PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.
_History.--Dr. Rigby's division of hæmorrhages before labour into
accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.--
Turning.--Partial presentation of the placenta.--Treatment._
There are few dangers connected with the practice of midwifery which are
more deservedly dreaded, and which are wont to come more unexpectedly,
both to the patient as well as to the practitioner, than that species of
hæmorrhage which occurs in cases where the placenta is implanted either
_centrally_ or _partially_ over the os uteri. Well has a celebrated
teacher observed, that "there is no error in nature to be compared with
this, for the very action which she uses to bring the child into the world
is that by which she destroys both it and its mother." (Naegelé, _MS.
Lectures_.) In other words, where there is this peculiar situation of the
placenta it becomes gradually detached, either in proportion as the cervix
expands during the latter months of pregnancy, or as the os uteri dilates
with commencing labour, and is thus unavoidably attended with a profuse
discharge of blood, which generally increases as the dilatation proceeds.
The peculiar feature of this species of hæmorrhage, necessarily
accompanying the commencement of every labour where the placenta is
implanted over the os uteri, was first fully described in this country in
1775, by the late Dr. Rigby, in his classical _Essay on the Uterine
Hæmorrhage which precedes the Delivery of the full-grown Foetus_, a work
which has been justly looked upon, both in England and the Continent, as
the great source to which we are indebted for our practical knowledge in
the management of these dangerous cases.
_History._ There is abundant evidence to prove the sudden attacks of
hæmorrhage during pregnancy, attended with circumstances of great danger
to the life of the mother and her child, were known from the earliest
times, and especially noticed by Hippocrates where he says, "that the
after-burden should come forth after the child, for if it come first, the
child cannot live, because he takes his life from it, as a plant doth from
the earth." (_De Morbis Mulierum_, lib. i. quoted by Guillemeau.)
Hippocrates, therefore, evidently supposed that this presentation of the
placenta at the os uteri was owing to its having been separated from its
usual situation in the uterus, and fallen down to the lower part of it.
This view has been closely adopted by Guillemeau, to whom we are indebted
for having called our attention to the above passage. He has devoted his
fifteenth chapter[140] to the management of a case where the placenta
presents, and shows that "the most certain and expedient method is to
deliver the patient promptly, in order that she may not suffer from the
hæmorrhage which issues from the uncovered mouths of the uterine veins, to
which the placenta had been attached; that, on the other hand, the child
being enclosed in the uterus, the orifice of which is plugged up by the
placenta, and unable to breathe any more by the arteries of its mother,
will be suffocated for want of assistance, and also enveloped in the blood
which fills the uterus and escapes from the veins in it which are open."
The operation of turning, which had been newly practised by his teacher,
Ambrose Paré, and still farther brought into notice by himself, at that
time formed a great æra in midwifery, for it furnished practitioners with
a new and successful means of delivering the child in cases where urgent
danger could only be avoided by hastening labour; hence, therefore, in all
cases of profuse hæmorrhage coming on before delivery, it was a general
rule, if the case became at all dangerous, to turn the child.
Guillemeau's explanation of the nature of placental presentations was
still more explicitly adopted by Mauriceau, La Motte, and many others.
Mauriceau invariably speaks of the placenta, when at the os uteri, as
"entirely detached;" and adds that "even a short delay will always cause
the sudden death of the child if it be not quickly delivered; for it
cannot remain any time without being suffocated, as it is now obliged to
breathe by its mouth, for its blood is no longer vivified by the
preparation which it undergoes in the placenta, the function and use of
which cease the moment it is detached from the uterine vessels with which
it was connected: the result of this is the profuse flooding which is so
dangerous for the mother; for if it be not promptly remedied she will
quickly loose her life by this unfortunate accident." (Vol. i. p. 332, 6th
ed.) He also adds, "it must be observed that the placenta, which presents,
is nothing more than a foreign body in the uterus when it is entirely
separated," (p. 333,) "for when it comes into the passage before the
infant, it is then totally divided from the womb." (_Chamberlen's Transl._
p. 221. 8th ed.) In the sixteen cases which he has detailed, he has
distinctly mentioned the fact in thirteen that the placenta was _entirely
separated_ from the uterus, and presented at the os uteri. In two of
these he has expressly stated his conviction that the placenta had been
detached from the uterus, by the mother having been exposed to a violent
shock, when the cord was shortened from being twisted round the child.
These facts prove that Mauriceau, considered presentations of the placenta
to arise solely from its having been separated by some _accident_ from the
fundus, and fallen down to the os uteri.
Dr. Robert Lee, in his "Historical Account of Uterine Hæmorrhage in the
latter Months of Pregnancy," (_Edin. Med. and Surg. Journal_, April 1839,)
has omitted all mention of this circumstance, and from the account which
he has given of Mauriceau's observations, would infallibly lead his
readers to suppose that Mauriceau was fully acquainted with the real
nature of these peculiar cases. Thus, he commences with saying, "The
symptoms and treatment of cases of placental presentation are here
accurately described, and in all cases of hæmorrhage from this cause he
recommends immediate delivery;" and again, he observes, "The rules for the
treatment of these cases are laid down with the greatest precision. When
the placenta was entirely separated, then only did he consider it as a
foreign body, and recommend its extraction before the child." The student
would be led by such a statement to suppose that Mauriceau did not
consider the _entire separation of the placenta_ as the most usual
occurrence in these cases, and will therefore naturally infer that in the
majority of cases of placental presentation, he recognised the
implantation of the placenta upon the os uteri. That such was very far
from the case, we have already shown by quotations from various editions
of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of
placenta prævia from Mauriceau, and has given a short summary of them. Out
of the thirteen cases in which Mauriceau has distinctly mentioned that the
flooding had been caused by the entire separation of the placenta which
presented, Dr. Lee has noticed it in only three; and in one of these he
has reversed the expression by saying, "placenta presenting and entirely
detached:" thus leading his reader to infer that the placenta had
presented at the os uteri, but had become detached from it. Nor is the
case (No. 423,) to which Dr. Lee has referred "as a proof that Mauriceau,
was aware of the fact, that the placenta had not been wholly detached from
the uterus," at all tend to show that he had any idea of the placenta
being implanted upon the os uteri.
By stating that "Mauriceau has also recorded the histories of thirty-seven
cases of uterine hæmorrhage in which the placenta did not present, but had
adhered to the upper part of the uterus and been accidentally detached,"
Dr. Lee has confirmed the erroneous inference that the implantation of the
placenta upon the os uteri was known to this valuable author; whereas, we
have proved by numerous quotations, that Mauriceau distinctly supposed
that in _all_ cases of hæmorrhage before labour, _whether the placenta was
found presenting or not_, it had been originally attached "to the upper
part of the uterus."
Paul Portal was the first, as far as we are acquainted, who describes the
placenta as _adhering_ to the os uteri. He has recorded eight cases, "in
which," as Dr. Rigby observes, "he was under the necessity of delivering
by art, on account of dangerous hæmorrhages, and in all of them he found
the placenta at the mouth of the womb." (_Essay on Uterine Hæmorrhage_, p.
22, 6th ed.) In these he distinctly mentions the placenta adhering to the
os uteri. In several of these he separated it from the os uteri and
brought it away; and in seven he turned the child. In the other (Case 39,)
the head burst its way through the placenta. In one case only (51,) does
he attempt to make any practical inference whatever, having in all the
others contented himself with merely stating the fact of the placenta
adhering to the os uteri. In this instance, however, he has described the
real nature of the case, and pointed out the cause of the hæmorrhage. On
introducing his hand he "found the after-burden placed just before and
quite across the whole inner orifice, which had actually been the occasion
of the flux of blood; for by the opening of the orifice the said
after-burden then being loosed from that part where it adhered to before,
and the vessels containing the blood torn and opened, produced this
flooding, which sometimes is so excessive as proves fatal to the woman
unless it be speedily prevented." (_Portal's Midwifery_, transl. p. 167.)
There is no doubt, as Dr. Renton has very justly observed, "that Portal in
1672 (not 1683) knew as much on the subject of uterine hæmorrhage
occasioned by the displacement of the placenta from the os uteri, and the
practice necessary for its suppression, as we do at the present time."
(_Edin. Med. and Surg. Journ._ July, 1837.) But we cannot coincide with
him in the passage which follows, viz. "It is to him unquestionably that
we are indebted for our knowledge on the subject," because, as Dr. Renton
himself has shown, all the authors in midwifery up to the time of Roederer
and Levret (1753) were ignorant of Portal's explanation. We do not even
except Giffard, as there is sufficient evidence to show that he, for some
time, entertained the prevailing erroneous opinions of Mauriceau, until he
at last discovered the real nature of the case himself. We attribute the
omission solely to the above observation of Portal being so short and
isolated, and to its having been entirely unaccompanied by any other
practical remarks or inferences which might have been expected from so
remarkable a fact. To this reason _alone_ can we attribute the
circumstance of its not having been expressly mentioned by Dr. Rigby when
alluding to Portal's cases. In a similar way we can explain why Portal has
not had the merit of a valuable improvement in the operation of turning
which has been attributed to Peu, viz. the passing the hand between the
membranes and uterus up to the fundus before rupturing them, solely
because he mentions it as a cursory observation, without any farther
notice or practical inference.
The next author who has at all alluded to the real nature of placenta
prævia is Giffard, whose posthumous work was published in 1734. The value
of his evidence on this subject is considerably modified by his having
made no allusion to the implantation of the placenta upon the os uteri in
the first ten cases of flooding, where he found the placenta presenting,
but repeatedly describes the placenta as being wholly separated and lying
in the passage, and in some, he expressly mentions that the placenta had
fallen down to the os uteri. In cases 115, 116. and 224. he gives a
perfectly correct explanation of the cause of flooding, but the opinion is
expressed with such a degree of hesitation, and so cursorily, that we
doubt much if it attracted more notice than the observations of Portal,
above alluded to, more especially as in the six cases of placenta prævia,
which occur between the last two above-mentioned (viz. 120, 121. 158. 160.
185. and 209.,) he returns again to his former mode of describing them.
We, therefore, regret that Dr. Renton has not mentioned this circumstance,
and that in quoting from "two of the numerous cases which he relates," he
has not stated that these were two out of the only three cases which
Giffard had described correctly.[141]
It is, therefore, to the above-mentioned circumstances of Giffard having
given what is now recognised as the correct explanation, in only three out
of nineteen cases, that we can explain why so little notice was taken of
the subject at that time; why Dr. Smellie, when speaking of it, makes no
allusion to Giffard; and why Dr. Rigby, in his _Essay on Uterine
Hæmorrhage_, was led to suppose that he was ignorant of the real nature of
these cases: certain it is that his opinion could scarcely be called a
decided one.
Smellie mentions that "the edge or middle of the placenta sometimes
adheres over the inside of the os internum, which frequently begins to
open several weeks before the full time; and if this be the case, a
flooding begins at the same time, and seldom ceases entirely until the
woman is delivered; the discharge may, indeed, be intermitted by coagulums
that stop up the passage, but when these are removed it returns with its
former violence, and demands the same treatment that is recommended
above." His cases contain no observation beyond the recital that a
considerable hæmorrhage had occurred, the placenta had been found
presenting, and that he had turned the child. In his sixth case (Collect.
33, No. 2.) which is dated 1752, it is evident that he was ignorant of
what had been said on the same subject by Giffard and Portal; for he
observes, "This case being uncommon, I was uncertain at first how to
proceed; but at last considering with myself, if I broke the membranes to
evacuate the contained waters, so as to allow the uterus to contract and
restrain the flooding, the foetus would be lost by the pressure of the
head against the funis (which presented) in the time of delivery. I
resolved in order to prevent this misfortune to turn the child, and bring
it along in the preternatural way, which would give it a better chance to
restrain the one, and save the other, if the operation could be performed
in a slow cautious manner." This forms the amount of his observations on
this important subject, and, therefore, justifies the observation which
Dr. Rigby has made, viz. that there are no practical inferences drawn from
the cases; nor in his directions about the management of floodings, are
there any rules given relative to this situation of the placenta.
Roederer decidedly stands pre-eminent, as being the first author who gave
a distinct and complete description of this species of hæmorrhage; he
points out the cause of it, and accurately describes its symptoms and mode
of attack; he shows that the placenta may be entirely or partially
attached to the os uteri; that in the one case the hæmorrhage will be very
profuse, and artificial assistance will be required; in the other it will
be slighter, and in many cases it may be left to nature.[142]
Levret cotemporaneously with the first edition of Roederer's work,
published at Paris, a valuable paper on placental presentation, which,
with the above-mentioned chapter of Roederer, must be looked upon as the
first observations in which this form of hæmorrhage was made a distinct
subject of consideration. Although Levret has in no wise claimed the merit
of being the first who had noticed the fact of the placenta being
implanted upon the os uteri, still there can be no doubt that to him and
Roederer we are indebted for having first investigated the subject and
called the attention of the profession to its peculiar characters.
Levret has reduced his observations under three heads, viz. that the
placenta is occasionally implanted over the os uteri, that hæmorrhage
under such circumstances is inevitable, and that the safest mode of
remedying this accident is the _accouchement forcé_. He has also added a
few valuable remarks, but by far the greater part of the essay is occupied
with theoretical arguments to prove that it is impossible for the
placenta, which had been attached to the fundus, to sink down to the os
uteri. Indeed, beyond stating the three above-mentioned positions, which
are undeniably of great practical value (although by no means original,)
Levret has added but little which is not contained in Giffard, his chief
merit being that of making it a subject of distinct consideration, and
establishing it as a matter beyond doubt.
Levret cannot, however, be looked upon as the first who considered that
the flooding, in cases of placenta prævia, was "inevitable," although,
from his not having quoted Giffard, we willingly concede to him the merit
of originality, as far as he himself was concerned: it was Giffard,
however, as far as we know, who first pointed out that hæmorrhage was the
necessary consequence of placental presentation, as is shown from what we
have already quoted from him, although, to a certain extent, it was hinted
at by Portal, in his fifty-first case. Levret's memoir was afterwards
reprinted in his large work, entitled _L'Art des Accouchemens_: the third
edition, which appeared in 1766, was quoted by Dr. Rigby in the first
edition of his _Essay on Uterine Hæmorrhage_, 1775,[143] in farther proof
of the placenta being implanted over the os uteri, and being the cause of
hæmorrhage.
We are chiefly indebted to Dr. Rigby for a complete exposition of this
important and interesting subject. His well-known essay on the uterine
hæmorrhage which precedes the delivery of the full-grown foetus has stood
the test of time, and will ever remain, not less remarkable for its
practical value, than "for the perspicuity and simplicity of its style."
(Renton, _op. cit._) To Dr. Rigby, without doubt, is due the merit of
having first distinguished hæmorrhages, which occur before delivery, into
_accidental_ and _unavoidable_, a division so truly practical and
appropriate, as to have placed this subject in the clearest and simplest
possible light. "He was," as Dr. Collins has justly observed, "the first
English author who fully established this most important practical
distinction in the treatment of uterine hæmorrhages, although Levret had
many years before published a somewhat similar statement." Dr. Rigby's
arrangement has been adopted by Dr. Merriman, Dewees, and every other
modern author of any note; and the medical world have amply testified
their sense of its value, as well as of the work itself in general, by the
numerous editions which it has undergone in this, and translations and
reprints in other countries.
We have entered into an historical detail of the literature of this
subject, from its having been asserted that Dr. Rigby "published an
abstract of the doctrines of Puzos and Levret with the addition of some
cases from his own practice," (Burns, _Principles of Midwifery_, 9th ed.,
1837, p. 364;) that he availed himself of the discoveries of Dr. Smellie
and M. Levret, while he contrived to make the profession believe that his
doctrines were original, (Hamilton, _Practical Observations_, &c., 1836,
vol. ii. p. 238;) and that "no fact of the slightest importance has since
(Smellie) been discovered relating to the causes and treatment of uterine
hæmorrhage in the latter months of pregnancy." (Dr. R. Lee, _Edin. Med.
and Surg. Journ._, 1839, vol. li. p. 389.) We, therefore, deem it only
just to our readers, and also to the author, to lay before them his own
account of what, at the time, he supposed to be a discovery, and how far
he considered himself justified in laying claim to its originality.
"A case of hæmorrhage, in which I found the placenta attached to the os
uteri, occurred at a very early period of my practice; but not finding
such a circumstance recorded in the lectures which I had attended, or
taken notice of in the common elementary treatises on midwifery, I
considered it at first merely as a casual and rare deviation from nature.
In a few years, however, so many similar instances fell under my notice,
as to convince me, that it was a circumstance necessary to be inquired
after in every case of hæmorrhage: and this conviction was confirmed by
the perusal of cases in midwifery; for I then found that the fact of the
placenta being thus situated had been recorded by many writers, though in
no instance which had then reached me, had any practical inferences been
deduced from it. It appeared to me, indeed, most extraordinary that such a
fact, known to so many celebrated practitioners, should not long before
have led to its practical application, and in consequence to more fixed
principles in the treatment of hæmorrhages from the gravid uterus; and I
may, perhaps, be allowed to say, that I congratulated myself, young in
years and practice as I was, in being, probably, the first to suggest an
important improvement in the treatment of one of the most perplexing and
dangerous cases in midwifery; and that I committed my observations on the
subject to paper, not only under a conviction of their practical utility,
but certainly also under an impression that my suggestions were original.
"Not long after the first edition was at press, indeed before the first
sheet was printed, Levret's dissertation on this subject fell into my
hands, and in a note I referred to it as additional testimony in proof of
the placenta, in these cases, being originally attached to the os uteri.
"I have been led into this little detail, because it has been suggested
that I have borrowed my theory from Levret. After remarking the gross
folly I should have been guilty of in quoting Levret, had I furtively
adopted his opinions, it will, I trust, be sufficient for me unequivocally
to declare that my original ideas on the subject were derived solely from
my own personal observation and experience; and that having previously
neither read nor heard of the placenta being ever fixed to the os uteri,
the knowledge of such a circumstance, derived as before observed, came to
me and impressed me as a discovery.
"I was, certainly, afterwards struck with the coincidence of the
sentiments of Levret and myself on the subject, with the similarity of our
practical deductions, and, allowing for the difference of language, even
with the sameness of our expressions. I am farther not reluctant to
acknowledge, that after reading Levret's dissertation, I felt less
entitled to the claim of absolute originality on the subject; and I now
rest perfectly satisfied to divide with him the credit arising from the
mere circumstance of communicating a new physiological fact. But were I
even denied all claim to originality, I should still not be without the
satisfaction of having, at least, materially contributed to diffuse the
knowledge of an important fact, and of having established its practical
utility on the unequivocal testimony of experience; for, had I seen
Levret's dissertation sooner, or had even my attention been first directed
to the subject by its perusal, ought it to have superseded my publication?
Was the practice in this country, at that time, at all influenced by
Levret's dissertation? or has it even since been translated into the
English language? Was it, at that time, generally known that the
attachment of the placenta to the os uteri was a frequent cause of
hæmorrhage? and were any directions for our conduct in these cases,
founded on the knowledge of the fact, given by those who there lectured on
the art of midwifery?
"Levret's facts, moreover, though they proved that the placenta might be
originally attached to the os uteri, (and a single instance would
establish this,) were scarcely sufficient to prove the frequency of its
occurrence, from which alone arises the necessity of practically
attending to it in every case of hæmorrhage. His observations (perhaps
even more creditable to him for being founded on such scanty materials)
were derived from four cases only, and of these, but two were under his
own immediate cognizance; whereas, in the first edition of this essay my
opinions were supported by 36 detailed cases, in 13 of which the placenta
was found at the os uteri; and in the fourth edition the number was
increased to 106, 43 of which were produced by this peculiar original
situation of the placenta." (Preface to the 5th ed.)
The _causes_ of this peculiar deviation from the usual situation of the
placenta are little if at all known. The condition of the decidua shortly
after the entrance of the ovum into the cavity of the uterus, will
probably influence the situation of the placenta considerably. Under the
ordinary circumstances, this effusion of plastic lymph has already
attained such a degree of firmness and coherence as to prevent the ovum
from passing beyond the uterine extremity of the Fallopian tube from which
it has emerged; but in cases of placental presentation it may be presumed
that at this period the decidua was still in a semi-fluid state, had
formed little or no attachment to the walls of the uterus, and had,
therefore, no effect in preventing the ovum gravitating to the lower part,
or even to the mouth of the uterus itself. We state this, of course, as a
mere matter of theory, since the difficulty of investigation at such early
periods, and the comparative rarity of placental presentations, will
probably ever prevent our ascertaining the real cause.
_Symptoms._ The first symptom which warns us that the placenta is
presenting, is the sudden appearance of hæmorrhage, which is usually more
copious than ordinary hæmorrhage, and apparently comes on without any
assignable reason: it is usually the more profuse the nearer the patient
is to the full term of pregnancy, for not only now are the ruptured
vessels larger, but the separation of the placenta is generally greater.
If she has still some time to go, the discharge will be probably slight,
and with rest and quiet, &c., will cease, to return again in ten days or a
fortnight with increased violence: this usually happens at what would have
been a catamenial period. The suddenness of its attack, the profuseness of
the discharge, and its coming on without any evident cause, are peculiarly
suspicious.
It has been stated that the abdomen is less distended in these cases than
usual, from the placenta not being in the upper parts of the uterus: it is
an observation, however, which requires to be confirmed, and certainly our
own experience, as yet, has not led us to such a conclusion.
On examination, the os uteri is found to be larger and thicker than
ordinary: it has a loose spongy feel, for its vessels are now as immensely
distended as those of the fundus, when the placenta has its usual
situation. If the placenta be partially attached over the os uteri, it is
generally upon the anterior lip, which is much thicker. In this case we
shall feel the edge of the placenta projecting at one side of the os
uteri, and the bladder of membranes, and probably the presenting part of
the child at the other. Whereas, if the placenta be centrally attached, we
shall find it attached to the whole circumference, except perhaps where
the separation is, from which the hæmorrhage proceeds. We shall
distinguish the placenta by its spongy mass, by its soft irregular
surface, and by the stringy feel which it communicates where it has been
torn.
The character of the hæmorrhage is also different from that of common
hæmorrhage, inasmuch as it increases during a pain, and diminishes or
ceases during the intervals, whereas, in hæmorrhage under ordinary
circumstances it is the reverse.
Where the hæmorrhage takes place at some distance of time from the full
period of utero-gestation, it probably arises from the gradual development
of the cervix during the latter months of pregnancy: where, on the other
hand, it does not appear till just before labour, the separation of the
placenta will have been produced by the incipient dilatation of the os
uteri itself. It might therefore be supposed, that the period of the
attack would, in great measure, depend upon whether the placenta was
centrally, or only partially, attached to the os uteri; that in the former
case the placenta would be more liable to be separated by the gradual
development of the inferior segment of the uterus; and that, therefore,
hæmorrhage would come on several weeks before the full term; whereas, if
only a portion of it cover the edge of the os uteri, the patient would
probably go to the very end of pregnancy before any flooding appeared.
Although this view is supported by the high authority of Professor
Naegelé, still we can scarcely agree with it, since not only do a
considerable majority of recorded cases show that a patient with central
presentation of the placenta may go to the full time without an attack of
flooding, but also several of those which have come under our own
observation lead to a similar conclusion.
The most alarming attacks of hæmorrhage are doubtless at the full term,
when the os uteri is beginning to dilate from commencing uterine
contractions, and the placenta is centrally attached over it: in these
cases the discharge experiences little or no abatement beyond an
occasional short remission, but returns with the pains, increasing in
profuseness as the gradually dilating os uteri produces a still farther
separation of the placenta. Such cases, if left to themselves, would
almost necessarily prove fatal. The first fainting fit or two would
probably produce a temporary cessation of the discharge, and favour the
formation of coagula in the upper part of the vagina; but with returning
contractions of the uterus, the hæmorrhage would be renewed with
increased violence, and quickly reduce the vital powers. In such cases
the patient will probably die undelivered, or soon after the birth of a
dead child. In some rare instances, the pains have been sufficiently
powerful to force the head through the placenta, and thus enable the
mother to be delivered by the natural means, although with little chance
of the child being born alive, from the injury which the foetal vessels in
the placenta have received. Portal's twenty-ninth case terminated in this
way. A similar and very interesting case was lately communicated to us by
Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have
been centrally attached to the os uteri, and where, in consequence of two
or three powerful pains, the head was forced _through_, tearing it quite
across. The child was born dead, but the mother did well.
In a few rare cases the placenta has been entirely separated and expelled
before the child, but these have usually been attended with a most
alarming loss of blood. In almost all the cases related by Mauriceau, and
in the majority of those by Giffard, the placenta is stated to have been
entirely detached from the uterus, but this was evidently under the
mistaken supposition of the placenta having been originally separated from
the fundus. "It is extremely rare to meet with a total separation of the
placenta. Dr. Clarke informed me that he met with but one case of total
separation; the patient dying before he reached the house." (Collin's
_Pract. Treatise_, p. 92.) A still more remarkable instance is recorded by
Dr. Collins, where the placenta had been expelled many hours (probably
about 18) before the birth of the child. "The membranes had ruptured, and
the waters been discharged a fortnight previous to admission, from which
time, until the evening before she was brought to the hospital, she had
more or less hæmorrhage. It was now ascertained that the placenta had been
expelled the evening before her admission, and separated by the midwife in
attendance. She left the hospital well on the thirteenth day."[144] (_Op.
cit._ p. 103.) In all these cases the child has been born dead, and must
ever be so, where any period of time has elapsed between the expulsion of
the placenta and that of the child. The only case we know of where a
living child was born after the expulsion of the placenta is recorded by
F. Ould. "I found this woman in imminent danger, being seized with
faintings and hiccough, having her face pale and Hippocratic. Upon
examination, I found the placenta presented to the orifice of the womb,
which I immediately extracted; and although the head was far advanced in
the passage, I put it back into the womb, and taking hold of the feet
brought a living though very weakly child into the world. The mother also
recovered, though with much difficulty." (_Treatise on Midwifery_, p. 77.)
La Motte has described a similar case, but where the child died
immediately after birth. (_Obs._ 238.)
The irregularity with which cases of placental presentation have appeared
at different times, have more than once excited notice: thus it frequently
happens to ourselves that several years have elapsed without our meeting
with a single case, although connected with a large lying-in hospital;
whereas, at other times two or three cases have followed each other at
comparatively short intervals. In selecting ten successive years from the
period during which Dr. Rigby observed the numerous cases recorded in his
essay, we see this irregularity remarkably exemplified.
In 1779 three cases.
In 1780 four cases.
In 1781 none.
In 1782 five cases.
In 1783 one case.
In 1784 five cases.
In 1785 two cases.
In 1786 two cases.
In 1787 one case.
In 1788 two cases.
A still more remarkable variation has been described by the celebrated
Matthias Saxtorph, of Copenhagen. Having stated that placental
presentation had occurred only once in 3600 cases, he adds, "the reader
will be astonished when I assure him that this case, which is so rare that
I had only seen it twice in so many years, and that I had met with it but
once out of so many thousand labours at our lying-in hospital, occurred to
me in the last six months, _eight times_." (_Collect. Soc. Med._ Havn.
1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his
lectures, and states, that in some years placental presentation was so
frequent that it seemed as if it were almost epidemic.
Experience proves beyond doubt, that, of the serious floodings which occur
during the last weeks of pregnancy, the majority arise from the attachment
of the placenta to the os uteri. Dr. Rigby also states "that this
attachment of the placenta to the os uteri is much oftener a cause of
floodings than authors and practitioners are aware of, I am from
experience fully satisfied; and so far am I convinced of its frequent
occurrence, that I am ready to believe that most, if not all, of those
cases which require turning the child, are produced by this unfortunate
situation of it."
The period of pregnancy at which hæmorrhage may come on from placental
presentation, varies very considerably. Although, in by far the majority
of these cases, it does not come on until the last four or six weeks, it
now and then occurs at a much earlier period, viz. the sixth or even the
fifth month, and sometimes even earlier. Where this is the case, it must
rather be looked upon as one of "accidental" hæmorrhage or abortion, for
it can scarcely be supposed that any changes about the os or cervix uteri
could have been sufficient to have produced an "unavoidable" separation of
the placenta at this time. Thus, for instance, in Dr. Rigby's
seventy-fifth case, the first attack of hæmorrhage had appeared when the
patient "was about three months gone with child;" and at that early period
could hardly have been attributed to the peculiar situation of the
placenta, but to the more common causes of hæmorrhage connected with
abortion. In his forty-third case, the hæmorrhage, which came on about the
twenty-sixth week, appears at first to have been purely "accidental,"
although it was afterwards produced by "unavoidable" attachment of the
placenta. "We very seldom meet with unavoidable hæmorrhage before the
sixth month of pregnancy; it is not until the cervix uteri begins to
distend freely, and the changes that take place previous to the approach
of labour commence, any suspicions are observed; consequently, it will be
in the last three months of utero-gestation that hæmorrhage of this nature
is found to occur." (Collins, _op. cit._ p. 93.)
The examination of a case where the placenta presents is not always easy;
the natural position of the os uteri during the latter months of pregnancy
in the upper part of the hollow of the sacrum makes it very difficult for
the finger to reach so completely as to afford us the means of
ascertaining satisfactorily whether the placenta be attached to it or not.
"For this purpose, however, the usual method with one finger will not
always suffice, but the hand must be introduced into the vagina, and one
finger insinuated into the uterus; for in several of the following cases
it will appear, that though the women were frequently examined in the
usual way, the placenta was not discovered till the hand was admitted for
the purpose of turning the child." (_Essay_, 6th ed. p. 35.)
_Treatment._ We have already stated that the earlier the period at which
the flooding comes on, the less profuse it will be; the treatment,
therefore, where the hæmorrhage is inconsiderable, differs but little from
that in an ordinary case of abortion or miscarriage. The indications, in
fact, are the same, viz. to stop the discharge, and allay any disposition
to uterine contraction.
The patient must be placed upon a mattress, and covered as lightly as
possible with safety and tolerable comfort to herself. If the circulation
be active, the pulse strong, with more or less heat of surface, it may
even be desirable to reduce this by means of the lancet. "Under any kind
of active hæmorrhage, when the pulse is vigorous, the taking away blood
from the arm has uniformly been found useful, by producing contraction by
the mere unloading of the vessels, and more especially in diminishing the
velocity of blood within them." (Dewees, _Compend. Syst. of Midw._ p.
441.) Cold cloths must be applied to the vulva, loins, and over the
symphisis pubis; gentle saline laxatives with nitrate of potass should be
given if the bowels are confined; and if there be the slightest appearance
of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat.
into the rectum will be necessary. This may be given immediately where the
bowels are not confined, or, if they are, after the rectum has been washed
out by a large domestic enema. If necessary, she should also take an
opiate by the mouth. Her food must consist of little else than plain
drinks, as tea, milk and water, &c., all of which must be taken cold; and
she must preserve the most perfect quiet of body as well as mind. We
cannot agree with Dr. Dewees in permitting "our patients, under treatment
for uterine hæmorrhage, to be five or six days without a discharge from
the bowels;" as a loaded state of the lower bowels cannot fail in our
opinion to obstruct seriously the free return of the circulation from the
pelvic viscera, and thus greatly increase the disposition to congestion
and hæmorrhage.
The longer the patient has still to go, the more desirable is it that we
should, if possible, control the symptoms, and prevent them from
proceeding to such extent as to require artificial delivery. It is of the
utmost consequence that we should take such measures as will enable the
pregnancy to go on safely, if not to the full time, at least to a later
period, for by this means the uterus will have attained such a degree of
development as will enable the turning to be undertaken with ease to the
practitioner and with safety to the mother; the child also will have so
far advanced towards maturity as to give it a better chance of surviving
the operation.
Wherever hæmorrhage has occurred during the last three months of
pregnancy, which has come on suddenly and without any assignable reason,
we should earnestly warn the patient and her friends to summon the
practitioner the moment there are any symptoms of its return; for if it be
a case of placental presentation, it assuredly will return, and as
certainly much more profusely than at first.
Where the patient has gone nearly or quite to her full time, the first
attack is much more alarming; the hæmorrhage frequently appears with a
sudden gush, and in a few minutes a serious and even dangerous quantity of
blood is lost; thus a patient whom we had seen but a few hours previously
in perfect health, was suddenly seized with profuse flooding as she was
standing at the door of her house speaking to a person, and before she
could move, a large pool of blood had formed at her feet; in another case,
the patient while standing at her tea-table was attacked in a similar
manner, and in a moment the floor was deluged with the discharge.
Although artificial delivery by turning the child is required in every
case of central presentation of the placenta during the latter periods of
pregnancy, it is evident that this will not apply during the earlier
months, when the uterus from its size will preclude the possibility of
such an operation. Dr. Rigby has established a valuable axiom on this
point, viz. "that when the uterus is too small for the admission of the
hand, the expulsion of the placenta and foetus will happily be timely
effected by nature. It is well known that in the early months, instances
of fatal termination by floodings have been very rare, as abortion sooner
or later puts a stop to the discharge. It has been likewise before
observed, that in floodings at any period of pregnancy, women seldom die,
at least not in the first instance, unless a considerable quantity of
blood has been suddenly lost. Now, as the danger of a great and sudden
loss must obviously depend upon the size of the uterine vessels, and as
the enlargement of the vessels is in exact proportion to the increased
size of the uterus, it becomes probable that when the vessels have
acquired such a magnitude, that when detached from the placenta they would
bleed largely and suddenly, the uterus itself must have attained to such a
capacity as to admit the hand for artificial delivery." (_Op. cit._ p. 48,
6th ed.) He farther observes, "that as the most material increase of the
uterus does not take place until the end of the sixth month of pregnancy,
a hæmorrhage before that period will seldom require artificial delivery;
and after that period, should it become necessary, that it is probable the
hand may then be admitted for that purpose." (_Ibid._ p. 51.)
In almost every case where the patient is some time short of her full
time, the os uteri will be found unyielding and but little dilated; it
will, therefore, seldom be possible, and scarcely ever proper, to
introduce the hand into the uterus under such circumstances; the os uteri
either entirely resists our efforts, or if we do overcome it, the degree
of force required to effect this has been so great, as will in all
probability have been attended with serious injury to the part itself. In
no case is it proper or safe to force delivery by artificially dilating
the os uteri, when it is contracted and unyielding (see TURNING;) but
where the placenta is presenting, it is peculiarly dangerous, for even
slight laceration of the os uteri will be followed by serious
consequences. Where the placenta is situated in the upper part of the
uterus, it is of very little consequence if the edge of the os uteri has
been torn somewhat during labour; but in the present case it is very
different; the os uteri now plays the part of the fundus, its vessels are
immensely dilated, and large ones are ruptured, which cannot be closed by
the firmest contraction of the uterus.
"In recommending early delivery, I think it right, however, to express a
caution against the premature introduction of the hand, and the too
forcible dilatation of the os uteri before it is sufficiently relaxed by
pain or discharge; for it is undoubtedly very certain that the turning
may be performed too soon as well as too late, and that the consequences
of the one may be as destructive to the patient as the other." (Rigby,
_op. cit._ p. 37.) Cases have occurred where the os uteri has been
artificially dilated, where the child was turned and delivered with
perfect safety, and the uterus contracted into a hard ball; in fact, every
thing seemed to have passed over favourably; a continued dribbling of
blood has remained after labour, which resisted every attempt to check it;
friction upon the abdomen and other means for stopping hæmorrhage by
inducing firm contraction of the uterus were of no use, for the uterus was
already hard and well contracted; the patient has gradually become
exhausted, and at last died; on examination after death, Professor Naegelé
has invariably found the os uteri more or less torn.
"It must be acknowledged, indeed," says Dr. Rigby, "that it may sometimes
happen that at the very first coming on of the complaint, if the discharge
be small, and more especially, if it be the patient's first child, and the
parts be close and unyielding, the admission of the hand into the vagina,
as I have directed, will be attended with the utmost difficulty, and,
perhaps, be almost impracticable: in this case let us wait (but let it be
with the patient) till the discharge increases, and has continued long
enough to relax the parts; for certainly, if the woman be able to bear
losing a little blood, which at first she may safely do, the examination
will be thereby rendered more easy, and the turning of the child, if
necessary, be more practicable and safe." (_Op. cit._ p. 36.)
We have already shown (see TURNING, p. 236.) that there is no means of
rendering a rigid os uteri yielding and capable of admitting the hand
equal to the relaxation produced by loss of blood: wherever the powers of
the system have already suffered from the effects of hæmorrhage, we may
feel almost certain that we shall find the os uteri capable of dilating,
even if it be so little open as barely to admit the finger. Where the
patient has become faint or fallen into actual syncope, the relaxation of
the soft parts is very striking, and frequently to an extent which could
scarcely be believed by those who have not felt it; all resistance seems
to be at an end for the time, and the hand enters the flaccid passages
with scarcely a sensation of pressure from them, but rather (as has been
aptly compared, to that of some wet bladder wrapped around it.)
"It has been advised (observes Dr. Rigby) never to introduce the hand till
nature has shown some disposition to relieve herself by the dilatation of
the os uteri to the size of a shilling, or a half-crown; and this rule is
certainly founded on a rational principle, for when it is so much dilated,
there is no doubt but the turning may be easily and safely effected; but
from some of the annexed cases it appears that a dilatation to this degree
sometimes does not take place at all; and that even when the woman is
dying from the great loss of blood, the uterus is very little open; the
reason for which, seems to be, that when the discharge has been
considerable, and more particularly when much blood has been suddenly
lost, such a faintness is brought on, that though the uterus be totally
relaxed, and might, therefore, be opened by the most gentle efforts, yet
nature is unable to make use of these efforts; and, moreover, if there be
slight pains, the adhesion of the placenta to the internal surface of the
mouth of the womb, counteracts their influence, and thereby hinders its
giving way to a power, which would otherwise, probably, very easily open
it." (_Op. cit._ p. 39.)
_Plug._ Where, however, the case is at that doubtful period of early
pregnancy, when even under the most favourable circumstances, as
above-mentioned, the hand must experience considerable difficulty in
entering the os uteri, and yet the expulsion of the child cannot be safely
trusted to the natural powers, it becomes necessary, as in certain cases
of premature expulsion, to have recourse to such means as shall enable the
os uteri to go on dilating without the danger of farther hæmorrhage; in
other words, we must plug the vagina. "If, after the commencement of a
flooding, we favour the formation of a coagulum by means of a plug, are we
not aiding nature? It brings on labour much sooner, and the os uteri has
time to dilate without farther loss of blood." (Leroux, _Sur les Pertes de
Sang._ § 309.) By means of the plug, we enable the patient to go on with
perfect security until the pains have produced a sufficient dilatation of
the os uteri to admit the hand; after a time we may withdraw it, and if
then not satisfied with the state of the os uteri, it must be again
introduced until our object be effected. (For directions as to the use of
the plug we must refer to p. 152.)
"This remedy should be early employed, as it will, by proper management,
save a prodigious expenditure of blood. We gain by its application
important time; time that is essential for the successful delivery of the
foetus; for, by it, the woman's strength is preserved; pain is permitted
to increase; and, eventually, though tardily, the os uteri is dilated, the
placenta and foetus thrown off, and the flooding almost immediately
controlled. The other means which we have constantly pointed out, should
also be tried: they may aid the general intentions, and render the
operation of the tampon more certain." (Dewees, _Compend. Syst. of Midw._
§ 1142.)
Although Dr. Rigby has given a short account of Leroux's views respecting
the use of the plug in these cases, we cannot but agree with Dr. Dewees,
in regretting that he either did not "put his plan in execution," or that
if he did, he has not given us the details of his experience upon it. From
what Dr. Gooch, however, has stated in his _Account of some of the more
important Diseases peculiar to Women_, there is every reason to suppose
that Dr. Rigby was latterly in the frequent habit of using the plug, and
that he thought highly of it. The plug is not only useful in keeping the
hæmorrhage under due control until the os uteri be sufficiently dilated,
but may occasionally prove of the greatest value in cases of extreme
exhaustion from loss of blood, where the patient is too much reduced to
undergo the act of delivery, without running the risk of dying during the
operation; the plug will enable us to wait with safety until the system
has had time to rally its powers and be recruited by the administration of
proper nourishment. "Mr. Grainger, of Birmingham, on visiting a poor woman
with placenta prævia, and apparently in a moribund condition, immediately
filled the vagina and os uteri with linen cloths, and waited two days
before he durst hazard delivery, which he accomplished with an auspicious
result." (Ingleby, _on Uterine Hæmorrhage_, p. 155.)
_Turning._ The operation of turning the child will, in no wise, differ
from that under more ordinary circumstances, and will require to be
conducted according to the rules which we have already given. In no case
is it more important to preserve the membranes unruptured until the hand
has fairly entered the uterus than here; the hand should be carefully
insinuated between the os uteri and placenta; if possible, this should be
done at the part where the separation which has caused the flooding has
already taken place, in order to avoid all unnecessary detachment of the
placenta; the pressure of the hand prevents any great discharge of blood;
and as it gradually makes its way between the membranes and the uterus,
the arm which now occupies the vagina will effectually act as a plug.
Portal, was, probably the first who practised this mode of operation, viz.
passing his hand between the os uteri and placenta, and then between the
uterus and membranes before rupturing them: in this respect he anticipated
Peu, whose work appeared nine years after, (see TURNING, p. 234.) and
would have undoubtedly been looked upon as the originator of this
improvement in turning, had he given any reasons for this mode of
practice, or deduced any inferences from it.
Some discrepancy of opinion has existed as to whether it is better to
perforate the placenta, or to follow the plan we have just recommended.
Dr. Rigby's authority has rather tended to confirm the former opinion,
although he afterwards modifies it so much so as to make us almost suppose
that he must have preferred the other method. He states, "that by this
means, (perforating the placenta,) not more of the placenta may be
separated than is necessary for the introduction of the hand, and,
consequently, that as little increase of bleeding as possible may be
produced by the operation; but if it be impracticable, as I have more than
once found it, and it must ever be when the middle of the placenta
presents to the hand, from the thickness of it near the funis, it must be
carefully separated from the uterus on one side, and the hand passed till
it gets to the membranes." (_Op. cit._ p. 61.)
To Dr. Dewees are we chiefly indebted for having put the inexpediency of
perforating the placenta in the strongest possible light. "We are advised
by some," says he, "to pierce the placenta with the hand; but this should
never be done, especially as it is impossible to assign one single good
reason for the practice, and there are several very strong ones against
it.
"1. In attempting this, much time is lost that is highly important to the
patient, as the flooding unabatingly, if not increasingly, goes on.
"2. In this attempt we are obliged to force against the membranes, so as
to carry or urge the whole placentary mass towards the fundus of the
uterus; by which means the separation of it from the neck is increased,
and consequently, the flooding augmented.
"3. When the hand has even penetrated the cavity of the uterus, the hole
which is made by it is no greater than itself, and consequently much too
small for the foetus to pass through without a forced enlargement, and
this must be done by the child during its passage.
"4. As the hole made by the body of the child is not sufficiently large
for the arms and head to pass through at the same time, they will
consequently be arrested; and if force be applied to overcome this
resistance, it will almost always separate the whole of the placenta from
its connexion with the uterus.
"5. That when this is done, it never fails to increase the discharge,
besides adding the bulk of the placenta to that of the arms and head of
the child.
"6. When the placenta is pierced, we augment the risk of the child; for in
making the opening, we may destroy some of the large umbilical veins, and
thus permit the child to die from hæmorrhage.
"7. By this method we increase the chance of an atony of the uterus, as
the discharge of the liquor amnii is not under due control.
"8. That it is sometimes impossible to penetrate the placenta, especially
when its centre answers to the centre of the os uteri; in this instance
much time is lost that may be very important to the woman." (_Op. cit._ §
1153.)
We have already stated why it is so particularly important not to use any
force in passing the hand through the os uteri: the less we separate the
placenta, the less also will be the hæmorrhage; and even this will be in
great measure controlled by the presence and pressure of the hand itself.
In no case of turning is it so important to have all the circumstances
connected with the operation as favourable as possible, for the case
itself is sufficiently dangerous without being increased by other
unfavourable causes. To hurry the delivery would be only to increase the
danger: the operation must be performed slowly and with caution: every
rule which we have given, (see TURNING,) for ensuring its safe and
successful termination, must now be adhered to with double vigilence.
"Should the woman," says Dr. Dewees, "be very much exhausted before we
commence our operations, we should use additional caution in the delivery.
It should be very slowly performed, and we should have at each step of the
progress assurances, if possible, that the uterus has not lost, or rather
that it possesses, sufficient contractility to render the completion of
the operation eventually safe, if performed with due and necessary care."
(_Op. cit._ p. 463.)
When once the os uteri is sufficiently dilated to admit the hand, there
will not be much fear of the patient losing much blood during the turning,
for during the first part of the operation the hand and arm act both as a
compress and plug; and afterwards, when the body of the child is
advancing, this will act in a similar manner. There is little danger of
hæmorrhage coming on after the child is delivered, for the contraction of
that part of the uterus to which the placenta has been attached is much
greater in these cases than it is where the placenta is situated in the
upper parts of the uterus under ordinary circumstances. The placenta,
which is already separated to a certain extent by the introduction of the
hand, usually comes away without any trouble as soon as the child is
delivered. We once met with a case where it was firmly adherent to the os
uteri on one side, and required to be artificially removed, which was
effected without difficulty. In this instance, hæmorrhage returned after
the labour from uterine inertia, and was checked by the means already
recommended. (_Med. Gaz._ Sep. 2, 1837.) The after treatment should be
conducted upon the same principles as in other cases of hæmorrhage.
_Partial presentation of the placenta._ Where this is the case, the danger
is rarely so alarming, nor is it always necessary to effect artificial
delivery by turning. The edge of the placenta frequently projects but a
very little over that of the os uteri, feeling, as it were, like a second
lip; at other times it covers a third or more of the opening, and is
usually attached upon the anterior portion of it. Our own observations
have rather led to the conclusion, that where the placenta is but
partially attached over the os uteri, the first attack of flooding is
rarely delayed until the full term of pregnancy, but makes its appearance
some weeks earlier. We are inclined to attribute this to the os uteri
being only in part covered with placenta; that its other portion, being
free, is more capable of dilatation from slight causes, than it would be
were the placenta centrally attached: from a similar reason we may
understand why the hæmorrhage is seldom so profuse in these cases as to be
dangerous, and why the os uteri usually dilates sufficiently soon to allow
the head to descend and be born by the natural powers. We are confirmed in
this view by what we have already quoted from Dr. Rigby respecting the os
uteri being prevented dilating by the close adhesion of the placenta--an
opinion which is, moreover, approved of by Dr. Dewees as being "both
ingenious and probable." Hence, also, we may reverse our position, and
say, that in a case of partial presentation of the placenta, we shall
seldom find the hæmorrhage very profuse, until the os uteri has attained a
considerable degree of dilatation. Besides the portion of placenta which
presents, there will be also a bag of membranes occupying the remaining
portion of the opening; we shall rarely, if ever, meet with those
difficulties connected with a contracted and unyielding state of the os
uteri, which we described in cases of central presentation; and if the
hand requires to be introduced, which is not often the case, it will
seldom experience much opposition.
_Treatment._ In our treatment of partial presentation of the placenta, we
must be guided, in a great measure, by the strength of the pains and the
degree of dilatation which the os uteri has attained; the extent to which
it is covered by the edge of the placenta, must also be taken into
consideration. Where the pains are strong and active, the pressure of the
membranes distended by liquor amnii against the mouth of the womb will be
sufficient to check the hæmorrhage; if not, by rupturing them we shall be
enabled to let off the liquor amnii, and thus allow the head to press
directly upon the os uteri, and act in the double capacity of a plug and
compress. Where the pains are slow and inactive, the rupture of the
membranes will diminish the size of the uterus, and thus excite it to more
powerful contraction; if not, a dose of secale cornutum, repeated
according to circumstances, will be of great assistance. If the patient
has suffered a good deal by the loss of blood, a little beef-tea, in small
quantities frequently repeated, will rouse the powers; wine or a little
brandy, may also be given at intervals; but unless the prostration be very
serious, we have not found stimulants so useful as beef-tea, which is
usually, also, much more grateful.