The Hand as a Curette in Post-Partum Hemorrhage BY HENRY P. C. WILSON, M. D. BALTIMORE, MD. REPRINT FROM VOLUME III. ffiimccologfcal 1879 THE HAND AS A CURETTE IN POST-PARTUM HEMORRHAGE. BY HENRY P. C. WILSON, M. D., Baltimore, Md. On the 21st of May, 1878, at 8.30 a. m., I was called to attend Mrs. J. in her fourth labor; the child was born at 10 a. m., and weighed ten pounds. The head had presented with the occiput to the left acetabulum. There was no ne- cessity for interference in the delivery of the child, but at her earnest solicitation, I gave a little chloroform from time to time, not enough, however, to destroy consciousness before the last two pains, when it was pushed to the point of destroying her consciousness of the birth of the child. The head was received with my right hand as it passed comfortably and safely over the perineum, the uterus be- ing grasped firmly with my left hand on the abdomen for the purpose of making it follow the child with the last pain, so as to secure expulsion of the placenta, and by firm con- traction, guard against hemorrhage. The cord was wrapped around the child’s neck. The nurse’s hand was made to take the place of my hand, above the pubes, in holding the firmly contracted uterus, while I tied and severed the cord, and removed the child to another part of the bed. My left hand then took the place of the nurse’s hand on the abdomen, when I found that the uterus had enlarged again. The index finger of my right hand found the pla- centa in the vagina, and a little tightening of the cord brought it away in a perfect state. Up to this point, there had been no visible hemorrhage ; but in a few seconds, blood poured from her in a perfect 2 THE HAND AS A CURETTE. avalanche, deluging the bed and running down upon the floor. I called for ice, and at once passed my right hand into the cavity of the uterus, manipulating its surface, while I grasped its fundus firmly with my left hand. The uterus responded promptly, expelling my hand into the vagina, while I held it firmly contracted with my hand above the pubes. A drachm dose of Squibb’s fluid extract of ergot was given, and I considered everything safe ; but in a few minutes I felt the uterus enlarging, and another large gush of blood came from the vagina. My right hand, containing a lump of ice, was a second time passed into the cavity of the uterus, the clotted blood turned out, and the hand and ice retained there until the uterus expelled them. The hand was withdrawn, but the ice left in the vagina. Drachm doses of Squibb’s fluid ex- tract of ergot were being given every five or ten minutes, and two drachms were introduced hypodermically, but it brought no response from the uterus. A second time I considered the case safe, so firm was the womb contracted under my hand, but I was doomed to disappointment. In a few minutes the uterus expanded for the third time, and blood came gushing from the vagina. My hand, with a large lump of ice, was a third time carried into the cavity of the uterus with the same results as above. Allowing the hand and ice to remain in the vagina against the os uteri, the os was found speedily to relax, and up they went for the fourth time into the uterus, to be expelled as before and with no better results. I then threw half an ounce of Squibb’s fluid extract of ergot into the rectum ; and with this she had taken one and a half ounces of ergot, and still it had shown no perceptible effect in producing tonic contractions of the uterus. The patient had felt nothing like after-pains. She was becoming nauseated. I could push the ergot no further. Her face was blanched, her sight dim, and her pulse very frequent and feeble. Instead of profuse hemor- I/E NR Y P. C. WILSON. 3 rhage at intervals, there was now constant and free bleed- ing, with an occasionally increased gush. The uterus under the hand, on the abdomen, was evidently much larger than it ought to be, and full of blood. I began to be apprehensive of the result. The uterus showed not the slightest disposition to tonic contraction. It would contract and expand, contract and expand, as often as means were brought to bear upon its cavity, and with- drawn. I speedily revolved in my mind cases of obstinate and profuse uterine hemorrhage, not following labor at term, and the means which I had used to arrest them. I thought of hemorrhage from fungous granulations in the cavity of the uterus, and its prompt arrest by the curette ; I thought of hemorrhage following abortions, immediately or weeks after, and its prompt arrest by raking off the surface of placental attachment, with the curette or finger-nail. I thought of injections of hot water, Churchill’s iodine, Mon- sell’s solution of sub-sulphate of iron, the galvanic battery, compression of the abdominal aorta. The pros and cons of all these remedies were rapidly considered, and I determined to pass my hand for the fifth time into the cavity of the uterus, and with my finger-nails, as a curette, rake thor- oughly the placental surface. This was done with the right hand, after all the clotted blood had been turned out, while the left hand, above the pubes, steadied the organ. As I raked, the uterus made efforts to expel my hand, but they were so feeble that with a little effort I was enabled to keep it in the cavity until I had accomplished my purpose pretty thoroughly, be- fore it was expelled into the vagina. The hand remained there only a few seconds, before relaxation of the os al- lowed it to enter the uterus again, and I proceeded to give the placental surface a second thorough raking with my finger nails, not being fully satisfied with the first manipu- lation of this kind. Feeble were the efforts of the uterus that expelled my hand this time, and in a few minutes it expanded again ; 4 THE HAND AS A CURETTE. but notwithstanding this state of atony, my patient did not lose a teaspoonful of blood after the first raking of the placental surface, The uterus remained enlarged and its mouth patulous for about forty-five minutes, when severe after-pains set in, producing firm contractions of the organ, and I had no further trouble in the case. The pains continued for sev- eral days, and were so severe that I was obliged to give morphia and camphor-water liberally. Her uterus and va- gina were washed out daily with warm water, for eight or ten days. I never had a patient make a better recovery. The frequent and successful use of the curette in my hands, in many cases of uterine hemorrhage where other means had failed, suggested the use of the hand as a curette in the above case; and it will be seen, from the history of this case, that, although the uterus remained relaxed and much enlarged for three quarters of an hour after my last manipulation, there was no loss of blood from the moment I commenced the use of the manual curette. In any future case of post-partum hemorrhage, where I cannot produce prompt contraction of the uterus, or where the contractions are clonic and not tonic, I would not waste time with the usual manipulations in its cavity to excite con- tractions, or wait for ice or other styptic remedies. I would promptly use my hand as a curette to the placental surface, confidently expecting prompt arrest of the hemorrhage. The cause of clonic contractions of the uterus in this case, and the resulting hemorrhage, is not perfectly satisfactory to my mind. While the patient was in labor I never saw pains better, or more efficient. Each pain told most percep- tibly on dilatation of the os, and then on expulsion of the child. There was no delay in its progress from beginning to end. The last pain shut the uterus up, and forced the com- plete placenta into the vagina, yet in a few minutes the uterus was greatly enlarged and pouring out torrents of blood. Some, who are opposed to the use of chloroform in labor, may be inclined to attribute the post-partum atony of the uterus in this case to the anesthetic, yet it had no effect in diminishing the force of the pains, or retarding the prog- ress of the labor, even to the point of expelling the pla- centa ; and I may here add, that in a large obstetrical prac- tice of twenty-eight years this is the second case in which I have had any troublesome post-partum hemorrhage, al- though the cases of labor are very rare in which I fail to give chloroform. My first and only case previous to this was in a primipara, to whom I gave no chloroform, because she and her friends were afraid of it. HENRY P. C. WILSON. 5 NOW READY: Gynecological Transactions. VOLUME III. Being the Transactions of the American Gynecological * Society for the Year l8/8. CONTENTS. I. Annual Address on the Relation of Neurasthenia to Diseases of the Womb. By the first Vice-President, Dr. William Goodell. II. A Case of Rupture of the Perineum without Implication of the Vulva. By Dr. J. C. Reeve. III. On the Surgical Treatment of Stenosis of the Cervix Uteri. By Dr. J. Marion Sims. IV. A Case of Extra-uterine Pregnancy, with Discharge of the Fetal Bones through the Bladder. By Dr. J. P. White. V. A Case of Foot and Head Presentation; Fracture of the Spine in Utero. By Dr. J. T. Johnson. VI. The Necessity of Early Delivery, as demonstrated by the Analysis of One Hun- dred and Sixty-one Cases of Vesico-vaginal Fistula. By Dr. T. A. Emmet. VII. The Hand as a Curette in Post Partum Hemorrhage. By Dr. H. P. C. Wilson. VIII. The Treatment of Post Partum Hemorrhage. By Dr. R. A. F. Penrose. IX. Dermoid Tumors of the Ovary. By Dr. W. H. Byford. X. A Contribution to the Study of the Treatment of the Acute Parenchymatous Ne- phritis of Pregnancy. By Dr. W. L. Richardson. XI. Alternating Anterior and Posterior Version of the Uterus. By Dr. S. C. Busey. XII. Remarks on Gastro-elytrotomy. By Dr. H. J. Garrigues. XIII. The Pendulum Leverage of the Obstetric Forceps. By Dr. A. H. Smith. XIV. Rectal Alimentation in the Nausea and Inanition of Pregnancy; Intestinal Inhaustion, an Important Factor and the True Solution of its Efficiency. By Dr. H. F. Campbell. XV. Three Cases of Rupture of the Uterus. By Dr. T. Parvin. XVI. On the Early Delivery of the Placenta when Previa; with the Relation of a Case of Spontaneous Detachment of the Placenta without hemorrhage. By Dr. I. E. Taylor. XVII. Unexpected Narcotism induced suddenly on the Third Day of the Adminis- tration of Three-grain Suppositories of Opium. By Dr. J. P. White. XVIII. Treatment of Pelvic Indurations and Adhesions. By Dr. E. Van de Warker. XIX. On some Points in Connection with the Treatment of Sterility. By Dr. A. Reeves Jackson. XX. A Case of Extreme Anteversion and Anteflection of the Uterus at the Full Term of Pregnancy. By Dr. I. E. Taylor, of New York. XXI. Memoir of Edmund Randolph Peaslee, M. D., LL. D. By Dr. Fordyce Bar- ker. XXII. In Memoriam: Washington Lemuel Atlee. By Dr. T. M. Drysdale. XXIII. The Mechanism of Retroversion and Prolapsus of the Uterus considered in Relation to the Simple Lacerations of the Cervix Uteri and their Treatment by Bloody Operations. By Dr. Nathan Bozeman. Index of Obstetric and Gynecological Literature of all Countries for the Year 1877. Price of Vol. III., $5.00 ; Vols. I. and II., contents of which will be found on the following pages, will be sent to one address by mail or ex- press, prepaid, on receipt of $10.00 by the publishers. The three volumes supplied for $15 00. Address HOUGHTON, OSGOOD AND COMPANY, WINTHROP SQUARE, BOSTON. TRANSACTIONS OF The American Gynecological Society. VOL. 1., FOR THE YEAR 1876. 4.00 pages. Many illustrations. The Annual Address by the President, Dr. Fordyce Barker, of New York, and thcfollowing papers : — I. Etiology of Uterine Flexures, with the proper mode of treatment indicated. By Thomas Addis Emmet, New York. II. Cicatrices of the Cervix Uteri and Vagina. By Alexander J. C. Skene, M. D., New York. III. Extirpation of the Functionally Active Ovaries for the Remedy of otherwise Incur- able Diseases. By Robert Battey, Rome, Ga. IV. On Central Rupture of the Perineum. By J. Matthews Duncan, M. D., Edinburgh, Scotland. V. Viburnum Prunifolium (Black Haw); its Uses in the Treatment of the Diseases of Women. By Edward W. Jenks, M. D., Detroit, Mich. VI. An Illustration of Xenomenia. By Theophilus Parvin, M. D., Indianapolis, In- diana. VII. Relations of Pregnancy to General Pathology. By Robert Barnes, M. D., Lon- don, Eng. VIII. The Spontaneous and Artificial Destruction and Expulsion of Fibrous Tumors of the Uterus. By W. H. Byford, Chicago, 111. IX. Case of Abdominal Pregnancy, treated by Laparotomy. By T. Gaillard Thomas, M. D., New York. X. Pneumatic Self-Replacement in Dislocations of the Gravid and Non-gravid Uterus. By Henry F. Campbell, M. D., Augusta, Ga. XI. Hydrate of Chloral in Obstetrical Practice. By W. L. Richardson, M. D., Boston, Mass. XII. Labor Complicated with Uterine Fibroids and Placenta Previa. By James R Chadwick, M. D., Boston, Mass. XIII. Latent Gonorrhea, with Regard to its Influence on Fertility in Women. By Emil Noeggerath, M. D., New York. XIV. Death from Urinemia in Certain Cases of Malignant Diseases of the Uterus. By Alfred Wiltshire, M. D., London, England. XV. Clinical Memoir on some of the Genital Lesions of Childbirth. By William Good- ell, M. D., Philadelphia, Pa. XVI. Hermaphroditism. By Lawson Tait, F. R. C. S., Birmingham, England. XVII. Cases of Cystic Tumors of the Abdomen and Pelvis. By George H. Bixby, M. D., Boston, Mass. XVIII. Case of Solid Uterus Bipartitus; both ovaries removed for the relief of epileptic seizures ascribed to ovarian irritation. By E. Randolph Peaslee, M. D-, New York. XIX. The Origin and History of Calculi found in the Bladder after the Cure of Vesico- Vaginal Fistula by Operation. By Henry F. Campbell, Augusta, Ga. XX. Rare Forms of Umbilical Hernia in the Fetus. By James R Chadwick, M. D , Boston, Mass. XXI. In Memoriam Gustav Simon By Paul F. Mundd, M. D., New York Price of Volume I., $5.00. As contributions to advanced gynecology they exceed in value anything which we have ever before seen collected in any one volume. — IV. Y. Medical Record. This volume of Transactions is certainly superior to any book of the kind that has been issued by the American Press.— St. Louis Clinical Record. Now we have the first of, we hope, a long row of volumes which will bear comparison with the Transactions of European Societies. Indeed, these must look to their laurels in this noble emulation. — Edinburg Medical Journal. This volume is one of the best collections of gynecological papers that has been published this year. — A nnales dt Gynlctlogie. VOLUME II., FOR 1877. Contains the following papers, with the discussions to which they gave rise : — I. Annual Address, on Medical Gynecology. By the President, Dr. Fordyce Barker, of New York. II. The Functions of the Anal Sphincters, so called. With two wood-cuts. By Dr James R. Chadwick, of Boston, Mass. III. Excision of the Cervix Uteri; its Indications and Methods. With one wood-cut. By Dr. John Byrne, of Brooklyn, N. Y. IV. Report on the Corpus Luteum. With twelve chromo-lithographic plates. By Dr. John C. Dalton, of New York. V. The Pathology and Treatment of Puerperal Eclampsia. By Professor Otto Spiegel- berg, of Breslau, Prussia. VI. Dilatation of the Cervix Uteri for the Arrest of Uterine Hemorrhage. By Dr. George H. Lyman, of Boston. VII. The Principles of Gynecological Surgery applied to Obstetric Operations. By Dr. A. J. C. Skene, of Brooklyn, N. Y. VIII. On the Necessity of Caution in the Employment of Chloroform during Labor. By Dr. William T. Lusk, of New York. IX. The Present Status of the Intra-Uterine Stem in the Treatment of Flexions of the Uterus. By Dr. Ely Van de Warker, of Syracuse, N. Y. X. Supplement to the report of a case of Xenomenia made at the first Annual Meeting in 1876. By Dr. Theophilus Parvin, Indianapolis, Ind. XI. A Case of Vaginal Ovariotomy. By Dr. William Goodell, of Philadelphia, Penn. XII. Is there a Proper Field for Battey’s Operation? By Dr. Robert Battey, of Rome, Ga. XIII. Subsulphate of Iron as an Antiseptic in the Surgery of the Pelvis. By Dr. H P. C. Wilson, 01 Baltimore, Md. XIV. Tetanus after Ovariotomy. By Dr. Theophilus Parvin, of Indianapolis, Ind. XV. Sarcoma of the Ovaries. By Dr. Washington L. Atlee, of Philadelphia, Penn. XVI. The Value of Electrolysis in the Treatment of Ovarian Tumors, as seen in the Light of Recent Experience. By Dr. Paul F. Mundd, of New York. XVII. Congenital Absence and Accidental Atresia of the Vagina; Mode of Operation to Establish the Canal, and to Evacuate retained Menstrual Blood. With three wood- cuts. By Dr. Thomas Addis Emmet, of New York. XVIII. Case of Sarcoma of the Kidney in a negro child. With Heliotype. By Dr. W. H. Geddings, Aiken, S. C. • XIX. The Hystero-Neuroses. By Dr. George J. Engelmann, of St. Louis, Mo. XX. Cases illustrating Important Points connected with Ovariotomy. By Dr. Gilman Kimball, of Lowell, Mass. XXI. The Radical Treatment of Dysmenorrhea and Sterility by Rapid Dilatation of the Canal of the Neck of the Uterus With one wood-cut. By Dr. Ellwood Wilson, of Phil- adelphia, Penn. XXII. Dr. Uvedale West’s Views of Rotation, as illustrated by the Contrast between the Mechanism of Simple Occipito-Posterior Positions and those of the Bregmato-Coty- loid Variety. By Dr. John P. Reynolds, of Boston, Mass. XXIII. Vascular Tumors of the Female Urethra; with the Description of an Instru- ment devised to Facilitate their Removal. By Dr. A. Reeves Jackson, of Chicago, 111. XXIV. Lying-in Hospitals; especially those in New York. By Dr Henry J. Gar- rigues, of Brooklyn, N. Y XXV. The Simpler Varieties of Perineal Laceration; their Consequences and Treat- ment. By Dr. Thaddeus A. Reamy, of Cincinnati, Ohio. XXVI. The Cyclical Theory of Menstruation By Dr. John Goodman, of Louisville, Ky. XXVII. In Memoriam Charles E. Buckingham With a Heliotype Portrait By Dr. George H. Lyman, of Boston, Mass. Index of Obstetric and Gynecological Literature of all Countries, from July 1, 1876, to January 1, 1877. The price of Volume II. is $6.50. Vols. I. and II. will be sent by mail or express, post-paid, for $10.00. Address, 650 pages, 12 chromo-lithographs and many other illustrations. HOUGHTON, OSGOOD & CO., Boston OPINIONS OF THE PRESS. As contributions to advanced gynecology they exceed in value any- thing which we have ever before seen collected in any one volume. With- out exception, every paper has an interest and value attached to it which is intrinsic, and which reflects the best efforts of the respective authors. .... The work is elegantly printed, neatly and tastefully bound. — N. Y. Medical Record. This volume of Transactions is certainly superior to any book of the kind that has been issued by the American press. The papers read and here presented are well written and well digested; and the discussions re- ported have almost as much value as the papers themselves. — St. Louis Clinical Record. We think that never before was such a number of excellent monographs collected together in one volume of Transactions. It is a model in every respect. It is a volume that should be in the hands of every general prac- titioner as well as specialist, as in it may be found most useful suggestions for every day practice. We cannot commend the work too highly, and it is our earnest hope that future meetings of the society will give origin to volumes of Transactions equal to the one before us. — The Hospital Ga- zette. In conclusion, we cannot but regard this volume as a fitting monument of the progress of this most progressive department of medicine. The discussions are rich, and are full of such epitomized good sense well ex- pressed, as is rarely found in any volume of Transactions, while the whole contents exhibit the most careful supervision of the editor.— Toledo Medi- cal and Surgical Journal. Organized amid the whirl and bustle of last summer, the American Gynecological Society bids fair to realize the brightest hopes of its found- ers. Its first volume of Transactions, now before us, will bear the closest scrutiny, and safely challenge the severest criticisms, so superior is it in its breadth 5f thought and observation, scientific worth, and literary excel- lence ; the writers of the papers in these Transactions being no mere novices, but men skilled in the profession they represent, and experts in the branch of study and practice which they especially call their own. — Philadelphia Medical Times. It is not a trifling matter to be able to say of this volume that it is the handsomest of the kind anywhere produced But this is not only an elegant volume, it is a good one ; creditable to the authors, creditable to the great republic Now we have the first of, we hope, a long row of volumes which will bear comparison with the Transactions of European Societies. Indeed, these must look to their laurels in this noble emula- tion.— Edinburgh Medical Journal. This book of nearly 400 pages contains a series of excellent articles upon gynecological topics, written by the most prominent gynecologists of America and England. — Allg. Wiener Med. Zeitung. This volume is one of the best collections of gynecological papers that has been published this year We do not doubt that it will confer the greatest honor upon the medical literature of America. — Annales de Gyntcologie. Few volumes that have recently come under our notice have been so ex- tremely interesting and instructive. The papers reach a very high order of excellence, and some indeed are superlatively good. — American Jour- nal of Obstetrics.