The influence of religious impressions, joined to the treatment, soon determined the excitement and irritation to the brain and its membranes, which in the course of a few hours, exploded with dangerous symptoms. This continued to increase for two days and nights, under increasing doses of opium and other "nervous sedatives." W. B. was at this time quite unmanageable, his countenance was flushed-his eyes injected, and rolling in “liquid fire”—breathing vengeance and threatenings against all who entered his chamber. It was not without great difficulty that I could examine his pulse. This I found remarkably full, and incompressible-slow and creeping, which, from the agitated and excited state of the patient's brain, created some surprise. His tongue was dry and coated-skin hot, and free from the least moisture. The primitive pectoral symptoms were entirely merged in the encephalic inflammation. After at least two hours trial and delay, I succeeded in opening a large orifice in one of the veins of the arm. blood flowed until the pulse fell and the skin became moist. He also grew somewhat calm.

The

To second the bleeding, I ordered stimulating hot pediluvia, and an active dose of prot. chlorid. hydrarg. and ext. colocynth. comp. was administered in some sugared coffee, this being the only beverage he could be induced to take. August 15th, patient more composed, after the V. S., pediluvia, and administration of the purgative.

Two or three copious dark dejections were procured by the medicine, assisted by laxative and stimulating lavements. Pulse 80, full and somewhat resisting; condition of tongue improved a little. V. S. repeated ad deliquium animi. For first time, patient recognised those around him-answered a few questions. Much conversation, however, prohibited in his presence. Continue cathartic medicines, in small, but repeated doses. Ordered his head shaved, (it was impossible to effect this before, owing to the intractable disposition of the patient.) Cold applications to the head, light excluded, and every cause of excitement carefully guarded against. Patient improving-some appetite-light soups-cerebral symptoms somewhat aggravated, in consequence of patient's rising from bed to chastise his nurse. Cups to occiput. At this time pectoral symptoms returned, with some pain, and slight cough-respiration hurried. Blister to affected sideexpectoration mucous-pulse feeble. In this manner he gradually improved, but as the cerebral inflammation subsided, the pectoral affection seemed increased. This I, however, attempted to obviate by keeping up a discharge from the blistered surface. Nothing occurred to impede the progress of the cure, until the night of the 17th, when, by mistake, the nurse gave him two or three large potions of camphor mixture, which induced violent delirium, restlessness, and great agitation. Pulse small, and frequent-skin dry-tongue coated-secretion from blister arrested.

As repeated venesections, cups, and active cathartics, had greatly reduced the powers of the system, I could not appeal to them the second time, without hazard of life. I therefore, as the last remedial agent, resolved to test the efficacy, in this case, of cold affusions upon the head.

This surpassed my most sanguine expectations-it soothed the feelings, regulated the pulse-"quenched delirium," and the patient became peaceable, and rational, expressing for the first time some gratitude for our kindness and attention. A quiet sleep was brought on, after a short time, which only left him, to give place to convalescence.

P. S. The above case occurred in a neighbouring state.

ART. III.-CLINICAL LECTURE ON INTERNAL UTERINE HE

MORRHAGE.

BY J. T. INGLEBy, m. d.'

Fellow of the Royal College of Physicians, Edinburgh.

On the present occasion I wish to call your attention to the subject of uterine hemorrhage, in one of its most peculiar and imminently dangerous forms-I mean hemorrhage accompanied by a detachment of the placenta, together with an infiltration of blood in its substance, constituting what has been termed placentary apoplexy, and arising about the close of pregnancy. It may occur either independently of labour, or whilst labour is progressing. The one object I have in view being to have the matter fully understood by you all, I will enter upon the subject without further preface, studying only plainness and clearness of description.

I have said I wish to call your attention to hemorrhage, accompanied with detachment of the placenta. First of all, then, I would have you observe, that the detachment usually commences about the centre of the mass, and extends to every part of it, the edge excepted, which maintains its natural apposition; consequently, a large quantity of blood soon becomes confined between the placental and uterine surfaces. The uterine tumour at these points becomes raised in proportion to the amount of effusion, its rapid augmentation constituting the most striking feature in the case. But it is important to observe, that the effusion may commence any where between the centre of the placenta and its edge, which almost necessarily becomes more or less detached, so that whilst a large coagulum is confined, partly underneath the placenta and partly exterior to the membranes, the liquid blood continues detaching the membranes until it reaches the vagina: I have seen both forms of hemorrhage. The first, or concealed form, from its greater liability to deceive the practitioner than the second, may be regarded as the more dangerous case, although the extent of hemorrhage in this form is less considerable than in the other. I shall presently state a remarkable exception; but this, as a rule, is generally correct.

CASE.-Mrs. B. has ten or eleven children, and was subjected to my professional notice when about nine months advanced in pregnancy. During the night of Friday, Sept. 8, a discharge of blood, both clotted and fluid, occurred several times; and at three o'clock, on Saturday morning, my friend Mr. Rice was called to see her. Although she had reached the full period of pregnancy, no pain took place until subsequently to the attack of hemorrhage, and the degree of pain which then arose was inconsiderable. The amount of hemorrhage was trifling, three napkins only having been stained, but the depression of the general system had progressively increased, and was at that time most alarming. On examining the uterine tumour, Mr. Rice's attention was immediately directed to a very marked singularity in its shape, the shape being exceedingly pointed, having its long diameter in the antero-posterior direction. I accompanied Mr. Rice to the patient at eight o'clock. A. M. There was great prostration of strength, an exsanguine countenance, and the gaping which attends the state of syncope. The pulse was feeble and slow, and the defined eminence which occupied the summit of the uterine tumour, and for some extent around it, was much more elastic than the surrounding parts. Under a strong conviction-a conviction previously entertained by Mr. Rice-that the symptoms depended upon a large internal effusion of blood, I recommended immediate delivery; and, as Mr. Rice entertained similar views of the case, he undertook the operation without delay. Although there had been no regular labour-pain, the uterine orifice was moderately well dilated, and the membranes were sufficiently distended to admit of the bag being very easily

1 London Lancet, Jan. 11, 1840, p. 553.

ruptured. The circumstance of the membranes being distended, deserves your notice in reference to the manner in which the liquor amnii acquired its bloody appearance. On the membranes being ruptured, a large amount of deep-coloured, bloody fluid instantly rushed out of the vagina. During the delivery of the lower extremities, a quantity of tolerably consistent blood, mixed with small clots, continued to escape, and, on the completion of the delivery, an immense clot was expelled somewhat forcibly. This was rapidly followed by the placenta having, upon its uterine surface, and within about a third of its texture, a mass of coagulated blood. The coagula were so interwoven with the parts as to admit only of very partial removal, and this not without tearing the placenta. The shape of the placenta was sacculated at such of its parts as were not infiltrated, but merely covered by clot, the greater part of the blood having been confined in the sac. Brandy and the tincture of ergot, in combination, were resorted to several times during the delivery with excellent effect in sustaining the pulse, and securing an efficient uterine contraction. The patient would necessarily have been greatly alarmed by the vast disgorgement of blood from the uterus, had we not prepared her mind for the occurrence. As there was no direct escape of blood from the general system, there was no actual shock; rather, indeed, a revival from impending death to a state of comparative security. The large clot, of which I spoke above, weighed two pounds; and the liquid blood, such as, at least, could be collected, weighed two pounds more. Making allowance, then, for the blood which had become mixed with the liquor amnii, as well as for the blood which had escaped on the bed and napkins during the night, the actual loss, within six hours, must have been upwards of five pounds, at the least. It is certain that the uterus contained, at the moment of delivery, upwards of four pounds. I need scarcely say, that under so large and so sudden an effusion the fœtal circulation would very speedily cease.

And now, gentlemen, let us inquire what practical inferences can be deduced from this narrative? Let us examine it in several points of view.

1st. The mode of attack.-The attack occurred suddenly, and was not the result of external injury-a very probable means of producing not only separation, but laceration of the placenta,' and laceration even of the uterus itself. Each of these injuries I have personally witnessed as the result of physical force, but in this case there was no pretence whatever for supposing the existence of such a cause. The circumstances which occasioned the separation of parts, and consequently the effusion of blood, can however only be conjectured. We can only say, with any certainty, that the effusion must have proceeded from a very large vessel.

2dly. The symptoms.-The symptoms were both local and constitutional. The former comprising the hemorrhage, which appeared external to the body-the shape of the uterine tumour-the sensation imparted to the hand when placed over its most projecting part (a sensation of undue elasticity when compared with the very slight elasticity which characterised the other parts of the uterine tumour,) and the peculiar character of the pains, the feeling being one of distress from distention, rather than of suffering from contraction. Hence it is impossible to resist the conclusion, that the pains arose as a consequence of the effusion. It has been already observed, that the pains were preceded by visible hemorrhage. The constitutional symptoms were merely those that are common to all severe hemorrhages, viz. torpor, drowsiness, repeated syncope, a pallid countenance, a feeble slow pulse, gaping, and coldness of skin.

I have only one remark to offer, in reference to the depression of the sys

'The case related by Mr. Wildsmith is a striking instance of this kind. The patient died during pregnancy, and on examination, P. M., a clot of blood was discovered, weighing eighteen ounces, at the anterior part of the fundus of the womb, and the pla. centa was lacerated.-See North of England Med. and Surg. Journ., vol. i, p. 446.

tem, viz. that it was very great, and yet altogether disproportionate to the amount of visible discharge. Still the fact of an existing visible hemorrhage would naturally impres the mind with the conviction, that the sinking of the vital powers and the hemorrhage, slight as it was, must have had an important connection. In this respect, the evidence, if not altogether conclusive in the instance before us, was far more conclusive than characterised several fatal cases of a similar kind.

3dly. The condition of the membranes and of the liquor amnii, is a point not altogether destitute of practical interest. There was nothing peculiar in the state of the os uteri; it was relaxed and partially open, but these characters are common to the uterine orifice at the close of pregnancy, in a person having had sevaral children, as was Mrs. B.'s case. The membranes were apparently entire, the presenting portion being moderately distended with fluid. The liquor amnii had a very bloody appearance, and gushed out very forcibly on the bag being ruptured. In its passage through the vagina, it is indeed usual for the liquor amnii to acquire a stain from the blood which may be lodging there, but here the fluid was uniformly bloody, the colour being almost as deep as blood itself. The precise cause of this is not easily explained. The foetal side of the placenta was perfect, consequently the stain must have taken place, either from a slight tear at the edge of the placenta (a circumstance which would not prevent the presenting part of the sac from being moderately distended,) or it must have been the result of transudation. I incline to the former opinion, the period of transudation having been very short, although the transuding surface, from the size of the coagulum, was considerable. Certainly the fact of the liquor amnii not containing coagula may be supposed rather to favour the view last suggested. One is naturally led, therefore, to make an inquiry as to the source of the blood. Did it proceed from the placenta itself, or from the vessels of the uterus in connection with it? What are the probabilities? The placenta was very pulpy throughout, and about one third of the mass, from the edge towards the centre, was so completely infiltrated with blood, as to render the removal of the clots impracticable without breaking up the structure of the placenta itself. Consequently it was impossible to detect any open vessel. I am disposed to think, that the blood proceeded from the uterine system and not from the placental, and I will give my reasons for this opinion. As already observed, the infiltration was very limited in its extent, although it pervaded the whole thickness of the mass. Now, had the blood emanated from the interior of the placenta it could only have proceeded from a large vessel belonging to the umbilical system, and it is more than probable that the greater part of the placental mass would have been infiltrated. Moreover, had the case been so, I think the extravasation would have been apparent through the coverings of the fatal surface. But it was not apparent in any degree. Neither is it probable that the blood, after traversing the interior of the mass, could have retained its fluidity sufficiently long to have passed in such large quantities into the uterine cavity. I can only account for the infiltration, by the supposition of a breach of surface having taken place in the placenta, whilst the extent of detachment was slight.

Such is as complete an outline of this remarkable case as it is possible to set before you in a lecture; and, considering the danger young practitioners are in, of forming a wrong judgment upon the symptoms, and the danger of improper treatment to the patient, I do most earnestly press upon you the duty of a careful study of this and similar cases. I will now lay before you all the information I have been able to obtain on this particular kind of hemorrhage, and a case or two not previously recorded. My own work, on "Hemorrhage," contains scarcely any thing on the subject; indeed the records respecting it are very scanty. Dr. Simpson's elaborate paper, on "Diseases of the Placenta," contains several references to the class of cases immediately before us; I recommend you to peruse this paper carefully. It

evinces great research, and is replete with practical information.' Dr. Merriman alludes very briefly to the circumstance, that syncope, or even death itself, may be occasioned by an effusion of blood between the uterus and placenta, whilst "there may be very little appearance of discharge from the vagina." Dr. Blundell, also, in adverting, in general terms, to instances of death occurring suddenly in the last months of pregnancy, observes—" On laying open the body after death, two or three pounds of blood may be discovered within the cavity of the uterus, and this, too, although there may have been no external bleeding." The first case which I have met with is related by the celebrated Albinus, where only the central part of the placenta being loosened, a large quantity of coagulated blood was lodged between it and the uterus, as it were, in a bag, and, consequently, not a drop was discharged per vaginam. "Had the nature of the case been understood (observes Albinus,) the patient might have been saved by rupturing the membranes, and delivering immediately." Four cases are related by M. Baudelocque. The mother was saved in three of the cases, but the child perished in each of them. In one of these the quantity of blood behind the placenta was estimated at four or five palettes.3 Baudelocque relates a fifth case; the hemorrhage, however, took place within the membranes, and not behind the placenta. Two cases are related by M. de Laforterie; the first case terminated fatally, after twelve hours' labour pain, and before competent assistance could be obtained. M. De Laforterie, however, performed the Cæsarean operation, and, on opening the fundus uteri, a pound and a half of liquid black blood immediately gushed out, which had been contained in a sac, between the placenta and the uterine surface, the centre of the placenta having been detached, while the edge remained adherent. The child was extracted alive, but speedily died. In the second case, the quantity of blood is said to have measured three French chopines."

Mr. Saumarez adduces a well-authenticated, but fatal case, of this form of hemorrhage. There was no discharge per vaginam. On examination, P. M., the placenta was every where detached, excepting its edges, which "were completely adherent, forming a kind of cul de sac, into which blood had been poured to the amount of a pint and a half, which had become coagulated within the cavity thus formed." The patient was also attended by Drs. Denman and Denison. Dr. Hamilton describes two cases. In the first, premature labour occurred spontaneously. "In the central part of the placenta a strong coagulum of blood, the size of an afternoon teacup, was discovered. The adhesion of the edges of the placenta had saved the patient." The result of the second case was less fortunate. The symptoms were those of collapse, and "the lady felt as if she were going to burst; there was no discharge from the uterus, and no symptoms of labour. Immediate delivery was accomplished, by passing the hand into the uterus, and a dead infant was extracted, which was followed by an immense quantity of coagulated blood and the placenta. The patient almost instantly expired." I now refer you to a very clear and concise paper on this subject, illustrated by a particularly well-marked case, by my friend, Mr. J. M. Coley. The effusion was characterised by a sudden enlargement of the uterine tumour, together with a sensation of pain, as though the abdomen would burst, and by frightful collapse of the vital powers. There was no

'See "Edin. Med. and Chir. Journ." for April 1, 1836.

3" Annot. Acad.," lib. i, e. 10., P. 56.

The palette contains four ounces.-ED. L.

See Journ. Gén.," tom, 29, p. 384, and quoted in Mons. C. A. Baudelocque's "Traité des Hæmorrhagies Internes de l'Uterus."

The chopine contains about an English pint.-Ed. L.

See No. 6," New Lond. Med. and Phy. Journ.," p. 535.

See" Prac. Observ." part ii., p. 235-6.

* See Lancet for 9th January, 1830, p. 498.