Part 25 (1/2)
These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the haemorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the acc.u.mulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from haemorrhage, perhaps, without any blood having issued externally: this is the _internal uterine haemorrhage_, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quant.i.ty of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh acc.u.mulation of blood in its cavity.
_Treatment._ So long as the inertia or atony of the uterus continues without any symptoms either of external or internal haemorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, ”in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri.” (_Sur les Pertes de Sang_, 1776.)
We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a gla.s.s of wine may be given with good effect. If, however, haemorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.
In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p.
330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the haemorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the haemorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure.
If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the _shock_ which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such _shocks_ may be produced by using another wet napkin to the v.u.l.v.a, and a third to the sacrum and loins; an a.s.sistant should remove them in the order in which they have been applied, and dry the skin, for a repet.i.tion of the remedy, if necessary.
A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen.
This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of haemorrhage:--”Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased--a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock.” (_An Account of some of the more important Diseases belonging to women_, by Robert Gooch, M. D.)
Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest a.s.sistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding.
These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel a.s.sured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132]
It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal haemorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be pa.s.sed, to dislodge the clots, and a.s.sist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel.
Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother's breast. Under no circ.u.mstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child.
To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents.
If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a gla.s.s of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circ.u.mstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refres.h.i.+ng to the patient; it can also be taken in larger quant.i.ties, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, ”when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circ.u.mstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the haemorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the const.i.tution has suffered by the haemorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the const.i.tution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting.”
When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the v.a.g.i.n.a, upon the removal of which, the discharge will cease.
The application of the child to the breast is not less valuable for preventing any return of the haemorrhage than for stopping it in the first instance: we are _never_ perfectly secure against haemorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and haemorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a pract.i.tioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.
There is a form of haemorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse haemorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. ”I had now witnessed,” says Dr. Gooch, ”two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse haemorrhage had nevertheless occurred: let me be understood--after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes haemorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude haemorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the haemorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident.” This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen.
CHAPTER VII.
INVERSION OF THE UTERUS.
_Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.-- Chronic inversion.--Extirpation of the uterus._
The uterus is liable, although rarely, to a peculiar displacement called inversion, where the fundus is forced down into the cavity of the uterus, and so through the os uteri into the v.a.g.i.n.a; or where the whole uterus is turned wrong side outwards, the fundus appearing at the os externum, the former being the _partial_, the latter the _complete_ inversion: in the latter it is not only the entire uterus which is inverted, but it is also the v.a.g.i.n.a, so that the whole ma.s.s which the uterus forms at the os externum is attached to the inverted v.a.g.i.n.a as by a hollow pedicle, and is encircled by the os uteri close to the l.a.b.i.a; the external surface of the ma.s.s is the inner surface of the uterus.
As it is impossible for the fundus to descend through the os uteri when this is not dilated and open, it is evident that, except in certain cases of polypus, inversion of the uterus can only take place immediately after delivery. If, at this moment, especially when the uterus has been too suddenly emptied of its contents, any force be applied to the fundus, it may be easily pushed down into the cavity, or, by the continued action of that force, the fundus may be carried through the os uteri or even through the os externum.
_Causes._ Where this force has been applied externally, it may be produced by violent straining during the last pains, violent efforts, as coughing, vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which the abdominal muscles are put into powerful action. Where, on the other hand, it has been applied from within, it may arise from improper attempts to extract the placenta before the uterus was sufficiently contracted; where the cord has been unusually short, or twisted round the child, or where the patient has been suddenly surprised with violent pains, and the child dashed upon the floor before she could reach her bed, by which means the cord has received a violent jerk, or has been even broken.
It has been very much the habit to attribute inversion almost solely to these latter causes, and that, except where it takes place from the shortness of the cord, or the sudden expulsion of the child whilst the mother is in the erect posture, it must almost necessarily be a result of improper pulling at the cord on the part of the pract.i.tioner: the cases on record, however, go to prove that, in by far the majority of instances, no force of this sort had been applied to the fundus; and in those instances where the child has been dashed upon the floor and the cord broken (some six or seven of which have at different times occurred under our own notice,) the fundus has not once been pulled down, although the force applied to it must have been very considerable, since the very cord which had thus given way to the weight of the child resisted afterwards, on more than one occasion, a considerable effort which we made to break it. In by far the majority of these cases, the cord has given way nearly at the same spot, viz. about three inches distance from the umbilicus, apparently justifying the inference, that it was weaker here than elsewhere. Another reason why the fundus should not have been pulled down by the weight of the child might be stated, viz. that the placenta being at that moment above the brim of the pelvis, the direction in which the strain was made upon the cord (viz. in that of the outlet, or downwards and forwards,) was not much calculated to affect the fundus.
”The practice of pulling too early and violently at the cord,” says Dr.
Radford, ”after the expulsion of the child, before the uterus has contracted, so as to detach and expel the placenta, has been generally considered as the cause of inversion; but we know that the accident happens before any force has been applied to the funis. In case fourth, the descent was so rapid and forcible through the os externum, that it would have been quite impossible to have resisted the unnatural action by which the organ was carried down. It has occurred when the patient was delivered of a dead child, the funis so putrid as to break with a slight effort. It has been found before the cord was separated, and the child given to the nurse. In the practice of Ruysch, this circ.u.mstance took place after he had extracted a dead child.”[133]