaining part of the operation, which should be completed as if the nates and inferior extremities had originally presented, and which has already been very fully described. In actual practice, except in twin cases, the membranes have been ruptured and the liquor amnii is gone, in a great proportion of cases—in about ten to one—long before we are called upon to deliver by turning, and the operation is then a much more serious affair. Sometimes, when theos uteri is half dilated, there is an interval of freedom from pain for several hours after the rupture of the membranes, and partial escape of the liquor amnii. Here it is advisable to turn without delay; and the hand can be passed up into the uterus and the feet brought down with little more difficulty than if the membranes had not been ruptured."
The operation of turning is however beset with many difficulties, and unless the conditions for it are very favorable, and the operator skillful, it may cause greater mischief than it is intended to remedy. The probability is, as in the case of other operations, that it would seldom or never be needed if proper means were used in time, and perseveringly; and it is yet a question whether the prospect, for both mother and child, would not be more favorable if the delivery was always left to nature, in those cases where version is now attempted. Dr. Collins says, "As to turning, the risk to the mother is, in the majority of cases, so great as to forbid its employment, nor do I think the practitioner justified by the circumstances in so greatly hazarding his patient's life."
PART II.THE DISEASES OF WOMEN DURING PREGNANCY, AND IN CHILD-BED.Womenare liable during pregnancy, and after childbirth, to most of the diseases which afflict them at other times, and also to many derangements peculiar to those periods. As a general rule either of those conditions somewhat modifies the disease, and also necessitates certain differences in its treatment. My former work on theDiseases of Womenhaving treated on all those affections common to every other period, I shall in this confine myself chiefly to those peculiar to the two conditions referred to; giving their causes, symptoms, and treatment, with practical hints for their prevention.
THE DISEASES OF WOMEN DURING PREGNANCY, AND IN CHILD-BED.
Womenare liable during pregnancy, and after childbirth, to most of the diseases which afflict them at other times, and also to many derangements peculiar to those periods. As a general rule either of those conditions somewhat modifies the disease, and also necessitates certain differences in its treatment. My former work on theDiseases of Womenhaving treated on all those affections common to every other period, I shall in this confine myself chiefly to those peculiar to the two conditions referred to; giving their causes, symptoms, and treatment, with practical hints for their prevention.
SECTION IX.THE DISEASES OF PREGNANCY.Thediseases which are found during pregnancy are of two kinds; the first kind calledSympathetic, or nervous, consist of various derangements of different parts of the system, produced chiefly by nervous sympathy with the Womb. The second kind, calledIdiopathic, are real primary derangements of the Generative Organs themselves, or of those intimately connected with them. Each of these kinds will be treated of separately.
THE DISEASES OF PREGNANCY.
Thediseases which are found during pregnancy are of two kinds; the first kind calledSympathetic, or nervous, consist of various derangements of different parts of the system, produced chiefly by nervous sympathy with the Womb. The second kind, calledIdiopathic, are real primary derangements of the Generative Organs themselves, or of those intimately connected with them. Each of these kinds will be treated of separately.