UNAVOIDABLE HEMORRHAGE. 105 



after a week or so, and without any apparent cause, and thus comes 

 and goes till the end of gestation. With the first sensible contrac- 

 tions, the flooding occurs more profiisely, and is seen to increase 

 during each pain. An internal examination is necessary to discover 

 whether the implantation be complete or not. 



Diagnosis. — This variety of hemorrhage is distinguished by the 

 fact, that it usually begins without evident cause, and that it is in- 

 creased during a pain ; a per vaginam examination also reveals the pre- 

 sence of the placenta, which is distinguished from a clot of blood by 

 its being firmer and not breaking down under the finger. If it only 

 partially covers the os uteri, its edge will be felt continuous with the 

 membranes, and through the latter the presentation may perhaps be 

 felt. 



Treatment. — If the hemorrhage is slight and the term of gestation 

 not completed, palliative measures should be tried as before described. 

 If so profuse as to demand interference, there is no hope of a natural 

 termination, unless the pains be so violent as to force away the pla- 

 centa before the child. This, however, is so rare as not to justify 

 waiting. The only alternative is to turn and deliver as quickly as 

 possible. It fortunately happens that the continued bleeding so 

 softens the os uteri as to render it speedily dilatable. 



The hand is to be introduced in the usual manner, and insinuated 

 between the os uteri and the placenta, on that side on which the pla- 

 centa is believed to be thinnest ; the membranes should then be rup- 

 tured as high up as possible, and the feet seized and brought down. 

 When the body of the child is in the pelvis it will act as a tourni- 

 quet, and compress the bleeding vessels. Nevertheless, the labour 

 should be terminated as early as possible. 



Some authors recommend that the hand should be pushed through 

 the placenta — a thing much more difficult to effect. The placenta 

 should always be delivered as quickly after the child as possible, and 

 every care taken to prevent a recurrence of the hemorrhage. 



Some authors recommend that if the os uteri be undilated when 

 the hemorrhage comes on, the tampon should be used till dilatation 

 takes place. This has been objected to, on the ground, that it pre- 

 vents the attendant from knowing when the os uteri is dilated or 

 dilatable, and thus valuable time is lost. 



If the feet present, it is more favourable, as the operation of turn- 

 ing is rendered easier. If the placenta is only attached to the edge 

 of the OS uteri, and the pains are active, it should be treated as a 

 case of accidental hemorrhage, by rupturing the membranes. The 

 pressure of the head whilst dilating the os uteri will close the mouths 

 of the bleeding vessels with the placenta, and so arrest the flooding 

 till the child is expelled. 



Drs. Simpson of Edinburgh, and Radford, of Manchester, recom- 



