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application, vol. liniment and tinct. capsicum ; also poultices made of strong vinegar and wheat bran : the latter was applied only to the hands and feet.

Second day.-Symptoms much the same, only the black crisp places on the arms and legs had enlarged considerably, and I observed a small one upon the ear, also one upon the nose. I now ordered

R Port Wine..........
Peruvian Bark.........

zii. Mix. Dose: two tablespoonfuls every four hours. Also, four grains of quinine three times per day, and one grain of opium at bedtime. The vinegar poultices were ordered to be applied to the escharred surfaces as well as hands and feet. This treatment was kept up for two days, when the toes and fingers filled out with some tumefaction to their extremities, with a return of sensibility, and a proper warmth and color. After two days' improvement, the patient was directed to leave off the vinegar poultices from the hands, otherwise the treatment was the same. In twenty-four hours the fingers had dried up again, but the feet and toes continued to improve, the vinegar applications not having been discontinued from them. To be reäpplied to the hands, otherwise the treatment the same. The black crisped surfaces remained about stationary: the largest one was between the elbow and shoulder of the left arm, almost entirely covering its anterior and interDal face. After two days the fingers filled out again, and regained sensibility. The vinegar evidently controlled the condition of the parts; for upon gradually diluting it, the vitality, warmth, and sensibility would diminish, and when the strongest vinegar was again used, it would return. This process was tried several times. The parts apparently having maintained a healthy condition for ten days, I left off the vinegar applications entirely, and in less than twenty-four hours the fingers seemed to have lost every particle of vitality. The feet and toes, however, did well. It must be borne in mind that from the first application of the vinegar it had not until now been left from the feet. I could not, from these facts, come to any other conclusion than that it had a decidedly controlling effect upon the vitality of the parts.

It is not my object here to enter upon a discussion of the rationale of its action, but simply to present the fact as a matter of observation. The vinegar evidently saved the toes and feet, suspended and limited the mortification in the fingers and hands, and stopped its spreading in the escharred spots : however, none of these spots recovered their vitality, but after several weeks, lines of demarcation were formed between the

healthy and dead structures and large escharred surfaces, involving in every case the whole thickness of the integument, and in some places extending almost to the bone. One slough came away from the left arm, extending from the elbow to the shoulder, and about two-thirds around the arm. The dressing, to facilitate sloughing and the granulation, was Unguentum picis liquidæ.

In the left hand, the line of demarcation was at the metacarpo-phalangeal articulations—in the right, at the last phalangeal articulations. When the line of demarcation was fully formed, I amputated all the fingers with part of the left hand, and a part of all the fingers of the right hand. The progress of the case occupied about three months. The patient has since enjoyed good health. The constitutional treatment was all the while sustaining.

The question naturally arises, What was the cause of this condition ? There is no doubt but gangrene may be either a local or a constitutional disease. When it is simply local, it results either from a stasis of the blood, as a termination of inflammation; or it may be the result of a failure in the supply of blood to any particular part, as in an ossified condition of the arteries, or from organized lymph blocking up the channel of an artery, etc. But we have stated that it may be constitutional from the beginning; then the gangrene is but a symptom of a special crasis of the blood. We might with propriety, therefore, class it with that order of pathological phenomena denominated idiopathic. The first pathological event in the disease is a special lesion of the blood, and the local gangrene occupies about the same relationship in point of time to it, that the eruption upon and inflammation of the integument in small-pox does to the peculiar blood crasis of this disease, being an essential event. Indeed, there may be necrosis or sepsis of the blood as a primary lesion, or of any other organized fluid of the animal economy. This may be complete or only partial. It may extend to all the organic constituents of the blood, or some that are most essential, and necessarily involve a fatal result; or it may extend only to some organic constituent not so essential to the continuance of life, and which may be resupplied to the blood by a proper course of treatment. Doubtless both of these conditions find frequent illustration in malignant zymotic fevers. It is impossible to say what was the exact primary pathological state of the patient whose case I have detailed. It is conclusive, however, that the conditions which I have mentioned as premising and determining simple local gangrene were not present in this case, for we find the disease getting expression upon the superior and inferior extremities, the nose and ear, at the same time. It was evidently due to

some special crasis of the blood, entailed upon it in all probability by a failure or wrong direction of the progressive or retrogressive metamorphoses, or possibly from the presence of some foreign element introduced from without.

The indication of treatment to be fulfilled is to build up the decaying fabric of the blood by supplying to it new material, and assist the digestion and assimilation of this by stimulants and tonics.




EARLY on the morning of the 12th of June, I was called to attend the lady of one of our citizens, who had during the night so frequently passed large clots of blood from the womb, that it filled her and attendants with alarm. It was yet two weeks to the expected time of her confinement, and as she was the mother of seven children, and nothing of the kind had ever occurred in any of her previous confinements, she was fearfully apprehensive of some sad result to this labor. The first clot had passed off without any promonition having been given of its accumulation; and it had been so often repeated, that she had lost altogether about a pint of blood. To my question, "Have you had any pains, Madam ?" she replied, “None that could be called such, only that whenever the clots are expelled, there is a slight twinge in the womb, but it gives me no uneasiness.” “ Did you do any thing yesterday, Madam, that could have produced a strain on the muscles of the bowels, or did you suffer any pressure on the bowels ?” Nothing at all that I can recollect, Sir, except lifting a basket of fruit and placing it on the shelf.” “Were you bowels moved during the day ?” “Yes, Sir, twice.” “ Was it a diarrhea ?” “No, Sir."

Proposing an examination, I found the os tincæ high up in the cavity of the pelvis, and dilated to a very slight degree. Assuring her that labor had not as yet begun, I ordered the application of folded napkins to the abdomen, thoroughly wet with very cold water, administered an opium pill of one grain, and enjoined rest in the recumbent position, light diet and cold drinks.

At ten A. M. called, and found the discharge still continuing every half hour, each clot averaging the size of a walnut. But examination revealed nothing more than in the morning. Continued cold cloths and rest.

At two P. M., sent for in haste; had just passed a large clot while attempting to rise in bed. Very dejected, and expresses her fears, through her tears, that she is to die this time.

On examination, the os tincæ was found dilated just sufficiently to admit the forefinger through it without any difficulty,when at once it came in contact with a surface rough and irregular, not smooth as the surface of the membranes. It also appeared to have a rawness about it, like torn flesh. Strengthened now in my belief that I had a case of placenta prævia to deal with, and assuring my patient as to the cause of the hemorrhage, and that she should compose herself and allay her fears, as I would interfere in time to prevent any serious loss of blood, I orderedó (#453 applications of cold ice-water to be constantly renewed, and that she should by no means raise her head from a level with the body. Finding no increase of discharge at the expiration of an hour, I withdrew.

At six P. M. called, and found that she had just begun to feel slight labor-pains, occurring at lengthened intervals. On examination, found the mouth of the womb still further dilated, through which the rough, raw, uterine surface of the placenta could be distinctly felt, and, passing the finger around as far as it was prudent to do so, I became convinced that it was a case of central placental presentation. At each contraction, large clots of blood would be thrown off, showing the increasing danger of the case. Calling for strips of soft old linen, I endeavored to introduce them as a tampon, but such was the rigidity of the external organs, and such pain was caused by them, that I was compelled to withdraw what had been introduced, and await the result.

A gradual dilatation took place in the womb, affording quite a convex surface to the presenting placenta ; but now the blood, instead of coagulating, and being expelled in clots, came forth in a stream, every time there was a pain.

Eight and a half P. M., a gush of blood came away, which caused the mother to believe the waters had been expelled. Believing that it was my duty now to interfere to save the life of the mother, as the discharge was very copious, and the pulse had begun to flag, I proceeded in this manner to effect my object :

At the time of a severe pain I pressed the finger firmly against the placenta, and gradually pushed, or rather worked it through the spongy mass till I had reached the membranous surface. The penetration of

this gave a free passage to the waters, and as the pain instantly subsided, I was enabled to ascertain the position and presentation of the child. This found to be the first occipital presentation, though the head was still high up in the womb. Grasping the abdomen firmly with the left hand, and making pressure upon it, I found the head descend at the return of a pain and begin to engage in the expanded mouth. But, to my great fear, the placenta was also pushed forward with it. The womb not seeming to act with as much energy as I desired it should, I administered a full dose of select powder of ergot, an article fresh and genuine, and upon which I could rely; a pain soon came on, but as it expelled the child, it continued to expel the placenta also, so that one half of it fully was now protruded into the vagina. This pain was however succeeded by another, so quickly and so energetically, that my fears were allayed, for I found that it was acting so gradually and forcibly upon the chil' 18 already to have passed it beyond the placenta, and, as it continutu without cessation, it steadily expelled the child, delivery taking place in one hour from the laceration of the placenta. The child was asphyxiated, and, as the cord was pulseless, it was detached; then by cold applications and friction, it in a short time gave signs of returning animation, and has done well.

The placenta was found lying loose in the vagina, and on being removed was found lacerated within half an inch of the insertion of the umbilical cord. The womb, by cold applications, contracted firmly, and both mother and child did as well afterward as they could have done under the most favorable circumstances.

I have been thus minute in detailing this case, for the sole reason of saying that I believe its success depended upon its being left alone after the presenting placenta was ruptured. I do not believe that either of the other modes recommended, either turning or removing the placenta first, would have been any more successful. I do not believe they would have been as much so. It rarely happens in cases of this character that both mother and child are saved, the one or the other almost always losing life. In the management of this case my first object was to introduce the tampon so as to facilitate labor, but in its introduction I failed. I did not use ergot earlier in the stage of the labor, because I did not wish to tear asunder the placenta from the uterine surface before it had presented so far in advance that when I should lacerate it, the child might pass through without any delay; consequently I withheld its administration until it was necessary to use it to expel the child, and then in such quantity, that when it began to act, it should continue to do so till it had accomplished the object for which I admin

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