History. There is abundant evidence to prove 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[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 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 æra 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 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 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 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 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 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 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 Rœderer 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.