the hemorrhage was considerable, so much so as to measurably prostrate the patient; pains feeble. The tampon had been introduced at the doctor's first visit. Dilatation to the extent of a crown-piece, os rigid. The placenta was centrally implanted; presentation of child not ascertained. In consultation we decided to deliver at once. Patient under influence of chloroform, Dr. H. brought down one of the legs and delivered a still-born child; the placenta immediately followed; much blood was lost, but patient appeared cheerful and hopeful. Pressure with both hands upon the abdomen was constantly maintained, but in spite of persistent pressure, the uterus dilated and continued to dilate until it mounted up above the umbilicus, when the flooding became copious and fatal. The patient at once became conscious of approaching death; soon became comatose without any apparent intermediate syncope, and died in an hour and a half after delivery of post-partem hemorrhage.

We decided then and there, that if so unfortunate as to be ever called to another case of central implantation, that we would adopt another plan of procedure-a plan not recognized as authoritative. We had not long to wait, for on February 23d, another case presented itself, very nearly in the same locality of the city, and on April 4th, still another case, both of central implantation. The first, a multipara, German, aged 38 years. Hemorrhage first occurred on January 23d, at eight months utero-gestation. The air-ball was at once used, and the vagina effectually tamponed. At precisely four weeks to a day after the first attack of hemorrhage she was again attacked with flooding, and was now at the completion of her full period of utero-gestation. Labor pains soon commenced.

The patient was visited at 5 A. M. The air-ball again placed and retained in situ and the abdomen tightly bandaged. We resolved to wait in this case to the extreme point of waiting for efforts of nature to accomplish what she might be able to accomplish unaided, save appropriate means for the arrest of hemorrhage, and we did thus wait even beyond the verge of apparent safety, and did thus delay until the os was fully dilated. We had ascertained from external palpation that the position of the child was transverse. Pains had been considerable at noon, but now, at night at nine o'clock there were none. Hemorrhage had been

controlled by the tampon; at 9 P. M. the tampon was removed; the os found fully dilated; entrance of the hand within the uterine cavity easily made, the patient having been previously anæsthetised; one foot seized, brought down, and when the breach became engaged, hemorrhage which had just before been considerable, was now arrested, and the further delivery, as the pains had become active, was left to the unaided efforts of nature. This woman gave birth to a living child, and had, herself, a good recovery. I should add that pressure was constantly made with both hands upon the abdomen, and maintained for some considerable time after delivery.

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The other case occurred on April 4th; was the mother of three children, the youngest being nine years of age; the age of the patient was 40 years. Hemorrhage first occurred either at 8 or 8 months utero-gestation. At 9 P. M. April 3d, copious hemorrhage commenced; at 2 o'clock A. M. April 4th, labor pains set in. The air-ball was promptly used; the patient bandaged tightly and hemorrhage was controlled. Visited the patient along with Dr. Hauenstein at 1 P. M. At this time there was some hemorrhage in spite of the tampon; pains regular; pulse feeble; nearly nominal in frequency; tendency to syncope. Examination had been previously made and central implantation diagnosed; dilation was sufficient to easily admit one finger. Advised continuance of treatment. 5 P. M. patient much in same condition; counseled delay. 8 P. M. no material change; general condition of patient same; labor progressing; removed tampon; found dilatation of os about one-half completed; introduced air-ball; applied bandage, and was called again in haste at 3 A. M. April 5th. There had been some hemorrhage in spite of the tampon during the past hour. The position of the child was found on palpation to be transverse, as in the other case; pulse feeble and frequent. Patient under the influence of chloroform the child was turned and deliv ered, the os having been completely dilated and entrance of the hand within the uterine cavity easily made. Mother and child both saved and doing well. Constant pressure with both hands, as in the former case, was maintained during and for some considerable time after delivery.

At 11 A. M. April 5th, no untoward symptoms.

I am permitted to allude to another case occurring in the practice of Dr. Hauenstein, which was fatal, and the doctor assures me

that very little blood was lost. This was a case of placenta previa lateralis, and I am assured by the doctor who was in attendance from beginning to end of labor, that he had seen as much blood lost in an ordinary case of labor as he saw in this case. The child was turned and delivered.

It is worthy of note that six cases of placenta previa have occurred in the practice of Dr. H. in the space of the last eight months. Another fact worthy of note is, that three out of five cases seen by myself occurred within a few yards of each other.

These cases, their termination and management are suggestive, and incitive to thought. They suggest in regard to their management a suspension of pre-conceived views. They call to mind the principle long since laid down and acted upon generally by authors and practitioners of the danger of intermeddling midwifery, and suggest a greater reliance upon the provisions of nature and less dependence upon art. They also suggest that delay is not so much to be deprecated, and that it is not so hazardous as precipitous haste would be, and that if a woman must die within one or two hours after forcible entrance has been effected within her womb, and the child speedily delivered, that it may be better to wait for complete dilatation even if she must necessarily die a few hours later. In the one form of procedure the shock is much greater than in the other.

Taking these imperfectly reported cases as a basis for remarks, I have proposed to myself the task of making some clinical observations upon the subject of placenta previa, and have now in process of completion a paper which I hope to present to the Society at a future meeting.

DR. WHITE said:-Mr. President, the gentleman who has just taken his seat has introduced to the consideration of the members of this Society a subject of the gravest importance. Unavoidable hemorrhage, or placenta previa, though of rare occurrence, is sufficiently frequent, and the danger so imminent that it is of the first importance that every practitioner should be familiar with the best course to be pursued in its management. It is, in my opinion, therefore, our imperative duty to brand such crude doctrines as those just advanced, as heterodox, and disclaim on the part of this Society all endorsement of the treatment pursued in the cases related, and of the "new" rule of practice which the doctor finally

recommends as the result of his experience. Not doubting that the sole purpose of the member, Dr. Gay, in writing the paper to which we have just listened, was the advancement of medical science, I shall feel free to speak plainly in my comments upon the points discussed without fear of giving offense or being suspected of having the least personal feeling. The proposition, however, to leave all cases of unavoidable hemorrhage to nature; or in other words, the medical attendant sitting by, supinely folding his hands and permitting the poor woman to flow until death comes to her relief, is too startling to permit it to go out to the world from this Society unchallenged.

The

Let us first examine for one moment some of the cases related by Dr. Gay and the treatment pursued by him producing results which impelled him to this "new" method. The first case lost so much blood before art interfered for her relief that she apparently never rallied from her exhausted and exsanguine condition. reasons for this extraordinary delay are not very clearly stated, and perhaps as the woman was in the hands of a midwife during the early part of her labor, the only criticism which it would be fair to make is, that turning was resorted to too late to save the patient.

Proceeding to the second case, we find that having the unfortunate result from delay in the first case, staring him in the face, the doctor resolved not to be behindhand in this instance, and as he informs us proceeded "forcibly" to turn. I am astonished, Mr. President, to hear the word "forcible" used at this' late day to describe any of the manipulations practiced for the delivery of the parturient. The patient died, and as no post-mortem is reported, it is impossible to determine the condition of the organs after this "forcible" resort to version of the child in utero.

In the third case, not content with the course pursued in either of the preceding, finding the hemorrhage terrific, and "not knowing what to do," he resorted to free "venesection." A remarkable remedy with which to overcome the exhaustion consequent upon excessive uterine hemorrhage. Notwithstanding this superadded loss of blood, the woman survived. Can there be any difficulty, Mr. President, in accounting for the mortality in the cases related by Dr. Gay? It is only wonderful that any could have survived. Dissatisfied with the result of the practice pursued in the fore

going cases, the doctor concluded that "meddlesome midwifery was bad midwifery," and determined thereafter to "leave all to nature," simply inserting an "air-ball" into the vagina to lessen the hemorrhage. The wisdom of his course is demonstrated by lessened mortality in the cases which follow in his report, and in which little or no effort was made to interfere with nature in this unnatural position of the placenta.

Thus, Mr. President, does Dr. Gay propose to revolutionize the practice in all cases of placenta previa, and instead of making all cases, or nearly all artificial, as is the established practice, he would by his "new" course leave all these labors to nature, unaided. The course which I have thought, and taught, as the best to pursue, and to which opinion I must still adhere, notwithstanding the lucid arguments of the honorable member to whose paper we have just listened, is briefly this: that all cases of placenta previa should be treated as artificial from the moment the placenta was ascertained to occupy the uterine outlet, whether partially or completely, no matter whether labor came on at the full period of utero-gestation, or anticipated that time by a few weeks, as not unfrequently happens. Postponing delivery if the hemorrhage does not demand earlier interference, to the completion of gestation; at the commencement of the labor, and if possible, before much blood has been lost, effectually tampon the vagina and wait only until the uterine orifice is dilatable by gentle distension, and then at once proceed to turn and deliver, taking measures to secure uterine contraction at the same time.

As to the kind of tampon which the doctor recommends for the purpose of controlling the hemorrhage, it is not so good as soft, old muslin, torn into small slips and united by candle-wicking or tape, and then introduced through a cylindrical speculum. The latter can be made, if carefully introduced, and packed, to fill the vagina more completely than the ball, making more pressure upon the lateral aspects of the uterine outlet, and should fill the vagina thoroughly, so as to form a cylinder extending down to the os externum. Then making pressure upon the uterine tumor, over the abdomen, by a bandage or by the hand of an assistant, and applying a T bandage or a napkin held by a nurse to the external orifice of the vagina, pressure is made upon this cotton column which completely controls the bleeding. There is an additional advantage in the muslin tampon over the "new" one, or at least