100 to 130 or more. The temperature is raised to 102°, or in severe cases 104" or 105° F. In the more intense class of cases, in which the whole system seems overwhelmed with the poison, the disease progresses with great rapidity, and often without any appreciable indication of local complication. The pulse is very rapid, small and feeble. There may be little or no pain, or there may be slight tenderness on pressure over the abdomen; and, as the disease progresses, the intestines get largely distended with flatus. The countenance is sallow and sunken. In some cases, the intelligence is unimpaired; in others there is low muttering delirium, especially at night. Diarrhoea is a common symptom; the stools are thin, dark-colored and foetid. Vomiting sometimes occurs; a darkcoffee-ground substance is ejected. The tongue is generally moist, and sometimes loaded with sordes, but in many cases it gets dark and dry at or toward the termination of the disease. The lochia are generally suppressed, or changed in character, with a highly offensive odor. The secretion of milk is often, but not always, arrested. With more or less of these symptoms the case goes on, and when it ends fatally, it generally does so within a week; the fatal termination being indicated by more exhaustion, rapid intermittent pulse, marked delirium, and sometimes a sudden fall of temperature, with great tympanitis.

In considering the important subject of treatment, we certainly cannot follow a routine form of prescribing with any hope of success. The physician will naturally be biassed by the theory he has adopted concerning the nature of the disease. Yet the closely-observing practitioner will see indications for certain remedies and forms of treatment which will be crowned with success in many cases. 1st. We must discover, if possible, the source of the poison, with the hope of arresting further septic absorption. 2d. We must keep the patient alive until the poison can be overcome. 3d. We must meet all proper indications for remedies, internally and locally. The first is of great importance in cases of self-infection, in which fresh quantities of septic matter may be, from time to time, absorbed. Antiseptics should be thoroughly ap

plied to the interior of the vagina and uterus. Chlorate of potassa and carbolic acid, used in alternation, are as good as any that can be used. The results in some cases are remarkable, the pulse and temperature falling soon after the thorough use of the injections. If the bowels are constipated, a gentle action should be promoted by some mild aperient; always bearing in mind that an exhaustive diarrhoea is liable to set in at any time. If the pulse is moderately full, tincture of Veratrum viride in drop-doses, every hour, will be indicated; but if the pulse is small and thready, tincture of Aconite root in half-drop or drop-doses, every hour, will do better. If the breath is fetid, chlorate of potassa, in five-grain doses, should be given every two or three hours. If the base of the tongue has a pasty, dirty-looking coating on it, sulphite of soda is the remedy. Baptisia is indicated in the cases in which there is enfeebled capillary circulation, with dusty or livid mucous membranes. If the pupils are dilated and the skin clammy, tincture of belladonna should be given, in dropdoses, every hour or two. If the pupils are contracted with a determination of blood to the brain, indicated by flushed face, bright eyes and restlessness, we should prescribe gelsemium with great certainty. The indications for hydrochloric acid in all septic diseases are plain. The mucous membranes of the tongue and mouth are of a deep red color. The pathological indications for alkalies are a pasty-white tongue; the white extending to the tip. If there is periodicity, quinia, in doses such as the patient can bear, should be prescribed. If there is much tenderness over the abdomen, alcohol and tincture of opium should be kept applied. If there is great tympanitic distension, turpentine stupes are indicated. In regard to bathing, if the skin is soft and doughy, stimulating baths should be used; if hot and dry, something of a sedative nature is better. If the indications for internal remedies are for acids, a weak solution of hydrochloric acid should be used, but if the indications are for alkalies, bicarbonate of soda is as good as any. Such liquid food should be given as can be borne on the stomach; beef tea, mutton broth, oatmeal gruel, with good fresh milk, and brandy if needed.

It is needless to lay down fixed rules for the management of any individual case. When we learn to meet the pathological indications for remedies in each as they present themselves, we shall come nearer facts than has been done in a great many cases in times gone by.

THE USE OF ANESTHETICS AND THE FORCEPS

IN OBSTETRICS.

By JOHN PERRINS, M. D., Boston, Mass.

There are no cases in the practice of medicine which are calculated to give the patient and friends more anxiety and alarm than a tedious and prolonged labor; and none that I am aware of that so taxes the fortitude and confidence of the physician.

Let us take for example the case of a primipara. Labor has just commenced; the os is dilated sufficiently to admit the tip of the finger, or perhaps a little more. We give assurance that all is going on well, but add that as labor is only just commencing we will not be required for one or more hours. At the expiration of the time we call again; if indeed, we are not summoned sooner. We now learn that pains have been regularly increasing in strength and frequency, and we find that dilatation has fully taken place, or that the parts are dilatable.

A more thorough examination shows us we have a vertex presentation, and we are confident that all is progressing satisfactorily. After waiting and observing our patient have pain after pain, there seems to be sufficient to justify us in the belief that labor is or ought to be progressing favorably. But when we again examine we are surprised to find things, very much the same as before, and ask ourselves, what is the trouble. We endeavor to find out what position we have. This we may, or may not, be successful in doing. We will suppose that we find the position to be either the right or left occipitoanterior, the two most favorable positions we can have. The

posterior fontanelle is in or near the centre of the superior strait, proving the head to be well-flexed; and so far as presentation and position are concerned, we have all that we can desire.

The pains are strong and frequent, yet we find no advance; the head not even engaging in the superior strait. We exhibit our favorite remedies for facilitating progress according to the specific indications or otherwise; it may be by Gelsemium, Lobelia seed, Macrotys, or any known and tried remedy; still no better success. We employ the broad bandage put on over the clothing, drawn tight and secured with strong pins, which gives support to the back and to the abdominal walls, and thereby assists very much during the expulsive efforts of the uterus. But with all these valuable aids there is little or no advance. Several hours have now passed since the parts were dilatable; the pains are strong and frequent; our patient is manifesting signs of exhaustion, and her friends are becoming anxious in her behalf.

We cannot say in answer to their inquiries that all is going on well. Shall we now endeavor to content ourselves by repeating the old and worn-out phrases; "Give her time;" or, "Let nature take its course;" while we fold our hands and admit our helplessness; or shall we calmly and confidently advise the use of the forceps?

Let us examine the chances in each course. In the first place, we lose the patient's time and our own. The patient loses strength; the friends waver in their confidence in the physician, especially if he be young; the child parts with its chances of life, perhaps altogether. We lose a grand opportunity of demonstrating to both patient and friends, that when by any disproportion of child to mother, the natural effort is unable to deliver in a reasonable time and with a comparatively moderate degree of pain, we are both able and ready to come to the assistance of the patient before her strength is exhausted; and by the use of the forceps, safely and speedily to terminate what would otherwise have been a painful and tedious labor, and with almost certain death to the child.

This is not all. How often, after all, we are obliged to resort

to the use of instruments, and find in the end that we have delayed too long and that the child is dead. I know not whether any of you have ever encountered such a case, but once it was my unfortunate experience. I delayed as long as I thought it safe, hoping to get through alone, but finally called Dr. C. E. Miles in consultation. Instruments were used and the woman delivered, but the child was dead. The hopeful parents lost their first-born, and I never regained their patronage and influence.

What may we gain by pursuing the opposite course? We are convinced that with such pains as our patient is suffering, labor ought to be advancing; dilatation is complete; the hand can be passed if need be, into the uterus. Still there is no advance. We have done our best; the various expedients have been tried, but to no purpose. The friends anxiously inquire how she is getting along. We may say: very well so far; that everything is in good condition; the head presents, but that labor is not progressing quite as fast as it ought with such pains; that for the last hour the child has not moved, and we are not quite sure that she will be able to dislodge it from its present position without further aid; still we are willing she shall have all the time that will be well for her, and safe for the child. If she then fails it will be advisable to use instruments.

Then come the questions: "Doctor, do you think she will come through it safely; and, will the instruments hurt her?" We can answer that we have no fear for the mother; and as for hurting, it will be far less than if she is left to herself; that it will give the child double the chance of being born alive; besides, if she wishes she may take ether and so get rid of the pains altogether. It is very seldom that the patient will go through more than two or three more pains before she will ask:

"Doctor, have you your instruments with you?"

If I am now only ten minutes' walk from home, or in the night a shorter distance, I reply:

"Oh yes, I always come prepared for my work. Would you like to see them?"