"Where the placental presentation is complete, the operation of turning should be performed, in all cases, as soon as the orifice of the uterus is so much dilated or dilatable as to allow the hand to be introduced without the employment of much force. It is seldom safe to attempt to deliver by turning before the os uteri is so far dilated that you can easily introduce the points of the four fingers and thumb within it: however soft and relaxed it may be, until dilatation has commenced, and proceeded so far, I am convinced there are very few cases in which the operation of turning will be required, or completed without the risk of inflicting some injury on the os uteri. This is a point of the greatest practical importance, but I do not know in what manner to communicate to you, in words, a more clear and definite idea of the grounds upon which you ought to proceed.
"In every case, before attempting to turn, make a most careful examination of the os uteri, and endeavor, from the degree of dilatation, and the thinness and softness of the orifice, to form a correct judgment upon this point, before interfering, for the hemorrhage will be renewed if the attempt is unsuccessful, and the patient will be placed in a worse condition than she was before. When you have resolved to turn, let the patient lie on the left side, with the pelvis close to the edge of the bed, and introduce the right hand into the vagina as before described, and then pass the fingers and hand gently and slowly in a conical form through the os uteri, giving it time to dilate, and onward into the cavity between the detached portion of the placenta and the uterus: then force the fingers through the membranes, grasp both feet, and bring them down into the vagina, and slowly extract the child as in the cases of nates presentation, and do not afterwards be in a hurry to remove the placenta, unless it is wholly detached and lying in the upper part of the vagina. This operation is easily and speedily performed when the os uteri is widely dilated and dilatable. It is, however, a great exaggeration of the facility with which turning may be accomplished in these cases, to represent it as a very simple process—like putting the hand into the coat-pocket and pulling out your handkerchief. At the best it is a dangerous operation, and you can never tell with certainty whether or not the patient will recover after its performance, however easily it may have been effected.
"But there is not unfrequently most profuse and alarming flooding from complete placental presentation, where the os uteri is so thick, rigid, and undilatable, that it is impossible to introduce the hand into the uterus without producing certain mischief. In thirteen out of thirty-six recorded cases the os uteri was rigid and undilatable. The tampon or plug has no power to restrain the hemorrhage in such cases, nor do I know of any other means—either cold, quietness, or opium—which effectually have, and it is sometimes absolutely necessary under such circumstances to deliver by turning, before the hand can possibly be introduced into the uterus without producing fatal contusion or laceration of the part. I have found in several of these cases, however, that the delivery may be safely accomplished by merely passing the hand into the vagina, and afterwards the fore and middle fingers between the uterus and detached portion of the placenta, grasping with them the feet, which are generally situated near the os uteri, and drawing down the inferior extremities into the vagina, and delivering. I know that the inferior extremities may often be brought down in this way where it is impossible to pass the whole hand through the os uteri."
The same state of things may however result from other causes, and a very different mode of proceeding may then be needed, as the doctor very clearly shows.
"Flooding may take place in the latter months of pregnancy, and during labor, where the placenta does not adhere to the neck of the uterus, but to the body or the fundus, and is detached by some external or internal cause. The separation of the placenta from the upper part of the uterus may be produced by violence, as blows, falls, pressure over the hypogastrium, and shocks of various kinds; but it arises much more frequently from internal causes, of which morbid states of the placenta, and twisting of the umbilical cord once or oftener round the neck of the child, are the most common and obvious. This variety of hemorrhage, though usually termed accidental, can rarely, however, be referred to accident. Sometimes the flooding occurs to a great extent without any assignable cause; a large portion of the whole of the placenta, when in a healthy condition, being suddenly detached from the uterus, when the patient has been exposed to no external accident, or injury of any kind, and when no symptoms of increased determination of blood to the uterus have preceded the attack. When this happens a large quantity of blood is poured out between the placenta and uterus, a small portion of which only at the time usually escapes from the vagina, to indicate what is going on within the uterus. There may be a great internal hemorrhage, accompanied with the ordinary constitutional effects resulting from loss of blood—as faintness, sickness, or vomiting, coldness of the extremities, rapid feeble pulse, hurried breathing; when there is little or no discharge from the vagina to excite alarm, or to point out the source of danger, when it is extreme. It is from the general symptoms of exhaustion, and by the disagreeable sense of uneasiness, weight, or distension of the uterus, experienced, and not from the quantity of blood which appears externally in these cases, that we are led to discover the true state of the patient—to suspect that internal hemorrhage is going on. But much more frequently only a small portion of the placenta is at first detached, and the greater part of the blood which is extravasated between it and the uterus separates the membranes, and descends by its weight to the orifice, and escapes through the vagina. In all cases, however, of uterine hemorrhage in the latter months, the danger cannot be so accurately estimated by the quantity of blood which appears externally, as by the general symptoms. The portion of placenta which is detached, never re-unites to the uterus, but when expelled it is usually seen covered with a dark coagulum adhering to the uterine surface.
"When the blood escapes in small quantity, and there are no labor pains present, and no disposition in the os uteri to dilate, and the constitutional powers are not impaired, an attempt should be made to prevent a return of the discharge, and the occurrence of labor pains. For this purpose, if the pulse is full and frequent, some blood may be taken from the arm, and the patient should be kept in the horizontal position, surrounded by cool air, cold applications made over the hypogastrium, and acetate of lead and opium, mineral acids, and other remedies that diminish the force of the circulation and promote the coagulation of the blood, should be taken internally. The plug is here totally inadmissible; it can only convert an external into an internal hemorrhage. But where the flooding occurs at first profusely, and is renewed even in a moderate degree, in spite of our efforts to check it, the continuance of pregnancy to the full period cannot be expected; it will be of no avail to bleed and administer internal remedies, except for the purpose of checking the discharge, and thus averting the immediate danger until the uterus is emptied of its contents.
"The operation of turning, which is required in all cases of complete placental presentation, is rarely necessary in uterine hemorrhage where the membranes are felt at the orifice. In a great proportion of these cases, where, on making an examination, you can feel the smooth membranes extending across the neck of the uterus, the flooding will be arrested, and the labor safely completed, if the membranes are ruptured, the liquor amnii discharged, and contractions of the uterus excited by gentle dilatation of the orifice, and other appropriate means. The only cases in which this treatment fails are those in which it has not been had recourse to sufficiently early, or where the whole or a large portion of the placenta has been suddenly separated from the uterus, and a great internal hemorrhage has taken place. The uterus will not contract effectually in these cases after the membranes have been ruptured; the pains, instead of becoming stronger, become more and more feeble, return at longer intervals, and during these the blood flows more profusely, and death would take place before delivery, if the child were not extracted by the forceps, crotchet, or by the operation of turning. In all cases, then, of uterine hemorrhage in the latter months of pregnancy, and in the first stage of labor, where the placenta does not present, and the quantity of blood discharged is so great as to render delivery necessary, where it appears improbable that the pregnancy can go on longer with safety, or to the end of the ninth month, rupture of the membrane with the nail of the forefinger of the right hand, evacuate the liquor amnii by holding up the head of the child, dilate very gently the os uteri with the fore and middle fingers expanded, and occasionally make pressure with the fingers around the whole orifice; apply the binder, give ergot and stimulants, and the uterus will, in all probability, contract upon its contents, and expel them without further trouble. If the hemorrhage should, however, continue after the employment of these means, delivery must be accomplished by the forceps, craniotomy, or by turning, according to the peculiarities of the case. In women who are liable to attacks of flooding after the expulsion of the child or placenta, rupture the membranes at the commencement of labor, even before the os uteri is much dilated, if the presentation is natural, and you will often succeed in entirely preventing hemorrhage."
The recommendation to bleed may be with good reason objected to, at least in the great majority of such cases; and I cannot but think that a timely and persevering use of the ordinary remedies, namely, keeping quiet, using acid drinks, and cold fomentations to the abdomen, would do away with any necessity for it at all. I question very much if ever bleeding really prevented abortion from flooding, and I cannot but think that it has often brought it on sooner. Nevertheless, if all other means fail to arrest the discharge, and there are no decided objections to the contrary, it might be cautiously tried; though the policy of taking more blood from a person who is already losing too much, is not very evident.
I have often known the most severe flooding stopped, merely by the female lying on her back, drinking plentifully of lemonade, and applying cold wet cloths over the abdomen. A small dose of laudanum occasionally is also useful; and complete rest and tranquillity of mind is as indispensable as rest of the body. Many females flood and miscarry merely from worrying and fretting themselves, and from passion, or strong excitement, particularly of a certain kind. This in short must be carefully avoided, and the patient must live strictly as if a widow.
This accident is likely to occur in subsequent pregnancies, at nearly the same time, and should therefore be guarded against by a careful avoidance of all excitement, or violent bodily exertion, during the whole time. Keeping the bowels gently open, and practising a regular diet, are also requisite. A good supporting bandage is also of frequent service. For much more valuable information on this subject however, I refer to my work on "The Diseases of Women," in which it is fully treated.