considered that they have been produced by some inflammatory process taking place between the uterus and placenta; and certainly the firm feel and lighter colour of the part which has been adherent might, perhaps, justify such a conclusion. Cases have occurred where the inflammatory action has extended in the contrary direction (outwards,) producing mischief in the neighbouring parts, viz. abscess and injury of the pelvic periosteum with subsequent pelvic exostosis. (Neue Zeitschrift für Geburtskunde, band v. heft 1.) We may also observe, that these adhesions of the placenta usually occur several times in the same individual.

Prognosis and treatment. The danger in these cases depends chiefly on the presence or absence of hæmorrhage; in the latter case, we may wait safely, and give the uterus the opportunity of contracting upon the placenta, so as ultimately to dilate the stricture and expel it. In most instances, where the os tincæ is the seat of the contraction, and the placenta (as is usually the case here) already detached, a little patience, aided by gentle friction of the fundus, and carefully abstaining from all irritation of the os uteri, will be sufficient to attain this object; the os uteri will gradually relax, and the placenta slowly exude into the vagina. Where, from the feel of the fundus, the uterus appears still unable to exert such a degree of contraction as shall overpower the os uteri, we may follow the plan of Dr. Dewees, in his section "On the enclosed and partially protruded Placenta," and rouse its activity by some doses of ergot: "Should this not succeed within an hour, the uterus must be gently entered, by slowly dilating the os uteri, and the placenta removed." One finger after the other must be passed through the os uteri, until it has yielded sufficiently; if the placenta be quite detached, two fingers will generally be sufficient for this purpose, by which means it may be gradually brought down into the palm of the hand, and then removed.

Where more or less of it is morbidly adherent, which may be presumed when it continues for some time at the upper part of the uterus without any disposition to descend, we must carefully introduce the whole hand, and endeavour to find the edge of the placenta at which we should begin the process of separation. Where, however, the edge is very thin, and the attachment firm, it is not easy to effect this without risk of injuring the structure of the uterus itself with the nails, nor can we always distinguish the thin and closely adherent edge of the placenta from the uterus itself: in these cases it will be safer to plunge the fingers into the central and thicker portions of the mass, and gradually separate it towards the circumference. Wherever this close adhesion prevails over a considerable extent, it becomes nearly impossible to prevent portions being left adhering to the uterus; thus it not unfrequently happens where a placenta under these circumstances has been artificially removed, that there are one or more large irregular cavities on its uterine surface, from a portion of its mass having been torn from it, and left adhering. Cases have occurred to us, where the whole central portion has thus remained, the amniotic surface of the placenta having come away entire, with the larger umbilical vessels attached to it, and merely a narrow margin of parenchyma at its edge; in others, the whole mass has broken up, the cord, the

larger branches of the umbilical vessels, and the membranes have come away, but the greater part of the placenta has remained closely adhering to the uterus. In such a case it becomes a question, whether it be safe to persist in our efforts to remove the remains of the placenta, or whether it will not be better to leave the case to nature: experience shows that the latter plan is the safer, and that a practitioner is not justified in running the risk of severely injuring the uterus by repeated and violent efforts to effect his object.

Placenta left in the uterus. Where a portion of placenta has been thus left in the uterus, the case may terminate in one of three ways: either it may be expelled in the course of from twelve to twenty-four hours, without any perceptible marks of putrefaction, and with but little or no disturbance to the system; or where, after a longer interval, the discharges have become very offensive, and the placenta has been expelled in a putrid state, with serious disturbance of the health; or, lastly, where the lochia has been sparing but natural, and where no trace whatever of the placenta has appeared.

In the first mode of termination it may be presumed that the attachment of the placenta has yielded either to the continued contraction of the uterus, or from a slight degree of incipient putrefaction, by which its union with the uterus was weakened; in the second case, from contact with the external air, and being constantly kept at a considerable temperature by the heat of the surrounding parts, the lacerated placenta rapidly putrefies, putrid matter is carried into the system, producing all the effects of a deadly poison, and the patient is placed in a state of the greatest danger; the pulse becomes quick and small, the tongue red and dry, accompanied with great depression of the vital powers, the uterus frequently swells, grows hard, and excessively painful, followed by general peritonitis; it is not, however, the inflammation which necessarily destroys the patient, but the prostrating effects upon the nervous system, produced by the introduction of an animal poison into the circulation.

Absorption of retained placenta. Where the placenta has not been much lacerated, or at any rate where every portion has been removed which could be separated without violence, where also the uterus has contracted firmly and closely, the part which is retained does not pass into putrefaction, little or no inconvenience is experienced by the patient; the lochia, as we before observed, is sparing but natural, and ceases after the usual time, but not a trace of the placenta comes away. This fact has been repeatedly noticed, especially in later years; but the attention of medical men was first called to the subject by Professor Naegelé, of Heidelberg, in 1828. In 1802, and again in 1811, cases of premature expulsion of the foetus occurred to him, where the membranes and placenta did not come away, and where no trace whatever of them appeared afterwards. In 1828, his assistance was required in a case of unusually firm adhesion of the placenta, and where, from this as well as other circumstances, the extraction was so difficult that he was compelled to leave considerably more than one-third in the uterus. (Med. Gaz. Jan. 10, 1829.)

"I have reason to believe that a placenta which is entire and uninjured, which is enclosed in the uterus, adherent to it, and shut out from access of air, never becomes putrid." (Matthias Saxtorph, Gesamm. Schriften.)

About the same time, a most interesting case was published by Professor Salomon, of Leyden, where the whole placenta of a child only three weeks short of the full time was retained by the firm contraction of the uterus, and according to Dr. Salomon's view of it, removed by the process of absorption. About the end of the third week, the uterus, which had hitherto been larger than is natural under ordinary circumstances after labour, and more globular, now diminished considerably, and began to assume the usual form as in the unimpregnated state. Besides the cases already alluded to, which we have described in our Midwifery Hospital Reports, we may again refer to one which was mentioned by Dr. Young, formerly professor of Midwifery at Edinburgh: "I could get my hand to the placenta, but no farther, the uterus having formed a kind of pouch for it, so that I at last was obliged to trust to nature; what was very remarkable, the placenta never came away, yet the woman recovered."

Cases have also occurred where the placenta, after having been retained many days in the uterus, has been expelled quite fresh, the edges worn or rather dissolved away by the process of absorption; thus Dr. Denman mentions one where the whole placenta was retained till the fifteenth day after labour, and was then expelled with little signs of putrefaction except upon the membranes, the whole surface which had adhered exhibiting fresh marks of separation. Cases of abortion have occasionally been observed where the embryo has escaped, but the secundines have never come away, although the discharges, &c., have been watched with the greatest attention; after a time the menses have returned, the patient has again become pregnant, and has passed through her labour at the full term without any thing unusual occurring.

The subject has recently been considered very fully, and much interesting knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the fact beyond all doubt, he shows that cases of total adhesion are rarely, if ever, fatal, and that, where cases have terminated fatally, the placenta has only partially adhered, and the patient has been either destroyed by hæmorrhage, or by the effects arising from the absorption of putrid matter, or from injury of the uterus in attempting to remove the placenta. He considers that a placenta which is not fixed to the uterus by organic and intimate adhesions cannot be absorbed, though it may perhaps be retained for several days without danger, if there is contraction of the uterus. (Gazette Médicale de Paris, July 8, 1840.) It may, however, be doubted whether this last observation be correct, as it is a well-established fact that cows which had been supposed with calf, and in which the symptoms of pregnancy had again subsided, have afterwards been killed, and nothing but the bones of the calf found in the uterus, the soft parts having been removed by absorption. The same fact has been observed also in sheep and other animals; and knowing how abundantly the human uterus is supplied with absorbents, coupled with what has been already stated, there can be little or no doubt but that the placenta in these cases had been acted upon by a similar process. Although we strongly deprecate repeated attempts to remove the adherent portions of placenta, especially where we have brought away a considerable quantity of its foetal part, still we would warn our readers against leaving any loose ragged pieces in the uterus, for these rapidly pass into putrefaction,

and produce the alarming symptoms above-mentioned. The safety of our patient mainly depends on the firm contraction of the uterus preventing the access of air, and on our constantly removing, by means of injections, any putrid discharge which may have collected. The sparing quantity of lochia which has generally been observed, especially where the whole surface of the placenta has adhered, can easily be accounted for, the greater portion of the vessels which ordinarily furnish this discharge being closed up by the adherent mass: from the same reason we can explain why cases of total attachment of the placenta are rarely or never attended with hæmorrhage.

Lastly, should any symptoms of fever or abdominal inflammation supervene, they must be treated according to the rules which we have given under these heads.*

[An interesting memoir on retained placenta, by Dr. Edward Warren, of Boston, will be found in the American Journal of Med. S., May, 1840, p. 71.-ED.]

CHAPTER IX.

PRECIPITATE LABOUR.

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VIOLENT UTERINE ACTION.-CAUSES.-DEFICIENT RESISTANCE.-EFFECTS OF PRECIPITATE LABOUR.-RUPTURE OF THE CORD.-TREATMENT-CONNEXION OF PRECIPITATE LABOUR WITH MANIA.

THE second division of Dystocia comprises those species of labour where it becomes dangerous for the mother or child, without obstruction to its progress. Of these, we shall first consider precipitate or too rapid labour, not only because it is liable to be followed by a great variety of injurious results, but also because it has received little or no notice by the obstetric authors of this country.

Precipitate labour depends on one of two conditions; either the expelling powers exceed their ordinary degree of activity, or the resistance to the passage of the child is less than usual. "Every normal labour has a certain course, which is neither too slow nor too quick. The passages are thus dilated gradually and without excessive suffering, the uterus is felt alternately hard and soft; and the pains have certain and regular intervals, which become very gradually shorter, during which both mother and child are enabled to recover themselves." (Wigand, Geburt des Menschen, vol. i. p. 68.)

Violent uterine action. In the present case the pains are extremely violent from the very commencement of the labour; they produce great suffering; each pain lasts a considerable time, and the intervals between them are very short. During their presence, the patient is irresistibly compelled to bear down and strain with all her force; the whole body partakes of the general excitement: the patient is more restless and less manageable than usual, her manner is altered and becomes strange; the head is hot, the face flushed, and the pulse quick and full.

In some cases the intervals between the pains are scarcely perceptible, for one pain has scarcely left off before the next has already commenced; or the uterus falls into a state of continued violent contraction, which does not cease until the child is driven into the world. The abdomen is very hard during the pain, the whole body stiff and rigid; the patient expresses her sufferings very loudly, or actually raves with pain. From the constant and irresistible effort to strain, it seems as if she has scarcely time to get her breath, for she continues to hold it so long that respiration might be almost supposed to have stopped altogether. "As long as consciousness remains, the impulse to lay hold of any object within reach, and pull by it is extraordinarily strong, until, at length, in the midst of a violent scream, or grinding of the teeth, covered with sweat, with