in the different parts of the uterus. The greater contractile energy should be exerted by the fundus. We must then seek-1, means to relax the crampy constriction of the lower segment; and, 2, means to evoke the supremacy of contraction of the fundus and body. The cases we have been considering comprise those in which the placenta is retained simply from want of uterine energy to detach and expel it. These are by far the most common cases. But the placenta may be retained by morbid adhesion to the uterus. Cases of this kind are comparatively rare; they are more troublesome and dangerous than the first, and require more decided treatment. True adhesion of the placenta commonly depends upon a diseased condition of the decidual element. The most frequent is some form of inflammation with thickening, hyperplasia. This, in all probability, began in the mucous membrane before pregnancy. It is liable to aggravation when the mucous membrane is developed into decidua. Sometimes there is distinct fibrinous deposit on the uterine surface of the placenta; sometimes the decidua is studded with calcareous patches. The maternal origin of the forms of diseased placenta leading to adhesion is proved often by the history of previous endometritis or other disease, and by the frequent recurrence of adherent placenta in successive pregnancies. I have adverted to this subject under " Abortion." (See p. 468.) Further information will be found in memoirs by myself,* Fromont,† Hüter, and Hegar. § Diagnosis of Placental Adhesion. -You may suspect morbid adhesion, if there have been unusual difficulty in removing the placenta in previous labours; if, during the third stage, the uterus contract at intervals firmly, each contraction being accompanied by blood, and yet, on following up the cord, you feel the placenta still in utero; if, on pulling on the cord, two fingers being pressed into the placenta at the root, you feel the placenta and the uterus descend in one mass, a sense of dragging pain being elicited; if, during a pain the uterine tumour do "Brit. and For. Med.-Chir. Rev.," 1854. "Mém. sur la Rétention du Placenta." Bruges, 1857. not present a globular form, but be more prominent than usual at the place of placental attachment. The removal of a morbidly adherent placenta must be effected in the same manner as that just described for retained placenta ; but you must be prepared to encounter more difficulty. The peeling process must be effected very gently and steadily, keeping carefully in the same plane during your progress, being very careful to avoid digging your finger-nails into the substance of the uterus. In some cases the structures of the uterus and of the placenta are so intimately connected, seeming, in fact, to be continuous parts of one organization, that you cannot tell where placenta ends and uterus begins. In endeavouring to detach the placenta, portions tear away, leaving irregular portions projecting on the surface of the uterus. In trying to take away these adherent portions you must proceed with the utmost caution. The connected uterine tissue is, perhaps, morbidly soft and lacerable. It is very easy to push a finger into it, to the extent of producing fatal mischief. A very serious practical question now arises. To what extent must you persevere in trying to pick off the firmly-adherent portions of placenta? If you leave any portions, hæmorrhage, immediate or secondary, is very likely to follow; in decomposing and breaking-up, septicemia is likely to follow; and there is, besides, the liability to metritis. If a fatal result ensue, and a portion of placenta be found after death in the uterus, it is but too probable that blame will be cast upon the medical practitioner. The nurse and all the anility of the neighbourhood will be sure to cry out, "Mrs. A. died because Dr. Z. did not take away all the after-birth." The position is a very painful one. The true rule to observe is, simply to do your best; make reasonable effort to remove what adheres. It is safer for the woman to do too little than too much. You cannot repair grave injury to the uterus. To save your own reputation, you must fully explain the nature of the case at the time. You may lessen the risk of hæmorrhage and septicemia by injecting perchloride of iron and permanganate of potash. In a few days the process of disintegration may loosen the attachment of the placental masses, and they may come away easily. The safest way, if it can be done, of removing these "placental polypi," is to pass a wire-écraseur over them. As this instrument can only shave the uterine surface smoothly, you are secure against injuring the uterus. I have practised this in several cases with perfect success. As a warning against attempting too much, and as ammunition to repel an unjust charge of having done too little, remember the following passage from Dr. Ramsbotham, the truth of which I can attest from my own experience:-"Instances are sometimes met with in which a portion of the placenta is so closely cemented to the uterine surface that it cannot by any means be detached; nay, I have opened more than one body where a part was left adherent to the uterus, and where, on making a longitudinal section of the organs, and examining the cut edges, I could not determine the boundary-line between the uterus and the placenta, so intimate a union had taken place between them." Smellie, Morgagni, Portal, Simpson, Capuron, relate similar instances; and there is an instructive case reported by Dr. R. T. Corbett, in the Edinburgh Monthly Journal, 1850. A very soft placenta, especially if it be thin, of large superficies, so as to be diffused over a considerable portion of the surface of the uterus, is a frequent cause of adhesion. The contracting uterus does not easily throw off such a placenta, that is, completely. To be cast easily, a placenta must have a certain degree of firmness, and not be too large. Perhaps a large part may be expelled or withdrawn, and appear to be all; but a portion of a cotyledon remains behind; bleeding and irregular action of the uterus are kept up, until the hand is introduced, and the offending substance removed. A very rare-but on that account the more likely to be overlooked-event is the leaving behind a lobe of a placenta succenturiata. I have seen some singular examples of this. distance from the main body of the placenta, perhaps three or four inches or more from the margin, a mass of chorion-villi will be developed into true placental structure, and connected with the main body only by a few vessels. It resembles a lobe or cotyledon which has grown far away from the rest by itself. Such an accidental or supernumerary placenta may very easily remain attached after the main body, which is complete in itself, has been removed. These placentæ succenturiatæ rarely exceed in size that of a single cotyledon, ie, they measure about two or three inches in diameter. But I was once called by a midwife of the Royal Maternity Charity to a case of a different kind, at first very puzzling, The child was born, the cord tied, and the placenta, apparently entire, removed, when there followed a second placenta. Both were of nearly similar size and form. The first and natural conclusion of the midwife was that there was a second child still in utero; but she could not feel it, so sent for me. I passed my hand into the uterus, ascertained that it was empty, and made it contract. The second placental mass was developed on the same chorion as the chief placenta; vessels ran from it across the intervening bald space of chorion to join the single umbilical cord which sprang from the chief placenta. Dr. Hall Davis exhibited a similar double placenta to the Obstetrical Society. Another form of placenta associated with hemorrhage is where the cord is velamentous. In this case, the umbilical vessels, instead of meeting on the surface of the placenta to form the cord, run for some distance along the membranes, uniting perhaps several inches beyond the margin to form the cord. This part of the membranes containing the umbilical vessels spread out, may be placed over the cervix uteri. These vessels must be torn during the passage of the child. The hæmorrhage thus resulting comes from the placenta, and of course endangers the child. Dr. V. Hüter describes this formation of the placenta fully. Two cases of this kind are related by Caseaux. Joerg, quoted by Hegar, describes a case in which bundles of vessels were found over the greater part of the chorion, but no proper parenchymatous placenta; thus resembling the diffused placenta of the pig. Most of the unusual forms of placental development and of arrangement of the vessels in the placenta are beautifully illustrated in Dr. Jos. Hyrtl's splendid work, Die Blutgefässe der menschlichen Nachgeburt, Wien, 1870. "Monatssch. für Geburtskunde," 1866. M M LECTURE XXIX. HÆMORRHAGE AFTER THE REMOVAL OF THE PLACENTA FORMS: IMMEDIATE, PAULO-POST, AND SECONDARY" OR THE general or systemic conditions which lead to " Accidental Hæmorrhage" also predispose to post-partum hæmorrhage. Some of the conditions which lead to hæmorrhage before the removal of the placenta may also persist and keep up hæmorrhage after its removal. Of these the most formidable is inertia. When the uterus is perfectly relaxed, it may be said that the flood-gates are opened, and that the blood issues in torrents. In a few minutes life may be extinguished. In short, the accumulation of blood in the uterus, especially if coagulated, |