Any condition that will produce uterine congestion may contribute to uterine hemorrhage, as systemic plethora, over-heating, alcoholics, drastic purgatives. A loss of the normal contractility of the uterine bloodvessels may be a factor in the production of postpartum hemorrhage.

Prolonged and profound anesthesia suspends uterine innervation to such an extent that before the uterus has time to recover its contractile energy, blood is poured in large quantities from the open vessels of the placental site. Many obstetricians do not believe that anesthesia is a factor in increasing hemorrhage after childbirth. To be sure, they modify their opinion by the advice that the anesthesia should be moderate, should not be pushed to the depth demanded by a surgical operation. The writer's experience justifies him in delivering the opinion that if the anesthetic is pushed to the extent of doing effective service, more than a physiologic amount of blood is lost and that if the anesthesia is profound, is surgical or approaches near to the surgical condition, there is imminent danger of genuine postpartum hemorrhage.

A changed condition of the blood is a factor in the production of postpartum hemorrhage. A loss of fibrinogen from the system prevents the formation of fibrin to a physiologic extent; the clots of blood usually organised to close the uterine bloodvessels become deficient in firmness and fail to do their appointed service. This changed condition of the blood is notably observed in cases of albuminuria and malaria.

The hemorrhagic diathesis accounts for some cases of postpartum hemorrhage. The factors concerned in the causation of the hemorrhagic diathesis have not been accurately determined. That such a condition exists is clearly proven by well-attested facts. In many cases in which this condition is present ancestral history strongly points to heredity as a prominent causal factor. If a parturient presents this condition and her ancestors for several generations have suffered in the same way, we must conclude that hereditary influence is largely responsible for its origin and development. It is incontestible that postpartum hemorrhage is an outcome of this diathesis.

Traumatism.-Uterine inversion when complete and occurring immediately after delivery is apt to be followed by profuse hemorrhage. However, the hemorrhage will not be severe unless the placenta is detached. Doubtless the most common cause of puerperal uterine hemorrhage is imprudent traction on the cord. It may be the result of a rapid labor when the cord is unusually short or encircles some part of the child's body; in such a case, if the placenta is not very firmly attached to its normal site the strain upon the cord may be sufficient to draw down the fundus

and invert the uterus. The systemic shock, caused by the uterine inversion, tends to increase hemorrhage by increasing muscular relaxation and decreasing uterine innervation. The author has had under observation only one case of puerperal uterine inversion. Its probable causes were a relaxed condition of uterine muscular fiber and too energetic traction upon the cord. The hemorrhage was profuse.

Too many are the causes of puerperal uterine rupture to be mentioned in full detail in this paper. It may result from any force which abnormally enlarges the uterine cavity and thus greatly distends and weakens its walls; all organic alterations that degenerate and soften uterine tissue; a previous Cesarean operation; all obstructions that increase the difficulties of labor; instrumental interference for the delivery of the child; excessively strong uterine contractions. The hemorrhage of a ruptured uterus occurs, not only from the surfaces of the rent, but also from the vessels of the placental site. The contractions of a ruptured uterus are not uniform throughout the uterine tissue and are inefficient; hence they do not properly close the mouths of the bleeding vessels and flooding is the consequence.

Internal hemorrhage.-Postpartum hemorrhage may be internal as well as external. Internal hemorrhage may be the result of some obstruction to the uterine orifice which prevents the escape of blood, as coagula or a part or whole of the placenta.

SYMPTOMS.

The prominent symptoms of postpartum hemorrhage are a profuse discharge of blood, generally sudden, sometimes immediately after the birth of the child and again after several hours, usually not until the placenta has been dislodged from its site; relaxation of the uterus which can be detected by placing the hand upon the abdomen; the usual signs of severe hemorrhage, as pallor of the face, intense desire for air, gasping respiration, dimness or loss of vision, a rapid, feeble pulse, dilated pupils, ringing in ears, skin bathed in cold sweat, syncope. When these events occur there can be no doubt that the accoucheur has before him a case of postpartum hemorrhage.

DIAGNOSIS.

The differential diagnosis of external postpartum hemorrhage presents no special difficulties. The enumeration of symptoms made above furnishes a sufficient and certain warning to the obstetrician that he must grapple with a postpartum hemorrhage. The differential diagnosis of internal hemorrhage is sometimes quite difficult. The enlarged abdomen supposed to be caused by

an accumulation of blood in the uterine cavity, may be due to expansion of the intestines. Resonance on percussion will indicate that the resonant sound is due to the presence of gas. A distended bladder may simulate a uterus filled with blood; in such a case evacuation of the bladder will prevent a diagnostic mistake. Syncope immediately or soon after child birth may be due to a very rapid labor; in such a case the bloodvessels which have been compressed by the distended uterus are relieved of their compression and receive the blood rapidly from the head, hence faintness sometimes follows. This condition may be relieved by placing the head lower than the rest of the body. If under any circumstances doubt arises as to the existence of internal hemorrhage, a digital exploration of the uterine cavity will change the doubt into certainty.

PROGNOSIS.

Flooding after labor is an exceedingly dangerous accident; a few minutes may decide a woman's fate. The more profound the uterine inertia, the more abundant will be the hemorrhage. Internal hemorrhage places the patient in more danger than external, because it is more apt to escape detection. In both external and internal hemorrhages a speedy death is indicated by chills. or convulsions, increasing dyspnea, prolonged syncope, sharp and continued pains in the loins, vertigo, loss of vision, dilated pupils. In the very large majority of cases recovery may be confidently expected. This result will be secured by the resourceful and ever-ready obstetrician.

TREATMENT.

The methods which have been employed in the treatment of postpartum hemorrhage may be classified as follows-namely, pressure, astringents, nerve stimulation, miscellaneous. Some of the methods to be mentioned may be appropriately admitted to more than one of these classes. The object of all kinds of treatment is the contraction and retraction of the uterine muscle for the purpose of closing the wide-open mouths of the uterine blood

vessels.

Pressure-Pressure may be made from without and from within the uterus. The hand placed upon the abdomen grasps the uterine walls and compresses them in order to bring their opposite internal surfaces into close contact, when, speaking generally, they will act as ligatures to the bleeding vessels. An aseptic hand may be passed into the uterus, to remove therefrom any portions. of placenta or clots which may remain therein and to make firm

pressure upon the placental site. The hand should be retained. in this position until it is forced from the uterus by contractions of that organ. The latter procedure may be tiresome to the obstetrician, but it has the advantage of direct pressure at exactly the place of difficulty; it is also advantageous, because the hand is always near and ready and can be used on the spur of the moment. Pressure may also be made by forcing the uterus into an anteflexed position. To accomplish this, place one hand on the abdomen behind the uterus and press it forward; at the same time with two fingers of the other hand in the posterior cul-de-sac press the cervix forward. This maneuvre will bring together the inner surfaces of the uterine walls and compress the bleeding vessels.

Another method of pressure is compression of the abdominal aorta, said to have been first advocated by Rüdiger, a practitioner of Tübingen, in 1797. He introduced his hand into the uterus and compressed the aorta through the uterine wall. In 1825, Ulsamer introduced the method of pressure upon the aorta through the abdominal wall. According to the latter method the obstetrician stands on the right side of the patient and depresses the abdominal wall just above the uterus and a little to the left of the median line; the aortic pulsations are felt and continued pressure with two or three fingers at that point will control the hemorrhage. Notwithstanding the fact that the arterial supply from the ovarian arteries cannot be cut off in this way, it has proved to be a very rapid and effective method of controlling uterine hemorrhage; it stimulates the aortic uterine plexus and, even if it affords only temporary relief, time is given for instituting a more permanent method and saves to the patient a large quantity of needed blood. Compression of the aorta is specially indicated in organic disease of the uterus, such as a fibroid tumor. A rubber bag carried into the uterus and filled with either hot or cold water or air will act as an efficient compressor of the uterine bloodvessels. With many obstetricians iodoform gauze packed into the uterine cavity and allowed to remain 24 or 48 hours is a favorite remedy.

Astringents.-Salts of iron by injection, swabbing and tamponing have been largely used for the relief of postpartum hemorrhage. In each case before using iron the uterus should be freed from any retained pieces of placenta or clots and hot water injected for thorough washing. Robert Barnes, in 1857, was the originator of its use by injection, or at least was its earnest advocate. At the beginning of this practice he used a combination of 4 perchloride of iron and 3/4 water, but later 1 part iron to 10 or 12 parts water. Iron coagulates the blood in the mouths

of the vessels, acts as an astringent to the inner surface of the uterus and promotes uterine contraction. By injection iron is regarded by some obstetricians as a hazardous remedy on account of producing metroperitonitis. The clots formed by the iron. may become septic and septicemia has followed. Doubtless the safest method of using iron on the internal surface of the uterus is by a piece of sponge or swab of cotton. Other astringents, as alum, witch hazel, and tannin have been used for the relief of postpartum hemorrhage, but none has had such wide advocacy as some preparation of the ferric salts.

Nerve stimulation.-The object of nerve stimulation is to produce contraction of uterine tissue. This is accomplished by means external and internal, as follows: external massage over the uterus; hot water or hot salt solution at a temperature of 110 to 120° F., injected into the uterine cavity through a double current catheter; flapping the abdominal wall with a wet towel: cold water poured upon the abdomen from a height, said to be objectionable because it increases shock, which already exists, but many of the methods used for checking postpartum hemorrhage are promotive of shock; application of ice to the abdomen; introduction of pieces of ice and injection of cold water into vaginal and uterus; vinegar by injection into uterine cavity, first advised by Leroux, in 1776, and highly recommended by Penrose in desperate cases; hypodermic injection of ergot, its absorption being too slow when taken by the mouth; the Faradic current, which is quite effective, but generally not available; hypodermic injections of sulphuric ether are said to have been used with remarkable success in some cases of collapse.

Miscellaneous.-Transfusion in nearly all cases is impractica

ble. However, cases are reported in which life was saved after an unsuccessful trial of several other methods. Autoinfusion by bandaging the extremities may accomplish the same object as transfusion; pulmonary embolism has occurred from its use. Injections of salt solution, both intracellular and intravenous are of extreme utility; they may be dangerous from too great a quantity of the infused fluid; the blood may thus lose largely its power of coagulation. Small infusions frequently given are preferable excessively large infusion. Helpful adjuncts to all kinds of treatment are lowering the patient's head and raising the foot of the bed.

Antiseptic precautions are demanded in all internal manipulations and procedures. It is all-important to secure not only contraction but retraction. Occasionally, even a severe case when left to nature recovers. Such recoveries, however, are so infre