T R A N S A C T I O N S OF T H E U L S T E R M E D I C A L SOCIETY.

SESSION 1883-84.

President--PROFESSOR DILL, M.D. Hon. Secretary--WiLLiAM G. MAcKENzIE, L.R.C.P. & S. Edin.

PROFESSOR DILL in the Chair.

Brie f Observations on the I~arl?/ and Forcible Dila2ation o f the Os Uteri, as a more Successful Method of Treatment in "Placenta Prcevia." Il lustrated by an unique case, at which Drs. Kevin and J. C. Smyth assisted. By Dr. JAMES SYIITII (Shankhill Road).

MR. PRESIDENT AND GENTLEMEN',

Permit me, before proceeding to read the few notes I have written out on the subject of "p lacenta pr~evia," or "p lacenta l presentations," to offer some apology for again obtruding myself so soon on this Society. Indeed I had no intention of occupying any of your valuable time on the present occasion, had it not been for the importunities of your energetic Secretary, Dr. MacKenzie, who insisted on my hunting up an obstetric case which might add a little variety, and~ perhaps, some interest, to his programme for to-night. Moreover, he intimated to me that this would probably be the last meeting of the Session, and used other persuasive arguments which left me no alternative but to comply- - hence my presence here as a contributor this evening. I have chosen this subject (placenta pr~evia) for three reasons - -v iz , 1st. Because my brief observations may serve as an appendix to Professor Dill 's remarks on the same subject made here, I understand, on the last night of meeting. 2rid. Because I was assisted in the case by two members of this Society, who will likely have something to say on the merits or demerits of the operation. 3rd. Because the plan of treatment and mode of delivery differ somewhat from the usual methods. I consider it unnecessary to waste your time discussing the various supposed causes of "p lacenta prmvia~" or "placenta l presentations," and the endless varieties of treatment and operations recommended in our numerous midwifery text-books. Suffice it to say that the causes are not yet manifest~ and the treatment, so far~ has been attended with great mortality. Statistics at present show a death-rate among mothers of 1 in 3, while 65 per cent. of the children are still-born. These facts prove that there is room for improvement in the treatment of "placenta

84 Tra~sactions of the Ulster Medical Society.

prmvia." t Iav ing said so much by way of preface, let me now indicate the plan of procedure I have adopted on two occasions, and in each instance to the salvation of both mother and child.

To some people i t may seem rather ~ heroic" treatment, but I am satisfied that the results just ify the means, which consist in thrust ing the hand through the os uteri at an earlier stage than usually recommenc~ed. However, this proceeding looks worse than i t really is, for r igidi ty of the os uteri rarely co-exists with placenta pr~evia. On the contrary, the whole uterus is atonic, soft, and flaccid, and the os participates in the general relaxation ; and, when the lat ter has attained the size of half-a- crown, the hand is forced through it with as little difficulty as through an elastic ring. I t will be unnecessary for me to describe the two cases i have referred to, inasmuch as the details of treatment and operation are precisely similar, so that I shall content myself with narrat ing only one, which is unique in that it presented a contracted pelvic brim as well as the placental presentation. This abnormality on the sacrum retarded delivery, but it did not necessitate recourse to any kind of instrumental aid. I now proceed to give you some details regarding this interesting cas% which are t hese : - -On the 2nd of April , 1883, I was awoke from my slumbers about 6 a.m., and was informed that Mrs. C. (whom ][ ha~t attended early the previous year in her first confinement) had had a ~ dreadful flooding," and was in a faint or swoon. I dressed myself with expedition, and was promptly at her bedside. I found ample corroboration of the messenger's statement to me in the perilous condition of Mrs. C. On inquiry I learned she was past the eighth month of gestation ; that she was bothered through the night with trifling pains. These she at tr ibuted to having taken oil. During the night there was no h~emorrhage. I t came on suddenly and alarmingly, just immediately before I was summoned.

I now busied myself for the safety of the patient, and the first thing I did was to make a vaginal examination. This revealed a placenta through an os into which I could insert my index finger. I do not enter here into the various minor details, such as lowering the head, raising the hips, cooling the room, &c.- -a l l these things are implied, if not expressed ; but I plugged after the following fashion~ which I think an improve- ment on Schrceder : - - I first introduced~ through a large-sized speculum~ a sponge saturated with tannic acid glycerine. I then filled the vagina in the manner recommended by Schrceder. Before employing the plug I drew off the urine. After plugging I placed a binder round the patient to compress the presenting part against the p lug - - th i s is the chief aim of plugging, and it should never be forgotten. A restorative in the shape of egg-flip was administered, and, the patient having been made comparatively safe, I withdrew.

I saw her again at 10 a.m. and 2 p.m.~ but nothing transpired at either of these visits to call for special notice.

Transactions of tlte Ulster Medical Society. 85

About 5 p.m. Dr. J. C. Smyth had paid me a casual visit~ and just as I was mentioning the case to him~ and asking his help, a messenger hurriedly came and reported matters worse. We both hastened down~ and found the patient blanched and almost pulseless. Restoratives were given~ the old plug was removed, and as labour had set in and the os was dilated to the size of a two-and-slxpenny piece, we resorted only to the temporary expedient of plugging with a sponge. Meanwhile we informed the husband (who was related to a medical gentleman in town) of the critical state of his wife~ laying stress not only on the immediate danger~ but also on the gloomy prospeets~ and enjoined him to tell his relative that we would be glad of his co-operation and assistance. Our advice was taken~ and the medical friend sought, but, being unable to get away himself, he despatched to our aid Dr. Kevin~ in whom we found an efficient substitute.

Al l the necessaries being arranged for the operation~ and Dr. Kevin having confirmed our diagnosis as to the presentation of the placenta, extent of dilatation of the os uteri~ and the pelvic deformity, we pro- ceeded to deliver. The operation was performed thus : - - D r . J. C. Smyth gave chloroform, Dr. Kevin steadied the uterus externally, while I thrust my hand through its os (with as little difficulty and resistance, I repeat, as through an elastic ring) into the uterine cavity, and pulled down the r ight foot. As Dr. Kevin relaxed his grasp of the uterus while I was turning, he now resumed pressure, and facilitated the expulsion of the body of the foetus. Al l we wanted now was the delivery of the head, which was evidently arrested at the pelvic brim. After a slight pause, during which the child kicked vigorously and the cord pulsated strongly, we made another effort, which was crowned with success. The birth of the child was followed by the immediate expulsion of the placenta, and no hmmorrhage ensued, but as a safeguard we gave a full dose of ergot and firmly encircled the patient with a well-adjusted binder. Both mother and child did well.

In conclusion, I beg to express my obligations to Drs. Keviu and Smyth for the able manner in which they discharged their respective duties~ for to their competence and skill I attribut% in a great measure, the success of the operation that I have just endeavoured feebly to depict.

HI]KROD'S ASTHMA. CURE.

J . S. HEAR~ says that this consists of equal parts by weight of powdered lobelia, stramonium leaves, nitrate of potash and black tea, well mixed and sifted together .~St . Louis Courier of Medicine.