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with reference to the value of intracellular injections. But there are times in the experience of every surgeon when he cannot wait for the absorption of the normal salt solution when injected under the mammary gland. In fact, in conditions of extreme depression, I question very much whether the absorbent vessels are able to properly carry on their work, and in those conditions we derive the greatest benefit from intravenous transfusion.

PLACENTA PREVIA, WITH SPECIAL REFERENCE

TO TREATMENT.

BY W. H. WENNING, M.D.,

CINCINNATI.

A FEW years ago I had the honor to present to this Association an essay entitled, "A Study of the Pathology of Placenta Previa." Within it were set forth the various theories advanced up to that time on the etiology and interpretation of clinical symptoms in this most interesting anomaly of pregnancy. Its intimate connection with the doctrine of expansion of the lower segment of the uterus, and retraction, as well as contraction, of the upper segment of the uterus, was discussed, and an endeavor made to harmonize the various conflicting theories in reference to the anatomical position of the inner os during labor in its bearing upon the development of the previal placenta. The length of the paper precluded the more practical consideration of the treatment of this accident. A regret was then expressed by several members that I had not entered into this subject in its therapeutical aspects, which I accordingly briefly reviewed in the interesting discussion that followed the reading of my paper.

On this occasion, therefore, I have taken the liberty to recur to this subject, not so much with the intention of presenting any new and startling contribution, as to simply review (1) some of the means at our disposal for arresting the hemorrhage, the cardinal symptom of placenta previa, and (2) the methods of expediting labor, which is almost always imperative in the interest of the lives of both mother and child.

In no other condition of pregnancy is the danger to life so imminent, in no other is a knowledge of the proper methods for averting this danger so essential, and in no other is a judicious

discrimination as to the relative value of each of the several procedures so necessary as in placenta previa.

An affection in which the maternal mortality has been at various times computed as ranging from 25 to 50 per cent. and the fetal from 50 to 75 per cent. certainly merits our closest attention.

Fortunately for womankind, this fearful death-rate has been greatly lessened within the last few decades, thanks to improved methods of treatment and earlier recognition of this condition, even if no very great strides forward have been made in the saving of infant lives.

Unfortunately, however, even at the present time this decreased mortality has not been so general as it should have been, and it is only from well-conducted institutions, under skilful management, that successful results of a marked character have been obtained. The maternal mortality in a number of recorded cases has been decreased to the encouraging figure of from 4.50 to 7 per cent., yet the general fatality in unselected cases still reaches the high figure of from 25 to 33 per cent.

When we examine into the cause of this great difference we must, of course, make allowance for the different degrees of placenta previa, which, in many instances, may have been recognized only in the fatal cases; but certainly much better results should have been obtained in general practice if two absolute rules could be more generally inculcated-namely (1), timely intervention, and (2) a proper judgment of the means applicable to the case in question.

The relative merits and demerits of this or that method have time and again been reiterated, so that the conclusion naturally forces itself upon us that every procedure has its advantages and disadvantages, and that no particular treatment is applicable to each and every case. This will also explain the fallacy of statistics, which perhaps are nowhere so unreliable, when made conformable to a certain mode of action, as in placenta previa.

To illustrate, I will briefly summarize the methods of treatment resorted to by fifty American writers in the same number of cases reported in the last five years, almost uniformly with a good result -at least for the mothers. Three depended solely on expectant treatment; three used the tampon alone, one with rupture of the membranes; three punctured the membranes; four instituted

bipolar version; three ordinary version; four adopted Barnes's method of dilating the cervix, four resorted to this method and followed it by version, two by the use of the forceps, and two by version and forceps applied to the after-coming head. In fifteen instances recourse was had to accouchement forcé—namely, manual dilatation of the cervix followed by version. In three instances separation of the placenta was practised, and in two instances Cesarean section was made. Of this number only two deaths are recorded-one after the use of the tampon, the other following Cesarean section.

This collection, taken at random, simply proves that all methods may be followed by good results, and that no fixed rule can be established for every case. It is remarkable, however, that, notwithstanding the excellent results achieved after the rehabilitation of the Braxton Hicks method of bipolar version, only four cases are reported as having been treated in this manner, while the muchcondemned procedure known as accouchement forcé, viz., manual dilatation followed by version, is mentioned as often as fifteen times, and that among these last cases we find some of the best and most eminent teachers of our land.

Discarding the more antiquated forms of treatment, which by common consent have fallen into disuse, we will confine ourselves to a discussion of three of the methods most commonly employed. These are (1) the tampon, (2) rupture of the membranes, and (3) version. Each of these means may be used by itself, or, which is more frequent, in combination with one or two of the others. It is my purpose to show that each method of procedure has its specific indications, and that it is not just either to extol one or condemn the other, to the exclusion of the rest. It is the knowledge of the applicability of a specific treatment in a given case and a nice discrimination among the various methods that will give the best results.

While not wishing to appear dogmatic, and admitting that there may be some exceptions to the following rule, I would make the broad statement that the tampon is applicable only before dilatation of the os, rupture of the membranes after the onset of labor pains, and version after sufficient dilatation or dilatability of the cervix.

It is the non-observance of this principle that, in my estimation,

is responsible for the fearful mortality that has followed each of these methods when employed injudiciously-that is, at the wrong period; and to the observance of this principle that the excellent results are attributable after judicious use of each of these three methods. It is just as irrational to use the vaginal tampon when the os is sufficiently dilated for delivery, either spontaneous or artificial, as it would be to attempt version with a closed or rigid os. As a rule, it is as improper to puncture the membranes before labor has sufficiently advanced to permit the presenting part or head to engage in the cervix, and thus arrest bleeding, as it is to wait for a spontaneous rupture of the membranes when bleeding occurs from a well-dilated or dilatable os, readily permitting manual interference. Then, again, each method is subject to its modifications, and such questions as the following may present themselves: When shall we use the vaginal and when the cervical tampon? Shall we rupture the membranes as soon as the os is permeable to two fingers for the performance of bipolar version, or shall we wait until the hand can be gradually introduced for ordinary podalic version? When shall we resort to Braxton Hicks's method, and when to internal version?

While one or two of these methods may be elective, there are proper indications for each which may now be considered in detail.

THE TAMPON. The vaginal tampon is simply a preparatory measure. It serves to arrest bleeding until the time comes for active interference. Its office begins with the onset of hemorrhage and ceases with dilatation of the os. It serves a double purpose in that, when properly applied, it checks bleeding and assists in bringing on labor. As both are accomplished by pressure, it is necessary that the tampon be at the same time large and firm. This property of inducing labor, which often contraindicates the tampon in abortion, serves a good purpose in placenta previa, for it is positively proven that no woman who has hemorrhage of such an alarming extent as to require active measures for arrest in placenta previa is safe until she is delivered. The indication of labor, to my mind, is imperative with the first onset of copious hemorrhage. What is more reasonable, therefore, than to check the latter and expedite the former? The tampon fulfils both indications. By its means we gain time for further manipulations, and at the same time maintain the strength of the patient.

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