ON THE TREATMENT 
OF 
PLACENTA PILE VTA. 
BY 
JOSEPH TABER JOHNSON, A. M„ M. I)„ 
Professor of Obstetrics and Diseases of Women and Infants, Medical 
Dep’t University of Georgetown; Fellow of the American 
Gyneecologieal Society, etc., etc., etc. 
EXTRACTS FROM A PAPER 
Read before the Medical Society of the District of Columbia, 
ZVtii., 1878. 
from flic ftatiomil ipirbital $ltbie(tr. 
WASHINGTON, I). C. 
THE GLOBE PRINTING OFFICE. 
1878. ON THE TREATMENT 
OF 
PLACENTA PR/EVIA. 
Dr. .Johnson, after remarking upon the importance of prompt 
diagnosis and skilfull treatment, presented the views of former writ- 
ers and teachers of midwifery, giving the statistics of the results 
obtained, with the treatment which they recommended and practiced. 
In a paper read by Greenhalgh, before the Obstetrical Society 
of London, 1864, the following statement is made: “From large 
and impartially collected statistics of cases of placenta prasvia, one 
mother out of every four and one-quarter is lost, and two-thirds of 
all the children are still-born.” 
The foetal mortality was so great in the modes of treatment gene- 
rally practiced previous to 1864, that Sir James Simpson and 
Churchill expressed the opinion “that the hope of saving the child 
ought scarcely to influence the treatment,” and, with their fol- 
lowers, so managed these cases as to practically disregard its safety. 
Dr. Johnson stated it as his belief that by selecting a time for 
the induction of premature labor, in cases clearly diagnosed, and 
before the vital powers of the patient had become exhausted by 
copious or repeated hemorrhages, that the lives of many women and 
children could be saved, which, as we see by Greenhalgh’s figures, 
were lost under the form of treatment so universally in vogue pre- 
vious to the date of his paper. 
The two following histories of cases selected from the doctor’s con- 
sultation practice illustrate the treatment which has heretofore been 
the routine practice, and which still has the indorsement of many 
text-books: 
Case I—Was called in consultation on the evening of January 23, 
1877, to see a case of placenta praevia with Dr. M. The lady was 36 
years of age and the mother of four children. She had been the sub- 
ject of exhausting hemorrhage in each confinement. During the last 
two months of this pregnancy the doctor had treated her for three 4 
severe attacks of flooding, which he had been able to control, and she 
was now in actual labor at her natural term. Treatment which had 
formerly succeeded now failed. She had previously been relieved by 
using tinct. opii, acetas plumbi, galic acid, cold drinks, and 
cold applications freely used about the vulva, thighs and abdomen, 
and quiet in bed. In this attack gushes of hemorrhage occurred on 
the evening of the 22d. They increased in quantity and frequency, 
and labor pains setting in, the doctor was called about daylight of 
the 23d. So alarming was the flooding at one time during the day, 
tliat the doctor expressed his fears to the family that she might not 
survive. She, however, rallied under the use of brandy, ammonia, 
and beef-tea. When I saw the patient, twenty-six hours after the 
commencement of labor, she was much prostrated and had a pulse of 
145 to the minute. Her pains had almost entirely died out, accom- 
plishing actually nothing but the discomfort of the sufferer. The 
vagina was securely tamponed with sponges medicated with matico, 
and no hemorrhage had taken place for several hours. After ad- 
ministering another potation of brandy and beef-tea, at the doctor’s 
request, I removed the tampon and easily diagnosed a partial 
placental attachment over the os uteri and a vertex presentation. 
By the use of Barnes’ dilators the cervix was, at the end of an hour, 
sufficiently dilated to easily admit the hand, and podalic version was 
performed without difficulty. The child was still-born. The mother 
had felt no signs of life, and the foetal heart was not heard for twelve 
hours previous to delivery. Soon after the introduction of the dilator 
contractions came on and were encouraged by the use of ergot, 
pressure and friction. As the child was extracted Doctor M. fol- 
lowed the uterus down with his hand, securing at the same time ex- 
pression of the placenta and firm uterine contraction. The vulva 
was washed with cold water and dry napkins placed against it. 
The interior of the uterus had been mopped over with a solution of 
matico, and so firm contraction secured by it and constant pressure 
that no further hemorrhage occurred. The lady rallied for a while, 
but subsequently sank and died, in the full possession of her faculties, 
seven hours after the delivery of the child. 
Case II—Was called in great haste from the Medical College on 
the 10th of October, 1877, to see a lady in labor, and flooding to an 
alarming degree. I found the patient was under the care of a female 
homeopathic* physician. The urgency of the symptoms were such 
that I could not decline to render any service which I might to avert 
what seemed to be speedily approaching death. The history of this 5 
case was similar to the one just detailed. The lady was the mother 
of four children. She had had several attacks of hooding, and a 
diagnosis of placenta praevia had been plainly made six or eight 
weeks before labor came on. Hemorrhage had subsided each time 
under quiet, rest in bed, cold drinks and cold applications and some 
kind of infinitesimal dosing, I don’t know what. I found that in 
this attack the lady had lost much blood, and the labor pains, which 
had at first been powerful, had nearly died out. Her vital fluid was 
constantly oozing away. Her pulse was 148; she was excited and 
anxious. Her prostration was so great that it did not seem wise to 
make any change in her position in bed. The patient, family, friends 
and the attending physician all urged speedy delivery, and as an 
empty and firmly contracted uterus seemed to present the only hope 
of controlling the hemorrhage and saving her life, I passed my 
hand through a very dilatable cervix, turned and slowly delivered a 
still-born child. The placenta came away soon after. The uterus was 
made to contract firmly, and no subsequent loss of blood took place; 
an hour after her delivery the patient had a fair pulse, and only 98 
to the minute. My connection with this case ended with the grateful 
acknowledgements of the husband as I left the house. The attend- 
ing physician then resumed charge of the patient. She called and 
informed me two weeks later that Mrs. C. died on the ninth day after 
delivery. She never fully recovered from the loss of blood which she 
had sustained, though, until the fifth day she gave fair promise 
of recovery. When left alone on the fifth day she got out of bed and 
walked barefooted into the next room, where she was found by some 
of the family, having fainted. After this she had chills, high tem- 
perature, and great prostration, and grew worse until the ninth day, 
when she died. She had no abdominal pain or hemorrhage after 
delivery. 
These two women and their unborn children perished from the 
effects of hemorrhage. This hemorrhage was not controlled by the 
treatment usually practiced. Although the attacks occurring pre- 
vious to confinement were arrested, no human wisdom or foresight 
could calculate at what hour other and perhaps fatal attacks might 
come on. They were certainly liable to occur at a time and under 
circumstances precluding the possibility of securing skillful medical 
aid in time to prevent death. Their greatest safety, therefore, was 
in eliminating the element of danger, and by the induction of pre- 
mature artificial delivery, securing an empty and firmly contracted 
uterus. The risk to the child, as well as to the mother, is less by 6 
this mode of treatment than to allow the case to progress, he the 
patient watched ever so vigilantly. 
Had a time been selected after the first hemorrhage, when the 
diagnosis was clearly made out, and premature labor brought on, 
these viable children and their mothers, in the cases just referred to, 
would have had a much better chance of living than by temporizing 
with the treatment used. The prospect for the child, which is usu- 
ally so poor when horn prematurely, is really better when safely out 
of the uterus, than in it, with this sword of Damocles suspended 
over its innocent head by such a brittle thread. Thomas says upon 
this subject: l‘\ cannot resist the conviction, that when premature 
delivery becomes the universal practice for placenta praevia the 
statistics of the present day will he replaced by others of a far more 
satisfactory kind.” 
Barnes, in 1864, gave a total of 83 cases of placenta praevia treated 
by the induction of premature labor. The deaths were only 6, or 1 
in 14. Grreenhaigh had seen 10 cases without a single maternal 
death, and only two of the children were lost. Barnes reported 63 
cases in succession with only one foetal death ; and Hall Davis had 
induced premature labor in 24 placenta praevia cases with only two 
deaths. Thomas reports 11 cases with only two deaths. Grrailey 
Hewitt refers to cases lost under the temporizing method, which, he 
believes, could have been saved by the timely induction of labor, 
and in a speech in the Obstetrical Society, of London, in 1864, 
urged that body “ to express its emphatic opinion on this subject for 
the purpose of giving authority to this operation, so that patients 
known to have placenta prfevia would not be left by practitioners 
to perish at any moment from hemorrhage.” This point was illus- 
trated by the following case from Meigs, given in the language 
of that author : “ 1 may say that we had here in Philadelphia three 
physicians, the celebrated Prof. Dewees, Dr. Eberle, and Dr. John 
Ruan, each of whom had a considerable share of the obstetric prac- 
tice of the city. Dr. Eberle had under his care a lady in Market 
street, whose residence was about two and a half squares from his 
own house. Dr. Ruan lived about a square, and Dr. Dewees was 
distant three squares. After Dr. Eberle had made the diagnosis of 
placenta pra3via, the flooding having been suspended, he engaged 
the husband of the lady to send off three messengers as soon as the 
attack should come on again, one for Dr. Ruan, who was nearest, one 
for himself, and one for Dr. Dewees, hoping in this way to secure the 
prompt attention of at least one of the three. Not long after this, 7 
hemorrhage came on again, and was so violent as to prove fatal 
before they could assemble at her bedside.” 
Had these very able physicians employed their skill to empty that 
lady’s uterus, after they became aware of the existence of placenta 
praevia, instead owaiting, they would probably not have been called 
upon to lament the untimely death of herself and child. 
Greenhalgh shows that only one maternal death occurs in fifty- 
three cases where premature labor is induced, and that only one-third 
of the children are lost. 
Dr. Johnson also cites corroborative evidence from Playfair, Leish- 
man, Hicks, Eliott, and Parvin in support of inducing premature 
delivery in similar cases. 
Meadows is also very emphatic. He says : “ No matter what the 
period of utero-gestation, any large loss of blood demands the ter- 
mination of pregnancy, for, to leave a patient to be subjected to an- 
other attack, coming on, as it would do, without any warning, is, in 
truth, to place her life in imminent danger. The only justifiable 
ground for a temporizing policy is a slight discharge, absence of 
pain, an undilated os, and a period of pregnancy short of six 
months.” 
Barnes, the highest living authority in obstetric practice, as Dr. 
Albert Smith, of Philadelphia, declares, makes use of the following 
language: “The first question, we have seen, is to decide whether 
the pregnancy can he allowed to go on. If the pregnancy is only five 
or six months, the os not dilated, all pain absent, and the hemorrhage 
very moderate, we may temporize, watching, however, most vigi- 
lantly. But if the hemorrhage be at all profuse, and there be any 
sign of uterine action, act at once ; accelerate the labor. Above all, 
do not trust to the weak conventional means of keeping the patient 
in the recumbent position, in a cool room, with cold cloths to the 
vulva, mineral acids, and acetate of lead. This is but trilling in the 
presence of a great emergency. Commonly they do no good what- 
ever ; they always lose precious time. The great ha3inostatic agent 
is contraction of the uterine fibre. To obtain this contraction is, 
therefore, the end to be sought.” 
Playfair and Leishman refer to the use of astringents in every 
possible form and confess that they are not even in the slightest de- 
gree to be depended upon. 
Dr. Johnson summed up his remarks upon prophylaxis as follows : 
“ I have now, Mr. President, drawn the attention of the society to 
the dangers of delay in temporizing in these very hazardous cases. 8 
We have seen that up to 1864, according to Greenhalgh, one mother 
out of every four and a quarter was lost, and more than two-thirds of 
the children were stillborn ; from past experiences eminent obstet- 
ricians have regarded the loss of the foetus as so probable that they 
have advocated and practiced treatment in which its welfare was 
totally disregarded ; that when hemorrhage has once occurred we 
cannot tell at what hour we may have a copious and perhaps fatal 
return of the flooding ; that it is liable to occur suddenly and at a 
time when medical aid cannot be speedily procured.” 
In the practice of former methods of treatment we are constantly 
in doubt and tormented with anxiety. With the most vigilant 
watchfulness and the engagement of the most skillful accouch- 
eurs, cases are liable to terminate fatally before their arrival at the 
bedside, as in the case from Meigs, detailed above, or to have sus- 
tained a loss of so much blood as finally to cause death through ex- 
haustion or anaemia, as in the cases reported by myself. Instances 
of either kind will be remembered by all busy practitioners. While, 
by the timely and skillful induction of premature labor, we have 
seen that Greenhalgh saved all the mothers and eight of the children 
in ten cases occurring in his practice. Barnes had eighty-tliree cases 
with only six deaths, and sixty-seven cases successively without a 
single death, and two-thirds of the children were born alive. Hall 
Davis induced premature labor for this condition twenty-four times 
with only two deaths.” 
“Hemorrhage is the one great source of danger, and is fatal alike to 
mother and child. Women die, of course, from laceration of the 
vascular cervix, absorption of sceptic material, and are predisposed 
to puerpural diseases, but this is the chief factor. With the uterus 
empty and firmly contracted this factor is eliminated, our anxiety is 
allayed, and the safety of the patient comparatively assured.” 
u Objection is urged against the premature induction of labor on 
account of the danger to the child and the difficulty of keeping it 
warm' and nourished after its safe delivery. Upon this point I agree 
with Thomas that an eight-months’ child out of the uterus, and de- 
pending upon pulmonary respiration, has a decidedly better prospect 
for life than one in that cavity, and depending for the aeration of its 
blood upon a crippled and bleeding placenta.” 
We pass now to those cases in which labor is actually in progress, 
and to the best means of conducting the patient safely through this 
dangerous ordeal. I think all will agree that turning has long been 
considered the remedy par excellence in placenta pnevia. That this 9 
is not the best remedy in all cases, and that when it is really indicated 
it should be performed in a somewhat modified form, and with more 
gentleness and care in the dilatation of the cervix than has hereto- 
fore been taught and practiced, will be established, without doubt, 
by a study of the mortality statistics of cases treated by the vaginal 
tampon and rapid version. Rapid extraction was practiced for the 
purpose of evacuating the contents of the uterus as soon as possible, 
and thus securing firm contraction of the uterine fibre and suppres- 
sion of the hemorrhage. If the bleeding can be controlled by a less 
severe means, and this chief element of peril eliminated from the 
case, the labor may be allowed to proceed without further interfer- 
ence or assistance. This hasty but time-honored method is referred 
to in our books as the “ rapid treatment,” forcible entrance into the 
os,” “rapid dilatation of the cervix,” “forcible delivery,” “ ac- 
couchment force,” “pushing the hand rapidly through the os,” 
&c. Several authors speak of the “absolute necessity of delivering 
at once at all hazards,” under the belief that so long as the labor 
continued the hemorrhage would go on, even increasing ; the logical 
conclusion being that it was necessary for the salvation of the patient 
to empty the uterus as quickly as possible. Rigby, Leveret, and 
others declared, in emphatic terms, that “manual extraction of the 
foetus was absolutely necessary to save the life of the mother,’* and 
for many years all subsequent authorities concurred in accepting 
their doctrines and adopting this practice. Forcible delivery often 
proves fatal to the mothers, by injury done the cervix, and fnany of 
the old writers confess that on examination, after'death, they invari- 
ably found the os uteri more or less torn. Collins and others relate 
instances of this kind. 
Laceration and flooding are not the only dangers in accouchment 
force. By a little reflection it will become apparent why these 
dangers arise. Labors complicated by placenta praevia frequently 
come on—Matthews Duncan believes—as a result of the accidental 
separation of some portion of the placenta from a uterus which is 
immature, not ready yet for parturition, and whose cervical tissue 
has not reached the necessary muscular development to safely undergo 
this laborious process. Its tissues, instead of being muscular and 
dilatable, are exceedingly vascular and irritable, and the bruisings 
and contusions and lacerations which are caused by forceable delivery, 
no doubt explain the frequent occurrence of phlegmasia dolens, 
scepticmmia, puerpural fever, cervical ruptures and inflamations. 
The practical question to which I desire to direct especial atten- 10 
tion is, if the accouchment force is environed by so many dangers, 
what treatment can we adopt which will present a better and safer 
mode of accomplishing delivery and firm uterine contraction. Let 
us study this point a little. It has frequently been noticed that the 
rupture of the amniotic sac has been sufficient to eliminate the 
chief danger in these cases, and the labor, carefully watched through- 
out the remainder of its course, has required no further aid to pre- 
vent hemorrhage. 
As the liquor amnii escapes, the uterus is reduced in hulk, is pro- 
voked to greater activity, and acts to better advantage. The head, 
ill that is the presenting part, is driven down, and as the cervex di- 
lates, the pressure of the head controls the hemorrhage. Barnes and 
others maintain that hemorrhage will be spontaneously arrested by 
the detachment of that part of the placenta which is attached to the 
dangerous or cervical zone of the uterus. The complete detachment 
and removal of the placenta, (Simpson,) besides being almost cer- 
tainly fatal to the child, must require an operation hardly less severe 
to the woman than version itself. 
Sponge or laminaria tents may be used in cases of hemorrhage from 
an undilated os. While the tent expands it at the same time pre- 
vents hemorrhage and dilates the cervix. When the tent has ex- 
panded to its fullest extent it is removed or slips away, and the small- 
est size Barnes dilater may be inserted in its place, which in turn is 
replaced by a larger, and then a larger one, until sufficient dilata- 
tion i6 produced; while at the same time the cervix is completely 
plugged or tampohed. This process may require from two to six 
hours, according to the dilatability of the os. Should dilatation go on 
well, uterine contractions set in powerfully, as is the fact in a large 
proportion of cases, the hemorrhage is thus controlled until the pre- 
senting part of the foetus becomes itself the plug, no further treat- 
ment may be required, and version will be avoided. But if the 
pains are inefficient and the hemorrhage goes on, in cases where some 
part other than the head or breech presents, malpresentations being 
not infrequent in placenta praevia, turning must, of course, beresorted 
to. The last edition of Leishman declares that this operation is the 
one in which the great majority of experienced practitioners still 
place the greatest confidence. 
In view of the dangerous and fatal results which have been re- 
ported in consequence of forcing the hand through an undilated 
vascular cervix, and of rapid delivery through parts which, even 
when everything is normal, slowly, and gradually expand, it seems 11 
to me that the entry of the hand into the uterus at all should he 
avoided, if it is possible to do so. The method of hi-polar or bi- 
manual version, so successfully practiced by Braxton Hicks, of 
London, can here be applied with the most beneficial results. By 
manipulation with one hand upon the abdomen and with two fingers 
of the other in the uterus, a foot of the child can he hooked down. 
Unless the case is urgent, nature can he trusted to effect, the expul- 
sion unaided after the leg or half breech has been drawn far enough 
into the cervix to act as a tampon. If considered advisable, con- 
tinued gentle traction may, of course, be made, combined with and 
aided by external pressure over the uterus by elastic abdominal band- 
age and ergot. The shock of rapid extraction is thereby avoided, 
and the danger of lacerating the vascular cervix is greatly lessened if 
not prevented. I desire to add, in conclusion, that I am firmly con- 
vinced that in proper cases, and when seen in time, the induction of 
premature labor will save many lives, both foetal and maternal; and, 
also, that when the above-mentioned gentle means of dilating and 
at the same time plugging the cervix, are universally adopted, the 
fearful mortality in these cases will be greatly reduced.