But, in fact, when the adhesion is so strong that the uterus cannot abolish it by its contraction, the same result is virtually attained as if the ossification above supposed should really exist.

Hemorrhage following delivery of the After-birth.-The application of a compress, made by folding one or two napkins, and securing them upon the lower part of the abdomen by the common bandage, is a precaution that ought never to be overlooked where there is a great disposition to hemorrhage. Such a pressure not only prevents the womb from filling again, but it tends very successfully to secure a firm tonic contraction of the organ. Besides this com press, we shall find that the sacchar. saturni, combined with opium, in doses of three or five grains of the former, with from half a grain to a grain of the latter, repeated in an hour, offers us a very useful resource in the styptic influence of the acetate of lead. In like manner, infusion of red rose-leaves, with elixir of vitriol; powders composed of five or ten grains of sulphate of alumina, with a few grains of nutmeg; and the application of cloths pressed out of cold vinegar and water to the pubes-all these are measures that must be sometimes resorted to, when the flow of blood continues after the delivery of the secundines has taken place.

Violent and dangerous effusions of blood sometimes come on immediately after the delivery of the placenta, and at a time when the labor is supposed to have been terminated in the most successful and fortunate manner. If half an hour elapses after the delivery of the afterbirth, without any flooding, we shall rarely meet with it, and may, for the most part, consider the patient safe. Nevertheless, it does sometimes come on many hours later; or even many days are passed, without any apparent tendency to the accident, before the female is attacked.

The causes of this bleeding are to be sought for in the relaxed state of the womb, arising from loss of power in its muscular element. The cases are almost invariably connected, too, with an excited and impetuous circulation, by which the blood is propelled with such power and momentum into the uterine arteries as to force open their extremities, when they are not sufficiently supported and constringed by the muscular contractility of the uterus.

Such an attack ought to be foreseen in the state of the pulse, and obviated by the use of such measures as may serve to abate the violence of the blood's motion; and the patient ought not to be abandoned by the physician, until he has become fully satisfied that the danger is past. Let the patient lie in a truly horizontal posture; let blood be

taken from the arm if required; let cool drinks be given, and cold water applied to the face and forehead; and let great care be taken to ascertain, from time to time, by the touch externally, whether the womb is firmly condensed or not. It is not good, I am sure, to allow the napkins that are usually applied to the vulva, to be too firmly pressed to the parts; they act, when so pressed, as a sort of tampon, which enforces the coagulation of the blood in the vagina; and that itself is a dangerous tampon. The blood which cannot escape accumulates within the womb and constitutes a concealed hemorrhage, that is likely to increase with frightful rapidity and that may sink the patient irrecoverably by the time it is discovered. When blood has once escaped from its vessels, it is of no further service, and therefore the sooner it is got rid of, the better for the sufferer.

If the Student should find the hemorrhage not to be stayed by his treatment, let him press his fingers, gathered into a cone, firmly down upon the aorta, near the umbilicus. If the patient should not be troubled with extraordinary obesity, he will be able to feel the throb of the aorta with the points of the fingers. Let him compress the tube according to his judgment, in such a way as to check the downward rush of the torrent. This will operate usefully in two ways: first, by lessening the force with which the blood reaches the bleeding orifices, which will then have an opportunity to close themselves more or less completely; and second, by causing a greater determination of blood to the encephalon, whereby the tendency to deliquium will be lessened. Many lives have apparently been saved by thus compressing the aorta.

I have always governed myself as much as possible by the rule acted on and enforced in his lectures by the late Professor James, which was, "Don't leave your patient for one hour after the termination of the labor." The pressure of business upon a medical man in a large practice will sometimes make it impossible to stay so long near the lying-in woman, but, when under the necessity of leaving her, he ought always make arrangements for his recall in case of need. Leaving a newly-delivered woman a few minutes after the deliverance, he exposes himself to the shock of hearing, upon his return to his house after one or two hours, that "Mrs. B. wants him immediately, as soon as possible-has sent again and again-they think she is dying!"

I have many times been saluted with such messages, and it would be difficult to express the emotions they excite. It is true that most of the cases are neither fatal nor even dangerous; yet occasionally a woman is found to sink and die, almost without warning, from effu

sion of blood which either flows out upon the bed, or is retained within the vagina and womb, distending them enormously, without giving rise to the least suspicion in the friends or nurse that the woman is bleeding.

In case of being summoned in this sudden manner to return to the patient, it is obviously the first duty of the physician to make sure of the state of the womb; and accordingly as soon as he reaches the bedside, he should place his hand on the hypogastrium in order to learn whether the organ is too much distended; if it be found too large, his course is plain-he must break up the clots which fill it and press them out. This is to be done in every such case. If it be not too much distended-and yet there are those signs of weakness which show that the patient has lost too much blood, while no great external or open flooding has taken place-he should still act as if there were really a hemorrhage. Let him then introduce one or two fingers into the vagina, and he will be almost sure to find that the tube is filled to distension with a very solid clot-a clot as large, perhaps, as a child's head, and extending up into the womb. Upon tearing this clot with his fingers, and pressing at the same moment with the other hand on the lower part of the belly, and exhorting the woman to bear down, the coagula are expelled with more or less violence, and the woman immediately expresses herself as relieved. I must reiterate in this place the injunction, never to forget that, in uterine hemorrhage, all proper measures must be taken to cause the womb to contract; never to forget that with a condensed womb there is no hemorrhage, nor that the womb will nearly with invariable certainty contract or condense itself, if some antagonist or distending force does not prevent. Remove or withdraw, therefore, the antagonist force, and the patient is saved. Always turn out the clot.

The bandage for the abdomen ought never to be omitted in these cases of flooding; for the belly growing suddenly flaccid by the contraction of the womb, there is produced a feeling of inanition and weakness, that often is, alone, able to bring on faintness or a state approach. ing to it; and that is highly conductive to the increase of uterine hemorrhage. I have already, in my remarks on labors, spoken on this topic, and will refer my readers to page 360 of this volume.

I have long been impressed with the beautiful simplicity and graphic fidelity of the following affecting story, from the pen of the celebrated Mauriceau; and as his writings are little known in the United States, I have, on that account, as well as for the intrinsic practical importance of the case, resolved to translate it for this part of my work. Those who read it must, I think, agree with me, that it conveys a most

instructive lesson to the Student of Midwifery, and, if I am not mistaken, will require no apology for its introduction here.

Case of Mauriceau's Sister.-"Many women (says Mauriceau, liv. i. p. 158) have perished, together with their offspring, for want of prompt assistance on such occasions [hemorrhage]: and not a few have escaped from an otherwise inevitable death by early succor; while their children have received the holy sacrament of baptism, of which, but for that aid, they would have been deprived. Guillemeau, in liv. ii. chap. 13, of his De l'Accouchement, mentions six or seven cases confirmatory of this truth, in most of which it is seen that both the mothers and their children were the bleeding victims of want of promptitude in delivery under such circumstances, while some of them escaped in consequence of early assistance. But, that I may confirm this doctrine by the results of my own experience, I shall relate one case, among many, that is very remarkable; and the remembrance of which is so vividly impressed upon me, that the very ink with which I now am writing, in order to make it known for the benefit of the public, seems to me to be turned into blood; for on that piteous and fatal occasion, I witnessed the effusion of a part of my own vital fluid, or, to speak more correctly, the whole of what resembled the blood of my own veins.

"It was sixteen years ago that my sister, who was not yet quite. twenty-one years of age, about eight months and a half gone with her fifth child, and at the time in excellent health, was so unfortunate as to hurt herself, though to all appearance very slightly, by a fall on her knees, the belly at the time striking the ground; subsequent to which she passed a day or two without experiencing any considerable inconvenience, so that she neglected to keep herself as quiet as she ought to have done; but on the third day, at about eleven o'clock in the morning, she was suddenly seized with strong and frequent pains of the belly, which were also accompanied by a great discharge of blood from the vagina. She immediately sent for the midwife, who was not too well versed in her occupation, and who, when she arrived, informed my sister that it was necessary, before delivering her, to wait until the pains should spontaneously open the mouth of the womb, assuring her that she had nothing to fear from the accident, and would be soon delivered, because the child presented very favor ably. In this way, she fed her with vain hopes for three or four hours, until, the flow of blood continuing very great, the pains began to leave her, and the poor lady fainted away several different times; upon seeing which, the midwife requested that a surgeon might be

sent for to assist her. They came immediately to my house, to notify me of the affair; but being unfortunately not at home, they called on one, who, they supposed, was one of the ablest obstetricians or surgeons in the whole city at that period, and he was immediately conducted to my sister's residence, where he arrived about four o'clock in the afternoon. Having seen the state she was in, he contented him. self with merely saying that she was a dead woman, for whom nothing was wanting but the last sacraments of the church, and that it was absolutely impossible to deliver her. To all this the midwife readily agreed, for she thought the opinion of this man, so universally esteemed, must be, beyond doubt, correct. As soon as he had pronounced his judgment, he went away, refusing to stay any longer; and in this deplorable condition, and without offering the smallest succor, he left this lady, whose life, as well as that of her child, he could certainly have saved, had he delivered her then, which he might easily have done, as will be seen in the sequel of this history. "After the judgment of a person of such great reputation, added to that of the midwife, every one who was present thought that since M. could do nothing for her, there could be no other recourse, in so great a misfortune, than placing confidence in God, to whom alone everything is possible.

"They now endeavored, as well as they could, to console my poor sister, who with a passionate earnestness desired to see me, that she might know whether I also would pronounce the same judgment upon her; and whether her disease, which was constantly growing worse, was beyond all remedy; for her blood was steadily flowing in great abundance. At last, I returned to my house, where they had been a long time before, to tell me this sad news; and where most unfortu nately, I was not to be found at the time, as I have already related. As soon as I heard of it, I hastened to her house, and upon arriving there, saw so piteous a spectacle, that all the passions of my soul were, at the sight, agitated with many and different emotions; after which, having somewhat recovered my composure, I approached the bedside of my sister, who had just received the last sacraments; and being there, she implored me again and again to assist her, saying, that she had no hope but in me. After I had learned from the midwife all that had happened, and she had told me of the opinion of the surgeon, who had seen her more than two hours before, for it was now past six o'clock, I perceived that the blood still continued to flow profusely and without ceasing, though she had already lost more than three quarts, and, what is remarkable, more than forty-eight ounces within the two hours since the surgeon left her-as I supposed from the