SECONDARY PUERPERAL HEMORRHAGE.
Hemorrhages of this nature are less grave than those we have just de scribed, but they may be serious in their complications. When primary inertia has been overcome, we must not fall into the error of believing our patient safe, for frequently secondary inertia sets in. If we do not carefully watch our patient this may pass unnoticed, and all may be lost at a time when we thought all was gained. At the end of a variable period, from a few minutes to a few hours, hemorrhage occasionally re curs, and the patient is, of course, in a very bad condition to withstand this recurrent loss of blood. Whence the stringent rule, when once we have overcome a hemorrhage, not to leave our patient for some hours, and to keep her quiet in the bed where she was confined, without at tempting to change the sheets or to disturb her in any way.
There are two symptoms which will foretell the impending hemor rhage. The one from the side of the uterus, which, instead of being hard and globular, is soft, extends above the umbilicus, and on pressure gives exit to blood; the other, from the side of the pulse, which is very fre quent and small.
The explanation of this secondary hemorrhage is the following: Deliv ery has been regular, the third stage normal, and the loss of blood moder ate. Precisely because this loss is moderate, has it a tendency to coagulate, and there forms in the cavity a clot which keeps the uterus from con tracting, and leads to deficiency in retractility. The uterus is kept at an increased size. Ordinarily, at the end of a variable time, the woman has a few after-pains, and expels the clot, but frequently there results pro fuse hemorrhage, both internal and external. In such cases we must re sort again to the treatment applicable to primary inertia.
In order to forearm themselves against this late hemorrhage, certain accoucheurs are in the habit of giving ergot to all their patients. We be lieve this practice more harmful than the reverse, for in such cases, we often see small clots, retained in the uterus, putrefy and become the start ing-point of puerperal complications. [We have elsewhere given our
reasons for disagreeing with the author. We simply repeat here that the routine administration of ergot, by keeping the uterus firmly contracted, prevents largely the formation of clots.—Ed.] In other instances, the puerperium progresses normally for forty-eight hours, and even longer, when hemorrhage occurs, without, at first sight, known cause. In the majority of cases, it is due to the neglect or error of the accoucheur. There has, perhaps, been left a portion of the after birth in the uterus, which would not have happened had the placenta been carefully examined. If we examine these patients, indeed, there will often be found engaged in the cervix a shred of placenta or mem brane, and when this has been extracted, the hemorrhage ceases. Some times, however, the accoucheur is not at fault, where, for instance, the placenta has been closely adherent, and it has been impossible, except at the risk of injury to the patient, to remove all. In such cases the hem orrhage is really salutary, for it indicates the separation of these adherent portions, which might otherwise putrefy. Finally, in certain cases of supernumerary placenta, we meet with these hemorrhages, and yet the accoucheur could not have suspected the existence.
There is still a further variety of secondary hemorrhage occurring towards the twenty-fifth to the thirtieth day, even later. It occurs both in women who nurse, and in those who do not. In the first instance it seems as though the irritation of the breasts interferes with involution. If it become at all profuse, the indication is to stop lactation, and to give ergot. Hot injections sometimes cause the cessation of these hemorrhages. Hot general baths have yielded us the best results. (SeeVol. I, under the Puerperium.) In women who are not nursing, the uterus remains large and volumin ous. Absolute rest, ergot, hot baths constitute the treatment.