Some Considerations in Reference to Uterine Hem- 
orrhage, Puerperal and Non-Puerperal. 
BY 
Al. VANDERVEER^ M. D.? 
ALBANY, N. Y., 
Professor of Didactic, Abdominal and Clinical Surgery, Albany Medical 
College, President American Association of Obstetricians 
and Gynecologists, 1892. 
REPRINTED FROM 
The American Gynecological Journal, Toledo, Ohio, 
OCTOBER. 1892. SOME CONSIDERATIONS IN REFERENCE TO UTERINE HEM- 
ORRHAGE, PUERPERAL AND NON-PUERPERAL.1 
BY A. VANDERVEER, W. D., PROFESSOR OF DIDACTIC, ABDOMINAL AND 
CLINICAL SURGERY, ALBANY MEDICAL COLLEGE, ALBANY, N. Y., 
PRESIDENT AMERICAN ASSOCIATION OF OBSTETRICIANS 
AND GYNECOLOGISTS, 1892. 
Taking our profession as a whole, we are apt to look upon the 
surgical side as embodying that which at times calls for the greatest 
amount of heroic courage. In the days of my obstetrical practice, 
occasionally I let my thoughts run in channels of comparison, and 
when brought face to face with an unexpected or unlooked for case of 
post-partum hemorrhage, have wondered if it was possible to place a 
practitioner of medicine in a position where greater reach of thought 
was required, and where more prompt employment of means and rem- 
edies was necessary. 
We enter the home in many cases where all is bright, there is 
hopeful expectancy and a cheerful outlook. Suddenly, perhaps at the 
moment of almost triumphant success, comes that train of conditions 
that startles all. The life of the wife, the young mother, is in the bal- 
ance and the household shudders at the possible entrance of death. Of 
all the points of anxiety that now present themselves, none equal that 
of hemorrhage. 
The obstetrician, with his surgical training, remembers well his 
teaching and reminds himself that "the first rule in surgery is not to 
let your patient bleed to death." He examines with rapidity the con- 
dition of his patient, he recalls rapidly in his mind what are the possi- 
ble complications and what is it that now threatens her life ? To have 
his mind act clearly and quickly, to apply promptly that form of relief 
which the case requires and bring back joy and thankfulness where all 
has been grief and fear, stamps the true physician. 
1. Presidential address delivered before the American Association of Obstetricians and 
Gynecologists, St. Louis, Sept. 21st, 1892. 2 
We, as the Fellows of this Association, are the consultants in many 
such cases. We can look back when, as younger men, we were being 
tried in the crucible of practical experience. Now, as we work onward 
and upward, it should be our aim to give those in general practice, who 
are guided and aided by the specialist, all assistance possible. With 
this object in view I have selected this subject for my address. Not 
that my effort may bring forth much that may be of value, but that the 
discussion of the subject, covering as it does the lines of work followed 
out by both obstetrician and gynecologist, who constitute the fellowship 
of this Association, may be such as will bring strength and comfort to 
him who, in the lonely hamlet or in the wealthy mansion, in that mid- 
night hour when assistance seems so far away, may be aided in fighting 
alone and single-handed, but successfully, the battle that has been so 
unrelentingly waged against his patient. There can be no doubt but 
that the text books of to-day are eliminating much that has been of 
little service in finding out the causes and suggesting the rational treat- 
ment of puerperal hemorrhage. 
Gratitude is due, and is, and should be rendered, to our modern 
writers, who, ignoring the traditions of this book, or the several editions 
of that work in hereditary transmission, have taken up the subject 
anew, and, as it were, given out new chapters on planes of reasoning, 
regarding investigations and treatment, that has brought about a 
renewal and lengthening of the life of motherhood. We have had 
from many sources, within the past five years, and especially from our 
own Fellows, Price, Rohe and others, the methods and ways of prepa- 
ration of our patient for the lying-in room, that has resulted in recov- 
eries unknown heretofore. Yet, when we consider deaths that are 
recorded, or that occur before our first visit permits us to leave the sick 
or lying-in room, have we not still something more to do in lessening 
the certificates of death from immediate and fatal hemorrhage ? 
I have witnessed death in many forms, but none so sad as that oi 
puerperal hemorrhage. In the days of my obstetrical practice I was 
grateful in having escaped such an experience, but, in consultation, to 
see the last of a human life ebbing to an end is sad, sad indeed. If 
there be one line of thought and work I would urge upon the general 
practitioner, or he, who in his circle of metropolitan or rural practice is 
known as the obstetrician, it is this, a more clear and definite history of 
the case than is frequently secured previous to the day and hour of 
accouchment. I repeat that, too often, the doctor enters the room of his 
puerperal patient knowing by far too little of her previous history. In 
this direction of teaching, precept and following out of duty, there is 
need of great improvement. The public should be taught, the mature 
parents should impress more earnestly upon the expectant mother than 
is done, the necessity of her informing the family physician fully her 
physical make-up, and, if there be any, her family peculiarities. No 3 
surgeon of to-day approaches an operation without fully learning all 
that pertains to that particular patient, especially if he is to bring his 
percentage of recoveries up to that point maintained by the best opera- 
tors. Too often our fatal cases are the ones in which, from haste, or 
circumstances that apparently at the time could not be controlled, we 
find, when too late, that had we known certain conditions of our pa- 
tient it would have been better for all concerned. I am satisfied that 
this is a field for greater study, from which obstetrical art will receive 
much benefit. 
Consider for a moment conditions of heredity. That family, one 
of whose members is about to enter the lying-in room, is known to 
come from a family of bleeders. 
This the family physician should certainly take into consideration. 
In my early practice I attended Mrs. Q. in her first confinement. She 
had always flowed very freely during her menstrual periods, and stated 
that this was characteristic of her mother and one or more of her sis- 
ters. There was nothing in her labor abnormal except that she flowed 
very freely, and this was only controlled by free use of ice, internally 
and externally, with ergot, and constant hand pressure over the fundus 
of the uterus. Two years after she died from hemorrhage, from what I 
believed to be a ruptured tubal pregnancy. Nearly twenty years after 
I attended her daughter, in an emergency, in a case of abortion brought 
on by a fall, at the end of the sixth week of pregnancy, in which the 
hemorrhage was frightful and persistent, only controlled by prompt 
cleaning out of the uterus. 
These cases I know are but types of a class of conditions familiar 
to us all. The obstetrician of experience has well in mind all possible 
complications that may present to his patient as the parturient hour 
begins. The length and condition of the cord is one of the factors that 
must be quickly considered in the sudden hemorrhage that at times 
presents, either in the slow or rapid delivery. The coiling of the cord 
about the body of the child so shortens it at times that too sudden 
separation of the placenta occurs, and the uterine sinuses are left wide 
open, though the uterus may be ever so willing and in proper condition 
to contract. These are the cases in which the large coagula and masses 
of blood are apt to form within the cavity of the uterus, and which 
must be removed at once. How necessary, just here, for the obstetrician 
to have a clean, septic hand. Is it any wonder that, in the past, septic 
conditions have arisen when former methods were adopted by the hand 
with " nails in mourning;" no curetting, no stream of hot water even 
suggested ? The short cord is too often overlooked, and the damage so 
quickly done not promptly recognized. It is plainly the duty of the 
attending physician to recognize this at once. There must be no wait- 
ing for the nurse to tell him that his patient is bleeding. The injury is 
done ere the child is born, and the necessary assistance must be ren- 4 
dered the uterus at once. It matters not whether the delivery has been 
a fairly strong and quick one, or a slow', tedious affair, in which at last 
it has been thought best to apply the forceps. The short cord is apt to 
bring the placenta quickly into the vagina. This the careful, exper- 
ienced obstetrician will recognize at once, and now is the time for action. 
Let me illustrate : 
Mrs. B. K., ill in her first confinement; a good family history; 
always an active and energetic society girl, of a decided sanguine, ner- 
vous temperament. Her labor was natural, and at the end a few sharp 
pains brought the child through the external soft parts somewhat 
quickly. I realized at once we had a short cord, and which really 
measured only about nine and one-half inches ; tied it quickly ; passed 
babe to nurse, but the hemorrhage that presented was frightful. The 
best of help was present in the room-her husband being a physician, 
as well as the brother, who were both there. I removed the placenta 
promptly, w'hich was free in the vagina, emptied the uterus of clots, 
applied ice externally and internally, gave ergot, kneaded the fundus, 
used promptly the Faradic current, applied by Dr. F. Townsend, who 
came quickly ; raised the foot of her bed, lowered the head of the pa- 
tient, saw rapidly coming on that dusky, leaden, bleached appearance 
of the face, felt the velvety condition of the skin, on surface of body, so 
noticeable in sudden loss of blood ; no pulse to be observed in any of 
the external arteries; abdominal artery could only be recognized as 
constant pressure was kept applied to it; loss of consciousness imme- 
diate, and now a fearful convulsion due to anaemia of the brain. What 
a startling change in so short a period of time. Hypodermics of brandy 
and aromatic spirits of ammonia were made use of. Dr. Townsend 
continued faithfully the use of the battery ; I sent at once for my trans- 
fusion case, the brother of the patient, strong and willing, furnished the 
fresh blood, and though very difficult for me to find the vein in her 
arm, I did succeed in transfusing a moderate amount of blood, and its 
beneficial effects were at once apparent. There was some evidence of 
returning consciousness. The lower limbs were bandaged, and gradu- 
ally our patient came back to life, and to permanent recovery. I am 
glad to report this patient has since borne another child and all went 
well. In the latter case the cord was of normal length, and every pre- 
caution to prevent hemorrhage was employed. 
Take this case as a study, and is it possible in any branch of sur- 
gery to have one more trying? Since its experience I have had some 
serious abdominal work to perform, yet seldom that which brought 
greater and keener anxiety for the time. 
Traumatisms of the neck of the uterus, of the vagina and of the ex- 
ternal soft parts may bring on a bleeding that is in itself alarming at 
the time. Fortunate now is the patient if she have an attendant 
possessed of some surgical skill. Take, for instance, a case in which 5 
laceration of the cervix has occurred. The circular artery has been torn, 
lacerated or ruptured. The uterus is empty, contracted, all is normal 
in that direction; careful examination reveals the true source of the 
hemorrhage, and now the vessel must be tied, and, at the same time, 
unless the patient is too greatly exhausted, immediate closure of the 
laceration, placing a glass drainage tube in the cervix. Lacerations of 
the perineum, vagina and external soft parts are often the source oi 
serious hemorrhage, and, to my mind, should be repaired at once. The 
general practitioner has yet much to learn, and must exercise more 
promptness in the immediate repair of these lesions. 
Varicose veins in and about the vulva are at times the source of 
serious hemorrhage, at delivery of the child. 
Permit me to report the case of Mrs. T. from my note book : Aged 
thirty-six years, in her third confinement, Dec., 1879; others had been 
fairly normal, but she had suffered from the first from varicose veins of 
the lower extremities. This labor natural, but immediately after de- 
livery of the child and placenta, I was alarmed by the bleeding, which 
continued so long as to cause exhaustion and syncope. A careful, quick 
examination assured me uterus and all was normal. As should be done 
in all these cases, a careful examination of the placenta was made ; no 
portion was torn, and the membranes gave that normal cone-like bag, 
so pleasant to see. On examining the external parts, with a view of 
going still further up the vagina, and to the cervix, I was surprised to 
find venous blood flowing freely from large varicose veins on the left 
side of the vagina and from the internal labia. I made use of my 
thumb and finger for immediate pressure. Being much younger in 
practice, and patient's condition alarming, I sent for Dr. Lansing, who 
had previously attended her, and who responded quickly, but I had 
continued pressure for one-half hour, and in placing patient in posi- 
tion for tying the vessels it was found the bleeding was controlled and 
did not return. Patient made a good recovery. 
Arteries about the clitoris are sometimes torn, and will require 
tying or the application of the clamp. 
Fibroid tumors are sometimes a source of serious hemorrhage, and, 
to my mind, if we have to deal with that condition called hour-glass 
contraction, we should be thoroughly on the outlook for this lesion. 
I have an impression that fibroids situated in the lower third of the 
uterus, especially interstitial, are the most frequent cause of this trouble, 
when such conditions really exist. 
Late at night, January, 1873, I was requested to go twelve miles in 
the country to see Mrs. C., aged thirty-two, in her second confinement; 
the child was delivered, but her physicians were unable to remove the 
placenta, and I was sent for. I found her with the lower segment of 
the uterus empty, but the upper portion retained the placenta, which I 
did not have very much trouble in removing, finding, however, that 6 
she had a uterine fibroid the size and shape of a goose egg. She re- 
covered from her confinement and two years afterwards, in making an 
examination, no trace of the fibroid could be discovered. I have no 
doubt that in the process of involution, that took place after the birth 
of her child, the fibroid was absorbed. 
Later I was requested by Dr. Fowler, at 3 a. m., to see Mrs. II., 
whom he had just attended in confinement, and where the hemorrhage 
had given him much anxiety, leaving, as he thought, large clots in the 
uterus and vagina. On thorough examination I found a fibroid the 
size of a child's head, occupying the anterior lower portion of the uterus. 
The bleeding was soon controlled, and the patient made a good recovery. 
As stated in the former case, as involution went on the tumor was 
absorbed. 
I am certain that syphilitic infection is more frequently the cause 
of hemorrhage than the profession has been led to believe. Take a 
case of abortion after abortion, and where by judicious treatment the 
patient finally goes on to full time. These cases must be carefully 
watched. 
Mrs. B., aged 30, who had had six abortions, ranging from four to 
eight months each, and all giving evidence of syphilitic trouble, but 
who, by the use of chlorate of potassium and iodides, alteratives and 
proper tonics was brought to full time. She had always flowed freely, 
and the family was told to send promptly whenever her sickness pre- 
sented. They did so, but I happened to be out at the time. She was 
so anxious to have me attend her that they waited a few moments, but 
growing worse, another physician was sent for. Returning, I im- 
mediately responded to the call, but in the hour, the hemorrhage had 
been so terrific, she was dead. Such a condition as that bed and room 
presented, I shall never forget. It never seemed possible to me that 
the human body could have held so much blood. The body was as 
white and bleached as I have seen dead soldiers on the battle field, 
when dying from a clean-cut wound of the femoral or popliteal artery. 
The placenta presented as a large, fatty mass, and there apparently had 
been no attempt on the part of the uterus to contract. 
In another like case, seen in the practice of Dr. Bailey, and where 
we had a chance to examine the uterus, the sinuses presented as great, 
open spaces, the bleeding being fearful. 
Those who have read Dr. Oliver Wendell Holmes' charming paper 
on "The Selection of the Family Physician," can readily endorse all he 
has to say there. I would add one additional point: let the young 
doctor, in the first confinement of his patient, and even after, examine 
well the appearance of the placenta. A tendency to a large placenta is 
a tendency to hemorrhage, and especially if there be evidence of an 
extra lobe. A small and possibly adherent placenta, from inflammatory 
changes, is no more dangerous, though perhaps giving greater anxiety 7 
in its immediate removal. Of placenta praevia, central or marginal, I 
can hardly speak. It is a subject within itself. I can only endorse 
much that has been written of late, and modern lines of treatment, 
prompt, energetic means, never forgetting the tampon-like effect of the 
head when it presents, and remembering that chloroform, with rapid 
dilatation and delivery, has saved the life of many a mother and child. 
Again, let the physician, who, as a stranger, is called to attend a 
new patient, in perhaps her second, third or fourth accouchment, learn 
all the points connected with her previous confinements. 
I well remember, not many years ago, in being called to see Mrs. 
M. in her second confinement, and in getting her history, she said: "I 
nearly died from hemorrhage in my former sickness." I could get no 
history of heredity, or such conditions as would give alarm, but was on 
the alert. All went natural at the time of labor, yet in the delivery of 
the placenta a severe hemorrhage occurred, soon controlled by prompt 
measures near at hand, the want of which has sometimes cost the life 
of the patient. 
A class of cases that have always commanded my admiration, yet at 
times sorrow, is that of a noble wife and mother, who, having patiently 
given birth to six or more children, perhaps in somewhat rapid suc- 
cession, at last in a confinement suddenly dies from hemorrhage. The 
family physician in these cases should never forget the possibilities of 
atony of the uterus or irregular uterine contractions; of the want of 
development of uterine tissue in an already overworked organ. That 
term uterine inertia too frequently means thin muscular walls-want 
of muscular growth. How indefinite an expression, when already a 
pathological, fatty change is present. These patients should be pro- 
tected in time, rest from conception should be enforced, later tonics, 
and by all means the use of a mild Faradic current of electricity. 
The fibroid tumor must not be overlooked in sometimes causing a 
thinning of the uterine walls. In these last two class of cases I am 
certain that at times hemorrhage results from too earnest use of Crede's 
method, rupture, inversion and like complications, or irregular hour- 
glass contractions, so-called. In these conditions organic diseases of 
the heart should never be lost sight of. 
As surgeons we are fond of quoting, 
"The thoughtful surgeon, skilled our wounds to heal, 
Is more than millions to the common weal." 
I would say a thousand times more emphatically, give us the faith- 
ful, intelligent physician, skilled to save the lives of our loved wives 
and daughters. 
Holowko, British Gynecological Journal, May, 1892, p. 127, pub- 
lishes an unusual case of hemorrhage: "The patient, a pregnant mul- 
tipara, strained to lift a heavy weight of clothes. Pain in the abdomen 
came on and rapidly increased in severity. The temperature rose to 8 
104°, the pulse to 120. Labor came on, a dead child was born. The 
pains grew worse. The abdomen became distended, the pulse rose to 
140, and soon after the placenta came away she died. The post-mor- 
tem showed that the uterus was healthy, but that a large quantity of 
fluid blood which filled the abdomen had evidently come from the 
adhesions round the ascending colon, which had recently been rup- 
tured. There was no sign of anaemia and the hemorrhage had not been 
diagnosed." 
I once saw a case precisely like this occurring in the practice of 
the late Dr. Craig. 
I must not weary your patience, or I might continue and illustrate 
by cases such other rare conditions as present in the causes of puer- 
peral hemorrhage. Every case of hemorrhage is a study within itself. 
In addition to what I have so briefly stated, the relaxed and abnormal 
position of the organ must be recognized. When corrected, how quickly 
contraction will at once go on and control the bleeding. It has been 
well said, "the best preventive of uterine hemorrhage is absolute control 
of the uterus." 
"All the same conditions which cause primary hemorrhage may 
cause hemorrhage at any time during the puerperal period, and in 
addition to these there are a few other causes. After the first twenty- 
four hours following labor, retarded involution of the uterus stands in 
the same casual relation to secondary hemorrhage as deficient contrac- 
tions to primary hemorrhage. In other words, it is the most frequent 
cause of secondary post-partum hemorrhage." 
In a recent paper by Mr. Jonathan Hutchinson, of London, entitled: 
"On Causes of Death in Midwifery," he states, "the statistics of mid- 
wifery and the causes of death after child-birth are not without their 
interest for the operating surgeon." 
To a considerable extent, the same kind of risks are encountered 
after delivery as after a large operation wound, and the same kind of 
precautions are needed. 
My friend, Dr. Aveling, one of the highest authorities on these 
matters, assures me that, in spite of all modern improvements in prac- 
tice, the ratio of mortality after parturition in English practice has not 
been reduced lower than one in two hundred. The chief triumphs in 
recent days have occurred in the reduction of mortality in lying-in 
institutions. In private practice it is probable that for long the ratio 
has not been higher, and that no great change has resulted recently. 
It would appear, to judge from the statistics of individual practitioners, 
that it is very difficult, even under the most favorable circumstances, to 
beat the record. 
What are the means we are to make use of in these cases? 
I am convinced that they require the same line of work as the sur- 
gical ones suffering from shock and collapse. 9 
First control hemorrhage ; ice, hot water, electricity, direct pressure 
of the abdominal aorta, are not to be lost sight of. In employing the 
latter 1 have often thought, if one had it at hand, to apply the large, 
Lister horse-shoe tourniquet would be wise. One soon tires of making 
pressure over this vessel. I have often been in doubt as to how rapidly 
the stomach does its work at such a time, but ergot, hamamelis, capsi- 
cum, opiates must not be lost sight of. Diffusible stimulants, nitrate 
of amyl, nitro-glycerine, hypodermics, transfusion of blood-saline solu- 
tions I believe equally as good-bandaging the extremities, all methods 
employed such as would be used for shock. 
Each case, as it were, demands a special line of treatment, and then, 
in general, we may say every case will bear the carrying out of a general 
course of treatment. Most certainly we ought at once to reach the 
cause, and the diagnosis must be made quickly. In all cases where we 
have reason to believe that portions of the placenta or clots are retained, 
I am sure greater use can be made of the large uterine curette, em- 
ploying at the same time a free current of plain hot water. By the 
latter term I mean water to the temperature of 120°. The closure of 
the utero-placental vessels should be uppermost in our minds. 
Methods employed should have this end in view. 
" The value of the tampon of iodoform gauze in treating post-partum 
hemorrhage is proven by Staheli, (Correspondenz-blatt /ar Schweizer 
Aerzte, No. 21, 1891, quoted in the Am. Jour. Med. Sciences, Jan., 1892.) 
In the clinic at Berne, nine fatal cases of post-partum hemorrhage oc- 
curred in 5,424 births, during a period of eight years. In forty-nine 
cases in which the tampon was used, better results were obtained than 
by any other method of treatment. These cases were divided into two 
groups; one, in which the hemorrhage occurred from a source which 
was determined, and the other, in which the tampon was used as a 
prophylactic against hemorrhage. In the first were cases of placenta 
prsevia, transverse position, and other similar complications. In the 
second class were cases of contracted pelvis, and also of Caesarean section. 
"In using the tampon, strips of iodoform gauze are preferred; 
thorough antiseptic precautions should be taken to disinfect the patient 
and the material which is used." 
In the last volume of our transactions is a valuable paper on this 
subject by our worthy Fellow, Dr. Clarke, of Cambridge, in which he 
refers to a case reported by Dr. F. H. Davenport, where much good 
seemed to have resulted from the use of quinine given every two or 
three hours before the birth. 
The second division of my subject, that of non-puerperal hemor- 
rhage is, and has been, to me, in my gynecological practice and consul- 
tation work, one of much study and of great anxiety. 
Beginning my professional life as a general practitioner, and 
largely given to surgical work, I have always looked upon hemorrhage 10 
as a condition requiring prompt and energetic measures; therefore, I 
studied from the first my cases of uterine hemorrhage with care, and 
the different phases they presented. It seems to me there is no sub- 
ject so important for us to understand thoroughly as the causes and 
conditions that produce this form of hemorrhage. The errors made by 
the patients in the estimation of their cases are so frequent, and yet so 
apparent, that the histories given us are often deceptive. 
What a strange introduction is that of infantile hemorrhage, or 
infantile menstruation, as it has been classified in a few of our text 
books. How little is known, and scarcely anything said by many 
authors upon the subject. The pathological explanation of these cases, 
that of " excessive development," is perhaps a correct one, and yet they 
are cases claiming our attention. In the American Journal of Obstetrics 
and Diseases of Women, Vol. 16, No. 9, 1883, will be found a very re- 
markable case of this condition reported by myself. 
Again, how important is the study of hemorrhage at the age of 
puberty. How many a young girl is allowed to drift on at this time in life 
without a proper looking-into of her case, until she has established a 
well-marked metritis, accompanied with a uterine colic or a more 
especially hemorrhagic form, in which we have the alteration of the 
mucous membranes, and at last a fungus-like growth resembling exuber- 
ant granulations, which will keep up a constant and profuse hemor- 
rhage. It is quite as important for us to study this form of uterine 
hemorrhage as any condition of bleeding that may, present, following 
abortion or confinement. Take, as an illustration, that class of cases in 
which the young girl begins a menstruation, it being almost a constant 
hemorrhage. She is possibly treated intelligently, after some form of 
medical treatment, until medicines, electricity, massaging, change of 
climate, all, as far as possible, have been tried, but she does not im- 
prove. She is better for a time, then to relapse. Now conies a time 
when I am certain the family physician should most earnestly urge 
upon the parents the necessity of a physical examination, either by 
himself, or to be made by the specialist of that particular section. 
I am no advocate of the unnecessary examination of young women, 
but I am certain that some cases are allowed to go on too long without 
this careful observance, and, when once this examination is made, how 
frequently it is found that there is present some form of flexion, with 
enlargement of the body of the uterus, tender and sensitive to the 
touch, or there is a stenosis of either the external or internal opening 
of the, cervical canal, with partially retained menstrual flux, or there is 
a polypus present, or, in a lesser degree, that condition denominated 
endometritis fungosa, or, as the result of some illness, some injury, a 
traumatism of any kind, a pelvic peritonitis, and your patient has that 
condition denominated in the text-books chronic endometritis, perhaps 
para-metritis. 11 
These are only a portion of like conditions found in these eases. 
Such conditions, with others that I have in mind, are so often found 
among a group of young girls, which extends through school life into 
womanhood, and to be found in a class of cases known as the invalid of 
the family. They are the cases which for a certain number of days in 
each month are to be placed in bed-not a great inconvenience to some, 
to others a loss of time, of labor, to be measured by the standard of 
wage earning, and throwing upon some other member of the family a 
greater strain and probable illness. 
These are the cases with which we are constantly coming in con- 
tact, and which require a more careful and thorough looking into. 
Medicines will sometimes cure, but not always. Perhaps a marriage 
and the birth of a child carries them on to an atmosphere of continued 
health, but this is rather the exception than otherwise. Too often the 
marriage is followed by a condition of invalidism distressing to both of 
the contracting parties, resulting not too infrequently in much suffering 
and misery. 
A condition of hemorrhage that is likely to be met with at any 
time in life is that associated with fibroid tumors in some form, either 
the simple polypus, the small submucous, or interstitial fibroid, all of 
which give a train of symptoms, first of menorrhagia, then of metror- 
rhagia, at last leading to a careful examination. It is to me astonish- 
ing how long the young girl, the young woman, the middle aged, the 
adult, the advanced in life, will continue under this strain of abnormal 
hemorrhage and seem to place so little stress upon it. In the case of 
the young girl the parents will continually offer the excuse that when 
she comes about a little more regularly all will be well. The middle 
aged woman is continually thinking that it is due to some irregularity 
of menstruation that will probably right itself, and contents her mind 
in that manner. When once the age of thirty-five or forty is reached 
she is constantly looking upon any form of hemorrhage as the approach 
of the menopause, and how many are the sad cases that come under 
our observation through this mistaken idea. Even though the meno- 
pause has been passed for many years, yet, upon the appearance of 
bleeding, how many, many cases in advanced life are looked upon as a 
return of the menstrual How. I know of no particular point in the 
study of hemorrhage that needs to be pursued with such care and 
caution as at the time of the so-called change of life. This is a period 
when patients suffer on and on, unwilling to have a careful, thorough 
examination, and yet how necessary for the family physician to impress 
upon them the importance of knowing fully their real condition. Now 
is the time when the various forms of polypi and fibroid tumors are 
likely to present, now is the time when malignant disease is apt to 
show itself, and yet these cases are frequently neglected until the patient 
is in such a feeble state of health, that when she does present for careful 12 
examination her case is almost hopeless. This too frequent belief that 
it is their change of life is something that women should know more 
about. In a paper entitled, u She Thought it was Her .Change of Life," 
published in the Journal of the American Medical Association, July 5, 
1890, I have referred to this subject somewhat earnestly. 
Of the many conditions that are apt to present as causes of hemor- 
rhage, the bearing of subinvolution-chronic metritis-does not receive 
the attention always that it should. A condition of endometritis 
fungosa is also too frequently overlooked. Hemorrhagic metritis, in its 
various forms, is not as promptly recognized as it should be. The 
bearing of a lacerated cervix, in its relation to hemorrhage, at all times 
in life, and especially at the menopause, should receive more careful 
study than it does. While I am frank to confess that the operation for 
closure of lacerated cervices has, at times, been carried too far, yet there 
are many, many cases neglected and allowed to go on, until, through 
the hemorrhage, that is continuous, the element of malignancy is allowed 
to enter, and a change is observed, that, from a simple lacerated cervix, 
we have to deal with an epithelioma. 
Let me illustrate a condition that too frequently presents in our 
hospital practice, in the case of Mrs. I., who presented for examination 
August 8, 1892; aged thirty-two; mother of five children, four of whom 
are living. The last child was born seven months ago. Two months 
previous to this confinement she noticed occasionally from the vagina 
a bleeding, but gave it no especial concern, thinking it was the out- 
growth of her then pregnant condition. She flowed very little at the 
time of her confinement, and apparently, from her description, it was 
quite normal, but since then she has flowed more or less, sometimes 
quite severely, then again would go for a period of two or three weeks 
without any show. Three weeks ago she consulted a physician, who 
told her that she had serious ulceration of the neck of the womb. On 
making an examination I found a severe laceration of the cervix on one 
side, while the other portion was quite entirely destroyed by epithelial 
ulceration, the walls of the vagina invaded, the uterus fixed and the 
broad ligaments infdtrated. A sad, sad case of epithelial cancer, and 
in which nothing could be done in the way of an operation. This con- 
dition had stolen upon the patient quietly, without giving any alarming 
symptoms, yet the ulceration must have been present at the time of the 
delivery of the child, but was unobserved by her then medical attend- 
ant. . These cases of lacerated cervices more frequently give an inter- 
mediate history of prolonged flowing between their pregnancies. 
In many of these conditions that I have referred to, the hemor- 
rhage continues through many months, and suddenly the patients find 
that they are invalids. There is but little pain associated with it, 
there is some backache, some pelvic distress, now and then menstrual 
pains, but the patient goes on to a dangerous condition of anaemia and 13 
her state of health is alarming to her friends. How soon we recognize 
the expression of the face in such cases as they enter our office. 
That condition called membranous dysmenorrhoea, if not, in many 
cases, thoroughly controlled, leads to hemorrhage, which becomes 
severe and carries our patient into all the tissue changes of the uterus, 
which is so frequently observed, when at last the patient does come 
under observation and for treatment. 
We must never lose sight of the fact that not infrequently diseased 
tubes, diseased appendages, may be the cause of severe uterine hem- 
orrhage; the possibility of a small ovarian tumor producing hemor- 
rhage is not to be overlooked. These experiences have come to many 
and doubtless to the most of us. 
Next to the importance of the study of hemorrhage connected with 
fibroid tumors (and let me say just here thp,t we must lay more stress 
upon the fact that these tumors will grow and develop after the meno- 
pause, and that the element of hemorrhage becomes a very serious symp- 
tom) is that to be observed after the supposed change of life, after the 
patient has really and fully passed her menopause. She has now had 
a period of absolute rest for three, five or more years, but suddenly she 
has a hemorrhage. If left to herself she is likely to conclude that it is 
a return of her menstrual periods, but in the majority of cases it is the 
forerunner of some malignancy; howeyer, there are many exceptions to 
this latter view of the case. Take for example the following cases from 
my note book: 
Mrs. R., aged sixty-three, who had passed her change some thir- 
teen years before, had been in apparently good health, when suddenly 
she began to How and believed that her periods had returned. The 
case would naturally arouse one's suspicion as to malignant disease, 
and yet this was nothing more than a simple hemorrhage due to a 
slight endometritis, which finally passed away under treatment, and the 
patient continued in good health, dying at the age of seventy-five. We 
would naturally conclude, and with truth, that the chances were she 
was developing a case of malignancy. 
Another case that of Mrs. F., aged seventy-four, and whom I saw 
fifteen years ago in consultation with her family physician, had a flow 
develop some ten-years after her change, and which had been a source 
of great alarm to herself and family. Upon examination I feared, from 
the hardened condition of the cervix, that it was likely to be a genuine 
case of carcinoma, yet upon removing some of the detritis from the 
cervical canal and examining it, it did not present any of the charac- 
teristic conditions of malignant growth. It was evidently a case of 
endometritis fungosa. Curetting was done, applications were also 
made to the lining membrane of the uterus-and which seemed neces- 
sary about once in six months or once a year, sometimes going on much 
longer than that. At the present time she occasionally has a slight 14 
hemorrhage, but is in excellent health, has no enlargement of the organ 
or infiltration of the appendages. 
I have seen many patients who would develop a hemorrhage at 
this time from simple endometritis, endometritis fungosa, from the de- 
velopment of a small fibroid tumor or polypus, from other conditions 
not unlike those which present previous to the change of life; many 
conditions, strictly non-malignant and which the patient should have 
the comfort of knowing, for which a simple line of treatment is suffi- 
cient. 
I have realized for a number of years that the diagnosis of carci- 
noma of the body of the uterus, in its early stages, particularly when it 
is present after the menopause, is not by any means easy. 
The American Gynecological Journal, November, 1891, con- 
tains a translation of an article by Hofmeier and Leopold (Gazetta degli 
Ospitalia) upon the subject. Hofmeier regards cancer of the body of 
the uterus as an epithelial growth, having its origin in the superficial 
epithelium, or in that of the glands. Leopold holds practically the 
same view and insists that such tumors never originate in the connect- 
ive tissue. He advises the abandonment of the term malignant 
adenoma, " for the word adenoma indicates a benign glandular tumor, 
and if the neoplastic glandular tumor present the characteristics of 
malignancy, the condition in question is a papillary carcinoma." 
The development of the growth is said to depend upon a diffuse 
infiltration much more frequently than through the formation of 
isolated nodules. Hofmeier states that cancer in this part of the uterus 
develops frequently in multipara or in women of small family, and 
rarely appears before fifty years of age. The earliest symptoms are 
usually hemorrhages, which are followed by a serous discharge, more or 
less fetid. Pain similar to that of uterine colic is also present. 
In others of my cases the element of hemorrhage was most per- 
sistent and finally led to a correct diagnosis, that of true cancer, all 
methods of treatment having failed, and only complete removal of the 
organs was left to do. 
In these cases of persistent hemorrhage from the body of the 
uterus, that continues after curetting, we should be thoroughly aroused 
in our suspicions of malignancy. The following case will illustrate, 
and shows the necessity of thorough, careful watching of the patient 
after one curetting. 
Mrs. E. M. K., aged 38, married seventeen years; one child aged 
16; confinement normal; never had any serious illness; regular in her 
menstruation; became a widow seven years ago; married her second 
husband five years ago, and has been perfectly regular in her menstrua- 
tion until her present trouble. Believed herself to be well when suddenly, 
in May, 1892, she had a severe attack of hemorrhage. She was seen by 
her attending physician, and after a thorough course of medicine sub- 15 
mitted to a thorough curetting of the uterus some time the latter part 
of June. In July, she had, as she believed, a normal, regular men- 
strual flow. Some time during July she was visited by her family 
physician, but no examination was made. In fact, no examination 
was made at any time after the curetting, as she stated. In August she 
had another severe hemorrhage, the local pain being now very severe, 
her system showing much exhaustion. She came to my office August 
25, 1892, presenting the characteristic appearance of great loss of blood. 
I gave her a careful examination and found a large epithelial growth, 
implicating the entire cervix and extending somewhat down the vaginal 
wall. The mass was movable, but there was evidently infiltration of 
the broad ligament. 
I did not think an operation advisable. Had this case been care- 
fully watched after the curetting, it would have been apparent in a 
short time that vaginal hysterectomy would have been the proper 
operation for her, and which might have resulted in permanent recovery. 
This patient has at various times since curetting been anxious to 
have another examination and the more complete operation, as she in- 
forms me, but that her female friends, the old ladies particularly, were 
constantly importuning her not to have anything more done, as it was 
simply her change of life and that she would come out all right later on. 
Among the conditions that occasionally keep up a uterine hemor- 
rhage the pathological state called hjematosalpinx perhaps is quite as 
difficult as any to make a diagnosis in. The symptoms are very likely 
to be overlooked. The patient is treated frequently for a long time for 
some believed diseased condition of the cervix or body of the uterus, 
and the true trouble is not reached until, as it were, by the method of 
diagnosis by exclusion. It is likely to be confounded with hemorrhagic 
endometritis, where there is a constant dribbling of blood, instead of 
the normal menstrual period; whereas, in the haematosalpinx we get a 
more decided flow, a hemorrhage that is inconsistent with the patho- 
logical condition of the uterus itself. Haematosalpinx cannot be looked 
upon as a simple transitory pathological incident. 
Few men have done so much to impress upon us the importance 
of a proper understanding of true haematosalpinx, and the necessities 
for an operation, the pathological changes that will occur, making the 
case one of pyosalpinx, with all its attendant dangers, as has our 
Fellow, Dr. Joseph Price, and whose ideas are now being incorporated 
in our most advanced text books upon this subject. 
Reviewing then, somewhat briefly, the subject of uterine hemor- 
rhage,' one is impressed, particularly as we take into consideration our 
gynecological and consultation work, with the necessity of studying each 
case carefully and reaching a correct diagnosis as early as possible. 
When once that has been accomplished what is to be our line of 
treatment ? 16 
Take the case of prolonged hemorrhage in girlhood ; the conditions 
are present, such as we have referred to, a flexion of some sort, a sten- 
osis with enlargement of the body of the uterus, the endometrium is 
covered with a fungoid growth, small polypi are present, there may be 
a true condition of endometritis fungosa, perhaps there may be present 
a distinct polypus. Have we any better line of treatment for these con- 
ditions than a thorough, careful dilatation of the cervical canal, com- 
plete and thorough curetting, and then, with care, packing the cavity of 
the uterus with sterilized gauze, dipped or not in a solution of some 
mercurial, or iodoform gauze, thereby maintaining complete and 
thorough drainage. This is a method of treatment I have followed out 
for the past five years, enlarging upon it more and more as the degree 
of safety seems to have become greater, occasionally allowing the pa- 
tient to wear afterwards, for relief of the flexion, an intra-uterine stem 
pessary. I believe that in all cases where a simple uterine polypus 
has been removed a thorough curetting should be done, and packing 
with gauze carried out. 
Take the condition of hemorrhage that follows parturition, and 
which keeps up for many months or years, as the result of subinvolu- 
tion-chronic metritis. 
The patient has probably been given medicines unlimited, yet her 
recovery will not follow until some such line of treatment is pursued. 
In the treatment of hemorrhage due to uterine fibroid, I am 
thoroughly anchored in the belief that for the small, persistent, bleeding 
fibroid, there is no better course to be pursued than the removal of the 
uterine appendages, although it is possible now and then, when the 
fibroid is simply submucous, that by careful curetting we may be able 
to enucleate it sufficiently, or that the uterus will take on contractions 
and force it out, thereby saving our patient the more formidable opera- 
tion ; however, these cases must be handled with great care. Rigid 
antisepsis must be carried out and the after treatment cautiously pur- 
sued or septic conditions will develop. In a medium sized or large 
fibroid, where it becomes difficult to remove the uterine appendages, 
and the hemorrhage is gradually destroying the patient, there can be 
no better treatment, it seems to me, than hysterectomy in some form, 
and when we consider how favorably these operations are presenting in 
the hands of such men as Joseph Price, Ross, Eastman and others, we 
cannot but believe that our position should be strong in discouraging 
the use of electricity and of temporizing; yet, occasionally, a case is 
brought to us in which the hemorrhage has continued so long a time, 
the tumor having grown to that size that the patient is so feeble, so 
anaemic, with occasional attacks of syncope and loss of appetite, blood- 
less lips and waxen face, that the operation of hysterectomy is quite 
out of the question. She will inevitably die of shock. Can we do 
anything for her to bring her into better condition ? I am most em- 17 
phatic in saying that I believe we can; that these cases, by being care- 
fully and thoroughly curetted, can be improved so' that they may 
recover sufficiently to stand the more formidable operation later on. 1 
might refer to cases to illustrate my point, but I have done this some- 
what more fully in a paper that I am about to read before the Vermont 
State Medical Society ; however, I would like to present some points 
in connection with the following case taken from the British Gynecological 
Journal, May, 1892, page 71, reported by Mr. Bowreman Jessett. He 
says : "It appears to me that, with our present knowledge of the dif- 
ferent methods of performing hysterectomy, it is very difficult to lay 
down any hard and fast rule as to which is the best method of operating 
in this or that case. As we all know, who are in any way versed in 
these distressing cases of myomata connected with the uterus, one rarely 
meets with two cases alike, and although we may decide upon one plan 
of action before opening the abdomen, yet when the tumor and its sur- 
roundings are brought into view, we may have to adopt a totally differ- 
ent course to that originally planned. 
" Patient aged forty-four, a fat and somewhat phlegmatic woman. 
Came under my care June 13, 1891. Married ; no children ; no mis- 
carriages. Ten months before admission into hospital, had a flooding, 
and another, very severe, four months later, since which time never en- 
tirely free from hemorrhage. Considerable pain in abdomen and back, 
especially in the right side; micturition very frequent. Hard, solid 
tumor in abdomen, rising to within an inch of umbilicus. Per vaginam, 
uterus found to be drawn up out of pelvis ; os felt with difficulty. 
Varicose veins in one leg, eczema in both legs. Patient kept absolutely 
at rest for six weeks and treated with iron and ergot. Left hospital 
July 29th, having had but one attack of hemorrhage. Attended as an 
out-patient, but flooding returned with eczema. Re-admitted Sept. 17; 
treated again in former manner ; no return of hemorrhage for six weeks; 
discharged Oct. 5,1891. Circumference of abdomen at umbilicus thirty- 
nine and one-half inches ; umbilicus to left iliac crest, nine inches; to 
right iliac crest, eight and one-half inches ; umbilicus to ensiform car- 
tilage, seven inches ; to pubis, eight and one-half inches. Suffered from 
vomiting and constant desire to pass water. Hysterectomy suggested, 
but postponed on account of age, hoping at menopause hemorrhage 
would cease. Re-applied for admittance much worse, Dec. 30, 1891. 
Begged for an operation, and on Jan. 19, 1892, I performed abdominal 
hysterectomy." 
He here describes his method of operating very fully. 
"She was very collapsed after operation and died on 21st, or thirty 
hours after operation. At post-mortem there was no hemorrhage or 
peritonitis to account for death, which can only be attributed to unsat- 
isfactory state of health she had been in for so long a time." 
This patient died from shock, and death was probably due to the 
great loss of blood that had been going on for so long a time. 18 
She illustrates clearly a class of cases that are left too long by the 
general practitioner, bleeding, bleeding, ever bleeding; they have 
applied electricity and tried various forms of remedies, but only to let 
the patient keep on bleeding. I must repeat, let these cases have the bene- 
fit of curetting and then the more formidable operation of hysterectomy. 
As to the class of cases in which hemorrhage occurs at, or after 
the menopause, if we cannot be certain that they are malignant, 
requiring either a vaginal or supra-vaginal hysterectomy, let us give 
the patients the benefit of the doubt, keeping them from the atmos- 
phere of fear of malignancy just as long as possible, but in the persis- 
tent hemorrhage that may come on from the non-malignant conditions 
that present after the change of life, let us by all means give them the 
benefit of thorough curetting and the treatment that I have endeavored 
to bring out in this paper. 
I know that there have been many criticisms made upon the 
question of entering the cavity of the uterus in so formidable a manner, 
but I am certain, from the experience I have had in many cases, that it 
is a safe procedure, but must be done in the most thorough way, as to 
cleanliness and drainage, and I believe there is no drainage superior to 
that of the gauze packing. THE 
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