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means to an end, none which requires a sounder judgment or more incessant watching to combat every assault which exhausts vital power.

On a former occasion, I very briefly alluded to the principal indications in the treatment of this disease. I propose now to examine more in detail the agencies we have the control of in fulfilling these indications. The first indication is to eliminate from the system as much of the morbid poison as possible, by means of depletion and the other evacuants, as purgatives, emetics, diuretics, etc. I said that unfortunately this indication, owing to the peculiar character of this disease, can rarely be fulfilled, except to a limited degree. The effects of the poison are developed so rapidly, that the patient will not bear the use of such means, and it is the effects that we are obliged to combat. Within the past year, I have twice resorted to venesection in puerperal fever with most satisfactory results. Both patients were young and plethoric, and the toxæmic influence was strikingly evident in producing great cerebral disturbance. I bled for the same reason that I would bleed similar subjects in uremic convulsion. I would here incidentally suggest the inquiry, whether the type of disease is not again becoming more sthenic, or whether there has not been an epidemie tendency to cerebral congestion. Within the past twelve months, I have bled thirteen pregnant or parturient women—more in the aggregate than I have bled for the seven years before. I may also add that I believe I have had authentic accounts of the death of twenty-one from this cause in the same period of time. I will add nothing to my former remarks in regard to venesection in puerperal fever.

Purgatives I have rarely used in this disease, for I have regarded tympanites as a contra-indication for their use, and in many cases there has been a remarked tendency to diarrhoea, which sometimes has been difficult to control. In some few cases, where there was evident obstruction of the portal circulation, or there was reason to believe that there was intestinal irritation from previous constipation, I have given an active cathartic of calomel, rhubarb, and nux vomica. In a later stage of the disease also, when the patient has been supported by a liberal use of beeftea and alcoholic stimulants for some days, there sometimes comes a period when the digestive apparatus refuses to take up what is put in the stomach, a mercurial laxative has had a most happy effect in unloading the portal system, and relieving the congestion of the capillary circulation of the mucous membrane of the alimentary canal, and the patient at once is able to assimilate what is taken into the stomach.

Emetics were at one period regarded as a specific for puerperal fever, but now they are rarely used. In three cases, I have decided on their

The disease was ushered in by recurring chills, nausea, and bilious vomiting, with a marked icterode hue of the skin and conjunctiva. The agent selected was the Turpeth mineral in five-grain doses, which acts very promptly without producing prostration. But, on the contrary, in these cases they professed to feel less weakness after vomiting, and the symptoms which induced the selection of an emetic were at once relieved.

The second indication mentioned was to control the vital disturbances resulting from reaction. These are principally vascular excitement and nervous irritation. The value of veratrum viride in reducing vascular

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excitement has in this disease been confirmed by many observers in this city, and my own additional experience. It will most surely reduce the quickened pulse of inflammation and irritation. Its use is not incompatible with that of stimulants. Experience has abundantly demonstrated the truth of this apparent paradox. One patient who recovered took, every hour for two days, one ounce of brandy and three to ten drops of the tinc. veratrum viride, the quantity of the latter being determined by the frequency of the pulse, which was vever allowed to rise above 80 per minute, although it sometimes fell down to 40. In another case the veratrum viride did not seem to produce any effect on the pulse, which remained steadily above 130, until the condition of the patient was such that I decided to give brandy. After the first ounce was given, it fell to 108; after the second, to 86. Continuing the brandy, the veratrum viride was suspended for a few hours, and the pulse again rose to 130. After this it was curious to note the fact, that if either agent was suspended the pulse would rapidly increase in frequency, while under the combined in. fluence of the two it was kept below 80 per minute. I have little to add to what has already been said on the use of opium in puerperal fever. In all cases, it should be given to the extent of entirely subduing the pain. When the peritoneal lesion predominates, it is the principal agent on which we must rely, and the quantity in which it is to be administered is only to be determined by the effect which it produces.

Third, to combat the local secondary lesions which may be developed. This indication implies the use of a great variety of means, which will often tax the resources of the medical attendant to the utmost. I have already spoken of the value of opium in the peritoneal lesion. The tympanitis is often the most striking and distressing symptom, and I regret to say that I know of no treatment by which we can always be sure of relieving it. I rely, however, mostly on the use of turpentine, internally and endemically. In some cases I have seen good results from the use of the acetate of lead, and in others I have seen all means fail. In those cases where the secondary lesions are developed in the uterus, its veins, or its lymphatics, I have seen no advantage from leeching or blistering. The exposure of the abdomen to the air more than counterbalances the problematical advantages resulting from the former, while the latter only adds to the nervous irritation already existing. In these cases, the only local treatment I make use of is chlorinated vaginal injections repeated several times a day, and hot linseed meal poultices kept constantly applied over the hypogastrium.

Fourth, to sustain the vital powers of the system. I believe more patients die from the neglect of this point than from any other error of treatment in this disease. The patient is often sacrificed by a contest between the doctor and the disease, both contributing to exhaust the vital powers. In very many cases remedies are utterly powerless in combating the disease, and the province of the physician is to keep the patient alive until the disease is exhausted. This can only be done by proper putrition, and the prevention of waste, and the restoration of nerve-power by the use of alcoholic stimulants. I will not enlarge upon this point; but I still believe that when a patient with puerperal fever has lived for forty

eight hours, there is a constant encouragement for effort, and that the danger is in a certain sense diminished in proportion to the duration of the disease. I will only allude to two points of practice which seem to me of some importance. The first I have already mentioned the value of a mercurial laxative when the patient has been supported for some days by the liberal use of beef-tea and alcoholic stimulants, until the stomach loses the power of taking care of what is put into it, apparently from obstruction of the circulation and congestion of the capillary circulation of the mucous membrane of the alimentary canal.

There is another class of cases where the stomach seems to give out all at once from another cause, which I will not undertake to explain. Every thing is rejected in a few minutes after it is swallowed, with a painful feeling of burning and excoriation. Now, if the condition is not changed, the patient will soon die, as she can no longer be sustained. I have in several instances been able to persuade the stomach to resume its functions, by adding to each tablespoonful of beef-tea one drop of nitromuriatic acid, the proportion of the mixture being one part of the nitric and two of the hydrochloric acid. I will no longer ask the attention of the Academy, but will conclude with the expression of the hope that other members will give us the benefit of their clinical experience.

Dr. Gardner then made the following remarks :

Mr. President :-In common, I doubt with you and the members of the Academy generally, I have listened with great satisfaction to the Professors Smith, Clark, and Barker, in their full and lucid statements respecting the etiology, pathology, and therapeutics of puerperal fever. I have read, too, the full resumé of kindred debates upon this same subject at the meetings of our illustrious namesake, the Academy of Medicine at Paris; and I may, perhaps, be pardoned here, Mr. President, if I state that I have felt no little accession of national pride in instituting a comparison between these debates; for here the anatomical facts and the pathological deductions of Professor Clark, and also his heroic opium treatment, and the more novel treatment of Professor Barker with the veratrum viride, have at least added something to the sum of knowledge on these points, given us food for thought, and a stand-point (even if a little boggy and uncertain) from which to start for fresh investigations in a somewhat different direction from that which we have been following. The debates of the French Academy have been truly flat, stale, and unprofitable, without a new point made, unless I include the mention there of the opium and veratrum viride treatments.

Still, Mr. President, it seems to me that even when so much has been done, more might still be effected, and I venture to intrude my few remarks upon the attention of the Academy, not with the expectation of personally adding to the common fund, but in hopes, by drawing attention to another side of the question, to elicit new opinions, perhaps, upon old matters. We have heard but little said of the treatment of puerperal fever, except by new methods. Puerperal fever is no new disease : it dates far back in time, for we have monographs upon this subject dated as early as 1659, by Willis, Hake, and Berger. In 1746, puerperal fever prevailed in Paris, chiefly at Hotel Dieu, where scarcely any recovered from it, as might be supposed by any one who has ever seen the ill. ventilated wards of this renowned hospital. The post-mortem examinations there revealed large amounts of albuminous exudations in the peri. toneal cavity, appearing like coagulated milk on the surface of the intestines, with a copious effusion of whey or milk - like serum ; wherefore, effusion was viewed as a metastasis of milk, and hence it was for a time considered as milk-fever, although a closer attention would have shown that the milk is rarely entirely arrested.

But, as I was proceeding to remark, little has been said in this Academy respecting the treatment of this disease, except to suggest novel methods of treatment. It cannot be possible that there is nothing good in the prophylaxis and therapeutics in general use for the last two centuries ! The results may not have been what is desired, but certainly there must be something good in it all! For my part, I do not believe in the opium treatment or the veratrum viride treatment as treatments, while I am willing to accord to both of these powerful remedies a place in the list of medicaments appropriate to some of the ever-changing symptoms of this, in certain situations, very fatal disease. I see in opium a powerful narcotic, efficient in relieving the intense pain often present, and for this I would administer it till the pain is overcome, even if compelled to exceed the immense doses which Dr. Clark, as well as Dr. McNulty in his paper on opium lately read here, has proved the human constitution is able to safely withstand. I sec in both opium and veratrum viride an agent effectual in calming the vascular excitement, but not to cure the cause of this excitement, for this is still found to be present when the calming potion is removed. Veratrum viride I am ready to give experimentally, empirically, but not with any idea of its specific qualities, as a curative agent. They both act as palliative to inflammatory symptoms : they serve to remove the vis a tergo, to restrain the action of the heart from sending more blood to the already gorged and diseased tissues.

For specific remedies, I am compelled to stick to the old treatment, notwithstanding my dissatisfaction with it-my unwillingness to follow a course that will not save every patient. I am obliged to hold on to it until something better is offered for my adoption. Calomel is the only reliable sheet-anchor that I have found. It is the mercurial only that will defibrinate the blood when the inflammatory symptoms are the most serious. It is the mercurial alone that is powerful to eliminate the subtle materies morbi in those less fearful-looking but more dangerous forms of this disorder where the springs of life are destroyed by secret and hidden disease, traced by Dr. Clark to its lurking-places in the obscure ampullæ of the internal uterine sinuses. Theoretically, calomel is the remedy demanded: no medicine acts so efficaciously upon all inflammatory affections of all serous membranes, whether it be of the brain, the lungs, or the peritoneum: no medicine more surely destroys morbific poisons than the mercurial: no treatment is more potent to diminish the abnormal plastic elements of the blood, or to restore the hyperæmic tissues and organs to their proper, healthy condition. Still I do not con. sider that calomel is a positive agent. As in scarlatina, the invasion of

to the grave.

the disease is sometimes signalized by such terrific aggravation of every and all symptoms united, that before the system can be brought under the influence of any form of treatment, the patient is lost—so intense occasionally become the inflammatory symptoms, that the most vigorous treatment will not overcome them; for I have seen women after several days' sickness die, when profusely salivated—a fact denied by some, but which I have seen, though in but one instance that I can recall with distinctness.

The mercurial treatment, then, is in nowise to be neglected; com. bining, as may be necessary, opium, or the veratrum viride, to any desired extent, yet remembering that in so doing you are administering no curative agent; that the opium but imitates the treatment of the surgeon, who applies splints to a broken leg, producing quiescence and relieving pain : the puerperal poison is still there, and till that is eliminated, you have only made your patient comfortable, and perhaps but soothed her passage

But before any action can be expected from mercurials, there is time and occasion for other treatment. The disease sometimes is apparent before or during parturition. In the case of a woman whom I delivered by craniotomy, after several days' labor, there was no subsidence of the abdomen after the removal of the child, weighing 8} lbs., and the secundines, but it remained tumid, tympanitic, and the woman was finally enumerated as one of the unsuccessful of Dr. Clark's cases of treatment by opium; the woman dying of hæmorrhage on the sixth day after.

Topical depletion, when severe inflammatory symptoms are present, I have great faith in. Forty or sixty leeches upon the abdomen, with perhaps a repetition of half that number in from twelve to forty-eight hours, I have known beneficial, but I have no faith in general bleedings to any amount, or in the application of ten or twenty leeches. If any benefit is to be derived from them, they must be sufficiently numerous, if not to overwhelm the disease, at least to markedly affect it.

I attach more importance to turpentine than to any remedy after calomel. What the extent of its therapeutical powers may be I am not prepared to fully define. I believe them to be very great, and very little appreciated by the profession. In one case of ruptured uterus, I consider the life was saved by application of this agent alone. Whether administered by the mouth with the yolk of an egg in ten minim doses every hour, or applied constantly for forty-eight or seventy-two hours to the abdomen, or internally and externally united, I have seen results forcing me to believe in its specific properties.

The secondary affections, the results of pyæmia, are not peculiar to puerperal fever, and need not be especially considered in this category.

Considering it both desirable and becoming that all who have any especial interest or experience in this class of diseases should lay their views before the Academy, I have offered these few remarks.

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