Part 29 (2/2)

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 haemorrhage 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 haemorrhages, and in all of them he found the placenta at the mouth of the womb.” (_Essay on Uterine Haemorrhage_, 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 haemorrhage. 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 haemorrhage 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 pa.s.sage 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 circ.u.mstance 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 pa.s.sing 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 praevia 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 pa.s.sage, 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 praevia, 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 circ.u.mstance, 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 circ.u.mstances 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 Haemorrhage_, 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 pa.s.sage, 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 haemorrhage 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 haemorrhage; 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 haemorrhage will be very profuse, and artificial a.s.sistance 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 haemorrhage 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 haemorrhage under such circ.u.mstances is inevitable, and that the safest mode of remedying this accident is the _accouchement force_. 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 establis.h.i.+ng it as a matter beyond doubt.

Levret cannot, however, be looked upon as the first who considered that the flooding, in cases of placenta praevia, 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 haemorrhage 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, ent.i.tled _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 Haemorrhage_, 1775,[143] in farther proof of the placenta being implanted over the os uteri, and being the cause of haemorrhage.

We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine haemorrhage 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 haemorrhages, 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 haemorrhages, 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 a.s.serted 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 haemorrhage 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 haemorrhage, 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 circ.u.mstance 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 circ.u.mstance necessary to be inquired after in every case of haemorrhage: 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 pract.i.tioners, should not long before have led to its practical application, and in consequence to more fixed principles in the treatment of haemorrhages 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 circ.u.mstance, 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 ent.i.tled 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 circ.u.mstance 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 haemorrhage? 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 haemorrhage. 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 circ.u.mstances, this effusion of plastic lymph has already attained such a degree of firmness and coherence as to prevent the ovum from pa.s.sing 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.

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