child only once, and told the parents to remove the bandage at the end of four weeks, when the opening was found entirely closed. The child is now nine or ten years old, perfectly healthy, and always has been.

DR. CHARLES CALDWELL.-The Fellows of the Society have evidently misunderstood the nature of the case described in the paper. I am sorry that such obscure and confused conceptions have been conveyed. The case was one of hernia of the umbilical cord, consisting in "the escape from the abdomen, at the point of insertion of the cord," of some of the fetal abdominal viscera, and was due either "to arrested embryonic development, preventing the complete closure of the abdominal cavity, or failure of the fetal intestines, originally situated outside the abdomen, to enter the same" (Lusk). The remarks of most of the Fellows are accordingly irrelevant.

As no one who witnessed the operation was present at the discussion of my paper, several questions were unanswered.

Dr. Sawyer wished to know why we decided so quickly that surgical interference was necessary to save the child's life?

The consultation was held about twenty hours after the birth of the child, and at that time the outer layer of the sac, the amnion, was dark and gangrenous in several spots. Its nutrition was cut off when the cord, with its umbilical vessels, was ligated, and it would have sloughed off in a few days, leaving the viscera covered by the peritoneum only. We were of the opinion that such a condition as then existed would be followed by general peritonitis and death without some surgical operation.

Dr. Byford wished to know the literature of the subject. I have been able to find but one case similar to mine.

Thomas Bryant, in the last edition of his "Surgery," mentions the only case he ever saw and his treatment. In June, 1876, a child, one day old, was brought to him with hernia of the cord. The sac was translucent, the size of a small egg, and contained the cecum and vermiform appendix. He pressed back the bowel with the thumb and forefinger, stitched up the cord at the umbilical orifice with deep sutures and ligatured the cord itself at the apex of the congenital hernial sac.

Recovery was complete without a single bad symptom. He recommends his operation in all similar cases, evidently considering it the only treatment indicated. So we were supported by the best of authority, in operating instead of trying to apply a compress. Should I ever meet with a similar case, I would perform an operation different from either Bryant's or mine.

I would first remove the amniotic layer of the sac, if it could be separated from the peritoneum, excising or amputating it at its junction with the skin, return the viscera and peritoneal sac to the abdominal cavity, and close the abdominal opening as in a case of exploratory incision or simple laparotomy. Either incising the peritoneal sac to better protect the bowels from needle points, or stitch to the bottom of the wound by deep sutures, and support the sutures by adhesive strips around the abdomen.

I would recommend this operation after observing how quickly the amnion sloughed away. It might just as well be removed at once if it can be easily separated from the peritoneum.

DR. JOHN BARTLETT made remarks upon and exhibited specimens of

(1) A CASE OF DERMOID CYST COMPLICATING LABOR. (2) A CASE OF PLACENTA PREVIA IN WHICH THE PLACENTA WAS EXPANDED OVER THE ENTIRE OVUM.

Dr. Bartlett said, "I have recently seen two interesting cases of labor, and I wish to present a specimen obtained at each of these to the Society.

The first was a case in which I was called to assist Dr. John S. Clark. The patient, a primipara, about 30 years old, had been in labor under the care of a midwife about twenty-four hours. The head was making no progress, and exhaustion was approaching; about one ounce of fluid extract of ergot had been given. Dr. Clark found the head lying with the antero-posterior diameter corresponding with the conjugate, the parietal eminences had passed the brim. He applied an old style, high curve, Bedford's forceps, but found his efforts unavailing in causing the head to advance. Dr. Bartlett then attached his direct traction handle, and descent of the head was effected. After delivery of the head there was difficulty in delivering the shoulders. When an effort at extrusion was made, there appeared in the perineal region, between the vulva and tuberosity of the ischium, a jutting outward of the tissues in the form of a tumor. It seemed as if an obstructing body was wedged in front of the shoulders. Counter-pressure was made upon the protrusion, and the delivery was completed. Following the child came a tumor the shape and size of a large pear, presenting at the small extremity a pedicle. It was a thin dermoid cyst containing a mass of fatty substance, imbedding numberless long intertwining hairs. The tumor could not be felt during labor, and a careful inspection showed that it had not been attached to the child. It was probably attached to the uterine surface, resting between the head and the shoulders. Possibly it was the cause of the dystocia in diverting the head from an oblique diameter of the brim. Depression of the vital powers with high fever set in soon after delivery, resulting in death within four days. Dr. Clark's examinations post partum detected no injuries beyond laceration of the perineum. The child was stillborn.

The second case was one of placenta previa.

Mrs. N. had had several children, and, within eighteen months past, two miscarriages. In January last, when she was nearly four months advanced in pregnancy, I was called because of serious hemorrhage. The uterus presented to the touch nothing peculiar, there was none of that extra development of the lower segment of the organ which is supposed by some to indicate placenta previa. The tampon was applied, opiates given, rest enjoined, and the bleeding ceased. At four and one-half months the hemorrhage recurred. Under treatment, the bleeding was in some measure controlled. For the two following months it was continuous, generally moderate, occasionally quite severe, at all

times, as she declared, fourfold greater than the flow of menstruation. I then deemed it best at six and one-half months to induce labor, but Dr. John S. Clark, in consideration of the probable nonviability of the child, advised further delay. The flow, however, was so great that the tampon was applied, and in forty-eight hours thereafter labor began.

Upon removing the plug, the os was found thin, softened, and three-quarters of an inch in diameter. At about the fourth hour of labor, the os rather suddenly enlarged to a diameter of one and a half inches, and the hemorrhage became profuse. The half hand was introduced into the vagina, and the placenta stripped off over an area the radius of which was three-fourths the length of the middle finger. With the bullet forceps, used by me with advantage in such cases, the membranes were torn, and the opening so made was freely enlarged by the finger. Hemorrhage immediately ceased, and labor became more active, so that in the course of an hour the child was delivered, breech first. Several inspirations were made by the fetus, a fact of interest in view of the peculiarities of the placenta, which I here present. In order to display the specimen to better advantage I have filled the cavity of the membranes with horse hair, and sewed up the aperture. It will be observed that the main body of the placenta, the normal placental mass, is not previa, but attached near the fundus, and that the rare anomaly is here presented of a continuous placental tissue spreading over the entire ovum. Observe that the extra, adventitious portion, continuous with the normal placental edges, and everywhere enveloping the membranes, is comparatively thin; in the present state not thicker than one-eighth or threesixteenths of an inch."

DR. W. H. BYFORD spoke of a specimen he exhibited some time ago at the Chicago Medical Society-a dermoid cyst which was expelled from the vagina. It was sent to him by Dr. White, of Bloomington, who said the tumor was situated in the anterior wall of the vagina, and as the child was delivered the pressure of its head pushed the tumor out before it. He thought that in the case under discussion the tumor may have been developed in the vaginal walls. The localities of these growths are not uniform, and we find dermoid cysts situated in the vaginal walls. Bartlett said in answer to a question from Dr. Byford, that the existence of the cyst was not discovered before but during labor; that it was beyond the head, and may have been an ovarian tumor; it was not outside the vagina, but between the head and shoulders. Dr. Byford thought it almost certainly a dermoid tumor of the vagina. He thought that these cases were almost always found in old or multiparous patients.

Dr.

With reference to Dr. Bartlett's second case, he asked if the hemorrhage ceased before rupturing the membranes, or if the whole operation was done at once. Barnes claims that if the membranes are separated over the cervical zone the hemorrhage will stop; that there will be sufficient retraction of the cervical zone to close up the mouths of the vessels. He thought it a point of

interest to know whether or not that would have stopped the hemorrhage, and whether it would not have been sufficient. He thought in that case one is not called upon to leave the membranes intact.

DR. DE LASKIE MILLER said that the effect of endometritis is usually to increase the area of the development of the placenta, and he had not infrequently seen cases of placenta of the usual size, on which projections appear in different parts in the interior of the uterus, partially connected or entirely disconnected. He asked whether a case of endometritis might not allow the villi of the chorion to form these placenta succenturiatæ. He was inclined to think that that condition would encourage it. Another fact in the history of the case that would perhaps justify this theory was the several miscarriages the patient had experienced before this pregnancy.

DR. T. D. FITCH said that in thirty-five years of practice, in which he had probably attended more than a thousand cases, he had seen but one case in which he suspected placenta previa. He was sometimes ashamed to make the statement, for fear his experience had been from lack of close observation, or inability to recognize a case, but he had seen only one, and did not know that that was really a case of placenta previa. He did not detect it by manual examination; the symptoms were altogether subjective. It was a seven months' labor and the child lived. There was a good deal of hemorrhage. He had no difficulty with the labor, except from the hemorrhage, and that did not prove serious. THE PRESIDENT asked if any one could suggest the origin of the tumor? Was it a twin or a dermoid thrown off from the fetus, or was it from the mother? He asked Dr. Bartlett if it was a part of the child, and was answered that after a careful examination no place was found where it might have been attached. It was perfectly loose in the vagina; probably the pedicle had been ruptured.

DR. EDWARD WARREN SAWYER thought, with reference to Dr. Bartlett's second case, that the case had several very interesting features, and the subject itself was full of interest. He referred to a conversation earlier in the evening, in which Dr. Byford had said that he had been in practice many years before seeing a case of placenta previa, and the first case he ever saw was the first of three in one night. It had happened to Dr. Sawyer to see a number of cases of placenta previa. He had had two fatal cases and had learned something of early diagnosis, which had been profitable to him since, and he thought of it in the obscurity of the diagnosis in Dr. Bartlett's case. He said that in one of his cases, after reading of the ease with which one could auscultate the lower segment of the uterus under these circumstances, he prolonged his stethoscope with a long flexible tube, put a cup on the end of it and had no trouble in introducing it into the woman's vagina. He had repeatedly detected portions of the cervical attachment of the placenta by this mode of auscultation. The remark made by Dr. Byford had received some confirmation in his experience, viz., that many cases of placenta previa aborted early, and that he believed this to be a frequent cause of early abortion. Spiegelberg says that placenta previa is of very frequent occurrence. An interesting fact in connection with Dr. Bartlett's case was the alarming amount of hemorrhage which took place from the placenta and placental attachment away from the main part of the

placenta, or in other words, there were sinuses in the cervical zone of this uterus which were covered only by the velamentous portion of the placenta, sinuses large enough to bleed, and exsanguinate the woman. Dr. Sawyer spoke of a case to which a former pupil of his was called. A midwife summoned him at midnight to see a woman who was bleeding to death. As he entered the room she handed the doctor a cord (the child was delivered), and the placental end of the cord was a disc about as large as a butter dish. That fleshy mass had been pulled directly from the placenta and the woman was actually bleeding to death. This little mass was very thin, and he was at a loss to understand to what part of the placenta it could have been attached. He delivered the woman completely and she was saved. He found a hole through the placenta corresponding to the disc which had been pulled out, it was in the thin portion of the placenta, and the bleeding was somewhat alarming. Referring to the question that Dr. W. H. Byford asked, concerning the mode of treatment advocated by Barnes, Dr. Sawyer said he was full of the idea, and the feasibility of it was accepted by him in his first reading of Barnes' work, and he tried to adopt it in practice, but he hoped no one would ever get himself into such a dilemma, as he was sure he lost his patient by that cause. Theoretically you may detach enough of the placenta to save the woman from hemorrhage. The so-called cervical zone is not to be measured by the finger; he did not think it had any definite boundaries; it might sometimes extend half-way to the fundus on one side of the uterus, and he thought the more we detach the more dangerous it may become. He felt quite confident that the poor woman who was the victim of the theory of Barnes, would not be dead to-day if he had adopted a more rational treatment.

There was one point in connection with the causation of placenta previa that excited a great deal of interest in his mind. He had seen two cases strongly confirmatory of the movement of the ovum in the early days of its sojourn in the uterus. One case was also seen by the President, but he had never spoken to him of the theory of which the examination of the placenta had been the origin. Dr. Sawyer had written to several prominent obstetricians of this country, asking if they knew anything in literature which would answer the question: Can the ovum once attached to the decidua of the uterus become detached and again attach itself to the lower part of the uterus and go on through pregnancy? In other words, can the ovum detach itself, drop from the top of the uterus to the bottom, and re-attach itself in the cervical region? Many learned men replied that they had never heard of such a possibility. But Dr. Harris, of Philadelphia, hit upon this happy expression: "Rotation of the ovum." He had seen two cases in which he thought the ovum rotated in the earliest days of pregnancy: not a complete rotation, but an almost complete detachment and rolling, or rotating, downward and there attaching itself. The second case was in the practice of Dr. Doering. The subsequent examination of the placenta showed a case of partial placenta previa. The umbilical cord springs from the margin of the placenta in both instances; and his theory was that in the first case, which was that of a young primipara, the placenta was fixed normally at the fundus and the cord sprang from the middle; there was a history of a sudden jar of the body when she was about three weeks pregnant; she jumped from a high wagon and im