a. Retarded Expulsion. without the.placental adhe sions are not firm, and the probable cause of retention is functional trouble of the uterus, or slight mechanical obstacles, then the efforts of nature may suffice for its elimination, and this occurs shortly through uterine contractions alone. It is about the tenth to the fifteenth day that the placenta begins to separate, and that hemorrhage reappears; but the in terval may be months, and the only sign accompanying the shedding is sub-involution, and one of its consequences, hemorrhage. The placenta may be slightly degenerated, but this is not always so; it is especially the case when we are dealing with shreds of the ovum. Baudelocque has noted such retention for many months. Cazeaux says: " When we examine these placentas they are not altered, and have no odor, and they may be as fresh, even after weeks, as though extracted immediately after miscar riage. The integrity of the vascular connections has given them lease of life, and explains the innocuousness of this prolonged retention. SchC.:11er has noted retention for eleven weeks; Metz for two and a half months; Prost, 103 days; Plasse, 15 weeks, and Reichmann, 13 weeks.
Unfortunately, the above is not always the case, and hemorrhage may be so profuse as to compromise life. Reeking cites a case where the pla cental remnant was passed only at the eud of four and a half months. During this entire period the woman had profuse hemorrhages.
During retention, the uterus retains its increased size. Sometimes the vaginal portion of the cervix is shortened, the external os open, ' the lips softened and swollen, the internal os patent. The lower segment of the uterus is full and distended, the boundary between cervix and body is not marked. Again, the cervix is closed, and has resumed its shape; and again, the internal os alone is closed. The functional troubles of the uterus are manifested by pains, occurring, usually, when the placenta partially detaches itself. From time to tima, the women have pains in the back, in the abdomen, frequent desire to urinate. The lochial discharge, instead of being almost ni/ as after completed miscarriages, persists, remains reddish, sometimes is fetid: but what predominates is hemorrhage, which may be profuse, even though the placental remnant be small. Finally, the woman may have slight rise of temperature.
(b.) Expulsion of the Placenta Altered and Without symptoms of septic infection.—In these cases the marked phenomena are localized in the uterus and its neighborhood. The lochia 'become fetid, and this persists, until the 'placenta has been expelled, either spontaneously, or by instrumental means. Inflammatory symptoms from the uterus, or the adjacent organs, not rarely supervene, but these are ae,companied only by slight fever, and hemorrhage. Even as the lochia may be putrid without the presence of micro-organisms, even so the placenta may become putrid in the absence of such organisms. The alterations are purely chemical in nature, and consist in the production of alkaloids of very penetrating odor; fermentative microbes are not present, and, therefore, there is no danger of serious intoxic,ation. 2d. With septic infection.—Degeneration of the placenta may occur before the expulsion of the fcetus. Kauffmann has reported a case of miscarriage at the fourth month, where, before the expulsion of the fcetus, the woman had chills, hemorrhages, high temperature, with escape of putrid clots. Two-thirds of the placenta remained in the uterus after the expulsion of the fcetus, and the woman died in four days, of septic fever.
When the retained placenta putrefies, and septic fever supervenes, it may be acute, or sub-acute, from the start. The woman may die quickly
after the expulsion of the fcetils. At other times, the progress is less rapid; it may last from weeks to months, and end in cure or in death. In these instances, to the signs we have already noted as following on retention of the placenta, are joined those which are characteristic of placental putrefaction. The lochia become sero sanguinolent, blackish, and cont,ain remnants of placenta or membrane, intolerably fetid. When injections are administered, this odor is diminished, but it quickly reappears. At the same time there are symptoms of metritis, metro-peritonitis, and all those of septic infection —chills, fever, diarrhcea, change in the appearance.
(c.) Absorption of the Placenta. —May this occur? The fact is admit ted by Velpeau, Lagemard, Maslieurat, and denied by Madame Boivin, and others. Hegar has lately studied the question, and he thus tabu lates the reported cases: lst. Cases in which no discharge, either bloody or serous, purulent or putrid, has been observed, in which the placenta might have passed away. Such are the cases cited by Nigele, Gabillot, d'Outrepont, Villeneuve, Porcher, Charleston, Maslieurat, Lagemard; 2. Cases in which there has occurred more or less abundant discharge of putrid sero-sanguinolent fluid. Such are those of Salomon, Schmidtmul ler, Burger, Steinberger, Kyll, Ovalide, Velpeau, Dubois, Planque, Ingle by, Glover, Morlane, Deubel, Villeneuve, Delpierre, Godefroy.. Hegar first establishes the fact that cases in the second category can not be of placental absorption, and that they must be considered as instances of retention of the placenta with degeneration. But is this also true of the cases in the first category? By resorption of the placenta authorities understand not absorption of putrefied and loose placentEe, but of those still adherent to the uterus, neither liquefied nor putrefied. And in the seven observations noted, tlie existence of an adherent placenta had been assured. No uterine or vaginal discharge, containing remnants, had been present; on the contrary the lochia are said to have been diminished, without odor. Both cord and membranes had been expelled. With the exception of slight fever, and a few after pains, nothing in particular was noted. In five ca,ses menstruation reappeared from the seventh to the thirteenth week, and in those there speedily occurred another pregnancy, and normal confinement.
Certainly, at first sight, absorption seems incontrovertible. Hegar proposes three hypotheses: 1. Either the accoucheur was in error in observation, or there was deception on the part of the patient ; 2. Or there occurred retention of the placenta, and consecutive alteration; _3. Or true absorption took place. In conclusion, without absolutely denying the possibility of absorption he does not consider as credible the cases heretofore recorded. It is most likely that the retained portions were liquefied, and broken up, thus passing away in the vaginal excre tions.
(d.) Indefinite Sojourn of the Placenta in the is granted by Hegar that the placenta, and even the entire ovum, may remain in the uterus even up to the death of the woman. They undergo retro grade metamorphosis, and this is the explanation of those curious cases where, after death, foreign bodies, containing fcetal debris more or less altered, have been found in the uterus of women of the age of 75, 80, and 90. Such are recorded by Kilian, BOhmer, Sandifort, Vallisnieri, Morgagni, Van Swieten, Camerarius, Declek, Niemann.