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WITH THREATENING UREMIC CONVULSIONS; RAPID MANUAL DILATATION OF THE OS UTERI • TURNING AND DELIVERY; RECOVERY.* to th« Montreal Di.penwry; an.l Consulting GynecologiBt to the Women's Hospital, Montreal. By permission of Dr. S. F. Wilson, of this citv, who called nie in consultation, I am allowed to report this case Mr? neaitn until her first pregnancy, eight vears atro when she t"?en%r"t"r' ^T"^''! convulsfons. ' She uSs'onry a^eS n omh? a)l ' h". ' Tl "''• ^': ""■''«^^'^""''" force It seven months, after having had convulsions everv week from the fourth month, m spite of treatment. She 'became pregnant mnnt^'f °"".^ "'"1^ "^"^ '^'' fi""^* of November anTf^ery month after that she had considerable hemorrhage without whln'sh; £h''"^J"'' ''"■ '''^^°' ""^'^ ^^"^ '^^ sSth month: uhen she had such a severe one that she sent for Dr Wilson etot toT * hT'"^ '^/'^^"'" P^^^''^ ^"^ P^'^'^^ «n'l ^aTe ergot to .top the hemorrhage until I could be sent for ren.nVinc!"^' 'Y"'''' ^^^ '''""^" '''^^ '" ^ ^'^O' Serious condition wK nr u -r """""'". .'"^^ 'hypodermics of strvchnine. nr M^^r^ °" ^^?^^°'"e: these things and his partner. Dr Morrison, was administering the anaesthetic, I was pre 'bdS"and'?h -'•'.?' '" ' ^" '"""""^ ^^-^'^ one hand on'^^^e ..Odomtn and the other m the uterus I had rapidiv dilated the cervix and caught a foot an.l brought it down without r^p! than ,t takes to ell it the six months foetus was delivered xam1nin"J it1.,r"" /I" ';'='""*^ ""'^-^'^- ^o'lo-ed and "n bv a Zk fin -l' T ''"'^ "^ I' *-■""'•' l'^' ^'■^^'^ t^' ''^- *^"vered become deinZ IK ';?^'"*^^P'^"*''"^' t" t'^" surface which had tJecome detached bv the first contractions. The hemorrhatre n-hich had been furious until 1 introduce,! nn Iian 1 "en edTo have^opped from that moment, and there was no ireding • Read liefore llie Clinicil So :iely "f (he Montreal Di pen<;.Tr> , f une, fqo2. * (ASK OK I'LAUKNTA I'KAEVIA. alter tlic extraction of the child, the uterus having then been able to contract enough to close the bleeding openings. The child died in halt" an hour and the mother, after running the gauntlet of the profound anaemia as well as the condition of the kidneys, gradually came back to life. She later developed a temperature and has now a pelvic abcess, probably a pus tube, which Dr. \\ ilson intends to have me open by the vagina and drain in the meantime, to be followed later, when her strength will bear it, by an abdominal incision. This was my third case of placenta previa and in view of the present ten- dency to perform so serious an operation as Caesarian section for the relief of the condition, it may be of interest to refer to the other two cases, both of which terminated in recovery of the mother. My first case occurred twenty-three years ago in a woman four months pregnant. This was just before Brax- ton Hicks had published his method ; so I did the best I could with the knowledge we then had at our disposal, which was to put the woman in the knee-chest position and tampon firmly the vagina. The result could not have been more satisfactory ; she did not lose a drop of blood after that ; and in eight hours I saw the woman safely delivered ; first the cylinder of tightly packed cotton, about four inches long, then about two inches of clot, then the placenta, which must have been centrally im- planted, for it fitted on the child's head like a Scotch bonnet, and then came the child ; all of them coming out in one piece, so to speak. This woman was up and cleaning offices in less than ten days. The next case was a woman near term who was suddenly taken with a terrible hemorrhage. On exami- nation the placenta was found to be centrally implanted. I was very ill at the time and had to hand the case over to Dr. Johnson, who summoned an expert, who immediately anaes- thetized the patient and turned and delivered. There was a gush of blood which flew across the room as he mtroduced his hand, but the moment he drew on the foot the bleeding stopped and did not return. This child was too asphvxiated by the mother's hemorrhage to live, but the mother made a good recovery. Judging from my knowledge of these three cases. I cannot sec how an\- one could justify himself in performing a Cae- sarian section, far less in comj)lete!y removing the tubes and ovaries with the uterus, as has reccntlv been so strongly ad- vocated by several obstetricians of the first rank. The' onlv possible excuse wliich they could give is that when Caesarian section i^ jierformed before the mother or child have been weakened by hemorrhage, the chances of the child should be CASE OF PLACENTA PRAl'VIA. 3 much better than by version ; but how are we to discover cases of placenta praevia before the hemorrhage begins ? Moreover, it is quite probable in my mind that if the child is viable it would have just as good a chance of surviving if delivered by version as when delivered by Caesarian section. While for the majority of cases the child does not count for anything, for the simple reason that it is already dead or that it is not pos- sible for it to live, no matter how it is delivered — while of the total removal of the uterus and appendages it is no excuse to say. as some of these authorities do, that the woman after having the case explained to her was quite willing that she might he rendered unable to have another pregnancy ; a woman in that condition is a very bad judge of the advantages o^ maternity. To the general practitioner who meets with this appalling hemorrhage, 1 would say "summon expert help immediately, antl while waiting for him to come, to control the hemorrhage for a few minutes by means of clean handker- chiefs soaked in vinegar packed in the vagina : but failing to ob- tain assistance promptly 1 would advise the rapid but thorough sterilizing of the hands and a ])artial anaesthetization of the patient by another doctor, or even by a neighbour, with the A. C. E. mixture and then to dilate the os with the fingers formed into a cone, so that they fill the os pretty thoroughly. As soon as the hand can be made to enter the uterus, grasp a foot with the right hand and assist the version by the left hand on the abdomen ; there will, as a rule, be no more hemorrhage after the soft plug formed by the child's thigh and buttock covers the bleeding sinuses." The cause of all the deaths of the mother, and they are not many under this method, and of many of the deaths of the viable child, are not due to the me- thod, but to the delay in employing it. and these conditions are as essential in Caesarian section for its success, br i as regards the mother and the child. Even in a primipara with the os closed it is invariably softened by the pregnant condition so that in twenty or thirty minutes at most first one and then two and then three fingers can be bored into the uterus until the constricting muscles arc tired out and the whole hand can be passed in. The hemorrhage almost alwa> s stops the moment the foot is drawn down. I would also like to say a few words about the other fea- ture of the first case above renorted, namely, the convulsions. I believe that more women have died from the remedies us 'al- ly employed than from the disease : T mean the prolonged use ot chloroform and chloral. Ry the hypodermic injection of half a grain of morphine followed in ten minutes by the hypo- s»ii»«fffri ■^■ast—rf CASE OK I'LAt'ENlA FKAEVlA , dermic injection of twenty-five minims of tincture of vera- trum viride, I have in my last three cases at once brought the pulse down from 160 to 50 or 60 and the woman had no con- vulsion later than ten minutes after. My former assistant, Dr. DeCotret, now director of the largest lying-in hospital in Canada, who introduced the veratrum treatment at my request, tells me that he has had thirty-eight cases of eclampsia with- out a death of a mother. 245 Bishop St., Montreal. .i^:.*«^f?