the child was subject to, its prematurity, and the difficult operative measures necessary for the delivery. (5) From the results of these two series of cases, private and hospital, we find that the balloon is very reliable in the management of placenta previa. The immediate danger of this complication for the mother is, of course, hemorrhage and it is our aim in the treatment of these cases to stop this bleeding as soon as possible. I believe that the cause of maternal death in placenta previa is the excessive hemorrhage only in neglected cases, but that most of the deaths are due to a ruptured uterus. Our statistics will substantiate this statement. In 59 cases of placenta previa of the hospital series there were 4 deaths of the mother,. one of these women was exsanguinated on admission, would not. respond to stimulation and intra-venous infusion, and died. The cause of death in the other 3 cases was a ruptured uterus. There is no doubt that the lower segment of the uterus is more friable at the site of placental attachment than when the placenta is normally placed, and when, in our eagerness to get down a foot or extract a child, the cervix is torn and the tear runs up into this tissue, there results a ruptured uterus with its accompanying shock and increased hemorrhage, which soon causes the death of the mother. This complication we fear more than anything else in the management of placenta previa, and to escape it many a child is lost. For after a foot has been brought through the cervix, controlling the bleeding, we wait for pains and softening of the cervix before extracting the child. From our statistics we learn that for marginal and partial placenta previa the modified Champetier de Ribes balloon acts in an ideal manner, and I believe that when we have more courage we will employ it in more cases of the complete variety. In both series I have reported but one such case. In this the mother was in extremis when admitted to the hospital, but reacted to an intravenous infusion while a bag was in the cervix, and was subsequently delivered successfully. Why do we recommend the use of a balloon in placenta previa ? Because it stops the hemorrhage and prepares the case for a delivery which will be more easily performed and in which less damage will be done to both mother and child. How does the balloon act to accomplish this? If the membranes are ruptured, the bag is simply inserted into the amniotic sac, and acts as a plug, pressing the separated portion of the placenta against the uterine wall. If the membranes are intact, or the placenta is over the os, there is probably some separation of this organ, but the bag presses against the open uterine sinuses. and the hemorrhage is in this way controlled. The balloon then lying in the cervix is an excellent tampon, although in some cases traction on the tube is necessary before the bleeding entirely stops. In placenta previa the bag accomplishes more than simply controlling the hemorrhage. It starts pains, softens and dilates the cervix, and prepares the way for an easier and less dangerous delivery, for, when the largest balloon comes through, the forceps can be readily applied or the hand can be introduced into the uterus, the child turned and extracted without difficulty. This is quite a different task from that of doing a Braxton-Hicks vercion through a tough undilated cervix. Finally, the child is more apt to survive by the use of the balloon in placenta previa. Take a case with a rigid cervix where a version is done at once. The hand is quickly forced through, of necessity tearing it, the membranes are ruptured, and the foot of the child grasped and brought down. In our haste we separate a considerable portion of the placenta, the cord may be dislodged, and to control the hemorrhage traction is made on the foot. What happens? The child, deprived of the required amount of oxygen, and considerably compressed, at once shows signs of asphyxia. We then have this problem to solve. Shall we extract the baby to save its life at the risk of increasing the cervical tears, which may involve the lower uterine segment or the broad ligament, or shall we wait, slowly dilating the cervix. If we take the former alternative, we may save the child, but we often lose it and the mother, too. If we adopt the latter plan, the child is certainly lost. I claim that we would not be placed so often in this predicament if the largest balloon had been used in the beginning, for, after this bag comes through the softened and dilated cervix, the version can be readily done, the child can be extracted at once, and the mother runs less risk by the operation. I might add here that for placenta previa the gauze tampon is an efficient adjuvant temporarily, when we have not the bags with us, or during the time required for getting ready for their introduction. In both series of placenta previa cases, in private and at the hospital, where the balloon was used, there was no maternal mortality. In the private series both the infants survived, and in the hospital cases only 22 per cent. of the babies were lost. This per centage is very low considering that four out of the nine babies were under eight months' gestation. My plea, therefore, in the care of placenta previa patients is to use a balloon as a preliminary measure in all possible cases. When, however, the cervix is soft and dilatable and the mother cannot stand the delay,-when the bag is unnecessary or inadvisable, then an accouchement forcé can be done at once. OBJECTIONS TO THE BALLOONS. (1) They may rupture the membranes. This happens rarely, and it makes little difference if they do. The fetus suffers some, but little, as the waters cannot all drain away. If the fluid does escape, the dilatation is rapid enough to do little harm. (2) They may separate the placenta-only in placenta previa. But the bag either arrests the hemorrhage on being filled or when traction is made on the tube. (3) They may increase the tension in the interior of the uterus. It is not great and no harm is ever done. It is not painful to the patient and never ruptures or weakens the uterus. (4) They may displace the presenting part. This is possible, but by slow distention of the bag and by watching the presenting part during the distention, we can keep it in place. This accident occurred occasionally in the above series but was easily rectified. It is more apt to occur in cases of flat pelves. (5) The cord may prolapse. For this to occur the cord must be long or loosely coiled about the neck. This accident has happened a few times, but so far as I have been able to learn, was not responsible in any of these cases for the baby's death. In my first article I reported a case where it was detected too late to save the child. It is a good rule to always examine carefully when a bag is expelled, for the cord may come down. If this does occur the proper management should be at once employed. (6) Sepsis. The balloons can be boiled. If the aseptic technique is correct there should be no infection. There were a few cases of sepsis reported in this article, but I cannot attribute this complication to the use of the balloon. CONCLUSIONS. I. The modified Champetier de Ribes balloon is the best artificial hydrostatic dilator of the cervix. 2. pains. The balloons are especially effective in dry labors to start 3. Labor, if prolonged and protracted from whatever cause, is hastened and in a large percentage of the cases terminates spontaneously after their use. 4. The balloon is the best and most certain method of inducing labor for all indications. 5. In eclampsia and in placenta previa the balloon has a field of usefulness which diminishes markedly maternal and fetal mortality. Sloane Series.-4,272 cases (September 1, 1899-September 1, 1903). Dry labors, 626 cases; bags employed, 48 cases. Protracted labors, 238 cases; bags employed, 50 cases; manual dilatation, 19 cases. Induction of labor, 147 cases; bags employed, III; bougie alone, 6; tampon of cervix alone, I; scarification vulva, 1; accouchement forcé, 28. Total number of bag cases, 209. Total number of manual dilatation cases, 73. Eclampsia.-65 cases; 14 post-partum; 3 spontaneous delivery; 6 bags alone used; 11 bags followed by version or forceps; 31 delivered by an accouchemert forcé. Deaths-mother, 7; II per cent. mortality. Causes of death-pulmonary embolus, I; ruptured uterus, 2; purulent peritonitis, I; hemorrhage hepatitis and toxemia, 3. Child, 32; 49 per cent., including all cases; nonviable children, 19; true mortality, 29 per cent. Placenta Previa.-61 cases; 7 delivered normally; in I, membranes ruptured; 4 delivered by breech extraction; 3 by forceps; 19 by version; in 10 balloons were used; 17 delivered by accouchement forcé. Deaths-mother, 4; 6 per cent. mortality. Causes of death-3, rupture of the uterus; I, hemorrhage (moribund on admission). Child, 23; 35 per cent. mortality; nonviable children, 4; real mortality, 29 per cent. Private Series.-200 cases; dry labors, 47 cases; bags employed in 4. Protracted labors, 19 cases; bags employed in 4. Induction of labor, 32 cases; bag employed in 29; bougie alone, 3. Placenta previa, 3 cases; bags employed in 2; accouchement forcé, I. Total number of bag cases, 39. Total number of manual dilatation cases, 15. Accouchement forcé, 3; eclampsia, 1; placenta previa, I; protracted labor, 1. Manual dilatation lightly, II. 159 WEST 59TH STREET. DURING ACCIDENTAL PERFORATION OF THE UTERUS CURETTAGE—A CASE WITH BOWEL INJURY AND RESECTION OF FOUR FEET OF SMALL INTESTINE.1 BY WILLIAM HESSERT, M.D., Surgeon to Cook County, German and St. Francis Hospitals (Evanston); THE literature relating to accidents during curettage dates back to the time of the first use of the curette by Récamier. From that time to the present, accidents of various kinds have been reported. The perforations were caused by any and all of the different instruments that are inserted into the uterine cavity. The accident either was followed by no ill effects or resulted in death. Between these two extremes all varieties are represented. Perforation of the uterus during curettage has occurred in the hands of experts. More frequently, probably, the accident has happened as the result of inexperience and carelessness. The expert recognizes at once the making of a false passage and institutes the proper treatment. The novice may remain forever in ignorance of what he has done or come to a horrible realization when he pulls out, not membranes, but gut. In spite of warning and teaching to the contrary, curettement is generally considered by the rank and file an innocent, simple and easy operation. It is said to belong to minor surgery, and every beginner performs it. Success in a number of cases may lull a man into a state of security and contempt for such a little operation, until suddenly he is brought to a proper realization by the mischief he has done. The object of this paper is to report a case of accidental perforation, to present a résumé of the literature and to call attention again to the danger that may lurk in a seemingly simple operation like the one in question. History of Case.-Mrs. B., age 46. Has had 6 children and several miscarriages; the last one a year ago required curetting. She was a hard-working woman, and her general health was fairly good. She had been a few months pregnant and again 'Read by invitation before the Chicago Gynecological Society, November 18, 1904. |