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For the London Medical and Physical Journal. Symptoms, Prognosis, and Treatment, of Internal Hentorrhage after Delivery of the Child and Expulsion of the Placenta. By THOMAS ATKINSON, Esq.

IN

N the different Treatises on Midwifery which have passed under my inspection, I do not recollect to have ever read any observations on internal hemorrhage, which sometimes occurs after delivery. In these cases, the danger is great, and (no blood appearing externally) the symptoms are so very insidious, that, to those unacquainted with their true source, they may be confidently referred to causes of a transient and less alarming nature, viz. faintness, weakness consequent to labour, &c.; from such unfortunate error, the principal, and almost only, means of saving the patient would be certainly neglected, and the sacrifice of her life the probable consequence.

We not unfrequently hear of death soon after delivery which could not be satisfactorily accounted for, as every thing seemed going on well previous to the fatal event; and it is a query with myself, whether not a few of such melancholy occurrences may not be fairly referable to flooding internally; as during my own practice I have met with cases, which, from the attendant symptoms and examination, evidently arose from this insidious cause. The adoption of decisive treatment was attended with a favourable result. In one case, the patient, from the great exhaustion, was for some time in a doubtful state, but recovered. But it is unnecessary for me to add more on this subject, so clearly explained in the following lecture of Professor Hamilton, as transcribed from my note-book, and now sent for insertion in your widely circulated Journal.

"After delivery, the blood has a peculiar tendency to coagulate, from this the uterus and vagina become stopped with coagula, none appearing externally; hence it is called internal hemorrhage, or flooding, in which the danger is great; the prognosis, in conse quence, must be guarded.

"We judge of the presence of internal hemorrhage by the symp toms; if the patient complains of the room turning round and of singing in the ears, we then fear hemorrhage is going on internally; if sickness and retching ensue, we are then more confirmed in our opinion; and, if the pulse become feeble, and faintings or delirium ensue, we are then sure of it. When we suspect this, we must lose no time, but introduce the fingers into the vagina, when, should bemorrhage have taken place, we feel the vagina dilated, and plunge our fingers into coagula,-if no flooding have taken place, we feel the vagina contracted,

The symptoms of hemorrhage internally are feigned by irregular hysteria, therefore we should never lose ourselves in doubt, but immediately examine; when its presence is ascertained, no time should be lost, the hand must be introduced into the vagina, not only to extract the coagula, but also to make pressure on the uterus, which seems as flabby as wet paper; and this must be continued till the uterus be made to contract, and, as it were, expel the hand. This practice is certainly horrible, and the woman, though in a faint, often groans during the operation; it is, however, the only one that must or can be followed, and by it many a valuable mother has been saved, who would certainly soon have died, were we to stand supinely looking on and doing nothing.

66

Although this practice seems very severe, yet, in some cases, we are obliged to resort to means equally distressing. When the hand has removed the coagula, and pressed on the sides of the uterus for some time, without its contracting, then the hand may be withdrawn, and a pitcher of cold water must be dashed on the naked abdomen of the patient, without regard to decency, or the impertinence of attendants; or this may be done while the hand remains in utero, and a cold water glyster may be also administered. After the hemorrhage has ceased, and the uterus contracted, it has again come on, and the uterus again been required to be dilated to the size before delivery; a third time it has been requisite to introduce the hand and cause contraction, yet the patient has recovered.

« In some cases, before introducing the hand, we give the patient a lump of sugar moistened with spirit, to support the vis vite, which it is always necessary to do also after cessation of the hemorrhage, by a large dose of opium, and this frequently repeated. In these cases, the woman must not be left for three or four hours after delivery, lest immediate death, from recurrence of the hemorrhage, be the consequence. A woman, having had flooding in former labours, should not be left until three hours after delivery. In some cases, when the hemorrhage has not been considerable, coagula may be formed in the uterus not bigger than one's fist, and no bad symptoms then ensue; but, in eight or ten days, the vital powers become enfeebled, and either death or lingering debility ensues. The consequences of leaving coagula in the uterus arise from their putrescency, similar to those of the placenta being left. A bandage round the abdomen is proper always, whether hemorrhage supervene to delivery or not. A woman, who has been much debilitated by hemorrhage, must not be allowed to suckle the infant, as marasmus is often the consequence."

Kilham, Yorkshire; Nov. 10, 1817.

Though the above remarks are not entirely new, yet, as we are assured the case has not occurred to, or been suspected by, some medical practitioners, we have inserted the above paper. is impossible we should be too much alive to this important period

it

of

of the most interesting part of medicine. At the same time, where no unfavourable symptoms exist, we have not those horrors of putrefaction from the remains of the placenta which we were once taught to apprehend. On this subject, we shall gladly receive the opinions of the most experienced.

COLLECTANEA MEDICA,

CONSISTING OF

ANECDOTES, FACTS, EXTRACTS, ILLUSTRATIONS, QUERIES, SUGGESTIONS, &c.

RELATING TO THE

History or the Art of Medicine, and the Auxiliary Sciences.

Quicquid agunt medici,
nostri farrago libelli.

History of a Case of Rupture of the Brain and its Membranes, arising from the Accumulation of Fluid, in a Case of Hydrocephalus Internus. By JOHN BARON, M.D. Physician to the Infirmary at Glocester. (From the Medico-Chirurg. Trans.)

SARA

ARAH BARGUM was born on the 18th of September, 1815. At the time of birth the head was observed to be remarkably large. She was brought to me at Glocester, on the 11th of the following December. At that time the circumference of the head was twenty-eight inches. In the course of another week it increased about an inch. The bones were separated from each other to the greatest possible degree, and all the divisions of the foetal skull were very observable. The circumference did not further enlarge, but a swelling began on the top of the head over the posterior fontanelle, which, in the space of another week, acquired the magnitude of a goose's egg. At this period of the disease, the mother, on going one morning to take up the child, was very much surprised to find that the swelling had become much smaller, and perfectly soft. She observed likewise a constant dribbling of water from the urinary passage, and that the bed was soaked with the discharge. It continued incessantly for three days and three nights. By this time the swelling had entirely disappeared, the head was considerably smaller, and the integuments, which before were very much distended, now fell in large wrinkles over the child's forehead, so as actually to cover the eyes,

An increased flow from the urinary organs continued for nearly two months. When it became smaller in quantity, the head began again rapidly to enlarge, the swelling on the top re-appeared, and acquired a much greater bulk than before, it having on this occasion

extended

On the 7th of

extended itself over the head and part of the face. March, the tumour had arrived at its greatest size. watery discharge, tinged with blood, was seen to nostrils and mouth, It continued without ceasing till the 10th,' when the swelling on the top of the head had vanished, and the head itself was much smaller.

On that day a' ooze from the

The fluid never again accumulated in the sac on the outside, nor did the head ever gain its former magnitude, because the discharge from the nostrils was kept up, with slight intermission, till the time of its death on the 8th of this month. When, by any accident, the oozing from the nostrils ceased, the parents affirm that there was a corresponding increase in the urinary discharge. When the head was held forward, the fluid ran freely from the nostrils.

The child continued to eat well to the last. The evacuations from the bowels are reported to have been natural, but its powers of assimilation appear to have been destroyed, as she did not seem to have increased in bulk from the time I first saw it. She was sensible to external impressions, but the parents were not in that rank of life to make many observations, either on the nature or effect of such impressions. She never appears to have made the slightest attempt to articulate.

As she lived in the forest of Dean, I had it not in my power to examine her so frequently as I could have wished. But the foregoing facts were perfectly established, by what I saw myself, and by the testimony of a friend* who lives in the neighbourhood, and had an opportunity of ascertaining their truth. The second filling of the head, after it had been emptied by the great discharge from the urinary organs, seems to have been accomplished in little more than a fortnight. For though the first swelling disappeared in three days, the secretion from the kidnies appears to have been sufficiently active to prevent a second accumulation, till towards the end of February, when the swelling was again observed. As has been already noticed, it gained its greatest size on the 7th of March, and on the 10th it was no more visible.

On the 10th of this month I went to examine the child. Being obliged to perform the dissection in presence of the parents, it was less minute in some respects than I could have wished.

The circumference of the head was about 20 inches, being less by nine inches than it was before the swelling on the top first appeared.

I made a crucial incision, and dissected back the integuments. On uncovering that part formerly occupied by the swelling, I saw immediately what accounted for its origin, and explained many of the phenomena. A little to the right side of the falx the dura mater was ruptured, as was demonstrated by a well-defined circular opening nearly one inch in diameter, which communicated directly with what was the external tumour and the interior of the brain. Through

NO. 226.

* J. Pyrke, Esq. of Little Dean.

30

this

this opening I evacuated between three and four pints of fluid, which was contained in a bag formed by both hemispheres of the brain. The expansion of the brain was so great, that round the margin of the opening of the dura mater, it did not equal the thickness of a shilling; and under the opening it had entirely disappeared, proving that it had given way when the dura mater yielded, and allowed the fluid from the internal cavity to escape into the outward swelling.

The cerebellum was entire, and the organs of the different nerves seemed unimpaired. I could not well examine the ethmoid bone, but I easily passed a probe throught it into the nose.

The inferences deducible from this case are so obvious, that I forbear to mention them. I am not aware that any of a similar kind has ever been recorded. For that reason it appears to me not unworthy of a place in the Memoirs of this Society.

The expansion of the brain, of its membranes and of the cranium, seems to have gone on till the parts would stretch no longer. Then the rupture took place which caused the first swelling, and established a free and large communication between it and the interior of the brain. This fact is demonstrated by the rapid and remarkable absorption of the fluid in the tumour and in the head, so that the first entirely disappeared, and the latter became so much diminished in size, that the integuments hung in large folds, as already described. We have more convincing illustration of the same fact in the second appearance of the swelling. It was not circumscribed as at first, but extended over the head and face.

I have seen one case similar to that recorded by Mr. Earle in the last volume of the Transactions. The tumour was in the same situation, and had been twice punctured. The event of the disease has not yet been ascertained.

Glocester; Feb. 28, 1817.

On the internal and external Use of the Nitro-Muriatic Acid, in the Cure of Diseases. By H. SCOTT, M.D. (From the same.) [In the first article of our Analysis, we have given our opinion on the remedy recommended below. As, however, the subject is more particularly concentrated by the author himself in the following paper, we have thought it right to select the most im portant part for this division of our labours.]

I LEFT India in very bad health, and long remained ill in this country. During this period I often reflected on my experience with the acids, and resolved, as soon as an opportunity should occur, to return to the use of the nitro-muriatic acid, and to satisfy my mind on the subject from further observation. Above a year ago I came to London, and had an opportunity of getting the nitromuriatic acid employed to a considerable extent. At first, I mixed three parts of nitrous acid with one of muriatic, in order to imitate the acid I had used in India. Of late, however, I have employed the acids in equal weights, and I give a preference to this propor