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 vaginal 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 passed 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' 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 ammoniæ fœtidus 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 circumstances hysterical convulsions are by no means dangerous, and, beyond a little fatigue and exhaustion, the patient recovers from them almost immediately.

22

CHAPTER XII.

PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.

HISTORY.-DR. RIGBY'S DIVISION OF HÆMORRHAGES 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 practitioner, than that species of hæmorrhage 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." (Naegelé, 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 hæmorrhage, 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 classical Essay on the Uterine Hemorrhage which precedes the Delivery of the full-grown Fatus, 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 that the sudden attacks of hæmorrhage during pregnancy, attended with circumstances 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 passage. He has devoted his fifteenth chapter to the management of a case where the pla

*

* In the edition which has been translated into English, A. D. 1612, it is the twelfth * chapter.

PLACENTAL PRESENTATION.

centa 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 hæmorrhage 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 assistance, 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 Paré, and still farther brought into notice by himself, at that time formed a great era in midwifery, for it furnished practitioners 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 hæmorrhage 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 lose 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 passage 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 Hæmorrhage in the latter Months of Pregnancy," (Edin. Med. and Surg. Journal, April, 1839,) has omitted all mention of this circumstance, 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 hæmorrhage 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 prævia 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 does 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 thirtyseven cases of uterine hæmorrhage 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 hæmorrhage 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 hæmorrhages, and in all of them he found the placenta at the mouth of the womb." (Essay on Uterine Hæmorrhage, 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 hæmorrhage. On introducing his hand he "found the afterburden 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 hæmorrhage 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 passage 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 Ræderer 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 circumstance 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 passing 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 prævia 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 passage, 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 prævia, 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 circumstance, 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.*

• We subjoin the passages to which we have referred in the three above mentioned

cases :

Case 115. "I cannot implicitly accede to the opinion of most writers in midwifery, which is, that the placenta always adheres to the fundus uteri; for in this, as well as many former instances, I have good reason to believe that it sometimes adheres to or near the os internum, and that the opening of it occasions a separation, and consequently a flooding."

Case 116. "The first thing I met with was the placenta, which I found closely adhering round the os internum of the uterus, which, among other things, is a proof that the placenta is not always fixed to the bottom of the uterus, according to the opinion of some writers in midwifery. Its adhering to the os internum was, in my opinion, the