"I have very seldom introduced a plug of any kind into the vagina in these cases, but when there has been a draining of blood from the uterus, after the practice now described has been employed, a large soft sponge passed into the vagina, and pressed up against the os uteri, has appeared in some cases to promote the coagulation of the blood. The sponge, however, cannot be employed with safety after the expulsion of the child and placenta, unless the uterus be firmly compressed above the brim of the pelvis to prevent its becoming distended with blood. More frequently I have had recourse with good effect, to the introduction of several pieces of smooth ice into the upper part of the vagina, and allowing them to remain there, in contact with the os uteri, and be dissolved, or pieces of ice have been inclosed in a bladder and laid over the pubes.
"Other means besides those now described have been recommended in cases of flooding after the expulsion of the placenta. It has been proposed to inject cold water into the cavity of the uterus by means of the stomach pump, and favorable reports have been given of the practice. The effect, I think, would be similar to directing forcibly a stream of cold water against a stump soon after amputation; the coagula in the cavity of the uterus and in the orifices of the vessels would be all washed away: nevertheless, it might perhaps be advantageous in some desperate cases. Port wine and water, as cold as possible, Dr. Collins says, injected into the rectum, has been of service. Some of the earlier writers on midwifery, and many in the present century, have strongly recommended the introduction of the hand within the uterus for the purpose of removing the coagula accumulated within the cavity, and to excite the uterus to contract. But it is not necessary to pass the hand into the uterus for the removal of coagula, because if the binder has been properly applied, and strong pressure made over the fundus uteri, clots cannot accumulate within the uterus, and if they have been permitted to collect in consequence of neglect, then expulsion will immediately follow the use of proper compression of the hypogastrium, without the introduction of the hand. Nor do I consider it necessary, to excite uterine contractions, that the hand should ever be introduced into the cavity of the uterus after the removal of the placenta. I am fully convinced, from repeated observation, that this practice, which is so common as to be almost universal in this country at the present time, is often not only ineffectual for the purpose, in the worst cases of flooding, but that it is often followed by the most pernicious effects; the coagula which nature has formed have been displaced by the hand, and the uterus has not been excited by the stimulus of it to secure a permanent contraction. In the greater number of fatal cases of uterine hemorrhage after the expulsion of the placenta, which have come under my observation, the hand had been introduced into the cavity, and the closed fist had been pressed for a longer or shorter time round and round against the lining membrane, to make the uterus contract. I do not recollect a single fatal case, where the unfortunate result could be fairly attributed to the want of the introduction of the hand into the cavity of the uterus, and the friction of the knuckles against the lining membrane. I have repeatedly passed the hand into the uterus to produce contraction, but it has refused to obey the stimulus of the hand; it has remained like a soft flaccid bag, more like a piece of intestine than uterus, and the blood has continued to pour down the arm, until the hand has been withdrawn, and more efficient remedies employed. Leroux was well aware that the stimulus of the hand would not in all cases excite the uterus to contract, for he observes, "where the os uteri is contracted, the means indicated by Levret are very efficacious, and remove the hemorrhage as if by a charm. But it is not so in complete inertia of the uterus; often it is widely dilated, and offers no resistance to the introduction of the hand. The introduction even of the whole hand excites little sensation, and the woman will promptly perish from hemorrhage if other means more active and certain are not employed to prevent it." The tampon or plug is the remedy Leroux recommends in cases of flooding after delivery, and he affirms that it will often succeed in stopping the flow of blood when all other means fail. Dr. Dewees observes, that he has not found it necessary to introduce the hand for the purpose of stopping an hemorrhage after the expulsion of the placenta, during the last five-and-thirty years, as he regarded the practice as always frightful, and oftentimes unnecessary and pernicious. But it is difficult to subvert an established mode of practice, however unsound, and probably some of you, without much reflection, because you have heard this recommended, will pass up the hand into the cavity of the uterus after the expulsion of the placenta, on the very first occasion that you have an opportunity of doing so, remove all the coagula, and rub the inner surface with the fist till you are tired, without effect. I have seen cases repeatedly where this has been diligently performed by those who had neglected to apply the pad and binder, and all the other means now described. If you pass the hand at all within the parts, which I strongly suspect you will do, let me entreat you to carry it no farther than the os uteri, which you may, with much less risk and with greater effect, press and rub with the fingers and irritate than the inner surface of the body and fundus of the uterus.
"Mauriceau recommends that women who are subject to flooding after delivery should be bled twice or thrice from the arm during pregnancy, and once, or oftener, after labor has commenced. There are cases of uterine hemorrhage after the delivery of the child and expulsion of the placenta unconnected altogether with the plethora, or an excited state of the heart and arteries, and where bleeding and low diet do not prevent the accident. Rupturing the membranes at the very commencement of labor is by far the best remedy, the only thing indeed upon which any dependance can be placed.
"After attacks of uterine hemorrhage, the patient should not be raised from the horizontal position for several hours, and the strength should be supported by wine, beef-tea, and light nourishment. Brandy in gruel sometimes agrees when wine is rejected. A good large dose of the liquor opii sedativus often produces the most decided benefit after the hemorrhage has ceased; there are few cases before this in which opium does good, though it is constantly given in all the varieties of flooding, even when the great object is to excite uterine action. Where recovery is to take place after uterine hemorrhage, says Dr. M. Hall, the pallor of the countenance, the disposition to syncope, the coldness of the extremities, the feeble state of the pulse, and uninterrupted respiration, pass gradually away. Where the case is to terminate fatally, the symptoms gradually assume a more alarming aspect, the countenance becomes pale and sunk, the respiration stertorous, and the pulse cannot be felt at the wrist. There is great restlessness, and before death one or more fits of convulsions sometimes occur. Where recovery takes place, in some women it is astonishing how little permanent inconvenience is felt from the great loss of blood which they have sustained. In the course of ten days or a fortnight the effects have entirely disappeared; and this is the most common result. In some women, a violent determination of blood takes place to the brain, marked by heat, strong pulsations of the carotid and temporal arteries, intolerance of light, and all the symptoms of inflammation of the brain or its membranes. A strong febrile attack is also sometimes experienced, without an increased determination of blood to any particular organ. These affections of the brain and nervous system are aggravated by depletion. The patient should be kept in a cool, dark room, and mild cathartics, anodynes, and antispasmodics, occasionally given. Where there is much headache and throbbing, a few leeches should be applied to the temples, and a cold lotion to the scalp."
These remarks of Dr. Lee, as to bleeding frequently making the after symptoms worse, should be carefully borne in mind. There is no doubt but that too copious, or too frequent bleeding, during pregnancy or labor, disposes the female to many serious dangers afterwards. I have known some suffer constant headache, dizziness, and loss of memory, for weeks after from it; and others have even been made light headed.
To the above remedies I would only append one other, which has, on many occasions succeeded, when all others have failed, namely Galvanism. This has, at the last moment, when the female was sinking, brought on uterine contractions, stopped the flooding, and saved her life. The application is very simple; one pole being placed on the back, immediately between the hips, and the other over the uterus. Or one of the poles may be coated with wax, all but the end, and introduced into the vagina, so that the unwaxed part may touch the mouth of the womb, while the other is placed over the fundus, or on the back, as found most efficient. The power should be sufficiently strong to produce contraction, and the application must be continued till the contraction remains after the pole is withdrawn. No medical man should give any female up who is flooding, no matter how severely, till he has tried Galvanism. In my "Neuropathy" and "Practical Facts" will be found many cases, with such plain directions that any one could follow them and apply it.
The presentation of the placenta, or its growth over the mouth of the womb, is the most serious cause of flooding, and generally makes any attempt to check it of no avail, except delivery. The discharge however nearly always occurs before the full period, and either causes miscarriage or necessitates premature delivery. Dr. Lee remarks:
"In the greater number of cases of placental presentation the discharge of blood takes place spontaneously in the seventh and eighth months of pregnancy, and cannot be referred either to bodily exertion, external violence, nor to any unusual determination to the uterine organs, or congestion of their vessels. The hemorrhage generally comes on suddenly, when the woman is in a state of rest, and the blood continues to flow until faintness or even syncope takes place. It often ceases entirely, and the patient resumes her usual occupations, and has no dread of another attack. But after an interval of several days, and sometimes not before two or three weeks, the flooding is renewed, and perhaps with increased violence, or a constant profuse discharge takes place, and a decided effect is produced upon the constitution,—the pulse becomes rapid and feeble, and the countenance pale. Similar attacks return at longer or shorter intervals, and if delivery be not accomplished by art, sooner or later death takes place. The first attack of flooding seldom proves fatal, but it sometimes does so; for in the second case related in the table, which occurred in the British Lying-in Hospital, the life of the patient was at once extinguished by a single gush of blood from the uterus. I examined the body after death. The centre of the placenta was over the centre of the os uteri.
"When flooding takes place to an alarming extent in the seventh or eighth months of gestation, you ought first to ascertain, by a careful internal examination, whether or not the placenta be situated at the os uteri. It is impossible, from the manner in which the discharge of blood takes place, to be certain of the fact; for there are some cases of hemorrhage from detachment of the placenta from the upper part of the uterus, where the flooding occurs spontaneously, and to as great an extent as in cases where the placenta presents. In some cases I have been induced, from the symptoms, to believe that the placenta was at the os uteri when it was not. As the treatment and the successful or fatal result of the case will, in a great measure, depend on the correctness of the diagnosis, the examination should be conducted with so much care and circumspection as to leave no room for doubt on the subject. An ordinary examination, with the fore and middle fingers, is generally sufficient to enable us to ascertain the true state of the case, but where the os uteri is very high up, and directed backwards, it becomes requisite to introduce the whole hand within the vagina. The finger should then be passed gently through the os uteri, and, if the placenta adheres to the cervix, it will be distinguished from coagulated blood, the only substance with which it can be confounded, by its firmer, fibrous, vascular structure, and, above all, by its adhering at one part to the uterus, and being separated at another. If you will take the trouble to pass the finger carefully and repeatedly over the uterine surface of a recently expelled placenta, you will never, in actual practice, mistake a placenta at the os uteri for a clot of blood, however firm. In all cases it is requisite to proceed at once to determine by an examination, so carefully conducted as to render a mistake impossible, whether or not the placenta presents—even though the hemorrhage should be slightly renewed by the displacement of the coagula; you cannot be too early acquainted with the precise condition of the patient. You ought, at the same time, to ascertain whether the placenta adheres partially or completely to the cervix uteri, and whether the os uteri is in a condition to admit of the operation of turning being performed.
"The operation of turning, which is required in all cases of complete placental presentation, is not necessary in the greater number of cases in which the edge of the placenta passing into the membranes can be distinctly felt through the os uteri. Sometimes there is profuse and dangerous hemorrhage where the placenta does not adhere all round to the neck of the uterus, but only partially. If the os uteri is not much dilated or dilatable, the best practice in these cases is to rupture the membranes, to excite the uterus to contract vigorously, by the binder, ergot, and all other means, and to leave the case to nature: by adopting this treatment the operation of turning may be avoided with advantage in the greater number of cases of partial placental presentation. But, if the hemorrhage is profuse, has returned at different intervals, and a great quantity has been lost, and the constitution is really affected, it is the safest practice at once, if the orifice of the uterus is in a condition to allow the hand to pass without difficulty, to deliver by turning the child.