[RepriHted from the Boston Medical and Surgical Journal 
of September 20, 1894.J 
A CASE OF ACCIDENTAL CONCEALED HEM- 
ORRHAGE.1 
On March 29th, I was asked by Dr. E. L. Twomblv 
to see with him a patient with the following history: 
The night before, when eight months pregnant, she 
had begun to suffer moderate labor-pains, and after 
they had continued a few hours felt very faint; but 
on Dr. Twombly’s arrival, shortly afterwards, she 
appeared in her usual health. Slight labor continued 
during the night, and early in the morning she again 
felt faint. There was at this time an external dis- 
charge of a small amount of reddish sero-sanguinolent 
fluid. She had been rather over-active for several 
days, but there was no history of any accident. 
When I saw her, at about 9.30 A. m., March 29th, 
her face was pale and slightly drawn, and her lips con- 
siderably blanched; the pulse was very feeble, but its 
rapidity was only 60. I regret that I did not count it 
at the heart, as its character and the subsequent his- 
tory leads me to think that I should have found a 
greater rapidity there. On palpation the uterine pari- 
etes yielded to the fingers some slight suggestion of 
an undue tonicity. The contour of the uterus was 
uniformly rounded, with the exception of a spot on the 
left side of the fundus, where a circular area of about 
six inches in diameter seemed to project slightly above 
the general level and to be of a softer consistency. 
The fetal heart was absent. On vaginal examination 
the cervix was found firm and resistent, not at all 
1 Read before the Obstetrical Society of Boston, April 14, 1894. 
EDWARD REYNOLDS, M.D. 2 
shortened; the internal os barely admitted the finger 
to the surface of the membranes; the head presented ; 
no previa was felt. There was, at this time, no ex- 
ternal bleeding. 
I was inclined to make a diagnosis of the existence 
of an internal concealed hemorrhage, but in view of 
the rigidity of the cervix thought that any attempt at 
immediate delivery would be extremely hazardous, 
from the grave liability which I thought existed, that 
a profuse hemorrhage might start up while the os was 
Btill but partially dilated and undilatable. I recom- 
mended a policy of inaction, except in so far as it 
might be possible to expedite labor by cautious stretch- 
ing of the os at intervals with the fingers, without ether. 
I saw the patient again at one p. m. Her condition 
was then unchanged, except that the labor-pains were 
stronger and the cervix decidedly shortened. There 
had been no further hemorrhage. 
At eleven p. m. I was again called, to find the acces- 
sory tumor larger, the patient decidedly more feeble, 
the uterus in a state of marked tonic contraction, the 
cervix spasmodically rigid, and the os about a third 
dilated, the membranes still unruptured. The patient 
was at once etherized: under ether the os became 
thoroughly relaxed, and was easily stretched to an 
almost complete dilatation by the hand. The mem- 
branes were then ruptured, and a considerable amount 
of liquor amnii, slightly tinged with blood, escaped. 
The patient was allowed to recover from her ether, 
and within five minutes a dead, but unmacerated, eight 
months’ fetus was expelled from the vulva. The birth 
of the body was followed by the spontaneous and 
forcible expulsion of the placenta, with from a quart 
and a half to two quarts of dark clot. On examina- 
tion of the uterine aspect of the placenta, it was found 
that small, firm clots existed in the spaces between the 3 
cotyledons over the greater part of its surface. The 
mother’s recovery was uninterrupted. 
The history of this case, together with that of the 
very similar case which I reported to this Society two 
months ago, leads me to question somewhat the cor- 
rectness of the position I have hitherto held in regard 
to the treatment of these most alarming accidents. 
In 1891, in the course of a discussion before the 
American Gynecological Society upon the extremely 
able paper of Dr. Henry C. Coe on accidental hemor- 
rhage during the first stage of labor, I stated my own 
opinion that this hemorrhage could be checked by one 
means and by one means only, that is, by securing 
contraction and retraction of the uterus after the 
delivery of the child, and advocated that measure for 
all cases where the condition of the patient is not so 
bad as to preclude all interference. That opinion was 
based not only upon my small previous experience with 
this rare accident, but upon the statistics of the oper- 
ation previously published in the paper referred to, 
which is, so far as my knowledge extends, the latest 
statement of the experience of the profession on this 
subject; Dr. Coe places the general mortality at 51 
per cent., the mortality under the expectant treat- 
ment at 75 per cent., and that which attends immediate 
delivery at 30 per cent. I am led to question whether, 
with regard to treatment, we are not bound to classify 
the cases in accordance with the severity of the symp- 
toms and the condition of the cervix. It is theoreti- 
cally possible that there may be cases in which the 
strength of the uterus is sufficient to keep the hemor- 
rhage within bounds for a length of time sufficient to 
allow a dilatation of the os to occur, or, at least, soften- 
ing of the cervix by the natural forces. Upon the 
other hand, no obstetrician of experience will doubt 
the statement that a dilatation of the rigid cervix may 4 
well occupy sufficient time to allow the hemorrhage to 
become fatal if it should start up during the operation, 
an accident which the history of these cases shows to 
be not unusual. 
The treatment which T should propose for myself 
in future cases of this desperate nature is as follows: 
If the hemorrhage is from the start so profuse as to 
occasion great distention of the uterus and an early 
and alarming collapse of the patient, a large majority 
of the women will be lost under any method of treat- 
ment ; but I still believe that a prompt delivery then 
offers the only chance that there is for the life of the 
mother. 
[The question of the possibility of saving such cases 
by the prompt performance of Porro’s operation has 
been suggested, but the time does not seem to me ripe 
for more than the merest mention of this question.] 
If the onset of the hemorrhage is gradual, if the 
initial collapse is not extremely alarming, and the pro- 
gress of the hemorrhage seems to have become arrested 
before any extreme distention of the uterus occurs, I 
shall determine my choice of treatment by the condi- 
tion of the cervix. If this is so rigid as to offer a 
prospect of extreme difficulty in its dilatation, I shall 
confine myself, as in this last case, to efforts at pro- 
moting the action of the natural forces by moderate 
dilatation of the os with the fingers, stimulation, and 
other measures intended to sustain the strength of the 
patient. But I wish to be understood that if this method 
of treatment is adopted, a physician competent for 
prompt delivery must be continuously by the bedside 
of the patient and ready to interfere. 
If, in this latter class of cases (with limited hemor- 
rhage and moderate collapse), the conditions are such 
as to warrant the belief that immediate dilatation and 
version will be reasonably easy, I believe that will 5 
offer the best chance of saving the patient. The life 
of the mother is always so seriously endangered, and the 
fetus has in the past so rarely been saved, that the ex- 
istence of the latter should ordinarily be left out of 
consideration in determining the plan of treatment 
which should be adopted.