Bumm's theory seems to be simple and to apply to all forms: the ovum arrested at the lower segement, perhaps at the inner os, in a uterus with only a capillary lumen and with its anterior and posterior walls in contact, gives rise to a placentation which may involve the entire lower segment and lead to the various forms of central, lateral, and marginal placenta previa. Others maintain the cause lies in the ovum itself, whose embedding depends upon a definite stage of development and that the ovum implanted itself wherever it happened to be when this stage is reached; that normally this period requires five to seven days after fecundation and that generally at this time the ovum has reached the upper uterine segment; that disharmony in the relations of maturity and wandering of the ovum causes dystopic implantation and that if the ovum reaches the uterus unprepared for embedding, it wanders till arrested at the lower segment. Whatever the cause or causes may be, clinically it generally is observed in multiparæ who have had a number of pregnancies and frequently in rapid succession; in those who exhibit endometritis or subinvolution of the uterus from any cause. The placenta previa is frequently thinner and more widely spread than usual, adhesions are frequently strong, requiring manual interference in the removal of the placenta and postpartum hemorrhage is common because the thin lower uterine segment is unable to contract firmly upon the bleeding vessels. The source of the bleeding is always maternal and for the most part from the uterine wall, although we admit the possibility of some fetal hemorrhage if the placenta has been broken up by manual interference. The clotting in the detached portion of the placenta often prevents the continuous loss of blood from the placenta itself, which we might expect to flow constantly, because of the free communication of the maternal blood spaces throughout the whole placenta. While the amount of bleeding in the central previas is generally the most severe, it may be very mild, whereas the partial variety may cause the most profuse hemorrhage; it is a wise policy to consider as dangerous any bleeding from a placenta previa, for while in the beginning it may be slight and soon cease, it may later return with severity, and it must be remembered that small repeated hemorrhages are just as grave as the profuse variety. As a rule, bleeding in placenta previa does not manifest itself before the seventh month of gestation, and when it is found at an earlier date, it is not particularly dangerous, not one of the numerous cases reported by Müller having died when hemorrhage occurred before the seventh month; however, an occasional death has been reported by other observers at an earlier stage; there can be no doubt that many abortions in the earlier months are caused by placenta previa. Bleeding in the later months of pregnancy is the only subjective sign of the abnormality and the diagnosis must be made by a vaginal examination under anesthesia, if necessary inserting the finger within the internal os to feel the gritty placental surface. Too much reliance must not be placed upon the boggy feeling of the lower uterine segment, nor upon increased pulsation of the vessels in this locality, and it must be remembered that organized blood clots in the cervical canal may simulate placental tissue. The condition of placenta previa is potentially so grave that once the diagnosis is made, labor should be induced directly. For the prognosis in great part is dependent upon the patient's condition before operative measures are instituted, as one who has had repeated or profuse hemorrhages is in such a devitalized condition that in many cases no form of treatment will prove satisfactory. The treatment of placenta previa depends upon the condition of the cervix and the amount of hemorrhage. With a rigid cervix-a circumstance uncommonly found with placenta previa-admitting only one finger, with moderate or profuse bleeding, a vaginal tampon of gauze well packed in the fornices with considerable pressure, is strongly recommended by the authorities of the Rotunda in Dublin. However, as the cervix dilates and further separation of the placenta takes place, the tampon will not suffice in many cases to stop the bleeding and recourse must be had to other methods. It has been observed clinically in many cases that mere rupture of the membranes causes the bleeding to cease, due probably to the fact that when the liquor amnii is drained away, retraction of the muscle wall presses the torn vessels and allows the placenta to recede with the cervix and the presenting part to compress the bleeding vessels of the uterine wall; therefore, as soon as the cervix permits, the finger should be introduced and the membranes ruptured, or if the central previa be present and the bleeding not profuse, it should be perforated; the combination of drainage of the amniotic fluid preceded by vaginal tampon has proved very satisfactory, especially in the partial variety. When the hemorrhage is severe and the cervix admits two or more fingers, the best results, as far as the mother is concerned, are obtained by the performance of Braxton Hicks' or internal podalic version, using the child's thigh and buttocks as a tampon. This method gives a high fetal mortality of about 60 per cent., but the maternal is reduced to about 3 to 6 per cent. In this relation it is important to emphasize the necessity of the slow extraction of the child after the foot has been brought down; for if rapid delivery be attempted with an incompletely dilated cervix, rupture of the lower uterine segment with the attendant mortality will deprive the method of all its advantages. To diminish the fetal mortality, various other forms of treatment have been used, as the introduction of the Champetier de Ribes bag after the membranes have been ruptured, manual dilatation of the cervix and accouchement forcé, the performance of vaginal and the various forms of abdominal Caserean section, and in Europe the use of the Bossi dilator. In regard to the use of bags, there seems to be some diversity of opinion as to their power of reducing the child's death rate, Pinard and Zimmermann reducing the fetal mortality to 31 and 36 per cent. respectively, with no increase in maternal, while Hofmeier and others deny any improvement with the method. It would seem, however, that in proper hands the use of Champetier's bag should be encouraged in the hope of lowering the fearful fetal mortality, and in those cases where after rupture of the membranes bleeding still continues, and we fear the danger to the mother in a version. The manual dilatation of the cervix followed by immediate extraction of the child has, at the hands of certain men, given excellent results both for mother and child, Meuleman of Amsterdam in forty-five cases giving a fetal mortality of only 15 1/2 per cent. and a maternal of 4 1/2 per cent. With a soft cervix and inconsiderable bleeding and with a competent operator this method should be encouraged, but if the cervix does not dilate easily, it is a dangerous method especially for the mother. The use of the Bossi dilator in placenta previa is not looked upon with favor in this country. Vaginal Cesarean section for placenta previa has been condemned generally by obstetricians, and the published reports on this procedure are not very encouraging; however, I have seen rare cases where the operation has seemed to be indicated, e.g., a live child at or very near full term, a pelvis of ample proportions, a cervix which does not easily admit of dilatation, in a patient with a central or partial placenta previa, who has lost but little blood and who is bleeding but slightly at the time of examination; in such a case the technical difficulties at the time of operation would not be great, and the result for mother and child would probably be satisfactory; however, we do not often find a combination of circumstances such as we have described. In regard to abdominal Cesarean section, including the Porro, the extraperitoneal and intraperitoneal operations, there is considerable divergence of opinion, many good authorities stating that the operation is seldom indicated and then the predominating idea is to rescue the child. When we consider how many children are premature when the placenta previa is recognized, and how many mothers have bled profusely before coming under observation at the hospital and are in no condition to withstand the shock of a Cesarean section, when we appreciated the chances of infection having taken place and our inability to always have a proper technical environment, the field for Cesarean section certainly becomes limited. However, under proper surroundings with efficient help, an uninfected uterus, with a live child at term, and especially if the size of the pelvis would seem to indicate a tardy delivery, when the cervix is not easily dilatable in a mother who has not bled profusely and in whom the bleeding may be controlled by a vaginal tampon, with a central placenta previa, Cesarean section is the operation of choice. In the class of cases I mention the mortality from Cesarean section should be no greater than the same operation for other conditions, and that is as low as the least mortality for nonoperative measures in placenta previa, and in addition we may save nearly all the children. To avoid loss of blood and to take care of a possible uterine infection, the Porro operation was recommended by Lawson Tait in 1898 and by Gillette in 1901 and by numerous others since. The perusal of the mortality records for placenta previa, especially the central variety, is not a pleasant task, particularly in regard to the child, and the results obtained are dependent upon the age of pregnancy, the condition of the mother when first seen, upon the method of treatment and upon the skill and good fortune of the obstetrician. 59 WEST FIFTY-FOURTH STREET. SHOULD ECLAMPTIC MOTHERS NURSE THEIR NEW-BORN? BY JAMES R. GOODALL, B. A., M. D., C. M., Assistant Gynecologist and Gynecological Pathologist to the Royal Victoria Hospital, WITHIN the last few years several pathetic cases have come under my notice, the sincere consideration of which has led me to endeavor to find a satisfactory answer to the title of this paper, Should eclamptic mothers nurse their new-born? The question considered from the point of view of the interests of the child is a new one, one upon which nothing has been written and upon which little if any discussion at all has taken place. My cases are three in number, where healthy infants, or seemingly healthy infants, evinced no signs whatsoever of disease until the first copious nursing, when they suddenly died without apparent cause. These children died a death so similar in its antecedents that we are compelled to think that their exitus was from a common cause. They were well, even in vigorous health, until two hours after a copious nursing, and they were so insidiously and rapidly taken ill that it was easy to see that there was no chance of recovery, even though seen in the early stage of the onset. Let me describe the cases in full and later consider some of the broader questions dealing with the effects of eclampsia upon both the mother and her offspring. I am writing of these cases, not in the spirit of the man who feels that when he has completed his report the last word will have been said upon so weighty a matter, but rather in the spirit of the man who seeks after knowledge, with an open mind, hoping that his lines may draw forth evidence from other sources either to corroborate or refute his conclusions. CASE I. The first case was a near relative, a young woman of thirty-five years, mother of three children, and a more healthy specimen of womanhood one seldom sees. She was delivered at full term of a strong, healthy infant, which cried lustily immediately after birth. According to the physician's statement, and this is fully corroborated by statements of near relatives, the patient had shown no signs of eclamptism either before or after delivery. The labor was easy and free from instrumentation. I |