of Rhodes. Spurious works Andronicus.

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almost inevitable.

While the word drainage seems hardly appropriate in the
latter class of cases, it has been employed so long that the use
of the word seems to be established. Frequently, however,
writers use the word "packing** instead of the word "drainage,'*
and say that a given cavity was "packed with gauze.** The
latter word is, perhaps, preferable to the former, but is objection-
able because the verb "pack,** with its derivatives, means that
more or less firmness has been employed in placing the material,
as when a person packs a trunk; whereas, in using gauze for the
purposes contemplated, the end is best accomplished if the
gauze is placed in a fluffy way, so as to lightly support the parts,
and give at the same time ample surface for the absorption of
any discharge or exudate.

The older method of drainage, by which a tube of either
rubber or glass was passed into the culdesac, at the lower angle
of the incision, this tube perhaps being replaced after a little
by a wisp of gauze, I never found entirely satisfactory. It
required a good deal of attention on the part of the nurse, there
was liability to infection, it left a weak point in the abdominal
wall, and in a number of reported cases it resulted in a fecal
fistula. Such drainage passes through considerable territory
previously free of infection, and increases materially the danger
of ileus, since loops of Small intestine will be in contact with the
tube, and adhesions involving the small bowel are much more
apt to make trouble than similar adhesions involving the sigmoid.

In an ordinary pus tube case, acute or chronic, we find the
pelvis filled with the distended tubes, bedded in exudate with
their corresponding ovaries, which may or may not be infected,
the re trover ted uterus being probably involved in the common
mass. In operating upon these cases the lines of cleavage are
found so that the general mass is lifted up and forward, then the
tubes are removed, with or without the ovaries as the case may
require, and hemostasis secured in the ordinary way. If the
operation has been successfully performed, the tubes have been
enucleated without rupture; but frequently, in spite of every
care, rupture has taken place, with the escape of more or less
pus which is or is not sterile according to circumstances. If
there has been no escape of pus we simply have a raw surface
left, which by no possibility can be covered by peritoneum.



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78 BALDWIN: DRAINAGE IN PELVIC AND ABDOMINAL SURGERY.

unless the retroverted uterus is again dropped back, and the
peritoneum from in front stitched to the sigmoid and tissues
behind. Such a reposition, however, leaves everything in bad
condition, and is, of course, undesirable. If pus has escaped lit
will usually be sterile, and will do no harm, but of its sterility
one can never be quite sure, hence must always guard against the
possibilities of infection. It is in these cases, therefore, that
drainage of some sort is of very great importance if the best
results, or even good results, are to be obtained. If this drainage,
or packing, or " fluffage,*' if I might be permitted to coin a word,
is resorted to, and the end of the gauze brought out at the lower
angle of the incision, we not only have necessarily left a weak
point where a hernia may develop, but the discharge must
run up hill, and when the gauze is withdrawn the last point to
heal — namely, the opening in the abdomen — is in exactly the
wrong place.

In these cases, therefore, I have for many years opened the
vault of the vagina, having previously always thoroughly washed
out the vagina in anticipation of such use, and then passed the end
of a strip of iodoform gauze from above downward through
this opening, after which the rest of the gauze is packed in,
in as fluffy a way as possible, so that the denuded or infected
surface is entirely covered by the gauze. This covers the
denuded posterior surface of the uteruis, as well as the other
boundaries of the pelvis, and on this are carefully arranged the
ovaries and the sigmoid flexure of the colon. The omentum is
also brought down in front, and arranged so as to cover any
interstices which may be left. If the operator fears some dis-
arrangement a few catgut stitches can be used to catch the
parts together. We thus secure a complete floor of the abdomen^
and a complete roof of the pelvis. No peritoneum comes in
contact with raw or infected surfaces. After the ** fluff '* drainage
is thus in place, and the toilet of the pelvis completed, the
abdominal incision is closed in the operator's customary way.

After the operation is finished the vagina is carefully wiped
out so as to free it of any blood or pus. The piece of gauze pro-
truding at the opening in the vault is brought down a little, so as
to be readily caught for removal, and another piece of gauze
packed into the vagina. This second piece should be so in-
troduced as to hold the cervix well up and back, so as to relieve
any strain upon the fundus. This second piece of gauze can be
removed in two or three days and, if there is much discharge,



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BALDWIN: DRAINAGE IN PELVIC AND ABDOMINAL SURGERY. 79

creolin or other antiseptic douches can be used, until at the end
of a week the first piece is withdrawn; after which ordinary
sterile douches can be used for cleanliness until healing is com-
plete. If the opening at the vault has been made of good size
there is no retention whatever and the entire cavity rapidly
closes.

Any pus which may be present is absorbed by the gauze, and
the same is true of any oozing of blood. Within a very few
hours the tissues on top of the gauze have adhered together,
and a firm barrier is thus presented to any infection from below.
At the end of a week this roof over the gauze is thoroughly es-
tablished, and the gauze can then be removed safely, and with
a minimum of discomfort to the patient. Care should be taken
that the opening into the vault of the vagina is of ample size,
so that the gauze may be removed easily, and that the opening
may not close until the tissues above have sunk down so as to
obliterate the space formerly occupied by the gauze.

In removing the tubes great care is taken to see that each is
removed thoroughly into the horn of the uterus, so that there
will be no lumen left to serve as a nidus for trouble. This re-
moval leaves a V-shaped gap into which is brought a loop of the
round ligament and fastened by a continuous chromicized
catgut suture, which includes both flaps and between them the
loop of ligament. In this way no raw surface is exposed and
the ligament is firmly attached. If it seems wise to still farther
hold the fundus forward the utero vesical fold is detached with
care and reattached at the fundus.

It is well known that in cases of pelvic infection operation
during the early stages of the disease has usually been attended
with quite a pronounced mortality. For these reasons a num-
ber of abdominal surgeons have recommended that the patient
shall be kept at rest, and nothing done until the acute stage has
passed and the conditions have become chronic. In this way it
is claimed, and undoubtedly with truth, that the mortality is
greatly reduced. The objection to this delay, however, is that
tissues which when the patient first comes under observation are
healthy, become involved in the infection as the days and per-
haps weeks go by, so that the final operation requires much more
extensive sacrifice of parts than would an earlier operation.
That is, what were originally t,ubal abscesses may become tubo-
ovarian abscesses, requiring the sacrifice perhaps of all the
appendages. By the method of treatment suggested above,



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80 STEWART: A NOTE ON POST-PARTUM HEMORRHAGE.

early operation may be undertaken without any fear of un-
toward results. Prompt convalescence may be confidently ex-
pected, and we may be sure that viscera will be saved that
would otherwise be lost.

In cases of appendicial abscess, the usual methods of drainage
are so satisfactory that nothing remains to be said; but in cases
in which the abscess is small, or is not found directly under the
line of incision, it is frequently much better to drain with a wick
passed through a stab incision to the outer side, so that the
primary incision can be completely closed. The stab incision is
small, and is made through thick tissues, so that there is practi-
cally no danger of hernia.

In treating these local infections of appendicial origin, and the
same is true of pelvic abscesses, it is frequently advantageous to
wipe out the cavity and the infected area with a weak solution
of the tincture of iodine. After the iodine has been thoroughly
applied, and the tissues wiped dry, the drainage wick can be in-
troduced and brought out through a stab incision, and, before
more pus will have formed than can be taken care of by the
gauze fluff, adhesions will have formed around the gauze to pro-
tect the general peritoneal cavity.

In a few cases I have had occasion to reopen the abdomen,
months or years after this operation, and have been surprised to
find how natural the culdesac looks. The peritoneum has re-
formed, the uterus is up in good position, no loops of intestine
are found adherent, and all the parts seem to be thoroughly
restored to a normal condition. In not a single instance have I
had any ileus to contend with.

125 South Grant Avenue.



A NOTE ON POSTPARTUM HEMORRHAGE.'

WITH TWO QUICK WAYS OF MEETING IT.

BY

DOUGLAS H. STEWART, M. D.,

New York.

An attentive and discriminating ear may sometimes distinguish
a certain tone in a speaker's voice which evidences that the man
is only uttering words, but the brain behind the voice has
no conception of the ideas expressed in those words. As an
instance we have but to recall medical student days and our

I Read at the Twenty-second Annual Meeting of the American Association of
Obstetricians and Gynecologists at Fort Wayne, September 21-23, 1909.



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STEWART: A NOTE ON POST-PARTUM HEMORRHAGE. 81

stumblings over physical diagnosis and its "percussion note*'
and ** pitch." How glibly we talked of high and low and how
we tried to persuade ourselves that we understood, as ^e repeated
what the books said! How we hammered on chest, thigh,
abdomen, walls and tables till our fingers were sore ! ^ How in
answer to eager questions, our teachers made things muddy by
explaining that ** pitch" had nothing to do with ''quality"; not
one had gumption enough to tell us to "sing the note."

Well, all through that time of darkness our words were clear
but our voices had the tone-quality alluded to and that quality
marked our utterances as mere "student-patter" of bright
sentences but dim understandings; of correct verbal explanation
and very limited mental comprehension.

The same old student-patter and the same old tone and
inflection may be found to-day when the average physician
speaks with assumed familiarity on the subject of post-partum
hemorrhage. A listener who has managed just one first class
hemorrhage of this sort, and who knows, and who knows that he
knows, how deep the accompanying shock is, will have conveyed
to his ear that peculiar impression of words, combined with his
mental concept, that the speaker never saw a genuine instance
of post-partum hemorrhage in his whole life. He may, however,
discover muQh grim humor in such statements as "ten minutes
were well spent in hand-sterilization," when the emergency that
he himself met gave him scarcely time to remove an overcoat,
and he may smile silently at the idea of any leisurely procedure
in face of a hemorrhage which he found, possibly, but little less
rapid than decapitation in a fatal issue. Death is possible even
though every facility, assistance, and management are within
easy reach; and it is accompanied by peculiar sadness inasmuch
as labor has been completed and a motherless child is left.

Treatment begins with precaution; and an excellent preventive
is a cupping glass to each breast. These should be at once
applied when the head is delivered, if the labor has shown any
symptoms of uterine inertia, or even if progress has been slow or
exhausting to the mother. The uterine contractions produced
are clonic and therefore simply reinforce nature's processes in a
natural way. I am informed that among savage peoples if
there is any delay in the delivery of the afterbirth the child, or
even another and older infant of some other woman, is at once
put to the breast. I have tried it several times but it should
never be combined with Credo's method. The one should, or
6



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82 STEWART: A NOTE ON POST-PARTUM HEMORRHAGE.

may be, used after the other but if both are used simultaneously
the placenta is expelled with force. Some of the membranes
are torn off, hence remain behind. This happened but once in
my practice and then through the enthusiasm of an assistant;
the placenta fairly jumped out of the vulva, examination showed
most of the membranes, or at least most of their hanging ends,
missing — and owing to the weak condition of the patient curet-
tage was not done for seventy-two hours; but then the dull wire
curet and the finger removed just about what might have been
anticipated. Strange to say there was no alarming or even
noticeable excess of bleeding and the uterus was well contracted.
The cupping glasses are good but they are nothing like so
prompt, neither are the contractions so powerful, as those
resulting from suckling a child. In other words they are sub-
stitutes used for reasons of availability and diplomacy.

Credo's manoeuvre has an established value but as some-
times misused it is unnecessary traumatism; it has a proper
time, place and mode of application, and it is something very
different from driving the clenched fist into a woman's abdomen
at the end of the second stage of her labor. If the squeeze of the
operator's hand but slightly reinforces t&e natural uterine con-
tractions, in such a manner that only the weight of the hand
rests on the fundus during the quiescent interval, and the
thumb and fingers execute a sort of rolling-kneading movement
during the active period then the results are usually excellent.
The point to be emphasized is that the Credo's method properly
applied is what is known by masseurs as "simple petrissage"
and it is never *' compound petrissage" or any other proceeding
which would either squeeze the uterus against the spine or cause
fatigue of the massaging hand; and, furthermore, the desired
uterine action bears no proportion to the force employed,
therefore petrissage is more effective than violence or force
which can only produce traumatism directly, and the issue
sought, only crudely.

Ordinarily there is a distinct advantage in giving the patient a
rest of forty-five minutes after delivery of the child, if she can get
so much repose, for nature sometimes intervenes, and during
this period watch, or have an assistant watch, the pulse primarily,
the uterus secondarily, and both carefully. A pulse rate under
105 evincing a tendency to fall means that the uterus will care
for itself. On the contrary a rate of 105 or over maintained for
ten minutes is the largest kind of a danger-signal. It means that



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STEWART: A NOTE ON POST-PARTUM HEMORRHAGE. 83

massage of the fundus and all appropriate means should be at
once initiated. It has been urged against allowing a little rest
to a an exhausted woman that it leads to a partial separation of
the placenta and the accumulation of blood behind it, but a
placenta generally does begin to separate partially and the
partial separation extends until complete; but I never have
heard that any hemorrhage visible or concealed, external or in-
ternal, could be very urgent, or large, without affecting the pulse.

Experience with the Rose bandage leads me to think that a
lax abdominal wall is an important factor in causing hemor-
rhage; as when this bandage is applied after ordinary labor,
there is nowhere near the amount or duration of flow that there
is without it. In post-partum hemorrhage it should not be used
until the danger is past and the uterus contracted. Its ad-
vantages are: it holds the abdominal organs in place, it pro-
duces necessary pressure on the nerve plexus along the aorta by
taking up the slack left by the disappearance of the pregnant
mass, it equalizes the abdominal circulation and probably
through this stimulates the abdominal brain into action and
thereby maintains firm uterine contractions.

It may not be generally known that an ounce of vinegar ad-
ministered by the mouth will result in a prompt and firm con-
traction of the uterus. Ergot works better on a full uterus,
vinegar on an empty one, otherwise the results are similar.
Should the patient be unable to swallow, then lift the fundus
against the anterior abdominal wall, rub and push the intestines
up, out of the way, and through the linea alba and into the sub-
stance of the uterine wall inject a hypodermic syringeful of
filtered vinegar. The process is quite easy and as to bad effects
I have never seen or heard of any. The abdominal wall is thin
and relaxed and of course easily manipulated, and ordinary
aseptic precautions are to be observed. Action upon the uterus
should begin in ninety seconds and should be progressive. As
soon as the patient can swallow administer the vinegar by the
mouth, and then the contractions should quickly become tonic.
This expedient is valuable in hemorrhage occurring some hours
after delivery. It does not necessitate the introduction of hand
or instrument into the parturient canal.

Should the emergency threaten while the accoucheur is in
actual attendance, and while he has everything aseptic, let him
take a small wipe, fasten it securely to a vnlsellum forceps, soak
it in chloroform, squeeze out the drip,^ introduce it up to the



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84 STEWART: A NOTE ON POST-PARTUM HEMORRHAGE.

fundus, give it a turn or two and then withdraw it rapidly or he
will have trouble removing it, so speedily does the uterine con-
traction follow that from seventeen to twenty seconds elapse
before definite results are manifested. Choloroform seems to
stimulate the uterus, to clot the blood, to make tampons in the
mouths of gaping bloodvessels and to squeeze those op>enings
shut, all at the same time.

In a severe case of post partum hemorrhage a man needs all
the expedients of which he has knowledge, and perhaps a few
additional ones. One he certainly cannot be too familiar with
and that is cording the extremities.

SUMMARY.

1. The term post -partum hemorrhage should be applied solely
to [a flow of blood after delivery, i,ooo c.c. or more in amount,
which blanches the lips, produces air hunger, and which gives
rise to the pulse symptoms of severe hemorrhage. Other bleed-
ings occurring under similar circumstances are properly named
''excess bleeding," *' threatened post-partum'' or "traumatic
hemorrhage*' as the case may be.

2. A good precaution is to allow the mother forty-five minutes
rest after delivery of the child.

3. A hemorrhage occurring some hours after delivery may be
checked by the administration of an ounce of vinegar by the
mouth. If this fails a hypodermic injection of the same, into the
uterine w^all is an efficient means of meeting the emergency.

4. A Rose bandage will hold the patient safe, after bleeding
has been checked.

5. Threatening or actual hemorrhage at the immediate com-
pletion of labor may be forestalled or checked by the application
of chloroform to the interior of the uterus, without the sticky
black gum consequent upon the use of MonsePs solution or other
iron preparations for the same purpose.

6. The writer simply desires to add to other more or less
valuable means two simple ones which have served him well, so
far at least, in dealing with this rare but always possible condi-
tion. However when it does occur it presents a picture which is
finely described by Withington of Boston in these words :

"If the bleeding is not stopped the patient dies at once, even
in the midst of the gratulations of her friends on the apparently
successful completion of her labor."

128 West Eighty-Sixth Street.



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wiener: hematoma of the abdominal wall. 85



A CASE OF HEMATOMA OF THE ABDOMINAL WALL
SIMULATING A DESMOID TUMOR.*

BY

SOLOMON WIENER, M. D.,

Assistant Adjunct Gynecologist, Mt. Sinai Hospital,

New York.

Although there are many varieties of tumor of the abdominal
wall, it is not common to meet with them even in a large hospital
service. Their diagnosis often presents very diflScult problems,
and it is by no means always easy even to determine whether
the tumor be intramural or intraabdominal.

According to Pfeiffer, who collected a series of 400 cases of
desmoid, this is by far the commonest variety of tumor of the
abdominal wall. He found that desmoids are seven times as
frequent in women as in men; 94.3 per cent, of them occur in
women who have bom children, and they are usually first
noticed after delivery or after some slight trauma. In 72 per
cent, of the cases they occurred below the level of the umbilicus,
and the majority were situated on the right side.

Hematomata of the abdominal wall, other than such occurring
during convalescence from typhoid fever and such as are due to
direct injury, are exceedingly rare. Taking these facts into con-
sideration, the following case becomes of considerable interest
from the view-points of pathogenesis and of diagnosis.

Mrs. Bessie V., aet. forty-two; no history of tuberculosis,
syphilis, or typhoid fever. Family history negative. Patient
had always enjoyed good health. Married twenty-seven years;
eight children; last child six years ago; labors normal and easy;
no miscarriages.

Menstruation regular every four weeks, lasting five to six days;
flow moderate. Last menstruation two weeks previously.
Six weeks before examination patient had slipped and fallen
on her back on a wooden floor. At that time she had slight
pain referred to the lower abdomen, but paid no further atten-
tion to it, as it soon subsided. For three weeks she had experi-
enced occasional dull pain and for several days had noticed
a swelling of the right side of the abdomen. There had been
no vomiting, no disability, no disturbance of urination or defe-
cation. She sought advice solely because of the presence of
a palpable tumor.

* Presented at the Section for Gynecology and Obstetrics, New York Academy
of Medicine, October 28, 1909.



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86 wiener: hematoma of the abdominal wall.

The patient was referred to the writer as a probable case of
fibroid tumor of the uterus, although there was some doubt as
to the diagnosis.

Examination revealed a stout woman in excellent general
condition, with no signs of organic disease. No fever. The
right lower quadrant of the abdomen bulged slightly. On pal-
pation there was a smooth, rounded, not very sharply defined
mass, about the size of a closed fist, extending from just below
and to the right of the umbilicus to just above Poupart's liga-
ment. It was firm, not elastic, not tender. When the patient
contracted her abdominal muscles, the mass became less distinct,
but was still palpable. It was slightly movable from side to
side, but not from above downward. It did not move with
respiration. Percussion over the mass gave a dull tympanitic
note. The thickness of the belly wall made palpation very
difficult and unsatisfactory.

On bimanual examination the mass was much more distinctly
palpable; it felt very hard, not elastic, not tender. If the patient
relaxed, it cauld be pushed down into the pelvis by the examiner's
abdominal hand; still it gave the distinct impression of being
between the layers of the belly wall.

The uterus was small, retroverted, freely movable; the
adnexa not distinctly palpable. There were moderate cysto-
rectocele and bilateral laceration of the cervix.

During six days' observation there was no change in the
size or consistency of the tumor. The preoperative diagnosis
was ** desmoid tumor.''

Operation. — Vertical incision made just within outer border
of right rectus muscle. After dividing the skin and superficial
fascia, the rectus sheath and aponeurosis of the external oblique
were bulged forward by a purplish mass underneath. The
tumor still felt solid, there was not the slightest fluctuation to
be obtained anywhere; it apparently infiltrated all surrounding



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 9 of 109)