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hours with liquid food at frequent intervals, the pulse became gradually more perceptible, and the patient was rescued from a state of imminent danger. The sponge was expelled into the vagina upon the third day, and was removed by the attached string without difficulty, and the patient recovered more rapidly than could have been expected after such a loss of blood.

I have since used the same plan in several cases of uterine hemorrhage in my own practice and when I have been called in to assist other practitioners, and it has been attended with unvarying success. I believe the plan to be valuable (as in the case I have recorded) in some apparently hopeless cases. No doubt the elasticity of the sponge keeps up a constant regular pressure upon the whole of the internal superficies of the uterus, whilst its spiculæ orrhage also stimulate the uterus to contract.

I have been in the habit of injecting a weak solution of carbolic acid to arrest fetor, both before and after the sponge is removed; but if it were desired to apply any other remedy, such as the solution of the perchloride of iron, &c., it could not be applied better than by injecting it into the sponge. But one great advantage of this plan of treatment is that it can do no harm.— Lancet, Feb. 13, 1869, p. 223.

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90. THE INJECTION OF PERCHLORIDE OF IRON IN POSTPARTUM HEMORRHAGE.

By Dr. ROBERT BARNES.

Dr. Barnes recommends the use of perchloride of iron as an injection in cases of post-partum hemorrhage, where other means of arresting the hemorrhage have failed.]

A very convenient preparation is the liquor ferri perchloridi fortior of the British Pharmacopoeia. Half a pint of this may be carried in the "obstetric bag," and when wanted it may be diluted to a quart by adding a pint and a half of water. This dilution should be put into a small deep basin. The syringe most convenient is Higginson's, fitted with a uterine tube about nine inches long. My syringe has a common mount, which is made to fit either the elastic dilators or the uterine tube. Care should be taken that air is not sucked up into the syringe. To avoid this, keep the entrance-tube of the syringe at the bottom of the fluid, and pump through back into the basin until the syringe is filled with the fluid. The apparatus being ready, pass the left hand into the uterus, clear away all placenta and clots, then slip up the uterine tube along the palm of the hand, so as to carry the end of the tube up to the fundus of the uterus; then compress the syringe gently and steadily, so that the fluid may trickle down over the whole inner surface of the uterus. The pumping may be repeated until the basin is nearly emptied —not quite, lest air be taken up. As the iron acts by coagulating the blood in the mouths of the vessels, and mere contact is enough for this, it is unnecessary to pump with any force.

The effect of this injection is to corrugate the inner surface of the uterus, and commonly some degree of muscular contraction follows. I have hardly ever known any more hemorrhage to occur after one injection. Henceforth the patient is safe from further loss; and if not already too far exhausted by previous loss, there is nothing to prevent the patient's recovery.

I have practised this plan for several years, and in a great number of desperate cases, where kneading, compression, ergot, cold in every form, had failed, and I have seen no bad consequences from it, Practised with the precautions I have laid down, I believe it is in itself safe, and I am certain that not a few lives have been rescued by it from otherwise imminent death.

I have also used it in cases of excessive flooding attending abortion. But where the uterus is small, and the cervix not admitting more than the finger, I now prefer to apply the styptic on a swab, such as a common probang. I have a strong suspicion that in one case of early abortion, an injection made

too forcibly by means of a caoutchouc bottle was the cause of a fatal catastrophe. The patient died almost suddenly soon after the injection, with symptoms resembling those consequent upon air entering the circulation.

This, the only accident I am acquainted with, suggests caution. But in a desperate emergency, like flooding, we must be prepared to encounter some risk, rather than suffer the patient to lose that little stock of blood in which the life of the patient lingers.-Lancet, Jan. 30, 1869, p. 175.

91.-OBSERVATIONS ON A CASE OF SUDDEN DEATH AFTER DELIVERY FROM EMBOLISM OF THE PULMONARY ARTERY. By Dr. W. S. PLAYFAIR, Assistant Obstetric Physician to King's College Hospital. By embolism we mean those cases in which a portion of fibrine is detached from a clot in a blood-vessel, and is carried through the circulation until it becomes impacted in another, and possibly very distant, part of the circulatory system, where it may become the nucleus round which fresh fibrine is subsequently deposited. When the fibrine is deposited in situ, in the place where it is found after death, the term thrombosis is the one which should be used; and it is to be observed that every case of embolism must necessarily be preceded by thrombosis, for, unless a thrombus or clot exists in some part of the circulatory system, there is no deposited fibrine from which an embolus can be detached.

Although the words can be used in reference to any part of the vascular system, I would wish to be understood as referring more particularly to those cases in which fibrine is found obstructing the right side of the heart and pulmonary arteries; cases which in reference to the puerperal state, are of extreme importance to the accoucheur, and deserve the most careful study.

There can be no doubt that embolism in this situation has been more generally considered the cause of sudden death after delivery than thrombosis. This is the view that has been maintained by Virchow, and by Wade and others who have written on the subject in this country. In fact the possibility of the coagulum forming in situ has been almost entirely overlooked. In the paper above alluded to, I ventured to maintain a contrary opinion. I then said: "I believe that a careful examination of the now numerous instances of sudden death after delivery will show that in a large proportion of them there was no history whatever of peripheral phlebitis or venous obstruction from which an embolus could be derived." I am pleased, therefore, to find that Dr. Richardson, who has devoted much attention to the point, considers true embolism to be comparatively rare; and points out, very graphically, how the heart and pulinonary arteries are, from their anatomical arrangements, a likely situation for the separation of fibrine.

It seems to me that the term embolism should never be applied to cases of fibrinous obstruction in the heart and pulmonary arteries, unless two conditions are met with on post mortem examination. One is the existence of a clot in some part of the peripheral venous system, from which an embolus can be derived; the other is the existence in the pulmonary clots of separate travelled portions of fibrine, corresponding in structure to the peripheral thrombus, round which more recent fibrine is generally deposited. If no clots exist in any of the veins, the case clearly cannot be one of embolism. Many cases have been carefully examined in which the existence of true pulmonary embolism is beyond all doubt. The following, in which the travelled embolus was not only found, but the exact site from which it was detached also determined, is so remarkable that it seems to me to be well worthy of record.

Jane W., 21 years of age, was admitted into King's College Hospital. under the care Mr. Henry Smith, early in the month of December, 1868, suffering very severely from intense pain on defecation, which was ascertained

to depend on a fissure in the rectum. She was then in the sixth month of her third pregnancy. Two years ago she had suffered in the same way, and her symptoms were then so severe that Mr. Smith had operated on her, although she was then far advanced in pregnancy. No unfavourable results followed, and she had gone to the full time, the rectal symptoms having been greatly alleviated. Encouraged by his former success, Mr. Smith determined to operate again, and this was accordingly done on the 5th of December.

On December 7th, she began to complain of pain in the back, accompanied by a slight discharge of blood, when she was at once removed into a separate ward. Opiates were administered, and the usual treatment for averting premature delivery resorted to. For several days it was hoped that labour might be prevented; for, although slight uterine contractions recurred every now and then at long intervals, the os remained unopened, and there was no discharge. The appetite was good, the pulse quiet and regular, the pain on defecation much diminished, and the patient was in every other respect apparently in perfect health.

Things went on exactly in the same way until December 13th, on the morning of which day she had one or two very slight pains, but was otherwise cheerful and well. Late on the evening of that day, however, her pulse and temperature gradually rose without any evident cause, and at 10 p. m. her pulse was found to be 160, her temperature 103, and her respirations 40. She complained of no pain, and there was nothing to show what could be the cause of this sudden change. Shortly afterwards she vomited a large piece of undigested meat, showing no sign of mastication, which, she stated, she had swallowed accidentally when disturbed during her dinner on the same day.

At 1.30 a. m., uterine contraction had increased in strength; the pulse being now 104, the temperature 100. At 5.45 a. m., the entire contents of the uterus were expelled, the membranes being unruptured.

The condition of the patient was noticed by Mr. Pedler, the resident accoucheur, to be at this time as follows: "She was suffering from extreme dyspnoea, the countenance was excessively pale, her lips white, the face generally expressing extreme anxiety. The uterus was well contracted. No pulse could be felt at the wrist, nor at the posterior tibial artery. The sounds of her heart were almost nil." In fact, she had all the symptoms of obstruction at the right side of the heart, most characteristically developed. Stimulants were administered freely. The patient called incessantly for air, and said she was being suffocated. She died at 7.45 a. m., and during the last few seconds of her life the face was convulsed.

A post mortem examination was made eight hours after death by Dr. Kelly, the pathological registrar to the hospital, from whose notes the following account is abridged. On opening the thorax, the lungs were found collapsed; there were no adhesions or fluid in the pleura; the lungs themselves were quite healthy, unusually light, and containing very little blood. The bronchial mucous membrane was a little congested, and there was no frothy mucus nor pus in the tubes. The heart weighed nine ounces, and was quite healthy in structure. The right side of the heart was extremely distended, and also the large veins of the neck and the two cavæ; the left ventricle was small, and the pulmonary veins were nearly empty. The right side of the heart was filled with a soft black coagulum, on the upper surface of which was a little discoloured fibrine; it had all the appearance of a recent post mortem clot. At the bifurcation of the pulmonary artery, plugs of firm fibrine were found obstructing the passage of the blood, more especially on the left side, where they extended for about an inch and a half into the primary divisions of the pulmonary artery. Beyond these the arteries were nearly empty, containing only a little fluid blood. These clots were of a yellowish or buff colour, very firm, but not moulded to the vessel in which they lay, and were very different from the soft gelatinous clot in the right ventricle. They were of a leathery consistence, and were not surrounded by any black coagulum. On section, they were all uniform in colour, and partially laminated, with the exception of one, which

lay across the pulmonary artery, and was nearest to the heart. In the centre of this, was found a piece of fibrine, of the shape of an almond, and three-quarters of an inch long, surrounded by, but separate from, the remainder of the fibrine, which was of less firm consistence. At its base was an irregular surface, which fitted closely to a corresponding rough surface in a clot in the iliac vein. The valves of the heart and large vessels were quite healthy in structure, and none of the clots were adherent. At the junction of the internal and external iliac veins on the right side was a clot of fibrine about two and a half inches long, adherent at its distal end to the internal iliac vein, while its other extremity was free and lay in the common iliac vein, but not filling up the whole of its canal. About its centre was the roughened portion previously described, from which the nucleus in the pulmonary clot seems to have been detached. The uterus was perfectly healthy and well contracted, and its veins contained no coagula.

The symptoms which caused the death of the patient were so characteristic of obstruction of the right side of the heart and pulmonary arteries, that no other diagnosis was possible. They are precisely those which have been described in numerous cases of the kind which have been recorded. The very careful post mortem examination conducted by Dr. Kelly clearly showed that this was a true case of embolism. For, first, was found the firm coagulum obstructiug the right iliac vein. showing a ragged portion of the juncture of the right with the common iliac vein, which looked exactly as if a piece of fibrine had been detached from it, and markedly different in appearance from the smooth surface of the coagulum at every other part. Then in the pulmonary arteries were found various masses of fibrine obstructing their calibre, and in the centre of one of these a separate nucleus of fibrine, differing in texture from that surrounding it, and presenting at one extremity a jagged portion, which accurately fitted the corresponding point in the iliac clot.

It is very clear, therefore, what had occurred. At some period during the eight days which elapsed between the operation and death, a coagulum had formed in the iliac vein. The portion found in the centre of the pulmonary coagulum had become detached, and was carried through the venous circulation until it was arrested in the pulmonary artery. This, probably, corresponded with the sudden rise in the pulse and temperature on the evening preceding delivery. During the night, the fresh fibrine which surrounded it was deposited, and the pulmonary arteries became more and more obstructed until death ensued. The original coagula in the iliac veins seem to have caused no symptoms, or at least none that were observed.

This explanation of the phenomena is necessarily theoretical, but it is, I believe, the only one which will fully account for the symptoms, and it is strictly in accordance with what has been observed in other cases which have been recorded. There is one difference, however, between this and every other case of undoubted pulmonary embolism after delivery, which I have yet met with, which is worthy of remark. I have shown by an analysis of twenty-five cases after delivery that, in twelve which were probably due to embolism, the death occurred a considerable time after delivery-generally after the nineteenth day; while, in the remaining fifteen, where the coagulum apparently formed in situ, the fatal result occurred at a much earlier period. I explain this curious difference on the supposition that embolism must be preceded by the formation of a bloodclot in some of the peripheral veins, in consequence of a similar blooddyscrasia to that which produces primary coagulation in cases of pulmonary thrombosis, and occurring about the same time after delivery, and it is not till then the clot so formed has had time to change and soften that a portion of it becomes detached and carried through the circulation to the heart.

In the case above narrated, however, the embolus seems to have been detached before delivery. The difference is probably due to the fact that

the iliac clot was formed during some portion of the eight days which elapsed between the operation and the death of the patient; and its original deposition may have been produced by some blood-changes resulting from the operation itself. In the absence of any definite data as to the exact time at which it was formed, there is nothing to prevent us from believing that a sufficient period had elapsed to allow of those retrograde metamorphoses of the fibrine which favor the separation of a portion. As this is the only case in which death so nearly coincided with delivery, and as it was preceded by an operation, it seems a very fair inference that the operation was in some way the determining cause of the coagulation in the iliac vein, from which the embolus was derived. There can be no doubt that the alteration in the blood due to pregnancy favoured the recurrence; but, beyond this, it is questionable whether the delivery itself had anything to do with it; and I see no reason to alter the conclusion at which I formerly arrived, "That embolism usually occurs at a much later period after delivery than thrombosis; and that spontaneous thrombosis probably corresponds with, and is due to, some similar in its nature to that which produces the obstruction of the peripheral veins in true cases of embolism.-Brit. Med. Journal, March 27, 1869, p. 282.

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92.-PROLAPSUS UTERI OF SEVENTEEN YEARS' STANDING CURED BY OPERATION.

Under the care of Mr. NORTON, at St. Mary's Hospital

The patient, whose case is appended is at the present time-a year and a half after the operation-a milk carrier in London; and though the weights she bears are excessive, there has been no return of the disease, nor have there been any bearing-down pains. She continues in perfect health.

Mrs. M. had laboured under the severe effects of an extensive prolapse of the womb since the birth of her last child, a period of seventeen years. She stated that she was unable to walk, or in any way to gain a livelihood, and that she was only free from pain when lying down.

On examination, the uterus was found altogether external to the vagina. It was much enlarged, thickened, and indurated, and around the os, and upon different parts of the vagina, were several small ulcerations. Pessaries of various forms had been used to support the womb, but without effect.

Mr. James Lane saw the patient with Mr. Norton, and it was determined that the operation which Mr. Lane had performed on several occasions should be adopted.

On the following Wednesday Mr. Norton removed an eliptical piece of the mucous membrane about three inches and a half in length, by two in breadth, from the vesical wall of the vagina. The cut margins were then brought together by means of ten silver-wire sutures, and the uterus returned to its normal position. The bowels were confined by opiates to the sixth day, and then relieved by castor oil. The vagina was syringed daily with warm water, and after eight days the sutures were removed.

Fourteen days after the first operation, Mr. Norton removed by a horseshoe incision rather more than an inch of the mucous membrane of the posterior and lateral walls of the vagina, including the cutaneous margins of the fourchette. The denuded surfaces were now approximated as in the operation for ruptured perineum, and were firmly fixed by means of silver-wire quilled sutures. The projecting lips were more evenly adapted by a second row of wire sutures somewhat deeply placed. As on the previous occasion, the bowels were quieted by opiates throughout the week. The quilled sutures were removed after forty-eight hours, and the others in seven days. On the removal of the quilled sutures a few drops of pus exuded, and the parts round showed some little redness and induration, but these symptoms were relieved by a bread-and-water poultice.

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