Volume 1

The cyclopedia of practical surgery, including an etymological and critical terminology; detailed descriptions of instruments and apparatus; a copius bibliography; and an historical view of the progress of the science to the present day: ... a complete digest, alphabetically distributed, of the doctrines and practice of surgery / conducted by William B. Costello ; assisted by numerous distinguished writers ; illustrated with numerous engravings and wood-cuts.

Date:
1841-
Catalogue details

Licence: Public Domain Mark

Credit: The cyclopedia of practical surgery, including an etymological and critical terminology; detailed descriptions of instruments and apparatus; a copius bibliography; and an historical view of the progress of the science to the present day: ... a complete digest, alphabetically distributed, of the doctrines and practice of surgery / conducted by William B. Costello ; assisted by numerous distinguished writers ; illustrated with numerous engravings and wood-cuts. Source: Wellcome Collection.

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    the intensity of the spasm, the amount of haemorrhage, and the existence of morbid ad- hesion of the placenta to the uterus. If there be no haemorrhage, four hours is not too long to desist from manual interference, keeping the patient perfectly quiet, and endeavouring to calm her feelings. An opiate enema, or a dose of laudanum may be given sufficiently large to allay irritability, but not so great as to lead to a danger of inertness of the uterus. Bleeding has been recommended, but should only be regarded as an exceptional practice, as we cannot foresee the amount of haemor- rhage which will take place from the uterus. VV^arm fomentations, or a large poultice of bran and hot water are often useful. Under this treatment the spasm will occasionally re- lax and the placenta readily come away. If not, the opiate may be repeated, the introduc- tion of the hand being employed only as a last resource, on account of hsemorrhage, con- vulsions, or considerable lapse of time. The observation of Meckel is repeatedly borne out, that repose frequently suffices to complete what the hand of the accoucheur had in vain endeavoured to effect. Four hours, however, is perhaps the limit of delay, as there is a pos- sibility that the uterus may undergo sueh a degree of contraction, as to prevent the intro- duction of the hand, and lead to the necessity of full opiates. When we have determined to remove the placenta, the hand is to be intro- duced as before till it arrives at the con- striction, through which one finger is to be gently insinuated, then another, another, and lastly the whole hand. The placenta is then to be separated, when, in all probability, the uterus will contract strongly, and expel it with the hand. It is well to withdraw the hand very gradually, to ensure a general con- traction of the uterus, and, if necessary, the broad part of the hand may be retained a short time at the point of principal contrac- tion till the other portions act. Where the neck of the uterus is the seat of spasm, and is contracted forcibly around the placenta, part of which is in the vagina, a little cautious dilatation of the os uteri will remove all difficulty. III. Retention from morbid adhesion between the placenta and iderus. This adhesion may be total or partial, slight or intimate ; sometimes there is no great difficulty in separating the opposed surfaces, at others the tissues are so confounded toge- ther that it is impossible to distinguish them, or effect separation without abrasion of the uterus. Sometimes the adhesion is in one circumscribed spot, at others around the whole circumference, while in another class the bor- ders are free, several points of the middle portion firmly adhering. The rarest case of all is where the adhesion is total. The nature of these adhesions is by no means clearly understood ; the older writers attributing them to scirrhosities of the uterus or placenta, while many more recent authors believe they are owing to the effusion of co- agulable lymph from the lining membrane of the uterus under inflammatory action. There are objections to both assumptions, for the placenta is frequently found to have under- gone more or less scirrhous degeneration, to be indurated or softened, and to contain cal- careous or osseous granules, or scrofulous tu- bercles, where not the slightest morbid adhe- sion has existed. Velpeau also states that he has never heard of a case of morbid adhesion where the uterus was scirrhous, and that it is well known the placenta contracts a less inti- mate union with fibrous tumours upon which it has been developed, than with the uterus itself. Inflammation may probably be a cause in certain cases, as when, after some injury, a pain is felt in a part of the uterus corre- sponding to the spot at which the placenta is afterwards found attached. But sometimes such a pain is observed through a great por- tion of the term of pregnancy, where no ad- hesion follows, and it is very common to meet with adhesion where there have been no such symptoms. And, further, we know that in- flammation of mucous membranes very rarely leads to the effusion of lymph and adhesion of their surfaces to each other, or to bodies with which they may be in contact. Careful anatomical observation is still required to settle this question. The signs of this condition are continuance of uterine contraction, without descent of the placenta; and, on passing the hand into the uterus, we find that the retention is not owing to irregular contraction, but that the placenta is adherent and probably indurated. There is usually more or less haemorrhage, as it is a rare case to meet with such total adhesion that no separation has taken place. The uterus, in most cases, is pretty firmly con- tracted, on account of the efforts it has made to expel the placenta ; but it is sometimes in a state of inertia, and at others there is irre- gular contraction. Two very different modes of practice have been recommended by accoucheurs, in the treatment of cases of morbid adhesion of the placenta; one class of practitioners leaving the patient to the unassisted efforts of nature, the other most earnestly enforcing immediate separation by the hand. The principal arguments in favour of the former view are, that the placenta may re- main an indefinite time without injury to the mother ; and that the dangers of removing it are so great as to render the practice unjusti- fiable. Thus, Dr. Denman relates a case where a placenta was expelled evidently just separated, which had been retained fifteen days, yet there were very slight traces of putrefaction. The late Dr. Young, of Edin- burgh, is said to have met with a case in W'hich the placenta never came away, yet the woman recovered. Naegele also has brought forward cases to prove that the whole, or a considerable portion, of the placenta may be retained in the uterus, without any dangerous consequences to the mother; and Dr. Salo-