In deciding which procedure should be adopted in any given case. the two most important factors to be considered are, first, the amount of blood that is being lost at the time; and, secondly, the amount of collapse that is present. When bleeding is going on rapidly it is absolutely necessary to stop it. On the other hand, when collapse is extreme it is in the highest degree unsurgical to attempt operative measures which must make the condition more grave by added haemorrhage, even though slight in amount, and by the production of a greater or less degree of shock. Fortunately, when collapse is extreme the hxmorrhage usually ceases for the time. Lastly, we must remember that until the uterus is emptied the normal mechanism for stopping hxmorrhage from the placental site— retraction of the uterus—cannot come into action.
• Rupture of the membranes is indicated when the os is dilating or well dilated, as in these circumstances it accelerates delivery. It is also indicated when the uterus is distended by a concealed or partially con cealed hxmorrhage, as the escape of the waters permits the overstretched uterine muscle to contract, and the lessening of the uterine distension relieves the acute pain which is a considerable factor in the condition of shock from which these patients are usually suffering. When the mem branes have been ruptured and the binder applied an injection of ergotin should he given. If the patient is collapsed, saline transfusion either into a vein or beneath the breasts (see under I hemorrhage or Operations, After-Treatment) should be practised. If the instruments for transfusion are not available, the patient should be encouraged to drink hot water, warm milk or milk and soda-water in small quantities at frequent intervals, and an injection of 2 pint of saline with J, oz. of whiskey may be given by the rectum, and repeated in an hour. The head should be kept low and the feet and legs elevated, and external warmth should be applied by means of hot-water bottles.
Plugging the vagina is indicated when labour has not commenced, or when pains are feeble and the cervix not taken up or the os not dilated. as it is a powerful stimulant to uterine contraction, and when properly 5 2 applied the vaginal plug by its pressure produces softening and induces dilatation of the os. It is also indicated when rupture of the mem branes has failed to check the hemorrhage, as it is undoubtedly a powerful means of securing luemostasis when the plugging is carried out thoroughly as described above. When this method of treatment is adopted, gr. of morphia hypodermically may he given, and if collapse is present measures should be taken to combat it while waiting for the plug to produce dilata tion. If on the removal of the plug at the end of 6 hours dilatation does not rapidly take place, the vagina may be plugged again for a further period of 4 to 6 hours. If the os is dilating, but bleeding recommences,
the membranes should be ruptured and if that does not stop the lacmor rhage a second plug should be inserted.
Aecortchement force by rapid dilatation is to be condemned. In those dangerous cases where the patient is already suffering from profound shock and collapse the inevitable additional shock and Immorrhage entailed by this method is likely to have the worst possible effect. When the symptoms are less severe, at least equally good results may be got by Barnes' or the Rotunda method with infinitely less risk to the patient.
The results that have been obtained by Abdominal Caesarean Section, followed by supravaginal hysterectomy, are so good that when the services of anyone competent to perform the operation are available, it should, in my opinion, be given the preference over other lines of treatment in concealed accidental hemorrhage. The operation should be preceded by saline transfusion and injection of morphia, and in my experience the rapid disappearance of shock and the speedy convalescence of patients after this operation are both surprising and gratifying. There is little objec tion to the sacrifice of the uterus, as in most cases the patient is a multi para, and in all probability the condition of the uterine muscle is such that another pregnancy is neither probable nor desirable.
A final word of warning may be given. These cases are very apt to suffer from hemorrhage after delivery, and the practitioner should be on the watch for it, as a small additional loss of blood may prove fatal. A careful watch should be kept on the uterus even after the placenta is ex pressed, and it should not be waited for too long. If it has not left the uterus at the end of 5 or to minutes it is best to effect manual removal. The hand and forearm must be carefully disinfected by scrubbing with soap and water, rinsing in 7o per cent. spirit, and soaking in I in 2,000 per chloride. The whole hand is introduced into the uterus, and the placenta peeled off the fundus, which is pressed down by the other hand on the abdomen. It is recommended not to pull the freed placenta out im mediately, but to wait for a contraction of the uterus to expel it and the hand together. In all these cases clots are certain to be left in the uterine cavity, and to remove them as well as to induce firm contraction it is advisable to give a copious hot (Ito° to tie F.) intra-uterine douche through a double current intra-uterine nozzle (Gibson's is the best). Pituitrin (t c.c.) should be given hypodermically, and a careful watch kept on the uterus for at least ,1 hour after the placenta has come away.