says an "early rupture of the membranes may be produced." On the other hand, Schroeder* says, "we would not, however, recommend the rupture of the membranes at so early a period," i. e., before the os is dilatable, "because it is not absolutely certain that the bleeding is stopped by those means, and if it does not succeed, it may give rise to internal hemorrhage," or, as he better expresses it on the same page, not to proceed to "rupturing the membranes until the presenting part be firmly pressed against the lower uterine segment, or until the os is so far dilated as to admit the hand for turning and extraction." Cazeaut approves of the method of Puzos, and says that after dilation of the os uteri "the rupture of the membranes will then be effected to the greatest advantage."

When we remember that in all cases there must have been rupture of the membranes, either spontaneous or intentional, it is unfortunate that more attention has not been paid to that point by the reporters. We might then have arrived at more accurate and just conclusions, as to its importance as a remedial agency in pla centa previa; but as it is our study must necessarily be very unsatisfactory.

The principal object, however, appears to be, by emptying the membranous sac of its liquid contents, we excite the uterus to more vigorous contraction, and allow the presenting part to compress the bleeding surfaces until delivery can be effected. Whether it should be done early or late, before or after dilation of the os, is a mooted question, as appears from the above quotations.

The following table includes all cases in which rupture of the membranes was reported as a remedial measure:

*Manual of Midwifes, page 312. †Cazean's Midwifery, page 706.

This table shows that a large proportion were cases of partial presentation and had moderate hemorrhage.

The mortality to the mother was exceedingly light, only two cases dying.

The mortality to the child was comparatively light, except in cases of partial presentation.

These results are indeed flattering; but were they due wholly to the treatment pursued? In a large number of the cases, delivery occurred soon after rupture of the membranes, and the histories of the cases indicate that vigorous uterine action was present in almost every instance, so that although the treatment shows such good results here it most assuredly would not be reliable as a dependence in cases of greater gravity, or absence of active uterine contractions.

We are not able to determine the practice of a majority of the reporters in reference to rupture of the membranes, before or after the dilatation of the os uteri. In the two cases which proved fatal to the mother, it was reported as having been ruptured early, and shows the unfortunate result that may occur where labor is not completed soon, or more heroic measures are subsequently

demanded.

The advantage of the unruptured membrane in securing dilatation of the os uteri is recognized as a great one in parturition, and there is no reason why it should not be of same advantage in cases of this kind; very probable not so great as where the placenta does not occupy the inferior segment of the uterine cavity, but even if its utility as a dilator is somewhat impaired, especially in complete presentations, it is not so much impartial, and we should benefit all we can by it, and secure dilatation before permitting its rupture. If the rupture of the membranes is remembered as "the first thing to be done," we lose its influence in dilating the os uteri, its influence against internal hemorrhage, and do not know that we gain a single advantage instead; but when we have secured dilatation and the membranes can be reached at the margin of the placenta and punctured, the experience of the reporters in this collection coincides with the almost unanimous expression that the uterus is roused to action and vigor, and the presenting part so pressed upon the cervix as to stop entirely or effectually repress the hemorrhage, and delivery is soon terminated.

Although our collection does not conclusively demonstrate the fact, yet I believe we are justified from its study in concluding that the membranes should, in placenta previa, be ruptured but little if any earlier than in cases of ordinary labor.

Entire Detachment of the Placenta. -This practice was followed by some of the reporters in this collection, and in some cases the detachment was spontaneous. We have classed them together and present their analysis in the following table:

The placenta presentation was complete in every instance. The character of the hemorrhage is in about the same proportion as in the whole collection.

The mortality to the mother was very light. Three of those

died undelivered.

The mortality to the child was extremely large under each

condition.

The experience of this collection would not indorse the treatment as one of universal application in placenta previa, where any regards whatever are had for the welfare of the child; nor has it ever been recommended by anyone, not even its intense and enthusiastic advocate Simpson, as a treatment to be followed invariably, but as a measure applicable in certain cases in which too great risks attended other well-recognized methods of procedure. Whether or not the rules so explicitly given by Simpson were observed in determining upon this course of treatment in the cases here reported, we are unable to say, but our mortality was not so favorable as in the cases collected by him. The mortality in his

collection was seven per cent. of the mothers and sixty-nine per cent. of the children.

Some of the cases are not clearly reported, but the histories as given indicate a spontaneous detachment in many of them. "Spontaneous delivery of the placenta is more apt to occur in central presentations" is verified in our collections, for every case in the table had complete presentation. This is an example of nature's efforts to relieve herself of the abnormal position of the placenta, and one which it would be well to follow in many cases seriously threatening the life of the mother. In cases of spontaneous delivery of the placenta, the uterine contractions are active, with speedy dilatation of the os and rapid delivery of the child, which may be living, as in some of those cases, while in artificial detachment there may not be active contractions and speedy dilatation of the os; hence the result will not be so favorable to the child. But as regards the mother, it is not essential that delivery of the placenta should immediately follow its separation, if the flooding ceases, and time may then be allowed for the os to dilate, the patient to rally from the exhaustion, and labor to progress with a reasonable expectation that the mother may be saved.

Although not expressly stated in every case, the histories infer that the hemorrhage ceased in most of them after detachment of the placenta. The argument in reference to the hemorrhage being moderate or profuse in proportion to the number of cases of partial or complete presentations, which we will elucidate when discussing the tampon cases, if applied to these would show that detachment of the placenta exercised considerable influence over the amount of the hemorrhage, for in this table we had no cases of partial presentations yet had nine cases with moderate hemorrhages.

Entire detachment of the placenta should not be accepted as a general practice in placenta previa, but resorted to only under the circumstances that have been so ably given us as guides by Simpson, and even in some of these not always the most advisable, unless the individual circumstances of the case are of such gravity as to preclude all hope for the child and our whole attention be absorbed in efforts to save the mother.

Forceps. The use of the forceps has by many writers been recognized as of great value in cases of placenta previa, especially

to abridge the second stage of labor, but evidently it has not obtained general acceptance, for in the whole collection it was used in only ten cases, which are here tabulated:

The mortality to the mother is exceedingly heavy, except in the cases with moderate hemorrhage, and those having complete presentation, of which a large number had entire detachment of the placenta preceding the use of the forceps.

The mortality to the child was also very heavy, with the same exceptions as those of the mother.

The results shown in these few cases do not encourage us to hasten the delivery by forceps. Their use immediately after detachment and delivery of the placenta, as a means of saving the child, may be successful, as in a few cases reported.

For the introduction of the forceps we pass a part of the mother-the os and cervix uteri-that in those cases are abundantly supplied with blood vessels immediately under the recent attachments of the placenta, increasing the susceptibility to lacerations of the cervix uteri and dangers of subsequent hemorrhage, as septic poisoning and making their use more dangerous than in ordinary labors. We, therefore, venture to assert that the application of the forceps should be extremely limited in placenta previa, other circumstances than the position of the placenta determining as to the necessity of their use.

Tampon.-The tampon is one of the old treatments in placenta previa, and one that still retains a strong hold in the mind of obstetricians, as is shown by the large number of cases in which it