S^c S Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/therapeuticsofgyOOatki THE ODERN THERAPEUTIC SERIES. I. MODERN MEDICAL THERAPEUTICS : a Compendium of Recent Formulae and Specific Therapeutical Directions, from the Practice of Eminent Contemporary Physicians, American and Foreign. By George H. Napheys, A. M., M. D., etc. Seventh Edition, enlarged and revised to 1880. 1 vol. 8 vo. Pp. 608. Price, cloth, $4.00; sheep, $5 00. II. MODERN SURGICAL THERAPEUTICS: A Compendium of Current Formulae, Approved Dressings, and Specific Meth- ods for the Treatment of Surgical Diseases and Injuries. By George H. Napheys, A. M., M. D., etc. Sixth Edition, 1879 1 vol. 8 vo. Pp. 601. Price, cloth, $400 : sheep, $5.00. III. THE THERAPEUTICS OF GYNECOLOGY AND OB- STETRICS : Comprising the Medical, Dietetic, and Hygienic Treatment of Diseases of Women, as set forth by distin- guished contemporary specialists. Edited by Wm. B. Atkin- son, A. M., M. D., etc. 1 vol. 8 vo. Pp. 370. Price, cloth, $3.00; sheep, $350. ^^ Any of the above works sent by mail, post-paid, on receipt .of the price, by the publisher. D. G. BR INT ON, 115 South 7TH Street, Philadelphia. THE THERAPEUTICS OF Gynecology ^ Obstetrics COMPRISING THE Medical, Dietetic, and Hygienic Treatment OF Diseases of Women, AS SET FORTH BY DISTINGUISHED CONTEMPORARY SPECIALISTS. EDITED BY WILLIAM B. ATKINSON, A. M., M. D., AUTHOR OF " HINTS IN THE OBSTETRIC PROCEDURE," LECTURER ON DISEASES OF CHILDREN AT THE JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE DE- PARTMENT OF OBSTETRICS AND DISEASES OF WOMEN, HOWARD HOSPITAL; CORRESPONDING MEMBER OF THE GYNECOLOG- ICAL SOCIETY, BOSTON; FELLOW OF THE AMERICAN ACADEMY OF MEDICINE; HONORARY MEMBER OF THE MEDICO-CHIRURGICAL SOCI- ETY, BOLOGNA, ITALY; ETC., ETC. PHILADELPHIA : D. G. BRINTON, 115 SOUTH SEVENTH STREET. 1880. Entered according to Act of Congress, in the year 1880, by D. G. BRINTON, In the Office of the Librarian of Congress. All rights reserved. FROM THE PRESS OF THE INQUIRER P. & P. CO., LANCASTER, PA. PUBLISHER'S NOTICE. The present volume is the third in the Series of " Modern Ther- apeutics," originally projected by the late Dr. George H. Naph- eys, but which his death prevented him from completing. The work has been finished under the able supervision of Dr. Wm. B. Atkinson, whose wide experience in this branch of professional study is a sufficient guarantee that it has been well done. The aim of the Series is to present the most modern and ap- proved plans of treating the diseases considered, as set forth by the most eminent authorities, and specialists in this country and Europe. The word Therapeutics is taken in its widest sense, in- cluding all efficient means of combatting disease, not only phar- macal, but hygienic, dietetic, climatic and specific as well. A number of authors are quoted, and their views accurately pre- sented. When they differ, as is not infrequently the case, no ma- gisterial attempt is made to decide which is in the right, as this difference of opinion is evidence that further observation and a very wide induction are demanded to reach a positive decision. It is better that such difference should be noted by practitioners, and that the circumstances of the case and its surroundings should be the guide to the selection of remedial measures. The " Resumes of Remedies," added to each disease, are in- tended to set forth, in alphabetical order, all the agents which have been recommended in its treatment by good, recent authorities. New methods and recent additions to the Materia Medica are given special attention, but only such admitted as appear to have solid evidence in their favor. Those of special value are marked with an asterisk (*). In this department recent medical periodical liter- (v) vi PUBLISHER S NOTICE. ature has been closely scanned for information, and references are given to special articles and monographs. Substantially the same plan is carried out in all the volumes of the series, and the favorable reception which the Medical Thera- peiitics and the Surgical Therapeutics have met with, induces a hope that the present volume will be found not less serviceable to the practicing physician. EDITOR'S PREFACE In compliance with the wish of the publisher, the editor of the present volume has carefully reviewed the material prepared for it and has added extensively from recent treatises, monographs, and journals, containing matter on the two specialties represented. The great activity which has been manifested of recent years in these branches, particularly that of Gynecology, renders it almost impossible for a physician who has to attend to a large general practice to follow the rapid advance in therapeutic methods which has taken place. This work is designed to present him all of these which are worth his attention ; great care has been exercised that nothing of ascertained value should be omitted ; and the editor believes that very few omissions of this character will be found. In accordance with the plan preferred by the publisher, precise directions in the plans of treatment have been preserved, and the exact formulse presented whenever these could be obtained. Undoubtedly, in some instances, the therapeutic vagueness which is fashionable in many books on practice at the present day, is largely chargeable with the distrust of remedial measures often encountered among medical men. It has been deemed best to preface each chapter with a "Syn- opsis of Diagnostic Points," setting forth, in brief but clear forms, the distinctive signs and symptoms between the diseases consid- ered in the chapter. This permits the etiological plans of treat- ment to be presented more distinctly, and may also serve as a reminder in cases of puzzling similarity. PI dl ad dpi da, 1880. (vii) TABLE OF CONTENTS. PAGE. Publisher's Notice 5 Editor's Preface , 7 Table of Contents 9 PART I. GYNECOLOGICAL THERAPEUTICS. CHAPTER I. DISEASES OF THE OVARIES, DISORDERS OF MENSTRUATION, AND GENERAL DISEASES. Synopsis of Diagnostic Points 17 Ovaritis 17 Ovarian Tumors 18 Amenorrhea 21 Dysmenorrhea '. 22 Menorrhagia and Metrorrhagia 23 Chlorosis and Anemia. 24 The Change of Life 24 Ovaritis (Acute, Subacute and Chronic ) 26 Ovarian Neuralgia 27 Ovarian Dyspepsia 28 Ovarian Hyperemia 29 Acute and Chronic Ovaritis 29 Resume of Remedies 30 General Methods 30 Ovarian Tumors 31 Internal Medication 31 Injections into the Sac 31 Electrolysis 32 Amenorrhea 33 Menstruation is and always has been absent 33 Menstruation is scanty or irregular ^t, Suppression of the Menses 34 (ix) X TABLE OF CONTENTS. PAGE. Chronic Suppression 34 Plethoric Amenorrhea 37 Nervous Amenorrhea 37 Tuberculous and Scrofulous Amenorrhea 37 Amenorrhea by Counter Fluxion , 37 Amenorrhea from Anemia and Chlorosis 39 Resume of Remedies 41 General Measures 44 Dysmenorrhea 46 Neuralgic Dysmenorrhea 46 Congestive Dysmenorrhea 46 Obstructive Dysmenorrhea 46 Membranous Dysmenorrhea 46 Ovarian Dysmenorrhea 47 Neuralgia of the Uterine Neck 49 Spasmodic Dysmenorrhea 49 Dysmenorrhea from General Causes 49 Dysmenorrhea through Insufficiency 5° Menorrhagic Dysmenorrhea 5° Irregular Dysmenorrhea , 5° Rheumatic Dysmenorrhea 52 Membranous Dysmenorrhea 54 Resume of Remedies 55 Mechanical Remedies 57 Menorrhagia and Metrorrhagia 59 Passive Hemorrhage 59 Resume of Remedies 65 Vaginal Injections 7° Hysteria 7 1 Resume of Remedies ' 74 External Remedies 76 Chlorosis 77 Resume of Remedies 79 The Climacteric Epoch, or the Change of Life 81 Resume of Remedies 83 CHAPTER II. DISEASES OF THE UTERUS AND ITS ANNEXES. Synopsis of Diagnostic Points 85 General Observations 85 Uterine Symptoms S6 Uterine Inflammations 87 Metritis and Cervicitis 88 Endometritis and Endocervicitis 89 TABLE OF CONTENTS. xi PAGE. Metritis (Non- puerperal, Endo , Peri-, Para-Metritis, Uterine Catarrh, ET c) 97 General Treatment. Local Treatment. . . 90 91 Chronic Endometritis 02 Chronic Metritis 06 Acute Endometritis , c6 Parametritis 06 Perimetritis o5 Pressure in Uterine Diseases 07 Intra-uterine Medication 03 Uterine Injections g8 Medicated Injections no Pledgets (Pinceaux) l OI Crayons or Pencils 102 Ointments and Glyceroles 102 Capsules 1 o ^ Powders IC >3 Pessaries or Intra-uterine Tents lo-> Resume of Remedies io ^ External Measures IO , Cervicitis (Ulceration and Granulation of the Os, etc.) 105 Indolent Ulcers io c Inflamed Ulcers i - Fungous Ulcers IO r Senile Ulcers io ^ Diphtheritic Ulcers 105 Caustics 107 Ignipunctm-e 108 Interstitial Injection :.... 112 Mechanical Treatment ur Tents for Dilating the Cervix 1 16 Resume of Remedies 117 Uterine Tents ug Other Measures , 121 Displacements 122 Retroversion and Anteversion 123 Anteflexion 125 Prolapsus of the Uterus 125 Inversion of the Uterus 126 Pessaries , 126 Flexures of the Uterus 129 Procidentia 130 Chronic Inversion of the Uterus 130 Rules for the Use of Pessaries 131 Non-Malignant Growths 137 Polypi 137 Fibrous Growths 139 Xll TABLE OF CONTENTS. PAGE. The Medical Treatment of Uterine Tumors 142 Resume of Remedies 145 Other Measures 147 Maltgnant Growths 148 Cancer 148 Epithelial Cancer 150 Sterility and Anaphrodisia 152 Nymphomania 155 Resume of Remedies 155 CHAPTER III. DISEASES OF THE VAGINA, URETHRA; AND BLADDER. Synopsis of Diagnostic Points 157 Vaginitis 157 Cystitis 158 Urinary Disorders , 158 Vaginitis, Acute and Chronic — Vaginal Catarrh- — Leucorrhea — Col- pitis , 1 60 Vaginal Injections ; 160 Vaginal Irrigations 160 Medicated Tampons 161 Vaginal Cataplasms - 1 61 Vaginal Suppositories 161 Resume of Remedies , . 167 Vaginal Injections 168 Vaginitis (Specific, Gonorrheal) 172 Gonorrheal Cervicitis 174 Gonorrheal Acute Ovaritis 174 Gonorrheal Metritis 174 Vaginismus and Dyspareunia 176 Resume of Remedies 178 Vaginal Growths 1 79 Caruncle of the Urethra 179 Non-Syphilitic Wails 179 Vegetations, flat and horny ; . . . 180 Pruritis Vulvae seu Vaginae, and Vulvitis. 181 Eczema Genitale 182 Resume cf Remedies 184 Cystitis 1S7 Urethritis 190 Catarrhal Urethritis 190 Urinary Disorders— Irritable Bladder, Dysuria, Polyuria, Ischuria, etc. 192 Vascular Growths 193 Irritable Bladder 194 Incontinence of Urine 194 TABLE OF CONTENTS. XI II PART II. OBSTETRICAL THERAPEUTICS. CHAPTER I. THE DISORDERS OF PREGNANCY. PAGE. The Hygiene of the Puerperal State 197 Food 198 Clothing 198 Exercise 198 Sleep • 198 Mental Condition , 199 Marital Relations 199 Abortion and Premature Labor 200 Induction of Premature Labor 206 Resume of Remedies , 211 Uterine Sedatives and Tonics 211 Ecbolic and Abortifacient Agents 212 Vomiting and Nausea of Pregnancy 214 Resume of Remedies 217 Internal Remedies 217 Local Measures 219 Sympathetic Nervous Disorders 221 Palpitation 221 Syncope 221 Neuralgia , 221 Headaches 221 Insomnia 222 Hypochondriasis 222 Nervous Cough 222 Pruritus 223 Digestive Derangements of Pregnancy 225 Gingivitis, Puerperal Salivation 225 Diarrhoea 226 Constipation 226 Hemorrhoids 226 Albuminuria of Pregnancy 228 Resume of Remedies 232 CHAPTER II. COMPLICATIONS, DISORDERS AND SEQUELAE OF PARTURITION. Anesthetics in Labor , 233 Conclusions on 235 XIV TABLE OF CONTENTS. PAGE. Propositions on 237 Resume of Remedies . 238 Tedious Labor Rigid Os and Atony of Uterus 239 Feeble or Irregular Action 242 Excessive Distension of the Uterus 242 Resume of Remedies 244 External Measures 246 After Pains 248 Resume of Remedies 249 Puerperal Hemorrhage 250 Resume of Remedies 260 General Measures 261 Puerperal Eclampsia 264 Resume of Remedies 269 General Measures » N 270 Puerperal Mania 271 Puerperal Fever (Puerperal Septicemia, Puerperal Pyemia) 276 Excessive and Septic Lochial Discharge 276 Septicemia ; 279 Antiseptic Management of Labor 280 Resume of Remedies 287 General Remedies 288 Puerperal Thrombosis and Embolism 289 Puerperal Shock 291 Pelvic Cellulitis and Peritonitis (Puerperal Phlebitis and Metritis). . 292 Diagnostic Points 292 Treatment 292 Puerperal Metritis 295 Puerperal Peritonitis 297 Resume of Remedies 3°° Other Measures '. 3 DI Phlegmasia Dolens '• • 3°3 Mllk Fever 3°4 Puerperal Convalescence 3°6 Retarded Involution 3°7 Laxatives for Puerperal Women 3°7 CHAPTER III. DISEASES OF THE MAMMARY GLANDS AND OF LACTATION. Mastitis and Mammary Abscess 3°9 Antiseptic Method of Opening an Abscess 311 Resume of Remedies 3 l % General Measures 3 X 9 TABLE OF CONTENTS. XV PAGE, Mammary Tumors 321 Diagnostic Points t 321 Adenoma, Sarcoma, Scirrhus 321 Encephaloid Cancer, Benign Cystic Growth .... 322 Hysterical Breast 322 Treatment 322 Mammary Hypertrophy 323 Milk Tumors 323 Serous Cysts 323 Hydatid Tumor 324 Fibroid and Adenoid Tumors 324 Carcinoma 324 Caustic Arrows 325 Mammary Neuralgia (Mastodynia) 326 Galactorrhea 327 Resume of Remedies 330 Agalactia and Oligogalactia 332 Means to Increase the Milk 332 Means to Re-establish Lactation 332 To Prevent Accidents from Sudden Cessation 332 Galactagogues 334 Food as a Remedy , 335 Resume of Remedies. 336 Diseases of the Nipples , ^37 Resume of Remedies 34c PART I. GYNECOLOGICAL THEEAPEUTICS. CHAPTER I. DISEASES OF THE OVARIES, DISORDERS OF MENSTRUATION. AND GENERAL DISEASES. Synopsis of Diagnostic Points — Ovaritis, Acute and Chronic {Ovar- ian Neuralgia, etc.) — Ovarian Tumors — Amenorrhea — Dysmen- orrhea — Menorrhagia and Metrorrhagia — Hysteria — Chlorosis and Anemia — The Change of Life, or Climacteric Epoch. SYNOPSIS OF DIAGNOSTIC POINTS. OVARITIS. The principal diseases of the ovaries are acute, subacute, and chronic ovaritis or oophoritis, and ovarian tumors. The following are the distinctions between the two forms of inflammation of the organ. Acute Ovaritis. Chronic Ovaritis. Preceded by sudden suppression of menstruation, gonorrhea, pelvic peritonitis or external violence. Preceded by displacements of uterus, irregular menstruation, or neglect of precautions at menstrual epoch. (17) DISEASES OF THE OVARIES. Fever, perhaps chill ; severe pain in one or both iliac fossae. Great sensitiveness over the ovary, which may sometimes be felt as a round ball. Abscess or resolution in four to six days. The disease is rare. Fixed pain over one or both ovaries, dysmenorrhea and hysteria, pain in rectum and down thighs, worse after defecation, leucorrhea, sometimes sterility and dyspareunia. Chronic, and not amenable to treatment. The disease is quite common. In the subacute form, by the recto-vaginal touch, we may grasp with the two fingers a smooth, roundish body, as large as a cherry, producing exquisite pain. This sign is characteristic of subacute oophoritis, for neither simple morbid congestion of the ovary, nor oophoralgia, nor retro-uterine hematocele, nor metritis, nor lymphadenitis, nor perimetric phlegmon, will give the phenom- enon of pain so well marked and so precisely localized. It should be remembered that gonorrheal infection is an occa- sional cause of acute ovaritis, in which case specific treatment is demanded after the first symptoms have abated. In chronic/Ovaritis Atthill has observed that persistent vomit- ing was a prominent symptom. In a lecture reported in the London Medical Times and Gazette, Dr. J. Matthews Duncan states that occasionally this disease is seen as a consequence of fever, especially typhoid, cholera, rheum- atism ; and, in close connection with these diseases, it is very fre- quently a result of the use of alcoholic liquors, even when these are not taken to excess ; and this view of the causation of the dis- ease is in the most gratifying manner frequently corroborated, if not proved, by the cure which follows upon the adoption of strictly temperate living. A great mass of cases occur as a consequence of recent marriage, suppression of menstruation, abortion, and delivery at the full time, when there is no evidence of blood poisoning. OVARIAN TUMORS. The diagnosis of these tumors is often of the utmost difficulty. In the first place, pelvic tumors generally are simulated by preg- nancy, ascites,' obesity, intestinal and vesical distention, and similar conditions. When a tumor is actually present, it may arise from other sub-peritoneal tissues as well as from the ovary. And when from the ovary, it may be either malignant or benign. SYNOPSIS OF DIAGNOSTIC POINTS. 1 9 Professor Kceberle, of Strasburg, lays down the following gen- eral rules : In subperitoneal serous cysts, there is no loss of flesh. The tumor, unilocular, presents a very manifest fluctuation ; its walls are thin ; its development slow, though at times rapid enough ; it sometimes attains a considerable size without becoming adherent. to neighboring organs ; sometimes it is small and very adherent. In cysts of the ovary, wasting is pronounced. The tumor, whether uni- or multi-locular, often presents a limited fluctuation ; its walls are occasionally thin, occasionally more or less thick and resistant, hard and nodulated ; its development is ordinarily rapid, sometimes slow; lastly, it is adherent whenever the volume is at all considerable. A more positive method is by aspiration and examining the con- tained fluid. This diagnosis rests principally on the presence or absence of albumen, metalbumen, and paralbumen. Parovarian cysts, or those of the broad ligament, contain a very fluid liquid, generally colorless and limpid as water, sometimes quite salt, but generally not containing any albuminous material ; when it does contain albumen, it is the paralbumen that is precipitated by nitric acid, but the precipitate redissolves in acetic acid. Cysts of the Fallopian tube contain only albumen, and no par- albumen ; the precipitate produced by nitric acid is increased by acetic acid. Ovarian cysts furnish a liquid charged with albumen, metalbu- men, and especially paralbumen, giving a precipitate soluble in nitric acid. Well marked, these reactions are conclusive ; but there are ex- ceptional cases where they are but feebly present. All doubt is removed, however, and we have to do with an ova- rian cyst, when puncture gives exit to a glutinous fluid, sometimes entirely uncoagulable by heat and nitric acid, rarely limpid, con- taining only traces of albumen (colloid cysts), or a fatty liquid con- taining in suspension mucus and epidermic detritus or hair (der- moid cysts). Lastly, examined by the microscope, the fluid of ovarian cysts contains granular globules, yellowish, 0.003 milli- metres to O.060 millimetres in diameter, the envelope being ren- dered more apparent by acetic or phosphoric acid. Mr. Spencer Wells remarks that in ascites, the stomach and intestines, containing air, float on the surface of the fluid, and, 20 DISEASES OF THE OVARIES. therefore, the highest points of the tumor, the patient lying on her back, give out a clear sound on percussion. If, however, the fluid be contained in a cyst, the stomach and intestines are pushed aside, as the tumor rises in the abdomen, and lie in the epigastric and two lumbar regions. Hence, the highest points of an ovarian tumor emit a dull sound when percussed, and the epigastric and lumbar ones give a clear sound. By applying these general rules in any ordinary case, a few seconds will enable a surgeon to clear up all doubt. Atlee says mobility diminishes as size increases, there is free- dom from constitutional symptoms, the emaciation is most strik- ing about the face, neck, shoulders and arms, the expression of countenance is anxious, careworn, the features attenuated, the complexion pale. An important point is the position of the tumor in relation to the viscera; it is usually in front, and gradually crowds them backward, upward, and to the sides. There is a dull percussion sound over the space occupied by the tumor. Fluctuation can be recognized only in the tumor. The form of the abdomen is rarely uniform. As a general rule, according to Dr. T. M. Drysdale, ovarian fluids have an animal odor ; they are rarely clear, usually cloudy, and frequently opaque ; in color they vary from that of white of egg or clear starch, to shades of yellow, red, green, or dark chocolate, or even inky black ; in consistence, they may be almost like water, or thin syrup, mucilage, oil, or molasses, or ropy, or jelly-like; but they always are sticky and viscid, and generally feel slimy. A sediment rarely fails to form after a few hours ; this is viscid, and often like pus. Reaction generally alkaline. Chemically they con- sist of albumen, fats, extractives and salts. Notably they contain an excessive amount of solid matter, often T V of the whole weight of fluid. They never contain fibrin, unless hemorrhage has occurred into the cyst, or it has been inflamed. Microscopically they usually display free granular matter, oil globules, epithelial cells, crystals of cholesterine, etc., but no matter what other cells may be present or absent, the cell which is almost invariably found in ova- rian fluid As the granular cell. This is generally round or may be slightly oval, delicate, transparent, contains a number of fine granules, but no nucleus. The granules are well defined. Acetic acid makes them more distinct. Ether renders them nearly trans- parent. Other cells, on the addition of the acid, increase in size, become very transparent and exhibit nuclei. SYNOPSIS OF DIAGNOSTIC POINTS. 21 AMENORRHEA. Amenorrhea may be primitive or acquired. In the first form menstruation has never taken place, or if it has occurred at all, the discharge has always been scanty, or has appeared at pro- longed intervals, or both. In the second form menstruation has taken place regularly and healthily, and has afterwards become suppressed. The following table represents the various forms of this affec- tion, their causes and pathological significance : Menstruation absent (emansio mensiuml. Menstruation scanty. Menstruation irregular and gen- e r a 1 1 y scanty. PRIMITIVE AMENORRHEA. Uterus undeveloped or absent ; Ovaries well or ill-developed, or absent. 'Anemia. Chronic disease. Bad hygienic conditions. Emotional shocks. Physical shocks. Acute diseases. Change of residence. Exposure. Bathing. [Plethora. (?) No formation of decidua.. Uterus well-de- veloped, but inactive. Ovaries, well- developed. Scanty forma- tion of decid- [ Irregular and generally scanty forma- tion of decid- ua. Uterus small. Ovaries well or ill-developed. Uterus well-de- f Anemia, veloped. j Bad health. Uterus usually small, but j Anemia, may be well- j Bad health, developed. Menstruation absent (suppres- s i o m e n- sium). No decidua formed. Uterus and ov aries well formed. ACQUIRED OR SECONDARY AMENORRHEA. 'Anemia. Chronic disease of lung, liver, kidney, ovaries, uterus, or gastrointes- tinal canal. Bad hygiene. Shocks, physical or emo- tional. Acute diseases. Blood-taint. Exposure. Bathing. Change of residence. Over-involution after labor. Early menopause. In place of the discharge of blood, there may be a leucorrhea, more or less profuse. 22 DISEASES OF THE OVARIES. It should never be forgotten that in not infrequent instances amenorrhea, supervening apparently without cause, is the first sign of phthisis, and in all such cases should arouse the most active attention of the physician. Some writers hold that in these cases the amenorrhea is not so much the sign as the exciting cause of the tuberculous change. DYSMENORRHEA. The forms and causes of dysmenorrhea are denned by Prof. T. G. Thomas, in accordance with the following table : Form. Neuralgia. Dysmenorrhea. Congestive or In- flammatory Dysmenorrhea. Obstructive Dys- menorrhea. Membranous Dysmenorrhea. Ovarian Dysmen- orrhea. Symptoms. Pain usually sharp and fixed. No expulsive pains ; flow steady ; no clots ; no obstruction ; occurs gradually ; is habitual ; no en- dometritis. Pain severe, sudden ; discharge lessens or ceases. General py- rexial signs, and inflammatory constitutional disturbance. Pain sudden and accompanied with an expulsive effort after menstruation has commenced some hours ("uterine colic"); recurrence of these symptoms. Discoverable obstruction. Pains steady, becoming violent and expulsive ; passage of membrane at each period ; as seauelae, endometritis and men- orrhagia. Very rare. Pain, dull and sickening, usually precedes the flow several days, and lessens when it comes on. Breasts painful or tender. " Submammary pain." " In- termenstrual pain," occurring between the epochs. Ovaries often enlarged and tender. Pain habitual at each epoch ; often shoots down the thigh. Causes. The neuralgic diathe- sis ; phethora or chlorosis ; malaria ; theumatoria ; onan- ism. Exposure to cold and wet ; tumors ; men- tal disturbance, en- dometritis, etc. Contraction of cervix ; uterine flexion ; pol- ypus or fibroid ; ob- turator hymen. Early abortions ; diph- theritic endometri- tis. Ovaritis ; excessive nervous hyperes- thesia. Barnes says a characteristic sign of ovarian congestion is that the body of the uterus is drawn towards the affected ovary. SYNOPSIS OF DIAGNOSTIC POINTS. 23 MENORRHAGIA AND METRORRHAGIA. By mcnorrhagia is meant an excessive flow of blood at the men- strual period ; by metrorrhagia, a flow of blood between the men- strual epochs. Neither of these forms of trouble can be called a disease, as they are solely symptoms of several kinds of uterine affection. In order to diagnose the cause, and thus obtain the indications for treatment, a careful examination becomes necessary. In most instances, it is the result of general debility, as from protracted nursing. Locally, it may be caused by the presence of tumors, as polypi, etc., affections of the os and cervix, congestion of the womb or ovaries, subinvolution of the womb, or inversion of that organ. Debility as a cause, is recognized by the usual symptoms, and the accompanying predisposing circumstances, as lactation, anx- iety, exhausting labor, etc. Polypi, when low down, are easily recognized by the finger, though the speculum may be used to confirm the diagnosis. In these cases there is leucorrhea, more or less bloody, and at inter- vals discharges of pure blood, without relation to the period of menstruation. Where a polypus is not found pendent in the vagina, the prsence of these growths may be suspected above, as in the canal of the neck, or even within the uterus itself, and at- tached to the fundus. The absence of other causes of the hem- orhage would demand dilatation of the organ if necessary, and a careful search for these excrescences. Subinvolution only occurs in women who have been pregnant Here, the womb, after delivery has been accomplished, fails to re- turn to its proper condition. The diagnosis is readily made by ex- amination. The uterus is much larger than natural, the os soft and patulous ; there are pains in the back, irritability of the blad- der, frequent micturition, with tenesmic efforts, and generally very profuse leucorrhea. These may end in erosion of the os and cervix, and added to these we may have congestion of the lips of the womb. Again, hemorrhage may be due to the presence of a portion of the placenta, which is frequently the case after an abortion. This might be suspected from the history of the case, and the diagnosis fully made by an exploration with the sound, when the foreign DISEASES OF THE OVARIES. body is detected. In such cases there is generally a certain amount of odor, as of a decaying body in the cavity. In the unmarried, a spongy state of the cervix is generally a cause ; this is shown by eversion of the lips, and granulations on the surface. Malignant disease as a cause is detected by the general history; there has been more or less pain, often lancinating, in the lower part of the abdomen, the back, around the hips, and extending down the thighs, which frequently seems to be much relieved after profuse hemorrhage has occurred. This hemorrhage would occur from a slight exertion, or after coitus. Examination shows in advanced cases fixation of the uterus, hardness and irregularity of the parts. In early cases, these symptoms all exist, but to a less extent. CHLOROSIS AND ANEMIA. These two diseases, though not strictly synonymous, may, from their great resemblance, be treated of as one. A marked feature is amenorrhea, or imperfect menstruation. The complexion is pale, or of a greenish yellow. The patient is listless, loses appe- tite, or only desires dainties, generally craves acids, or may even prefer articles of an injurious or loathsome nature; she is irritable, hysterical, suffers with headache, which is sure to come on after the slightest excitement or exertion. The poverty of the blood is shown by cold extremities, swelled feet and hands, puffiness of the face, dark rings around the eyes, and blowing sound of the heart. Though not always present, yet, in many instances, there are vague neuralgic stitches in the breasts, the head, the sacrai region. In rare cases, after the disease has continued a while, a slow fever sets in, which may lead to an error in diagnosis. THE CHANGE OF LIFE. This period, known as the climacteric or menopause, varies greatly as to the time of its appearance. The woman menstruates for about thirty-five years, and then occurs a marked change, which may be sudden, or may slowly steal upon her. Most com- monly this is attended by a variety of troubles, which to a greater or less extent affect the general health. A most frequent symptom is irregularity of the menstrual function. It ceases, perhaps for months, and as suddenly reappears. Or the flow becomes alarm- ingly profuse, exhausting the patient, draining her. With this SYNOPSIS OF DIAGNOSTIC POINTS. 25 may be associated hemorrhages from the nose, from the bowels, profuse leucorrhea, and brain symptoms as of congestion, vertigo, frequent syncope, epileptic or apoplectic seizures. Barnes regards the headache as peculiar, chiefly occipital, involving the nucha and spinal cord. The mind is affected. There are irritability, loss of memory, despondency, even partial insanity, but all of which are generally acknowledged by the patient, and she regrets her want of self-control. The appetite is capricious or lost, generally the bowels are obsti- nately costive, fat begins to accumulate, and these symptoms often give rise to the belief that the woman is pregnant, which is speedily dispelled by the proper examination. The liver and kidneys, in fact nearly every organ, are liable to become affected and to add to the general discomfort. Morbid growths are now extremely apt to present themselves, or when previously known, to take on increased action. In rare instances, a change for the better, a marked improvement occurs, and an invalid is now restored to health, or at least greatly re- lieved. OVARITIS (ACUTE, SUB-ACUTE AND CHRONIC). PROFESSOR J. MATTHEWS DUNCAN, M. D., OF EDINBURGH. On the subject of acute and chronic ovaritis, this author states there is no specific treatment. In chronic cases, two, three or four leeches may be applied to the cervix uteri, through a speculum, after the monthly periods. Croton oil liniment, or antimonial lini- ment, or a blister, may be applied to the inguinal canal adjacent . to the affected gland. The bowels should be regulated by gentle saline .laxatives. Leucorrhea, if present, should not be actively treated, but by mild injections only. Mercury and iodide of po- tassium may be given in small doses. PROF. GRAILY HEWITT, M. D., OF LONDON. In acute cases, entire rest is essential. When the attack is owino- to a chill, from exposure, leeches should be applied over the ovaries, followed by hot anodyne poultices. Hot turpentine stupes are also valuable. In chronic cases, cold affusions and hip baths are often useful. Sexual indulgence must be strictly limited. At the menstrual periods, the patient should remain on the couch, and a stimulating nourishment be avoided. Between the epochs moderate out-door exercise is valuable, Tartar-emetic ointment or other counter- irritants may be used over the ovary. To relieve pain the follow- ing pill is efficacious : I. ty. Pulveris opii, gr.ss Extracti cannabis indicse, g r -/^ C amphorae, gr.j. M. For one pill, night and morning. EDWARD JOHN TILT, M. D., OF LONDON. In severe ovario-uterine pain, this practitioner recommends plac- ing a pledget of cotton-wool soaked in laudanum, or acetate of morphia, near or upon the neck of the womb. This may be re- peated daily or every other day. Two or three grains of morphia may be used at a time in this manner. When the ovaries are congested or inflamed, the best method of treatment is to leech the womb. Four leeches may be applied to (26) OVARITIS (ACUTE, SUB-ACUTE AND CHRONIC.) 27 the cervix a day or two after the flow has ceased. The effect is usually well-marked. Blisters and ointments to the hypogastric region only act on the ovaries indirectly, and even double the number of leeches mentioned, when applied over the ovary, do not produce so permanent an effect. In chronic and obstinate forms of ovario-uterine disease, silk setons applied above the pubes, as recommended by Huguier, deserve trial. For the pelvic and spinal pains of ovario-uterine disease, Dr. Tilt recommends rubbing the surface twice a day with one of the following ointments : 2. fy. Linimenti belladonnas, f.3ij Glycerinas amyli, f.Jj. M. 3. $. Morphias acetatis, gr. x Glycerinas, • f.3ss Otto rosarum, gtt.j Unguenti petrolei, §j. M. 4. I£. Potassii iodidi, 3j Magnesias, gr.v Otto rosar., gtt.j Aquas, f-3j Unguenti petrolei, 3}. M. Apply twice daily. 5. I£. Atropias sulphatis, gr.ij Morphias sulphatis, g;r.iv Olei olivas, f.3j Olei lavandulas, gtt.x Unguenti hydrargyri fortis, §j. M. A piece about the size of a small walnut is to be rubbed in morning and evening, over the sensitive ovary. LOMBE ATTHILL, M. D., DUBLIN, Finds great benefit from the inunction twice a day, over the part, of equal portions of the ointment of veratria and iodide of potas- sium, and in some cases he adds a small quantity of ointment of cantharides. J. WARING CURRAN, M. D., LONDON. Ovarian Neuralgia. This writer maintains that in various in- stances we meet with true ovarian neuralgia, independent of any local lesion, and more remediable by constitutional than by local treatment. He identifies it with the ovarian irritation of Dr. Churchill. His prescription for such cases is : DISEASES OF THE OVARIES. 6. fy. Ammonias muriatis, 3ij Tincturae aconiti, f.3ij Syrupi aurantii corticis, f.gviij. M. A teaspoonful thrice daily in the treatment of ovarian neuralgia. Dr. Curran states that this combination has almost a magical influence in many cases. He reports [Medical Press and Circidar, August 19th, 1868), six cases in which various sedatives and ano- dynes had been .tried in vain. In all he found that before the above mixture was finished by the patient, the pains had entirely ceased. Dr. T. J. Newman, of Chicago, confirms the usefulness of this mixture, and records (in the Chicago Medical Examiner, for No- vember, 1869), three cases of neuralgia of the ovaries treated by it with success, after the failure of other remedies. In the same painful complaint, Dr. Roberts Bartholow has obtained excellent results from the following recipe : 7. fy. Extracti belladonnas, gr.iv Extracti stramonii, gr.v Extracti hyoscyami, gr.v Quinias sulphatis, 9ij. M. Make twenty pills. One three times a day, in ovarian neuralgia and neuralgic dysmenorrhea. DR. J. MILNER FOTHERGILL, OF LONDON. Ovarian Dyspepsia. This writer has pointed out that a frequent complication and often the most prominent symptom of subacute ovaritis is a form of gastric atony which he calls " ovarian dyspep- sia." [American Journal of Obstetrics, January, 1878.) For the treatment of such cases he recommends as the great therapeutic agent, the bromide of potassium. 8. ty. Magnesias sulphatis, 3j Potassii bromidi, Bj Infusi gentianas, f.§j. M. This amount three times a day, with an aloes and myrrh pill at bed time if necessary. A blister should be applied over the tender ovary. For the vaginal loss, injections of astringents in solutions by means of a Higginson's syringe, or the small india rubber ball and tube used to give babies enemata (much better in every way than a glass syringe), must be used twice a day, with hip baths daily, if the patient's condition will admit of it. This is far from unimpor- OVARITIS, (ACUTE, SUB-ACUTE AND CHRONIC.) 20, tank When there is menorrhagia, quietude and the avoidance of all warm drinks and food during the flow are desirable. For the imperfect digestion, light and easily digestible food, milk, if neces- sary, combined with an alkali, or beef-tea with a little cream in it, or custard, are indicated. Such food should be given at short in- tervals, and small quantities at once. The irritable stomach will often retain small quantities of food when larger amounts are at once rejected. LAWSON TAIT, F. R. C. S., BIRMINGHAM This writer {Diseases of Women, 1879), divides inflammatory affections of the ovaries into (1) ovarian hyperemia, (2) acute ovaritis, (3) chronic ovaritis. Ovarian Hyperemia. — This is frequently met with in young girls and in young married women with vigorous husbands, and in prostitutes of tender age. The patient should rest in a prone position for a few days before, during, and after the menstrual period ; a counter-irritant should be placed over the ovarian region just before the flow is expected ; and she should take ergot before and during the period, and the salts of potassium contin- uously during the intermenstrual time. His favorite formula is : 9. ty.. Ergotinae (Bonjean), gr. ss. Lupulinse, q. s. M. For one pill. In addition to this, between the epochs, 10. 5l. Potassii bromidi, gr. v-x. For one dose, night and morning, after meals. All cases of ovarian hyperemia which Mr. Tait has met with at puberty have yielded to this treatment, and most of those of a later age. Acute and Chronic Ovaritis. — No time can be laid down where ovarian hyperemia passes into ovaritis, nor between the acute and chronic forms of the latter. The treatment should consist of local and systemic rest, and the administration of ergot. Locally, counter-irritation in the inguinal region, with linimentum iodi every morning until the spot is sore, and this repeated frequently, will nearly always do good. Bromide of potassium may be com- bined with the ergot. Arsenic and cod liver oil are also useful, and some cases will yield to large doses of quinine, when every- thing else has failed. 30 DISEASES OF THE OVARIES. RESUME OF REMEDIES. Ammonia Marias is often efficient in ovarian neuralgia. (F. 6). Antimonii et Potassii Tartras. Counter-irritation by means of tartar emetic ointment is of service in subacute ovaritis. Atropia, hypodermically, T ^ - -^ grain in ovarian neuralgia. Bella- donna in plaster is often of service. Brominium. Barnes says that this agent seems to possess a specific power in diminishing ovarian irritation. Camphor a is very serviceable in ovarian pain. (F. i). Hydrargyri Ungnentum. Dr. E. J. Tilt, of London, recommends in subacute ovaritis — II. fy. Unguenti hydrargyri, 5ij Extracti belladonna;, 5j Cera?, 3ij Adipis, §j. M. Warm water enemata, and gentle aperients (castor oil), should accompany the treatment. Iodininm. Painting the sensitive regions with tincture of iodine is a useful means of counter-irritation. Opium. Vaginal suppositories of opium gr. ij, made up with paraffin, frequently give great relief. Aran was accustomed to pour two drachms of laudanum daily or every other day, through a speculum, on and into the cervix. *Potassii Bromidum. This agent is asserted to possess almost specific powers in reducing ovarian irritation, and pain, nymphomania, etc. (F. 8, 10). Potassa cum Cake. In chronic ovaritis, Barnes recommends as a means of derivation, setting up a small issue or eschar on the vaginal portion of the uterus with this agent. Terebinthince Oleum, used in the form of hot epithems, is frequently available. GENERAL METHODS. Blisters over the ovarian region are frequently of service in the sub-acute forms. Enemata. Warm water enemata, retained as long as possible, are often of great benefit. Ice applied in a bag to the painful spot, is said by Dr. Tilt to relieve the pain of acute ovaritis. leeches are a very valuable means of relief. (See page 26.) Pessaries. A light pessary, to support the womb and keep the ovaries in their normal position, will often prove of decided advantage. Ovariotomy. As a last resource in severe ovaritis, the organs may be re- moved by Battey's operation. * o^Virw ' S " -' "^ ^"l^ L OVARIAN TUMORS. The medical treatment of tumors of the ovaries embraces: Internal medication. Injections into the sac. Electrolysis. Internal medication. It has been believed by some practitioners that a prolonged use of muriate of ammonia has led to atrophy, absorption and disappearance of certain benign ovarian tumors. Two such cases are recorded at length by Dr. E. H. W. Hunter, in the Trans., of the Georgia State Med. Soc, 1877. He gave gr. xx of the muriate, four times daily. In ovarian dropsy, the free use of chlorate of potassa is said to have resulted in marked diminution of the contents. PROF. E. R. PEASLEE, M. D., NEW YORK Believed that, in several instances, the growth of ovarian cysts had been checked by the application into the vagina, of iodide of lead. The ointment may be smeared on a cotton tampon, and intro- duced from time to time. Care must be exercised that too great irritation is not excited. Injections into the sac. The substance usually employed for this purpose is iodine. Some surgeons use the pure tincture. Dr. Boinet, of Paris, employs — 12. I£. Tinct. iodinii, f.^iij Potassii iodidi, 3j Acidi tannici, 3ss Aquae destillatae, f.giij. M. He injects the whole of this amount, brings it in contact with the entire surface of the sac by gentle agitation, and then with- draws it. Prof. T. Gaillard Thomas recommends as the best procedure to empty the sac by the aspirator, and without withdrawing the needle, fill it with tincture of iodine, and in ten minutes draw it off. He would confine this plan of treatment only to a late period, in cysts of moderate size, with few compartments, and containing a fluid which is not very viscous. (SO 32 DISEASES OF THE OVARIES. Electrolysis. Within the last few years, great attention has been given, especially in Germany, to the dispersion of ovarian tumors by electrolysis, and it was at one time confidently announced that this plan would supersede ovariatomy. Further observations show that while in many instances elec- tricity, properly applied, will reduce the tumors very materially, the effect of the agent is temporary, and it is very doubtful whether any permanent and real benefit accrues from the procedure. In Vienna, the electrolytic treatment has been carefully and repeat- edly tested, and it is now wholly neglected as of no avail. (See Am. Jour, of Obstetrics, Oct., 1878. EPHRAIM CUTTER, M. D., BOSTON, In a report to the Amer. Med. Assn., in 1879, savs ^ ^ s dangerous to operate on a person suffering with albuminuria. He regards it as proved, that the results obtained are due to the passage of a current, and not to solely to puncture. With Dr. Kimball, he has Operated on 61 cases. In one case, the fibroid was extracted from the vagina fifty-three days after the application. In a similar case, there was a small, nodulated, mobile fibro-myoid attached at and in- corporated with the fundus. The os was ulcerated, and the operation was advised to arrest the hemorrhage*. A current was applied for seven minutes. Two months after, no tumor could be felt, and the os was healed. In one case, an electrode was applied per vaginam, and the circuit was completed by a sponge electrode over the pubis, but with such alarming results that the procedure was shown not to be safe. It is best to confine the action of the current to the tumor, as it alone is in fault, and needs the whole force. This is effected by complete insulation of the needle in the healthy tis- sues. AMENORRHEA. JOHN WILLIAMS, M. D., LONDON. Referring to the classification of the forms of amenorrhea al- ready given (see page 21), this writer suggests the general line of treatment as follows {Lancet, May 26, 1877): Menstruation is and always has been absent. The great majority of cases of this class which will come under observation will be young girls between sixteen and twenty years of age. Many of them will suffer from anemia and disorders of the digestive organs. Such cases are instances of late or tardy evolution of the genera- tive organs. The form and figure may be well developed, but the uterus grows slowly, and the treatment consists in waiting and adopting all means that favor its growth. There will, after all, re- main a few in which the discharge will not make its appearance. In these it will be found that the uterus is small, and the best treatment is non-interference. Menstruation is scanty or irregular. If it be due to an undevel- oped condition of the uterus, and if it be accompanied by no pain, the generaj. health being good, it requires no special treatment. General means which favor physical development, as exercise of all kinds, may be recommended. If the uterus have obtained its full size, there will, in almost all cases, be found a disordered state of the general health. The most common condition is anemia. In such cases the physician should regulate the bowels, for there is generally constipation, and give iron, iodine, salines ; good diet, fresh air, and exercise in the open air, are essential. Exercises of all kinds are good — riding, walking, swimming, dancing. If the monthly molimen be present, emmenagogues may be prescribed, but they should never be administered when indications of ovarian and uterine action are present. The medicines supposed to have a direct action in bringing on the menses are numerous, but few of them are of much or even of any value. The best are electricity, aloes, and the stimulating diuretics — nitrous ether, spirits of juni- per, and oil of turpentine. Hot hip-baths for five or six nights in succession before the expected return of the molimen are useful. Guaiacum, ergot of rye, oil of savin, cantharides, have proved suc- cessful in the hands of some. Dr. Atthill recommends the warm. 3 (33) 34 DISEASES OF THE OVARIES. hip-bath for eight or ten evenings in succession before the ex- pected time. Suppression of the menses. When the suppression has taken place suddenly during a menstrual flow, the patient should have a hot bath, go into a warm bed, and take a dose of Dover's powder. A stimulating diuretic or a diaphoretic should be at the same time prescribed. Should fever, heat in the skin, vomiting, pain in the abdomen, and symptoms of local inflammation or of general peri- tonitis set in, they should be treated irrespective of the suppres- sion. If the flow is not re-established, the case becomes one of chronic suppression. Chronic suppression. The general health should be attended to, and if menstrual molimina be present they should be encouraged, and efforts made to establish the flow by the means already enum- erated. If molimen be absent, we must limit our aid to the treat- ment of the general health. PROF. R. J. GRAVES, M. D., DUBLIN. This author observes, in his Clinical Lectures, that the periodicity of the function of menstruation can still be traced, even in cases where suppression has continued for a great length of time, by means of the menstrual molimina (pains in the loins, thighs, and hypogastric region, flushing, colicky pains of the abdomen, general feeling of malaise), which occur at stated intervals ; in endeavoring to bring on the discharge, therefore, we must be guided as to the time the attempt should be made, by an observance of the period at which these molimina occur. For a few days before that time, our efforts to produce a determination of blood to the uterus may be judiciously employed; and if they fail, the attempt should be abandoned until a few days before the next menstrual period. Of course, however, the general constitutional treatment must be con- stantly persevered in; one of the chief means of bringing back this evacuation being the restoration of health to the natural stand- ard. But all such remedies as pediluvia, stuping of the genitals, leeches to the inside of the thighs, near the labia, aloes and other stimulative purgatives, etc., should be only used at the times spoken of. To use them at any other period, either after the molimina have disappeared, or during the intervals between them, tends, in most cases, still further to derange nature, by determining to the uterus at an unseasonable time, when there is no natural AMENORRHEA. 35 tendency to that organ. Under such circumstances, the very same means fail and prove injurious, which, applied so as to coincide with the time of the natural effort, would have been successful. To illustrate these principles by an example. We are consulted in the case of a young woman affected with various hysterical symptoms for several months, and during that period more than usually subject to headache, languor, loss of spirits, diminution of appetite, and irregularity, and usually constipation of bowels; she is pale, and complains of various pains and uneasy sensations, and has not menstruated since the appearance of these symptoms. Here it is evident that the constitutional treatment must be strengthening and tonic. The practitioner will, therefore, recom- mend regular hours, much exercise in the open air, a nutritive diet, and afterward cold shower-baths ; he will regulate the bowels, and afterward prescribe a course of tonic medicines, chalybeates, pre- parations of bark, strychnia, etc. ; he will likewise inquire carefully when the last period happened, and where, and how often since that occurrence menstrual molimina were observed. He thus ascer- tains when they should again recur, and contents himself with en- forcing the constitutional treatment until about six days before the calculated time. Then he lays aside the other medicines, and has recourse to those means which determine to the uterus. Two leeches are applied to the inside of the thigh, near the labium, every second night, until they have been three times applied. The bleeding is encouraged by stuping. On the intermediate days the bowels must be actively moved by aloetic pills ; and for three nights before and after the molimina, hot pediluvia, rendered stimu- lating by mustard seed, may be used. During the same time, also, frictions, with stimulating liniments, should be applied to the feet and legs every morning, and oil of turpentine or tincture of can- tharides may be exhibited internally, while the necessity of more active exercise is inculcated. If these means fail, they must for the moment be laid aside, and the constitutional treatment must be again resumed, until the same number of days before the next period, when the list of remedies above spoken of must be again tried, and in few cases indeed shall we find them to fail. PROF. T. GAILLARD THOMAS, M. D., OF NEW YORK, In cases of rudimentary or atrophied uterus suggests local stimu- lation and distention. Every week or two it should be distended 36 DISEASES OF THE OVARIES. by a tent. In the intervals, an intra-uterine galvanic pessary- should be worn. This however, requires time. After general treatment, in cases of anemia, etc., he uses other local stimulation by dry-cupping the cervix uteri. Electricity is of value. One pole of the battery may be placed over the lower part of the spine, and the other either passed over the hypogastrium, or brought in contact with the neck of the womb; or it may be carried within that organ by means of a wire covered with a gum catheter. E. J. TILT, M. D., OF LONDON, Advises a couple of aloes and myrrh pills each night, to produce moderate alvine action ; the legs placed in a pail of hot water on rising, and a warm hip-bath at night ; mustard to the inner parts of the thighs and breasts on alternate nights ; the breasts dry- cupped, or rubbed with a stimulating liniment. On retiring, a linseed meal poultice as hot as can be borne to the lower part of the abdomen. These measures are to be tried for three days, and again after an interval of twenty-one days, and in the interval, a chalybeate is to be taken, and a bit of piline sprinkled with alco- hol to be worn during the day over both ovarian regions. This he continues for three or four months. Occasionally, during the three day, he gives a mixture of acetate of ammonia, chloric ether, and fluid extract of ergot. When the head is much distressed, he applies six leeches to the labia, followed by a hot hip-bath, or a hot poultice to the labia. He offers the following: 13. I£. Oil of savin, f.3j Spirits of nitrous ether, f.3iij Mucilage, f-5j Water, to f.^vj. Shake well. Dose. — A teaspoonful every two hours, when the patient is half comatose from suppressed menstruation. Or, 14. I£. Tincture of ergot, f.3ij Syrup of saffron, f.§ss Comp. decoction of aloes, f.§iss. Dose. — A teaspoonful three times a day. He recommends the association of podophyllin and aloes, in pills, for the same purpose. AMENORRHEA. 37 PROF. ROBERT BARNES, OF LONDON, Thinks that the blood is in want of salines as well as of iron, and that this is the first want. He gives solution of acetate of ammonia, adding a little nitrate of potassa, and a light tonic as hop, cinchona or calumba. He employs iron in the form of the ammonia-citrate, the solution of the acetate, or the dialyzed iron. Between salines and iron, he would give iodide of potassium in doses of five grains three times a day. He believes that the res- torative power of iron is much increased by the addition of strych- nine or ergot. PROF. J. B. FONNSAGRIVES, OF PARIS. This learned author divides amenorrhea, for the treatment, into the following classes : i. Plethoric amenorrhea. Local and general bleeding, the re- sinous purgatives, and low diet, are here indicated. Siredey rec- ommends in addition bicarbonate sodium, gr. v. daily, two or three days before the period ; or solution of the acetate of ammonia. 2. Nervous amenorrhea, characterized by a condition of general nervous erethism. Raciborski in such cases gives twenty to thirty drops of the solution of acetate of ammonia, in hot water, several times daily, for three or four days before the period, and also has recourse at times to ergot and vaginal fumigations with carbonic acid gas. 3. Tuberculous and scrofidous amenorrhea require the general treatment of dyscrasise. 4. Amenorrhea by counter-fluxion. This arises when some other organ, by reason of its congestion, checks or prevents the normal uterine molimen of the menses. In such cases the attention of the practitioner must be directed to removing the congested con- dition of the interfering organ. DR. EMIL DILLENBERGER, VIENNA. Treatment demands the removal of those errors and lesions which lie at the bottom of the malady, If the amenorrhea con- sists of some anomaly of the sexual organs, congenital or ac- quired, and such as cannot be remedied, or in some other irre- mediable malady, treatment is useless. If menstruation has been already established, the physician must convince himself, by a careful examination, whether or not pregnancy is the cause of the 38 DISEASES OF THE OVARIES. cessation of the periods. Internally are used aloes and myrrh, as follows : 15. I£. Pulveris aloes, gr.lxviij Pulveris myrrhae, gr.xxxiv Extracti glycyrrhizae, q. s. M. For sixty pills. Two to four pills two or three times a day. 16. fy. Pulveris aloe's socotrinae, Pulveris myrrhae, aa gr.xlviij Croci sativi, gr.xxxiv Extracti glycyrrhizae, q. s. M. For ninety pills. From four to six twice a day. Or, savine, as follows : 17. I£. Pulveris frondis sabinae, Sacchari albi, aa gr.xxxiv Olei menthae piperitae, gtt.ilj M. Divide into six powders. One to be taken three times a day. 18. ]£. Olei sabinae, gtt.vj-xij Sacchari albi, g r -lx. M. Divide into six equal powders. Put in waxed paper. Take one pow- der three times daily. 19. I£. Pulveris frondis sabinae, - gr.lxviij Croci sativi, gr.xxij Olei sabinae, . gtt.viij Extracti gentianae, q. s. M. For sixty pills. From three to five- pills two or three times daily. Or, direct crocus and borax, as follows : 20. I£. Boracis venalis, gr.xxxiv Croci sativi, gr.xiij Sacchari albi. gr.xxij Olei menthae piperitae, gtt.j. M. Divide into six powders. One powder three times a day. Amenorrhea is often more certain to be cured by putting an end to serous or bloody discharges from various organs, by treat- ing for an improved condition of the blood, with good nourish- ment and a corresponding regimen, with iron, preparations of cin- chona, cold washing, etc., than by theemployment of emmena- gogues without any plan. For outward application, the following are useful : Warm uterine douche; brushing the mouth of the womb with tincture of iodine ; leeches to the portio vaginalis uteri, to the labia pudendi, to the inner side of the thighs, or to the perineum ; dry cuppings AMENORRHEA. 39 and mustard poultices to the inner sides of the thighs ; warm stimulating foot-baths, with mustard, salt, potash, or aqua regia ; warm sitz-baths, or half-baths ; bath at Ems, etc. In many girls marriage is the first thing that regulates the menstruation. DR. FRITZ, OF PARIS. This writer gives the following directions in the Union Medicale, No. 151, 1878. If the flow has been suppressed by the patient's catching cold, warm hip-baths, vapor-baths, and stimulating foot- baths will be found useful. The patient must be well covered with warm clothing, and take sudorific drugs and stimulants, such as ether, acetate of ammonia, or infusion of lime blossoms. Hot fomen- tations must be applied to the lower part of the abdomen and the genital organs, and mustard plasters to the inner surface of the thighs ; cupping might be advisable instead of mustard. Stimu- lating injections will also be found very useful. This treatment has to be continued for some days, and renewed when the next period is due. If the patient is plethoric, and con- gestions have been determined in the pelvic organs by the sup- pression of the period, leeches must be applied to the perineum, the labia, or the thighs cupped, and if the patient be constipated, a purgative must be given. If the suppression be caused by some moral cause, and the woman is excitable, the nervous system must be treated with antispasmodics and sedative drugs. HOSPITAL OF THE UNIVERSITY OF PENNA., PHILADELPHIA, In amenorrhea from anemia and chlorosis, the following pre- scription embodies the hospital practice : 21. ~fy. Pulv. ferri sulphat., Potassii carb. purse, aa 3ij Mucil. tragacanthi, q. s. M. Div. in pil. No. 48. S. To be given daily in doses gradually increasing, until three pills are taken after each meal. This gives the large quantity of twenty-two and a half grains of the dried sulphate of iron per diem. To counteract the possible costive effect of the sulphate of iron, this aperient mixture is given : 40 DISEASES "OF THE OVARIES. 22. ^l. Pulv. glycyrrhizse rad., Pulv. sennas, aa §ss Sulphuris sublim., Pulv. foeniculi, aa 3ij Sacchar. purif, giss. S. One teaspoonful in half a cupful of water at bed-time. Where the disease is due to torpidity of the ovaries, this pre- scription is used : 23. ^. Ex. aloes, 5j Ferri sulphat. exsic, 3ij Assafcetidas, 5iv. Signe. One pill after each meal. This number to be gradually in- creased to two and then to three pills after each meal. If the bow- els are at any time over-affected, return to the initial dose of one pill after each meal. DR. PINTSCHOVIUS, OF KETZIN. 24. I£. Extracti Pulsatillas, Foliorum Pulsatillas, aa q. s. Divide into pills of three grains each ; one three times a day. * PROF. J. M. DA COSTA, M. D., PHILADELPHIA. 25. I£. Apiol, gr. iv. In the form of a granule, or " pearl," four times a day, as an emmenagogue. To be taken for three days before the expected period. Apiol is an excellent remedy for amenorrhea, when there is no uterine disease. PROF. COURTY, OF PARIS. 26. I£. Pulv. rutas, Pulv. sabinas, Pulv. ergotas, aa gr.f , Pulv. aloe's, § r -i~i- For one pill. Of these thirty are ordered, and three are taken the first day, six the second day, and nine the third day, always in three doses. They are suited for cases of idiopathic amenorrhea, without great reaction on the economy, and when there is reason to suppose that the suppression of the menses is due either to an insufficient determination towards the genital organs, or to a difficulty of dis- charge due to inertia of the uterus. In order to encourage the fluxion towards the genital organs, Dr. Courty orders, before be- ginning the pills, foot-baths, sitz-baths, and fumigations. He also AMENORRHEA. 41 applies leeches to the labia during the three days the pills are be- ing taken. The pills generally induce colicky pains, and often a little diarrhoea. RESUME OF REMEDIES. Achillea Millefolium (Yarrow). Dr. Ronzier-Joly reports very success- ful use of this plant in amenorrhea in tuberculous girls. He uses an infusion of the flowering tops, 5hj to aquas Oj. Stille believes that this plant possesses peculiar relations to the pelvic organs. It is especially called for where imperfect or absent menstruation depends upon a condition of atony in the repro- ductive organs. Aconitum may be employed, in the form of the extract, with advantage in amenorrhea. Dr. Ringer, of London, recommends it in the sudden suspension of the menses, as from cold. Aloes, in a small enema, containing gr. x, employed at the proper men- strual period, is said to be a very certain emmenagogue. Dr. E. J. Tilt, of London, recommends its internal administration combined with podophyllin. It is frequently combined with myrrh. Aloin. Dr. Tilt gives : 27. fy. Aloin, gr. ij Cocoa butter, gr. x. Make a suppository. Ammonii Murias, in the hands of Dr. Anstie, in gr. x doses, three times a day, in cases of amenorrhea marked rather by general feeble- ness than by anemia, has occasionally seemed to conduce di- rectly and considerably toward the cure. But of this, as of all other emmenagogues, it is pre-eminently true that it is worth absolutely nothing if not exhibited precisely on the fit occasion. Ammonice Aqua has been successfully employed in the form of injection into the vagina : 28. ~Bf.. Aquae ammonias, f.5j Lactis, Oj-ij. M. To be injected into the vagina daily. Apiol is highly recommended by Dr. Jaret (Bull. G;n. de Th'erap., August 15, i860), and others since, as one of the safest and best of emmenagogues, not being even contra-indicated in inci- pient pregnancy. It is said to be especially adapted for cases attended with local or general nervous symptoms. (F. 24.) Argenti Nitras, applied in substance lightly to the os uteri at the time of the expected appearance of the menses, has proved successful in obstinate cases. Artemisia Vulgaris. The mugwort once enjoyed considerable reputation as an emmenagogue. 42 DISEASES OF THE OVARIES. Belladonna. In plethoric amenorrhea, belladonna is an efficacious remedy. It is quite popular on the continent and recently Dr. F. T. Porter, of Dublin, has reported marked success with it. Cantharid?s . Dr. W. P. Dewees placed much confidence in the internal use of tincture of cantharides, in doses of gtt. xx., gradually increased to gtt. xxxv. or xl Dr. T. H. Tanner, of London, combined it with bromide of potassium. Cimicifuga has been found an effectual remedy in some cases. Crocus Sativus. The saffron as a stimulant aromatic has efficacy in func- tional amenorrhea. The celebrated " Pills of Rufus " are com- posed as follows : 29. ~Bf_. Aloes, gr. iss Myrrhae, gr. \ Croci, _ gr. ^ Syrupi absinthii, q. s. For one pill ; 5 to 10 pills daily. * Ergot is recommended by Dr. Tilt, of London (in doses of gr. v-x, in powder, two or three times a day). He usually gives it in con- junction with other remedies : 30. fy. Tincturse ergotae, n\xxx Syrupi croci, f-§ss Decocti aloe's compositi, f.5iss. M. A teaspoonful three times a day. Or, 31. I£. Liq. ext. ergot., f.5j Prepared lard, gr.iv Cocoa butter, up to gr. xv. Make a suppository. *Ierriim Redactum, and the other ferruginous preparations, are indis- pensable in the anemia which constantly accompanies stoppage of the function. Galbanum may frequently be. combined, with benefit, with the salts of iron. Hydrargyri Chloridum Mite is contra-indicated, if the patient be feeble, and is capable of doing much mischief in unsuitable cases. But Drs. Graily Hewitt, Ashwell, and others, have found it a decided emmenagogue. Dr. Hewitt directs that on two successive nights, at the time of the expected period, a dose be given of five grains of calomel and six grains of aloes, followed by a Seidlitz powder in the morning. Iodine frictions over the abdomen have been found to give good results. Iodoform, internally, has been recommended. 32. I£. Iodoformi, Extr. gentianse, aa 5j Pulv. gentianaa, q s. Make 100 pills. Three to six daily. AMENORRHEA. 43 Mentha Pulegium. Pennyroyal has a popular reputation as an emmena- gogue. Myrrh, in combination with iron and aloes, is a standard remedy in amen- orrhea. Dr. Tilt, of London, recommends the following so- called "Elixir of Paracelsus:" 33. fy. Tinctures myrrhas, f-oiv Tincturae croci, Tincturas aloes, aa f.§iij. M. F.3ij-iiji twice daily, in a little water. Potassii Bromidum. The value of bromide of potash in amenorrhea, especially that connected with nervous and hysterical phenom- ena, neuralgia, ovarian irritation, scanty and painful menses, has lately been strongly urged by Dr. M. Rosenthal, of Vienna ( Wiener Med. Presse, No. 46, 1878). He repeats it in full doses for some days before the menses begin. Pulsatilla is said by Phillips to be of the greatest value in functional amenorrhea, and that following fright or chill; gtt.j-v of the tincture three or four times a day. Rata Graveolens. The rue has been recognized as a direct emmena- gogue since the time of Hippocrates. As it is a decided irri- tant of the intestinal canal, it must be given with caution. According to E. Hamelin {Diet, des Sciences Medicales, 1877), it is especially indicated where suppression is due to atony or inertia of the uterus. The powder is used by Dr. Courty (F. 26). A better preparation is the essential oil. The follow- ing is from Dr. Dubois : 34. $. Oleirutas, Olei sabinas, aa gtt.vj Sacchari, 3 V U Rub together and add Aquas aurant. flor., f.jiiss. M. A dessertspoonful every hour. A rectal injection of an infusion of rue, 3j to Oj, is occasion- ally serviceable. Sabina is considered by Dr. Tilt, of London, as the most reliable of a very uncertain set of remedies. He has never seen any ill effects from its use, though he has given gtt.xx. of the oil, twice a day. He orders : 35. Iff., Olei sabinas, f.3j Spiritfls setheris nitrosi, f-3uj Mucilaginis, f.§j Aquas, f.fvj. M. A teaspoonful every two hours, the bottle being previously shaken. A plaster containing the oil may also be worn over the ovarian region. Pereira, Home, Phillips, Locock, and Sir Charles Clarke, all testify to its efficacy. 44 DISEASES OF THE OVARIES. Senega was first recommended as an emmenagogue by Dr. Hartshorne, of Philadelphia. He gave a pint of a saturated decoction daily , during a fortnight before the expected appearance of the dis- charge. Sinapis. A hot mustard hip-bath is often useful, the patient remaining in it for an hour each time. Sodii Biboras. Dr. Copland recommends the following : 36. R. Sodii biboratis, 5ss Aloes socotrinae, Pulveris capsici, aa gr.xx Olei lavandulae, q. s. Make eighteen pills. Take two thrice daily. Strychnia. Small doses of the 'extract or alkaloid of nux vomica, com- bined with aloes and myrrh, are sometimes of service. Tanacetum has a popular reputation. Terebinthince Oleum. Turpentine enemata have been given with success: 37. R Oil of turpentine f.gss Barley water. Oj. For one enema, to be given once or twice a day. Zingiber. Hot ginger tea is a popular remedy for suppression from cold. GENERAL MEASURES. Electricity. This agent has been found useful in various instances. In chronic suppression, Dr. P. S. Hayes, of Chicago, places one of the electrodes alternately over each ovary and the uterus, the other electrode over either sacro-iliac synchondrosis, the current being frequently reversed ( Chicago Medical Examiner, Jan. 1875). Dr. Julius Althaus considers the most effective form of applying electricity in amenorrhea to be the induction of catelectrotonus of the ovaries {Medical Times and Gazette, March 14, 1874). He places the negative electrode of the con- stant battery, alternately to the right and left ovarian region, putting the anode alternately to the lumbar spine and to the os uteri, by means of an insulated sound. The action should be kept up for fifteen minutes at a time, and repeated daily about the period the molimen should recur. ' The late Sir James Simpson was accustomed to use, with advantage, an intra- uterine galvanic or zinc and copper pessary, in the treatment of amenorrhea, the result of imperfect development of the uterus. Leeches. Trousseau strongly recommends leeches. His method of using them was peculiar. He placed a single one, or at most two, on the thigh or knee at the time the menses were due. As soon as the leech fell, he arrested the bleeding, so as to promote congestion of the surrounding tissue. Sometimes, he asserts, the menstrual pains begin almost as soon as the bleeding is thus checked. AMENORRHEA. 45 Massage. This is appropriate in cases of suspended menstruation. Dr. Douglas Graham of Boston, has given some illustrations of its successful employment {Boston Medical and Surgical Jour- nal, Feb., 1876). The mode of procedure is manipulation of the whole body, with percussion of the back, resisting move- ments of the feet, legs, and thighs, in all their natural direc- tions ; this being repeated daily. Milk Diet. A strict skim-milk diet has been found successful by Prof. Tarnier of Paris, • in several cases of amenorrhea in obese young women. With the disappearance of the extra fat, the menses returned. Baths. Sitz-baths or foot-baths, using salt water or mustard water, are often sufficient where there is suppression following exposure. The mustard should be placed in a linen bag and soaked with occasional pressure in the water, until the latter receives a greenish color. The time of the bath should be fifteen to twenty minutes. Atthill especially commends the cold hip- bath. He directs the patient to sit in a bath containing cold water, so as to cover the pelvis, the legs and feet not being immersed, but kept warm by coverings of flannel, or by a pan of hot water. The temperature of the bath should be about 60 ° ; taken at bedtime, and for a period of from five to fifteen minutes ; after which the patient should be well rubbed with a coarse towel, and put to bed. Chilliness must be obviated by a hot jar to the feet, and if there is discomfort after the bath, it should not be repeated, or used for a shorter period. This is not applicable where there is anemia, or constitutional disease. DYSMENORRHEA. PROF. T. GAILLARD THOMAS, M. D., OF NEW YORK. Pursuing the classification of the forms of dysmenorrhea, given by this authority (See page 22), he recommends the following plans of treatment : Neuralgic Dysmenorrhea. The skin should be kept warm and active by wearing flannel, and bathing. If the rheumatic or gouty diathesis is present, colchicum, guaiac or vapor baths are called for. Chlorosis, plethora, or malaria, if present, should receive attention. A sound should be occasionally introduced into the uterus. Parturition often cures it entirely. Of specific drugs, apiol is the most reliable (one capsule night and morning). Tincture of cannabis indica, gtt. xxv. every fourth hour, will relieve the pain. Where a spasmodic element exists, the following is effectual : 38. I£. Extracti belladonnse, S r -X Butyri cocose, q.s. For one vaginal suppository. Repeat every eighth hour. Enemata of tincture of assafcetida, f.5ij in a gill of warm water, otten produce great relief in this condition. Congestive Dysmenorrhea. If from chill and exposure, opiates, diaphoretics and sedatives will give speedy relief; if from plethora, bleeding, cathartics and low diet are required ; if from a displaced uterus, as is often the case, this must be corrected. Local inflam- mations must receive attention before a cure can be expected. Obstructive Dysmenorrhea. Constrictions of the cervix require enlargement, either by dilatation or incision. Sounds, tents, and dilators, are used for the first mentioned methods. Sea-tangle, sponge, etc., are materials of which tents may be composed. Obstruction from flexion or version of the uterus requires a proper pessary or operation. Membranous Dysmenorrhea. This is relieved with difficulty. As soon as the menses begin, the patient should go to bed and apply hot water bottles to the feet, abdomen and sacrum alternately. She should then take an enema : (46) DYSMENORRHEA. 47 39. $. Tinct. assafetidae, f.Siij Tinct. belladonnse, gtt xx Tinct. opii, =■" gtt.x Aquae tepidse, f.^iijss Throw the whole into the rectum and retain. Instead of this, the following may be given by the mouth : 40. $. Chloral hydratis, Potassii bromidi, aa 5ij Morphia; sulphatis, gr.iss Syrupi aurantii corticis, ± . § i i j - A dessertspoonful in a wineglass full of water every four hours while in pain. Ovarian Dysmenorrhea. The most efficacious remedies are the bromides of potassium and ammonium, in full doses, commenced a week before the menstrual act, and continued until its close. A rectal suppository of gr. v. iodoform, gives great relief. Change of air and scene, warm sitz-baths, or warm vaginal injections, and general hygienic measures, are essential. LAWSON TAIT, F. R. C. S., BIRMINGHAM. Ovarian Dysmenorrhea. In milder cases, treatment is generally successful. First of all therapeutic remedies is iron, whether there are general indications for its employment or not. There can be no doubt but that many forms of this remedy exert a spe- cific power over- the sexual organs. It is best given during the intermenstrual period in small doses, liquor ferri perchloridi, gtt.j— v, well diluted, and increased suddenly to gtt. xv-xx, for a day or two previous to and during the menstrual flow ; or an iron and aloes pill may be substituted for this large dose. Hot hip-baths and leeches to the perineum at the period are useful additions, with an occasional blister on the sacrun. Marriage is, perhaps, the most efficient remedy, and one we ought seldom to hesitate to recommend. The last and most powerful aid is mccJianical irritation of the uterus. The most convenient and least troublesome is the inser- tion of Simpson's galvanic pessary. In a large number of cases this is beneficial ; but its use should be confined to those which resist simpler measures. Its introduction may give rise during the first week to considerable discomfort, but this passes off if the patient keeps her bed for a few days. It should be retained for several months. The uterus rapidly enlarges under its action, and 48 DYSMENORRHEA. the ovaries take part in this increased activity. Mr. Tait does not share the prejudice against this instrument which some writers have manifested. CHARLES R. DRYSDALE, M. D., OF LONDON. This author maintains {Obstetrical Journal of Great Britain, Oct., 1875,) that there is too great a tendency to expect to find an evi- dent physical cause for all painful menstruation. Spasm and neu- ralgia are quite sufficient to account for the vast majority of cases. Membranous shreds, also, are frequent causes of obstruction to the monthly flow. The rational treatment of dysmenorrhea commen- cing at an early period, consists not in the use of pessaries, or of incision of the uterus; but in the use of cold baths in the morning, with short walks in the open air afterwards; in hot baths, a few days previously to the menstrual periods ; and in palliative treat- ment of the paroxysms by means of antispasmodics at the epoch of pain. Marriage sometimes cures such cases at once; at other times, it is of no use. PROF. J. MATTHEWS DUNCAN, M. D., OF EDINBURGH. This teacher strongly advocates the treatment of dysmenorrhea by mechanical means. He would not hesitate to employ it in vir- gins when the severity of the case was urgent. The treatment he refers to is that by bougies introduced into the cavity of the womb through the cervix. He states that it is unaccompanied by danger. The only evil result he has ever seen from it is a tem- porary perimetritis. It is a treatment the innocence of which arises from the fact that there is no cutting, and that the instru- ment is not left in the womb above a few minutes at a time. It is allowed to remain till the pangs of pain which it brings on have passed. In order to effect a cure you must go up considerably above a No. 9. You must go up so as to stretch and distend the internal os uteri ; and this stretching or distention of the internal os may require you, in different cases, to reach different sizes. A No. 1 1 is quite sufficient in many cases ; in others you will go up to a 12 or 13, rarely above that. These various numbers are not all used in one day, but in successive days, or every second or third day, and generally the whole is effected in a few sittings — say from four to eight. You are not to expect that this treatment will cure every case. By this treatment he says that most of the DYSMENORRHEA. 49 characteristic cases are, if not cured, at least greatly amelio- rated. PROF. F. A. ARAN, OF PARIS. This well-known gynecologist has highly praised the local ap- plication of opium in neuralgias of the uterine neck, which some- ■ times accompany dysmenorrhea {Bull, de Therapeutique, vol. lxvii). His method is as follows: Having introduced a speculum, thirty to fifty drops of Sydenham's laudanum are allowed to flow to the bottom of the vagina ; sufficient powdered starch is then thrown in to form a magma with the laudanum; upon this is placed a moderately large pledget of cotton, and the whole is left in the vagina, to be renewed daily or every other day as occasion re- quires. He reports very great relief by this simple means. PROF. J. B. FONNSAGRIVES, OF PARIS. For therapeutical purposes this writer {Traite de Therapeutique Appliquee, 1878), divides dysmenorrhea as follows: 1. Spasmodic Dysmenorrhea. The flow is normal in quantity and regular, but accompanied by sharp pains, and easily inter- rupted. The indications are, baths and anti-spasmodics, as an enema : 41. I^. Powdered valerian, 3iii Laudanum . 10 drops Warm water, 8 oz. M. For a rectal enema. Or the valerianate of ammonia maybe used in a similar manner. Hot poultices to the lower abdomen and sedative lotions to the hy- pogastric regions are also useful. Of internal remedies, two espe- cially deserve mention, the acetate of ammonia and casioreum. The former should be given in doses of a fluidrachm well diluted, several times daily for several days before the period. Castoreum is especially indicated where the pains are associated with disten- tion of the bowels and tympanites, or when the discharge is scanty and tenesmus uteri present. Its power is then real and pos- itive. It may be given in pill, powder, or ethereal tincture, in doses of gr. v-xxx. Its failure is often owing to the impurity of the drug. 2. Dysmenorrhea from ge?ieral causes, as anemia, plethora, ner- vous excitement, etc. As here the disturbance of the function is merely symptomatic, it should be so treated. 4 5<3 DISEASES OF THE OVARIES. 3. Dysmenorrhea through insufficiency. When the proper amount of blood has not been lost, the woman experiences general dis- comfort, sense of weight at the hypogastrium, hysterical symp- toms, obstinate headache, and local congestions. The indication here is to supplement the menses by a moderate bleeding from the arm (foiij-yj), or by leeches. 4. Menorrhagia Dysmenorrhea is nearly always associated with the change of life, and will be considered under that section. 5. Irregular Dysmenorrhea. The quantity is normal, but the periods of return are irregular and the function painful. This is generally found either at the beginning or the close of menstrual life, or at the outset of diathetic disease. In other cases, it is proper to solicit the molimen at regular times by emmenagogues. DR. EMIL DILLENBERGER, VIENNA. When there is evident hyperemia of the womb, several leeches to the portio vaginalis uteri, or to the insides of the thighs, warm soft poultices, or injections of lukewarm water, are very beneficial. When the dysmenorrhea is of nervous origin, some advantage is derived from the application of warmth, warm baths, mustard poultices, or dry cuppings applied to the loins and thighs, and internally from narcotics, especially opium. 42. ty. Pulveris opii, gr.j Sacchari albi, 3j Olei menthse piperitae, gtt.ij. M. Divide into six powders. Take one every two to four hours. Or, 43. -fy, Tincturas opii, nixxx Infusi anthemidis, f.^iv Aquas menthas piperitae, Syrupi simplicis, aa f.gss. M. One to two tablespoonfuls every one or two hours. PROF, THEODORE JEWETT, M. D., BOWDOJN MEDICAL COLLEGE. 44. I£. Camphoras, 5ijss Extracti belladonnas, Ouinias sulphatis, aa 5ss Pulveris acacias, q- s - ™. For eighty pills. One to be taken every four hours until relieved. DYSMENORRHEA. 5 I 45. I£. Extracti Scutellariae fluidi, Decocti aloes compositi, aa f.gss. M. A dessertspoonful every two or three hours until relieved. Dr. C. W. Frisbie, of East Springfield, N. Y., writes that he used the above formula in his practice many times, and, when the cases had been properly selected, with the most happy results. DR. A. DESPREZ, SURGEON TO THE LOURCINE HOSPITAL, PARIS. In dysmenorrhea, warm water occasions congestion of the uterus, and the congestion is followed by a return of the menses, and consequently by a marked alleviation. Injections of warm water act like the cataplasms and warm lotions, which are so usefully employed in inflammation of the integument. The injections of warm water are practiced at the hospital with irrigators, of which the jet is not very strong. The water used should be of 95 ° to 104 Fah., and it is renewed two, four, or six times in a day. This therapeutic means is convenient, and not repugnant to the patient. DR. LISFRANC, PARIS. 46. ^. Vini opii, gtt.x-xx Camphorae, gr.ij-ivss Decocti althaeas, f.gijss Vitel. ovi, Sijss. M. For an enema, to be given nearly cold, at bed-time, to relieve the pain of menstruation. Hot fomentations on the abdomen. 47. ]£. Assafetidae, 5j Vini opii, tflxv Extracti Valerianae, 3ss Decocti althaeae, f.giijss Vitel. ovi, 5v. M. An enema, in hysterical dysmenorrhea. HENRY HARTSHORNE, M. D., OF PHILADELPHIA. Whatever be the cause of dysmenorrhea in any case, the sub- ject of it should always avoid being much on her feet for a day or two before her monthly time ; and should go to bed when the pain begins. Cloths wrung out of hot water, or whisky and water, may be placed on the abdomen and renewed as they cool. Inter- nally the following may be given : 52 DISEASES OF THE OVARIES. 48. I£. Spiritus camphorae, f.5j Tinct. opii camphoratse, f.Sij Tinct. zingiberis, f.5ss Tinct. lavand. compos., fjss Aquam, ad f.gij. M. Take a dessertspoonful every hour or two. Large vaginal injections of hot water, and dilatation of the os and cervix, are other useful measures. No medicine appears to exert a prophylactic effect, unless it is iron in cases of anemia. PROF. N. S. DAVIS, M. D., OF CHICAGO. Rlieumatic Dysmenorrhea. This practitioner has called attention {American Practitioner, October, 1877), to a numerous class of cases of dysmenorrhea from chronic rheumatic irritation : First, the patient should wear constantly good warm under- clothes of flannel, eat plain, easily-digested food, drink no kind of stimulating drink, and take a full, warm alkaline bath twice a week. On getting out of the bath the water should be wiped off quickly, and the whole surface briskly rubbed with dry flannel, which brings a pleasant feeling of warmth and elasticity. Second, medicines should be prescribed on the same principles as we would for chronic rheumatic irritation in any other structure of the body. Whatever medicines are given, however, must be continued faithfully from two to four months, during the interval between each menstrual period. Treatment during the menstrual week can have no effect beyond palliating the suffering of the patient temporarily. To become cur- ative it must be extended through the interval, for the purpose of so changing the condition of the uterine structure and sensibility as to prevent the recurrence of the pain at the next period. In the most common class of cases, in which the pain is severe and the flow scanty, Dr. Davis has for many years used success- fully the following formula : 49. If.. Tinct. cimicifugae, f.§iij Tinct. stramonii, f.3ss Vin. colchici rad., f.^ss. M. Take one drachm at each meal time in water. If, by long continuance or unusual susceptibility, the cimicifuga causes dull headache, as is sometimes the case, either the dose should be lessened, or the fluid extract of cypripedium may be DYSMENORRHEA. 5 3 substituted in its place. In the same manner, if the colchicum should cause disturbance of the bowels, its quantity must be les- sened in proportion to the other constituents. Another prescription with which he has succeeded in many in- stances, especially when the pain and soreness extended to the region of the ovaries, is as follows : 50. I£. Ammoniaehydrochlor., §iij Tinct. stramonii, f.§ss Tinct cimicifugae rac, f.giss Syr. glycyrrhizse, f* . § i j . M. Teaspoonful three times a day. Another useful prescription is : 51. I£. Acidi salicylici, 3iij Sodii bicarbonatis, 5ij Tinct. stramonii, Vini colchici radicis, aa f.5iv Glycerinas, f.S Aquae, f.§iij. Teaspoonful four times a day in water. M. In connection with their medical treatment, Dr. Davis instructs his patients to place themselves in the " knee and chest " position for a few minutes three times a day. The hips are high, the knees and chest low, thus throwing the uterus by the force of gravity into its natural position. Any form of pessary only adds to the sufferings of these patients. DR. JULIAN S. WOODRUFF, OF SOUTH CAROLINA. To meet the severe pain which occurs in some of these cases of dysmenorrhea, this writer states, when morphine and atropine are combined in solution and injected under the skin for the relief of the suffering, their instantaneous effects are truly wonderful and charming. An injection of this combination subcutaneously has in three minutes extinguished all pain, the patient straightening out and laughing and talking. DR. HENRY E. WOODBURY, OF WASHINGTON. The treatment of this practitioner ( Va. Med. Monthly, Sept. 1878), is to introduce a very small tent of elm bark into the cervix about a week before the menstrual flow commences. After intro- ducing the tent, a plug of cotton, to which a cord is attached, is passed through the speculum to keep the tent in situ. The plug 54 DISEASES OF THE OVARIES. is then saturated with carbolic acid and olive-oil, or glycerine, in the proportion of I to 7. By means of the cords attached to the tent and plug, the patient removes them next morning, and uses an enema of water and Castile soap. In an obstinate case, a tent is used every day up to the time at which the flow should com- mence, unless it is established sooner, substituting larger and larger ones as the cervical cavity becomes dilated. As soon as the tent, on removal, is found to be freely stained with blood, its use is suspended until a week before the next period. The remedies administered internally are concentrated tincture of helonias, fluid extract of ergot, tincture of gelsemium ; or syrup of the iodide of iron. The patient commences to take one of these three weeks before the regular date of her flow, and contin- ues it till this is fully established. She then suspends it for a week or ten days, after which she resumes it. Sometimes better results are obtained by using two of the above-mentioned remedies alter- nately, as the helonias and the iron, or the ergot and iron. A gentle current of electricity is passed through the uterus once a day for two or three days before the period. This treatment has been successfully employed in cases of dysmenorrhea due to sub- acute inflammation or displacement resulting in the constriction or occlusion of the cervix. DR. JOHN WILLIAMS, OF ENGLAND. Membranous Dysmenorrhea. This writer {Obstetrical Transactions, 1877), is of opinion that the inflammation of the internal surface of the uterus, often found in these cases, is the result, not the cause, of the membranes, but is the result of the membranous dysmenorrhea. He does not believe they are the results of abortion, as they frequently occur in virgins. The source of mis- chief must be looked for in the walls of the uterus itself. The membrane is the decidua ordinarily shed as debris at menstruation. Dr. Williams thinks there is something wrong in the uterus from puberty ; in fact, imperfect evolution. As regards treatment, everything should be done to favor the physical development of the young girl. Once the condition is established, the only means whereby a cure is likely to be effected is electricity, eitljer in the form of the continuous current, or by a galvanic stem. ftjjju* t-tZvvc vvvOL^v^yCu^ lit ^y-^fuy )^*i^OVi. DYSMENORRHEA. RESUME OF REMEDIES. * Ammo nice Acetatis Liquor. In painful menstruation, f.3j doses of this preparation of ammonia, given every hour when the pains come on, will often be found to lessen or wholly dissipate them. Barnes recommends : 52. R. Spiritus setheris comp., f-3ss Liq. amnion, acetat., gtt. xv. M. For one dose several times daily. Ammo nice Marias. The following is highly recommended by Dr. O. Ward, of Tennessee, in the painful dysmenorrhea of the climac- teric period : 53. R. Ammonise muriatis, 3ij Extracti glycyrrhizae, §ss Aquae, f-3 v j- M. A dessertspoonful three times a day. Amyl Nitrite has been found of great benefit in spasmodic dysmenorrhea by Dr. Mary Putnam Jacobi, especially when supported by belladonna, commenced previous to the beginning of menstrua- tion {New York Medical Record, Jan. 2, 1875) ; or it may be given in one-drop doses in peppermint water every half hour (Sell). Apiol, in the hands of Dr. Tilt, of London, acts like a charm when given in doses of four grains, so soon as the pains of dysmenorrhea begin. It of is little use, however, when the dysmenorrhea de- pends upon disease of the uterus. ^Belladonna. In neuralgic dysmenorrhea, Dr. Anstie, of London, re- commends {British Medical Journal, August 22, 1868,") the extract, as a palliative, in doses of gr. \. He obtained still bet- ter results from the hypodermic injection of the sulphate of atropia, in doses of gr. yro" - ¥0"' twice a day, and continued for several weeks, at once reducing the quantity when marked dry- ness of the throat appeared. In constitutions very intolerant of belladonna in any form, the acetate of morphia may be advan- tageously substituted for the atropia. A belladonna plaster to the sacrum is often of benefit ; so also is a suppository of extract of belladonna. Brominium acts efficiently, according to Barnes, in ovarian dysmenor- rhea. Camphor. Dr. Dewees regards camphor as a very certain and uniform palliative, in doses of gr. x, every one or two hours, until relief be obtained. Or the following injection may be given : 54. R. Camphors, 3ss-j Tincture opii, f.3j Mucilaginis, q. s. M. For an enema. 56 DISEASES OF THE OVARIES. Camphor liniment, or ointment, well rubbed into the loins, also affords relief. Cannabis Indie a is sometimes a useful remedy. Cimieifuga. The eclectic practitioners speak of this as a most efficient remedy in dysmenorrhea, and temporary suppression from cold, or where there is a rheumatic diathesis. Phillips endorses this statement from his own experience {Mat. Med., 1879). (F. 49.) Colchicum is useful in dysmenorrhea connected with a tendency to gout or rheumatism. It should be given with blue pill every other night ; flannel at the same time should be worn, and exposure to cold avoided. (F. 48.) Cocculus Indicus. In thin and nervous females, where the discharge is scanty, and preceded by paroxysmal griping pains, Dr. C. D. F. Phillips {Mat. Med. and Ther., 1879), states that the administration of cocculus, commenced a few days before the period, will frequently ward off the pains and render the discharge natural. The dose is niij-x, of a tincture 1-8. * Ferri Chloridi Tinctura and Ferri Vinum are both excellent prepara- tions in ovarian atonic dysmenorrhea. Sir Charles Locock recommends the following formula : 55. ^. Vini ferri, Spiritus astheris sulphurici compositi, aa f.3j Mixturae camphoras, f-5 v j- M. Take one-fourth part every six hours. Crocus Sativus. The saffron is much employed by French practitioners in dysmenorrhea, both as infusion and tincture, and also locally. The following " cataplasme antispasmodique " is highly recommended in painful cases : 56. I£. Croci contusi, 5iij Pulv. camphoras, Opii pulveris, aa 5j Lini, gviij Aquae ferv, q. s. Mix the saffron and opium with a little water, and then stir this and the camphor into the poultice and lay it warm upon the painful uterus. It is especially grateful in " uterine colic," or "utenue rheumatism." Gossypium. Dr. L. Alexander, of Penna., has found much benefit in the following : 57. ~2f.. Extracti gossypii fluicli, f.^ij Extracti ergotae fluidi, Tinct. hellebori nigri, aa f.$j. M. Teaspoonful every three hours, commencing two or three days before the expected attack. *Guaiacum is often productive of the greatest benefit. The tinctura guaiaci ammoniatce is especially serviceable. In ovarian and DYSMENORRHEA. 57 rheumatic forms, .it deserves to be called a specific. In chronic cases, it should be accompanied by the iodide of potassium. Oleum Terebinthince, in doses of gtt.xx, thrice daily, with warm baths, is recommended in membranous dysmenorrhea by Trousseau. * Opium. Opiates are often best exhibited in the form of enemata. Dr. E J. Tilt, of London, recommends a hot linseed-meal poul- tice, sprinkled with laudanum, to be applied to the hypogas- trium. A single hypodermic injection of morphia, when the pain is habitually severe, will often be sufficient at each men- strual period. * Potass ii Bromidum. This sedative is especially valuable in neuralgic, ovarian and membranous dysmenorrhea. It should be given in large doses, prior to the commencement of the period. Potassii A T itras has been found highly serviceable, in doses of gr. xv-xx, well diluted with barley water. Sinapis. Dr. Ashwell recommends the mustard hip-bath, to be repeated three or four times a day, the patient remaining in it for from thirty to sixty minutes, or even, if the pain be very severe, until faintness is induced. Sodii Biboras is of advantage combined with extract of belladonna. Stramonium is said to be of marked benefit in the severe form of the disease. Taraxacum. A half teaspoonful of the extract in a little warm milk every night proves useful, by keeping up a healthy action of liver and skin. Veratria. Mild veratsia ointment, rubbed over the hypogastric region twice a day, greatly relieves the pain. Viburnum Prunifolium affords often great relief if taken for a few days before the menses appear. Dr. E. W. Jenks ( Trans, of the Amer. Gyn. Soc , 1876), states that in all forms of dysmenor- rhea attended with profuse menstruation it is of much value, but where the flow is scanty, it does not prove beneficial. It is not sufficiently sedative, if given alone, freely to relieve the suffer- ings of spasmodic or neuralgic dysmenorrhea ; but it is a valu- able adjunct to sedative and antispasmodic remedies. The dose is f.3ss-j of the fluid extract, three or four times a day. MECHANICAL REMEDIES. Galvanism. Dr Wm. B. Neftel (New York Medical Record, Oct. 6, 1877), gives notes of the cure of two cases of aggravated dys- menorrhea of long standing, which had been treated thor- oughly but unsuccessfully, by some leading gynecologists, but which readily yielded to treatment by the galvanic current. He believes that dysmenorrhea is essentially of nervous origin (a visceral neuralgia), though it is frequently accompanied by structural or mechanical derangements of the womb ; and that these derangements are frequently the consequences of the ner- vous affection rather than the cause thereof. His treatment is as follows : A constant current of consid- 58 DISEASES OF THE OVARIES. ter, discovered by Budge in the spinal cord (situated somewhat erable intensity is directed chiefly towards the genito-spinal cen- above the lumbar enlargement), and a current of moderate in- tensity toward the medulla oblongata. No local treatment of the womb is resorted to. Rapid Dilatation of the canal of the neck of the uterus in painful men- struation resulting from a narrow and restricted condition of the uterine canal, has been very successfully applied by Dr. Ellwood Wilson, of Philadelphia ^American Gynecological Transac- tions, 1877). .This he accomplishes by means of an instrument designed for the purpose. MENORRHAGIA AND METRORRHAGIA. PROF. ROBERT BARNES, OF LONDON, Says in all cases of hemorrhage from the uterus, obtain and main- tain a patulous condition of the cervical canal. This, of itself, often arrests the bleeding-. Remove everything in the shape of a foreign body, as clots, retained ova, membranes, or placenta. To do this, one or two fingers may be passed in to break them up. Hemostatics may be introduced by means of a swab of cotton wool, twisted on a roughened probe; or where, by reason of the narrowness of the canal, this is impracticable, injections or solid styptics may be used. The best way is by inserting small bits of sponge in a tube made like the uterine ointment positor, and satu- rating this with the styptic. The tube is then passed into the uterus, and pressure of the piston squeezes out the fluid, drop by drop, upon the bleeding surface. This failing, the styptic must be injected boldly. In passive hemorrhage, the general vascular tension, the in- creased action of the heart, and the determination of blood to the pelvic organs, must be moderated. The most useful agents here are digitalis, aconite, bromide of ammonium or potassium, some- times opium, ipecacuanha, chloral, salines, as acetate of ammonia, nitrate of potassa. Cold is often useful. Ice in the vagina or cold water injections should always be tried early. Position is important ; keep the pelvis above the level of the body. Saline purgatives especially operate with advantage. Internally, the most useful are turpentine in capsules, ergot in fluid extract or powder, or ergotine, tincture of hamamelis in five or ten drop doses every three or four hours, quinia, strychnia, sulphuric or phos- phoric acid, tannic or gallic acid, acetate of lead, the vinca major, Indian hemp, ipecacuanha. All failing, styptics locally must be used. The after-treatment does not at first require iron ; this only adds fuel to the fire ; the system requires, first, salines, these serve better to replenish the exhausted circulating fluid. They subdue vascular excitement, allay fever, calm nervous irritability, improve the secretions, and prepare the way for iron and other tonics. The (59) 60 DISEASES OF THE OVARIES. best form of saline is the freshly prepared acetate of ammonia ; to this may be added a sedative, as Battley's solution, and sometimes digitalis or aconite. Later, hamamelis, ergot, quinine, mineral acids, and a decoction of bark, and later still, iron. The best forms are the citrate, acetate or chloroxide in an effervescent form, or the dialyzed iron, at first in small doses to feel the way. Sleep is of signal service, opium with the saline, or as the compound opium pill in five-grain doses, or as pulv. ipecac, comp., ten grains. If not well borne, we have a precious resource in chloral, in scruple doses. PROFESSOR T. GAILLARD THOMAS, NEW YORK. This author says that in cases of menorrhagia the patient should be kept perfectly quiet upon her back ; cloths wrung out of cold water should be laid over the uterus, vulva and thighs ; cold acid- ulated drinks should be given freely ; and the injection of all warm fluids strictly interdicted. In addition, the apartment should be kept cool, the nervous system quieted by opium or an appropriate substitute, and all conversation prohibited. In mild cases this may suffice, but in severe ones it will not. Then the speculum should be introduced, a sponge-tent passed into the cervix, and the vagina filled with a tampon. This will rarely fail. But in certain cases, as, for instance, those of cancer of the neck, the tent will not be admissible. Under these circumstances, a soft sponge or wad of cotton should be saturated with a solution of persul- phate of iron, laid upon the cervix, and the tampon placed against it; or a small linen bag may be filled with powdered alum, placed in contact with the cervix, and held in place by a tampon ; or two drachms of tannin may be left free against the part. To these means almost all cases will temporarily yield, more especially if the use of the tent is admissible. Where the menorrhagia is due to a fungous degeneration of the intra-uterine membrane, the curette is a most valuable resource ; or the lining membrane of the uterus may be modified by ener- getic agents, as nitric acid, tincture of iodine, nitrate of silver, etc. In very obstinate cases, change of climate will often prove of decided benefit. f . MENORRHAGIA AND METRORRHAGIA. 6 1 PROF. ROBERTS BARTHOLOW, M. D., PHILADELPHIA. When menorrhagia is the result of impoverished state of the blood, iron is the most appropriative medicament. It maybe com- bined with arsenic. Gallic acid is very effective, as in the following formula: 58. R. Acidi gallici, 3ss Acid, sulphur, dil., f.5j Tinct. opii deod., f.3j Infus. rosag comp., f.§iv. M. A tablespoonful every four hours, or oftener. When there is a large spongy uterus, ergot is indicated. When, caused by ovarian excitement, bromide of potassium will promptly relieve. Ipecacuanha possesses very valuable anti-hemorrhagic powers ; it should be frequently repeated. 59. R. Ext. ipecac, fluidi, f.5ij Ext. ergotae fluidi, f.3iv Ext. digitalis fluidi, f.'3y. M. Thirty minims to a teaspoonful at a dose, as required. In debilitated and relaxed subjects, menorrhagia may be relieved by determining an afflux of blood to the uterine system. Iron and aloes may be here associated. But the latter would be contra- indicated where there already existed congestion of the pelvic viscera. EDWARD JOHN TILT, M. D., LONDON. This writer lays much stress on the importance, in severe cases, of placing the head on a level with the body. Sedatives are always beneficial. The bromide of potassium or of ammonium has been known to check the tendency to menorrhagia. In many cases, damaging blood loss may be checked by the ex- hibition of full doses of the liquid extract of ergot and the tinc- ture of digitalis, f.oss three times a day, as: 60. R. Tincturae digitalis, Extracti ergotae fluidi, aa f-3iij Aqua? destillatae, ad f.§vi. M. The sixth part to be taken three times a day for three days. While giving these remedies, a two grain opium suppository should be passed into the rectum once a day, even if there be no 62 DISEASES OF THE OVARIES. pelvic pain, for opium has often helped to quell blood-flow. In any case, it is well to commence with small doses of ergot and digitalis a few days before the menstrual period is due. PROF. GRAILY HEWITT, M. D., LONDON. The treatment must of course in all cases have reference to the exciting cause of the profuse flow. Flexion or congestion of the uterus is frequently present. It must receive attention. The external employment of baths is of the greatest service, especially cold hip-baths and sponge-baths. Cold to the spine, by means of ice-bags, has proved of service. Injections of cold or iced water into the rectum is a valuable means of arresting the flow of blood in bad cases. Dr.- Hewitt believes that styptics taken internally are frequently found very serviceable; of them, he considers the most efficient to be matico in combination with tincture of iron, or the latter alone in large doses, TT^xxx-xl. Opium has been highly extolled, but does not appear to be adapted for chronic cases. Where the discharge is exhausting, stimulants and nourishment should be freely administered in small quantities at frequent in- tervals. PROF. WILLIAM H. BYFORD, M. D., OF CHICAGO. This practitioner, in the Transactions of the International Med- ical Congress, 1876, discusses in considerable detail the treatment of metrorrhagia. In the palliative treatment, isolation, quietude, and recumbency, are very important cautions to be enjoined. Plain food, cool clothing, and general hygienic rules, are indispensable. In regard to druo-s, Dr. B. has derived considerable advantage from astrin- gents proper. The most generally applicable agent is ergot; but it will usually fail when the flow is venous, as in retroversion, pelvic infraction, tumors, etc. When there is much pain in the pelvis, and a dry state of the skin, opium and ipecacuanha are very serviceable. When vascular and nervous excitement is prominent, lobelia, gelsemium, digitalis, aconite, and veratrum vir- ide, are all of use. These measures failing, we must resort to either mechanical or chemical means. The former is represented by the tampon ; the latter by powerful hemostatics. They may be all advantageously MENORRHAGIA AND METRORRHAGIA. 63 combined, as in the plan proposed by Dr. Marion Sims. His hemostatic is — 61. I£. Liquoris ferri subsulphatis, f.§ss Aquae, f.gj. M. The finest cotton wool is saturated with this, and then submitted to moderate pressure and dried for use. Its application is made by wrapping a sufficient quantity around a long, small piece of whalebone, and introducing it into the cavity of the uterus, when the cotton is detached and left there. If the hemorrhage is moderate, one such piece will suffice ; if severe, it will be necessary to stuff the uterine cavity full. Strong thread can be attached to the cotton to withdraw it when necessary. From twelve to twenty-four hours is as long as it should remain. In the intermenstrual period, curative measures should be resorted to, as alteratives, tonics and derivatives. Muriate of ammonia will be found especially valuable. When debility is present, among the very best remedies is — 62. ty.. Hydrargyri chloridi corrosivi, gr. ^-i Tinct. cinchonas compositi, f.3j. M. This amount thrice daily. Iodine, iodide of potassium, and iodide of iron, are also effi- cient. A beneficial derivative measure is dry cups over the sacrum often repeated. The cups should be large, and allowed to remain for an hour or more. M. PAN AS, M. D., OF PARIS. Among the various manipulative measures used in severe metrorrhagia, preference is given by this writer to plugging the cavity of the neck of the womb, which has several advantages over plugging the vagina in such cases. It stops the blood more effectually, the patients bear it better, and there is less chance of putrid absorption. The plan adopted by M. Panas consists of introducing into the cavity of the uterine neck a pledget of cotton wool, rolled up to about the thickness of a goose-quill, and steeped in a solution of the perchloride of iron of the French Codex, to which is added one part of water, to prevent its caustic effects. This being done, he introduces a ball of cotton wool and places it in the posterior cnl-de-sac of the vagina, where it not only forms a support to the uterine plug, but it absorbs, any liquid that may 64 DISEASES OF THE OVARIES. escape through it, and thus protects part of the vagina (which is covered with the peritoneum) from the corroding effects of the perchloride of iron and the acrid discharges from the womb. DR. EMIL DILLENBERGER, VIENNA. The treatment of menorrhagia according to the Vienna school comprises rest, horizontal position with the pelvis elevated, low diet, and cooling drinks, such as : 63. R. Acidi tartarici, gr.x-xxij Syrupi aurantii floris, f-3 v j Aquae, f.§xv. M. For drinking. 64. R. Tamarindi, §j Fiat decoctum librae unius, (Acidi sulphurici aromatici, f-3j-ij) Syrupi rubri, f.§ss-j. M. For drinking. 65. R. Acidi sulphurici aromatici, f.3ij Syrupri rubri, f.§j. M. One to two teaspoonfuls in a glass of water as a drink. These directions and prescriptions, together with pure air, only moderately warmed, in the room, are some of the most important points which alone will often restrain rather free bleeding. When there is passive hemorrhage, use cold dressings, injections of cold water, or the following astringents : 66. R. Aluminis, Aquae, For vaginal injections. 67. R. Acidi tannici, Aquae, For vaginal injections. 68. R. Zinci sulphatis, Aquae, For vaginal injections. 69. R. Catechu, Aquae, For vaginal injections. 70. R. Extracti krameriae, Aquae, For vaginal injections. 3ij-ivss f.giv. M 3ss-iv f.^xv. M gr.x-xxxiv Oj. M, 3ij f.§xv. M, 5ij f.gxv. M. MENORRHAGIA AND METRORRHAGIA. 65 Plugging $e vagina is also an effectual remedy. Among internal remedies, those that have generally shown themselves the best are : 71. ty.. Ferri chloridi, gr.xvj Tincturae opii, gtt.x Syrupi tolutani, f.^ij Aquae, f.§vj. M. A tablespoonful every one to two hours. 72. fy. Pulveris ergotae, Sacchavi albi, 5S gr.xxxiv Olei cinnamomi, gt.j. M. Divide into six doses. One powder every five minutes. 73. R. Extracti ergotae fluidi, Tixxx-xl Syrupi acacise, f.3U Syrupi aurantii florum, f.§ss Aquae, f.^iij. M. One tablespoonful four times a day. 74. I£. Extracti krameriae, gr.vj-xx Aluminis, Sacchari albi, aa gr.xxij Olei cinnamomi, gt.j. M. Divide into six powders. One powder every two to five hours. 75. J£. Aluminis, gr.xxxij Tincturse cinnamomi, f.5U Syrupi aurantii corticis, f.§ss Aquae cinnamomi, f.§iv. M.. One tablespoonful hourly. RESUME OF REMEDIES. Achillea Millefolium, the yarrow, has beneficial properties where the excessive flow depends on atony of the organs. Acida. The mineral acids internally have been familiar to the profession for many years as remedies for excessive flowing, but their efficacy has been doubted of late years. (See F. 58, 65). A lumen often proves successful in controlling the hemorrhage. Dr. E. J. Tilt, of London, says that in uterine hemorrhage, alum, in solution with sulphuric acid, is the first remedy to try. Ammo nil Bromidum. In cases of too frequent menstruation, not spec- ially connected with menorrhagia, but rather with abnormal activity of the genital system, Dr. J. R. Black, of Ohio, has found decided benefit from this drug, gr. x, four times daily, beginning at least a week before the expected molimen {Half Yearly Compendium, July, 1879). Argenti Oxidum is an efficient remedy in menorrhagia. More than three grains daily should not be given. Arseniosum Acidum. Fowler's solution is said to check uterine hemor- 5 66 DISEASES OF THE OVARIES. rhage, given at first in the dose of ttjx-xx, and repeated in ttix doses every twenty minutes until the discharge ceases. This remedy must not, of course, be pushed too far. Berberies Sulphas. Dr. R. H. Andrews, of Pennsylvania {Trans, of the Pa. Slate Med. Soc, 1877), reports very satisfactory results with this drug in cases of profuse exhausting menstruation. He prescribed the remedy as follows : 76. I£. Berberiae sulphatis, Bj Sacchar. albi, 3iss. Make 12 powders. One of these powders is directed to be taken when the flow is very free, or if not free, in three or four days after the menses have appeared ; repeated in four or eight hours, according to indications. The effects of such an administration of the remedy are, a cessation of the profuse flow, diminution in the length of the period, and in a measure curative of the disease. Borax is employed by some practitioners. (See under Ergota). * Cannabis Indica. Dr. Churchill, of Dublin, obtains from the tincture of Indian hemp, in doses of gtt v-x, thrice daily, remarkable success in the treatment of menorrhagia and uterine hemor- rhage. Dr. Thomas, of New York, pronounces it one of the best agents in this disease at our command. Catechu may be used in passive hemorrhage. (F. 69). Cimicifuga. Dr. Ringer, of London, says this remedy will certainly arrest menorrhagia, though he regards it as inferior in this affection to the bromide of potassium Cinnamomum is a grateful stomachic, and nearly always of value in ute- rine hemorrhages. It may be given as tincture or in the pow- der, 9j. at a dose. Digitalis is useful in menorrhagia and other forms of uterine hemorrhage, unconnected with organic disease. Dr. E. J. Tilt, of London, employs the following : 77. $. Tincturae digitalis, f.5ij Acidi hydrocyanici diluti, ttjxxx Morphias acetatis, gr.j Aquam, ad f.§yj. M. A dessertspoonful every two or three hours. Dr. W. H. Dickinson recommended the infusion §j— iss. * Ergota, though not equally beneficial in all cases, is a useful remedy in menorrhagia. Dr. Waring-Curran states {Medical Press, Nov. 17, 1869), that it proves most useful in that form of menorrha- • gia which occurs in women of a scrofulous habit, who suffer from constipated debility, and in whom leucorrhcea exists as a consequence of previous hemorrhage. He gives freshly pre- pared infusion of ergot and borax in menorrhagia from obstruc- tive cardiac disease, in that associated with a diseased portal • MENORRHAGIA AND METRORRHAGIA. 67 system, in that consequent upon a scorbutic state of the system, and in genuine menorrhagia (*. . Zinci valerianatis, 3j Syrupi, q. s. Divide into twenty pills. One to be taken three times a day. PROF. FELIX VON NIEMEYER, M. D., TUBINGEN. 94. I£. Auri et sodii chloridi, gr.v Tragacanthae, 5j Sacchari, q, s. M. Divide into forty pills. Order at first one of these pills to be taken an hour after dinner, and another an hour after supper. Afterwards order two pills to be taken at these hours, and gradually increase dose up to eight pills daily. Dr. N. speaks of this preparation as a nervine of great efficacy in hysteria. He has made use of it with signal effect in many cases where there was no indication for the local treatment of uterine disease, or else where the hysteric symptoms persisted, although the local uterine affection had been cured. DR. F. T. PORTER, OF DUBLIN, Has found (Dublin Journal of Medical Science, April, 1874,) the bromides to act most injuriously in hysterical cases, deranging digestion, weakening the heart, and retarding menstruation. He prefers the valerianates, hemlock, and lupulus. When there is spinal tenderness, he employs iron. When plethora is present, as evinced by increased temperature, vascular relaxation and con- tracted pupil, he considers belladonna a most efficacious remedy. DR. S. WEIR MITCHELL, OF PHILADELPHIA, Believes that mimetic hysteria can be cured almost unfailingly; but to accomplish this the patient must be isolated from the cares 74 DISEASES OF THE OVARIES. and sympathy of home, and placed in an institution under strict surveillance. Valerianate of zinc in 12 gr. doses thrice daily is a valuable sedative. If there is marked anemia, the patient should be put to bed and fattened by the use of massage, electricity, and excessive feeding. EDWARD JOHN TILT, M. D., LONDON. 95. I£. Tincturae castorei, f.3iij Spiritus lavandulae compositi, f-3vj Aquam camphors, ad. f.§vj. M. A tablespoonful two or three times a day when cerebral symptoms and hysterical phenomena are marked, The therapeutical indications in the treatment of hysteria are : 1st. To blunt the sensitiveness of the nervous system by sedatives and antispasmodics, and to strengthen it by metallic and other tonics, and by hygiene. 2d. To cure all diseases of the sexual organs, and save the nervous system from visceral irritation, by good hygiene at menstrual periods; or by marriage, when the sexual organs crave their legitimate satisfaction. GERMAN PHARMACOPOEIA. 96. I£. Tincturae asafcetidae, f.3i v Tincturse castorei, f-3jij Tincturae opii, f.5j. M. From fifteen to thirty drops, by the mouth or in enemata, twice or three times a day, in the hysterical attacks of dysmenorrhea. Bitter drinks and preparations of iron in the intervals of the attacks, if the patient be anemic. RESUME OF REMEDIES. ALther. Nothing, according to Stille, so distinctly moderates the par- oxysms of this disease as the inhalation of ether. Those who have found the spasms aggravated by a certain degree of etheri- zation have not administered a sufficient quantity of the vapor. If persisted in, it would undoubtedly have put an end to the fit. Allium. The smell of bruised garlic will sometimes promptly terminate a hysterical paroxysm. Atropia. In hysterical trismus, nothing acts so well as hypodermic in- jections of this alkaloid. Full doses are required. Auri et Sodii Chloridum is prescribed by Dr. Niemeyer. (F. 93.) Aloes. The pill of aloes and asafcetida is very serviceable in the con- stipation of hysteria. * Ammonium. The carbonate, the aromatic spirits, the foetid spirit, the valerianate, and other preparations, are much used and of great value. HYSTERIA. 75 Amhemis. A wineglassful of the infusion of chamomile may be given with advantage thrice daily. * Asafcetida is a most valuable medicine in this disease. It may be given alone, or combined as directed in the following form : 97. I£. Tincturae asafoetidae, Tincturae castorei, Tincturae Valerianae ammoniataa, aa f.5u Aquae camphorae, f . 3 v i j . M. Dose. — One or two tablespoonfuls every hour. Asafaetida may also be given, in the form of an enema. (F. 95.) Aurantii Flores. Orange-flower water is much used and valued in France. It is an elegant stimulant and antispasmodic, in doses of from one to two fluid ounces. Cajuputi Oleum internally is often of benefit. Camphor a is a very serviceable remedy, either alone or in combination with asafcetid aor opium. Cannabis Indica is sometimes useful. Chloroform inhalation is highly praised by Dr. Brown-Sequard and Dr. Graily Hewitt, in severe and prolonged hysterical parox- ysms. Internally it may be given with ammonia or asafcetida. A liniment of chloroform often speedily relieves hysterical pain in the side. Cupri Sulphas, in small doses, long continued, is recommended by Sir B. Brodie, in obstinate hysteria. Cusparia Cortex. The infusion is an eligible light tonic in hysteria. Ferrum is indicated in hysteria associated with anemia. It may be given combined with valerian and other antispasmodics. Galbanum sometimes agrees better than asafcetida, and may produce equally favorable results, particularly in cases associated with disordered uterine functions. A galbanum plaster over the sacrum often affords relief. * Lavandula is sometimes an effectual remedy. Lupulin has been recommended in chronic hysteria, attended with mor- bid vigilance, in doses of ten grains every six hours. Moschus, in doses of gr. x-xv thrice daily, is a valuable remedy, particu- larly when the surface is pale and the pulse languid. Potassii Bromidum is sometimes a useful sedative in hysteria. Its use was suggested in this disease by Sir C. Locock. Ruta. From two to five drops of the volatile oil, on sugar, is a popular remedy; so also is the infusion of rue. ^Santonin sometimes proves useful in revealing the true cause of the hys- terical symptoms, viz., worms in the intestinal canal. *Spiritus AZtheris Nitrosi is often very effectual in relieving hysterical spasms. Terebinthince Oleum, in enema, will often arrest a severe paroxysm when ordinary means fail. j6 DISEASES OF THE OVARIES. * Valeriana is a valuable remedy ; it may be given both during the parox- ysm and in the intervals. Zinci Oxidum is considered by Dr. Waring-Curran as more efficacious in hysteria than the valerianate. Zinci Sulphas, in the dose of one grain, combined with extract of gentian, in pill, two or three times a day, is a valuable remedy in cases of hysteria depending upon debility. It will be found to agree better with many women than the preparations of iron, causing less irritation. Cathartics are to be administered if constipation exists, as it is important in hysteria to keep the bowels open. Aloes are indicated* if there be torpor of the uterine system ; mercurials or podophyl- lin, if there be biliary derangement; and salines, if there be plethora; but active purgation is in no case advisable. EXTERNAL REMEDIES. *Shower Baths are indispensable in the treatment of the paroxysms. (See p. 72.) Dry Cupping at the nape of the neck, between the shoulders, or below the clavicles, during a paroxysm of hysteria, has been found, by Dr. Graves, to be attended with the best results. Electricity. Dr. Laycock advises the persevering and systematic applica- tion of electro-galvanism to the abdominal and pelvic regions, in combination with the internal use of tar. Emetics, An emetic of ipecacuanha, given when the paroxysm is im- pending, often prevents it. Frigus. The sudden application of cold to the surface of the body, in hysterical cases simulating death, will revive the signs of life. Manipulation. Professor Thierry, of the St. Pierre Hospital, Brussels, arrests hysterical paroxysms by what he calls "torsion of the abdominal walls. He grasps in his hands the entire walls of the abdomen, either in their bare state or covered with the chemise, and imparts to them a certain amount of torsion, which he gradually increases, and which he maintains until the paroxysm has passed away, and the woman is come entirely to herself. CHLOROSIS. This name, or that of green sichif.ss, is given to the anemic con- dition of young girls, associated with disordered menstrual func- tion. The blood has an excess of fibrine, and undergoes some chemical change in, its pigments which produces the greenish hue of the skin, whence the disease has its name. Attention to hy- gienic conditions, baths, nutritious food, regularity of the bowels, and judicious mental and physical exercise, are first in import- ance. DR. FREDERICK T. ROBERTS. This writer on Practice considers aloes the best form of aperient, either the extract, or as pit. aloes cum myrrha. For the unpleas- ant sensations in the stomach, bismuth, with hydrocyanic acid, is particularly valuable. For the pain in the side often complained of, a belladonna plaster is usually efficacious. Iron is the great remedy ; and it is frequently desirable to change the form of the preparation from time to time. PROF. A. P. REID, OF MONTREAL. This writer (Canada Medical Record, 1875,) has adopted, with signal success, in uncomplicated chlorosis, the use of Honor potasses, gtt.x-xv, in mucilage, thrice daily. It defibrinizes the blood, and often acts promptly for good where iron is of no avail. DR. BRETONNEAU, FRANCE. 98. I£. Ferri redacti, 3ij Quinise sulphalis, Zingiberis pulveris, aa gi'.vij Extracti cinchonas, ■ £)j Aloes socotrinas, gr.iij. M. Divide into fifty pills. One to five a day. These pills have the advantage of not causing constipation. DR. GAILLARD, PARIS. 99. fy. Ferri carbonatis, Extracti cinchonas, ila 3ijss Extracti opii, gr.xv. M. Divide in!o cne hundred pills. From two to four a day, principally at meal times. When there is constipation, this formula ought to be modified as follows : (77) 7 8 DISEASES OF THE OVARIES. ioo. $. Ferri carbonatis, 5'j Extracti cinchonae, Extracti rhei, aa 5i ss Extracti opii, gr.xv. M Divide into one hundred pills. To be taken as above. PROF. E. J. TILT, M. D., Believes that, in addition to the general treatment, we require some means of increasing ovarian energy. He directs the patient to wear during the day a bit of piline large enough to cover the ovarian regions, sprinkled with alcohol. DR. LOMBE ATTHILL, OF DUBLIN, Regards strychnia as of the highest value; he gives five drops of the liquor strychniae, equal to ^ of a grain of the alkaloid, gradu- ally increased to IO drops three times a day, or combined with tincture of perchloride of iron. Strychnia acts as a powerful stim- ulus to the ovaries as well as a general tonic. When there is no anemia, five drops of tincture of iodine, and five of solution of strychnia, are of great value. For the constipation, he uses two grains of sulphate of iron with a quarter or half a grain of extract of aloes, three times a day. This often acts like a charm. PROF. T. GAILLARD THOMAS, M. D., NEW YORK. Regards the indications as to remove the cause, cure the neurosis, repair damages ; then change of air, well-regulated open air exer- cise, sea bathing ; tonics, as arsenic, strychnine and quinine. The continuous electric current and general electrization often are beneficial. For the anemia he gives : 101. I£. Ferri vini amari, f.gvijss Tr. nucis vomicae, f.Siv Liq. potas. arsenit., f..3U- M. A dessertspoonful in a glassful of water just after each meal. GRAILLY HEWITT, M. D., LONDON, Regards the accompanying dyspepsia as best treated by food fre- quently and in very small quantities for days together, and of the simplest character, avoiding solids. Ferruginous preparations are essential, but should be given in small doses, and are best in the form of mineral waters. CHLOROSIS. 79 HENRY M. FIELD, M. D., OF BOSTON. In cases of females where their maladies were connected with anemia indicating the use of iron, this writer has been very much pleased with the action of oxalate of iron, a preparation first brought to notice by Prof. Craig, of the Smithsonian Institute. It is a light and tasteless powder, with nothing repulsive in its appearance or odor. It may be given as a powder to those patients who object to the pill form. The dose is gr. ij-iij. He states that it is less liable to cause irritation or constipation of [the bowels than other ferruginous preparations, and many patients who have asserted they could not take iron in any form, have taken this without difficulty. RESUME OF REMEDIES. Aloes. This is frequently very efficient. (Seep. 77.) Bismuthi Subnitras. Sir H. Marsh states {Medical Press, March 6th, 1867), that in chlorosis, bismuth is an excellent substitute for iron, when the latter is not well borne. Cocculus Indiais is recommended by Phillips in chlorosis with amenor- reha. Ergot, in five-grain doses, three or four times a day, is recommended by Churchill, in chlorosis and leucorrhea. * Ferri Iodidum. In chlorosis, accompanied by much torpor of the sys- tem, Dr Ashwell has found this salt particularly efficacious, in the following formula : 102. Of.. Ferri iodicli, gr.xvj Tincturae calumbae, f.§j Aquae, f-§vij. M. Take two tablespoonfuls twice a day. *Ferri Mistura Composita, Ferri Chloridi Tinctura, Ferri et Quinice Citras, Ferri Sulphas, and Ferri Vinum, are all excellent fer- ruginous preparations in chlorosis. Sir H. Marsh advises {Medical Press, March 6th, 1867), the following formulae : 103. fy. Liquoris ammonias citratis, m Ferri et quiniae citratis, Syrupi, Aquae, gr.vij-xxiv f.5iv. M Two tablespoonfuls three times a day. 104. I£. Ferri sulphatis, Aloes, Pulveris cinnamomi, aa g r -U gr.v. M For two pills, to be taken at dinner-time, and repeated at night if necessary. 80 DISEASES OF THE OVARIES. Sadce Biboras. Dr. Copland advises the following formula: 105. Vf.. Sodas biboratis, 3ij Sulphuris praecipitatce, 5j Mucilaginis acaciao, q. s. M. Make twenty-four pills. Three to be taken three times daily. Nux Vomica. Dr. Copland has derived benefit in some obstinate cases of chlorosis from the following formula: 106. 'B/.. Pilulae aloes c. myrrha, 3ij Extracti nucis vomicae, gr.x. M. Thirty-six pills. Take one to two night and morning. Potassaz Liquor will occasionally overcome persistent anemia which has defied all other means. Dose 3ss-j, largely diluted, two or three times a day. [For the general treatment of Anaemia see further suggestions in Napheys' Medical Therapeutics, Chapter VI.] THE CLIMACTERIC EPOCH, OR THE CHANGE OF LIFE. PROF. ROBERT BARNES, M. D., LONDON. This author remarks that in many cases the local and constitu- tional disorders which attend the menopause are numerous and severe. Among these may be enumerated uterine and vicarious hemorrhages, a peculiar occipital headache, convulsive seizures, as vertigo and epilepsy, despondency, irritability, and loss of mental power, and various nervous disorders. Dyspepsia, colic, and excessive constipation, are among the most common attendants. Hysteria and pseudocyesis are also frequent. The principles of treatment are primarily to regulate the secre- tions, and exact a strictly hygienic mode of life. If the abdomen is large and the bowels distended with gas, a broad, well-fitting' abdominal belt will give great relief. When the patient is plethoric and florid, the abstraction of eight or ten ounces of blood from the arm, or by half a dozen leeches behind the ears, or by cupping between the shoulders, will often be of signal service. As an alterative, the acetate of ammonia is one of the best ; it may be combined with colchicum or lithia if a gouty diathesis is suspected. A most valuable remedy is bromide of potassium, gr. x-xx, two or three times a day, to calm and regulate the nervous centers. Quinine and strychnia are to be preferred as nerve tonics. To- keep the bowels open the habitual use of laxative saline mineral waters is the most serviceable means. DR. G. E. SUSSDORF, OF GERMANY, In speaking of the general rules for the treatment of disease at the change of life, this author makes the following points (London Med. Record, Dec. 1878). 1. The time of the menopause, as regards the inception and ag- gravation of disease, equals in importance that of puberty, or any other epoch of life. 2. That while, as a rule, the majority of functional and organic diseases of the female generative organs decrease in intensity after the menopause, there is a considerable proportion of cases in which the reverse happens, even to the extent of the disease becoming malignant. 6 (81) 82 DISEASES OF THE OVARIES. 3. In many instances these latter cases do not present decided local symptoms of the pathological conditions present, but are indicated by general signs, which attract attention because they occur at that particular time of life. 4. In no case of general or local disorder, just before or during the menopause, should local examination be omitted, which will frequently reveal at a glance the origin of the hitherto inexplicable phenomena, and also indicate the therapeusis. 5. Such therapeusis should be radical and effective, quite regardless of this particular time of life, the dangers of operating during which have been undoubtedly exaggerated. PROF. J. B. FONNSAGRIVES, OF MONTPELLIER. The indications of treatment for the complications of the meno- pause are as follows [Traite de Therapeutique Applique e. Paris, 1878): 1. To combat the condition of general and local plethora. No measure is so frequently successful as general bleeding, espe- cially from the foot ; or if the uterus is much congested, from the arm. The life should be active, the diet restricted, the sleep light, etc. 2. To combat the menorrhagia. The two most efficacious drugs are ergot and the urtica urens, as : 107. ~fy. Ergotinae, Extracti matico, aa gr.xv. M. Make ten pills. Give one every one or two hours. The urtica urens may be given in decoction, Sj to aquae Oj, of which a wineglassful may be taken every hour or two. Cold baths taken twice a day during the intermenstrual period are often of service. Cold vaginal injections also are beneficial. 3. To combat the nervous complications. These must be treated in detail as they present themselves. An enlightened hygiene is all important. As a rule the use of alcoholics, spiced food, and venereal excitements, should be prohibited. Dr. F. adds the ad- vice, that after the permanent cessation of the menses, sexual ap- proaches should absolutely cease, as they induce to the uterus a congestive afflux, which, useless for the function of reproduction, can only serve to cause various organic affections. THE CLIMACTERIC EPOCH, OR THE CHANGE OF LIFE. 83 PROF. FORDYCE BARKER, M. D., OF NEW YORK. In menorrhagia associated with the climacteric period, the uterus is generally found somewhat increased in size and weight. When such is the case, Dr. Barker directs the patient to use for a week previous to the return of the expected period, rectal supposi- tories made after the following formula : 108. I£, Extracti ergotae aquosse (Squibb), 9ij Butyri cocoa?, 3j- M. Make twelve suppositories. Introduce one into the rectum morning, noon and night. They should be carried well up into the bowel, and the patient should lie down for an hour afterwards. Another plan of treatment, which is usually entirely successful if repeated for two menstrual returns, is to introduce into the cav- ity of the uterus cylinders of iodoform, made according to the fol- lowing formula : 109. fy.. Iodoformi, 3ijss Gum tragacanthse, gr.xv Mucilaginis, q. s. Divide into ten cylinders, each one and one-half inches in length. One of these is to be carried completely into the cavity of the uterus, and a pledget of cotton introduced against the cervix to retain it in position. One of these is to be introduced daily for five or six days before menstruation. The iodoform has an un- pleasant odor, but is the most efficient of all preparations which Dr. Barker has tried in these generally obstinate and troublesome cases. RESUME OF REMEDIES. Ammonia Acetas is considered by Dr. Barnes the best of the saline alter- atives. Carbolicum Acidicm. Dr. Bartlett, of New York {Buffalo Medical Journal, Sept., 1878,) places great confidence in carbolized sponge tents introduced within the cavity of the uterus. He has never seen ill effects, and has frequently controlled, by a single tent, climacteric hemorrhages which had resisted the or- dinary tampon and various astringents. He introduces the tent through the speculum, well up to the fundus, and tampons over it in the usual way. Ergota is an invaluable drug in many cases. (F. 107.) Iodoform is very highly praised by Dr. Barker. (F. 109.) 84 DISEASES OF THE OVARIES. Matico is given internally by Prof. Fonnsagrives. (F. 107.) Urtica. The various species of nettle have long enjoyed a reputation as efficient hemostatics in the hemorrhage of the critical epoch. Dr. W. B. Johnson, of Alabama, speaks highly of the urtica urens (New Orleans Medical and Surgical Journal, Vol. VI.), and Prof. Fonnsagrives gives the weight of authority in its favor. (P. 82.) Purgatives. Mr. Lawson Tait {Diseases of Women, 1879,) says that for the relief of nearly all the subjective symptoms of the climacteric period, he knows nothing better than the occa- sional use of a drastic purgative, and removal from home at frequent intervals. They take the place of bleeding, which, in small amounts, gives in some cases immense relief. CHAPTER II. DISEASES OF THE UTERUS AND ITS ANNEXES. Synopsis of Diagnostic Points — Metritis {Non-puerperal Endo-, Peri-, and Parametritis, Uterine Catarrh, etc) — Cervicitis {Ulcerations and Granulations of the Os, etc.) — Displacements — Non-malig- nant Growths {Polypi, Fibroids, etc) — Malignant Groivths — Steril- ity and Anaphrodisia — Nymplwmania. SYNOPSIS OF DIAGNOSTIC POINTS. GENERAL OBSERVATIONS. The most enlightened school of modern gynecologists discoun~ tenance making gynecology a specialty, either in diagnosis or treatment. In other words, they insist on studying it as a depart- ment of general medicine. " There is, in truth," says Dr. Robert Barnes in a recent lecture {Lancet, May 25, 1878), " nothing more special in gynecology than there is in the study of heart disease, lung disease, or any other disease." And in the same spirit Prof. J. H. Etheridge, of Chicago, writes {Chicago Medical Journal and Examiner, November, 1878): "Just so far as gynecologists can separate this so-called ' science' from the general science of medi- cine, will they obscure the mind of the ordinary practitioner with the error that gynecological cases need special care and skill, and are beyond the necessity for general prescribing." As general rules in the diagnosis of uterine disease, Dr. Barnes recommends that all the functions and organs be studied in a cer- tain regular order, as follows : (1) Aspect, plumpness, color and state of the skin generally. (2) The circulation, pulse, respiration, and temperature. (3) Nutrition, the tongue, appetite, digestion, stomach, intestines, defecation, and bile. (4) The urinary organs, the kidneys and bladder, as to pain, as to retention or other characters, as well as the characters of the urine itself. (85) 86 DISEASES OF THE UTERUS AND ITS ANNEXES. (5) The nervous system, sleep, motor power, general languor or exaltation, excito-motory system, mental state, delirium, pain, and its seat and kind. (6) The sexual organs, the menstrual functions, child-bearing, and the secretions. All these phenomena should be, as far as possible, explored by the aid of manipulation, and the appropriate instruments of ex- ploration. It is a dangerous thing to form a subjective diagnosis ; it is equally dangerous to accept the diagnosis from the patient. With regard to the special symptoms and signs which an exam- ination of the uterus and uterine functions may disclose, we quote from a lecture by Dr. Graily Hewitt the following two lists the first (A) a list of the symptoms of all kinds which may be observed in connection with diseases or affections of the uterus, these symptoms being placed as nearly as possible in their order of frequency. The second (B) is a list of the various physical changes which the uterus may undergo : A. Uterine Symptoms. ( 1. Spontaneous. Pain^ 2. Produced by motion (dyskinesia). ( 3. Undue sensitiveness of uterus to touch. Leucorrhea. Dysmenorrhea. Menorrhagia. Amenorrhea. [If married — Sterility, abortions.] Various reflex phenomena : — 1. Sickness or nausea. 2. Hysteria. 3. Convulsions. 4. Cephalalgia. 5. Melancholia. Disturbance of functions of bladder. Disturbance of functions of rectum. Disturbance of sexual functions (dyspareunia). B. Uterine Changes (non-organic). Change in position. Change in size of walls. " " cavity. '* " cervix. Change in shape. Change in patency of canals. Change in texture. Undue hardness. Undue softness. . Increased vascularity. Disorders of innervation. Increased secretion. SYNOPSIS OF DIAGNOSTIC POINTS. 87 Here, then, we have the data for the construction of a pathology of the uterus; all the possible changes on one side, all the possible effects on the other. It must be understood that organic diseases of the uterus, cancer and fibroid tumor, are excluded from the list, the nature, course, and effects of these organic diseases being better understood. It must not, however, be forgotten that these organic diseases may occasion one or all of the uterine symp- toms. UTERINE -INFLAMMATIONS Are usually divided into the acute and chronic forms of metritis, endometritis, cervicitis, and endocervicitis. The distinction has also been made between parametritis and perimetritis, and various forms of inflammation of the os, granular, catarrhal, ulcerative, etc. So far as treatment is concerned, in nearly all cases it is suffi- cient to distinguish between cervicitis, in which the os is alone or principally affected, and metritis, in which the body of the womb is also implicated. The distinctions which have been drawn between endometritis and endocervicitis, are compared by Dr. Etheridge on the follow- ing page : DISEASES OF THE UTERUS AND ITS ANNEXES. i. Gene ral symp toms. 2. Touch, 3. Specu- lum. 1. Metritis. 4. Probe. Acute. ( Very rare. a. Violent pelvic pain, accompanied with rectal, vesical, and uterine tenesmus, and sometimes with nausea and vomiting b. Pressure over ab domen reveals great sensitiveness. a. Vagina hot and dry, unless, from co existing endometritis, there be purulent dis- charge. b. Organ low in pel vis, os enlarged, cer- vix swollen, pressure on cervix very painful. c. Painful tender- ness most apparent upon rectal touch and conjoined manipula- tion. a. Usually produces too much pain to be used. Chronic. a. Dull, heavy, dragging pain in pel vis, increased by loco- motion. b. Defecation and coition painful. c. Menses accompa- nied with pain, which begins several days previous. d. Pain in mammas during and before menstruation. e. Darkening of are olae of the breast. f. Nausea and vom iting. g. Great nervous dis turbance. h. Pressure on rec turn, with hemorrhoids and tenesmus. i. Pressure on blad der, with vesical tenes 1US. a. Enlargement. b. Tenderness. 2. Cervicitis. Chronic. Nothing revealed specially. a. Pain in back and loins. b. Pressure on blad- der and rectum. c. Painful and some- times profuse men- struation. d. Difficulty of lo- comotion. e. Nervous disor- ders. f. Pain during sex- ual intercourse. g. Dyspepsia, head- ache, general lassi- tude, and debility. a. Uterus low down. b. Cervix large, swollen, and painful, and os may admit finger. c. Usually tender- ness. Produces intoler- a. Usually reveals able pain, and cannot some flexion or ver- usually be resorted to. sion, tenderness. Confirms signs evinced by touch. Reveals great sen- sitiveness before reaching os internum, but nothing beyond that. SYNOPSIS OF DIAGNOSTIC POINTS. 8 9 3. Endometritis. General symp- toms. Touch. Chronic. a. Leucorrhea ; streaked, glairy,and bloody. b. Menstrual dis- orders. c. Pain in back, groins, and hypo- gastrium. d. Nervous disor ders. e. Tympanitis. /. Symptoms of pregnancy. g. Sterility. 4. Endocervicitis. Acute. Specu- lum. Probe. a. Conjoined ma nipulation reveals tenderness of fun- dus. a. Reveals noth- ing special. a. Patulous os in- ternum. b, Uterine cavity prolonged. c. Tenderness. Withdrawal follow-Jblood ed by blood. a. D r a g g i n g weight and pain in pelvis, pain in back, groin and thighs. b. Rectal and ves- ical tenesmus. c. Purulent dis- charge, sometimes bloody after 3 or 4 days. d. Tympanitis and tender abdomen. Chronic. a. Dragging sensation in the pelvis. b. Pain in back and loins increased by exercise. c. Profuse, irritating leu- corrhea, like boiled starch. d. Menses, too scanty or vice versa, too frequent or vice versa. e. Nervous, irascible, moody, or even hysterical. f. Digestion impaired, ultimately spanemia, sometimes nausea, etc. a. Vagina hot and a. Osin normal position, dry, or covered with' may be enlarged, lips puffy above discharge. [or may be roughened. b. Os gaping, cer-! b. Pain results from plac- vix swollen and ten- mg the finger under the der, body slightly'cervix and pressing up- enlarged, whole or- wards, gan lower in pelvis than normal. a. Cervix puffy, swollen, and red, fluid exuding from os, either clear, al- buminous looking, muco-pus, or stringy and tenacious. a. Great tender- ness throughout whole organ, and removal followed by a few drops of a. Long.stringy, tough, te- nacious mucus, difficult to remove, exuding from os. b. Cervix not usually en- larged, may be puffy and swollen and very red, as if ulcerated, due to removal of investing epithelium. a. Meets with obstruction at os internum. b. Does not produce pain by striking against the walls of the fundus, nor is its removal followed by blood or mucus. METRITIS (NON-PUERPERAL, ENDO-. PERI-, AND PARA- METRITIS, UTERINE CATARRH, ETC.) PROF. WM. H. BYFORD, M. D., OF CHICAGO. The treatment of chronic inflammations of the uterus, is divided into the general and local treatment. General Treatment. The patient must be placed under the best practicable hygienic and dietetic rules, and sexual congress for- bidden during treatment. For the nervous prostration, fresh and cold air is one of the most valuable tonics. The patient should be in the open air as much as possible ; or if confined to the house, she should be well covered and all the windows and doors of the room thrown open several times daily. She should keep in open cold rooms ; and the use of stimulants, to which such cases are given, should be forbidden. For the nervous excitability, regular rest, exercise, and outdoor exposure, are the most efficacious means. Medicines as a rule are not well borne in these cases. Quinine, nux vomica, wild cherry and chamomile, are the best. Stimulants must be exhibited cautiously, and opium is generally not well borne. Nervous headache, insomnia, and neuralgic pains, are often greatly relieved by bromide of potassium in full doses (gr. xxx-lx every hour in abundance of water, until relieved). Anemia and plethora, if present, must be appropriately met. Con- stipation is often present, and must be overcome by prompt atten- tention to the desire of defecation, by a full vegetable diet, espe- cially fruits, and by drugs. Of the latter, sulphate of magnesia, 5ij-iv, may be given with some acid in the morning ; or gr. vj— x of blue mass may be given every fourth or fifth night, followed by Epsom salts in the morning. When through long habit, the secre- tions of the intestines are scanty, and their coats atonic, a special tonic is called for. Simple and effective formulae are : no. I£. Strychniae sulphatis, gr.j Ferri sulphatis, gr. viij Acidi sulphurici diluti, q. s. Aquae, f.gij. M. For a solution. One teaspoonful three times a day after eating. (9°) METRITIS. . 91 in. ]£. Strychnise sulphatis, gr.j Extracti rhei, Biss Sulphatis ferri, gr. x. M. For 16 pills. One to be taken once, twice or three times a day, as may be necessary. 112. ~fy. Ouiniae sulphatis, gr.j Pulveris nucis vomicae, gr.v. M. For one pill. To be taken after each meal. These are our most valuable remedial agents. Massage is not unfrequently a valuable aid (See Resume of Remedies for the method employed). Cold water may be thrown into the rectum twice a day in small quantities, say f.Sviij. Or a suppository may be used, as 113. ^l. Extracti gentianae, 9j Butyri cocose, q. s. M. For a rectal suppository. Quinine, gr. v, may be employed in a similar manner. As a means of relaxing the sphincter ani, and removing its irri- tability, we can sometimes employ with advantage an ointment of belladonna : 114. ]£. Extracti belladonnas, 5ij Unguenti simplicis, §j. M. Ayply to the anus externally on going to bed at night. When the rectum is weak and becomes readily filled with accu- mulated feces, this can in a measure be prevented by wearing an air or sponge pessary, which will press the rectum against the sacrum and thus reduce its capacity. Local Treatment. Of the local measures employed, baths may be first mentioned. Injections are internal baths. The most com- mon bath is the sitz- or hip-bath. Where there is much pain, with little inflammatory action, this often affords great relief. In many cases the patient can advantageously introduce a speculum while in the bath, so that the medicated water can readily reach the uterus. That temperature should be chosen which is most comfortable to the patient. Vaginal injections are applicable to almost all cases of cervical inflammation. Dr. Byford condemns intra-uterine in- jections as dangerous. The quantity of simple injections should generally be large — from one to eight quarts. Astringent injec- tions ought not to be used more often than twice a day, the rule 92 DISEASES OF THE UTERUS AND ITS ANNEXES. being never to repeat so long as the vagina is dry from the preced- ing one. The temperature should be governed by the feelings of the patient. Anodyne, astringent and alterative suppositories, pessaries, and powders, may be resorted to with profit in many instances. The " suppository syringe" will enable the patient to place ointment in contact with the uterus very conveniently. In using narcotics in the vagina, the proper dose is double that by the mouth. The vaginal mucous membrane absorbs much more slowly than that of the rectum. The local remedies most employed by Dr. B. are the various depletory measures, nitrate of silver, tannin, acid nitrate of mer- cury, nitric acid, and caustic potassa. Nitrate of silver he prefers in the solid form. It should be slowly and gently passed over the inflamed or ulcerated part. If we use no more force than is necessary to keep it in contact with the part, there is no danger of keeping it there too long. It can be applied about once in six days. If applied in solution it should be strong — one part to four of water. It is not so applica- ble in aged persons, and they are often made worse by it. Creo- sote or caustic potassa is better in these cases. It also sometimes causes such severe pain that a substitute must be found. DR. LOMBE ATTHILL, OF DUBLIN. Chronic Endometritis. This disease presents itself in two forms, requiring different treatment. I. As it appears in women who have borne children ; and 2, in nulliparae and virgins. In women who have borne children the os is patulous and the sound is readily introduced, although causing pain. The lips of the os are usually swollen and soft. An important preliminary step in such cases is local depletion by puncturing the cervix. One or two punctures, one-eighth of an inch in depth, will generally be followed by sufficiently free bleeding. To this should follow the application of strong caustics to the interior of the uterus. Dr. A. prefers nitric acid and the solid nitrate of silver. Nitric acid seldom causes any pain if properly applied, and it has a wonderful effect in bringing about a healthy condition of the mucous mem- brane. It is readily applied on cotton, through the author's platinum canula or similar instrument. Carbolic acid may also METRITIS. 93 prove serviceable in mild cases. If vegetations on the endome- trium exist, they should be removed with the curette before the caustic is applied. In virgins and women who have never been pregnant, endome- tritis is usually accompanied by an elongated, probably swollen and congested cervix uteri, with a very small os from which a clear and slightly viscid discharge exudes. Flexion of the fundus is also often present. In these cases the first indication is division of the cervix so as to insure a free escape for the* contents of the uterus. Often this procedure will be sufficient : if it is not, we should have recourse to the subsequent treatment of the unhealthy mucous membrane by the application of carbolic acid, or some similar agent. Dr. A. regards blisters as of great value in chronic metritis and endometritis, where local blood-letting does not relieve. He applies them of small size, about two inches in diameter, and repeats them at intervals of a few days, placing them alternately over the sacrum and over the pubes, or over the ovary, if that be the chief seat of pain. In debilitated patients the application of iodine is preferable to blisters, as it does not weaken so much. Its use must be contin- ued for weeks, and it is best to direct it to be rubbed in over a limited space only, and when that spot becomes tender, to apply it to an adjoining part. To relieve the distressing backache in these affections, Dr. A. recommends : 115. fy. Linimenti camphorse comp., f„5x Tincturae aconiti, Chloroformi, aa f.3iij« M. For a liniment. Or, 116. ty.. Unguenti veratrise, Unguenti potassii iodidi, Partes sequales.M. For an ointment. Either of these is to be well rubbed in over the seat of pain. DR. L. PLAYFAIR, LONDON. This writer observes that in many long-standing cases of ute- rine catarrh it is vain to expect a permanent cure by any means 94 DISEASES OF THE UTERUS AND ITS ANNEXES. which do not act directly on the seat of the disease, which is the lining membrane of the cavity of the uterus and cervical canal be- yond the external os ; accompanied, of course, with secondary morbid states of the body of the uterus and cervix, such as hy- pertrophy, congestion, etc. Rest, applications to the exterior of the cervix, and general treatment, will unquestionably cause a temporary improvement, but on a recurrence to the old habits of life all the old symptoms return. There are serious objections to intra-uterine injections, unless the os is first dilated with laminaria tents, as they are apt to bring on severe uterine colics. By means of fine probes of whalebone or flexible metal round which a thin film of fine cotton wool is wrapped, alterative applications can readily be made to the interior of the uterus, without pain or dan- ger. In the very numerous cases in which this plan of treatment has been carried out, in no single instance has anything but the greatest benefit accrued. It is no doubt advisable to select the cases judiciously, and where there is much uterine tenderness, intra-uterine treatment should be postponed until this has been di- minished by rest, leeching, etc. ; but with proper precaution the treatment is perfectly safe. A concentrated solution of carbolic acid, eighty parts to twenty of water, is used, and it acts so well that for a long time nothing else has been employed. After the first application, the discharge is sometimes increased, but after the second or third it is generally greatly diminished, and a single application is often sufficient to cure superficia lerosions of the cervix. As a rule, there is no difficulty in passing the probes, as in true uterine catarrh the os is invariably patulous. PROF. ROBERT BARNES, M. D., LONDON, In cases of simple metritis, applies twelve to twenty leeches above the pubes. A plasma consisting of one drachm of extract of belladonna, mixed with half an ounce of mild blue ointment, and two ounces of simple cerate, spread thinly in lint and applied to the hypogastrium, the whole covered with cotton wool, will give ease and subdue the inflammation. Tepid vaginal irrigations with water or decoction of poppyheads, or with laudanum, are useful. One grain of calomel with half a grain of opium may be given every six hours for a day or two, taking care not to salivate. Next salines, especially the acetate of ammonia, and nitrate of potassa, METRITIS. 95 with sedatives, are useful. When there is septic infection, avoid leeches. Use the plasma as above, and salines combined with qui- nine and tonics. Offensive discharges are to be corrected by in- trauterine injections of permanganate of potassa in carbolic acid. In the chronic form, it is important to aid the womb in throw- ing off its congestion, and hence support by a proper pessary is very useful. Warmth is of great service, as by heated bags of salt or bran, or water to the hypogastrium, or even the whole, or hip- bath, at go° to 95 F. Free access must be given for the warm water to the vagina, by the use of the bath speculum. Irrigation may be employed, as the use of the patent syringe to play upon the cervix for fifteen or twenty minutes at a time. The general treat- ment must be tonic. PROF. T. GAILLARD THOMAS, NEW YORK, Insists upon perfect rest in bed. He applies warm poultices in towels wrung out of hot water to the hypogastrium, and covered with oil-silk. The patient should be kept under the moderate use of opium. In chronic cervical endometritis, he relies upon general regimen as the removal of depressing influences, etc.; vegetable tonics, mineral acids and iron ; appropriate diet, but no stimulation ; fresh air and exercise. As a tonic and cathartic he gives: 117. I£. Magnesiae sulphatis, gij Ferri sulphatis, gr. xvj Ac. sulph. dil., f.3j Aquae, Oj. M. Two tablespoonfuls in a tumbler of iced water daily on rising. Or, 118. ~fy. Sodii et potassae tart., ■ §ij Vini ferri amari, f.gij Ac. tartarici, f-3iij Aquae, f.fxiv. M. Two tablespoonfuls as above. If necessary, the draught may be repeated during the day. As a digestive tonic, he gives : 119. I£. One rennet washed and chopped, Sherry wine, Oj Macerate for twelve days, decant, filter and add Ac. muriat. dilut., Tr. nucis vom., aa f.5ij Bismuthi subnit., 5ij. One teaspoonful in a quarter of a tumbler of water, before each meal g6 DISEASES OF THE UTERUS AND ITS ANNEXES. Emollient Applications. Irrigations for twenty or thirty minutes of the cervix night and morning by warm water, with the addition of salt, glycerine, boiled starch, infusion of linseed, slippery-elm, or tincture of opium. Alterative Applications. First, dilatation of the cervix. The sur- face having been thoroughly cleansed, it should be well painted with a saturated solution of copper, zinc or lead. Next a bit of cotton with a piece of stout thread attached, dipped in glycerine, should be applied to the cervix. This treatment may be repeated once a week. Or applications may be made by means of the probe wrapped with cotton, which is then saturated with the solution to be em- ployed. LAWSON TAIT, F. R. C. S., BRIMINGHAM. The treatment of chronic metritis consists most essentially in ab- solute rest in bed during menstruation, and total suspension of marital life. For medicines there is nothing like bromide of po- tassium and ergot, and there is nothing so bad as iron. No mat- ter how anemic the patient is, iron should not be given until the uterine condition is cured, after which, indeed, it will often work marvels. Intra-uterine remedies are powerful adjuvants. Desic- cated sulphate of zinc, carbolic acid, and even nitric acid, may be used. Where the chronic metritis is the result of an acute pro- cess, very great caution must be observed in applying any intra- uterine medication, lest the original mischief be re-excited. Acute Endometritis is nearly always the result of gonorrheal in- fection. Its characteristic signs are severe pain, some fever, ten- derness of the uterus, and a profuse yellow purulent discharge from the os. The treatment is rest in bed, pessaries of lead and opium, hot fomentations over the abdomen, or even a blister, with general antiphlogistic measures. Both vaginal and intra-uterine injections are to be sedulously avoided. Parametritis often occurs in the first few months of wedded life. Its treatment is by absolute rest in bed, with opiates and warm fo- mentations or poultices. If the tumor can be felt from the vagina, it should be tapped as soon as the indications of pus are clear. PHILADELPHIA HOSPITAL. Perimetritis. As regards internal remedies, one-twenty-fourth of a grain of the bichloride of mercury, with ten grains of the METRITIS. 97 muriate of ammonia, are given three times each day in the mist. glycyrrh. comp. A pessary of cotton is constructed, which can be so adjusted as to hold the womb up. This cotton is dipped in a solution containing three-quarters of a grain of morphia to the drachm of glycerine. The morphia allays the pain and reduces the inflammation, and the glycerine usually sets up a copious watery discharge from the vagina. Iron is not employed until late in the progress of the disease. After the inflammation is subdued, the patient is put upon the following mixture : 1 20. 1^. Hydrarg. chloridi corros., gr.j Liq. chloridi arsenitis, f.3ss Mist, ferri chloridi, Acid, muriat. dil., aa f.3ij Syrupi, f . 3 i i j Aquam, q. s. ad f.gvj. M. S. One tablespoonful after each meal. DR. ROBERT BATTEY, OF ROME, GEORGIA. This writer has found of excellent effect what he denominates iodized phenol {American Practitioner, Feb., 1877). 121. I£. Iodinii, §ss Acidi carbolici crystal., §j. M. Combine by gentle heat. This is an energetic escharotic and alterative, and may be used, applied on lint or cotton, to cancerous surfaces. But for metritis, chronic affections of the cervix, hypertrophy, and subinvolution, he takes the following : 122. $. Phenol iod. (No. ), §iss Acidi carbolici crystal., §i Aquae, f-3ij- M. Make a solution. This is to be used either of full strength or diluted with glycer- ine, to one-half, one-third, or one-fourth, according to the nature and requirements of the case. It is applied on cotton, the interior of the canal and uterus being mopped out (after the dilatation of the inner os), with the fluid. DR. V. H. TALIAFERRO, OF ATLANTA, GEORGIA. Pressure in Uterine Diseases. This practitioner has brought prom- inently to notice the application of pressure in diseases of the 7 98 DISEASES OF THE UTERUS AND ITS ANNEXES. uterus, especially in the forms of chronic metritis {Trans. Med. Assoc. Ga., 1878). The pressure is exerted by filling the vagina firmly with well-prepared cotton or sheep's wool, in the manner of a tampon. In commencing the use of this tampon, the vagina should not be entirely filled. It is better to fill first the upper portion of the canal, which may be done quite tightly, and gradually to encroach upon the entire canal as it becomes inured to the foreign sub- stance. Not unfrequently the tampon will irritate the vagina in the commencement of treating by its use, when it should be left off for'a day or two, and hot water injections substituted. If, how- ever, there be but little irritation, the use of a little simple cerate, or better, vasaline,.upon the vaginal surface, will enable us to con- tinue the tampon. He is convinced that in this method we have a remedy for the rapid reduction of chronic congestions of the part, superior to any other. In adhesions of the uterus, with inflammatory deposits, however extensive, its patient and persistent use is absolutely cur- ative. INTRA-UTERIN'E MEDICATION. This is applied in the various forms of injections, pledgets, oint- ments, pessaries, crayons or pencils, capsules, and powders. UTERINE INJECTIONS. Prof. Carl Schroeder, of Erlangen, recommends the following cautions in the use of uterine injections: 1. They should be avoided where there is marked tenderness or inflammation of the uterus or its appendages. 2. There must be a free exit of the injected fluid ; hence it is better first to dilate, in every case, the uterine neck. 3. Only a small quantity of fluid must be injected. 4. The fluid should be slightly warmed, and slowly injected. 5. Where there is flexion of the uterus, it is advisable to draw the fluid back into the syringe after a minute or two. Of substances used, probably the solutions of alum and iodine are the most useful, and these do not form precipitates with the albumen of the discharge, as iron, acetate of lead, nitrate of silver, etc. The safety of uterine injections has been much debated of late years, and is doubted by Drs. T. G. Thomas, and Paul F. Munde, METRITIS.' 99 of New York, and others ; but the tendency now is to consider them as without risk, if not too violent, and performed with all necessary precautions, especially that the internal os or cervix be fully dilated. Nevertheless, it is true that the French writers (Gal- lard, Lebloxd, Guichard, etc.,) reject this dilatation as not ne- cessary. A sense of heat, some pain, and a slight febrile movement, often follow an intra-uterine injection, and continue some hours. Should these symptoms not disappear, an anodyne poultice should be laid over the abdomen, and a moderate dose of opium or mor- phine be given. Contra-indications. Any acute inflammation in or near the uterus is a positive contra-indication against the use of intra-uterine injections. Hence where there is cystitis, ovaritis, or perimetritis in an acute form, we must not have recourse to this means. It is also advised on similar grounds to avoid this form of medication during the menstrual epoch, and for a week before and after the period. A marked uterine flexion is also held to be a contra-indication, inasmuch as the Fallopian tubes may be so displaced and dilated that the fluid may easily find its way into the peritoneum, giving rise to serious results. Medicated Injections. One of the most successful agents in intra- uterine medication is " Dr. Churchill's tincture of iodine." Ac- cording to the formula given by that author in 1864, it is made as follows : 123. IJ.. Iodinii, fiiss. Potassii iodidi, §ss Alcoholis, Oj. M. This is used with great advantage as a stimulant, alterative, counter-irritant, caustic, and hemostatic. It has been very exten- sively employed in the New York State Women's Hospital. The internal os is thoroughly dilated, and the instrument used for in- jection is an ordinary hard rubber uterine syringe. The patient is strictly enjoined to keep her bed for a week after the injection. In chronic endometral disease, and after the removal of fibroids, etc., its action is exceedingly beneficial. i Dr. E. J. Tilt considers iodine the safest agent to inject into the uterus. He recommends the employment of a one ounce india- rubber bottle with a pointed nozzle, fitting tightly into the end of a female catheter. The principal formulas he employs are : IOO DISEASES OF THE UTERUS AND ITS ANNEXES. 124. ty. Tincturas iodinii, Aquae destillatae, aa f.fj. M. 125. I£. Liquoris ferri subsulphatis, f.5v Aquas destillatae, f.§iv. M. 126. I£. Ferri perchloridi, 3ij Sodii bicarbonatis, gr.x Aquae destillatae, f.^iv. M. 127. I£. Acidi chromici, 3ij Aquae destillatae, f.gj M. As a vehicle, glycerine is preferred by some, as it flows more slowly, and thus exerts the action of the agent for a longer time upon the uterine walls. As it is somewhat harsh when applied pure, it should be diluted. Oil of sweet almonds may also be em- ployed. Dr. Liebman uses, 128. ^. Tincturae ferri perchloridi, 1 part Glycerinae, 10 parts. M. Nitrate of silver should not be used for intra-uterine injections, as even in weak solutions it gives rise to violent uterine colics, often of long duration. The Swedes favor the sulphate of copper. Dr. Eckland of Sweden states that in the severer cases with ulcerations, hyper- trophy and neoplasms of the papillae, the best agent is sulphate of copper, with which, in dilute form (1:5 to 1:50). This author has had extensive experience, applying it by means of an applicator to the entire interior of the uterus, it being very efficacious, with- out being followed by any inconvenience, such as erosion of the mucous membrane, which is produced by some of the other agents employed. Prof. James P. White, M. D., of Buffalo, in catarrhal metritis, prefers the following as a local application : 129. I£. Iodinii, 5i Potassii iodidi, 5ss Acidi tannici, 3j Glycerinae, q. s. to dissolve. Dr. W. W. Wilkens, of New Hampshire {Half Yearly Com- pend., 1876), speaks very favorably of the following : 130. I£. Acidi carbolici crystal., Aquae, q. s. to dissolve. Glycerinae, aa equal parts. M. METRITIS. 101 This mixture will not cauterize or destroy tissue. It may be applied to a healthy mucous membrane without inflaming it ; but it will stimulate to healthy action one already inflamed. It should be ap- plied to the entire mucous membrane of the womb every week or ten days. As a rule, no pain follows its use, and it never causes metritis or has other dangerous sequelae. " Lugol's solution " of iodine in a concentrated form has been found efficacious by Dr. Joseph Kammerer. His formula is: 131. fy.. Iodinii, 1 part Potassii iodidi, 2 parts Aquae, 4 parts. M. Its use is chiefly indicated where catarrh of the uterus is com- bined with hypertrophy of tissue. Where the surface is eroded with a tendency to hemorrhage, the same practitioner employs pyroligneous acid in its undiluted form, or else carbolic acid dissolved in an equal part of water. In those cases of hypersecretion where no erosions are visible, the follow- ing is a valuable astringent: 132. I£. Zinci sulphatis, gr. x Aquae, f.gj. M. PLEDGETS (PINCEAUX). These are small masses of cotton, charpie, sponge, or other soft and porous substance, which are moistened with the medicated fluid and applied to the inner wall of the uterus. They are in- serted by means of various instruments, as the "applicator" of Dr. H. E. Woodbury, of Washington, or that devised by Barnes. The liquids used in this manner are tincture of iodine, p ere hloride of iron, solutions of nitrate of silver, and nitric acid. The last mentioned agent especially has given excellent results in the hands of a large number of practitioners, in the treatment of chronic endometritis. The slight pain which it produces and the rapidity of its effects make good its claim to be the most valuable of all applications in many cases of this malady. The use of such pledgets is preferable to other means in the lighter forms of endometritis, where there is little or no hemor- rhage, where the intra-uterine area is small, dilatation slight or absent, and the canal not tortuous. They should not be em- ployed when inflammation is active. 102 DISEASES OF THE UTERUS AND ITS ANNEXES. CRAYONS OR PENCILS. These are inserted into the uterine cavity and allowed to remain, the cervical canal being stopped by a plug of cotton. For ex- ample : 133. I£. Iodoformi, Sijss Pulv. acaciae, Mucilaginis, q. s. Divide into ten equal cylinders about one-and-a-half inches long. These pencils are hard, resisting, and capable of being divided into pieces of any length ; they should be preserved from light. They are used with advantage against superficial ulcerations of the uterus. They are introduced into the cavity and allowed to re- main. Nitrate of silver has been largely used in this manner. Re- camier introduced the solid nitrate into the body of the womb by means of Lallemand's porte caustique. Dr. Tilt prefers the porte caustique of Simpson, and leaves gr.v-x of the lunar stick to dis- solve, provided the os be fully dilated. Prof. Pajot, {Annates de Gynecologic, 1877, No. 21,) takes a laminaria tent two millimetres in diameter, dips it in thick mucilage, and then rolls it in finely powdered fused nitrate of silver, and al- lows it to dry. He thus obtains an elastic crayon of the ordi- nary size, which may be introduced into the uterus without fear of breaking. He believes this means to be applicable to other cavi- ties, and for other more powerful caustics. The sulphate of zinc is also prepared in the form of crayons, twelve to fifteen centigrammes of the salt in each, for introduction in this form into the uterus ; it is recommended by Leblond, and is considered by Barnes one of the most useful agents in uterine catarrh. (See page 107.) Crayons of tannin have been used by some, but on account of their tendency to produce severe uterine colic and other accidents, they are not to be recommended. OINTMENTS AND GLYCEROLES. Dr. Robert Barnes remarks {British Medical Journal, January, 1873), that a most precious way of applying almost any medicinal agent to the interior of the uterus is in the form of an ointment or pasma. They can be introduced by means of a hollow sound, with a piston working in its centre, the "ointment positor." Where METRITIS. 103 grease is objectionable, glycerine, cocoa butter, cosmoline, vaseline, etc., may be used. Thus bromine, iodine, mercury, etc., can be safely applied. In simple chronic endometritis, Dr. A. Leblond [Traitc de Chi- rurgie Gynecologique, 1878), has employed the following with ex- cellent effect : 134. $. Cerati simplicis, 20 grammes Pulveris iodoformi, Olei amygdal. dulc, aa 5 grammes. In cold weather, the amount of oil should be increased. Glyceroles of starch, tannin, and other substances, may also be employed. CAPSULES. The introduction into the uterine cavity of various medical sub- stances enclosed in capsules has been suggested by Dr. E. P. Sale, of Aberdeen, Miss. {American Practitioner, June, 1875). They may be made of gelatine, and introduced in the same manner as pledgets. POWDERS. The insufflation of powders of alum, tannin, calomel, iodoform, etc., into the uterine cavity has been practiced by Prof. N. Guen- eaude Mussy and others. Several serious accidents have, how- ever, resulted with most of these agents in this form, and except, perhaps, in the case of iodoform, there is no advantage, and an ab- sence of safety in this plan of medication. PESSARIES, OR INTRA-UTERINE TENTS. These are usually of cotton, saturated with some medicated fluid, allowed to dry, and introduced by a probe or a positor. The internal os generally requires to be dilated before this can be done. A thread may be .attached to the tent, by which it may be with- drawn after a few hours ; or, it may be allowed to remain until thrown off by the action of the uterus, which usually occurs within forty-eight hours (Battey). RESUME OF REMEDIES. Acidum Carbolicum is used as a local application by Playfair (page 94). Acidum Chromicum is advocated as a cauterant by Dr. Tilt (F.126). Its application to the uterus sometimes produces the most severe vomiting, hence it is not very safe (Tait). 104 DISEASES OF THE UTERUS AND ITS ANNEXES. Acidum Nitricum is one of the most efficient local caustics in many cases. For introduction into the uterus it is probably the safest of the fluid, caustics. See pages 92, 101. The following method of using it is recommended by Dr. D. N. Kinsman, as possessing advantages over any other {Obstetric Gazette, Nov. 1878): A piece of white wax smoothed down to the requisite size to enter the cervical cavity and given the proper curve, is dipped into the acid ; a sufficient quantity adheres, for the purpose to which it is to be applied. The wax bougie is grasped with a pair of dressing forceps and passed into the cervix ; applied in this manner there is no excess of acid to run over adjacent parts, while there is enough to act as a caustic or alterant. Argenti Nitras is preferred as a caustic by many physicians. Belladonna, internally, is recommended (F. 114"). Boracicum Acidum has been suggested as a useful agent. Cupri Sulphas is used in Europe (p. 100^. Ferrum. The preparations of iron are used internally as tonics, and the tincture of the chloride locally (F. 128 J. Tait warns against iron in any form in chronic metritis (See p. 96 . Iodinium in several forms is in use by nearly all practitioners (F. 121, 123). Iodoformum, although disagreeable 'to most patients, has been found an excellent application (F. 133). Tannicum Acidum is an astringent of great value. Veratria, in the form of ointment, is an efficient local anodyne (F. 116). Zinci Sulphas was applied in undiluted form to morbid uterine tissues by Simpson. Others have preferred it more or less diluted and made into sticks. EXTERNAL MEASURES. Blisters are highly commended by Dr. Atthill. (p. 93.) Massage of the Uterus. This has been recommended in uterine atro- phy, chronic metritis, and chronic uterine catarrh, by Prof. G. Asp, of Helsingford (Schmidt's Jahrbiicher, Bd., 181,) and others. The proceeding, as stated by this writer, is as follows : The operator with one or two fingers in the vagina grasps the body of the uterus so that he can exert upon it a steady pres- sure, while the counter pressure is exerted by the other hand through the walls of the lower abdomen. If these walls are sufficiently loose and enlarged, by this procedure, the uterus can be held between the fingers of the two hands, and gently pressed and kneaded. When the organ is displaced, it is usu- ally necessary to correct the displacement before this method can be effectually used. CERVICITIS (ULCERATION AND GRANULATION OF THE OS, ETC.) ROBERT ELLIS, M. D., OF LONDON. This author defines as follows the varieties of ulceration of the os, and what he considers the very best methods of treating them. 1. Indolent Ulcer. Cervix hypertrophied, of a pale pink color, and hard. Os patulous to a small extent. Ulcer of a rose red. Granulations large, flat, insensitive, and the edge of the ulcer sharply defined. Discharge : mucus, with a little pus, and occa- sionally a drop of blood. Treatment. For a few times the caustic pencil — solid nitrate silver. Afterward, the solution of nitrate of silver in strong nitric acid. 2. Inflamed Ulcer. Cervix tender, hard, a little hypertrophied, hot and red. Vagina hot and tender. Ulcer of a vivid red. Gran- ulations small and bleeding. A livid red border around the ulcer. Discharge : a muco-pus, yellow and viscid, with frequently a drop of bright-red blood entangled in it. Treatment. Occasional leeching, hip-bath (warm), emollient in- jections. Then acid nitrate of mercury several times, succeeded by the solid lunar caustic, potassa fusa, or cum calce. 3. Fungous Ulcer. Cervix soft, large, spongy to the touch. Os wide open, so as to admit the finger. Ulcer large, pale, studded with large and friable granulations. Discharge : glairy, brownish mucus, frequently deeply tinged with blood. Treatment. At first, the caustic pencil. Subsequently, nitric acid, solution of nitrate of silver, or acid nitrate of mercury; elec- tric, or actual cautery. 4. Senile Ulcer. Cervix small, red, a little hard. Ulcer small, extremely sensitive, of a bright-red color. Granulations very small, red, and irritable. Discharge : a thin muco-pus. Treatment. Potassa fusa, or strong nitric acid, \vith nitrate of silver once or twice at long intervals. The solid sulphate of cop- per, in pencil. 5. Diphtheritic Ulcer. Cervix of ordinary size, a little hot, dry, and tender. Ulcer covered in patches with a white membrane, adher- (i°5) 106 DISEASES OF THE UTERUS AND ITS ANNEXES. ing closely, irritable, and readily bleeding beneath. Discharge : a thin acrid mucus, without pus, but occasionally tinged with blood. Treatment, At first, electric cautery, potassa cum calce, or acid nitrate of mercury, two or three times at long intervals. No nitrate of silver. Subsequently, stimulating applications, tincture of iodine, or sulphate of copper. DR. A. LEBLOND, OF PARIS. This writer states that ( Traite Elementaire de Chiruagie Gyneco- logique, Paris, 1878,) the treatment of the os and cervix by means of cauterizing agents is so prominent that it deserves to fix our attention. The caustics employed are directed (1) to the surface the os of and cervix, or (2) to the parenchyma. They have also been classified as (1) mild, and (2) energetic caustics. In follicular ulceration of the surface of the os and cervix, a strong solution of nitrate of silver gives excellent results. The ap- plication produces a slight eschar, which is detached in five or six days, after which it may or may not be renewed. When the ulcerated surface is red and softened with tumefaction of the cervix, the tincture of iodine is to be preferred on account of its resolvent properties ; or, what in some respects is better, iodo- form, which is at once an energetic cicatrizant and a local anaes- thetic. Bleeding ulcerations, with a varicose aspect, will be happily modified by a solution of perchloride of iron @ 30 . It should be repeated at the close of five or six days. Obstinate ulcerations will sometimes yield in a satisfactory man- ner by application of a solution of hydrate of chloral. 135. Vf.. Chloral hydratis, 2 grammes Aquse, 25 grammes. The ulceration to be touched daily with this for some time. When the ulcerations are swollen and fungous, a more potent caustic than those above mentioned is required. Scanzoni used pyroligneons acid ; Dr. Gallard, crystallized acetic acid, or carbolic acid. The first mentioned is the least painful. Pencils or crayons of nitrate of silver, sulphate of zinc, perchlo- ride of iron, iodoform, or other substances, may often be advanta- geously employed. Those of tannin are to be prepared as follows : CERVICITIS. 10/ 136. ty. Tannin, 1 gramme Pure glycerine, . . 1 y 2 drops. Rub together and roll into two crayons each 5 centimetres in length. The most suitable formula for crayons of the other ingredients mentioned is the following : 137. I£. Sulphate of zinc (or other agent), Gelatine, aa 2^ grammes Pure glycerine, 5 drops. To make ten crayons of 6 centimetres each. Powder the gelatine and place in a capsule in a sand-bath. Add the glycerine and ten drops of water. Stir till melted and smooth. Add the zinc or other agent with a few drops of water if necessary. Mix carefully, then cool and mould rapidly into pencils. In certain cases where there is simply morbid enlargement of the os (as sometimes in chronic metritis) without ulceration, this engorgement may often be reduced by inserting some iodide of potassium enclosed in a tampon of wadding. Placed in contact with the neck, this substance generally produces a slight ulceration which rapidly heals, and is followed by a diminution of the organ. After eight or ten days, it may be repeated. In cases of vegetations and rebellious ulcerations, more potent agents are required. Of these chromic acid is ranked by some as one of the best. It produces a dry, yellowish eschar. The crystals are used, being applied directly against the part, until the whole of it is covered with the eschar. It is not uncommon for this appli- cation to be followed by vomiting and diarrhea, and precautions must be taken that as little of it as possible be absorbed into the system. Caustic potassa, Canquoin's paste, Vienna paste, and Fit/ios' caustic, are other powerful caustics occasionally applied. They should be used with great caution. Dr. Filhos' caustic is a solid form of Vienna paste, and is more manageable than* it. Nitric acid is con- venient of application, and has furnished good results. The acid nitrate of mercury is apt to extend beyond the diseased structures, and is said to leave troublesome cicatrices. It has, however, been especially recommended in syphilitic ulcerations of the os. In that form of cervicitis accompanying chronic metritis, where the cervix is enlarged, infiltrated, softened, and generally more or less ulcerated, as well as in a later stage of the same morbid process, when the cervix is enlarged, thick and hardened, the ac- tual cautery will usually furnish the best results. This may be IOS DISEASES OF THE UTERUS AND ITS ANNEXES. applied as the hot iron, the thermo-cautery, the galvano-cautery, the gas cautery, or the cauterizing pencils. The application of the red-hot iron is not at all painful. It is followed by an eschar which is detached after eight or ten days, leaving a healthy granulating surface, and is not followed by a contracting cicatrix. The iron should be nearly at a white heat in order to prevent the adherence of the tissues which takes place when it is at a dull red. Of the other methods of cautery mentioned, the cauterizing pen- cils of M. Bonnafond may be described. They are little cylin- ders made of powdered charcoal and nitre, as follows : 138. fy. Nitrate of potassa, 2 grammes Powdered wood charcoal, 30 " Gum tragacanth, 10 '* M. Or, as follows : 139. I£. Nitrate of silver, 1 gramme Wood charcoal, 28 " Powdered acacia, 4 " Water, q. s. M. They are lighted at a candle and applied to the part; but as they are at once extinguished by the application, they are suitable only when superficial eschars are desired. Cauterization by ignipuncture has been advised in this form of cervicitis when very rebellious. Filiform cauteries are used, and are inserted into the tissues to the depth of four to eight millimet- res. Four to six punctures are made, distributed over the lips of the os. After the Cautery has been applied, the vagina should be washed with cold water, and the patient keep her bed for the rest of the day. DR. T. GAILLARD THOMAS, NEW YORK. The cardinal point is to look upon the ulcer as a local manifes- tation of diseased action in the cervix or body, which is the lesion to be treated. The ulcer is a symptom of a graver and more important morbid state, which must be kept in view. It often happens that one symptom of a disease so distresses the pa- tient that the remedy must be addressed solely to it; as when the ulcer by its profuse discharge calls for prompt relief. When the ulceration results from inflammation confined to that part of the cervical tissue immediately underlying it, the relief of the CERVICITIS. IO9 ulcer by the alterative and counter-irritant action of the means adopted, may effect the cure of the disease producing it, and the fact of the existence of such disease may not be recognized. "But when it depends upon the irritation of the discharges from the cav- ity of the cervix or the body of the uterus, or upon deep-seated areolar hyperplasia, cure js more difficult." Caustics will be quite sufficient for ordinary granular degenera- tion, but when there are exuberant development of villi, so-called cock's-comb granulations, it is well to snip these growths closely by a pair of long-handled scissors, or even to scrape them off smoothly with a curette, and then apply the caustic. Of these, Richardson's styptic colloid is excellent. It is a direct alterative, and forms a protecting crust over the ulcer. Where there is eversion of the cervix, the hemorrhoidal mem- brane may be removed as above, and the actual cautery, or the nitrate of silver applied. An excellent method of cauterizing these ulcers is the gas jet cautery of Acosta, of Paris. An ordinary rubber bag is filled with carburetted hydrogen from the gas jet ; a blow-pipe is fitted to the end of a tube attached to the bag, the escape of the gas being prevented by pinching the tube. The bag is compressed, the gas ignited, and the tiny flame is applied through the speculum to the spot. After such treatment the patient is to be kept in bed, and the parts copiously irrigated two or three times a day ; glycerine, laudanum, or infusion of bran or linseed, may be used. In a week or ten days, according to the potency of the caustic, the slough has separated. If the surface appears healthy, the milder alter- atives are to be employed, as a pledget of cotton, saturated with equal parts of glycerine and solution of subsulphate of iron, or glycerine f.ovj and tannic acid f.5ij. In addition, the patient should inject each night and morning a gallon of warm water, contain- ing an ounce of glycerine and a drachm of sulphate of zinc ; or two drachms of sulphate of alum, acetate of lead, or tannin, for ten or twenty minutes. Medicated suppositories may be used, of zinc oxide; or sulphate of alum, gr.iij ; or ung. hydrarg., gr.x ; or plumbi iodidi, gr. v; or acid tannic, gr.ij. And, as an anodyne, may be added to either of these : ext. belladonnas, gr.j ; or pulv. opii, gr.ss. These articles may be made into a mass with tragac- anth, starch, slippery elm, and glycerine, and covered with cocoa butter. I I O DISEASES OF THE UTERUS AND ITS ANNEXES. When needed, the caustics may be repeated, but not too fre- quently, time should be allowed for the development of their stim- ulant effect; once a fortnight, or even once a month. In follicular ulcer, evacuate the cysts and cauterize their cavities thoroughly by nitrate of silver, chromic acid, or the acid nitrate of mercury. DR. T.OMBE ATTHILL, OF DUBLIN. The first step in the more acute forms of inflammation of the cervix is to relieve the congestion by puncturing the cervix. The point of the knife should penetrate from 1 /q to ^ of an inch # When the lining membrane of the cervix is extensively implicated, the next step is to apply strong nitric acid freely to the whole in- terior of the cervical canal. The acid is introduced on cotton wrapped around a platinum probe, and care must be exercised that it does not touch the walls of the vagina. This may be followed after a few days by the glycerole of tannin, applied in a similar man- ner ; or the glycerole may be used instead of the acid. 140. ]J. Acidi tannici, gr.x Glycerinae, f.§j. M. Thoroughly saturate a pledget of cotton with this, and then attaching a piece of string to facilitate its removal, introduce it up to the os uteri through the speculum, and leave it there for twenty- four hours. This is often productive of great benefit. If much irritation exist in the vagina, omit the tannin and use plain glycer- ine. When the cervix is greatly engorged, cedematous, and covered with papillae, sometimes the above procedures fail, and nothing promises relief but the total destruction of the diseased surface by caustic potash. Whenever this caustic is used, it should be applied through a glass speculum, and rubbed freely against the part ; a pledget of cotton saturated in vinegar should be previously inserted between the lower lips of the os uteri and the edge of the specu- lum, so as to neutralize any of the potash which may escape ; and the vagina should be washed out with vinegar immediately after the application. The patient should remain in bed several days. When much induration exists, the potash may have to be applied several times. Milder applications are nitrate of silver and tincture of iodine. The latter seems to allay the backache so much complained of in these affections. CERVICITIS. I I I The actual cautery, either the hot iron or charcoal pencils (F. 137), are also valuable aids in obstinate cases. Iodized cotton may be introduced into the cervix as recommended by Dr. Green- halgh. dr. kceberle. In the Annates de la Societe de Medecine de Gand, M. Kceberle prefers chromic acid as a cauterizing agent to the other remedies usually used, as pernitrate of mercury, iodine, nitrate of silver, and the actual cautery. He uses it in the crystalloid condition. It is a very anhydrous substance, and readily absorbs the moisture from the tissues which it may touch. M. Kceberle applies it through an India-rubber speculum on a tampon of cotton-wool. Vomiting often supervenes within fifteen or twenty minutes from the applica- tion of the acid. When the tissues are seriously altered, it is nec- essary to repeat the cauterization, but M. Kceberle has hitherto found three applications to suffice. After the application he ap- plies a tampon, and advises the patient to use two soap and-water injections daily. He treats all ulcerations of the os in this way, as in epithelioma. DR. ROBERT BELL, OF GLASGOW. This writer, in the Lancet, Aug. 10, 1878, describes a very suc- cessful and simple mode of treatment of those cases of papillary ulceration of the cervix, in which on examination the vaginal mucous membrane is found to be turgid and red, and unduly sen- sitive to the touch. The vaginal portion of the uterus is hyper- trophied, and around the os the finger detects a sponginess of the mucous membrane, and the lips are everted. On introducing the sound, hemorrhage to a small extent is induced. The uterine canal measures three inches. The speculum reveals a granular ulcer extending both outwardly and inwardly from the external os. This has evidently been due, in the first place, to erosion of the papillae, which, by continued irritation, has developed into this granular condition. The slightest touch causes it to bleed very freely. The treatment commonly employed in such a case is the uterine douche night and morning, which the patient uses herself, while an application twice a week of a moderately strong solution of nitrate of silver is made by the physician. Dr. Bell finds he can effect a cure jn half of the time by another 112 DISEASES OF THE UTERUS AND ITS ANNEXES. method. All the discharge is wiped away by means of cotton- wool, and then pure tar is applied to the diseased surface on a pledget of cotton. This is allowed to remain in contact with the ulcerated part for twenty-four hours at least, when the patient with- draws the cotton by means of a piece of string which has been left for the purpose. The application is made twice a week, and in from two weeks to a month the cure is complete. The tar is made fluid by the addition of one part of rectified spirits to eight parts of pure tar. This application has another great advantage besides its healing properties : it acts as an anodyne ; and then a further benefit is derived from the support which the pledget of cotton- wool gives to the enlarged uterus. DR. ROBERTS, MANCHESTER, ENGLAND. In ulceration of the os, this writer, while commending the carbolic application, does not consider the strong acid necessary in super- ficial ulceration. A mixture of one part of the strong acid with two of olive oil seems to answer all ordinary purposes ; but in cases of veiy deep ulceration the use of the strong acid may be called for. In such cases, Dr. Roberts desires the acid to be liquefied by the addition of a very small quantity of water. This has not been found always to answer the purpose, but it has been noted that the addition of a few grains of camphor will dissolve the acid, and will, moreover, prevent it again becoming solidified, even at a freezing temperature. The application of the carbolic oil to the os uteri is best effected by soaking a little cotton-wool in the liquid, securing it by a string, and introducing it through a speculum, the string being left depending out of the vagina, and the patient being directed to pull it away on the second day. This procedure is repeated in ordinary cases about twice every week. If it be desired to apply the acid to the cervical canal, it may readily be done by passing in a gum-elastic catheter smeared with the carbolic oil. DR. J. M. BENNETT, OF LIVERPOOL. Interstitial Injection. In chronic cervical metritis (enlarged os, inflammatory enlargement and induration of the os), this writer {Lancet, Nov. 2, 1878), has tried with gratifying results the inter- stitial injection of iodine. He first prepares the patient both generally and locally ; the lat- CERVITICIS. II3 ter by relieving any super-engorgement by means of local deple- tion, carried out by means of cupping, the frequent use of warm water, and the application of glycerine, so as to induce osmotic action, care being taken to avoid the period of menstrual excite- ment. He then uses a simple modification of the hypodermic syr- inge, which is sufficiently long to be used with Ferguson's specu- lum ; its points are made of eighteen-carat gold ; and the other portion, which might come in contact with the iodine, bromine, or other agent inimical to any metal less resistant than gold or plati- num, is mercurially gilt. The instrument should be charged with a solution composed as follows : 141. R. Potassii iodidi, Potassii bromidi, aa gr.x Tinctune iodinii, f.3ss Aquam destill., ad. f.3ij. M.. He then either punctures through the speculum, leaving the- uterus free if the os and cervix be very large and low down, or fixes it with Sims's tenaculum, using a duckbill speculum. He generally makes from three to five punctures, according to the amount of hyperplastic matter to be absorbed. A cotton pledget- well soaked in glycerine is placed against the part,, and rest en- forced for at least twelve hours. Seldom more than three opera- tions are required ; and he has never found any disturbance of moment set up, either generally or locally, by the procedure ; on the contrary, a number of cases turn out successfully when other methods have proved unavailing. Internally he uses the bromide of potassium in large doses, both for the purpose of quieting excitement, and secondly of obtaining some of the benefits described by Prof. Bixz, of Bonn, who speaks of the potash salts as being positively specific in subinvolution; and he believes he has many times seen advantages derived from a continuous use of this salt, quite equal to those described by Dr. R. Williams, who attributed such wonderful powers to its action in splenic hypertrophy. The above treatment can usually advantageously be joined to dilatation of the os by means of a sponge tent, after the first effect of the injections has passed off. Richardson's Styptic Colloid. According to Dr. R. E. Beach, of Illinois {Illinois Medical Recorder, Aug., 1878), in granular condi- tions of the os, Richardson's styptic colloid painted over the os 114 DISEASES OF THE UTERUS AND ITS ANNEXES. seems to produce good results. " It appears to act as a direct alter- tive, and by forming a protective crust over the surface, constitutes for it a shield against friction and uterine discharges, and by its constringing effects diminishes local congestion. (For the prepara- tion of the styptic colloid, see Napheys' Surgical Therapeutics, sixth ed., p. 1 14.) DR. HALTON, OF DUBLIN. In the Dublin Journal of Medical Science, June, 1876, Dr. Hal- ton gives a number of cases, explaining his plan of treatment which consisted in producing local congestion by local means and touching the excoriated surface with the strong nitric acid. This was always carried into the cervix when that appeared dis- eased, and the acid brought in contact with the whole surface of the canal, and even to the fundus if necessary.* It never gave rise to the slightest symptom of danger or distress, and in the vast majority of instances was altogether unfelt. When pain did occur, its amount was so trifling as to attract little notice from either the patient or physician. Astringent injections were found to be of little use, and whether this was from the patient's awkwardness in managing them or not, they have been latterly dispensed with by him, and their place supplied by the tannin, pessary, or bougie placed in contact with the os or introduced into the canal. The skin of the abdomen has been leeched or blistered, as seemed most suitable, over the tender spot in the region of the ovary, with very marked benefit. When much leucorrhea was present, small blisters to the sacrum were found servicable, while ergot and Indian hemp were useful internally, particularly when hemor- rhage was present; but, undoubtedly, the most generally effective drugs were strychnine, in small doses, in combination with dilute nitric acid. The following is the formula used : 142. fy.. Liquor of strychnine, f.3iss Dilute nitric acid, f . 3 i j Tincture of gentian, f.^ss Hoffman's solution, f-5iij Water, q. s. g.viij. M. The dose is one tablespoonful thrice daily, before meals. If pyrosis * It is by no means necessary in all cases to dilate the os before touching the interior of the uterus with nitric acid. In many cases where this becomes necessary, the canal of the cervix is sufficiently patulous to admit the stillette covered with cotton-wool soaked in this agent. CERVITICIS. II5 is present, a drachm and a half of sedative liquor of opium added to the above for a week or two, taking care to regulate the bowels with suitable aperients, will be found serviceable. MECHANICAL TREATMENT. T. GAILLARD THOMAS, M. D., NEW YORK. When eversion of the cervical mucous membrane is the result of injury, as in parturition, an operation is necessary. The edges of the fissure must be pared and approximated with deep sutures of silver wire. A. J. C. SKENE, M. D., NEW YORK.* Some preparatory treatment is generally required, before the operation can be performed. The cervix is usually found gaping, enlarged, eroded from pressure on the pelvic floor, and often in a state of cystic degeneration. In a bilateral laceration extending nearly, or quite, to the vaginal junction, the eversion of the parts is often so great as to require the removal of large portions of their surfaces before bringing them into apposition, or the tension on the sutures will be so strong as to cause them to cut into the tissues and prevent perfect union. In these cases, about ten days before the final operation, bring the parts together, without any freshening of their surfaces, and confine them by means of a small piece of sheet lead on either side of the cervix, held in position by a silver suture passed con- tinuously through both ends of the leads. Then tampon the- va- gina carefully with marine lint, which can be retained in situ for two or three days without becoming offensive, thereby protecting the surrounding parts from the chafing of the clamp. At the end of 'a week, remove the clamp. Three days later, operate. The use of the marine lint tampon, above referred to, is, even without the clamp, of service in reducing the abnormal condition of the lacerated cervix. He prefers the ordinary silk suture, as it cuts the tissue much less than silver wire. This is easily tied by using Carroll's knot ties, or by passing a loop of the Thomas curette, and making traction laterally with that, holding the other thread firmly in the fingers. For after-treatment the less they are interfered with, the better. Remove the. tampon in forty-eight hours, and do not use the vaginal injection unless absolutely requisite. * Proceedings of Kings County Medical Society, June, 1878. Il6 DISEASES OF THE UTERUS AND ITS ANNEXES. TENTS FOR DILATING THE CERVIX. The use of tents of any kind is not without danger. Serious maladies and death have at various times resulted from their in- sertion. Dr. T. Gaillard Thomas gives the following rules with regard to their employment : Rule i. — In the introduction of a tent, no force whatever should be employed. Should that first essayed not pass the os internum easily, it should be withdrawn and either bent so as to follow more accurately the course of the cervical canal, as ascertained by the probe, or exchanged for a smaller tent. Rule 2. — A tent should never, under any circumstances, be in- troduced at the physician's office, and the patient allowed to go home with it in utero. Such practice is hazardous in the extreme. Even when introduced at the patient's home, she should at once be confined to the bed. Rule 3. — The practitioner should always investigate as to the previous existence of chronic pelvic peritonitis, one of the most common of the diseases of women. Should it have existed, tents should be carefully avoided. Rule 4. — A tent should never be allowed to remain in the uterus more than twenty-four hours ; and, if it be compatible with the ac- complishment of the desired result, it should be removed in twelve hours. Rule 5. — After the removal of a tent, the vagina should be washed out with an antiseptic fluid, and if any pain, chilling or discomfort, follow the removal, opium should be freely adminis- tered and perfect rest enjoined. Rule 6. — After the removal of the tent, the patient should be kept in bed at least twenty-four hours, and never allowed to travel before the expiration of four or five days. Dr. Tilt lays stress on the importance of examining the patient with a speculum in full daylight, to be sure nothing is amiss with her pelvic organs. A tent should only be introduced every third or fourth day, and at some days remove from the menstrual epoch. If much irritation is produced, the dilatation should be suspended. Vaginal injections should be used with great care at this, time as severe uterine colic may result from the fluid entering the dilated os. Dr. B. S. Schultze, of Jena, {Central-blatt fur Gyncekologie, Nov. 7th, 1878), uses sea-tangle tents with strict antiseptic precau- CERVITICIS. 117 tions, and having succeeded without an accident in several hundred cases, believes that if his method is followed the usual contraindi- cations to dilatation of the cervix may be dispensed with. One principle of his procedure is the assumption that for safe dilatation the tangle tent must never come in contact with a raw wound sur- face. But, besides this, he takes the strictest antiseptic precautions that the conditions of the operation allow of. He first employs flexible copper sounds, of varying thickness, by which he ascer- tains the exact size and curvature of the cervical cavity. Having settled these points, a tangle tent, corresponding in thickness with tne sound, which just passes the cervical cavity, is immersed for one or two minutes in boiling water, and being thus rendered flex- ible, the same curvature is given to it as that of the sound, which has been previously adapted to the cavity of the uterus. On cool- ing, the tent retains the curvature thus communicated to it, and after steeping it in a T f ¥ solution of carbolic acid, it is introduced through a speculum, the cervix being meanwhile held down by an assistant with a hook or vulsellum. If a drop of blood is seen coming from the cervix during any of these processes, the opera- tion is to be postponed for at least twenty-four hours. The patient is to be kept strictly at rest during the whole time that the tent is dilating, and the strictest care is to be taken in the removal of the distended tent that no injury is caused to the cervix. The vagina and cervical canal ought to be then carefully washed out with a T -| ¥ solution of carbolic acid. It is remarked by Dr. W. Goodell, that the danger of inserting tents increases with each introduction. Hence the importance of dilating the canal with one or at most two introductions. When sponge or laminaria is used, the cervix should be irrigated every few hours with a strong solution of table salt or of chlorate of potassa. RESUME OF REMEDIES. AGENTS APPLIED TO THE OS,. Acidum Aceticum, in crystals, is said to be but slightly painful and very efficient. (See page 106 ) Acidum Bichloraceticimi, has been recommended by Schmidt & Urner. It is obtained by the action of chlorine on hydrated acetic acid under the influence of the solar rays. Acidum Carbolicum, in crystals, is an efficient agent, and as it is also a local anaesthetic, the pain is less prolonged than with the min- I 1 8 DISEASES OF THE UTERUS AND ITS ANNEXES. eral acid. Galabin considers it the most widely useful of all applications for the cervical canal. The vagina must be pro- tected and well-washed out after the application. Acidum Chromicum is preferred by Dr. Kceberle for the reasons given (page in). It is also a favorite with some American practi- tioners. Dr. Atthill says it is more irritating than nitric acid. Acidum Nitricum is preferred by A. Courty and others to any other caustic. Dr. Atthill has especially advocated it in Great Britain. Acidum Pyroligneum was used largely by Scanzoni and the Vienna school. Ahimen, in powder, or ointment, or strong solution, or as burnt alum, has been occasionally employed. Antimonii Chloridum is an energetic caustic, but of uncertain action. Argenti Nitras has long been the most popular of all caustic applications to the os uteri. Dr. Tilt observes: "I have no hesitation in saying it is the most valuable of all the agents that enable us to cure inflammatory affections of the reproductive mucous mem- brane." His usual solution is gr. xl to aquas f.§j. He applies it every four or five days when the os is red and sensitive, as well as when ulceration is present. Bismuthi Subnitras. Dr. A. Courty {Maladies de V Uterus, 1866), considers this substance, insufflated upon the part, one of the most powerful modifiers of ulcerations of the os. It has also been very strongly recommended, made into a thick cream with glycerine, applied to ulcerations of the os. It may be con- veniently introduced through a tube, and retained in place by a pledget of cotton. Creasotum was formerly used, but carbolic acid has taken its place. Cupri Sulphas is a favorite agent with the Swedish physicians. They claim it is curative, and not followed by troublesome sequelae. Ferri Chloridi Tinctura. For hemorrhage depending on a granular con- dition of the cervix, this is a valuable agent. It is best applied on a small roll of cotton saturated with it, another and larger roll wet with glycerine being placed outside it (Atthill). They should not be left over a few hours, or sloughing may en- sue. Aran applied to ulcers of the os the following glutinous compound : 143. fy. Tinct. ferri chloridi ether., Collodion, aa equal parts. M. Ferri Subsulphas has been largely employed as a styptic, especially in the form of Monsell's solution. Hydrargyri Nitras. The acid nitrate of mercury is well spoken of by Tilt and other practitioners. It must be applied with consid- erable care, so as to avoid injuring other parts, and a solution of bicarbonate of soda should be at hand to neutralize it. On the other hand, Atthill never employs it, and A. Courty {Mala- CERVITICIS. 119 dies de P Uterus, 1866) formally condemns it as difficult of man- agement and liable to be followed by severe mercurial poisoning. Iodinium. In ulcers of the os, iodine is not so effective as nitrate of sil- ver (Tilt), but when the latter disagrees, tincture of iodine is the best application. To the simple tincture Dr. Goodell pre- fers the saturated ethereal tincture lodoformum is a soothing and healing application, principally objection- able from its odor and the unpleasant taste it imparts. Pix Liquida has been employed by Bell. (P. 112). Potassa Fusa. This is principally used in the form of potassa fusa cum cake, which is of two strengths, known respectively as, Filhos' caustic : 144. I£, Potassae fusae, 1 part Calcis, 2 parts. Melt together. Bennett's caustic : 145. $. Potassae fusae, 2 parts Calcis, I part. Melt together. Dr. Tslt says that in obstinate cases of unhealthy condition of the lining membrane of the cervix, in highly irritable ulce- ration of the cervix with soft hypertrophy, in pseudo mem- branous ulceration of the neck, and to establish an issue on the healthy mucous membrane covering a hard hypertrophied cervix, these preparations are exceedingly useful. Dr. Atthill finds the caustic potash eminently useful in those eases where the os uteri is in a state of granular erosion. Potassii lodidum acts as a moderate caustic in certain cases. (See page 107.) Tannicum Acidum is frequently employed as a stimulating application. It may be made into a crayon by moistening with glycerine, rolling out, and drying. Zinci Chloridum. This agent is a very painful one. Zinci Sitlpk is. In the more chronic stages of cervical endometritis, solid points of fused sulphate of zinc have been introduced by Dr. Braxton Hicks, and are often useful, but are liable to cause considerable pain and irritation when any active hyperemia is present. uterine tents. Althea. The root of the marshmallow has been employed as a tent. Cloth. Tents made of cloth were introduced in 1871, by Dr. V. H. Taliaferro, of Georgia, {Jour. Gyn. Soc, Boston, Vol. V.) and have been advantageously employed. Corn-stalk Pith. In the Transactions of the Medical Association of Georgia, 1878, Dr. W. T. Goldsmith urges many reasous for I JO DISEASES OF THE UTERUS AND ITS ANNEXES. the use of this substance for tents. Take a joint of dried corn-stalk; strip it of its cuticle, and compress the pith, slowly and firmly, between the thumb and index-finger. By continued pressure, it is reduced to four or five times less than its original size. It has a dilating power equal to sea tangle or sponge. The corn-stalk tent is of easy introduction Its rig- idity overcomes any slight resistance. Dr Goldsmith has used this tent for the last seven years. He has not had a single acci- dent from its use, although he has introduced the tent many hundreds of times. The advantages of this corn stalk tent are that it dilates effectually, but not too rapidly. It is smooth, soft, and can be removed without force. It produces no lacerations, abrasions, or irritation of the mucous membrane. It can be medicated with any substance as easily as the sponge or cloth tent. It is of vegetable origin, and hence does not become putrid and poisonous to the patient, and it may be retained, non-compressed, for days without injurious results, if no pain occurs. Gentian Root. French physicians have used this occasionally. It does well as a dilating agent. Ivory, which has been softened by exposure to acids, is recommended by some. In twenty-four hours it swells to double its first size. Laminaria or Sea Tangle. This aquatic plant swells, when moistened, to three times its size when dry. It has the advantage over sponge that it contains no animal matter, and emits no fetor. When perforated from end to end as recommended by Dr. Green- halgh, such tents dilate rapidly and aho allow the fluids of the uterine cavity to escape. They cause, however, much severer pain than sponge, and run a danger of tearing a resisting os. Mr. Tait disapproves of them for these reasons. Slippery Elm Bark. This substance is praised by Dr. Wm. Goodell as a material for tents. Though of less expansive power than la- minaria or sponge, it may be left in longer as it softens down, and becomes dissolved by the discharges. It is of especial value in cases requiring no very great dilatation, but a prolonged treatment, such as in flexions. Sponge. This is the substance preferred by many for tents. Its expan- sive power is considerable and it is easily adjusted to the size and shape of the neck. But it produces a fetor which is but partially overcome by treatment with carbolic acid and irriga- tion of the vagina. Tait prefers sponge tents, impregnated with oil of cloves, but adds that even with these there is some risk of infection, and to secure entire immunity recommends that the tent be enclosed within an elastic capsule. Tupelo. The root of the tupelo tree, Nyssa-micltiflora, has been ad- vocated by Dr. G. E. Sussdorf, of New York city. It is light, smooth, and its power of absorption is said to be greater than that of sea tangle. CERVITICIS. 121 OTHER MEASURES. Galvanism. In ulcerated os with leucorrhea, Dr. O. E. Hfrrick, of Greenville, Michigan, writes to the New York Medical Record, 1879, extolling this line of treatment. He introduces a pessary, made of a ring covered with rubber and supported by a Y- shaped support of twisted silver wire, held up by a perineal band. Outside, and held up by the waist-band, is a small plate of zinc, enclosed in a a chamois-skin bag with a sponge moist- ened with vinegar. The zinc plate is united to the silver wire of the pessary by a copper wire, thus making a complete gal- vanic battery. In one patient, in thirty six hours after the gal- vanic attachment was made, he found healthy granulations in- stead of the unhealthy ulcer ; and the leucorrhea had stopped almost entirely, which had not taken place for a year before. In one week, there was neither ulceration nor leucorrhea; he then removed the copper wire and zinc, but left the uterine supporter a week longer. The patient was discharged cured, and remained so after the removal of the apparatus. Local Blood-letting. Prof. J. Y. Simpson says frequently where there is en- gorgement or hypertrophy, the abstraction of two or more ounces of blood greatly relieves the stress from which the patient is suffering, and aids in the beneficial results from other remedies. This may be effected by leeches applied to the cervix through the speculum, or by scarifying around the os with a tenotomy knife with a long stem. It is well to make the patient sit over a dish of hot water to favor the flow, and then ypply a warm vaginal douche, taking care that' the patient is not wetted and chilled during the process. DISPLACEMENTS. PROF. E. J. TILT, LONDON. Displacements of the uterus would seldom require mechanical treatment if the congestion, and other affections were properly- treated. It is bad practice to employ mechanical measures prior to the cure of inflammatory lesions. This, by diminishing enlarge- ment, will likewise relieve displacement. The stem pessary will not be borne, when the cervical mucous membrane is inflamed. When the displacement is congenital or of long standing, the cure of the inflammation does not correct it, but by a tonic treatment, with opium suppositories at night, astringent injections, and elec- tricity', many are enabled to perform their household duties. Al- ways make light of displacements to the patient, as otherwise fright interferes with the cure. Retroversion and anteversion depending greatly upon relaxation of the vagina, astringent injections prove of value, as strong solu- tions of alum, sulphate of zinc, or tannin. Aid is obtained by suppositories containing alum, iron alum, tannin, or matico. A good plan is to enclose in cotton wool a small lump of alum, the size of a hazel-nut, tie round it a string long enough to hang out of the vagina, then place the alum ball as high as possible in the vagina. The wool imbibes the fluids, the alum gradually dissolves and acts powerfully on the vaginal walls. Remove the wool next day and irrigate the vagina freely to remove the coagulated mucus, prior to a second application. Cold vaginal douches are often use- ful, applied twice a day, for fifteen or twenty minutes. Douching the loins, while the patient is perspiring from a vapor bath, often relieves the pains of displacements. Prolonged repose is hurtful, though rest for a few hours daily in the recumbent posture will diminish pain and congestion. Con- sider the periods of menstruation as seasons of disease, and enforce complete rest, with the use of hip baths and large abdominal poultices. Parturition generally greatly modifies and even cures uterine displacements. They are then mechanically rectified, and the active nutrition furnishes sounder tissues. Hence, after partu- rition, in such cases keep the patient on her back longer than ( 122 ") DISPLACEMENTS. I 23 usual, and employ twice daily after the red lochia have ceased, as- tringent injections, and continue them for months. When adequate improvement does not follow constitutional treatment, mechanical means may be employed. The womb may be placed at rest by a hypogastric bandage with a vertebral sup- port. It takes off the pressure of the intestines. Prolapsus and procidentia may be greatly relieved by the styptics as above. In case of complete prolapse, when the womb can not be re- placed, its volume may be diminished by scarifications and lead lotions, or when necessary by strapping it with strips of adhesive plaster until its size is reduced. Then, with the patient in the genu-pectoral position, the surgeon may force the womb back into the pelvis. Globular pessaries of boxwood or vulcanized rubber are often useful, and may gradually be reduced in size, till they can be omitted. The air pessary will often give great relief, even though it does not cure the displacement. All pessaries should be occasionally removed and cleansed. A pessary made of rubber covered watch-spring is easy of in- troduction and tends to counteract the relaxation of the vaginal walls. A heavy prolapsed womb is well supported by Coxeter's gutta percha pessary, which resembles a funnel, the mouth covered with thin vulcanized rubber on which the womb rests. This mem- brane is pierced with holes to permit the secretions to drain off freely. Another by Coxeter has a spring which distends a thin rubber cup which supports the womb; the lower end is fixed in the perineal band, so that the patient can remove or draw it aside. Bourjeaud's mushroom pessary is made of vulcanized rubber and may be inflated by a tube after it is placed. When distended, it is well calculated to support the neck of the womb in the depression in its upper part. It is secured by elastic bands fastened to an abdominal belt. It has two advantages, its size may be regulated, and it diminishes vaginal irritation. In complete prolapsus, the tow-pessary may be employed. The vagina, after replacement, is packed with carded oakum, called "antiseptic marine lint," or with chloralum cotton wool. The va- gina is allowed a limited power of contraction, the pressure does not cause pain, and the pessary is not readily displaced, nor does it interfere with the functions of the surrounding organs. The plug should be replaced weekly, less being required each time. 124 DISEASES OF THE UTERUS AND ITS ANNEXES. This is highly praised by Dr. Copeman of Norwich and Mr. Morgan of Litchfield. Various plans have been proposed to narrow the vagina, and thus cause the womb to be retained. Dr. Marion Sims cuts off slips of mucous membrane at appro- priate distances, and brings the c%t surfaces together by silver sutures. When old adhesions prevent the reposition of the womb, Edwards of Denbigh and others propose its removal. In three- fourths of these cases, the operation has been followed by recovery. For uterine flexions, Dr. Goodell, of Philadelphia, introduces into the cervix a powerful dilator and forcibly dilates it, so as to crack the circular fibers. This is done under ether, and is claimed to be very successful. LOMBE ATTHILL, M. D., DUBLIN, In retroflexion believes that where a pessary can be borne, its action will aid the cure. He prefers Hodge's lever pessary with transverse bars; or Dr. Greenhalgh's spring pessary, which is made of copper wire bent like the Hodge pessary, cased in rubber tubing ; but the wire is wanting at the lower or wide end, the tubing alone crossing there. A double advantage is that the tubing here adapts itself to the parts and does not irritate the neck of the bladder, and also it permits the sides to close during introduction. Great care is requisite in adjusting the pessary as to its size. When too large it causes pain, when too small it slips out. Stem pessa- ries are especially useful in dysmenorrhea with retroflexion. The best is Greenhalgh's flexible' pessary; the stem is of rubber tubing, admitting an ordinary sound, which must be passed into it when being introduced. Near the upper extremity is a bulb with four slits in it, through which the secretions escape, the lower extremity terminates in a shield. Stem pessaries should never be left in longer than a month, and should be avoided if possible. Bear in mind that cases are often met with which seem to cause no distress, and should not be interfered with. Retroversion is rare, and is generally connected with pregnancy and usually occurs at the close of the third month, causing reten- tion of urine; on emptying the bladder, a globular body will be found occupying the hollow of the sacrum, while the os uteri is DISPLACEMENTS. 125 high up behind the pubes, and the fundus will be found absent from its proper place. Two indications are to keep the bladder empty, and to restore the uterus to its normal position. In these cases always use a loniological in character than those following the use of ergot. In administering it, he prefers an infusion of the fresh leaves and roots to any other form (5ij-ivto water Oj), to be taken in two or three doses at intervals. Sabina. The reputation of this plant as an ecbolic is probably not just- ified. Dr. E. Hamelin, who has studied its properties care- fully, doubts whether it excites directly any uterine action ; if such follows, it is the result of transmitted irritation. Sodii Boras. The use of boras as an ecbolic is of doubtful efficacy. Tanacetum, often used for criminal purposes as an abortifacient, is, in the opinion of Stille, incapable of producing any such result. VOMITING AND NAUSEA OF PREGNANCY. PROF. G. TARNIER, PARIS. In slight vomitings, some aromatic infusion or tea will generally relieve. When they occur after a daily meal, it is useful to change the order of the repast. Thus if, as is usual, the vomiting is very copious after the evening meal, the woman should make merely a light repast, and eat more at breakfast. Cold food is least likely to be ejected. Ices, aerated waters, or small pieces of ice may be taken with the best results. The subacetate of bismuth, in doses of a grain or half a grain before each meal, is very beneficial ; or after the meal, two or three teaspoonfuls of Kirsch. In obstinate cases, a pill, or two or three centigrams of aqueous extract of opium, may be given an hour before the meal, and to prevent onc- stipation, a slight purgative occasionally. Where the vomiting is accompanied with pain and tension at the epigastrium, lotions of laudanum are useful ; or a small blister, subsequently powdered with one or two centigrams of the muriate or acetate of morphia. Dezon has succeeded by the application of cold water to the epi- gastrium. Alcohol to a slight intoxication has proved success- ful ; hence champagne frequently at once gives relief. Breton- neau has calmed the irritability in grave cases by frictions on the stomach with a concentrated solution of belladonna. Tarnier applied this in a very bad case in the form of the extract to the in- ferior segment of the uterine neck and the vaginal walls with the best results. Stackler has succeeded with the black oxide of mercury, 5 centigrams daily, without salivation. Eulenberg applied tincture of iodine to the os. Ricord and Bacarisse also gave 50 centi- grams of iodide of potassium daily, and with equal success. The salts of cerium, particularly the oxalate, are extremely useful in doses of 5 centigrams, 3 or 4 times a day. Obstinate constipation generally is present with the vomiting. Here he gives scammony , 50 centigrams, with one grain of jalap at bed-time. If the first is vomited, repeat it immediately, and even a third dose. Generally the second or third will be retained and act purgatively. When an examination reveals a retroversion ( 214) VOMITING AND NAUSEA OF PREGNANCY. 215 of the uterus, generally its replacement will at once put an end to the vomitings. In cases likely to prove fatal, especially when the pregnancy has advanced to a point that assumes the vitality of the child, prema- ture labor may be deemed necessary. PROF. KARL SCHROEDER, OF ERLANGEN. This author suggests subcutaneous injections of morphia. Pip- pinskold has cured it with enemata of broth, oil, and wine. If the child be viable, labor must be induced. It must not be for- gotten that it may be due to a round ulcer of the stomach. WM. LEISHMAN, M. D. LONDON. Breakfasting in bed and not rising for awhile often speedily relieves the trouble. In cases where the bowels are sluggish, the granular effervescing citrate of magnesia is useful, or the " potion de Riviere " given so that the effervescence occurs within the stomach : 236. I£. Acid, citric, gr. xxxvj Syr., simp., f. gi Aquae, f.§ij. M. 237. IJl. Potassii bicarb, ■ gr. xxxvj Aquae, f.giij. M. A tablespoonful of each to be taken successively. When there is ex- haustion, stimulants are required. Pepsin is valuable. Often simple milk, and lime-water, and barley water (especially the latter), are retained in very grave cases. Nutritive enemata may be employed to sustain the failing powers or inunctions of cod or other oils. DR. ALBERT EULENBERG, BERLIN. 238. fy. Tincturae iodinii, ltixv Alcoholis, f^iij. M. Give three drops several times a day, in a tablespoonful of an aro- matic infusion. 239. I£. Tincturae iodinii, gtt.x Aquae destillatae, f.giij Syrupi aurantii corticis, £.Jj. M. A teaspoonful, or even a tablespoonful. Other approved prescriptions are : 240. ¥,.. Bismuthi subnitratis, 3iij Acidi carbolici, gr.iv Mucilaginis acaciae, f.3J Aquae menthae pipentae, f-o^j- M. A tablespoonful three or four times a day. 2l6 DISORDERS OF PREGNANCY. 241. IjL Atropias sulphatis, gr.ij Aquae destillatae, f.§j. M. Two drops in water, before meals. 242. I£. Cerii oxalatis, gr.x Bismuthi subnitratis, gr.xxx. M. Make ten powders. One five or six times a day. Sometimes a rectal injection of chloral hydrate, gr.xxx, morning and evening, will effectually control this symptom. Bromide of potassium, 3j, thrice daily; chloroform, gtt.ij, in mucilage, and medicated pessaries, may also be tried. Dr. E. Copeman, of Nor- wich, Eng., claims invariable success to follow dilatation of the os uteri with the finger, once often being sufficient to relieve the nausea completely. {British Medical Journal, May 25, 1875.) A somewhat similar plan is that suggested by Dr. M. O. Jones, of Chicago, to wit : Painting the os and cervix with tincture of iodine, or cauterizing them with solid nitrate of silver. This plan has met with great success in obstinate cases, and has been en- dorsed by Dr. J. Marion Sims. W. STUMP FORWOOD, M. D., OF DARLINGTON, MD. This practitioner recommends the following as almost a specific in the vomiting of pregnancy [Half Yearly Compendium, Vol. III., p. 96) : 243. I£. Columbae, §ss Sennas, 5j Zingiberis, iss Aquas bull, Oj. M. A wine glass full three times a day. HENRY F. CAMPBELL, M. D., OF AUGUSTA, GA., Has called attention to the importance of rectal alimentation in the nausea and vomiting of pregnancy, not merely as a last resort, but as an expedient for supplementing inadequate nutrition by the stomach in moderately severe cases {Trans. Am. Gyn. Soc, 1878). He uses about eight ounces of beef tea, or other nutrient liquid, twice daily, injecting it very slowly and gently, so as to avoid exciting the lower bowel to expulsive efforts. To supply fluids, during the intervals of the morning and evening injections, a full goblet of water, not quite cold, was twice given some hours apart. The results, in the instances reported were highly satisfactory, the nutrition being maintained, the nausea abated, and the sympathetic irritation of the stomach relieved. VOMITING AND NAUSEA OF PREGNANCY. 21 J RESUME OF REMEDIES. INTERNAL REMEDIES. Acidum Hydro cyanic urn Dilutum, gtt. v., is a valuable sedative. Aconitum. A few drops of the tincture of aconite will relieve some cases. Armoracia. Dr. Tilt recommends a small portion of horse radish, scraped fine, and moistened with vinegar. Arsenicum. Single-drop doses of Fowler's solution will sometimes afford astonishing relief. Atropia has been used with advantage (F. 241) Wm. Boys, M. D., Waverly, Iowa, in the Med. Brief, Oct. 1879, gives the following : 244. 5. Atropine sulph., gr.j Morph. sulph., gr. iv Ac. sulph. arom., f-3hj Aquae, f.3v. M. Dose, gtt. x-xx 3 times a day. Belladonna, in ten minim doses of the tincture, is recommended by Tilt and others. Bismuthi Subnitras will be found at times an efficient sedative (F. 240). Calumba, according to Phillips and Bartholow, will frequently allay the nausea and vomiting. Carbolicum Acidum, in drop doses of the crystallized acid, in mucilage, thrice daily, has been recommended by English writers. Cerii Oxalas has attained great favor. Dr. F. E. Image {Practitioner, June, 1878,) prefers this formula: 245. I£. Cerii oxalatis, Pulv. trag. co., aa gr. x Tinct. aurant, f.3ss Aquam, ad f.gj. M. For one dose as required. It is often given in too small a dose ; gr. x is required. The filtrate of cerium has also been used. Chloral Hydras, in simple nervous erethisms of the stomach, often acts promptly; gr.xxx in mucilage for a rectal injection is the best form of administration. Chloroformum may be given in doses of a few drops in a spoonful of milk. Sir C. Locock recommended repeated chloroformization almost to insensibility. Creasotum should, according to Dr. Ringer, be given in very small doses, for instance, added to water just so that the latter tastes of it, and then a dessertspoonful of the fluid taken from time to time. Cupri Sulphas, gr.iv to aquae f.lj. Six drops at a dose will sometimes relieve. (Bartholow.) 2l8 DISORDERS OF PREGNANCY. Ether. A few drops at a time in water, or inhaled, will at times relieve the nausea. The spine has also been sprayed with the ether spray with most excellent results, by Dr. Dubelski, of Warsaw. Hydrargyrum Chloridum Mite. Dr. Tilt occasionally administers gr.x- xv of calomel for its sedative action; or combines it in smaller quantities with opium. Hyoscyamus. Dr. Pitois, Professor at the Medical school at Rennes, re- ports two striking cases of relief by hyoscyamia. After trying, unsuccessfully, all the usual means, he administered a teaspoon- iul every hour of a mixture containing five milligrammes of hy- oscyamia in 125 grammes of fluid. The next day the vomiting ceased. Ingluvin. This substance, used to facilitate digestion, has been favorably reported upon. Iodinium, in drop doses of the tincture every hour or two, will, according to Bartholow, sometimes greatly relieve this symptom. Ipecacuanha. Dr. C. Fuller {Lancet, Dec. 4, 1869,) introduced the treatment of vomiting of pregnancy by single drop doses of wine of ipecac, in a teaspoonful of water every hour. Others have also reported favorable results from this plan. Lactopeptin. This peptic compound has in a number of instances relieved the nausea and vomiting. Magnesia in small quantities occasionally affords relief. Nux Vomica, in tincture, gtt.v-x, as required, is relied upon by Playfair and others. Bartholow says it is best adapted to cases with much nausea and little vomiting, in doses of half a drop to a drop. Opium and Morphia are, according to Tilt, the first remedies to be tried. He recommends suppositories containing gr. ij-iij of extract of opium, or gr.j morphise acetatis; or the drug may be given by the mouth. Inquiry, however, must be made as to the idiosyncrasy, as it is well known that any fosfrn of opium produces vomiting in some persons. Dr. Atthill combines morphia with atropia for a hypodermic injection : 246. Ify. Morphise acetatis, gr.viij Atropiae liquoris (B. Ph.), nixlviij Glycerinas, niv Aquam, ad f.5iv. M. * Dose. — Five to ten drops for a hypodermic injection. Pepsina, either as wine or in other forms, will often succeed. Potassii Broniidum. Dr. S. C. Busey, Washington, D. C. {A'mer.Jour. Med. Sci., January, 1878), has obtained decided and immediate reiief from the bromide of potassium. He gives 30 grains to a drachm, dissolved in beef- tea, to which brandy and laudanum may be added, according to the condition of the patient. He gives it in enemata every four hours. Potassii Iodidum is occasionally of service. VOMITING AND NAUSEA OF PREGNANCY. 2IO, Salicin has been occasionally found to be of service. Strychnia. Dr. Tilt strongly recommends : N 247. B. Strychnia?, g r -H Tinct. zingiberis, f-5vj Aquae, f.§iv. M. Dose - — A teaspoonful every one or two hours. Tannicum Acidum, in the form of a pill, gr i-ij, morning and evening, has been found very successful by Dr. Diboue {Arch, de Tocolo- gie, Sept, 1877). Stimulants. Recourse must be had to these cautiously, on account of the relief they sometimes give leading to the habit of tippling. When accessible, the best is probably dry champagne, iced, of which tablespoonful doses may be given every 15 minutes. LOCAL MEASURES. Caustics. Dr. J. Marion Sims believes that the treatment should always be directed to the seat of the irritation, and claims the best re- sults from the use of caustic to the os ; two or three applications generally suffice. This method he employs even when there is no sign of erosion of the mucous lining of the os, and the parts appear perfectly healthy. Dr. F. D. Lente {Med. Record, 1879), agrees with Dr. Sims, and freely touches the os and cer- vix with the nitrate of silver. He quotes Dr. M. O. Jones, Chicago, as using this method with the best possible result, and where, in the majority of cases, the os presented no signs of disease. Dr. Playfair considers the measure hazardous. Cold, applied to the epigastrium, or by swallowing pieces of ice, is often beneficial. Electricity. Dr T. Gaillard Thomas, of New York, employs elec- tricity. He fixes one broad flat electrode, made by stitching a flat sponge to sheet rubber, by means of adhesive plaster on the epigastrium, and a similar one under the spine, the patient ly- ing supine. Then a gentle current is passed, and continued steadily for 10, 12, or even 24 hours. He has seen no evil result, and esteems this remedy higher than any other. Dr. da Venezia relates in the Giornale Veneto di Scienze Med. (January, 1879), a case °f chronic nervous vomiting in pregnancy which was cured by electricity. The patient was a young woman aged 24, in the seventh month of her first preg- nancy. She had been suffering for the last two years from fre- quent attacks of vomiting after food, which had been so fre- quent during the last month, that she had become greatly re- duced in strength. The usual therapeutic agents were then emp'oyed; but, as no relief was obtained through them, the author resolved to try electricity. A faradic current of mod- erate strength was used, one of the rheophores being applied to the side of the neck along the course of the vagus nerve, and the other to the epigastrium. After the first sitting the patient was better, and after the fourth the vomiting ceased. 220 DISORDERS OF PREGNANCY. Heat. Tanner mentions hot fomentations to the epigastrium and hot poultices, as occasionally useful. Injections, either rectal or vaginal, are efficient means. Those containing opium are most useful. In the Boston Medical and Surgical Journal, 1879, Dr. Greene, of Dorchester, advocated the use of warm vaginal lavements for many cases of obstinate vomiting of pregnancy. He also reports a case where warm olive oil succeeded after the water had failed. Leeches to the os have been used by Clay, but their propriety has been doubted by Playfair. Dr. Tilt mentions that in some cases the vomiting has been promptly checked, after the failure of ordinary measures, by the application of a few leeches to the pit of the stomach, although there were no signs of inflamma- tion there, and the patient was not plethoric. Suppositories , both rectal and vaginal, containing opium or its alkaloids, are among the earliest resources indicated. As a medicated pessary, Dr. Tanner prescribes:, 248. f£. Extracti belladonna?, gr.xxv Extract! hyoscyami, gr.lxxx Plumbi iodidi, 3j Theobromae cocoa?, oJ Olei olivae, f.3ij- M. For eight pessaries. One to be introduced into the vagina every night. The author has in many extremely obstinate cases obtained the most prompt benefit from the employment of suppositories of bel- ladonna and hyoscyamus. '7 SYMPATHETIC NERVOUS DISORDERS. These are palpitation of the heart, headache, syncope, cough, neuralgia, pruritus, hypochondriasis. PROF. W. S. PLAYFAIR, M. D. LONDON, For the palpitation, would give ferruginous preparations, and a general tonic regimen. When it does not seem to result from debility, anti-spasmodics are indicated. Syncope occurs generally in women of a highly-developed nerv- ous temperament, and generally about the time of quickening. The treatment should consist in the use of diffusible stimulants, as ether, ammonia, and valerian, the patient being recumbent with the head low. In the intervals, tonics and iron are necessary. Neuralgia is generally controlled by tolerably large doses of quinine. If caries of the teeth is present, the affected tooth should be removed without fear. Nitrous oxide gas maybe administered without difficulty or risk. ELY VAN DE WARKER, M. D., OF NEW YORK. This writer extols the black cohosh, cimicifuga racemosa, for the nervous disorders of pregnancy [Half Yearly Compe?idium, Vol. XIII., p. 176). He says: "Women are oftentimes the subjects of distressing symptoms as pregnancy advances. Among these are a train of nervous symp- toms : Restlessness, sleeplessness, darting pains in the back, flanks and thighs, and stiffness and soreness in movement, 3re yery common and troublesome. For these conditions I find black cohosh, cimicifuga racemosa, a sovereign remedy. I give thirty minims, or half a teaspoonful, of the fluid extract at bed time, in cases of restlessness ; and in cases of neuralgia of the lumbar or abdominal muscles, or in cases of stiffness or soreness in move- ment, the extract may be given in the same amount, at intervals of three to five hours during the day. THOMAS H. TANNER, M. D., LONDON. The headaches of pregnancy are usually due either to debility or to sympathy. The first is dull and steady, the skin cool, and (221) 222 DISORDERS OF PREGNANCY. the pulse feeble. Its successful management demands quinine and iron, good diet, exercise, and general hygiene. The sympathetic headache is generally limited to a small space, or a single spot. The pain is acute and penetrating. The treatment is a moderate purgative followed by tonics. The extract of aconite, gr.}4, every four or six hours, sometimes gives prompt relief in such cases. In puerperal cases, insomnia is not unfrequently the precursor of delirium or mania. It demands, therefore, careful attention, and, if persistent, the cautious use of hypnotics. Groundless despondency, hypochondriasis, is not very unusual during the period of gestation. The bowels should be acted on with rhubarb and soda, pepsin taken after the meals, and a tonic, such as the following, be prescribed : 249. I£. Spiritus ammonise aromat, f-5iij Spiritus chloroformi, f.5ij Ferri et quinine citratis, gr.xxx Liquons strychnia?, irixxx Tincturae zingiberis, f.3ij Aquam, ad f.§viij. M. A sixth part two or three times a day. Sometimes the union of the tonic with an alterative is desirable, as : 250. I£. Ammonii muriatis, gr.lx Extracti cinchona? liquoris, Trixc Vini rhei, f-3vj Aquam menth. piper., ad f.§viij. M. A sixth part twice daily. The moral management of such cases is also important. Posi- tive assurances of the future must be given ; the demeanor must be humane and sympathizing; and she must be guarded from scenes and tales of suffering. Pregnant women toward the eighth month are sometimes subject to sudden attacks of intensely acute pain in the right side. The treatment should be to make the patient lie on her left side, cover the region of the pain with hot fomentations containing belladonna and opium, and administer a full dose of an anodyne and carmina- tive mixture. As long as any pain remains, she should keep her bed, and lie on the left side. The sympathetic nervous cough of pregnancy comes on in violent paroxysms, especially at night, without expectoration or steth- SYMPATHETIC NERVOUS DISORDERS. 223 oscopic signs. In its treatment, he has found antispasmodic mixtures like the following to give great relief: 251. I^. Spiritus etheris, f-Siij Tinct. chloroformi comp, f.3j Acidi hydrocyanici dilud, fl xv Liquoris morphiae sulphatis, f.5i Tinct. cardamomi comp, f-5vj Aquam, ad f . 3 v i i j . A sixth part every 6 or 8 hours. Or, 252. I£. Tinct. Valerianae amnion., "Ixxx Tinct. sumbulis, v\xx Tinct. belladonnae, ""1.x Tinct. camph. comp., tlkxx Aquam camphorae, ad f.3*ij M. For one dose. Efforts must be continued to check the cough when violent, as its continuance sometimes leads to abortion. TYLER SMITH, M. D., LONDON, Regards pruritus as the result of follicular irritation of the vulva. The secretion from the surface is generally very acid, which may- be relieved by washing with common yellow soap. Dilute hydro- cyanic acid, Battley's solution, of each f.5ij, and carbonate of soda, 5ij, water f.Svj, make an excellent wash, using only a tablespoon- ful at a time. A lotion of borax is good; sometimes an acidulated lotion is preferable, or a lotion of tar water. In obstinate cases, paint the vulva with nitrate of silver, 10 grains to water one ounce every day, or every other day ; or with tincture of iodine with an equal part of water. Where the os uteri is thus troubled, inject the lotion of borax or nitrate of silver. Tepid or cold bathing, cooling . diet, and aperients, are also aids in the cure. Should it assume a periodic form, quinine is the remedy. PROF. W. S. PLAYFAIR, M. D., LONDON. Pruritus is frequently associated with leucorrhea of an acrid nature; or there maybe aphthous patches on the mucous mem- brane, ascarides in the rectum, or pediculi in the hairs of the mons and labia. Sedative lotions are useful, as Goulard's, or an ounce of the solution of muriate of morphia with a drachm and a half of hydrocyanic acid in six ounces of water ; or chloroform, one part to 224 DISORDERS OF PREGNANCY. six of almond oil. A pledget of cotton- wool soaked in equal parts of glycerine of borax and sulphurous acid, may be placed in the vagina at bed-time, and removed in the morning. In obstinate cases, the solid nitrate of silver may be brushed lightly over the vulva. Generally the aperient mineral waters and bromide of potassium aid in the cure. PROF. S. TARNIER, PARIS, Gives this formula : 2 53- $• Deutochloride of mercury, 2 grams Alcohol, IO " Rose water, 40 " Distilled water, 450 " He employs this night and morning thus : Bathe the parts with warm water to remove any discharges, then, having carefully dried the surface, rapidly sponge the seat of the affection with the lotion. In a few minutes, wash again with fresh water. The_cure is gen- erally rapid. [For further suggestions regarding the Pruritus of Pregnancy, see Part I., Chap. III., under Pruritius of the Vulva. DIGESTIVE DERANGEMENTS OF PREGNANCY. GINGIVITIS, PUERPERAL SALIVATION. Dr. A. Pinard of the Clinique d' Accouchement, of Paris (L Abeille Med. Jan., 1878), remarks that in many cases of pregnancy, the gums are the seat of more or less morbid phenomena. They are redder and more congested than normally ; they are swollen ; the edge of the free border, especially the inter-dental membrane, covers a part of each tooth. The slightest pressure exerted on this edge, causes a slight hemorrhage. At a more advanced de- gree, the teeth lose their solidity. The mastication, at first injured, becomes more painful and more difficult as the lesions are more pronounced. For the relief of this condition, he has used : 254. fy.. Chloral hydratis, Tinct. cochleariae off., aa partes equales. Apply daily, or every other day, to the diseased edge of the gums, with a mop. This dressing is slightly painful, and the cauterization very light. The eschar disappears generally twenty-four or thirty-six hours after the application. In thirty women attacked with gingivitis, who were subjected to this treatment, twenty-five were cured in less than fifteen days. In two of them the cure was slower, com- plications having supervened which necessitated the use of mercu- rial ointment. In five others the treatment could not be continued. Dr. Thomas H. Tanner remarks that some writers say the sali- vation should not be checked ; but he distrusts this view. He has found small blisters behind the ears or to the neck more efficient than any other remedy. Local remedies are seldom of use • one of the best is 255. ]£. Sodii boracis glycerini, f ?;; Aquae rosae, ' f!§vj.. M. For a gargle. To be used twice daily. Belladonna is the only internal remedy he has seen diminish the discharge, but this often fails. Chlorate of potassa may be tried. 15 ( 22 5) 220 DISORDERS OF PREGNANCY. DIARRHCEA Occasionally is present, and Playfatr regards it as due to errors of diet. It should not be neglected, as it may bring on labor pre- maturely. The chalk mixture, with aromatic confections and small doses of chlorodyne and laudanum, will generally check it. Leishman counsels the removal of any fecal accumulations by castor oil and then the use of astringents. CONSTIPATION. Leishman regards this as due to the pressure of the womb on the bowel, reducing its calibre and paralyzing its muscular fibres. In other cases, a want of bile occasions it. If clay-colored stools show this, a few grains of blue pill will do good. Playfair suggests appropriate diet, as fresh fruits, brown bread, oatmeal, etc. The aperient mineral waters answer well, and an occasional dose of confection of sulphur ; or a pill of three grains of extract of colocynth, quarter of a grain of extract of nux vomica, and a grain of extract of hyoscyamus at bed-time ; or a teaspoon- ful of compound liquorice powder at bedtime. This condition is effectually combated by giving, twice a day, a pill of two grains of inspissated ox-gall with a fourth of a grain of extract of bella- donna. Enemata of soap and water are good. Scybalae must.be broken up and removed by mechanical means. Dr. W. Craig, Edinburgh (Edinburgh Med. Jour., June, 1875), has found the following an excellent pill for the constipation so common in females of a sedentary habit : 256. R. Aloin., gr.ss Ferri sulph. exsic, gr.iss Extract, nucis vomicae, gr.ss Extract, belladonnas, gr.ss. Fiat pil. One or two pills daily. Another writer gives : 257. ~fy. Ext. colocynth comp., gr.xij Pulv. rhei, g r - v j Ext. belladonnas, gr.iss " hyoscyami, g r -iij- M. Divide. into six pills. One at bed-time. ^ grain of strychnia may be added to each pill. HEMORRHOIDS. 'Leishman says the treatment must be purely palliative. Spong- ing with water; fomenting with sponges wrung out of hot water, DIGESTIVE DERANGEMENTS OF PREGNANCY'. 227 and applied as hot as they can be borne; applications of ung-. gallse cum opio ; and cold injections for hemorrhage. Cazeaux gives every night a cold enema ; when this is evacua- ted, a second of about one-fourth the quantity, this to be retained. Playfair likes the sulphur electuary. When tender and swol- len, he covers the tumors with an ointment of four grains of muri- ate of morphia to an ounce of simple ointment. R. P. Harris, M. D., adds to the ung. gallae cum opio 5j — ext. of stramonium 5j. The tumors should always be returned care- fully within the sphincter, and punctured if necessary to lessen-the congestion, prior to the attempt at reduction. Tarnier relieves the constipation, then uses cataplasms and lo- tions, emollient and narcotic. When internal, introduce supposi- tories within the rectum. Opium and belladonna are most useful. During pregnancy and the puerperal period, hemorrhoids often occur. For them Dr. Barker recommends the following formula : 258. ft. Pulv. alo;s soc. Sapo cast., aa 9j Ext. hyoscyami, 3ss Pulv. ipecac, gr.v M. Divide in pills No. xx. Sig. — One morning and evening. When the hemorrhoids are associated with an irritable rectum, and with frequent small, teasing, thin evacutions, he substitutes for the hyoscyamus a small quantity of opium, giving also a less quantity of aloes, as in the following formula: M. Locally he applies the following ointment to the tumors and well up in the rectum twice daily : 260. R. Ung gallae co., §j Ext. opii aq., 9j Sol. ferri subsulphatis., f.3j M. Ft. ung. 259. $. Ferri sulph., B) Pulv. aloes, gr.x Ext. opii aq., gr.x Sapo cast., gr.x. Ft pil. No. xx. Sig. - One morning and evening. ALBUMINURIA OF PREGN'ANCY. PROF. WM. LEISHMAN, M. D., GLASGOW, Says antiphlogistics must only be used with the greatest caution. Baths are useful by promoting the function of the skin. Diuretics are of doubtful value. Dr. J. S. Parry, the Philadelphia editor, urges the following : 261. $. Tr. ferri chlo., f.3hj Liq. ammon acet., f.^iij Ac. acetic, ""Ixv 01. gaultheriae, gtt.v Syr. aurant. cort., f -Jj . M. Dose. — One to two drachms three times a day. It is of great importance to recognize the presence of albumen early. Such symptoms as edema, even of the minor form, should always prompt the physician to test the urine for albumen. It may, indeed, exist, and apparently in no way affect the general health. When this is the case, active medication is needless. It will be enough to regulate carefully the diet, and maintain in nor- mal action the secretory functions. Cases which are wholly due to the pressure of the enlarged uterus and its contents, often con- tinue to the close of the pregnancy and pass through confinement without any untoward accident. The avoidance of interference therefore, and a watchful supervision of the case, embrace all that the physician is called upon to do. It must be borne in mind that the disease is one of debility, and implies impoverishment of the blood, so that lowering treatment is usually out of place, and tonics and a generous diet are rather called for. Occasionally some of the mildest diuretics maybe exhibited, but, as above men- tioned, their general use is of questionable propriety. PROF. W. S. PLAYFAIR, M. D., LONDON, Saline diuretics, as acetate or bitartrate of potassa, and watery purgatives, as the compound jalap powder, are most useful in pro- moting the urinary secretion and relieving the renal congestion. Dry cupping over the loins, frequently repeated, and the vapor or Turkish bath, will aid greatly. The diet should be mainly of milk (228) ALBUMINURIA OF PREGNANCY. 229 and white of egg, and a little white-fish. The tincture of perchlor- ide of iron, with the tincture of digitalis, acts well. The induction of labor must depend upon the gravity of the symptoms. TYLER SMITH, M. D., LONDON, Believes in small bleedings where there is distinct lumbar pain and general febrile excitement, or cups to the loins, or sinapisms. Warm and vapor baths, aided by diuretics, as acetate of potassa, oil of juniper, infusion of broom, will tend to remove the effusion, and cause the kidneys to act. Then tonics, iron, and good diet. Where the phosphatic diathesis exists, we require the mineral acids, opium, and rest. PROF. S. TARNIER, PARIS,* At the Maternite, has for some years treated albuminuria entirely by milk, and with most excellent results. One litre (i^ pints) of milk, increased to three and four litres a day, are given, and the albuminuria rapidly diminishes or disappears. The effect is shown in a week or a fortnight. PROF. MONTROSE A. PALLEN, M. D., NEW YORK, Regards as the correct treatment the relief of the hyperemia of the kidney by sponging the surface with hot water and alcohol and by keeping the pores open with vaseline inunctions ; to this may be added the hot air or Turkish bath ; milk is given as the most digestible food; kumyss was added because of the very slight amount of, and easily digested alcohol in it. The patient is to be kept in bed, to maintain the skin at a uniform temperature ; massage stimulates the circulation, and equalizes the blood cur- rent ; cathartic water is the best aperient. If eclampsia is threat- ened, have recourse to chloroform, and bleeding. PROF. EDW. S. DUNSTER, M. D., ANN ARBOR, MICH. In treating of the prophylaxis of puerperal convulsions, this au- thor suggests in albuminuria, the relief of the congestion of the kidneys by causing the skin to act ; he gives bitartrate of potassa, compound jalap powder, citrate of magnesia, and sulphate of mag- nesia acidulated with sulphuric acid, and the natural mineral * Annates de Gynaccologic, Jan., 1876. 23O DISORDERS OF PREGNANCY. waters. He promotes diaphoresis by the vapor and hot air bath, or the Turkish bath if accessible. Vichy and Seltzer waters are well borne. Cupping, wet or dry, over the kidney, particularly when there is pain over it, and the urine is scanty, or smoky. A hard bounding pulse, severe pains in the head, flushed and hot skin may be met by venesection, though in many instances saline laxatives, freely used, will overcome these symptoms. Counteract the impoverished state of the blood resulting from the loss of albumen by good nutritious food, fresh air, an appro- priate mode of life and tonics. Generally white meats and fish are well borne. Milk is excellent as a diet. The tincture of the chloride of iron is the best tonic. It should be given largely dilu- ted, and not to the extent of blackening the feces. Quiet the nervous and digestive disturbances by complete regu- lation of the habits and mode of life, and an out-of-door life short of fatigue ; constant and cheerful occupation for both mind and body. Avoid opiates, but give nervous sedatives or soporifics that are non-constipating, as chloral in severe cases. The bromide of potassium and the monobromide of camphor are useful. They ameliorate the condition, and give considerable immunity against convulsions at the time of labor. For the loss of appetite and con- stipation, pepsin, bismuth, and nux vomica, are serviceable. Induce premature labor when all else fails. DR. A. S. COE, OF NEW YORK. According to this practitioner [Am. Joitr. Obstetrics, Oct., 1878) when albumen makes its appearance early in pregnancy, there are three important indications to be met: (1) to eliminate the poison as far as possible; (2) to support the patient; (3) to allay the ner- vous tension, and guard against exciting causes. In the first, ace- tate or some of the other salts of potassa, with digitalis, acts favor- ably upon the kidneys, and diminishes the quantity of albumen in the urine. Much of the poison can be eliminated by the action of saline cathartics upon the bowels. The second is best met by a liberal diet, tonics, and iron. To meet the third, absolute rest and quiet are necessary, with the use of opium and bromide of potassium, if an outbreak of convulsions or other paroxysms is threatened. When there is much cerebral disturbance, the appli- cation of ice to the back of the head and upper part of the spine answers an excellent purpose. ALBUMINURIA OF PREGNANCY. 23 1 Convulsions are usually preceded by a rapid accumulation of uric poison in the blood and a scanty secretion of urine, and often the patient is attacked with only a slight premonition of coming disaster. In the treatment of these cases, he has found that sulph. morphia, injected hypodermically, answers the best purpose. He never was able to get satisfactory results from bleeding or the use of chloroform. PROF. J. B. FONSSAGRIVES, M. D., PARIS. This author considers it doubtful whether any direct means are available to combat the superabundance of albumen in the serum ; but indirectly much can be done by regimen and diet. One of the most important points is to keep the bowels soluble by laxatives ; constipation in such cases must be sedulously avoided by means of alkaline purgative waters, in doses sufficient to act moderately and no more. Whether the diet recommended in Bright's disease should also be adopted in the albuminuria of pregnancy, remains an open question. Often by attention to the bowels and general regimen, no such means need be resorted to. PROF. CARL R. BRAUN, M. D., VIENNA. Hydremia, at an early stage of pregnancy, is ameliorated by nutritious diet, vegetable tonics, and iron, tepid baths, and espec- ially vapor baths. To neutralize the carbonate of ammonia in the blood, make use of benzoic acid, lemon juice, or tartaric acid. To obviate congestion of the head, prevent constipation by vinegar injections, aloes, jalap, etc. When exudation has taken place into the Malpighian capsules, and the tubuli of Bellini and Ferrein, the cylindrical clots must be removed from them, and new ones pre- vented. If the current of fluid from the bodies into the capsules be strong, then the copious use of diluents will suffice to wash away the clots. But if the urine be scanty and uremia threaten, then the force of the current must be increased by acids, as above, and Seltzer and Vichy waters. Pills of tcuiniu and extract of aloes are useful to restore the normal tone. Premature delivery is not to be thought of, unless uremia has appeared, and the life is threatened. But it will be rational to resort to this procedure if from the duration of the disease, its severity, the quantity of cylindrical clots, the great hydremia, the 2$2 DISORDERS OF PREGNANCY. dropsy, and disturbances of the heart, lungs, brain, etc., cause fear of the existence of great degeneration of the kidneys. Should symptoms indicate the death of the foetus, operative interference may at once be employed, as its retention greatly adds to the danger to the mother. RESUME OF REMEDIES. Benzoicum Acidum, gr.v, twice daily, in pill form, has given satisfactory results in uremic attacks during pregnancy. Chloral has been tried with marked success in a few cases by Dr. E. Noeggerath, of New York. (Amer. Jour, of Obstetrics, Oct., 1878). He gave gr. xx-xxx every night, with the result that the albumen immediately began to diminish, and soon disap- peared entirely. Digitalis. The duretic powers of this drug are frequently available. It can often be advantageously used as a poultice as recommended, by Dr. P. C. Russel (Brit. Med. Jour., December, 1878). Ferrum. The use of ferruginous preparations combined with diuretics is always indicated. Taborandi and Pilocarpin must be used cautiously in these cases, as they have ecbolic properties which may lead to abortion. . Oleum Juniperi was preferred by Simpson as a diuretic, but has not been approved by others. Oleum Tiglii is occasionally called for in severe cases, to act on the bowels and kidneys. Potassii Acetas and Bitartras usually secure an abundant renal secretion. Potassii Bromidum is valuable to relieve headache and control nervous excitement. Milk Diet. A diet of skimmed milk is probably the only remedy now known which has a radical influence on albuminuria. On the general treatment of Albuminuria, see the section on Eclampsia, and also Napheys' Medical Therapeutics,. Chap. V. CHAPTER II. COMPLICATIONS, DISORDERS, AND SEQUELS OF PARTURITION. Ancestlietics in Labor — Tedious Labor {Rigid Os, Uterine Atony, etc.) — After Pains — Puerperal Hemorrhage — Puerperal Eclamp- sia — Puerperal Mania — Puerperal Septicemia — Thrombosis and Embolism — Shock — Pelvic Cellulitis and Peritonitis {Puerperal Phlebitis and Metritis) — Phlegmasia Dolens — Milk Fever — Puer- pt ral Convalescence. ANESTHETICS IN LABOR. PROF. FORDYCE BARKER, M. D., NEW YORK. Anaesthetics are of great value in preventing lacerations of the perineum. In that form of rigidity caused by excessive irritability of the muscular fibres, the perineum relaxes and dilates with re- markable rapidity after the inhalation of chloroform. Where dan- ger arises from violent uterine contractions, profound anaesthesia will save the perineum. Even in tedious labors, chloroform causes relaxation and a restoration of the normal moisture and tempera- ture of the parts, and efficient action of the uterus is at once resumed. PROF. KARL SCHROEDER, ERLANGEN. Chloroform in labor has the same advantage as in surgical operations. It facilitates all midwifery operations. In parturition, it easily acts in a small quantity, and it is not necessary to pro- ducec omplete anaesthesia merely to mitigate pain. A few whiffs relieve the acute pain, and this cannot injure mother or child. Even profound anaesthesia has not been found to influence the child when continued for a short time. It does not induce hemorrhage, and reduces the temperature, both favorable effects. It cannot be questioned that chloroform is advisable in normal ( 2 33) 234 COMPLICATIONS OF PARTURITION. parturition to suppress the intense sufferings. Chloral has an equally beneficial effect. PROF. S. W. PLAYFAIR, M. D., LONDON. Anaesthesia is a perfectly legitimate means of assuaging the sufferings of child-birth. Chloral may be safely given when chloroform cannot. It does not relax contractions, while it pro- duces a drowsy state, in which the pains are not so acutely felt. Hence, in the first stage, during the dilatation of the cervix, it is most useful ; especially in those cases where the pains are intolera- bly acute, with but little effect on the labor, 1 5 grains may be given every twenty minutes, for three doses ; the patient becomes drowsy, dozes, and wakes up as each contraction commences. Rarely is a fourth dose required. It does not interfere with the use of chloroform, but of that less will be required. It is a very valuable aid in the management of labor. Chloroform should only be given during the pains, and never to unconsciousness. Watch its effects : if the pains lessen in force and frequency, stop its inhalation, beginning again when the pains are stronger. It is believed that the addition of about one-third absolute alcohol will increase the stimulating effects and diminish its tendency to cause undue relaxation. As the head distends the perineum, it may be used more freely, and even to complete insen- sibility just before the child is born. Ether acts well, and does not relax the uterus, and even seems to intensify the pains. Bear in mind the tendency of chloroform to produce uterine relaxation, and hence take extra precautions against post-partum hemorrhage. In operative midwifery, complete ansesthesia is required, and here the operator should employ the aid of another physician, and his undivided attention should be given to the anaesthetic, while the operator is otherwise engaged. Dr. Robt. P. Harris, American editor of Playfair, says that in the United States chloroform is rarely used in midwifery, but preferably pure sulphuric ether. After anaesthesia, uterine inertia is very apt to follow, and result in post-partum hemorrhage. DR. FRACHAUD Read a paper before the Section of Obstetrics and Gynecology of ANAESTHETICS IN LABOR. 235 the International Medical Congress, on the nth of September, 1878, on anaesthetics. The following are his conclusions : (1) The employment of anaesthetics is to be advised, as a gen- eral rule, in natural labor. (2) The principal agents employed at present, are ether, chloro- form, amylene, laudanum, morphine by subcutaneous injection, and chloral by the mouth and by enema. (3) Chloroform is the one he considered preferable. (4) It should be administered according to the method of Snow, that is, in small doses at the commencement of each pain ; and it should be suspended as soon as the pain has passed. (5) It should never be pushed to complete insensibility, but a diminution of pain only should be aimed at. (6) It is generally advised to administer chloroform only during the period of expulsion ; but in some cases of extreme nervousness and agitation, it is better not to await the complete dilatation of the os. (7) Experiment has shown that anaesthetics do not stop either the uterine contractions or those of the abdominal muscles, but that they lessen the resistance of the perineal muscles. (8) The employment of anaesthetics has no injurious effect on the health of mother or child. (9) In lessening to a greater or less degree the sufferings of the woman, anaesthetics are of great service to those women who dread the pain; it lessens the probability of their having nervous attacks, and hastens their convalescence. (10) Anaesthetics are extremely useful to calm the extreme agitation and control excitement which labor often causes in very nervous women. (11) Their employment is indicated in cases of natural labor, which is suspended or retarded by the sufferings caused by previ- ous disease, or that coming on during the labor, and in cases where irregular and partial contractions occasion great suffering without advancing the labor. (12) Chloroform should not be employed in natural labor with- out the consent of the woman and her friends. M. Courty spoke in high terms of M. Frachaud's paper, and stated that he agreed with him in every particular. 236 COMPLICATIONS OF PARTURITION. PROF. F. CHURCHILL, M. D., DUBLIN. In most obstetric operations, anaesthesia is of value to relax the soft parts and moderate uterine action, etc. The dose should be administered at each pain, and increased when the head is passing the perineum. The anaesthetic state may be kept up for hours without mischief. The best mode is by a clean white handkerchief, folded funnel shape, into which a drachm and a half of chloroform is poured; this is placed over the mouth and nose, and it is a good plan to let the patient hold it herself, as thus deep anaesthesia is prevented. C. J. CAMPBELL, M, D., PARIS, Has for years employed chloroform in labor with good results. The administration of cliloroform in intermittent doses, during the second stage of labor, is of undoubted value. Had it no other but a moral effect on the patient, even then it would be most valuable, inasmuch as it abolishes the dread of coming pain, and enables her to enter labor with confidence and tranquillity. But chloroform, without diminishing the force of the uterine contraction, relaxes the parturient canal, abolishes the sensation of the straining pains which during this period are most violent and agonizing, and economizes the mother's strength by sparing her the exhaustion consequent upon the extreme tension of the nervous system. With regard to post-partum hemorrhage, the danger is infinitesi- mal, if the chloroform be withdrawn at the conclusion of the second stage. M. LUCAS CHAMPIONNIERE, PARIS, Says (Le Progres Med., Apr. 6,) that he uses chloroform in almost every case, but not to complete anaesthesia. Its action varies, requiring a larger amount and longer time in some than in others. Early in labor a quite small quantity gives great relief, and yet the labor goes on rapidly. Later, it requires a greatly increased dose, .and the anaesthesia must be more profound, and must be main- tained. When the waters are evacuated and the uterus firmly contracted on the child, the resistance is greatly increased, and more trouble is experienced in obtaining the good results. Here the chloroform may be pushed until sleep is induced. This author finds that it never retards labor, generally accelerates it, does not cause stupor in the child, and the woman has a better convales- AN/ESTHETICS IN LABOR. 237 cence in every way. He has seen no contra-indications to its use in any case. PROF. WM. T. LUSK, M. D., NEW YORK, In a paper " On the Necessity of Caution in the Use of Chloro- form During Labor," states the following- propositions : I. Deep anaesthesia, carried to the point of complete abolition of consciousness, in some cases weakens uterine action, and some- times suspends it altogether. II. Chloroform, even when given in the usual obstetrical fashion, namely, in small doses, during the pains only, and after the com- mencement of the second stage, may, in exceptional cases, so far weaken uterine action as to create the necessity for resorting to ergot or forceps. III. Patients in labor do not enjoy any absolute immunity from the pernicious effects of chloroform. IV. Chloroform should not be given in the third stage of labor. The relative safety of chloroform in parturition ceases with the birth of the child. V. The more remote influence of large doses of chloroform during labor upon the puerperal state, is a subject that calls for further investigation and inquiry. With these five propositions he is prepared to close his indict- ment against chloroform in midwifery. It is not a formidable one, and need not deter from its cautious employment. But the sense of possible danger which governed its use in the hands of those to whom we owe its introduction into practice, has been replaced by an overweening confidence. PROF. R. BARTHOLOW, M. D., PHILADELPHIA, Says when labor is of short duration, and not excessively painful, anaesthetics are not to be used. But when the labor is protracted and suffering great, they favor progress, and prevent exhaustion and uterine inertia. Caution is required with primipara. Inhala- tion should not begin till the close of the first stage, unless there are " nagging pains," and only during a pain. The effect must be watched, and the inhalation stopped if the pulse fails, the respira- tion becomes short, and the pains lose efficiency. Complete un- consciousness is not necessary. In instrumental delivery, anaesthesia is important ; it facilitates 238 COMPLICATIONS OF PARTURITION. the operation, and prevents shock. It must be carried so far as to ensure quietude of the patient, but not complete muscular reso- lution. In turning, chloroform narcosis must be deep enough to suspend uterine contraction. RESUME OF REMEDIES. Alcohol. In default of other anaesthetics, a full dose of whiskey or other spirits is a popular obtunder of pain. By some obstetricians a mixture is used containing alcohol, as that proposed by the Medico-Chirurgical Society of London. 262. I}. Alcoholis, 1 part Chloroformi, 2 " Etheris sulph., 3 " M. Chloral has been suggested, but its absorption is slow and its results un- certain. Injecting it into the veins, after the method of Dr. Ore, of Bordeaux, is said to be dangerous. Playfair prefers chloral to chloroform ■ he gives gr.xv at a dose, and repeats in twenty minutes, if necessary. Chloroform. Simpson recommends chloroform to be used in labor, by laying a single fold of a handkerchief over the nose and mouth, and dropping the anaesthetic upon it, a single drop at a time. In this way it becomes thoroughly mixed with air, and is en- tirely safe. Drs. J. Ringer, Playfair, and others, believe that chloroform weakens uterine contraction. According to a recent writer in La Presse Medicate, chloroform acts more vigorously and persistently upon the retractility than upon the contractility of the womb. To secure this action, prolonged inhalations, rather than complete anaesthesia, are desiderated. The con- traction of the abdominal muscles is more diminished by the chloroform than uterine contraction is. But whilst both these effects of this anaesthetic are in proportion to the intensity of the anaesthesia, they disappear rapidly, indeed, almost instanta- neously, on the cessation of the inhalation, whilst the diminution of uterine retractility continues longer. Ether. Pure, well-washed, sulphuric eother, is claimed by many to com- bine more in its favor as an anaesthetic in labor than any other agent. But as Dr. R. P. Harris points out (notes to Play- fair's Midwifery), only in exceptional cases does it act satisfac- torily. In many it induces intoxication and excitement, and diminishes or stops the expulsive efforts, and leads to uterine inertia and consequent post partum hemorrhage. Its adminis- tration should be preceded by a small dose of brandy, to pre- vent gastric disturbance. Morphia. The hypodermic injection of morphia has been found to arrest uterine contraction, and is therefore not adapted to labor. Nitrous Oxide, a safe and agreeable anaesthetic, produces an influence of too short duration to be conveniently employed in obstetrics. TEDIOUS LABOR. RIGID OS AND ATONY OF UTERUS. ALBERT H. SMITH, M. D., PHILADELPHIA, 111 a paper read before the Philadelphia County Medical Society, [Medical and Surgical Reporter, Aug. nth and 18th, 1877), says the causes of delay may be divided into classes : Rigidity of the os or absence of the dilatory force, or real and apparent rigidity. Spasmodic contraction of the os is a neurosis, and for its relief we require such means as quiet nervous excitement, allay sensibility, diminish the activity of the circulation, and control the local con- gestions. First of these is opium. Acts promptly, without danger, and never contra-indicated.. A suppository of one-half a grain to a grain of watery extract, or its equivalent in morphia, powdered opium, or an enema of laudanum, or the hypodermic ; or in case of much fever, morphia with digitalis and diaphoretics, will be certain of good results. Ether or chloroform may give the same, but are not so safe, and diminish the force of the contractions, and may cause inertia uteri and hemorrhage. Passive rigidity, that is, a want of distensibility, must be met by the douche of hot water, 105 to no°, injecting a quart at a time by the syringe against the os and cervix, and repeating every hour or two. Traction by the finger upon the anterior lip is here of great value, though not when there is spasm. When the mem- branes are not ruptured, care should be taken not to do this. The india-rubber bags are valuable dilators — that of Braun, of Vienna, or better, the fiddle-shaped bags of Barnes ; they should be filled with warm water until fully expanded. After dilatation has given room, apply the forceps within the lips, and thus we gain an addi- tional dilating power. There can be no more risk to the tissues than by the passage of the head without them. During each con- traction the forceps may be gently drawn upon. Incision is justifiable only under extremely rare conditions. In delay from absence of the dilating wedge, which is the most common cause of delay, this is often the result of inertia, and may be met by abdominal frictions, diffusible stimulants, ginger, balm, ( 2 39) 240 COMPLICATIONS OF PARTURITION. mint, or other hot teas, hot and cold douche, etc. The best of all is the bisulphate of quinia — say 15 grains in one dose. When the preternatural distension of the amniotic sac stretches too greatly the uterine fibres, its rupture will generally speedily correct the evil. Irregular contractions are best met by the quiet and rest of opium, anaesthetics, chloral, etc. Premature labor would also cause delay, and require opium or chloral for relief. In cases of disproportion of the head and pelvis, the one abnor- mally large, or the other small, the only remedy is to carry the forceps within the os, and the accomplishment of the delivery as above detailed. W. H. LONG, M. D., LOUISVILLE, KY., Speaks of viscum album or mistletoe as an oxytocic. He has used it for ten years. It acts with more certainty and promptness than ergot, and does not cause continuous or chronic contractions. The fluid extract is preferable, in doses of a drachm, repeated every twenty minutes until the desired effect is induced. The infusion is made by taking 2 oz. of the dried, or 4 oz. of the green leaves, pouring over them one pint of boiling water, covering until cool enough to drink. Dose, two to four ounces, repeated in twenty minutes, if necessary. He has seen excellent results follow its use in post-partum hemorrhage and in menorrhagia. J. H. BENNETT, M. D., WAUSEON, OHIO, Proposes (Detroit Lancet) to facilitate and shorten labor by giving a hypodermic of morphia, gr. ^. When rest has restored the nervous energy, he places the patient on her back, the thighs flexed, the shoulders bolstered up, the smaller or lumbar portion of the spine down, so as to form a curve, the convexity of which is down ; thus the axes of the two straits form a continuous curve. Labor commencing, the os is gently pulled forward by the index finder, causing dilatation, at the same time pressing the fundus gently upwards and back so as to bring the child in proper relation with the lower strait. During the passage of the head into the lower strait, he continually draws forward the anterior lip of the os, at the same time pressing the anterior portion of the os back under the os pubis, with other soft tissues that protrude with the anterior portion of the os and neck, which narrows the antero-pos- TEDIOUS LABOR. 24I terior diameter. As the os dilates under the forward and lateral pressure, during the interval of pain, the anterior lip of the os passes back under the arch of the pubis, and finally over the occiput; thus increasing the antero-posterior diameter and facilita- ting very much the passage of the head, also saving the contusion of the urethra, which so frequently occurs. After this stage he protects the urethra and tissues adjacent, by pressing upon the occiput forwards and downwards with the digital and middle fingers, each side of the urethra, until it passes from under the os pubis ; thus avoiding the necessity of being called to use the catheter, also preventing one of the causes of vesico-vaginal fistula, and lessening the danger of laceration of the perineum by the occiput rising in front of the os pubis, sooner than it would if the anterior portion of os with folds of the vagina and other soft parts protruded in front of the head. In this way the pressure on the perineum is lessened. During the above management, if the patient is weak and the- pains feeble, to induce instinctive action of the uterus and abdom- inal muscles, pass the middle and index fingers of the right hand (the palmar surface down) back with gentle pressure downwards, against the perineum and vulva, producing the sensation of ad- vance of the head. HENRY L. HORTON, M. D., NEW YORK, {Am. Jour. Obst., July, 1878,) states that atropine injected into' the tissues of the cervix uteri will lessen the pain and shorten the duration of the first stage of labor, by overcoming the spastic rigidity of that structure. He uses about one-fortieth or fiftieth part of a grain of atropia sulphate for each injection. He has had manufactured a hypodermic syringe, long needle with a hook- curve at the end. "After hooking the anterior lip of the cervix, with the index finger of the right hand and drawing it slightly forward, he carries the needle along the palmar surface, keeping the point pressed quite firmly against it, so as to avoid wounding the maternal parts. After carrying its points well within the cervix, he raises it from the finger, and by a slight traction, buries it somewhat deeply into the muscular structure of that portion of the uterus. After discharging its contents, he retains it in that position a few moments, in order that the absorption of the atro- pine may be certain to take place." 16 242 COMPLICATIONS OF PARTURITION. PROF. W. S. PLAYFAIR, M. D., LONDON. Where there is feeble or irregular action, a loaded rectum is often the cause, and a large enema will generally produce a remarkable effect. Excessive distension of the uterus is relieved by rupture of the membranes. Adherent membranes may be separated by sweeping the finger or a flexible catheter round within the os. Uterine deviations must be corrected by placing the patient on the oppo- site side to that towards which the organ points, or when anterior, place her on her back and apply a bandage to prevent the organ falling forward. Temporary exhaustion requires rest, as by an opiate, as 20 minims of Battley's solution or an enema of the same. When pains are irregular, spasmodic and painful, chloral is of great value. Oxytocics or remedies to increase the force of the pains, are borax, cinnamon, quinine, galvanism, and ergot. The latter has serious disadvantages to both mother and child. It is only allow- able when the os is fully dilated. Manual pressure often produces the most speedy effect. The best way is to place the patient on her back at the edge of the bed, and spread the palms of the hands on each side of the fundus and body of the uterus, and when a pain begins, make firm pres- sure down and back in the direction of the outlet ; relax the pres- sure when the pain goes off, and resume when a new pain comes. The patient need not lie on her back; pressure may be made in the ordinary obstetric position on the left side, the left hand spread over the fundus, leaving the right free to note the progress per vaginam. This plan is completely at the will of .the operator, and ,can be nicely regulated ; it imitates nature, and is without risk to child or mother. The pressure must be firm, but not rough. The use of the forceps is now becoming the rule in place of the excep- tion, to put an end to protracted labor. It diminishes in a marked .degree infant mortality. There is no danger to the mother, but .often great danger from a delay in their use. PROF. WM. LEISHMAN, M. D., GLASGOW. In rigid os, anaesthetics are required. Chloroform is preferred, but chloral is more marked in its effects. When the os seems occluded, mechanical means to dilate must be employed, as sponge-tents, and the like. Inertia of the uterus may be caused TEDIOUS LABOR. 243 by rheumatism, neuralgia, etc. A distended bladder or rectum may act mechanically, and in such cases there is generally cramp of the lower limbs, and this agony weakens the action of the womb. The means of relief here is patent and immediately effi- cient. Ergot, to increase the activity of the pains, is never perfectly safe, and the forceps should, when possible, be preferred. ALFRED MEADOWS, M. D., LONDON. Tartar emetic will be found of the greatest service in small and frequently-repeated doses, so as to cause nausea, when the rigidity readily yields. Sometimes it appears to act better when combined with opium, or is facilitated by saline purgatives, as where there is gastric derangement, with foul tongue, offensive breath, con- stipation, etc. Opium alone is of the utmost value. Chloroform is another valuable remedy. Bleeding, in plethoric subjects, requires a full stream, to the amount of twelve or sixteen ounces. A vaginal pessary — one part gelatin, four of glycerine, made with two or more grains of extract of belladonna, soon melts and is absorbed, and may aid the dilatation. In certain cases all these fail, and we require the artificial dilator, the india-rubber bag. Where rigidity is obstinate, and there is fear of uterine rupture, or exhaustion of the patient, the cervix should be incised, not too deeply, say from a quarter to half an inch in several directions. ARTHUR WIGLESWORTH, M. D., LIVERPOOL. This writer {Obstetric Journal Great Britain and Ireland, Sept., 1877), advances these propositions: An os more or less dilated, but rigid with active contractions, is rigidity from spasm ; this may arise from direct or indirect causes, but with the same results ; this condition may be removed by the administration of morphia, with the object of relaxing the circular fibres without inducing either nausea or exhaustion. The dose must be regulated according to physical condition of the patient, the amount of rigidity, the con- dition of the stomach. A nervous, excitable temperament requires a smaller dose than a phlegmatic one, also if there is much ex- haustion. A thick rigid os, with a phlegmatic system, requires a larger dose, or a repetition. If the stomach is loaded, a larger dose is required. 244 COMPLICATIONS OF PARTURITION. Where rigidity has been long existent, and there is exhaustion without relaxation, and a subsidence of uterine action, ergot and morphia should be combined. WM. STEPHENSON, M. D., LONDON, In the Obstetric Journal Great Britain and Ireland, Aug., 1878, directs the introduction of one or more fingers of the right hand within the os, opposite the thyroid foramina in first and second positions, and the sacro-iliac junction in the third and fourth, and thus to lift or support the head during each pain. His design is to effect the extrusion of the occiput through the os, securing greater flexion and aiding rotation. It is employed after rupture of the membranes, before complete dilation, and when the cervix does not yield and recede over the head. RESUME OF REMEDIES. Alcohol counteracts the tendency of anaesthetics to weaken uterine action, and acts as a general stimulant to the muscular forces in labor (Dr. D. Morton, Amer. Practitioner , Dec, 1874). Antimonii et Potass ce Tart/as, in tedious labor from rigid os, in doses of g r . t,\j— yV every fifteen minutes, is an ancient and often efficient method of overcoming spasmodic muscular contraction. Amy I Nitrate. When the uterus is spasmodically contracted on the foetus, Dr. Maury, of New York, believes that this agent is a most valuable remedy. Atropia is given by Dr. Horton, as above (see p. 241), in cases where the uterus has btcome completely or partially spas- modically contracted on the fetus, or on a separated placenta, in order to overcome the spasm. Dr. Frankel, of Breslau, recommends a hypodermic of one-thirty-third of a grain of atropia, and one-quarter of a grain of morphia, with inhalation of chloroform five minutes later. The uterus relaxes speedily and yieldingly. There need be no fear of post-partum hemor- rhage. Belladonna, in the form of ointment of the extract, is an agent of old renown. Carbonis Sulphidum. Milne Edwards and Varaseau assert that a few drops sprinkled on the abdomen of a woman in labor, will reawaken uterine contraction. Caulophylhtm Thalictroides. At a meeting of the Obstetric Section of the New York Academy of Medicine, Dr. Sell related a case as an example of several, in which he used the concentrated tincture of caulophyllum, blue cohosh or squaw-weed, with the happiest results, as a remedy to ward off tedious labor. The remedy was especially applicable in those cases in which the woman had habitually suffered severely during the first stage of TEDIOUS LABOR. 245 labor. As a preparatory remedy in such cases, it should be administered in twenty-drop doses three times a day, for three or four weeks previous to confinement. Cannabis Indie a. Dr. Alex. Christison claims that cannabis indica equals ergot, bu,t being quicker, more energetic, but of shorter duration. Chloral acts at times indirectly as an accelerator of parturition. Dr. Wm. L. Richardson remarks (Trans. Am Gyn. Soc, Vol. I ) that it seems especially adapted to that large class of cases in which the pains occur at very short intervals, last but a moment, and are very severe. Little progress is made, and the patient suffers intensely, and becomes restless and nervous. In such cases the administration of chloral is followed by the happiest results. The dose may be gr.x-xx, repeated if called for. Dr. T. A. Reamy, of Cincinnati, says that close observation has convinced him that no bad effects on the child follow the administration of this drug (Obstetric Gazette, Nov., 1878). Chloroform, administered for its anaesthetic properties, will often do away with spasmodic rigidity of the os. Cimicifuga Racemosa is alleged by the eclectics to exert some ecbolic powers. Cimicifugin is extolled as of great value as a substitute for ergot, acting speedily and energetically. The contractions, unlike ergot, are not powerful and continuous, and hence there is less danger to the child. After labor, it allays nervous, excitement and relieves the after pains, and checks hemorrhage. (Phillips.) Cinnamomum has some slight power as a uterine stimulant. Ergota. The accelerator of uterine contraction is par excellence the ergot of the cereals ; that of rye is usually employed. The pro- priety and rules of its use have been much and variously debated. Points generally agreed upon are that it should not be given if there is rigidity of the os, nor until the os is dilated or dilatable. The contractions it causes are continuous and violent ; hence it is suited to the third stage only. Gelsemium is a valuable remedy in cases of rigid os during labor, gtt.v of the fluid extract every ten minutes until there is nausea. Ipecacuanha. In cases of irregular uterine action, and protracted, agon- izing, yet insufficient pains, this drug exercises the happiest powers, relieving the pain and hastening the termination of the labor. The dose maybe gr.ij every fifteen minutes; it takes effect in about thirty minutes. A very favorite form with some practitioners is "Dover's powder" in repeated small doses, com- bined either with ergot or chloral, as occasion demands. Lobelia Inflata is asserted by Scudder and other eclectics to be a specific in rigid os. It probably acts from its nauseating properties. They prescribe : 263. R. Tinct. lobeliae, f.5j Aquae, f.^iv. M. A teaspoonful every fifteen minutes. 246 COMPLICATIONS OF PARTURITION. Oleum Ricini in small doses, for some time before labor commences, is said to facilitate it. Opium and its alkaloids are of advantage to control the nervous restless- ness and exhaustion which supervene in tedious labor, and to lessen the spastic rigidity of the os. Small quantities, gr. |, of morphia, in camphor water, may be given hourly or half-hourly. Of its employment during labor Dr. Lusk says that from a number of observations, there is no reason to apprehend any direct effect on the child from morphia hypodermically adminis- tered to the mother during labor. The propriety of its use, therefore, is to be determined by purely obstetric considerations. When given to meet some urgent need in the mother, it proba- bly conduces indirectly to the welfare of the child. Quinia. That sulphate of quinine has a direct power to promote normal labor, cannot longer be disputed. Dr. Albert H. Smith, after a careful study of the subject, said some years ago {Obstet. Jou?:, June, 1875,) tnat ^ " increases the activity of the normal uterine contractions ; the pains becoming more frequent and more intense, the expulsive power being greater, while the yielding of the circular fibres of the os is more prompt ; the contractions maintaining their proper intermittent character, the relaxation and rest in the interval being complete ; showing in this respect an entirely different action from the continuous spasmodic contraction caused by ergot. ... It promotes permanent tonic contraction of the uterus after the expulsion of the placenta. ... It diminishes the lochial discharge to a normal standard. ... Its use is followed by less after- pains than usual, in a majority of cases. . . . Given during parturition, it never disturbs the brain or causes its usual unpleasant effects, even in patients who at other times are very susceptible to its influence." The dose is gr.xv, repeated if necessary. Others give gr.viij-x. Sodii Boras has a doubtful claim to being an oxytocic. Ustilago Maidis, the ergot of maize, has been recently introduced. It is not dissimilar from other ergots. Viscum Album, the mistletoe, has alleged parturifacient properties. (See p. 240). EXTERNAL MEASURES. Abdominal Friction is an excellent agent for expediting labor. Much force should not be used. The object is by gentle friction and pressure to excite uniform and effective uterine contractions. Dilatation of the os by the finger has been strongly recommended by Dr. James Braithwaite, where the rigid os gives rise to symptoms of exhaustion. In the method he employs, the right index finger is introduced within the os uteri, with its palmar surface toward the sacrum ; the left index finger is then passed, with its palmar surface toward the pubes, the left hand crossing over the right for this purpose. By gentle pressure in opposite direc- tions the os is readily made to dilate ; the fingers being hooked TEDIOUS LABOR. 247 within the os, the pressure is also made downward, thus very closely resembling the natural process. As soon as the os is dilated to the size of a five-shilling piece, two fingers of each hand can be introduced for manipulating. Electricity has been employed as a uterine stimulant, but it has proved inconvenient in practice, not easily manageable, and not very effective. Incision of the os, as a surgical measure, may be resorted to in obstinate, and especially in cicatricial rigidity. Injections of warm water into the vagina, in properly chosen cases, will accelerate the labor without causing any increase of suffering to the mother. The only instrument required, besides a bowl of warm water, is a syringe fitted with a vaginal tube ; but this apparatus can be improved by the addition of a yard of india- rubber tubing, three-eighths of an inch in diameter, joined to the vaginal tube so as to carry off the water direct from the vagina into a receptacle, thus avoiding wetting the bed. The water should be as warm as the patient can comfortably bear, and in practice it is advisable not to begin with water raised to the full temperature, but gradually to add boiling water until the temperature of about 105 F. has been attained. The injection requires to be continued from five to twenty minutes, according to circumstances. Hip-Baths, as hot as the patient can comfortably bear, will often expedite labor, and relieve the patient in the most satisfactory manner. Venesection, in cases of obstinate spasmodic contractions, is hardly ever necessary, now that the means above enumerated are within our reach. AFTER-PAINS. ALFRED MEADOWS, M. D., LONDON. This author believes after-pains to be healthful in a certain sense ; but if excessive, he would give henbane and camphor, lettuce and chlorodyne, morphia, which is better than opium, and the liquid extract of the British Pharmacopoeia is the best of the opiates. The regular application of the child to the breast suffices to expel clots from the uterus. PROF. W. S. PLAYFAIR, M. D„ LONDON, Advises an opiate, or if the lochia be scanty, a linseed-meal poul- tice sprinkled with laudanum, or the chloroform and belladonna liniment. Quinine in ten-grain doses is excellent, especially when the pains are neuralgic in character. PROF. TYLER SMITH, M. D., LONDON, Counsels the removal of any coagula that may be in the uterus. When the pains are neuralgic, an opiate, and a warm linseed-meal poultice, with laudanum sprinkled on it, applied to the abdomen, afford great relief. An anodyne embrocation applied to the breasts is of service. BERNARD KELLY, M. D., OF LONDON, Has found {Medical Press and Circular, Feb. 20, 1878,) small doses of opium, frequently repeated, combined with an alkali or acid, as indicated, to answer an excellent purpose. It is much safer than giving a single large dose, which has a tendency to suddenly paralyze nervous action, and subsequently lead to passive enlarge- ment and congestion of the uterus. This objection derives addi- tional force from the occasional presence (often unsuspected by the young accoucheur) of albumen in the urine, and the consequent danger of uremic convulsions ; when, if a large dose of the nar- cotic be blindly administered, fatal effects will almost inevitably follow. Here there is no remedy to compare in safety and value with the. old-fashioned tincture of iron, which may be given, prop- erly diluted, in large doses and ad libitum. When pains, unat- tended by uterine action, follow labor, ergot may be advantageously (248) AFTER-PAI.NS. 249 prescribed. But to exhibit it in cases where the viscus is already, so to speak, madly in action, would be simply applying 'spurs to the willing horse. RESUME OF REMEDIES. Actcea Alba. The white cohosh in tincture or infusion is alleged by the eclectic practitioners to be a specific in after-pains. Camphor a, in the form of camphor water, or pills, gr.ij, of the powder, may be used with advantage. Chloral, in moderate doses, will usually be found efficient. Hyoscyamus is well spoken of by Dr. Meadows. Lupulina, from its specific sedative effect on the generative system, has been suggested. Opium and its alkaloids are extensively given, but may profitably be sup- planted by other anodynes. Potassii Bromidum is a safe, and usually an efficient, sedative. Quinics Sulphas, in doses of gr.x, repeated if required, has a great deal of testimony in its favor. Hot Water Injections. Dr. Albert H. Smith, of Philadelphia, has found that hot water injections, no°-i2o° Fall., will always relieve, and often arrest, the most severe foims of after-pains {Med. Tunes, Aug., 1879). a, ^t^L^ / Li ^J ^^~ / (/&^< - £**{Zrl* - ^ ^^ , Y* {4u?/£^ip) U^^^^ c^i^/^^ Aj^*-f«£]r f+™-4X X^lCtyx^u. fy^U* AW^ s^uoi^ fru^^AA, *% ■> Y^t^^C<^y PUERPERAL HEMORRHAGE. Hemorrhage may occur either before labor or after it. Ante- partum hemorrhage may be due to the existence of placenta prsevia, which generally is manifested by the bleeding occurring about the seventh month ; or to the accidental detachment, of the placenta, or the rupture of a large vessel of the mouth or neck of the uterus, or in the vagina. This latter may be expected where the presence of varicose veins is observed about the abdomen, thighs, etc. We have reason to believe that the same condition may exist within the labia and vagina. When hemorrhage occurs, until the os is sufficiently dilated to permit of delivery and a speedy termination of the labor, plugging the vagina is the only resource. This may be accomplished by the use of cotton, wool, etc., saturated in a styptic glycerine, or by the colpeurynter, which fully closes every avenue for the escape of the blood, and acts efficiently as a dilator of the os. This should never be filled with air, for should its walls give way above, the air would be forcibly driven into the uterine veins, and death would be inevitable. PROF. W. S. PLAYFAIR, M. D., LONDON, Gives the treatment by puncture of the membranes as the most effi- cacious; plugging the vagina, or, better, the cervix itself; turning, of course, when dilatation admits of it, as after the previous plan ; separation of the placenta, especially when the child is dead, when it is not yet viable, when the hemorrhage is great and dilatation is not sufficient for turning, when the pelvic passages are too small for safe and easy turning, when the mother is too exhausted to bear turning, when the evacuation of the waters fails, or when the uterus is too firmly contracted for turning. This operation is performed by passing one or two. fingers as far through the os as they will go; feeling the placenta, pass the finger between it and the uterus, sweep it around so as to separate the placenta as far as can be reached ; if the membranes can be reached and have not been already opened, tear them. Generally the hemorrhage soon ceases. He recapitulates : Before viability, temporize, by absolute rest in bed, cold, astringent pessaries, etc. After the seventh month, (250) PUERPERAL HEMORRHAGE. 25 I terminate the pregnancy. In all cases, rupture the membranes. If the bleeding ceases, leave the case to nature ; if not, turn if it can be done, or plug carefully, and endeavor, by compression and ergot, to bring on labor. Do not leave the plug in but a few- hours. If necessary, use Barnes' bag to dilate; this also acts as a plug.. Separate the placenta from its attachment to the cervix. Of course, all these methods would apply for any form of ante- partum hemorrhage. The great hemostatic is uterine contraction. PROF. F. WINCKEL, M. D., ROSTOCK, GERMANY. When from absence of contractions, give ergot, 3 grams, every fifteen minutes; cold injections into the vagina; compression with the hand is preferable to all other measures. If prostration is the cause, claret, 1 to 2 teaspoonfuls every five to ten minutes. If all else fails, styptics must be applied to the inner surface of the uterus, as ice, in small pieces the size of a walnut ; or introduce liq. ferri sesqui-chlorid. by means of a cylindrical wad of cotton- wool soaked in it; or inject equal parts of iron and water with Braun's syringe. When stricture and irregular contraction are present, and the patient complains of severe after-pains, anti-spasmodics are best, as, pulv. ipec. comp., laudanum, an emetic, or a sinapism over the sacrum after the clots have been removed from the uterus. Ene- mata with 20 drops of laudanum, an emulsion of bitter almonds with 20 drops of extract of hyoscyamus, are of great service. When the uterus is firmly contracted and the genitals and vagina are not the seat of hemorrhage, it must arise from the cervix, and local styptics are required, as cold injections, made of cotton-wool soaked in solution of chloride of iron, passed into the cervix, and plugging the vagina with balls of cotton-wool rather than the colpeurynter. Manget squeezed the juice of half a lemon into the cervix with complete success. A. D. L. NAPIER, M. B., LONDON, [Obst. J. G. B. and I., Feb., 1877,) observes that we should have no fear of using iron injections, as the os is patulous, and the return of the fluid is certain. Absorption is not active, hence we need not fear pyemia. Brandy, beef-tea, and ergot are foremost as internal treatments. Ergot is greatly increased in its specific action by the addition of strychnia. 252 COMPLICATIONS OF PARTURITION. H. OTIS HYATT, M. D., KINGSTON, N. C, {Obstet. your. Grt. Brit, and Ireland, Sept., 1877,) proposes the use of the condom, or, better, the toy balloon tied over the end of a Davidson syringe nozzle, and passed within the flaccid womb, and then distended by warm or cold water, thus pressing directly upon the mouths of the bleeding vessels. He has successfully employed it in a number of cases. He regards it as effectual in one or two minutes ; and harmless, as if it should burst it would only wash out the womb. A. V. MACAN, A. B., LONDON, (Obst. y. G. B. and /., July, 1876,) injects ether subcutaneously, say half a drachm, at once, and with the most remarkable results. LOMBE ATTHILL, M. D., Has had equally good results, using a drachm of ether. DR. M'CLINTOCK, OF LONDON, Regards this as a valuable acquisition to our resources, and one which has great advantages over transfusion. DR. BAILLY, OF PARIS, In secondary post-partum hemorrhage, {Archives de Tocologie, Nov., 1877,) has used the hot bath with great success. One had hemorrhage eighteen days after delivery. The uterus could be felt two fingers' breadths above the pubes. Spite of injections of iron and the use of ergot, the loss continued obstinately for ten days. After the first hot bath, the loss was much diminished; after the second, it was suspended. It recurred in thirty-six hours, but a third bath arrested it, and involution was rapidly completed. A similar case set in twenty-seven days after delivery. It was continuous and profuse. A hot bath of twenty, minutes' duration entirely stopped the hemorrhage. He attributes the benefit to the relief of uterine congestion, consequent upon the dilatation of cutaneous capillaries, the resulting determination of blood to the surface, and diminished vascularity of deep-seated organs. The baths are of a temperature of 34 Centigrade, and the immersion from twenty to thirty minutes. PUERPERAL HEMORRHAGE. 253 DR. KOEHLER, OF GERMANY, This writer {All. Med. Central- Zeitnng, No. I, 1879,) states that he has, for the last seven years, in cases of uterine hemorrhage, applied warm fomentations to the head, to prevent anemia of the brain, and also to the heart. Hot sand-bags are also very efficient, and the patients often will bear sand which is so hot that it can scarcely be touched with the hand. As soon as the fomentation or bag has been applied, consciousness is restored ; the pulse grows stronger; the patient herself states that she feels better, that the ringing in the ears has ceased, and that she likes the appliance. As soon as it becomes cooler, she wishes it to be renewed. Dr. Koehler has, he says, saved patients even in the most dangerous cases of hemorrhage, by this proceeding, by which the physician never loses time, as the fomentations may be watched and renewed by any one. JAMES BRISBANE, M. D., OF LONDON, Uses per-chloride of iron by the " ready method ; " it acts like a charm. Nothing more is required than to carry a two ounce bot- tle of ordinary tincture of the chloride of iron. A piece of sponge is compressed in the palm of the hand, and the iron poured on it, and thus conveyed up to the bleeding surface of the uterus, there pressed and left. The blood coagulates, the womb contracts, and the danger is over. At the next visit, the sponge is found in the vagina, and no bad results follow. It is better than injections, no time is lost, and the objections of thrombosis, injecting air, etc., are obviated. PROF. KARL SCHROEDER, ERLANGEN. This author counsels the tampon or colpeurynter, etc.; as soon as the dilatation will allow it, a finger should be passed to one side when the placenta is lateral, and an effort made to turn by one foot. When the placenta is central, one cotyledon is to be separated from the side of the os, and then the foot sought for. One foot is to be brought down, and so on until the delivery is complete. It is, however, advisable to continue with the tampon until the head is firmly pressed against the bleeding surface, or until dilata- tion will allow of turning. It is always best for mother and child to turn as soon as practicable, and only to omit doing so when the head stops the bleeding. The forceps may be used if necessary. 254 COMPLICATIONS OF PARTURITION. If the child is dead, the placenta may be separated entirely, and delivered before the child. Hemorrhage may also arise from the vessels of the cord, and the child is in great danger. Here the rupture of the membranes should be delayed as long as possible, and the rubber-bag used until dilatation will allow of immediate extraction. ALFRED MEADOWS, M. D., LONDON. Accidental hemorrhage is known by the blood being almost entirely liquor sanguinis. In placenta praevia, the vagina is filled with coagula. The treatment will be recumbent position, cool drinks, astringents, as the acetate of lead, two grains given in one- half a drachm of dilute acetic acid, to prevent its decomposition in the stomach, every four or six hours; or gallic acid; or sulphuric acid, as in the infus. rosas comp., or both combined, which is far more powerful than singly; opiates in large doses. If these fail, plug the vagina. Avoid this if possible, when the time is not full, as it is liable to bring on labor. The plug must be firm and the vagina completely filled. Its effects will be enhanced if, at the same time, a firm bandage is placed over the abdomen. The vagina must be full, but not distended. When the discharge is very great, with pain and pregnancy at full time, expedite delivery. In placenta praevia, act according to the necessities of the case ; plug and wait for dilatation, then turn and deliver. If there is not dilatation, and the loss is great, puncture the membranes, and secure dilatation with the rubber dilators, and deliver speedily. The separation of the placenta seems to be most safe. When due to retention of the placenta, introduce the hand and peel it off with the utmost carefulness. In doing this, keep the other hand on the fundus uteri, so as to steady the womb. Next guard against the evil effects of decomposition by syringing with antiseptics. When due to atony of the uterus, use ergot, cold, pressure and galvanism. These failing, introduce the hand to excite the womb to contract. When the womb relaxes after once contracting, support the pa- tient with brandy ; grasp the womb firmly, and by pressure cause it to expel its contents, or turn them out with the other hand. Irritate it by manipulation within and without. Ice may be intro- duced within the organ, or a cold douche thrown on the abdomen. PUERPERAL HEMORRHAGE. 255 Electricity rarely fails to induce permanent contraction. Place one pole over the fundus and the other on the perineum. All failing, inject solution of perchloride of iron into the uterus, first clearing out all coagula. Remember the danger of this injec- tion, and only use it as a last resort. PROF. WM. LEISHMAN, M. D., GLASGOW, Epitomizes thus : The evacuation of the waters is best in partial placenta prsevia, and where the membranes can be reached, and where the foetus is immature. Ergot and oxytocics may be given, but it must be remembered that these and the above render turning more difficult. Plugging is called for, and may be applied in the vagina or in the os uteri ; it is a temporary expedient, and in turning is essential as a preliminary. Extraction of the placenta is not to be done unless the circum- stances are very exceptional, as when turning is impossible, and separation has failed. Separation of the placenta is more justifiable, but the operation of turning is that in which the majority place the greatest confi- dence. PROF. FORDYCE BARKER, M. D., NEW YORK. This author recommends the production of contraction by pressure by the hand ; the removal of any blood clots that may remain in the uterus ; ice in the vagina; injection into the uterus of half an ounce of the solution of the sub-sulphate of iron, diluted with an equal measure of water; and internally administer thirty- drops of the fluid extract of ergot with twenty drops of the tincture of nux vomica every half hour, until well assured that the uterus is well contracted. If the patient has suffered a severe shock from loss of blood, twenty drops of laudanum and alcoholic stimulants should be given, and repeated at short intervals until reaction is restored, and then give the ergot and nux vomica. If there be a portion of the placenta retained, the ergot and nux vomica should be administered as a precautionary measure. If the hemorrhage results from a uterine polypus, Dr. Barker recommends its removal with the vulsella forceps. If from lacera- tion of the vagina or vulva, involving varicose veins or arteries, he recommends ligation or such local measures as are demanded in hemorrhages. 256 COMPLICATIONS OF PARTURITION. T. G. THOMAS, M. D., NEW YORK Urges (American Practitioner, May, 1877,) the induction of pre- mature labor in placenta prsevia. It is the only method by which the danger can be avoided. It is a rational and perfectly warrant- able means, and has no danger to be compared with that of non- interference. It removes the hazards incident to delay, and re- lieves the great anxiety of patients, friends and physicians. GEO. T. HARRISON, M. D., NEW YORK, Gives the resources thus' (Am. Jour. Obstet., No 36, p. 576): They are enumerated in the order they are to be employed — (1) Friction, kneading and compression of the uterus. (2) Hypoder- mic injection of ergot above the symphysis pubis. (3) Injection of hot water at a temperature of at least 100° F. into the uterine cavity. (4) The injection of Churchill's or U. S. tincture of iodine into the uterus. Ergot, thus hypodermically used, he says, unfolds its peculiar power over the muscular tissue with a degree of promptness and certainty of which those who know of the action of the drug only through the other modes of administration can have no idea. He refers to intra-uterine injections of ergot in the following manner : Remove coagula ; then, with a Davidson syringe, wash out all blood with cold water, and quickly inject into the cavity f.Sss Squibb's fluid extract of ergot, with water f.§iv. The effect has invariably been to bring on promptly strong, permanent tonic contraction of the muscular fibres of the uterus. Dr. Strudwick has tried it in six cases of hemorrhage, and says it surpasses Monsel's styptic. He has never been disappointed in ergot thus applied, and con- fidently recommends its use to those who have never tried it. Its superiority over the iron treatment must be obvious to any intelli- gent practitioner, since the latter application is often followed by serious consequences, and is never used without grave apprehen- sions of serious results, whereas the ergot is perfectly harmless and unirritating. Some critic may say, the result obtained should be ascribed to removal of coagula and cold injections, etc. ; but such is not the case, since after trying all those measures repeatedly — with ergot by mouth and rectum — each time only bringing on slight trans- PUERPERAL HEMORRHAGE. 257 ient contraction, until ergot was tried, with the unfailing success which always attends its use wlien thus applied. PROF. W. S. PLAYFAIR, M. D., LONDON. Urges preventive treatment in all cases. The hand should be kept upon the womb until the placenta is expelled, and continuous contraction kept up for at least half an hour after delivery, by grasping the contracted womb with the palm of the hand and pre- venting its relaxation. It is also good practice to give a full dose of ergot after the placenta has been delivered. When the previous history causes an expectation of hemorrhage, the ergot should be given, and preferably hypodermically, about 10 to 20 minutes before the labor is expected to be concluded. Then any means should be taken to insure contraction of the organ, and it is advisable to rupture the membranes early, as soon as the os is dilated or dilatable, to insure stronger uterine action. Care should be had in all cases where the pulse is high some ten or fifteen minutes after the birth of the child, as hemorrhage often follows. Hence, never leave a patient until the pulse falls to the normal. After speaking of pressure, he alludes to another plan : pass the fingers of the right hand high up in the posterior cul-de-sac of the vagina, so as to reach the posterior surface of the uterus, while counter-pressure is exercised by the left hand through the abdo- men. The anterior and posterior walls are thus closely pressed together. Brandy must not be relied upon. In bad cases it merely fills the stomach, and may be thrown up unaltered. It may bring on. intoxication, which is mistaken for coma of syncope, etc. A drachm of ether may be injected hypodermically in great exhaustion. Give fresh air, keep the head low down, so that syn- cope cannot occur. Empty the uterus of clots or other foreign, bodies. Intra-uterine injections of warm water, 1 io° to 120 , are highly recommended. This succeeds after all the usual remedies fail,, especially where the uterus contracts and relaxes. A distended bladder will often prevent contraction. Evacuate it with the catheter. Never plug the vagina. Compression of the abdominal aorta is a temporary expedient, and. 258 COMPLICATIONS OF PARTURITION. supplements other means, as also when there is great exhaustion, the firm bandaging of the extremities with the elastic bandage to retain the blood in the trunk, and lessen the likelihood to syn- cope. In the last extremity, inject the strong liquor of chloride of iron, diluted with six times its bulk of water, being very careful to ex- clude the air from the syringe. The secondary treatment will be opium as a restorative, 30 to 40 drops of Battley's solution by the mouth or in enema, quiet, beef, essence, milk, eggs, etc., in small quantities given frequently. Stimulants as demanded. PROF. R. A. F. PENROSE, M. D., PHILADELPHIA. Saturates a 'cloth with common vinegar, and passes it into the uterine cavity, and squeezes it. In a paper read before the Ameri- can Gynaecological Society, he claims that this procedure rarely fails to stop the flow immediately. It can be easily obtained. It can be easily and instantly applied without apparatus. It has never failed in his practice. It is sufficiently irritating to excite the most sluggish uterus to contraction, and yet not so irritating as to be subsequently injurious. It is an admirable antiseptic. It acts upon the lining membrane of the uterus as an astringent. H. P. C. WILSON, M. D , BALTIMORE, Urges the introduction of the hand within the uterus, and raking the surface which has been occupied by the placenta with the finger-nails. He says that in one case no further hemorrhage occurred, though the uterus did not contract, and its mouth remained open for nearly an hour after this operation. LOMBE ATTHILL, M. D., OF DUBLIN. This author is convinced that there are cases where a powerful local hemostatic in the uterus is absolutely essential to save life. He states his conclusions formally : 1. That cases of post-partum hemorrhage occur in which the injection of the perchloride of iron, or some similar styptic, is alone capable of arresting the hemorrhage. 2. That the injection of such styptic does not necessarily increase the tendency which exists in such cases to the occurrence of pyemia, septicemia, or peritonitis. PUERPERAL HEMORRHAGE. 259 3. That this treatment is specially applicable to anemic patients. 4. That while it should never be had recourse to unnecessarily, it should not, on the other hand, be delayed too long. In using the solution of the perchloride of iron, he carries out in the main the directions given by Dr. Barnes. He has not however, in any case injected more than six or eight ounces, sometimes as little as four ounces of the fluid. He also uses it somewhat stronger than Dr. B. does — namely, in the proportion of one part of the strong liquor, B. P., to two of water. The import- ant point in using it is to take care that the end of the tube is passed up to. the fundus of the uterus, and that the fluid be injected slowly. GEORGE A. TYE, M. D., OF CANADA. In using the hot water in post-partum hemorrhage, this practi- tioner {Canada Lancet, Nov., 1879,) dissolves in it one ounce of alum to the pint. He has found this attended with less disadvan- tages than the tincture of the chloride of iron. In a comparison of the two, he states the following conclusions: 1. That we possess two powerful topical remedies for post- partum hemorrhage. 2. That the iron is the more powerful to control hemorrhage, but by far the more dangerous one. 3. That hot water is nearly equal in hemostatic power, and with- out danger. 4. That we are rarely justified in using the iron before the hot water has been tried. 5. When the hot water fails, it is the duty of the accoucheur to use the iron. 6. The hot water has these advantages over the iron; it can al- ways be procured; it washes away all clots, leaves the uterus clean, and therefore, no danger from thrombus or septicemia. 7. Alum is a valuable addition to the hot water, securing two forces, viz : the contraction of the uterus and the coagulation of the blood. 8. That we have not yet reached perfection in the treatment of the hemorrhage, and that abundant ground is open for observation and research. In a discussion of this measure, at one of the London medical societies recently, Dr. John Walters stated four conditions essen- tial to success: 260 COMPLICATIONS OF PARTURITION. 1. The uterus must be emptied completely. 2. The temperature of the water must be from ioo° to no°. 3. The tube must be passed to the fundus. 4. A considerable quantity of water must be used. The advantages of warm water are that it is cleanly, always at hand, antiseptic, and perfectly safe. He drew three conclusions; 1. Severe hemorrhages were controlled by warm water. 2. Cold or ice, in conjunction, was useful. 3. In some cases, peichloride of iron must still be used. RESUME OF REMEDIES. Acetum. Vinegar has a longstanding reputation in post-partum hemor- rhage. Dr. Davis {Obstetric Medicine, 1836,) recommended the intra-uterine injection of one part of vinegar to two of water. It has recently been highly praised by Dr. Penrose, of Phila- delphia. (See page 258.) Cannabis Indica was much esteemed by Dr A. Christison, but most later observers have failed to verify his statements. Dr. Wm. Don- ovan, however {Edinburgh Med. Jour., June. 1875), sa ) ,s * n doses of gtt. xx. p. r. n., he never knew it to fail. Capsicum. A teaspoonful of tincture of capsicum will often prove the best of stimulants in atony. Chloralum, as at once a styptic and antiseptic, has been preferred for intra uterine injections by some writers. Ergota has been used in large doses by the mouth, in hypodermic injec- tion, and locally as an intra-uterine application. Dr. Lombe Atthill says that it is a most uncertain agent, and while most useful if administered some time before the occurrence of the hemorrhage, is, in his opinion, seldom of much value if given after it has set in. Ergot takes at least twenty minutes to act, and besides is often in these cases vomited. Injected hypoder- mically, it is capable of doing much good; but its irritating properties when thus used, render this method of employing it not altogether unobjectionable. Erigeron Canadense, the " squaw- weed," has a popular reputation as a hemostatic in uterine hemorrhage. A teacupful of the infusion or five drops of the oil, may be given every half hour in light cases. Ether has been used in hypodermic injection and as spray to the hypogas- tric region. The former has been especially recommended by Prof. Von Hecker, of Munich, in conditions of collapse from hemorrhage. The chief point to be attended to in making the injection, is to pass the syringe well down in the subcutaneous cellular tissue ; otherwise troublesome abscesses may form at the seat of the injection. The quantity to be injected depends entirely on the pulse. Professor Von Hecker frequently injects from two to four drachms at short intervals. The effect isvery transient, so that the injection may have to be repeated. PUERPERAL HEMORRHAGE. 26l Fcrri CLloridi Tinctura, strongly eulogized by Barnes, Atthill, Hicks, and others as an intra-uterine injection, has been severely con- demned by Dr. Snow Beck as dangerous. In certain desperate cases it seems the only resource which is efficient (see page 259). The tincture may be diluted, or used of full strength. The tube of the syringe should be carried to the fundus, and the contents gently injected ; or a sponge may be steeped in the solution and carried to the fundus. Ferri Sulphas and MonseVs Solution have at times been used, and may have some advantages over the chloride. Dr. Wilson, of Baltimore, states that the sub sulphate should be combined with glycerine, as the simple solution acts as an irritant. Others use f §ij of Monsel's solution to water f.fvj, to wash out the uterus. It is sure to check the hemorrhage, but the sequelae may not be agreeable. Iodinii Tinctura has been used, some employing several drachms of the pure tincture, others diluting- it in the proportion of f.5j to water f.Jj. In a paper read before the Obstetrical Society of London, October, 1874. Dr. Trask recommends this article as an injection into the cavity of the uterus, in hemorrhage after delivery, as perfectly safe — at any rate, free from the evils incident to the employment of iron. It is an antiseptic, and is probably the surest of all means of counteracting a tendency to absorption of septic matter into the system after delivery. Ipecacuanha. In some cases a full dose of this drug, bringing on rapid emesis, causes strong contraction after inertia, and promptly checks the hemorrhage. Nitrite of A my I has been used by Dr. E. W. Kerr (Brit. Med. Jour., Nov. 1, 1S69,) with excellent effect. Five minims were admin- istered through an inhaler. Plumbi Acetas. Dr. J. Workman, of Toronto {Canada Lancet, Jan., 1878), urges acetate of lead in large doses, from ^ a drachm to a drachm ; it will generally be found that in these large doses it acts as a moderate purgative within twenty-four hours ; and, if it be desirable that, in order to avoid transformation, it should be expelled from the bowels in this way, it may be better to err on the safer side, which certainly is not its exhibition in small doses. In one case he gave 6 drachms in twelve hours. He quotes Dr. Daniel Clark and others of eminence, who give it in even larger doses, and with like good result. Viscum Album, the mistletoe, has been introduced as an agent in post- partum hemorrhage by Dr. W. H. Long, U. S. M. H. S. {Louisville Med. News, March, 1878). But as it requires "from twenty-five to fifty minutes " to produce uterine con- tractions, its efficiency is slight. general measures. Cold. This should never be neglected. Fanning the genitals, spinal ice-bags, injections of ice water, a lump of ice in the uterus, ether or rhigolene spray to the hypogastric region, spine or 262 COMPLICATIONS OF PARTURITION. thighs, are some of the methods in which it may be used. A tumblerful of ice water flavored with brandy will sometimes act like magic, when given just after the second stage is completed. Compression of the Abdominal Aorta may be carried out in thin subjects with delicate abdominal parietes. Electricity and Galvanism have been found of decided advantage in some light cases, but cannot be depended on in severe ones. Heat is at times more energetic than cold. Chapman's spinal hot water bags have been spoken of for the purpose. Dr. Windebrand reported {Deutsche Med. Woch. June, 1876,) a desperate case where he threw into the uterus water at 120° F. by means of a uterine tube, which immediately caused a renewal of the pains, which, after an interval of five to ten minutes, and some eight or ten injections had been made in the meantime, ended in the expulsion of the whole of the contents of the uterus. Other cases have been reported by Atthill, Mann, etc. Dr. Koeh- ler (Gazeta Ckarska, No 8, 1878,) has obtained relief in the most desperate cases by applying very hot sand bags to the head and cardiac regions. They are particularly useful to pre- vent collapse, and do not interfere with other means. Mammary excitation, by applying the child, the mouth of the nurse or a cupping glass, to the mammas, will occasionally excite uterine contractions. Massage of the uterus by gentle and continued " hand kneading" is a simple and valuable plan to awaken the muscular contractility. Position is always of great value. "It is most important," observes Dr. J. H. Aveling {Influence of Posture on Women, 1879), "that every woman suffering from uterine- hemorrhage should be im- mediately placed in a recumbent position with the hips raised as far above the level of the shoulders as can conveniently be effected." Pressure. " The value of pressure on the fundus," says Dr. Atthill, "can hardly be overestimated. It should be combined with friction." Mr. David Christie {British Medical Jorunal, June. 1878,) describes a method of arresting uterine hemor- rhage by fluid pressure. He introduces an elastic bag into the uterus, connected with a tube seven feet and a half in length, the free end of which, after the bag is filled, is placed in water at the proper height. Mr. Christie reasoned that, as a tube placed in an artery has a column of water raised seven and a half feet by the heart's action, so his method would effectually arrest any hemorrhage that could occur, and allow the womb to contract and relax without the pressure of the water being interfered with. Sinapisms to the extremities are among the means currently used, but are not very efficient. These are aimed to bring the blood to the limbs. With a somewhat similar idea, Dr. Moller, of Vienna, has recommended ( Wiener Med. Presse, No. 8, 1874,) applying the Esmarch bandage to the arms and legs. Transfusion has been growing in favor of recent years, in desperate cases PUERPERAL HEMORRHAGE. 263 of bleeding. The forms of transfusion most employed and attended with the best results are : 1. Transfusion with defibrinated blood. 2. Mediate transfusion with pure blood. 3. Immediate transfusion from "vein to vein." 4. Immediate transfusion from " artery to vein.' 1 '' The first and third methods are most generally adopted — the danger of clots is avoided. The second is generally aban- doned, as leading to embolism, etc. Instead of blood, Dr. J. W. Howe (N. Y. Med. Jour., 1875,) recommended goat's milk; and Dr. T. G. Thomas and others have successfully employed cow's milk. The conclusions reached by Dr. Thomas are em- braced in the following propositions : 1. Injection of milk into the circulation, in place of blood, is a perfectly feasible, safe, and legitimate procedure. 2. In this procedure, none but healthy milk, drawn from the udder of the cow within a few minutes of its introduction into the vein, should be employed. 3. A glass funnel, with a rubber tube and a suitable pipe attached, is much better and safer than a more elaborate ap- paratus. 4. Intra- venous injection of milk is an infinitely easier opera- tion to perform than transfusion of blood. 5. Intra- venous injection of milk, like that of blood, is com- monly followed by a chill and rapid rise of temperature ; but these symptoms soon subside, and are replaced by a great im- provement in the general condition of the patient PUERPERAL ECLAMPSIA. For many valuable points on the prophylaxis of this complica- tion, see Albuminuria. PROF. KARL SCHROEDER, ERLANGEN. There are two methods of treatment, the abstraction of blood, or the use of narcotics. Venesection has often given favorable and exceedingly rapid results, but frequently the attacks have soon recurred, and then taken a more unfavorable course. A more rational treatment would be the paralysis of the activity of the voluntary muscles, and this can be done by narcotics ; thus the convulsions are certainly checked for hours, and the blood is not deteriorated. Scheinesson has shown by experiment that chloro- form diminishes the blood pressure in the arterial system. Experi- ence is decidedly in favor of this treatment; but to be effectual, the narcosis must be absolute, so that the voluntary muscles no longer contract. As long as an eyelid quivers, another dose is required. Chloroform will do this, but as it must be maintained, morphia is better ; or if haste is necessary, chloroform first, and replace it by subcutaneous injections of morphia. Chloral is also of great advantage, and may also be used subcutaneously ; or an enema of mucilage of starch, y 2 cupful with 32 grains chloral in an ounce of decoction of althaea. Venesection may safely be omitted. No obstetric manipulation is required for the safety of the mother, but labor may be hastened to save the child. PROF. W, S. PLAYFAIR, M- D., LONDON, There are good grounds for believing that blood-letting is of only temporary use, and that it may even increase the convulsive ten- dency. In special cases, as where there is evidence of great cere- bral congestion and vascubr tension, as a livid face, a full-bounding pulse, and strong carotid pulsation, the patient a strong, healthy woman, it may be employed. Even here, a single bleeding is all that is ever likely to be of service. As a temporary expedient, the carotids may be compressed. Purgatives to remove any irritant matter lodged in the intestinal tract, may act well ; as the comp. jalap powder in a full dose, or a (264) PUERPERAL ECLAMPSIA. 265 drop of croton oil, or a quarter of a grain of elaterium may be placed on the back of the tongue. Chloroform may be used to control or ward off the paroxysm. It is advisable, however, to have a remedy more continuous in its action, and requiring less personal supervision. Chloral is decid- edly this remedy, and, in combination with bromide of potassium, in the proportion of 20 grains of the former to half a drachm of the latter, repeated at intervals of from four to six hours. Dr. Harris, the American editor of Playfair, has used bromide of sodium and chloral with good effect at shorter intervals, and the chloral in doses of 10 to 15 grains. If the patient cannot swallow, it may be given by enema. The remarkable influence of bromide of potassium in controlling the eclampsia of infants, seems to be an indication of its use here. Morphia may be given subcutaneously in the dose of % of a grain, repeated in a few hours so as to keep up its effect. Acetic and benzoic acid, as antidotes to uremic poisoning, are too uncertain. During the paroxysm, prevent the patient from injuring herself, especially biting her tongue, by placing something between her teeth. As to the delivery, adopt that course least likely to irritate. If the fits seem to be induced and kept up by the pressure of the fetus, and the head be within reach, apply the forceps, or even resort to craniotomy. Otherwise, leave the case to nature. PROF. FORDVCE BARKER, M. D., NEW YORK. This physician places among the exciting causes of puerperal convulsions, anemia, albuminuria, uremia, indigestion, constipa- tion, retention of urine, excessive distention of the uterus, reflex pains, or moral shocks. As a prophylactic, he removes as speedily, and effectually as pos- sible these exciting causes by appropriate treatment. If at the advent of labor, convulsions be threatened, he abstracts from the patient a moderate amount of blood, not enough to weaken her, but sufficient to restore the equilibrium of the circulation ; he does not permit the bladder to become distended. If the patient is irri- table, restless, complains loudly of little annoyances, and is sleep- less, he tranquilizes her by a moderate opiate. 266 COMPLICATIONS OF PARTURITION. When the convulsion has occurred, he says, bleed at once, then give a brisk cathartic, as : 264. !£.. Hydrarg. chloridi mitis, gr.x Pulv. jalapse, gr.xx M. Ft. pulv., No. j. Sig. — Take at once. But if she be comatose, he mixes a quarter of a grain of elate- rium with a third of a teaspoonful of butter, and places it upon the back of the tongue. This is to be repeated every half hour until active catharsis. To arrest and prevent convulsions, administer chloroform by inhalation. Having overcome the immediate danger from convulsions by the means stated, he administers a full dose of morphia hypoder- mically. DR. CHARLES, OF BELGIUM, In the Memoirs of the Belgian Academy of Medicine, 1876, sums up as follows the treatment of eclampsia in his memoir on the convulsions of parturient women, which was crowned by the Belgian Academy of Medicine : 1. Mechanical eclampsia from the sixth to the ninth month : (a) Bleeding, if the case be urgent, or if there be true or apparent plethora ; (b) drastics, in all cases, which may be more or less replaced by diaphoresis ; (c) chloroform when the fits are about to commence, and during the clonic convulsions ; (d) chloral in the intervals of the attacks, as an injection to beneficially fill the place of narcotics ; any antispasmodic, such as bromide of potassium, may be added to it ; (e) to finish the delivery, if possible, bring on labor, if the fits do not show signs of disappearing; to bring on forced delivery in very serious cases. 2. Reflex eclampsia before six months gestation, and after deliv- ery : (a) Bleeding is but very rarely indicated ; (b) purgatives are always somewhat useful ; (c) chloroform, chloral, etc., should be continued as in mechanical eclampsia, and antispasmodics should not be neglected. 3. Toxic eclampsia : Fulfill the symptomatic indications; gen- eral or local bleedings to combat congestion of the brain and spinal cord when it is very marked ; cold applications to the head, purgatives, diaphoretics, baths, revulsives, narcotics, anaesthetics, etc. PUERPERAL ECLAMPSIA. 267 M. DUNCAN, M. D. Comes to the conclusion {Practitioner, April, 1875, ) that Bright's disease as a cause is overestimated. A temporary appearance of albumen in the urine is no certain indication of Bright's disease. The treatment is to empty the uterus ; but, if labor is only com- mencing, it should only be done if the symptoms are desperate ; with severe and frequent fits, cyanosis and profound coma, move the bowels, draw off the urine ; tide over the crisis with bleeding; chloroform and chloral are useful; chloroform must be used with great caution where cyanosis is great. PROF. F. WINCKEL, M. D., ROSTOCK, GERMANY, Says venesection is very rarely required. Only the most imminent danger will be an indication for resorting to this measure. Gener- ally severe attacks become milder when profuse perspiration is established after the delivery. Excite copious evacuations by drastics, as jalap, aloes, ext. colocynth, and enemata of vinegar and salt. As diuretics, tartaric acid, lemon juice, and flower of benzoin may be given. During the attack, chloroform may be used. If this be of no avail, strong doses of opium are of great value. Hypodermic injections, if the patient be unable to swallow. If there is great central congestion, leeches may be applied to the forehead or behind the ear. Cold compresses, ice bags, sinapisms to the back of the neck, or even cold irrigation of the head, are advisable. Afterwards, stimulants to prevent collapse when threatened, tonics and nourishment for hydremia. WM. BERRY, M. R. C. S., EDINBURGH. For the treatment we have three periods : During pregnancy, when we must employ purgatives, bleeding, chloroform, and chloral. During labor, chloroform and delivery. After delivery, chloral and bromide of potassium. A single dose of 30 grains each of chloral and bromide will usually prevent a recurrence of the convulsion, and produce quiet sleep {Obst. Jour. Grt. Brit, and Ireland, April, 1878). ANGUS MACDONALD, M. D., EDINBURGH, {Obst. Jour. G. B. and I., Aug., 1876), regards as the most im- portant, sedatives and anaesthetics, and especially chloral, chloro- 2 58 COMPLICATIONS OF PARTURITION. form, ether, and bromide of potassium. He trusts chiefly to chloral, giving it in doses of 25 grains every six hours, so long as the fits continue or threaten. He believes that it acts to dilate the arterioles, thus favoring the disappearance of anemia in the brain ; acts as a sedative to the nervous system generally; allays muscu- lar irritability and spasm, and thus tends to obviate cerebral con- gestions and extravasations. AFTER LABOR. A. E. AUST- LAWRENCE, M.D., BRISTOL, ENGLAND, {Obst. your. G. B. and I., Oct., 1876), feeds carefully on milk diet for the first three or four days. Robust women who have eaten well up to confinement, require an aperient within 48 or even 24 hours after confinement. He prefers : 265. ^. Hydrarg. chlorid. mit. Pulv. rhei, aa gr.ij Ext. belladon., Ext. opii, aa grj^. M. For one pill, to be repeated every 6 or 8 hours till the bowels act ; gen- erally three are required. He urges ergot for the first week or two, if the uterus does not involute as it should. H. B. WHITE, M. D., BROOKLN, N. Y., Employed jaborandi in the case of a primipara at full term, highly anasarcous and urine very scant. The drug was given in infusion, one drachm of the leaves being used and divided into three doses at short interval's. After the first dose, profuse sweating and salivation ensued. There were three convulsions prior to, and several after delivery. The article was continued for three days, drenching the patient in perspiration. She completely recovered. PROF. OTTO SPIEGELBERG, BRESLAU. This writer {Trans. Am. Gyn. Soc, Vol. II.,) states that the treatment must be directed to effect three objects : 1. The renal secretion must be restored. 2. The arterial pressure must be diminished. 3. Irritation of the nerve centers must be reduced. These results are most easily attained by (1) venesection; (2) narcotics, and (3) if the patient be in labor, by its speedy comple- tion. H^ ^(A— &W ^JjJ^AsAa. ( a^ c^aAaV ; x ' , ■ - L ^~fyU v PUERPERAL ECLAMPSIA. 269 In the treatment of true eclampsia he places venesection first. As soon as the patient is seen, let the brachial vein be opened and from six to sixteen ounces of blood be taken ; and this be repeated unless its effects are decisive. In mere eclamptiform attacks, bleeding may be omitted. Narcotics should be adminis- tered soon after venesection. Among them, chloroform is the most advisable. The inhalation must be guarded, and only take place when the aura of another attack is observed. Its administration may be combined with that of morphia or chloral; the former sub- cutaneously, the latter by the rectum ; of morphia gr.J^, of chloral gr. xliv, are sufficient doses to begin with. When there is coma, cold applications to the head are useful. In the paralytic stage, stimulants must be resorted to. Diuretics are useful as after- treatment during convalescence. RESUME OF REMEDIES. Aconitum has been used to reduce the arterial pressure. It is highly- praised by Phillips. Belladonna is recommended by some writers as a sedative to the nervous system in these cases. Benzoicnm Acidum, as a diuretic, is valued as a prophylactic and to hasten convalescence. Chloral Hydras acts as an anaesthetic, is claimed to be similar to chloro- form in its effects, to allay irritation of nerve centres, and to have a decided effect in controlling convulsions from whatever cause. It thus relieves the physician of the difficulty of decid- ing whether the cause be plethora or anemia, whether to bleed or not. But, like bleeding, it is accused of producing anemia. It may be conveniently given by the rectum in an enema hold- ing in solution gr.xxx-lx. Dr. Delauny, in a prize thesis, 1879, savs triat statistics show that puerperal convulsions treated by revulsives and antispasmodics show 50 per cent, of mortality, by blood-letting 24 per cent., and by chloral 13 per cent. Chloroform is acknowledged by all authorities to be of the greatest value either with or without venesection. For particulars as to its administration, see page 269. faborandi and Pilocarpin have both been advocated for their diaphoretic effects by Massmann, Tehling, and others {Cent. Blatt. fiir Gyn., 1878 . The modus operandi is attempted to be explained on the Fraube-Rosenstein theory of the convulsions. It is argued that the salivation and perspiration induced by the jaborandi or its alkaloid, relieve the excessive vascular tension. Two drachms of the fluid extract of jaborandi may be thrown into the rectum. Opium and Morphia. These are invaluable narcotics in this disease. 2/0 COMPLICATIONS OF PARTURITION. They are best administered, opium by the rectum, morphia hypodermically. In sthenic cases, they should promptly follow venesection. Potassii Bromidum is excellent as a prophylactic, gr.x, three to six times daily. In the attack, it may be advantageously administered between the seizures combined with chloral, of each. 3ss. Sodii Bromidum acts similarly to the potassic salt, and may be used in its place. Veratrum Viride has been much discussed as an aterial sedative. Some practitioners claim that it entirely does away with the need of the lancet. It maybe given in hypodermic injection of gtt.v-x of the fluid extract ; or by the mouth, in doses of gtt.v-xxx, repeated as required. If the pulse is full and above 80, give the doses fearlessly {Trans. Am. Med. Assoc, 1876, p 240). An ounce has been administered in twenty-four hours with success. Others fear the depressing character of this remedy, and do not favor it. GENERAL MEASURES. Cold, in the form of ice to the head, spinal ice bags, etc., are valuable in states of coma. horesis, in order to produce a derivative effect and relieve the kidneys, has been attempted, both by means of drugs, as pilo- carpi, and by Jacquet, by enveloping the body in wet sheets wrung out in quite hot water. This can only be relied upon in mild cases, and rather as a prophylactic. Purgatives diminish arterial attention, draw congestion from the renal regions, and are a rational mode of treatment. A full dose of calomel and jalap maybe given if the patient is able to swallow; otherwise a drop of croton oil may be applied to the back of the tongue. In both cases an enema of castor oil and oil of turpentine, one tablespoonful of each in chamomile tea, should be thrown up the rectum (Spiegelberg). Venesection is, in sthenic cases of true eclampsia, the most valuable of all remedial measures. See p. 264. PUERPERAL MANIA. A. H. KUNST, M. D., WESTON, W. VA., In a paper read before the State Medical Society, gives the treat- ment as follows : His belief is that the tendency in such cases is towards exhaustion, hence depleting measures must be regarded with great circumspection; rarely is venesection justifiable. At the onset, if the secretions are locked up, a dose or two of calomel or blue mass, and warming laxatives, may be given according to circumstances, with great care to prevent a drain. If there be increased heat of the scalp, apply cold to the head. A warm bath in the evening will be useful and soothing, and promote sleep. The best hypnotic is a combination of chloral and bromide of potassium. Symptoms may, however, indicate hyoscyamus, conium, camphor, monobromated camphor, opiates, etc. Tran- quillity should be invited and encouraged by the attentions of a trained nurse, and all interference prohibited. Husband the strength, and, if necessary, use the camisole to restrain too con- stant movements. Diet should be nutritious and generous, and easy of digestion. Iron, quinine, phosphorus, etc., should be employed as indicated. If acute delirium occur, and she refuses food, use the oesophagus tube, and inject twice daily beef tea, and milk, and eggs alternately. The moral management is important, and she should be guarded against self-injury. Generally, the wiser plan is to remove her from her familiar surroundings, to change the train of ideas. Interviews with husband and friends should be restricted. Often she regards them as her enemies, and their visits add to the trouble. Exercise in the open air, with some light, cono-enial employment, is of great value. Convalescence should be aided by a few weeks at an agreeable resort, or pleasure- traveling. S. PUTNAM, M. D., MONTPELIER, VT., Says, in the Transactions of the Vermont State Medical Society, 1879: First learn betimes the vulnerable points and tendencies of patients, and regulate their hygiene and medication accordingly. Should a latent albuminuria be found, let the patient live upon (271) 2/2 COMPLICATIONS OF PARTURITION. milk diet; use the warm sitz bath at night, followed by abundant frictions to the back and limbs. In the morning, cold or tepid sponging, with friction, to be followed by walking, or carriage exercises. At lying-in, avoid as far as possible the causes of anemia, prostration, irritation and excitement. Should the patient be unable to sleep, make the conditions the most' favorable to secure that result, and if sleep does not occur, use chloral, morphia and camphor, or whisky in quantities ordi- narily adequate to produce that effect, and we shall seldom have puerperal mania to treat. But should a threatening case explode, notwithstanding your care, perhaps a cathartic is needed, espe- cially if constipation exists, after which a more efficient use of anodynes, stimulants and tonics may succeed. Should they not, and the delirium be violent, aconite, veratrum or digitalis might be used, oreven anaesthetics. When uremic delirium or stupor is evident, use ten grains nitrate of potassa, one drachm nitrous ether, and five drops of dilute nitric acid in water, every four hours; or instead, when insomnia persists, ten or fifteen grains bromide potassium every two hours, alternately with twenty drops tinctura ferri chloridi. Meanwhile, nutrients, stimulants and tonics, are to be given as needed. PROF. WM. LEISHMAN, M. D., GLASGOW. We can scarcely doubt that when there are indications of cere- bral disturbance, much may be done to ward off an attack, particu- larly where there is a hereditary taint, or where insanity has been present at previous confinements. It must be remembered that it is essentially a disease of debility, and hence blood-letting must be used, if at all, with very great caution, for we may thus precipitate a fatal result. It should only be used in actual phrenitis. Gastro-intestinal disturbance will require from the first prompt attention. Relieve the overloaded bowels, and keep them cleansed. Aloetic purgatives are very appropriate. Where the powers are not low, and there is a foul tongue, offensive breath, a yellow eye, an emetic of ipecacuanha may be given. Gooch believed this, and most modern writers agree. But, of course, this is contra- indicated when the face is pale, the skin cold, the pulse quick and weak. When much vascular excitement presents, cold to the head, or, even better, laving the forehead and temples with warm PUERPERAL MANIA. 2J '3 water, after which there is a refreshing coolness, may produce the desired effect. Tartar emetic very guardedly, or tincture of aconite, or of veratrum viride, are useful. The nervous sedatives are most important, and at the head of the list is opium, the sheet anchor. It must be given in very large doses. If there is difficulty in giving it, introduce a supposi- tory into the rectum, of one or two grains of morphia. Remem- ber that Tuke says opium or other narcotics are not to be used in acute mania. Chloroform has been employed beneficially ; the patient being placed fully under its effect, and so kept for a sea- son. Hyoscyamus, with ether or ammonia, and Indian hemp, have been used for the same purpose. Gooch's favorite was camphor.. Chloral has now superseded opium, and is a most valuable article The warm bath is an excellent sedative, and may succeed in the failure of drugs. Procure sleep, and the patient may at once re- cover. PROF. W. S. PLAYFAIR, M. D., LONDON. Maintain the strength of the patient, calm the excitement, rest the disturbed brain. Over-active measures, as bleeding, blistering the shaven scalp, and the like, are distinctly contra-indicated. Abundance of nourishment comes next. Give solid food prin- cipally, reserving beef-tea and brandy later. Food must be given: forcibly, if necessary. Stimulants increase the excitement, and are only useful in melancholia. Keep the bowels well cleansed. Procure sleep; nothing is so valuable as chloral, alone or in combination with bromide of potassium; 15 to 30 grains at bed- time rarely fails to procure sleep ; give this in an enema, if the patient will not swallow. Opiates are apt to do more harm than good. Blandford, on this point, says he believes opium never does good, and may do great harm. This applies equally, whether by the mouth or hypodermically. Often, after an opium sleep, the patient quickly rouses, and all is worse than before. In melan- cholia, in moderate doses, it may be given with advantage. The prolonged use of the warm bath, say at 90 , for half an hour, has acted well as a sedative. The wet pack, is equally good,, and is more readily applied in refractory cases. 274 COMPLICATIONS OF PARTURITION. ALFRED MEADOWS, M. D., LONDON, Takes almost precisely the same ground. Remove all supposed sources of irritation ; quiet the nervous system ; support the strength. Oppose constipation with 20 or 30 grains of jalap powder and two to five grains of calomel, followed by saline aperients. Rigby advised antimony with calomel and ipecacuanha, as too speedy to depress, and acting as a rapid purge ; it acts, she falls asleep, perspires freely, and wakes greatly refreshed. As a rule, eschew opiates, they increase the irritability and favor cere- bral congestion. Chloral may be given in doses of 20 to 60 grains, induces sleep without excitement or depression ; henbane and chloroform are of great service. White hellebore has been recommended, and Indian hemp also. Hydrocyanic acid in doses of 5 minims of the dilute acid, every four hours, has been found of great value, Vigilance must be great. Support with beef tea, wines, etc. PROF. FORDYCE BARKER, M. D., NEW YORK. Bleeding is useless, even injurious, as are vascular sedatives, except where there is also a latent local inflammation. Laxatives and emetics should never be given, except when positively re- quired. Insomnia, a striking feature, would suggest opium, but it will not, in any doses, cut short an attack, but may be of service where there is latent pelvic peritonitis. Allay brain excitement by restoring exhausted nerve power ; improve the nutrition of the brain by easily-assimilated food. Tonics are of great service, as tinct. of chloride of iron, chlorate of potassa, and the sulphate of berberina. The latter is preferable to quinine, as it has much less tendency to induce cerebral con- gestion. Induce sleep. Neither opium nor bromide of potassium will, as a general rule, do this. Chloroform also has disappointed nearly all. Chloral is of immense value ; it does not interfere with any of the organic functions, is not followed by any unpleasant second- ary effects like opium, and never fails to produce sleep. This is prolonged for hours, and if interrupted, the patient falls asleep again without a renewal. It is best given in doses of 15 or 20 grains well diluted, and repeated every two hours till the effect is produced. PUERPERAL MANIA. 275 Combat all complications. Give laxatives for constipation, diuretics for deficient renal secretion. If cerebral erethism arise, shown by the flushed face and red eyes, give bromide of potassium, 20 to 30 grains every six hours ; but at night, for sleep, suspend this and give chloral. Watch for local inflammations, and employ appropriate remedies. In puerperal mania accompanied with, high fever, restlessness, head symptoms and scanty secretion of milk, aconite acts speedily and markedly if given soon after the chill. (Phillips.) When the delirium is wild and furious, but intermittent, with scanty secretion of milk, etc., stramonium is useful. The nervous system is relieved, the flow of milk renewed, and sleep restored. From a quarter to a half grain of the extract in 10-20 minims of the tincture maybe given every three or four hours until relief is obtained. The lochia, etc., should be watched, and the patient's powers sustained by nutrition and stimulation. (Phillips.) In puerperal hypochondriasis, Sir Jas. Y. Simpson, after failure with many remedies, used tincture of cimicifuga, fifty drops a day. In eight or ten days, the change for the better was marvelous, and the patient was completely restored to her former health and spirits. Prof Bartholow also speaks of its value. PUERPERAL FEVER (PUERPERAL SEPTICEMIA, PUERPERAL PYEMIA). JAS. G. GLOVER, M. D., LONDON. In the Lancet, Feb. I, 1878, includes under the term "puerperal pyrexia," all cases of high temperature not associated with obvi- ous external inflammation as in the breast, or with obvious infec- tion from the common infectious diseases. Presumably the local lesion is uterine or peri-uterine, for there is almost always more or less pain in and tenderness over some part of the uterus, with a good deal of abdominal distention. There is also generally a quick pulse, and the thermometer, which is an invaluable guide in such cases, shows a high temperature. In no case has he seen suppu- ration, and the patient has got well gradually. He sums up the treatment : First, a dose of quinine and iron every three or four hours. The following is a good form in which to give these : 266. 1^. Ouiniae sulphatis, gr.ij Ferri chlor. tinct., Sp. chloroformi, aa "nix Syrupi simp., f.3ss Aquas destil., f.§j. M. For one dose. Secondly, a dose of opium every three, four, six, or eight hours, according to the pain, without ipecacuanha, which may set up sickness, and without calomel, which may set up unnecessary irri- tation of the bowels. The dose of opium, say half a grain, is best given in a small pill. Thirdly, a large linseed or bran poultice over the stomach, repeated every three or four hours. A little laudanum in it often adds much to its soothing effect. Fourthly, and specially, vaginal injections, at least twice a day, of warm water with a little Condy's fluid in it. The diet should consist of good beef-tea or chicken-broth, with generally a small regulated allowance of brandy, a dessert-spoonful every three or four hours. Sometimes the brandy is best given with arrowroot. HUGH MILLER, M. D., OF GLASGOW. Excessive and Septic Lochial Discharge. This teacher, in a clin- ical lecture, reported in the Edinburgh Medical Journal, Nov., (276) PUERPERAL FEVER. 2/7 1878, recommends the following prescription in cases in which there is an excessive discharge, accompanied by a relaxed condi- tion of the uterus. He administers 5j- doses of liquid extract of ergot, repeated every three or four hours', and 267. I£. Ouinise sulph., 3ss Acidi hydrobromici, 5 v j Aquam, ad gij. Dose, teaspoonful in water three times a day. By this method large doses of quinine may be given without caus- ing headache. In septic cases Dr. Miller advises the employment of sidpho- carbolate of potassa, in the form of powders, in doses of 10-15 grains internally three times a day. When the discharge is sus- pended, the treatment consists of turpentine stupes applied over the lower part of the abdomen, with the addition of warm moist cloths, or of sponges pressed out of hot water, and applied to the external parts. In special cases, which require an antiseptic plan of treatment, Dr. Miller makes use of a solution of thymol, 1 part to 5C0 parts of water, or, better, three grains of thymol to an ounce of Eau de Cologne. This mixture, which has a pleasant and rather refreshing odor, is simply sprinkled over the napkins before they are used. In severe cases, with a putrid odor, a solu- tion of permanganate of potassa, injected with Higginson's syringe, provided with a vaginal portion, is made use of; the injection of the fluid is continued till it returns unaltered in color. In all cases where the discharge is excessive, tincture of arnica is em- ployed ; the tincture is used in the proportion of one teaspoonful to a cupful of water; it acts as a mild astringent and disinfectant. PROF. FORDYCE BARKER, M. D., NEW YOKK This author has an exalted opinion of veratrum viride in this disease. He however recommends small doses, and the effects to be carefully watched. If the remedy produces symptoms of de- pression, these symptoms have been readily dissipated by brandy, whisky, or carbonate of ammonium. The veratrum viride should not be discontinued too early, as its premature withdrawal may be attended with renewal of the symptoms. He usually com- mences by giving five drops every hour, and gradually increasing the dose, if there be not a perceptible impression upon the pulse after giving two or three doses. After the pulse is reduced, it is 278 COMPLICATIONS OF PARTURITION. thus maintained by administering two, three or four drops every second hour. It is also very important in this disease to allay pain, quiet ner- vous irritation, and secure sleep. These ends are best secured by opiates. He prefers Magendie's solution of morphia by the mouth, if the stomach is not irritable, but hypodermically, if there be nau- sea and vomiting. The next indication is to reduce fever. Quinine, mineral acids, cold sponging, alcohol, and appropriate nutrition, are the antipy- retics upon which the medical profession now relies. Of the mineral acids, our author prefers phosphoric acid. He believes that it allays nervous irritability and that it acts specifically as a tonic. He adds a teaspoonful of the dilute acid to a tumblerful of water, flavored with the syrup of orange peel. If the patient be disinclined to drink, he has sometimes substituted ten to fifteen drops of dilute sulphu- ric acid every two or three hours. The treatment of pyemia must be governed to a great extent by the therapeutical indica- tions of its associated diseases. Prof. B. regards quinine and alco- hol as the two great remedies in the constitutional treatment of this disease. He prescribes ten to fifteen grains of quinine in the morning, and from fifteen to twenty at night. If from idiosyncrasy there is an intolerance of this agent, he combines it with from ten to fifteen grains of the bromide of potassium. This counteracts the unpleasant cerebral symptoms which sometimes occur. He has never seen quinine produce paralysis of the motor power of the heart. He thinks a free use of stimulants obviates this danger. These he pushes to a degree of tolerance. To procure rest he advises an opiate at bedtime. 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. If the urine become scanty, bloody and albuminous, he orders dry cups over the kid- neys, the free use of diluent drinks, and the tincture of the chloride of iron. The latter is very useful in conjunction with the chlorate of potassium when there are very profuse discharges of pus from external abscesses. He esteems the following combination : 268. I£. Tinct. ferri chloridi, f-3SS Aquae purae, f.§ijss Potassii chloratis, §ss Syr. aurant cort., Glycerini puri, aa f.jij. M. Sig. — Tablespoonful in a wineglassful of sugar and water four times a day. PUERPERAL FEVER. 279 SEPTICEMIA. PROF. W. S. PLAYFAIR, M. D., LOXDON, Regards the indications: to discover, if possible, the poison, in the hope of arresting further septic absorption; to keep the patient alive until the effect of the poison has worn off; and to treat any local complications that may arise. Antiseptic injections must be employed at least twice a day. He employs Higginson's syringe with a long vaginal pipe attached. He prefers the alternate use of Condy's fluid largely diluted, and the tincture of iodine. The washing should be thorough, and by the physician himself. Food and stimulants to keep up the powers. Not more than one or two hours to elapse without nutriment of some kind. In moderate cases a tablespoonful of brandy or whisky every four hours ; but when the pulse is rapid and thready, there is low delirium, tympanites or sweating, indicating great exhaustion, give them in larger quantities and at shorter intervals. In severe cases eight to twelve ounces, or even more, may be given in twenty-four hours with benefit. Never bleed.. Give medicines to lessen the force of the circulation without ex- hausting, and to diminish the temperature. Tinct. of aconite is most valuable. Give a single drop every half hour, increasing the interval according to the effect. Generally, after four or five doses the pulse falls, and then a few doses every two hours will suffice. Watch it, and stop if the pulse becomes too weak, or in- termits. To reduce the temperature, give quinine ten to twenty grains morning and evening. The head and other unpleasant symp- toms may be lessened by the addition of ten to fifteen minims of hydrobromic acid to each dose. Salicylic acid ten to twenty grains, or the salicylate of soda in the same dose, is a valuable anti- pyretic. It requires to be watched. Warburg's tincture, the basis of which is quinine, has a power- ful antipyretic effect. Cold may be applied in suitable cases. The ice-cap is best ; it comforts, relieves the throbbing headache, and the temperature usually falls. When the temperature reaches 105 , cold to the body may be used, but only as a temporary expedient. Where there is much tympanites, turpentine, fifteen to twenty minims, may be given in mucilage. It acts as a strong nervine stimulant. 280 COMPLICATIONS OF PARTURITION. Purgatives are doubtful and often exhausting. ALFRED MEADOWS, M. D., LONDON. Quiet the system by opiates in the early stages, moderately excite the bowels by a saline, stimulate the skin by small doses of carbonate of ammonia or other stimulating diaphoretics. Local applications, poultices to the abdomen to keep the part warm and moist, will be of service, and opium may be added to these. When the reactive phenomena of inflammation are well marked, leeches may be applied over the abdomen, from six to twelve, as may be demanded. Venesection, when needed, must be pleno rivo, thus producing the effect at once, and with less loss. Next, nauseating doses of tartar emetic to lower the force of the heart's action; and if the pulse again becomes hard and full, repeat the bleeding till the disease is subdued. Calomel and opium freely, in order that the system may be brought quickly under the mercurial. Mercurial frictions may be used. Turpentine has been successfully given in y 2 ounce doses, two or three times a day, especially in tympanites. The uterus should be well disinfected by warm water and carbolic acid, or Condy's fluid. If there be much pain, give Dover's powder frequently, and keep up the strength. His own plan is to support by a moderate use of stimulants, a hot, dry skin being a contra-indication; warm emollients to the vagina and to the abdomen ; cleanliness in the atmosphere, the clothes and the uterus. The diffusible stimulants, opiates, salines, diaphoretics, and vegetable tonics, when the acute symptoms are gone, are the drugs to be preferred. With a high temperature, pulse quick, hard and full, skin hot and dry, nothing can compare with aconite, one drop every hour. THE ANTISEPTIC MANAGEMENT OF LABOR Has been recommended by a committee of the Berlin Obstetrical Society, as a preventive of septicemia. BISCHOFF AND ZWEIFEL Prescribe cleanliness in the parturient woman and her surround- ings ; the use of antiseptic injections in the vagina in the beginning and at intervals during the course of labor; and the thorough disinfection of the hands before, and inunctions with carbolized oil during examinations. Immediately after delivery, the vagina is PUERPERAL FEVER. 28 I injected, as well as the uterus, if its cavity has been entered by the hand ; and, during the puerperal state, vaginal injections are con- tinued daily. The vulva and perineum are protected by a pad soaked in ten per cent oil, which is frequently renewed. PROF. ZWEiFEL, ERLANGEN. Antiseptic Midwifery. In the Berliner Klin. Wochenschrift, No. I, 1878, he alludes to the plans of several authorities: Bischoff, of Basle, gave a bath at the outset of labor, washing out the vagina with a two per cent, carbolized lotion, anointing the fingers of the attendant with a ten per cent, lotion at every examination, previ- ously disinfecting the hands by washing in carbolized water. When the hand must be passed within the uterus, or if the foetus was well decomposed, the cavity was irrigated well with the lotion, and the injections were continued for thirteen days after delivery. After labor, any wound was touched with a ten per cent, lotion. A pad of wadding soaked in carbolized oil, one part to ten, was placed at the opening of the vagina, and frequently renewed. H. Fehling, at Leipsic, applied salicylic acid and starch, one part to five, to all wounds, and syringed the vagina Several times a day, in case of fetid discharge, with a salicylic lotion. Schucking employed at the close of labor a carbolized lotion of five per cent., to irrigate the parts. Zweifel's own method is partly the use of antiseptic measures, and partly adoption of the most scrupulous cleanliness in connec- tion with the surroundings of the puerperal woman. All vaginal examinations during pregnancy are made only after careful wash- ing of the hands and smearing with carbolic oil, the vagina being further washed out afterwards in some cases with five per cent, carbolic solution. The reason for these precautions is the possi- bility of infectious matter being introduced into the vagina previ- ous to labor, of its lying there and being sucked up into the uterus after the expulsion of the foetus. The rooms and beds destined for the use of the lying-in, are carefully disinfected, by burning sulphur in them in fire-proot vessels, allowing about four grammes of sulphur to each cubic metre of space. The bedclothes are spread out so as to expose as large a surface as possible to the fumes, which, after a few hours, are allowed to escape by opening the windows. After each labor in which the hand has been introduced into 282 COMPLICATIONS OF PARTURITION. the uterus, or where air has gained entrance to it, or gaseous decomposition occurred in it, the uterus is washed out with several litres of fresh water. Since almost all the cases of puerperal fever are found to be complicated either with ruptured perineum, small rents in the vagina and vulva, or with the introduction of air into the uterus during some operation, the greatest care is bestowed on all ex- ternal wounds, to which Fehling's mixture of salicylic acid and starch is applied with the best results. Careful examination of th*e external genitals day by day, and the use of the thermometer, are also rigorously attended to. PUERPERAL FEVER. DR. FRITSCH, OF HALLE, In the Sammlung Klinischer Vbrtrdger, No. 107, insists on pro- phylaxis. A bottle of strong carbolic acid solution is always to be carried. Before examination, the hands, washed, are to be disin- fected with the acid and a nail brush. When labor sets in, the woman is to be placed in a hip-bath, well washed with soap, and the vagina syringed and the vulva cleansed with carbolic acid. Repeat if labor is slow, and before and after any operation. Fehl- ing, of Leipzig, has abandoned parturition under carbolic spray, believing that it predisposes to post-partum hemorrhage. The author recommends its use in lying-in-hospitals at all operations when fever is endemic. After delivery in all cases the vagina is to be syringed and the vulva cleansed with the acid twice a day. If fever arise, and where a fcetus is decomposed, intra- uterine injec- tions are used. SEPTICEMIA. S. E. ROBINSON, M. D., WEST UNION, IOWA, Gives (in Med. and Surg. Reporter, 1878) his success in the pro- phylaxis. He learned the plan from Prof. Cleaver, of Keokuk, who directed a copious vaginal injection of carbolized water three or four times a day for several days after delivery. Dr. Robinson has followed this plan for several years, and has failed to see any case of puerperal infection since. WALTER IZARD, M. D., LIBERTY, VA., In the Va. Med. Montldy, Aug., 1878, regards the cause to be the retention and absorption of excrementitious and morbific mat- PUERPERAL FEVER. 283 ter. Hence he strikes at the root by employing, not intra-vaginal washes, but intra-uterine. He employs a double catheter similar to that in common use for washing out the bladder, only with a larger and more gradual curve, and a slight prolongation of two tubular orifices through which the injected fluid makes its en- trance and exit ; the exit tube should be several sizes larger than the other. It may be made of gutta percha or silver ; two pieces of rubber tubing 2]/ 2 to 3 feet long should then be fitted to the tubular orifices ; to that of entrance a large glass funnel should be attached. Everything being prepared, and the patient occupying the dorsal decubitus, with the lower extremities flexed, and the body having been placed near the edge of the bed by assistants, the left index finger, well oiled, should be placed in contact with the external os uteri ; then the catheter, passed along this finger as a guide, should be passed to the fundus uteri — meeting in this condition no resis- tance at the internal os. Then the fluid having been poured into the funnel, it should be raised to the height of two feet above the bed, and the fluid allowed to flow into the uterus, the only force used being hydrostatic pressure. The fluid will be found to return almost immediately through the waste tube, so changed in appear- ance as to leave no doubt as to whether it has come in contact with the internal uterine walls or not. This funnel arragement is the one calculated to accomplish the desired end with the least pos- sible amount of injurious force. By the Davidson's or any other pump-syringe, the fluid is thrown in with such force as almost to render its escape through the Fallopian tubes a certainty. The washing out of the uterine cavity should cause no pain, although slight uneasiness is sometimes complained of by patients during the introduction of the instrument. The fluids used for washing out the uterine cavity have been several — preferably potas- sae permanganate (grs. 7J to one pint of tepid water), or carbolic acid (5j. to the pint of water) and a weak solution of salicylate of soda in glycerin and water. JOSEPH HOLT, M. D., OF NEW ORLEANS. In reviewing the subject, this writer says {New Orleans Medical Journal, Sept. 1876), that the physician's first duty is, to guard every obstetric patient against septic contamination from without, by refraining from attending such cases if we have reason to be- 284 COMPLICATIONS OF PARTURITION. lieve that our hands or clothing are infected ; by the liberal use of disinfectants about the apartment or premises, and even removing the patient if we suspect the unhealthiness of the locality. We are to guard against auto-infection by cleanliness, by the free use of vaginal injections when there is even the slightest pu- tridity of the lochia, by the immediate removal of any remnant of decomposing placenta or coagula, by the avoidance of anything likely to check the lochial discharge, as cold and dampness, and when it is checked, inviting it again by the repeated warm douche. As a disinfecting wash, he earnestly recommends the formula of Dr. I. L. Crawcour, of New Orleans : 269. I£. Acidi carbolici, §j Tincturae iodinii composite, - f-3ss Glycerinse, f.gijss, M. Sig. — A tablespoonful to be stirred into a quart of tepid water, and in- jected high up in the vagina two or three times daily, as the case may require. If infection has already occurred, we are to look to antiseptic remedies as offering the most reasonable hope of success. If pu- erperal fever is septicemia, it is irrational to expect a positive con- trolling influence from opium or calomel, purgatives, emetics, ven- esection, cardiac sedatives, or any other remedy not having the quality of directly disinfecting the blood. There is no doubt but that some of these drugs and expedients are extremely useful in the treatment of this disease, but as a main- stay, experience has taught that none of them are to be relied upon. He has administered, with an apparent speedy amelioration of symptoms, the following formula : 270. 1$.. Acidi carbolici, gtt.xx Sodii sulpho-carbolatis, §ss Glycerinae, f.§j Aquae, f.§v. M. Sig. — Tablespoonful every three hours. The old remedies, approved by experience, are called for when specially indicated ; as in many cases keeping the bowels freely open by mercurial purgatives, the pill of calomel and compound extract of colycynth, subduing excessive heart action with vera- trum viride, blistering when the inflammation localizes itself, and attending to the state of the lochial discharge. In cases where the local inflammation is attended with excruci- PUERPERAL FEVER. 285 ating pain (of such common occurrence), he has been able to con- trol it perfectly by applying over the suffering part a fly-blister, removing the cuticle, and then laying on a plaster composed as follows : 271. ]£. Ex. belladonnas, Ex. opii, aa 5j Adipis, §j. M. For a plaster. The effect of this plaster is so tranquilizing as to do away with the necessity of narcotics given internally. The physician must carefully watch its effect, and remove it for a while if much nar- cotism is induced, protecting the blistered surface in the meantime with an emollient poultice. The strength of it may be increased or diminished according to the effect, and it may be continued as long as there is abdominal tenderness. PROF. CARL RICHTER, M. D., OF BERLIN. The treatment of puerperal disease pursued by this writer [Zeiischrift fur Gyn., 1877,) may be briefly stated as follows: As soon as the lochia became offensive or arrested, or offensive placental debris or coagula were discharged, or the temperature or pulse rose, or any inflammatory reaction in the genital tract ap- peared, or the uterine regions and surroundings became sensi- tive, or the broad ligaments appeared swollen — at once the uterine cavity and vagina were thoroughly washed out, first with a three per cent., then with a two per cent, carbolic solution, two or three times a day; the permanent ice-bladder was applied, preceded, if indicated, by leeches ; and, according to the severity of the symp- toms, first salicylate of soda in doses of gr.xv-xxx several times a day. The ice was continued so long as sensitiveness remained ; the irrigations and soda salicylate, until pulse and temperature were reduced to the normal. It should be mentioned that a combination of sulphate of quinia (gr.viij), with soda salicylate (gr.xv-xxx), could be relied upon with tolerable certainty, although but temporarily, to reduce the high temperature, without causing salicylic intoxication; a ten per cent, solution of carbolic acid was very useful as a local applica- tion to wounds of the parts. 286 COMPLICATIONS OF PARTURITION. PUERPERAL SEPTICEMIA. W. H. PARISH, M. D., PHILADELPHIA, In a paper read before the Philadelphia Co. Med. Soc, being a clinical study of the cases at the Philadelphia Hospital, concludes as follows : Puerperal fever and puerperal septicemia, are dependent upon one and the same poison, and this poison originates in a great va- riety of forms of decomposing organic material. The source of the poison may be within the woman herself, or it may have its origin in sources external to her. Puerperal fever or puerperal septicemia may be conveyed from one puerperal patient to another. If a lying-in patient is suffering with traumatic inflammation, she is thereby rendered more liable to internal infection. The poison develops with great rapidity in a lying-in patient, suffering with traumatic inflammation, and from her it may be transferred to other lying-in patients, and in them it may produce septicemia or puerperal fever, though the original patient may herself have escaped infection. In a patient suffering with auto-genetic infection, the symptoms vary greatly, according to the absence or presence and degree of traumatism, and according to the special mode of the internal in- fection. The symptoms in patients suffering from external infection are more uniform in their manifestations, as are also the pelvic and abdominal lesions. The treatment of cases of internal infection must vary greatly for the same reasons that the symptoms vary. In cases of external infection, the treatment is more uniform,- and should consist, as a rule, of local abstraction of blood by leeches, 16 to 20 f.§, of warm, moist applications, of warm, dis- infecting vaginal or intra-uterine injections, of quinia in full doses, of morphia as a calmative, of a mild diuretic, of stimulants accord- ing to depression, of moderate constipation after an enema, and of liquid and highly nutritious diet. The prophylaxis is of, however, paramount importance, and should consist of measures that will prevent the formation of septic material within the woman, and that will prevent the con- veyance of septic material to her person from external sources. PUERPERAL FEVER. 287 RESUME OF REMEDIES. Acetum. As a germ destroyer and disinfectant, Dr. Alexander Simpson, of Edinburgh, calls attention to common vinegar, which on many occasions he has found extremely efficacious {Trans, In- ternat. Med. Congress, 1876). Aconitum. Phillips is very positive as to the good effects of aconite in drop doses every hour or two day and night. If employed im- mediately after signs occur, it will be most beneficial. Alcohol in strong solution has been used by French practitioners. Arnica is used by Dr. Miller. Calcii Chloridum in weak solution is available. Carbolicum Acidum is the most widely used of the antiseptic agents. Chloral Hydras. Dr. J. A. Larrabee, of Louisville, has found a solution of chloral of mild strength, gr.x to f.ij, much more efficacious in checking an epidemic of puerperal fever than carbolic acid or anything else {Half Yearly Compendium, July, 1878). He states that in all labors there is an odor to the lochia, plainly discernible at the end of the first twenty-four hours. If this condition remains uncorrected, and the nurse neglects to attend to her duties, there is great danger 6f septic poisoning. A so- lution of chloral of mild strength, in water, and by means of the douche or fountain syringe, removes at once not only the odor, but destroys the noxious influence of such poison. Carbolic acid, although it has been much lauded, is, in his judgment, entirely unreliable, and merely substitutes its own odor for that of the disease. Ferri Subsulphas is an antiseptic agent of value, as well as a hemostatic. Dr. H. P. C. Wilson, of Baltimore, recommends that it be com- bined with glycerine when used in the uterine cavity. Iodinium. Dr. E. J. Tilt believes that tincture of iodine is the best dis- infectant for uterine injections. He uses as an injection after labor, four drachms of the tincture in half a pint of tepid water. He speaks very highly of the results of the practice of Dr. Dupierris, of Cuba, who had great success in preventing and curing puerperal fever by injecting into the womb, immediately after removing the placenta, the following : 272, fy.. Tincturae iodinii, f.5iv Potassii iodidi, gr.x Aquas destillatae, £§j. M. For one intra-uterine injection. Opium and Morphia. Enormous doses of these preparations can be taken with advantage in puerperal fever. Dr J. P. White, of Buffalo, says he has given as much as one grain of morphia every hour for forty-eight consecutive hours, with success. 'Dr. E. H. Trenholme, of Montreal, gives from one gra*in to a grain and a third hourly, and has never lost a case. {Trans. Internal. Med. Congress, 18 J 6.) 288 COMPLICATIONS OF PARTURITION. Fotassii Permanganas in weak solution answers very well as an antiseptic wash. One objection to it is, that it stains the bedding, etc. Where soreness and tenderness of the vagina after labor are complained of, Dr. P. J. Murphy, of the Columbus Hospital for Women, Washington, uses : 273. fy. Potassii permanganatis, 9j Potassii chloratis, 5iv Aquae, Oij. M. A teacupful to be added to a quart of warm water, and used as a vaginal injection night and morning. Dr. Bartholow states that internally it has been given with advantage, gr. %-j, in water, three times a day. Quinice Sulphas, especially in the form of "Warburg's tincture" has lately been asserted to be a very valuable remedy in puerperal septicemia. Cases are given by Dr. A. Baird, Edinburgh, Med. Jour., Aug., 1879. Bartholow speaks of the undoubted good effects of quinia in doses of gr.v-xx, every four hours. Salicylicum Acidum has been used both locally and internally. Sodii Benzoas has been introduced comparatively recently by Prof. Klebs, of Prague. It is said to be useful in every kind of septic injection. The dose is 3ij-iv in solution, repeated as needed. A few cases have been reported in which its adminis- tration seemed to do good, but they have not been sufficiently numerous to be decisive as to its merits. Sodii Salicylas, as more agreeable than the acid, should be preferred for internal use. Sulphur o sum Acidum, for injection and irrigation, has been advocated. Terebinthinaz Oleum is said, by Bartholow, to have decided clinical experience in its favor. Thymol has been employed as an antiseptic by Dr. Miller. Veratrum Viride has its defenders as a valuable means to control arterial action. But the present tendency is to distrust this drug. general measures. Blisters are often of great service. Purgatives have been long used in the treatment of this condition. Venesection is less used than formerly. As the disease is one of an asthenic character, the cases in which loss of blood is desirable must be very rare and exceptional in number. PUERPERAL THROMBOSIS AND EMBOLISM. PROF. W. S. PLAYFAIR, M. D., LONDON. When there are evidences of pulmonary obstructions generally, the fatal results follow so speedily that no time is given to do any- thing. Keep the patient alive by stimulants, brandy, ether, ammo- nia. Possibly leeches or dry cups to the chest might aid in reliev- ing the circulation. Enjoin the most absolute and complete repose, with the hope that the vital functions may be continued until the coagulum is absorbed or lessened, so as to permit the passage of the blood. Death often follows the most trivial exertion, such as rising out of bed. Feed the patient with abundant fluid food, milk, strong soups, and the like. Richardson suggested ammonia. He has since advised liquor ammonia in large doses, 20 minims every hour, in the hope of caus- ing solution of the deposited fibrine, and says he has seen good results of it. Others urge the use of alkalies to favor absorption. The best that can be said of them, is that they are likely to do much harm. Where there is evidence of obstruction in a limb or other point, nothing can be done. Rest absolute, generous diet, and sedatives for pain, is all. In case of gangrene of an extremity, amputation above the line of demarcation may save the life of the patient. THROMBUS. PROF. F. WINCKEL, M. D., ROSTOCK. If the vagina be the location, plug with cotton wool or with a colpeurynter filled with ice-water. Cold to the tumor if in the labia, and ice, digitalis and opium internally, the latter to allay ex- citement and pain. W 7 hen it ceases to enlarge, use absorbents. Do not open unless a special indication to that effect exists. Em- ploy ice compresses, cloths soaked in warm lead water and opium, 4 drachms tinctura opii to one pound of lead water, infusion of chamomile flowers, arnica, etc. If the tumor does not decrease, the pain is intense, and the skin gets darker, open, turn out the clots, and if the bleeding continues, fill the cavity with charpie soaked in solution of tannin, or, better, a 3 per cent, solution of carbolate of soda; lay a compress over it, 19 (289) 290 COMPLICATIONS OF PARTURITION. and secure with a T bandage. It is best to wait if possible until the hemorrhage has ceased before opening the tumor. General indications will be to support the system, and give quinine and acids. Vaginal thrombus usually arises immediately during or after child-birth, and is formed in the loose tissue between the vagina and rectum, whence, however, it sometimes extends to the gluteal regions, and even to the thighs and psoas muscles. The treatment as recommended by Dr. Kucker ( Wiener Medical Wochenschrift, No. 52, 1878), consists in the prompt application of cold, as ice and ice water, and compression. As soon as the thrombus ceases to extend, poultices are indicated. PROF. FORDYCE BARKER, M. D., NEW YORK. If the thrombal tumor be not so large as to cause great pain by its pressure on the adjacent tissues, or to interfere materially with the delivery, or if laceration and escape of blood almost immedi- ately follow the development of the tumor, apply the forceps and deliver at once. Arrest the flow of blood which usually occurs at the moment of the delivery of the head, with compresses of cotton batting saturated with a solution of the subsulphate of iron. As soon as this hemorrhage is controlled, deliver the placenta. He opposes the use of the tampon on the ground that it retains the lochial discharge, and exposes the patient to septic poisoning. To the laceration he applies a lotion of carbolic acid and glycer- ine, not only as an antiseptic, but as a means of protecting the parts from excoriation by the irritating discharges of the urine and the lochia. Avoid disturbing the coagulum formed by the subsulphate of iron, so as to avoid secondary hemorrhage. As a precaution against this accident, the bladder should be evacuated for several days by a catheter. When the tumor has attained such a size as to offer a mechanical obstacle to delivery, incise at once, remove all clots that have been formed, and then deliver by the forceps. The longer the incision is postponed, the greater will be the amount of extravasa- tion, the greater the distension of the parts, and the more extensive the laceration of the areolar tissue. If the laceration does not appear until after delivery, incision should not be made so long as the tumor is increasing in size. He advises that the physician should wait until after the coagulum is formed, which arrests the hemorrhage by pressure on the lacer- ated vessels. PUERPERAL SHOCK. PROF. WM. LEISHMAN, M. D., GLASGOW. Shock to the nervous system by a tedious or severe labor may prove fatal, without hemorrhage or organic injury. As Travers observes, pain of itself is destructive. This author believes it must be the pain of the second stage. The treatment is the union of an anodyne with stimulants ; wine and brandy freely, till reaction is obtained, and then substituted by chicken broth. Meantime, give 274. IJl. Mist, camphoras, f.^vj Ammon. carb., 3U Tr. opii, gtt.lx. M. Dose. — Tablespoonful every one, two, or three hours. With this, she must be perfectly quiet, the room darkened, and the patient allowed to sleep as long as she can. It is with the view to avoid the shock, the exhaustion of the second stage of labor, that the editor would urge the use of chloral, until the delivery can be accomplished by the employment of the forceps. The best treatment will be to prevent shock by avoiding its causes. It would appear that chloral, even while producing a calm, re- freshing sleep, does not by any means check the progress of labor when this has commenced. For it is invariably found that dilata- tion has continued, and generally so readily is this accomplished, that a speedy delivery often follows its use. The editor regards this remedy as producing results similar to those of snaesthetics in surgery, and therefore similarly indicated. Again, while it re- lieves the pains of travail, it thus greatly contributes to a safe and speedy convalescence. It prevents the terrible exhaustion and shock to the system too often seen to follow an unaided labor.* * On the prevention of shock by the early use of the forceps, see also that subject in " Hints in the Obstetric Procedure." (291) PELVIC CELLULITIS AND PERITONITIS (PUERPERAL PHLEBITIS AND METRITIS). T. G. THOMAS, M. D., NEW YORK, Has tabulated the points of differential diagnosis between pelvic cellulitis and peritonitis as follows : 10. 1 1. 12. Cellulitis. Tumor easily reached ; general- ly felt in one broad ligament; may be felt above the pelvic brim. Marked tendency to suppura- tion. Abdominal tenderness in one iliac fossa. Tumefaction laterally in the pelvis. Tendency to monthly relapse not marked. Pain severe and steady. Facies not much altered. Nausea and vomiting not exces- sive. Not accompanied by tympani- tes. Uterus fixed to a limited extent. Not necessarily displaced. Cause. Parturition, abortions, operations on the pelvic viscera. Peritonitis . Board-like feel to the vaginal roof. Tumor very high, only felt in the vaginal cul de sac ; does not ex- tend above the superior strait. Suppuration rare. Abdominal tenderness excessive above the brim. Tumefaction near or upon the me- dian line. Tendency to monthly relapse very marked. Pain excessive, often paroxysmal. Very anxious. Nausea and vomiting often exces- sive. Always accompanied by tympanites. Uterus immovable on all sides. Always displaced. Diseases of the ovaries, gonorrhea, exposure during menstruation, fluid in the peritoneum. PROF. WM. GOODELL, M. D. PHILADELPHIA.. In Pldladelphia Medical Times, Feb. 2., gives the following advice as to treatment : The disease having been recognized, administer at once a full hypodermic dose of morphia, and from ten to twenty grains of quinia by the mouth. These measures, taken promptly, will often stop the disease at once. Failing to abort the attack, we must paint the abdomen with (292) PELVIC CELLULITIS AND PERITONITIS. 293 iodine and put on a poultice, covering it with oiled silk, or greased brown paper ; it will then remain soft for twenty-four hours. The patient must have large doses of quinia. If the temperature be high she should have ten grains at a time, and from thirty to forty grains in the course of the day. Large doses of morphia must also be given. If the woman be plethoric, the morphia may be given by the mouth, with neutral mixture and wine of ipecacuanha, or in some other fever mixture. In some cases tonics are demanded. If the sickness last for more than a week, and the local tenderness increase, put on a blister promptly. Later, muriate of ammonia is an excellent remedy in this disease ; so, too, is aconite. Dr. Goodell usually prescribes the following : 275. ^. Mist, glycyrrhizas comp., f-Syj Ammonise muriatis, 5>j Hydrarg. chloridi corrosivi, gr.j Tinct. aconiti radicis, gtt.xxiv. M. A tablespoonful in water every six hours. As concerns routine treatment, the patient should take plenty of milk, whisky, beef-tea, and large doses daily of dialyzed iron. PROF. W. S. PLAYFAIR, M. D., LONDON. The important points are relief of pain, and absolute rest. If seen at an early stage, blood taken locally by leeches to the groin or to the hemorrhoidal veins may give relief. Leeches to the uterus are likely to cause harm by the irritation of passing the speculum. Opiates in large doses, or by suppositories, or subcu- taneously, are the best when the pain is at all severe. When par- oxysmal, use suppositories immediately the pain threatens. When there is much pyrexia, give large doses of quinine. Keep the bowels free ; nothing answers so well as castor oil, yb a teaspoonful every morning. Warmth and moisture to the abdomen give great relief in the form of linseed meal poultices, or if these are too heavy, use spongeo-piline soaked in boiling water. Poultices may be sprinkled with laudanum or belladonna liniment. Absolute rest in the recumbent position must be enforced for some time after the symptoms abate. Then absorption may be favored by the long- continued use daily of tincture of iodine until the skin peels, or by frequently repeated blisters. This is betTer than keeping an open sore by irritants. When an abscess has formed and points in the groin, make a free incision, and employ antiseptics. Wait 294 COMPLICATIONS OF PARTURITION. till the pus is near the surface. In these operations, the aspirator is a valuable instrument. Diet should be abundant, simple and nutritious. Make up for the drain caused by suppuration. Tonics, iron, quinine, and cod- liver oil, will be useful. PROF. FORDYCE BARKER, M. D., NEW YORK. In this disease this author directs absolute quiet in bed, and re- gards the danger of relapse as imminent if the patient gets up or moves much. If there be much pain in micturition, and the blad- der be not thus entirely emptied, a catheter should be used. He believes that the bowels should be kept free from fecal evacuations by teaspoonful to tablespoonful doses of the compound magnesia powder, or the compound licorice powder, of the German pharma- copoeia. If the pain be very acute in the commencement of the attack he usually wmvhelms it by one hypodermic injection of morphia, and relies afterwards upon opium suppositories. The lower portion of the abdomen should be kept covered by hot poul- tices of ground flaxseed, over which should be placed oiled silk, so that the poultice may retain its warmth for some hours. After the acute stage has passed away, cotton wool wet with laudanum and also covered with oiled silk may be substituted for the poultices. For some years he has discarded cups, leeches, and local depletion. In the cases which assume a subacute or chronic form, he has witnessed much benefit from injections of water into the vagina as hot as can be comfortably tolerated. In the employment of these injections, the patient should lie across the bed, with the hips well over its edge and the feet upon two chairs. An India-rubber sheet should be placed well under her, between her hips and her cloth- ing, not only to prevent the latter from getting wet, but also to conduct the water, as it flows back from the vagina, down to a ves- sel which is placed on the floor. Then by the use of a Davidson syringe, two or three gallons of hot water may be injected into the vagina by the nurse. A still more easy method is to have a pail with a stop-cock at the bottom, which connects with a long India-rubber tube, having a vaginal pipe at the end. This pail is placed on an elevation of a few inches above the patient, and the water is allowed to run in and out of the vagina. Not only do the patients generally derive great comfort from this warm poul- ticing, but if the physician immediately after makes a vaginal ex- PELVIC CELLULITIS AND PERITONITIS. 295 amination, he will need no argument to convince him what a powerful agent this is in modifying tissue. He employs quinine at an early period of this disease, giving it in as full doses as the patient can bear without inconvenience. If symptoms of suppuration, cachexia and hectic fever, come on, he relies 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, Prof. B. directs that it be aspirated. He con- siders this a safe procedure — that it gives immediate relief to pain, that it shortens the duration of the disease, and is a prophy- lactic measure against disorganization of adjacent tissues. Puerperal metritis. If he finds the patient with pain in the hypo- gastrium, and the uterus larger than it should be at the time of the puerperal period and painful on pressure, the lochia diminished in a marked degree, or perhaps wholly arrested ; or, on the other hand, a return or positive increase in the amount of blood lost in the discharge, with a quick pulse, and more or less fever, he at once gives the following powder well mixed in a wineglass of sugar and water : 276. I£. Tully's powder, Potass, bicarb., aa gr.x Hydrarg. chlorid. mite, gr.v. M. If the skin be very hot and dry, and the pulse very hard, he may substitute the following : 277. IJl. Pulv. potass, nitrat., . gr.x Pulv. gum camphor, Hydrarg. chloridi mitis, aa gr.v Pulv. Jacobi veri, gr.iij Pulv. opii, gr.j Vel. morphise sulp., g r -X* M. He anticipates the following effect from these powders : The pain will be relieved; nervous irritation allayed; sleep induced; fever subdued ; diaphoresis promoted ; and eight or ten hours after, an easy revulsive cathartic action will follow. If cathartic action do not follow in ten hours, he orders a saline cathartic. He also directs that turpentine stupes be applied over the uterus and kept on until the patient insists 'on their removal, when cotton batting should be laid over the uterus, and this should be covered 296 COMPLICATIONS OF PARTURITION. with oiled silk. If the patient complains of severe pain or burning from the turpentine, the cotton may be wet with laudanum. If the disease be of a sthenic type, he has derived great benefit from the application of six or eight wet cups over the uterus, but repudiates the use of leeches as very objectionable. If after two or three days there be not evident decrease in the uterine tumor, applies a blister over the uterus. In cases in which the uterus does not undergo the usual involution, while the lochial discharge is profuse and sanguineous, he has derived advantage from the following combi- nation : 278. ty. Ext. ergot, fid., Tinct. nucis vomicae, Tinct. ferri chloridi, aa foss Glycerine, Syrup aurant. cort, aa f.fj. M. Sig. — Teaspoonful in a wineglassful of sugar and water every fourth hour. This usually reduces the size of the uterus, and diminishes the hemorrhagic lochia within twenty-four hours. He also regards vaginal injections as absolutely essential throughout the whole treatment of puerperal metritis. Formerly he used Labarraque's solution of the chlorinated sodium in warm water, as strong as the patient can bear without smarting ; recently he has employed the following : 279. ^. Acid carbolic, glacial, Glycerine, aa f.§j Aquse purse, f-§vij. M. Sig. — A tablespoonful in a tumbler of warm water. If the lochial discharge be very purulent, and particularly if the odor be offensive, the injections should be used four, five, or six times a day. If the discharges be positively fetid, this author advises intra-uterine injections; and that intra-uterine injections be given with either a Scanzoni or French irrigator, or a fountain syringe, because we can thus adjust the force with which the fluid enters the uterine cavity. He believes that the fatal results which have ensued in the employment of intra-uterine injections, have accrued from their improper application. The danger seems to arise from the entrance of air into a vein, as in some cases, in which death has been sudden, or from the passage of fluid into the Fallo- pian tubes, and peritonitis or phlebitis has ensued. In the suppurative and putrescent stages of puerperal metritis, our main reliance in connection with the intra-uterine injections PELVIC CELLULITIS AND PERITONITIS. 297 must be on alcohol and quinine. He prefers giving the quinine in doses from five to ten grains twice a day, instead of the smaller doses frequently repeated. The whiskey or brandy should be administered as freely as the patient can take it without any unpleasant effects. Puerperal Peritonitis. For this disease this author regards opium as the great remedy ; that it retards or arrests the peristaltic move- ments of the bowels, gives the inflamed parts absolute rest, pain is relieved, nervous system tranquillized, sleep secured, and thus the depression of the vital forces, resulting from the shock of the attack, is lessened. The opiate, therefore, should be given in such doses as to secure all these. The amount is only limited by the effect produced. It should be given freely until some narcotism is produced, and the respirations diminished in number, but it should not be pushed beyond this point. If the respirations fall below twelve or fifteen, and the pupil be much contracted, the opiate should be withheld until these effects pass by. This line of treat- ment should be pursued until the inflammation is completely ex- tinguished. Our author directs that we begin treatment by giving ten drops of Magendie's solution every hour, and gradually increasing the dose if the effects sought be not manifested. If the drops be rejected by the stomach, administer morphia hypodermically until the stomach will tolerate it. In some cases the tolerance of opium is remarkable. One case took 106 grains of opium and its equiv- alent in morphia during the first twenty-six hours, and in the second twenty-four hours 472 grains of opium. Prof. B places also a high estimate on veratrum viride in al- laying vascular excitement. In conjunction with morphia, it re- duces the number of pulsations without reducing the strength or increasing the degree of vital depression. For the pain in the abdomen and the tympanites, he applies the oil of turpentine on two thicknesses of flannel, previously dipped in hot water and wrung out as dry as possible; this to be left on as long as the patient can be induced to bear it. On taking off the flannel the abdomen should be covered with a light layer of cotton wool, at least an inch or two in thickness and wet with laudanum. The turpentine stupes should be reapplied once or twice a day, if the abdomen show a tendency to again become distended and painful, and the cotton batting with the laudanum should be reap- 298 COMPLICATIONS OF PARTURITION. plied every few hours. In cases in which the symptoms of perito- nitis have in a great measure subsided by apparent localiza- tion and induration, almost forming a circumscribed tumor, our author has witnessed much benefit follow the application of a blister. He directs that it be applied 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 blister is well filled with serous exudation, there is very little pain or soreness, and all danger of strangury is averted. In all cases in which the peritonitis is a complication of puer- peral fever, he has found quinine an efficient remedy, especially in cases in which the chills are recurrent, or when there are symp- toms indicating a tendency to purulent exudation. He prefers giving it in one or two impressive doses during the day to the small and frequently repeated doses — that is, give about five to ten grains in the morning and from ten to twenty in the evening. There is a decided tolerance to quinine in this disease. He also values alcohol in this disease. It renews the nervous forces, which are generally in a state of extreme prostration, probably by the cerebral hyperemia induced by the alcohol. In this, as in other diseases with great depression, patients are able to bear four, five, or even ten times the quantity that could be taken in health, without the least approach to intoxication. It diminishes waste, and thus tends to cause a diseased structure, in which vital changes are abnormally active, to return to its normal and much less active condition. With the whiskey or brandy he combines veratrum viride if there be considerable vascular excitement. This combina- tion often reduces the pulse when either of these agents individu- ally fail. He also recommends the following vaginal injection: 280. fy. Glycerin, Acid, carbolic, glacial, aa f.Jj Aquae purse, f-l v j- M. Sig. — A tablespoonful added to half a pint of warm water, and care- fully injected into the vagina twice a day. If the lochia be very abundant and fetid, the amount of carbolic acid may be doubled or even quadrupled. The food should consist of beef tea, panada, caudle, milk, and lime water. Our author has no confidence in the aplastic properties of mer- PELVIC CELLULITIS AND PERITONITIS. 299 cury ; yet in cases in which there is vomiting of bilious matter he gives ten grains of calomel well rubbed up with twenty grains of bicarbonate of sodium. Although generally averse to venesection in this disease, he believes it is strongly indicated in some of the more sthenic cases, and employed with good results. Stimulants should be given so soon as feebleness of the pulse, clamminess of the surface, profuse perspirations, or cold extremi- ties, are noticed. Stimulants decrease the frequency and increase the force of the pulse. Another important point, is nutrition. Food in a liquid form should be taken as freely as it can be digested and assimilated. Milk, eggs, gruels, beef-tea, mutton broth, chicken soup, given every two or three hours, are useful. Purgatives, as a rule, are not desirable. Sometimes, however, when the tongue has a thick pasty coat, and there is a great deal of bilious vomiting, he gives a powder composed of from five to ten grains of calomel, and twenty grains of the bicarbonate of sodium. PROF. F. WINCKEL, M. D., ROSTOCK. Puerperal Metritis. He advises in this disease the horizontal posture ; avoidance of all needless movements, and the use of enemata. When the abdominal pain is great, leeches may be applied to the abdominal wall ; but a speedier effect is obtained by ice water, compresses, and the ice-bag. When this can be dis- pensed with, inunction with fifteen grains of mercurial ointment should be made every two hours until salivation occurs, or with iodide of potassium ointment, together with warm compresses. If the discharge is offensive, inject with tar-water or permanganate of potassa, and with mucilaginous fluids. Promote absorption in every way, if there is effusion. If there is pus, evacuate speedily. When the fever subsides, give diuretics and iodide of potassium, five grains three times a day. PROF. WM. LEISHMAN, M. D., GLASGOW, The most important point is to relieve pain. When above the pelvic brim, poultices and fomentations with laudanum are most grateful. When vaginal, the douche, or medicated pessaries, may be used. Bernutz strongly urges the use of coniiim internally. The bowels are to be kept free, and the comfort of the patient is 300 COMPLICATIONS OF PARTURITION. greatly aided by an injection of soap and water, to which turpen- tine may be added, given every night. Leeches to the locality may prevent suppuration. Bernutz insists that they should be applied directly to the uterus. Apply three at a time, and, if necessary, encourage the flow by a warm hip-bath. In addition to the remedies already mentioned by others, when not contra-indicated, use the perchloride of mercury, tV of a grain, until faint mercurialization occurs. Iodide of potassium, or the tincture of iodine, may be used with little hesitation. Blisters may be used, but iodine is preferable, used externally, so as to continue its effects within moderate bounds for a long period. RESUME OF REMEDIES. Aconite is recommended by many (F. 275). Bartholow combines it with opium. 281. R:. Tinct. aconiti rad., f.Sij Tinct. opii deod., f.3yj. M. Dose. — Eight drops in water every hour or two. This in peritonitis. Acidum Carbolicum in vaginal injections. (F. 279, 280.) *Ammonii Murias is believed by many to act powerfully as a sorbefa- cient. Canifthora, in combination with nitrate of potassa and opium, is used by a number of practitioners. (F. 277.) Conium is urged by Bermetz (p. 299). * Hydrargyrum, either by the mouth or by inunction, is generally em- ployed. *Iodinium. This remedy is highly useful, externally applied to the ab- domen. ^Morphia. In full doses, and combined with quinia, is regarded by many practitioners as the best means of treatment. (See p. 292). Bartholow says that the hypodermic injection of morphia will sometimes jugulate peritonitis, if given at the outset. If the period for such a favorable result has passed, the course and duration can be greatly modified by opium judiciously used. The quantity will be determined by the effect ; the pain should be relieved, the pupils somewhat contracted. *Potassii Iodidum, is very useful to aid in the absorption of effusions. Potassii Nitras is useful when the skin is hot and dry, and the pulse hard. (F. 277.) * Quinia must be given in large doses, and continued. Terebinthince Oleum, in the form of stupes, during the acute stage, is rec- ommended by Bartholow and others. Veratrum Viride, either alone or combined with morphia, to allay vascular excitement. PELVIC CELLULITIS AND PERITONITIS. 3OI OTHER MEASURES. Blisters favor absorption, and should be frequently repeated. Cold, in peritonitis, is recommended in the form of the ice bag by Winckel and Bartholow. The latter says when the inflam- mation is recent, the abdomen may be covered with an ice bag. It is proper to interpose a napkin between the skin and the bag. Injections of hot water are highly lauded, especially by Prof. Barker. They act like local poultices, and certainly are capable of great good. Vaginal injections of carbolic acid, permanganate of potassa, and chlorinated sodium, are also extremely valuable as disinfec- tants and antiseptics. Leeches applied to the groin or to the hemorrhoidal veins may be em- ployed. Never to the uterus. Barker discards them entirely. Poultices are very comforting by their warmth and moisture. These may be greatly aided by the addition of laudanum, belladpnna, etc. Rest. This must be absolute, and not departed from until all danger of a relapse has disappeared. PHLEGMASIA DOLENS. PROF. FORDYCE BARKER, M. D., NEW YORK. The disease tends to a spontaneous recovery, and generally dis- appears without serious consequences. Hence any treatment which disturbs the system or the normal functions, is objectionable. The indications are : 1. To allay the irritation of the nervous system, which can best be done by full doses of opium where there is no idiosyncrasy to prevent its use. 2. To support the system by nutritious food, stimulants and tonics. Of the last mentioned, quinine and iron hold the first place. Only in cases where special indications exist should catharsis be induced, or cups be applied over the kidneys. In nearly all cases there is no occasion whatever for these. After the first two or three days, the disease becomes mostly local. The patient should keep quiet, the limbs be elevated at an angle above the trunk by raising the lower part of the mattress, and where there is hyperesthesia of the surface and pain in the deep-seated nerves, much relief will be obtained by gently rubbing the surface with a liniment like the following : 282. I£. Linimenti saponis co., f.-jvj Tincrurae opii, f.§iss Tinct. aconiti radicis, f.^ss. Extracti belladonna?, §ss. M. For a liniment. The rubbing with this should be gentle and continued for fif- teen or twenty minutes, and ahvays tozvard the trunk. This may be repeated every six hours, after which the leg should be envel- oped in cotton batting and covered with raw silk. After the period of acute tension, the leg should be examined for localized phlegmon, and if any circumscribed collection of pus be discovered, it should be evacuated at once ; otherwise the ton- icity of the tissues will best be promoted by applying a roller bandage, beginning at the toes and carrying it up the whole length of the limb. This should be worn so long as there is any ten- dency to oedema of the foot and leg. The patient should not be (3° 2 ) PHLEGMASIA DOLENS. 3O3 permitted to walk until all evidence of local disease has disap- peared. PROF. W. S. PLAYFAIR, M. D., LONDON, Agrees in the main with the treatment above recommended. For the relief of the pain, he has found one of the best measures to be wrapping the entire limb in linseed meal poultices, or in warm flannel stupes, the surface of which may be freely sprinkled with laudanum, chloroform, or belladonna liniment. Blisters, leeches, or any form of counter-irritation or abstraction of blood, he does not approve of. Internally he thinks chlorate of potassa, with dilute hydro- chloric acid, quinine, ammonia, and iron, are the drugs most likely to prove of service. As an anodyne, generally nothing answers so well as the hypodermic injection of morphia. At a later stage, support with a roller may be combined with gentle inunctions of weak iodine ointment. And shampooing or rough friction of the limb should be avoided, on account of the danger of producing embolism. The occasional use of the elec- tric current is said to promote absorption. PROF. F. WINCKEL, M. D., ROSTOCK. The leg must be raised a little higher than the thigh, and the knee flexed ; the foot and calf supported by pillows to prevent the rotation outward ; apply compresses of lead- water ; rub over the skin about Poupart's ligament a piece of unguent, hydrarg. the size of a bean, three times a day. If the pain is acute add lauda- num to the lead-water. Open any vesicles that may form, and evacuate the serum. When the pain and swelling subsides, paint with tinct. iodine or Lugol's solution, and cover with wet com- presses ; bandage the leg to produce reduction. Bcer claims good results from a blister the width of two fingers around the thigh just above the knee. A proper support of the limb will be required when the patient leaves the bed. MILK FEVER. This affection, formerly so much dreaded, and believed so fre- quently to occur on the third day, on the occasion of the appear- ance of the milk, is now reasonably regarded as virtually a myth. In many instances, a slight increase of heat, pulse, etc., occurring at the time when the secretion of the milk commences, is regarded as a true form of fever, and treated with so much energy as fre- quently to induce a real disorder more or less serious. The best authorities now agree that the better regimen allowed to the lying-in woman, and the more sensible mode of conducting labor which at present has become the practice, prevents many of these abnormal tendencies. Playfair, Winckel, Grunewall, D'Espine, and others, agree in this belief, or regard the fever as a mild septicemia. Grailly Hewitt believes that it only occurs where the patient is weakened either by a prolonged and exhausting labor, from hemorrhage, or from insufficient nourishment. PROF. FORDYCE BARKER, M. D., NEW YORK, Regards it as an exceptional incident of child-bed, and gives the following prophylactic measures : Secure to the patient some hours of sound and refreshing sleep immediately after delivery. Give such food as will be abundantly nutritious, without over- taxing the digestive organs. Apply the child to the breast as soon as the patient has recov- ered from the exhaustion of labor. When the symptoms of milk fever present themselves, if the bowels have not been fully moved, give a saline laxative; subdue vascular excitement and promote diaphoresis. The following is very effective : 283. ty.. Tinct. aconit. rad., gtt.xx Antimonii et potassas tartratis, gr.ij Spirit, etheris nitrici, Syrupi simplicis, aa f.gj Aqme aurantii flor., f.gij. M. A teaspoonful in a wineglassful of sugar and water every two hours. Have the nurse gently but thoroughly rub the breasts from the (3°4) MILK FEVER. 305 circumference toward the nipple with warm sweet oil every two hours till the distention has subsided, allay pain and nervous irri- tability, and secure sleep by a diaphoretic anodyne, as eight to ten grains of compound ipecac, powder or of Tully's powder. PROF. KARL SCHROEDER, ERLANGEN, AND PROF. W. LEISHMAN, M. D., GLASGOW, Agree that the milk fever is due to the distention of the breasts, and regardless of the amount of fever, these organs demand prompt attention, as by keeping them soft, frequently emptying them, ap- plying evaporating lotions, relieving the dragging, etc., by sus- pending the inflamed gland ; in short, by removing the cause, the fever itself is removed. 20 PUERPERAL CONVALESCENCE. PROF. FORDYCE BARKER, M. D., NEW YORK. During this period, the chief indications are : First, the restora- tion of the pelvic organs to their normal condition, and the devel- opment of lactation. The accomplishment of the first in the multiparas is usually attended with uterine contractions of an inter- mittent character. Our author thinks much can be accomplished by way of preventing their occurrence ; that they are usually the result of coagula in the cavity of the uterus which distend its walls, and excite spasmodic contractions. The retention of these may be obviated by firm pressure over the fundus during the time the trunk of the foetus is being expelled, and maintained until the placenta is delivered, and a permanent contraction of the uterus is •secured. If the second stage is too rapid, or too prolonged, he gives a teaspoonful of the fluid extract of ergot, just as the delivery of the child is taking place. If the after-pains come on a few hours after the delivery, the first pressure should be renewed so as to expel coagula. It often gives relief. At a late period this must not be attempted, for fear that it may excite irritation and inflam- mation. He then relies on the following formula, known as Tully's Powder : 284. B. Pulv. g. camphor, Cretse pp., Pulv. glychrrh., aa 9j Morphias sulph., gr.j. M. Dose. — The same as Dover's powder. The severe after-pains sometimes occurring a day or two after labor, and excited by the pressure of flatus, must not be con- founded with peritonitis. This diagnosis is easily made; while a slight touch causes pain, the pain entirely disappears upon contin- ued pressure; it returns as soon as the pressure is removed. On the other hand, the pain due to peritonitis will be increased in ratio to the pressure made. After-pains due to flatus are most speedily relieved by turpentine stupes and turpentine enemata. Sometimes after-pains of a purely neuralgic character are encountered. They do not yield to opium in its fullest doses, but are relieved by qui- nine and chloroform liniment. He gives the quinine in doses from (3°6) PUERPERAL CONVALESCENCE. 307 five to ten grains, night and morning, and applies the liniment by saturating a piece of flannel of double thickness. The formula for the liniment is 285. I£. Chloroformi, f . 5 j Liniment, saponis co., f-§vj. M. RETARDED INVOLUTION. If the uterus can be felt above the pubes a few days after partur- ition, our author prescribes the following : 286. ]£. Ext. ergot, fluid., Tinct. nucis vomicae, Tinct. ferri chloridi, Tinct. cinnamom cort., aa f.^j. M. Sig. — Teaspoonful in a wineglassful of sugar and water, four times a day. LAXATIVES FOR PUERPERAL WOMEN.] PROF. DR. FORDYCE BARKER, M. D., NEW YORK. Our author opposes the indiscriminate dose of castor-oil, and very truthfully states that it often excites hemorrhoids. He highly recommends the following pills : 287. Iju Ext. colocynth co., 9j Ext. hyoscyami, gr.xv Pulv. aloes soc, gr.x Ext. nucis vomicae, gr.v Podophyllin, Pulv. ipecacuanhas, aa gr.j. M. Ft. — Pil. no. xii. Two of these usually secure the desired evacuation of the bowels. One of these may be taken daily to keep the intestinal canal free from fecal accumulations. When there are flatulence and severe after-pains in consequence of constipation, he recommends the following : 288. ]£. Ext. sennae fluid., Syrup, zinziberis, aa f.3yj Tinct. jalap, f.^ss Tinct. nucis vomicae, gtt.xl. M. Sig. — A tablespoonful in a wineglassful of sugar and water. Diet. — Our author very positively dissents from the formerly pursued plan of restricting the diet of the parturient woman to to astand tea. He very judiciously remarks that at this epoch of maternity, her wearied and exhausted system, with the additional 308 COMPLICATIONS OF PARTURITION. taxation of lactation, requires food to meet the new demand for the nourishment of her offspring, and to restore her own strength and vigor. He further objects to the application of any arbitrary rules to all women, and enjoins the necessity of individualizing each case and adapting the diet to the various conditions of the patient. Some are very much benefited by an immediate restora- tion to their former diet, while others need more restrictions, and he adaptation of the diet to the various pathological conditions evinced. It should, however, in all cases be as abundant as the digestive organs can digest, and the assimilative organs can appro- priate without inconvenience, and of nutritious quality. CHAPTER III. DISEASES OF THE MAMMARY GLANDS 'AND OF LACTATION. Mastitis; Inflammation of the Breasts — Mammary Tumors — Mam- mary Neuralgia [Mastodynid) — Galactorrhea — Agalactia and Oligalactia — Diseases of the Nipple. MASTITIS AND MAMMARY ABSCESS. PROF. FORDYCE BARKER, M. D., NEW YORK. This author endeavors to abort the abscess by tincture of iodine painted over the inflamed breast. If unsuccessful in this he applies, over the breast, bread and milk or linseed meal poultices as hot as can be borne. Usually he prefers warm water dressings made by soaking two folds of lint in warm water, and these covered over by oiled silk. He denounces the routine practice of rubbing the breast in mas- titis as absolutely pernicious. As soon as the abscess points and the fluctuation can be detected, it should be opened in the most dependent point, care- fully avoiding, however, the areola. To relieve pain and procure rest, he gives ten grains of Dover's or Tully's powder. When there is an epidemic or endemic tendency, he avoids all depressing agents and gives full doses of quinine. In the treatment of the sub-glandular form the same general principles should govern us as to constitutional measures, as in the subcutaneous variety. He has no confidence in any topical treatment. The sole reme- dial measure 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 circum- (3°9) 5IO DISEASES OF MAMMARY GLANDS AND LACTATION. ference of the breast, so as to prevent secondary inflammation of the glandular structure or of the subcutaneous areolar structure. Sometimes the signs of sub-glandular abscess existed, but no fluc- tuation ; he has detected the presence of pus by lifting up the gland from the thorax and passing between them an exploring needle. He then makes a sufficiently large incision with a long tenotomy knife. But if the abscess point on the anterior surface, then the opening must be made where the fluctuation exists, and care must be taken to prevent its closure before the pus is all discharged, by the insertion of a tent. Glandular inflammation or mammary adenitis presents two types; one rapid in its course, in the other the inflammatory pro- cesses are in tardy succession. In the former, resolution may be secured in a month; in the other, the period of several months may be required. The first requires vascular sedatives, saline laxatives, anodynes and an antiphlogistic regimen; while in the other, tonics, stimu- lants and nutritious diet are indicated. Nursing must be forbidden, as the pain and excitement thereby produced will aggravate the inflammatory condition. If, however, the secretion of milk be ac- tive, accumulation of this fluid must be avoided, the breast must be disgorged by artificial means. Rub the breast with the hand lubricated with sweet oil until the breast is soft and all nodulated indurations have disappeared. To prevent the return of the lacteal engorgement, he then covers the breast with the extract of bella- donna, softened with a little glycerine. If these means do not secure resolution, the abscess must be opened when the- presence of pus is determined. Then by adhesive straps applied so as to support the breast and firmly compress it from circumference to the centre, he secures the relief of engorgement of other lobules, the removal of indurations, the prevention of purulent infiltration into the adjacent areolar tissue, and the formation of obstinate fis- tulous sinuses. PROF. W. S. PLAYFAIR, M. D., LONDON, Urges that much may be done to prevent abscess by removing engorgement of the lacteal ducts when threatened, by gentle hand friction with warm oil. Combat feverish ness by gentle salines, mi- nute doses of aconite, and large doses of quinine, and relieve pain by opiates. Confine the patient to bed, and support the breast by a MASTITIS. 311 suspensory bandage. Warmth and moisture are best to relieve local pain, as hot fomentations, light linseed meal poultices, or bread and milk ; and the breast may be smeared with extract of belladonna rubbed down with glycerine, or the belladonna lini- ment may be sprinkled over the poultices. Generally the pain produced by nursing is so great as to prevent the child being put to that side, and the tension must be relieved by poultices. When pus forms, remove it as soon as possible ; nothing is to be gained by waiting till it nears the surface; delay leads to greater spread of the disease. The antiseptic method of operation should always be employed, as thus, in place of weeks or months, the abscess will be closed in a few days. Mr. Lister's method is so perfect that no more can be desired. "A solution of one part of crystalized carbolic acid in four parts of boiled linseed oil, having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture, and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised, while the upper edge is kept from slipping by an assistant, a common scalpel or bistoury dipped in the oil is plunged into the cavity of the abscess and an opening about V± of an inch in length is made, and the instant the knife is withdrawn, the rag is dropped upon the skin as an anti- septic curtain, beneath which the pus flows out into a vessel placed to receive it. The cavity of the abscess is firmly pressed, so as to force out all existing pus as nearly as may be (the old fear of doing mischief by rough treatment of the pyogenic membrane being quite ill-founded) ; and if there be much oozing of blood, or if there be considerable thickness of parts between the abscess and the surface, a piece of lint dipped in the oil is introduced into the incision to check bleeding and prevent primary adhesion, which is otherwise very apt to occur. The introduction of the lint is effected as rapidly as may be, and under the protection of the antiseptic rag. Thus the evacuation of the original contents is accomplished with perfect security against the introduction of liv- ing germs. This, however, would be of no avail unless an anti- septic dressing could be applied that would effectually prevent the decomposition of the stream of pus constantly flowing out beneath it. The following may be relied upon as trustworthy ; about six tea- spoonfuls of the above-mentioned oil are mixed with carbonate of lead to the consistence of a firm paste; it is, in fact, glazier's putty \yf1 — i / ' A 312 DISEASES OF MAMMARY GLANDS AND LACTATION. with the addition of a little carbolic acid. This is spread upon a piece of common tin-foil, about six inches square, so as to form a layer about a quarter of an inch thick. The tin-foil is placed upon the skin so that the middle of it corresponds to the position of the incision, the antiseptic rag being removed the instant before. The tin is fixed securely by adhesive plaster, the lowest edge being left free for the escape of the discharge into a folded towel placed over it, and secured by a bandage. The dressing is changed once in twenty-four hours, but if the abscess be large, it is prudent to see the patient twelve hours after it has been opened, when, if the towel be much stained with discharge, the dressing should be changed to avoid subjecting its antiseptic virtues to too severe a test. After this one daily dressing is enough. The changing of the dressing must be done as follows : A second piece of tin-foil is spread with the putty, a rag is dipped in the oil and placed on the incision the moment the first tin is removed. This guards against the possibility of mischief occurring during the cleansing of the skin with a dry cloth, and pressing out any discharge which may exist in the cavity. If a plug of lint was introduced when the abscess was opened, it is removed under cover of the rag, which is taken off at the moment when the new tin is applied. The same process is continued daily until the sinus closes." In long continued suppuration, methodical strapping of the breast with adhesive plaster, so as to afford steady support and compress the opposing surfaces, will be best. The sinus may be laid open, or injected with tincture of iodine or other stimulant. Support the system with food, stimulants, iron and quinine, as indicated. PROF. F. CHURCHILL, M. D-, DUBLIN. Bleed if the fever is high, or leech and follow with a large soft poultice or fomentation. A convenient and simple mode of apply- ing warmth, is to immerse a wooden bowl in hot water, and having wrapped some flannel around the breast, place it in the bowl. Purge briskly with salines, to which add a little tartar emetic. The latter may be continued in doses of one-sixteenth grain every hour, to induce slight nausea, and generally in twenty-four hours the symptoms are mitigated, and the breasts smaller and softer. Diet bland and fluid. If an abscess is unavoidable, favor it and open early MASTITIS. 3 I 3 J. S. PARRY, M. D., PHILADELPHIA, At the Philadelphia Hospital, urged the use of a fever mixture with ipecacuanha, or even tartar emetic, in a dose large enough to nauseate. This would be followed by relief of pain, fall of tem- perature and pulse. Where the subcutaneous areolar tissue is in- volved, iodine and astringent lotions are very useful. Put the iodine on freely, and then cover the treasts with cloths wet with acetate of lead lotion and opium. Give narcotics for pain and sleep. Dr. P. believes that rubbing the breast is an irrational process, and that milk accumulated in the breasts is not injurious. It is not a cause of mastitis. He would delay opening the abscess when formed, and the popular idea that an abscess should " be ripe" before it is opened, is not entirely without foundation. He waits until the pus has approached the surface, and is almost ready to open sponta- neously. Where sinuses form, carry a stick of nitrate of silver to the bottom, and leave it there, or inject iodine, sulphate of zinc, or copper. O. C. SMITH, M. D., CALIFORNIA. 289. ^. Olei lini. f.^iv Chloral hydratis, §ss. Powder the chloral very fine, then mix it thoroughly with the oil. Apply, spread thickly, on a piece of soft woolen flannel, a little larger than necessary to cover the breast, with a central opening through which the nipple may protrude. Apply as warm as can be borne, and keep warm whilst it re- mains applied by warmed sacks of chamomile flowers or hops. The plaster should be renewed every four to six hours, until all pain, swelling and induration are relieved. {Pacific Medical Journal, May, 1878.) In acute mammitis, a number of observers have reported striking success with tho. poke root : 290. fy. Fluidi extracti phytolaccas, q. s. Twenty drops every three hours. Others have seen benefit from : 291. I£. Tincturae belladonnas, Tincturae digitalis, aa f.3j M. Ten drops every three or four hours. 3I4 DISEASES OF MAMMARY GLANDS AND LACTATION. In chronic mammitis, Prof. Hunter McGuire, M. D., of Rich- mond, Va., condemns ( Virginia Medical Monthly, September, 1875), the severe and needless practice of slitting up the sinuses, or of in- jecting them with stimulating fluids. Nearly every case can be cured by proper bandaging with adhesive plaster. Cut the plaster into strips from four to six inches in length, and from a half to three-quarters of an inch in width, according to the size of the breast. After warming the plaster, apply one end of a strip to the circumference of the gland, near the axilla. Take another strip of the same length and width, and fasten its end to the inner circumference of the breast, near the sternal bone. The ends of the two strips of plaster thus applied are held in place by an assistant, while the surgeon takes the free extremities of the strips, and drawing them toward each other, that is, drawing the breast from its circumference toward its centre, crosses the strips and fastens them. Two more strips are then applied just below, and lapping slightly the first two pieces. Continue in this way till the whole breast is covered (somewhat upon the same principle and manner that we use strips in an indolent sore on the leg), leaving the nipple and fistulous orifices uncovered. A piece of moistened lint is placed over the sinuses to catch the pus which escapes. ASHBURTON THOMPSON, M. D., LONDON, Speaking of mammitis [Medical Times and Gazette, January, 1875), mentions two modes of treatment, (1) the administration of tincture of aconite, and (2) the total abstention from fluids during the necessary number of days. By giving minim doses of aconite every hour, he had succeeded in cutting short inflammations of the breast which there was no doubt would otherwise have run on to suppuration very frequently ; indeed, in three cases out of four. In cases of still- birth he had hitherto found abstention from fluids sufficient in every case to avoid every kind of mammary disturb- ance. Ice was allowed in moderate quantity, and no other fluid, from the time of delivery until the fourth or fifth day, when the breasts generally return to their normal state of quiescence. The deprivation of fluid caused but little distress. JOHN B. C. GAZZO, M. D., THIBODAUX, LA., In Med. and Sur: Reporter, May 6, 1876, gives his treatment as light diet, alteratives, and tonics, a compress moistened with the MASTITIS, 315 linimentum, ammoniae iodidi et chloroformi applied to the breast as high as the axillae, carefully enveloping the diseased mammae, covering the compress with oiled silk, and keeping the whole in a suspensory bandage ; during the first day renew the application once in two or three hours. This proceeding must be repeated every day until the swelling disappears, which is, usually, the second or third day. The liniment of chloroform and iodide of ammonia should be applied the moment that pain and engorge- ment of the mammary glands manifest themselves; it will then act as an abortive in suppressing incipient pain, and thereby prevent the inflammation which threatens the mammary structure. The inflammatory period of the mammary is not only shortened, but the entire duration of the disease is diminished by at least one- half. After the large, heavy and inflamed mammae become perfectly flaccid, completely cool, and the flow of milk begins anew, allowing of the freest handling, omit the application. The only inconvenience attending it is the irritation produced upon the skin; this, however, is more than compensated for by the deriva- tive action of the iodide of ammonia and chloroform upon the inflamed breast, which will very often, in all probability, prevent abscess and suppuration. In addition to appropriate medical remedies, the following pre- scriptions were employed with the happiest results ; the first, an excellent detergent and purifier of the blood, preventing the form- ation of matter within the glandular system ; and the second, a tonic in restoring the mucous membranes. 292. ^. Potassae chlorat., 3ij Aquae destil., f.gviij Acidi. hydrochlorici, gtt.xxx Syrupi aurantii, f . §iij - M. Sig. — One tablespoonful every two hours. 293. I£. Cinchona? sulph., 3ij Ouinias et ferri citras., 3hj Tinct. ferri. chloridi, f.5U Syrupi sennse, f»? vr j- Sig. — One tablespoonful three times a day, after diet or meals. The liniment of iodide of ammonia is prepared as follows: 294. ^. Iodinii, 5iij Ammonia? iodidi, 3U Chloroformi, Olei oliva;, aa f.§x Glycerinae, f.%v. M. Dissolve the first two by rubbing in the chloroform ; then add the olive-oil and glycerine. 316 DISEASES OF MAMMARY GLANDS AND LACTATION. C. B. KEIPER, M. D., INDIANA. The first fifteen years of practice he used belladonna poultices, and so forth. Now and then he would have a suppurating breast; and in cases that did not suppurate, it would require from six to ten days to subdue the inflammation. In the last fifteen years he made no other applications than cold water and muriate of ammonia ; two ounces of muriate of amnion- nia to a half gallon of cool water. Where ice cannot be had, put the solution in a tin bucket, and place this bucket in an- other one of cool water, so as to keep it at a low temperature (in city practice ice may be employed); then take two pieces of cotton goods, each about twenty inches square, and double each one four times, and then cut a hole in the centre about two inches in diameter, so as to protect the nipple, and dip these in the solution, and apply to the parts affected; removing every twenty minutes, to immerse anew in the solution. This continue till the inflam- mation is subdued, which generally requires from one to three days. HUGH MILLER, M. D., OF GLASGOW. In cases where acute congestion occurs in the mammary glands when commencing to secrete, this author (Edinburgh Med. Jour- nal, December, 1877), employs with great success a preparation of belladonna. It is an alcoholic extract of double the usual strength, kept fluid by collodion. Camphor is combined with it for the pur- pose of aiding to arrest the natural mammary secretion. This preparation is painted on the breasts much in the same way that you would use blistering fluid. No rubbing in is necessary. The fluid dries quickly, is much more cleanly for the patient, has a less offensive odor than the ointment, and in his experience, it is more reliable in its action. This liquid preparation is painted over the affected parts of the breast night and morning, until the acute symptoms give in. In- deed, it can only be of service as a good local sedative when the free and frequent application of it to the affected part has been persevered in until decided results are secured. He has used this preparation with very satisfactory results. Whether the inflam- matory irritation accompanying the onset of the lacteal secretion had for its exciting cause exposure to cold, inflamed nipples, or obstruction in the lacteal ducts, the preparation has always seemed to be of value. He has also used the preparation beneficially by MASTITIS. 3 I 7 applying it to both breasts every day when the mother did not in- tend to suckle her child : and is satisfied that it may be safely re- lied upon for restraining the secretion of milk, and acting on the walls of the arterioles so as to prevent engorgement. It has the advantage over the old plan of evoporating lotions, in that it is more cleanly, and is more comfortable to the patient. When the remedy is employed to prevent the secretion of milk forming at all, it is best to begin applying the liquid immediately after the birth of the child. EDGAR KURZ, M. D., OF TUBINGEN. In the lying-in hospital at Tubingen, this author treated the very frequent cases of commencing mastitis in the following manner: When the breast is tense with milk and becomes hard and sensi- tive, it frequently suffices merely to restrict the diet of the patient, and to remove the superabundant milk by nursing several children, or drawing it out with one of the various appliances devised for the purpose, or by gently expressing it. When the affection has advanced a step farther, and the breast is much swollen and lumpy, and the skin reddened, and suppuration appears imminent, it is necessary to adopt energetic measures. The diet is still more re- stricted, laxatives are given, the breast is securely bound up by a cloth, without, however, exerting compression, which is suitable only for chronic cases, or the residual nodosity following acute mastitis. The main point of the treatment is the application of cold, which in light cases consists merely in iced compresses ; in severe cases in the unremitting application of a bladder filled with ice. The often intolerable pain, which is increased by compression, yields rapidly to this treatment ; the tension decreases, suppuration is prevented, and in a few days even mastitis may be cut short in this manner. During two years of this treatment, not one case of mastitis terminated in suppuration, whilst under compression it frequently occurred. PROF. F. WINCKEL, M. D., ROSTOCK. Applies dry heat if very acute pain persists after the use of com- presses of cotton batting, cold compresses, or the ice-bag. When headache is severe and the tongue coated, he gives large doses of iodide of potassium To reduce the thickness of the skin and expedite the evacuation of pus, he paints with iodine. Evacuate pus promptly. 3 1 3 DISEASES OF MAMMARY GLANDS AND LACTATION. When a portion of the gland is tender, swollen, and the surface red, give the breast as much rest as possible, by less frequent nursings, or entire cessation on that side. Use compresses, wet with lead water, night and day, renewing them every few minutes, supporting the breast. Keep the bowels free. Continue until the nodules disappear, or alternate the lead with tincture of iodine, if there is reason to believe that an abscess is forming. Pointing of pus is thus hastened. A plaster of Paris bandage applied to the breast is excellent after evacuation of pus, as it insures uniform compression of the gland. Change it every two or three days. Other methods have been employed, but this should completely supersede the use of warm poultices. To remove any lacteal nodes, mercurial ointment or iodide of potassium may be rubbed on, or the parts covered with emplast. saponis., emplast. cicutae, or emplast. melliloti, and iodine, given in- ternally, the child having been weaned. J. L. POWERS, M. D., REINBECK, IOWA. This writer., in the Medical Brief, October, 1878, uses tobacco salve spread upon drilling, the size of the breast, with a hole in the centre for the nipple. Internally, when inflammatory symptoms are marked : 295. $. Spt. ether, nit., f.§ss Tr. veratri virid., f.5ss Aquae, f.^iij. M. Teaspoonful every hour or two, until it produces a sedative effect, and then less frequently. With concentrated tincture of phytolacca, fifteen to twenty drops, and this used persistently, he believes an abscess may be avoided. RESUME OF REMEDIES. Acetum. The application of a cloth wrung out in hot vinegar, which is then covered with a bowl moderately heated, is a popular means of aborting threatened inflammation of the breasts. Aconitum, in minim doses of the tincture, is recommended by Dr. Thomp- son (p. 314)- Ammonii Murias, as a resolvent local application, has been found very efficient (p. 316;. ^Belladonna. In recent induration and inflammation of the breasts, re- markable effects are produced by belladonna in arresting the se- cretion of milk. Either as plaster or ointment, or also inter- nally, its use should not be omitted. MASTITIS. 3I9 Chloral \% applied locally by Dr. Q. C. Smith (F. 289). Conium. In chronic engorgement or hyperplasia of the breasts, the pro- longed use of conium internally has a decided influence in re- ducing the size. Digitalis in inflammatory states may sometimes be advantageously com- bined with belladonna (F. 291). Ergota moderates the secretion of milk, and has been used to prevent mammary abscess and engorgement of the breasts during weaning. Iodinii Tinctura, in the chronic forms of engorgement, is a valuable re- solvent. Petroselinum. Freshly bruised parsley leaves are a popular remedy in commencing mammary inflammation at the beginning of lacta- tion. * Phytolacca Decandra, is known popularly as the " garget weed " and is extensively used for garget (mammary inflammation) in cows. Considerable evidence has been adduced that it possesses equal value in the human female. It is given in doses of gtt.xx of the fluid extract of the root every three or four hours {Am. Jour. Med. Sciences, 1873, p. 275 ; Med. and Surg. Reporter, Jan., 1875). Dr. J. G. Allen, states {Am. Jour Obstetrics, Oct., 1879), that it is not of value where the mammitis begins at the nipple or only involves small lobes of the gland ; but where the whole or a large portion is swollen and congested, and in the condition of congestion that sometimes results from an attack of ephemeral fever, the phytolacca is almost a spe- cific. Plumbi Acetas. Dr. Huebner, of Dresden, recommends the constant application of lukewarm lead-water in compresses, followed, if required, by strapping of the breast and free incision. Plumbi Iodidum. The discutient powers of this agent may be advanta- geously called into play in chronic engorgement of the mammary glands Stramonium. The fresh leaves of stramonium, made into a cataplasm and applied externally, have been found successful for discussing indurated lacteal glands in the breasts of nurses (Phillipsj. Tabacum, in the form of ointment, gr.xxx to lard 5j, has long been used in some parts of this country as a domestic application to in- flamed and " caked " breasts. GENERAL MEASURES. Cold. Some writers are very positive in praise of cold applications in threatened inflammation of the mammary gland. Pounded ice is placed in a bag and laid directly upon the gland, to be renewed from time to time. The pain and swelling is said to abate promptly, "within an hour," and in a few days the in- flammatory action has quite disappeared (see p. 31 1). Compression is highly praised by most authorities (see pp. 310, 312, 314, 3181. Dr. Koening says that in mammary lymphangitis it is "infallible." The method which he employs {London 320 DISEASES OF MAMMARY GLANDS AND LACTATION. Med. Record, April, 1877, is the following: The diseased breast is covered with a layer of cotton wool, and a bandage is applied which is known in minor surgery as the bandage of Mayor, or the triangular bonnet of the breast. The form of the bandage is a triangle, a yard in length from one extremity to the other, and fifty centimetres (nearly twenty inches) from the apex to the base. The base of the triangle is placed ob- liquely under the diseased breast, then one of its extremities is directed under the corresponding armpit, and the other over the opposite shoulder, and there united behind the shoulder- blade The apex of the triangle is then lifted in front of the diseased breast, it is carried over the corresponding shoulder, and firmly fixed behind. Sometimes a linseed poultice is at the same time applied on the inflamed part. The effects of treatment thus arranged are almost marvelous ; the pain is immediately calmed, the inflammatory redness, and the oedema are diminished at the end of a very short time. Heat is more popular than cold as a means to effect resolution. Hot vin- egar, lead-water, etc., warm poultices, heated bowls or plates, etc., are familliar applications, and often successful. MAMMARY TUMORS. DIAGNOSTIC POINTS. The diagnosis of mammary tumors is confessedly difficult. We give from various surgical authorities a few points to serve as diag- nostic landmarks. I. The tumor presents itself as a small nodule in the breast. It may be merely a benign chronic mammary tumor (adenoma), or the beginning of sarcoma, or scirrhus. Adenoma. Patient under thirty and single. Tumor dense, but elastic and movable under die skin, and movable on the deeper part of the breast. Pain, if present, of a neu- ralgic character, and worse at the menstrual period. Skin and lymphatics never involved. Grows very slowly, and varies in size. Nipple not retracted. No family history. Sarcoma. Patient any age. Tumor elastic and mov- able, but rapidly in- volving the surround- ing tissues. Pain not severe as a rule. Skin eventually in- volved, but no lym- phatic enlargement. Grows very rapidly, and apt to recur locally. Nipple often exudes fluid. No family history. Scirrhus. Patient over thirty. Tumor hard, and at- tached to the deeper part of the breast, though at first mova- ble beneath the skin. Pain severe, and of a sharp, lacerating char- acter, and shooting down the arm. Both skin and lymphat- ics involved early. Grows rapidly, except in old people. Nipple often retracted. Often hereditary. Of these signs, the enlargement of the lymphatic glands of the axilla and neck is the most important point in the diagnosis of scirrhus. Adenoma generally occurs in the breasts of young, healthy women, during their period of developmental perfection. Among married women it often occurs among those who are suckling. It usually grows slowly, and as it enlarges, pushes the breast aside; it never infiltrates it. It may grow to a great size, and stretch the skin even to the point of rupture; but the skin is never infiltrated,, nor the tissues beneath. The tumor is encapsuled, and usually movable, and can be readily turned out. It is never associated with any secondary glandular enlargement. 2. The tumor is elastic. 21 (3 21 ) 322 DISEASES OF MAMMARY GLANDS AND LACTATION. Its contents should be drawn to the extent of a drop or two by a needle, and examined. If the fluid proves to be : (a) Pus, the case is one of abscess. (5) Milky fluid, it is galactocele. ( 57- from general causes ) 49. through inefficiency, 50. menorrhagic, 50. irregular, 50. rheumatic, 52, 56. membranous, 54, 57- neuralgic, 46, 55, 57. ovarian atonic, 47, 56, 57. Dyspareunia, 176. Dyspepsia of chlorosis, 78. ovarian, 28. of pregnancy, 225. Dysuria, 159,192. Eclampsia, puerperal, 229, 231, 264, 267. reflex, 266. Eczema genitale, 182, 183. with diabetes, 182. Edema in pregnancy, 228. Embolism, 289. Encephaloid cancer of breast, 322. Endo-cervicitis, 87, 89. Endometritis, 87, 89, 92,95, 183. Enuresis, 159. Erythema of the nipple, 345. Excessive distension of uterus, 242. Excoriations in vagina, 176. Excrescences in vagina, 179. Exercise during pregnancy, 198. Fallopian tubes, cysts of, 19. Fatty degeneration of chorion villi, 200. Feeble action of uterus in labor, 239, 242. Fetid vaginal discharge, 170. Fever, milk, 304. puerperal, 276, 282. Fibroid tumors of breast, 324. Fibrous tumors of uterus, 139, 142. Fissures of nipple, 337, 338, 344. Flexures, uterine, 129. Fluids, in the breast, 322, 324. Fluids ovarian, 20. Food during pregnancy, 198. Forceps, the, in labor, 234, 237, 239, 242, 243» 26 5> 2 9 J - Galactocele, 322. Galactagogues, 332, 333, 334, 335, 336. Galactorrhea, 327. Gangrene of a limb, 289. Genitals, pruritus of, 181. Gingivitis, 225. Glands, mammary, congestion of, 316. Gonorrheal acute ovaritis, 174. cervicitis, 174. metritis, 174. urethritis, 174. vaginitis, 157, 172. Green sickness, 77. Growths, malignant, 148. non malignant, 137. papillomatous, of vulva, 179. Habitual abortion, 203. Headache of pregnancy, 221. Heart palpitation in pregnancy, 221. Hemorrhage, accidental, during pregnancy, 205, 254. Hemorrhage, from the cord, 254. passive, 59, 64. post-partum, 234, 250, 260. post-partum, secondary, 252. puerperal, 250. uterine, 23. Hemorrhoids, 226. Hydatid tumors of the breast, 324. Hydremia of pregnancy, 231. Hygiene of the puerperal state, 197. Hyperemia of the kidneys, 229. ovaries, 27. Hypochondriasis of pregnancy, 222. Hysteria, 71. Hysterical breast, 322. Impoverished blood in pregnancy, 228. 230. Incontinence of urine, 194. Induction of premature labor, 206. Inertia uteri in labor, 242. Insomnia of pregnancy, 222. Instrumental delivery, see Forceps. anesthesia for, 237. Inversion of uterus, 130. Irregular action in labor, 242, 251. Ischuria, 159. Kidney, congested, in pregnancy, 229. hyperemia of, 231. Labor, anaesthetics in, 233. antiseptic management of, 280, 281 . atony of uterus in, 239. complications of, 233. disorrers of, 233. to facilitate, 240. to shorten, 240. induction of premature, 206. irregular action in, 242, 251. lacerations of perineum in, 233. premature, 200. INDEX OF DISEASES. 351 Labor, occluded os uteri in, 242. rigid os in, 239, 242. rigid perineum in, 233. • tedious, 233, 239. Lacerations of perineum, prevention of, 233- . Laceration of vagina or vulva, in labor, 255- Lactation, to establish, 332, 333. Lead-poisoning from cosmetics, 166. Leucorrhea in pregnancy, 164, 167, 168, 169, 223. Life, change of, 24, 81. Lochial discharge, excessive and septic, 276. Lymphangitis, mammary, 319. Mammary abscess, 309. adenitis, 310. adenoma, 321. glands, acute congestion of, 316. hypertrophy, 323. lymphangitis, 319. neuralgia, 326. sarcoma, 321. scirrhus, 321. tumors, diagnosis. of, 32 1. treatment of, 322. Mammitis, acute, 313. chronic, 314. Mania, puerperal, '271. Marital relations during prepnancy, 199. Mastitis, 309. Mastodynia,326. Melancholia of pregnancy, 222. Membranous dysmenorrhea, 54, 57. Menopause, 24, 81. Menorrhagia, diagnosis of, 23. treatment of, 59, 82, 240. Mental condition during pregnancy, 199. Menstruation-, too frequent, 65. Metritis, 88, 90, 96. gonorrheal, 174. puerperal, 295. Metrorrhagia, diagnosis of, 23. treatment of, 59. Milk fever, 304. Milk, to increase the flow of, 332. decrease the flow of, 327, 328, 329, 330.33I- Milk tumors, 323. Milky fluid in the breast, 322. Mucous polypi, 138. "Nagging pains," anesthesia for, 237. Nausea of pregnancy, 214. Nervous cough in pregnancy, 222. Neuralgia in pregnancy, 221. of the uterine neck, 49. of breast, 326. of ovaries, 27. Neuralgic dysmenorrhea, 46, 55, 57. Nipples, diseases of, 337. cracked, 338, 339, 345. erythema of, 345. fissures of, 337, 338, 344. phlegmon of, 345. sor e, 337, 339- Nymphomania, 155. Obstetrical therapeutics, 195. Obstructions, pulmonary, 289. Occluded os in labor, 242. Oedema of the vulva, 158. Oligogalactia, 332. Ovarian cysts, 19, 31. Ovarian dropsy, 31. Ovarian dyspepsia, 2S. Ovarian dysmenorrhea, 47, 56, 57. fluids, 20. granular cell, 20. hyperemia, 29. neuralgia, 27. tumors, 18. diagnosis, 19, 31. Ovaries, diseases of, 17. Ovaritis, 17. chronic, 17. acute, 17. treatment of, 26. Oxytocics, 242, 244. Pain in right side in pregnancy, 222. vagina, 177. Pains, after, 248. Palpitation of heart in pregnancy, 221. Papillomatous growths of vulva, 179. Parovarian cysts, 19. Parturition, complications of, 233. Passive hemorrhage, 59, 64. Pelvic cellulitis, 292. peritonitis, 292. Perimetritis, 96. Perineum, lacerations of, in labor, 233. rigidity of, in labor, 233. Peritonitis, diagnosis of, 292, 306. pelvic, 292. puerperal, 292, 297. Phlegmasia dolens, 302. Phlegmon of nipple, 345. Phosphatic diathesis in pregnancy, 229. Phthisis, amenorrhea in, 22. Placenta prtevia, 250, 253, 254, 255, 256. retention of, 254, 255. Poisoning from cosmetics, 166. Polypi, 23, 137, 138. uterine, complicating labor, 255. Polyuria, 159. Post-partum hemorrhage, 240, 250, 260. from anesthetics, 234- Pregnancy, congestion of kidney in, 229. constipation of, 214,226, 230, 231. 352 INDEX OF DISEASES. Pregnancy, disorders of, 197. albuminuria in, 228. antiseptics during, 281. ammonia in blood during, 231. cerebral disturbance in, 230. clothing during, 198. diarrhea of, 226. exercise during, 198. food during, 198. headache of, 221. hemorrhage during, 205, 254. hydremia of, 231. hypochondriasis during, 222. impoverished blood in, 228, 230. indigestion of, 225. insomnia of, 222. leucorrhea in, 164. 167, 168, 169, 223. marital relations during, 199. melancholia in, 222. mental condition during, 199. nausea of, 214. nervous cough in, 222. neuralgia in, 221. oedema in, 228. pain in right side in, 222. palpitation of heart in, 221. phosphatic diathesis in, 229. pruritus of, 223. salivation of, 225. sleep during, 198. syncope in, 224. Premature labor, 200. Procidentia uteri, 129, Prophylaxis of puerperal eclampsia, 229. sore nipples, 344. Prolapsus uteri, 132. Pruritus of diabetic, 182. pregnancy, 223. pudendalis, 182. vulva?, seu vaginae, 181. Puerperal convalescence, 306. eclampsia, 229, 231, 264, 267. fever, 276, 282. mania, 271. metritis, 295, 299. peritonitis, 292, 297. pyemia, 276. septicemia, 276. shock, 291. state, hygiene of, 197. thrombus and embolism, 289. salivation, 2 25. women, laxatives for, 307. Pulmonary obstructions in labor, 289. Pus in the breast, 322. Pyrexia, 276. Rectum, disease of, 178. Reflex eclampsia, 266. Relaxation of uterus, 254. Renal congestion, 228. Retarded involution of the womb, 307. Retention of placenta, 254, 255. Rigid os uteri in labor, 239, 242. Rigidity of perineum in labor, 233. Salivation, puerperal, 225. Sarcoma of breast, 321. Scirrhus of breast, 321. Septicemia, 201, 276, 279, 280, 281, 282, 286. Sero-purulent discharge from vagina, 169. Serous cysts of breast, 323. Shock, puerperal, 291. Sleep during pregnancy, 198. want of, during pregnancy, 222. Sore nipples, 337, 339. Sterility, 152. Subinvolution, 23. Suppuration of breast, 312. Sympathetic nervous disorders, 221. Syncope in pregnancy, 224. Syphilitic infection, 200, 204. Tedious labor, 233, 239. Tenesmus uteri, 49. Threatened abortion, 203. Thrombus, 289. Toxic eclampsia, 266. Tumors of breast, 321, 322, 324. uterus, 137, 139, 142, 148. milk, 323. ovaries, 18, 19, 31. Turning, anaesthesia for, 237. Tympanites, 279. Ulceration of the nipple, 337, 338, 344, 345-. Ulcer, indolent, 105. inflamed, 105. fungous, 105, 106. senile, 105. diphtheritic, 105. Ulcerations, bleeding, 106, 145. Uremia in pregnancy, 231. Urethra, caruncle of, 179, diseases of, 157. Urethritis, 190. gonorrheal, 174- Uiinary disorders, 158, 192. Urine, incontinence of, 194. Uteri, carcinoma, 148. procidentia, 129. prolapsus, 132. tenesmus, 49. Uterine atony in labor, 239, 242. catarrh, 168. changes, 86. displacements, 122, 130. flexures, 129. inertia in labor, 234, 239, 242. inflammations, 87. involution retarded, 307. INDEX OF REMEDIES. 353 Uterine, polyp, hemorrhage during labor from. 255. relaxation, 254. by chloroform, 234. symptoms, 86. tenesmus. 49. tumors, 139, 142. Uterus and its annexes, diseases of, S5. excessive distension of in labor, 242. neuralgia of neck of, 49. occlusion of os, in labor, 242. Vagina, absorptive power of, 161. contraction of, 1 76. diseases of, 157. excoriations in, 176. excrescences in, 179. hyperesthesia of, 178. pain in, 177. sero-purulent' discharge from, 169. Vagina or vulva, laceration of in labor, 255- varicose veins in, 250, 255- Vagina or vulva, vegetations in, 179. Vaginal discharges, fetid, 170. growths, 179. injections, 160. irrigations, 160. thrombus, 289. walls, atony of, 167. Vaginismus, 176. Vaginitis, 157, 160. gonorrheal, 157, 172. specific, 157, 172. from lead poisoning by cosmet- ics, 167. Varicose veins in vagina, 250, 255. Vegetations in vagina, 179. Vesical irritability, 159. irritation, 192. tenesmus, 159. ■ Vomiting of pregnancy, 214. Vulva, oedema of, 158. papillomatous growths of, 179. pruritus of, 181. Vulvitis, 181. Warts in vagina, 179. Womb, see Uterus. INDEX OF REMEDIES. Abdominal frictions for inertia uteri, 239, 246. Abortifacients, 212. Abscess of mam ma, to prevent, 309, 3 1 0,31 1. Abstention from fluids to cure mammitis, 3H- Acacia, 339, 345, 347. Acetum, 144, 261, 287, 318. Achillea millefolium, 41, 65. Acid, with opium, 248. Acid nitrate of mercury. See Liquor. Acida, 65, 189, 231, 290. Acidum aceticum, 106, 117, 144, 179, 205, 228, 254,265. arseniosum, 29, 65, 148, 180, 211, 217. benzoicum,i87,23i. 232,265,269. bichloraceticum, 117. boracicum, 104, 182, 184. carbolicum, 54, 83, 92, 94, 97, 100, 103, 106, 112, 117, 142, 148, 149, 163, 164, 166, 174, 178, 179, 181, 183, 184, 191, 215, 217, 281, 282, 283, 284, 290, 296, 298, 300, 311, 337, 343.. 346. carbonicum, 37, 149, 160. 23 I IF, I46', I8l, 97, 11S, Acidem chromicum, ioo, 103, 107, 118, 179. citricum, 215. gallicum, 61, 67, 14c, 145, 202, 254. hydrobromidum, 277. hydrocyanicum dilutum, 66, 1S3/1S5, 217,223,274. muriaticum dilutum, 72, 95 .201, 303, 315. nitricum, 92, 104, 107, 114 148, 179, 272. nitro-muriaticum, 1S9, 193. phosphoricum, 278. picricum, 338. pyroligneum, 106, 11 8. salicyiicum, 53, 168, 189, 279, 281, 282, 288, 347. sulphuricum aromaticum, 64, dilutum, 61, 69 205,254,278, 344- sulphurosum, 184, 288. tannicum, 31, 64, 69, ioo, 109, 119, 132, 164, 165, 168, 188, 189, 211, 219, 338,347- 147- 95, 324, 104, 166, 337, 354 INDEX OF REMEDIES. Acidum tartaricum, 64, 95, 231. Aconitia, 1S4. Aconitum, 28, 41, 62, 93, 217, 222, 269, 272, 273, 275, 279, 280, 287, 293, 300, 302. 304, 310, 314, 318, 326. Acosta's gas cautery, 109. Actea alba, 249. . racemosa, 326. Actual cautery, 107, 179, 193. Acupressure, 323. Aether — See Ether. Agaricus albus, 330, 335. Air pessary, 207. Alcohol, 148, 214, 224, 244, 255, 278, 287, 295, 297, 298, 323, 344, 347. Alcohol as an anaesthetic, 238. Alimentation, rectal, 216. Alkalies with opium, 248. in cystitis, 189. in vaginitis, 167, 172. to favor absorption, 289. Alkaline baths, 52. carbonates, 174, purgative water, 231. Allium, 74. Aloes, 33, 35, 38, 40, 41, 51, 74, 77, 79, 168, 212, 227, 231, 272, 307. Aloes cum myrrha, 80. Aloin, 41, 226. Alterative applications, 96. lotions, 188. Althaea, 51. tents, 1 19. Alumen, 64, 65, 70, 109, 118, 149, 162, 163, 167, 168, 259, 330, 335, 345. Alumen, objection to injections of, 168. Aluminae nitras, 184. Ammonisemurias. See Ammoniichloridum. Ammonii benzoas, 187. bromidum, 61, 65. carbonas, 231, 277, 280, 291. chloridum, 28, 30, 31, 41, 53, 55, 63, 97, 144. 145, 168, 184, 222, 293,300,316, 318,323. iodidum, 316. valerianas, 49. Ammonium, 74, 303. Amputation of cervix uteri, 125, 148. Amyl nitrite, 55, 244. Anaesthetics, 240, 272. in labor, 233, 235,236, 237. conclusions on, 235. propositions on, 237. Anisum, 335. Anodyne plasters, 323. Anthemis, 50, 75, 289, 303. Antigalactics, 328. Antimonii chloridum, 118. Antimonii et potassii tartras, 30,244,273, 274, 2S0, 304, 312, 313. Antiphlogistics, 228. Antiseptic marine lint, 123. Antiseptic midwifery, 281. surgery of the mammas, 311. Antiseptics, 141, 276, 277, 279, 280, 290, 293. 3"- Apiol, 40, 41, 46, 55. Aqua ammoniae, 41, 184, 289. bullientis, 51 . calcis, 184, 185, 345. fervida, 184. pimenlae, 164. Arbor vitas, 179. Argenti nitras, 41, 92, 100, 102, 104, 105, 108, 118, 149, 165, 166, 169,173, 177, 178, 179, 184, 188, 191, 194, 216, 223, 224, 314, 335, 337, 339. 340, 342, 344, 345- oxidum, 65. Armoracia, 217, Arnica, 277, 287, 289, 341. Arsenici iodidum, 148, 180, 323. Arsenicum, 323, 326. Arseniosum acidum. See Acidum. Artemisia vulgaris, 41. Artificial vesico-vaginal fistula, 188. Aspiration, 19. Assafcetida, 46, 47, 51, 70, 73, 75, 204. Astringent injections, 173. lotions, 188, 313. tonics, 329. for nipples, 341. Atropia and Atropias sulphas, 27, 30, 53, 55, 74, 178, 191, 216, 217, 218,244, 33°- Atropine, 241. Aurantii flores, 75. Auri et sodii chloridum, 73, 75. Balsamum Peruvianum, 187, 338, 344, 345. Bandage, hypogastric, 123. Bandaging in mammary sinuses, 314. for swelling of arm, 323. Barnes' method for premature labor, 208. Barnes' rubber bag, 125, 239, 251. Baths, 45, 62, 82, 91, 147, 228. hot air, 229, 230. shower, 76. Turkish, 229, 230. Battey's operation, 30. Battley's solution, 200, 223, 242, 258. Belladonna, 27, 28, 42, 46, 47, 50, 55, 91, 94, 104, 109, 161, 176, 177, 178, 192, 194, 2ro, 214, 217, 225, 226, 244, 268, 269,285,293,302, 303, 310,311,313, 316, 318, 325, 326, 328, 329, 330, 331, 335- Bennett's caustic, 1 19. Benzoinum, 344, 345. Berberias sulphas, 66, 274. Bismuthi oxidum, 185. subacetas, 214. subnitras, 79, 95, 118, 162, 169, 183, 215, 216, 217, 230, 342, 346. INDEX OF REMEDIES. 355 Black cohosh, 221. Blisters, 30, 93, 104, 288, 293, 29S, 300, 3 OI > 3°3- Block tin pessaries, 127. Boletus, 334. Boracicum acidum. See Acidum. Bougies, 4S. Bourjeaud's Dessary, 123. Brandy. See Stimulants. Braun's colpeurynter, 207, 239. Brick clay, 182. Brominium, 30, 55> J 4^- Buchu, 187, 188. Carlsbad salts, 182. Caffea, 327, 330. Cajuputi oleum, 75. Calcii chloridum, 144, 146, 148, 287. phosphas, 335. Calumbse infusum, 144, 216. tinctura, 79, 216, 217. Camphora, 26,30, 50, 51, 52, 55, 56, 75, 112, I55, l8l, 184, 271, 273, 29I, 295, 300,306, 316, 33O, 33I. Camphoras spiritus, 323, monobromidum, 155, 230, 271. Canella, 166. Cannabis Indica, 26, 46, 55, 66, 75, 140, 146, 155, 205, 211, 245, 260, 273, 274, 33°- sativa, 330. Canquoin's paste, 107. Cantharides, 42, 167, 212. Capsicum, 260. Capsules, 103. Carbolic acid. See Acidum. Carbolized oil and lotions, 281, 285. Carbonate of ammonium. See Ammonii carbonas. Carbonate of lead. See Plumbi carbonas. Carbonic acid gas, 37, 149. how to' prepare, 160. Carbonis sulphidum, 244. Carotids, compression of, 264. Caryophyllus, 345. Cascanlla, 164. Cassava, 334. Castoreum, 49, 72, 74. Castor oil bean, 334. Catechu, 64, 66, 169, 344. Cathartics, 76, 272. Catheter, use of, to induce premature labor, 207, 210. Caulophyllum thalictroides, 244. Caustics, 106, 107, 119, 149, 150, 219, 324, 3 2 5.342. Caustic arrows, 325. potassa, 92, 107, I IO, 149, 150, 335- Cauterization of gums, 225. Cauterizing pencils of Bonnafond, 108. Cautery, actual, 150. galvanic, 10S, 1 37. gas, 108. thermo, 108, 150. Cerii oxalas, 216, 217. Cerium, salts of, 214. Cervix uteri, amputation of, 150. Chalk mixture, 226. Chamomile. See Anthemis. Charcoal pencils, ill. Chloral, 47,60, 106, 151, 184, 188, 191, 192, 202, 216, 217, 225, 232, 234, 238, 240, 242, 245, 249, 264, 265, 266, 267, 271, 273, 275, 287, 291, 313, 319. Chloralum, 260. cotton wool, 123. Chlorodyne, 200, 226, 248. Chloroformum, 75, 93, 144, 160, 185, 216, 217, 223, 229, 233, 234, 235, 236, 237, 238, 239, 242, 243, 245, 264, 265, 274, 303, 307, 315. injection of vapor, 161. in intermittent doses, 236. Chloroformi spiritum, 222, 276. linimentum, 306. Chromic acid. See Acidum. Churchill's tincture of iodine, 99, 140. Cicuta, 323. Cider vinegar, 144, 261, 287, 318. Cimicifuga, 42, 52, 53, 55, 66, 221, 245, 275- Cinchonia, 63, 77, 78, 166, 222, 315, 327. Cinnamomum, 65, 66, 140, 242, 245. Citric acid. See Acidum. Civeolia levigata, 342. Clitoridectoniy, 156. Cloih tents, 119. Clothing in the puerperal state, 197, 198. Cloves, 345. Cocculus indicus, 55, 79, 169. Cochlearia tinctura, 225. Codeia, 182. Cod liver oil, 29, 326, 335. Coffee, 327, 330. Cohen's method for inducing premature labor, 208. Colchicum, 52, 53, 55, 183, 328, 329, 330. Cold, 70, 76, 172,191,254,260, 261, 262, 270,271, 279, 301, 316, 317, 319, 329- affusions, 26, 214. douche, 240, 254. water enemata, 205. injections for hemorrhage, 251. poultices for vaginal growths, 1 80. Colocynth extract, 226. Collodium, 329, 345, 346, 347. Colpeurynter, 209, 250, 253, 254. Compound licorice powder, 294. m. gnesia powder, 294. Compresses, 303. 35^ INDEX OF REMEDIES. Compression of abdominal aorta, 257, 262. in mammary inflammation, 3 T 9- for swelling, 302. tumors, 290, 324. Condom, the, for puerperal hemorrhage, 252. Condy's fluid, 141, 276, 279, 280. Confectio sulphuris, 226. Conger eel soup, 333. Conium, 155, 271, 299, 319, 329, 331. Constipation, diet for, 226. pills for, 226. Copaiba, 162, 167, 187. Cork powder, 337, 347. Corn sow-thistle, 334. Corn-stalk pith tents, 1 1 9. Coronilla juncia, 334. Cow basil, 334. Coxeter pessary, 123. Creta prseparata, 304, 306. Creasotum, 92, 118, 185, 217. Crayons, 102, 106, 108. Crocus sativus, 38, 42, 56. Cubeba, 167, 173. Cupping, 63, 76, 230, 278, 296. Cupri acetas, 179. sulphas, 75, 100, 118, 169, 217, 313. Curette, the, 60. hand as a, 258. Thomas', 115. Curved sponge tents with spring, 133. Cusparia cortex, 75. Cypripedium, 52. Deer balls, 334. De Vigo's plaster, 323. Depletion, local, 92. Diaphoresis, 270. Diaphoretics, 239, 301, 305. Dialyzed iron, 293. Diet in albuminuria, 228, 231. mammary tumors, 322. peritonitis, 299, vaginitis, 172. for agalaxia, 335, 336. for nursing women, 333. for sterility, 154. for puerperal women, 197, 198, 3°4, 3°7- regulation of for non-malignant growths, 140. to restrain the milk secretion, 327. * to prevent mastitis, 317. Digestive tonics, 95. Digitalis, 61, 146, 155, 232, 239, 272, 289, 313. 319- Dilatation of cervix uteri, 70, 124. os uteri, 94, 216. os uteri with the finger, 246. os uteri by graduated fluid pressure, 208. Dilatation of urethra, 194. vagina, 176. rapid, of canal of uterine neck, 58, 66. Dilator bag in labor, 243. Dilators in rigid os uteri, 239. Diluents in albuminuria, 231. Diuretics, 228, 267, 299. Division of cervix uteri, 93. Drastics, 266, 267. Dry heat, 317. Ecbolics, 212. Ecraseur, 138. Emmet's, 138. Elaphomices granulatus, 334. Elastic pressure, 130. Elaterium, 265, 266. Electricity, 33, 36, 44, 54, 76, 145, 219, 247, 255, 262, 303, 333. Electrolysis, 32, 147. Emetics, 76, 272. in abortions, 212. Emmenagogues, 33, 210, 334. Emollient applications, 96. Emplastrum plumbi, 346. Enucleator, Emmet's, 138. Enemata, 30 ; cold, 227. of broth, oil and wine, 218. Ergota, 36, 40, 42, 54, 56, 61, 65, 66, 79, 83, 142, 143, 146, 167, 201, 204, 211, 212,242,243,245,251,254, 255, 250, 257, 260, 268, 296, 306, 307,319. 331. with morphia, 244. Ergotine, 29, 82, 142, 166, 201, 203. suppositories, 145. Erigeron canadense, 260. Essentials to the arrest of puerperal hem- orrhage, 260. Ether, 74, 155, 217,273, 289, 346. hypodermically, 252, 257, 260. spiritus, 223. Excision of growths, 179. Exercise, 33, 35. in the puerperal state, 197, 198. Extractum colocynihidis, 226. Extractum colocynthidis compositum, 2S4, 307- Faradic current, 145. Faradisation, 332, 336. Feculum, 169, 186, 281, 282. Fehling's mixture, 282. Fennel, 335. Ferri ammoniata, 335. bromidum, 69, 155. carbonas, 77, 78. chloridum, 63, 65, 100, 106, 149, 180, 258, 259 260. chloridi tinctura, 55, 62, 69, 79, IOO, Il8, 144, 169, 185, 228, 261, 272, 296, 307, 31*5, 326. INDEX OF REMEDIES. 357 Ferri et ammonii citras, 149. quiniae citras, 78, 222. iodidum, 54, 79- lactas, 335. mistura composita, 79. oxalas, 79. subcarbonas, 166. subsulphas, 118, 150, i3o, 261, 287. liquor, 109, 144, 14°> 227, 261. sulphas, 39, 79. 90. 9i>95, i 6 5> l66 ' 227, 261. exsiccatum, 226. vinum, 55, 79- amarum, 78, 95. valerianas, 326. Ferrum, 67, 75, 104, 146, 231, 232, 303, 328, 3^9- redactum, 42. Filh'o's caustic, 107, 119. Fish diet, 230, 333. Fceniculum, 335. Fomentations, 166, 226, 299, 33b. Food. See Diet. Forceps, the, 242, 243, 290, 291. in rigid os uteri, 239. Forcible dilatation of cervix uteri, 124. Friar's balsam, 342.. Frictions, mercurial, 280. Frigus. See Cold. Fucus crispus, 1 61. Fuller's earth, 342. Fungi, edible, 333. Galactogenic agents, 332, 323. Galbanum, 42, 73, 75, 3 2 3- Galla, 167, 346. Gallega officinalis, 332, 336. Galvano-cautery, 108, 137. Galvanic pessary, 47, 54- Galvanism, 57, 121, I47> 2I °' 2 4 2 > 2 54, 262. Gariel's air pessary, 207. Gas-cautery, 108. Gastric juice dressing, 1 4.8. Gehrung's pessaries, 135. Gelsemium sempervirens, 54, 62, 172, 245. Gentian-root tents, 120. Gentian, 91. Genu-Dectoral position, 53, 130, 154. Glycerina, 100, 107, 141, 142, 162, 169, 290, 298, 315, 343. 346. Glycerine ot borax and sulphurous acid, 224. Glycerole of borax, 225. iodine, 148. lead, 346. tannin, HO, 338, 344, 34 6 Glyceroles, 103, 161. Gossypium, 56, 212. Goulard's extract, 17S, 323, 324. lotion, 223. Granati radicis cortex, 169. Greenhalgh's flexible pessary, 125. spring pessary, 125. Guaiac, 56. Gutta percha collodion, 329. Hamamelis, 59, 67. Hcematoxyli lignum, 167. Hard-rubber pessary, 197. Heat, 70, 220 262, 300. Helleborus album, 274. nigrum, 56. Helonias, 54. Hemostatics, local, 258. Hicks' wire-rope ecraseur, 137. Hip baths, 26, 33, 247. Hedge's lever pessary, 124, 127. Hot bath for puerperal hemorrhage, 252. fomentations, 311. sand-bags for puerperal hemorrhage, 253- water douche, 239, 240. injections, 249, 294. vaginal injections, 197. Humulus, 313. Hydrargyrum, 300. _ Hydrargyri chloridum corrosivum, 03, 90, 97,140,146,169, 179, 185, 204, 224, 293, 300. mite, 42, 190, 266. 268, 271, 274, 280, 284, 295, 299, 346- iodidum rubrum, 146. viride, 148. oxidum rubrum, 185. nigrum, 214. Hygiene, puerperal, 194. Hyoscyamus, 28, 156, 187, 217,226, 227, 248,249,251,271,273, 276,307. Hypodermic use of ergot, 143, 146. ether, 252, 257, 260. morphia. See Morphia. Ice, 30, 59, 62, 70, 178, 230, 232, 254, 267, 289, 290, 299, 3 X 7, 3'9- Ice bag, 299,317, 3*9- Ignipuncture, 108. Incision of breast, 309. in rigid os uteri, 239, 243, 247. Ingluvin, 217. Injections, astringent, 122. hot water, 91, 126, 128, 301. of iron, etc., into the womb, 91,98,99, 258, 259, 260. of warm water into vagina, 247. rectal, 230. vaginal, 173, 220. Instrument to remove ovum, 205. place tents, 207. Interstitial injection of iodine, 112. 353 INDEX OF REMEDIES. Intra-uterine dilator, 209. douche, 208. injection of ergot. See In- jections. hot water. See In- jections, in puerperal hem orrhage, 255- tents, 103. Iodide of ammonium, 315. potassium, see Potassium. Iodine liniment, 29. Iodinii tinctura, 106, 113, 145, 160, 165, 170, 214, 215, 216, 223, 293, 303, 309, 318, 3 I 9>3 2 3- lodinium, 30, 31, 42, 93, 99, loo, 101, 104, 118, 141, 145, 147, 170, 185, 217, 287, 300, 313, 315, 317, 323, 331, 335. Iodized cotton, in. phenol, 97. Iodoformum, 42, 83, 102, 103, 104, 106, 118, 151, 176, 177, 178,347. Iodo-tannin, 145. Ipecacuanha, 61, 67, 162, 191, 217, 227, 245, 251, 261, 272, 274, 293. 307, 3*3- et opii, 309. Iron increases tendency to hemorrhage, 137, 140. Iron injections into the womb. See injec- tions. Inspissated ox-gall, 226. Ivory, tents of, 120. Jaborandi, 212, 232, 268, 269. Jalapa, 214, 231, 264, 266, 274, 307. Jatropha manihot, 334. Juniperus, 167. Kiwisch's ascending douche, 209. Knee-and-chest position, 53, 130, 154. Knot ties, Carroll's, 115. Krameria,64,65,68, 167,177,178,338, 347. Krause's method lor premature labor, 208, 210. Kumyss, 229. Labor, antiseptic management of, 280. Lactopeptin, 217. Lactucarium, 248. Laminaria tents, 94, 120. Laurel water, 328. Lavandula, 52. 75. Laxatives for puerperal women, 307. Leeches, 26, 30, 44, 94, .147, 174, 220, 267, 286, 293, 296, 299, 301, 303, 312, 323- Lemon for puerperal hemorrhage, 251- Lentils, 333. Ligation of varicose veins, 255. Linimentum ammonia^ iodidi et chloro- form i, 315. Linimentum chloroformi et belladonnas, 248. camphoras compositum, 93. saponis camphoratum, 302, ,3°7- Liquor ammonias acetatis, 37, 49, 55, 81, 83, 228. citratis, 79. arsenici chloridi, 97. calcis, 183, 339, 346. hydrargri nitratis, 105, 107, 118, 141, 150, 179, 324. iodinii compositus, 101, 303. ferri chloridi, 47, 251. subsulphatis, 63, 100. morphias sulphatis, 223. plumbi subacetatis, 181, 186, 289, 3°3>337> 338,345- potassae, 77, 80. potassas arsenitis, 78, 203. sodas chlorinates, 165, 186, 296. strychnias, 78, 114, 222. Lister's antiseptic method, 311. Lobelia, 62, 245. Local applications, 140. Local blood-letting, 121. Lotions, 172. Lupulina, 29, 75, 156, 249. Magendie's solution of morphia, 278, 297. Magnesia, 217. Magnesii citras, 215, 229. sulphas, 68, 95, 229. Maize, ergot of, 143. Mammary excitation, 262. > Manipulation, 76. Manual pressure in labor, 242. Marine lint, 115. Marital relations in pregnancy, 199. Marriage as a remedy, 47, 48. Massage, 45. of the uterus, 104, 262. Matico, 62, 68, 82, 84, 170. Mechanical dilata'ion of os uteri, 209. Medical treatment of tumors, 142. Medicated pessaries, 161, 162, 166. Mental conditions in pregnancy, 199. Menthas oleum or essentia, 186. Mentha pulegium, 43. Mercury, 299, 322. Milk diet, 45, 187, 229, 230, 232, 293. Mineral acids, 204, 278. waters, 147, 229. Mistletoe, 69, 146, 240, 246, 261. Mistura potassii citratis, 293. Morphia, 26, 27, 47, 53, 145, 161, 173, 186, 188, 215, 218, 248, 266, 269, 273, 286, 287, 292, 293, 294. 295, 300. used hypodennically, 231, 238, 239, 240, 243, 297, 303. Morphias murias, 186, 223, 227. INDEX OF REMEDIES. 359 Moschus, 75. Myrrha, 38, 43. Narrowing the vagina, 124, 125. Neutral mixture, 293. Nitrite of amy], 261. Nitrous oxide gas, 221, 238. Nux vomica, 91, 95, 218, 226, 230, 307. Nutrition. See Diet. Oak bark, 162. Ointments, 27, 102. Oldham's ointment, 1S1. Oleum carbolizatum, 2S0, 2S1. cajuputi, 75. olivse, 186. morrhure, 29, 326, 335. ricini, 226, 246, 293. terebinthinae. See Terebinthinae. tiglii, 232, 265. Opium, 26, 30, 47, 49, 50, 51, 57, 61, 109, I4O, l62, l66, I74, 178, 187, 2CI, 202, 203, 204, 211, 2l8, 23O, 239, 24O, 243, 246, 248, 249, 254, 255, 268, 269, 27I, 273, 276, 278, 280, 285, 287, 289, 293, 295, 2 97- Opii, extractum, 77, 78, 214. tinctura, 205, 251, 291, 302, 303. deodorata. 300. Ovariotomy, 30. Oxalas, ceiii, 214. Oxytocics, 240, 242, 255. Paquelin, thermo-cautery of, 150. Paracelsus, elixir of, 43. Pareira brava, 189. Pencils, 102, 106. Pepsin, 215, 218, 230. Pessaries, 30, 47, 54, 103, 122 et seq. 126, 134, 135. 197, 207. medicated, 173, 174, 216. rules for use of, 131. Pilocarpin, 212, 232, 269. Pinceaux, 101. Pin us canadensis, 191. Pix liquida, 112, 1 19, 186. Placenta forceps, 206. separation of, 251. Pledgets, 101. Plugs of charpie, 177. Plugging neck of the womb, 63. vagina, 209, 250. Plumbi acetas, 68, 109, 166, 170, 174, 181, 183, 188, 202, 205, 211, 254, 261. iodidum, 31, 109, 150, 161. permanganas, 166. subacetas, 170. Plumbum, 178. Podophyllum, 36. Porte-tampon, 161. Position in hemorrhage, 140. labor, 242. swelling of leg, 303. Potassa cum calce, 30. fusa, 105, 119. Potassii acetas, 183, 228, 230, 232. bicarbonas, 175, 193, 215, 295. bitartras, 228. 229, 232. bromidum, 28, 29, 30, 43, 47, 57, 68, 75, 81, 90, 113, 147, 156, 173, 216, 218, 224, 230, 232, 249, 265, 266, 267, 270, 272, 2 73, 275, 278. chloras, 31, 163, 169, 170, 173, _ 201, 225, 274, 278, 303. citras, 193. iodidum, 27, 31, 37, 93, 99, 100, IOI, 107, 113, 119, 147, 148, 164, 175, 179, 214, 218, 300, 328. nitras, 57, 108,167,175,272,295, 300. permanganas, 149, 163, 176, 277, 283, 288, 299. sulpho-carbolas, 277. "Potion de Riviere," 215. Poultices, 26, 95, 171, 248, 276, 293, 294, 2 99» 3°i ^OS- Powders, 103. Premature labor, method for, 206, 207. Pressure by hand in hemorrhage from womb, 255. in uterine disease, 97, 141, 147. Prophylaxis of eclampsia, 265. Pulsatilla, 40, 43, 167, 170. Pulvis jacobi veri, 295. glycyrrhizas compositum, 226. jalapse compositum, 228, 229. Punctures, no. Puncture of membranes to induce labor, 209. for hemorrhage, 250. Purgatives, 270,, 272 288. Quercus alba, 70. 170. Q uinia, 28, 50, 69, 77, 91, 147, 211, 212, 223, 276, 277, 278, 279, 285, 286, 288, 290, 292, 293, 295, 297. 298, 300, 303. in labor, 240. " Ready method" for puerperal hemor- rhage, 253. Rectal injections, 192. Reflex action for premature labor, 210. Rest, 172, 174, 189, 2S9, 301. Rhatany, extract of, 167. Rhei, extractum, 78, 91. vinum, 222. Rheum, 68, 226, 268. Richardson's styptic colloid, 109, 1 13. Rufus, pills of, 42. Rupture of membranes to hasten labor, 242. 360 INDEX OF REMEDIES. Ruta graveolens, 40, 43, 75, 213. Sabina (savine), 38, 40, 43, 69, 168, 211, 213. Sabinfe oleum, 36. Saffron, 36. Salicin, 218. Saline aperients, 274. Santoninum, 75. Sapo, 227. Saponified coal tar, 161. Sassafras, 162. Scammonium, 214. Scheel's method for premature labor, 210. Scutellaria, 51. Seltzer water, 231. Senega, 44. Senna, 40, 216, 315. Separation of membranes for premature labor, 211. Separation of placenta in puerperal hem- orrhage, 253. Setons, 27. Sinapis, 44, 57. Sinapisms. 262. Slippery elm bark tents, 120. Smith's modification of lever pessary, 134. Soda, chlorinated, 296. Sodii boras, ^^ 44> So, 162, 170, 181, 186, 187, 213, 225, 246, 340. benzoas, 288. bicarbonas, 37, 223, 299. bromidum, 265, 270. carbonas, 176, 179. et potassas tartras, 95. salicylas, 188, 279, 283, 2S5, 288. sulphis, 186. Spiritus aetheris chlorici, 72. nitrosi, 75. 272, 304. compos 1 us, 56. ammonise aromaticus, 222. foetid urn, 73. lavandulse compositus, 74. rosmarini, 185. Sponge tents, 70, 120, 133. to dilate a rigid os uteri, 242. for premature labor, 206 Spring tents, 133. Squaw weed, 260. Starch, 169, 186, 281, 282. Stem pessaries, '124. Stimulants. See Whisky. Stramonium, 28, 52, 53, 178, 227, 275. Strychnia, 37, 44, 78,90, 91, 142, 191, 219. Styptics, 251. Styptic glycerine, 250. Sulpho-carbolates, 188. Sulphuris, 40, 80,281. Sulphur, 'electuary 227. Sumbul, 72. Suppository, rectal, 187. Suppositories, 109, 122, 145, 174, 177, 220. Sutures, uterine, 1 15. Tabacum, 162, 1S6. Tamarindum, 64. Tampon for cystitis, 188, 204, Tampons, medicated, 161, 163. Tanaceium, 44, 186, 213. Tannin, 107, 109, 171, 178, 191, 231, 253, 254, 289. Tannin, bougie, 190. Taraxacum, 57. Tartar emetic ointment, 26. Tents, in dysmenorrhea, 53. ivory, 120. gentian root, 120. laminaria, 94, 120. rules for use of, 116. sea-tangle, 1 16. slippery elm bark, 120. tupelo, 120. uterine, 103, 1 19, 206. to induce labor, 209, 210. action in non-malignant growths, HL Tepid bath, 231. Terebinthinse oleum, 30, 44, 57, 69, 72, 75, 168, 1S7, 202, 211, 288. Thea, 171. Thermo-cautery, 108, 150. Thuja occidentalis, 179. Thymol, 150, 182, 186, 277, 288. Thymolized clay, 131, 182. Tinctura belladonnse, 223. benzoini compositum. 337, 346. camphorce, composita, 223. cardamomi composita, 223. castorei, 74. ammoniata, 73. chloroformi composita, 223. cinnamomi, 307. conii, 188. ferri chloridi. See Ferri. gallae, 145. gentiana, 1 14. hyoscyami, 186. iodinii. See Iodine. t composita, 284. nucis vomicae, 78, 193, 255, 296. opii. See Opium, opii deodorata, 61. sabina; composita, 164. sumbulis, 223. Valerianae ammoniata, 223. Tobacco, 162, 186. Tormentilla, 171. Torsion of the abdominal walls, 76. Traction on lip of os uteri to cause dilata- tion, 239. Transfusion, 262. Triticum repens, 149, 1S9. INDEX OF AUTHORS. iOI Trocar to puncture the membranes, 209. Tupelo tents, 120. Turning in hemorrhage, 250. in placenta preevia, 254, 255. Ulmus, 162. Unguentum gallae cum opii, 229. hydrargyri, 109, 185, 299, 303- 3 l8 - iodidi, 303. petrolei, 183. Urtica, 69, 82, 84. Uterine douche, III. exonerants, 212. injections, 98. sedatives and lotions, 211. Ustilago maidis, 143, 147, 246. Uva ursi, 189. Vaginal cataplasms, 161. injections, 160, 168. irrigations, 160. . suppositories, 161. Valeriana, 49, 51, 71, 72, 75. Vapor baths, 231. Varicose veins, ligation of. 255. Vaseline, 182, 191. inunctions, 229. Venesection, 229, 230, 243, 247, 264, 265, 266, 267, 26S, 269, 270, 272, 274, 280, 288, 299. Veratria, 27, 57, 93, 104. Veratrum viride, 62, 270, 272, 273, 277, 284, 288, 297, 300. Viburnum prunifolium, 57, 69, 211. Vichy water, 231. Vienna paste, 107. Vinca major, 147. Vinegar, 202, 258. injections, 231. Viscum album, 69, 146, 240, 246, 261. Wallace's spring sponge tents, 133. Warburg's tincture, 279, 288. Warm bath as a sedative. 273. fomentations to the.iead for puerpe- ral hemorrhage, 253. sitz bath, 191. water injections, 173. Weiss' female urethral dilator, 194. Whisky, 219, 272, 279, 293, 297, 298, 299. Zinci bromidum, 156. Zinci chloridum, 1 19. Zinci chloridi liquor,' 173. Zinci oxidum, 69,76, 109, 171, 183, 186. Zinci sulphas, 64, 69, 76, IOI, 102, 104, 107, 109, 119, 162, 171, 177, 18S. Zinci sulpho-carbolas, 182. Zinci valerianas, 73, 74. Zingiber, 44, 164, 216, 239. tinctura, 222. INDEX OF AUTHORS. Abegg, 335- Acosta, Mr., Paris, [09. Aitken, Wm., Edinburgh, 71. Alexander, L., Pennsylvania, 56. Allen, Joshua G., Philadelphia, 329. Althaus, Julius, 44, 333. Amussat, 141. Andrews, R. H., Pennsylvania, 66. Anstie, F. E., London, 41, 55, 326. Anselmier, 345. Aran, F. A., Paris, 49, 69, Arnold, A. B., Baltimore, 72. Ashhurst, John, Jr., Philadelphia, 146. Ashwell, S , London, 42, 57, 79, 170. Asp, G., Helsingford, 104, Atlee, Washington L., Philadelphia, 141, 145- Atthill, Lombe, Dublin, 18, 27, 33, 45, 67, 78, 92, no, 11S, 119, 124, 138, 142, 158, 162, 168, 169, 170, 218, 251. 259, 260, 261, 262. Aust-Lawrence A. E., Bristol, Eng., 151, 268. Aveling, J. H., London, 262. Bacarisse, 214. Bailly, Dr., Paris, 252. Baird, A., Edinburgh, 288. Barker, Fordyce, New York, 83, 211,227, 232, 255, 265, 274, 277, 290, 294, 301, 302, 304, 306, 307, 308, 326, 336. 337, 346, 347- Barnes, Robert, London, 37, 55, 59, 69, Si, 83, 85, 94, iG2, 138, 189, 208, 209, 239, 259 261. Bariholow, Roberts, Philadelphia, 28, 61, 217, 218, 237, 275, 288, 300, 301. Bartlett, Dr., New York, 83. Battey, Robert, Rome, Ga., 97, 103. Bayes, Dr., 154. Beach, R. E., Illinois, 113. Beck, Snow, 261. 362 INDEX OF AUTHORS. Becquerel, M., 333. Bedford, G. S., New York, 179. Bell, Robert, Glasgow, ill, 119, 145. Bennett, J. H. Wauseon, Ohio, 240. Bennett, J. M., Liverpool, 112. Bernutz, 299, 300. Berry, Win., Edinburgh, 267, 328. Binz, Prof., Bonn, 1 13. Bischoff, 2S0. Bixby, Geo. H., Boston, Mass., 169. Black, J. R. Newark, Ohio, 65, 184. Blacquieres, Dr., France, 338. Blandford, 273. Boer, M., 303. Boinet, A. A., Paris, 31, 164. Bond, Henry, Philadelphia, 206. Bonnaford, 108. Bouchut, E., Paris, 177, 178. Bourdell, M., 344, 345. Boys, Wm., Waverly, Iowa, 317. Brabazon, Dr., 194. Braithwaite, Jas., 246. Braun-Fernwald, Vienna, 186. Braun, Carl, Vienna, 209, 231, 239. Bretonneau, Dr., France, 77, 214. Brisbane, Jas., London, 253. Brochard, M., 337. Brodie, Sir Benj., 75. Brown, I. Baker, London, 156, 178. Brown-Sequard, Paris, 75. Brunninghausen, 209. Bumstead, F. J., New York, 179. Burns, Robert, Philadelphia, 69, 203. Busey, S. C, Washington, 218. Butt, R. L., Alabama, 186. Buys, Dr., Bordeaux, 164. Campbell, C. J., Paris, 236. Campbell, Henry F., Augusta, Ga., 216. Cazeaux, M., Paris. 227. Chambers, Thos. King, London, 72. Championniene, M. Lucas, Paris, 236. Charles, Dr., Belgium, 184, 226. Chapman, John, London, 70. Charcot, 156. Charriere, Dr., Paris, 338, 347. Christison, Alex., 245, 260. Christie, David, England, 262. Churchill, F., Dublin, 66, 79, 140, 205, 210, 211, 236, 312, 344. Clarke, Charles, London, 43, 164. Clarke, Daniel, Canada, 261. Clay, Charles, London, 210, 220. Cleaver, H. T., Keokuk, Iowa, 282. Clendenning, 21 1. Coe, A. S., New York, 230. Cohen, 208. Cooper, Astley, London, 171. Copeman, E., Norwich, Eng., 124, 216. Copland, Dr., 44, 80. Conteux, 330. Courty, A., Paris, 40,43, 118, 166, 235. Coxeter, 123. Craig, Prof., Washington, 79. Craig. W., Edinburgh, 226. Crawcour, J. I., New Orleans, 284. Curran, J. Waring, Dublin, 27, 66, 76. Cutter, Ephraim, Boston, Mass., 32, 140, 335- DaCosta, J. M., Philadelphia, ,40. Darby, J. T., New York, 172. Da Venezia, Dr., Italy, 219. Davis, N. S., Chicago, Illinois, 52. Davis, , 260. Delauny, Dr., 269. Demarquay, J. N., Paris, 165. D'Espine, 304. Desprez, A., Paris, 51. Dewees, W. P., Philadelphia, 55, 68, 167, 169. Dezon, 214. Dickinson, W. H., 66. Dillenberger, Emil, Vienna, 37, 50, 64. Diboue, Dr., 219. Donovan, Wm., Edinburgh, 260. Doutrepoint, 329. Dubelski, Dr., Warsaw, 218. Dubois, Paul, 212. Duncan, J. Matthews, London, 18, 48, 267. Dunster, E. S., Ann Arbor, Mich., 151, 229. Druitt, Robert, London, 338, 344. Drysdale, Chas. R., London, 48. Drysdale, Thomas M., Philadelphia, 20. Eckland, Dr., Sweden, 100. Edis, A. W., 179. Edis, Thos., London, 130, 154, 163. Edwards, Dr., Denbigh, 124. Ellis, Robert, London, 105. Elsasser, 345. Emmet, Thos. Addis., New York, 126, 138, 150, 188, 191. Etheridge, J. H., Chicago, 111., 85. 87. Eulenberg, Albert, Berlin, 214, 215. Fehling, H., Leipsic, 269, 281. Field, Henry M., Boston, Mass., 79, 167. Fifield, Dr., Weymouth, 328. Finch, T., Illinois, 163. Flint, Austin, sr., New York, 71. P'onnsagrives, J. B., Paris, 37, 49, 82, 168, 178,212, 231, 331, 332. Forwood, W. S , Darlington, Md., 216. Fothergill, J. Milner, London, 28. Fournier, M., Paris, 171. Frachaud, Dr., 234. Frankel, Dr., Breslau, 244. Frisbie, C. W., East Springfield, N. Y., 51. Fritsch, Halle, 282. Fritz, Dr., Paris. 39. Fuller, C, 218. INDEX OF AUTHORS. 363 Gaillard, Dr., Paris, 77. Galabin, N. L., London, 147, 157. Gallard, M. T., Paris, 106, 176. Gallois, F. A., Paris, 145. Gardner, Dr., 329. Garratt, A. C, Boston, Mass., 181. Gazzo, Jno. B. C, Thibodaux, La., 3T4. Gehrung, Eugene C, St. Louis, Mo., 135, 188. German Pharmacopoeia, 74. Hospital, Philadelphia, 339. Gilbert, S. F., Elysburg, Pa., 189. Gill, D., St. Louis, Mo., 184. Glover, Jas. G., London, 276. Goldsmith, W. T., Georgia, 119, 120. Godson, Clement, London, 125, 206. Gooch, 272, 273. Goodell, Win., Philadelphia, 67, 117, 120, 124, 146, 147, 179, 192, 292. Goolden, Dr., 328, 329. Graham, Douglas, Boston, Mass., 45. Graves, R. J., Dublin, 34, 76. Greene, Dr., Dorchester, 220. Greenhalgh, Dr., m, 120, 124. Griffith, G. De Gorrequer, London, 141. Gross, Samuel D., Philadelphia, 322. Grunewall, 304. Guadriot, Dr., Paris, 173. Guipon, Dr., Paris, 166. Hall, Marshall, London, 154. Halton, Dr., Dublin, 114. Hamburger, Dr., 161. Hamelin, E., 43, 213. Hamilton, Dr., Edinburgh, 207. Hardy, Dr., 182, 344. Harris, Robert P., Philadelphia, 200, 227, 233, 238, 265, 336. Harrison, Geo. T., New York, 256. Hartshorne, Henry, Philadelphia, 44, 51. Haussmann, Dr., Berlin, 337, 346. Hayes, P. S., Chicago, 111., 44. Hauck, 335. Herrick, O. E. Greenville, Mich., 121. Hewitt, Grailly, London, 26, 42, 62, 68, 75, 78, 86, 148, 153, 170, 179, 184, 185, 189,304. Hicks, Braxton, 119, 149, 182, 261. Hildebrandt, 143, 146. Holt, Joseph, New Orleans, 283. . Hoist, 178. Home, 43. Horton, H. L,, New York, 241, 244. Hopkins, 209. Hospitals of Paris, 132. Hospital of University of Pennsylvania, 39- Howe, J. W., New York, 263. Huguier, Dr., France, 27. Huebner, Dr., Dresden, 319,338. Hunt, Harry, Dartmouth, England, 211. Hunter, E. H. W., Georgia, 31. Huter, 209. Image, F. E., 217. Izard, Walter, Liberty, Va., 282. Jackson, A. Reeves, Chicago, 111., 182. Jacobi, Mary Putnam, New York, 55. Jacquet, 270. Jaret, Dr., 41. Jenks, E. W., Chicago, 111., 57, 212. Jewett, Theodore, Bowdoin College, 50. Johnson, Dr., 344. Johnson, W. B., Alabama, 84. Jones, G. S., Boston, Mass., 181. Jones, M. O., Chicago, 111., 216, 219. Joulin, 335. Kammerer, Joseph, 101. Keating, W. V., Philadelphia, 146, 330. Keifer, C. B., Indiana, 316. Kelly, Bernard, London, 248. Kerr, E. W., England, 261. Kimball, G., Lowell, Mass, 32. Kinsman, D. N., 104. Kirkpatrick, J. R., Dublin, 131. Kiwisch, 209, 335. Klebs, Prof., Prague, 288. Kluge, Dr.. 209. Koeberle, Prof., 19, m, 118. Koehler, Dr., Germany, 253, 262. Koening, Dr., 319. Krause, 208. Kucker, Dr., Germany, 290. Kunst, A. II., Weston, W. Va., 271. Kurz, Edgar, Tubingen, 317. Lane, John Win., London, 329. Lange, 335. Langlebert, Edmund, Paris, 165. Larrabee, J. A., Louisville, Ky., 287. Laycock, Dr., 76. Leblond, A., Paris, 103, 106, 160, 17S. Legroux, 345. Le Dieborder, Dr., Paris, 33S. Leishman, Wm., Glasgow, 202, 207, 215, 226, 228, 242, 255, 272, 291, 299, 305, 327, 336, 344. Lente, F. V., Saratoga, N. Y., 219. Lever, 211. Liebman, 100. Lisfranc, Dr., Paris, 51. Lister, Dr., London, 31 1. Locock, Charles, 53, 56, 75, 217. Long, W. H., Louisville, Ky., 240, 261. Loudon, Charles, 154. Ludlow, J. L., Philadelphia, 331. Lusk, W. T., New York, 237, 246. Lyman, G. H., 70. Macan, A. V., London, 252. Macdonald, Angus, Edinburgh, 267. Maddon, T. M., London, 146, 147. 364 INDEX OF AUTHORS. Maissonneuve, M„ Paris, 165, 325. Mann, Dr., 262. Marsh, H., 79. Massmann, Dr., 269. Maury, Dr., New York, 244. McClintock, Dr., London, 140, 145, 252, 344-. McGuire, Hunter, Richmond, Va., 314. Meadows, Alfred, London, 68, 155, 156, 203, 209, 243, 248, 249, 254, 274, 280. Meissner, 209. Miller, Hugh, Glasgow, 287, 288, 316. Milne-Edwards, Dr., 244. Milton, Dr., 185 Mitchell, S. Weir, Philadelphia, 73. Moller, Dr., Vienna, 262. Morgan, Mr., Litchfield, Eng., 124, Morris, John, Baltimore, Md., 173. Morton, D , United States, 244. Muller, P., Berne. 212. Mulreany. Jos., England, 174. Munde, Paul, New York, 98. Murphy, P. J., Washington, 288'. Mussy, N. G., 103. Napier, A. D. L., London, 251. Napheys, Geo. H., Philadelphia, 198. Neal, Richard, London, 182. Neftel, Wm, B., New York, 161. Newman, T. J., Chicago, 111., 28. Newman, W., Fulbeck, England, 328. New York State Women's Hospital, 99. Neimeyer, Felix Von, Tubingen, 73. Nceggerath, E., New York, 232. O'Hara, Michael, Philadelphia, 347. Oppenheimer, L. S., Louisville, Ky., 70. Ore, D., Bordeaux, 238. Pajot, Prof., 102. Pallen, Montrose A., New York, 131, 182, 229. Panas, M., Paris, 63. Parish, W. H., Philadelphia, 286. Parry, John S., Philadelphia, 228.313. Peaslee, E. R., New York, 31, 145, 178. Penrose, R. A. F., Philadelphia, 258, 260. Pereira, 43, 168. Peters, Dr., Prague, 180. Philadelphia Hospital, 96, 313. Phillips, C. D. F., London, 43, 56, 79, 169, 170, 217, 245, 269, 275, 2S7, 319, 345- Piffard, H. G., New York, 179. Pinard, A., P;uis, 225. Pintschovius, Dr., Ketzin, 40. Pitois, Prof., Rennes, 218. Playfair, L., London, 93, 103. Playfair, W. S , London, 200, 209, 218, 219,220,221,227,228, 233, 238, 242, 248, 250, 257, 264, 273, 279, 289, 293, 303, 304, 310, 343. Porter, F. T., Dublin, 42, 73. Powers, J. L., Reinbeck, Iowa, 318. Purple, S. S., New York, 347. Putnam, S., Montpelier, Vt., 271. Raciborski, 37. Recamier, Madame, 70, 102. Reamy, Thad. A., Cincinnati, O., 245.' Reid, A. P., Montreal, 77. Reynolds, 211. Richardson, Dr., Tunbridge Wells, 329. Richardson, W. L., United States, 245. Richter, Carl, Berlin, 285. Ricord, 214. Ringer, Dr., London, 41, 66, 68, 185, 217, 238. Roberts, F. T., Manchester, 77, 112. Robinson, C. E., West Union, Iowa, 282. Rokitansky, jr., 209. Ronzier-Joly, 41. Rousset, Prof., 328. Routh, C. H. F., London, 146, 148, 327, 328, 329, 333, 342. Russel, P. E., England, 232. Sale, E. P., Aberdeen, Miss., 103. Sawyer, E. W., Chicago, 111., 342. Saxe, A. W., California, 140, Scanzoni, Prof., Germany, 106, 1 18, 163, 178, 210. Scheel, 209. Schmidt and Urner, 117. Scholler, 209. Schroeder, Karl, Erlangen, 98, 177, 181, 204, 208, 215, 233, 253, 264, 305. Schucking, 281. Schullze, B. S., Jena, 116. Schnerr, Dr., 328. Scudder, 245. Sell, E. H. M., New York, 244. Simpson, A. R., Edinburgh, 69, 147, 287. Simpson, Sir Jas. Y., Edinburgh, 44, 67, 121, 141, 147, 149, 178, 275, 324. Sims, J. Marion, New York, 124, 141, 178, 216,219. Sireday, 37, 161. Skene, A.J. C, New York, 115, 187, 192, 201. Skinner, 333. Sloan, S., Glasgow, 339, 344. Smith, Albert H., Philadelphia, 134, 238, 246, 249, 346. Smith, Q. C, California, 313, 329, 346. Smith, Tyler, London, 168,210,223, 229, 248. Spiegelberg, Otto, Breslau, 26S, 270. Stackler. 214. Stanislaus, Martin, Auvergne, 329. Stephenson, W., London, 244. Stille, Alfred, Philadelphia, 41, 74, 213, 331- Stokes, J. G., Illinois, 212. INDEX OF AUTHORS. 36 = Storer, H. R., Newport, R. I., 1S1. Srrudwick, Dr., 256. Sussdorf, G. E.. New York, 81, 120. Swayne, J. G., England, 205. Taliaferro, V. H., Atlanta, Ga., 97, 119. Tait, Lawson, Birmingham, Eng., 29, 47, 84, 96. 103, 104. 120, 158, 166, 174, 183, Tanner, T. H., London, 42, 67, 170, 184, 186, 220, 221, 225, 326. Tarnier, S., Paris, 45, 209, 211,214, 22 4> 227, 229. Thierry, Prof., Brussels, 76. Thomas. J. P. Kentucky, 162. Thompson, Ashburton, London, 314, 3 rS. Thompson. H., London, 149, 189. Thompson. Rezin, U. S., 162. Thomas, T. Gaillard, New York, 22, 31. 35, 46, 60, 66, 70, 78, 95, 108, 115, 116, 137. 149. !5 2 , 2I 9> 2 5 6 . 26 3> 2 9 2 - Tilt, Edward J., London, Eng., 26, 27, 30, 36, 41, 42, 43, 55, 57, 61, 65. 66, 67, 69, 70, 71., 78, 99, 102, 103, 116, 118, 119, 122, 146, 147,148,154, I.56, I58, 165, l6S, I70, I79, l82 3 l87,I90,2I9,220, 287. Trask, Dr., London, 261. Traube-Rosenstein, 269. Travers, Dr., 291. Trelat, Prof., P iris, 164. Trenholni, E. H., Montreal, Canada, 287. Trousseau, Prof., Paris, 44. Tuke, Dr., London, 273. Turnbull, Laurence, Philadelphia, 155. Tye, Geo. A., Canada, 259. Varaseau, 244. Veit, Dr., 335. Velpeau, Prof., Paris, 144, 345. Vienna Hospitals, 347. Von Hecker, Prof., Munich, 260. Walker, J. W. Indiana, 143. Wallace, Ellerslie, Philadelphia, 133. Walters, John, London, 259. Ward, O , Tennessee, 55. Warren, John S., New York, 193. Weber, F., St. Petersburg, 176. Wells, Spencer, London, 19, 147. West, Dr., London. 185, 1S6. White, H. B., Brooklyn, N. Y., 268. White, James P., Buffalo, N. Y., 100, 287. Wiglesworth, Arthur, Liverpool, England, 2 43- Wiikins, W. W., New Hampshire, 100. Williams, John, London, 33, 54, 130. Williams, R , 113. Williams, Wynne, London, 148. Wilson, Ellwood, Philadelphia, 58. Wilson, Erasmus, London, 185, 339. Wilson, H. P.C.,Baltimore, Md.,258, 261, 287. Wilson, Dr., Glasgow, 343. Wilson, 345. Winckel, F., Rostock, Germany, 182, 251, 267, 289, 299,301.303,304, 3i7,335o45- Windebrand, Dr., 262. Woodbury, Henry E., Washington, 53,101. Woodruff, Julian S., South Carolina, 53. Workman,}., Toronto, Canada, 68, 261. Wright, C. O., Cincinnati, Ohio, 185. Van DeWarker, Ely, New York, 152, 221. Zweifel, Prof., Erlangen, 2S1. Published by I>. C*. BRINTON, M. 13. , 115 South Seventh Street, Philadelphia, Pa. B@" Any of these works will be forwarded by mail, postpaid, on receipt of the printed price. Remittances may be made at the risk of the publisher, and the safe delivery of the books to the purchaser is guaranteed, provided the amount is sent either (1) by postal order, (2) by registered letter, (3) by bank draft on Philadelphia or New York, or (4) by express. All postal orders and drafts to be drawn to the order of D. G. Brinton. A WEEKLY JOURNAL. Edited Toy I>. G5-. BE^XlNTOINr, MI. I>. ISSUED EVERY SATURDAY. LARGE OCTAVO, DOUBLE COLUMNS, 22 TO 24 PAGES OF READiNG MATTER IN EACH 99UMBER. The Reporter was established in 1848, and now has attained as large, if not the largest, circulation of any medical weekly in this country. It has achieved this through its independence of all cliques, its steady devotion to the highest interests of the regular profession, its energy in obtaining the most important scientific news, the value of its original articles, its broad national character, and its attention to the practical and clinical aspects of professional study. The CONTENTS of the Reporter are arranged as follows : 1 . Original Lectures, reported expressly for it from the leading clinical centres of the Union. 2. Original Communications, embracing articles on special subjects by experts, and by no means excluding the less authoritative but often highly valuable contributions of private practitioners and country physicians. In fact, the Reporter has always aimed to bring into the service of science the stores of practical medical knowledge accumulated by medical observers in the rural districts. 3. Hospital Reports, being selected clinical cases from the hospitals at Philadel- phia, New York, Boston, Chicago, Louisville, Cincinnati and other cities; as, also, reviews of the hospital treatment of usual diseases in the great hospitals in all parts of the country. All these reports are original, and to be found solely in the Reporter. 4. Medical Societies. — The proceedings of all the National Societies, the Ameri- can Medical, Social Science, Gynaecological, Ophthalmological, etc., and of most of the State and many county societies, in so far as they have a direct interest for the practising physician, are carefully presented, usually by reporters representing this journal only. Thus the whole profession, in its organizations, is regularly recorded. 5. Periscope. — Under this heading are grouped translations from the German, French and other languages, and abstracts and selections from English and Ameri- can journals. The exchange list of the Reporter includes all the prominent medi- cal journals of the world, and the selections from this immense mass of material are made by competent gentlemen, with the view of giving the greatest variety and freshest information, particularly in the departments of Diagnosis and Treatment. 6. Notes on Current Medical Literature are brief references to the mass of pamphlets, reprints, monographs, announcements and new journals, which constantly pour into an editor's office. 7. Reviews and Book Notices. — All new books received from medical publishers of this and other countries are promptly noticed by judicious and impartial critics. The notices are rarely lengthy, but they are aimed to express a correct opinion of the merits of the book, without fear or favor. 8. Editorials. — One or more editorials appear in every number, usually on some question of current interest. They are written by different hands, but the editor assumes full responsibility for the opinions expressed. 9. Notes and Comments, — These are brief editorial notes on the views of other journals, on novelties in surgical or medical invention, on new remedies, on points of practice, on pending discussions, etc. Very generally a column or two are given to " Therapeutic Notes," wherein the latest suggestions in therapeutics are brought forward. 1 0. Correspondence. — This department is an important feature. Brief letters, replies and criticisms, letters from foreign parts, and original suggestions of all kinds here find a place. 11. News and Miscellany. — Under this heading are presented the medical news of the day, items bearing on professional movements, personals, obituary notices and resolutions, " queries and replies," and marriages and deaths of medical men and in their families. 12. Advertisements. — The wide circulation of the Reporter renders it a favorite medium for those who have anything which they wish to bring to the notice of the profession. New remedies, novel surgical appliances, medicinal waters, human and bovine virus, approved pharmaceuticals, new books, medical colleges, sanitary retreats and asylums, practices for sale and desired — all will here be found, besides many other matters of interest. While the editor does not hold himself responsible for statements made either by correspondents or advertisers, he never knowingly admits any advertisement of any secret nostrum or quack remedy, instrument or institution. In its Contributors the Reporter aims to represent the whole country, not any section, city or state, and a wide variety of medical opinion and research. Within the past year (1879) not ^ ess tftan three hundred and thirty-one (331) different writers contributed original material to its columns. Of this large number we quote the names of a few, as follows : Dr. D. Hayes Agnew, Philadelphia. " A. B. Arnold, New York. " John H. Brinton, Philadelphia. " William A. Byrd, Quincy, 111. " Hiram Corson, Pennsylvania. " L. A. Duhring, Philadelphia. " G. Do well, Galveston, Texas. " S. D. Gross, Philadelphia. " William Goodell, Philadelphia. '■' William A. Hammond, New York. " J. M. Keating, Philadelphia. " A. H. Loomis, New York. " J. Morris, Baltimore. " D. J. Reynolds, Louisville. " L. A. Sayre, New York. " T. Gaillard Thomas, New York. " R. A. Vance, Cincinnati. " H. C. Wood, Philadelphia. Dr. E. Andrews, Chicago. " H. R. Bigelow, Washington. " L. D. Buckley, New York. " J. Solis Cohen, Philadelphia. " J. M. Da Costa, Philadelphia. " N..S. Davis, Chisago. " A. Flint, New York. " M. Gunn, Chicago. '•' Frank H Hamilton, New York. " A. Tacobi, New York. " R. J. Levis, Philadelphia. " J. J. Larrabee, Louisville. " William Pepper, Philadelphia. " B. W. Richardson, London. " E. C. Seguin, New York. * L. Turnbull, Philadelphia. " A. Vanderveer, Albany. " J. T. Whittaker, Cincinnati. Price and Terms. — In proportion to the actual amount of reading mat- ter furnished subscribers and the quality of its make-up, the Reporter is not surpassed in cheapness by any medical journal in the United States. Its two volumes yearly (beginning in January and July) contain over twelve hundred (1200) large, double-column pages of reading matter, printed on super-calendered paper manufactured expressly for it. The price is five dollars ($5.00) a year, payable in advance. A Specimen Copy will be mailed free to any address on application by postal card ; and the journal may be taken " on trial " for three months for one dollar, at the expiration of which time, if the journal is continued, five dollars for a full year is to be remitted. Subscriptions may begin at any time during the year. 3 THE HALF-YEARLY COMPEL OF MEDICAL SCIENCE. Edited by D. G^. BRIINTOX, M. I>. PUBLISHED JANUARY AND JULY OF EACH YEAR. LARGE 8VO. EACH NUMBER ABOUT 300 PAGES, WITH INDEX. The Compendium has been established over ten years and commenced with January, 1880, its third series. It is made up of translations, selections and abstracts from all the regular medical and pharmaceutical journals of the world, and is intended to represent, in brief, the advance of all departments of medical science every six months. While experimental and theoretical branches are included, attention is chiefly given to the conquests of positive medicine and the matured results of chemi- cal experience. The articles in each number are arranged under the following heads ; I. Anatomy, Physiology and Pathology. II. Physics, Botany, Chemistry and Toxicology. III. Pharmacology, Materia Medica and General and Special Therapeutics. IV. General Medicine, including the History of Medicine, State Medicine, Epidemiology and Animal and Vegetable Parasites. V. Clinical Medicine, divided into General and Local Diseases. VI. Obstetrics, Diseases of Women and Diseases of Children. VII. Surgery, including General, Military and Mechanical Surgery, Local Sur- gery, Diseases of the Skin and Venereal Diseases. Of the various Retrospects and Abstracts published in this country this is the only one which gives at once full and fair attention to American as well as Foreign medi- cal writers, and as such, and on account of its intrinsic excellence, it deserves the especial support of the American profession. Every number is illustrated, and is indexed and complete in itself; but the paging is so arranged that at the close of each series, each of the above seven parts can be bound to form a separate volume, for which a separate index is supplied. The Compendium, while an independent publication, is arranged to be taken along with the Reporter. The same article does not appear in both journals ; the Com- pendium is made up with a view to include no article which has been or will be printed in the pages of the Reporter. Hence the two periodicals are complementary of each other, while still wholly independent. PRICES. The regular price for the Compendium for one year (two numbers, 300 pages each, bound in paper,) is $2.50. A discount is allowed on the Reporter and Compendium when taken together, as follows : The Weekly Medical and Surgical Reporter, - - ^5 00 The Half-Yearly Compendium of Medical Science, - - 2 50 The Reporter and Compendium, taken together, - - 7 00 Jg^T Payable in advance, direct to the publisher. A Table of Contents of a number of Half- Yearly Compendium will be sent on application to the publisher. A single copy will be sent for examination for One Dollar. "A number of ' Visitiny Lists 9 offer tliemselves as candidates for doctors 9 favor. We are decided in our opinion that 'Butler's Physician's Pocket Record/ issued by JD. G. Brinton, is unri- valed in its excellence." — Louisville Medical News. THE PHYSICIAN'S DAILY POCKET RECORD, COMPRISING A Visiting List, Many Useful Memoranda, Tables, etc. By S. W. BXJTJL.ER, M. 3D> . Fourteenth Year. New and Thoroughly {Revised Stereotype Edition for 1880, with Metric Posological Table, do. Edited Annually, and Adapted for 35 or 70 Patients Daily. Strongly Bound in American Russia, "With Steel Spring Clasp. T)T)Tpr /EDITION FOR 35 PATIENTS DAILY, - $1.50 1 j\1UJL/1 EDITION FOR 70 PATIENTS DAILY, - 2.00 The name of the purchaser will be stamped, in gilt letters, on the tuck, for ten cents extra. For this year (1880), this favorite Visiting List has been brought out, with many improvements. The popular arrangement of the ruling and blank forms has been continued, as well as the "perpetual almanac " feature. The latter gives this List the great advantage that it may be begun at any time during a year, and may be used, continuously, one full year from the first entry, and does not, like other Visiting Lists, become as useless as an old almanac at the close of the calendar year. The binding of the Pocket Record is in desirable red leather (American Russia) ; and instead of a tuck (which often tears), it has a steel spring clasp. exceedingly convenient in use. A pocket is provided in the cover, for carrying pre- scription blanks, etc. The contents of the new stereotype edition of the Pocket Record are as follow : 1. A Perpetual Almanac, from 1861 to 1917. 2. Explanation of the Metric System. 3. Posological Table, arranged in alphabetical order, giving the doses of medicine in both apothecaries' weight and the metric system. 6. Doses of medi- cine for Hypodermic Injection. 7. Doses for Inhalation. 8. Doses for Supposi- tories and Pessaries. 9. The Treatment of Emergencies, including Poisoning, Poisonous Bites and Wounds, Asphyxia and Drowning. 10. Table exhibiting the normal and abnormal qualities of urine, their significance and tests. 11. New Remedies and Recent Preparations in Pharmacy, described with doses and uses. 12. Table of Signs. 13. Table for calculating period of Utero-Gestation. 14. Vis- iting List, Obstetric Record, Vaccination Record, Cash Record, Death Record, etc. Many physicians who have made use of this Record during the period it has been before the profession, have expressed themselves in the highest terms of its convenience and suitability for the purpose. It is sufficient to quote the opinion of the editor of the Louisville Medical News, given above, and the following, lately received from Dr. L. C. Butler, ex-President of the Vermont State Medical Society : "After using the Physician's Daily Pocket Record for the past twelve years, I am still so well pleased with it that I would not change it for any one of the numerous works of the kind that have been published during that time. It is all the ' Day Book' a physician needs. The new edition just issued is an improvement on the former, in the new and important matter introduced, greatly increasing its prac- tical value." THE MEDICAL REGISTER AND DIRECTORY OP THE UNITED STATES, SYSTEMATICALLY ARRANGED BY STATES. Comprising Names, Post-office Address, Educational and Professional Statis- tics, of more than 60,000 Physicians, with Lists of Medical Societies, Colleges, Hospitals and other Medical Institutions, -with Abstracts of the Medical Laws of each State, Notes of Mineral Springs, etc. By SAMUEL W. BUTLER, M. D. Second Edition, Revised and Corrected. One Volume, large octavo, double columns, 874 pages. Price, Cloth, $5.50 ; Leather, $6.50. The Second Edition of this important work has been prepared at great cost of time and money. The lists have been carefully revised by leading medical men in each State. Nearly ten thousand new names have been added, and numerous cor- rections made. )§£§"*' The publishers will be glad to receive information of changes of location from physicians. A Biographical Dictionary of Contemporary American Physicians and Surgeons. SECOND EDITION. Edited by WM. B. ATKINSON, M. D., Permanent Secretary of the American Medical Association, and of the Pennsylvania State Medical Society ; Lecturer on Diseases of Children at the Jefferson Medical College, etc. €ne Volume, Royal Octavo, Double Columns, 780 Pages, on Fine, Tinted Paper. Price, in extra cloth,, beveled edges, $5.00; in full leather, $6.00. This really monumental work, the fruit of enormous labor and outlay, contains the biographical sketches of more than twenty-eight hundred contemporary regular physicians of the United States, prepared from materials in most instances furnished by themselves, and hence entirely trustworthy. Indexes of names and places are appended. The effort has been made to embrace all who have visibly contributed to the advancement of medical science in all parts of the Union, and the volume presents a mass of most valuable historical, biographical and scientific material. AST A few copies of the First Edition, with nearly a hundred fine steel engrav- ings, for sale at $10.00 each. Operative Surgery and Surgical Anatomy. BY PROFESSOR CLAUDE BERNARD, Membre de ITnstitut (Academie Fran9ais et Academie des Sciences), and OH. HTJETTE (DE MONTARGIS.) Illustrated by eighty-eight PLATES, Drawn from NATURE and Engraved on STEEL. Translated from the French, and Edited, by ARTHUR TREHERNE NORTON, F. R. O. S., Lecturer on Surgery, St. Mary's Hospital, London, etc. In One Volume, 441 Pages, 88 full-page Steel Plates. Price, Cloth, $8.00; Full Leather, $9.00. This magnificent and classical work deserves the especial attention of the Ameri- can profession. The names of the authors are a guarantee of its excellence, and it can be claimed, without fear of contradiction, that the artistic finish and anatomical accuracy of the plates surpass any others which have been placed in the market. The remarkably low price at which it is offered renders it the cheapest, as well as the most perfect, work on Operative Surgery ever published in this country. The highest testimonials to its value have been given by the English and Ameri- can press. It covers the whole domain of surgery, embracing surgical gynaecology and orthopedics, as well as all the most approved general and special operations. The descriptions are full, clear and accurate, and will be found to be of the most, satisfactory character to practical surgeons. The translator, Mr. Norton, has added abundant details of the many improve- ments in Operative Surgery which have been introduced since the publication of the French work, and where more than one operation may be performed, special refer- ence is made to that most approved by surgeons of the present day. He does not confine himself to a mere rehearsal of the steps of a procedure, but gives the surgical anatomy of the part, and the points of diagnosis, describes the instruments, and mentions the accidents which may follow. In this manner the work is rendered a. standard treatise of great completeness and permanent value. In size it is a com- pact octavo, convenient for holding, and for this reason superior to the large atlases. The general contents of the work may be seen from the following summary : Plates I- VI. Minor Surgery, Arteriotomy, Torsion. " VII-XVII. Ligations of Arteries. XVIII-XXVII. Disarticulation. XXVIII-XXXIV. Amputations and Resections. XXXV-XLIII. Operations on the Eye and Ear. XLIV-LVII. Hare-lip, Stammering, Nasal Polypi, Staph ylor- aphy, Extirpation of Goitre, Brorichotomy,. etc. LVIII-LXXI. Operations on the Abdomen, Hernia, Artificial Anus and Rectal Surgery. LXXII-LXXX. Operations on the Penis, Scrotum and Bladder, Lithotomy, etc. " LXXXI-LXXXVI. Operations on the Genital Organs of Women. " LXXXVII, LXXXVIII. Tenotomy, Club Foot, etc. Each one of the plates contains from two to ten figures, most carefully designed, and engraved. THE MODERN THERAPEUTICS SERIES. EDITED TO 1880. I. MODERN MEDICAL THERAPEUTICS. A Compenaium of Recent Formulae and Specific Therapeutical directions from the practice of eminent contem- porary physicians, American and foreign. By Geo. H. Napheys, A. M., M. D. 1 vol., 8vo., pp. 607. Price, Cloth, $4.00; Sheep, 85.00. II. MODERN SURGICAL THERAPEUTICS. A Compendium of Current Formulas, Approved Dressings and Specific Methods for the treatment of Surgical Diseases and Injuries. By Geo. H. Napheys, A. M., M. D. 1 vol., 8vo„ pp. G08. Price, Cloth, $4.00; Sheep, S5.00. HI. THERAPEUTICS OF GYNAECOLOGY AND OBSTETRICS. Edited by Wm. B. Atkinson, M. I)., etc. 1 vol., Svo., pp. 366. Price, Cloth, S3.00; Sheep, $3.50- Sold separately at the prices given, or the three volumes, in cloth, at one order, for $10.00 ; in sheep, at $12.00. The very great popularity which the first two of these works have achieved has led to the completion of the series on the same plan, by the addition of the third member, the Therapeutics of Gynecology and Obstetrics, under the able editor- ship of Dr. Wm. B. Atkinson. It is not too much to say that there are no other works in the language of equal practical value to the working physician. Proof of this lies in the fact that since their first appearance the publisher has offered, in all cases where the books were ordered without previous examination, to take them back and refund the price, if, on arrival, they were not satisfactory, and that, in not a single instance, has he been asked to do so. This offer is continued. THE MEDICAL THERAPEUTICS. The total number of authors quoted is 723, and the precise formulas given, 11 24. Each disease is taken up and its treatment presented according to the latest and best authorities in Europe and this country. Many of the directions and formulae have never been published elsewhere. A "Resume of Remedies " follows each disease, showing all the drugs which have a well-merited reputation in the therapeutics of the complaint. Nor are the descriptions confined to drugs only, but every therapeutic resource in a disease is specified, including electricity, bathing, mineral waters, external applications, climate, diet, sanitation, etc., etc. Thus, in the Therapeutics of Diseases of the Respiratory Organs, we have : Grindelia, lobelia, caffea, etc., in asthma. Formulae for medicated cigarettes. Thirty pages are devoted to the treatment of acute and chronic bronchitis, coryza and catarrh. Hay asthma (rose cold) is thoroughly discussed. On Phthisis there are 25 pages, giving, besides the ordinary treatment from Da Costa, Williams, Flint, Walshe, etc., the hygienic rules of Aitken, Both's plan of cal- cification of the lungs, Churchill on hypophosphites, Dobell's pancreatic emulsion, Jaccoud's arsenical treatment, Maclaren's rules for sea voyaging, Yeo on antiseptic inhalations, etc. Special attention has been paid to New Remedies, New Preparations, and the indigenous materia medica of the United States. THE SURGICAL THERAPEUTICS. The number of authors quoted is 418; the number of their prescriptions given, 1008. The special object of this work is to set forth the medical aspect of Surgery, to collect in one volume the Therapeutics of Surgery, the formulae and medical treatment of Surgical diseases of the most eminent surgeons. The following points from the chapters on " Wounds," will show the subjects treated : General and local anaesthetics, anaesthetic mixtures, anaesthesia of the larynx. Burow, Porcher and Wood's open treatment of wounds, Gamgee's anhydrous dressings, Guerin's raw cotton dressings, water dressings, Dolbeau's alcoholic dress- ings, Hewson's earth dressings, Lister's carbolated dressings, Spence's boracic acid dressings, Polli's sulphite dressings, etc. Bartholow's, Hyatt's and Holmes' methods with erysipelas. Dr. Garretson's specific combination. Hemorrhage : Richardson's styptic colloid, styptic lint, wool, cotton and col- lodion. Styptic mixtures of Pancoast, Pagliari, Martin, etc. Methods of torsion, and pressure, and cold. The immediate and later treatment of primary and second shock, by Brunton, Hood. Fothergill, Smith, Gross, Fuller, Holmes, etc. The use of physostigma, aconite, atropia, strychnia, etc., in tetanus. Wier Mitchell on traumatic paralysis and neuralgia. The latest views of the German surgeons, Esmarch, Stromeyer and Billroth, on gunshot wounds. The best remedies in hydrophobia. Halford's ammonia treatment of snake bites. Numerous applications for burns, scalds, frost bites, bed sores, carbuncles and boils. OPINIONS OP THE PRESS. From a very large number of lengthy and favorable reviews of this work we quote the following brief expressions : Boston Journal of Chemistry. " Contains the latest improvements in treatment." New York Medical Journal. "Of much value to the surgeon and general practitioner." New York Medical Record. " Invaluable to every practicing physician." Buffalo Medical and Surgical Journal. "Wisely made up from the best and most recentauthorities." Philadelphia Medical and Surgical Reporter. " A pre-eminently useful work." Philadelphia Medical Times. "All that is in the book is good." Maryland Medical Journal. " Most valuable additions to medical and surgical litera- ture." Cincinnati Medical News. " It affords the reader an intelligent idea of the combining of remedies for the fulfilling of definite indications." Cincinnati Lancet and Observer. " Two volumes, equally valuable to the general practitioner." Cincinnati Clinic. " The thoroughness of this collection seems quite surprising." Detroit Lancet. " The author has attained his aim with more than usual success." St. Louis Clinical Record. " A unique book ; it shows vast labor on the part of the author." Louisville American Practitioner. " Cannot fail to help almost any practitioner." The Dental Cosmos. "A valuable addition to any medical library." The Therapeutics of Gynecology and Obstetrics. EDITED BY WM. B. ATKINSON, A. M., M. D., ases of Children, at the Jefferson Medical College ; Physician to th rics and Diseases of Children, Howard Hospital, Philadelphia ; Pern Secretary of the American Medical Association, etc. 1 vol., 8vo., 366 pp. Price, Cloth, $3.00; Full Leather, $3.50. Lecturer on Diseases of Children, at the Jefferson Medical College ; Physician to the Department of Obstetrics and Diseases of Children, Howard Hospital, Philadelphia; Permanent Secretary of the American Medical Association, etc. This new work, just issued, presents a condensed, carefully weighed and accu- rately presented review and estimate of the therapeutical resources of the gynaeco- logist and obstetrician. The remarkable activity which has characterized this specialty of late years, the numerous monographs and journals devoted to it, have vastly increased its materia medica and forms of therapeutics ; and a summary of these discoveries and improvements cannot fail to be welcome. The general plan adopted is similar to that so deservedly popular in "Napheys' Modern Therapeutics." The most recent publication of the European press, and all the special journals of both continents have been laid under contribution. It is divided into two parts, embracing the principal diagnostic features and the treatment of leading practitioners in diseases of women and obstetric complications. The contents of the two parts are as follow : PART I.— GYNAECOLOGICAL THERAPEUTICS. CHAPTER I. Diseases of the Ovaries, Disorders of Menstruation, and General Diseases. Synopsis of Diagnostic Points — Ovaritis, Acute and Chronic (Ovarian Neuralgia, etc.) — Ovarian Tumors — Amenorrhcea — Dysmenorrhcea — Menorrhagia and Me- trorrhagia — Hysteria — Chlorosis and Anaemia — The Change of Life, or Climac- teric Epoch. CHAPTER II. Diseases of the Uterus and its Annexes. Synopsis of Diagnostic Points — Metritis (Non-puerperal Endo-Peri and Parametritis, Uterine Catarrh, etc.) — Cervicitis (Ulcerations and Granulations of the Os, etc.) — Displacements — Non-malignant Growths (Polypi, Fibroids, etc.) — Malig- nant Growths — Sterility and Anaphrodisia — Nymphomania. CHAPTER III. Diseases of the Vagina, Urethra and Bladder. Synopsis of Diagnostic Points — Vaginitis, Acute and Chronic, Non-specific — Vagin- itis, Specific, Gonorrhceal — Vaginismus and Dyspareunia — Vaginal Growths — Pruritus Vulvae and Vulvitis — Cystitis, Acute and Chronic — Urethritis — Urinary Disorders — Irritable Bladder, Dysuria, Polyuria, Ischuria, Enuresis, Vesical Tenesmus, etc. PART II.— OBSTETRICAL THERAPEUTICS. CHAPTER I. The Disorders of Pregnancy. The Hygiene of the Puerperal State — Abortion and Premature Labor (Prevention and Induction) — Vomiting and Nausea of Pregnancy — Sympathetic Nervous Disorders (Palpitation, Syncope, Neuralgia, Pruritus, etc.) — Digestive Derange- ments of Pregnancy (Dyspepsia, Constipation, Diarrhoea, Hemorrhoids, Albu- minuria). CHAPTER II. Complications, Disorders, and Sequels of Parturition. Anaesthetics in Labor — Tedious Labor (Rigid Os, Uterine Atony, etc.) — After- Pains — Puerperal Hemorrhage — Puerperal Eclampsia — Puerperal Mania — Puer- peral Septicemia — Thrombosis and Embolism — Shock — Pelvic Cellulitis and Peritonitis (Puerperal Phlebitis and Metritis) — Phlegmasia Dolens — Milk Fever, Puerperal Convalescence. CHAPTER III. Diseases of the Mammary Glands and of Lactation. Mammitis, Inflammation of the Breasts — Mammary Tumors — Mammary Neuralgia, Mastodynia — Galactorrhcea — Agalactia and Oligolactia — Diseases of the Nipple. / 10 A MANUAL OF EXAMINATION OF THE EYES. A COURSE OF LECTURES DELIVERED AT THE " EOOLE PRATIQUE," By I>r-. E. LANDOLT, Directeur-Adjoint of the Ophthalmological Laboratory at the Sorbonne, Paris. TRANSLATED BY SWAN M. BURNETT, M. D., Lecturer on Ophthalmology and Otology in the Medical Department of the University of Georgetown, and Ophthalmic Surgeon to the Central Dispensary, Washington, D. C. REVISED AND ENLARGED BY THE AUTHOR. I vol., 8vo, pp. 307. With numerous Illustrations and a large Chart. Price, cloth, $3.00. This entirely new and valuable work has received the very highest testimonials, both in Europe and America. We quote the following from the American press : — " Dn . La . ndolt is one °f tne clearest writers of the day. This little manual will certainly, in its English dress, prove of very great value to students of ophthalmology, and to those general practitioners who have a taste for examining eyes, for it gives instructions on very complicated subjects in a very terse and clear way. It would hardly seem possible to get so great an amount of matter into so small a space as Dr. Landolt has done in this book." — Cincinnati Lancet and Clinic, April, iS/p. "The author of this excellent work has succeeded in simplifying the subjects which he has put before the profession to such an extent as to render his book far superior to anything of the kind that has yet appeared in print. "The plain, easy, and yet scientific manner in which Dr. Landolt presents the various subjects contained in his work is emphatically suggestive of an honest, earn- est, astute student, and shows at once that the contents of the volume are the result of the work of a careful and conscientious observer. The book has no scent of scissors or paste pot. Although reference is made to other authors, I believe there is not a single quotation in it. "The twenty-second lecture is upon examination of the fundus in detail. The special feature of this lecture is the manner in which the optic nerve and its sheaths are described. Nowhere can there be found a cut which so nearly represents the true nature and relations of the optic nerve and its sheaths. I believe that it is unique ; at all events, it far excels all other efforts in this direction. "The book is one that can be recommended to the doctor and student, with the assurance that it will meet every demand. May the author live long and continue his work in the same direction, is the wish of the reviewer."— Louisville Medical News, July, 1879. " This book is a most admirable and complete expose of our means and methods of making a thorough scientific examination of the human eye. Written in the attractive, easy style of lectures, unencumbered by unnecessary mathematical formu- las, printed on heavy paper and in large and clear type, translated with care and skill into fluent English, this book will contribute largely toward awakening greater inter- est for ophthalmology among the reading members of our profession." — Chicago Medical Journal and Examiner, August, 18*19. 11 CONSPECTUS OF COMPRISING The Vegetable and Animal Drugs, their Physical Character, Geographical Origin, Classification, Constituents, Doses, Adulterations, &c, 1 Vol., 8vo., pp. 220, with Folding Tables. Price, in Cloth, by mail, post paid, $2.00» PLAN OF THE WORK. The Chart. — In the space of seventeen of the first pages is found the whole Materia Medica, arranged according to Natural Orders. Every drug is mentioned. Opposite the column of drugs are arranged in a tabular manner all the following points concerning it : Officinal Name, Botanical Name, Common Name, Habitat* Part Used, Constituents, Medical Properties, Dose, Officinal Preparations; making in all io columns, supplying the place of the cumbrous broadsides heretofore in use for this purpose. Geographical Grouping of Drugs. — This comprises three pages, giving the charac- teristic drugs derived from different sections of the world. Botany. — This subject is treated as an introduction to other and more voluminous treatises, under the following heads : The Cell, Cell Modification, Tissues, Cell De- velopment, Contents of Cells; The Stem, Subterranean Stems, Leaves, Flowers, Fruits and Seeds. The arrangement and display of the material is such that it will rather fascinate than tire the student. The botanical terms are, in every case, made clear by definition, so that they are readily comprehended. Natural Orders. — This chapter opens with a general treatise upon the subject,, followed by a tabular arrangement of the principal natural orders. The most promi- nent characteristic of these and their sub-orders are brought out unencumbered with such detail as a manual of botany would give, thus furnishing points to refresh the memory, and giving an appropriate outline for the beginner. Drugs— Their Characteristics, Constituents, &c, &c— This subject occupies the body of the work. In one hundred and fifty pages are embraced not only all the drugs which are officinal in the U. S. P., but others of any prominence, especially those recently brought into favor. They are arranged according to their physical characteristics, thus bringing together the various parts of the plants, furnishing groups as follows : Roots, Rhizomes, Tubers, Bulbs, Stems, Woods, Barks, Leaves and Leaflets, Herbs, Flowers and Parts of Flowers, Fruits and Parts of Fruits, Seeds, Cellular Drugs not easily recognized as parts of plants, Drugs destitute of Cellular Tissues, &c, closing with a chapter upon Animal Drugs. Tables. — Two tables complete the work ; one of the Alkaloids and one of the Antidotes and Incompatibles. It may be said of the former, it contains all of the officinal and most of the prominent alkaloids, and gives in a tabular form many interesting points concerning them not heretofore mentioned. 12 DIFFERENTIAL DIAGNOSIS: A MANUAL OF THE COMPARATIVE SEMEIOLOGY OF THE MORE IMPORTANT DISEASES, By F. T>E HAVILLAND HA.L.3L,, M. »., Assistant Physician to the Westminster Hospital, London. American Edition, -with Extensive Additions. One Volume, 8vo., pp. 205. Printed on handsome tinted paper; bound in English pebbled cloth, with beveled boards. Price $2.00. Dr. Hall's work has received the highest encomiums from the English medical press, for its lucid arrangement, completeness and accuracy. He himself is known in London as a practitioner of great skill, and an unusually successful medical teacher. Most of the diseases which may be confounded are presented in comparative tables, setting forth their distinctive characteristics in the clearest possible light, and thus greatly facilitating their prompt diagnosis. OPINIONS OF THE PRESS. The British Medical Journal says: "This is not of the type of books brought out by ' grinders.' The tables it contains are invaluable aids by the bedside, enabling the student and practitioner readily to compare signs met with in disease." The North Carolina Medical Journal says : " The tabular method of comparing symptoms is well utilized. Very many valuable diagnostic formulae are brought together. ' ' The Atlanta Medical Journal says : " The comparative symptoms are given in a very satisfactory manner. The work will afford valuable aid to practitioners." The Boston Medical and Surgical Journal, March 6th, 1877, says : " The physi- cal signs and the symptoms of the various affections are arranged in tabular form for convenient reference, and the facility thus afforded for comparison and discrimination enables this manual to supply a want often experienced in more elaborate treatises." The New Orleans Medical and Surgical Journal says : "The plan of the work we regard as highly commendable for its convenience of reference and the precision of which it is capable." THE DISEASES OF LIVE STOCK, Including Horses, Cattle, Sheep and Swine. Containing a description of all the usual diseases to which these animals are liable, and the most successful treatment of American, English and European Veterinarians. By LLOYD V. TELLOR, M. D. 1 vol., 8vo., pp. 474. Price, Cloth, $2.50. This work is divided into four parts, as follows : I. General Principles of Veteri- nary Medicine. II. Diseases of the Horse. III. Diseases of Cattle, Sheep and Swine. IV. Hygiene and Medicines. The author of this work is a regular physician, whose practice in the country has led him to study the diseases of domestic animals, and we can point to it as the first and only book, by an American physician, which describes, with scientific accuracy, and yet in plain language, these common and important maladies. 13 OBSTETRIC PROCEDURE. BY WILLIAM B. ATKINSON, A. M., M. D„ Lecturer on Diseases of Children, at the fefferson Medical College. Physician to the Department of Obstetrics and Diseases of Children, Howard Hospital, Philadelphia, Penna. SECOND EDITION. ENTIRELY RE- WRITTEN AND ENLARGED. 13mo., CLOTH. PRICB, $l.QO. "The charmingly informal style of the author renders the reading of the mono- graph a positive pleasure. Conscientiously we feel that we are working in the inter- ests of both physician and patient when we say to all who do riot own it now, order at once a copy of these Hints for your own use." — The Detroit Lattcet, July, 1879. 11 The author, a teacher of experience, treats his subjects in a way to make it especially useful to the student, but not to the student alone." — The Richmond and Louisville Medical Journal, June, 18/p. " Dr. Atkinson fully appreciates the vast importance of the obstetric art in both its immediate and remote effects on mothers and children, as well as the reputation of the physician, and, in this interesting little work, gives valuable hints, which are intended to guide us in the management of women before, during and after the ter- mination of labor." — Canada Journal of Medical Science, July, 18/9. " The many valuable points cited, the practical manner in which they are stated, together with the sound views of practice enunciated, make this little mono- graph truly valuable." — The Southern Practitioner, January, 1879. "It is the gist of the obstetric art in convenient form, and will serve to refresh the practitioner's mind in any case pertaining thereto." — Maryland Medical Jour- nal,June, 1879, ON COUGHS, CONSUMPTION, AND DIET IN DISEASE. By HORACE DOBELL, M. D., F. E. M. 0. S., Consulting Physician to the Royal Hospital for Diseases of the Chest, London, etc. 8vo., Cloth. Illustrated. Tinted Paper. Pages, 222. Price, $2.00. This work consists of three parts. Part I. treats of the Diagnosis of Bronchial and Pulmonary Diseases. Part II., which makes the bulk of the book, is taken up with the all-important subject of the treatment of pulmonary affections. Part III., which is the shortest, is a succinct, condensed exposition of the principles and rules of dietetics in disease. As an authority on the above subjects, Dr. Dobell ranks second to none in Great Britain. His experience has been immense, and the peculiarly practical tone of his mind renders his writings unusually instructive to the practicing physician. From the New York Medical Record : " The book is well printed, and contains many valuable suggestions." From the Virginia Medical Monthly : "We find in this work a great deal to approve, and but little to criticise." From the Pacific Medical and Surgical Journal : "Dr. Dobell brings much new light to this important subject. His work will be pursued with great satisfac- tion. It is a very handsomely printed volume." From the Sanitarian :■ "A good book on these subjects has a wide application, and such is the one now before us. Dr. Dobell has long been known as one of the most accomplished physicians of London." 14 LESSONS IN GYNECOLOGY. By WM. GOODELL, A. M., M. D., Professor of Clinical Gynaecology in the University of Penna. WITH NUMEROUS ILLUSTRATIONS. SECOND EDITION. THOROUGHLY REVISED AND CONSIDERABLY ENLARGED One Volume 8vo. Price— Cloth, $4=; Siieep, S4..50. The Second Edition of this able work was demanded within three months from the publication of the first. The author has, however, taken the time to give it a very careful revision, and has added a large amount of new and unpublished material. The following table of contents will indicate its. scope: Lesson I. Gynaecological Instruments. Modes of Examination. Caruncle, and other Affections of the Female Urethra. Vesical Diseases of Women. Fistulae of the Female Genital Organs. Closure of the Vulva for incurable Vesico-vaginal Fistulae — Tumors of the Vulva. Some Affections of the Vulva and Surrounding Parts. On the Causes, Prevention and the Cure of Lacerations of the Female Perineum; the Primary Operation. Secondary operation for Laceration of the Female Perineum. Metritis and Endometritis, Acute and Chronic. Local and Constitutional Treatment for Chronic Metritis and Endo- metritis. Retroversions and Retroflexions of the Womb. Anteversions and Anteflexions of the Womb. Dilatation of Cervical Canal ; Rapid Dilatation ; Tents. On the Use of the Closed Lever Pessary, and of the Intrauterine Stem Pessary. Different kinds of Pessaries ; Abdominal Supporters. Prolapse of the Womb; Prolapse from Simple Descent ; Prolapse from Hypertrophic Elongation of the Infra-vaginal Portion of. Cervix. Prolapse of the Womb from Hypertrophic Elongation of the Supra- vaginal Portion of the Cervix. Laceration of the Cervix Uteri. Cancer of the Womb. Vegetations of the Endometrium. Polypus of the Womb. Fibroid Tumors of the Womb. Treatment of Fibroid Tumors of the Womb. Ovaritis and Prolapse of the Ovaries. Spaying for Fibroid Tumors, and for other Diseases of the Womb. Ovarian Cyst ; its Diagnosis, and its Treatment by Tapping, by Injections of Iodine, and by Drainage. Ovariotomy by Abdominal Section. Vaginal Ovariotomy. Nerve-Tire and Womb-Ills, or the Relation which the Nerves Bear to the Diseases of Women. The Prevention of Uterine Disorders. The Sexual Relations as Causes of Uterine Disorders. The Relation which Faulty Closet Accommodations Bear to the Dis- eases of Women. II. III. IV. V. VI. VII. VIII. IX. X. XL XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. XXVIII. XXIX. XXX. XXXI. XXXII. XXXIII. 15 A Treatise on Hernia, "With a New Process for its Radical Cure, and Original Contributions to Operative Surgery, and New Surgical Instruments. BY GREENSVILLE DOWELL, M. D., Professor of Surgery in Texas Medical College ; Late Professor of Surgery in Gal- veston Medical College; Member of the American Medical Association, etc., etc. One Volume, large 8vo., 76 Illustrations, 6 Full-Page Plates. Price, Cloth, $2.00. BY THE SAME AUTHOR. Yellow Fever and Malarial Diseases. Embracing a History of the Epidemics of Yellow Fever in Texas ; New Views on its Diagnosis, Treatment, Propagation and Control ; Descriptions of Dengue, Malarial Fever, Jaundice, the Spleen and its diseases, and Diarrhoea Hemorrhagica. BY GREENSVILLE DOWELL, M. D. Cloth, 8vo., with Map and Two Chromo-Lithographs. Price, $2.00- The long experience of Dr. Dowell in the Diseases of which this work treats, constitutes him one of the most competent living authorities on the subject. He has treated many hundred cases of yellow fever, and claims to be able, by the plan be lays down in detail, to reduce the mortality in that disease to five per cent. Aids to Botany. BY C. E. A. SEMPLE, M. D. i2tno., paper, pp. 56. Price, 30 cents. One of the popular series of aid-books for students ; favorites in England. Aids to Anatomy. BY GEORGE BROWN, M. R. C. S., L. S. A., Late Demonstrator of Anatomy at Westminster Hospital Medical School, etc. 12mo., pp. 64. Paper. Price, 30 cents. A cheap, accurate and convenient summary of anatomy for students. The Anatomy and Histology of the Human Eye. BY A. METZ, M. D., Professor of Ophthalmology in Charity Hospital Medical College, Cleveland. 8vo., pp. 184, with 75 Wood Cuts. Price, Cloth, 32.00- A very carefully prepared, clear and distinct presentation of the anatomy of the eye, by a competent hand. " Cannot fail to be of great value to the general practitioner, as well as to the student of ophthalmology." — Boston Medical and Surgical Journal. "An excellent text-book." — -Chicago Medical Examiner. 16 ANDERSON'S SCRIPTiON BLANKS, Cloth Case, with Carbonized Paper and Three Packages of Prescrip- tion Blanks, 50 each, for $1,00. By these convenient Records the physician makes a copy of his prescription at the same time that he writes it for the patient. The duplication is by means of carbon paper. All who have tried the plan have been highly pleased with it. The prescrip- tion is written with the ordinary lead pencil, and the writing is clear and black. The Prescription Blanks are prepared in neat packages of 50 blanks each, and when one such package is exhausted it is removed from the case and another one substituted, one case thus serving for any number of prescriptions. $^* The special attention of readers of this catalogue is asked to the advertise- ment of ¥l\e Weekly ^iedickl kr\d gttfgicftl ffeporte* ¥l\e Sklf- Yearly don}cpei|(iitiir} of ^iedidkl $cier\6e, to be found on pages 1-3. Any of the Works in this Catalogue can be had from DATE DUE exp pre the DAT M«V MM9 T Demco, Inc. 38-293 "** he as ith C28(1158)100M COLUMBIA UNIVERSITY LIBRARIES 0043076785 &/'