to an intelligent physician, intimation sufficiently clear to engage him to proceed aright in lessening the bleeding superficies, either by merely discharging the liquor amnii, or by turning, or by delivering with the forceps. The symptoms, under such circumstances, would be weakness; dull pain in the womb; suddenly increased size and tension of the organ; frequency and smallness of the pulse; paleness; yawning and sighing; and syncope. The occurrence of such phenomena, in a pregnant woman, if alarmingly great, would, I think, be a full warrant for opening the ovum, or for an expeditious delivery; the latter always, however, to be held in reserve until the womb is dilated or dilatable. Such a case invariably deserves to be profoundly considered before proceeding to the adoption of an extreme measure. The ergotic action might, with great prospect of advantage, be resorted to, in case the hemorrhagic symptoms should not abate upon the discharge of the liquor of the amnios. I will now show how I lately proceeded in a

of--St., being preg

CASE. In February, 1854, Mrs. S▬▬ C▬▬, of nant near seven months, descended the stairs to dine, being conducted to the saloon by a gentleman who was the guest. At the foot of the last step laid a favorite dog asleep, and she not perceiving it, stepped upon the animal, which made a great howling as if badly hurt -the lady, who was nearly thrown to the floor, was greatly agitatedbut recovering, took her place at the table and thought no more of it. Three days later, she was suddenly seized with flooding, so that a large quantity of fluid and clotted blood fell from her on the carpet, and wetted her dress excessively. She got to bed and sent me an urgent message. I found her in labor-but flowing considerably. As soon as the os became about 13 inches in diameter, I ruptured the membranes, and not long afterwards the foetus was expelled dead. I found that nearly the whole uterine face of the placenta was invested with a dense coagulum of a dark almost black hue, and in some places more than half an inch thick. Only a very small part of the placental surface was red or fresh. Hence, I supposed that hemorrhage commenced soon after the accidental mishap above mentioned, and, that three days elapsed before the concealed hemorrhage became open or manifest flooding.

Post-Partum Hemorrhage.-The hemorrhages that take place between the delivery of the child and the expulsion of the placenta, are frequently met with, and are so violent as to excite great alarm in the patient herself, or her friends who happen to witness the distressing symptoms that accompany the accident. I think that, in a

great majority of labors, the placenta is partially detached by the time the child's head has emerged from the vagina, and that the complete separation frequently takes place still earlier.

In such women as have feeble pains, with long intervals, the effusion of blood is sometimes very great, so that a large quantity frequently is found to be expelled immediately after the child is born, being evidently the result of hemorrhage taking place in the intervals between the pains, yet detained behind or above the presenting part until the delivery of the child is completed, whereupon it rushes forth with great violence. If this is a correct statement, then it may, à fortiori, happen, that the effusion may go on rapidly as soon as the body of the child has escaped. The womb, in some instances, is perfectly passive for a good while after the great effort it has made, and the placental super. ficies being exposed, a torrent of blood issues and suddenly fills and distends the cavity, and the woman faints and dies without any one perceiving that she has flooded at all. I believe that this blood would always flow out of the vagina, were it not that a firm clot occasionally happens to stop the os uteri, or vagina, like a tampon, so that none can escape; and if the womb be deprived of its irritability, its fibres will offer no resistance to the fluid poured into the cavity, which, being sealed up by a coagulum at the os uteri and in the vagina, must expand more and more, and with a rapidity that augments as the placental surface grows larger and larger.

A careful practitioner ought not to allow such an event to take place, in his presence. He will frequently place his hand upon the hypogastrium of his patient, and ascertain whether the womb be properly contracted, and enforce its contraction, if necessary, by frictions, and by gently pressing the womb with his fingers applied to the lower part of the abdomen. The irritability of the organ is readily excited into effect by this means; and when the womb becomes properly con densed, there is little danger of any effusion taking place. It should be an invariable custom to place, after the child is born, the hand on the mother's abdomen, to make sure of the contraction of the uterus. This custom will always give prompt information of the existence or non-existence of a tonic contraction; and he who fails of attention to this point will, sooner or later, bave reason to regret the neglect of so salutary a precaution.

But when flooding comes on, whether after delivery or antecedently to it, the same universal principle of practice is applicable, namely, to empty the cavity as speedily as possible consistently with prudence. Let the placenta be taken away, and, after its removal, let pressure be made on the hypogastrium by the hand, or by a compress and band

age, and the pressure continued until the signs of hemorrhage have completely ceased. After having removed the placenta, or after having turned out from the cavity of the womb a pound of coagula, more or less, the woman cannot be deemed safe until the lapse of an hour. or more shall have given assurance that no repetition of the hemorrhage can take place. I have, on a great many different occasions, found myself compelled to turn out the clot again and again, to prevent the patient from falling into fatal syncope. Let the Student, therefore, take heed, that, while he may have saved his patient from fatal hemorrhage at ten o'clock, she fall not into the same hazard again at halfpast ten or eleven, or at half-past eleven, being careful not to quit her apartment till he can clearly pronounce her safe. Where the flooding returns again and again, let the Student feel for the pulsating aorta above the fundus uteri, and, pressing the vessel with the ends of his fingers, endeavor so to check or lessen the circulation in that great artery, as to hinder the excess of circulation in the branches below, and so of the uterine arteries. In this way, some lives have been preserved.

It happens that the womb is incapable, sometimes, of separating the placenta wholly from its surface; but if it be half detached, there may flow a great quantity of blood, while the uterus continues unable to expel the after-birth. The duty of the medical attendant here is to separate it entirely, by introducing his hand, and gently detaching it with his fingers; taking every possible care not to leave any portion behind, which, by keeping up a continued irritation, would tend to maintain a hemorrhagic nisus, or even dispose the patient to metritis. He will separate the placenta, then, in order to let the uterus contract for the suppression of the hemorrhage, which it will do as soon as it can thrust the secundines forth from its cavity: but let it be always remembered that the hand is not to be introduced unless real need for it exists.

The greatest care should be taken, in this case, to keep the patient. quiet, and strict order should be given not to lift her head from the pillows, until all the appearances of danger are gone. Indeed, she ought to have no pillows. Any attempt to sit up in bed, or even to turn, for a woman excessively reduced by hemorrhage, is dangerous; since any muscular effort, by occasioning faintness or exhaustion, invites a renewal of the hemorrhage and debility, which are both to be deprecated.

Hour-glass Contraction.—I have met with several examples of the hour-glass contraction of the womb; of which incident, although I

have spoken of it at p. 340, I desire to add something in this connec tion. Hour-glass contraction depends either upon the contraction of the womb at the upper limit of its cervical portion, so that the afterbirth is contained, as it were, in a separate cell, or the contraction may take place so as merely to include the placenta still retaining its origi nal connection with the uterus. The finger may pass up to the constricted point, and find the cord closely embraced by it. If no bleed. ing comes on, it is commonly deemed proper to wait an hour, to see whether the co-ordinate action of the muscular fibres will not overcome the horizontal constriction; but, if an hour elapses without the least change in the case, we have reason to infer that two, or even four hours may not suffice to remove the difficulty, and we are always justified in taking away the secundines in that time, even should we not be prompted to do so earlier. It is, in general, not difficult to overcome the stricture, by introducing, first, the hand into the vagina, and then inserting one, then more fingers alongside of the cord, until a sufficient portion of the hand is introduced to command the placenta.

But I can truly say that I have never yet met with an hour-glass contraction in which I was not compelled to separate the placenta with my hand.

I cannot well conceive of an hour-glass contraction, independently of a preternatural adherence of the after-birth to the womb.

I suppose that when the after-birth is so firmly attached that the contractions of the womb cannot slide it off, the substance of the placenta acts as a soft splint, counter-extending the utero-placental superficies. The rest of the womb, having nothing to antagonize it, contracts as usual, leaving the placenta shut up in an upper pouch: it usually contracts at the upper extremity of the cervix. Sometimes, as where the placenta is situated upon the side of the womb, and cannot be displaced by its contractions in consequence of the preternatural adherence, the pouch in which it is contained is on the side of the womb, and the fingers, in dilating the constricted part, must be conducted to the right, or to the left, or to the front, or backwards into the chamber containing the after-birth, as the case may be.

If this explanation be just, there is no very well-founded reason to hope for the spontaneous expulsion of the after-birth-for the adhesion will not give way after the birth of the child, if it would not do so just before that event. Hence, the indication in hour-glass womb is, perhaps, to deliver at once, and I now heartily and warmly advise the Student to introduce his hand and separate the placenta, as soon as he can clearly determine that the real hour glass contraction does exist.

He will be compelled to do so sooner or later-and the sooner it is attempted, the easier will it be effected.

What can be more disagreeable, or even distressing, than to be compelled to carry the hand and half of the forearm inside of the body of a patient already weakened and exhausted by the labor, and, above all, to be obliged to remove from the womb, while she is agonized, the adhering mass, which sometimes is so firmly united as to be apparently confounded with the texture of the womb. I am sure that, in performing this painful office, one is occasionally obliged, by a sense of duty to the patient, to continue the effort to get off the placenta, even when far from certain that he is not either leaving portions of the lobules still united to the uterus, or perhaps injuring the uterine tissue itself; all that can be expected of any practitioner, under such circumstances, is that he should faithfully do his duty according to his ability. If he cannot get off the whole after-birth, he must leave portions of its lobules. Let him, however, always try to get every vestige of it off. To leave an ounce adhering is better than to leave a pound, and he can and ought to protect his own credit against any untoward results by a full and candid statement of the difficulty he has met with, and of the impracticable nature of the case. I have taken away a great many such, and all of the women save one have recovered, even where I was certain that my utmost care and desire to succeed in removing the whole had been in vain. The Student will learn that he will rarely, in practice, meet with these vexatious adhesions in cases that go on regularly and with a proper celerity; but if he have a labor that gives him great trouble and long detention, from irregular action and feebleness of the pains, he may justly fear that the after-birth will not come off easily. I doubt not that a very firm adhesion of the after-birth is capable of greatly impairing the regularity and strength of the uterine contractions. Such an after-birth, by preventing that part of the womb in which it is situated from contracting in due proportion with the other parts of the organ, is probably the cause of most of the difficulty we have to contend with throughout the whole parturient process in such a case. When the placenta adheres with such preternatural force, the uterine surface on which it rests is, to a certain extent, splinted or counter-extended during the contractile efforts of the rest of the organ.

If one could suppose a placenta converted into bone, and retaining such preternatural union with the womb, it is clear that so much of the organ as should be united to it could not contract, and that all the rest of the womb might contract, shutting the ossified placenta within a cell.