Where the adhesions are slight, it is not a very difficult matter to peel the placenta off with the finger, but usually, unfortunately, the uterus rebels against the introduction of the hand, or the adhesions are very firm and resisting. In the last instance the placenta must be scraped off, and with the greatest care, in order to be sure of removing the entire portion of the placenta and membranes. (Fig. 152.) In case after extraction a portion is lacking, the hand must be re-introduced. If great difficulty is met with it is better to desist, rather than by persisting injure the uterus. To say nothing of absorption of the placenta, which, although admitted by Velpeau and others, seems to us very problematical, we believe that the retention of a cotyledon or shred of the membranes is less dangerous than repeated attempts at extraction. From the observations of Hegar and many others, it is proven that often these cotyledons remain in the uterus a certain time without alteration, and are spontaneously expelled without much hemorrhage and without odor. Gueniot saw a fresh pla centa expelled at the end of two days; I have seen the same occur at the end of five days. Usually, however, this is what occurs: A portion of the cotyledon breaks up and passes away in the discharges. Another por tion putrefies and alters. This is either expelled at the end of a few days, (in a personal case at the end of thirty-seven days,) or else it becomes con verted into a so-called placental polyp. The woman has but little fever, and tonic treatment as well as vaginal injections soon restore her to health. This, however, is not the rule. Under the influence of degeneration of the remnant, the woman is seized with chills, fever, and other symptoms of putrid infection, and, if we do not interfere, her life is greatly endan gered. As to treatment, authorities are not in accord. lulu iii England, and especially in Germany, active intervention is as dilatation of the cervix, curetting, etc., in France we are not so bold; and although Pajot uses the curette, and Depaul placental forceps, for our part, after having tried these means, we have rejected them, and we limit ourselves to intra-uterine injections twice, and vaginal eight to ten daily. In two cases we succeeded in saving septic women. To these measures, we add, of course, quinine, tonics, etc. The intra-uterine injections must be administered by the accouthenr, and with the double current catheter.
[Under the subject of miscarriage (Vol. II.), we have given our reasons in favor of an entirely different action from that which Charpentier ad vocates. It is unnecessary to repeat them here. We would simply lay stress on the following points, which are not emphasized as they should, be in the text: Whenever the hand or instrument is introduced into the uterine cavity, give an intra-uterine injection of hot water (carbolized or sublimated, according to choice); and further, never fear injury to the uterus if manipulation is gentle, whether with the finger, dull curette, or placental forceps, half as much as the possible results from leaving a por tion of the placenta or membranes in the uterus, to putrefy and poison the woman. Granting for a. moment, even, that the chance of this oc curring is slight, we would maintain that the accoucheur has no right to subject his patient to even this chance, when by prompt and timely action he can avert it without the least damage to her. We cannot repeat too
often that the immediate removal of adherent placenta and membranes is, if done lege arils, not only not dangerous but salutary.—Ed.] Spasmodic Contraction of the as in labor, the contractions may become exaggerated, lessened, perverted, so, during the third stage, they may present the same anomalies, which Stoltz considers spasmodic, and divides into spasm of the external os, of the internal os, of the body, partial or total. Of these four varieties, that of the external os and total of the body are rare. The latter usually is seen in case of presentation of the shoulder, where the physician or midwife has prematurely ruptured the membranes, in order to make the diagnosis, and where ergot has been administered. It is then that tetanus results, rendering version impossi ble, and calling for embryotomy.
Spasm of the internal os is relatively common. The uterus is divided into two cavities, a superior portion, hard, rigid, contracted; an inferior portion, soft and relaxed. The uterus assumes the form of an hour-glass, whence the term hourglass contraction. In this condition, the placenta may: 1, be retained in the uppet portion, the cord only passing through the os; or, 2, a small portion projects through the os; or, 3, one half of the placenta is above, and one half below the os; or, 4, the greater por tion is below the internal os, and the remainder above.
The complication is the graver the more the placenta lies above the constriction. ' The real danger, however, is the association of adhesions and of hemorrhage. As long as there is no loss of blood, we may wait, the constriction yielding at the end of a few hours or less, and, if the pla centa be not adherent, it is expelled spontaneously. If it be adherent, once the constriction yields, the hand should be introduced into the uterus and the placenta peeled off. If, however, at the end of this interval the constriction does not yield, the patient must be anaesthetized, and first one finger and then another passed gently through the os, and extraction proceeded with, all the more urgently, of course, in case there is hemor rhage. Stoltz recommends smearing the hand with extract of belladonna.
In partial spasm of the body, the placenta is encysted in a portion of the uterine wall. In this case the constriction is above the internal os, and the uterus is divided into three cavities, the one as far as the internal os, the second between this and the constriction, the third above the lat ter, where the placenta lies. The placenta may be encysted entirely or partially, or one or more cotyledons separately, the multilocular encyste ment of Guillemot.
On palpation the uterus is found irregularly contracted, the upper lobe being usually lateral, at a superior angle. Cases have been recorded by Riecke, d'Outrepont, Aschern, Payan and Scanzoni, where a portion of the placenta was inserted in the uterine end of the Fallopian tube..
As for the etiology, the majority of authors attribute the condition to partial and irregular contractions of the uterus. Bubendorf, however, claims that it is due to a paralysis at the placental site, the remainder of the uterus being well contracted.