pleasant one, is a very just one, that, even where we succeed in getting a good contraction, we can have no sense of absolute security against concealed or open hemorrhage, in a patient whom we may have put to bed ever so comfortable or apparently safe: it is our duty always to remain within call for at least one hour after the delivery. If a whole hour passes without any such accident we may feel quite at liberty to go away. I advise every student to mark and observe this as a rule of conduct.

The influence of position in determining the momentum of blood in the vessels is well known to the profession; but there are few cases wherein it is of more consequence to pay a profound regard to this influence, than in parturient women. A uterus may be a good deal relaxed or atonic, and yet not bleed if the woman lie still, with the head low; whereas, upon sitting up suddenly, such is the rush of blood down the column of the aorta, the iliacs, the hypogastrics, and the uterine and spermatic ateries, that the resistance afforded by a feeble contraction is instantly overthrown, and volumes of blood escape into the womb and vagina with almost unrestrained impetuosity. The vessels of the brain under such circumstances become rapidly drained, and the patient falls back in a state of syncope, which now and then proves immediately fatal. I may be excused for stating here that I have never met with but one of these sudden and fatal hemorrhages in my own practice. It is, perhaps, due to the special attention I have always considered it a duty to pay to this point, that I have hitherto avoided so serious a misfortune. Surely, I have, in a multitude of persons, by a prompt attention to the state of the womb, put aside the stroke of death by proceeding without delay to empty the organ by turning out with my fingers the masses of coagula with which it was filled. If you leave your patient soon after her deliverance, and are hastily recalled to see her with an announcement perhaps that she is dying, your first duty on reaching her bedside is to examine the hypogaster to ascertain if the uterus be firmly contracted or not, and, if you find that the uterine globe is not too large, too much distended or expanded, then do not rest satisfied until by a vaginal examination you shall have learned that there is or is not a clot-tampon in the vagina.

CASE.-In conversation with my late venerable friend Professor James, upon this very subject, he informed me that he delivered a lady a few years before, after an easy natural labor. The uterus contracted well, and all things seemed as favorable as possible. As the accouchement took place early in the morning, he was, subsequent to the event, invited to breakfast down stairs, whither he proceeded, after

having given strict caution to the lady on the subject of getting up. While the persons at breakfast were conversing cheerfully, and exchanging felicitations upon the fortunate issue of affairs in the lyingin room, the nurse was heard screaming from the top of the stairs, "Doctor, doctor, for God's sake come up!" He hastened to the apartment, and the lady was lying across the bed quite dead. It was found that, soon after the doctor went below, the lady said to the nurse, "I want to get up." "But you must not get up, madam; the doctor gave a very strict charge against it," replied the nurse. "I do not care what the doctor says," rejoined the patient; and thereupon arose, and throwing her feet out of the bed, she sat on the side a few moments, reeled, and fell back in a fatal fainting fit. The remarks of Dr. James, as he related the occurrence to me, made upon my mind a deep impression of the vast consequence of careful and well-timed instruction of the nurses; who, if they could have the dangers of mismanagement fully exposed to them, would surely avoid some accidents that every now and then are attended with shocking results.

Though large discharges are not apt to occur when the womb has once contracted pretty firmly-there are precautions which ought always to be observed: for example :—

CASE. I left a woman half an hour after the birth of her child. She was as well as could be desired. I gave the usual directions. In a short time her husband came running to me, in the street, where he met me, and said his wife was dying. Upon hastening to his house, I found her, in fact, pulseless, pale, and completely delirious, with a constant muttering of incoherent phrases. Upon inquiry, the following occurrences were found to have taken place. She felt some desire to pass the urine. The nurse told her to get up. "But the doctor says I must not get up." "Oh, never mind what the doctor says; it won't hurt you; get up." A chamber-pot was placed in the bed, and Mrs. F. was lifted upon it, in a sitting posture. She fainted in the woman's arms, was held up a short while, and when laid down, the vessel was discovered to be half full of blood. She had nearly died; and did suffer long and severely in consequence of this imprudent disregard of orders. When I left her, the uterus was well contracted; but the change of momentum in the arterial columns produced the hemorrhage, than which I have scarcely seen one more dangerous.

CASE. It is of the highest consequence to secure a firm contraction of the womb after delivery, in all those women who have before suffered severely from flooding soon after the birth of the child. A

lady in three successive labors, of which the first occurred on the 30th. of December, 1819, and the last on the 28th of September, 1824, which were rapid and easy, was brought almost to the gates of death by enormous discharges, which commenced about five minutes after the birth of the foetus. I saw her lie pulseless, and as near as possible to dissolution in those labors. In two subsequent confinements, she took one scruple of ergot, just as the foetal head began to emerge. This was given to her, not for the purpose of aiding in the expulsion of the child, or placenta, which had never occasioned any embarrassment in antecedent labors; but to save her from those dangerous losses, by constringing the womb permanently; and I am pleased to say that, in both instances, she experienced none beyond the ordinary amount of effusion. I could cite numerous examples of similar results. I scarcely ever omit such a precaution for any patient, of whom I am informed that she floods after delivery.

Sitting up too Soon.-As regards the danger of sitting up soon after delivery, there are some important suggestions for the Student that ought not to be here omitted.

Certain women are met with who pass through the conflict of parturition unscathed, and who are quite as competent to the performance of their daily toil on the following day as the Chief's wife who so much excited the astonishment of Hearne on his Northern Journey. I have found that many of my patients, and some in the class of what are called the "upper ten thousand," were completely destitute of all symptoms of indisposition as the halest Potawattomie or Ottowa woman. Such people might get up; and I have seen very elegant women get up and "be about" on the third day without pretence of after indisposition. Still, it is a safe rule to advise the keeping of the bed for many days, since to leave the bed is to go forth à la chasse for some malady. Hemorrhages, chill, prolapsions, and an evil train attend those imprudent women who leave the lying-in couch too early. A rest of nine days is a short rest after nine months of fatigue crowned by the exhausting conflict of a labor.

It is well known that the coagulability of the blood becomes greater in proportion as any hemorrhage progresses-therefore a woman who has lost during her labor forty or eighty ounces of blood has the rest of it more coagulable than it was before the flooding commenced. Again, fainting consists in the too little intensity of the pressure of the blood, in the brain capillaries-it is encephalic anæmia—and a woman just gone through a flooding, experiences a sensation of faintness from lessened vascular tension of her encephalon. If she suddenly assume

an erect position, the tension becomes instantly much lessened in consequence of the gravitation of the blood. But-and this is the danger -if she faint badly while her blood is become thin and highly coagu lable from hemorrhage-the scarcely moving current nearly stops in the heart, and when she comes out of the deliquium, if ever, she sometimes does so with a clot in the auricle and ventricle-she has got a false polypus in the heart-and she will surely die.

Heart-Clot. Many women have died soon, almost immediately after giving birth to the child, or speedily after the delivery of the placenta. Some of them have perished suddenly upon rising up in bed, within a day or two, or more, after a labor attended with hemorrhage, from which, however, they were then so far recovered as to give no apparent cause for anxiety about them.

It used to be considered as an unaccountable circumstance, that some women should suddenly expire, either soon after the birth of the child, or not long after the delivery of the secundines, or within a few days subsequent to their being layed. I had noticed, on various occasions, the total want of any means of explaining such disasters, and remained as much in the dark as my compeers, until I discovered that the incident depends, most commonly, on the sudden coagulation of the blood that occupies, for the time, the right auricle of the heart, and, in some of the cases, even that which is in the ventricle and the pulmonary artery. A person who should suddenly have these cavities filled with a strong, firm clot, could hardly be expected to survive the accident, and would perish with symptoms of asphyxia; for, to choke up the way of the blood, either in the heart or in the pulmonary artery, would have nearly the same effect on the life, and give rise to nearly the same symptoms as would attend a ligation of the vena cava or the arteria pulmonalis.

My first publication on this subject, and which I consider to have made the rationale extensively known in the United States, appeared in the Medical Examiner, No. 51, for March, 1849, now seven years ago. Since that time, I have both seen and heard much of this sudden heart-clot, so that my views having been confirmed by my own observation and that of other physicians, I shall seize the present occasion to explain them to the student.

As the life of the blood is intimately connected with that of the vessels in which it circulates, it is reasonable to infer that the health and vitality of the former should bear a certain ratio to those of the latter.

It is beyond cavil, that the blood of an animal slowly bled to death

becomes more and more coagulable as the hemorrhage proceeds, and that the last ounce that is extravasated will coagulate in a shorter time than the first ounce would. Hence, the coagulability of the blood remaining in the vessels after profuse hemorrhage is considerably augmented, and sometimes to so great a degree, that care is to be taken to avoid bringing on a fainting fit, which increases the already dangerous tendency to heart-clot.

Copious hemorrhages produce weakness not of the blood only, but of all the organisms, whose forces, indeed, depend on the crasis of the blood, forces which are lessened by the blood's weakness, while its strength is equally dependent on the living solids it inhabits. The blood is weak when the vessels are weak, strong when they are in tone, and dying when they are likewise dying. It draws its life from the living solid of the endangium, which is the only tissue to which it has any relation of contact. To withhold from the blood this vascular lifeforce, is to cause the blood to die by coagulation; for when the nervous mass no longer influences the blood through its endangium, it must die-its coagulation is its death.

If a woman loses, by flooding, a very great quantity of blood, the vessels soon become as full as they were previous to the accident, but the blood has become hydræmical or watery, and incapable of taking up in the lungs, and delivering over to the body, a suitable sum of oxygen. Hence the propensity to faint after hemorrhages; and hence the danger of rising up from a recumbent position. If the patient have become ever so hydræmical, and yet keep the head low, she will hardly faint, for, while she is down, the encephalon contains its full proportion of the watery blood, which, poor though it be, is still equal to the wants of the economy, if the woman but keeps her head as low, or lower than the trunk. But if she rises up and sits, or stands on the feet, then the encephalon becomes anæmical, and the lessened tension of the brain allows her to fall down in a fainting fit.

In an ordinary state of health, a fainting fit may be brought on by various causes, as mental emotion, a sudden nausea, &c., and it is not a dangerous incident, because the blood is strong, and speedily restores the suspended innervations. But where the blood is so weak that it is necessary to keep the head as low as the trunk to avoid fainting, it is very dangerous to faint badly, because the blood, already excessively reduced in strength, and prone to coagulation, is likely to become concrete if it but come to a stop in the auricle.

Let a woman, who has lost by flooding, say 150 ounces, bring on a bad fainting, by sitting or standing up, and she will seem quite exanimate. All motion of the muscles is suspended. It is a question