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Negrier on Placental Presentations.

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For further information on this subject we must refer our reader to M. Jacquemier's excellent Chapter on Trunk-presentations.

In the accidental form of dystocia, M. Jacquemier considers uterine hæmorrhage in the latter months of pregnancy. This subject includes both accidental and unavoidable hæmorrhage, and M. Negrier also treats of them in his work.

M. Negrier endeavours to explain the cause of a placental-presentation. He reverts to his researches on the human ovaries, in which he claims the merit of having started the recent theory of menstruation, and he states "that he has there proved that every menstrual epoch is the consequence of the development, separation, and escape of an ovum from a Graafian vesicle. This ovum, carrying a living but unimpregnated germ, is seized by the tube, and almost always conducted by it to the cavity of the uterus. This ovum is carried on towards the inferior angle of the cavity by the menstrual blood, if the blood is still flowing, or by the whitish mucus which follows the menstrual exudation." M. Negrier thinks that the ovum may be fecundated at any point between the ovary and the outlet of the womb, wherever the semen may meet it; and that in a placenta-presentation the ovum must have arrived at the internal orifice of the womb, where it becomes fixed.

In a normal fecundation the decidua is forming before the ovum gets into the uterus, and it is the means by which the ovum is confined to the upper part of the womb; but, in abnormal presentations, the ovum not yet impregnated, is conducted into the uterine cavity before the arrival of the semen or the formation of the decidua.

A partial placenta-presentation results from the ovum having arrived near the inferior aperture of the cavity of the womb before it is fecundated, and a complete placenta-presentation implies that the ovum should have got still nearer the lower angle. When it is impregnated at this place, the chorion throws out its villi every where around the superior aperture, and the placenta is fixed, centre pour centre-over the os uteri internum. M. Negrier explains the well-known fact that, in some placenta-presentations, hæmorrhage occurs at the end of the 5th month, and, in others, that it is postponed to a later period, by supposing that, in the latter cases, some of the radicles of the placenta, towards the middle of gestation, descend into the upper opening and become fixed in the walls of the cervix itself, and this part of the placenta is not, therefore, stretched out and disrupted, as the cervix is taken up during the latter months of gestation. The early hæmorrhages occur from the placenta lying over the os internum, and as the placenta does not yield to the development of the neck, its structure is lacerated, and hæmorrhage ensues. It is then the central insertions which are attended with early and copious bleedings.

M. Negrier illustrates the subject of uterine hæmorrhage by narrating and commenting on two sets of cases; first, those connected with a normal insertion of the placenta at or near the fundus of the uterus, the bleeding in these cases coming from the walls of the cavity of the womb; and second, those bleedings coming from the inferior part of the womb, and from the inner surface of the cavity of the neck, on which parts the placenta has been engrafted.

M. Jacquemier designates the first class of bleedings (the accidental

hæmorrhage of English authors) as a utero-placental hæmorrhage, of which there are two varieties, the first internal or latent, the latter external or apparent; whilst M. Negrier applies the term cervico-placental to the unavoidable forms of bleeding.

With reference to the first class of bleedings, M. Negrier relates twelve cases, all of which are described in a clear and direct way; and the reflections which accompany them are generally judicious and appropriate. The first six cases are examples of hæmorrhage either before or during parturition. The second is a case of latent bleeding after delivery, with a second bleeding twelve days after labour, coming on when the child was sucking. The eighth also is a case of hæmorrhage a month after delivery, brought on by the act of sucking. The two succeeding cases are examples of adherent placenta with hemorrhage, and the twelfth is a natural labour, in which the perineum was lacerated, hæmorrhage followed delivery, then metritis, which was cured. On the 18th day after delivery the patient was walking about. On the 29th day the patient walked about alone and without assistance, and on the same day, having eaten more freely perhaps than she should have done, she experienced a strong emotion of joy, and at the same moment spasms, abdominal swelling, particularly at the epigastrium, constant vomiting, considerable fever, came on-and the following day she died. No inspection was permitted.

It will be seen that these cases are in many respects very dissimilar, but they agree in the one thing which the author had in view, namely, that the hemorrhage in all of them came from the body of the womb. The remarks on the first case appear to us to contain the gist of the author's design in relating them, which is to draw a distinction between the bleedings from the upper and the lower part or the neck of the womb. After relating the case M. Negrier says "In this case the blood flowed regularly-without intermittent pains-without increase up to the last; it was blackish. These signs suffice to show that the bleeding came from the fundus of the womb from a detachment of the placenta. It would have been otherwise if the placenta had been near the upper opening-the flow would have been more red-it would have been irregular, and would not suddenly have ceased after the expulsion of the ovum." In the remarks on other cases, M. Negrier notices also the effect of contraction in diminishing the accidental, and increasing the unavoidable hæmorrhages, and he insists also on the increased danger which attends the latter

cases.

There are eight cases related by M. Negrier of hæmorrhage, caused by detachment of the placenta inserted into the neck of the uterus. The deaths and recoveries in these cases are equally divided, there being four of each. The abbreviated account of each case, as shown in the heading of them, is as follows:—

Case 1.-Insertion of the placenta over the neck of the uterus-placentar adhesions-plugging-recovery-child alive-spontaneous delivery. Case 2.-Insertion of the placenta over the neck of the uterus-extensive placentar adhesions-copious bleedings-plug-recovery-spontaneous delivery.

Case 3.-Very large insertion of the placenta over the neck of the uterus-frequent bleedings during the last three months of gestation-in

1847]

Negrier on Uterine Hæmorrhage.

sufficient labour-pains. Forceps applied at the brim.

and child.

61

Death of mother

Case 4.-Large insertion of placenta over the neck of the uterushæmorrhage--version-compression of the aorta. Death of mother

child alive.

Case 5.-Large insertion of the placenta over the neck of the uterus— copious hæmorrhage-ergot-forceps-compression of aorta. Death of mother and child.

Case 6.-Very large insertion of the placenta over the uterine neckhæmorrhages-ergot--version-compression of the aorta. Death of mo

ther-child alive.

Case 7.-Large insertion of the placenta over the neck of the uterus▬▬ frequent hæmorrhages-plug-ergot--version-perpendicular pressure over the body of the womb. Recovery of mother-child alive.

Case 8.-Large insertion of the placenta over the neck of the uterus-vaginal plug-version--perpendicular pressure of the uterus. Recovery of mother-child restored to life.

M. Negrier devotes a chapter to the prognosis of hæmorrhage from placentar presentations. He quotes several opinions on the extreme danger of this accident, but he prefers the following laconic expression of M. Naegele: "When these hæmorrhages are abandoned to themselves, or relieved too late, they almost always end in death."

M. Negrier says, too, that "the cervico-uterine bleedings are almost the only ones which kill. Doubtless bleedings from the walls of the body of the uterus may be fatal, but such cases are exceptions."

Although the early bleedings at the sixth and seventh month indicate a large insertion of the placenta at the cervix, still M. Negrier does not regard these cases as so dangerous as those where, towards the close of gestation, a sudden and large detachment of the placenta takes place, especially if it occur in a multipara. He considers the most unfavourable case possible to be as follows:-"The placenta shall be very largely grafted on the walls of the cervix, but notwithstanding the large implantation, the cervix should have increased till the normal term of gestation. It should not be a first pregnancy, and labour should have set in energetically and suddenly, by a very large separation of the placenta. In such circumstances, the hæmorrhage is so sudden and copious, that it almost always causes the death of the patient, whatever may have been the skill and promptitude of the treatment.

The third and concluding part of M. Negrier's treatise is occupied in the treatment of the hæmorrhages which follow a detachment of the placenta. This he divides into three parts. 1. The treatment of hæmorrhage during gestation. 2. During labour, including the unavoidable bleedings from placenta-presentations. And 3. Post-partum hæmorrhage. It is almost a constant practice, says M. Negrier, to bleed women who are attacked with hemorrhage before the seventh month of pregnancy. Our author, however, does not fall in with this axiom. His views on this subject are thus summarily stated.

Bleeding from the arm is a uselessly wasteful means to combat hæmorrhages from detachment of the placenta.

Bleeding is useless for the preservation of the fetus whenever a third

of the placenta is detached; and M. Negrier thinks that this is indicated. with sufficient exactness when 60 grammes* of blood flow in the course of an hour, and, excepting in special cases, such a loss will prevent gestation going on, in spite of bleeding.

Bleeding is particularly hurtful in placenta-presentations. An exact plugging of the vagina is the only effective means to suspend copious bleedings during gestation. The plug ought to be covered with a greasy and tenacious matter, and it ought not to be impregnated with vinegar.

In the second class of cases, where hæmorrhage comes on during labour, M. Negrier insists on the great importance of determining without delay whether the placenta presents or not. If it does not, and the os uteri is closed, the plug ought to be used to arrest the bleeding. When labour has set in actively, and the os uteri is supple, then the membranes ought to be perforated. This plan is contra-indicated if the child presents transversely, or if the pelvis is contracted. If the hæmorrhage continues after the rupture of the membranes, the plug ought again to be used, for the double purpose of arresting the bleeding and exciting the uterus to contract. The ergot of rye is now too very useful, excepting only when exhaustion from loss of blood is present, when it will not act. The uterus ought to be followed as the child is expelled, and its contraction secured by friction or circular compression of the belly. Stimulants are more needed at this time than opiates. The forceps ought only to be used when the head is low down in the pelvis, and well placed.

In the treatment of placenta-presentations, if the detached portion is large, and the loss of blood is great, every effort ought to be made to empty the womb, and version is the most prompt and efficacious means for this purpose. If the os is unopened it ought to be forcibly dilated (forcé)--and in women who have had children it rarely offers any dangerous resistance. To perforate the ovum with the hope of lessening the bleeding, is a useless and absurd practice. When the orifice of the womb is completely blocked up by the placenta, we ought to search for the side. on which it is stretched out the least, and detach the placenta from this part. If the placenta is very largely attached, and is adherent and thick to the touch--the centre pour centre insertion-M. Negrier would, without hesitation, perforate it, in order to turn the child. Fatal hæmorrhage from the tearing of the placenta is rarely dangerous, if the extraction of the fetus is quickly executed. The tearing away of a loose portion of the placenta to stay hæmorrhage can only be useful when the uterine neck preserves the form and consistence of a canal.

M. Negrier ends this chapter by observing "that the complete separation of the placenta before the extraction of the fœtus, and its expulsion from the uterus before the escape of the child, do not bring any modification to anti-hæmorrhagic means-they are complications which render the speedy emptying of the womb more imperious."

This is the general outline of M. Negrier's views on the cause, symptoms, diagnosis, prognosis, and treatment of placenta-presentations. We cannot but think that he has added very little to what was well known

* A gramme is equal to 15-438 grains Troy weight.

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Negrier on Placental Presentations.

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upon the subject. We need scarcely say that it is one of special present interest-an interest founded on the views of Dr. Radford and Professor Simpson. It appears from the last paragraph which we have quoted, as well as from a long foot-note, that M. Negrier is not ignorant of the recent investigations on this subject. The note which we refer to is a running commentary on Dr. Radford's series of propositions on the class of cases in which the artificial separation of the placenta and the use of galvanism is applicable. They were published in the fourth number of the second volume of the Provincial Medical and Surgical Journal, and were copied into the Journal de Chirurgie, which is the source of M. Negrier's information upon them. It is beside our purpose to enter critically into the views of Dr. Radford and Dr. Simpson; but, in order to comprehend M. Negrier's comment, we copy at length Dr. Radford's propositions.

First. As neither delivery nor detaching the placenta ought ever to be attempted until the cervix and os uteri will safely allow the introduction of the hand, rest, the application of cold, but above all the use of the plug, must never be omitted in cases where they are respectively required.

Secondly. If there are unequivocal signs of the child's death, the placenta is to be completely detached and the membranes are to be ruptured. The case is then to be left to the natural efforts, provided there be sufficient uterine energy; if otherwise, the ordinary means are to be used, and in addition galvanism.

Thirdly. When a narrow pelvis exists in connexion with placenta previa, the practice is to detach the placenta and to remove it, then to perforate the head as soon as the condition of the parts allow, and to extract it by means of the crotchet.

Fourthly. When the os uteri is partially dilated and dilatable, so as to allow the easy introduction of the hand, when the membranes are ruptured and strong uterine contraction exists, the practice is to detach the placenta completely.

Fifthly. In all cases of exhaustion, as already referred to in my paper,* the practice is to draw off the liq. amnii by perforating the placenta, as there recommended, then to detach completely this organ and apply galvanism.

Sixthly. In all cases of partial presentation of the placenta, the artificial rupture of the membranes will generally be found sufficient to arrest the hæmorrhage, but if that should prove ineffectual then we must apply galvanism.

Dr. Simpson has also shortly indicated a class of cases in which the artificial detachment of the placenta may advantageously be had recourse

"I believe it will be found," he says "the proper line of practice in severe cases of unavoidable hæmorrhage complicated with an os uteri so insufficiently dilated and undilatable as not to allow with safety of turning; in most primipara; in many of the cases in which placental presentations are (as very often happens) connected with premature labour and imperfect development of the cervix andos uteri; in labours supervening earlier than

Lecture on Galvanism, applied to the Treatment of Uterine Hæmorrhage. Provincial Medical and Surgical Journal, Dec. 24th 1844.