in such cases; its sustaining and quieting effects gave nature the opportunity to make the effort at reparation which could scarcely have been effected other wise.

"Persons not unfrequently sink without a rally under the shock consequent upon great and extensive injuries. Might not opium, given on the principles advocated above, afford such patients a chance of reaction, and ultimately of restoration?"-Dub. Quart. Journ. of Med. Sci., August, 1857.

61. Puerperal Fever.-The Academy of Medicine in Paris has for some time been occupied in a discussion on Puerperal Fever, in which the leading obstetricians of the French metropolis have given utterance at length to their opinions. From among the numerous speeches, we translate that of M. CAZEAUX, as it gives a very good digest of the different opinions entertained.

I think that it would be superfluous, after the speeches which you have heard, to revert to the symptomatology and anatomical characters of the disease or diseases collectively described under the names of puerperal fever or puerperal peritonitis. These points in the discussion appear to me to have been sufficiently studied by M. Depaul and M. Cruveilhier. You are aware of the importance given by the last named speaker to lymphangitis among the alterations peculiar to puerperal fever; so much so, that he considers it characteristic of that disease. But that opinion has been vehemently disputed by M. Béhier, who maintains, on the contrary, that, in autopsies of women who have died of puerperal fever, he has found inflammation of the veins more frequently than of the lymphatics. This assertion of M. Béhier's has surprised me greatly. I have, for my own part, opened a good number of bodies of women who have died of puerperal diseases, and I declare that, like M. Cruveilhier, I have found pus much more frequently in the uterine lymphatics than in the veins. Does not M. Béhier's error depend on an anatomical confusion? For it is remarkable that, although he describes the pus as being in other vessels than M. Cruveilhier does, he still finds it in the same parts of the uterus or its appendages; that is to say, in those portions which are particularly rich in lymphatic vessels. But there is one question which has in an especial degree excited the speakers; it is that of knowing what is the nature of puerperal fever, and what nosological rank it is proper to assign to the lesions which it presents.

In this respect the speakers have been divided into two camps. In the one, they admit the existence of an essential fever-of a pyrexia; in the other, they see only local phlegmasia. Up to the present moment M. Beau is the only one who has formally declared himself in favour of this latter doctrine. With regard to the doctrine of essentiality, it has found supporters in M. Depaul, who has the most boldly and the most clearly laid down the question; in M. Danyau, who has also spoken out resolutely enough; in M. Trousseau, who, after having formally rejected the puerperal fever, has so well generalized it subsequently, that he has admitted it not only for women in child-bed, but even for women not in the puerperal state at all, for the foetus, for the new-born child, and for all subjects attacked by any kind of traumatism. M. Dubois has equally announced himself an essentialist; but he has produced no new arguments in favour of that opinion, and he has enveloped his ideas in such thick clouds, that it is difficult through such a veil to distinguish a pure essentialist. The question, therefore, is solely and entirely between M. Depaul and

M. Beau.

M. Beau appears to me to have replied victoriously to M. Depaul, invoking the epidemic and contagious characters of the disease as proofs of its essentiality. I will not revert to these arguments; but I will add that one of the characters of pyrexia, viz., the manifestations of the fever some days before the appearance of the local symptoms, as is the case with typhus and smallpox, is not what is observed in puerperal fever, in which the pain, which is the sign of local phlegmasiæ, shows itself almost at the same time as the shivering, which is the sign of the general pathological state. I find also a very good argument against essentialism in the speech of M. Dubois, who nevertheless makes profession of being an essentialist. Have we not heard that honourable professor tell us that the multiplicity, the variety of the lesions in puerperal fever,

would be inconsistent with placing it among pyrexiæ, the principal character of which is to present anatomical alterations, constant and always identical? With regard to the negative autopsies quoted by M. Depaul as an argument in favour of essentiality, while I admit, as I do willingly, that they have been well made, I can neither consider them as convincing proofs, nor as motives for rejecting the doctrine of local phlegmasias. In fact, do we not see peritoneal inflammations, traumatic, or by perforation, kill so promptly, that material alterations have not had time to be formed? Do we not see, also, burns in the first or second degree cause a rapid death-the effect assuredly, not of the lesion of the tissue, but solely of the extent and violence of the inflammation? On the other hand, is it really necessary to find severe organic lesions to explain functional disorders, and even death, in puerperal fever? I do not think it is; for, in my opinion, the blood in this disease has undergone so profound an alteration as to account for all the accidents, and for the usually fatal termination of the disease.

The mistake committed by those nosologists who have wished to assign a place to puerperal fever consists, in my opinion, in their having studied it under its epidemic form. In order to form a true and clear idea of the disease, we must look at it under its sporadic form; that is, in its condition of simplicity, disengaged from the special elements of gravity necessarily given to it by the epidemic character. Let us then imagine a physician who has never seen a case of puerperal fever, and who has never read a description of this malady. He is brought into the presence of a woman recently confined, in whom a laborious parturition, a prolonged labour, has produced numerous bruises and lacerations, speedily followed by violent shivering, by very severe abdominal pains, and by a series of other severe general and local symptoms which will rapidly terminate in death. At the autopsy, he finds pus in the peritoneum, in the veins and lymphatics of the pelvis. What idea can this physician form of the nature of the disease, but that it is a phlegmasia?

Now, must we admit that there exists a natural difference between the epidemic and the sporadic forms of puerperal fever? By no means--any more than that there exists a difference between epidemic and sporadic pneumonia. Nevertheless, M. Trousseau has brought forward one difference which he describes as very essential; it is the existence of a specific cause, of a kind of virus which would be the essence of the epidemic puerperal fever. Well, a specific cause always produces a corresponding specific disease, announcing itself by signs or lesions always identical; thus, the virus of rabies always produces rabies; the virus of syphilis, syphilis; the smallpox virus, smallpox; while here we have to do with a disease which presents itself with lesions the most varied, sometimes a metritis, sometimes a peritonitis, sometimes a phlebitis, at other times a lymphangitis, a pneumonia, a pleurisy, a suppurating arthritis, etc. We cannot, therefore, allege a sole cause for effects so varied. The difference which I admit, for my own part, is not where M. Trousseau has placed it-in the nature of the disease; I find it in the very fact of the epidemic, which renders the disease more severe, without changing anything of its essence. It is here with puerpural phlegmasia as with cholera, angina, dysentery, and a hundred other affections that I might name.

Do not think, however, that beyond the local inflammation I see nothing whatever, and that I believe that in that resides the whole gravity of the affec tion. If, indeed, I do not admit a puerperal fever, I do admit a puerperal state, which, in preparation throughout the pregnancy, arrives at its maximum of intensity at the time of the accouchement, and shortly afterwards. This puerperal state consists in a notable alteration of the fluids, which is present, in a greater or less degree, in all pregnant women. I have heard M. Trousseau speak to us with some disdain of recent hæmatological researches. For my part, I think they are destined to open to medicine a way of progress, and to enlighten us on many questions which are still obscure. It is not in my place here to recall all the results already obtained; but I cannot be silent on the very special services rendered by hæmatology to obstetric physiology and pathology. Thanks to that science, gentlemen, it is now admitted that preg nancy, so far from constituting a condition of plethora, actually, on the contrary, engenders an anæmic state. Thanks to hæmatology, we now understand

the etiological analogies existing between eclampsia and the epileptiform convulsions which terminate Bright's disease. It has been established very clearly that in both cases the nervous phenomena depend on an intoxication of the blood by urea-on an uræmia.

It is also in the blood-in the blood so profoundly modified in pregnancythat we must seek the first cause and the point de départ of puerperal diseases. Thus, diminution of globules, of albumen, of iron, a notable augmentation of water and of fibrine-such are the modifications-I ought to say, the alterations of the blood in a woman about to lie in. If in such a condition there supervene an extensive inflammation of an important organ, you may conceive what development it must assume in invading an organism so seriously altered. Who can forsee to what extent these alterations of the blood may go, and what may be the consequence of them? For myself, I do not hesitate to say that, in certain cases, they may be carried to a point at which they will produce a transformation of blood-globules into pus-globules; and that without a wound, without phlebitis, without any lesion of the solids.

And on this subject, let me recall a fact reported by M. Andral, and which is very well adapted to impart a certain value to this hypothesis. A man was brought in dying, in a most formidable ataxo-adynamic state; he died at the end of three days. At the autopsy, numerous abscesses were found in the brain, in the lungs, in the spleen, in the kidneys; the blood everywhere was like very loose currant-jelly. In the midst of the blood-globules, which were misshapen, strawberry-like (framboisés), a great number of pus-globules were plainly distinguished. Nowhere was there the slightest trace of phlebitis. Collections of pus in many of the solids, and pus in the blood itself, were the only alterations demonstrable.

There is, therefore, in lying-in women, as M. Trousseau has said, a great morbid aptitude, which I will at once call a pyogenic state, which not only manifests itself in abdominal phlegmasias, but makes its sad influence felt, whatever be the disease attacking the puerperal female. It is thus that, according to M. Chomel and M. Grisolle, the pneumonias which supervene during the puerperal state acquire an extraordinary degree of virulence, which renders them promptly mortal.

Be the puerperal fever sporadic or epidemic, it always consists essentially in an alteration of the blood and a special aptitude of certain organs to inflame and to rapidly produce pus; with this sole difference, that with epidemics this aptitude finds itself singularly increased by this agent, unknown in its essence, but so manifest in its effect, and to which has been given the vague denomination of epidemic influence (génie épidémique); whence also the greater gravity of the disease, and its termination more promptly and more constantly deadly. I will only say this regarding the contagious character of puerperal fever, that I adhere without reserve to what MM. Depaul and Danyau say about it. After a demonstration so clear, so peremptory, as that furnished by those two speakers, it is impossible that there can remain any incredulous on the point. M. Danyau has therefore, with good reason, insisted on the precautions to be taken to avoid the dangers of contagion.

What shall I say of the treatment? The speakers who have preceded me have superabundantly proved the uselessness of the different methods of cure, and the vanity of certain remedies considered prophylactic.

For the curative treatment, I will confine myself to the declaration that all the means I have tried have failed in my hands, as in those of my colleagues, in cases of virulent or epidemic puerperal fever. I must, however, say that I have obtained good effects from the employment of mercury. I have seen every case get well in which powerful doses of mercury have produced an abundant salivation; a circumstance which induces me to think that he who shall find an infallible means of bringing on a copious salivation will have perhaps discovered a specific for puerperal fever.

As for prophylactic measures, I see none better at present than such as consist in diminishing the agglomeration of women in lying-in; and on that point, I entirely agree with M. Danyau. The measures he proposes appear to me the wisest, the best understood, and the most conformable to the rules of a prudent hygiene.-British Med. Journ., May 15, from Gaz. Hebdomadaire, April 16, 1858.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

62. The Condition of the Lung not Invariably to be Depended on, as a Proof that the Infant has been Born Alive. By THOS. WILLIAMSON, M. D.—In a medicolegal point of view, all fresh cases bearing upon the important subject of infanticide, should be carefully recorded.

During the past eighteen or twenty years of a somewhat extensive midwifery practice, five or six instances have occurred to me, which go far to establish the correctness of the remarks of Dr. Taylor, in his work on Medical Jurisprudence, when referring to the extreme caution and care which ought to be observed by medical men in forming their opinion as to the cause of the infant's death. The mere proof, derivable from the condition of the lung, that the child has respired, is by no means per se sufficient to establish the fact that it has been born alive. In writing upon this subject, Dr. Taylor says: "Mr. Price has communicated to the Medical Gazette the account of a case, in which the cord was so tightly twisted around the neck of a child, that he was compelled to divide it before delivery could be accomplished. There was in this case a deep groove formed on the neck, and it conveyed the impression to himself and a medical friend that, in the absence of any knowledge of the facts, they would have been prepared to say that the child had been wilfully strangled by a rope. In this instance the cord was very short."

In all of my cases, I was under the necessity likewise of dividing the cord previous to the birth of the infant. Had I failed in doing so, life would have been inevitably destroyed; and had a stranger to the history of the cases been called upon to institute a post-mortem examination, he must have arrived at the conclusion that these infants had been born alive.

Immediately upon the birth of the head, in the instances which have occurred to me, the infant has respired freely, but upon running the finger round the neck, one or more loops of the cord have been found firmly encircling the throat. In all similar cases, generally speaking, little or no trouble is experienced in at once disengaging the coil of cord, and thus permitting the almost simultaneous propulsion of the shoulders; but, in the instances referred to, owing to the extreme shortness of the umbilical cord, this manoeuvre was found utterly impracticable. Each succeeding contraction of the uterus was found to tighten and constrict the umbilical ligature still more and more; respiration ceased, and the face of the infant became black and congested. Sometimes I have succeeded, with much difficulty, during the interval of pains, in slipping a double ligature around the cord, and severing it at random; at other times, I have been necessitated to divide the cord without any such precautionary measures, dreading alike mischief to the mother and child, and running all the consequent risk of fatal hemorrhage, at least to the infant. I may mention that the umbilical cord rarely exceeded sixteen or eighteen inches in length, and had effected a deep indentation around the neck of the child. In the last of my cases (which occurred within the past few days), shortly after the birth of the infant, upon proceeding to remove the placenta, I discovered that it was firmly retained; the uterus having assumed the hour-glass form of contraction, and refusing to dilate again without the previous administration of a large opiate. Was not this nature herself stepping in to prevent the serious displacement of the uterus, the placenta being still undetached from its fundus, whilst the suffocating infant was struggling to get free?

In certain instances of suspected infanticide, which will at once occur to the mind of every one, it must be obvious how very damaging to the accused, is the fact, when brought out by post-mortem examination, of respiration having been fairly established. The ordinary inference, where, from the state of the lungs, this process has been proved to have existed, is, that the child must have been born alive. Had the cases, however, to which I have referred, been left to themselves, the infants would have been born dead, with an indented groove encircling their necks; and yet a post-mortem examination would have revealed all the indications usually regarded as conclusive proof that they had been born alive. Hence, then, the necessity of great caution in forming an opinion of the cause of death in all such cases.-Edinburgh Medical Journal, Feb., 1858.

63. Death from Chloroform.-AUGUSTIN PRICHARD, Esq., reported (Feb. 25th, 1858) the following example of this to the Bath and Bristol Branch of the British Medical Association.

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"Wm. Howell, aged 49, was admitted as my patient into the Bristol Royal Infirmary, on Tuesday, February 9th, after a consultation recommending the operation of excision of the elbow for long continued disease of the joint. His elbow had been injured two years before, and he had suffered occasionally ever since. He had been under my care once before, and the disease had been arrested by treatment, and he resumed his work. Lately, it had again become worse; and about a month ago, I detected disease of the articular extremities of the bones, with ulceration of the cartilages, and effusion into all the tissues round the joint, with fistula leading into its cavity. His forearm was held almost extended in a line with the arm, and he carried it about with his other hand, as patients do when they have ulceration of the cartilages of the elbow. His health had suffered, inasmuch as he was greatly out of condition, from the discharge and constant pain; but he showed no sign of other organic disease. The operation was fixed for Friday, February 12th; and at the appointed time, he walked into the operation-room, where all my surgical colleagues were assembled, with the house-surgeon and assistant house-surgeon, and most of the pupils of the Infirmary. I believe one or two visitors were also present; and some of the physicians came in afterwards. He got up without much help and lay down upon the table; and Mr. Powell, the assistant house-surgeon, examined his chest, as he invariably does before administering chloroform, but detected nothing abnormal. The patient had taken no food since his breakfast: this rule is always followed, when possible, to prevent the chance of vomiting, and the danger of solid food impeding respiration by obstructing the glottis when the patient is insensible from the effects of chloroform, and he is always kept in a reclining position. I should mention, in passing, that a boy had just been operated on for phimosis by Mr. Harrison, and the same chloroform and the same sponge that were used in the case of my patient, were used in his.

"A drachm of chloroform (which had been obtained from Duncan and Flockhart, of Edinburgh) was poured upon the centre of a hollow sponge, and held over the patient's nose and mouth. He asked whether he was to breathe it; and was, of course told to do so. I then found that he had still his waistcoat on, and directed him to sit up and take it off, which he did, the sponge being removed for the purpose; and after he lay down, I again made him sit up and remove the shirt-sleeve from the diseased arm, a process that took two or three minutes at least, in consequence of the pain produced by any sudden movements of the limb. He then lay down again, and continued to inhale a portion of the same drachm of chloroform which had been evaporating all this time. I turned round to speak to some of the surgeons of the Infirmary, who were standing near the fire, and in about two minutes my attention was called to the patient, by the assistant house-surgeon saying: "This patient does not bear chloroform well." He was then gasping, but not breathing; his limbs were moving slowly and irregularly in the convulsive motion of death; the eyes were fixed, with dilated pupils; and his pulse had stopped; and he was, in point of fact, dead, as surely as and more rapidly than if he had taken a large dose of prussic acid.

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We tried every available means of restoration. A powerful battery was at hand, and going, and was applied at once. I opened his trachea; and we kept up artificial respiration for half an hour, by blowing into the tube and pressing the abdomen alternately. The battery was applied with sufficient strength to contract forcibly the muscles of the face, neck, and trunk, and to produce the movements of respiration, but without affecting the heart in the slightest degree; and, at the suggestion of some one present, I injected a warm saline solution into the cephalic vein, to try to stimulate the heart; but all our efforts were in vain, for the man was dead.

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The post-mortem examination was made the next day. able rigor mortis. The vessels of the scalp were empty. pale, and the sinuses were rather empty. A good deal

There was considerThe dura mater was of clear subarachnoid