ON THE TREATMENT OF UTERINE HÆMORRHAGE AFTER SHEWING THE INEFFICIENCY OF THE PRE- BY J. R. PRETTY, Esq. M.R.C.S.E. &c. resting it, a principal one is cold, and this is often, though not always, very successfully employed, and some caution and discretion are required in its application. I know a lady who lost the use of her lower limbs for a considerable time, from the application of it, by one of our first accoucheurs during a severe and almost fatal flooding. To shew that some tact and caution are required in the use of cold, I need only quote the words of Sir Richard Blackmore, (narrated in Denman's THE frequency and violence of uterine Midwifery), in a case of flooding. hæmorrhage doubtless depend much "If," said Sir Richard, "you had used upon the management of the patient less cold applications this patient would during the second and third stages of have died, and if you had continued parturition. Many accoucheurs at- them longer you would have extintend only to the perinæum, but Dr. guished the powers of life." Ergot of Murphy has well pointed out in his rye cannot be depended on; it takes some lectures the necessity of also following time to act, and if it should excite the down the contractions of the uterus; uterus to contract, it may cause it to and to do so you are directed to stand do so irregularly (as the hour-glass by the side of the woman, and support contraction), and convert an external the perinæum with your right hand into an internal hæmorrhage. Opium whilst you follow down the contrac- is doubtless a very servicable remedy tions with your left. Thus irregular in restoring the tone of the system, action or a torpid state of the uterus is and diminishing its irritability, but greatly guarded against after the birth this is not a certain, though a toleraof the child, and the third stage of bly safe remedy. I say tolerably safe, labour consequently shortened. Another for we know that some women, as means of effecting these objects is the the hysterical, are peculiarly affected proper application of a broad bandage by this drug. The introduction of directly you have liberated the child one hand into the uterus, and the from its mother, for the purpose of (to other placed on the abdomen, and use the words of Dr. Murphy), pressing the uterus between the two, "affording a diffused and equable sup- may fail to accomplish your object; port" to the uterus, which the abdo- and there is a risk of fatal inflammaminal muscles frequently fail to do, on tion following so extreme a measure. account of their not being well de- Friction of the abdomen over the uteveloped, and this being caused by the rus has been resorted to, but this is sedentary and luxurious mode of life almost playing with your case, and too generally followed by women, and should any effect ensue it may be only also from their tight lacing. Hence a contraction of the anterior fibres. we find that severe cases of flooding Lastly, we have pressure; and it is on occur more frequently in large towns, this point that I would venture to diwhere these bad habits are more gene-rect the attention of accoucheurs. A rally followed. As regards the treatment, we are told that it must be such as to produce contraction of the uterine fibres, and certain means are enjoined. Every experienced accoucheur knows that in severe cases this is easier to talk about than to effect, especially in mismanaged cases, where you are called in to assist the attendant. We also know that some of the worst hæmorrhages will occur after every precaution has been used, and when the delivery of the placenta has been properly managed. Of the usual means of ar grasping pressure by the hands, and a kneading motion, have been recommended, but these in some cases are far from being efficient. Dr. Ramsbotham gives a very fair and candid account of the means at our command in these cases, and owns that they will sometimes fail, and as a last resource transfusion is recommended. Should the student, however, look at some works on midwifery, he would think that he had only to follow the directions given, and that success must ensue. It is strange to see how au thors have followed one another, and that the treatment should differ so little in all. It is also singular that efficient pressure should have been so disregarded, especially when other means have been found to fail. The late Dr. Davis, however, departed from the path of his predecessors. He, in his work, seemed to rely chiefly on pressure, although he was not so successful in his mechanical contrivances here as elsewhere. Dr. Murphy states, inertia of the uterus is not common, and that it is frequently mistaken for a suspended action of that organ. I think it very probable that in severe cases the latter may first occur, and give rise to hemorrhage, and as an effect of this an atonic state may ensue, and then comes the difficulty of rousing the uterus to its duty, and it is here where the good effects of wellapplied pressure are so distinctly seen. Dewees says, that "the suddenly emptying of the uterus by the evacua tion of the waters, and the rapid delivery of the child, are the most common causes of the atonic state of the uterus." I think this may be explained in the following way. In the operation for paracentesis abdominis, to use the words of an accomplished veteran surgeon, Mr. Samuel Cooper, "Whenever a considerable quantity of fluid is let out of the abdomen by tapping, the quick removal of the pressure of the water off the large blood-vessels and viscera may produce swooning, convulsions, and even sudden death, and to prevent this the whole abdomen must be equally compressed." A strong analogy, therefore, exists between this case, and that of hæmorrhage occurring from the cause just mentioned; and this is a very strong argument in favour of the application of the broad bandage after delivery, to prevent hæmorrhage ensuing. Dewees, and all authors of works of Midwifery, state, "that the uterus should contract before it (the hemorrhage) can possibly be arrested. Now, after severe flooding, it is found sometimes impossible to effect this, and we should, if this were true, have no means of saving our patient; and I believe it is this notion, and the regarding these cases in almost too theoretical a light, and considering the treatment quite different from that of other hæmorrhages, that has caused the accoucheur to have only one object in view-an excellent, but occasionally an unattainable one. I need only refer the reader to the statistics in Dr. Churchill's work, as a proof of the insufficiency of the means at our command. It is there stated, that out of 230 cases, in the practices of some of our first accoucheurs, the average number proving fatal was 1 in 14. Doubtless, these parties may not have had the attendance of all these cases from their commencement, but still, I believe, that many of them might have been saved if an efficient means of applying pressure could have been obtained. Is it not probable that the pressure being suddenly removed by the birth of the child too quickly following the escape of the liquor amnii, or in some cases the too rapid birth of the child, or, even in others, where there is a predisposition to hæmorrhage, the birth of the child in the usual way, may not the removal of this pressure affect the abdominal veins, and thus influence primarily the circulation, and secondarily the uterus? If so, the effects, of course, would be milder in degree than in paracentesis abdominis, and the recumbent position of the patient would also prevent her feeling at first a sense of faintness. I think that it is not absolutely necessary to have a contracted state of the uterus to temporarily arrest the haemorrhage, although this must occur before you can permanently stop it; and here, I think, lies the secret of the great advantage of efficient pressure, especially in the last stage of severe flooding cases: when you cannot excite the uterus to contract by it, you may mechanically arrest the flow, or the draining, without fearing its return by a movement of the patient, and then wait until the system has recovered its tone, and for the consequent contraction of the uterus. Should, however, the pressure be applied at its commencement, I doubt not but that the uterus would in general quickly contract; if not, you need not make it a matter of the first importance, as by using pressure in the way I shall describe, you arrest the hæmorrhage, and contraction will follow, and thus measures may be avoided, which, if they can be dispensed with, are scarcely justifiable. As to transfusion I believe it would become a visionary affair. Some accoucheurs may say they prefer pressure by the hands because they can know how matters are going on, but it cannot be continued with sufficient force for any length of time without very great fatigue and uncertainty. I heard an eminent accoucheur state, that, as a dernier resort, he had been compelled, with the aid of an assistant, to use pressure thus for the space of eighteen hours! In the treatment of these cases we should also recollect that when there has been one gush, and that not renewed, the woman does not feel this loss as she would a much smaller quantity under different circumstances as from venesection; for, as Denman states, "should every drop of blood which circulates in the uterus be discharged in an instant, it would be of no immediate consequence to the patient, the very existence of the uterus not being necessary for life;" but if this were not followed by permanent contraction danger must ensue from the demand made upon the system, and if you cannot excite contraction the loss of your patient is the consequence. But, if pressure is applied, you prevent the vessels refilling, and stop the drain upon the constitution, and the consequent successive gushes of blood. I will now say a little concerning the application of pressure. Professor Murphy has pointed out the principle on which it should be employed. Dr. M. uses a series of graduated pads, made of any material that can be procured at the time. Some of these are packed closely on each side of the uterus to prevent its sliding laterally, whilst others are placed over that organ, and the whole covered by one large pad and a bandage, which is to encircle the body, and be fastened as tightly as possible. The uterus by this means is thoroughly confined, and equally pressed on. This method might prove troublesome to a person unaccustomed to it, as some dexterity and time would be required in adjusting the whole properly, and when you have done so the pressure may not be sufficient. My father has for many years advocated the more efficient use of pressure, and has been in the habit of using a common tourniquet and a pad, made either of cork, or a book well padded with a napkin, and by these means he has been very suc cessful, even in cases where he has been called in to assist, and when all other means had failed. An account of a very good case of this kind, showing the great advantage of efficient pressure over other means, appeared in the GAZETTE Some three or four years since. It was this success that induced Mr. Elam, of Oxford Street, to make a bandage with a pad and a tourniquet, which he thought would be approved of by the profession, and I believe that he has sold a great many of them; but we cannot by the use of his belt, &c. accomplish all the objects that could be desired. If the reader will recal to his memory a dry pelvis, he will perceive, from the prominence of the anterior part of the crista ilii, and also that of the anterior border of this bone, especially the anterior superior spinous process, that the pressure of Mr. E.'s broad bandage can only tell upon his single pad, and that the sides of the uterus are left unguarded, and, consequently, from its unfixed condition, it might slide into either iliac fossa, and thus escape from pressure. This evil is also increased by his having contrived a peculiar tourniquet, the turning the screw of which to tighten the bandage, raises the latter at the same time, and causes a downward pressure on the pad, and thus a complete arch is formed, and the bandage still more separated from the sides of the uterus. In conversation with Mr. G. Epps, some time since, I recommended to him the use of the tourniquet, and advised him to see Mr. Elam's contrivance; he did so, and ordered Mr. Coxeter to make him one on the same principle, with these modifications. The broad bandage was made of linen, neatly stitched, like ladies' stays, and Mr. Coxeter's tourniquet was attached to it. Mr. Coxeter also suggested and made a very useful addition to it, viz. a narrow band attached behind to the broad one, so as to tighten the whole without displacing parts in front. When it was completed I was asked to see it, and found that it possessed an improvement over Mr. Elam's, in the belt not being raised from the pad when it was tightened; but this great defect existed, viz. the central pad was not stiff, and had no metal plate behind it to diffuse the pressure, so that when the screw was turned the upper and lower borders was relaxed. I gave Mr. Coxeter directions to make an oval concavo-convex pad, with, a metal plate attached. The shape of this pad is quite different from that of Mr. Elam's. The same objection, however, holds good in this case, although in a less degree, as in Mr. Elam's, viz. the want of lateral support to the uterus, and the danger of its sliding sideways, and escaping from pressure; and to obviate this, I first thought of lateral pads being added, but I found these would make the whole unnecessarily bulky, and have therefore contrived the following bandage and pads, which I believe will be found thoroughly efficient, and more portable than either of those that I have described. It consists of three pads, the central one being the largest; the lateral ones are the thicker and narrower, and fold over the central one when not required for use, and these can be carried separately from the belt, &c. and when together are not larger than a small book. The belt is of webbing about three inches wide, and is fastened by a buckle and strap. It has attached to it Mr. Coxeter's improved tourniquet, the screw of which is only one-half the length of the one on the old principle, and yet it raises as much web, so that this is easily carried. The application is very simple: you merely adjust the pads, pass the belt under the woman, and fasten it on the right side as tightly as possible, and then give the tourniquet screw one or two turns. You thus have a most powerful grasping pressure at your command, from which the uterus will not slip; the pressure is at the same time made as diffused and equable as possible, and to accomplish the latter point, I had one at first made larger than that which I have spoken of, but found that it was unnecessarily large. The lateral pads quite do away with the necessity of a broad bandage, as the use of the latter would be to afford support in front, which it fails to do; and the advantages of a narrow one are these, it is more portable, it is more easily passed under the patient and fastened, and it presses behind only on bony structures, and not, as the broad one, half upon these and half upon the yielding soft parts above them. The lateral pads can be made pockets, with the metal plate behind, and to be filled with soft materials when required for use, as old linen, or they might be made air cushions, to be inflated when required for use, though it is doubtful if these last would thus answer. The stuffed ones are not at all too large to be easily carried in the pocket, and no one, save a very fastidious person (which an accoucheur is not likely to be) could object to carry them. However persons may differ from me in the views I entertain, I do hope that it will not prevent a fair trial of this apparatus; and I believe the only differences that can exist would be theoretical ones, as I feel convinced that these pads, &c. will be found equal to arrest violent FIG. 1.-a a, Lateral pads; b, central pad. Measurement, when folded up, 6 in. by 44 in.; 1 in. thick. FIG. 2.-a a and b, Top margin; c, band and compress sarew. traces of sugar, though none was subsequently detected. I ordered a dose of compound senna mixture to be taken every morning, with a view of watching the state of the urine. 19th. Two specimens of urine were sent. The one passed on the evening of the 18th was acid, slightly turbid, sp. gr. 1024; and I found small octohedra of oxalate, with much epithelium and many organic globules. Urea was slightly in excess. The other passed this morning was PATHOLOGY OF OXALATE OF LIME clear, of a very high colour, acid, sp. IN THE URINE. BY J. H. STALLARD, ESQ. Surgeon to the Leicester General Dispensary, &c. [Continued from page 1375 of the last Volume.] MR. T. G., æt. 37, married, of sanguine temperament, had an attack of acute rheumatism 13 years since, which confined him to bed for some time, and to the house for three months. He has since had frequent but very slight attacks of chronic rheumatism, and has, ever since his first illness, suffered from a peculiar irritability of the bladder, being unable to retain much urine, and feeling considerable pain when voiding it. March 18th, 1845.-I was requested by my father to examine him, as he suspected that he had stricture of the urethra. I found him with the following symptoms:-Pain along the course of the urethra, and up the side of the bowels, when the urine is passed; he compares it to the cutting of a knife; it is most severe after breakfast, the first time he relieves the bladder in the day. The urine is decreased in quantity, and it passes in a very small stream. The general health is exceedingly good; has no dyspepsia, and complains of neither depression of spirits, or any of the symptoms described by Dr. Golding Bird as the usual characteristics of the oxalate of lime diathesis. The bowels were constipated at the time of my visit, and were rather costive. A specimen of urine passed this morning was turbid, acid, sp. gr. 1030; with nitric acid it very quickly formed a cake of nitrate of urea, and the microscope discovered large octohedra of oxalate of lime. I may remark that Trommer's test yielded gr. 1022, crystals of oxalate small, and no excess of urea. Epithelium and organic globules abundant. 24th. Since I last saw him he has had no violent pain; but though slighter, it still remains. Urine has been less abundant, and not passed so frequently. It is usually most turbid at night. He says he is quite well, takes a great amount of exercise, and sleeps soundly. He always perspires very much, even with little exertion, but the want of exercise always increases the urinary irritation. Bowels were opened by the medicine. He was ordered to continue. 25th. The urine passed last night was of a bright amber colour, highly urinous smell, neutral, sp. gr. 1030 at 60° F. Oxalate in octohedra not very abundant; when treated with nitric acid, it after some time formed a mass of crystals. 1000 grains were carefully evaporated; they yielded 59 grains of solid matters, from which I obtained 18 grains of urea. Urine passed this morning was very high-coloured, bright, and of a remarkably oily appearance; neutral. Sp. gr. 1030, 60° F. Octohedra small, not very abundant; much epithelium, and some organic globules. I give an analysis : |