ADDRESS IN OBSTETRICS.

By R. DAVIS, A.B., M.D.,

OF WILKESBARRE.

IN the selection of a theme for the "Address in Obstetrics," which your distinguished President did me the undeserved honor of appointing me to deliver on this occasion, I have been guided by a desire to choose some subject which is of general practical importance, not to the specialist alone, but to the practitioner of midwifery everywhere, whether in city or country, in hospital or in private practice. And it has seemed to me that the Treatment of Placenta Prævia furnishes me with such a theme. To this topic, therefore, I now have the honor of directing your attention.

The importance to every practitioner of midwifery of a thorough practical knowledge of the subject of placenta prævia can hardly be over-estimated. This importance it acquires, 1st, from the great fatality, to both mother and child, which attends it; 2d, from the suddenness with which a fatal result may supervene; 3d, from the fact that the prevention of a fatal result often depends entirely upon the knowledge, judgment, promptitude and skill of the medical attendant; and, 4th, from the fact that the attendant must frequently rely wholly on his own resources, there being no time to call to his aid even his nearest neighbor. Unlike many diseases of rare occurrence (it is estimated that this complication occurs only once in 500 labors), placenta prævia may not be neglected by the general practitioner on the plea that it is a rare disease, and therefore the study of it may safely be left to the specialist or college professor. There are some diseases of women of rare occurrence in the treatment of which it is not absolutely essential that all who practise midwifery or gynæcology should be expert. One need not be a skilled ovariotomist in order to be able to give his patient with ovarian tumor the best chance for her life which the resources of our art affords; for in that case he will have ample time to call to his aid a Peaseley, a Wells, or an Atlee. In like manner may he commit to the charge of a Sims, an Emmett, or an

Agnew, his case of vesico-vaginal fistula, thereby feeling well assured that his patient will not suffer in consequence of his own lack of skill in the performance of the operation for the relief of this distressing malady.

But he to whose lot falls the duty-as it may to the humblest member of our profession-of managing a case of placental presentation, can rarely call to his aid either a Barker, a Thomas, or a Goodell. Indeed, often before he can summon to his side his nearest neighbor, the time for action on his part will have passed beyond recall; the golden moment in which the issues of life and death to two human beings hang trembling in the balance!

These considerations, therefore, shall be my excuse for selecting this subject for discussion at this time; and I am the more strongly impelled to choose it, from the further consideration, that for the last five years or more it has not received at the hands of the profession an amount of attention at all commensurate with its importance. While papers, and essays, and addresses and discussions of societies ad infinitum, and well nigh ad nauseam, have appeared upon the subject of puerperal fever-a disease which adds but little more than placenta prævia to the general mortality of child-bed— yet a few dozen pages would comprise all that has been published upon the latter disease for several years past. There is need of working up this subject anew, and if I can succeed in inducing some others more competent than myself to undertake the work, I shall feel that this paper, however valueless it may be in itself, will, nevertheless, not have been written in vain.

The questions pertaining to placenta prævia other than that of its treatment, such as the causes of placenta prævia; the cause of the hemorrhages which are incident to it both during pregnancy and at the time of labor; the sources of these hemorrhages; the mechanism of their spontaneous arrestment, as well as the mechanism of the spontaneous detachment of the placenta,-these questions it is not my purpose to discuss, except so far as their discussion may be essential to the establishment of a correct basis of treatment. Neither is it intended to discuss the question of treatment in all its bearings; but the paper will be devoted mainly to an inquiry into the comparative merits of head-last and head-first labors in placenta prævia. I shall inquire by what title the dangerous operation of turning holds the prominent position which it does in the methods of treatment generally recommended by obstetrical authorities even at this day; and, stimulated more by a desire to induce others to study the subject than by any expectation of being able to convince you of its truth, I make the following pro

position, and shall offer some considerations tending to sustain it, viz., That more lives, both of mothers and of children, would be saved if every case of placenta prævia in which the head presents were conducted with a view to finally delivering by the head rather than the feet.

For two hundred years the rule of practice by which the accoucheur was governed, and which received the sanction of science, was what is rightly named the accouchement forcé. This practice was based upon a rough deduction from observations showing that the hemorrhages generally stopped when delivery was complete, and that unless delivery was effected the hemorrhage continued. It consists in the immediate extraction of the child from the womb by main force. The hand is forced through the os into the uterus; the feet are seized; the child and placenta extracted with all possible speed, and at all hazards. So universal was the sanction given to this practice seventy-five and even fifty years ago, that he who should lose a patient in an attempt to deliver by any other method would subject himself to prosecution and conviction, by the testimony of his compeers, for malpractice, if not for manslaughter.

But it was not in the nature of things that such an absolute law should endure always without question or mitigation in practice. Gradually the fact began to be recognized that nature was able, in some cases, to effect a safe delivery without the interference of art; and in other cases it was discovered that by rupturing the membranes, and exciting the uterus to contract by ergot, etc., turning was rendered unnecessary. So that in 1844 we find Dr. Robert Lee saying: "The operation of turning, which is required in all cases of complete placental presentation (central), is not necessary in the greater number of cases in which the placenta, passing into the membranes, can be distinctly felt through the os uteri. If the os uteri is not much dilated, the best practice is to rupture the membranes, to excite the uterus to contract vigorously by the binder, ergot, and all other means, and to leave the case to nature." About this time also, Dr. Simpson began to inveigh against the operation of version, for which he proposed as a substitute the practice of artificial detachment and extraction of the placenta, letting the child remain to be delivered by the ordinary process of labor.

But it is to the labors of Dr. Robert Barnes that the credit belongs of having made the deepest inroads into the old practice of accouchement forcé. In 1847, Dr. Barnes began to publish the results of his study of this subject; and the reasonableness of the theories which he advanced, and the remarkable success of his practice, have undoubtedly had a powerful influence in re-moulding the opinion of

the profession upon this subject, and inducing recent writers to exclaim in the language of Schroeder, "The accouchement forcé always avoid."

In order to show, however, with what tenacity opinions and practices once and for a long time entertained will maintain their hold upon the profession, I will quote from several recent authors to show that the treatment recommended by them differs but little from that against which, thirty-five years ago, Lee, Simpson, and Barnes began to exert the influence of their great names and genius. Prof. Chas. Meigs, writing in 1856, says: "From these remarks let the student gather that my instruction for him is this, videlicet: in placenta prævia the indication is, to turn and deliver by the feet." Again: "Hence, when the student asks me what he is to do in his case of placenta prævia, I invariably answer, turn and deliver by the feet, for if the child does not present by the pelvic pole, the indication of treatment is certainly to turn and deliver, so that I am almost ready to say that the word placenta prævia is not merely a denotative but a connotative word, meaning at the same time a placenta on the orifice and the necessity of turning and delivery by the feet."

Dr. Bedford in his work on obstetrics, published in 1862, says: "Version I hold to be the cardinal remedy in placenta prævia if the head of the fœtus be still at the superior strait, and the mouth of the womb will allow the introduction of the hand." Cazeaux, Hodge, and Dr. Tyler Smith express similar views. Schroder, whose work is one of the most recent, says: "The treatment during labor is very simple: 1st, a tampon to the vagina until the cervix is so dilated that the foot can pass through it; 2d, one foot is brought down by the combined manipulation (bipolar method of turning), and gradually the foot is more strongly drawn upon." In case of failure to turn by the bipolar method while the os is the size of two fingers, the tampon must be again applied until the os is sufficiently dilated to admit the hand and the turning of the child.

Dr. Leishman, while not committing himself strongly to any mode of treatment, says of version: "The operation of turning is that in which the great majority of experienced practitioners still place the greatest confidence." It is evident, however, that he himself entertains doubts as to the wisdom of the practice, for he adds: "But it is not to be forgotten that the operation of turning is one which involves special risks; of which laceration of the os and cervix, terminating in phlebitis, is not the least, and that, therefore, we must weigh well the responsibilities we undergo before we reject all other modes of procedure in favor of this operation, as it is

usually performed." Weighty words from a high source, which I commend all advocates of turning in placenta prævia carefully to ponder!

The quotations already given from well-known authors, together with scores of others which might be made to the same effect, show that the operation of turning still holds a very prominent, if not the first, place in the estimation of the mass of obstetricians in the treatment of this formidable complication of labor, so that what Dr. Meigs said was true of himself is probably still true of the great majority of our profession throughout the world, viz., that the enunciation of the word placenta prævia never fails to waken in their minds this compound idea-a placenta on the orifice, and the necessity of turning and delivery by the feet.

The present treatment differs from the old accouchement forcé mainly in this, that the forcible introduction of the hand through an undilated os uteri is discarded; but in place of this, it is recommended, if the os is undilated, to resort to the use of Barnes's dilators, of the colpeurynter, the tampon, and of ergot, for the purpose of checking the hemorrhage, and expediting the first stage of labor. Some also speak well of the evacuation of the liquor amnii, of Barnes's operation of partial detachment, and, in exceptional cases, of Simpson's method of artificial detachment and extraction of the placenta. A few admit the possibility of ending the labor by the forceps, "if the head should have descended into the pelvic excavation."

The sheet-anchor in the treatment of placenta prævia, however, according to most authors, is version; the other procedures mentioned being recommended only as preparatory steps to the operation of turning, by which the labor is ultimately to be terminated.

What claim has version to this distinction? It is estimated that, even in cases of natural breech presentations, only fifty per cent. of the children are born alive. A still smaller proportion survive in cases where turning is resorted to; while, according to all statistics, over two-thirds of all children delivered by turning in placenta prævia are still-born.

But, even if we entertain the opinion expressed by Simpson and Churchill, that the hope of saving the children ought scarcely to influence the treatment, an opinion in which I by no means concur, is the success of the treatment by turning satisfactory, as regards the saving of the lives of mothers? According to the statistics of Simpson and of Trask, one-third of the mothers delivered by version die. Surely, a mode of treatment of placenta prævia which sacrifices the lives of one-third of the mothers, and two-thirds of