Some remarks on the treatment of unavoidable hæmorrhage by extraction of the placenta before the child : with a few observations on Dr. Lee's objections to the practice / by J.Y. Simpson.

James Young Simpson

Date:: [1845]

Credit: Some remarks on the treatment of unavoidable hæmorrhage by extraction of the placenta before the child : with a few observations on Dr. Lee's objections to the practice / by J.Y. Simpson. Source: Wellcome Collection.

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Here we have only three mothers saved out of eleven operated upon ; and two of the three saved evidently made a very narrow escape from death. I doubt if the most fatal of all human diseases—the plague itself—be found to destroy so large a proportion of those attacked. At all events, the opera¬ tion of turning and artificial delivery, in unavoidable haemorrhage, with the os uteri imperfectly dilated, would, from these and other cases, appear to be more deadly than any operation that is deemed justifiable in the whole circle of surgery. It is more mortal even than Ovariotomy. I believe, on the other hand, that in the above and similar cases, by the introduction of a finger, or of a common sound or bougie, (such as Dr. Hamilton employed when the os uteri was still shut, and in order to sepa¬ rate the membranes for some inches from the cervix* *, in order to induce premature labour), the placenta might be readily and completely detached—the attendant bleed¬ ing in this way arrested—and the labour subsequently allowed to proceed to a natural and safe termination, if it were a head or pelvic presentation. And if the child were placed transversely, a more safe and proper period could be w7aited for and selected for the version of it. Would the strength of the natural organic adhesions of the placenta to the uterus pre¬ vent the easy separation in this way of the one organ from the other ? I believe not. Speaking of the mere anatomical fact, Dr. William Hunter, in his celebrated work on the Gravid Uterus, observes, that the sepa¬ ration of the placenta from the uterus is “ commonly practicable with the least ima¬ ginable force.” In his paper on the Struc¬ ture of the Placenta, published in the Philo¬ sophical Transactions for 1832, Dr. Lee, whose intimacy with Dr. Hunter’s work is well known, curiously uses not only a simi¬ lar, but exactly the same quaint expression and words, telling us that generally after labour the placenta is detached from the uterus “ with the least imaginable force.” Thirdly.—Dr. Lee argues against the practice of extracting the placenta before the child, because it wras not followed by “ Guillemeau, Mauriceau, Portal, Levret, Giffard, &c. &c.” If the argument were true, it would be one of no weight, because, on exactly the same ground, nothing novel should ever be allowed to be introduced into practice. Dr. Lee has fallen into some cu¬ rious mistakesf in the two or three different many hours ai'ter, but the circulation in the ex¬ tremities was gradually restored, and she re¬ covered.” * Dr. Lee himself seems to have met with no difficulty of any kind in following this practice. See Lectures, p. 319; and Clinical Midwifery, Cases 142, 145, &c. t “ We are solely (says Dr. Lee) indebted to Levret for the discovery of every important fact relating to the causes, the symptoms, and the histories which he has attempted to give of placental presentations. I shall leave it to my professional brethren whether the fol¬ lowing misrepresentation is to be referred to the same category of mistakes, or is capable of—a more direct and simple explanation. Dr. Lee has given in his published “ Lec¬ tures on the Theory and Practice cf Mid¬ wifery” a special and detailed account of the individual cases of placental presentation recorded by Portal, and had therefore taken evidently very great pains to study minutely that author’s views and practice in this com¬ plication. In his late paper in the Medical Gazette, Dr. Lee strongly asserts that Portal is one of those great practical accou¬ cheurs who never “attempted in a single instance to tear awray or detach the placenta from the neck of the uterus, when it was so undilatable as to render it impossible to pass the hand to turn the child and deliver, nor in any other condition whatever of the part, before the birth of the child.” p. 895. In describing his 43d case, Portal ob¬ serves “Je glissay ma main dans l’entree de la matrice, on je sentis l’arriere-faix qui se presentoit. L’ayant separe, afin de me frayer le chemin, je sentis les membranes des eaux que je peryay, et les eaux s’estant ecoulees^'e tiray Varriere-faix le premier, afin qu’il ne m’incommodast point a la sortie de l’enfant.” Here Portal distinctly states that he separated and extracted the placenta first, and before trying to extract the child. He states the same thing in his 69th case, and, if possible, still more expli¬ citly*. Dr. Lee, who, on the present occa¬ sion, so strenuously asseverates that Portal did never, in a single instance, follow this practice, actually quoted and printed last year in his published Lectures, and from the French edition of Portal’s work the first half of the above sentencef, in which Portal him¬ self so circumstantially declares that he did follow this practice. (See the quotation in Dr. Lee’s Lectures, p. 366.) I feel assured that any additional comment of mine will be here excused, as entirely superfluous. Fourthly.—Dr. Lee states that the prac¬ tice which I have ventured to recommend in placental presentations “ was performed two hundred years ago by an ignorant and auda¬ cious impostor, on a lady w7ho died in Paris, whose case is related, with denunciations of the practice, by Guillemeau.” treatment of this (the unavoidable) variety of flooding in the latter months of gestation.”— (Researches on the Diseases of Women, p. 209.) In his late Lectures, p. 368, Dr. Lee adduces a variety of evidence to shew that Levret on this point only “ undertook to prove (to use again Dr. Lee’s own words) what, it appears, had pre¬ viously been demonstrated”—by Portal, Mauri¬ ceau, Giffard, Smellie, &c. * Je separay tout doucement cet arri&re-faix, et je tiray dehors ; ensuite je glissay ma main dans la matrice, &c. &c. t Dr. Lee’s quotation terminates at the word “ peryay.”

Some remarks on the treatment of unavoidable hæmorrhage by extraction of the placenta before the child : with a few observations on Dr. Lee's objections to the practice / by J.Y. Simpson.

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