APPENDIX-Section on Obstetrics and Diseases of Women and Children.

found adequate to meet the indications to be fulfilled.

If, by support of the perineum, the term is to be considered in a strict literal sense, and that no other indications are to be fulfilled, then we are ready to agree with Goodell and others that the perineum does not require support; but such is not the case, as relaxation and retardation are both accomplished by this method.

For the delivery of the placenta, various diametrically opposite opinions exist amongst the most able and experienced obstetricians in both Europe and America. The method of expression commonly known as Crede's method receives the endorsement and sanction of our ablest American authors and reviewers. It is claimed that the prejudice against this method has been from the want of a thorough understanding of the mode of procedure taught and practiced by Crede; that sufficient time has not been allowed, after delivery of the child, for the uterus to assume its contractile functions, and the placental mass to loosen its connections with the uterus. No effort should be made to dislodge the contents of the uterus until a contraction sets up, either from its own action or from excitement by gentle friction, and only to be followed and put in force during each subsequent contraction, until the placenta is delivered. As soon as energetic contractions of the uterus take place, the uterus is grasped in such a manner as to include the fundus in the palm of the hand. Compression between the thumb and fingers enables circular compression to

Report of C. C. Francis, M. D., Chairman, Cleburne, Texas.

be made so as to force the placenta from the uterine cavity.

It is urged by Barnes that the easiest and safest method of delivering the placenta is by the following mode: Gentle pressure is to be applied to the uterus for a few moments after the delivery of the child; no undue friction or kneading is to be attempted; two fingers are to be carried along the course of the cord to its root, and firmly pressed into the body of the placenta, so that traction may be made in the direction of the vulva; pressure is to be made backwards along the curve of the sacrum, with the other hand; gentle traction is to be made on the cord, by the combined action of both hands; a downward and backward force is exerted on the placental mass, and, at the same time, by the aid of an assistant, steady pressure is made upon the fundus uteri. If this method fails, then the Crede method is advised.

Again, we are confronted with the experience and results obtained by Dorhn, leaving the delivery of the placenta to efforts of nature. In 2000 cases, one half left to nature, the other half expressed by Crede's method, he sums up the result as being largely in favor of trusting to the natural expulsive efforts. In commenting upon these results, Ahfield, in support of this conservative course, dwells particularly upon the fact that, when the Crede method was employed within five minutes after delivery, the patient was more liable to hemorrhage, puerperal fever, or retained shreds of membrane.

APPENDIX-Section on Obstetrics and Diseases of Women and Children.

Statistics are given to establish the correctness of the conservative course advised. From the various opinions advised and facts elicited in support of the success obtained by these different methods, we cannot do otherwise than come to the conclusion that the conflicting results and opinions are not so much dependant upon the modes of procedure as they are upon the manner in which they are accomplished. However, it is conceded that a majority of obstetricians favor the Crede method of expression, when strictly carried out, with the proper precautions.

PLACENTA PRÆVIA.

In placenta prævia, when dangerous hemorrhage occurs in the early stage of gestation, the induction of abortion is regarded as the safest course to pursue. Subsequently, and at a later period, the recent success of Lomer, Hofmeier and others, by the practice of the Braxton Hicks method-bi-polar or combined method of version-in placenta prævia, places this method in the front rank of all the modes of delivery.

The patient should be placed transversely, and the nates brought to the edge of the bed; the legs are to be supported, and rotated outwards by two assistants; the vagina tamponed, if not capable of being dilated by a careful introduction of the hand. Complete anæsthesia should be obtained, the position of the foetus ascertained, and the rectum and bladder evacuated. If the tampon has been used, the attendant must wait until sufficient

Report of C. C. Fruncis, M. D., Chairman, Cleburne, Texas.

dilatation of the vagina has occurred to admit of the in-, troduction of the hand. After removal of the tampon the presenting part of the foetus must be reached by pushing the fingers through the cervix uteri and placental mass; then, placing the other hand on the abdomen, the two hands should push the foetus in different directions, so as to bring the buttocks down until a foot can be reached. When this is accomplished, there will be no trouble in bringing the breech to bear upon the lower segment of the womb, so as to act as a tampon, and thereby control the hemorrhage. The case may now be left to natural expulsion, or until sufficient dilatation has taken place to complete delivery by manual assistance, or the careful administration of ergot, if deemed advisable.

Lusk recites the advantages of this method, as summed up by Lomer, as follows: (1) It does away with the tampon, and consequent danger of infection. (2) It allows us to operate early. (3) It arrests hemorrhage with great certainty. (4) It gives time for the patient to rally, for the cervix to dilate, and for pains to set in. It, therefore, prevents post-partum hemorrhage.

Dr. W. T. Baird, of Albany, Texas, in an article published in the American Journal of Obstetrics, 1885, speaks in favorable terms of the use of electricity (faradic current), in controling hemorrhage and the induction of labor in placenta-prævia. He reports a number of cases (5), in all of which electricity acted promptly, efficiently and satisfactorily.

APPENDIX-Section on Obstetrics and Diseases of Women and Children.

Further observation will be required to fully establish the merits of this method of treatment as being superior to other recognized modes of procedure; but the reported success obtained in the hands of Dr. Baird certainly entitles it to the careful consideration and attention of the profession.

POST-PARTUM HEMORRHAGE.

to;

There is no period during the third stage of labor that presents graver symptoms, or calls for more deliberate action on the part of the attending physician, than that of post-partum hemorrhage. Immediate, prompt and decisive interference must be speedily resorted otherwise, speedy and certain death will follow, as a consequence. There can be no excuse, on the part of the attending physician, for a fatal result, except from his own ignorance, or want of immediate action, as there is no stage of labor when grave symptoms are present that offer a more hopeful or better success than is obtained in post-partum hemorrhage, by the action of a wide-awake obstetrician. It is a well recognized fact that the objects to be obtained are: (1) to rid the cavity of the uterus of all extraneous matters, let it be the placental mass, wholly or in part, or coagulated blood; (2) to secure and maintain a firm contraction and retraction of the uterine muscular fibres. These indications fulfilled, when no rent or lesion exists, will most certainly and effectually control the hemorrhage.

In my own practice, I have resorted to only one