A System of Midwifery

by Edward Rigby

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.[141]

It is, therefore, to the above-mentioned circumstances 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 Hæmorrhage, 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 passage, 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 hæmorrhage 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 fœtus 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.

Rœderer decidedly stands pre-eminent, as being the first author who gave a distinct and complete description of this species of hæmorrhage; 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 hæmorrhage will be very profuse, and artificial assistance 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 Rœderer’s work, published at Paris, a valuable paper on placental presentation, which, with the above-mentioned chapter of Rœderer, must be looked upon as the first observations in which this form of hæmorrhage 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 Rœderer 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 hæmorrhage under such circumstances is inevitable, and that the safest mode of remedying this accident is the accouchement forcé. 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 establishing it as a matter beyond doubt.

Levret cannot, however, be looked upon as the first who considered that the flooding, in cases of placenta prævia, 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 hæmorrhage 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, entitled 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 Hæmorrhage, 1775,[143] in farther proof of the placenta being implanted over the os uteri, and being the cause of hæmorrhage.

We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine hæmorrhage which precedes the delivery of the full-grown fœtus 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 hæmorrhages, 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 hæmorrhages, 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 asserted 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 hæmorrhage 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 hæmorrhage, 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 circumstance 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 circumstance necessary to be inquired after in every case of hæmorrhage: 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 practitioners, should not long before have led to its practical application, and in consequence to more fixed principles in the treatment of hæmorrhages 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.