“This remedy should be early employed, as it will, by proper management, save a prodigious expenditure of blood. We gain by its application important time; time that is essential for the successful delivery of the fœtus; for, by it, the woman’s strength is preserved; pain is permitted to increase; and, eventually, though tardily, the os uteri is dilated, the placenta and fœtus thrown off, and the flooding almost immediately controlled. The other means which we have constantly pointed out, should also be tried: they may aid the general intentions, and render the operation of the tampon more certain.” (Dewees, Compend. Syst. of Midw. § 1142.)
Although Dr. Rigby has given a short account of Leroux’s views respecting the use of the plug in these cases, we cannot but agree with Dr. Dewees, in regretting that he either did not “put his plan in execution,” or that if he did, he has not given us the details of his experience upon it. From what Dr. Gooch, however, has stated in his Account of some of the more important Diseases peculiar to Women, there is every reason to suppose that Dr. Rigby was latterly in the frequent habit of using the plug, and that he thought highly of it. The plug is not only useful in keeping the hæmorrhage under due control until the os uteri be sufficiently dilated, but may occasionally prove of the greatest value in cases of extreme exhaustion from loss of blood, where the patient is too much reduced to undergo the act of delivery, without running the risk of dying during the operation; the plug will enable us to wait with safety until the system has had time to rally its powers and be recruited by the administration of proper nourishment. “Mr. Grainger, of Birmingham, on visiting a poor woman with placenta prævia, and apparently in a moribund condition, immediately filled the vagina and os uteri with linen cloths, and waited two days before he durst hazard delivery, which he accomplished with an auspicious result.” (Ingleby, on Uterine Hæmorrhage, p. 155.)
Turning. The operation of turning the child will, in no wise, differ from that under more ordinary circumstances, and will require to be conducted according to the rules which we have already given. In no case is it more important to preserve the membranes unruptured until the hand has fairly entered the uterus than here; the hand should be carefully insinuated between the os uteri and placenta; if possible, this should be done at the part where the separation which has caused the flooding has already taken place, in order to avoid all unnecessary detachment of the placenta; the pressure of the hand prevents any great discharge of blood; and as it gradually makes its way between the membranes and the uterus, the arm which now occupies the vagina will effectually act as a plug. Portal, was, probably the first who practised this mode of operation, viz. passing his hand between the os uteri and placenta, and then between the uterus and membranes before rupturing them: in this respect he anticipated Peu, whose work appeared nine years after, (see Turning, p. 234.) and would have undoubtedly been looked upon as the originator of this improvement in turning, had he given any reasons for this mode of practice, or deduced any inferences from it.
Some discrepancy of opinion has existed as to whether it is better to perforate the placenta, or to follow the plan we have just recommended. Dr. Rigby’s authority has rather tended to confirm the former opinion, although he afterwards modifies it so much so as to make us almost suppose that he must have preferred the other method. He states, “that by this means, (perforating the placenta,) not more of the placenta may be separated than is necessary for the introduction of the hand, and, consequently, that as little increase of bleeding as possible may be produced by the operation; but if it be impracticable, as I have more than once found it, and it must ever be when the middle of the placenta presents to the hand, from the thickness of it near the funis, it must be carefully separated from the uterus on one side, and the hand passed till it gets to the membranes.” (Op. cit. p. 61.)
To Dr. Dewees are we chiefly indebted for having put the inexpediency of perforating the placenta in the strongest possible light. “We are advised by some,” says he, “to pierce the placenta with the hand; but this should never be done, especially as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it.
“1. In attempting this, much time is lost that is highly important to the patient, as the flooding unabatingly, if not increasingly, goes on.
“2. In this attempt we are obliged to force against the membranes, so as to carry or urge the whole placentary mass towards the fundus of the uterus; by which means the separation of it from the neck is increased, and consequently, the flooding augmented.
“3. When the hand has even penetrated the cavity of the uterus, the hole which is made by it is no greater than itself, and consequently much too small for the fœtus to pass through without a forced enlargement, and this must be done by the child during its passage.
“4. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested; and if force be applied to overcome this resistance, it will almost always separate the whole of the placenta from its connexion with the uterus.
“5. That when this is done, it never fails to increase the discharge, besides adding the bulk of the placenta to that of the arms and head of the child.