The X-rays, the latest great discovery in electrotherapeutics, has already been applied to a wide range of diseases with reasonable expectation that the number will become greater. When we review its history and the relief it has already afforded to suffering humanity the wonder is that the thought which gave it birth remained dormant for so long a time. Russell, of England, in 1836, first suggested the possibility that a valuable occult force would be found in the wake of the cathodal ray, but it remained for Röentgen, of Germany, sixty years later, to discover and put into practical use this important force. This new power, still in its infancy, has already brought to light the diseases, displacements, and injuries of the internal organs. Fractures and dislocations of the bones and joints are made clear as to extent and numbers. Tumors and foreign bodies in every part or texture of the human frame (except some of those beneath the calvarium) have been brought into view. Former methods of electrolysis have been replaced by the use of the X-rays. Extraneous hairs and nevi have been successfully removed without pain-cures of lupus have been reported from the use of the X-rays-more recently tumors of every description and hyperplasias have yielded to the cathodal rays. Reports from those in authority as to the use of the X-rays in cancers are all decidedly encouraging, and to the effect that tumors, both benign and malignant, yield to the occult force. It is also believed that time will reveal greater benefits in this direction. The result of experiments on pulmonary consumption and tuberculous diseases with the X-rays has renewed hope that the tubercle bacillus has met its direst enemy. The wondrous effects of electricity upon seeds, growing plants, and animals that have been recorded by scientists are such as to cause the hope that this great force may some day, not in the far distance, be carried further into the domain of life. May it be not possible by the use of so great a power to rearrange the deviating cells and twisted neurons of the brain, and replace wasted power in those mentally defective and irresponsible for their acts? Let us hope on, and believe that in time some Franklin or Newton will appear on the scene with a matured method by which electricity may be used to restore healthy functions to all of the automatic occult forces within the disordered human brain. LOUISVILLE. VERSION.* BY WALKER B. GOSSETT, M. D. Instructor in Obstetrics in the Louisville Medical College; the Visiting Physician to the Morton Church Home Version is an operation by which we change the position of the fetus in utero. The object of version is to substitute one of the fetal poles for some other presenting part. Version is divided into cephalic or podalic. "Turning of the child in the uterus is one of the oldest obstetric operations, for it was known in the time of Hippocrates, whose comparison of the fetus lying transversely to an olive similarly placed in a bottle is so well known; but the great master committed a sad error in teaching that the fetus could not be delivered unless the head came first, an error which though some centuries afterward Celsus corrected still ruled, sustained as it was by the great name of Galen-for who could dispute what Hippocrates and Galen taught?—until soon after the invention of printing in the fifteenth century (1596), and then the illustrious French surgeon Paré established for podalic version its legitimate place. Guillemeau, the friend and pupil of Paré, advised turning by the head or by the feet in case the placenta came first. "The famous Louise Bourgess recommended podalic version in prolapse of the cord and also in case of uterine hemorrhage during labor, and then extract the child by the feet, saying that it was necessary to rupture the membranes as one forces an entrance into a burning house in order to save it. "Until the invention of the forceps, and the knowledge of this instrument became the property of the profession, podalic version occupied a most important place in obstetrics, and turning by the head sank into comparative neglect, for prior to possessing this instrument the accoucheur was powerless to end the labor though he had brought the head in a favorable position. "Among the aboriginal tribes of Mexico a curious custom prevailed in cases of difficult labor. A woman was seized by the feet, suspended head downward, and vigorously shaken. If the dystocia was due to a transverse position of the fetus in utero this rough and unscientific treat*Read before the Kentucky State Medical Society, Paducah, Ky., May 7-9, 1902. ment might in a certain number of cases be effective, and it was, no doubt, in consequence of a few successes that the custom had its origin. "In Japan, before the country had reached its present high stage of civilization, it was customary to apply massage to the abdomen of pregnant women in order to straighten out a possibly faulty position of the fetal ellipse. In many primitive races some form of version has been and is in vogue, handed down as a custom of ancient origin.' Cases in which version may be required: (1) Transverse presentations; (2) contracted pelves; (3) cases in which rapid delivery is necessary, provided delivery by the forceps is not safe or practicable, as in placenta previa, rupture of the uterus, prolapse of the cord, convulsions, tedious labors, and puerperal hemorrhage, etc. Choice of version: (a) When correction of a malpresentation is all that is required, and circumstances do not render subsequent immediate delivery necessary, a cephalic version may be performed; (b) when a rapid delivery is necessary, perform a podalic version. Before performing version the operator must have a true mental picture of the position of the fetus in utero, and he must have a personal knowledge that all the necessary preparations for the various emergencies which may arise are at hand. There are three ways of performing version: (1) External manipulation; (2) combined manipulation; (3) internal manipulation. The operation of version by external manipulation. It is used mostly for the correction of a transverse presentation, either before the labor begins, or the labor having begun then before the liquor amnii has been discharged, or as soon thereafter as possible, while the child is easily movable. To perform the operation the woman should be placed on her back, with the thighs flexed; uncover the abdomen; then with the flat hands one over the child's head, the other over breech - gently push the head toward the pelvic brim and the breech up toward the fundus uteri. Manipulate only at interval of pains; if the pains come on, stop manipulating but hold the child firmly enough to retain any degree of change in its position already gained. When the child slips around into its right position rupture the membranes, may contract and keep it there. two pads one on the side of the uterus high up against the breech, the other on the opposite side lower down against the head - and retain them with a binder. if the labor has begun, that the uterus Now, if the labor has not begun, place This method The operation of version by combined manipulation. was first proposed by Bush and Dr. Wright, of Cincinnati, and was later advocated by Braxton Hicks, of London. This is the second least dangerous method; it is to be tried after external version has failed. Thus in head presentations the operation comprises three steps, viz.: Ist. The fingers inside, lift the head toward that iliac fossa toward which the occiput points, while the hand outside depresses the breech along the opposite side. 2d. The fingers inside can now touch the shoulder or sternum, and they push or lift it in the same direction as the head. The hand outside still depresses the breech. The breech and knee are now within reach of the fingers. 3d. Grasp the knee- the membranes, if unbroken, may now be ruptured and pull it down, while the hand outside changes its position so as to push the head up toward the fundus. The foot may now be reached, and case managed as a footling or breech. In cephalic version the fingers inside will push the shoulders in the direction of and after the breech; the hand outside depresses the head. The operation of version by internal manipulation. This operation is comparatively easy before the waters have escaped and when the uterus is not rigidly contracted around the child. Conditions necessary before this operation should be attempted, viz.: First, the pelvis must be of sufficient size to admit the delivery of the child; second, the os uteri must be dilated or dilatable; thirdly, the presenting part must not have descended so low or become so firmly impacted in the pelvis that it can not be pushed back above the superior strait without risk of lacerating the uterus. This opera Cephalic version by the internal method is not now performed. The operation of podalic version by the internal method. tion comprises three steps, viz.: (1) Introduction of the hand and grasping the feet; (2) turning of the child; (3) extraction of the child. The first two steps are to be proceeded with only during the interval of the pains; when a pain comes on hold the hand still, relaxed and flat, thus avoiding the risk of rupturing the uterine wall with the knuckles. The third step is performed during a pain. The woman is placed on her back, the hips brought to the edge of the bed. In these cases complete anesthesia is required. The operator should have his arm bare to above the elbow and anointed with vaseline, etc., on all parts except the palm of the hand. Use the hand whose palm corresponds to the abdomen of the child. The finger ends are brought to a cone and introduced into the vagina in the axis of the pelvic outlet, back of the hand to the sacrum. Introduce the hand into the uterus in the axis of the brim, while the other hand is outside making support and counter-pressure. With the thumb between the head and pubes, and the fingers between the head and sacrum, the head is grasped and lifted out of the way; the wrist resting against the forehead keeps it in position. Pass the hand on up, grasp the feet, one or both, and then turn the child. (Second step.) Should the membranes be unbroken they should be ruptured when the hand passes by the head into the uterus. Where to find the feet: "Use the right hand for right presentation, and left for the left. In a right lateral presentation, when the position is a dorso-anterior, the feet will be found toward the right and posterior part of the uterus above the right sacro-iliac synchondrosis. So pass the right hand along the hollow of the sacrum to the right and higher up of the promontory and grasp the feet. In a dorso-posterior position of the same right lateral presentation the feet will rest toward the left and anterior part of the uterus above the left acetabulum. So pass the right hand directly up and grasp the feet behind the pubes and acetabulum, instead of going behind the child's breech and pronating round it. This method is made easier by placing the woman on her side - the side toward which the feet are directed - while the operator, standing behind her, passes the hand-right one for right, and left one for left, as before stated with its back toward the pubes and acetabulum, directly to the feet." (King.) Dr. D. Berry Hart, in a paper read before the Edinburgh Obstetrical Society and published in the Scottish Medical and Surgical Journal, has this to say in his choice of the feet in podalic version: "Seize the knee or leg which maintains the dorso-anterior position or converts the dorsoposterior into a dorso-anterior; that is, take the farther limb in dorsoposterior cases, the nearer in dorso-anterior cases. When, however, in dorso-anterior cases the breech is in the fundus, traction on the nearer leg may convert it into a dorso-posterior, and when the breech is near the os in dorso-posterior position, traction on the farther leg may not alter the posterior position of the back after version, owing, again, to the want of the necessary obliquity in the pull." When the child has been turned the case may be left to nature unless circumstances render rapid delivery necessary. |