Treatment of Placenta Prœvia by Plugging the Vagina

1846.] Midwifery. 519

myself justified in testing the validity of Dr. Simpson’s views, and so far as one
case can confirm what he has advanced, I think the preceding worthy of the atten¬
tion of your numerous readers, supporting as it does those opinions.

66. Treatment of Placenta Prcevia by turning. —Mr. Newnham conceives the pro¬
posed plan of detaching the placenta, and then leaving the case to nature, to be so
ifaught with danger to both foetal and maternal life, that it cannot be too thoroughly
weighed before we venture upon disturbing the established practice.

On consulting the records of his obstetric practice, he finds “ there have been
thirteen cases of placenta previa since the 1st of January, 1812, and of these, twelve
recovered perfectly; the thirteenth case was that of a very poor woman, who had
suffered much from hemorrhage before Mr. N. saw her, whose external circum¬
stances were as wretched as possible, who had been borne down by the affliction
of a large family and a bad husband, and by want and misery in every shape:
she was a picture of woe and emaciation, and, to Mr. N.’s surprise, she lived
two hours after she was delivered. In this case the turning was undertaken as
a forlorn hope, and as an effort to be made to save her, rather than allow her to
die without such effort.

“ The preceding results,” says Mr. N., “ were sufficiently satisfactory to me: that
twelve out of thirteen should have been saved, while the thirteenth was only waiting
to be carried off by the first shock the system might sustain, was a result as favour¬
able as could have been hoped for, and one which I was disposed to attribute,—1st,
to my invariable rule, in every case of doubtful hemorrhage, to make myself
perfectly certain as to the cause of the flow of blood; 2dly, having ascertained
that it was from placental presentation, to lose no time in effecting delivery by
toning—to turn at once if the os uteri were sufficiently dilated, or dilatable—and
if not, to adopt every possible means to secure this object, and to turn as soon as
it was obtained; and 3dly, to the possession of an extremely small hand, which
enabled me to do all I had to do with less violence to the mother, and conse¬
quently with less present hemorrhage, and less subsequent irritation.

‘‘The above thirteen cases are all that have occurred to me; six of them were
under my own exclusive care, and the remaining seven, including the fatal one,
were midwives’ cases; they are not, therefore, selected cases, or taken from one
class of life, but may be considered as a fair sample of country practice.

“ I am sorry to say, that I have no record of the number of children born living,
but my impression is, that this has always turned upon the presence or absence
—the more or less of pain—the more or less of delay in the final expulsion of
the child: if the child has been born quickly, it has been born alive, and if much
delay has occurred, it has been still-born. I regret the inability to furnish this in¬
formation the less, however, because the question of treatment can never be
referred to the relative danger to the infant, this being unquestionably greater by
the modem proposal of first detaching the placenta.

“ Such being the result of my own practice, aided by the convictions of all my
literary research, I should feel so satisfied with the established mode, that I could
not venture upon adopting the more novel treatment, except upon far more en¬
larged testimony than we at present possess.

“Nevertheless, I can conceive of cases complicated with placenta previa, as
in narrow pelvis, or any other case in which the head is presenting, and it might
be ultimately necessary to diminish the size of that head: I can conceive of such
a case, in which the early detachment of the placenta might give the opportunity
for employing the perforator and crotchet, and might thus afford a valuable re¬
source in circumstances of extreme difficulty. But this is an exceptional case,
and the rule must not be deduced from it. In cases, therefore, of necessary hemor¬
rhage, the rule must still be, turn and deliver as soon as circumstances admit; but
when circumstances render this rule impracticable, it is a comfort to be able to
fall back upon another practice with the conviction that it may be hopefully em¬
ployed.”— Lcmd.'Med. Gaz., Nov. 14th, 1845.

67. Treatment of Placenta Prcevia by Plugging the Vagina.— Dr. J. Hall Davis,
in some interesting “contributions to the practice of midwifery,” ( Lancet , Nov.
8th, 1846,) expresses- his preference for the treatment of plugging the vagina in

830 Progress of the Medical Sciences.

cases of placenta prrevia where the hemorrhage continues after the liquor amnii
shall have been discharged, over that of extracting the placenta before the child,
as recommended by Dr. Simpson. He has been led to this preference by the
results of the cases which he has himself treated and seen treated during fifteen
years.

“ The plug to be used,” he quotes from his father’s “ Principles and Practice
of Obstetric Medicine,” “ must be sufficiently ample, not only to charge the vagina
pretty completely in its ordinary state of capacity, but so effectually to occupy the
space within it, as to leave no room for the escape of even the smallest stream of
blood from the uterus, a mechanical security not to be attained by merely intro¬
ducing a few loose shreds of old linen into the lower part of the vagina.” The
author then advises soft sponge as the preferable material for the purpose; and
adds—“'This tampon also acts as a powerful means of exciting the uterus to con¬
traction by its mechanical irritation.”

“ The object for which the plug,” he remarks, “ was applied having been ful¬
filled—the orifice of the uterus being judged by the character, strength and fre¬
quency of recurrence of the pains, to be adequately dilated—it must, of course,
be withdrawn, which will be generally within twelve hours, often within five:—
The orifice of the uterus now being found ready for our purpose, what will be
our next course of proceeding 1

“ If the placenta is centrally attached , the remaining treatment of the case will
consist in delivery by turning. The hand should now be passed into the uterus,
not by the barbarous procedure of perforating the placenta at its centre, which
involves a serious injury of its texture, a return or increase of hemorrhage, and a
risk of effecting, after all, the entire detachment of this vascular structure (so
strongly advocated by Dr. Simpson), but, by the safer plan, both to mother and
child, and the easier route by the side of it. We should discover towards its cir¬
cumference where it may already have been detached, or where the placental
tissue may be thinnest, and there effect our entry.

“If the placenta is partially implanted only, the practice should consist of rupturing
the membranes, and discharging the waters; but, supposing the hemorrhage might
not be arrested by that measure, and the operation of turning not be practicable
on account of rigidity of the os tincae, here I would plug the vagina as in the
previous case. After the removal of the plug, its object having been attained,
we shall frequently find that the operation of turning will not be required; the
head offers itself, is found gradually pressing downwards, and the birth, the pelvis
being of good conformation, is speedily accomplished by the natural efforts. On
the other hand, if the head remains high up above the brim of the pelvis, and
the hemorrhage continues, we proceed to the delivery by turning.

“ There are certain items of treatment which it will often be found advantageous
to pursue. In the event of restlessness, or any trace of nervous excitability ap¬
pearing about the patient, or should her rest have been much broken, I am in the
habit of exhibiting a full dose of laudanum, and with 1 excellent effect. The patient
gets some refreshing sleep, and awakes with- a breathing moisture upon her skin,
which was not there before; and the action of labour is speedily and fully insti¬
tuted. In some cases, the os uteri being, though undilated, free from rigidity, I
have derived good effects from the exhibition- of the ergot of rye, both after the
administration of opium, and where that remedy has not been indicated, in hast¬
ening the action of labour. But I have not frequently found it necessary to give
that medicine at this period of gestation, (the last three months,) the use of the
plug not only arresting the hemorrhage, but promoting the action of parturition.

“ With regard, again, to the plan pursued by Dr. Simpson, his friends and fol¬
lowers, I am of opinion that it might be advantageous in cases of distorted pelvis,
rendering lessening necessary, where nothing could be gained by the operation of
turning, by which then the mother would be exposed to a needless jeopardy. But,
as a preparatory proceeding, which I should consider a necessary measure of
safety to the mother, I would plug the vagina, supposing on my reaching the
case, that the orifice of the uterus might not be sufficiently dilated to admit of
delivery, even by the crotchet.”

“It is iu states of os tines preventing the easy introduction of the hand, and as
an alternative to forced delivery, that I apprehend Dr. Simpson would more par-

1846.] Midwifery. 521

ticulady urge the treatment which he advises, and in the eases in which I would
myself, as the safest proceeding, adopt the practice of plugging the vagina. In
this class of cases, a considerable time would have to elapse between the entire
detachment of the placenta—supposing it always feasible—and the birth of the
child; and here we should find no saving, I apprehend, of children's lives, and,
agreeably to my views of the uterine circulation, no great safety' to mothers.”

Dr. Davis relates two cases to illustrate the treatment he prefers in placenta
previa, one of which is the following.

Case of uterine hemorrhage under entire implantation of the placenta over the uterine
orifice — in the eighth month of pregnancy of a seventh child—treated by the application
of the plug—the exhibition of a fall dose of opium, and subsequent delivery by the opera¬
tion of turning. —At the request of Mr. Jones, of Berners-street, I was called, Sept.

27th, this year, to the case of Mrs.-■, aged thirty, in the eighth month of her

seventh pregnancy. Slight pains had commenced, between six and eight A. M.,
with hemorrhage, which had latterly become profuse; she had flooded on the
previous day, and had had a previous attack of flooding a fortnight before. I was
informed by my friend, prior to my arrival, that on the previous day he had felt
the placenta presenting. I visited the patient immediately (mid-day) and found
the condition of things such as had been represented. The mouth of the womb
was then dilated to the diameter of half a crown; it could scarcely be said to be
rigid; it was not possible, however, to effect the introduction of the hand, without
risk of contusing or lacerating the parts. I might easily, I have no doubt, have
effected the separation of the placenta with the index finger, had I chosen to do
so. The patient was pallid; had a quick and frequent pulse; the hemorrhage
was continuing. I obtained several pieces of soft sponge, which I cut into smaller
sections; these I passed into the vagina, packing, successively and completely , the
upper, middle, and lower portions of the tube; a broad belly-band was applied,
secured in its position by a cross piece, fixed to its mid-point behind and in front,
and passed over the vulva. One drachm of laudanum was exhibited. At half¬
past four, four hours from the introduction of the sponges, good bearing pains had
supervened, and the patient had slept; there was a breathing moisture upon the
skin, which was not there before. I removed the ping, which had been quite
efficient, only those portions of sponge in contact with the uterine mouth being
tinged with blood; and now passed my hand readily into the uterus, separating
the placenta, as I proceeded on one side of its attachment, and only to the extent
sufficient for my purpose of securing a foot. Coursing my hand upwards, outside
the membranes, I grasped a foot, ruptured the membranes, and at once and with¬
out difficulty accomplished the turn, and with but little delay the delivery of the
child. The child was pallid on its birth and asphyxiated; it rallied under the ap¬
plication of the usual measures, but continued feeble, and died in six hours after¬
wards under an attack of convulsions. The flooding continuing after the birth
of the child the'placenta was removed, the uterus contracted, and the hemorrhage
ceased. The uterus showing some disposition again to relax, my friend secured
his patient by the application of a bandage and compress, and by two or three
draughts of cold spring water. To prevent restlessness, likely to ensue upon the
loss of blood, fifty drops of laudanum were exhibited, and strict injunctions, which
were observed, were left for the rigid maintenance of the horizontal posture. At
our visit on the following day there had been no return of hemorrhage; the
patient had slept comfortably; the uterus was well contracted ; broth was ordered,
as the patient was feeble. The remainder of the treatment was judiciously con¬
ducted by Mr. Jones, and I am informed by him (Nov. 1) that his patient has
recovered without a single bad symptom.

I apprehend that the fatal results which have swelled Dr. Simpson’s tables are
chiefly due to the delay incurred before assistance is sought; to the practice of
forced delivery; to the misunderstanding of the principle of the “ plug,” a cambric
or silk pocket handkerchief, a few dossils of linen, or a sponge pushed up to the
os uteri, being thought quite adequate to the purpose. Such plugging is worse than
useless, Bince not only does it allow of a continuing hemorrhage, but brings by its
failure, when thus misapplied, a most valuable measure into undeserved disrepute.

The very first moment that we can ascertain the unavoidable nature of the hemor¬
rhage, we ought to act. It is our first and imperative duty in hemorrhage of the last
No. X_X.IL— April, 1846. 34

522 Progress of the Medical Sciences. [April

three months of gestation, if the orifice of the uterus will admit a forefinger, to
feel for the placenta, and should we find it centrally , ay, even partially , attached to
the cervix, we ought to engage ourselves actively, and at once, about the safety
of our patient's life.

John L. Ion also advocates the use of the plug in similar cases, and relates
(Lancet , Dec. 13th, 1845), a case of placenta prsevia in which he employed it
with success.

68. On the treatment of cases of Placenta Prcevia by removal of the Placenta , and not
by turning. —Dr. Samuel Ashwell has published in the London Medical Gazette,
Nov. 1845, some very interesting remarks on this subject. “ The necessity,'’ he
observes, “ for disturbing the existing practice arises from the assumed great fatality
to the mothers attendant on turning the child prior to the removal of the placenta. Dr.
Simpson says, the average rate of mortality in placental presentations is 1 in 3;
and he strengthens this statement, perhaps not quite fairly, by the declaration of a
• doubt, if the most fatal of all human diseases, the plague itself, be found to de¬
stroy so large a proportion of those attacked.' There should be, to render this
argument effective, something like resemblance in the things compared; and espe¬
cially in the number of cases. I cannot believe that this is a correct average of
maternal fatality. I have had at least twenty cases of complete placenta prarvia.
in consultation and private practice, (exclusively at the hospital,) during the last
twenty-five years, with only two deaths. In one of these, a patient ot Mr. New,
of Mile End, the first gush destroyed life; and in the second, two large scirrhous
tumours in the walls of the uterus, (vide Guy’s Hospital Reports, accompanied
by drawing of the growths,) there was gangrenous degeneration.

“ My friend and colleague, Dr. Lever, in answer to some inquiries as to our
Lying-in Charity at Guy’s, thus writes, Oct. 28th, 1835:— 1 Between the years 1833
and 1840, 4666 women were attended by our pupils. In 14 cases presentation ot
the placenta occurred; in 9 the placenta entirely covered the os uteri, while in 5
it partially presented: in all, delivery was accomplished by the operation of turn¬
ing. Eight of the children were still-bom; in one, the head was unavoidably
lessened, owing to the contracted slate of the pelvis, (this operation had been
resorted to in her previous labour;) two of the 14 cases terminated fatally to the
mother; in the first case the patient’s age was 34; it was her ninth confinement,
and you well remember she underwent the operation of transfusion with tempo¬
rary benefit, but died the day after delivery. In the other case, the patient’s age
was 39 ; it was her sixteenth confinement; she had, previously to the occurrence
of labour, been exhausted by two severe losses of blood, without sending for
assistance: she died soon after delivery.

“ ‘ From Oct. 1840 to Oct. 1845, there have been 11 or 12 cases, but as yet I am
unable to say how many were partial or how many complete presentations; neither
can I give you the maternal mortality; but I trust, when the table is completed, it
will show results as favourable as our first reports.’ In one of the two fatal cases
alluded to by Dr. Lever, where I transfused, it was our, and the late Mr. Tweedie s
conviction, that the delivery was attempted too late, and that even blood itself
could not preserve the fast-sinking life of the patient. From extensive inquiries
amongst men largely engaged in midwifery practice, I am persuaded that Dr.
Simpson’s rate of maternal fatality, under this form of presentation, is far too high.”

With regard to the proposition advanced by Dr. Simpson “that in placenta
pr®via the discharge issues principally or entirely from the vascular openings
which exist on the exposed placental surface,” Dr. Ashwell says, “ it would
have been well if these orifices and their capacities had been demonstrated. I
have never yet seen them, although I have subjected numerous placentas to exami¬
nation, both before and after injection: nor have I been more successful when I
have carefully peeled off an adherent placenta after death. It is, on the contrary,
easy enough to show to the satisfaction of the most incredulous, the great openings
existing in the lining membrane of the uterus, exactly opposite the attachment of
the placenta, and which are covered by interposed decidua. Into many of these
the tip of the finger may be inserted, while their course and extensive communi¬
cations with the uterine sinuses, full of blood, are evident at a glance. Surely such
an organization affords the clearest proof of the source of the hemorrhage in pla-