Part 29 (1/2)
_Treatment._ Our treatment of these cases will not vary essentially from that of exhaustion from haemorrhage under the ordinary circ.u.mstances; the patient must be placed with her head low, and as soon as she is able to swallow, a little hot brandy and water, or ammonia, should be given to rouse the circulation to a sufficient degree of activity. If the uterus be still flaccid and disinclined to contract effectively, a dose of ergot will be advisable, and the abdomen should be tightly bandaged with a broad towel. When the powers of the circulation have rallied somewhat, a little plain beef-tea will frequently prove very grateful and appear to revive her more powerfully than even the stimulants above-mentioned; and now, as it is of the greatest importance to calm the irritability of the brain and nervous system, we must proceed to the use of sedatives. Of these, opium and hyoscyamus have the preference, the latter especially so, from its not being liable, like opium, to derange the stomach, or contract the bowels.
Moreover, where the exhaustion is very alarming, it is not always easy to control the sedative action of opium within due bounds; and in such cases we are sometimes apt to produce so much sopor, as to render it even difficult to rouse the patient. For this reason, the combination with a diffusible stimulant is always desirable: five grains of camphor and of extr. hyosc. in two pills, form, perhaps, the best and safest sedative which can be given; these may be repeated every hour, and then at longer intervals of two or more hours, until sleep has been produced. Sleep, in cases of this kind, is of the greatest importance, and produces the most favourable change in the patient's condition; the intense headach and irritability of the mind, of the sight, and of the hearing, all abate; the circulation becomes calmer, the pulse more full and soft, the heat of the body more equable; in short, the whole nervous system is returning to a more natural and regular state of action, the stomach is more capable of receiving and digesting its food, the bowels are more manageable, and we may now venture to remove a state of constipation, if present, or any morbid intestinal contents without running the risk of bringing on diarrhoea and increasing the debility.
We rarely find that the convulsions return when once the patient has enjoyed the calm of a sound and refres.h.i.+ng sleep, and consider the victory as more than half gained when this favourable state has been produced. The laxative should be of the mildest form, such as will merely excite the peristaltic action of the intestines without increasing their secretions; for this purpose a warm draught of rhubarb manna with hyoscyamus, or castor oil guarded by a little liq. opii. sed., will be the safest. Food of the blandest and most nutritious quality should be given in small and frequently repeated doses; it is important not to load the stomach much or suddenly, for vomiting is easily produced, and when once excited, the stomach becomes so irritable as to be scarcely capable of retaining any food whatever.
Where, on the other hand, several hours have pa.s.sed, not only without sleep but without even a temporary state of quiet; where the headach alternates with restless delirium; where the medicines and nourishment have produced little or no effect, or have been rejected by vomiting; where the pulse becomes quicker, and the debility increases, we have not only to dread a return of the fits, but that the stage of actual sinking is at hand.
”It would perhaps,” says Dr. Marshall Hall, ”be difficult to offer any observations on the nature and cause of excessive reaction; but it is plain that the state of sinking involves a greatly impaired state of the functions of all the vital organs, and especially of the brain from defective stimulus. The tendency to dozing, the snoring and stertor, the imperfect respiration, the impaired action of the sphincters, the defective action of the lungs, and the acc.u.mulation of the secretions of the bronchia, the feeble and hurried beat of the heart and pulse, the disordered state of the secretions of the stomach and bowels, and the evolution of flatus, all denote an impaired condition of the nervous energy.” (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.)
_Hysterical convulsions_ scarcely deserve the name of puerperal convulsions, being liable to occur under circ.u.mstances quite independent of the puerperal state; they rarely occur during the process of labour itself, but are chiefly observed during the last few weeks of pregnancy, and the first week or so after labour, especially when the milk is coming on.
_Symptoms._ The patient is of a nervous hysterical habit; ”she is either still very young, or is of a slim and delicate make; the face is pale and interesting; she has full blue eyes and light hair, and was always of a highly sensitive const.i.tution; the pulse is quick, small, and contracted; the temperature of the skin is rather cool than otherwise; her spirits are variable, fretful, and anxious; she starts at the slightest noise, cannot bear much or loud talking, and misunderstands or takes every thing amiss.
During her slumbers, which are short, there are slight twitchings of the eyes and mouth, and in her sleep the eyes are in constant restless motion, and she frequently starts. She complains of sickness, and has frequent calls to pa.s.s water, which is very pale; slight rigours alternate every now and then with flus.h.i.+ng, and she is easily tired, even by trifling pains, and dozes a good deal during the intervals. She is excessively sensitive, even to the most gentle and cautious examination; the os uteri remains thin, hard, tense, and painful to the touch longer than is usually the case. The ordinary tension and stretching of the os uteri at the termination of a regular contraction is attended with much more pain, and with a peculiar feeling of la.s.situde, although uncomplicated with any rheumatic affection. The pains follow no regular course, being sometimes stronger, at others weaker, and frequently cease entirely for considerable periods. The uterus has a great disposition from the slightest irritation, to partial and spasmodic contractions.” (Wigand, _Geburt des Menschen_, vol. i. p. 164.)
Before the fit the patient usually pa.s.ses a large quant.i.ty of colourless and limpid urine; she has oppression at the stomach, anxiety, difficulty of breathing and palpitation, with globus, sobbing, and other hysterical symptoms. There are not those precursory symptoms of cerebral congestion as mark genuine epileptic puerperal convulsions; the headach is neither so severe, nor is it in the same place, being usually at the temples and across the forehead; the face is rather pale than flushed, and when the fit begins, we see little or none of the convulsive twitching among the small muscles, as is the case with an epileptic attack; the face is less distorted, but the large muscles of the trunk and extremities are much more violently affected; the patient struggles furiously, and in severe cases has more or less of opisthotonos; she screams, and never appears to lose her senses so entirely as in the epileptic form; her raving may generally be controlled to a certain extent by suddenly das.h.i.+ng cold water in her face, and speaking loudly and sharply to her; at any rate it instantly produces a deep and sudden inspiration, which is frequently attended with a prolonged hooping sound; this is followed by sobbing, gasping, choking, and the ordinary phenomena of an hysteric fit, but the convulsions themselves are usually arrested more or less by this application: we hold the effects of cold water to be one of the best diagnostics of the disease from epilepsy, in which the patient is entirely insensible to such impressions.
A similar fact is observed during v.a.g.i.n.al examination; the patient seems aware of our intention, and resists in every possible way.
”The patient, after the fit, can for the most part be roused to attention or will frequently become coherent so soon as she recovers from the fatigue or exhaustion occasioned by her violent struggles; and though she may lie apparently stupid, she will nevertheless sometimes talk or indistinctly mutter. After the convulsion has pa.s.sed over, she will often open her eyes and vacantly look about, and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head in the clothes.” (Dewees's _Compend. Syst. of Midwifery_, -- 1240.)
When sufficiently recovered to be capable of swallowing, she should sip some cold water, or what is still better, take a dose of spiritus ammoniae foetidus in water; this soon produces copious eructations from the stomach, which are followed with much relief. Where there is a disposition to vomiting, and other evidences of a deranged stomach, it should be encouraged by some warm water, chamomile tea, &c. The bowels are almost always in an unhealthy state, which frequently produces much irritation, and in plethoric habits so much tendency to cerebral congestion as to endanger even an attack of the epileptic convulsions. One or two doses of a pretty brisk purgative should, therefore, be given, and if there be still heat or pain of head, a bleeding may be required.
Under ordinary circ.u.mstances hysterical convulsions are by no means dangerous, and beyond a little fatigue and exhaustion, the patient recovers from them almost immediately.
CHAPTER XII.
PLACENTAL PRESENTATION, OR PLACENTA PRaeVIA.
_History.--Dr. Rigby's division of haemorrhages before labour into accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.-- Turning.--Partial presentation of the placenta.--Treatment._
There are few dangers connected with the practice of midwifery which are more deservedly dreaded, and which are wont to come more unexpectedly, both to the patient as well as to the pract.i.tioner, than that species of haemorrhage which occurs in cases where the placenta is implanted either _centrally_ or _partially_ over the os uteri. Well has a celebrated teacher observed, that ”there is no error in nature to be compared with this, for the very action which she uses to bring the child into the world is that by which she destroys both it and its mother.” (Naegele, _MS.
Lectures_.) In other words, where there is this peculiar situation of the placenta it becomes gradually detached, either in proportion as the cervix expands during the latter months of pregnancy, or as the os uteri dilates with commencing labour, and is thus unavoidably attended with a profuse discharge of blood, which generally increases as the dilatation proceeds.
The peculiar feature of this species of haemorrhage, necessarily accompanying the commencement of every labour where the placenta is implanted over the os uteri, was first fully described in this country in 1775, by the late Dr. Rigby, in his cla.s.sical _Essay on the Uterine Haemorrhage which precedes the Delivery of the full-grown Foetus_, a work which has been justly looked upon, both in England and the Continent, as the great source to which we are indebted for our practical knowledge in the management of these dangerous cases.
_History._ There is abundant evidence to prove the sudden attacks of haemorrhage during pregnancy, attended with circ.u.mstances of great danger to the life of the mother and her child, were known from the earliest times, and especially noticed by Hippocrates where he says, ”that the after-burden should come forth after the child, for if it come first, the child cannot live, because he takes his life from it, as a plant doth from the earth.” (_De Morbis Mulierum_, lib. i. quoted by Guillemeau.)
Hippocrates, therefore, evidently supposed that this presentation of the placenta at the os uteri was owing to its having been separated from its usual situation in the uterus, and fallen down to the lower part of it.
This view has been closely adopted by Guillemeau, to whom we are indebted for having called our attention to the above pa.s.sage. He has devoted his fifteenth chapter[140] to the management of a case where the placenta presents, and shows that ”the most certain and expedient method is to deliver the patient promptly, in order that she may not suffer from the haemorrhage which issues from the uncovered mouths of the uterine veins, to which the placenta had been attached; that, on the other hand, the child being enclosed in the uterus, the orifice of which is plugged up by the placenta, and unable to breathe any more by the arteries of its mother, will be suffocated for want of a.s.sistance, and also enveloped in the blood which fills the uterus and escapes from the veins in it which are open.”
The operation of turning, which had been newly practised by his teacher, Ambrose Pare, and still farther brought into notice by himself, at that time formed a great aera in midwifery, for it furnished pract.i.tioners with a new and successful means of delivering the child in cases where urgent danger could only be avoided by hastening labour; hence, therefore, in all cases of profuse haemorrhage coming on before delivery, it was a general rule, if the case became at all dangerous, to turn the child.
Guillemeau's explanation of the nature of placental presentations was still more explicitly adopted by Mauriceau, La Motte, and many others.
Mauriceau invariably speaks of the placenta, when at the os uteri, as ”entirely detached;” and adds that ”even a short delay will always cause the sudden death of the child if it be not quickly delivered; for it cannot remain any time without being suffocated, as it is now obliged to breathe by its mouth, for its blood is no longer vivified by the preparation which it undergoes in the placenta, the function and use of which cease the moment it is detached from the uterine vessels with which it was connected: the result of this is the profuse flooding which is so dangerous for the mother; for if it be not promptly remedied she will quickly loose her life by this unfortunate accident.” (Vol. i. p. 332, 6th ed.) He also adds, ”it must be observed that the placenta, which presents, is nothing more than a foreign body in the uterus when it is entirely separated,” (p. 333,) ”for when it comes into the pa.s.sage before the infant, it is then totally divided from the womb.” (_Chamberlen's Transl._ p. 221. 8th ed.) In the sixteen cases which he has detailed, he has distinctly mentioned the fact in thirteen that the placenta was _entirely separated_ from the uterus, and presented at the os uteri. In two of these he has expressly stated his conviction that the placenta had been detached from the uterus, by the mother having been exposed to a violent shock, when the cord was shortened from being twisted round the child.
These facts prove that Mauriceau, considered presentations of the placenta to arise solely from its having been separated by some _accident_ from the fundus, and fallen down to the os uteri.
Dr. Robert Lee, in his ”Historical Account of Uterine Haemorrhage in the latter Months of Pregnancy,” (_Edin. Med. and Surg. Journal_, April 1839,) has omitted all mention of this circ.u.mstance, and from the account which he has given of Mauriceau's observations, would infallibly lead his readers to suppose that Mauriceau was fully acquainted with the real nature of these peculiar cases. Thus, he commences with saying, ”The symptoms and treatment of cases of placental presentation are here accurately described, and in all cases of haemorrhage from this cause he recommends immediate delivery;” and again, he observes, ”The rules for the treatment of these cases are laid down with the greatest precision. When the placenta was entirely separated, then only did he consider it as a foreign body, and recommend its extraction before the child.” The student would be led by such a statement to suppose that Mauriceau did not consider the _entire separation of the placenta_ as the most usual occurrence in these cases, and will therefore naturally infer that in the majority of cases of placental presentation, he recognised the implantation of the placenta upon the os uteri. That such was very far from the case, we have already shown by quotations from various editions of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of placenta praevia from Mauriceau, and has given a short summary of them. Out of the thirteen cases in which Mauriceau has distinctly mentioned that the flooding had been caused by the entire separation of the placenta which presented, Dr. Lee has noticed it in only three; and in one of these he has reversed the expression by saying, ”placenta presenting and entirely detached:” thus leading his reader to infer that the placenta had presented at the os uteri, but had become detached from it. Nor is the case (No. 423,) to which Dr. Lee has referred ”as a proof that Mauriceau, was aware of the fact, that the placenta had not been wholly detached from the uterus,” at all tend to show that he had any idea of the placenta being implanted upon the os uteri.
By stating that ”Mauriceau has also recorded the histories of thirty-seven cases of uterine haemorrhage in which the placenta did not present, but had adhered to the upper part of the uterus and been accidentally detached,”