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Practical Remarks on Retention of the Placenta, with Especial Reference to the ConditionTermed "Hour-Glass Contraction of the Womb"Author(s): Richard HodgesSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 14, No. 11 (May 29, 1850), pp.283-285Published by: BMJStable URL: http://www.jstor.org/stable/25501275 .

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MR. HODGES ON RETENTION OF THE PLACENTA. 283

in the report) a sensation of tightness round the waist,

cotemporary with the loss of power;-the immunity of

the bladder and rectum from paralytic torpor;-and the marked beneficial influence of warmth upon the

extremities, all indicate the peripheral origin of the

attack. . That there existed, however, during the pro

gress of the case, some local congestion of the spine,

resulting from deranged nervous influence, and pro

ducing pressure, is more than probable, and to this

may perhaps be attributed in some measure the subse

quent loss of power. In the treatment, the principal indications appeared

to be the removal of anesthesia by restoring lost tone

to the affected nerves, and the withdrawal of any local

congestion or serous effusion, that might exist within

the membranes of the spinal cord. The warmth of

bed, galvanism, and steel, amply fulfilled the former

indication, while the exhibition of the bichloride of

mercury, and the tincture of cantharides, by exciting the absorbents, and relieving pressure, satisfactorily effected the latter.

[To be continued.]

PRACTICAL REMARKS ON RETENTION OF THE PLACENTA,

WITH ESPECIAL REFERENCE TO THE CONDITION

TERMED " HOUR-GLASS CONTRACTION OF THE

WOMB."

BY RICHARD HODGES, ESQ., F.R.C.S.

To the Editors of the Provincial Medical and Surgical Journal.

GENTLEMEN,-The great importance of this division of the practice of Medicine, will, I trust, form a

sufficient apology for my sending you the enclosed

communication, the insertion of which, if it be regarded by you of any worth, will greatly oblige

Your faithful Servant, RICHARD HODGES.

Rochford, Essex, March, 1850.

The delivery of the placenta has ever been considered a matter of the greatest interest: many of the diffi culties the surgeon meets with are traceable to its

retention; and complications often of a fatal character now and then arise when the placenta is kept back either through inaction, fatigue, or exhaustion, or from

spasmodic or irregular action of the expelling organ, the prominent evil attendant upon such conditions

being hemorrhage; and I need not here remark that there are no cases in the whole practice of midwifery

more fearful to behold, or which call for the exercise of greater promptness and skill than those which are

accompanied by severe flooding. The management of the placenta has, in all ages of the world, been con ducted on the most opposite principles; for we find one eminent individual recommending that the mass should be removed immediately after the birth of the

child; another, that the woman be allowed to rest

awhile, and recover from the fatigues of parturition; and a third advising that the placenta be suffered to

come away entirely by itself-be left until the un

assisted powers of nature expel it.

On reflection, it is to be admitted that general rules

are in some degree useful, and serve as guides to the

uninitiated, and are often approximative of the proper

plan of practice; yet experience teaches us no one rule

can be applicable to all conditions. The wisest course

appears to be to observe the operations of Nature, and

to act as she may dictate, for by so doing we shall be

less likely to err than by adopting any artificial rule

which may be established. We cannot keep her too

prominently before us. She should be our guide; for

we see that even in those cases where the assistance of

art is necessary, the feeble efforts of the surgeon would

be unavailing were she to withhold from him her

powerful aid.

On proceeding to the more immediate object of this

paper, namely, the consideration of retention of the

placenta, it may not be irrelevant in this place to

mention the experience which the attending of upwards of a thousand cases of labour has given me in relation

to this subject. In rather more than one-third of the

cases the placenta was either expelled at one and the

same time with the child, or passed away of itself in

from five to twenty minutes after the birth of the

infant. In three or four cases it was retained through uterine inaction, or fatigue, the consequence of difficult

or tedious labours, and in one of which cases there was

partial adhesion of the placenta to the uterus. In two

instances the afterbirth was kept back through what is

termed hour-glass contraction of the womb, the nature

of which induced me to draw up the present communi

cation, as an additional proof, if one were wanting, that the state called hour-glass contraction of the

uterus does now and then occur; and to convince,

through the medium of your journal, those who may doubt its existence, or be unprepared to meet with the

complication when called upon, either on account of

flooding or prolonged retention, to remove by operation a placenta from the uterus. In the remaining cases, and these constitute by far the greater number, the

afterbirth was not excluded within the period specified

twenty minutes. The uterus, however, was in all of

them firmly contracted, and the placenta consequently separated from it, the mass remaining partly in the

vagina and partly in the uterus, in a position from

which it might be at any time safely taken, provided that the womb be felt "hard as a ball" through the

walls of the abdomen. From observation, therefore, I

infer that it is not at all uncommon for the placenta to

remain behind a long time, and that many have taken

to themselves the credit of having performed a serious

operation, whereas, in reality, no operation has been

performed at all, save that of removing the mass from

the vagina,-a very different matter from having to

perform the more rare operation of introducing the

hand and arm into the cavity of the womb itself. I

have been called in on many occasions for the purpose

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284 MR. HODGES ON RETENTION OF THE PLACENTA.

of removing, by operative means, a placenta which had

not passed after an interval of four or five hours; but

upon placing my hand on the abdomen, I felt the womb

firmly contracted, when I knew that the mass was

partly or wholly in the vagina, completely separated from the uterus, and removable with facility and safety, The following is a rule to which I have as yet met with

no exception, namely, that if the uterus, upon examina

tion, be felt firmly contracted, and the insertion of the

cord into the placenta easily distinguishable, and the

finger capable of being carried round the mass when in

the vagina, it can be removed with safety aud advantage.

On looking at the results of the cases which came under

my care, it will be observed that Nature, in the majority of instances, was adequate to the end in view; but

that occasionally, although rarely, she failed of accom

plishing her work. After a tedious or difficult labour,

however, when the system and uterus were alike worn

out by long-continued action, the womb having flagged, or ceased to act, the result was either retention of the

afterbirth, or flooding to a greater or less extent, or

both of these evils combined; retention, through

atony, as it is sometimes termed, is distinguished from

the condition above described by the uterus not being found in a state of firm contraction, and by the fact

of the insertion of the cord into the placental mass not

being perceptible. This form of retention requires the introduction of the hand and arm into the uterus, and not one moment is to be lost if there be flooding. The operation is to be effected in the gentlest manner

possible. " Arte non vi " should ever be the surgeon's motto. And, according as the placenta be loose or

adherent, the surgeon is either to direct the hand

between it and the uterus, that that organ may contract

upon and expel its contents, or, in the case of adhesion, to expand the fingers over the foetal surface of the

mass and draw its edges towards the centre, by which

manoeuvre frequently it is separated, and safely taken

away.

Having alluded to retention from atony and adhesion, I have now to speak of detention of the afterbirth

from spasmodic or hour-glass contraction of the uterine

fibres-the most rare cause of all. I am quite at a

loss to give a satisfactory reason for the occurrence of this singular irregularity, and therefore shall not

attempt any explanation respecting it, but shall proceed at once to detail the cases themselves.

On two occasions only have I met with the true

hour-glass contraction of the womb, in one of which

instances the ergot of rye had been given, in the other

not, consequently it cannot be said that ergot invariably

produces it. In one instance recently under my care

I noticed that the os uteri closed rapidly, embraced the

placenta tightly, and thus for a time retained it-a

state of things which, I imagine, might easily be mis

taken for the above; and it is not improbable that this

very condition has been, on more than one occasion, set down for the true hour-glass contraction, but I need

not add that the two cases are very different, and that

the operation for the removal of the placenta is much

more easily accomplished in the one case than in the

other. In the case in which I first met with this rarity the true hour-glass-the patient had been a long time in

labour with her first child, under the care of a friend of

mine, at the time I was at St. Thomas's Hospital, in

the year 1843. Ergot had been administered to expe dite the process, but from the labour not progressing so rapidly as my friend wished, he requested me to

visit the poor woman with him. Upon examination I

found that all was proceeding very favourably; the

head was pressing on the perineum, which seemed dis

posed to yield, and in a short time the child was born;

the patient, however, was beginning to get exhausted, for she had been ill for thirty-six or forty hours, and

the uterus acted feebly and irregularly, the latter

circumstance most probably being the result of the

administration of the ergot, for the actions induced by it are very unnatural, and such as would induce

irregularity and spasm. The placenta not passing for

a considerable time-an hour and upwards-I proceeded in the gentlest manner possible to pass my right hand

and arm through the os uteri into its cavity, when after

a further introduction I came into contact with what

appeared to be the fundus of the uterus, and soon

detected, by closely following the direction of the cord, an aperture in the centre, through which the funis pro ceeded. The real state of things was now evident: one

finger after the other was very gently insinuated through this small opening until the hand and arm could be

carried into the upper compartment, where the placenta was discovered, and from which it was easily removed.

Our patient speedily recovered without an unfavourable

symptom.

The particulars of the second case are as follows:

Mrs. Henry B., of Rochford, sent for me on the 17th

of last month, when in labour with her tenth child. I

was quickly in attendance, and soon after my entering the room the child was born. In about a quarter of an

hour afterwards flooding to a great extent took place,

syncope at once occurred, the pulse could not be per

ceived, the surface was cold and blanched, and she

appeared at the point of death. I immediately intro

duced my right hand and arm into the womb; met

with no difficulty until I had passed some way beyond the os uteri, when I soon discovered the womb to be

firmly contracted at about its centre, leaving only a

small aperture through which the cord escaped from

the upper into the lower part of the organ; one finger after another, as in the preceding case, was slowly introduced through this opening, when the hand and

arm after a time passed into the upper division of the "

hour-glass," and the placenta having been detached,

for it was slightly adherent, was easily taken away. She soon recovered, remaining only weak from the loss

of blood prior to the operation described.

The operation of removing a placenta when retained

through inaction is comparatively easy of execution.

In such an instance, however, the greatest gentleness,

patience, and delicacy of manipulation are required; but still more are such qualities called for when it is

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CASE OF COMPOUND FRACTURE OF THE RIGHT LEG. 285

found that the womb is irregularly contracted, or

divided as it were into two parts by a drawing together of its centre, for in proportion to the strength of the

spasm will the operation be rendered more or less

difficult.

CASE OF COMPOUND FRACTURE OF THE

RIGHT LEG, WITH SEVERE LACERATION, SECONDARY AMPUTATION,

AND DEATH.

BY E. GYLLES CROOKE, M.D., EDIN.,

M.R.C.S., ED., and L.A.C.

I WAS hastily summoned about half-past five P.M.,

April 1st, to visit Catherine Bamber, aged 10 years, whose leg had been severely injured in the cog-wheel of a bark grinding mill at a tan-yard.

On my arrival I found an enormous wound, involving the flesh of part of the anterior, the internal, and

posterior aspects of the right leg. The course of the

wound was diagonal, from the outer side of the patella to the back of the ancle. The internal surface of

the tibia was denuded three or four inches, as also

the whole patella, with its ligament. The fibres of

the gastrocnemiuse muscle were considerably lacerated; the detached flap at the central and broadest part was

seven inches in width, and had the appearance of having been crushed after laceration. Synovial fluid appeared to escape from the inner side of the knee-joint, but

no distinct wound was apparent. The anterior edge of the tibia was fissured, but as the inferior portion of the bone was covered with the tumid integument it

was impossible to ascertain with accuracy the extent of

fracture. A great quantity of blood had been lost, and

there had been considerable vomiting before my arrival, which was about two hours and a half after the injury. The hemorrhage had, however, then ceased, the sur

face of the body was cold, the pupils slightly dilated, but the pulse was between 90 and 100, of moderate

tone and equal in rhythm. As reaction appeared to be

commencing, with the exception of the application of

warmth, I did not think it prudent to administer stimu

lants. As far as the irregularity of the laceration

would allow, by means of sutures and adhesive plaster, I brought the compound fracture into the condition of a simple one, applied a bandage tolerably firmly over the whole limb, and placed it in Liston's double

inclined splint, with foot-piece. The leg was ordered

to be kept continually moistened with cold water, and

the following medicine was prescribed:-R. Hydrarg. cum Creta, gr. iv.; Ext. Hyoscy., gr. ij., fiat pilula statim sumenda. R. Liq. Ammon. Acetatis, oz. j.;

Tinct. Hyoscyami., dr. ij.; Mist. Camphorse, oz. iij. M. Cap. coch. j., mag. omni secunda hora. At the

same time I expressed my opinion to her friends that

mortification would supervene, and render amputation imperative.

April 2nd.-The child has had no sleep, is very restless from the excruciating pain, and complains of the limb feeling numb. The leg is not much swollen,

but has an inflammatory blush, extending some distance

above the knee, especially in the ham; there is much

thirst and headache; the pulse is full but soft, and

about 120; the bowels have not been moved; drink is

rejected. Warm applications were ordered to be sub.

stituted for the cold. Five grains of calomel, with a

tablespoonful of castor oil, were prescribed immediately. Of an eight-ounce effervescent mixture, containing twelve minims of hydrocyanic acid (P. L.,) and three

drachms of the solution of the muriate of morphia, a

tablespoonful is to be taken every hour.

3rd.-The limb is more swollen and less sen

sible to touch; the blush is of a more livid hue, and

now occupies the whole ham; the pulse is about' 120,

soft, small, and irregular; the vomiting is very trouble

some; the skin dry and hot; the pupils irregular, one

dilated, the other contracted; the bowels have not yet been moved; the tongue is but very slightly furred; the child dozes a little, and has been very delirious

and restless through the night. The features are

putting on the Hippocratic expression. A tablespoonful of a warm aromatic aperient is to be taken every hour

until the bowels are opened, the dose of morphia to be

decreased one-third, the effervescent mixture continued, and a tablespoonful of port wine and water to be given

every three hours. The sutures were taken out to-day. and warm poultices applied.

4th.-The bowels have been opened three times; the sickness is not so urgent; the delirium is less; she has slept four hours at once, and complains of

no pain; the facies Hippocratica is now evident. She

has asked for and eaten some bread and butter. The

thirst is not so troublesome; the pulse about 130, weak

and small; the surface of the body is cooler, and the

girl expresses herself as more comfortable, but the

temperature of the leg has increased; it crepitates under pressure; the wound gapes and discharges a

foetid sanious pus; sensibility has diminished; a dis

tinct line of demarcation is forming immediately above

the patella in front, from the commencement of the

ham posteriorly, to within four inches of the foot

anteriorly, and behind down to the ankle. The quan

tity of port wine is to be increased, and tonic medicine, with the opiate, prescribed. Yeast poultices are ordered, to be changed every four hours. The father is informed

that amputation is indicated.

5th.-The detachment of the slough has com

menced; the hamstring muscles are visible, and it is

evident that the whole of the integuments-probably the muscles as well-will slough off. The pulse is as

yesterday; the tongue clean; the skin cool; the vomit

ing has ceased; the appetite is improved; and the

bowels have been moved twice since yesterday. The

necessity of amputation was now urged upon the

father, but was refused. The medicine, wine, and

poultices are, therefore, to be continued.

6th to 13th.-The process of detachment has pro

ceeded, and is this morning completed; the whole limb

is bare to the extent before mentioned, the muscles

both of the anterior and posterior region are involved, and can be detached piecemeal with a sponge. The

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