means at hand for exciting uterine contraction are manipulations and kneading the uterine body by the hand over the fundus through the abdominal walls. This manipulation should be of such a character as to irritate and stimulate as much of the uterine body in as general a way as possible: the stimula tion should not be confined to any particular spot when the inertia is general by one or two fingers, but all the surface that can be should be impressed by the whole hand; the manipulation should be decided and positive. Hands off the cord. This failing, two fingers should be inserted in the vagina resting upon and supporting the anterior wall of the body, elevating the uterus, thereby getting a better control and more general influence over the entire organ. This failing fluid extract ergot in 5cc doses should be administered by the mouth, still persisting in our manipulation. There are very few cases which will not safely and properly respond to this method. If the inertia persists in spite of these efforts the hot douche (vaginal) or electricity are to be utilized. If the delivery is accomplished before the use of the ergot, ergot should be given to insure against relaxation and promote involution.

If all these fail, which is not at all probable, "watch and wait" and work is the inflexible law. In the work must be embodied judgment; that the aid rendered does not overstep the border of necessary, into the domain of meddlesome midwifery.

As soon as inertia disappears and contraction appears we are then placed in a position demanding the application of different principles.

Second, uterine inertia with hemorrhage. Here the degree of hemorrhage for the moment may modify our action. The conditions in this case are those of life and death to the patient. The responsibility of the physician is of the greatest, and there must be no hesitancy or procrastination of thought, judgment or action. It is a demand on the physician of the moment, and if he is not fortified by clear, concise and correct principles of action the result can be lamentable. In

other words the case demands a scientific application of a thorough and systematic knowledge of the subject. By scientific applica. tion I mean the application according to the laws and principles of science. By science I mean the application of experience to the conditions present, based upon a uniform or der of things in nature, on the assumption that such order will persist. In the conditions of the second case what then must we do. Those cases of slight bleeding in which the inertia is of a moderate degree and in which moderate relaxation follows contraction in rythmical order, can and should be met with those methods detailed above for the first class; save with this exception that I believe on account of the presence of the hemorrhage and the extradanger attending, the ergot should be at once given. The reason for this is that there being already more or less separation of the placenta, every manipulation is more apt to still further separate the secundines; the tendency toward continuous contraction that ergot has the power of generating is eminently fit and proper, and its use is based upon scientific principles, as we hope to show further on. The only delay therefore we are justified in then in this state of affairs, is that attending the immediate use of ergot and execution of the method detailed above.

Where the hemorrhage is pronounced and the inertia also, the scene changes. Full doses of ergot (5cc) at once, frequently repeated, vigorous, strong manipulation of the uterine body through the abdominal walls,introduction of the hand into the uterine cavity, and a complete, clean and entire immediate delivery of the placenta and membranes is absolutely demanded. After this persistence in the foregoing methods and the addition of the hot douche, electricity, hot vinegar, all of them intra-uterine, if necessary, followed by stronger but less desirable styptics should they be demanded. As regards violence in the action, if it is meant by this strength, vigor and effectiveness, it is necessary; if rupture of perineum, vagina, cervix or uterus is meant we do not want it.

I have no doubt in the above I am not only at variance with Prof. Pajot but also with many others; yet, for all that, I think the position assumed can be scientifically sustained, and is, therefore, correct.

Correctness from an individual experience is not enough; it must be from the experience of the many, and the many must be competent to judge.

We all know and are familiar with the following facts: That when the uterus is perfectly contracted after delivery of the secundines, hemorrhage from the placental site is impossible. That the smaller size the uterine body can be got to assume the better is the degree of contraction; that the presence of any body in the cavity of the uterus occupies room or space in proportion to its size; that the presence in the cavity of this body prevents the uterus from assuming the smallest size possible, and therefore the degree of contraction, while it may be of equal power, is not of equal advantage in power and quality; that the removal of the body from the cavity will produce the most favorable conditions for the uterus to assume the most advantageous state. We furthermore all know that involuntary muscle is the structure that enables the uterus to assume the proper state to control hemorrhage. We know the laws of contraction of involuntary muscular fiber, the influence of mechanical irritation, the conditions that result in fatigue of the same, the state of moderate contraction which the fiber is in while at rest. familiar with the influence of venous blood compared with arterial, the former being the excitant of growth and secretion, the latter of function, energy and power. The foregoing facts and phenomena we all know by experience are characterized by uniformity in nature. Wherever we find them they are always the same, and they therefore become to us rules and laws of nature. Those who have had the experience know the prompt and almost universal manner in which the uterus responds to the use of ergot. To further strengthen this knowledge we know its action is uniform over all tissue which contains the

We are

same character of muscular fiber as the uterus. Again, this same class of persons know that mechanical irritation of this peculiar muscular fiber is almost universally followed by contraction, the degree of irritation within certain limits producing proportional degrees of contraction. Again, we know that irritation applied both externally and internally on the uterus is a much more powerful stimulation than externally alone; that almost invariably whenever the hand is introduced into the puerperal uterus the response is prompt and vigorous, the same rule holding good here as regards degree of irritation as else. where. Experience of many has also established the fact that in retained secundines the best thing to do is to remove everything clean and entire, so that the uterus can assume the most favorable condition, namely, small size, rest of its elements, an assured supply of arterial blood, relief from venous, thereby insuring function and vigor, and an absence of anything within, thereby avoiding fatigue. We see, therefore, the same uniformity in nature, also based upon the experience of the many. Again, we all find that there are some exceptions to this uniformity in nature, and that they are most generally due to uniform causes. We also find that a knowledge of these exceptions, or rather a knowledge that they are going to present themselves, we do not possess, and that this ignorance is absolutely uniform to all persons. Therefore experience of this ignorance is scientifically established. If these exceptions of the uniformity of nature are so occult for us that the application of our experience with them to the new conditions presented (the exceptions), based upon our knowledge of what they should be, is of no avail in preventing their occurrence (which is a fact), we certainly, in the absence of this foresight, are only to be commended in following the dictates of our experience with the uniform order of things, and letting the exceptions take care of themselves.

Having presented to us then all the foregoing experience, uniform action and phenomena in nature of them, the almost uniform result

of applied means of relief, and the uniform want of power to foresee the exceptions, it seems but a rational conclusion to say that in retained placenta with hemorrhage, the following method of treatment is scientifically proper and correct:

In slight hemorrhage with moderate inertia manifest by moderate relaxation and contraction in rythmical order, ergot should be given at once, combined with the methods used in inertia without hemorrhage.

are the following: a wave-like or peristaltic contraction affecting a part or the whole or gan; the sectional contraction, in which the contraction may pervade more or less of the entire organ,with relaxation of the rest at the same moment; the clasified hour-glass contrac tion. The first form is readily recognized through the abdominal walls by the hand; the sensation is like that of feeling a bag of moving worms. The second form is determined by feeling a lump or projection of soft doughy

In pronounced inertia with pronounced hemorrhage, full doses of ergot (5 cc), frequently repeated, by mouth, hypodermically if possibly, persistent, vigorous and strong manipulations of uterine body through abdominal walls, introduction of the hand into cavity of uterus, and complete, clean and entire immediate delivery of secundines; after this, if necessary, the intra-uterine use of hot antiseptic douche, ice, electricity, hot vinegar, followed by stronger but less desirable styptics, if demanded.

The condition of inertia with organic union of placenta with no separation cannot be discussed under the head of inertia, because we are not justified in making the examination necessary to determine the fact of union until contractions have been established, which state of affairs carries us into one of the last two divisions of the subject. Where he morrhage is present the treatment is to be governed by the rules laid down under inertia with hemorrhage, and here we are able to determine the question of organic union only after we have reached the point when it is necessary to introduce the hand into the uterine cavity.

The only division that now remains of the subject is faulty or irregular uterine contraction. Some writers prefer to place this state of affairs under the head of inertia. While this may be true in part, I think it more properly should be considered under a distinct head. The inertia, if it exists at all, is localized as regards the entire uterus. Those forms that have come under our observation

wall of the uterus; save its consistence, it resemblance a fibroid nodule; it is generally lo cated at the cornua or lower segment of the uterus.

It will be observed also that as soon as these doughy lumps contract the placents is simultaneously started and soon expelled. The third form is generally perceived by an intra-cervical examination, except when it is at the fundus and at an angle to the vertical axis of the uterus.

The practice that should govern us in these conditions, when the placenta is retained, as it most usually is, differs but little from those previously considered, and the presence or absence of hemorrhage is the determining fac tor; when there is no hemorrhage-kneading and stimulation of the uterine body by the hand on the abdomen. In the first form the stimulation should be as general as possible, and this demands the support and elevation of the uterus by two fingers in the vagina.

The second form, sectional contraction, the stimulant should be applied at the relaxed part. The third form, hour glass or strictural contraction, demands more extended mention. Until hemorrhage should supervene we are justified in resorting to the or dinary means of stimulation, kneading, etc., for a reasonable time. If the patient is wor ried mentally or physically by our efforts and the mess she is more or less contaminated with, I consider it perfectly proper and better to introduce the hand, dilate the stricture and deliver; if such is not the case, and she seems indifferent, there is no reason for immediate action nor delay. In fact this is one state of

affairs where do as you please is perfectly legitimate. If an urgent case awaits you, deliver; if not and you are tired, delay and rest, but do not let go of the uterus.

Where hemorrhage is present the amount of it modifies the practice, as in inertia with hemorrhage, and the same means are to be resorted to.

Ergot is demanded as before, and the time of and quantity for administration are determined by the same rules and principles as in inertia with hemorrhage.

[TO BE CONTINUED.]

SEVERAL ITEMS OF OBSTETRICAL INTEREST.

BY JOHN BARTLETT, M. D.

Read before the Gynecological Society, of Chicago, June 24, 1887.

I. Some twenty-five years ago, as well as my memory serves me, the question began to be mooted whether quinine were an abortifacient and oxytocic or not. Prior to 1862, so far as I am aware, preparations of cinchona were given to pregnant women freely and without any suspicion that harm might result therefrom. To-day the profession is divided in opinion on this subject; some scrupulously withholding quinine from the pregnant woman, others giving it without reserve. In the course of my reading, I have chanced upon

an observation of Mauriceau's which indicates

that two years prior to Sydenham's notice of the bark, this obstetrician had sought an answer to the query in question. I quote: Obs. CCLXXII: "On the 28th of October, 1680, I delivered a woman who had had during a period of fifteen days three or four violent accessions of tertian ague, which obliged me, after a bleeding from the arm to administer cinchona. By the use of this remedy the fever entirely ceased. After having continued in good health for ten or twelve days, she was happily delivered of a large healthy boy. This experience caused me to recognize a fact, which has since been confirmed by a number of similar cases, to wit, that pregnant

women can take cinchona with the same benefit as other persons, without its occasioning any injury to the mother or child.

I cannot but regard it as a curious and interesting fact that a question as to the specific action of a medicine put forth in 1680 should be adhuc sub judice.

II. Last year I reported to this Society a case of placenta previa in which the placental tissue extended over the entire ovum. Cases have been reported by Sirelius, Barnes, Hegar, Hicks, and Judell in which placenta have been so spread out as to occupy nearly the whole of the internal surface of the uterus.

In connection with this subject, I call your attention to the following observation of La Motte's

Observation CCCCI.-"The twenty-second of July, 1717, Dr. Ducet sent to desire me to go to a farmer's wife, two leagues off, who had been in labor ten days and ten nights, during which time she had not the least rest." (La Motte here proceeds to describe how he delivered by turning, and continues:) "I had a great deal of trouble in bringing away the placenta, which was not one-third so thick as usual, but merely membranous, of about the thickness of a child's diaphram; it not only adhered to the bottom of the uterus, but to its whole circumference; so that a young practitioner would hardly have believed that any placenta at all was left behind."

III. In Charpentier's treatise on obstetrics, we find the following list of authors who admit that in certain cases of placenta previa it is possible that the placenta find attachment within the neck of the uterus; Sirelius, Barnos, Thudicum, Chavanne, Marchal, Thévenot, Keppler, Pajusko, Rokitansky, Sackreuter; Mettenheimer, LaChapelle, Pinard, Tarnier, Hubert, and Noël.

I desire to prefix to this list the name of Andre Levret. From his work, "L'Art des Accouchment," I extract the following passage from his paper on Placenta Previa, published at Paris in 1751.

Page 373: "An interesting question naturally arises in this connection: Why some

women having the placenta adherent in the neck proper of the uterus arrive at term, whilst others, by far the majority, under the same conditions, do not reach the normal limit of gestation?

This variation in effects proceeding from the same cause must depend upon some particular circumstances as a determining cause. I explain the matter in this way. According as the placenta is primarily attached higher or lower in the neck proper of the uterus, hemorrhage will occur earlier or later. Thus when that vascular mass has taken root nearer to the os tincæ, the woman will be able to approach nearer to the term of gestation than if it had been implanted as high as the constriction (internal orifice) of the uterine neck. And thus the time of interruption of the pregnancy by bleeding will vary with the level of attachment of the placenta between the two extremities of the neck. It is demonstrated as well by the mechanism of pregnancy as by the daily experience of the accoucheur, that the neck does not begin to expand to aid in augmenting the capacity of the cavity of the uterus except in the later months of gestation; and that it is by segment after segment that the cervix continues thereafter to expand from above downwards. Now, the neck cannot thus expand without sooner or later obleging the placenta, which is not susceptible of like expansion, to detach itself in part, either in some point of its circumference if it be more advanced upward on one side than the other, or at its center if this be in exact correspondence with the upper end of the cervical canal. It follows then as a necessity that a hemorrhage shall occur at a time more or less near, or more or less distant from the natural term of pregnancy, according as the placenta shall be attached further from or nearer to the [lower orifice of the] central

canal."

IV. In the text-books on midwifery, the credit of first suggesting abdominal section as a mode of treatment of the rupture of the cyst in abdominal pregnancy is generally given to Osiander and Heim. In Levret's

work on obstetrics may be found the following sentences. His appreciation of the difficulty incident to the detachment of the placenta in such a proceeding is complimentary to his foresight and sagacity.

"In extrauterine pregnancy, the fetus inclosed in the Fallopian tube or ovary ordinarily bursts its envelopes before full term, and the mother perishes of hemorrhage with her infant in her abdomen. This sad accident seems to indicate abdominal section, but I doubt very much whether an operation would succeed in saving the mother, even if there were present sufficient symptoms to enable one to decide promptly, upon an operation. Because, it would be necessary, in order to hope for success, that the site of attachment of the placenta should have power, such as the womb has, to contract very powerfully and quickly; and that is an impossibility."

V. Some writer has said that, after inventing an instrument, the first thing that one meets is an objection. It is objected to the Tarnier direct-traction forceps that the screw by which the handles are approximated so as to take hold of the head may exercise a dangerous compression. My object in this communication is to show that such compression need not be made, and that the screw does not therefore constitute on objection to the instrument.

I beg leave here to quote from Dr. Barnes: He says: "Let us study the power of the forceps How does it take hold? You may at first sight suppose that this is accomplished by grasping the handles. The hold, especially in shorthandled forceps, cannot be due to the handles. It is really due to the curvature of the blades, which fit more or less accurately upon the globular head, and the compression of the bows of the blades against the soft parts of the mother, supported by the bony ring of the pelvis. In many cases, this outward pressure upon the bows of the blades is enough to serve for traction. It is not necessary to tie the handles of the