5. Give small doses of strychnine (not more than two doses, of one-thirtieth of a grain each, by hypodermic injection).

The latter recommendation is given with some confidence, notwithstanding the adverse views of certain surgeons. lieve at the same time that large doses of this medicine are exceedingly dangerous in certain cases of either shock or collapse.

66

In the discussion which followed the reading of my paper at the Toronto meeting, it was stated, that the same results could be obtained in many different ways. In Dublin the practice was to plug the vagina; in Edinburgh to rupture the membranes."

I had no opportunity to reply, but I desire now to call attention to the fact that in one of the cases reported (which is also reported to-day), the clot resulting from the outpour of blood was entirely post placental, the whole margin of the placenta being adherent to the uterine wall. Neither the vaginal plug nor the puncture of the membranes could in this case mitigate the serious symptoms of pain and shock.

The combined internal and external accidental hemorrhage, whether occurring before or during labor, is more easily diag nosticated than the purely concealed form; but in certain cases, the diagnosis is sufficiently difficult to cause much perplexity. When, for instance, a quart of blood is retained internally and only two ounces escape externally, we have a condition closely similar to the concealed variety, with intense pain and shock. Under such circumstances it seems reasonable to suppose that the pain and shock are still the prominent symptoms, and should receive very prompt treatment. After complete or partial recovery from pain and shock it would seem well to carry out the so-called Dublin treatment, to which further reference will be made, or perform a vaginal Cesarean section. A report of a case with similar conditions and symptoms will be given later.

In what is known as the external accidental hemorrhage there is little or no shock, but there may be collapse from loss of blood. It is probably in such cases that the greatest difference of opinion prevails, especially as to two procedures, rupture of the membranes, and the introduction of the vaginal tampon. The puncture of the membranes and the use of the plug are very old procedures in the treatment of accidental hemorrhage.

We are told that one hundred and thirty years ago there was a great difference of opinion on this question, and at that time

Leroux, of Dijon, was a strong advocate of "rupture of the membranes," and the "administration of ergot of rye to check the flooding."

The discusions as to these two methods during the first and second thirds of the last century were interesting, and were equal in many respects, and perhaps better in some respects, than the discussions of the last forty years. It would appear from the discussion last August in Toronto that we have not made much progress in a century and a half as to the proper

FIG. 1.-Pregnant uterus, seven months, membranes intact, uterine wall tetanically contracted cervix hard as iron, showing a post-placental clot between a portion of the placenta and the uterine wall.

estimate of these two procedures. There can be little or no doubt, however, that each method is good in its proper place.

All things considered, the vaginal plug appears to be more generally useful, and safer, for the various kinds of accidental hemorrhage than any other procedure. And yet, a candidate at a final examination, who expressed such an opinion before a board of examiners in London, England, ten years ago, would

probably have been plucked because of such dangerous heterodoxy. That terrible danger of converting an external into an internal hemorrhage was ever present for many years in the minds of the orthodox.

About twenty-five years ago, Speigelberg and Smyly reintroduced the use of the plug, and England and Scotland were for a time horrified. The results at the Rotunda have been so remarkably good that the whole world has been forced to modify its opinions respecting the procedure. No one pretends, however, that such introduction of a plug is always safe; but it is understood that the proper application of an abdominal binder greatly minimizes the dangers.

It is difficult to understand, at the same time, how plugging could accomplish much good in concealed accidental hemorrhage, although we are told that in three cases of this form of hemorrhage occurring at the Rotunda, a plug was used with good effect. I do not know how the diagnosis was reached in these cases, nor when the plug was introduced; but I should suppose that such introduction would be absurd while the patient was suffering, perhaps dying, from shock.

If I should again meet a case similar to that which I have reported in which severe pain came on four days before the onset of labor, I should now be inclined to interfere after the patient had rallied, say on the day after the advent of the acute symptoms. After such a severe nerve storm as I have described, with its prolonged condition of uterine tetanic spasm, a fetus is, so far as I know, always dead.

Although I believe that the statement made by Goodell, that in such cases the rule should be imperative "to deliver the woman as soon as possible," has done a large amount of harm, by encouraging the operation of accouchement forcé, even while the cervix is "as hard as iron," yet I believe that the patient can hardly be considered safe until the uterus is emptied. I think, therefore, when all symptoms of shock have disappeared, it might be well to introduce a bougie into the uterus, according to the Krause method (being careful not to rupture the membranes), and at the same time introduce a plug into the vagina. This can be done best by using some form of Sim's speculum, introducing a gum elastic or rubber bougie, about 12, English size, as far as possible, and packing the vault of the vagina with antiseptic gauze. I prefer 5 per cent. iodoform gauze.

It seems remarkable that rupture of the membranes in cases of accidental hemorrhage should have had so many advocates during the last one hundred and fifty years. While one of the oldest, it is one of the crudest, and one of the most objectionable

obstetrical operations when performed before the onset of labor. There is no doubt, however, that the procedure is an excellent one in its proper place, but its scope as compared with that of the introduction of the vaginal plug is much more restricted. In the case of concealed accidental hemorrhage before the onset of labor, and especially before the effacement of the cervical canal, it is, I think, never justifiable. In the case of the combined internal and external accidental hemorrhage before labor, one cannot speak so positively, but it seems probable that in such cases the operation is unjustifiable. If, however, labor has commenced and the external hemorrhage is serious, the rupture of the membranes will frequently, or perhaps generally, produce a good result by diminishing or frequently stopping the flooding. The puncture of the membranes may produce good results even if done before the onset of labor if there is

FIG. 2.-Placenta from Fig. 1 after delivery, showing on the maternal surface the saucer-shaped cavity occupied by the clot.

effacement of the cervical canal. I have not, however, had sufficient experience with this procedure to give a definite opinion in that regard.

It would not be profitable to spend much time discussing accouchement forcé. Its mortality rate, when the patient is suffering from shock, and the uterus is tetanically contracted, is, in my opinion, exactly 100 per cent. I know of no operation in obstetrics or surgery respecting which one can speak more definitely. A certain amount of force may, however, be used when the os is dilatable. For instance, we may have ruptured the membranes before the os is dilated; there may still be considerable hemorrhage, making an early emptying of the uterus desirable. In such a case manual dilatation of the os, with version or forceps delivery, may be advisable. It is doubtful, however, whether the manual dilatation, under such circumstances, should be designated accouchement forcé.

I should like to discuss the operation of vaginal or abdominal Cesarean section, but I have had no experience in connection with either operation for accidental hemorrhage. In the case of either concealed, or combined internal and external accidental hemorrhage, with the patient suffering from shock and a cervix as "hard as iron," any operation would probably be unjustifiable. The shock should be properly treated; and if, in spite of such treatment, the symptoms of shock grow worse instead of better, the patient is probably going to die. If, on the other hand, the patient recovers from the shock, it is certain that in some cases, if not in the majority, serious operation is not advisable. It might happen, however, that internal hemorrhage was taking place into a uterus whose walls were stretching rapidly, and the loss of blood was the chief factor. If, in such an emergency, it was not possible to dilate the os, and deliver soon enough to save life, some form of Cesarean section might be deemed advisable. Vaginal section, in one of its varieties, seems the best radical operation in sight; but I am inclined to think its field is exceedingly limited. It seems tome entirely unsuited for such a case as I have reported to-day, especially when there is doubt as to the diagnosis; but it may be indicated in cases where labor is imminent, or present, especially where loss of blood, whether internally or externally, or both, is the serious factor.

I shall now submit to the Fellows of the Association a case reported something like ninety years ago: "A lady of weakly constitution and delicate habit was attacked in the later months of pregnancy with a slight discharge of blood from the vagina, not amounting altogether to half an ounce, accompanied with alarming symptoms of exhaustion and debility. The os uteri was scarcely dilated to the size of a sixpence, and was in such a state of rigidity as precluded the possibility of affording any manual assistance. The lady in consequence died, and, on examination after death, it was found that the separation of the centre of the placenta from the parietes of the uterus had taken place, whilst its edges 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."

What would you do in such a case as this? Did this woman die from shock, or from loss of blood, or from a combination. of the two? I have never met a case where the loss of a pint and a half of blood without other complication caused death; but I must admit that such a hemorrhage is a serious matter.