Part 17 (1/2)
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.)