curve, showing the maxima and minima of temperature, and tracing the whole course of the disease.

As an illustration of the practical application of the thermometer to the study of disease, I take typhoid fever. The thermometer I am in the habit of using is made by Geissler, the world-known glass-apparatus maker in Berlin. It distinctly shows one-tenth of a degree, and is highly correct. I generally examine the temperature in the axilla, taking care that the small cylinder containing the mercury should be hermetically surrounded by the skin, and left for a quarter of an hour to attain the temperature of the blood. If the heat be intense, the thermometer will rise very rapidly; but, even then, it must be kept for at least a quarter of an hour in the same position, to be sure that we obtain the correct figure because a few tenths can be decisive for the prognosis.

This curve is quite characteristic for the diagnosis of typhoid fever, and no other disease presents similar fluctuations of temperature. So the thermometer proves of the highest importance here, for by no other means can we make a positive diagnosis of typhoid fever in the first four days. With the thermometer we can say at once that there is no typhoid fever when on the first evening or second morning the temperature has risen to 40° (104° F.), or when it approaches the normal on the second, third, and fourth evenings. There is, again, no typhoid fever when the temperature remains the same during the first two or three mornings, or two or three evenings; or when but once a descent in the temperature below that of the same hour on the previous day can be detected on either of the first mornings or evenings.

The second stage-the acme or fastigium-runs as Typhoid fever, like other acute diseases, can have a follows. The heat continues to rise during the exacermild or grave course, and its different stages, following bations until it arrives at its maximum, 40°-41.5° (104° almost always a regular weekly or half-weekly period, -106.7° F.) and remains so for several consecutive evenare distinctly recognized with the thermometer. No-ings, falling off in the morning remissions from half a thing can be said of the period of incubation, for it degree to a degree and a half. Then, at the end of the has scarcely ever been noted. The first stage of ty- second week, sometimes after a critical perturbation, phoid fever, the period of invasion, is very regular and but generally at once, begins the period of defervescence. characteristic, its temperature increasing in regular During it the exacerbations become lower, and the rezigzags, rising from every morning to every evening by missions fall considerably deeper, until all difference 1° or 14°, and falling back from every evening to every between the morning and evening temperature has morning by to °, until on the fourth evening it has disappeared, and the return of the normal 37° (98.6°F.) attained 40° (104°F.) and more, according to the follow- announces the convalescent stage. ing figures (Wunderlich *):

This is the curve of the regular mild typhoid fever, and even in the most severe cases, the first and last stages remain characteristically the same. Between them only can run the undecisive period (Wunderlich's amphibolous period), lasting from a few days to several weeks, presenting a great variety of irregularities in the fluctuations of the temperature, which generally remains as high as during the fastigium. Sometimes the amphibolous stage begins with a prolonged remission, after which the heat suddenly rises nearly to the height of the fastigium, and with only very short morning remissions. Or the temperature will gradually diminish, arrive near the normal, and keep ascending again for a few consecutive days, repeating it several times over. When by no other means a disturbance can yet be detected, this irregular rising of temperature is the early and sure sign of some local trouble, either in consequence of new deposits in the intestinal canal, or of some complications, or of a relapse of the disease. When, on the other hand, the temperature has suddenly fallen, sometimes much under the normal, it is the earliest symptom of perforation of the bowels, or hæmorrhage.

The amphibolous stage goes over either into the defervescent or into the proagonic stage; in which last case the heat continues to rise enormously, without remissions, to 42.5°-43° (108.5°-109.4° F.).

In the convalescent period the temperature falls to 37° (98.6° F.), and continues to remain normal. As long as this is not the case, the patient cannot be considered convalescent, or out of danger, though he may appear so in every other respect.

With regard to prognosis, the thermometer is again our best guide. A case is always severe when the morning temperature exceeds 39.5°-40° (103.1°-104° F.), and that of the evening gets over 40.5-41° (104.1°-105.8°F.); when the exacerbations begin early, or continue after midnight, and the remissions commence late, and are of short duration-in general, every irregularity in the thermometrical curve must arouse our suspicion, and every case with an amphibolous stage is intensely dangerous.

According to Wunderlich,* the temperature of 41.2o * Op. cit., p. 292.

(106.16° F.) is of very great danger; at 41.4° (106.51° F.)
twice as many patients die as recover; and from 41.5
(106.7° F.) upwards recovery is an exception. If the
morning temperature rises to 41.2° (106.16°F.), death is
certain. According to Liebermeister an excess over
42° (107-6° F.) is incompatible with life. Uhle takes as
the extreme for possible recovery 41.2° (106.16° F.);
Thomas, 41.5° (106.7° F.); Fiedler, 41.7° (107.06° F..)
For an exact diagnosis and prognosis the thermome-
trical observations must be carried on systematically.
But sometimes a single observation may at once reveal
the nature of a disease; so, for instance, we can with-
out a mistake recognize intermittent fever, if even
once, in the first days of a febrile disease, the tempera-
ture approaches the normal. This early diagnosis is of
the highest importance in the pernicious quotidian inter-
mittents, which often simulate typhoid, and, if not
properly treated, soon become continuous, and may ter-
minate fatally. Very instructive is the fact that, when
after intermittent fever the patient is considered cured
by himself and his physician, the thermometer will de-
tect the presence of malarious influence in the system,
and show an increased temperature-38° (100.4° F.)
and more. In such cases the paroxysms are sure to re-
turn, unless the specific treatment be continued until
the temperature has become constantly normal.

and Liebermeister * confirmed his method by excellent scientific investigations; and in the large hospitals of St. Petersburg this plan of treatment has been tested on a wide scale, and with excellent results, by Zdekauer, † Grünewaldt, Rauchfuss, and others.

Brand's principal rule is never to allow the temperature to rise above 39.5° (103.1° F.); and as soon as it comes to it, immediately to cool the patient according to the degree wanted. The mildest degree of cooling is attained by sponging the body with cold water, or by keeping the patient continually in a wet sheet, or again by a full tepid bath, and especially with cold water gradually added to it; the next degree by a tepid half-bath with cold affusions; the highest degree by cold affusions, shower bath, or cold bath with cold affusions . The treatment is as follows: Brand § gives his patients a tepid half-bath with cold affusions four or six times per day. As the greatest heat occurs from 10 to 12 A.M., and from 4 to 6 P.M., a bath is given just before 10 and before 4 o'clock, and besides, at every other time when the thermometer shows 39.5° (103.1° F.) The patient is left in the bath from five to fifteen minutes. The cold bath diminishes the temperature of the body from 1° to 3° (1.8-5.4° F.), according to its intensity and duration. In order that the evaporation of water should continue to produce cold, the patient is not dried after the It is not necessary to dwell long on the treatment of baths, between which he is occasionally sponged over. typhoid fever. We know that the degree of its inten- A wet cloth is laid on the head, and another on the sity and danger to life depends on the high temperature. chest and abdomen, so that a continual refrigeration is However the action of excessive heat upon our sys-kept up on one third of the body. Every quarter of an tem may be explained theoretically—whether by pro-hour, if the patient is not asleep, he is offered a little ducing some parenchymatous changes in the muscles cold water to drink, and every three hours, nour(Zenker*, Waldeyer†), heart, nervous centres, or other-ishing food in a fluid state. The room is kept well wise-for the practical physician there remains but one vent lated, and stimulants are avoided, unless a collapse predominating indication, to subdue the heat. Hence should take place; that, however, does not occur under every means of diminishing it must be resorted to, and this treatment. the contrary avoided. We find a favorable change in the patient, and the thermometer shows a decline, after a mild aperient, or calomel, or digitalis, during the first stages of the disease; and a rising of temperature and increase of fever after stimulants. But for regulating the temperature of the body with mathematical precision, we possess but one means-cold, in its various forms and methodically applied.

The effect of this treatment is so wonderful, that those familiar with typhoid patients will not recognize them. By keeping the temperature below 39.5° (103.1° F.) the exacerbations are avoided and the fever kept in a continuous remission. The patients are never unconscious, never delirious; the tongue always remains moist and clean; the bronchial catarrh is very slight; so is the diarrhoea, if any at all. Already in the last century James Currie had made ex- There is no tympanites, no hæmorrhage, no comtensive thermometrical observations, and introduced the plication, and we have every reason to believe that rational treatment with cold water. My first acquaint- the intestinal ulcerations do not occur at all. The paance with the use of water in diseases was during the tients, aided by some one, have strength to walk to Crimean war in 1853. I was then attached as a physi- their bath; they have a good appetite, and very quiet, cian to the Imperial Russian Guard, where a murderous refreshing sleep. On coming out of the bath, they generepidemic of typhus fever prevailed, with a most distres-ally eat and take a sleep. Under this treatment the sing figure of mortality, resisting all our efforts to sub-course of typhoid fever is very mild and short, the condue it by every known method of treatment. Follow-valescence very rapid, and the mortality none whatever ing then only the instinct of the patients, and watching (Brand). From my own experience, I may say, that a closely the immediate effect of cold water, I soon began great number of patients, treated by myself according to appreciate its beneficial influence upon the course to this method, have all recovered without exception. and termination of the disease, and commenced treating In this city I had a patient, whose morning temperature all the cases with cold sponging and affusions. The re- once reached even 41.3° (106.34° F.)—a case absolutely sult surpassed my hopes, and was far better than that fatal under every other treatment; she is nevertheless obtained by any other method. I was myself attacked by recovering the disease, and was saved from death only by my own mode of treatment. But still my treatment then was purely empirical and symptomatic.

In 1861 Brand published his first monograph on the treatment of typhoid fever with water. Jürgensen §

F. A. ZENKER: Ueber die Veränderungen der Willkürlichen Muskeln im Typhus Abdominalis. Leipzig, 1864.

+ WALDEYER: Ueber die Veränderungen der Querge treiften Muskeln bei der Entzündung u. d. Typhus-process. Virchow's Archiv, Bd. 34, p. 473.

BRAND: Die Heilung des Typhus. Berlin, 1868.

JUERGENSEN: Klinische Studien über die Behandlung des Abdominaltyphus mittelst des kalten Wassers. Leipzig, 1866.

As the principal seat of the affection is the intestinal canal, I generally begin the treatment with the administration of a mild aperient, to free it from the irritating contents. This is always followed by a diminution of the temperature. In the course of the fever I occasionally give injections of cold water, which, as I have observed, reduce the heat sometimes by a whole degree,

*Deutsch. Archiv für Klin. Med. Bd. I., IV., p. 413-435.]

+ Petersburg. Med. Zeitschrift, 1864, p. 47.
BRAND: Op. cit., p. 61.

Op. cit., p. 81.

to the greatest comfort of the patient. For all the rest, S. Waterfield, of Cottage Grove, Tenn., kindly furI strictly adhere to Brand's plan of treatment. nished me the notes of the case.

CASE XV. Humerus, lower end: two and three-quarters inches removed.-J. H-, a soldier in the late Confederate army, Company H, Sixth Arkansas Regiment, was wounded July 21, 1864, in the lower portion of the humerus, by a Minié ball. Resection was performed immediately, removing two and three-fourths inches of the lower end of humerus. A portion of the olecranon process was carried away by the ball. Abscesses continued to form around the wound occasionally until April, 1866, nearly two years, in consequence of caries and necrosis of the bone. In April, 1866, Dr. S. H. Bayless, of Falcon, Arkansas, removed the diseased fragments of bone; and since that time the arm has been healthy. The patient has good use of the arm; he can plough, use an axe, write, lift heavy weights, in fact, use it in every way, except flexing it.

The result in this case has been good. I think it probable that had the fragments of diseased bone been early removed, the abscesses would not have continued to form as long as they did. The operators were Dr. Sam Turner, now of Texas; and Dr. McFadden, of Pocahontas, Arkansas. The notes of this case were kindly furnished me by Dr. S. H. Bayless of Falcon, Ark. CASE XVI. Humerus, lower third: nearly five inches removed.-Captain A. Benson Brown, Co. C, Ninth New Jersey Volunteers, was wounded at the battle of Fort Darling, the 16th of May, 1864, buck and ball striking the lower portion of right humerus, and making a compound comminuted fracture. Very near four inches of the humerus were exsected, the exsection extending to within about an inch and a half of the elbow-joint. Abscesses formed occasionally for about a year; since that time the arm has been healthy. The operation was performed by Dr. A. W. Woodhull, then surgeon of the regiment, now of Newark, N. J. On the 8th of August, 1864, Captain Brown applied to Prof. Joseph Pancoast for advice, and became his patient. Prof. Pancoast introduced a screw which drilled its way obliquely through the ends of the bones, to hold them together and keep up irritation, with a view to bring about bony union. Captain B. informs me that the screw remained in the bones for seven months. He states that, about a week after its introduction, he was attacked with fever, and continued to be quite ill for some time. Captain Brown is of the opinion that the introduction and presence of the screw was the cause of the attack of fever. I am not prepared to give an opinion in reference to that, as I did not see the captain while he was sick, and, in fact, never met him until a few days since, when on examination I found complete bony

union existed.

The result in this case is highly gratifying. The arm is very useful; and when we consider that complete bony union has taken place, it proves to be a case of more than ordinary interest. I examined the arm and made the notes of the case as given above.

Original Lectures.

PUERPERAL CONVULSIONS:

ABSTRACT OF A CLINICAL LECTURE DELIVERED AT BELLEVUE
HOSPITAL,

BY FORDYCE BARKER, M.D.,

PROF. OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN,

BELLEVUE HOSPITAL MEDICAL COLLEGE.

CASES I. & II. Puerperal Convulsions: Puerperal Mania: Convulsions in the Infant: Recovery of both Mother and Child.-Bridget D., æt. 25, Irish, primipara. Admitted into hospital last July. Labia, vulva, and lower extremities then so much swollen as not to pit upon pressure. Frontal headache and pain in lumbar region on first admission, but all these symptoms soon disappeared. Neither casts nor albumen found in the urine previous to confinement, although several examinations were made. On the afternoon of Sept. 16th, the patient was suddenly seized with a convulsion, characterized by all the usual phenomena, lasting five minutes, and leaving her in a semi-comatose condition. A more protracted convulsion followed about twenty minutes later. Dry cups were applied to the loins, and three drops of croton oil placed upon the tongue; chloroform was then administered freely and continued whenever convulsions were threatened, until the labor ended. As, after a proper interval, the croton oil did not act, an enema of an ounce of castor oil, with three drops of croton oil and a pint of warm water, was given, which moved the bowels in about ten minutes. At 7 P. M., three convulsions occurred in rapid succession. During the intervals between them the patient was semi-comatose, with pupils markedly contracted. vulsions till 4 P. M. of the 17th, when three occurred rapidly. There was an intermission till 3 A.M. of the 18th, when three more occurred; and ten minutes after the last the child was suddenly expelled alive. The placenta soon came away; the uterus contracted well; and there was little hemorrhage. The mother had three convulsions after delivery; puerperal mania then developed and lasted nearly two days. She had since done well, had a good appetite, and complained only of headache. On the day of the first of the postpartum convulsions, the urine contained a small On the first day amount of albumen, but no casts. after delivery, the urine contained about twenty-five per cent. of albumen, and no casts. To-day, the albumen was barely appreciable. The treatment consisted in applying dry cups over the kidneys, after which the patient soon became conscious, and was able to swallow. Bitartrate of potassa, two drachms four times a day, was then given. For some days she had been taking two grains of sulphate of quinia, with fifteen drops of tincture of the chloride of iron, three times a day, and had been put upon nutritious diet. After delivery the child had a convulsion precisely similar to those of the mother, and in the course of two hours, two more. It had since done well, had had no more convulsions, nursed well, and was thriving,

No recurrence of the con

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NEW WORKS 10 BE Published by the NEW SYDENHAM SOCIETY.-Four works will be published by this learned Society during the year 1869. The second volume of Trousseau, the second of Lancereaux, a Biennial Retrospect for 1877-8, and a sixth fasciculus of the Atlas of Skin Diseases.

DR. BARKER stated that fourteen years ago he had published a table of cases of puerperal convulsions,

to him, and in it had shown that 32 per cent. of all cases which occurred before and during labor ended fatally, and 22 per cent. of those after delivery. The statistics of the present day would show that the fatality had been greatly diminished, owing to our increased knowledge of the pathology of the affection, and to im

*The cases are given from notes of Dr. R. A. Vance, House Physic'an.

416

proved therapeutical measures. probably diminished 50 per cent. The mortality was Apoplexy did not produce convulsions, except by pressure; but it might be a consequence of them, and a very dangerous one. clearly explained how convulsions may produce Dr. Marshall Hall had first apoplexy. The convulsive fit has the effect of interrupting the circulation: first, by direct pressure of the platysma myoides on the jugular veins, preventing the return of the blood from the brain; second, by the spasm of the glottis impeding respiration, and preventing the passage of venous blood into the lungs; third, by the pressure on the venous circulation of the extremities, the blood, by the spasmodic contractions of all the voluntary muscles, being forced too rapidly forward into the great central trunks; fourth, by the increased pressure on the venous circulation in the uterus, in consequence of its more powerful contractions.

On the etiology of convulsions, Dr. Barker continued:

lesion of the kidney. The most careful examination either before or after the occurrence of the convulsions. has failed to detect either albumen or casts in the urine, In many cases, when death has resulted from the conslight congestion, has been found in the autopsic exvulsions, only the most trivial lesion of the kidney, as amination. Secondly, I am sure that many others, as well as myself, have often had cases of marked albuminuria during pregnancy, in which convulsions have not occurred. I will make the assertion still stronger, by saying that in the very considerable number of cases of albuminuria during pregnancy, that I have seen, convulsions have occurred in but few. Even M. Blot, one of the early and most zealous investigators in regard to this affection, met with but seven cases of peral convulsions in forty-one women who had albuminous urine. Some writers have met with a larger puerproportion than this, but I am not aware that any one albuminuria. Thirdly, in many cases where the most has claimed that they occur in one-half of the cases of failed to detect albumen, convulsions have occurred, careful and repeated examinations of the urine have and afterwards the urine has been loaded with albumen. In the case we have before us, several examinations were found; but after the convulsions occurred, the were made of the urine, and neither albumen nor casts albumen was abundant. It seems to me, therefore, that there may be some reason for inquiring whether the same profound impression on the spinal system which in the pregnant or parturient woman culminates in puerperal convulsions, may not also so modify the functions of the kidney as to result in albuminuria; or, in other words, instead of regarding the albuminuria as the cause of the convulsions, whether we have not some reason for believing that both the albuminuria and the convulsions are the effect of some common cause, the exact nature of which science has not yet determined.

Physiology has demonstrated that all convulsions must arise from some irritation of the true spinal system-which includes the spinal marrow within the theca vertebralis, the medulla oblongata, and the corpora quadrigemina--and that no irritation of the cerebral system-that is, of the brain and cerebellum and that part of the spinal cord which conveys sensation and voluntary motion to and from the brain-will produce them. These causes may be divided into two classes: 1st, those which act directly on the spinal system, or the centric causes, as they have been termed; and 2d, those which act indirectly, or the reflex causes. The centric causes are said to be: 1st, pressure upon some part of the true spinal system, from congestion, from serous effusion, or from coagula; 2d, deficient nutrition of the spinal system, from anæmia; and, 3rd, toxæmia. The reflex causes are those which produce irritation of the incident or excitor nerves, that react upon has demonstrated that urinary albumen has not the same Robin, in his recent work on the fluids of the body, the spinal system; as morbid excitation of the peri- composition as the albumen of the blood, and that pheral nerves of any of the vital organs of the body. For some years past, the prevailing opinion, with a the albumen of Bright's disease differs essentially from great majority of writers on this subject, has been, that easily be shown by special chemical reagents. the temporary albuminuria of pregnancy, which can puerperal convulsions result, in a very large proportion albumen of the urine in Bright's disease, when of cases, from toxæmia, the special poison being uræmic, brought in contact with the oxide of copper in a soluThe and that this is demonstrated by the presence of albu- tion of caustic potash, assumes a beautiful reddish viomen in the urine. I take it for granted that none of let color, and produces a more or less abundant floccuyou suppose that albuminuria, that is, albumen in the lent black precipitate. Now, the urinary albumen of urine, is the cause of the convulsions; but the belief has pregnancy, where Bright's disease does not exist, while been, that, where this is found, the urea is retained in it coagulates readily by heat and nitric acid, does not the blood, and that this substance is, directly or by its exhibit any such reaction from contact with the oxide decomposition, a poison which produces a most dele- of copper. So also Robin has demonstrated that the terious and profound impression on the nervous system. granular casts are not characteristic of any particular Many eminent authorities have gone so far as to assert morbid state or pathological change of structure. that, excluding hysterical convulsions occurring peral women, the cases not due to this cause are ex-jority of the profession in this country do not accept in puer- I am inclined to believe that, even if a large maceptional. Considered with reference to their cause, they in fact regard puerperal convulsions as occurring under two forms, uræmic and hysterical. Albuminuria is regarded by them as conclusive evidence of some lesion of the kidney, that is, congestion from pressure, or the structural disease known as Bright's disease.

I

the extreme views of Professor Braun of Vienna,namely, that puerperal convulsions are generally the result of Bright's disease in an acute form, which, under certain circumstances, spreading its toxæmic effects on the nutrition of the brain and whole nervous system, Now, that convulsions occur sometimes during the them as the result of some functional disturbance or produces this fearful accident,-they at least regard progress of Bright's disease is an accepted fact in medi- lesion of the kidney, of a temporary character. cine. That puerperal convulsions are frequently asso- have long entertained doubts as to the soundness of ciated with albuminuria is also well known. But it these views. I have long been accustomed to warn seems to me that there are many reasons for doubting medical students against the popular use of the term, whether this association necessarily proves the relation Bright's disease, in connection with their puerperal paof cause and effect. In the first place, there are many tients, because the public have come to associate the cases of puerperal convulsions, having all the character- term with an inevitably fatal termination, and the inistic phenomena which attend this fearful malady, influence of the morale on this class of patients cannot be which there have been no symptoms indicative of any overestimated.