On the other hand, it must be remembered that some laceration of the cervix by the aftercoming head is practically inevitable, even if the case is left to nature, and when the os is already fairly well dilated, the mother has lost little blood and is in good condition, and the child is alive and there is a fair prospect of its survival, I think that it is justifiable to take the extra risk of immediate delivery, provided the practitioner is prepared to control bleeding from the cervix by suturing the rent at once. In the cases where this method is justifiable only a very slight amount of force is required. I I much exertion is needed to pull the child through the os, dilatation is not sufficiently advanced for the manoeuvre to be performed without the certainty of a deep laceration, and the practitioner should at once desist.
The method of treatment by the insertion of a plug within the cervix may next he considered. One form of this treatment, in which a gauze plug is packed into the lower uterine segment and into the cervical canal after a preliminary separation of the placenta around the internal os as high as the finger can reach, cannot be regarded as comparable in point of efficiency to version and bringing down a foot. It may, however, he useful, combined with a vaginal plug, as a temporary measure in those rare cases where hemorrhage is going on and the os will at once admit one finger.
The method of plugging with a dilatable bag has, however, many advo cates, and is recommended by them in preference to version. The advan tages of this method are that the bleeding is checked as effectually by the bag as by the child's breech, that dilatation is as rapidly and as efficiently carried out, and that finally the presentation is not interfered with and the child escapes the dangers of a pelvic presentation. The disadvantages are more likely to be felt in general practice than in a hospital. 'rhe method requires for its performance a certain amount of perishable appar atus, which is apt to be found out of order when required at long and uncertain intervals, as is certain to he the case in private practice, where years may elapse without a case of placenta prxvia being encountered. Time is required to sterilise the apparatus. and its intro duction into the uterus, especially if no assistance is at hand. will take decidedly more time than the performance of podalic or even of bipolar version. And, lastly, it is quite possible for a hurried or inexpert operator to fail in lodging the hag securely within the uterine cavity, and in consequence to fail in stopping. or, what is worse. to succeed in masking the which must weigh against its use in urgent cases, except in the hands of experts. Either Braun's bag, which is elastic, or, better, Champetier de Ribes'. which is not, may be used, and a large size is preferable, so that when the bag is expelled dilatation will be practically complete. The bag is boiled, rolled up tightly and grasped in special introducing forceps. The finger is passed through the os and the membranes ruptured or the placenta bored through. Partial escape of the waters is rather favourable than otherwise.
The bag is then introduced abope the placenta and the forceps removed. To the india-rubber tube of the bag the nozzle of a syringe is then attached, and the bag is pumped full of weak Lysol solution, a basin of which should be in readiness. When the bag has been filled the rubber tube is clamped with artery forceps or a piece of tape is tied around it to prevent the fluid from escaping. The finger should be then introduced
into the vagina to make sure that the bag is properly in position within the cervix and above the placenta, as, if it has escaped from the cervix and is lying in the vagina. hemorrhage may go on above it unobserved. The patient is then left alone till the uterus expels the bag; if there is any sign of hxmorrhage, traction is made gently on the rubber tube; indeed, some authorities advise intermittent gentle traction even in the absence of hzemorrhage in order to hasten dilatation. When the hag has been expelled the head follows it into the cervix, and when it has passed through the os, forceps should be put on and delivery completed unless the progress is very rapid.
It may be mentioned that should the practitioner, on his first arrival, find the os fully dilated and the placenta marginal, his best plan of action is to rupture the membranes and complete delivery with forceps.
During the third stage there is a gond deal of risk that the placenta will be slow in separating and that there will he bleeding either from a laceration or from the placental site. The placenta should not be waited for more than about five minutes. when the sterilised hand should he introduced and manual removal carried out. In all cases a hot intra uterine douche of drachm to the pint saline solution should be given with the patient on her back and Pituitrin (t c.c.) given hypodermically. If bleeding of any consequence continues the cervix should be drawn down with volsella and inspected. If the blood comes from a laceration, it should be sutured with catgut, the whole thickness of the cervix being taken up, and the highest stitch being inserted just at the apex of the tear.
17 If the bleeding is from the placental site, the uterus and cervical canal should be plugged with gauze wrung out of drachm to the pint lysol solution. If the bleeding is severe, the vaginal vault should also be packed wth cotton-wool pledgets wrung out of lysol solution. Plugging may be done for a laceration if proper suturing cannot be carried out for lack of materials or assistance, or through obscuring of the parts by copious htmorrhage.
The practitioner may find his patient faint and collapsed from loss of Hood on his arrival. In such a case the bleeding has usually stopped of itself for the time, and if the collapse is very extreme it is wise to take measures for combating it by saline transfusion, &c., before attempting the treatment of the placenta A certain amount of support has been accorded to treatment by Ca-sarean section, and the tendency of the day is in favour of a more extended use of this method of rapid delivery in any case where delivery per vias naturales is likely to be more than usually dangerous to mother or child. This is, of course, a method which is only available for hospital patients and for those who can afford surgical nurses and specialists. It cannot be said to offer a greater chance of safety to the mother than version or plugging with the bag, and is therefore only applicable to cases where the child is alive and viable, the mother is not greatly weakened by hemorrhage, and attempts at treatment have not already been carried on. It is the best method for the rare cases where the OS persistently refuses to dilate.—R. J. J.