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BY ROSE TALBOTT BULLARD, M.D., LOS ANGELES, CAL. As so large a percentage of post- of a few such cases may therefore be partum hemorrhages is due to atony of interest. of the uterus, we are too much in- I will take as a text a truism from clinei to direct our attention to r eans an article by Commandeur (L'Obfavoring its contraction, neglecting stetrique, July, 1900): "If there is careful exploration to definitely locate persistent hemorrhage, when the the cause in the individual case. A uterus is well contracted and does not patient recently came under my ob- present zones of inertia, a tear of the servation, with a deep bi-lateral lac- soft parts must exist. In these cases eration of the cervex,
attended one should always palpate the birth in confinement by physician canal from the vulva to the contracof high standing another city, tion ring.” who
gave history of having We will begs at the vulva. A had the most profuse hemorrhage the laceration of the vestibule opening doctor had ever seen, and yet no local the deep venous plexuses about the examination was made beyond the urethra would seem especially easy to perineun..
find and it is if you look for it, but In the deep tears of the cervix and as the parts are bathed with blood, upper vagina we encounter the pos- we may assume that the hemorrhage sibility of an immediate fatal hemor- is of uterine or vaginal origin and rhage, furnish a most favorable field fail to discover the source so for a profound sepsis, or these hav- at hand. ing been escaped, we have still to Case I. November 10, 1897, I atthink of a sub-acute infection and the tended Mrs. B., aged 22, primipara. remote results of lacerations which Just as the vertex became fixed under heal by granulation with tardy involu- the pubes, bleeding was noticed antion, distortion of structures and teriorly, which became profuse on the painful cicatrices. The consideration birth of the head. Pressure was made
*Read at the Southern California Medical Society. San Diego, Cal., May 2, 1901.
with gauze while waiting for the shoulders. After delivery a törn surface was found extending from the clitoris to the meatus with blood welling up freely and allowing little opportunity to see except for an instant after pressure was removed. The bleeding showing no tendency to diminish under pressure, ligation was first tried, but with almost no benefit.
I then proceeded to suture; as the tear involved the upper border of the meatus, anu was deep, a catheter
introduceu into the urethra and left in position to obviate possibility of closing it; two catgut sutures controlled the bleeding at once. The mother was about the average in size; the child weighed 914 pounds, the head being large and unyielding. Little attention is paid in obstetric literature to this accident, but its gravity is attested by the fact that fatal cases have resulted :rom failure to recognize and properly treat it. I would emphasize the ease with which the bleeaing may be controlled by suture.
As etiological factors in the production of tears of the vagina we have been taught to consider primiparity, the age of the primipara, malpositions, instrumental or other intervention and unusual size of the infan.. Yet they may occur at the most unexpected times, illustrated by the next case.
Case II. January 28, 1898, I attended a Chinese woman, primipara, aged 19, of medium build. First stage, twelve hours; although the vagina was narrow, it did not excite any concern as bag of waters was present, only rupturing at mouth of vagina, and the labor was not precipitous. In the second stage I retarded progress for some time, hoping to prevent external tear, and received the commendation of an ignorant neighbor (my only assistant) because of we excellent care I was giving the patient. My pride
fell, however, when, on the birth of the child an alarming hemorrhage occurred.
The placenta quickly followed and Es the uterus contracted well, I knew there must be a tear and attempted to control bleeding by tamponing with gauze while waiting for assistance. The tampon, which was renewed several times, was not well placed and much blooa was lost. On the arrival of Drs. E. A. Praeger and F. D. Bullard, the patient was placed across the bed and with speculum and tenacula, we with difficulty, on account of the continued hemorrhage, made out a transverse laceration of the upper vagina, involving the posterior lip of the cervix, and extending laterally and downward
both sides, the vaginal mucous membrane seemed then to have been pusned forward by the head and torn loose from most of the posterior vaginal wall. The patient was by this time almost pulseless and Dr. Praeger wisely advised to tampon rather than to attempt suture. A strip of iodoform gauze was passed into the uterus, which remained well contracted; the vaginal mucous membrane was raised into place and the vagina firmly packed with iodoform gauze, effectually controlling the bleeding. This was removed thirty-six hours later. There was no local inflammation; wounds had healed by the ninth day. As evidence that the scars offered no obstruction, will state that a child was born to her one and one-half years later, before she had time to call a physician.
Case III. September 30, 1900, I was. called to Mrs. M., primipara, aged 21. Pains all day, becoming more severe avier 6 p.m. Membranes ruptured at 12 m., after which pains every five to seven minutes, but not very strong. October 1, 6 a.m., os nearly dilated, but head not fixed. Usual efforts by medication, baths and posturas treatment were made to increase efficiency
of pains which continued at intervals of three to five minutes, but without progress. The heart sounds of the child failing, the patient was placed on table at 2 p.m., anesthetized by Dr. F. D. Bullard, and although cervix was not completely dilated I delivered by forceps, with considerable difficulty, a child weighing nine pounds. There was profuse bleeding and I found on the right side a laceration of the cervix extending into the vagina, on the left a laceration of the cervix only. Five sutures were at once introduced on the right and two on the left side. Aseptic ergot and strychnia gr. 1-20 were given hypodermatically. As the uterus had not contracted strongly during labor, fearing relaxation, and wishing to conserve all the blood possible, as much had been lost, I resorted to the device recommended for atony by Arendt in 1898 of drawing down the uterus with vulsellum forceps in anterior and posterior lips. several pulls will produce uterine contractions and prevent further bleeding, but Schwertassek (Centralbl. fued Gynaek No. 7, 1900,) observed renewed hemorrhage on relaxing tension and recommended that the traction be continued a long time. I therefore left the forceps on the uterus and, as there was some leakage between edges of wound of vagina, a strip of gauze was passed into the uterus and the vagina tamponed, thus compressing the veins in the cellular spaces of the pelvis and preventing the formation of a hematoma. The fundus watched and light traction on the cervix continued for four or five hours; there was no further bleeding. Gauze was removed in thirty-six hours. Recovery uneventful. Four months later, on examination the cervix did not show that it had been lacerated and there was only a fine linear scar on the side of the vagina.
The number of expediments resorted to in the last case may indicate a lack of confidence in
any of the methods. I think the patient might. have done just as well without the use of the vulsellum forceps, but having observed the effect of traction on. the uterine vessels in vaginal hysterectomy I felt an added security in having the forceps there. Compression of the aorta should have been made to reduce the hemorrhage while the suturing was being done, but was neglected.
Treatment depends upon the site of ·the tear and is by suture or tampon, each method having its advantages and disadvantages. The suture is ideal where it can be made to include in its grasp the extent of the bleeding surface, a condition which obtains in laceration of the cervix or the lower half of the vaginal wall. In the superior part of the vagina, however, the tear extends into the broad ligaments and opens up the vessels in the cellular tissue, which cannot be closed by superficial sutures of the vaginal wall. Here the tampon is preferable to controi bleeding by pressure; however, if the urgency of the case does not forbid, I think better results will be achieved by the introduction of a few sutures even in this instance, drawing the edges of the mucous membrane together, thus minimizing the extent of raw surface and the resulting scars.
The cases are not unique, but show the importance of always being prepared
for such emergencies, carrying gauze, speculum and vulsellum forceps that in case of hemorrhage the parts may be inspected, and the necessary treatment, either suture or tampon, applied without jeopardizing the patient's life by delay.
245 Bradbury Block.
INTRA-UTERINE INFECTION BEST TREATED BY INTRA
BY 0. D. FITZGERALD, M.D., LOS ANGELES. This is one of the most ancient of moderate pressure the fluid did not so gynecological usages, advised and enter. Hennings' experiment coinpracticed by Hippocrates some twen- cided. Klem could make the fluid ty-two hundred years ago, for medi- pass through the fallopian tubes only cating the interior of the uterus or on great pressure. Palmer, on “The cleansing it. Subsequently it was Inflammatory Affections of the used by others amongst the ancients, Uterus," in "System of Gynecology," and later on py the eminent French by Mann, tells of having made simisurgeon Ambrose Pare in the six- lar experiments by constricting with teenth century; within the past forty a stout cord the cervix around a tube years it has been quite extensively fitted to a strong air-tight syringe. employed. There is scarcely a thera- No fluid could be forced through the peutic resort so old or one which has oviducts unless they
were dilated. passed through many phases of These experiments were in the dead practice-to be forgotten, revived, subject where there is no instinctive then rejected and finally reinstated contraction of the sphincter at the and indorsed. With the ideal
utero-salpingizn orifices; how much flux irrigator in general use today, greater will be those met in the livpreceded when necessary by thorough ing? The question may be asked: Do dilation and under antiseptic precau
intrauterine injections ever so penetions, intra-uterine irrigations are
trate in the living subject? In answer considered safe and effective.
I would say that since the uterus If the healthy uterus be injected when injected is usually diseased in with fluid, without proper dilatation, some way or contains morbid mathe following syn.ptoms will prob- terials and as under these conditions ably be noticed: Uterine pain and the orifices of the organ
are frecolic, abdominal tenderness, feeble, quently dilated, it follows that in a frequent pulse, coldness of the ex- certain rare proportion of cases, penetremities, and otuer evidences of tration of fluids to within the abshock. If, however, the uterus is in dominal cavity does occur. Posta pathologic condition, the dilator is mortem examinations and Lawson often not called for, because, as Tait's operation prove the existence rule, the cervical canal is sufficiently af patulous and dilated tubes in many patent to admit the irrigator and un- instances. Barnes and others report toward or dangerous symptoms are cases where on autopsy, solutions of apt to be provoked with less severity, iron salts were found at the fimbria. or may be absent altogether, accord- But notwithstanding these admissions ing to the capacity of the canal to and provings, evidently the symptoms afford ready exit to the fluid and cannot be traced to such causes, exother contents of tne cavity of the cept possibly in rare instances. In uterus. I may say in passing that view of these facts, various precauthe fears formerly entertained of the tions can be observed here which injection of fluids into the oviducts tend to prevent the ill effects of inand on into the peritoneal cavity, has tra-uterine injections. The following by experiments at different times, are the more important: demonstrated the rare possibility of (1.) Dilatation of the Cervical this accident. Vidal first operated Canal.—Whether this is the result of upon the cadaver and found that with the disease or is accomplished artifi
cially by a dilator, it matters not, so that the injected fluid flows out of the uterus, retention and distention thereby being prevented. For manifest reasons, it is more dangerous to inject the uterus when that organ is greatly flexed. A ready exit of the current is also secured by the use of a double or reflux canula. There are a number of these, as Notts, Byrnes, Skenes and others. The one used by tce writer since 1880, and which is in general use, is all that could be desired in such an instrument, as it readily permits of a free reflux current, and with it distention is impossible. The canula is fitted to an airtight syringe or a reservoir at a sufficient elevation to give the injectin; fluid a gentle force. The fluid should be sterilized water at a temperature of 100 degrees F., and with some reliable antiseptic, carbolic acid, boric acid, bichloride of mercury, or permanganate of potash, etc. For most cases of bichloride (1:200-8000) is the best of all, but the drug is dangerous if continued too long in a given case. It must be admitted that certain risks attend intra-uterine injections, even under the circumstances of a large uterus, a patulous canal, and a free exit for the fluid. But the risks are not great and compared with the dangers of septic absorption, or the urgency for the removal and disinfection of septic matter, fresh invoices of which by a conunuous or intermittent imbibition into the vascular system are being kept up, these risks are very small. Fortunately, the uterus is in a condition less susceptible to these risks of shocks, retention of the fluid and distention of the cavity, the passage of the same into the peritoneal cavity, etc., when the urgency for the employment of antiseptic injection is greatest. Nevertheless, the utmost precaution ought to be instituted in every single case.
(2.) Shock is diminished by using
fluids at a temperature of 100 degrees F.
(3.) Distension and shock are diminished by using the least possible force..
(4.) The possibility of injecting air is prevented by using the fountain syringe and a moderate pressure.
I may say, as a valuable hint, that intra-uterine medication of any kind by injection is contra-indicated when the uterus or the perimetric tissues are especially tender.
It was when a student that my preceptor often cautioned me not to introduce a probe into the cavity of the womb, excepting when it was evidently practical, and plainly demanded, and then with the utmost caution, as it was
regarded by him as not a slight matter by any means to invade this cavity, even with a small probe and in dexterous hands and rigid precautions.
The warning thus given me when an inexperienced student has not been forgotten, although
than quarter of a century has passed since that time. In this connection, I will say that the instrument in universal use at that time was quite unlike the delicate silver probe found in almost every gynecologist's kit of instruments today, as the two I here exhibit will show.
I also have with me a sharp and a dull curette, also a reflux irrigator, which I wish to show in order to the better impressing upon our minds the accelerated danger of using the sharp curette in ordinary cases and the comparative safety attending the use of the dull one. As to the irrigator, I am sure there can be no just criticism.
I am free to admit that the sharp curette has its rerits, but is too frequently followed by very dire, even, in some instances, fatal results to the patient; while the dull an te used with almost entire safety, so far