TWINS--DELAY OF SECOND CHILD—AR

TIFICIAL DELIVERY-DEATH.

A. HENLEY, M. D., FAIRMOUNT, INDIANA.

Was called Monday, September 29, 1879, to see Mrs. S, a short, thick, heavy-set woman of sanguine-bilious temperament, in her first labor. The case was in charge of Dr. S. F. Brunt, and labor pains had set in on Saturday previous, but dilatation of the os did not take place until about 7 P. M. Sunday, after which labor progressed without any untoward symptom until 8 A. M. Monday, when a male child was born alive. Immediately the doctor discovered there was another in utero, and on examination per vaginam he found the placenta protruding at the os, and a little higher up the sac of waters could be distinctly felt, which, on making an attempt to rupture, receded beyond reach, unless the whole hand was introduced into the vagina, which was thought not justifiable, as the pains had ceased.

After waiting some two hours, and using all the usual means at command to excite efficient uterine contractions, and failing, I was sent for, and arrived some four hours after the birth of the first child. I found the woman resting quietly; said she felt no symptoms of a return of the pains, nor had she since the birth of the child. There had been but little hemorrhage, and her condition every way seemed to be good. A vaginal examination disclosed the neck of the womb to be firm and unyielding, and about on a level with the anterior and right lip of the os, and completely filling the orifice. I found the placenta, with, as I thought, a very

small portion detached, as I could insert my finger but a little way between the edge of the placenta and cervix uteri.

The question that now came up was what to do next. We had a case before us which I venture but few practitioners ever see. One child delivered, the placenta presenting in advance of a second child, and the uterus calmly settled down and firmly contracted around the body of the child, as though nothing further was required of it. Some authors would have advised an opiate and employed venesection, as the safest and shortest way out of the quandary; while others would have resorted to the more bold and certain method of introducing the hand, rupturing the membranes, seizing the feet and bringing the child down by force; and yet others would advise the more conservative course of giving rest with the opiates. The first proposition was objected to from the fact that our patient might lose more blood than was desirable, as we did not know what moment we might have an alarming hemorrhage by a detachment of the placenta. Secondly, we considered it impossible, in any case, to perform the operation of turning without more or less danger to the mother, and that it ought not to be had recourse to without necessity. All these matters having been discussed, and as there was no hemorrhage or any other symptom demanding immediate interference, the patient not having slept any for two nights previous, and having expressed herself as being tired and sleepy, we determined on adopting the latter course, thinking that with a few hours' rest and sleep the uterine energy would so far recuperate as to expel the child per vias naturales. A possibility, too, of there being a difference in the time of conception had its weight in determining the latter course. Consequently we ordered her nourishment, then an opiate; the room to be kept quiet, so that she might sleep. Our patient had a good sleep, and expressed herself as feeling considerably refreshed. Night soon came on, and yet, so far as labor-pains were concerned, everything was as calm as a summer's morn.

Another consultation was held; again we decided to wait, as there were no physical signs requiring immediate action, thinking surely the pains would return some time through the night. Our patient rested well all night. Morning dawned without relief, and with it came an outside pressure for immediate action. The husband and

friends now were clamorous for us to do something; consequently about 7 A. M., after a short consultation, and the necessary arrangements having been made, while the doctor administered chloroform, I prepared to operate by turning, should it be found necessary. On reaching the os with my right hand it was with difficulty that I could introduce it on the fetal surface of placenta, so firm were the contractions, but by steady pressure I soon reached the upper border of placenta, where the uterine cavity seemed to cease, and for a moment I thought of a double uterus. But on manipulating a little further, a finger slipped through the constriction and touched a portion of the child. It was now plain to me why the sac of waters receded when an attempt was made to rupture them; also, why we could not touch them or the child in previous examinations. There was a complete hour glass contraction between the placenta and child. On passing my hand through the constriction I discovered the nates presented, left side anterior, but on attempting to reach a foot the uterus contracted with such force that I thought at first I should have to withdraw my hand, for the pain endured could not have been much greater had it been squeezed in a vise. But with patience and perseverance I was rewarded by reaching the left foot, which I brought down, and drew the hips through the os, then brought down the other foot; but now, instead of finding delivery quickly and easily accomplished, as I had expected, I found every inch of territory contested by a persistent stubbornness worthy of a better cause. The circular fibers of the uterus alone seemed to contract, by which the child was grasped and held by a force but little inferior to that of my own. But after a continued effort for the space of about three-fourths of an hour I succeeded in delivering all but the head, which was resting in the cavity of the pelvis. My grip having given out, I requested Dr. Brunt to complete the delivery, which he did—child dead.

The uterus now contracted firmly down on its contents, and after using expression with friction to abdomen, with slight traction on cord, without effect, I introduced my hand and found the same irregular contractions existing as before, there being two placentæ, one attached high up on the left side, the other as before stated. I had but little difficulty in removing them by making the separation, the upper one being detached first. There was not more hemor

rhage than in an ordinary case, and our patient rallied from the effects of the operation nicely, and we congratulate ourselves as having got through with a knotty case. And as a preventive against typho-malarial fever, which was prevalent in that vicinity, we ordered quinia in full doses every three hours, with disinfectant vaginal irrigation and generous diet. I called the next evening and found patient looking bright, and expressing herself as feeling able to get up and go to work; skin moist, a slight headache, but no pain in bowels or unusual tenderness; lochia, free; tongue shows malarious coating; pulse, 93; temperature, 102°; patient to have quinia and chlorate of potash freely and bromide of potash for headache. Wednesday morning-pulse, 100; temperature, 102°; had rested well through the night; appetite, good; was ordered a dose of castor oil. 2 P. M.-pulse, 120; temperature, 105; heavy, yellow coat on tongue; bowels moved by oil; but little tenderness or swelling; urine free and passed with ease; takes food with a relish; gave solution soda sulphate with spirits nitre dulc. every three hours up to 7 P. M., then to have two grams of quinia in the space of three hours, to be followed by the solution. Thursday, 7 A. M.-pulse, 100; temperature, 102°; had perspired freely after taking quinia; but little deafness or ringing in the ears; bowels acting freely; ordered same medicine as before, and also opium and bismuth. Thursday afternoon her temperature ran up to 105°; pulse, 112; the lochia became scant and the bowels tender; continued the irrigation and gave quinia, tincture of iron, paregoric and dovers powder. Friday morning-pulse was 96; temperature, 102°. Afternoonpulse, 96; temperature, 105°. Patient about the same on Saturday, but worse on Sunday morning and rapidly grew worse during the day, and died at 4 P. M., apparently from the effects of the continuous high temperature.

PLACENTA PREVIA.

OCCULT HEMORRHAGE AND MAL-PRESENTATION.

E. S. ELDER, M. D., INDIANAPOLIS, IND.

Mrs. J. L, aged 28, light complexion, delicate, spare-built woman; multipara, second child; first child was said to have been an eight months one, and lived one week after birth.

Eight months after birth of first child the mother again became pregnant. Had threatened abortion or premature labor every month since the second month; is now supposed to be eight months advanced. One month ago she had violent hemorrhage and severe irregular pains, lasting forty-eight hours, after which she became strong, and was heartier than before during pregnancy. On May 18, 1879, at the end of the eighth month of gestation, she was attacked with severe pains and threatened miscarriage, and upon being summoned I found her suffering from well defined indications of labor, and with well marked uterine contractions, and notwithstanding the faithful and persistent use of the remedies usually employed in those cases the pains grew gradually more severe and continuous, until labor was fully inaugurated. Upon examination I found the os uteri but very little dilated. The pains were severe, but not bearing down in character—no hemorrhage. At the expiration of four hours I again examined the uterus, and found the os but very little dilated. I was barely able to introduce the point of my index finger into the external os; therefore was unable to diagnose position of child, or what parts were presenting.