ON A NEW TREATMENT IN POST-PARTUM

HÆMORRHAGE.

BY W. HANDSEL GRIFFITHS, PH.D., L.R.C.P.E.,

Corresponding Member of the Therapeutical Society of Paris, and of the Pharmaceutical Society of St. Petersburg; Lecturer on Chemistry in the Ledwich School of Medicine, Dublin.

ALTHOUGH not an obstetric practitioner, I have recently been consulted in two cases of severe post-partum hæmorrhage. In both cases every means had been adopted but unavailingly. It flashed across my mind in the first case to try the effect of the ether-spray, and accordingly I directed a large spray over the abdominal walls, along the spine, and over the genitals; the uterus at once responded, and the cessation of the hæmorrhage was almost immediate. In the second case I lost no time in adopting a similar treatment, and with an equally successful result. I have consulted several eminent obstetric practitioners in Dublin, and am informed by them that they are not aware that this treatment has been heretofore proposed. The advantages of the ether-spray over the application of cold water and the other means usually adopted in these cases must be patent to every practitioner of midwifery.

ON DIPHTHERITIC PARALYSIS.

BY THOMAS STRETCH DOWSE, M.D., F.R.C.P.E.,

Physician Superintendent Central London Sick Asylum, Highgate.

It is well-known that this especial form, or, indeed, that a form of paralysis has been known to succeed an attack of diphtheria, or an inflammation of the throat, from the time of Hippocrates. So that in the fact of the existence of this especial paralytic affection we have nothing new, yet in its peculiar clinical and characteristic features we find a disease of most absorbing interest both in regard to its etiology and pathology. Its diagnosis is easy, and its prognosis favourable.

Dr. Eade stated at the British Medical Association in 1874, that he was the first person in England who pointed out (in 1859) that paralysis followed diphtheria.

In the British Medical Journal for October 2, 1875, we find a very interesting letter from Dr. Wade, of Birmingham, entitled "An Historical Note on Diphtheritic Paralysis," showing that both diphtheria and its paralytic sequela were well known in 1749. The book from which the extract is taken is entitled "An Historical Dissertation on a Particular Species of Gangrenous Sore Throat which Reigned the Last Year among the Children of Paris; translated from the French of Dr. Chomel, which was printed at Paris in the year 1749, by N. Tomano, M.D., London, 1753." It is of such interest that I give it in detail. "Miss Blossac the younger, aged 61 years. The patient did not seem to be quite free and out of danger until the 45th day of the disease, having always a pain in expressing herself, speaking through the nose by reason of the fallen uvula.

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I have since been advised that for two months together they gave her, in order to lessen the disagreeable speaking through the nose, a little camphorated brandy with equal parts of lukewarm water to draw up her nose, and she used the remedy with pleasure" (p. 31).

"Miss Bonai was taken ill of the disease at home, and was cured. . . . I have since learned that this patient, after the 40th day of the disease, spoke very much through her nose, became squint-eyed and deformed, but that as she grew stronger, she also regained day by day her normal state" (p. 37).

"The patients grow leaner and leaner daily, speak much through the nose, have great trouble to articulate their words. . . . The fever lasts dangerous even beyond the 45th day; the uvula is a long time trailing or pendulous. The patients are a long time very weak and languid" (p. 41).

This very graphic writer leaves no doubt that the disease of which he treats was veritably diphtheria.

Admitting with Dr. Jenner that we may have six varieties of diphtheria-namely: 1st, the mild form; 2nd, the inflammatory form; 3rd, the insidious form; 4th, the nasal form; 5th, the primary laryngeal form; 6th, the asthenic form-I ask the question, Can we, provided such definition be an accurate one, take either of these forms and say that our patients will be more liable to paralysis after it than from any of the others?

In my own experience—and I believe it is considered to be the rule-it has been impossible to state with any degree of certainty in what patients an attack of paralysis is likely to supervene that of diphtheria, although Dr. Balthazar Foster states that "he has never known paralysis to follow the non-febrile form of diphtheria." For we often find a very severe attack of paralysis to follow a slight or most modified attack of diphtheria, whilst on the other hand, a very severe attack of diphtheria will be unaccompanied with paralysis, neither have I been able to trace in the constitution of the patients any especial nervous idiosyncrasy to render them more prone to paretic influence, but my knowledge of this disease is not so extensive as to permit me to speak with certainty upon this point.

But judging from other nervous diseases, such as chorea, hysteria, tetany, and so on, I think we should find, if the matter

were more closely investigated, that in those persons suffering from paralysis after the devitalizing agency of some septic or morbid influence, there was, either by hereditary or some constitutional predisposing cause, a want of inherent tonicity throughout the nervous system and nervous centres, which renders them more easily excited or acted upon by external agency. This is conspicuously demonstrated in the poisoning by lead. Some men will go all their lives and get their systems saturated with lead without any form of paralysis resulting, whilst others even from the application of lead plaster or ointment to the skin will suffer from palsy of the extensors and abdominal muscles.

M. Sanné, in his recent work on diphtheria, says that the alterations of the blood in this disease, in reference to its intimate composition, are little known, and that chemical analysis gives uncertain results, so that we are compelled to consider in a general manner the changes which this liquid undergoes.

Andral and Gavanet have shown that the fibrin is notably diminished. The globules undergo rapid disintegration; and M. Bouchut has drawn attention to the large increase of leucocytes. In most of the observations of M. Labadie Lagrave, he states that in the normal condition scarcely three of these bodies are to be seen in the field of the microscope, whilst in diphtheria they often amount to sixty.

M. Sanné states that the red blood globules are altered in various ways, notably when the blood takes abnormal colourings. The abnormal increase of the débris of the red corpuscles, which is rare in the normal state, is considerably increased through the agency of the diphtheritic poison which produces their rapid destruction. Consequent upon this alteration in the normal constitution of the elements of the blood, we find the urine to be loaded with albumen, which, as stated by Dr. Sanderson, is not associated with a lessened excretion of urea, but rather, as in other pyrexiæ, by its abnormal increase, therefore we are not likely to get any form of convulsions or paralysis of toxic or uræmic origin. I make note of this especially for the reason that the stage at which diphtheritic paralysis makes its appearance is usually subsequent to what might be called the

albuminuric period. Frequently not a trace of albumen can at the time be detected in the urine, although a copious production previously existed, yet it is by no means rare for the albumen to reappear with the paralysis.

The co-existence of albumen in the urine, in various forms of paralysis (not diphtheritic), has upon many occasions led me to give a hopeful prognosis, and as the albumen passed off, so the paretic troubles have gradually declined, showing that the nerve lesion was merely functional, and due to some blood change inducing a vaso-motor paresis, leading to passive exudation of primordial plasmic matter, not only from the blood-cells themselves, but also from the vessels, thereby exercising pressure upon the nervous centres.

The significance of diphtheritic paralysis has been fully noted and described of late years by M. Roger, Trousseau, Gubler, Colin, Charcot et Vulpian, Herman Weber, Sir J. R. Cormack, Ormerod, Duchenne, Greenhow, Wade, Bailey, Dr. Sanné, and many others.

We have first to consider the period when this paralysis makes its appearance, and then proceed to describe its clinical characteristics, treatment, and pathology.

On the authority of M. Sanné, if during convalescence from diphtheria the temperature suddenly rises, paralysis must be anticipated. There can be no doubt that it is capricious alike in its origin, seat, and departure, sometimes it is fixed to one organ, at others attached to many, or it may involve the whole body. It is sometimes limited to the throat alone, and to those muscles supplied by nerves taking their origin in the bulb of the medulla, and so far it represents in a very striking manner what is termed Labio-Glosso Pharyngeal or bulbar paralysis, but there are marks of distinction which I will endeavour to draw as I proceed.

Paralysis may occur in a few days after the cure of diphtheria, or it may not make its appearance for a month, six weeks, or even two months. It is usually symmetrical. When it comes on later it is frequently found to be more persistent than when it occurs earlier after the presumed cure of the disease, although in the latter case it is liable to recur in some different form. The duration of the paralysis cannot be well defined. When it is limited to the throat or larynx it does not usually exceed eight