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away with a renewal of bleeding and syncope; this may be repeated
until death occurs.

After a profuse hemorrhage one is intensely pale and of sort of
greenish tinge, the eyes are fixed in a glassy stare and pupils widely

* Read before the Louisville Society of Medicine, December 5, 1898.



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dilated, respirations are shallow and sighing, skin covered with a cold
sweat, legs and arms extremely cold, pulse small, soft, compressible,
fluttering or often can not be detected at all, heart very weak. When
such a dangerous condition is due to a visible hemorrhage, temporarily
arrest hemorrhage by digital pressure in the wound, lower the head^
and make compression on the femorals and subclavians so as to divert
more blood to the brain, apply artificial heat, inject hypo., brandy, and
strychnia (Vij gr.), and as soon as reaction begins, arrest hemorrhage
permanently by ligature.

Hemostatics used are (i) the ligature, (2) acupressure, (3) torsion,
(4) compression, (5) styptics, (6) the actual cautery, (7) forced flexion of
the limbs. The ligatures may be made of silk, catgut, etc., but they
must be made aseptic. The ligatures should be about ten inches
long; the vessel is drawn out with forceps and separated from surround-
ing tissues. Some use tenaculum to catch the vessel with, but forceps
are best in most cases, because the tenaculum makes a hole through
which blood may exude. Tenaculum best used when vessels lie in
hard tissues; tie with a reef knot both ends of the vessel. If an artery
is incompletely divided, tie on each side of the cut and entirely sever
the vessel between the ligatures. If bleeding comes from an artery
very close to its point of origin, tie the main trunk as well as the
bleeding branch, otherwise the clot will be too short and secondary
hemorrhage will be inevitable. Never include a nerve in ligating.

By means of torsion the internal and middle coats are ruptured
and the external coats twisted. It is a safe procedure, and is practiced
by many surgeons of high standing upon vessels as large as the fem-
orals.

Acupressure is pressure with a pin passed under a vessel (trans-
fixion), leaving a little tissue on each side between the pin and the
vessel. A needle can be passed under a vessel and a wire thrown over
the vessel and twisted (circumclusion); the needle can be inserted on
one side, passed through half an inch of tissue up to the vessel, be
given a quarter twist, and be driven in the tissues across the artery
(torsoclusion); some tissue is picked up on the needle, folded over the
vessel, and pinned to the other side (retroclusion). Acupression is
used for inflamed or atheromatous vessels, in sloughing wounds, and
where a ligature will not hold.

Compression is either direct or indirect; that is, in the wound or
upon its artery of supply ; compression and hot water, 120° F., will stop



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The American Practitioner and News. 49

capillary bleeding, and also that from superficial veins. The knotted
bandage of the scalp will arrest bleeding from the temporal artery ; long
continued pressure causes pain and inflammation. Chemicals are now
rarely used. In epistaxis we may pack with plugs of gauze saturated
with antipyrine. Bleeding from a tooth socket, pack with styptic
cotton, also in an incised urinary meatus.

Cold water or ice acts as a styptic by producing reflex vascular
contraction. Hot water produces contraction and coagulates albumin ;
the temperature should be from 115° to 120" F. A mixture of equal
parts of alcohol and water will often check capillary oozing.

The actual cautery is a very ancient hemostatic ; it is still used in
bleeding after removal of malignant growths, in continued hemor-
rhage from the prostatic plexus of veins, and to stop oozing after the
excision of venereal warts. We are driven to it in the "bleeders,"
that is, those persons who have a hemorrhagic diathesis, and who may
die from having a tooth pulled or from a scratch, etc.

Forced flexion is a variety of indirect compression; it will stop
bleeding, but will soon become intensely painful. If we fail to look
into a wound, we can not know what is cut; it may be only a branch
and not a main trunk. Ligate veins as you would arteries ; in a wound
of the superficial palmer arch tie both ends of the divided vessel. In
a wound of the deep palmer arch, enlarge the wound if necessary in
the direction of the flexor tendons, at the same time maintaining pres-
sure on the brachial artery ; if the artery can be caught by but can
not be tied over the point of forceps, leave the forceps on for four days.
If vessel can not be caught by forceps or tenaculum, insert a small
piece of gauze in the depth of the wound, over this a larger piece, and
keep adding over this bit after bit, each one larger than the one before,
until there is a conicle pad, the apex of which is against the extremi-
ties of the cut arch and the base well external to the palm ; bandage
each finger and thumb, put a piece of metal over the pad, also a com-
press in front of the elbow, flex the forearm upon the arm, wrap the
hand in gauze, place the arm upon a straight splint, apply firmly an
ascending spiral reverse bandage of the arm, and hang the arm in a
sling. The pad is left in place for six or seven days unless bleeding
keeps up or recurs. If bleeding begins again, ligate the radial and
ulnar. If this fails, we know that the interosseous artery is furnishing
the blood, and the brachial must be tied at the bend of the elbow ; if
this fails, amputate the hand. In primary hemorrhage, if the bleeding



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50 The American Practitioner and News.

ceases, do not disturb the parts to look for the vessel ; if the vessel is
clearly seen in the wound, tie it ; otherwise, do not, as the hemorrhage
may not recur.

When a man has delirium tremens, mania, or when he is a heavy
drinker, in these cases, always look for the vessel and tie it. When a
person is bleeding to death, arrest hemorrhage temporarily by digital
pressure in the wound, and apply above the wound a tourniquet or
Esmarch bandage. Bring about reaction, then ligate, but do not
operate during collapse if the bleeding can be controlled by pressure.
When a branch of a large vein is torn close to the main trunk, tie the
branch and not the main trunk ; apply practically a lateral ligature. If,
after tying the cardial extremity of a cut artery, the distal extremity
can not be found, even after a careful search, enlarge the wound and
firmly pack it. In bleeding from the internal mammary artery pass a
large curved needle holding a piece of silk into the chest under the
vessel and out again, then tie the thread tightly. In collapse due to
the puncture of a deep vessel, the bleeding having ceased, do not hurry
reaction by stimulants ; give the clot a chance to hold ; wrap the patient
in hot blankets if the condition is dangerous ; however, stimulate to
save life. In punctured wounds, as a rule, try pressure before using
ligature.

After a severe hemorrhage always put the patient to bed and elevate
the damaged part if it be an extremity or the head. A clot which
holds for twelve hours after a primary hemorrhage will probably hold
permanently, but even after twelve hours be watchful and insist on
rest. In bleeding from a tooth socket use ice ; if this fails, plug with
gauze infiltrated with tannin ; close the jaws upon the plug, and hold
them with Barton's bandage. If this fails, soak plug in MonsePs solu-
tion, and lastly use cautery. Pressure on the carotid and ice over the
jaw and neck are indicated ; it may be necessary to tie the common
carotid. A ruptured varicose vein requires a compress bandage from
the periphery up and the limb elevated. Pressure above a wound stops
arterial hemorrhage, but aggravates venous bleeding. In severe bleeding
from the ear, elevate the head and put on ice-bag over the mastoid ; give
opium and lead acetate, and if blood runs in the mouth, plug the
eustachian tube with a piece of catheter.

Subcutaneous hemorrhage demands that an incision be made and
ligation be performed. Bleeding from a cut urethral meatus requires
the insertion of styptic cotton and application of pressure. Moderate



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The American Practitioner and News, 5 1

bleeding from the urethra can usually be arrested by a hot bougie or
hot injections ; ice to the perineum does good ; if these means fail, per-
form an external urethrotomy and reach the bleeding point.
. Vaginal hemorrhage requires the tampon or the ligature. Bleeding
from the stomach is treated by the swallowing of ice, giving tannic
acid, dose twenty to thirty grains. Never give tannic acid and MonsePs
solution at the same time, as they mix and form ink. Opium is usually
ordered ; acetate of lead, opium, and gallic acid are favorite remedies,
and ergot is sometimes used ; give no food at all. Hemorrhage from
phthisis or bleeding from the lungs is treated by morphia hypo., by per-
fect rest, dry cups or ice over the aflfected spot if it can be located, by
ergot and gallic acid ; gallic acid aids coagulation.

Recurrent hemorrhage, called also consecutive, intermediate or inter-
current, comes on during reaction from an accident or operation ; that
is, during the first forty-eight hours, and is usually due to a badly ap-
plied ligature, or it may result from vascular excitement, or from hyper-
trophied heart, the jumping artery loosing the ligature. The Esmarch
apparatus is not unusually the cause. To lessen the danger of the
Esmarch apparatus, use a broad constricting band rather than a tube.
In any severe recurrent hemorrhage, open up wound at once and ligate.

Secondary hemorrhage may occur at any time in the period of
forty-eight hours after the accident or operation and the complete
cicatrization of the wound. Secondary hemorrhage may be due to
atheroma, to slipping of ligature, to the inclusion of a nerve, fascia or
muscle in the ligature, to sloughing, erysipelas, septicemia, pyemia,
gangrene, and to overaction of the heart. If during an operation the
vessels are found atheromatous, acupressure had best be used, or pass
a thread by means of a curved needle around the vessel, including a
cushion of tissue in the loop of the ligature to prevent cutting through
the vessel. One great trouble with atheromatous arteries is that their
coats can not retract ; another trouble is that the ligature cuts entirely
through them. If after an operation the pulse is found to be forcible,
rapid, and jerking, give aconite, opium, and low diet.

Hemorrhage from the prostate may follow the relief of retention of
urine, may be due to stone, inflammation, tumors, etc., or may arise
from traumatism, instrumental or otherwise. The color of the urine is
usually bright red, but if long retained in the bladder it becomes black
and often tarry ; the reaction is alkaline ; the clots when floated out are
large and without definite shape. In micturition the urine is clear or



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52 The American Practitioner and News.

only a little colored at the beginning, but becomes darker and darker as
micturition ends, at which time the flow may consist of almost pure
blood. In very small vesical hemorrhage the urine may be smoky ; the
microscope shows colorless and swollen corpuscles and many polygonal
cells. In urethral hemorrhage, blood comes independently of mic-
turition, or blood comes out first, and is followed by pure water.
Urethral hemorrhage arises from an acute urethritis, from an inflamed
stricture, from the passage of an instrument, or from some other trau-
matism. Intracranial hemorrhage may be either spontaneous or
traumatic ; in the vast majority of instances spontaneous hemorrhage
comes irom the lenticulo-striate artery and produces apoplexy. Trau-
matism during delivery is a not unusual cause of hemorrhage from
the middle meningeal artery.

A traumatic hemorrhage may take place (i) between the bone and
the dura (extra dural), (2) between the dura and brain (subdural), (3) in
the brain substance (cerebral). Extra-dural hemorrhage arises from
the middle meningeal, or more often from one of its branches ; it is
usually but not always accompanied by fracture ; in fact, in some cases
not even a bruise can be found. The accident may or may not cause
temporary unconsciousness, but even if it does, from this unconscious-
ness the patient almost always reacts, and there is a distinct period of
consciousness between the accident and the lasting coma, the coma being
due to a pressure from a continually increasing mass of extravasated
blood. If the main trunk or a large branch is ruptured, the period of
consciousness is short ; if a small branch is ruptured, the period of
consciousness is prolonged for hours, or perhaps for days. The pulse
becomes frequent, the breathing stertorous, the temperature rises, and
in compound fractures the pressure of the escaping blood may force
brain matter out of the wound. In treating extra-dural hemorrhage,
localize the clot not by the seat of the wound or contusion but by the
symptoms entirely, and trephine to find the bleeding vessel.

Subdural hemorrhage is usually due to depressed fracture and
rupture of the middle cerebral artery, or of a number of small vessels ;
the symptoms are identical with those of extra-dural bleeding. The
treatment is trephining at the first hemorrhagic point, turning out the
clot, ligating the bleeding point, elevating any depression of bone, and
draining and stitching the dura with catgut.

Rupture of a sinus usually arises from compound fractures or
during a brain operation. The treatment, if the rupture happens from



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The American Practitioner and News. 53

a fracture, is trephining, enlarging the opening, and pack with one large
piece of iodoform gauze, or catch the rent with hemostatic forceps, leav-
ing them in place for three or four days, or apply a lateral ligature and
elevate depressed bone. In rupture during operation, control hemor-
rhage by packing. In prolonged hemorrhage from leech bite, try
compression over a plug saturated with alum or tannin. If this fails,
pass under the wound a hair-lip pin and encircle it with a piece of
silk; if this fails, use the actual cautery. Umbilical hemorrhage in
infants requires pressure over a plug containing tannin, alum or gelatin
solution. If compression fails, pass hair-lip pins under the navel and
apply a twisted suture. If this fails, use the actual cautery.

Rectal hemorrhage requires elevation of the buttocks, insertion of
plugs of ice, ice to the anus and perineum, astringent injections
(alum), and the internal use of opium and acetate of lead. If these
means fail, plug the bowel over a catheter, or insert and inflate a Peter-
son bag or a colpeurynter, or tampon and use a T bandage. If the
bleeding persists, or if a considerable vessel is bleeding, stretch the
sphincter, catch the bowel and draw it down, seize the vessel and tie
it if possible ; if not, leave the forceps in place. Failing in this, the
actual cautery must be used. Vesical hemorrhage usually ceases
spontaneously, in which case the urine must be drawn oflf and the
viscus be washed out frequently with a solution of boric acid to pre-
vent septic cystitis. If blood-clots prevent the flow of urine, break them
up with a catheter or lithotrite and inject vinegar and water, a two-per-
cent solution of carbolic acid, or a solution of bicarbonate of sodium.
Perfect quiet is to be maintained, cold acid drinks to be given, ice bags
to be put to the perineum and hypogastric region, and opium with
acetate of lead, ergot or gallic acid to be given by the mouth. If the
hemorrhage is severe or persistent, perform a suprapubic cystotomy.
Renal bleeding requires ice to the loin, tannic acid and opium, gallic
and sulphuric acid, and perfect quiet. If the bleeding threatens life
and the diseased organ is identified, make a lumbar incision and suture
or perform a nephrectomy; if not sure which organ is diseased, perform
an abdominal nephrectomy. The use of a cystoscope will show from
which ureter blood is emerging.

In hemorrhage from the small bowel give acetate of lead and
opium, sulphuric acid, or MonsePs salt in pill form (3 grains), allow no
food for a time, and insist on a liquid diet for a considerable period.
If hemorrhage threatens life, do a celiotomy and find the cause ; if



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54 The American Practitioner and News.

ulcer exists, excise it. If violent hemorrhage follows injury, explore to
discover the cause. In bleeding from the large bowel, use styptic injec-
tions (ten grains of alum or five grains of bluestone to one ounce of
water). If bleeding is low down, use small amounts of solution ; if
high up, large amounts. Do not use absorbable poisons. In dangerous
cases perform an exploratory operation to find the cause.

Severe uterine hemorrhage (unconnected with pregnancy) requires
the tampon. Persistent hemorrhage due to morbid growths may require
removal of the tubes and appendages, ligation of the uterine and ovarian
arteries, or hysterectomy. Post-partum hemorrhage is often controlled
by ergot, hot injections, elevation of hips, the introduction of a hand
with or without ice, ice over the abdomen, etc.

LOUISVILI^E.



2Eleport5 of Societies.



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, December a, 1898, Frank C. Wilson, M. D., President pro tern., in

the chair.

Hydatiform Cysts: Report of Two Cases. Dr. T. S. Bullock: I
present these two cases not from the fact that they are unique, because
every doctor who does much in obstetrics sees cases of this kind, but
from the fact that they are very rare, occurring only once in every three
to four thousand cases, and because of the variety of theories and the
mystery that formerly surrounded the etiology and pathology of such
conditions — for these reasons I deemed the specimens of sufficient
interest to be brought before the Society.

These are instances of what is known as the vesicular mole or
hydatiform cyst, which we now know is due to cystic degeneration of the
chorionic villi. In the specimens before you the cysts vary in size from
a millet seed to that of a small egg. This condition occurs most often
in multiparae between the ages of thirty and forty years. The moles
are ordinarily extruded between the third or sixth month of utero-
gestation. The symptoms are hemorrhage, the passage of these little
cysts, and the distension of the uterus being out of all proportion to
the period of gestation at which the patient has arrived. Sometimes

« Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.



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The American Practitioner and News. 55

they are not extruded, but the term of gestation is very much prolonged,
and these villi penetrate the walls of the uterus and cause death from
hemorrhage into the peritoneal cavity from rupture of the peritoneal
coat, or a portion may be left in the uterine cavity and cause death from
sepsis. These cases are interesting from the fact that in olden times
each vesicle was supposed by some authors to be a separate fetus ; thus
Ambrose Pare reports that a certain Countess Margaret gave birth to
three hundred and sixty-five children at one time, one hundred and
eighty-two males and one hundred and eighty-two females, the odd one
being an hermaphrodite. The Catholic priests of olden times admin-
istered the rite of baptism to each separate cyst. If that had been car-
ried out in the two cases the specimens of which are before you, the
Father would have had a long job in one case, particularly as there are
many hundreds of these little cysts.

The first case was seen in consultation with Dr. Borgman, and the
mass before you represents but a small portion of the material extruded
spontaneously from the uterine cavity.

The second case is one seen at the clinic of the University of Louis-
ville; the woman presented herself last Wednesday with a history
which was extremely interesting. She had disturbance of respiration
and of circulation, the heart was so rapid and the respiration so dis-
turbed that it might have been suspected, except for the lack of protru-
sion of the eyeballs, that she was suflFering from exophthalmic goitre.
She had been losing blood for some time, and the diagnosis of the real
condition was not made because she had not been passing any of these
little cysts, and while we had seen her only once, we deemed it neces-
ary to empty the uterus immediately. Dr. Anderson introduced a
bougie and tamponade, and in six hours this enormous mass was passed
from the uterus. The mass contains some of the largest cysts that I
have ever seen in a condition of this kind. When these cysts are
retained, as already stated, the gestation is prolonged, and then they
are nearly akin to cancerous cases, and the patient often loses her life
in this way. This woman is still passing some of these little cysts.

The diagnosis is not always easy, the three prominent symptoms
being, first, the loss of blood from the uterus ; second, enormous disten-
sion of the uterus, and third, pathognomonic evidence being the
passage of some of these small vesicles. This distension is most
marked when the degeneration begins, while the chorion is shaggy.
At this time it is called the chorion laeve, in distinction from the



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56 The American Practitioner and News.

chorion frondosum, and I take it this is what has occurred in these
two cases, the degeneration occurring while the whole surface of the
chorion was covered with these villi.

The indications are, of course, to immediately empty the uterus,
but it is very important to be careful how this is carried out ; it is bet-
ter to depend on the tampon and not to introduce into the uterus any
instrument, as the uterine walls are very much thinned and there is
danger of rupture.

Ordinarily a fetus is found, but in these cases there was no evidence
of an ovum, the entire fetal products having degenerated into these
vesicles. The condition is recognized as a true mole, and depends
entirely upon pregnancy ; it can not occur without it.

I was somewhat surprised in looking up the subject that it was so
rare in its occurrence. For instance, Mme. Boivin reports only two
such cases in twenty thousand pregnancies. Hirst, of Philadelphia,
says he has only seen two cases in an experience of ten years. These
are the first and only two I have seen. Both women were multiparae,
and the condition, as previously stated, is more likely to occur in such
patients than in primiparae.

Discussion. Dr. W. O. Roberts : Counting the two specimens before
us, I have seen three cases of this kind. Some years ago I had a case
in a young lady eighteen years of age. She married, and soon after-
ward her menses stopped; she was thought to be pregnant; she vom-
ited almost constantly, beginning directly after marriage and continu-
ing until the sixth month ; she was worn almost to a frazzle, and I
decided that it was advisable to bring about a miscarriage. Dr. Scott
saw the case in consultation, and he soon became convinced of the same
thing. Labor was induced, and she passed an enormous mass like the
second one shown by Dr. Bullock.

Dr. J. G. Cecil : I have seen one or two other specimens of this
kind, but have never had such a case in my own practice. They are
extremely unusual and therefore interesting.

Dr. E. Speidel : I am proud to say that in my limited experience I
have had one well-marked case of hydatiform cysts. The woman was
the patient of another physician ; he could not be found at the time,
and I was called in. When he was finally located, I was retained in
the case as a matter of courtesy. Another physician, an expert obstet-
rician, was called in the case later on because of some complication



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The American Practitioner and News. 57

Manual dilatation of the os was intrusted to the other physician, and
he becoming tired, I was asked to relieve him. I finally got my entire
hand into the uterus, and then noticed that I could feel no fetal ele-
ments, and upon removing my hand from the uterus I found in the
palm of my hand a few small cysts. I stepped aside and showed them
to the other physician, and told him I thought hydatiform degeneration
of the chorionic villi was the proper diagnosis, and such it proved
to be.

Amputation of the Leg for Ttiberculotis Bone Disease, Dr. W. O.
Roberts: A boy was recently sent to me from West Baden, Indiana.



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