Symploni.v. —In general, there are none of a precursory nature. The hem orrhage appears suddenly. Certain authors attach importance, as a pre cursory sign, to the absence of the chill or chilly sensations which usually follow the completion of labor. But this is fallacious, seeing that in per fectly normal cases these sensations may be wanting. In a general way it may be said that there is danger of hemorrhage as long as the placenta and clots are within the uterus. The hemorrhage may be internal, ex ternal or mixed, usually the latter. In case of internal hemorrhage the uterus increases rapidly in size, and is soft to the palpating hand. The woman feels that she is losing blood, and often first notifies the accou cheur. Pallor, anxiety, tendency to syncope supervene; the pulse is frequent, small; convulsions, coma, set in, and death follows if the hem orrhage be not arrested. The fundus of the uterus may rise above the umbilicus, and is filled with clots which may be expressed.
The important point is to determine the cause of the hemorrhage, for on its localization depends the safety of the patient. Vaginal examina tion will give the most certain information. We must assure ourselves at the outset if the placenta has separated or not, if a portion only remains, for the presence of this foreign body means increase in the hemorrhage.
The indications for treatment consist in: 1. To empty the uterus of the contained placenta and blood.
2. To awaken contraction as speedily as possible.
3. To check the affiux of blood to the uterus.
4. To overcome the immediate and consecutive effects of the hemor rhage.
1. To fulfill the first indication, the woman must be placed flat on her back, the head low, and if there is retention of the placenta, it must be extracted at once. If the placenta has only partially separated and in ertia is also present, common sense tells us to act against both at the same time, and fortunately the same measure suffices, and this is the introduc tion of the hand into the uterus. The cavity must be emptied of placenta and clots, but the hand must not be withdrawn too soon. The uterus must be compressed by the external hand. Where adhesions exist, it is sometimes impossible to remove all of the placenta. Indeed, in case of firm adhesions, the operation of removal is one of the most delicate and difficult in the whole range of operative obstetrics. Never should force be used, lest the uterus itself be injured. Hiiter proposes scratching away the placenta piecemeal till every trace has been removed, but the French • teachers are less bold and radical, and when the adhesions are too resisting, they prefer to leave the expulsion of a portion to nature. Usually this remnant passes away in a few days in the lochia. Vaginal injections prevent the sojourn of the debris in the genital passage. We are not as yet in France sufficiently accustomed to the use of intra-uterine injec tions, and I believe that we are wrong in not resorting to them more fre• quently.
In case the placenta has completely separated, nothing is simpler, seeing that a few tractions on the cord will suffice to complete the third stage.
After the extraction of the placenta, the uterus must be watched with the greatest care, for often the organ relaxes and hemorrhage again sets in from what has been called secondary inertia.
In case the retention of the placenta is complicated by spasm of the uterus, and if there is hemorrhage, the manner of action is somewhat dif ferent. If the spasm is at the internal os, it yields usually at the end of a few hours, unless it has been artificially produced by large doses of ergot.
In this instance, however, there is no hemorrhage, for the entire uterus partakes of the spasm. In case there is hemorrhage, we must proceed rapidly to overcome the spasm. Sometimes enemata of laudanum, twenty to twenty-five drops, belladonna to the cervix, cause relaxation, and al low of delivery of the placenta. If the hemorrhage is excessive, however, the hand must be passed boldly into the uterus. The same remark ap plies to cases where the placenta is encysted.
At the same time as the placenta is removed, we must evoke uterine contraction. Frictions over the uterus, irritation of the cervix, ergot, the introduction of the hand into the uterus, cold drinks, cold over the abdomen, [ice in the cavity of the uterus, the faradic current—Ed.], these are measures which suggest themselves. The English use opium, digitalis, turpentine, by the mouth, but these are means tardy in action. This does not hold true of intra-uterine injections. While in France we hardly dare use plain water, in England and Germany not only is cold water used, but also with vinegar or alcohol. Nowadays the belief is that the fear of penetration of fluid through the tubes into the abdominal cavity has been much exaggerated, especially since double catheters have been employed. In England and in Germany, obstetricians have even gone further, and injected into the uterine cavity styptic solutions, such as iron, where the hemorrhage cannot be controlled by other meant Ontrepont was the first to resort to this, and he was followed by Scan zoni and Kiwisch, who employed strong solution of the muriate of iron. Barnes, in England, lays down the following rules: He empties the uterus of clots and of placental debris, and then, by means of a Higgiuson syringe, he injects the iron solution directly into the cavity, with the pre caution of first filling the syringe completely to avoid the injection of air. The fluid returns mixed with clots, and the perchloride of iron checks the hemorrhage by coagulating the blood directly in the mouths of the vessels. by corrugating the mucous coat of the uterus, by causing contraction, fre quently, of the muscular fibres. " The perchloride of iron comes to our aid, and saves the women often when their condition is most desperate. The hemorrhage rarely returns if the injection be made as I have out lined, and in case it does, the process may be repeated. I grant that the perchloride may do harm, but we must remember that the hemorrhage. if it continue, may be fatal, and that the other means of checking it are not without danger. Our choice, then, must lie between an assured good. bought at a possible risk, and a certain ill which will probably tt.,sult fatally. The following arc the results which I have obtained by the nee of the perchloride of iron: In many cases it has saved the patients when all other means were failures; in certain cases the hemorrhage has been instantly checked, and the women have had a phlemasia alba dolens. In a number of instances, where the women were in extrenti.s, the hemor rhage has been checked, but not soon enough to be of avail. The remedy was used too late. The lesson taught us is that the perchloride must not be left to the last, when even it will do no good. It should be used early before complete collapse. I lose no time in resorting to the measure, such is my confidence in it." (Barnes.) I have quoted thus at length from Barnes, because I wished to show how strongly he is in favor of the method. Personally I am not so en thusiastic, and in face of the possible risks, I would leave it as the last resource.