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.

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:
(<i) absence of arterial pulsation below the thrombus ; (6) sometimes increased
force of pulsation above the thrombus ; (e) pain below the seat of the throm-
bus ; (</) 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 ; (<) secondary to a lesion of the paren-
chyma of the lungs ; (d) arieritis 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 embplbm 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 . . . p. 247

CONTENTS. xi

LECTUEE XIV.

PTTEEPEEAL PHLEBITIS.

Case Recovery Two cases of death Autopsical lesions *Three forms of puerperal
phlebitis: adhesive, circumscribed suppurative, and diffuse suppurative
Ranvier's pathological histology Uterine phlebitis Symptoms : rapid pulse,
rise in temperature, recurrent chills of moderate severity Pain, generally not
severe, but uterine tenderness Abdominal tenderness and tympanites not
symptoms of phlebitis Involution not retarded by uterine phlebitis Typhoid
symptoms : rapid depression of the vital powers, delirium, subsultus, diar-
rhoea, profuse perspiration, profuse and very offensive lochia Signs of puru-
lent infection Differential diagnosis of uterine phlebitis from peritonitis and
metritis Terminations of uterine phlebitis Rapid death from septicaemia or
embolism of the pulmonary artery Recovery by resolution Slow recovery by
eliminative suppuration on the external surface Death as a result of purulent
deposit hi serous cavities or in the parenchyma of important organs Secondary
bronchitis or pneumonia Tendency of this disease to impair assimilation and
nutrition, and subsequently to destroy life by marasmus or acute tuberculosis
Treatment Page 280

LECTUEE XV.

PIJEBPEEAL METRITIS.

Case Puerperal metritis very frequently a prominent lesion of puerperal fever, and
generally found associated with peritonitis or phlebitis In this case, compli-
cated only with cystitis, which is not uncommon as a puerperal disease Puer-
peral metritis includes endometritis and parenchymatous metritis Metritis
frequently the primary lesion, in the development of phlebitis or peritonitis
Physiological modifications of the mucous membrane of the uterus during the
puerperal period Pathological anatomy of puerperal metritis Causes Symp-
toms Duration and terminations Treatment p. 303

LECTUEE XVI.

PTJEEPEBAL PEBIT ONITIS.

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 p. 324

xii CONTEXTS.

LECTURE XVII. "

PELVIC PERITONITIS AND PELVIC CELLULITIS.

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, Page 365

LECTURE XVIII.

PCERPEBAL SEPTICAEMIA AND 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,
pyrcmia, 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 phlegmasiac, 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 p. 390

LECTURE XIX.

PUEEPERAL FEVER.

CONTENTS. xiii

Variety of theories The theory of the localists The theory of trau-
matism and septicaemia 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 Pro-
fessor 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 Page 429

LECTURE XX.

PUEBPEBAL FEVEE.

Symptoms of puerperal fever Anatomical lesions Symptoms due to the secondary
lesions Progress and termination Symptoms indicating the probability of re-
covery Unfavorable symptoms Treatment Arterial sedatives Necessity for
careful watching Case illustrative of the action of the veratrum viride Opi-
ates Agents to reduce fever Quinine The mineral acids Alcohol Food
Treatment of the secondary lesions Illustrative case Treatment by elimina-
tion Venesection (?) Leeches (?) Emetics (?) Purgatives (?) Mercu-
rials (?) . p. 478

APPENDIX 615

INDEX 522

PUERPERAL DISEASES.

LECTURE I

PUERPERAL COISTALESCENCE.

: In our lying-in wards, where we have
monthly from forty to fifty or more cases of labor, you
have the opportunity of studying clinically, and be-
coming practically acquainted with, every variety of
puerperal disease, to a greater extent than is found any-
where else in this country. You have already seen
most interesting cases of some of the forms of post-par-
tum inflammation, of puerperal convulsions, mania, and
puerperal fever. Before discussing the various path-
ological conditions incidental to the puerperal state,
which you have seen and will see in our wards, let us first
study normal puerperal convalescence. This includes
two distinct classes of phenomena : first, the restoration
of the pelvic organs to their normal state, which, during
i

2 PUERPERAL DISEASES.

gestation and parturition, nave been the seat of extraor-
dinary modifications in tissue, function, and position ;
second, the development of a new function, lactation,
for the nutrition of the infant.

Puerperal convalescence is normal, when these two
conditions are perfectly attained without injury to the
health of the mother or child. During gestation, the
organs concerned in this function are the seat of a most
active evolution, which exerts an important influence
over all the vital functions, and culminates in the pro-
cess of parturition.

During the forty weeks of utero-gestation, the uterus
enlarges from nearly three inches in length and one and
three-quarters in breadth, to twelve or fifteen in length
and nine or ten in breadth. It increases from about
two ounces in weight, to twenty-five or thirty ounces.
Its cavity, before impregnation, is less than one cubic
inch, while, at the full term of pregnancy, it is extended
to above four hundred cubic inches, and the surface of
the organ increases from about five or six square inches,
to nearly three hundred and fifty square inches. (Simp-
son.) Its serous tissue undergoes a corresponding ex-
tension ; and, as this takes place without a decrease in
thickness, it must be the seat of a much more active
nutrition, to prevent its attenuation. Its lining, or mu-
cous membrane, becomes actively hypertrophied, con-
stituting the decidua, which, after parturition, is exfo-
liated, and a new mucous membrane is formed.

The reduction of the uterus after delivery to its
normal size, its involution, as it is termed, takes place
by fatty transformation of its component fibres, and ab-
sorption. The cicatrization of its internal surface is
accomplished by the exudation of organizable lyrnph
and the development of a new layer of mucous mem-

PUERPERAL CONVALESCENCE. 3

brane. This rapid exposition of some of the physiolo-
gical changes which take place during puerperal conva-
lescence is necessary, in order that we may properly
appreciate the clinical phenomena pertaining to this
period.

During the first hours after delivery, the genital or-
gans are more or less swollen and painful. The vagina
is distended, soft, and bloody. It has, of course, been
very much stretched by the passage of the child, but it
is so elastic that it soon recovers its natural state. The
anterior edge of the perinseum is often slightly torn in
first labors, but, if it be not more than this, it is of no
consequence, except that it may become the seat of ab-
sorption of septic matter.

The uterus should be felt firmly contracted, as a
hard, round tumor, about the size of an infant's head,
just above the pubes. It gradually diminishes in size,
until it sinks into the pelvis. It ordinarily cannot be
felt above the pubes later than from the sixth to the
tenth day ; when it can be felt later, this indicates arrest
of involution, the cause of which should be investi-
gated.

Professor Murphy divides puerperal convalescence
into three periods : 1. The interval between the birth of
the child and the commencing secretion of milk ; 2. The
period during w^hich the function of lactation rises to
its highest point of activity ; 3. The period occupied in
restoring the uterus to its original condition previous to
conception. During the first hours after delivery, there
should be complete repose. The patient, by proper
management, should be secured a sound and refreshing
sleep. If the labor have been a severe and tedious one,
and in all cases where operative procedures have been
required, I am in the habit of giving a full opiate ; that

4: PUERPERAL DISEASES.

i*, a grain of opium, or the equivalent of some of its
preparations, as soon as the binder lias bsen applied,
and the soiled clothes have been removed. Every thing
which would disturb or excite the patient should be care-
fully avoided, and she should be kept perfectly quiet.

Retention of Urine. Before leaving a woman who
has just been delivered, you should be very careful to
direct the nurse, within a few hours, to try and induce
her to pass the urine, as this precaution may save you
from a good deal of subsequent trouble, and your pa-
tient from great annoyance and some suffering. Unless
her attention be called to the subject by the nurse, she
may not feel the sensations which ordinarily attend the
distention of the bladder, and she should therefore be
persuaded to make the attempt. Sometimes, by turning
the patient upon her face and knees, she may be able
to accomplish the result, when she could not in any
other posture, but she should not be allowed to exhaust
herself in fruitless efforts.

The retention may be due to loss of contractility of
the muscular tissue of the bladder, a kind of paralysis
from over-distention, or to a mechanical obstruction,
the meatus or urethra being closed by tumefaction.
The first condition is usually relieved by giving the
patient, every fifteen minutes, for an hour or two,
twenty drops of the fluid extract of ergot. After de-
livery, especially if the second stage be long, I always
examine the bladder before leaving my patient, and, if
I have reason to suspect that it contains much urine, I
give the nurse some ergot with directions as to its use.
It is, therefore, very rarely that I am compelled to use
the catheter in the puerperal woman; but, when the
retention is due to the second cause mentioned, the
catheter is the only resource. As your text-books give

PUERPERAL CONVALESCENCE. 5

you minute directions as to the guides for introducing
this instrument, I shall not detain you by a repetition
of these rules. I will only suggest to you the great
advantage of becoming perfectly familiar with these
guides by the sense of touch, by availing yourselves
of every opportunity for practice on the cadaver, as it
has frequently happened that physicians have damaged
their reputations and lost the confidence of their pa-
tients by their awkwardness or unskillfulness in using
the catheter. When necessary, the catheter should be
used every eight hours, until the patient is able to re-
lieve herself.

It sometimes happens that the physician may be
misled by the unintentional misrepresentations of the
nurse and of the patient herself, as in the following
case : I was called, some years since, in consultation
with an excellent physician and highly-esteemed friend,
to see a young lady, aged nineteen, whose first labor
had terminated fifty-two hours before I saw her. She
had slept none since her delivery, and I found her with
a very sharp, irritable pulse, hot skin, flushed face, red
eyes, excited manner, and tympanitic abdomen. She
complained of violent headache and of intense pain over
the hypogastrium, and, for some hours previous to my
seeing her, she had been frequently delirious for a few
minutes at a time. My friend, who was in attendance,
in answer to repeated inquiries, had been assured, both
by the nurse and the patient herself, that she had passed
urine many times since her delivery, and that " there
was no difficulty in that respect." A thorough and
careful palpation of the abdomen was very difficult, on
account of the great tympanites and exquisite tenderness
on pressure ; but I thought that I was able to detect,
above the pubes, the outline of a large, elastic tumor,

6 PUERPERAL DISEASES.

quite different from the uterine tumor, which, at this
period, I ought to be able clearly to define. I there-
fore asked permission to introduce a catheter, and
drew off over five pints of very offensive urine. An
anodyne was then given, the catheter was used every
eight hours for a few days, and the subsequent con-
valescence was uninterrupted by a single unpleasant
symptom. In our lying-in wards in this hospital, al-
though our house-staff are usually on their guard as
to this source of error, I have in several instances found
a large quantity of urine in the bladder, the house-phy-
sician having accepted the statement of the patient that
she had passed water very frequently. I learned a les-
son on this point some twenty-five years ago. I was
asked by one of my confreres, in the town where I then
resided, to make a post-mortem examination of a woman
who had died a few days after her confinement. He
attributed her death to some obscure cerebral disease ;
but he also said that severe peritonitis came on soon
after her confinement, which, he thought, he had success-
fully combated by venesection, blisters, opium, and
calomel. For my present purpose, it is not necessaiy
for me to detail the results of the autopsy farther than
to say that I found in the bladder nearly a gallon of
urine. This was considered very curious, as the patient
was reported by the nurse to have passed water very
frequently from the time of her confinement up to with-
in two hours of her death. It was not for me to wound
the feelings of my Mend, who was many years my sen-
ior, by unkind comments^ but I internally drew my
own inferences and " made a note of it." Enough has
been said to lead you to see the necessity for making a
careful examination of the abdomen frequently after
confinement.

PUERPERAL CONVALESCENCE. 7

After-pains. Sleep is sometimes prevented by se-
vere after-pains, which may come on soon after delivery.
They may be even more severe than ordinary labor-
pains, particularly in those who have borne many chil-
dren. By proper management, much may be done by
way of preventing their occurrence. They are usually
the result of the presence of coagula in the cavity of
the uterus, which distend its walls and excite spas-
modic contractions. If firm, steady pressure be kept up
over the fundus of the uterus during the time the trunk
of the foetus is expelled, and this pressure be not sus-
pended until after the delivery of the placenta and the
binder be properly applied, a permanent contraction of
the uterus is secured, which so effectually closes the
open mouths of the utero-placental vessels, as greatly to
diminish the amount of blood poured into the cavity.
If the second stage of labor be too rapid or too pro-
longed, I give a full dose of ergot (a teaspoonful of
Squibb's fluid extract in half a wine-glass of water, for
example), just as the delivery of the child is taking
place. The precautionary measures which should al-
ways be adopted to prevent post-parturn hemorrhage,
are also, to a certain extent, a prophylactic against
after-pains. When they come -on a few hours after de-
livery, they may sometimes be speedily relieved by
again making firm pressure over the fundus of the
uterus, which causes the expulsion of coagula; but
this method of relief should only be tried a few hours
after delivery, as the pressure may excite irritation re-
sulting in inflammation. Some preparation of opium
should then be given. A great variety of different for-
mulae have been proposed for this purpose. My favorite
prescription in these cases is ten grains of Tully's pow-

8 PUERPEKAL DISEASES.

der, 1 repeated, if necessary, in four or five hours ; "but, in
most cases, ten grains of Dover's powder, a tea-spoonful
of elixir-paregoric or Dewees's camphor-julep, will prob-
ably accomplish the result as well.

Sometimes, a day or two after labor, severe after-
pains are excited by the presence of flatus in the intes-
tines. In these cases, the abdomen is tympanitic, and a
slight touch causes severe pain, while the uterus cannot
be felt. If the pressure be steadily increased, the pain
diminishes until it entirely disappears. If the hand
be now suddenly lifted up from the abdomen, the pain
at once returns with great violence. If the pain, tym-
panitis, and tenderness on pressure, be due to inflam-
mation of the peritonaeum, the greater the pressure, the
greater the pain. The after-pains due to flatus are most
speedily relieved by turpentine-stupes and turpentine-
en em ata.

There are, also, some rare cases of after-pains which
I have met with, that seem to be purely neuralgic in
their character. There is no distention or tenderness
of the abdomen, nor is the uterus enlarged. On the
contrary, it is very firm, but quite sensitive on pressure.
There is an entire absence of other symptoms, such as
febrile reaction and constitutional disturbance, which
attend inflammation of the pelvic organs. These neu-
ralgic pains do not seem to yield to opiates in the full-
est doses ; but within a few years past I have treated
them successfully by quinine,' internally, and the appli-
cation of chloroform-liniment externally. I generally

1 TUXLY'S POWDER.
I. Pulv. g. camphor.,
Greta} pp.,
Pulv. glycyrrh.,

Morphias sulph., gr. j.

M. Dose. The same as the Dover's powder.

PUERPERAL CONVALESCENCE. 9

prescribe from five to ten grains of quinine night and
morning, but this is rarely needed for more than a day
or two. The liniment is the following : IJ. Chloroform,
3J, lin. sapo. co., vj. M. Wet a piece of flannel of
double thickness, larsre enough to cover the whole uter

/ O O

ine region, and lay upon the skin, immediately covering
the patient with the bed-clothes. The application, for
the first moment, causes a disagreeable sensation of
cold, which is at once succeeded by a burning, but not
ungrateful heat. A patient whom I saw a few weeks
since in consultation had been suffering intense agony
for over forty-eight hours, and, in addition, she was
experiencing the disagreeable effects of large doses of
morphine that had been given her to relieve the pain
and induce sleep. One dose of ten grains of quinine,
with the application of the liniment I have just men-
tioned, gave her entire and permanent relief.

I should not omit to mention that, in some few
cases, cramps in the legs seem to take the place of
after-pains. I believe Drs. McClintock and Hardy were
the first to call attention to this fact, which my own ex-
perience has verified in two or three instances. The
cramps disappeared after the expulsion of coagula from
the uterus.

TJie Locliia. This is the term applied to the dis-
charges which take place from the vulva from the time
of delivery until puerperal convalescence is complete.
In different women, who are perfectly healthy, there are
great variations in the quantity, duration, and character
of the discharge. It is at first sanguineous, being com-
posed principally of the blood w^hich oozes from the open
mouths of the uterine veins. It then becomes greenish
yellow, thick and oleaginous, and lastly, thin and serous.
During the first twenty-four hours, the patient usually

10 PUERPERAL DISEASES.

soils ten or twelve napkins. It generally is considerably
less on the second day, and not unfrequently the dis-
charge is temporarily suspended for a few hours when
the function of lactation is at first fully developed, a fact
which you should remember, as nurses are sometimes
alarmed by such an occurrence, and injudiciously excite
the apprehension of the patients on this account. The
duration of the lochia varies from a few days to four
or five weeks. As a sanguineous discharge, it usually
continues but a few days. If it be prolonged three or
four weeks, the probability is that it is due to some
local lesion, as ulceration of the cervix, or lacerations
which have occurred during labor ; and local explora-
tion should be made to determine the exact character
of the lesion. The suppression of the discharge at an
early period after labor is not to be regarded as an un-
fortunate symptom, unless it be attended with other
symptoms of an inflammatory nature. It usually ceases
much earlier in those who are delivered of still-born
children, when the foetus has been dead some days pre-
vious to labor.

Although there is a peculiar odor ordinarily attend-
ing the discharge, yet, if it be decidedly offensive, this
condition demands particular attention. It indicates
the decomposition and putrefaction of coagula or some
foreign substance in the uterus, or some graver and
more serious lesions of the uterine tissues. To correct
this odor, the following prescription is perhaps as effi-
cient as any you can use :

3- Acidi carbolic! glacial., j.

Glycerini, j.

Aquae purse, vij.

M. S. A tablespoonful in eight ounces of warm water, twice
a day, as a vaginal injection.

PUERPERAL CONVALESCENCE. 11

I am in the habit of directing the above injection,
somewhat weaker, for the first few days after confine-
ment, in all cases in private practice.

If the discharge have a coffee-ground color, with a
fetid odor, it should lead to the suspicion of gangrenous
inflammation of the uterus or vagina, and the above
injections should be used several times a day. Some-
times the discharge becomes purulent. The source
of this may be in the vagina, or in the cervix, or the
cavity of the uterus ; and, after the lochia have ceased,
and the discharge has become a purulent leucorrhoea,
an examination with the speculum should be made to
determine its source. Otherwise, your patient may re-
main for a long time more or less an invalid after her
confinement, seriously compromising thereby your repu-
tation.

The lochial discharge usually decreases in a very
marked degree for a few hours, on the second or third
day, during the existence of what is termed the milk-
fever. It is sometimes entirely suspended at this time,
and the nurse should be prepared, by your instructions,
for such an occurrence. The turpentine-stupe placed
over the hypogastrium, and retained as long as the
patient can bear it, will usually restore the discharge.
On the other hand, the sanguineous discharge may con-
tinue too long and be of too bright a color. Examine
the uterus, and ascertain whether its size be progres-
sively decreasing. Keep your patient rigidly in the
horizontal position, and free from all emotional excite-
ment.

If the uterus remain so enlarged for a few days
after parturition, that it can be readily felt above the
pubes, and there be no symptoms of other disease, ex-
cept those of delayed involution, you will probably

12 PUERPERAL DISEASES.

accelerate this process by the use, for one or two days,
of a prescription like the following :

#. Ext. ergot, fl. (Squibb's),
Tine, nucis vomica?,
Tine, ferri chloric!.,
Tine, cinnamom. cort.,
M. S. A teaspoonful in a wine-glass of sugar and water, four
times a daj r .

If your patient be feeble, delicate, and anssmic, and
the lochial discharge continue somewhat free and of a
bright color, after the uterus is well contracted down
in the pelvic cavity, you will find a tonic course of
great service, as in the following :

I. Quiniae sulph., 3j.

Ferri sulph., gr. xv.

Ext. nucis vomicje,

Pulv. capsici, aa gr. v.

M. Ft. pil. (argent.), No. 12.
S. One thrice a day after eating.

You will frequently see this condition associated
with a temporary profuse lactation, which is an addi-
tional drain upon the system, and the patient becomes
very nervous and irritable, and suffers from head-ache
and insomnia. You may then add to the formula I
have just given, four grains of opium ; and she will
take one-third of a grain of opium in each pill, or one
grain in twenty-four hours.

The normal duration of the lochia varies greatly in
different individuals. Sometimes the nurse, and even
the patient herself, is greatly alarmed from an appre-
hension that the lochia have ceased at too early a period
after delivery. The early cessation of the lochia, un-
accompanied by any other symptom of puerperal dis-
turbance, is not a cause for anxiety, but it may be a

PUEKPERAL CONVALESCENCE. 13

symptom of great importance in connection with the
various puerperal diseases, which we shall study by-
and-by. But I will here say that I have frequently
seen, in healthy women, the lochia entirely cease in a
few days after confinement, and the patient has had a
perfectly normal and rapid convalescence ; while, on the
other hand, I have often seen most grave and even fatal
puerperal disease, in which the lochial discharge has
continued throughout, without any marked change
either as to quantity or character. It is well to remem-
ber that, as in abortion, if the ovum be some time dead
previously to its expulsion, there is usually very little
hemorrhage ; so, at full term, if a woman be delivered
of a child which has been some days dead, the lochial
discharge is usually much less, and ceases at an earlier
period than is usual.

Secondary Hemorrhage. In some cases, which are
fortunately rather rare, a profuse and dangerous dis-
charge of blood may come on a few days after delivery.
The term, secondary hemorrhage has been applied to
those cases of profuse sanguineous discharge which take
place any time, from six hours after delivery up to the
end of the month. These hemorrhages are often se-
rious, and many cases have been published which have
terminated fatally. They are but slightly noticed in
your obstetrical text-books, but excellent papers on this
subject have been published by Dr. A. H. McClintock,
of Dublin, and the late Mr. Roberton, of Manchester.
They arise from a variety of causes, which it is very
important to thoroughly understand, in order to treat
them successfully. I shall describe these causes, and
the appropriate treatment of each, in the order of fre-
quency, according to my experience, in which they
occur.

14 PUERPERAL DISEASES.

I. From simple relaxation of the uterus. This oc-
curs most frequently within twenty-four hours after
delivery, and I have never met with it later than the
third day. Although, in this hospital, the obstetric
staff and nurses are drilled to the habit of securing per-
fect and permanent contraction of the uterus, by fol-
lowing its fundus with pressure of the hand during the
expulsion of the trunk of the foetus ; by the administra-
tion of ergot before the delivery of the placenta ; by
continued pressure afterward, until the uterus is felt
to be firmly contracted ; and then the careful applica-
tion of the binder, never for a moment leaving the pa-
tient until permanent contraction is apparently secured,
yet this form of secondary hemorrhage does occur here,
I should think, at least three or four times a year. The
patients in whom this accident occurs are usually those
whose systems have been broken down by their habits
of living, by destitution, by mental depression, or by
long-protracted labor, sometimes continuing for many
hours before they are brought into the hospital. In
private practice, it seems to arise generally either from
some imprudence on the part of the patient or of her
nurse, in raising her too early to the erect posture in
bed to change her clothing or to assist her to empty
the bladder. I am always very minute in my directions,
in case it should be necessary, for any reason, to raise
the patient for a few moments to the erect position,
that, on laying her down again, the binder should be
unfastened, and the uterine tumor carefully examined ;
and, if it be found at all relaxed, firm pressure should
be made with the hands for a few moments before the
binder is readjusted.

In one case, a most fearful and critical secondary
hemorrhage seemed wholly due to an emotional cause.

PUERPERAL CONVALESCENCE. 15

The patient, a young and healthy primipara of nineteen,
was devotedly attached to a gay husband, who did not
at all deserve such love from any woman. During her
labor, she was constantly reiterating her desire that her
child should prove to be a boy, asserting that if it were
not, she should wish to die, as her husband would neither
love her or her child. At six in the morning, she was
safely delivered of a fine girl. She at once demanded,
with a fearful earnestness, to know the sex of the child.
I jokingly replied that I could never tell the sex before
they were fifteen or sixteen years old ; but, after I left
the patient, the nurse .boldly lied, and assured her that
the child was a boy. Her condition was in every respect
perfectly satisfactory, until the next evening, when her
husband returned from a yachting trip, and, brutally
expressing his disgust, informed her of the sex of the
child. The nurse noticed, in a few moments, that she
was very pale and breathing badly, and at once dis-
covered that her bed was flooded with blood. I never
have seen a patient recover from so fearful a hemor-
rhage. For days her life literally seemed to hang upon
a thread, and for several months she had the most
bleached, pallid-looking countenance that I have ever
seen in a living woman.

Before I point out to you what you should do in
such cases as these, you will indulge me in a slight di-
gression, for some general remarks which will have a
bearing on many of the subjects which I shall have the
honor to discuss with you. In no department of medi-
cal practice, not even in surgery, is there so great a
liability to the occurrence of sudden emergencies where
success of treatment depends wholly upon the prompt-
ness and efficiency with which the resources of our art
are applied. And in some of the most rapidly dangerous

16 PUERPERAL DISEASES.

emergencies of obstetric practice, these resources are ab-
solutely successful in averting danger. I could give
you many illustrations of the truth of this remark, but
it is unnecessaiy, as we shall have frequent occasion to
refer to them hereafter. Let me, therefore, strongly
impress upon you the importance of having fixed prin-
ciples of conduct thoroughly settled in your .minds for
every obstetric emergency that you may encounter.
Then you will be able to act promptly, and without
doubt or hesitation. You can act coolly yourself, give
directions to others in a quiet but firm manner, and
thus inspire confidence in the attendants and friends
who are present. This greatly assists in keeping up
the morale of the patient, and may be the essential ele-
ment of success, without which your physical resources
might fail. Therefore, in your early practice, begin the
habit of asking yourselves, in every obstetric case that
you attend, what you would do, should it prove to
be placenta prsevia if convulsions should occur if
post-partum hemorrhage should follow and so on.
Have the answers to these questions well settled in
your minds. You will thus avoid all danger of " losing
your head " in the lying-in room, as I have often heard
physicians accused of doing, while you need not fear
the charge of acting impulsively. Such charges will
not damage you if the impulses be the results of careful,
well-weighjed previous study, and turn out successfully.
I will add also : begin your professional life by training
your senses, sight, hearing, touch, so that in a moment,
as it were, you can take in all the external features of
the case. Then teach yourselves how to ask questions
with a point, meaning, and logical sequence to them.
It is with physicians, as it is with lawyers ; one learns
more essential truth in regard to a case by ten ques-

PUERPERAL CONVALESCENCE. 17

tions rightly put than another, by fifty vague, motive-
less, inconsequential inquiries.

To resume our special topic, I shall now give you
some general axioms with regard to puerperal secondary
hemorrhage, from relaxation.

(1.) If the hemorrhage occur within seventy-two
hours, at once unfasten the binder, and carefully ex-
amine the uterine tumor.

(2.) Make a careful vaginal examination. This rule
should be absolute, in all cases of secondary hemor-
rhage.

(3.) While making these examinations, take the
opportunity to learn all about the histoiy of the at-
tack.

Having settled the question, that the uterus is re-
laxed, and that the blood has been poured out from
the open mouths of the utero-placental vessels, it is
no matter whether this relaxation be due to constitu-
tional feebleness, to exhaustion from protracted labor,
to emotional excitement, to physical imprudence on the
part of patient or nurse, the result is practically the
same, and so are the indications for treatment. Now,
what shall you do ? I will give you succinctly the
directions that I would give to one of my house-staff
under such circumstances :

(1.) Remove all clots from the uterus and the va-
gina by firm pressure on the uterus, and by the fingers
in the vagina.

(2.) If the hemorrhage continue, keep up the press-
ure, and use every resource of reflex action to stimu-
late uterine contraction. If ice be readily accessible, in-
troduce lumps into the vagina.

(3.) Inject very carefully, and without force, into
the uterine cavity, a half-ounce of the solution of the
2

18 PUERPERAL DISEASES.

persulphate of iron, diluted with an equal quantity of
water.

(4.) If your patient show no sign of shock from
loss of blood, give thirty drops of Squibb's fluid ex-
tract of ergot with twenty drops of the tincture of
nux-vomica. Repeat every half -hour until well as-
sured that the uterus is well contracted. As a general
rule, not more than two or three doses will be neces-
sary.

(5.) If the patient exhibit shock from loss of blood,
do not give the ergot until reaction is established. First
give twenty drops of laudanum or the equivalent dose
of whatever opiate you may have at hand. Give some
alcoholic stimulant in small quantities, repeating it at
short intervals. When reaction is established, then
give the ergot and the nux-vomica.

(6.) Before leaving, give minute and specific direc-
tions to the nurse as to watching the uterus, moving
the patient, and such other points as the special feat-
ures of the case may indicate.

II. Secondary hemorrhage may occur from retention
of a portion of the placenta.

Hemorrhage from this cause is veiy rare in this
hospital, but I meet with it not infrequently in consul-
tation practice. It is very far from the truth to say
that this always arises from the neglect or the igno-
rance of the medical attendant, for this casualty has
occurred in the hands of some of the ablest and most
eminent obstetricians, who have reported numerous
fatal cases of hemorrhage from this cause. But I can-
not impress upon you too strongly, in all cases where
the artificial removal of the placenta is required, to
exercise the greatest care to remove the whole of it, if
this can be accomplished. In some cases of very close

SECONDARY HEMORRHAGE. 19

and intimate morbid adhesion, it may not be possible
to accomplish this. But this I will say in unqualified
terms, that every physician should know whether or not
he has left a portion of the placenta behind, and he is
justly censurable when he is ignorant on this point;
Hemorrhage from this cause is liable to come on at any
period, from the third day up to the end of the month.
Indeed, some cases, and even fatal ones, have been re-
ported where the hemorrhage did not recur until five
or even six weeks after delivery. I shall have occa-
sion, hereafter, to speak of septicaemia, another dan-
ger from retention of a portion of the placenta, but
at the present time I shall confine my remarks to the
hemorrhage. This results, from the cause mentioned,
chiefly in the three following methods : (1.) By pre-
venting complete and entire contraction of the uterine
fibres, at that point where a portion of the placenta
remains adherent ; (2.) by keeping up an increased de-
termination of blood to the organ, and thus retarding
involution ; (3.) when the retained portion is detached,
whether three days or three weeks after delivery, the
utero-placental vessels are left open to pour out blood.
When you know that a portion of the placenta has been
left behind, you will of course be on the alert to pre-
vent hemorrhage, and to arrest it, should it come on.
It is to be inferred that you have secured as complete
contraction as possible, during the first three days.
Then I should recommend to you, as a precautionary
measure, to give the ergot and nux-vomica thrice a day
for three or four days, as I believe that this not only
assists in keeping up the contraction of the uterine
fibres and in diminishing the capillary circulation of
the uterus, but also that it accelerates that metamor-
phosis of tissue which we call involution. I may, at

20 PUERPERAL DISEASES.

some future time, give you my reasons for believing
that a metamorphosis of retained placental tissue oc-
casionally takes place, as normally occurs in the uterine
tissue. But, as we cannot always be sure of this result,
it will be well for you to order the vaginal injections
of carbolic acid, glycerine, and warm water, to be care-
fully but thoroughly used twice a day, as a prophylactic
measure against septicaemia.

When hemorrhage does come on from this cause,

^ O /

at once make a vaginal examination. If you feel the
blood coming from the uterus, and the os be con-
tracted and somewhat firm, then, I should say, tampon
the cervix uteri with the compressed sponge-tent, if you
have it with you or it be easily accessible. Then apply
a pad and binder firmly over the uterus. It is true
that the uterus has been distended by the accumula-
tion of blood, and patients have died from internal
hemorrhage, even two, three, and four weeks after par-
turition. But I think this danger can be effectually
guarded against, by the proper use of the pad and
binder, and by frequent examinations of the uterus,
to see that it is not enlarging. I have applied the
sponge-tent w r ith success the third day after labor. I
never allow the tampon to remain in the cervix more
than six or eight hour?. It frequently is the case that,
when the tampon is removed, the cervix is sufficiently
dilated to permit the examination of the cavity of the
uterus, and it is then sometimes possible to remove
with the fingers the retained portion of the placenta.
Then apply tightly the binder, and inject the solution
of persulphate of iron and water.

If, on vaginal examination, at the time of the hem-
orrhage, the os is found patulous and feels at all sloughy,
do not tampon, but inject the solution of iron and water,

SECONDARY HEMORRHAGE. 21

as I Lave before mentioned, and see to it that the pad
and binder are well applied.

Whether you use the tampon or the injection of
the solution of persulphate of iron, immediately after-
ward, direct that an enema of one ounce of the oil of
turpentine with a naif-ounce of olive-oil be slowly
thrown into the rectum and retained there as lono- as

possible. From a long experience in the use of this
agent in this way, I am thoroughly convinced of its
great value as an hemostatic and as a stimulant to
excite uterine contraction.

III. From the Retention of a Coagulum in the
Uterus. If the condition of the uterus be well watched
for twenty-four hours after delivery, this, as a cause of
secondary hemorrhage, must occur very rarely. I hardly
need say to you that, as long as there is a clot in the
uterus, there is a danger of hemorrhage. Madame La
Chapelle relates one case of hemorrhage from this cause,
on the eighth day after delivery, which resulted in the
death of the patient in a few hours. Collins, Burns, and
McClintock, each refers to this as a cause of secondary
hemorrhage. I have seen two cases in this hospital,
and one in consultation-practice, where a very consid-
erable hemorrhage, a few days after labor, has suddenly
come on, a large and pretty firm, clot has been expelled,
and the hemorrhage has at once ceased. You should
always think of this as a possible cause, when you can
find no other, and especially if you find the uterus large,
and that it hardens under firm pressure. The indication,
then, is obvious ; excite the uterus to expel the clot, and
then to contract firmly.

IV. From Polypus of the Uterus. A great many
cases have been published by obstetric writers where
polypus has complicated labor and the puerperal state.

22 PUERPERAL DISEASES.

Ill two instances in this hospital, I have applied a liga-
ture, and then excised a polypus during labor, and
have had no farther trouble from this source. In a
third case, a woman had a pretty severe hemorrhage
on the night of the fourth day after the birth of her
seventh child, which was apparently controlled by the
means used by the house-physician to the lying-in
wards. There was no repetition of the hemorrhage
until the night of the ninth day, when it again came
on so profusely, and continued with so much severity,
tli at I was sent for at four o'clock in the morning. As
the house-physician had given ergot, applied ice in the
vagina, compressed the uterus, and plugged the vagina,
without apparently lessening the hemorrhage, I re-
moved the tampon, and made a thorough examination.
Just within reach of the point of my finger, high up
within the cavity of the uterus, I could feel a firm,
smooth substance, which seemed to be movable ; but I
was unable to decide in my own mind what this sub-
stance was. So I thoroughly tamponed the cervix
uteri with cotton- wool, packing the vagina with layers
of the same material. I directed an enema of turpen-
tine and olive-oil, to be retained in the rectum as long
as possible. The patient seemed to be too feeble and
exhausted to bear ergot, and I therefore ordered ten
drops of laudanum and a half-ounce of whiskey, to be
given at once, and repeated in one hour if necessary.
On visiting the hospital at nine the next morning, I
found the general condition of the woman very slightly
improved from what it was four hours before ; but, in
spite of the plugging, blood had again begun to ooze
pretty freely from the vulva. Removing all of the
plugging, on a second examination, I could easily feel a
polypus in the cervix. Placing the woman in a proper

SECONDARY HEMORRHAGE. 23

position, I seized the polypus with the vulsella forceps,
and pulled it out down, which required some force,
and then excised it. The polypus was one-third larger
than my thumb, with a pedicle about the diameter of
my little finger. I had, previous to the operation, pre-
pared a little pledget of cotton-wool, attached to a
strong thread. As soon as I had excised the pedicle, I
saturated this pledget with the solution of the persul-
phate of iron, and, by means of Simpson's sound, I
pushed it up as far as possible into the cavity of the
uterus. I did not then tampon the vagina, as I wished
to know at once, if hemorrhage should again come on,
but from this time she did not lose an ounce of blood.
The next day she suffered from severe pains in the
uterus, which she described as worse than any pains
that she had ever suffered in childbirth ; but these
ceased at once as soon as the pledget of cotton was
pulled out. I' felt very great anxiety regarding the
issue of this case, not only because several cases of
death had been reported as the result of the opera-
tion for the removal of polypus in puerperal women,
but also because puerperal fever was then endemic in
our wards. But this woman recovered, without a sin-
gle unpleasant symptom after the pledget was removed
from the uterus.

I have seen three other cases in which secondary
hemorrhage from polypus occurred during the puer-
peral period ; but in these, the hemorrhage was con-
trolled by ergot and other means, and the operation
for removal was not performed until some weeks later.
Notwithstanding the fact that a number of fatal cases

have been reported as resulting from the operation
for the removal of a polypus during the puerperal
period, I give it as a rule that the polypus must be

24 PUERPERAL DISEASES.

removed if the hemorrhage cannot be arrested by other
means.

V. From Inflammatory Ulceration of the Cervix.
Dr. Henry Bennet, of London, in his classical work on
" Inflammation of the Uterus," was the first to speci-
fically assign this as a cause of secondary hemorrhage.
There is no doubt of the correctness of the opinion enun-
ciated by Dr. McClintock, that this condition of the cer-
vix uteri is much more frequently the cause of a profuse
and long-continued lochial discharge than of a true
secondary hemorrhage. But I am sure that I some-
times meet with sudden actual hemorrhage due to this
cause alone, as the treatment of the ulceration arrests
the hemorrhage just as effectively, as in other cases it
arrests the profuse and long - continued lochial dis-
charge. I am certain, also, that this condition exists
much more frequently in puerperal women than most
physicians, even at the present day, seem to believe.

VI. From Lacerations of the Vagina or Vulva, in-
volving Varicose Veins or Arteries. When the lacera-
tion takes place, the parts are frequently so compressed
by the foetus, that the open vessels are blocked up by
coagula. Some hours, or it may be some days, after
delivery, these coagula give way, and we have hemor-
rhage. Several such cases have occurred in my service
here. In one case, on the second day after labor had
terminated, the hemorrhage came on so gradually that
it was not discovered until the patient began to ex-
hibit the constitutional signs of loss of blood. The
house-physician was puzzled on finding that the uterus
was well contracted, and that the blood apparently did
not come from this organ. I was sent for, and, on
making a careful and prolonged examination, I found a
jet of blood spurting from a small artery at the inferior

SECONDARY HEMORRHAGE. 25

border of the right labium. A ligature was applied,
and we had no farther trouble with the case. Other
cases, similar in their character and history, will be
alluded to in my lecture on lacerations of the perinaeuni.

VII. From Partial or Complete Inversion of the
Uterus. While it has been my great good fortune to

have met with but one case of secondary hemorrhage
due to this cause, yet I have seen a sufficient number of
cases of inversion, partial or complete, subsequent to the
puerperal period, to make me feel strongly that there is
blame somewhere, when, at this day, any woman is per-
mitted to suffer from this trouble, weeks, months, and
years, after it has occurred. I hold that it would be
unpardonable in any physician to overlook this acci-
dent, and to permit his patient, either to drag out a
miserable existence, or to die from hemorrhage.

There are several other causes of secondary hemor-
rhage, reported by authors, and I will therefore mention
them, although I have never seen such a result from the
causes assigned. These are :

VIII. Premature sexual intercourse.
IX. Malignant diseases of the cervix.

X. Pelvic cellulitis.
XL Obstinate constipation (?).
XII. Functional disorders of the liver (?).

LECTUKE II.

DIET OF PUEEPEEAL WOMEN.

The puerperal period does not require an abstemious diet Good, nutritious,
easily-digestible food should be taken in 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.

GENTLEMEN : The theory that a puerperal woman is
in an inflammatory condition, or in a state predisposed
to inflammation, has, in a great measure, governed the
profession, and has been inculcated by most of the ob-
stetric authorities, from Celsus down nearly to the pres-
ent time. They have consequently taught that a puer-
peral woman should be restricted to what was termed
an antiphlogistic diet. I should, however, mention, as
one of the prominent exceptions to the above remark,
" the judicious " Denman, whose rule was to place his
patient at once upon a regimen accordant with her pre-
vious habits.

At the present time, a change of practice, more in
accordance with sound physiological reasoning and good
sense, is rapidly taking place. Dr. Graily Hewitt, of
London, has written forcibly on this point ; and a dis-
cussion on this subject, in the Edinburgh Obstetrical

DIET OF PUERPERAL WOMEX. 27

Society, plainly demonstrates that the routine practice,
which restricted the puerperal woman to gruel, tea, and
toast, for three days after labor, and a bill of fare but
slightly extended until after the ninth day, is not the
rule at the present time. Some eighteen years ago, I
was led to carefully review this whole subject, with the
result of an entire change in my theory, teaching, and
practice; and the opinions I then formed have since
been fully confirmed by close and conscientious obser-
vation, based upon an extensive clinical experience. Is
not the theory a strange one, that the organs connected
with parturition will be more rapidly restored to their
condition prior to conception ; that the metamorphosis
of tissue, called involution, will be more easily and
effectively accomplished, and that the new function
of lactation will be more surely and perfectly estab-
lished, by depriving the system of its accustomed ali-
mentation ! I cannot doubt that in all ages there must
have been some whose practice was governed by a sound,
intuitive judgment and good sense, and who have there-
fore freed themselves from the fetters of professional
tradition, and followed a rule similar to that incul-
cated by Denman.

I should say, in general terms, give the puerperal
woman as good nutritious food as she has an appetite
for, and can easily digest and assimilate. You will at
first find many nurses who will not accept these views,
and they may fail to fully carry out your directions in
this particular ; but my experience has been that, after
a time, the intelligent ones become enthusiastic con-
verts to this course. The woman, exhausted by labor,
first needs rest. This gained, as soon as she shows any
desire for food, give that which is the most acceptable
to her, and which will best sustain her a cup of good,

23 PUERPERAL DISEASES.

clear beef-soup, or of chicken or mutton broth. There
are those whose instincts or habits lead them to prefer
a cup of tea, or gruel, or panada. Very well, only in-
sist that they take enough. Then, as soon as the appetite
will permit, guided only by this and the general con-
dition of the woman, and not by the question of time,
whether it be the third or the ninth day, gradually give
solid food, as birds, poultry, tenderloin of beef, or a mut-
ton-chop. I have had patients eat a good piece of ten-
derloin steak, the day after labor, with a relish and with
happy results. Of course, I only advise snch plain, nu-
tritious, and digestible food, as good sense would sug-
gest, but give enough of this kind. By following this
course of regimen, I believe you will find that your pa-
tients rest and sleep better, and their functions are estab-
lished with less disturbance, than they would be with a
spare or insufficient diet. Since I have adopted this
method with my puerperal women, I am very sure that I
have much less frequently met with those annoying and
troublesome nervous phenomena that so commonly fol-
low parturition, as the nervous system is then apt to be
in a condition of exalted susceptibility. The function
of lactation is thus generally established without that
disturbance of the system which was called milk-fever,
and was formerly so common. It is certainly more in
accordance with sound physiological principles to feed
puerperal women upon easily digestible nutritive arti-
cles, than to administer that which contains but little
nourishment and a larger amount of undigestible resi-
due. We shall see, by-and-by, that there are many
puerperal diseases mainly due to exhaustion and inani-
tion. In short, I will say that I have seen much suffer-
ing and many diseases in puerperal women, where one
of the chief elements was defective nutrition ; but I

LAXATIVES FOR PUERPERAL WOMEN". 29

have never seen the slightest evil result from good,
ample, judicious alimentation.

Laxatives. In many women, after confinement, the
bowels are not opened until some means are used
for this purpose, and castor-oil is undoubtedly given
more frequently than any thing else. I suppose that
more than one-half of the women confined in this
country take a dose of castor-oil on the second or
third day after delivery, and I see that this is recom-
mended by some of the most eminent German ob-
stetricians. Now, I do not consider this routine-
practice judicious. Many patients do not require any
laxative, the bowels acting spontaneously on the second
or third day. I therefore wait for some indication of
the necessity of a laxative before prescribing one, and
then I very rarely select castor-oil, because, to most
women, it is an exceedingly nauseous, disagreeable
medicine, and where there is any tendency to piles,
which is frequently the case after labor, it is one of the
worst agents that can Jbe selected. I have frequently
observed severe suffering from piles, following the evac-
uation of the bowels from a dose of castor-oil. For
these reasons, I have almost wholly given up its use as
a laxative after confinement. The choice of the agent
to be used for this purpose must depend upon the
special indication in each individual case. If a laxa-
tive be required simply on account of torpor of the
bowels, an enema of warm water and castile-soap,
thrown up the rectum very slowly and gently, is much
better than any medicine administered by the mouth.
But where the patient has a great aversion to an
enema, as you will find some do have, two of the fol-
lowing pills will usually act efficiently and without
causing pain :

30 PUERPERAL DISEASES.

$. Ext. colocynth co., 3j.

Ext. hyoscyami, gr. xv.

Pulv. aloes soc., gr. x.

Ext. nucis vomicae, gr. v.
Podophyllin p.,

Ipecacuanha, aa, gr. j.
M. Ft. pil. (argent.), No. 12.

Let me here say that, for reasons so obvious that I
need not here enumerate them, it is always best to give
laxatives to puerperal women, in the morning, before
breakfast. I am very much in the habit of ordering,
the second morning following the action of the med-
icine, after the first dose of two pills, one to be taken
daily, until the bowels acquire the habit of moving
spontaneously.

When there are flatulence and severe after-pains,
in consequence of constipation and intestinal irrita-
tion, I have found the following an excellent combina-
tion :

IJ. Ext. sennae fld.,

Syr. zingib., aa 3 vj.

Tine, jalap., f ss.

Tine, nucis vomicae, gtt. 40.

M. S. A table-spoonful in a wine-glass of sugar and water.

I shall mention other laxatives in cases where a
derivative action is required, when I discuss milk-fever
and the other disturbances accompanying lactation.

I take the present opportunity to make some re-
marks on hemorrhoids in pregnant and puerperal
women.

During gestation, we have, as a predisposing cause
of this disorder, pressure of the gravid uterus upon
the rectum, which retards or prevents the return of the
blood from the hemorrhoidal plexus of veins to the
inferior mesenteric veins. But this exists as a cause in

HEMOKRHOIDS. 31

every pregnant woman ; and therefore some other ele-
ment seems to be necessary for the development of the
disorder. This is either constipation or diarrhoea.
In constipation, there is probably the same atony of
the coats of the hemorrhoidal veins as exists in the
muscular coats of the rectum, and the pressure of
accumulated fecal matter contributes to make these
veins varicose, and, if long continued, to develop the
hemorrhoidal tumors. The effect of a purgative is to
stimulate an abnormal peristaltic action in precisely an
opposite direction to the blood returning from the hem-
orrhoidal veins.

Some, who are subject to piles, are never consti-
pated, but have habitually a loose, relaxed condition
of the bowels, the same atony of the venous coats re-
sulting from the irritation and exhaustion of diarrhoea
as exists in constipation. So, therefore, either constipa-
tion or diarrhoea may develop hemorrhoids.

If the hemorrhoidal veins have become varicose
during the later periods of gestation, the tumors may
be developed by long pressure of the foetal head on
the rectum during labor. The veins sometimes swell
enormously at this period, as they are probably weak-
ened by the distention they have suffered during the
progress of the labor, and regain with difficulty the
power of contracting at this time. In many women,
hemorrhoids are first developed by the action of the
purgative given two or three days after confine-
ment.

I shall now describe the treatment which I have
found the most successful in each of the above condi-
tions, and which I have substantially taught in my lect-
ures for more than twenty years.

When hemorrhoids are developed during the later

82 PUERPERAL DISEASES.

periods of pregnancy, the indications are obviously
to counteract the constipation or the diarrhoea, and
to stimulate and restore the tonicity of the hemor-
rhoidal veins. The inquiry will then naturally suggest
itself, have we any agent, or combination of agents, in
the materia medica, capable of effecting these results ?
I know of no article which so clearly and positively
produces these two results as aloes, and on this I have
mainly relied. I am well aware that the general voice
of the profession is against the use of aloes where there
is any tendency to hemorrhoids. That " aloes is con-
tra-indicated by hemorrhoids " is not only the doctrine
of the " Dispensatory of the United States " (Wood and
Bache), but it has also been the opinion of most writers
on this subject, from ancient times down to the present.
It is stated in Stille's " Therapeutics and Materia Med-
ica " that " Fuchsius was of opinion, that of one hundred
persons who should take aloes frequently as a laxative,
ninety would be attacked with the piles. Murray
blames physicians who are induced by the gentle
and certain action of this medicine to expose their pa-
tients to so serious a consequence. It was to this pur-
gative that Fonseca attributed the prevalence of piles
among the inhabitants of Padua ; and Stahl makes a
similar statement in regard to the people of Hamburg.
Calvin is cited as a prominent example of this mischief
produced by aloes, for this celebrated reformer is said
to have died ultimately from the effect of the piles
which it gave rise to, but, as he was of a frail constitu-
tion, subject to quartan ague, gout, and gravel, the
part which aloes bore in his demise may reasonably be
judged to have been small."

These opinions have not been accepted by all ; for
Cullen, Sir Benjamin Brodie, Trousseau and Pidoux,

HEMORRHOIDS. 33

and others, have doubted whether aloes is productive of
piles, and attribute this infirmity, not to the medicine,
but to the constipation which aloes is used to remove.
I will, however, say that, from my own observation, I
am convinced that aloes will, under certain conditions
of the system and in certain doses, develop piles. The
special property of aloes is " to excite the muscular con-
tractility of the colon and rectum," and " to stimulate
the venous system of the abdomen, and especially of
the pelvis." That these are the effects of this agent, I
not only have the authority of special writers on thera-
peutics, as Pereira, Wood and Bache, and others, but I
believe the general experience of the profession will
also confirm the assertion.

It would seem, therefore, that the use of aloes for
the cure of hemorrhoids in pregnant women would
have been suggested by a priori reasoning, but I am
not aware, from, any thing that I have read, that it ever
has been. I suppose that the general impression that
aloes is contra-indicated where there is any tendency to
piles, and that it possesses emnienagogue properties,
has had great influence in preventing this. In my
own case, the use of aloes for this purpose was the re-
sult of gradually- accumulating observation rather than
from any reasoning on the subject. In the early days
of my professional life, I was engaged to attend a wom-
an in her confinement, who suffered from obstinate con-
stipation. I prescribed for her the Dewees pills, in
which aloes is one of the most prominent articles. At
the time of her confinement, she mentioned that in her
former pregnancies she had suffered very much from
piles, but that my pills had cured them. If I had
known of her hemorrhoidal tendency, I should not
have given these pills, and I was, therefore, quite sur-

34: PUERPERAL DISEASES.

prised by her statement, as the result seemed so con-
trary to all that I had been taught. From this time I
began to experiment as to the effect of aloes in the
treatment of hemorrhoids associated with constipation
in pregnant women, and for many years past I have con-
stantly made use of this drug for their cure, whether
the hemorrhoids were the result of constipation or of
diarrhoea. I give it, combined with other agents, and
in such doses as I learn by a knowledge of the peculiar
idiosyncrasy of the individual to be necessary to se-
cure one easy, free, daily evacuation of the rectum.
Some require a grain morning and evening, while in
others, a half-grain is sufficient. In anaemic patients, I
combine aloes with the sulphate of iron. The follow-
ing is a frequent prescription with me :

I. Pulv. aloes soc.,

Sapo Cast., aa 3j.

Ext. hyoscyami, 3 ss.

Pulv. ipecacuanha, gr. v.

M. Ft. pil. (argent.), No. 20.

S. One morning and evening.

When the patient is anasmic, I add to the above one scruple of
the sulphate of iron.

When the hemorrhoids are associated with an ir-
ritable rectum, and with frequent small, teasing, thin
evacuations, I substitute for the hyoscyamus a small
quantity of opium, giving also a less quantity of the
aloes, as in the following formula :

$. Ferri sulphas, 3j.

Pulv. aloes soc., 1

Ext. opii aq., ," aa gr. x.

Sapo Cast.,

M. Ft. pil., No. 20.

S. One morning and evening.

It is unnecessary for me to multiply formulae, as the

HEMORRHOIDS. 35

general principles by which I am guided will be suffi-
ciently evident from what I have already said.

In some cases I have not been consulted, and have
not known of the hemorrhoidal tendency of the patient
until my attendance during labor, when the hemorrhoi-
dal tumors sometimes become very large. Dewees
says : " Much may be done during labor to prevent a
severe spell of piles by the accoucheur making a firm
pressure upon the verge of the anus with the palm of
his hand, guarded by a diaper, during the progress of
the head through the external parts, and by carefully
returning them after the expulsion of the placenta, as
the sphincter is now fatigued, and will not oppose their
descent."

I have frequently tried this experiment, but can-
not say that it has been very successful, as the tumors
soon came down again, and under these circumstances
they are very apt to become strangulated, inflamed, and
cause a great deal of suffering. When this condition
of things exists, I have, within a few years past, adopted
the plan of forcible dilatation recommended by my
friend and colleague Professor Van Buren. My method
is this : the patient being fully under the influence of
chloroform, I select the moment after the delivery of
the child, and before the placenta is brought away. I
push back the tumors within the sphincter, if this can be
done readily ; if not, I leave them alone, and introduce
both thumbs, back to back, well in the sphincter, and
then, opening them as widely as possible, I draw them
through the sphincter, thus forcibly dilating, and per-
haps tearing, the fibres of this muscle. During this
time firm pressure should be made on the uterus by an
assistant. In several instances the operation has been
followed by the sudden expulsion of the placenta from

36 PUERPERAL DISEASES.

the vagina. I then direct the following ointment to be ap-
plied to the tumors, and well up the rectum, twice daily :

#. Ung. gallae co., j.

Ext. opii aq., 3j.

Sol. ferri persulph., 3 j.
M. Ft. ung.

The result of this procedure has been, in every in-
stance, that the tumors have rapidly disappeared ; and the
patients have had very little suffering from the operation.

When hemorrhoids come on after labor, the suffer-
ing is generally much greater than when they occur
during pregnancy. They are very often brought out
by the action of the purgative, given two or three days
after confinement.

As I before remarked, I have for a long time been
convinced that castor-oil is one of the worst agents
that can be used as a laxative when there is a tendency
to piles ; and, in many instances, I have seen them de-
veloped by its action. For Several years, I have spoken
of this to the medical class before whom I have lect-
ured, and I have received many letters from former
students corroborating my statements by their own ob-
servation. But I have never seen this alluded to by
writers, except in one work, that of McClintock and
Hardy, " On Midwifery and Puerperal Diseases." They
incidentally make the following remark : " We may
first observe that castor-oil is ill suited for patients
who have hemorrhoids, being very apt to produce in
them tenesmus and considerable irritation of the rec-
tum." I may add the following from Quain's work on
" Diseases of the Rectum : " " Common opinion has as-
signed to castor-oil a character for blandness (probably
because of its being an oil) to which it is not. entitled.
It is an efficient purgative ; but, except when given in

HEMORRHOIDS. 37

minute quantities, it usually irritates the rectum." In
Wood and Bache's " United States Dispensatory " (arti-
cle, Castor-oil), we find the following sentence : " Some
apothecaries are said to use it as a substitute for olive-
oil in cerates and unguents, but the slightly-irritating
properties of even the mildest castor-oil render it unfit
for those preparations which are intended to allay irri-
tation." It is curious that its irritating action on the
mucous membrane of the rectum has not attracted more
attention.

In those who have, or who are predisposed to have,
hemorrhoids, I give the following on the second day
after confinement :

3 . Magnesias sulph., 1

Magnesias carb.,

e L on Z co

T i i / titt *> 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. (<?.) There
is a great difference in women in the elasticity and dis-
tensibility of the perinaBuin, depending partly upon the
amount of adipose tissue in its structure. Where this
is very considerable, there is sure to be an unyielding
peringeum. (cl.^) Laceration is liable to occur when
there is extreme -smallness of the vulva. According to
Velpeau, its mean size from the clitoris to the posterior
commissure is one inch and a half. In some cases, ex-
ceptional ones to be sure, that I have had, I am sure
that the measurement between these two points could
not have exceeded three-fourths of an inch. There is a
prevalent notion, even among medical men, that the size
of the vulva corresponds with the size of the mouth, but
I am convinced that the opinion has no foundation in
fact.

2. The perinseum is liable to laceration from the
excessive size of the head or the shoulders of the

LACERATIOXS OF THE PERINEUM. 45

foetus. Tliis excess may be absolute, as in one case
that several of you saw nie deliver by forceps in tliis
hospital, where the occipi to-mental diameter of the
fcetal head was six and five-eighths inches, one and one-
eighth of an inch beyond the ordinary normal measure-
ment. In another case, where there was no excess in the
size of the head, I found great difficulty in delivering
the shoulders, and, on measurement, the bis-acromial
diameter proved to be six inches and three-quarters.
The excess may only be relative as compared with the
size of the vulva.

3. Laceration of the perinseuui is often liable to occur
from certain peculiarities in the mechanism of labor, as :
(.) In vertex-presentations, where the occiput rotates
backward into the hollow of the sacrum, because here
an occipito-frontal diameter must first pass out of the
vulva, which is three-fourths of an inch greater than
the sub-occipito-bregmatic diameter, which ordinarily
first passes out, in occipito-anterior deliveries. (#.)
In face -presentations, because, during delivery, the
vulval orifice must be distended to the length of
the longest diameter of the foetal head ; that is, the
occipito-mental diameter, which is ordinarily five and
one-quarter inches. (<?.) Incomplete flexion, when the
head presses upon the perinaeum, may also be a cause
of great danger of this accident, as in this case the
occiput does not fully engage under the arch of the
pubes, and thus the occipito-frontal, instead of the
sub-occipito-bregmatic diameter, will first be driven
through the vulval orifice. (d.) On the other hand,
excessive flexion may also tend to this result, as the
direction of the expulsive force of the uterus, fall-
ing nearer the occipital half of the occipito-frontal
diameter, will be an obstacle to the extension of the

46 PUERPERAL DISEASES.

head, which takes place in its normal exit through the
vulva.

4. The physiological character of the labor is an
important element as regards the danger of this acci-
dent : (.) When the labor is too rapid, from the
intensity and frequency of the uterine contractions, and
especially if the sacrum be somewhat less curved than
is usual, the head may be driven through the vulva
before the perinaeum has had time to be gradually ex-
tended. (.) Or, where the labor is very tedious, and
the head remains a long time at the lower strait, until
the perinaeum becomes hot, dry, congested, and unyield-
ing, if a rapid delivery be effected, either by means of
ergot or the unskillful use of the forceps, the sudden
expansion of this tissue is very apt to involve a more
or less extensive laceration. (<?.) Excessive nervous
irritability, causing the patient to make most violent
straining efforts to force the head through the vulva

o o

before the perinaeum is prepared for it by a gradual
expansion. My house-staff have repeatedly mentioned
cases to me, occurring in the hospital, where patients
have suddenly withdrawn themselves during a violent
pain, and thus the perinaeum, being deprived of all sup-
port, is lacerated to a greater or less extent. I am
confident that a majority of the cases of laceration that
have come under my observation here have occurred
in this way, if I can accept the testimony of my assist-
ants, which I certainly do.

5. I must not omit to mention unskillful or careless
manual or instrumental delivery as a cause of lacera-
tion of the perinceum. I shall here only allude to this
fact, as a full discussion of this point necessarily per-
tains to your instruction on manual and instrumental
labor.

LACERATIONS OF THE PERINEUM. 47

Now the practical question comes up ; what means
have you for preventing this accident from the various
causes which I have mentioned ? Until quite recently,
nearly all the standard works on obstetrics have taught
that to "support the perineum" was an absolute duty,
in all cases, never to be neglected. The reasons which
have been urged for this have been wonderfully diverse
and contradictory. But, within a few years past, this
subject has been studied anew, and most ably reviewed,
more prominently by Professors Leishman, of Glasgow,
and Graily Hewitt, of London, and Dr. Win. Goodell,
of Philadelphia. In the number for January, 1871,
of the American Journal of the Medical Sciences, Dr.
Goodell has an article on this subject, which is very
remarkable for its historical and learned research, its
analysis and condensed summary of the teaching of
past authorities, and its novel suggestions. Were I to
thoroughly go over this whole ground, it would occupy
more time than I have for this subject, if I am to give
the due relative proportion to the other topics which I
must discuss with you. I can therefore only give you
my conclusions, or, rather, tell you what principles gov-
ern me as to this matter.

Now, let me say that, in many cases, just that kind
of assistance, which is called " support of the peri-
na3uni," is of great service. The remark of Denman,
so often quoted, that, "when women were delivered
without assistance, I have not, in any case, observed
any considerable laceration," is quite opposed to my
experience. Two of the most severe lacerations that
I have ever seen were in women who were brought
into this hospital, one of whom was delivered in the
street, and the other in the police station-house. An
instructive incident occurred to a teacher of midwifery

48 PUERPERAL DISEASES.

in this city, while lecturing on this accident to a class of
medical students by the bedside of a woman in the last
stage of labor. He said that " he had never known a
case of severe laceration of the perineum, except where
it had been well supported" His experience was then
and there somewhat enlarged, for, while he was yet
talking, the woman had a . severe pain, by which the
head was delivered, and it was found that the peri-
neum was torn down to the sphincter ani. I agree
that the term " support of the perinseum ". is an unfor-
tunate one, because it conveys a wrong impression as
to the kind of assistance rendered, when the hand is
applied to the perinseum, as authors direct, during the
last stage of labor. I believe that this often materially
facilitates the mechanism of the labor, when intelli-
gently done, by aiding extension of the head in occipito-
anterior positions, and flexion of the head in occipito-
posterior positions. It is thus that this application of
the hand protects the perinseum. I think, also, that
this application of the hand to the perinseum may be
made most useful, in some cases, in directing the force
of the uterus from the perinseum toward the vulva,
and, in others, in counteracting the too violent efforts
of the uterus.

From what I have already said, it will be inferred
that the danger of laceration is to be met by special
means adapted to each particular condition, and that,
for- an obstetrician to be competent to successfully avert
this danger, he must be thoroughly familiar with the
mechanism of labor. He will then understand how the
improper or maladroit use of the forceps may, in some
cases, cause this accident ; while in occipito-posterior
deliveries, in some face-presentations, and in those
cases of vertex-presentation where there is excessive

LACEKATIOXS OF THE PERIXJEUM. 49

flexion of the head, and the sacrum has a less curvature
than is normal, the use of the forceps may be absolutely
necessaiy to prevent laceration.

Anaesthetic agents are another important means of
great value in preventing this accident. They are indi-
cated, for this purpose, in four classes of cases : 1. In
that form of rigidity of the perinseum depending upon
excessive irritability of the muscular fibres that enter
into its composition. I have repeatedly been struck
with the rapidity with which relaxation and dilatation
of the perinaeuin, under these circumstances, have fol-
lowed the inhalation of chloroform. 2. In those cases
where the danger arises from the violent and rapid
uterine contractions, driving the head or the shoulders
through the vulva before the perinoeum has been suf-
ficiently expanded. I have frequently, just as the labor
was terminating, pushed the chloroform to the extent
of carrying the patient into the state of profound anaes-
thesia, for no other reason than to protect the peri-
naeuin. 3. Paradoxical as it may appear, after what I
have just said, an anaesthetic is often indicated to pro-
tect the perinseum in tedious labors. Long-continued
pressure of the head may produce congestion and in-
flammation of the perinseurn, which not only renders it
more unyielding, but more easily torn. It becomes hot
and dry, and very painful, and uterine action becomes
irregular and feeble, in consequence of this condition.
Now, under these circumstances, I have seen the inha-
lation of chloroform followed by immediate relaxation
of the perinaeuni, and a restoration of the normal moist-
ure and temperature of the parts, while efficient action
of the uterus was at once resumed.

When the vulval orifice is excessively small, or
when the amount of adipose tissue in the perinaaum is

50 PUERPERAL DISEASES.

too great to admit of its necessary expansion, I think
that our only resource against the accident of laceration
is a small incision of the lateral superior portions of the
perinseum. An incised wound heals much more rapid-
ly than a lacerated one. It affords an opportunity for
election as to the point where the lesion shall occur,
and thus the obstacles which prevent immediate ad-
hesive union may be more effectually guarded against,
and experience seems to prove that an incision of
two or three lines on each side is sufficient to prevent
laceration in the median line, the extent and result of
which cannot be foretold. So I perform this opera-
tion, on the ground that we thus select the lesser to
prevent the greater evil, and, in several instances, I
have done this with most favorable results in all
respects.

Dr. Goodell, in the paper which I have alluded to
before, suggests a new method of managing the peri-
nseum to prevent its laceration. I shall give his sugges-
tion in his own words : " Whenever, therefore, it seems
proper to aid Nature, insert one or two fingers of the
left hand into the rectum, the woman lying on her left
side, with the knees well drawn up and separated by a
pillow, and hook up and pull forward the sphincter ani
toward the pubes. The thumb of the same hand is
then to be placed upon the foetal head,. scrupulously
avoiding all contact with the fourchette. The right
hand need not remain idle; it assists the thumb in
making the head hug the pubes, or in retarding its
advance ; after a pain, it presses back the head from the
perinaoum, and thus represses reflex uterine action ; it
restrains the movements of the woman ; it pushes up
the corrugated scalp, so that no folds shall remain be-
neath the sharp edge of the perinseum to increase the

LACERATIONS OF THE PERINEUM. 51

circumference of the child's head; finally, it supports
the emerging head and body, causing them to describe
the curve of Cams." He claims for this method the
following advantages : 1. By pulling up the sphincter
ani toward the pubes, not only is Nature imitated,
which always dilates the anal orifice, but the perinseum
is brought forward without direct pressure, and the dila-
tation is diffused over its entire surface, causing a cor-
responding relaxation of the strain on the posterior
commissure in the line of its raphe. In addition, its
muscular fibres are crowded up to, and consequently
strengthen the line of greatest tension, just as a pru-
dent general hurries up reinforcements to the point of
attack. 2. The same force which dilates the sphincter
ani compels the occiput to hug the pubes and favors
extension, especially if the fingers in the rectum be
hooked over the prominences of the foetal face, or over
the chin. 3. This aid is not liable to sudden interrup-
tion, for, however restless the woman may be, the
thumb and fingers, once well applied, follow her move-
ments without relaxing their hold. 4. The thumb of
the left hand, together with the fingers of the right,
can, by direct pressure upon the presenting part, re-
strain its too rapid advance, without exciting reflex
uterine contraction. 5. The circulation of the blood is
left free, the nerves are not benumbed by pressure, and
the perinaeum therefore continues in its normal condi-
tion that of a living, elastic, and sentient tissue. 6.
After the parts attain their maximum dilatation at the
.occipito-bregmatic circumference of the fcetal head, it is,
in my experience, as well as in that of Lacombe, the
rapid springing back of the fourchette over the project-
ing nose, or the rapid expulsion of the shoulders, that
often produces lacerations. These causes are, however,

52 PUERPERAL DISEASES.

well controlled by my method, in the former instance,
by merely pulling forward the sphincter ani ; in the lat-
ter, by adding the support of the right hand to the
emerging shoulders.

The method suggested by Dr. Goodell strikes me
as eminently sensible, and his reasoning in support of
the plan is most sound and forcible. But I have not
yet had the opportunity of testing his views by a suffi-
cient number of cases to speak with a practical expe-
rience in regard to its value. As my practice is to de-
liver the woman lying on her back whenever danger
is threatened to the perinseum, I should be obliged to
effect the result by a somewhat different manipulation,
but the end would be practically the same that is, to
carry forward the periuaeum toward the pubes "by
hooking the fingers into the rectum." In one case of
forceps-delivery, where the danger to the perinamm was
imminent, I practically carried out the suggestions of
Dr. Goodell by the fingers of an assistant, and I was
delighted with the result. It is not my province to
speak of the surgical treatment of this accident, as that
you will have taught and admirably illustrated by my
colleagues, Professors Taylor and Lusk.

LECTUKE IV.

THEOMBUS OF THE VULVA A1STD VAGINA.

" CASE V. 1 Margaret , aged nineteen, New York, primi-

para. Labor-pains began about 12 o'clock, the night of January
loth, and continued, with only slight intensity, all the next day.
At 5 P. M. (January 16th) the bag of waters broke, and the patient
was immediately sent to the lying-in ward.

" On examination, no deformity of the pelvis or of the soft parts
was found; the cervix was soft, moist, and dilatable, the os being
an inch and a half in diameter. The vertex "was presenting in the
left occipito-anterior position. Foetal heart heard on the left side
below the umbilicus, 130 per minute. . At 7.30 P. H. the cervix was
f iilly dilated, and the uterine pains continued good and regular.
In a short time, the head descended to the inferior strait, and re-
mained there till 11.10 P. M. The woman seemed to suffer a good
deal of pain, and could not be made to bear down. -

" While making an examination at this time, I noticed that the
right labium majus was more swollen than at the previous exami-
nation, and that it was rapidly enlarging. I immediately supposed
that I had to deal with a thrombus of the vulva, and endeavored,
by moderate and equable pressure, and the application of ice, to
prevent its increase. The patient says she never noticed any tumor
about the vulva during pregnancy, nor had she received any injury
in that situation.

1 Reported by Alexander 0. Graham, M. D., house-surgeon to Bellevne
Hospital.

54 PUERPERAL DISEASES.

" In twenty minutes, the thrombus was as large as the fist, its
mucous surface being purple ; and the patient was suffering in-
tensely. The labor -pains now ceased the head being at the
inferior strait, not yet having distended the perinasum. While
making preparations to incise the tumor, its coverings broke, and
profuse hemorrhage of an arterial character followed. The open-
ing at the border of the mucous membrane was enlarged by in-
cision ; the clots turned out ; and the cavity, three inches in depth,
filled with a piece of ice. The head was not far enough down to
make compression, and efforts to make the labor advance were un-
availing. The hemorrhage still continuing, the cavity was tam-
poned with pieces of sponge soaked in the liquor ferri persulphatis ;
this, with firm compression made by the hand, arrested the flow of
blood.

" An ounce of urine was now drawn from the bladder, and, on
ausculation, the foetal heart was found to be pulsating. Dr. Barker
was sent for, and, at twenty minutes after 12 o'clock, the patient
being under chloroform, applied the short forceps. The child,
weighing seven pounds and three-quarters, was born at half past
twelve. The placenta came away in a few minutes. The hemor-
rhage \vas now frightful a perfect stream of blood, of a bright-red
color, falling into the vessel, at the foot of the bed. The opening
was again enlarged by incision, and the cavity of the thrombus
tightly plugged with pieces of cotton, soaked in liq. ferri persul-
phatis. The bleeding now ceased ; but the pulse had become im-
perceptible, and the face was intensely pale. Two drachms of U. S.
sol. morphite sulphatis, in an ounce of whiskey, were immediately
given, and repeated in half an hour. After the first dose, the pulse
was 165, very small and weak. At 3.30 A. M., it was 120, and fuller.
As much beef-tea as the patient would take was given, and she soon
fell asleep.

"At 10 A. M., January 17th, there had been no return of the
hemorrhage. The vulva was gently washed with warm water con-
taining liq. sodae chlorinatae, great care being taken not to disturb
the large clot. The urine was drawn off, and the parts were cov-
ered with a piece of lint, soaked in carbolic acid and glycerine (1 to
20). Ordered the vagina to be thoroughly syringed, several times
daily, with water containing the liq. sodae chlorinatae ; two grains of
quinine and .one-half grain of opium every six hours ; stimulants
and a nutritious diet.

"January 18th, 10 A. M., pulse 92; respiration 18; temperature

THROMBUS OF THE VULVA AND VAGINA. 55

100 3 . The same treatment to be continued. There was no sloughing
about the wound. "While washing the vulva, part of the clot came
away, but there was no bleeding. At 7 P. M., pulse 120 ; respiration
21. This afternoon, a poultice was applied to the vulva, and to-
night the patient passed her water. Her bowels are confined ; the
lochia are free.

" January ZGth. The patient has steadily improved, without an
unfavorable symptom. Her bowels were moved, several days after
her confinement, with a laxative. The wound has cleaned off and
is granulating nicely. Ordered iron and quinine. The tumor has
now almost entirely subsided, with but slight suppuration, and no
sloughing whatever. The parts have been kept scrupulously clean
by a wash of chlorinated soda. All excoriation, or irritation from
the passage of urine, has been prevented by the use of the catheter,
and by having the parts covered with a solution of carbolic acid in
glycerine. Her recovery was rapid and complete."

This accident is one which may occur during the
later periods of gestation, or as a complication of labor,
or it may not become manifest until after the labor has
terminated. It is not of frequent occurrence ; but you
may meet with it, as I did, in the very beginning of
your professional life. We have had two cases in this
hospital within the last two months. Johnston and
Sinclair report seven cases during their seven years'
service as assistant physicians in the Dublin Lying-in
Hospital, two of which died. Scanzoni met with fif-
teen cases the tumor occurring in eight cases before
the expulsion of the child, six times during the deliv-
ery of ths placenta, and once, in a twin case, between
the birth of the first and second child. Death occurred
in but one of Scanzoni's cases. In a French monograph
on this subject, by Deneux, published in Paris in 1830,
he gives sixty-two cases of thrombus of the labia, oc-
curring before, during, and after labor ; and, out of this
number, twenty-two of the women died, and twenty-
one of the children were lost. But Deneux himself, in

56 PUERPEKAL DISEASES.

fourteen years' practice, met with but three cases ; and
the late Baron Dubois saw but three in fourteen thou-
sand labors. Two cases have occurred in the practice
of my colleague, Professor Sayre, in one year ; and Pro-
fessor Wood has seen one, in consultation, in the same
period.

During pregnancy, the most frequent cause of this
accident is undoubtedly some local violence ; but some
cases have been reported where the thrombus seems to
have been brought on by emotional causes alone. The
pressure of the gravid uterus so interferes with the re-
turn of the venous blood, as frequently to cause oedema
of the lower extremities, and often a varicose condition
of not only the veins of the lower extremities, but also
of the vulva and vagina, and of the other parts con-
tained in the pelvic cavity. But this condition does not
seem to predispose especially to thrombus, as, in a veiy
large majority of the cases of thrombus, no such antece-
dent condition has been found.

During labor, this accident may be generally re-
ferred to the prolonged delay of the head in the pelvic
cavity from any cause whatever. "When it occurs after
delivery, it is very obvious that the determining cause
of the lesion must have been effective before or during
labor.

The anatomical seat of this lesion is very much more
frequently in the extended labia than anywhere else,
generally in one labium alone, but in both sometimes.
But the effusion is often vaginal that is to say, in the
pelvic cavity. It is only in very exceptional cases that
the thrombus occurs in both sides of the vagina at the
same time. In a thesis by Perret, formerly an interne
at the Maternite, Paris, it is stated that the most com-
mon variety of vaginal thrombus is where the tumor ex-

THROMBUS OF THE VULVA AND VAGINA. 57

tends toward the vulva (strictly speaking, a vulvo-va-
ginal thrombus), which occurred sixteen times in forty-
three cases. The extension of the tumor toward the
abdomen occurred seven times, while it extended both
toward the vulva and the abdomen but three times in
forty-three cases. I should have before remarked that,
in labial thrombus, the effusion in some cases extends to
the perinseum, either penetrating the superficial cellular
tissues of this part in all directions, or passing more pro-
foundly to the iliac fossa laterally, or posteriorly to the
sacrum, and even to the lumbar region. So, also, in the
vaginal thrombus, the infiltration of blood may extend
to the adjacent parts, into the areolar tissue of the
broad ligament, or the sub-peritoneal areolar tissue of
the abdomen. Cazeaux published one case where the
autopsy revealed this result ; and Ferret reports a case
at the Mater nite, where, by the post-mortem examination,
a large sanguineous tumor was found filling the left lat-
eral half of the pelvic cavity, and the infiltration of
blood had extended into the sub-peritoneal cellular
tissue of the abdomen.

Thrombus of the vulva and vagina, being always con-
sequent upon a traumatic lesion, has no prodromic symp-
toms ; but there are symptoms which indicate the
presence of the sanguineous tumor. The formation of
the thrombus is generally preceded by a few moments
of very severe, acute, lancinating pains, quite different
in character from labor-pains. These pains are gen-
erally seated in the vulva or vagina, but they are rarely
confined to these limits, radiating often to the legs, or
back to the loins. Deneux asserts that pain is never
absent ; but other authors have specially mentioned
the fact that in some cases this symptom has been ab-
sent ; and in one case, which I saw in consultation with

58 PUERPERAL DISEASES.

Dr. Davis, although the distention of the labia was
very great, the patient absolutely declared that she
had suffered no pain in the part. But all evidence
shows that such exemption from the characteristic
pains is quite exceptional. These pains are due to
the severe compression of the nerves involved in
the tumefaction, and, from the same cause, we have in
some patients the sensation of a thousand pins pier-
cing the internal parts of the thighs, or of cramps in
the legs. Every movement, especially of the lower ex-
tremities, greatly aggravates these symptoms. The for-
mation of the thrombus takes place very rapidly after
these symptoms have made their appearance. When
the seat of the thrombus is in the vulva, the rapidity
of the swelling, and inspection of the parts, will at
once clear up the question as to the nature of the
trouble. But, when the tumefaction is within the cav-
ity of the pelvis, a vaginal and rectal examination be-
comes necessary, in order to acquire a precise idea of
the character of the tumor, its seat, and its limits.

No doubt the many errors in diagnosis which we
read of in practice must have arisen from ignorauce of
the fact that such an accident is liable to occur. For it
would seem that the characteristic symptoms which I
have mentioned, in connection with a careful physical
examination, which at the present day can be made with
the patient completely anaesthetized, should render the
diagnosis of thrombus comparatively easy. It can read-
ily be conceived that a small thrombus may give rise
to no local symptoms, and that its existence may there-
fore be overlooked. If the tumor be intra-pelvic and
large, and the examination be made while the extrava-
sated blood has simply infiltrated the cellular tissue
and not yet lacerated it, the tumor will seem hard,

THROMBUS OF THE VULVA AND VAGINA. 59

feeling very much, like the foetal head covered with the
tumefied scalp. Ferret asserts that an examination of
all the published cases shows that no example ex-
ists in science where the thrombus has been mistaken
for some part of the foetus. But, wdthin my personal
observation, it was once mistaken for the foetal head,
and, in another case, for placenta praevia.

You naturally ask, how these cases of thrombus
end. The answer is, that, in some cases, a rupture of
the sanguineous tumor occurs, the contents are dis-
charged, the walls of the cyst adhere, and cicatrize
within a few days a week or less. In a small num-
ber, the rupture produces a fatal hemorrhage. But the
thrombus may end in resolution, suppuration, or gan-
grene. The most rare termination is by resolution, as
Ferret found this result only four times in forty-four
cases. It may, however, be hoped for, when the tumor
is very small, and when it is unaccompanied by lacera-
tion, or in which the effusion has taken place without
any severe injury of the cellular tissue. The tumor
may suppurate, whether it be ruptured or opened by
incision, and even in some cases when its cyst remains
closed. Thrombus may also terminate in gangrene ;
and there is decided danger of this when the patient
is exposed to the endemic influence of septicaemia or
of puerperal fever.

The historical records of this lesion would seem, to
prove that the prognosis must be very unfavorable. I
have already referred to the monograph of Deneux, in
which it is stated that death resulted in twenty-two
out of sixty-two cases, and, in twenty-one cases, the
child was lost. Blot has collected nineteen cases, pub-
lished since 1830, when Deneux's essay was printed,
and in these nineteen, there were five deaths. In an

60 PUERPERAL DISEASES.

analysis of forty-three cases, by Ferret, there were sev-
enteen deaths, and one other probably terminated fa-
tally. But I venture to say that, at the present day,
the cause and character of the lesion are now so much
better understood than in former times, and conse-
quently the appropriate treatment is so much more
promptly adopted, that the ratio of fatality has been
greatly diminished. In fifteen cases, Scanzoni lost but
one, and this patient died from puerperal fever. Two
cases have occurred in my wards this winter, both of
which recovered. The cases that I have referred to as
occurring in the practice of Professor Sayre, and of Pro-
fessor Wood, recovered. The whole number of cases
that have occurred in my service in this hospital is
thirteen, of which two died, both from puerperal fever,
which, at the time, was endemic in the hospital. In pri-
vate and consultation practice, I have seen nine cases,
and I believe that every one of these cases recovered.

The deaths following thrombus have been ascribed
to the following causes : Hemorrhage, external or in-
ternal ; peritonitis ; suppuration, with hectic fever ;
gangrene ; pyaemia ; septicaaniia ; and puerperal fever.

In discussing the treatment of this lesion, I shall
restrict my remarks to cases occurring during and after
labor, as those which happen during gestation hardly
come within the scope of my present course. Besides,
in Caseaux's " Midwifery " you will find the directions
given for the management of those' cases belonging to
the time of gestation, so full and so excellent, that I
should have nothing of value to add. Neither shall I

have any thing to say in regard to the prophylaxis of
this lesion, for I know of no preventive treatment which
would promise any thing as a safeguard against this
accident.

THROMBUS OF THE VULVA AND VAGINA. 01

Many suggestions have been made, having this end
in view, and particularly by those writers who have
believed that the accident is almost always a conse-
quence of varicose veins. I have already said that this
belief seems to be erroneous. I could give you some
reasons for the opinion, that a varicose condition of the
blood-vessels of the vulva and vagina is a prophylactic
against this accident ; but I shall content myself with
saying that I have seen many cases where this con-
dition has existed, and, in none of them, was it fol-
lowed by thrombus ; and that, in all cases of thrombus
that I have seen, it has not been known that the acci-
dent was preceded by a varicose condition of the ves-
sels involved.

In now detailing to you the treatment which I shall
recommend, where the thrombus is developed during
labor, I must say to you that you will find other and
different plans of treatment proposed by high authori-
ties ; but I shall give you my reasons for the mode of
practice which I suggest, and you must subsequently
weigh, compare, and decide for yourselves. It is in
this way only that you will become good practitioners,
and not by accepting the simple dictum of any teacher
or writer.

(1.) If the thrombal tumor be not so large as to
cause great pain by its pressure on the adjacent tissues,
or to interfere materially with the delivery, or if lacera-
tion and escape of blood almost immediately follow
the development of the tumor, apply the forceps, and
deliver at once. The exciting cause of the accident is
the arrest of the venous circulation by the mechanical
pressure of the presenting part of the foetus. The
sooner the pressure is removed, the sooner will the
danger be over, and the less will be the injury to the

62 PUERPERAL DISEASES.

parts. At the moment of the delivery of the head,
there is usually an excessive flow of blood. Be pre-
pared to meet this great gush of blood with compresses
of cotton-batting, saturated with the solution of the per-
sulphate of iron, which you apply directly to the bleed-
ing, and keep up pressure till the hemorrhage stops,
which is usually in a few moments. During this time,
watch that your assistant keeps up firm pressure on the
uterus ; then deliver the placenta as soon as the hemor-
rhage from the lacerated vessels is controlled ; and, after
this, again apply your compresses with the persulphate
of iron ; but pressure on the parts is ordinarily required
only for a short time. Direct the nurse to watch vigi-
lantly for some hours for hemorrhage, and give her
specific directions to follow in case of its recurrence, if
you find that she has intelligence enough to trust her
with such responsibility. If not, stay with the patient
yourself. Most authors I think every one that I have
consulted direct that, under the circumstances just de-
scribed, a tampon should be applied. I must say, and
with the strongest conviction that I am right, that I
consider this direction a very bad one. In the first
place, there is no need of the tampon after once arrest-
ing the hemorrhage by the means that I Lave de-
scribed. In the next place, if the vagina be tamponed,
you have pressure upon the urethra and the other
parts, which have just been subjected to pressure and
contusion, and you have the lochial discharges retained
and decomposing. The safety of the patient requires
you to guard against every possible danger of abscesses,
sloughing, and decomposition, whether of the lochial
discharge or of the blood effused, as, at this time, the
system is especially liable to septic poisoning. Next to
hemorrhage, I think the greatest danger in these cases

THROMBUS OF THE VULVA AXD VAGINA. 63

is from septicaemia. Hence, you should freely use anti-
septics. I was greatly struck with the fact that our dis-
tinguished countryman, Dewees, who, in his work on
"Diseases of Females," gave a very clear description
of this class of accidents more than a half-century since,
recommended pyroligneous acid as an application in
these cases of laceration, thus anticipating the antiseptic
treatment by carbolic acid, which is now so much in
vogue. We employed, in the cases you have seen, a
lotion of carbolic acid and glycerine, not only as an
antiseptic, but as a means of protecting the parts from
excoriation by the irritating discharges of the urine and
the lochia.

It is an important point in the subsequent dressing
not to detach the coagulum formed by the persulphate.
This presents a black, ugly-looking mass, which you are
strongly tempted to clear away, but you must never
remove any part of it, except such as is completely
loosened, for fear of secondary hemorrhage. Still far-
ther to guard against this event, the patient should not
be allowed to evacuate the bladder spontaneously, but
the catheter should be employed for several days. In
the case that you have just seen, after the coagulum
had become detached, the surface looked irritated, a
poultice was applied for one day, and healthy granu-
lations appeared. Formerly these cases were treated
by bleeding, antiphlogistic medicines, and a spare diet.
This case has been treated on directly opposite princi-
ples that of restoring the exhausted vital powers as
rapidly as possible, by opium, alcohol, quinine, iron,
and the most nutritious diet.

(2.) When the tumor has attained such a size as to
offer a mechanical obstacle to delivery, incise at once,
remove all the clots that have formed, and then deliver

64 PUERPERAL DISEASES.

by the forceps. The longer the incision is postponed
the greater will be the amount of extravasation, the
greater the distention of the parts, and the more exten-
sive the laceration of their areolar tissue. The subse-
quent management will be the same as in the condition
just described.

(3.) When the thrombus does not appear until
after delivery, incision should not be made, so long as
the tumor is increasing in size ; or, in other words, not
until after the coagulum is formed which arrests the
hemorrhage by pressure on the lacerated vessels. In
these cases, there is no doubt that the rupture of the
vessels has occurred during the labor, but the extrava-
sation has been prevented by the pressure of the head.
When the ruptured vessels are very small, the effusion
takes place slowly, and the tumor may not be discov-
ered or even formed for many hours after delivery.
Now, although in some cases the tumor may be ab-
sorbed, yet, if it be of any considerable size, it seems to
me that the danger from suppuration and from septicae-
mia is infinitely greater than the danger, with the styp-
tics we now have at command, from hemorrhage fol-
lowing the incision ; and, therefore, the safe course is to
incise early, except when the tumor is high up in the
pelvic cavity. Then, it may be a question to be care-
fully weighed and decided, after a due consideration of
all the elements of the case. I trust, gentlemen, that you
will be prepared for this emergency. Although some-
what rare, it may occur to any one of you ; and while,
in the past, it has been attended with a fearful fatality,
both to the mother and child, I hope, in the future, a
more enlightened practice may render it less dangerous.

LECTUEE V.

PUEEPERAL ALBUMINTJEIA.

Case In a majority of cases of puerperal albuminuria, Bright's disease is not
present Meaning of the term Albuminuria and uraemia not identical The
albumen of the urine in Bright's disease differs from the albumen of puerperal
albuminuria 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.

"CASE VI. 1 October 13th; Mary , aged thirty-three, mar-
ried ; has had five living children and two miscarriages, one at five
and the other at six and a half months. Entered the hospital,
October 12th, pregnant for the eighth time. Last menstruated,
January 25th. Patient very feeble. Pulse 120 when sitting up,
108 when in the recumbent posture. Face very much swollen,
and of a leaden hue. Both upper and lower extremities highly
cedematous, as well as both labia, which are enormously swollen.
Tongue pale and flabby. Patient reports that she has suffered
constantly from headache for two months, and began, at about
the same time, to have specks before her eyes, and ' now her sight
is very bad ; ' ' would not know the face of her own daughter.'
For several weeks, has suffered much from nausea and vomiting,
and, for some days, has been sick all the time, and can retain no
food. She is very thirsty, .but rejects liquids as soon as she drinks.
Says her bowels are regular, but has had no movement for two days
before entering the hospital. Desires to pass water quite often^ but
never more than a tablespoonful at a time. On auscultation with
Camman's stethoscope, neither the sound of a fcetal heart nor a uter-
ine souffle could be heard. A catheter was passed, and three and

1 Case reported by the house-physician to the lying-in wards of Bellevue Hospi-
tal, who neglected to append his name to the report.
5

60 PUERPERAL DISEASES.

a "half ounces of water were drawn off. Specific gravity of the
urine not ascertained, but, on applying heat and nitric acid, more
than one-half was coagulated. Directed that all the water she
should pass be saved for examination. Ordered eight dry cups to
be applied over each kidney, a sinapism to the epigastrium, and
one drachm of pulverized compound jalap every second hour, until
cathartic action.

" October 14th. No action from the powders, but she has had
frequent vomiting and constant nausea. Has slept none ; intelli-
gence very dull ; has not passed water, nor felt any desire to. Pulse
130, and very feeble. Examined by Professor Barker, who drew
off, by the catheter, less than one ounce of water. Dr. Barker
ordered one-eighth of a grain of elaterium to be mixed with a little
butter, and to be put into the mouth every half-hour until catharsis
resulted. This was repeated five times, before any effect, ex-
cept vomiting, followed. After the sixth dose, she began to have
very profuse, watery discharges, number not known, but probably
not less than twelve or fifteen during the night ; she slept well,
except when disturbed by the action of the bowels.

" October loth. Patient says she feels stronger and better. Has
but little nausea, and much less headache. Has taken a pint of
milk this morning. Dr. Barker ordered

IJ, . Tine, ferri chloridi,

Glycerini,

a
Syr. simp.,

Aq. purae,
M. S. A teaspoonful in sugar and water every third hour.

" October ~L6th. Patient passed a good night. Pulse 108. Bow-
els moved yesterday four times very watery discharges. She has
passed six ounces of water, highly albuminous, containing quite a
number of hyaline casts. She has taken beef-tea and two eggs.
No nausea, and but little headache, but her sight is not at all
improved. Labor came on at 6 P. M. First stage, three hours ;
second stage, half an hour. Rupture of membranes, followed by
an enormous discharge of waters. Child, a female ; had evidently
been dead for some time ; weighed six and a quarter pounds. Third
stage, fifteen minutes. Placenta very small, and fatty degeneration
very marked, as shown by the microscope. Patient did not lose
an ounce of blood.

"October Ilth. Pulse 108. Patient very comfortable in every
respect. No after-pains. Lochia very scanty.

PUERPERAL ALBUMINURIA. 67

" October ISth. Bowels moved freely -without medicine. Has
passed, during twenty-four hours, eighteen ounces of water, still
highly albuminous, with numerous casts. Patient says she is hun-
gry. Ordered to have all the beef-soup and milk alternately that
she will take. The iron has been continued regularly, except during
the night.

" October 19^A. Pulse 96. Breasts full and painful. Lochia
stopped. Has passed forty-four ounces of water ; albuminous de-
posit not more than one-eighth of the bulk. CEdema of face nearly
gone ; still some oedema of the legs and feet. By her request, a
child is given her to nurse.

" October 2Mh. Patient able to go up two flights of stairs to
Dr. Barker's clinic. Urine abundant ; entirely free from casts, with
but a very small proportion of albumen. Patient's only trouble
now is her impaired vision."

This woman, gentlemen, has been in the convalescing
ward, and her appearance has so changed since I last
saw her, one week ago, that I can hardly persuade
myself that she is the same woman whose history you
have just heard read. It is a- typical case of puerperal
albuminuria, a disease of which nothing was known in
medical science little more than thirty years ago, but in
regard to which every year adds something to our
knowledge. We now know it to be one of the most
frequent of all the puerperal diseases. It is sometimes
so trivial that it gives rise to no disturbance of preg-
nancy or parturition, while in other instances it causes
most alarming and dangerous symptoms in the preg-
nant, the parturient, and the puerperal woman. Puer-
peral albuminuria was first observed and studied in
connection with eclampsia, until naturally it came to
pass that it was regarded as essentially the cause of
these convulsions. It is fully understood now, by all
advanced men, that albuminuria has an immediate
bearing on a great variety of pathological conditions
other than convulsions that it often exists, as in the

68 PUERPERAL DISEASES.

case before you, in its fullest development, without
causing convulsions that dangerous and fatal convul-
sions may occur when albuininuria is wholly absent
and, still farther, that the nervous perturbations which
cause the convulsions may also be the cause of albu-
minima, or even that the convulsions themselves may
be the cause of albuininuria. In the present state of
science, albuininuria is no longer believed to be a
symptom of Bright's diseases only. In fact, it is prob-
able that, in nineteen cases out of twenty of puerperal
albuminuria, the structural lesions of the kidney, im-
plied in the term Bright's diseases, do not exist.

Now, let us understand what is the meaning of the
terms we use : By albuminuria, it is implied that,
through the medium of the kidneys, the albumen is
filtered off from the blood to a greater or less extent,
and discharged from the system in the urine. When
this occurs, it is believed, also, that the kidneys fail in
some measure to depurate the blood by eliminating
urea. Albuminuria and uraemia are not identical terms,
as either condition may exist and the other be absent ;
but I suppose that albuminuria cannot be developed to
any considerable extent without being accompanied by
more or less uraemia.

Robin, in his recent work on the fluids of the body,
has demonstrated that urinary albumen has not the same
composition as the albumen of the blood, and that the
albumen of Bright's disease differs essentially from that
occurring in the temporaiy albuminuria of pregnancy, as
can easily be shown by its chemical reactions. The al-
bumen of the urine in Bright's disease, when brought in
contact with the oxide of copper, assumes a beautiful
reddish-violet color, and produces a more or less abun-
dant flocculent black precipitate. Now, the urinary

PUERPERAL ALBOII N'URIA. 69

albumen of pregnancy, when Bright's disease does not
exist, while it coagulates readily by heat and nitric acid,
does not exhibit any such reaction with the oxide of
copper. So, also, Robin has demonstrated that granular
casts are not characteristic of any particular morbid
state or pathological change of structure of the kidneys.

The question then naturally arises, What are the
causes of puerperal albuminuria ? I regret to say that,
at present, we cannot fully or satisfactorily answer this
question. It is an accepted fact that, in a large number
of cases, gestation develops a temporary albuminuria,
which may disappear during or soon after puerperal
convalescence. The phenomena pertaining to this con-
dition are rarely manifested before the sixth month of
pregnancy. Statistics seem to prove that it occurs more
frequently in first than in subsequent pregnancies.
These elementary facts would seem to make plausible
the theory first suggested, many years ago, if I am not
mistaken, by Dr. Cormack, that the albuminuria results
from congestion of the venous circulation of the kid-
neys, caused by the pressure of the gravid uterus on the
einulgent veins. But, while there is probably much
truth in this theory of the mechanical cause of the
albuminuria, it does not contain the whole truth ; and
it does not even include all of the mechanical causes.

The process of parturition sometimes interrupts the
venous circulation to such an extent as to produce a
temporary hyper&mia of the kidneys, and develop
albumimiria which had not existed during gestation.

So, also, in many cases, where the most careful and
repeated examinations of the urine, made during gesta-
tion, have failed to detect albumen, convulsions have
occurred during labor, and afterward the urine has been
found loaded with albumen. Here, it seems probable

70 PUERPERAL DISEASES.

that the violent spasmodic contractions of the muscles
of the abdomen which attend the convulsions, have so
interrupted the venous circulation of the kidneys, as to
produce an intense, though temporary congestion.

But this condition may arise from causes altogether
distinct from any mechanical interruption of the circu-
lation. Any of the causes which produce active con-
gestion of the kidneys, as, for example, a sudden cold,
may develop albuminuria. I will mention a case illus-
trating this point, which I have recently had in my
private practice. A young lady of twenty became
pregnant two months after her marriage. Before this
time, she had been regarded by her family as very
delicate, but pregnancy seemed to make a great change
in her system. In seven months, she gained twenty-four
pounds in weight, and her general health had never
been so good. In visiting another member of the family,
I accidentally saw her at about the eighth month of
gestation, and, as I was engaged to attend her at the
time of her confinement, I was so struck by the change
of her appearance, that I questioned her somewhat
closely. The only symptom that she complained of
was, that she was always " too hot," and this was con-
stant. Every function seemed to be normal, but the
appearance of her face so impressed me that I privately
begged her mother to get a quantity of her urine and
send it to me, which was done a few days afterward.
The specimen was examined by Professor Austin Flint,
Jr., and reported to be perfectly normal. The morning
after this report, I was summoned to visit her, and re-
ceived the following history : The evening before, a
warm evening in April, she had taken rather a long
walk with her husband ; when she returned, perspiring
quite freely, she went directly to her room, undressed,

PUERPERAL ALBUMINUEIA. 71

and sat in lier night-dress, with bare feet, for quite
half an hour, by an open window. Her husband then
canie into the room, and, remonstrating with her for
her imprudence, persuaded her to go to bed. In the
night, she was awakened by a severe chill, which lasted
a long time, but she again w r ent to sleep, and did not
awake until nearly eight. She then complained of a
most intense headache, with nausea ; she was exces-
sively nervous, frequently asserting that she was dying.
I found her with a very flushed face, conjunctiva very
red, skin hot (temperature 101 Fahr.), pulse 112, hard,
bounding, and, in addition to the headache, she now
complained of a dull pain in the lumbar region. As
she was confident that she haa. passed no water since
the afternoon before, I persuaded her to make the effort
at once, but she did not succeed in passing a teaspoonful.
I now bled her from the arm, taking away about eigh-
teen ounces, with great relief to her headache. She was
directed to remain in bed, well covered with blankets,
and to take a bottle of the solution of the citrate of
magnesia. Any water passed was to be saved for ex-
amination. At my evening visit, I found her free from
pain. At one o'clock she had passed four ounces of
very dark, smoky urine, fully one-third of which coagu-
lated on applying heat and nitric acid. The laxative
commenced to act at four o'clock, and her bowels had
been freely moved three times. I directed that large
pieces of spongio-piline, wrung out of hot water, should
be kept over the kidneys, and that at ten o'clock she
was to have ten grains of Tully's powder with twenty
grains of the bicarbonate of potash. On the following
morning, in answer to my questions, she said that she
had slept all night, and was now perfectly well. But
she had passed no water since my last visit. She was

72 PUERPERAL DISEASES.

directed to take a tablespoonful of the following pre-
scription, in a wine-glass of water, every three hours, and
to drink freely the artificial Vichy water when thirsty.

]. Potass, citrat., f j.

Syr. simp., | j.

Aq. purge, 3 vij.

Tine, digitalis, f 3 jss.
M.

The subsequent history of this case was to me both
interesting and instructive. The husband was a young
man of fortune and leisure, with some pretensions to
scientific dilettanteism, and he at once procured all the
materials for examining the urine, and Dr. Flint's little

O '

book. At every visit, from this time until the per-
fect recovery of his wife, I was shown by him a test-
tube, with the result of the examination of the water
last passed. In the twenty-four hours following the
use of the prescription I have given, she passed twenty-
eight ounces of water, specific gravity 1022, nearly one-
fourth coagulated. From this time, the quantity and
character of the urine constantly improved, and, on the
ninth day after the attack, hardly a trace of albumen
could be discovered. Labor came on somewhat prema-
turely, on the seventeenth day after the attack. It was
severe, lasting ten hours, when I delivered her by the
forceps of a boy weighing eleven and a half pounds.
Ten hours after the labor, the water contained albu-
men, about one-eighth coagulating. On the second

7 O O O

day, there was hardly a trace of albumen. Lacta-
tion was established, with considerable febrile disturb-
ance, as she had small, retracted nipples, while the
breasts were excessively swollen and painful. On the
fourth and fifth days after delivery, albumen was veiy
abundant, nearly as much so as at the time of her

PUERPERAL ALBUMIXURIA. 73

first attack ; but, on the eighth day, not a trace could
be found ; and, from this time, she convalesced rapidly.

I think that this case illustrates how albuminuria,
to which the system was predisposed by pregnancy,
was first developed by cold, subsequently reproduced
by labor, and, afterward, by febrile excitement from
lactation. Hervieux, physician to the Maternite Hos-
pital, of Paris, in his recent great work " On Puerpe-
ral Diseases," seems to regard puerperal albuminuria
as mainly caused by what he calls "puerperal poi-
son," and as analogous to the albuminuria which
occurs from the scarlatinal poison. Hereafter, I shall
discuss more fully the views of Hervieux in regard to
this puerperal poison, but at present I shall only say
that he seems to me to give undue prominence to this
as a cause. But clinical observation has amply demon-
strated that convulsions, the various phlegmasiae inci-
dent to the puerperal condition, the pyasmic diathe-
sis, septic absorption, and puerperal fever, or any of
these causes, may develop albuminuria, where it has
before either been latent or has not existed at all.
In practice, I have often been led to suspect that the
presence of albumen in the urine has been regarded as
a cause of the pathological phenomena, when in reality
it was only an effect. Albumen in the urine is not the
disease, but it is the aggregation of symptoms, of which
this is one, that constitutes the disease that we call al-
buminuria.

The symptoms may be classified with reference to
the nervous, the vascular, and the nutritive systems :

(1.) The most frequent and constant of the nervous
symptoms is, perhaps, headache. When persistent, in
the latter months of gestation, I think this should al-
ways be regarded as very significant, and particularly

74: PUERPERAL DISEASES.

so when it is associated with insomnia, impaired vision,
hesitation or embarrassment in vocal utterance, and
great nervous irritability. Delirium, coma, paralysis
of special nerves, hemiplegia, and convulsions, are the
full culmination of the nervous disturbances caused
by albuminuria.

(2.) The most prominent symptom referable to the
vascular system is oedema of the face and of the upper
and lower extremities. This cedema is not always
present, even in very severe cases of albuminuria, but
it is sometimes observed in the face in the morning,
after the woman has passed some hours in the recum-
beut posture, and entirely disappears during the day.
(Edema, confined to the lower extremities, is not a diag-
nostic symptom of much value, as this may simply indi-
cate obstruction of the abdominal venous circulation
caused by the pressure of the gravid uterus. General
anasarca is not very uncommon, and, in some cases, the
whole areolar tissue seems to be infiltrated. In one
woman, in my service in this hospital, this symptom
existed to a most exaggerated degree, so that, on the
side on which she lay, the neck, the breast, and, in fact,
the whole side, were puffed out to an enormous extent.

(3.) Gastric irritability is important, when asso-
ciated with the other symptoms mentioned. When
albuminuria is of some weeks' duration, the appetite
is generally lost, and there frequently are nausea and
vomiting. Sometimes there is obstinate constipation,
while, in other cases, there is a tendency to diarrhoea.

The urine is variable in quantity, being sometimes
less and sometimes more than is normal. The specific
gravity usually bears a certain ratio to the quantity,
and ranges, in different cases, from 1010 to 1025. I
shall refer to other symptoms in speaking of the effects

PUERPEKAL ALBUMINURIA. 75

of alburninuria on gestation, parturition, and the puer-
peral state.

I shall first allude to its effects on gestation. The
fact has been established by numerous observers, that
abortion and premature labor are peculiarly liable to
occur when the maternal system is suffering from albu-
minuria, and it can be readily conceived that the vitality
of the ovum must be more or less impaired so long as it
is nourished by blood impoverished by albuminuria, or
poisoned by urea. In several instances, I have known
this to be the apparent and probable cause of repeated
abortions, or the premature delivery of a dead foetus.
One of my patients, who never gave birth to a living
child, was prematurely delivered of four dead children.
In her third pregnancy, she came under my care at the
sixth month, on account of the symptoms characteristic
of albuminuria, and a foetus, which had evidently been
dead for some days, was expelled, just after the seventh
month of pregnancy had commenced. The symptoms
of albuminuria rapidly disappeared, and she apparently
quite recovered her health, until she became pregnant
for the fourth time, when the symptoms reappeared at
the beginning of the fifth month. As I was just leav-
ing town to pass the summer in Europe, I placed her
under the care of my friend and colleague, the late Pro-
fessor George T. Elliot, and from him I learned that she

O '

suffered greatly from irritability of the stomach, per-
sistent and intense headache, oedema, anemia, and
amaurosis, until the sixth month, when she expelled a
-putrid foetus. She died of phthisis eighteen months
after this, and it is worthy of remark that some months
before her death the albumen disappeared from the
urine, her sight was restored, and she was entirely free
from gastric irritability, oedema, and headache.

76 PUERPERAL DISEASES.

Another of my patients was prematurely confined
with three dead children. I first saw her on the fif-
teenth of September, 1861, when she found, on rising
in the morning, that she was quite deaf, and that she
had great difficulty in articulation. The face was very
cedematous, and for some days she had been suffer-
ing from severe headache. On the 24th of Octo-
ber, she was delivered of a dead, hydrocephalic child.
A few weeks after her accouchement, the deafness and
difficulty in articulation entirely disappeared, and, two
months after, I sent a quantity of her urine to Dr.
Flint, Jr., for examination, who found it quite normal.
In the first volume of " Transactions of the London Ob-
stetrical Society," there is a report of a case by Dr.
Tyler Smith, in which abortion, with albuminuria and
convulsions, had occurred in six successive pregnancies.

It is unnecessary for me to multiply illustrations of
a fact which has been so often observed. I shall only
add that, in some cases reported by Hervieux and
others, the albuminuria seems to have been the pre-
disposing cause of a partial separation of the placenta,
hemorrhage, and premature labor. It should also not
be forgotten that the danger to foetal life from this

o o

source is not confined to the period of gestation. The
labor may be complicated with convulsions in the
mother, which are very fatal to the child.

I shall not detain you now with a discussion of all
the effects of albuminuria upon puerperal convalescence,
but I will say here that it must be obvious, that the
system which has been impaired for some weeks by
this condition must be specially liable to the various
puerperal phlegmasise, and particularly susceptible to
morbific influences of an endemic or epidemic charac-
ter. Then, again, you must remember that the various

PUERPERAL ALBUMIXDPJA. 77

puerperal diseases frequently develop albuniinuria, when
it liad not previously existed.

Any attempt at formal statements with regard to
prognosis in albuminuria would be but a reiteration,
in other terms, of ideas that I have already expressed.
You have observed that the greatest anxiety which
the patient before you manifests, is with reference to
the recovery of her sight ; and you will naturally ask,
" What encouragement am I warranted in giving her ? "
Although but few cases have been published of recov-
ery of the sight, when seriously impaired as a result
of puerperal albuminuria, yet I have seen several where
it has been complete. I have already mentioned one.
In another patient, who had the characteristic symp-
toms of albuminuria in the eighth month of her preg-
nancy, vision was impaired to such a degree that she
she could barely distinguish the outline of objects when
placed in a strong light. She had one convulsion pre-
vious to her labor, and five after the birth of the child.
Her convalescence was rapid ; the albumen disappeared
from the urine, and her recovery was perfect in every
respect, except her sight. I repeatedly urged her to
consult some one of our eminent oculists. Three
months after her accouchement, her husband determined
to take her to Berlin to consult Von Graefe. On the
voyage out, her sight manifestly improved, and, while
in England, the improvement was so rapid that they
deemed it unnecessary to consult any oculist, and she
returned, after eight months' absence, with the sight
perfectly restored. Three years after, she again be-
came pregnant, and, in the last months of gestation,
there were some symptoms of albumiuuria, and some
impairment of vision, but, in other respects, the preg-
nancy and labor were normal. I have attended her in

78 PUERPERAL DISEASES.

three subsequent pregnancies, without any recurrence
of the symptoms of albuminuria.

In a discussion of this subject before the New York
Academy of Medicine, our distinguished oculist, Dr.
Noyes, stated that a colored woman came under his ob-
servation, " who had convulsions three or four weeks
prior to delivery, and her sight had been impaired for
two months, during which time the retina presented
the characteristic appearances of fatty degeneration.
She so far recovered that, after a period of ten months,
she was able to read fine print. She afterward became
pregnant, and miscarried at the end of the sixth month ;
and, although she had convulsions at that time, there
was no increase of the eye-trouble."

A most striking case is reported in the July num-
ber, 1862, of the American Journal of the Medical Sci-
ences, by Dr. Fourgeaud, of San Francisco, California.
The patient had had several miscarriages, and two liv-
ing children, who were born before the eighth month.
Dr. Fourgeaud first saw her a week before labor came
on, September 24, 1861. "Her face was then oedema-
tous, and she complained of loss of sight, so that she
was unable to read printed matter, or to distinguish
persons a few feet from her." She was delivered, Octo-
ber 1st, "of a seven-months' child, which had been
dead, to all appearances, for three or four days." Her
labor passed off without convulsions, which immunity
Dr. Fourgeaud attributes to the prophylactic treatment
iinder which she had been placed for a week, and to
the use of chloroform during the labor. On the morn-
ing after, the doctor found his patient paraplegic.
" The motor power of both legs was entirely lost, sen-
sibility being but partially impaired. There was pa-
ralysis of the rectum and sphincters, with involuntary

PUERPERAL ALBUMIXURIA. T9

discharge of the faeces, paralysis of the bladder with
retention of the urine, amaurosis, the eyesight being
almost entirely gone." On the 22d of November, the
doctor reports that the cedema had disappeared, and
the paralysis of the legs was considerably diminished,
and she had so far recovered her sight as to be able to
read. I saw this lady at the Metropolitan Hotel in
this city, in November, 1862, with my friend Dr. Fes-
senden N. Otis, under whose professional care she then
was ; and, so far as her sight was concerned, the recov-
ery remained as complete as reported by Dr. Fourgeaud.

It seems to me, therefore, to be the duty of the phy-
sician, under these circumstances, as in all cases where
there is paralysis or paresis of special nerves from a
reflex cause, when this reflex cause has not produced a
centric lesion, to give his patient the full benefit of a
confident hope of restoration.

I shall add a few remarks with reference to the
treatment of albuminuria in each of the three periods,
pregnancy, parturition, and the puerperal state.

During pregnancy, the indications from this condi-
tion are :

(1.) To relieve the hypersemic or congested kidneys
by the use of laxatives, especially those which produce
a hydragogue action, such as the bitartrate of potash,
the compound powder of jalap, or the citrate of mag-
nesia. These agents act on the mucous membrane of
the intestinal canal in abstracting by exosmosis serum
from the blood, while they do not diminish its corpus-
cles. In this way they take off part of the load which
is imposed upon the kidneys. In conjunction with
these laxatives, when the renal secretion is defective,
we may use, both with safety and advantage, such diu-
retics as the acetate or the citrate of potash, assisted by

80 PUERPERAL DISEASES.

digitalis in small doses, but not long continued. The
artificial Vichy and Seltzer waters may be drunk freely,
and are often very grateful to patients, and decidedly
useful as diuretics. When the attack is acute, and
there is pain or tenderness over the kidneys, with a se-
cretion of only a small quantity of smoky urine, dry or
wet cups over the lumbar region often give relief, and
increase the quantity and change the character of the
urine. When albuininuria is associated with plethora,
as manifested by persistent redness of the face, in-
jection of the conjunctiva, hot skin, lancinating pains
in the head, and a hard, labored pulse, denoting arterial
tension, I am convinced that the use of the remedies
that I have just spoken of should be preceded by a
prophylactic venesection. The quantity to be ab-
stracted for this purpose must be a question of judg-
ment, to be determined by the special indications and
the immediate effects produced, but I should say, in
general terms, that it would probably be from ten to
sixteen ounces.

(2.) To prevent the impoverishment of the blood
which results from albuminuria. The statement of
this indication may seem to conflict with the re-
marks that I have just made relative to venesection.
But a little reflection will convince you that the two
propositions are really not antagonistic. Cazeaux and
others have shown that chloro-anaemia is a very com-
mon condition in pregnancy. In puerperal albuminu-
ria, we often have hydramia, and a kind of serous
plethora, in which there is absolutely an excess in the
quantity of blood, which causes great disturbance of
the circulation, 'and local congestions. I am disposed
to believe that the renal congestions from this constitu-
tional origin are absolutely the predisposing cause of

PUERPERAL ALBUMINURIA. 81

many cases of puerperal albmninuria. At any rate, it
is often found to be good practice to diminish the se-
rum, and to increase the relative proportion of hema-
tosine. So, after the use of the measures which I have
just mentioned, you will frequently jfind it of great
service to your patients to give them iron, and the
best preparation for this purpose is, probably, the tinc-
ture of the chloride. It is not only useful in improving
the condition of the blood, but it unquestionably ex-
erts an influence as a diuretic.

(3.) To prevent the nervous disturbances which ter-
minate in paralysis, or often culminate in convulsions.
This implies care in preventing all emotional excite-
ment, or in overtaxing the physical powers in every
way, either by violent exercise or by household duties,
a close attention to the digestive organs, and espe-
cially to guard against constipation. I am inclined,
also, to think that the necessity for good ventilation
and the free circulation of pure air in the sleeping-
apartment is not sufficiently appreciated.

But, in spite of all these measures, and of every
other resource at our command, these nervous disturb-
ances will continue, in some cases to such a degree as
to dangerously imperil the life of both mother and
child. There, then, remains only one thing to do, and
that is

(4.) To induce premature labor. The propriety of
this measure has been much discussed, and I suppose
that professional sentiment is still not unanimous on
this point. I shall not enter upon any elaborate argu-
ment in defense of my views, but I have no hesitation,
whenever the symptoms from, albuminuria are of so
grave a character that there is every probability that
their continuance will result in the death of the mother,
6

82 PUERPERAL DISEASES.

in advising and urging that labor should be brought
on. I feel well assured that I have seen a number of
valuable lives thus saved, which otherwise would inev-
itably have been lost. I have never regretted giving
this advice. The only regret that I have ever had on
this subject has arisen when such action has been too
long postponed by baseless hopes on the part of
those with whom I have been associated. The ques-
tion is a much more difficult one, when it turns upon
the propriety of the measure, solely for the purpose of
saving the life of the child. But, even in this case, if
there be a probability of accomplishing such a result, I
hold it to be a duty. The success or non-success of the
measure has nothing to do with the moral of the ques-
tion.

I shall only add that such a measure as this should
only be adopted after consultation, as it might be most
hazardous for any one man, and particularly for a
young man, to assume alone such a responsibility.

LECTURE VI.

PUEKPERAL 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, acd eventual recovery from hemiplegia Recovery
from convulsions, with permanent aphasia remaining.

" CASE VII. 1 Bridget D , Irish, primipara. Admitted into

Bellevue Hospital two months ago, near the seventh month of preg-
nancy ; labia, vulva, and lower extremities so much swollen as to
pit upon pressure. Frontal headache and pain in lumbar region
on first admission, but all these symptoms soon disappeared. Nei-
ther albumen nor casts found in the urine previous to her confine-
ment, although several examinations were made. On the after-
noon of September 16th, the patient was suddenly seized with a
convulsion, characterized by all the usual phenomena, lasting five
minutes, and leaving her in a semi-comatose condition. A more
protracted convulsion followed about twenty minutes later. Dry
cups were applied to the loins, and three drops of croton-oil placed
upon the tongue ; chloroform was then administered freely, and
continued whenever convulsions were threatened, until the labor
ended. As, after a proper interval, the croton-oil did not act, an
enema of an ounce of castor-oil with three drops of croton-oil, and a
pint of warm water, was then given, which moved the bowels freely

1 Case reported by E. A. Vance, M. D., house-physician to Bellevue
Hospital.

81 PUERPERAL DISEASES.

in about ten minutes. At 7 P. sr., three convulsions occurred
in rapid succession. During the intervals between them, the pa-
tient was semi-comatose, with pupils markedly contracted. After
this, there was no recurrence of the convulsions until 4 P. M. of the
17th, when three occurred in rapid succession. A few moments be-
fore this attack, there were some manifestations of uterine contrac-
tions for the first time, and the cervix was now beginning to dilate.
There was now an intermission of the convulsions (the patient mod-
erately taking chloroform when there were any threatening symp-
toms, and whenever there were uterine contractions) until 3 A. ai.,
of the 18th, when three more occurred, and, ten minutes after the
last, the child was suddenly expelled alive. The placenta soon came
away ; the uterus contracted well, and there was little hemorrhage.
The mother had three convulsions soon after delivery ; as there had
been scarcely any secretion of urine for the past twenty-four hours,
and the patient remained unconscious, dry cups were applied over
the kidne}'S. Soon after their application, she became conscious, and
was able to swallow. Two drachms of the bitartrate of potassa
were then given four times a day. After the first attack of convul-
sions, the urine for the first time contained a small amount of albu-
men, but no casts. On the first day after delivery, the urine con-
tained about twenty-five per cent, of albumen. Puerperal mania
was developed the second day after delivery, lasting two days. She
has since done well, has had a good appetite, and has complained
only of headache. To-day, the tenth since delivery, only a trace of
albumen can be found in the urine. For six days past, she has
been taking, three times a day, two grains of sulphate of quinia
and fifteen drops of the tincture of the chloride of iron, with the
most nutritious diet. Just after delivery, the child had a convulsion
precisely like that of the mother, and in the course of two hours
two more. It has since done well, has had no more convulsions,
nurses well, and is thriving."

Gentlemen : Those of you who have never witnessed
a case of puerperal convulsions will naturally ask first,
" What are the phenomena which characterize these at-
tacks ? " Let me tell you that, when you have seen one
case, you have seen the phenomena that occur in all,
the difference being only as regards the frequency, dura-
tion, and intensity of the paroxysms. Frequently, the

PUERPERAL CONVULSIONS. 85

attack occurs in the later periods of pregnancy, without
any premonitory symptoms having been observed by
the patient or her friends. Indeed, in the most severe
and the most dangerous cases of puerperal convulsions
that I have seen for some years past, the patients have
had no premonitory symptoms to attract attention, and
therefore have had no prophylactic treatment.

It may be that, while engaged in her ordinary oc-
cupations, she suddenly stops, becomes pale, with a
fixed expression of her countenance, and a general im-
mobility of her whole system. This lasts but a moment,
when the eyelids begin to twinkle, the eyeballs to
turn in their sockets, under the upper lid, so that only
the white of the eye is seen ; the angles of the mouth
are drawn, producing a horrid grimace, which Baron
Dubois has aptly compared to the countenance of the
satyrs of the fable. The angle of the mouth being
drawn up on one side, the face turns to the same shoul-
der, then the muscles of the face begin rapidly to con-
tract, and this contraction almost immediately extends
to the muscles of the trunk and the extremities. The
neck swells, the jugular veins stand out prominently,
and the carotids beat violently. The fists are doubled,
generally with the thumb of one or both hands com-
pressed in the palm by the fingers. Sometimes one
arm is raised as if in an attitude to ward off a blow.
The muscles of the throat and larynx strongly contract,
and cause a momentary suspension of respiration ; the
foce is intensely congested, and of a purple hue. This
condition of tonic convulsion does not continue, ordi-
narily, more than twenty or thirty seconds, when it is
followed by the clonic convulsive movements. Rapid,
jerking movements of the muscles of the face, body,
and extremities now succeed the muscular rigidity.

86 PUERPERAL DISEASES.

A short, noisy, broken inspiration, with stertorous
expiration, is attended with the escape from the mouth
of a white foam, sometimes bloody, from lacerations of
the tongue. The patient can neither feel, see, nor hear.
The circulation is soon influenced by the respiratory
troubles. The spasmodic contractions of the diaphragm
and the other thoracic muscles interrupt decarbonization
and oxygenation ; the pulse, which was at first hard and
strong, now becomes rapid and feeble, capillary circula-
tion is arrested, which causes a purple hue, particularly
noticeable on the hands. Toward the end of this parox-
ysm, all these symptoms progressively disappear. The
spasmodic movements of the muscles become less fre-
quent and less violent, until they entirely cease, the
respiration and circulation become regular, the super-
ficial congestions disappear, and the surface recovers its
natural color. This period of clonic convulsions lasts
from two or three minutes to twenty. The tonic con-
vulsions are really much more dangerous to life, and,
when patients die in the convulsion, it is in this period,
the death probably being due to asphyxia. But the
phenomena of the clonic convulsions are usually much
more frightful in their appearance to the uneducated
by-standers.

Following these paroxysms, the return of the intel-
ligence and sensibilities is not immediate. There is a
period of coma, varying in character, profoundness, and
duration, in a ratio proportionate to the intensity and
severity of the convulsive attack. In some, this is lit-
tle more than a profound somnolence, lasting but a mo-
ment or two, when the patient opens her eyes and looks
around with astonishment at the objects about her.
She slowly recovers her intelligence, but has no recollec-
tion of what has happened. In some, the sight or hear-

PUERPERAL CONVULSIONS. 87

ing or memory is impaired, while in others, all the func-
tions are restored, the recovery is complete, and there
is no return of the convulsions. In others, again, after
a period of a few minutes, or, it may be, of hours, in
which the patient presents the delusive appearance of
complete recovery, there is observed an unnatural calm
and taciturnity, or a nervous agitation, which is the
prelude to a new access of convulsions. After repeated
convulsions, with increasing violence, the intervals of
sleep are longer and more profound, and the woman is
awakened with difficulty. With an appearance of
effort, she opens her eyes, mutters a few incoherent
words, makes some automatic movements, and again
falls into a profound slumber. Finally, when the cere-
bral disturbance is excessive, the respiration becomes
heavily stertorous, the coma is profound, and the con-
vulsive paroxysms recur without any temporary inter-
vals of consciousness ; and this condition continues un-
til terminated by death. One word in regard to this
coma : it seems to be essentially different from, and to
be due to another cause than the coma which is often
an initial symptom of convulsions in Blight's disease.
In the latter case, the brain is overwhelmed by a spe-
cial poison, urea. In puerperal convulsions, the cir-
cumstances under which the sopor is developed, the
characteristic signs of cerebral congestion which pre-
cede and attend this coma, as well as the evidences
that have been accumulated by autopsic examinations,
seem to demonstrate conclusively that this coma is the
result of intense cerebral congestion, and sometimes of
serous effusion. It has been shown in some cases that
rupture of cerebral vessels has taken place, and a clot
has formed, with its consequent paralysis.

Now, the inquiry will arise in your minds, whether

88 PUERPERAL DISEASES.

there be any signs whicli should lead you to anticipate
these frightful attacks. I am compelled to answer that,
in some few cases, the most careful observation will
fail to detect any forewarning symptom. Near the end
of gestation, some, whose condition has been apparently
normal in every respect, whose urine has been carefully
and frequently examined, without a trace of albumen
being detected, have been suddenly seized with convul-
sions, even when no exciting cause for the accident
could be ascertained. So, also, when the same condi-
tions of apparent health have existed throughout ges-
tation, parturition has gone on normally, until convul-
sions have occurred. In the winter of 1 869, the wife
of a physician in this city was delivered of a fine,
healthy boy at eight o'clock in the evening, after a
labor (not severe for a primipara) of nine hours. In
the last months of pregnancy, her health had been bet-
ter than ever before. Her husband had made almost
daily examinations of the urine, without finding a trace
of albumen. I have always suspected that he was
over-anxious in regard to the dangers of post-parturn
hemorrhage, for he detailed to me with great minute-
ness the steps that he had taken to secure the firm and
permanent contraction of the uterus, and added that
the delivery of the placenta was not followed by the
loss of an ounce of blood. I should say that she had
not taken anaesthetics, as she objected to them; and, as
she bore her pains very well, her husband had not
urged the use of chloroform or ether. Soon after the
labor was over, she took a small cup of panada, and
then fell asleep for an hour or more. On awakening,
she gave expression to her feelings of intense happiness,
held her baby in her arms for a few moments, warmly
kissed her husband good-night, and again fell into a

PRECURSORY SYMPTOMS OF CONVULSIONS. 89

sound sleep. All arrangements for the night were
then made, the nurse and child being in an adjoining
room, with open folding-doors, while the husband lay
down upon a sofa, which he had placed close by the
bed of his wife. At two o'clock, he was awakened by
finding her in violent convulsions. At 4 A. 31., when I
first saw her, she had had eight veiy severe convul-
sions, remaining, during the intervals, in a state of com-
plete, unconscious coma.

As I shall refer to this case again, when discussing
the cause and treatment of convulsions, I will now
pass on to say that the cases of this kind, which occur
either before or during and after labor without pro-
dromic symptoms, are fortunately so few in number as
to be rather exceptional.

The precursory symptoms of puerperal convulsions
are now well known to the profession, and it cannot be
doubted that, in many cases, this knowledge has been
made available to prevent their recurrence, by a success-
ful prophylactic treatment. The first and most fre-
quent of these symptoms is headache, sometimes dull'
and continuous, and, in other cases, throbbing and re-
current. It is occasionally intermittent for days or
weeks, until a few hours before the attack, when it be-
comes constant. It is frequently attended with vertigo
on making any movement of the head.

The symptom next in frequency, and still more sig-
nificant of danger, is impairment of vision. This, like
the headache, is frequently temporary at first, after-
ward becoming permanent. In some, the sight, which
had previously been good, appears to be suddenly lost.

In connection with either or both of the symptoms
I have just described, I should mention oedema, particu-
larly of the face, coexisting with oedema of the ex-

90 PUERPERAL DISEASES.

tremities. It occasionally happens tliat this symptom
exists alone, and even this in so slight a degree, as not
to be observed, unless carefully sought for, when the
two other symptoms are wholly absent. Under these
circumstances, it becomes an imperative duty to care-
fully and frequently examine the urine, and test it for
albumen. Indeed, in this hospital, it is the duty of the
house-physician, or his assistant, to make this examina-
tion of all the women in " the waiting-wards."

Whether albumen be or be not found in the urine,
or even when the other symptoms I have just de-
scribed are absent, if a pregnant or parturient woman
suddenly complains of sparks before her eyes, or dim-
ness of sight, or ringing in her ears, or difficulty in ar-
ticulation, or suddenly becomes nervous, irritable, and
complains of a severe pain in the head, the danger from
convulsions is imminent.

You next ask, " What are the consequences of puer-
peral convulsions in the pregnant, parturient, and puer-
peral woman ?

(1.) In the pregnant, they may bring on labor pre-
maturely, destroy the life of the foetus, of the mother,
or of both. Happily, in some, they terminate in recov-
ery, without either of these results.

(2.) The same consequences may follow when the
convulsions occur during labor. If they be very se-
vere and numerous, and occur for many hours previous
to the termination of the labor, if they be associated
with any cause of dystocia, as a bad presentation, a de-
formed pelvis, or hydrocephalus of the fcetus, the child
is almost inevitably lost. If they occur in a mother
severely suffering from albuminuria or who really has
Bright's disease, or who is very anaemic, or if they
develop cerebral lesion, the danger to life is very grave;

PUERPEKAL CONVULSIONS. 91

but even under these conditions we are not warranted
in saying the case is hopeless.

(3.) After delivery, puerperal convulsions may be
followed by severe and dangerous hemorrhage, due
either to the exhaustion of nerve-power to such a de-
gree that permanent uterine contractions cannot be
effected, or to the condition of the blood, which from
persistent albuminuria has lost its normal plasticity.
This fact seems to have been first signalized by M. Blot,
who published a case which occurred at the Maternite,
where hemorrhage followed convulsions (the blood
being fluid and decolorized), and resisted the most
prompt and active treatment, the patient dying un-
der his eyes, fourteen hours after delivery. Since the
publication of this case, several other observers have
noted the same result, and one has occurred in my
service in this hospital. Case xciv., in the " Obstetric
Clinic" of Prof. Elliot, is another illustration, I take it,
of the same fact. Again, puerperal convulsions are fre-
quently followed by puerperal mania. I have often
seen this, and you will find numerous cases of the kind
in the clinical reports of Johnston and Sinclair, Elliot,
Hervieux, and others, and I will remark here, paren-
thetically, that mania follows puerperal convulsions in
quite as large a number of cases where albuminuria has
not existed, as in those where it has been present.

Another question of interest is, " In which period is
the occurrence of convulsions the most dangerous?"

Eighteen years ago, I published, in the New York Medi-
. cal Times, a table of cases of puerperal convulsions which
I had collected from all the sources accessible to me, and
analysis of that table proved that thirty-two per cent,
of all cases which occurred before and during labor,
and twenty-two per cent, of those that occurred after de-

92 PUERPERAL DISEASES.

livery, ended fatally. Now, within a period of eighteen
years, the true pathology of this disease is much better
and much more generally known to the profession, and
its therapeutics is still more improved, so that I have
no doubt that the relative fatality has been diminished
at least fifty per cent. I suppose that the propor-
tionate fatality in the different periods has been consid-
erably changed by the acceptance of the induction of
premature labor as a therapeutic resource.

But death still too frequently results from puerperal
convulsions. In some exceptional cases, this occurs
during the paroxysm, from acute asphyxia. Much more
frequently, the woman dies in the comatose period, from
exhaustion and asphyxia combined ; or the convulsions
may directly or indirectly produce complications which
cause a fatal termination. I have already mentioned
hemorrhage as one. Cerebral hermorrhage, serous effu-
sion, and meningitis, are to be included in these com-
plications. Cazeaux lost two cases out of seven, which
he had in a short period of time, and in both, the au-
topsy showed the anatomical characters of meningitis.

I must add that, while the albuminuria ordinarily
disappears in the course of a week or so after delivery,
yet it sometimes persists weeks or months, until at length
the death of the woman results from the renal lesion.

As regards the child, Braun and Jaccoud deny that
the convulsions may be propagated from the mother to
the child. Simpson and others have held a contrary
opinion, and the case which we have shown you to-day
confirms this view. In two cases in private practice, the
mothers had severe convulsions during labor, but
recovered. In both, the child was born alive, but died
a few hours after birth, from convulsions, precisely iden-
tical in character with those of the mother.

PROGNOSIS IN PUERPERAL CONVULSIONS. 93

Now, let us next study the symptoms which indi-
cate the probable termination of the convulsions, either
by recovery or death.

We may anticipate recovery with a good degree of
confidence, when we find the convulsive attacks are of
short duration, and are not severe in their character,
while the intervals between each recurrence become
longer and longer. Especially may we be encouraged
under these circumstances, if, on examination of the
iirine, we find that it contains but a moderate quan-
tity of albumen, and is free from casts or blood, or
other foreign elements w^hich denote a profound lesion
of the kidneys. Even if these signs of renal disturb-
ance be present, we see occasionally that the casts en-
tirely disappear after the third day following delivery,
the 03deina is wholly gone in a week, and the albumen
is no longer to be found after a week or ten days.

In some cases, whether the evidence of renal trouble
be present or wanting, it happens that the convulsive
attacks are suspended for some hours, and then two or
three come in rapid succession they are again sus-
pended, and again recur. This happened in the case
that you have seen to-day. Now, in such cases, where
no indications of albuminuria have previously existed,
I am in the habit of predicting that albumen will subse-
quently appear in the urine. So, also, I expect it to be
found, when absent before, if the convulsive attacks re-
cur a great number of times, as I have seen them, rang-
ing from twenty up to fifty or more within twenty-four
hours. I am always hopeful, where there have been
repeated, careful examinations made by competent per-
sons, and the signs of albuminuria have been found
wanting until after the attack of convulsions.

Ao;ain, when the sierns of alburninuria are known

O / O

94: PUEEPERAL DISEASES.

to have previously been absent, I am not discour-
aged, when convulsions produce cerebral troubles so
profound as to be attended with deep and prolonged
coma and slowly-recurring convulsive attacks. The
case is not absolutely hopeless, even if we have the
most marked evidences of albuminuria and serous infil-
tration. I learned a lesson on this point some fifteen
years ago, from a case which Professor Alonzo Clark
and myself saw in consultation with Dr. Livingston, of
this city. I will give the history of this case, as com-
municated to me in a note from Dr. Livingston :

" The patient to whom you refer was delivered of a
fine boy, July 19, 1857, at about 2 o'clock A. M. The
labor was in every respect normal, and very rapid for a
primipara. Presentation vertex, first position. Two
hours after her delivery, I visited her again. She was
as comfortable as any patient I ever saw in the like sit-
uation. Her skin was cool and moist, pulse calm and
natural, and she was cheerful and disposed to jest at
my needless anxiety in her case. I had only seen her
the week previous, and was quite reluctant to assume
the care of her, as she presented strong indications of
albuminuria. She was very oedematous in the face,
neck, and upper extremities, as well as the lower, and
the urine was loaded with albumen. At about 5 A. M.,
three hours after delivery, I was suddenly summoned
to the patient, with the statement that she was in a fit.
When I arrived, a few moments later, I found her ap-
parently as well as I had left her an hour before.
The pulse only was a little excited. The convul-
sive paroxysms at first recurred at intervals of half
an hour, but gradually grew more frequent and pro-
longed, and, by 11 o'clock A. M., the -lucid intervals
had ceased, and she was profoundly comatose. Mucus

PUERPERAL CONVULSIONS. 95

began to be thrown in jets from the mouth and nostrils
at every expiration, and it was necessary for one per-
son to continually wipe her mouth and face on account
of the abundant secretion, and she could only breathe
at all by being held in the semi-upright position. The
face was of a dark mahogany color, and much bloated,
the pulse was entirely lost at the wrists, and the heart's
action so feeble and irregular as to presage immediate
dissolution. This was her state when you saw her,
and turned to her friends with the remark that l she
must die ; ' and well you might, for, two hours before
this, she was pronounced ' beyond human skill ' by Prof.
Alonzo Clark."

This patient entirely recovered, and Dr. Livingston
attended her in two subsequent confinements, " both of
which were normal and rapid, and the recoveries all
that could be desired."

I have seen cases recover where the most serious
cerebral troubles have apparently followed puerperal
convulsions. In 1859, a lady, aged twenty-two, in her
first confinement, was attacked with convulsions. Pre-
vious to labor, there were no signs of albuminuria.
although I most carefully sought for them. She had a
great many, I dare say more than twenty convulsions,
and I delivered her by forceps while she was in a coma-
tose state. She remained after delivery in a profound
coma for thirty-two hours, and it was many hours after,
before her intelligence was fully recovered. I discov-
ered, as she came out of this state, that she had lost the
power of movement, and, to a certain extent, the sensibil-
ity of the right side. But in a few weeks she was able
to walk with assistance, and eventually without diffi-
culty, although it was quite a year before she was able
to write or to play upon the piano. In 1865, she was

96 PUERPERAL DISEASES.

confined with her second child, and attended by Dr.
Elliot, as I was absent from the city. I have attended
her in two confinements since, without the slightest
abnormality occurring in either.

I must also mention to you the very curious, and,
so far as I know, unique case of a lady whom I well
know in this city. Nearly forty years ago, in her first
and only accouchement, she had very severe convul-
sions, followed by long-continued coma. On recovering
from, this, it was found that she had quite lost the power
of vocal expression. The only words that she has since
articulated, have been " Oh, yes." She seems to retain
her intelligence, understands every thing said to her,
and takes the liveliest interest in every thing connected
with her family and friends. I am not quite sure
whether she reads or not. Her immediate family
converse with her, apparently without difficulty. The
varied inflections of the voice, in usins; the words " Oh,

/ O

yes," and the number of times the words are repeated
with different inflections at each repetition, distinctly
convey, to those who are intimate with her, an affirma-
tion, a negation, a statement, or an inquiry. The only
irritation she ever manifests is, when she finds that she
is not understood by those whom she has been with for
some time, but who have not yet learned the meaning
of her peculiar inflections. 1

If you now ask me what are the signs which con-
clusively show that convulsions must terminate fatally,
I shall find it difficult to answer you. I should advise
you never to take it for granted that death must be
the result, unless the breathing has stopped, and the
heart has ceased to beat. But, otherwise, fight for life
as long as you have a resource at command.

1 It will be noticed that this case occurred long before the researches of
Virchow and Kirkes, relative to the effects of cerebral embolism.

LECTUKE VIL

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 Xo signs of albuminuria Death Serous effusion in the subarachnoid cav-
ities and ventricles of the brain Xo renal lesion^Puerperal convulsions always
of the same character No reason for classifying them as apoplectic, epileptic,
hysterical, etc. Etiology of puerperal convulsions Suggestions made in 1862
before the New York Academy of Medicine Rosenstein's views published in
1863 Dr. J. Braxton 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. Tyler Smith's theory Treatment, before
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.

"CASE VIII. 1 Maria , aged twenty-six, married, Irish, pri-

mipara, was admitted into the hospital in labor, and sent to the
lying-in-ward, on the evening of January 3d. She had an easy and
rapid labor, and gave birth to a living female child. She gave no
history of previous convulsions, but she had oedema of the feet and
legs, and for some days she had suffered from headache and im-
paired vision. Two hours after delivery, she awoke from sleep,
said she was frightened, and immediately had a convulsion, and,
before eight of the morning of January 4th, she had nine more. In
the intervals, she was in a semi-comatose condition, but could be
roused to swallow. During this time, she had taken, in divided
doses, a half-grain of elaterium, and she had had two enemata, by
means of which the bowels were moved once pretty freely. After

1 Case reported by Frank T. Kinnicut, M. D., house-physician in Belle-
vue Hospital.

98 PUERPERAL DISEASES.

this she lapsed into a completely comatose condition, with loud,
stertorous breathing. Pulse was strong and slow. The hot-air bath
was now tried, and chloroform cautiously administered when her
appearance threatened a convulsion, but between 8 A. M. and 1 p. M.
she had three more convulsions. At 1^ r. M. she was seen by Dr.
Barker, and ordered another half -grain of elaterium, of which she had
already taken a grain. But, while Dr. Barker was still in the ward,
she had another convulsion of so violent and prolonged a character,
that he determined to bleed. The median cephalic vein was opened
and nearly forty ounces of blood were abstracted, and the patient
seemed to be immediately relieved. The pulse, which before had
been strong, full 80 per minute, now became soft and frequent, and
rose to 120. In forty-five minutes it fell to 108. At 3^ P. M., one
hour and three-quarters after the bleeding, the patient was sleeping
very quietly, and the pulse was 96. At 5 P. IT., the pulse was 80.
The patient opened her eyes and swallowed some milk and wine.
Up to this time, since her admission into the hospital, the patient had
passed no water. An ounce and a half was now drawn off by the
catheter. She was ordered thirty grains of citrate of potassa, to
be taken in syrup and water every third hour. She now fell into a
slumber, which lasted until morning, except when she was roused
to take her medicine.

" January 5th, 8 A. jr. Patient passed nearly a quart of water,
which, en examination, was found to be heavily loaded with albu-
men. Fully one-half solidified by heat and nitric acid. Continue the
medicine. In the afternoon, the bowels were freely moved by a
very watery discharge, apparently from the elaterium.

"January Gth. Patient has had no convulsion since she was
bled, passes water freely, which still co'ntains albumen abundantly.
Continue the medicine. To have beef-tea and milk, all she wishes.

" January lO^A. Patient has steadily convalesced without a sin-
gle unpleasant symptom. Says she is perfectly well. Urine still
contains some albumen.

" January 15A. Patient quite well, went to amphitheatre be-
fore the medical class."

Gentlemen, before entering upon a discussion of
the general subject of puerperal convulsions, I wish to
call your attention to a few points of special interest
in this case :

PUEKPERAL CONVULSIONS. 99

(1.) You will observe that this patient had no
more convulsions after she was bled. My reasons for
bleeding were (.) To remove the vascular tension
of the brain, and ward off the danger of secondary cere-
bral lesions. (&.) To take off the pressure on the la-
boring heart, and relieve the congestion of the lungs,
and thus avert the danger from asphyxia. If you had
seen her swollen, mahogany-colored face, and heard her
laborious, stertorous breathing, you would have been
convinced that this was no hypothetical apprehension.
(<?.) To remove from the system urea, an active nar-
cotic poison. Dr. B. W. Richardson says, that experi-
ments have shown that of two animals, each with the
function of one kidney suppressed, one will die if left
alone, while the other will recover, if, when the coma
and convulsion of uraemia appear, there be abstraction
of blood. Now, in this case I had two good reasons for
believing that the patient was suffering from uraemia ;
first, the functions of both kidneys were almost entirely
suppressed, for she had secreted less than an ounce and
a half of urine in eighteen hours; and, secondly, I
learned from the house-physician, who was with her
during labor, that at that time " she hardly lost blood
enough to stain the bed."

It is only in a very few instances of puerperal con-
vulsions, so far as I know, that this excess of urea has
been demonstrated. In one, a patient whom I saw with
my colleague, Professor Sayre, the blood was analyzed
by Professor Doremus, and was found to contain urea
largely in excess, although I have forgotten the exact
proportions. But I remember that the urinous odor was
very strong, as the blood was being evaporated down
for analysis. In this, as well as in another case, the
history of which you will hear, and the autopsic results

100 PUERPERAL DISEASES.

you will see, I am fortunately able to demonstrate the
fact of excess of urea in the blood. Dr. Thomas K.
Cruse, one of the senior assistant house-physicians of
this hospital, has made an analysis of the blood taken
from this patient, and has proved that it contains 1.0
part of urea to every 960 parts of the other constit-
uents. Picard, of Strasbourg, who, I believe, is the
latest authority on this subject, states that the normal
proportion of urea in the blood is 0.16 part per 1,000;
but, in the puerperal state, this proportion is somewhat
increased, that is, it is 0.18 part per 1,000. Thus you
see that the proportion of urea in the blood of this
woman was just about six times greater than the nor-
mal proportion in puerperal women.

(2.) You will please remark how rapidly the func-
tions of the kidneys were restored, after bleeding had
relieved the congestion of these and the other vital
organs. In eighteen hours after venesection, she se-
creted and passed full thirty ounces of urine.

(3.) In twelve days, all evidence of renal disturb-
ance has entirely disappeared. You see that, by apply-
ing heat and nitric acid, we do not now find a trace of
albumen in the urine.

Now, let us contrast this case with another that we
have just had in our wards :

" CASE IX. January 8th. Matilda , age unknown, was

brought to the hospital from Staten Island, where she had been
seized with convulsions. It could not be ascertained how many she
had before admission, nor could any thing be learned of her pre-
vious history. There were some indications that labor had begun,
and she was at once taken to the lying-in ward. Fifteen minutes
after she entered this ward, she had a very severe convulsion.

" A half-grain of elaterium was now given, and chloroform was
employed to ward off the convulsions. Dr. Barker was now sent for,
but, before his arrival, she had two more very severe convulsions.

PUERPERAL CONVULSIONS. 101

Venesection was recommended, and twenty ounces of blood ab-
stracted. For a time, her breathing and general appearance were
considerably better. The catheter was used, and little water was
found in the bladder, but this was very albuminous. One hour after
the bleeding, she had another severe convulsion, after which the
bowels were freely moved. Three hours now passed without a re-
currence of the convulsions, when, at 11^ p. M., they again returned,
and she had three very severe attacks in rapid succession. As labor
did not seem to progress, and the patient was apparently growing
more feeble, the pulse becoming smaller and more rapid, the os was
dilated by the fingers sufficiently to introduce one of Barnes's dila-
tors, after which she was delivered by forceps, at 2^- A. ar., January
9th, of a still-born child.

" January $th. Patient has had no convulsion since the deliv-
ery, but remains very feeble. With difficulty roused to speak or to
swallow. Pulse 120; respiration 20; temperature 101.

"January IQth. Condition much the same, except that the
respiration is more frequent (32 per minute), and the tempera-
ture is 104.5.

"January Hth. Patient died early this morning, fifty hours
after delivery."

Please, now, to examine the kidneys taken from this
poor woman, which will be passed around the amphi-
theatre. You will see that the capsules are loose, and
separate with great ease. The cortical surface has nu-
merous elevations and depressions, and its substance is
softened, and easily breaks down on pressure. The cap-
illaries of the Malpighian tufts and the minute arteries
of the cortical substance contain numerous oil-globules.
In short, by the microscope, it was difficult to find
healthy structure of the cortical substance in any part,
as the kidneys were in an advanced stage of Bright's
disease. The liver was fatty, and adherent to the dia-
phragm, from antecedent inflammation ; spleen normal ;
lungs healthy; heart, slight thickening of the mitral
valves, but in other respects normal. The peritonaeum,
especially in the pelvic region, was, to a considerable

102 PUERPERAL DISEASES.

extent, mottled with fibrinous flakes, and the pelvic
cavity, especially in the anterior and posterior culs-de-
sac, contained a large amount of pus.

You have thus had the history of two cases of puer-
peral convulsions, one of which was associated with
temporary albuminuria, that disappeared rapidly after
delivery, and the other with Bright's disease.

Let me now read to you the history of a third case,
that occurred in this hospital a few years since, from
notes given me by Dr. Sebastian Ainabile, formerly a
house-physician. In this case, puerperal convulsions
terminated fatally, although there was neither Bright's
disease nor even temporary albuminuria :

" CASE X. Tliis patient was brought to the hospital on Sun-
day, September llth, by a policeman, who said that she had passed
the night before in the station-house, and that, early in the morn-
ing, she had a fit, with frothing and bleeding from the mouth. A
police-surgeon was sent for, who arrived about two hours after the
fit. She was then conscious, and he advised that she should be
sent to Bellevue. On admission, she refused to give her name, was
very depressed and taciturn, but, little by little, she gave the fol-
lowing history, which was all that could be learned :

" Age nineteen ; born in Maine, not far from Bangor ; mother
died whe.n "she was a baby ; father living ; has half brothers and
sisters. Came to the city, by boat, Friday morning ; walked the
streets, and tried to get into several hotels, but was refused admis-
sion, and bought some cakes from a stand to eat. In the night, sat
down on some steps, and fell asleep ; was awakened in the morn-
ing by a policeman, who was very rough. Her gloves, veil, shawl,
and money had been stolen while she had been asleep. She does not
recollect what she did on Saturday, or how she went to the police-
station. This was all that could be got from her. Her dress was
draggled, but of good quality; and her manner and language indi-
cated a good education. It was apparent that she was near the end
of pregnancy, but she would answer no questions on this subject, and
seemed much frightened when such inquiries were made. With
difficulty, some of her urine was obtained, and found entirely free
from albumen. She passed her time in weeping or reading, never

PUERPERAL CONVULSIONS. 103

speaking to any one, except very reluctantly answering my ques-
tions. She complained of nothing, and, when asked, always replied
that she was well. On the Tuesday following, September 13th,
while sitting by her bed, she suddenly fell upon the floor in a severe
convulsion. This could not have lasted more than a minute ; for,
on entering the ward, I found her staring wildly around, and she
was soon perfectly conscious. As it could not be ascertained when
the bowels had been moved, I now gave her hydrarg. chlor. mit.,
gr. v, pulv. jalap., 3j, ol. tiglii, gt. j, at 10 P. M. Four hours
after, as no effect had been produced by the medicine, an enema
was ordered, but, before it could be given, she was again seized
with convulsions, which recurred every five or ten minutes, she re-
maining profoundly comatose in the intervals. Before the arrival
of Dr. Barker, who had been sent for, she had fourteen convulsions,
without an interval between any two, longer than ten minutes.
A catheter was now introduced, and twenty ounces of urine were
drawn, which, on examination, was found wholly free from albumen.
The pupils were contracted almost to a point, and did not dilate
when suddenly exposed to the light of a candle. On auscultation,
the uterine souffle and the sounds of the foetal heart could plainly
be heard, although beating over 180 per minute. As the head was
in the pelvic cavity, although not pressing on the perinaeum, and
the cervix was dilated about two and a half inches in diameter and
evidently dilatable, Dr. Barker now introduced the forceps and de-
livered, in -less than five minutes, a living child, weighing eight and
a half pounds. A few moments after, the placenta was found to
have come away, with a considerable, though not an excessive, quan-
titv of clots. The uterus contracted well. For something more than
an hour, the breathing was very loud and stertorous, after which, she
went into apparently a profound sleep, without stertor. At 5 A. ii.,
six hours after delivery, she awoke, and swallowed nearly a cupful of
water. Her pulse, during this time, was generally 140. The seven
succeeding hours, she slept soundly, without stertor, now and then
partially awakening for a moment. At twelve, noon, thirteen hours
after delivery, she awoke to full consciousness, asked several ques-
tions, and talked more than she previously had, since her admission.
She also drank a cup of the hospital beef-soup. The nurse brought
her child to her. She took it, looked at it very fixedly for a mo-
ment or two, and then threw it from her with such violence that it
would have gone upon the floor, had it not been caught, and she
immediately went into a convulsion of great severity. This was

104 PUERPERAL DISEASES.

followed by stertorous coma, in which condition she remained for
three hours, and then died.

" Examination, twenty-five hours after death. Slight laceration
of the fourchette, but none of the muscular structure of the peri-
naeum. Uterus well contracted, but contained three small clots,
neither of which was larger than a Lima-bean. Other pelvic or-
gans healthy. The same was true of the other abdominal and
the thoracic organs. The cerebral vessels were very markedly in-
jected ; and, in the cavity and lateral ventricles, it was estimated
that there were quite two ounces of serum. There were no clots
or ruptured vessels. The structure of the brain seemed perfectly
normal. At the request of Dr. Barker, the kidneys were sub-
mitted for inspection to Professor Alonzo Clark, who pronounced
them slightly congested, but, in other respects, perfectly healthy."

Let me remark here that many writers have sought'
to divide puerperal convulsions into different classes,
based either upon the difference of phenomena sup-
posed to be offered in different cases, or upon differences
in the constitutional condition of the subject in whom
the attack occurs, or upon a theory of the cause of
the convulsions. Thus, one author would make three
classes ; the apoplectic, the epileptic, and the hysterical.
Another would divide them into the ura?mic, the hyper-
semic, the anaBmic, and the hysterical. Another would
only make two classes, the ursemic, and the hysterical.
My friend and colleague, Professor Elliot, followed this
last division, calling those convulsions which were gen-
eral in their character, and attended with loss of con-
sciousness, eclampsia ; and he believed that these were
always associated with renal lesions. But, in his " Ob-
stetric Clinic," he gives one case of hysterical convul-
sions, as he terms them, which terminated fatally, and
the autopsy revealed cerebral but no renal lesions; and
another case, in which there was subsequently hemiple-
gia. In my lectures, a few years ago, I was accustomed
to make a similar classification ; but I am now convinced

PUERPERAL CONVULSIONS. 105

tliat any such division of the forms of puerperal convul-
sions has no clinical basis. I have been for some years
watching this point closely, and I now believe that we
meet with puerperal convulsions precisely identical in
their character, but associated with, or caused by, entire-
ly diverse anatomical lesions. I now give up the term
" hysterical " as applied to any puerperal convulsion ;
because I believe that we meet with convulsions, devel-
oped by emotional causes, unassociated with any ana-
tomical lesion, except so far as the general system is
modified by the condition of pregnancy, precisely like,
in all respects, those convulsions that are due to, or are
associated with, albuminuria or uraemia. I do not think
the most skillful word-painter could have described any
difference between the character of the convulsions in the
three cases, the histories of which you have just heard.
For twenty years past, there has been going on a
most active inquiry as to the etiology of puerperal con-
vulsions, with constant additions to our knowledge of
the subject, and frequent modifications of theory ; but,
even at the present day, science has not settled the
question. The prevailing opinion, with a great major-
ity of writers on this subject, has been, that puerperal
convulsions result, in a veiy large proportion of cases,
from toxaemia, the special poison being ursemic. Many
eminent authorities have gone so far as to assert that,
excluding hysterical convulsions, the cases, not due
to this cause, are exceptional. I take it for granted
that none of you suppose that albumen in the urine,
of itself, is the cause of the convulsions ; but the be-
lief has been that, where this is found, the urea is re-
tained in the blood, and that this substance is, either
directly or by its decomposition, a poison which pro-
duces a most deleterious and profound impression on

106 PUERPERAL DISEASES.

the nervous system. The proposition of Dr. Carl
Braun, of Vienna, that, " eclampsia parturentium is com-
monly the result of ursemic intoxication, arising from
Bright's disease, and produced mostly by carbonate of
ammonia in the blood, and perhaps also extractive mat-
ters of the urine," was for a time very generally ac-
cepted. Now, as to the ammonia part of this theory,
which originated with Dr. Frerichs, of Berlin, the experi-
ments of my colleague, Professor Hammond, published
in the American Journal of Medical Sciences, January,
1861, seem to prove that there is no reason to believe
that urea in the blood does decompose into carbonate
of ammonia, and to demonstrate that the symptoms of
ursemic poisoning are not produced by such a decom-
position. Then, as I think, the other part of the propo-
sition by Dr. Braun should be greatly modified. That
excess of urea in the blood is an active poison, which
exerts its toxsemic effects on the brain and whole ner-
vous system, and causes convulsions, and that puerperal
convulsions are frequently associated with albuminuria,
are now accepted facts.

(1.) But there are many cases of puerperal convul-
sions, having all the characteristic phenomena which
attend this fearful malady, in which there have been no
symptoms indicative of any lesion of the kidney. The
most careful and repeated examinations have failed to
detect albumen or casts in the urine, either before or
after the occurrence of the convulsions. In many cases,
when death has resulted from the convulsions, only the
most trivial lesion of the kidney, as slight congestion,
has been found in the autopsic examination. It is no
longer true, as same have said, that these lesions are not
found because they have not been sought for, for they
have been sought for by competent observers.

PUERPERAL CONVULSIONS. 107

(2.) In a large proportion of marked cases of albu-
minuria during pregnancy, convulsions do not occur.

(3.) In many cases where the most careful and re-
peated examinations of the urine have failed to detect
albumen, and there have been no other signs of albu-
rninuria, convulsions have occurred, and, afterward, the
urine has been found loaded with albumen. It seems to
me, therefore, that there may be some reason for inquir-
ing whether the association of albuminuria and puer-
peral convulsions necessarily proves the relation of
cause and effect, or whether it may not be that the
same profound impression on the nervous system which,
in the pregnant or parturient woman, culminates -in
puerperal convulsions, may not also so modify the func-
tions of the kidneys as to produce albuminuria.

In a discussion on albuminuria, before the New
York Academy of Medicine, in 1862, I emphatically
brought out these three points, as you will find in the
second volume of the Bulletin of the Academy. I dare
say the same ideas had occurred to others, but I know
of no published expression of them until the work of
Rosenstein (" Die Pathologic und Therapie der Meren-
Krankheiten," Berlin, 1863). As this treatise has not
been translated into English, I will give you a con-
densed abstract of the views of the author on the point
that we are now discussing. Rosenstein admits the
frequent congestion of the kidneys as a result of me-
chanical pressure in pregnancy, which is manifested by
the presence of albumen and casts in the urine, and,
often, actual diminution of the urinary secretion. This
congestion, however, he asserts, is not confined to the
kidneys, but extends to the liver, and possibly to the
spleen. At the same time, in a majority of the cases,
the patient is hydrsemic, and exhibits dropsical ten-

108 PUERPERAL DISEASES.

dencies. He also admits the coincidence, in a certain
proportion of cases, of albuminuria with convulsions
during gestation, but, in common with other observ-
ers, he finds, in the large majority of cases, that the
eclampsic attacks occur during or subsequent to par-
turition. The act of parturition and the consequent
disturbances of circulation are thus shown to exert
great influence in developing eclampsia. Moreover, he
says, the attacks usually occur just at the time when
the albuminuria has been occasioned by excessive
local congestion, and at a time when the structural
alterations of the kidneys are not such as to occa-
sion uraemic poisoning. Besides, in those cases where
diffused nephritis really has existed, no convulsions
have taken place. Again, he adds, there are frequent
enough observations of puerperal convulsions without
albuminuria. Now, in view of these facts, and taking
into consideration the great nervous reflex excitability
of pregnant women, especially primiparse, and the ten-
dency therefrom to affections of the nervous system ;
taking into account, also, the condition of the blood dur-
ing pregnancy, and its tendency to transudation ; con-
sidering, moreover, the frequent occurrence, as shown
by autopsies, of cedema and anaemia of the brain, Rosen-
stem says, we are perhaps justified in regarding eclamp-
sic convulsions as a phenomenon attending the altera-
tion of the circulation within the brain. For, under
the influence of a process like parturition, through the
action of the entire muscular system, an enormous press-
ure is exerted upon the aortic circulation, which in the
presence of a dilute serum, and acting upon the finest
arterial vessels, occasions cedema and secondary anae-
mia of the brain, and thus may call forth convulsions.
At any rate, he says, the identification of the eclampsic

PUEKPERAL CONVULSIONS. 109

manifestations with those produced by uraemic intoxi-
cation ought to be maintained only in cases where
there is really considerable suppression of the excretion
of urine, and in which urea or some of its products can
be detected in the blood.

In the discussion before the New York Academy
of Medicine, which I have before referred to, I asked :
" Have we not some reason for inquiring whether the
same profound impression on the spinal system, which,
in the pregnant and puerperal woman, culminates in
puerperal convulsions, may not also so modify the func-
tions of the kidneys, as to result in albuminuria; or, in
other words, instead of regarding the albuminuria as
the cause of the convulsions, have we not some reason
for believing that both the convulsions and the albu-
minuria are the effect of some common cause, the exact
nature of which science has not determined ? "

In 1866, Dr. J. Braxton Hicks, of London, Physi-
cian-Accoucheur to, and Lecturer on Midwifery and
the Diseases of Women at, Guy's Hospital, read a very
able and remarkably suggestive paper on this subject,
before the Obstetrical Society of London. You will
find it in vol. viii. of the Transactions of this Society,
and it is well worthy of your careful study. It is
mainly devoted to the discussion of those cases in
which the signs of albuminuria are not manifested be-
fore the eclampsic attacks, but are very evident after-
ward. Or, to quote his own words, such cases as the
following:

" A woman approaching the full period of preg-
nancy, apparently in perfect health, without albumen
in the urine, is suddenly seized with an epileptiform
attack. After a certain time has elapsed, albumen is
noticed in the urine, at first in small quantities, shortly

110 PUERPERAL DISEASES.

in profusion ; then blood-globules, waxy and epithelial
casts are found in it. At this time, the urine becomes
scanty, of high specific gravity, with very high-colored
crystals of lithic acid in considerable quantity. The
case, which is now one of acute desquamative nephritis,
may terminate by gradual recovery, the albumen slow-
ly disappearing ; or death may ensue from the violent
effects of the original attack, or from the retention of
urea, etc., in the system, in consequence of the acute
mischief in the kidneys. Now, if these cases can be
shown to occur, and if albumen in the urine be an indi-
cation of uraemia, and if those experiments above
quoted be right ; viz., that twenty -four hours at least,
after the kidneys have ceased to act, must elapse before
symptoms of uraemic poisoning can occur then it fol-
lows that the convulsions cannot be owing to uraemia,
at least the result of kidney-disease. If this point be
granted and it seems that, so far as our present knowl-
edge extends, it must be then the only modes of ex-
plaining the occurrence of the acute nephritis are in
one of these three ways : either

" 1. That the convulsions themselves are the cause
of the nephritis.

" 2. That the nephritis and the convulsions are
produced by the same cause ; e. g., some detrimental
ingredient circulating in the blood, irritating both the
cerebro-spinal system and other organs at the same
time.

" 3. That the highly-congested state of the venous
system, as is produced by the spasm of the glottis in
eclampsia, is able to produce the kidney complication."

Since the publication of this paper by Dr. Hicks,
a work has appeared, " On the Nerves of the Uterus,"
by Frankenhauser, of Jena, based on careful dissec-

PUERPEEAL CONVULSIONS.

tions, and illustrated by most beautiful plates, in which
is demonstrated a direct connection between the nerves
of the uterus and the renal ganglia. This discovery,
if it prove true, may be the means of leading to an
explanation of the true pathology of puerperal convul-
sions. Frankenhauser reasons, from his discoveries,
that the theory, that the albuminuria of eclampsic
patients is due to pressure of the distended uterus
upon the large abdominal vessels or the renal vessels,
is highly improbable. He says that, to be sure, many
circumstances seem to favor such a view, as, for exam-
ple, the more frequent occurrence of eclampsia in twin
pregnancies, in primiparse with unyielding abdominal
parietes, in persons *of small stature, etc., but he thinks
also, that the same causes could equally well serve to
excite the renal nerves, and those in connection with
them. He finds another argument in the fact that we
frequently observe that women have no convulsions
who have suffered from albuminuria, both before and
after pregnancy, the direct result of renal degeneration,
in which, therefore, renal congestion really existed. He
therefore considers it questionable whether the access
of albumen, which is observed after puerperal convul-
sions, is the result of congestion, or is due to the excita-
tion of the uterine plexus. He believes that the sudden
occurrence of the eclampsic attack following all exter-
nal sources of irritation (as pressure of the foetal head
upon the cervix, digital examinations, etc.), and from
emotional causes, goes to prove that the nervous sys-
tem, and not the vascular system, is the starting-point
of puerperal convulsions, and that the changes ob-
served in the kidneys of women dying from convul-
sions are too trivial and transitory, to indicate a long-
continued congestion; and further, in confirmation of

112 PUERPERAL DISEASES.

these views, are to be added, the undeniable cases of
convulsions when no albuminuria has existed. All
these facts, in his view, point to the importance of the
connection between the uterine and the renal plexus.
I must add, that the theory of Frankenhauser seems
to have been anticipated, many years before, by Dr.
Tyler Smith, of London, who suggested that the albu-
minuria " may depend upon sympathetic irritation of
the kidneys by the gravid uterus, similar with the irri-
tation of the salivary glands, the mammae, the thyroid,
etc., and not upon mere pressure."

In conclusion, then, I will say that our present
knowledge of the etiology of puerperal convulsions may
thus be concisely stated. Clinica]. observations have
established these facts, that the following conditions
are predisposing causes of convulsions in pregnant,
parturient, and puerperal women; viz., albuminuria,
hydraemia, anaemia, uraemia, and primiparity. Perhaps I
should add, hereditary and atmospheric influence. By
the former term, I simply mean that an excessively
nervous temperament has been inherited. My atten-
tion was first directed to atmospheric influence as a pre-
disposing cause, from the singular experience of one
day in the winter of 1870, in the course of which I saw
the following cases : Early in the morning, a lady,
with Dr. Cheesman, in the eighth month of pregnan-
cy, in violent convulsions associated with albuminuria.
Soon after, with Drs. Sabine, George A. Peters, and Pro-
fessor McLane, a primipara, in uraemic coma, some hours
after delivery. Another, with Dr. Howard Pinkney, a
primipara, in convulsions, and also two cases of convul-
sions in my service in this hospital. On another day of
the same week, I saw, in consultation, three cases of
eclampsia. At a meeting of the Obstetrical Society of

PUERPERAL CONVULSIONS. 113

this city, I mentioned these facts, and asked the experi-
ence of the members on this point. Since then I have
found that atmospheric influence has been alleged as a
predisposing cause, by Andral, Duges, and other French
authors, and by Smellie, Denman, Ramsbotham, Davis,
and Simpson, of the English authors.

Of the exciting causes of puerperal convulsions, I will
briefly say that, in highly-nervous temperaments, and in
the very impressible nervous systems of those suffer-
ing from anaemia, album inuria, or uraemia, any thing
which produces direct or indirect irritation of any part
of the nervous system may bring on convulsions as,
in the pregnant, indigestion, constipation, retention of
urine, excessive distention of the uterus, reflex pains, or
moral shocks. During labor, besides all these causes
which I have just mentioned, every thing which makes
pain severe, whether it be pressure of the head on the
cervix, rigidity of the soft parts, the irritation from
digital examinations, and all varieties of dystocia.
Convulsions occurring after labor are probably due to
those exciting causes which labor has developed, as
the accumulation of urea in the blood during labor,

O 7

cerebral or renal congestions, the sudden changes in the

O / O

circulation following the removal of long-continued
pressure on the great abdominal vessels, exhaustion of
nerve-power, and moral disturbances.

"VVe now pass to the most important part of the
subject, the treatment.

As to prophylactic treatment, I shall refer to what I
have said in regard to the treatment of albuminuria, as
immediately bearing on this point in, probably, a ma-
jority of cases. I cannot go so far as Dr. Tyler Smith,
who, in speaking of albuminuria, remarks : " It has been
said that this disorder cannot be arrested during preg-

114: PUERPERAL DISEASES.

nancy, but I Lave never met with a case that resisted
treatment, unless it had been neglected until the end
of gestation." While my experience will not warrant
me in making so strong an assertion, yet I can truly
affirm that I now rarely encounter puerperal convul-
sions, when the previous detection of albuminuria has
led me to be particularly apprehensive of their occur-
rence. Indeed, I will go farther, and say that, in most
cases, where any of the predisposing causes that I have
mentioned are discovered sufficiently early, they may
])e successfully treated, and convulsions will occur only
in a small percentage. The removal of renal conges-
tion by saline and hydragogue laxatives, which diminish,
by exosmose, the excess of serum ; by mild diuretics and
the free use of mineral drinks, to carry off the cylindric
exudations that obstruct the uriniferous tubes ; the
cure of anremia by the chlorate of potassa, and iron ; a
nutritious diet, and moderate exercise in the open air ;
the relief of local congestions, uterine, renal, and cere-
bral, by judicious venesections, are all prophylactic
measures against puerperal convulsions. If these meas-
ures fail, and the symptoms of threatened convulsions
be imminent, we have another prophylactic resource in
the induction of premature labor. In addition to what
I have said on this point in connection with albuminu-
ria, I shall only add that, in six of my private patients,
I have felt it a duty to adopt this resource. In two of
them, the child was born feeble, but afterward did
well. In the other four, the death of the child -was be-
lieved to be well assured before the means were used to
provoke labor. In two cases, that I saw with Professor
Elliot, which lie alluded to in his " Clinic," we decided
that this measure was necessary, and one of the patients
gave birth to a living child. Every one of these ladies has

PUERPERAL CONVULSIONS. 115

since been pregnant, and given birth to living children,
one or more. In another lady, suffering from albuminu-
ria in an extreme degree, whom I saw several times with
Professor J. "W. McLane, we had decided on bringing
on labor before a convulsion occurred, but one or more
attacks of eclampsia took place before we commenced
the measures for this purpose. The child was evidently
dead before the labor. I am told that this patient has
happily gone through with her second pregnancy, and
given birth to a living child. Now, in these nine pa-
tients, the symptoms were such as to leave the firm
conviction on my mind that death w T ould have resulted
had not premature labor been induced.

During labor, the only prophylactic treatment that
I think it necessary to specify, aside from all those hy-
gienic measures that good sense would naturally sug-
gest, is the use of chloroform and early delivery, as
soon as the condition of the parts will permit.

In a paper on the " Treatment of Puerperal Convul-
sions," read before the New York Academy of Medi-
cine, in 1855, and published in its Transactions, I ex-
pressed the opinion that the use of chloroform would
diminish the fatality from this disease at least fifty per
cent. I think that the united experience of the profes-
sion, in the seventeen years that have elapsed, has fully
verified the prediction.

After labor, when the antecedent symptoms have
been of such a character as to create an apprehension
of convulsions, I should urge the following, as prophy-
lactic measures :

(1.) At the time of delivery, permit the patient
to lose a moderate amount of blood, not enough to
weaken her, but sufficient to restore the equilibrium
of the circulation. The patient actually requires less

116 PUERPERAL DISEASES.

blood than before delivery, when the uterine system
demands an increased supply, and two beings are to be
nourished.

(2.) Watch carefully the renal secretion, and do not
permit the bladder to become distended.

(3.) If the patient is irritable, restless, complains
loudly of little annoyances, and is sleepless, tranquillize
her by a moderate opiate. The propriety of using opium
in any cases of threatened or developed convulsions is
a controverted question, but I shall presently give you
my reasons for believing it often both safe and useful.

Before giving you the plan of treating puerperal
convulsions, which I shall recommend, let me urge
upon you the importance of thoroughly studying this
subject, and fixing in your minds the rules of practice
which you intend to follow, so that, when the occasion
demands, you may act promptly, without doubt or hesi-
tation. This will enable you to preserve a cool, calm,
self-possessed manner, which will dominate over the
alarmed friends in the room, and may react more or
less on the patient herself.

First, ask yourselves what is to be done during the
convulsive attacks. Place a cork or some other sub-
stance between the teeth, so as to prevent the severe
lacerations of the tongue, which sometimes occur. Do

O /

not permit two or three persons to hold the patient
down upon the bed, or forcibly to restrain the convul-
sive movements ; but, nevertheless, she should be pre-
vented from throwing herself off the bed. Keep the
room quiet, cool, and well ventilated. See that nothing
in her dress embarrasses either the circulation or the
respiration. This is all that you can do during the at-
tacks. Now, then, what is to be your treatment after-
ward ?

TREATMENT OF PUERPERAL CONVULSIONS.

(1.) When the attack occurs before labor, if the pulse
be strong and hard, with great fullness of the vascular
system, and the appearance of the face indicate cerebral
congestion, bleed at once. The bleeding is sedative to
nervous irritation ; it removes the tension from the
brain, and protects it from the injury which might
otherwise result from the convulsions ; it relieves con-
gestion of the kidneys and lungs, and takes off the
pressure from the laboring heart ; and it may be that
it supplements the action of the kidneys, and removes
from the blood a portion of its excess of urea. The
quantity of blood to be abstracted must be a question
of judgment, taking away sufficient to accomplish the
objects that I have just specified, but not so much as
to depress the vital powers.

(2.) Then give a brisk purgative. The usefulness
of this medication as a derivative and a means of elimi-
nating the toxic elements which the kidneys have failed
to carry off, may be regarded as settled by the clinical
experience of the profession. Many different articles
are used for this purpose ; but, without stopping to dis-
cuss them, or to assign my reasons for the preference, I
will say that, when, in the intervals between the attacks,
the patient swallows readily, I give twenty grains of
jalap with ten of calomel. But, if she be comatose, I
mix a quarter of a grain of elateriuui with a third
of a teaspoonful of butter, place it upon the back
of the tongue, and it soon slips down. This is to be
repeated every half- hour, until free catharsis takes place.
In this hospital, our experience is, that the elaterium fur-
nished is not very good, and we generally give it in
half-grain doses. Some prefer croton-oil to elaterium.
Stimulating purgative enemas are sometimes very use-
ful in hastening the action of the medicine, but, unless

118 PUERPERAL DISEASES.

the patient be profoundly comatose, there is danger that,
in the administration of the enemata, reflex irritation
will be increased, and a renewal of the convulsions pro-
voked. ' I have more than once seen this result.

(3.) To arrest and prevent the convulsions, admin-
ister chloroform by inhalation. Whatever difference
of opinion there may be as to the comparative safety
of different anaesthetics, I believe that there can be no
question that, to control convulsions, chloroform, for
many reasons, is to be preferred to any other agent.
There are still some men to be found in the profession,
who are fearful of tisinoj chloroform in these cases, and

O '

others who are doubtful as to the amount of good to
be attained by its use ; but I believe that all observers
of large experience as to its effects in these cases, tare
unanimous in their convictions that this agent has done
more than all the other resources known to our art, to
diminish the fatality from puerperal convulsions. The
inhalation should be suspended during the convulsive
attacks, and while there are symptoms of greatly-im-
peded circulation and respiration. But it should be
commenced in full inhalations, whenever symptoms
indicate a return of convulsions; and, if the intervals
between the attacks be very short, it is necessary to
continue the inhalation through the comatose period.
The extent to which the anaesthesia is to be carried
should be proportioned to the violence and frequency
of the convulsions. If the attacks be not severe, and
occur at long intervals, the patient should not be kept
under the constant influence of the chloroform, but
it should be renewed whenever there is the slightest
threatening of a new access. But, if the attacks be very
severe, with very short intervals, a profound anaesthe-
sia should be induced and kept up for a long time.

PUERPERAL CONVULSIONS. 119

I have frequently, tinder these circumstances, kept pa-
tients for five or six hours profoundly under the in-
fluence of the chloroform, and I have no doubt that the
failure of good results from chloroform, which some
have complained of, has often been due to fear of its
use to a sufficient degree to accomplish the end in
view.

(4.) Having overcome the immediate danger from
convulsions, by the means which I have just indicated ;
viz., venesection, a hydragogue cathartic, and the inhala-
tion of chloroform, the next point is to secure an exemp-
tion from the return of the eclampsia, by allaying nervous
irritability. For this purpose, I should say, administer
hypodermically a full dose of morphia, that is, from
ten to twelve drops of a solution of sixteen grains to
the ounce of water. I am well aware that many writers
have taught that the use of opiates is highly dangerous
when convulsions are the result of uraemia. This was
the belief of my colleague, the late Dr. Elliot, and I
believe that this opinion is strongly held by my col-
league in the hospital, Dr. Alonzo Clark. But, having
carefully examined the grounds on which this appre-
hension is based, I am convinced that the alleged dan-

' O

ger of inducing fatal narcotism, when renal lesions exist,
is chimerical in cases of puerperal convulsions. For
eight or ten years past, my teaching and my practice
have been in accordance with the rule that I have just
given. It is my firm belief that the hypodermic ad-
ministration of morphia is the most efficient means
yet known for allaying that irritation of the spinal sys-
tem which culminates in convulsions, and that uraBmia
does not contraindicate the use of this agent. In this
opinion I am happy in being supported by my friend, Dr.
John T. Metcalfe, who combines, to a rare degree, thera-

120 PUERPERAL DISEASES.

peutic knowledge with a therapeutic instinct. I am
not aware that his views on this point have ever been
published, but, in an incidental conversation with him,
a few years since, he expressed, in unqualified terms, his
belief in the usefulness and safety of morphia in ursemic
convulsions. There. is the great advantage, in the treat-
ment of a patient in convulsions, by chloroform and the
hypodermic administration of morphia, that both agents
can be used when the patient is unconscious and in-
capable of the voluntary effort of swallowing. 1

I will remark here, that I had hoped for great re-
sults from the use of chloral-hydrate, under the circum-
stances in which I have advised the hypodermic use of
morphia, but I have been disappointed. The thera-
peutic discovery of Liebreich is one of immense value,
and I should hardly know how to do without it in many
cases in practice, but my clinical experience has led
me to give up its use in puerperal convulsions. I can-
not explain the reason, for the chemists tell us that, by
decomposition, it becomes chloroform in the system.
It certainly does not act therapeutically like chloroform,
except that both agents produce sleep ; but I am con-
vinced, by observation of many cases, that it does not,
like chloroform, allay reflex nervous irritability, and I
am strongly suspicious that it excites it. I shall again
allude to the chloral-hydrate, in discussing puerperal
mania, in which I have found it of great service. But
it has not been so in puerperal convulsions. I ought,
however, to add that several writers have published

1 As corroborating the opinions which I have expressed, I refer with
great pleasure to an excellent and important paper, by Professor A. L.
Loomis, on acnte urcemia, published in the New York Medical Record,
August 1, 1873, Dr. Loomis relies mainly on the hypodermic use of
morphia, and the infusion of digitalis, in the treatment of non-puerperal
uramiic convulsions.

PUERPERAL CONVULSIONS. 121

cases reporting favorable results from tlie use of cliloral
in this malady.

(5.) In a certain proportion of cases, all the means
that I have enumerated are unavailing to arrest the con-
vulsive attacks. In many cases, the effect of the con-
vulsions is to provoke labor; uterine contractions are
excited, and the cervix is found to be dilating. Here,
the duty is plain: nothing should be done to retard
the labor, but every thing, to advance it.

In other cases, the convulsions continue, and per-
haps increase in severity, with persistent dangerous
coma in the intervals, while a vaginal examination
shows that the cervix is undilated, and that the uterus
is making no effort to expel its contents. I think there
can be no doubt that it is the duty of the accoucheur
to bring on labor, under these circumstances, as soon as
possible. The means of accomplishing this result with
safety are now much better understood than they were
a few years ago.

When convulsions occur during labor, you should
first ascertain whether any of the eccentric causes exist,
such as improper food in the stomach, constipation, or
a distended bladder. If there be indigestible food in
the stomach, it should be removed by an emetic of
zinc. If the bowels have been constipated, they should
at once be freely evacuated. The state of the bladder
should be carefully examined, and, if necessary, the
catheter should be used. If there be venous turgescence
of the face and neck, a flushed face, hot skin, and a
strong, full, bounding pulse, venesection should be
promptly resorted to. This is a powerful sedative of
spinal action, and thus it not only is an important
measure to prevent cerebral, but also to cure the spinal
disease. When the disease results from stimulation of

122 PUERPERAL DISEASES.

the spinal system by excess of blood, or from mechani-
cal pressure of blood on that organ, or from counter-
pressure of the distended brain upon the medulla ob-
longata, bloodletting is often alone sufficient to subdue
the disease. It is also equally important to preserve
the brain from injury by the convulsion, as the attack
may cause such turgidity of the vessels of the head as
to result in fatal cerebral congestion, or serous or san-
gineous effusion.

The measure which I consider as next in importance,
is the use of chloroform. It has been supposed by many,
that a tendency to cerebral congestion contraindicates
the use of chloroform. But, on the contrary, sound
reasoning and clinical experience conclusively show,
that a tendency to cerebral congestion in parturition is
a decided indication for the use of chloroform, as, by its
use, the spasmodic contractions of all the voluntary
muscles, which contribute so essentially to force the
blood to the head, are overcome. The contraction of
the platysma myoides, the pressure of which prevents
the return of the blood from, the head, is also over-
come ; and lastly, the tendency to spasm of the glottis,
which impedes respiration and prevents the passage of
venous blood into the lungs, is averted. After inhala-
tion of chloroform, I have repeatedly seen the swollen,
flushed face become calm and tranquil, the bounding,
frequent pulse become soft and natural, and the patient,
who was before restless and irritable, tossing about
from one side of the bed to the other, now lying in
apparent sweet repose, while the uterine contractions
were still going on with the utmost regularity. Dur-
ing labor, I never resort to the hypodermic use of mor-
phia, but rely exclusively on the chloroform to allay
the nervous irritation.

PUERPERAL CONVULSIONS. 123

I will add a word of caution in relation to the
measures to be adopted to hasten delivery. In such a
fearful complication of labor as puerperal convulsions,
the feeling that, the sooner the labor is completed, the
sooner the danger to the mother and child will be over,
may sometimes prompt to injudicious measures to ter-
minate the labor. Indeed, w r e were formerly taught
that it was our duty, in all cases of convulsions, to
deliver by any means in our power as speedily as pos-
sible, and I am convinced that I have, in times past,
erred in some cases, from my anxiety to accomplish
this result. In the first case of convulsions, the histoiy
of which was given you in a former lecture, I was
strongly inclined to apply the forceps, long before the
child was born, and I visited the patient several times
for this purpose. But you will observe that, by the use
of chloroform and other means, we had two long inter-
vals, one of which was nearly eight hours, without con-
vulsions, and I feared that the irritation from forced
delivery would be greater than the irritation from un-
aided labor. The child was born alive. I think the
principle which should govern us, in such cases, is this :
Whenever delivery by art can be effected by less irri-
tation than would be produced by the continuance of
the child in the parturient canal, it should be re-
sorted to.

The treatment of puerperal convulsions after labor
should be modified by the different condition in which
the patient now is. There are no longer the reflex irri-
tations of gestation and parturition, but there is, fre-
quently, a depressed condition of the vital powers, re-
sulting from exhaustion. Hence the necessity of cau-
tion in the use of chloroform to control or prevent the
convulsions after labor.

124 PUERPERAL DISEASES.

The convulsions occurring after labor may be due
to causes which existed during gestation and parturi-
tion, which were kept in abeyance, either by prophy-
lactic treatment or by the use of chloroform during
labor ; or to causes developed by labor, as a temporary
suspension of the renal functions, and the accumulation
of urea in the blood ; or the sudden changes in the cir-
culation following the removal of long-continued press-
ure on the great abdominal vessels ; or from renal or
cerebral congestions ; or from anaemia of the brain ; or
from emotional causes. A careful study of the antece-
dents of the attack and of the actual condition of the
patient will generally enable you to form an opinion as
to which one or more of these causes have developed
the attack, and the treatment can then be judiciously
adapted to their removal. If the vascular system be
labored and excited, if the pulse be strong and hard,
and especially if the woman have lost much less than
the usual quantity of blood at the time of delivery,
there should be no hesitation in bleeding. The pa-
tient you have just seen in this room had fourteen
convulsions, the first occurring two hours after deliv-
ery, but she had none after venesection.

If the renal functions be suspended, you must act
vicariously through the bowels, by giving elaterium,
the quickest and most efficient of the hydragogues, fol-
lowing the action of this medicine by such diuretics as
the citrate or the acetate of potassa. Then tranquillize
the nervous system by morphia hypodermically.

When the patient is anaemic and exhausted, the hy-
dragogues and the diuretics may still be necessary,
but I should not use chloroform. In this condition,
the morphia may be freely used, keeping the patient
well under its influence.

PUERPERAL CONVULSIONS. 125

In conclusion, I must call your attention to the
rapid improvement which has been made within a few
years past in the successful treatment of this fearful
malady. Merriman says that Hunter, Lowder, and
other teachers, were accustomed to state that one-half
the patients attacked with this disease died. The sta-
tistics of all the published cases which I could collect
in 1855 showed that 32 per cent, of all occurring before
and during labor, and 22 per cent, of those after de-
livery, ended fatally. Braun, of Vienna, reports 12
deaths in 36 cases. From a very able article on
" Eclampsie," in the " Nouveau Dictionnaire de Mede-
cine," by M. Emile Bailly, I learn that Professor Pajot,
of Paris, observed 12 fatal cases in 26 at the Hopital
Clinique, in the service of Baron Dubois, and M.
Bailly, while chef de cliniqiie in the same service,
noted 6 deaths in 15 eclampsic cases, and in this
article he gives a total of 119 cases, from different
sources, with 51 deaths ; that is, a mortality of 42.85
per cent., or nearly 1 in 2.33. Now, in these cases, I
am quite sure that chloroform was very rarely used,
and, indeed, I have no evidence that it was used in any
case. In the 63 cases at the Dublin Lying-in Hospital,
from 1847 to 1854, reported by Johnston and Sinclair,
there were 13 deaths, that is, 20 per cent. But these
cases occurred in the early days of chloroform, and it
must also be mentioned that 44 of the 63 cases were
unmarried primiparae. In a very excellent practical
article on the " Treatment of Puerperal Convulsions/'
by Dr. J. Hall Davis, of London, published in volume
xi. of the " Obstetrical Transactions," it is stated that
" in the Royal Maternity Charity of London, in which
the patients are married women, and the deliveries con-
ducted at their own homes, the Eastern District, as re-

126 PUERPERAL DISEASES.

ported by Dr. Ramsbothani, 1820-'50, yielded 43 cases
of convulsions, with 3 deaths ; that is, a mortality of
1 in 14.3, or 7 per cent. In the Western District, of
which Dr. Davis had charge, the deaths from convul-
sions were 1 in 11, or about 9 per cent. Since 1855,
I have had 7 cases in my own private practice, and I
have seen 58 others in consultation-practice, not includ-
ing those which have been in this hospital ; and, in
these 65 cases, there have been 9 deaths, or a little
over 14 per cent. 1 I fully believe, with Dr. Davis,
" that this mortality will be still further reduced, as
that valuable agent chloroform comes more to be em-
ployed in suitable cases for its administration, and
other indications are fully recognized."

1 Since this lecture was prepared for the press, I have seen seven cases
of puerperal convulsions, six of which were in consultation, and all of them
recovered.

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.

GENTLEMEN : We conie now to the second period of
puerperal convalescence, during which the function of
lactation should be fully developed. It is scarcely
necessary for me to tell you that the breasts and nip-
ples are the organs directly connected with this func-
tion, and that the preparation for it commences at an
early period of pregnancy. During the second and
third months, the nipple swells, and becomes more erec-
tile, sensitive, and projecting, and often of a deeper
color. Then the skin around the nipple is gradually
discolored, varying in depth of shade, intensity of dis-
coloration, and extent of surface, and these changes
increase with the progress of gestation. In some
women, almost as soon as conception has taken place,
the breasts become tender and swollen, and this en-
largement is accompanied with prickling sensations, or
even positive pains. This swelling sometimes dimin-
ishes during the fourth or fifth month, reappearing,
larger than before, near the end of gestation. You
should also be aware of the fact, that there is a liabil-

128 PUERPERAL DISEASES.

ity to two variations from the normal modifications which
occur in the breast during pregnancy : First, the func-
tional activity is so exaggerated in a few individuals
as to produce fever, analogous to what is called the
milk-fever after confinement ; and this may even be car-
ried to the extent of producing inflammatory engorge-
ment, terminating in abscess. I have occasionally vis-
ited professionally one lady, who suffers more from this
cause, in each of her pregnancies, than from every thing
else connected with pregnancy and parturition. After
her confinement, she has no difficulty in lactation. Sec-
ond, in some, the breasts at first enlarge, but after-
ward the tumefaction subsides, and they remain flaccid
and soft until after delivery. This is not a good sign,
for, according to Donne, women in whom this condition
of breasts occurs, prove very poor nurses, on account
both of the bad quality and small quantity of their
milk ; and, in my own experience, I have several times
verified the correctness of his assertion. You may
remember that, in my lecture on Abortion, I mentioned
the decrease in size, and flaccidity of the breasts, as one
of the signs of the death of the ovum ; but please bear
in mind, that this is not a pathognomonic sign of this
event, but that it is one of the signs in conjunction
with the others that I then enumerated.

The secretion of milk frequently commences as early
as the fifth month of pregnancy, and some women are
quite annoyed by the running out of the milk in the
latter months of gestation.

After delivery, the breasts yield, on suction, a thin
watery fluid, of a yellowish color and sweetish taste,
which has received the name of colostrum, and is admi-
rably adapted to form the first nourishment of the in-
faut, as it seems to be slightly laxative, and well fitted

MILK-FEVER. 129

to unload the bowels of its viscid, green contents, called
meconium. The full development of the function of
lactation is not ordinarily attained until forty-eight or
seventy hours after delivery, and in some a still longer
period is required for this end. In connection with
this development, we sometimes meet with a combina-
tion of symptoms, which, in their aggregate, have been
designated as milk-fever.

MiUk-Fever. It was formerly supposed that milk-
fever generally accompanied the secretion of milk ; but
at the present day, from the great improvement in the
hygienic management of those recently confined, espe-
cially in securing a period of absolute rest and sleep
after delivery, in giving good nourishment, and in ap-
plying the child to the breast after the woman has re-
covered from the exhaustion following labor, milk-fever
is an exceptional incident of the puerperal state. I give
you the following proof of the correctness of this asser-
tion : In 1867, I had blank forms printed, to be filled
up by the house-physician, and kept at the head of the
bed of each patient, so that, in my visits, by a glance, I
could see what the condition of the patient had been in
each twenty-four hours. If any puerperal disease oc-
curs, the pulse, respiration, and temperature, were
noted, morning and evening, and, in severe cases,
hourly. I here show you a specimen of one report as
it is filled up. (See following page.)

Now, I have here fifty-two of these reports for the
month of November, signed by Dr. P. R. Cortelyou,
-house-physician, and only four of these note any symp-
toms, either of increased frequency of the pulse or a
rise in the temperature, indicating milk-fever. I have
forty-eight reports, signed by Dr. "W. H. Johnston, the
house-physician to the lying-in wards for the month of

130

SPECIMEN OF HOSPITAL BED-CARD.

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MILK-FEVER. 131

December, and four of these cases, also, exhibited mod-
erate symptoms of febrile disturbance, arising from the
development of lactation. I must remark here that,
during both of these months, there was a strong ten-
dency to septicaemia and puerperal fever from en-
demic causes in the hospital, and all of our puerperal
patients, for the first week after confinement, exhibited
a hio-h thermometric range, averaonns; from 99 to 100

o o / o o

Fahr.

I should say that the prophylactic measures for the
prevention of milk-fever are the following :

(1.) Secure to your patient, by every possible means,
some hours of sound and refreshing sleep, immediately
after delivery. During labor, the vital forces have been
stimulated to their maximum of intensity, in order to
accomplish the expulsion of the child. A period of com-
plete repose is absolutely essential to prevent more or
less violent reaction, which is naturally increased by the
development of the new function of lactation.

(2.) Give her such food as will be abundantly nu-
tritious, without overtaxing the digestive organs.

(3.) Apply the child to the breast as soon as the
patient has recovered, by rest and sleep, from the ex-
haustion following labor. Before the breasts are dis-
tended by the secretion of milk, the nipple can be more
readily seized and drawn out, the flow through the lac-
teal tubes is more easily secured, the earlier secretion
of milk is excited, and, being drawn as fast as it is
secreted, the breasts do not ordinarily become over-
distended, and the nipple is permanently elongated.
The only exception I should make to this rule, is
where the woman manifests a strong tendency to sore
nipples, or where she has suffered from this after pre-
vious confinements. In such cases, I think the child

132 PUERPERAL DISEASES.

should be withheld until after the secretion of the rnilk
and an easy flow through the ducts has been established
by gentle rubbing of the breasts with warm sweet-oil ;
for fruitless efforts of the child to draw the breasts may
lead to excoriation. Some writers direct that the child
should be applied as soon as possible after the delivery
of the after-birth, and that the accoucheur should never
leave until this has been done ; the argument for this
rule being, that by this means, and by this means alone,
the patient is secured from the danger of post-partum
hemorrhage. But, with all due deference to the opin-
ion of others, it seems to me that the cases where this
rule should be followed are exceptional. In those cases
in which the vital forces have not been exhausted by
the labor, we have other methods of securing, by reflex
action, the permanent contraction of the uterus, and in
those cases in which the hemorrhage has been great, and
nerve-power is worn out, the fatigue and excitement in-
duced by the effort to make the infant nurse quite coun-
terbalance the advantages that might result.

In some women, the secretion of milk is inevitably
attended by more or less febrile reaction, which the
most watchful care will not avert. The symptoms of
milk-fever may be tersely described as follows : head-
ache, a flushed face, slightly-furred tongue, thirst and
loss of appetite, heat and dryness of the skin, quick
pulse, painful and distended breasts, sometimes to such
a degree as to embarrass and render painful the re-
spiratory movements. The rise in temperature, as indi-
cated by the thermometer, is ordinarily about one de-
gree, never, from this cause alone, in any case that I
have seen, more than a degree and a half.

By judicious treatment, the symptoms of milk-fever
are usually overcome in twenty-four or thirty-six hours.

TKEATMENT OF MILK-FEVEE. 133

Perhaps you will find tlie following plan as good as
any:

(1.) If the bowels have not been moved freely, give
a saline laxative.

(2.) Subdue vascular excitement, and promote dia-
phoresis. For this purpose, I have found a combination
like the following very effective :

Tfc. Aq. aurantii flor., ij.
Spts. ether, nit.,

Syr. simp., aa j.

Antimonii et potass, tart., gr. ij.

Tine, aconit. rad., gtts. xx.
M. S. A teaspoonful in a wine-glass of sugar and water every
second hour.

(3.) Direct the nurse to gently but thoroughly rub
the breasts, from the circumference toward the nipple,
with warm sweet-oil, at least every two hours, until
the painful distention nas subsided. Of course, you
will not neglect to have the breasts often drawn, either
by a child or a breast-pump, but take care, in doing this,
not to permit the nipples or breasts to be irritated.

(4.) Allay pain and nervous irritability, and secure
sleep at night, by a diaphoretic anodyne. You may
give eight or ten grains of Dover's powder for this pur-
pose, but I am generally better pleased with the effects-
of the same dose of Tully's powder.

Lactation may be prevented or seriously interfered
with by a variety of conditions, of which you should
be aware. It sometimes occurs that a woman may have
large and handsomely-formed breasts, but there is ab-
solutely no secretion of milk. The mammae seem to be
made up entirely of adipose tissue, lacking the proper
glandular development. After judicious measures have
been tried, for a sufficient length of time to demonstrate

134 PUERPERAL DISEASES.

the impossibility of securing the lacteal secretion, all at-
tempts should be abandoned, as inflammatory action
may be excited, which might terminate in mammary
abscess. Again, in other cases, the secretion is abun-
dant enough, but it is not retained. It runs out as fast

O /

as it is formed, to the great annoyance of the mother,
and the serious deprivation of the infant. Very often
this running out of the milk lasts for a short time

and then gradually ceases ; but, when it takes place
to the extent of depriving the child of its requisite
nourishment, positive treatment is required to arrest
this untimely flow. Astringents applied to the nip-
ples have been recommended for this purpose, but
I have never seen much good result from such ap-
plications. The only eifective means to accomplish
this is compression of the whole breast, exclusive of
the nipple, by strapping it with adhesive plaster for
two or three days. The compression should be mod-
erate in degree and equably applied over the whole
breast, in such a way as to keep it up, and an inci-
dental benefit from this measure is that it tends to
preserve the form of the breasts in their virgin beauty,
a result which most women bear with exemplary for-
titude.

Depressed Nipples. The absence of sufficient promi-
nence for the child to seize hold of is sometimes a
serious obstacle to nursing. But, by drawing out the
nipples with the breast-pump, and the early and fre-
quent application of the child to the breasts before
they are distended by the secretion, and by wearing
constantly, when the child is not nursing, the breast-
shells, as they are called, this difficulty is usually over-
come.

Among the most troublesome, painful, and intract-

SOEE NIPPLES. 135

able of the conditions which interrupt normal lactation,
should be mentioned the following :

Sore Nipples. This term includes a variety of
pathological conditions, as erosions and excoriations, in-
flammation and ulceration, cracks or fissures at the base
of the nipple, and eczema, each of which requires a dif-
ferent treatment. From the vague directions found
in most of the obstetric text-books in regard to their
management, I suppose that many young practitioners
have found these among the most perplexing and un-
satisfactory of all the minor pathological affections
which they are called upon to treat in the puerperal
woman. You will find in your standard authors a great
variety of remedies mentioned as useful local applica-
tions in such cases ; but, when called upon to treat
them, there is such a lack of every thing like specific
and definite direction as to the choice of these remedies
in any given case, that, if your experience should be any
thing like inine, it will seem to you as if you were com-
pelled to grope in the dark. Without stopping to dis-
cuss the value of all the different agents proposed as
useful in these cases, I shall only detain you by a con-
cise statement of what niy experience has led me to
believe is the best method of treatment in each special
condition.

Erosion or, when it is more extensive, called ex-
coriation of the nipple is a superficial wound of the
skin, in which the derm is laid bare by the removal of
the epidermis by nursing. Sometimes it produces little
vesicles, one or more, on the apex or sides of the nip-
ple, which are broken by sucking, scabs form, which are
again and again pulled off, and we have what the nurses
call, chapped nipples. From this, results entire destruc-
tion of the derm, and we then have ulceration of the

136 PUERPERAL DISEASES.

nipple. The surface is then of a bright-red color,
granulated, frequently swollen, and grooved in fissures.
When such a condition exists, you can readily under-
stand that the act of nursing produces intolerable suf-
fering, to such a degree that patients have often told
me that the pains of labor could be more easily en-
dured. I have sometimes seen half of the nipple bev-
eled off by this ulcerative process. But, if you see the
case sufficiently early and treat it properly, and the
nurse and patient scrupulously follow your directions,
the ulcerative process may always be avoided. If the
nipple be very sensitive and tender, I find the best ap-
plication, for preventing erosion and excoriation, is the
nitrate of lead, as recommended by Professor Wilson,
of Glasgow. I am not in the habit of using it in this
hospital, because I fear the nurses and patients may be
negligent in washing off the lead, before applying the
child. But, in private practice, I very frequently direct
this application, and have obtained more satisfactory
results, than from any other. The formula is :

I. Plumbi nitrut., grs. x.-xx.

Glycerine, 3 j.

After nursing, the nipple should be carefully wiped with
a piece of soft linen, and the solution applied freely. It
should be carefully washed off before the child is again
put to the breast, and reapplied after each nursing. In
the early stage of erosion and jgxcoriation, direct that as
soon as the child leaves the nipple, it should be very
carefully wiped dry with a soft piece of linen, and then
painted over, by means of a camel's-hair brush, with
the compound tincture of benzoin. Brush it over
three or four times, allowing an interval of a minute or

/ o

two for each application to dry. This forms a kind of

LACTATION. 137

artificial cuticle, which should be renewed each time
that the child nurses, and, if it be possible to make the
child nurse through it, direct that a nipple-shield should
always be used. Very good ones are now kept by our
apothecaries generally, but, in selecting one, be careful
that its base is sufficiently large and elastic, so as not
to strangulate the nipple. The first application of the
benzoine produces a little smarting and burning pain
for a moment or two, but its renewal is not usually
painful. If the ulcerative process have commenced, stop
nursing from that nipple. There is no other way ; and
the more promptly you decide to do this, the more
speedily will the nipple be cured, and very frequently
it is not necessaiy to suspend the nursing more than
twenty-four or thirty-six-hours. Empty the breasts by
gentle rubbing only. This can only be done by tact
and perseverance, although it sometimes requires ten
minutes to get the first few drops. Then paint over
the ulcerated surface, twice a day, with a solution of
nitrate of silver, gr. x to 5j of distilled water, and
keep the surface covered with carbonate of magnesia.
or what I think is still better, calomel.

Fissure, or crack, at the base of the nipple, occa-
sions intense suffering ; often I have thought quite as
severe as the form of sore nipple that I have just de-
scribed. It sometimes is so small that it can only be
seen in a good light by bending the nipple over to
the opposite side. To cure this, pencil the bottom of
the fissure with a very fine point of the solid stick of
nitrate of silver, and then cover it with collodion. If
the fissure be not associated with the form of sore nip-
ple that I have before described, or with inflammation
of the nipple that I am about to speak of, it is cured
speedily by these means.

138 PUERPERAL DISEASES.

Inflammation of tjie nipple is sometimes a cause,
and in other cases a consequence, of the preceding con-
ditions, and the inflammation frequently extends to the
areola. It is not an unfrequent cause of one form of
mammary abscess. The nipple is conical, red, swol-
len, and excessively painful. Apply a soft bread-and-
milk poultice for a few hours, and then keep it cov-
ered with one or two thicknesses of linen, wet with a
solution of lead and opium :

IJ Aq. rosa?, 3 iij ss.

Liq. plumbi diacet. dil., ss.

Ext. opii aq., 3 j.
M. Ft. lotion.

After the inflammation is so far subdued that nurs-
ning can be borne without much pain, the nipple
should be very carefully washed before the child is
applied, and, after nursing, the following lotion may
be used :

I. Aq. rosre,

Glycerine, aa 3 ij.

Acidi tannic., 3 ij.

M. Ft. lotion.

I have described each of the above forms of sore
nipples as distinct affections, but you should not for-
get that either of the two, or the three forms together,
may be associated, when the treatment must be modi-
fied or combined according to the special indications.

Eczema of the nipple is a rare, but very trouble-
some affection, which is sometimes met with in nursing-

' O

women. The cases that I have seen have all been of
some weeks' or months' duration before they have come
under my observation. I have used with great bene-
fit an ointment which I heard Velpeau prescribe many
years ago for a case of this kind at La Charite, Paris :

LACTATION. 139

3 Ung. aq. rosee, | j.

Magnesias carb., 3ij.

Hydrarg. clilor. mit., 3 j.

M. You should direct the apothecary to rub it up very thor-
oughly, or it will be lumpy.

But, undoubtedly, the best advice which I can give
you on this affection is a quotation from a letter which
I received from Dr. Tilbury Fox, of London, whose
authority on affections of this class will be accepted
by all.

The directions of Dr. Fox are as follows :
. "1. Great cleanliness, and care in washing away
any remnants of milk after each time that the child is
put to the breast ; and, if the nipple be tender and ex-
coriated, use

" 2. A little liquor plumbi and calamine powder as
follows :

3 . Liq. plurnbi, 3 j ss.

Pulv. calaminje prasp., . 3 j ss.

Glycerine, 3 j.

Adeps, ad. j. M.

" 0. I cover over the nipple with a lead nipple-shield.
This excludes the air, keeps the part from being chafed,
and I think the lead does good after the part has be-
come less red and sore. I often use a little glyceral
tannin painted on night and morning.

" The above application can always be removed
with a little cold cream and a little warm water, spong-
ing before the child goes to the breast."

LECTURE IX.

MASTITIS A1STD MAMMARY ABSCESS.

Mastitis more liable to occur during the early weeks of lactation Literature of the
subject Causes of mastitis Anatomical seat 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.

GENTLEMEN : I call your attention to-day to a class
of affections, the importance of which can hardly be
exaggerated. Inflammation of the breasts and mam-
mary abscess are more liable to be developed during
the first four weeks after confinement than at any other
period, but they may occur at any time during lacta-
tion or gestation. They, sometimes, although much
more rarely, are met with, entirely unconnected with
either of these states, as I have seen, in the young girl,
and even in the new-born infant of both sexes, and this,
too, where I had no reason to believe that the breasts
had been maltreated by an ignorant or prejudiced
nurse, from .the absurd belief that the milk in the
breasts of the infant must be squeezed out. When in-
flammation of the breasts and mammary abscess occur
during the puerperal state, it is always a deplorable
and, sometimes, a very grave and dangerous complica-
tion, as, not unfrequently, there is a succession of ab-

MASTITIS AND MAMMARY ABSCESS.

scesses, which not only interrupts, but may permanently
destroy the functions of the organ ; the spirits of the
patient are broken, the strength of mind shaken, and
the general system is exhausted and, for a time, seri-
ously impaired. You should also know the fact that
such cases sometimes terminate fatally, even when un-
der the treatment of the first talent and those of the
largest experience in the profession, as for example:
Velpeau gives a resume of two hundred cases which
occurred in his service, three of which died, one hundred
and thirty-nine were cured, in twenty-eight, the cure was
incomplete, and the results in the remainder of the cases
were unknown. The reputation of the medical attend-
ant, under such circumstances, is also seriously jeopar-
dized, as the popular belief is, that such a train of con-
sequences must be due either to neglect or mismanage-
ment on the part of the monthly nurse or the doctor.
And we see the influence of such a belief on the profes-
sion in the statements which now and then appear in
the medical press, that inflammation may be arrested
and abscess prevented by rubbing the breasts, or by the
use of belladonna, or by some other special local treat-
ment. Now, all such statements are worse than nonsense ;
for they are sure to mislead and grievously disappoint
those who place any reliance upon them. Whenever
you meet with such statements, you may be sure that
they emanate from those of little clinical experience,
who have deduced general principles from a very lim-
ited number of observations. The special literature on
-this subject is unusually rich, as, in addition to all you
find in your obstetrical and surgical text-books, Sir
Astley Cooper, the brilliant English surgeon, has writ-
ten a treatise on the diseases of the breasts, which will
long be a classical authority. Velpeau, who held a

142 PUERPERAL DISEASES.

corresponding rank among the surgeons of France, pub-
lished, a few years since, a volume of more than seven
hundred pages on this subject, which ought before this
to have received an English translation. A very sug-
gestive paper on Mammitis, with an analysis of seventy-
two cases, by Mr. T. W. Nunn, Surgeon to the Middle-
sex Hospital, was read before the Obstetrical Society
of London, and published in its Transactions.

Important contributions on this subject may be
found scattered through the medical periodicals of this
country, and of Europe. I may particularly mention
some articles which have appeared in our own journals;
as, in the New York Journal of Medicine, one by Dr.
Conant Foster, formerly physician to this hospital ; a
report of fourteen cases, by Dr. John G. Johnson, for-
merly house-surgeon to this hospital ; and, in the Ameri-
can Medical Monthly, a valuable essay, by my friend
Professor Thomas. I give you the principal literature
of the subject, because, if any of you should have a per-
plexing and tedious case of this kind, as may very likely
happen to you soon after commencing practice, if you
feel the right kind of interest in your cases, and are ani-
mated by a true medical spirit, you will be anxious to
search out all that is known on the subject. I fear
also that you will find that the appropriate treatment
adapted to each special indication, and to each special
case, is still left somewhat vague and uncertain. In a
clinical lecture, you can only anticipate a discussion of
the pathology and therapeutics of the subject, and, from
the opportunities that I have had to study it practical-
ly, both in hospital and private practice, I shall aim to
give you, not a recapitulation of w T hat you can read
better in the authorities I have mentioned, but to sup-
ply, however imperfectly, a want of definite principle

MASTITIS AND MAMMARY ABSCESS. 143

and rule for practice, which I am sure has often been
felt.

Causes of Mastitis. Lactation is by far the most
frequent of the predisposing causes. Thus, of Mr. Nunn's
72 cases, 58 occurred during lactation, 7, during preg-
nancy, and 7, in women neither pregnant nor in lacta-
tion. Of the 58 cases during lactation, 57 per cent, oc-
curred during the first two months ; during the subse-
quent seven months, only 14 per cent. ; but after the
ninth month, 29 per cent. You thus see that over-lac-
tation is also a predisposing cause. Epidemic influence
should also be mentioned as a predisposing cause, just
as some years we see an epidemic tendency to boils and
carbuncles. This was particularly manifest in the fall
and winter of 1859-'60, in this city; and, as I learn
from the statements of physicians, it was equally so in
other parts of the State, and in New England. When
I came on duty in this hospital, in October, 1859, there
were 14 cases of mammary abscess in the wards. Dur-
ing my service, there were 16 additional cases, while
three-fourths of all confined here exhibited more or less
tendency to inflammation of the breasts. During my
service this winter, I have had the opportunity of show-
ing you but two cases, and those I found here when my
service began. I am not aware that any author has
mentioned epidemic influence as a predisposing cause,
but you see, from the facts that I have just mentioned,
that it really is so. If you look at Velpeau's cases, you
will see that he had 24, in 1837, and but 4, in 1839.
The principal exciting causes are : exposure to cold ; in-
flammation of the nipple, extending to the breasts ; re-
pression of the secretion of milk at an early period ; ob-
structed lacteal ducts ; bruises, and other external injur-
ies ; and emotional causes, as mental disturbances, fright,

144 PUERPERAL DISEASES.

etc. The influence of the latter, although frequently
overlooked, has "been particularly noticed by many au-
thors, and is another illustration of the great importance
to the physician, of a thorough appreciation of what is
called the morale of his patients.

Anatomical Seat. Inflammation of the breasts may
occur in three situations : first, in the subcutaneous
areolar tissue ; second, in the gland itself; and third, in
the areolar tissue between the gland and the thoracic
walls ; and, as this inflammation frequently some au-
thors say generally goes on to suppuration, we have
three kinds of mammary abscess ; viz., the subcutaneous,
the glandular, and the subglandular. Different terms
have been used by authors to describe these forms of
abscess, but those I have used seem to me the most
simple and significant. The inflammation is described
by Sir Astley Cooper and no one since has given
a better description as adhesive in the first stage,
suppurative in the second, and ulcerative in the
third.

The same laws g-overn inflammation of these tis-

sues of the breasts, as govern inflammation of the
same tissues in other parts of the system, modified only
by certain peculiarities of anatomical arrangement of
structure. In the first stage, these laws are precisely
the same. In the suppurative stage, they are the same,
when the inflammation is confined to the subcutaneous
areolar tissue : it is a simple phlegmonous inflammation,
differing in no way from abscesses of this kind in other
situations, except that it is always distinctly circum-
scribed. The third stage of this form of mammary ab-
scess is also like the same stage in other phlegmonous
abscesses, as it opens by ulcerating the tissues from the
interior to the exterior; unless, for the purpose of

MASTITIS AND MAMMARY ABSCESS. 143

curing it more speedily, an artificial opening be made
by means of the lancet or bistoury.

In the glandular variety, one lobule after another
may become inflamed, so that successive abscesses form
in different parts of the gland. In the subglandular
variety, the pus usually at first finds an exit at the
lower and outer side of the gland, but generally it also
appears later at other points of the circumference. The
apertures through which the pus discharges itself fre-
quently degenerate into fistulous canals, which are often
very difficult to cure. Here we have some of the modi-
fications due to peculiarity of arrangement of the ana-
tomical structure. If you look over the published re-
ports of the cases by the authors that I have men-
tioned, you will find very many in which the succes-
sion of abscesses and number of apertures for the dis-
charge of pus, count up to ten, twenty, thirty, and,
in one of Velpeau's cases, even to forty-five in the same
breast. You can readily conceive how such a train of
events will wear out the system, and break down both
body and mind. But these are not all of the condi-
tions which may contribute to such a result. The
ulcerative process is generally gradual and of a normal
kind, that is, preceded by a fibrinous exudation, which
protects the adjacent tissues ; but not unfrequently in
the glandular, and especially the subglandular forms,
there is a destructive disorganization of texture, result-
ing in more or less extensive sloughs. The percentage
of such cases is by no means small. The extent of the
slough is of course proportionate to the destruction of
tissue. In one of the cases reported by Dr. Foster, the
slouch is described as beino; as lar^e as a hen's-e^o-

o o o oo

But this is not all ; the destructive ulcerative process
may involve the blood-vessels of the part where the ab-

146 PUERPERAL DISEASES.

scess is situated, and dangerous and even fatal hem-
orrhages may result. Professor Miller, of Edinburgh,
refers to thirteen such cases, published in different
medical periodicals, and he asserts that there are others.
The continued destructive ulcerative process will some-
times go on, in spite of the most judicious and best-
directed local and constitutional measures ; and it has
happened that the medical attendant has been accused
of causing the recurrent hemorrhages which occur in

o o

these cases, by wounding an artery when opening the
abscess.

Diagnosis. While it is of great importance, with
reference to the prognosis and treatment, that an accu-
rate diagnosis should be made as to the form of mas-

titis that we have to encounter, it must not be forgot-
ten that any two or three varieties may be met with,
or one variety may be primitive, and one or both of
the others may be secondary.

Subcutaneous mastitis presents only the ordinary
signs of phlegmonous inflammation of the areolar tissue,
which it is unnecessary for me to describe; for I must
assume, in a clinical lecture, that you are familiar with
the principles of general pathology. If suppuration
have taken place, where the abscess points . the tegu-
mentary covering becomes thin and of a bluish or a
livid color. To detect fluctuation, with one hand, press
the breast against the chest, while .with the fingers of

O ' O

the other, you palpate the projecting tumor. If there
have been circumscribed tumefaction, redness of the sur-
face, a thinning of the skin, and other signs of local
inflammation gradually developing for some days, it
will hardly be possible for one of ordinary intelligence
and acquirement to make a mistake as to the case he
has to treat. In this form of inflammation, where ap-

MASTITIS AND MAMMARY ABSCESS. 14.7

propriate treatment is resorted to, it rarely happens
that we have more than one abscess.

The constitutional symptoms attending glandular
inflammation are more marked ; there is more febrile
reaction, and the local pain is much more intense.
During the inflammatory stage, there is a nodulated
induration, varying in size according to the extent
of gland involved, called by nurses a lump in the
breast ; and the function of lactation is painful, imper-
fect, and often entirely suspended, so far as the breast in-
volved is concerned. It is this form of mastitis which
succeeds lacteal obstruction or engorgement, when either
of these exists. The abscesses resulting are frequently
multiple, particularly if the gland be irritated by a
continued effort to keep up lactation. Velpeau says
that he has seen, in the course of two or three months,
twenty, twenty-five, thirty-three, forty-six, and, in one
case, fifty-two abscesses in the same breast. He re-
gards this form of abscess as much more frequent than
either of the others. Suppuration takes place more
slowly than in the other forms, where the seat of the in-
flammation is the areolar tissue, two, three, or four
weeks passing before pus is formed, during which the
breast is engorged, either partially or completely, and
is the seat of profound, lancinating pains.

The subglandular inflammation usually occupies the
whole of the areolar tissue at the base of the breast. The
surface of the breast is not usually sensitive to the touch
or painful, but there is a deep-seated pain, greatly in-
-creased by pressure on the whole organ. "When sup-
puration has taken place, the breast presents a smooth,
even surface, without lumps, but is often greatly en-
larged, sometimes enormously so, with a feeling of great
weight and distentiou, irregular chills and partial per-

148 PUERPERAL DISEASES.

spirations. If both the areolar and glandular tissues
be inflamed, or one be developed as secondary to the
other, there will, of course, be found more or less of the
signs characteristic of each combined.

Prognosis. This must include questions, not only
as to the duration of the disease, that is, the time re-
quired for its cure, but the effect upon the general
health, the probable recovery, the possibility of con-
tinuing lactation in the affected breast, and the sub-
sequent capacity of the organ for its functional duties.

First, as to duration. This will depend in a great
measure upon the seat and type of the inflammation,
and the character of the abscess, as well as the condi-
tion of the general system. The inflammation of the
subcutaneous areolar tissue may terminate either by
resolution or by suppuration, and either result is at-
tained much more rapidly than it is where the glandu-
lar structure is involved. Unless appropriately treated
at an early stage, it almost always ends in suppuration-,
which usually takes place within a week or ten days.
Even when resolution is secured, there is apt to remain
some induration of the tissue involved, and a slight
cause will be sufficient to reawaken the inflammation.
The subcutaneous abscess is usually cured within a
week or ten days after it is opened. It is very rare
that this form of abscess lasts two or three weeks.

The existence of inflammation of the subglandular
areolar tissue can very seldom be positively deter-
mined, until after suppuration has taken place, and, even
if it be suspected, very little can be done by treatment
to prevent such a termination. For this and other
obvious anatomical reasons, the duration of the sub-
glandular abscess is much longer than of the subcuta-
neous. Inflammation here exhibits a marked tendency

MASTITIS AND MAMMARY ABSCESS. 149

to become diffuse, while, in the former case, it is ordi-
narily circumscribed. Even if it be circumscribed, and
the pus be formed near the centre of the gland, it is
very difficult to ascertain its existence, and thus secure
an early discharge by an artificial opening with the
knife. If left to come to the surface spontaneously, the
pus not unfrequently finds an exit through several chan-
nels, and results in those intractable fistulas to which
I have before alluded. Again, inflammation of the
parenchymatous structure of the organ is very liable
to be developed as a secondary affection. So, if you
look over the published reports of cases of this kind,
you will see that they are apt to last two or three
months, and sometimes longer.

The duration of the glandular inflammation is
usually much longer than that of the superficial or
deep areolar tissue of the breast. Its march is much
less rapid, suppuration takes place more slowly, and
there remains an induration which requires a long time
to disappear. It may attack one or more lobules at
first, and, while these are passing through the process
of suppuration, contiguous lobules become inflamed, and
thus we may have a succession of abscesses lasting for
months. A prudent physician will be very guarded
in his prognosis as to the duration of this kind of mas-
titis, as it is very variable, and must depend upon the
number of lobules successively involved. To use Vel-
peau's illustration, suppose that the second abscess does
not open until a week from the first, the third a week
from the second, and so on, it is evident that when fif-
teen, twenty, or thirty abscesses are developed, as has
frequently happened, the poor woman must be a suffer-
ing victim for months. One of Velpeau's cases lasted
for eight months, another, six, several, three. Indeed,

150 PUERPERAL DISEASES.

Velpeau says that from two to three months is the usual
duration of this form of mastitis. The cases reported
by other authors confirm this opinion. So, gentlemen,
if you conscientiously study your cases, and are fully
informed as to all that is known in regard to the laws
of the disease, its progress, result, and treatment, and
have exercised a sound judgment in the application of
your knowledge, you need feel no self-reproach for re-
sults which are common to those of the largest clinical
experience, and acknowledged practical talent.

The next question that arises is, as to the influence
of mastitis on lactation. The answer will depend upon
the tissue involved, and the extent and termination of
the inflammation. Circumscribed inflammation of the
areolar tissue, whether superficial or deep-seated, when
the glandular structure is not implicated, may not arrest
lactation, even if it terminate in abscess. Lactation may,
indeed, be temporarily interrupted, and afterward com-
pletely restored. "When the inflammation is diffuse, and
the pus is discharged by several openings, the secretion
of milk is usually arrested. This may be partly due to
the extent of the inflammation, and may be partly owing
to the necessary treatment of the case. But, in these
cases, the subsequent functional capacity of the organ
is not impaired, unless more or less sloughing of tissue
has occurred, and, as a consequence, such cicatricial ad-
hesions as must necessarily involve the lacteal ducts and
the glandular structure of the organ. I have found the
impression general with monthly nurses and with pa-
tients, that if a breast be broken, as they call it, it will
ever after remain useless as an organ of lactation. But
you see that is not necessarily the case. It is the ex-
ceptional result in subcutaneous and subglandular ab-
scesses, and is by no means a universal result of glan-

MASTITIS AXD MAMMARY ABSCESS. 151

dular abscesses. In the latter, it depends upon the
amount of glandular structure involved. I have seen
lactation restored and nursing resumed, in many cases,
after the cure of glandular abscess. But where there
is a succession of this form of abscesses, so much struct-
ural lesion is produced as permanently to destroy the
functional capacity of the organ. Hence, I have seen
quite a number of women in whom one breast has been
compelled to do the duty of both.

As regards the general health of the patient, mam-
mary abscess is always a serious and deplorable com-
plication. Most patients recover their health eventual-
ly, but Velpeau, Burns, and others, have reported cases
where the result was fatal. I have never known a case
to terminate in death, but I have seen more than one
where I have been very apprehensive as to the result.
You can all understand what sad inroads may be made
upon the constitution by numerous sinuses and large
purulent cavities. The patient has repeated chills, fol-
lowed by fever and exhausting perspirations. There is
generally entire loss of appetite, amounting to a loathing
of food, frequent nausea, and vomiting of bile, and often
diarrhoea. The pulse is frequent and gradually becomes
more feeble. The patient emaciates rapidly, the nervous
system becomes excessively irritable, the spirits de-
spondent, the mind weakened, and sometimes the brain is
seriously disturbed. I know of no affections which pro-
duce such mental despondency, unless it be some con-
nected with the organs of generation. Dr. Thomas says,
sometimes the patient becomes furiously delirious, and
the symptoms would lead to a diagnosis of puerperal
mania, when this slight collection of pus is the cause
of the mental aberration. I have seen such a case, and
readily accept the proposition ; and Ramsbothani relates

152 PUERPERAL DISEASES.

a case which confirms the statement. Now, if we thor-
oughly appreciate the gravity of the disease that comes
under our care, we shall feel the necessity of perfectly
understanding its appropriate treatment.

Treatment. I shall aim to give you minute, special
directions, not only in regard to the management of
each form of mastitis, but also for each special condi-
tion which may arise, because it seems to me that most
young practitioners will find the directions given by
authors, in many particulars, vague, indefinite, and un-
satisfactory, and because there is still a difference of
views in some points of practice.

First, then, in regard to the subcutaneous form, it is
to be treated exactly as you would treat phlegmonous
inflammation in other parts. You must, however, re-
member that inflammation is usually (not always) of
an asthenic character, and, consequently, antiphlogistic
means of an active character are not admissible. I
trust all of you have read or will read Paget's " Lect-
ures on Inflammation," and, if so, you will see how im-
proper, oftentimes, antiphlogistics are in suppurative
inflammation. Well, then, if there be strong febrile re-
action and a high degree of vascular excitement, you
will give a diaphoretic sedative, such as aconite. To
allay pain and procure sleep, at night, give eight or ten
grains of Tully's powder or of Dover's powder. Some-
times, you will find it well to add to the powder a
couple of grains of calomel, and to give the next morn-
ing a Seidlitz powder or a bottle of the solution of ci-
trate of magnesia. When there is an epidemic or en-
demic 1 tendency to this form of suppurative inflamma-

1 In visiting the convalescent wards of the puerperal patients in Belle-
vue Hospital, on Monday, March 10, 1862, I found five women with subcu-
taneous mammary abscess. These were all, undoubtedly, due to an en-
demic cause ; viz., the impure air of the ward.

MASTITIS AND MAMMARY ABSCESS. 153

tion, you will avoid such agents as the aconite and
others which depress the system, but, instead, give
your patients quinine, in as full doses as the system
will tolerate. By the use of this, you will often pre-
vent suppuration, as I have frequently demonstrated,
both in the hospital and in private practice. As for
the local treatment, an abscess may frequently be
aborted, if you see the case sufficiently early, by freely
painting over the inflamed surface with iodine, just as
you may abort a boil or carbuncle. But, in order that
this treatment should prove successful, I think the ap-
plication should be made within twenty-four hours of
the commencement of the inflammatory process. As in
other phlegmonous inflammations, warmth and moist-
ure are of the greatest service in relaxing the tension,
favoring the effusion, and thus relieving the over-dis-
tended vessels. You apply this by means of either
a bread-and-milk or linseed-meal poultice, as hot as it
can be borne, or, which I generally prefer, by water-
dressings, that is, two folds of lint soaked in warm
water, and covered over with oiled silk, which should
extend all around, much beyond the lint. In this form
of mastitis, as also in the subglandular form, rubbing
the breasts, which, with some, seems to be a routine
practice, is absolutely pernicious. A moment's reflec-
tion will convince you that it must be so ; and yet I
have been often surprised to see how carelessly it is
prescribed. So, also, in these cases, the application of
belladonna is entirely useless, except as it relieves pain.
As soon as the abscess points, and the fluctuation can
be detected, it should be opened in the most dependent
point, but carefully avoiding the areola, as, if it be
opened here, the cicatrix may produce retraction of the
nipple, and thus prevent the use of the breast after sub-

154: PUERPERAL DISEASES.

sequent labors. If my patients have a great liorror
of the lancet, while I tell them that they will probably
be saved two or three days' suffering, and the cure
will be effected two or three days sooner by opening
the abscess, I do not insist upon it in the subcutaneous
variety, as I do in the glandular and subglandular ; for,
in the latter, serious consequences may result from a
neglect to do so. The poultices should be continued
until the abscess is emptied. But be careful not to ap-
ply them too long. The breast should always be well
supported. If the induration remain after the abscess
is healed, compression, either by adhesive plaster or. by
the compressed sponge, should then be applied. I shall
discuss this point fully in connection with the other
forms of abscess.

In the treatment of the subglandular form of mas-
titis, the same general principles should govern us, as
to constitutional measures, as in the subcutaneous vari-
ety. Either sedatives, anodynes, laxatives, or tonics,
like quinine, may be indicated, and the indications are
too plain to be mistaken by any but the merest routinist.
But little can be anticipated from any topical treat-
ment. Rubbing the breasts, for reasons already given,
will be worse than useless. The application of the
extract of belladonna will do little to mitigate the pain,
and nothing to prevent the formation of pus, while its
offensive odor is a strong objection against its use, un-
less we are certain to do good by it. Furthermore, if,
as is now generally supposed, it has a direct influence
in arresting the lacteal secretion, it may do positive
harm, because otherwise this function might be pre-
served. So, too, compression by any means is not to be
thought of, and for the following reason : The purulent
accumulation is between the breast and the chest, and

MASTITIS AND MAMMAKY ABSCESS. 155

it seeks an exit at the surface. The most favorable
point for this is at the inferior circumference of the
gland. But, if compression be used, it may result in the
formation of several sinuses at the circumference, or the
ulcerative^ process may be developed in the areolar tis-
sue, between the lobules of the gland, and subcutaneous
abscess may appear as secondary to the subglandular.
Indeed, several subcutaneous abscesses may result from
one purulent cavity between the gland and the chest.
While these occasionally are spontaneous results, it is
certain that compression, especially if it be effected by
the compressed sponge, as recommended by Dr. Foster,
must favor such re'sults^ as, in the latter case, we have
compression and a poultice combined. Poultices in
this form of mastitis can have no influence in pro-
moting resolution or advancing suppuration. Their
sole effect must be to soften the tegunientary covering,
and they may, for this reason, cause the pus to come to
the surface at one or more unfavorable points. So I
never use them in these cases. The sole remedial meas-
ure of value is, to secure the early discharge of the pus
by incision. If the conditions of the case will admit of
an election, the opening should be made at some inferior
point in the circumference of the breast, so as to prevent
secondary inflammation of the glandular structure or of
the subcutaneous areolar structure. Sometimes, where
the signs of subglandular abscess existed, but .no fluc-
tuation could be detected, I have cleared up all doubts,
by lifting up the gland from the thorax, and passing
between them an exploring needle. If pus were found
in the canula, I have then made a sufficiently large in-
cision with a long tenotorny-knife, and these cases have
been rapidly cured. But if the abscess point on the
anterior surface, then the opening must be made where

156 PUERPERAL DISEASES.

the fluctuation exists, and care must be taken to pre-'
vent its closure before the pus is all discharged, by
the insertion of a tent. After a few days, compression
should be used, leaving the sinus open, for the purpose
of completely evacuating the purulent cavity, and pro-
moting adhesion of its walls.

Glandular inflammation, or mammary adenitis, if
you prefer to use the less simple term, presents two
types. In the one, the different stages of the inflam-
matory process succeed each other with great rapidity.
If resolution be not obtained, suppuration and cicatri-
zation require but a comparatively short time. Thus,
among the cases of Velpeau, you will find one, in which
several lobules were involved, terminating in abscess,
but completely cured in nineteen days. Another case
of multiple lobular abscess was entirely well in a month.
All practitioners of any experience have met with such,
and these are undoubtedly the cases which have led
some writers for medical journals to believe that some
special treatment peculiar to themselves is a great ad-
vance upon every thing before known. But in the
other type, the different phenomena of inflammation are
slowly developed, and the corresponding symptoms are
much less intense ; and you see, therefore, cases reported
by Dr. Foster, Dr. Johnson, Velpeau, and many others,
running on for two, three, or four months, and some-
times for six or eight months. The first class generally
occurs in those of vigorous constitution, active circula-
tion, cheerful temperament, and happy nervous organi-
zation. The second is most frequently met with in
those of a lymphatic temperament, an irritable nervous
system, low vital powers, and a despondent morale.

In the first class you will readily see that vascu-
lar sedatives, saline laxatives, anodynes, and an anti-

MASTITIS AND MAMMAKY ABSCESS. 157

phlogistic regimen, will be required, while in the other
class, as nutritious a diet as the stomach will, take care
of, stimulants, such as ale, wine, or brandy, tonics such
as quinine and iron, and opiates, will be indicated. I
take it that it is unnecessary for me to say more than
this in regard to the constitutional treatment. The local
measures demand a much more extended discussion.
First, then, primitive glandular inflammation is almost
invariably preceded or accompanied by obstruction of
the lacteal ducts, or lacteal engorgement, as it is termed.
Inflammation seems for a time to increase the functional
activity of the organ, in some cases, while, on the
other hand, lactation aggravates the inflammation, and
increases the tendency to the formation of pus. Nurs-
ing, therefore, should be forbidden, as the pain and
excitement produced by the infant at the breast must
act unfavorably upon the inflammatory process ; but if
the lacteal secretion appear to continue with activity,
the breast must be disgorged by artificial means. This
can be best effected by rubbing the breast gently but
perseveringly, from the circumference to the nipple, the
hand being lubricated with sweet-oil. The rubbing
should be continued until the breast is soft, and all
nodulated indurations have disappeared, and for one or
two days this process should be frequently repeated.
This is a method which has long been adopted in the
Dublin lying-in Hospital, and is warmly recommended
both by Dr. Foster and Dr. Thomas; and, from a
large experience, I am able to fully indorse all that
they have said in regard to its value. Then, the next
question is, as to the best means of preventing the
return of the lacteal engorgement. Camphor is gen-
erally believed to exert a specific influence in dimin-
ishing the lacteal secretion ; and some have therefore

158 PUERPERAL DISEASES.

recommended the camphor-liniment, others, a saturated
solution of camphor in glycerine, to be used instead of
olive-oil.

I prefer the olive-oil for rubbing the breast; and
then cover it with the extract of belladonna, softened
with a little glycerine. Sometimes I direct that the
breast be kept covered with a cloth on which the ex-
tract of belladonna has been spread, leaving a hole
for the nipple. Belladonna not only relieves the pain
resulting from the tension of the tissues, but, from
its power of relaxing muscular fibre, it seems to allow
a more free exit of the milk, by dilating the lactifer-
ous tubes ; and, within a few years past, it has been
believed to possess the property of arresting the lac-
teal secretion. But of this I am certain ; that it is a
most valuable application to the breast, in glandular
mastitis, and I have used it for this purpose (and
have also applied it to the leg in phlegmasia dolens),
for more than twenty years. I received this hint from
Dewees, who professes to have obtained it from Ranque.
If these means do not secure resolution, it only remains
to open the abscess when suppuration has taken place.
The opening should be large enough to allow all of the
pus to freely and easily escape.

The next remedial measure, having for its object
the relief of engorgement of other lobules, the re-
moval of induration, the prevention of purulent infil-
tration into the adjacent areolar tissue, and the for-
mation of obstinate fistulous sinuses, is compression.
This should be applied so as to support the breast and
firmly compress it, from the circumference to the centre,
without closing the aperture for the escape of pus ; and
it is usually best effected by means of adhesive plaster.
There are several modes of applying adhesive strips,

MASTITIS AND MAMMARY ABSCESS. 159

described by different authors, either of which may be
preferable to all others in certain cases. I shall not
stop to describe each of these methods, as none of them
are adapted to all cases, and some are open to this ob-
jection, that they seriously interfere with respiration.
It is impossible to lay down a definite rule for the ap-
plication of the adhesive strips, because the breast dif-
fers so much in different women, in size, shape, form,
and position of attachment on the chest. I shall only
give you this general rule apply the straps so as not to
impede respiration, but in a way to support the breast,
and firmly and equally compress all its parts from the
circumference to the nipple, leaving the latter free, and
also an opening for the escape of the pus, where the
discharge has taken place. Your success in securing
these results will depend upon individual tact, and, if
you have not that, no rules will supply its place.

With regard to compressed sponge as a means
of compression, I shall only say that I have seen it
of great service where warmth, pressure, and moist-
ure are all required, to promote resolution of glan-
dular inflammation. But it strikes me as liable to
two objections in open abscess : First, the sponge
absorbs and retains the discharged pus, which, in a
short time, becomes decomposed, and is extremely of-
fensive ; and second, the rollers applied around the
body, to secure the compression, must interfere some-
what with respiration, and, if the compression is to be
kept up any length of time, this becomes a serious ob-
jection.

I have said nothing about the use of stimulating
injections, such as the tincture of iodine, the solution
of sulphate of zinc, or sulphate of copper, to cure ob-
stinate fistulous sinuses, because I have no experience

160 PUERPERAL DISEASES.

in their use, Laving never met with a case which was
not readily cured by compression.

Before closing my remarks on abscess of the breast,
I must not neglect to mention that purulent deposits
not unfrequently take place in the breast, as a result
of pyaemia, septicaemia, or puerperal fever, and this is to
be regarded as rather a favorable symptom, as I shall
explain when discussing these diseases.

Mammary Neuralgia. I shall say a few words
on this affection, as preventing lactation, since I do
not remember to have seen any allusion to it by any
author. I Lave, however, met with a few cases, where
nursing produced such intense agony as to compel the
poor sufierer to abandon it, although not the slightest
disease either of the nipple or the breast could be dis-
covered by the most careful examination. In the cases
which I have seen, this symptom has not been devel-
oped until two or three weeks after nursing has been
commenced. There was not the slightest pain or ten-
derness, except when the child was at the breast, neither
could the pain be produced by any manipulation of the
organ. In one patient, the nursing of one breast pro-
duced intense neuralgia in both. In the first few cases
that I saw, I could do nothing, either by local or con-
stitutional treatment, and the patients were compelled
to give up nursing. But those which I have seen within
a few years past have been cured by quinine, given in
as full doses, twice a day, as the patient could tolerate.

LECTURE X.

PUEEPEEAL 31 A N I A .

Cases Frequency in this hospital Comparative frequency hi 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.

" CASE XI. 1 Mary , aged twenty-nine years, born in England,

married, entered Bellevue October 5th, primipara; menstruated
last, January 28th. Labor commenced 2 A. M., October 8th, first
stage, ten hours ; second stage, three and a half hours ; third stage,
twenty minutes. The child, male, weighed nine and a half pounds.
Patient was very anaemic, but lost very little blood at the time
of labor.

" October 9th. Pulse 84, respiration 18, temperature 99.

" October 10th. Pulse 80, respiration 20, temperature 98.5.

" October llth. Pulse 84, respiration 20, temperature 98, breasts
full. Took two laxative pills, which moved freely twice, without pain.

"October 12th. Pulse 88, respiration 20, temperature 98.5.
Has a large supply of milk ; nurses, by her request, another child
beside her own.

1 Reported by the house-physician, who neglected to sign his name to
the report.

162 PUERPERAL DISEASES.

"October 13th. 7 A. M., pulse 112, respiration 28, temperature
99. Patient answers questions in an excited way ; stares wildly,
eyes very red, but face pale ; says the other women in the ward
kept her awake, and were talking all night about her. Lochia
natural and without odor. 5 P. M., pulse 120, respiration 30, tem-
perature 99.5. Signs from auscultation and percussion negative.
Urinary secretion abundant ; no albumen ; has been examined every
day. No pain or tenderness over the uterus, which is well con-
tracted down in the pelvic cavity. Ordered morphias sulph., one-
fourth grain.

" October l&th. Patient became so violent in the night that it
was necessary to remove her from the ward and to place her in a
cell. She talks incessantly and incoherently, using most profane
and obscene language. Refuses to nurse her child. 2 P. M.,
seen by Dr. Barker. Pulse 120, respiration 36. Patient so violent
and restless, that it was impossible to get the temperature. Ordered
beef-soup every three hours, and, immediately after, quiniae sulph.,
gr. ij, tine, ferri muriat., gtts. xv. As patient had for some twenty-
four hours absolutely refused to nurse her child, the breasts were
very much swollen and hard ; the following to be well rubbed over
them: 1^. Ext. belladonnas, 3 j, glycerine, 3 ij- M. At eleven o'clock,
to have chloral-hydrat. grs. xxx.

" October loth. Patient is reported to have slept several hours,
is very much less violent, but talks incoherently. Answers no
questions. Pulse 108, respiration 24. On attempting to use the
thermometer, she was apparently frightened, and immediately be-
came very excited. The same treatment to be continued.

" October 16th. Slept a good deal during the night, is much
more quiet in her movements, and is very silent generally, but at
long intervals talks with great volubility and incoherency. Respi-
ration 28, pulse 112, temperature not obtained. Her condition
remained very much the same for the three following. days, except
that her movements were more strikingly lascivious. Says that she
is Mary Magdalen, and calls her nurse sometimes Martha, and at
other times Lazarus.

" October 20th. Very quiet, disposed to weep, answers ques-
tions. Asks to have the "nasty stuff" taken off her breasts. Pulse
108, respiration 24, temperature 99. Removed back to the wards.
Chloral-hydrate reduced to grs. xx. at bedtime.

" October 21st. Very quiet, taciturn, but occasionally strange.
Asked, for the first time, for her child. Cried bitterly when she

PUERPERAL MANIA. 1G3

found the child could get no milk. Wishes to keep it at her breast
the whole time. Has revealed to-day, for the first time, that her
husband deserted her and left for Colorado with another woman, six
weeks before she came into the hospital. From this date, she
steadily improved. The milk returned to the breast, and she left
the hospital to fill a situation as wet-nurse.

" CASE XII. 1 Julia H., aged twenty-two years, single, born in
Ireland, pregnant first time. Menstruated last in March, 1871. Dur-
ing the latter part of pregnancy, had some swelling of the feet and la-
bia, but chemical examination of the urine, negative. Was admitted
to the hospital only the day before labor began. Labor began 7 A. M.,
November 9th. First stage fourteen hours. Position L. O. A.
Second stage, two hours and five minutes. Pains were only mod-
erately severe, but the patient was very nervous and excitable, and
seemed to suffer a good deal. Was delivered of a healthy girl,
weighing six pounds, fourteen ounces, a few minutes after 11 p. M.
Placenta came away ten minutes after delivery of the child. The
uterus contracted well, and patient passed a quiet night.

" Nov. 10. A. M., respiration 24, pulse 68, temperature 100.5.

p. M., " 27, " 64, " 100.5.

Complains of pain and soreness in the chest ; occasional pains in

the pelvic region. Ordered Magendie's solution of morphia, gtts. x.

" N~ov. 11. A. M., respiration 26, pulse 76, temperature 100.
Had a chill, beginning at 12 M., which lasted two hours, followed
by high fever and sweating. During chill, complained of pain in
the lower part of the back and abdomen.

" 7 P. M. Respiration 32, pulse 148, temperature 104. No
sweating, no pain, except when she moves. Slight tenderness
in inguinal region. Breasts swelling, no tympanites. Ordered
tincture aconite, gtts. iij, every hour, until three doses have been
taken. Quinias sulph., grs. v, every third hour.

''JVbv. 12. 9 A. M., respiration 32, pulse 104, temperature 105.
12 M., " 32, " 108, " 105.

3P.M., " 30, " 108, " 104.7.

9P.M., " 30, " 132, " 104.

No pain or tenderness in abdomen. Occasional pain in back, run-
ning down the legs.

" N~ov. 13. A. M., respiration 32, pulse 112, temperature 105.
7 P. M., " 32, " 100, " 101.

1 Reported by John A. McCreery, A. M., M. D., house-physician to
Bellevue Hospital.

164: PUERPERAL DISEASES.

Aconite stopped, continue quinine. Patient feels much better. Has
a little milk in the breast this evening for the first time.

" Nov. 14. A. M., respiration 28, pulse 84, temperature 101.5.
r. M., " 30, " 112, " 103.7.

Has a little cough and some soreness of the chest, with a little pain
in the lower part of the abdomen when she coughs. Some tym-
panites. Ordered Magendie's sol. of morph., gtts. xx, and turpentine-
stupes to abdomen.

" Nov. 15. A. M., respiration 25, pulse 84, temperature 101.3.
p. M., " 24, " 96, " 102.5.

No pain, very little tenderness. As bowels have not moved for
two days, ordered a laxative.

" Nov. 16. A. M., respiration 30, pulse 96, temperature 104.3.
P. M., " 30, " 104, " 103.5.

Nervous and excited, no pain, bowels moved, tongue cleaner.
" Nov. 17. A. M., respiration 30, pulse 96, temperature 102.

p. M., " ' 30, " 109, " 104.5.

Patient very excited. Has some pain in the stomach and over the
uterus. Vaginal examination reveals tenderness on both sides of
the uterus, but no swelling or hardness. Quinine, grs. v, every third
hour. Poultices to abdomen.

P. M. Patient very wild. Has been nervous and hysterical ever
since her confinement. Has been suffering great mental anxiety for
fear that her misfortune would be known. Yesterday a friend vis-
ited her in the hospital, and told her that her seducer was married.
Since then she has acted very strangely, at one time crying bitterly,
then begging the nurse not to heed her, and then again becoming
very violent, with delusions as to her identity. Bowels open.
Potass, bromidi, 3 ss, at bedtime.

" Nov. 18. A. M., respiration 30, pulse 84, temperature 100.5.
p. M., 26, " 96, " 103.5.

Patient more quiet, with less delusions, but still very excitable.
Slept most of the night. No pain.

" P. M. Complains of pain and tenderness over the hypogastric
region. Ordered poultice to the abdomen and a suppository of ext.
opii aq., gr. j.

"Nov. 19. A. M., respiration 30, pulse 96, temperature 101.5.
P.M., " 34, " 112, " 104.5.

Patient rational. Pain and soreness in the right iliac region.

"p. sr. Ordered tinct. aconiti rad., gtts. ij, every second
hour.

PUERPERAL MANIA. 165

" Nov. 20. A. M., respiration 30, pulse 72, temperature 99 J .
Patient feels better. Aconite stopped.

" P. M. Respiration 36, pulse 96, temperature 102.7. Patient
very nervous. Says she did not sleep last night. Pain, tenderness,
and some tympanites of the abdomen. Turpentine-stupes, and
chloral-hydrat. grs. xxx.

" From this date until the 25th, the condition of the patient did
not essentially change. She slept well under the influence of the
chloral-hydrat.

" Nov. 25. Respiration 22, pulse 88, temperature 97.8. Pa-
tient feels well. No pains, and appetite good. She subsequently
left the hospital perfectly well."

Gentlemen : The cases you have just seen belong to a
class which occurs very frequently in this hospital, or to
quote from the " Obstetric Clinic " of Professor Elliot :
" In Bellevue we receive a great many cases of puer-
peral mania, on account of the fact that so large a pro-
portion of our pregnant women are unmarried primi-
parse, and because others of the poorest classes, who
cannot be controlled at home, are sent to the hospital."

Since I have been connected with this hospital, now
seventeen years, I have had one or more cases of this
malady, every time I have been on service, with but one
exception. In the autumn of 1861, the first year of our
late war, I had five cases of puerperal mania ; in the
spring of 1862, three ; in the autumn of 1863, fol-
lowing the great riots in this city, I had six cases ; and
during my present service (November and December,
1870) I have had three. I estimate the ratio of puer-
peral mania to the whole number of cases of labor to
be one in eighty in this hospital.

I beg you to notice the wonderful contrast in
frequency of this malady here, as compared with the
statistics of hospitals in other parts of the world.
Scanzoni states that in Wiirzburg, in forty-six years,

166 PUERPERAL DISEASES.

there were five cases of puerperal mania out of 7,438
confinements, that is, 1 in 1,487. He also states that
the records of Prague, from 1835 to 1848, show that, in
23,347 cases of labor, there were 19 instances of puer-
peral mania, 1 in 1,228.

In the lying-in wards of St. Giles's Infirmary, one
series of cases gives 1 case of puerperal mania in 1,888
of labor, and another series, 1 in 950. McClintock and
Hardy, in 6,634 cases of labor, give 8 cases of puerperal
mania, 1 in 810. Jbhnston and Sinclair (Dublin Ly-
ing-in Hospital), 26 cases of mania in 13,748 of labor, 1
in 528. At the Westminster General Lying-in Hospital,
there were 9 cases in 3,500 of labor, or 1 in 383. At
Queen Charlotte's Lying-in Hospital, there were 11 in
2,000, or 1 of mania in 182 of labor.

Now, let us look at the statistics of this disease from
another point of view.

Marce, who has written in some respects the most
complete essay on this subject that has yet appeared,
finds that the records of " Public Institutions for the In-
sane " show that about eight per cent, of the insane
cases are due to puerperal causes.

The statistics of Scanzoni, taken also from public
institutions, some being the same as those of Marce, also
furnish a percentage of about seven per cent., resulting
from puerperal causes.

Dr. J. B. Tuke, whose valuable papers on the statis-
tics of puerperal insanity, published in the Edinburgh
Medical Journal, in 1865 and 1867, are the most sug-
gestive of any thing that I have read on the subject,
gives the following statement : " Between January 1,
1846, and December 31, 1864, there were 2,181 female
cases of insanity treated in the Royal Edinburgh Asy-
lum ; " of these, 155 were so-called puerperal cases, mak-

PUERPERAL MANIA. 107

ing a percentage of 7.1. You see that there is a re-
markable agreement of authorities in regard to the pro-
portion of insanity from puerperal causes, compared
with all other causes, as shown by the statistics of pub-
lic institutions.

Another point, not to be overlooked, is that, in pri-
vate practice, probably one-half of the patients recover
from this malady, without entering a public institution.
My own experience would lead me to suppose the pro-
portion to be much greater than this. At all events, I
think it may reasonably be assumed as proven, that
fully seven per cent, of the insanity which occurs
among women, in civilized and Christian communities
that support insane hospitals, are due to causes con-
nected with child-bearing.

Let me say here that the term puerperal mania is
ordinarily used very loosely. Dr. Tuke, in the papers
that I have just alluded to, remarks with truth and
great force : " In works on midwifery and mental dis-
eases, we find the several forms of insanity which occur
during pregnancy, follow parturition, and supervene on
lactation, all arranged under the common head of puer-
peral mania. This, with regard to the first and third
divisions, is of course a misnomer, a contradiction in
terms ; and it seems rather curious that it should have
been so long adhered to, more particularly as it tends
to confuse and almost stultify deductions made from the
few statistics of puerperal mania of which we are pos-
sessed. For instance, any comparison, drawn between
any given number of labors and any given number of
so-called puerperal cases, must lead to erroneous conclu-
sions, if the insanity of pregnancy is confounded with
puerperal mania, or if, as is the case, the anaemic in-
sanity of lactation is confounded with either."

168 PUERPERAL DISEASES.

The 155 cases of Dr. Tuke are classified by him as
follows :

Insanity of pregnancy 28

Puerperal insanity 73

Insanity of lactation ....... 54

The first group, insanity of pregnancy, thus bears
a percentage of 18.06 to the total of 155; the second,
puerperal insanity proper, 47.09 ; and the third, insan-
ity of lactation, 34.08.

The insanity of pregnancy and the insanity of lac-
tation are more frequently met with by the alienists
and the physicians to insane hospitals, than by the ob-
stetrician proper ; and, although my remarks will be
chiefly confined to the subject of puerperal mania, I
shall say a few words in relation to each of these forms,
and also another form, the delirium of labor.

Insanity of Pregnancy. It is a matter of common
observation that, in women of certain temperaments,
habits, and education, pregnancy so modifies the ner-
vous system as to produce morbid appetites, changes of
temper and disposition, sometimes moral perversion,
unnatural sadness, or a settled conviction of impending
death.

The diseases of the female sexual organs often pro-
duce these reflex disturbances to such a degree as to
cause real insanity ; and, as it is important for all of you
who are to have the responsibility of the health and
happiness of the families committed to your charge to
understand this, I shall take the present opportunity to
say a few words on this too-neglected subject. 1

1 A portion of this lecture, " On Insanity caused by the Diseases of
the Female Sexual Organs," was published in the Boston Gynecological
Journal, May, 1872.

PUEKPERAL MANIA. 169

Pregnancy is a physiological process ; and the in-
stances in which the reflex disturbances from this con-
dition result in insanity must be rare. I have seen but
two such cases, and in both, the evidence of hereditary
predisposition was conclusive. One of them had re-
peated attacks of epilepsy, the first year of her men-
strual life, and the other had been previously insane,
but was supposed to have entirely recovered more than
two years before her marriage. In both cases, the in-
sanity was permanent. I am indebted to others, and
especially to Dr. Tuke, for what I have to say in regard
to this form of insanity.

Esquirol found hereditary predisposition in more
than one-third of the cases that came under his obser-
vation (5 in 13). Dr. Tuke's statistics show that piimi-
parse are by far the most liable to this malady, " a cir-
cumstance which might have been expected when we
take into consideration the moral exciting causes, anxi-
ety, and dread of the coming event, which exist to a
greater degree in the inexperienced woman." The type
of the disease is almost invariably melancholia. In the
28 cases of Dr. Tuke, only 2 are reported as character-
ized by mania, and he believes that, in those rare in-
stances where mania occurs, it will be found that the
patient has previously been the subject of insanity in
that form.

In no form of insanity is the suicidal tendency
so well marked as in the melancholia of pregnancy.
In the earlier stages, it seems very amenable to treat-
ment. Cases are on record in which the insanity of
pregnancy is said to have disappeared with labor, but
this does not seem to be a common result. If the men-
tal symptoms disappear before or at the time of confine-
ment, there is a marked tendency to recurrence for a

170 PUERPERAL DISEASES.

longer or shorter period. These cases seem to be par-
ticularly benefited by treatment in the special hos-
pitals for insane, as the assurance of protection, the
regularity, amusement, and employment, alone to be
found in an asylum above all, the freedom from do-
mestic anxiety and the injudicious expressions of sym-
pathy by relatives in a large majority of cases are pro-
ductive of the best results.

Tlie Delirium of Labor. This is sometimes excited
by the force and intensity of the pains in the second
stage. It has been described by Velpeau, Cazeaux, and
more fully illustrated by the late Dr. Montgomery, of
Dublin, and I suppose most who have been long in
practice have occasionally met with such cases. Since
the common use of anaesthetics in midwifery, these cases
must be very rare. I have seen but one in the past
twenty-four years, and, as this was a very peculiar one,
I will briefly relate it :

The patient, a lady of high culture and remarkable
good sense, without the slightest hysterical tendency
that I have ever been able to discover, awoke about
five in the morning, near the end of her first pregnancy,
shrieking, " I am drowning. I am drowning ! " and

37 O' O

jumped from her bed. The nurse, who was sleeping
in the hall-bedroom adjoining, with the door standing
open, and the husband, who occupied the back-chamber,
rushed in and found her tearing about the room in the
most frantic manner, screaming incessantly, without lis-
tening to a word said to her. I was immediately sum-
moned, and, living very near, was with her in a few
moments. I had previously ordered chloroform in an-
ticipation of her labor, but it required the united efforts
of her husband, nurse, and the servants in the house,
to hold her sufficiently quiet for me to bring her under

PUEEPEEAL MAXIA. 171

the influence of the anesthetic. I overwhelmed her
with the chloroform as speedily as possible, and then,
on making an examination and finding an arm protrud-
ing from the vulva, I delivered at once a living child
by turning. The after-birth speedily followed, the
binder was applied, and she was placed in a dry bed
before she awoke. She had, undoubtedly, been aroused
from a sound sleep by the rupture of the membranes,
discharge of the waters, and escape of the child's arm.
It is quite certain that less than an hour elapsed from
the time of this occurrence until she awoke quite calm
and quiet from the sleep of the chloroform, yet one can
easily understand the emphatic declaration of her hus-
band, that this hour was an eternity to him. By my
urgent injunctions, no allusion to the incidents of her
first labor has ever been made before the patient, and
she has often expressed her surprise to me that her only
recollection of it should be that, on awakening, she saw
her mother holding a baby.

Insanity of Lactation. I have seen but seven cases
of this type, and these were all in consultation. All
recovered from the insanity, but two died within a few
months after I saw them, from phthisis. All of these
were cases of melancholia. As I before remarked, the
physicians to insane hospitals see these cases much
more frequently than obstetricians. It is essentially
due to anaemia of the brain. Dr. Tuke says that when
mania occurs, it is of an evanescent nature, violent while
it lasts, but not associated with the obscenity of lan-
guage observable in puerperal mania. Both forms, ma-
nia and melancholia, are readily curable when taken in
time.

Puerperal Mania. The insanity which first shows
itself during the puerperal period is most properly

172 PUERPERAL DISEASES.

called puerperal mania, for this is the type of the dis-
ease in a great majority of cases. In Dr. Tuke's table,
57 out of the 73 cases of puerperal insanity were cases
of mania. It is my belief that, if the cases which occur
in private practice during the first fortnight after labor,
and which either recover within a couple of weeks or
pass into the stage of dementia or melancholia, and
form no part of hospital statistics, could all be aggre-
gated, it would be found that fully ninety per cent, have
the original type of mania. Again, puerperal mania is
generally manifested during the first two weeks after
confinement, and, by the end of the month, the patients
have recovered, or the disease has passed into a different
type. Puerperal melancholia rarely, if ever, is devel-
oped until the latter half of the month, and these, being
the most intractable, are the cases most likely to be
transferred to insane hospitals. At least, this is the
result of my observation.

Puerperal mania is the form with which obstetri-
cians have most frequently to deal. In some few rare
cases, it is suddenly developed without any forewarn-
ing symptoms, but, in by far a larger number, there are
very characteristic prodromic symptoms, sometimes con-
tinuing for a few days and in other instances only a few
hours before the explosion. There is generally an un-
usual excitement of manner, although, in a few, a mor-
bid melancholy air first attracts attention. A sudden
aversion is displayed toward those who have been be-
fore best loved ; an excessive loquacity, or an obstinate
silence, weeping or laughing equally without a motive^
a morbid sensibility to light, to noises, to odors, a sus-
picious watchful expression of the eye, and sleepless-
ness, are symptoms, which, occurring in a woman who
has been confined within ten or fifteen days, indicate an

PUERPERAL MAOTA. 1Y3

impending attack of puerperal mania. There are often
muscular movements of the eyelids, the face, and the
hands, very much resembling the appearance of a patient
on the brink of delirium treinens. Indeed, the general
symptoms are often wonderfully like those which are
characteristic of the bes-innin^ of delirium tremens, and,

O O 99

in the case of the wife of a medical friend, which I shall
presently relate to you, a painful suspicion existed in
the mind of her husband at first that the real disease
was delirium tremens.

There are certain symptoms which very generally
characterize the moment of the attack, but these are
usually of short duration. The facial expression is
very peculiar, and, having once been seen, will always
be remembered. The features are drawn, pallid,
the cheeks and forehead are covered with little drops
of perspiration, and the whole air of the expression is
unsettled, indicative of fright or fury.

When the malady is fully developed, the patient
becomes very boisterous and noisy, incoherent in her
language and in her gestures. She stares wildly at
imaginary objects in the air, seizes any word spoken
by those near, and repeats it with " damnable iteration,"
clutches at every thing and every one near her, throws
off all covering, jumps from the bed, and even the most
refined and religious women, when possessed with the
demon of puerperal mania, will scream out oaths and
obscenity with a volubility perfectly astounding. Erot-
ic manifestations occur in a majority of cases. Mas-
turbation is sometimes noticed, but I believe, as Dr.
Tuke suggests, that this is more the result of a wish to
allay than to excite irritation. Nearly one-half of these
cases manifest a suicidal tendency, but rather as a sud-
den impulse than as a settled determination.

PUERPERAL DISEASES.

While many of these appearances are very like those
of delirium tremens, the physical symptoms are in strik-
ing contrast with those of this disease. The patient is
pale, cold, clammy, with a quick, small, irritable pulse ;
the features are pinched, at times almost collapsed-look-
ing. There is usually great muscular weakness, with
now and then a momentary spasmodic display of un-
usual strength.

I wish especially to urge it upon your attention,
that other grave diseases may exist in a latent form,
coincident with the mania, the manifestations of which
are masked by the mental symptoms. In this hospital,
one patient has died with pelvic peritonitis, another,
with pneumonia, and a third, with pericarditis and en-
docarditis ; and in neither, was the disease suspected
until revealed by the autopsy. All recent authors
agree that phrenitis connected with puerperal mania
is excessively rare.

Prognosis. This involves the three questions, of the
duration of the disease, the mental recovery, and the re-
covery of the general health. Dr. Tuke says : " Puer-
peral mania of itself does not kill, and when you have
to combat it alone, not only death is not to be dreaded,
but, in the very large proportion of cases, a return to
sanity may be prognosticated. It is, perhaps, the most
curable form of insanity. This statement is made ad-
visedly, but does not extend to those cases which are
placed under asylum treatment as a dernier reasort? As
to the duration of the disease, in some, but comparative-
ly few cases, it entirely disappears in a few days. I
have been struck with the fact that, in all the cases
which I have seen, where the mania has followed puer-
peral convulsions, the duration of the mania has been
limited to three or four days, and the patient has

PUERPERAL MANIA. 175

speedily recovered, or she lias died within this period.
I only mention the fact, without attempting to offer
any theory to explain it.

In a majority of cases, the mania gradually subsides
within a period of three weeks, more frequently earlier,
and is followed by a condition of partial dementia, with
some delusions, especially as regards personal identity.
These gradually disappear, leaving a kind of intellect-
ual barrenness, like one waking from a dream. From

' O

this condition, you may confidently hope for ultimate
recovery. In some cases, the malady is prolonged two
or three or more months ; but, if beyond six months,
the chances of recovery are very small. When death is
the result, it is almost invariably due to some associated
disease, as peritonitis, or cellulitis, pneumonia, and in
some exceedingly rare cases, phrenitis, the fatal result
usually occurring in a very few days.

Causes. Among the predisposing causes, heredi-
tary tendency is the most prominent, especially tracea-
ble to the female side of the family, much more frequent-
ly than to the male. This was proven to exist in 22 of
the 57 cases of Dr. Tuke ; Esquirol, 1 in 2.8 ; Marce", 24
in 56 ; Helftt, of Berlin, 51 in 131.

The next cause which I shall mention as predispos-
ing to this malady is dystocia. In the 73 cases of Dr.
Tuke (including both mania and melancholia), the
labor was complicated in 23. Dr. Tuke remarks : " The
various irregularities of labor doubtless operate in dif-
ferent ways, those where the suffering has been long
continued depressing the nervous system directly, those
in which large quantities of blood have been lost pro-
ducing anaemia of the brain, and, in the case of the
child beins; still-born, a moral shock acting on the mind

O / O

naturally predisposed to this affection." I shall add, to

176 PUERPERAL DISEASES.

those causes that I have mentioned, anaemia and eclamp-
sia. Moral causes are no doubt among the most fre-
quent of the predisposing causes, but they are also ex-
citing causes.

Exciting Causes. It is my firm conviction that
mental emotions constitute the exciting cause of puer-
peral mania infinitely more frequently than all other
causes combined. The relative frequency of puerperal
mania is just in proportion to the susceptibility to the
influence of emotional causes. In Wiirzburg, the pro-
portion of cases of mania to the whole number of con-
finements was 1 in 1,487; in Prague, 1 in 1,228. It
is not strange that Scanzoni, studying the ' malady in
this field, should regard the frequency of mania as ex-
aggerated, at the same time that he admits that hospital
records probably do not accurately represent the rela-
tive frequency in private, as it is notoriously more com-
mon in the well-to-do classes. Now, while this is un-
doubtedly true in Scanzoni's field of observation, the
exact reverse of this statement is true with us. I have
visited the lying-in hospitals of Wiirzburg, Prague,
Munich, and many others in Germany, and I have con-
versed with Scanzoni on this very subject. From him
I learned that with most patients in these hospitals,
there is no sacrifice of domestic ties or social position
in going to the hospital, but, on the contrary, many are
in every way better off than when out of the hospital.
They have never before been so well cared for. For
most of them, there is no stigma of disgrace in being
there, and no consciousness of moral wrong or loss of
position among their associates by becoming a mother
without being a wife. Among the lower classes in some
parts of Germany, I believe it is considered a perfectly
legitimate business for young girls to become pregnant

PUERPERAL MANIA. 177

to qualify themselves for the position of wet-nurse and
earn some money. There is, then, an entire absence of
those moral causes of puerperal mania, which exist in
tremendous force in this hospital, as I shall presently
show you.

Then contrast the difference in frequency between
the patients in the lying-in wards of St. Giles's Infir-
mary, where, in one series, there was one case of mania
in 1,888 confinements, and the patients of Queen Char-
lotte's Lying-in Hospital, where there was one of mania
in 182 of labor.

Now, mark the difference between the moral condi-
tion of the patients in this hospital and those whose
statistics I have given. A large majority of patients in
our lying-in-wards are of foreign birth. They have
come to a new country, leaving friends behind, with
the hope of improving their condition, and many are
disappointed in this respect. A large proportion, prob-
ably more than one-half, are unmarried. It is impos-
sible to ascertain the truth on this point, for many rep-
resent themselves as married and deserted by their
husbands, and some of these are subsequently found to
be single. But this very deceit shows a moral sense
on this point. Then many, who have been wronged and
abandoned by their seducers, prefer to die in the hos-
pital rather than have their disgrace known to their
relatives. In addition to this, I a^i well convinced
that our climate has a marked influence in developing
the nervous susceptibilities of Europeans who come
here. Then, again, there is no part of the world where
the lapse from, virtue in women is so severely punished
by social ostracism as in New England, and she con-
tributes her quota of poor girls who rush to a great

178 PUERPERAL DISEASES.

city to hide themselves, and are at last driven to the
hospital as their only resource.

Now, in view of all these facts, I think that you
will agree with me that, if statistics ever prove any
tiling in regard to the causes of disease, they prove that
moral emotions are the great exciting cause of puerperal
mania.

I will mention a curious fact that has occurred in
my experience: Since 1855, I have seen thirteen cases
of puerperal mania in the wives of physicians, nine in
this city, and four in the adjoining cities. All but one
were primiparse. It has struck me as very extraordi-
nary, that so large a number should have occurred in
one special class, and I think the following is the
probable explanation : All of these were ladies of edu-
cation and more than usual quickness of intellect, and,
beginning a new experience in life, and having access
to their husband's books, they probably had read just
enough on midwifery to fill their minds with appre-
hensions as to the horrors which might be in store for
them, and thus developed the cerebral disturbances,
just as any other moral emotions may.

Some authors have sought to show that the exciting
cause of puerperal mania was to be found in the pe-
culiar state of the sexual system which occurs after
delivery. Others w^ould make anaemia and exhaustion
the principal exciting cause.

Others, again, and most prominently the late Sir
James Simpson, regard puerperal mania as especially
due to a toxaemia, and as most frequently associated
with albuminuria. Sir James Simpson suggests that
" mental emotion probably acts intermediately on the
mind by its morbific agency on the body." He also says
that " he has only seen one instance of late years at-

PUERPERAL MAXIA. 179

tributable to such a primary depressing mental cause,
arid in this case the urine was highly albuminous, as it
is usually found in puerperal convulsions." Many others
have seemed to adopt the views of Professor Simpson
in regard to the influence of albuminuria in developing
puerperal mania. Dr. Foster Jenkins, of Yonkers, pub-
lished an interesting case of puerperal mania in the
American Medical Monthly, 1857, in which Professor
Alonzo Clark and himself found albumen abundant in
the urine ; the patient was treated mainly for albuminu-
ria, and recovered. My friend, the late Professor Elliot,
was disposed to regard albuminuria as a prominent ele-
ment in causing puerperal mania, 'but, of the five cases
of puerperal mania reported in his " Obstetric Clinic,"
not one was associated with albuminuria.

As for myself, since the suggestions of Sir James
Simpson were first published on this subject, I have been
on the constant watch for albuminuria in every case
of puerperal mania that I have seen, and I have found
it associated with so small a proportion of the cases,
that I am compelled to regard it, when present, as sim-
ply a coincidence and not a cause. To adopt Professor
Simpson's remarks relative to anaemia and exhaustion
as a cause, I should say the alleged cause is very, very
often present in practice, without the alleged effect fol-
lowing. The theory at best, if applicable at all, is ap-
plicable to a veiy limited number of cases, and affords
no more satisfactory explanation of the origin of the
disease than does the more general statement, that puer-
peral mania results from the peculiar state of the sexual
system which occurs after delivery.

Treatment. Dr. Tuke says: "To shave and apply
cold to the head, administer tartar-emetic, purge, and
blister, are not uncommon remedies (!) applied where

180 PUERPERAL DISEASES.

mania exists. In puerperal insanity this bad treatment
insures a lapse into dementia the patient can resist
the disease, but not the remedy; each dose of anti-
mony, each cold application, each blister, puts the case
further and further beyond the control of the physi-
cian." As regards my own experience and observation,
I am heartily in accord with Dr. Tuke.

The most recent article on puerperal mania, which
has been probably more generally read than any other
by the profession now in practice in this country, is the
lecture by Sir James Simpson, in the volume of " Clinical
Lectures on Diseases of Women." The warm admiration
for his genius, the great respect for his remarkable tal-
ents and industry, and the deep-felt sorrow for the loss
which the profession and the w r orld sustained in his com-
paratively early death, combine to add force to the in-
trinsic weight of his suggestions. But his remarks on
the treatment of puerperal mania leave the strong im-
pression on my mind that he could not have had the
personal supervision of many cases, although he proba-
bly saw a great many in consultation. I refer more
especially to his remarks on " nervous sedatives," " spe-
cifics," and " depurants," which bear the stamp of theo-
retical suggestions, rather than of practical deductions
from clinical observation.

Bleeding, once so much in vogue, it is now settled,
is not only useless, but positively injurious in all but
very exceptional cases. A vast majority of cases are
undoubtedly associated with anaemia and nervous ex-
haustion. In one case only, I have seen venesection
positively beneficial. The patient was in a sthenic
condition. She had lost very little blood at the time
of labor, and the symptoms of phrenitis were very
marked.

PUERPERAL MAXIA. 181

Vascular sedatives are equally useless, except when
the mania is complicated with, evident symptoms of
some latent local inflammation, a complication which
cannot be too sedulously watched for.

Laxatives and emetics should never be given, ex-
cept when there are positive indications of their neces-
sity.

As insomnia is one of the most striking features of
puerperal mania, opiates are naturally suggested, and I
have found, in the cases that I have seen in consulta-
tion, that they have generally been tried. Dr. Tuke
says : " Drugs seem of no avail ; opiates, more especial-
ly, do more harm than good. A large dose, given at
the very first indication of insanity, is said to have the
effect of cutting short the attack ; this I cannot speak
to, but repeat the statement previously made: that
when it has fairly established itself, although large
doses of opium may moderate the intensity, they tend
to prolong the period of mania."

For my own part, I have never seen opium in any
doses cut short the attack, although I have often
known it to be tried. I think I have seen opiates
prove of great service, in some few cases, where I have
believed that the mania was complicated with latent
pelvic peritonitis. But it is only in such cases that I
have ever found them apparently useful. Mind you, I
am now speaking of mania, not of melancholia.

It is obvious that the leading indication is to allay
the brain-excitement. The question is, How best to
accomplish this ? My answer would be :

1. By restoring exhausted nerve-power:

(.) By improving the nutrition of the brain. I
look upon good food, a plenty of such as is easily as-
similated, to be one cf the most important points in

182 PUERPERAL DISEASES.

the treatment of this malady. Some obstinately refuse
to take any thing, but, by management, tact, and per-
severance, this difficulty is generally overcome after a
time. Then, in many cases, even in the early periods
of mania, you will find that tonics are of great service.
Those which I most frequently recommend are, the
tincture of the chloride of iron, the chlorate of potash,
and the sulphate of bebeerine. The latter is greatly to
be preferred to quinine, from the fact that it has much
less tendency to induce cerebral congestion.

(&.) By inducing sleep. This is nearly as impor-
tant in puerperal mania as in delirium tremens, but
there is this difference : In delirium treinens, when we
have secured for our patient some hours of refreshing
sleep, we ordinarily find that the disease is essentially
overcome. But this is not the case in puerperal mania ;
for I have often seen patients, in whom good sleep has
been secured for nights ; and yet, when awake, the
maniacal condition has continued for some days as
before. Still, there is no doubt that every hour of good,
sound sleep contributes something toward the patient's
recovery. Now, neither opium nor the bromide of
potassium will produce sleep in maniacal patients, as a
general rule. I have used the latter largely for this
purpose in puerperal mania. I have often found it very
useful under certain circumstances, to which I shall
presently allude, but not as an hypnotic in mania.

Soon after the discovery of the anaesthetic effect of
chloroform, by Professor Simpson, I suppose that I, in
common with many others, anticipated great benefits
from its use in puerperal mania. But I think all have
been disappointed in this particular. The sleep in-
duced was of very short duration, patients seemed in no
way benefited by this sleep, and generally the excite-

PUERPERAL MANIA. 183

inent seemed greater after its use than before. Professor
Simpson says : " I have sometimes found that a patient,
after being anaesthetized by means of chloroform, has
continued to sleep on, and has afterward wakened up
quite well." I am quite confident that this must be a
very exceptional result, for I have never seen it.

It is in this disease that I have found the chloral-
hydrate of immense value. It apparently does not inter-
fere in the slightest degree with any of the organic
functions ; it is not followed by any unpleasant second-
ary effects, as opium often, and bromide of potassium
sometimes is; and in mania I have never yet seen it
fail to induce sleep.

Whatever chemists may tell us, I am certain that
the effects of chloroform and of chloral-hydrate differ in
many essential particulars :

Chloroform induces a very profound sleep, but this
is of short duration. If the patient be awakened, she
does not fall asleep again, without a renewal of its
administration.

The sleep from chloral-hydrate is prolonged often
for hours, and, if awakened while under the influence,
the patient at once falls asleep again.

After the sleep of chloroform, there is frequently
cerebral disturbance for a few moments after waking,
as there is also just before the subject comes under its
influence.

The sleep from chloral-hydrate is neither preceded
nor followed by symptoms indicative of cerebral ex-
citement.

Chloroform is of immense value in preventing and
controlling convulsions, but is of no service in produc-
ing sleep and allaying excitement in the maniacal.

The chloral-hydrate has very little if any influence

184 PUERPERAL DISEASES.

in preventing or controlling convulsions, but is by far
the best agent known for inducing sleep in puerperal
mania. I usually prescribe it in fifteen or twenty-grain
doses, well diluted, to be repeated every two hours
until the effect is produced. I have given it in thirty
and forty-grain doses, but I have now settled on the
smaller quantity, as being safer and just as efficacious,
if repeated until the desired influence is obtained. 1
2. By combating all complications :

1 Since this lecture lias passed out of my hands for publication, riy at-
tention has been called to a very important and interesting paper, published
during my absence from the country, in the New York Medical Journal,
June, 1872, by Robert Amory, M. D., Boston, Mass., entitled "Experi-
ments on Animals, disproving the Theory that Chloral-hydrate acts on the
Organism on account of its Decomposition into Chloroform, by the Alka-
line Carbonates in the Blood."

The results of these experiments seem curiously to harmonize with my
observations from the clinical study of the comparative action of the chlo-
ral-hydrate on the organism.

On the other side, it should be mentioned that Dr. Oscar Liebreich, to
whom the world is indebted for the discovery of the immense therapeutic
value of the chloral-hydrate, has recently published a third edition of his
"Treatise on the Chloral-hydrate," in which he still maintains his original
theory in regard to the action of this agent by its decomposition in the
blood into chloroform. His reasoning, like my own, is based purely on
clinical observations, but with quite opposite results. For example, he
mentions that, in a case of gout, a dose of hydrate of chloral produced ex-
citement, but, when the patient had been treated with carbonate of soda
for a week, the same dose acted as an hypnotic. Dr. Liebreich's theory is,
that this was due to the circumstance that, at tirst, the formation of urate
of soda deprived the blood of its normal amount of alkali, and thus pre-
vented the transformation of the chloral into chloroform. In confirmation
of this theory, he asserts that it has been noticed in typhus, where there is
an excess of alkali in the blood, that small doses of chloral readily produced
.sleep, while larger (even moderate) quantities gave rise to symptoms of
poisoning. He also states that the hydrate of chloral has been found to
act beneficially in a number of cases of puerperal convulsions, and ho ex-
plains this by accepting French's theory, that the convulsive attacks are
connected with the transformation of urea into carbonate of ammonia, and
by supposing that, besides the production of chloroform, there is a forma-
tion of hydrochloric acid which neutralizes the ammonia.

In my lecture on puerperal convulsions, it will be seen that I am com-

PUERPERAL MANIA. 185

(# .) Functional. If there be constipation, give lax-
atives. If the renal secretion be deficient, of course,
diuretics will be useful. It is always important to
watch that the bladder does not become over-dis-
tended.

(b.) Cerebral Erethism. Maniacal excitement often
produces a cerebral erethism shown by the flushed
face and red eyes which, no doubt, was formerly often
mistaken for phrenitis. It is in just these cases that the
bromide of potassium is very useful. I have frequently
seen great benefit from giving twenty to thirty grains
once in six hours. But it does not often induce sleep,
under these circumstances, and so at night I suspend
the bromide, and give the chloral-hydrate.

(<?.) Local Inflammations. Let me again warn you
of the dansrer of overlooking the existence of these com-

o ~

plications, as they are not manifested by the usual
symptoms, being masked by the mania. The treat-
ment must be adapted to the special form and locality
of the inflammation, modified by the general condition
of the patient.

In this connection, I will give you the brief history
of a case which, to me, was very interesting and sugges-
tive : In November, 1869, a medical friend asked me to
see his wife, who had been confined with her sixth child,
just a week before. I had never before seen her, and
found her pale, with a hot skin, a staring expression of
the eyes, and a pulse of 140. Every question asked her,

pelled to differ from Dr. Liebreich, both as regards the facts and the theo-
ries, as to the action and the value of this agent in puerperal convulsions.

It seems to me that the experiments of Dr. Amory, so far as they have
gone, have conclusively demonstrated that the theory of Dr. Liebreich is
erroneous. It is to be hoped that Dr. Amory will continue his experi-
ments, as he intimates his purpose of doing, to determine whether chloro-
form be present in the urine of a person taking chloral.

186 PUERPERAL DISEASES.

she answered with an abrupt negative. The day be-
fore, she had taken castor-oil, and seemed to suffer a
good deal of pain when the medicine acted, and for the
first twenty-four hours after labor there had apparently
been a good deal of difficulty and pain in passing water.
She would neither permit myself nor her husband to
place the hand upon the lower part of the abdomen, and
of course a vaginal examination was not to be thought o
When I attempted to put a thermometer in the axilla,
she exhibited great resentment of manner, apparently
thinking it immodest. On retiring to another room, I
found that she had been a model w T ife, and that her
husband had been accustomed to lean upon her, leaving
to her the management of all his affairs, except those
which were purely professional.

Three weeks before h.er confinement, she had lost by
death her eldest daughter by a former husband, and
since that period she had never been seen to weep, and
had never spoken of her daughter, but attended to all
her duties with a silent, unnatural calmness of manner.
Her labor had not been long, and was in every respect
normal. The mammary secretion was less than in her
former confinements, and she seemed unusually weak ; .
for this reason her husband had given her, for the
two days previous to my seeing her, a little brandy
twice a day. On the day before, she began to ask very
frequently for it, and this excited the alarm of her hus-
band. He had formerly held an official position where
he had seen a great deal of delirium tremens, probably
a hundred-fold more than I ever saw. From the fact
that, before this illness, she would take wine, only
when absolutely prescribed, and that now she urgent-
ly demanded^ brandy, and also from the change of
her manner, her husband had adopted the theory, ter-

PUEEPERAL MANIA. 187

ribly distressing to him, that grief had driven her to
secret drinking, and that she was now on the verge of
delirium tremens.

I should mention, as a curious circumstance, that he
had been in active practice thirty-two years, and had
never seen a case of puerperal mania, although other
physicians, who have been equally long in practice, have
told me the same thing.

I expressed the strong conviction that she had
severe inflammation of the pelvic organs, and that she
was about to have puerperal mania, I suggested that
poultices should be kept over the lower part of the
abdomen, that a suppository of the aqueous extract
of opium and three grains of the butter of cacao
should be pushed into the rectum every third hour;
that she should have beef-tea, all she could be induced
to take, at short intervals ; and that, as a means of
bribery and corruption, to induce her to permit the use
of the suppositories, she should havie a tablespoonful
of brandy in a half-tumbler of milk after each supposi-
tory was introduced.

The next afternoon (Sunday) I was again sum-
moned, when I found her furiously maniacal, with all
the characteristic symptoms of puerperal mania. She
had kept the poultice on about two hours, and then took
it off and threw it violently at the head of her husband.
She had not permitted the use of a single suppository.
She had taken no beef-tea, and but one glass of milk
and brandy. About noon, she became very violent,
perfectly astounding her family by her swearing and
language generally. I put her under the influence of
chloroform as soon as possible, and then made a careful
examination. The evidences of peri-metritic inflamma-
tion were conclusive, and the whole abdomen was very

188 PUERPERAL DISEASES.

much swollen and tympanitic. On coming out from
the influence of the anaesthetic, she was even more vio-
lent than before. While under the effects of the chloro-
form, the pulse was 120, and the temperature, 105.

As I looked upon the peritoneal inflammation as
the dangerous feature in this case, I advised that all
our efforts should be directed to arrest this, and that
we should address no treatment to the cure of the mania.
I recommended that ten drops of the tincture of the
veratrum viride and three drops of Magendie's solu-
tion of morphia should be given every hour, until there
should be some indication for suspending or diminish-
ing one or both of these articles. I saw her ao-ain late

o S3

in the evening, at seven the next morning, and again,
before eleven, and at three in the afternoon. Both
medicines were continued without interruption, and
without any apparent effect.

Early in the evening, I received an urgent summons
to see her, as her husband believed her to be dying.
I found her under the full influence of the veratrum
viride. Her pulse was full, beating slowly at the rate
of 44 per minute. Her face was very pale, her skin
cool ; she was sweating most profusely, and had. vom-
ited twice. She was constantly talking in a low tone,
very rapidly, indistinctly, and incoherently. She had
taken over half an ounce of the tincture of veratrum
viride, and more than a drachm of Magendie's solution. I
have used the veratrum viride more than thirty years ;
but this lady took at least four times the quantity I
have ever given to any other patient before she began
to show any evidence of its specific effects. The symp-
toms which most alarmed her husband I knew to be
due to the veratrum viride, and I assured him with
great confidence that she was radically better. She

PUEEPEEAL MANIA. 189

was very thirsty, and swallowed with avidity every
thing put into her mouth. I now recommended that
she should have beef-tea or milk-punch at short inter-
vals, and no medicine, unless the pulse rose above 80,
when she was to have five drops of the veratrum
viride, to be repeated in such doses as might be neces-
sary to keep it below that point. She slept none that
night nor the next day, but kept up her incessant chat-
tering in a low tone. She took the veratrum viride,
three times, with three drops of the morphia, during
the following twenty-four hours. She also took a suffi-
cient quantity of beef-tea and milk-punch.

I now proposed to give her a half-drachm of the chlo-
ral-hydrate, stating that I had never yet seen or heard of
its being given in such a case, as it was quite a new medi-
cine. Her husband consented with great reluctance. In
less than ten minutes after she took it, she was asleep,
and continued so for seven and a half hours, except that
three times during this period her husband roused her
sufficiently to give her some nutriment. The chloral-
hydrate was repeated the next night. The mania now
gave place to occasional lucid intervals, with more or
less intellectual wandering, which continued for some
weeks, but perceptibly and constantly decreased until
she was perfectly restored as to her mental condition.
But I regret to say that she is still a feeble woman. I
examined her but a short time since, and found the
uterus very decidedly enlarged and immovable in the
pelvic cavity, and she suffers from the symptoms which
are generally associated with this condition.

3. By such moral treatment as will best secure the
patient against all causes of nervous excitement, and
will tend to excite in her a desire to obtain self-
control :

190 PUERPERAL DISEASES.

This is difficult to define in words, and still more
difficult to secure. It implies the greatest kindness,
but no demonstrations of excessive solicitude ; firmness,
but no appearance of governing or controlling; inces-
sant care and watchfulness, concealed by an air of
indifference; a ready tact in turning the current of
thought or will, but no contradiction or impatience.
Few nurses, and still fewer friends, are able to exercise
all these combined qualities. The physician will better
teach them to the attendants, by his own manner when
with the patient, than by didactic instructions.

If the moral treatment can be secured in a great
measure at home, and the patient begin to show une-
quivocal signs of improvement within two or three
weeks of the commencement of the attack, it is better
that she should remain at home. But if she cannot have
the advantage of proper moral treatment, and especially
if the malady be not positively mitigated within the
puerperal month, I have no doubt that the chances of
recovery will be greatly increased by placing her in an
asylum, w^here all the benefits of moral treatment are
certain to be secured. This should not be delayed too
long ; as all physicians to these institutions are agreed
in saying that the probabilities of cure are diminished
just in proportion to the duration of the disease.

There is not the same objection to the removal to
insane hospitals of those who suffer from puerperal
mania, as exists in other forms of insanity, because this
removal does not suggest the same loss of family or
social position. The public are ready to accept the puer-
peral state, which does not imply previous weakness of
intellect or mental disease, as the specific cause of the
overthrow of the mind, and therefore they have sound
reasons for anticipating a perfect recovery.

PUERPERAL MAXIA. 191

I shall only add by way of caution that, in my ob-
servation, even those who are perfectly cured generally
manifest some little occasional signs of moral perversion
or mental eccentricity for months, and sometimes for a
year or more.

I have nothing to add in regard to puerperal
melancholia, because I have literally no clinical experi-
ence in this malady. I have seen but one case in
private practice. In this hospital, we frequently have
cases of this form of the disease, although it is very
much more rare than mania, but, as it is generally
developed the latter half of the puerperal month, and
as it is more chronic in its type, the patients either die
of some intercurrent disease, which is often the case, or
are transferred to the asylum on Blackwell's Island.

LECTUKE XI.

RELAXATION OF THE PELVIC SYMPHYSE3.

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 Scanzoui Debout Stoltz May be
developed during pregnancy A certain degree of relaxation physiological
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.

" CASE XIII. Mary , born in Ireland, age unknown, married,

admitted into Bellevue, January 12, 1861. Was delivered by Dr.
Elliot, with forceps, of her seventh living child, five weeks since.
Weight of child, eight and a half pounds, male. Former labors have
always been short and natural. Patient suffered from severe after-
pains, and for five days it was necessary to use the catheter. Had no
other bad symptom, but, when she attempted to stand, she found it
impossible, nor has she been able to walk, even with assistance, since
her confinement. In all other respects, her health is perfectly good.
The lochia ceased about two weeks after her confinement. Lacta-
tion is abundant, there is no vaginal discharge, and no pains in tlie
pelvic region, except when she attempts to stand or walk. Has
been suspected of malingering."

" The history of the labor will be best given by the following
note from Dr. Elliot, which I shall read :

" Dr. Fernandez, the house-physician, sent for me about three

(/clock A. M., to see Mary , in her seventh or eighth labor.

Former labors had been easy. The membranes had ruptured twen-
ty-two hours before, and the pains had been regular and frequent,

RELAXATION OF THE PELVIC SYMPHYSES. 193

but not strong. For two hours, they had been decreasing in force
and frequency. Her pulse was now 120, and weak ; she was very
restless, tossing about in the bed, and her mind was wandering.
Before my arrival, the catheter had been used, and about twenty
ounces of urine drawn off. On examination, I found the pelvis nor-
mal, and it seemed to me rather larger than usual. The head was
but slightly engaged at the brim, with the occiput at the right
sacro-iliac symphysis. She was put under chloroform, and I applied
my forceps, and, rotating the occiput round to the symphysis pubis,
I delivered with great ease. My forceps worked admirably, and I
do not believe that I could have accomplished rotation, at least so
easily, by any other. The catheter was necessary for a few days,
but I heard of no other abnormal symptom during my term of ser-
vice."

Gentlemen : You now see that this patient can stand,
resting her weight on one or the other leg, but not on
both at the same time, and those who are near can see a
perceptible elevation of the ilium on the side upon which
she bears her weight, and that her head and body in-
stinctively incline to the side that she rests upon. These
attempts evidently cause pain, but the character and seat
of the pain, the patient describes very obscurely. JSTow,
placing her on the table, you observe that strong trac-
tion on either leg causes a perceptible movement of the
pubic bone of that side I should think, an eighth of
an inch. These movements, however, cause much less
pain than movements with the weight of the trunk
resting upon the pelvis. I cannot demonstrate to you
that there is widening or swelling of the interosse-
ous tissues between the pubic bones, nor am I abso-
lutely certain that there is any. But you can see that
she is short, not more than five feet in height ; that, for
a woman of her size, she has very broad, capacious hips ;
and, although confined only five weeks since, she has a
very lax, pendulous abdomen, with a heavy fold of in-

194: PUERPERAL DISEASES.

tegument hanging over the crest of the pubes. I saw
her for the first time yesterday, and then found, by
using a catheter, after she had evacuated the bladder as
thoroughly as possible, there would still remain four or
five ounces of urine. This experiment hns been re-
peated three times, with the same result.

The symptoms that this patient suffers from are
due to relaxation of the symphysis pubis, an affection
of rare occurrence, as you will infer from the fact that
this is the only case of the kind that I have known of
in this hospital ; but I have seen quite a number of
cases in private practice and in consultation. In many
of your obstetric works, you will find no allusion to it,
and in most others there is only a slight reference. In
the work of Denman, in the first part, in describing the
anatomy of the pelvis, he gives a very complete expo-
sition of this affection ; and Dr. Francis, the editor, adds
a full note on the subject, with the report of a case in
the practice of Dr. Wright Post, and another of relaxa-
tion of the sacro-iliac symphysis, in the practice of
Dr. Hosack. Next to Denman, Burns and Meigs give
the best discussion on the subject. Churchill, Tyler
Smith, Cazeaux, and Bedford, make only a slight allu-
sion to it.

The most recent, as well as the most complete essay
on this subject, in the English language, is by my friend,
Dr. Frederick Gr. Snelling, of this city, which was pub-
lished in the American Journal of Obstetrics, vol. ii.,
No. 3, February, 1870. I shall have frequent occasion,
in my remarks, to refer to this essay.

Although the subject has been too much overlooked
by obstetric writers generally, yet it has been known in
medicine, since the time of Hippocrates, and has been
the theme of several monographs by able authorities,

EELAXATIOX OF THE PELVIC SYMPHYSES. 195

which you will find referred to in the paper by Dr. Snel-
ling r . It may occur in the practice of any one of you ;
and, as nothing is more apt to damage the reputation
of a young obstetrician than that a patient should fail to
recover rapidly after childbirth, unless the obstacle to
her recovery can be made perfectly clear to her friends,
you see the importance of being alive to the existence
of this affection, and of fully understanding its char-
acter.

Before telling you my own views, I shall give you
the opinions on this subject of the most recent German
and French writers.

In the fourth edition of Scanzoni's "Lehrbuch der
Geburtshiilfe," his views on this subject are thus given :

"Sometimes the ordinary relaxation of the pelvic
ligaments during the gravid state increases to such* an
abnormal degree that every stronger contraction of the
muscles inserted into the pelvis occasions considerable
motion of the bones upon one another, which is at-
tended with the most tormenting pains, and renders
the slightest motion 'impossible, confining the patient
uninterruptedly in bed. The affection begins with a
dull pain in the pelvic ligaments, in the thighs, and in
the lumbar region ; motion gradually becomes difficult
and painful, so that walking is impossible. The patient
feels, on standing, as though the unsteady body would
fairly tear the pelvis asunder, and sink between the
feet to the ground. In higher degrees of the trouble,-
it is possible to feel the motion of the pubic bones at
the symphysis, and to hear and feel a peculiar crepitus,
such as exists between fragments of broken bone. The
skin over the symphysis becomes so sensitive as to
render the slightest touch intolerable. We are not to

include in this category cases of osteomalacia, and puer-

196 PUERPERAL DISEASES.

peral inflammation of the symphysis, where the relaxa-
tion is simply a local expression of a general disease.

" It occurs especially in persons who have had preg-
nancies following one another in rapid succession.
Many were persons with narrow pelves, presenting a
repetition of a normal phenomenon in many classes of
animals, where the size of the fcetus requires a consid-
erable separation of the bones, and an enlargement of
the pelvic apertures.

"In these cases, it seems as though the uterus devel-

' O

oped in the narrow pelvis, and, hindered in its ascent,
worked with such force toward the periphery of the
pelvis, as to contribute in an important manner to
separation of the bones, through the relaxation of the
cartilage and ligaments. We have frequently seen this
condition in narrow pelves, reaching such a degree, that
even moderate tractions with forceps have caused a
rupture of these connections, and a separation of the
pubic bones. We have likewise observed that puer-
peral inflammations of the pelvic bones are especially
frequent in persons with contracted pelves.

" We regard the influence of this disease upon preg-
nancy and labor to be highly exaggerated, and we be-
lieve the most painful symptoms ascribed to it belong
properly to other diseases, especially to osteomalacia.
We regard repeated exact observations as alone ca-
pable of throwing light upon this subject and the
whole treatment consists in avoiding all exertion dur-
ing pregnancy, and wearing a suitable bandage. Tonic
and astringent internal remedies, and fomentations,
accomplish nothing. We know of no case of recovery
during pregnancy, but have several observations of per-
fect cures after delivery." (Grelurtshiilfe, fourth edi-
tion, vol. ii., p. 126.)

KELAXATIOX OF THE PELYIO SYMPHYSES. 197

In the third volume, page 487, of the same work,
Scanzoni remarks that he has met with but a single
case of abnormal relaxation of the pelvic ligaments,
occurring independently of any inflammatory process.
This was the case of a young woman, who complained,
in the course of her second pregnancy, of painful sen-
sations in the sacro-iliac synchondroses, and difficulty
in using the lower extremities. These pains increased
to a considerable degree during labor, which termi-
nated naturally, after forty-two hours' duration. The
child's head was unusually hard and large. When
we saw her, four months after delivery, she was anaemic,
but the functions of the internal organs were undis-
turbed. On the other hand, every motion of the lower
portion of the body was impossible, partly on account
of violent pains in the sacral synchondroses and pubic
symphysis, and partly from a feeling of giving way in
the ligaments. Besides, every time she attempted to
turn over, she felt a rattling in the region of the right
synchondrosis, as though two bony surfaces were rubbed
upon one another.

An examination showed no perceptible morbid
alteration, except an abnormal sensitiveness in the
region of the right sacral ligament, but we often had oc-
casion to feel clearly the above-mentioned rattling by
means of the outspread hand. The patient said the
motion of the syinphysis some weeks after delivery was
so considerable that, upon raising the right lower ex-
tremity with the hand, the elevation of the extremity
.of the right pubic bone could be quite plainly dis-
tinguished. She was eight months under treatment,
during which time, neither local inflammatory nor gen-
eral feverish symptoms were manifested. After four
months' treatment (iron, iodide of potash, ointments

198 PUERPERAL DISEASES.

containing narcotic remedies, steel-baths), she' had
recovered sufficiently to turn in bed, while the rattling
had entirely disappeared. After six months, she was
able to walk short distances, and finally the employ-
ment of Briickenau mud-baths brought about complete
recovery. Soon after, she again became pregnant, and
the labor terminated without any disturbance. The
patient, during childbed, complained of some pain in
the right synchondrosis, but this soon entirely disap-
peared.

"Such cases are to be distinguished from rupture
of the pelvic ligaments, whicji, as a rule, result from
difficult labors terminated by forceps. We have only
seen one case after a natural labor :

"A woman, twenty-two years old, accustomed to
field-work, who had already had one natural labor, suf-
fered from most violent pain during her second confine-
ment, which ended but slowly. The child was unusually
large, the head was very hard, and above the standard,
in all its diameters. After delivery, the woman was ex-
tremely exhausted and complained of violent pains in
the region of the right hip, running down to the knee.
These pains increased in intensity until the next day,
when they became worse, so that the patient could not
make- the least movement of the lower half of the body.
At each attempt to move, she felt crepitus in the region
of the right sacro-iliac synchondrosis. In this spot there
appeared a long, smooth, reddened, and sensitive swell-
ing, the size of the palm of the hand, which was the seat
of the most violent pains upon pressure. There was
pain, also, in vaginal examination, on touching the right
sacral symphysis. When the patient moved, crepitus
could be plainly felt, and a loud, crackling sound heard
several steps from the bed. Fourteen days after de-

RELAXATION OF THE PELVIC SYJIPHYSES. 199

livery, a liard swelling, along Poupart's ligament, two
fingers' breadth, caused by an exudation in the perito-
naeum, appeared, which yielded to warm baths and
cataplasms, after two weeks. Six weeks after labor,
the patient was able to make attempts at walking, by
supporting the body with both arms upon the right
knee. In the eighth week, violent pains returned in the
region of the right synchondrosis, while the swelling
in this situation presented fluctuation, so that the ab-
scess had to be opened ; whereupon more than a
pound of thickened pus escaped. On introducing the
probe, the rough, bare-lying bones could be felt, with-
out the probe, however, passing into the joint itself.
An improvement now took place, and, two days later,
after about two ounces of a sticky, clear, albuminous
fluid had passed away, the wound healed rapidly. Four-
teen weeks after parturition, the patient was allowed to
leave, in a healthy condition, but still a little lame.

"When the rupture has taken place at the sym-
physis pubis, we may quite frequently diagnosticate
the malady during life, by the wide separation of the
pubic bones, while the separation of the sacro-iliac
synchondrosis can only be rendered probable by the
presence, at the same time, of inflammatory manifesta-
tions in the ligaments, also taking into consideration
the events occurring during the course of labor."

In ' ; Schmidt's Jahrbuch," 1868, there is the follow-
ing resume from Debout, Danyau, and Stoltz :

" Debout, and most other authors, call attention to
a minor degree of relaxation of the pelvic ligaments,
during the latter months of pregnancy and after par-
turition. This relaxation, however, soon proceeds so
far, that the movements of the bones upon one another
are recognizable. Jacquier shows, by several exam-

200 PUERPERAL DISEASES.

pies, that the same thing may occur in non-pregnant
women, and likewise in males. Debout furnishes
historical notices of the occurrence of relaxation of
the ligaments, with cases. Heretofore, constitutional
diseases, scorbutic and scrofulous diatheses, were re-
garded as the most important causes of the difficulty.
Debout, however, found seventeen cases, nearly half of
which were persons of robust constitution ; and in none,
was there the slightest trace of scrofula or rachitis. In
most cases, the first symptoms were manifested during
pregnancy, some, at the outset, but most, in the seventh
and eighth months. The attack began usually with
slight pains, at first experienced only after protracted
exertion or lifting heavy weights. These pains after-
ward became more severe, radiating from the symphysis
pubis and the sacro-iliac synchondrosis. There was then
an increased mobility of the pelvic bones. This usually
occurred, to a greater degree, immediately after par-
turition. The pains frequently increased, so as to be-
come very violent upon lifting the feet. They were
often attributed to general debility, or, as Danyau had
already remarked, to some uterine trouble occurring as
a complication, especially as they frequently disap-
peared after the employment of measures adapted to
uterine complaints, such as rest, lying in bed, etc.

" Diagnosis. The impossibility, when recumbent, of
the patient's raising the legs, especially the limb corre-
sponding to the affected side, is a most important symp-
tom. Shortly after parturition, there is evident motion
at the points of junction of the pelvic bones, so that,
upon extending and flexing the femur, with one hand
upon the symphysis pubis, the pubic bone upon the Side
of the femur may be felt rising and sinking. The same
motion is experienced, if the hand be placed on the ilium.

RELAXATION OF THE PELVIC SYMPHYSES. 201

To investigate the sacro-iliac joint, which is the one most
frequently affected, seize the cristse ilii with both hands,
and get the patient to walk, either with or without
help. At each step, the ilium of the affected side is
felt to be shoved upward, while that of the other side
stands considerably lower. Occasionally, the patients
complain of a sensation as though the body were sink-
ing between the thighs. The pains are not propor-
tioned to the degree of mobility. In some cases (the
result of puerperal processes), inflammation and suppu-
ration had partially or fully destroyed the joints.

" Treatment. The most suitable time to cure a case
is during the period of childbed ; later attempts often
require much time. Debout prefers compression by
means of Martin's truss. In the last months of preg-
nancy, women incommoded in walking are surely re-
lieved by the employment of a leather spring-bandage,
stuffed like a hernia-truss, and buckling in front. Wear-
ing the bandage two or three months after delivery suf-
fices to prevent relapses. When the bandage is applied
at a late period, say, after a year's time, the cure is of-
ten no longer possible, or at best imperfect, unless, per-
haps, a subsequent pregnancy, during which, and four
or five months after delivery, a bandage is worn, ac-
complishes a recovery. Where the trouble has been
of several years' duration, th'e bandage will not, of
course, cure, but simply render walking possible.
Couerdt furnishes two cases, treated by Martin's band-
age with favorable results. Pategnat reports a case
where radical recovery took place, in which he em-
ployed a towel-bandage about the pelvis. In these
cases, there was no rupture, but a simple stretching of
the pelvic ligaments. Stoltz regards the relaxation of
the pelvic ligaments as the result of a pathological pro-

202 PUERPEKAL DISEASES.

cess. The physiological relaxation in most pregnant
women could not possibly produce so wide a separation
of the syinphysis as to render parturition more easy. It
is then really of a pathological nature, and occurs either
spontaneously and slowly, or suddenly, upon the em-
ployment of force, or in consequence of extraordinary
natural efforts. In the first class of cases, there were,
abdominal plethora, an unusual enlargement of the ab-
domen, as the result of interference in the circulation,
and a considerably increased volume of the uterus ; and,
in connection with these occurrences, proximate pressure
exercised upon the pelvic walls, a cachectic condition, im-
moderate bodily exercise and exhaustion, rarely or never
scrofulous dyscrasia, acted as direct causes, whereby ir-
ritation and inflammation were produced, and served
as the forerunners of the disease in question. As cura-
tive means, the malady seldom requires that the pa-
tient should remain an unusual length of time in
childbed. Besides internal tonic measures and exter-
nal remedies (salves, baths, etc.), Stoltz found great
benefit from the mineral baths at Baden-Baden. Cases
of forcible separation of the syinphysis belong to the
domain of surgery ; and bandages may prove of great
service, though Stoltz never found himself compelled to
employ them."

I have thought it my duty thus to give you the views
of the most recent eminent writers on this subject, as
there is so little to be found on it in your obstetric
works. All agree that it may be developed during preg-
nancy, generally during the last two months of gesta-
tion ; but, in some rare cases, it has occurred at an
earlier period, and has even followed abortion.

The first case of this kind which I saw was in the
early days of my professional life, 'and was developed

RELAXATION OF THE PELVIC SYMPHYSES. 203

during pregnancy. A lady, in the eighth month of her
first pregnancy, had, for several days, great difficulty in
walking, with severe pain in the pubic bones, till one
day she fell, while walking across her drawing-room.
She supposed that she had caught her toe in the carpet.
From that time up to her confinement, she could not
walk or stand. After a very careful examination, I was
unable to make out the diagnosis ; and none of the au-
thorities at my command threw any light on the ques-
tion. I therefore called in consultation two quite promi-
nent surgeons ; one of them diagnosticated fracture
of the neck of the femur ; the other, fracture of the
ilium or ischium. I watched the case very anxiously,
naturally expecting a difficult labor and some untow-
ard result ; but, to my surprise, the labor, though a
first one, proved brief and easy, with no abnormal
symptoms. The patient passed through the puerperal
condition, with nothing to excite apprehension ; yet,
on essaying to rise, it was found that she was still
wholly unable to bear her weight. Some six weeks
after confinement, I got her out of bed, and care-
fully attempted to make her walk. A point which
struck me, and which I have never seen mentioned, was
that she could stand with comparative ease, resting upon
either one les; or the other, but could not balance her-

O /

self upon both legs at once. This, of course, convinced
me that there was no fracture of the thigh-bone ; and
the fact that there was no difference in her ability to
rest upon the two sides showed that there could be no
fracture of the ilium or ischium. Led by this to exam-
ine the symphysis pubis, I thought there seemed to be
an increase of the space between the pubic bones ; and
also that the cartilage between them seemed softer than
natural. "When I left the place, some four years after-

204 PUERPERAL DISEASES.

ward, this patient was able to walk, only with great
difficulty, upon crutches. Three or four years later yet,
she was much improved, though still compelled to use
crutches. I am told that, some fifteen years after that
unfortunate pregnancy, she entirely recovered, and that
she now walks perfectly well.

Dr. Snelling, in the essay to which I have referred,
quotes the following very characteristic case from Pro-
fessor Hodge, of Philadelphia, although the professor
does not refer to the disease under consideration, "but
speaks of the peculiar phenomena in connection with
a retroverted uterus, disappearing upon the removal of
the displacement :

" About two months previous to the birth of the
patient's fifth child, while walking across the room, she
was suddenly checked in her progress by the seeming
dislocation of the pubic bones, which she believed to
be jointed, causing intense agony, accompanied by a
sound like a pistol-shot. Leaning on something near
by for support, her movement caused the bone to slip
into place again, when she was enabled to take a few
steps, but with great suffering. These painful sensa-
tions and sounds occurred again and again, when at-
tempting to get up or lie down, till the birth of a fine,
large child, which, it may be well to say, caused less
pain than she had ever experienced on any previous oc-
casion ; leaving her, however, with so-called prolapse
of the womb, and the innumerable distressing sensa-
tions of such disease, for eighteen months. She then
became again pregnant, and enjoyed good health until
two or three months before confinement, when she suf-
fered as before, until the birth of the child, which, contra-
ry to expectation, brought no relief. The pain in the bones
seemed permanent numbness and stiffness were pres-

RELAXATION OF THE PELVIC SYMPHYSES. 205

ent in the left hip, which also gave way, with a noise and
pain, when she would lift her foot. She then dragged
it as if paralyzed. This continued for six months,
until she was taken to Philadelphia, where she was re-
lieved of some of her suffering ; but ten months elapsed
before she was sensible of a decided improvement in
the condition of the bones."

I am fully in accord with Dr. Snelling as to the
probability that a certain degree of relaxation and
ramollissement of the symphysis occurs in many preg-
nant women, which may be regarded as physiological.
He says :

" I think it is not forcing a conclusion to regard it
as proven, from, what has been advanced, that an uncer-
tain, varying degree of relaxation or ramollissement does
obtain in a very large number of cases, in the pregnant
and puerperal condition, of a physiological and benign
character, and entirely consistent with health, and that
it is to the excess alone of this condition that the path-
ological results above described are due. The ligaments
become saturated with serurn and lose their firm and re-
silient qualities ; the synovia is greatly increased and
presses the bones asunder ; the pelvis becomes incapa-
ble of sustaining the weight of the body, and so, grad-
ually yields to the weight above ; or some slight and
insignificant movement of the patient suifices to precip-
itate the whole train of symptoms suddenly and at once.
I am convince!, that more such cases occur than is gen-
erally believed. There are so many distressing sensa-
tions incident to the lying-in state, that, if the affection
be but slight and non-persistent, it is most natural to
attribute it to the puerperal condition, or to some uter-
ine displacement or irritation. Women themselves are
so accustomed to vague pelvic and uterine and lumbar

206 PUERPERAL DISEASES.

pains, that they almost regard them as a natural heri-
tage, and themselves assist in deceiving the physician
by ascribing them to the uterine system."

In a great majority of cases, however, where this has
gone to the extent which constitutes a pathological con-
dition, the characteristic phenomena are first manifested
during the puerperal period, as in the case that you have
just seen.

Dr. Snelling relates, also, the following -case, occur-'
ring in his practice :

" Mrs. H , aged twenty-two, primipara, was safe-
ly delivered, on the 14th of last August, of a healthy
female child, at full term. The labor was short, lasting
but eleven hours; the presentation, normal, and deliv-
ery was accomplished without accident. The case pro-
gressed favorably in every respect until the tenth day
after confinement, when she was allowed to leave her
bed. She almost immediately complained of the great
difficulty of walking, and of the singularly distressing
sensation caused by motion in an upright position. I
made a digital examination, expecting to find mal-
position of the womb. I found that there was relaxa-
tion of the anterior wall of the vagina, but the womb

was high up, and not larger nor heavier than it should
be at such a time. I advised rest in the recumbent posi-
tion, and (the lochia having ceased) injections of alum
and water, a pill of two grains of the extract of gentian
and one-fourth of a grain of extract of nux-vomica, a3
a general tonic. At my next visit, two days afterward,
having remained the greater part of the time in a re-
cumbent position, she was somewhat improved, but the
improvement was but temporary. At a subsequent
visit, I found her in tears, all her symptoms and sensa-
tions having returned. They were peculiar. There were

EELAXATIOX OF THE PELVIC SYMPHYSES. 207

vague pains in the pelvis, no particular sense of drag-
ging or weight, none of the train of nervous symptoms
which attend uterine displacements ; but her main com-
plaint was of the impossibility of walking. She could
not tell why, nor for what reason, but she simply could
not do it. After dragging herself partly across the
room, her sensations became so peculiar and unendur-
able that she was forced to sit down at once, lest she
should fall. Professor Barker, who saw the case in con-
sultation with me, thought that it might be a case of
relaxation ; and I therefore examined her in an upright
position, by grasping the symphysis pubis, from before
backward, between the two fingers in the vagina and
the thumb upon the mons veneris, and then directing
the patient to balance herself first upon one leg and
then upon the other. The movement of the bones was
distinctly felt, one upon the other, to the extent of a
quarter of an inch or more. A girdle firmly applied
about the hips relieved her in two months."

Causes. Scanzoni seems to regard this malady as
one which occurs most frequently in women with nar-
row pelves, and as somewhat analogous to the phenom-
ena which occur normally in many classes of animals,
where the size of the fcetus requires a considerable
separation of the bones and an enlargement of the pel-
vic aperture. He says, " that it seems as though the
uterus developed in the narrow pelvis, and, being
hindered in its ascent, it worked with such force tow-
ard the periphery of the pelvis, as to contribute in an
important manner to separation of the bones, through
the relaxation of the cartilage and ligaments."

o o

This theory seems to my mind wholly untenable,
and as not having the good sense and logical force
which ordinarily characterize this eminent writer.

208 PUERPERAL DISEASES.

To make this explanation valid, the symptoms of
this affection should be manifested in the early periods
of pregnancy; whereas such an occurrence is very ex-
ceptional. Again, the uterus rises out of the pelvis
into the abdominal cavity just as soon as the progress
of its development demands this change of position,
the period being earlier in those with a narrow pelvis
than in those with a broad pelvis.

Again, I believe the fact to be, that this malady
occurs most frequently in those whose pelves are very
broad and capacious at the superior strait. Such, at
least, has been my observation. Many of the published
reports of such cases do not allude to the size and form
of the pelvis; I have studied all the reports of such
cases as I can find, with reference to this, and I see
that most who do refer to the size of the pelvis, speak
of it as normal or more than usually large ; but I must
add, with the implication, that this feature made the
case more remarkable.

In the cases that I have seen, the process of labor,
whether unaided, or assisted by art, bore no relation to
the case as a cause of the malady. In those reported
by authors, where the symptoms of the disease imme-
diately followed difficult labors, it is quite evident that
the pathological condition of the tissues of the sym-
physis must have existed antecedent to the labor.

All authors are agreed in discarding constitutional
diseases, such as cachexia or scrofulous dyscrasia, as a
cause of the malady.

My belief is, that the serous infiltration and con-
sequent relaxation of the tissues of the symphyses may
be due to the mechanical obstruction to the return of
the venous blood by the pressure of the presenting
part or the foetal head. In the cases which I have seen

RELAXATION OF THE PELVIC SYMPHYSES. 209

before labor, the patients have had very broad and
capacious pelves, and the foetal head has lain very low
in the pelvic cavity during the last months of ges-
tation.

Those that I have seen after confinement, have had
the same kind of pelvis, an unusually pendulous ab-
domen, and great difficulty or impossibility of com-
pletely evacuating the bladder, doubtless due to over-
distention, during pregnancy, from the same mechanical
cause which produced the serous infiltration of the
tissues of the symphysis. To this cause is to be ascribed,
the irritable bladder, which Churchill and some others
have mentioned as frequently attendant on these cases.

During, gestation, there is an increased vascular
activity of all the pelvic organs, and, no doubt, a certain
amount of relaxation of all the pelvic articulations.
But the propositions of Martinelli, maintained before
the Imperial Academy of Medicine in 1867, that, during
pregnancy and labor, the different parts of the female
pelvis are movable in a high degree, and that this mo-
bility is not fortuitous, but an indispensable condition
of childbirth, are, I believe, altogether erroneous. Such
was the accepted doctrine, in the time of Sigault, whose
suggestion to divide the symphysis pubis by an opera-
tion in cases of difficult labor, was received by the
medical world with unparalleled enthusiasm, but is
now discarded, with equal unanimity. It has been
demonstrated that it would require a separation of the
pubic bones to the extent of at least an inch, to gain
one or two lines in the antero-posterior diameter.

If the relaxation existed, as a physiological condi-
tion, to the extent believed by Martinelli, women could
neither stand nor walk in the last weeks of gestation,
or for some time after parturition ; for this movement in
14

210 PUERPERAL DISEASES.

bipeds requires a solid pelvis, which will not yield or
separate by the weight of the body.

The symptoms belonging to this pathological condi-
tion have been so fully detailed and illustrated by the
cases quoted, that it is needless for me now to formally
recapitulate them. But I will detain you by a few re-
marks in regard to the diagnosis of this condition. The
pathognomonic symptom, of course, is the pain produced
by attempting to stand or to walk, and, in severe cases,
an entire inability to do either. But this pain is very
vaguely defined by patients, and I have never seen one
who could fix the precise seat of the suffering, until as-
sisted by the examination of the physician. Now, if this
pain be associated with vaginal discharges, irritability
of the bladder, febrile movements, or any other consti-
tutional disturbance, it is most natural that the diffi-
culty in standing and walking should be attributed
to some cause, as cervicitis, endo-metritis, retarded
involution, which are very frequent after parturition,
instead of a cause which is very rare. I committed
this error (and a very stupid blunder it was on my
part, for I had seen enough of such cases to put me on
my guard) in the case of the wife of a friend and col-
league. On the third week after labor, she could not
stand, or walk, as she could after her previous confine-
ments. There were symptoms indicating that perfect
cicatrization of the tissues and involution were not yet
completed ; and I supposed that her symptoms were due
to this condition. Two weeks more elapsed, and the or-
gans in the pelvic cavity seemed perfectly healthy, and
not in the slightest degree sensitive to the touch ; but
it was painful for her to stand, and, in walking, she wad-
dled like a duck, and this caused severe suffering.

' O

I now examined the case more intelligently, and

RELAXATION" OF THE PELVIC SYMPHYSES. 211

found that pressure of the symphysis pubis between the
thumb and fingers caused precisely the same suffering
as standing and walking ; and, in changing the weight
of the body from one side to the other, there was a dis-
tinct and perceptible movement of the pubic bones.
There was also tenderness on pressure over the sacro-
iliac synchondroses.

On adjusting firmly a strong towel around her hips,
she could stand and walk, with but little pain or diffi-
culty. Being a person of great mechanical ingenuity,
she made for herself, what she very appropriately termed
a " hip-binder," and, after wearing this for a few weeks,4
all her difficulties in locomotion disappeared. In two
subsequent pregnancies, she suffered in the same way in
the last weeks of gestation and after confinement ; but
she did not require that I should tell her either the
cause of her troubles or the proper remedy.

In November, 1866, I was called to Philadelphia to
see a lady who had been confined eleven weeks before,
but who was still unable to walk across the room with-
out assistance, and in whom, every movement, while
standing, caused severe pain. As she did not get along
well after confinement, the physician who attended her
was dismissed, and another one was employed. He
found some local lesions, and treated her with nitrate
of silver injections and various internal remedies, for
five weeks, until she would no longer submit to his
" operations," as she called them. I adjusted a towel
very firmly around her hips, and the surprise of both
-her husband and herself was very great, when she found
that she could walk with comparative ease. I wrote a
note to both of her former attendants, informing them
of the results of my examination, and the suggestions
that I had made, but I received no reply from either.

212 PUERPERAL DISEASES.

The following summer, I met this lady walking in front
of the Kursaal, at Homburg, and was told by her that
all of her troubles disappeared in about three months
after I saw her.

Another case which I saw in consultation illustrates
how unjustly a young man may suffer in reputation
from hasty remarks by an older man of prominence.

A lady, in her third confinement, was attended by a
young physician, in whom the family felt much interest
and confidence. Both of her previous confinements had
resulted favorably, under the charge of an old physician
who had recently died. This third labor was perfectly
normal, and the lady seemed to be recovering well, un-
til she attempted to get out of bed, when she found
that she could not stand. A week and two weeks
passed, and, each time the attempt was made, the result
was the same.

The case went on to the eighth week after confine-
ment, the patient being perfectly well in all other re-
spects, when an older and much more prominent gentle-
man was called in consultation, who discovered a hard
tumor in the pelvis, which he thought scybalous, as it
proved- to be. By the use of very large injections, this
tumor disappeared, an early cure was promised, and the
young man was severely blamed for neglect. Five
weeks after this, I. was called in, as there had been no
perceptible change in her condition. The true nature
of the case was easily demonstrated, and was proven
by her subsequent recovery after the use of appropriate
means that is to say, the wearing of a " hip-binder."

As to the duration of this affection, if its true char-
acter be recognized, and the appropriate means used
for its cure, this is generally effected in a few weeks.
But, in one case that I have before alluded to, the first

RELAXATION OF THE PELVIC STMPIIYSES. 213

case that I ever saw, the patient could not walk with-
out crutches for several years, although I believe that
subsequently she entirely recovered. Several cases, con-
tinuing for years, have been reported by authors.

From what I have already said, you will readily in-
fer what the treatment of this affection must be. The
object to be secured by treatment is the consolidation
of the tissues of the symphysis. This can only be at-
tained by making the articulations of the pelvis fixed
and immovable. That compression of tissues promotes
absorption has long been a settled axiom in medicine.

During the puerperal period, I think that the pa-
tient should be kept in the recumbent position ; but,
after this time, it is my belief that absorption and con-
solidation will be promoted by frequently allowing the
weight of tne body to rest upon the pelvis, and such
exercise as the ability of the patient will permit, pro-
vided that the articulations be made firm by proper sup-
port. In all the cases that I have seen, this has been
accomplished by a little ingenuity, in making and ad-
justing a hip-binder of very strong, coarse cloth.

What is known as Martin's girdle is strongly recom-
mended by several authors. " It consists of a very
solid metal ring surrounding the whole pelvis. The
spring is an inch and a third broad, padded in the same
manner as a truss, both branches or arms of which are
directed downward and forward, where they are fast-
ened firmly by a buckle. The apparatus can also be
worn during pregnancy, without interfering with the
.enlargement of the womb or belly." In cases where
Martin's girdle causes discomfort or is too heavy, Dr.
Snelling suggests the use of a strong, sole-leather appa-
ratus, properly moulded to adjust itself to the shape,
and secured in the same manner as Martin's bandage.

214: PUERPERAL DISEASES.

As regards the various other remedies wliicli authors
have suggested and tried, such as vaginal injections,
cold baths, cold douches, stimulating frictions, certain
mineral waters, and various internal medicines, I do not
see how they can have any more effect in consolidating
the tissues of the symphysis than they would have in
promoting the reunion of fractured bones.

I shall close this lecture by quoting, from Dr. Snel-
ling's essay, the description of another form of disease
of the pelvic articulations, incidental to the puerperal
state, but which I have never seen except in one case,
where it was one of the sequels of puerperal fever :

" Suppurative inflammation, with its attendant
dangers, frequently sets in and carries off the patient
in spite of all that care or skill can do, after the most
protracted and agonizing suffering; and, furthermore
(what would seem at a first glance an actual impossi-
bility), rupture of the symphysis may take place as a
crowning result.

" The first of these ; viz., suppurative inflammation,
has been treated of by Hiller, Monod, Danyau, Hayn,
and others. It may arise either before or after labor, as
in the case of simple relaxation, and its earlier symp-
toms are very similar ; viz., pain in the symphyses, of
varying degree, greatly aggravated by movement, and
sometimes intermittent ; crawling and pricking, and oc-
casionally numbness in the lower extremities, and tot-
tering and, uncertain gait. The gait varies according
to the part affected ; and, in one case, a woman could
only walk with bent knees dragging the feet over the
floor, without the ability to raise them in the least.

" When the pubic symphysis is the point affected,
dysuria is apt to be present ; and, where the sacro-iliac
symphyses are the seat of inflammation, there are tenes-

RELAXATION" OF THE PELVIC SYMPHYSES. 215

mus and pruritus, especially during defecation. On -the
occurrence of suppuration the symptoms assume a grav-
ity which should put the accoucheur on his guard.
Fever, followed by rigors, sets in, the patient's counte-
nance is expressive of anxiety, the tongue becomes
furred and the bowels confined, together with the other
symptoms of the inflammatory condition. The case as-
sumes, in fact, the aspect which is peculiar to suppura-
tive inflammation in the cavity of a joint; and, of
course, the prognosis is eminently unfavorable. "Death
may occur, indeed, before suppuration sets in, but, if this
occur, extensive abscesses are formed in various parts.
If it be the pubic symphysis which is affected, pus
forms about the rnons veneris, and burrows along the
vagina and down into the thighs. If of the posterior
symphyses, of which the right is more often affected
than the left, it may cause purulent collections in five
different places; viz., directly upon the joint, in the
gluteal region, in the lumbar region, in the pelvic sub-
peritoneal pouch, and, lastly, near the rectum, whence
it may spread to the gluteal region, to the greater
trochanter, or to the horizontal ramus of the pubes.
Caries of the bones may take place, and it then runs a
tedious course, and invariably ends in death. Anchy-
losis seldom takes place. The cartilages are loosened,
and the soft parts infiltrated with serum, pus, and ichor.
" Its diagnosis is not difficult. In distinguishing be-
tween it and simple relaxation, it should be borne in
mind that, in consequence of the inflamed condition of
the symphyses, the difficulty of walking stands in direct
relation to the intensity of the pains, and that, in gen-
eral, the patient has more control over the lower limbs,
in consequence, of the bones being still held in place
by the inflamed cartilages; and especially does this

210 PUERPERAL DISEASES.

hold good when the inflammation is confined to one
symphysis. The vaginal touch, the imposition of the
hand upon the affected points during movement of the
patient, and the probe, after the evacuation of ab-
scesses, will be found sufficient to establish a diag-
nosis.

" The treatment should be directed primarily against
the inflammation and the collection of pus, and rest in
the recumbent position should be enjoined. After the
subsidence of the inflammation, a pelvic bandage should
be worn for a lengthened period.

" In slight cases, the affection may be so insignificant
as to be confounded with the general results and in-
conveniences of the lying-in state, attracting no par-
ticular attention, and pass off with rest and quiet. In
others, it may be so severe as to call for some treat-
ment, though generally it is not even then that its true
nature is recognized, as the patient recovers after a
few weeks of discomfort and confinement. But treat-
ment should be prompt and decided, even in these
cases, lest there should ensue the deplorable results
which various authors have reported." '

1 "While these pages are passing through the press, I had an opportunity
of examining in the Bellevue Hospital (November 14, 1873), a case of relax-
ation of the right sacro-iliac synchondrosis, in a patient at about the eighth
month of pregnancy. This occurred in the service of my colleague, Pro-
fessor William T. Lusk.

LECTURE XII.

PHLEGMASIA DOLENS.

I propose to discuss to-day one of the
puerperal diseases which is not very unfrequent. We
have had a case in the hospital which I hoped to have
had an opportunity of showing to you to-day, but, un-
fortunately, I can show you only its autopsical results :

" CASE XIV. 1 January 25, 1866 ; E. C., aged twenty-four ; Irish,
domestic, married. Fell in labor with her first child, at 5 P. M., Janu-
ary 23, 1866. Before the membranes had ruptured and the os had

1 Eeported by William Hunter Birkhead, M. D., house-physician to
Bellevue Hospital.

218 PUERPERAL DISEASES.

become fully dilated, a face-presentation was recognized, engaged in
the right mento-iliac position. The labor, though tedious, ended
successfully on the 24th, at 8.28 A. M., in the delivery of a female
child weighing eight pounds. No untoward circumstance mani-
fested itself until the morning of the fifth day subsequent to con-
finement, and at this time she complained only of a severe pain in
the calf of the right leg. No pain existed either in the popliteal
or the inguinal regions, and no induration of the vessels could be
discovered. The leg was not cedematous. Before the occurrence
of these symptoms, she had slight indications of milk-fever, but the
secretion of milk was well established. The pulse was now some-
what increased in frequency, though the skin was cool ; and the
lochia continued healthy, both as regards quantity and quality. No
chill preceded the pain. The urine, which had been several times
examined previous to confinement, and found free from all evidences
of renal disease, was not now again tested. The limb was dressed
with ung. stramonii, covered with cotton, and the whole enveloped
in oiled silk. At the same time, it was elevated at an angle of
about 30, by raising the lower half of the mattress. Before the ap-
plication of the ointment, iodine was freely applied along the course
of the vessels. Quinine, eggs, and milk, and an opiate at night, con-
stituted the remainder of the treatment. The following day (Janu-
ary 29th) there was considerable febrile reaction ; the patient seemed
more oppressed, the pain was increased, and the leg, very much
swollen. No evidence of peritoneal or uterine irritation was no-
ticed. At the evening visit, she was found to be quite delirious ;
face flushed, pulse 130, skin hot and dry ; gtt. xv. of Magendie's
solution of morphia in 3 ij of whiskey caused her to sleep the re-
mainder of the night, and in the morning she appeared much more
comfortable. The bowels were at this time regular, and the urine
copious.

"February 1st. No change for the better or worse was ap-
parent in the morning. The pulse during the day rose to 140, and
she became dull and perspired freely. A small patch of erysipela-
tous inflammation now appeared on the back of the left hand,
while the pain in the leg became less severe. Urinary secretion
free. The lochia were somewhat fetid. She now received 3 xij of
whiskey, four eggs, three pints of milk, and grs. xvj of quinine daily.
Opiates were administered at night in sufficient quantity to pro-
duce sleep. Applications to the limb were continued as before.
Vagina was ordered to be syringed morning and evening with

PHLEGMASIA DOLE^S. 219

diluted " Labarraque's solution," two tablespoonfuls to a pint of
tepid water. On the 2d, the pulse, though still weak, fell to 120.
Other conditions remained about the same. Patient passed nearly
3 xl of urine during twenty-four hours.

" February 3d. Pulse has again run up to 140 ; patient seems to
be failing rapidly. Sleeps most of the time, and is with difficulty
roused. Abdomen moderately tympanitic, but pressure elicits no
evidence of pain. Lochia and milk continue, urine still copious,
of a dark amber color. By direction of Dr. Barker, it was again
examined, and found to have a specific gravity of 1020. Heat and
nitric acid now coagulated about one-third of the urine ; and the
microscope revealed an abundance of highly-granular and a few
fatty casts. The oedema in the left leg is very decided, but none
appears in other parts, At 4 P. M., the pulse is 150, and at 5 P. M.
she died.

" Autopsy twenty-two hours after death. Abdomen highly tym-
panitic. On turning back the abdominal parietes, the stomach was
seen distended to thrice its natural size, and its cavity contained
about a pint of greenish fluid, consisting, most probably, of de-
composed eggs and milk. Peritonaeum and uterus did not present
the slightest evidence of inflammatory action, nor was there any pus
discoverable in the lateral ligaments or in the uterine walls."

I shall now pass around the room, for your examina-
tion, the uterus, both kidneys, and a part of the right
femoral vein. The uterus u is of a firm consistence
weight one pound ten ounces, avoirdupois. Kidneys
much congested, and, under the microscope, a certain
amount of dark, granular matter is found in the cells.
They weighed together 3xj, avoirdupois. The other
abdominal and thoracic organs presented no deviation
from the healthy standard. The right femoral vein, at
point of union with the internal saphenous, was found
.occluded by a clot of soft consistence and stringy in
character. No clots were found in the adjacent vessels.
The walls of the vein were much thickened, and, from
its cut extremity, a considerable amount of pus could
be squeezed out. Its inner surface presented one point

220 PUERPERAL DISEASES.

which seemed due to ulceration, while, in various parts
of its course, what appeared to be lamina of false mem-
brane covered its internal coat. The areolar tissue sur-
rounding the vessel was infiltrated with serum. The

leer itself was cedematous."

Before discussing this case, which presents many
interesting and some very rare features, I shall detain
you by a few general remarks on the disease which has
long been recognized and described under different
names, but is now generally known as phlegmasia do-
lens, or phlegmasia alba dolens.

Symptoms. The prominent symptoms of this dis-
ease are the following : ,

It usually commences between the tenth and twen-
ty-first day after confinement ; but, in a small minority
of cases, it has been manifested both at an earlier and a
later period. It is very rare, however, that the first
symptoms have appeared after the end of the month.

Pain, either in the calf of the leg, the popliteal
space, the thigh along the tract of the femoral vein or
its principal branches, is usually the first symptom.
This pain is increased by pressure and by movements
of the affected limb, which is sometimes impossible for
the patient. Both legs may be affected, but it is never
developed in the two simultaneously that is, the same
day although the interval is sometimes short between
the attack of the two legs. It is the left leg which is
the most frequent seat of this affection, in about the
proportion of three to one. Various explanations of
this fact have been suggested by authors. The most
plausible of these theories is, that it is due (1) to the
position of the rectum on the left side, which must
necessarily excite more or less pressure on the veins
of that side, and (2) to the arrangement of the arterial

PHLEGMASIA DOLEffS. 221

and venous trunks at the promontory of the sacrum,
where the primitive iliac vein is crossed almost trans-
versely by the right common iliac- artery. It has been
found, in autopsical examinations, that, where the iliac
vein contains a clot, a very marked depression is ob-
served in the clot, at the point where the artery crosses
the vein. Some obstetrical writers have suggested that
this may be the result of the more frequent occurrence
of the left occipito-iliac position in labor ; but, as, in this
position, it is not the longitudinal, but the transverse
diameters of the foetal head which press upon the veins
of the left side of the pelvis, if the process of parturi-
tion had any influence in causing this disease, it ought
to be found more frequently in the right leg than in
the left.

Swelling of the part affected is a constant and one
of the most prominent features of this disease. The
pain usually precedes the swelling by some hours, but
in many cases these symptoms are observed simul-
taneously, or it is difficult to decide which has ap-
peared first. The patient naturally first notices the
sensation of pain ; and, in some instances, when this
has been complained of, I have made a most careful
examination, and found no swelling, when it became
very apparent a few hours subsequently.

Many authors, as Puzos, Levret, White, Gardien,
and others, assert that the swelling begins at the upper
part of the leg and gradually descends toward the foot.
Trousseau declares that he has never seen the swelling
.progress in this direction, but that it always begins at
the lower extremity and ascends toward the pelvis.
My own experience is in accord with that of Bouchut
and some others, that neither assertion is absolutely
true, but that in some cases the swelling begins below

222 PUERPERAL DISEASES.

and advances upward, while in other cases exactly the
reverse is true. In one lady, the swelling, which was
very great, was confined entirely to the thigh, and, at
all times during the course of the disease, a shoe of
the same size could be put on either foot.

The swelling is generally very considerable, some-
times doubling the size of the limb. The skin is white,
glistening, and so elastic, that most authors have as-
serted that the swelling does not pit on pressure.
This is true if the finger be pressed on the swollen part
only for a moment, which is sufficient to leave the pit-
ting in ordinary oedema, but I have often demonstrated
at the bedside, that if the pressure be made with some
force and prolonged for a minute or two, the pitting is
then as manifest as in any oedema.

Loss of all muscular power of the limb is another
characteristic of this affection. In some, not only is it
impossible to move the thigh or the leg, but also to
flex or extend the toes. This immobility is sometimes
the result of great pain in the articulations, produced
by motion, but in other cases it seems like a quasi
muscular paralysis, as passive motion does not cause
pain.

In some patients, hard, knotty, painful cords can be
traced along the course of the crural vein or its branches,
but, in others, the most careful examination will fail to
detect any such cords.

There is a great discrepancy of statement as regards
the temperature of the affected limb. Valleix, Graves,
and Simpson, assert that there is an increase of tem-
perature where the swelling exists ; but Trousseau denies
that this disease produces any modification of tempera-
ture in the part affected. By applying the hand to the
surface of the swollen part, I have rarely been able to

PHLEGMASIA DOLEXS. 223

decide that there was greater heat than in the limb
which was not affected, but the question as to tempera-
ture will now soon be positively determined by the use
of Dr. Seguin's surface-thermometer, and I have no
doubt that important points, affecting the diagnosis
and treatment of this disease, may result from the use
of this instrument.

The constitutional symptoms are by no means uni-
form. In some, the local symptoms are suddenly mani-
fested, with no prodroinic indications of constitutional
disturbance. But, in most cases, there are one or more
chills, with febrile reaction, a rapid pulse, loss of ap-
petite, and a general condition of malaise and depres-
sion before the patient begins to complain of the pain
and swelling of the leg. The tongue is usually moist
and covered with a white coat, the face is pale, the
countenance anxious, and there is a great tendency
to frequent and profuse perspiration. The function of
lactation is generally very much impaired, and some-
times wholly arrested by the development of the disease.

The lochial discharges seem, in many cases, to be
very little influenced by the onset and progress of this
disease, but, in others, they have been observed to be
very fetid and offensive.

Some authors have mentioned, as occasional symp-
toms of this malady, nausea, vomiting, delirium, and
excessive depression of the vital powers, and all these
existed in the case which you have just heard read;
but they are the symptoms of the consecutive or the
coincident phlebitis and pyaemia, and are never found
in uncomplicated phlegmasia dolens.

Progress and Duration. We have seen that in the
commencement of this disease the development of
symptoms is very rapid, but those of its disappearance

PUERPERAL DISEASES.

are very much slower. The usual termination is by
resolution. The general symptoms of constitutional
disturbance gradually subside, and the disease remains
as purely a local malady. The pain decreases day by
day, passive movement can be made without suffering,
and in a little time the patient recovers the power
which had been lost. The elasticity of the skin rapidly
becomes less, as is shown by the fact that, before any
decrease in size is manifest, the pitting on pressure is
very much more marked, and is evident even when the
pressure is but momentary. Resolution has now com-
menced, and is followed by absorption of the fluid
effused in the cellular tissue, and the restoration of the
impeded venous circulation. The hard, knotty cords,
along the tracts of the veins little by little diminish in
size, firmness, and sensibility, until they can no longer
be detected.

In favorable cases, these results are generally at-
tained in three or four weeks. But, in others, months
elapse before all the consequences of this affection dis-
appear. The limb remains feeble and enlarged, with
pronounced oedema toward evening, if the patient have
been on her feet during the day. In some, no doubt,
there occurs a permanent obliteration of the venous
trunk, which is transformed into a mere fibrinous cord.
The affected limb remains weaker, with a great tenden-
cy to swell, and this state continues for years, or even for
life. This condition existed in both legs, in the wife
of a very eminent general officer of the army, a patient
of my friend, Professor Metcalfe. Before coming under
his care, she had phlegmasia dolens in one, and then in
the other leg, in two successive confinements. I found the
same condition also in a lady sent to me by Dr. Pitcher,
of Detroit. The oedema of both legs was very great

PHLEGMASIA DOLEXS. 225

after walking for a little distance, and both pain and
oedema of the legs were constant phenomena during
her menstrual periods.

In rare cases, phlegmonous inflammation of the con-
nective tissue is developed, which terminates in suppu-
ration. I have known large abscesses form in the calf
of the legs and the thigh, and in one patient, who, as
my service terminated, passed under the charge of my
colleague, Professor Lusk, the amount of pus discharged
was enormous, and she subsequently died from the
effects of the disease. When the phlegmon is circum-
scribed, a favorable result may be confidently anti-
cipated ; but, when it is diffused, involving a great ex-
tent of tissue and vast suppurations, all treatment
seems powerless to avert a fatal termination.

The case I have just had in my 1 service, whose his-
tory you have heard and the autopsical results you have
seen, was associated with an exceedingly rare but most
fatal complication, suppurative phlebitis. You see the
soft, stringy clot that occluded a portion of the right
femoral vein. The walls of the vein are very decidedly
thickened. Various parts of its internal coat are cov-
ered with flakes of false membrane, and in one point it
seems to have been destroyed by uleeratijpn. From the
cut extremity of the vessel, pus can be squeezed out in
considerable quantity. The pus was mingled directly
with the blood in its circulation, and you observe that
the symptoms which preceded the death of the patient
were those of purulent infection.

This disease may also terminate in another formi-
dable manner. A fragment of the clot which occludes
the vein may become detached, carried into the circula-
tion, and lodged in the pulmonary artery. Although I
think that we have good ground for believing that pa-

226 PUERPERAL DISEASES.

tients do sometimes recover after the occurrence of this
event, yet it is probable that the most frequent result
is death within a short period. But this topic is so im-
portant that it will form the subject of a special lect-
ure.

Another very rare termination mentioned by au-
thors is gangrene ; but, as I have never seen this result,
I shall allude only to its possible occurrence.
V^ Pathology. I shall not occupy your time with a dis-
cussion of the opinions of the past as to the nature of
tliis affection. I shall only say that the belief of the
earliest writers on this affection was, that it was due to
a metastasis of the milk from the breast to the leg.

The next doctrine, which was sustained by many
partisans, half a century ago, and still finds supporters
at the present day, was, that it is essentially an affec-
tion of the lymphatic system.

The belief that the disease is due to suppression
of the lochia, which was subsequently determined to
the affected limb, was held by a few, but soon proved
to be groundless. Some eminent writers in the past
have regarded the disease as arising from inflammation
of the nerves. Others, again, have advocated the doc-
trine that it is in reality an inflammation of the eel
lular tissues of the affected limb.

Our own Dewees, and some others, finding it im-
possible to explain the symptoms by any one of these
exclusive theories, arrived at the conclusion that it i
due to inflammation of all of the tissues.

The first great step made in advancing the knowl-
edge of this disease, from speculative theories to the do-
main of pathological science, was by Dr. Davis, Pro-
fessor of Midwifery in University College, London,
who, in 1823, published his discovery that, in several

PHLEGMASIA DOLEXS. 227

instances, lie liad found, in making post-mortem exami-
nations in this disease, that the femoral and iliac veins
were impermeable from being filled with firm coagula
of blood. This, which, at the time, must be deemed
a discovery of immense value, was very soon after con-
firmed by the published observations of Bouillaud and
Velpeau, of Paris.

From this discovery resulted the doctrine of crural
phlebitis, which, as you will presently see, is still held
to be the v true theory of the disease by some of our most
able and recent writers.

A few years later, in 1829, Dr. Kobert Lee, of Lon-
don, believed that he had made a great discovery;
viz., that the disease is primarily a uterine phlebitis ;
that is, that it commences in the uterine branches of the
hypogastric veins, and is subsequently propagated to
the iliac and femoral trunks of the affected limb.

But, as observations of this disease accumulated and
were published, it was found that this is not a disease
peculiar to the puerperal period, or to the lower ex-
tremities, or even to the female sex. It was observed
that it is often associated with other diseases, as you
will see cases published in which it has occurred in con-
nection with phthisis, chlorosis, erysipelas, typhus fever,
dysentery, or perineal abscess, and, more frequently
still, in cases of cancer. Virchow has published several
observations of cancer of the stomach, in which this
disease occurred in some, in the upper extremities, and
in others in the lower limbs.

In October, 1870, 1 visited, in consultation, a lady
fifty-two years of age, with most characteristic phlegma-
sia dolens of the left le;. She was cachectic, and, not-

O / /

withstanding the absence of all other signs, I ventured
to make the diagnosis that the phlegmasia dolens was

228 PUERPERAL DISEASES.

due to cancer. In the course of a few weeks, the leg got
entirely well, but the correctness of my diagnosis has
been verified by the subsequent development of cancer
in the pelvis.

The knowledge that this disease is not confined ex-
clusively to the puerperal state or to the female sex was
a great step in elucidating its pathology.

The next advance was made by the hematologists,
Andral and Gavarret, and Becquerel and Rodier, who
demonstrated the existence of a peculiar modification of
the blood in the cachexias, and that this modification
often exists in pregnancy. This consists in a change in
the proportion of the elements of the blood. There is an
excess in the amount of fibrine and serum, and a defi-
ciency of the blood-corpuscles, as compared with the
normal state, and the term Jiyperinosis is used to define
this condition. In this state of the blood, there is a
special predisposition to coagulation.

I should not omit to say that it is asserted that this
special tendency to coagulation has been sometimes
found to exist where the physiological proportions of
the constituents of blood are not changed from the nor-
mal state.

This abnormal tendency to coagulation of the blood
has been denominated, by Vogel, inopexia, 15, wo?, fibrine,
Tri^t?, coagulation, and the term, a very appropriate and
significant one, is now adopted in science. Now, it is
known that whenever phlegmasia dolens occurs, whether
in the puerperal period or in association with other
diseases, there is inopexia.

That my subsequent remarks may be perfectly
understood, I shall explain the meaning of another term,
that I shall have frequent occasion to use. When this
tendency to coagulation, or inopexia, exists, and the cir-

PHLEGMASIA DOLEXS. 229

dilation is blocked by the formation of a clot in the
vein, this lesion is now termed thrombosis.

If you ask me what is the accepted doctrine of
science at the present day, as to the nature of the func-
tional changes and structural lesions which constitute
phlegmasia dolens, I am compelled to answer that the
question is not yet settled.

The latest book which has appeared on puerperal
diseases is by M. Hervieux, physician to the Maternite
Hospital of Paris, a very large book, and richer in its
clinical illustrations of these diseases than any pub*
lished since the great work of Mauriceau, and the au-
thor is evidently a most conscientious observer, who
has had exceptionally large opportunities for studying
these affections.

M. Hervieux regards this disease as a phlebitis of
the crural vein and its branches, excited by a puerperal
toxaemia, and that its nature is now perfectly settled.
While he gives an historical abstract of the various
opinions which have been formerly held, he says, " God
forbid that I should reopen a discussion which has
Ions: since been closed ! "

Now, as Providence does permit me to reopen this
discussion and to comment upon this view of Dr. Her-
vieux, which is so confidently asserted, I shall first re-
mark, that it seems to me that two elements are
absolutely essential to constitute the true theory of
any disease : (1) that the assigned cause or condition
should always be present when the disease exists ; (2)
that the disease should always exist when the assigned
cause is present in its full development. I think all
theories of disease should be brought to the rigid tests
of such a standard.

In the case, the history of which has furnished the

230 PUERPERAL DISEASES.

theme for my remarks to-day, phlebitis did exist. The
characteristic and constitutional symptoms of this dis-
ease and of purulent infection were manifest during
life, and the autopsical lesions demonstrated the phle-
bitis. But such a combination of symptoms is exceed-
ingly rare in phlegmasia dolens.

As a rule, phlegmasia dolens is not accompanied
with symptoms of great constitutional disturbance, and
all the symptoms of this character pass off in a few
days, while there remain only those of a purely local
disease. But it is not so with phlebitis, which, through-
out its whole course, even when it terminates in re-
covery, is attended by constitutional symptoms of a
marked type, which I shall fully describe in my lecture
on that subject. We have no reason for assuming the
existence of any disease when its characteristic symp-
toms are not present. Phlegmasia dolens generally ter-
minates in recovery, while this result is very far from
being the rule in phlebitis.

As death from uncomplicated phlegmasia dolens is
a very rare occurrence, we cannot prove by numerous
autopsical examinations that phlebitis is generally ab-
sent. But I think the number of cases of well-marked
phlegmasia dolens, in which death occurred and the
veins were found to be perfectly healthy, reported by
such observers as Rigby and Hugh Fraser, of England,
Jacquernier, of France, Casper, of Leipsic, Kiwisch, of
Wtirtzburg, and others, is sufficient, in connection with
the fact of the general absence of the symptoms of
phlebitis, to prove that phlegmasia dolens is not crural
phlebitis. Those of you who heard me last winter on
the subject of puerperal embolism will remember the
patient who died very suddenly from this cause. In
this case, there had been phlegmasia dolens, and we

PIILEGMASIA DOLEXS. 231

found thrombosis of the femoral and saphenous veins,
but not the slightest disease of the veins could be de-
tected, nor had the patient during life any symptoms
of phlebitis.

Again, on the other hand, we may have fully de-
veloped phlebitis of the crural vein and its branches,
without phleginasia dolens. I have just had in my ser-
vice in this hospital two cases which demonstrate the
truth of this assertion :

" CASE XV. 1 Rachel Greenstein, aged twenty-four ; single ; born
in Germany ; was delivered of twins, December 30, 1868. The pa-
tient was a primipara. Her labor was quite tedious, the first stage
continuing between two and three days. Soon after delivery, her
pulse became quite feeble and rose to 96. Respiration 40 ; tongue
furred ; lochia free ; skin dark and cold. She complains of constant
pain in the hypogastrium. Uterus hard. No abnormal signs could
be detected in connection with the heart and lungs.

" December 31st. Patient has fever and abdominal pain. Pulse
120 ; respiration 60 ; temperature 104 ; tongue brown and coated;
lochia profuse ; bowels loose. Had several chills during the night
and morning. She was ordered a tablespoonful of liq. ammon.
acet. every hour, and morphine enough to quiet the pain.

" January 1, 1869. Pulse 130 ; respiration 50 ; temperature
105.5 ; tongue dry ; profuse diarrhoea. Ordered four grains of qui-
nine v three times a day, and ten grains of the subcarbonate of bis-
muth after each movement of the bowels. Morphine p. r. n.

" January 2d. Pulse 140; respiration 60 ; temperature 105.5.
The patient has profuse perspirations. Countenance dusky and
sunken. Tongue very dry. Abdomen tender and tympanitic. Diar-
rhoea continues. Complains of pain in the calf of the right leg, but
there is no swelling or oedema that can be detected. Dr. Barker
first saw her to-day, and ordered the sulphite of soda, in the follow-
ing prescription :

IjL Sodse sulphitis, 3 ij.

Syrup, simp., 3 iij.

Aquae, = j.

M. S. A tablespoonful every four hours. Also a half-ounce of
whiskey every hour. Morphine as before.

1 Reported by "W. J. Chandler, M. D., house-physician to Bellevue Hospital.

232 PUERPERAL DISEASES.

" January 3d. Pulse 140 ; respiration 40 ; temperature 103.
Diarrhoea still continues. Discharges very black and fetid. Tongue
more moist. A small swelling discovered over the seat of pain in
the right leg. The sulphite was discontinued this evening, and the
bismuth was ordered in twenty-grain doses after each passage.
Whiskey to be continued as before.

" January 4cth. Pulse 120 ; respiration 30 ; temperature 103.
Diarrhoea subsiding, but abdomen still tender and tympanitic. Ab-
scess forming in the calf of the right leg. Treatment continued.
Ordered a lead-and-opium wash to be applied to the limb.

" January 8th. Pulse 120 ; respiration 30 ; temperature 103.
Patient has continued about the same since last date. The diar-
rhoea has nearly ceased. Several abscesses are forming along the
course of the saphenous vein.

" January 12th. Pulse 110 ; respiration 25 ; temperature 100.
Patient improving. Mind cheerful and clear. Diarrhoea stopped.
A chain of abscesses formed along the inner aspect of the thigh
and leg, some of which opened and discharged a bloody and offen-
sive purulent fluid. The tympanites and abdominal tenderness very
much diminished. The limb is dressed with the hospital lotion of
carbolic acid and linseed-oil. Her general condition is very much
better. Appetite good, and she now nurses her child (one had be-
fore died). She takes quinine and iron, and the best diet of the
hospital.

" January 25th. Thrombosis in the left calf. Patient has had
three attacks of diarrhoea since last date, each of which lasted two
days. She has also had several chills, followed by profuse perspi-
ration. Pulse 112 ; respiration 25 ; temperature 103.

" February 1st. Patient was found sitting up in bed. Feels
well and much stronger. Pulse 104 ; respiration 22 ; tempera-
ture 100.

" February th. A large abscess was opened in the left calf,
and about two quarts of pus discharged. The patient transferred
from the convalescent puerperal to the surgical wards.

" February 13th. Patient has been steadily growing worse
since last date. She is much emaciated and very weak. Appetite
poor. She has profuse sweats and a pyaemic odor. The diarrhoea
has returned, and, in addition, she has a troublesome cough, with a
scanty expectoration of white frothy sputa. Pulse 124, feeble and
compressible ; respiration 30. Examination of the lungs revealed
only an occasional mucous or sibilant rale. She has quinine, iron.

PHLEGMASIA DOLENS. 233

and stimulants, with extra diet. The patient continued to fail, and
died, February 27th.

" A complete autopsy could not be made, as her friends would
not consent. Permission, however, was granted to open the veins
of the legs. In both legs, were found conclusive evidences of phle-
bitis, most marked near the seat of the thromboses. The coats of
the femoral and saphenous veins were much thickened and reddened,
and, at spots, infiltrated with pus."

Now, tliis patient had no phleginasia dolens during
any period of her disease. Neither was there phleg-
masia dolens in the following case, the histoiy of which
is also given by Dr. Chandler. The patient has now
quite recovered :

" CASE XVI. Winifred Sears, aged twenty-eight ; sibgle ; was
delivered of her first child, December 28, 1868. The labor was nat-
ural and easy, and the patient was doing well in every respect, until
the morning of the 30th, when she had a chill. The pulse was 136,
irregular and feeble ; the respirations were forty per minute ; and
the temperature in the axilla, 103. She complained of no pain, but
had a general feeling of uneasiness, and her countenance was hag-
gard and sunken.

" December 31st. Pulse 130 ; respiration 52 ; temperature
103.5. Chills repeated, followed by profuse perspiration. The pa-
tient complains of severe pain at the precordia, and also a little in
the calf of the right leg. The stethoscope revealed an aortic ob-
structive murmur. The veins of the leg are enlarged, at points,
quite tender on pressure, and the thigh is slightly swollen.

" January 1, 1869. Pulse 132 ; respiration 36 ; temperature
104. Chills as usual. Pain and tenderness, with several points
of redness along the inner side of the thigh, which is more swollen
and slightly cedematous. The leg was wrapped in cotton-wool and
oil-silk. Dr. Barker saw the patient for the first time, and ordered
four grains of quinine, and twenty drops of the tine, ferri chlorid.
four times a day. Also a half-ounce of whiskey every second hour,
and the most nutritious diet the hospital affords.

" January 2<7. Pulse 112 ; respiration 40 ; temperature 103.
Chills again. Abscesses beginning to form along the inner course
of the thigh, and one just below the knee.

234 PUERPERAL DISEASES.

" January 3d. Pulse 120 ; respiration 36 ; temperature 102.
Patient much the same.

"January 4tth. Pulse 80; respiration 36; temperature 100.
One of the abscesses just below the inner condyle of the femur
was opened and discharged a large quantity of sanious pus. It was
dressed with the hospital solution of carbolic acid and linseed-oil
(one part of the acid to seven parts of oil). Patient looks better,
and complains much less of pain.

"January 8th. Pulse 100; respiration 30; temperature 99.
No chills to-day, for the first time. A second abscess opened in the
thigh. The first abscess is in process of healing. The whole thigh
is much swollen, pits on pressure, and is exquisitely sensitive.

"January 25th. The fifth abscess discharged itself to-day.
There are yet two more on the upper and inner side of the thigh.

"January 31st. The last of the abscesses broke to-day. The
patient feels much relieved from pain. She has had no medicines
during the whole of her illness, except those above mentioned,
which have been steadily continued, with morphine to relieve pain,
which at times has been horribly severe.

" February 20th. The patient has steadily improved since last
date, and is now walking about the wards."

I think that every one will agree that this was a
case of thrombosis, with suppurative phlebitis, but I
am quite sure that no one, seeing the case, would ever
think of calling it phlegmasia dolens. And so I must
conclude that phlegmasia dolens is not crural phlebitis.
They may occur together, but either may exist, in its
full, typical development, without the other.

The most recent elaborate discussion of the pathol-
ogy of phlegmasia dolens, in the English language, is
by the late Sir James Y. Simpson. His doctrine is that
phlegmasia dolens does not arise from phlebitis proper-
ly so called, but is immediately due to obstruction of
the veins by coagulated blood, and any resulting phle-
bitis is a secondary consequence only.

He says : " This coagulation of the blood and ob-
struction of the veins may, in their turn, depend on one

PHLEGMASIA DOLENS. 235

or other of two causes; viz., either, first, on some mor-
bid alteration in the blood itself, tending to its consoli-
dation or coagulation ; or, second, on some morbid con-
dition in the lining membrane of the veins, in virtue
of which the relation between the blood-vessels and the
blood becomes disturbed, and coagulation of the latter
is induced. I believe that in some cases of phlegmasia
dolens this required morbid condition in the lining
membrane of the veins may be primarily due to phle-
bitis, as where the veins of the uterus have been in-
flamed, and the inflammation, having extended, by con-
tinuity, to the iliac vessels, has led to coagulation of
blood in the veins below. But, in the great majority
of cases, it seems to me that we must look for the pri-
mary cause of the disease in some morbid condition of
the circulating fluid, leading, first of all, perhaps, to
some peculiar change in the lining membrane of the
veins, and, through this, secondarily, to coagulation of
the blood, occlusion of the vessels, and obstruction to
the limb. 1 '

The pathological views of Professor Simpson seem
to be wholly based on the experiments and deductions
of the late Dr. Mackenzie, of London, whose essay on
" The Pathology of Obstructive Phlebitis, and the Na-
ture and Proximate Cause of Phlegmasia Dolens," and
whose Lettsonian lectures were most valuable contri-
butions to our positive knowledge on this subject. Pro-
fessor Simpson says : " From all Dr. Mackenzie's obser-
vations and experiments, therefore, it seems probable
that phlegmasia alba dolens is essentially due to the
presence of a morbid material circulating in the blood
and exerting such an influence on the internal surface
of the veins as leads to consolidation or coagulation of
the blood w r hich they contain." He refers to the blood

236 PUERPERAL DISEASES.

as being in the condition described as hyperinosis, and
adds : " In the puerperal patient matters are rendered
still more complicated, and the proclivity to disease
still further increased by the circumstance, that in her
constitution great and important changes are at the
time taking place, such as the degeneration and the re-
sorption of the hypertrophied uterine mass and the
establishment of the new mammary secretion, in con-
sequence of which the blood becomes loaded and de-
teriorated by the introduction of a quantity of effete

organic material. In short, the blood is so altered as

o '

to render the patient peculiarly liable to spontaneous
coagulation of blood in the blood-vessels, or, as it has
been called, thrombosis, and all its consequences."

I was very much impressed by the writings of Dr.
Mackenzie, and studied them with great care. I think
he has conclusively proved (1) that crural phlebitis, in
a pure and uncomplicated form, cannot give rise to all
the local and general phenomena of the disease, and
therefore cannot be its proximate cause ; and (2) that
phlebitis itself is for the most part not a primary, but a
secondary affection, and, in the great majority of cases,
is a consequence of the circulation of impure or morbid
blood in the veins. But I cannot accept his deductions
and the theory so elaborately argued by Professor Simp-
son, as an adequate explanation of the pathology of
phlegmasia dolens.

You see, the theory may be thus tersely stated : In-
opexia is the predisposing cause, and toxaemia the ex-
citing cause of venous coagulation, which produces the
disease known as phlegmasia dolens. . It practically im-
plies that all the phenomena of phlegmasia dolens are
due to the arrest of the circulation in the veins. This
doctrine was first enunciated by Bouchut, in 1844.

PHLEGMASIA DOLEXS. 237

Now, let us examine this for a moment. Simpson
says : " Several experimenters have tied the femoral vein
and have succeeded in producing obliteration of it in
many different ways, but without producing any of the
peculiar phenomena of phlegmasia dolens. No increase
in the heat of the limb has resulted, and no tension,
tenderness, or impaired mobility ; nothing further than
a slight degree of oedema, partial and passing." He
refers to a case which was carefully watched by Dr.
Moir, of Edinburgh, and himself, in which there was not
a symptom in the least degree approaching to phleg-
masia dolens, but in which it was found that the
femoral vein was obstructed with coagulated blood to
the extent of two inches below Poupart's ligament.
While, therefore, admitting that thrombosis in the
largest veins of the limb is not sufficient to produce the
phenomena of this disease, he believes that, "if this
coagulation extends to the branches of the third or

fourth order of size as well, we shall then have some-
thing more than mere oedema, but the heat, swelling,
tension, and paralysis, characteristic of phlegmasia do-
lens in a very marked degree."

I cannot see that there is any adequate or decisive
proof of this assertion, furnished either by the experi-
ments of Dr. Mackenzie or by clinical observations. I
believe, with Sir James Simpson, that, if coagulation
and obstruction of blood in the veins existed to the ex-
tent that this theory implies, there would be something
more than mere oadema resulting, and I will add, some-
thing more than phlegmasia dolens. I cannot see how
the obstruction of blood in numerous veins of this
calibre could be removed, and terminate in reestablish-
ment of the circulation and recovery in a few days.

According to this theory, phlegmasia dolens ought

238 PUERPERAL DISEASES.

to be a common result of thrombosis; but the fact is,
that, while thrombosis is one of the common phenomena
of phlegmasia dolens, the converse of this is very rare.
Phlegrnasia dolens is an exceptional phenomenon of
thrombosis. I could give you numerous examples which
have been published, where the thrombosis has extended
even to the smallest veins, in which there was no phleg-
masia dolens.

The relation which the thrombosis bears to phleg-
masia dolens seems to me to be that of an effect rather
than a cause; for I have often observed and pointed
out to my staff in this hospital, the first development
of the knotty, cord-like veins, two or three days after
the disease had existed in its highest degree.

In a very able and interesting paper, in the Trans-
actions of the London Obstetrical Society, by Dr. Til-
bury Fox, the objections to the theory of Mackenzie and
Simpson are presented, with a train of reasoning, some-
what similar to that which I have urged ; but Dr. Fox
seeks to explain the phenomena of phlegmasia dolens,
by the theory of lymphatic thrombosis. He gives a
summary of his views in seven propositions, the first
four of which are so in harmony with the opinion that
I have expressed, that it is unnecessary for me to quote
them. The fifth, sixth, and seventh, are as follows :

" 5. Obstruction of the main lymphatic channels
alone is capable of giving rise to white leg, and acts by
preventing the removal of lymph from the affected
limb.

" 6. The obstruction may be the result of, a. Exten-
sive pressure. Ex. tumors of all kinds, b. Throm-
bosis, due to sudden (compensatory) absorption of
vitiated fluid after sudden loss of any kind.

" 7. Inflammatory changes in the vessels themselves."

PHLEGMASIA DOLEXS. 239

Many authors before have sought to explain the
pathology of this disease by some abnormal condition
of the lymphatic vessels, some referring it to rupture
of these vessels at the brim of the pelvis, allowing of
the escape of lymph into the cellular tissue and its
gravitation downward into the limb ; while others
have regarded it as due to obstruction of the lymphatic
glands ; and others have ascribed it to inflammation of
these vessels and glands.

The pathology of the lymphatic system in connec-
tion with the puerperal state is now receiving much
more attention than formerly ; and puerperal lymphatic
thrombosis is now a recognized lesion, which has been
described by Virchow, Klob, and others.

Now, in the first place, normal lymph contains fibri-
nogenous but no fibrino-plastic material, and therefore
lymphatic fibrine does not coagulate spontaneously.
In lymphatic thrombosis, the fluid has undergone some
change which produces coagulation of the fibrine. So
far as is known, therefore, this disease is always sec-
ondary, the primary affection usually being either en-
dometritis, or pelvic cellulitis, or peritonitis, diseases
which have no necessary connection with phlegmasia
dolens. Dr. Fox himself regards lymphangitis as a
rare cause of the thrombosis; and certainly we rarely
have evidence of its existence in phlegmasia dolens.
So I must say that, while the theory of Dr. Fox is sup-
ported by ingenious and plausible reasoning, no proof
of its truth has yet been furnished, either by pathology
or morbid anatomy.

To conclude this part of my subject, I can only add
that, while we know that phlegmasia dolens occurs in
the puerperal state and in association with diseases
which cause inopexia, and that its most uniform autop-

240 PUERPERAL DISEASES.

sical lesion is venous thrombosis, we are still as ignorant
of its real pathological nature as we are of that of rheu-
matism and many other diseases.

Treatment. I am inclined to believe that the pro-
portion of recoveries in phlegmasia dolens was as great
under the treatment of our predecessors, as it is at the
present time. Theories did not seem, in this disease, as
in many others, to bias their shrewd perceptions as to
the therapeutical indications, or their good sense in the
application of remedies. The most brilliant genius of
all our American obstetricians, the late Professor Meigs,
of Philadelphia, was an enthusiastic advocate of the
doctrine that phlegmasia dolens is a crural phlebitis,
which most writers, at the present day, believe to be
an error ; yet I suspect that very few, if any, treat the
disease more successfully than he did.

The truth is, that the disease tends to a spontane-
ous recovery, and I believe that the blocking up of the
veins by thrombosis is one of the conservative efforts
of Nature to promote this end. It is in this way that
the system is protected from the dangers of general
toxaemia. This effort sometimes fails, by decompo-
sition of the clots, and phlebitis and purulent infec-
tion may result, or a fragment of the clot may become
detached and transported to the right side of the heart,
and thus cause death ; but, as a general rule, the effort
is successful.

Holding such opinions, I am compelled to say that
the treatment will be judicious and successful, just in
proportion as it is free from all bias, from theoretical
speculations as to the pathological nature of the affec-
tion, and just in proportion as it is based on a sound
and just appreciation of the special indications of the
case. I cannot agree with the most eminent and the

PHLEGMASIA DOLENS. 241

most recent writer on the treatment of this disease,
that " depuration of the blood holds the first rank
among the general indications " for the treatment of
phlegmasia dolens. On the contrary, any treatment
which perturbates the system, or disturbs the normal
functions, or depresses the vital powers, I must regard
as objectionable. If there be a positive indication for
a cathartic, an emetic, a diuretic, or any other elimina-
tive agent, give it, of course, but do not make use of
any such medicines merely on the theoretical ground
that the blood must be depurated.

General Indications. Now let us see what the in-
dications are : If you study the constitutional symptoms
which usher in the disease, but ordinarily subside in a
few days the rapid pulse, the slight febrile movement,
the depressed expression of the countenance, the gen-
eral malaise, and the local pains I think that you
will agree with me that they are all referable to ner-
vous irritation and depression. So I should say of the
general indications :

First: Allay all irritation of the nervous system.
In doing this, you aid in restoring the normal functions,
and in rallying the depressed vital powers. The great
agent for this purpose is opium or some of its prepara-
tions. Give it in such doses and at such intervals as
may be found necessary to accomplish the purpose of
allaying the irritation, relieving pain, and inducing
sleep. In the beginning of this disease, I have seen the
pulse fall from 140 to 100, within a few hours after a
full opiate had been taken, and, in private patients, who
are not exposed to the endemic or epidemic toxic in-
fluences of hospitals, I have rarely seen any return of
the vascular excitement during the whole course of the

disease.

242 PUERPERAL DISEASES.

My friend Dr. G. C. P. Clark, of Oswego, has writ-
ten an essay, in which he seeks to demonstrate that
opium is a grand specific for phlegmasia dolens, and,
although he writes with the extra vacant zeal of an

o o

enthusiast, his essay contains many truths which are
too generally overlooked.

If special indications exist, you may give a cathartic,
apply cups over the kidneys, or resort to any other
measures which may be necessary before giving the opi-
ate. But, in private patients, I have rarely seen such
indications, except where the disease had developed so
late in the puerperal period that medical supervision
had ceased.

The fact is often forgotten, that our role as physi-
cians is more frequently to treat the results of disease
than the disease itself. Now, this disease occurs in a
system nourished by blood deficient in hematosine, and
is, therefore, asthenic in its character ; so you will be
prepared to hear me say that the second indication
is, to give the most nutritious food that can be easily
assimilated, stimulants, just sufficient to make digestion
easy and keep up nerve-power, and nerve and blood-
tonics. You are sufficiently advanced to require no
elementary instruction in the details of this indication.
I shall only say, in regard to medicinal agents, that,
for various reasons which I have not now the time to
discuss, I regard the tincture of the chloride of iron

7 O

as the best preparation to administer as a tonic, and
that quinine is especially useful, not only as a nerve-
tonic, but also as an anti-pyogenic agent. I shall take
another opportunity to refer more distinctly to this
property of quinine.

Local Treatment. As I have before remarked,, after
the first two or three days, both the symptoms and the

PHLEGMASIA DOLENS. 243

effects of the disease are principally local. At first, it
is needless to urge upon the patient the necessity of
keeping perfectly quiet, because she cannot help do-

ing so.

The limb should be elevated at an angle above the
trunk, and this should be effected by raising the lower
part of the mattress, as any thing placed under the leg
for this purpose must have some tendency to arrest
capillary circulation, and is certain to cause pain and
discomfort. The object in keeping the limb raised is
not so much to favor the gravitation of the fluids back
toward the trunk, as to retard gravitation of the blood
toward the limb.

While the swelling is tense and elastic, there is hy-
peraesthesia of the surface, in addition to the severe pain
in deep-seated nerves. This will be greatly allayed by
gently rubbing the surface with a piece of soft flannel,
well saturated with a stimulating emollient and ano-
dyne liniment, like the following :

$. Liniment, saponis co., vj.

Tine, opii, jss.

Tine, aconit. rad., ss.

Ext. belladon., ss.

M. Ft. liniment.

Direct the nurse to rub so gently as not to cause
pain, to continue rubbing for fifteen or twenty minutes,
and always to rub up toward the trunk, and make her
comprehend the reason for this direction. I generally
order that these medicated frictions should be used every
.six hours, and that, immediately after the rubbing, the
leg should be enveloped thickly with cotton-batting
and then covered with oil-silk. I am always careful to
show the nurse how to wrap, the limb with the oil-silk,
so that it can be opened again for the purpose of re-

244 PUERPERAL DISEASES.

newing the friction, without giving the patient the pain
of turning or moving the limb. These frictions and
most effective fomentations not only relieve the ten-
sion of the connective tissues and give your patients an
immense deal of comfort, but they probably have also
considerable influence in promoting resolution, for my
experience coincides with that of. Professor Meigs, in
that I" never have this stage of acute tension continue
more than forty-eight hours.

When this stage has passed, and the leg begins to pit
easily on pressure, the hypersesthesia is gone, although
there may still remain deep-seated pains, if the leg be
moved, or if pressure on certain points be made. Now
is the time when you must strenuously insist on abso-
lute rest of the limb. I am in the habit of saying to
my patients that, if they put their foot to the floor,
every minute that it is down prolongs the duration of
the disease a day, and I am not certain that this ex-
pression exaggerates the danger. Not one patient in
flfty has the sense to appreciate such a thing unless it be
forcibly presented.

After the period of acute tension, the frictions and
fomentations should no. longer be used. ' You should
now carefully examine the leg to see whether there
be any tendency to localized phlegmon. If you find
any point where this seems to be threatened, your
treatment must at once be directed to this. I think
that, in two instances,' I have seen phlegmon aborted
by the application of a few leeches, but this is the only
condition in which I should ever recommend leeches in
the treatment of phlegmasia dolens. I have also seen
good result from painting the seat of the threatened
phlegmon with iodine. - So soon as you discover that
there is a circumscribed collection of pus, you should

PHLEGMASIA DOLEKS. 245

evacuate it at once, to prevent infiltration into the adja-
cent tissues. .. But, if there be no tendency to phlegmon,
your treatment must now be directed to the condition of
the vessels of the limb. They have , been greatly
distended; and their muscular coats have lost their
elasticity and contractility. So soon, therefore, as the
pressure of the finger leaves pitting in the tissues, the
indication is to promote absorption of the effused fluids,
to overcome the stasis of these fluids, and to restore
the tonicity of the vessels. This is best accomplished
by applying a roller, commencing at the toes and carry-
ing it up the whole length of the limb. At first, I gen-
erally use a flannel bandage, as its elasticity permits
an adaptation and yielding to the distended sensitive
tissues, but, after a few days, the linen roller is borne
without pain, and is more effective.

Hervieux objects to the use of the bandage, because,
he asserts, it has the grave inconvenience of exasperat-
ing the pain, so that, in a very little time, it becomes
intolerable. I have never found this to be the case.

You should first apply the bandage yourself, and
continue to do so until the nurse has thoroughly learned
how to put on the roller, and some, you can never teach.
At first, the bandage should be readjusted twice in the
twenty-four hours, but, as the swelling subsides, once a
day will be all that is necessary.

Each time the roller is -readjusted, the leg should be
thoroughly washed with an alcoholic lotion, gently rub-
bing the surface upward, with a soft piece of flannel.

Some have objected to this friction, from fear of de-
taching and carrying into the circulation some fragment
of a clot in the vein. The susrsrestion strikes one forci-

bly, coming, as it does, from some eminent authorities ;
but, as this friction must have been used in thou-

246 PUERPERAL DISEASES.

sands of cases, and as no case of embolism is yet re-
ported as thus originating, I am disposed .to continue
the use of means which are so palpably advantageous,
rather than to give them up, from apprehension of an
hypothetical danger.

The use of the roller should be kept up so long as
there is any tendency to oedema of the foot and leg, af-
ter the patient begins to walk.

The patient may be permitted to walk so soon as
all evidence of the local disease has disappeared, but
not before. The effort at first generally causes pain,
but this gradually disappears as the patient becomes
accustomed to use the limb.

The treatment of the secondary phlebitis and pya3-
rnia will be more appropriately discussed in another
lecture.

LECTUKE XIII

PUEKPERAL THKOMBOSI8 A!NT> 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 :
(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

(<?.) Sucli lesion of the parenchyma of the lungs as
arrests the current of the blood through the smaller
branches of the pulmonary artery.

(d.) Arteritis, which is exceedingly rare.

From an analysis of twenty-five cases of sudden
death after delivery, Dr. Playfair infers that the diag-
nosis between spontaneous thrombosis and embolism
of the pulmonary artery may probably be determined
by the period after delivery when the phenomena of
the lesion are first developed. He believes that true
embolism does not occur until after the nineteenth day
after delivery, and generally not until a much later
period than that, because a considerable time is re-
quired for the thrombi in the peripheral veins, from
which an embolus is derived, to soften and disintegrate
sufficiently to admit of a portion being detached and
carried to the right side of the heart. But, when death
happens shortly after delivery, he believes that the co-
agulation in the pulmonary arteries corresponds to the
formation of the original thrombus in the peripheral
veins, which must of necessity occur in cases of true
embolism. If subsequent and more extended observa-
tions confirm this theory, it strikes me as a pathological
fact of great practical importance, although Dr. Play-
fair himself speaks of it as a question more interesting
from a theoretical than a practical point of view.

Symptoms of TJirombosis and Embolism of tlie Pul-
monary Artery. The most characteristic and prominent
of the symptoms, and usually the first to be noticed, is
the great difficulty in breathing. This is sometimes
frightful, the respirations suddenly increasing to forty
or fifty a minute, with convulsive contractions of the
muscles of the chest, and inexpressible anguish and
anxiety, followed by rapid prostration of the vital

26G PUERPERAL DISEASES.

forces. The movements of the heart are at first im-
petuous and irregular, but speedily become very feeble
and rapid. The pulse in a short time becomes veiy
frequent, small, weak, and sometimes imperceptible.
The patient prays for air, the face becomes livid, the
surface is covered with a cold sweat, and the extremi-
ties are cold.

In some, death follows a few moments of agony,
while in other cases, after a little time, there is a
mitigation of the symptoms, and the fatal result is
postponed for a few hours, or it may be for a few days.
I have no doubt that a very considerable number of
such cases entirely recover. In my own experience, I
think that I can recall several such, some of which
occurred before I had any knowledge of the real nature
.of the affection. It would seem as if the obstruction
of the artery is gradually removed, either by displace-
ment or fragmentation, and all the symptoms result-
ing from the occlusion disappear.

I shall briefly detail one case of most intense interest
to me, which, in the light of our present knowledge, I
should include in this class :

CASE XIX. Mrs. , of Mobile, whose mother and two sis-
ters had died from post-partum hemorrhage, came to New York
to be attended by me in her first confinement. She had the fixed
conviction that her own death was certain to result in the same
way, and always spoke of it with perfect calmness, but as an
event which was absolutely certain to occur. She was at the
New York Hotel, and her labor commenced about eight in the
morning, June 6, 1857. It was not more severe flian ordinary
first labors, and terminated at nine in the evening by the birth of a
fine male child. There was not the slightest manifestation of ner-
vousness or hysteria, but she absolutely declined to inhale chloro-
form, assigning as a reason that while she lived she wished to have
her full senses. Of course I had taken every precaution against
post-partum hemorrhage, and there was none. At half-past ten,

PUEKPEKAL THEOMBOSIS AND EMBOLISM. 267

she was, in every respect, apparently in as good condition as any
woman an hour and a half after labor, and her husband and myself
left her, to go to the dining-room of the hotel. We returned about
an hour afterward, and found that she had slept nearly the whole
time of our absence. She was very cheerful, and spoke of her
past apprehension as absurd. I examined her very carefully, and,
finding that there was no hemorrhage, that the uterus was well con-
tracted, and the pulse normal, I took leave of her for the night.
But I had net descended the first flight of stairs^ when I was called
back by her husband's voice in a tone that thrilled through me,
saying that she was dead. In stooping to kiss her good-night, he
observed a sudden change in her face, and a fearful gasping for
breath. My first thought was of internal hemorrhage, but I was
soon satisfied that there was none. Her agony for breath was
indescribable, and her whole appearance was so much like one
dying from hemorrhage, that I made repeated examinations. The
pulse could not be felt at the wrist, and the heart was beating
irregularly and tumultuously, but with a feeble impulse. Her
countenance seemed to bear the stamp of death, her face and fore-
head were covered with cold drops of perspiration, and her extremi-
ties were cold.

From this time until after six in the morning, I never left her
for one moment. She took, during this time, a full half-ounce of
McMunn's elixir of opium, a full bottle of brandy, and a wine-
glassful from a second bottle. Many times, as the liquid was put
into her mouth, it gurgled in her throat, and I was obliged to
stimulate deglutition by all the reflex means at my command.
Twice I applied a lighted taper to the epigastrium for this purpose.
This excited a gasping respiration, breathing having apparently
ceased, and deglutition immediately followed. At half -past six
in the morning, her respiration had greatly improved, her pulse had
returned to the wrists, and the extremities had become warm. I
need not tell you with what anxiety I watched this case until she
had perfectly recovered.

Tlie following autumn, I saw a case almost precisely
like this, with the late Dr. Henry G. Cox. The patient,
the wife of a Moravian clergyman, had given birth to
twins four or five hours before the symptoms of
asphyxia had appeared. In this case, I think the quan-

268 PUERPERAL DISEASES.

tity of brandy given by Dr. Cox was even greater than
the amount taken by my patient. She recovered, but
subsequently had phleginasia dolens, when I again saw
her with Dr. Cox. Neither of us at this time sus-
pected any condition of the blood as bearing a com-
mon relation to the phenomena of the different at-
tacks.

But you may ask me what reasons I have for regard-
ing these as cases of thrombosis of the pulmonary arte-
ries rather than as cases of " idiopathic syncope."

I answer, because the symptoms were those of
asphyxia and not those of syncope. In syncope, con-
sciousness is abolished ; in asphyxia, the intelligence is
enfeebled by the great depression of the vital powers,
but the consciousness may remain until just as death
is impending. Perhaps we are apt to associate with
the idea of asphyxia, simply the absence of respirable
air. But respiration implies an interchange of elements
between the blood and air, and asphyxia may be equally
due to absence of blood in the lungs.

Thrombosis of the pulmonary arteries may suddenly
cause death by complete -asphyxia, or life may be pro-
longed some hours or even days, and gradually termi-
nate by a series of attacks of asphyxia.

If the thrombosis be confined to minute branches of
the pulmonary artery, there a-re no signs of asphyxia, or
other symptoms of the lesion at the time of its occur-
rence, but we then have, as a consecutive result of the
obliteration, lesions of the parenchyma of the lungs,
limited in extent by the number of branches involved
in the thrombosis. There is no doubt that the lobular
pneumonia of puerperal women is not unfrequently
due to this cause, and that, in some cases, this pneumo-
nia terminates in gangrene.

PUERPERAL THROMBOSIS AND EMBOLISM. 269

Treatment. I have but little to add in regard to the
treatment of this affection.

"When the symptoms of asphyxia are suddenly de-
veloped, do not hastily give up your patient. If you can
only bridge her over the danger of the first attack, you
have much to encourage you to continue your efforts.

Perhaps the stimulus of hope, inspired by your
own quiet, confident, self-assured manner, may be really
as effective as the alcoholic drinks and the opiates that
you prescribe. I say opiates, because I regard them as
quite as essential as wine or brandy. It does not now
come within my province to discuss this great thera-
peutical problem ; and so I must be content with merely
expressing my belief, that the value of opium in restor-
ing the vital powers, depressed by the shock of as-
phyxia, is not less than in shocks from other causes.

In all cases, and especially where the symptoms of
thrombosis of the pulmonary arteries are consecutive to
an attack of phlegmasia dolens, you cannot insist too
rigidly on the necessity of absolute rest. The patient
should not be allowed to make the slightest physical
effort for days, at least until the impulse of the heart
has recovered its normal force.

As to the chemical therapeutics of this lesion, I
think that we are yet too much in the dark to warrant
me in making any suggestions.

The indications for the use of quinine, iron, and
agents of this class, are too obvious to require com-
ment.

Cerebral Embolism. But few cases have been pub-
lished in which cerebral embolism has occurred in the
puerperal woman. Professor Simpson, in the paper to
which I have before referred, quotes one case from Dr.
Burrows, in which the patient, the wife of an esteemed

270 PUERPERAL DISEASES.

obstetrical friend, became suddenly hemiplegic on the
right side, but without symptoms of cerebral conges-
tion, about six weeks after delivery. The hemiplegia
and impaired powers of speech and memory remained
to the time of death. At the autopsy, abundant vege-
tations were discovered on the aortic and mitral valves,
so that they were softened and ulcerated through. The
left corpus striatum was reduced to a mere diffluent
pulp, and the branch of the left middle cerebral artery
passing to this part of the brain was obliterated by a
small mass of fibrine, like a grain of wheat, implanted in
the vessel at its origin from the middle cerebral artery.
The artery beyond the obstruction looked like a pale,
thin string, and was impervious.

A case of cerebral embolism occurred in our lying-
in wards last year :

" CASE XX. Delia C , aged twenty-two, single ; primi-

para ; was delivered of a living girl, weighing eight pounds, Feb-
ruary 11, 1872. I have a full report of the case, furnished by Dr.
Edward "W. Burnett, house-physician, up to February 24th, when,
unfortunately, owing to illness, he was unable to continue his rec-
ord. On the 13th, two days after delivery, she had a chill, followed
by fever, thirst, and severe pain in the region of the uterus, and
for some days the catheter was required to empty the bladder. The
temperature was high, 104.8, and the pulse, 132. There was
but little change in her symptoms for the following seven days,
when she was apparently convalescent. But, on the 22d that is,
on the eleventh day after delivery the temperature rose to 105,
and the pulse to 124. On the 23d, she was found to have aphasia,
although she apparently understood every thing said to her. It is
also said that fluid ran out of the left corner of her mouth. She
died on the 27th, and Professor Janeway has kindly given me the
following notes of the autopsy, which he made on the 28th :

" Exterior. Poorly nourished; abdomen tympanitic.

" Brain. 'Left middle cerebral artery contains a firm, white clot,
at its first bifurcation. This clot is prolonged into both vessels at
the bifurcation for some distance, and backward, as a reddish throm-

PUERPERAL THROMBOSIS AXD EMBOLISM. 271

bus of a later date. The artery going toward the third frontal con-
volution is plugged by a thrombus of more recent date than the
h'rst named. At the termination of the fissure of Silvius, the pia
mater has a slight lymph-exudation in its meshes. The anterior
half of the left corpus striatum, especially its lower portion, is little
changed in color, but is considerably softer than natural. The tis-
sue is infiltrated with serum, which oozes out in sections, giving a
worm-eaten appearance, the line of demarcation between softened
and healthy tissue being well marked. Outer portion of island of
Reil in same condition. The third frontal convolution and remain-
der of brain normal.

" Heart. Size normal ; aortic valves normal ; mitral valves thick-
ened to a moderate degree, somewhat shortened, and present vege-
tations on their auricular surface, a couple of which are one-eighth
of an inch in length.

" Lungs. Right ; old firm adhesion. Left ; slight exudation on
diaphragmatic surface of pleura.

"Abdomen. Slight exudation upon liver and intestines, and con-
siderable between rectum and uterus.

" Liver. Large, but appears normal.

" Spleen. Three times the usual size, wedge-shaped infarction at
upper part. Artery going to this, obstructed by whitish thrombus.

" Kidneys. Present a few small, yellow infarctions, the size of
a pin's head.

"Stomach and Intestines. Nothing special.

" Uterus. Inner surface, at seat of placental attachment, pre-
sents a number of protruding clots of creamy color. Upon the
anterior surface, a little below the anterior border, there protrudes
into the cavity, a rounded swelling. On cutting through this,
there is found a portion of uterine wall, one inch in length and one
and one-quarter inch in thickness, which looks like an infarction
of the uterine substance, partly surrounded by a suppurative pro-
cess, which has nearly separated it. The right ovary shows the
corpus luteum more cedematous than usual, surrounded by a thin,
white wall, looking like fibrous tissue. No other abnormal appear-
ances are discoverable."

At my request, Dr. Henry F. Walker, of this city,
lias furnished me with the following report of a very in-
teresting and rare case, which occurred in his practice :

272 PUERPERAL DISEASES.

" CASE XXI. Mrs. J , aged thirty-two ; primipara ; of blonde

complexion and plump figure ; had been remarkably well during
her pregnancy. She was naturally of a nervous temperament, and
had often been hysterical. During the seventh and eighth months
of gestation, she had suffered slightly from dyspepsia. Her urine
was examined two or three times, at intervals of a week, and found
free from albumen, but, during the last six weeks preceding labor,
it had not been tested. The patient, however, had felt unusually
well, walking two miles the day before her confinement.

" May 2, 1870. I was first called to see her at 5 A. M. The os
uteri was dilating, being the size of a nickel cent, pains occurring
every five minutes, vertex presenting in the first position. The mem-
branes had ruptured early, and with each pain there was a dis-
charge of liquor amnii. She complained of slight headache, which
passed off after taking food. I saw the patient every hour till half-
past one P. M. At that time she was comfortable. The os uteri was
as large as a silver dollar, its edges thick, but dilatable. The pains
were of moderate intensity, and the morale of the patient was good.

" At 3 P. M., I was summoned in great haste. I found Mrs.

J completely hemiplegic. The left side was paralyzed in both

motion and sensation. Her sister, a very intelligent lady, who had
not left her for a moment, stated that the patient had acted queer-
ly, had cried out with an intense pain in the head, putting her hand
to the right temple, and had torn her hair, but that she became
suddenly quiet, without loss of consciousness, or convulsive move-
ment. Then the sister noticed that Mrs. J mumbled in 4ier

speech, and, when offered a drink, the water ran from her mouth.

" The patient was quiet, complained of slight pain in the right
side of the head, seeming entirely conscious of what was said and
done, but was unable to articulate intelligibly, although she would
speak until she completed the sentence attempted.

" I gave her four drops of Magendie's solution of morphia hypo-
dermically, drew and tested the urine, which was highly albuminous,
and sent for Dr. Thomas, who in turn sent for Dr. Peaslee. Imme-
diate delivery was decided upon, and Dr. Thomas, after the patient
was chloroformed, further dilated the uterus manually, applied for-
ceps, and delivered a large, living female child, which throve from
its birth. The uterus contracted slowly but firmly. Patient slept
quietly at night.

May 3d. Headache quieted by morphine given hypodermically,
gtts. v. of Magendie's solution every four hours. Pulse 100.

PUERPERAL THPvOMBOSIS AND EMBOLISM. 273

" May kth. Pulse 120. Skin hot and dry. These symptoms
were relieved by a single hypodermic injection. Treatment was
commenced with special reference to the renal trouble, a wine-glass
of a solution of potass, bitart. being given every three hours, which
apparently affected the kidneys beneficially, the urine becoming
much less albuminous. Her diet was milk and beef-tea. After the
third day, there was no rise of temperature or acceleration of pulse.

" May 7th. Headache still continued, but checked by the hypo-
dermic use of morphia. The paralysis of the face less, sensation
returned slightly to the leg, but no power of motion.

"May Tilth. Patient was to-day told that she was paralyzed.
She had complained of numbness in the extremities of the left side,
but was only puzzled at her condition. She said that she supposed
her hand obeyed her will, and it was only when she touched one
with the other that the left ' felt like a clump.' When she arranged
the bedclothes at her throat with her right hand, she supposed that
she coordinated with the other. Morphia omitted. Five grains of
potass, bromidi to be given if restless. Voluntary micturition was
impossible from the tune of delivery to May 17th, when vesical
power became perfect. From this time improvement was constant.

"June 3d. She walked about the room pushing a chair.

At the present date, May, 1873, she is entirely well in all matters
of nutrition and perception, but she still has diminished control over
the paralyzed side. The hand is more manageable than the foot and
leg, and, for a slight contraction at the ankle, which still persists, the
patient is employing treatment by passive movements with benefit.

" In this case, the diagnosis would be between cerebral hemor-
rhage and embolism. The patient was under most careful observa-
tion, and nothing like convulsions could have occurred unnoticed.
If a convulsion had occurred, leaving the patient permanently hemi-
plegic, cerebral hemorrhage would alone explain the paralysis, but,
as the result of either convulsion or primary apoplexy, we should
have had either mental hebetude or entire loss of consciousness,
neither of which was manifested. Embolism only explains the im-
mediate and subsequent symptoms."

I regard this case as one of remarkable interest,
and in some respects it is unique in obstetric literature.
I think there can be DO doubt as to the correctness of
the diagnosis of Dr. Walker, and that the right middle

274 PUERPERAL DISEASES.

cerebral artery was the seat of the embolism. The
character of the attack, the absence of coma, the head-
ache, and the age of the patient, are all in accord with
this theory. The slow recovery also indicates the col-
lateral ceclema or softening which is associated with em-

bolism.

It is impossible to diagnosticate embolism of the
right middle cerebral artery with the same certainty as
the same lesion on the opposite side, as there is not the
symptom of aphasia to aid us in the diagnosis. Most
authors agree in the assertion that embolism of the left
middle cerebral artery occurs much more frequently
than of the right, and this is explained by the anatomi-
cal fact that the left carotid artery takes its origin
from the arch of the aorta in a direct line with the
current of the blood, while the right carotid springs
from the arteria innominata, and thus forms an angle
with the aorta, Thus, a detached vegetation from the
aortic or mitral valve would be easily carried along
with the current in the left carotid.

A case has recently occurred in this hospital, in the
service of my colleague, Professor William T. Lusk. So
small a number of cases of cerebral embolism in puer-
peral women have as yet been published, that I shall
make no apology for giving, in its full detail, the fol-
lowing report, by L. J. Brooks, M. D., house-obstet-
rician :

" CASE XXII. Mary , admitted September 24, 1873 ; aged

nineteen ; seamstress. Born in Providence, R. I. Family history
good. Parents still living. She states that she has always had
excellent health, and has ' never been sick a day.' She is a temper-
ate woman, and, save the present attack, has never suffered from
rheumatism, or any chronic affection. Menses began at the age of
fifteen, and were always regular. Patient gives no evidence of any
uterine trouble and never had coition, except on the occasion

PUERPERAL THROMBOSIS AXD EMBOLISM. 275

which resulted in the present pregnancy. There is no history of
any cardiac trouble.

" She menstruated last in December, 1872, the beginning of her
present pregnancy. During gestation, nothing unusual occurred.
Her labor began September 2, 1873, at 5 P. M., and the attendance
of a midwife was secured. She delivered the patient of a boy,
at the expiration of two hours. The delivery was followed by
post-partum hemorrhage, by which she lost a large amount of
blood. This occurrence prostrated her very much, but she never-
theless got up on the third day after confinement. For the three
weeks following, she daily lost some blood, which gradually weak-
ened her more and more, so that, on admission (September 24th),
she was forced to take to the bed. The child is healthy and vigor-
ous, and probably aided in exhausting the strength of the patient.

" On admission to Bellevue, she was pale and anasmic. The
skin white no redness in the cheeks or lips the eyes bluish-white,
pulse soft but regular, temperature a little elevated. Complains
of great weakness, loss of appetite, and general prostration. The
knees and ankles are a little swollen and tender, and the inflamma-
tion in them appears to be rheumatic in character. Thjs trouble
began yesterday, and is the first of the kind she has ever had.

" She is ordered nourishing diet tonics porter perfect quiet
and the affected joints are enveloped in cotton, saturated with
lotio plumbi et opii, and covered with oil-silk.

" October \st. Patient appears to be growing weaker. Has
lost no blood since admission. Spirits languid, and expression dull.
Skin anaemic, hot, and dry. Tongue a little coated, and papillae
prominent; some thirst; anorexia; bowels confined. No abdominal
pain or tenderness. Temperature a little elevated. Pulse some-
what rapid and feeble.

" Physical Examination. Right lung, behind slight dull-
ness, increased fremitus, diminished breathing, increased voice-
sounds, and abundant loud, sibilant, and sonorous rales. Over
left lung, some sibilant and sonorous rdles.

" Heart a loud mitral regurgitant murmur, transmitted to the
left, over the posterior surface of the left chest and along the
spine.

" She was ordered quiniae sulphat. gr. v., three times a day, and
vini ferri et cibi cum cinchona, 3 ss, thrice daily, and to continue
porter and extra diet.

" October 5th. Her condition is a little improved. Has some

276 PUERPERAL DISEASES.

tenderness in both iliac fossae. Same physical signs in the chest
remain. Treatment continued.

" October 8tk. Patient has been getting out of bed for several
days to go to the Avater-closet, although positive orders are given
for her not to do so. While disobeying this order last night, she
was suddenly taken with what the nurse called a ' fainting-fit,' and
could with difficulty be got back to bed. Fifteen minutes later,
she was in a condition of partial collapse, extremities very cold,
skin pale, radial pulse just perceptible, respirations labored, and
prostration very marked. Pain in the head, which she says she
has had for two or three days. She was ordered heat to extremi-
ties and body, and 3 ij of brandy every half-hour for three hours;
then, 3 ij every hour.

" This morning her condition is as follows : Partial hemiplegia of
the left side, face included. Angle of mouth drawn to the opposite
side. Tongue protruded to the left; pupils equal; no change in
speech. Left arm and leg are partially paralyzed, as regards motion.
Sensation of affected side normal. Temperature a little lowered.
Grip feeble; no difference in radial pulses. Skin very pale, lips
bluish, tongue coated white, not dry. Pulse very feeble, acceler-
ated, and somewhat irregular. Prostration very marked. No pain
in the head. Conscious. Abundant dry rdles over the lungs in
front. Behind, no examination was made, owing to her weak con-
dition. Ordered brandy, 3 ij every hour, and ammon. carbon, gr. v
every third hour. 3 P. M., temperature 104. Ordered brandy,
3 ij every half-hour. 5 P. M., respiration 32, pulse 96, temperature

102}-

" October 9th, 9 A. 3J. Pulse 110, soft and compressible; respi-
ration 36 ; some tracheal rdles ; temperature 102. Skin hot, dry,
and bleached. Paralysis a little more marked. Tongue a little dry
and coated white. Slept well. No cephalalgia. Pupils equal and
respond to light. Says she feels well, but very weak. Takes little
nourishment. Ordered brandy, 3 ij every hour, and to continue
ammonia. 5 P. M., respiration 28, pulse 96, temperature lOlf .
Slept nearly all day. Is conscious, but stupid ; a little wandering
delirium. Answers rationally.

" October lO^A. Paralysis the same. She is very dull and drowsy.
Involuntary evacuation of urine and fasces. Pulse 108, very feeble;
respiration 38; temperature 102^. Stimulants continued (egg-
nog). 5 P. M., respiration 32, pulse 110, temperature 102.

" October llth. Respiration 24, pulse 116, temperature

PUERPERAL THROMBOSIS AND EMBOLISM. 277

Paralysis the same. Pupils large. Eats some. Tongue clean.
Bowels free. Temperature of the left side much diminished. 5
p. 3f., respiration 33, pulse 112, temperature 102f.

" October 12th. Respiration 40, pulse 120, temperature 103f .
She appears a little brighter. 5 P. M., respiration 34, pulse 116,
temperature 103-f-.

" October 13th. Respiration 40, pulse 130, temperature 104f.
Paralysis to-day complete. Affected muscles soft and flabby, and
temperature low. Delirium a little more marked, wandering and
incoherent. Marked thirst. No pain in the head, 5 P. M., respira-
tion 36, pulse 128, temperature 104.

" October 14th. Respiration 28, pulse 120, temperature 103 J.
Constant wandering delirium. Slept some ; answers rationally.
Appears to be failing. Skin very dry and bleached. Tongue clam-
my. Abundant large and small mucous rdles and some tracheal
rales are heard in front of the chest. 5 P. M., respiration 30, pulse
138, temperature 104-J .

" October 15th. Respiration 30, pulse 126, temperature 102.
She slept well by taking potass, bromid. More stupid this fore-
noon. Tongue dry and a little brown in the centre. Passes urine
in bed, and she has two small bed-sores. 5 P. M., respiration 34,
pulse 134, temperature 103f .

" October 16th. Respiration 30, pulse 124, temperature lOlf .
Abundant rdles over the chest. Delirium and stupor more marked.
5 P. M., respiration 44, pulse 140, temperature 103-|.

"October 17th. Respiration 36, pulse 130, temperature 102|.
Slept but little ; still more delirium ; says the same thing over and
over. 5 P. M., respiration 36, pulse 148, temperature 105.

"October 18th. Respiration 60, pulse liO, temperature 102.
Sordes on gums ; dry tongue ; muttering delirium. Slept none.
Breathing labored. 5 P. if., respiration 32, pulse 144, temperature
104.

" October 19th. Respiration 54, pulse 140, temperature 102f .
5 P. M., respiration 52, pulse 136, temperature 104|. Is rapidly
failing. At 12, midnight, respiration became labored and gasping.

" October 20^. 4.30 A. M. patient died."

Autopsy, by Professor Janeway, October 20th :

" Exterior. Small bed-sores on the nates.

" Urain. Right corpus striatum, for the most part, of a dirty

278 PUERPERAL DISEASES.

color and partially softened, and a small artery leading to it from
the middle cerebral is obstructed at its point of origin, by a reddish-
gray coagulum, not firmly adherent to the vessel. On the left side,
a branch of the middle cerebral, supplying the island of Reil, is ob-
structed by a similar coagulum, and the outer half of the island of
Reil is softened. In other respects the brain is normal.

"Lungs. Considerable serum in the pleural cavities. Lower
lobes compressed ; upper lobes cedcmatous. No infarctions.

" Heart. Normal size. Right cavities normal, and contain partly
red and partly white post-mortem clots. Aortic valves normal.
Left ventricle is filled with reddish coagula. Mitral orifice almost
completely obstructed by a mass of vegetations, adhering to the
valves on the auricular surface. The posterior leaf is thickened and
a linear rupture exists, half an inch above the border. Around this
is a mass of soft vegetations, through the centre of which and the
ruptured valve, the blood flowed.

"Liver. Large and congested.

" Spleen. Twice the usual size, with a large, recent infarction,
the artery of supply at this point being obstructed by coagula.

" Kidneys. Exhibit several infarctions, some recent and red,
arteries varying in color from w r hite to yellow.

" Peritonaeum, stomach, intestines, uterus, ovaries, and ovarian
veins, all normal."

In a recent excellent treatise on apoplexy, by Li-
dell, you will find the reports of ten cases of cerebral
embolism, but not one occurred in a puerperal woman ;
and the only case published by writers on this disease,
which I now recall, is the one that occurred in the prac-
tice of Dr. Burrows, w T hich I have quoted from Sir
.Fames Simpson. But, as I have now added three, all
of which have occurred in this city within the past
three years, I suspect that the reason why more cases
have not been published is found in the fact, that the
attention of obstetricians has not been directed to the
study of this lesion.

Special writers on this subject tell us that the lesion
is always preceded by characteristic premonitory syrnp-

PUEEPEEAL THROMBOSIS AND EMBOLISM. 279

toms. Xiemeyer says, " These are not brain-symptoms,
but those of the diseases which almost exclusively cause
embolism of the cerebral and systemic arteries that is,
of valvular disease of the heart of endocarditis and
severe destructive diseases of the lungs." He asserts,
also, " that the occurrence of these premonitory symp-
toms, and the presence or absence of valvular disease,
endocarditis, or some disease of the lungs, have such
an effect on the diagnosis that, with the same set of
symptoms, we may diagnosticate embolism, if we find
them, and exclude it with certainty if they are absent. 17
Still, errors in diagnosis between cerebral embolism and
cerebral hemorrhage have been made by some eminent
men, and Bamberger, a high authority, considers it im-
possible always to avoid this mistake.

Age furnishes an indication of importance. In
young persons, when hemiplegia occurs suddenly with
an apoplectic attack, the presumption is in favor of em-
bolism. Cerebral hemorrhage occurs chiefly, although
not exclusively, in advanced age. Embolism may hap-
pen in a person of any age.

The symptoms of hemiplegia and apoplectic seizure
are almost always suddenly developed, at the commence-
ment of the attack, in cerebral embolism. In cerebral
hemorrhage, these symptoms are generally developed
more or less slowly ; that is, one after another, and not
all at once.

Another symptom of diagnostic value in cerebral
embolism is the sudden occurrence of very acute pain
in the affected part of the head. The patient frequent-
ly announces the attack by a scream. Cerebral hem-
orrhage is not usually attended with headache, but is
more generally ushered in by a feeling of faintness or
sinking.

LECTURE XIV.

PUERPERAL PHLEBITIS.

Case Recovery Two cases of death Autopsical lesions Three forms of puerperal
phlebitis : adhesive, circumscribed suppurative, and diffuse suppurative
Ranvier's pathological histology Uterine phlebitis Symptoms : rapid pulse,
rise in temperature, recurrent chills of moderate severity Pain, generally not
severe, but uterine tenderness Abdominal tenderness and tympanites not
symptoms of phlebitis Involution not retarded by uterine phlebitis Typhoid
symptoms : rapid depression of the vital powers, delirium, subsultus, diar-
rhoea, profuse perspiration, profuse and very offensive lochia Signs of puru-
lent infection Differential diagnosis of uterine phlebitis from peritonitis and
metritis Terminations of uterine phlebitis Rapid death from septicaemia or
embolism of the pulmonary artery Recovery by resolution Slow recovery by
eliminative suppuration on the external surface Death as a result of purulent
deposit in serous cavities or in the parenchyma of important organs Secondary
bronchitis or pneumonia Tendency of this disease to impair assimilation and
nutrition, and subsequently to destroy life by marasmus or acute tuberculosis
Treatment.

" CASE XXIII. 1 Ann Strohmayer, born in Germanjr, aged twenty-
two, married, was delivered of her first child, a girl weighing seven
and one-half pounds, at 12.20 P. M., November 22, 187], after a
short labor of an hour and a half. Although the placenta was part-
ly forced into the vagina by the last pains which expelled the child,
the uterus did not contract well, and there was some difficulty in
removing the after-birth. The delivery of the placenta was followed
by the escape of a large quantity of clots. Strong pressure was made
on the uterus, but it did not respond, and ice was applied both ex-
ternalty and internally ; but, for nearly a half-hour, there was a good
deal of bleeding, and the uterus was constantly disposed to relax.

1 Reported by John A. McCreery, M. D., house-physician, Bcllevue
Hospital.

PUERPERAL PHLEBITIS. 281

Pressure was steadily kept up over the uterus by the hand of one
of the house-staff or myself for over three hours before the bandage
was applied. After this, for the succeeding twenty-four hours, the
patient was very comfortable, with the exception of some severe
after-pains, followed by the expulsion of clots. She appeared to be
rapidly regaining her strength and color. Respiration 22, pulse
104, temperature 98.2. As there was some tenderness over the
uterus, turpentine-stupes were laid over the abdomen.

" November 2<ith. Respiration 28, pulse 128, temperature 103.
Considerable tenderness over the uterus, which is not well con-
tracted. No pain except at long intervals. Very little tympanites.
Skin hot and dry ; face flushed ; tongue coated. Had a chill in the
evening. Ordered quinice sulph. gr. v ter in die ; tine, aconit. gtts.
v every two hours ; suppository of the aqueous extract of opium,

g r - J-

" November 25th. Respiration 28, pulse 132, temperature 103.
Has vomited brown matters several times. Sweats profusely. Bad
taste in mouth. Tongue thickly coated. In the evening, very little
change ; pulse, respiration, and temperature, same as in the morning.
Has been delirious during the day. Bowels have not moved since
her confinement, and a cathartic was ordered.

" November 2Qth. At midnight, she began to vomit stringy mu-
cus with a brown sediment. Bowels moved while she was vomit-
ing, and she had severe bearing-down pains. The pulse fell to 80 in
the night, and was, for a time, irregular. The aconite was stopped.
The quinine was continued, and an opium-suppository was intro-
duced. At 9 A. M. Respiration 22, pulse 108, temperature 101.
Bowels moved several times, but she has not vomited since mid-
night. Lochia very free and exceedingly offensive. Ordered vagi-
nal injections of carbolic acid. Evening. Pulse and respiration
same as the morning, temperature 100. Ordered quinine by the
rectum ; afterward, opium-suppositories every two hours while the
pain lasts, and as much egg-nog as she will drink. During the night,
the pulse ran up to 120. Marked pain and tenderness over the
uterus. Gave her gtt. xv of Magendie's solution of morphia.

" November 27tfA, 7 A. M. Respiration 26, pulse 120, temperature
102. Bowels moved several times during the night. Patient feels
well, but the countenance is sunken and of a leaden hue. Sweats
very profusely. Occasionally delirious subsultus. Ordered, qui-
nine, gr. xv, by the rectum, twice a day. Since the vaginal injec-
tions, the lochial discharges are much lessened in quantity, and the

282 PUERPERAL DISEASES.

odor is less offensive. Has had sharp, darting pains over the uterus,
with marked tenderness.

" November 2Sth. Respiration 20, pulse 104, temperature 101.
Patient is cinchonized. No vomiting or movement of the bowels
since yesterday. Pain and tenderness over the uterus much less.
From this time, her convalescence was steadily progressive, and, by
the middle of December, she was perfectly well."

Gentlemen : I am sure that all of you who think
must have asked yourselves the question, What is the
meaning of these grave symptoms which appeared so
soon after delivery ? The labor was unusually short,
it was followed by a pretty severe hemorrhage, but, in
twenty-four hours, the patient apparently rallied from
the effects of the loss of blood. Then she had chills,
fever, a pulse from 128 to 132, a temperature of 103,
respiration 28. The lochia became profuse and exceed-
ingly offensive, the nervous system was greatly de-
pressed, as shown by vomiting, subsultus, and delirium,
and all her symptoms were very discouraging for several
days. What pathological process had been set up,
which could cause all these phenomena and render the
condition of our patient so critical for eight days after
her labor ? I shall ask your attention to a brief abstract
of the report, by Dr. McCreery, of two other cases, which
have just occurred in my service, the general features
of which resemble, in the essential points, the history
you have just heard. The light thrown upon the
symptoms by the autopsies! lesions, in these two cases,
may perhaps aid us in answering the question :

" CASE XXIV. A married woman, born in Connecticut, was
prematurely confined at the seventh month. The labor was easy
and normal, but the child lived only an hour. The third day after
her confinement, the patient began to cough, and auscultation re-
vealed the existence of bronchitis. On the fourth day, she was
slightly delirious. Pulse 140, temperature 104, respiration 28.

PUERPERAL PHLEBITIS. 283

Her bowels moved regularly. There were no abdominal pains or
tympanites. She now began to have profuse sweating (she had
before had chills) ; there was a peculiar sweetish odor of the breath ;
and the teeth were incrusted with sordes. The pulse ran up to 160,
respiration 40, while the temperature fell to 101. Finally, there
was continued low muttering delirium, subsultus, hiccough, and
she died on the thirteenth day after labor.

Autopsy. The uterus was contracted down to nearly its normal
size. Its cavity contained putrid, broken-down clots. The uterine
veins were filled with a puriform fluid. The right Fallopian tube
contained pus. There was a little serum in the peritoneal cavity,
and slight fibrinous exudation on the peritoneal surface of the
uterus. The lungs were congested, and the bronchial tubes con-
tained muco-pus. Heart healthy. Liver medium size its lower
border covered with fibrinous exudation. Spleen large and soft.
Kidneys of medium size, cortex thick."

" CASE XXV. A German woman, aged twenty-five, married,
who was delivered, December 15th, after a perfectly natural la-
bor, of her third child. She had a chill on the second day after
delivery, and her pulse rose to 120, and the temperature to 102.
After this, she had repeated chills, profuse sweating, and delirium,
but never complained of pain, except when pressure was made
over the uterus. There was very little tympanites or abdominal
tenderness. Her pulse ran up to 140, and her temperature, to
104, but there was no essential change in her general symp-
toms, except those indicating a progressive failure of the vital
powers. The lochial discharges were at first profuse and excessively
offensive, but the use of injections of carbolic acid and warm water
in a great measure removed the fetor. She died on the thirteenth
day after delivery.

" Autopsy. The uterus was found less contracted than usual
at this period after delivery, measuring fully six inches in length.
The inner surface was of a dark color, and coated over with bloody
pus. The sinuses over the seat of the placental attachment were
open, and pus could be squeezed from them. The uterine veins
also contained pus, especially near the entrance of the Fallopian
tubes. The right ovarian veins were enlarged and filled with
thrombi, and some of them contained a purulent fluid. The vena
cava contained clots, some of them a half-inch in length. The
spleen was much enlarged and very soft. In the upper lobe of the
left lung, there was an infarction the size of a large pea."

284 PUERPERAL DISEASES.

In these three cases, the general symptoms were
very much the same in all, and they were the symptoms
which have been regarded as characteristic of uterine
phlebitis. In the two who died, the autopsical lesion
common to both was uterine phlebitis.

I therefore take this opportunity to discuss this
form of puerperal disease, in regard to which there
has been a great deal written, and yet there is still
great diversity of opinion among obstetric patholo-
gists, as to its nature, frequency, and relative signifi-
cance.

Some believe it to be the essential primary lesion
of that fearful malady, puerperal fever. Others regard
it as a rare secondary lesion of that disease. Others,
again, deny altogether the existence of this as a pri-
mary pathological state, but regard it as always sec-
ondary to some blood-change. Others tfyere are, who
consider this as always the primary lesion of various
secondary lesions of great importance ; such as phleg-
masia dolens, thrombosis, embolism, purulent infection,
metastatic abscess, and so on.

As it is quite impossible for me to examine the
various conflicting doctrines which have been held, and
still find warm advocates, I must be content with the
effort to make you understand the real nature of this
lesion, to describe to you the symptoms which charac-
terize it, and to tell you all I know about its treatment.

We are chiefly indebted for our knowledge of puer-
peral phlebitis to the original contributions of Dance,
Tonelle, Mr. Henry Lee, of England, Behier, of Paris,
and, more recently, to Yirchow, of Berlin, and Charcot
and Ranvier, of Paris. The micrographic researches of
the latter on this point are given in the work on " Pu-
erperal Diseases," by M. Hervieux, to which I have

PUEEPEEAL PHLEBITIS. 285

before referred, and it seems to me that they conclu-
sively establish certain facts in science which were
before only conjectural.

We meet with three forms of puerperal phlebitis :

(1.) The term adhesive phlebitis has been applied
to one form because, in connection with the evidence of
inflammation of the coats of the veins, the circulation
is found to be obstructed by fibrinous clots. Obliter-
ative phlebitis would, perhaps, be a better term. The
question has been much discussed, and is still unsettled,
whether the inflammation of the vein be the cause
or the consequence of the coagulation of the contained
blood. In a former lecture, I have given you my rea-
sons for the belief that thrombosis frequently occurs
without either antecedent or coincident phlebitis. The
doctrine of Virchow is, that the phlebitis is a conse-
quence, and therefore secondary to the blood-change.
I think a very strong argument in favor of this view is
found in the fact that uterine phlebitis is a very fre-
quent secondary lesion of puerperal fever, and is rare
as a primary puerperal disease.

The absolute demonstration of this form of uterine
phlebitis, where the uterine sinuses are filled with fibri-
nous clots, is thus given by Hervieux, as the result of
the investigations of Ranvier :

In disintegrating these clots, the microscope reveals
a great quantity of flattened epithelial cells of the
veins, of a fusiform appearance, often united at their
borders to the number of two or three. All of these
cells present, in their interior, fatty granulations, very
minute but clearly defined. By the side of these,
other flattened and irregular cells are seen, which

O /

also contain fatty granulations. Other round cells,
having a diameter from .015 to .02 of a millimetre,

PUERPERAL DISEASES.

in one or more nests, contain fatty granulations.
There are, also, numerous cells, in appearance exactly
like pus-globules, or white blood-globules, but all con-
taining fatty granulations. There are, in addition, great
numbers of free fatty granulations, and granules soluble
in acetic acid.

As Hervieux remarks, 'the microscope proves that,
in thrombosis of the uterine sinuses, the internal mem-
brane of the sinus is denuded of its epithelium,' and
that there is a special kind of inflammation which gives
rise, in the first place, to a considerable multiplication
of plasma-cells, and then to a fatty granular degenera-
tion of proliferous cells. With the change which takes
place in a thrombus, and its gradual dissolution, there
is often a change in the coats of the vein ; its muscular
coat is bedimmed with fine granular elements, and is
softened or destroyed, and small purulent collections
are sometimes found in the external coats. By the de-
struction of the walls of the vein, there sometimes re-
sults abscess in the contiguous uterine tissue. Similar
results also may occur, from the dissolution of thrombi
in veins other than those of the uterus.

(2.) Another form is the circumscribed suppurative
phlebitis, in which the veins are found to contain pus,
or a purifonn liquid between the clot and the vein, or
sometimes real cysts, with a clot, above and below, in
the vein. The different coats of the veins may be infil-
trated with pus. Sometimes the suppuration is limited
to the external tunics of the vein. In other instances,
the internal coat is destroyed, as a sequence of the in-
flammation of the external coat, just as the cornea is
sometimes destroyed as a sequence of conjunctivitis, and
then the cavity of the abscess communicates with the
cavity of the vein, and pus is mingled with the blood.

PUEKPERAL PHLEBITIS. 287

(3.) Diffuse suppurative phlebitis is not very rare,
in phlebitis of the veins of the lower extremities. I
shall reserve my remarks on this form for another occa-
sion, when I discuss the subject of pyaemia.

The anatomical seat of puerperal phlebitis may be
the veins in any part of the system, the veins of the
uterus, and other veins in the pelvic cavity, in those of
the lower, but rarely those of the upper extremities.

I remember a case of extraordinary interest, pub-
lished, I should say, some fifteen years ago, by that
honest and indefatigable worker in obstetric pathol-
ogy, Dr. A. H. McClintock, of Dublin, of puerperal
phlebitis, in which the veins involved were the jugu-
lars, the subclavians, and, if I am not mistaken, the
innominata.

But uterine phlebitis is the more common form ; it
is the form which we now have encountered, and, with
these few remarks, my observations will relate chiefly
to this. I do not regard this as a disease of very fre-
quent occurrence, either in hospital or in private prac-
tice, except when there is epidemic or endemic puerperal
fever ; yet, every year, I see some two or three cases.

The symptoms of this affection have been carefully
studied by numerous observers among whom, M.
Behier, of Paris, should be mentioned as one of the
most zealous and competent. M. Hervieux also gives
an admirable description of the phenomena which
characterize this lesion.

All writers agree that the initial symptom of this
affection is most frequently a chill, generally of moder-
ate severity. It is true that there is sometimes one
severe rigor, but, as a rule, it may be said that the chill
consists rather of irregular and repeated sensations of
shivering, induced by the most trivial causes, as the

288 PUERPERAL DISEASES.

movement of the bedclothes, turning in bed, or the
opening of a door. There is a marked tendency to
recurrence of these chills for several days, but without
periodicity ; that is to say, they come on irregularly, and
are unequal as to their duration and intensity.

Immediately in connection with the chill, there is
increased frequency of the pulse, which generally rises
to 110 or 120 per minute. The temperature also shows
a corresponding rise, from 101 to 103 Fahr. The
respiration is somewhat hurried, ranging from 24 to 28
or 30 per minute.

The appetite is lost at the very onset of the attack ;
patients frequently complain of a bad taste in the
mouth, and the tongue is, at an early period, covered
with a thick, white coat. Some authors speak of ur-
gent thirst as a common symptom, but, in my obser-
vation, this is not usually the case. There is simply a
desire to wet the mouth, to clear it from a disagreeable
taste.

There is generally, but not always, a moderate com-
plaint of pain, referred to the uterus. This is not acute,
nor does the patient usually speak of it, except when
questioned, and she then often speaks of it as being
only felt in certain movements, or when she coughs, or
when pressure is made over the uterus.

There is not usually any considerable tenderness or
tympanites of the abdomen, nor is there much sensi-
tiveness to pressure, except when lateral compression
of the uterus is made. If the fundus uteri be fixed
between the thumb and fingers, and then the pulp of
the fingers be rubbed along the sides of the uterus,
painful points are usually very apparent. But this
sign is only of value for the first two or three days, as
the sensitiveness to pressure disappears.

PUERPERAL PHLEBITIS. 289

In this affection, there is not necessarily either in-
duration or tumefaction of the uterus. It is a curious
fact that involution of the uterus does not seem to be
retarded by uncomplicated uterine phlebitis. In one
of our cases, the uterus was contracted down to nearly
its normal size ; and I have seen other cases, which con-
firm the observation of Hervieux, that the uterine
sinuses may be full of pus in a uterus, the tissue of
which is perfectly healthy, and is contracted down to
its normal size. If the phlebitis be complicated with
metritis, of course there will be tumefaction.

On vaginal examination, the cervix is found soft
and patulous, sufficiently so to admit the first phalanx
of the finger; and, if the phlebitis be not complicated
with inflammation of the adjacent tissues or with me-
tritis, the uterus is movable in every direction, and not
very sensitive to pressure.

In phlegrnasia of the other tissues in the pelvic
cavity, the initial symptoms may be much more intense
and striking ; but, in uterine phlebitis, one of the most
characteristic features is the rapid depression of the
vital powers. The patient looks very ill, which, to the
inexperienced, seems in striking contrast with the com-
parative mildness of the symptoms. Her countenance
bears an expression of indifference to every thing
around her, her look is vague, gloomy, and oppressed,
sometimes stupefied, and she is rarely seen to change
her position in bed.

I have never seen, in this disease, the aggregation
-of symptoms which Dr. Meigs describes as hysteroid
intoxication ; and it seems to me that his sketch, un-
doubtedly drawn from Nature, belongs rather to a
certain phase of puerperal mania.

But there is usually, at quite an early period, con-

290 PUERPERAL DISEASES.

siderable cerebral disturbance. "When the patient has
a high fever, a pulse of 120, temperature of 103, a
dry tongue and diarrhoea, she will assert that she is
quite well. There is manifest incoherence in her ideas,
and, in most cases, especially during the night, a mild,
tranquil delirium. Hervieux mentions an exceptional
furious delirium as sometimes occurring, but this has
never been manifested in any of the cases that I have
seen.

The skin is at first hot and dry, in some cases ; in
others, it is moist, and, as the disease advances, there
are profuse and irregular perspirations.

The lochial discharge is occasionally suppressed for
a day or more, in the commencement of the disease ;
but, in my observation, this is the exception rather than
the rule. More frequently, as in the three cases that
we have just had in the hospital, the lochia are at
first greater in quantity, sometimes almost amounting
to hemorrhage, and they are almost invariably exces-
sively fetid. It is not uncommon, however, to see these
discharges entirely cease two or three days before the
disease terminates fatally.

In nearly all of the cases, there has, sooner or later,
been a marked tendency to diarrhoea, and, in a less de-
gree, to vomiting. The fecal discharges are generally
at first dark, and afterward become black and exceed-
ingly offensive, and, near the end, they are involuntary.

You observe that this disease rapidly tends to de-
velop a typhoid condition. There is subsultus. The
mouth becomes so dry that articulation is very diffi-
cult and indistinct, the teeth are covered with sordes,
and, a little time before death, delirium is succeeded by
coma.

You will find that some authors believe that the

PUEEPEEAL PHLEBITIS. 291

symptoms which I have just enumerated only occur
when there has resulted, from the phlebitis, purulent
infection. But others besides myself have seen all these
symptoms in cases where the most careful research has
failed to detect any evidence of purulent infection.

The evidences of purulent infection are found in a
peculiar yellow tinge of the skin, in painful swellings
in one or more of the articulations, in phlegmons in
any part of the system, in mammary abscess, in puru-
lent ophthalmia, or in the signs of pulmonary infarc-
tions.

Gangrene of parts which are subjected to pressure,
as the sacrum, the trochanters, or the heels, is not a
very rare sequence of this disease.

The diagnosis of uterine phlebitis must be based on
a careful analysis of the symptoms, and a just apprecia-
tion of the physical signs. It is often one of the most
dangerous and important of the secondary lesions of
puerperal fever. It also occurs often as a primary lesion,
complicated with peritonitis or with metritis. But I
believe that it occurs, and not very unfrequently, as
an uncomplicated primary disease of the puerperal
state. The other puerperal phlegmasise with which it
may be confounded are metritis and peritonitis.

Metritis arrests the process of involution, and hence,
in this affection, the organ is always found decidedly
larger than it should be at the given puerperal period,
indurated and very sensitive to manipulation. It is
also characterized by more persistent and severe idio-
pathic pains in the organ, but, at the same time, very
much less grave constitutional disturbances. Recurrent
chills, profuse sweats, subsultus, diarrhoea, delirium,
with a rapid tendency to a typhoid state, are not symp-
toms which belong to metritis.

292 PUEEPEEAL DISEASES.

To one not much accustomed to see puerperal dis-
ease, the general appearance of a patient suffering from
uterine phlebitis would seem to resemble very much
that of a patient with peritonitis. In both, there is a
kind of vis inertiw, an indisposition to move or turn in
bed. In both, the countenance may bear the stamp of
a stupid, vague gloom, although, in peritonitis, this is
at first accompanied with a more marked expression
of suffering and pain ; and in both there is a marked
tendency to low delirium. In short, both diseases rap-
idly enfeeble inneryation.

In peritonitis, the pain is usually very severe, and
even when the inflammation is confined to the serous
membrane in the pelvic cavity, if pressure be made on
the lateral vaginal cul-de-sacs or in the iliac fossae, there
is exquisite tenderness, while, in phlebitis, the tender-
ness to pressure is chiefly evident on the lateral por-
tions of the uterus. It is true that, in puerperal fever,
the peritoneal lesions may be very severe, and the in-
tense pain and sensitiveness , to pressure which charac-
terize puerperal peritonitis may be absent, but, in these
cases, the diagnosis is cleared up by the tumefaction
and tympanites, which are generally present in perito-
nitis.

Again, peritonitis is sometimes ushered in by one
chill ; while, in phlebitis, the chill is generally much less
severe, but it is repeated and irregular in its recur-
rence. It is true that we sometimes meet with succes-
sive and progressive attacks of inflammation of the
serous membrane, and, with each onset, there may be a
renewal of the chill, but there are also corresponding
local signs of the progressive disease. Each chill in
peritonitis is attended with a new development of acute
pain and new points of sensitiveness to pressure, and

PUERPERAL PHLEBITIS. 293

in these points there are manifest tumefaction and in-
crease of the tympanites.

In phlebitis, the repeated chills are not attended
with a new access of pain ; but, on the contrary, the
nerve-sensibilities seem to grow less keen, and the pain
is not complained of, except in answer to interrogation
on this point.

Having decided that you have to deal with a case
of uterine phlebitis, your next inquiry is, How is this
disease to result, what is its duration, and what are its
terminations ?

The duration of this affection is greatly modified by
the character of the attack, and the epidemic type of
the season. In some cases, the attack is overwhelming,
the inflammation rapidly extends from the uterine si-
nuses to the pelvic veins, and perhaps still farther to the
veins of the extremities, or to the vena cava, and an
early fatal issue is to be apprehended. This result may
be due to one of two causes ; either to rapid poisoning
of the Mood, septicaemia, which occurs at an earlier
period than suppuration and purulent infection ; or, the
death may result from secondary thrombosis or embo-
lism of the pulmonary artery. In each of these ways,
uterine phlebitis sometimes terminates fatally in two,
three, or four days from the time of the attack.

The violence and intensity of the symptoms which
usher in the attack afford a veiy uncertain basis on
which to make a prognosis as to the duration or the
termination of this disease. In our patient who has
"recovered, the symptoms, the first four days of her ill-
ness, were much more severe than in the two patients
who died. I have seen a number of cases, more in pri-
vate than in hospital practice, where the diagnosis of
this disease has seemed to me conclusive, as proven by

294: PUERPERAL DISEASES.

the irregular, recurrent cLills, the local uterine signs,
negative and positive, and the rapid development of
the usual typhoid symptoms, to such a degree that
death seemed to be the only possible termination, and
yet, entire recovery has taken place after an illness of
ten or fifteen days.

When secondary purulent infection occurs as the re-
sult of uterine phlebitis, the disease may be prolonged
for weeks, and then terminate by recovery or death.

We may anticipate recovery under these circum-
stances, when there is a subsidence of the general symp-
toms, at the same time that there is a tendency to puru-
lent deposits on the external surface, as in the breasts,
or in the connective tissues of any part of the system,
more frequently on the legs or the arms, generally near
the joints. It is by this process that the pus is elimi-
nated from the blood.

But the deposits may take place in the serous cav-
ities, as in the peritonaeum, the pleura, or the pericar-
dium, or in the parenchyma of important organs, as the
lungs, the liver, or the kidneys. Under these circum-
stances, death occurs sometimes several weeks after the
original attack of uterine phlebitis.

There is another sequela to uterine phlebitis and
purulent infection, which I have never seen alluded to
by any writer on this subject, but which, for years, I -
have been accustomed to mention to medical classes,
and to those gentlemen in the profession who have done
me the honor to call on me in consultation.

In certain patients who have apparently recovered
from the immediate consequences of the phlebitis and
the purulent infection, the disease seems to have so im-
paired the functions of nutrition and assimilation, that
the woman breaks down and dies from marasmus. I

PUERPERAL PHLEBITIS. 295

tliink that every year we Lave one or more sucli cases
in this hospital. In some instances, they die from acute
tuberculosis. I have, strongly impressed on my mem-
ory, the case of two ladies, one of whom died in 1856,
and the other, in 1862. They were equally lovely in
character as in person, surrounded by every thing which
seemed to promise a happy and a long life, and in nei-
ther of them could the slightest hereditary tendency to
tuberculosis be traced, but both had, following their
first parturition, uterine phlebitis, and, apparently re-
coverino; from this, died some months after, from acute

O / /

phthisis. These cases were quite distinct from the bron-
chitis and pneumonia which are now well recognized
secondary results of this affection.

I must also mention, as other occasional secondary
results, an erythematous or erysipelatous condition of
the skin, appearing on some parts of the body, but
which does not terminate in suppuration and bed-sores.

Treatment. 1. I should say, first ascertain the func-
tional indications, especially those relating to the
excretions. If a laxative be needed, and there be no
marked peritoneal complications, select such as will
effectively evacuate the alimentary canal, without pro-
ducing local irritation or depressing the vital powers.
If the urinary excretion be deficient, carefully in-
vestigate whether this be due to the kidneys or the
bladder. If there be evidence of renal hyperaBmia or
of cystitis, one or the other of which is very frequently
met with in the commencement of an attack of uterine
phlebitis, this special indication should at once receive
its appropriate therapeutics. Thus, at the commence-
ment of my treatment of this affection, I generally find
it necessary to apply cups over the kidneys, or to give
alkaline diuretics, as the citrate or the acetate of pot-

296 PUERPERAL DISEASES.

ash, or perhaps to use the catheter. These are points
in the treatment which should not be overlooked.

2. Allay those vital disturbances which the shock
of the attack produces.

(c/.) Vascular excitement. Formerly, venesection
was regarded as the chief agent for reducing vascular
excitement, and there is no doubt that, in some cases,
this measure was tolerated, and proved of great service.
But, as we have seen, this disease rapidly tends to de-
press the vital forces, and every thing which accelerates
such a result should be avoided. We have, however,
two agents in our materia medica which act specifically
as vascular sedatives. These are aconite and veratrum
viride. Simply as a vascular sedative, I greatly prefer
the veratrum viride (for reasons which I shall not now
stop to discuss), and I think this is the fact with all who
have had any considerable experience in the use of both,
but I must tell you that this class probably constitutes
but a small minority in the profession. I meet with
many who have a great fear of the veratrum viride, be-
cause it sometimes produces the appearances of danger-
ous collapse. But this is a very temporary condition,
which, so far as I have heard, has never terminated dis-
astrously. The appearance of one who has taken too
much veratrum viride is almost precisely like that pro-
duced by tobacco in those unaccustomed to its use. I
have often seen this, but now, when I do, it causes no
alarm, as I am sure that the effects will soon pass off.
There is no objection to assisting reaction in such cases,
by carbonate of ammonia, or small quantities of some
alcoholic stimulant. In a small percentage of cases, it
is quite liable to cause nausea, but this is readily coun-
teracted by giving it in combination with the tincture
of ginger. As to its positive effects, I will say, that you

PUERPERAL PHLEBITIS. 297

can, by it, absolutely and certainly control the frequency
of the pulse of inflammation and of irritation, but, of
course, if it will accomplish this, you would not expect
it to reduce the rapid pulse of exhaustion, as found in
the last stages of phthisis or in typhus fever.

But, I must also add that the use of veratrum
viride is not incompatible with stimulants. My expe-
rience has abundantly demonstrated the truth of this
apparent paradox. In one case, the veratrum viride
did not seem to produce any effect on the pulse, which
remained constantly above 130, until the condition of
the patient was such th.at I decided to give brandy.
After the first ounce had been given, it fell to 108 ; after
the second, to 86. Continuing the brandy, the veratrum
viride was suspended for a few hours, and the pulse
again rose to 130. After this, it was curious to note
the fact, that if the use of either agent were suspended,
the pulse would rapidly increase in frequency, while,
under the combined influence of the two, it was kept
below 80 per minute. Another of my patients, who
recovered, took one ounce of brandy and from three
to ten drops of the tincture of veratrum viride, every
hour, for two days, the quantity of the veratrum viride
being regulated by the frequency of the pulse, which
was never allowed to rise above 80 per minute, al-
though it sometimes fell to 40.

The directions which I generally give to my staff
in this hospital are, to begin the use of the veratrnm
viride at once, and, carefully watching its effects, bring
the pulse down to 80, and hold it there. After the
specific effect of the veratrum is once produced, it can
be kept up by very much diminished doses.

(5.) Nervous irritation. Opium is the great agent
for allaying this. It is desirable in this disease to save

298 PUERPERAL DISEASES.

the stomach as much as possible, and I therefore gener-
ally administer the opium either in the form of rectal
suppositories, one grain of the aqueous extract to three
grains of butter of cacao, or else in the form of hypo-
dermic injections of the solution of morphia. Through-
out the whole course of this disease, I believe the use
of this agent to be most essential. It not only allays
pain, but is also of great service in promoting sleep,
quieting delirium, and checking the tendency to diar-
rho3a. The quantity required to accomplish these ends
is generally not large, nothing like what is required in
some of the other phlegmasise, more especially perito-
nitis, nor is there a necessity for its frequent use, for I
often find it sufficient to use an opiate at night only.

3. I have before alluded to the great danger from
septic absorption, and to the fact that septicaemia
sometimes causes death at a very early period, before
the process of suppuration has commenced. The pro-
phylaxis against this danger is therefore one of the most
essential and important elements in this, as well as
in other puerperal diseases. The necessity of frequent
changes of the napkins worn to absorb the lochial dis-
charges, of the greatest cleanliness of the person, cloth-
ing, and bedding of the puerperal woman, and of thor-
ough ventilation of the room, are points of the great-
est importance, which the physician should strenuously
insist upon and personally supervise. You will meet
with many monthly nurses who are excessively appre-
hensive of danger by cold from necessary ablution,
from change of soiled clothes, or from admission of
pure, fresh air into the room, but who have not the
slightest fear that the woman under their charge will
become a laboratory for the generation of septic poison.
I am always on the alert for mischief ahead when, on

PUERPERAL PHLEBITIS. 299

my first visit to a patient after her accouchement, I find
her perspiring under a load of blankets, the air and
light excluded from the room by closely-drawn, heavy
curtains, or thick shawls fastened before the windows,
with one of those nurses who "does not believe in
changing the napkin any oftener than is absolutely
necessary," or in " washing a second time after labor
until after the third day." The number of nurses who
believe in such and other equally absurd and pernicious
theories is, I suspect, much greater than is generally
supposed by medical men who have not taken the
pains to inquire curiously on this point, with the art
and skill of a detective.

As regards medicinal prophylaxis, I have but one
suggestion to make, but I regard this as one of great
importance. I refer to vaginal injections of warm
water and carbolic acid, in the proportion of five grains
or more to the ounce. Where there is any liability to
septicaemia, these injections should be used every three
or four hours. It is absolutely certain that they most
effectually correct the offensive odor, and diminish the
quantity of the lochial discharges.

I have now had several years' experience in the use
of vaginal injections of carbolic acid, but, a year ago, I
gained new light on this subject from my friend, Dr. J.
D. Trask, of Astoria, formerly Professor of Midwifery
and Diseases of Women in the Long Island College
Hospital.

In the New York Medical Journal \ for October, 1871,
you will find the report of a case by Dr. Trask, which
was certainly the most remarkable recovery from sep-
ticaemia and a complication of other puerperal diseases
that I have ever seen. The facts pertinent to my pres-
ent subject may be thus briefly stated: On the third

300 PUERPERAL DISEASES.

day after labor, the patient exhibited symptoms of sep-
ticaemia in the highest degree and in its most dangerous
forms. She had a severe rigor, followed by high febrile
action, alternating through the day with oft-recurring
chills of short duration. In the afternoon, when Dr.
Trask saw her, there were heat, profuse sweating, ex-
treme restlessness, tenderness over the uterus, urgent
diarrhoea, the dejections being involuntary, and of in-
tolerable odor, and a pulse of 160.

Dr. Trask regarded it as a case of septica3rnia, com-
plicated with peritonitis, and he determined to attempt
to impregnate the system as far as possible with car-
bolic acid. He at once commenced its administration
by the mouth, rectum, and vagina. A half-drop of Cal-
vert's solution was given in mucilage by the mouth
every two hours. The solution for the rectum was one
drop, increased to five drops to an ounce of mucilage, a
half-gill being thrown up after every dejection. The
vaginal injection was not less than five drops to the
ounce every three or four hours. There was, at the
time, a supposed idiosyncrasy forbidding the use of
opium. "Within twenty-four hours, the diarrhoea ceased,
and the pulse was reduced to 120. The inflammatory
symptoms were after this in the ascendant, while the
signs of septicaBmia were in abeyance. "The system
seemed to be saturated with carbolic acid. She tasted
it in every thing, inhaled it, as she thought, in every
breath (I cannot say that she exhaled it), and was so
disgusted that she refused to have it longer brought to
the bed for any purpose. No other antiseptic was sub-
stituted by the mouth, but the bisulphate of lime, or
the permanganate of potash, was employed abundantly
in vaginal injections, until convalescence began."

Since I saw this patient with Dr. Trask, I have had

PUERPERAL PHLEBITIS. 301

the opportunity of carrying out a similar treatment in
only three cases, but the results of these were so satis-
factory, that I shall hereafter give this plan of saturat-
ing the system with carbolic acid a thorough trial.

4. The importance of keeping up the vital powers,
by giving the best nutrition that can be assimilated, by
stimulants and tonics, is so obvious that I need not de-
tain you by any prolonged observations on this point.
The tonics on which I chiefly rely are the tincture
of the chloride of iron and the chlorate of potash,
fifteen drops of the first, and ten grains of the latter,
every third hour. But, when the signs of purulent in-
fection are present, quinine is the great resource. I al-
ways desire that it shall be given in doses up to the
full point of tolerance. Patients who are suffering
from purulent infection frequently take, for three or
four days, from twenty to thirty grains of quinine a
day, without complaining of ringing in the ears or any
other symptom of cinchonic intoxication.

I should hardly be doing justice to you if I gave
you only my own treatment of this affection. I must
therefore tell you that M. Hervieux, whose great work
was published last year, and whose experience in this
disease at the Maternite must have been very large, re-
commends an emetic of ipecac at the commencement of
the attack. He believes that this will produce a good
effect in three ways : 1. By relieving the gastric irrita-
bility. 2. That it weakens, but does not aggravate, the
violence of the initial symptoms of the attack. 3. That
it eliminates the toxic elements which otherwise Nature
seeks to carry off by the diarrhoea.

He also recommends, as revulsive treatment, the
application of from six to ten wet cups over the hypo-
gastrium. But he seems to have the greatest faith in

302 PUERPERAL DISEASES.

mercurial inunction, carried to the extent of producing
salivation, and lie regards the salivation as a most
promising sign of recovery.

Even at this day, I now and then meet with phy-
sicians who tell me that they never lose a case of
typhus or typhoid fever when they are able to salivate
the patient. I cannot express an opinion founded on
experience, as to the usefulness of the treatment advo-
cated by M. Hervieux, neither do I regard it as prob-
able that I shall ever be able to do so.

LECTURE XV.

PUEEPEEAL METEITIS.

Case Puerperal metritis very frequently a prominent lesion of puerperal fever, and
generally found associated with peritonitis or phlebitis In this case, compli-
cated only with cystitis, which is not uncommon as a puerperal disease- Puer-
peral metritis includes endometritis and parenchymatous metritis Metritis
frequently the primary lesion, in the development of phlebitis or peritonitis
Physiological modifications of the mucous membrane of the uterus during the
puerperal period Pathological anatomy of puerperal metritis Causes Symp-
toms Duration and terminations Treatment.

" CASE XXVI. 1 Bridget , aged thirty-four, widow (hus-
band died at Blackwell's-Tsland Hospital in September last), was de-
livered of her eleventh child, a boy, weight nine and a half pounds,
December llth, at 9^- A. M. ; first stage two hours, second stage one-
half hour, third stage five minutes, L. O. A. Considerable hemor-
rhage followed the rapid and spontaneous expulsion of the placenta.
Uterus did not contract well, and 3 j of tincture of ergot was given
three times, and constant pressure over the fundus was kept up for
nearly two hours before the binder was applied. For three days,
the patient suffered much from after-pains, which opiates seemed to
have very little influence in mitigating. Bowels moved without
medicine on second day. No milk-fever. Mammary secretion was
very abundant on the second day, so that, for six days after, she vol-
untarily nursed another child besides her own. Lochial discharges
very free and very high-colored. In all other respects, patient ap-
parently doing well.

" December lQth. For the first time, it was observed that the
lochial discharge had an offensive odor, and was still very red and

1 Reported by N. S. Westcott, M. D., house-physician to Bellevue
Hospital.

304 PUERPERAL DISEASES.

profuse. Patient has no appetite, feels weak and ' good for noth-
ing,' and has had very little milk in the breasts for the last twenty-
four hours. No pain anywhere, has had no chills, no fever, very
little thirst, and complains of nothing but weakness. Ordered vagi-
nal injections, one part of Labarraque's solution in twelve parts of
warm water, night and morning. Quiniae sulph. gr. ij, ter in die.

"December 20th. Examined by Professor Barker before the
class. Decided emaciation of the face, and countenance anxious.
Tongue covered with a thin, whitish coat. Gums very white.
Pulse 96. Skin natural, and no heat of surface. No appetite or
thirst. Hardly a drop of milk could be squeezed from the breasts.
No pain anywhere. Sleeps pretty well, but wakes up tired. Lochial
discharge red, very free, and still quite offensive. Abdomen flat,
walls thin and yielding, with no tenderness on pressure. The ovoid
tumor of the uterus very easily mapped out three and a half inches
above the symphysis pubis. Borders of tumor moderately sensitive
to pressure. She turns and moves in bed, coughs, etc., without the
least pain. On vaginal examination, the cervix was found so high
up in the pelvic cavity, that the second finger only could reach it.
Os very large and patulous, and not tender on pressure, except when
pressure is made at the same time by the other hand on the fundus.
Uterus not easily and only slightly movable. Patient now says
that ' it has been hard work, and hurt her to pass water for three
or four days.' Catheter was passed, and five ounces of turbid, offen-
sive urine were drawn off, which, on subsequent examination, was
found free from albumen, but contained a good deal of mucus and
some pus-globules. Dr. Barker prescribed

$. Fld.-ext. ergot.,

Tine, nucis vomica?, aii 3 iij.

Tine, ferri chloridi, 3 v.

Aq. puree,

Syr. simp., aa 3 ij.

M. S. A tablespoonful, in a little water, every fourth hour.

" December %lst. Patient feels stronger, and passes water with-
out pain, and in much greater quantity. Has more appetite. No
milk in the breasts. Pulse 104. Skin natural. Lochial discharge
less, and of a lighter color, but still very offensive.

" December 22d. Pulse 116. Countenance not so good. Has
had, since 4 A. M., three large and offensive, black, thin evacuations
from the bowels. Appetite gone, and she complains that the medi-
cine sickens her. The uterine tumor very palpably diminished, as

PUERPERAL METRITIS. 305

it now can only be felt an inch and a half above the pubes. Ordered
to have two teaspoonfuls of the mixture every third hour.

"December 23(1. Patient looks badly. Pulse 120, weak and
compressible. During the night, she had several times complained
of being chilly, with slight shivering, but, when the nurse covers
her more warmly, she soon complains of heat, and throws off the
clothes. Has not retained the last two doses of the medicine given.
Dr. Barker finds the fundus uteri about two fingers' breadth above
the pubes. The lochial discharge is much less, and of a darkish-
brown color. On vaginal examination, the cervix was much lower
in the pelvic cavity, os large and open, so that the finger could be
inserted more than an inch. Not painful on pressure, even when
compressed between the fingers on the cervix and the fingers of the
other hand over the fundus uteri. The odor on the fingers with-
drawn from the vagina was so unexpectedly offensive, that Dr. Bar-
ker (not the patient) instantly vomited most freely. The mixture
was discontinued. Quinize sulph., gr. iij, was ordered every third
hour, and a half-ounce of whiskey every hour. Vaginal injections
of warm water, made as strong with Labarraque's solution as she
can bear without smarting, were to be given every fourth hour.
She took but two doses of the quinine, and the whiskey four or five
times, when the stomach began to reject every thing taken. She
sank rapidly during the evening, and died at 2 A. M., December 24th.

" Autopsy, thirteen hours after death. Some slight, old pleuritic
adhesions to the left lung, but all the thoracic organs healthy.
Spleen normal, of moderate consistence, but perhaps a little paler
than usual. Kidneys healthy.

" Peritonaeum. Xo effusion of any sort in the cavity ; mem-
brane of a perfectly healthy color in every part, and but a slight
adhesion of a knuckle of intestine over the fundus uteri.

" Bladder. The mucous membrane, thickened and mottled,
with irregular patches, of a reddish-brown color. Its surface covered
with mucosities, mingled with a yellowish, purulent matter. The
ovaries, Fallopian tubes, and broad ligaments, normal.

" Uterus. Weight 18 ounces, length 7-J inches, breadth 5
"inches. The muscular walls of the uterus were generally of a dark-
purple color, or, in circumscribed portions, of a yellowish color, soft
and flabby, and contained numerous purulent collections. The cav-
ity contained, perhaps, two drachms of a dark-brownish, extremely
fetid fluid. The mucous membrane was of a dark -brownish color,
seemed swollen and much thicker than usual, and there were nu-
20

306 PUERPERAL DISEASES.

merous patches of dark-brown shreds, which could not be washed
off, but were easily detached. The placental seat was irregular in
its form, and, after water was poured over it, of a dark-grayish
color."

Gentlemen : You have just listened to the history
of the case of the patient who was brought before you
last week. You were perhaps, surprised, as was Dr.
"Westcott, to hear nie express such grave apprehensions
as to the result of the case, when there were so few sali-
ent or striking symptoms indicative of severe illness.
She had had no chills, no fever, no thirst, her tongue was
but slightly coated, her pulse was but 96, after she had
been brought to this room. She had no pain anywhere,
she slept well, she could turn, move or raise herself in
bed without pain or difficulty, and she answered ques-
tions brightly and intelligently. She seemed rather to
enjoy being brought before you, as patients often do,
feeling that their case is one of special importance, and
that they are receiving a great deal of medical attention.
In four days after you saw her, she died. You will
remember that I pointed out to you the very unusual
size of the uterus, for the ninth day after delivery,
which was easily demonstrable to you all, as the ab-
dominal walls were very flat and yielding.

In physiological convalescence, the uterus disappears
below the pubes, from the sixth to the tenth day after
parturition. In primipara, at the earlier period, and
later in the multipara, somewhat in proportion to the
number of children borne. Now, if there be an arrest
of the process of involution, so that, by the ninth day,
the fundus is three or four inches above the pubes, we
may be well assured that some morbid element exists,
of sufficient importance to demand careful examination.

In this case, the uterus did not contract well af-

PUERPERAL METRITIS. 307

ter delivery, and there was a marked tendency to hem-
orrhage ; the lochial discharge had been unusually
large, and had continued of a red color much longer
than usual, with an offensive odor. The mammary se-
cretion, which at first was very large, had entirely
ceased. I therefore expressed the opinion that, al-
though the case was in many respects exceptional, it
would prove to be a very grave case of metritis.

The uterus is on the table, and will be passed around
for you all to examine ; and, although two days have
elapsed since it was removed from the body, but little
change has taken place, except as to color. Now, there is
nothing very remarkable or exceptional in that uterus.
I have seen many like it, varying only in degree and
extent, taken from patients dying from puerperal fever,
or when this condition of the uterus was associated
with peritonitis or phlebitis. But, in my .experience, it
is unique, in that it is not associated with puerperal
fever, of which there has not been a case in the hos-
pital for some months, nor with any other lesion of the
pelvic organs, except cystitis, which, by-the-by, I re-
gard as a more frequent and important puerperal dis-
ease than is generally suspected.

This uterus is an excellent specimen of puerperal
metritis, which includes both inflammation of its mu-
cous membrane, or eudometritis, and inflammation of
its muscular walls, or parenchymatous metritis. This .
is a very common and a very prominent lesion of puer-
peral fever in some epidemics, and, in others, it is never
found. We have also reasons for believing that it is
frequently the primary lesion in many cases of general
or local peritonitis, and in many of the suppurative in-
flammations of the other pelvic tissues. I am not aware
that any case has yet been reported of inflammation of

308 PUERPERAL DISEASES.

tlie walls of the uterus, unassociatetl with endornetritis,
and hence it has been inferred by some that it always
commences as an endoinetritis. But there is no proof
of this, and I think it very doubtful. "We generally find
the two affections associated, but I shall be able to give
you a more clear idea of both, if I describe each sepa-
rately.

Before studying the pathology of endonietritis, let
us first see what are the physiological modifications
of the mucous membrane of the uterus after parturi-
tion. These modifications, as described by Robin, are
as follows : There is a marked difference between
the mucous membrane of the placental seat and that
which covers the rest of the internal surface of the
uterus. The placental seat, which, before delivery,
measured from six to eight inches in diameter, is
reduced, after delivery, to three or four inches, and this
decrease of surface is constantly progressive. The
form of the placental seat also changes : at first being
nearly circular, it becomes irregularly oval, its long
diameter corresponding wdth the long diameter of the
uterus, with irregular, sinuous, notched borders. Thus,
according to Robin, what the mucous membrane of the

O /

placental seat loses in extent of surface, it gains in
thickness. At the same time, it wrinkles up, becomes
rugous and niammillated, and of a brownish color,
softening gradually until it becomes of a pultaceous
consistency. The borders of this membrane are irregu-
larly projecting, and very adherent to the circumfer-
ence of the placental seat, where it is continuous with
the mucous membrane which covers the rest of the
inner surface of the uterus. The salient projections of
this part are due to vascular dilatations, easily demon-
strated by careful minute dissections. An incision made

PUERPERAL METRITIS. 309

through the rnannnillatecl projections shows, immedi-
ately beneath the mucous membrane, a hollow areolar
tissue, resembling erectile tissue. In proportion as the
time becomes remote from the period of parturition,
these vascular dilatations atrophy and become obliter-
ated, the mammillated projections contract and flatten,
and there only remains, at the placental seat, a red-
dened portion, more prominent than the rest of the sur-
face, which is easily distinguishable for a long period,
until the physiological repair is complete.

The part of the mucous membrane which covers
the rest of the surface of the uterus is smooth, almost
shining, and bedewed with a reddish secretion, and is
altogether quite different from, that of the placental
seat. The serotine membrane disappears slowly by
exfoliation, and, according to Kolliker, the new mucous
membrane is not fully reproduced until the end of the
second or third month.

Some authors have expressed the belief that the
uterine sinuses are closed, after the detachment of the
placenta, by a physiological thrombosis of these vessels.
But I am in accord with Hervieux, in the belief that
they are closed by the contraction and compression of
the tissues in which they are embedded, and that, when
fibrinous clots are found blocking up these sinuses, they
are the result of some morbid process, either from the
violence of the separation of the placenta, or some
pathological change in the surrounding tissues.

Inflammation of the mucous membrane of the uterus
arrests these physiological changes, and causes numer-
ous modifications, varying in degree and intensity in
proportion to the exciting causes and under different
epidemic influences. If an opportunity occur for ex-
amination of the uterus, in the early stages of puerperal

310 PUERPERAL DISEASES.

endometritis we find the mucous membrane covered
with a thick, viscous, reddish coating, which consists of
epithelial debris, and mucus, blood, and pus-globules.
This covering is easily detached, by scraping with the
back of a scalpel, or even by pouring upon it a stream
of water. Beneath this, the membrane is found de-
cidedly thickened, especially at the placental seat, the
color varying from a light to a dark-brown red. If
the disease have advanced to the suppurative stage, we
find yellowish or reddish-gray purulent flakes lining the
internal surface of the uterus, the most thick and con-
sistent of which are over the placental seat. When
this is washed off, the mucous membrane beneath is
more or less softened, as if macerated in the purulent
fluid to a greater or less depth, extending, in some cases,
even to the muscular walls of the uterus. An incision
made in the placental cotyledons reveals its sinuses,
some of which are filled with dark blood, partly liquid
and partly coagulated, others containing yellowish, pu-
riform concretions. In some, these fibrinous concre-
tions are softened to that degree, that pressure causes
drops of pus to gush from the open sinuses of the in-
ternal surface of the uterus, or from the surface of the
section. The odor from the surface is very strong and
marked, but can hardly be called fetid. Sometimes
false membranes, to which the German writers apply the
term diphtheritic, of variable size and extent, are found
over the internal surface of the uterus, particularly over
the cavity of the cervix and the placental seat. In still
more severe and advanced cases, the internal surface of
the uterus is covered by a greenish-brown or black
putrilage, which has a most excessively fetid odor. In
very severe epidemics, we meet with cases of real gan-
grene of the mucous membrane of the uterus. The en-

PUERPERAL METRITIS. 311

tire internal face of the uterus is covered with a green-
ish-black or black pulpy matter, which gives an over-
whelming, gangrenous odor.

Endometritis frequently occurs without involving
any pathological changes in the walls of the uterus, but
I am not aware that any instance has ever been pub-
lished in which parenchymatous metritis has existed
without endonietritis. Indeed, it is the opinion of Klob,
that inflammation of the substance proper of the uterus,
in the majority of cases, is a consequence or extension of
endonietritis. According to Virchow, it commences as
hypersemia, which is characterized by tumefaction, red-
ness, and softening of the muscular fibres of the uterus.
This state necessarily involves an augmentation of the
volume of the organ, and it also retards or arrests the
process of involution. As the inflammation advances,
pus is formed in the connective tissue, which is more
or less destroyed by purulent invasion, while the ad-
jacent muscular elements pass either into a state of fat-
ty degeneration, or else into sloughing. Thus, small
abscesses are formed, generally in isolated and limited
portions of the uterine walls, but sometimes forming
purulent collections of considerable size. Hervieux
states that he has seen the whole uterus converted into
a veritable purulent sponge.

Sloughing of the walls of the abscess sometimes oc-
curs, so that the pus perforates through either of the
uterine surfaces. A discharge into the cavity of the
uterus is the more safe termination, and perforation into
the peritoneal cavity the more dangerous, as it leads
directly to peritonitis. Perforation sometimes takes
place into the cavities of the adjacent viscera, which
had previously become adherent to the uterus. In
some cases, the muscular walls are found in a state of

312 PUERPERAL DISEASES.

putrescent softening, cither in circumscribed points or
involving the whole substance. The tissue, then, is not
red or reddish, but of a greenish-gray or slate color. In
these cases, the walls are not hypertrophied, but are
flabby, thinner, and more yielding to pressure.

In severe epidemics, it is not very rare to meet with
genuine gangrene of a portion of the uterus. This con-
dition will be readily recognized by a black or livid
portion, surrounded by a more or less unequal fringe
of red, by the pulpy softness of the degenerated tissue,
by the disorganized detritus, and by the peculiarly of-
fensive odor of the gangrenous portion. The gangrene
is almost always limited, and is oftener found in the
cervix than in the body of the uterus. The mu-
cous membrane is more frequently the seat of the gan-
grene than the walls, and it is probable that gangre-
nous endometritis is the original point of departure of
parenchymatous gangrene.

Let us now briefly study the causes of puerperal
metritis. If we recall the extraordinary modifications
which the uterus undergoes during gestation, the won-
derful development of its mucous and its muscular tis-
sues, and, more especially, of its vascular apparatus
during this period, the violence of the muscular con-
tractions at the time of labor, and the compression and
the lacerations which ensue, both in natural labor and
in operations necessary to accomplish delivery, the rup-
ture of vessels which takes place in the detachment of
the placenta, and the more or less considerable loss of
blood which results as a consequence, and the rapid
change which takes place in the organ immediately
after delivery, we shall not be surprised to find all the
tissues of the uterus very susceptible to take on mor-
bid processes. We are, then, prepared to accept as

PUERPERAL METRITIS. 313

causes of puerperal metritis : (1.) Imprudence, such as
rising from bed prematurely, too long continuance in
the erect position, too early resumption of family du-
ties or of sexual intercourse in fact, all these causes,
which favor the gravitation of blood to the pelvis, in-
duce congestion or provoke hemorrhage. (2.) Trau-
matic lesions, either of the cervix or of the vascular tis-
sues of the placental seat, or, it may be, of the muscular
walls of the uterus. (3.) Toxaemia, as uremia, septi-
caemia, pyaemia, but, more frequently than all others,
the special toxaemia of puerperal fever.

Now then, what are the symptoms which indicate
that these causes have developed endometritis, paren-
chymatous metritis, or both ? These diseases are so
generally complicated with phlebitis, peritonitis, or
with various blood - changes, especially in epidemics,
that it is somewhat difficult to isolate the symptoms
which belong to the metritis from those due to the
other affections. But, in some epidemics, the metritis
has been the most prominent characteristic lesion, and
the symptoms in these epidemics have been so nearly
identical with those where the disease has been demon-
strated as arising from traumatic causes, that we can
describe, with a good deal of confidence, those which
belong to the metritis.

The first symptom which I shall mention is, pain in
the uterus, resembling after-pains, but occurring in the
primipara, or in nmltipara after the second day. These,
if persistent, should receive serious attention. The
pain differs in a very marked degree from the intense
agony of peritonitis, but is usually dull and obscure,
extending toward the inguinal regions and the loins,
increased by movement, but not stamping the face with
suffering, or eliciting from the patient groans of anguish,

3U PUERPERAL DISEASES.

as in peritonitis. Pressure over the fundus usually
causes pain, but not always, as it is sometimes neces-
sary to compress the sides of the uterus between the
thumb and finder to determine the existence of morbid

sensibility in this organ.

s^f Increased volume of the uterus, as compared with
irte normal size for the time of the puerperal period, is
a symptom never absent in metritis. This augmenta-
tion of size varies extremely. On the second day after
delivery, it is sometimes found from three to six inches
above the pubes ; on the fifth or sixth day, from two to
four inches, and this size is even observed in this dis-
ease from the fifteenth to the twenty-fifth day after de-
livery. It is thus evident that this increase of size is
not merely due to arrest of involution, but to positive
tumefaction of the tissues. It is readily ascertained to
exist, both by abdominal palpation and by the vaginal
touch. The fundus of the uterus may be found, by pal-
pation, at any point between the pubes and the umbili-
cus. Owing to the enlargement of the body of the
uterus, which prevents it from sinking into the pelvic
cavity, the cervix is sometimes very high, so as to be
beyond the reach of the finger in vaginal exploration.
In the first days after delivery, the cervix is soft and
patulous, and the closure of the os is often retarded by

* the metritis, and especially if there have been any con-
siderable laceration of the cervix.

The next symptom to which I shall call your atten-
tion is the lochial discharge. Most authors speak of
this discharge as being diminished or suppressed by
metritis. It is true of some violent and acute attacks,
that the lochia are suppressed. Nurses, and even phy-
sicians, are sometimes ready to assign this effect of dis-
ease as the cause of all the subsequent troubles. The

PUERPERAL METKITIS. 315

suppression is the effect of tlie metritis, but it is not to
be forgotten that it may also induce very bad results
through septic or purulent absorption. The return
of the lochia, normal in character and quantity, is
to be regarded as a favorable symptom. But, if
the lochia be purulent at an early period, we have
strong reason for believing that we have to deal with a
case of metritis, or, more emphatically, with endometri-
ti*. Our apprehensions are confirmed if the discharges
have a marked fetid odor. A symptom of still greater
gravity is, the continuance of the discharge of a sanguin-
olent character beyond the usual normal period ; that
is, beyond three or four days. If the discharge be still
chiefly blood, after the first week of the puerperal
period, or if it become markedly more sanguinolent,
or if, after it has once notably diminished, there be a
reappearance of any considerable loss of blood, we
may be almost sure of the existence of endometritis or
metritis, particularly if this reappearance be attended
with febrile exacerbations and more or less severe
pains in the region of the uterus. "We are not to
regard this as merely a drain on the system, which
retards convalescence and postpones the cure of the
patient, but as a symptom of grave significance. I have
often spoken of this to my staff in this hospital, and
have frequently referred to it in my clinical lectures;
and I am therefore glad to see that Hervieux has given
this symptom, which has heretofore been but slightly
noticed by other writers, a very marked prominence.

Simple puerperal metritis is rarely ushered in with
a chill, when it is uncomplicated, at the beginning, with
either phlebitis or peritonitis. But there are usually
some febrile symptoms, with a feeling of lassitude and
depression. The pulse ranges from 90 to 100, the tern-

316 PUERPERAL DISEASES.

perature, in uncomplicated metritis, varies from 100
to 104. Except over the uterine tumor, the abdomen
is soft and yielding. The appetite is generally dimin-
ished, but not absolutely wanting, and there is neither
nausea, vomiting, nor diarrhoea. If the metritis or en-
dometritis have gone on to the suppurative stages, the
symptoms are of a more grave character. We then
may have slight recurrent chills, more marked febrile
exacerbations, a quicker pulse, and a higher range
of temperature. If the disease go on to putrescent
softening or to gangrene, the prostration becomes ex-
treme, the face pale, often bedewed with moisture,
the pulse is quick and feeble, the extremities cold, the
lips blue, the cheeks often of a dark scarlet color and
the respiration hurried, while the lochial discharges are
offensive beyond the power of language to describe.

"When the metritis is complicated with peritonitis
or phlebitis, we have the characteristic phenomena of
these affections superadded, perhaps, to such an extent
as to mask, in some degree, the symptoms indicative of
metritis.

As regards the duration of puerperal metritis, vio-
lent and intense forms of it, in epidemics, go through
its various stages of suppuration, putrescence, and gan-
grene in two or three days, allowing no time for the con-
servative efforts of Nature or for therapeutic resources.
An acute but less severe form is often of much longer
duration, but is attended with great danger. Suppura-
tion commences early, and may be followed by putres-
cence or gangrene, or may develop lymphangeitis, phle-
bitis, or peritonitis ; and, with such complications, we
have great reason to expect a ital result. But there
is no doubt that a certain proportion of even such
cases get well. We sometimes see a pneumonia, or a

PUERPERAL METRITIS. 317

pleurisy or a mammary abscess, supervene, and the nae-
tritis with its complication at once begins to subside.

I believe that a benign form of metritis occurs very
frequently in puerperal women. While the local and
physical signs of its existence are undoubted, there is
an absence of the grave general symptoms, such as
marked febrile exacerbations, a very quick pulse, high
temperature, or total loss of appetite ; and, at the end of
a few days, the recovery is complete. But, if the metri-
tis be overlooked or disregarded, there is a tendency to
complication, particularly by the development of pelvic
cellulitis, and thus convalescence may be retarded for
several weeks. Every year I am called more or less in
consultation to see cases of what are called " bad get-
ting up." The patients are very slow in recovering
their strength, the pulse is rather quick, the tongue is
slightly coated, the appetite is capricious, and a careful
history of the case, combined with a thorough physical
exploration, leads me to the conclusion that they have
had an attack of metritis which has developed celluli-
tis. Fortunately, a large majority of such cases termi-
nate by resolution, but in some the cellulitis goes on
to suppuration. Unfortunately, some cases of puerpe-
ral metritis pass into the condition which is generally
termed " chronic metritis," but which my friend Pro-
fessor Thomas prefers to call " areolar hyperplasia of
the uterus."

Now comes the most important question of all,
How shall this disease be treated ? I shall try to give
you my ideas on this point as clearly as possible.
First, then, when the symptoms of metritis are manifest
in a puerperal woman that is, when I find the patient
with pain in the hypogastrium, the uterus larger than
it should be at the time of the puerperal period, and

318 PUERPERAL DISEASES.

painful on pressure, the lochia diminished in a marked
degree or perhaps wholly arrested, or, on the other
hand, a return or positive increase in the amount of
blood lost in this discharge, with a quick pulse and
more or less fever I at once give the following powder,
well mixed in a wineglass of suj^ar and water :

o o

I. " Tally's powder,"

Potass, bicarb., iiii gr. x.

Hydrarg. chlor. mite, gr. v. M.

If the skin be very hot and dry and the pulse very hard,
I may substitute the following :

I. Pulv. potass, nitrat., gr. x.
Pulv. gum-camphor.,

Hydrarg. chlor. mite, ua gr. v.

Pulv. Jacobi veri, gr. iij.

Pulv. opii, gr. j.

Vel morphias sulph., gr. . M.

I anticipate the following effects from these powders :
The pain will be relieved ; nervous irritation allayed ;
sleep induced ; fever subdued ; diaphoresis promoted ;
and, eight or ten hours after, an easy, free, revulsive ca-
thartic action will follow. Please observe that I give
the calomel simply because its cathartic action is more
free, easy, and painless, than any other. If the cathar-
tic action do not follow in ten hours, I order whatever
saline laxative can be the most easily taken by the pa-
tient.

I also direct that a turpentine-stupe shall be applied
over the uterus, and kept on until the patient insists on
its removal, when cotton-batting should be laid over
the uterus, and this should be covered with oil-silk. If
the patient complain of severe pain or of burning from
the turpentine, the cotton may be wet with laudanum,
which will soon comfort her. It is curious to observe,

PUERPERAL METRITIS. 319

as I often have, the apparently paradoxical results from
the turpentine, that, if the lochia have "been suppressed,
the application is usually followed by their return, or,
if they have been excessive and sanguinolent, the tur-
pentine produces a palpable decrease in the amount of
blood lost ; but, I think, after a few moments' reflection,
you will see the reason why the turpentine produces
such apparently opposite results.

The pain is generally in a great measure overcome
by the means that I have just mentioned. If the dis-
ease appear to be of a sthenic type, I have found great
benefit from the application of six or eight wet cups
over the uterus. I never make use of leeches in these
cases, because of the inconvenience and danger from ex-

' O

posing the parts to cold during the uncertain period
while the leeches are on, and while the subsequent
bleeding continues. If, after two or three days, there
be not an evident decrease of the uterine tumor, I have
found positive improvement follow the application of a
blister, great care being taken that strangury is not ex-
cited. In those cases where the uterus is very large and
the pain has been subdued, while the lochial discharge
is profuse and sanguineous, I very frequently, in private
practice, write a prescription as follows :

#. Ext. ergot, fid. (Squibb's), "j

Tine, nucis vomicae, > 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 :

]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

vagina, otherwise the cavity may be over-distended, and
some of the evils to which I have referred may follow.

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 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

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*.

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.

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 : (<?.) They renew the
nervous forces, which generally are in a state of ex-
treme prostration, probably, by the cerebral hypersemia
induced by alcohol. In this, as in other diseases with
great depression, patients are able to bear four, five, or
even ten times the quantity that they could take in
health, without any unpleasant effect, or the least ap-
proach to intoxication. (Z>.) 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.
(<?.) For this reason, it is often of great service in allay-
ing; vascular excitement, in connection' with the vera-

o /

trum viride. I have seen many cases in which the spe-
cific influence of the veratrum viride as an arterial seda-
tive was not obtained until the use of alcohol was
combined with it, and I have repeatedly, in this disease,
found that the pulse could not be influenced by either
agent alone, but was readily reduced by both conjoined.
(VZ) In the rapid pulse of exhaustion, which we find
attending the hectic fever and purulent cachexise of this
disease, alcoholic stimulants freely given often cause
the pulse to fall in frequency, but to increase in force.
In puerperal peritonitis, I have often given from half an

PUEEPEEAL PERITONITIS. 351

ounce to an ounce and a half of whiskey or brandy
every hour, and have continued this with advantage
for several days, until, as convalescence was established,
there was no longer a necessity for its use. I believe that,
by the use of alcohol, the lives of some patients have
been saved which, without it, would have been lost.

(6.) I regard vaginal injections as very important
in this, as in many other of the puerperal diseases. I
generally give the following formula :

$. Glycerin.,

Acid, carbol. glacial., aa 3 j.

Aq. puree, vj. M.

I direct that a tablespoonful of this should be put
in half a pint of water as warm as can be borne, and
carefully injected into the vagina, twice a day. If the
lochia be very abundant and fetid, the proportion of
carbolic acid may be doubled or even quadrupled,
and the injection should be used every six or eight
hours. Nurses should be carefully instructed so to
use the injections as not to annoy or fatigue their pa-
tients, who generally, indeed, express themselves .as
greatly soothed and comforted by their use.

The patient should be urged to take as much as
possible of such bland and easily-absorbed nutrition as
beef-tea, panada, caudle, milk, or milk and lime-water.

You must strongly insist on the necessity of abso-
lute rest. Make the nurse and friends thoroughly un-
derstand that not the slightest movement, active or pas-
sive, that causes pain, should be permitted. I have seen
a very severe renewal of the disease, which had been
apparently subdued, simply from the maladroit efforts
of the husband and the nurse to move the patient from
one side of the bed to the other. The patient should
not be allowed to make any considerable straining effort

352 PUERPEKAL DISEASES.

to empty the bladder, and, if this cannot be done with-
out severe effort and pain, the catheter should be used.

From what I have said before in regard to the ne-
cessity of quieting and arresting peristaltic action, I
think that you will naturally infer that, in my opinion,
purgatives are to be most carefully avoided. There is
infinitely less danger from constipation than from the
action of a mild purgative. I have often seen the
bowels move easily and without pain after a week had
passed without any evacuation. The only exception I
make to the rule, forbidding the use of purgatives, is in
some very rare cases. Where the vomiting of bilious
fluid is excessive in frequency and in quantity, I have
given ten grains of calomel well rubbed up with
twenty grains of the bicarbonate of soda. A small
dose of the calomel would be irritating, as I have
learned by experience, but the full dose in this combi-
nation is usually followed by two or three painless,
fluid evacuations, greatly to the comfort of the patient,
in whom generally a very moderate diarrhoea now takes
the place of the vomiting. This is the only way in
which I ever use mercurials in the treatment of this
disease. It seems to me that the old theories as re-
gards the so-called antiplastic and sorbefacient action
of mercurials have no foundation in fact ; and I there-
fore read with astonishment in the great work of
Hervieux, on " Puerperal Diseases," that, in peritonitis
and phlebitis, he finds it advisable to induce salivation
if possible by mercurial inunctions, and that, as soon
as the gums are touched, he finds a marked improve-
ment in the symptoms of these diseases.

As, until within comparatively a recent period, vene-
section has been recommended by most standard writ-
ers, and has been the almost universal practice in this

PUERPEKAL PERITONITIS. 353

disease, I ought, perhaps, to add a few words ill re-
gard to it. In this country, this mode of practice has
been very generally given up, because observation and
experience have demonstrated that general puerperal
peritonitis is a disease which tends rapidly to destroy
life by asthenia. But I am not sure that we may not
have erred in entirely discarding venesection. In my
early professional experience, I can distinctly recall two
cases in which I thought the life of my patients was
saved by it. For twenty years or more, I never bled a
patient in this disease, nor have I seen a single instance
in this hospital where I think depletion would not
have been positively injurious. But I have often
thought of a case which I had some years ago in
Brooklyn, with a feeling of regret that I had not re-
sorted to venesection. In January last, I did bleed a
patient with general puerperal peritonitis, and with such
manifest good results, that I shall briefly detail the case.
The patient, twenty-two years of age, married eleven
months, was delivered, at 8 A. M., January 9th, 1873, of
her first child, a boy weighing eleven and a half pounds,
after a rapid and normal labor of less than four hours.
The placenta and membranes came away entire, imme-
diately after the expulsion of the child, and without
hemorrhage. I do not think that an ounce of blood
was lost. The uterus contracted well. I had seen
the patient but once before her confinement, when she
reported herself as being in perfect health and without
a single unfavorable symptom. During gestation, she
had grown very stout, and had greatly increased in
weight. At my visits in the afternoon of the same
day and en the next day, her condition was just as I
wished to see it in every respect. The nurse, however,
remarked that the lochial discharge was hardly suffi-

354: PUERPERAL DISEASES.

cient to make a stain. At 10 A. M., January llth, the
pulse and respiration were normal, temperature 99.5,
but the breasts were very full and tender. As the
nurse again spoke of the scanty lochial discharge, I
very thoroughly examined the abdomen, and found it
flat, the uterus well contracted, and even strong press-
ure was well borne over every part of the abdomen.
The bowels had moved without medicine early in the
morning. The patient had slept so well as not to be
awakened by the crying of the baby, and, except for
the tenderness of the breasts, she expressed herself
feeling as well able to get up and move about as before
her confinement. At 6 p. M., she complained of pain
in passing a very small quantity of water. She made
another eifort at 9 p. M., but it caused so much pain,
that it was unsuccessful. Hot flannels were applied to
the abdomen, and she went to sleep. Soon after 11
o'clock, she was awakened by a severe chill, which
lasted a long time, during which she began to complain
of intense pain in the abdomen. I saw her at 2 A. M.,
January 12th. She was then lying on her back, breath-
ing very rapidly, and each breath was accompanied by
a groan of agony. Her face was much flushed, her eyes
red, as if she had been weeping, the pulse was 116, very
full and hard, and the skin was very hot I did not
at this time stop to ascertain the temperature by the
thermometer the abdomen was enormously swollen.
She was much nauseated, and had vomited three times
since the chill. I immediately took from the arm about
twenty ounces of blood. I next introduced the cath-
eter and drew off about ten ounces of urine, which,
on a subsequent examination with heat and nitric acid,
became nearly one-half solidified. Turpentine-stupes
were at once applied to the abdomen, and I injected
hypodermically twelve drops of the following solution :

PUERPERAL PERITONITIS. 355

Morphia} sulph., grs. xvj.

Atropin., gr. j.

Aqiue, j.

At 6 A. 3r., and hourly afterward, she took ten
drops of Magendie's solution. I left her quietly sleeping,
soon after 9 A. M. I need not detail the subsequent his-
tory of the case, and I shall only add that, three days
after, not a trace of albumen could be found in the urine ;
and every vestige of the peritonitis had disappeared at
the end of ten days. I think that there can be no ques-
tion as to the usefulness of bloodletting in some such
very exceptional cases as that I have just described.

You will find, gentlemen, that many writers speak
of general puerperal peritonitis as a very hopeless dis-
ease ; and the past statistics of large hospitals, in
which we have the results of this disease chiefly in
severe epidemics of puerperal fever, seem to justify so
desponding a view. But I think, at the present day, the
therapeutics of this disease are based on a much more
correct pathology, are dictated by good sense and sound
reason, instead of by theory and routine-precedent, and
that, in consequence of this, the ratio of fatality is re-
duced at least one-half. It is my belief that there are
few diseases in which the physician can see so satisfac-
torily demonstrated the results of active and positive
therapeutical agencies.

I append to this lecture, as rather forcibly illustrat-
ing some of the views expressed therein, the report of
the foil owing' interesting case, by Dr. Howard Pinkney :

" CASE XXVIII. Mrs. H , aged about twenty years, daugh-
ter of a physician, was taken in labor on the evening of March 27,
1872, -with her first child. I was called early the folio-wing morning,
and found the patient greatly fatigued and exhausted from frequent
and severe pains. The os was fully dilated, and the head was en-

356 PUERPERAL DISEASES.

gaged in the superior strait. The pains were accompanied with fre-
quent desire to micturate, and considerable tenesmus. I again saw
her about three hours after, still suffering great pain, and, there being
no advance of the head, I applied the forceps and delivered a living
male child, weighing about eight pounds. The mother and child did
remarkably well until April 5th, or eight days after delivery, at
which time I found the mother suffering from acute pain in the
hypogastric region. Upon inquiry, I found that she had been sit-
ting up the evening before, and dressed her little sister for a con-
cert in which she was to take part. After having been dressed,
the child said or did something that threw the patient into con-
vulsive fits of laughter, causing considerable pain in her sides.
The pain was so severe when I saw her, that I immediately gave
gtts. x of Magendie's solution hypodermically, and applied warm
fomentations to the abdomen. This was followed by gtts. vj of the
Magendie, and gtts. iij of veratrum viride, every two hours, until the
pain should be relieved and the pulse reduced. On April 6th, 7th,
and 8th, the patient did well, so that the medicines were dis-
continued, although the milk diminished in quantity and disap-
peared. On the 9th, the patient suddenly became worse, without
any apparent cause, the pulse running up to 160, temperature to
104.5, and the respiration to 32. Morphia and veratrum viride were
again immediately resorted to, and, between 12 M. of the 9th to
12 M. of the 10th, 440 drops of Magendie's solution were given
by the mouth, and 47 drops, by hypodermic injections.

gtts.

From 12 M., April 10, to 12 M., April 11, 995 by the mouth, 47 hypod.

" 11, " " 12, 1,070 " 30 "

" 12, " " 13, 1,340 " 120 "

" 13, " " 14, 940 " 170 "

" 14, " " 15, 550 " 90 "

" 15, " " 16, 450 " 160 "

" 16, " " 17, 2,010 " 60 "

14 17, " " 18, 1,980 " none "

" 18, " " 19, 2,490 " " "

" 19, " " 20, 980 " " "

" 20, " " 21, 320 drops of McMunn's elixir.

" It will thus be seen, that the patient took, during eleven days,
13,969 drops of morphine, 724 of which were given hypodermically.
An hourly record of the case, from the time the patient was seen
by Professor Fordyce Barker, is appended. After April 21st, the
patient made a rapid and perfect recovery."

PUERPERAL PERITONITIS.

357

Record Kept ly the father of the patient, a physician, who devoted his time
exclusively to the care of his daughter, from the time she was seen by
Professor Barker until her convalescence. She was generally visited three
times a day by Dr. PinTcney.

"If

TIME.

REMAPvKS.

C.3

-i

.Jj

a o

<n*

Hours.

Gtts.

Professor Barker, with Dr. Pink-

Wed'y, Apl. 10.
2 15 p. M

130

104|

ney. Enormous tympanitic
distention of abdomen. Pain
severe ; respiration wholly tho-
racic. To have milk or beef-

2.45 "

3.10 "
4.00 "

tea ad libitum.
Brandy, a half-ounce every hour.

4.20 "

5.00 "

5.30 "

3 ss

Between 5 and 7 P. u., slept.

6.10 " ....

6.30 "

7.00 "

7.30 "

8.00 "

8.30 "

9.00 "

10.15 "

160

Very feeble, and restless.

11.20 "

11.40 "

Sweating.

12.00 "

140

Thurs., Apl. 11.

1.15 A. M

No sleep.

2.10 " ....

3 ss

3.15 "

4.00 " ....

5.00 "

8.00 "

3 ss

108

Slept some, between 8 and 10.

9.00 "

10.30 "

Great pain in urinating, and se-

11.30 "
1 10 P M.

60
30

vere burning and constant
pain in region of the bladder.

1.40 "

108

102

acid, by direction of Professor

2.45 "

Barker.

3.30 "

140

103|

4.45 "

136

103}

6.05 "

134

7.15 " ....

136

104

8.15 "

128

103-J-

9.40 "

104|

10.50 "

104

11.15 "
Friday, Apl. 12.

The respiration became slower.
Constant nausea.

1.30 A. M

120

1041

Pulse feeble and thread-like. Im-

2.15 "
2.45 "
3.45 " ...

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

Temperature.

| Respiration. |

REMARKS.

Hours.

Gtts.

Friday, Apl. 12.

5 50 A. M

C j

102i

8.45 "

101}

9.45 "

1045 "

101}

11.15 "

12.45 P. M

., ,

Appears much better. Has slept

1.45 "
2.45 "

70
70

3 S3

101}
101}

considerably.
Vaginal injection as before.

4.00 "

4.20 "

132

102}

5.-20 "

" ss

Nurse obliged to leave her, by

6.15 "

128

102}

which she was much excited.

8.05 "

103^

9.40 "

154

104

10.40 "

148

103}

11.45 "

Satur'y, Apl. 13.
1.10 'A. M

80
80

Verat
viride.

140

103^

Constant and severe pain.
Vaginal injection. .. "*

2.10 "

2.45 "

3.15 "

3.45 " ...

4.30 "

103^

4.40 "

128

5.05 "

Pain much relieved, but no sleep

5.50 "

120

103

since one o'clock yesterday af-

6.20 "

ternoon.

8.00 "

9.30 "

11.00 "

128

103

Brandy.

12.00 M

128

103

J.40 p. M

3 ss

128

1031

No sleep.

1.55 "

VW JJ

2.40 "

Vaginal Injection.

4.35 "

102J

5.00 "

T.20 "

120

102

At 9.30 an involuntary and un-

10.00 "

conscious discharge from the

10.40 "
12.00 " ..-..

80
80

120

102}

bowels.
Intense pain.

Sunday, ApL 14;

1.00 A. M

2.30 "

3 S3

120

102}

No sleep. General appearance
very much worse. Evidently
failing.

PUERPERAL PERITONITIS.

359

RECORD OF CASE (Continued).

TIME.

.-9

'(U

REMARKS.

7*
M

Hours.

Gtts.

Sunday, Apl. 14.

3.00 A. M

4.25 " ;-...

3* j

126

103

5.20 "

6.20 '

7.50 <

3 j

8.50 '

9.30 '

grs.x

101

10.00 '
11.20 '
1.45 p M
3.15 <

90
90
90

!J
fj

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 <

4.15 '

4.25 "

Blister, 5x5, over hypogastrium.

6.00 "

2" j.

120

102

7.10 "

grs. xv.

8.00 "

102^

Digitalis

9.10 " ....

Removed blister, and applied

10.00 " ....

120

103

poultice.

11.00 "

5 j

102

12.00 "

No sleep ; refuses brandy.

Monday Apl. 15.

Ilydrat.

chloral.

1.00 A. M

10 grs

2.00 "

112

102J

3.00 "

10 grs

3.30 l!

5.15 "

10 grs

6.00 "

101J

7.00 "

1 S3

Quinine, grs. x.

8.00 "

102

A very large passage from the

8.30 "

10 grs

bowels, without pain.

10.30 "

3 j

Vaginal injection.

11.00 "

10 grs

12.00 M

A large passage.

1.00 P. M

128

101J

2.00 "

10 grs

3.00 "

Quinine, grs. xv.

5.00 "
8.15 "
10.30 "

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

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.

Temperature.

Bespiration.

BEMARKS.

Hours.

Gtts.

Tuesday, Apl. 16

5.00 A. M

6.00 "

112

lOOf

Has slept soundly nearly two

7.15 "

hours.

8.15 "

8.30 "

9.20 "

9.50 "

11.20 "

11.30 "

112

12.15 p. M

104

1.00 "

1 45 '

120

100

2.45 "

Pain very severe in cheat and

3.30 "

left shoulder.

4.45 "

6.00 "

7.00 "

8.00 "

IBS

No sleep.

9.00 "

10.00 "

140

Breathing badly.

11.00 "

Quinine, gr. XT.

12.00 "

Wed'y, Apl. 17.

1.00 A. M

1.30 "

128

100

2.00 "

120

3 ss

3.10 "

3 ss

3.45 "

4.15 "

1 S3

4.45 "

6.00 "

128

lOOj

6.45 "

7.30 ' ....

8.30 '

9.30 '

111

Bleeping finely.

10.30 '

Calls for food.

11.50 '

1230 p. M

1.25 "

Moved her to another room, which
she bore well.

2.00 '
3.00 '

90
90

Sleeps between each dose.

3.30 '

4.00 '

112

5.00 '

Quln.

6.00 "

gr.xv

8.00 '

112

PUEEPEKAL PERITONITIS.

361

RECORD OF CASE (Continued).

TIME.

Magendie's sol. of
morphine internally.

Veratrum viride.

Temperature.

Respiration.

REMARKS.

Hours.

Gtts.

Wed'y, Apl. 17.

10.00* p. M

12.00 "

Thurs'y, Apl. 18.

1.00 A. M.. . .

- j

112

lOOf

1.45 "

3.00 "

3.30 "

5 10 "

6.20 "

lOlf

Lay on her back for two hours.

7.40 " ....

Complains greatly of difficulty in

8.20 "

breathing.

9.00 "

103}

9.45 "

10.00 "

11.45 " ....

1.00 P. M

1.50 "

1 88

Has taken more nourishment than

2.20 "

usual.

2.50 " ....

103

Dr. Barker finds pleuritic effusion in

3.20 "

the left side.

3.50 "

4.00 "

4.20 "

Sleeps well, but often starts and jumps

5 00 "

in her sleep.

5.25 "

144

101}

6.15 " ....

6.40 "

7.00 "

7.45 "

8.00 "

120

102^

8.50 "

9.50 "

Very large passage from the bowel*.

10.50 "

11.15 ....

12.00 "

122

104}

Friday, Apl. 19.

12.50 A. M

A second large passage.

1.10 " ....

1.20 "

1 j

1.30 "

122

103

2.00 "

2.30 "

Sleeps welL

3.30

4.10 ....

120

4.45 "

6.00 "

102

Fain most intense.

6.00 "

120

102}

7.00 "

362

PUERPERAL DISEASES.
RECORD OF CASE (Continued).

TIME.

>
g

EEMAEKS.

IF 5

-
-

Hours.

Gtts.

Gtts

Grs

Friday, Apl. 19

8.40 A. M

103

9.05 " ...

9.15 " ...

120

9.40 ' ...

Pain in left chest very severe.

10.40 ' ...

11.40

1 00 p M

120

104

Applied blister to left side of

1.25

chest.

3.00

4.00

Two large passages.

5.00

5.45

120

103

6.30

Removed blister and applied

7.30

poultice.

8.00

120

104

Quinine, gr. xv.

10.30

11.00
Satur'v, Apl. 20.
12. 30 "A M

103|

Very large and watery movement
of the bowels.
Gave rectal injection of two

2.15

144

103J

ounces of starch and one
drachm of McMunn's elixir

2.25

opii.

2.50

Went to sleep.

4.15

144

103|

4.40

Great difficulty in passing water.

6.00

6.30

103

7.30

8.30

Complains of great pain and diffi-

9.30

104

culty in passing water.

10.15

10.30

10.50

132

103|

11.30

Vaginal injections.

12 55 P M

136

103J

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 "

2.35 "

132

Sleeps now most of the time.

4.45 "

120

102$

6.00 "

118

102$

7.00 "

Micturates with great pain and

8.50 "
9.00 "

120

102^

scalding. Afterward verv faint,
but face crimson, calling'for air,

10.00 "

12.00 "

120 120

Cold sweat, extremities cold.

PUERPERAL PERITONITIS.

RECOED OF CASE (Continued).

363

TIME.

McMunn's elixir
opiL

Tinct. ferri chloridi.

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

Gtts.
6

120

120
120

120

120
120

108

108
112

102J

102
lOlf
lOli

lOlf

lOlf
101J

100J
99f

99
99f

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 "

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).

TIME.

KEMAEKS.

Hours.

Tuesday, Apl. 23

10.30 A. M

104

12.40 p. M

1.60

100

98 J

4.00

100

98f

5.00

From this time, the convalescence waa

7.00

Tery rapid.

8.50

100

98f

9.15 '

11.00 ' ..,.

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-

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

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-

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

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.

" 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

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

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.

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<A. Respiration 36, pulse 120, temperature 104.
She had a chill in the night. The patient has not a single symp-
tom to correspond with this record. She is quiet and rational, and
has no pain anywhere. Lactation established yesterday. Lochia
normal.

" January \oth. Respiration 24, pulse 100, temperature 104.6.
Nervous and wild. Quinine and morphine. Vaginal injections
with carbolic acid.

" January IGth, A. M. Respiration 25, pulse 135, temperature
103. Very nervous. P. M. Respiration 30, pulse 136, temperature
103. Quiet. 10 P. M. She suddenly became very wild. Talked
very boisterously, and was very obscene. Face flushed. She is
ordered chloral hydra t. 3j, potass, bromid. grs. xxv, every second
hour until she sleeps.

u January nth, A. 1L Respiration 24, pulse 120, temperature
102. Very quiet. P. M. Respiration 24, pulse 108, temperature
102. Chloral and the bromide have been given twice to-day. Has
had no excitement.

" January 18?A, A. M. Respiration 22, pulse 104, temperature
102. Face and palms of hands covered with an eruption resembling
erythema nodosum. Complains of pain in the bones, p. M. Respi-
ration 24, pulse 108, temperature 100. Face still flushed, but the

1 Condensed from a report by George A. Van "\Vagenen, iT. D., house-
physician, and M. H. Forrest, M. D., senior assistant physician, to Bellevue
Hospital.

434: PUERPERAL DISEASES.

eruptive congestion has subsided. Rational, and saj s that she is
very comfortable.

" January 19/*, A. M. Respiration 30, pulse 108, temperature
101. G. Has slept well. P. M. Respiration 28, pulse 12G, temper-
ature 103. Rational, and feels well.

" January 20th, A. M. Respiration 26, pulse 118, temperature
103. Slept well last night, p. si. Respiration 20, pulse 114,
temperature 103. The bowels, which before have been regular,
were quite loose to-day. Perfectly rational.

fl January %lst, A. M. Respiration 18, pulse 104, temperature
102. P.M. Respiration 18, pulse 108, temperature 103. She
has been taking, since the 18th, quinine, morphine, brandy, and milk,
but she has not required either chloral or the bromide. 7.30 P. M.
Respiration 18, pulse 120, temperature 105. Has a little pain and
tenderness in the abdomen for the first time, and slight tympanites.
11.30 P. M. Respiration 30, pulse 150, temperature 105. Tympa-
nites and tenderness increased, but not severe.

" January 22f7, A. M. Respiration 18, pulse 120, temperature
102. 5 P. M. Respiration 24, pulse 120, temperature 103. She
became delirious again to-day, and screams when spoken to. 11
p. M. Respiration 20, pulse 124, temperature 105.

" January 23d (eleventh day), A. M. Respiration 22, pulse 136,
temperature 108. She gradually sank, and died at 11 A. M.

" Autopsy by Dr. J. W. Arnold. Heart, lungs, liver, and kid-
neys, normal. Spleen, dark-olive color. Abdomen, no injection of
the peritonaeum, and no fluid in the peritoneal cavity. No exudation,
except on the external surface of the uterus, and a portion of intes-
tine adhering to it. Internal surface of the uterus normal for the
period, except that the sinuses at the cornua were filled with a puri-
form fluid. The pelvic connective tissue appeared normal.

" CASE XXXV. 1 Miss S , born in Germany, aged twenty-
four, was delivered by forceps, after a labor of twenty-seven hours,
February 2, 1873. The perinfeum was slightly torn, and two sutures
were applied.

"February 3f7, A. M. Pulse 80, temperature 100. No pain.
Milk appearing.

" February 4tfA, A. ar. Respiration 24, pulse 106, temperature
104.7. She had a chill, and then pain in the abdomen all night.

1 Condensed from a report by M. B. Early, M. D., house-physician to
Bellevue Hospital.

PUEKPEEAL FEVER. 435

Thirst. Ordered solution of morphia (U. S. P.), 3 ij, and tine, aconit.
(Flemings's) m.ij, every hour. Also three laxative pills, p. M.
Respiration 28, pulse 108, temperature 103.5. Pain less, and but
slight tenderness over abdomen. The pills having had no effect, an
injection was ordered. Morphia and aconite, in the same doses,
every second hour.

"February 5th. Respiration 18, pulse 100, temperature 100.
Some pain and tenderness in the right iliac fossa.

''February 6th. Respiration 22, pulse 108, temperature 101.7.
Some abdominal pain.

" February 7th. Respiration 32, pulse 120, temperature 102.5.
Vomiting and diarrhoea. Very nervous. Complains of pain in the
abdomen. Tine, aconit. TH,. ij, sol. morph. (U. S. P.) 3 iij, every hour.

" February 8th. Pulse very rapid, temperature 102. Skin hot
and dry. Both cheeks red, swollen, and painful. Tongue dry. No
diarrhoea to-day. Quinine, grs. x, ter in die. Brandy and extra diet,
p. M. Respiration 38, pulse 128, temperature 102.5. Solution of
morphia, 3 ss, on account of severity of pain.

" February Qth, 3 A. M. Sol. morph. (U. S. P.), 3 ss. 9.30 A. M.
Respiration 30, pulse 128, temperature 102.7. Abdominal pain, ten-
derness, and tympanites, slight. Patient feels better. Treatment
continued. 7.30 p. M. Respiration 28, pulse 140, temperature
101.5. Skin warm and moist.

" February ICtfA, 9.30 A. M. Severe pain in the abdomen, which
was very tympanitic. Respiration 60, pulse 140, temperature 105.5.
11 P. M. Respiration 48, temperature 105. Pulse could not be count-
ed. Died, February llth, 1.45 A. M.

" Autopsy, by Dr. Francis Delafield. Brain, not examined.
Heart and lungs, normal. Both pleura covered with pus and fibrine.
Liver, rather large and soft. Spleen, large and soft. Kidneys,
normal. Peritonaeum, venous congestion, coated with fibrine and
pus, and a small amount of purulent serum in the cavity. Uterus
well contracted. Internal surface and walls normal. In the right
side, some of the sinuses at the insertion of the lateral ligament
were full of puriform fluid. Pelvic subperitoneal tissue normal.
Bladder, normal." J

In the cases which recovered, the histories of which
I have not given, the symptoms were of the same char-
acter as those which occurred in the fatal cases. Some

430 PUERPERAL DISEASES.

were, for a time, apparently more severely ill than those
who died You will observe that all who died were sin-
gle women, a fact on which I shall make some comment
hereafter. In most cases, convalescence commenced
within a week from the time of attack ; but two cases
were very tedious and protracted. Elizabeth E
was delivered January 8th. On the 9th, her record
was as follows : Respiration 24, pulse 75, temperature
100. January 10th, respiration 18, pulse 102, temper-
ature 101.5. January llth, respiration 24, pulse 84,
temperature 100.5. From this time the respiration
was never less than 24. The pulse, except when re-
duced by aconite or the veratrum viride, ranged from
112 to 140, and the temperature, from 104 to 105.
From February 8th to February 17th, the respiration
and temperature were nearly normal, but the pulse kept
above 100. On the 17th, she had recurring chills, and
there came on pain and swelling in the left inguinal
region. This was painted with the tincture of iodine,
and she was given quinine in full doses. On the 25th
of February, the inguinal pain and swelling had disap-
peared. The respiration was 20, pulse 92, and temper-
ature 99, and she was thoroughly convalescent. Thus
her illness continued forty-five days. The case of Mrs.
J. "VY- was still more remarkable. While on her
way to this city, she was delivered in the cars on the
Erie Railroad, January 14th, and she was brought to
the hospital January 15th. On the 16th, her respira-
tion was 24, pulse 90, temperature 99.5. In the after-
noon, she had a severe chill, which lasted a long time.
January 17th, A. M., respiration 34, pulse 158, tempera-
ture 104.5. Her skin was hot and dry, face flushed
and dusky, and she had some abdominal pain and tym-
panites. The tongue was slightly coated, but moist.

PUERPERAL FEVER. 437

Lactation had been established, but the breasts were
not painful. Her condition until February 7th was
very critical, and after this time her recovery was slow,
as she was not able to be up and about the wards until
March 8th.

I attribute the recovery of many patients, in a great
measure, to the intelligent, faithful, and constant care of
the house staff, who had the immediate charge of the

/ O

cases. And here I may take the opportunity to say that,
during the many years of my obstetric service in this hos-
pital, I have constantly had occasion to express my warm
appreciation of the untiring zeal and self-sacrificing de-
votion of my staff to the care of the puerperal patients.
In severe cases, the symptoms Lave been recorded every
hour, day and night, and I have many written reports
of such cases. Some members of the staff have been
severely ill after finishing their obstetric service, and
generally it is found necessary to give them a little
vacation to recruit their strength.

Now, if we study this group of puerperal cases, we
shall find that certain prominent symptoms character-
ized all of them, and, clinically speaking, the disease
was the same in all. From the second to the fifth day
after labor, the pulse became quick, from 120 to 140;
the respiration hurried, from 24 to 36 ; and the temper-
ature high, from 101 to 105. The attack was ushered
in by a chill, and fever was a constant phenomenon.
Neither abdominal nor uterine pain was an initial symp-
tom. Generally, on the second day of the disease, a cer-
tain degree of abdominal pain and tenderness was pres-
ent in most of the cases, but in no case were these symp-
toms so severe as to prevent the patient from lying on
either side, or on the back with the legs extended ; and
in every case the pain was easily controlled by moderate

438 PUERPERAL DISEASES.

doses of morphine. The abdomen usually became some-
what tympauitic the day following the complaint of
pain, but the tympanites was never excessive, except
just before death. Vomiting occurred with several pa-
tients, but it was never a constant or a severe symptom.
It often seemed to be due to veratrum viride, or, in some
cases, to intolerance of certain kinds of stimulants. A
moderate diarrhoea occurred in most patients, but in
none was this so severe as to require treatment to pre-
vent exhaustion. The mammary secretion was gener
ally established, but diminished during the illness. In
some, it returned abundantly after convalescence. The
lochial discharges usually continued throughout the
illness. Vaginal injections with carbolic acid were
ordered to be used twice a day for every woman deliv-
ered in the hospital, and hence offensive or fetid lochia
were very rarely observed. In the beginning of the
attack, the tongue was usually moist, and covered with
a white or brownish coat, but, after the second day, a
dry, brownish streak dow^n the centre and at the base of
the tongue would be observed. In some of the cases,
and in two that died, the appearance of the tongue was
but little altered during the whole illness. The face
was very much flushed in nearly all of the cases at the
beginning of the attack, but this usually disappeared
on the second or third day of the disease. Jaundice
was not observed in a single case. The cerebral dis-
turbances were not very marked, although in nearly all
there was some wandering or mild delirium. In one

fatal case there was violent mania. The skin was always
hot and dry in the beginning, but profuse perspirations
were common after the first two or three days.

While the clinical features of all these cases bear
such a resemblance as to warrant us in asserting that

PUERPERAL FEVER. 439

all were attacked by the same disease, you will ob-
serve that there is a very considerable diversity in
the autopsical lesions. In the first and the second case,
there was a very large effusion of purulent serum in
the peritoneal cavity, and there was pus in the uterine
sinuses. In the third case, the peritoneal and uterine
lesions were veiy slight. In the fourth case, the lesions
were chiefly of the pleura and peritonaeum. The pelvic
lesions were trivial. The connective tissue in the pel-
vic cavity was normal in all of the cases.

The same disease has been very prevalent in the
city outside of the hospital, and has been proportion-
ally more fatal among women of the upper classes, who
lived under the best sanitary conditions attainable in
the city, and who were able to command all the com-
forts and luxuries of life, than among the poor women
who were crowded in tenement-houses, or those who
were delivered in the lying-in wards of this and the
Nursery Hospital. 1 During the first four months of the
present year (1873), the mortality from puerperal dis-
eases has been greater among women who may be de-
scribed, with reference to their social condition, as be-
longing to the better classes of this city, than for the
twenty preceding years.

Now, what is this disease ? We call it puerperal
fever; the name first given to this malady by Strother,
who published a work on fevers, in 1716. More than
two hundred epidemics of this disease have been de-
scribed by different authors since 1740. It has been a
terribly fatal disease in lying-in hospitals in all the
great cities where such hospitals exist. It also occurs
as an epidemic disease in private practice, not only in
cities, but in rural districts. My first practical knowl-

1 See Appendix.

440 PUERPERAL DISEASES.

edge of it began in 1843, in a country district of Con-
necticut, in which every woman who was delivered
within a certain area, for some two months, died. The
previous year it prevailed in the northern section of
Vermont and New Hampshire. In the American Jour-
nal of the Medical Sciences, October, 1842, Drs. Hall
and Dexter say that " its effects were observed in every
situation and condition of life, in the populous town
and lonely settlement, in the home of the rich and in
the log-cabin of the poorest squatter." In the county of
Caledonia, Vermont, there were thirty cases of " puer-
peral peritonitis," only one of which recovered. In
Bath, New Hampshire, a little village of fifteen or six-
teen hundred inhabitants, twenty mothers died from
this disease. The late Dr. Samuel Jackson, of Philadel-
phia, formerly of Northumberland, and Dr. Dutcher, of
Lawrence County, Pennsylvania, each described an epi-
demic of this disease which occurred in rural districts
of Pennsylvania. Dr. H. G. Cary, of Dayton, Ohio, re-
ported an epidemic of this malady which occurred in
parts of the county of Montgomery, Ohio. This win-
ter, I have noticed, in the Philadelphia Medical and
Surgical Reporter, cases reported by Dr. W. O. Smith,
as occurring in Newport, Kentucky.

I could give you many other illustrations which
demonstrate that the opinion, held by some, is an error,
that this is a disease peculiar to lying-in hospitals, or
large cijties, or that it is confined to the lower classes,
and those who dwell in crowded, ill- ventilated, dirty
apartments. I could also give you many facts showing
that this disease is sometimes endemic ; that is, that it
occasionally prevails in a single locality, as in a hospital,
or in a circumscribed district, and nowhere else, and
therefore it is probably due to some local cause.

PUEKPEKAL FEVER. 441

Furthermore, I think the evidence is overwhelming
and conclusive that it is a contagious disease. I shall
have more to say on this point hereafter.

But, if you consult your books to ascertain what
the nature of puerperal fever is, you will find a greater
diversity of opinion than exists in regard to any other
disease. Very much more has been written on this
than on any other one disease. I find that more than
twenty thousand pages have been published on this
subject within the last twenty years, and a complete
bibliographical catalogue of all that has been written
on puerperal fever would fill many pages of an octavo
volume. The plethora of literature on this subject is a
proof of the difficulties in its study, arising from the
complications with which it is surrounded. It is a dis-
ease occurring in a peculiar state of the system, arising
from a modified condition of the blood induced by
gestation ; from lesions of organs, resulting from, com-
pression, contusion, and laceration by the process of
parturition ; from a retrograde metamorphosis of uter-
ine tissue ; from the special physiological changes of
the internal surface of the uterus ; and from the devel-
opment of the function of lactation.

Another reason why so much has been written on
this subject, comes from the fact that authors have
formed their opinions as to the nature of the disease
from its study in one locality, or in one epidemic, and
have adopted those restricted, exclusive ideas which
result from the observation of one peculiar type. Many
have written most dogmatically on the subject, who
have made no comprehensive examination of all that
has been learned as to the phenomena of the disease
and its laws in varied localities, and in different epi-
demics. More than three-quarters of a century ago,

442 PUERPERAL DISEASES.

Dr. Jolin Clarke wrote as follows : " Unfortunately, the
uniformity of the disease was assumed, and each author
erected his own experience into a standard, by which to
judge of the descriptions and the practice of others."

I should not be warranted in taking up your time
in giving you even a sketch of the various theories
of the past, which now are dead and buried by the
progress of science. But it is my duty, as a clinical
teacher, to tell you what are the doctrines of the day ;
what are the teachings of writers of authority, who in-
fluence the profession at the present time. There are
various distinct theories, each sustained by men of abil-
ity, and of the highest rank in the profession.

First, the theory of the localists, those who believe
that there occurs primarily an inflammation of some
one or more of the organs or tissues connected with

the process of parturition, and that the fever and the
general symptoms are secondary to and the consequence
of these local inflammations.

At an early period, the theory of this school re-
stricted the inflammation to one organ. You will find
that many of the older writers believed the disease to
be a metritis. Then came up another class, who re-
garded it as an inflammation of the omentum and intes-
tines. There was another class, who believed the dis-
ease to be peritonitis, and another still, who believed it
to be peritonitis connected with erysipelas, or peritonitis
of an erysipelatous character. Then another set of ob-
servers, finding that in certain cases, and in certain epi-
demics, there was no peritonitis, believed the disease to
be a phlebitis. Then, from this, followed the theory
of lymphangeitis, and of purulent infection, and, finally,
the more comprehensive school, which included in its
theory of puerperal fever all the puerperal inflamma-

PUERPERAL FEVEPv. 443

tions. But another class of observers, finding that the
phenomena of these inflammations differed in many re-
spects from those of ordinary inflammations, would ex-
plain this by the theory of a specific origin, but still
claim that the disease -is first developed as a local in-
flammation in some one of the organs or tissues cori-
nected vdth parturition. But I have only time to refer
to such writers as influence the belief and the practice
of the profession at the present day.

The late Professor Meigs, of Philadelphia, published
a work on this disease, less than twenty years ago, the
avowed object of which was "to prove that it is a sim-
ple state of inflammation in certain tissues of pregnant
women and of women lately confined, and that the
fever that attends it is a natural effect of intense con-
stitutional irritation from the local disorders." Dr.
Meigs considered puerperal fever as a metritis, a metro-
phlebitis, a peritonitis, or an ovaritis, or two or more
of these plegmasiaB combined. In a discussion of this
subject before the New York Academy of Medicine, in
1857, Professor Alonzo Clark declared that "the pri-
mary lesions of puerperal fever are in the organs of
generation, the secondary are in the blood." He thinks
that, in every case where a full examination is made,
one of four lesions will be found; either peritonitis,
phlebitis, lymph angeit is, or endometritis. He regarded
those cases which had been described by authors as
cases of puerperal fever without anatomical lesion, as
probably being primarily an endometritis, resulting in
pyaBinia. " The patient died, not from the endometri-
tis, but from the pyaemia." 1 In 1858, the year after the
discussion had been opened here, this subject was taken
up by the Academy of Medicine of Paris, and its dis-

1 Xew York Journal of Hedicine, 1857, vol. ii., third series, p. 370, et seg.

444 PUERPERAL DISEASES.

cussion was continued for nineteen sessions of the Acad-
emy, and thirteen of the most prominent obstetricians
and the most eminent pathologists took part in it. The
theory that the disease is a local inflammation was ad-
vocated by Beau, Piorry, and Jacquemier. Cazeaux
regarded the disease as an inflammation, modified by a
peculiar condition of the blood and epidemic influences.
Trousseau considered the disease as a peculiar inflam-
mation, due to a specific cause. Velpeau regarded it as
a local inflammation modified by the puerperal state.
The same year (1858), Professor Behier published a most
interesting and able essay on puerperal fever, in the
form of letters addressed to Professor Trousseau, and his
theory of the disease was that it is a purulent phle-
bitis. His opinion was based on the study of an epi-
demic, and the post-mortem examination of eighty-four
women who died from this disease in the Hopital
Beaujon, and he avers that the uterine veins contained
pus in every instance. The object of his essay was to
prove that pus in the uterine veins is a constant ana-
tomical lesion, and that this is always signalized by
one constant local symptom which precedes all the gen-
eral symptoms. This symptom, which is never absent,
according to Behier, is a cord-like hardness and a sen-
sitiveness to pressure on the sides of the uterus where
the appendages are attached. He distinctly asserts, in
this essay, his belief that peritonitis in this disease is
not primary but secondary to the phlebitis.

The theoiy that the disease is primarily a local in-
flammation has also been most ably sustained by M.
Mattel and Professor Pajot, and by Dr. Berne, of Lyons,
in an essay published in 1860. It, however, has found
but few supporters among German writers, and I be-
lieve not a single obstetric writer of prominence in

PUERPERAL FEVER. 445

Great Britain has advocated this doctrine within the
last twenty-five years. Indeed, the only English writer
of the present day who has defended the local theory of
this disease, that I can recall, is Dr. Robert Lee, who can
hardly be supposed to have much influence on profes-
sional opinion, as his unfortunate habit has always been
to advocate, with bitter zeal, doctrines which the prog-
ress of science proves to be untrue.

Another school regards puerperal fever as analogous
to traumatic fever, and the severer forms of it as being
due either to septica3inia or to pyaamia. Many years
ago, Cruveilhier pointed out the analogy between the
surface of an amputated stump and the inner surface
of the uterus, and he thought it not surprising that
the secondary evils of amputation should be so similar
to those of the puerperal state. In 1850, the late Sir
James Simpson published a paper, in which he dis-
cussed the analogy between puerperal and surgical
fever. He sought to prove that these diseases assimi-
lated to each other: 1. In the anatomical conditions
and constitutional peculiarities of those who are the
subjects of them. 2. In the pathological nature of the
attendant fever. 3. In the morbid lesions respectively
left by either disease. 4. In the symptoms which
accompany each affection. In this school we must in-
clude Raciborsld, who regarded puerperal fever as a
traumatic fever, which originated in the uterine veins

and terminated as a suppurative uterine phlebitis.
Hervez de Chegoin, Piorry, Bouillaud, and many others
whom I miorht mention, were also advocates of the doc-

O '

trine that the phenomena of this disease were due either
to purulent or putrid infection, or to both. During the
past year, Dr. H. A. D'Espine, of Paris, has published
a very interesting and able contribution to the study of

446 PUERPERAL DISEASES.

puerperal septicaemia, which he regards as identical
with puerperal fever. His conclusions may be thus
briefly summarized :

He considers the disease as a series of accidents,
more or less grave in proportion to the amount of
septic material absorbed by traumatic surfaces in
the utero-vaginal canal, and that the disease is not pe-
culiar to the puerperal state, but assimilates to that
which is produced in animals by experiments, and
occurs surgically. He regards the disease as originat-
ing either in the uterus or in the vagina ; that the lym-
phatics are the usual channel of absorption ; that the
peritonitis is a lesion of continuity due to the deposit
of septic material by the uterine lymphatics, and he
compares the peritonitis to the local inflammations which
develop around infected wounds. The effect of ab-
sorption of septic material is to determine congestions
in all of the organs, especially in the lungs, kidneys, and
intestines, sub-serous ecchyrnoses or interstitial apo-
plexies, external or internal inflammations which local-
ize by preference in serous membranes, and these effects
are manifested during life by fever, diarrhoea, pulmonary
congestion, epistaxis, and frequently by fugitive cuta-
neous eruptions. D'Espine believes that purulent ab-
sorption and septic absorption are confounded together
as clinical affections. He furthermore asserts that there
is no such thino; as milk-fever, but what is called so is

O '

due to a slight septic infection from absorption of the
lochia by small traumatic surfaces in the utero-vaginal
canal. He considers puerperal pyaemia as a complica-
tion of septicaemia, which nearly always coincides with
suppurative phlebitis.

In Germany, the theory that puerperal fever origi-
nates in traumatism, and is the result of absorption of

PUERPERAL FEVER. 447

septic material, seems to be accepted by a large major-
ity of the most recent obstetrical writers. Professor
Spiegelberg, of Breslau, seems to belong to a modified
school of localists, but is, at the same time, a supporter
of the doctrine of traumatisin and septicaemia. He
says, that the entire class of puerperal diseases are in-
flammations which are seated either upon the inner sur-
face of the genital canal, in its parenchyma, or in the
adjacent tissues, or often in both the latter at the same
time, and run their course either as local processes or
lead to simple or embolic pyaemia. He asserts that the
error of those who defend the theory of a primary
blood-poisoning lies 1. In insufficient or inexact local
observation ; or, 2. In part, that the internal surface of
the uterus has been so frequently regarded as the sole
point of departure, and that, in consequence, the equally
important affections of the vagina or vulva, and the
more important affections of the connective tissue, have
been overlooked. The state of the internal surface of
the uterus and of the placental seat after delivery has
been made the subject of special study by M. Robin,
of Paris, Dr. W. O. Priestley, of London, Dr. Matthews
Duncan, of Edinburgh, and Dr. Carl Friedlander.

Spiegelberg adopts the views of the latter, that the
decidua is divided into two layers, the upper or cell-
layer proceeding from the connective tissue of the mu-
cous membrane, and a deeper, the glandular layer. Dur-
ing labor, the separation of the decidua takes place in
the cell-layer, a thin portion of which, together with
the glandular layer, remains adherent. At the place of
placental attachment, precisely the same remains behind
as remains over the entire uterine surface, and is only
distinguished by the naked and thrombosed openings of
the veins. The new epithelial cover is now gradually

448 PUERPERAL DISEASES.

formed, probably from the epithelium of the glands.
Spiegelberg considers the internal surface of the uterus
as a vast wounded surface, although in a different sense
from what most authors have intended, when they have
compared the placental site to an amputated stump.
" For," he says, " a mucous membrane deprived of its
epithelium and its superficial layer is just as much a
wounded surface as a denuded corium." He adds, " The
significance of this wound is heightened by the pres-
ence of the vein-lesion." To these wounds, found in
every puerperal woman, he would add, " the slight
contusions and abrasions of the cervix, without which
hardly any labor takes place, the erosions and lacera-
tions at the lower portion of the vagina, and the inner
surface of the labia and vulva." These, he regards as
rarely absent, and in this he agrees with Schroeder, who
saw distinct rents of the mucous membrane of the
vaginal orifice in eighty-nine out of ninety-three cases.
Spiegelberg understands, by septicaemia, only the ab-
sorption of really putrid substances as they occasion-
ally present themselves in diphtheritic inflammation of
the genital mucous membrane exposed to the air, or
where coagula or portions of th,e ovum have been re-
tained.

One of the most recent of the German writers on
this subject is Professor Schroeder, of Erlangen. He
holds that "the theory that puerperal fever is due
to infection with a specific material formed under at-
mospheric, cosmic, and telluric influences, acting exclu-
sively upon puerperal women, is quite untenable," and
he asserts that it is now almost universally abandoned.
He defines puerperal fever as "all those diseases of
puerperal women which are caused by the absorption
of septic matter; that is, organic substances in pro-

PUERPERAL FEVER. .449

cess of decomposition. That absorption may take
place, a fresh wound is required by which the septic
poison can enter." He says that, " through the intact
skin or mucous membrane, through the lungs or intes-
tinal canal, septic materials, as a rule, never as such-
enter the blood." And he then adds : " Fresh wounds
exist in every puerperal woman. The sources from
which the infecting matter is derived are twofold, one
belong] no; to the infected organism itself, auto-infec-

o o o /

tion ; the other introduced from without, hetero-infec-
tion." After pointing out the various materials from
which both auto-infection and hetero-infection may be
derived, he adds, " Puerperal fever is nothing else but
poisoning with septic material from the genital organs."
He does not regard "puerperal fever as really conta-
gious, for by a contagious disease is meant one in which
a specific poison is produced within a diseased organ-
ism, and which, transferred to other individuals, always
produces the same specific disease." He admits that
" the disease is manually transferable, as the secretions
of puerperal-fever patients, transferred to other women,
may produce puerperal fever; but there is nothing
specific in this, for it would be productive of the same
results, if the secretions of decomposing organic com-
pounds were transferred to any other wounds."

A third school regards puerperal fever as primarily
a blood- disease, developed, like other zymotic diseases,
by epidemic, endemic, and contagious causes ; that in
this disease a modification of the general organism oc-
curs antecedent to the local lesions, and consequently
the local lesions are secondary ; that is, they are the re-
sult of the disease and not the cause in short, that it
is an essential fever.

This is the view of the disease which was rnain-

450 PUERPERAL DISEASES.

tained by the late Professor Joseph M. Smith and by
myself, in the discussion before the New York Academy
of Medicine, in 1857. It is the doctrine which was
advocated by Guerard, Dubois, Depaul, and Danyau, in
the discussion before the French Academy of Medicine,
in 1858. A remarkably interesting and able essay,
sustaining this view, was published by Dr. Paul Lorain,
in 1855, and another of equal merit by Dr. Stephane
Tarnier, in 1858.

This theory of the disease is also advocated by the
eminent M. Monneret, who, in his course of lectures on
" General Pathology," defines puerperal fever as an es-
sential protopathic fever, prepared and developed by
the puerperal state giving lise to morbid processes,
of which the genital organs are the usual seat, and
which consist of suppurative inflammations and other
pathological changes, such as softening, gangrene, and
hemorrhage. According to Monneret, " the only incon-
testable fact is, that the fever is primitive, spontaneous,
and results in the rapid production of inflammation in
all the organs, and especially those of generation." He
says that these inflammations develop in two or three
days after the fever, in the same way as, in small-pox,
there occur hundreds of little inflammations of the skin,
first exudative, then suppurative.

In the transactions of the Obstetrical Society of
London, for 1861, there is a most valuable paper by
Dr. Tilbury Fox, based on a study of the disease,' as it
occurred at the General Lying-in Hospital of London,
from 1833 to 1858, inclusive. During this time, there
were four hundred . cases and one hundred and eighty
deaths, from puerperal fever. The conclusions of
Dr. Fox lead me to class him as belon^in^ to the

O O

school which regards this disease as an essential fever,

PUERPERAL FEVER. 451

while he believes that the special fever-poison is iden-
tical with that of erysipelas. 1 Dr. Evory Kennedy, of
Dublin, also belongs to this school, as you will readily
see by reading his earnest and able work on " Hospital-
ism and Zymotic Diseases ;" and I must include, also,
another eminent obstetrician of Dublin, Dr. Alfred H.
McClintock.

As I shall have occasion to discuss the doctrines of
this school more fully hereafter, I shall pass to a fourth
class, who include under the term puerperal fever all
the zymotic diseases, such as typhus fever, scarlet fever,
erysipelas, diphtheria, hospital gangrene, septicaemia, and
all of the severe primary inflammations when they
occur in a puerperal woman. This class does not reject
the idea of a primary vitiation of the blood, but terms
the disease a puerperal fever, whatever may be the
specific nature of the primary poison. In this "class is
probably included a majority of the most eminent ob-
stetricians of Great Britain, and among its support-
ers are such names as the late Dr. Tyler Smith, Drs.
Robert Barnes, Braxton Hicks, Hall Davis, Graily
Hewitt, "\Y. S. Play fair, Wynn Williams, Leishmann, of
Glasgow, and many others.

In the discussion of the paper of Dr. Tilbury Fox,
before the Obstetrical Society of London, Dr. Tyler
Smith, in speaking of the importance of recogniz-
ing the infectious and contagious nature of puerperal
fever, remarked that " the disease would not so often
occur, if all accoucheurs recognized the fact that erysip-
elas, typhus, scarlatina, small-pox, hospital gangrene,

1 lam informed by Dr. John C. Boyd, of Monroe, Orange County, X. Y.,
that, in 1850, malignant erysipelas occurred in a family in that village.
Seven or eight women in the neighborhood were confined within a few
weeks afterward, every one of whom died from puerperal fever, or, as he
termed the disease, puerperal peritonitis.

452 PUERPERAL DISEASES.

putrid sore-throat, diphtheria, the post-mortem, and
other poisons were excessively prone, if brought near
the lying-in woman, to originate puerperal disease. He
did not question but that any of the agents which pro-
duced zymotic maladies might cause puerperal fever, or
that it might arise in individual cases from the reten-
tion and putrefaction of portions of placenta, or mem-
brane, or coagula, or the decomposition of fibrinous
clots in the uterine vessels, especially in women who
were predisposed by hemorrhage, albuminuria, or other
causes of debility ; but contagion and infection, which
might, to a great extent, be recognized and avoided,
were its chief and most preventable sources."

In a course of lectures on puerperal fever, by Dr.
Barnes, published in the Lancet, in 1865, the same
doctrine as to the origin of the disease is advocated.
He divides the causes which originate the disease, into
two classes: " 1. The heterogenetic or external causes,
those agencies which, taking their rise in conditions
foreign to the patient herself, have to be brought
to her while she is in a state of susceptibility to their
influence, in order that puerperal fever may be produced.
2. The autogeuetic or internal causes, those which take
their rise in conditions proper to the patient herself,
there being no contamination from without. The poi-
son, which ferments into fever, is generated within the
patient." Dr. Barnes also gave expression to similar
views, in the discussion of a paper read before the
Obstetrical Society, in 1870, by Dr. Braxton Hicks.
The paper of Dr. Hicks is based on a careful study of
eighty-nine cases, which he classifies, not according to
the symptoms, as is usually done, but according to the
causes, so far as they could be ascertained. He divides
these cases into two groups, the first having an ascer-

PUERPEEAL FEVER. 453

tained or probable cause, which lie enumerates in the
following classes: Class 1 Scarlet fever, A, with the
usual rash, 20; B, without the rash, 17, of which 15
had been distinctly exposed to the fever, and the other
2 had very probably been exposed. Class 2 Erysipe-
las, 6. Class 3 Diphtheria, 7. Class 4 Typhus or
typhoid fever, 2. Class 5 Decomposition of uterine
contents, 9. Class 6 Emanations from sloughy womb,
1. Class 7 From puerperal fever, 1. Class 8 From
mania (?), 4. Class 9 Pyaemia from sore nipples (?), 1.
His second group comprises those cases in which the
cause was uncertain. In this group there were 21 cases,
in which the symptoms appeared before or during labor
in 4, and between the third and fifth day in 17.

These opinions, as expressed by Drs. Tyler Smith,
Barnes, and Braxton Hicks, are sufficient to give you a
correct idea of the doctrines of my fourth class. In
Germany, Scanzoni is the most distinguished of the
obstetricians whose views in regard to puerperal fever
would come in this class. In this country, there have
been no recent publications on this disease which
enable me to give you the views of our leading obste-
tricians, but, from my personal intercourse with the pro-
fession, I am inclined to believe that a majority, under
the influence of the eminent English writers to whom I
have referred, should be included in this last class. I
know, however, some very able men who are strong
supporters of the traumatic and septicseniic theories of
the causes of this disease.

I must also give you two theories which demand
notice, from the character and position of the persons
who advocate them, but which do not express the opin-
ion of a sufficient number of the profession to represent
a class.

PUERPERAL DISEASES.

The first is the theory of Professor Edward Martin,
of Berlin, that " the diphtheritic process in the genitals
of lying-in women is the only essential element of pu-
erperal fever." He does not include, in the term puer-
peral fever, the febrile affections which result from local
inflammation, nor the fevers of contagious diseases, as
scarlatina, variola, and typhus. His definition of the
diphtheritic process is, that " it consists of a fungous
formation, the spores of which are seen under the mi-
croscope to penetrate, not only into the tissues, but
within the blood-vessels, producing in this way a gen-
eralized disease." He admits that, in diphtheria of the
genital organs, investigations have as yet not extended
thus far, but he assumes that " it is the same as when
the disease exists in the pharynx." He claims that, " in
a majority of cases of puerperal fever, we find, on the
external genitals and the vagina, a diphtheritic deposit
covering those wounded spots, which, in the form of
larger or smaller lacerations of the mucous membrane,
so frequently occur during labor. The circumference
of these spots is more or less considerably swollen. In
many cases, the diphtheritic deposit is thus confined to
the external genitals, and the disease pursues its course
by casting off the deposit without, or with very little,
general disturbance." But, he says, "In the major-
ity of cases coining under medical recognition, the diph- .
theritis is not confined to the entrance of the vagina,
but is found deep within the canal, covering the large
or small lacerations of the os uteri, and within the
cavity of the uterus itself. Here it occupies both the
site of the placenta and the upper parts of the organ,
and it is sometimes found exclusively here, and in no
places accessible to the eye." He admits that, in many
autopsies of women dying of puerperal fever, no diph-

PUERPERAL FEVEE. 455

theritic deposit lias been found, but he asserts that,
not only Lave the symptoms been present, but careful
examination of the patient during life has shown the
presence of the deposit. In explanation of this appar-
ent contradiction, he asserts that " the diphtheritic de-
posit in many cases very quickly disappears, and espe-
cially when injections or caustics have been employed,
while its consequences may persist and undergo further
development. The diphtheritic process spreads rapidly
from the genital organs, rarely toward the skin of the
thigh and nates, more frequently into the urethra and
rectum, if it has not already appeared there primarily ;
but its most common modes of spreading are, either by
means of the connective tissue surrounding the vagina
and neck of the uterus, by the mucous membrane of
the tubes to the peritonaeum, or by the lymphatics and
veins: these various modes of extension being often
combined with each other."

Next, as to the doctrines of Heivieux : He begins by
asserting that there is no puerperal fever, in the sense
in which the word is ordinarily used, and he adds : " The
admission of this seductive and convenient hypothesis
is chaos, it is a return to the infancy of art ; it is a ne-
gation of all diagnostic science; it is an obstacle to all
therapeutic progress in every thing that concerns the
puerperal maladies." He then very superficially and
imperfectly examines some of the arguments which
have been urged to support the theory of an essential
puerperal fever. He also rejects the doctrine of trau-
matism, and of purulent, and of putrid infection, which
he thinks is overthrown by the numerous incontestable
facts that the disease is developed before and during
labor.

He believes that there is a plurality of puerperal

156 PUERPERAL DISEASES.

diseases, as numerous as the local lesions, each of a dis-
tinct character, but developed by, and taking their spe-
cial type from, what he terms puerperal poison, a miasm
of lying-in hospitals, which, like the miasm of camps;
and like the miasm of the surgical wards of a hospital,
can engender numerous and very different diseases.
These, originating from the same source, proceeding
from the same cause, remain none the less as essentially
distinct morbid entities. He asserts that, from this pu-
erperal poison, not only originate phlebitis, peritonitis,
and purulent infection, but that it equally is the source
which develops scarlatina, erysipelas, pleurisy, pneumo-
nia, cerebral hemorrhage, and many other affections
which he could cite. He divides the causes of this pu-
erperal poisoning into the general or determining causes,
and the individual or predisposing causes. He enumer-
ates, as the general causes of puerperal poisoning, at-
mospheric influences, vitiation of the air in the lying-in
wards, the crowding of patients together, infection, and
contagion. The individual causes which engender pu-
erperal poisoning are, physical or moral distress, want
of acclimation in hospital air, constitutional and antece-
dent diseases, first labors, and obstetrical operations.

In short, the theory of Hervieux is, that there is
a puerperal poison, a peculiar miasm, which engenders
peritonitis, phlebitis, metritis, and a multiplicity of
other puerperal diseases, just as the miasm of camps
causes typhus and typhoid fevers, dysentery, and puru-
lent infection, just as the miasm of surgical wards gives
rise to erysipelas, to phlebitis, to purulent infection,
and to hospital gangrene, and just as the miasm of hos-
pitals for children determines ophthalmias, erysipelas,
diarrhoeas, purulent pleurisies, purulent peritonitis, and
diphtheria.

PUERPEEAL FEVER. 457

I have thus endeavored to give you a true and just
idea of the numerous theories, in regard to puerperal
fever, in vogue at the present day, and I have aimed to
represent these theories without prejudice or partisan
coloring, and to do justice to the arguments by which
they are supported. I shall now give you niy own
views in regard to each of these theories, and my rea-
sons for the opinions which I hold. At the same time,
I warn you not to accept the doctrines which I teach,
unless the arguments with which I support them con-
vince your judgment. Where conflicting theories exist
in regard to medical subjects, you should cultivate the
habit of looking on all sides of the question, of broadly
examining all the arguments for and against every
given theory, and then form your own distinctive per-
sonal conclusions and opinions. There is no greater
barrier to the progress of medical science than the pro-
fessional habit of accepting the opinions of medical
authors and teachers simply because they are regarded
as authorities.

Now, let us first examine the theory of the localists.
I shall here reproduce the arguments which I made use
of in the discussion of this subject, before the Academy
of Medicine in this city, sixteen years ago. For, with
the most anxious desire for truth, the conscientious
study of this disease, in seven epidemics which we have
had in this hospital since that time, has only confirmed
me in the opinions that I then expressed. I object to
the theory that the disease is primarily a local inflam-
mation, and that the fever and the general symptoms
are secondary to, and the consequence of, these local
inflammations :

(1.) That puerperal fever has no characteristic ana-
tomical lesions. There is a great variety of structural

458 PUERPERAL DISEASES.

lesions found, the most frequent of which are those of
the peritonaeum, those of the veins of the uterus, those
of the inner surface of the uterus, and those of the
lymphatics. But these lesions are not uniform or con-
stant. In the same epidemic, we have the greatest
variety in their seat and their degree. In another epi-
demic, all lesions of the pelvic tissues are absent, and
the lesions are chiefly of the thoracic organs. We find
an entire absence of lesions of the peritoneum, of the
uterus, or the uterine sinuses, or the ovaries, or the
broad ligaments, but we find the same kind of patho-
logical lesions in the pleura and pericardium as are
seen upon the peritonaeum when the lesions are mani-
fested there.

(2.) These lesions are often not sufficient to influ-
ence the progress of the disease, or to explain the cause
of death. The most malignant form of the disease, that
in which a fatal result occurs the most speedily, offers
the fewest and the least striking structural lesions. The
longer the disease continues, the more prominent and
the more manifest are the organic lesions. This would
seem to prove that the lesions are consecutive or sec-
ondary ; and that there is a primary disease, an original
cause of vital depression, which sometimes destroys life
so rapidly that there is no time for the development
of the secondary morbid alterations. The cases are not
very infrequent in which patients have manifested the
first symptoms, and died within thirty-six or forty-eight
hours ; and, in these instances, the anatomical lesions
are so few or so slight, that many have been reported by
such observers as Gooch, Simpson, Locock, Tessier, Bour-
don, Bouchut, Voillemier, Tonnelle, and others whom I
could name, as cases of puerperal fever without lesion.
I have seen several such in this hospital. It is character-

PUERPERAL FEVER. 459

istic of those authors who belong to the school of local-
ists, and who have studied the disease in one locality
alone, or in one epidemic, to assume that certain lesions
uniformly belong to it, and they modestly tell us that
those who do not find them are either incompetent or
imperfect observers. With this class, two or three
drops of pus found in the sides of the uterus, near the
attachment of the tubes, or of the broad ligaments, in a
patient who has died after three or four days' illness, is
a triumphant demonstration that the fetal disease had
a local origin.

(3.) There may be inflammation, even to an intense
degree, of any of the organs in which the principal
lesions of puerperal fever are found, and yet the dis-
ease will lack some of the essential characteristics of
puerperal fever. I mean to say that there may be peri-
tonitis, phlebitis, or metritis, in the puerperal woman,
and yet the disease may be quite distinct in its mode
of attack, in its symptoms, and its pathological anatomy,
from puerperal fever. Take peritonitis, for example. It
may be excited by a difficult and protracted labor, by
improper exposure, and by other well-known exciting
causes. But puerperal fever, with the peritoneal lesion,
may attack the patient after the most favorable de-
livery, and without any obvious cause. Then the symp-
toms of the disease show that it has a special character,
for, in the puerperal fever with the peritoneal lesion,
the symptoms of the first stage of peritonitis are gener-
ally absent ; the peritoneal symptoms are those of the
second stage, or of collapse, as, for example, there is
very frequently diarrhoea instead of obstinate constipa-
tion. In peritonitis, the pulse, respiration, and temper-
ature correspond in character with the local symptoms,
the two former increasing in frequency, and the tempera-

1GO PUERPERAL DISEASES.

ture rising, as the local symptoms increase, diminishing
as they disappear. So I might take up in turn each
one of the local inflammations which occur as idiopathic
diseases in the puerperal woman, and point out the
difference, in the mode of attack, the symptoms, and
the progress of the disease, between these affections,
which follow the laws of ordinary inflammations, and
the lesions of the same tissues, the pseudo-inflamma-
tions of puerperal fever.

(4.) The lesions of puerperal fever are essentially
different from spontaneous, or idiopathic inflammations
of the tissues where these lesions are found. In the
Dublin Quarterly Journal of Medical Science, August,
1857, you will find these distinctions most clearly de-
scribed by Dr. Murphy, formerly Professor of Mid-
wifery in the University of London ; and the difference
between the lesions of puerperal fever and those of sim-
ple inflammation were also noted as early as 1787, by
Dr. John Clarke, and, since that time, by many other
observers. In idiopathic peritonitis in a puerperal
woman, there is intense injection of the arterioles of
the surface of the peritonaeum, the intestines are streaked
with bright scarlet lines, and there is an exudation of
plastic lymph. The lymph poured out is adhesive,
uniting the different parts of the intestines, like glue.
The quantity effused is not great, and, being lodged
in the pelvic cavity, may at first escape observation.
In puerperal fever, it is generally the venous radicles
which are injected, and hence the intestines have a livid
hue, and the patches and streaks on the surface, instead
of being of a scarlet color, have a dusky-red appearance.
In puerperal fever, the exudation is very much less ad-
hesive, and very much more abundant, often covering
the fundus of the uterus, the intestines, the liver, and.

PUERPERAL FEVER. 461

the diaphragm, and frequently is found in the pleura.
In idiopathic inflammations, the surface of the intestine
on vrMch the exudation has occurred is rough, while,
in puerperal fever, the surface where the exudation is
found is smooth. In both, there may be an effusion of
sero-purulent fluid, but in this particular the measure
and intensity of the morbid processes are marked by
almost opposite results. In simple inflammation, the
more intense the peritonitis, the greater the amount of
the sero-purulent effusion. But, in puerperal fever,
the more intense and violent the seizure, the less the
chance of meeting any lymph, and the less the amount
of the effusion. In the most intense forms, death may
take place before any effusion occurs. When the dis-
ease is less severe, there may be found a large amount
of serum, colored brown by blood, in the peritonaeum
and throughout the tissues. The effused lymph is of
the same color, Laving no adhesion to the surface on

/ O

which it lies, as if the fibrine of disorganized blood had
been deposited there, or the same kind of lymph or
fibrine is found, of a yellow color, with a quantity of
sero-purulent fluid. In those cases where the constitu-
tion struggles successfully for a time against the fever,
some adhesive lymph will be found, mixed with a
large quantity of sero-purulent exudation.

I have taken up the peritoneal lesion, as being the
most frequent and the most prominent in puerperal
fever. I might go on and point out characteristic
differences between the other lesions of this disease
and simple inflammations in corresponding tissues, but,
as these inflammations have already been fully discussed
in former lectures, I think that this part of my argu-
ment requires no further illustration.

(5.) Puerperal fever is often communicable from one

4:02 PUERPERAL DISEASES.

patient to another, through the medium of a third party.
This is not the fact in regard to simple inflammations
in puerperal women. The question, whether puerperal
fever "be contagious, was long in dispute, but I think
that the fact is no longer doubted by the profession in
Great Britain and in this country. In regard to this
point, Hervieux says :

" The direct proofs of the reality of contagion are
not wanting, and, at this day, it ought to be super-
fluous to recall them. The belief in contagion is in-
deed universal. There is not a capital in Europe
where the medical public does not accept this belief.
Paris, it must be acknowledged, remained a long time,
in respect to this question, behind the other scientific
centres ; but, to-day, there is not one among us who,
even if unknown to himself, does not speak and act
as if he were convinced of the power of contagion."

In Germany, there are, however, still to be found
certain writers who, forming their opinions on this ques-
tion from their own limited observation, and apparently
ignorant of the facts which have been accumulated by
others in proof of this doctrine, deny that puerperal
fever is contagious. I do not purpose to argue this
question now, but, if any of you have any doubts on
this point, let me refer you to a small volume on " Puer-
peral Fever," by Professor Oliver Wendell Holmes, pub-
lished by Ticknor and Fields, Boston, 1855, in which
he has brought together such an array of facts bearing
on this, and presented them in his own inimitable style,
with such a logical force as must convince the most
skeptical. I may add, that I think this little work
ought to be in the hands of every man who practises
midwifery, as the influence of it might be the means of
protection for some of his patients. Professor Holmes

PUERPERAL FEVER.

gives more than thirty different series of cases, with up-
ward of two hundred and fifty sufferers, and one hun-
dred and thirty deaths, as the result of his researches,
in which the evidence seems conclusive that the disease
was directly communicated through the medium of the
physician or nurse. Since the publication of his book,
in 1855, many other facts of the same kind have been
published, and I could add largely to his numbers, from
the private communications which I have received from
physicians in this city, and from different parts of the
country.

I wish you here to remark that the evidence of
contagion is not based on observations made in hos-
pitals, where the air has been vitiated by an accumula-
tion of patients. All admit that the saturation of the
air with the exhalations of surgical and puerperal pa-
tients is eminently toxic, and engenders erysipelas, puru-
lent and putrid infection, and other assimilated affec-
tions. This source of disease, which has been termed
nosocomial malaria, is undoubtedly one of the most
efficient and frequent causes of the development of
puerperal fever in hospitals, but the facts on which the
doctrine of contagion and infection is based are drawn
from private practice and largely from country practice,
where nosocomial malaria can have no influence.

These, then, are my reasons for believing that puer-
peral fever is a distinct disease from the febrile reaction
of inflammation of any of the tissues of the puerperal
woman ; and for believing that the anatomical lesions
found in this disease bear the same relations to it as
the pustules on the cutaneous surface bear to small-pox,
as the chancres and buboes bear to the syphilitic diseases,
as the morbid changes found in the Peyerian and soli-
tary glands of the small intestines bear to typhus fever.

464: PUERPERAL DISEASES.

Let us next examine the doctrine of traumatism and
septicaemia, and see whether this explain the phenom-
ena of puerperal fever. I think not, for the following
reasons :

(1.) The septicaemia- theory is incompatible with
the authentic facts which demonstrate that puerperal
fever is contagious and infectious. Those who believe
that puerperal fever is identical with septica3mia deny
that the disease is really contagious, although they
admit that it is " manually transferable." Now, I shall
mention two facts, which alone seem to me sufficient to
establish the distinction between puerperal fever and
septicaBniia :

It has often occurred that one physician is tracked
by puerperal fever, following a series of labors, while,
in the same neighborhood, village, or city, the dis-
ease is not met with in the practice of any other
physician. Dr. Gordon's treatise on puerperal fever
was published in 1795, and in this he says: " It is a
disagreeable declaration for me to make, that I myself
was the means of carrying the infection to a great num-
ber." He enumerates a number of instances in which
the disease was conveyed by midwives and others to
the neighboring villages, and declares that, " I arrived
at that certainty in the matter, that I could venture to
foretell what women would be affected with the dis-
ease, upon hearing by what midwife they were to be
delivered, or by what nurse they were to be attended,
during their lying-in, and, almost in every instance, my
prediction was verified." In the essay on puerperal
fever, by Dr. Armstrong, a number of instances are given
of the prevalence of the disease among the patients of
a single practitioner. In the town of Sunderland, Eng-
land, there were in one year " forty-three cases of puer-

PUERPERAL FEVER. 465

peral fever, and of this number forty were witnessed by
Mr. Gregson and Ms assistant Mr. Gregory, the other
three having been separately seen by three accou-
cheurs." In the essay of Dr. Gooch, on this disease, he
says : " It is not uncommon for the greater number of
cases to occur in the practice of one man, while the other
practitioners of the same neighborhood, who are not more
skillful* or more busy, meet with few or none," and he
gives several illustrations of this fact. Dr. Rams-
botham asserted, in a lecture on this subject, that " he had
known the disease spread through a particular district,
or be confined to the practice of a particular person,
almost eveiy patient being attacked with it, while others
had not a single case." In the London Medical Ga-
zette, for January, 1840, Mr. Roberton, of Manchester,
makes the following statement, which I give as con-
densed by Dr. Holmes :

" A midwife delivered a woman on the 4th of De-
cember, 1830, who died soon after with the symptoms
of puerperal fever. In one month from this date the
same woman delivered thirty women, residing in differ-
ent parts of an extensive suburb, of which number six-
teen caught the disease and all died. The other mid-
wives, connected with the same charitable institution as
the woman already mentioned, are twenty-five in num-
ber, and deliver, on an average, ninety a week, or about
three hundred and sixty a month. None of these women
had a case of puerperal fever. Yet all this time this
woman was crossing the other midwives in every direc-
tion, scores of the patients of the charity being delivered
by them in the very same quarters where her cases of
fever were happening."

At a meeting of the Royal Medical and Chirurgical
Society of London, Dr. King mentioned that a practi-
se

i66 PUERPERAL DISEASES.

tioner at Woolwich lost sixteen patients from puerperal
fever in one year. He was compelled to give up prac-
tice, his business being divided among the neighboring
practitioners. No case of puerperal fever occurred
afterward, neither had any of the neighboring sur-
geons any cases of this disease.

In different parts of the United States, both in the
country and in cities, numerous instances have been
published, where a series of cases of this disease has
occurred in the practice of one man, while the other
physicians in his vicinity have not had a case. Many
such have been communicated to me, personally and by
letter, from different members of the profession, but I
need not multiply illustrations, as the number already
published, amounting to hundreds, is sufficient to de-
monstrate the fact.

Septicaemia is very frequent in surgical practice,
especially in hospitals, for I doubt whether it can be
called a very frequent affection in country practice.
The surgeon is constantly occupied with traumatic
lesions, which offer a surface for the absorption of sep-
tic material much greater than ordinarily exists in
the puerperal woman. I presume that no one will
claim that surgeons, as a class, are more scrupulous,
as to cleanliness and the use of disinfecting agents
after exposure to septic materials, than obstetricians.
But, after consultation with eminent surgeons in this
country and in Europe, and from my own researches in
medical literature, I am unable to find that a single in-
stance has yet been published, where septicaemia has
tracked the practice of one surgeon in any city or vil-
lage, while the other surgeons in the same neighborhood
did not meet with this affection. It seems to me that
this one fact alone is sufficient to demonstrate that puer-

PUERPERAL FEVER. 467

peral fever is not septicaemia. I concur with Schroeder,
that septicaemia is "manually transferable," but that
it is not contagious or infectious, and this is one of the
proofs to my mind that puerperal fever is not septicae-
mia. In the discussion of the paper of Dr. Hicks, be-
fore the Obstetrical Society of London, to which I have
before referred, Dr. Barnes, who regards septicaemia as
one form of puerperal fever, remarked : " The a'utogenetic
forms proper did not appear to possess active powers
of propagation. For example, a common form, that
which arose from decomposition of the placenta setting
up septicaeinic fever, generally began and ended in the
patient attacked. It was not very liable to spread to
others. So with other varieties of autogenetic puerpe-
ral fever." On this point, my own experience and ob-
servation are in entire accord with the remark of Dr.
Barnes.

(2.) Puerperal fever differs from septicaemia in its
origin, its mode of attack, and its symptoms. The
former disease originates from, epidemic causes, and from
contagion and infection. The latter, from nosocomial
malaria, from autogenetic infection, and from direct in-
oculation. The symptoms of the former are frequently
manifested a day or two before, or during labor, even
when the child is subsequently born alive. This fact
has been noted by many observers, and I suppose that
it must have been remarked by every one who has seen
epidemics of this disease. But, in septicaemia, the symp-
toms are never observed before or during labor, except
when the foetus is putrid, as a traumatic lesion is a neces-
sary element for the absorption of the septic material.
I have already given you the symptoms of septicaemia
in a former lecture on this subject, but I shall here
remark that it is better for you not to be content with

468 PUERPERAL DISEASES.

my description, but that you should make a careful
study of those German authorities who have devoted
so much attention to this subject. Take, for exam-
ple, the work of Billroth, which has been admirably
translated, and compare his description of the symp-
toms of septicasmia with the symptoms of puerperal
fever, as detailed by any competent observer of an
epidemic of this disease, such as Campbell, Collins,
Ferguson, or McClintock. I refer you to such as have
described the disease from their own observation,
rather than to the systematic writers, for the obvious
reason that their description is unbiased by any theory
of the disease. I think that no one can make this com-
parison without coming to the conclusion that Billroth
describes a disease radically and essentially different
from, the one described by the authors that I have
named. At the same time, you will please observe
that I do not deny, on the contrary, I am quite con-
vinced, that septicaemia not unfrequently occurs in con-
nection with puerperal fever, more especially in hos-
pitals.

(3.) That puerperal fever is not identical with sep-
ticaemia is demonstrated, also, by the difference in the
influence of the two diseases on the infants of the
mothers affected. There are two diseases which are
extremely liable to occur in the infants of mothers suf-
fering from puerperal fever. Erysipelas is the most
frequent, and it proves fatal in a large majority of cases.
In this hospital, it has been very common in several of
the epidemics of puerperal fever. That the erysipelas
is not developed exclusively by the vitiated air of hos-
pitals, but is directly the result of the maternal disease,
is evident from the fact that it occurs with great fre-
quency in private practice in the infants of mothers suf-

PUERPERAL FEVER.

fering from puerperal fever, who are sin-rounded by
the most favorable hygienic conditions possible in a
city. I have seen this in repeated instances, both in the
country and in this city, and in families of wealth, where
the greatest care was taken to prevent disease, by the
removal and destruction of all sources of infection.

The other disease which has been frequently ob-
served in connection with puerperal fever is, trismus
nascentium. In one epidemic in this hospital, in 1867,
one in every three children born in the hospital during
one month died of trismus nascentium. The connec-
tion of this disease with puerperal fever has also been
noted in other hospitals, as in the Lying-in Hospital
of Dublin, in hospitals in London and in Stockholm.
But in no instance that I have ever seen, or have ever
found in medical literature, has the infant suffered
from symptoms of septicaemia. My attention was called
to this point by an incident which occurred during the
month of May of the present year. I had a patient
extremely ill with puerperal fever, one of the most se-
vere cases that I ever saw recover. On the fifth day of
her illness, her child was circumcised, and the child was
apparently never ill in the slightest degree. This was
to me a suggestive fact. That the infants of mothers
suffering from puerperal fever are frequently infected,
developing either erysipelas or trismus nascentium, is a
well-known and accepted fact in medicine. I have never
known an instance where the infant has been supposed
to be infected by a mother suffering from autogenetic
septicaemia; neither, after very considerable research, can
I find that any such instance has ever been published.
The traumatic lesions of a circumcised infant offer a
greater exposed surface for the absorption of septic
material than the lesions of most puerperal women. It

4-70 PUERPERAL DISEASES.

is incredible to suppose that all these circumcised infants
are protected by greater precautions against septic ab-
sorption, than many mothers who get puerperal fever in
a series of cases, from the attendance of one physician.
I therefore made inquiries of such medical gentlemen
in this city as had large experience in the observation
of circumcised infants, and of such of our most eminent
German practitioners as would be most likely to be
thoroughly familiar with German medical literature,
whether their own observation or medical literature
furnished one single instance where a circumcised infant
had septicaemia from suspected infection by the mother.
The answer from every one was an unqualified negative.
If, as the experimentalists and the advocates of the
septicaemia-theory of puerperal fever tell us, an infini-
tesimal quantity of sepsine, less than a millionth part
of a grain, be sufficient to infect, and if puerperal fever
and septicaemia be identical, is it not reasonable to sup-
pose that the infection of circumcised infants would
have been observed, at least in a few instances, when
we so often see infection of infants who do not offer
this traumatic lesion, by mothers suffering from puer-
peral fever?

Departing from the order in which I have before
mentioned the different theories of puerperal fever now
in vogue, I shall next make a few comments on the the-
ory of Hervieux, that there is a plurality of diseases
which originate in puerperal poisoning. He admits
that there are antecedent blood-changes, produced by
the poison of miasm, and his plurality of diseases is
the result of this primary affection. Wherein does this
doctrine differ from the theory of a puerperal fever,
which implies nothing more than the idea of a primary
blood-disease that results in a great variety of local le-

PUERPERAL FEVER. 471

sions? The answer of Hervieux is, that each of these
local lesions is a " distinct morbid entity." By the
same process of reasoning, it might be argued with
equal force, that the paralysis which frequently occurs
iii diphtheria is a distinct morbid entity, that the albu-
minuria which so often results from scarlet fever is a
distinct morbid entity, and so on, with numerous other
affections, which, in the present state of science, are
generally regarded as secorrdary lesions, when they are
met with in zymotic diseases.

It seems to be the belief of Hervieux that, unless
these secondary local affections be regarded as distinct
diseases, there will be no diagnosis of their existence
and no appropriate therapeutics. Now, is it true that
this doctrine of Hervieux does tend to a more careful
study of the symptoms and physical signs of these lo-
cal lesions, than they receive from those who regard
them as secondary affections, and that thus the science
of diagnosis is advanced ? And does this theory lead
to better therapeutic results ? I have failed to find any
evidence which would justify an affirmative answer to
either question. To parody a phrase from Hervieux,
place the most ardent partisan of his hybrid localism,
which is only one of the debris of Broussaisism, in pres-
ence of a severe case of puerperal fever which destroys
life in two or three days, and would he .be able to de-
cide, by the symptoms and physical signs, whether the
case were a peritonitis, a metritis,.a lymphangeitis, or a
phlebitis, and, when the autopsy reveals the fact that
all these lesions existed, as they frequently do, would
he say that the patient died from " four distinct morbid
entities ? " Carry this theory out to its logical conclu-
sion, and you must admit as many distinct diseases as
there are organs and tissues in which lesions are found.

72 PUERPERAL DISEASES.

As a rule, I liave a great dislike to the tu quoque
argument, but it is quite legitimate to judge of a theory,
from its application by its originator. I may, there-
fore, with perfect propriety, refer you to the great work
of Hervieux, as furnishing the strongest argument
against his theory. You will find in this work nu-
merous cases reported under the designation of one dis-
ease, which, from its symptoms and its necroscopic le-
sions, might, with equal significance, have been called
one of two or three other diseases. For example, cases
reported as peritonitis, both general and partial, might
have been designated with equal truth as cases of ova-
ritis, or phlebitis, or metritis, as each of these lesions
was found. In short, take out of his book many of his
cases, in which the symptoms and the autopsical lesions
are given, and it would be impossible for the best-in-
structed physician to determine in which of his dis-
tinct " morbid entities " Hervieux had classed them.

So, also, there is a great temptation to use the tu
quoque argument in regard to the therapeutics of his
work, but, if there be a class of what are called minds,
that find in his new system of nomenclature, for it can
hardly be called more than that, an evolution of science
from chaos an advance from the infancy of art a
progress in diagnostic accuracy and therapeutic success
further argument on this subject would be useless.

I have but a few words to say in regard to the the-
ory of Professor Martin. The German writers seem to
use the term diphtheria in a different sense from that
accepted generally in the English language. Thus, the
terms " diphtheritic membrane " and " croupy patches "
are indifferently applied to describe the exudative cover-
ing which is often found on traumatic surfaces, especially
in patients infected by nosocomial malaria. But, if

PUERPERAL FEVER. 473

Professor Martin mean that puerperal fever is identical
with the zymotic disease which we call diphtheria, it is
a sufficient answer to his theory to mention the well-
known fact that, for at least thirty years, diphtheria
was an unknown disease in this country. It prevailed
at irregular periods in different parts of the country,
from 1771 to 1820. Then it seemed to entirely disap-
pear, and there is no proof that the disease again oc-
curred in any part of the country, until about 1856.
But, during this time, there were many epidemics of pu-
erperal fever. I have seen but one case of diphtheria
in a puerperal woman, and this was in a patient of the
late Professor C. K. Gilman. The disease commenced
with high fever and delirium, and for a time it was
supposed to be a case of puerperal fever, but subse-
quently the true nature of the disease became very evi-
dent.

Let us next examine the doctrines which have been
previously referred to in my third and fourth classes.
I shall discuss them together because, in reality, the es-
sential difference between them is more in the use of
terms than in pathological opinions. The one includes,
in the term puerperal fever, all the puerperal dis-
eases which are attended with fever, as all of the local
inflammations, septicaemia, the exanthemata, and the
idiopathic fevers. This class does not exclude the idea
of an essential fever in puerperal women, but, in writ-
ers belonging to this school, you will frequently meet
with an expression of regret that the term puerperal
fever has been adopted in medical nomenclature, the
reason assigned being that it is an unfortunate one, in
that it is- used loosely to include entirely distinct
groups of disease. But those who make this complaint
are the greatest sinners in this way, and confession with

474 PUERPERAL DISEASES.

them is not accompanied by repentance and reform.
Let us see whether the objection rest on an essential
foundation, or whether it be entirely of artificial crea-
tion.

It is in accordance with established usage in medi-
cal nomenclature, to designate the disease by the pri-
mary affection. If the disease be primarily local, the
name of the disease is derived from the name of the
organ involved. When inflammation of lung is accom-
panied with typhoid symptoms, it is often called typhoid
pneumonia, but it is still pneumonia. If the lung be-
come inflamed during the course of a typhoid fever,
the disease is still called typhoid fever, and the pneu-
monia is regarded as secondary. No one would desig-
nate such a case as typhoid pneumonia. Pericarditis
and endocarditis occur as primary idiopathic diseases,
but, when either is developed in the course of an attack
of rheumatism, the disease is. still rheumatism, and the
cardiac affection is considered secondary. Gastritis is
often a primary disease, but, when it is caused by arse-
nic, the case ; would not be reported as one of gastritis,
but as a case of arsenical poisoning. I might give numer-
ous other illustrations to prove that, when the symptoms
of general or constitutional disturbance are the conse-
quence of a primary local affection, it is the organ affect-
ed which gives the name to the disease. But, when
general disease precedes the local affection, the name is
characterized by some feature belonging to the general
disease. Now, in the puerperal woman, local inflamma-
tions frequently arise and cause severe constitutional
disturbances, but the disease, under these circumstances,
should be called peritonitis, metritis, or phlebitis, as the
case may be, or, if two or more tissues or organs be
involved, it is strictly correct to give the name which

PUERPERAL FEVER. 475

will best express the fact, as nietro-phlebitis, or metro-
peritonitis.

The accepted doctrine of the present day is, that
the general diseases are chiefly due to certain known
and unknown blood-changes. When the cause of these
blood-changes is known, the name of the disease is
derived from this cause. Thus the disease which is
recognized by a certain group of symptoms, and which
is known to be due to an accumulation of urea in the
blood, is called ursemia. The disease resulting from
putrid infection is called septicaemia, and that which is
produced by purulent infection is termed pyaemia. It
seems to me incorrect to class these diseases among; the

fevers, and therefore those cases which Dr. Barnes would
call autogenetic puerperal fever would be more proper-
ly named septicaemia.

The term fever, as used generically to designate a
class of diseases, means a general disease which results
from unknown blood-changes. It is called essential, be-
cause its characteristic symptoms are not due to a local
cause.

All of the fevers have certain phenomena in com-
mon, which serve to distinguish the disease as a fever.
Almost without exception, the development of a fever
is manifested by a chill, and, in some instances, by rigors.
Invariably there is a rise in the temperature, as shown
by the thermometer. This is usually attended with
lassitude, restlessness, imperfect sleep, and often with
pain in the limbs, the back, or the head. The organic
Junctions are also more or less disturbed. The appetite
is lost, there is often nausea, and, in some fevers, vomit-
ing. Thirst is also a very characteristic symptom, and
there is generally a diminished secretion of urine. Kow,
when there is this aggregation of symptoms, without

476 PUERPERAL DISEASES.

*
any local disease to cause them, we are warranted in

calling the disease a fever. Fordyce, whose work on
this subject is still classical, defines fever " as a disease
which affects the whole system. It affects the head, the
trunk, and the extremities. It affects the circulation,
the absorption, and nervous system. It affects the skin,
muscular fibres, and the membranes. It affects the body
and it affects likewise the mind. It is, therefore, a dis-
ease of the whole system in every kind of sense."

I shall now make my confession of faith in the fol-
lowing propositions :

1. There is a fever which is peculiar to puerperal
women, and is, therefore, appropriately named puerpe-
ral fever.

2. The symptoms of this disease are essential and
are not the consequence of any local lesions, and it is as
much a distinct disease as typhus fever, typhoid fever,
or relapsing fever.

3. It belongs to the class of zymotic diseases, and
results from some unknown blood-changes.

4. We are as ignorant of the specific cause of these
blood-changes as we are of those which develop relaps-
ing fever, scarlet fever, or any of the other essential
fevers.

5. The determining cause of this fever may be either
epidemic influences, contagion, infection, or, probably,
nosocomial malaria.

6. Any of the local inflammations may occur in the
puerperal woman without puerperal fever ; and, on the
other hand, puerperal fever may be so severe as to
destroy life without sufficient local disease to account
for the symptoms or explain the cause of death.

7. The specific causes which develop the exanthe-
mata, such as scarlet fever and sma]l-pox, may develop

PUEEPEEAL FEYEE. 477

the specific disease with, intense malignancy in the
puerperal woman ; but this does not transform the dis-
ease into a puerperal fever.

8. Septicaemia may be developed in a puerperal
woman, either from autogenetic or heterogenetic infec-
tion, without puerperal fever, but this infection may
also complicate puerperal fever.

LECTURE XX.

PUEEPEEAL FEVEE.

Symptoms of puerperal fever Anatomical lesions Symptoms due to the secondary
lesions Progress and termination Symptoms indicating the probability of re-
covery Unfavorable symptoms Treatment Arterial sedatives Necessity for
careful watching Case illustrative of the action of the veratrum viride Opi-
ates Agents to reduce fever Quinine The mineral acids Alcohol Food
Treatment of the secondary lesions Illustrative case Treatment by elimination
Venesection (?) Leeches (?) Emetics (?) Purgatives (?) Mercurials (?).

GENTLEMEN : In all zymotic diseases, the symptoms
vary greatly in different epidemics, and this is pecul-
iarly the fact in regard to puerperal fever. I shall
aim in this lecture to describe the symptoms which
generally characterize this disease, and to point out the
various modifications which result from epidemic influ-
ences, and the peculiar types of secondary lesions.

In a large majority of cases, the first symptoms of
puerperal fever are manifested between the first and
the third day after delivery. I have before mentioned
the fact that the disease is sometimes developed a day
or two before, or during labor. It rarely appears after
the fifth day from delivery, and I have never met with
a case in which the disease has come on after the eighth
day.

During an epidemic, an experienced eye will often
detect certain indications of the approach of the dis-

PUERPERAL FEVER. 479

ease, in the aspect of the patient, some hours before
its invasion. I have often remarked the haggard
countenance, the trembling lips, the paleness of the
cheeks, the wandering eyes, the vague answers, and the
air of undefined suffering, before the appearance of
other symptoms, and before the patients would make
any complaints. I observed these appearances in one
of my patients, whom I visited at six in the evening
of the second day after delivery. The pulse was 84,
the temperature 99, and the patient declared that she
was feeling perfectly well. But her appearance caused
me such anxiety that I called again at ten, making a
frivolous excuse for the call, so as not to excite alarm.
I then found her with a pulse of 124, and a tempera-
ture of 102, but she still could not be induced to
make a complaint. I left her room, but not the house,
mentally resolving not to do so for that night. Less
than an hour from that time, the nurse rushed down-
stairs, requesting that I should be sent for at once. For
the four days following, it was very doubtful how this
case would terminate.

The first symptom, in most cases, is a chill, but this
is sometimes so slight as to pass unnoticed, unless special
inquiry be made in regard to it. But in many cases the
chill is severe, lasting a half-hour, or even longer. The
chill very rarely recurs a second time, and, when it does
for two or three times, you have strong reasons for be-
lieving that the fever is complicated with suppurative
phlebitis or with pyaamia.

In most cases, soon after the chill, there is a sudden
development of abdominal pains, often vague and un-
determined as to their seat, but generally beginning in
the hypogastrium. This symptom is very rarely ab-
sent. I have been very much impressed by the fact

480 PUERPERAL DISEASES.

that, even in those epidemics that I have seen in which
the secondary lesions were chiefly thoracic, the abdomi-
nal pains were almost invariably present in the delut
of the disease. I have also observed, in several in-
stances, that this symptom was much less prominent
when the disease was associated with septicaemia. As
I have before told you, the abdominal pains seldom
occur in autogenetic septicaemia.

The abdominal walls are generally soft and yielding,
and abdominal distention is not a very marked symp-
tom. Even when the secondary peritoneal lesions are
the most prominent, the tympanites, the tenderness,
and the pain, are much less striking than in idiopathic
peritonitis. Patients are generally able to lie indiffer-
ently on the sides, or on the back, with the legs extend-
ed. In puerperal fever, when the disease approaches a
fatal termination, there is often a rapid distention of the
abdomen, due to an accumulation of gas in the intestines.

The temperature is always from three to six degrees
higher than the normal standard, and my observations
lead me to the conclusion that the oscillations of the
thermometer are increased in a very remarkable degree
when the disease is associated with pyaemia, and that
the range is decidedly higher when it is complicated
with septicaemia.

A constant symptom in this disease is a great fre-
quency of the pulse. I should say the pulse is never
below 110, and frequently is as high as 160. During
the time of the chill, the pulse is small and quick, but,
after the chill has passed off, the pulse becomes fuller,
without increase of force, so that it is easily compressed
by the finger. It is often irregular, and, as death ap-
proaches, it becomes very frequent, irregular, and thread-
like.

PUERPERAL FEYER. ' 481

The respiration is always hurried in this disease,
the inspirations being from 24 to 50 or CO a minute.
In some cases during the epidemic of this spring, the
rapid breathing was one of the earliest symptoms, pre-
ceding, in a few cases, the chill and the abdominal pains.

The tongue is generally moist, with a whitish coat,
and it is often indented by the teeth. It is only dry
and cracked in those cases where the patient breathes
with the mouth open, on account of the difficulty of
respiration.

The cerebral disturbances in this disease are not
usually very marked. There is frequently some delir-
ium, especially during the night, when the patient has
hallucinations, cries out, and sometimes tries to get out
of bed. But she is generally tranquil during the day,
and quite forgets the excitement of the night. I have,
however, in several instances, seen violent mania devel-
oped during the course of the disease, and the patients
have apparently died from the exhaustion which results
from the maniacal excitement. In such cases, when I
have had an opportunity of making an autopsy, no le-
sions of the brain or of its meninges have been found.

Vomiting is rather a common symptom, the matter
ejected being of a dark, greenish color, and containing a
large quantity of bile. In quite a number of instances,
both in this hospital and in private practice, lumbricoid
worms have been vomited. Hiccough is also a frequent
symptom in grave cases.

Diarrhoea is also very common, and sometimes the
vomiting seems to be supplanted by the diarrhoea, but
very rarely do the two symptoms occur at the same
time, even in very severe cases. I have known both of
these symptoms to be absent during the whole course
of the disease.

PUERPERAL DISEASES.

The character of the lochial discharge furnishes no
evidence in regard either to the existence or the intensity
of the disease. Schroeder, who believes puerperal fever
to be a disease entirely resulting from the absorption
of septic material, remarks : " The discharge of fetid de-
composed lochia is not, and cannot be, considered a
proof that infection has taken place. We have often
had the opportunity of observing that, within a few
days after delivery, large quantities of foul-smelling
lochia have been discharged, without there being any
trace of disease. Decomposition of the lochia almost
always takes place when large shreds of the decidua,
partly separated from their connection with the surface
of the uterus, have remained behind in the uterine
cavity."

On the other hand, the remains of the placenta are
not unfrequently retained for days and weeks, without
any putrid decomposition taking place, or any symptoms
of puerperal fever appearing. In fact, it often seems that
the only symptom which results from this retention is
repeated hemorrhage.

In puerperal fever, the lochial discharge often di-
minishes immediately after the invasion of the disease,
and, after a day or two, nearly or quite disappears. In
other cases, it increases in quantity and changes in char-
acter, becoming either more sanguinolent or more puru-
lent. In some cases, the odor is very fetid, in others, not
at all so. In other cases, again, I have seen the disease
go on to a fatal termination without apparently affecting
the lochial discharge, either as to quantity, quality, or du-
ration. I may also add that I have repeatedly observed
all of these varieties as to the lochia, in the same epidemic.

I must also remark that the disease seems to have
no constant influence on the function of lactation. In

PUERPERAL FEVER. 483

most cases, the invasion is manifested before tliis func-
tion is established, and, in a majority of such cases, there
is usually very little secretion of milk, and, when there
is, it ceases after two or three days. In a small number,

I have seen lactation established and continue through-

out the disease. In a number, so few that I must regard

' D

them as exceptional, I have seen this function developed
or restored after convalescence.

There has recently appeared a very interesting essay
by Dr. Eugene Quincjuaud, of Paris, on " Puerperisme
Infectieux," a new term, which the author proposes to
substitute for puerperal fever. The special feature of this
essay is a study of the influence of this disease on the
amount of the urea and of the chlorides eliminated in
the urine. I have not yet had the opportunity to form
any opinion as to the utility or value of this study, but I
welcome all honest work which adds to our knowledge
of the phenomena of any of the essential diseases.

If, now, it may seem to any of you that I have not
given any positive, definite symptom by which puerpe-
ral fever maybe recognized, it must be remembered that
tli ere are no pathognomonic symptoms of any of the
essential diseases, with the exception of the exanthe-
mata, and these can hardly be called exceptions. All
admit that small-pox or scarlet fever may occur and de-
stroy life, without th,e pathognomonic cutaneous lesions.
Puerperal fever, like typhus fever, typhoid fever, relaps-
ing fever, and all the essential diseases, is only known
by a general combination of phenomena, nor is the
presence or absence of any one symptom sufficient to
determine the existence or 'non-existence of the disease.

I shall next call your attention to some special symp-
toms which result from the modifications of the disease,
either by epidemic influences or by individualism.

PUERPERAL DISEASES.

Epidemic influences seem to determine the special
character of the secondary lesions, and, of course, the
symptoms which attend these lesions. Although, in
the same epidemic, there is the greatest variety in
their seat and their extent, yet certain epidemics of pu-
erperal fever manifest a special tendency to the perito-
neal lesions, others to the uterine tissues, others to
phlebitis, to embolism, or to pyaemia, and, in other epi-
demics, we find very few lesions of the pelvic tissues,
but these are chiefly observed in the thoracic viscera.
Again, in other epidemics, the special tendency seems to
be to septicaemia.

M. Charrier describes one epidemic at the Hbpital
Lariloisiere, in which the first half of the cases was
characterized by peritoneal lesions, while, in the second
half, lesions of the pleura were the uniform rule, and it
was rare that lesions were found of any of the organs
specially associated with parturition. M. Dubois ob-
served one epidemic in which all who died were found
to have perforation of the intestines. M. Danyau, in
enother epidemic, found a constant alteration of the
mucous membrane of the large intestine in its whole
extent, the lesion being a solution of continuity, as if
made by a punch.

I have, in former lectures, so fully discussed these
lesions when they occur as idiopathic inflammations,
that it is unnecessary for me now to do more than de-
scribe the difference in the local symptoms, when these
lesions are secondary.

When the peritoneal lesions predominate, there is
generally pain, which commences in the hypogastriuin
or in one of the iliac regions, and gradually radiates
over the abdomen. The pain is, in some cases, slight,
and in others, severe ; in some it is continuous, and in

PUERPERAL FEVER. 485

others it returns in paroxysms. The intensity or the
continuity of the pain cannot be relied upon as amr.i--
ure of the extent or the degree of the peritoneal lesion.
In many cases, where the autopsy has revealed the most
remarkable peritoneal lesions, there was neither pain
nor tenderness. There was no pain in nineteen of one
hundred and seventy-three cases analyzed by Ferguson,
and in eight of thirty-three cases reported by Dr. Rob-
ert Lee. It seems, also, that the most fatal cases are
those in which pain is absent.

The abdomen usually becomes distended and tyni-
panitic when the peritoneal lesion occurs, but in a much
less degree than in idiopathic peritonitis. In puer-
peral fever, the morbid sensibility, of the abdomen is so
moderate as to permit us often to determine by percus-
sion the presence of effusion, which rarely is possible
in idiopathic peritonitis. Diarrhoea is also a much
more frequent symptom when this lesion is secondary.
The dejections are sometimes involuntary, and they are
usually dark and fetid when the disease is of a very
grave character.

When the uterine lesions are the most prominent,
in addition to the general symptoms of puerperal fever,
there is usually a certain amount of pain in the region
of the uterus, but this is often not very marked, except
when pressure is made over the pubes or the sides of
the uterus. The process of involution is retarded or ar-
rested, and the uterus remains larger, harder, and more
sensitive, than usual. There is generally suppression of
the lochia, except in those cases where the chief seat of
the lesions is the internal surface of the uterus. Then
the lochial discharge is often greater than usual, and, at
an earlier period than usual, it becomes purulent. If
subsequently the lochial discharge become very profuse

486 PUERPERAL DISEASES.

and fetid, we liave strong grounds for inferring that the
endometritis has gone on to putrescence or necrobiosis.
With this lesion, there is often difficulty in passing
water, and sometimes very distressing strangury.

The local symptoms indicative of lesions of the
uterine veins are less marked and striking than those
that I have before mentioned. There is generally more
or less pain in the uterine region. Professor Behier in-
sists that one physical sign of this lesion is always pres-
ent. He asserts that, if the bladder be empty and the
uterus be firmly secured in a fixed position by one hand,
by compression of the sides of the uterus between the
thumb and two fingers of the other hand, a painful, cord-
like induration is found on one or the other side of the
uterus near the attachment of the placenta, or extend-
ing to one or the other iliac fossa. Behier affirms that
this sign may always be found, and that it constantly
exists antecedent to the other symptoms. I regard it
as an important sign, but in no degree pathognomonic
of uterine phlebitis, for I have often pointed it out to
my hospital staff, and in some cases where no autopsical
lesions of the veins were found. I think that, with the
phlebitic lesions, there is generally more headache, more
cerebral disturbances, greater thirst, and greater nervous
depression, as manifested by muscular tremblings of
the face and extremities, than is usually observed with
the other secondary affections. Most writers seem to
think that phlebitis is generally attended with recurrent
chills, and it certainly is so, when this affection is asso-
ciated with purulent infection.

There are no peculiar symptoms which characterize
the lesions of the broad ligaments and of the ovaries,
and it is only by an intelligent and experienced physi-
cal exploration that their existence can be determined.

PUERPERAL FEVKIi. 487

The secondary thoracic affections will be made out
by a careful study of the objective symptoms, and by
percussion and auscultation. I have before discussed
these points in my remarks on pyaemia, and I shall,
therefore, not go over the ground again.

Septica3niia, as a secondary affection in puerperal
fever, is usually a result of endometric lesions. Pri-
mary or autogenetic septicaemia is developed at an .early
period after delivery. The secondary septicaemia of
puerperal fever may not be developed until the fever
has existed for one or two weeks, and, indeed, I have
seen cases where the characteristic phenomena of this
infection have not appeared until the third week.
Then the intellectual apathy and apparent dullness
of sensation, the tendency to a semi-coma, the dry,
hard tongue, the indistinct articulation, the subsultus,
the profuse sweating, sometimes alternating with a very
dry skin, the persistent diarrhoea with excessively fetid
discharges, the cold extremities and the irregular, thread-

O / O '

like pulse, are such a combination of. phenomena as
leave no doubt as to the nature of the infection.

Pya3mia is a secondary affection of a late period of
the disease. The recurrent chills, followed by fever and
perspirations, the suppurations of subcutaneous cellu-
lar tissue, the effusion in the articulations, the rational
symptoms and physical signs of pneumonic inflamma-
tions or of purulent effusion in the pleura and the peri-
cardium, and the character of the urine, are phenomena
sufficiently characteristic to establish the nature of the
secondary affection.

Puerperal fever is a disease which produces its effects
very rapidly. Fatal cases ordinarily terminate between
the second and the sixth day of the disease. In severe
epidemics, the majority of deaths occur on the fourth

88 PUERPERAL DISEASES.

and fifth days, but there are usually a few patients who
die within forty-eight hours from the time of the attack.
In such cases, the chill, the abdominal pains, the vomit-
ing and diarrhoea, the hurried and labored respiration,
the profuse perspirations, and the cold extremities, suc-
ceed each other so rapidly, that, from the commencement
of the attack, it is plain to see that the disease must be
inevitably fatal.

The French apply the term foudroyant, which liter-
ally signifies thunder-striking, crushing, to characterize
overwhelming attacks of any disease, and it is so ex-
pressive that it has been adopted in English medical
literature.

When death occurs later than the sixth day, it usually
results from some of the secondary affections.

Recoveries are also sometimes very rapid. We oc-
casionally meet with cases very formidable in the begin-
ning, that are thoroughly convalescent in four or five
days. But much more frequently the recoveiy is very
slow. The abdominal pains disappear, and are renewed
again and again. The pulse, the temperature, the tym-
panites, and all the other symptoms, are found much
better one day and worse the next, and often without
the manifestation of any new secondary affection, or
any other assignable cause.

But, as a general rule, the convalescence is tedious in
proportion to the extent and severity of the secondaiy
affections. From three to four weeks is the usual time
required for recovery, and I feel extremely well satisfied
if patients are quite well at the end of the puerperal
month. But it often happens that secondary affections
of the pelvic organs, or extensive suppurations of subcu-
taneous cellular tissue, or some of the thoracic affections,
may require weeks for their cure and disappearance.

PUERPERAL FEVER. 489

I shall first mention the symptoms which indicate a
probability of recovery. Perhaps the most significant
is a permanent decrease in the frequency of the pulse,
coincident with a corresponding fall of temperature. If
the pulse become less frequent while the temperature
still remains above 103 or 104, you must not antici-
pate a continuance of the improvement in the pulse.
Furthermore, it is not safe to pronounce a decided im-
provement, unless the reduced frequency of pulse and
fall of temperature have continued for twenty-four
hours. I have seen the pulse brought down below 80
by the veratrum viride, and the temperature reduced to
100 or 101 by quinine, and a few hours afterward I
have found the pulse as frequent and the temperature
as high as ever before. The effects of the therapeutic
agents seemed to be for a time overcome by a new in-
vasion of the disease. This has been again controlled
by the vascular sedative and the antipyretic, until at
last a permanent effect is secured.

Another favorable symptom is the disappearance of
the abdominal pain, coincident with subsidence of ab-
dominal distention, but its cessation is no proof of radi-
cal improvement, except when, at the same time, the
tenderness on pressure and the tympanites decrease in
a corresponding degree.

Cessation of vomiting, if it be not replaced by ex-
hausting diarrhoea, is also a favorable omen. A mod-
erate diarrhoea appearing late in the disease, in my ob-
servation, is usually followed by improvement. Pa-
tients frequently express themselves as feeling better
after each discharge, and, unless the number of these ex-
ceed three or four a day, I do not attempt to arrest them.

I usually look upon the appearance of external sup-
purations, such as abscess of the breast, or of the nates,

i90 PUERPERAL DISEASES.

or of the extremities, as favorable. I have frequently
observed that a decided improvement in the general
symptoms corresponds with the development of these
abscesses.

I am also very much inclined to look upon the ap-
pearance of herpes labialis as a good symptom, indica-
tive of an eliminative process, as I have several times
remarked that a manifest improvement has commenced
in patients who were very ill, about the same time as
the appearance of this eruption.

It is hardly necessary for me to enumerate, as favor-
able symptoms, an increased demand and capacity for
food, a clearing up and a brightening of the intellec-
tual faculties, and a cheerful, hopeful morale.

I have before alluded to a combination of symptoms
which are usually observed in those cases which prove
rapidly fatal. I shall now point out those which in-
dicate that the disease is very grave. I do not think
that any conclusion can be drawn as to the prognosis
in the case, from the violence or the duration of the
initial chill, or from the severity of the abdominal
pains, for I have seen as many fatal cases, which began
with very slight chills and with but little complaint of
abdominal pain, as I have of those in which these symp-
toms were very striking. The initial symptoms which
to me are the most alarming, are a pulse above 140, a
temperature above 104, and a very rapid, laborious
respiration. I regard the latter as the most significant
and serious symptom of the three, when it appears very
early in the disease, before it can be due to distention
of the abdomen and mechanical interference with the
action of the diaphragm, or before the development of
the secondary thoracic affections. The symptom to
which I refer will easily be discriminated from the rapid
breathing which is caused by emotional excitement.

PUERPERAL FEVER. 491

Severe diarrhoea, in the early period of the disease,
is also a measure of the intensity of the attack. When
both vomiting and diarrhoea occur together, and there
are also a rapid pulse, high temperature, and hurried
breathing, the prognosis is exceedingly grave. In such
cases, you will usually observe, at a very early period,
profuse sweats, .cold extremities, and a very feeble, ir-
regular pulse.

Subsidence of pain, while the abdominal distention
is absolutely increasing, is a very unfavorable symptom.

Pyaemia or septicaemia is, of course, a very serious
complication ; but I am quite certain that it is a mis-
take to regard either as inevitably fatal. I am sure
that I have seen recoveries when the existence of one or
the other of these infections could not be doubted.

Purulent effusion in the great serous cavities, as the
peritonaeum, the pleura, or the pericardium, usually re-
sults in death.

The influence of mental depression in leading to a
fatal termination has been remarked by nearly all writ-
ers on puerperal fever. Our four patients who have
died in the present epidemic were all unmarried.
Campbell says that, of eight unmarried mothers
attacked by this disease, six died, and similar state-
ments are made by Leake, Clarke, Armstrong, and Fer-
guson.

The development of mania in a patient with puer-
peral fever, in my experience, almost invariably leads
to a fatal termination. I do not refer to the delirium,
which, in a certain degree, very generally occurs in this
disease, but to an absolute mania.

The treatment of puerperal fever is, perhaps, quite
as unsettled as its pathology. I shall not attempt to
give you the various methods which have been rec-

492 PUERPERAL DISEASES.

ommended by different writers, but I shall endeavor to
point out those general principles which, in my estima-
tion, should govern the treatment, with those special
indications which arise from the peculiar character of
the disease. I shall begin by observing that there are
no specifics for puerperal fever, any more than for typhus
fever, yellow fever, or relapsing fever. As has been
before remarked, the type of the disease varies to an
extraordinary degree in different epidemics, and there
must be a corresponding variation in the treatment.
This must also be modified in accordance with the indi-
vidual conditions of the system, and with the extent
and intensity of the secondary affections. There is no
disease which requires more acute discrimination in the
adaptation of means to an end ; none which requires a
sounder judgment or more incessant watching to com-
bat every assault w r hich may exhaust vital power. The
leading indications are to allay and control the vital
disturbances which the disease causes, and to combat
the secondary affections which may result.

(1.) No argument is needed to convince you that
the vital powers are rapidly exhausted by disease, when
the heart is driving the blood through the system at
the rate of 120 or 140 beats in a minute. It also must
be evident that something is gained in prolonging or
saving life, if arterial excitement can be reduced with-
out loss of vital power. There are several agents which
may be properly termed vascular sedatives, but the
most efficient and certain of these are veratrum viride
"and aconite. Digitalis is usually regarded as belonging
to this class, but there is a decided difference between
the action of this a^ent and that of veratrum viride

and aconite. The two latter will reduce the rapid
pulse of inflammation and of irritation, but not the

PUERPERAL FEVER. 493

quick pulse of exhaustion, while digitalis is less effi-
cient as an arterial sedative in the former conditions,
but it does steady and retard the quick pulse of ex-
haustion, and it is believed by many to act as a cardiac
tonic. I have, in a former lecture, given my reasons
for preferring the veratrum viride to any other agent,
when the object is to reduce the frequency of the
pulse. I find a great number of physicians who re-
gard this article as unsafe and uncertain, because, if
given in too large doses, it produces nausea and vom-
iting, and other symptoms resembling collapse. The
pulse becomes very slow, the countenance pale, and the
surface is cold and covered with a clammy sweat.
These appearances very naturally cause alarm ; but, after
an experience of more than thirty years in the use of the
veratrum, I feel warranted in asserting that these phe-
nomena are really not dangerous. I have never known
any serious result to follow from its use. This condition
is purely temporary, and patients pass out of it in a
short time, even if no restoratives be given. Diffusible
stimulants, such as ammonia, wine, or brandy, will very
soon bring the patients out of this apparent condition
of collapse. Still, it is very desirable to avoid such
explosions, by commencing the use of this medicine in
small doses, carefully watching the effect and increasing
the dose very gradually until a positive effect is pro-
duced on the pulse, on account of the alarm which they
are apt to excite, not only with friends, but sometimes
with, the patient herself. When the frequency of the
pulse is very decidedly reduced, the number of drops
in each dose may generally be diminished, but yet the
effect must be kept up for several days after all suspi-
cious symptoms have disappeared. Over and over
again, I have seen the mistake made of stopping the

PUERPERAL DISEASES.

veratrum viride too early; and thus the disease Las
been allowed, as it were, to renew itself. I have found
that this medicine is less apt to produce nausea if it he
given with syrup or a few drops of the tincture of gin-
ger in a little susrar and water. There is a notable dif-

o o

ference in the strength of the tincture as it is found in
the shops, and it is therefore wise to commence with
small doses, increasing gradually, until you ascertain
the quantity necessary to produce the specific effect on
the pulse. The use of this drug is objected to by
some, because it requires constant watching. But, to
my mind, this i^ an argument in its favor. The dis-
ease itself demands constant watching; and no man
should take charge of a case of puerperal fever, unless
he be able to give it the most devoted attention and in-
cessant care. Success in treating a severe case of this
disease will turn, in a great measure, on the prompt-
ness with which each symptom is met, and, day and
night, not only faithful but intelligent, educated vigi-
lance is demanded. It is not safe, in this disease, to leave
the patient in the hands of the best of nurses for many
hours, unless an exceptional one be found, who is able to
record the pulse, the respiration, and the temperature,
and one, too, who never loses self-possession, and who
has the intelligence and the judgment to compre-
hend and follow directions for such modification in the
treatment as change in the symptoms may demand.
Except with such a nurse, and there are but very few,
I should not feel easy if I did not see a patient with
puerperal fever three or four times a day, and I should
not think of allowing a night to pass unless the pa-
tient were watched, either by myself or by some other
physician.

I was recently in attendance on a very severe case

PUERPERAL FEVER. 495

of puerperal fever. I had for two nights watched the
patient myself, and a young medical friend of the family
had remained with her for two other nights. I visited
her one evening at eleven o'clock, thinking that she was
so decidedly convalescent, that I might safely return to
my ow r n house and secure a good night of sleep. But,
while detained below for a few moments, I took from
the drawing-room table a book, the title of which I do
not remember, but the author was Dean Alford, and
my eye fell on the following sentences: "There are
moments that are worth more than years. A sick man
may have the unwearied attendance of his physician for
weeks, and then may perish in a minute because he is
not by." On going to the room of my patient, I found
her condition in every respect satisfactory. Her tem-
perature was 102, it had been 105; her pulse was 92,
and she expressed herself as feeling perfectly well, and
a solicitude that I should have a good night's rest.
But the words I had just read were burned in my
mind. "When I went down-stairs, I said to her husband,
" Your wife appears to be doing well in every respect,
and I have taken leave for the night of all up-stairs,
but I think that I shall get more refreshing sleep on
the sofa in this room than in my bed at home." Be-
tween one and two o'clock, I was awakened by a com-
motion in the room above. I found my patient very
excited, complaining of intense pain in the hypogas-
trium, with a pulse of 144, and a temperature of
105.4. The nurse had put a bedpan under her, to
enable her to empty the bladder, when she suddenly
screamed out with pain. I at once gave hypodermically
fifteen drops of a solution of morphia (sixteen grains
to the ounce of water), and then, as she complained
greatly of pressure in the bladder, I introduced the

496 PUERPERAL DISEASES.

catheter and drew off about ten ounces of urine. The
abdomen was then covered with hot turpentine-stupes.
Ten drops of the solution of morphia were afterward
twice administered hypodermically, at intervals of one
hour, but it was six in the morning before my patient
fell into a sound sleep. The two days following she
remained so ill as to cause me great anxiety, but after
this time her recovery was rapid. Now, if I had gone
home, and the time required to get a carriage and send
for me had been lost, it is my firm conviction that this
lady would have died. With such physical symptoms
as were suddenly developed in this patient, who will
doubt that the influence of emotional excitement, con-
tinued for an hour, would have made the case perfectly
hopeless? My immediate presence tranquillized both
the family, who were excessively alarmed, and the pa-
tient.

In puerperal fever, I usually commence by giving
five drops of the tincture of veratrum viride, every
hour. If a decided impression be not made on the pulse
after two or three doses, I increase each dose by one
drop, until a positive effect is gained, and thus I seek to
bring the pulse down from 120, 130, or 140, to below 80
In a large majority of cases, it can be brought down to
this point, but, in some, it cannot be brought below 100.
This is apt to be the case with very nervous patients.
The influence of the veratrum viride should be steadily
kept up until two or three days after all constitutional
disturbance has subsided. After a little experience, you
will learn just how many drops are necessary for this
purpose in each patient. When the pulse is once re-
duced by the veratrum viride, usually two, three, or
four drops, every second hour, will be sufficient. If
vomiting come on, wait until the pulse begins to rise,

PUERPERAL FEVER. 497

and tlieii begin again with a nrinnnuni dose, but do not
give up its use. Now, let me be understood on this
point. I do not regard the veratrum viride as a specific
remedy for puerperal fever, but I do consider it a very
valuable and important agent for controlling vascular
excitement, and believe that, by its use, cases have been
cured, which, without it, would have terminated fatally.
In the following severe case, which occurred in this
hospital, in 1857, and was reported by Dr. Cobb, then
house physician, the veratrum viride was the only
medicine used, and you will see, by the report, its influ-
ence in reducing the pulse. I should remark that the
tincture then used was probably about half the strength
of that now generally found in the shops :

CASE XXXVI. <; Kate S , aged twenty-three years, fell in

labor in full term, at 2 o'clock P. M., February 25th, and was deliv-
ered of a healthy child at 8.12 o'clock on the morning of the 26th.
Nothing unusual occurred in her labor, except that the second stage
was somewhat prolonged. The placenta came away in due time, and
was not followed by hemorrhage. First pregnancy.

" February 28th. At 8 A. M., she was seized with a very severe
chill, followed by increased frequency of the pulse, and pain over
the hypogastric region, extending as high up as the umbilicus.
This pain was very much increased by taking a full inspiration,
or by pressure. Tympanites very considerable. The discharge,
abundant and very offensive. Pulse 140, respiration 24.

" At 1 o'clock P. M., Dr. Barker saw her, and recommended that
she be transferred to the fever-wards, and put on the use of the
tinctura veratri viridis.

" At 2 o'clock P. M., after having been removed to the fever-
wards, her pulse was 140, respiration 24. Pain over the hypogas-
tric region intense. Tympanites very considerable. Lochia abun-
dant and very offensive. No mammary secretion. Dr. Barker re-
quested she should be seen hourly by one of the house staff, and
that her condition, as to the state of the pulse, respiration, and
other symptoms, and the dose of the veratrum. viride given, should
be recorded at each visit. The following is the record thus kept:
32

498

PUERPERAL DISEASES.
RECCED OF CASE.

TIME.

Pulse.

Reap.

Drops.

REMARKS.

February 28.

2.00 p. M

140

3.00 '

127

6.00 '

140

6.00 '

132

7.00 '

120

8.00 '

Bowels moved once.

9.00 '

Vomited a greenish-colored fluid. Bow-

els loose.

10.00 '

Vomiting ceased. Bowels moved once.

11.00 '

12.00 '

March 1.

1.00 A. M

Respiration very irregular. Inclined to

sleep.

2.00 "

Sleeping.

8.00 "

Hiccough and headache.

4.00 "
5.00 "

60
66

18
20

Hiccough still continues.
Severe headache. Vomited a greenish-

colored fluid.

, 6.00 " ....

Headache severe, and very restless. Vom-

ited several times within the last hour.

Hiccough.

7.00 "

Vomited once since last visit. Vertigo

and headache.

8.00 "

Sleeping.

9.00 "

10.00 "

Slight hiccough.

11.00 "

12.00 M

Tenderness over abdomen marked. Tym-

panites somewhat diminished. Lo-

chia dark, bloody, and very offen-

sive.

1.00 P. M

Visit of Professor Barker.

2.00

3.00

Face flushed.

4.00

Sleeping.

5.00

Sleeping.

6.00

7.00

Slight hiccough. Bowels moved once.

8.00
9.00

66
68

18
24

Vomited a greenish-colored fluid.
Vomited once since last visit.

10.00

Sleeping.

11.00

, .

Still sleeping.

12.00

Still sleeping.

March 2.

1.00 A. M

2.00 " ....

Complains of pain hi left thigh. There is

slight swelling, and, along its inter-

nal surface, over the veins and lym-

phatics, the tenderness is so great

that she can scarcely bear the light-

est touch. Tenderness over abdomen

still continues. Slight tympanites.

Lochia dark, profuse, and offensive.

PUERPERAL FEVER.
RECORD OF CASE {Continued).

499

TIME.

Pulse.

Resp.

Drops.

REMARKS.

March 2.

3 00 A. M . . .

No mammary secretion.

4.00 "

Sleeping.

5.00 "

6.00 "

8.00 "

9.00 " ...

10.00 "

Bowels moved once.

11.00 "

12.00 M

1.00 P. M.. .

2.00 "

3.00 "

6.00 " .. .

7.00 "

9.00 "

Face flushed.

10.00 "

11.00 "

12.00 "

Sleeping.

March 3.

1.00 A. M

"Vaginal discharge now ceases to be offen-

sive. No mammary secretion. Tym-

panites still remains. Tenderness over

abdomen still continues, though not so

well marked. Tenderness and swelling
in left thigh still continue.

2.00 "

Slight hiccough.

3.00 " ....

4.00 "

6.00 "

Vomited* a greenish-colored fluid.

6.00 "

Headache. Hiccough. Bowels moved

twice.

8.00 "

9.00 "

10.00 " ...

12.00 M

1 00 p M

2.00 "

3.00 "

4.00 "

Sleeping.

5.00 "

7.00 "

8.00 "

9.00 "

10.00 "

11.00 "

12.00 "

Sleeping.

March 4.

1.00 A. M

Tenderness over abdomen not so in-

2.00 "

tense. Slight tympanites. Vaginal

3.00 " ....

discharge now appears to be natural.

Tenderness and swelling on internal

surface of left thigh now seem to

be diminishing. No mammary secre-

tion.

500

PUERPERAL DISEASES.
RECOBD OF CASE (Continued).

TIME.

Pulse.

Resp.

Drops.

REMARKS.

March 4.

4.00 A. M

5.00 ' ...

6.00 ' ...

7.00 ' ...

Bowels moved twice.

8.00 '

9.00 '

10.00 '

11.00 "

12.00 M

1.00 p. M.

2.00 "

3.00 "

4.00. "

5.00 "

Sleeping.

0.00 "

7.00 ' ....

8.00 '

9.00 '

10.00 '

11.00 '

12.00 ' ....

March 5.

1.00 A. M

C3U 1. f 1 IV.

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 "

Sleeping.

3.00 "

4.00 "

5.00 "

6.00 " ....

7.00 "

8.00 "

9.00 "

10.00 "

11.00 "

12.00 M

1.00 P. M

2.00 "

3.00 "

4.00 " ...

5.00 "

6.00 " ....

7.00 " .

8.00 "

9.00 "

PUEEPERAL FEVEK.
EECOED OF CASE (Continued).

501

TIME.

Pulse.

Resp.

Drops.

REMARKS.

March 5.

10.00 p. M. . : . .

March 6.

8.00 A. M

Feels well. Improvement marked. No

tenderness on pressure over the abdo-

men. No tympanites. Lochia still

scanty, but normal. Slight mammary

secretion.

11.00 "

12.00 sr.

1.00 P. M.

5.00

6.00

7.00

8.00

^ B

9.00

10.00

March 7.

9.00 A. M

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

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<A, 3 A. M. She slept quietly since last note. Magendie's
solution, gtts. 5. 9 A. M. Pulse 92, temperature 101. She feels

PUERPEEAL FEVL3. 509

very well and enjoys her food. Abdomen still enlarged, but -with
no pain and but slight tenderness.

" The decrease in the size of the abdomen was very slow, but
after this time there was a steady, progressive improvement. The
temperature ranged from 100 to 102 for the four succeeding days,
after which it fell below 100. The pulse, from this time, never rose
so high as 100, and my attendance ceased two weeks from this date."

In some remarks on puerperal fever which were
published in various medical journals sixteen years
ago, I said that " the first indication is, to eliminate
from the system as much of the morbid poison as is
possible, by means of depletion and the other evacu-
ants, as purgatives, emetics, and diuretics." Within a
few years past, the conviction has gradually grown
upon me that this is bad advice ; first, because it is im-
practicable, and second, because the attempt to follow
it may be positively injurious. The theory of eliminat-
ing from the system the poisons which cause the pri-
mary blood-changes in the essential diseases seems at
first plausible ; but, when the disease is developed, the
poison has produced its effect, and, both from reasoning
and observation, I am convinced that it is just as im-
possible to arrest puerperal fever by elimination, as it
is to arrest, in this way, typhus or scarlet fever. While,
then, the probability of any good being effected by such
means is very small, the chances that positive harm may
result from the attempt are very much less doubtful.

Let us examine somewhat in detail each method of
elimination. In some epidemics, venesection has been
relied upon as the chief and most important therapeutic
measure, and better success seemed to be obtained by
this means than by any other. This was the fact in
certain epidemics described by Gordon, Hey, Arm-
strong, Campbell, and others; but it is the testimony
of other equally sagacious observers of most epidemics

510 PUERPEEAL DISEASES.

of puerperal fever of later times, that bloodletting could
not be borne. I am very certain that, in the epidemics
that I have seen, it would have been positively injuri-
ous. Still, in certain cases, venesection may be indi-
cated, and a wise physician will carefully avoid exclu-
sive routine practice. The same principle, as regards
bloodletting, should govern our practice in this as
in any other disease. Good sense, not theory, should
be our guide. Venesection should never be resorted
to simply because the case is one of puerperal fever,
but because the symptoms indicate that vascular de-
pletion is necessary. In a few cases, I have bled the
patient to relieve severe cerebral symptoms. In one
patient, puerperal fever was ushered in by a chill on
the third day after delivery. On the "fifth day, symp-
toms of cerebral congestion of the most alarming char-
acter were suddenly developed without premonition.
I at once abstracted about thirty ounces of blood, with
entire relief of the cerebral symptoms. The blood was
analyzed by my friend, Professor Doremus, and found
to contain an abnormal quantity of urea. Previous to
her accouchement, the urine had several times been
tested for albumen, but none was found. A few weeks
since, I saw a lady in consultation, on the fourth day
after confinement. Two days before, she had a pro-
longed chill, followed by severe abdominal pains, vom-
iting, and the other symptoms of puerperal fever. At
the time of my visit, she was suffering from a severe
headache, the pulse was hard and bounding, 116 per
minute ; the face was flushed, and the temperature was
104. I learned that she had lost very little blood at
the time of labor, and that, since the first day, there had
been absolutely no lochial discharge. No urine could
then be obtained for examination, but I was afterward

PUERPERAL FEVER. 511

told that it contained a large amount of albumen.
With some difficulty, I persuaded my friend, who had
charge of the case, to open a vein and take away about
a pint of blood. She was afterward treated with the
acetate of potash, veratrum viride, and such other rem-
edies as were indicated, and made a good recovery.
This is the only instance where I have recommended
venesection in the epidemic of this spring.

Leeches are very much employed by French and
German practitioners for the purpose of subduing local
inflammations ; but I never advise them in this dis-
ease, as it is my belief that the various methods of ac-
complishing this result, which I have recommended in
former lectures, are quite as efficient, and very much less
annoying. I think it a good rule, in the treatment of
disease, to do nothing which can add to the suffering and
discomfort of a patient, if this can possibly be avoided.

Emetics at one time had a great reputation in the
treatment of puerperal fever, and still have with French
physicians, who make frequent use of ipecacuanha for this
purpose. I have seen it tried in many cases, but have
long since given it up in my own practice, for the reason
that I have never seen it followed with any positive
good results. I am convinced that every thing which
perturbates or irritates the system, from which a posi-
tive good cannot be demonstrated as a result, should
be avoided. Vomiting is one of the symptoms of the
disease, and I cannot see that we gain any thing by
aggravating any one of the symptoms. It is true that,
under certain circumstances, the action of an emetic is
followed by a cessation of vomiting, and therefore it is
sometimes wise to give one for this purpose ; but this
is a very different thing from giving emetics to cure
puerperal fever.

512 PUERPERAL DISEASES.

Purgatives have been extensively used in the treat-
ment of this disease, and I think that no one who care-
fully reads the clinical reports that abound in medical
literature can fail to come to the conclusion that there
is no evidence of their utility, but abundant proof that
they have been, in numerous instances, positively injuri-
ous. Take, for example, the classical work of Fergu-
son, and you will find several cases reported, where the
action of castor-oil was followed by the development
or aggravation of severe peritoneal irritation. If con-
stipation exist, simple enemata are ordinarily sufficient
to remove it. In some comparatively rare cases, where
the tongue has a thick, pasty coat, and there is a good
deal of bilious vomiting, with inability to retain nutri-
ment, and the bowels have not moved for two or three
days, I have given from five to ten grains of calomel,
well rubbed up with twenty grains of bicarbonate of
soda. This acts efficiently, but gently, as a laxative,
and causes no pain or irritation. I can almost say that
this is the only laxative that I ever give in puerperal
fever, and, I may add, that it is only as a laxative that
I ever give calomel in this disease.

Mercurials have been, and still are, advised by many
authors. By some, mercury is supposed to be particu-
larly efficacious in the treatment of phlebitic lesions,
but I find no evidence that it is so, either from my own
or the experience of others, neither can I discover any
scientific reason why it should be of service in arresting
phlebitis, peritonitis, or any other of the local inflam-
mations.

I have made extensive trial of the sulphites, so
highly recommended by Professor Polli, of Milan, but
without any satisfactory evidence of their efficacy in
the treatment of puerperal fever.

APPENDIX

APPENDIX.

THE fact that puerperal fever is specially liable to appear in
lying-in hospitals, and that it sometimes occurs as an epidemic in
connection with other zymotic diseases, particularly with erysipe-
las, is conceded by all. I think, also, that the majority of the pro-
fession believe that all those causes of nosocomial malaria, such
as aggregation, bad ventilation, contact with septic material, etc.,
which have a tendency to induce septicaemia or pysemia in surgical
cases, have an equal tendency to develop the disease known as pu-
erperal fever, in women recently confined.

Some writers assert that this disease never occurs, except under
one or the other of the above conditions, and that it never appears
as an epidemic, unless associated with some one of them.

During the early months of the present year, puerperal fever
prevailed in the best parts of this city, and in that class of society
possessed of abundant means and living under as good sanitary
conditions as are possible in any large city, to a degree and
extent here unknown for the past twenty-five years. Previous
to this year, I think that this disease has been comparatively rare
in those classes of society who are able to live well. From my
observation, confirmed by all of the profession whom I have had
an opportunity of interrogating on this subject, I feel warranted in
saying that the disease seemed to attack, with equal severity, pri-
miparge and multiparae, those in previous good health, as well as those
who were feeble and delicate, those who had normal and easy labors
equally with those in whom the labors were tedious and difficult.

It is impossible to ascertain what the comparative fatality of
the disease was, but, from all the sources from which I could gain
information, I made the estimate that one in five of those attacked
died. Some of ray professional acquaintances have expressed to
me the belief that this estimate of the proportionate mortality is
too high ; but this was absolutely the proportion of deaths to the

51G APPENDIX.

number of cases mentioned to me by other physicians, added to the
number which I saw, either in consultation or in my own private
practice, the number of cases being ninety-five, and the number of
deaths nineteen.

I think the profession in this city universally believe that puer-
peral fever can be transmitted by the physician from one patient
to another, and consequently it cannot be doubted that every one
took the greatest precaution to guard against so terrible a calamity.
Certainlv, no authentic evidence has come to my knowledge, that
the disease tracked the practice of any one man during the epi-
demic of the present year.

Erysipelas was not epidemic in that part of the city where pu-
erperal fever was rife, nor, indeed, in any part of the city, although
there were a few sporadic cases. I may also mention that I have
not seen a case of diphtheria for more than a year.

I was particularly impressed by the fact that, in Bellevue Hos-
pital, a smaller proportion of puerperal women were attacked by
the fever than in several former epidemics that I have encountered
in the hospital, and that dispensary physicians did not speak of the
disease as being of remarkable frequency in the crowded and poorer
quarters of the city.

These facts struck me as so singular, that I addressed a note to
my friend, Dr. Charles P. Russel, then Register of the Board of
Health, having charge of the Bureau of Records of Vital Statis-
tics, inquiring if he could furnish me with a record of deaths for
the first four months of 1873, reported as due to puerperal fever or
puerperal septicaemia, and also those reported as of puerperal perito-
nitis, metro-phlebitis, etc., so as to include all the metria, to adopt the
term used by the Registrar-General of Great Britain. I further in-
quired whether the Bureau of Records could give any information
as to the comparative mortality in different parts of the city, and
as to the social status of those who died. In reply, Dr. Russel had
the tables prepared for me, which I append. They were made out
by non-professional officials, who had no theory to support, and who
were quite ignorant of the use that was to be made of them.

These tables seem to me very remarkable and significant. In
Table I., the total number of deaths is 62, of which 33 occurred
in the Nineteenth, Twentieth, Twenty-first, Twenty-second, and
Twelfth Wards. These wards embrace that par^ of the city north
of Twenty-sixth Street. The population of these wards, according
to the census of 1870, was as follows :

APPENDIX.

517

Twenty-second Ward 71,349

Nineteenth Ward 86,090

Twentieth Ward 75,407

Twenty-first Ward 56,703

Twelfth Ward 47,497

Total 337,046

The population of the whole city was, at this time, 942,292.
Thus it will be seen that, in a population of 337,046, there were
reported 33 deaths, while in the remaining part of the city, with a
population of 605,246, there were but 29 deaths.

In Table II., the total mortality was 81, and 47 of these deaths
occurred in the same five wards.

In Table III., the total mortality is 143, and the deaths in the
five wards were 80.

The residences of those who have an annual income of over
$5,000 are almost exclusively in the Fifteenth, Sixteenth, Eigh-
teenth, Nineteenth, Twentieth, Twenty-first, Twenty-second and
Twelfth Wards, and a large majority of these are in the last five
wards. In these, as compared with many others, there are propor-
tionally few of the class of dwellings known as tenement-houses,
in which the poor are aggregated. From statistics furnished me
by my friend, Dr. Stephen Smith, member of the Board of Health,
I find the population to the square acre to be in the

Nineteenth Ward 56

Twentieth Ward 173

Twenty-first Ward 120

Twenty-second Ward 50

Twelfth Ward 21

This is in striking contrast with the population to the square
acre in some of the other wards ; and, to make this more clear, I
give a comparative exhibit of the population to the square acre, of
the poorer classes of New York and London :

Eleventh Ward 328

Thirteenth Ward 311

Fourteenth Ward 275

Seventeenth Ward.. . 289

Strand 307

St. Luke's 259

East London 266

Ilolborn.. . 229

I found it impossible to get the number of births in each ward dur-
ing the period included in these tables, as they are not registered
by wards ; but the whole number of births registered in the city, for

518

APPENDIX.

this period, was 8,238. If the number of births in the five wards
first indicated be estimated by the ratio to the population, it will
be 2,946.

Assuming this number to be nearly correct, these tables prove
that in five of the best wards in the city, as regards wealth and ag-
gregation, there were 80 deaths from metria, in 2,946 births, from
January 1 to May 15, 1873, or 1 in 36.8; while, during the same
period in the rest of the city, there were 63 deaths from the same
cause, in 5,292 births, or 1 in 84.

Table IV. offers a most curious and significant contrast to the
above results. In the five wards, the number of deaths certified as
from childbirth, rupture of the uterus, hemorrhage, placenta praevia,
and puerperal convulsions, was 20, or 1 death in 147.3 births ; while,
in the other parts of the city, in which mainly the poor reside, who
are unable always to command skilled obstetrical assistance, the
deaths were 1 in 79 births.

TABLE I.

Deaths certified as by Puerperal Fever and Puerperal Septicaemia
in the City of New York, from January 1 to May 15, 1873.

Mortality in Different Wards.

ret ward.

-venth ward.

&hth ward.

inth ward.

enth ward.

oventh ward.

wclfth ward.

lirtecnth ward.

iftccnth ward.

xtccnth ward.

jventcenth ward.

ghteentli ward.

ineteenth ward.

vventioth ward.

wenty-flrst ward.

wenty-sccond wa

otal Deaths.

Mortality in Different Classes of Dwellings and Public Institutions.

V 11

itrm

- i.

r '

;

..
-

One family.

Two families.

Three families

Four families.

Five families.

Six families.

Seven families

Eight families

Ten families.

Twelve familic

Thirteen faini 1

Fourteen fumi

Sixteen famili

Eighteen farai

Twenty famili

Colored Ilome

Bollevno IIocp

Small-pox IIos

Nursery (indCl

Ward'* Inland

\
oT

Total DralliH.

APPENDIX.

519

TABLE II.

Deaths certified as Puerperal Metritis, Puerperal Peritonitis, and
Puerperal Metro-peritonitis, from January 1 to May 15, 1873.

Mortality in Different Wards.

irst ward.

ifth ward.

xth ward.

3venth ward.

ighth ward.

inth ward.

enth ward.

leventh ward.

welfth ward.

iirteenth war

ifteenth ward.

xteenth ward

jventeenth wa

ighteenth war

ineteenth war

wentieth ware

wenty-flrst wo

iventy-second

utal Deaths.

Mortality in Different Classes of Dwellings and Public Institutions.

IN HOUSES OJ 1

-c

One family.

Two families.

Three families.

Four families.

Five families.

Seven families

Eight families.

Nine families.

Ten families.

Twelve familie

Thirteen famil

Fourteen famil

Sixteen familie

Eighteen famil

Twenty familie

Twenty -four fa

Park Hospital.

Nursery and C

Ward's Island

Bcllevue Hosp

Total Deaths.

520

APPENDIX.

TABLE III.

Total Deaths by the Various Forms of Puerperal Fever (includ-
ing Puerperal Fever, Puerperal Septiccemia, Puerperal Metritis,
Puerperal Peritonitis, and Puerperal Metro-peritonitis) as given
in Tables I. and IL, from January 1 to May 15, 18T3.

Mortality in Different Wards.

First ward.

Fourth ward.

Fifth ward.

Sixth ward.

Seventh ward.

*o
t.
a

Ninth ward.

Tenth ward.

Eleventh ward.

Twelfth ward.

Thirteenth ward.

Fifteenth ward.

Sixteenth ward.

Seventeenth ward.

Eighteenth ward.

Nineteenth ward.

Twentieth ward.

Twenty-first ward.

Twenty second ward.

Total Deaths.

143

Mortality in Different Classes of Dwellings and Public Institutions.

IN HOUSES OF

ri.

One family.

Two families.

Three families

Four families.

Five families.

Six families.

Seven families

Eight families

Nine families.

Ten families.

Twelve familie

Thirteen famil

Fourteen fami

Sixteen familie

Eighteen famil

Twenty familif

Twenty-four fa

Bellevue Hosp

Colored Home

*
o

1
03

Nursery and C

Ward's Island

Park Hospital.

Hotels, Boardi

Total Deaths.

-7

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.

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

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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.

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.

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., ] *

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" Among the numerous records of Medicine and the collateral sciences pub-
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The attention of the profession is called to the fact that subscribers to the NEW
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The MOXTHLT enables us to utilize at least several years more of life than it
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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.,

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The character and scope of this series will be best indicated by a reference to the names and
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and negotiations are pending for contributions from other eminent scientific writers.

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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
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