HÆMORRHAGE.

BY MILLIE J. CHAPMAN, M.D.

Hæmorrhage as a cause of puerperal mortality may accompany abortions or labor at full term. There are records of epidemics of abortion, viz., in 1685-95, in 1712-88-9, even as late as 1832. Constitutional dyscrasias may produce abortions, but the cases we usually meet with are the results of accident or design. When the occurrence has been repeated one or more times it is likely to recur about the same time of every pregnancy. Will be met, most frequently at the third month. Hæmorrhage is more profuse and more likely to result fatally when the abortion is spontaneous than when resulting from accident. Uterine contractions are less prompt and hæmorrhage occurs. In some cases that habitually abort, vascular engorgement is a predisposing cause. The flow usually ceases with the expulsion of the contents of the womb prior to the sixth month. After that date we may have a continuance of the trouble. Hæmorrhage is recognized as accidental, unavoidable and postpartum. The first results from a premature separation of a normally situated placenta; the second is due only to placenta prævia, while the latter is generally caused by a relaxation or atonic condition of uterine fibers.

Accidental hæmorrhage, not connected with abortion, is seldom alarming unless occurring during the later months of gestation. Hæmorrhage may appear during labor from ulceration of the os uteri, but not in a quantity to endanger life. Lacerations of the cervix also produce hæmorrhage, but it follows labor and is controlled without difficulty. The presence of uterine polypus is an occasional source of hæmorrhage during labor. This may sometimes be relieved by use of remedies. If internal medication fail to check the flow, the tumor must be removed before delivery is effected. It is not always possible to accomplish the removal with safety to the mother.

In unavoidable or postpartum hæmorrhage the flow comes on suddenly but from other causes is often preceded by premonitory symptoms. A sensation of languor or weariness is followed by weight and numbness in the pelvic region, in the groin or thighs, increased in the erect position. Pain in the abdomen renders standing or walking impossible. These symptoms are aggravated by straining at stool and during micturition, for which there is frequent desire. The foetal movements become more and more feeble until they cease altogether. When the hæmorrhage continues profuse there is vertigo, dimness of sight, tinnitus aurium, fainting, pallor of face, frequent and feeble pulse. If the flow is not arrested syncope becomes more frequent, retching and vomiting set in, with sighing and labored respiration, the pallor increases, the pulse becomes weaker, restlessness, chills, and cold sweats take place, convulsions and death terminate the suffering.

The most frequent cause of hæmorrhage before delivery is either partial or complete detachment of the placenta. In the earlier months of pregnancy this separation may be followed by effusion, and the resulting clot finally cause abortion. If the hæmorrhage is considerable, and the presenting part of the child prevents escape, or clots form at the internal os, death may occur before the cause is recognized. In this concealed hæmorrhage, in addition to the above symptoms, there is very severe pain of a tearing character, attended by a bulging out of the membranes through the internal os, which is not influenced by uterine contraction. Hæmorrhage is always alarming, but in case it is concealed, the danger to both mother and child is greater.

External hæmorrhage being early recognized and actively treated, oftener results favorably. The danger is said to be greater in primipara than one who has previously borne children; also at seven or eight months, than when occurring at full term.

Unavoidable hæmorrhages, resulting from placenta prævia, appears during the last three months of gestation. It occurs suddenly, each attack increasing in quantity, recurring every few days or weeks, from the sixth to the ninth months. It is a dangerous complication of labor. The mortality of the mothers large, and of the children said to be fully fifty per cent. This subject was made

a study by the bureau last year. For statistics concerning cases and the treatment, you are referred to the Transactions for 1880.

Postpartum hæmorrhage is said to occur more frequently than any of the other forms. Is generally due to lack of complete and persistent contraction of the womb. There may be portions of placenta retained, or blood clots that prevent the contraction, or may be a general debility and lack of tone to all muscular fiber. Irregular or hour glass contractions are also a cause of hæmorrhage. It may result from exhaustion after severe and protracted labor, or one of the attendants of shock following sudden labor. May appear immediately after delivery of the child, or not until some time after completion of the third stage.

An unusual quickness of the pulse, lasting after the excitement of labor is over, is said to be a premonitory symptom. But in some cases the opposite, a very slow pulse, is followed by severe flooding. When the pains during labor have set in suddenly, attained their height soon and quickly disappeared, there is danger of hæmorrhage.

Treatment. Hæmorrhage can be prevented in a large number of cases. The pregnant woman should always be under the care of her physician. If seen from time to time, the disturbances and tendencies met as they appeared, much suffering and danger would be avoided. All women do not receive such attention and hæmorrhage does occur; when the treatment cannot be prophylactic, it may be curative. This will consist of medicinal or mechanical measures according to the circumstances in which we find the patient, the term of gestation, or the means at hand. In persons having a hæmorrhagic diathesis, the use of such remedies as Phos., Phos. acid and Ars. alb., has repeatedly changed the condition so that labor has passed with no excessive flow. In case of threatened abortions, if the physician is called before dilation of the os and profuse loss of blood has taken place, internal medication may check the hæmorrhage and the patient complete the term of gestation. Many cases of hæmorrhage during labor will yield to the action of a well chosen remedy. Either in my own practice, or in that of some member of this Institute, I have known hemorrhage to be checked by the following remedies:

Secale cor. Hæmorrhage, with little or no pain. Blood very dark and uncoagulated, sometimes fetid. The pains are either feeble or absent, or violent and spasmodic, causing continuous contractions. The patient is extremely prostrated, with palpitation, intermittent pulse, fainting, convulsive movements, coldness of the skin, but dislike to being covered. Cases of atony of the uterus or death of the foetus.

Ustilago madis. The blood is dark, flow abundant, painless, worse from motion, very sallow countenance.

Ferrum. In abortions, blood pale, worse from motion, fiery red face, copious discharge, sometimes fluid, again clotted and dark, with labor pains in abdomen and back, sensation as if face were bloated.

Millefolium. Discharge excessive, with pain like labor, darkcolored or bright red clots or offensive fetor.

Phos. Either ante or postpartum hæmorrhages. Tall, thin women-weak, empty feeling across the abdomen, flow pouring out freely then ceasing for a time and reappearing.

Apocynum cann. Threatened abortion with vomiting, flow fluid or clotted, nausea, palpitation, pulse quick, feeble when moved, fainting when raising head from the pillow.

Caulophyllum thal. Hæmorrhage after hasty labor-due to lack of tonicity of uterine fibers; habitual abortion from uterine debility. Erigeron Canadense. Uterine hæmorrhage with violent irritation of the rectum and bladder, abortion, with profuse flow, diarrhoea and dysuria.

Aletris farinosa. Habitual tendency to abort, sensation of weight in uterine region, nausea, vomiting, colic, loss of appetite, myalgia, passive hæmorrhages.

Arnica. In threatened abortion from accident or mechanical injury, soreness of muscular system, slow mental action, blood bright red or mixed with clots; also useful in active hæmorrhage, either ante or postpartum, with violent pains.

China off. Hæmorrhage from atony of uterus, dark, clotted blood, uterine spasms, desire to urinate, colic, coldness and blueness of the skin, heaviness of the head, ringing in the ears, loss of sight, fainting.

Ipecac. Constant flow of bright red blood, with cutting about the umbilicus, constant nausea and vomiting, oppressed breathing and sighing respiration, morose, extremely impatient.

Belladonna. Badly smelling hæmorrhage, light, clotted blood, a violent pressing and urging towards the sexual organs, as if everything would fall out; face becomes suddenly pale or red, staring eyes, dilated pupils, throbbing of the carotids, violent throbbing headache, extreme sensitiveness to noise, odors and movements, or stupor; desire to escape, violent delirium.

Crocus sat. Postpartum flow, discharge thick and black changeable moods from sad to lively; excessive gayety, bordering on delirium; sensation as if something living and jumping about in the abdomen.

Chamomilla. Dark blood, with pressure toward the uterus, and frequent discharge of colorless urine; great irascibility.

Firm and lasting contractions of the uterus are secured by the "Crede" method of expelling the placenta. With this practice hour-glass contractions and the formations of clots cannot occur Should the former be present when we see the case, continued firm pressure with the fingers at the os, while the other hand supports the uterus, will correct the condition. Where the pains have become deficient, turning the patient to the side she is accustomed to lie on will induce contractions and check the flow. Partially adherent placenta induces hæmorrhage, and if not removed will give rise to a secondary flow. Great care should be exercised to remove every portion. In extreme cases the hand must be introduced to separate and remove the placenta or to excite contractions where the flow is due to inertia. Because of evil results this method should not be resorted to if irritation made on the cervix, while pressure or friction over the fundus of the womb will bring contraction. Ether spray on the abdomen over the uterus is useful, and preferable to the use of cold water or ice. But hot water enemas with temp. 110 is greatly superior to either.

The tampon may be used in abortions or where dilation is desired and even during the later months of pregnancy may be introduced and permitted to remain one or two hours. When