be repeated thirty to fifty times per minute. I have in several instances witnessed the good effect of applying cloths over the cardiac region wrung out of water as hot as could be borne by the hands. This was in cases of amputation after railroad injuries before reaction had fully set in, and when the pulse became much more feeble during the administration of chloroform. The immediate strengthening of the pulse was perceptible under the use of the hot applications. With some authorities the purity of chloroform is a great desideratum. It is claimed that it is safer, its action is more prompt and enduring, and it causes less bronchial secretion, cough, vomiting, and more regular respiration. It should be kept in colored bottles and exposed as little as possible to artificial light.

A CASE OF PLACENTA PRÆVIA, WITH PROLAPSE OF THE CORD.

By WM. FITCH CHENEY, B. L., M. D.,

Adjunct to the Chair of Obstetrics, Cooper Medical College, San Francisco. (Read before the San Francisco Gynecological Society.)

The following case, involving, as it did, one of the most serious accidents that can happen to woman in labor, and yet terminating in the perfect recovery of both mother and child, seems worthy of report in detail. It shows that even those conditions we are taught to regard as most alarming in obstetrics, fortunately do not always bring fatality with them.

Mrs. N., aged 30, a native of England, expected her confinement on Nov. 14th, her last period having come to an end on Feb. 8th. The woman had previously given birth to two boys,. while residing in an Eastern State, one on Sept. 24th, 1888, and the other on October 11th, 1889, barely a year apart. The perineum had been torn with the first child, and not repaired; otherwise, both labors had been normal. The patient was thin and pale, had suffered much from leucorrhea and from pain in the back and loins since birth of her last child, and showed a poor condition of nutrition and general health. Examination revealed a laceration of the perineum half-way to the rectum, a bilateral laceration of the cervix and a retroversion and prolapse of the uterus.

In the middle of April, about two months after the cessation of the menses, while the patient was busy with her household

duties, she had a sudden gush of blood from the vagina, losing, she estimated, about a pint. She at once lay down and kept quiet the rest of that day, and had no more hemorrhage, although a little color continued to show itself for two days afterward. Nothing further occurred until May 22nd, when a few spots of blood appeared again on her napkin during the day; but this time there was no hemorrhage of consequence. On Oct. 13th, Mrs. N. was again disturbed by the occurrence of frequent but feeble uterine pains, which she feared would lead to premature labor. But there was no color to the vaginal discharge, examination showed no dilatation of the os, and a mixture containing viburnum prunifolium soon quieted the uterine contractions. Finally, on the morning of Nov. 13th, I was called again to this case. On my arrival I was told that pains had set in the evening before, though feeble and irregular. About two o'clock in the morning, while out of bed on the vessel, passing her water, the patient was surprised by the expulsion from the vagina of a blood-clot, the size of two fists, followed at once by a discharge of bright red blood, enough to fill an ordinary washbowl. A fainting spell ensued, and she had to be lifted back into bed by her husband. The bleeding soon stopped, but vio·lent pains came on which lasted for an hour or more, gradually dying away again toward the time at which I was summoned.

At 8 A. м., when I saw the patient, her pulse was 80 and as strong as ever on previous occasions when I had counted it. There had been no more bleeding since the time mentioned. Pains were quite mild and occurred at intervals of fifteen minutes. There was no elevation of temperature. On external examination, the foetal heart-sounds were found two inches above and one inch to the left of the umbilicus; they were 140 per minute, strong and distinct. This position of the heart-beat led me at first to believe the case one of breech presentation. On internal examination, however, I found the cervix unusually soft and infiltrated; the os would admit but one finger, and this came in contact in all directions with a yielding mass, and not with any part of the foetus. But on the right side of the os, by pushing the finger still higher, I was able to get past this mass, and, to my surprise, found the child's head presenting. The membranes were not ruptured.

Taking into consideration the patient's history during her

pregnancy, and her hemorrhage of the night before, there seemed no doubt that the mass filling up the cervix was the abnormally situated placenta. This crowded the foetus toward the fundus, and caused its heart sounds to be heard above the umbilicus, even though the head presented. The mass extended clear across the os uteri. Probably in the beginning it had its lower edge attached to the right side, and it was the tearing away of this attachment, as the uterus dilated, that caused the hemorrhage. At any rate, the examining finger had to push aside the placenta to the left and crowd past it, in order to reach the presenting vertex.

The state of affairs once discovered, the treatment was entirely expectant. The woman was kept quiet in bed and under constant watch. During the day the pulse remained about 80 and fairly strong; no more hemorrhage occurred; and there was no unusual pain-on the contrary, the irregularly occurring contractions were too feeble to accomplish much. Thus there seemed nothing in the patient's condition to warrant active interference; but everything was made ready to meet an emergency, should it arise. In anticipation of another hemorrhage, iodoform gauze and the necessary instruments were kept at hand to tampon the vagina at a moment's notice.

The feeble pains effected but little change in the os during the day. Realizing that danger was always pre sent while the child's head remained so high, and that very little advance was being made, at 6 P. M. I asked Dr. Henry Gibbons, Jr., to see the case with me. He suggested the propriety of artificially rupturing the membranes to increase the force and frequency of the pains. Shortly after his departure from the house, I acted on his suggestion and ruptured the membranes during a pain. Only a few ounces of liquor amnii escaped. This had the effect desired; but it had another effect that was certainly not desired, and had not been anticipated: the next few pains brought down into the vagina numerous coils of the umbilical cord.

Every effort was now directed to the restoration of the cord to its proper place. The woman was turned on her elbows and knees, and with two fingers in the vagina, the slippery coils were gradually pushed back inside the os; but with the next pain they were all out again, and even more of them than before. The struggle to replace the cord was kept up for over an hour, the strong and frequent pains that had come on since rupture

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of the membranes undoing very quickly the work that was performed between them. It was very much like the attempt to return prolapsed intestines through an abdominal incision, when the patient is straining and retching. Postures of all sorts were tried, as aids to the replacement. A repositor was also devised, from a catheter and piece of cord, but after comple tion this refused to work; I had doubt as to its value, after all, when so large an amount of cord had prolapsed.

At last I summoned Dr. Gibbons again to my aid. The pulsations of the cord had in the meantime been carefully watched, And though they had grown feeble, they had never ceased. Dr. Gibbons was of the opinion that manual reposition, with posture, offered the best hope of success; but the two fingers in the vagina had so long proved powerless against the strong contractions from above, that we decided to administer chloroform, to relax the parts, while he introduced the entire hand into the vagina. This was accordingly done, while the woman was kept on her elbows and knees. In this way it was possible to carry the cord much higher, past the child's head; and after this was once accomplished, the mass was grasped by another hand from the outside, through the abdominal wall, and retained in its proper place. It was a wonderful piece of good fortune, that the cord, after being prolapsed for fully three hours, still continued to pulsate; but the foetal heart sounds after reposition were perfectly distinct. Tarnier forceps had been made ready, to extract the child at once, if the cord would not remain in place; but after holding it up for nearly an hour, with one hand at the cervix and the other keeping the coils above the foetal head, there was no further prolapse.

The subsequent progress of labor was exasperatingly slow. Repeated examinations showed no advance of the head, and but slight additional dilatation of the os, though the cervix grew steadily softer and more dilatable. The advisability of using forceps was more than once considered during the night, but still there was no absolute indication for such interference. The pulse continued good, the patient was not exhausted, the uterine contractions were regular and forcible, and the foetal heartsounds still clearly perceptible. The patient suffered much at this time, referring all of her pain to the left iliac region, where the child, no doubt, was endeavoring to crowd the placenta aside, to make a way for itself into the world; but suffering is

not an indication for forceps, so long as it shows no effects on the heart's action and is accompanied by good contractions. And so each time that forceps were considered, it was concluded to wait.

At last, at 4 A. M., Nov. 14th, the head suddenly escaped through the cervix; and fifteen minutes later, as a reward for patient waiting, the child was born unaided. The position was right occiput anterior. The child was slightly asphyxiated, but was soon revived by Sylvester's method. It was a boy, and weighed eight pounds. The placenta followed five minutes afterwards and the uterus promptly contracted, without more than the ordinary blood loss. There was nothing unusual about the placenta, as regards size or thickness; and the cord was centrally implanted. The mother made an uninterrupted recovery, without a temperature at any time above 99°, getting up out of bed on the eleventh day. The child was cyanosed for the first twenty-four hours after birth, but this gradually wore away entirely.

The condition present in this case was undoubtedly that described in the text-books as partial placenta prævia; the placenta not only came down to the os, but overlapped it. And in the beginning, before dilatation had begun, the small segment overlapping the os probably had attachment on the opposite side, completely covering the outlet.

Of the causes usually assigned for the condition, several were present here. Lusk and Parvin state that placenta prævia occurs six times more frequently in multiparæ than in primiparæ; and this woman was a multipara. Winckel says that women who have borne children in rapid succession seem to be especially predisposed; and this woman had had her two previous children barely a year apart. Spiegelberg maintains that placenta prævia occurs more frequently in poor women than in those in better circumstances, owing to insufficient rest after childbirth, with consequent subinvolution. This patient certainly belonged to the poorer class, and her condition when first examined—the lacerated perineum and prolapsed and retroverted uterus-gave reason to believe that subinvolution as well was present in her case; while her history of constant leucorrhoea since birth of the last child speaks for a co-existing chronic catarrh of the uterus. These different causes lead to placenta prævia by producing enlargement of the cavity of the uterus, relaxation of its