It will be seen by the above that but slight differences existed between the two limbs at the end of seven weeks from the time of the operation. These differences may be further discounted by the fact that the right limb, under normal conditions, is found to be slightly larger than the left. The patient was presented (two years and nine months after the operation), and measurements made of the lower extremities by some of the members present. These were found to be of the same size, due allowance being made for the normal differences in sizes usually found in favor of the right limb. He pursues his trade as a mason without any appreciable impairment of function of the right limb. At no time was there sufficient embarrassment to the circulation to awaken any anxiety in my mind. The operative procedure was easily carried out, but no easier, to my mind, than the bolder operation of ligature of the external iliac outside the peritoneum, which operation I had theretofore practised, and have since employed. Besides, the transperitoneal route offers increased dangers from the possible supervention of peritonitis. In the extraperitoneal procedure the transversalis fascia and peritoneum roll so easily away from the groove above Poupart's ligament after the muscular strictures are incised, that the vessel is easily secured above its deep epigastric and external circumflex branches. No more than this can be accomplished by opening the peritoneal cavity.

Ever since the case of successful ligature of the external iliac artery by Sir Astley Cooper, the dissection of the limb eighteen years afterward revealing a remarkably free anastomizing circulation, the application of a ligature to this vessel has been considered a justifiable procedure under circumstances requiring its employment.

The original operation of arrest of blood-supply for the cure * Guy's Hospital Reports, vol. i, p. 50.

of this disease, as proposed and practised by Carnochan, was by ligature of the femoral, just below Poupart's ligament. Hueter of Greifswald proposed ligature of the external iliac artery as an improvement upon Carnochan's operation. I am not aware that the proposition of Hueter has ever been carried out prior to my own application of it.

PUERPERAL MORTALITY IN BROOKLYN DURING 1895.

BY JAMES L. KORTRIGHT, M.D.

Read before the Brooklyn Gynecological Society, October, 1896.

During the year 1895, 224 women died of puerperal causes in the city of Brooklyn. When we reflect that each unit of the above number represents the passing of an adult life, and in most instances the loss of an infant life, we find in this simple statement, abundant food for thought. Moreover, these lives have all ended under circumstances that appeal most strongly to the community, at a period of greatest usefulness to family and friends, under conditions which have emphasized the vanity of expectation, and which have added to the bitterness of sorrow. Furthermore, to the lay minds at least, no woman ought to die in consequence of childbirth, and in no class of cases is the attending physician more unsparingly criticised or more surely blamed. Danger at the puerperal period appeals to our self-interest as medical practitioners, and compels our attention as scientific inquirers.

case.

To study the causes and conditions of this mortality, an attempt was made to communicate with each physician signing the death certificate, and from him to obtain a history of each But the responses were so few that the attempt was unsuccessful. To those physicians who returned histories in answer to the request, the author desires to extend his thanks and his acknowledgements. In consequence of this imperfect return we are compelled to rely upon the meager data furnished by the death certificates for materials for study.

The cases of death fall into two great classes, (1) those in which pregnancy was a condition of the mortality; (2) those in which it was the direct cause of the mortality.

Table of the "first class :"

In all these cases the primary cause of death was apart from pregnancy or the puerperal period. These latter conditions modified or accelerated, or rendered hopeless the preëxisting or intercurrent disease. At some future time, I hope to discuss the relationship between the various diseased states and pregnancy, and the puerperal period.

Deaths

In class second we find the following subclasses. occurring early in gestation, those occurring at the time of labor, and those occurring remote from delivery but in consequence of it.

Abortion. Only eighteen deaths are reported as caused by abortion. Of these, four are certified by the coroners as being without medical attendance. It is impossible to say how many cases included under the headings of puerperal septicemia are really cases of abortion with sepsis. It is also impossible to say how many more abortions have been falsely certified as dying of other acute diseases. I do not wish to imply that such false certificates are ever returned, but one can readily see how such might be the case. It is said that one pregnancy in seven terminates in miscarriage. On that basis, the prognosis of abortion is very much better than that of labor at full term.

Two patients died from extra-uterine gestation. In one of them, it was stated, celiotomy was performed. Freudenthal (The American Gynecological and Obstetrical Journal, ix, 307) gives the prognosis in this condition as follows: In cases after operation 20 per cent. died, in cases treated conservatively, 66 per cent. died. On this basis there must have been only seven cases in Brooklyn last year. Still in a single general hospital, doubtless more than seven cases were treated.

One death occurred from hyperemesis during the early months of pregnancy.

Deaths at term and during the puerperal period. Sepsis is reported under three heads: septicemia 40, puerperal fever 10, puerperal peritonitis 26; 76 deaths are clearly due to preventable

Septic material is occasionally introduced by the medical attendant. Much more frequently it is brought to the patient by officious examinations of the nurse or by her carelessness after delivery. A very large proportion of our population are unable to pay for a trained nurse at childbed, and are compelled to employ some one who will attend the patient and perform the house

hold duties at the same time. The uncleanly habits of many of our families afford a favorable nidus for the growth of septic microbes. It is impossible to know what proportion of these 76 patients were attended by physicians; 20 of these deaths occurred among those of German parentage. This proportion is somewhat in excess of the proportion that the German bears to the entire population. Germans usually employ midwives, and are very cleanly in their homes. 29 per cent. of fatal septic cases occurred among Germans, who form 25 per cent. of the total population. 13 deaths occurred among those of Irish parentage. Allowing for those cases in which the nationality was not stated in the death certificate, this number forms 19 per cent. of the whole. The Irish usually employ physicians, and are slovenly in their homes. They form 231⁄2 per cent. of the population. Nine deaths occurred among those of English parentage, 12 per cent. the entire number. English people are about 71⁄2 per cent. of the total population. They too are disorderly in their homes. Five deaths of Italians are reported. These people usually employ midwives, and are very uncleanly about their homes, though very careful of their beds. Although they are but three per cent. of the general population, they furnished seven per cent. of the septic mortality. In fact, there were only three deaths of Italians other than from sepsis. Eleven deaths occurred among those of American parentage-sixteen per cent. of the whole. Americans are twenty-nine per cent. of the total population. Among them. there is the greatest intelligence and order.

Occurring by months, the deaths from sepsis are as follows:

This table shows what has long been known-that the largest number of septic cases occur during the winter months.

Affections of the kidney are reported as follows: Uremic or puerperal convulsions, 28; uremia, 9; nephritis, 13; total, 50.

It has been impossible to ascertain in which pregnancy the fatal convulsion, or albuminuria, or coma occurred. By ages, there were 4 deaths under 20, 15 from 20 to 25, 17 from 25 to 30, 8 from 30 to 35, 4 from 35 to 40, 2 from 40 to 45. Two girls,

both colored, died of puerperal convulsions at the ages of 13 and 15 years respectively. Thirteen (or twenty-six per cent.) of these deaths occurred among those of Irish parentage, who, as we have just seen, form 23% per. cent. of the population; 4 (or 8 per cent.) were of Scotch parentage, who are about 2 per cent. of the population; 3 (or 6 per cent.) were of English parentage, or 71⁄2 per cent. of the population; 9 (or 18 per cent.) were of German parentage, or 25 per cent. of the population; 10 (or 20 per cent.) were of American parentage, or 29 per cent. of the population. It would seem as if the Irish, Scotch, and English peoples had weaker kidneys than those of other nations. The three mentioned form the great spirit-drinking nations of the world. The high death-rate among Americans is doubtless due to the greater age at which our people begin child-bearing. Whereas, among the people at large 72 per cent. of the deaths from renal causes occurred before the age of 30 years, among Americans only 50 per cent., or 5 deaths, occurred before that age. Of these 5, 2 were the colored girls to whom reference has already been made; the history of the third stated that she was pregnant for the third time at the age of 17; the fourth was married to a man with a strongly Irish name.

Hemorrhage.-Nineteen deaths occurred from post partum hemorrhage, 4 from ante partum hemorrhage, 16 from placenta previa.

In addition, 2 deaths are recorded from uterine hemorrhage. The causes of post partum hemorrhage are, broadly stated, the causes of prolonged labor, repeated child-bearing, bearing children progressively increasing in size, subinvolution of the abdominal and uterine walls, contraction of the pelvis. Ireland furnishes of these deaths 40 per cent., instead of 231⁄2 per cent.; Germany furnishes 4, or 16 per cent., instead of 25 per cent.; the United States furnishes 5 deaths, or 20 per cent., instead of 29 per cent. The causes of ante partum hemorrhage are to be sought among influences affecting the blood-vessels. Ireland furnishes 2 cases, and Holland, strange to say, supplies the other 2. Placenta previa, it is considered, is caused by uterine. subinvolution and its accompanying endometritis. It occurs once in 1000 to 1600 labors. In our table it occurs once to each 1500 labors. Whatever its etiology, it seems to occur most frequently among those nations that habitually get up too soon after confinement. Germany furnishes 4 cases and Ireland 4. Only a single case was American, and that is an obscure one. The number of deaths from hemorrhage is striking--41 in all, or 20 per