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readily be expected to take fever off where in animals when dying than at any other peit existed before. Supposing even that the riod; hence he argues that coagulation is patient gets quite clear from any return of always in proportion to necessity. the hæmorrhage, the fear that remains is, With regard to treatment we may obwhether she have not already too much for serve, that in slight cases, where the quanthe constitntion to repair ; and we must tity of blood lost is very trifling, it will not again wait in expectation of the fever ; if be necessary to notice the existing state of that do not come on, so much the better; pregnancy, but to make use of the common that is another danger got over. But she remedies for the checking of slight hæmormay die at the end of twelve months, and rhage from any internal part. But if there be that from the effects of a single attack of this increased action of the heart and arteries, complaint. This will in most instances and we know the constitution will bear it
, happen in women who are of a flabby loose we may take away ten ounces of blood, texture, and have a heavy fat body. Hy- and suppress the animal food; moderating drothorax, or ascites, will in these persons the sanguiferous action, so that there shall supervene at a great distance of time, be no risk of displacing the newly-formed entirely from the debilitating effects of the coagulum, in its recent state, a tender loss of so large a quantity of blood has in- jelly. If these things are attended to, the duced.
blood will perfectly cork up the bleeding With regard to the powers by which hæ- grifices of the ruptured vessels. We should morrhage is naturally restrained in different at the same time empty the bowels, proparts of the body, we may say that they are bibit all stimulating aliment, and advise a two in number; one of which is the con- horizontal position. All this, however, retraction of the blood vessels themselves, the fers to slight cases, and an early period ; if other is the coagulation of the blood in the after this period, or during labour, we must mouths of the vessels which are ruptured. seldom be beguiled from more active meaWith regard to the contraction of blood sures. The only solid security is a deli. vessels, it is well known that an hæmorrhage very of the child, which in all cases of prois frequently stopped by that power alone. If fuse or continued hæmorrhage we should imwe prick our finger, or shave a bit off, it mediately prepare ; and in the process to be would bleed everlastingly, were it not for pursued we are of course to turn the child. the contraction of the divided branches, Wherever, in doing this, the os uteri very which stops it, and that so effectually, that easily gives way, it is the very essence of if from time to time we even wipe away the danger, proving the want of contraction in blood with a sponge to prevent any assist the uterus. In the present instance, howance which might arise from the formation ever, we do not want to empty the nterus of coagulum, yet the bleeding will stop. 80 much as we wish for its contraction; for But as the vessels contract gradually and if we get away its contents at a time when slowly, the blood which forms on the sur- it cannot or will not contract, we do no face being exposed to the air coagulates, good. If the placenta seal up the os uteri, and becomes the second cause of the blood we must go directly through: we may ceasing to flow from the divided vessels. So easily, indeed, screw, our hand through it, that hæmorrhage, considered in general, for it is a loose pulpy mass easily torn. We may be said to be restrained partly by the should not wait long, nor be afraid, and, if contraction of vessels, and partly by the the labour be recent, we may turn the coagulation of blood in the vessels. The head and bring down the feet: if the head natural powers by which hæmorrhage is be low enough to apply the forceps, we may usually restrained are the coagulation of the deliver in this manner. The whole of this blood as it flows, and the contraction of the practice lies in a very small compass; in vessels. To these a third power is added determining to deliver early, and in deterin the uterus; it is the contraction of the or- mining that onr patient shall not die ; and gan itself, and it is not only one of the it is founded on the principle that hæmorthree, but the most important, as being the rhage from the uterus cannot be restrained most effectnal power of them all, in stopping by the two powers which are sufficient for the hemorrhages which flow from the inter- stopping a flow of blood in most other parts nal surface of the uterus. It should appear of the body, by the contraction of the vesalso from the experiments of Hewson, that sels, and the coagulation of the blood in the coagulation of the blood is more rapid them; and that nature has here appointed a third power, by the presence of which with two great violence, by which the pla. the human uterus differs from that of all centa comes to be injured ; and this happenother animals. It is right, however, after ing when the uterus is not disposed to con turning, and bringing down the feet, to al tract, the vessels will, for a time, remain low the child to remain undelivered for a exposed and bleed, This is the reason why short time, attending to the least pain that it happens so frequently in the hands of bad may be felt, and gently assisting in the fore practitioners, as midwives; and that it is so warding the expulsion; and when the child rare when no improper treatment is adopted is born, to wait the action of the uterus in regard to the placenta. again for the expulsion of the placenta ; for Now supposing the hæmorrhage yet rewe must still recollect the grand object is mains, that is, after the uterus is emptied, the contraction of the uterus, without the child bord, and the placenta come which, its being emptied would produce away; what are the means next to be emvery little good. It will then happen, that ployed to restrain the hæmorrhage? the ap. the same contraction which expels the pla- plication of cold, and the abstraction of heat centa will diminish the area of the vessels, in every possible way; we should take the and the danger from flooding ceases. But clothes from the bed, leave nothing but a if this contractiou do not take place soon, sheet to cover, and that from motives of and the hæmorrage continue for some mi decency alone. If there be a fire in the mutes after the extraction of the child, we room it must be put ont; the windows kept must consider whether the strength will not open to preserve a cool and fresh air, and if be lost, and the safety of our patient en- the patient be faint she may have a cup of dangered : if so, the placenta without de- cold water. lay must be separated by introducing our
Cold water and ice are the proper applihand.
cations both to the parts themselves and the Immoderate Discharge of the Lochia. The body round them. The coldest water made next view of uterine hæmorrhage, is that colder by throwing two handsful of salt into where it does not stop on the extraction of a couple of quarts of it, may be used by the placenta. Such cases as these are very cloths many times doubled dipped in this, rare; there may be a sudden gush of blood, and laid over the back and abdomen; beand often is, following the placenta ; the sides which, we may with the greatest ad. reason of which is, that the uterus, at the vantage expose the body to a great degree time it expels the placenta, forces down of cold, if it can be done. every particle of blood with it; and in this If these means do not answer, we must way a pound or a pound and a half may es. introduce ice into the vagina, or even uterus; cape, but that need not be regarded in the this will often succeed; if this be ineffectual, least; it does not affect the constitution, we must as the last resource plug up the because it was not evacuated immediately vagina with lint or tow, or something capa. from vessels; it was lying in the uterus. ble of entangling the blood ; for while there So when we amputate a limb, there is no is a clear channel there will be no coagulum loss of blood to the constitution, because formed. If the flooding still continue, the the whole of the blood which is taken away best plan is that of carrying something peris necessary to the limb, and no longer ne. manently cold into the uterus itself; a large cessary than while the limb was to be sup. dossil of lint, dipped in the cold solution, plied. But supposing that from the vessels will carry up a degree of cold; but the best not being properly secured in the opera thing is to carry up a piece of ice, and allow tion, there is a bleeding afterwards from the it to thaw in the uterus. Dr. Baillie, of stump, then it is that the constitution suf: New York, who was the first who introducfers; there is a demand made upon the mass ed the use of cold applications here, was of circulatiog fluids, which mast be replaced in the habit of using a ball of snow for this before the heart can recover its proper ba- purpose, which often stopped it directly, lance in the system. Apply this to the when nothing else would. Ice being introaterus, and we shall consider the blood as duced into the vagina, will often prevent belonging to the gravid nterus, and not to abortion; this then is the best and last rethe circulating system. This is what is, in medy in floodings; if none of these things the practice of physic, called an immoderate will stop it, there is nothing else that will. discharge of the locia. Such hæmorrhages After the hæmorrhage has ceased, the frequently arise from the cord being pulled patient will be so rednced, so exhausted,
the action of the heart so weak, and the child do not separate and bring down the quantity of blood circulating so deficient, placenta. This is said to save another one. that our first care must be to supply the cessary pain. It is said that the uterus will waste, and remove the greatest danger, afterwards contract, and all will be well. which is that of the patient's having been The truth is, the uterus is meant to expel exhansted beyonel the point at which the the placenta as well as the child: if it were constitution is able to rally, and recover necessary to have extracted the placenta itself
. These cases must be supported and directly as the child was born, nature would stimulated; boiled milk with grated crumbs have made some further provision : all the of bread in it, must be quickly cooled by works of nature are perfect in all their parts. spreading it on a flat dish, and when cool There is a case in Haller where it was left may be given as one of the most nutritious to nature, and remained, it is said, thirty things that can be had; or good broth in days. We should never think of leaving which the grated bread is mixed; and if our patient while the placenta remains bethese remedies do not stimulate the heart hind. When a woman is properly managand arteries, the probability is that the pa. ed, it will rarely be necessary to separate tient will die. In many of these cases the best with the hand. In this Dr. Hunter's pracstimulant is the volatile alkali, next to which tice was exceptionable; he was in the habit brandy and water, or the ammonia, which is of leaving this to nature: he used to leave preferable, because, although the first effects the woman upon the child's being born, deof the spirits is good, it produces too much siring the nurse to put the placenta into the heat in the system at large, while that effect bason when it did come away; that was never arises from the volatile alkali. It is enough for him. sometimes two, or even three hours, before We should never leave the placenta in we can leave such a patient in the certainty the uterus; and if we have left it two hours, of her living.
we should never leave it beyond that time. After the flooding has stopped, we are It is always right to bring it away. If it not to consider the patient as safe. The adhere to the uterus, we may introduce our fever coming on about the third day, may hand as in turning, guiding the hand by the be troublesome; nothing is so efficacious cord; we should then separate the edges of for this as the saline draughts, with laudanum the placenta from the uterus, peeling it grato the amount of a grain of opium in the dually and carefully off. After the whole twenty-four hours. Immersing the hands is separated, we may make a feint to with and feet in warm water to about 80° Fah- draw our hand to observe if the uterus will renheit is useful; it brings down the pulse, contract; if it do not, we should use a and does a great deal of general service. degree of pressure against its side, and it will
After flooding, another circumstance re. generally bring on its action. quires atteuding to, a throbbing of the head The placenta may be retained by a con. and loss of memory, which will remain for tracted uterus, of which there are two kinds, weeks: in such cases there is nothing so one in which the uterus is as long as before good as purging, although the cause of the delivery, but narrower. This state will de. complaint be hemorrhage. The best way pend on too speedy delivery. We must is to give infusion of senna with the Epsom patiently overcome the contraction with salts, after which a draught of the decoction our hand, and separate and bring away the of bark.
placenta, as in other situations. There is Consequences of the Placenta remaining, little hazard in this case, as the ready conand its treatment. The general treatment traction gives us little reason to fear the ill of the placenta has been already explained, effects of hæmorrhage after we have got where nothing more than ordinary attends away the placenta. The other sort of conit, together with the proper time which it traction is that in which the uterus may be may be allowed to remain. We will now said to resemble an hour glass, called thereconsider the consequence of its remaining, fore the hour glass contraction; this must and its treatment when it does remain. be overcome in the same way as the other.
It was said before, when it remained too Whenever we introduce our hand to bring long, it was necessary to pass up the band, away, the placenta, we must take care to and bring it away by separating it from the bring away the whole; it has been stated uterus. Some say, that immediately after that a part of it has been found in a state of the child is born we shonld go up and bring schirrous adhesion to the uterus ; now it it away, if the same pain wbich expelled the certainly will adhere, that often happens: but of schirrous adhesion we know nothing. is produced, the effect is in all cases the However we should always do a thing per- same; it may be attended with profuse fectly: if we set out with the intention of fooding, or the uterus may contract; it is doing it at all, we should do it completely. lucky if a flooding come on, since it máy It is better to leave the whole than a part; lead to an examination, when the tumour becanse if the whole be left, most probably will be felt in the vagina, aud must be re. the uterus will contract upon it, since it turned, the fundus being reduced first. It is a stimulus which the uterus is able to act should be done as early as possible. The upon, while part of it cannot be acted upon difficulty consists in the os uteri forming a by the uterus with the same facility. sort of ligature behind, which prevents the
Consequences of a portion of the Placenta return of the uterus through it. When the remuining. Pursuing the subject, we come os uteri is before us it is easily dilated; but next to the consideration of that state which when we have to work through a substance arises from a portion of the placenta being to it the case is changed. Sometimes hæleft. No great inconvenience seems to morrbage will take place early after deliarise till the third ur fourth day, when the lo- very; and whenever it does, we should chial discharge increases and becomes more always examine: there is no difficulty in offensive; the after pains, which generally examining, and it ensures the safety of our cease about the third day, remain after that patient. If we know of the case directly time, arising from the tendency in the ute- it has happened, and we return it, there is rous to throw off what it cannot get rid of. an end of the mischief; but if we neglect There is occasionally a shivering fit, suc- to ascertain its existence tin the next day ceeded by heat, but rarely ending in per- only, we stand a very fair chance of losing spiration. The pulse rises to 120 or 130, our patient: it will be hardly possible to the patient becoming emaciated and very reduce it unless attempted directly. It is pale, though when the fever is npon her she then of the utmost consequence that the looks as if painted: by degrees the hectic practitioner be careful in extracting the flush lessens ; the pulse becoming smaller, placenta; and that he never pull the cord acquires a wiry hardness, and this continues : forcibly, till upon passing his finger up the the woman becomes tender at the lower vagina he feel the root of the placenta; for part of the belly when it is pressed upon, be may be then satisfied that it has separat. though it is not violent pain as in puerperal ed. inflammation; frequent retching and vomit- Reviewing then what has been said npon ing now arise; and if she live long enough, this division of labonrs, we find that it combiccup succeeds to the last symptom, toge prises difficulties of two descriptions; the ther with which the mouth and tongue be- one resulting from what has been called come sore : she is at length worn out by all cases of arrest, or of impaction; and the this, and lays down her head and dies, other from merely collateral circumstances.
The discharge becoming greater and more It is rarely that the aid of instruments can offensive is the best marked symptom, and be of service, or even employed in the latfrequently causes the death of the woman. ter description : while they may very freThis does not strike those people who liap- quently be of the utmost assistance in the pen to attend without being practitioners former. We call it a case of arrest when in midwifery; they see the fever, which the head is got down into the pelvis, and they attribute to the effects of lying-in, and remains unmoved, not because there is too they liope it will soon get better.
much resistance, but because the woman is Inverted Uterus. This happens most fre- too weak for any further exertion. The quently in the practice of female midwives, state of things in arrest is very different they being more in the habit of pulling away from that which happens in impaction; in the placenta; and they in this way inveit arrest we find the head not compressed, nor upon the same principle that the finger of a the scalp drawn into folds or swelled, the glove is inverted when a string is passed up stools come away naturally, and the woman the inside knotted to the end of the finger, makes water easily: and with regard to the and then drawn down the interior,
constitution, it is languid and weak; in short In pulling at the cord it will often hap- she is a very debilitated woman. What pen that the placenta will separate from the then will be the consequence in this view of uterus at the same time that the inversion the case? Is the woman likely to overcome takes place, and the operator is not aware the difficulties now the powers are worse? of what has happened; now, however this No. Is there any danger with regard to
the constitution? No. While there is a Are we to leave the patient to the powers number of little pains which last four or five of nature? There is not any difference bedays, is it right to leave a woman? No. tween pushing a man into the water, and Then why not deliver her with the forceps, in not helping him out of it, if we see him which there is no danger; it is only bringing drowning; neither in the same way is there along the child, while the mother has not any difference between destroying a wopower sufficient to do it herself. In a case man purposely, and neglecting to employ of impaction the powers of a woman may those means which, when she is in danger, be as good as those of any woman in the will certainly save her life. There are mahighest health. But there is a resistance ny other cases in which the forceps may which cannot be overcome, so that things with propriety be used : hæmoptoe, synare very differently situated to what occurs cope, flooding, presentation of the navel in arrest only. The bones of the head are string, rupture of the uterus; all these ocwrapped over each other, the scalp is swel. currences justify its application, provided led and wrinkled, and is so altered, that up- the case is within the power of management on any person feeling it who had never been by these means, either forming impaction or at a labour, he would guess it to be any arrest. part but what it is. If it be a genuine case We proceed, therefore, to examine into of impaction, the head will be locked in the the origin and nature of the instruments surrounding parts, producing a stoppage of usually and advantageously employed on the evacuations of stool and urine; so that such occasions. on this account it would be clear that the head filled the aperture of the pelvis.
ORIGIN AND USE OF INSTRUMENTS. In the next place we must attend to the constitutional changes. For the first twenty
Sometime towards the latter end of the four hours after being taken in labour the century before last, two instruments were woman works away very vigorously; while invented; the vectis, and the forceps. during the last twelve hours the labour will The veclis is what the name implies, a hardly make any progress, and she is sweat- lever which is intended to assist the deliing extremely. This state will at last very of the child's head. The forceps conchange; it will gradually sink down to a sists of two levers joined to each other in mumbling half delirious state, wandering such a way that the fulcram of each blade and low. No woman should be allowed to is found in the opposite half of the instrugo into this state ; and if she be in such a ment. situation, she should not be allowed to re- In employing a lever there are three main in it. For if the pressure of the ves. points to be considered; the point of acsels npon the brain be allowed to continue, tion, the moving power, and the fulcrum she will become apoplectic. Besides, there or intermediate space between the two. will be harm done to the abdominal mus. In using, then, the vectis, the point of accles. What good will be done by allowing tion is the head of the child. And here the woman to deliver herself, if the vagina it is too obvious to need mentioning, that and bladder slough with the parts around, the force applied by the instrument must which is another thing that may happen be eqnal to the resistance, if not superior In a consultation that was held in a case of to it; and then the mischief may arise to this kind, it was agreed that nature certainly the parts of the child's head so acted upon, should be able to deliver the woman: she producing much injury: the ear may be therefore was not interfered with; she did injured; the lower jaw or zygomatic prodeliver herself, but lost her life for it; she cess of the temporal bone may be broken; died, and that at a time when an ear was to or any part of the surface from the presbe felt, which certainly was a piece of bar- sure may slough off: these evils are by no barity. It is safe to assert, that if, after we means imaginary; there are various inare able to feel the ear, the woman is not stances recorded of each of them, and that delivered in six hours, we ought always to under the hands of the most careful and deliver with instruments. We know that in dextrous men. When an instrument of strangulated hernia nature has, in one case out this sort is used, it is proper to make the of 50,000, made an artificial anus through hand the fulcrum on which it acts: now if the side, after the parts themselves have the force required be but small, this may sloughed off. But are we for that reason to certainly do well enough; but where great avoid operating for the strangulated hernia? force is required, this is a very bad support;