Muller gives the following statistics in connection with version in pla centa pnevia: The mortality is 30 per cent. Comparing these results with those of version in cases of normal implantation, as given by Sickel, out of 3476 versions there were 291 deaths, or 8.3 per cent. Of 416 children deliv ered by version in case of placenta proavia, 250 died (60 per cent.); in 10,910 versions with normal implantation, 5653 died (51.8 per cent.) Muller reports 92 cases of accouchenient force followed > version, with a maternal mortality of 47.8 per cent., and a foetal of 62.7 per cent.; in 34 cases, in which the os was first dilated by the tampon or colpenrynter, 35.2 per cent. of the mothers and 50 per cent. of the children perished.
The same writer states that in 105 cases in which the tampon was ap plied according to the German method, the hemorrhage was arrested in only 58; in 128 cases in which the influence of the tampon on uterine contractions was studied, iu 55 the pains became vigorous in from 1 to 12 hours. Out of 161 women with placenta prEevia, in whom contractions were caused by the introduction of the tampon, 126 mothers and 64 children were saved, 6 of the latter dying soon after delivery.
Chassagny uses his intra-uterine dilator to dilate the cervix and hasten delivery, but its hmmostatic action is limited. Legroux ruptures the mem branes, and then has the woman supported in a standing posture, with the view of causing the descent of the head, so that it may act as a tam pon.
Separation of the Placenta.—This method, proposed by Radford, and ardently championed by Simpson, has been generally attacked in France and Germany, while in England it is especially advocated by Barnes. Hav ing collected some 40 cases in which the placenta was expelled before the child, the hemorrhage being arrested, and noting that this arrest was due to compression of the vessels by the head of the child, and also that the child was always born dead under these circumstances, lite laid down the following nine propositions: 1. Neither delivery nor detachment of the placenta should be at tempted until the os is sufficiently dilated to allow the introduction of the hand. 2. If the foetus is certainly dead, we should detach the placenta completely, rupture the membranes, and leave the case to nature. 3. If the pelvis is narrow, extract the placenta, then perforate and extract the child with the crochet. 4. If the os admits the hand, detach the placenta, if the membranes are ruptured and the pains strong. 5. If there is an exhaustive hemorrhage in central placenta prEevia, perforate the placenta at its centre, and use galvanism. 6. In cases of partial insertion rupture
the membranes, and use galvanism if there is hemorrhage. 7. Remove the placenta if all other means fail to check the bleeding; also 8. When artificial delivery is dangerous or impossible. 9. When the death of the fcetus renders the safety of the mother the only consideration, extract the foetus immediately.
Now, Simpson's theory is false at the outset. The hemorrhage, as Lee and Ashwell have proved, comes from the uterus, and not from the pla centa; moreover, Simpson would detach the placenta before the os is suffi ciently dilated to allow version. Simpson reports 141 cases of extraction of the placenta before the birth of the child; in 47 cases there was an interval varying from ten hours to ten minutes between the expulsion of the placenta and the birth of the child, 44 mothers and only one child being saved; in 24, in which the child was born within ten minutes after the extraction of the placenta, 21 mothers and 11 children were saved. In 30 cases the placenta came away immediately before the child, or both were expelled together, 21 mothers and 11 children surviving; in 40 the exact time that elapsed between the separation of the placenta and the birth of the child was not known, but 36 mothers and 7 children were saved. To summarize, 129 mothers and 31 children out of 141 were saved. Other writers have not had the same success with Simpson's method, Walter having lost 10 mothers and 30 children in 33 cases, Hecker 27.5 per cent., and Trask, 13 mothers and 41 children in 61 cases.
Finally Barnes proposes the following: If the pregnancy has only reached the fifth or sixth month, the os is not dilated, there are no pains, and the hemorrhage is moderate, we can wait; if there is considerable bleeding and the contractions arc fair, no matter what may be the age of the pregnancy, we ought to act at once and hasten the labor by: 1. Puncturing the mem brane. 2. Applying a tailed-bandage to the abdomen, so as to excite con traction. 3. Introducing a tampon. 4. If the os is sufficiently dilated, and if there is hemorrhage, separate all that part of the placenta which is attached to the cervical zone. 5. If the os is not dilated, dilate by means of the dilators, and then detach the placenta from the cervical zone, by introducing the hand into the vagina, and sweeping two fingers around the os, so as to detach the placenta as high as they can reach. After di lating, bipolar version is practised.