Unless the placenta be found detached, it ought not to be removed, but left to come away afterwards. The attempts to detach it might very possibly tear through the cyst, and open into the peritoneal cavity."

Hohl, in his Lehrbuch der Geburtshülfe,' second edition, 1862, a work of high authority in Germany, says, with reference to the primary operation, that "gastrotomy is only to be performed when the fœtus is mature, when the heart-beat declares it to be in vigorous life, and when the mother has made up her mind for the operation, and her condition during pregnancy and at the time justifies the hope of recovery." With reference to the placenta, he says, "Most obstetric practitioners teach in this case to separate and remove the parts which can be detached. We are not of this opinion. As to the consequences, it is indifferent whether only a part or the whole placenta remain behind. When the ovum is surrounded by a firm sac one would do well to leave it untouched, when it cannot be easily removed because the surrounding parts are intimately adhering to it.

In a recent excellent monograph (1872) on the subject, Dr. Keller, first relating two cases operated upon by Koeberlé, of Strasbourg, in both of which this eminent surgeon designedly left the placenta in sitú, and both of which ended in recovery, thus expresses himself on the question of how to deal with the placenta :-"In gastrotomy for extra-uterine gestation none of the favorable conditions present in Cæsarian section (which dictate removal of placenta) are present. The placenta is almost always much spread out, and sometimes very adherent. Moreover, if the extraction of the placenta were possible, would it be prudent to effect it? The placental insertion is not endowed with contractility, as in uterine gestation; the maternal sinuses will remain gaping, and hæmorrhage will be great. This objection (to gastrotomy whilst the child is living) loses some of its force if the attachments of the placenta are religiously respected, as the greater number of operators have understood the necessity for doing. (Cette objection tombe en partie si l'on a soin de religieusement respecter les attaches du placenta, comme du

reste l'ont compris la plupart des opérateurs.) The elimination is thus effected slowly, and the maternal vessels have time to contract and to become obliterated." From this passage it will be seen that Keller, who reproduces Koeberle's views on the subject, argues for the primary operation, and shows that, in this operation, as others have done in the case of the secondary operation, the placenta should not be touched. Indeed, if it be unwise to meddle with the placenta in cases where the child has long been dead, and where consequently all active vascularity has ceased, à fortiori is it unwise to meddle with it when the vascular communication is at the height of activity.

I trust the preceding quotations are sufficient to show that, at least since 1860, the date of Ramsbotham's and Adams's case, there has been a general consent as to the rule not to touch the placenta when gastrotomy is performed to remove a fœtus, dead or alive. I admit that my own decided opinion upon the subject is greatly based upon this case, and my respect for Ramsbotham's judgment, which I knew was based upon experience. It could not be expected that Dr. Meadows should be so deeply impressed by this experience as I am. It is, however, gratifying to find that his own experience has led him to the same conclusion; and he will not, perhaps, regret to find that he is amply supported by the experience and judgment of many eminent men, although they have anticipated him in his conclusion.

Dr. MEADOWS was very glad that Dr. Barnes had brought this subject again under the notice of the Society in the note just read, and he wished to thank him for the courteous way in which he had referred to his (Dr. Meadows's) paper, and also for kindly allowing him to read the note before bringing it to the Society. Dr. Meadows's sole object in introducing this subject would, he felt quite sure, now be attained by the discussion which his paper had elicited, and by the authoritative expression of opinion that the correct practice in these cases is to leave the placenta alone, and to make no attempt whatever to remove it. He was convinced that the great danger hitherto attending the operation of gastrotomy in these cases was due to the attempt

made to remove the placenta; if this were once recognised as bad and unnecessary practice, then he was sure that gastrotomy would become the rule in all cases of extra-uterine pregnancy where a living and viable child existed, and the lives of many children would thus be saved which now are allowed to be lost. It was, after all, a matter of very small importance who first advocated such practice, or who attempted its revival after it had become obsolete; the highest ambition of us all is the grand object of saving life, and without that this Society would have no raison d'être. In view of such a thought he cared very little whether or no the practice inculcated was or was not laid down in any of our obstetric works, especially as he had no doubt that after this discussion it would be expressly formulated. To this end Dr. Barnes's note was a most valuable contribution, for it showed conclusively that the practice advocated was sound and true. Dr. Meadows felt constrained, however, in justice to himself, to repeat his former statement that no obstetric writer that he knew of had expressly laid down the rule now sought to be established in any work on midwifery. Dr. Barnes's note was, he thought, conclusive as to the practice in cases where the foetus was dead, but in nearly all of them the operation was not only not attempted, but was intentionally deferred till after the death of the child, and this appeared to be the rule that was generally adopted. In the few cases where gastrotomy was performed in order to save the child attempts had generally been made to remove the placenta, and this had led to such fearful hæmorrhage that the practice had been generally abandoned. It was in order to obviate this that he (Dr. Meadows) had brought forward his paper. With reference to the note just read by Dr. Barnes, there occurred two important errors which he would notice. In the first place, he (Dr. Meadows) had not operated in the case which he had brought forward; the operation was performed in his absence by his colleague, Mr. Scott; secondly, Dr. Barnes appeared to think that Mr. Hutchinson had, in his report and in his article in 'Holmes's Surgery,' considered the whole subject of the treatment of the placenta in all cases where gastrotomy was performed for extra-uterine fœtation, whether the child was living or dead. This, however, is not the case. His report is "On the Treatment of Cases of Extra-Uterine Fotation extending beyond the full period of Pregnancy," and he expressly limits it to those cases where the foetus had died. The terms "primary" and "secondary" he thus explains:-"In all the cases given in the first table suppuration had occurred in the cyst, and the operation consisted in enlarging the opening already made by ulceration and then extracting the fœtus. Operations of this class may suitably be termed 'secondary' abdominal section, the term 'primary' being

reserved for those of the class contained in the second table, in which no abscess had yet opened. No cases have been included in either table in which the foetus had not advanced to nearly its full time before death, and in a large majority the natural period had been completed." All his remarks subsequently show that he only contemplated the performance of gastrotomy in cases where the foetus was already dead, and his report was limited to them; he expressly states, indeed, that "whoever will carefully examine the cases will come to the conclusion that the longer the interval allowed to elapse between the death of the fœtus and the operation the less is the risk attending the latter." It was important to note this as it had a bearing upon the point in dispute between Dr. Barnes and himself, and though Dr. Meadows entirely concurred in Dr. Barnes's opinion that if it be sound practice to leave the placenta in cases where the fœtus is dead, à fortiori is it where the foetus is living; still, the fact remained that, so far as he knew, this practice had nowhere been explicitly advocated. He had no doubt, however, that when this discussion became widely known it would soon be added to the precepts of our obstetric text-books.

ON THE SYSTEMATIC EXAMINATION OF THE ABDOMEN, WITH VIEW TO RECTIFYING MALPOSITIONS OF THE FETUS IN CASES OF LABOUR.

By ARTHUR W. Edis,

PHYSICIAN TO THE BRITISH LYING-IN HOSPITAL, ENDELL STREET; ASSISTANT PHYSICIAN TO THE HOSPITAL FOR WOMEN, SOHO SQUARE.

In bringing this subject prominently before the attention of the Society, it is not with the idea of advancing any novel mode of procedure, but of inculcating more earnestly the universal adoption of this simple expedient.

Most of the recognised works on midwifery in France and Germany describe fully the process, but few of our English authors lay sufficient stress upon the importance of the subject.

The more extended application of the method in British midwifery would, I feel sure, tend materially to diminish the fœtal as well as maternal mortality, and might well be

advocated by our systematic authors and clinical teachers, until every student shall learn to consider it as his duty to examine carefully the position of the fœtus in utero on first visiting his patient, and, if need be, rectify any malposition that may occur.

In the thirty-second report of the Registrar-General for the year 1869, over 2000 mothers are stated to have died from accidents of childbirth, exclusive of more than 2000 others who succumbed to puerperal fever and other complications. Churchill estimates that the superior extremities present once in every 243 cases; that about one half the children and about 11 per cent. of the mothers are lost.

With these facts before us, surely any plan is worthy of consideration that will tend to diminish this sad mortality, more especially when that suggested is a simple operation which involves no risk to either mother or child, and which any one qualified to attend the lying-in chamber may perform.

Natural labour may terminate favorably in the midst of inactive ignorance; unnatural requires action guided by an enlightened judgment; and the sooner the latter is brought to bear upon the former the less will be the risk and suffering incurred by both mother and child.

The advantage of detecting malpositions in the early stage of labour is considerable, for whilst the membranes are still intact very little effort is required in rectifying the presentation, and little or no danger is incurred by the mother or fœtus, for it is not a question of passing a hand into the uterus and bringing down a foot, necessitating the administration of chloroform and subjecting the patient to the attending risks of shock to the system, or even rupture of the uterus, but the process is so simple that an intelligent midwife could perform it; it is merely a question of substituting the head or normal presentation for the abnormal one by external manipulation alone, thereby lessening considerably the risks to both mother and child.

6

Wright, in his prize essay On Difficult Labours and their Treatment,' written in 1854, states that