A System of Midwifery Part 16

The whole process of introducing and fixing the forceps should be conducted in as gentle and gradual a manner as possible: no attempt should be made to proceed with the operation during a pain; and in no case is force either necessary or justifiable.

Every thing being now prepared for the extraction, we must endeavour to make this resemble as far as possible the natural expulsion. When a pain, therefore, comes on, we should grasp the handle firmly, and pull gently, at the same time giving them a rotatory motion. The direction of the handles, as before said, will depend upon the situation of the head in the pelvis: if it be at the outlet, it will point downwards and forwards; if in the cavity, nearly directly downwards. If the head makes but little or no advance with one or two efforts, it will be advisable to tie the handles firmly together, and thus keep up a continued pressure upon it, and dispose it the more to elongate and adapt itself to the pa.s.sages. As it advances and begins to press upon the perineum, we must be more than ever cautious not to hurry the expulsion, and give the soft parts time to dilate sufficiently. At this period it is desirable to make the extractive effort not so much forwards as the direction of the handles would seem to indicate: we thus avoid pressing too severely upon the urethra and neck of the bladder, which might otherwise suffer, and a.s.sist the dilatation of the perineum. When the head is on the point of pa.s.sing the os externum, all farther extractive efforts should cease; the perineum must be supported in the usual manner, and the head should be expelled if possible by the patient herself.[87]

In applying the curved forceps we must bear in mind another rule in addition to the one above-mentioned for selecting the first blade, viz.

the pelvic curvature must correspond with that of the sacrum. As with the straight, so also with the curved forceps, the extremity of the blade will be our best guide as to the direction in which we should hold the handle at the moment of introduction; it must be directed more or less forwards in proportion to the degree of the pelvic curvature of the blade. If, for instance, it be the upper blade which is to be introduced first, we pa.s.s it obliquely over the lower thigh or nates of the mother, making it glide closely round the convexity of the head, between it and the pelvis, without impinging either on the one or the other. As the position of the head is still more distinctly oblique at this earlier period of its progress through the pelvis, so will the blades require a more oblique direction, and also (as in the former case) they must be introduced in the contrary oblique diameter to that in which the head is.

As the blade pa.s.ses up between the head and pelvis, so does the handle gradually make a sweep backwards, until at length it approaches to the edge of the perineum. During the process of introduction, one or two fingers should press against the posterior edge of the blade to guide it up to the brim of the pelvis, and prevent its slipping too far backwards towards the hollow of the sacrum.

The second blade will be guided in its direction by that of the first: it must be introduced so that the inner surface of its handle corresponds exactly with that of the first. The locking must be performed under the same precautions as with the straight forceps: the more so, as in some cases it has to take place just within the os externum, and therefore requires the most careful attention to prevent the soft parts from being caught and pinched between the blades when they are brought together. In extracting the head we must bear in mind the part of the pelvis in which it is impacted, and make our effort in the direction of its axis; we must also recollect the curved form of the instrument, and that we must not pull in the direction in which the handles point, but rather hold them firmly with one hand, and, by pressing against the middle of the forceps with the other, guide the head downwards and backwards into the cavity of the pelvis. We shall thus make our extractive effort in the direction of the upper portion of the blades, or that part which has the chief hold upon the head: hence, therefore, as it descends, the handles are directed more and more forwards, so that when it has reached the perineum, the handles will not only point forwards, but considerably upwards. Whilst extracting we should, as with the straight forceps, slowly move the handles from side to side, and even make them describe a circle: we thus not only use the forceps as a simple extracting instrument, but make it act as a lever in every direction, and greatly facilitate the advance of the head, even under circ.u.mstances of considerable impaction. It is in these cases where keeping up a continued pressure upon the head by tying the handles tightly together, and tightening it after every successive effort, has such excellent effects in diminis.h.i.+ng the degree with which it is wedged against the pelvis and soft parts, and in disposing it by gradual elongation to a.s.sume a form which is better adapted for advancing through the pa.s.sages.

The slow and gradual pressure of the forceps thus exerted upon the head of a living foetus will have a very different result to that of the experiments by Baudelocque and others, in attempting to compress the head of a dead foetus by the application of a sudden and powerful force. Even if we were capable of effecting no greater diminution of its lateral diameter than a quarter, or at the most, three-eighths of an inch, as stated by Dr. Burns, we should, in most cases of impacted head, where the forceps is justifiable, find it quite sufficient to remove the obstructing causes.

The forceps is also occasionally required in presentations of the face and nates. In the first case we must pa.s.s up the blades on each side of the face, and along the side of the head, having previously ascertained to which side of the pelvis the chin is turned. In nates cases, the blades should also be pa.s.sed up along the sides of the child's pelvis, and here the advantages of a broad fenestra will be very evident, for otherwise our hold will not be firm enough without exerting an improper degree of pressure.

Cases every now and then occur, where from convulsions, &c., it is desirable to apply the forceps whilst the patient is lying upon her back, as is practised upon the continent. "The patient is placed across the bed, propped up in a half-sitting posture, by pillows, &c., her pelvis resting upon the edge, her feet on two chairs, the knees supported by a.s.sistants.

Two, and generally three fingers are pa.s.sed, if possible, up to the os uteri, on the side where the blade is to be introduced: the index finger, is held a little behind the middle finger, so that this last, by projecting somewhat, forms a species of ledge upon which the blade slides, and which acts as a fulcrum to it. The handle is held at first nearly perpendicular; but as the blade advances, it gradually approaches the horizontal direction, being guided by the pelvic curve of the instrument.

The middle finger, along the ulnar surface of which the convex edge of the blade slides, prevents its extremity from pa.s.sing too far backwards, and directs it in the axis of the pelvis. When introduced to the full extent, the handle is inclined obliquely downwards, and is now grasped by an a.s.sistant pa.s.sing his hand below the patient's thigh. The other blade is introduced in the same way on the opposite side of the pelvis; and the locking, extraction, &c., conducted much in the same manner as in England." (_British and Foreign Med. Rev._ vol. iii. April 1837, p. 419.)

_History of the forceps._ We have already mentioned some historical points connected with the improvements of the present French and English forceps; it will now be unnecessary to enter more fully into the history of this instrument. The earliest trace of the midwifery forceps which we possess is under the form of a secret in the hands of an English family, named Chamberlen. As to when and by whom it was first invented, this must probably remain for ever unknown; and at any rate there is no more reason to suppose that Dr. Hugh Chamberlen was the inventor than his father or brothers were. He was compelled to quit England on account of being involved in the political troubles of the time, and went to Paris in the beginning of the year 1770, and evidently had then been some time in possession of the secret. He returned to London, in August of the same year, having in vain attempted to sell it to the French government, after having entirely failed in a case of difficult labour which he had a.s.serted he could deliver in a few minutes, although Mauriceau had stated that the Caesarean operation would be required. Dr. H. Chamberlen published in 1772, a translation of Mauriceau's work, which had appeared four years previously, and in his preface he publicly alludes to this secret, and says, "My father, brothers, and myself (though none else in Europe, as I know) have, by G.o.d's blessing and our industry, attained to, and long practised a way to deliver women in this case without any prejudice to them or their infants: though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy, one or both, with hooks." He thus apologizes for not having divulged this secret: "there being my father and two brothers living, that practice this art, I cannot esteem it my own to dispose of, nor publish it without injury to them."

Whether a work, ent.i.tled _Midwife's Practice_, by Hugh Chamberlen, 1665, was by the translator of Mauriceau's work, or by his father, must now remain a matter of doubt: it was, however, in all probability by the latter, from what the translator says in his preface, viz. "I designed a small manual to that purpose, but meeting some time after in France, with this treatise of Mauriceau, I changed my resolution into that of translating him." On account of his being attached to the party of James II. he was again obliged to quit England, in 1688, and crossed over to Amsterdam, where he settled, and in five years after succeeded in selling his secret to three Dutch pract.i.tioners, viz. Roger Roonhuysen, Cornelius Bokelman, and Frederick Ruysch, the celebrated anatomist. In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it generally known. It turned out to be a flat bar of iron, somewhat curved at each end: this lever was stated to have been received from Roonhuysen, one of the original purchasers of the Chamberlen secret; but there is no reason to suppose that any such instrument had been communicated by Chamberlen either to him or the others, as we have distinct evidence that both Ruysch and Bokelman possessed _forceps_, the blades of which united at their lower end by means of a hinge and pin. It is known also that Roonhuysen used a double instrument consisting of two blades. The above-mentioned flat bar of iron, commonly called Roonhuysen's lever, was, without doubt, invented after his time, by Plaatman, who received the Chamberlen secret from him. (_Edin.

Med. and Surg. Journal_, Oct., 1833.)

[Ill.u.s.tration: Chamberlen's Forceps.]

Not many years ago a collection of obstetric instruments were found at Woodham, Mortimer Hall, near Mildon, in Ess.e.x, which formerly belonged to Dr. Peter Chamberlen, who, having purchased this estate "some time previous to 1683," was, in all probability, one of the brothers alluded to by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's work. This collection, (now in the possession of the Medico-Chirurgical Society, of London,) contains several forceps, two of which appear to have been used in actual practice: these differ from each other only in size, and present a great improvement upon the instrument possessed by Hugh Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well formed: the locks are the same as of a common pair of scissors, except that in one case the pivot is riveted into one lock, which pa.s.ses through a hole in the other when the blades are brought together. In the smaller forceps there is merely a hole in each lock through which a cord is pa.s.sed, and then wound round the shanks of the blades to fasten them together, an improvement in which Dr. Peter Chamberlen had evidently antic.i.p.ated Chapman, in making the first approach to the present English lock.

The earliest professors of the forceps, besides the Chamberlens, were Drinkwater, who commenced practice at Brentford, in 1668, and died in 1728; Giffard, who has given cases where he used his extractor as early as 1726; and Chapman, who possessed a similar instrument about the same time. These forceps correspond very nearly with the above-mentioned ones of Dr. Peter Chamberlen; and as it is well known that from those of Giffard and Chapman, the forceps of the present day are descended, we cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for these instruments, to which his bear so distant a resemblance, as to his relations, who, from living together in England, had doubtless a.s.sisted each other by their mutual inventions, and thus brought the instrument to that state of improvement in which it was found as above-mentioned.

For more detailed information respecting the history of the forceps we may refer our readers to Mulder's _Historia Forcipum_, &c., particularly, the German translation by Schlegel, to a similar work brought down to the present time, by Professor Edward von Siebold, to our own lectures on this subject, published in the _London Med. and Surg. Journal_, for March 28, 1835, vol. vii., and to the two papers already alluded to in the _London Med. Gazette_, Jan. 8, 1831, and _Edinburgh Med. and Surg. Journal_, October, 1833. [Also, _Researches on Operative Midwifery_, &c. By FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. _Dublin_, 1841.--ED.]

CHAPTER II.

TURNING.

_Turning.--Indications.--Circ.u.mstances most favourable for this operation.--Rules for finding the feet.--Extraction with the feet foremost.--Turning with the nates foremost.--Turning with the head foremost.--History of turning._

Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os uteri and v.a.g.i.n.a, and in this manner the child delivered. (Naegele, _MS.

Lectures_.)

Besides turning with the feet foremost as now described it has also been proposed, as being safer for the child, to bring down the nates or the head, but these operations, especially the former, have scarcely ever been practised, and in most cases are impracticable.

Turning, in the strict sense of the word, is that operation, by which, without danger to the mother or her child, the position of the latter is changed, either for the purpose of rendering the labour more favourable, or for adapting the position of the child for delivering it artificially.

The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the child, it has been very properly recommended by Deleurye, (_Traite des Accouchemens_, 1770,) Boer, (_Naturliche Geburtshulfe_, 1810,) Wigand, (_Geburt des Menschen_, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling powers; hence, therefore, under these circ.u.mstances, artificial extraction of the child with the feet foremost can scarcely be said to exist, the operation itself being confined to changing the position of the child.

Where, however, the circ.u.mstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation.

The artificially changing the child's position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty.

_Indications._ The artificially delivering the child with the hand alone, or the extraction of it with the feet foremost (which of course presumes that it has presented with the feet, either originally or has been brought into that position by interference of art,) is indicated in all cases where the labour requires to be artificially terminated either on account of insufficiency of the expelling powers, or from the occurrence of dangerous symptoms. Under this head, on the part of the mother, are violent floodings, especially under certain circ.u.mstances, convulsions with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;--on the part of the child, prolapsus of the cord under certain circ.u.mstances. (Naegele, _Lehrbuch der Geburtshulfe_, ---- 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the foetus, or which demand a hasty delivery of the child, but which cannot be attained by the application of the forceps.

Turning is an operation which is far inferior to that of the forceps, both as regards the safety of the mother and her child, and also the ease with which it is performed. Whenever the circ.u.mstances under which it is undertaken are unfavourable, it not only becomes a very difficult operation, but also one of considerable danger: for the child especially is this the case, as the very circ.u.mstance of its being born with the feet foremost shows that it is necessarily exposed to the same dangers as those already mentioned in nates presentations, in addition to those of the first part of the operation, viz. the changing its position.

The most favourable moment for undertaking the operation of turning is when the os uteri is fully dilated and the membranes are still unruptured.

In this state, the v.a.g.i.n.a and os uteri are most capable of admitting the hand, and the uterus, from being filled with liquor amnii, is prevented contracting upon the child, the position of which is changed with great ease and safety; but when the os uteri is only partially dilated, its edge thin and rigid, the membranes ruptured, and the liquor amnii drained off for some hours, it becomes a matter of great difficulty and danger either to introduce the hand into the uterus under such circ.u.mstances, or to attempt changing the child's position: the os uteri tightly encircles the presenting part, and the uterus contracts upon the child itself so as to render it nearly, if not altogether immoveable.

The os uteri ought always if possible to be fully dilated: this however is not so essential as with the forceps, for when once it has reached the size of a crown piece, it mostly yields easily to the introduction of the hand. Where turning is indicated in malposition of the child we may safely await its full dilatation so long as the membranes remain unruptured.

Where the membranes have been ruptured some hours and the os uteri hard, thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cus.h.i.+ony, and dilatable.

In cases which require turning as a means of hastening labour, as for instance in flooding from placenta praevia and other causes, the haemorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand.

Where convulsions indicate turning, the bleeding and other depleting measures, which are necessary to control them, will have a similar effect in preparing the os uteri for this purpose.

In ordinary cases of turning there will be no need to change the patient's position, as it will be just as easy to perform it as she lies upon her left side, merely bringing her pelvis nearer to the side of the bed in order to reach her with greater facility. Where, however, from the position of the child or from the state of the uterus, the introduction of the hand and searching for the feet will probably be attended with considerable difficulty, it may be advisable to place her across the bed, sitting upon its edge, her back supported by pillows, her feet resting on two chairs, in the same way as it is used by the Continental pract.i.tioners for applying the forceps; or if it be really a case of very unusual difficulty, it will be better to put her upon her knees and elbows, for in this position we gain the upper and anterior parts of the uterus with greater ease.

In choosing which is the best hand for performing the operation, the pract.i.tioner must not only be guided by the position of the child, but also by the hand with which he possesses most strength and dexterity: many always use the left hand for turning when the patient lies upon her left side; for our own part we have always used the right, and have never failed except in one or two cases of great difficulty, where we judged it more prudent to put the patient on her knees and elbows than risk any injury by using too much force. In introducing the hand into the v.a.g.i.n.a as the patient lies on her left side, the right is moreover preferable, as we can pa.s.s it more completely in the axis of the v.a.g.i.n.a, than we can the left.[88]

The directions which are usually given to introduce one hand or the other according to the child's position, are not practical, because cases occur where it is impossible to ascertain this point without pa.s.sing the hand into the uterus, as in placenta praevia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repet.i.tion of this operation, merely because the position of the child is such as is stated in books to require the left hand instead of the right.

Having evacuated the bladder and r.e.c.t.u.m, and greased the fore-arm and back of the hand, we should gently insinuate the four fingers, one after the other, into the os externum: the whole hand must be contracted into the form of a cone; the thumb will pa.s.s up easily along the palm; the pa.s.sage of the knuckles is the most difficult, for as the os externum is the narrowest part of the v.a.g.i.n.a, and the hand is widest across the knuckles, it follows that this is the point of the greatest resistance and suffering, and that, when once this is overcome, our hand will advance with greater ease both to ourselves and to our patient. This part of the operation can scarcely be conducted too gradually or gently, for if we give the soft parts sufficient time to yield, it is scarcely credible what an extent of dilatation may be effected by a comparatively moderate degree of pain; the os externum is also the most sensitive part of the v.a.g.i.n.a, and serious nervous affections may even be provoked by the intolerable agony arising from a rude and hasty attempt to force the hand through it.

We must not advance the hand merely by pus.h.i.+ng it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the v.a.g.i.n.a gradually ride over this projecting part as the hand advances.

In pa.s.sing the os uteri the same precautions must be observed, particularly when the os uteri is not fully dilated; at the same time we must fix the uterus itself with the other hand, and rather press the fundus downwards against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand; for we thus not only enable the hand to pa.s.s the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the v.a.g.i.n.a from the uterus, in all cases where the turning is at all difficult. "In those cases (says Professor Naegele) where artificial dilatation of the os uteri is required to let the hand pa.s.s, it should be done in the following manner:--during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and by gently turning them and gradually expanding them we endeavour to dilate it sufficiently to let the hand pa.s.s. This must only be done under circ.u.mstances of absolute necessity and always with the greatest caution--in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is sufficiently yielding or dilated." (_Lehrbuch der Geburtshulfe_, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the _forcible_ dilatation of the os uteri is justly deprecated by Madame la Chapelle: "I never attempt to produce this forced dilatation, _not even in cases of haemorrhage_. But we may frequently promote the dilatation of the pa.s.sages in a remarkable manner by moistening and relaxing them and diminis.h.i.+ng their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding." (p.

49.) Her diagnosis of the condition in which the os uteri will yield to the introduction of the hand is well worthy of attention. "If the inactive uterus be unable to expel the child, or to make the head clear its orifice although considerably dilated, if, in this state of affairs, the membranes give way, we can feel the os uteri retract, from being no longer pressed upon. How different is this state of pa.s.sive contraction to the rigidity of an orifice which has not yet been dilated: in this case, although the os uteri is contracted and even thick, it is soft, supple, and easily dilatable; there is no feeling of tightness or resistance; it is little else than a membranous sac, and the head has not descended sufficiently to press upon it; or if the head does not present, it is some part of the child, as for instance the shoulder, which is unable to advance and act upon the os uteri: in this case operate without fear--in the other wait."

(_Pratique des Accouchemens_, p. 86.)

If the membranes be not yet ruptured we should use the greatest caution to preserve them uninjured: the hand must be gently insinuated between them and the uterus, and should be pa.s.sed either until the feet are felt, or at least, until it has gained the upper half of the uterus. Now, and not till now, ought they to be ruptured. As this is done at the side of the uterus little or no liquor amnii escapes, for the torn membranes are pressed closely against the uterine parietes, and the v.a.g.i.n.a is completely closed by the presence of the arm in it acting as a plug; the uterus is unable to contract upon the child on account of the fluid which surrounds it, and the hand, therefore, pa.s.ses up with great facility. The uterus is not diminished by the loss of its liquor amnii; its contractile power is, therefore, not increased. When the hand has broken the membranes it can move about in perfect freedom: if the feet have not as yet been reached they will now be easily found, and the position of the child will be changed without difficulty.

The importance of pa.s.sing in the hand without rupturing the membranes was first shown by Peu in 1694.[89] But it excited little or no notice at the time, not even by La Motte, who paid so much attention to improving the operation of turning. Dr. Smellie appears to have been the first after Peu who recommended this mode of practice, although he makes no mention of his name. "Then introducing one hand into the v.a.g.i.n.a we insinuate it in a flattened form within the os internum, and push up between the membranes and the uterus as far as the middle of the womb: having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them without moving the arm lower down, then turn and deliver as formerly directed." (_Treatise on the Theory and Practice of Midwifery_, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us "introduire la main dans la matrice _sans_ percer la poche des eaux, detacher les membranes des parois de ce viscere, et les percer a l'endroit ou l'on juge que les pieds peuvent le plus naturellement se trouver."[90] Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye's mode of practice,[91] and it has still farther been confirmed by Professor Naegele.

Turning under these circ.u.mstances is an easy operation, and a very different affair compared with its performance in cases in which the membranes have been some time previously ruptured, and the uterus drained of liquor amnii: the hand is pa.s.sed up with difficulty, the feet are quickly found, and the child moved round with a degree of facility which is scarcely credible. Where, however, the uterus is irritable and closely contracted upon the child, the liquor amnii having long since escaped, where the os uteri is not more than two-thirds dilated, its edge thin, hard, and tight, as is especially seen in a neglected case of arm or shoulder presentation, every step of the operation is attended with the greatest difficulty, and in fact is neither possible nor justifiable, until by bleeding to fainting, by the warm bath and opiates, we have succeeded in producing such a degree of relaxation as to enable us to introduce the hand. "Blood-letting is the only remedy with which we are acquainted that has any decided control over the contracted uterus. It is one almost certain of rendering turning practicable under such circ.u.mstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the pract.i.tioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it." (Dewees'

_Compendious System of Midwifery_, -- 629.) "The v.a.g.i.n.a is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active haemorrhage, and this is equally the case in primiparae as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient's sufferings, under these circ.u.mstances delays to introduce his hand until the haemorrhage shall have ceased. The moment this is the case, the v.a.g.i.n.a regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state of syncope." (Wigand, _Geburt des Menschen_, vol. ii. p. 428.)

When once a powerful impression has been made upon the system by an active bleeding, opiates, which before it, would have only tended to render the patient feverish, are now of great value: they relax the spasmodic action of the uterus, allay the general excitement and irritability, and induce sleep and perspiration. As with bleeding in these cases, they must be given in decided doses: a grain of hydrochlorate of morphia given at once, or in two doses quickly repeated, and at the same time from half a drachm to a drachm of Liquor Opii Sedativus thrown into the r.e.c.t.u.m with a little thin starch or gruel, will rarely or never fail to produce the desired effect. The opiate by the mouth may be advantageously combined with James's powder, and thus a.s.sist its diaph.o.r.etic action. The warm bath will also prove a valuable remedy.

"If the arm or funis of the child presents and is prolapsed into the v.a.g.i.n.a, we must not try to push back these parts into the uterus again, but we must endeavour to pa.s.s our hand along the inner surface of the presenting arm; or if it be the cord, we must guide it so as to press the cord as little as possible: if however a coil of it has pa.s.sed out of the v.a.g.i.n.a and is still beating, we had better carry it upon the hand with which we are about to turn the child." (Boer, _op. cit._ vol. iii. p. 5.

1817.) For farther information on this head we must refer to the observations on _Malposition of the Child_.

If the head or nates be occupying the brim of the pelvis it will be necessary to raise them gently and press them to one side: this however is usually effected by the very act of pa.s.sing up the hand, and seldom produces any difficulty, unless these parts have already advanced deeper into the pelvis; in which case, as turning under these circ.u.mstances can only be undertaken with a view to hasten labour, it will become a matter of consideration whether we shall not be able to attain this object better by the aid of the forceps.

Although it ought ever to be considered as a rule that turning must not be attempted whilst the pains are violent, the introduction of the hand into the uterus always excites it more or less to contraction: the degree of pressure and impediment which it will produce to the progress of the hand will in a great measure depend upon the quant.i.ty of liquor amnii which it contains. Where the uterus has been drained of the fluid, every contraction will be felt in its full force by the operator: his hand is firmly jammed against the child, and if it happens to be caught in a constrained posture at the moment, is liable to be attacked with a severe fit of cramp, which benumbs and renders it powerless. Wherever we find that the hand is tightly squeezed during a pain, we should lay it flat with the palm upon the child, and hold it perfectly still: in this posture it will bear a powerful contraction without inconveniencing ourselves or injuring the uterus; and by letting it be quite flaccid and motionless we shall not provoke the uterus to farther exertions. Attempting to turn during the pain would not only be useless, but we should exhaust the strength of our hand which cannot be spared too much; we should torture the patient unnecessarily, and run no small risk of rupturing the uterus.

In letting the pressure of our hand be upon the child during a pain, instead of against the uterus, we must select any part rather than its abdomen, for pressure here seems to act as injuriously as pressure upon the umbilical cord.

_Rules for finding the feet._ In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of pa.s.sing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circ.u.mstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman's simple rule, that the hand "must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child." The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction.