With the Compliments of the Author. 
POST-PARTUM HEMORRHAGE: 
ITS ETIOLOGY AND MANAGEMENT. 
BY 
AUGUSTUS P. CLARKE, A.M., M.D., 
OF CAMBRIDGE, MASS., U. S. A. 
President of the Gynecological Society of MoMrm-f Member, -of the Massachusetts Medical 
Society; Member of the Cambridge Society for Medical Improvement; Member of the 
American Academy of Medicine ; Member of the American Medical Association ; 
Member of the American Association of Obstetricians and Gynecologists; 
Member of the American Public Health Association; Member of the 
Ninth International Medical Congress, Washington; Member of 
the Tenth International Medical Congress, Berlin; Delegate 
to the British Medical Association ; Late Surgeon of the 
Sixth Regiment, New York Cavalry; Late Surgeon- 
in-Chief of the First Cavalry Division of the 
Army of the Shenandoah; Brevet 
Lieutenant- Colonel, etc. 
READ BEFORE THE 
AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
NEW YORK, SEPTEMBER, 1891. 
REPRINT FROM TRANSACTIONS, 1891. rOST-PARTUM HEMORRHAGE: ITS ETIOLOGY 
AND MANAGEMENT. 
By AUGUSTUS P. CLARKE, M.D., 
CAMBRIDGE. 
The physician who, having had an extended practice in the 
department of obstetrics, has had the experience of a case 
in which every symptom seemed favorable for a happy and 
speedy termination of labor, and then suddenly without 
warning has been confronted with a post-partum hemorrhage 
which put to the severest test all the resources of his art, his 
past experience, and his mature judgment, will not fail to regard 
the subject of such hemorrhage as one at all times worthy of 
the highest consideration. Among the causes contributing to 
uterine hemorrhage is the want of tone in the uterine struc- 
tures. In every such case careful inquiry will almost always 
reveal the fact that an excessive development of the vascular 
tissue has encroached upon the normal enlargement of the 
muscular structures, and thus rendered them weak, inefficient, 
and incapable of sustaining the shock incident to the parturient 
process. Taking this view of the subject here presented, the 
hemorrhage following the expulsion of the fetus will appear 
to depend more upon the abnormal or pathological processes 
than upon accidental or mechanical conditions. This view 
offers an explanation as to the extreme difficulty in effecting 
or maintaining uterine contraction, notwithstanding the adop- 
tion of the most approved means of accomplishing it. 
Case I.—Mrs. W., aged thirty-two years, a multipara. Hemorrhage 
occurred immediately after the birth of twins at full term. The first and 
second stages of labor were easy and natural, lasting only six hours. The 
pains, however, were sharp, brisk, with abrupt endings and long pauses be- 
tween them. There was no hemorrhage until after the birth of the second 
child, when the utero-placental sinuses failing to contract, hemorrhage sud- 2 
AUGUSTUS P. CLARKE, 
denly became alarming. The middle and lower segments of the uterine 
tissue were preternaturally soft and flexible. A limited portion of the 
fundal segment, however, appeared somewhat thicker and firmer, but the 
severe strain imposed upon it during the six hours of continuous labor so 
much exhausted it that it became impossible to bring it into a state of suffi- 
cient and permanent contraction. As soon as the hemorrhage became 
alarming my friend Dr. A. L. Norris arrived. 
For a while it appeared that the patient would be saved. Full doses of 
ergotine, of opiates, and stimulants were given. Supra-pubic pressure and 
regular massaging were employed, also intra-uterine applications of hot 
water, cold water, and even ice, were tried; and tampons filling the vagina 
and the uterine cavity were also employed. These, instead of promoting 
uterine contractions, appeared to retard them. Electricity was also resorted 
to. Other methods of procedure were ventured upon, but they did not 
produce permanent contraction or arrest of hemorrhage. The patient 
speedily sank and died from the effect of the profuse hemorrhage. 
Case II.—Mrs. R., aged thirty-four years, also a multipara; the first and 
second stages of labor were not unnatural, except each pain appeared marked 
by acute beginning with an abrupt ending and a pause noticeably long 
before the occurrence of another pain. As soon, however, as the pla- 
centa began to descend, a most profuse and alarming hemorrhage ensued; 
the patient quickly fainted and had an ashen, deathly paleness. Every 
effort was made for her relief; she died within twenty minutes from the 
first occurrence of the hemorrhage. At the autopsy, the vascular struc- 
tures of the uterus were found unusually developed, while the muscular 
portions were weak and soft, and in many places showed only a rudimentary 
or a partially developed condition. 
These two cases occurred in my earlier practice; since 
then I have been on careful watch for unusual occurrences 
and surprises, but have scarcely met with a case presenting 
such peculiar pathological conditions of uterine development. 
Undoubtedly, in a large percentage of the cases an atonic con- 
dition of the uterus exercises a most influential part in in- 
ducing post-partum hemorrhage. In all such cases there must 
be what the old masters used to term want of irritability and 
contractility in the muscular tissue of that organ. Excessive 
engorgement of the uterine vessels is often attendant on a 
deficiency of growth and of expansion of the normal textures 
during gestation. There is always a complex interlacing of 
the oblique fibres of the middle layer of the uterine muscular 
coat. This intermediate layer is essentially formed of flat 
bundles of transverse muscular fibres, also of longitudinal and 
oblique ones. In the midst of these are plexuses of large POST-PARTUM HEMORRHAGE. 
3 
veins. The veins through the medium of the capillaries are 
in direct communication with arteries and arterioles. The 
longitudinal fibres of the external and internal portions during 
pregnancy are at best but exceedingly thin and slender. The 
transverse fibres of these two layers are somewhat thicker and 
stronger but are largely distributed toward the Fallopian tubes 
and their immediate vicinity, and also toward the uterine 
cervix. Unfortunately, however, they do not afford much 
direct support to the central portions of the uterus. 
In the cases in which the uterine vascular tissue is preter- 
naturally developed, and in which the mucous glands and 
follicles are much increased, the evolution of the central 
planes of the muscular structures becomes encroached upon. 
They, therefore, present but a deficient and feeble develop- 
ment. Indeed, all the elementary cells entering into the forma- 
tion of the muscular coat become more fusiform, their oval 
nuclei do not have the requisite length; the fibre-cells appear 
but partially formed or immature, and their whole structure 
microscopically becomes commingled with abnormal or per- 
verted tissues of an adventitious character. A case illustrating 
in some measure deficient development of the central uterine 
muscular tissue occurred recently in my practice : 
Case III.—Mrs. 0., aged twenty-one years; second labor. The history 
of the patient showed that during her first confinement, which was also at 
full term, there was troublesome post-partum hemorrhage. At the time 
I was called I found that the os and cervix had undergone dilatation, and 
that the head of the fetus had entered the pelvic brim. The presen- 
tation was occipito anterior. Finding that pains were becoming inefficient 
and that the equatorial segments of the uterine structures were thin, 
soft, and incapable of sustaining prolonged efforts at propulsion, I adminis- 
tered ether and effected delivery by the application of the long forceps. 
Gentle pressure and methodical massaging of the fundal portions aided in 
accomplishing easy and safe expulsion of the secundines. The vessels of 
the fundus were large and tortuous. The funis was above the normal size, 
but its length scarcely exceeded seventeen inches. Hemorrhage soon followed, 
necessitating continued pressure over the fundus uteri, and the application 
of a firm bandage, and the introduction of intra uterine tampons of iodoform 
gauze and wool. The central uterine walls, anteriorly, were found to be thin 
and distended. They were similar in deficiency of development to the tissues 
found in a case of a woman to which I was hurriedly called, who had sus- 
tained spontaneous rupture of the uterus in labor. The hemorrhage, at the 4 
AUGUSTUS P. CLARKE, 
time, was controlled. Some ten hours later the uterine walls relaxed and a 
brisk hemorrhage ensued. A resort to the same means for controlling the 
hemorrhage finally checked it altogether. 
In this connection I might incidentally remark that in some 
cases of uterine inertia, and also in post-partum hemorrhage, 
forcible compression or friction for aiding in the accomplish- 
ment of more active uterine contraction may be attended with 
serious results. A resort to such vigorous measures may 
lacerate or rupture the attenuated muscular planes and the 
plexuses of veins and arteries with which they are often so 
plentifully interlaced. The site or location of the placental 
attachment exercises an influence in restraining or in produc- 
ing hemorrhage. If the attachment is at the fundus, the 
hemorrhage may be but trifling. Sometimes ectasis of the 
fundal vessels, sometimes certain lesions, and sometimes solid 
edema of the parts induced by perverted secretion or by in- 
flammatory changes may prevent immediate contraction, and 
thus give rise to troublesome or profuse hemorrhage. When 
the attachment is at the fundal segment and the structures in 
the vicinity are otherwise normal, there may be immediate and 
permanent closure of all the sinuses with scarcely any loss of 
blood. If the attachment is at the lower uterine segment, the 
thick and unyielding condition of the textures induced by in- 
flammatory and other changes incident to the cervical portion, 
may materially interfere with the tonic contraction necessary 
to prevent occurrence of hemorrhage at this part. The size 
of the placenta and its area of attachment are not unimportant 
factors for consideration in post-partum hemorrhage. 
A placenta may be thick and bulky and yet its diameter may 
scarcely attain to that of a normal one. In such a case the 
expulsion of the placenta may follow almost immediately on 
the birth of the fetus without the occurrence of excessive 
hemorrhage. In another case the depth of the placenta may 
be much less than normal and yet its area of attachment may 
be very extended. In such a case, to which I was once called, 
the placenta appeared as flat as a pancake; its vessels appeared 
small and insignificant, yet the uterine sinuses were so open, 
distended, and deep, 'that the normal uterine contractions 
exercised over them for some time only partial control. In POST-PARTUM HEMORRHAGE. 
5 
addition to the normal features of the placenta, there may be 
a proliferation of the placental vessels, constituting an extra 
or supplementary lobe. The retention of such a mass even 
after the placenta has been expelled, may give rise to profuse 
hemorrhage. I have notes of a case to which I was once 
hurriedly called, in which there had been only a partial separ- 
ation and expulsion of the placenta. On collecting the de- 
tached parts that had been expelled, and washing and placing 
them on a clean surface, it was discovered that the placenta 
was cotyledonous; that is, the several cotyledons appearing on 
the uterine surface were continuous through the mass of the 
placenta to its fetal surface. The medium or union of con- 
nection between the several lobes was very fragile. It was 
found necessary to administer again an anesthetic and to em- 
ploy the curette in accomplishing the removal of the retained 
portions of the placental mass. After that there was no further 
troublesome hemorrhage. Undue length of the funis may be 
productive of post-partum hemorrhage. In the case in which 
hemorrhage from this cause occurs, the funis is usually found 
coiled about the neck, body, or about one or more of the fetal 
extremities. 
Case IV.—Not long since I was called in consultation where there had 
been some hemorrhage and a peculiar sensation at the anterior and fundal 
portions of the uterus. The cervix was well dilated and the head of the 
child had entered the pelvic brim, but made no further descent. Forceps 
was applied. As soon as the child emerged from the vulva the placenta 
followed. The funis was found coiled round the neck and body of the child, 
leaving less than ten inches of the funis free between the child and the 
centre of the placental mass. The most remarkable thing about the case 
was that there was a knot in the funis seven inches from the umbili- 
cus. The knot was not tight; respiration was established before the knot 
tightened so as to arrest circulation. The hemorrhage which followed was 
profuse; the patient suddenly became pale and fainted. By the use of 
nitrite of amyl, tincture of opium, stimulants, supra-pubic pressure, and of 
a firm binder, and the intra-uterine irrigation of hot and cold water, the 
hemorrhage was brought under control. 
The cause of the hemorrhage was evidently a too rapid 
separation and expulsion of the placenta from the undue 
shortness of the disengaged section of the cord. 
Other factors sufficient to give rise to hemorrhage might 
O o © 6 
AUGUSTUS P. CLARKE, 
be here enumerated. Post-partum hemorrhage may be de- 
pendent upon some form of laceration extending into the 
vaginal or vulval canal. In one case to which I was called, I 
found a laceration extending to the upper portion of the vulva, 
including the artery at the base of the clitoris. The applica- 
tion of aseptic animal sutures to the torn structures effectually 
arrested the hemorrhage. The presence of uterine fibroids or 
morbid growths may be an exciting cause of hemorrhage. 
Retained placenta from adhesions between the serous and mus- 
cular coats of the uterus, either in whole or in part, may give 
rise to profuse hemorrhage. So, also, may placenta previa, 
whether it be of central or marginal implantation. The same 
is true in cases of retention of the placenta after abortion oc- 
curring at any period of utero-gestation. Irregular or hour- 
glass contraction of the uterus may be a prolific source of 
post-partum hemorrhage. The late Dr. Fordyce Barker1 
mentioned cardiac disease as prominent among the causes. 
He, therefore, expressed his preference for chloroform in 
obstetric practice. 
There can be no question that not only chloroform, but also 
sulphuric ether, is capable of conserving the nerve force and 
of preventing exhaustion and uterine inertia. There is, I 
believe, still much misapprehension on the part of some ac- 
coucheurs in reference to the advisability of using anesthetics 
in cases in which there are affections of the heart, lungs, and 
of other important organs. My own experience and observa- 
tion when anesthetics are judiciously used, fully justify me in 
making the statement that they are of incalculable benefit in 
lessening many of the dangers incident to the parturient pro- 
cess, and particularly in cases of uterine inertia dependent on 
the exhaustion of the system generally. In cases of advanced 
or serious renal affection, chloroform may be the safer of the 
two anesthetics. 
On this point, however, I will not enter into a further dis- 
cussion, for I am not unaware that I have already ventured to 
walk upon that forbidden ground from which “ I would fain 
keep aloof.” Atony and deficiency of the uterine muscular 
1 Braithwaite’s Retrospect. Part 95. POST-PARTUM HEMORRHAGE. 
7 
tissue are likely to occur in women who have borne several 
children. Frequent dilatation and expansion of the uterine 
walls interfere with the normal nutrition of the muscular 
fibres, rendering them weak and susceptible of being easily 
overcome by the parturient process, especially in cases of 
lingering labor, or in cases in which instrumental interference 
has been too long deferred. I have been called to cases of 
excessive hemorrhage which appeared to be due solely to 
coagula or to fibrinous masses of blood which had not been 
expelled but had been allowed to remain. Notwithstanding 
there may have been a preternatural activity of some of the 
uterine fibres, hemorrhage has followed and has been the 
source of much alarm. In every such case, after the removal 
of the retained clots, hemorrhage has ceased, the cavity of the 
uterus closed, and the patient has been relieved of the dis- 
tressing symptoms. It is, indeed, surprising to observe how 
much disturbance and even ultimate mischief a few small 
ooagula may occasion, and what marked, sudden, and per- 
manent relief may be afforded by their thorough removal. 
Post-partum hemorrhage is especially apt to occur in cases of 
women who are of “ relaxed habit,” or in those who belong 
to that class of persons termed “ bleeders.” Mrs. W. and also 
Mrs. R., who died of uterine hemorrhage, as mentioned in this 
paper, had the history of belonging to this class. Mrs. W. 
had suffered in her previous labors from hemorrhage ; her 
mother had frequently suffered from hemorrhage. The same 
was true in regard to Mrs. R. 
In the Boston Medical and Surgical Journal/ Dr. Horace 
Thurston reports a case of post-partum hemorrhage, in which 
the patient died in forty-five minutes from the attack. In her 
first confinement, twenty months previous, she narrowly 
escaped with her life from flooding. Her mother suffered from 
excessive flooding in seven successive labors, and was barely 
saved from the exhaustion due to loss of blood occurring in 
one of them. 
Locations of great altitude are sometimes the exciting or 
predisposing cause of hemorrhage. A friend of mine who has 
.1 Vol. lv., 1857. 8 
AUGUSTUS P. CLARKE, 
had an extended practice in obstetrics in a section of the high 
tablelands of this country, has noticed this peculiarity. In 
India post-partum hemorrhage is of more frequent occurrence, 
it is said, than in England. Another cause of hemorrhage 
after the expulsion of the placenta, is the speedy occurrence 
of the birth of the fetus after the rupture of the membranes 
and evacuation of the liquor amnii. 
For a prophylactic against the occurrence of hemorrhage, it 
is safe to encourage the evacuation of the waters before the 
final expulsion of the child through the vulval or vaginal out- 
let. Pressure or support over the fundal uterine segment as 
the child recedes from it, will greatly aid in keeping up con- 
tinuous or regular uterine contraction, and thus lessen the 
risks of the occurrence of severe hemorrhage. The adminis- 
tration of ergotine and ergotinine will assist in reestablishing 
normal contraction. Hypodermatic injections of ergotinine 
should be used after the expulsion of the placenta. As a pro- 
phylactic in cases of anticipated hemorrhage, it may be used 
before the placenta has been expelled. When used hypoder- 
matically its physiological action is often speedily and per- 
manently manifested. The administration of ergot or even 
ergotinine is more satisfactory in the milder class of cases. 
In cases in which hemorrhage is profuse, intra-uterine injec- 
tions will be of most material service. In persons of full or 
plethoric habit cold water may be employed; in those who 
suffer from nervous affections or who are chilly, water from 
115° F. to 125° F. is to be preferred. In some cases the alter- 
nation from hot to cold water will be most beneficial. In two 
cases, at least, by this method I am confident of having saved 
life. Doubtless, when hemorrhage is arrested by such employ- 
ment of hot water, it is owing to the formation of thrombi 
more or less extended into the vascular tissues on the uterine 
surface. The employment of cold has a reflex action; it gives 
a toning effect to all the tissues; it facilitates the constriction 
of the muscular coat of the dilated vessels. 
Caffeine is an agent of great benefit in uterine hemorrhage 
I have used it in connection with benzoate of soda and distilled 
or pure water. This may be used hypodermatically. Dilute 
acetic acid and also common vinegar are useful when employed POST-PARTUM HEMORRHAGE. 
9 
externally over the abdomen, in stimulating to action the 
nervules, and in hastening contraction of the arterioles. 
Stimulants should always be at hand. The application of 
some form of electricity will aid in some measure in promoting 
contraction of the uterine muscular fibres. 
In cases in which hemorrhage is anticipated, the early 
administration of quinine may in a large measure serve to 
keep the hemorrhage under control. The occurrence of cer- 
tain pains may, as already stated, lead us to anticipate post- 
partum hemorrhage. If the pains are acute and brisk, with 
abrupt ending, and followed by unusually long pauses, we may 
infer that there is a deficiency of nerve force. This may lead 
to atony of the muscular structures and to failure to effect 
contraction of the uterus and closure of the utero-placental 
vessels. Dr. F. II. Davenport1 reports a case in which he at- 
tributes the less profuse post-partum hemorrhage to the use of 
quinine two and three hours before the birth, ergot as soon as 
the os was fully dilated, and the alternate application of heat 
and cold to the uterus. In each of the patient’s two previous 
confinements, according to her history, she came near dying 
of uterine hemorrhage. In cases in which hemorrhage pro- 
ceeds from the lower section of the uterus, or from the upper 
portion of the cervix, the application of iodoform wool and 
gauze and of styptics or of iodine, will be of service. I have 
great confidence in the employment of nitrite of amyl; it is 
an arterial and cardiac stimulant of the most extraordinary 
power. 
Another method for consideration is the resort to intra- 
venous injection or transfusion. The advisability of its em- 
ployment and the dangers attending its use, are matters for 
determination in each individual case. 
I might here add, that resort to alcoholic intra-venous injec- 
tions for their dynamic or tension effect will often be found 
most beneficial. My early experience with the employment of 
intra-venous injections was in cases of epidemic Asiatic 
cholera, and in cases of great hemorrhage from gunshot 
wounds occurring during an extended service in the late war 
1 Boston Medical and Surgical Journal, vol. cxiii. 10 
POST-PARTUM HEMORRHAGE. 
of the Rebellion. My later experience favors adoption of the 
method of hypodermatic injection or transfusion of spiritous 
saline solutions. This method, which is applicable in other 
cases in which there has been great loss of blood, is more con- 
venient, is safer and is more likely to be followed by favor- 
able results. 
Other methods adopted for controlling hemorrhage have been 
found in tamponading the vagina and cervix, in the employ- 
ment of elastic pressure, in the use of ether spray externally, 
in full doses of opiates and in the use of stimulants, in the 
local use of injections of iron alum, of perchloride of iron, in 
the administration of emetics to excite vomiting that through 
the vascular sympathy between the uterus and the stomach 
there may be set up firm uterine contraction. Some recom- 
mend for overcoming hemorrhage to put the child to the 
breast at the earliest moment. My own experience is particu- 
larly favorable to this last-mentioned practice. 
Compression of the abdominal aorta may be tried. This 
may, in some measure, for a short time, give us control over 
the hemorrhage by saving the last of the vital current which 
would otherwise flow out. By this means we may be enabled 
ultimately to save the patient when all other means have failed 
us. For the approval of this procedure we have the high 
authority of Barnes, Churchill, Caseau, Chailly, and of Simp- 
son, as well as many of the older writers, including French 
and German authors. Ploucquet and Saxtorph were advocates 
of this practice. My teacher, the late Dr. D. Humphreys 
Storer, used to emphasize the importance of making compres- 
sion of the abdominal aorta in the final endeavor to prevent 
such loss of blood.