_Symptoms._ The first symptom which warns us that the placenta is presenting, is the sudden appearance of haemorrhage, which is usually more copious than ordinary haemorrhage, and apparently comes on without any a.s.signable 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 circ.u.mference, except perhaps where the separation is, from which the haemorrhage proceeds. We shall distinguish the placenta by its spongy ma.s.s, by its soft irregular surface, and by the stringy feel which it communicates where it has been torn.

The character of the haemorrhage is also different from that of common haemorrhage, inasmuch as it increases during a pain, and diminishes or ceases during the intervals, whereas, in haemorrhage under ordinary circ.u.mstances it is the reverse.

Where the haemorrhage 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, haemorrhage 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 Naegele, 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 haemorrhage 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 v.a.g.i.n.a; but with returning contractions of the uterus, the haemorrhage 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 Suss.e.x, 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 haemorrhage. 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 pa.s.sage, 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 a.s.sure 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 Naegele 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 pract.i.tioners 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 haemorrhage 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" haemorrhage 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 haemorrhage 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 haemorrhage connected with abortion. In his forty-third case, the haemorrhage, 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 haemorrhage 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 haemorrhage 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 v.a.g.i.n.a, 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 haemorrhage 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 haemorrhage, 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 v.u.l.v.a, loins, and over the symphisis pubis; gentle saline laxatives with nitrate of pota.s.s 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 r.e.c.t.u.m will be necessary. This may be given immediately where the bowels are not confined, or, if they are, after the r.e.c.t.u.m 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 haemorrhage, 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 haemorrhage.

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 pract.i.tioner 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 haemorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any a.s.signable reason, we should earnestly warn the patient and her friends to summon the pract.i.tioner the moment there are any symptoms of its return; for if it be a case of placental presentation, it a.s.suredly 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 haemorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quant.i.ty 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 quant.i.ty 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 haemorrhage 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 circ.u.mstances; 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 pa.s.sed 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 haemorrhage 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 Naegele 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 v.a.g.i.n.a, 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 haemorrhage, 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 pa.s.sages 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 circ.u.mstances, 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 haemorrhage; in other words, we must plug the v.a.g.i.n.a. "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 haemorrhage 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 praevia, and apparently in a moribund condition, immediately filled the v.a.g.i.n.a 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 Haemorrhage_, p. 155.)

_Turning._ The operation of turning the child will, in no wise, differ from that under more ordinary circ.u.mstances, 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 v.a.g.i.n.a will effectually act as a plug.

Portal, was, probably the first who practised this mode of operation, viz.

pa.s.sing his hand between the os uteri and placenta, and then between the uterus and membranes before rupturing them: in this respect he antic.i.p.ated 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 pa.s.sed 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 a.s.sign 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 ma.s.s 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 pa.s.s through without a forced enlargement, and this must be done by the child during its pa.s.sage.

"4. As the hole made by the body of the child is not sufficiently large for the arms and head to pa.s.s 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 haemorrhage.

"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 pa.s.sing the hand through the os uteri: the less we separate the placenta, the less also will be the haemorrhage; 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 circ.u.mstances 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.