It is rather a surprising circumstance that Mauriceau, who was so largely engaged in midwifery practice, and who witnessed a good many cases of placenta prævia, should have been supposed to be ignorant that the original attachment of the after-birth was on the cervix. It has been asserted that this distinguished writer always supposed that, when the placenta was before the child, it was owing to an accidental detachment of it from the fundus, and that it had afterwards fallen down to the orifice, so as to get in advance of the presenting part; and yet, he very distinctly gives directions how to pass the hand, so as in the easiest way to get it by the placenta, when the operation of turning has to be performed; and the twenty-eighth chapter of his second book is devoted to a very full account of the mode of delivery in such cases-and he gives at full length the description of twelve cases of placenta prævia most admirably managed by himself, which are in the first volume. The celebrated Levret gives us, in his article on placental presentations, an elaborate résumé of the history of opinions on that accident as expressed by writers antecedent to him. It seems that many practitioners had treated the case, and well, too, but without possessing such correct notions upon it as are entertained at the present time.

It will have been perceived that I have not, in this article on placenta prævia, adverted to the new method of treatment which has been. so strongly advocated by Drs. Simpson, Radford, and other eminent persons among the brethren in England and in this country. I mean, the total separation of the placenta, by the hand of the accoucheur, as a certain method of putting a stop to the effusion of the blood. The journals and other publications, in which this treatment has been set forth and recommended, contain the relations of numerous cases in which the placenta was either accidentally or designedly separated from its place on the womb, and in which the blood ceased to flow immediately after the complete detachment of the after-birth. Not withstanding the good success of this practice has begun to render it very popular, I think that too much confidence is reposed in its power to arrest this most dangerous flooding, and I attribute its success so far rather to the well-known power of nature to cure the cases than to the method or the dexterity of the friends and promoters of it. It has been supposed heretofore that alarming uterine hemorrhages proceed from patulous orifices of vessels of the womb, and that the essential remedy for these effusions consists in the condensation of the uterine texture under the active contractility of its muscular fibres. But the advocates of the new practice in placenta prævia explain their success and urge the adoption of their method upon the new ground

that the blood flows, not from the uncovered portion of the uterine placental superficies, but from the uncovered surface of the placenta itself, averring that while a part of the placenta is detached and the rest of it retains its adherence to the uterine surface, the blood of the uterus continues to pass into the cells of the still attached placenta, from whence it escapes into the cells of the detached portion, and thence issues in torrents from its free surface; whence the idea that, by wholly separating the placenta from the womb, no more blood can gain admission to the cells of that tissue, and therefore no more blood can be lost. I regret to see that this unphilosophical and anti-physiological view still has its advocates—as for example in a discussion on Dr. Barnes' paper in the Medical Society of London, Dec. 22d, 1848, reported in Lancet, No. 1, vol. i. 1856, p. 14. Dr. Barnes advises that part of the circumference should be detached, to obviate the traction of the rest, and Prof. Murphey, in his remarks, insists that the flooding proceeds from the womb through placental vessels. I hope a sounder physiology may soon remove so erroneous an impression, and set aside so evil a practice.

Entertaining those views, which I have already, at page 202, expressed, as to the constitution of the placenta, and its connection with the uterus, and to which I beg the Student to refer, it is clearly impossible for me to admit the truth of the foregoing explanation of the hemorrhage of placenta prævia.

To say that the detachment of the placenta, without any consequent reduction of the superficial contents of the uterus, could arrest a hemorrhage by breaking off the curling arteries (as they are called) of the womb, appears too quite unphilosophical, for there are thousands of facts of ante-partum and post-partum hemorrhages to prove that the arrest of hemorrhage is the consequence of condensations of the womb under its muscular contraction.

The incision of the womb, in a Cæsarean operation, often cuts through the most vascular part of the organ, and as the bistoury sinks into the tissues, the blood spirts from numerous divided vessels; but as soon as the child and the secundines are taken out of its cavity, and the organ is allowed to contract, the immense orifices are nullified by the condensation of the texture, a cut of five inches in length being immediately reduced to a length of not more than two or two and a half inches, and its incised edges scarcely allowing of the smallest sanguine exudation.

This I have observed to happen in the instance of Mrs. Raybold, whose case is related in this work. To separate the placenta, and not allow the womb to contract, is to gain nothing; for the hemorrhagic

molimen, or the mere traumatic flow, cannot be supposed to cease merely because the curling arteries (so called) are broken off.

Further, in placenta prævia the effusion is, in many instances, most dreadful, long before the hand of the accoucheur can be passed upwards, in order to turn and deliver. Nay, it is alarmingly great in some samples, while the os uteri is still not larger than a quarter of a dollar. But as the placenta is eight inches in diameter, it seems to me not possible to detach the whole viscus with a finger, which is not long enough to reach the very circumference of a centrically implanted after birth, and, à fortiori, not long enough to reach to the remote edge of one not centrically implanted. How shall the acconcheur accomplish the detachment in a rigid and slightly open cervix? If the os uteri be dilated, or dilatable enough to introduce the hand for turning, the time has arrived for that operation, and there is then assuredly no occasion to detach the placenta. Let the operation be performed at the earliest possible period; for the indication, as in all dangerous uterine hemorrhages, is to let the womb contract, which it cannot effectually do until the ovum is extracted or expelled from its cavity. When that is done, it speedily draws itself to the smallest possible cubic content. Messrs. Simpson, Radford, and the other gentlemen who advocate the new method in placenta prævia, very earnestly recommend the prompt separation of the whole of the placenta, and they are persons whose opinions are justly to be esteemed of the greatest weight; but, notwithstanding the profound respect with which I receive any statement of theirs, I cannot but think that in any case in which it is possible to detach the whole of the placenta, it would be also possible to introduce the whole of the hand, and thus commence at once the operation of turning, which ought to be esteemed as the essential indication of treatment, and which the earlier it is done so much the greater chance does it give both of rescuing the child and saving the woman from fatal losses of blood.

Heretofore, in turning for a shoulder presentation, I have found the placenta lying at the fundus uteri, wholly detached and without any immediate hemorrhage; but I have seen a vast number of most dangerous post-partum hemorrhages, occasioned by coagula filling the vagina, and acting there as a tampon, allowing the uterus to expand again with influent blood, and rendering the orifices of vessels upon its placental superficies nearly as patulous as before the birth of the child. I cannot suppose, therefore, that when I have found the pla centa wholly detached at the fundus uteri in a labor, hemorrhage failed to occur because of that detachment; nor can I suppose that, in placenta prævia, hemorrhage is arrested because of the artificial

detachment, but rather, in both cases, from association of the hemorrhagic molimen, with the disruption of the utero-placental bond. Let me, before I lay aside this subject, say that, should the Student happen to come in charge of such a labor, and find the woman dangerously exhausted of blood at his arrival, I advise him, when about to deliver, to raise the foot of the bed, so as to let the patient lie upon an inclined plane, the head downwards. I once delivered a poor woman in such a case. The foot of the bed was elevated some fifteen or twenty degrees, so that I might say that I lifted the child upwards in delivering it. Probably I saved her from fatal deliquium by this precaution.

Although I have, already, at page 253 of this volume, made mention of Braun's colpeurynter, and spoken of the applications I have made of it in the case of very obstinate retroversions of the womb, it becomes necessary to show, in this place, the great advantages derivable from its employment in placenta prævia.

No person will ever be able to persuade me that it is either good physiology or sound practice to proceed in curing or rather in trying to cure placenta prævia by detaching the whole placenta, with an incomprehensible notion that to do so, is certainly to arrest the hemorrhage, and that on the erroneous assumption that the blood in this condition runs out of the uterine vessels into certain hypothetical cells of the placenta, and from those cells into the womb or vagina. I utterly deny the doctrine and sincerely hope that the American Student will reject it, which he cannot but do if he will but receive proper views as to the structure and functions of the human placenta. With these opinions I adhere to the long settled practice of Turning and delivering by the feet in all cases of placenta prævia in which the indication is presented of emptying the womb as soon as it can be safely done. In saying so, I am not forgetful of the fact that I have in placenta prævia delivered by means of the forceps, a case that might occur a few times in one's practice of half a century. Nor am I oblivious of the undeniable truth that some women have had vigor enough to thrust the presenting part of the child upon the placenta prævia and push it rapidly before it, so as to expel the foetus by a labor so rapid as to prevent the loss of any considerable quantity of blood.

Unhappily, these rapid labors are very uncommon, and the woman is compelled to suffer dangerous and sometimes fatal losses of the vital fluid, before the os becomes sufficiently open to allow a hand to pass within it.

Should the Student find himself in charge of a case of placenta prævia, with excessive flooding and a slow dilating os, he would be sure to reflect that turning is the indication which is to be fulfilled as soon as the os will permit, and he will think that if any measure could be taken to get the os open enough to allow the hand to pass upwards in search of the feet, such measures ought to be resorted to. He has just the thing he wants in Braun's colpeurynter. (Vide Fig. 74, p. 253.)

If a colpeurynter should be placed within the vagina, he might fill it with water at 60°, or 50°, or 45°, and he might gently go on with the injection of water into the vulcanized rubber bag until the woman. complains of the distension. I have thrown cold water into the sac in such quantity as to make it expand to the size of the child's head; and in doing so I have felt quite sure that I was not only aiding in the process of dilatation, but I was applying a salutary therapeutic means (cold) for the checking of the flooding.

If a head is above the os uteri striving to dilate or force it open, a colpeurynter below the os, and made as large as the head, could not but materially assist the dilatation. Indeed, so effective is the method that, if a woman be seized with the flooding, without any dilatation, a colpeurysis, continued about four hours, generally opens the os uteri enough to allow the hand to pass within and explore for the feet. Such a dilatation, effected within four hours, with the double advantages of being an admirable cold application, would save a large proportion of blood that must be inevitably lost in a case where the dilatation might require twelve or fifteen hours before the hand could pass upwards to Turn. I believe few cases of placenta prævia will, henceforth, be treated by European or American accoucheurs, without the use of colpeurysis; and I trust every Student will, on going into practice, be provided with a set of well constructed instruments of the kind.

Concealed Hemorrhage.-There is another kind of hemorrhage that is met with in parturient women; I mean the concealed hemor rhage. It may take place from the placental surface, and continue to a dangerous extent, without detaching the circumference of the afterbirth from its connection with the womb. In this case, the whole placenta is separated from the womb, with the exception of its rim; and the distensible material admits of so large a quantity of blood being effused betwixt itself and the womb, as to make it take the ap pearance of a bag filled with blood, and depressed into the uterine cavity. I have never met with a clear sample of this kind of bleeding; but the phenomena that accompany excessive loss of blood would give