Ernest Watson Cushing.

Annals of medical practice online

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filled with a fluctuating mass. Temperature 104° F. Breath-
ing very shallow and difficult. Incision revealed a clear, shining
cyst wall; this was punctured and the fluid evacuated. There
were no adhesions. The other ovary showed signs of cystic de-
generation and was removed. Operation particularly easy and
correspondingly rapid.

It was a peculiar sensation to put the hand into an abdomen at
a temperature over 104°. It felt actually hot I examined the
small intestines carefully to see whether any disease of Peyer^s
patches could be detected by sight or touch, thinking that the op-
portunity in the living subject would not often occur. No ab-
normalities could be found in the intestines.

The patient recovered from the operation nicely, but had a
long and hard struggle with the fever. The oppression of breath-
ing was relieved at once. There were thirteen hemorrhages from
the intestine, on the Sunday thirteen days after the operation. It
seemed as if she would hardly recover, but youth and good care
brought her through finally, although she was ill over three
months. She lost all her hair, and seemed a perfect wreck.

There was at no time any suppuration of the abdominal wound.
The young lady finally made a most perfect convalescence, and
has developed into a handsome, active girl, of great physical and
mental vigor, now nearly 18 years old.

As it is not often that the ovaries are removed before puberty,
it may be interesting to add that in no respect whatever does she
seem, or, as far as can be ascertained in such a delicate matter, by
her mother, does she feel at all different from girls of her age.

168 Newbury Street, Boston.

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Assistaiit Professor of Surgical Pathology, Tafts College Medical


Case I. — On November 15, 1895, we were called out of town
to see Mrs. I. M., a healthy young lady of twenty-seven, who was
six months pregnant with her first child, and the following his-
tory was obtained. For the past three months at regular inter-
vals of four weeks, a bloody discharge occurred from the vagina,
which lasted several days on each occasion, and at the same time a
heavy feeling in the lower abdomen was complained of. On the
evening previous to our visit, after an afternoon at golf, a slight
bloody discharge appeared, which continued throughout the
night There were no labor pains, and the os was not dilated.
The pulse was seventy-seven, and the temperature 37^ C. Urine

The usual treatment of threatened miscarriage was ordered,
namely, absolute rest in bed and tinct opii in full doses. The
bleeding ceased after a few hours and for one week all went well
and we were about to allow the patient to sit up when the nurse
telephoned that a severe flow of blood had suddenly appeared
without any cause. We arrived in about an hour and by palpa-
tion the uterus appeared somewhat larger than it should be and
the fetal heart sounds were indistinctly heard, although they
could be detected. The os was not dilated. The pulse was one
hundred and five, regular and quite strong. Temperature

The vagina was tightly packed with subgallate of bismuth
gauze and two milligrams of strychnia given subcutaneously.
Labor pains soon appeared and within an hour the gauze was
removed and the cervix was found to be dilated to the extent of
a silver dollar. A soft mass presented. A gush of blood then
came from the uterus and a hemorrhage commenced.

The vagina and vulva were rapidly disinfected, the cervix was
dilated, and with the hand the placenta, which was completely de-
tached and presenting, was easily delivered, and by pushing the
fetus down so that the head plugged the os the bleeding decreased,

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and in twenty minutes a well developed male fetus was deliv-
ered without further interference. A hot intra-uterine douche
and ergotin were given. The patient made an uninterrupted re-

Macroscopical and microscopical examination of the placenta
did not reveal any pathologic change.

Case II. — On the morning of January 12j 1 898. we wpre asked
to see Mrs. W. EL, set. 32, who had recent
The patient was a medium sized but well bu
been living in New York City where the stre
most constant state of repair, but no history

We were informed that a short time bef o
tient experienced pain in the abdomen, an
amniotic fluid had been discharged along wi

The patient stated that her last menstruat
3, 1897, and that she expected to be deliverc
of February, 1898. Her first pregnancy, fo
in a miscarriage during the eleventh week, an
ago she was delivered of a seven months' f eti

Examination showed that the breasts were
and areolae were pigmented, and a few ei
veins could be seen. The glands were well
colostrum could be pressed from the nipples,
pigmented. Temperature normal, pulse six

The fundus uteri extended three fingers
umbilicus, while the fetal head presented
back of the child was to the left and the sm8
pated on the right side. The heart sounds
on the left. A diagnosis of left occipital pr

Per vaginam, the cervix was found direci
and the external os was sufficiently dilated t
ger to pass, while the head could be felt be
There was a bilateral laceration of the cer\'
on the left.

The patient was given a subcutaneous in
and absolute quiet in bed was ordered, but (
otic fluid and blood continued to be pissed,
was negative.

The next morning the child was still alive

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were good in spite of a considerable amount of amniotic fluid and
blood still escaping. At four in the afternoon a hemorrhage oc-
curred, and upon examination the cervix was found dilated to the
extent of a silver dollar. The placenta presented and was found
to be almost entirely detached from the uterus. The position of
the fetus had not changed.

Ether was given, and after preparation of the vulva by shaving
and scrubbing with brush, soap and water, and a vaginal irriga-
tion of a solution of creolin, the cervix was manually dilated. The
left hand was then introduced into the uterus and the left foot
seized and brought down, after the placenta was pushed aside and
a dead fetus being easily delivered in a second breech position.

An intra-uterine creolin irrigation was given, the uterus con-
tracted well and its cavity and vagina were packed with xerof orm

The following morning the temperature was 38.° 8 C, but fell
to 37.° 4 C. in the evening, and in three weeks the patient was al-
lowed to be out of bed.

The placenta was found intact and microscopical examination
revealed a marked fatty degeneration of the decidua,

Lesner has said that premature detachment of the placenta is
due to the fact that the adhesions binding the organ to the uterus
cannot resist the contractions of the uterine muscle during labor.
Hegar believes that a fatty degeneration of the decidua is the
cause, while Dohm considers that this complication is produced by
the elimination of necrotic tissue from embryonic cell formation,
similar to that produced by granulating surfaces.

As the primary causes of premature detachment of the placenta,
uterine contractions, or traumatism, must be admitted, which give
rise to hemorrhage at the site of the placental attachment to the
uterine cavity, thus tearing the placenta away as the hemorrhage
overcomes intra-uterine pressure.

We must here take into consideration all those changes which
are entirely due to the process of normal pregnancy, and are in
no way pathologic in nature; from the beginning they render the
uterus more liable to hemorrhage. In the first place the blood of
pregnant women undergoes quantitative and qualitative changes,
in this sense that the quantity increases, but its tenor in red blood
corpuscles relatively decreases. According to some authorities
there is a true plethora, while for others there is hydramia. Ki-
wiach termed this condition serous plethora, while Virchow des-

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ignated it as physiological leucocytosis. K a given case presents
one or the other condition of the blood, it simply means that the
woman was previously healthy to her pregnancy, or was either
anemic or chlorotic.

As the left ventricle of the heart " -^^ ^ - ^ ^ * —

phied from pregnancy the quantiti
naturally cause an increase in the
quence of the poorer condition of 1
well nourished, and for this reason
ease when submitted to an increase

To this we may add the mechani
rus, producingpressure on vena ca^
an engorgement of the abdominal
tion in the decidua serotina throng
also remember that towards the en
insertion of the placenta contains o:
ing tissue on account of newly f on
blood vessels already existing. I
that only a slight traumatism is su:
the vessels, which will result in a ]
tachment of the placenta.

It is, nevertheless, a fact, that t
frequently met with among the w<
to traumatism during gestation, an
that in most cases there are severs
the etiological factors. We may t
classes, viz., the predisposing and
stances we are obliged to simply su
factors in a given case.

As predisposing causes we have
the bloQjd and vessels directly due t
nephritis, and more particularly t
in other organs of the body, the les
a high arterial pressure in the utei
changes in their walls, bringing a
struation, which if moderate, may
pregnancy, but if severe, will lea<
the placenta. Instances of this kin
•ell, Blot, Lohlein, Cohn, and man]

Thirdly, we have hyperemia of
arterial hyperemia or venous stasii

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by a preexisting endometritis, metritis, or an inflammatory pro-
cess in the adnexa, the use of strong purgatives or drastics, over-
indulgence in alcoholic drinks, hot baths, etc. Venous stasis is
caused by compression of the vena cava inferior from a very large
uterus, or from neoplasms in other abdominal viscera, tight lac-
ing, or excessive walking or other exercise. Pathologic changes
in the placenta or decidua serotina, as well as displacements of tlie
uterus, are prominent etiological factors in premature separation
of the placenta, and diseases of the more distant viscera, such as
the liver, heart or lungs must not be forgotten. Instances of this
complication havebeen reported as occurring in morbus Bascdowii
by Bennike and others. Anemia, chlorosis and hsemophilia, the
hemorrhagic diathesis following a severe infectious disease, such
as typhoid fever, cholera, icterus gravis, etc., all have their bear-
ing upon premature separation of the placenta. GoodcU believed
that repeated pregnancy was a predisposing cause, and nervous
conditions may also be included in the list

As direct causes we have traumatism of all kinds; a severe shak-
ing of the body such as results from falling, jumping, riding or
driving. In some instances vomiting, coughing or sneezing have
been considered as the direct cause. Bodily exertion, as lifting
heavy weights, dancing, slipping, etc., have appeared as the only
direct factor, and Brunton has collected thirty-two cases from
English literature, eleven of which were caused from bodily ex-

Premature separation of the placenta may also be produced by
an hydramnios or an exaggerated development of the utenu, be-
cause in the latter instance the placenta does not grow in propor-
tion to the uterus, and in the former case after some of the liquid
has been expelled the uterus contracts, and the site of the inser-
tion of the placenta is diminished and the organ becomes de-
tached. During labor the sudden exit of the liquor amnii may
have the same effect. Scanzoni considered tetanus uteri as an
important cause, and Schroder has pointed out that a short um-
bilical cord will also produce premature separation of the pla-
centa. Bunge says that a part of the placenta may become de-
tached when the ovum ruptures, if the membranes keep the os
uteri fully dilated so that it finally appears at the vulva.

Considering now the symptomatology of premature separation
of the placenta it may be said that hemorrhage, especially when
accompanied by some lesion of the circulatory system, is mort al-

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ways preceded by a general malaise, dizziness, vague pains in the
abdomen, diarrhoea, etc., and usually the blood appears suddenly.
The symptoms of internal and external hemorrhage are naturally
quite different and must be considered separately.

Internal hemorrhage occurs if only the central part of the pla-
centa is separated from the uterine wall, or when the ovum tigh^
ly hugs the lower segment of the uterus preventing the blood from
making its exit. In some few cases the blood has forced its way
directly through the placenta into the cavity o:
then made its exit mixed with amniotic fluid.

The patient suddenly complains of a bearing
and severe abdominal pains which may extend
iliac f ossfiB. Severe vomiting may also occur. A
of marked anemia appear rapidly such as ringing
ziness ending in syncope, etc. The skin become
the vision is dim, and the pulse small and thready.

Death will rapidly take place if the bleeding cannot be arrested,
and is sometimes preceded by convulsions.

Another important symptom is an increase in the size of the
uterus due to the issue of blood into its cavity, but Hennig has
pointed out that the uterine muscle may become relaxed just be-
fore death. The distended uterus may produce a mechanical

The membranes of the ovum are distended to their fullest ex-
tent and can be felt, according to Winter, projecting into the cer-
vical canal. Spiegelberg, Herman and others believe that the
collapsus is not so much due to an anemia as to shock produced by
the sudden and excessive distension of the uterus.

The shape of the uterus becomes changed from the accumula-
tion of blood within it Habit says that it becomes globular,
Hennig upholds that it presents two projections divided by a sul-
cus, while Scanzoni declared that the anterior wall of the organ
was more particularly distended. A number of accoucheurs be-
lieve that the site of the hemorrhage may be made out by deep
abdominal palpation, and Leroux claims that a distinct fluctua-
tion can be made out. The fetal parts cannot usually be felt
where the blood has collected, or only so with difficulty.

External hemorrhage is quickly detected, the discharge of
blood from the vagina being continuous or interrupted, but in
the latter case, although it may stop for some little time, it will
sooner or later again start up.

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If the hemorrhage be slight, the blood will coagulate in the
yagina, in which case clots only will be expelled, but occasionally
a large amount may collect in the vagina to such a degree that all
trace of hemorrhage may be absent. When such is the case, the
patient will suddenly complain of pain in the abdomen which is
accompanied by the feeling as if something had given way. Then
the same symptoms as those met with in internal hemorrhage fol-
low, viz., anemia, syncope and death.

Complete external hemorrhage is, however, infrequent, and
usually internal and external hemorrhage occur simultaneously
or follow each other, so that it is quite natural that the symptoms
are greatly changed and are not at all characteristic. If the
hemorrhage only takes place gradually, the subjective symptoms,
and especially severe pain, are not so severe, and the general con-
dition of the patient will also influence the conditions present.

Although the diagnosis is very easy in some cases it may be of
great difficulty in others, the external hemorrhage being always
quickly recognized. ^Hemorrhage from a lacerated cervix or
vagina can be easily eliminated, but a placenta previa, which is
the most frequent cause of uterine hemorrhage, must be excluded.

Important data will be gained in carefully going over the
anamnesis of the case. Premature separation of the placenta is
usually preceded by traumatism, while hemorrhage from a pla-
centa previa is sudden and unexpected, and no cause can be attrib-
uted for its occurrence. It is also unattended by abdominal pains.
In the one there is hemorrhage from a contracting uterus, while
in the other contractions are absent. A diagnosis of placenta
previa is more certain when the os uteri is dilated sufficiently to
admit a finger or two as the protruding portion of the placenta can
be felt and recognized.

A diagnosis of concealed hemorrhage can only be made by get-
ting an exact anamnesis, making a thorough examination and
careful observation of the patient. The etiological data of pos-
sible value are sudden abdominal pain, symptoms of acute anemia
and collapsus, and make the diagnosis of concealed hemorrhage
probable, but it will only be certain when every other lesion can
be eliminated by exclusion, including rupture of the uterus. In
the latter condition we may have similar sudden symptoms and
even syncope, but by abdominal palpation a ruptured uterus will
be found decreased in size, the protruding parts of the child re-
tract and can be felt quite distinctly under the abdominal walls.

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When there is a concealed hemorrhage going on the uterus in-
creases in volume. Finally a diagnosis of rupture of the uterus
will not be made if there are no conditions present which could
produce this accident.

In hydramnios we have a gradual but abnormal distension of
the uterus unattended by pain in most cases, but we
may meet with instances in which there is a sudden increase
in size, accompanied by severe pain. The pulse is full and hard,
while in concealed hemorrhage we would find it rapid and

In twin pregnancy the uterus, although it may be larger than
usual, will develop gradually in size, two fetal heart sounds can be
heard on auscultation, and two heads can be found by palpation.

An anamnesis badly taken may lead to the erroneous diagnosis
of apoplexy or paralysis of the heart, when in reality a concealed
hemorrhage is taking place, and Brunton has shown that the mem-
branes of the ovum will be distended when internal hemorrhage
is going on so that a careful digital examination through the in-
ternal OS, when dilatation is sufficient, will reveal the true state of

All obstetricians are of the opinion that a rapid delivery is the
most important therapeutic measure by means of power-
ful uterine contractions, and for this purpose we can strongs
ly recommend the subcutaneous use of strychnia at the dose of
two or even three milligrams.

The weakened condition of the patient should be attended to
by treating the anemia by artificial serum injections, the follow-
ing formula having been found most useful by the writer:

Natrii chlorid.,


Natrii glycero. phosphat

Natrii sulphat..

aa 2.0

Aq. deet.

800 C.C

An injection of 300 c.c. may be repeated several times if neces-
sary, but in our experience not more than two will be needed un-
less the collapsus is extreme.

The general condition of the patient, the amount and severity
of the hemorrhage^ and the stage of labor must be all taken into
consideration, and each individual case must be treated according
to its requirements. The most important consideration is wheth-
er the hemorrhage is external or internal

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An attempt to control an external hemorrhage, when the loss
of blood is moderate and the os only slightly dilated, may be made
by hot or cold irrigations, but a thorough gauze packing of the os
and vagina is by far the most prompt in action and at the same .
time will stimulate uterine contraction. We also think that a
tightly applied abdominal binder aids the vaginal tamponade, and
if necessary an ice bag may be placed over the uterus. The exhi-
bition of ergot in any form should, in our opinion, be condemned
as long as there is anything in the uterine cavity.

If bleeding continues or is severe, no time should be lost. The
06 should be dilated manually and the membranes ruptured. The
uterus will then contract well, and from this fact the hemorrhage
is controlled. Care should be taken to only puncture the mem-
branes with a very fine instrument so that the anmiotic fluid will
drain away slowly, and if the uterine contractions do not appear,
strychnia should be given.

If dilatation is complete, the forceps may be applied or version
may be resorted to. We believe, however, that "accouchement
forc^'' as recommended by Mangiagalli, Winter, and others, is a
dangerous method, and the same may be said of instrumental di-
latation as taught by Schroder.

When concealed hemorrhage is going on, an early rupture of
the membranes is liable to occur from over distension, and if thia
should take place the intra-uterine pressure is lost on account of
the escape of the liquor amnii. If the indications for emp-
tying the uterus of its contents are not too pressing it is better not
to rupture the membranes when the dilatation is not complete,
otherwise the hemorrhage may become severe, and the case will
end fatally.

The delivery of the placenta must be done with care, and as
post partum hemorrhage is very prone to arise in these cases, the
patient must be closely watched during the first few days follow-
ing delivery. She should be kept quietly in the horizontal posi-
tion, and the bladder and rectum must be kept empty by the

We believe that it is good practice to pack the uterine cavity
and vagina with gauze for the first forty-eight hours following de-
livery in these cases as it is the best uterine stimulant that we pos-
sess. After the packing is removed a pill of ergotin and hydrastin
given two or three times daily, according to the therapeutic effect
produced, for one week will be found of service.

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If, however, post partum hemorrhage should take place, com-
pression of the abdominal aorta or bimanual compression of the
uterus, as recommended by Fasbender, should be resorted to. We
.believe that the old method of intra-uterine irrigations with a so-
lution of the sesquichloride of iron, long ago recommended by
Barnes and Braxton Hicks, is of much value, or vinegar, alum or
tannin may be used if the iron salt is nol

For stimulating the heart, subcutanc
camphor, caffein or musk, are of value, tl
ing of value:

'^. Camphor, trit,
01. olivar.,

M. D. S. For hypodermic use.
grams of camphor.



M. D. S.

M. D. S.

Camphor, trit.,
Tinct digitalis,
Ext. opii, *
Vitel ovi,
Aq. dest.,

For an enema.

Natrii benzoat,
Aq. dest., q

For hypodermic use. Ea<
grams of caffein.

Enema containing cognac in considei
a surprisingly rapid effect, and should no

The food must be plentiful but liquids
small quantities and often.

The mortality in premature separation
high both for mother and child, over 50
and 95 per cent for the child, but with p
ness on the part of the physician, it w(
mother at least, it can be greatly reduced

871 Beacon Street, Boston.

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about one month after the miscarriage, and at this time the infec-
tion was already generalized. Nevertheless, even done as late as
this it produced an improvement, so much so that the patient was
considered for some days as having been saved.

This case also illustrates how - -'"- ^-" ^

placenta of relatively consideral
other local symptom than a sligh

In the cases so far reported, w
we have been dealing with cases
ning, where operation was done
tion of the infection or a septic ]
form of a phlegmon or an abscesi
report, curettement was done m
ten days after the commencemen
the patient was in a full puerpera
treatments had been tried witho
j[)erfect success was the result i
which would lead to suppose thj

Case VIL— Mrs. H. B., mul
well up to the time of her last c

Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 33 of 77)