What is the source of the hemorrhage? According to Simpson it comes from the maternal vessels, according to Depaul and others from the uter ine sinuses. According to Duncan there are four sources: 1. A gush of blood comes from the blood-sinuses of the maternal portion of the pla centa, at the moment of separation. 2. It comes from the placental sur face itself. 3. From the circular sinus which is at the border of the pla centa. 4. From the open uterine sinuses. Mackenzie and Snow Beck affirm that the gaping arteries at the point of separation form another source of the hemorrhage. Coagulation, local and general anemia, uterine contraction, separation of the placenta, etc., favor arrest of bleeding.
3. Hemorrhage after Delivery.
Hemorrhage from placenta previa is very grave if it occurs after de livery; it is due largely to uterine inertia, as well as to the extremely vascular condition of the inferior segment.
is without difficulty, if the previous history of the case is studied with special reference to the occurrence of bleeding dur ing pregnancy without known cause. After the placenta has been ex pelled, it is easy to recognize the site of its insertion. When the placenta is inserted at the fundus, the membranes rupture at the most dependent point, that is to say, at the part in contact with the os internum; hence the sac is at the opposite extremity from the placenta. But when the latter is inserted in the lower segment the membranes can with difficulty rupture spontaneously, so that the attendant must rupture them with the hand or an instrument. When the insertion is marginal, the membranes rupture at the most dependent part, which is near the edge of the pla centa.
prEevia is one of the gravest complications of preg nancy and labor. We would first call attention to the frequency of labor before term: As to the maternal mortality, it varies from 32 per cent. to 25 per cent.; and as to the foetal mortality: Simpson of 106 children lost 73; Depaul of 63 lost 39; Muller of 853 lost 486. The mortality in general may be stated as 64.18 per cent. It varies considerably according to the month when labor sets in: thus at 7 months, 15 per cent., at 8, 29 per cent., at 9, 18 per cent., at term 35 per cent.
It varies with the mode of insertion of the placenta. In 739 cases the mortality was 57 in marginal and 109 in central implantation. If the contractions are regular and strong, the labor will be terminated sooner to the advantage of both mother and child. The prognosis for the mother becomes more favorable after the death of the child, as the hemor rhage diminishes. The placenta may be adherent, as in 80 cases out of 341, collected by Muller and others.
The maternal mortality in cases of spontaneous delivery is from 11 to 14 per cent., in artificial about 21.8 per cent. The foetal mortality in
the former case is 32 per cent., in natural delivery preceded by a pre liminary operation, 54.2, and in artificial delivery, 57.3 per cent. The following results were obtained by inducing premature labor: Hecker, out of 40 women, . lost only 3 Hoffmann, " 33 " . 2 Spiegelberg, " 74 " 4 methods have been followed by different authori ties, according to the diverse theories which have been adopted. One thing is to be remarked, most of them have made little account of the child's life as compared with that of the mother. We shall see if it is not possible to consult the safety of both.
The prominent symptom is hemorrhage, and this must be treated ac tively, and not with mere palliative means. There is one remedy which, although it may be of benefit in hemorrhages occurring during the first six months of pregnancy, is certainly contra-indicated during the last three; we refer to venesection. It would only hasten the fatal issue if employed when a patient is already exhausted from loss of blood, and should be condemned in cases of placenta prievia. Opium tends to diminish the contractions, and may therefore do more harm than good; cold and astrin gent injections are not sufficiently powerful; we are accordingly limited to a few other agents. These are ergot, forced delivery, the tampon, rup ture of the membranes, and separation of the placenta and extraction of the same before the child, according to the plan recommended by Simp son, Barnes, and other English writers.
Forced Delivery.—Accouchement Force.—This is the most ancient method, which has been practised by many authorities; Levret recom mended it only in cases of central insertion. It is a deplorable procedure, and ought not to be employed except when all other means have failed. The old obstetricians used to introduce one or two fingers through the as, and then the entire hand, after which they turned and extracted the child. This operation, no matter how gently it may be performed, al ways results in contusions or tears of the cervix, sometimes with resulting gangrene. It is only possible to practise it after the cervix has become softened in consequence of the preceding hemorrhage; and besides, after the child has been turned and partially extracted, the cervix may grasp its neck so firmly, that it is impossible to extricate it. Now it is custom ary to obtain more room by making multiple incisions, preliminary dilata tion having been effected by introducing two fingers through the os; but, although such incisions are usually harmless, they may sometimes extend beyond the inferior segment.