T.H. Shute
1857 The Lancet  
53 pregnancy. In such cases, the ovum being lodged in an abnormal situation, ill adapted to supply sufficient nutriment for the embryo, it is not uncommonly found that the greater part Qr the entire surface of the chorion is developed into placenta. There is a well-marked example of this in Guy's Museum. I There is a form of placental growth by no means uncommon, which fnrther corroborates the view that any part of the chonon may be developed into placenta, according to the requirements of the
more » ... equirements of the embryo. There are the placenta spu2-ia and the .placenta succentw'iata, to prove that true placental outgrowths may take place at a distance from the main placenta. Sometimes a placental mass of the size of a crown piece or larger is found wholly separate from the main placenta. This is not an unfrequent cause of secondary haemorrhage after delivery. The placenta sltccenturiata remains adherent after the expulsion of the.true placenta and the bulk of the membranes. But there is yet another fact, of extreme importance in relation to this subject. I have been struck with the frequency with which praevial attachment is complicated with disease of the placenta and foetus. In examining and reflecting upon particular cases it has appeared to me that placental tufts may ibpot out from one part of the chorion in preference to other parts, because some points, being diseased, are unfitted for efficient placentary development, or because some parts of the chorion, itself healthy, may be in contact with an unhealthy pprtion of decidua. Thus, if the fundal mucous membrane is diseased, there will be a tendency to placental development on that aspect of the ovum which is directed towards the lower segment of the uterus. Another circumstance illustrating the frequent complication of disease with praevial placenta, is adhesion. It is important, however, not to confound the cases of true adhesion, in which there is organic change of structure, or abnormal deposit in the decidual portion of the placenta, with those more frequent cases in which the adhesion is merely the result of absent or ineffectual contraction of the uterus. We shall see by-and-bye that the muscular structure about the lower segment of the aterus is far less perfectly adapted to cast off the placenta than ip the muscular structure of the fundus. This is one cause-a frequent one, and often unsuspected-of placental adhesion or retention. During my researches into the diseases of the placenta, many placentas have been brought to me, which having been retained, had been manually separated from the uterus on account of supposed morbid adhesions. It was rare to find in these specimens any trace of disease. In a recent excellent paper, the present Dr. Legroux says, that placenta previa mostly occurs in pltiriparae, and that it is due to the greater than normal enlargement of the uterus, which thus allows the ovum to spread its attachments lower than is possible in the more inferiorly contracted, or pyriform, uterus of primiparas. One circumstance has struck almost every observer, and that is, the frequency with which the prsevia.1 attachment of the placenta has occurred in the same patients. Some women are, therefore, especially prone to this complication. Is it rational to conclude that some women are especially prone to an "accidental" attachment of the placenta to the lower segment of the uterus ? No. It is not then an "accident;" but an occurrence depending upon definite and ascertainable causes. I believe the etiological arguments thus enunciated are wellfounded. They do not exhaust the etiological historv. There re probably other causes. To complete the list is, I submit, I1P object eminently deserving of research. We should not rest contented with the quaint evasion of Portal, that these things happen, " selon qu'il plait A la nature de se jouer." DIAGNOSIS OF PLACENTA PR2EVIA. Are there any signs by which ve ina.,?l discej'n the exi8tence oj placenta pl'aevia b fore the occurrence of Labour ? This question is important, because, if we knew that this complication existed beforehand, we should be foreartned, and the better prepared to encounter the impending difficulty. Levret has examined the question with his usual acumen. He enumerates the following signs of central or lateral placenta :— 1st. The belly of the patient is not pointed, or rounded as a ball, but somewhat flattened. 2ndly. It appears as if it were divided into two parts, as in the case of twin-pregnancy; but that which essentially distinguishes the first case from the second is, that the division i8 not found exactly in the middle, nor according to the vertical line of the body, but more on one side than the other, and a little obliquely. Moreover, if we question the woman, she will admit that in the first months of pregnancy she felt a swelling, with hardness, in one or the other side of her belly. Z,5 3rdly. This hardness had gone on increasing, and had never changed sides. 4thly. This side is the most painful spot of the whole belly, and that in which she feels the movement of her child the least. These signs are perhaps wanting in precision, but their existence in any given case should at least indicate more minute investigation. Gendrin gives two signs. He says that a pulsation may be felt at the os uteri not synchronous with the mother's pulse; and, secondly, that owing to the interposition of the placenta ballottement cannot be performed. Neither of these signs is universally true. It may be stated that the lower segment of the uterus is generally larger, softer, more fleshy than in ordinary gestation. The presenting part of the child either cannot be made out at all, or very indistinctly; and occasionally, when the os uteri will admit the finger, the quaggy place'ttal mass may be felt. Sometimes a persistent dragging pain in a particular part has led to a stethoscopic examination, when the cervical attachment of the placenta has been accurately determined. This I have myself experienced. Dr. Cohen, of Hamburg, has described the means of diagnosticating placenta praevia in a paper to which I shall again have occasion to refer. His especial object is to determine which side of the lower segment of the uterus the main bulk of the placenta adheres to. He says the side of the uterus to which the main placenta grows is more swollen. In by far the greater number of cases this side is painful. The pain in the right epigastric region known to every accoucheur is' a suffering so common in these circumstances that we regard the cases in which it does not appear ihere or on the other side as exceptional. Whenever this pain was strong, Cohen always found considerable fibrinous deposits in the placenta, and often stringy adhesions of the fcetal placenta to the uterus; The smaller part of the placenta, he says, is attached either to the right or left side; so seldom to the fore or after side, that for diagnosis it is enough to examine the right and left sides. Moreau places little confidence in the condition of the os and cervix. He says: " One only phenomenon may cause a suspicion of the cervical insertion of the placenta: this is the epoch at which the haemorrhages occur. Generally, they take place early in pregnancy, but they never arise before the moment when the neck of the organ begins to unfold itself. Most frequently, it is from the sixth to the seventh month." The indications in diagnosis may be usefully summed up as follows :-1. The general signs, such as flattening of the abdomen, division of the abdominal tumour, and especially swelling and pain in one side of the pelvis pointed out by Levret, should lead to minute exploration by the finger and stethoscope. 2. Abortions, disease of the placenta, dead children, and placenta prasvia in former pregnancies, should also incite to minute physical exploration. PHYSICIAN TO THE TORBAY INFIRMARY. As any case tending to elucidate the physiology and pathology of the brain is of importance, I send the following, thinking it presents many points of interest to the readers of THE LANCET:-Elizabeth S-, aged twenty-six, married three years, no family, was admitted under my care March llth, reported to be suffering from chorea. She presented the following appearance : --Countenance not sunken nor pallid, and not evidencing pain ; fea,tures not distorted; muscular and adipose tissues sufficiently developed; tongue furred, protruded with a jerk; head constantly moving to the left side; articulation very imperfect ; understands and answers everything that is said to her; constantly talking whilst awake; left arm in perpetual movement, being jerked across the chest, (during sleep the convulsive movements cease, and she is quite tranquil;) total inability to support herself on her legs, but she can move them up in the bed; sensation not affected; has a constant short cough, as if caused by accumulation of mucus; pulse 90; urine acid : no albumen. There was much difficultv in examining
doi:10.1016/s0140-6736(02)38705-1 fatcat:s256dlscjjcaxblnuwwknsyo2q