effusions of blood, in labor, indicate that the placental surface of the womb is exposed by the separation of the after-birth from it.

If the after-birth is torn off, or in any manner separated from its place, the womb still remaining undiminished in size, it is evident that the blood may continue to flow for an indefinite period, and that the woman may be brought into great danger thereby-for the bleeding orifices may, for an indefinite term, continue to have the same degree of aperture as that which first allowed them to bleed. Supposing the superficial content of the gravid uterus to be two hundred inches, and that of the non-gravid womb to be only three inches, then it is evident that the great desideratum in uterine hemorrhages, before delivery, is to empty the organ as soon as practicable, in order to reduce its superficial content, as nearly as may be, to the smallest number of square inches, or the non-gravid superficies. In treating cases of alarming hemorrhage, therefore, we should ever keep in view the fact that, if the womb be allowed to contract or condense itself, its own muscular fibres will, by their contraction, lessen the calibre of all the blood vessels that are distributed on or in the organ, and in proportion to this condensation or contraction will be the certainty of arresting the sanguine effusion. It is not the orifice only that is closed, but the whole tractus of the vessel that is constringed.

If a labor should commence ever so favorably, with the child presenting the vertex in the first position, and the pains should propel the child downwards, so as to give reason to think the process about to terminate in the most happy manner, it might yet happen that hemorrhage should commence, and continue so abundantly as to make it absolutely necessary to deliver the child, in order to let the womb contract perfectly. This delivery by artificial means converts the labor, which commenced naturally, into a preternatural one. We should hardly be inclined to call that a preternatural labor which, though accompanied with a great effusion of blood, should terminate well, without any assistance on the part of the accoucheur.

There may also be a very copious and dangerous effusion of blood between the time of the birth of the child, and the delivery of the after-birth; and even after the after-birth has been discharged, the flow of blood may be so considerable as to involve the woman in the greatest danger. In the management of all these kinds of bleeding, the same indication is to be kept always in view; to wit, the condensa tion or contraction of the womb; for when that organ is fully con tracted and condensed, the blood cannot flow so abundantly as to endanger the patient, except in some very rare, and almost unheard of cases.

But among the causes of uterine hemorrhage, there is one which has been called the unavoidable cause, and is, perhaps, the most dangerous and difficult to manage: I mean that case which depends on the situation of the placenta happening to be on the cervix and os uteri. This is essentially a hemorrhagic labor, inasmuch as the conoidal cervix of the womb must not only dilate, but must dilate completely into a cylindrical form, in order to admit of afterwards carrying out the great object, the final condensation of the womb. Such a hemorrhage begins very moderately, but as larger and larger portions of the placenta continue to be detached with every successive dilating pain, it follows that the nearer the womb is to its complete dilatation, the more profuse and dangerous will be the hemorrhage.

Every considerable effusion of blood in labor does not demand the manual or instrumental assistance of the accoucheur. A woman may shed a quart of blood, and yet the pains may suffice to expel the fœtus in a natural way, after which the flow ceases. It is the effect, or the probable effect, of the bleeding, that renders it needful to interfere. If the pulse begins to grow small and frequent, the patient becoming weaker, the countenance paler, and the pains less energetic, we have to resolve what course we must take, and then resort to some of the numerous expedients for checking the discharge.

If the pulse in uterine hemorrhage be full and throbbing, and the constitution not as yet affected with debility, we may, with great safety and propriety, have recourse to a bleeding from the arm in order to lessen the momentum of the blood, which, by its too great impetuosity, tends to keep up the flow and the determination to the womb-just as we would bleed in a pleurisy or hæmoptoe, with a similar view. Such a course, however, would be very strongly contraindicated in the case of a feeble pulse, and a general state of weakness, faintness, or sinking, where, indeed, there would be no reasonable ground to hope for relief by the use of venesection.

The application of cold to the hypogastric region is often found to have a good effect in checking the sanguine effusion, and should be freely resorted to by stuping the lower belly with napkins, hard wrung out of cold vinegar and water; the application being renewed from time to time, until we are satisfied that success is, or is not, to reward our efforts. During the employment of the above-mentioned means, the patient ought to be placed in a horizontal posture, with the head very low, and the body covered only with sufficient bedclothes to keep her comfortable; the apartment should be freely ventilated, and the patient allowed to take any reasonable quantity of iced water, or

lemonade, while, at the same time, she makes use of the infusum rosa rubra with elixir of vitriol, or the plumbi acetas with opium.

Such are the general means for repressing the sanguine movement towards the womb; but these means do not suffice always, and we ought to examine by the Touch, in order to make sure, if possible, of the cause of the hemorrhage. If, upon inserting the finger within the os uteri, no portion of the placenta can be felt, and the membranes are found to be unbroken, we may, perhaps, resolve to rupture the ovum, with a view to diminish the size of the womb by letting its waters run off. If a quart of water should escape from the organ immediately after the breaking of the membranes, the superficies of the womb, and of course the placental superficies, would be sensibly lessened, since the organ contracts as soon as the escape of the waters permits it to do so This is the method proposed by Louise Bourgeois, a female practitioner in France, many years ago, and it is found to answer perfectly well, in many cases. Louise says, "The bag of waters being as yet not formed, we must break open the membranes that enclose the child, just as we would break open a door to save a house on fire, and draw forth the child by the feet; for this is the way to save the mother's life, and give the child a chance to receive the rite of baptism."-Obs. Diverses, &c. &c., 1627, 12°, Paris, p. 65.

There are circumstances, however, that might well induce one to defer to the latest period the breaking of the ovum; such as a known. bad presentation of the child, requiring it to be turned. In such a case, no prudent person would be willing, without an absolute neces sity, to permit the water to escape from the womb previous to dilatation, since the operation of turning is vastly more difficult, when per formed in a female from whom the waters have been quite evacuated, than in one in whom they are still present. Hence, if the mouth of the womb be still very rigid and undilatable, rendering it impossible or improper to introduce the hand for turning, any prudent person would give a very deep consideration to the question, whether the membranes ought to be now broken or not; he would certainly feel inclined to defer, till it should become unavoidable, the rupture of the membranes. Louise goes on to say, "Je n'entend pas que, si tost qu'une femme a une perte de sang, que l'on y procede de cette façon là, mais il faut veiller sur elle comme le chat la souris, et faire la au doigt et à l'œil"-p. 67.

guerre

"I do not pretend to say that, as soon as ever a woman is seized with a flooding, we are to proceed after this fashion; but that we must watch her as a cat watches a mouse, and carry on the war by seeing and by feeling."

If, upon rupturing the ovum, the flow of blood should not be stayed, and the os uteri should still continue to be so rigidly contracted as to make it impossible to turn the child, recourse should be had to ergot, in small doses, with a view of producing a feeble ergotism, or tonic contraction of the womb-not severe enough to injure the child, but yet so strong as to condense the uterine tissue sufficiently to arrest the flow of blood from its vessels. With this purpose, five grains of the secale cornutum, in powder, ought to be administered every half hour, or every hour, according to the pressing nature of the demand for its aid; or a teaspoonful of the vinous tincture of the same article might be exhibited, at proper intervals, with the same view.

There is, in general, under these circumstances, a strong disposition among practitioners to make use of mechanical means of stopping the hemorrhage, such as the application of napkins to the vulva, strongly compressing the orifice; and also the plug or tampon, which, filling the vagina, is supposed to favor the coagulation of the blood. But, if it be remembered that the bleeding orifices of the placental superficies on the womb are-except in placentia prævia-near the fundus uteri, and that the extravasated fluid trickles down, betwixt the chorion and the womb, from the fundus to the orifice, I think it will be seen that such mechanical means can scarcely exert any other than injurious effects in the case. They may enable us to conceal the fact both from the patient and from ourselves, that the vital fluid is escaping in a dangerous abundance; but common sense ought to show us that, while we may prevent the fluid from falling out of the orifice of the vagina, by plugging that orifice with sponge or other materials, we do not prevent it from flowing back upon the outer surface of the ovum and the placenta, both of which it detaches more and more completely from the womb, leaving the woman exposed to greater hazard than she would incur were we to permit the blood to escape as fast as it is effused. Such methods, assuredly, will not favor the arrest of the effusion by coagulation; the source of the flow being too distant from the compress. It is better, in uterine hemorrhage near term, to let all the blood that escapes from the vessels also escape from the vagina. When the uterine superficies is diminished, the bleeding is stayed. The application of cloths, wrung out of iced vinegar and water, to the hypogastrium, is of greater avail, and far more safe than the tampon. I would gladly urge upon the Student the necessity of the greatest caution in the employment of so dangerous an agent as the tampon, except in the early stages of gestation, or where the capacity of the womb is not sufficiently large to admit of its containing a great quan

tity of blood. No hemorrhage is so dangerous as the concealed hemorrhage.

Whenever, in a hemorrhagic labor, it is clearly ascertained that the period has arrived for the delivery to be hastened, which is known by the state of the patient's strength, the pulse, the color of her lips and cheeks, and by the dilatation or dilatability of the mouth of the womb, preparation should be made for the operation by placing the woman at the foot of the bed, as in the case before mentioned. The choice of means, whether it is to be of the hand or the forceps, will turn on the degree of advancement of the head, which is readily seized by the forceps, if low in the pelvis, but which is to be pushed away to make room for the search after the feet, provided it be still within or above the brim of the pelvis. In all cases wherein the vertex is to the left side of the antero-posterior diameter of the pelvis, the left hand is to be used; while the right hand is adapted for turning, in all examples of labor where the vertex is to the right half of the pelvis. The operation differs, in no respect, from the one already described, except that the head instead of the shoulder must be pushed out of the way. If the head should have already occupied the upper strait, that strait would be nearly filled with the mass; the hand could not be carried up alongside of it. The palm of the hand, therefore, being placed underneath the head, would push it gently upwards, in the absence of pain, and carrying it to one side, it would be retained on the brim, by the wrist or arm of the physician, which occupies the space recently in possession of the head, while the exploration or search for the feet would be then conducted as in the case already treated.

When I come to speak of the use of the forceps, I shall say what is requisite concerning the indications and manner of its use in the hemorrhagic affections; wherefore, it seems by no means needful for me to anticipate here, what I shall feel obliged to say in a future page of this book.

Placenta Prævia.-The unfortunate location of the placenta on the cervix and os uteri is an accident which does not very frequently happen, and which, when it does occur, can scarcely ever fail to produce much anxiety and alarm among all those who understand the case, and feel any interest whatever in the mother and her offspring. The after-birth may cover the os uteri so exactly, that the very centre of the placenta may correspond to the orifice. The danger is enhanced by as much as the location is more central; that case being the least dangerous in which the edge of the placenta is nearest to the

os uteri.