an cause
fibre,
axiom to the effect that by far the most common of placental retention ia inertia of tho uterine and although I do not deny that the axiom holds
true, I take exception altogether
to the plan of treatment which has been based upon it. This plan as generally laid down, especially for the guidance of students, is to wait for half an hour for the expulsion of the placenta to take
and
place by natural means, and then to give ergot, should the ergot fail, there is then no longer
that,
any doubt that the
cause
of the retention is to bo
found,
not in inertia but in the existence of either morbid adhe-
sions or of irregular contraction. I will first point out as many of the evils of this plan of treatment as occur to me, and will then give my reasons for pursuing an entirely different course to be
presently
THE
DELIVERY OF THE PLACENTA.
By R. J.
Baker,
M. D.
Dub.,
L. R.C. S. I., Loh.
Bombay Medical Service. The question relating to the delivery of the Placenta, the manner of its natural expulsion, the causes of the non-occurrence of such expulsion, and the treatment in such cases has ever been regarded as of the utmost
importance
to the
gynaecologist.
True that one of the lives entrusted to the skill and care of the physician has (except in cases of Placenta previa, which it is not my intention to speak of here) at least temporarily ceased to give anxiety at the period of a labour case to which this paper refers ; but the no less valuable life of the mother is now more than ever threatened with the possibilities 0f many and varied dangers ; and with most of these dangers the time and mode of the expulsion of the placenta is closely connected. The two dangers most apparently thus connected are of course haemorrhage in the present and puerperal pyemia in the future. It is, I opine, generally conceded that there are no more common causes of serious post partum haemorrhage than those conuected with placental retention. Again it is universally acknowledged that the presence of putrid masses of placenta or membranes is at least one of the chief causes of the dire condition known as puerperal pyemia, and it is I think impossible to deny that there may be a similar connection at present untraced between placental accidents, if I may so call them, and many other puerperal diseases whose pathology is at
present obscure, e.g. The
to be
Puerperal mania. adopted, therefore,
in the case of retention from any cause, is one the consideration of which is of the gravest importance. There is or has been in most obstetric institutions with which I have become acquainted a fi^ed rule for the management of the placenta, and this rule is grounded the axiom laid down in the upon an implicit belief iu standard works on midwifery, the all not if large majority course
placental
described.
Amongst the evils resulting from leaving the uterus without, and as I believe, wanting a stimulus for half an hour, is the oozing of blood which, inconsiderable as it look, amounts to a very considerable loss in tho time mentioned. Add to this the discomfort of the patient, who knows well that her trouble is not yet over, and that much
danger may yet
accrue.
How often does it happen that this routine practice being followed when the half hour has elapsed and the ergot is given and the enfeebled and flaccid uterus at
length responds, although there may have been absolutely no hajinorrhage during the time of waiting prescribed by routine, when the placenta is expelled there are expelled with it large quantities, amounting in some instances to a pint or more, of blood which ha3 been collecting in the uterine cavity during the half hour's law, at once
as
it is sometimes termed.
It will I trust be
acknowledged that a large number?in my opilarge majority of placenta) can be expelled by the
nion a action of tho attendant who grasps the uterus as the child is being born, always of course assuming that this manoeuvre is properly executed. But there are, and always will be, a considerable number of cases in which
of tho uterus behind tho receding child entrusted to tho hands of an inexperienced or unskilful attendant, and in such cases the placenta does not follow the child. In such a case what is to be done ? tho
grasping
must be
The routinists will say wait. How long? Half an hour of course. Now I have met with but one book, that of Tyler Smith, on the subject which recommends what I am about to mention, as in my belief tho proper course to pursue. Your nurse or other assistant has failed to cause expulsion of the placenta, but is that any reason why you should also fail ? Some will say do not hurry, you will fatigue your patient, and even you may fail, as irregular contraction I would reply that or adhesions may exist. my patient will be more fatigued by 30 minutes' unnecessary pain
and gradual loss of blood caused perhaps by unavailing because unassisted uterine struggles to free itself of the now functionless placenta than by as many seconds added to tho immediate pain of childbirth. I have mentioned haemorrhage as an argument against the
THE; INDIAN MEDICAL GAZETTE.
96
festina occurs
lente plan, not that it
generally or even frequently dangerous in itself, but because this small, is unnecessary, and cannot be
to an extent
however beneficial. As to the possibility of your failing because of adhesion or irregular contraction, I hold that the sooner the existence of such a condition is, ascertained the better. I have known practitioners at home in. such a case to leave, saying that if the retention be caused by
loss,
irregular contraction, i,t will relax before their next visit, and if caused by adhesion, then manual extraction may be resorted to.
And such
a course*
of
action,
however inexcusable in
itself, is founded upon exactly the
same theory as the waiting for half an hour for the expulsion of the placenta, I mean the theory (for I hold it is no more than a theory) that to put the hand into the uterine cavity is a proceeding fraught with the utmost danger, so much so that one of the ablest German writers, "Winckel, in his Pathology of Children, when discussing the treatment of post partum hemorrhage, expresses his opinion that it is a more dangerous,, proceeding than that of injecting the puerperal,uterus, with a. solution of per-
chloride of iron. If then it be granted that.no case.should be lefjt until the, placenta be either expelled, or extracted in practice, at home, how much more urgent ar.e the.indications for the observance of this rule in this climate?favourable as it is known to be to the relaxation of tissues pro-
moting haemorrhage and to the rapid putrefaction of organic debris?increasing the danger of septic absorp-
tion and its consequences. I believe then that if the necessary stimulu s be given to the uterus, by proper manipulation, in; 95 cases out of 100 the plapenta will bp at once expelled.and that in the rqm-iinipg 5 cases no, good will.be done by
waiting,
certain-y,, either adhesion or irregular contraction will be found to obtain. I have acted upon my conviction in the treatment of as.in all probability,
not to say
such cases while senior assistant to the maternity in connection with Dr^ Steeven's H ospital in Dublin, and. I can safely say that in the cases where manual extraction had to be resorted to, I never noticed any delay, in convalescence or any indication that my hand had been the vehicle for any
septic influence.
[April 1,
1882.
fibre,
axiom to the effect that by far the most common of placental retention ia inertia of tho uterine and although I do not deny that the axiom holds
true, I take exception altogether
to the plan of treatment which has been based upon it. This plan as generally laid down, especially for the guidance of students, is to wait for half an hour for the expulsion of the placenta to take
and
place by natural means, and then to give ergot, should the ergot fail, there is then no longer
that,
any doubt that the
cause
of the retention is to bo
found,
not in inertia but in the existence of either morbid adhe-
sions or of irregular contraction. I will first point out as many of the evils of this plan of treatment as occur to me, and will then give my reasons for pursuing an entirely different course to be
presently
THE
DELIVERY OF THE PLACENTA.
By R. J.
Baker,
M. D.
Dub.,
L. R.C. S. I., Loh.
Bombay Medical Service. The question relating to the delivery of the Placenta, the manner of its natural expulsion, the causes of the non-occurrence of such expulsion, and the treatment in such cases has ever been regarded as of the utmost
importance
to the
gynaecologist.
True that one of the lives entrusted to the skill and care of the physician has (except in cases of Placenta previa, which it is not my intention to speak of here) at least temporarily ceased to give anxiety at the period of a labour case to which this paper refers ; but the no less valuable life of the mother is now more than ever threatened with the possibilities 0f many and varied dangers ; and with most of these dangers the time and mode of the expulsion of the placenta is closely connected. The two dangers most apparently thus connected are of course haemorrhage in the present and puerperal pyemia in the future. It is, I opine, generally conceded that there are no more common causes of serious post partum haemorrhage than those conuected with placental retention. Again it is universally acknowledged that the presence of putrid masses of placenta or membranes is at least one of the chief causes of the dire condition known as puerperal pyemia, and it is I think impossible to deny that there may be a similar connection at present untraced between placental accidents, if I may so call them, and many other puerperal diseases whose pathology is at
present obscure, e.g. The
to be
Puerperal mania. adopted, therefore,
in the case of retention from any cause, is one the consideration of which is of the gravest importance. There is or has been in most obstetric institutions with which I have become acquainted a fi^ed rule for the management of the placenta, and this rule is grounded the axiom laid down in the upon an implicit belief iu standard works on midwifery, the all not if large majority course
placental
described.
Amongst the evils resulting from leaving the uterus without, and as I believe, wanting a stimulus for half an hour, is the oozing of blood which, inconsiderable as it look, amounts to a very considerable loss in tho time mentioned. Add to this the discomfort of the patient, who knows well that her trouble is not yet over, and that much
danger may yet
accrue.
How often does it happen that this routine practice being followed when the half hour has elapsed and the ergot is given and the enfeebled and flaccid uterus at
length responds, although there may have been absolutely no hajinorrhage during the time of waiting prescribed by routine, when the placenta is expelled there are expelled with it large quantities, amounting in some instances to a pint or more, of blood which ha3 been collecting in the uterine cavity during the half hour's law, at once
as
it is sometimes termed.
It will I trust be
acknowledged that a large number?in my opilarge majority of placenta) can be expelled by the
nion a action of tho attendant who grasps the uterus as the child is being born, always of course assuming that this manoeuvre is properly executed. But there are, and always will be, a considerable number of cases in which
of tho uterus behind tho receding child entrusted to tho hands of an inexperienced or unskilful attendant, and in such cases the placenta does not follow the child. In such a case what is to be done ? tho
grasping
must be
The routinists will say wait. How long? Half an hour of course. Now I have met with but one book, that of Tyler Smith, on the subject which recommends what I am about to mention, as in my belief tho proper course to pursue. Your nurse or other assistant has failed to cause expulsion of the placenta, but is that any reason why you should also fail ? Some will say do not hurry, you will fatigue your patient, and even you may fail, as irregular contraction I would reply that or adhesions may exist. my patient will be more fatigued by 30 minutes' unnecessary pain
and gradual loss of blood caused perhaps by unavailing because unassisted uterine struggles to free itself of the now functionless placenta than by as many seconds added to tho immediate pain of childbirth. I have mentioned haemorrhage as an argument against the
THE; INDIAN MEDICAL GAZETTE.
96
festina occurs
lente plan, not that it
generally or even frequently dangerous in itself, but because this small, is unnecessary, and cannot be
to an extent
however beneficial. As to the possibility of your failing because of adhesion or irregular contraction, I hold that the sooner the existence of such a condition is, ascertained the better. I have known practitioners at home in. such a case to leave, saying that if the retention be caused by
loss,
irregular contraction, i,t will relax before their next visit, and if caused by adhesion, then manual extraction may be resorted to.
And such
a course*
of
action,
however inexcusable in
itself, is founded upon exactly the
same theory as the waiting for half an hour for the expulsion of the placenta, I mean the theory (for I hold it is no more than a theory) that to put the hand into the uterine cavity is a proceeding fraught with the utmost danger, so much so that one of the ablest German writers, "Winckel, in his Pathology of Children, when discussing the treatment of post partum hemorrhage, expresses his opinion that it is a more dangerous,, proceeding than that of injecting the puerperal,uterus, with a. solution of per-
chloride of iron. If then it be granted that.no case.should be lefjt until the, placenta be either expelled, or extracted in practice, at home, how much more urgent ar.e the.indications for the observance of this rule in this climate?favourable as it is known to be to the relaxation of tissues pro-
moting haemorrhage and to the rapid putrefaction of organic debris?increasing the danger of septic absorp-
tion and its consequences. I believe then that if the necessary stimulu s be given to the uterus, by proper manipulation, in; 95 cases out of 100 the plapenta will bp at once expelled.and that in the rqm-iinipg 5 cases no, good will.be done by
waiting,
certain-y,, either adhesion or irregular contraction will be found to obtain. I have acted upon my conviction in the treatment of as.in all probability,
not to say
such cases while senior assistant to the maternity in connection with Dr^ Steeven's H ospital in Dublin, and. I can safely say that in the cases where manual extraction had to be resorted to, I never noticed any delay, in convalescence or any indication that my hand had been the vehicle for any
septic influence.
[April 1,
1882.
