21st. I found my patient better. Skin moister, pulse at 120, respiration slower, pain still present but less severe, dorsal decubitus as before, nausea entirely gone, thirst slightly abated and the lochia returning. The powders had all been taken. This time I directed,

S.

Proto-Chlor. Hydrarg, grs. xl.,

Opii, Pulv., grs. xvj.,

Ipecac, grs. viij.,

Ft. Chart, viij.,

One to be taken every three hours.

Left with instructions if the pain, &c., became aggravated, to acquaint me with the fact.

22d. All indications decidedly favorable; no pain present; some tenderness and flinching upon pressure, but this was to be expected. Skin moist, yellowish appearance of tongue changed to a slight whitish coating-pulse at 86, no nausea, diminished thirst, lochial discharge in sufficient quantity. The urine also was more copious and of lighter color, one alvine dejection had been obtained during the night. The anxious expression which previously characterized the countenance had yielded to a more placid appearance. Decubitus on the left side.

This to be repeated the next day, late at night. Mass. Hydrarg. grs. xviij to be taken and followed with Ol Ricini, q. s., provided that no action be obtained by 8 A. M. of the following day. The effervescing draught with demulcent drinks to be used interchangeably. Thinking personal attendance no longer requisite, I directed Mr. M to acquaint me with progress day by day.

She

26th. I was sent for in haste to visit my patient again. had been doing well in the interim since my last call until this morning; her appetite was becoming good, febrile symptoms disappearing, and nothing unfavorable had manifested itself until a few hours before my arrival. Trusting too much to a rapid convalescence, she neglected my dietetic rules and indulged her appetite, and also imprudently exposed her health by rising from her

Severe abdominal pains again

bed and passing over a damp floor. present, emesis frequent and violent, the matter ejected being apparently bile and altered mucus of acrid character, pulse at 160 and very small, respiration at 36-lochia entirely suppressed, decubitus unfavorable. Here a question arose in my mind as to the propriety of further venesection. Although my patient was debilitated and the attack secondary, there were two considerations not to be lost sight of, viz: that the inflammation was confessedly sthenic, and my patient young and of full habit. The lancet was used, and some 20 oz. of blood abstracted, the pulse softer, attended with an increase of volume, and fell 40 pulsations within an hour, thus triumphantly vindicating the treatment. A blister was applied over the hypogastric and right iliac region, also sinapisms to the stomach, warm cloths to the vulva, pediluvia, &c., as before.The subjoined was exhibited.

Proto-Chlor. Hydrarg., grs. xxxij.,
Morph. Sulph., grs. lv.,

Ft. Chart, xij.,

One to be taken every two hours.

27th. My patient feels better. Gums tender, pulse ranging at 100, pain greatly diminished, very little nausea, skin not so torpid, bowels in a soluble condition, and the lochia returning, tongue not heavily coated, but rather too pointed and red at the tip. The ensuing was directed,

28th. Pulse at 94, soft and full. Pretty freely salivated, stomach quiet, with gentle diaphoresis, pain nearly absent, thirst moderate, bowels open-a general amelioration of all the symptoms. I prescribed accordingly. Upon visiting Mrs. M― the next morning, she was as nearly as could be determined, in statu quo, though of course, relatively worse, (these stand points are not agreeable to the practitioner,) and here the case began to assume a more unfavorable aspect than at any time before. In a few hours the pulse rose to 120, notwithstanding the presence of what was deemed a judicious anti-phlogistic course, (active depletion being at this late stage inadmissible) and for several days occupied

a varying range between that point and 100, accompanied with a partial return of the abdominal pain. Distressing and frequent vomiting was once more added to the list of symptoms. The tongue assumed a darker color, sordes accumulated on the teeth, respiration more frequent, with occasional singultus. Abdomen. tympanitic, uterine discharges horribly fetid. The case was growing worse, the system cachectic; an asthenic inflammation had obtained. After a review of my therapeutics, I could not accuse myself of mal-practice, but the treatment must be modified. After applying "flying blisters" over the stomach, she was directed, Ol. Terebinth, 3ss., Tr. Opii., gtt. xxx., Mucilage, 3j.

Ft. Haust.

This to be repeated every four hours. Local applications, hygiene, &c., as at first. It would be tedious further to pursue the conduct of this case. By the use of opiates, terebinthinates, &c., with an early exhibition of generous wine, and light, but nutritious food, the lady recovered.

It may be thought that the treatment instituted was rather heroic. While the patient was before me I did not think so, nor can I at this date, upon a retrospect, believe it. Let us see. She bore depletion well, an incubus appeared to be thrown off the circulation

the biotic powers rallied; innervation, secretion and absorption conclusively proved it in each instance. Why a sthenic inflammation merged into an asthenic condition under such auspices, is more than I can divine; for evidently, the treatment was not wholly depletory and exhausting. Perhaps it is referable to a changed condition of the blood dependent upon the absorption of deleterious agents from the diseased tissues, added to depressing influences which a continuance of the disease would necessarily involve.That the constitution of the atmosphere was a causative agent in this example, would be ruled out, on the ground of the indubitable fact that the inflammation was sthenic at its advent, and markedly so even after the relapse. Due attention had been given to the management of the sick room-no noxious effluvia had existence in the neighborhood-no local cause whatever, in so far as could be discovered, for the induction of adynamic manifestations. Due attention had been given to the removal of acrid substances from

the vagina and uterus, by emollient injections, as I believe that negligence in this respect is apt to be attended with pernicious results.

It is true that an asthenic condition frequently follows its opposite; of this we have examples daily, but cases like that recorded above are rare. The sudden accession of graver symptoms, and the extreme prostration witnessed, could not have been anticipated reasonably, during the first and second stages. We must be satisfied with placing it among the inexplicable phenomena whose arcana may yet be patent; in the meantime deriving all the benefit from it which is practicable. Two practical hints may be deduced, viz: to watch the character of peritoneal inflammation jealously, and commence a roborant treatment early.

Walnut Camp, Arks., Sept. 6th, 1854.

CASES IN PRACTICE.

BY D. L. MCGUGIN, M. D.,

Prof. Physiology and Pathology in Iowa Medical Department. CASE I.—Mrs. P―, pregnant with her eighth child, had been a sufferer from dysentery for the period of sixteen days, at the end of which time I was consulted. I found her in such extremity of suffering, that she could not give me a satisfactory history of her case. She had suffered much from dysenteric discharges, and the attendants stated that during the above period, a number of times every 24 hours, the paroxysms of suffering were as great as the aggravated character which they then presented. I found her tossing, and rolling over the bed, in the most indescribable torture, evidently paroxysmal, but the intermissions short and incomplete. Although a woman of full habit, her pulse was frequent and feeble, numbering 140 to the minute. The tongue was slightly furred, and the expression of her countenance was one of great anxiety. She had slept but little during the above period; there had been. distressing thirst for the past few days, and all her symptoms indicated great exhaustion. The dysenteric discharges were not remarkably frequent, nor were they of a character indicating much lesion of the lower bowels. The character of the suffering indicated to me that labor was then in progress, and the history of her case led to the belief that this had been the cause of her suffering VOL. II. NO. II.-3

for many days, and perhaps from the first, as she was strongly impressed with the opinion, that her term closed with the advent of her suffering. The "touch" discovered the os uteri dilated and dilatable, but looking backward toward the sacrum, and laterally to the right iliac fossa. I concluded at once that here was an anterior and lateral obliquity. An examination into the form and situation of the abdominal tumor, showed that the position of the uterus was to the left, and anteriorly, and also that there was very great laxity of the abdominal walls. The tumor was unusually large, nor did the examination reveal that the usual distension was owing in any great degree to over accumulation of liquor amnii. The fibres were contracting somewhat firmly, and revealed to a certain extent the form and position of the foetus. This would not have been obtained, had there been a superabundance of the waters. The foetus was living, as the pulsation of the foetal heart was plainly perceptible.

The indication was now plain enough, and a proceeding was adopted in consonance. The change of position of the patient upon her back, and the adjustment of a broad roller over the abdomen with some firmness, were but the work of a moment. The bandage over the abdomen was to supply the requisite support which the abdominal parietes, by their extreme laxity, refused to afford, In a short time the pains increased in force, the propulsive effect was made evident, and in half an hour a healthy child of twelve pounds was born. In a few days the dysentery ceased under remedies, and she continued to improve.

This woman was doubtless in labor for some time, but the unavailing propulsive efforts were followed by a surrender of the uterine fibres after each, to be renewed after a regular period to another fruitless trial. Thus it continued, and thus it would have continued, unless accident had placed the uterus in a situation and relation to the axis of the pelvic cavity, or until her strength would have been exhausted, and the foetus not yet delivered. This case is suggestive of a wise caution. In protracted labors we should enquire into all the particulars, with the view to the discovery of "all and singular" the causes arresting the labor in any of its stages. As already intimated, there was not half the usual quantity of the liquor amnii, the placenta followed promptly, and the uterus contracted readily and fully.