With the exception of those instances where it is desired to remove a large amount of blood, it suffices to apply from four to six leeches. More than six of the large or eight of the small is excessive, since they interfere with one another.
In a short time the leeches have taken hold, and during the applica tion the patients complain of a greater or less drawing sensation, and the tampon is then to be removed from the speculum. In a few minutes a drop or so of blood will appear, and this is the signal that one of the leeches has dropped off. This leech is at once removed as also any other which may not have taken hold. The insertion of a fresh leech is gen erally ineffective, seeing that it.will satisfy itself with the blood in the speculum. When the last leech has dropped off, and this can at any time be secured by pouring in a little salt solution, the leeches should again be counted, and if none are lacking, the blood in the speculum is allowed to flow out by tipping the instrument, and the speculum is then removed.
If the bleeding is not profuse enough, this may be increased by the injection of warm water, or by the application of hot poultices over the abdomen and the genitals; in case the bleeding is too profuse, then it may be checked by the insuffiation of styptic powder (alum, tannin), or by touching the bleeding spots with lunar caustic, the cautery, the in jection of liquor ferri, or by the tampon. The surest way is by passing a suture under the bleeding site. Injection of cold water or the applica tion of ice should, where possible, not be resorted to.
The application of leeches to the uterus require a number of condi tions. It must be possible to insert a rather large speculum, and yet in the presence of an acute inflammatory process it is often impossible to do so on account of the pain caused. In such instances the leeches may be applied around the anus, or to the inside of the thighs, or on the labia, in which event, of course, the parts should first be shaved. It is preferable to refrain from applying leeches to the uterus in the presence of extensive acute inflammatory processes of the pelvic peritoneum, or the pelvic cellular tissue, for then we are rather likely to increase the congestion than to diminish it. Pregnancy, further, is a contra-indication to leech
ing, although a number of cases have been recorded where the course has not been interfered with.
The use of leeches is open, however, to a number of disadvantages which make us desire the possession of some substitute. The mere thought of their application and the possibility of their escaping excite the patients greatly, so that often during and after their use there are present nervous disturbances of an aggravated nature. Great pain, more or loss uterine colic, even when no leech has entered the uterine cavity, hysterical attacks, collapse, vomiting, the appearance of erythema or tirticaria, as noted first by Scanzoni, and then by Veit, Leopold, Schramm, and others, these occurrences are by no means infrequent, and are alarming to the patients and to their attendants. It is, therefore, advisable, before the application, to tell the patient and her friends of the possibility of such occurrences, and further that they do not amount to anything. An injection of morphia, or the local application of an anodyne, generally suffices to overcome these symptoms.
In case a leech has opened a large vessel there may result profuse hemorrhage, and frequently enough the repeated application leads to great anemia. This is true especially of cases of so-called chronic metritis, where repeated venesections have been considered necessary in the treat ment, and the cervix may become hard and misshapen from the repeated bites. The hemorrhagic diathesis, the presence of papillary, readily bleeding ulcers or new growths, are contra-indications to the use of leeches.
Another means of performing venesection on the uterus is the open ing of vessels by means of cutting or scarifying instruments. For the purpose of scarification we do not need complicated apparatus, such 1 1 that of Miller, Storer and others, but a long-handled knife, which is either convex like Scanzoni's or pointed like C. Mayer's. Any sharp pointed bistoury will suffice, however, or where it is desired to puncture deeply, as is recommended by Kristeller, Spiegelberg, Schroder and Fritsch, any long, stout, sharp needle.