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prævia, in which head-first delivery was effected, and in which the rule of practice, now generally inculcateci, of turning as soon as the os is sufliciently dilated to admit the hand, was disregarried. The majority of these cases occurred in my practice, and that of my neighhors, in Wilkesbarre. Six occurred in the practice of Dr. Thomas, of New York, and six in that of Dr. I. S. Eshleman, of Philadel. phia. One of Dr. Thomas's patients died of post-partum hemorrhage, artificial extraction having been practised in this case four hours previous to the birth of the child. One of Dr. Eshleman's patients died of heart-clot, induced by sitting up in bed an hour after safe delivery by the forceps. All the remaining 26 cases recovered. Of the children, 12 of the 28 were born alive, or one in 2.17. Of the 16 stillborn, at least four were non-viable. The condition as to viability in four cases is unknown. In only eight cases, in which the period of viability is known to have been reached, were the children still. born; in two of these cases the placenta was extracted several hours before delivery; in one, the brain had to be punctured. In the remaining five cases, death is supposed to have been caused by extensive detachunent, and its consequent hemorrhage.

If it be objected to these cases that the mere fact of their having been delivered head first is prima facie evidence that they were not difficult cases, I would reply that their histories show that the os internum was completely covered by placenta in twenty-six of them, and in the remaining two partial cases, the hemorrhage was so profuse before dilatation as to require plugging of the vagina and artificial dilatation. Indeed, I believe that they were all of that character as to severity, which, according to the teachings of Prof. Meigs, and many others, would have required turning.

In one of the mildest, as it is the most recent of these cases, the attendant, an old physician who was educated under the teachings of Charles D. Meigs, called to his aid a young practitioner, who found the patient exsanguinated to that degree that she could ill afford to lose another ounce of blood. The os, which was dilated about two inches and a half, was more than half covered by placenta. Old Physic, in accordance with his teachings and former practice, proposed immediate turning and delivery by the feet. But Young Physic said no; crowd the placenta to one side, rupture the membranes, and give ergot. This was done, and, as a consequence, the head engaged in the os, vigorous pains were excited, and the hemorrhage immediately and entirely ceased, and the patient was soon safely delivered. Is it not probable, considering her blanched, exhausted state, that the shock inflicted by the operation of version, bad it been performed according to the advice of

Old Physic, would have been more than the patient could have borne ? Many obstetricians of to-day, prominent among whom is Dr. Thomas, of New York, have strongly advised against version under these circumstances, lest the shock inflicted by it might destroy the patient; and I firmly believe, that, by a timely resort to the operation of complete lateral detachment, rupturing the membranes, the use of ergot, and the application of the forceps, if necessary, turning will seldom be required, and that the former procedure will be attended with far less risk both to mother and babe.

If it be objected to this plan of treatment, that it contemplates the application of the forceps in many cases, while the head is yet at the superior strait, and within the cavity of the womb, and that this is a difficult operation to perform, requiring great skill and experience on the part of the operator; I reply that version is also an operation requiring much skill in its performance; and I will venture the assertion that physicians generally, in this country, have more skill in the use of the forceps than in the operation of turning, and that less violence is likely to attend its use in their hands. Let any one read Barnes's description of the operation of version, and of the accidents, dangers, and delays to which its performance is liable, and I think he will hesitate before selecting that operation in preference to applying the forceps to a head which presents within the os. There are commonly present in placenta prævia, two conditions rendering the operation of turning particularly hazardous. One is this state of exhaustion from loss of blood; the other is a uterus whose tissue is not fully developed, and con- . sequently is ill-adapted to expand. The latter condition renders the shock from turning greater; and the former renders the patient less able to withstand the shock.

On the other hand, a more extended use of the forceps, and a greater degree of skill in its use, bas taught the profession that to deliver a woman with forceps when the head is yet within the cavity of the womb, is by no means the formidable operation which it was once thought to be. The obstetric art has probably in no respect made greater advancement within the last seventy-five years, than in the extension of the benefits of the forceps; and skill in its use has undoubtedly, in these days, been brought to a degree of perfection, never dreamed of in the days when Hunter, Denman, Osburne, Collins, and Blundell fulminated against it. And may it not be that this operation of version in placenta prævia is a relic of the time when the forceps was unknown; or of that later time when the adverse influence of the great masters of the art above mentioned,

bad succeeded in well nigh banishing its use from obstetric practice?

Prominent attention has recently been directed to the subject of the early application of the forceps, before full dilatation of the os, by Dr. Johnston, present Master of the Rotunda Lying-in Hospital, Dublin, who reports a large number of cases in which it was thus used in that hospital, and with the most gratifying success. In his report for 1875, just published, he says that since he began the practice, the forceps has been thus used 169 times; and in a large proportion of the cases the application was made when the dilatation did not exceed 15 inches. He says: “ The more we see of early interference, and the benefits arising from it, the more we are induced to persevere in it;' and he closes his report with the broad assertion, “that there was no doubt that the forceps was a perfectly innocuous instrument when in careful and skilful hands." In the discussion of this treatinent before the Dublin Obstetrical Society, it was stated that this practice “ would constitute a remarkable epoch in the history of midwifery, and opened out a new era in practice, because it was so much at variance with all the principles and maxims of the great and acknowledged authorities in obstetrics."

The use of the forceps, however, in the manner and for the purpose here described, is, I believe, not so new to the obstetricians of this country as it appears to be to the savants of Dublin. I am only stating what has frequently been said before, when I say, that the use of the forceps has a much wider range and latitude in this country than it has either in Great Britain or on the continent. To apply the forceps before the os is fully dilated is, in this country, an event of no uncommon occurrence; and the practice may be, I believe, and has been, with great benefit, extended to the treatment of placenta prævia.

To Dr. I. S. Eshleman, of this city (Philadelphia), belongs the credit, so far as I have been able to ascertain, of having first applied a narrow-bladed long forceps in placenta prævia, through an os dilated to the extent of only an inch and a half, for the purpose, at the same time, of producing expansion of the os, and making pressure with the head upon the placenta and vessels to prevent hemorrhage. Two cases thus treated were reported by him in the Phila. Med. Times for March 20 and August 14, 1875. In one case a living child was delivered. In the other the forceps were applied through a crevice found in the placenta over the os. In both cases he was eminently successful, both in causing the os to dilate, and in completely controlling the hemorrhage. May I not predict that

by this operation is opened out a new era in the treatment of placenta prævia ? It seems hardly to admit of a doubt, that when the instrument has once been accurately adjusted, and gentle traction made upon it, the head will so effectually tampon the os as to make any considerable hemorrhage impossible. In the performance of the operation undue haste in the extraction of the child is unnecessary, and should be avoided. If the bleeding be effectually controlled, the rigidity of the os may be gradually overcome by gentle, intermitting traction in imitation of nature, and kept up, if need be, for an hour or more. Such a proceeding, it is believed, will be attended with less pain, and will be less likely to produce shock, or other serious after-consequences, than the operation of turning, as ordinarily performed, while the chances of delivering a living child must also be greatly increased.

While the credit is thus due to Dr. Eshleman for first using the forceps while the os is dilated only an inch and a half, and for the purpose of dilating the os and controlling the hemorrhage, many others have used them before the os was by any means fully dilated. This I have done repeatedly, as have also my friends, Drs. Mayer and Murphy, of Wilkes barre, who have for years preferred the forceps to turning in these cases.

of the 28 cases of head-first deliveries before referred to, in 15 the forceps was used, with only one death, that being from heart. clot, induced by imprudence after delivery. In all of these the instrument was applied before full dilatation had occurred. Sis children out of the fifteen were born alive, and at least three of the remainder were non-viable. In only three cases was there a failure to deliver living children where the period of viability is known to have been reached, and in one of these craniotomy had to be performed.

I will close this paper, already grown too long, by again briefly indicating what I regard as the best treatment to be pursued in placenta prævia. If active interference is called for, in consequence of flooding, before dilatation has begun, I would strive, by every means known to our art, to control the bleeding and lasten dilatation. Preferably, I would use for this purpose: lst, Molesworth's dilators, preceded, if necessary, by a sponge-tent; 2d, Barnes's dilators; 3d, the tampon, or colpeurynter; 4th, ergot, if the presentation is not transverse; 5th, evacuation of the liquor amnii. By a judicious and skilful use of these means I believe that fatal hemorrhage, if the case be seen in time, may almost always be prevented until the os is dilated an inch and a half or two inches. Then, if the os be not covered by placenta, rupture the membranes; and, if

the hemorrhage does not then cease, apply the forceps after Dr. Eslıleman's method. But if the os be covered by placenta, Dr. Eshleman's procedure must be preceded by the operation of lateral detachment, and drawing the placenta down to one side, as recommended in this paper. In a large proportion of cases, after the execution of this procedure, and giving ergot, kneading the abdomen, and applying the binder, bleeding will stop, and the case may be left to nature. If, however, the womb refuses to contract sufficiently to cause the head to tampon the os, and stop the bleeding, an attempt should at once be made to apply the forceps; and once the blades of the instruinent have been properly adjusted to the child's head, the accoucheur becomes master of the situation.

As to version, this much-vaunted operation I would reserve for two classes of cases : 1st, cases of transverse presentation of the child, provided, that cephalic version cannot be easily performed by the bi-polar method ; 2d, cases in which, for some reason, the blades of the forceps cannot be made to grasp the head within the cavity of the uterus.

I hope to see the method of treatment here advocated submitted to the test of further experience.

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