NATIONAL LIBRARY OF MEDICINE NLfl D05AQ33M 0 ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 mmmmX ■raM X^^pg^Ba^'^S^y^^EjBtfaill ^^^^^^^^^^s^^ '^flBjSwlitLjCi Section... ___.....__ Number _^..^-T!\-.Tn_^5>____j__.__ Form 113c, W. D., S. G. O. ■po 3—10543 (Rev.sed Juno 13, 1G36) NLM005803340 ■ ♦ V * u '^c* % < _2^>[ T \ s V THE PUERPERAL DISEASES. CLINICAL LECTUKES DELIVERED AT BELLEYUE HOSPITAL. BY FORDYCE BARKER, M. D., f •. CLINICAL PBOFESBOE OF MIDWIFERY AND THE DISEASES OF WOMEN IN THE BELLEVCE HOSPITAL MEDICAL COLLEGE ; LATE OBSTETEIC PHYSICIAN TO BELLEVTE HOSPITAL; SUEGEON TO THE NEW YORK STATE WOMAN'S HOSPITAL; FELLOW OF THE NEW YOEK ACADEMY OF MEDICINE; FOBMEELY PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK J LATE PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY; HONO- ^ BABY FELLOW OF THE OBSTETRICAL SOCIETIES OF LONDON AND EDINBURGH; HONOEARY FELLOW OF THE ROYAL MEDICAL SOCIETY OF ATHENS, GREECE; CORRESPONDING FEL- LOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC., ETC., ETC. NEW YORK: D. APPLETON AND COMPANY, 1, 3, and 5 BOND STREET. 1883. B25£p 188:' Entered, according to Act of Congress, in the year 1874, By D. APPLETON AND COMPANY, In the Office of the Librarian of Congress, at Washington. PREFACE TO THE THIRD EDITION. A note from the publishers of this work informs me that only a few copies remain at their disposal, and that it is necessary to prepare a third edition for the press. The rapidity with which the former issues have been sold, eight months having hardly elapsed since the work first appeared, the flattering reception which has been universally accorded to it by the medical press, both here and in Europe, the fact that it has been republished by the Messrs. Churchill in London and that I have been solicited to permit translations in German, French, and Italian — soon to appear in Berlin, Paris, and Milan—are accepted by the author as evidence that a special work on the Puerperal Dis- eases was demanded by the profession. I have merely to add that this edition is essentially the same as the former issues, with such changes only as result from careful revision and correction. 85 Madison Avenue, New Yoek, October, 1874. PEEFACE. 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 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 he 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 Madison Avenue, New Yoek, January, 1874. CONTENTS. LECTURE I. PUEEPE4A1 OONVALESOENOE. 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 uteru3 ; 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 LECTURE II. DIET OF PUERPERAL 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 . . . p. 26 LECTURE III. LACERATIONS OF THE PERINEUM. 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 perinasum; 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 perinaeum" really means—The forcep3 as a means of pre- vention-rHow anaesthetics may act in preventing this accident—Incision, when necessary—Method proposed by Dr. Goodell, of Philadelphia . . p. 38 viii CONTENTS. LECTURE IV. THROMBUS 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 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 . . 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—No reason for classifying them as apoplectic, epileptic hysterical, etc.—Etiology of puerperal convulsions—Suggestions made in 1862 before the New Yoik 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 CONTENTS. ix 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..........Page 9*7 LECTURE 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. 127 LECTURE IX. MASTITIS AND 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............p. 140 LECTURE X. PUERPERAL MANIA. 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 LECTURE XL RELAXATION OF THE PELVIC SYMPHYSES. Case—Not much referred to by obstetric authors—Dr. Snelling's monograph—Im- portance of a knowledge of this subject to young practitioners—Recent Ger- man and French writers on the subject— Scanzoni—Debout—Stoltz—May be developed during pregnancy—A certain degree of relaxation physiological— z CONTENTS. 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 AND EMBOLISM. Case—Meamng 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; (b) sometimes increased force of pulsation above the thrombus ; (c) pain below the seat of the throm- bus ; ( ...........515 Index.............622 PUERPERAL DISEASES. LECTURE I PUERPERAL 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. Gentlemen : 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 postpar- tum inflammation, of 23uerperal 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 l 2 PUERPERAL DISEASES. gestation and parturition, have 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 lymph 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 which 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 1 PUERPERAL DISEASES. is, a grain of opium, or the equivalent of some of its preparations, as soon as the binder has been 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 patiejat, 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 sareful 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 necessary 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 j>assed 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 friend, 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-partum 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- mula} have been proposed for this purpose. My favorite prescription in these cases is ten grains of Tully's pow 8 PUERPERAL 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 emata. 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 TULLY'S POWDER. R. Pulv. g. camphor., ) Cretan pp., V aa 3j. Pulv. glycyrrh., ) Morphise 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: $. Chloroform, 1 j, lin. sapo. co., 3 vj. M. Wet a piece of flannel of double thickness, large enough to cover the whole uter- 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. The Lochia.—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 which 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: IJ. Acidi carbolici glacial., c i. Glycerin. z i Aquae purae, ? 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 hyj)ogastriurn, 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 L2 PUERPERAL DISEASES. accelerate this process by the use, for one or two days, of a prescription like the following: IjL Ext. ergot, fl. (Squibb's), Tine, nucis vomicae, I .. - ■ Tine, ferri chlorid., Tine, cinnamom. cort., M. S. A teaspoonful in a wine-glass of sugar and water, four times a day. If your patient be feeble, delicate, and anaemic, 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: IjL Quinise sulph., 3j. Ferri sulph., gr. xv. Ext. nucis vomicae, 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 PUERPERAL 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. L4 PUERPERAL DISEASES. L 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 unnecessary, 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. Ycu 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 praevia—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-weighed 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 history 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 clue 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 L8 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 very 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 clays. 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, 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 with success the third day after labor. I never allow the tampon to remain in the cervix more than six or eight hours. 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 have 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 half-ounce of olive-oil be slowly thrown into the rectum and retained there as long 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. In 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 clay 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, that 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 nice 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 othei 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 perinaeum. 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 : Vni. Premature sexual intercourse. IX. Malignant diseases of the cervix. X. Pelvic cellulitis. XL Obstinate constipation (?). XII. Functional disorders of the liver (?). XIII. Distended bladder. XIV. Sub-involution. LECTURE II. DIET OF PUERPERAL WOMEN. The puerperal period does not require an abstemious diet—Good, nutritioua, 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 WOMEN. 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, 28 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 such 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 wrorst agents that can be 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. IjL 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 : !r>,. Ext. sennae fid., Syr. zingib., aa 3 vj. Tine, jalap., § 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 HEMORRHOIDS. 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 32 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 emmenagogue 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- 3 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 : IjL 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 anaemic, 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: IJ. Ferri sulphat, 2)i. Pulv. aloes soc, ) Ext. opii aq., I 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: fy. Ung. galhe co., 1 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 irritatino; 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: $. Magnesiae sulph., Magnesias carb., 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. aa x ss. LECTURE III. LACERATIONS OF THE PERINJEUM. 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 perinaeum" 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. " 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 perinaeum 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 Oases reported by Chas. H. Suydam, M. D., house-physician to Belle- vue Hospital. LACERATIONS OF TnE PERINJEUM. 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 perinaeum, 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 perinaeum. 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 woman, 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 AO 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 perinaeum, 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 perinaeum 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 perinaeum 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 PERINAEUM. 41 any measure in preventing its occurrence. There is no doubt that the anterior border of the perinaeum, or four- chette, is generally lacerated in primipara. 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- parae, 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- naeum, 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 perinaeum 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 transversalis .perinei, all of which meet and have a common insertion at the centre of the peri- naeum. The length of the perinaeum 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 perinaeum £2 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 perinaeum, 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- tum. 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 perinaeuni 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 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 PERINAEUM. 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) 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 perinaeum 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 perinaeum in a line nearly parallel with the axis of the superior strait, (b.) The direction of the vulval open- ing differs very greatly in different women. I am not aware that any author has 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 perinaeum, 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. (c.) There is a great difference in women in the elasticity and dis- tensibility of the perinaeum, depending partly upon the amount of adipose tissue in its structure. Where this is very considerable, there is sure to be an unyielding perinaeum. ( dant flocculent black precipitate. Now, the urinary PUERPERAL ALBUMINURIA. 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 2 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 emulgent 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 hyperaemia of the kidneys, and develop albuminuria 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 TO 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 moraine 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, perspirino quite freely, she went directly to her room, undressed, PUERPERAL ALBUMINURIA. 71 and sat in her night-dress, with bare feet, for quite half an hour, by an open window. Her husband then came 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 went 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 had 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. IJ,. Potass, citrat., 3 j. Syr. simp., 3 j. Aq. purse, § vij. Tine, digitalis, f3 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 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 clay 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 day, there was hardly a trace of albumen. Lacta- tion was established, with considerable febrile disturb- ance, as she had small, retracted nipples, Avhile the breasts were excessively swollen and painful. On the fourth and fifth days after delivery, albumen was very abundant, nearly as much so as at the time of hej PUERPERAL ALBUMINURIA. 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 pyaemic 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 oedema 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- bent 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 PUERPERAL ALBUMINURIA. 75 of albuminuria 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 suffered greatly from irritability of the stomach, per- sistent and intense headache, oedema, anaemia, and amaurosis, until the sixth month, when she expelled a putrid foetus. She died of phthisis eighteen month? 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 21th 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 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 phlegmasia?, and particularly susceptible to morbific influences of an endemic or epidemic charac- ter. Then, again, you must remember that the various PUERPERAL ALBUMINURIA. 77 puerperal diseases frequently develop albuminuria, when it had 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 albuminuria, 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 cedema- 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 clays." Her labor passed off without convulsions, which immunity Dr. Fourgeaud attributes to the prophylactic treatment under 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 ALBUMINURIA. 79 discharge of the faeces, paralysis of the bladder with retention of the urine, amaurosis, the eyesight being almost entirely gone." On the 2 2d of November, the doctor reports that the oedema 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 hyperaemic 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 albuminuria 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 hydraemia, 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 albuminuria. 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 find 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. 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—CEdema—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. " Case VII.1—Bridget D----, Irish, primipara. Admitted into Bellevue Hospital two months ago, near the seventh month of preg- nanc}'; 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 R. A. Vance, M. D., house-physician to Bellevue Hospital. 84 PUERPERAL DISEASES. in about ten minutes. At 7 p. m., 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. M., 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 deliver}'; 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 kidnej'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 face 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 tnev 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 Bright'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 which 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 1869, 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-partum 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. m., when I first saw her, she had had eight very 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 clays 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 clanger, 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 that 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 joregnant, 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 foetus, 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; PUERPERAL 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 eilected, 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- ccd 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 CONY [TLSIONS. 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 urine, we find that it contains but a moderate quan- tity of albumen, and is free from casts or blood, or other foreign elements which 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 clay following delivery, the oedema 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 signs of albuminuria are known 94 PUERPERAL 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 cedematous 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 ' 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 using the words " Oh, 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. LECTURE VII PUEEPEEAL 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—No reason for classifying them as apoplectic, epileptic, hysterical, etc.—Etiology of puerperal convulsions—Suggestions made in 18G2 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- rue Hospital. 1 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 l£ p. 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. M., 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. m.—Patient passed nearly a quart of water, which, on 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 6th.—Patient has had no convulsion since she was bled, passes water freely, which still contains albumen abundantly. Continue the medicine. To have beef-tea and milk, all she wishes. " January 10th.—Patient has steadily convalesced without a sin- gle unpleasant symptom. Says she is perfectly well. Urine still contains some albumen. " January 15th.—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: PUERPERAL 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, (b.) 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. ( w Db. BAEKEK, Obstetric Physician. W. H. JOHNSTON, House-Phygician. 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 high thermometric range, averaging from 99° to 100° 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 Avill 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 milk 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 postpartum 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. TREATMENT OF MILK-FEVER. 133 Perhaps you will find the 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 : ]J. 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 has 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 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 effective 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- SORE 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 vasnie 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 mine, 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 my 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: P*. Plumbi nitrat., grs. x.-xx. Glycerin., ?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 excoriation, 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 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 benzoin 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 necessary 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 the 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, reel, 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: Aq. rosae, 1 iij ss Liq. plumbi diacet. dil., 1 ss. Ext. opii aq., 3> M. Ft. lotio. 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. rosae, Glycerin., aa § ij. Acidi tannic, 3 ij. M. Ft. lotio. 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- 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 I£. Ung. aq. rosae, § j. Magnesias carb., 3ij. Hydrarg. chlor. mit., 3 j. M. You should direct the apothecary to rub it up very thor- oughly, or it will be lump}'. 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: Liq. plumbi, 3jss. Pulv. calaminae prsep., 3jss. Glycerin., 3j. Adeps, ad. |j. M. " 3. 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 AND 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 pyajmia, 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. 141 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, Sii A.stley 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 what 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. 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 T 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 govern 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. 145 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 subglanclular 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 slough is described as being as large as a hen's-egg. But this is not all; the destructive ulcerative process may involve the blood-vessels of the part where the ab- 10 146 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 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 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. 147 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 distention, irregular chills and partial per- L48 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, L50 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 subodandular ab- scesses, and is by no means a universal result of glan MASTITIS AND MAMMARY ABSCESS. 15] 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 Bamsbotham relates L52 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- demic1 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 iborted, 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, what 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 forrn 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- L54 PUERPERAL DISEASES. sequent labors. If my patients have a great horror 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 MAMMARY 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 results, 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 tegumentary covering, and they may, for this reason, cause the pus to come to uhe 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 tenotomy-knife, and these cases have been rapidly cured. But if the abscess point on the anterior surface, then the opening must be made where L56 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 MAMMARY 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 L58 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 plastei 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, having 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 have, however, met with a few cases, where nursing produced such intense agony as to compel the poor sufferer 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. PUERPERAL MANIA. 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. " 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 11th.—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 '.he report. 11 162 PUERPERAL DISEASES. "October 13th.—7 A. m., pulse 112, respiration 28, temperature 99°. Patient answers questions in an excited way; stares vvildly, 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 lUh.—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, quinias 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: P*. Ext. belladonnas, § j, glycerine, 3 ij. M. At eleven o'clock, to have chloral-lrydrat. grs. xxx. " October 15th.—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. 163 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. " JVbv. 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. " JSTov. 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. uJVbv. 12.—9 A. m., respiration 32, pulse 104, temperature 105°. 12 m., ' " 32, " 108, " 105°. 3 p.m., " 30, " 108, " 104.7°. 9 p.m., " 30, " 132, " 104°. No pain or tenderness in abdomen. Occasional pain in back, run- ning down the legs. " JVbv. 13.—a. M., respiration 32, pulse 112, temperature 105°. 7 p.m., " 32, " 100, " 101°. 1 Reported by John A. McOreery, A. AT., M. D., house-physician to Bellevue Hospital. I64t 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°. p.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. "JVov. 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. " JVov. 16.—a. M., respiration 30, pulse 96, temperature 101.3°. p.m., " 30, " 104, " 103.5°. Nervous and excited, no pain, bowels moved, tongue cleaner. " JVbv. 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 ot 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. " JVov. 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. "JVov. 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. M.—rOrdered tinct. aconiti rad., gtts. ij, every second hour. PUERPERAL MANIA. 165 " Nov. 20.—A. m., respiration 30, pulse 72, temperature 99°. 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- parae, 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 816. Johnston 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 Boyal Edinburgh Asy- lum ;" of these, 155 were so-called puerperal cases, mat PUERPERAL MANIA. 167 mg 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 : a 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." L68 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 posed 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 leg or the other, but could not balance her- 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 serum 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 suffices to precip- itate the whole train of symptoms suddenly and at once. I am convinced 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 disj)lacement 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 hen. 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, as 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 RELAXATION 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 foetus 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." 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. 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, 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 Avas 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 SYMPHYSES. 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, com 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 the 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 which 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 sequelae 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 jDoint 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 mons 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 216 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. 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. Gentlemen : I purpose 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 Reported 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 oedematous. 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 §" 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 DOLENS. 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 "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 §xj, 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 leg itself was oedematous." 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 DOLENS. 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, although 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 occurs. 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 (raced 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 tern 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 DOLENS. 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. Sequin'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 prodromic 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- come 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 224 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 DOLENS. 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 service, the history of which 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 ulceration. 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< 15 226 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. Pathology.—I shall not occupy your time with a dis- cussion of the opinions of the past as to the nature of this affection. I shall only say that the belief of the earliest writers on this affection was, that it was due tc 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 hilar 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 is due to inflammation of all of the tissues. The first great step made in advancing the know! 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 DOLENS. 22? instances, he had 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 true theory of the disease by some of our most able and recent writers. A few years later, in 1829, Dr. Bobert 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 leg. She was cachectic, and, not 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 hyperinosis 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, *?, wo?, fibrine, 7n)£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 DOLENS. 229 culation 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 long 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, Jacquemier, of France, Casper, of Leipsic, Kiwisch, of Wurtzburg, 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 PHLEGMASIA DOLENS. 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 duiing 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 phlegmasia 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. Pier 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. amnion. 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 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 : IJ. Sodae sulphitis, 3 ij. Syrup, simp., | iij. Aquae, | j. M. S. A tablespoonful every four hours. Also a half-ounce of whiskey every hour. Morphine as before. Reported by W. J. Chandler, M. D., house-pbysician 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 Ath.—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 verj- 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 9th.—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 19th.—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, this patient had no phlegmasia dolens during any period of her disease. Neither was there phleg- masia dolens in the following case, the history of which is also given by Dr. Chandler. The patient has now quite recovered: " Case XVI.—Winifred Sears, aged twenty-eight; single; 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 oedematous. 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 2d.—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 Mh.—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 waa 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 3r 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 flu'd, 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." 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 which 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 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 DOLENS. 23^ 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 oedema 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. Phlegmasia 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 DOLENS. 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. 10 242 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 extravagant zeal of an 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 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- peresthesia 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 : P*. 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 clay, and I am not certain that this ex- pression exaggerates the danger. Not one patient in fifty 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 DOLENS. 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 suggestion 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 pyae- mia will be more appropriately discussed in another lecture. LECTUBE XIII. PUERPERAL THROMBOSIS AND 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 ; (b) 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 : (a) more frequently (?) i due to an embolus ; (b) 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. rjolism—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 Reported by Walter Judscm, M. D., house-physician to Bellevue Hospital. 24S 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 off. 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 8th.—Was called to see the patient at 5 A. M., eleven hours after the labor, on account of very violent hemorrhage. The bed was 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 LJp. 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 wTard, 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, Avater § 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°. " December10th.—Pulse 112; respiration 28; temperature 101°. "December 11th.—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 l&th.—Pulse 96; respiration 24; temperature 99.5°. "December 15th.—Pulse 84; respiration 24; temperature 99°. " December lQth.—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 22d.—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- tal, 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: IJ. 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 thigb of eight drops of the solution of morphia. " December 23d.—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, amnion., aa § j. M. S. A teaspoonful in syrup and water every third hour. 250 PUERPERAL DISEASES. " December 2Wi.—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, wTith precisely the same result as yesterday. She was persuaded to remain in the hospital until her month was up. " December 30th.—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 over each kidney, and the following prescription: IJ. Potas. citrat., § j. Aq. pura?, | vij. Syr. simp., § 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 PUERPERAL 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. u 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, MorgagnA, Gould, Burserius, Brown, Cullen, Huxham, 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 PUERPERAL 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 efifioXo? 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 emboli, 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 the 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. Robert 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 PUERPERAL THROMBOSIS AND EMBOLISM. 057 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 17 258 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 toxaemic 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 exj)erience 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 ansesthetic, 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 seemed 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 saw 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. 261 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 had phlegmasia dolens of the same leg after the birth of her third child. Thrombosis and Embolism of the Pulmonary Ar- teries and of the Might 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 Virchow belongs the honor of having established 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 very 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 262 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 perijxheral 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' exj)erience 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, andj 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. On 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 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 albuminuria 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 forcej)S 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 Avas 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 Cheeseman. 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 very 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: (<2.) An embolus from a clot in a peripheral vein. (£.) Spontaneous, arising from the same condition of the blood (hyperinosis and inopexia) as causes throm bosis in the veins. PUERPERAL THROMBOSIS AND EMBOLISM. 265 (c.) Such 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 Thrombosis and Embolism of the 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 266 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 very 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 than 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, PUERPERAL THROMBOSIS 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. The 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 phlegmasia 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 are 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 lobulai 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. " Drain.—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 AND 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 first 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 oedematous 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, has 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 her 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 THROMBOSIS AND EMBOLISM. 273 " May Ath.—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 r,'th.—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 11th.—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 time of delivery to May 17th, Avhen 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 thah 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 no doubt as to the correctness of the diagnosis of Dr. Walker, and that the right middle 18 £74 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 oedema 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 AND 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 anaemic. 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, This 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 1st.—Patient appears to be growing weaker. Has lost no blood since admission. Spirits languid, and expression dull. Skin amemic, 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 rales. " Pleart—a loud mitral regurgitant murmur, transmitted to the left, over the posterior surface of the left chest and along the spine. " She was ordered quinise sulphat. gr. v., three times a day, and vini ferri et cibi cum cinchona, § 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 fossa?. Same physical signs in the chest remain. Treatment continued. " October 8th.—Patient has been getting out of bed for several days to go to the water-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 verv 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 1044;°. Ordered brandy, 3 ij every half-hour. 5 p. M., respiration 32, pulse 96, temperature 1024/\ " October 9th, 9 a. m.—Pulse 110, soft and compressible; respi- ration 36 ; some tracheal rdles y 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 101f°. Slept nearly all da}\ Is conscious, but stupid; a little wandering delirium. Answers rationally. " October 10th.—Paralysis the same. She is very dull and drowsy. Involuntary evacuation of urine and fseces. Pulse 108, very feeble; respiration 38; temperature 102^°. Stimulants continued (egg- nog). 5 P. M., respiration 32, pulse 110, temperature 102|-°. " October 11th.—Respiration 24, pulse 116, temperature 1034/. 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. m., respiration 32, pulse 112, temperature 102|°. " October 12th.—Respiration 40, pulse 120, temperature 103f °. She appears a little brighter. 5 P. M., respiration 34, pulse 116, temperature 103f °. " 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 l&th.—Respiration 28, pulse 120, temperature 1034/\ 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 rdles are heard in front of the chest. 5 P. m., respiration 30, pulse 138, temperature 104|°. " 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 101|°. 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 110, temperature 102^°. Sordes on gums; dry tongue; muttering delirium. Slept none. Breathing labored. 5 P. M., 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 20ih.—4.30 a. m. patient died." Autopsy, by Professor Janew^ay, October 20th: " Exterior.—Small bed-sores on the nates. " Drain.—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 oedematous. 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 white 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, which I have quoted from Sir James 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 symp PUERPERAL THROMBOSIS AND EMBOLISM. 270 toms. Niemeyer 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 wre find them, and exclude it with certainty if they are absent." 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. LECTUKE 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 Germany, 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, 1871, 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- ternally 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, Bellevue 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 2en 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 region, 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. 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- 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 secondary 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- rhoea 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- nitis ; but it is not always so, for I have seen excessive tympanites in cases of moderate intensity. A more frequent respiration, as I have already remarked, is a necessary result of the abdominal tym- panites, and this, therefore, you must remember as one of the characteristic symptoms of puerperal peritonitis. You will find your patient breathing from twenty-four to forty or fifty times a minute. You will observe that there is always a comparative, although not a defi- nite and fixed relation, between the respiration, pulse, and temperature. The more frequent the respiration, the more rapid the pulse and the higher the temperature. When an exception occurs, it generally can be easily ex- plained by some peculiar phenomenon in the case; as, for example, latent pleurisy, which is not a rare com- plication, may cause the respiration to be as frequent as fifty or sixty a minute, while the pulse is not above 112-120, and the temperature 102°-103°. Headache, although not very severe, is generally complained of at the time of the chill or soon after, but this usually disappears after a day or two. A moderate degree of delirium in the later periods of general peritonitis is manifested in a majority of cases. Prostration of the vital forces and of the muscular powers supervenes at an early period. The patient lies in a fixed position, apparently indisposed to make the least effort of the will or to move. There is extreme lassitude, with a corresponding intellectual feebleness. 22 338 PUERPERAL DISEASES. The voice is weak and tremulous, and the articulation is often indistinct. Morally, there is an apparent tor- por and indifference to every thing going on, but nurses and friends in attendance often greatly err in supposing that there is real apathy. I have sometimes thought that this appearance masked increased vividness of sen- sibility, for I have seen slight moral disturbances, in connection with the nurse, the child, or other members of the family, cause great agitation, resulting in a quick- ening of the pulse, a rise of temperature, a renewal of abdominal pain, and an increase of the tympanites. During the time of the chill and the period of severe pain which follows, the countenance, as I have before remarked, is very expressive of pain and suffer- ing. After this time, the eyes become sunken and sur- rounded by a dark areola, the nose pinched, the cheeks hollow, and often with a crimson hue, while the general color is darker. Writers have described the counte- nance as losing all expression, or as dull and stupid; but to my eye the expression which patients generally wear in the advanced stages of general puerperal peri- tonitis is rather that of absent, dreamy reverie. The lochia furnish no indication by which we can judge of the severity of the disease. They are some- times diminished or suppressed, while, in other cases, they continue without any marked modification through the whole period of the disease. They frequently are very much diminished duiing 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, PUERPERAL 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 was 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 has 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 ot 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 j)ain, 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 and 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 uot 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. 34:4 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. 3j) every hour. If the effect sought for be not manifested after two or three doses, increase, by two or three drops, every third dose, until the desired impression be made. If the drops be rejected by vomiting, administer the morphia hypodermically. 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 340 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 hypodermically, 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 Watson, 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 VideRamsbotham's "System of Obstetrics," edited by Keating, Phil- adelphia, 1865, page 538. 2 Vide report of the case at the end of this lecture, PUERPERAL 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 veratrum 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 PUERPERAL 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: (a.) They renew the nervous forces, which generally are in a state of ex- treme prostration, probably, by the cerebral hyperaemia 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. (&.) 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- 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, (d.) In the rapid pulse of exhaustion, which we find attending the hectic fever and purulent cachexiae 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 PUERPERAL 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 : 1>. Glycerin., Acid, carbol. glacial., aa | j. Aq. purse, § 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 PUERPERAL 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 PUERPERAL PERITONITIS. 353 disease, I ought, perhaps, to add a few words in 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 on 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- 23 354 PUERPERAL DISEASES. cient to make a stain. At 10 a. m., January 11th, 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 effort 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. 356 Morphia? sulph., grs. xvj. A tropin., gr. j. Aquae, Ij. At 6 a. m., 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 following 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 following 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. 10, to 12 M. April 11, 995 by the mouth, 47 hypod. 11, cc ' 12, 1,070 ' 30 k 12, 1( ' 13, 1,340 ' 120 « 13, " " 14, 940 170 u 14, 11 ' 15, 550 ' 90 it 15, i( < 16, 450 160 k 16, (( ' IT, 2,010 60 u l?i K ' 18, 1,980 ' ' none « 18, " ' 19, 2,490 < a n 19, 11 ' 20, 980 < « « 20, 1( ' 21, 320 drops of McMunn'j i 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 oy the father of the patient, a physician, who devoted his time exclusively to the care of his daughter, from the time she was seen ly Professor Barker until her convalescence. She was generally visited three times a day oy Dr. PinTcney. "3 cf © u OX TIME. QQ ' 2 "3 o 29 ° .J3 £ M Ph B M Hours. Gtts. Gtts. Gtts. Professor Barker, with Dr. Pink- Wed'y, Apl. 10. ney. Enormous tympanitic distention of abdomen. Pain 2.15 p. m...... Iss 130 104| 34 severe; respiration wholly tho- 2.45 " ___ 12 racic. To have milk or beef- 3.10 " ___ 4.00 " ___ 15 6 §ss tea ad libitum. Brandy, a half-ounce every hour. 4.20 " ___ 6 §ss 5.00 " ___ 45 5.30 " ___ 6 = ss Between 5 and 7 p. m., slept 6.10 " ___ 55 6.30 " ___ 6 §ss 7.00 " 60 7.30 " .... 6 §ss 8.00 " ___ 20 8.30 " ___ 6 9.00 " ___ 70 10.15 " ___ 90 6 §ss 160 20 Very feeble, and restless. 11.20 " ___ 60 6 Iss 11.40 " ___ Sweating. 12.00 " ___ 90 § ss 140 Thurs., Apl. 11. 6 1.15 A. M..... 25 6 1 ss No sleep. 2.10 " ___ 30 6 §ss 3.15 " ___ 20 6 §ss 4.00 " ___ 80 6 20 5.00 " ___ 80 ?ss 8.00 " ___ 90 3 ss 108 30 Slept some, between 8 and 10. 9.00 " ___ 90 Iss 10.30 " .... 50 Great pain in urinating, and se- 11.30 " ___ 60 § ss 34 vere burning and constant pain in region of the bladder. 1.10 P. M...... 30 ij Injection of starch and carbolic 1.40 " ___ 40 §ss 108 102 28 acid, by direction of Professor 2.45 " ___ 40 Barker. 3.30 " ___ 90 8 5j 140 103i 4.45 " ___ 90 8 §ss 136 103} 6.05 " ___ 60 6 5j 134 7.15 " .... 80 6 §ss 136 104 8.15 " ___ 80 6 128 1031 9.40 " ___ 80 li 104£ 10.50 " ___ 6 104i 11.15 " ___ 80 Ij « The respiration became slower. Friday, Apl. 12. Constant nausea. 1.30 A. M...... 80 Ij 120 104i 16 Pulse feeble and thread-like. Im - 2.15 " ___ 6 pulse of heart very weak. 30 Professor Barker substituted digi- 2.45 " talis in place of veratrum vi- 3.45 " ... 80 Sj ride. 358 PUERPERAL DISEASES. Recoed of Case—(Continued). TIME. Hours. Friday, Apl. 12. 5.50 a. m. .. 8.45 " .. 9.45 " . . 10.45 " .. 11.15 " .. 12.45 P. m... 1.45 " .. 2.45 " .. 4.00 " .. 4.20 " .. 5.20 " .. 6.15 " .. 8.05 " .. 9.40 " .. 10.40 " .. 11.45 " .. Satur'y, Apl. 13. 1.10 A. M.., 2.10 " .. o p. a o sa 2.45 k 3.15 " 3.45 it 4.30 u 4.40 11 5.05 !< 5.50 1( 6.30 U 8.00 U 9.30 (( 11.00 (( 12.00 M. ... 1.40 1.55 u 2.40 « 4.35 it 5.00 (C 7.20 (i 10.00 (< 10.40 (( 12.00 « Sunday, Apl. 14 1.00 \. M..... 230 " Gtts. 80 80 80 70 70 70 70 70 80 80 80 80 90 li Gtts. 30 20 30 30 30 30 Gtts. 10 ij §88 §ss Verat. viride. 10 Brandy. §ss Iss H li li li li I ss li 96 132 128 154 148 140 128 120 128 128 128 120 i 120 120 1021 101 101} lOlf lOlf 102} 102f 103^ 104 103f 103^ 103£ 103 103 103 103i 102i 102 102| 102} 24 32 24 24 30 REMAEK& Appears much better. Has slept considerably. Vaginal injection as before. Nurse obliged to leave her, by which she was much excited. Constant and severe pain. Vaginal injection. Pain much relieved, but no sleep since one o'clock yesterday af- ternoon. No sleep. Vaginal injection. At 9.30 an involuntary and un- conscious discharge from the bowels. Intense pain. No sleep. General appearance very much worse. Evident]? failing. PUERPERAL PERITONITIS. 359 Record of Case—{Continued). TIME. fli I-a 14. Hours. Sunday, Apl. 3.00 a. 4.25 " 5.20 " 6.20 " 7.50 " 8.50 " 9.30 " 10.00 " 11.20 " 1.45 p. 3.15 " 4.05 " 4.15 " 4.25 " 6.00 " 7.10 " 8.00 '< 9.10 " . . 10.00 " . . 11.00 " .. 12.00 " . . Monday, Apl. 15. 1.00 a. M. 2.00 " 3.00 " 3.30 " 5.15 " 6.00 " 7.00 " 8.00 " 8.30 " 10.30 " 11.00 " 12.00 m. 1.00 p. M. 2.00 " 3.00 " 5.00 " 8.15 " 10.30 " 12.00 " Tuesday, A 2.00 A. M 3.40 " Gtts. 80 90 90 90 90 90 90 90 90 80 80 80 80 80 90 80 80 90 90 90 90 90 90 90 Gtts. 30 30 20 50 pi. 16 grs. x Digitalis 10 Hydrat. chloral. 10 grs 10 grs 10 grs 10 grs 10 grs 10 grs 15 grs 15 grs 15 grs 15 grs SJ §ss li 3 J li §ss li li 3J J S3 Ph | "5 u a a; H . i a o 1 "3. M 126 103 101 108 102J 108 101 120 102 102.] 28 120 103 1021 112 102} 101} 102 128 101} 27 128 101} 28 128 102} 28 128 128 101} 102} 28 28 120 101} 27 REMARKS. A very large and extremely offen- sive passage from the bowels, without pain, followed by col- lapse, and very cold extremi- ties. Blister, 5x5, over hypogastrium, Removed blister, and applied poultice. No sleep; refuses brandy. Quinine, gr3. x. A very large passage from the bowels, without pain. Vaginal injection. A large passage. Quinine, grs. xv. No pain after this hypodermic in- jection. Begins to get short and frequent naps. Complains of severe pain under left breast, after taking any thing in the stomach. 360 PUERPERAL DISEASES. Record of Case—{Continued). 7a TIME. Hours. Tuesday, Apl. 16 5.00 A. M.. 6.00 7.15 8.15 8.30 9.20 9.50 11.20 11.30 12.15 1.00 1.45 2.45 3.30 4.45 6.00 7.00 8.00 9.00 10.00 11.00 12.00 Wed'y, Apl. 1.00 A. M. 1.30 2.00 3.10 3.45 4.15 4.45 6.00 6.45 7.30 8.30 9.30 10.30 11.50 12.30 1.25 2.00 3.00 3.30 4.00 5.00 .00 i.00 17. P. M.. Gtts. 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 120 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 p Magnesise sulph., / Sulphur, sublim., Vaa|ss. Potass, bitart., j M. S. From a teaspoonful to tablespoonful of the powder, in sugai and water, early in the morning. PELAGIC PERITONITIS AND 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----, aged 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 j^ears 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 Avas 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 sAvelling Avas noticed in the left groin, Avhich 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 Avere applied, and on the next day the opening began to freely discharge pus, and continued io do so for tAvelve 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 Aveak and anaemic, and extremely emaciated. There was a large, hard, red, and tender swelling, Avith irregular but Avell-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 Avas ordered to be painted with iodine twice a day, immediately after Avhich 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 Avith 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 SAvelling is noAV less than one-third of its former size, is not so hard, nor is it Aery 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 lAth.—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 poAvder, with five grains of calomel, to be taken at bedtime. PELVIC PERITONITIS AND PELVIC CELLULITIS. 377 " August 16th.—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 signs of each of these affections, and how are wre to 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 wThat 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, Ave 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 he 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 unjust, however, to omit to say that the differential diagnosis of Bernutz refers esj^ecially 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 hypogastrium, 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 efforl 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 dejDres- 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 very 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 culs-dc-sac filled up and harder than usual, and some- times all the vaginal culs-de-sac 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 Ave 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 Ave 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 tAvo diseases in the puerperal period are the folloAving: (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, Avhile 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 t\vo 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, AA'hile 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 AND PELVIC CELLULITIS. 381 consultation Avith others. In very many of them, there was no eA^idence 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 Aveakness, accompanied by certain symptoms referable to the pelvic organs, as a dragging Aveight 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 Ave 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 Avithin the pelvic cavity, as felt by" vaginal exploration, are very 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, Avhen the SAvelling 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 toAvard the evening, and several Aveeks elapse before the patient recovers. Day by day, the SAvelling and tenderness in the hypogastrium subside, the uterus dis- appears behind the pubes, and by vaginal exploration it is found that the hardness and SAvelling 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. MattheAvs Duncan, in his Avork 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 sj>ecial 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 Avhen abortions have occurred, for Avhich I could assign no other cause than the fixation of the uterus, Avhich 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 nevei free from a dull sense of suffering in the vicinity of the uterus, Avhich becomes positive pain from certain move- ments of the body, from defecation, and especially dur- ing menstruation, Avhen the normal hyperemia of the PEL 710 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 Ioav grade of chronic inflammation, and I knoAV of no pathological law AArhy the Avails of the non-gravid uterus should not be the seat of the same morbid pro- cess, and no philological law Avhy we should not call this condition chronic metritis AArith adhesions. Some of these cases get Avell after the climacteric period has passed, but others do not, as my friend Professor Charles A. Budd and myself ha\Te had occasion to knoAV 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 haA'e knoAvn the uterus to be fixed and immovable at one period in a very considerable number of women, and haA^e 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. Two Aveeks after, from imprudence, she had a severe attack of pelvic peritonitis, which in a feAV 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 feAV moments, or to Avalk 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 Avere very anxious to have children, and tAVO years after her last abortion I was requested to examine her for the sole purpose of ascertaining whether I could find any cause Avhy 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, y^asses into the suppurative stage, it is impossible to foretell hoAV or when it will terminate. Authors seem to be agreed in stating that suppuration is a frequent termi- nation of pelvic peritonitis and cellulitis, Avhen occurring during the puerperal period, but, in my experience, this is very rare, except Avhen they are associated Avith py- aemia or puerperal fever. It is with some diffidence 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. In a feAV cases, these diseases do not seem to be influenced by treatment. After two or three Aveeks1 illness, the patient begins to have hectic fever, with slight irregular chills; there is entire 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 x\ran 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 Avith any authority on this point. But Hervieux, whose oppor- tunities must have been Arery large, expresses the same vieiv so strongly as to make the mode of exit of pus a means of diagnosis between cellular abscess and peri- toneal abscess. He asserts that, in cellulitis, the pus 25 386 PUERPERAL DISEASES. has a tendency to burrow between the pelvic organs and find exit in fistulous canals, sometimes in the vicinity of the rectum, sometimes folloAving 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, Avhere the peritoneal abscess tends to open, 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 Avhere 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 PERITONITIS AND PELVIC CELLULITIS. 387 a catheter, and draAving 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 tAvice a clay. As regards the use of laxatives, I am aware that some authors have recommended that, in the early stages of acute cases, the boAvels should be kept constipated. I have tried this method in contrast Avith the plan of keeping the bowels soluble, and I am thoroughly convinced that it is a great error to alloAV the faeces 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 poAvder 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 AArater at night. The patient should be kept en- tirely free from pain by the use of opiates. The 1 Pulv. glycyrrhizEe comp. of-the Prussian pharmacopoeia: R. Senna-leaves, Licorice-root, powdered, aa ^ iij. Fennel-seeds, Sulphur, aa 5 Jss- Refined sugar, % ix. M. An agreeable and efficient laxative. 388 PUERPERAL DISEASES. amount required for this purpose is generally very moderate, as compared Avith 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 afterward 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-Avool, 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 haATe, 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 Avater as hot as can be comfortably tolerated. These may be 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, betAveen her hips and her clothing, not only to prevent the latter from getting wet, but also to con PELVIC PERITONITIS AND PELVIC CELLULITIS. 389 duct the Avater, as it flows back from the vagina, doAvn to a vessel which is placed on the floor. Then, by the use of a Davidson's syringe, tAVO or three gallons or more of the hot Avater 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 feAV inches above the patient, and the Avater is al- loAved to run in and out of the vagina. Not only do patients generally derive great comfort from this wrarm 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, So soon as the least fluctuation can be detected in any part of the pelvic cavity, it should be aspirated. My experience leads me to the conclusion that this is a perfectly safe procedure, that it gives immediate re- lief to pain, that it shortens the duration of the disease, and that it is a prophylactic measure against disorgan- ization of adjacent tissues. LECTURE XVIII. PUERPERAL 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, 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 septicemia and pyae- mia, made by many eminent men in Germany. Septicaemia—Tendency, at the present day, to exaggerate the frequency of septicae- mia, by asserting it to be the sole cause of puerperal fever, the various puer- peral phlegmasiae, and even milk-fever—Septicaemia not always traumatic in its origin—Illustrative cases—Symptoms of septicaemia—Pathological anat- omy—Treatment—Reasons why it cannot be treated by elimination—Great im- portance of preventing the renewal and continuance of the infection—Keep the patient alive^-Alcohol, quinine, food—Chlorate of potash—Tincture of the chloride of iron. Pyaemia—Cases—Contrast of the symptoms in the case of septicaemia with the case of pyaemia—Capillary embolism discussed in connection with pyaemia—Pyaemia without traumatism—Puerperal pyaemia not a very frequent disease—Diagno- sis—Prognosis—Treatment. " Case XXXI.1—Margaret S----, born in German}*, aged twen- ty-four, married, fourth pregnancy, was brought into the hospital, February 11th, while in labor. The head had just entered the cav- 1 Reported by Richard 0. Van Wyck, M. D., house-physician to Belle- vue Hospital. PUERPERAL SEPTICEMIA AND PYAEMIA. 391 ity. I/. 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 12th.—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 128 ; 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 Itth, 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, § 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 haj 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 rdles over the entire chest. Urine has several times been ex- amined for albumen with negative results. 2 p. h.—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°. 1 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 16th, 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 nitration, degeneration and disorganization of paren- chymatous organs, softening and mortification, stupor, PUERPERAL SEPTICAEMIA AND PYiEMIA. 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 j)hilosophi- 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's Journal de physiolocjie, the first in 1822, under the title "Memoire physiologique sur les maladies purulentes et putrides, etc.;" the second in 1824, " Second memoire 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. PUERPERAL SEPTICAEMIA ANO 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 that then it causes different grave inflammations, as pneumonia, carditis, dysentery, 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 every 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.) 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 pathologists, 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 AND PYiEMIA. 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 regarded 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, Robert 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 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- ring 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 adoj)ted 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 PYAEMIA. 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 leucocythaemia, which is characterized by phenomena entirely different from those belonging to pyaemia, 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 belongino; to 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 septicaemic blood, and thus we have been furnished with another element of distinc- tion between septicaemia and pyaemia. 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 septicaemia, 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 Pecord, 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, Grunewaldt, and D'Espine, PUERPERAL SEPTICAEMIA AND PYAEMIA. 401 have 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 of 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 tincae, 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 26 £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 sloughing or gangrene. Hence we see that this dis- 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 everything 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 PYAEMTA. 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 less than an hour after the membranes had ruptured, with very slight manifestations of labor, she 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 very 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- able to keep any thing on the stomach. The pulse was 120 and very feeble, and the temperature, 104.5°. On auscultation, neither the bruit de soujfe 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 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 which 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 traumatism is a necessary 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 lVide 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. ±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 AND PYAEMIA. 407 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 metritis. 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- nounced, 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 108 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 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 PUERPERAL SEPTICAEMIA AND PYAEMIA. 409 jections (and probably the 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, 110 PUERPERAL DISEASES. in the evening. I have 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 veratrum viride. The tendency of septicaemia is to dyscrasia, not to inflammation. Veratrum 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 drug, 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, moderating excessive action, the heart appears to contract more vig- orously, 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 PYAEMIA. 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 H2 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.2—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, but 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 extremelj unhappy and despondent on account of her seduction. She only permitted her friends to know where she was, on the day before her death. s Reported by R. C. Van Wyck, M. D., house-physician to Bellevue Hospital. PUERPERAL SEPTICAEMIA AND PYAEMIA. "Feb. 3.—10 A. m., respiration 21, pulse 72, temperature 98c 4 a 5 a 6 a 7 n 8 a 9 a (t 2 P. M., a 8 P. M., 2-5 " 70, K 99°. 22, " 84, li 100°. 20, " 84, U 100°. 20, " 96, a 99.5°. 18, " 84, u 99°. 20, " 84, a 102°. 20, " 116, u 104.5°. 22, " 112, u 102°. morning visit. Complains of no pain, but appears very restless. " Feb. 10.—10 A. m., respiration 22, pu]se 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°. " 5 p.m. " 24, " 116, " 103.5°. " Had a slight chill to-day, followed by profuse perspiration. Savs 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.° 3 p.m., " 24, " 112, " 103.° " 8 p.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 deaJ 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. 114 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. Pales 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. Pales 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 AND PYAEMIA. 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 of 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 symp- 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 PUERPERAL SEPTICEMIA AND PYEMIA. 417 of Dance until the discoveries of modern patholoo-ists 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 pyaemia is not simply a diseased condition due to excess of pus-corpuscles. The phenomena of this affec- tion are eminently of a toxaemic 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 pyaemia. 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 pyaemia is manifested by symptoms of severe toxaemia. Capillary embolism no doubt often consti- 27 418 PUERPERAL DISEASES. tutes 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 SEPTICEMIA AND PYEMIA. 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 tincae 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 toxaemia. Hence, I think that the significance and importance of trau- 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 comes up, whether the symptoms and sierns of this affection be so clear and well-deter- mined, as to enable us to make the diagnosis of its ex- 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 120 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 104°, 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 septicaemia 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 extrem PUERPERAL SEPTICEMIA AND PYEMIA. 40! 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 rdles 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 R. 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 pyaemia. 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 pyaemia turns very much on the PUERPERAL SEPTICEMIA AND PYEMIA. 423 question as to what diseases precede or are associated with it. It greatly adds to the danger of the various pelvic phlegmasiae. 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 even 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 11th. 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 124 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 pyaemia developed during the course of a puerperal fever. The complication of pyaemia with septicaemia, or septicaemic pyaemia, 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 1860. 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 pyaemia 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 pyaemic 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 pyaemia; 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 SEPTICEMIA AND PYEMIA. 425 dial agents in the constitutional treatment of pyaemia. In expressing my conviction that quinine is nearly as valuable and efiicient 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 pyaemic 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 pyaemic 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 was all given very reluctantly 426 PUERPERAL DISEASES. by a teetotal mother. I may here remark, parentheti- cally, that this lady, since her recovery, has 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. Pyaemia 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 pyaemia 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 inrportant 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 rdles or broncho-vesicular respiration be heard, I should recommend dry cupping between the shoulders, and PUERPERAL SEPTICEMIA AND PYEMIA. 427 subsequently I have 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 effusion 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, I 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 over 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 428 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 : fy. Tine, ferri chloridi, § ss. Aq. purte, 1 iijss. Potass, chlorat., § ss. Syr. aurant. cort., Glycerin, puri, aa § 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. LECTURE XIX. PUERPERAL 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 septicemia—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 septictemia —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. Gentlemen : During my 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 have 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 bth, 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 8th, 11 a. m.—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 9th.—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. Van 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 10th, a. m.—Respiration 18, pulse 90, temperature 100.7°. 12 m.—Respiration 30, pulse 105, temperature 102°. 10 p. m.—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 11th, A. ir.—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. :xr.—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 m.— Respiration 18, pulse 114, temperature 103.7°. She has had a natural fecal stool. No abdominal tenderness. Tongue dry and covered to the tip with a brown coat. 6 P. 3r.—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 13th, 4 A. m— Respiration 30, pulse 120,temperature 103°. 9 A. M.—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 Delafeld, twenty-two hours after death.—Brain not examined. Pleura normal. 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 PUERPERAL DISEASES. uterine tissue. Fallopian tubes deeply congested. Ovaries 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 unhappy, and she was very much depressed after her labor. On the next day, the respiration was 36, 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 4: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 intelligent!}-. 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. Ge. 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., house- 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 13th (second day), a.m.—Respiration 18, pulse 80, temperature 99°. p. m.—Respiration 35, pulse 105, temperature 102°. In the evening, she was in 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 lUh.—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 15th.—Respiration 24, pulse 100, temperature 104.6°. Nervous and wild. Quinine and morphine. Vaginal injections with carbolic acid. " January 16th, 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 hydrat. 3j, potass, bromid. grs. xxv, every second hour until she sleeps. " January 17lh, a.m.—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 18th, 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. ivr.—Respi- ration 24, pulse 108, temperature 100°. Face still flushed, but the 1 Condensed from a report by George A. Van Wagenen, M. D., house- physician, and M. H. Forrest, M. D., senior assistant physician, to Bellevue Hospital. 28 ±34 PUERPERAL DISEASES. eruptive congestion has subsided. Rational, and says that she ia very comfortable. " January 19th, A. m.—Respiration 30, pulse 108, temperature 101.6°. Has slept well. P. M.—Respiration 28, pulse 126, temper- ature 103°. Rational, and feels well. " January 20th, A. m.—Respiration 26, pulse 118, temperature 103°. Slept well last night, p. m.—Respiration 20, pulse 114, temperature 103°. The bowels, which before have been regular, were quite loose to-day. Perfectly rational. " January 21st, 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 22d, 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. S. 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 perinaeum was slightly torn, and two sutures were applied. " February 3d, a. m.—Pulse 80, temperature 100°. No pain. Milk appearing. " February 4th, a. m.—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. PUERPERAL FEVER. 435 Thirst Ordered solution of morphia (U. S. P.), 3 ij, and tine, aconit. (Flemings's) npij, 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. tti. 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, § ss, on account of severity of pain. " February 9th, 3 a. m.—Sol. morph. (U. S. P.), § 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 10th, 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 11th, 1.45 A. M. "Autopsy, by Dr. Francis Delafeld.—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." 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 136 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: Eespiration 24, pulse 75, temperature 100°. January 10th, respiration 18, pulse 102, temper- ature 101.5°. January 11th, 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. W----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 vto 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 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 have 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 138 PUERPERAL DISEASES. doses of morphine. The abdomen usually became some what tympanitic 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 down 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 very 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 know! 1 See Appendix. 140 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. Gr. 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 cities, 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. PUERPERAL 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, 142 PUERPERAL DISEASES. Dr. John 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 lymph angeitis, and of purulent infection, and, finally, the more comprehensive school, which included in its theory of puerperal fever all the puerperal inflamma- PUERPERAL FEVER. 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 con- nected with 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 plegmasiae 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, lymphangeitis, 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 pyaemia, " The patient died, not from the endometri- tis, but from the py semia."' 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 Kew Yorh Journal of Medicine, 1857, vol. ii., third series, p. 370, et seq. 144 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 theory that the disease is primarily a local in flammation has also been most ably sustained by M Mattei and Professor Pajot, and by Dr. Berne, of Lyons, in an essay published in 1866. 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 septicaemia or to pyaemia. 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 Raciborski, who regarded puerperal fever as a traumatic fever, which originated in tine uterine veins and terminated as a suppurative uterine phlebitis. Hervez de Chegoin, Piorry, Bouillaud, and many others whom I might mention, were also advocates of the doc- 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 ecchymoses 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 thing as milk-fever, but what is called so is 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 traumatism 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 the 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 belonging to the infected organism itself, auto-infec- 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 main- 29 150 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 rise 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 haemorrhage. 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 belonging to the 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. Every 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, W. S. Playfair, Wynn Williams, Leishman, 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 0. Boyd, of Monroe, Orange County, N. 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. 152 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 autogenetic 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- PUERPERAL FEVER. 453 tained or probable cause, which he 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 clay 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 strono- supporters of the traumatic and septicaemic theories of the causes of this disease. I must also give you two theories which demand notice, from the character and position of the piersons who advocate them, but which do not express the opin- ion of a sufficient number of the profession to represent a class. 454 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 coming 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 dipk PUERPERAL FEVER. 455 theritic deposit has been found, but he asserts that, not only have 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 Hervieux: 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. PUERPERAL 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 my 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 45S 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 peritonaeum, 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 1 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 clays' illness, is a triumphant demonstration that the fatal 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- 160 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 which 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, having no adhesion to the surface on 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 162 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. 463 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 sej)ticaemia-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 septicaemia 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 septicaemia : 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 his 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 every 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 caup\ht 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 30 466 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 autogenetic 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 septicaemic 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 168 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 septicaemia 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. 469 fering from puerperal fever, who are surrounded 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 170 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 in 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 secondary 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. 472 PUERPERAL DISEASES. As a rule, I have 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 twro 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, for 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. R. 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 metro-phlebitis, or metro- peritonitis. The accepted doctrine of the present clay 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 uraemia. 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 functions are also more or less disturbed. The ajypetite 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. Now. 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 small-pox, may develop PUERPERAL FEVER. 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 FEVER. 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 pyaemia. 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 debut 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 nevei 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 FEVER. 481 The respiration is always hurried in this disease, the inspirations being from 24 to 50 or 60 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 clelir- 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 hosjntal 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. 31 482 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 this 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 them as exceptional, I have seen this function developed or restored after convalescence. There has recently appeared a very interesting essay by Dr. Eugene Quinquaud, 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 there 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 the 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. 484 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 Hopital Lariboisiere, 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 hypogastrium 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 a meas- 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 tym- 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 186 PUERPERAL DISEASES. and fetid, we have 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 antecedently 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 FEVER. 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. Septicaemia, as a secondary affection in puerperal fever, is usually a result of enclometric 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- like pulse, are such a combination of phenomena as leave no doubt as to the nature of the infection. Pyaemia 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 488 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 fioudroyant, 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 recovery 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 secondary 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, 190 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 ain 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 which 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 agent 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 ovei again, I have seen the mistake made of stopping the 494 PUERPERAL DISEASES. veratrum viride too early; and thus the disease has been allowed, as it were, to renew itself. I have found that this medicine is less apt to produce nausea if it be given with syrup or a few drops of the tincture of gin- ger in a little sugar and water. There is a notable dif- 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 is 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 own 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 ot 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, w7ho 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 then begin again with a minimum 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. Recoed of Case. TIME. Pulse. Eesp. Drops. REMAKES. February 28. 2.00 p. m...... 140 24 10 3.00 " ____ 12V 22 10 5.00 " ---- 140 22 10 6.00 " ---- 132 12 10 7.00 " ---- 120 20 10 8.00 " ---- 80 20 9 Bowels moved once. 9.00 " ---- 75 16 Vomited a greenish-colored fluid. Bow-els loose. 10.00 " ---- 66 16 4 Vomiting ceased. Bowels moved once. 11.00 " ____ 65 22 7 12.00 " ____ 58 13 2 March 1. 1.00 A. M..... 64 52 6 Eespiration very irregular. Inclined to sleep. 2.00 " ____ 58 25 2 Sleeping. 3.00 " ____ 59 21 Hiccough and headache. 4.00 " ____ 60 18 i Hiccough still continues. 5.00 " ____ 66 20 Severe headache. Vomited a greenish-colored fluid. 6.00 " ___ 66 21 Headache severe, and very restless. Vom-ited several times within the last hour. Hiccough. 7.00 " ____ 58 20 Vomited once since last visit. Vertigo and headache. 8.00 " ____ 52 28 . , Sleeping. 9.00 " ____ 60 19 10.00 " ____ 68 21 i Slight hiccough. 11.00 " 70 23 2 12.00 M..... 80 28 3 Tenderness over abdomen marked. Tym-panites somewhat diminished. Lo-chia dark, bloody, and very offen-sive. 1.00 P. M...... 80 20 4 Visit of Professor Barker. 2.00 " ____ 92 24 8 3.00 " ____ 16 24 8 Face flushed. 4.00 " ____ 76 28 9 Sleeping. 5.00 " ____ 68 28 8 Sleeping. 6.00 " ____ 66 28 8 7.00 " 68 26 6 Slight hiccough. Bowels moved once. 8.00 " ____ 66 18 Vomited a greenish-colored fluid. 9.00 " ____ 68 24 Vomited once since last visit. 10.00 " ____ 60 28 Sleeping. 11.00 " ___ 64 28 Still sleeping. 12.00 " .... 66 28 2 Still sleeping. March 2. 1.00 A. M...... 56 32 2.00 " ____ 70 24 3 Complains of pain in left thigh. There ia 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. 499 Record of Case—(Continued). TIME. Pulse. Reap. Drops. REMARKS. March 2. 3.00 A. M..... 76 24 4 No mammary secretion. 4.00 " ___ 65 20 3 Sleeping. 5.00 " ___ 78 22 8 6.00 " ___ 68 22 4 8.00 " ___ 64 24 4 9.00 " ... 72 24 6 10.00 " ___ 64 28 2 Bowels moved once. 11.00 " ___ 72 28 6 12.00 M..... 70 24 5 1.00 P. M..... 64 24 3 2.00 " ___ 60 20 3.00 " ___ 64 24 6.00 " .. . 68 28 3 7.00 " ___ 72 28 5 9.00 " ___ 80 28 6 Face flushed. 10.00 " ___ 80 26 6 11.00 " ___ 80 28 8 12.00 " ___ 80 28 10 Sleeping. March 3. 1.00 A. M , . 80 29 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 " ___ 78 28 10 Slight hiccough. 3.00 " ___ 80 28 8 4.00 " ___ 72 20 4 5.00 " ___ 68 28 Vomited a greenish-colored fluid. 6.00 " ___ 64 24 Headache. Hiccough. Bowels moved twice. 8.00 " ___ 60 24 9.00 " ___ 68 24 5 10.00 " ... 70 24 3 12.00 m..... 72 28 6 1.00 P. M..... 80 28 6 2.00 " ___ 80 22 8 3.00 " ___ 76 30 4 4.00 " ___ 76 26 5 Sleeping. 5.00 " ___ 72 32 4 7.00 " ___ 64 32 2 8.00 " ___ 72 28 5 9.00 " ___ 68 30 4 10.00 " ___ 68 28 3 11.00 " ___ 72 28 5 12.00 " ___ 70 30 7 Sleeping. March 4. 1.00 A. M .... 72 32 8 Tenderness over abdomen not so in- 2.00 " ___ 70 30 .. • tense. Slight tympanites. Vaginal 3!oO " .... 64 28 2 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. Reoobd of Case— (Continued). TIME. Pulse. Resp. Drops. REMARKS. March 4. 4.00 A. M..... 64 28 3 5.00 " ___ 60 24 2 6.00 " ___ 60 28 2 7.00 " .... 60 28 2 Bowels moved twice. 8.00 " .... 58 28 9.00 " --- 60 28 10.00 " ___ 56 28 2 11.00 " ___ 64 32 3 12.00 M..... 72 24 4 1.00 P. M..... 78 32 6 2.00 " ____ 80 28 8 3.00 " ____ 80 24 8 4.00 " ___ 80 30 8 5.00 " 80 28 8 Sleeping. 6.00 " ___ 60 32 ,. 7.00 " 64 24 6 8.00 " ____ 60 24 2 9.00 " ____ 60 28 2 10.00 " ___ 60 24 2 11.00 " ___ 60 26 12.00 " ____ 58 24 March 5. 1.00 A. M___ 60 22 3 She now says she feels much better. Her countenance looks much brighter, and she appears to be improved in every respect. The tenderness which has been so intense over the abdomen, now is scarcely noticeable. Tympanites very slight. Lochia very scanty, but normal. No mammary secretion. The swelling and tenderness on the in-ternal surface of the thigh, in the course of the veins and lymphatics, have now disappeared altogether. 2.00 " 68 26 4 Sleeping. 3.00 " ____ 60 22 2 4.00 " .. ,, 5.00 " ___ ., .. 6.00 " ____ 70 30 *6 7.00 " 64 24 4 8.00 " ___ 76 24 6 9.00 " 76 24 6 10.00 " ____ 72 28 6 11.00 " ____ 64 24 3 12.00 M..... 68 24 6 1.00 P. M..... 64 28 5 2.00 " ____ ., . # 3.00 " ___ 56 28 4.00 " ____ ,, • • 5.00 " ____ 64 24 5 6.00 " ___ % a 7.00 " ... . , , , 8.00 " ____ 68 26 4 9.00 " ... .. PUERPERAL FEVER. 501 Recoed of Case—(Continued). TIME. Pulse. Resp. Drops. REMARKS. March 5. 10.00 p. m..... 72 24 4 March 6. 8.00 A. M..... 70 24 6 Feels well. Improvement marked. No tenderness on pressure over the abdo-men. No tympanites. Lochia still scanty, but normal. Slight mammary secretion. 11.00 " ___ 76 24 4 12.00 M..... .. 1.00 P. M..... 72 24 5.00 " ___ 78 28 *8 6.00 " ___ 7.00 " ___ 76 26 8.00 " ___ . . 9.00 " ___ 10.00 " ___ 72 24 4 March 7. 9.00 A. M..... 76 24 She says she feels well and hearty. No tenderness over the abdomen. No tympanites. Lochia healthy. No ten-derness or swelling in left femoral region. Appetite good. Bowela regu-lar. March 8. 10.00 A. M 76 24 Continues to improve very fast. From this time she continued to improve, and in a short time was discharged well. It is as necessary to know when not to use the ve- ratrum viride, as to know when to prescribe it. It should not be given in those cases in which rapid pros- tration is manifested by a feeble, thread-like, irregular pulse, profuse sweats, and cold extremities. (2.) It is also very important, in this disease, to al- lay pain, quiet nervous irritation, and secure sleep. Opiates therefore are strongly indicated to a sufficient extent to accomplish these ends. When the disease is of the peritoneal type, the tolerance of opiates is some- times quite remarkable, but still in a very much less degree than in those cases where peritonitis occurs as a primary disease. I generally use Magendie's solution of morphia (sulphate of morphia grs. xvj, water 5j), 502 PUERPERAL DISEASES. but, if the stomach be irritable, the morphia may be ad- ministered hypodermically. The patient should be care- fully watched while under the influence of morphia, and the respiration should not be allowed to become slower than 12 or 14 in the minute. The morphia should be continued as long as the least sensitiveness to pressure or tympanites of .the abdomen remains. Here also I have often seen the mistake made of giving up the morphia when it should have been continued two or three days longer. (3.) The next indication is to reduce the fever. The danger in any case of puerperal fever is measured pretty accurately by the thermometer, and no patient with this disease can be regarded as safe while it ranges above 100°. At the present day, we no longer make use of those agents called antiphlogistics, to reduce fever, but we rely upon another class, which have been termed antipyretics. Quinine, the mineral acids, cold sponging, alcohol, and appropriate nutrition, are prob- ably the most efficient antipyretics in puerperal fever. Quinine has been extolled by some as almost a specific in this disease, but I think that its real value lies in its effects as a means of allaying fever. This result is better attained by giving it in full doses, morning and evening, rather than in smaller doses, repeated several times a day. I generally find that, in this disease, from five to ten grains in the morning and from ten to fifteen in the evening are well borne, and rarely cause the cere- bral symptoms of cinchonism. The mineral acids are also very useful as antipyretics. I am more in the habit of giving the phosphoric acid than any other, from the belief that it decidedly allays nervous irrita- bility, and that it acts specifically as a nerve-tonic. A teaspoonful of the dilute phosphoric acid in a tumbler- PUERPERAL FEVER. 503 ful of water, with simple syrup or syrup of orange-peel, makes a very pleasant drink, which I allow patients to take ad libitum, and many take three or four tumbler- ful s in the twenty-four hours. Some patients are disin- clined to drink, and for them I have prescribed from ten to fifteen drops of dilute sulphuric acid in syrup and water, every two or three hours, with perhaps just as good results. Sponging with cold water and alco- hol is another most efficient and grateful antipyretic, which I always direct should be used at least twice a day. 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 part 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. Perhaj)s 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, who 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°. " May 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°. "May 6th.—I was summoned to see her at 1£ A. m. She was awakened from sleep by a severe chill at 1L| 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. M.—Complains of some pain and tenderness over the ute- rus for the first time. Pulse 120, perspiration 32, temperature 105°, Bkin dry. Magendie's solution and tine, verat. virid., gtts. 5 each. 506 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 6th, 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 7th, 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. m.— Asked for and drank a cup of tea. Pulse 92, respiration 13. 7 A. m. —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 verat. 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 P. m.—Pulse 80, temperature 101.5°. Abdomen softer and less swollen. Lochial discharge more free and more colored. 8 P. M.— 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. 3], Magendie's solution and verat. virid., p. r. n. 10.30 p. m. —Pulse 96, temperature 102°. Complains of some pain in the right 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 and 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. m.—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 p. 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. " May 9th, 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. m.—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. M.—No passage. Took two cups of farina and an ounce of brandy, Magendie's solution and verat. virid., each, gtts. 5. 8.30 P. M. —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 cupfuls of farina. Magendie's solution, gtts. 5. Some pain in bowels. Hot fomentations, with laudanum applied to the abdomen. 508 PUERPERAL DISEASES. "May 10th, 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. sr.—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 § 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, temrjer- 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 sheny. 12 p. m.—She has not slept. Severe pain in the abdomen. Ten drops of solution of morphia and atropine hypodermically. " May 11th, 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 r. 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 12th, 3 a. m.—She slept quietly since last note. Magendie's solution, gtts. 5. 9 a. m.—Pulse 92, temperature 101°. She feels PUERPERAL FEVER. 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 therajoeutic 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 PUERPERAL 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 oj>en 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 curf 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. 33 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 zvmotic 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 septicemia or pyaemia 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 1 have had an opportunity of interrogating on this subject, I feel warranted in saying that the disease seemed to attack, with equal severity, pri- miparse and multiparas, 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 my 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 516 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 universal!}* 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. Certainly, 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 part 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. Thua 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, 1 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 Holborn................. 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 Septicmmia in the City of New York, from January 1 to Maj-15, 1873. Mortality in Different Wards. T3 r~ -o <3 T3 U a .a V u u a C3 is a r3 u %■ Xi B o ■a <5 •a a o o 5 %■ .s ~ a ■p. o a o a o •— >■. t*> O u u a o To a a > "3 •5 0> o > o a s 1 a o fe pa 02 H A H W H t- ta 02 m w fc H E-i H H 2 1 1 1 2 1 3 4 l 1 2 8 6 9 7 7 G 62 Mortality in Different Classes of Dwellings and Public Institutions. 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. ■d >S ._: ■e ca is 13 U ej is a V HI 03 2 03 "3 e3 fcS 1 'd eS ss 02 ■a t. C3 IS X a a> 02 2 d ei SS J3 to s 1 ss 3 is j= a o> Eh 4 13 *■< 13 X B o > 0> 5 cs fS .a 0> 6 c3 fcs ,g a a> la Eh 1 c3 a o 4> s 2 6= ■g a o o a o > o 02 10 C3 s to 1 os fS X a 8 03 fcs £ o 0 0> f£ H 12 is > a V is H 8 T3 a o j>> a o> fcs Eh 13 .a e3 o; fi "3 o Eh 81 1 3 1 Mortality in Different Classes of Dwellings and Public Institutions. 1 IS HOUSES Off d 1 ft ca v A a ■S a a 6 s o £s 1 <2 eo o (H X a a o o 6 •2 o CD a «2 0) a a a > a X tc a ■2 a a a a a > is a a o .5 a 4) O M a <2 9 1> X to a) a <2 a a «3 a •2 a 4) s 5 'a, o ft ,M la O -a a S3 0) tn 3 w ■a a 03 l-l QQ 0) d w a > X C3 O (=1 O In H pa. PR 02 02 w 2 H H H N 02 W H H <± 'A n Eh 9 3 10 11 4 6 4 6 i 2 3 1 1 4 3 2 1 1 1 3 5 81 co One family. 3 w o g w o * Two families. Three families. CO Four families. o> Five families. to Sis families. • Seven families. 1—' tO Eight families. - Niiie families. *> Ten families. • Twelve families. to Thirteen families. - Fourteen families. «, Sixteen families. 0» Eighteen families. to Twenty families. - Twenty-four families. Nnrsery and Child's Hosp. w Ward's Island Hospital ~ Park Hospital. eo Hotels, Boarding-houses. >-• >*• CO Total Deaths. CO First ward. 1—' Fourth ward. (-J Fifth ward. eo Sixth ward. eo Seventh ward. to Eighth ward. CO Ninth ward. Ol Tenth ward. 00 Eleventh ward. o Twelfth ward. to Thirteenth ward. eo Fifteenth ward. >£» Sixteenth ward. i—■ 00 Seventeenth ward. -T Eighteenth ward. ~) Nineteenth ward. <» Twentieth ward. Twenty-first ward. I—" o Twenty-second ward. co Total Deaths. * ^"e h ,»3 3 a i a rS s^ © b s N H+5 >-3 iO U 8 s ^ 5-1 P 0 £ c ,** p '^s ^ ^ 3 ^ ^ «Q S bo o APPENDIX. 521 Table IV. Deaths certified as from Childbirth, Pupture of Uterus, Hemor- rhage, Placenta Prcevia, and Puerperal Convulsions, from January 1 to May 15, 1873. Mortality in Different Wards. d >d u a -d as X Ut 3 O V X -d u S3 •d si iS a p- 03 is "si -d C3 X a -d S3 is .g a o C3 is a V fe-ci 'd S3 P= .B "3 is V 3 ps X "S ~£ !a ■d 5 is X a 3 O -d si X a o CJ d S-i ci (S a o o S3 fcs a o 0) a > -d s* 03 (S a a > a CJ X 03 CJ ft o Pa Fa pa 02 02 W 'A fcH Pa H H Pa ia 02 02 N 2 H H H 1 1 5 8 2 1 5 3 2 6 11 11 6 2 4 V 4 5 1 2 1 8Y I1NTDEX, PAGE 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,.................... 1 ----• causes,.................... 1 ----diagnosis,................. 8 Albuminuria, puerperal, case of, ... 65 ----meaning of the term,........ 68 ----causes,.................... 69 ----symptoms,................. 73 ----influence on gestation,....... 15 ----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 Anaesthetics as a means of prevent- ing laceration of the perinajum,.. 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 Ball, Dr. Benjamin, on pulmonary embolism,..................252 PAGB 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 dolens,.... 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,..........512 Cazeaux, Dr. P., on thrombus of the vulva,....................... 60 Chandler, Dr. William J., report of two cases of suppurative phlebitis, 231 Cheeseman, Dr. T. Matlack, case of pulmonary embolism,..........263 Chloral-hydrate, use of, in 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 n PA0B 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. Thomas 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 foetus from albuminuria, 75 Delafield, Dr. Francis, " Haud-book of Post-mortem Examinations and of Morbid Anatomy,".......... 332 ----reports of autopsies in cases of puerperal fever,............431, 435 Delirium of labor,.............. 170 D'Espine, 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,....................... 179 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,................. 279 TAGE Emetics in the treatment of puerpe- ral fever,..................... 511 Endometritis,................... 309 Fever, definition of,..............475 Fox, Dr. Tilbury, on phlegmasia do- lens, ......................... 238 ----on eczema of the nipple,.....139 ----on puerperal fever,..........450 Franketihauser, Dr. F., on the nerves of the uterus,........... 110 Frerichs, Professor F. T, theory of the decomposition of urea,..... 106 Gaspard, Dr. B., 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 ulceration 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 Hewitt, Professor Graily, on the diet of puerperal women,........... 26 ----on support of the perinamm,.. 47 Hicks, Dr. J. Braxton, 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 of giving,..... 388 524 INDEX. PAGE Inopexia, derivation and meaning of, 228 Insanity of pregnancy,........... 168 ----of lactation,................ 171 Involution of the uterus,.......... 2 ----treatment of, when retarded,.. 11 Janeway, 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 G., 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. Evory, 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, Professor Edward, of Berlin, on puerperal fever,............. 454 Mastitis,........................ 140 McClintock, Dr. Alfred H., on sec- ondary hemorrhage,............ 24 ----extraordinary case of phlebitis, 287 ----case of septicaemia,..........405 McClintock and Hardy, on cramps in the legs taking the place of after-pains,.................... 9 ----on the use of castor-oil,...... 36 McCreery, Dr. John A., report of a case of puerperal mania,....... 163 ----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,............. 252 ----on phlebitis,................ 397 ----on puerperal fever,..........443 Mental depression in puerperal fe- ver, .........................491 Mercurials in puerperal fever,...... 512 Metcalfe, 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,..................... 129 ----considered by some, a mild sep- ticaemia, ......................401 Monneret, Professor M., on puerpe- ral fever,.....................450 Murchison, Dr. Charles, on pyaemia, 418 Necrobiosis, ...................402 Neuralgia, mammary,............ 160 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 PAGE Woyes, Dr. Henry D., on amaurosis in connection with puerperal con- vulsions,..................... 78 Nutrition in puerperal fever,........ 503 Opium in puerperal peritonitis,..... 344 ----in puerperal fever,........... 501 Otis, Dr. Fessenden iV., 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 phlegmasiae,...... 343 ----treatment,................. 344 Phlebitis,......................280 ----cases of,.......231, 280, 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 Pinkney, Dr. Howard, report of a complicated case of puerperal peri- tonitis, ....................... 355 Playfair, Professor W. S., on pul- monary thrombosis and embolism, 262 Premature labor, caused by albumi- nuria, ....................... 75 ----reasons for inducing, in albu- minuria,..................... 81 Puerperal fever,.................429 ----symptoms characterizing a re- cent epidemic,.................437 ----an eoidemic in New York, in spring of 1873,................ 439 ----theory of the localists,.......442 PAGS Puerperal fever, theory of the local- ists, objections to,.............457 ----theory of traumatism and sep- ticaemia,...................... 445 ----objections to, ..............464 ----theory that puerperal fever is an fessential fever,.............449 ----use of the term, as including the zymotic diseases, as well as the inflammations occurring in puerperal women,..............451 ----theory of Professor Martin,... 454 ----objections to,............ .. 472 ----theory of Hervieux,.........455 ----objections to,...............470 ----contagion of,...............461 ----general propositions in regard to,...........................476 ----symptoms,.................479 ----symptoms modified by epidem- ic influence,................... 484 ----duration,.................487 ----treatment,................. 492 Pulmonary thrombosis and embolism, 261 Purgatives in puerperal fever,...... 512 Putnam, Dr. Mary C, on septicae- mia and pyaemia,............... 400 Pyaemia,.......................411 ----cases of,...............411, 412 ----symptoms of, as contrasted with those of septicaemia,......415 ----nature of,.................416 ----results sometimes from morbid conditions of the blood without wounds or external suppuration,. 418 ----prognosis,.................422 ----treatment.................. 424 ----as a complication of puerperal fever,.....................487, 491 Quain, Dr. Richard, on castor-oil as a laxative,.................... 36 Quinine in puerperal peritonitis, ... 349 ----in pyaemia,................425 ----■ in puerperal fever,..........502 Quinquaud, 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 Sayre, Professor L. A., cases of thrombus of the vulva,......... 56 526 INDEX. Scanzoni von, Professor F. W., throm- bus of the vulva and vagina,.. .55, 60 ----on relaxation of the pelvic sym- physes....................... 195 Schroeder, Professor Karl, on puer- peral fever,...................448 Septicaemia, puerperal,........... 390 ----tendency to exaggerate its fre- quency,......................400 ----puerperal conditions favoring,. 401 ----caused by a dead foetus,.....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,......178, 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 Snelling, Dr. Frederick G., on relax- ation of the pelvic symphyses, .. 194 Spiegelberg, Professor Otto, on puer- peral fever,...................447 Sulphites in puerperal fever, ...... 512 Taylor, Professor L E, case of pul- monary embolism,.............262 Thomas, Professor T. Gaillard, 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 PAGB Trask, Dr. J. D., on the treatment of septicaemia,................ 299 Tuke, Dr. J. B., on puerperal insan- ity, ......................... 166 Urine, retention of,............... 4 Uterus, position and size after 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,. 35 Vance, Dr. R.A., report of a case of puerperal convulsions,......... 83 Van Wagencn, Dr. George A., re- ports of cases of puerperal fever, 430, 432, 433 Van Wyck, Dr. Richard C, report of a case of peritonitis,.........324 ----report of a case of septicaemia, 390 ----report of a case of pyaemia,.. 412 Venesection in peritonitis,........ 353 ----in puerperal fever,.......... 510 Veratrum viride as a sedative in phlebitis,.....................296 ----in peritonitis,..............347 ----not indicated in septicaemia,.. 410 ----in puerperal fever,..........493 ----illustrative case,............497 Virchow, 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 Westrott, Dr. Ar. 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 the. vulva,......... 56 THE END. u APPLETON & CO.'S MEDICAL PUBLICATIONS. Elliot's Obstetric Clinic. A Practical Contribution to the Study of Obstetrics and the Dis- eases of Women and Children. By George T. Elliot, Jr., A. M., M. D., Prof, of Obstetrics and the Diseases of Women and Children in the Bellevue Hospital Medical College, Physi cian to Bellevue Hospital and to the New York Lying-in Hos- pital, etc., etc. 8vo, pp. 458. . . Cloth, $4.50 This volume, by Dr. Elliot, is based upon a large experience, including fourteen years of service in the lying-in department of Bellevue Hospital of this city. The book has attracted marked attention, and has elicited from the medical press, both of this country and Europe, the most flattering commendations. It is justly be- lieved that the work is one of the most valuable contributions to obstetric literature that has appeared for many years, and, being eminently practical in its character, cannot fail to be of great service to obstetricians. " The volume by Dr. Elliot has scarcely less value, although in a different direction, than that of the Edinburgh physician (Dr. Duncan, Researches in Obstetrics). The materials com- prising it have been principally gathered through a service of fourteen years in theBellevue Hospital, New York, daring the whole of which time the author has been ensaged in clini- cal teaching. The case9 now collected into a handsome volume illustrate faithfully the anx- ieties and disappointments, as well as the fatigues and successes, which are inseparable from the responsible practice of obstetrics—a line of practice which, under difficulties, de- mands the greatest moral courage, the highest skill, and the power of acting promptly on a sudden emergency. Dr. Elliot's favorite subject appears to be operative midwifery; but the chapters on the relations of albuminuria to pregnancy, ante-partum haemorrhage, the in- duction of labor, and the dangers which arise from compression of the funis, are all deserving of careful perusal. The pleasure we feel at being able to speak so favorably of Dr. Elliot's volume is enhanced by the circumstance that he was a pupil at the Dublin Lying-in Hospital when Dr. Shekelton was master. We can certainly say that his teachings reflect great credit upon his Alma Mater."—London Lancet, April 11,1868. " This may be said to belong to a class of books ' after the practitioner's own heart.' In them he finds a wider range of cases than comes under his observation in ordinary practice; in them he learns the application of the most, recent improvements of his an; in them he finds the counterpart of cases which have caused him the deepest anxiety ; in them, too, he may find consolation, for the regret—the offspring of limited experience, which has always cast a shadow on the remembrance of some of his fatal cases—will pass away as he reads of similar ones in which far greater resources of every kind failed to avert a fatal termination. " There are not many books of this kind in our language: they can probably all be num- bered on the fingers of a single hand. * * * Many circumstances concur, therefore, to influ- ence us to extend to this work a cheerful welcome, and to commend it as fully as possible. 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 Science, April, 1808. "As the book now stands, it is invaluable for the practitioner of obstetrics, for he will hardly ever in practice find himself in a tight place, the counterpart of which he will not find in Dr. Elliot's book."—New York Medical Journal, February, 1863. " The book has the freshness of hospital practice throushont, in reference to diagnosis, pathology, therapeutical and operative proceedings. It will be found to possess a great amounts valuable information in the department of obstetrics, in an attractive and easy style, according to the most modern and improved views of the profession."— Cincinnati Lancet and Observer, April, 1868. " As a whole we know of no similar work which has issued from the American press, which can be compared with it. It ought to be in the hands of every practitioner of mid wifery in the country."—Boston Medical and Surgical Journal. "One of the most attractive as well as forcibly instructive works we have had the pleasure of reading. In conclusion, we recommend it as one having no equal in the English language, as regards clinical instruction in obstetrics."—Am. Jour, of Obstetrics, Aug., 1868. " Many ripe elderly practitioners might, but few young could, write a book so distin- guished by candor, want of prejudice, kindly feeling, soundness of judgment, and extent of erudition While we do not say the book is faultless, we say there is no book in American obstetrical literature that surpasses this one. * * * * .The work now under review is his first-born book or volume, and shows how fine opportunities he nas had, chiefly at Belle- vue Ho«pital for acquiring experience, and how diligently he has availed himself of them. But his book'shows much more. It is the work of a physician of higu education, a qualifi- cation m which jbstetric authors are often deficient—it shows qualities of mind and skil' of hand rarely attained by so young a man."—Edinburgh Medical Journal. Feb.. 18f.a. LECTURES ON Ortliopeflic Surgery anil Diseases of tlie Joints. Delivered at Bellevue Hospital Medical College during the Winter Session of 1874-75. By LEWIS A. SAYRE, M. D., Professor of Orthopedic Surgery, Fractures and Dislocations, and Clinical Surgery, in Bellevue Hospital Medical College; Surgeon to Bellevue Hospital; Consulting Surgeon to Charity Hospital; Consulting Surgeon to St. Elizabeth's Hos- pital; Consulting Surgeon to Northwestern Dispensary, etc., etc. Illustrated with 247 Engravings on Wood. 1 vol., 8vo, 476 pages. Cloth, $5.00; sheep, $6.00. " The name of the author is a sufficient guarantee of its excellence, as no man in America or elsewhere has devoted such unremitting attention for the past thirty years to this department of surgery, or given to the profession so many new truths and laws as applying to the pathology and treatment of deformities."— Western Lancet. " Dr. Sayre has stamped his individuality on every part of his hook. Possessed of a taste for mechanics, he has admirably utilized it in so modifying the inventions of others as to make them of far greater prac- tical value. The care, patience, and perseverance which he exhibits in fulfilling all the conditions necessary for success in the treatment of this troublesome class of cases, are worthy of all praise and imitation."— Detroit Review of Medicine. "Its teaching is sound and the originality throughout very pleasing; in a word, no man should attempt the treatment of deformities of joint affections without being familiar with the views contained in these lect- ures."— Canada Medical and Surgical Journal. A PRACTICAL MANUAL ON THE TEEATIEIT OF CLUB-FOOT. By LEWIS A. SAYRE, M. D., Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon to Belle- vue and Charity Hospitals, etc. Third Edition, Enlarged and Corrected. 1 vol., 12mo. Illustrated. Cloth, $1.25. "The object of this work is to convey, in as concise a manner as pos- sible, 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."—New YorTc Medi- cal Journal. New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. Medical and Hygienic Works PUBLISHED BT D. APPLETON & CO., i, 3, & 5 Bond St., New York. PRICE ANSTIE (FRANCIS E.) Neuralgia and Diseases which resemhle it. By Francis E. Anstie, 'M. D., F. R. C. P., Senior Assistant Physician to Westminster Hospital; Lecturer on Materia Medica in Westminster Hospital School; and Physician to the Belgrave Hospital for Chil- dren; editor of "The Practitioner" (London), etc. 12mo.. .Cloth, $2 50* BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for Travelers and the General Reader. 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