mouth and neck. Sometimes the placenta is com- of the placenta, as the best means of saving the pletely separated, and expelled before the child. life of the mother. Of course, he assumes, as a This occurs in cases in which it is centrally im- general inevitability, either the present or paulo planted over the os uteri. In those cases in which | post death of the child; the earlier the separation, it is attached rather to one side, with its centre re- the more certain this result. He has compiled a moved from the mouth of the womb, it, of course, separates at that portion on which it has the smallest area of attachment; and this partial separation preserves its longest adhesion on the opposite side, for it is now no longer dragged, or put on the stretch, by the contrary or contending action of the opposing sides. It is to this circumstance that the child is indebted for the prolongation of life, though, according to Dr. Simpson, the safety of the mother is more jeopardized than by complete separation. Dr. Simpson's reasons for holding this belief are based on his peculiar and wholly untenable views of the anatomy and circulation of the placenta.

list of 140 cases, in which the placenta was either expelled by the pains, or manually extracted before the birth of the child, and this list shows that only 10 mothers out of the 140 were lost. On the other hand, he exhibits a table of 339 cases, in which 115 women perished, where the labor was differently conducted. It might have been instructive to be informed as to the management of these 115 victims. To prove that any bad system is good by comparing it with one that is worse, is but feeble logic. By mere figures you can prove anything, or disprove whatever you choose; figures are too often but deceptive exponents of facts, unless they are accompanied by true and full details. of the facts represented by them.

Complete separation of the placenta without simultaneous and rapid expulsion of the child must Let us, however, follow up Dr. Simpson's prindestroy its life. It is held by many that each suc- ciples to their legitimate issues. He says, "The cessive pain tends to augment the hemorrhage, not complete separation of the placenta is generally, or merely by lacerating more vessels, but likewise by nearly always, followed by a great diminution of opening still wider those already torn. There the hemorrhage ;" but the explanation of this fact, seems to me to be no valid reason for believing that given by him, is quite vague and unsatisfactory. the lacerated vessels are opened still wider by each He says, "It is explicable not on the idea that the pain. On the contrary, I should rather be inclined descending head of the child acts as a plug or to think that the uterine contraction tends to com- compress on the exposed orifices of the uterine press, or narrow, their mouths; for as the neck and sinuses, but on the mutual vascular economy of lips of the womb are put on the stretch, in order the uterus and placenta, and the circumstance that to increase the diameter of the mouth, we may the hemorrhage principally comes from the parconsider that the stretching of the zone around it, | tially detached surface of the latter." Such were tends to narrow this zone; so that, supposing it to have been a certain breadth before the os began to open, by the time the opening attains, say to an inch wide, the cervical zone will have narrowed itself proportionally, and will thus have contracted the mouths of the torn or opened vessels; and were it not that with each pain the blood is driven with great force into the uterine vessels, we should find the hemorrhage not so great as may have been supposed.

Dr. Simpson's words.

Now as to the child's descending head not tending to stop the flow of blood, he is right, provided the head has not yet reached the seat of hemorrhage, which means it cannot press the vessels before it does press them; but certainly he is wrong if he holds that the hemorrhage will be as copious after the head has begun to press them, as it was when they were not so pressed.

In the second place, as to the mutual vascular It is not then, in my opinion, because of the in- economy of the uterus and placenta,"-what have we creased dilatation of these vessels by each pain, here but so many fine words? What substantial idea that the blood escapes more copiously, but because do they convey to the mind of the student? If each pain leaves an additional number newly they mean anything at all, it is that the separation opened, and probably each successive pain opens of the placenta from the uterus puts an end to the more than its predecessor did. Prof. Simpson act- demand by the placenta for the supply of maternal ually advocates the early and complete separation | pabulum, and therefore that supply is rot furnished;

and why not so? for Dr. Simpson might ask- malia. Each of these has its own distinct vascular what can a dead child want of such superfluity?

It would certainly be a great consolation to the anxious obstetrician to feel assured of this fact, when he is on the look-out for flooding, after the separation and expulsion of the placenta in ordinary labors. O! a fig for the fear of hemorrhage, let him say, the "mutual vascular economy" will take care of that. But we do, however, unfortunately know that the separation of the placenta and its expulsion after the birth of the child, despite Dr. Simpson's "mutual economy," are too often followed by hemorrhage, and that too, questionably from the mother.

system, which has no inosculation with the vessels of adjacent cotyledons, or lobes; so that did the mother's blood actually flow into the yet adherent lobes, it would not cross over into the detached ones, as Dr. Simpson imagined. This dissociated association of the constituents of the placenta, is, in my opinion, a very important factor in the " mutual vascular economy of the uterus and placenta," for I believe that the associated cotyledons, or lobes, may through the distensibility of the interlobular connective tissue, undergo a certain extent of sepun-aration from one another, and thus accommodate themselves for a time, at least, to the enlarging uterine surface. During the period of uterine enlargement, it is presumable that the placenta enlarges pari-passu with the enlarging uterus, and thus an harmonious economy is preserved; but exceptions to this uniformity of pace may occur, and then a struggle must arise. It may be in some such struggle that those early hemorrhages in the 6th and 7th months of pregnancy, take place. These, in their inception, are unaccompanied by pains; they come on suddenly, without any admonition to the woman, so that it would seem they have not their origin in uterine muscular contraction, or if such contraction is present it is not associated with the usual sensation.

In the third place, Dr. Simpson's idea as to the hemorrhage coming principally from the detached portion of the placenta, is so visionary as to excite our astonishment that it could ever have been entertained by even the most poverty-stricken advocate of a new theory. It would appear utterly incredible had we not the statement from Dr. Simpson's own pen, that he entertained the belief that the unavoidable hemorrhage in cases of placenta prævia "principally comes from the partially detached surface of the placenta." Assuredly whatever blood may thus escape is not drawn from the mother, but from the child, for there is no community of blood circulation between the mother and the child. It is true the child derives its nutriment from the blood of the mother, but not by the transmission of this into the vascular system of the child. This fact has been established beyond all controversy. The mother, then, will never bleed to death from the placenta, which is, in truth, no part of her system, but an organ of the fœtus, formed by, and for itself. But the mother does too often bleed to death, and the child then comes also to death, partly perhaps by the escape of its blood from the detached portion of the placenta; but mainly in cases of total placental detachment, from cessation of blood renovation by its vicarious placental lungs.

It has been most unfortunate for Dr. Simpson's theory that he ever descended to the discussion of its rationale. His great name and fame might else have conferred on it a more enduring vitality. It is always indiscreet, in propounding new theories, to enter into extended discussion of their merits.

The fact would seem to have been overlooked by many, that the placenta, in its normal attachment to the uterus, is a resisting body, and that it resists uterine effort. The action of the uterus is directly towards the dilatation of its own mouth, and the extension of the length and narrowing of the breadth of the cervical zone underlying the placenta. The placenta is pretty firmly attached to this zone, and must, to no trivial extent, resist the process of distension. Were the placenta at tached with abnormal firmness to the uterus, as in. deed it sometimes is, we might even believe that

Dr. Simpson's notion as to the blood passing over from the still adhering portion of the placenta into the detached portion, is surely out of accord with the anatomy and vascular economy of the organ. The human placenta, although appar-instead of a dissolution of the natural connection, ently an individual mass, is, in reality, but a corporate assemblage of numerous placentula, which are the analogues of the cotyledons of other mam

an actual tearing asunder of the placental structure would finally occur. The fact is unquestionable that some force, often in truth considerable, is re

quired to detach it from the uterus.

for this force implies resistance to it, and this resistance must, quoad hoc, retard the opening and normal dilatation of the os uteri, and consequently prevent the narrowing and elongation of the cervical zone.

The necessity of which correspond to our central os uteri, or the insertion of the umbilical cord. The continuous stretching of the inner or lower margin of this zone, must at once narrow its breadth, and continuously lay bare more and more of the uterine area, on which the placenta was placed. This recession or shrinking upwards, of the lower part of the zone, being the equivalent of the elongation of its inner boundary, and of its decrease of latitude, must be concomitant with a very notable change of form and condition of the blood-vessels passing lengthedly through the uterine wall, between its fibres, and opening on its surface, so that when the whole process of severance is accomplished, and the os is sufficiently distended to permit the passage of the child's head, or of its breech, the blood vessels have become compressed and strangulated, and are now no longer pervious. This is the actual "vascular economy" of the case, but certainly not that economy which Dr. Simpson alleged, for his is an utterly one-sided mutuality; it economizes for the mother at the cost of the child.

Here comes the important practical question, as to how, and how far, we may safely and profitably aid nature. Whatever promotes the effective dilatation of the os and cervix uteri, and thus consent aneously advances the labor, and closes the torn vessels and exposed sinuses, must be in the right and safe direction; but whatever foreruns this, and throws upon nature premature requirements, must be wrong. We always best aid nature by imitating her. It is my belief that Prof. Simpson, by some process of latent cerebration, rather than by the adjuvancy of his "mutual vascular economy of the uterus and placenta," did actually imitate nature, and by releasing the uterus from the resisting tenacity of the placenta, gave it a fair opportunity for doing its appropriate work. At all events I am quite prepared to believe, that in the 130 cases cited by him, as terminating fortunately by nature's spontaneous action, this "mutual economy" of forces and resistance was actually observed. When the placenta has been in part detached, that part which still adheres, resists, to a certain extent, the distending process; but when the adherence is finally and totally broken up, the cervix uteri obeys the unbridled force of the longitudinal fibres, and the placental zone becomes narrowed so as to obliterate totally the mouths of bleeding vessels. Could we then exactly appreciate the extent to which the placental adherence is retarding the process of dilatation, and feel assured that the vessels we tear, and the sinuses we uncover, will be promptly sealed by uterine muscular contraction, as they undoubtedly are in cases of spontaneous detachment and expulsion, to that extent might we safely anticipate nature's action.

In the process of distension the uterine surface on which the placenta sits, undergoes a complete change of form. From having been at first a circle, (or rather a quasi inverted cone,) with radii of 3 or 31⁄2 inches, it is, by the opening at the centre, which is increased by every successive pain, converted into a zone, now approximating to the form of the earth's temperate zones, whereas it primarily had the form of the frigid zones, the polar centres

I have before said that we best aid nature by imitating her. That we may, in any process, imitate nature, it is indispensable that we should see, and clearly comprehend, how she does her work. We may, by imitating her, hatch eggs by a properly graduated heat, but if we should ignorantly overheat them, or by a higher heating, fancy that we shall shorten the period of normal incubation, we shall find that we have made a sad job of it.

When spontaneous detachment of the placenta. takes place, nature does not effect it by tickling the child till it kicks off the placenta. She does her work more skilfully and more gradually. She does not tear off adhering portions before the denuded uterine surface is prepared to close the lacerated or exposed vessels. Because of the resisting uteroplacental adhesion, her contracting energy and action must always be considerably in advance of the completion of her work, so that, to use a vulgar adage, she has not "to seek for the ladle when the soup is in the fire." But how must matters go when we dash away ahead of her, at tearing pace, and lay bare a large utero-placental surface not yet in a state of progressing active contraction?

Dr. Charles Bell, in a paper published in the Edinburgh Medical Fournal, June, 1878, on the subject of placenta prævia, makes the following pointed and most truthful assertion: "There is no

part of the uterus from which the placenta can be troduced by Dr. Simpson, needs no very labored separated artificially without the danger of hemorr-explanation to account for it, for we believe that hage, unless uterine contraction immediately takes the separated placenta acts as a mechanical plug place." upon the orifices of the bleeding vessels, promotI have observed, of late, that the subject of pla- ing the coagulation of the blood in and around centa prævia has been under frequent discussion them, and thus effectually presenting a barrier to in the medical societies of the United States, and its further flow. How then is this indication to be I have read, with warm interest, the reports of fulfilled? We answer simply on the same mechanthese discussions, and of the papers which gave ical principle. If the os uteri is not sufficiently rise to them. It would seem to be a constitutional dilated to allow of the operation of turning being frailty of our cousins over the lakes, to regard as performed, our own practice has been, for the last a benevolent virtue, the confession of other people's twenty years, to introduce at once into the vagina sins in preference to their own. One might sup- sufficient soft linen, lint, or other suitable material, pose, from the utterance of some of their speakers as to form an accurate, well adjusted, and efficient and readers, that Professor Simpson's theory of plug. By thus filling the vagina no blood is alplacenta prævia, and the practice taught by him, lowed to escape through it, and hence it must achad been accepted by the entire medical profession cumulate immediately around the bleeding vessels; of Great Britain and Ireland, and that they had it cannot force its way into the uterire cavity, encontinued faithful disciples. But no one who has trance being there prevented by the placenta and kept pace with the course of obstetric literature, the other contents of the uterus. Not only does can charge our trans-atlantic brethren with any the theory of this mode of treatment sound very such servility. It would be but offensive pedantry plausible, but we have abundantly exemplified its in me to enter, before this assemblage, into cita- real utility in practice." Dr. Braithwaite, further tions of the diversities of opinion which have char- on, makes the following additional observations on acterized the writings of Dr. Simpson's cotempor- the safety of the plug treatment: "The introducaries and successors in the field of obstetric sci- tion of the plug in the early periods of placenta. ence. Certainly we may reach any conclusion prævia, has many great advantages which the plan other than that of general tacit acquiescence in his of Dr. Simpson does not possess. It is perfectly doctrine. safe and readily applicable; it promotes" (impels, I would say,) "uterine contraction, ensuring the safe dilatation of the os; it preserves the strength of the mother, by preventing the serious discharges which would otherwise take place; and, lastly, it obviates the necessity of, at least as little as possible, endangering the life of the child. The plug, so introduced, may be removed every six or eight hours, or oftener, as the practitioner may deem advisable, to allow the evacuation of the contents of the bladder or the rectum, or any examination as to the state of the os, to be made. If we find the os then sufficiently dilated, we immediately introduce the hand, separate only as much as is required of the placental attachment to the uterus, rupture the membranes, turn, and so expedite the labor as much as possible."

Might we not whisper to onr brethren of the Great Republic, that "there were great men before Agamemnon"? As early as 1847, Dr. Braithwaite, editor of the Retrospect, a gentleman of large and ripe experience, took strong grounds against the views and practice of Dr. Simpson. In 1851, in part 22 of the Retrospect, he expressed himself thus: "For our own part, we beg to differ from Dr. Simpson, both as to the propriety of the operation of separating the attachment of the placenta from the cervix uteri in cases of placenta prævia, and as to the reason of the cessation of the hemorrhage. Our objection to this mode of practice is, that although it may be a safe one as regards the mother, it assuredly is a fatal one as regards the child. With regard to the second point, although of slight importance as far as theory is concerned, it is nevertheless of the greatest importance, as indicating a most valuable mode of practice to be adopted. We consider that the fact of the flooding ceasing (?) by the method of manipulation in

Though, as may be obvious from the preceding quotations, Dr. Braithwaite is no model of clear writing, it is pretty evident that he was a sagacious and reflecting practitioner of midwifery; and so far as regards his views of the value of the plug, our neigh