One of the most efficient means of exciting uterine contractions is thorough tamponade of the vagina. In case of placenta prmvia, before the membranes have ruptured and before dilatation is sufficiently ad vanced for the purpose of the active method to which we will shortly re fer, the tampon may be used without fear of concealed hemorrhage. It must, however, be rightly applied, and the sole way of accomplishing this efficiently is through Sims' speculum, in the lateral position. Where this speculum is not at hand, the woman should still be made to assume the lateral position, and two or more fingers of the hand may be used as a perineal retractor. The tampons, it is immaterial of what substance, provided it be clean, should be so inserted as to compress the lower uter ine segment and the cervix, that is to say, they are placed first firmly in the posterior fornix, and then in the anterior, and finally a layer over all. They should not remain in place longer than twenty-four hours, and ordinarily less than this time is sufficient to enable one to resort to the active step which constitutes the modern treatment of placenta prsevis, and the best, as well, for the reason that by means of it, not only are more mothers saved, but also no more children lost.
In the " American Journal of Obstetrics," for December, 1884, will be found the most valuable contribution to the subject of the treatment of placenta prtevia, which has ever been written. It was contributed by Lomer of Berlin, who, in a judicial manner, weighs the evidence in favor of the various methods of treatment heretofore advocated, and then proves that through resort to bi-manual version (the method of Braxton-Hicks), as soon as the cervix is sufficiently dilated to permit the procedure, the ma ternal mortality is reduced to figures never even approximated by any other procedure, not excepting the method so ably advocated by the elder Barnes.
The method consists, briefly, in performing bi-manual version as soon as possible, pulling down a leg and tamponing with it and the breech of the child, the ruptured placental vessels. " Do not extract the child then; let it come by itself, or at least only assist its natural expulion by gentle and rare tractions. Do away with the plug (tampon) as much as possible; it is a dangerous thing, for it favors infection, and valuable time is lost in its application. Turn as soon as you can pass one or two fingers through the cervix. If the placenta is in your way, try to rupture the membranes at its margin; but if this is not feasible, do net lose time; perforate the placenta with your finger, get hold of a leg as soon as possible shd pull it down." By this method it may seem, at first sight, as though, after all, but little regard was shown for the infant's life, but, as the statistics we annex show, the results for the child are certainly no worse than by other methods, and yet incomparably better for the mother.
Up to the time of writing, Lomer was able to present the following re sults from this method: that is, a maternal mortality of 4.5 per cent., while we have seen that the lOwest mortality by any other method of treatment was 25 per cent., as given by Trask, 23 per cent. as given by Muller, and 22.5 per cent., as
given by Bing (Indiana), taking cases collectively, and when taken singly, by operators, Spiegelberg 16 per cent., Hecker 10 per cent., Barnes 8.5 per cent., Hecker and Murphy (30 cases) 0 per cent. These latter are selected results, and, to apply the same process to Hoffmeier's, Behm's and Lomer's personal cases, we have a series of 93 cases with 1 death.
As for the children, the mortality rate in the cases recorded by Lomer was 60 per cent., practically the same as by other methods, but in refer ence to this question, Lomer draws the following conclusions, which are eminently just: 1. The average mortality of children born spontaneously after turning, is not superior to that of children extracted immediately after turning. The danger the child runs by not extracting it has there fore been overrated. 2. In case of placenta prania, a child's life is of s) little practical value compared with that of the mother, that, should it be endangered by leaving it to be born by the natural powers, we are entitled to sacrifice it in cases in which we would endanger the mother by quick ex traction. The only objection that could be made to the method is, there fore, of no serious importance.
For further information in regard to the method advocated, and the detailed analysis of the results obtained, we are forced to refer to the monograph itself. It will repay careful study, and will bear critical judg ment.—Ed.] In regard to the results obtained by various methods the following sta tistics are given by Weil: In 32 cases 15 mothers were saved, G out of 8 in which the tampon alone was used, and 9 out of 24 in which the tampon was employed with subsequent resort to rupture of the membranes, for ceps, or version, or a combination of the same. Among 11 cases reported by Bailly, out of 5 were saved by version, and 5 out of 6 by the use of the tampon alone. But the latter writer fails to state the conditions under which he acted. The results in the Clinique de la Fee:tile, were as follows: Among 16,613 cases of delivery which took place during the years 1852-1873 (the record for 1853 being defective) there were 65 of placenta prievia, 43 mothers and 23 children being saved; 53 women were multiparte, and 12 primiparie; in 21 cases the insertion was central, in 44 marginal. 33 patients were delivered spontaneously, with 8 maternal and 19 foetal deaths, 22 by version, with 9 maternal, and 16 foetal deaths, and 9 by the forceps, 4 mothers and 6 children succumbing. The conclusion to be drawn from these statistics is opposed to that of Bailly, because, if spontaneous delivery was followed by such good results when the tampon was not allowed to remain indefinitely, it shows that his success was due not to the fact that he left it until expelled, but because delivery was spontaneous. In short, interference of any kind is undesirable, and we ought then to abstain from it. Unfortunately, this is not always possi ble, and we are then compelled to resort to the only means that are left to us, that is to say, to delivery by the forceps or by version, and this is the plan followed at the Clinique.