These are very much the cases in which all modern accoucheurs would exclude the operation of turning; and it was specially when that was unsuitable that Simpson advised extraction of the placenta. As his theory of the source of hemorrhage is now almost universally disbelieved, so has the practice based on it fallen into disuse, and it need not be discussed at length. It is very doubtful whether the complete separation and extraction of the placenta was a feasible operation; unquestionably it can be by no means so easy as Simpson's writings would lead us to suppose. The introduction of the hand far enough to remove the placenta in an exhausted patient would probably cause as much shock as the operation of turning itself; and another very formidable objection to the procedure is the almost certain death of the child, if any time elapse between the separation of the placenta and the completion of delivery. The modification of this method, so strongly advocated by Barnes, is certainly much easier of application, and would appear to answer every purpose that Simpson's operation effected. It is impossible to describe it better than in Barnes's own words:1

"The operation is this: Pass one or two fingers as far as they will go through the os uteri, the hand being passed into the vagina if necessary; feeling the placenta, insinuate the finger between it and the uterine wall; sweep the finger round in a circle so as to separate the placenta as far as the finger can reach; if you feel the edge of the placenta, where the membranes begin, tear open the membranes carefully, especially if these have not been previously ruptured; ascertain, if you can, what is the presentation of the child before withdrawing your hand. Commonly, some amount of retraction of the cervix takes place after the operation, and often the hemorrhage ceases."

It will be seen from what has been said, that no one rule of practice can be definitely laid down for all cases of placenta prævia. Our treatment in each individual case must be guided by the particular conditions that are present; and, if only we bear in mind the natural history of the hemorrhage, we may confidently expect a favorable termination.

It may be useful, in conclusion, to recapitulate the rules which have been laid down for treatment in the form of a series of propositions : 1. Before the child has reached a viable age, temporize, provided the hemorrhage be not excessive, until pregnancy has advanced sufficiently to afford a reasonable hope of saving the child. For this purpose the chief indication is absolute rest in bed, to which other accessory means of preventing hemorrhage, such as cold, etc., may be added.

2. In hemorrhage occurring after the seventh month of utero-gestation, no attempt should be made to prolong the pregnancy.

3. In all cases in which it can be easily effected, the membranes should be ruptured. By this means uterine contractions are favored and the bleeding vessels compressed.

4. If the hemorrhage be stopped, the case may be left to Nature.

1 Obstet. Operations, 2d ed., p. 417.

If flooding continue, and the os be not sufficiently dilated to admit of the labor being readily terminated by turning, the os and the vagina should be carefully plugged, while uterine contractions are promoted by abdominal bandages, uterine compression, and ergot. The plug must not be left in beyond a few hours, and careful antisepsis should be used.

5. If, on removal of the plug, the os be sufficiently expanded, and the general condition of the patient be good, the labor may be terminated by turning, the bi-polar method being used if possible, and the lower extremity of the child will form a plug until delivery is completed. If the os be not open enough, it may be advantageously dilated by a fluid dilator bag, which also acts as a plug.

6. Instead of, or before resorting to, turning, the placenta may be separated around the site of its attachment to the cervix. This practice is specially to be preferred when the patient is much exhausted and in a condition unfavorable for bearing the shock of turning.

[Dr. J. Braxton Hicks's bimanual method of turning, as tested in Berlin by Drs. Hofmeier, Behm, and Lomer, promises much better results than any other method of treatment in cases of placenta prævia. According to Dr. Lomer's report in the Amer. Journ. of Obstetrics for December, 1884, Dr. Hofmeier operated upon 37 cases, and saved 36 women and 14 children; Dr. Behm, upon 40 cases, all saved, but lost 31 children; and he himself, with eight other assistants, upon 101 cases. saving 94, with 50 children. This gives 8 deaths of women and 105 of children in 178 cases, or a mortality of 4 per cent. of the former and 60 per cent. of the latter. Dr. Lomer's directions are as follows: "Turn by the bimanual method as soon as possible; pull down the leg, and tampon with it and with the breech of the child the ruptured vessels of the placenta. Do not extract the child then; let it come by itself, or at least only assist its natural expulsion by gentle and rare tractions. Do away with the plug as much as possible; it is a dangerous thing, for it favors infection and valuable time is lost with its application. Do not wait in order to perform turning until the cervix and the os are sufficiently dilated to allow the hand to pass. Turn as soon as you can pass one or two fingers through the cervix. It is unnecessary to force your fingers through the cervix for this. Introduce the whole hand into the vagina, pass one or two fingers through the cervix, rupture the membranes, and turn by Braxton Hicks's bimanual method." "If the placenta is in your way, try to rupture the membranes at its margin; but if this is not feasible, do not lose time; perforate the placenta with your finger; get hold of a leg as soon as possible, and bring it down."-ED.]

CHAPTER XIV.

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED

PLACENTA.

Definition. This is the form of hemorrhage which is generally described in obstetric works as accidental, in contradistinction to the unavoidable hemorrhage of placenta prævia. In discussing the latter we have seen that the term "accidental" is one that is apt to mislead, and that the causation of the hemorrhage in placenta prævia is, in some cases at least, closely allied to that of the variety of hemorrhage we are now considering.

When, from any cause, separation of a normally situated placenta occurs before delivery, more or less blood is necessarily effused from the ruptured utero-placental vessels, and the subsequent course of the case may be twofold: 1. The blood, or at least some part of it, may find its way between the membranes and the decidua, and escape from the os uteri. This constitutes the typical "accidental” hemorrhage of authors. 2. The blood may fail to find a passage externally, and may collect internally (see Plate IV.), giving rise to very serious symptoms, and even proving fatal, before the true nature of the case is recognized. Cases of this kind are by no means so rare as the small amount of attention paid to them by authors might lead us to suppose; and, from the obscurity of the symptoms and difficulty of diagnosis, they merit special study. Dr. Goodell' has collected no less than 106 instances in which this complication occurred.

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Causes and Pathology.-The causes of placental separation may very various. In a large number of cases it has followed an accident or exertion (such as slipping down stairs, stretching, lifting heavy weights, and the like) which has probably had the effect of lacerating some of the placental attachments. At other times it has occurred without such appreciable cause, and then it has been referred to some change in the uterus, such as a more than usually strong contraction producing separation, or some accidental determination of blood causing a slight extravasation between the placenta and the uterine wall, the irritation of which leads to contraction and further detachment. Causes such as these, which are of frequent occurrence, will not produce detachment except in women otherwise predisposed to it. It generally is met with in women who have borne many children, more especially in those of weakly constitution and impaired health, and rarely in primiparæ. Certain constitutional states probably predispose to it, such as albuminuria or exaggerated anemia; and, still more so, degenerations and diseases of the placenta itself.

1 Amer. Journ. of Obstet., 1869-70, vol. ii. p. 281.

VERTICAL MESIAL SECTION OF UTERUS WITH PLACENTA PARTIALLY ATTACHEDfrom a case of abdominal section for hemorrhage during labor. After BARBOUR.

(To face page 430.)