THE ST. LOUIS CLINICAL REVIEW.

VOLUME VI.

PHILO G. VALENTINE, A. M., M. D., EDITOR.

PLACENTA PREVIA.-REPORT OF CASES WITH

REMARKS.

BY DR. W. R. ELDER, TERRE HAUTE.

Read at the Seventeenth Annual Session of the Indiana Institute of Hom œopathy, May 9th, 1883.

The condition known as placenta prævia, is universally regarded as one of the most alarming accidents that can happen in utero-gestation. Though not in all cases necessarily fatal, it never fails to excite the gravest apprehensions and alarm.

There is perhaps no other condition in the management of which, it is so difficult to decide the proper time for resorting to the necessary manual assistance. Hesitancy and delay permit the insidious hemorrhage to sap the vital forces, while ill-timed and meddlesome manipulations may precipitate disasterous results.

Happily this abnormal condition is of comparatively rare occurrence; statistical evidence showing that it occurs on an average but once in about 1500 births. Aside from lying-in hospitals, and some physicians in large cities who specially control a large obstetrical practice, probably more than half the medical profession do not meet a single case in a lifetime. These facts render the report of such cases of great interest to the profession, especially the one I am about to give, because there is probably not another such on record.

In this case there was complete placenta prævia in three successive births, and the mother still lives, perhaps, in due time to furnish the fourth.

The patient is a patron of my friend, Dr. Moore, of our city, who has requested me to report the case, and has given me the privilege of making the following extract from a paper he read before our Hom. Med. Society last winter on "Uterine Hemorrhage and its Treatment," in which he describes the case in detail. In that paper the doctor says:

"On the 22d day of December, 1880, I was called to visit Mrs C, who stated that she had suffered several severe hemorrhages during the months of November and December, previous to the time of my visit. That she had an attack some five weeks prior to this time while alone in the house, but she gathered all the cloths within reach and applied to the vulva for the purpose of staunching the flow. She lay helpless on the bed for two hours before she dared assume an erect position. With foolhardy presumption she again resumed her household duties which she continued until the day of my visit. On that day, her husband returning home from work, found her prostrate on the kitchen floor in a pool of blood, shocking to behold; calling for help, which was readily obtained, she was carried to an adjoining room and a messenger dispatched for medical aid. On my arrival I found the patient speechless and no pulse preceptible at the wrist. Upon making an examination I was confronted by a case of complete placenta prævia. My first impression as to the course to persue, was to provoke pains and hasten delivery, but on second thought I determined to try to check the hemorrhage if possible by remedial means and allow the patient a little time to rally from her exhausted condition. With this view I administered my old and tried remedy, erigeron canadensis, at 5 P. M., and left the patient until 8 P. M., when I found conditions somewhat better, the patient able to talk in whispers, preceptible pulse and diminished waste. I ordered the treatment continued and left for home,

directing them to call me promptly if pains returned in the night. The call came at 2 A. M., and not feeling warranted in assuming the responsibility of so grave a case alone, I directed the messenger to call my friend Dr. Elder, to accompany me, which he did. On our arrival, I examined and found labor had progressed to the extent, that the waters were discharged, the os dilated and the placenta protruding through it in advance of the head of the child. I asked Dr. Elder to examine and satisfy himself of the conditions. During his examination a pain occurred, and the entire placenta was delivered into his hands. He severed the cord and removed it from the bed. All this time the patient was kept under the influence of erigeron, and no further hemorrhage occurred. After the expulsion of the placenta, the pains ceased for a time, but stimulated by remedies, came on again about 7 o'clock, and about 8 o'clock the patient was delivered of a dead child weighing ten pounds. Contrary to expectations, she made a good recovery.

Again, on the fourth day of March, 1882, just fifteen months less eleven days after the occurrence of the case above described, I was called to attend the same lady with another case of placenta prævia as before, but under more favorable circumstances. An early discovery of the nature of the case prompted me to enjoin quiet and rest, mostly in a recumbent position, for two or three weeks before the confinement, and with the use of the erigeron, before and during labor, the hemorrhage was controlled. At the confinement, I pursued the course agreed upon by Dr. Elder and myself of making a slit through the placenta by separating it between the cotyledons with my finger, puncturing the membranes and discharging the waters. The head presented through the opening, and in due time the woman was safely delivered of a dead child, and made a fair recovery.

The third case occurred on March 15th, 1883. The patient had been suffering from an attack of pneumonia for two weeks previously, attended by severe cough. This condi

tion brought on labor prematurely by about six weeks. This time there was not only complete placenta prævia, but the additional complication of extensive adhesions. I conducted the case on the same general plan as the last, and although the labor was unusually protracted, it terminated without special accident except the death of the foetus. Convalescence was very slow, owing partly to the weakened condition of the system as a consequence of the pneumonia.

Thus these three cases of complete placenta prævia occurred successively in the same patient, between December 23, 1880, and March 15, 1883, a period of only two years, two months and twenty-two days."

There is no doubt but this is the most remarkable case of the kind on record, but I have not presented it for that reason alone, but to call attention to the manner of conducting the management of a case of placenta prævia which I consider most hopeful of success.

The two last cases mentioned above, Dr. Moore, by my advice, treated upon the same general principle that I had previously pursued in the case occurring in my own practice, and which I reported to this institution four or five years ago.

The profuse hemorrhage which occurs in these cases, is the result of the separation of the placenta from its attachment to the provisionally vascular inner surface of the uterus, directly over and around the internal os. Therefore in the very commencement of labor, the dilation of the os, though at first slight, breaks up some of these attachments, and blood flows profusely from the ruptured capillaries. This recurs with every pain, as more and more the dilatation proceeds and the attachments are broken. This being true, it follows that if such separation can be prevented, there need be no hemorrhage.

If in the very earliest stage of labor, just as soon as the dilatation is sufficient to permit the introduction of a finger through the os, a rent is made through the placenta

on a line with the antero-posterior diameter of the superior strait of the pelvis; through it the membranes are ruptured and the waters discharged; the head of the child will almost immediately come down into the fissure thus made, and by its firm unyielding pressure with every pain, force the divided placenta to either side as the dilatation progresses, and thus not only prevent any further rupture of attachments, but effectually close up the bleeding orifices of any vessels that may have been previously broken.

By this management, other things being equal, the labor progresses as in natural cases. The child is literally born through the placenta, which becomes detached at the proper time, in the usual way.

The objection I have heard urged against thus tearing a hole through the body of the placenta, for fear of provoking hemorrhage by breakage of its vessels, is scarcely worth consideration, except to correct the false idea that such a thing can happen. The albuminous tissue of which the substance of the placenta is composed, is so exceedingly tender and so easily torn, that its lobes are most easily separated without the least danger of breaking its blood vessels, and even if broken, they would not bleed, for all uterine hemorrhage comes from the vessels of the uterine surface, and not from the placenta.

I advocate this mode of procedure, not as being especially new, but for the purpose of giving it emphasis, as decidedly the safest course, to the best results, as vastly superior to what I consider the criminally barbarous method taught in most of the so-called Standard Works on Obstetrics, such as Dewes, Meigs, Churchill, etc., of forcibly dilating the os, introducing the hand, detaching the placenta from one side and delivery by turning; a course attended not only by inexpressible agony, but extremely hazardous to the lives of both mother and child.

So great is my confidence in the method I have referred