[In addition to the combined use of the tampon and of ergot, there is a further agent which we can strongly recommend, from the fact that it has been of marked service to us, in cases of uterine inertia, by invok ing contractions, by intensifying them, and thus hastening delivery, and checking hemorrhage. This agent is the Faradic current. A mild current is all that is requisite; the main point in its application being the intermittency of its application. The patient should hold one electrode, it is an indifferent matter which, and the other should be passed to and fro over the abdomen. A strong current is to be avoided, in order not to produce spasm of the uterine muscular fibre. A further useful point about this method, is the fact that the patient's suffering is markedly diminished, although the pains are rendered more effective.
A word about the tampon will here not be out of place. As the au thor says with truth, the tampon, in order to be effective, must be ap plied well. The only way to efficiently tampon the vagina is, with the patient lying in the left lateral position, to insert them through the Sims speculum. The posterior cul-de-sac should first be thoroughly packed, then the anterior, and finally the vagina underneath. The tampons further should be carbolized, in case it is likely they will re main in place for a longer interval than a few hours.—Ed.] We may have to face one of two conditions: 1. The placenta, although in the uterine cavity, is in part engaged in the cervix. 2. The placenta is entirely in the cavity above the cervix.
In the first instance we advise ergot, with or without the tampon, according to the amount of hemorrhage; and, if the ovum has passed completely, or nearly so, through the external os, digital extraction— but only when we are perfectly sure it is not at all adherent to the ute In the second instance, we make, with Gueniot, five subdivisions: 1. Miscarriage has occurred, but the afterbirth is incomplete, and there is no complication calling for immediate action. 2. The same exists, but with complications. 3. Miscarriage has occurred, but there is uncer tainty as to whether it is complete or not. 4. Miscarriage is certainly complete, but there are complications calling for interference. 5. Mis carriage is in progress, inevitable, and more or less advanced.
At the outset, it is apparent that, where all is normal, there is no call for interference. All authorities agree that here expectation is the proper conduct. The difficulty is to draw the line where justifiable in terference begins. But when delivery is prolonged, ought we still to abstain, ought we to wait, or ought we to interfere actively in order to forestall the complications which almost infallibly will result, and in terfere, further, at a time when it is far easier than later, when we may be forced to action? Such is the problem, the answer to which divides obstetricians into two opposing forces. The one insists on active in
tervention, in order to terminate the process as soon as possible, and thus prevent complications. The other, having deep faith in the powers of nature, only allows interference in case of serious complication.
The following propositions may be laid down as acceptable to all au thorities: 1. It is necessary to interfere in case of complication, opin ions only varying as to the manner of interference. 2. In miscarriage during the first two months, since hemorrhage may be completely con trolled by the tampon, and since the placenta is small, pliable, and may become disintegrated and discharged in the lochia, septic complica tions are not apt to be pronounced or serious, and are easily mastered by antiseptic injections and tonic treatment, aided by alcohol, and the sulphate of quinine. 3. At a more advanced period of pregnancy, mechanical means of delivery, other than manual, are very difficult of application, and expose the woman to the danger of metritis, and peri tonitis.
In the first two months, therefore, retention of a portion of the ovum, no matter for how long, calls for no active interference, unless serious accidents supervene, and then we must extract these remnants as soon as possible. It is, then, after two months, that opinions vary.
Views of those in favor of active speak simply of our contemporaries, we mention, in England, Tyler Smith, Murray, Hall Davis, Priestley, Leishmann, Simpson—in Germany, Spondly, Botters, Veit and Fehling—in America Muncie [and many others.—Edl—in France Gueniot. The reasons given by Spondly, in favor of active in terference, are similar to those advanced by the others. The frequency of retention of the afterbirth; the dangers which may supervene in pro longed delivery; the almost constant possibility of manual extraction. Veit is possibly, with Simpson, the most active partisan of interference. If the cervix is dilated, or patent, ho acts at once; if it is not dilated, he dilates at once with prepared sponge, removing this at the end of sixteen hours. The woman is then anDesthetized, the uterus depressed as much as possible by the external hand, and with the index finger of the other he removes the placenta and the membranes. If he cannot sufficiently depress the uterus with the hand, he does not hesitate to forcibly drag it down by a double tenaculum fixed in the cervix, as is also done by Simpson, and IIegar and Kaltenbach. It is evident that he does not always succeed, for he speaks of the possible persistence of hemorrhage after this method. In order to stop this he washes out the cavity with a solution of carbolic, and then applies to the endometrium, the sub-sul phate of iron, or pure phenic acid.