A System of Midwifery Part 29

_Treatment._ Our treatment of these cases will not vary essentially from that of exhaustion from haemorrhage under the ordinary circ.u.mstances; the patient must be placed with her head low, and as soon as she is able to swallow, a little hot brandy and water, or ammonia, should be given to rouse the circulation to a sufficient degree of activity. If the uterus be still flaccid and disinclined to contract effectively, a dose of ergot will be advisable, and the abdomen should be tightly bandaged with a broad towel. When the powers of the circulation have rallied somewhat, a little plain beef-tea will frequently prove very grateful and appear to revive her more powerfully than even the stimulants above-mentioned; and now, as it is of the greatest importance to calm the irritability of the brain and nervous system, we must proceed to the use of sedatives. Of these, opium and hyoscyamus have the preference, the latter especially so, from its not being liable, like opium, to derange the stomach, or contract the bowels.

Moreover, where the exhaustion is very alarming, it is not always easy to control the sedative action of opium within due bounds; and in such cases we are sometimes apt to produce so much sopor, as to render it even difficult to rouse the patient. For this reason, the combination with a diffusible stimulant is always desirable: five grains of camphor and of extr. hyosc. in two pills, form, perhaps, the best and safest sedative which can be given; these may be repeated every hour, and then at longer intervals of two or more hours, until sleep has been produced. Sleep, in cases of this kind, is of the greatest importance, and produces the most favourable change in the patient's condition; the intense headach and irritability of the mind, of the sight, and of the hearing, all abate; the circulation becomes calmer, the pulse more full and soft, the heat of the body more equable; in short, the whole nervous system is returning to a more natural and regular state of action, the stomach is more capable of receiving and digesting its food, the bowels are more manageable, and we may now venture to remove a state of constipation, if present, or any morbid intestinal contents without running the risk of bringing on diarrhoea and increasing the debility.

We rarely find that the convulsions return when once the patient has enjoyed the calm of a sound and refres.h.i.+ng sleep, and consider the victory as more than half gained when this favourable state has been produced. The laxative should be of the mildest form, such as will merely excite the peristaltic action of the intestines without increasing their secretions; for this purpose a warm draught of rhubarb manna with hyoscyamus, or castor oil guarded by a little liq. opii. sed., will be the safest. Food of the blandest and most nutritious quality should be given in small and frequently repeated doses; it is important not to load the stomach much or suddenly, for vomiting is easily produced, and when once excited, the stomach becomes so irritable as to be scarcely capable of retaining any food whatever.

Where, on the other hand, several hours have pa.s.sed, not only without sleep but without even a temporary state of quiet; where the headach alternates with restless delirium; where the medicines and nourishment have produced little or no effect, or have been rejected by vomiting; where the pulse becomes quicker, and the debility increases, we have not only to dread a return of the fits, but that the stage of actual sinking is at hand.

"It would perhaps," says Dr. Marshall Hall, "be difficult to offer any observations on the nature and cause of excessive reaction; but it is plain that the state of sinking involves a greatly impaired state of the functions of all the vital organs, and especially of the brain from defective stimulus. The tendency to dozing, the snoring and stertor, the imperfect respiration, the impaired action of the sphincters, the defective action of the lungs, and the acc.u.mulation of the secretions of the bronchia, the feeble and hurried beat of the heart and pulse, the disordered state of the secretions of the stomach and bowels, and the evolution of flatus, all denote an impaired condition of the nervous energy." (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.)

_Hysterical convulsions_ scarcely deserve the name of puerperal convulsions, being liable to occur under circ.u.mstances quite independent of the puerperal state; they rarely occur during the process of labour itself, but are chiefly observed during the last few weeks of pregnancy, and the first week or so after labour, especially when the milk is coming on.

_Symptoms._ The patient is of a nervous hysterical habit; "she is either still very young, or is of a slim and delicate make; the face is pale and interesting; she has full blue eyes and light hair, and was always of a highly sensitive const.i.tution; the pulse is quick, small, and contracted; the temperature of the skin is rather cool than otherwise; her spirits are variable, fretful, and anxious; she starts at the slightest noise, cannot bear much or loud talking, and misunderstands or takes every thing amiss.

During her slumbers, which are short, there are slight twitchings of the eyes and mouth, and in her sleep the eyes are in constant restless motion, and she frequently starts. She complains of sickness, and has frequent calls to pa.s.s water, which is very pale; slight rigours alternate every now and then with flus.h.i.+ng, and she is easily tired, even by trifling pains, and dozes a good deal during the intervals. She is excessively sensitive, even to the most gentle and cautious examination; the os uteri remains thin, hard, tense, and painful to the touch longer than is usually the case. The ordinary tension and stretching of the os uteri at the termination of a regular contraction is attended with much more pain, and with a peculiar feeling of la.s.situde, although uncomplicated with any rheumatic affection. The pains follow no regular course, being sometimes stronger, at others weaker, and frequently cease entirely for considerable periods. The uterus has a great disposition from the slightest irritation, to partial and spasmodic contractions." (Wigand, _Geburt des Menschen_, vol. i. p. 164.)

Before the fit the patient usually pa.s.ses a large quant.i.ty of colourless and limpid urine; she has oppression at the stomach, anxiety, difficulty of breathing and palpitation, with globus, sobbing, and other hysterical symptoms. There are not those precursory symptoms of cerebral congestion as mark genuine epileptic puerperal convulsions; the headach is neither so severe, nor is it in the same place, being usually at the temples and across the forehead; the face is rather pale than flushed, and when the fit begins, we see little or none of the convulsive twitching among the small muscles, as is the case with an epileptic attack; the face is less distorted, but the large muscles of the trunk and extremities are much more violently affected; the patient struggles furiously, and in severe cases has more or less of opisthotonos; she screams, and never appears to lose her senses so entirely as in the epileptic form; her raving may generally be controlled to a certain extent by suddenly das.h.i.+ng cold water in her face, and speaking loudly and sharply to her; at any rate it instantly produces a deep and sudden inspiration, which is frequently attended with a prolonged hooping sound; this is followed by sobbing, gasping, choking, and the ordinary phenomena of an hysteric fit, but the convulsions themselves are usually arrested more or less by this application: we hold the effects of cold water to be one of the best diagnostics of the disease from epilepsy, in which the patient is entirely insensible to such impressions.

A similar fact is observed during v.a.g.i.n.al examination; the patient seems aware of our intention, and resists in every possible way.

"The patient, after the fit, can for the most part be roused to attention or will frequently become coherent so soon as she recovers from the fatigue or exhaustion occasioned by her violent struggles; and though she may lie apparently stupid, she will nevertheless sometimes talk or indistinctly mutter. After the convulsion has pa.s.sed over, she will often open her eyes and vacantly look about, and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head in the clothes." (Dewees's _Compend. Syst. of Midwifery_, -- 1240.)

When sufficiently recovered to be capable of swallowing, she should sip some cold water, or what is still better, take a dose of spiritus ammoniae foetidus in water; this soon produces copious eructations from the stomach, which are followed with much relief. Where there is a disposition to vomiting, and other evidences of a deranged stomach, it should be encouraged by some warm water, chamomile tea, &c. The bowels are almost always in an unhealthy state, which frequently produces much irritation, and in plethoric habits so much tendency to cerebral congestion as to endanger even an attack of the epileptic convulsions. One or two doses of a pretty brisk purgative should, therefore, be given, and if there be still heat or pain of head, a bleeding may be required.

Under ordinary circ.u.mstances hysterical convulsions are by no means dangerous, and beyond a little fatigue and exhaustion, the patient recovers from them almost immediately.

CHAPTER XII.

PLACENTAL PRESENTATION, OR PLACENTA PRaeVIA.

_History.--Dr. Rigby's division of haemorrhages 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 pract.i.tioner, than that species of haemorrhage 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." (Naegele, _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 haemorrhage, 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 cla.s.sical _Essay on the Uterine Haemorrhage 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 haemorrhage during pregnancy, attended with circ.u.mstances 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 pa.s.sage. 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 haemorrhage 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 a.s.sistance, 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 Pare, and still farther brought into notice by himself, at that time formed a great aera in midwifery, for it furnished pract.i.tioners 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 haemorrhage 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 pa.s.sage 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 Haemorrhage in the latter Months of Pregnancy," (_Edin. Med. and Surg. Journal_, April 1839,) has omitted all mention of this circ.u.mstance, 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 haemorrhage 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 praevia 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 haemorrhage 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 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.