crawled about considerably, and this caused the inflammation of the bursa in front of the ligamentum patellæ. It is the first case I ever saw in a man. He was taken before

Dr. Yandell's clinic December 11th, and he kindly asked me to operate. The tumor was as large as an orange. I dissected out the sac from the surrounding tissues, and removed it during the operation with strict antiseptic precautions. The wound did well, uniting by first intention. The temperature never went above normal.

Until the day of antiseptic surgery it was considered most hazardous to perform excision of a housemaid's knee. All authors writing earlier than about five years ago condemned it in unmeasured terms. It is far more satisfactory than the old way of tapping and injecting iodine, or the use of setons and the like, and I should think less dangerous.

The warning given by authors against excision is unnecessarily conservative. There are two bursæ in this location; one a "bursa mucosa," situated in the cellular tissue and in front of the ligamentum patellæ; the other a synovial bursa situated behind the ligamentum patellæ between it and the tibia. The latter often communicates with the knee-joint.

It is inflammation of the first variety, the "bursa mucosa" caused by friction, which causes housemaid's knee. As it has no connection with the knee-joint, there is no danger of arthritis when excised.

There is one danger, however, and that is of opening the deep fascia of the leg. This deep fascia is inserted into the edges of the patella, and by keeping to the center of the bone it will not be opened.

CASE 4. Mr. J., aged forty. Had gonor rhea fifteen years ago. Stricture resulted soon afterward. Was sent to me by Dr. Cartledge December 24, 1887, he being not well enough to attend him.

Found him suffering with extravasation of urine. The perineum and scrotum were greatly distended and were very tender to the touch. Suppuration had ensued. Temperature was 103°, pulse 120. Was passing

water by the urethra in small quantities every few minutes. I at once determined upon perineal section. I was assisted by Prof. Roberts, Drs. Pierce and Milligan.

A curved staff grooved centrally on its convexity was introduced into the bladder, and an incision one and a half inches long made through the raphe of the perineum down to the staff at a point in front of the junction of the membranous and prostatic urethra. A large amount of pus and urine were evacuated. The bladder and abscess cavity were well irrigated with warm boracic-acid solution. There were three or four scars showing the location of old perineal fistulæ. The point of interest in this case was the fact of urinary extravasation having taken place when the stricture was of large caliber. It readily permitted the passage of the staff. The extravasation must have resulted from ulceration.

Case did uninterruptedly well; was passing water per urethram entirely in ten days.

LOUISVILLE.

THE MANAGEMENT OF POST-PARTUM HEMORRHAGE.

BY WM. B. BLACKSTONE, M. D.

Not long since I read with much interest in the AMERICAN PRACTITIONER AND NEWS, a clinical report of three cases of "Post-partum Hemorrhage," by E. J. Kempf, M. D., and it is with a view of emphasizing the importance of this subject that I submit the following summary of the methods of treatment that have proved effective in the hands of eminent accoucheurs.

By post-partum hemorrhage is meant an excessive flow of blood occurring at the placental site in the body of the uterus after birth of the child. It occurs as a result of one or all of the three following factors:

1. Uterine inertia, due to hydramnion, precipitate labors, etc.

2. Mechanical causes, as retained placenta and blood-clots.

3. Hypinosis, an impaired condition of the blood, in which there is a diminution of the fibrin-forming element.

The prognosis is conditioned on the amount of hemorrhage, its suddenness, length of time it has continued, degree of paralysis, and skill of attending physician. A hemorrhage occurring at this time is always alarming, but if treatment be inaugurated promptly and judiciously a favorable termination can always be expected. If death ensues, the accoucheur is alone responsible, not Providence. No physician should attend a woman in confinement unless he is prepared to meet any emergency that may arise. He should have a complete outfit of obstetrical instruments and a full line of such medicines as are usually employed in obstetrical practice. A thorough diagnosis should be made, when appropriate treatment can be instituted. The treatment is prophylactic and curative.

(a) Prophylactic. Under this head is embraced every thing pertaining to the proper management of child-bed cases, and need not be enumerated in this article.

(b) Curative. Under this head I will give the various modes of procedure in a brief manner, in the order of their importance:

1. Ergot. This is par excellence the best medicinal agent we possess for the control of uterine hemorrhage. It can be administered by the mouth, rectum or hypodermically. When given per os its action is slow, and is liable to cause nausea. For hypodermic use Squibb's aqueous extract is an efficient preparation. When employed When employed subcutaneously the needle may be inserted. either on the outer or inner side of the thigh. If in the latter situation, the needle should be introduced to the inner side of the saphenous vein.

2. Massage. This is best accomplished by placing the right hand behind the posterior surface of the uterus, and the left hand on the abdomen over the anterior wall of the uterus. In France massage is performed by introducing two fingers of the left hand into the vagina behind the posterior lip of the cervix, where pressure upward and forward is made; while, with the right band on the abdominal wall, pressure is made downward and backward on the fundus of the uterus. The action of this maneuver

is three-fold: (a) Uterine massage; (b) forced anteflexion; (c) irritation of the ganglion of the cervix.

3. Removal of Placenta and Clots. This can be effected by means of instruments or hand-preferably by the latter. After the placenta is removed and clots turned out, perform external and internal massage very gently.

4. Injection of Cold Water through the Umbilical vein of the Cord. By this process the placenta is distended, and as the water trickles through into the cavity of the uterus, contractions are induced and the placenta is expelled. This method is now practiced very extensively in the German schools.

5. Application of Vinegar. This method. is an excellent one. Applications of this agent can best be made by saturating sponges and carrying them up into the interior of the uterus and there squeezing them out. 6. Cold-water Irrigation.

7. Hot-water Irrigation. When hot and cold-water irrigations are used alternately, the result is usually very favorable. When used in this manner, uterine contractions are more quickly induced. Not more than one quart of water should be used, and care should be taken that no air gains access to the interior of the uterus.

8. Introduction of Ice. Small pieces are carried up into the body of the uterus. Is very efficient, but is liable, in some cases, to cause uterine rheumatism.

9. Intra-uterine Injections of Tincture of Io line.

10. Intra-uterine Injections of Astringents. The objection to the employment of the tineture of the chloride and solution of the subsulphate of iron is that they are liable to cause a metro phlebitis when used in a concentrated form. If they are employed, a solution stronger than two per cent should not be used.

11. Suction of Nipples. This is occasionally successful, but on the whole is not reliable.

12. Compression of Abdominal Aorta. This is effected: (a) By digital compression

BY AP MORGAN VANCE, M. D.

The marked results I have obtained from the above-named drug in many of the subacute and chronic surgical troubles that have come under my care induce me to bring the subject before the Society to-night, that we may hear some expressions from the Fellows concerning the subject.

In subacute or chronic joint diseases, the result of either synovitis or rheumatism, I have obtained very marked improvement from the use of the potash, also in hydroceles, pleuritic effusions, and in neuralgia, the result of rheumatism. I think the secret of success in any of the above-named troubles is the same as in the treatment of Potts' paralysis by the same drug, as recommended by Dr. V. P. Gibney, of New York, that is, to give it in rapidly increasing

Read before the Louisville Medical Society, January —, 1888.

doses until the maximum amount to be borne is reached and continued.

Commence with ten or twenty drops of the saturated solution and increase a drop every dose until marked constitutional effects are manifest, then return to the original dose and increase gradually again, always directing that it be taken largely diluted with water, milk, or vichy, and only after eating. I can recall a number of instances where I know much good has been done by this method after the patients had received no benefit from the ordinary doses of ten to thirty grains three times daily.

I will report in a brief way a few cases, and trust to the discussion to develop all the points unmentioned.

CASE 1. Child of Mr. E. of Newcastle, Kentucky, aged two and a half years, Potts' disease, high dorsal region, developed complete paraplegia during a severe attack of whooping-cough. This child was put upon iodide of potassium, commencing with gtt. v ter die, gradually increasing to gtt. lxv ter die, when the drug was discontinued because of an acne which appeared in the external auditory canals. The eruption soon disappeared, when the medicine was again commenced, and increased to gtt. xcv ter die, which was continued for several weeks with every evidence of improvement from the time gtt. xx were reached. This child has recovered the power of locomotion almost completely, and in a very much shorter time than is usual.

CASE 2. A gentleman, theological student, thirty-two years of age, giving history of general rheumatism three years previous to my seeing him, came to me for relief of constant pain and tenderness in both heels. Had not been able to walk except on his toes for nine months. Upon examination. I could discover no symptoms, except that when deep pressure was made in the center of the heel acute pain was evinced. My diagnosis was a neuritis of rheumatic origin. This case was completely cured by large doses of potassium iodide, commencing at gr. x ter die, and gradually increasing gr. c ter die. CASE 3. Miss R., aged twenty-two, sales

women, had been suffering at intervals for more than a year with great pain about the left little toe, she believed that the trouble was of rheumatic origin; potassium iodide was given freely, with complete relief. One year passed, and in the damp weather of last spring she was again disabled completely by the old pain returning, extending this time along the nerve trunks to the hip, and making her very lame. A diagnosis of sciatica from rheumatism was made, and large doses of iodide given, with a cure soon resulting. This patient was burned once with Pacquelin's cautery.

CASE 4. Mrs. R., aged thirty. When I was called she had been suffering with inflammation of the right knee for six weeks. The physician in charge had treated her for acute rheumatism of the joint with the usual remedies, and had been giving gr. xv pot. iodide ter die for two weeks without benefit. The joint was very stiff at an angle of ninety degrees. The limb was straightened with weight and pulleys and a posterior splint of leather applied, the iodide being increased one drop per dose until she took lxxv gr. ter die. Within ten days she was able walk without pain, and recovered with perfect motion in joint.

LOUISVILLE.

Societies.

LOUISVILLE SURGICAL SOCIETY. Meeting March 5, 1888; the President, Dr. D. W. Yandell, in the chair.

Dr. Rodman read a report of four casesLaparotomy, Lithotomy, Housemaid's Knee, etc. (See page 196.)

In the discussion of the first Dr. Vance said: "I have recently had a similar case. A negro, seventeen years old, was wounded with a thirty-two caliber pistol ball. I probed with my finger, and the tip of it came upon the kidney.. I catheterized, and drew off only one ounce of urine. The patient was in collapse; pinched features, temperature 97°. I made an incision six inches long down the line of the oblique muscle, and the gut came out. The edges of wound were ecchymosed

and peritoneum turned up. I freshened the edges and sutured. There was some escape of fecal matter--little hemorrhage. Before daylight patient was again catheterized, and much bloody urine brought out. Patient received only whisky and digitalis. He lived ninety-five hours. Post-mortem showed all wounds intact, but localized peritonitis around wounds. The ureter had been cut one third in two, and there was blood and gummous matter in left iliac fossa. I found the ball lying just over convexity of spinal column. I believe laparotomy the thing to do in knife and gun-shot wounds of the intestine."

Dr. Roberts: One point of interest in such traumatism is the absence of the normal dullness in the hepatic region-the liver being displaced upward by gaseous distension. Another relates to where the inc sion should be made-whether at the site of the wound, or in the median line. Most authorities prefer the latter. But when the wound is over the fixed viscera he cuts down at that point. In reply to whether the previous speakers had trimmed away the powder-burnt edges of the wounds, he was answered, they had.

Dr. Roberts remarked that there was stercoraceous vomiting in this case, supervening the second day after the operation-a rare event in cases that recover from gut wounds.

Dr. Yandell thought the significance of stercoraceous vomiting was much exaggerated by the profession, both in gut wounds and gut obstruction. He had recently seen three cases of the kind all ending in recovery. One was a case of extreme constipation. Stercoraceous vomiting was marked during thirty-six hours. The constipation yielded -the vomiting ceased. The patient recovered, to die some weeks after with cancer of the pylorus. The second case was sent to him from a neighboring county-obstinate constipation-fecal yomiting. Alvine dejections being secured, recovery was rapid. The third case he had seen with Dr. Roberts. Patient had stercoracious vomiting for three days and recovered.

Dr. Yandell held that there had for some

time back been too much slashing of the abdominal cavity in shot wounds for purely exploratory purposes. In his mind the question is still sub judice. Unless there are symptoms following the traumatism, he inclines. to defer the laparotomy. Symptoms usually supervene very quickly, if the injury is of any real moment. He had many times seen men shot in the belly with pistol-balls who got well. He saw H. C. within one hour after a pistol-ball had entered the abdominal cavity just below the crest of the ileum. Patient was in collapse and soon died. On opening the belly there were found twentyfive or thirty wounds of the gut. Laparotomy could have done nothing here. Again: a young man died in three hours after getting a pistol ball in his belly, Dr. Y. saw him when he was in extremis. The post-mortem revealed the epigastric artery severed and the intestines riddled. Laparotomy would have been of no use in this case. But while he would not, as a rule, do laparotomy for shot wounds of the belly without symptoms, he would in view of our present knowledge of the safety of the procedure make an exception in wounds of the bladder, such unmistakably and extensively opened this organ, without waiting for symptoms. He had seen seven bladders cut, in one battle, by minie-balls--death following in all within thirty-six hours. He thinks that if he had known then what is known now, that some of these cases might have been saved. He recalls a case which got a pistol-ball in the suprapubic region. The subject continued on duty for several hours; but twenty-four hours after he was dead. Dr. Y. thinks the finger should not be used as a probe in recent wounds until made aseptic.

Dr. Anderson: In pistol-ball wounds of bladder I do not see where extreme danger lies in comparison with other wounds. I remember a case where a pistol-ball lodged in the bladder. One night, five years after, the patient came with ball in fossa navicularis.

Dr. Yandell asked of Dr. Cartledge what he thought of the gravity of stercoraceous

vomiting. In answer Dr. Cartledge said that in most of his cases of obstruction (hernias) there was no stercoraceous vomiting. Had only seen it three times, and the cases did not get well.

Lithotomy. Dr. Cartledge was prejudiced in favor of median lithotomy, button-hole operation. In a case where he removed seven and one half inches of rubber catheter with a lithotrite, he thought he got all at the time, but after several months the patient returned with symptoms of stone, and he did median operation and got out three and one half inches of encrusted cath

eter.

Dr. Bloom stated, that on the Continent these cases were diagnosed with the cystoscope, an instrument by which the entire interior of the bladder can be brought to view. He explained its construction and various

uses.

Hous-maid's Knee. Dr. Yandell said that he had removed three like cysts to that reported by Dr. R, but all were about wrist; had no trouble except in a scrofulous boy, who had been treated by another physician for thirteen months by iodine injections and incision, but without antisepsis. The boy were in wretched condition, and several sinuses present when Dr. Yandell saw him. These he split up and scraped. Recovery in six weeks.

Urethral Stricture. Dr. Cartledge never saw a case of stricture of wide caliber followed by perforation. He cited a case of stricture of small caliber. The obstruction lay at junction of bulbous and membranous urethra. He passed his finger into the rectum and found prostatic abscess, and to this he gave outlet by a filiform bougie passed per urethram.

Dr. Mathews spoke on antiseptic pre autions in laparotomy cases. He criticised the fact that in Dr. Rodman's and Dr. Vance's cases antiseptic precautions were taken, as he believes they ought to have been, and the patients died, whereas Dr. Roberts' case was successful without antiseptics, and patient recovered. Dr. M. thinks this a significant fact.