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variety being by far the more common. It is one of the gravest conditions met with in obstetrics. There are two varieties in which this may declare itself; it may be frank or open or hidden or concealed. The open form being the more common, while in some cases both forms may be present at the same time. In normal labors separation of the placenta does not occur until the child has been delivered.
Observations in cases of Cesarean sections have shown the placenta separating as the child is delivered, and also that it remains attached until the third stage have begun. We may, therefore, speak of premature placental detachment in all cases where the placenta separates in whole or in part from its attachment to the uterus before the head of the child has been delivered. Under this definition may be included several examples of detachment of the placenta; premature detachment of a placenta situated low in the uterus may give rise to symptoms of placenta previa and also to premature detachment; second, if the placenta separates during the last few minutes of the second stage of labor, the child may be delivered dead or in a state of asphyxia, depending on the length of time since the interruption took place. The exit of the child is attended by a gush of blood and often followed by the placenta; such cases are not rare. A short cord may be the cause or unruptured membranes may pull the placenta after it. In twin pregnancies, after the delivery of the first child, the condition is recognized by the external hemorrhage in shoulder presentation; in prolonged labor the placenta may separate before delivery, finally there is the detachment of the normally situated placenta in pregnancy or during early labor.
The causes of this condition are variously given; accident may be the cause, with the predisposing cause of a diseased uterus or decidua or placenta as endometritis, nephritis, hemorrhagic infectious diseases. Once a separation begins, it may continue until it is complete. If one included all the varieties of premature placental detachment, the occurrence is very common; if one specified only those cases assembled under ablatio placenta they are quite rare. Expulsion of old black clots is pathommonic. Partial separation is not uncommon; this con
dition is often recognized only by finding an old clot in a depression of the placenta; complete separation is rare and usually fatal.
The external hemorrhage may be only considered a diagnostic sign, never be the criterion as to the amount of blood which has escaped from the woman's vessels; the systemic evidence alone should be our gauge in all cases. Another sign is accessory tumor, a prominence of the uterine wall due to blood stored up behind the placenta; another sign is escape of blood serum from genitalin, it is dependent upon blood retention.
Besides the appearance of blood in the open variety, there is generally pain which is at times persistent and of a tearing, piercing character or cramplike colicy and bearing down. The suffering varies greatly in different cases; it may be localized at the placental region or at the lower uterine segment due to stretching from retained clots. Instead of a sudden gush of blood there may be a more or less continuous dripping, part escaping and part coagulating. This condition may continue for weeks. The symptoms of the concealed variety are chiefly extreme collapse and exhaustion without any apparent cause. Shock may exist even when there is no great loss of blood; this is due to the enormous distention of the uterus.
When there is an external flow, the prognosis for the mother is not so unfavorable, for the condition may be readily recognized and treated; in the concealed variety, however, there is far more danger, the mortality is great, for often the diagnosis is not made until the patient is in nearly moribund condition.
Treatment: If the hemorrhage takes place during pregnancy and is not severe, the treatment should be similar to the treatment of threatened miscarriage; rest in bed, morphia, and careful nursing will sometimes give good results. In the presence of a more severe hemorrhage the first thing to do is to bring on uterine contraction. One of the best means at our hands is to rupture the membranes, give hypodermic injection of ergot. This is one of the conditions in which ergot is indicated. A firm abdominal binder should be applied to prevent blood from collecting and filling the uterine cavity after the membranes are ruptured. If the hemorrhage still continues,
the sooner we can empty the uterus the better. This may be done by version, if our patient is able to stand the shock of the operation; or if the head has passed the pelvic brim apply the forceps.
Some physicians may go through a lifetime of practice and not meet a real case of post partum hemorrhage. Some troublesome bleeding occurs from tears in the anterior commissure or on either side of the urinary meatus or a badly lacerated cervix. These, while they are alarming are not so much so as a real post partum hemorrhage.
The frequency of this complication varies. In the young practitioner I believe it is more frequent, for practical experience has not taught the proper management of the third stage of labor.
Causes: Some of the women are by nature bleeders. Certain conditions in their blood, as albuminaria, malarial poisoning, leucocythemia and alcoholism; this condition is more frequent in multipara than primapara, in women whose menstruation is profuse and of delicate constitution, twin pregnancy and hydramnios.
The most frequent exciting cause comes from the improper management of the second and third stage of labor. The too rapid emptying of the uterus in too great a hurry to remove placenta; the use of the forceps, excessive and needless use of ether or chloroform; retention of placental membranes and blood clots. There are other causes pertaining to the patient's mental condition, as fright, anxiety, etc., but the above I believe to be more frequently the cause.
Symptoms: Unless we are anticipating and looking for a hemorrhage, we may not know it is taking place; it may come on very insidiously; everything may have gone very well, but the first thing we know the patient will begin to get uneasy, complains of feeling faint, that the atmosphere is close, and that something is running away from her. This is a signal that we should investigate immediately; there may be only a slight discharge of blood, or it may come in torrents. On palpatating the uterus, it is found to be soft, flabby and flaccid, rising to or above the umbilicus, or we may not be able to out
line the uterus in uterine inertia; if we put our fingers on the pulse we find it increased in frequency and decreased in force; if the uterus is filled with clots, our patient will complain of a steady pain in her back. If on palpatating the uterus we find it enlarged and distended, or flabby and flaccid, it is reasonable to suppose that the hemorrhage comes from the uterus; if on the other hand the uterus is firmly contracted, the hemorrhage most likely comes from a lacerated cervix or the vagina, or if it occurs ten or fifteen minutes after the birth of the child, it is not usually due to the cervical or vaginal tears. When this hemorrhage does occur, it is one of the most alarming conditions in the lying-in chamber.
The prognosis depends on several factors. It is graver the earlier it takes place or in the syphilitic or hemophilic or diseases of the uterus; also more dangerous in the internal variety, for it may escape detection.
The preventive treatment of these cases is to treat the cause, if we know the causes that are likely to bring on this condition, they should be corrected, if possible, before labor sets in, and the proper management of the second and third stages of labor. It is commonly understood that contraction of the uterus and thrombosis of the veins by clots is nature's method of preventing hemorrhage, and anything that will bring about these conditions is the practical method of treatment.
The first thing we do is to grasp the uterus firmly. It may be sufficient to clean out the clots and further hemorrhage will be arrested. If this does occur we must keep up contraction by gently kneading the uterus until we are satisfied that undue relaxation will not occur.
If that procedure does not arrest hemorrhage, it may be necessary to pass the fingers or hand in the vagina and clean out clot, at the same time exciting the uterus to contract. At this time we should give the patient a hypodermic of some preparation of ergot; if this does not arrest hemorrhage, then we might try a hot injection of sterile water; if not controlled by these measures, try ice internal and external styptics, and lastly packing with gauze.
The management thus far given should be sufficient to arrest hemorrhage in most cases.
Puerperal hemorrhage: Secondary or late hemorrhage, causes, retention of placental fragments, pieces of membrane, hypertrophied decidua, displaced uterus, dislodgment of clots from the placental site, emotional disturbances, relaxation of the uterus, fibroid tumors, pelvic engorgment, cardiac, renal or hepatic diseases.
BY DR. A. C. BROOKS, WILKES-Barre, Pa.
Although the origin of pentosuria may have been due to Eve eating the forbidden fruit, no historical knowledge of the existence of pentosuria is known until it was discovered by E. Salkowski and Jastrovitz in 1892, when they found an optically inactive sugar which did not ferment with yeast. This sugar they found to be different from dextrose, levulose, galactose, etc., which contain six carbon atoms in the molecule, and are termed hexoses. These hexoses are the sugars we are all familiar with, and are looking for when we examine urine for sugar, and when dextrose or glucose is found the urine is said to contain glycosuria. When levulose, a fruit sugar, is found, the urine is said to contain levulosuria, and when lactose, or milk sugar, is found, the urine is said to contain lactosuria. In contradiction to the hexose, or often called glucose group, we have a group of sugars which contain five carbon atoms in the molecule, and this group is therefor called pentose because it contains five carbon atoms. Pentoses are common in the vegetable kingdom in fruits, leaves, roots, and stems. Such fruits as apples, plums and pears are especially rich in pentoses. The pentos group is also found in the animal kingdom among the nucleo-proteids. The various members of the pentose group differ from one another in the position of attachment of the OH groups, as do dextrose, levulose, and lactose among the hexoses. The most important pentoses