Till: TREATMENT OF POST-PARTUM HEMORRHAGE 
Read before the Philadelphia Courtly Medical Society, November 8, 1882, 
BY W. H. PARISH, M.D. 
[REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES FOR DECEMBER 16, 1882.] 
HAVING been requested by the di- 
rectors of this Society to discuss in a 
paper the treatment of post-partum hem- 
orrhage, it would be inappropriate to at- 
tempt a consideration of the general sub- 
ject, hemorrhage after labor. In fact, the 
proper limit of a paper to be read before 
the Society, and to be discussed by it, does 
not admit of such a consideration in ex- 
tenso. Yet, in order rationally to weigh 
the various methods of management of 
this sometimes fatal and always important 
accident, it will be necessary briefly to re- 
call some of the salient conclusions bear- 
ing directly on the indications in treat- 
ment. 
The term as used in the title of this 
paper has been generally understood to in- 
dicate an unusual loss of blood, during or 
subsequent to the after-birth period, from 
those uterine vessels which have orifices in 
the placental site. I, however, deem it 
best to make the term embrace any un- 
usual bleeding from the genitalia occur- 
ring soon after the delivery of the foetus. 
With such an understanding as to the 
signification of the term post-partum hem- 
orrhage, we recognize all such bleeding, 
with rare exceptions, to be either from the 
placental site or from a laceration of some 
portion of the genital canal. Hemorrhage 
coming from the placental site is associ- 
ated with either a partial or a complete 
detachment of the placenta. The after- 
birth may be in the uterus, or it may have 
been expelled, or a portion may be re- 
maining and adherent and the rest have 
been extracted. During such hemorrhage 
the uterus is in an imperfect state both of 
contraction and of retraction. This con- 
dition of the womb may be dependent 
upon an atony of its muscular fibres that 
is independent of influence exerted upon 
the uterus by its contents; an atony that 
prevents its sufficient contraction and re- 
traction even if entirely empty; an atony 
dependent upon a variety of causes which 
the scope of this paper does not permit me 
to investigate. It is essential, however, to 
bear in mind that such an atony does at 
times exist. 
Again, the presence of any substance in 
the uterus after the birth of the child may 
act mechanically, and in some other not 
well-understood manner, in preventing con- 
densation of the womb sufficient to close 
the calibres of those vessels which are torn 
off in a partial or a complete separation of 
the placenta. In this way blood-clots, es- 
pecially if somewhat firm, intra-uterine 2 
THE TREATMENT OF POSTPARTUM HEMORRHAGE. 
tumors, the placenta or any portion of it 
or of membranes, may bring about bleed- 
ing. In the case of tumor, and especially 
of a partially-attached placenta, not only 
is an influence exerted similar in nature to 
that exerted by other intra-uterine sub- 
stances, but these structures further act as 
splints over the surfaces of their attachment 
to prevent contraction of muscular fibres 
in that special portion of the womb, and a 
localized inaction or paralysis is produced. 
Moreover, while attached they determine 
a flow of blood into the vessels of that 
special uterine area. 
But an atony not dependent upon the 
existence of some substance in the uterus 
is itself productive of retention of placenta, 
clots, membrane, etc. It is also apt to be 
associated with adhesion of the placenta; 
for the cause of this adhesion may have 
been operative also as a cause of uterine 
inertia. The presence of a tumor is also 
liable to have engendered atrophy of some 
portion of the uterine walls. Thus, then, 
do we often find an atony that in its origin 
antedates labor associated after the delivery 
of the foetus with some intra-uterine con- 
dition itself hemorrhage-producing. 
I desire to emphasize the fact that hemor- 
rhage from the placental site has as its one 
invariable cause insufficient uterine con- 
traction with insufficient retraction. The 
insufficient contraction and insufficient re- 
traction are dependent upon uterine inertia, 
whether this inertia is independent of or 
dependent upon some intra-uterine condi- 
tion, and whether the uterus is empty or 
contains such substances as placenta, mem- 
branes, clots, tumors, etc. Hemorrhage 
from the placental site is due to insufficient 
shortening of uterine muscular fibres, to 
insufficient uterine condensation, to insuf- 
ficient compression through this conden- 
sation of the uterine vessels leading to 
the placental site. Hemorrhage from the 
placental site means an insufficiently con- 
tracted and insufficiently retracted uterus. 
Bring about sufficient uterine conden- 
sation, and we secure that physiological 
compression of the bleeding vessels by 
which nature when undisturbed limits the 
loss of blood to physiological requirements. 
Place, then, the uterus in a condition favor- 
able to condensation, and secure promptly 
this condensation. Empty the uterus of 
its contents, and make it contract and re- 
tract. Such are the two indications, and 
under all ordinary circumstances these two 
measures must be instituted quite simulta- 
neously. To empty the uterus without as- 
suring its condensation might prove fatal; 
to attempt to obtain condensation, and at 
the same time to leave within the uterus 
portions of after-birth, membranes, clots, 
etc., would prove futile, and possibly fatal. 
The immediate removal of an intra- 
uterine tumor, productive of post-partum 
hemorrhage, must depend upon the extent 
to which the tumor is attached to the 
uterine wall. If not too intimately con- 
nected, i-ts immediate removal with wire 
ecraseur, or with scissors, after ligation of 
its pedicle, is indicated. If it cannot be 
promptly and with comparative safety re- 
moved, condensation of the uterine walls 
about it must be attempted. 
The influence of thrombi in controlling 
bleeding from the placental area is too un- 
reliable to merit our confidence. In low- 
ered conditions of the system, as in ex- 
haustion from hemorrhage, or in shock, 
they may act temporarily in checking the 
bleeding; but when the force of the circu- 
lation is somewhat regained, the thrombi 
are apt to be washed out and bleeding to 
recur, unless a firm retracted state of the 
womb has been in the mean time secured. 
Moreover, such thrombi are fruitful sources 
of septic infection ; for they are very prone 
to undergo septic decomposition. In the 
relaxed state of the womb which accom- 
panies their existence, atmospheric air is 
accessible to them, and they are also in 
contact with lochia, likely itself to become 
septic in character. Thrombi thus cir- 
cumstanced are in one sense only slightly 
and most uncertainly conservative, and 
in another sense most certainly and greatly 
dangerous. The very existence of thrombi 
in the exposed vessels at the placental area 
seems to me pathological, and assiduously 
to be avoided. It is only as a dernier res- 
sort that we should ever employ those reme- 
dial measures which control hemorrhage by 
producing coagula in the vessels of the 
placental area. In order to prevent hem- 
orrhage from these vessels, nature, when 
acting with normal efficiency, does not 
plug them with fibrinous masses, but she 
obliterates their calibre by the compress- 
ing action of uterine retraction. She does 
not keep the walls of these vessels apart 
by blood-clots, fragments of which may 
escape into the circulation and become 
emboli, probably septic emboli, in more 
or less remote parts of the economy, or THE TREATMENT OF POSTPARTUM HEMORRHAGE. 
3 
which, after conversion into sepsin, and 
being beyond the reach of detergent and 
antiseptic syringing, are certain to infect 
dangerously the entire system. It is through 
uterine condensation, then, and not through 
the production of thrombi, that we must con- 
trol hemorrhage from the placental area. 
Hemorrhage from a laceration of the 
cervix, vagina, perineum, or vulva is, of 
course, not dependent upon uterine inertia. 
The state of the uterus bears no relation to 
the occurrence or continuance of bleeding 
from a tear of the vagina or of the exter- 
nal genitals. Hemorrhage from a tear of 
the cervix is comparatively greater if the 
uterine body is relaxed, but it will at times 
continue excessive during decided uterine 
condensation. The uterine globe may be 
felt as of cannon-ball hardness, and yet 
active bleeding continue from the cervix. 
Retraction of the uterine body may dimin- 
ish a hemorrhage from the cervix, but it is 
not efficient in actually stopping, and not 
always in materially lessening, the bleeding. 
Loss of blood from the uterine body will 
be effectually controlled by retraction of 
the uterus, but a tear of the neck or of 
any portion of the genital canal other than 
the uterine body will bleed, subject to the 
same influences as those which determine 
the extent of hemorrhage from a tear in other 
portions of the system. Such bleeding 
is, however, apt to be excessive. The en- 
tire genital apparatus and contiguous struc- 
tures are greatly increased in vascularity 
during pregnancy, the blood-vessels be- 
come larger,—may become varicose or 
aneurismal,—and some of them, as those 
of the cervix, are devoid of valves, while 
other vessels are markedly erectile in char- 
acter, as is most especially the case with 
those in the bulbs of the vestibule. 
Usually bleeding from a laceration is less 
profuse, less immediately threatening to life, 
than if it proceeds from patulous utero- 
placental vessels; but it may nevertheless 
be very active, especially in varix or in 
aneurism of the vessels of the lacerated 
portion, or if the bulbs are torn. Although 
such hemorrhage usually is less profuse, it 
may continue for hours, or, by repeated 
detachment of thrombi, recur at short in- 
tervals for days. The aggregate of blood 
thus lost becomes very great. The mag- 
nitude of the detriment to result to the 
patient must not be estimated entirely by 
the immediate magnitude of the flow. 
Any considerable loss of blood from a 
laceration may lead to secondary hemor- 
rhage from the placental area by inducing 
relaxation of the uterine fibres, and, further, 
it may endanger life by gradual exhaustion, 
or, through lowering the vital powers, en- 
courage the formation of sloughs, and 
also render the system incapable of resist- 
ing the inroads of septic poison. Again, 
should such a patient escape death from 
cerebral anaemia, septicaemia, and inflam- 
mation, the future still holds in store for 
her all the ills incident to sabinvolution of 
the genital organs and surrounding tissues. 
Hemorrhage from a laceration, then, should 
not be overlooked, nor should its treat- 
ment be neglected. 
Hemorrhage from the placental area 
and that from a laceration may coexist. A 
too rapid labor or a too greatly protracted 
labor is liable to cause uterine inertia, and 
also to produce a laceration of the soft 
parts. If bleeding is progressing, and the 
uterine body is relaxed and flabby, it is 
quite certain that the bleeding is largely, 
at least, from the severed utero-placental 
vessels ; but blood may at the same time be 
escaping from a laceratioh of the cervix. 
During such an active hemorrhage there 
is no time to spare for the elimination of 
a coexisting loss from such a laceration. 
There is not time for making even a casual 
examination for such a purpose; and to 
determine the condition of the cervical 
and vaginal tissues after labor, a careful 
and necessarily somewhat protracted ex- 
amination is required. The deduction is 
apparent,—viz., that in endeavoring to 
check a bleeding from the placental area 
our remedial measures should not be of 
a kind calculated to increase a bleeding 
from a laceration, but that greatly to be 
preferred are those measures capable of 
controlling either or both forms of hemor- 
rhage. 
I have already stated that excessive 
bleeding may continue from a laceration 
after the uterine body has been brought 
into a state of complete retraction, and 
hence it is clear that our remedial measures 
should not be limited to that class capable 
only of securing uterine condensation ; for 
such measures cannot control a bleeding 
from a possibly, or probably, coexisting 
laceration. 
After loss of blood the system by reason 
of increased activity of the absorbents re- 
ceives septic poison rapidly into itself, and 
by reason of its enfeebled condition passes 4 
THE TREATMENT OF POST-PARTUM HEMORRHAGE. 
quickly, and to a dangerous extent, under 
the influence of this poison. Our remedial 
measures, then, should not be of a charac- 
ter to increase to the slightest extent the 
liability to septic infection. 
As is well recognized, traumatic condi- 
tions, such as contusions and lacerations, 
are, in puerperal women suffering from 
great loss of blood, exceedingly prone 
to inflammation of an erysipelatous or 
other adynamic type : hence our remedial 
measures should not be of such an irritant 
nature as to increase in the slightest degree 
the tendency to inflammatory action. Our 
remedies for post-partum hemorrhage must 
be of such promptness as to ward off danger 
immediately threatening, they should be 
certain in their action, and, if possible, 
fraught with no harm, immediate or re- 
mote, to the patient. A maximum of 
promptness and certainty combined with 
a minimum of noxiousness to the patient 
must be aimed at in the choice of treat- 
ment for post-partum bleeding. 
In the light of the various considerations 
which I have endeavored to present, let 
us now proceed to analyze, and to endorse 
or to reject, the more prominent of the nu- 
merous agents and measures at present in 
vogue. 
To attempt a consideration of the preven- 
tion of post-partum hemorrhage would carry 
me over the entire management of labor ; 
for its causes may antedate delivery for 
hours, or may antedate labor itself. How- 
ever, immediately after the escape of the 
foetus the hand should be placed on the 
abdominal wall over the uterus, and by 
moderate pressure its retraction be insured 
about the still-remaining but probably 
partially-detached placenta. If there is as 
yet no unusual bleeding, the after-birth 
should be allowed to remain for ten to 
fifteen minutes ; but if there should be too 
profuse a loss of blood, and the absence of 
sufficient retraction should suggest the loss 
to come from the placental area, the ute- 
rus should be made further to retract by 
compression of it with the hand over the 
abdomen, and if the hemorrhage does not 
promptly stop, the placenta should be im- 
mediately expressed by Crede’s method, 
and the uterus should be brought into a 
further state of retraction by the hand ex- 
ternally compressing it. If there is reason 
to believe that the bleeding is almost en- 
tirely from a torn cervix,—and this con- 
clusion may be arrived at by eliminating, 
through inspection, a perineal, vulvar, or 
lower vaginal tear, and by observing a 
womb retracted about the placenta,—it is 
still best practice to express the placenta 
if the bleeding is considerable ; otherwise, 
in the effort to control such bleeding the 
hand and the attention of the physician 
will be taken from the uterine body, and 
its relaxation may take place, with an es- 
tablishment of a bleeding from the pla- 
cental area. The same rule in reference 
to the expression of the placenta holds 
good if there is very excessive loss of blood 
from a tear of the perineum, or of some 
part of the vulva, as of the bulb ; but if the 
bleeding from such tears is not excessive, 
only moderate, the placenta should be 
allowed to continue in utero the usual ten 
or fifteen minutes, the uterus being care- 
fully watched while measures are instituted 
for the control of the loss from the lacer- 
ation. 
The rule to remove promptly the pla- 
centa in excessive bleeding from a lacer- 
ated cervix, the uterus being retracted, is 
not an absolute one, provided the phy- 
sician is favored by having a quick and 
reliable nurse, and the means are at hand 
for controlling such hemorrhage,—viz., 
hot water and the necessary requisites 
for its injection against the cervix. This 
measure will not only check the bleeding 
from the torn neck, but it will also stimu- 
late the uterus into safe retraction. 
Ergot is often administered as the child 
is being born, with the view of preventing 
hemorrhage, more particularly after the 
escape of the placenta. The objection to 
the administration of ergot at this time is 
that it may place the womb in a state of 
tetanic contraction before the escape of 
the placenta, and this structure may thus 
be incarcerated so firmly that etherization 
and dilatation with the hand will be needed 
for its removal. Such an effort does at 
times follow the resort to ergot at the end- 
ing of the second stage, but only as a rare 
occurrence. The action of ergot is usually 
noticeable only after a number of minutes 
have elapsed, so that after the onset of 
hemorrhage it cannot be relied on to the 
exclusion of other more prompt and, I 
will add, more certain agents. During 
hemorrhage it should always be given hy- 
podermically. When thus administered 
its action is decidedly more prompt and 
more certain than when given by the 
mouth. Yet, in shock and after consider- THE TREATMENT OE POSTPARTUM HEMORRHAGE. 
5 
able exhaustion from loss of blood, ergot, 
when used hypodermically, is an unrelia- 
ble agent, and if given by the mouth it 
may produce vomiting, when not only is 
its oxytocic effect lost, but the prostra- 
tion from vomiting is superadded to that 
due to shock or other cause. This drug is 
of greater value in preventing relaxation 
of the uterus after it has once been well 
retracted, and it is of special value in 
diminishing that gradual leakage from the 
placental area which at times constitutes a 
too great lochial flow. It is of little value 
in checking a hemorrhage actively pro- 
gressing, because of the slowness and un- 
certainty of its action. Yet it should 
always be administered in hemorrhage, be- 
cause of its value in maintaining retraction 
of the womb after that condition has been 
secured by means of other more prompt 
agents. I know of no remedy which, act- 
ing after its entrance into the circulation, 
is equal in its oxytocic effects to ergot. 
There are serious objections to the in- 
troduction, during hemorrhage, of the hand 
into the uterus or into the vagina to re- 
move a retained or loosely-attached pla- 
centa. In hemorrhage the existence of a 
tear of the upper vagina or of the cervix 
cannot be excluded. Such a tear may ex- 
ist, and the passage of the hand into the 
genital canal, or more especially its with- 
drawal when grasping the after-birth, will 
most probably increase the extent of the 
laceration and add to the contusion of 
tissues. Hemorrhage from the tear will 
be increased, the liability to subsequent 
sloughing or to inflammation be enhanced, 
and shock induced, or, if present, aggra- 
vated, not to dwell on the additional dan- 
ger of transferring manually septic poison. 
The latter accident ought never to occur, 
with the light thrown, by our somewhat 
recently attained knowledge, on its oc- 
currence and its prevention. The bulk of 
the hand may even originate a laceration 
in tissues that have been greatly weakened 
by being compressed and overstretched by 
the emerging child. If the placenta is so 
adherent that external manual expression 
cannot secure its removal, and hemorrhage 
continues, it will be necessary to introduce 
the hand promptly but cautiously into the 
uterus, and to secure properly the detach- 
ment and extraction of the after-birth. 
But it is always unfortunate when such a 
manoeuvre is necessitated. 
If the physician does not reach the pa- 
tient until she is in a state approaching 
syncope from excessive loss of blood, and 
the placenta has not been delivered, and 
the hemorrhage is in abeyance, it will still 
be best to express the placenta with the 
hand externally applied, being at the same 
time exceedingly careful to secure full 
uterine retraction during and after its ex- 
pulsion. If the after-birth is still longer 
allowed to remain, the bleeding may occur 
at any moment, and a fatal result follow. 
If, however, in such a case of extreme 
exhaustion from loss of blood, the placenta 
is too adherent to be thus expressed, the 
bleeding having entirely ceased, it becomes 
a serious question as to the propriety of im- 
mediately introducing the hand for its de- 
tachment and extraction. The shock thus 
aggravated may prove fatal in the then low 
condition of the woman. Under such 
circumstances it will probably be best while 
securing retraction, if possible, about the 
placenta, at the same time and without de- 
lay to direct proper measures towards the 
relief of cerebral anaemia. 
If further hemorrhage does not super- 
vene, it would be best, while treating the 
extreme exhaustion, to wait a short time 
for some reaction before extraction of the 
placenta with the introduced hand. If 
further hemorrhage should appear before 
reaction is apparent, the critical nature of 
the case is greatly intensified, and the im- 
mediate introduction of the hand into the 
uterus becomes an unavoidable necessity, 
with increased probability of a fatal result. 
The increased danger would be largely due 
to shock incident to dissecting off a firmly 
adherent placenta. 
I doubt if the circumstances would ever 
be such as to warrant permitting the pla- 
centa to temain in the uterus for hours or 
for days, as has been occasionally advo- 
cated. In case of hemorrhage after the 
complete removal of after-birth and of 
membranes, any clots that have formed in 
the uterus may be easily removed by ex- 
ternal compression without the introduc- 
tion of the hand. 
Now, as to the means for securing con- 
densation after the uterus has been emptied. 
External compression will usually secure 
this, but not always. There is excellent 
authority for introducing the hand into the 
uterus and, by there moving it about, to 
excite contraction and retraction. I must, 
however, deprecate such practice as un- 
necessary and harmful. There is great 6 
THE TREATMENT OF POST-PARTUM HEMORRHAGE. 
probability of lacerating tissues or of in- 
creasing existing lacerations, of irritation 
and of contusion, of producing or aggra- 
vating shock. The procedure is a danger- 
ous one, and, moreover, will not always 
produce uterine condensation, and may 
increase bleeding from lacerations. A 
patient thus treated, if escaping present 
dangers, will, by reason of this special 
treatment, be in increased danger from 
inflammation, sloughing, secondary hem- 
orrhage, and septic infection. The hand 
should never be introduced into the 
uterus solely with a view of provoking ute- 
rine condensation. Under some circum- 
stances the hand may be introduced for 
diagnosis, as when there is reason to be- 
lieve that a portion of membranes or 
placenta has been left, or that an intra-ute- 
rine tumor is present. Very rarely indeed, 
however, will it be necessary or justifiable 
to introduce the hand, except to remove 
such contents as are so adherent or in- 
carcerated that they cannot be removed in 
any other manner. It has been advised to 
carry a peeled lemon or a cloth saturated 
with vinegar into the uterus with the hand, 
and then to squeeze it so that the fluid may 
stimulate condensation. To this procedure 
there are the same objections as those ex- 
isting against the introduction of the simple 
hand. The juice of the lemon or the vin- 
egar thus applied will superinduce contrac- 
tion, and the hand will not remain long in 
the uterus, yet the very introduction and 
withdrawal of the hand are objectionable. 
The lemon-juice or the vinegar acts largely 
by reason of its astringent and irritant ef- 
fects ; but it is scarcely sufficiently an irritant 
to produce special harm. The injection 
of diluted vinegar into the uterus is effec- 
tive, doubtless, in securing contraction ; the 
agent does not specially irritate, it does not 
produce hard clots, though productive of 
soft coagula, and it has the advantage of 
being disinfectant. Yet it is something of 
an irritant, is often not quickly accessible 
in sufficient quantity, and cannot well be 
employed to wash out the genital canal. It 
is a remedy against which strong objec- 
tion cannot be urged, but I do not deem 
it the most feasible or the most desirable 
one. A per-salt of iron in different solu- 
tions in water has been largely used and 
strongly’advocated on the continent of 
Europe and in Great Britain. Its advo- 
cates are among those highest in authority 
as teachers, writers, and practical obste- 
tricians. It is injected into the uterine 
cavity in Continental Europe in a deep 
wine-colored solution, and in Great Brit- 
ain in the proportion of one ounce of 
Monsel’s solution, or one ounce of liquor 
ferri chloridi, to three ounces of water. 
This remedy cannot be so decidedly 
harmful as its opponents have claimed. 
Had it so proved, it would not have con- 
tinued until now in the confidence of so 
many able and experienced physicians. 
There are to my mind, however, objections 
to the iron salt which do not obtain against 
some other agents. It acts chiefly by pro- 
ducing coagula in the patulous vessels, and 
I have already insisted that such thrombi 
should be assiduously avoided; it also 
produces hard clots, which remain in the 
uterine cavity as irritant masses, provo- 
cative of inflammation ; it has a minimum 
of influence in securing uterine condensa- 
tion ; after its employment, and after the 
hemorrhage has been checked, the womb 
will be found large and soft, evincing im- 
perfect retraction. In oljiet words, the 
calibres of the uterine vessels are not oblit- 
erated through condensation. They must 
contain coagula liable to all the changes in 
character and in location that such thrombi 
under such circumstances are usually liable 
to. There must be danger of septicaemia or 
pyaemia resulting, of undue inflammatory 
action, or, at best, of tardy convalescence. 
If used at all, I should prefer the stronger 
solution, as most likely to excite that spe- 
cial desideratum, decided uterine retrac- 
tion. Swabbing the interior of the uterus 
with a cloth or a sponge saturated with the 
undiluted solution of the Pharmacopoeia 
necessitates the introduction of the hand 
into the vagina, and partially or com- 
pletely into the uterus, in addition to the 
other objections to the employment of a 
per-salt of iron. I feel that a resort to 
this use of iron will be rarely necessitated, 
and that the agent should be reserved for 
such very rare cases as do not respond to 
other treatment. 
The tincture of iodine has been recom- 
mended as a substitute for the iron salt. 
It certainly does not produce hard coagula, 
as does the iron, and must doubtless stim- 
ulate uterine retraction. But it is not reli- 
able, except in a somewhat concentrated 
state, when it is too irritating. 
Ice introduced against the cervix, or, 
most effectively, into the uterus, becomes 
a decided, and generally a reliable, stimu- THE TREATMENT OF POST-PARTUM HEMORRHAGE. 
7 
lant to condensation. But the hand must 
be usually carried into the vagina in order 
to introduce ice into the uterus. The injec- 
tion of cold water into the uterine cavity 
is free from this objection, and is gen- 
erally reliable. The application of ice to 
the abdomen, while at the same time com- 
pressing the uterus with the hand exter- 
nally, is also usually of great service. The 
cold douche over the abdomen from a 
height is certainly a very powerful reflex 
stimulant to the uterine fibres, but it floods 
the patient and the bed. The objection 
to cold in any form is that it is liable un- 
duly to chill the patient, and possibly to 
contribute to exhaustion, inflammation, 
etc. An objection even more vital is that 
in great prostration cold in any form loses 
its power to excite uterine contraction, and 
the hemorrhage continues. In one instance 
I nearly lost my patient by trusting too long 
to its influence. I was forced in that case 
to resort to Monsel’s solution in order to 
prevent a fatal result. 
1 come now to a remedy not so long in 
vogue, but one that has in my hands given 
most satisfaction. I refer to hot water. 
Water at a temperature of 1120 or 1150 F. 
freely injected into the uterus becomes a 
prompt excitant of retraction. 
It will produce this effect with greater 
promptness than will cold water or ice, 
and will bring about uterine condensation 
after ice has failed because of the patient’s 
great exhaustion. It should also be ap- 
plied externally over the abdomen. I am 
in the habit of folding a towel as a flat 
compress, saturating it with water as hot as 
my hands will possibly endure, squeezing 
out the redundant water, applying the wet 
and hot towel on the abdomen, and then, 
placing my hand on the towel through it, 
compressing the uterus. The womb will 
be felt to harden promptly even when the 
same manoeuvre with iced water has previ- 
ously not succeeded in obtaining conden- 
sation. The remedy may be rendered 
disinfectant with permanganate of potash, 
carbolic acid, etc., or even more efficient 
in producing retraction by the addition of 
vinegar, though I have never seen this 
addition necessitated. Hot water controls 
bleeding from the placental site by se- 
curing with certainty prompt and complete 
condensation. It has no, or at least very 
little, influence in the formation of thrombi; 
it washes out all clots and leaves the uterus 
clean; it will secure condensation after 
other agents have, by reason of the pa- 
tient’s exhaustion, failed; it is operative 
when the patient is under ordinary ether- 
ization ; it controls bleeding from lacera- 
tions at the same time that it controls the 
loss of blood from the placental area; it 
controls bleeding from the laceration by 
producing contraction of the vessels, and 
not by causing coagulation of the blood ; 
it is more invariably attainable than other 
agents, and can be had in all seasons and 
in all climates. 
The water should be hot enough,—as hot 
as the hand, or, better, the uncovered arm, 
can endure. This degree of heat is not 
usually painful to the patient, excepting to 
a limited extent at the external genitals. 
There is no shock resulting from its use: it 
is a remedy against shock. It is followed 
by an increased feeling of comfort. It 
will regulate irregular uterine contraction 
by stimulating the entire body into con- 
traction, and will thus check bleeding 
when superinduced by paralysis of the 
placental area. It is valuable in the pre- 
vention of hemorrhage in “bleeders,” or 
in any case in which there is reason to 
expect undue loss of blood. 
Of all remedies directed towards the 
stopping of post-partum hemorrhage, hot 
water thus combines the maximum of 
promptness and certainty with the mini- 
mum of noxiousness to the patient. 
To summarize very briefly the line of 
management, I would say, as soon as the 
child is born, secure, with the hand over 
the abdomen, retraction about the pla- 
centa ; if hemorrhage occurs, express the 
placenta and continue with the hand ex- 
ternally to effect retraction. If the bleed- 
ing does not promptly stop, inject hot 
water in considerable quantities into the 
cavity of the uterus. YVhile the injection 
is being effected, apply or have applied at 
the same time a hot wet compress over the 
abdomen, and, by a hand placed on this 
compress, make firm pressure on the uterus. 
Ergot should be as soon as possible in- 
jected hypodermically, but the above 
measures should take precedence in time 
of application. 
In post-partum hemorrhage dependent 
upon a laceration of a cancerous cervix, I 
have had of late no opportunity to use the 
hot water. In such a laceration It should 
be employed ; but if the bleeding is not 
quickly controlled, a piece of cloth satu- 
rated with Monsel’s solution should be 8 
THE TREATMENT OF POST-PARTUM HEMORRHAGE. 
pressed with the fingers against the bleed- 
ing surfaces. In post-partum bleeding fol- 
lowing placenta prsevia I have not used 
hot water, but should expect its favorable 
action. In one such case, swabbing the 
placental area around the internal os with 
Monsel’s solution acted so promptly in 
preventing death that I should prefer at 
once to resort to this remedy in such 
cases. I should never make an applica- 
tion of Monsel’s solution by way of merely 
preventing hemorrhage even in cancer of 
the neck, nor in placenta prgevia; for 
bleeding after labor is not an invariable 
accompaniment of either of these con- 
ditions. 
There are not a few minor adjuvants 
in the treatment of post-partum hemor- 
rhage, such as compression of the aorta, 
lowering the head, admitting fresh air, 
etc., which are more or less valuable, but 
which do not demand discussion in this 
paper. 
In cerebral anaemia following an ex- 
cessive loss of blood, the hypodermic in- 
jection of stimulants—whiskey, ether, etc. 
—is of very special value, as in syncope 
absorption from the stomach is very slow 
or in total abeyance. 
Small doses of an opiate aid in filling 
the cerebral vessels, diminish shock, and 
quiet restlessness. 
Of other remedies indicated or recom- 
mended I must refrain from speaking, be- 
cause of the already probably too great 
length of this paper.