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Henry J. (Henry Jacques) Garrigues.

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which may be attended to later, whereas the uterine hemorrhage is
an urgent indication for immediate therapeutic action.

Treatment. — The treatment is partly prophylactic, partly curative.
Much can be done to prevent post-partum hemorrhage, and it may
even be said that with proper management of labor the event is rare
and may never be seen in its higher degrees. From the moment the
child is born till at least half an hour after the placenta is delivered,
the fundus of the uterus should be held \vithout interruption by the
hand of the obstetrician or the nurse. When it is properly con-
tracted, nothing more should be done. But the moment it is felt to
soften, the abdominal wall should be moved gently from side to side
and from the front to the back and vice versa. In this way a mild



512 ABNORMAL LABOR.

tickling of the peritoneal surface of the fundus is produced, which
may be all that is needed to call forth renewed powerful contractions.
If that does not suffice, the womb may be kneaded and squeezed
with the same hand.

The pulse gives sometimes a warning of impending danger. In
normal deliveries it drops to 70 or 60 beats in a minute. If it ranges
from 100 to 120 the obstetrician should be particularly watchful, and
should under no circumstance leave the patient.

The rectum should always be emptied before labor. A full blad-
der should be evacuated Avith the catheter, unless the patient can
micturate.

If the hemorrhage is not serious, the uterus need not be entered.
It suffices to compress the fundus. As soon as there are contrac-
tions, the accoucheur should try to press the placenta out by Crede's
method. Blood-clots are likewise pressed out from above or helped
out by introducing one finger into the os. But if this does not arrest
the hemorrhage, the well-disinfected hand should be introduced and
the placenta removed as described above (p. 419).

The aorta can easily be felt and compressed against the vertebral
column a little above the promontory. This procedure does not shut
off the blood supply of the uterus, since there comes as much blood
through the ovarian artery as through the uterine ; but it diminishes
the supply by one-half, and once located, the artery may be com-
pressed by an unskilled assistant, while the doctor is otherwise en-
gaged in the interest of the patient.

The uterus itself may be powerfully compressed by pushing two
fingers up in the posterior vault of the vagina, against the posterior
wall of the uterus, and forcing the fundus down with the other hand.
Sometimes the compression can be made even more effectual by plac-
ing the inner fingers against the anterior vault so as to reach the
anterior wall of the anteflexed uterus.

Both the extremes of temperature are exciters of uterine contrac-
tion ; but there is this difference, that a low temperature weakens the
patient, who is already cold and exhausted by loss of blood, while a
high temperature is a powerful restorative. Cold should therefore
be applied only in a transient way. A towel may be wrung out of ice
water and used for slapping the lower part of the abdomen in front
of the uterus. Heat may be applied in the shape of intra-uterine
injection of hot water (110-115° or even 120° F.). Although this is
very painful, the patient must stand it. There is no time for admin-
istering an anaesthetic, and, besides, it is too dangerous.

All the remedial resources so far considered aim at the establish-
ment or strengthening of uterine contraction, a physiological act which
will in the vast majority of cases result in arrest of the hemorrhage.



HEMORRHAGE. 513

If, however, the flow continues, another class of remedies is at
our disposal, those which chiefly act in a chemical way, by causing
the blood to coagulate. Instead of using plain hot water, the writer
employs an emulsion of creolin (one per cent.), which is both astrin-
gent and antiseptic. An ounce of undiluted tincture of iodine was
injected to great advantage by Dupierris, a physician practising in the
West Indies, and his example has been followed by many others. The
tincture certainly coagulates blood, and is one of the best antiseptics,
and the coagula formed are not so hard as those produced by iron salts.

The late Dr. R. A. F. Penrose, of- Philadelphia, praised in the
highest terms common vinegar, both as an irritant and as an astrin-
gent. He recommended to pour a few tablespoonfuls of vinegar out
into a vessel, dip a clean rag or pocket-handkerchief into it, carry it
with the hand into the cavity of the uterus, and squeeze it. If neces-
sary, this procedure is repeated two or three times. This sounds
rather antiquated in our days, when we hear only of aseptic gauze,
sterilized fluids, and disinfected hands. But I can easily imagine sit-
uations in which this old remedy may be the best available and may
save lives that otherwise would be lost. Advices that are admirable
in lying-in hospitals and may be followed to advantage in wealthy
private practice, where every possible event has been anticipated and
provisions made to meet it, may not be practicable under all circum-
stances. Let us, for instance, take the case of a physician called in a
hurry by a midwife, whose patient is bleeding to death. Under such
circumstances it Avould be folly to abstain from acting because of the
remote danger of infection. The present danger of collapse and
death from loss of blood is the issue to be met, and perhaps it is well
then to think of the old time-honored vinegar, which is found in every
dwelling, can be applied without apparatus, excites the uterus to con-
traction, coagulates albumen, and even has antiseptic properties.

I purposely keep the liquor ferri chloridi for the last. I carry it
always in my satchel, but I do not think that I have ever used it in
an obstetric case. It is a most powerful styptic, and by the chlorine
it contains it has also antiseptic value ; but the coagula produced by it
are hard and slow to disintegrate, and before their removal they are
apt to become infected. I look, therefore, upon this remedy as a last
resort, to be used only when everything else fails. It may be used as
intra-uterine injection diluted with from six to ten parts of water or
squeezed out undiluted from a pad carried up to the fundus. After
having used a styptic, the uterus should no longer be compressed, as
the compression might lead to the detachment of a thrombus, and
thus start the bleeding again.

Of late the extract of tlie suprarenal capsule has been much
praised for any kind of hemorrhage. It is said both to be astringent

33



514 ABNORMAL LABOR.

and to cause uterine contraction. Dr. James B. Moore dissolved 3iii
of Armour's pulverized extract in sviii of -water and filtered it through
sterile gauze. In this he dipped a strip of gauze three-fourths of an
inch (two centimetres) wide and one and one-half yards long, and
packed it all into the uterus, removed it shortly after, and washed
out with sterile water. Simultaneously he gave gr. x of the extract
by the mouth. The htemostatic effect of the drug when used locally
or internally is said to occur in less than a minute.^ Parke, Davis &
Co. have two preparations. — solution adrenalin chloride 1 : 1000, and
suprarenal liquid with chloretone, — either of wdiich may be adminis-
tered internally in doses of n\^v-xxx.

Stypticin given internally in doses of gr. |-1 (from 3 to 6 centi-
grammes) or hypodermically, dissolved in water, in doses of gr. i-|-
(1-2 centigrammes) and repeated according to circumstances is also
a valuable haemostatic. It is said also to be analgesic.

If an electric battery is available, it should be used at an early
date. Either the faradic current or the interrupted battery current
may be applied to great advantage. One pole should be placed at
the fundus and the other alternately at either side of the cervix
through the abdominal wall, where it will reach the large cervical
ganglion that is in connection with most of the nerves supplying the
uterine muscle bundles. It is probably the most powerful exciter of
uterine contractions. As soon as the uterus is empty, some prepara-
tion of ergot should be given hypodermically.

Besides these measures directly aiming at uterine contraction and
coagulation of the blood in the veins of the placental site, there are
others which may be attended to simultaneously. The windows
should be opened ; the patient should be fanned. If pure oxygen is
available, it should be administered. The foot end of the bed should
be raised, with a view to causing the blood in the body to gravitate
towards the brain. All four extremities may be wrapped up in roller
bandages, beginning from the distal end and ending with circular com-
pression of the arms and legs near the axilla and the groins. By
this means — so-called auto-infusion — the blood is concentrated around
the vital organs, — the heart, the lungs, and the brain.

Transfusion of defibrinated blood from another individual is
effective, but takes much time and is not easily obtained. Much
simpler is the intravenous or subcutaneous injection of normal salt
solution. (See Operatioxs.)

Strychnine, nitroglycerin, digitalis, or atropine should be injected
hypodermically as stimulants for heart and lungs. Strong spirits of

1 J. B. Moore, private communication ; W. H. Bates, N. Y. Med. Record,
February 9, 1901, vol. lix., No. 6, p. 207 ; E. A. Shafer, British Medical Journal,
April 27, 1901.



HEMORRHAGE. 515

ammonia should be held near the nostrils. Camphorated oil may be
injected into the. muscles.

When the imminent danger is passed, the patient should be
watched, and the injection of normal salt solution or the administra-
tion of the above-mentioned drugs should be repeated until all danger
is passed.

After emptying the uterus, it has been recommended to pack it
and the vagina with iodoform gauze. So large a quantity may be
needed for this purpose that it may not be without danger from the
poisonous quality of the iodoform, which would be obviated by taking
sterilized gauze. The method has met with favor, but seems to
be inferior to the other methods recommended above. It is more
rational and more in harmony with nature's own methods to rely on
contraction and coagulation without leaving any foreign body in the
uterus. Tamponing is in most cases surperfluous. It is not reliable,
and it contains an element of danger as to sepsis. At all events, this
method should be reserved for cases where the hemorrhage resists all
other treatment, and then I take it to be better to soak some of the
gauze in diluted liquor ferri chloridi.

Hemorrhage is often followed by a stage of nervous excitement.
When reaction sets in, the patient may suffer from intense throbbing
headache, great intolerance of light and noise, or general prostration.
The best remedy for these troubles is opium.

When the acute danger is over, attention should be directed to
proper alimentation and compensation for loss of blood. The food
should be nitrogenous, — milk, meat-juice, and eggs ; later, oysters,
boiled sweet-bread, and, finally, poultry, ham, and meat. At this
stage burgundy or port wine may also be useful, while, as long as
there is any tendency to bleeding, alcohol, by increasing the inclina-
tion thereto, does harm and should not be given, except in the form
of whiskey or brandy as a stimulant to combat threatening collapse.

Regarding drugs, the extract of red bone marrow (carnogen, hae-
maboloids) is the most effective rebuilder of blood that I know of.
The peptonoid of iron and manganese (among the imported prepara-
tions Gude's and Diettrich's, among the domestic feralboids) is claimed
to be more assimilable than other chalybeates. The author has, how-
ever, seen excellent effect of —

R Solution ferrous malate (Amer. Pharm. Mfg. Co.)

(or Tinctura ferri pomata of the German Pharmacopoeia),
Tinct. cinchonse co., aa part. teq. — M.

Sig. — A teaspoonful three times a day after meals.

With the drugs named may also to advantage be combined arsenic,
phosphorus, cod-liver oil, terraline, and other tissue builders.



516 ABNORMAL LABOR.

Secondary Hemorrhage. — Hemorrhage may recur within a few
hours of the primary one, and may then be looked upon as a con-
tinuation of the same ; but it may also appear weeks and even months
after delivery.

It may be brought on by a sudden mental emotion, pleasant or
unpleasant. It may appear when the patient suddenly rises to the
erect posture or strains herself in any muscular effort. Abuse of
alcoholic drinks is very apt to lead to it. It may be due to sexual
intercourse. Albuminuria or malaria may give rise to it. Sometimes
the cause is retention of a piece of the placenta or of the membranes,
or retroflexion of the uterus.

Treatment. — The treatment differs according to the amount of
blood lost and the cause of the trouble. A retroflexed uterus should
be replaced and kept up with a large pessary during the period of
involution, at the end of which it is advisable to fasten the organ in
the right position by some suitable operation.^ If any part of the
ovum is retained, it is removed by curettage." If there is reason to
believe the hemorrhage is of malarial origin, quinine and arsenic are
indicated ; and, if possible, the patient should change her residence,
at least temporarily. Albuminuria demands proper treatment of the
kidneys. The bowels must be kept open. The fluid extract of ergot
should be given. The writer has also seen good effect of a decoction
of cotton-root bark :

R Gossypii radicis corticis raspati, ^iv.
Sig. — Boil 3 heaping teaspoonfuls with 1 pint of water for 15 minutes ; strain.
Drink one-third, cold, three times a day.

Some praise tinctura cannabis indicae. Plain hot vaginal douches
are useful and may be strengthened by the addition of liquor ferri
chloridi (gss to Oi). Tannin pessaries may also be left in the vagina.
A blister on the sacrum is said to have a good effect. If the hemor-
rhage is considerable and does not yield to these remedies, the vagina
should be tamponed, and counter-pressure exercised over the lower
part of the abdomen.

§ 6. Inversion of the Uterus. — Inversion consists in the turn-
ing inside out of the uterus. It is said to be so rare that only one
case was observed in 200,000 cases of confinement in the Rotunda
of Dublin. I am inclined to think that this is due to the superior
method in which normal labor has been conducted of old in that
institution. Having personally seen at least three cases, I cannot
believe that the accident should be one of so extreme rarity, and most
authors speak of it in terms of familiarity. Still it is undoubtedly

' Garrigues, Diseases of Women, third ed., pp. 471, 474-478.
2 Ibid., p. 180.



HEMORRHAGE.



517



rare, and has become much rarer since the management of normal
labor has been improved, particularly since pulling on the umbilical
cord has given way to expression of the placenta.

Three degrees of inversion may be distinguished. In the first
there is a mere indentation of the fundus, a bulging inward. In the
second degree (Fig. 390) the partially inverted uterus forms a tumor
in the vagina. In the third degree the inversion is complete (Fig. 391),
the whole uterus, inclusive of the cervix, being turned inside out and
forming a tumor outside of the vulva.



Fig. 390.




Incomplete inversion of the uterus. (Denuc6.)

Etiology. — The inversion may be produced artificially through
improper management, or arise spontaneously. Under all circum-
stances it can only happen when the placenta is not implanted, as it
normally is, on the walls of the body, but on the fundus. Formerly
the placenta was removed by winding the cord around the fingers
of one hand, and often by pressing simultaneously on the pla-
centa in the neighborhood of the cord. If we suppose the placenta to
be somewhat adherent and the uterus not to be well contracted, we
can easily imagine that the fundus might follow the traction exer-
cised on it from below and become inverted. This movement
would be seconded if, instead of grasping the whole upper part of
the uterus, mere flat pressure were exercised on its top. Even the
expression method, if not used properly, may favor it. Thus, if the



518



ABNORMAL LABOR.



accoucheur is in too great a hurry about expressing the placenta, and
does it in the absence of a spontaneous contraction, he may push the
fundus in.

But there is no doubt that inversion may occur without any fault
of the obstetrician, the midwife, or the patient herself. In the first
place, the accident is apt to occur in cases of precipitate labor, where
nobody touches the womb. In such cases it is the child dangling
between the legs of the mother which pulls on the cord, and, if this

Fig. 39L




Complete inversion of tlie uterus. (Boivin and Duges.)



does not tear or the placenta become detached, the fundus may be
pulled down through the contraction ring. Secondly, there are nu-
merous observations in which the mechanism could be distinctly felt
to consist in the relaxation of the central part, corresponding to the
placental site, and strong contraction of the surrounding tissue, so that
the lax part sank inward, was seized, and was, so to say, sucked down
by the contracting part.

Inversion has been observed also as a post-mortem occurrence,
the gases developed in the abdominal cavity having expansive power
enough to turn the uterus inside out.

Symptoms. — The inversion is often accompanied by a sudden,



HEMORRHAGE. 519

sharp pain in the abdomen, but the chief symptom is a post-partum
hemorrhage that may assume such proportions that the patient faints,
goes into convulsions, or even dies.

Diagnosis. — By placing the hand on the womb, it is found bulging
inward, or the whole ball formed by the organ in normal delivery
may be absent. A red, globular, bleeding tumor, covered with
mucous membrane, may be seen protruding from the genitals ; or it
may be felt with one fmger in the vagina or in the uterus ; or if the
whole hand is passed into the cavity, one may feel the fundus bulging
downward.

The only thing inversion may be confounded with is a uterine
polypus, but the differential diagnosis is easily made with a uterine
sound, which passes a polypus and ascends to the fundus, while in
inversion it is soon arrested by the invaginated uterus. In a case of
hollow polyjnis the sound does not enter the uterus either, but the
tumor contains fluid, is softer than the inverted uterus, and is an
exceedingly rare affection, that by its nature is excluded from a puer-
peral case.^

Prognosis. — Inversion is a very dangerous condition, which may
end fatally.

Treatment. — As soon as the diagnosis is made, the uterus should
be replaced, which is much easier in the beginning than later.

If the uterus is only indented, the hand must be introduced and
the closed fist used to push back the incurved portion of the womb.
If true invagination is already accomplished, the fmgers of one hand
should be inserted through the abdominal wall into the funnel-shaped
depression formed by the inverted uterus, and excentric pressure
should be exercised on the ring encircling the invaginated portion,
while the accoucheur tries to replace the prolapsed portion with the
other hand. If he should simply press on the most prominent por-
tion of the tumor in the hope of reinverting it, he would probably
meet with insuperable resistance, for by so doing he would create a
new invagination inside of the other and going in the opposite direc-
tion. He has better chances if he tries to replace the uterus, like the
intestine in a hernia, by pressing on the part that has come out last and
trying to replace that first and then the next highest portion, and last
of all the fundus (McClintock's method). But the best of all methods
is based upon the known anatomical distribution of the fibres of the
inner layer of the muscular coat of the uterus (Fig. 121, p. 89), By
pressing exclusively on the uterine opening of one of the Fallopian
tubes, while counter-pressure is exercised from above, this horn may
be rein verted, thereafter the other, and finally the remainder of the
uterus (Noeggerath's method).

1 Garrigues, Diseases of Women, third ed., p. 488.



520 ABNORMAL LABOR.

When the uterus is replaced it should be manipulated with both
hands, so as to bring it into a condition of strong contraction, which
should be followed by a hot antiseptic intra-uterine injection, and, if
needed, even a styptic injection. Besides replacing and kneading the
organ, the accoucheur should use the remedies described in treating
of post-partum hemorrhage.

The question presents itself how to deal with the placenta, if that
is still attached to the inverted wall of the uterus. Here the obstet-
rician finds himself between the two horns of a dilemma. By remov-
ing the placenta he will diminish the surface to be replaced, but in
peeling it off he may increase the hemorrhage. If the placenta is
partially detached, it is best to detach it altogether before attempting
reinvagination. If, on the other hand, it is still adherent all over, it is
best to leave it undisturbed and try to push it back together with the
inverted portion into the interior of the uterus. But if the accoucheur
does not succeed in his attempt, he should try the other way and
remove it first.

If reposition proves impossible, a colpeurynter filled with ice-water
should be placed in the vagina. This will arrest hemorrhage, and
sometimes at the end of some hours it may be possible to replace
the uterus. Before giving up the case, the obstetrician should try
Courty's method, in which two fingers of the left hand are introduced
into the rectum, and attempt to open the constricting ring, while the
fingers of the right hand are made to press on the base of the tumor ;
and even the method of Tate, of Cincinnati, who dilates the urethra
until he can introduce the right index-finger into the bladder and
press on the ring from this side, while the left index-finger and mid-
dle finger are used as in Courty's method and the thumbs press on
the tumor.

Whatever method is chosen, the operation is much facilitated by
anaesthetizing the patient, whereby not only the element of pain is
excluded, but the uterus is relaxed. The only contra-indication is if
the patient is in such a condition of exhaustion in consec|uence of loss
of blood that the use of an anaesthetic becomes too hazardous.

If the case is not seen before days or weeks have elapsed since
the accident occurred, reposition may still be tried, but then the
prospect of its being successful is much smaller than immediately
after delivery. If it does not succeed, protracted elastic pressure
should be used, as for incarcerated retroflexed uterus (p. 299). If
there is any bleeding, it should be checked by tamponade, which at
the same time prepares the uterus for reinvagination. After the
lying-in period, the case passes into the domain of gynaecology, and
may, as a rule, be successfully treated by operation.^

^ Garrigues, Diseases of Women, third ed., p. 490.



HEMORRHAGE. 521

§ 7. Thrombus, or Haeraatoma, of the Vulva and the Vagina. —
A thrombus, or haematoma, is an extravasation of blood into the con-
nective tissue of the parturient canal. It may be deej:), or interstitial^
or superficial and pedunculated. The interstitial haematoma is most
commonly situated in the labia majora of the vulva, more rarely
around the vagina, and least frequently on the wall of the upper part
of the pelvis. The seat and extension of the haematoma depend
upon the source of the extravasated blood. If this is situated below
the pelvic fascia, the blood accumulates in one labium majus, but
may extend to the perineum and surround the anus. Or it may be
found on one side of the vagina or surround it more or less com-
pletely. If, on the other hand, rupture takes place between the pelvic
fascia and the peritoneum, the blood may ascend to the iliac fossa and
thence to the region of the kidney or in front up to the umbilicus.
Very rarely there are two collections of blood, which may even com-
municate so as to form an hour-glass-shaped cavity.

The blood is at first fluid, but coagulates later. It may become
absorbed, or the tumor may rupture, form an abscess, or become
gangrenous.

The formation of a thrombus is a rather rare affection, occurring
on an average only once in 1500 confinement cases.

Etiology. — Little is known about the cause of a haematoma. So
much is sure that varicose veins, which are so common, have nothing



Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 47 of 80)