Rupture of the Membranes.—Puzos proposed this method, which still bears his name, although his claim to be its originator is not well founded. It consists in rupturing the membranes after the os has become moder ately dilated, on the ground that this causes the pains to become stronger, and consequently checks the hemorrhage. One or two fingers are in troduced into the os, and it is slowly dilated, pressure being suspended at intervals in order to allow the pains to recur. The membranes now protrude, and are freely ruptured. After some of the water has escaped, the inferior uterine segment can contract to greater advantage, so as to force the head downwards, and thus to compress the bleeding vessels. In this way both mother and child are saved, whereas they would inevita bly have been lost in a spontaneous delivery, and would have neon seri ously imperiled by forced delivery. This method is not applicable to all cases. When the os is completely covered by the placenta, some advise perforating the latter in order to rupture the membranes. Gendrin pre fers to separate the placenta at one edge, until the membrane is reached. and then to puncture the latter. Dubois only resorts to rupture in cases of marginal implantation. We follow Gendrin at the Maternite wherever it is possible. Of course rupture of the membranes is contra-indicated in cases of faulty presentation; it does not always hasten labor, end we have then sought to aid it by employing other ecbolic means.
Ergot.—Ergot occupies the front rank among these; but it is a remedy which is dangerous for the child, if not for the mother, and should there fore be used with caution. Labor ought to be clearly advanced, and the head well engaged. Zn moderate doses it may be of great service in has tening dilatation by increasing the contractions, and thus facilitating de livery, as well as in preventing postpartum hemorrhage. It must never be given in cases of contracted pelvis, where there are organic lesions of the uterus, or where the presentation is faulty, because under these cir cumstances we should be liable to produce results just the opposite of those at which we aimed, and, unfortunately there are only too many cases on record in which the unwise administration of ergot has produced rup ture of the uterus.
The Tampon.—This is the best means of controlling hemorrhage in placenta prEevia, but, in order to obtain actual results with it, it is necessary to introduce it properly, and under proper conditions. Leroux (of Dijon) should be credited with popularizing this agent, which is now generally employed, except by Barnes, who has a special method of his own. The vaginal tampon is simply a dam, opposed to the stream of blood, which favors coagulation of that fluid, and obstruction of the openings of the vessels, and thus puts an end to the hemorrhage. Cotton and charpie make the best tampons, but any substance (tow, sponge) may be used in an emergency. As artificial tampons may be mentioned, Gariel's, Braun's colpeurynter, and Chassagny's balloon; but these act less perfectly than the classical tampon. This consists of pledgets of cotton, either united or single, the latter being preferable. The tampon must be sufficiently firm and resistant to close the vagina hermetically. The quantity of cotton necessary is enormous, a pound or a pound and a half not being too much in some cases, especially in multiparte. This amount is divided into three portions, one consisting of balls the size of small nuts (20 or 30), with a long thread attached to each; the other of pledgets of the same size, without threads, the third portion not being thus separated; 5 or 6 compresses and a T-bandage complete the apparatus. To introduce a tam pon, place the woman on a couch, either transversely, or in the ordinary position, and give a vaginal injection of warm water, in order to wash away blood and clots; then empty the bladder, and the rectum also, if there is time. Some are accustomed to the first tampon in a weak solution of perchloride of iron. I see no especial advantage in this, and I much prefer to anoint them with oil or cerate, so that they will glide in more easily. We do not aim at producing an astringent effect, but at making pure mechanical pressure. Having greased the pledgets, introduce them one by one, beginning with those toewhich threads are at tached, and finally tie the latter together; press them in firmly, so that no space remains. Some insert the first tampon into the cervix, and then fill the fornix, others pack the euls-de-sae first, and then cover the cervix.
After the tampons with threads have been introduced, the vagina is filled with the ordinary ones, which are packed into all the interstices, until the cavity is about three-fourths full. On arriving at the vulva, fill it out with dry cotton, apply three or four compresses over this, and secure the whole with a T-bandage. If the tampon has been properly applied, it will remain nearly dry, that is, the outer layer will not be moistened. If a reddish fluid soaks through, do not hesitate to remove the tampon, and to insert another. The rule is to proceed slowly, pressing the tam pons firmly against the cervix and the posterior part of the vagina; the whole success of the operation depends on this. The patient's life only depends upon the rapidity and dexterity with which we can practise it. After tamponing the patient, we keep her perfectly quiet, on liquid diet, administering small doses of ergot, if indicated. In order to be effective, the tampon should remain in situ from twelve to twenty-four hours. Now, Barnes advises that it be removed in an hour, but it is impossible to ob tain good results in this way. Practitioners are always in too much of a hurry to remove it, and they thus lose all the advantage of it. In Ger many the modus operandi is a little different. A speculum is introduced so as to expose the os, and through the instrument a cambric handker chief is inserted, the interior of which is filled with pledgets of cotton, the speculum being withdrawn as the vagina is distended. The entire tampon may be withdrawn by drawing out one corner of the handkerchief. The opponents of the tampon claim that it substitutes internal for exter nal hemorrhage, brings on premature labor, and causes the patient pain, as well as disturbance of the bladder, etc. To the first objection it may be answered that it is impossible that there should be much internal hemorrhage, e en granting that it does occur, because the uterus is still occupied, and the membranes are moreover the tendency is to co agulation and arrest of the hemorrhage. After the membranes have ruptured, there are usually uterine contractions, which tend to diminish the size of the uterine cavity; moreover the foetus is still. present to di minish the space in which blood might accumulate. In reply to the ob jection that the tampon tends to hasten labor, it should be stated that the hemorrhage usually appears after the seventh month (or thirtieth week), when the child is viable; but many observations prove that the tampon has, in some instances, remained in situ even as long as forty-eight hours without inducing labor, and even when this does occur, can we hesitate between this inconvenience and the danger which inevitably threatens mother and child if the hemorrhage is allowed to continue; and should we for this reason deprive ourselves of a resource which almost certainly saves the mother, and does not deprive the child of every chance of sur viving? If is very easy to remove a few tampons in order to catheterize a patient, and the rectum should be emptied before the cotton is intro duced. How long shall we leave the tampon in place? Pajot and Depaul would not disturb it, unless there is fresh bleeding, for twenty-four or thirty-six hours; but while the latter believes in terminating the labor as soon as possible, Pajot would leave entirely to Nature the successive ex pulsion of the child and of the tampon. Depaul removes the tampon after the expiration of the time mentioned, and does not insert another unless the hemorrhage continues, but the patient is carefully watched, so that she can be at once tamponed in case of need. This treatment is usually sufficient if labor has not begun. If it has commenced, but dila tation is slight, a fresh tampon is introduced, and a small dose of ergot is administered; the pains then increase, the cervix dilates, and in from eight to twelve hours the cotton is removed, and the membranes are punctured. As a rule, labor proceeds without much hemorrhage, and as soon as the os is sufficiently dilated, the child is extracted with the forceps, or after version. If, on the contrary, profuse bleeding recurs, or the woman has been exhausted by the previous lose of blood, the tampon is not disturbed until dilatation is complete. The placenta is extracted immediately after the birth of the child.