THE PUERPERAL DISEASES, CLINICAL LECTUKES-- ' DELIVERED AT BELLEYUE HOSPITAL. FORDYCE BARKER, M. D., CLINICAL PROFESSOR OP MIDWIFEKY AND THE DISEASES OP WOMEN IN THE BELLETITE HOSPITAL MEDICAL COLLEGE ; OBSTETRIC PHYSICIAN TO BELLEVUE HOSPITAL ; CONSULTING PHY- BICIAN TO THE NEW YORK STATE WOMAN'S HOSPITAL ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE; FORMERLY PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK; HONORARY FELLOW OF THE OBSTET- RICAL SOCIETIES OF LONDON AND EDINBURGH ; HONORARY FELLOW OF THE ROYAL MEDICAL SOCIETY OF ATHENS, GEEECE, ETC., ETC., ETC. NEW YORK: D. APPLETON AND 549 & 551 BROAD\] 1874. EXTEKED, according to Act of Congress, in the year 1874, BT D. APPLETON AND COMPANY, In the Office of the Librarian of Congress, at Washington. PREFACE. FOE nearly twenty years, it has been my duty, as well as my privilege, to give clinical lectures at Bellevue Hospital, on midwifery, the puerperal and the other diseases of women. This volume is made up substan- . tially from phonographic reports of the lectures which I have given on the puerperal diseases. Having had rather exceptional opportunities for the study of these diseases, I have felt it to be an imperative duty to util- ize, so far as lay in my power, the advantages which I have enjoyed for the promotion of science, and, I hope, for the interests of humanity. I therefore have devoted the vacations of the past two summers to the work of selecting, fusing, and making homogeneous, the phonographic reports of my lectures. In many subjects, such as albuminuria, convulsions, thrombosis and embolism, septicaemia and pyaemia, the advance of science has been so rapid as to make it necessary to teach something new every year. Those, therefore, who have formerly listened to my lectures on these subjects, and who now do me the honor to read iv PREFACE. this volume, will not be surprised to find, in many particulars, changes in pathological views, and often in therapeutical teaching, from doctrines "before incul- cated. In describing disease, I have conscientiously aimed " to hold, as 'twere, the mirror up to Nature ; " so that the picture may be recognized at the bedside. The therapeutics of the maladies discussed have received prominent attention ; believing, as I do, that the grand mission of the physician is to relieve suffer- ing, arrest disease, and save life. In entering the room of a puerperal woman, every obstetrician must feel that the responsibility of the happiness of a family, and, it may be, the life of two of its members rest, in a great measure, upon his wis- dom and judgment. This responsibility is multiplied to the clinical teacher by the number of his listeners. Something of this feeling has had an influence in o o deterring me hitherto from publishing my lectures, until the experience of years should give the " courage of my opinions." At the present day, for the first time in the history of the world, the obstetric department seems to be as- suming its proper position, as the highest branch of medicine, if its rank be graded by its importance to society, or by the intellectual culture and ability re- quired, as compared with that demanded of the physi- cian or the surgeon. A man may become eminent as a physician, and yet know very little of obstetrics ; or he may be a successful and distinguished surgeon, and PREFACE. v be quite ignorant of even the rudiments of obstetrics. But no one can be a really able obstetrician, unless lie be both physician and surgeon. And, as the greater includes the less, obstetrics should rank as the highest department of our profession. A growing appreciation of the importance of this department is demonstrated by the organization, within a few years past, of active and most efficient Obstetrical Societies in London, Edinburgh, Dublin, Berlin, Leipsic, New York, Philadelphia, Boston, and Louisville, and also by the publication of journals in the United States and in Europe, specially devoted to obstetrics and gynaecology. The great success and popularity of such works as those by McClintock and Hardy, Johnston and Sinclair, are an evidence that the profession demands information which these works contain. It seems singular that no book has yet appeared, in the English language, to oc- cupy the ground which I have attempted to cover. If this volume meet with a success which can be accepted as proof that it is wanted by the profession, it will un- doubtedly stimulate others to work in the same field, and, in this way, at least, accomplish a positive good. 85 MADISOX AYENUE, KEW YOKE, January, 1874. CONTENTS. LECTUEE I. PUEEPEBAL CONVALESCENCE. What is understood by the term Three periods Some symptoms which interrupt normal convalescence After - pains The lochia Secondary hemorrhage ; from simple relaxation of the uterus; from retention of a part of the pla- centa ; from a coagulum in the cavity of the uterus ; from polypus ; from in- flammatory ulceration of the cervix ; from lacerations ; from partial or com- plete inversion of the uterus ; from premature sexual intercourse ; from malignant disease of the cervix ; from pelvic cellulitis ; from obstinate con- stipation ; from functional disorders of the liver .... Page 1 LECTUEE II. DIET OF PUEEPEEAL WOMEX. The puerperal period does not require an abstemious diet Good, nutritious, easily-digestible food should be taken hi sufficient quantities Many puer- peral disturbances are due to exhaustion and inanition Laxatives Routine practice of giving castor-oil on the third day Castor-oil not to be given when there is a tendency to hemorrhoids Hemorrhoids during gestation The predisposing and exciting causes of Treatment during gestation When they are developed by labor During the puerperal period . . . p. 26 LECTUEE III. LAOEEATIOSS OF THE PEBIXJETIM. Reports of cases It cannot always be prevented Four varieties Causes Liable to occur from certain anatomical peculiarities ; as from a sacrum of less curve than usual ; from the direction of the vulval opening ; from excess of adipose tissue in the perinaeum ; from extreme narrowness of the vulva ; from dis- proportionate size of the head and shoulders ; from certain peculiarities in the mechanism of labor ; from some of the physiological phenomena of the labor ; from unskillful or careless manual or instrumental delivery What "support of the perineum" really means The forceps as a means of pre- vention How anaesthetics may act in preventing this accident Incision, when necessary Method proposed by Dr. Goodell, of Philadelphia . . p. 38 viii CONTENTS. LECTURE IV. THROMBI'S OF THE VULVA AND VAGINA. Case Frequency of occurrence Causes During gestation During labor After Delivery Anatomical seats of the extravasation Symptoms Diagnosis Fatality to mother and child from this cause Causes of death Treat- ment Page 53 LECTURE V. PUERPERAL ALBUMINURIA. Case In a majority of cases of puerperal albuminuria, Bright's disease is not present Meaning of the term Albuminuria and unemia not identical The albumen of the urine in Bright's disease differs from the albumen of puerperal albumiuuria Granular casts not characteristic of any peculiar lesion of the kidney Causes of puerperal albuminuria Symptoms Effect on gestation, parturition, and puerperal convalescence Prognosis Treatment . . p. 65 LECTURE VI. PUERPERAL CONVULSIONS. Case Symptoms characterizing the convulsive paroxysms Prodromic symptoms Sometimes entirely absent Case of the kind occurring some hours after labor Headache the most frequent precursory symptom Impaired vision the most significant (Edema Symptoms which indicate that an attack is imminent Influence of convulsions on gestation, parturition and puerperal convalescence Comparative fatality before and during labor, and after delivery Symptoms on which to base the prognosis Case of recovery from profound and prolonged coma Case of recovery, and eventual recovery from hemiplegia Recovery from convulsions, with permanent aphasia remaining . . . . p. 83 LECTURE VII. PUERPERAL CONVULSIONS. Case Convulsions after labor Ceased after bleeding Urea in the blood, six times the normal amount Recovery, and all signs of renal disturbance absent on the twelfth day after delivery Case Venesection Delivery by forceps Death on the third day after delivery Fatty kidneys Pelvic peritonitis. Case No signs of albuminuria Death Serous effusion in the subarachnoid cav- ities and ventricles of the brain No renal lesion Puerperal convulsions always of the same character Xo reason for classifying them as apoplectic, epileptic, hysterical, etc. Etiology of puerperal convulsions Suggestions made in 1862 before the XewYoik Academy of Medicine Rosenstein's views published in 1863 Dr. J. Brnxton Hicks's paper, before the London Obstetrical Society Frankenhaueser's plates demonstrating the connection between the nerves of the uterus and the renal ganglia Dr. Trier Smith's theory Treatment, before CONTEXTS. i x and during labor After labor The improvement in treatment as shown by comparison of the proportionate mortality at the present time, with that of former periods .......... Pa^e 97 LECTUEE VIII. LACTATION. Condition of the organs of lactation during gestation Milk-fever Prophylaxis Treatment Breasts with excess of adipose tissue, but defective in glandular structure Depressed nipples Erosions and excoriations Fissure or crack Inflammation of the nipple Eczema of the nipple . . . . p. 12Y LECTUEE IX. MASTITIS AND MAMMARY ABSCESS. Mastitis more liable to occur during the early weeks of lactation Literature of the subject Causes of mastitis Anatomical scat Varieties Diagnosis Progno- sis as to duration Influence on lactation Effect on the general health Treat- ment of each variety Mammary abscess sometimes a result of pyaemia, and sometimes one of the eliminative processes in puerperal fever Mammary neu- ralgia ............ p. 140 LECTUEE X. PTTERPEKAL MASIA. Cases Frequency in this hospital Comparative frequency in other hospitals Percentage of insanity in women from this cause The loose use of-the term puerperal mania, including insanity of pregnancy and insanity of lactation Insanity of pregnancy Delirium of labor Illustrative case Insanity of lac- tation Puerperal mania Mania Melancholia The former much the more frequent Symptoms Threatening an attack During the access Complica- tion with latent inflammations Prognosis Duration of the mania Mental and bodily recovery Causes Predisposing Mental emotions the great excit- ing cause Albuminuria not an exciting cause Treatment Leading indica- tions: (1) to restore exhausted nerve-power By nutrition, tonics, sleep Chloral-hydrate The effect of chloral-hydrate and chloroform contrasted (2) to combat all complications Illustrative case Moral treatment Removal to an asylum p. 161 LECTUEE XI. RELAXATION OF THE PELVIC STMPIIYSES. Case Not much referred to by obstetric authors Dr. Snelling's monograph Im- portance of a knowledge of this subject to young practitioners Recent Ger- man and French writers on the subject Scanzoni Debout Stoltz May be developed during pregnancy A certain degree of relaxation physiological r CONTEXTS. As a disease, seen most frequently in the puerperal period Causes Not due to a narrow pelvis More frequently occurs in those having a broad, capacious pelvis Probably due to a mechanical cause, which prevents the return of the venous blood from the tissues involved Symptoms Diagnosis Duration Treatment Inflammation of the pelvic articulations . . . Page 192 LECTURE XII. PHLEGMASIA DOLENS. Case Symptoms Progress Duration Usually terminates by resolution Phleg- monous suppuration sometimes occurs Phlebitis, a secondary phenomenon of this disease Suppurative phlebitis, very rare, and generally fatal Sometimes terminates in embolism of the pulmonary arteries and speedy death Gangrene, an exceedingly rare termination Former doctrines as to the pathological na- ture of this disease The discovery of Professor Davis, that the femoral and iliac veins were obstructed by clots Theory that the disease is primarily a crural phlebitis The theory of Dr. Robert Lee, that the phlebitis originates in the veins of the uterus Phlegmasia dolens not peculiar to the female sex, or to the puerperal state Frequent, in association with cancer, and occurs occa- sionally in many other diseases Inopexia, a condition of the puerperal state, as well as of all diseases in which phlegmasia dolens occurs Thrombosis, meaning of Doctrines of the most recent authors on this disease Hervieux Mackenzie Simpson Tilbury Fox Objections to the doctrines of each Case of crural phlebitis terminating fatally, in which there was no phlegmasia dolens A second case, in which phlegmasia dolens was absent Thrombosis does not generally produce phlegmasia dolens Is not the thrombosis an effect instead of a cause of phlegmasia dolens ? Treatment . . p. 217 LECTURE XIII. PUERPERAL THROMBOSIS AXD EMBOLISM. Case Meaning of the terms thrombosis and embolism Dr. Robert Barnes's pa- per and tables Arterial thrombosis The great pathological discovery by Virchow Causes of arterial thrombosis Symptoms of arterial thrombosis: ( So. Potass, sup. tart., Sulphur sublim., Mix thoroughly. S. From a teaspoonful to a tablespoonful of the powder in a wine-glass of sugar and water before eating in the morning. This powder produces a soft evacuation, without pain, even when the hemorrhoids are inflamed. By procuring a daily evacuation with this powder, and the use of the ointment before mentioned, I have found the hemorrhoids in puerperal women soon cease to give trouble. LECTUKE III. LACEKATIONS OF THE PEEINJEUM. Reports of cases It cannot always be prevented Four varieties Causes Liable to occur from certain anatomical peculiarities ; as from a sacrum of less curve than usual ; from the direction of the vulval opening ; from excess of adipose tissue in the perinaeum; from extreme narrowness of the vulva; from dis- proportionate size of the bead and shoulders ; from certain peculiarities in the mechanism of labor ; from some of the physiological phenomena of the labor ; from unskillful or careless manual or instrumental delivery What "support of the perinaeum" really means The forcep3 as a means of pre- vention How anaesthetics may act in preventing this accident Incision, when necessary Method proposed by Dr. Goodell, of Philadelphia. "CASE I. 1 Primipara, aged twenty-six. The labor presented nothing unusual, the child, a female, weighing eight pounds and three-quarters, being born in about eight hours after labor com- menced. The vertex presented in the right occipito-posterior posi- tion, and the occiput, instead of rotating under the pubes, passed into the hollow of the sacrum. The labor, however, progressed favorably, and the head soon appeared at the vulva. The perinzeum was then carefully supported, and, as soon as the head was born, pressure was made on the uterus, and kept up during the delivery of the body of the child, and afterward, to secure permanent con- traction of the uterus. The cord having been tied and cut, and the child removed, the perinaeum was examined, and found to be lacer- ated to the extent of about an inch. It was noticed that there was some hemorrhage, but it was thought that it would cease on the re- moval of the placenta. This was easily accomplished in a few min- 1 Cases reported by Chas. H. Snydam, M. D., house-physician to Belle- vue Hospital. LACERATIONS OF THE PERIX^EUM. 39 utes ; but, as the bleeding continued, particular attention was given to the uterus, upon which steady, firm pressure had been kept up from the time of the delivery of the child's head, and the uterus was found to be firmly contracted. Remembering then a case which I had seen some weeks before, in which, although the uterus was firmly contracted, severe haemorrhage had occurred, and Professor Barker found that the bleeding was from lacerated vessels in the perinoeum, I concluded that the present was a similar case. I there- fore at once endeavored to arrest the haemorrhage by sponging away the blood and clots, so as to discover the source of the bleed- ing, which, I should have stated, did not come on in a profuse and general flow, as if it were from several points at once, but in a steady, continuous jet, about as large as a small quill. I then passed two fingers into the vagina, and, with the thumb externally, I firmly compressed the lacerated edges of the perinseum. This at- tempt was not at first successful in arresting the haemorrhage ; but, after changing the position of my fingers several times, I succeeded in arresting any further flow ; and, when, after an hour and a quar- ter's continuous pressure I gradually withdrew my hand from the vagina, it was .not followed by any bleeding. Firm pressure was kept up by my assistant upon the uterus during the whole time, but it showed no disposition to relax. The patient's knees were then tied together, a full opiate was given, and she was directed to remain perfectly quiet, and a nurse was left by her side to enforce my directions, and to send at once for aid should the hemorrhage recur. It did not, however, and the patient made a very good recovery, adhesion taking place kindly. The amount of blood lost was estimated at rather more than a quart." " CASE II. occurred in a w r oman, aged twenty-six, who was de- livered of her second child, after a labor lasting about nine hours. The child was a female, weighing nine pounds and three-quarters, the presentation, left occipito-anterior. There was, in this case, the same series of events as in the one just described the firm pressure on the uterus after the delivery of the child's head, the permanent contraction of the uterus, and the rapid delivery of the placenta, and hemorrhage, continuing, notwithstanding that the uterus was ' well contracted. The amount of blood lost could not be accurately determined, but it was very considerable ; and the veins of the labia and thighs, which were varicose, were decidedly less prominent when the hemorrhage was arrested than when it began. The bleeding was stopped by the same means as in the first case, and PUERPERAL DISEASES. the patient recovered well. The perinaeum in this case, too, was supported during the passage of the child, but the laceration was not so extensive as in the former case. " CASE III. was in a primipara, aged thirty-three ; the labor last- ing ten hours ; vertex presentation, left occipito-anterior position ; the child, a girl, weighing seven and a quarter pounds. The case was in all respects similar to the last there was hemorrhage from the lacerated vessels of the perinjeum, which was arrested in the same way. This woman, too, recovered well. " CASE IV. Primipara, aged seventeen ; left occipito-anterior position ; the labor lasting fourteen hours ; the child, a male, weigh- ing nine pounds. In this case, the perimeum was not supported, as the child was born when I was not with the patient, and the lacera- tion was much more extensive, reaching to within half an inch of the anus. The hemorrhage, also, was much more severe than in the other cases, amounting, as it was judged, to nearly two quarts. Press- ure, moreover, failed to arrest it, and it was only stopped, after it had continued some time, by packing the vagina with ice, and retain- ing it by a compress. As an illustration of the force of the flow, I may mention that, as I withdrew my hand, after finding pressure would not arrest it, probably because I could not succeed in finding the bleeding vessels, a jet of blood escaped with such force as to strike the patient's knee, she being on her back with the legs ex- tended. The recovery of this patient was not so rapid as that of the others, probably owing chiefly to mental causes. Nothing se- rious, however, interrupted her convalescence, and she soon regained her natural color. In all the cases, the knees were tied together, the bowels were kept quiet by opium, and the lacerations united kindly." Gentlemen : Laceration of the perinseum is an acci- dent of parturition which has occurred in the practice of the best obstetricians, and cannot always be prevented ; but I believe that a thorough appreciation of the condi- tions under which it is liable to happen, and a judicious and timely use of means appropriate to each special con- dition, to avert the danger, will render the accident a very rare one. We have no statistics from which we can learn either its comparative frequency, or the success of LACERATIONS OF THE PERINEUM. 41 any measure in preventing its occurrence. There is no doubt that the anterior border of the perinseum, or four- chette, is generally lacerated in prirnipara. The late Dr. Williams, of Manhattanville, who was obstetric physi- cian to the Emigrants' Hospital, Ward's Island, asserted that a visual examination would show that, in first la- bors, the mucous fold, called the fourchette, was always lacerated ; and, to satisfy myself on this point, I went with him to Ward's Island, on three different occasions. We carefully inspected these parts in sixty-two primi- para3, and I must say that, in every one, this mucous fold was found to be torn, but, in thirty-seven, there was no laceration of the other tissues of the perinaeum. If we study the anatomical structure of the peri- nseum, and recall the enormous distention to which it is subjected during the last stage of labor, we can but wonder why serious laceration of its tissues does not occur more frequently. The perineum is the space be- tween the anus and the lower border of the vulva, and consists of skin, fascia, adipose tissue, nerves, blood-ves- sels, and muscular fibre. The muscles found here are : the constrictor vaginae, the sphincter ani, the ischio-caver- nosus, and the transversal is perinei, all of which meet and have a common insertion at the centre of the peri- neum. The length of the perineum is ordinarily from an inch to an inch and a quarter or an inch and a half, but its tissues are so distensible that, when put on a stretch during labor, it will frequently measure from four to five inches. After parturition, it is some ten or twelve days before it contracts to its normal length. "This should be remembered, for reasons which I shall allude to hereafter. Mr. Baker Brown, in his work on the surgical dis- eases of women, divides laceration of the perineum. 42 PUERPERAL DISEASES. into four varieties : 1. That in which the perinaeum is torn to the extent of an inch or less from the fourchette. This degree of injury is of no great moment, is little marked when the parts return to their normal state, and requires no special treatment. 2. Where the perinaeum is torn between the constrictor vaginae and sphincter ani, those muscles remaining intact. This is actually a perforation, and quite a number of cases have been pub- lished in which the child has been delivered through this accidental opening. 3. Where the laceration occu- pies the entire length of the periiiseum, but does not in- volve the sphincter ani. 4. Where it extends so as to divide the sphincter ani, and even the recto-vaginal sep- tuin. In one case that I saw, there was laceration of the recto- vaginal septum, and at least some of the fibres of the sphincter ani, while the remaining anterior por- tion of the perinseum was preserved. In November, 1857, I was called in consultation by a physician of this city, to see a lady twenty-one years of age, who had been in labor with her first child twenty-six hours. I found the perinaeum enormously distended by the press- ure of the head, and the left hand and forearm project- ing through the anus. The doctor *informed me that O O the head had been pressing on the perinaeum for some hours, and the pains were so regular and so violent that, with each pain, he had confidently looked for the exit of the head from the vulva. But just before sending for me, the hand and arm suddenly appeared through the anus, after which the pains had ceased. After some consultation, it was decided that we should not attempt to replace the arm, but leave it alone, and that I should attempt to deliver the head by the forceps. With great care, I succeeded in doing this with very moderate trac- tion, the handles of the forceps being directed upward LACERATIONS OF THE PERItfJSU}!. 43 at an acute angle from the plane of the abdomen of the mother. For some ten days, the "bowels of this patient were kept closed by opium, and complete cicatrization followed, the only interruption to normal convalescence being that the catheter was required to empty the blad- der for nearly three weeks. It is the province of the obstetrician much more fre- 'quently to prevent this accident than to cure the patient after it has occurred. To be able successfully and skill- fully to do this, it is absolutely essential that the condi- ^tions which are likely to produce it should be thorough- ly appreciated. We may, perhaps, give a more clear conception of these conditions by classifying them as follows : 1. Certain anatomical conformations of the maternal organization are peculiarly liable to this accident, as () a very straight sacrum. Now and then you will meet with a woman in whom the sacrum has little if any more curvature than is ordinarily found in the sa- crum of the male. This is the case with the woman whom I have shown you in the wards, with complete procidentia uteri. The perinseum was lacerated in a labor some years ago, and the posterior border of the vulval opening is not three lines from the anus, and on examination we found that the sacrum was remarkably straight. In such a pelvis, the effect of the uterine con- tractions is to drive the head directly down upon the perinaeuni in a line nearly parallel with the axis of the superior strait. (&.) The direction of the vulval open- ing differs very greatly in different women. I am not aware that any author lias alluded to this, but your own future experience will surely verify the truth of the assertion. In some, the ostium vaginae is nearly parallel with the plane of the trunk, while in others, it 44 PUERPERAL DISEASES. is nearly at right angles with this plane, or, to put the statement in other words, in some, the direction of the vaginal canal is nearly parallel with the axis of the pelvic cavity, while in others, it more nearly corre- sponds with the axis of the outlet. This difference does not depend entirely, as you may at first suppose, upon the length of the perinseum, nor upon the straightness or curvature of the sacrum, but a careful study of the subject has led me to the belief that it is due more to the conformation of the soft structures within the pel- vic cavity. You can readily understand how rupture or laceration of the perinaeum is much more liable to occur, where one condition exists, than where the other is present. You can also see the bearing of this anatomi- cal fact, if you admit it to be an anatomical fact, upon the necessity in some cases, and the proper mode in dif- ferent cases, of supporting the perinaeum. (r? r^ j.^ ^^3 m ^3 O r ^ o i. W o ' .H ;s .2 'S !5 -2 S 525" EH O H - 10 P ^ o 1 Z- 1 t: 1 t: 1 C- ^f* % m o EH W cT ^eT.ijarJjo'iJcr c3O P d a to < EH 5 fllO . 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Case Meaning of the terms thrombosis and embolism Dr. Robert Barnes's pa- per and tables Arterial thrombosis The great pathological discovery by Virchow Causes of arterial thrombosis Symptoms of arterial thrombosis : (a) absence of arterial pulsation below the thrombus ; (6) sometimes increased force of pulsation above the thrombus ; (c) pain below the seat of the throm- bus ; (d) coldness of the limb ; (e) paralysis Difference between this and nervous and cerebral paralysis Prognosis Case of probable arterial throm- bosis Thrombosis of the pulmonary artery Causes : () more frequently (?) due to an embolus ; (6) spontaneous ; (c) secondary to a lesion of the paren- chyma of the lungs ; (d) arteritis Diagnosis between spontaneous thrombosis and embolism Theory of Dr. Playfair, that the date after delivery may deter- mine the question whether the thrombosis be spontaneous or be due to em- bolism Symptoms of thrombosis or embolism of the pulmonary artery Ter- minations Probable case of, and recovery How embolism of the pulmonary artery causes asphyxia Embolism of the minute branches, frequently a cause of puerperal pneumonia Treatment Cerebral embolism Cases Diagnosis and symptoms. " CASE XVII. 1 Margaret Regenberger ; born in Germany ; age unknown. Was brought into the hospital by the police, and found to be in labor. She speaks English very imperfectly, and no satis- factory previous history could be obtained. The membranes were ruptured, and the head, R. O. A. position, was in the cavity, but not pressing on the perinasum. Pulse 120. There were but slight mani- festations of labor-pains. An ounce of whiskey was given to her, and she also took, with apparent relish, nearly a pint of beef-soup. After this, she slept for about four hours, with occasionally some ap- pearance of labor-pains. Her pulse now seemed to be growing more feeble, and a second examination was made, when it was found that 1 Eeported by Walter Judson, M. D., house-physician to Bellevue Hospital. 24:8 PUERPERAL DISEASES. no change in the position of the head had taken place. The cathe- ter was passed, and twenty-six ounces of very offensive urine were drawn oif. Tested by heat and nitric acid, no albumen was precipi- tated. Specific gravity 1028. Immediately after the bladder was emptied, strong pains came on, which were almost continuous, and in twenty minutes a still-born child was expelled. Weight eight pounds and four ounces. All efforts to establish respiration in the child, which were kept up fully an hour, proved fruitless. The pla- centa followed in ten minutes after the expulsion of the child, and the uterus contracted readily and firmly. The whole amount of blood lost at the time of labor could not have exceeded two ounces. One hour after labor, the patient was found sleeping. The uterus was well contracted and firm, and the napkin, but moderately stained with blood. Pulse 104, and much stronger ; temperature 99. " December Sth. Was called to see the patient at 5 A. M., eleven hours after the labor, on account of very violent hemorrhage. The bed \vas literally flooded. The uterus was very large and soft, and pressure expelled a large mass of clots. Pulse very rapid and feeble, respiration hurried and catching. By application of lumps of ice in the vagina and pressure on the uterus, the hemorrhage was at once arrested and the uterus contracted down. Two drachms of ergot in a half-ounce of whiskey were at once administered, and the patient was carefully watched for hours, to see that the uterus remained firmly contracted. At 1^ p. M., she was seen for the first time by Dr. Barker. The pulse was now 120, respiration 32, temperature 99. The manner of the patient was peculiarly nervous and excited. A full opiate was ordered, and the frequent administration of whiskey and beef-soup in small quantities. But, before any thing could be given or Dr. Barker had even left the ward, she was seized with most violent convulsions, and she had three, with only short inter- vals of a minute or two between each. Dr. Barker now ordered an hypodermic injection of twelve drops of the solution of morphia (sulphate of morphia grs. xvj, water 3 j). She had no recurrence of the convulsions after the hypodermic injection. The patient slept most of the time for the twenty-four hours following, but was easily roused to take beef-soup and whiskey. "December 9th. Pulse 120; respiration 18 ; temperature 102. " December IQth. Pulse 112 ; respiration 28 ; temperature 101. "December llth. Pulse 108 ; respiration 24 ; temperature 100. " December 12th. Pulse 100 ; respiration 24 ; temperature 100. " December 13th. Pulse 88; respiration 24 ; temperature 100. PUERPERAL THROMBOSIS AND EMBOLISM. 249 "December 14^/t. Pulse 96; respiration 24 ; temperature 99.5. "December 15th. Pulse 84; respiration 24 ; temperature 99. "December 16t7i. Pulse 84; respiration 24 ; temperature 99. " During the above periods the patient appeared to be rapidly con- valescing. The bowels moved naturally. The urine was normal in appearance and quantity, and was several times examined for albu- men and casts, with negative results. No secretion of milk could ever be detected in the breasts. " December 22(7. Patient in the convalescent ward. She com- plains of severe pain in the abdomen, which is very tympanitic and sensitive to pressure, and also of pain in the left thigh. The attack appears to have come on very suddenly, after some disagree- ment with another German patient in the ward. As she had al- ways exhibited a peculiar temper since her admission to the hospi- ial, the attack was supposed to be hysterical, associated, perhaps, with intestinal irritation, as, on vaginal examination, the rectum was felt to be filled with hardened faeces. Turpentine-stupes were laid upon the abdomen, and the following pills were ordered : ]J. Hydrarg. chlorid. mit., gr. v. Pulv. aloes soc., gr. iij. Ext. hyoscyami, gr. ij. Ipecac., . gr. j. M. ft. pill. No. 3, to be taken at once. Evening : The cathartic had operated freely and the tympanites and abdominal pain had nearly gone, but she still complains of severe pain in the left thigh. Hy- podermic injection in the thigh of eight drops of the solution of morphia. " December 23(7. Patient slept well. She complains of no pain in the abdomen, but is unwilling to have the hand placed upon it. Says that she has no pain in the thigh, but she keeps the knee bent, and says that she cannot move it. On examination, there is no tenderness on pressure anywhere in one leg more than in the other, nor can any swelling be detected by the eye ; but, on measur- ing with a piece of tape three inches above the knee, the left leg is found to be a full half-inch larger than the other. Measurements be- low the knee are precisely the same at all points in both legs. Urine examined, and no albumen found. Pulse 108. Her manner is ner- vous and hysterical, and the following prescription was ordered: IJ. Tine, hyoscyami, Tine, valerian, ammon., a a, 3 j. M. S. A teaspoonful in syrup and water every third hour. 250 PUERPERAL DISEASES. " December 2th. Patient sitting up by the side of her bed and says she is well. Asks to go out of the hospital to-morrow ' be- cause it is Christmas.' But, as in walking she is evidently lame, although she denies that she has any pain, both legs were again carefully examined, with precisely the same result as yesterday. She was persuaded to remain in the hospital until her month was up. " December 3Qth. Since last date, patient has been apparently doing well in every respect, until to-day. Lameness had entirely disappeared. I was hastily summoned to the ward, and found her lying upon the floor, and breathing with great difficulty. Pulse could be scarcely felt at the wrist. Impulse of the heart very weak. Countenance very anxious, with the appearance of immediate dis- solution. She was lifted upon her bed, and whiskey, and, soon as it could be procured, carbonate of ammonia were given, and an improve-, ment was soon manifest. But her pulse remained quick and feeble and her breathing, hurried, although she complained of no pain any- where. " December 31st. Patient was again seen and carefully examined by Dr. Barker. Pulse 124 ; respiration 32 ; temperature 97. Aus- cultation furnished only negative signs, except that the heart-im- pulse was feeble, with a slight tendency to intermission. It was ascertained that she had passed no water since her attack yesterday afternoon, nineteen hours. With some difficulty, she was persuaded to permit the catheter to be passed, and six ounces of thick, muddy urine were drawn off, and, on applying heat and nitric acid, nearly one-half in the tube solidified. Dr. Barker ordered eight dry cups to be applied ever each kidney, and the following prescription : $. Potas. citrat., j. Aq. pura?, 3 vij. Syr. simp., 3 j. Tine, digitalis, 3 jss. M. S. A tablespoonful every third hour. "Suspecting cardiac thrombosis, Dr. Barker strictly enjoined that she should not get out of bed, and sent for one of the staff, who speaks German, to make her fully understand this order. " January 1st. Patient obstinately refused to permit the appli- cation of the cups, and exhibited so much excitement in regard to it, that it was thought best not to insist. Pulse 120 ; respiration 32 ; temperature 97. Has passed, in a bed-pan, during the last twenty- four hours, fourteen ounces of highly-albuminous urine. She very PUEEPEEAL THROMBOSIS AND EMBOLISM. 251 strongly objects to the use of the bed-pan. The same treatment continued. " January 2d. Pulse 112; respiration 30; temperature 99.5. Passed twenty-four ounces of urine. Patient very unwilling to stay in bed. She has always been very difficult to control. " January 3d. Pulse 112 ; respiration 30 ; temperature 99. Passed thirty ounces of water ; proportion of albumen diminished more than one-half. She insists that she is well, and wishes to leave the hospital. During the succeeding night, the patients in the ward were awakened by a noise, and this woman was found lying by the door of the water-closet. I was immediately summoned, but she died almost immediately after I entered the ward.. " Autopsy, fourteen hours after death. Lungs, apparently em- physematous anteriorly and congested posteriorly. Heart, right .auricle and ventricle filled with dark, non-adherent coagula. Pul- monary arteries contained fibrinous coagula slightly adherent to the coats of the vessels. These coagula did not extend to the smaller branches. Liver normal. Spleen, seemed smaller and somewhat paler than natural. Both kidneys were highly congested, the left being more so and decidedly larger than the right. The vena cava contained a fibrinous clot which obstructed both renal veins, but was easily detached from the coats of the vessels, which seemed perfectly healthy. In the left femoral vein, there was also a pale, firm coagulum, more strongly adherent than that in the vena cava. No coagula could be found in the iliac veins. The uterus was somewhat large, but showed no evidence of disease, either in its veins or its lining membrane. The other pelvic organs and the peritonaeum healthy. No pathological lesions were found in the brain or its meninges. Spinal cord not examined." Gentlemen : The circulation of the blood is so uni- versally known to every one of common intelligence, and the knowledge of this is acquired so early in life, that it seems to us an ordinary, elementary fact ; and it is only when we consider at how late a period in the history of the world this fact was first made known, that we can appreciate the immense discovery of the immortal Harvey. I suppose that coagula and fibrinous clots have been 252 PUERPERAL DISEASES. observed in the heart and blood-vessels, at post-mortem examinations, thousands of times since this discovery, without any special significance being attached to the observation, until within a very recent ^period. It is true, as Dr. B. W. Richardson has shown in his paper " On the Cause of the Coagulation of the Blood," that many of our eminent predecessors, as Vesalius, Morsjagni, Gould, Burserius, Brown, Cullen, Huxham, O O / ' ' * ' ' and others, had observed these coagula, and , theor- ized as to the cause of their production. Dr. Ben- jamin Ball, of Paris, in his very able thesis " On Pul- monary Embolism," published in Paris, 1862, has re- called the fact which had been generally forgotten, that Van Swieten, who wrote more than one hundred and twenty-five years ago, had frequently .referred to this lesion, and comprehended it, and that he regarded the prognosis as very grave, when coagulation took place in the veins, and the clots were carried by the circulation into the pulmonary arteries. He also de- monstrated, by experiments on dogs, that this coagu- lation may be produced by injecting acids into the veins, and the phenomena which he describes as result- ing from these experiments are precisely the same as those we now understand to result from thrombosis of the right cavities of the heart, or embolism of the pul- monary arteries. Still, these facts which had been known in science, were practically buried in the past. Our distinguished American obstetrician, the late Professor Meigs, through the unfortunate bias of a preconceived theory, just es- caped the honor, which is now, and will hereafter be given, to the eminent Virchow, of Berlin, of a great pathological discovery. Dr. Meigs was essentially a solidist ; and, while he jt ^ERPEKAL THROMBOSIS AND EMBOLISM. 253 was one of the earliest to report cases where the circu- lation was arrested by coagula in the right cavities of the heart and the pulmonary arteries, and, at the same time, while he fully appreciated the pathological significance of the facts, he believed that the primary lesion which produced this result was in the lining membrane of the veins, or, to use his favorite term, in the endangium. His theory was, that this membrane contained or transmitted that nerve-power by induction which is essential to the formation and preservation of the blood in a living state in short, that the endangium was the blood-making tissue. But, at the time he wrote, phys- iological science had advanced, some steps beyond his knowledge, and, consequently, the doctrines of the day were beginning to change clinical facts received new interpretations, and the earnest, enthusiastic, and some- times eloquent writing of Dr. Meigs on this subject made little impression on the medical mind. It rarely if ever occurs that one mind can grasp the full development of new truths in science ; and we shall see, in discussing this subject, that even the great Vir- chow generalized beyond the point at which he could be supported by more numerous and complete observations. ' Let me stop here to define the meaning of terms, which I shall have frequent occasion 'to use, because I observe that some writers use these terms loosely, and thus confuse the ideas which they are seeking to ex- press. I have noticed that one writer proposes to re- strict the term thrombosis to obstruction of the veins by coagula, and embolism to obstruction of the arteries by coagula or any foreign substance. . It seems to me absurd to seek to attain precision of language by this purely arbitrary use of terms. 254: PUERPERAL DISEASES. You already understand by thrombosis, the arrest of circulation by coagulation in any of the vessels, whether it be the arteries, veins, or lymphatics, and so we have arterial thrombosis, venous thrombosis, and lymphatic thrombosis. Now, if you bear in mind the etymological derivation of embolism, you will avoid all confusion in the use of these terms. The Greek word e/i/3o\o? signifies something inserted, as a wedge something blocking up. If a fragment of clot in a vein become detached, and be carried by the circulation up to the heart, and thence to a branch of the pulmonary artery which is too small to permit it to pass on, this stops the current of blood, and constitutes embolism of that artery. If an excrescence be detached from one of the aortic valves, and be carried into the arte- rial circulation, when it reaches an artery of too small a calibre to permit it to pass on, there is embolism at the point where the circulation is arrested. It may be small enough to be carried on to a capillary vessel, and then we have capillary embolism. Thus you see that an embolism implies that the blocking agent, whether it be a detached fragment of coagulum, a valvular ex- crescence, a pus-globule, or any foreign substance, has been transported from some other point in the circula- tion. Furthermore, it is obvious that the eniboli, or blocking agents, if in the veins, are always carried tow- ard the heart ; but, if in the arteries (excepting, of course, the pulmonary arteries), they are always car- ried from the heart. You see that this subject opens up a wide domain in general pathology, but my remarks must be restrict- ed to its relations to the puerperal state ; and you will perhaps best remember and comprehend the points to which I especially wish to call your attention, if I PUERPERAL THROMBOSIS AND EMBOLISM. 255 speak of them in tlie systematic order of pathological anatomy. Arterial Thrombosis. To the late Sir James Simp- son, all must give the credit of writing, in 1854, the first essay on this, as a lesion of the puerperal state; and this has always struck me as one of the most able and origi- nal of all his numerous contributions to medical science. Since this essay was published, many writers have re- ported cases confirming the observations of Professor Simpson, and, in the fourth volume of the Transactions of the London Obstetrical Society, you will find a paper by Dr. Kobert Barnes, probably more valuable than any which has yet appeared, for its analysis of the antecedent conditions, the symptoms, and the post- mortem results of this lesion. Thrombosis may occur, as a lesion of the puerperal period, in any part of the arterial system. Cases have been reported, where one or more arteries of the lower extremities have been found blocked up by coagula. In other cases, the thrombus was in the aortic or iliac or other arteries of the trunk, and in others, again, the lesion was found in one or more arteries of the upper extremities or in the brain. The number of cases reported of this lesion in the trunk and extremities is as yet very small. As a puer- peral accident, I have seen but one in which I sus- pected its existence, and, in this instance, the subse- quent entire recovery of the patient rendered it im- possible for me to be certain of the correctness of my diagnosis. I can therefore only give you such a summary of its causes, symptoms, and prognosis, as I have gathered from the writings of others on this subject. Causes. -There is no doubt that, in a large majority 256 PUERPERAL DISEASES. of cases, arterial thrombosis is the result of an embolus, the original seat of which was the heart. (1.) The embolus is, in some cases, a detached portion of a valvular excrescence which has been washed away and carried into the arterial circulation, for the nucleus of the embolus, around which concentric layers of fibrine have been deposited, has been shown by the micro- scope to be exactly like the vegetations which were at- tached to the aortic or mitral valves. In several in- stances where this condition has been found, it was known that the patients had previously suffered from rheumatism and endocarditis. (2.) In other cases, there seem to be good reasons for believing that the embolus was a clot which had origi- nally formed in the left cavity of the heart and was carried into the circulation. The argument in favor of this view is based not only on the negative evidence, that sometimes nothing has been found in the thrombus except a fibrinous nucleus, and that the valves of the heart were free from disease, but also on the positive evidence, that fibrinous polypi have been found in the left cavities, and that the symptoms of cardiac distress have preceded the signs of local obstruction. I have before referred to inopexia, as a condition peculiarly liable to exist in the puerperal period, and I concur also in the opinion of Dr. Barnes and of Hervieux, that this may be rapidly developed by some puerperal toxaemia. It is known that arterial thrombosis is sometimes the result of that exceedingly rare . disease, arteritis, which itself is never a primary lesion, but is always secondary to pathological changes in contiguous tissues or to puerperal toxaemia. Symptoms. The symptoms of this lesion, which PTJERPEEAL THROMBOSIS AND EMBOLISM. 257 were observed by Simpson and others who have re- ported cases, and which are enumerated in the table of cases published by Dr. Barnes, are chiefly the following : (1.) Absence of pulsation in the artery below the point of the thrombus. Most of us are in the habit of examining only the radial pulse, but, when severe neuralgic pains occur in the track of an artery of either an upper or lower limb, and there is an absence of all signs of local inflammation, it is incumbent upon us to examine the pulsation of the artery at all accessible points. In some cases, the force of the pulsations above the point of the thrombus is greatly increased, but this by no means appears to be a uniform symptom, as its absence has been sometimes specially noted. (2.) Pain in points below the seat of the thrombus is mentioned in nearly every case. It is described as " very severe," " excruciating," " neuralgic," or " rheu- matic." It seems generally to subside, after a period of more or less duration, but it persists in some cases, and is the most prominent and striking of all the symp- toms. (3.) Coldness of the limb, as compared with the one not affected, is another very marked symptom. This is not always noticed by the patient, who sometimes even complains of heat in the part affected, but the difference in temperature is very perceptible to the hand of the physician. (4.) If the arterial obstruction be sudden and com- plete, there is, for a period, varying in duration in pro- portion to the importance of the artery affected, com- plete paralysis of the nerves of motion and sensation, to which there succeeds only diminished mobility and impaired and perverted sensation. M. Hervieux very clearly points out the characteristic differences between IV 258 PUERPERAL DISEASES. paralysis due to arterial thrombosis, and nervous and cerebral paralysis. There is no special modification of the pulse in nervous and cerebral paralysis, but, when the artery is obliterated, there is no pulsation. The temperature of the part affected is habitually depressed in arterial thrombosis it remains normal in nervous and cerebral paralysis. The paralysis from arterial thrombosis is frequently followed by gangrene, but this result is not common in other varieties of paralysis. (5.) Several cases have been published, in which gangrene of the extremity has followed the arrest of the arterial current. Gangrene is a very important symptom of this lesion, if associated with other of the prominent signs, but it must be remembered that gan- grene in the puerperal woman is not unfrequently a result of toxseniic causes, as we have repeatedly seen, in this hospital, gangrene of the uterus, of the vulva, of the sacrum, or of the mamma. In some instances of gangrene from arterial thrombosis, the affected limb has been amputated, and the patient has recovered. Prognosis. Arterial thrombosis is a lesion of great danger, both to life and limb ; but it has been demon- strated that a considerable number of cases have re- covered. It is therefore manifestly important that we should be able to appreciate the conditions which should govern our prognosis. The more complete the obliteration, the more seri- ously is the organ, which derives its nutrition from the artery implicated, threatened as to its functions and vitality. As a law, subject to certain modifications re- ferable to the condition of the general system, we may say that the greater the size and importance of the artery which is blocked up, the greater the danger in- volved in the thrombosis ; as, for example, thrombosis PUERPERAL THROMBOSIS AND EMBOLISM. 259 of an artery in the foot is less serious than thrombosis of the tibial artery, thrombosis of the latter is less dangerous than that of the femoral artery, and so on. When the thrombosis involves one of the cerebral arteries, the prognosis must be based upon the evidence furnished by the functions of the brain, which are dis- turbed by the lesion. The more essential the organ is to life, the greater the danger from the obliteration of its nutritive artery. Paralysis, if complete and persistent, and more espe- cially if followed by gangrene, certainly involves the loss of the limb affected, and very generally a fatal re- sult is to be anticipated. If, however, this be wholly a local affection, and not associated with severe constitu- tional disturbance, there are reasonable grounds for hope. The prognosis must always be grave, when the signs and symptoms are conclusive, that the thrombosis is the result of a cardiac embolus. I have seen several cases of this lesion, but, as I be- fore remarked, only one, connected with the puerperal period. As this case is unique in my experience and somewhat curious, I shall give its history in detail : " CASE XVIII. Mrs. , twenty years of age, was confined with her first child on the 28th of April, 1860. Three weeks before, she had rather a severe attack of measles, but, with the exception of a cough, she had quite recovered before her accouchement. With this exception, she had never been confined to her room a day by illness, since her infancy. Her labor and subsequent conva- lescence were in every respect normal. " At midnight, May 22d, I was summoned to see her, on account of a most excruciating pain in the foot, more especially in the heel. I think that I never saw the appearance of greater agony, which was the more striking, as she had borne severe labor-pains without an anaesthetic, and without a groan. But now she was constantly 260 PUERPERAL DISEASES. reiterating : * Give me something to relieve me, or kill me at once.' Her pulse was somewhat excited, but indicated no grave constitu- tional shock. She was as fearful of having her foot touched as I ever saw one in the most severe paroxysm of gout. But the foot seemed entirely free from swelling and redness. In short, she had no other symptom, except intense local pain, nor was there any symp- tom preceding the attack. She had taken a drive the previous af- ternoon for the first time, without feeling in the least fatigued, had eaten a hearty dinner, and retired to bed at ten. The pain in the heel came on suddenly about eleven, and, as I subsequently learned from her husband, immediately after sexual connection, which he had indulged in for the first time after her accouchement. " I at once injected into the calf of the leg, ten drops of the so- lution of the muriate of morphia (sixteen grains to the ounce of water). After waiting a half-hour, and finding that the morphia had made no impression, I again injected fifteen drops, and the same quantity again after the lapse of an hour. The last geemed to have some effect. I remained an hour longer, fearing that the large quantity of morphia introduced into the system might produce narcotism ; but, as she slept lightly, often wakening to complain of pain, I now left her. At 5 A. M., I was again called, and found her suffering nearly the same as when I first saw her. Fifteen drops of the solution were again injected, and this was repeated in a half- hour, when she fell into a sound sleep. " At 9 A. M., I again saV her. The pain had returned with miti- gated severity, so that I was now able to examine the foot with great care. She declared that it was impossible to flex the ankle or the toes. This foot seemed decidedly colder than the other to my hand, although her sensation was that it was warmer. I could detect no pulsation in the tibial artery, while, in the other leg, the pulsation was very distinct. I could perceive no increase of force in the arterial pulsation at the popliteal space, or in the femoral artery. " I now accepted with great pleasure the proposal for consul- tation with one of our most prominent surgeons, and met him at half-past one that afternoon. The pain in the heel and foot had , then returned, but with much less intensity than before. My friend, the surgeon, was disposed to regard the phenomena as due to hysteria, and spoke of the wonderful tolerance of morphia as an evidence of this. But, on calling his attention to the difference of temperature between the two feet, and asking him to feel the pul- PUERPERAL THROMBOSIS AND EMBOLISM. 201 sation of the posterior tibial artery, he was greatly surprised to find that he could detect none. When I suggested the probability of arterial thrombosis, he objected that there were no signs of arteritis. He was evidently unaware that this lesion is much more frequently due to embolism. " The pain gradually disappeared, and, on the following day, she could flex her toes. On the fourth day after the attack, I was able to detect a feeble pulsation in the artery, and, in two weeks, my pa- tient seemed to have entirely recovered." I will add that this patient liad plilegmasia dolens of the same leg after the birth of her third child. Thrombosis and Embolism of the Pulmonary Ar- teries and of the Hight Cavities of the Heart. These are lesions which undoubtedly occur much more frequently in puerperal women than arterial thrombosis and embo- lism. In a former lecture, I have referred to hyperi- nosis and inopexia, as a condition of the blood in the latter months of gestation and for a certain period after delivery. Venous thrombosis has long been recognized as one of the frequent lesions of the puerperal period, but to Yirchow belongs the honor of having established O O the fact in medical science that a portion of a venous clot may be detached and carried into the circulation, and cause sudden death by its arrest in the pulmonary artery. From autopsical examinations, and from the results of a series of experiments, Virchow arrived at the conclusion that thrombosis of the pulmonary artery was always due to embolism, except in the veiy rare cases where it resulted from lesion of the parenchyma of the lungs, or from disease of the artery itself. But more recent observations have demonstrated that clots may form, both in the pulmonary artery, and in the right cavity of the heart, as a primary lesion. If the conditions of hyperinosis and inopexia be increased by hemorrhage or any other cause which 2C2 PUERPERAL DISEASES. results in anaemia and asthenia, spontaneous thrombosis may occur in the pulmonary artery or in the right car- diac cavities, in some cases, when there is no throm- bosis in the veins, and in other cases, at the same time or even before the clotting in the peripheral veins. These facts were prominently brought out by Dr. W. S. Playfair, of London, in a series of able papers on this subject, published in the London Lancet, in 1867. M, Hervieux, in the work to which I have before referred, advocates opinions similar to those of Dr. Playfair, and both give cases illustrating spontaneous thrombosis. Indeed, there can be no doubt at the present day that this is often the cause of the sudden or rapid deaths which occur in the course of various diseases, as rheu- matism, typhus fever, phthisis, and various other com- plaints, as well as those which occur in the puerperal period, which were formerly believed by obstetricians to be due to " idiopathic syncope." Most men who have had some years' experience in obstetric practice have probably met with one or more cases of sudden death arising from this cause. In 1861, I received an urgent summons to visit a lady in Union Square, but, on my arrival at the house, I found that she had just died. I subsequently learned from my friend, Professor I. E. Taylor, who had attended the case, that, on the fourteenth day after confinement, she was attacked with phlegmasia dolens of the right leg. The disease had subsided in about ten days after the attack, and she was apparently convalescent. She was anxious to move to another room, and, being a person of strong will and difficult to control, Dr. Taylor had felt the importance of absolute quiet and had emphati- cally insisted that she should remain in the same room. The morning of her death, his visit was delayed an PUERPERAL THROMBOSIS AND EMBOLISM. 263 hour or two later than usual. Ou arriving at the house, he was hurried to her room and found her gasping for breath, throwing herself from one side of the bed to / O the other, and she died a few moments after he entered the room. On the 2d of July, 1866, I attended the wife of a prominent lawyer of this city, in her second confine- ment. At the time of her first labor, she had convul- sions. In the latter weeks of her second pregnancy, she had many symptoms of aiburninuria and was placed under the prophylactic treatment for this affection. I was extremely apprehensive of convulsions at the time of labor, but they did not occur, and she was safely delivered by forceps of a very large and healthy boy. Her convalescence for ten days after was in every respect satisfactory, and I left the city. On the six- teenth day after labor, she was attacked with phlegma- sia dolens, when she was attended by my friend, Pro- fessor C. A. Budd. The attack was apparently not severe, and the disease seemed readily to yield to treat- ment. She had so far recovered as to be able to go out for a drive, and Dr. Budd had practically ceased his attendance, when, after rising from bed to dress, while pulling on her stocking, she suddenly fell over, the face became purple, and she made violent gasping ef- forts to breathe. Her mind was perfectly clear, but she died in less than an hour from the time of the attack. In February, 1870, I several times saw a patient with Dr. T. Matlack Cheesenian. In the seventh month of gestation, she had albuminuria and several convul- sions, for which she had been bled and treated by elaterium and citrate of potash. All trace of albumen had disappeared from the urine before her confinement, and the labor terminated without convulsions. About 264: PUERPERAL DISEASES. three weeks after, she had some swelling and pain of the right leg, which she could move only with diffi- culty, but there was no phlegmasia dolens. One morn- ing, on rising to go to the wash-stand, she was suddenly seized with palpitation, very great difficulty of breath- ing, and the appearance of asphyxia, to such a degree that she was supposed to be dying. When Dr. Cheese- man and myself saw her, the pulse was very feeble, the impulse of the heart was veiy weak, the respiration was gasping, the face livid and the surface cold, and we were perfectly agreed in ascribing her symptoms to embolism of the pulmonary artery. She was given ammonia and other stimulants as freely as they could be taken, and the most rigid abstinence from every attempt at muscular effort of any kind was strenuous- ly insisted upon. During the day, she had a second attack of the same kind, but less severe. The correct- ness of our diagnosis seemed to be confirmed by the evi- dences of pulmonary infarctions which soon followed, as shown by pains in the lungs, cough, with scanty ex- pectoration of tenacious sputa, slightly tinged with blood, and feeble respiratory murmur, with an occa- sional bronchial rale. A few days after, she had a third attack of asphyxia, and, again, the fourth, in which she died. Although there was no autopsy in either of these three cases, yet I think that no one can have any doubt as to their real character. We should say, then, that the causes of thrombosis of the pulmonary artery are : (.) An embolus from a clot in a peripheral vein. (I.) Spontaneous, arising from the same condition of the blood (hyperinosis and inopexia) as causes throm- bosis in the veins. PUERPERAL THROMBOSIS AND EMBOLISM. 265 ( aa ss. Tine, ferri chloridi, Glycerine, Syr. aurant. cort., aa j. M. S. A teaspoonful in a wineglass of sugar-and-water, every fourth hour. Generally within twenty-four hours, the influence of these medicines, in reducing the size of the uterus and 7 O in diminishing the hemorrhagic lochia, is very evident. 320 PUERPERAL DISEASES. la tliis hospital, also, a similar prescription of mine Las been mucli used, and I believe the staff Lave been de- cidedly convinced of its usefulness. Throughout the whole treatment of puerperal me- tritis, I regard vaginal injections as absolutely essential. Formerly, I used for this purpose warm water impreg- nated with Labarraque's solution of chloride of soda, as strong as the patient could bear without smarting. Re- cently, I have generally used the carbolic acid, as in the following formula : o ]J. Acid, carbol. glacial., Glycerin., ua j. Aq. purse, 3 vij. M. S. A tablespoonful in a tumblerful of warm water. If the lochial discharge be very purulent, and particu- larly if the odor be offensive, the injections should be used four, five, or six times a clay, great care being taken to instruct the nurse how to use them without annoying or fatiguing the patient. If the discharges be posi- tively fetid, we must not rely on vaginal injections, but must resort to their use within the cavity of the uterus. It is my belief that intra-uterine injections should be administered with the greatest care, and always by the physician himself. They have been condemned by some very eminent authorities, and quite a number of deaths have been published as resulting from their use. I am quite convinced that the death of two patients, whom I visited once each, in the month of March in the present year, was directly the result of intra-uterine injections ; and a physician of decided prominence in this city has told me that he has lost two patients, as he believed, from the same cause. Thus I must admit that four cases of death from this cause in this city have come to my knowledge. But, on careful inquiry, I am PUERPERAL METRITIS. 321 satisfied that the fatality was not, in either of these cases, a necessary result of what may be termed a wash- ing out of the cavity of the uterus with an antiseptic fluid, but was entirely due to the mode in which these intra-uterine injections were made. I have never used and shall never advise the use of a syringe for this pur- pose, in puerperal metritis, for I think it is impossible with a syringe to exactly measure the force with which the fluid passes into the cavity of the uterus. The danger seems to arise from the entrance of air into a vein, as in some cases where the death has been sudden, or, in other cases, from the passage of the fluid into the Fallopian tubes, and peritonitis or phlebitis has ensued. I think, therefore, for intra-uterine injections, either Scanzoni's irrigator, or the French irrigator, or the " fountain syr- inge " (which is not a syringe at all) should be used, as we can thus exactly adjust the force with which the fluid enters the uterine cavity. Another point of great importance is, that the fluid injected should easily and rapidly flow back again out of the uterus. Therefore, the canula for carrying the fluid into the cavity should have a double canal, like the one which I now show you, made for me by the direction of Dr. Robert T. Newman, of this city, or the very ingenious canula of Dr. Byrne, of Brooklyn. These canulas are easily con- nected, by a piece of India-rubber tubing, with whatever irrigator you may choose to employ. By such precau- tions as these, I think intra-uterine injections may be made with perfect safety, and I am absolutely certain of their great usefulness. Let me again refer to the ne- cessity of ascertaining that the liquid flows freely back, either through the free canal of the canula or from the O vagina, otherwise the cavity may be over-distended, and some of the evils to which I have referred may follow. 21 322 PUEEPERAL DISEASES. M. Hervieux affirms that he has often observed, after each intra-uterine injection, a marked decrease in the size of the uterus, in some instances, from two to two and a half inches in forty-eight, and even in twenty-four hours, in cases of metritis, where it had be- fore for a long time remained stationary, and that he almost constantly has noticed, as a result, a progressive subsidence of the fever, the pulse falling from 112, some- times 120, down to 104, 96, 92, and 84. I have never had the good fortune to mark such striking changes as these in so short a period, but I have frequently seen this disinfection of the lochia followed by a veiy marked improvement in the general symptoms, such as the disappearance of the abdominal pains, the return of the appetite, and the gradual fall of temperature and decrease in frequency of the pulse. I think that I have omitted to remark, that, during the whole treatment of this disease, opiates should be given, when necessary, to relieve pain or secure sleep. But, unless the metritis be complicated with peritonitis, a very moderate dose given at bedtime will generally be found sufficient for this purpose, and I am very much in the habit of giving the opiate in the form of a rectal suppository as, for example, one grain of the aqueous extract of opium with three grains of butter of cacao because I wish to reserve the stomach for the absorption of other medicines, stimulants, and food. In the suppurative and putrescent stages of puer- peral metritis, our main reliance in connection with the intra-uterine injections must be on quinine and alcohol. Instead of giving the quinine in two or three-grain doses, at intervals of three or four hours, as I formerly did, I think that I now much more effectively secure the anti-pyretic and anti-pyogenic effects of this remedy. PUEKPERAL METPJTIS. 323 by giving a full dose twice a day ; as, for example, from five. to ten grains in the morning, and from ten to fif- teen in tlie evening. Either whiskey or brandy should be administered as freely as the patient can take it with- out any unpleasant effects. I have often seen patients, with the symptoms that I have mentioned as belonging to the suppurative and even the commencement of the putrescent stage of puerperal metritis, bridged over, as it were, a very dangerous point of a few days, by means of uterine injections, quinine and alcohol, and they have eventually recovered. LECTUKE XVL PUEEPEEAL PEEITONITIS. Case Puerperal peritonitis formerly regarded by many as synonymous with puer- peral fever Very frequently secondary to phlebitis, endometritis, or some other suppurative phlegmasia in the pelvic tissues Sometimes a primary affec- tion, and general from the beginning In other cases, becomes general by con- tiguous extension Most liable to occur early in the puerperal period Some- times developed before or during labor Causes Symptoms Progress and duration Time when death occurs Modes by which recovery takes place Diagnosis Treatment Opiates Veratrum viride External application of the oil of turpentine Blisters Quinine Alcoholic stimulants Vaginal in- jections Nutrition Absolute rest Purgatives dangerous Mercurials (?) Venesection (?) Report of a case appended. " CASE XXVII. 1 Annie N , born in England, age twenty- nine, married, was delivered of her third child, February 1st, mid- night, after a short labor of two and a half hours, vertex-presenta- tion, and L. O. A. position. Boy, weight 8f Ibs. " February 2d. 10 A. M., respiration 20 ; pulse 68 ; tempera- ture 97.5. 11 February 3d. 10 A. M., respiration 18; pulse 74; tempera- ture 98.5. " February 4:th. 10 A. M., respiration 20 ; pulse 84 ; tempera- ture 99. 4 P. M., respiration 28 ; pulse 116 ; temperature 101.5. " The patient, a few hours before, had got out of bed and gone with bare feet to the water-closet. Soon after her return to bed, she had a severe chill which lasted a half-hour. She then com- plained of severe pain in the abdomen, most severe at the umbilicus. Some tympanites, and great sensitiveness to pressure. Ten drops 1 Eeported by Eichard 0. Van Wyck, M. D., house-physician to Belle- vue Hospital. PUERPERAL PERITONITIS. 325 of Magendie's solution of morphia, and turpentine-stupes to the ab- domen, were ordered. " 10 P. M., respiration 24 ; pulse 120 ; temperature 104. Pains more severe and increase of tympanites. The same dose of mor- phia to be given every hour until the pains are relieved. "February 5th. 9 A. M., respiration 24; pulse 116; tempera- ture 102. 2 P. M., respiration 24 ; pulse 124 ; temperature 103- 10 P. M., respiration 28 ; pulse 132 ; temperature 103. She took, during the -night, thirty drops of the morphia. The pain is much less severe, but the abdomen is very sensitive to pressure and ex- tremely tympanitic. In the morning, she vomited several times a dark, greenish fluid. In the evening, bowels moved four times. Lochia very profuse, purulent, but without much odor. Eyes sunken and surrounded with a dark areola. Surface clammy. De- lirious. Warm injections with carbolic acid. "February 6th. 9 A. M., respiration 24; pulse 112; tempera- ture 102. 2 P. M., respiration 24 ; pulse 116 ; temperature 103.5. 9 P. ir., respiration 20; pulse 132; temperature 103.5. Diarrhoea continues. Patient does not complain of pain, except when the bowels move. Bismuth, subcarb. gr. x, after every dejection. Ten drops of morphia, hypodermically, p. r. n. " February 1th. 9 A. M., respiration 28 ; pulse 136 ; temperature 102.5. 2 P. M., respiration 32 ; pulse 148 ; temperature 104. 10 p. M., respiration 20 ; pulse 152 ; temperature 103. Patient died at 4 A. M., February 8th. "Autopsy, eleven hours after death. On opening the abdomen, the intestines were seen distended with gas. The peritoneal cavi- ty contained a large quantity of sero-purulent fluid, with lymphy flocculi. The intestines were in some parts agglutinated with what appeared to be new adhesions. The lower border of the liver and the spleen were more or less covered with patches of false membrane. The peritonaeum was thickened in various points, and injected with numerous arborizations. The uterus was six and a half inches in length, four and a half in breadth. Its walls seemed to be perfectly healthy. Incised in every direction, no pus could be detected any- where, either in its parenchyma or its sinuses. Its internal coat was covered with a dirty-reddish coating, which was not fetid and was easily washed off. The Fallopian tubes, ovaries, and broad ligaments were entirely healthy. The liver was somewhat en- larged and fatty. All the other abdominal and the thoracic organs were normal." 326 PUERPERAL DISEASES. Gentlemen : Peritonitis, general or partial, is one of the most common, as it is one of the most serious, of the puerperal diseases that we have to encounter. As I was out of town, I did not see this patient, un- til the day before her death ; but, from the history of the case and the results of the autopsy, I regard it as one somewhat exceptional in my experience. The peculiarity of the case consists in the fact that it was general and primary ; that is, it was not consecutive to any other local inflammation or propagated by con- tinuity from the pelvic cavity, nor was it a secondary lesion of puerperal fever. It is so frequent and strik- ing a lesion of certain epidemics, that, by some authors, not many years ago, puerperal peritonitis was used as a term synonymous with puerperal fever. The tenden- cy of the doctrine of the day is to regard puerperal fever as a traumatic fever ; and those who accept this view believe that peritonitis is generally secondary to inflammation of the other organs and tissues in the pelvic cavity. It is true that, in a majority of cases, we find peri- tonitis either coincident with, or a consequent of an en- dometritis, a metrophlebitis, a pelvic cellulitis, or a sup- purative inflammation of the broad ligaments or of the ovaries ; but, in the patient whose history you have just heard, it was not associated with either of these lesions. As a general proposition, it may be stated that peritonitis, in the puerperal woman, is sometimes a primary affection, and is general at the onset ; or it be- comes general, by contiguous extension from the start- ing-point, which is most frequently that portion of the serous membrane which covers the uterus, or is ad- jacent to it ; although, in more rare cases, it seems to commence at the hypochondrium or the umbilicus. PUERPERAL PERITOXITIS. 327 Thus we meet with cases where, from the com- mencement of the attack, the whole peritonaeum seems equally involved, and the pain and tenderness are no greater at one point than another, being the same at the epigastric, the hypochondriac, or the umbilical region, as in the iliac fossa or over the uterine tumor ; and the autopsical lesions are found to be no more intense or farther advanced in one part than in another. This form of general peritonitis sometimes occurs sporadically in private practice, and in the country, but it is more frequently met with in cities and in hospital practice, and it is specially characteristic of certain epidemics. It also occurs uncomplicated with any other lesion, as in the present case, in which no pathological modifi- cation was found, either in the uterus or its append- ages ; but in my experience this is quite a rare event. My own observations are entirely in accord with the statement of Hervieux, that there are cases of general puerperal peritonitis, independent of any pathological alteration of the uterus or its appendages, in the same manner as we meet with cases of uterine phlebitis, with or without purulent infection, and without the slightest trace of peritonitis. "While, then, it is undoubtedly true that general peritonitis does occur as a primary affection from the onset, the evidence furnished by the clinical history and the autopsical lesions seems conclusive that, in a majority of cases, the inflammation commences in the pelvic cavity and becomes general by propagation from contiguity, and also that it is generally associated with, and perhaps is secondary to, lesions of the uterus, or of the ovaries, or of the Fallopian tubes. I think that all who have had a large experience in the study of 328 PUERPERAL DISEASES. tliis disease will concur with the statement of Her- vieux, that, in a majority of women who die from puer- peral peritonitis, the autopsy reveals either metritis, uterine phlebitis, abscesses in the uterus, putrescence or, it may be, true gangrene of the uterine tissue, or else phlegmon of the broad ligaments, suppurative inflam- mation of the Fallopian tubes, or suppurative or hem- orrhagic ovaritis. In a large majority of cases, this disease attacks puerperal women during the first three days after con- finement. Thus, Hervieux states that in 247 cases ob- served at the Maternite, Paris, by Berrier-Fontaine, the attack occurred from the first to the third day in 185, from the fourth to the tenth, in 60, and in two, on the eleventh and twelfth days. In 87 cases observed at this same hospital, by Tarnier, the invasion of the dis- ease took place Immediately or very shortly after delivery in 21 One day after delivery 27 Two days after delivery 20 Three days after delivery 11 Four " " " 4 Five " " " 1 Eight " " " 3 After the eighth or tenth day, it is very rare that a woman is attacked with this disease, except when it occurs as a consequence of imprudence or .errors of diet, or when the disease is consecutive to some other pelvic phlegmasia, as a metritis, or a phlegmon of the broad ligaments, or a pelvic cellulitis. You observe that, in twenty-one of these cases, the attack came on immediately or very shortly after deliv- ery. This has been the fact in quite a number of cases that have come under my observation, in private as well PUEEPERAL PERITONITIS. 329 as in hospital practice. Indeed, I may say that, in sev- eral instances, the patient has exhibited for a short per- iod, just before and during labor, such symptoms that the attack was not a surprise to me. A few days before labor, there have been, perhaps, slight febrile exacer- bations, with a quick pulse, thirst and loss of appetite, soreness and tenderness over the uterine tumor, and, in some cases, marked symptoms of cystitis, which I regard as very ominous. When labor has come on, the pulse has been quick throughout the whole labor, the pain has been disproportionate to the force of the uterine contractions, and the patient has been very in- tolerant of pressure over the uterus, and especially to the application of the binder after delivery. In several cases that I have seen in consultation with medical friends, and particularly in a very severe case that I saw with my friend, Dr. Trask, of Astoria, I was strong- ly impressed by the mention of more or less of these symptoms as having been present antecedent to or during labor. So that now, whenever I find that such symptoms have existed or are manifested during labor, my fear of peritonitis is so great that, immediately after delivery, I put my patient under the full influence of an opiate, which I continue until all grounds for apprehension have been removed. The progressive expansion of the gravid uterus and its invasion in the abdominal cavity, with the consequent unusual pressure on the tissues within the cavity, cause, in many women, chills, spasms of pain, and other disturbances, and undoubtedly, in some in- stances, predispose the peritoneal membrane to take on morbid action. So, also, the violence done to the uterus and its appendages by parturition frequently induces local inflammations, which are propagated by contiguity 330 PUERPERAL DISEASES. - to that portion of the membrane which covers these organs, and thus consecutively induce inflammation of the whole peritonaeum. But these modifications are physiological in most women, and become pathological in a very few. Other elements are therefore necessary to develop morbid action. It has long been settled by the best pathologists, that peritonitis is rarely a spontaneous and primitive disease. As I have before remarked, in puerperal women, it is generally associated with some inflamma- tion, either of the uterus, the ovaries, the Fallopian tubes, or the broad ligaments, or some suppuration that explains the peritoneal inflammation, which is at first circumscribed, but gradually involves the whole serous membrane. But there are exceptions to this rule, and the case, the histoiy of which you have just heard, is an example. These exceptions are sufficiently numer- ous to establish the fact that puerperal peritonitis may occur independently of any lesion of contiguous organs, just as we meet with pleurisy, pericarditis, or menin- gitis, as primary lesions. I have no doubt that exposure to cold may de- velop puerperal peritonitis. I suppose that every year my house-physician has given me a similar history to that of the present case, in which the attack seems attributable solely to this cause. The patients have got out of bed and gone with bare feet on the cold floor to the water-closet. Explicit orders and warn- ings of danger seem to have but little influence with our patients in preventing this accident. In private practice, I have seen but one case where exposure to cold could with certainty be ascribed as the cause of puerperal peritonitis. Monthly nurses are generally much more careful in guarding their patients PUERPERAL PERITONITIS. 331 from exposure to cold than in protecting them against bad ventilation and impure air. The patient I alluded to was in excellent health during gestation, and was delivered of her sixth child after a perfectly normal labor of five and a half hours. On the following morning, twenty-six hours after the labor, I found her in a most satisfactory condition in every particular. It was a very warm day in September, and she was much annoyed by profuse perspiration. She was an imperi- ous woman, of great force of character, and two hours after my visit she insisted that her nurse should sponge her all over with cold water, during which process she was entirely uncovered, with the exception of her lochial guard. The sponging was hardly finished, when she was seized with a violent chill of some minutes' duration. She would not consent to have me sent for until some hours after, when I found her lying on her back, with her knees drawn up, breathing rapidly, suffering from intense pain in the abdomen, which was enormously distended and exquisitely sensitive to the slightest touch ; and the lochial discharge, which with her was always very free, was entirely arrested. For several days she was extremely ill, but she eventually recovered. In puerperal women, as in the non-puerperal, and in men, peritonitis is incidental to certain blood- changes, as in the renal diseases which induce albti- minuria or uraemia, in erysipelas, in pyaemia or in sep- ticaemia. But undoubtedly by far the most frequent of all the causes of puerperal peritonitis is the special toxaemia of puerperal fever, and, in connection with that subject, I shall again have occasion to call your at : tendon to certain peculiar features of the disease. I shall not detain you by a discussion of the patho- logical anatomy of puerperal peritonitis, for I think 332 PUERPERAL DISEASES. that I can more profitably refer you to the work of Klob, on the " Pathological Anatomy of the Female Sexual Organs," or the excellent little " Hand-Book of o / Post-mortem Examinations and of Morbid Anatomy," by Dr. Francis Delafield, with the contents of which you should all be thoroughly familiar. We have now to study the symptoms which clini- cally characterize general peritonitis. I have before re- marked that, when the disease is primary, in a majority of cases, it attacks puerperal women, during the first three days after delivery. But, when it is secondary to endometritis, uterine phlebitis, or suppurative inflam- mation of any of the tissues within the pelvic cavity, or when induced by imprudence of any kind, it may be developed at any time during the puerperal period. The symptoms, therefore, will vary according to the mode and the period of the attack, and the epidemic type of the season. In general terms, it may be said that this disease is ushered in by a chill, accompanied with or followed by pain, either limited to certain parts or extending over the whole abdomen, a frequent, sharp, or hard pulse, a rise of temperature, gradual or rapid enlargement of the abdomen, increased frequency of respiration, loss of appetite, vomiting, constipation or diarrhoea, and sub- sequently troubles of innervation, as exhibited by the facial expression, by feebleness and prostration, with headache, and sometimes delirium and coma. After this rapid exposition of the general symptoms of the disease, let us now study them more in detail. I do not remember that I have ever seen a case which was not ushered in by a chill. This is some- times so violent as to cause the teeth to chatter and the whole body to be shaken with trembling, while the PUERPERAL PERITONITIS. 333 x countenance is anxious and pinched, and the patient demands with great earnestness additional clothing. In other cases, it is only a slight shivering or a passing sensation of cold, which the patient attributes to a draft of air, an open door, or insufficient covering. The duration of the chill is generally proportionate to its in- tensity, lasting, in the slightest, but a minute or two, and continuing, in the very severe, perhaps an hour or more. Some writers assert that puerperal peritonitis is characterized by a single chill. This is true in many cases, particularly in the very acute, and in some spo- radic primitive cases, but it would not be safe to base a diagnosis on this assertion. For the truth is that, when the inflammation commences at any one point of the abdomen and progressively invades different parts of the peritonaeum, each successive step in the disease is often announced by a recurrence of the chill. So also, when the peritonitis is secondary to an endo- metritis, a suppurative inflammation of the broad liga- ment or of an ovary, as each tissue is attacked by the inflammation, there is generally a return of the chill. The pain in the abdomen rarely occurs before the chill, but is manifested with it or speedily follows it, and is generally very severe. In many cases, it is first complained of in the umbilical region or one of the iliac fossae, and extends rapidly to the hypogas- trium, to the lumbar regionj the epigastrium, and both the hypochondria. In primary general peritonitis, the pain does not thus attack successively different parts of the abdomen, but the patient complains of atrocious agony, which she localizes sometimes in one part and sometimes in another, but the whole of the abdominal walls are exquisitely sensitive, so that the slightest palpation is intolerable, and even the weight of the 334: PUERPERAL DISEASES. bedclothes cannot be borne. The patient consequent- ly lies fixed and immovable, avoiding the slightest movement of any part of the body, and the respiratory action is wholly thoracic. Most writers describe the position of patients in this disease as being dorsal, with the knees drawn up, but I have seen many cases in which the patient lies with the legs extended. Both the position and the countenance are most significantly expressive of anxiety and intense suffering. The very severe pain usually continues but one or two days. At a later period, there only remains great sensitive- ness to pressure in limited points, and this often disap- pears when the abdomen has become excessively tym- panitic. The pain seems to subside as the sero-fibrin- ous exudation takes place, and it generally is entirely absent after the exudation has become purulent. The symptom next in importance is the accelerated pulse. This persists, with but slight remissions and ex- acerbations, from the commencement to the end of the disease. It is a constant measure of the intensity of the inflammation, increasing or diminishing in frequency as the disease progresses or retrogrades. During the chill, the pulse, while increased in frequency, is often compressible and feeble, but, as a rule, in general peri- tonitis, after the chill has passed off, the pulse remains full, strong, and hard, sometimes until the patient is moribund. But, generally, as the fatal period ap- proaches, it becomes feeble, thread-like, and now and then imperceptible. In most cases, the pulse is found more frequent, by from six to ten beats, in the evening than in the morning*. O A rise of temperature, as shown by the thermom- eter, is a constant symptom in this disease. Even dur- ing a chill, when the patient was urgently demanding PUERPERAL PERITONITIS. 335 more covering, and the hands and feet were cold, I have seen the thermometer mark 104.5, and, after the chill passed off, the temperature fell to 103. During the progress of the disease, the temperature remains con- stantly high, ranging, in different cases, from 101 to 104, according to the intensity of the inflammation. There is a positive relation "between the frequency of the pulse and the temperature, but this is not fixed or con- stant. I have several times observed an increased fre- quency of the pulse in the evening as compared with the morning, while the temperature has remained the same, or even fallen a degree or more. So, on the other hand, I have often seen the temperature remain high, while the pulse has been gradually reduced in frequency by the use of the veratrum viride, down to 80, or even a lower number. The tongue sometimes remains moist and without coating throughout the whole course of the disease. o o Generally, it is at first moist but slightly whitened, gradually becoming covered with a moderately thick white or yellowish coat, and it is frequently sticky and flabby, showing the indentations of the teeth. Then it gradually becomes dry, and the coating, brown and shriveled. In some cases, the teeth are covered with sordes ; viscous, tenacious mucosities interpose between the tongue and the roof of the mouth, rendering articu- O f O lation painful and difficult, and this condition is at- tended with an urgent and incessant thirst. In some, the white coat disappears at an early period, and the tongue remains red. Generally, the appetite is entirely wanting, but, oc- casionally, we see patients who complain of hunger as the disease approaches a fatal termination. During my present term of service, one patient called for and par- 336 PUERPERAL DISEASES. took of more milk and beef-tea in the six hours previous to her death than she had taken altogether in the five days of her illness. In many cases, the stomach is disturbed at an early period, and nausea and vomiting continue at intervals during the whole course of the disease, or until the pa- tient is convalescent. At first, the matter thrown off is merely the contents of the stomach mixed with mucus, afterward bilious matter, and finally green, brown, and black, or, as it has been termed, " coffee-ground," fluids are ejected. Vomiting is not a constant phenomenon in this disease. Where peritonitis results as a lesion of puerperal fever, this symptom is seldom absent, but, in cases of moderate intensity, and when it is secondaiy to other pelvic inflammations, it sometimes does not oc- cur even when the disease has a fatal termination. The vomiting sometimes suddenly ceases, either spontane- ously, or, as the result of treatment, and is immediate- ly followed by diarrhoea, and so, in some, if the diar- rhcea be arrested, the vomiting returns. In puerperal peritonitis, diarrhoea is much more fre- quent than constipation, and it is sometimes so exces- sive as essentially to contribute to the fatal result. Her- vieux, much more emphatically than any other author, has signalized the excessive predominance of bile in the evacuations, both from the vomiting and the diarrhoea, as peculiar and characteristic of puerperal peritonitis, and my own observations are quite in accord with his. A moderate diarrhoea often seems to be followed by an improvement in the condition of the patient. One of the most constant and one of the most char- acteristic symptoms of general puerperal peritonitis is abdominal tympanites, which begins to appear soon af- ter the chill and the pain. It sometimes becomes so PUERPERAL PERITONITIS. 337 great as to make the abdomen more prominent than be- fore delivery, and the pressure on the diaphragm from this cause may diminish the capacity of the chest, and seriously impede respiration and the action of the heart. As a rule, we may say that the severity of the tym- panites is proportionate to the intensity of the perito- nites ; but it is not always so, for I have seen excessive tympanites in cases of moderate intensity. A more frequent respiration, as I have already remarked, is a necessary result of the abdominal tym- panites, and this, therefore, you must remember as one of the characteristic symptoms of puerperal peritonitis. You will find your patient breathing from twenty-four to forty or fifty times a minute. You will observe that there is always a comparative, although not a defi- nite and fixed relation, between the respiration, pulse, and temperature. The more frequent the respiration, the more rapid the pulse and the higher the temperature. When an exception occurs, it generally can be easily ex- plained by some peculiar phenomenon in the case ; as, for example, latent pleurisy, which is not a rare com- plication, may cause the respiration to be as frequent as fifty or sixty a minute, while the pulse is not above 112-120, and the temperature 102-103. Headache, although not very severe, is generally complained of at the time of the chill or soon after, but this usually disappears after a day or two. A moderate degree of delirium in the later periods of general peritonitis is manifested in a majority of cases. Prostration of the vital forces and of the muscular powers supervenes at an early period. The patient lies in a fixed position, apparently indisposed to make the least effort of the will or to move. There is extreme lassitude, with a corresponding intellectual feebleness. 22 338 PUERPERAL DISEASES. The voice is weak and tremulous, and the articulation is often indistinct. Morally, there is an apparent tor- por and indifference to every thing going on, but nurses and friends in attendance often greatly err in supposing that there is real apathy. I have sometimes thought that this appearance masked increased vividness of sen- sibility, for I have seen slight moral disturbances, in connection with the nurse, the child, or other members of the family, cause great agitation, resulting in a quick- ening of the pulse, a rise of temperature, a renewal of abdominal pain, and an increase of the tympanites. During the time of the chill and the period of severe pain which follows, the countenance, as I have before remarked, is very expressive of pain and suffer- ing. After this time, the eyes become sunken and sur- rounded by a dark areola, the nose pinched, the cheeks hollow, and often with a crimson hue, while the general color is darker. Writers have described the counte- nance as losing all expression, or as dull and stupid ; but to my eye the expression which patients generally wear in the advanced stages of general puerperal peri- tonitis is rather that of absent, dreamy reverie. The lochia furnish no indication by which we can judge of the severity of the disease. They are some- times diminished or suppressed, while, in other cases, they continue without any marked modification through the whole period of the disease. They frequently are very much diminished during the chill, but are reestab- lished when reaction takes place. Ordinarily they dimin- ish in proportion as the disease approaches a fatal termi- nation. "When excessive, purulent, or fetid, we may infer that the peritonitis is complicated with uterine lesions. As regards the mammary secretion, it is ordinarily very much diminished at the onset of the disease, PUERPEKAL PERITONITIS. 339 and sometimes entirely disappears. In other cases, it returns even while the disease is progressing, and, again, I have known it to be arrested during the dis- ease and to return after recovery. The progress and duration of peritonitis vary greatly in different cases. In some, the disease is gen- eral from the beginning. In other cases, it becomes general by successive steps, commencing in some one point, most frequently in one or the other of the iliac fossae, or in the pelvic cavity. Death may take place, in severe cases, in from two to six days. In other cases, the disease commences with intense violence, but appar- ently becomes less severe on the second or third day, although steadily going on to a fatal result. In some, the patient seems to resist the disease for so long a time as to lead to delusive hopes of recovery, unless there be a careful recognition of the condition of the abdomen, the tympanites, the temperature, the feebleness of the pulse, and the diarrhoea. Often, in such cases, death does not occur until two or three weeks from the beginning of the attack. So, also, there is equal variety in the mode of recovery. In some, the attack is most sharp and violent, but seems to be aborted, and terminates, apparently, as suddenly, in two or three days, leaving behind but slight traces of its effects. In a majority of cases, even when peritonitis is the prominent lesion of puerperal fever, if the dis- ease apparently abate the day following the attack, it subsequently reappears, rarely with its primary vio- lence, but with increasing gravity, until it reaches its acme, and then gradually subsides. Peritonitis terminates by recovery in a variety of ways. The disease, which w^s general in the beginning, sometimes gradually localizes, or becomes circumscribed 340 PUERPERAL DISEASES. in one or more points, as in the hypogastrium, or in one or the other iliac fossa, and a favorable termina- tion results in one of several different modes. When the patient has been previously in good health, and her convalescence is not retarded by epi- demic influences, the localized exudation may be rapidly absorbed, and the patient recover her health in a few days, and, by the end of the puerperal period, she may be as well as if the disease had not occurred. But, in many cases, the localized exudation becomes indurated and forms a circumscribed tumor, painful on pressure, while the adjacent tissues are not sensi- tive. The tongue remains white, the pulse quick, 100 or more, the temperature continues two or three de- grees above the normal standard, the appetite remains delicate and capricious, generally, there is neither nausea nor vomiting, but usually constipation; and this con- dition sometimes lasts for weeks, and then finally dis- appears, and the patient gradually regains her health. In a smaller number of cases, the localized peritoni- tis terminates in a purulent collection, which is almost always signalized by chills, (which are often recurrent,) hectic fever, night-sweats, total loss of appetite, and either constipation or diarrhoea. The pus is encysted by false membranes; and fluctuation, which is at first ob- scure, gradually becomes distinct. When this takes place, as the pain is much less, notwithstanding the hectic fever and the cachexia, patients usually express themselves as feeling better. The purulent collection finds exit, in some cases, externally, as in the groin, or near the um- bilicus, or between the umbilicus and the crest of the ilium. If the discharge of pus take place internally, the intestines are the most favorable channel for its exit. But many cases have been reported in which PUERPERAL PERITONITIS. 341 the pus lias been discharged into the bladder, the va- gina, or the uterus. Recovery, in some of these cases, requires weeks or even months. The purulent discharge by the intestines, as well as by the other internal chan- nels, may take place so slowly and so imperfectly that the patients die from the purulent cachexia and hec- tic fever. When the discharge of pus takes place by the intestines, I have known it to continue for months, and even for years, the patient ultimately recovering. Another mode of recovery from general puerperal peritonitis is that by which it seems to be supplanted by some other disease, as an erysipelas, a pleurisy, a pneumonia, a bronchitis, an abscess in the breast, or sup- puration in one or more joints. Convalescence, in such cases, is very slow, sometimes requiring several weeks. In describing the symptoms of general peritonitis, I have already given you the elements on which the diagnosis is based. I have told you that the promi- nent characteristic symptoms are the chills, abdominal pain, tenderness, and tympanites, quick pulse, a con- stant temperature from 3 to 6 above the normal standard, vomiting, either diarrhoea or constipation, and great depression of the vital forces. No one of these symptoms can be regarded as pathognomonic. Their diagnostic value consists in their combination. Many of them are common to other diseases, and some of the most characteristic of them are frequently ab- sent in the general peritonitis of certain epidemics of puerperal fever. For example, the tympanites has been very prominent in certain cases of puerperal fever, in which the autopsy has revealed phlebitis, endometritis or suppurative inflammation of some tis- sue in the pelvic cavity, but not the slightest trace of peritonitis in any part of the pelvic or abdominal 342 PUERPERAL DISEASES. cavity. Again, in some very rare cases, where the autopsy has demonstrated the existence of intense peri- tonitis, the abdomen has remained flat, without pain or marked sensitiveness, throughout the whole course of the disease. Now, then, in what other disease do we meet more or less of these symptoms, which might lead us to mis- take it for general puerperal peritonitis? When this disease is epidemic, some cases of after-pains, it is said, are liable to be mistaken for it. But these pains are paroxysmal ; they are accompanied by perceptible con- tractions of the uterus ; they are not ushered in by a chill ; the pulse is not steadily increased in frequency ; there is no marked variation from the normal tempera- ture; these pains do not usually continue after the third day ; the tenderness on pressure, except during the time of pain, steadily decreases, while, in perito- nitis, it rapidly increases. In several instances, I have known puerperal peri- tonitis to be suspected, where the symptoms were due to retention of urine. One of the best men whom I have had serve with me as house-physician in this hospital called my attention to a case of supposed puerperal peritonitis, when it was epidemic in the hos- pital. The patient had a chill, about sixty hours after the termination of labor. The pulse was constantly above 100, the temperature, 101, the abdomen, enlarged anc^ tender, with constant pain ; there was a good deal of headache and some wandering, no appetite, but consid- erable thirst. Observing an ovoid, slightly-elastic tu- mor above the pubes, which was no more sensitive to pressure than the adjacent abdominal walls, I made minute inquiry in regard to urination. The physician and the nurse declared that she passed water frequent- PUERPERAL PERITONITIS. 343 ly and easily, both during and since labor, and the patient herself asserted that she had no difficulty in doing so. I asked my friend to pass a catheter, and nearly two quarts of water were drawn off, and all the symptoms of peritonitis disappeared. While the water was flowing, I observed a high color in the face of my young friend, who thanked me for the kind way in which I had pointed out his error, expressing his con- viction that I- would not again catch him making that mistake. Intestinal irritation sometimes assumes certain of the features of puerperal peritonitis ; such as a coated tongue, nausea and vomiting, constipation or diarrhoea, and tympanites. But the abdominal pain and tenderness are not so severe, and are not ushered in by a chill, or fol- lowed by the constitutional disturbance, as shown by the pulse, temperature, and depression of the vital forces, which attend puerperal peritonitis. I think it hardly possible to mistake a metritis, a phlebitis, or a suppurative inflammation, either of the broad ligament or of an ovary, for general peritonitis, unless it be complicated with one or the other of these diseases. One or all of them may be overlooked, but either, without complication, could not easily be mis- taken for peritonitis. We now come to the most important part of our subject ; that is, the treatment of this disease. It would, perhaps, be very interesting to review the treatment of the past, and also to discuss the various methods of -treatment which now receive the sanction of high au- thorities in different parts of the world. But we have not the time for this, and I must, therefore, limit my- self to the duty of pointing out to you the treatment in which I believe. 344 PUERPERAL DISEASES. (1.) The most important of all agents in controlling and in arresting this disease is opium in some form. Let us see what we gain by its use. The peristaltic movements are retarded or arrested, and thus the in- flamed tissues have absolute rest; pain is annulled; emotional excitement is allayed ; the nervous system is tranquillized ; sleep is secured ; and thus the depression of the vital forces, resulting from the shock of the at- tack, is lessened. The opiate, therefore, should be given in such doses as to secure all this. The amount required is to be measured only by the effect produced ; and you will find the system, when peritonitis exists, extraordi- narily tolerant of opiates. They should be given, and their influence steadily kept up to a point approaching semi-narcotism, as shown by the slow respiration and the somnolency, but it is never necessary to carry nar- cotism to the point of danger. Fortunately, in some cases, this seems almost impossible; but the patient should be carefully watched, and care should be tak- en that the respirations do not fall below 12 or 15 a minute, that the pupils are not much contracted, and that somnolency is not induced to a degree from which it is difficult to rouse the patient. The opiate should be steadily kept up to the point of tolerance, as long as there remains the least trace of the disease. I wish es- pecially to emphasize this last remark, for very many times I have seen relapses occur, and the inflammation take a new start, from the suspension of the opiate, un- der the delusive belief that the disease has been con- quered. Very often I have found it necessary to con- tinue the opiate for some days or even a week or two after the abdominal pain, tenderness, and tympanites had disappeared, because the appetite did not return, the pulse remained quick and the temperature high. PUERPERAL PERITONITIS. 345 The tolerance of the agent diminishes as the disease re- cedes. This you will find an infallible guide as to the measure in which you can reduce the quantity and di- minish the frequency of your doses. To enter more into detail, I would say, begin by giv- ing your patient ten drops of Magendie's solution of morphia (morphiae sulph. gr. xvj, aq. 5 j) every hour. If the effect sought for be not manifested after two or three doses, increase, by two or three drops, every third dcse, until the impression desired be made. If the drops be rejected by vomiting, administer the morphia hypoderrnicalry. The solution, in the same proportion, should be freshly made, without acid, every second day, and thus the danger of local abscess where the needle of the syringe is inserted is avoided. After one or two hypodermic injections, the drops can usually be again tolerated by the stomach, which is preferable, because hypodermic injections almost invariably cause some emotional excitement and nervous disturbance, which are to be avoided if possible. While I believe the tolerance of opiates to be very re- markable in this disease, without exceptions, yet, in dif- ferent patients, this tolerance varies exceedingly. The quantity which some patients bear and seem absolutely to require, in order to control this disease, would appear incredible to those who have not had experience in its use. In a case treated by Professor Alonzo Clark, " the patient, who was unaccustomed to the use of opium in health, and who was not intemperate, took, the first twenty-six hours, of opium and sulphate of morphia, a quantity equivalent to 106 grains of opium ; in the sec- ond twenty-four hours, she took 472 grains, on the third day, 236 grains, on the fourth day, 120 grains, on the fifth day, 54 grains, on the sixth day, 22 grains, and on 346 PUERPERAL DISEASES. the seventh, 8 grains." 1 In a patient, whom I repeatedly saw in consultation with Dr. Howard Pinkney, the quantity daily administered, either by the mouth or hypodennically, was nearly as great, while it was found necessary to continue this enormous quantity for a much longer period, before convalescence was established.' But these are exceptional cases, for, ordinarily, the ef- fects are produced by doses much less than those I have just mentioned. In this hospital, for more than twenty years, the opiate-treatment, as I have described it, has been chief- ly relied upon in peritonitis. To Professor Alonzo Clark, of this hospital, belongs the credit of introdu- cing it, and of establishing the fact of the remarkable tolerance of opiates in general puerperal peritonitis, and of the necessity of pushing it to the point of tol- erance, in order to secure the curative effects of the remedy. The use of large doses of opium in the treat- ment of peritonitis had been advocated previously by some distinguished men, as by Armstrong, Sir Thomas AVatson, Bates, of Sudbury, and by Graves and Stokes, of Dublin. Dr. Stokes published a paper in the first volume of the Dublin Journal of Medical and Chemical Science, on the use of large doses of opium in peritoni- tis, and he especially noted its value in " the low typhoid peritonitis arising after delivery." But the treatment which I have described is a good deal more than that recommended by the above authors, and I do not hesi- tate to say that the records of this hospital will demon- strate a success in the treatment of this disease far beyond that which has ever been secured by any other method. 1 V.ide Rambotham's " System of Obstetrics," edited by Keating, Phil adelphia, 1865, page 538. a Vide report of the case at the end of this lecture. PUEKPEEAL PERITONITIS. 347 (2.) I regard it as very important to allay vascular excitement, as this necessarily leads to a rapid depres- sion of the vital forces. Our predecessors resorted to venesection to accomplish this, but the general experi- ence of the profession led to the universal abandon- ment of this practice, as it was found that, in this dis- ease, it involved absolute loss of vital power. But, in the veratruni viride, we have an agent which reduces vascular excitement without real loss of vital power. There is a positive distinction between depression of the vital forces and absolute loss of power. As I have, on other occasions, fully discussed the action of the veratrum viride, it is sufficient for me now to say that, in conjunction with the -solution of morphia, you will do well, in puerperal peritonitis, to gradually reduce the frequency of the pulse, by the use of the tincture of the veratrum viride. Commence with five drops with each dose of the morphia. By carefully watching the effects, and graduating your doses short of provoking vomiting, you may bring the pulse down to 70 or 80, and then you should endeavor to hold it there. Even if vomiting do come on, and, for a time, your patient seem almost in a state of collapse, this condition need excite no alarm, as it lasts but a short time, and the pulse is effectually reduced in frequency, sometimes to 30 or 40 a minute. I have seen this occur a hundred times at least, and the greatest evil resulting from it is the alarm and excitement which it causes to the friends or attendants. It is, therefore, desirable to avoid this explosion, so to speak, of the action of the veratrum viride, if possible. If the pulse have once been reduced, three, two, or even one drop may be found sufficient to control it. Remember that the veratrum viride controls the excited pulse of inflammation, but does not reduce 348 PUERPERAL DISEASES. the rapid pulse of exhaustion. If, therefore, the disease advance to the stage of purulent cachexia and hectic fever, the veratrum viride should not be given. (3.) For the pain in the abdomen and the tympa- nites, we have a remedy of great value in the oil of tur- pentine. As soon as these symptoms appear, direct that two thicknesses of flannel, sufficiently large to cover the whole abdomen, be dipped in hot water, then wrung out as dry as possible, saturated with the oil of turpentine, and placed over the abdomen. This should be covered with oil-silk and kept on as long as the patient can be persuaded to bear it ; that is, from fifteen minutes to a half-hour. . The surface should be well reddened by the application. On taking off the flannel, the abdomen should be covered with a light layer of cotton-wool, at least an inch or two in thick- ness, over which should be poured a couple of tea- spoonfuls of laudanum, and this again should be cov- ered with the oil-silk. The patient usually complains bitterly of the smarting and burning from the turpen- tine, but this subsides in a short time after the flannel has been removed, and then it will be found that the abdomen is much flatter and softer, and that the pain is very much less, the patient being able to move and breathe much more easily. The countenance of the patient is frequently much improved in color, and she appears as if she had been stimulated by a cordial, and often the lochial discharge, which had been sus- pended, becomes free. For these reasons, I am con- vinced that the good effects of the turpentine are not wholly, or even chiefly, due to its rubefacient action, but to its absorption. The turpentine-stupes should be reapplied once or twice a day, if the abdomen show a tendency to again become distended and pain PUEEPERAL PERITONITIS. 349 ful, and the cotton-batting with the laudanum should "be reapplied every few hours, and continued until the subsidence of the abdominal symptoms. You will observe that the effect of the turpentine applications is very different from that of blisters. I sometimes find the latter very useful, when the symptoms of general peritonitis have, in a great measure, subsided, by apparent localization with induration, almost form- ing a circumscribed tumor. I have found a blister ap- plied over this point of great service, not only in speed- ily relieving the pain, but apparently in hastening reso- lution of the indurated tissues. Great care should be taken to prevent strangury from the use of the blister, and I therefore usually direct that it should be ap- plied in the morning, so that it can be well watched, and that it be taken off and a warm poultice applied as soon as vesication has fairly commenced. In this way, the blistered surface is well filled with the serous exudation, there is very little pain or soreness, and all danger of strangury is averted. (4.) In all cases where the peritonitis is a lesion of puerperal fever, I regard quinine as an agent of great value. I shall' more fully discuss its mode of action and its advantages, in connection with that subject. In all cases of general peritonitis, where the chills are re- current, or where there are any of the symptoms that I have before described as indicating a tendency to puru- lent exudation, I believe quinine is indicated. My ex- perience has gradually led me to the conviction that it is most useful when given in full, impressive doses, once or twice a day. As a general practice, in the class of cases that I have just referred to, I give from five to ten grains of the sulphate or the hydrochlorate of quinine in the morning, and from ten to twenty grains in the 350 PUERPERAL DISEASES. evening. It is seldom that patients with this disease complain of the unpleasant effects of the remedy in such doses such as headache, giddiness, or ringing in the ears and, if they do, the quantity should be slow- ly and cautiously reduced, if we would not lose all that we have gained from the use of this agent. (5.) For many years, I have found alcoholic stimu- lants of great service in general puerperal peritonitis. I think the following effects can be very manifestly ob- served to result from their use : (.) If alcohol do not act as food, it seems to diminish waste, and thus, according to Dr. Lionel S. Beale, it tends to cause a diseased tex- ture, in which vital changes are abnormally active, to return to its normal and much less active condition. ( M H M Hours. Gtts. Gtts. Gtts. Professor Barker, with Dr. Pink- Wed'y, Apl. 10. 2 15 p. M 12 83 130 104| 34 ney. Enormous tympanitic distention of abdomen. Pain severe ; respiration wholly tho- racic. To have milk or beef- 2.45 " 3.10 " 4.00 " 15 6 88 tea ad libitum. Brandy, a half-ounce every hour. 4.20 " 6 SS 5.00 " 45 5.30 " 6 3 ss Between 5 and 7 P. u., slept. 6.10 " .... 55 6.30 " 6 88 7.00 " 60 7.30 " 6 ss 8.00 " 20 8.30 " 6 9.00 " 70 10.15 " 90 6 88 160 20 Very feeble, and restless. 11.20 " 60 6 83 11.40 " Sweating. 12.00 " 90 88 140 Thurs., Apl. 11. 6 1.15 A. M 25 6 SS No sleep. 2.10 " .... 30 6 3 ss 3.15 " 20 6 88 4.00 " .... 80 6 20 5.00 " 80 88 8.00 " 90 3 ss 108 30 Slept some, between 8 and 10. 9.00 " 90 88 10.30 " 50 Great pain in urinating, and se- 11.30 " 1 10 P M. 60 30 88 34 vere burning and constant pain in region of the bladder. 1.40 " 40 88 108 102 28 acid, by direction of Professor 2.45 " 40 Barker. 3.30 " 90 8 j 140 103| 4.45 " 90 8 33 136 103} 6.05 " 60 6 j 134 7.15 " .... 80 6 88 136 104 8.15 " 80 6 128 103-J- 9.40 " 80 j 104| 10.50 " 6 104 11.15 " Friday, Apl. 12. 80 j The respiration became slower. Constant nausea. 1.30 A. M 80 j 120 1041 16 Pulse feeble and thread-like. Im- 2.15 " 2.45 " 3.45 " ... 80 30 6 Sj pulse of heart very weak. Professor Barker substituted digi- talis in place of veratrum vi- ride. 358 PUERPERAL DISEASES. RECORD OF CASK (Continued). TIME. Magendie's sol. of morphine, Internally. Solution of morphine, hypodcrlnically. Tincture of digitalis. tit O pq (S Temperature. | Respiration. | REMARKS. Hours. Gtts. Gtts. Gtts. Friday, Apl. 12. 5 50 A. M 80 C j 102i 8.45 " 80 j W 101} 9.45 " 10 1045 " 80 101} 11.15 " 12.45 P. M 70 ., , Appears much better. Has slept 1.45 " 2.45 " 70 70 3 S3 96 101} 101} considerably. Vaginal injection as before. 4.00 " 70 o 4.20 " 30 132 102} 5.-20 " 70 " ss Nurse obliged to leave her, by 6.15 " 30 128 102} which she was much excited. 8.05 " 80 103^ 9.40 " 80 154 104 32 10.40 " 80 148 103} 11.45 " 80 Satur'y, Apl. 13. 1.10 'A. M 80 80 Verat viride. 10 140 103^ Constant and severe pain. Vaginal injection. .. "* 2.10 " 2.45 " SO 3.15 " 80 3.45 " ... 80 4.30 " 10 103^ 4.40 " 80 128 5.05 " 30 Pain much relieved, but no sleep 5.50 " 30 10 120 103 since one o'clock yesterday af- 6.20 " 30 ternoon. 8.00 " 80 9.30 " 80 11.00 " 80 10 128 103 Brandy. 12.00 M 80 20 10 S3 128 103 J.40 p. M 3 ss 128 1031 24 No sleep. 1.55 " 80 VW JJ 2.40 " 30 3J Vaginal Injection. 4.35 " 10 3J 102J 5.00 " 30 T.20 " 3J 120 102 24 At 9.30 an involuntary and un- 10.00 " 30 conscious discharge from the 10.40 " 12.00 " ..-.. 80 80 5J 3J 120 102} so bowels. Intense pain. Sunday, ApL 14; 1.00 A. M 2.30 " 90 30 10 3 S3 120 102} No sleep. General appearance very much worse. Evidently failing. PUERPERAL PERITONITIS. 359 RECORD OF CASE (Continued). 1 i 1| 1 TIME. .-9 '(U II 1 1 REMARKS. it II CD .9 ! 1 II P 1 1 1 i H 7* M Hours. Gtts. Gtts. Sunday, Apl. 14. 3.00 A. M 30 4.25 " ;-... 80 3* j 126 103 5.20 " 90 !J 6.20 ' 90 7.50 < 90 3 j 8.50 ' 90 j 9.30 ' grs.x 101 10.00 ' 11.20 ' 1.45 p M 3.15 < 90 90 90 !J fj !J 108 108 101 A very large and extremely offen- sive passage from the bowels, without pain, followed by col- lapse, and very cold extremi- ties. 4.05 < 90 !J 4.15 ' 30 4.25 " 30 Blister, 5x5, over hypogastrium. 6.00 " 80 2" j. 120 102 28 7.10 " 80 grs. xv. ss 8.00 " 80 1J 102^ Digitalis 9.10 " .... 80 10 Removed blister, and applied 10.00 " .... 80 SJ 120 103 poultice. 11.00 " 90 5 j 102 12.00 " 80 S3 No sleep ; refuses brandy. Monday Apl. 15. Ilydrat. chloral. 1.00 A. M 80 10 grs 2.00 " 90 112 102J 3.00 " 30 10 grs 3.30 l! 90 5.15 " 90 10 grs 6.00 " 90 101J 7.00 " 90 1 S3 Quinine, grs. x. 8.00 " S3 102 A very large passage from the 8.30 " 90 10 grs bowels, without pain. 10.30 " 90 3 j Vaginal injection. 11.00 " 10 grs 12.00 M A large passage. 1.00 P. M ij 128 101J 27 2.00 " 10 grs 3.00 " 20 Quinine, grs. xv. 5.00 " 8.15 " 10.30 " 50 15 grs 15 grs I j 128 128 128 101J lOli 28 28 No pain after this hypodermic in- jection. Begins to get short and frequent naps. 12.00 " Tuesday, Apl. 16 2.00 A. M 15 grs 128 120 102J lOli 28 Complains of severe pain under left breast, after taking any thing in the stomach. 3.40 " .... 15 grs 360 PUERPERAL DISEASES. RKCOBD OF CASE (Continued). TIME. Miijrr n die's sol. of morphine internally. Solution of morphine, hypodennically. Veratrum virlde. q e B 3j 1 Temperature. Bespiration. BEMARKS. Hours. Gtts. Gtts. Gtts. Tuesday, Apl. 16 5.00 A. M 80 6.00 " 30 112 lOOf 28 Has slept soundly nearly two 7.15 " 90 hours. 8.15 " 90 8.30 " 30 9.20 " 90 9.50 " 90 99 25 11.20 " 99 11.30 " 90 112 12.15 p. M 104 1.00 " 90 1 45 ' 120 100 23 2.45 " 90 !J Pain very severe in cheat and 3.30 " 30 99 left shoulder. 4.45 " 90 SJ 6.00 " 90 j 7.00 " 90 ss 8.00 " 90 IBS No sleep. 9.00 " 90 ss 10.00 " 90 10 140 99 80 Breathing badly. 11.00 " 90 j Quinine, gr. XT. 12.00 " 90 10 Wed'y, Apl. 17. 1.00 A. M 90 1.30 " 6 128 100 28 2.00 " 120 3 ss 3.10 " 90 3 ss 3.45 " 30 6 4.15 " 90 1 S3 4.45 " 90 6.00 " 90 6 128 lOOj 27 6.45 " 90 3J 7.30 ' .... 90 8.30 ' 90 6 9.30 ' 90 j 111 99 26 Bleeping finely. 10.30 ' 90 Calls for food. 11.50 ' 90 3J 1230 p. M 90 6 1.25 " 90 li Moved her to another room, which she bore well. 2.00 ' 3.00 ' 90 90 6 3J Sleeps between each dose. 3.30 ' 90 C 4.00 ' 90 112 5.00 ' 90 3J Quln. 6.00 " 90 gr.xv 8.00 ' 90 6 j 112 99 28 PUEEPEKAL PERITONITIS. 361 RECORD OF CASE (Continued). TIME. Magendie's sol. of morphine internally. Veratrum viride. f o> I Temperature. Respiration. REMARKS. Hours. Gtts. Gtts. Wed'y, Apl. 17. 10.00* p. M 90 12.00 " 90 1J Thurs'y, Apl. 18. 1.00 A. M.. . . 90 - j 112 lOOf 27 1.45 " 90 3.00 " 90 3.30 " 90 5 10 " 90 6.20 " 90 lOlf Lay on her back for two hours. 7.40 " .... 90 Complains greatly of difficulty in 8.20 " 90 breathing. 9.00 " 103} 34 9.45 " 90 10.00 " 90 11.45 " .... 90 1.00 P. M 1.50 " 90 3 1 88 Has taken more nourishment than 2.20 " 90 usual. 2.50 " .... 3 SS 103 Dr. Barker finds pleuritic effusion in 3.20 " 90 the left side. 3.50 " 90 SS 4.00 " 3 4.20 " 90 Sleeps well, but often starts and jumps 5 00 " 3 in her sleep. 5.25 " 90 6 !j 144 101} 36 6.15 " .... 90 6 6.40 " 6 ij 7.00 " 90 7.45 " 90 8.00 " 90 3 ss 120 102^ 28 8.50 " 90 9.50 " 90 3 Very large passage from the bowel*. 10.50 " 90 11.15 .... 3 1J 12.00 " 90 122 104} 28 Friday, Apl. 19. 12.50 A. M 90 A second large passage. 1.10 " .... 3 1.20 " 90 1 j 1.30 " 122 103 28 2.00 " 90 2.30 " 90 8S Sleeps welL 3.30 90 4.10 .... 120 88 4.45 " 90 6.00 " 3 SS 102 Fain most intense. 6.00 " 120 102} 7.00 " 90 3 362 PUERPERAL DISEASES. RECORD OF CASE (Continued). ** 4 i ij i 2 TIME. - > g 3 3 EEMAEKS. l! i 1 3 . 1 1 IF 5 3 ss ~ la > 5 i & - - Hours. Gtts. Gtts Gtts Grs Friday, Apl. 19 8.40 A. M 90 103 9.05 " ... 3 9.15 " ... 3 120 30 9.40 ' ... 90 Pain in left chest very severe. 10.40 ' ... 90 11.40 90 1 00 p M 3 120 104 30 Applied blister to left side of 1.25 90 chest. 3.00 90 3 4.00 90 Two large passages. 5.00 90 5.45 3 120 103 6.30 Removed blister and applied 7.30 80 poultice. 8.00 3 120 104 25 Quinine, gr. xv. 10.30 3 11.00 Satur'v, Apl. 20. 12. 30 "A M 90 103| Very large and watery movement of the bowels. Gave rectal injection of two 2.15 5 144 103J ounces of starch and one drachm of McMunn's elixir 2.25 90 opii. 2.50 5 Went to sleep. 4.15 5 144 103| 4.40 90 Great difficulty in passing water. 6.00 5 6.30 90 103 7.30 5 8.30 90 Complains of great pain and diffi- 9.30 6 104 culty in passing water. 10.15 90 10.30 6 10.50 132 103| 11.30 6 10 Vaginal injections. 12 55 P M 10 136 103J 24 Dr. Barker suggests the Magen- die's solution be given up. and McMunn's elixir opii given 1.15 " instead. FMnim'i elixir. 1.20 " 60 6 2.35 " 80 132 24 Sleeps now most of the time. 4.45 " 120 102$ 1 6.00 " 118 102$ l 7.00 " 60 Micturates with great pain and 8.50 " 9.00 " 15 120 102^ 24 scalding. Afterward verv faint, but face crimson, calling'for air, 10.00 " 6 12.00 " 120 120 1 Cold sweat, extremities cold. PUERPERAL PERITONITIS. RECOED OF CASE (Continued). 363 TIME. McMunn's elixir opiL Tinct. ferri chloridi. a 5 g OH Temperature. Kespiration. REMARKS. , Hours. Sunday, April 21. . . . 12.15 A. M 60 60 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Gtts. 6 120 120 120 120 120 120 108 96 108 112 102J 102 lOlf lOli lOlf lOlf 101J 100J 99f 99 99f 24 24 24 35 32 32 32 32 Slept some, but breathes badly. Dr. Barker suggests tine, ferri chloridi, in 5-drop doses every hour. Takes more nourishment bran- dy, milk, and eggs. Pain and swelling in left groin, which was painted over with iodine. Pulse very much stronger, and of better character. Pain and scalding still severe in micturition, and constant in the vagina. Severe griping pain in abdomen, followed by an enormous, green, clay-colored stool. Another enormous and painful discharge from the bowels. Perspirations, yet complains of being cold. Good appetite. Asks for beef- Bteak, which is given. Xanseated, and finally vomits. Mustard-plaster to stomach. Asks for beef-tea. Breathes easier, and looks much bet- ter. Sleeps. 2.50 " 3.10 " 3.15 " 4.25 " 7.00 " Quln. gr. x 9.10 " 11.00 " 12.30 p. M 1.30 " 2.30 " 3.30 " 4.50 " 6.00 " 6.30 " 6.30 " 8.00 " 9.00 " 10.00 " 11.35 " Monday, April 22... . 1.00 A. M 2.00 " 3.25 " 4.00 " 4.40 " 8.20 " 9.15 " 10.45 " 12.00 M 1.30 p M 2.30 " 3.40 " 6.15 " 8.25 " 9.20 " 9.45 " 12.00 " Tuesdav, April 23 1.00 '" 3.00 " 4.30 6.00 A. M 8.15 " 10.20 " 364: PUERPERAL DISEASES. RECORD OF CASE (Continued). 3 TIME. 1 I KEMAEKS. I 1" t 1 fi 1 1 Hours. Tuesday, Apl. 23 10.30 A. M 104 99 12.40 p. M 5 1.60 5 100 98 J 4.00 5 100 98f 28 5.00 5 From this time, the convalescence waa 7.00 5 Tery rapid. 8.50 100 98f 9.15 ' 5 11.00 ' ..,. 5 LECTURE XVII. PELVIC PERITONITIS AND PELVIC CELUJLITIS. Case Epidemic influence not confined to zymotic diseases Pelvic peritonitis and cellulitis are often met with when puerperal fever is epidemic What is under- stood by the terms pelvic peritonitis and pelvic cellulitis Reasons for using- these terms instead of others which have been proposed Causes Patho- logical anatomy Cases Duration Terminations ; (a) resolution ; (6) adhe- sions ; permanency of these adhesions ; (c) suppuration Treatment. " CASE XXIX. 1 Mary R , aged twenty-eight, born in Ireland, widow, had one child four years ago, which she says was delivered by instruments and was still-born. After this confinement, she soon re- covered her health. Her second labor began November 18th, and lasted about twenty-four hours. The child presented by the foot, was still-born, and weighed thirteen pounds. The fourth day after de- livery, the patient had a severe chill, followed by high fever, abdomi- nal pain and tenderness, nausea, and vomiting of a greenish mate- rial. The record shows that for three days she had a pulse ranging from 116 to 128, and a temperature of 103-104. She was treated by morphine and veratrum viride, turpentine-stupes and abdominal fomentations, quinine and stimulants p. r. n. Ten days after, on the fourteenth day after her confinement, all bad symptoms had disappeared, and she was able to be up and walk about the ward. " December 18th. She was transferred from the convalescent lying-in ward to the uterine ward, of which I then had charge. A few days before her removal to my ward, she had a recurrence of chills, with moderate abdominal pain and tenderness, loss of appe- tite, and profuse perspirations. On my first examination, her pulse 1 Eeported by Walter Judson, M. D., house-physician to Bellevue Hospital. 366 PUERPERAL DISEASES. was 128 and very feeble ; temperature 103.5, some abdominal pain and tenderness, and moderate tympanites, vomiting occasionally a greenish matter, bowels constipated, micturition not painful, now and then slight chills, but very frequent and quite profuse perspira- tions, countenance anxious, and eyes sunken and surrounded by dark lines. On vaginal examination, the uterus was immovable, with great tenderness on all sides, but much more marked in Douglas's cul-de-sac and on the left side of the uterus. The patient was treated by hypodermic injections of morphia, stimulants p. r. n., and large doses of quinine with dilute phosphoric acid. " December 20th. Pulse 140 ; temperature 104.5 ; symptoms as before, but worse. " December 22d. Patient rapidly failing ; temperature 105 ; pulse '160 ; profuse perspirations and occasional delirium. Died at 5 P. M., December 22, 1870. " Autopsy. Larynx and trachea present yellowish mucus in their interior, with the odor of gastric juice. Brain, heart, lungs, and liver, normal, as. also were the kidneys and spleen. Stomach and intestines distended with gas, and the stomach was filled with a large quantity of yellowish fluid, which had the odor of gastric juice. The intestines were glued together, and, in the pelvis, on the left side, there was an abscess shut in between a knuckle of in- testine, the uterus, and the broad ligament. Within the broad liga- ment of this side, there was also an abscess, which communicated with the peritoneal abscess. The uterus was four inches in length, and all its tissues appeared normal for the time after delivery. The ovaries were also normal." Gentlemen: I suppose that there is no one subject pertaining to medical science, concerning which our ignorance is more absolute, than with regard to the O O causes and nature of epidemic influence. It bloweth where it listeth and we see the effects thereof, but can- not tell whence it cometh or whither it goeth. For the last two years, small-pox has been prevalent in all the great cities of the civilized world in London, Paris, Berlin, Manchester, Liverpool, New York, and Philadelphia to an extent not known before for half a century ; and it is found that great numbers at this time PELVIC PERITONITIS AND PELVIC CELLULITIS. 3G7 are susceptible to the vaccine virus, who have been often vaccinated before, without any result. And so I might refer to cholera, influenza, diphtheria, and numer- ous other diseases, which at various times have appeared in the same way. Neither is this epidemic influence re- stricted to what are called zymotic diseases. We see it equally apparent in what we generally regard as local inflammations, of which I might give numerous illustra- tions. In the winter of 1859-'60, this influence was very remarkable in the development of mastitis and mam- mary abscess, not only in this city, but, as I have learned from the statements of physicians, in other parts of this State and in New England. At that time, three out of every four who were delivered in this hospital exhibited more or less tendency to mammary abscess, until I adopted the plan of putting every one after delivery under treatment, with full doses of quinine, which proved to be an efficient prophylactic. Now I can almost say, that we have an epidemic of pelvic peri- tonitis and pelvic cellulitis. When I came on duty at my present term of ser- vice, there were four of these cases in the obstetric, and seventeen in the uterine wards, of which thirteen ori- ginated during the puerperal period. I may add that I have seen, within a few weeks past, eight cases of this kind, occurring in puerperal women, and I have heard of others seen by Dr. Peaslee and Dr. Thomas, within a certain district of the northeast part of the city, that is, between Fifty-fifth and One Hundred and Fourth Streets, east of Central Park. When puerperal fever is endemic in this hospital, we generally have a few cases of pelvic peritonitis and pelvic cellulitis. It would seem that they occurred in patients who were moder- ately infected by this poison, but only to such a degree 368 PUERPERAL DISEASES. as to cause these local troubles. So my friends, Dr. Sims and Dr. Emmet, have often remarked to me, that they could always assume that we had puerperal fever in Bellevue, when they found that they could not per- form any surgical operation on the pelvic organs at the Woman's Hospital, on account of the great tendency to pelvic peritonitis and pelvic cellulitis. But at the present time, and for months past, we have had no puerperal fever in the hospital, nor have I heard of a case in the city. I mention this latter fact because eleven of the thirteen cases in the uterine wards were not delivered in the hospital. Before going any farther, I shall define what I mean by pelvic peritonitis and pelvic cellulitis, be- cause these terms were not found in medical writings until within a comparatively recent period ; and I shall also briefly give my reasons for adhering to their use, instead of accepting others which have been proposed. By pelvic peritonitis is meant, inflammation of the serous covering of the uterus, or of its appendages. Virchow has proposed the term peri-metritis for this inflammation, using the Greek word Tre/^, as implying inflammation of serous membranes, and irapa, to imply inflammation of the cellular, or connective tissues. These terms have been adopted by many in Germany and by a few in other countries, the most eminent of whom are Matthews Duncan, of Edinburgh, and the late M. Aran, of Paris. But I very much doubt whether they will ever be generally accepted, and for these reasons : (1.) There is nothing significant in the Greek word Tre/ai, as carrying the idea of serous membranes, or in the word mipa, as referring distinctly to cellular or connective tissue. (2.) Their use in this arbitrary sense is not warranted either by precedent from analogous usage, as PELVIC PERITONITIS AXD PELVIC CELLULITIS. 369 applied to any other organs of the body, or by the ne- cessity for new terms to distinctly define the disease. No one, as yet, has proposed to substitute the word peri-pneumonitis for pleuritis, or endo-pneumonitis for bronchitis. It is true that we have the word peri- carditis, meaning inflammation of the serous covering of the heart, but this word is used because pericardium is the accepted name of this serous membrane, and not for any reason in connection with the prefix peri. (3.) Because these prefixes have already been adopt- ed in medical literature, with a different and even an antagonistic meaning. Trousseau uses the term abces peri-nephrique (peri nephritic abscess), and abces peri- liysterique (perimetritic abscess), meaning, in both in- stances, abscess of the cellular tissue around these organs. Dunglison, in his " Medical Dictionary," uses the word para-nephritis, to express inflammation of the suprarenal capsules. Professor Thomas, who has an evident predilection for classical nomenclature, in which he is generally very correct, devotes a chapter of his most excellent work on ." Diseases of Women," to Periuterine cellulitis, a Greek prefix used in exactly the opposite sense to that which Virchow proposed, con- joined with a Latin noun. By pelvic cellulitis is meant inflammation of the cellular or connective tissue around the uterus, the ovaries and broad ligaments. The terms periuterine or perimetritic phlegmon, inflammation or abscess of the broad ligaments, and pelvic abscess, have each been used by different writers to describe the same disease, but all of them are objectionable, from the fact that each describes only a limited phase or a certain stage of the disease. We study pelvic peritonitis and pelvic cellulitis to- 24 370 PUEKPERAL DISEASES. gether, because they are usually associated with each other, and it is often very difficult, and frequently quite impossible, to determine which disease preponderates or is the primary affection, and because the therapeutic in- dications are very much the same in both. The two affections occur in non-puerperal women, but I beg that you will bear in mind that all I have to say in regard to them will be confined to their discussion as puerperal diseases. Both affections originate from the same common O causes, which I shall mention in the order of frequency, as they have occurred under my personal observation : (1.) The special poison of puerperal fever and epi- demic influence. (2.) Imprudences, such as rising out of bed prema- turely, too long continuance in the erect posture, too early resumption of family duties or of sexual inter- course, etc. (3.) Metritis, especially endometritis and phlebitis. I have very little doubt of the cardinal fact which Dr. Matthews Duncan so strenuously insists upon, that both of these affections primarily originate in some uterine lesion, but, as cases come under our observation in act- ual practice, we have not always positive evidence of this, even after the most careful inquiiy into their ante- cedent history. Inflammation of the peritonaeum in the pelvic cavity produces the same results as when it occurs in other parts of this serous membrane. There is first hyper- aemia of the tissues, and then exudation. The disease may terminate at this stage by absorption and resolu- tion, or in adhesion, and there results agglutination / 7 OO of the different organs within the pelvic cavity. Thus we find adhesions of the uterus to the rectum, to PELVIC PERITONITIS AND PELVIC CELLULITIS. 371 the bladder, to the ovaries, to the Fallopian tubes, to any part of the broad ligaments, or to some portion of the intestines, as in the case just read to you, in which the adhesions between the broad ligament of the left ide and a knuckle of intestine included a purulent col- lection. Dr. Matthews Duncan was the first to signalize the fact that the serous effusion in some cases becomes encysted by adhesions. I have no doubt of this fact, and I shall to-day bring before you the patient, whom you saw two weeks ago, when, at the close of my lect- ure, I drew off nearly two ounces of serum from what I suppose to be such a cyst. In a more advanced stage of pelvic peritonitis, the effusion becomes sero-purulent or purulent, with a ten- dency to accumulate in the more dependent parts of the pelvic cavity. But suppuration may occur at any part of the peritonaeum, and in different parts at different periods, and small purulent cavities may be found, in- closed by adhesions, between the uterus and the blad- der, or the uterus and the rectum, or on the surface of the broad ligaments, or included between-intestinal ad- hesions and the uterus or some of its appendages. In some cases, the suppuration results in one large puru- lent collection, and this may terminate in perforation and discharge into the cavity of either of the viscera to which it may be adherent. The most frequent seat of pelvic cellulitis is at that point of the cervix uteri, posteriorly and laterally, where the vagina is attached, as here the cellular tissue com- O ' .municates freely with that which surrounds the vagina, and also with the cellular tissue of the adjacent organs and the iliac fossa; in the broad ligaments ; and pos- teriorly, between the vagina and that part of the peri- tonaeum which covers the recto-uterine cul-de-sac. The 372 PUERPERAL DISEASES. cellulitis is not confined to the original seat of the at- tack, but extends by contiguity to all the cellular tissue in the pelvic cavity. It follows the same laws as phlegmon in other parts of the body, and may termi- nate by resolution or suppuration. Before describing to you the signs and symptoms of pelvic peritonitis and pelvic cellulitis, I shall bring before you two cases, which will aid me in giving you a clear idea of these affections: You will remember the first patient, Bridget M , whom you saw in this room two weeks ago to-day. I shall briefly recall to your minds the chief points in her case. She is married and has had four children, the last of which was born October 16th. She .was at- tended at that time by a midwife, but her labor was less than two hours. One week after, she was able to be up and resume her ordinary work ; that is, to do the cooking for her family and take care of her children. The day that her child was three weeks old, while engaged in washing clothes, she began to suffer from "pain in the womb," as she says, and this finally became so severe that she was at last compelled to give up her work and go to bed. She does not recollect that she had any chills, but she was quite unable to pass water either that day or night. The next morning, she had nausea and vomiting, and the pain had ex- tended over the whole abdomen. In the afternoon, she was visited by the midwife, who told her that she had " falling of the womb," and pretended to replace it. She also put a hot poultice over the abdomen, and gave her sweet spirits of nitre. After this, she passed a little water every few minutes day and night, but always with great pain. The third day from her attack, she .was visited by a dispensary physician, who advised that PELVIC PEKITOXITIS AND PELVIC CELLULITIS. 373 she should be removed to this hospital. She was brought here the next day, November 10th, and Dr. McBride, finding that her bowels had not been moved for several days, ordered a full dose of castor-oil, and an enema a few hours after, if the oil did not operate. It was found impossible to give her the enema, as it not only caused her great pain, but it would not pass into the bowels. However, the oil acted very freely during the night, although its action was painful. I first saw her in this amphitheatre, November llth. You will remember that her countenance was very anxious and sunken, and her pulse very rapid, but we could draw no inference from these symptoms, as she was very much excited and nervous in being brought before such a crowd of young men. She lay on her back with her left leg drawn up, which she said was the position that caused her the least suffer- ing. On physical examination, I first introduced a catheter and drew off about eight ounces of very offen- sive urine. "We then found a decided prominence in the left inguinal region, as compared with the right, and this could be seen very plainly by you all, when I persuaded her to extend her left leg for a moment or two. This prominence was very painful on pressure, so that I was unable to make out any well-defined tumor, but the swelling seemed to extend above Poupart's ligament. Pressure was much better borne over the right iuo;ui- o o nal region, and you will remember that I thought I could distinctly trace the fundus uteri here, just above .the pubis. On vaginal examination, I described the pelvic cavity as being filled ; and particularly the left half, as being full, hard, and very sensitive to pressure, while it was very evident that there was marked right lateral obliquity of the body of the uterus. The cer- 374 PUERPERAL DISEASES. vix was large and tender, and the uterus was fixed and immovable in any direction. A rectal exploration con- firmed the conclusion that I had arrived at from vaginal, examination, but, on compressing the swelling on the left side of the uterus between the first finger in the vagina and the second finger in the rectum, I was quite sure that I got an elastic, yielding impression which wa.s due to a contained fluid. Now, although she would not admit that she had ever had chills or even passing chilly sensations, yet my diagnosis was abscess of the left broad ligament, and I expected to demonstrate its correctness by passing into the swelling a small explor- ing trocar, and getting some drops of pus ; but, instead of pus, you saw flow through the canula, nearly two ounces of a straw-colored fluid, without any purulent aspect. I then remarked that it appeared to be one of those cases of pelvic peritonitis which I had never before met with, but which had been described by Dr. Matthews Duncan as " serous encysted peri-metritis." My directions were, that the patient should remain in bed, and that rectal suppositories of opium and butter of cacao should be used as often as was found necessary to keep her free from pain, that the left inguinal region should be painted twice a day w T ith the tincture of iodine, and that every other morning she should take our compound laxative powder of magnesia, 1 and, as she was very anaemic, she was also to have twenty drops of the tincture of the chloride of iron and three grains of sulphate of quinine, three times a day. 1 5. Magnesia carb., Magnesia sulph., / Sulphur, sublim., f fl Potass, bitart., M. S. From a teaspoonful to tablespoonful of the powder, in sugar and -water, early in the morning. PELVIC PERITONITIS AXD PELVIC CELLULITIS. 375 For the last four days, she has been up and around her ward, and to-day she insisted that, instead of being carried on a stretcher, she was able to walk up to this room, but this we would not permit her to do. You now see the great change in her appearance. The mam- mary secretion, which was very scanty when she en- tered the hospital, is now abundant, she declares that she has now absolutely no pain, and she is anxious to leave the hospital and return to her family. But, as there is still a good deal of tenderness and tumefaction around the uterus, which remains fixed and immovable, we shall try to persuade her to remain here another week. In the next patient, we have quite a different history, which Dr. McCreery will please read to you : " CASE XXX. 1 Annie N , nged twenty-five, born in Eng- land, married, was delivered of a boy, after an easy labor of five hours, August 8, 1871. She had one child five years ago, which died of scarlet fever when about three years of age. The patient did well for the first eight days after confinement, but then, after being moved from one ward to another, she began to complain of pain in the left inguinal region, which, she says, was relieved by walking, and was worse at night and in bad weather. I could not get a very satisfactory history of her case during this time, as Dr. , who then had charge of her, is now ill, but I am told that this pain con- tinued, and the patient began to lose appetite and strength, and emaciated rapidly. Early in October, a small, hard swelling was noticed in the left groin, which rapidly enlarged and softened, and, in about ten days, was opened, giving exit to very little pus, but to a great deal of offensive gas. Poultices were applied, and on the next day the opening began to freely discharge pus, and continued to do so for twelve or fourteen days, when it gradually decreased, and the escape of offensive gas from the opening entirely ceased, but she neither recovered her appetite nor strength. On the 1st of November, she came under my charge. She was confined to her bed, 1 Reported by J. A. McCreery, M. D., house-physician to Bellevue Hos- pital. 376 PUERPERAL DISEASES. very weak and anannic, and extremely emaciated. There was a large, hard, red, and tender swelling, with irregular but well-defined edges, occupying a large part of the hypogastric and left inguinal region, and from an opening in this swelling a very small amount of pus escaped. On vaginal examination by Dr. Barker, the uterus was found with the fundus pushed to the right side, fixed and im- movable, and, to the left side of the cervix, the roof of the vagina was hard and swollen, and very tender on pressure. The tumor was ordered to be painted with iodine twice a day, immediately after which a poultice was to be applied, and quinine and iron were to be given three times a day. She was also ordered an ounce of whiskey three times a day. On the day after the examination, she complained of a throbbing pain in the part, and, on a second exam- ination, softening was found to have begun at a little distance from the first opening. This softened spot gradually increased in size, and approached the surface, and, on November 9th, it broke, giving exit to considerable clotted blood, mixed with pus of a very offensive odor, but with no escape of gas. After this, the patient felt much relieved, and she recuperated rapidly. Her appetite returned, she gained strength, micturition and defecation became regular, and were no longer attended with pain. At the present date (November 23d) she has no pain, except in the back when she sits up too long, and she has gained very much in flesh and strength during the past week. The swelling is now less than one-third of its former size, is not so hard, nor is it very tender on pressure, and there is now no dis- charge from the opening. On vaginal examination, but little change can be found of the organs in the pelvic cavity, as the uterus is firmly fixed and immovable. There is, however, evidently less tumefaction, hardness, and tenderness around the cervix." I copy from her obstetric card, which includes eight days after her confinement, the record only for the sixth, seventh, and eighth days, as, previous to the sixth day, the record exhibited a perfectly normal condition : " August 14th. Pulse 96 ; respiration 24 ; temperature 102.5. Chills during the day, with nausea and vomiting, but no pain any- where. " August 15th. Pulse 112 ; respiration 24 ; temperature 102.5. Chills again, followed by nausea and vomiting. Bowels not moved for two days. Complains of a good deal of pain in passing water, but no pain at any other time. 'Ordered ten grains of Dover's powder, with five grains of calomel, to be taken at bedtime. PELVIC PERITONITIS AXD PELVIC CELLULITIS. 377 " August 16/i. Pulse 96 ; respiration 20 ; temperature 100. Slept well. Bowels have moved twice. No chills, nausea, nor vom- iting." The patient assures us that she has had neither chills, nausea, nor vomiting, since she first began to suffer from the pain in her groin. In this case there is no doubt that the dominant affection has been pelvic cellulitis ; but we have also strong reason for believing that pelvic peritonitis has coexisted. The two diseases are often associated, and again one is often consecutive to the other. Now you will naturally ask, What are the symptoms and sisrns of each of these affections, and how are we to O * decide whether we have to deal with one or the other, or, if both, which predominates ? It would be very desirable to give a clear and satisfactory answer to these questions ; for although, as I have before re- marked, the therapeutical indications in the early peri- ods of both diseases are very much the same, yet the prognosis is infinitely more grave, in pelvic peritonitis, if the disease pass into the suppurative stage, than in cellulitis. But it is impossible to base a differential diagnosis on the symptoms, as in the early stages they are nearly identical in the two diseases. A de- scription of symptoms, based on a preconceived the- ory of what they should be, from the pathological changes in the anatomical relations and physiological functions of the tissues involved, is not always verified by clinical observation, and this seems to me a mistake which authors have frequently made. Even Bernutz, . to whom, more than any one else, perhaps I should say, more than all others, we are indebted for our knowl- edge of pelvic peritonitis, seems to me in some instances to have fallen into this error, when he attempts to give the differential diagnosis between pelvic peritonitis and 378 PUERPERAL DISEASES. cellulitis ; as, for example, when lie speaks of retraction of the thigh as being common in cellulitis, but as not existing in pelvic peritonitis. Yet you will remember that this was a very marked symptom in the patient from whom I drew off, by puncture through the vagi- nal tumor, nearly two ounces of serum. It would be imjust, however, to omit to say that the differential diagnosis of Bernutz refers especially to non-puerperal cases of these diseases, and he expressly states that the diagnosis is very difficult in puerperal cases. The initial symptoms of pelvic peritonitis are chills, and, subsequently, nausea and vomiting, but they are less striking than in general peritonitis. The chills are often slight, and, when the disease occurs during an epi- demic of puerperal fever, in many cases they are not sufficiently distinct to be remembered by the patient, or be observed by the nurse. So also we often see cases in which there is neither nausea nor vomiting. In such, the first symptom complained of is pain in the hypogastriurn, or behind the pubes, and in the pelvic cavity. The pain often radiates to the hypogastrium, the lumbar region, and the anterior part of the thighs, and is increased by abdominal pressure over the pubes, or by pressure on the tissues within the pelvic cavity in making a vaginal exploration, by the slightest effort to move the uterus, by deep inspirations, or by a cough. The fever is generally moderate, the temperature rang- ing from 100 to 102, and the pulse is usually found between 92 and 108 per minute. There are generally loss of appetite, furred tongue, and constipation, and frequently painful micturition. In some severe cases, the patient finds it impossible to empty the bladder, and the catheter is required. Except in extreme cases, there is not the anxious expression of the face, the dry- PELVIC PERITONITIS AND PELVIC CELLULITIS. 379 ness of the tongue, the diarrhoea, or the great depres- sion of the vital forces, that is observed in general peri- tonitis. And now let us see what are the physical signs which are found in connection with these symptoms. Following the pain and the fever, there is a puffiness or swelling at the point most sensible to pressure in the hypogastric region. As the tumefaction is chiefly within the pelvic cavity at an early period, it is not easily appreciated by abdominal palpation, for it is dif- fuse and not well defined. But, at a later period, it is so distinct that it becomes comparatively easy to deter- mine its size and consistence. By vaginal exploration, the vagina is found hot, the neck of the uterus veiy large, usually patulous, and painful on pressure. The uterus is larger than normal for the period after deliv- ery, and is often more or less displaced, and immova- ble. We generally find one or more of the vaginal cul-de-sacs filled up and harder than usual, and some- times all the vaginal cul-de-sacs are filled up, and the neck of the uterus can only be distinguished by its ori- fice, being, as it were, buried in an indurated mass which fills the pelvic cavity. In these cases, the rectal exploration should never be neglected, as it permits ex- amination to a higher point in the cavity than the vagi- nal touch, and we are thus able to ascertain the form, extent, position, and density of the abnormal tumefac- tion. Thus far, neither the symptoms nor the physical signs give us any indication by which we are able to decide whether the disease be essentially an inflamma- tion of the serous membrane, or inflammation of the connective tissue. But, in the progress of the case, the characteristics of each become more manifest, and we 380 PUERPERAL DISEASES. are often able to form a pretty accurate judgment, either from the symptoms or the physical signs, or from a careful analysis of both, which has been the dominant affection. According to Bernutz, the differential characteris- tics of the two diseases in the puerperal period are the following : (1.) The initial pain in the pelvic organs occurs at an earlier period after labor in pelvic peri- tonitis than in cellulitis. (2.) The disturbance in the digestive functions (nausea, vomiting, diarrhoea) ex- ceeds in severity the febrile reaction in pelvic perito- nitis, while in cellulitis the febrile reaction is more prominent than the digestive disturbance. (3.) The different characters of the two swellings. For the last fifteen years, in my study of these cases, as I have met with them, in this hospital and in private practice, I have carefully borne in mind these statements of Bernutz, and I have been forced to the conclusion that the first two are based wholly on a preconceived theory, founded on anatomical considerations, and that they are entirely valueless in actual practice. In this hospi- tal, these cases are almost invariably consecutive to, and are often coincident with, other pelvic lesions, as metritis, phlebitis, and ovaritis, or they seem due to a moderate degree of infection from the poison of puer- peral fever, and both pelvic peritonitis and cellulitis occur, as has been demonstrated by numerous autopsies, at any time during the puerperal period, while the symptoms of febrile reaction, and those arising from digestive disturbances, are governed more by the spe- cial epidemic or endemic type of the season than by the anatomical seat of the inflammation. In private practice, the facts have been somewhat different. A large majority of those that I have seen have been in PELVIC PERITONITIS AXD PELVIC CELLULITIS. 381 consultation with others. In very many of them, there was no evidence that the disease commenced until after the accoucheur had ceased his usual attendance, and the development of the disease was unattended with symptoms of sufficient severity to induce the patient to send for her physician, until she had suffered for some days from loss of appetite, febrile exacerbations, ner- vous depression, and weakness, accompanied by certain symptoms referable to the pelvic organs, as a dragging weight about the uterus, perhaps occasional lancinating or throbbing pains, and difficulty or pain in micturi- tion or defecation. I therefore think it quite impossi- ble to establish a differential diagnosis from the symp- toms. But we are often assisted in forming an opinion " by the character of the two swellings," as Bernutz says, and by the progress of the case. The swellings within the pelvic cavity, as felt by vaginal exploration, are veiy much the same as regards induration and sensibil- ity to pressure, but there is no doubt that pelvic peri- tonitis causes a greater degree of uterine displacement than cellulitis, and that, when the swelling can be dis- covered above the pubis, it carries the uterus forward, and to the healthy side, and its borders are not easily determined, either by percussion or by pressure ; while the phlegmon has well-defined limits, easily marked by the sensibility and induration of the tissues involved, and often a well-marked tumor in the iliac fossa, and a projection of the abdominal walls above Poupart's liga- ment. As to the duration of these affections, I. may say that, when early recognized, with careful management and appropriate treatment, the symptoms in many cases disappear in a few days, and leave no trace behind. But in many others the improvement is slow, the appe- 382 PUERPERAL DISEASES. tite continues delicate and capricious, the tongue slight- ly furred, and there are febrile exacerbations, especially toward the evening, and several weeks elapse before the patient recovers. Day by day, the swelling and tenderness in 'the hypogastrium subside, the uterus dis- appears behind the pubes, and by vaginal exploration it is found that the hardness and swelling in the roof of the vagina have melted away, and that the tumor around the uterus gradually grows smaller until it entirely disappears. But, in many cases there result, from the inflammatory exudation around the uterus, adhesions which leave it more or less fixed and immova- ble in the pelvic cavity. Dr. Matthews Duncan, in his work to which I have before alluded, has discussed the subject of adhesions more fully and more satisfactorily than any other author. My own clinical experience is fully in accord with his statement, that there are two classes of adherent and fixed uterus, characterized by the one not having distressing pain in addition to the fixation, and the other having special pain as an ac- companiment. In the one, the fixation or the immo- bility of the uterus is the only disease in the pelvis, and this may exist for several years, the patients being in excellent health and making no complaints. But I have become cognizant of this condition by attending them when abortions have occurred, for which I could assign no other cause than the fixation of the uterus, which prevented it from rising out of the pelvic cavity as the pregnancy advanced. In the other class of adhe- sions, pain is more or less constant. The patient is never free from a dull sense of suffering in the vicinity of the uterus, which becomes positive pain from certain move- ments of the body, from defecation, and especially dur- ing menstruation, when the normal hypersemia of the PELVIC PERITONITIS AND PELVIC CELLULITIS. 383 period develops a more positive inflammatory action. In the accepted usage of medical language, it is con- ceded that even fibrous and osseous tissues may be the seat of a low grade of chronic inflammation, and I know of no pathological law why the walls of the non-gravid uterus should not be the seat of the same morbid pro- cess, and no philological law why we should not call this condition chronic metritis with adhesions. Some of these cases get well after the climacteric period has passed, but others do not, as my friend Professor Charles A. Budd and myself have had occasion to know by a tedious and trying experience in the treatment of one remarkable case. Another question of great interest is, whether these adhesions be permanent. I am fully convinced that, in many cases, after a certain lapse of time, they disappear. I have known the uterus to be fixed and immovable at one period in a very considerable number of women, and have subsequently found it perfectly movable. Pregnancy seems to effect a cure in some, probably by elongation and atrophy of the adhesions. A lady in this city, five months after marriage, was severely hurt by the sudden starting of the horses when getting out of her carriage, and aborted of a three months' foetus. O / Two weeks after, from imprudence, she had a severe attack of pelvic peritonitis, which in a few days became general, and came near being fatal. She re- mained an invalid for several months, suffering more or less from pelvic pains, and being unable to stand, .except for a few moments, or to walk any distance. "When she again became pregnant, she took the greatest care of herself in every particular, but again aborted at the tenth week. After convalescing from this mis- o carriage, her health rapidly improved, the pelvic pains 384 PUERPERAL DISEASES. disappeared, she was able to walk long distances with- out suffering or fatigue, and she had very much less pain with her menstrual periods than at any former time of her life. Both her husband and herself were very anxious to have children, and two years after her last abortion I was requested to examine her for the sole purpose of ascertaining whether I could find any cause why she did not become pregnant. I found marked right lateral obliquity of the uterus, which was absolutely immovable in any direction. The strongest efforts to move the organ caused no pain, neither did the introduction of the sound, by which I found the uterus to measure two and three-quarter inches. I could find absolutely nothing the matter with her except an ad- herent uterus, which I thought it utterly useless to attempt to remedy. My opinion was accepted as final, both by herself and husband, but I was particularly careful not to discourage their hopes as to the future. Three years after this, that is to say, about five years after her last miscarriage, she again became pregnant, and happily went through to the end, giving birth to a living child. When the inflammation, in these affections, passes into the suppurative stage, it is impossible to foretell how or when it will terminate. Authors seem to be agreed in stating that suppuration is a frequent termi- nation of pelvic peritonitis and cellulitis, when occurring % during the puerperal period, but, in my experience, this is very rare, except when they are associated with py- aemia or puerperal fever. It is with some delicacy that I make this assertion, apparently in contradiction to most authorities, and I may add that I am strongly in- clined to the belief that this difference in experience is due to the treatment by quinine carried to its ex- PELVIC PERITONITIS AND PELVIC CELLULITIS. 385 treme point of tolerance, which I have for some years adopted. Iii a few cases, these diseases do not seem to be influenced by treatment. After two or three weeks' illness, the patient begins to have hectic fever, with slight irregular chills; there is en tire loss of appetite, and the complexion has a leaden or often an icterode hue, all indicating that the affection has become puru- lent. There is a tendency for the pus to find an exit through various channels, more frequently either into the rectum or externally. The most common external discharge is in the groin, between the internal and ex- ternal inguinal openings. In rarer cases, the purulent collection finds an opening by the side of the anus, or on the upper and inner part of the thigh, or in one of the labia. When the exit of pus is internal, the dis- charge is most frequently through the rectum. In a smaller number of cases, it takes place through the vagina, and, still more rarely, through the bladder. In some exceptional cases, the pus has opened into the peritoneal cavity. Duncan expresses the opinion that the abscesses from cellulitis open more frequently externally than those resulting from purulent pelvic peritonitis, and Aran asserts, as his belief, that the latter very seldom find an exit through the abdominal walls. From a priori reasoning on anatomical grounds, I should be ready to accept this opinion, but I have seen too few autopsies of such cases to permit me to speak with any -authority on this point. But Hervieux, whose oppor- tunities must have been very large, expresses the same view so strongly as to make the mode of exit of pus a means of diagnosis between cellular abscess and peri- toneal abscess. He asserts that, in cellulitis, the pus 25 386 PUERPERAL DISEASES. has a tendency to burrow between the pelvic organs and find exit in fistulous canals, sometimes in the vicinity of the rectum, sometimes following the track of the sciatic nerve in one of the nates ; at other times, the pus finds exit at the upper and inner part of the thigh, through the crural canal, or, accompanying the round ligament, it finds exit in one of the labia. But he asserts that, where the peritoneal abscess tends to op/n, it follows other channels. It either opens externally at the hypogastrium, or into some part of the intestinal canal, or into the vagina, the bladder, the uterus, or into the peritoneal cavity. Only a very small percentage of the cases of pelvic peritonitis and cellulitis terminate fatally. In a few, the local peritonitis suddenly becomes general, and then the termination may be very doubtful. In the purulent forms of these diseases, patients may die from exhaustion, or from a general peritonitis induced by the opening of an abscess into the peritoneal cavity, and even some few instances have been reported where death has occurred suddenly from this cause without peritonitis. In the treatment of these affections, it is necessary, in acute cases, that the patient should be kept absolute- ly quiet in bed. Many times have I known slight im- prudences, as the patient regarded them, in getting up and moving around, to greatly intensify symptoms which had, in a great measure, been subdued by treatment, and manifestly prolong the continuance of the disease. In the next place, you should watch the condition of the bladder and the rectum. Pain in micturition is al- most a constant phenomenon in these cases, and it often happens that, by reason of this pain, the patient does not half empty the bladder, as I have found by introducing PELVIC PEEITOXITIS AND PELVIC CELLULITIS. 387 a catheter, and drawing off several ounces of extremely offensive and turbid urine, immediately after the pa- tient had made the effort to relieve herself. While this condition continues, for obvious reasons, the catheter should be used at least twice a day. As regards the use of laxatives, I am aware that some authors have recommended that, in the early stages of acute cases, the bowels ^should be kept constipated. I have tried this method in contrast with the plan of keeping the bowels soluble, and I am thoroughly convinced that it is a great error to allow the fa3ces to accumulate in the rectum. The condition is very different from that which exists in general peritonitis, as there is no indi- cation for arresting peristaltic action throughout the whole of the alimentary canal, and the mechanical irri- tation and stasis of the circulation in the pelvic cavity, produced by a distended rectum, are obviously injuri- ous. Again, I believe that the danger from general peritonitis is greater from the use of cathartics to over- come an induced constipation, than from the frequent use of such laxatives as easily and painlessly empty the rectum. I therefore usually direct that from a tea- spoonful to a tablespoonful of the compound magnesia powder be given early every alternate morning, or a tea- spoonful or more of the pulv. glycyrrhizae comp. 1 of the Prussian pharmacopoeia, may be given in a wineglass of cold water at night. The patient should be kept en- tirely free from pain by the use of opiates. The 1 Pulv. glycyrrhizaj comp. of the Prussian pharmacopoeia : 3. Senna-leaves, Licorice-root, powdered, aa iij. Fennel-seeds, Sulphur, aa 1J SS - Refined sugar, ix. M. An areeable and efficient laxative. 388 PUERPERAL DISEASES. amount required for this purpose is generally very moderate, as compared with what is required in general peritonitis. If the pain be very acute in the com- mencement of the attack, I usually overwhelm this at once by one hypodermic injection of the solution of the sulphate of morphia, and rely aftenvard upon rec- tal suppositories of opium, which should be used as often as is necessary to keep the patient perfectly com- fortable. The lower part of the abdomen should be kept covered with a hot poultice of ground flaxseed, over which should be placed oil-silk, so that the poul- tice may retain its warmth for some hours. After the acute stage has passed, cotton- w r ool, wet with laudanum and also covered with oil-silk, may be substituted for the poultices. I may remark here that, for some years, I have given up, in the treatment of these cases, local depletion, either by cupping or leeching, because I have become convinced that the annoyance, trouble, and evils, resulting from these means, more than counterbal- ance the benefit obtained by their use. In the cases which continue beyond the acute stage, I have, for the last fifteen years, been in the habit of recommending, and have found great benefit from, what may be called internal poulticing, twice a day ; that is, from the use of large vaginal injections of water as hot as can be comfortably tolerated. These maybe easily managed so as not to fatigue and annoy the patient, but greatly contribute to her comfort, and, by their influence in modifying tissue, greatly accelerate resolution and ab- sorption. The patient should lie across the bed, with the hips well over its edge, and the feet placed upon two chairs. An India-rubber sheet should be placed well under her, between her hips and her clothing, not only to prevent the latter from getting wet, but also to con- PELVIC PERITONITIS AXD PELVIC CELLULITIS. 389 duct the water, as it flows back from the vagina, down to a vessel which is placed on the floor. Then, by the use of a Davidson's syringe, two or three gallons or more of the hot water may be gently injected into the vagina by the nurse. A still more easy method is, to have a pail with a stopcock at the bottom, which con- nects with a long India-rubber tube, having a vaginal pipe at the end. This pail is placed on an elevation a few inches above the patient, and the water is al- lowed to run in and out of the vagina. Not only do patients generally derive great comfort from this warm poulticing, but, if the physician immediately after make a vaginal examination, he will need no argument to convince him what a powerful agent this is in modi- fying tissue. At an early period in the treatment of these affec- tions, I commence the use of quinine, giving it in as full doses as the patient can bear without -inconven- ience. For years past, I have often had occasion in this room to express my strong conviction as regards the anti-pyogenetic effects of this remedy, and I shall add nothing now on this point. If symptoms of suppura- tive cachexia and hectic fever come on, we must rely chiefly on quinine and alcohol, pushed to the point of tolerance as internal remedies, and on surgical means for giving exit to the purulent collection. LECTURE XVIII. PUERPERAL SEPTICAEMIA AKD PYAEMIA. Case The effects of putridity, and its connection with some malignant fevers, some local diseases, and certain epidemics known to and well described by the older authors The ancients studied only the resulting phenomena, and reasoned back from these to the causes Experimental study of effects, produced by in- troducing putrid material into the living system, of modern date, beginning with Gaspard, in 1808 Deductions of Gaspard from his experiments A brief history of modern researches, and the advancement of our knowledge on this sub- ject within the past twenty-five years Term septicaemia suggested by Piorry Sedillot's experiments Theory of phlebitis Virchow's discoveries in relation to thrombosis and embolism, and their connection with suppuration Phlebitis, pyaemia, and septicaemia, confounded together for a time The part due to each only clearly defined within the past ten years Chemical, microscopical, and thermometrical researches as to the nature and effects of septicaemia and pyae- mia, made by many eminent men in Germany. Septicaemia -Tendency, at the present day, to exaggerate the frequency of septicae- mia, by asserting it to be the sole cause of puerperal fever, the various puer- peral phlegmasiae, and even milk-fever Septicaemia not always traumatic in its origin Illustrative cases Symptoms of septicaemia Pathological anat- omy Treatment Reasons why it cannot be treated by elimination Great im- portance of preventing the renewal and continuance of the infection Keep the patient alive Alcohol, quinine, food Chlorate of potash Tincture of the chloride of iron. Pyaemia Cases Contrast of the symptoms in the case of septicaemia with the case of pyaemia Capillary embolism discussed in connection with pyaemia Pyaemia without traumatism Puerperal pyaemia not a very frequent disease Diagno- sis Prognosis Treatment. " CASE XXXI. 1 Margaret S , born in Germany, aged twen- ty-four, married, fourth pregnancy, was brought into the hospital, February llth, while in labor. The head had just entered the cav- 1 Reported by Kichard 0. Van "Wyck, M. D., house-physician to Belle- vue Hospital. PUERPERAL SEPTIC^MIA AXD PYAEMIA. 391 ity. L. O. A. The child was born at 11 A. M., within an hour and a half after she entered the lying-in ward. The child was small six pounds very feeble, and died three hours after birth. The pla- centa, which was expelled with the same pain as the child, was un- usually large, friable, and broken. A careful examination was made to see that no portion of it -or of the membranes remained behind. Less blood than usual followed delivery, and the uterus contracted well. As soon as the binder was applied, the patient asked earnest- ly for food, and a pint of beef-tea was given to her. " Evening. The patient says that she is well. Has taken food several times with relish. Pulse 80 ; respiration 20 ; temperature 98.5. "February 12tk. Patient has slept well, except when awak- ened by after-pains. A few clots have come away. Pulse 84 ; res- piration 20 ; temperature 99. Passes water without difficulty. " Evening. Bowels have moved twice. Had some after-pains and a few small clots. Pulse 90 ; respiration 20 ; temperature 100. "February 13th." Patient had a severe chill during the night. Face very red ; tongue white ; lochia natural ; thirst ; no pain or tenderness anywhere ; uterus as large as the evening after de- livery ; breasts not swollen. Pulse ] 28 ; respiration 24 ; tempera- ture 103. 2 P. M. Seen by Dr. Barker. Pulse 120 ; respira- tion 20 ; temperature 100.5. Ordered quin. sulph., gr. v, at once, gr. x, at bedtime. Vaginal injections of carbolic acid. " Evening. Pulse 130 ; respiration 32 ; temperature 104.5. From this time, until the death of the patient, she was seen by my- self or my assistant, and the symptoms noted, every hour. During the night, she was often delirious, and she also had four passages from the bowels. " February 14?A, 9 A. M. Pulse 132 ; respiration 22 ; tempera- ture 104.5. Quin. sulph., gr. v, every sixth hour. 2 p. M. Pulse 128 ; respiration 32 ; temperature 103. Tongue dry, with a brown streak in the centre. No pain anywhere, and bears strong pressure over and all round the uterus. Lochia rather scanty, with no odor perceptible, even when examined before the injections are given. Eyes wandering. Answers questions, sometimes rationally and sometimes wildly. Whiskey, 3 ss, every hour. 7 P. M. Pulse 152 ; respiration 36 ; temperature 104.3. Countenance sunken and be- dewed with perspiration. Hands and lips trembling. Has had two involuntary stools in bed. Bismuth, subcarb., gr. xv, with five grains of Tully's powder. To be repeated in the night, should the 392 PUERPERAL DISEASES. diarrhoea continue. During the night, she slept very little, was very- wild, and often got out of bed before she could be stopped. ''February 15th, 9 A. M. Pulse 140; respiration 36 ; tempera- ture 104.5. Countenance sunken and leaden. She has had but two passages. Vomited a little several times. Positively refuses to take whiskey, quinine, or any thing else in her mouth. Bron- chial rales over the entire chest. Urine has several times been ex- amined for albumen with negative results. 2 P. M. Very tranquil, and has had very little delirium since three o'clock this morning. Diarrhoea has stopped. Abdomen tympanitic, but no tenderness anywhere. Pulse 152 ; respiration 28 ; temperature 99. 7 P. M. Pulse, very feeble, 164 ; respiration 52 ; temperature 97.5. Gen- eral surface cold and moist. Abdomen enormously distended. Died at 11 P. M. " Autopsy, February IGth, 3 P. M. Brain normal. Thorax, pleura, and pericardium normal. Heart, right auricle and ventricle, contained some dark clots. Lungs congested at the base, but per- fectly normal in other respects. Abdomen : intestines greatly dis- tended with gas. Peritoneal cavity did not contain a half- ounce of serum, and not a trace of inflammation anywhere on the surface, except some very small patches of soft, false membrane over both ovaries. The veins of the broad ligaments were swollen, with dark, soft coagula. Uterus, seven and a half inches in length, five inches in breadth. The internal surface of the uterus was covered with a sanious coat, which was easily washed off. At the placental seat, were some adherent putrescent debris of the placental tissue. Incision through every part of the uterine tissue disclosed only one vessel filled with pus, which opened into a little abscess not larger than a pea. Everywhere else the tissue of the uterus was perfectly healthy. Ovaries : the usual appearances at this period after deliv- ery. Liver normal. Spleen, decidedly larger than usual and more friable. Kidneys normal." Gentlemen : Physicians in all ages of the past have been aware of the fact that the introduction into the living system, of the organic elements of animal tissue, decomposed by putrefaction, produced hemorrhagic in- filtration, degeneration and disorganization of paren- chymatous organs, softening and mortification, stupor, PUERPERAL SEPTICAEMIA AND PYAEMIA. 393 debility, and that aggregation of symptoms which we now include under the term typhoid. And so, when these conditions were recognized as occurring in fevers, in the puerperal state, and in surgical affections, the terms used by the older authors to describe them were putrid fever, putrid infection, and putrid resorption. The phenomena of these affections were studied with great care, and their relations with the medical consti- tution of the individuals affected with a peculiar class of diseases, and with epidemic and atmospheric influ- ences, were most thoroughly investigated and described, with an accuracy and fidelity which have not been sur- passed by any modern observers. The works of the illustrious Sydenham, the essays of Pringle, " On the Diseases of Armies in Camps and in Garrisons," and " On Fevers in Hospitals and in Prisons," and his ex- periments on septics and antiseptics, or the remarkable treatise of Huxham on fevers, might be studied with great advantage by some of the most recent writers on septicaemia. You will find many of the arguments which are now urged in support of the doctrine that puerperal fever, with its varied and numerous lesions, originates exclusively from the absorption of septic material into the system, have been urged with quite as much force and logical power by those great minds of former days, to demonstrate that the phenomena of various forms of malignant fevers, and many local dis- eases which induce disorganization and death of tissue, were due to putrid infection. I do not mean to say that there is not a great deal of truth in the doctrines advanced, both by the writers of a former day and those of the present time, but I shall try to point out to you wherein errors have resulted from exclusive and restricted views. 394 PUERPERAL DISEASES, There is, however, one great and radical difference between the study of this subject in former times and at the present day. Our predecessors studied exclu- sively the phenomena resulting from what they be- lieved to be the cause, and all reasoning as to causes was reasoning back from effects. It is only within the last half-century that an experimental and philosophi- cal study of the causes has begun. I think it doubtful whether one of you have ever heard of the name of Gas- pard, a physician in St.-Etienne, a small town in France, who, in my estimation, deserves to be ranked among the great names of those who have made positive discoveries in medical science, as he first inaugurated those experi- mental inquiries which, I may say, have established the causes of septicaemia. The labors of others more recently, in this field, have only developed and demon- strated what Gaspard had previously advanced. He began his experiments in 1808, and his first essay on the subject was published in 1809. But his most im- portant essays were published in Magendie'st/bwrrc^ de plujsiologie, the first in 1822, under the title "Memoire physiologique sur les maladies purulentes et putrides, etc.;" the second in 1824, " Seconde niemoire physiolo- gique et medical sur les maladies putrides." In these essays, he gives the details of his experiments made by injecting the natural, diseased, and decomposed animal fluids into the veins of animals. From these experi- ments, he deduced the following conclusions : (1.) That pus introduced into the blood-vessels, in a small quantity, can circulate through the system with- out causing death ; provided, however, that, after having caused a good deal of disturbance in the system, it be expelled by some critical excretion, chiefly by the urine or the faeces. PUEEPEEAL SEPTICAEMIA AJO PYAEMIA. 395 (2.) But that, introduced several times successively in small quantities, it ends by destroying life. (3.) That this result is obtained much more quickly if a large dose be at once introduced into the veins, and O ' that then it causes different grave inflammations, as pneumonia, carditis, dysenteiy, etc. (4.) That it is susceptible of being absorbed, but it then causes inflammation of the serous membranes, and of the cellular tissue with which it comes in contact. (5.) That most of the symptoms which are ob- served in slow fevers or consumptions, seem to have relation to pus in the system, since in all these cases there is profuse suppuration, with general disturbance of the secretions. Gaspard also made several experiments by the in- jection of putrid pus, and found the general result to be a peculiar inflammation, accompanied by a kind of passive hemorrhage from the mucous membrane of the intestinal canal. He also endeavored to ascertain which of the chemical constituents of putrilage the carbonic acid, the hydrogen, the sulphur, or the ammo- nia produced the poisonous effects. He then enumer- ates all the diseases in which he had observed putrid- ity, which he divides into three classes, based on the following causes : (1.) A peculiar putrid diathesis, which is spontane- ous, individual, and constitutional, and in this class he includes the condition of the system resulting from, starvation, from scurvy, from malignant pustule, from carbuncle, and adynamic fever not due to any known cause, except an individual diathesis with a spontane- ous tendency to putrefaction. (2.) Absorption of putrid substances, in which he classed eveiy variety of typhus, the putrid fever of 396 PUERPERAL DISEASES. villages, putrid dysenteries, the malignant fevers with putrid symptoms caused by the effluvia from marshes. (3.) To atmospheric heat, which tends to produce putrefaction in the animal economy ; and in this class he includes the plague, yellow fever, cholera, some ty- phus fevers, and all the diseases which are found only in hot climates, in the torrid zone, between the two tropics. I have given you this brief abstract of the experi- ments and deductions of Gaspard, made fifty years ago, because his name is seldom mentioned now, while oth- ers, who have recently simply worked out the details of what he so comprehensively grasped, have justly become famous. Soon after the time of Gaspard, the character and symptoms of putrid and purulent ' infection began to be studied more closely. But, with most medical and surgical writers, the distinction was not made between the symptoms caused by putrid infection, and those re- sulting from pus in the blood, and the latter received by far the greater share of attention. It would be most interesting to trace, step by step, the progressive advance in our knowledge of these pathological condi- tions during the past thirty-five years. We should find that we owe much to the study of the physiology and pathology of the blood, by Magendie, Andral and Ga-, varret, and other hematologists, who have come after them, as Becquerel and Rodier, and Robin and Verdeil. Then, how much we owe to the pathologist s, chief among whom I should mention Piorry and Bouillaud ! The former gave the appropriate name of septicaemia to the disease resulting from the absorption of septic material, and both he and Bouillaud clearly and fully described the disease, in its acute, and in its PUERPERAL SEPTICAEMIA ASD PYAEMIA. 397 chronic, in its sporadic, and in its epidemic forms. Nor should I omit the names of Berard and Sedillot. The former, in a celebrated article on pus, in the Diction- naire de medecine, gave the most comprehensive ac- count of the phenomena of purulent and putrid infec- tion which had yet appeared, although he ascribed these phenomena chiefly to the influence of the pus in the blood. Sedillot, in 1849, published the results of a great variety of experiments made by the injection of healthy pus, of putrid pus, and of filtered putrid se- rum, inducing thereby all the forms of purulent and pu- trid infection, including what has been termed metas- tatic abscess and putrid gangrene. Indeed, he seems to have anticipated most of the leading ideas on this subject, which have been established at the present day. But obstetrical pathologists had already begun to call attention to the pathology of the veins, and, for a series of years, phlebitis was studied so exclusively as to bury, as it were, the knowledge previously acquired in regard to the blood-changes. And thus we see how it came to pass that, for a time, phlebitis, pyaemia, and septicaemia, were inextricably confounded together. Thus, by many eminent writers, the mixture of pus with the blood was regardec) as the essential cause of the phenomena which were studied ; phlebitis was the primary inflammation which resulted in the purulent infection ; and septicaemia was an accidental complica- tion. In proof of this assertion, I could refer you to numerous obstetrical authors, prominent among whom I might mention Dance, Tonnelle, Behier, Kobert Lee, and our American obstetrician, Meigs. In the work of the latter, "On Child-bed Fevers," published in 1854, it is amusing to see with what enthusiasm he ad ' O 398 PUERPERAL DISEASES. vocates this doctrine, boldly asserting that all the blood-changes are a consequence of inflammation of the lining membrane of the veins, "the endangium," and how he sneers at and ridicules the doctrine of primary blood-vitiation. But this phlebitic pathology was not accepted by others of equally high authority, as you will see by refer- rino- to the writings of Paul Dubois, Danyau, Kiwisch, Rigby, and especially to the classical work of Robert Ferguson, " On Puerperal Fever," and many other au- thors whom I might mention, that the blood-vitiation, putrid infection, or, as we should now say, septicaemia, was regarded by them as the primary cause of the phenomena that we are now studying. But, until within the last ten years, there was not any well-defined distinction made, so as to determine what part of the phenomena in question was due to pus in the blood, what part to putrid infection of the blood, and what part to phlebitis. Let .us now briefly examine the different steps by which this result has been obtained. In 1846, Virchow repeated the experiments of Gaspard, and adopted the term septicaemia, which had been suggested by Piorry. Next in order of precedence, both as regards time and importance, I should mention the researches and dis- coveries of Virchow, in regard to thrombosis and 'embo- lism, and their relations to phlebitis, to infarctus, to suppuration, and purulent infection. I should not omit the zealous and conscientious study of phlebitis, and its connection with purulent infection, ' by Behier. Then the chemical properties of the putrid poison were studied by Blum, Bergmann, Panum, Stich, and others, and many important points have been settled by their combined investigations. The aid of the microscope PUERPERAL SEPTICAEMIA AND PYJ2MIA. 399 was invoked to clear up other obscurities connected with these subjects. It seems to be settled that coagu- lation and the subsequent suppurative degeneration of the clots are not an effect of phlebitis, but are often a cause of this lesion. By microscopy it was demonstrated that the pus-corpuscles and the white corpuscles of the blood are identical, and both are now called leucocytes. But, as excess of leucocytes constitutes, so far as at; present is known, the essential morbid condition of the disease known as leucocythsernia, which is characterized by phenomena entirely different from those belonging to pya3mia, it is certain that the essential morbid con- dition of the latter cannot be due to an excess of leuco- cytes, but that some other toxic element belonsrino; to . ' O O pus causes these phenomena. And so, by the micro- scopical researches of Tigri, Davaine, Leplat and Jail- lard, Burdon-Sanderson, Coze and Feltz, and others, the infusoria called bacteria were discovered and found to be a constituent of septicaBmic blood, and thus we have been furnished with another element of distinc- tion between septicremia and pya3mia. These bacteria, however, seem to be a product of changes effected in the blood by septic poisoning, rather than a cause of the morbid phenomena which appear in septica3mia, for the experiments of Bergmann and others have demon- strated that, when these bacteria are alone introduced into the blood, they give rise to none of these phenom- ena, and are absolutely innocuous. Billroth and Weber followed Virchow in the experi- mental study of putrid and purulent infection, but, in addition, they, as well as Griesinger, Otto, Roser, Blum, Stromeyer, Pirogoff, and others, have carefully ana- lyzed and described the clinical phenomena of these affections, and particularly their essential characteristic, 400 PUERPERAL DISEASES. the fever, which, by the aid of the thermometer, is measured and described, as to its periods of develop- ment and subsidence, in all its gradations. In this brief and very imperfect history, in which I have doubtless omitted many names equally worthy of mention, you see how, by the combined and accumulated researches of many, we have arrived at our present state of knowledge on these subjects. Very much yet remains to be found out, but it is now clearly established that septicaemia, pyaemia, and phlebitis, are entirely distinct diseases, although it must not be forgotten that either of the two, or, indeed, that all the three, may be coinci- dent in the same patient. I must refer you to an excel- lent paper by Dr. Mary C. Putnam, which was first read before the " Medical Library and Journal Association," and subsequently published in the April number (1872) of The Medical Record, of this city, for a concise and careful summary of our present knowledge of these affections. My discussion of them must be here restrict- ed to their puerperal relations. At the present day, septicaemia seems to have taken full possession of the medical mind, and, in my judg- ment, here, as in numerous other instances in medical history, there is a tendency to exaggerate its frequency and its importance. Thus, some, to whom I shall refer hereafter, regard puerperal fever as being exclusively due to traumatic lesions, and the absorption of septic material at the surface of these lesions. Others, again, seem to consider metritis, lymphangeitis, phlebitis, peri- tonitis, in fact, all the puerperal phlegmasiae, as results only of septicaemia, entirely ignoring all the other known causes which induce inflammation during the puerperal period. Others, again, among whom I may mention Hecker, Winckel, Griinewaldt, and D'Espine, PUEEPEKAL SEPTICAEMIA AND PYAEMIA. 401 liave entirely abolished milk-fever, and see, in the febrile disturbances which sometimes appear when the function of lactation is being developed, only evidence that the system has absorbed a small dose of septic poison. Still, we find in actual practice that this so-called form bf septicaemia is easily and rapidly cured by relieving the congestion of the mammary glands, and establishing, by appropriate means, a free flow of milk through the lacteal ducts. The conditions of the puerperal state would seem eminently favorable for the development of septicaemia. There are the traumatic lesions of the placental disk, of the os tincaa, and of the vulva, which occur in some de- gree in every labor. There are the thrombi, which of- ten, according to Robin, block up the uterine sinuses at the placental surface, and the blood-clots, often retained in the uterine and vaginal cavities for a sufficient period to decompose and degenerate into septic material. But how many hundreds of women go through this period without the slightest evidence that the system has been disturbed by septic infection, where one exhibits the phenomena of this disease ! We find one explanation of this exemption in the fact, first signalized, I think, by Billroth, that septic poison is not absorbed by the surface of wounds, after the granulating process has commenced and the surface is covered with pus. We have reason to believe, therefore, that this process pro- tects the system, after sufficient time has elapsed for the blood-clots to decompose and form septic material. Any condition of the system which interferes with the healthy granulation of traumatic surfaces, must there- fore favor the tendency to the development of septicae- mia. The miasm of hospitals, the poison of puerperal 2G 02 PUERPERAL DISEASES. fever, of erysipelas, of typhus and of scarlet fevers, and various epidemic influences, may thus act, not only as predisposing causes of septicaemia, but they may also develop an idiopathic or non-traumatic septicaemia, as, indeed, may all diseases which are liable to terminate in slouo-hins; or o-an^rene. Hence we see that this dis- o o o o ease does not arise exclusively from the absorption of septic material from without, but the septic matter may be formed within the system by those morbid pro- cesses which result in disorganization and death of tis- sue, to which Virchow has applied the term necrobiosis. And here I shall remark that I feel quite confident that Schroeder and several other writers are in error, when they assert, in substance, that the mother cannot be infected by a dead foetus, if the access of air have been prevented, that is, if the membranes have not been rup- tured and the waters discharged. I shall briefly refer to two cases and I have seen others in which the symptoms seem to prove conclusively that this event did occur. One patient was the wife of a physician in this city, who, about the seventh month of her first pregnancy, having previously been in good health, began rapidly to lose strength. Then she became dull and disposed to sleep, but complained of no pain. There were some fever and moderate thirst, although she drank but little, as the stomach rejected every thing almost as soon as swal- lowed. She had also diarrhoea, the discharges being fluid and very offensive. My friend, Professor Charles A. Budd, then saw her with others, and recommended that labor should be brought on at once ; but, unfortunately, as I think, he was overruled by the voice of the others with whom he was in consultation. Four days after this, I saw her for the first time. She was then almost PUERPERAL SEPTICAEMIA AND PYJEMIA. 403 unconscious, her countenance was very much sunken, and the complexion was of a very peculiar icterode and leaden hue. Her pulse was very rapid and feeble, the skin dry, and the extremities were cold. Four hours after my visit, the membranes ruptured while she was vomiting; there was a very large discharge of most offensive waters, and I was again asked to see her. In ]ess than an hour after the membranes had ruptured, with very slight manifestations of labor, sfce was de- livered of a putrid foetus, and she died a few hours after. My second case was that of a lady, who, while on a visit to Richmond, Va., in the seventh month of her second pregnancy, received a great shock from seeing the bodies of some who had been fatally injured by a catastrophe which occurred in a public building. From this time she never felt the slightest motion of the child. I saw her about three weeks after this event. She then looked so veiy ill as to alarm me extremely. Her pulse was rapid and feeble, and she told me that she had been unable to take food for some days, as she vomited every thing taken. She was then up, but I directed her to go to bed at once, to apply sinapisms to the epigastrium, and to take a tablespoonful of milk- punch every few minutes. I also ordered fifteen grains of the sulphate of quinine, in two powders, one to be taken at once, and the other in the evening. On visit- ing her in the evening, I found that the first powder of quinine had been retained, and that, for a few times, the milk -punch had been grateful, but after a while free vomiting had come on, and from this time she was un- O i able to keep any thing on the stomach. The pulse was 120 and very feeble, and the temperature, 104.5. On auscultation, neither the Iruit de souffle nor the 404: PUERPERAL DISEASES. sounds of the foetal heart could be heard. The surface of the abdomen, over the uterus, was cold, in marked contrast to the contact of the hand on contiguous parts. I obtained a specimen of the urine, which, on subsequent examination by Professor Austin Flint, Jr., was found to contain neither albumen nor casts. I then deter- mined to rupture the membranes, which was very easily done by the finger alone, when a very large discharge of waters took place, with such an overwhelmingly offen- sive odor that I was compelled to rush precipitately to an adjoining room. She had very little labor-pain, but, two hours after, a putrid foetus was expelled. There was no blood discharged with the placenta, which was very much broken down by degeneration and extremely fetid, so that, in spite of repeated washings with a so- lution of the permanganate of potash and with carbolic acid, the odor seemed to cling to my fingers for several days. This, however, was probably only the memory of the vivid impression which the odor first made. I had the vagina well washed out by carbolic-acid injec- tions, and these were often repeated. After the deliv- ery of the foetus, there were for some hours less vomiting and diarrhoea. The patient was disposed to doze, but at the same time was very restless. From this time until her death, three days after, I was assisted by the valuable aid and advice of my friend, Professor T. M. Markoe. We endeavored to support and keep our patient alive by nutritious, stimulating, and tonic ene- mata, which she generally retained well, and by inhala- tions of oxygen. But the vomiting was frequent, the fluid ejected being sometimes of a grass-green color, and at other times of a coffee-ground appearance. The occasional discharges from the bowels were excessively offensive. The mind was wandering-, though not active- O' O PUERPERAL SEPTICAEMIA AND PYAEMIA. 405 ly delirious, and sometimes there would be almost a comatose stupor. I do not see how one can resist the conviction that this was a case of septicaemia developed by a dead foetus, which had not been exposed to the air. Al- though little was known of septicaemia, as it is at pres- ent understood, at the time when Kiwisch died, yet he gives cases resembling in their general character those which I have just described, which he ascribed to "blood-dissolution." I have no doubt that a careful search of medical literature, and the experience of the profession, could furnish many illustrations of a similar kind. 1 There are two sources of infection : one within the individual, or auto-infection, absorption taking place of septic material, resulting from the retention and decom- position of blood-clots, or from tissues w T hich have by disease terminated in necrobiosis ; the other, hetero- infection, the poison coming from without, the septic materials being absorbed by the surface of a recent wound, either by direct contact or from particles in the air. From what I have before said, you will infer that I do not believe that trauniatism is a necessaiy antece- dent of auto-infection. Whether this be the case or not for hetero-infection, is not yet determined, because it has not yet been demonstrated, so far as I am aware, that the septic material can enter the system through the medium of the respiratory mucous membrane. The symptoms of septicaemia will vary according to 1 ViJe report of a very interesting case of the same kind, in "An Ac- count of the Recent Epidemic of Puerperal Fever as it appeared in the Dublin Lying-in Hospital," by Alfred II. McClintock, M. D., M. R. I. A., Master of the Hospital. Published in the Dublin Quarterly Journal of Medical Science, May, 1855. Also a case published by Mr. McWhinnie, in the Medico-Chirurgical Transactions, vol. xxxi., page 65. 4:06 PUERPERAL DISEASES. the amount of the poison absorbed and the consequent intensity of the disease. It may be so intense as to de- stroy life in a few days, or so mild as only to excite a moderate degree of fever for a few days, and then all disturbance of the system disappears. In other cases, the symptoms may continue for days or weeks, and then terminate in either recovery or death. A question of great interest is, What is the cause of this fever this rise of temperature, which the thermometer proves al- ways to occur in septicaemia ? The most ingenious and most probable explanation which has been given is, that it is due to the chemical changes produced by the poison, to an acceleration of the molecular metamor- phosis of the blood and tissues. It is said that this disease has been rarely ushered in by a chill, but you observe that it was the case with our patient. There was, however, no recurrence of chills, and it is alleged that this is never the case in pure septicaemia, and it is asserted by some that, when the chills are repeated, it is an evidence that the sep- ticaemia is complicated with pyaemia. But the eleva- tion of temperature, as shown by the thermometer, is a constant phenomenon, and measures, to a certain extent, the intensity of the poison. It ranges from 100 up to 106 or even 107. But another point to be remembered is, that the fall of temperature does not indicate, apart from the other symptoms, a corresponding decline of the disease. It often happens that, as the case ap- proaches a fatal termination, a rapid fall of tempera- ture is noted, as was the fact with the patient whose history has been given you. Another curious fact has been mentioned by some writers, that, immediately af- ter death, there is for a few moments a marked rise of temperature. I have repeatedly called the attention of PUERPERAL SEPTICAEMIA AXD PYAEMIA. 4QT the members of my staff to this point, but no instance of the kind has as yet been reported to me. Pain is not a characteristic of this disease, which, on the other hand, seems to deaden the morbid sensibilities of other diseases when associated with it, as I have often noticed, particularly as regards peritonitis and rnetritis. Indeed, one of the striking peculiarities of septicaemia is its effect on the nervous system. Patients do not generally suffer much, but they are dull, heavy, and sleepy, and sometimes almost comatose. There is usually more or less wandering delirium, but very rare- ly a high degree of maniacal excitement. Diarrhoea is a very frequent symptom, and it is sometimes very pro- fuse. Vomiting always occurs in the severe, but is frequently absent in mild cases. There is thirst, and the tongue is generally dry, but the patients are too apathetic to call for drink. Perspirations are common and are sometimes profuse in the beginning of the disease, but usually the skin is dry and flabby in the later stages. Now, this group of symptoms, more or less pro- . nouuced, according to the amount of poison absorbed, is accepted as being characteristic of septicaemia, and they coincide with those which are produced in the in- ferior animals by the injection of septic material into the veins. But, in actual obstetric practice, we meet with few cases of pure, uncomplicated septicaemia, for it is usually associated with other affections, as puerperal fever, or phlebitis, metritis, peritonitis, or other of the puerperal phlegmasiae. We therefore more commonly find the symptoms of septicaemia com- bined with, sometimes masking, or at other times over- shadowed by, those of some associated disease. The autopsical lesions of this affection are principally 08 PUERPERAL DISEASES. a dark, fluid condition of the blood, and a softened, con- gested state of the visceral organs. The mucous mem- brane of the intestinal canal is generally softened and swollen with that kind of dark-purple hyperaemia which results from congestion of the venous radicles. There are neither the thrombi, nor the phlebitis, nor the metas- tatic abscesses, which are found so often with pyaemia. As to the treatment of septicaemia, I would first ob- serve that the idea of elimination of the toxic elements through the various channels of the intestinal canal, the O / kidneys, and the skin, would naturally suggest itself. But I am convinced that little can be effected by these means, for, in the first place, the disease is the conse- quence of the poison which has already produced its effects. I think that the point is often overlooked in medicine, that when treatment of disease is needed, the time for removing causes has already gone by. It is the results which we are to counteract by our thera- peutic resources. Now, the results of septicaemia are such a condition of the blood as necessarily involves ataxia, and hence would forbid the use of any agents which have a tendency to enfeeble the vital powers ; and such a condition of the visceral organs and of the mucous membrane of the intestinal canal as would ren- der them intolerant of the irritation necessary to stim- ulate increased excretion. Indeed, I think that we have reason to believe that the tumefied, softened condition of the intestinal mucous membrane is the consequence of the effort of the system to eliminate the poison through this channel. It is of the greatest importance that every safe measure should be used to prevent the continuance and renewal of the infection ; and the danger from this is very great in puerperal patients. Vaginal antiseptic in- PUEEPEKAL SEPTIC^MIA AXD PYAEMIA. 409 jections (and probably tlie carbolic acid is quite as good as any other for this purpose) should be thoroughly used two or three times a day. The necessity and pro- priety of intra-uterine injections should be carefully weighed and a decision made, based on the considera- tions which I have alluded to, when discussing their use in endometritis. I should certainly not hesitate to recommend them, if the history of the case and the symptoms indicate that the septicaemia was the conse- quence of, or was complicated with, endometritis. Our measures for preventing the renewal and con- tinuance of the infection should not stop with merely giving directions for antiseptic injections. I often think that success in treating very grave diseases is frequently secured by minute attention to details, and in this dis- ease, you cannot be too particular in directing that the lochial guards should be often changed, and that they should be soaked after removal in a solution of carbolic acid, that the sponge or linen used in washing should always be washed in this solution, and that the clothing and bed-linen should be changed every day (with great care not to fatigue the patient by the process), and these also should be washed with the disinfectant, and that the apartment should be kept well ventilated. The chief indication is to sustain the vital powers ; or, in other words, to keep the patient alive while the system is making an effort to get rid of the poison and to recover from its effects. The fever rapidly exhausts and wears out the patient, and so it is obvious that it must be allayed by means which do not enfeeble her. Experience seems to prove that quinine is the most efficient agent for this purpose. In proportion to the gravity of the case, from five to ten grains may be given in the morning, and from ten to fifteen or twenty grains, 410 PUERPERAL DISEASES. in the evening. I Lave often observed a decided fall of temperature, as shown by the thermometer, after a full dose of quinine. I shall here remark, because I think this is a point often misunderstood, that this is not a disease to be treated by an arterial sedative, such as the veratruin viride. The tendency of septicaemia is to dyscrasia, not to inflammation. Veratruin viride does not reduce the rapid pulse of exhaustion, but the quick, hard pulse of inflammation. Professional friends have frequently spoken to me of their disappointment in the use of this drus;, which I am convinced has often arisen from a O/ failure to recognize this distinction. The influence of food and alcohol in lowering tem- perature is now much better understood than in former times. As I have before discussed these effects in 'con- nection with other topics, I shall only say here that sep- ticaemia is eminently a disease which demands all the nutritious food that can be easily assimilated, and alco- hol in as full doses as will be tolerated. The alcohol does not excite increased cardiac action, but, moderat- ing excessive action, it appears to contract more vigor- ously, and thus, by driving the blood through the im- peded capillaries, it relieves the congestion of the venous radicles, which is so characteristic of this affection. Agents which improve the hematosin, are obvi- ously indicated ; and I have made large use of the chlorate of potash and the tincture of the chloride of iron in the treatment of septicaemia. I am thoroughly convinced of the value of the former, having repeatedly observed a favorable change very soon after com- mencing its use. In grave cases, I give from fifteen to twenty grains every third hour. It is easily taken and readily absorbed, if the stomach be in a condition PUERPERAL SEPTICAEMIA AND PY.EMIA. 4H to absorb any thing. As regards the tincture of the chloride of iron, my experience has led me to believe that it is often very serviceable in the convalescence from septicaemia, but that it is not well tolerated during the active stages of the disease, as the stomach is apt to reject it. I shall only add, that the treatment of septicaemia must be greatly modified and controlled by the com- plications with which it may be associated. In many cases, it is to the complications chiefly that we must address our therapeutic measures. Let me now call your attention to another form of disease, which I think is quite distinct from septicaemia, although the two affections were long confounded. Three weeks ago, I brought before you several cases of mammary abscess, and you will remember one which had a very peculiar and interesting history. I then remarked that I should take an early opportunity to discuss the subject of pyaemia. I shall briefly recapitu- late the main points in the history of this case. The girl had been delivered of her first child, six weeks before you saw her. The labor was normal, and her obstetric card shows that every thing went on favor- ably until the fifth day. Then she had a chill, with severe pain in the hypogastrium ; her pulse was 112; her temperature 102, and she appeared to have a sharp attack of metro-peritonitis. But these symptoms had all disappeared on the eighth day after confinement. Two days after this, she again had a chill and com- plained of pain in the left knee, and during the night this became much swollen. The swelling con- tinued and was very painful for three days, and then disappeared as rapidly as it came. But she had no appetite, and the temperature remained high, varying 412 PUERPERAL DISEASES. from 101 to 104. The day after the swelling left the knee, the left submaxillary glands began to enlarge, and the swelling extended over the whole side of the face to such an extent that, for one day, it was impos- sible to get even liquids into the mouth. As this dis- appeared, the same process of enlargement of the sub- maxillary glands was repeated on the right side of the face. This also disappeared after a few days, without suppuration. Next the breasts became the seat of swell- ing, first the left, which rapidly went on to suppura- tion, and then the same occurred in the right. The quantity of pus which had been discharged was abso- lutely enormous. When she was brought before you, which was also the first time that I had seen her, she appeared to be decidedly improving. She was reported to be gaining in flesh and strength ; there was then very little discharge from the abscess ; the breasts were not much enlarged, and she was taking milk, eggs, beef-soup, and porter, in abundance. But I regret to say that, a a few days afterward, pulmonary symptoms began to manifest themselves, and at present, I regard her con- dition as very unpromising. 1 Dr. Van Wyck will now read the report of another patient, who has recently died in my service. " CASE XXXII. 8 Bridget B , aged thirty years, single, pri- mipara, labor commenced 8 P. M., February 2d. First stage, nine hours ; second stage, four and a half hours ; third stage, fifteen minutes. Vertex. L. O. A. Boy, weight, eight and a half pounds. 1 This patient died five weeks after the time of this lecture, hut her friends would not permit an autopsy. During the whole time that she was in the hospital, her moral state was very depressing, as she was extremely unhappy and despondent on account of her seduction. She only permitted her friends to know where she was, on the day before her death. 2 Reported hy R. C. Van Wyck, M. D., house-physician to Bellevue Hospital. PUERPERAL SEPTICAEMIA AND PYAEMIA. 413 "Feb. 3. 10 A. M., respiration 21, pulse 72, temperature 98. " 4 " " 22, " 70, " 99. " 5 " " 22, " 84, " 100. " 6 " " 20, " 84, " 100. " 7 " " 20, " 96, " 99.5. " 8 " 18, " 84, " 99.. " 9 " " 20, " 84, " 102. " " 2 P. M., " 20, " 116, " 104.5. " " 8 P.M., " 22, " 112, " 102. " Patient had a chill just after morning visit. Complains of no pain, but appears very restless. " Feb. 10. 10 A. M., respiration 22, pulse 108, temperature 102.5. " 2 P.M., " 22, " 112, " 103.5. " 8 P. M., " 22, " 108, " 101.5. " Quinine, grs. v, every sixth hour. " Had another chill to-day at noon. On the inner aspect of left leg, there was discovered a hard, circumscribed tumor, exactly over the internal saphenous vein. The vein above the tumor was en- larged and varicose. She complains of difficulty in moving the leg, but not of pain in the tumor. Urine scanty and quite thick. On examination, it was found alkaline, and contained pus, blood-corpus- cles, and mucus. Dry cups over both kidneys. Continue quinine. Potass, citrat., 3 ss, in syrup and water, every fourth hour. " Feb. 11. Respiration 22, pulse 108, temperature 102.5. " SP.M. " 24, " 116, " 103.5. " Had a slight chill to-day, followed by profuse perspiration. Says her leg is better, and the tumor is decidedly smaller. " Feb. 12. Respiration 20, pulse 100, temperature 99.5. " Patient says that she is quite well, and wishes to get up. "Feb. 13. 9 A. M., respiration 24, pulse 116, temperature 104. 3P.M., " 24, " 112, " 103. " SP.M., 22, " 112, " 101.5. " Had chills again this morning. Did not sleep well. Has no appetite, and feels weak. Not much thirst. Countenance anxious, and patient asks if she is going to die. Left wrist a good deal swollen, but has no pain except when moving it. " Feb. 14. Respiration 34, pulse 108, temperature 102. " Evening, 34, " 112, " 100.5. " Has had no chill to-day. Feels much better, and has a good appetite. Bowels, which have before been regular, moved twice to-day. 414 PUERPERAL DISEASES. " Feb. 15. Respiration 32, pulse 112, temperature 103. " Evening, " 34, " 108, " 102. "No chills, but sweats profusely. Right shoulder swollen and painful. Was kept awake last night by the pain in it. To have two teaspoonfuls of solution of morphia (U. S. P.) at bedtime. Has been troubled by cough all day, which causes pain in the shoulder. No expectoration. " Feb. 16. Respiration 38, pulse 120, temperature 103.5. Evening, " 42, " 124, " 104. "Again had a chill. No pain except in the right shoulder. Coughs a good deal, with expectoration of bloody, frothy mucus. Hales abundant in both lungs. No dullness on percussion. Mind clear. No nausea or diarrhoea. Eight dry cups were applied be- tween the shoulders, which greatly relieved the cough. The qui- nine is continued. The carbonate of ammonia, gr. iij, is substituted for the citrate of potash, every second hour. Also to have whiskey, a half-ounce every second hour. "Feb. 17. Respiration 32, pulse 136, temperature 103.5. " Evening, " 36, " 148, " 103.5. " Countenance sunken, skin yellowish. Complains of difficulty of breathing. Hdles louder and more abundant. " Feb. 18. Respiration 48, pulse 158, temperature 105.5. "Face bathed with a cold sweat. Breathing very labored. Has had no expectoration since last evening. Died at 2 P. M. "Autopsy, Twenty-Jive Hours after Death. Rigor mortis had disappeared. Heart normal, except in the right cavities, where there were fibrinous clots. Pleura normal. Both lungs were deeply con- gested, more especially the lower lobes, and in the right lung there were several small abscesses, from the size of a pea to that of a fil- bert. In the lower lobe of the left, there were no abscesses, but several points of apoplectic extravasation. There was no appear- ance of peritonitis or effusion in the peritoneal cavity. Liver nor- mal. Spleen much larger and softer than usual. Left kidney larger than the right, and its cortical portion seemed softer. Uterus firmly contracted down, and incisions being carefully made through every part, no pus was found in the sinuses or in the uterine walls. In the right ovary, there was a small, unopened abscess. The blad- der was quite contracted, and its mucous membrane was thickened and softened. On opening the articular cavity of the right shoulder, nearly two ounces of a purulent fluid escaped. The left saphenous vein was enlarged, and contained a firm clot nearly an inch in PUERPERAL SEPTICAEMIA AXD PYAEMIA. 415 length, but no pus. The lining membrane of the vein seemed healthy. There was extensive cellulitis around the vein, extending above the knee, but no suppuration. Careful examination was made for clots in other veins, but none were found." Now, let us briefly contrast this case with, the one the history of which was read at the commencement of this lecture. In the first case, there was but one chill, which occurred on the second day after delivery, and, I may here observe, that frequently, in septicaemia, no chill is noted. In the latter case, a chill first occurred on the seventh day after delivery, and then again on the eighth, ninth, eleventh, thirteenth, and fourteenth days. I believe that chills always occur in pyaemia, and are repeated at irregular intervals ; sometimes in ten or twelve hours, but more generally the period is from twenty-four to forty- eight hours. They vary in degree, from a slight, tremu- lous, and cold sensation, to a violent shaking of the whole body, and last from a few minutes to a half-hour, or even a longer period. In the first case, there was marked cerebral disturbance. The patient became de- lirious the first evening of the attack, and the mind was disturbed throughout the whole course of the disease. C5 In the latter case, there was never delirium, and the intel- lect of the patient remained clear to the end. In pyae- mia, we never meet with the wild delirium, the mania, which often occurs in septicaemia, but brain-power seems to be exhausted, the patient becomes incohe- rent, stupid, and incapable of thought or expression. Diarrhoea was a very prominent symptom in the first case, as it almost invariably is in septicaemia, but it did not occur in the latter, nor is it a characteristic symptom cf pyaemia. In the first case, the patient was attacked with the disease on the second day after delivery, and died on the fifth day. In the latter case, the initial synip- 416 PUERPERAL DISEASES. torn of the disease occurred on the seventh day, and she died on the sixteenth day after delivery. I believe that septicaemia generally commences at an earlier period after delivery, and, when fatal, the disease is of much shorter duration than pyaemia. The latter affection rarely begins in the first week of the puerperal period, and the most rapidly fatal cases of this disease continue a week or ten days, while a majority of them lasts two or three weeks. In some rare cases, two or three months, or even more, elapse before they termi- nate in recovery or death. I do not know that I can give you any authority for these statements, but, as the results of my observation, I think them to be correct. The difference in the lesions found after death in these diseases is quite as striking as the difference in symptoms. I have before told you that one of the most constant lesions found in septicaemia is the hyperaemic, swollen, and softened condition of the mucous mem- brane of the intestinal canal ; but I regret to say that, in the report of the autopsy of the first case, there is a neglect to mention the condition of the intestinal mu- cous membrane. In the latter case, there were several small abscesses in the right lung, points of apoplectic extravasation in the left, pus in the right shoulder- joint, thrombosis of left saphenous vein, all being characteristic lesions of pyaemia, but not of septicaemia. Now, what is pyaemia ? We understand by this term, a disease due to absorption of pus or its constitu- ents in the blood. I have before incidentally alluded to some of the past theories which have been enter- tained as regards the origin of this infection. That it generally resulted from antecedent suppurative phle- bitis, was the accepted doctrine of many from the time PUEEPEEAL SEPTICAEMIA AXD PY^MIA. 417 of Dance until the discoveries of modern pathologists demonstrated its fallacy, by proving that inflammation of the lining membrane of the vein is very rare, and that thrombosis is not the result, but is more frequent- ly the cause of phlebitis. Then there was the doc- trine of purulent absorption; and there was a great deal of discussion as to whether it was possible for pus- corpuscles to pass into the blood through the coats of vessels without solution of continuity, and be deposited in different organs. Now, although it appears to have been demonstrated by very recent microscopical research- es, that, under certain conditions of disease, pus-corpus- cles do pass through the coats of vessels and migrate from abscesses into other tissues, yet it seems very certain that pyaBmia is not simply a diseased condition due to excess of pus-corpuscles. The phenomena of this affec- tion are eminently of a toxa3inic character, and there is no reason for believing that this quality belongs to the pus-corpuscle per se. The discovery of Virchow, that capillary embol- ism results in small points of hemorrhagic extravasa- tion, or infarctions (infarctus), as they are termed, which cause mechanical obstruction and excite sup- purative inflammation, just as any other foreign body would, seems to explain the metastatic abscesses of pya3mia. But the embolism-theory does not explain the constitutional symptoms of this affection, which are altogether disproportionate to these local causes. These visceral infarctions have been found without the con- stitutional symptoms of pyaemia; and, on the other hand, there are well-marked cases of pyaemia without infarctions. The effects of embolism are chiefly mechani- cal; while pya3rnia is manifested by symptoms of severe toxemia. Capillary embolism no doubt often consti- 27 418 PUERPERAL DISEASES. tntes an important element in pyaemia, but the symp- toms of this disease cannot be explained by mechanical obstruction or by the disintegration or degeneration of thrombi. In a recent discussion of this subject before the Academy of Medicine of Paris, Professor Verneuil, in a brilliant rhetorical effort, advocated the theory that pyaemia is in fact only a severe septicaemia, with com- plications, or, as he would term it, septicaemic embolism. But I do not see how septicaemic embolism can explain the purulent deposits in the joints, or the subcutaneous abscesses of pyaemia. So, then, even at the present day, our positive knowl- edge of the pathogeny of this affection is little more than this : that, in certain conditions of the system, in- duced either by traumatism or by disease, the absorption of pus, or of some of its elements, into the circulation, develops a class of phenomena now well recognized and understood. The disease, then, is really a purulent infection of the blood. It is known to be this, because the same phenomena follow when pus, or even the serum of pus, is injected into the veins of animals, and because the disease occurs under those conditions following suppuration which permit the entrance of pus into the circulation. Thus it occurs after amputations and other surgical wounds attended with the secretion of pus ; it is particularly liable to follow injuries of the bones ; and it sometimes has resulted in consequence of operations for hemorrhoids, or has caused a fatal termination in cases of abscess in the ear. But it also occurs when there has been no antecedent traumatism. Dr. Murchison, of London, states that he has several times examined patients who had died of pyaemia fol- lowing typhus, in which there were no ulcerated sur- PUERPERAL SEPTICAEMIA AND PYAEMIA. 419 % faces, no bed-sores, no open wounds whatever, and yet pus was found deposited in the joints, under the skin, and in the internal organs. Professor Bennett, of Ed- inburgh, Sir Thomas Watson, and, indeed, many others, have reported cases where pyaemia has occurred in the course of other diseases, such as fevers and rheuma- tisms, in which the disease has not been preceded by open wounds or external suppuration. It seems evi- dent, then, that certain morbid conditions of the blood, which exist in these diseases, predispose to the forma- tion of pus, and its absorption in the circulation. In the puerperal state, a certain amount of trauma- tism always exists at the placental seat of the uterine cavity, and generally at the os tinea? or at the vulva; but this is a natural, constant, and harmless condition, and not a formidable, permanent danger. The trauma- tism only becomes dangerous, when there exists some an- tecedent morbid condition of the blood, either from epi- demic influence or from some special toxemia. Hence, I think that the significance and importance of trail- matism, in developing puerperal pyaemia, are greatly ex- aggerated by many recent writers on this subject. The disease is not a frequent one, even in hospital practice. In several epidemics of puerperal fever, which have occurred in my service in this hospital, pyaemia rarely, if ever, was met with as a complication, but, in two of these epidemics, it was rather frequent. Now the question conies up, whether the symptoms and signs of this affection be so clear and well-deter- mined, as to enable us to make the diagnosis of its ex- / O istence. In my previous remarks, I have incidentally referred to many of the symptoms, but let us now study them, more carefully. The chills, which recur repeatedly, but without fixed 20 PUERPERAL DISEASES. periodicity, are never absent in pyaemia. The severity of the chill is, to a certain degree, a measure of the in- tensity of the pus-poisoning, but, in estimating this, we must make due allowance for individual differences, in the nervous irritability of the subjects of attack. Each recurrence of chills is an indication of a new invasion of pus in the blood, and, very probably, a new point of tissue-inflammation. In connection with the chills, we have to note also a rapid rise in temperature, which reaches its height at the end of the chill. The skin and the limbs feel cold because the blood has been driven away from the capillary surface by the spasm of the subcutaneous muscles which the chill produces, but the thermometer demonstrates that the actual tem- perature has risen several degrees, generally as high as 10-4, sometimes to 105, 106, or 107. After the chill, the temperature begins to fall. As in fever and ague, the chill is generally followed by a period of dry heat, and then a period of sweating, during which the ther- mometer falls to the lowest point which occurs during the disease. But there is no complete intermission, no periodicity of recurrence. Sometimes the chills do not return for two or three days, and then again they may recur two or three times a day. The complexion in pyaemia becomes of a leaden, yellow hue, and often de- cidedly jaundiced, while in septica3mia there is gener- ally a dark scarlet redness of the cheeks. It is wonder- ful to see what a quantity of pus the system will form and discharge in pyaemia. Rapid emaciation is there- fore a symptom which we should naturally expect in this disease. Beside these general symptoms, there are also those which arise from the local developments of the disease, such as abscesses in the cellular tissues of the extrein- PUEEPERAL SEPTICAEMIA AXD PY.EMIA. 421 ities or in the decumbent portions of the trunk, puru- lent effusions in the articulations, or suppurative in- flammation of the breast or of the eye. The symptoms which characterize purulent deposits near the external surface and in the joints are readily recognized, but they are often very obscure when the deposit takes place in internal serous cavities, such as the pleura and pericardium, as are also the symptoms of metastatic inflammation in the lungs, the liver, or the kidneys. The pulmonary complication is the most frequent. The small abscesses in the lungs may be so scattered as not to give rise to cough or dyspnoea ; but, if there be bloody sputa with catarrh, we may feel well assured of their existence. If the pulmonary affection be of any considerable extent, it will probably manifest itself by hurried respiration, cough, and perhaps pains in the chest, and, on auscultation, there will be heard bronchial rales with broncho-vesicular respiration. Of course, percussion will settle the question whether there be pleuritic effusion or not. Purulent accumulation in the pericardium is some- times very large. Some years ago, I was present at an autopsy made by my colleague, Professor James E. Wood, in a patient of Dr. Livingston, who died of py- aemia after miscarriage, and we estimated the amount of pus in the pericardium to be not less than twelve ounces. Generally, purulent effusion in the pericar- dium is complicated with either pericarditis, or endo- carditis, or both. Jaundice is not conclusive evidence that there are hepatic abscesses ; as, even when most intense, in some cases, there has only been found acute diffuse softening of the liver. But, if there be great pain in the region of the liver, we have strong grounds for suspecting the existence of abscesses. 422 PUERPERAL DISEASES. If, in the course of pyaemia, the urinary secretion greatly decrease in amount, and the urine become bloody and albuminous, and contain epithelial casts, we are safe in making the diagnosis of acute metastatic nephritis. I must add a few words in regard to the prognosis in puerperal pyramia. You will find that most writers speak of it as a very fatal disease, and some go so far as to say that a great majority of cases die. I am very much inclined to the belief that it has got this charac- ter chiefly from its frequent fatal termination in surgi- cal cases, and that, as a puerperal disease, it does not deserve so bad a reputation. In surgery, the danger is greatly increased by its association with severe wounds and injuries, which demand the full vigor of the vital powers for repair. Both as a surgical and a puerperal disease, the danger is in proportion to the intensity and frequency of the infection, and, in the former, the source of the infection is generally more constant and perma- nent. We determine the intensity of the infection by the severity of the chills, and the degree of fever, measured by the thermometer. The more frequently the chills are repeated, the more rapidly the system becomes affected, and the earlier the symptoms of metastatic in- flammation appear. If the chills be mild in degree and recur only after intermissions of one, two, or three days, and if the highest rise of the thermometer be not over 104, then we may have a reasonable hope that the metastatic inflammations will be mild and limited in extent. It is obvious that purulent effusions in the articulations and abscesses in the subcutaneous cellular tissues are much less dangerous than metastatic inflam- mations of the visceral organs. The prognosis in pyamiia turns very much on the PUERPERAL SEPTICAEMIA AXD PYAEMIA,. 423 question as to what diseases precede or are associated with it. It greatly adds to the danger of the various pelvic phlegmasise. It is a very serious complication with phlegmasia dolens. When it occurs in puerperal fever, I think the prognosis is always grave, although I have seen quite a number of cases of recovery eve*n under these circumstances. For example, I may briefly refer to one case, because it occurred in my service in this hospital, was reported by Dr. Cobb, then house- physician, and was published seventeen years ago. In January, February, and March, 1857, we had a severe epi- demic of puerperal fever here, and, in two out of every three cases of death, the autopsies revealed extensive suppurations or abscesses in the lungs. The patient re- ferred to, Matilda Smith, was delivered of her first child in our lying-in wards, February llth. Six days after, that is, February 17th, she was attacked with puerperal fever, which commenced with a severe chill. For ten days she had a very weak and irritable pulse, generally rang- ing from 135 to 140, with profuse and offensive vaginal discharges ; she vomited frequently a greenish colored, fluid, and she became somewhat deaf. February 28th, that is, the seventeenth day after delivery, symptoms of pyaemia appeared. She had recurrent chills, followed by profuse perspirations, and then a severe attack of capillary bronchitis, undoubtedly due to pulmonary metastatic inflammation, which was treated by extensive dry cupping and the carbonate of ammonia. About the same time, there came a large bed-sore and an abscess in the right mamma, which gave exit to at least two pints of offensive pus. There had been no secretion of milk for more than two weeks. On the 4th of March, it is recorded that she took a moderate quantity of beef-tea, two bottles of porter, and thirty ounces of 424 PUERPERAL DISEASES. port-wine. At this time, her pulse ranged from 125 to 135, and she had very profuse perspirations. Her convalescence was slow, on account of the extensive suppurations ; but early in April she was discharged cured. Since this case was published, I have seen several other cases of recovery from pyaBmia developed during the course of a puerperal fever. The complication of pyaainia with septicaBmia, or septicrcrnic pya3mia, I regard as a very fatal disease. I must also mention one complication, in which I have never seen a case of recovery, that is, pericarditis or en- docarditis with puerperal pyaemia. In my service in this hospital, I have had four deaths from this cause, since I860. The publication of the very remarkable essay on puerperal arterial obstruction, by Professor Simpson, in 1854, and that on puerperal endocarditis by Vir- chow, in 1858, are the two papers which first called the attention of the profession to the puerperal cardiac lesions. Many cases have since been reported by dif- ferent observers, and these lesions are found to be not very rare. The treatment of pya3mia must be governed, to a great extent, by the therapeutic indications of its associated diseases. In discussing mammary abscesses, phlegmasia dolens, metritis, phlebitis, pelvic peritonitis and pelvic cellulitis, I have already given my views, to a certain extent, on the treatment required in connection with pysemic complications, and I shall again refer to it, in my lectures on puerperal fever. I shall now, therefore, only make a few suggestions, first, in regard to the con- stitutional treatment of pya3mia; and, second, as to the special treatment of the local lesions of this affec- tion. I regard quinine and alcohol as the two great reme- PUERPERAL SEPTICAEMIA AND PYJEMIA. 425 dial agents in the constitutional treatment of ppernia. In expressing my conviction that quinine is nearly as valuable and efficient in the treatment of pyaemia as in the treatment of intermittent fever, many, no doubt, will regard the remark as extravagant. I am well aware that my constant insistence on the anti-pyogenic effect of quinine, in my clinical lectures for the last fifteen years, may excite the suspicion of undue enthusiasm, and diminish the weight of my opinion, but it is a firm faith with me, based on constantly-accumulating expe- rience. The quinine should be given in full, effective doses, as from ten to fifteen grains in the morning, and from fifteen to twenty at night. I have even given it in larger doses than these. When, from idiosyncrasy, there is intolerance of this agent, I give from ten to fif- teen grains of the bromide of potassium with each dose of the quinine, which seems effectually to counteract the unpleasant cerebral symptoms, which it sometimes causes. It has been objected to large doses of quinine, that there is danger of producing paralysis of the motor power of the heart. But I have never observed any tendency to such a result, perhaps because of the large use which I make of stimulants at the same time. These should be given as freely as the patient can be induced to take them. The tolerance of alcoholic stimulants in pysemic patients is very remarkable. It seems quite impossible to intoxicate them. One delicate lady, who had never been accustomed to the use of wine, but who had pysernic pneumonia, abscesses in both breasts, and an abscess in the calf of the left leg, which discharged an enormous quantity of pus, took, in four days, five bottles of brandy, and two and a half drachms of qui- nine. I know that the patient, instead of the nurse, got the brandy, because it 1 was all given very reluctantly 426 PUERPERAL DISEASES. by a teetotal mother. I may here remark, parentheti- cally, that this lady, since her recovery, Las had a great aversion to every kind of stimulant, and, I will add, that I have never known a single instance where a pa- tient has acquired a dangerous taste for stimulants by their use in the treatment of an acute disease. Gener- ally, it is difficult to get patients to take a sufficient quantity. They soon become disgusted, and, with my private patients, I find it necessary to frequently change the article from brandy to whiskey, rum, sherry, ma- deira, or champagne. Pyrcrnia is not a disease usually attended with much pain, but patients are restless and uneasy, and I therefore advise an opiate at night to secure good sleep. Food, the most nourishing and the most easily digested, should be urged upon the patient, and skill should be used to make it tempting and palatable. The importance of keeping the room well ventilated, and of refreshing the patient by frequent and local ablutions, is sufficiently obvious without farther remark. The treatment of the local lesions of pyaBinia is a very important consideration. Little can be done for the effusion in the articulations, except to apply ano- dyne fomentations. These effusions sometimes disap- pear as quickly as they come, but, when this happens, you may always expect a speedy development of the disease in some other quarter. Hence, in these cases, it is very important to make frequent physical exami- nations of the thorax by auscultation and percussion, for the pulmonary and cardiac lesions are very latent, and, in the onset, are frequently manifested by but few of the general symptoms of these lesions. If bronchial rales or broncho-vesicular respiration be heard, I should recommend dry cupping between the shoulders, and PUERPERAL SEPTICAEMIA AND PYAEMIA. 427 subsequently I Lave found blisters over the chest to be of great service. If symptoms of capillary bronchitis appear, the carbonate of ammonia seems to be the best remedy that we have. When there is extensive eifusion into the cavity of the pleura, I should not hesitate to recommend the withdrawal of the fluid, either by Wyman's instrument, recommended by Bowditch, or by the aspirator of Dieu- lafoy. In two cases of puerperal pyaemia, I have per- formed thoracentesis, one of which recovered, and I saw her, eight years afterward, in very good health. In puerperal pyaemia, I am disposed to think the metastatic inflammation of the liver is rare. In 1857, 1 had three cases in this hospital, which were ushered in by recurring chills, nausea, bilious vomiting, and pain over the liver, with a very deep icterode hue of the skin and conjunctiva. Two five-grain doses of turpeth min- eral were given at intervals of fifteen minutes, which acted very promptly and easily as an emetic, without being followed by prostration. On the contrary, each of the patients declared that she felt less weak after the action of the emetic was over. Dry cups were after- ward applied oyer the liver, .and, with the subsequent general treatment of pyaemia, all of these cases recov- ered. I have seen no cases like these since that time. The nephritic lesions have been, in my experience, much more frequent than the hepatic. I believe the reverse is said to be true in surgical pyaemia. If the urine become scanty, bloody, and albuminous, I order dry cups over the kidneys, the free use of diluent drinks, such as the mineral waters, and the tincture of the chloride of iron. This also is very useful, in conjunc- tion with the chlorate of potash, when there are very profuse discharges of pus from external abscesses. It 4-28 PUERPERAL DISEASES. is very desirable that medicines should be made as lit- tle disagreeable as possible, and I shall therefore give you a formula, which I frequently use in the adminis- tration of the tincture of the chloride of iron : 5. Tine, ferri chloridi, 3 ss. Aq. purse, 3 iijss. Potass, chlorat., 3 ss. Syr. aurant. cort., Glycerin, puri, fia ij. M. S. A tablespoonful, in a wineglass of sugar and water, four times a day. At the period when the chloride of iron is required, the time has gone by for the prophylactic and curative effect of the large doses of quinine, but I frequently find it useful to add, to each dose of the above mixture, from three to five grains of the hydrochlorate of quinine. In conclusion, gentlemen, I shall only add, when you have a case of puerperal pyaemia, do not pronounce the verdict of death, even in your own minds, but deter- mine to combat it with all the wisely-selected therapeu- tic resources which you can command, and I am sure that your chance of success will be greater than if you be influenced by skeptical doubts as to the value of remedies. LECTUKE XIX. PTJEKPEK AL FEVEE. Cases Analysis of the symptoms in these cases Prevalence of a similar epidemic in the city Proportionally as severe in the wealthy classes as among the poor Frequently occurs also in rural districts It is therefore not a disease peculiar to hospitals Great diversity of opinion as to the nature of puerperal fever Variety of theories The theory of the localists The theory of trau- matism and septicamia D'Espine, Spiegelberg, and Schroeder The theory that puerperal fever is an essential fever The term puerperal fever used by some to include all diseases of the puerperal state, which are accompanied with fever Opinions of Tyler Smith, Barnes, and Braxton Hicks The theory of Professor Martin, of Berlin The theory of Hervieux Objections to the the- ory of the localists Objections to the theory of traumatism and septicaemia Objections to the theory of Hervieux Objections to the theory of Professor Martin Objections to the use of the term puerperal fever as including all the febrile diseases which occur in the puerperal state A few general laws of medical nomenclature General propositions in regard to puerperal fever. GEXTLEMEX : During iny present term of service, which began January 1, 1873, four women have died from a peculiar form of puerperal disease. In nearly all who have been delivered in the hospital, during this service, there have been more or less symptoms of con- stitutional disturbance, with a quick pulse and a high temperature. Some were very ill for a few days only, after which the convalescence was rapid. Others were very sick for two or three weeks, and did not perfectly recover until after five, six, or seven weeks. I have very full reports made by the house-physicians who had the charge of these cases, but it would take up altogether 430 PUERPERAL DISEASES. too much time to liave these read in detail, and I shall therefore give you only an abstract of the report of each fatal case, and of some that recovered. " CASE XXXII. 1 Annie S , aged twenty-five, single. Born in Germany, a lady by birth and education. She has been in this country four and a half months. She has not allowed her family to know where she is. She has been extremely nervous and depressed. She was delivered December 31, 1872, of a boy weighing nine pounds, eight ounces. Vertex, R. O. P. Labor twenty-seven and a half hours. Evening. A few hours after labor. Respiration 28, pulse 104, temperature 99. " January 1st, A. M. Respiration 20, pulse 120, temperature 102. P. M. Respiration 50, pulse 145, temperature 105. "January 3d, A. M. Respiration 40, pulse 105, temperature 103. Sweating profusely. ''January 4th, A. M. Respiration 30, pulse 138, temperature 102. Patient has had a chill, but has complained of no pain, and there is no abdominal tenderness. She is excited and nervous, and often wanders. " January 5th, A. M. Respiration 40, pulse 120, temperature 102. "January 6th, A. M. Respiration 36, pulse 138, temperature 101 "January 1th, A. M. Respiration 30, pulse 110, temperature 102. Abdomen somewhat tympanitic, with slight pain on the right side. "January 8t7t, 11 A. ai. Respiration 60, pulse 135, tempera- ture 104. 3.30 P. M. Respiration 36, pulse 120, temperature 100. 8 P. M. Respiration 36, pulse 120, temperature 102.7. Patient says she feels quite well. She has taken quinine, morphia, and had turpentine-stupes to the abdomen. " January $th. During the day, the respiration was from 24 to 30, pulse 120, and temperature 103, with but slight variation. The bowels, which before have been regular, did not move to-day. She has never complained of nausea or vomited. Perspires pro- fusely. Has no pain. Some subsultus. She is taking quinine and 1 Condensed from a report by George A. Yan "Wagenen, M. D., house- physician to Bellevue Hospital. PUERPERAL FEVER. 431 the tincture of the chloride of iron, with occasionally small doses of morphia. Tincture of veratrum viride, gtts. iij, every second hour. "January 10*7*, A.M. Respiration 18, pulse 90, temperature 100.7. 12 M. Respiration 30, pulse 105, temperature 102. 10 p. 3i. Respiration 25, pulse 108, temperature 103. During the afternoon, there was slight pain over the abdomen, and, for the first time, she complained of tenderness on percussion. She vomited in the morning a dark-green liquid, after which she said that she was very much better. Medicine continued. " January ll^A, A. M. Respiration 16, pulse 90, temperature 102.7. Very much under the influence of the morphia and vera- trum viride. Some abdominal tenderness. Respiration shallow and irregular. 12 M. Respiration 30, pulse 105, temperature 103.6. Cheeks much flushed. Taking brandy and milk. 9 P. 31. Respira- tion 18, pulse 110, temperature 102.5. Has taken during the day a pint of ale and as much beef-tea. " January 12th, 3.45 A. M. Respiration 18, pulse 90, tempera- ture 103. Has no abdominal pain. Pulse stronger. Vomited for the first time in twenty-four hours, after taking some porter. Sleeps most of the time, but when awake answers intelligently. 12 31. Respiration 18, pulse 114, temperature 103.7. She has had a natural fecal stool. No abdominal te-iiderness. Tongue dry and covered to the tip with a brown coat. 6 P. M. Respiration 20, pulse 120, temperature 103.6. Face flushed and burning-hot. Mild delirium, which later became more active. She has vomited several times. Hands cold, but feet warm. " January 13tk, 4 A. M. Respiration 30, pulse 120, temperature 103. 9 A. 31. Respiration 28, pulse 150, temperature 105. 4 p. M. Respiration 26, pulse imperceptible at the wrist, temperature 107. Died, 4.15 P. M. "Autopsy, by Dr. Francis Delafield, twenty-two hours after death. Brain not examined. Pleura ncrmal. Lungs, only the lower lobes congested. Slight serous effusion in pericardium, and slight atheroma of aortic valves. Kidneys normal. Entire peritonaeum and viscera coated with thick, yellow lymph. The peritonaeum not congested. About two pints of purulent serum in the peritoneal cavity. No change in the connective tissue of the pelvic cavity. The peritoneal covering of the uterus, coated with lymph. The uterine sinuses, at the insertion of the broad ligaments, filled with puriform fluid and broken-down thrombi. Small abscesses in the 432 PCERPERAL DISEASES. uterine tissue. Fallopian tubes deeply congested. Oraries and broad ligaments normal. " CASE XXXIII. 1 Annie S , born in England, single, age seventeen, was delivered of her first child, a girl weighing six pounds, fourteen ounces, January 1, 1873, after a short and nor- mal labor. Her parents reside in Michigan, and she was sent away from home after she was found to be pregnant, which made her very unhappv, and she was very much depressed after her labor. On the next day, the respiration was 3G, pulse 140, temperature 103. She had a chill, but no pain. Vaginal injections with carbolic acid. Quinine, grs. xxx, during the day. " January 3d (third day). Respiration 36, pulse 140, tempera- ture 103. Slight abdominal pain. Vagina washed out with car- bolic acid. Quinine, morphia, and veratrum viride. "January &th. Respiration 16, pulse 120, temperature 102. Has slept well. Very little pain. Moderate tympanites. Turpen- tine-stupes to the abdomen. Other treatment continued. " January 5th. Respiration 16, pulse 120, temperature 102. Countenance anxious. Occasionally starts with pain. " January 6th. Respiration 36-40, pulse 140-160, temperature 99-106. She vomited this morning about a half-pint of yellow fluid, and with it a lumbricoid worm about twelve inches in length, after which there were less pain and tympanites, and the patient said that she felt much better. The veratrum viride was stopped. The other treatment was continued, with brandy as freely as she would take it. " January 7th. Respiration 26-30, pulse 140-160, temperature 103-104. Delirious, but answers questions intelligently. During the day, she vomited frequently in small quantities. The tongue be- came dry and brown. Hiccough and subsultus. The abdomen be- came very much distended. Appetite good. She asks for food. But a few hours before death, she drank a glass of milk and ate a piece of bread. Died at 4.35 A. M., January 8th." " Autopsy, "by Professors J. W. S. Arnold and E. G. Jane- way. Heart, lungs, and spleen, normal. Liver, fatty and congested. Interstitial nephritis. General and metro-peritonitis. Abdominal cavity filled with purulent fluid, which contained but little lymph in proportion to the amount of pus. There was endometritis, and the 1 Condensed from a report by George A. Van "Wagenen, M. D., Louse- physician to Bellevue Hospital. PUERPERAL FEVER. 433 uterine walls were infiltrated. The uterine sinuses also contained a sero-purulent, semi-solid material. Cellular tissue of broad liga- ments infiltrated with a serous material containing pus." " CASE XXXIV. 1 Ellen H , aged eighteen, born in Ireland, was delivered of a girl weighing seven pounds, twelve ounces, Janu- ary 11, 1873. Labor normal. First stage, four and a half hours; second stage, two hours and twenty minutes ; third stage, ten min- utes. " January 12th (first day). Respiration 18, pulse 70, tempera- ture 98. ''January 13^7* (second day), A.M. Respiration 18, pulse 80, temperature 99. P. M. Respiration 35, pulse 105, temperature 102. In the evening, she was iu a terrible state of excitement. With a face flushed, and with violent sobbing, she accused other pa- tients of telling stories about her. Morphine. " January 14 one now says she teels mucu better. Her countenance looks much brighter, and she appears to be improved in every respect. The tenderness which has been so intense over the abdomen, now is scarcely noticeable. Tympanites very slight. Lochia very scanty, but normal. No mammary secretion. The swelling and tenderness on the in- ternal surface of the thigh, in the course of the veins and lymphatics, have now disappeared altogether. 2.00 " 68 26 4 Sleeping. 3.00 " 60 22 2 4.00 " 5.00 " 6.00 " .... 70 30 'e 7.00 " 64 24 4 8.00 " 76 24 6 9.00 " 76 24 6 10.00 " 72 28 6 11.00 " 64 24 3 12.00 M 68 24 6 1.00 P. M 64 28 5 2.00 " 3.00 " 56 28 4.00 " ... 5.00 " 64 24 5 6.00 " .... 7.00 " . 8.00 " 68 26 4 9.00 " PUEEPERAL FEVEK. EECOED OF CASE (Continued). 501 TIME. Pulse. Resp. Drops. REMARKS. March 5. 10.00 p. M. . : . . 72 24 4 March 6. 8.00 A. M 70 24 6 Feels well. Improvement marked. No tenderness on pressure over the abdo- men. No tympanites. Lochia still scanty, but normal. Slight mammary secretion. 11.00 " 76 24 4 12.00 sr. 1.00 P. M. 72 24 5.00 78 28 8 6.00 7.00 76 26 8.00 ^ B 9.00 10.00 72 24 'i March 7. 9.00 A. M 76 24 She says she feels well and hearty. No tenderness over the abdomen. No tympanites. Lochia healthy. No tan- derness or swelling in left femoral region. Appetite good. Bowel:) regu- lar. March 8. 10.00 A. M 76 24 Continues to improve very fast. From this time she continued to improve, and in a short time was discharged well. It is as necessary to know when not to use the ve- ratrum viride, as to know when to prescribe it. It should not be given in those cases in which rapid pros- tration is manifested by a feeble, thread-like, irregular pulse, profuse sweats, and cold extremities. . (2.) It is also very important, in this disease, to al- lay pain, quiet nervous irritation, and secure sleep. Opiates therefore are strongly indicated to a sufficient extent to accomplish these ends. When the disease is of the peritoneal type, the tolerance of opiates is some- times quite remarkable, but still in a very much less degree than in those cases where peritonitis occurs as a primary disease. I generally use Magendie's solution of morphia (sulphate of morphia grs. xvj, water 5j), 502 PUERPERAL DISEASES. but, if the stomach be irritable, the morphia may be ad- ministered hypodermically. The patient should be care- fully watched while under the influence of morphia, and the respiration should not be allowed to become slower than 12 or 14 in the minute. The morphia should be continued as long as the least sensitiveness to pressure or tympanites of the abdomen remains. Here also I have often seen the mistake made of giving up the morphia when it should have been continued two or three days longer. (3.) The next indication is to reduce the fever. The danger in any case of puerperal fever is measured pretty accurately by the thermometer, and no patient with this disease can be regarded as safe while it ranges above 100. At the present day, we no longer make use of those agents called antiphlogistics, to reduce fever, but we rely upon another class, which have been termed antipyretics. Quinine, the mineral acids, cold sponging, alcohol, and* appropriate nutrition, are prob- ably the most efficient antipyretics in puerperal fever. Quinine has been extolled by some as almost a specific in this disease, but I think that its real value lies in its effects as a means of allaying fever. This result is better attained by giving it in full doses, morning and evening, rather than in smaller doses, repeated several times a day. I generally find that, in this disease, from five to ten grains in the morning and from ten to fifteen in the evening are well borne, and rarely cause the cere- bral symptoms of cinchonism. The mineral acids are also very useful as antipyretics. I am more in the habit of giving the phosphoric acid than any other, from the belief that it decidedly allays nervous irrita- bility, and that it acts specifically as a nerve-tonic. A teaspoonful of the dilute phosphoric acid in a tumbler- PUERPERAL FEVER. 503 ful of water, with simple syrup or syrup of orange-peel, makes a very pleasant drink, which I allow patients to take ad libitum, and many take three or four tumbler- ful s in the twenty-four hours. Some patients are disin- clined to drink, and for them I have prescribed from ten to fifteen drops of dilute sulphuric acid in syrup and water, every two or three hours, with perhaps just as good results. Sponging with cold water and alco- hol is another most efficient and grateful antipyretic, which I always direct should be used at least twice a In a former lecture, I have discussed so fully the value of alcoholic stimulants in the treatment of puer- peral diseases, that I shall only add now a few words in regard to their use in puerperal fever. They should be given so soon as feebleness of the pulse, clammi- ness of the surface, profuse perspirations, or cold ex- tremities, are noticed. The special stimulant should be selected that is the most agreeable, or is the least dis- tasteful to the patient. The quantity required will vary extremely in different cases, and will call for the exercise of sound judgment. The good effects of the stimulants are seen in the decrease in frequency and increase in force of the pulse, with often a reduction of temperature and subsidence of delirium. In some, a half an ounce or an ounce of brandy or whiskey, every four or six hours, may be all that is required, while, in extreme cases, I have often given with benefit an ounce or more every hour. The symptoms of intoxication should never be produced, and, when convalescence is established, the tolerance of stimulants rapidly de- creases. Another important point is nutrition. Even if there be a repugnance to food, owing either to a re- 504: PUERPERAL DISEASES. luctance to be disturbed, or to want of taste and ap- petite, it should be deemed a pare of the medical treat- ment, that as much food should be taken as can be re- tained, digested, and assimilated. It should be given at frequent intervals, in a liquid form in as large quan- tities as can be retained without vomiting or causing discomfort from over-accumulation or indigestion. The kind of food should be often varied, so that the patient may not become disgusted with any one article. Most nurses, and I am sorry to say a few doctors, are igno- rant of the fact that a patient may starve with an abundance of beef-tea. A variety of elements is neces- sary for healthy alimentation, and the patient should have, in alternation, milk, eggs, gruels, beef-tea, mutton- broth, chicken-soup, some one of these every three or four hours during the day and two or three times dur- ing the night. (4.) The next indication is to combat, by appro- priate means, the various secondary local affections which may be developed. I trust that it is unneces- sary for me to enter into any details on these points. If I have quite failed in giving clear expression to my views in former lectures, it will be useless for me now to point out to you the importance of antiseptic vagi- nal injections, or to tell you how and when intra-uterine injections are to be used, or to describe the indications for turpentine-stupes, blisters, and other treatment that may be necessary for the local lesions. Perhaps I shall best illustrate my idea of the way in which this dis- ease should be managed by the report of a recent case in my private, practice, in which the attack of puerperal fever was foudroyant. The report is made up from my own notes and those kept by Dr. A. A. Smith, to whom the patient is indebted for most careful and PUERPERAL FEVER. 505 intelligent watching, with the sacrifice of sleep for several nights, and I am indebted for most efficient aid in bringing the case to a successful termination : CASE XXXVII. " Mrs. L , aged twenty-six, primipara, \vho had been remarkably well during the whole period of gestation, was delivered, by forceps, of a fine, healthy boy, at 12 noon, May 4, 1873. The placenta followed in fifteen minutes, with sufficient but not ex- cessive loss of blood. She slept for nearly an hour after labor was over, and then awoke, feeling very well, and took a large cupful of beef-tea. In the evening, she expressed herself as feeling well enough to go down-stairs to dinner. Pulse 84, temperature 98.5. " Jfay 5th. Visited her morning and evening. She has had no after-pains, the appetite is good, and her condition is normal in every respect. Morning, pulse 72, temperature 98.5. Evening, pulse 84, temperature 99. " ]\fay Gth. I was summoned to see her at 1 A. M. She was awakened from sleep by a severe chill at 11^ p. M., which lasted nearly an hour. She complained of no pain, but was extremely nervous. On my arrival, I found her much agitated, breathing rapidly, the skin very hot, the face pale, with the exception of a dark-red circle, about the size of a quarter of a dollar, on each cheek. She declared that she was not alarmed ; did not know what was the matter. There was no pain and no tenderness on pressure over any part of the abdomen. Compression of the sides of the uterus caused no expression of suffering. Pulse 154, temperature 105.5, respiration 36. As soon as the medicines could be obtained, she commenced taking Magendie's solution of morphia, gtts. 10, and tincture of veratrum viride, gtts. 5, every hour. This was 3 A. M. At 7 A. M., she seemed very much inclined to sleep, and all nervous excite- ment had passed off. Pulse 136, temperature 105. Magendie's so- lution, gtts. 3, tine, verat. virid., gtts. 7, every hour. 10 A. M. She has slept, except when roused to take medicine or food, since 7 o'clock. Respiration 15, pulse 120, temperature 105. Omit morphia. To have varied liquid food every third hour. Tinct. verat. virid., gtts. 10, every hour. One dose of quinine, gr. 10, to be taken at once. 2 P. M. Pulse 100, respiration 24, temperature 102.5; is perspiring very freely. Magendie's solution, gtts. 3, tinct. verat. virid., gtts. 3, every hour. 5 P. :sr. Complains of some pain and tenderness over the ute- rus for the first time. Pulse 120, perspiration 32, temperature 105, skin dry. Magendie's solution and tine, verat. virid., gtts. 5 each. 5QG PUERPERAL DISEASES. 8 P. M. Pain in abdomen very severe, and abdomen much swollen during the last two hours. Hot turpentine-stupes. Pulse 120, tem- perature 105. Ten drops of each medicine hourly. 10 P. M. Pulse 116, temperature 105, respiration 15. Pain much less. Quinine, grs. 15, Magendie's solution and verat. virid., each, gtts. 5 hourly; vaginal injections with carbolic acid twice each day. " Dr. A. A. Smith remained with the patient this and the follow- ing six nights, and also alternated with me in visiting her during the day. The following record was kept by us jointly : " May 6?A, 11 P. M. Pulse 124, temperature 102.5. Magendie and verat. virid., each, gtts. 5. 12 P. M. Perspiring very freely. No pain. Has slept quietly for an hour. Pulse 120. Gave 5 drops of each medicine. " May 7^A, 1 A. M. She is doing well, and has slept continuously. Respiration 11 ; there was not sufficient light to count the pulse, but it was estimated at 120. Magendie omitted, but gave verat. virid., 5 gtts. 2 A. M. Sleeps all the time. Respiration 13, pulse 120. Says that she is hungry and took a cup of gruel. Verat. virid., gtts. 6. 3 A. M. Pulse 92. At 3.30 awoke and began to vomit. Gave brandy and Vichy-water ; sinapism to epigastrium. Gave five drops of Magendie. Nausea and vomiting kept up for an hour, dur- ing which the pulse ranged from 84 to 92. 4 A. M. Pulse 84, temperature 102, respiration 12. Vomiting stopped ; sleeping. 5 A. M. No vomiting, but sleeping quietly and perspiring freely. Respiration 12, but regular ; pulse 84, pupils contracted. 6 A. u. Asked for and drank a cup of tea. Pulse 92, respiration 13. 7 A. ar. Perspiring very freely. No nausea, and says that she feels well. Pulse 100, respiration 14, temperature 102.5. Magendie and verat. virid., each, gtts. 5. 8 A. M. Pulse 104. Feeling very comfortable. Took a cup of beef-tea. Magendie and v.erat. virid., each, gtts. 5. 10 A. M. Pulse 92, respiration 14, temperature 102. Quinine sulph., grs. 15. Turpentine-stupes to abdomen ; five drops of the morphia and veratrum to be given every second hour. The lochia have never been offensive, but the discharge has nearly stopped. 2.30 r. M. Pulse 80, temperature 101.5. Abdomen softer and less swollen. Lochial discharge more free and more colored. 8 P. ar. Pulse 92, temperature 101. Feels very comfortable. Gave qui- nine sulph., grs. 15. If bowels be not moved during the night, she is to take, early in the morning, hydrarg. chlor. mit., gr. 10, sodas bi- carb. 3j, Magendie's solution and verat. virid., p. r. n. 10.30 P. M. Pulse 96, temperature 102. Complains of some pain in the ri^ht PUERPERAL FEVER. 507 iliac region. Magendie and verat. virid., gtts. 5 each. 12.30 A. M. Has just awakened. Asked for food, and took a cup of beef-tea. Pulse 104. Magendie and verat. virid., gtts. 5 each. " May 8th, 2.30 A. M. She again awoke, complaining of severe pain in the right side. Gave Magendie, gtts. 5. The skin was hot nnd dry. The pain in the side is growing more and more severe. Gave solution of morphia and atropine, gtts. 12 hypodermically at 3 A. M. The pulse at that time was 120, temperature 105. 6 A. ir. Has slept since the hypodermic injection. Pulse 112, temperature 103. Took a cup of gruel, after which Magendie and Verat. virid., gtts. 5. 8 A. M. Says that she is very well. Pulse 104, temperature 103. Took the powder of calomel and soda. 10 A. M. Temperature 102.5, pulse 100. Slight nausea and some cerebral excitement. After the bowels have moved, to have Magendie's solution, gtts. 5, and turpentine-stupes to be again applied. 2 r. M. Bowels have moved very freely. Now sleeping quietly. Pulse 92, respiration 22, temperature 101.6. To have, on awakening, quin. sulph.,grs. 15, Magendie's solution, gtts. 5. 5.30 P. M. Pulse 92, temperature 101.5. Took a large cupful of chicken-soup. 10.30 P. M. Pulse 108, respiration 22, temperature 105. Gave quinine, grs. 10, Ma- gendie's sol., gtts. 5. She took also a tumblerful of milk-punch. " J/rty $th, 3.30 A. M. She has slept since last note until a few minutes since, when she had a very large passage from the bowels. Says that she feels well. Took a cupful of beef-tea and nearly a tumblerful of milk-punch, made with sherry-wine. Pulse 92, tem- perature 100. She has taken no medicine since 10.30 last night. 7.30 A. M. Another full movement of the bowels. Pulse 96, tem- perature 100.5. Magendie's solution, gtts. 5. A coffee-cupful of gruel. 11 A. M. Pulse 92, temperature 101. Quinine, grs. 15. 5 P. 3i. She has had five dejections since noon, the last two being attended with a good deal of pain, and she is now suffering very much. Pulse 112, temperature 103.5. Magendie's solution and verat. virid., each, gtts. 5, and the same to be repeated in one hour. 6 P. 3i. No passage. Took two cups of farina and an ounce of brandy, Magendie's solution and verat. virid., each, gtts. 5. 8.30 P. 31. She has had three passages. She took bismuth subcarb., grs. 15, pulv. kino, grs. 5, Magendie's sol., gtts. 5. Pulse 120, temperature 103. 11.30 P. M. She has slept since last note. No movement of the bowels. Two cupful s of farina. Magendie's solution, gtts. 5. Some pain in bowels. Hot fomentations, with laudanum applied to the abdomen. 508 PUERPERAL DISEASES. " May Wth, 1 A. M. Severe pain in bowels, with, desire for passage. Bismuth and kino; Magendie's. solution, gtts. 5. 3.30 A. M. Another passage from the bowels, with enormous discharge of flatus. Took two cups of arrow-root, a glass of sherry, and -Ma- gendie's sol., gtts. 5. 4.30 A. M. Magendie's solution, gtts. 5, with a tablespoonful of brandy. 7.30 A. M. She has slept quietly since last note. Pulse 112, temperature 103. She took a cup of coffee and a large cupful of chicken-broth. 10 A. M. Pulse 100, tempera- ture 103. Took quinine, grs. 15, Magendie's solution, gtts. 5, every second hour. 3.30 P. M. I was sent for hurriedly, the nurse and friends being greatly alarmed. She had been very comfortable, when she was awakened from sleep by a sudden start, and at once complained of agonizing pain in the abdomen, which I found exces- sively sensitive to pressure, and distended to a much greater degree than ever before. Gave a hypodermic injection of solution of mor- phia, gtts. 12 (morphia acetat., grs. 16, atropine, gr. 1, aquae 3 j), and applied turpentine-stupes. Pulse 132, temperature 105.5. 5 P. M. Magendie's solution and verat. virid., each, gtts. 5, to be repeated every hour. 8 P. M. Pain much less, but great meteorism. Ma- gendie's solution, gtts. 5, tinct. of verat. virid., gtts. 3, every hour. Took a cup of milk and a cup of mutton-broth. Pulse 108, temper- ature 103. 11 P. M. She has taken Magendie's solution and the veratrum viride every hour. Pulse 84, temperature 102. She took a cupful of thickened milk, with a glass of sherry. 12 P. M. She has not slept. Severe pain in the abdomen. Ten drops of solution of morphia and atropine hypodermically. " May HtfA, 2.15 A. M. Ten drops of solution hypodermically. 5.15 A. M. She has slept for two hours. Quin. sulph., gr. 10 ; so- lution of morphia and atropine, gtts. 10, hypodermically. A large cupful of farina and two tablespoonfuls of brandy in water. 8 A. M. She has slept since last note. Took a cup of soup and a glass of sherry. Pulse 112, temperature 101. She took a cup of farina and a glass of sherry. Quinine, grs. 10 ; continue Magendie's solution with verat. virid., gtts. 3. 4 p. M. Pulse 84, temperature 100. 9 P. M. She has taken nutrition twice. Pulse 60. She now com- plains of nausea. She took Magendie's solution, gtts. 5, and a large glass of iced champagne. 11.30 P. M. Has taken iced champagne twice, a cupful of chicken-soup, and five drops of Magendie's solu- tion. " May 12 4 6. 2 -7 8 6 8 1- 9 2 1 1 5 1 3 143 APPENDIX. 521 TABLE IV. Deaths certified as from Childbirth, Rupture of Uterus, Hemor- rhage, Placenta Prcevia, and Puerperal Convulsions, from January 1 to May 15,. 1873. Mortality in Different Wards. First ward. Fourth ward. Fifth ward. Sixth ward. Seventh ward. Eighth ward. Ninth ward. Tenth ward. Eleventh ward. Twelfth ward. Thirteenth ward. Fourteenth ward. Fifteenth ward. Sixteenth ward. Seventeenth ward. Eighteenth ward. Nineteenth ward. Twentieth ward. Twenty-first ward. Twenty-second ward. Total Deaths. 1 5 8 2 1 5 3 2 6 11 11 a 2 4 7 4 1 a 1 87 D E X . Abscess, mammary, 140 causes, 143 varieties, 144 diagnosis of each variety,. . . . 146 prognosis, 148 treatment, 152 Acid, carbolic, to correct offensive odor of the lochia, 10, 320 Adhesions, uterine, 382 permanency of, 383 After-pains, 7 causes, 7 diagnosis, 8 Albuminujia, puerperal, case of, ... 65 meaning of the term, 68 causes, 69 symptoms, 73 influence on gestation, 75 influence on puerperal conva- lescence, 76 treatment of, during pregnancy, 79 influence of, in causing convul- sions, 105 Alcohol, its use in peritonitis, 350 its use in pyaemia, 425 its use in acute diseases does not lead to dangerous habits,. . . . 426 its use in puerperal fever, .... 503 Aloes in the treatment of hemor- rhoids, 33 Amdbile, Dr. Sebastian, report of a case of puerperal convulsions, . . . 102 Amaurosis caused by albuminuria,. . 77 Amory, Dr. Robert, on the chloral- hydrate 184 An-csthetics as a means of prevent- ing laceration of the perinseum, . . 49 Arnold, Professor J. W. S., report of autopsies in cases of puerperal fever, 432, 434 Asphyxia from absence of blood in the lungs, 268 Bill, Dr. Benjamin, on pulmonary embolism, 252 Barnes, Dr. Robert, on thrombosis and embolism, 255 on puerperal fever, 452 Behier, Professor J., on phlebitis, . . 398 Bennett, Dr. James Henry, on inflam- matory ulceration of the cervix uteri as a cause of secondary hem- orrhage, 24 Birkhead, Dr. William H., report of a case of phlegmasia dolcns, .... 217 Brooks, Dr. L. J., report of a case of cerebral embolism, 274 Brown, I. Baker, on laceration of the perinaeum, 41 Budd, Professor Charles A., case of pulmonary embolism, 263 Burnett, Dr. Edward, report of a case of cerebral embolism, 270 Carbolic acid, use of, to correct the odor of the lochia, 10, 320 Castor-oil, objections to the use of, . 36 in puerperal fever, 612 Cazeaux, Dr. P., on thrombus of the vulva, 60 Chandler, Dr. William J., report of two cases of suppurative phlebitis, 231 Chceseman, Dr. T. Matlack, case of pulmonary embolism, 263 Chloral-hydrate, use of, hi puerperal convulsions, 120 in puerperal mania, 183 compared with chloroform,. . . 183 Chloroform, use of, in puerperal con- vulsions, 122 in puerperal mania, 182 Clark, Professor Alonzo, on opium in the treatment of peritonitis, . . 345, 346 on puerperal fever, 443 Clark, Dr. C. C. P., on the treat- ment of phlegmasia dolens, 242 Contagion of puerperal fever, 461 Convalescence, puerperal, 1 three periods of, 3 Convulsions, puerperal, 83 INDEX. 523 Convulsions, phenomena of, 85 precursory symptoms of, 89 influence of, on gestation, 90 on labor, 90 on the puerperal state, 91 prognosis, 91 presence of urea in the blood, . 99 atmospheric influence in caus- ing, 112 exciting causes, 113 : treatment, 113 prophylactic treatment, 115 treatment of, during the attack, 116 to prevent a return, 119 Cramps in the legs as after-pains, . . 9 Cruse, Dr. Tkomas K., analysis of the blood for urea, 100 Davis, Professor D. D., on phlegma- sia dolens, 226 Davis, Dr. j. Hall, on the treatment of puerperal convulsions, 125 Deafness from albuminuria, 76 Death of the fetus from albuminuria, 75 Delajield, Dr. Francis, " Hand-book of Post-mortem Examinations and of Morbid Anatomy," 332 reports of autopsies in cases of puerperal fever, 431, 435 Delirium of labor, 170 jyjStpine, Dr. H. A., on septicaemia and puerperal fever, 445 Dewees, Professor W. P., theory of phlegmasia dolens, 226 treatment of thrombus of the vulva, 63 Diet of puerperal women, 26 Duncan, Dr. Matthews, on pelvic peritonitis, 371, 374 on uterine adhesions, 382 Early, Dr. M. B., report of a case of puerperal fever, 434 Elimination in the treatment of sep- ticaemia, 408 in the treatment of puerperal fever, 509 Elliot, Professor George T., on albu- minuria as a cause of puerperal mania, 1 79 Embolism, 247 definition of, 254 causes of pulmonary, 264 symptoms, 265 cases of, 262, 263, 266 treatment, 269 cerebral, 269 cases of cerebral, 270, 272, 274 diagnosis, 79 Emetics in tho treatment of puerpe- ral fever, 511 Endometritis, 3U9 Fever, definition of, 475 Fox, Dr. Tilbury, on phlegmasia do- lens, 238 on eczema of the nipple, 139 on puerperal fever, 450 Frankenhauser, Dr. F., on the nerves of the uterus, 110 FrencJis, Professor F. T., theory of the decomposition of urea, 106 Gaspard, Dr. ., experiments in pu- rulent and putrid infection, 394 Goodell, Dr. William, on support of the perinaeum, 47, 50 Graham, Dr. A. C., report of a case of thrombus of the vulva, 53 Hemorrhage, secondary, 13 from simple relaxation of the uterus, 14 from retention of a portion of the placenta, 18 from retention of a coagulum, 21 from polypus of the uterus,. .. 21 from inflammatory ulcerution of the cervix, 24 from lacerations of the vulva or vagina, 24 from partial or complete inver- sion of the uterus, 25 other causes of, reported by au- thors, 25 Hemorrhoids, 30 treatment of, 31 Herpes labialis in puerperal fever, .. 490 Hervieux, Dr. E., theory of phleg- masia dolens, 229 on albuminuria, 73 on phlebitis, 285 on the treatment of phlebitis, . 301 treatment of peritonitis, 252 theory of puerperal fever,. . . . 455 Hewilt, Professor Graily, on the diet of puerperal women, 26 on support of the perinaeum, . . 47 Hicks, Dr. J. JBraxton, on puerperal convulsions, 109 on puerperal fever, 452 Holmes, Professor Oliver Wendell, on the contagion of puerperal fever, . 462 House-staff of Bellevue Hospital, . . 437 Hyperinosis, definition of, 228 Injections, intra-uterine, 320 vaginal, mode cf giving, 3S8 524 INDEX. Inopexia, derivation and meaning of, 228 Insanity of pregnancy, 168 of lactation, 171 Involution of the uterus, 2 treatment of, when retarded, .. 11 Janeieat/, Professor Edward G., re- ports of autopsies in cases of cere- bral embolism, 270, 277 Jenkins, Dr. J. Foster, on albuminu- ria in puerperal mania, 179 Johnson, Dr. John (jf., on mammary abscess, 142 Judson, Dr. Walter, report of a case of cardiac thrombosis and pulmo- nary embolism, 247 report of a case of pelvic peri- tonitis and pelvic cellulitis, 365 Kennedy, Dr. Every, on puerperal fever, 451 Kinnicut, Dr. Frank T., report of a case of puerperal convulsions,. . . 97 Labor, induction of premature,. .81, 114 Lactation, 127 causes which interfere with,. . . 133 Laxatives during the puerperal pe- riod, 29 Lee, Dr. Robert, theory of phlegma- sia dolens, 227 Leishman, Professor William, on support of the perinaeum, 47 Livingston, Dr. W. C., report of a case of puerperal convulsions, ... 94 Lochia, normal, 9 duration of, 12 in phlebitis, 290 in metritis, 314 in peritonitis, 338 Loomis, Professor A. L., on acute uraemia, 120 Lusk, Professor W. T., case of re- laxation of the right sacro-iliac synchondrosis, 216 case of phlegmonous inflamma- tion in connection with phlegmasia dolens, 225 case of cerebral embolism, . . . 274 Mackenzie, Dr. F. W., on phlegmasia dolens, 235 Mammary abscess, 140 causes, 143 varieties, 144 diagnosis of each variety, .... 146 prognosis, 148 treatment, 152 Mammary neuralgia, 160 Mania, puerperal, 161 Mania, puerperal, statistics of, 165 causes, 175 treatment, 179 moral treatment, 190 Markoe, Professor T. M., case of septicaemia, 404 Martin, Jroftssor Edward, of Berlin, on puerperal fever, 4S4 Mastitis, 140 McClintock, Dr. Alfred 11., on sec- ondary hemorrhage, 24 extraordinary case of phlebitis, 287 case of septicaemia, 405 McClintock and Hardy, on cramps in the legs taking the pla'jc of after-pains, 9 on the use of castor-oil, 36 McCreery, Dr. John A., report of a case of puerperal mania, 1C3 reports of cases of puerperal phlebitis, 280, 282, 283 report of a case of pelvic cellu- litis, 375 McLane, Professor J. W., case of convulsions, 115 Meigs, Professor Charles D., on pul- monary embolism, 2.V.J on phlebitis, 397 on puerperal fever, 443 Mental depression in puerperal fe- ver, 491 Mercurials in puerperal fever, 512 Mctcalfe, Professor John T., use of opiates in the treatment of uraemic convulsions, 119 Metritis, 303 endometritis, 309 parenchymatous, 311 causes, 312 symptoms, 313 frequency of, 317 ; treatment, 317 Milk-fever, lii'J considered by some, a mild sep- ticaemia, . .. .' 401 Monneret, Professor M., on puerpe- ral fever, 450 Murchison, Dr. Charles, on pysemia, 418 Xecrobiosis, 402 Neuralgia, mammary, 1 60 Nipples, depressed, 134 eroded and excoriated, 135 fissure or crack of, 137 inflammation of, 138 eczema of, 138 Nomenclature, medical, general prin- ciples governing, 474 INDEX. 525 Noyes, Dr. Henry D., on amaurasia in conaectioa with, puerperal con- vulsions, 78 Nutritiqa in puerperal fever, 503 Opium in puerperal peritonitis, 3i4 in puerperal fever, 501 Otit, Dr. Fessenden N., case of pa- ralysis following albuminuria, . ... 79 Paralysis, from albuminuria, 78 from arterial thrombosis, 257 Pelvic peritonitis and pelvic cellulitis, 365 reasons for adhering to the use of these terms, 368 causes, 370 differential diagnosis, 377 treatment, 386 Perinaeum, lacerations of, 38 support of, 47 Peritonitis, 324 period after delivery when most likely to occur, 328 symptoms, 332 prognosis, 339 differential diagnosis from af- ter-pains, . 342 from retention of urine, 342 from intestinal irritation, 343 from other phlegmas'ue, 343 treatment, 344 Phlebitis, 230 cases of, 231, 230, 282, 283 forms of, 285 symptoms, 287 diagnosis, 291 prognosis, 293 treatment, 295 Phlegmasia dolens, 217 symptoms, 220 progress and duration of, 223 pathology of, 226 in connection with cancer,. . . . 227 treatment, , 240 Pinkneii, Dr. -Hnoard, report of a complicated case of puerperal peri- tonitis, 355 Plat/ fair, Professor W. S., on pul- monarv thrombosis and embolism, 262 Prem iture labor, caused by albumi- nuria, 75 reasons for inducing, in albu- minuria, 81 Puerperal fever, 429 symptoms characterizing a re- cent epidemic, 437 an eoideraic in Xew York, in spring of 1873, 439 theory of the localists, -1 12 Puerperal fever, theory of the local- ists, objections to, theory of traumatism and sep- ticaemia, objections to, theory that puerperal fever is an essential fever, use of the term, as including PAQ3 457 445 434 449 the zymotic diseases, as well as the inflammations occurring in puerperal women, theory of Professor Martin,. . . objections to, . . theory of Hervieux, objections to, contagion of, general propositions in regard to,. symptoms, symptoms modified by epidem- ic influence, duration, treatment, Pulmonary thrombosis and embolism, Purgatives in puerperal fever, Putnam, Dr. Mary C., ou septicae- mia and pyaemia, Pyaemia, cases of, 411, symptoms of, as contrasted with those of septicaemia, nature of, results sometime? from morbid conditions of the blood without wounds or external suppuration, . prognosis, treatment as a complication of puerperal fever, 487, 451 454 472 455 470 461 476 479 484 487 492 261 512 400 411 412 415 416 418 422 424 491 Quain, Dr. Richard, on castor-oil as a laxative, 36 Quinine in puerperal peritonitis, . . . 349 in pyaemia, '..... 425 in puerperal fever, 502 Quinqiiaud, Dr. Eugene, on " puer- perisme infectieux," 483 Ranvier, Dr. L., on phlebitis, 285 Relaxation of the pelvic symphyses, 192 causes, 207 treatment, 213 Richardson, Dr. B. W., on the causes of the coagulation of the blood,.. 252 Robin, Professor C., on albuminuria, 68 Rosenstein on puerperal convulsions, 107 Sat/re, Professor L. A., cases of thrombus of the vulva, 56 526 INDEX. Scanzini von, Professor F. W., thram- bus of the vulva and vagina,. . .55, 60 on relaxation of the pelvic sym- physes 195 Schrocder, Professor Karl, on puer- peral fever, 418 Septicaemia, puerperal, 390 tendency to exaggerate its fre- quency, 400 puerperal conditions favoring, . 401 caused by a dead fuetus, 402 sources of infection, 405 symptoms, 405 treatment, 408 as a complication of puerperal fever, 487,491 Simpson, Sir James Y., on phlegma- sia dolens, 234 on puerperal mania, 1 78, 180 on arterial thromboses, 255 on puerperal fever, 445 Smith, Dr. Tyler, on puerperal fever, 451 Smith, Dr. A. A., report of a case of puerperal fever, 505 Spelling, Dr. Frederick G., on relax- ation of the pelvic symphyses, . . 194 Spiegclberg, Professor Olio, on puer- peral fever, 447 Sulphites in puerperal fever, 512 Taylor, Professor I. E., case of pul- monary embolism, 262 Thomas, Professor T. Gal/lard, on mastitis, 142 Thrombosis, 247 meaning of, 229 causes of arterial, 255 symptoms, 256 case of, 259 causes of pulmonary, 264 Thrombus of the vulva and vagina, 53 frequency of, 54 symptoms, 57 diagnosis, 58 cause of death in, 60 treatment, 61 Trask, Dr. J. D., on the treatment of septicaemia, 299 Tuke, Dr. J. J3., on puerperal insan- ity, 166 Urino, retention of, 4 Uterus, position and size alter par- turition, 306 mucous membrane of, after parturition, 308 closure of uterine sinuses, . . . 309 Van Buren, Professor W. H., on forcible dilatation of the rectum,. Vance, Dr. R. A., report of a case of puerperal convulsions, Van Wayencn, Dr. George A., re- ports of cases of puerperal fever, 430, 432, Van Wyck, Dr. Richard C., report of a case of peritonitis, report of a case of septiciemia, report of a case of pyaemia,. . Venesection in peritonitis, in puerperal fever, Veratrum viride as a sedative in , phlebitis, in peritonitis, not indicated in septicaemia,. . in puerperal fever, illustrative case, 433 324 390 412 353 510 295 347 410 499 4'J7 Virehow, Professor Rudolph, phleg- masia dolens in connection with cancer, 227 on pulmonary embolism,. .252, 261 researches in connection with septicaemia and pyaemia, 398 Walker, Dr. Henry F., report of a case of cerebral embolism, 271 Westcott, Dr. A T . S., report of a case of metritis, 303 Wilson, Professor James G., treat- ment of sore nipples, 136 Wood, Professor James R., case of thrombus of tho vulva, B6 THE END. INTERNATIONAL SCIENTIFIC SERIES. No. 1. No. 2. No. 3. No. 4. No. 5. No. 6. No. 7. No. 8. No. 9. 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V DESCRIPTIVE CATALOGUE OF MEDICAL WOBKS. D, APPLETON & CO., PUBLISHERS AND IMPORTERS, 549 & 551 BROADWAY, NEW YORK. 1874. INDEX OF SUBJECTS. PAGE Anatomy 15 An.-psthesia 25 Acne 81 Body and Mind 17 Cerebral Convolutions 6 Chemical Examination of the Urine in Dis- ease 9 Chemical Analysis 12 " Technology 29 Chemistry of Common Life 16 Clinical Electro-Therapeutics 10 " Lectures 81 Comparative Anatomy 81 Club-foot 24 Diseases of the Nervous System 11 ' " " Nerves and Spinal Cord ... 81 " " " Bones 18 " " Women 25, 26 " " the Chest 25 " " Children 27, 81 " " the Rectum 26 " " the Ovaries 29 Emergencies 14 Electricity and Practical Medicine 19 Foods 24 Galvano-Therapeutics 22 Hospitalism 25 Histology and Histo-Chemistry of Man 81 Infancy 5 Insanity in its Relation to Crime 10 Materia Medica and Therapeutics 22 Medical Journal . . 80 Midwifery 85, 26 Mineral Springs 28 Neuralgia 8 Nervous System 11 Nursing 22 Ovarian Tumors 28 " Diagnosis and Treatment 29 Obstetrics 8, 7, 25 Physiology 8, 9, 15 Physiology of Common Life 16 Physiology and Pathology of the Mind. . . . 17 Physiological Effects of Severe Muscular Exercise 10 Pulmonary Consumption 4 Practical Medicine 20 Physical Cause of the Death of Christ 24 Popular Science 80 Puerperal Diseases 81 Reports 4 Recollections of Past Life 14 " of the Army of the Potomac. 16 Sea-sickness 8 Surgical Pathology 5 " Diseases of the Male Genito-Uri- nary Organs 81 Surgery 6 Syphilis 81 Science 80, 82 Skin Diseases 21 Uterine Therapeutics 26 Winter and Spring 4 CATALOGUE OP MEDICAL WOEKS. IN ANSTIE. , and Diseases which resemble it. By FKANCIS E. ANSTIE, M. D., F. R. 0. P., Benior Assistant Physician to "Westminster Hospital ; Lecturer on Materia Medica in West- minster Hospital School ; and Physician to the Belgrave Hospital for Children : Editor of "The Practitioner" (London), etc. 1 vol., 12mo. Cloth, $2.50. "It is a valuable contribution to scientific medicine.''? 7 ^ Lancet (London). "His work upon Neuralgia is one of the most interesting, instructive, and practical. we have seen for a long time. We have given it careful reading and thoughtful study, and, for a treatise of its size, we are free to say that we have never met one that gives more practical information and is fuller of useful suggestions." Medical Record. BARKER On Sea-sickness. By FOEDYCE BARKER, M. D., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, etc. 1 vol., IGmo. 36 pp. Flexible Cloth, 75 cents. Reprinted from the NEW YORK MEDICAL JOURNAL. By reason of the great demand for the number of that journal containing the paper, it is now presented in book form, with euch prescriptions added as the author has found useful in relieving the suffering from sea-sickness. BAKNES. Obstetric Operations, including the Treatment of Haemorrhage. ' By ROBERT BARNES, M. D., F. R. C. P., LONDON, Obstetric Physician to and Lecturer on Midwifery and the Diseases of Women and Chil- dren at St. Thomas's Hospital; Examiner on Midwifery to the Royal College of Phy- sicians and to the Royal College of Surgeons; formerly Obstetric Physician to the London Hospital, and Late Physician to the Eastern Division of the Royal Maternity Charity. WITH ADDITIONS, by BENJAMIN F. DAWSON, M. D., Late Lecturer on Uterine Pathology in the Medical Department of the University of New York ; Assistant to the Clinical Professor of Diseases of Children in the College of Physicians and Surgeons, New York; Physician for the Diseases of Children to the New York Dispensary ; Member of the New York Obstetrical Society, of the Medical Society of the County of New York, etc., etc. Second American Edition. 1 vol., 8vo. 503 pp. Cloth, $4.50. To the student and practitioner this work will prove of the greatest value, being, as it is, a most perfect text-book on " Obstetric Operations," by one who has fiirly earned the right to assume the position of a teacher. "Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate th practice of the obstetric art in this country, and to be of great service to the practitioner." Lancet. 4 D. Appleton <& Go's Medical Publications. Bellevue and Charity Hospital Reports. The volume of Bellavue and Charity Hospital Reports for 1870, containing valuable contributions from ISAAC E. TAYLOR, M. D., WILLIAM A. HAMMOND, M. D., AUSTIN FLINT, M. D., T. GAILLARD THOMAS, M. D., LEWIS A. SAYRE, M. D., FRANK H. HAMILTON, M. D., and others. 1 vol., 8vo. Cloth, $4.00. " These institutions are the most important, as regards accommodations for patients and variety of cases treated, of any on this continent, and are surpassed by but few in the world. The gentlemen connected with them are acknowledged to be among the first in their profession, and the volume is an important addition *.o the professional literature of this country." Psychological Journal. BENNET Winter and Spring on the Shores of the Mediterranean; or, the Riviera, Mentone, Italy, Corsica, Sicily, Algeria, Spain, and Biarritz, a-s Win- ter Climates. By J. HENRY BEXNET, M. D., Member of the Royal College of Physicians, London; late Physician-Accoucher to the Royal Free Hospital; Doctor of Medicine of the University of Paris; formerly Resi- dent Physician to the Paris Hospitals (cx-Interue des Hopitaux de Paris), etc. This work embodies the experience of ten winters and springs passed by Dr. Bennet on the shores of the Mediterranean, and contains much valuable information for physi- cians in relation to the health-restoring climate of the regions described. 1 vol., 12mo. 621 pp. Cloth, $3.50. " Exceedingly readable, apart from its special purposes, and well illustrated." Even- Ing Commercial. "It has a more substantial value for the physician, perhaps, than for any other class or profession. . . . We commend this book to our readers as a volume presenting two capital qualifications it is at once entertaining and instructive. 1 ' N. Y. Medical Journal. On the Treatment of Pulmonary Con- sumption, by Hygiene, Climate, and Medicine, in it* Connection with Modern Doctrines. By JAMES HENRY BENNET, M. D., Member of the Royal College of Physicians, London; Doctor of Medicine of the University of Paris, etc., etc. 1 vol., thin 8vo. Cloth, $1.50. An interesting and instructive work, written in the strong, clear, and lucid manner Which appears in all the contributions of Dr. Bennet to medical or general literature. "We cordially commend this book to the attention of all, for its practic*! common- ieii>e views of the nature and treatment of the scourge of all temperate climates, pulmo- nary consumption." Detroit Review of Medicine. D. Appkton <& Co." 1 * Medical Publications. 5 BILLROTH. General Surgical Pathology and The- rapeutics, in Fifty Lectures. A Text-hook for Stu- dents and Physicians. By Dr. THEODOR BILLEOTH, Professor of Surgery in Vienna. Translated from the Fifth German Edition, with the special permission of the Author, by CHARLES E. HACKLEY, A.M., M.D., Surgeon to the New York Eye and Ear Infirmary ; Physician to the New York Hospital ; Fellow or the New York Academy of Medicine, etc. 1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $6.00. Professor Tlieodor Billroth, one of the most noted authorities on Surgical Pathology, gives in this volume a complete resume of the ex- isting state of knowledge in this branch of medical science. The fact of this publication going through four editions in Germany, and hav- ing been translated into French, Italian, Russian, and Hungarian, should be some guarantee for its standing. " The want of a book in the English language, presenting in a concise form the views of the German pathologists, has long been felt; and we venture to say no book could more perfectly supply that want than the present volume. . . . We would strongly recommend it to all who take any interest in the progress of thought and observation in surgical pathology and sur- gery." The Lancet. " We can assure our readers that they will consider neither money wasted in its purchase, nor time in its perusal." The Medical Investigator. COMBE. The Management of Infancy, Physiologi- cal and Moral. Intended chiefly for the Use of Parents. By ANDREW COMBE, M. D. REVISED AND EDITED By SIR JAMES CLARK, K. C. B., M. D., F. R. S., Physician-in-ordinary to the Queen. First American from the Tenth London Edition. 1 vol., 12mo. 302 pi). Cloth, $1.50. " This excellent little book should be in the hand of every mother of a family : and. if some of our lady friends would master its contents, and either bring up their children by the light of its teachings, or communicate the truths it contains to the poor by whom they are surround- ed, we are convinced that they would effect infinitely more pood than by the distribution of any number of tracts whatever. . . . We consider this work to be one of the few popular medical treatises that any practitioner may recommend to his patients ; and, though, if its precepts are followed, he will probably lose a few guineas, he will not begrudge them if he sees his friend's children grow up healthy, active, strong, and both mentally and physically capable." Thd Lancet. 6 X>. Appleton & CoSs Medical Publications. DAVIS. Conservative Surgery, as exhibited in remedy ing some of the Mechanical Causes that operate injuri- ously loth in Health and Disease. With Illustrations. By HENRY G. DAVIS, M. D., Member of the American Medical Association, etc., etc. 1 vol., Svo. 315 pp. Cloth, $3.00. The author has enjoyed rare facilities for the study and treatment of certain classes of disease, and the records here presented to the pro- fession are the gradual accumulation of over thirty years' investigation. " Dr. Davis, bringing, as he does to his specialty, a great aptitude for the solution of mechanical problems, takes a high rank as an orthopedic surgeon, and his very practical contribution to the literature of the subject is both valu- able and opportune. We deem it worthy of a place in every physician's library. The style is unpretending, but trenchant, graphic, and, best of all, quite intelli- gible." Medical Record. ECKER The Cerebral Convolutions of Man, represented according to Personal Investigations, es- pecially on their Development in the Jfcetus, and with reference to the Use of Physicians. By ALEXANDER ECKER, Professor of Anatomy and Comparative Anatomy in the University of Freiburg. Translated from the German by Robert T. Edes, M. D. 1 vol., Svo. 87 pp. $1.25. " The work of Prof. Ecker is noticeable principally for its succinctness and clearness, avoiding long discussions on undecided points, and yet sufficiently furnished with references to make easy its comparison with the labors of oth- ers in the same direction. " Entire originality in descriptive anatomy is out of the question, but the facts verified by our author are here presented in a more intelligible manner than in any other easily-accessible work. " The knowledge to be derived from this work is not furnished by any other text-book in the English language." Boston Medical and Surgical Journal^ January 20, 1873. D. Appleton & CoSs Medical Publications. 7 ELLIOT. Obstetric Clinic. A Practical Contribution to the study of Obstetrics, and the Diseases of Women and Children. By the late GEORGE T. ELLIOT, M. D., Late Professor of Obstetrics and the Diseases of "Women and Children in the Bellevue Hospital Medical College ; Physician to Bellevue Hospital, and to the New York Lying-in Asylum ; Consulting Physician to the Nursery and Child's Hospital ; Consulting Surgeon to the State Woman's Hospital ; Corresponding Member of the Edinburgh Obstetrical Society and of the Royal Academy of Havana ; Fellow of the N. Y. Academy of Medicine ; Member of the County Medical Society, of the Pathological Society, etc., etc. 1 vol., 8vo. 458 pp. Cloth, $4.50. This work is, in a measure, a resume of separate papers previously pre- pared by the late Dr. Elliot ; and contains, besides, a record of nearly two hundred important and difficult cases in midwifery, selected from his own practice. It has met with a hearty reception, and has received the highest encomiums both in this country and in Europe. It is justly believed that the work is one of the most valuable contributions to obstetric literature that has appeared for many years, and, being emi- nently practical in its character, cannot fail to be of great service to obstetricians. " The volume by Dr. Elliot has scarcely less value, though in a different di- rection, than that of the Edinburgh physician (Dr. Duncan, ' Researches in Ob- stetrics ')." Lancet. " This may be said to belong to a class of books ' after the practitioner's own heart,' and many circumstances concur to influence us to extend to this work a cheerful welcome, and to commend it as fully as possible. And we do thus welcome it as the production of a gentleman of great experience, acknowledged ability, and high position as an emanation from one of the leading schools of our country and as an honorable addition to our national medical literature." American Journal of Medical Sciences. "There is no book in American obstetrical literature that surpasses thia one." Edinburgh Medical Journal. " It ought to be in the hands of every practitioner of midwifery in the coun- try." Boston Medical and Surgical Journal. "It has no equal in the English language, as regards clinical instruction in obstetrics." American Journal of Obstetrics. " The book has the freshness of hospital practice throughout in reference to diagnosis, pathology, therapeutical and operative proceedings. It will be found to possess a great amount of valuable information in the department of obstet- rics in an attractive and easy style, according to the most modern and unproved views of the profession." Cincinnati Lancet and Observer. " It is invaluable for the practitioner of obstetrics." N. T. Medical Journal. 8 D. Appleton & CoSs Medical Publications. FLINT. The Physiology Of Man. Designed to rep- resent the Existing State of Physiological Science as applied* to the Functions of the Human Body. By AUSTIN FLINT, JR., M. D., Professor of Physiology and Microscopy In the Bellevue Hospital Medical College, and In the Lonp Island College Hospital; Fellow of the New York Academy of Medicine; Microscopist to Bellevue Hospital i In Five Volumes. 8vo. Tinted Paper. Volume I. The Blood / Circulation; Respiration. 8vo. 502 pp. Cloth, $4.50. " If the remaining portions of this work arc compiled with the same care and accuracy, the wliole may vie with any of those that have of late years been pro- duced in our own or in foreign languages." British and Foreign Medico- Chirurffi- cal Review. " As a book of general information it will be found useful to the practitioner, and, as a book of reference, invaluable in the hands of the anatomist and physi- ologist." Dulliji Quarterly Journal of Medical Science. " The complete work will prove a valuable addition to our systematic treatises on human physiology." The Lancet. " To those who desire to get in one volume a concise and clear, and at the same time sufficiently full resume of ' the existing state of physiological science,' we can heartily recommend Dr. Flint's work. Moreover, as a work of typographi- cal art it deserves a prominent place upon our library-shelves. Messrs. Appleton & Co. deserve the thanks of the profession for the very handsome style in which they issue medical works. They give us hope of a time when it will be very generally believed by publishers that physicians' eyes are worth saving." Medi- cal Gazelle. Yolume II. Alimentation Digestion ; Absorption / Lymph and Chyle. 8vo. 556 pp. Cloth, $4.50. " The second instalment of this work fulfils all the expectations raised by the perusal of the first. . . . The author's explanations and deductions bear evidence of much careful reflection and study. . . . The entire work is one of rare interest. The author's style is as clear and concise as his method ia studious, careful, and elaborate." Philadelphia Inquirer. " We regard the two treatises already issued as the very best on human physi- ology which the English or any other language affords, and we recommend them with thorough confidence to students, practitioners, and laymen, as models of literary and scientific ability." N. Y. Medical Journal. " We have found the style easy, lucid, and at the same time terse. The prac- tical and positive results of physiological investigation are succinctly stated, without, it would seem, extended discussion of disputed points." Boston Medical and Surgical Journal. " It is a volume which will be welcome to the advanced student, and as a work of reference." The Lancet. " The leading subjects treated of are presented in distinct parts, each of which is designed to be an exhaustive essay on that to which it refers." Western Jour- nal of Medicine. D. Appleton & CoSs Medical Publications. 9 Flint's Physiology. Volume ILL Secretion; Excretion; Ductless Glands; Nutrition; Animal Heat; Movements; Voice and Speech. 8vo. 526 pp. Cloth, $4.50. " Dr. Flint's reputation is sufficient to give a character to the book among the profession, where it will chiefly circulate, and many of the facts given have been verified by the author in his laboratory and in public demonstrations." Chicago Courier. " The author bestows judicious care and labor. Facts are selected with dis- crimination, theories critically examined, and conclusions enunciated with com- mendable clearness and precision." American Journal of the Medical Sciences. " The work is calculated to attract other than professional readers, and is written with sufficient clearness and freedom from technical pedantry to be per- fectly intelligible to any well-informed man." London Saturday Review. " From the extent of the author's investigations into the best theory and prac- tice of the present day, the world over, and the candor and good judgment which he brings to bear upon the discussion of each subject, we are justified in regard- ing his treatises as standard and authoritative, so far as in this disputed subject authority is admissible." New York Times. Yolume IY. The Nervous System. 8vo. Cloth, $1.50. This volume is now ready. It is a work of great interest, and, in conjunction with the " Treatise on Diseases of the Nervous System," by Dr. Wm. A. Hammond, constitutes a complete work on " The Physiology and Pathology of the Nervous System." Yolume Y. Generation. (In press.} Manual of Chemical Examination of the Urine in Disease. With Brief Directions for the Examination of the most Common Varieties of Uri- nary Calculi. By AUSTIN FLINT, JB., M. D., Professor of Physiology and Microscopy in the BeDerne Hospital Medical College ; Fellow of th New York Academy of Medicine ; Member of the Medical Society of the County of New York ; Resident Member of the Lyceum of Natural History in the City of New York, etc. Third Edition, revised and corrected. 1 vol., 12mo. 77 pp. Cloth, $1.00. The chief aim of this little work is to enable the busy practitioner to make for himself, rapidly and easily, all ordinary examinations of Urine ; to give him the benefit of the author's experience in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the utmost simplicity that is consistent with accuracy. " "We do not know of any work in English so complete and handy as the Manual now offered to the profession by Dr. Flint, and the high scientific reputa- tion of the author is a sufficient guarantee of the accuracy of all the directions, given." Journal of Applied Chemistry. ' We can unhesitatingly recommend this Manual." Psychological Journal. "Eminently practical." Detroit Review of Medicine. 10 -Z). Appleton <& CoSs Medical Publications. FLINT. On the Physiological Effects of Severe and Protracted Muscular Exercise. With /Special ref- erence to its Influence upon the Execretion of Nitrogen. By AUSTIN FLINT, JB., M. D., Professor of Physiology in the Bellevuo Hospital Medical College, New York, etc., etc. 1 vol., 8vo. . 91 pp. Cloth, $2.00. This monograph on the relations of Urea to Exercise is the result of a thorough and careful investigation made In the case of Mr. Edward Payson Weston, the celebrated pedestrian. The chemical analyses were made under the direction of K. O. Doremus, M. D., Professor of Chemistry and Toxicology in the Bellevuo Hospital Medical College, by Mr. Oscar Loew, his assistant. The observations were made with the cooperation of J. C. Dalton, M. D., Professor of Physiology in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Profess- or of Surgical Anatomy ; "SV. II. Tan Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., Professor of the Principles and Practice of Medicine ; W. A. Hammond, M. D., Professor of Diseases of the Mind and Nervous System all of the Bellevuo Hospital Medical College. " This -work will be found interesting to every physician. A number of important results were obtained valuable to the physiologist." Cincinnati Medical Repertory. HAMILTON. Clinical Electro-Therapeutics. (Medical and Surgical.} A Manual for Physicians for the Treatment more especially of Nervous Diseases. By ALLAN McLANE HAMILTON, M. D., Physician in charge of the New Tork State Hospital for Diseases of the Nervous System ; Member of the New York Neurological and County Medical Societies, etc., etc. With Numerous Illustrations. 1 vol., 8vo. Cloth. Price, $2.00. This work is the compilation of well-tried measures and reported cases, and is intended as a simple guide for the general practitioner. It is as free from confusing theories, technical terms, and unproved statements, as possible. Electricity is indorsed as a very valuable remedy In certain diseases, and as an invaluable therapeutical means in nearly all forms of NERVOUS DISEASE ; but not as a specific for every human ill, mental and physical. HAMMOND. Insanity in its Relations to Crime. A Text and a Commentary. By WILLIAM A. HAMMOND, M. D. 1 vol. 8vo. 77 pp. Cloth, $1.00. " A part of this essay, under the title ' Society verm* Insanity,' was contributed to Put- nam's Magazine^ for September, 1S70. The greater portion is now first published. The im- portance of the subject considered can scarcely be over-estimated, whether we regard it from the stand-point of science or social cconomv ; and, if I have aided in its elucidation, my object Trill have been attained." From Author's" Preface. D. Appleton & Co. 's Medical Publications. 11 HAMMOND. A Treatise on Diseases of the Nervous System. By WILLIAM A. HAMMOND, M. D., Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Beflevne Hospital Medical College ; Physician-in-Chief to the New York State Hospital for Disease* of the Nervous System, etc., etc. FOURTH EDITION, REVISED AND CORRECTED. With Forty-five Illustrations. 1 vol., 8vo. 750 pp. Cloth, $5.00. The treatise embraces an introductory chapter, which relates to the instruments and apparatus employed in the diagnosis and treatment of diseases of the nervous system, and five sections. Of these, the first treats of diseases of the brain ; the second, diseases of the spinal cord ; the third, cerebro-spinal diseases ; the fourth, diseases of nerve-cells ; and the fifth, diseases of the peripheral nerves. One feature which may be claimed for the work is, that it rests, to a great extent, upon the per- sonal observation and experience of the author, and is therefore no mere compilation. This work is already universally popular with the profession ; their appreciation of it may be evidenced by the fact that within two years it has reached the fourth edition. " That a treatise by Prof. Hammond would be one of a high order was what we anticipated, and it affords us pleasure to state that our anticipations have been realized." Cincinnati Medical Repertory. " This is unquestionably the most complete treatise on the diseases to which it is devoted that has yet appeared in the English language ; and its value is much increased by the fact that Dr. Hammond has mainly based it on his own experience and practice, which, we need hardly remind our readers, have been very extensive." London Medical Times and Gazette. " Free from useless verbiage and obscurity, it is evidently the work of a man who knows what he is writing about, and knows how to write about it." Chicago Medical Journal. " This is a valuable and comprehensive book ; it embraces many topics, and extends over a wide sphere. One of the most valuable parts of it relates to the Diseases of the Brain ; while the remaining portion of the volume treats of the Diseases of the Spinal Cord, the Cerebro- spinal System, the Nerve-Cells, and the Peripheral Nerves." British Medical Journal. " The work before us is unquestionably the most exhaustive treatise, on the diseases to which it is devoted, that has yet appeared in English. And its distinctive value arises from the fact that the work is no mere rajficiamento of old observations, but rests on his own ex- perience and practice, which, as we have before observed, have been very extensive." Ameri- can Journal of Syphitography, " The author of this work has attained a high rank among our brethren across the Atlantic from previous labors in connection with the disorders of the nervous system, as well as from various other contributions to medical literature, and he now holds the official appointments of Physician to the Xew York State Hospital for Diseases of the Nervous System, and Professor of the same department in the Bellevue Hospital Medical College. The present treatise is the fruit of the experience thus acquired, and we have no hesitation in pronouncing it a most valu- able addition to our systematic literature." GlasgO'W Medical Journal. 12 D' Appleton c& CoSs Medical Publications. HOFFMANN. Manual of Chemical Analysis, as applied to tlie Examination of Medicinal Chemicals and their Preparations. A Guide for the Determination of their Identity and Quality, and for the Detection of Im- purities and Adulterations. For the use of Pharma- ceutists, Physicians, Druggists, and Manufacturing Chemists, and Pliarmaceutical and Medical Students. BY FRED. HOFFMANN, PHIL. D. One vol., 8vo. Richly illustrated. Cloth. Price, $3. The preparation of the chemicals used in medicine and pharmacy has largely passed from the hands of the pharmaceutist into those of the manufacturer ; yet legal responsibility and professional duty require all who compound, dis- pense, or sell medicines, as well as the manufacturer, to determine, by correct tests, the identity, quality, and purity of every article dispensed or sold for med- ication. A work embracing the most approved methods of examinations, and forming a critical and useful guide for such tests, has as yet been a desideratum. This want has now been successfully met by the present work. The book is divided into two parts, the first ot' which treats of operations and reagents, and gives a general account of the principles and methods of chemical analysis. The second, or main part, gives, in an alphabetical order, a complete account of the medicinal chemicals, their physical and chemical characteristics, and directions for the establishment of their quality and purity, selected and arranged with care and judgment ; each compound is fully de- scribed according to its aspect and properties, its solubility in the usual sol- vents, simple and chemical, and its deportment with reagents (tests of Identity) ; this is followed by the Examination, under which heading the defects, or the accidental impurities, resulting from the processes employed in the manufacture of the chemicals, or from insufficient purification, and also the adulterations and substitutions, are considered, and their detection clearly and precisely described, so that they are readily understood by those having an average knowledge of chemistry, and ordinary chemical manipulations, many of which, as well as the more important apparatus, are illustrated by excellent engravings. A number of very useful tables is scattered through the text ; and the volume concludes with comparative tables of the thermometric scales, the troy and metric weights, and a complete index, embracing the common English terms and the Latin names and synonymes in use. The work has been brought up to the latest results of scientific research, within the briefest possible compass ; and forms a thoroughly practical and trustworthy guide, combining easy operations, simple apparatus, and economy of time, with the greatest attainable accuracy. D. Appleton & Co.'s Medical Publications. 13 In America it has already met with general and unqualified approval ; and in Europe is now being welcomed as one of the best and most important addi- tions to modern pharmaceutical literature. To give a better idea of the real merits and popularity of the book, we would call attention to the following : "A work of this kind has long been needed, and for this reason alone this volume would be heartily welcomed, even if it had been less complete than it is. ... This brief outline of the contents of this Yaluable work is scarcely sufficient to convey a correct idea of all the informa- tion presented in it. The descriptions and directions are clear and precise, and we feel sure that those whose vocation requires the examination of medicinal chemicals will find this valua- ble work what the author designed it to be a trustworthy guide for the determination of their identity and quality. 11 American. Journal of Pliarmacy. " A work of this character has long been a desideratum, and we may now truly say that the void has been well filled by this c:*ellent treatise, which will be cordially welcomed by every pharmacist and by all others to whom it is especially directed. In all the departments of the work Dr. Hoffmann displays extended research, and a critical familiarity with the subject, while at the same time he has placed the matter before the student with system, and in a language at once clear and concise. Not only is the author to be congratulated upon the excellent result of his labor, but every pharmaceutist also upon this most opportune addition to the literature of his art, and most valuable assistant hi his daily work." The Pharmacist (Chicago). " In this excellent work, the author, a thorough practical pharmaceutist, eminently fitted to the task, has successfully endeavored to crystallize into a single volume all that is essential to form a reliable and practical guide. 11 New York Medical Retieic. " The object for which this book has been written has been successfully accomplished ; it is an eminently practical work throughout ; its style and descriptions are clear and accurate, and it will prove very valuable to those who have occasion to examine drugs and chemicals. 1 " Boston Medical and Surgical Journal. ^ " This book has Ions been a desideratum, and will be well received. It treats of subjects of vital importance to the physician and druggist in a clear and concise manner. We do most heartily recommend this work as the best aid in the examination of medicinal chemicals." Nashville Journal of Medicine and Surgery. "This volume is a carefully-prepared work, and well up to the existing state of both the science and art of modern pharmacy. It is a book which will find its place in every medical and pharmaceutical laboratory and library, and is a safe and instructive guide to medical stu- dents and practitioners of medicine." American Journal of Science and Arts. " The appearance of this work must be regarded as very timely. That the physician and the pharmaceutist may have it in their power to examine by "the most approved methods the arti- cles they prescribe and dispense, the author has, carefully and with a mature judgment and sound discretion, collected and arranged in accessible form the most trusty tests of purity in medicinal chemicals." Medical and Surgical Reporter. " In this volume Dr. Hoffmann has supplied a want in the literature of his profession, by having gathered together the widely-scattered fragments of information relating to the exami- nation of chemicals, and has arranged them into a systematic and ready hand-book of especial interest and value, which certainly is entitled to a wide circulation. . . . With regard to indices, the work is a model ; it contains a number of valuable tables, and is largely illustrated with ex- cellent engravings, which serve to elucidate very much the descriptions of apparatus and ma- nipulations. The work is issued in Messrs. Appletons 1 best style, and presents not only an at- tractive appearance, but an unusual freedom from typographical defects and errors." Ameri- can Chemist, "The reputation of the author of this book is the best guarantee of its accuracy and value. Dr. Hoffmann is well known as a highly-valued contributor to scientific Journals, as a popular lecturer, and as an original investigator. He has himself practically applied the leading meth- ods set forth in the book, and has proved most of the tests recommended by him. . . . The book is a valuable addition to our pharmaceutical literature, and ought to have the effect of securing a still more extended knowledge of the medicinal chemicals most in use." Journal of Applied Chemistry. " This excellent volume carries out fully the prefatory promises, and fills a void which has heretofore existed in American pharmaceutical literature. It is not only a valuable acquisition to the librarv of the average pharmaceutist, but also an invaluable aid to those better qualified and practically familiar with the subject, and there is no doubt that this work will be regarded as a standard among works on pharmacy." Prof. C. Lewis DiefU, Louisville, Kentucky. " It is with great satisfaction that we note the appearance of this manual, especially adapted to the pharmaceutical chemist and manufacturer of medicinal chemicals. The processes recom- mended have been judiciously and carefully selected, and the instructions are full and trust- worthy ; and we hope that the circulation of this elaborate work, on both sides of the Atlantic, may tend to accomplish its objects." Chemical News (London). 14 D. Appleton & Co.'s Medical Publications. HOLLAND. Recollections of Past Life, By SIR HENRY HOLLAND, Bart, M. D., F. R. S., K. C. B., etc., President of the Royal Institution of Great Britain, Physician-in-Ordinary to the Queen, etc., etc. 1 vol., 12mo, 351 pp. Price, Cloth, $2.00. A very entertaining and instructive narrative, partaking somewhat of the nature of autobiography and yet distinct from it, in this, that ita chief object, as alleged by the writer, is not so much to recount the events of his own life, as to perform the office of chronicler for others with whom he came in contact and was long associated. The " Life of Sir Henry Holland " is one to be recollected, and he has not erred in giv- ing an outline ot it to the public." The Lancet. " His memory was is, we may say, for he is still alive and in possession of all hia faculties stored with recollections of the most eminent men and women of this cen- tury. ... A life extending over a period of eighty-four years, and passed in the most active manner, in the midst of the best society, which the world has to offer, must neces- sarily be full of singular interest; and Sir Henry Holland has fortunately not waited until Ilia memory lost its freshness before recalling some of the incidents in it." The New York Times. HOWE. Emergencies, and How to Treat Them. The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases of Poisoning, which demand Prompt Attention. Designed for Students and Prac- titioners of Medicine. By JOSEPH W. HOWE, M. D., Clinical Professor of Surgery in the Medical Department of the University of New York ; Visiting Surgeon to Charity Hospital; Fellow of the New York Academy of Medicine, etc., etc. 1 vol., 8vo. Cloth, $3.00. " This work has a taking title, and was written by a gentlemen of acknowledged ability, to fill a void in the profession. ... To the general practitioner in towns, villages, and in the country, where the aid and moral support of a consultation cannot be availed of, this volume will be" recognized as a valuable help. We commend it to the profession. Cincinnati Lancet and Obserrer. " This work is certainly novel in character, and its usefulness and acceptability are as marked as its novelty. . . . The book is confidently recommended." Rielimond and Louisville Med- ical Journal. " This volume is a practical illustration of the positive side of the physician's life, a constant reminder of what he is to do in the sudden emergencies which frequently occur in practice. . . . The author wastes no words, hut devotes himself to the description of each disease as if the patient were under his hands. Because it is a good book we recommend it most heartily to the profession." Boston Medical and Surgical Journal. "This work bears evidence of a thorough practical acquaintance with the different branches of the profession. The author seems to possess a peculiar aptitude for imparting instruction as well as for simplifying tedious details. ... A careful perusal will amply repay the student and practitioner.' Sew York Medical Journal.''' D. Appleton & Co.'s Medical Publications. 15 HUXLEY AND YOTJMANS. The Elements of Physiology and Hygiene. With Numerous Illustrations. BT THOMAS H. HUXLEY, LL. D., F. R. S., and WILLIAM JAY YOUMANS, M. D. New and Kevised Edition. 1 vol., 12mo. 420 pp. $1.75. A text-book for educational institutions, and a valuable elementary work for students of medicine. The greater portion is from the pen of Professor Huxley, adapted by Dr. Youmans to the circumstances and requirements of American education. The eminent claim of Professor Huxley's "Elementary Physiology" is, that, while up to the times, it is trustworthy in its presentation of the subject ; while rejecting dis- credited doctrines and doubtful speculations, it embodies the latest results that are established, and represents the present actual state of physiological knowledge. " A valuable contribution to anatomical and physiological science." Religious Telescope. "A clear and well-arranged work, embracing the latest discoveries and accepted theories." Buffalo Commercial. " Teeming with information concerning the human physical enconomy." Evening Jour- nal. HUXLEY. The Anatomy of Vertebrated Animals. BT THOMAS HENRY HUXLEY, LL. D., F. R. S., Author of "Man's Place in Nature," "On the Origin of Species," "Lay Sermons and Addresses," eta 1 vol., 12mo. Cloth, $2.50. The former works of Prof. Huxley leave.no room for doubt as to the impor- tance and value of his new volume. It is one which will be very acceptable to all who are interested in the subject of which it treats. "This long-erpected work will be cordially welcomed by all students and teachers of Com- parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most comprehensive guide on the subject of which it treats. To praise or to criticise the work of so accomplished a master of his favorite science would be equally out of place. It is enough to say that it realizes, in a remarkable degree, the anticipations which have been formed of It ; and that it presents an extraordinary combination of wide, general views, with the clear, accu- rate, and succinct statement of a prodigious number of individual facts." Future. 16 D. Appleton cfe Co.'s Medical Publications. JOHNSON. The Chemistry of Common Life. Illustrated with numerous Wood Engravings. By JAMES F. JOHNSON, M. A., F. K. S., F. G. S., ETC., ETC., Author of "Lectures on Agricultural Chemistry and Geology," U A Catechism of Agricultural Chemistry and Geology," etc, 2 vols., 12mo. Cloth, $3.00. It has been the object of the author in this work to exhibit the present condition of chemical knowledge, and of matured scientific opinion, upon tho subjects to which it is devoted. The reader will not bo. surprised, therefore, should he find in it some things which differ from what is to be found in other popular works already in his hands or on the shelves of his library. LETTERMAN. Medical Recollections of the Army of the Potomac. By JONATHAN LETTERMAN, M. D., Late Surgeon U. 8. A., and Medical Director of the Army of the Potomac, 1 vol., 8vo. 194 pp. Cloth, 81.00. " This account of the medical department of the Army of the Poto- mac has been prepared, amid pressing engagements, in the hope that the labors of the medical officers of that army may be known to an in- telligent people, with whom to know is to appreciate ; and as an aflfeo tionate tribute to many, long my zealous and efficient colleagues, who, in days of trial and danger, which have passed, let us hope never to re- turn, evinced their devotion to their country and to the cause of hu- manity, without hope of promotion or expectation of reward." Preface. " We venture to assert that but few who open this volume of medical annals, pregnant as they are with instruction, will care to do otherwise than finish them at a sitting." Medical Record. " A graceful and affectionate tribute." N. Y. Medical Journal. LEWES. The Physiology of Common Life. By GEORGE HENRY LEWES, Author of "Seaside Studies," "Life of Goethe," etc. 2 vols., 12mo. Cloth, $3.00. The object of this work differs from that of all others on popular science in its attempt to meet the wants of the student, while meeting those of the general reader, who is supposed to be wholly unacquainted with anatomy and physiology. D. Appleton & (70. 's Medical Publication*. 17 MATJDSLEY. The Physiology and Pathology of the Mind. By HENRY MAUDSLEY, M. D., LOUDOX, Physician to the West London Hospital; Honorary Member of the Medico-Psychological Society of Paris ; formerly Kesident Physician of the Manchester Boyal Lunatic Hospital, etc, 1 vol., 8vo. 442 pp. Cloth, $3.00. This work aims, in the first place, to treat of mental phenomena from a physiological rather than from a metaphysical point of view ; and, secondly, to bring the manifold instructive instances presented by the unsound niind to bear upon the interpretation of the obscure problems of mental science. " Dr. Maudsley has had the courage to undertake, and the skill to execute, what is, at least in English, an original enterprise." London Saturday Review. " It is so full of sensible reflections and sound truths that their wide dissemi- nation could not but be of benefit to all thinking persons." PsycJwlogicalJournal. " Unquestionably one of the ablest and most important works on the subject of which it treats that has ever appeared, and does credit to his philosophical acumen and accurate observation." Medical Record. " We lay down the book with admiration, and we commend it most earnestly to our readers as a work of extraordinary merit and originality one of those productions that are evolved only occasionally in the lapse of years, and that serve to mark actual and very decided advances in knowledge and science." N. Y. Medical Journal. Body and Mind : An Inquiry into their Con- nection and Mutual Influence, specially in reference to Mental Disorders / leing the Gulstonian Lectures for 1870, delivered before the Royal College of Physicians. With Appendix. By HENEY MAUDSLEY, M. D., LONDON, Fellow of the Royal College of Physicians ; Professor of Medical Jurisprudence in University Col- lege. London ; President-elect of the Medico-Psycholgical Association ; Honorary Member of the Medico-Psychological Society of Paris, of the Imperial Society of Physicians of Vienna, and of the Society for the Promotion of Psychiatry and Forensic Psychology of Vienna ; formerly Resident Physician of the Manchester Eoyal Lunatic Asylum, etc., etc. 1 vol., 12mo. 155 pp. Cloth, $1.00. The general plan of this work may be described as being to bring man, both in his physical and mental relations, as much as possible with- in the scope of scientific inquiry. " A representative work, which every one must study who desires to know what is doing in the way of real progress, and not mere chatter, about mental physiology and pathology." The Lancet. "It distinctly marks a step in the progress of scientific psychology." Tht Practitioner. 18 D. Appkton t& CoSs Medical Publications. MARKOE. A Treatise on Diseases of the Bones. By THOMAS M. MARKOE, M. D., Professor of Surgery in the College of Physicians and Surgeons, New York, etc. WITH NUMEROUS ILLUSTRATIONS. 1 vol. 8vo. Cloth, $4.50. SPECIMEN or ir.i.r s-i K ATI ONB. This valuable work is a treatise on Diseases of the Bones, embracing their structural changes as affected by disease, their clinical history and treatment, in- eluding also an account of the various tumors which grow in or upon them. None of the injuries of bone aie included in its scope, and no joint diseases, ex- cepting where the condition of the bone is a prime factor in the problem of disease. As the work of an eminent surgeon of large and varied experience, it may be regarded as the best on the subject, and a valuable contribution to medi- cal literature. " The book which I now offer to my professional brethren contains the substance of the lectures which I have delivered during the past twelve years at the college. ... I have followed the leadings of my own studies and observations, dwelling more on those branches where I had seen and studied most, and perhaps too much neglecting others where ray own experience was more barren, and therefore to me less interesting. I have endeavored, however, to make np the deficiencies of my own knowledge by the free use of the materials scattered so richly through our periodical literature, which scattered leaves it is the right and the duty of the systematic writer to collect and to embody in any account he may offer of the state of a science at any given period." Extract from AutAor't Preface. D. Appleton & (70. 's Medical Publications. 19 MEYER Electricity in its Relations to Practical Medicine. By DB. MORITZ MEYER, Royal Counsellor of Health, etc. Translated from the Third German Edition, with Notes and Additions, A New and Revised Edition, By WILLIAM A. HAMMOND, M. D., Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Bellevuo Hospital Medical College; Vice-President of the Academy of Mental Sciences, National Institute of Letters, Arts, and Sciences ; late Surgeon-Generji U. 8. A n etc. 1 vol., 8vo. 497 pp. Cloth, $4.50. " It is the duty of every physician to study the action of electricity, to become acquainted with its value in therapeutics, and to follow the improvements that are being made in the apparatus for its application in medicine, that he may be able to choose the one best adapted to the treatment of individual cases, and to test a remedy fairly and without prejudice, which already, especially in nervous diseases, has been used with the best results, and which promises to yield an abundant harvest in a still broader domain." From Author's Preface. 8PRCDCEN 07 n-LVSTEATlONS. Sfurton-Ettlnghansen Apparatus, " Those who do not read German are under great obligations to William A. Hammond, who has given them not only an excellent translation of a most ex- cellent work, but has given us much valuable information and many suggestions from his own personal experience." Medical Record. " Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious and conscientious student of the application of electricity to practical medicine, and the results of his labors are given in this volume. Dr. Hammond, in making a translation of the third German edition, has done a real service to the profession of this country and of Great Britain. Plainly and concisely written, and simply and clearly arranged, it contains just what the physician wants to know on the Bnbject." N. Y. Medical Journal. " It is destined to fill a want long felt by physicians in this country." Journal of Obstetrics. 20 D' Appleton & Co.'s Medical Publications. NIEMEYER A Text-Book of Practical Medicine. With Particular Reference to Physiology and Patho- logical Anatomy. By the late Dr. FELIX VON NIEMEYER, Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the University of Tubingen. Translated from the Eighth German Edition, by special permission of the Author, By GEORGE H. HUMPHREYS, M. D., Lt* jna of the Physicians to the Bureau of Medical and Surgical Relief at Bellevue Hospital for the Out-door Poor ; Fellow of the New York Academy of Medicine, etc., and CHARLES E. HACKLEY, M. D., One of the Physicians to the New York Hospital; one of the Surgeons to the New York Eye and Ear Infirmary ; Fellow of tho New York Academy of Medicine, etc. Revised Edition. 2 vols., 8vo. 1,528 pp. Cloth, $9.00 ; Sheep, $11.00. The author undertakes, first, to give a picture of disease which shall be as lifelike and faithful to nature as possible, instead of being a mere theoretical scheme ; secondly, so to utilize the more recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a clearer insight into the various processes of disease. The work has met with the most flattering reception and deserved success; has been adopted as a text-book in many of the medical colleges both in this country and in Europe; and has received the very highest encomiums from the medical and secular press. "It is comprehensive and concise, and is characterized by clearness and originality." Dublin Quarterly Journal of Medicine. " Its author is learned in medical literature ; he has arranged his materials with care and judgment, and has thought over them." The Lancet. " As a full, systematic, and thoroughly practical guide for the student and physician, it is not excelled by any similar treatise hi any language." Appletons' fournal. " The author is an accomplished pathologist and practical physician ; he is not only capable of appreciating the new discoveries, which during the last ten years have been unusually numerous and important in scientific and practical medicine, but, by his clinical experience, he can put these new views to a practical test, and give judgment regarding them." Edinburgh Medical Journal. " From its general excellence, we are disposed to think that it will soon take its place among the recognized text-books." American Quarterly Journal of Medical Sciences. " The first inquiry in this country regarding a German book generally is, ' Is it a work of practical value ? " Without stopping to consider the justness of the American idea of the ' practical,' we can unhesitatingly answer, ' It is ! ' " Neva York Medical Journal. " The author has the power of sifting the tares from the wheat a matter of the greatest importance in a text-book for students." British Medical Journal. " Whatever exalted opinion our countrymen may have of the author's talents of observation and his practical good sense, his text-book will not disappoint them, while those who are so unfortunate as to know him only by name, have in store a rich treat." New York Medical Record. D. Appleton & CoSs Medical Publications. 21 NEUMANN. Hand-Book of Skin Diseases. By DR. ISIDOR NEUMANN, Lecturer on Skin Diseases in the Royal University of Vienna. Translated from advanced sheets of the second edition, furnished by the Author ; with Notes, By LUCITJS D. BULKLEY, A. M., M. D., Surgeon to the Xew York Dispensary, Department of Venereal and Skin Diseases ; Assist- ant to the Skin Clinic of the College of Physicians and Surgeons, New York ; Mem- ber of the New York Dennatological Society, etc., etc. 1 vol., 8vo. About 459 pages and 66 Woodcuts. Cloth, $1.00. SPECUIEX OP ILLUSTRATION'S. Section of skin from a bald head. Prof. Neumann ranks second only to Hebra, whose assistant he was for many yeare, and his work may be considered as a fair exponent of the German practice of Dermatolo- gy. The book is abundantly illustrated with plates of the histology and pathology of the skin. The translator has endeavored, by means of notes from French, English, and Ameri- can sources, to make the work valuable to the student as well as to the practitioner. " It is a work which I shall heartily recommend to my class of students at the Univer- sity of Pennsylvania, and one which I feel sure will do much toward enlightening the pro- fession on this subject." Loui-s A. Duhring. " I know it to be a good book, and I am sure that it is well translated ; and it is inter- esting to find it illustrated by references to the views of co-laborers in the same field.'' Erasmus Wilson. " So complete as to render it a most useful book of reference." T. McCatt Anderson. " There certainly is no work extant which deals so thoroughly with the Pathological Anatomy of the Skin as does this hand-book." JV. Y. Medical Eecord. " The original notes by Dr. Bulkley are very practical, and are an important adjunct to the text. ... I anticipate for it a wide circniation." Silas Dvrfcee, Boston. "I have already twice expressed my favorable opinion of the book in print, and am glad that it is given to the public at last" James C. White, Boston. More than two years ago we noticed Dr. Neumann's admirable work in its original shape ; and we are therefore absolved from the necessity of saying more than to repeat our strong recommendation of it to English readers." Practitioner, 22 D. Appleton cfi Co.'s Medical Publications. NEFTEL. GalvanO-TherapeutlCS. The Physiological and Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, Sympathetic, and Pneumogastrio Nerves. By WILLIAM B. NEFTEL. 1 vol., 12mo. 161 pp. Cloth, $1.50. This book lias been published at the request of several aural sur- geons and other professional gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visiting physician to the largest hospital of St. Petersburg, has had the very best facili- ties for investigation. " This little work shows, as far as it goes, full knowledge of what has been done on the subjects treated of, and the author's practical acquaintance with them." New York Medical Journal. " Those who use electricity should get this work, and those who do not should peruse it to learn that there is one more therapeutical agent that they could and should possess." The Medical Investigator. 1STIG-HTINGALE. N OtCS On Nursing : What it is, and what it is not. By FLORENCE NIGHTINGALE. 1 vol., 12mo. 140 pp. Cloth, 75 cents. Every-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put the constitution in such a state as that it will have no disease or that it can recover from disease, takes a higher place. It is recognized as the knowledge which every one ought to have dis- tinct from medical knowledge, which, only a profession can have. PEREIRA. Dr. Pereira's Elements of Materia Medica and Therapeutics. Abridged and adapted for the Use of Medical and Pharmaceutical Practi- tioners and Students, and comprising all the Medi- cines of the British Pharmacopoeia, with such others as are frequently ordered in Prescriptions, or re- quii^ed by the Physician. Edited by ROBERT BEXTLEY and THEOPHILUS REDWOOD. New Edition, Brought down to 1872. 1 vol., Royal 8vo. Cloth, $7.00; Sheep, $8.00. D. Appleton <& Co.'s Medical Publications. 23 PEASLEE. Ovarian Tumors ; Their Pathology, Diagnosis, and Treatment, with reference especially to Ovariotomy. By E. E. PEASLEE, M. D., Professor of Diseases of Women in Dartmouth College; one of the Consulting Physicians to the New York State Woman's Hospital ; formerly Professor of Obstetrics and Diseases of Women in the New York Medical College ; Corresponding Member of the Obstetrical Society of Berlin, etc. 1 vol., 8vo. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDowell, the " Father of Ovariotomy." Price, Cloth, $5.00. This valuable work, embracing the results of many years of successful experience in the department of which it treats, will prove most acceptable to the entire profession ; while the high standing of the author and his knowledge of the subject combine to make the book the best in the language. It is divided into twd parts : the first treating of Ovarian Tumors, their anatomy, pathology, diagnosis, and treatment, except by extirpation ; the second of Ovariot- omy, its history and statistics, and of the operation. Fully illustrated, and abounding with information the result of a prolonged study of the subject, the work should be in the hands of every physician in the country. The following are some of the opinions of the press, at home and abroad, of this great work, which has been justly styled, by an eminent critic, " the most complete medical mono- graph on a practical subject ever produced in this country." " His opinions upon what others have advised are clearly set forth, and are as Interesting and important as are the propositions he has himself to advance ; while there are a freshness, a vigor, an authority about his writing, which great practical knowledge alone can confer." The Lancet. " Both WehVs and Peaslee's works will be received with the respect due to the great repu- tation and skill of their authors. Both exist not only as masters of their art, but as clear and graceful writers. In either work the student and practitioner will find the fruits of rich expe- rience, of earnest thought, and of steady, well-balanced judgment. As England is proud of AVells, so may America well be proud of'Peaslee, and the great world of science may be proud of both." British Medical Journal. " This is an excellent work, and does great credit to the industry, ability, science, and learning of Dr. Peaslee. Few works issue from the medical press so complete, so exhaustive- ly learned, so imbued with a practical tone, without losing other substantial good qualities." Edinburgh Medical Journal. " In closing our review of this work, we cannot avoid again expressing our appreciation of the thorough study, the careful and honest statements, and candid spirit, which characterize it. For the use of the student ire should give the preference to Dr. Peaslee's worA 1 , not only from its completeness, but from its more methodical arrangement." American Journal o/ Meilical Sciences. " Dr. Peaslee brings to the work a thoroughness of study, a familiarity with the whole field of histology, physiology, pathology, and practical gynaecology, not excelled, perhaps, by those of any man who ever performs the operation." Medical Record. " If we were to select a single word to express what we regard as the highest excellence of this book, it would be its thoroughness.' 1 '' New York Medical Journal. " We deem its careful perusal indispensable to all who would treat ovarian tumors with a good conscience." American Journal of Obstetrics. li It shows prodigal industry, and embodies within its five hundred and odd pages pretty much all that seems worth knowing on the subject of ovarian diseases." Philadelphia Medi- cal Times. > " Great thoroughness is shown in Dr. Peaslee's treatment of all the details of this very ad- mirable work." Boston Medical and Surgical Journal. " It is a necessity to every surgeon who expects to treat this disease." Leavenicorth Medical Herald. " Indispensable to the American student of gynaecology." Pacific Medical and Surgical Journal. " There is not a doubtful point that could occur to any one that is not explained and an- swered in the most satisfactory manner." Virginia Clinical Record. " The work is one the profession should prize ; one that every earnest practitioner should possess." Georgia Medical Companion. " Dr. Peaslee has achieved a success, and the work is one which no practical surgeon can afford to be without." Medical Investigator. 24 D. Appleton <* CoSs Medical Publications. SAYRE. A Practical Manual on the Treatment of Club-Foot. By LEWIS A. SAYRE, M. D., Professor of Orthopedic Surgery in Bellevne Hospital Medical College ; Surgeon to Bcllerue and Charity Hospitals, etc, 1 vol., 12mo. New and Enlarged Edition. Cloth. " The object of this work is to convey, in as concise a manner as possible, all the practical information and instruction necessary to enable the general practitioner to apply that plan of treatment which has been so successful in my own hands." Preface. " The book will very well satisfy the wants of the majority of general practitioners, for whose use, as stated, it is intended. 1 ' Xew York Medical Journal. SMITH. On Foods. By EDWARD SMITH, M. D., LL. B., F. R. S., Fellow of the Royal College of Physicians of London, etc., etc. 1 vol., 12mo. Cloth. Price, $1.75. Since the issue of the author's work on " Practical Dietary," he has felt the want of another, which would embrace all the generally-known and less-known foods, and contain the latest scientific knowledge re- specting them. The present volume is intended to meet this want, and will be found useful for reference, to both scientific and general read- ers. The author extends the ordinary view of foods, and includes water and air, since they are important both in their food and sanitary aspects. STHOUD. The Physical Cause of the Death of Christ, and its Relations to the Principles and Prac- tice of Christianity. By WILLIAM STROUD, M. D. t With a Letter on the Subject, By SIR JAMES Y. SIMPSON, BART., M. D. 1 vol., 12mo. 422 pp. Cloth, $2.00. This important and remarkable book is, in its own place, a masterpiece, and will be considered as a standard work for many years to come. The principal point insisted npon is. that the death of Christ was caused by rupture or lacer- ation of the heart. Sir James T. Simpson, who had read the author's treatise ana various com- ments on it, expressed himself very positively in favor of the views maintained by Dr. Stroud.' Psychological Journal. D. Applet on & (70. 's Medical Publications, 25 SIMPSON. The Posthumous Works of Sir James Young Simpson, Bart., M. D. In Three Volumes. Volume I. Selected Obstetrical and Gynaecological Works of Sir James Y. Simpson, Bart., M. D., D. C. L., late Professor of Midwifery in the University of Edinburgh. Containing the substance of his Lect- ures on Midwifery. Edited by J. WATT BLACK, A. M., M. D., Member of the Royal College of Physicians, London ; Physician- Accoucheur to Char- ing Cross Hospital, London ; and Lecturer on Midwifery and Diseases of Women and Children in the Hospital School of Medicine. 1vol., STO. 852pp. Cloth, $3.00. This volume contains all the more important of the contributions of Sir James Y. Simpson to the study of obstetrics and diseases of women, with the exception of his clinical lectures on the latter subject, which will shortly appear in a separate volume. This first volume contains many of the papers reprinted from his Obstetric Memoirs and Contri- butions, and also his Lecture Notes, now published for the first time, containing the substance of the practical part of his course of mid- wifery. It is a volume of great interest to the profession, and a fitting memorial of its renowned and talented author. " To many of our readers, doubtless, the chief of the papers it contains are familiar. To others, although probably they may be aware that Sir James Simpson has written on the sub- jects, the papers themselves will be new and fresh. To the first class we would recommend this edition of Sir James Simpson's works, as a valuable volume of reference; to the latter, as a collection of the works of a great master and improver of his art, the study of which cannot fail to make them better prepared to meet and overcome its difficulties." Medical Times and Gazette. Volume II. Anaesthesia, Hospitalism^ etc. Edited by Sir WAITER SIMPSON, Bart. 1 vol., 8vo. 560pp. Cloth, $3.00. " We say of this, as of the first volume, that it should find a place on the table of every practitioner ; for, though it is patchwork, each piece may be picked out and studied with pleas- ure and profit." The Lancet (London). Volume III. The Diseases of Women. Edited by ALEX. SIMP- SOX, M. D., Professor of Midwifery in the University of Edinburgh. 1 vol., 8vo. Cloth, $3.00. One of the best works on the subject extant. Of inestimable value to every physician. SWETT. A Treatise on the Diseases of the Chest. Being a Course of Lectures delivered at the New York Hospital. By JOHN A. SWETT, M. D., Professor of the Institutes and Practice of Medicine in the New York University ; Physician to the New York Hospital ; Member of the New York Pathological Society. 1 vol., 8vo. 587 pp. $3.50. Embodied in this volume of lectures is the experience of ten years in hospital and private practice. 20 D. Appleton & (70. 's Medical Publications. SCHROEDER A Manual of Midwifery, including the Pathology of Pregnancy and the Puerperal State* By Dr. KARL SCHROEDER. Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen. Translated from the Third German Edition, By CHAS. H. CARTER, B. A., M. D., B. S. Lond., Member of the Royal College of Physicians, London, and Physician Accoucheur to St George'n, Hanover Square, Dispensary. With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth. u The translator feels that no apology is needed in offering to the profession a translation of 8chroeder's Manual of Midwifery. The work is well known In Germany and extensively used as a text-book ; it has already reached a third edition within the short space of two years, and it is hoped that the present translation will meet the want, long fejt in this country, of a manual of midwifery embracing the latest scientific researches on the subject. TILT. A Hand-Book of Uterine foVtf and of Diseases of Women. By EDWARD JOHN TILT, M. D., Member of the Royal College of Physicians ; Consulting Physician to the Farringdon General Dispensary ; Fellow of the Royal Medical and Chirurgical Society, and of several British and foreign societies. 1 vol., 8vo. 345 pp. Cloth, $3.50. Second American edition, thoroughly revised and amended. " In giving the result of his labors to the profession the author has done a great work. Our readers will find its pages very interesting, and, at the end of their task, will feel grateful to the author for many very valuable suggestions as to the treatment of uterine diseases." The Lancet. " Dr. Tilt's ' Hand-Book of Uterine Therapeutics ' supplies a want which has often been felt. ... It may, therefore, be read not only with pleasure and instruction, but will also be found very useful as a book of reference." The Medical Mirror. " Second to none on the therapeutics of uterine disease." Journal of Obstetrics. VAN BUREN. Lectures upon Diseases of the Rectum. Delivered at the Bellevue Hospital Medical College. Session of 1869-'70. By W. H. VAN BUREN, M. D., Professor of the Principles of Surgery with Diseases of the Genito-Urinary Organs, etc, in the Bellevue Hospital Medical College ; one of the Consulting Surgeons of the New York Hos- pital, of the Bellevue Hospital ; Member of the New York Academy of Medicine, of the Pathological Society of New York, etc., etc. 1 vol., 12mo. 164 pp. Cloth, $1.50. " It seems hardly necessary to more than mention the name of the author of this admirable little volume in order to insure the character of his book. No one in this country has enjoyed greater advantages, and had a more extensive field of observation in this specialty, than Dr. Van Buren, and no one has paid the same amount of attention to the subject . . . Here is the experience of years summed up and given to the professional world in a plain and practical manner.' 1 Psychological Journal. D. Appleton <& CoSs Medical Publications. 27 VOG-EL. A Practical Treatise on the Diseases of Children. Second American from the Fourth German Edition. Illustrated by Six Lithographic Plates. By ALFEED VOGEL, M. D., Professor of Clinical Medicine In the University of Dorpat, Easeia. TRANSLATED AND EDITED BY , H. EAPHAEL, M. D., Late House Surgeon to Eellevue Hospital ; Physician to the Eastern Dispensary for the Disceace of Children, etc., etc. 1 vol., 8vo. 611 pp. Cloth, $4.50. The work is well up to the present state of pathological knowledge ; complete without unnecessary prolixity; its symptomatology accurate, evidently the result of careful observation of a competent and experi- enced clinical practitioner. The diagnosis and differential relations of diseases to each other are accurately described, and the therapeutics judicious and discriminating. All polypharmacy is discarded, and only the remedies which appeared useful to the author commended. It contains much that must gain for it the merited praise of all im- partial judges, and prove it to he an invaluable text-book for the stu- dent and practitioner, and a safe and useful guide in the difficult but all- important department of Pasdiatrica. " Rapidly passing to a fourth edition in Germany, and translated into three other languages, America now has the credit of presenting the first English ver- Bion of a book which must take a prominent, if not the leading, position among works devoted to this class of disease." N. Y. Medical Journal. " The profession of this country are under many obligations to Dr. Raphael for bringing, as he has dona, this truly valuable work to their notice." Medical Record. "The translator has been more than ordinarily successful, and his labors have resulted in what, in every sense, is a valuable contribution to medicai science." Psychological Journal. "We do not know of a compact text-book on the diseases of children more complete, more comprehensive, more replete with practical remarks and scientific facts, more in keeping with the development of modern medicine, and more worthy of the attention of the profession, than that which has been the subject of our remarks." Journal of Obstetric*. 28 D. Appleton & (70. 's Medical Publications. WALTON. The Mineral Springs of the United States and Canada, with Analyses and Notes on the Prominent Spas of Europe, and a List of Sea-side Resorts. By GEORGE E. WALTON, M.D., Lecturer on Materia Medica in the Miami Medical College, Cincinnati. 1 vol., 12mD. 390 pages, with Maps. Price, $2.00. The author lias given the analyses of all the springs in this country and those of the principal European spas, reduced to a uniform standard of one wine-pint, so that they may readily be compared. He has arranged the springs of America and Europe in seven distinct classes, and de- scribed the diseases to which mineral waters are adapted, with refer- ences to the class of waters applicable to the treatment, and the pecul- iar characteristics of each spring as near as known are given also, the location, mode of access, and post-office address of every spring are men- tioned, In addition, he has described the various kinds of baths and the appropriate use of them in the treatment of disease. " In this volume the author has endeavored to arrange all the known facts concerning mineral waters, in such a manner that they shall be readily acces- sible. For this purpose he has consulted the best European authors, their con- clusions being drawn from hundreds of years of laborious investigation of the spas of Germany, France, Switzerland, and Italy. It has been interesting, in the course of this study, to note how closely the conclusions drawn by them concerning the action of different classes of waters agree with the observations made at springs in this country, independent of any knowledge of foreign re- search. The portion relating to the springs of the United States is the result of a selection of credible evidence regarding them, gained by correspondence and personal observation." Extract from Preface. UNIVERSITY OF VIRGINIA, June 9, 1878. GENTLEMEN : I have received by mail a copy of Dr. Walton's work on the Mineral Springs of the United States and Canada. Be pleased to accept my thanks for a work which I have been eagerly looking for ever since I had the pleasure of meeting the author in the summer of 1871. He satisfied me that he was well qualified to write a reliable work on this subject, and I doubt not he has met my expectations. Such a work was greatly needed, and, if offered for sale at the principal mineral springs of the country, will, I believe, com- mand a ready sale. Very respectfully yours, J. L. CABELL, M. D. D. Appleton & CoSs Medical Publications. 29 WELLS. Diseases of the Ovaries ; Their Diagnosis and Treatment. By T. SPENCER WELLS, Fellow and Member of Council of the Royal College of Surgeons of England ; Honorary Fellow of the King and Queen's College of "Physicians in Ireland ; Burgeon in Ordinary to the Queen's Household ; Surgeon to the Samaritan Hospital for Women ; Member of the Im- perial Society of Surgery of Parts, of the Medical Society of Paris, and of the Medical Soci- ety of Sweden; Honorary Member of the Royal Society of Medical and Natural Science of Brussels, and of the Medical Societies of P'esth and Helsingfors : Honorary Fellow of the Obstetrical Societies of Berlin and Leipzig. 1 vol., 8vo. 478 pp. Illustrated. Cloth, Price, $4.50. In 1865 the author issued a volume containing reports of one hundred and fourteen cases of Ovariotomy, which was little more than a simple record of facts. The book was soon out of print, and, though repeatedly asked for a new edition, the author was unable to do more than prepare papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases accumulated. On the completion of five hundred cases he embodied the results in the present volume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to them and useful to suffering women. " Arrangements have been made for the publication of this volume in Lon- don on the day of its publication in New York." French and German transla- tions are already in press. WAGNER A Hand-book of Chemical Tech- nology. By RUDOLPH WAGNER, Ph. D., Professor of Chemical Technology at the University of Wurtzburg. Translated and edited, from the eighth. German edition, with extensive additions, By WILLIAM CROOKES, F. R. S. With 336 Illustrations. 1 vol., 8vo. 761 pages. Cloth, $5.09. Under the head of Metallurgic Chemistry, the latest methods of preparing Iron, Cobalt, Nickel, Copper, Copper Salts, Lead and Tin," and their Salts, Bismuth, Zinc, Zinc Salts, Cad- mium, Antimony, Arsenic, Mercury. Platinum, Silver, Gold, Manganates, Aluminum, and Magnesium, are described. The various applications of the Voltaic Current to Electro-Metal- lurgy follow under this division. The preparation of Potash and Soda Salts, the manufacture of Sulphuric Acid, and the recovery of Sulphur from Soda Waste, of course occupy prominent places in the consideration of chemical manufactures. It is difficult to over-estimate the mer- cantile value of Mond's process, as well as the many new and important applications of Bisul- phide of Carbon. The manufacture of Soap will be found to include much detail. The Tech- no lojrv of Glass, Stone-ware, Limes, and Mortars, will present much of interest to the Builder and Engineer. The Technology of Vegetable Fibres has been considered to include the prep- aration of Flax, Hemp, Cotton, as well as Paper-making; while the applications of Vegetable Products will be found to include Sugar-boiling. Wine and Beer Brewing, the Distillation of Spirits, the Baking of Bread, the Preparation of Vinegar, the Preservation of Wood, etc. Dr. Wagner gives much information in reference to the production of Potash from Sugar residues. The use of Baryta Salts is also fully described, as well as the preparation of Sugar from Beet-roots. Tanning, the Preservation of Meat, Milk, etc., the Preparation of Phospho- rus and Animal Charcoal, are considered as belonging to the Technology of Animal Products. The Preparation of Materials for Dyeing has necessarily required much space ; while the final sections of th book have been devoted to the Technology of Heating and Illumination. THE NEW YORE MEDICAL JOURNAL. TOT. T. ZUfiK, ST. J>., \ Vdltnra JA.S. B. HUXIEB, M.D., ] * Published Monthly, Volumes begin in January and July, " Among the numerous records of Medicine and the collateral sciences pub- lished in America, the above Journal occupies a high position, and deservedly BO." The Lancet (London). Terms, $4.00 per annum, Specimen Copies, 25 Cents. The attention of the profession is called to the fact that subscribers to the NEW YORK MEDICAL JOURNAL will be supplied with any foreign or American Medical Jour- nals at a liberal discount from the regular subscription price. Commutation rates will be given on application. THE POPULAR SCIENCE MONTHLY. Conducted by Prof. E. L. YOUMANS. Each nuniber contains 128 pages, with numerous Descrip- tive and Attractive Illustrations. PUBLISHED MONTHLY. Terms, $5.00 per annum, or Fifty Cents per Number. The great feature of this magazine is, that its contents are not what sci- ence was ten or more years since, but what it is to-day, fresh from the study, the laboratory, and the experiment ; clothed in the language of the authors, inventors, and scientists themselves, which comprise the leading minds of this most scientific age. In this magazine we have the latest thoughts and words of Herbert Spencer, Prof. Huxley, and Mr. Darwin, and the fresh experiments of Tyndall, Hammond, and Brown -Sequard. It also contains accounts of all the recent important discoveries by the eminent scientists of France and Germany. The MOXTHLT enables us to utilize at least several years more of life than it would be possible were we obliged to wait its publication in book-form at the hands of some compiler. The new volume commenced in May, 1873, and all new subscriptions should begin with that dale. OPINIONS OF THE PRESS. " A journal which promises to be of eminent value to the cause of popular education in this country." New York Tribune. " It is, beyond comparison, the best attempt at journalism of the kind ever made in this country." Home Journal. "The initial number is admirably constituted." Evening Mail. " In our opinion, the right idea has been happily hit in the plan of this new monthly." Buffalo Courier. "Just the publication needed at the present day." Montreal Gazette. New York Medical Journal and Popular Science Monthly $3 00 New York Medical Journal and Appletons' Weekly Journal of Literature, Science, and Art 7 00 Appletons 1 Weekly Journal and Popular Science Monthly 8 00 N ew York Medical Journal, Popular Science Monthly, and Weekly Journal. 11 60 Payment, in all eases, must btt made in advance. Remittances should be made by postal money-order or check to the Publishers, D. APPLETOff & CO., 549 & 551 Broadway, N. T, 30 NEW MEDICAL WORKS IN PRESS. On Puerperal Diseases. Clinical Lectures delivered at Bellevue Hospital. By FORDYCE BARKER, M. D., Clinical Professor of Mid- wifery and Diseases of Women in the Bellevue Hospital Medical College ; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York State Woman's Hospital, and to the New York State Hospital for Diseases of the Nervous System; Honorary Member of the Edinburgh Obstetrical Society, etc., etc. A course of lectures valuable alike to the student and the practitioner. Hand-Book of the Histology and Histo- Chemistry of Man. By Dr. HEINRICH FREY, of Zurich. Illustrated with 500 Woodcuts. Clinical Lectures on Diseases of the Nervous System. Delivered at the Bellevue Hospital Medical College, by WM. A. HAMMOND, M. D. Edited, with Notes, by T. M. B. Cross, M. D. A. CUB ; its Pathology, Etiology, Prognosis, and Treatment. By L. DUNCAN BULKLEY, A. M., M. D., New York Hospital. A monograph of about seventy pages, illustrated, founded on an analysis of two hundred coses of various forms of acne. Compendium of Children's Diseases, for Students and Physicians. By Dr. JOHN STEIXER. Diseases of the Nerves and Spinal Cord. By Dr. H. CHARLTON BASTIAN. Chauveau's Comparative Anatomy of the Domesticated Animals. Edited by GEORGE FLEMING, F. R. G. S., M. A. I. 1 vol. 8vo, with 450 Illustrations. On Surgical Diseases of the Male Geni- to-Uriuary Organs, including Syphilis. By W. H. VAN BUREN, M. D., and L. KEYES, M. D. D. APPLETON & CO., 649 & 551 BROADWAY, NEW YORK. 31 INTERNATIONAL SCIENTIFIC SERIES. ZLSTO'W IR E .A. 3D "ST - NO. 1. FORMS OF WATER, in Clouds, Kain, Kivers, Ice, and Glaciers. By Prof. JOHN TYXDALL, LL. D., F. E. S. 1 vol. Cloth. Price, $1.50. No. 2. PHYSICS AND POLITICS; or, Thoughts on the Application of the Principles of " Natural Selection " and "Inheritance " to Political Society. 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The character and scope of this series will be best indicated by a reference to the names and nbjects included in the subjoined list, from which it will be seen that the cooperation of the most distinguished professors in England, Germany, France, and the United States, has been secured, and negotiations are pending for contributions from other eminent scientific writers. The works will be issued simultaneously in New York, London, Paris, and Leipsic. The INTERNATIONAL SCIENTIFIC SEKIES is entirely an American project, and was originated and organized by Dr E. L. Youmans, who spent the greater part of a year in Europe, arranging with authors and publishers. The forthcoming volumes are as follows : Prof. T. H. HUXLEY, LL. B., F. R. S., Bodily Mo- tion and Consciousness. Dr. W. B. CARPENTER. LL. D., F. E. S., The Principles of Mental Physiology. Sir Jons LUBIIOCK, Bart., F. E. S., The Antiq- uity of Man. Prof. RUDOLPH VIRCHOW (of the University of Berlin), Morbid Physiological Action. Prof. BALFOUR STEWART, LL. D., F. E. S., The Conservation of Energy. Dr. II. CHARLTON BASTIAN, M. D., F. E. S., Tie Brain as an Organ of Mind. Prof. WILLIAM ODLLNG, F. E. S., The Few Chemistry. Prof. W. TniSTLETON DYER, B. A., B. Sc., Form and Habit of Flowering Plants. Dr. EDWARD SMITH, F. E. S., On Diet*. Prof. W. D. WHITNEY, Modem Linguistic Sci- ence. Prof. A. C. RAMSAY, LL. D., F. E. S., Earth Sculpture. Dr. HENRY MAUDSLEY, Responsibility in Dis- ease. Prof. MICHAF.L FOSTER, M. D., Protoplasm and the Cell Theory. Eev. M. J. BERKELEY. M. A., F. L.9., Fungi; their Nature. Influences, and Uses. Prof. CLAUDP. BERNARD (of the College of France), Physical and Metaphysical Phe- nomena of Life. Prof. A. QUETELET (of the Brussels Academy of Sciences), Social Physics. Prof. A. DE QUATREFAGES, The Negro Races. Prof. LACAZE-DUTHIERS, Zoology since Cuvier. Prof. W. KINGDON CLIFFORD. M. A., The First \ Prof. C. A. YOUNG, Ph. D. (of Dartmouth Col- Principlesoftke Exact Sciences explained to the yon- Mathematical. Mr. .T. N. LOOKYBR, F. E. S., Spectrum Analysis. W. LAUDER LINDSAY, M. I)., F. R. S. E., Mind in the Loictr Animals. B. G. BELL PETTIGREW, M. D., The Locomotion of Animals, as exemplified in Walking, Swimming, and Flying'. Prof. JAMES D. DANA, M. A., LL. D., On Cepha- lifation; or. Head Domination in it* Re- lation to Structure, Grade, and Develop- ment. Prof. 8. W. JOHNSON, M. A., On the Nutrition of Plants. Prof. AUSTIN FLINT, Jr., M. D , The Nervous S>/ttm, and its Relation to fie Bodily Functions. lege), The Sun. Prof. BERNSTEIN (University of Halle), T': Physiology of the Senses. Prof. HERMAN (University of Zurich), On Res- piration. Prof. LEUCKARD (University of Leipsic), Out- lines of Chemical Organiirttion. Prjf. EEES (University of Erlangen), On Para- sitic Plants. Prof. VOGEL (Polytechnic Academy, Berlin), Tft* Chemical Effects of Light. Prof. WCNDT (University of Strasbourg), On Sound. Prof. SCHMIDT (University of Strasbourg), The Theory of Descent Darwinism. Prof. EOSENTHAL (University of Erlangen), Physiology of Muscles and Nerves. Professors II. SAINT-CLAIRE DEVILLF, BEBTITELOT, and WURTZ, have engaged to write, but have not^yet announced their subjects. Other eminent authors, as WALLACE, HELMHOLTZ, PABKS, MILNE-EDWARDS, and H.EI-KEL, have given strong encouragement that they will also take part in the enterprise. D. APPLETON & CO., Publishers, 549 & 551 Broadway, U. Y 32 Date Due PRINTED IN U.S.* CAT NO 24 161 LIBRARY FACILITY A 000 499 578 3 WQ500 B255p Barker, Fordyce. The puerperal diseases; clinical lee- tures ... MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664