overcome the resistance of the venous walls on the nozzle of the instrument. Therefore he thought some form of syringe more likely to prove generally useful. It should be more generally known than it is that transfusion with defibrinated blood, so far from being a difficult operation, is in reality a very simple one. Dr. CLEVELAND also wished to express a hope that the Society might be enabled to give directions for facilitating the operation of transfusion, and mentioned a case in which a lady, after confinement, was threatened with death from hæmorrhage, when he requested the assistance of a distinguished Fellow of the Society who had invented a suitable apparatus. A healthy young man was procured, and in waiting upwards of two hours; but owing, as Dr. C believed, to the uncertainty of the operation, combined with the lingering hope that the patient might rally under the means employed, an opportunity was lost, and she succumbed. He could not help thinking that with a safe means of transfusing the result might have been different. It was proposed by Dr. Routh, and seconded by Dr. Heywood Smith, "that the Council be recommended to form a Committee to investigate the subject of transfusion." Dr. HEYWOOD SMITH showed a modification of his "angular scissors," which had been made since the last meeting. In these the small scissors had curved blades, and when bent forwards would be useful for the removal of polypi, and bent backwards for cutting the sutures after the operation for vesico-vaginal fistula. Dr. H. Smith thought this shape would prove of use in many operations, such as paring the edges in difficult vesico-vaginal fistulæ, cleft palate, &c. INVERSION OF THE UTERUS AFTER CHILD. BIRTH IN A PRIMIPARA. AMPUTATION BY ÉCRASEUR AT EXPIRATION OF TEN MONTHS ON ACCOUNT OF HÆMORRHAGE WITH GREAT EXHAUSTION. By J. HALL DAVIS, M.D., F.R.C.P., OBSTETRIC PHYSICIAN AND LECTURER ON OBSTETRICS AT THE MIDDLESEX MATERNITY CHARITY. THE patient from whom this uterus was removed, A. B—, is a young married woman aged twenty-two, of medium stature and good conformation, who was admitted under my care into the Middlesex Hospital February 20th, 1872. On admission.-I found her anæmic, emaciated, and in a state of great prostration from uterine hæmorrhage, which was still continuing, with occasional vomiting. P. 100, T. 98°. On vaginal examination I discovered a polypiform body occupying the vagina, suspended from within the lower part of the cervix of the uterus by a neck of the thickness of my index-finger. Measures for the abatement of the hæmorrhage were taken; the rectum, containing a fæcal accumulation, was cleared out by a soap-and-water enema. After this I made a more minute investigation, to decide whether the body which I felt was a polypus, which it had been suspected to be, or an inverted uterus. The uterine sound passed through the orifice of the uterus upwards to a distance of not more than one and a half inch. I next introduced the finger into the emptied rectum high up, and on directing its point forwards in search of the fundus of the uterus I could not feel it. The protruded body was very sensitive when compressed, and softer than a fibroid polypus usually is, and less smooth on its surface. Previous history.-Her health previous to marriage, two years ago, had been good. Menstruation had commenced at fourteen. She was delivered of her first and only child in April, 1871. Her labour was tedious, and at length delivery was effected by the forceps of a living child, which still thrives. The placenta, being adherent, required artificial removal; much hæmorrhage ensued, and considerable pain in the lumbar and pelvic regions of a dragging and bearing-down character. The diagnosis.-This history and the above local examination of the case led to the inference that it was one, not of polypus, as had been supposed, but one of inversion of the uterus, occurring at or soon after the delivery of the placenta. Treatment.—Reflecting on the patient's condition, one of extreme prostration from hæmorrhage, which had recurred at short intervals for the last ten months, I was convinced that her constitutional powers would not tolerate the treatment by persistent elastic pressure with a view to reduction. Moreover, the neck of the inverted portion of the uterus was too narrow to admit of the return through it of the fundus and body of the organ, at least not without long-continued and exhausting mechanical interference. The uterus had, moreover, undergone considerable involution, which set another barrier in the way of reversion. I therefore decided upon the only course left me under the circumstances-to remove the uterus, the displacement of which was the cause of the hæmorrhage immediately threatening the life of the patient. The operation was performed on February 23rd. Of the different methods of extirpating the organ, that of ligature only I feared would cause great suffering, as it has done in many cases, and in my patient's condition would probably induce peritonitis and septicæmia; ligature followed by excision might be expected to produce like results; excision only would most probably be followed by dangerous hæmorrhage; extirpation by the écraseur only, being very rarely followed by hæmorrhage in the case of polypi even with thick necks, especially if the division is slowly accomplished, was accordingly the method which I selected as the safest. I employed the single wire for the purpose, of the same kind which I have often used for the removal of polypi. I applied it without first dragging upon the neck of the uterus, thinking that if I avoided previous traction on the uterus, often recommended before extirpation, I should probably prevent, at least not be favouring, the sudden springing up into the peritoneal cavity of the severed cervical portion of the displaced uterus. Having applied the wire around the neck of the protruded body, and given its first degree of tightening without chloroform, the patient complained of agonising pain; I therefore loosened the wire for a few moments while she was placed sufficiently under chloroform, and then I completed the amputation slowly. No hæmorrhage followed, nor did it again recur. On recovering from anæsthesia my patient complained of severe pain in the hypogastrium; on this account my obstetric assistant, Mr. Lewis, administered, by my desire, a subcutaneous injection in the forearm of one third of a grain of morphia; this was repeated during the first twelve days, every two, three, four, six and eight hours, day and night, at varying intervals, as was necessary, for I found that any suspension of its use was followed by severe uterine and ovarian pains and restlessness. After this, for a few nights, hydrate of chloral in twenty-grain doses was substituted at bed-time and produced relief from pain and quiet sleep, Linseed poultices, sometimes containing laudanum, were kept steadily applied to the hypogastrium. The pulse was very small immediately after the operation, which was performed at 1.30 p. m., and the temperature at the same time fell to 97°. At 9 p.m. pulse 102, temp. 98.8°. The pulse mounted on the third night after the operation to 130, but the temperature reached its maximum, 102°, on the ninth day. After this both pulse and temp. fell gradually, the former to 72, the latter to 98°, on March 10th. There were transient chills before the temperature and pulse rose, but no evidence of peritonitis appeared; at least moderate pressure on the belly was tolerably well borne, and the abdomen did not become tense. The catheter was required for the first three days; the bowels were moved by a simple enema on the seventh day. The patient was watched day and night during the early days after the operation, re ceiving frequent small supplies of liquid nourishment; for a time, and while sickness occurred, this was administered per rectum; brandy in small quantities was also allowed to the extent which feebleness indicated as necessary. On the eighteenth day she was permitted to leave her bed for a short time, and did so without any bad results; a gentle aperient of compound rhubarb pill regulated the bowels sufficiently, and a chalybeate tonic given during the last fortnight of her stay in the hospital, added to her generous diet, advanced her strength. She was discharged convalescent on the thirty-second day, having a few days before had a slight sanguineous discharge per vaginam, apparently menstrual. She continues (July) in perfect health. The case here detailed and illustrated is one of partial inversion of the womb, the portion removed consisting of fundus and about the upper two thirds of the body of the uterus ; it did not protrude through the vulva, as in complete inversion, and its serous cavity does not contain the ovaries; that I ascertained immediately after its removal. The uterus has been cut across from above downwards for the purpose of displaying the serous cavity containing part of the Fallopian tubes and ligaments, and to show the thickness of the uterine walls. It is probable that in this case adhesion had taken place between the opposite serous surfaces of the inverted uterus at some point between the line of inflexion and the line of amputation, for on passing the point of my finger |