No. 1776.

SEPTEMBER 12, 1857.

Lettsomian LecturesON

MIDWIFERY.DELIVERED BEFORE THE

MEDICAL SOCIETY OF LONDON,MAY, 1857.

BY ROBERT BARNES, M.D.

LECTURE III.—(CMMM.) )THE TREATMENT OF PLACENTA PR2EVIA.

Sucgy then, being the dangers of forced delivery, a remedyis urgently required to replace, in certain cases at least, thisoperation.Do we find that remedy, that resource, in the artificial total

detachment of the placenta ?APPRECIATION OF THE METHOD OF ARTIFICIAL TOTAL

DETACHMENT OF THE PLACENTA.

Two things must be proved before we shall be justified inanswering this question in the affirmative.

1. That the total detachment of the placenta previous to thebirth of the child will arrest the hsemorrhage.

2. That the operation itself is one that can be accomplished{] mean in the class of cases we are now considering) withsafety.A subsidiary question is involved as to the fate of the child

in cases where this operation is performed. This question Ipropose to examine by itself on- another occasion.

1. I will at once state that many authentic cases are nowrecorded in which the haemorrhage ceased after the presumedtotal detachment of the placenta, either spontaneously orartificially effected. But it must also be stated that cases nota few are known where the haemorrhage- continued under thesecircumstances.In approaching this question I must at the outset declare my

conviction that it is not to be decided by statistics. I believethis opinion is now generally entertained by the: profession.The statistics, at least, that have hitherto been put forwardhave satisfied no one. We must not give up- physiological z,reasoning, or individual clinical experience, to a mass of figureswhich professto be the expression of facts similar in nature.From the moment that all the details of a case are eliminatedin. order to squeeze out one or two particular facts to form partof a statistical phalanx, we lose almost everything that is in-structive in the case, and run the most imminent danger offalling into false conclusions. We all know that a singlepregnant instance of a fact well observed is often absolutelydecisive as to a physiological or pathological law. There areihdividual facts against which no array of statistics can avail.

1. say this without any desire to depreciate the value of-theapplication of the numerical method to medical inquiries, butrather with a view to exact the most scrupulous care in ourappeals to this method. I have myself been within the sphere,ofthe influence of that great physician who has,so strenuouslyasserted the power of statistics in solving the diineultproblemsof medicine. At the H6pital Beaujon, and in an, occasionalvisit at the sittings of the Societe Medicale d’Observation; thave caught a spark of statistical enthusiasm. But a rigidcriticism of the fundamental facts which have been boundstogether into so-called’ statistical tables, showing the various’conditions of placenta prsevia, has convinced me that if we’would respect the first rules of statistical science, we cannot,.without risk of endless fallacies,, subject the greater number othese facts to any statistical operations.The last great statistical work on Placenta Praevia is that of

DrTrask.* It is a work of great research, industry, and merit;:but I could take,any one of his tables, and point out numerouscases which it is quite arbitrary to range in the columns wherethey help to swe11 an imposing aggregate, and are assumed to

* Statistics, of- Placenta Prrovia. By James D. Trask, M.D. FhU&delphia)1&5S.

strengthen by accumulation one particular deduction. And ifI doubt his facts, if I doubt the propriety of marshalling themin the order in which he has placed them, how can I trust hisconcluf3ions? These objections apply with infinitely greaterforce to other tabular arrangements of cases of placenta praevia,collected with so much labour and skill, for the purpose ofproving the superior advantages of wholly detaching the pla-centa. The objections I urged against these tables some yearsago have been, sufficiently recognised by subsequent writers.Dr. Trask especially has avoided the gross error pointed out byme, of confounding together cases of spontaneous, and cases ofartificial, total previous detachment of the placenta. I needbut repeat that things different in nature are added together,compared, and made the foundation for practical conclusions.The practice of gathering together from many different writingscases presenting some general features of likeness, which havebeen observed from different points of view, through manydifferent media, and therefore probably differing in manyessential points, must necessarily be unfitted for scientific com-parison. No after-analysis, no after-synthesis, can compensatefor the want of original essential details.Let us return to individual facts and details. Dr. Trask. ham

collected 36 cases in which there was previous spontaneous ex-pulsion of the placenta. In 13 of these we have no informationas to whether heemorrhage followed the total detachment ofthe placenta or not. In some, moderate haemorrhage did con-tinue. In the majority, there being active contraction of thewomb, the grand haemostatic agent-there was no haemorrhage.Dr. Trask has next collected all the cases- known to him wherethe placenta had been separated by the hand. These amountto 66. In 35 of these it is stated that the haemorrhage ceasedimmediately and entA1’ely after detachment. In the remainderthe information is vague, or it is stated that more or lesshaemorrhage continued.Now, to exhibit clearly the essential difference in the two

classes of cases, it is only necessary to state that the persist-ence of haemorrhage was more frequent after artificial than afterspontaneous detachment, and that more deaths occurred.. Thefact is that in. the spontaneous-cases the great characteristicwas active contraction; and in the artificial cases, relaxationand exhaustion. I will quote one- case - of continued hoemor-rhage after spontaneous separation from Dr. Lee ;* although- in-cluded as a recovery in Dr. Trask’s table, he has omitted torecord the continuance of the haemorrhage.CASE 13.-" On the 8th. February, 1830, I was called to a

woman. residing in Falconberg-court, who had been attackedwith profuse uterine haemorrhage at the end of the seventhmonth of pregnancy. The placenta was protruding throughthe orifice of the vagina. I immediately extracted it, and adead child followed. A great haemorrhage succeeded, and sheremained for a considerable time insensible, without any pulseto be felt at the wrist. She, however, gradually recovered.."

Dr. Johnson, of Dublin, is quoted by M’Clintock and Hardy,as having "seen an instance.where the haemorrhage continuedwith little abatement after the placenta. had been expelled spon-taneously, so that the hand had to be introduced, and deliverycompleted by turning." " This case is not quoted by Dr. Trask.

These cases establish that there is no specific virtue. in totaldetachment of the placenta in arresting haemorrhage., Thearrest of the haemorrhage is therefore due to some other cause.Now, an earnest, and, I believe, a candid analysis of the casesof arrest of boemofrhage ensuing upon detachment of theplacenta., has left no doubt upon my mind that in many ofthese cases the haemorrhage stopped under the influence of thatpreservative process which I have described. It stopped, netbecause the placenta was wholly detached, but because the de-tachment had reached that physiological limit, that boundary-line which, I have pointed out. Thus, in the tables of Pro-fessor Simpon, I find many cases in which the haemorrhagehad already ceased before the placenta.was wholly detached.

! Against it is reasonable to assume that there are other cases inwhich the placenta was not w7aolly"but only pazviudly detached,when it was observed that the haemorrhage had ceased. If thetables prove anything, they contain quite as much evidence mfavour of partial detachment as in favour of total’ detachment.j Weare, then, amply justified in concluding,that the artificial

total detachment of the placenta cannot be relied upon to arrestthe haemorrhage... IS ABTIFICIAH TOTAiù DETACHMENT OF THE. PLACENTA AN

:: OPERATION SAFE IN 1TSELF?

;. Upon this point positive evidence is deficient. It is to befeared that a larger proportion of the successful than of the

* Clinical Midwifery, p. 146.

262

unsuccessful cases have been published. When the woman hadied, we have not had recorded sufficiently minute accounts ato the state of the os uteri-whether injured or sound-an(other particulars, to enable us to distinguish how much oughto be attributed to the haemorrhage, and how much to th,operation. We must, then, consider the operation in itselfWhat is the degree of manual violence necessary to effect tinentire separation of the placenta? In precisely those case!

which are the most urgent, where the haemorrhage is profuseand the os at the same time undilated and rigid, it is difficulito conceive that the whole placenta can be detached withoutintroducing the whole hand. But whether the whole hand b(introduced for the purpose of turning the child or detachingthe placenta, the effect upon the uterus quoàd forcible eiltr3must be the same. We have seen what these effects are wherdiscussing the dangers of turning. No doubt the forcible ex.traction of the child after turning is an additional source o]

danger. But the violent opening of the womb is the first

danger. The total separation of the placenta in cases of rigid,undilated os is, therefore, excluded on the same grounds as iEturning. It is true cases are cited, in which it is said that" two fingers" or " one finger" were passed into the os, andsufficed to detach the placenta. It appears to me that thesecases are not what they are assumed to be. Unless the whole

placenta lies in a mass closely over the centre of the os-a caseinfinitely rare-it is next to impossible that it can be whollydetached by one or two fingers passed through the os. In the

great majority of cases, the chief bulk of the placenta rises toa considerable distance up the side of the uterus, where it re-quires the whole hand to follow it. I refer to the case men-tioned in the first of these Lectures for an example where theplacenta reached from fundus to os; and to the general law,described in Lecture I., that in cases of cervical or cervico-orificial placenta, the placenta is c01nmonly spread out over alarge superficies. * I conclude, therefore, for this reason, thatsome more of the cases chronicled as examples of the arrest ofhaemorrhage by totally detaching the placenta were, in reality,examples of kcemo3·rlaage ceasing on partial detachment. t.

Let me read a case in illustration. It is drawn from Dr.Trask, to whom it was communicated by Dr. Bland.CASE 14.—Dr. Bland was called at half-past ten P.M. to

Mrs. B-, aged thirty; fifth or sixth labour; previous goodhealth. The first intimation of approaching labour was, thatfeeling a desire to urinate, she availed herself of a closed vessel,and on arising from it, to her no small alarm and astonishment,it was observed half-full of blood. The haemorrhage continuedafter she resumed the recumbent posture in such excess as tosaturate and pass through the bed, running in a stream uponthe floor. " I was immediately sent for, and found her as fol-lows :-Great alarm, countenance blanched, pulse weak andfrequent, excessive restlessness, and constant discharge of blood.The os tincse was soft and dilatable, and open to the size of adollar. In attempting to introduce my finger to ascertain thepresentation, it was obstructed by the placenta on every side,the right excepted; here, with some difficulty, the finger wasintroduced." Dr. Bland considered that it had originally ad-hered on all sides. " On a more careful examination for someinches above the orifice, especially on the left side, the pla-centa was discovered to be unequally separated from the innersurface of the uterus, and the hemorrhage proceeded from theseunequal separations." This was clear to my mind from thefact that whenever I placed my fingers upon the placenta, and

gradually and firmly pressed upon the parietes of the uterusfrom which it was separated, I completely arrested the dis-charge. For some half hour the haemorrhage was completelycontrolled by these means. " Effective labour-pains havingnow almost entirely ceased, and discovering, whenever thehand was withdrawn, the haemorrhage returned with increasedviolence, I determined to turn and deliver by the feet."

" Before

acting upon this determination, in accordance with the sugges-tion of Dr. Simpson, he introduced the finger, carefully sepa-rated the placenta, bl’eakil1g up the irregular adhesions, and bythis means permittin.? the uterus to contrnct equally and regu- ;lal’ly upon its contents; " the result of which, to my gratificationand astonishment, was the entire cessation of the hœmorrhage,and consequent danger. I now pushed the part of the placentathat obstructed the progress of the head to the left side, andheld it there with my hand to prevent its descent before thehead. I paused a few moments to consider the course to be

* I have recently seen, in Dr. M’Clintock’s museum at the Dublin Lying-inHospital, a most interesting specimen of a uterus with placenta praivia, whichstrikingly iIlubtrates this position. The placenta extends from the os to thefundus, covering an extensive portion of the area of the uterus, the greater,part being quite beyond the reach of one or two fingers.

pursued. In the short time allowed for thought, I determinedto prevent, if possible, the descent of the placenta before thehead, and to sustain it until effective pains could be excited.To accomplish this, I gave thirty grains of ergot. In fifteenor twenty minutes I discovered considerable uterine action,which increased steadily, resulting, in about half an hour, inthe birth of the child, alive and vigorous, at about two P.M.There was no bleeding afterwards; the placenta was easilywithdrawn; and mother and child are doing well."

Dr. Bland states that his motive in preventing the descentof the placenta before the child was, "that the supply of arterialblood might not be entirely cut off. Though all direct con.nexion was of course destroyed (?) by the separation of theplacenta, the child appears to have survived an unusual lengthof time, and was born vigorous, not asphyxiated as might havebeen expected."A careful analysis of this instructive case cannot leave a,

doubt that the placenta was not, as supposed by Dr. Blandand Dr. Trask, entirely detached. It is hard to believe thatby merely passing a finger into the os, he could reach farenough to separate the whole placenta. It is still more diffi-cult to believe that had the placenta been entirely detached,the child would have lived on for half an hour, and been born" vigorous, not asphyxiated." Dr. Bland had, in fact, whileattempting to perform, and believing that he had performed,Dr. Simpson’s operation, unconsciously performed that recom.mended by Dr. Cohen and myself. It w.%s fortunate for thechild at least, if not for the mother also, that he accomplishedless than he intended.

(To be concluded.)

WHAT HAS PATHOLOGICAL ANATOMYDONE FOR MEDICINE AND SURGERY ?

BY F. J. GANT, ESQ., M.R.C.S. ENG.,ASSISTANT-SURGEON TO THE ROYAL FREE HOSPITAL, LATE SURGEON (STAFF) TO

HER MAJESTY’S MILITARY HOSPITALS, CRIMBA AND SCUTARI.

THE DIAGNOSTIC VALUE OF STRUCTURAL CONDITIONS ALONE,EXEMPLIFIED BY CANCER AND CANCROID GROWTHS.

THE LAW OF STRUCTURAL RETROGRESSION INDICATED.

THE Relation of Pathological Anatomy to Therapeutics mustobviously be affected by the actual condition of that science.I propose, therefore, to illustrate certain general defects in ourpresent knowledge of pathological anatomy, which must, atleast for a time, both limit and qualify the fulfilment of therelationship in question. I do not allude to the circumstancethat some diseases may, perchance, have hitherto altogetherescaped detection, but to defects in our knowledge of thosewith which we are more or less acquainted.Thus, respecting either the Physical Properties the Chemical

Constituents, or the Structure of diseased normal tissues and ofnew products, we do not know, in certain instances, what pecu.liarities these pathological elements may severally present.Given, any one such element, could we always predicate theremaining two ?-or given any two, could we determine thethird ? Again, if these conditions are known, then, in certaininstances, we do not know whether they co-exist in any specialand invariable combination. Their mutual relation is unknown.For example, are the varieties of cancer characterized by anysuch fixed and invariable co-existing peculiarities ?The following three pairs of converse propositions, and

their respective exemplifications, will further demonstrate thisposition. I may observe that the examples in question areselected from every gradation of structural disease, but certainsections of pathology more than others exemplify the de-ficiencies referred to. For the sake of accuracy, althoughperhaps at the risk of proving tedious, I shall adhere to thesame formula of expression for each proposition.PROP. 1.-What peculiarities of minute structure co-exist

with known conditions of chemical composition and of physicalproperties combined ?

Query. Carcinoma varieties of scirrhus, encephaloid, and .

colloid.PROP. 2, (Conversely.)- What peculiarities of chemical com.