1847 The Lancet  
of change in all that is momentous in the exercise of our profession, induces me to offer a few remarks on the proposed treatment of placenta previa, as recommended by Professor Simpson. I should imagine that the principles upon which the expediency of the practice depends are, the source of haemorrhage in these presentations, and the maximum of safety that can be best afforded to the mother. The subject is one of intense interest, and demands the grave consideration of each member of a humane
more » ... nd scientific profession, involving, as must be admitted that it does, maternal safety and infant life. The correctness of Dr. Simpson's physiological principle-viz., " that the haemorrhage in these cases proceeds from the placental surface alone," ends all argument, and there can be no hesitation as to the value of his discovery; but, opposed to this, if there be a doubt as to the vessels of the uterus being concerned before delivery, and while the placenta is still partially adherent, there can, I should imagine, be no difference of opinion, as to the haemorrhage proceeding from the uterus after delivery, with this organ perfectly empty. A more comprehensive knowledge of the anatomy and pathology of the gravid uterus, and its contents, the normal and abnormal changes which occur during parturition, will enable us to understand why such immense discharges of blood take place, when the placenta is only partially separated, and the uterus in a passive condition. This will also determine the best treatment to be pursued under these at all times most anxious circumstances. Fortunately, Nature has ordained, that in general the placenta should not adhere to the mouth and neck of the womb: there would be but few obstetricians if she did. It does, however, occasionally happen, and the most successful and safe treatment is the question at issue. Dr. Merriman observes, " that when the placenta was found presenting, it was formerly supposed that it had accidentally been separated from the fundus, and had fallen by its own weight to the os uteri, which it closed, so as to prevent the child from passing." An inference not improbable, but, like all human dicta, somewhat problematical. Portal, who practised midwifery extensively in Paris, seems to have entertained more correct opinions than his contemporaries. Rigby appears to have been the discoverer of the pathology of flooding before delivery, although Levret anticipated it, in a work from his pen, about the same time; since which the practice has been, in partial presentations, first to evacuate the liquor amnii, and if an arrest of haemorrhage follow, and the presentation be natural, to entrust the management to Nature. In complete presentations, also, this rule has been sometimes successful. At the same time we must bear in mind to puncture the opposing mass of placenta, although the practice is not without its objections, as the escape of the waters at so early a stage of labour will in all probability tend to increase the difficulty of version, which it is known should be resorted to as soon as the dilatation of the uterus admits, and while the strength of the patient is unimpaired. Blundell, Conquest, Lee, (cum multis aliis,) concur, that the safe and legitimate practice is early to evacuate the uterus-arte non vi; and that this is not dangerous, says Denman," when performed with care." Should these authorities be subverted by doubtful modern examples, and when a more successful issue cannot be obtained ? I must coincide with Dr. Simpson in his veneration for older measures, until I see just cause for their abrogation. In the number of your journal for May 8th, Dr. Simpson observes: " I hold turning to be the proper mode of practice in unavoidable haemorrhage, which cannot be restrained by less active measures; in a great proportion of cases the accompanying haemorrhage requires interference at so early a stage of the labour, that the only proper and possible mode of delivery is by the operation of turning. The great objection to it, however, is, the imminent danger of lacerating the cervix uteri, which in these presentations is exceedingly vascular. To avoid this, and insure the safety of the mother, he proposes the artificial separation of the placenta before the child, and adduces some proof, that the mortality under the old and recognised plan was much higher to the mother than in the proposed method of extracting the placenta before the child. One in three mothers was lost, according to Dr.'Simpson's statistics, but he does not state how many, on the new plan, are saved, nor how many children are born alive. In the present surcharged state of population, this preference of Dr. Simpson's is not to be wondered at, although backed by Dr. Hamilton, who states, " In some cases, before the orificium uteri can be sufficiently opened to admit of turning, the whole placenta will be disengaged and protruded, but that this separation and expulsion, previous to the birth of the child, is for the most part fatal to the mother;" and, he might have added, always to the child; "though some instances have occurred where the woman has been saved by Nature, the pains being so strong that the child has be-,n forced down with the placenta before it." Mr. Chapman relates a case where the placenta was expelled four hours before the child. Perfectly similar cases. Dr. Merriman also speaks of the like. No man therefore would presume to deny that a combination of circumstances cannot justify a deviation from the prescribed rule, such as the patient having a contracted pelvis, or having ascertained the child's death, or an obstinate, an undilatable os uteri, perhaps the placenta already in the vagina. These and other circumstances must very properly influence the most experienced practitioner, although it will be admitted that twenty-seven cases of successful turning, out of fifty-nine in placenta pra-via, as related by Dr. Lee in THE LANCET for May 15, are very great inducements, under favourable auspices, not to depart from the beaten track. These, in my mind, tend very greatly to quiet the excitement which has hitherto pervaded the profession on this important practical disputation. I am induced, therefore, to relate three interesting cases which have occurred to me, with their particulars, as they offer some interest in connexion with the subject before us. Mrs. S-, aged forty-eight, residing at Peckham, the mother of seven children; had reached the full period of gestation, or nearly so; constitution exceedingly weak and emaciated ; was seized with unavoidable haemorrhage, which gradually became profuse. When I saw her, she was faint and exhausted: I administered the usual restoratives, and examined, and discovered a complete presentation of the placenta, firmly adherent. After explaining to the husband the uncertain termination of these cases, he proposed sending for a second opinion. I mentioned my friend, Mr. Robinson, who will no doubt recollect the case: he agreed that no time was to be lost in delivery. The preliminaries arranged, I introduced my hand cautiously through a rigid os uteri and the placental mass, and the delivery was effected in a few minutes, by the feet, Mr. Robinson supporting the abdomen. The child was in a state of asphyxia, but lived; the mother, from the entire absence of contraction in the uterus, and excessive haemorrhage, after its complete evacuation, became comatose, with a pulse scarcely perceptible; all the usual remedies failing, a stream of cold water was poured upon the abdomen, and its effects were magical. The uterus very soon contracted, and returning consciousness animated once more the exhausted frame of our rescued patient. Removal from her saturated condition for twenty-four hours was impossible, as the uterus was secured in its contractility only by the firmest and most determined pressure. Let it suffice that she now lives to tell the tale, and had not more impediments than usual to her complete recovery. How far Professor Simpson's method of detaching the placenta would have been applicable-in the present and following cases I must leave to abler heads. Mrs. T -, thirty years of age, had reached the eighth month of her fifth pregnancy, and had been labouring under sanguineous discharge, with slight pains, for a few days, when a copious haemorrhage came on, which induced her to send for assistance. Upon examination, I found the os uteri very slightly dilated, and the placenta immediately over it. On a sudden, whilst removing her from the bed, a gush of blood took place to an immense extent, and syncope followed. I soon succeeded in dilating the os uteri, and penetrated the placental mass. As in the first case, delivery was effected soon afterwards; but hsemorrhage, producing asphyxia, followed, which defied the use of ergot in large doses, and for some time, cold water and other stimulants. She eventually did well, and the infant still lives, although not robust. Both parent and child may be said to bear the stamp of former innovations. Mrs. H-, of plethoric habit, aged thirty-five, the mother of ten children, was seized with slight haemorrhage, for a fortnight previous to the coming on of labour, at the end of which, a profuse discharge took place, which caused her to send for me. I found her pallid and retching, with more
doi:10.1016/s0140-6736(02)86529-1 fatcat:ylpl6jizsngj7h2hvidflb4ngu