ular or fatty substance, with or without a plain nucleus, their arrangement is less uniform, and between them are free fat globular or scattered granular masses. (The quotation is not literal.)

As the disease advances, new elements appear between the interstitial tissue, fibrillary and finely reticulated in appearance, its meshes filled with nuclei and cells, fibroid, striated, or homogeneous. It displaces and deforms the older cells, and leads to their degeneration. The utero-placental vessels undergo atrophy from compression, so that only hard, whitish foci, resembling old connective tissue, remain imbedded in the placenta; progressive formation of connective tissue on the uterine surface and in the adventitia of the placental vessels may cause obliteration of the maternal and fetal vessels with more or less extensive thrombosis and apoplexies.

Symptoms. Millet (These. Sur. le placent, 1861,) says: "Nothing is less precise than the symptomatology of this affection; nothing is less exact than its pathological anatomy; nothing, in a word, is less proven than this inflammation itself." (Whittaker, loc. cit.) “You may suspect morbid adhesions if there has been unusual difficulty in removing the placenta in previous labors; if, during the third stage, the uterus contracts at intervals firmly, each contraction being accompanied by blood, and yet following up the cord you find the placenta still in utero; if, on pulling on the cord, two fingers being pressed on the placenta at the root, you feel the placenta and uterus descend in one mass, a sense of dragging pain being elicited; if during a pain the uterine tumor does not present a globular form, but be more prominent than usual at the place of placental attachment." (Barnes, Obstet. Operations.) The opinions given, coming as they do from such authorities, are evidence worthy of consideration. Our own observations lead us to coincide with them. We believe a diagnosis before the beginning of the third stage of labor is doubtful. With all the symptoms and conditions given by Barnes we are able to make a diagnosis after the fetus is delivered.

The symptoms, excepting the death of the child, are all from the uterus. The fact that inflammation of the maternal portion of the placenta may exist without involving the fetal portion would make differentiation extremely difficult. But pain and tenderness of the uterus, dragging sensations in the pelvis, and a previous history of such a condition, together with death of the fetus, would be presumptive evidence of placentitis. At the end of the second stage of labor

usually while waiting for uterine contractions, a sudden hemorrhage occurs, frequently of an alarming character, and we find our efforts at placental delivery are futile. With each contraction and relaxation there is a gush of blood. The placenta acts like a sponge in the uterus. The conditions as described in the symptomatology are present, excepting in case of universal adhesions, when hemorrhage is impossible until detachment begins, and with proper care can be prevented at that time.

Treatment. Prophylaxis consists in avoiding all causes of endometritis enumerated before. Guard against abortions as far as practicable. Learn from Leopold not to make digital examinations in labor. Adhere strictly to the rules of asepsis. Treat endometritis if present. In the third stage of labor the placenta, if only partially adherent, may be removed by the Credé method. Traction on the cord in partial adhesions is contra-indicated, as inversion of the uterus may occur, especially if the attachment should be at the fundus. If adhesions are extensive, the hands should be thoroughly cleansed with soap and water, dipped in 1 to 1,000 solution of bichloride of mercury for a few minutes. The fingers and hand are then gently and carefully introduced into the uterus. The "peeling process" must be done with great care, that the nails may not wound the tissues or the fingers be pushed through the walls. It is not always possible to determine the line of division between the uterus and placenta. Barnes and Ramsbotham both speak of cases where the structures of the placenta and uterus were so intimately connected that it was impossible to locate the line of demarkation. Ramsbotham says: "I have opened more than one body where a part of the placenta was left adherent to the uterus, and where on making longitudinal section of the organs and examining the cut edges I could not determine the boundary line between them." Morgani, Portal, and Capuron report similar instances. With such conditions it would be an easy matter to push the finger through the morbidly softened tissue and produce fatal results. In detaching an adherent placenta pieces are frequently left behind. The question then arises, What is our duty in such cases? It is not an easy question to answer. If the placental tissue is left, it may cause immediate or secondary hemorrhage, or become a point of infection and sepsis. Where there is only a small portion, it may soon come away spontaneously. Introduction of the hand or instruments, however carefully done, may convey pathogenic microbes into the uterus. The safest thing to do, we believe, is to remove the

placenta as far as it is possible with fingers and dull curette, and irrigate the uterus with a 1 to 10,000 solution of bichloride of mercury. In abortions, where the placenta is retained, it is incurring great risk to allow the placenta to remain until nature takes the initiative to throw it off. The placenta often becomes necrosed and offensive, the patient infected, and hemorrhage of a dangerous character is liable to occur at any time. We therefore deem it best to dilate the cervix, remove the placenta at once, irrigate as in other cases, thus relieving the patient of risk and yourself of many anxious moments.

DAYTON, KY.

Reports of Societies.

THE CINCINNATI OBSTETRICAL SOCIETY, MAY 2, 1895.

Dr. C. B. Schoolfield read a paper entitled Retained Placenta. [See page 297.]

Discussion. Dr. Palmer: I do not think that anybody can doubt about the placenta being retained by adhesions sometimes. A retention of the placenta after the second stage of parturition is by no means uncommon. But my experience is, and I think my experience corresponds with the instructions given in most text-books, that these cases are largely attributable to imperfect action of the uterus or some irregular action of the uterine walls, and not entirely owing to placental adhesions. But that does not invalidate the fact we may have placental adhesions and the placenta may be retained on account of these adhesions. It has been my idea, and I am glad Dr. Schoolfield largely substantiates this idea, that these cases are largely attributable to endometritis which has antedated the pregnancy. I have seen a few cases of retained placenta from adhesions, and, so far as my recollection will now support this statement, I can recall two cases, one which happened in my own experience and one which was related to this Society a few years ago. Perhaps the members of this Society will recall an instance. of inability to deliver the placenta in two instances in the same woman, related by Dr. Trush and, I think, Dr. Underhill. Dr. Trush attended a woman a good many years ago, and after prolonged efforts to deliver the placenta was totally unable to do so. There was no post-partum

hemorrhage, and he abandoned the effort because there was no post-partum hemorrhage. He left the woman alone and the placenta was never delivered; it was practically absorbed. Of course that report excited a good deal of doubt in the minds of a good many of the members of the Society; but subsequent to that the doctor reported another case in the same woman, in which he made repeated and prolonged efforts to deliver the placenta, and called in Dr. Underhill, who also was unable to deliver the placenta, and in that instance the placenta was absorbed without any untoward effect.

The case which happened in my own practice occurred about the same time, when I was called in consultation to see a woman in Madisonville. I found a woman who had been confined two days before, and the physician in charge, Dr. Marsh, said he was not able to deliver the placenta. He had not tried the influence of chloroform, but had repeatedly introduced his hand and was unable to deliver it. He put the woman under the influence of chloroform and I inserted my hand, and after prolonged effort delivered the placenta piecemeal. You could recognize the odor the minute you entered the room; nevertheless, the woman made a good recovery. There was evidence she had endometritis before the delivery. The same was probably true in the other two cases. I think if you were to examine these cases post-mortem you would find the placenta adherent at the decidua serotina, and I have no doubt in all these cases there was some antecedent history, of perhaps months, may be years, of some underlying endometritis.

Dr. Wenning: This subject is of great interest to me, especially since recently I was brought into intimate connection with two cases of adherent or retained placenta.

It seems to me we should draw a distinction between adherent and retained placenta. The one is due to inertia of the uterus; the placental attachment does not become corrugated. An adherent placenta is one where there is an inflammation of the placenta itself. I do not know whether there is a placentitis or not, but there must be some disease process which fixes the placenta to the uterine wall. We know there is a retrograde metamorphosis which prepares the placenta for expulsion. In these abnormal cases I am confident such a change does not take place, and the farther the woman is removed from the normal pregnancy the more likely will the placenta not become detached easily. I think these cases are usually due to a chronic endometritis. In the adherent placentæ I have seen there has been a history of similar cases,

in multiparæ, existing before. I have seen two cases which terminated fatally, and they made a great impression on me at the time. A few months ago a gentleman asked me to attend his wife in labor, and desired me to see her. I told him I would see her but could not promise to deliver her. When I saw her she had labor pains, and she stated the waters had broken, but I do not think they had. I told him if possible I would see her next morning, but if I had no message from them in the morning I would take it for granted the pains had become less, and they need not call me after nine o'clock.

Next day, when I got home after one o'clock, I found the woman had been in labor; she had been delivered without anybody being present, but a neighboring physician delivered the after-birth. As the husband was rather anxious about his wife, since she had a retained placenta before, he asked me to see the placenta. It was all in pieces. I asked him whether the physician was going to take charge of the case. He said, "Yes," and I told him if any thing occurred to send for me. A few days afterward he called me, and said he believed his wife was going to die of septicemia. I asked why he had not sent for me. He said the physician called in Dr. Zinke, and he had treated it, curetted and packed with gauze. A few days later she died of septicemia.

The other case, which was to me still more unfortunate, was a case of abortion, a patient of Dr. Fackler's, a woman who had irregular hemorrhages, and whose husband said she had taken something to produce abortion about the third month. She had very slight pain, and, thinking probably the pregnancy would go on without any further trouble, I advised to temporize, as there was no evidence of any immediate danger. This went on for about a week or more, when she was seized with considerable hemorrhage. I then thought it best to expedite delivery. To hasten matters I introduced a tupelo tent. The cervix was dilated to the extent I could introduce my finger, but I could remove nothing. I left it alone, hoping the irritation would throw out the contents. But the cervix closed again, and when I came next day she had no hemorrhage. This lasted about a week, and she was again seized with hemorrhage. I then concluded there was no use of temporizing longer, and sent for Dr. Fackler, who chloroformed her. I dilated with the Wyeth dilator. I tried to pull away the product of conception with my finger, but was unable to do so, and used the curette and scraped out as much as I could, until the uterus seemed to be thoroughly empty and as thin as paper. I washed it out with-creolin solu