113 CASE OF ADHERENT PLACENTA WITH EXCESSIVE FLOODING, FOLLOWED BY METRITIS AND PYÆMIA. Reported by EDWARD MONTGOMERY, M.D., of St. Louis. In the latter part of October last I was sent for to attend Mrs. C. in confinement with her second child; I had attended her in her first accouchment about two years before, at which time she had a very severe and tedious labor, with great rigidity of the parts: the patient was a strong, muscular woman, and rather advanced in years. This time I found her very impatient and despondent, suffering very acutely with keen, lancinating pains, of short duration, but very frequent; the whole abdomen was very hard and tender, the skin hot and dry, and the pulse rapid. The os uteri was dilated to about the size of a dollar, the membranes slight protruding, and the presentation natural. As the patient was very stout and plethoric, I took about fifteen ounces of blood from her arm, and prescribed a mixture of extract of belladonna, tartrate of antimony, and sulphate of magnesia. Hot hop fomentations were applied over the abdomen. These measures seemed to have a happy effect; the tenderness and tension abated, the pains became less lancinating, the heat and dryness of the skin and also of the vagina moderated, and in about four hours my patient was delivered of a fine, large, healthy looking male child. Immediately after the expulsion of the child a violent flooding occurred: I grasped the uterus through the abdominal walls, and had a large stream of cold water poured from a height over the exposed abdomen. I found the uterus very large, the placenta not yielding to moderate tension on the cord, and the hæmorrhage still profuse, and on introducing my hand into the uterine cavity, I found extensive adhesion of the placenta. I proceeded at once to peel it off as carefully and expeditiously as I could, and gave a large dose of ergot. The flooding moderated at once, but my patient was as pale as a corpse, and passed from one fainting fit into another for several hours, notwithstanding the frequent administration of laudanum and brandy, beef tea, milk punch, &c. About eight hours after the birth of the child she was seized with a severe rigor. I was at once sent for, and on arriving found her extremely restless, haggard, and despondent, with great thirst, a small, rapid pulse and a continuous flow of bloody and serous fluid from the vagina. She complained of a deep seated pain or soreness in the region of the womb, but there was no tenderness on pressing upon the abdomen; she also suffered from severe pain in the back, so that she could not remain in one posture five minutes at a time. I ordered an enema of laudanum and beef tea, to be repeated whenever there was great jactitation or restlessness from the pain, and prescribed also a mixture containing bisulphite of soda and spirits of nitre, to be used as long as the hot febrile stage lasted. As soon as the sweating stage set in I omitted this mixture and gave pills containing extract of cannabis indica, sulphate of quinine, and citrate of iron, alternating these with the antiseptic febrifuge for six days. After that I continued the quinine and iron, with nutritious aliment, frequently injecting the vagina, and for the first three days the uterus itself, with weak solutions of chlorinated soda, permanganate of potash, etc. During all this time my patient seemed in a very hopeless condition, had severe rigors twice in twenty-four hours, with profuse sweats, intense thirst, sleeplessness, delirium, great jactitation, small, rapid, feeble pulse, and cadaveric appearance generally. From the fifth to the eleventh day of her illness there was also diarrhoea, tympanites, and dysuria: to relieve these turpentine was administered internally and also applied externally over the abdomen; afterwards gallic acid was given, followed by aromatic sulphuric acid in conjunction with iron and with quinine. Notwithstanding the frequent use of disinfectant injections the discharges per vaginam were very offensive; about the twelfth day abcesses were observed near the hip, knee, and ankle joints, which, when opened, gave issue to purulent matter of a most intensely sickening and fœtid odor. From the fifteenth day the patient began to manifest signs of improvement; the delirium gave place to quiet sleep, the profuse cold sweats abated, and in a month after her accouchment she was considered out of danger. This case was one of extreme gravity, and seemed certainly most unpromising from the very commencement: the great tension and tenderness of the abdomen, the intolerable lancinating labor pains, the quick pulse, the hot and dry skin, and the great anxiety and restlessness even in the first hours of labor; the immense loss of blood at this time, followed by the long continued putrid discharge, the hectic and toxæmic fever with its small, thready, rapid pulse, great prostration, insomnia and delirium, the diarrhoea, tympanites and dysuria, the long continued cadaveric appearance of the patient, and lastly, the putrid metastatic abscesses, presented an aggregate of complications sufficient to appall and discourage even the bravest. It may be a question still sub judice, how far therapeutic measures contributed to the happy result of the case, how far the ergot helped to control the hemorrhage, and the sulphites exerted an antiseptic influence. As to the detergent action of the chlorinated soda and permanganate of potash there can be no question. Positive utility may doubtless be claimed also for the tonics, viz., iron and quinine, which were so freely employed, as also for the spirits of turpentine, and gallic and sulphuric acids, which were given for the tympanites and for the profuse sweats. 1316 OLIVE STREET, January 1, 1868. A CASE OF CONGENITAL MALFORMATION OF THE FEMALE URETHRA-CEPHALÆMATOMA. Reported by H. BEAUCHAMP, M.D., of Hamilton, Ohio. Mrs. J. S., primipara, was taken with labor-pains at 9 P. M., October 14th. The child was expelled at 7 1-4 A. M., of the 15th, with one turn of the cord around its neck, and presenting, at the time, no unusual feature. Weight, six pounds: sex, female. During the afternoon of the 15th, a tumor appeared upon the left posterior side of the head, measuring five inches in length, by two and three-quarter inches in width, apparently filled with fluid. The bones of the cranium could be felt by displacing the fluid, and the pressure caused no inconvenience to the child; it was not affected during respiration, or by the action of the heart. The skin over the tumor was natural in appearance and free from ecchymosis. From these characters it was recognized as a true cephalæmatoma. No change took place in the tumor until November 3d, when a slight diminution was noticed in its size; after that time it gradually decreased, until on the 14th no evidence of it remained beyond a slight roughness marking the original outline of the disease. No treatment was adopted further than to enjoin care that no irritation by pressure or from accidental causes should be permitted, for fear of exciting inflammation. A few hours after the birth of the child my attention was called to the fact that she had not urinated. On examination I could detect no opening in the normal site of the meatus urinarius, and at once suspected an absence or malformation of the urethra. By the advice of Dr. I. S. MCNEELEY, it was decided to postpone any operation until the next morning, in the hope that possibly a passage might discover itself. During the early part of the morning of the 16th, urine was voided. At my next visit I introduced an ear speculum into the vagina, and upon separating the blades of the instrument, discovered the urine flowing from an opening in the anterior wall of the passage about three-fourths of an inch within the vulva: no obstruction existed in the vagina. No dribbling of urine has occurred, and up to this time, Dec. 14, no trouble has been experienced from the malformation. February, 1868. COHNHEIM'S RESEARCHES ON INFLAMMATION AND SUPPURATION. Communicated in extract by G. BAUMGARTEN, M.D., of St. Louis. A short notice of COHNHEIM's discoveries, as laid before the Medical Society of Berlin, has already been presented to the American public by several journals (Medical News and others). I propose to review at some length C.'s own essay on the subject, the elaborate paper published in Virchow's Archiv, in Sept., 1867-Vol. xl., Heft 1–2. The importance to our views on the pathology of inflammation and the origin of pus of the discoveries by C.'s experiments can not be overrated. They substitute observed facts in the place of theories long and carefully hatched, and now quietly to be laid aside; they give us an absolute certainty in at least one detail of the histology of inflammation that is most refreshing; they clear up our theoretical views by giving them a firm basis; in short, they will "mark an era" in our pathology of inflammation. BILLROTH, in his first lectures on surgery at the Medical School of Vienna (in the chair of the late lamented Prof. SCHUI), referred to these investigations in about the following words (Wien. Med. Presse, Oct. 20, 1867): COHNHEIM has directly observed how, in those inflammatory processes which lead to suppuration, the white blood cells migrate from the intact capillary wall into the surrounding tissue, and thence upon the free surface of the abdominal cavity, (the experiments having been made on the perito |