II.-REPORT ON OBSTETRICS.

By L. E. NEALE, M.D.

Chief of the Obstetrical Clinic and Demonstrator of Obstetrics in the

University of Maryland.

From the recent period at which I have been called upon to make this report, I have confined myself to certain practical points, illustrative of the advance of obstetrics as a true science and an applied To this purpose I can cite no more valuable contribution to obstetric literature during the past year than Lomer's original communication on

art.

COMBINED TURNING IN THE TREATMENT OF PLACENTA

PRÆVIA.*

The successive stages of a progressive science are especially noticeable in connection with this subject, for we have been taught respectively:

1. Rupture of the membranes.

2. Tampon.

3. Partial or complete placental separation:

4. The various methods of version, including: a. Internal cephalic version. b. Internal podalic version. c. External cephalic or breech version; and d. Combined Internal and External Version by Braxton Hicks.†

After an interval of obscurity, Hofmeier, followed by Behm § and Lomer,|| revived this latter plan of treatment, and obtained most excellent results, as the following table shows :

*Lomer, Amer Jour. Obstet., December, 1884.

+ Braxton Hicks, London Lancet, July, 1860. Obstet. Trans., vol. v, p. 222.

Hofmeier. Zeitsch f. Geb. u. Gynæ., vol. viii, p. 82.

§ Behm. Zeitsch f. Geb. u. Gynæ., vol. ix, p. 373.

Lomer. Loco citato.

Cases of Placenta Prævia Treated by Bimanual Version.

Hofmeier's Cases:

No. of Cases. Deaths.

Operated on by H. alone. Cases of the University

Hospital for Women in Berlin,

Behm's Cases:

Operated on by B. alone. Cases of the Charité Hospital in Berlin,

Lomer's Cases:

Operated on by nine different assistants. Cases of the University Hospital for Women in Berlin,

If we add to the cases of Hofmeier and Behm only those which were operated on by Lomer himself, sixteen in number, with no death, we have 93 cases with but one death, or a mortality of but a little over 1 per cent. This, however, would scarcely be a fair showing, as it represents the result of a skilled operator, and not that of the general profession.

The following table, "which places the statistics in the most unfavorable light possible, includes every single case" that could be collected from the Berlin records, "even such as had been treated according to other methods, previous to the employment of the bimanual method of turning :"

Hofmeier,

Behm,

No. of Cases. Deaths.

236 21

about 10 per cent.

When we consider that text-books place the maternal mortality in placenta prævia, under any treatment, at from 24 per cent. to 40 per cent., and that the lowest mortality from accurate and reliable general statistics hitherto recorded is that of Dr. King, of Indiana, (Amer. Jour. Obstet., vol. xii, p. 750,) who gives 240 cases with 54 deaths, or a mortality of 22.5 per cent., we are in duty bound to turn our most serious attention to this method of the London accoucheur. It is true that Simpson claimed a mortality of about 7 per cent. by the method of complete placental separation before the birth of the

child. But he classes in the same table, without distinction, those cases in which this occurred spontaneously, as well as those in which it was artificially produced; hence the non-reliability of his statistics and the inaccuracy of his deductions. Moreover, his own views on this subject were materially altered before his death.*

Out of 69 cases of placenta prævia treated by partial placental separation, Barnes obtained a mortality of only 163 per cent., but a more extended experience has not corroborated his conclusions.†

Combined version may be performed as soon as the os and cervix will admit one, preferably two fingers, providing the child be movable. These conditions exist par excellence when the membranes are intact and the presentation not too deeply engaged, although neither is an absolute requisite, for it is sometimes justifiable, possible, indeed perfectly safe and easy, to push the presenting head up out of and away from the pelvic excavation, even when the liquor amnii has escaped. The mobility of the foetus in utero being first determined, we place one hand over the abdomen and the other in the vagina, having one or two of its fingers in the cervical canal; then rupture the membranes if they be intact, and directly touching the presenting part by a series of gentle combined manipulations of counter or inverse pressures, made during a period of comparative or complete uterine relaxation, cause the child to turn between the two hands until the breech is brought below. A leg is then caught and pulled down to tampon the bleeding orifices of the torn vessels, when all active procedures should cease, unless the case requires immediate delivery. For these manœuvres the usual preparations for obstetric operations should be employed, and an aṇæsthetic administered, by preference, but not necessarily.

Should the placenta interpose between the fingers in utero and the child, it should be separated marginally or even centrally perforated, if necessary. The operator should not be alarmed by a sudden gush of blood during this stage of the operation.

Thus far the treatment has been active, and "experience shows that flooding now ceases." We should then leave the case either entirely to nature, or, if necessary, assist by slow and gentle tractions upon the leg; in a word, rather "let the child run its risk and even die, than endanger the mother by quick extraction."

"In turning early, it arrests hemorrhage; in allowing nature to

* Leishman's System of Midwifery, Ed. 1875, p. 398.

+ Loco citato.

expel the child, it prevents lacerations of the cervix." Cervical lacerations are especially serious in cases of placenta prævia, owing to the vascularity of the part.

Clinical results prove that by employing this method, the prognosis for the child is no worse-indeed even a shade better-than with other plans of treatment.

Lomer gives the advantages of Braxton Hicks' version in the treatment of placenta prævia as follows:

"1. It does away with the tampon, and with the dangers of infection and loss of time this involves.

2. It allows us to operate early, i. e., when not much blood has been lost.

3. It arrests hemorrhage with great certainty.

4. It gives the patient time to rally, gives time for the cervix to dilate, for pains to set in. It therefore prevents post-partum hemorrhage, laceration of the cervix, atony of the uterus.'

Remembering that these are clinical facts taken from the Berlin hospitals, and not theoretical ideas culled from a fertile brain, I fail to see upon what just or tenable grounds we can withhold the verdict, that in those cases in which this method can be employed, it is by far the best treatment hitherto advised for that most dreadful and formerly most lethal complication of pregnancy.

The tampon is now restricted to that comparatively small class of cases in which the os is undilated and undilatable, and is even here only a very temporary means, to be watched carefully, and withdrawn entirely, as soon as the cervix will admit one or two fingers for the performance of Braxton Hicks' bimanual version.

It is also advised that this latter treatment be employed in those cases of complete or central placental implantation, where Barnes' method of separating the placenta only from the inferior uterine segment, or zone of danger, was formerly recommended.

Inasmuch as bimanual version should be used in the treatment of flooding occurring during pregnancy, it consequently "may be counted, perhaps, among the proceedings having for their object the induction of premature labor in placenta prævia." Of course there still remain certain cases in which this treatment is not applicable. "When the placenta is only felt marginally, when the head has entered the pelvis, when the pains are strong and hemorrhage not very profuse, then rupture of the membranes seems to be the right thing. It must, however, not be forgotten that in adopting this

method of treatment, the chances for effecting an easy version are lost; and as sometimes hemorrhage does not cease after rupture of the membranes (five times in our cases), turning has then to be resorted to under unfavorable circumstances."

When a breech presentation already exists, version is no longer necessary. I believe the majority of authorities will sustain me in this assertion, although I am well aware that here Pinard advises cephalic version by external manœuvres.

If the os be dilated, the waters evacuated, or other unfavorable condition obtain, and the child be not sufficiently movable to permit of turning by combined manipulation, internal podalic version, if possible, may be performed. If the head be too firmly engaged to allow of any turning at all, forceps, or finally a destructive operation is indicated. There are also certain cases of transverse presentation (which presentation is by no means rare with placenta prævia), where the uterus, after the escape of the liquor amnii, is so rigidly contracted over the child, that version by any method becomes impossible, and we have to resort to a destructive operation.

It all comes back to the standard rule, that we cannot entirely and permanently arrest the hemorrhage until complete delivery is effected, and the uterus, being entirely empty, is firmly contracted and retracted upon itself.

The simplicity as well as facility of combined version is acknowledged by all who have tried it. Lomer states, that "as a matter of fact the hemorrhage does cease" after it has been practiced in cases of placenta prævia, and also, “in no case has internal or concealed hemorrhage occurred." In adopting this partly passive, partly active plan of treatment above described, complete delivery was generally effected in about 1 to 2 hours after the performance of the version, although, of course, this time varies with the peculiarities of each individual case. Nevertheless, it does not appear to be too long, when we consider that the operation is practiced at a period when the os is only sufficiently dilated to admit one or two fingers.

The one case of marginal placenta prævia occurring in my practice during the past year was a German emigrant in the eighth month of her pregnancy, who, after having suffered a considerable hemorrhage on ship-board some twelve hours previously, entered the hos pital. Examination revealed a dead fœtus in utero, membranes rup. tured, waters escaped, placenta partially torn away, and os readily admitting the entire hand. Internal podalic version and extraction