nia 1 TREATISE .^- " DISEASES OF FEMALES, EY WILLIAM P. DEWEES, M.D., =- :=: IATE PROFKS80E Ot MIDWIFERY IN THE UNIVERSITY O PENNSYLVANIA OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE ROYAL MEDICAL SOCIETY OF DENMARK, &C., &C. * WITH ILLUSTRATIONS. /HE AUTHOR'S LAST IMFROyELlENTS AND "CORRECTIONS UBANCHARD AND LEA. 1853. K Eastern District of Pennsylvania, to wit : BE IT REMEMBERED, that, on the twentieth day of November, in the fifty- lirst year of the Independence of the United States of America, A. D. 1827, WILLIAM P. DEWEES, M. D., of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the words following, to A-it: " A Treatise on the Diseases of Females. By William P. Dewees, M. D. Pro- fessor of Midwifery in the University of Pennsylvania, &c. &c." In conformity to the Act of the Congress of the United States, entitled, " An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned And also to the Act, entitled, "An Act supplementary to an Act, entitled, 'An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the benefits thereof to the arts of , engraving, and etching Historical and other Prints.'' D. CALDWELL, Clerk of the Eastern District of Pennsylvania. VT3J. 8. YOUNG, PRIXTEE. TO K. CHAPMAN, M.D., 1'ROFJCSSOR OF INSTITUTES AND PRACTICE OF PHYSIC, ETC., ETC.. Ciji5 iTjork is WITH SENTIMENTS OF THE HIGHESt ESTEEM, TOR HIS MANY VIRTUE; AND THE SINCEREST ADMIRATION OF HIS VARIOUS TALENTS, BY HIS OBLIGED FRIEND, THE AUTHOR. *> V : A U T H R ' S < f-?, . ADVERTI S.BMENT. THE following pages are presented to the public with- ' out preface or apology. The necessity of a work on the Diseases of Females, and especially the most common of them, seems to be pretty generally acknowledged; but the difficulty of executing it can only be known to him who undertakes it. This will plead with the liberal for moderation in criticism; though it may be no extenu- ation Avith those of a contrary feeling. From the ob- servations of the former we hope to profit, should any Hiich honour the work with their notice; and from the latter we will not flinch, however severe the castigation, as we know it is much easier to find fault than to excel. THE present edition of this valuable work contains the revisions and additions of the author, made by him a short time previous to his death. CONTENTS. CHAPTER I. Page. Of the Peculiarities of the Female System, . . 17 CHAPTER II. Of the Diseases of the External and Internal Organs, 25 SECT. I. Of the Tumours and Excrescences of the Exter- nal parts, . . T. .'.! 26 II. Of the Diseases of the Nymphse, . . 26 III. Of the Diseases of the Clitoris, . . 28 IV. Of the Adhesion of the Labia Pudendi of Chil- dren, . . V. Of the Abscesses of the Labia, . . 32 VI. (Edematous Swelling of the Labia, ' ^ 33 VII. Of Bloody Infiltrations in the Labia during or after Delivery, .... 35 VIII. Imperforation, and too great Density of the Hymen, .... 42 IX. Of Pruritus, or Aphthous Condition of the Vulva and Vagina, .... 46 CHAPTER III. Of the Diseases of the Vagina, . . .54 CHAPTER IV. Of Leucorrhoea, . . . . .55 Method of Cure, . & . 72 CHAPTER V. Of the History of Menstruation, * . . . 79 Xii CONTENTS. CHAPTER VI. Page. Of Deranged Menstruation, . . ^.. 101 SECT. I. 1. Of the Tardy Appearance of the Menses, 101 II. 2. Of the Suppression of the Menses, . 110 Case I. ... 115 Case II. ... Ill) III. 3. Of the Immoderate Flow of the Menses, 123 IV. 4. Of Dysmenorrhoea, or Painful Menstruation, 125 V. 5. Of the Decline of the Menses, . . 138 CHAPTER VII. Of Menorrhagia, . . . . * 150 CHAPTER VIII. Of the Signs which usually accompany Pregnancy, . 161 SECT. I. 1. Suppression of the Menses, . . 162 II. 2. Nausea and Vomiting, . . . 167 III. 3. Enlargement of the Mammae, . 168 IV. 4. Areolte, . . .. ; ..' 168 V. 5. Formation of the Milk, . . 16i> VI. 6. Enlargement of the Abdomen, f . +. 170 VII. 7. Increased size of the Uterus, . 171 VIII. 8. Pouting out of the Navel, . . 172 IX. 9. Spitting of Frothy Saliva, . . 172 X. 10. Salivation, . . . .173 XL 11. Of Quickening, ... 174 'CHAPTER ix. Of the General Condition of the System, and the Effects of certain Remedies during Pregnancy, . . 180 Bleeding, .... 186 Purging, . . . . 188 Emetics, . 189 Blisters, . $ . .190 CHAPTER X. On some of the Diseases of Pregnancy, . . 191 SECT. I. Of the Febrile Condition of the System during Pregnancy, . . vj . 191 CONTENTS. Xlii Page. SECT. II. Of Vomiting, **?V . . . * 195 III. Of Heartburn, . . & 199 IV. Of Salivation, . ..,,,' . . 200 V. Of Pain in the Right Side, '.,.* "-.> 202 VI. Of Inquietude and Want of Sleep, . . 204 VII. Of Costiveness, . . . r* 205 CHAPTER XI. Of Hemorrhoids, or Piles, .... 208 CHAPTER XII. Of Palpitation of the Heart, . 216 CHAPTER XIII. Of the Displacement of the Uterus, SECT. I. Prolapsus of the Uterus, II. Of the Chronic Inversion of the CHAPTER XIV. Of the Diseases of the Uterus, Ovaria and Tubes, , 236 SECT. I. Of the Disorders- and Diseases of the Uterus, 236 II. Of the Diseases of the Ovaries, . .. 237 III. Of the Diseases of the Tubes, . . 238 CHAPTER XV, Of the Particular Diseases of the Uterus, .. - 240 SECT. I. Of the Carcinoma Uteri, . 242 II. Of the Treatment of Carcinoma Uteri, . 244 1. Abstracting Blood, . . 245 2. Purging, . . . .247 3. Abstemious Diet, ', ? ' 249 1 4. Cleanliness, . . '.'' 250 5. Rest, . 252: III. Of the Polypus of the Uterus, , . 260 Case I. . . .' . 266 Case II. .... 266 Caselll 267 Case IV. .... 268 CaseV 269 Case VI. 270 XIV CONTENTS. . Page. SECT. IV. Mode of applying the Ligature for Polypi, 271 V. Of the Cauliflower Excrescence, 275 VI. Of the Symptoms, . "V" ' ; '' 278 VII. Of the Prognostics, . . : . * 278 VIII. Of the Treatment of Cauliflower Excrescence, 279 IX. Of the Hydatids of the Uterus, s '>.' . 283 X. Of the Irritable Uterus, 290 m"t i >"Prt ; it- I .- CHAPTER XVI. Of Uterine Hemorrhage, . . , ,311 SECT. I. 1. Of the Connexion of the Ovum with the Uterus, . . . .311 II. 2. Of the Causes which may tend to destroy this Connexion, . . . 312 III. 3. Of the Mode of Action of certain of the remote Causes, , . . 312 IV. 4. Of the Periods of Pregnancy at which He- morrhage may take place, -v r . .1 316 First Period, . . * 318 Second Period, . . . .326 V. Delivery considered as a Mode of arresting Hemorrhage, ' J *' : 328 CHAPTER XVII. Hysteritis, or Inflammation of the Uterus, .. \ t . ', 333 SECT. I. SPECIES FIRST. 1. Cause, . ^*. 334 2. Symptoms, .... 335 3. Constitutional Symptoms, . . 336 II. SPECIES SECOND. On the mixed Inflammation of the Uterus, or Accidental Puerperal Fever, 340 Treatment, . \ 1. ' ' , r . 342 a. Bleeding, . , . ' . v . 342 b. Purging, . . " . . 344 a. Fomentations, . ' , . 344 d. Blisters, v r . . 345 e. Sudorifics, '. 345 /. Opium, . . ., . 346 g. Emetics, . . . . 346 CHAPTER XVIII. Of Puerperal Fever, . . . i> . . 347 History, . . . . 350 Predisposing Causes, ' ''?'* . . . 352 CONTENTS. XV <4 Page. Prophylactics, . . . * * 355 Seat of the Disease, and its proximate Causes, V-'v- 1 357 Period of Attack, and Symptoms, ':' 1 '^-' &'. ;' 373 Diagnosis, . . . . . 379 Prognosis, . . . ,j * . 381 Contagious Nature of Puerperal Fever, ' 1% > * 384 Treatment, ..... ,; , JB 385 1. Bleeding, Stage First, , ft fff) v; ,.[j!';j 395 Purging, . v - -,.. -/'- o, i}*J 409 Emetics, . . -[v. .,,jv/ ;, 409 Blisters, . . BfJ ' r j .;.; . 412 Fomentations, .-,-).., -:!.. c ^ Spirit of Turpentine, . r-:>'ni Mercurial Frictions, . ^.", \^-- . 414 2. Of the Gangrenous Stage, , 3 ^ r . . 416 3. Of the Stage of Effusion, ,>/ ' .-.;,- . 421 General Directions and Rules, , . > ,: ; . 438 Case I. . . . '7' .^' 439 Case II. . . . . 441 Case III. .... 441 Case IV. . . ' . .442 Method of Cure, ... 446 Blood-letting and Leeching, . . . 447 Purging, &c. 447 Topical Applications, .... 447 Opium, ... . 448 External Applications, . . . 449 Blisters, . 449 Bandaging, ..... 450 CHAPTER XX. Of Milk Abscess, ..... 451 Of the Treatment, .... 455 1. Local Applications, . . . 456 2. Regimen, . . . . 459 3. Purging, ..... 459 4. Puncturing, .... 459 XVI CONTENTS, Page. 5. Caustic, . . . . * ; - 460 6. Seton, ...... 460 7. After- Treatment, . . . .461 CHAPTER XXI. Of Hysteria, , . . ft* .462 SECT. I. Of the predisposing Causes, . . 468 II. Of the exciting Causes, . . . 470 1, 2. Wind and Tough Phlegm, . 471 3. Worms, 475 4. Aliments, improper in Quantity or Quality, . . . .476 5. Schirrhous or other Obstructions in the Stomach, or Intestines, &c. . 477 6. Violent Affections of the Mind, 478 III. Of the Phenomena of Hysteria, . . 479 IV. Diagnosis, .... 482 V. Treatment, .'* 483 Case I. .... 487 Case II 488 1. Of the Paroxysm, 2. To prevent the Recurrence of Paroxysms ^ 499 Explanation of the Plates, . . \ * 511 Index, . . . . . .523 ON THE DISEASES OF FEMALES. CHAPTER I. OF THE PECULIARITIES OF THE FEMALE SYSTEM. HOWEVER powerful the influence of education and modes of life may be upon the human frame, they are not capable of effecting so great a change upon the female constitution, as to deprive it of its distinctive peculiarities. Yet we are aware that much is done by these great agents ; and that when they have been employed under equal circumstances, for an equal period, an approxima- tion of physical and moral similarity has been observed ; though they have never been able to alter the general character of the female BO much, as to leave the slightest doubt to which of the sexes the individual belongs, even independently of sexual pecu- liarity. The intentions of nature in the formation of man, are not, and cannot be fulfilled, by one sex alone; both must concur in this great objeefr; and it would be idle to decide, by any process of reasoning, to which is assigned the most important role in this great work. Participation is essential to the end in view; and to each is allotted respective duties ; duties which cannot be ex- changed or even varied; for they are immutable. To preserve, therefore, the moral and physical distinctions in his favourite creatures, and to prevent either neglect or confusion in the per- formance of the duties assigned to them, the Deity has imposed such distinctness of organization upon the sexes, as defies aliena- tion, or exchange in the exercise of the functions resulting from it. 1 1 Alphore le Roi is of opinion, that most of the causes which degenerate the human family, originate with the female. He says, " With a view more effectually 2 18 PECULIARITIES OP In this place, however, we have only to detail, and that very briefly, the peculiarities which distinguish the female from the male ; peculiarities which impose upon her functions and diseases altogether her own. For both her particular organization and her temperament are made subservient to the important part she is destined to perform; upon her devolves conception, gestation, delivery, suckling, and all the contingencies connected with these processes. To what evils, then, do not these processes subject the female ! yet, before she experiences them, she is liable to all such as may arise from sexual functions and organization: and before she can perform one of the ultimate intentions of her creation, she is ob- noxious from mere structure to painful, and sometimes to fatal diseases. For to her the period of puberty is oftentimes replete with evils ; she is constantly liable to irregularities in her menstrua, and menaced severely by their consequences. She may be visited by them precociously, and be debilitated by their quantity or frequency ; or they may be withheld so long, as to involve her health in ruin. Or she may be defective or exuberant in struc- ture ; and be obliged to submit, if not to dangerous, yet perhaps to indelicate operations, to compensate for the one or for the removal of the other. Besides these, she is liable to all the dis- eases of the male, that do not depend upon sexual distinction ; and thus is multiplied upon her almost all the evils that can befall two sexes. The anatomical and physiological peculiarities of the female are both numerous and curious; we shall only, however, succinctly enumerate a few. One of the most striking differences between the male and fe- male, is the inferiority of her stature. Her whole osseous fabric is more delicate and less extended. The bones of her cranium are thinner, smaller, and more pliant; and the space destined to be filled with the brain, is smaller. The chest is more elevated, in consequence of the ribs forming nearly right angles with the spine ; and these bones themselves are broader and flatter than in the male. This disposition of the ribs renders the thorax shorter, though its upper part is larger ; but the sternum and cartilages have less length, and are flatter ; the clavicles are longer and less crooked. The pelvis of the female differs in a number of points from that of the male ; it is to follow the labyrinth of the human economy, it appears necessary to study that of the female; in this we may perceive more certainly and frequently than in that of the man, the cause and progress of diseases. Moreover, the degeneration of the species always begins in nature with the female; to study the diseases of them is to arrive at the source of all that belong to the human species." Histoire Na- turelle de la Grossesse et 1'Accouchement, p. viii. . THE FEMALE SYSTEM. 19 calculated to subserve one of the most important as well as inte- resting functions of the body; namely, the passage of the child during labour : hence, we find all its diameters larger than those of the male ; together with a much greater expansion of the bones which constitute the arch of the pubes, &c. The general characters of the bones, as well as their connex- ions with each other, differ from those of the male ; their angles are less silent; and consequently their articulations are better concealed. The muscular system also differs ; its mobility is much greater ; the whole of the fibres of the female seem to possess a greater tenuity and sensibility; hence, the proneness of the female to spasmodic and convulsive diseases; hence, the greater suscepti- bility of impressions from physical and moral causes: hence, the greater quickness of contraction of the muscles; and hence, less permanency of impressions. The nervous system has also its peculiar properties ; the nerves themselves are smaller, and of more delicate structure. They are endowed with greater sensibility, and of course are liable to more frequent and stronger impressions from external agents, or moral influences ; and thus the nervous, with the muscular system, contribute to render the female liable to spasmodic diseases, and obnoxious to inordinate stimulation. But these peculiarities are considered by some, rather an ad- vantage, than an evil. Thus Vigarous declares, " Cette sensi- bilite" excessive, loin d'etre un mal, devient un avantage dans leur condition ; car plus les sensations sont grandes, moins elles sont durable, parce que la mollesse et la flaccidite des solids leur faisant opposer moins de r6sistance, leur r6action est moins forte et cesse bientot." " 111 n'en est pas de meme dans 1'homme ; la rigidite et la force de ses solides exigent plus d'energie et un plus grand degre d'entensite dans la cause qui agit sur lui; mais aussi reflect est plus durable, par la grand resistance que sont en 6tat d'opposer ses organs, resistance qui le fait souvent succomber. Je compa- rerois volentiers, dans ce cas, la femme ce frele roseau, qui, in- capable de resistance, flechit humblement la tete sous 1'effort de la tempete, et la releve doucement quand le calme est revenue; et 1'homme a.ce chene altier, qui se trouve abuttu, par la seule raison qu'il est fort et capable de resister." 1 In the sanguiferous system, we may perhaps recognise the united peculiarities of the muscular and nervous systems ; for in that system we constantly find the circulation carried on with more rapidity, but with less force ; the arteries are smaller, more irritable, and more easily urged into action, and less easily ap- HJ 1 Maladies des Femmes. Vol. i. p. 40. * 20 PECULIARITIES OF peased, after having been inordinately excited. The veins offer less resistance to any given distending force; hence, they are more strongly marked upon the surface of the body; more de- cidedly full, or permanently distended ; and more disposed to be- come varicose. The arteries have smaller calibers ; are quicker in their action ; and but rarely ossify. The cellular -system is more abundant ; more flexible ; and more easily distended. It is better supplied with moisture ; and from the compressibility of its texture, permits the blood vessels to divaricate, and pass unrestrainedly in all directions through it. From its abundance, and especially about the articulations of the great joints, and large foldings of the body, a roundness and beauty is given to parts, which in the male are angular, and per- haps even sometimes unsightly. The cutaneous system differs much from that of the male ; for it, of itself, almost becomes an object of beauty. Its texture is infinitely finer, more highly polished, and more decidedly trans- parent. It permits the veins to ramify gracefully through its structure; to be distinctly seen, and thus forming a fine contrast with the white ground on which they repose. It shows, from its fineness, to the greatest possible advantage, the arterial termina- tions which so beautifully assemble upon the cheeks. Its sensi- bility is much greater ; and its sympathies, if not more extensive, are certainly more vivid, than in the male. It is also much more distensible ; especially that portion of it which covers the abdo- men ; and makes, by this means, an important provision for the period of gestation. The capillary system, also appears to be more developed in the female than in the male system. Thus the great aptitude of the system of the former, to diseases attended with paleness of the skin, oedema, dropsy, and hemorrhages, and thus involving affections of both the serous and the mucous surfaces. The lymphatic system of the female does not differ widely, as regards conformation, from that system in the male: it absorbs and transmits, perhaps, with more rapidity, its appropriate fluids ; yet, there is no other known peculiarity in it, except the lympha- tic vessels are more numerous ; and when they have a certain pre- dominance, they constitute a temperament; and then, unfortu- nately for the possessor, it but too certainly and too frequently, becomes the seat of terrible, and oftentimes incurable disease. The peculiarities which we have thus briefly pointed out ne- cessarily render the female constitution one of a marked and distinct character. The assemblage of the differences which con- stitute it, renders it, in general terms, one in which the solids arc less dense and resisting : for these are found to be more relaxed and flabby than in the male, owing, probably, to the predominance of the cellular and nervous systems. The lymphatic system is THE FEMALE SYSTEM. 21 more extensive than the sanguineous ; which, it is supposed, gives to the female a greater quantity of fluids than to the male. To the operation of several of the peculiarities above enume- rated, is attributed the supposed predominant temperament of the female constitution ; namely, the sanguineous temperament, so much insisted on by Rousel, and agreed to by Vigarous. In attributing the sanguineous temperament as the predomi- nant one of the female, we only mean to express it as occurring as a general rule; for we are aware that there are many excep- tions to be found ; for, among them, as with the male, every tem- perament may be seen. It has, however, been given so general- ly, that some object must attach to its frequency ; and perhaps the opinion of Vigarous is as plausible as any. He says, "Des- tinees, comme elles le sont (females) at passer de revolutions en revolutions, & eprouver des transitions brusques dans leur mai6re d'etre, la nature a du former les femmes d'une trempe molle, pour les mettre en etat de resister aux orages auxquels elle sont expose'es," p. 39, vol. i. Besides the system just enumerated as belonging to the human system, many are disposed to give to the female another, namely, the uterine system ; and which they endow with an extent of in- fluence that belongs to no other. It has been handed down to us from time immemorial, that the uterus exerts a paramount power over every other system; and governs them with a sway no less whimsical than potent. That it creates, exalts, or modifies disease, in every portion of the b'ody; hence, the aphorism of Hippocrates, "morborum omnium qui muliebres vocantur uteri in causS sint." That it not only forms, or governs the moral character of the female, but regulates the physioal movements of her body: hence, the declaration of Van Helmont: "propter solum uterum, est mulier id quod est." By many, the uterus has been declared to possess a separate and peculiar life ; that it has its own mode of existence ; and is totally independent of the laws which govern the other portions of the system. Aretseus compared it to "an animal confined within another animal; that it travelled without restraint from any portion of the body to another; that it would take possession of any sense; or occupy any viscera, whether situated at the right or the left side of the body ; but that its movements were rather towards the inferior portions of it. It was like a wander- ing being; that it relished agreeable odours, and would move itself towards the place from which they appeared to emanate ; but would remove itself, in sadness, from places which had disa- greeable smells," &C. 1 Sydenham, Cullen, Good, and very many others, have given ' Chambon. 22 PECULIARITIES OF to this organ power to produce or modify disease. To venture an opinion, that would very much differ from the sentiments of the great men just named, would have the appearance, of fastidi- ousness at least, if not of rashness. But, as we have never wit- nessed any decided instance of this exclusive influence of the uterus in the production or modification of disease, we feel our- selves justified in entering our protest against its possessing such unlimited sway. In doing this, however, let us make ourselves as clearly understood as the nature of the thing will permit. First. We have ever found the unoccupied uterus to be one of great passiveness when in a state of perfect health ; and that so long as it preserved this condition, it manifested no agency in the production of disease, or in modifying it, when present. Thus, fever, inflammation, either local or general, or spasm, has never appeared to us to derive advantage, or suffer inconvenience, from the influence of this organ. Second. That when in a state of disease, we have found several parts of the body sympathize with the uterus : as the stomach, the head, the breast, &c.; but precisely the same thing may be said of other parts of the body ; yet for neither of these is such influence claimed, as is bestowed upon the uterus. Thus the brain, the stomach, the kidneys, the liver, &c., when in a diseased state, will have particular parts deranged by a sympathetic influ- ence ; yet it has never been asserted, that either of these parts had, at any other time, or under any other circumstance but disease, an agency in producing or modifying the affections of other portions of the body. Third. While the uterus is performing one of its functional duties, namely, forming the menstrual fluid; when it is known to be in a state of excitement, and decidedly engorged with blood ; a time when it would most likely exert an influence, if it really possessed any, we never find this organ exerting a power over other parts, so long as the functional process is carried on healthi- ly; and during this period, we have hitherto not been able to de- tect the slightest influence over any disease, that may have been present in the system ; nor has it ever made us vary a prescription, or modify a treatment. Fourth. That when the menstruous function is performed with pain and difficulty, other portions of the system are found to suffer from sympathy; but in no greater degree than these very parts have been known to suffer, when some other organ was the seat of irritation. In dysmenorrhoea, we have known the back and stomach suffer severely, the first from pretty intense pain, and the second by severe vomiting; but we have seen the same consequences attend an irritated kidney, or an inflamed neck of the bladder. Fifth. That when this organ is labouring under severe dis- THE FEMALE SYSTEM. 23 ease, as inflammation, scirrhus, or cancer, "where all its ordinary functions are either deranged, perverted, or suspended, and this for a long period together, we do not find, that it involves the system in any severer penalties than any other equally important viscus would, under similar circumstances. Sixth. That when its functional processes are irregularly and imperfectly performed; or are altogether suspended; if the gene- ral health suffer from this cause, it is not because the uterus has any superior power to effect this, but because a link is broken (and we are willing to admit it to be an important link,) whereby the chain of healthy functions is maintained. A similar condition of any of the other viscera would be followed by the same conse- quences. Seventh. That when the uterus is impregnated, various other portions of the system are deranged, in consequence of their strong sympathy with this organ ; but even here, the complaints are not sui generis; for every one of them can be, and have been, very often similated from other causes. 1 The whole phenomena of impregnation are so well understood as not to require reciting; but has not almost every body witnessed the whole train of these morbid sympathies to arise from very different causes? We would then ask, what evidence is there, that the uterus possesses such unlimited sway over the healthy or diseased move- ments of almost every other portion of the body? Does not this error proceed from the influence of authority, and a supineness and indifference to rational inquiry or correct observation ? Should the names of Hippocrates, Galen, Aretseus, Van Helmont, and a hundred others of greater or less authority, be permitted so to satisfy the judgment, or so paralyze exertion, as to prevent all investigation ? The discoveries of Gall and Spurzheim on the influence of the cerebral system upon other portions of the body, render it much more probable, that the various morbid phenomena attributed to the influence of the uterus, depend upon certain excitements in the cerebellum ; and that the several facts recorded as belonging to the genital system of the female, are themselves but evidences of the influence of cerebral irritation. In the male, at least, this point is pretty well settled as it has been found by Larrey and others, that certain wounds or injuries of the cerebellum, entail impotence. It is, therefore, much more rational to look for some 1 In this assertion, we do not mean to include that beautiful and magic-like play of sympathies, which is established for the future welfare of the expected being; namely, the swelling of the mammae, and the secretion of milk. These parts have a mutual, and an associated sympathy, which they with great fidelity maintain as long as they are capable of performing their appropriate functions. The nature and extent of these intercommunions are too well known to need a particular men- tion. 24 PECULIARITIES OP THE FEMALE SYSTEM. disturbance of the brain or nervous system, as long since suggested by Willis, for the origin of hysteria, &c., than to any direct influ- ence of the uterine system. Do not let it be understood, from -what we have just said, that we undervalue the importance of the uterus as an organ ; for as an organ we are free to admit that it has high destinies to fulfil ; we only wish to insist that it has no exclusive, or concurrent power, to produce, modify, exalt, or dimmish, any disease or af- fection of the body, beyond several other viscera; and, perhaps, less than some. The stomach, decidedly, and, perhaps, the liver, have a more marked influence, either in a state of health, or of disease, over the animal economy, than the uterus. Nor are we to be supposed to countenance the opinions ad- vanced by Mr. Fogo, 1 some few years since, in a paper entitled, " On the degree of importance which should be attached to the functions of the uterus, in regard to health." He declares it as his opinion, that the uterus is of so little consequence to the ani- mal economy, that it might be spared from the body, without the system suffering by its removal. He calls it " a simple, passive, accommodating organ ; and, on this account, can have but little influence or control upon the functions of the body." If the value of an organ be tested by such estimates, to what a low value would the brain or the stomach be reduced ? The stomach may, especially, be called "a simple, passive, accommodating organ;" possessing, perhaps, in a greater degree, these qualities, than even the uterus itself. In the first place, its structure is less complicated than the uterus ; it is equally pas- sive, when permitted to be so ; and it is doubtless as " accom- modating;" as the efforts of the gourmand have frequently proved. Yet Mr. Fogo, himself, would not hesitate to admit, that this "simple, passive, accommodating organ," cannot well be spared, because it possesses these qualities. In a word, we are of opinion, that the uterus ranks in the first order of the viscera ; that its health is every way important to the general health of the system ; but that it does not exert any particular power over other portions of the body, more than any other important viscus would, under the same circumstances ; namely, of disease. That its influence is greatest, while performing, or giving evidence of its best state of health; namely, during gestation. ' See an answer to Mr. Fogo's paper, in "Essays connected with Midwifery," by William P. Dewees, M. D., &c. DISEASES OF EXTERNAL AND INTERNAL ORGANS. 25 CHAPTER II. . AVi/L 'i&m.v.ytL vAv v> fc^Ksvfc/.'-: -M L*i* <>$*& >-.!. .-i^?. OP THE DISEASES OF THE EXTERNAL AND INTERNAL ORGANS. THE structure of the external organs is such as to render them liable to a variety of complaints that always excite alarm, how- ever free they may be from danger. Indeed, any disease of these parts creates a great deal of apprehension, especially in the married, or the pregnant woman. Women, especially the mar- ried, are often kept in a state of great anxiety, when labouring under any affection of these parts, until they can be assured it is not one of a particular kind, and that it will not be attended with danger. On this account, it is of consequence to the young practitioner, that he be acquainted with their general diseases, both in the unimpregnated and in the impregnated state of the uterus. It may be observed, as a general rule, with respect to the eco- nomy of these parts, that, from their great vascularity and sensi- bility, inflammation runs on very rapidly to suppuration, and is accompanied with much pain. Indeed, we have seen severe in- flammation of the labia terminate very rapidly in gangrene, though much exertion had been made to prevent it. It may, also, be observed, that suppuration of the labia is attended with more than a usual degree of fetor; owing, most probably, to their very cellular structure ; this tissue is found to die more easily when much accumulated, than when in more spare proportions. We may also add, that parts thus organized granulate more slowly after suppuration, than many other portions of the body, from the same cause. From the looseness of the texture of some of these parts, espe- cially the nymphae and labia. they become sometimes very much enlarged, from very slight irritation ; and when there has been a neglect of proper cleanliness, the natural secretions become acrid from stagnation, and produce itching, which, though slight at first, very much increases by the indulgence of scratching ; and if this be persisted in the parts become inflamed, and sometimes swell inordinately, but does no mischief ordinarily, if not too long persevered in. This happens especially with those who have a dread of water after the catamenial discharge; and who neglect to wash themselves after these purgations. On this account it, is important that the parts should be daily washed with warm water, particularly during the flow, and immediately after the menses have ceased; or if the woman be subject to fluor albus. 26 DISEASES OP THE NYMPH2B. The prejudice of some women on the subject of washing, should be removed, by the practitioner making it a point to recommend its frequent use, when consulted on these diseases. SECT. I. Of Tumours and Excrescences of the External Parts. Some parts of the external organs are more liable to tumours and excrescences than others ; thus, the labia and nymphse are more frequently the seats of these affections than other portions of the vestibuluni. The nymphse appear more obnoxious to in- durations and excrescences, than even the labia; and they are especially so, when they are sufficiently long to protrude beyond the labia. SECT. II. Diseases of the Nymplise. When these bodies become much enlarged, they present a very dark colour* are dense, and sometimes studded with a number of little tumours resembling warts. 2 From their position, they are constantly liable to irritation ; and in cold weather, to excoria- tion. Sometimes violent inflammation seizes upon these parts in consequence of the reaction which follows a great reduction of temperature. In such cases rest should be enjoined ; a free purging insti- tuted; and if the arterial system become involved, blood should be taken from the arm ; or from near the part, by leeching. A soft bread and milk poultice should be applied to the part, and renewed as frequently as occasion may require ; that is, in warm weather, every three or four hours ; in cool or cold weather, more seldom. These parts, from the intensity of the inflammation, (especially if they have been much irritated by scratching,) sometimes run on to suppuration. When this takes place, they must be treated as any other suppurating surface ; taking care that the labia are not permitted to coalesce during the healing. We once saw an instance of the nymphae suppurating, and by this means getting rid of a number of warty excrescences, with which they had been studded. Should these excrescences attend or follow a venereal affec- tion, it might be well, in some instances where the disease is obstinate, to try the effect of mercury; but this remedy holds out but little prospect of success, unless there be present an unsub- 1 Mr. Burns says white; but this we have never seen. a Duges says he has seen them from the size of a pea to that of a turkey's egg. We have never seen any so large as the latter. DISEASES OF THE NYMPHJE. 27 dued venereal taint. When they are in the form of warts, and these very numerous, as is the case very often, nothing will suc- ceed so well as keeping the parts very dry, and exposed as much as possible to the air. The following case will illustrate this practice sufficiently. Mrs. had been severely injured by her husband giving her the venereal disease in its most aggravated form ; namely, chancres and buboes. About six months after she appeared to have recovered from these affections, she found a vast number of little tumours spread over the labia, the nyraphse, and other por- tions of the vulva, which increased rapidly in number as well as augmented in size; from the whole surface of which there issued a disagreeable smelling matter which excited itching; and when the parts were rubbed, blood would follow. The gentleman who had attended this patient for the venereal complaint, was called on again on account of the warts; he pre- scribed mercury to salivation : this was complied with ; but the little warty tumours increased to such an extent, that a severe bleeding would follow every attempt at conjugal enjoyment. We were now consulted. The whole vulva was found to be completely occupied by these warty productions ; and were almost without number, and of great variety of sizes. As we had treated these productions in the male with success by exposing them to the air and keeping them perfectly dry, it was agreed, that our patient should follow this plan. The patient was ordered to bed, and the labia were kep't sepa- rate, by means of adhesive plaster: this being done, the whole vestibulum, and crop of warts, were exposed. A quantity of prepared chalk was dusted upon the surface, and no other appli- cation was permitted if we except the occasional washings with warm water, to remove the incrusted chalk; that is, morning and evening. This plan, though a little difficult of accomplishment, succeeded in about a fortnight to remove every excrescence, so as not to leave a vestige behind. It was truly remarkable to see with what rapidity these para- sitic productions lost their lives, by depriving them of moisture. They would drop off in large portions at every bathing of the parts, until all perished in turn. Besides the excrescences just noticed, these parts are subject to prodigious enlargements ; and sometimes require the knife for their removal. There is a preparation of this kind in the Museum of the Medical College of Pennsylvania, of an enormous size, and well worth the trouble of an examination. The extirpation of these tumours is considered by all surgeons, we believe, to be perfectly safe. The operation never seems to expose any large vessels. And Dr. Denman informs us, he has seen the enlarged nymphae and excrescences removed by the knife, 28 DISEASES OF THE CLITORIS. without the necessity of tying a single blood-vessel. Introd. Francis's ed. p. 100. In certain parts of the world, the nymphse are peculiarly lia- ble to enlargement; in some instances they have measured seve- ral inches, as among the Bosjesman women, if the accounts of travellers are to be depended upon. On the shores of the Persian gulf, the Christian women of Abyssinia, and in parts of Egypt, the girls have these parts removed as a ceremony : it is intended to resemble circumcision. SECT. III. Diseases of the Clitoris. The clitoris^ias occasionally been the seat of scirrhus, and of cancer, but when either of these seize the part, the cure is hope- less, unless the whole of the disease can be removed by an ope- ration. In the Medical and Physical Journal, vol. v., p. 1, Mr. Simmons relates a case of enlarged clitoris, which he removed by excision, which measured in length nine inches j while the cir- cumference of the stem measured five. 1 It is the augmentation of this part, and especially when it as- sumes an equivocal form, that has given rise to the absurd opinion of hermaphrodites. It occurs most frequently in hot climates. We have seen a number of instances in new-born children, where this part, as well as the nymphae, have stood entirely without the labia. Whether these parts increased in the same propor- tion as the body enlarged, we have never had an opportunity to ascertain. The existence of the hermaphrodite has gained the assent of the greater part of mankind ; so much so, that it would be diffi- cult to disabuse them : we shall, therefore, not attempt it. To the physician, frequent appeals are made for his opinion on this sub- ject, and he too often yields to the popular belief; but he should be informed, that, so far, no well-attested instance of this com- pound of sexes has ever been produced in the human subject. A resemblance in conformation does not prove identity of func- tion ; and, consequently, the general similarity of appearance, be- tween the clitoris of the female and the penis of the male, how- ever striking, does not prove them to be intended for the same 1 " A clitoris was amputated some time ago in Mercer's Hospital, in this city. (Dublin) which, in volume, was about equal to the head of a child of two years old." Churchill's Diseases of Females, p. 25, Am. Ed. Diseases of this part, from the gratification experienced by rubbing or scratching, have led, according to Mr. Churchill, to the establishment of Nymphomania, p. 17. The frequent mention of this complaint has induced me to the belief, that it is no uncommon occurrence in both Great Britain and France, but which is surely not the case in this country. ADHESION OP THE LABIA PUDENDI. 29 purposes. And it may be observed, that this similarity is more in the external form, than in the internal structure. Nor do the instances in other mammalia, purporting to be of the same kind, afford the slightest support to this opinion. For, perhaps, every instance hitherto examined has proved to arise from a defect in the arrangement or organization of the sexual organs. Besides, in the higher classes of animals, it does not comport with the general analogy of nature, that one should pos- sess the generative powers of both sexes. Dr. Francis informs us, that "the latest decisions in juridical medicine, reject the possibility of both sexes in the same indivi- dual of the human species." * SECT. IV. Of Adhesion of the Ldbia Pudendi of Children. The labia pudendi of young children are very often found ad- herent. This may be congenite ; but we believe it to be very rarely so. We have seldom seen this condition of the parts, in children under six months old; and still more rarely, after the age of a year. From these facts, it would seem to be almost always adventitious, and owing principally to a want of cleanli- ness. Had the child been born with the labia in this condition, it is more than probable it would have been discovered early, as nurses, generally speaking, are at least curious, if not always careful. When we consider the delicacy and vascularity of the mem- brane lining the internal face of the labia; the ease with which inflammation is provoked in parts so organized ; when we recol- lect how quickly the secretions of the parts become acrid, where proper attention to cleanliness is not bestowed upon them ; and how readily a slight inflammation may be increased by the flow of urine; we shall cease to wonder at the frequency of this com- plaint, and, perhaps, be even surprised that it does not occur oftener. We have reason to believe, that in many instances, this com- plaint had existed some time before it was discovered : this may especially be the case with fat or lusty children, and where the most scrupulous attention is not constantly paid to the condition of these parts. Therefore it must be looked upon, in general, as arising from a reprehensible neglect; for it is the bounden duty of every mother, however averse she may be from the performance of it, to carefully inspect these parts from time to time ; particularly until the child is fifteen or eighteen months old, in order that the 'Denman, p. 106. 30 ADHESION OP THE LABI A PUDENDI. inconvenience under consideration may not take place; or if it have, that it may be detected early. Parents should direct, and the performance should be insisted on, that these parts be regularly cleansed every time the child is washed, by carefully separating the labia, and applying water liberally to them; they should then be tenderly dried with a soft linen cloth, and dusted with hair powder, or powdered starch, in which there is no blue. If this were regularly done in early in- fancy, the parts would become so hardened as to diminish the risk, very much, of its taking place after less attention is paid to them. We have dwelt upon this subject, because we know its impor- tance; and because it has not sufficiently attracted attention. Sometimes, unfortunately for the female, it has not been discovered during infancy ; and it is especially unfortunate, when it remains concealed until womanhood ; when, perhaps, the first intimation she may receive of her situation, is at a time, when of all others she would wish to have been ignorant of it. The alternative, now, subjects her to an operation, which should have been performed in early life. This complaint sometimes becomes relieved, spontaneously. This occurs, probably, more frequently than we are aware of ; as the causes which may produce it are so constantly operating, as to lead us to suppose this accident to exist in cases where it has not been detected. We have had two instances of this sponta- neous change to happen under our own observation. In one of these, there was so much inflammation and tender- ness in the parts, that we did not think it advisable to operate, until the existing state of things was changed. We directed soft bread and milk poultices, and a cathartic. On our next exami- nation, we found that a complete separation had taken place, by the adhering parts having suppurated. Two raw surfaces were now exposed, which required much attention to prevent reunion in healing. The other case was something similar : suppuration had com- menced, and the connecting medium was nearly destroyed, when it was first observed. It was poulticed as in the other case ; and when about to heal, care was taken to prevent a second coa- lescence. This condition of the labia is easily detected by their refusing to be separated when the attempt is made for this purpose. For when the labia are separated by force as much as their condition will permit, a continuous line of union will be observed through their whole track ; that is from the meatus urinarius posteriorly, and to the fourchette below ; of course, the os externum is entire- ly concealed. The child passes its water with some little difficul- ADHESION OF THE LABIA PTJDENDI. 31 ty ; and when the complaint has been suffered to run on, or not discovered until womanhood, the menstruous fluid is evacuated through the same external aperture by which the urine is dis- charged. 1 There is but one remedy, that we know of for this complaint and that is dividing the parts. This is very easily performed, by passing a probe-pointed bistoury into the orifice immediately before the meatus urinarius, and cutting downward to the infe- rior junction of the labia. A small dossil of lint, moistened with sweet oil, may be insinuated between the separated portions. The wound heals, without the smallest difficulty, in two or three days. Dr. Denman, however, gives another opinion upon this subject : he says, " In such cases, we have been directed to separate them (the labia) with a knife ; and how far such an operation may be necessary in the adult, if the parts should cohere, either in consequence of some new affection, or if a cohesion, originating in infancy, should continue to adult age, must depend upon the judg- ment of the surgeon. But, in infants, such an operation is neither requisite nor proper ; because, a separation may always be made, by a firm and somewhat distracting pressure upon each labium at the same time, which scarcely makes the child complain ; though the small vessels, which had inosculated from one labium to the other, may be perceived to be dragged o,ut during the continuance of the pressure. When a separation of the cohering labia has been made in the manner before mentioned, a folded piece of linen, moistened in a very weak solution of the zincum vitriolatum, or some slightly astringent liquor, should be applied every night when the child is put to rest, to prevent the reunion, to which there is a great disposition." Introduction to Midwifery, Francis's Edition, p. 101. We cannot, from our own experience, give an opinion upon the success of Dr. Denman's mode of operating in adhesions of the labia. . But his reputation as a man of skill and judgment, would justify any one in making the attempt he proposes; though we should, ourselves, not be induced to imitate it. The little pain, and the entire success which has followed the use of the knife in the numerous cases we have employed it, give our mind a strong bias in its favour. A preference for the mode recom- mended by Dr. D., can only arise from an ill-founded dread of the knife ; it would, unquestionably, have required violent exer- tions to have torn some of the adhesions we have seen; and 1 That is, there is no other outlet for the discharges from the uterus but that which the urine has preserved for itself; and by this often passing, it prevents the entire adhesion of the labia. But this does not constitute the "imperforate hymen." 32 'ABSCESSES OF THE LABI A. much pain and inflammation, we think, would have followed such efforts. * t ' SECT. V. Abscesses of the Lqbia. A variety of causes may excite inflammation in the labia; and, when once produced, it is always interrupted with difficulty; the vascular and cellular construction of these parts contributes much to hasten the suppurative stage. We do not remember a single instance in which a phlegmonous inflammation terminated by resolution, though in several instances, the chances were as fair for trial, (from the early application of the patient for relief,) as these cases generally are. Indeed, our failures to procure resolution have been so uniform, that of late years we do not attempt it; on the contrary, the immediate application of the ung. hydrarg. fort, sine tereb., or a warm bread and milk poul- tice, is always advised. The progress of this inflammation to suppuration is usually so rapid, that but little time is permitted to make an attempt to pro- cure resolution. The suppurative stage we have known to take place in a few hours ; and it seldom continues beyond three or four days. 1 This complaint is usually announced by a sense of heat, or rather of burning, in one of the labia, and if it be touched, even slightly, pain is felt. Pain is also experienced upon any motion which employs the lower extremities, and especially upon sitting down or crossing the legs. The internal face of the labium is found distended, very red, and protruding beyond the external covering of this part. It is from the great tenuity of this internal membrane, and, on this account, bearing distention so ill, that we may look for the little success that has followed either general and local bleeding, purging, low diet, or sedative applications, to prevent suppuration. We have seen these abscesses in children, in several instances, follow bruises of these parts; they seem to be more painful in young subjects than in older ; they are almost always accom- panied, in children, as in older people, by fever; and require a strict antiphlogistic treatment. We have thought the application of the ung. hydrarg. fort, sine tereb., to be more useful than poul- tices, especially in young subjects; as it is always difficult to confine a poultice to the parts with sufficient exactness. One of the most painful and largest abscesses of this kind we remember to have seen, arose from a young lady sitting down suddenly * " This disease may be distinguished from Hernia by greater firmness of the swelling, and its more circumscribed character. It is increased by coughing, and is not reducible." Churchill's Principal Diseases of Females, p. 2. (EDEMA TO US SWELLING OF THE LABIA. 33 upon a hard pin-cushion ; this case was treated exclusively with the ointment, until the moment the latter was discharged. They sometimes succeed to labour, and more frequently after a first child, than with the subsequent ones; unless some violence has been used to terminate the labour. From the great delicacy of the membrane covering the internal face of the vulva, it is apt, when inflamed and much distended, to take on the erysipelatous form, and very quickly become vesicated; and if not soon relieved, will often slough. On this account, we have been in the habit, for some years, of exclu- sively employing the mercurial ointment for this species of in- flammation. Notwithstanding the rapidity with which matter generally forms, the inflammation is sometimes less active; requiring a number of days for it to pass through its stages. When this happens, the tumour feels like a moveable gland under the skin. But this lesser rapidity of march gives but little additional security against suppuration; for this will take place, though at a more remote period. When pain is considerable, laudanum must be given ; but, un- fortunately, it does not always procure rest. These abscesses are not, however, in every instance attended by severe pain; we have known them discharge themselves with very little inconvenience to the patient. It has been taught by many, that these abscesses should always be permitted to break spontaneously; but for what reason, we do not perceive. We have always pursued a contrary plan when we have had the opportunity ; only taking care that the lancet is not prematurely employed. It, however, does not often require our interference; as the tumour opens of itself in a short time; but should it not, we do not hesitate to puncture it, if the suffer- ing be great, and the fluctuation evident, for puncturing is all that is necessary, unless the most depending part of the tumour cannot be well commanded: in this case, it becomes sometimes necessary to lay it open to some distance, in order to secure a favourable healing. SECT. VI. (Edematous Swelling of the Labia. It is not an unfrequent occurrence, especially with pregnant women, for the external parts to swell, or become cedematous. Women who have borne many children, and who labour under the anterior obliquity of the uterus, are more liable to this com- plaint, than those who are pregnant for the first time, or those who have not this obliquity. Women of leucophlegmatic habits, 3 34 (EDEMATOUS SWELLING OF THE LABIA. who are much upon their feet, and who may he disposed to ana- sarca, are also more subject to this complaint than others. It rarely happens, however, that this affection is confined to the labia : it sometimes pervades the whole . of the lower extremities, to a very troublesome degree; nay, even to bursting. This condition creates a great deal of alarm, and is looked upon as a genuine dropsy. Some have thought it promised an easy la- bour ; we have never seen this connexion ; on the contrary, when excessive, we have thought it rather retarded this operation, by interfering with the voluntary exertions of the woman, and the development of the external parts: and on this account it subjects the labia, and perhaps the perineum, to laceration. At least we witnessed a case of this kind, in which the laceration took place, though not very extensively. The midwife, who had charge of this case, said she could account for it in no other way ; as from its thickness it would not yield. In this instance also, the labia suffered very much from giving way. There was much in- flammation of the erysipelatous kind ; and considerable sloughing followed, attended by a great discharge of ill-concocted pus, or rather of sanies. This case has made me attentive to these swellings before labour is expected, whenever consulted for them. When it is purely a consequence of gestation, it will sometimes recede of itself, several days before pain shows itself; but this must not be relied upon always, since this change does not constantly take place. This condition of the labia is almost sure to be accom- panied by a full, hard pulse, constipated bowels, and paucity of urine; notwithstanding that these swellings have their origin in a mechanical cause. We have sometimes found great advantage from the loss of & few ounces of blood, a horizontal posture, and twenty grains of nitre, three or four times a day; taking care to keep the bowels soluble by the neutral salts in small doses. If it be evident, from the degree of swelling, that the cutis will give way if not relieved, it is besttfo take off the distention by puncturing such parts as are most in danger; when the labia are punctured, it should be upon their internal face. Should it arise from a dropsical disposition in the general sys- tem, little can be done towards a cure, until after delivery : though it must be constantly proper to relieve the bursting skin by punc- tures, should labour even be begun. We have been obliged to do this in several instances, before the finger could be well introduced into the vagina ; nor "have we ever seen the least inconvenience follow the practice. The woman should be directed to confine herself almost entire- ly to the bed, for the last week or ten days of her time ; and BLOODY INFILTRATIONS, ETC. 35 she must be put upon her guard, against a full and stimulating diet. Indeed, the less she eats, the better. SECT. VII. Of Bloody Infiltrations in the Labia Pudendi. During labour a variety of accidents may occur to the parts concerned in this operation, among which, the one about to be noticed is not the least formidable in appearance, nor the least tedious in the cure. The disease to which I allude is the sud- den and excessive distention of the labia pudendi, or only one of them, with blood, from some neighbouring vessel giving way, either during the progress, or very quickly after the delivery of the child; or, in some cases, immediately after the expulsion of the head. This complaint is generally confined to one labium ; I have never seen it otherwise, though cases are related where it has happened to both. Thus, Baudelocque mentions a case, on the authority of Solayres, where the labia were equally affected. This is certainly not usual ; and perhaps may be accounted for from the peculiar nature of its cause; namely, a varicose condition of the veins of the labia and vagina. This accident, in every instance in which I have witnessed it, has taken place after the delivery of the child, though not always immediately; but this is by no means constant; as we are in- formed by Drs. Maitland and Perfect, that the swelling occurred before the child was delivered. Dr. Maitland says, in his patient, he found a soft tumour covering the os externum, very much resembling the distended membranes, which proved to be the right labium pudendi distended to the enormous size of a child's head. Dr. Burns is of opinion, that this swelling is owing to the rup- ture of a vessel within the nymphae; but it is hardly probable that any vessel belonging to these parts would yield so suddenly such an enormous quantity of blood as is sometimes expended ; for as much as five pounds have been discharged. In this case the patient died. In another instance, twenty ounces were eva- cuated, c. See Burns, James's Ed., p. CO. I am of opinion, that the blood proceeds from vessels situated rather within the vagina; for those which compose the vaginal plexus, immediately behind the corpus spongiosum, are the most likely to suffer during the passage of the child's head, and to furnish this large quantity of blood. And this opinion appears to be strengthened, by cases in which the accident happens before the delivery of the child; as the part just mentioned will suffer distention, before the head has entirely escaped through the os externum. Dr. Maitland accounts for 86 BLOODY INFILTRATIONS IN this case, by supposing, that, " from the pressure of the child's head, and the violent stretching of the parts during the labour pains, some of the small vessels had hurst." Med. Comment., vol. vi., p. 89. Now it must be evident, that the nymphJ}i1j'>ii.' y.'i 1 { 'l''LK'"'. i? :,.! ''' *' '' I ' T THE diseases of the vagina may be either natural or accidental. The natural consist, agreeably to Dr. Denman, of " such an ab- breviation or contraction as to render it unfit for the purposes for which it was designed." * We have never encountered more than one such case; and this was not so excessive as altogether to destroy the usefulness of the part. 2 A great difficulty was at first ex- perienced from coition ; but this gradually lessened, though never altogether removed. Upon examination, it was found to be difficult to pass the finger unless the parts were previously well lubricated; and this expedient was always necessary, before each conjugal consummation. The os uteri was found just within the os externum; and the whole distance to which the finger could be passed, did not exceed an inch, or an inch and a half. This person was barren, but extremely anxious to be fruitful ; aware of some natural defect, she submitted to the examination which led to the knowledge of what has been just stated. As there was nothing to be done in this case, the parts were left un- disturbed by any attempts to dilate the contracted passage. In greater departures, Dr. Denman says, "The curative indi- cations are to relax the parts by the use of emollient applications, and to dilate them to their proper size by sponge or other tents, or, which are more effectual, by bougies gradually enlarged." Dr. Denman informs us, that in a case of this kind, the efforts of the husband to overcome the resistance of the parts, so irritated them as to produce a purulent discharge from them, which was ' Morgagni mentions a case in which the vagina was only one-third of the common length; this was terminated by a firm fleshy substance this woman was barren. " Columbus dissected a woman who always complained of great pain in coitu. The vagina was very short, and had no uterus at its termination." Burns, p. 87. 1 Since writing the above, a woman of thirty-five years of age presented her- self for advice. She informed me she never had menstruated, nor had felt any symptoms that would indicate it. She had been married nine years, had all the marks of womanhood; was not averse to, but rather enjoyed sexual intercourse ; but never became pregnant. Upon an examination per vaginam, this canal was found narrow, and about an inch and a half in depth, terminating in a cul-de-sac. Nothing like a uterus could be felt. We have said, this woman had never been impregnated; not because she had an imperfect vagina, but because there was no evidence of a uterus; at least not of a healthy one; for had there been one, the menses would certainly have been secreted: and she might have been relieved by an operation. LEUCOERHCEA. 55 mistaken for a venereal affection. The inflammation was sub- dued by the ordinary means, and living for a time absque marito ; the parts were afterwards dilated by means of tents and bougies of various sizes. After her return to her husband, she became pregnant; and was safely delivered, after a slow, but not an uncom- mon labour. The accidental consists of cohesions of the sides from previous ulceration ; and of cicatrices after such ulcerations. The difficulties arising from such causes are severely felt in the time of labour, as they are rarely of such extent as to inter- rupt coition. The time to be useful in such cases is, before the parts heal ; if attended to then, much mischief may be avoided by the proper use of tents, &c. During labour extensive bleeding seems to be the only remedy. See System of Midwifery, chapter on Tedious Labour, by the author. CHAPTER IV. OF LEUCORRHCEA. THIS complaint has been familiar to the practitioner from the time of Hippocrates to the present moment; yet it is not so well understood as always to ensure the patient a certainty of cure. Indeed this affection, even at the present day, is ranked by many among the opprobia medicorum. Women seem to be obnoxious to leucorrhoea in every known climate ; and in every situation of life, she is more or less exposed to its occurrence. So decidedly is this the case, (at least in civilized life,) that the woman who has not had the complaint, appears to have escaped from an im- pending mischief, rather than to have been constitutionally en- titled to the exemption. Yet some are more obnoxious to it than others; and this difference arises principally from the following causes : First. Original constitution or temperament: thus, women of the sanguine temperament and rigid fibre are less liable to this complaint, than those who are fair-skinned, light-haired, and of a relaxed fibre. Second. Location, atmosphere, and occupation, have their influence, or so modify common agents, as to render them capa- ble of producing it. Thus women of high and mountainous countries, who enjoy a pure and dry air, are freer from this complaint than those who inhabit a moist and cold climate. 56 LEUCORRHCEA. Also, those who live in the country, and who, from the nature of their occupations, are obliged to use much exercise, are less visited by this scourge than the indolent women of large cities; hence, women of very sedentary habits, and who indulge in luxu- rious idleness, are almost sure to have this complaint. Mr. Churchill seems to imply that the uterine leucorrhoaa is as com- mon, or more so, than vaginal which if it be a fact in England is not so here ; indeed we consider this form of the disease to be extremely rare, agreeably to the experiments of ourselves. Third. Habits of life, and the quality and quantity of nourish- ment, will have an operation upon all constitutions or tempera- ments. Thus women who indulge much in bed, who keep late hours, who over-stimulate, who drink immoderately of thin, un- nourishing drinks, as tea and coffee, are more disposed to this discharge, than those who observe a contrary plan; and such are especially liable to it, who use the warm bath too freely, or are in the habit of employing " foot stoves." Hence, the women of Holland are particularly liable to leucorrhoea; as their climate, habits, and nourishment, all dispose to it. Fourth. Habits of cleanliness will tend very much to preserve the parts concerned from this discharge, even in those who may be disposed to it; while the neglect of this physical virtue will be almost sure to produce it, even in those not otherwise disposed to it. At all periods of life, females are liable to an increased dis- charge from the vulva; thus, we witness it in the infant girl, and in the aged matron, but not equally often in both; it is more fre- quently found with the latter than with the former. This com- plaint frequently commences about puberty it may, therefore, anticipate, accompany, or follow the menstrual secretion ; but, at this period, it is of but temporary continuance, for the most part, unless great errors have been committed in the management of the female at this time; or unless there should be a particular predisposition to the complaint, from hereditary taint, or original temperament. 1 As the woman advances in life, and after she has become a mother; when her necessities demand great exertion, and pre- vent proper indulgences during pregnancy, and after labour, she is more particularly liable to it, than at any other period ; and then generally in its worst forms. Hence, women in the lower walks of life are more obnoxious to leucorrhoea than those who 1 Gardien, and some others, think leucorrhoea is sometimes hereditary; he says, " Le catarrhe uterin peut attaquer, des le has Age, les filles qui ont eu pour meres des femes sujettes habituellement a un 6coulement; mais cette leucorrhee hereditaire ne pent pas etre distinguee de celle qui est entretenue par la debilite de la constitu- tion: comme cette derniere, elle depend de 1'organisation primitive, qui est faible et lache." Traite Complete, &c., vol. i. p. 321. LEUCORRHin chronique," p. 332. But this offers no illustration, or ex- planation, of which is the cause, or which is the effect. Be- sides, we feel rather disposed to doubt the frequency of this com- bination; for of one thing we are certain, that we have seen many instances of leucorrhoea without derangement of stomach ; and we have as certainly seen many cases of dyspepsia, without leucorrhoea. Indeed, he seems to confess, that causes are ad- mitted with too much facility; for he immediately after adds, " Les causes predisposantes et determinantes du catarrhe uterin sont extrement vari6es : peut-etre pourrait on reproche"r aux auteurs d'en avoir adinis plusieurs trop legerement, et d'avoir souvent conclu post hoc, Ergo propter hoc. Dans la recherche LEUCORRH03A. 61 des causes, on a souvent regard^ comme lies deux phenomenes qui ' n'etaient, que coexistans," p. 322. In the syphilitic leucorrhoea, as it is called, it woujd also be useful to know of its existence; since syphilis itself would re- quire a distinct treatment from common leucorrhoea ; in this case, the disease, as just observed, would not be leucorrhoea but syphilis, during the active stage ; but the remote effects would require no specific treatment, as the leucorrhoea following syphilis would yield to the same remedies as leucorrhoea from any other cause. Gardien's occasional extension of species into, 1st, sympathe- tic leucorrhoea; 2d, spasmodic leucorrhcea, answers no good pur- pose whatever in practice; especially as there is no satisfactory evidence of the existence of the latter; and the first will naturally range itself under the head of leucorrhoea, from remote or indirect irritation. He tells us, (with what propriety the profession must judge,) "J'ai donne le nom spasmodiques, a celles qui surviennent chez de jeunes personnes, pour avoir pris du lait, ou pour avoir fait usage de compositions emmenagogues," p. 319. The division we have made, we think, can be defended, by both reason and practical observation. Under the first head, or "the leucorrhoea of direct irritation," we would consider all such instances of this discharge as follow an active inflammation of the mucous membrane of the uterus or vagina produced by some local cause : as laborious parturition ; application of instruments ; excess of venery; irritating substances applied to the surface of the vagina; extraneous bodies intro- duced into it ; a prolapsed uterus ;' tumours within the vagina ; injections of too stimulating a kind ; or from the simple inflamma- tion of the parts, as every portion of the body is liable to such attacks, without our being able to determine why this or that part may have been Selected. We have known, in a number of instances, leucorrhoea to follow a lingering or tedious labour, both where instruments may have been used, and where they were not, &c. Under the second head, or "the leucorrhoea of remote, or indi- rect irritation," we would range all such instances in which the vagina sympathizes with some other portions of the body; as with the uterus during pregnancy; or, in long-obstructed menses; producing, or becoming, what is called chlorosis ; as when the menstrual action is about to furnish the catamenial discharge, or just after that action has ceased. With the rectum, when subject to hemmorrhoids, or when irritated by ascarides ; with the gums, as in early dentition ; with the stomach, when dyspeptic, &c. Under the third, or "leucorrhcea of habit," we would enume- 1 Of this particular cause, we have had occasion to speak under the head of " Prolapsus Uteri," which see. 62 LEUCORRHCEA. rate those instances, which continue after the active or inflam- matory condition of the . parts has ceased ; as after syphilis or gonorrhoea, and become like "gleet" in the male; a prolapsed uterus restored; or a tumour removed; for the vessels of the uterus and vagina seem to have less recuperative power than any other portions of the body. Almost every part of the body, which is susceptible of action, may have that action to continue after it has been once excited, though the exciting cause be re- moved ; we witness it in the nervous and muscular systems, as in chorea, hooping-cough, &c. ; in the vascular and glandular systems, as in the continuance of spitting, after the action of mercury has ceased; in the membranous and vascular systems, as the discharge of mucus after dysentery; and, agreeably to Mr. Hunter, as in the gleet after gonorrhoea. He distinguishes the condition of the mucous membrane of the urethra in gonor- rhoea, and in gleet, in the following manner. "The venereal in- flammation is of such a nature as to go off of itself, or to wear itself out ; or, in other words, it is such an action of the living powers as can subsist but a given time. But this is not the case with a gleet, which seems to take its rise from a habit of action which the parts have contracted ; as they have no disposition to lay aside this action, it of course is continued ; for, we find in those gonorrhoeas which last long, and are tedious in their cure, that this habit is more rooted than in those which go off soon." Treatise on the Ven. Dis. art. Gleet. It is, in many instances, precisely the same in leucorrhoea: the mucous membrane of the vagina may be irritated by a sponta- neous inflammation; by mechanical agencies; by acrid substances; by morbid poisons; or perhaps by some sympathetic influence, so as to produce leucorrhoea. The irritating causes may neverthe- less be altogether withdrawn ; yet the surface which had for so long a time continued to produce the fluor albus, will from habit persevere in its production. Hence,, the leucorrhoea of long standing is always much more difficult to overcome, than the one which is in its primitive and active condition. But this last species, it may be remarked, very rarely occurs, and is perhaps more common after gonorrhoea, than after any other cause. Gardien seems desirous to establish a species of leucorrhoea, "purely local;" we have endeavoured to prove them all to be so: but in this effort he unquestionably confounds two distinct conditions of the mucous membrane of the vagina. He says, "The acute uterine catarrh is a purely local affection, and de- pends on a peculiar irritation of the genital organs. It offers four periods Jn its progress; the first is announced by an itching, at first sliglit, of the vulva and interior of the vagina, which is occasionally extended to the womb. The woman complains of a considerable heat in the vicinity of this organ ; of a feeling of LEUCORRHCEA. 63 dryness, which suspends immediately the secretion of the muco- sities which lubricate the vagina, and of pains of the back ' and loins; the itching increases, and sometimes becomes insupporta- ble. In some cases it augments the sexual appetite ; if this dis- position be yielded to, the disease is aggravated. This period is accompanied by frequent disposition to pass the urine." "The second period, which takes place on the second or third day, is characterized by a serous discharge, not very abundant at first ; this augments in quantity, and assumes a green or yel- lowish colour, varying in intensity according to the degree of irritation; the ardor urinse becomes more fatiguing, the labia majora, the vagina, and sometimes the urethra, show signs of inflammation. Fever sometimes ensues; the pains, at first con- centrated in the loins, sometimes extend to the groins, to the haunches, internal part of the thighs, and perineum." "In the third period, which begins on the ninth or tenth day, the intensity of the inflammatory symptoms diminish ; the dis- charge is still very copious ; it successively becomes thicker and offers shades of colour, until it grows entirely white ; then it soon diminishes, and the ardor urinse suddenly disappears." " The fourth period, which forms the passage to the chronic state, presents many irregularities ; the discharge disappears for some time, and returns without obvious cause. That of which the matter is flocculent, or resembles glairy threads or jelly, is com- monly most difficult to cure," p. 324. We have made this long extract, concerning what the author terms the "leucorrhte aigu," to show, that he confounds almost all the discharges from the vagina under one general head; name- ly, "le catarrhe uterin;" than which there cannot well be a more obvious error : thus, the purulent discharge of gonorrhoea ; the mere increase of the natural discharge, or the temporary aug- mentation of it, (which he considers either sympathetic or criti- cal,) he classes under the same head, but looks upon them as constitutional. But a disease which he admits to be local and acute, and of which. we have given his own account, he also makes a leucorrhoea ; but to which it has not the slightest analogy, either in "its symptoms, or in the method of cure; for the disease in question consists of a peculiar inflammation, and oftentimes an aphthous condition of part of the vagina, and of the vestibulum especially ; and is properly a variety of the " pruritus" of authors. See section on Pruritus. The discharge constituting leucorrhcpa is declared by authors to proceed from the uterus and vagina. To determine this point, * All that portion of the vulva, which is anterior to the hymen in virgins, and the carunculae myrtiformes in those who are not, is called the vestibulum. 64 LEUCORRHCEA. may not appear at first sight to be of much consequence ; yet the practitioner may find it of great use in making his prescriptions; for the remedies which may be found useful in the one instance, may fail altogether in the other. We are of opinion, that this discharge rarely proceeds from the cavity of the uterus, even in its most aggravated form ; and when it does, it must always be looked upon as the most difficult of management. If Dr. Cullen's definition be admitted, leucorrhoea would be limited to the internal cavity of the uterus itself. He says, " Every serous or puriform discharge from the vagina may be, and has been, comprehended under one or other of these appellations leucorrhoea, fluor albus, or whites. Such discharges may be various, and may proceed from various causes, not yet well ascertained but I confine myself here to treat of those dis- charges alone which may be presumed to proceed from the same vessels which in their natural state pour out the menses. From this definition of fluor albus, it will be perceived at once that a pregnant woman cannot have this complaint; yet the fact is notorious, that all women, (or at least with very few excep- tions, as far as our observations have extended,) have, during this period, a greater discharge from the vagina than when they are not pregnant: and many have not this discharge, as already noticed, but at such times. Now, the discharge which continues, and even increases during pregnancy, and that which only takes place at that period, cannot be leucorrhcea ; or Dr. Cullen, con- fining this complaint to the " vessels, which, in their natural state, pour out the menses," must be wrong. Astruc, indeed, declares, he has seen both leucorrhcea and the menses flow at the same time. "I conclude," says the doctor, "a discharge from the vagina to be of this kind, (namely, from the vessels which furnish the menses.) 1. From this happening to women who are subject to an immoderate flow of the menses, and liable to this from causes weakening the vessels of the uterus." To this we would observe, that there is no natural connexion between the two complaints, as stated by Dr. Cullen; for our ex- perience furnishes us with so many exceptions to this rule, that we cannot look upon them as necessarily associated : we have seen many instances of menorrhagia without leucorrhcea ; and we have seen more cases of leucorrhcea without menorrhagia. Besides, the Doctor attributes this discharge following immode- rate flows of the menses, to "causes weakening the vessels of the uterus." It is an evidence of weakened vessels, when they are forced to secrete a fluid of a colour and quality different from that of the natural, and at the same time very much more abun- dant. Is not secretion an action ; and if that action produces a greater quantity of a material, than it does when it is acknow- LEUCORRHCBA. 65 ledged to be in health, would it not seem to imply an increase of power, rather than a diminution of force? What would seem to be the natural consequence of a weakened state of the uterine vessels, or any other vessels in a state of weakness? Certainly, that they must perform a lesser, instead of a greater duty. If the vessels of a part are really weakened, it seems to follow, that less exertion can be expected from them than when in a state of health and vigour; yet, agreeably to this doctrine, they perform more than in that state of vigour, because they are weaker, and (as we should think) less able to do so. It would also appear, that when vessels were really weakened, they would be less able to transmit their contents ; yet more is poured out first, in the form of blood, as in menorrhagia ; and then of an elaborated fluid, called fluor albus ; for elaborated it really is ; yet these vessels are said to be weaker than in a state of health. But would it not seem to be a natural effect, if the vessels of a part be preternaturally weak, that the loss of several ounces of blood immediately from them, would increase this weakness? Yet, so far is this from being the case, agreeably to the scheme of Dr. Cullen and many others, that they must be strengthened ; since the fluid they evacuate is more elaborated, and in greater quantity, than in a state of health. Will any one declare the vessels of the kidneys to be in a state of weakness in diabetes, because they yield quadruple the ordinary quantity of urine ? Will any one say that the salivary glands are in a state of weakness, because they secrete a superabundant quantity of saliva, under the action of mercury ? But Dr. Cullen does not stand alone in this assumption; for most of the writers upon the subject have yielded to the same erroneous opinion; thus, Chambon, Denman, Leake, Vigarous, Gardien, 1 Capuron, Burns, &c., all talk of debility, either local or constitutional, as the cause of leucorrhoea. Even Mr. Clarke. who has written so ably upon several of the complaints of females, joins in the same belief. Mr. Hunter says, that " the term weakness gives us no idea of a disease: and, indeed, there is none that can be annexed to the expression. By mechanical weakness is understood the inability to perform some action, or sustain some force. By animal weak- ness the same thing is understood: but when the expression is applied to the animals performing an uncommon or additional action, I do not understand it." Treatise, art. Gleet. "2d. From its appearing chiefly, and often only a little before, as well as immediately after, the flow of the menses." This will certainly prove nothing in favour of the position of 1 Gardien, it must be observed, has scarcely done more than given a literal trans- lation of a great part of Cullen's chapter on this subject. 5 66 LEUCORRH(EA. Dr. Cullen; for, though we admit it to be a fact, in many instances, that the discharge is increased "a little before" the appearance of the menses, it is not always the case immediately after ; though, if it were allowed to be precisely as stated by Dr. Cullen, it would not confirm his doctrine, nor militate against the explanation we shall give of that phenomenon. It is admitted by all, be their theories of menstruation what they may, that there is more blood invited to the uterus and its dependencies at the time the menses are about- to be secreted, during their secretion, and immediately after, than at any other . period, except when this organ is in a state of gravidity ; it will not then be disputed, that this increase of blood is intended to furnish the menstruous fluid ; and that this process is effected by an increase of action in the vessels of the uterus. Now, when the vessels of the uterus and vagina are more abundantly supplied with blood, it is more than probable that the vessels on the se- creting surfaces of these parts will be urged from this stimulus to greater duty ; and consequently, made to furnish a greater supply of the fluid they are in the habit of eliminating; and, hence, the appearance and sometimes increase of this discharge. 1 This will therefore account for the fluid being more abundant just before the menses appear ; and a continuation of this action, (which it is nowise doubtful sometimes exists,) after the menses have been poured out, will account for the fluor albus, or an increase of dis- charge at this time. For it may again be proper to observe, that the engorged state of the vessels of the vagina during pregnancy, produces very often the same consequences ; when it is every way certain, that this discharge cannot be furnished "from the same vessels which, in their natural state, pour out the menses." " 3d. From the flow of the menses being diminished, in propor- tion as the leucorrhoea is increased." Were this statement a fact, it would not interfere in the least with an explanation that is easily and well ascertained to have this effect in other portions of the body ; namely, that the conges- tive state of the uterine vessels, so essential to the production of the menses, are relieved, to a certain extent, by the continual drain of fluids from the vagina. 2 But the assumption of Dr. Cullen, that the menses diminish in proportion to the increase of ' Dr. Cullen himself tells us, par. 988, that " though the leucorrhcea depends chiefly upon the laxity mentioned, (of the extreme vessels of the uterus,) it may have proceeded from irritation inducing that laxity, and seems to be always increased by any irritations applied to the uterus." * Every body is familiar with the influence of drains of every kind in relieving local inflammation and congestion. It is upon this principle, that blisters, issues, and setons, are constantly employed, with so much success, in cases where this kind of counter-irritation is required, or even where it is desirable to counteract the waste from discharging su.faces, be these discharges sanguineous, serous, or purulent, or wherever situated. LEUCORRH'<* ':'.-- ; t ,'.\'i' r :i:' '} 1;: : I-I .' ~'T \*r r:--.i\--' <' :.V- ?' .[-,. t v 1 It has just been declared above, that the natural secretion of the neck of the uterus, was ' semi-transparent, and of great tenacity; adhering to the ringers like bird-lime." It seems, then, the first degree of morbid change alters the secretion to one that " is glairy and transparent, or resembling a thin starch made by boiling." A greater degree makes it " opaque, and of a perfectly white colour; and it resem- bles, in consistence, a mixture of starch and water made without htat ; or thin cream ; it is easily washed from the finger after an examination, and it is capable of being diffused through water, rendering it turbid." Clarke on the Diseases of Females, vol. ii. p. 5. " An attack of fever, high living, excess of venery, exercise carried to fatigue, intemperance in drinking, over stimulating injections, excessive costiveness, an attack of hemorrhoids, and approach of the menstrual period, will each occasionally increase the irritation at the neck of the uterus. * " A morbid state of the glands in the cervix of the uterus, probably gives rise to this discharge; at least, the cases in which it comes away, are those in which the symptoms are referred to this part, and when pressure is made upon this part, under such circumstances, the woman complains of considerable pain." Clarke on the Diseases of Females, vol. i. p. 37. 4 A pain in the small of the back is almost sure to attend a morbid condition of the cervix uteri, as in cancers, ulcers, lesions from rude delivery, or the incau- tious use of instruments. The bladder is frequently urged to discharge itself, and a numbness is felt down the thighs. Mr. Clarke makes two species of "the transparent mucous discharge;" the first is that which originates from, and is accompanied by, increased action of the vessels of the parts. The second, that which originates in debility; in which latter case, the former may terminate. Clarke on the Diseases of Females, vol. i. p. 300. It will be seen, that we acknowledge but the first of these as an original disease; and that when the inflammatory stage is subdued, and the discharge continues, it then becomes "the leucorrhoea of habit;" which almost always takes place before the cure is completed. LEUCOKRH at twenty or twenty-five, she may continue to breed to the age of forty or more. ' Phil. Trans, vol. Ixxvii. p. 233. 1 Does it not seem extraordinary that the plethora of Roussel should not exist until a certain period of life, (puberty;) and this period uniformly modified by climate, &c., or that it should not take place after another certain period of life, (after the cessation of the menses,) to maintain this discharge? ' Page 117. 84 HISTORY OF MENSTRUATION. discharge is a genuine secretion, and that the internal face or lining of this organ is the portion which furnishes it ; now, it will be evident, that whenever this part is in any way deranged, the quality of its product must also be impaired; but the injury does not consist so much in the imperfect elaboration of the menstrual fluid, as in the inability of this surface to furnish a healthy deci- dua after impregnation has taken place ; for there can be little doubt but that the same apparatus furnishes both one and the other. This condition of the uterus, I have reason to think, is not of un- frequent occurrence: an ovum may be fecundated, and duly con- veyed to the. cavity of the uterus ; but it perishes there, from the want of a healthy decidua: it is, therefore, cast off unperceived at the next menstrual purgation ; and thus the woman is relatively barren. What strengthens this opinion is, that this lesion of the uterus is frequently repaired, by either proper remedies, or by the powers of the system alone ; and the woman afterwards becomes fruitful. I am fully persuaded I have witnessed a number of such cases. If it depend upon an imperfection of the ovaria, it may not, perhaps, admit of relief. The diseases of the ovaria may consist, 1st, in their imperfect development; 2dly, in derangement of structure ; 3dly, in a want of healthy organization of the ova themselves. Now, either of these conditions of the ovaria may be so complete as to altogether destroy their influence upon the secre- ting surface of the uterus ; the catamenial discharge may, there- fore, continue, with all due regularity, and yet the woman may be barren ; and, hence, this discharge cannot be considered, rigidly, as a constant sign of fertility. Yet it may be safely admitted, as a general rule, that women who menstruate regularly and without pain, or the expulsion of coagula, or false membrane, are fecund; and that the reverse of these conditions is almost sure to be attended with sterility. It may also be observed, that we cannot attach much consequence to the quantity evacuated; for the woman who may evacuate double the quantity of another is not for this reason more cer- tainly prolific. I have known a number of instances of repeated impregnations, where, as far as could be ascertained, not more than two ounces were habitually evacuated ; and this not occupy- iag more than a day and a half, or two days, for its elimination ; while, on the contrary, I have known women who were barren, discharge three or four times this quantity ; and the fluid bear all the sensible marks of a healthy secretion. From this it would appear, that mere regularity in returns ; the elimination of a pro- per quantity of fluid, and this fluid apparently of a healthy cha- racter, do not always declare the woman to be fecund. Yet, when the woman has never menstruated, or when this discharge has altogether ceased, agreeably to the ordinary arrangement of HISTORY OP MENSTRUATION. 85 nature or from disease, she either never becomes impregnated, or ceases to become so, if she ever has been. It is true we are told, as observed before, by highly respecta- ble authority, that impregnation has taken place before the erup- tion of the menses, 1 as well as after their final cessation. The explanation of this seeming exception is not difficult, for the rea- son already assigned ; namely, that because a coloured fluid was not observed, it was taken for granted that the uterus had never assumed the menstrual action, or had not resumed it after it had ceased as a law of the system. SECT. III. Early Appearance of the Menses. Now, it is admitted by practical writers, 2 as a fact of no very rare occurrence, that the menstruous evacuation is sometimes serous, and this for several periods before the menstrual blood, properly so called, shows itself, to more decidedly mark the esta- blishment of the process. This is especially the case with those who have this discharge to commence early. And it may be well to caution the young practitioner against a common and natural error, when this anticipating discharge takes place, not to mistake it for leucorrhcea, and attempt its sup- pression. We shall have occasion, in another place, to point out the influence of leucorrhcea upon the menstruous discharge. See Sec. on the Tardy Appearance of the Menses. I was consulted, some months since, in the case of a young lady between twelve and thirteen years of age, who was labour- ing under a diseased spine, but who was also afflicted with head- ach, palpitations of the heart, and great sickness of stomach. She had also at somewhat regular periods a pain in the small of the back, with a bearing down sensation, a desire to pass water, an inclination to go to stool, &c. From these circumstances her mother concluded, and in this I concurred, that an effort was making for the production of the menses, though the common external signs of puberty were almost entirely wanting. I, how- ever, requested the mother to be careful in examining the linen worn by her daughter at these periods, and ascertain whether there was not a discharge from the vagina resembling leucor- rhosa. This was done: she reported there were considerable marks upon her linen ; and this was observed for at least four 1 Rondelet mentions a woman who wa3 delivered twelve times ; and Joubert another, who bore eighteen children, neither of whom had ever menstruated Gardien Traite U M.t1 .'/ T'Jf'J-f v'.l .u;^ ls. Of Bleeding during Pregnancy. From what we have said, it follows that the female constitu- tion, during pregnancy, has great susceptibilities, and even pecu- liarities, which are highly important to be known and regarded, especially when prescribing for an acute disease. The process of sanguification is much more rapid during this period ; as all the functions of the body are more quickly performed. Hence, at this time they bear so well the loss of blood ; hence, the more frequent necessity of abstracting it ; and hence the difficulty of overcoming the morbid actions of the system at such times. There is, very often, much clamour raised against this opera- tion ; the depletion of the pregnant woman. This is sometimes so great as to render it extremely difficult to subdue their dis- eases. 1 This prejudice, for so it truly is, is founded upon false views of the functions of the uterus, and the economy of the foetus, 1 The young or inexperienced practitioner must not be betrayed into over bleed- ing in cases of pregnancy, by the sizy appearance of the blood; for such is the indomitable nature of the blood vessels, that the blood would appear sizy to the last drop in the body. OF BLEEDING DURING PREGNANCY. 187 during the period of utero-gestation. It is imagined, that every ounce of blood the mother loses deprives the foetus of a certain portion of it ; consequently, that we should be very sparing of this fluid, that we may not rob the foetus of its due quantity of nourishment. On this account, the clamour of the friends fre- quently arrests the lancet, when its employment is most essential to the welfare of the mother. There are few mistakes of greater magnitude than the one just noticed; and, though founded in error, it has, nevertheless, often prevented, or very much interfered with the free and unbiassed practice of medicine. It very often causes the young practi- tioner to abandon some of the best established principles in the practice of his art ; namely, 1st, that women bear the loss of blood better, when pregnant, than at any other period ; and 2dly, that all the acute diseases by Avhich they may be attacked require a more extensive use of the lancet. If, then, the inter- ference of friends interrupt the free exercise of the judgment, the practitioner is reduced to the office of a nurse; for it is not he who prescribes, but the friends of the patient ; while all the responsibility rests upon his shoulders. We have known much mischief produced by yielding to these mistaken views of the animal economy, at this time. It should be recollected, that the circulation through the uterus has most wisely been rendered almost independent of the contingent condition of the general circulation of the system ; and that no one viscus in the body is so little influenced by qhanges in this important function, as this organ, during the whole period of utero-gestation. The uterus contrives, if we may use the expression, to make its demands upon the general mass always successfully; or, at least, so long as there is any thing to ask for; hence, when almost every other organ is but sparingly supplied, we find the uterus abundantly furnished. Who, in the practice of midwifery, has not seen a fully-developed foetus yielded by a mother in the last stage of a wasting disease, like phthisis pulmonalis, and where the quantity of circulating fluids was extremely diminished ? Is it to be supposed, then, in such, and in similar cases, that this could have happened, had the uterus had no more than a common participation in the distribution of the blood ? Certainly not ; since the quantity in every other portion of the body was reduced, by being deprived of part of their usual supplies. But it may be said that the uterus, in this respect, only enjoys the property of amassing supplies, in common with other viscera ; let this be so; it is not a part of our present purpose to inquire into it ; all that we insist on at this moment is, that the uterus absolutely possesses this power. 188 OF PURGING DURING PREGNANCY. We may be told that the foetus is by no means so secure as is represented, when the mother Buffers considerable losses of blood ; and they will attempt to illustrate this, by showing that the child often perishes from uterine hemorrhages. This is true ; but it does not interfere with our remark ; for we have not said that the uterus cannot be exhausted of blood, if blood be taken di- rectly from it, as in floodings : we have only declared, that when this fluid is drawn from the general system, as in bleedings per- formed for the relief of disease, that very large quantities might be abstracted, without making the uterus give up any portion of what it absolutely possesses ; and this is strictly true. But, on the other hand, it must not be supposed that pregnancy, merely as such, requires blood-letting. This error is as great as the one we have just attempted to remove; for we make it a con- stant rule in practice to discountenance blood-letting, unless there exist some inconvenience or disease to demand it. 2d. Of Purging during Pregnancy. )v . '. ;' : - The pregnant woman does not bear purging so well as one who is not so: or rather, if this operation be carried very far, there is a risk of producing abortion, owing to the strong consent between the uterus and rectum. Hence, the occurrence some- times of this accident, from a profuse diarrhoea, or a violent dysentery. Therefore, some caution is required, in treating the diseases of pregnant females by purging ; for if carried to a great extent, it may do mischief. But let us be understood exactly on this head, lest we deprive females of the advantages of this re- medy, in the acute forms of disease. We mean that a pregnant woman would not bear, with safety, as much purging, as if she were not pregnant ; yet she bears it with advantage, when car- ried to a considerable extent, especially if tenesmus be not ex- cited, either by the quality of the drug employed, or by the accidental severity of the operation of a medicine, otherwise generally eligible. In a word, we believe that a pregnant woman will bear, without risk, any common or necessary degree of pur- ging, unless she be prone to abortion. We should suggest caution in the choice of purgative medi- cines, rather than forbid the employment of this evacuation, as a remedy; for, with the pregnant woman, much depends upon the selection. All such as act with great force upon the bowels, should be avoided; such, for instance, as are classed among the drastic purgatives, as scammony, gamboge, colocynth, aloes, &c. ; because each of these produces, during its operation, great irritation in the rectum, and very frequently excites tenesmus. EMETICS DURING PREGNANCY. 189 It is this peculiar irritation which renders any cathartic unsafe that might produce it; no matter to what class of cathartics it may belong ; for, if castor oil, magnesia, or any other mild ca- thartic were to produce this effect, it would be as equally im- proper, as any of the drugs prescribed above. Hence we see abortion frequently occur from dysentery ; and but very rarely from diarrhoea, however profuse. Cases of habi- tual abortion, which are preceded by severe diarrho3a, might be considered as exceptions to this rule ; but this is, perhaps, more specious than just. For in all the instances which we have wit- nessed of this kind of diarrhoea, there was more or less tenesmus accompanying it ; and it is with us a doubtful point, whether this diarrhoea is not, in such cases, a concomitant, rather than a cause. For there is no fact better established, than that there exists a strong sympathy between the uterus, (and, perhaps, the mouth of this organ particularly,) and the rectum. We witness this oftentimes in the commencement of labour; during its pro- gress, or towards its termination. We have more than one patient, whose labours always com- mence with diarrhoea ; that is, so ; soon as the os uteri is stimu- lated to dilatation, the bowels yield. Now, in abortion, there must always exist some irritation at the os uteri, or it would not yield to the impulses of the fundus and body of this organ, for it is by no means a mechanical operation. And so soon as this nisus is perceived, (for the uterus prematurely throwing off its contents, is a kind of tenesmus of this organ,) the rectum sym- pathizes with the uterus, and a diarrhoea, with tenesmus, is pro- duced. If this be objected to, by saying, that abortion is sometimes prevented by the application of opium to the rectum, thereby removing the disease, or quieting the irritation which invited the action of the uterus ; we would answer, there is not the smallest proof from this circumstance; since the sympathy between these parts is reciprocal; and, consequently, when a remedy is applied to the one it will influence the other. In proof of this, how often do we successfully apply remedies to the rectum, when we mean its effect shall be felt by the uterus alone? We believe, then, it is not so much the frequency of the dis- charges from the bowels produced by the operation of purgative medicine that does the mischief in pregnancy, as the peculiar, and oftentimes severe irritation it produces in the rectum. * 3t?. Of Emetics during Pregnancy. Emetics should be given sparingly to pregnant women : they 190 OP BLISTERS DURING PREGNANCY. are rarely eligible after the fifth month, and should only be con- sidered as remedies of necessity. Towards the last months of pregnancy, their operation in properly, or freely evacuating the stomach, is oftentimes uncertain, as this organ can be very little aided in its efforts by the other powers concerned in this ope- ration ; and from the abdominal muscles being very much upon the stretch, much pain is experienced in their contractions during the efforts to vomit, followed, sometimes, by severe cramping pains. We have known severe and permanent pain produced by the exhibition of an emetic at the latter period of utero-gestation, and from which the patient was not entirely relieved until the termination of her labour. In the early months, nature oftentimes establishes this process for wise purposes; but even then, the action of the stomach is rather frequently, than violently excited; and it may generally b said, there is more nausea than vomiting. But, even in the early periods, emetics are to be used with caution ; and when determined on, the ipecacuanha should be made choice of. 1 4th. Of Blisters during Pregnancy. Blisters are to be used with great caution with pregnant wo- men : owing to the great excitability of their systems, they pro- duce a great deal of pain during their operation ; and this is not always followed by benefit. During pregnancy, blisters are much more apt to produce strangury than at other times ; and when this occurs it is almost sure to be followed by the most distressing and untoward symp- toms. We have seen entire retention of urine follow their use ; which has been only relieved by the catheter ; and attended with such distressing inclination, and violence of effort, as to be only surpassed by the pains of labour. Bloody urine has sometimes followed the use of a blister ; and a discharge of mucus from the internal face of the bladder has continued for a long time after. It is true these are extreme cases; but they nevertheless occur, and should, therefore, suggest a great deal of caution in their em- ployment, especially in the more advanced periods of gestation. We think we have seen two instances of premature labour from 1 A practitioner was called, about two years since, to a lady of my acquaint- ance, who was in her last month of pregnancy. He said she was very bilious, and must take an emetic. This he gave her, and it vomited her so severely as to induce the action of the uterus, which did not cease until premature labour took place, and finally delivery was the consequence: both mother and child had nearly fallen a sacrifice to this mischievous proceeding. FEBRILE CONDITION, ETC. 191 the action of blisters ; yet we must acknowledge they have been advantageously employed to prevent abortion. 1 CHAPTER X. ON SOME OF THE DISORDERS OF PREGNANCY. EVERT experienced accoucheur is aware, and it is highly im- portant to the young practitioner to be informed, that the preg- nant state imposes a peculiar character upon many common af- fections of the system; and that it gives rise to a morbid condi- tion of some particular organs, certainly during a part, and some- times during the whole term, of its continuance. We shall endeavour to point out, in what follows under this head, the peculiarities just spoken of; together with the particu- lar plan or modification of treatment in each of these affections, that the state of conception requires ; for it is essential to success- ful practice that the changes effected in the nervous and sangui- ferous systems from this cause be well understood. We shall, therefore, treat of the most common, as well as of the most im- portant of these diseases, as modified by, or originating from, the gravid state of the uterus. We have already pointed out the re- strictions and precautions that certain therapeutical agents re- quire, under the circumstances now contemplated. SECT. I. On the Febrile Condition of the System during Pregnancy. From what has just been said it would appear, that the system of the pregnant woman is almost always labouring under a degree of excitement not common to it at other periods ; and, conse- quently, that it will ill bear stimuli. But this acceleration of pulse, and susceptibility to stimuli, must not be looked upon as a state of absolute disease, when nothing more attends ; it should only be regarded as a state which may be easily operated on by morbid or other agents, and hence the proneness of the system to fever, from even slight causes. 1 We would by no means employ blisters to prevent abortion, but would sug- gest the propriety of their trial in cases where every thing else had been tried in rain: they have been useful in such cases. I suggested their employment long ago, in Rees' Cyclopaedia, article Abortion. 192 Dr. Denman conjectures, from the universality of this febrile dis- position, that "when duly regulated, it is probably intended to answer some important purpose to the child." He thinks there is something like proof, "by the blood of the pregnant woman, which, independently of disease, is always found to have what is called a sizy appearance, though of a peculiar kind, and evidently very different from that which is observed in cases of inflamma- tion, and which may be considered as a consequence of some new and specific action," p. 233. It is a fact notorious to almost every body, that the blood drawn from a pregnant woman exhibits an appearance very different from the blood of a healthy woman who is not preg- nant. This difference in the aspect of the blood, in the pregnant woman, depends upon a separation of the red globules from the coagulating lymph; while no such change is observed in the other. Dr. Denman declares this to be " evidently very different from that which is observed in cases of inflammation." This is by no means so evident to us the white, or rather yellowish coat, observed upon the surface of both these bloods, unquestion- ably consists of the same material, namely, the coagulating lymph. The difference which he declares to be so evident, un- fortunately, he has not pointed out; and it certainly remains to be proved, that this coat, in both instances, is not owing to an alteration produced by the same agency; namely, by that pecu- liar arterial action attending on both pregnancy and inflamma- tion. Mr. Hewson first taught us, that when this coat appeared on the surface of drawn blood, it was owing to the thinning of the serous parts of this fluid, which enabled the colouring matter and other denser parts of it to separate, and precipitate them- selves to the bottom of the vessel. That the density of this "coat" may differ in two instances, we have no objection to ad- mit, since this \xill not prove that both are not one and the same thing; namely, the coagulating lymph. Besides, to our view, the cause of this peculiarity appears so analogous in both in- stances, that we do not hesitate to admit them to be the same ; namely, an increased arterial action, which we call inflammatory, for want of a more definite term. We have already said that this condition of the arterial system is so general, as almost to force us to the belief that some spe- cific object is attained by it but what this condition is, can at present only be conjectured. Dr. Denman supposes it may contribute^ to some good to the child ; but how this is effected, he has not informed us. We will, therefore, offer a conjecture upon this subject. It seems now pretty generally admitted, that the foetus in utero is not nourished by blood furnished directly by the mother ; that is, there are no SYSTEM DURING PREGNANCY. 193 continuous vessels from mother to child ; consequently, the com- munication between the two must be indirect. The most probable manner in which this indirect mode is car- ried on, is that of Schreger, as published in his dissertation " De Functione Placentse Uterinae." He says, that "the uterine vessels pour nothing but serous fluids into the spongy tissue of the placenta ; and that the uterine portion of this mass is not as high-coloured as its corresponding, or foetal portion. And that the blood which circulates in the uterine vessels of the mother is already too highly charged with carbon and other heterogeneous matters, to serve as nourish- ment for the foetus ; it therefore only exhales its serous part, which is purer and more highly oxygenated." Agreeably to Schreger, then, the placenta performs, as regards the foetus, the office of a lung, in which the blood is revived, and becomes bet- ter fitted for nourishing the foetus, and the purposes of life. He also has a new theory for the uses of the umbilical vein. He says, "The serous fluid thrown out by the uterine arteries into the maternal portion of the placenta, is absorbed by a set of lymphatics which carry it along the umbilical cord to the thora- cic duct ; from thence to the left subclavian vein ; the superior cava; the heart; and from thence to the aorta, by means of the arterial canal. From this artery, after being mixed with the blood and hematose by the action of the vessels through which it has passed, it is carried to the umbilical arteries, which return it to the placenta. When it has arrived here, it is not poured into the cellules to be returned to the mother, but passes into the umbilical veins, whose radicals accompany those of the umbilical artery. Nevertheless, the lateral pores of these arteries depo- sit the fluid which the foetus could not elaborate, or which re- quires to be again submitted to the action of these organs, before it can serve as nourishment." This highly probable and ingenious theory would lead us to conjecture that the excitement in the arterial system so invaria- bly produced by pregnancy, is intended to have the blood more highly oxygenated, and, at the same time, from its increase of fluidity, to permit the lymph and serum more easily to be sepa- rated from the other portions of the blood in the maternal por- tion of the placenta, and by this means convey an additional quantity of oxygen for the purposes of the fcetus. The vermilion colour of the blood shows it is highly charged with this substance. May we not in this way account for the foetus in utero being so well sustained, while the mother is lingering in the last stage of phthisis pulmonalis ? And on the other hand, explain the fre- quency of abortion and premature delivery, in almost all the cases of small pox, measles, scarlet fever, &c., where the sanguineous system is tending to typhoid action ? And also in other cases 13 194 FEBRILE CONDITION OF THE SYSTEM. not of the exanthematous kind, where this typhoid disposition prevails ? So also in puerperal convulsions, where the paroxysms almost suspend respiration. This excited state of the sanguiferous system must not always be looked upon as bespeaking a morbid condition of it ; for were this always to be rigorously enforced and acted upon, much mis- chief might be done ; for, as it is, women frequently suffer from the injudicious use of the lancet, or the too frequent employment of cathartics. It should be considered only as a disease, when a mischievous tendency is perceived, by the formation of fever ; or in local determinations, giving rise to pain or other inconvenience, as headache, giddiness, imperfect vision, difficulty of breathing, pain in the side, which is augmented by breathing, a full, bound- ing pulse, and a hot dry skin, and especially, if these exacerbate, either in the evening or in the morning. When either of these conditions happen, the system calls for remedies. A few ounces of blood abstracted from the arm ; a vegetable diet; and keeping the bowels open by any of the mild purgatives, will be found sufficient for the immediate removal of this state of the system. If acidity prevail, magnesia will be the best pur- gative we can employ; if there be no acidity, pills of rhubarb; castor oil; Seidlitz powders; sulphate of magnesia; or flour of sulphur, will be found best. All stimulating substances should be carefully refrained from ; every kind of liquor should be pro- hibited water alone should be the drink. All fatigue should be avoided; crowded or heated rooms should be shunned; and all undue exercise, under the pretence of "wear- ing off the fever," should be forbidden. Dr. Denman is a strong advocate for exercise during pregnancy, and cites, as instances of its usefulness, the lower class of people, who are obliged to take much of it. We are always unwilling to differ with this gentleman, though oftentimes obliged to do so, as he furnishes so many opinions from which we cannot but dis- sent. The case before us is one of many, on which our experi- ence will not permit us to do otherwise than to differ. For we have always found, that those women whose habits of life did not, from their infancy, oblige them to be much upon their feet, were always injured by using much exercise, because it was thought "useful to their situation." Besides we are very far from thinking that the lower class of women bear the conse- quence of pregnancy, the fatigues of labour, and the contingen- cies of the puerperal state, better than women in the higher walks of life. In this country, we can declare, with much certainty, that a much larger proportion of the labours of those who are in the humbler conditions of life, have an unfavourable termination, than the same number of labours among the females in the higher VOMITING DURING PREGNANCY. 195 ranks of society. Besides, all analogy is against it, as the Doctor himself admits, by declaring, that quadrupeds "neglect their common pursuits, the gregarious disposition is suspended, and, if left to their own inclinations, gradually lessen their exercise, as they advance in pregnancy." Errors in diet are almost constantly committed during preg- nancy, than which, few things are more mischievous. We have already adverted to the tendency of the system to plethora, during this condition of the female ; on this account it cannot fail to be injurious to overcharge or to over-stimulate the stomach. No one circumstance has contributed so certainly to fix this error, as the vulgar speculation upon this subject ; namely, the necessity the female is under to prepare nourishment for two beings, at one and the same time; that is, for herself, and the child within her. She is, therefore, constantly recommended, to eat and drink heartily ; and this she too often does, until the sys- tem is goaded to fever; and sometimes to more sudden and greater evils, as convulsions or apoplexy. Mrs. , pregnant with her first child, complained of slight headache ; heat and restlessness at night ; disagreeable taste in the mouth ; a furred tongue in the morning ; loss of appetite, or rather disgust to .food, and constipated bowels. She was near her seventh month of pregnancy. She was directed to be bled; to take doses of rhubarb and magnesia; to drink rennet- whey, and use nothing stronger than water as drink. In a few days she was perfectly well, and returned at once to her old habits of full- feeding. She soon had a return of her old symptoms, which were relieved in the same manner, as just stated. After conti- nuing the moderate plan of living for some time with great ad- vantage, she was told she was very wrong to live so abstemiously, as it would weaken both her and her child so much, that much mischief would follow. She obeyed the advice of her ill-judging friend ; the consequence was convulsions ; from which she was saved with difficulty ; but her child perished. SECT. II. Of vomiting during pregnancy, In the early part of pregnancy, this effort of the stomach is considered among its rational signs; and it seems to be instituted for the purpose of preventing or subbing plethora. Its advan- tages, however, are confined to the eany periods. When it con- tinues after quickening, or renews itself with severity towards the latter period of gestation, its usefulness is equivocal, if not de- cidedly mischievous. Dr. Denman says, "If the vomiting should not be violent, and occur only in the early part of the day, though very troublesome, it is so far from being detrimental, that it is generally found to be 196 VOMITING DURING PREGNANCY. serviceable, by exciting a more vigorous action of the uterus, by bringing the stomach into a better state," p. 234. This appears to us a curious kind of reasoning; for, how vo- miting is to be useful, by producing more vigorous action of the uterus, when that action is not required, or would be certainly mischievous if excited, we cannot comprehend. Or, how vomit- ing can bring the stomach into a better state than it would be, when there is neither a necessity nor a disposition to this effect, is equally unintelligible. That the efforts of the stomach may be useful in removing offensive matters from it, when these matters produce nausea or vomiting, we can readily comprehend; but this certainly does not bring this organ into a better state than it was before such matters had deranged it. Vomiting we believe to be only useful as it may reduce or pre- vent plethora ; and for this purpose a very moderate degree of it is all that is necessary. For this end is almost always answered in one of two ways ; first, by discharging the food almost imme- diately after it is taken down, thus preventing its digestion by throwing it up; secondly, by severe and distressing nausea, with- out much vomiting, thus controlling the inordinate actions of the system by this subduing sensation and by diminishing or suspend- ing the powers of digestion. Now, this is for the most part only useful, as we have already said, in the earlier months of preg- nancy ; for, in the latter months, the increasing demands o? the foetus generally keep down the disposition to plethora. But, however useful the act of vomiting may be in the earlier periods, it becomes sometimes a most dangerous disease when continued through the greater part of the period of gestation. We have seen it involve the patient in imminent danger, from its indomitable nature, and from not being amenable to remedies. We have seen several instances where we thought it would be right to bring on premature labour, and would in one instance have dpne so, had not this taken place spontaneously, very soon after it had been determined on. In such extreme cases, we think it every way reconcileable to the most scrupulous morality, to induce premature delivery for the preservation of the mother. But it should also be recommended to the attending physician, in such cases, never to perform this operation, unless it be sanc- tioned by the result of consultation. The sickness commonly^ccurs as soon as the patient leaves her bed, and frequently brasses her for two or three succeeding hours. The matter thrown up is usually a sour, tenacious mucus ; at other times, a thin, extremely acid water, which no wand then even excoriates the fauces, and sets "the teeth on edge." At other times, bile accompanies the discharge even in considerable quantities. When bile is thrown from the stomach, an emetic of ipecacuanha will frequently be found useful, and may, in the VOMITING DURING PREGNANCY. 197 . early months, be given with safety. For the most part, this vo- miting is attended with confined bowels ; the appetite is either voracious, or nearly destroyed ; but almost always whimsical ; and, what is oftentimes remarkable at such times, the most un- promising, and apparently preposterous article, will not only be most acceptable to it, but best suited to its wayward humour. The vomiting, however, rarely proceeds to any very dangerous length; and as rarely requires a strict medical treatment; a pro re nata plan is, for the most part, all that is required. I have found a glass of warm water or chamomile tea, taken so soon as nausea is felt, very frequently abridge the sickness, by immedi- ately inducing vomiting, or by composing the disturbed stomach. Should much acidity prevail at such times, a glass of soda water will have a very good effect: or what succeeds admirably some- times, is the soda in the following form : R. Bi-carbon. sodae, 3Jss. Pulv. G. Arab. ^ij. O). menthae, gut. iv. Saech.alb. zij. Aq. Seltzer. iv. M. Of this a table-spoonful is to be taken every hour or two, as occasion may require. Should the bowels be in fault by their tardiness, small doses of calcined magnesia, in a little milk, will be found highly useful. If nausea and frequent vomitings occur during the day, and the food be thrown up, the patient should be confined to a table-spoon- ful of milk every fifteen or twenty minutes, and no one thing be- side ; this rarely fails to tranquillize the stomach, and enable it to take food with advantage: we may occasionally add a spoon- ful of lime water to the milk, until the stomach be relieved. But such is the predominance of acids, that none of the ant- acids is capable of overcoming it, though administered with a liberal, or even a daring hand. I rarely persevere in the use of the alkaline remedies, when I find that considerable doses will scarcely have a temporary effect: when this is the case, I re- commend the use of acids, for the relief of this most distressing state of the stomach. Both vegetable and mineral acids have been employed by me, with perhaps about equal success; but the vegetable will merit the pteferance in general, on account of the teeth. I have, in several mstances,^confined patients, for days together, upon lemon juice and water, with the most decided ad- vantage. 1 In two instances I have witnessed the best effects from substi- 1 One lady took the juice of a dozen lemons daily, ami nothing besides, for many days together, with the most marked advantage. This lady, in her last pregnancy, ate large quantities of ice, with great comfort to herself she ate nearly a quarter puck a-day. 198 VOMITING DURING PREGNANCY. luting a glass of iced water, for tea or coffee in the morning, by which the patients were enabled to retain a cracker or two upon their stomach, which would not have been the case, had they taken either of the other substances. When the vomiting is so persevering as to discharge every thing from the stomach as fast as taken in, the bowels should be carefully evacuated daily, by mild injections; permitting these to act rather by their bulk than by their stimulus. Should the pulse be full, as it almost always is under these circumstances, a little blood should be taken from the arm ; more especially if headache attend. Should pain, and a sensation of burning about the region,of the stomach be felt, much good is experienced by the application of a few leeches to the part, so as to abstract five or six ounces of blood. I have repeatedly found much benefit from the use of the spirit of turpentine three or four times a-day, in twenty-drop doses. This medicine is very easily taken, if mixed in cold water sweet- ened. When the system is not excited to febrile action, and where the stomach rejects every thing almost as soon as swal- lowed, I have often known a table-spoonful of clove tea 1 act most promptly and successfully. With respect to the diet of patients so circumstanced, it would be in vain to point it out ; as any plan we could devise would scarcely apply to any two patients I generally direct the use of such articles as their experience has proved best suited to their condition; and, sometimes, it is truly astonishing to observe the waywardness of the stomach upon such occasions. I have lately had a patient who could retain no article, except Indian meal cakes baked pretty hard upon a board these uniformly kept down, and she literally lived upon them for weeks. Our experience of opium confirms, in a great measure, the ob- servations of Dr. Denman, on the use of this drug. He says, " In cases of excessive vomiting, opium in tincture or substance is generally given, and often with great advantage. Perhaps no well-founded objection can be made to the occasional use of opiates, when violent pain, or any other urgent symptoms de- mand them. But I have persuaded myself, that their habitual or very frequent use, is prejudicial to the foetus," p. 235. We think we have found the solid opium newly made into a pill, of at least two grains, the best r Where this complaint is habitual at these periods, and parti- cularly when it observes a pretty regular movement, much ad- vantage is found from taking a small tea-spoonful of the Liq. Anod. Hoffm., about half an hour before it comes on. 1 If the period of attack be in the evening about bed-time, this remedy should not be neglected, as it will almost certainly relieve the sensation and procure sleep. If this complaint come on at any period of the day, or is pro- voked at any time by slight causes, we have found much advan- tage from a pretty steady use of the following tinctures : R. Tinct. Valerian, vol. Castor Of this, a tea-spoonful in sweetened water may be taken three or four times a day; or whenever the palpitation is troublesome. In the second place, if palpitation be unaccompanied by nervous sensations; if there be headach; flushed face; giddiness of the head ; and if these be increased upon rising up; if a sense of ful- ness in the head, with a feeling of oppression about the chest ; and if sleep be disturbed by unpleasant dreams, we shall find, almost always, that the arterial system is too much loaded; the pulse will be found tense, full, or creeping ; irregular, and sluggish ; r We feel it a duty to express our indignation at the almost constant substitu- tion of diluted vitriolic ether for the valuable article called Hoffman's Anodyne Liquor. This imposition upon the public has mainly arisen from three causes: 1st. On the part of the manufacturer, who wishes to make as much profit as pos- sible out of an article in very common use, the purity of which, but too few me- dical practitioners know how to ascertain. In the genuine liquor, there is an in- dispensable ingredient, called "the oil of wine," of which the spurious does not contain a drop. The oil of wine is easily detected, by mixing a few drops of the liquor with water, and if the oil be present, the water becomes instantly milky, as the oil is insoluble in water. We would recommend this test to the medical practitioner; and if the milky appearance does not take place, let him reject the article. 2dly, To Mr. Brande having lately declared, that in effect, there was no difference between the spurious and the genuine liquor; than which there cannot well be a greater error. The first has all the properties of diluted ether stimu- lating and heating: whereas the other is soothing and tranquillizing beyond any other substance, in certain cases, with which we are acquainted. 3dly, To the parsimonious conduct of the purchaser himself; of whom the manufacturer^ complains that he will not give the price for the genuine article : the last is re- ' prehensibly sordid, if not palpably dishonest. 218 OF THE DISPLACEMENTS OP THE UTERUS. which nothing will relieve, but the loss of blood, gentle purging, and an abstemious diet. Should stimulating remedies be given, as is too common, un- der the persuasion that weakness is the cause ; or that all nervous affections are to be treated by stimuli, much mischief may ensue; such as intense headache, fever, and sometimes, even convulsions. Mr. Burns says, that "Roderic a Castro prescribes a draught of hot water." This remedy, we have learnt, is sometimes very efficacious ; it must be, however, only when the stomach is in some manner or other the cause of the affection. When this complaint is accompanied by nausea or vomitings, the hot water may be serviceable, as it is very successful in allaying gastric irritation. CHAPTER XIII. OF THE DISPLACEMENTS OF THE UTERUS. UNDER this head, we might very properly place every devia- tion from the natural position of this organ. But to do this agree- ably to the exact meaning of the words "natural position," would require an extreme degree of minuteness of description, as well as a most useless division of the different portions of the vagina. We shall, therefore, not consider any deviation of position of this organ, as coming within the meaning of "displacement," that is not attended with more or less inconvenience to the pa- tient. I shall, however, confine myself, in the present wark, to the "prolapsus uteri," and the chronic inversion of this organ ; having treated of the several other displacements pretty fully in my "System of Midwifery." SECT. I. On Prolapsus of the Uterus. Notwithstanding the uterus has four ligaments, purporting to support and sustain it in situ, yet they so ill perform this office, as to render it very doubtful whether such was the express in- tention of nature in their formation certain it is, the uterus is subject to the impulses of the abdominal viscera; to the pressure of the distended bladder; and to the influence of the loaded rec- tum and sigmoid flexion of the colon, and we might add, to the influence of its own internal weight after conception. Besides, many other causes may tend to produce this displacement ; as falls, blows, delivery, fluor albus, severe coughs, &c. PROLAPSUS OF THE UTERUS. 219 Gardien 1 makes three degrees of prolapsus; namely, 1st, re- laxation of the uterus; 2d, descent, or falling of the uterus; 3d, the precipitation of the uterus. These distinctions are not en- tirely useless in practice ; for though they are only different de- grees of the same affection, they yet require a little difference in the mode of treatment. "In the first degree, the inconveniences arise from the in- crease of size of the uterus; and are confined to a disagreeable dragging towards the groin and the umbilicus. In the second degree, the woman complains of a sensation of weight about the fundament, and a dragging about the groin, back, and umbili- cus, which are more severe than in the first degree, and are aug- mented when the woman is on her feet and walks. If a hori- zontal position be observed for some time, it always affords re- lief; and the woman every morning would think herself cured, did she not know, from experience, all those symptoms would re- turn after exercise or standing. In the third degree, the uterus becomes engaged more or less in the os externum, and sometimes even escapes from the vulva. " In this case, it draws the vagina with it, which turns upon itself." "In this last degree, all the symptoms just enumerated are increased ; the woman feels a nisus, or bearing down effort at the anus and neck of the bladder, in consequence of the uterus being engaged in the external parts, thereby compressing the rectum and bladder. But if the uterus escape through the ex- ternal parts the symptoms last mentioned are less severe, or are found to moderate, when this takes place ; but the pain in the back, and the dragging about the groin, increase, in consequence of the fundus of the uterus being still lower," p. 179. Of the many casualties to which the uterus is liable, the pro- lapsus may be considered as the most frequent, as well as the most troublesome, though not the most dangerous. This dis- placement may take place at almost any period of life; for we have witnessed it in the aged matron, and have prescribed for it in the youthful virgin. Dr. Campbell (Introd. to the Study of Mid.) p. 445, says, " No age, however, is exempt ; for the author once encountered complete protrusion in a female of twenty-one, who, it was said, laboured under it for more than two years." Capurin tells us of a case of prolapsus, in a girl of fourteen. To this I can bear witness, from my own experience ; for one of the most severe cases of this kind I ever witnessed was in a girl of this age. These are important facts ; and will lead to the detection (by a proper examination) of the cause of a variety of severe symptoms, the origin of which were from this cause, but 1 Traite Comp. p. 179. 220 PROLAPSUS OF THE UTERUS. which would defy explanation, without the necessary explora- tions. "When we consider how imperfectly the ligaments attached to the uterus sustain it in situ ; and when we reflect upon the fre- quency of debilitating discharges from the vagina, sapping as it were the very foundation of its support, we need neither be surprised at its often occurrence, nor at the obstinacy of this distressing complaint. Fluor albus may be looked upon as one of the most frequent causes of prolapsus : it relaxes the vagina, and makes it yield to the weight of the superincumbent uterus, or to the impulses of the abdominal viscera. I have already re- marked, that neither the broad nor the round ligaments seem calculated to sustain the uterus in its natural position ; and if this be so, we must look to some other part for th$ support of this organ and this is the vagina itself. This office of the va- gina may be deduced from the manner in which it is united to the uterus, and the mode in which that canal is joined to the rectum and bladder. The whole of this arrangement gives at once the idea, that the vagina is the efficient support of the ute- rus. It then follows, that whatever is capable of weakening the foundation, will tend to injure the superstructure ; hence, leucor- rhcea, frequent deliveries; 1 too early rising after delivery; very large children; a very large pelvis; habitual coughs; severe pukings, and ill-conducted instrumental deliveries, may all tend to this end, by destroying the natural tone of this part, either by the debilitating effects of an immoderate discharge, or by the vagina being overstretched ; thus preventing the return of its natural firmness and resiliency; or by the frequently repeated concussions this part may suffer, from the abdominal viscera, by coughing and vomiting. The degree of precipitation to which the uterus may be liable, will depend on the extent of injury the vagina may have sus- tained, from the causes just enumerated : and will vary, from a slight depression, to an entire displacement: therefore, in some cases, it will be but barely within the os externum. The symptoms which characterize this complaint will be mo- dified by the greater or less descent of the uterus in the vagina they will be intense in proportion (caeteris paribus,) to the ex- tent of the displacement; but in all there will be a sense of some- 1 It has been declared by Mr. Roberton, that " the great distention which the vagina endures in giving passage to the child's head for the first time is produc- tive of more temporary injury to the canal, and the neighbouring textures, than happens in a subsequent delivery; and hence ensues a condition of parts favour- ing the descent of the uterus and bladder." We are of opinion there is some error in this statement, as it is a fact well known to every experienced practitioner, that these parts never recover their former condition with so much certainty as after a first labour. PROLAPSUS OF THE UTERUS. 221 thing sinking in the vagina, as if the perineum were sustaining an unusual weight ; with a dragging sensation about the hips and loins; a desire to make water, sometimes without the ability to do so ; or if it do pass, it is reluctantly, and oftentimes painfully hot a sense of faintness, and occasionally a number of nervous or hysterical feelings and alarms, which almost overwhelm the patient. A pressure, and a feeling about the rectum resembling a slight tenesmus, sometimes importunately demand the patient's attention, which, if she obey, almost always ends in unavailing efforts. The pain in the back is sometimes extremely distressing while the patient is on her feet; and gives to her walk the ap- pearance of weakness in her lower extremities. A benumbing sensation shoots down the thighs ; especially when the woman first rises upon her feet ; or when she changes this position for a hori- zontal one. In some few instances, the woman is obliged to throw her body very much in advance ; or is obliged to support herself by placing her hands upon her thighs when she attempts to walk. But all these unpleasant symptoms subside almost im- mediately if she indulge in a recumbent posture, and this circum- stance pretty strongly designates the disease. In addition to the inconveniences we have just stated, there is always from the vagina more or less of a discharge of a purulent appearance ; this, in severe cases, is frequently tinged with blood, and occasionally is offensive. In addition to this, we often find the menses suffer some derangement : they are almost always more abundant, and sometimes more frequent than they should be this, with the accompanying leucorrhoea, very often reduces the woman's strength to a very low ebb ; and, if not relieved, entails upon her permanent ill health. In married women, this complaint, when excessive, is often detected by the pain that coition is almost sure to inflict; and this becomes oftentimes one of the most powerful inducements with the female to apply for relief. Notwithstanding the diagnostics of a prolapsed uterus are so strongly and decidedly marked, yet they are not sufficiently so to warrant us in taking it for granted: we should never, but fron\ a careful examination, pronounce this complaint to be positively present, lest we commit an error, as once happened to myself. I was consulted by a lady, who had long suffered almost every symptom recorded above ; I pronounced her disease to be a pro- lapsus of the uterus ; and without an examination per vaginam, had a pessary made for its support but, to my sad mortification, when I was about to apply it, a careful examination proved that no such condition existed, and that all the unpleasant symptoms had arisen from a thickening of the neck of the bladder. In No. II. page 157, of North Amer. Arch., we find the follow- ing denunciation of the pessary, as a cure or relief of prolapsus 222 PROLAPSUS OF THE UTERUS. uteri. "In such cases, all the usual contrivances, from the simple sponge, up to the most complex machinery, -will be in- effectual, and cannot be borne by the patient. Any foreign body introduced into the vagina will give rise to an augmented mu- cous secretion, and occasion ulceration and offensive discharges. On this account, it will be difficult to induce the individual to persevere in the use of the instrument; the disease will continue to increase, and will finally assume a more formidable character. This will be especially the case, should the patient belong to the labouring classes. Such individuals cannot maintain the erect posture for any length of time without increasing the tendency of the organ to descend : as they cannot pursue their avocations while using the ordinary instruments, without suffering conside- rable pain, they are apt to lay them aside, and neglect their con- dition. The prolapsed parts will, therefore, become ulcerated, and indurated, and run into incurable disorganization; and finally, the constitution of the patient will be worn out and ex- hausted by fever and emaciation, and death will close the scene." It will be naturally asked, what does Dr. F. himself propose for the cure of this common, and oftentimes serious evil? We will show what is his substitute in his own words, and let our readers draw their own conclusions of the merits of the two plans. "All these difficulties maybe obviated and the disease effect- ually cured by episioraphy, which is an operation instituted with the view of accomplishing an adhesion between the labia, and thus securing a natural barrier, by which the uterus and vagina will be prevented from prolapsing. " The. operation is exceedingly simple, and is performed in the following manner. The patient is placed upon a table in the same way as for the operation of lithotomy, except that the hands and feet need not be tied. The operator seizes one labium bettveen the thumb and fingers of his left hand, and, with a sharp-pointed bistoury, commences an incision about two fingers' breadth below the upper commissure, and one finger's breadth from the margin of the labium itself. This cut must be carried by a bold sweep of the knife to the fourchette, where it should terminate with a slight in- clination inwards. In this manner a slip of the labium will be removed of the breadth of one finger. By a similar procedure, a portion of the other labium, of the same size, must be excised, taking care to unite the two incisions about a finger's breadth below the fourchette, at an acute angle, and include a portion of that frcenum. After securing the bleeding vessels, and arresting- the oozing of blood from the spongy tissue, by sponging the part with cold water, the lips are to be brought together by suture in the common way. Previously to doing PROLAPSUS OF THE UTERUS. 223 this, however, the operator should examine carefully the con- dition of the vagina and uterus, and if they require replacing, adjust them ; and, to maintain them in their situation, introduce a piece of soft sponge, previously oiled, and transfixed by a liga- ture, to withdraw it when necessary. The sutures must then be drawn close, and the edges properly approximated as low as the fourchette, which will generally require from ten to twelve liga- tures. The dressings should be simple, and secured by a T bandage. As it is desirable to obtain union by the first intention, and the contact of the urine might prevent it, it should be drawn off, for the first few days, by the catheter. The aperture which is left above, will be sufficient to give vent to the menstrual dis- charge, and the mucus of the vagina, and may, even, the consum- mation of the venereal act. Should conception take place, it will be easy, by means of a small incision, to make room for the pas- sage of the child! !" This horrible, severe, and ill-described operation, is seriously proposed by Dr. F. as a substitute for the simple, successful, and easily managed pessary. We confess we were much startled by the reading of the above serious and wonderfully mischievous effects of the pessary especially as we have applied many hundreds of these instruments within the last five and forty years ; and in no one instance of this extensive experience, and, we will add, careful observation, have we, in a single instance, observed either of the mischievous consequences named by Dr. Frick. If we have witnessed such effects, it must have arisen from the bad structure of the instru- ment itself, and unskilful mode of applying it, or from the cases being of an improper kind for the use of the pessary, and not as a necessary consequence of this instrument, considered as a remedial agent for the relief of prolapsus uteri. Our experience has long since taught us, that a well constructed pessary, proper- ly introduced, and the uterus and vagina free from inflammation, scirrhus, or any other morbid alteration of structure, is not only a safe, but a highly valuable remedy in this change of location, of the uterus, and that, so far from causing the evils so formida- bly presented by Dr. F., that it has proved not only a complete remedy for prolapsus, but, in several cases, for leucorrhoea, that had resisted other remedies. For, in some instances, this de- ranged position of the uterus acts as an irritant to the mucous membrane of the vagina. A pessary of proper construction is the only efficient remedy for this complaint it should be as well fitted to the parts as the nature of things will permit ; for much depends upon its proper adjustment. The one I prefer I have given a drawing of; it is to be considered but as a modification of the circular elastic gum pessary, or rather that of Levret. I made the alteration many 224 PROLAPSUS OF THE UTERUS. years ago, and I have every reason to be satisfied with it It is formed of silver, strongly gilt ; it is hollow, and pierced with a central hole of only sufficient size to permit the escape of the dis- charges incident to the parts. There are three different sizes, one larger than the one of which a drawing is given, and one smaller the medium size is most frequently required. The difference in size is only one eighth of an inch; either in addition or in re- duction. See plate XII. At the suggestion of Dr. Hopkinson, pessaries of many sizes, have been made of glass, which have been found, upon several years' experience, to answer, perhaps, even better than the gilt, 1st. They are very much cheaper ; 2dly. They are never acted upon by the secretions of the vagina ; 3dly. They are much more easily procured. The only objection I have found to the glass pessary, is its extreme smoothness this, however, is easily ob- viated, by exposing it to the action of the vapour of the fluoric acid as prepared by Dr. Goddard. When this is to be placed, care should be taken that the bowels of the patient shall have been freely opened, and the urine passed ; and also, that she should have kept her bed for an hour or two previously to the operation. She must be placed perfectly hori- zontally on the bed, and near its edge the parts lubricated, as well as the instrument, with hog's lard; the labia must be sepa- rated by a couple of fingers ; one placed on each labium, 1 and the pessary then pressed gently, but firmly, against the os externum, directing the force downwards towards the internal surface of the perineum, and backwards in the direction of the vagina ; but in such a manner as shall make the introduced edge look towards one of the sacro-iliac junctions. 2 We continue to press the in- strument forwards in the course just pointed out until the whole of it is received into the vagina. Then the finger must give it a transverse direction ; or, in other words, the breadth of the pes- sary must correspond with the small diameter of the inferior strait : this is easily effected ; and we can judge whether it be well placed by feeling for the hole in its centre, which must al- ways correspond with the axis of the vagina. The next consideration is to ascertain whether the neck of the uterus is placed in the excavation of the instrument ; (for it must be remembered it should be introduced so that its hollow face shall look upwards.) This may be known by passing the finger over the edge which is under the symphysis pubis and depress- ing it a little; the finger will then readily detect the position of the neck of the uterus ; and should it not be found in the centre 1 It is generally best to use the left hand for this purpose. See note following. * It will generally be found most convenient for the operator to have the right side of his patient next to him; as, in this position, he will command the intro- duction of the pessary with his right hand. PROLAPSUS OF THE UTERUS. 225 of the pessary, it can readily be drawn there by the extremity of the finger. When this is adjusted, we take care that the trans- verse position of the instrument be exact, before we withdraw the finger : the woman may now be permitted to get up. 1 The proper size of the instrument is a matter of considerable consequence ; and we cannot always determine, a priori, which of the sizes will answer best if it be too large, it will give pain ; and if too small, it will escape, perhaps, on the first effort to go to stool. We can ascertain when too large, by its producing much uneasiness in the parts, and by the difficulty of introducing it: should this happen, it must be removed, and one of a smaller size introduced. And for fear the instrument be too small, we should direct the patient not to go to the privy, for a day or two, lest it escape from her and be lost. The relief afforded by the introduction of the pessary, in many instances, is immediate ; but, if not, it is almost always secured, in a short time, if the instrument be of a proper size, and well adjusted. It may be proper to remark, that the pessary will do no good where the perineum has been destroyed by laceration. , Before I employ the pessary, I almost always, if there be much leucorrhoea, but not otherwise, and when the time can be commanded, make use of astringent injections for two or three weeks, with very decided advantage the best, perhaps, is a so- lution of alum in the proportion of a half ounce to a pint of wa- ter ; and after the instrument is adjusted, a few syringes full of fine soap and water should be thrown up the vagina daily if the gilt pessary be employed, it will need removal but very rarely ; not oftener than once in two or perhaps three months ; 2 this gives a very decided advantage over every other. The period it must be worn must' necessarily depend upon, 1st. The inveteracy of the disease ; 2d. The extent of the displacement ; 3d. The employment of the patient ; 4th. The greater or less disposition to fluor albus. As a general rule with young women, where the complaint has not been of long standing, from three to four months will sometimes be sufficient it will, of course, require a longer time where the woman is more aged, and where the complaint is of long standing one of my patients wore the in- 1 In some instances we have found it best to confine the patient to a horizontal position for three or four days, with the intention of giving the pessary an oppor- tunity of bedding itself in the vagina. This is particularly necessary where there is much sensibility in the parts, or where the instrument causes a little uneasiness after its introduction, though it fits the passage well. " Indeed, it is not always necessary to remove it so often: we have had many patients who have worn the gilt pessary for six months, and sometimes even longer, without having it removed. This is fortunate for the patient, as it spares much moral pain. And the glass one can be worn even longer, without any disadvau- tage. 15 226 PROLAPSUS OF THE UTERUS. strument a year; but this was the longest time I have known it to be required. 1 Besides the inconveniences just related, this condition of the uterus gives rise to a fixed pain in one of the sides, but especially the left, which bids defiance to all general as well as local appli- cations hitherto employed for its' removal. Larrey, the celebrated French surgeon, proposes a very differ- ent pathology of this complaint as well as mode of treatment. He says, it is owing to two causes, either an asthenic (debilitated) thickening of the uterine parietes, or an elongation of the liga- ments, and proposes for its cure that the loins, groin, and other adjacent parts, should be cupped. After this, he applies a moxa to each cupped spot, and this may be safely repeated; this to be aided by a horizontal posture, elevation of the pelvis, and flexion of the lower extremities; cold astringent applications and in- jections, lavements, and a mild, nutritious diet. He affirms he has made permanent cures in this way. In the complaint now alluded to, and which we shall exemplify by cases, no suspicion was entertained by the practitioners, who previously had had the care of them, that it depended upon the prolapsed condition of the womb ; and it is but a few years since I was myself aware of it. But, as this complaint is more com- mon than is generally suspected, and as it cannot be removed, so far as I know, but by the use of the pessary; and, especially, as I have, since the publication of the cases about to follow, received various communications and thanks for their promulgation, I have thought it proper to detail them in this place, that the at- tention of practitioners might be directed to its consideration. CASE I. Mrs. T., aged thirty-six years, applied for my advice, for a severe pain in the left side, immediately under the margin of the false ribs, extending to the spine of the ileum of the same side. She informed me she had had this for several years, with more or less severity, and for which she had undergone severe medical treatment, such as bleeding, purging, blistering, leeching, &c., without the slightest benefit. The pain was not increased by respiration, pressure, or motion, but some relief was constantly experienced upon lying down, and especially as the night ad- vanced. She could lie in any position without any increase of inconvenience, but felt most comfortable in a bent posture. I prescribed for her a variety of medicines, with no better suc- 1 Since writing the above, I have found several patients extremely reluctant to part with the pessary after there was every reason to believe it might have been removed without any inconvenience following. Two others have had the pes- sary restored, declaring they felt so much more secure with it but none have complained of pain, after the few first days, however long retained. In two or three other instances, they have been removed at the seventh month of pregnancy, being no longer of any use as a support to the uterus. These cases show that impregnation takes place, notwithstanding the presence of the pessary. PROLAPSUS OF THE UTEKUS. 227 cess than those who had preceded me ; and began seriously to despair of being in any way useful to her, when, thinking the leucorrhoea, with which she was severely afflicted, might iiave some agency in weakening her, and believing this, from the de- scription of her feelings, to arise from a prolapsed uterus, I men- tioned my suspicions to her, and stated the propriety of an exa- mination to ascertain the fact. To this she submitted ; and the uterus was found low in the vagina, I ordered her astringent injections, which were persevered in for three weeks, with as much advantage as I had contemplated -for the only benefit I expected from them was to giv6- a tem- porary tone to the vagina before I should introduce a pessary. At the end of three weeks, I introduced a gilt pessary, and de- sired my patient to place herself upon her feet this she did, and declared she felt much more comfortable than she was wont to do when she arose from her bed; and observed, that for the first time for several years, she was free from the pain in her side. Believing this to be accidental, I paid but little attention to the declaration at the moment but upon my visiting her the next day, she assured me she had no return of it whatever, nor has she had to this moment. This case made a strong impression upon me; especially as I could call to mind several similar instances of affections of the side, in which I had failed to give relief; and it made me deter- mine, should another case of painful side occur, to inquire imme- diately into the state of the uterus. It was not long before this opportunity presented itself in a lady from the West Indies. CASE II. Mrs. D. had, for several years, (five,) been much af- flicted by a train of severe nervous affections she would, fre- quently, from the slightest causes, be thrown into violent hyste- rical paroxysms, which required considerable time to calm. She had a fixed pain in the left side, which would occasionally appear to swell, and become extremely painful to the touch when this took place, she was almost certain that hysteria would follow. Her appetite was good, but her stomach could only digest certain articles her bowels were constipated, and she had a profuse leucorrhoea of a purulent appearance. She was considerably reduced in flesh, and much debilitated. She had tried a variety of remedies in the West Indies for the local affection of the side she had been repeatedly bled and blistered, without the smallest advantage took mercury to a considerable extent was freely purged and puked but to no purpose. When the pain was unusually severe, it was considered as spasm of the stomach. From the detail of her symptoms, I was led, however, to suspect a prolapsus of the uterus, and in- quired whether that opinion had been given by her physicians at home but she said it never had been suggested; it was consi- 228 PROLAPSUS OF THE UTERUS. dered as -an affection of the stomach altogether, and all remedies were addressed to it, either directly or indirectly. I proposed an examination per vaginam, to which she very reluctantly consented but that examination confirmed my first suspicion of her case. I ordered her the tincture of cantharides, and some astringent injections also, small but daily doses of rhubarb ; and continued this plan for nearly three weeks. At the end of this time I placed the pessary. She was almost instantly relieved from the usual symptoms attending a prolapsed uterus, and also the afflicting pain in her side. Experiencing such immediate relief, and the almost total ex- emption from her nervous feelings, she became careless, and al- lowed her bowels to become, as they were wont to do, exces- sively costive ; and in an effort to relieve herself, she discharged the pessary. This accident she concealed from her friends, until a recurrent of all her former inconveniences and pain, forced her to a confession. I was immediately sent for, and the loss of the pessary was made known to me. I placed another, and she again was restored to comfort : and now is in the most perfect health. She is no longer troubled with hysteria palpitation of the heart or any of her former nervous sensations. She can eat without selection, and her bowels are perfectly regular; and we may now add, that she has borne two children since. CASE III. I was requested to visit Mrs. P., who was repre- sented to be suffering very much from an habitual colic. Not being well, my friend, Dr. Knight, kindly visited her for me, and prescribed a dose of laudanum, &c., which procured her a tolera- bly good night's rest. I saw her the next morning, and found her labouring under the distressing after-effects of the laudanum, but comparatively easy. She gave the following history of her complaint. She was attacked about twelve years before with a pain in her left side, which was occasionally so severe as to pro- duce hysteria, and other disagreeable nervous affections. The pain was not augmented by 'pressure, cough, or respiration. She would swell sometimes very suddenly, and when this happened the pain was increased. She was much incommoded by exercise, or much standing, and if either were continued too long, it would occasion faintness, and a great deal of pain. When this took place, she would be obliged to go to bed, take laudanum, and be unable to rise for several days. She had leucorrhoea to a great extent was much debilitated extremely pale her appetite feeble and her digestion bad. She was much afflicted with headache, and pain in her back also with a severe numbness down the thighs, after standing awhile upon her feet. She had tried a great many remedies for the period above stated, and she considered herself growing worse daily. PROLAPSUS OF THE UTERUS. 229 Suspecting a prolapsus of the uterus to be the cause of her complaints, I proposed to ascertain it, to which she readily con- sented. The uterus was found very low ; the os uteri could be felt just within the labia. I procured a pessary, and introduced it immediately, without any previous preparation, as she was obliged to go to New York, her place of abode, the next day. She was instantly relieved by the pessary; and declared herself, in five minutes after its application, to be perfectly free from all pain and inconvenience, and is now in perfect health. CASE IV. Mrs. L., a very delicate woman, aged twenty-eight, after a premature labour, attended with a great expenditure of blood, was attacked with a severe cough, which seemed to threaten phthisis. She was, however, relieved of the cough, by a persevering use of remedies, and change of air ; but there re- mained a fixed pain in the left side ; a sense of bearing down in the pelvis, and a strong desire to make water, whenever she stood upon her feet. I was convinced she laboured under a pro- lapsus, and mentioned this opinion to her friends. She would not, however, submit to having it tested, but permitted an old nurse to prescribe leeching to her side, followed by blistering: as she experienced no advantage from these remedies, she was at length prevailed upon to allow an examination per vaginam. I was accordingly requested to visit her again, and to make the proposed search this proved the uterus prolapsed. After due preparation, as above suggested, I applied a pessary, and she was immediately relieved, and continues well to this moment. These cases most satisfactorily prove that the consequences of a prolapsed uterus are sometimes more extensive and severe than have hitherto been suspected; and also teach us, under circumstances like those detailed above, to make the necessary inquiries into the condition of the uterus. I will not pretend to account for the pain in the left side when it occurs there, for it is not invariably the seat of this sympathetic affection, though certainly the most frequent : it has prevailed in four consecutive cases ; but these should not by any means be considered as suf- ficient to establish a rule. 1 Since the above cases were published, a number of similar ones have occurred, of greater or less severity, all of which have been relieved by the same means. In one instance, a complete retention of urine attended; and so permanent was it, and so often repeated, that the husband was under the necessity of learning the mode of introducing the catheter, that he might give immediate assistance. The relief afforded by the pessary was instantaneous and effectual. 1 I think it probable, that the seat of the painful affection of the left side is in the spleen ; as this viscus is known to sympathize largely with the uterus. 230 PROLAPSUS OF THE UTERUS. The circular form of the pessary I employ I find answers per- fectly well, as regards its mechanical properties; it does not press too violently upon the neck of the bladder, or rectum. All that is essential to be observed, is its size ; it should be neither too large, nor too small. Many have preferred the oval pessary : thinking it allowed more room for the neck of the bladder, and: for the occasional distention of the rectum. But as we have never witnessed any advantage to arise from this shape, as re- gards the objects just stated; and as the small ends of the oval instrument are more easily acted upon than the circular, and in consequence more easily displaced, we give, after many trials, the preference to the circular form. Gardien says, "Le pes- saire de forme ronde est plus facile a placer : il est en outre moins sujet & sortir," p. 183. Gardien speaks of replacing the uterus in the first and second degree, by means of the finger introduced into the vagina, and pushing up this organ ; and then confining the woman for some time to a horizontal position ; and after all fear of inflammation has passed, to throw up cold astringent injections into the va- gina; and lays some stress upon the efficacy of sulphur waters for this purpose. Of this plan we can say nothing satisfactory from our own experience; it may succeed in certain recent cases, but must be totally inadequate to relieve a prolapsus of long standing. He objects to the use of pessaries, until every other means has been tried; and appears to entertain many apprehensions of the action of these instruments, which we are certain, from long experience, are ill-founded, provided they are properly constructed, judi- ciously used, and not employed when it is an. "irritable womb" that is down. See art. "Of the Irritable Uterus." In some eases, a subsequent pregnancy and delivery have cured a moderate prolapsus. .We have, in a number of instances, recommended this mode of cure, and sometimes it has succeeded perfectly. To succeed by this plan, however, requires a long perseverance; to which patients, in general, will not submit, how- ever strongly we may urge its importance. This method re- quires an almost exclusive confinement to a horizontal position after delivery, for six or eight weeks, (Gardien says four or five ; but we have never seen so short a confinement succeed.) The woman must be careful how she passes her water, or voids per anum; that is, she must not strain or make strong efforts for these purposes. .*" CHRONIC INVERSION OF THE UTERUS. 231 SECT. II. Of the Chronic Inversion of the Uterus. 1 We shall, in the present work, confine ourselves to treating of the Chronic Inversion of the Uterus; or that condition in which it remains after its complete inversion, where it was impossible to restore it, and where the woman has escaped the dangers which the acute or immediate inversion threatened her. We omit here the antecedent condition, together with its mode of treatment, be- cause it seems to belong exclusively to a system of midwifery. The consequences resulting from the complete inversion of the uterus are by no means trifling, should the woman even escape with life. She will necessarily remain for a long time weak, not only from what she had suffered from pain, but also from the loss of blood which attended the acute stage of the inversion. She will be liable, for a long time, to a sanguineous discharge from the surface of the uterus, as well as to a leucorrhoeal one from the vagina. In consequence of which she may become hectical, and die from exhaustion. Great care is required on the part of the woman, that she may not even suffer much, from the neglect of cleanliness. 2 It will be seen, by referring to case second, 3 that the catame- nial discharge may continue with perfect regularity for some time. It will then cease, most probably, from the influence of the external air upon the body and fundus of the inverted organ, by altering the arrangement of its secreting surface. Astringent injections have been recommended, and they have been found useful ; more, perhaps, from deterging the parts, than from any other influence. They should, however, always be employed; or at least injections of some kind should be regularly persevered in, so long as the discharge continues to be too abun- dant from the vagina. One remarkable circumstance attends the inversion of the ute- rus, which is, that it disqualifies the woman for conception, at 1 1 have confined myself, in this place, as hinted before, to the chronic condi- tion of the uterus after inversion ; having, in my System of Midwifery, treated at large upon the acute or recent inversion. * We were lately called in consultation to a recent case of " Inversion." The sufferings of the patient had been great, and the hemorrhagy exhausting. Upon examination, the inversion was found to be complete, and the flooding much abated, though the discharge was still considerable. Rest, nourishing diet, astringent in- jections, the extract of rhatany, &c., were prescribed with considerable advantage, for a time; but about every two or three weeks there would be a return of he- morrhagy, which would continue with more or less violence for several days. In this way, things went on for about five months, by which time the patient became so reduced, that it was resolved, in consultation, that the uterus should be re- moved by ligature, as the only chance for life but the patient died before the operation could be performed. ' See System of Midwifery, p. 516. 232 CHRONIC INVERSION OF THE UTERUS. least for a uterine one ; if she be able to conceive at all. This, however, appears to be as it ought; and must be considered as an act of great beneficence on the part of the Creator: for, did the woman conceive, to what misery would she be doomed at its completion? I know of no instance, where impregnation has taken place after an inversion of the uterus. Gardien observes, "Les femmes dont la matrice n'a pas ete reduite dans les premiers temps sont probablement inhabiles a la conception : cependant, une observation communique^ au Profes- seur Baudelocque par M. Chevreul, m6d6cin d' Angers, semble- rait indiquer que la conception peut encore, s'operer dans 1'une des trompes dont les extremit6s uterines s'ouvrent dans le va- gin." Vol. iii. p. 312. This observation is so unsatisfactory, for want of detail, that it would not be safe to consider it, even as his opinion, that it was an instance of conception, after the inversion of the uterus. Besides, he has not indicated from whence he derived the case, that more light might be received on this point. 1 A woman who has an unreduced uterus does not necessarily die suddenly, or even eventually, from this cause ; since a few rare cases are upon record, where, after such an event, they have enjoyed for some time a tolerable share of health: this was the case with Mrs. P., in case second, before referred to; the only one which has occurred in my practice of an unre- stored uterus after an inversion. 2 I have seen altogether but eight cases ; three of which were fatal ; two, to this moment re- main inverted ; and the three others were reduced pretty soon after the accident. The fatal termination of this disease, in a vast majority of cases, seems, however, to be rather the result of improper treat- ment, than the necessary consequence of the accident itself. From what we have seen of this complaint, we are certain that much is in the power of a well instructed practitioner, to prevent a fatal, or even a hazardous termination : for the disease, we re- peat, is by no means necessarily fatal. 3 Experience sufficiently proves, that in by far the greater num- 1 It is much to be regretted, that we have not a more satisfactory account of this case, than the one given by Gardien; for if it be as is stated, it is of much physiological consequence; inasmuch as it settles, beyond dispute, that the direct conveyance of the semen through the os uteri is not the mode by which impreg- nation takes place. But I do not feel myself disposed to take advantage of a statement so general as the above certainly is, to enforce what I have so fre- quently urged against the doctrine of the direct conveyance of the semen, and thus indirectly strengthen speculation on the subject. ' Since the above was written, I have met with another instance of complete inversion, and which has now become chronic. See System of Midwifery, art. Inversion of the Uterus, p. 464. * Ruysch, however, says, " If this accident be not immediately remedied, death presently follows." Obs. X. CHRONIC INVERSION OF THE UTERUS. 233 her of instances, the uterus may be restored, if the proper mo- ment be seized, and the operation be properly conducted; for certain it is, that the complete inversion rarely takes place at once, unless it be from some improper manceuvre executed upon the placenta ; a circumstance which cannot well happen in the hands of a judicious practitioner. Though we must admit that the inversion may happen in the hands of the best instructed, and most careful person, as he cannot foresee, nor always pre- vent that condition of the uterus which gives rise to it ; yet the accident, and its fatal consequences, will be comparatively rare with him. And when it does occur in such hands, it will almost always be a manageable disease, as it will be discovered, before the func^us and body have entirely escaped through the os uteri, to constitute the complete inversion; in which case it will be rarely otherwise than reducible. And when not reducible, though the inversion be not com- plete, as will occasionally happen, immediate death may perhaps be prevented, by making it complete. See System of Midwifery, p. 464, 3d edit. When the inversion has not been, or cannot be reduced, the woman may die suddenly, or in a short time, from the profuse- ness of the discharge ; or she may linger out a miserable existence for years. Sufferings, both severe and long-continued, await the woman who has an unreduced uterus ; her life is that of misery and wretchedness : and these augment in proportion to her inca- pacity to support them. Under such circumstances, it is justi- fiable to attempt almost any thing which would promise relief. Hence, it has been proposed to remove the pendant uterus by excision or by ligature. The extirpation of the uterus is not a novel proposition ; it has been frequently performed, and with, perhaps, a fair proportion of success; at least as far as can be determined by the histories of cases purporting to be of this kind. For the inverted uterus, and a polypus of this organ, may readily be confounded, and the mistake, either way, may give rise to very different results. The diagnostics of the inverted uterus, and a polypus of this organ, as laid down by writers, are both vague and discrepant. This has created no small embarrassment and uncertainty in the surgeon, who is about to undertake the removal of the tumour occupying the vagina; since he cannot satisfy himself of the real nature of the disease he has to contend with. Mr. Newnham appears to have felt all this uncertainty in its fullest force, when he was about to apply the ligature upon the uterus, and he makes this uncertainty the basis of his essay upon "inversio uteri." To aid his judgment in this interesting and perplexing case, he laboriously consulted almost all the author!- * 234 CHRONIC INVERSION OF THE UTERUS. ties extant ; and, after carefully collating their opinions, he re- duces them to the following summary. " It is generally remarked, that inversio uteri may be distin- guished from polypus of that organ by the os uteri not encircling the former tumour in cases of complete inversion : and by the im- possibility of passing the finger around the neck of the tumour, be- tween it and the os uteri, where the inversion has been only partial; by the form of the tumour, the polypus being broad at its base, and attached by a narrow peduncle, while the inverted uterus is broader above than below; 1 by the insensibility of the tumour in the one case, and by its extreme sensibility in the other ; by the comparative fixity of the one tumour, and the extensive sphere of motion of the other; by the rough and fungous surface of inver- sion, contrasted with the smooth and polished surface of polypus ; and by the previous history of the patient's disease." "But it is clear, that these diagnostics are liable to a great degree of uncertainty," as he proves by most ample quotations. Mr. Newnham has collected, as we have remarked, with great industry, nearly all that has been said upon the diagnostics of these two complaints ; and, from all that can be learned from these various sources, a conclusion must be drawn, that there are none which are absolutely certain. Mr. N. says, " On reviewing the foregoing testimonies, we shall be induced to conclude, that it is always difficult and sometimes impossible, with our present knowledge, to distinguish partial and chronic inversion of the uterus from polypus : since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be readily passed around it. And if, in order to remove this uncertainty, the whole hand be introduced into the vagina, so as to allow the fingers to pass by the side of the tu- mour, to the extremity of the space remaining between it and the os uteri; and if we find that the finger soon arrives at this point, it will be impossible to ascertain whether it rests against a por- tion of the uterus, which has been inverted in the usual way, or by the long -continued dragging of polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its enlarged base and narrow peduncle, we must also recollect the abun- dant evidence to prove, that the neck of such a tumour is often 1 We are a little surprised at this last distinction; for certain it is, we have never witnessed an instance " of the inverted uterus " being " broader above than below;" nor can we imagine how this can exist. We are every way sure, that the same relative proportions exist between the fundus and body, and that of the neck in both the natural and inverted conditions of this organ; consequently, the mark mentioned by Mr. N. cannot be present, but by some unusual arrangement ; and, of course, must not be considered as a diagnostic. CHRONIC INVERSION OF THE UTERUS. 235 as large, and sometimes larger, than its inferior extremity ; and we shall still be left in an inexplicable difficulty," p. 82. "But shall we not find some more infallible guide in those other characteristics which have been given as certain diagnostics ? " On the contrary, we shall always find it difficult to distinguish between the sensibility of the tumour, and sensation occurring in neighbouring viscera, which are irritated by the process of ex- amination, while, too, it must be remembered, that the sensibi- lity of the inverted uterus is greatly diminished in its chronic stage, and that the sensibility of polypus may be increased by the presence of inflammatory action ; we shall ascertain that the degree of apparent fixedness of the tumour will depend upon the extent of its attachment to the uterus, consequently, the polypus, with a considerable stem, will be fully equal, if not greater, than in the inversion of the uterus, the size of which has been diminished by time, and the action of the absorbents : that in either case, and interchangeably, according to the different periods and circumstances of the disease, the surface of the tu- mour may be either smooth and polished, or present a rough and fungous feel ; and that, with respect to the previous history of the case, it is embarrassed by the fact that polypi have been produced in the uterus, arid have only first passed into the vagina, im- mediately after the expulsion of the foetus, or of the placenta. In the case of recent inversion, the combination of some of these diagnostics may enable us to decide with accuracy on the nature of the case ; but they are insufficient to guide our judgment, when we are first called to give our opinion on the disease in its chronic stage," p. 83. The case which gave rise to the above conclusions proved to be an inverted uterus ; it was successfully removed by the liga- ture; and the woman was restored by the operation to perfect health, and without the loss of those feelings which it is thought have their origin in the ovaria; it was therefore presumed, that these bodies were not removed with the uterus ; neither did they appear to be attached to the removed portion of the uterus. The mode of applying the ligature is not described by Mr. N.; but we presume it is precisely the same as that recommended by Mr. Clarke for the removal of a polypus. See Chapter on Polypus. 236 DISORDERS AND DISEASES OF THE UTERUS. . n , CHAPTER XIV. OF THE DISEASES OF THE UTERUS, OVARIA, AND TUBES. THE whole of the internal organs of generation are liable to diseases, the most of which may be considered as incurable. To describe minutely the whole that are known would, of itself, re- quire a volume ; and, if this were done, we might be disposed, in many instances, to inquire for the cui bono, as regards the suc- cess of medical treatment. Such of the diseases of this system as consist in sensible alte- rations of structure, may be considered as arising from inflamma- tion of one or more of the tissues composing these organs ; or from the formation of tumours which have originated in inflammation, either acute or chronic, the existence of which was not betrayed by any cognizable symptom in its incipient state ; or into such as may have had that peculiar beginning, which, by the application of sufficiently powerful exciting causes, may give rise to malig- nant developments that may prove destructive to the different surrounding structures. SECT. I. Of the Disorders and Diseases of the Uterus. The affections of the uterus may be classed under the follow- ing general heads ; and were we disposed to enumerate every departure from a healthy condition we might make very many subdivisions, without adding to either perspicuity or to useful- ness : 1. Imperfections in structure. 2. Variations and changes of structure. 3. Diseases of its external and internal surfaces. 4. Diseases of its neck. 1st. Under this head we may reckon, a. When this organ is larger, or. smaller, than natural. b. Where the neck is altogether wanting. 2d. Under this head may be comprised, a. Extreme smallness of this organ. b. Where this organ is double, or is divided into two com- partments. c. Where this body is cartilaginous, or scirrhous. 3d. Under this head may be classed, a. Tumours of various kinds. b. Abscesses. DISEASES OF THE OVARIES. c. Ulcerations. d. Cancer. e. Tubercular, cpongy, or polypous excrescences. /. Hydatids. g. Cauliflower excrescences. 4th. Under this head may be included, a. Cartilaginous rings of the os uteri. 6. Its complete occlusion, from 1. Excrescences filling it up. 2. Stones obstructing it. 3. Membranes forming within it, and from membranes passing over it. 4. Scirrhous tumours. SECT. II. Of the, Diseases of the Ovaries. These bodies are more frequently diseased or disordered than the uterus itself; but neither the diseases, nor disorders to which they are liable, are of such dangerous consequence. They are, however, for the most part, more occult than the other diseases of the genital system, if we except those of the tubes. Hitherto no remedy has been discovered, that has a decided operation on these bodies ; consequently, they are very little under the control of remedies whose operations are felt upon the general system, or of those which may exert an influence on certain portions of it. It is probable, that during an active state of disease, as in- flammation, the usual remedies for fever or inflammation, may be availing, as bleeding, purging, low diet, blistering, &c.; but here, perhaps, the power of the materia medica ceases : for no one in- stance, with which we are acquainted, would lead us to the con- clusion, that any remedy has removed a disordered condition of these parts. They seem to be removed so far from the general sympathies of the system ; so insulated in position ; so independent in func- tion; that the common agents for-the removal or control of dis- ease, seem to waste themselves in unavailing attempts to influence their actions, or to modify their affections. Who flatters himself that he has removed a dropsy ; resolved a scirrhus ; or inter- rupted a suppuration in these bodies ? We believe, if he be can- did, none will declare he has. Little more then is ascertained, at present, than that these parts are very liable to disease, and but very little susceptible of cure. But, must we so humble the powers of the healing art, as to declare we never shall be master of these diseases? Certainly not. Advances are constantly making towards the improvement of this branch of science, though its perfection must necessarily be remote ; still, from time 238 DISEASES OF THE TUBES. to time, we become acquainted with substances, which have a specific action upon certain tissues of the human body. The time may arrive, when we will be in possession of a substance, the action of which shall be confined to the ovaries alone, or to simi- lar organizations, if any such there be, in other portions of the system. But until then, unfortunately, the victims to affections of these important parts must remain contented with the solace which palliatives afford. The affections of these organs may be classed as follows : 1. Scirrhous, or other derangements of organic structure. 2. The entire absence of the organ or organs ; if a negative may be assumed for a positive condition. 3. Contracted, dry, shrivelled. 4. Enormous distention of them; from pus, water, fat, &c. 5. Containing extraneous substances ; as hair, bones, teeth, &c. These conditions of the ovaries are far from being very rare ; Morgagni alone, from his own observations, furnishes a number of instances of them ; many others, who have been attentive to morbid anatomy, have done the same. For, unfortunately, they have much more frequently furnished subjects for the anatomist's knife, than triumphs of the physician's skill. Dr. Robert Lee relates the following cases, and shows to what extent the distention may go, and the mischief it may create. "In a case," says he, "under my own observation, (in the in- firmary of Marylebone,) an ovarian cyst became impacted between the bladder and rectum, producing all the symptoms of a stricture of the rectum. In a lady now under our care, the presence of an ovarium or uterine tumour in the pelvis, which presses upon the neck of the bladder, renders it impossible for the bladder to be emptied without the introduction of the catheter." Cyclop, of Pract. Med. Art. Ovaria, p. 229. SECT. III. Of the Diseases of the Tubes. The alterations in structure, which these bodies undergo, are different from those to which the ovaria may be liable. There is rarely any other change in these bodies than that which inflam- mation produces, 1 and they chiefly consist, 1. In the obliteration of their canals; or of one of them. 2. In adhesions with the ovaria, by means of their firnbriated extremities. 3. Sometimes, in a great distention of one of them, from the partial development of an ovum. 'They are, however, said sometimes to be involved, as also the ovaria, in can- cer of the uterus. DISEASES OF THE TUBES. The diseases of the tubes, like those of the ovaries, seem to be but little known at the moment at which we might anticipate success from treatment, namely, during the active stage of the complaint. That these bodies are much more frequently inflamed than is generally imagined, we should infer from the number of instances of derangement of structure which dissection brings to light. Yet we are of opinion, that few practitioners have ever admitted to themselves that they were directing their remedial views to an inflammation of one or both of these bodies. We have every thing yet to learn, as regards the diagnostics of the diseased tubes ; for to this moment we are altogether unacquainted with the portions of the body with which they sympathize, or what parts they call into sympathy. We have, in a number of instances, prescribed for a deep-seated pain in the situation we might suppose the .tube to be ; that is, a little to the right or to the left of the symphysis pubis, but posteriorly. If the part be pressed upon pretty firmly, some pain will be felt ; and upon turn- ing suddenly in bed, will be sometimes severely acute. There is constantly present, an aching, obtuse pain, and every now and then a lancinating one. There is a frequent desire to pass water ; and the water is scantily secreted : after passing it, a pain is felt at the neck of the bladder ; the urine is high-coloured, and of a strong alkaline smell. The stomach is occasionally sick, and easily provoked to vomit, if offended by medicine or food. The patient is easier on her back than side; but altogether unable to sit up without great agony. Efforts to vomit are attended by severe pain ; and going to stool is also attended by like inconvenience. The heat of the skin of the arms and hands, is below the natural standard; but other portions of the body are hotter than natural. The tongue furred; and a constant disagreeable taste in the mouth. The pulse rather quick, tense, and wiry. No disposition to moisture, though occasionally, without knowing why, a profuse perspiration breaks out, but without tarrying long or affording relief. The pain is sure to be aggravated at night ; so much so, some- times, as to prevent the patient from sleeping, unless under the influence of strong doses of opium; and these are not always found successful in destroying the severity of suffering. I have witnessed this pain on both sides of the pelvis at the same time; but more frequently only on one. In all the instances I have seen of this affection, there was an irregularity of the menses, and sometimes a total suppression of them. I have known the pain to continue from two weeks to three months, notwith- standing the most active plans were pursued ; such as bleeding, leeching, cupping, blistering, purging, rubefacients, &c. In one instance of unusual severity and pertinacity, after the disease had lost its acute form, it was removed in a short time by the volatile 240 PARTICULAR DISEASES OF THE UTERUS. tincture of guaiacum. Before this remedy was employed, the complaint had abated much of its severity; though the patient suffered considerably at the time it was commenced. I am, however, by no means certain, that the disease now de- scribed, was an inflamed tube or tubes ; but think it probable. That it was a disease of some one of the female organs of genera- tion, I am pretty firmly convinced, as I never met with a similar affection in the male. CHAPTER XV. OF THE PARTICULAR DISEASES OF THE UTERUS. Under this head I shall consider only such affections as attack the substance of this organ ; and shall confine myself at present to carcinoma, and a few other diseases of this part. The many complaints to which this organ is liable, and with which every practitioner should be familiar, renders it necessary to give a full consideration te some of them, while others, from their incurable nature, will require little more than their history ; as the method of cure is unknown to us at present. Thus, it would be proper to dwell upon all the derangements of menstruation, menorrhagia, leucorrhoea, prolapsus, retrover- sion, inversion, &c, ; while a short account of the carcinoma, cau- liflower excrescence, corroding ulcer, &c., will be sufficient, as we are unfortunately acquainted with little more than their ravages. The diseases about to be considered are not very common in this country; at least, they would appear to be less frequent here than in Europe : nor is this, perhaps, of very difficult expla- nation. It seems to follow, as a natural consequence, that that part of the body which receives the most injury from mechanical or other violence, will be the most liable to disease ; but whether these violences be capable of themselves of producing an original complaint, like carcinoma, &c., or only act as exciting causes upon certain predispositions, remains to be determined. We are of opinion, that no part however injured will suffer cancer, unless that part is predisposed to it; as it requires, it seems to me, a certain condition of the part before it takes on the cancerous action, and that predisposition may lie dormant until such lesion or injury is done to it, as shall excite inflammation in it ; and if the disposition to cancer be inflammation or ulcera- PARTICULAR, DISEASES OF THE UTERUS. 241 tion, it will run on to one or other, if not checked by suitable means, and it will terminate in cancer; but not otherwise. The inflammation is sui generis, and must have its appropriate agent. Common inflammation may be successfully combated by com- mon means ; but not so the inflammation of cancer. Hence, we see inflammation of a gland or glandular part treated safely and happily, unless there be a disposition to cancer, but if that exist, the consequences are always to be dreaded. Hence, many can- cers are attributed to a very slight degree of violence in the mamma, especially in a breast so disposed ; but double the force or injury to the breast disposed to cancer, will prove, perhaps, fatal ; thus we find scirrhus generally forerunning cancer, which latter tendency may lay dormant for many years, and perhaps always, if not called by accident into action. Therefore, the distinction of some of the French writers has no foundation, namely, "ulcer and ulcerated cancers;" the former intended to signify those cases where the ulceration is the primary affection, and the morbid disposition but secondary; whilst in the latter case, the scirrhus precedes the ulceration. I believe, in all cases of genuine cancer, a state of scirrhus precedes the ulceration, and never attacks any but glandular parts. Dr. Churchill says, " It is indisputable that in other parts of the body, the ulceration may occasionally precede the cancerous disposition." Churchill on the Principal Diseases of Females, p. 172. Although this is said with great apparent sincerity, yet it forces no conviction on my mind. In this it is similar to scrofulus. It has been attributed to chronic inflammation by Broussais; by Copland and Andral, an altered nutrition, &c., all of which goes to prove that we know nothing about it. Churchill, ib. All parts of the uterus are liable to it, but some parts appear to be more so than others, as the neck of the ute- rus, and all the difference in phenomena is only owing to the seat, or degree of development of the morbid structure. It is said, on the authority of Dr. Copland, that "the fluid from cancer slightly effervesces with sulphuric acid, and turns the syrup of violets green." Pract. of Med. p. 285. Nor will the development of its intimate structure or any che- mical analysis serve to explain its origin. After all the glands are destroyed, the other vessels in the neighbourhood seem to take on a healthy action or inflammation as the surrounding parts will be agglutinated, which would not be the case, did the cancerous disposition obtain in all of them. We believe these injuries, however, may be capable of doing both the one and the other ; but the character of the diseases produced under these different circumstances, will be very diffe- rent. Thus, tumours, or other indurations of the uterus, pass 16 ^ 242 CARCINOMA UTERI. too commonly under one common name, as scirrhi; but without scirrhus being the disease. While, on the other hand, when a predisposition to cancer exists, the true scirrhus, or carcinoma, may be formed by local injuries ; or, if formed, they may make cancer declare itself. Now, as it is a fact, sufficiently well established, that tedious, laborious, or impracticable labours are very much more common in Europe than in this country, it will necessarily follow, that the uterus of the European woman is, in the same proportion, exposed to injuries from this cause ; consequently, if the predis- position be admitted to be equal to the women of both countries, the exciting cause will be more rarely applied in the one instance than the other ; and hence, fewer instances of cancer uteri in the one case than in the other. SECT. I. Of the Carcinoma Uteri. Our opportunities of seeing this disease, as well as that of the corroding ulcer of the uterus, have not been sufficiently ample, to make us rely altogether upon our own observations, for their history, appearances, or mode of treatment. We shall, there- fore, mainly depend upon the descriptions given by Mr. Clarke, in his excellent work upon the diseases of females, as they en- tirely agree with our own experience. Mr. Clarke observes, that cases of carcinoma uteri 1 are fre- quently met with in practice, but that very young women are seldom attacked; women of middle age are much more liable to it. It rarely commences with violence ; but like carcinoma in other parts of the body, becomes, as it proceeds, more and more distressing. It attacks at first only the neck of the uterus ; and Mr. Clarke lays great stress upon this observation. For tumours of this or- gan elsewhere situated are of a different character ; having dif- ferent symptoms and terminations. 2 In the dead body, they have * " By carcinoma uteri is meant that disease where there is a tumour near to, or a thickening of the cervix of the uterus, which tumour or thickening is dis- posed to ulcerate." Diseases of Females, p. 207. Am. Ed. 1 Dr. Mackintosh gives an account of a tumour of the uterus, and which he calls a " vascular sarcoma" of this organ, which, upon weighing after death, was found to amount to more than fifty pounds avoirdupois. He observes, "This is, perhaps, the most extreme instance upon record, particularly in which life was preserved so long under such circumstances, as the tumour not only filled the ab- domen, but pushed the diaphragm so high, that it encroached upon the thorax, and lay over the heart and lungs, so as to conceal the respiratory sound over the whole anterior part of the chest." " On cutting into a uterus affected with vas- cular sarcoma, there is observed not only a resemblance to the natural structure, but a- absence of those lines which characterize scirrhus." Mackintosh's Prac- tice of Physic, Vol. II., p. 314. CARCINOMA UTERI. 243 some resemblance to carcinoma, but they are never found ulce- rated. Carcinoma particularly affects glandular parts; hence, its at- tack of the neck of the uterus. Tumours of a large size have frequently been called scirrhi, because they are hard in their texture : but the true carcinoma seldom become very large. 1 A sense of weight is felt in the vagina ; a discharge of mucus sometimes tinged with blood, or sometimes pure blood, after ex- ercise, comes away, and this in sufficient quantity at times to weaken even to fainting. Menstruation, if it have not ceased, becomes irregular, and more abundant than ordinary. Strangury almost always attends ; the inner membrane of the bladder secretes a transparent mucus, which falls to the bottom of the urinal. Pain, like the passage of a calculus from the kid- ney to the bladder is felt, and urticaria, heartburn, &c., attend. Care must be taken that these various affections of the sto- mach be not mistaken for the disease ; as they are only symp- tomatic of the condition of the uterus they augment as the dis- ease advances, and much mischief would ensue, if they were treated as original diseases. An examination per vaginam should always be requested. If the disease be carcinoma, the cervix of the uterus will be found thickened, and resisting like gristle ; or a distinct tumour will be perceived on some part of the neck of the uterus ; the other portions remaining healthy. In either case, pressure produces a lancinating pain.* 1 Dr. Homer and myself attended a lady with carcinoma, complicated with a polypus nearly the size of a hen's egg, which masked in great measure the condi- tion of the neck of the uterus until it was removed by ligature. After the re- moval of the polypus, the neck of the uterus was found to be ulcerated to a con- siderable extent; indeed, all round, with the exception of the spot to which the pedicle of the polypus was attached. The patient for some time remained very weak from the excess of discharges: they, however, diminished, and the ulcera- tion of the neck of the uterus was reduced to a surface not exceeding the size of a ten cent piece; the discharge from the vagina was scarcely any, and of a healthy appearance; strength was rapidly returning; in a word, every thing gave pro- mise of a recovery. But unfortunately, the patient, a little careless when about to sit down, fell with considerable force upon her seat, which gave her great pain, hemorrhage to some extent followed, by which she was very much reduced, and eventually died from exhaustion. * It is now well ascertained, that there are many affections of the neck of the uterus that are not eardiiomatous. We have seen a number of this kind ; a kind that at first alarmed us much; but which, by a proper mode of treatment, yielded eventually, if not suddenly, to our remedies. The remedies which are proper to the treatment of incipient carcinoma, are precisely such as will prove beneficial in the various intumescences of the neck of the uterus but especially, local bleed- ing, severe diet, and absolute rest. Leeching, immediately from the uterus, is incomparably better than more remote leeching; and notwithstanding the great aversion our American ladies have to this mode of depletion, we are happy to say, we have, in a number of instances, been able to overcome this reluctance, from 244 TREATMENT OF CARCINOMA UTERI. The os uteri will be found changed. It becomes larger, though it retains its shape it will sometimes admit the extremity of the finger. Patients rarely die during the carcinomatous state of .the disease; when they do, it is in consequence of frequent he- morrhagies. Clarke on Female Diseases. SECT. II. Of the Treatment of Carcinoma Uteri. , ' -U.-y-r /V.f '"*' M-'*W ; '"V'".-' ; It seems to be a doubtful point, by those best acquainted with this complaint, whether a cure, or mere suspension of the disease has ever been effected. Mr. Clarke, with all that caution which characterizes the honest practitioner, thinks he has cured this affection in its incipient state, though he dare not absolutely avow it. We feel ourselves precisely in the same predicament we have had two cases very similar to those described by Mr. Clarke; 1 in both of which there was a restoration of the neck of the uterus to its natural size, with an entire cessation of all the previous distressing symptoms ; these may not have been genuine cases of carcinoma, though we believe they were. which they have derived the most prompt and satisfactory advantage. One lady, who had numerous tumours about the neck and pelvic portion of the body, wag entirely relieved of them by persevering in the use of the ext. conii; she began with a grain three times a day, and gradually increased it until it amounted to one ounce, and one ounce and a drachm per day. 1 Since this time, two other similar cases have presented themselves, both of which have been entirely relieved. One of these cases presents so much interest that I shall briefly relate it. Mrs. has suffered, for seven or eight years, constant pain in the pelvis, which at times becomes highly aggravated, especially during the menstrual period. This discharge is sparing, very dark-coloured, and irregular. There is some leucorrhosa, which is rather offensive, if the utmost care be not paid to cleanliness. The pain during the menstrual flow is extreme, and almost always attended by strong hysterical paroxysms; strength impaired, appe- tite feeble and whimsical; feet swollen, but not excessively; very pale, and eye- lids tumid in the morning; pulse corded and irritated. The case has been treated as one of difficult menstruation; all remedies, so far, have rather tended to increase her sufferings. An examination, per vaginam, discovers the uterus enlarged, its neck much swollen, a number of small hard tumours placed up it, and as much of the body of this organ as can be felt in the vagina. The uterus precipitated so much as to rest upon the face of the perineum the whole space left in the vagina will not exceed that of a small wine glass. The vaginal parietes dense, and un- yielding the whole of the parts that can be touched with the finger exceedingly painful, especially the neck of the uterus. Coition impracticable, or nearly so. The subject is young, that is, twenty-six years of age; has been married eight or nine years, but never has conceived. Rest upon the bed almost absolute regimen strictly antiphlogistic leeches to thigh every three weeks purge every other day with jalap and cream of tartar live absque marito warm water injections per vaginam three times a day. This plan, with very trifling variations, was continued for thirteen months; the parts by this time were restored to their natural condition, as regards feeling and form. Suffers no inconvenience from matrimonial intercourse : catamenia re- gular, and sufficiently abundant. This improved condition has continued now for fourteen months without interruption in a word, the patient considers herself perfectly restored to health. 4 TREATMENT OF CARCINOMA UTERI. 245 Nor do we see any thing very irreconcilable in the case ; for if proper means be duly employed, they will almost surely be attended with advantage, if without absolute success ; and if the ulcerative process be prevented, or even retarded, which we are disposed to believe will often happen, very much is gained. In- deed, it is very well known that this disease is held long in sub- jection by the continuance of the menstrual discharge, and a temperate mode of living. And from this very circumstance a valuable practical hint may be taken, in the management of this disease. The first object, in the treatment of carcinoma uteri, is to pre- vent ulceration from taking place ; this is to be done by the re- duction of the local inflammation, (which is essential to the dis- ease,) by such means as are best calculated to diminish the quan- tity of circulating blood, and to abate arterial action. These ends will be found best answered by 1st. Blood-letting, both general and locaL 2d. By purging. 3d. By an abstemious diet. 4th. By cleanliness. 5tL By rest. 1. Abstracting Blood, We believe that an increased pulse always attends this disease, when it declares itself by pain in the lower region of the uterus, and an increase of the vaginal discharge. If the arterial system be not found at such times absolutely preternaturally increased, it is sure to be most easily excited. On this account, the ab- straction of a few ounces of blood becomes highly important from time to time; but if the catamenia have ceased, it becomes absolutely necessary. This may be taken from the arm, when considerable arterial excitement is present; and, so far as we have witnessed, it has been found with considerable buff, or even cupped. If there be less excitement, and particularly if there be a se- vere throbbing pain just above the sacrum, much immediate re- lief is found from losing six or eight ounces of blood by either cupping or leeching. We have found it necessary to have this operation repeated, sometimes every three or four weeks. We are generally directed to abstract blood from such patients as may be plethoric ; this is certainly a proper direction, so far as it goes but no farther; for it seems to forbid this operation, when this state of fulness is not manifestly present : now, were this operation to be withheld for the want of this evidence, we should very often deprive the patient of the best means of relief, TREATMENT OF CARCINOMA UTERI. though that relief may be but temporary. We have constantly found, when pain was severe, the pulse frequent and tense, or wiry; (for so it will almost always be found in these cases,) the skin hot, and sleep uncertain, that the abstraction of a few ounces of blood would afford not only considerable relief, but would place the system in a better condition for narcotics, so indispen- sable in such cases. Besides, it seems to lessen the hemorrhagic tendency of the uterus ; and thus abates the discharge of blood, which might otherwise be too abundant. We generally prefer local bleeding, when it can conveniently be had recourse to ; as its effects are more decided, and diminishes the strength less. But we have no experience ourselves to authorize us to decide whether it will be best abstracted from the back or abdomen. 1 Mr. Clarke says, " The relief produced by topical blood-letting is great, and often immediately felt : blood is generally procured more easily, when the cupping-glasses are applied to the back, than when they are placed upon the abdomen. Nevertheless, when blood can be procured in sufficient quantity from the lower part of the abdomen, it will be proper to direct that it should be so taken, especially when cupping on the back has failed to produce the expected advantage," p. 266, Vol. I. Leeches, applied to the vulva, have had, we think, a more prompt effect than when ap- plied to the back; and we are informed by Guilbert and Du- parcque, that when applied early to the neck of the uterus itself, that leeching is still more useful: this assurance not only applies to the early stages of the disease under consideration, but in an especial manner to the chronic phlegmasise of the uterus, when attended with an engorged condition of its neck. The efficacy can be easily believed ; but, to get our fair countrywomen to submit to these applications, I fear will be a work of no small difficulty yet it should be overcome, as it may save them from the most loathsome and painful'of all the diseases to which the sex is liable. We therefore hope, in due time, to see the preju- dices which now interdict the application of leeches immediately to the neck of the womb, done away, as the health and happiness of thousands will depend upon their cessation. We well remem- ber the time, when it was nearly, if not entirely, as repugnant to the female to receive a common clyster, as it would be now, perhaps, to submit to the use of leeches in the way just inti- mated. At all events, we feel it a duty to put the public in pos- session of every valuable or useful remedy that experience has justified; leaving, of course, its application to the choice of the 1 For the last few years, we have been in the habit of abstracting the blood from the inner surface of the thigh, as it seems to afford more immediate relief ; for blood can be abstracted with more rapidity and certainty from this part, than from either the back or abdomen. Besides, its revulsive power may have a salu- tary influence. TREATMENT OF CARCINOMA UTERI. 247 individuals concerned. As regards ourselves, we have but too frequently had cause to lament this overweening delicacy, as we are certain, in many instances, that have fallen under our notice, cures might have been performed, where only relief, and that sometimes but temporary, was procured. So far, it has been our misfortune to have, in no instance, a single compliance with this prescription ; but we do not despair that we may yet overcome this injurious reluctance. .--.. ' '': . >;. :./ .'.,'', 2. Purging. This should never be omitted ; for there is no one remedy that we can employ in this deplorable disease, that is of such decided efficacy as purging. It not only comports with the general ob- jects to be fulfilled, but it removes a prodigious source of irrita- tion. 'In conducting this process, however, regard must be had, 1st, to the quality of the purgative ; 2d, to the extent to which this must be carried; and, 3d, to the effects it produces. 1. It is not a matter of indifference which of the purgatives we select for the purpose of affecting the bowels, in the disease under consideration. Such should always have the preference as will sit best upon the stomach ; that will operate without pain, and afford copious discharges of fluids from the intestines them- selves. Such are the neutral salts; they therefore merit the preference. The sulphate of magnesia alone, or combined with an equal weight of the magnes. alb. ust. ; phosphate of soda; the Seidlitz powders ; crem. tart, and the flor. sulp. in equal quanti- ties ; and the sulphur and magnesia. Next to the neutral salts, we may place rhubarb, or rhubarb and aloes; the castor oil, the magnesia alone, &c. Mr. Clarke recommends, "when saline purgatives do not agree with the stomach, but excite vomiting, an additional quantity of acid may be given with them : thus, eight or ten drops of diluted sulphuric acid may be added advantageously," p. 227. We have known a saturated solution of the sulphate of soda, or of magnesia in small doses, repeated every morning, or every other morning, continue to agree with the stomach admirably, for months together, and move the bowels freely two or three times a day, without either nausea or pain. This solution must be taken in the quantity of a large table-spoonful, early in the morning, before eating; and, contrary to expectation, it sits well upon the stomach. This solution is not, however, always sufficiently powerful to keep the bowels soluble ; when this happens, a little calcined magnesia must be added. Where those medicines would be dis- gusting, the phosphate of soda, the Seidlitz powders, the cream of tartar and brimstone, or brimstone and magnesia may be substi- 248 TREATMENT OF CARCINOMA UTERI. tuted. The castor oil occasionally may be resorted to, but it does not, in general, answer well, when continued for a long time. I have mentioned rhubarb, as the next best general cathartic; this is a valuable medicine in almost all cases, where a perse- verance in purgative remedies is absolutely necessary, as it very seldom requires an increase of dose if it be regularly adminis- tered. But it happens with it, as with every other medicine, that it will sometimes, though rarely, lose its effect; when this happens, it should be combined with aloes. The following is the formula I generally employ: R. Gum Aloes, sue. gss. Pulv. Rhsei. 3J. Ol. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhsei. q. s. M. f. pil. xxx. One of these is to be taken every night, or every other night, as they may affect the bowels. This form rarely requires an increase of dose, unless the bowels are rendered costive by opium, which is very likely to happen, as this drug must be used in this complaint: if this happen, two or three of the pills may be required. It is familiar to us, that aloes is generally prescribed in all cases where the uterus yields blood too frequently, or in too large a quantity; but we believe this to be an ill-founded preju- dice. We have used the pills now prescribed in several instances of this complaint with entire success, as regards the object for which they were ordered ; namely, to gently purge the bowels ; and, certainly, without increasing the inconveniences under which the patient was labouring. It happens not unfrequently that the bowels become obstinately costive: nor can they be made amenable to common remedies, even in large doses: this condition is most unfortunate for the patient; for it not only deprives her of the advantages which con- stantly result from purging, but aggravates by a mechanical agency all the evils of her situation. In such cases, the bowels should be emptied by mild injections, when they can be thrown up the rectum ; this sometimes, however, is a matter of great dif- ficulty, but they should be made to act rather by their bulk than by their quality. The common stiff pipe, attached to a syringe, is but ill-calculated to succeed in cases where the rectum is par- tially obliterated by the enlarged uterus pressing against it : a flexible tube should always be used, when this difficulty occurs. 2. The extent to which purging must be carried, is next to be considered. It will readily occur, that this process should have a limit; or much mischief must ensue; indeed, its very objects would be frustrated. The use of purging is, to solicit large serous discharges from the intestines, with a view to relieve the TREATMENT OF CARCINOMA UTERI. 249 engorged state of the pelvic viscera, and at the same time not to weaken the system too much by its excess ; consequently, if purging be carried too far, we shall have the following incon- veniences to contend with ; 1st, the body will be unnecessarily debilitated from the excess of discharge; 2d, we shall have mu- cous discharges, instead of serous, which will be attended by griping pains ; 3d, instead of lessening the congestive tendency of these parts, it will increase it, by producing a sub-inflammation of the intestines ; 4th, we should increase the activity of the inflammation in the neck of the uterus, by the mechanical pres- sure of the sigmoid flexion of the colon and rectum, in the act of passing the feces. Therefore, more than two or three easy stools per day have ever proved both inconvenient and injurious, by the disturbances they create during their passage. 3. Regard must be paid to the effects purging produces. This must be determined, 1st, by whether the discharges are attended with much pain during the operation, or immediately after: if they are, the number of discharges must be diminished; unless the pain arise from the costive condition of the bowels ; 2d, by whether these discharges produce faintness, or other decided signs of weakness: if they do, they should be moderated; or, if judged proper, even suspended for awhile. 8. Abstemious Diet. There is no disease, unless it be one very much more acute, that so decidedly suifers aggravation from errors in diet, as the one under consideration. We have known severe and long-con- tinued pain to follow an apparently slight error in diet. For, it would seem evident, that, if any expectation be entertained of curing, or even alleviating this complaint, that diet, like every thing else remedial, should be made conformable to the great in- dications ; namely, to diminish the quantity of circulating fluids ; and to abate, both locally and generally, arterial aetion. Therefore, the most bland articles must be selected for this purpose ; as milk and vegetables. If milk agree with the patient, as a general article in diet, it should be used in preference to almost any other; it may be taken a little reduced by water, three times a day with bread, rice, Indian, or rye mush, or un- bolted wheat flour mush ; but especially the last, as there is almost always costiveness. The fruits of the season, tapioca, oatmeal, sago, Indian meal gruel, &c., may also be taken, the rennet whey, where the whole milk disagrees ; in a word, almost any vegetable that is neither stimulating nor of difficult assimilation. It is well known that food may offend by its quantity, as well TREATMENT OP CARCINOMA UTERI. as by its quality ; and though we have admitted a great variety of vegetable substances, it must be understood that those must be moderately indulged in ; otherwise they may offend by their quantity. The influence of this course of diet is much more efficient than we might at first be willing to admit ; but the fact is unquestion- able, that it almost immediately relieves pain, after it has been adopted. Mr. Clarke very well observes, that "the quantity of food taken should be very moderate; lest, not being digested, it should disturb the functions of the alimentary canal, and become the cause of fever ; or lest, being digested, it should add to the quan- tity of blood, and improperly increase the vigour of the system," p. 229. The patient, it must be remembered, must be forbidden, at the same time, every kind of stimulating drink. Wine, spirits, and fermented liquor of every sort, must be prohibited with even more rigor, if possible, than animal substances, as food. Spices, or any other condiment, must be considered as coming under the same ban. " All local stimuli should of course be avoided. Sexual inter- course must, therefore, be improper." Clarke, p. 229. 4. By Cleanliness. Nothing can compensate for the want of cleanliness ; yet, in this case, some care is required, to conduct it with advantage. In the history just given of carcinoma, it was observed that there was an increase of vaginal discharge. This, if permitted to accumulate, or suffered to undergo the changes which heat always effects upon the fluids when thrown off from the system, would become offensive and highly acrid; consequently, would increase the irritable condition of the cervix uteri, from its prox- imity and even contact with it. It therefore behooves the female to keep these parts extremely clean, by frequent ablutions with lukewarm water, or flaxseed tea, as well as deterging the vagina with the same material, by means of the female syringe. Many have thought to improve the efficacy of these mild applications, by the addition of certain medicaments ; but we believe, that advantage has rarely, if ever, been gained by this practice ; unless a substance has been ex- pressly added to destroy the fetor of the discharge, by its che- mical agency. If the disease has proceeded to ulceration, the smell sometimes becomes almost insupportable; for now a quantity of blood is almost constantly issuing from the ulcerated surface, which, TREATMENT OF CARCINOMA UTERI. 251 becoming putrid, gives out so pestiferous a gas, that few can support its presence without great aversion, or even nausea. The patient herself becomes much annoyed by this stench ; often so much so, as to deprive her of both appetite and sleep; she quickly becomes debilitated, even sometimes to exhaustion, from this cause. All her evils are increased by the pervading influence of this odour; her digestive powers are so weakened, as to reject the little sustenance a wretched appetite allows her to take ; and the effort to puke may renew a hemorrhage, which had been but a short time before arrested with difficulty. We once witnessed a very sudden death from this very cause : care should, therefore, be taken to guard against it. It becomes, on this account, a matter of much importance to diminish this fetor, both mechanically and chemically: mecha- nically, by frequent washings with warm water, or the flaxseed tea ; and chemically, 1st, by carbonic acid gas ; 2d. by lime ; 3d. by the pyroligneous acid; and, 4th. by the chloride of lime, or soda. 1st. By the carbonic acid gas. We have enabled several patients to derive much comfort, as well as temporary relief, from the extrication of this gas within the cavity of the vagina, by means of a flexible tube of sufficient length and size, attached to the mouth of a bottle, in which there is mixed diluted sulphuric acid, and the carbonate of lime. This may be introduced into the vagina several times in the twenty- four hours. In two or three instances, this substance has relieved the severity of pain whenever it was employed, as well as di- minished the offensiveness of the discharge. 2d. By lime. Lime may be usefully employed in two ways ; and both may be used at the same time. First, lime water, a little warmed, may be thrown up the vagina by the syringe, several times a day. One of the best forms we have tried is, where a portion of quicklime is slaked in an infusion of chamomile flowers, and permitted to settle clear before using it. The second is, by placing the caustic lime in various parts of the room, or even under the bed-clothes. For this purpose, it should be broken up into small portions, and renewed every two or three days, or so often as it is perceived to slack. 3d. By the pyroligneous acid. The defecating power of this acid is no less certain than sur- prising; and for the purposes now in view, is one of the most valuable articles of the materia medica. This substance, like the lime, may be used in two ways. First, as an injection, in weak solution; we cannot give any exact directions for its strength, since it varies, as do the feelings of different patients, and even of the same patient at different times. It should at first be made TREATMENT OF CARCINOMA UTERI. very weak, and used warm, as directed for the other injections ; its strength must be increased as the feelings of the patient may permit; remembering, the stronger it can be used, the more cer- tain is its control over the putrid exhalations. It may, at the same time, be used in its concentrated form, by wetting a folded towel with it, and placing it over the external parts this is to be renewed when dry. The cheapness of this article enables the patient to indulge in a liberal use of it. 4th. By the chloride of lime or of soda in solution, as an in- jection per vaginam, beginning with a feeble solution, (a drachm of either to the pound of water,) and gradually increasing the proportions as the parts may become accustomed to the applica- tion. 5. By rest. Rest is a sine qua non in this complaint ; whether it be in its incipient stage, or at a more advanced period of its progress. But by rest, do not let us be understood to mean absolute confinement to bed. By rest, we mean the indulgence of a horizontal posi- tion for the body, without intervening exercise. This auxiliary acts by equalizing the circulation ; by diminishing its force ; by abstracting the stimulus of motion ; by preventing the conse- quences of the pressure of the abdominal viscera upon the fundus of the uterus, and thus avoid irritating the cervix ; and in cases where hemorrhage attends, by permitting the coagula, which arrests for the time the bleeding, to remain undisturbed; thus preventing the renewal of it. It may be well to caution the young practitioner against too much anxiety for the occasional discharges of blood, which are almost sure to take place, sooner or later, in this disease; he should regard them for a time as so many leechings, from which the patient derives much immediate comfort, if not eventual benefit. Upon the same principle, he should not attempt to arrest the purulent discharge from the vagina, by the employment of astrin- gent or stimulating injections. We have already directed strict attention to cleanliness, by means of simple warm water: Avith this, there can be no fear of doing mischief by any stimulating property. But medicated injections of an astringent nature, must be forbidden; unless it may be the occasional use of a very weak solution of the acetate of lead from this injection we have thought advantage was derived by its sedative influence, to the irritable neck of the uterus. Tonics are ever inadmissible in this complaint. , Mr. Clarke concludes his remarks on the treatment of this dis- ease by observing, "In treating this disease, as no cure is known TREATMENT OF CARCINOMA UTERI. 253 for it, the practitioner must be satisfied with palliatives, and not be anxious to restore the vigour of the body, which might aggra- vate the disease again. Still, let it be remembered, that, by a strict attention to management, and an unwearied perseverance in the means suggested, all the cases of the disease may be relieved; in many, the farther enlargement of the tumour, or progress of the thickening, may be prevented; and if the author was not afraid of deceiving himself, or of deceiving others, he would venture to express a belief, that in a few instances, the disease has altogether subsided," p. 235. The consolation which this last suggestion affords should be constantly kept in mind ; as it holds out a strong inducement to both patient and practitioner, to persevere in the use of the reme- dies pointed out ; shows that this formidable and loathsome dis- ease may occasionally be prevented from running its terrible career; and restores a useful individual to society. We are equally persuaded with Mr. Clarke, that in instances of the en- largements under consideration, we have succeeded in entirely removing them by the plan laid down. And farther, that, from the success of such cases, strong inducements are held out to the timid sex to make known, at an early period, any unpleasant feelings they may experience in these parts, that the fairest chance may be given to perseverance in proper and well-devised remedies. And to the practitioner, it offers an inducement to exertion in the cause of humanity. For the most part, after ulceration has commenced, the patient suffers much from the violence and peculiarity of the pain, which now is almost sure to attend. This is so constant, especially at night, as to deprive her almost altogether of rest. There is no alternative now, but the employment of opium, or other narcotics, which but too soon lose their influence, however we may attempt to maintain it by increasing the dose ; and the patient thus early becomes deprived of the only solace art can give her. But in this state of carcinoma, the same regard must be paid to the general state of the system, as in its first stage. For, notwithstanding absorption has commenced, and ulceration is progressing, the system becomes implicated, and the arteries are found to be much excited. A high sympathetic fever is produced, accompanied by a hot dry skin, and almost insatiable thirst, to- gether with a sense of intense heat in the stomach itself. This burning aggravates all the other symptoms, by its intensity and pertinacity: sleep is interrupted, and the patient will sometimes almost starve, rather than take food at the risk of increasing this sensation. This feeling sometimes proceeds from acidity; when this is the case, absorbents or antacids should be given ; and the frequent use of small quantities of good sweet cream, is almost sure to afford at least temporary ease. 254 TREATMENT OF CARCINOMA UTERI. The pulse under these circumstances, is always, we believe, excited ; and in a degree that requires the loss of blood, either from the arm, or from near the part. Some may entertain fears of this remedy from the appearance of weakness which the pa- tient discovers ; but this must not create alarm ; for the state of the system declares its propriety. Indeed, nature seems to offer this relief, by producing a hemorrhage from the part, which hardly ever fails to afford it. Besides, it is sure to place the system in a more favourable condition for the operation of nar- cotics, to which, at this stage of the disease, we must always have recourse ; and happy is the patient, when she can obtain a truce to suffering, by their agency ; for the pain is generally so severe and protracted, as to quickly destroy their power. For this purpose, we believe it will be found that opium, in one form or other, is the only one that can be relied upon for any length of time together. Much, however, has been said in praise of several other nar- cotics, besides opium, in the disease in question; such as the belladonna, the hyosciamus, the stramonium, and the hemlock. We are sorry we cannot add any testimony in their favour. In our hands they have fallen far short of the anodyne powers of the opium ; and have constantly failed to merit the high enco- miums which have been bestowed upon them. I am happy to find myself supported in this experience, by Dr. Chauffard. 1 After pointing out the great abuses committed by persisting a long time in the use of narcotics, he observes, " The violence of pain often forces us to the administration of narcotics : but do not let us forget, that in such cases, two or three grains of opium will succeed better to calm it, than forty grains of the other extracts. I have seen eight grains of opium, in a terrible cancer, afford more complete comfort or relief, than two drachms of the extract of aconite, and this without worrying the digestive organs or disturbing the intellectual faculties in any like degree: and also much more promptly. This substance, (opium,) would procure some moments of refreshing sleep, which could not be obtained from the other." This is truly a matter of regret ; as it abridges our resources at a period when so few can be commanded, yet when so many are required. So frequent and so uniform have been our disappointments, that we neither consider the belladonna, hyosciamus, stramonium, nor the hemlock, as substitutes for opium. And though alto- gether aware how unfriendly some of its properties are to many constitutions, yet we cannot, as a general remedy, give it up for any other, with which we are acquainted. Every preparation of opium is not equally objectionable; the 1 Memoire sur 1'emploi et Tabus des medicaments stupefiants les plus usites. Trans. Med. &c. for July, 1830. TREATMENT OF CARCINOMA UTEKI. 255 I common laudanum is, perhaps, the most so of any; even more so than in its solid form. The least, (if we except morphia,) is the acetated tincture of this drug ; or what is commonly called " the black drop." In this form, several of its unfriendly ten- dencies are obviated altogether; and almost always, are very much diminished. It is seldom followed by headache or nausea ; nor does it constipate the bowels, in any like degree, as the lau- danum. It, therefore, always merits the preference, when it can be commanded ; and when it cannot, much of the inconve- nience of the laudanum may be avoided, by mixing the dose with sweetened vinegar ; or by the addition of a few grains of the carbonate of soda or potash. 1 It has been a usual practice in carcinoma, to give the cicuta in increasing doses. We have thought that we have sometimes derived a temporary benefit, but we have never witnessed a permanent advantage from it, to whatever extent we have car- ried it. We have thought, however, that opium was more cer- tain to give relief from pain, while the patient was using the, hemlock, than when she was not under its influence. We have frequently found, in the same patient, that opium would procure rest at one time much more certainly than at another, even under the same circumstances, as far as could be determined. Why this has happened, we cannot pretend to say ; but when opium has failed, we have found that camphor, in liberal doses, would oftentimes succeed. Indeed, we have several times found that the camphor was a valuable addition to our slender means of procuring rest, in cases of severe pain from ulcerated carcinoma ; and this especially where opium disagreed, or had worn itself out. We have also, in several instances, found that the spirit of turpentine, in twenty drop doses, has also procured sleep, when it could not be obtained by opium. The same may be said of the liq. anod. Hoffm. in tea-spoonful doses. 8 When opium either disagrees, or its efficacy is waning, giving it in the form of an enema, has very often a most happy effect. When employed in this way, a treble dose of the laudanum, in two ounces of warm water, should be given at a time ; and re- peated, pro re nata. 1 Since the above was written, we have become possessed of a preparation of opium that bids fair to supersede almost all the others; namely, the " denarco- tized laudanum." This is prepared from opium, that has been divested of its narcotine. It sits most kindly upon the stomach; and is very rarely followed by the after consequences of the common laudanum, even in those who are generally obnoxious to them. Morphia itself offers a valuable resource; it is very certain in its effects, and is not usually followed by the inconveniences of the other prepa- rations. It may be given either in substance or in solution; one-sixth of a grain is about equal to one grain of opium, or thirty drops of laudanum. a Care should always be taken that this substance has been faithfully prepared, See note to page 217. 256 TREATMENT OF CARCINOMA UTERI. When the stomach becomes affected, the case is always more deplorable, for reasons easily imagined. This rarely takes place, as a sympathetic affection, until ulceration has commenced ; and when it does, it goes on, pari passu, with the ulceration, and be- comes even more distressing sometimes, than the original com- plaint. We have but a sorry choice of evils, "when this condition of the stomach exists; for we are generally obliged to give up a system of diet, which is best calculated to mitigate the uterine sufferings, for one which is better adapted to appease a rebellious stomach. We must give up the vegetable course of diet, for one of animal substances, that we may tranquillize this organ ; and we must also neutralize the predominating acid, by the various antacids, or by the sulphuric, or nitro-muriatic acid, in small, but often repeated doses. One of the best sitting substances that we have found, when the stomach is extremely irritable, is rich sweet cream ; this must be given by the tea-spoonful ; and repeated every fifteen or twenty minutes. We shall conclude this account of carcinoma, with giving an extract from Mr. Clarke's work, so often mentioned. We do this, because his remarks upon this terrible disease are judicious, and bespeak the experienced practitioner, as well as the man of feeling. Moreover, there are some views of the disease which are novel, and a part of practice and resources, that is not suf- ficiently familiar to the American practitioner. We have pre- ferred giving his opinions and suggestions in his own language, to condensing them, though at the risk of being blamed for so long a quotation, by those who have not yet met with the dis- ease. But, from the practitioner who may have such a case in hand, and whose resources are nearly exhausted, we fear no such censure : on the contrary, we are sure we shall receive his thanks for any new suggestion that will, for even an hour, relieve his suffering patient. " The management of the discharge from carcinomatous sores, is a circumstance deserving the best attention of the surgeon. This discharge appears to have the power of converting the neigh- bouring parts, to which it is applied, in some instances, into sores of a similar character to that by which it was itself secreted : and there is reason to believe, that the spreading of carcinomatous ulceration may be greatly retarded by the employment of those substances which absorb or remove the ichorous fluid secreted by them. Common aphthous sores, which frequently arise in the vestibulum of women, who have long laboured under diseases of the female organs, may also possibly be converted into malignant ulcerations. These observations especially apply to carcinoma- tous ulcerations of the internal parts, in which the discharges are TREATMENT OF CARCINOMA UTERI. 257 more likely to be retained, than where the disease attacks ex- ternal surfaces. If it were only that the foetor attending such sores would be removed by cleanliness, attention to this circum- stance would be of great consequence, inasmuch as the patient's health, and that of such persons as may associate with her, will be less likely to suffer, than when constantly breathing an impure atmosphere. " Of all the modes of applying water to sores at the upper part of the vagina, none is so effectual as the use of the hip-bath ; in the employment of which, the water is brought into contact with the sore without any risk of infusing the latter. By these means, the object of maintaining cleanliness is not only obtained, but a soothing application is made to an irritable surface ; the carefully injecting warm water into the vagina, by a syringe, or the agi- tating the water with the hand, will render it more likely to remove any portions of coagulating lymph, or thickening matter, which may adhere to the inside 'of the vagina. The heat of the water employed should depend upon the feelings of the patient in some measure ; but, generally speaking, it may vary from about eighty- six to ninety-four degrees. Where the patient is too weak to bear the exertion of being put into a hip-bath, her hips may be brought over the edge of the bed, and warm water may be care- fully injected into the vagina by a small syringe. The quantity of the discharge is frequently increased by the means above-men- tioned, but the comfort which the patient will derive from it will abundantly compensate her for any debility which may be pro- duced by the remedy; and excruciating attacks of pain are some- times rendered very sufferable by a frequent recurrence to it. Strong decoction of carrots, sometimes used for the same purpose, has the happiest effects. Warm water may also be made the vehicle for a variety of sedative applications, which are found by experience to tranquillize all irritable sores ; and, in some, to ex- pedite the healing process. Amongst the different applications for this purpose, the extractum conii, or extractum hyosciami, maybe mentioned, either of which may be employed in the pro- portion of about three or four drachms to a pint of water. Solu- tions of opium, or of extract of poppy, may also be used ; of the former, two drachms ; of the latter, half an ounce may be dis- solved in each pint of water. Starch or mucilage of quince-seed, form good menstrua for these applications; their adhesive pro- perty enabling them to cling to surfaces to which they are applied. Three or four ounces of either of these fluids, impregnated with sedative substances, may be thrown into the rectum, in those cases where relief is not obtained by their application to the va- gina; but when opium is used for this purpose, the practitioner should be very careful to watch over its effects, as* it has some- times happened that unpleasant consequences have arisen from 17 258 TREATMENT OF CARCINOMA UTERI. the application of this drug to the rectum, such as vomiting, syncope, cold extremities, and irregularity of circulation. The action of the absorbents of the rectum is, in all probability, in these cases, increased by the inflammatory process which exists in the vicinity ; besides which, the action of the rectum itself is temporarily taken off, so that the enema will probably be retained during a considerable length of time. Plasters and liniments, into the composition of which opium enters largely, will sometimes be found serviceable in allaying pain, and are useful auxiliaries in a disease, in which all the resources of the practitioner may be required to diminish the sufferings of the patient. " There are some applications which produce a sedative or a stimulating effect, according to the strength of which they are used. A very diluted mixture of acetic acid, or of nitric acid in water, will form a soothing application to an irritable part, whilst, in different proportions, they will become highly irritating. Either of the lotions mentioned beneath may be employed. R. Acidi acetici, - ... ^ss. Aquse distillatae, - - - Oj. M.f. injectio. Or, R. Acidi nitrici, - - - - gutt. x. Aquae distillatae, - - - Oj. M. f. injectio. Or, R. Liquoris plumbi acetatis,' 3j. Acidi acetici, .... gii. Sp. Vinosi. ----- 3J. Aquse distillate, - - - xvss. M. f. injectio. " If the discharge should become so profuse as to induce great debility, injections which possess an astringent power must be sought for. R. Decocti corticis granati, - Oj. Sulphatis aluminse, - - gss. M. f. injectio. Or, R. Zinci sulphatis, - - - gss. Aquae distillatse, - - - 3jxv. Tinct. RLao. - - - - |j. M. f. injectio. "If the discharge should assume a sanguineous appearance, it should be considered how far it would be safe to permit its con- tinuance. If the patient should be in great pain at the time, it may be right not to restrain it hastily, unless the patient's strength should have been previously much exhausted ; but if it should appear desirable to diminish the hemorrhage, the astringents which have been before recommended, may be employed, and their strength may be increased, or the following may be em- ployed in their stead : TREATMENT OF CARCINOMA UTEKI. 259 R. Argenti nitratis, - i'^'^ . gr. x. Aquae distillatse, ..... Oi. M. Or, R. Cupri sulphatis, gss. Decocti cinchonse, .... Oi. M. tfi'y: '"sii'.v-.i'i ':>.'[ ut '* .!>>> ;vrLii;<( *i7 lv ii.'f,-y.-l -itfr ji)*irviTp *<->v>t{ tffiv^tittrt .i->r?\| *?.4j " A lady, about sixty years of age, who had several children, had, with violent pain, frequent hemorrhages from the uterus, so profuse as to bring her at each time of their return into thue greatest danger. When she permitted me to make an examina- tion, there was no polypus in the vagina, but the uterus was much distended, and the os uteri being opened nearly to one third of its circumference, I could discover within, and pressing upon it, a tumour of apparently a very large size. In the course of a few weeks, an immensely large polypus dropped into the vagina. 1 Her health was much reduced, and the extirpation of the polypus appearing the only chance of saving her, I made many and stre- nuous attempts to pass the ligature, but without success. I then procured a large and different instrument, like that used in tying the tonsils, but with this I was also foiled. In my endeavours to pass this instrument round the polypus, the surface was abraded, a blood vessel of a considerable size was wounded, and there was a loss of blood which rendered the patient still more weak. After a few days without any instrument, I gradually introduced my hand into the vagina, got the ligature over the polypus, and then tightened it. Dr. Orme and Mr. Croft were with me at the time. But many complaints came on, and she died in a few days, be- fore the polypus could be extirpated. <; The blood vessels which convey nourishment to a polypus probably bear a relation to its size, and must, of course, be some- times very large, so that in passing the ligature, it behooves us to be very careful that we do not wound the polypus ; and, perhaps, in every case when the polypus is large, it would be better, if possible, to introduce the hand, for the conveyance of the ligature, than to use the instrument. Much will also depend on the tex- ture of the polypus, which is sometimes so slight as to resemble an injected and corroded liver or kidney. I remember a case in which, though I only took a common examination, and the usual caution, so violent a hemorrhage was occasioned, that I thought the patient would have died instantly. Were a case similar to *'In this case the secale cornutam would most probably have succeeded in ex- pelling the tumour, and should always be tried in such cases. POLYPUS OF THE UTERUS. 269 this to occur to me again, I should be disposed to try the effect of styptic injections, deferring any attempt to pass the ligature, till I had seen the effect which would be produced by them. " The three preceding cases are the only ones, among a very great number, in which I have not been successful ; and I have judged it right to state them thus circumstantially to set others upon their guard, and to prepare them for the possibility of dis- appointment. " In the museum of the late Dr. Hunter, there is a large poly- pus from which an engraving was made, and by the register it appears, that after many attempts to pass the ligature, without success, this patient died. Perhaps by a knowledge of the causes of the miscarriages of others, (as in case 4th, just recited,) sub- sequent trials, even in the polypi which are of the largest size, may be more fortunate. I have very great pleasure in relating the following case which was lately under my care." -''. .-- - * - Case Fifth. " A foreign lady, who was born and had lived the greatest part of her time in a hot climate, applied to me. She had had every day, for more than three years, a very considerable dis- charge of blood from the uterus, together with others of a diffe- rent kind and complexion, by which her strength was very much reduced. She had been attended by different gentlemen, who had not given any decided opinion of the nature of her disease. When I first examined her, I was indeed very much surprised; for not only the whole vagina was filled up with a fleshy sub- stance, but the os uteri was as completely dilated as when the head of a child is passing through it, and the cavity of the uterus appeared to be much distended and filled with the same substance. I at first hesitated whether I should make an attempt to pass the ligature, as I could not reach the stem of the substance, but after deliberating on the state of the patient, who must soon perish, unless relief could be given, and knowing that if the ligature could be passed, I should have the power either of proceeding, or of stopping on the appearance of any untoward symptom, I deter- mined to make a trial. The first and second attempts to pass the ligature were fruitless, but I at length conveyed the ligature beyond the bulk of the tumour, and far beyond my reach, by means of a piece of thin cane notched at the end. The ligature being daily drawn gradually tighter, was at liberty on the sixth day. The external parts were unusually contracted, and as any endeavours to bring away the polypus at that time must have failed, it was left in the vagina to soften and decay. On the ninth day after the ligature was come away, she had pains as regular 270 POLYPUS OF THE UTERUS. as those of labour ; and when the os externum became somewhat dilated, I laid hold of a portion of the tumour, first with my fin- gers and then with a small sharp-pointed hook, favouring the expulsion of it as well as I could during the pains, by which it was at length propelled with considerable force, after a labour of four hours' continuance. From that time to the end of five weeks, there was not any discharge of any consequence. Then she menstruated regularly, and returned home in perfect health. "This polypus, which was the largest I ever saw, was put into the hands of Dr. Baillie, who saw the patient during the opera- tion. It weighed two pounds and three ounces ; so that, allow- ing for its decay, perhaps it could not originally have weighed less than three pounds. But the violence of the symptoms does not always depend on the large or small size of the polypus. " When polypi are too large to be extracted without much dif- ficulty after their separation, no harm can arise from their re- maining some days in the vagina, as I have found in several instances ; and their bulk hourly lessening by decay, their ex- traction is rendered more easy. " These cases lead to an observation on the difference between what is properly meant by the terms polypus, and excrescence. By the former is to be understood those excrescences that arise distinctly from the uterus or vagina; and by the latter, a morbid enlargement of those parts. The first of these generally admits of extirpation with safety and advantage ; but the latter, though they admit of extirpation, and even promise success, cannot with propriety and safety be removed." Case Sixth. " We were called to Mrs. A. in January, 1833, who was losing much blood every few days from the uterus. Upon examination per vaginam, the mouth of the uterus was more open than natural, admitting the point of the finger to pass a little distance within it without difficulty: the whole neck was larger than usual, but nearly of the ordinary length. Rest, and restricted antiphlogistic diet was ordered, with injections, per vaginam, of pretty strong lead water; that is, two drachms of the acetate, to fibiss. of water, three or four times a day. These would seem to control the hemorrhage temporarily, but they would recur, at short intervals, and by very slight exertions. The cicuta, in increasing doses, together with liberal doses of the extract of rhatany, were steadily persevered in, with some degree of advantage as regarded the quantity of discharge. This plan was persevered in until August ; at this time, an alarming discharge took place, so as almost to exhaust my patient. On an examination now, the neck of the MODE OF OPERATING FOR POLYPI. uterus was found much enlarged, and it immediately occurred to me, that this enlargement was owing to a concealed polypus making its way through it : with a hope of ending this work, I ordered thirty drops of the vinous tincture of the secale cornutum every four hours. In the course of 48 hours, slight uterine pains were produced, which were permitted to continue for two days, and were then checked by morphia ; at the end of a week, they were again renewed, and so on at intervals, for two months. On touching the mouth of the uterus now, a smooth round body, of the size of a large cherry, was perceived at its extremity, which, to my great satisfaction, confirmed the opinion I had given: the hemorrhage was now very much diminished, and could always be stopped by a small tampon of sponge. In this man- ner things went on for several months, the substance gradually protruding itself, by the occasional use of the tincture of ergot, and eventually, by December, 1834, the uterus freed itself of a polypus as large, nearly, as a goose-egg, forming a neck or pedi- cle of considerable thickness, more than an inch in diameter. I applied the wire ligature, and the tumour fell off on the eleventh day; no unpleasant symptom attended its application or followed its separation : my patient is rapidly recovering from the im- mense loss of blood, during #period of more than two years' con- tinuance. "The late Dr. Hamilton, of Glasgow, obliged me with the drawing of a polypus which weighed one pound and four ounces, and had dropped through the os externum, inverting and drag- ging along with it the fundus of the uterus. The patient died. Had the nature of this complaint been understood in due time, it would, in all likelihood, have been possible to have tied and extirpated it, before it had occasioned so much mischief. It is an example, among many others, of the impropriety of waiting till the polypus is excluded through the os externum, before we attempt to tie it; an opinion which some have entertained." SECT. IV. Mode of Applying the Ligature for Polypi. We shall give Mr. Clarke's mode of applying the ligature, with our own experience upon this plan. He directs, that previously to performing the operation, the rectum of the patient should be emptied by a clyster, or the in- testinal canal may be cleared in its whole extent by a mild pur- gative. For a short time before the commencement of the ope- ration the patient should be kept in the upright posture, that the neck of the tumour may be more within reach. "As the tumour possesses different degrees of convexity in dif- ferent cases, and as the distance of its neck from the os externum 272 MODE OF OPERATING FOR POLYPI. is very various, the practitioner must be provided with two or three rods of different lengths, made of flexible metal, so as to be capable of being adapted to the shape of the tumour. The author's brother, the late Dr. Clarke, has contrived a brass rod, which, being received into a hollow handle, is capable of having its length altered as each case may require ; and by this means the multiplication of instruments is rendered unnecessary. "A silver cannula, of a length sufficient to reach from the neck of the tumour to the distance of an inch, or an inch and a half from the os externum, should be prepared ; and near the extre- mity which is to hang out of the external parts, there should be placed two small shoulders, round which the ends of the ligature may be twisted. A sort of windlass has been recommended for this purpose in the cannula; but this is quite unnecessary, and renders the instrument more complicated. "The ligature should be made of waxed silk, of such a thick- ness, as neither to cut the neck of the tumour, nor to break, nor block up the cannula. 1 In order to pass the ligature through the cannula, a long piece of thin brass wire should be ready. This is absolutely necessary; because, when the ligature becomes slippery and pliable, it will not be possible to push it through the cannula. The patient should be placed upon a bed. She should lie upon her left side, and her knees should be drawn up towards the abdomen. If the external parts should not be readily dila- table, they should be dilated. The forefinger of the practitioner's left hand, (previously oiled,) is now to be carried through the vagina to the neck of the tumour. The brass rod (previously prepared with the ligature, and its curvature adapted to the shape of the tumour,) is to be passed up by the right hand to that part of the neck of the tumour where the forefinger of the other hand is placed. The ligature is then to be secured by the finger, and the brass rod is to be carefully carried round the neck of the tumour, till it comes'to that part where the ligature was secured. The practitioner is now to secure also under his finger that part of the ligature which has been carried round the neck of the 1 We are convinced, from late experience, that a double silver cannula, rather longer than it is ordinarily made, armed with a piece of fine steel well annealed wire, is much the simplest and best instrument. We have tried the rods, but did not succeed in applying the ligature. We merely mention the fact, without under- valuing Mr. Clarke's instrument. The failure may have been owing to our own mal-adroitness rather than to the want of suitableness in the instrument itself. We, however, succeed without difficulty with the long silver double cannula. We think the following advantages attach to the cannula and wire. First, its whole powers are more at the command of the operator. Secondly, the loop can always be enlarged or diminished at pleasure. Thirdly, it can be more easily removed, or have its location changed, if this be necessary. Fourthly, any degree of pres- sure can be made, , by a pair of pliers, that may be deemed expedient. Fifthly. the tumour is more completely strangled, and consequently, will be soon detached by ulceration. Sixthly, it requires but one instrument. V MODE OF OPERATING FOR POLYPI. tumour, and the rod is to be carefully withdrawn. In some cases, it will be found more convenient to steady a part of the ligature with the rod, and to carry the other part of the ligature round the neck of the tumour with the finger. In doing this part of the operation, great care is to be taken not to include any part of the os uteri. Before the ligature is tightened, the patient is to be desired to inform the operator if she feels pain ; because, if the tumour only is included in the ligature no pain will be felt. " The two extremities of the ligature which hang out of the os externum are now to be drawn through the cannula, by the piece of wire, (which had been previously doubled, and carried through the cannula, so as to form a noose projecting from it,) and after the cannula has been gently passed up to the neck of the tumour, they are to be drawn tight, and are then to be twisted round the shoulders of the cannula, where they are to be made secure. The ligature, therefore, should be long enough to encircle the neck of the tumour, to be carried through the cannula, and a suf- ficient length of it should remain to be affixed to the shoulders of it. More than one ligature should always be prepared, lest that which is first used should become too slippery to be managed. "After threading the eye of the rod, one extremity of the liga- ture is to be twisted once or twice round the instrument, whilst the other hangs loose. The patient should be made acquainted with the shape and situation of the instrument, that it may not be liable to be removed when she gets up to make water. She is also to be desired to remain constantly upon her side, and should not be allowed to move from one side to the other, unless when the practitioner is present. For want of attention to this caution, there is reason to believe that the cannula has been in- advertently pressed against, and its extremity pushed through, the uterus of the patient, so as to occasion her death. In the engraving given of the polypus cannula, there may be seen a contrivance, by means of which this accident may be prevented. The cannula is made of the same diameter from one end to the other, and a spiral screw is cut upon it. To this spiral screw is adapted another screw, placed in the centre of a kind of shield, which, (when the ligatures are fastened,) is to be placed in con- tact with the external parts. The shield in the plate is of a cir- cular form ; but in women who are corpulent, it may be more convenient that its shape should be oval. " The patient is now to be left, and great care is to be taken by the nurse that the cannula is not moved when the contents of the bladder are expelled. "Every day the practitioner is to examine the state of the ligature; and as often as it is found at all too slack, it is to be tightened. The mode of tightening it requires particular atten- tion. If the cannula should happen to be long, the practitioner 18 274 MODE OF OPERATING FOR POLYPI. should not hold the end of it whilst he tightens the ligature ; lest with the force used, the ligature should cut through the neck of the tumour, and the other extremity of the cannula should be forcibly and suddenly pushed by the left hand against the internal parts of the woman. In order to avoid this accident, the cannula should be firmly held close to the external parts of the woman, which prevents the possibility of mischief being done. If the cannula with a ligature is employed, it is next to impossible that this accident should happen. "A syringeful of warm water should be thrown into the vagina every day, when the ligature is tightened, in order to wash away the putrid discharge. " The time at which the ligature will come away, will depend .upon the thickness and firmness of the neck of the tumour, and the tightness with which the ligature is at first applied. The neck of the tumour sometimes is cut through in four days ; some- times ten or twelve days will elapse between the application of the ligature and the removal of the tumour, and occasionally the separation of the tumour will take up nearly three weeks, but this is an uncommon occurrence. "The neck of the tumour being destroyed, the tumour itself is to be brought away by the practitioner. This will be accom- plished in some cases with ease, by one or two fingers intro- duced into the vagina. If the polypus is large, or the external parts contracted, a single blade of a pair of midwife forceps may be used. If the size of the tumour should be such as not to be easily removed by these means, the crotchet may be fixed into it, and in this way it may be brought along. The palm of the hand should always be kept opposite to the beak of the instru- ment: so that if it should slip, the parts of the woman may not be injured by it. " The cavity of the vagina should afterwards be cleansed, by injecting some tepid water, and this should be repeated during severaf days. " The mucous and bloody discharge seldom continues long after the extraction of the polypus ; but if any should remain after a week or ten days, some astringent injection should be thrown into the vagina three or four times a day. "As the ligature is applied around the neck of the tumour, a part of the latter may remain between the ligature and the uterus. In consequence of the application of the ligature, this part putre- fies, and comes away mixed with the discharges. In one case in which the author extracted a polypus from the uterus, he found that the os uteri had nearly recovered its natural size at the end of five days from the time at which the ligature came away ; that at the end of fourteen days it was impossible to ascertain that CAULIFLOWER EXCRESCENCE. 275 any disease had existed in the parts ; and upon the sixteenth day, the patient menstruated. " It has been recommended, after the application of the liga- ture, that the tumour should be cut off with a knife ; but there does not appear to be any necessity for doing this, particularly as no harm arises to the patient from suffering it to remain till it falls off. Besides which, mischief might be done with a knife carried high into the vagina, and it is by no means certain that the tumour will not be more likely to return. "It sometimes happens that the ligature and cannula fall out of the vagina when the practitioner is not with the patient ; for which event she should be prepared, lest this occurrence should create alarm. Whenever this happens, it is obvious that the neck of the tumour is destroyed. "The food of the patient should be simple, easy of digestion, and nutritious. If the bowels should be confined, a clyster of warm gruel may be thrown into the rectum. If the stomach should be irritable, a saline draught in a state of effervescence may be given, with a few drops of laudanum ; and if the patient should complain of pain from long confinement to the same pos- ture, a sufficient dose of opium should be taken to procure rest. " The cause of debility being removed, the patient generally quickly recovers her strength ; but as an auxiliary, a draught con- sisting of a decoction of bark, with sulphuric acid, may be taken three times a day." SECT. V. Of the Cauliflower Excrescence. This is a disease of the uterus that the author has not seen. He has, in several instances, witnessed considerable discharges of a watery kind from the vagina, which he anticipated might be this disease ; but upon examination per vaginam, they did not prove to be so ; nor could the cause of such profuse discharges be accounted for: they all were relieved by astringent injections, the tincture of cantharides, the bals. copaiv., &C. 1 1 I lately witnessed a case of profuse and acrid discharge of water from the va- gina, which resisted all the remedies I employed, and eventually terminated in death. The neck of the uterus, when examined per vaginam, was much thickened, tender, and opened so much as to permit the finger to pass. The whole uterine mass seemed to fill up the lower portion of the pelvis, and appeared to be attached to the whole of the surrounding parts, so firmly, as to be immovable in the pelvic cavity, by any force which could be applied by the finger. There was also a con- siderable hemorrhage from time to time; and when this was not present, the watery discharge was constant and copious. The patient appeared to sink from the profuseness of this discharge. She laboured under this complaint about six months. Leave could not be obtained to inspect the body. There was not, at any time of her illness, any rising of the fundus above the pelvis; or, in other words, there was no distention of this organ, to lead to the suspicion that its cavity might be occupied by hydatids. 276 CAULIFLOWER EXCRESCENCE. The late Dr. John Clarke, of London, 1 we believe, was the first who described this disease. In this country it must be ex- tremely rare, or our experience, we think, would have furnished us with a case. It may almost be looked upon as among the in- curable diseases of these parts, though considerable relief has been experienced, at different times, by the application of the ligature, &c. This disease has taken its name from its strong resemblance to the cauliflower. " The surface is granulated, and it consists of a great number of small projections, which may be picked off from the surface, as the granules may be detached from the ve- getable." Clarke, p. 59. The whole of this excrescence is co- vered by a membrane of an extremely fine texture : from the sur- face of which an aqueous fluid is poured in great quantity; and thus gives a particular character to this disease. This tumour occupies, for a long time, the upper part of the vagina, as it is the product of the os uteri ; it, however, gradually, nay, sometimes very rapidly, enlarges so much as to fill up the whole of the vaginal cavity; and occasionally even to protrude beyond the labia. This extension of the disease gives an oppor- tunity to examine its texture, and to ascertain its colour. Its texture is so extremely delicate as to be injured by the slightest violence ; and when this has been done, a discharge of florid, arterial-looking blood, immediately follows ; the quantity of which will be in proportion to the extent of lesion the tumour may have suffered. The appearance of the tumour is of a bright flesh colour; giving evidence of great vascularity, with very little solidity of structure. This tumour possesses no sensibility, and is one of the rare in- stances of great vascularity being unaccompanied by exalted feeling. In no instance is the structure of the vagina involved, so far as observation has yet extended. It may originate from the whole circle of the os uteri, or only from a portion of it : hitherto it has never been traced within the uterus. Mr. Clarke thinks the growth of this excrescence is in some measure influenced by the capacity of the vagina; increasing more rapidly in capacious than in restricted vaginae. Hence in married women who have borne many children, the tumour increases very rapidly; and, on the contrary, "the pressure of the sides of a less capacious vagina, as in single women, will greatly tend to control its enlargement, acting like a bandage.' Clarke, p. 61. 1 See his paper, in Transactions of the Society for the Improvement of Medical Knowledge, 1812. CAULIFLOWER EXCRESCENCE. 277 It would seem that the enlargement of the tumour, at least, when it is so large as to protrude beyond the labia, occasions inconvenience by its mechanical pressure ; as the parts immedi- ately in contact with it will not unfrequently ulcerate. It is not ascertained what gives rise to this disease; conjec- ture even seems at bay. The mechanical violences of labour, are altogether insufficient to account for its production; for "married women, who have never been pregnant; nay, single women, are liable to the complaint, in whom no violence can have been offered to the os uteri," p. 62. " It cannot be traced to any syphilitic cause. The common prostitutes of this metropolis, (London,) are by no means more liable .to it, than any similar number of women in different sta- tions of life. The disease as often arises in the strong and robust as in the weak ; in persons who live in the country, as those who inhabit large towns; in those whose situation in life obliges them to labour, as well as in those who, from their rank in so- ciety, sometimes consider themselves privileged members of it. "No period of life, after the age of twenty, seems to be exempt from the disease. The author has known it fatal at the age of twenty ; and he has met with the disease at different periods of life up to old age." Clarke, p. 62. We have noticed above, that the blood which escapes from the tumour, when it has been injured, has the marks of arterial blood; indeed this excrescence seems to be but a mass or con- geries of arteries and veins. A very remarkable circumstance attends this disease; namely, its disappearance after death. Mr. Clarke declares, " No one has seen a tumour, resembling a cauliflower excrescence, in the dead body," p. 63. It seems that so soon as life ceases, the whole tumour shrinks, and leaves nothing which resembles itself. AH that can be perceived of the former tumour, however large it may have been, is " a soft, flaccid, slimy, whitish substance, resembling the foetal portion of the placenta of a calf, after it has been macerated in water," p. 66. Notwithstanding the extremely vascular nature of this excres- cence, it has hitherto resisted every attempt to inject it ; and, "though the uterine vessels were abundantly filled with the in- jection, the fluid escaped from its surface as fast as it was thrown in from the pipe of the injecting syringe. Many attempts have been made by different practitioners to procure a specimen of this disease ; but all had failed, until Mr. Clarke was fortunate enough to remove one of these tumours on the third day after the application of a ligature. So soon as it was relieved from the vagina, it was put into alcohol : it was from this specimen that his beautiful drawing and engraving were made. See plate IX. 278 SYMPTOMS OF CAULIFLOWER EXCRESCENCE. SECT. VI. Of the Symptoms of this Complaint. This complaint begins by an aqueous discharge from the va- gina: this is but little attended to in the beginning; nor, indeed, until the quantity rendered obliges the woman to protect herself against its excess. But as this profusion is not attended with either pain or stench, she neglects herself, until her health yields to this undermining disease. As a general rule the quantity of watery discharge is in proportion to the surface of the tumour. The water evacuated in this way may be altogether transpa- rent or colourless, or only occasionally tinged with red, upon the yielding of a small vessel : the quantity of water may be so small as not to create any great inconvenience, or it may be so excessive as to require constant attention. Sexual intercourse is always followed by a discharge of blood; even common exer- tions may be succeeded by a similar hemorrhage. Thus, cough- ing, sneezing, or straining at stool, will sometimes be followed by a great loss. The watery discharge diminishes in proportion as the san- guineous increases. From these multiplied discharges the sys- tem becomes very much debilitated, and the body wastes, but not to great emaciation ; the stomach becomes dyspeptic, and the belly tympanitic. Hysterical and nervous symptoms super- vene, to aggravate the distresses of the already oppressed pa- tient. Effusions now take place, and both local and general dropsy but too certainly follow. Sometimes the sufferings of the patient have an unexpected and fatal termination, from the profuseness of the hemorrhage which may have suddenly assailed her. SECT. VII. Of the Prognosis. Mr. Clarke is of opinion that the tonicity of the vagina will have a decided influence upon the progress of this complaint; which must consequently influence the prognosis. He says, "As the enlargement of vessels in other situations is much in- fluenced by pressure, so it will be found that the compression of the sides of the vagina will greatly retard the growth of this tu- mour. Now, as the quantity of the watery discharge depends upon the extent of surface the tumour presents, and as the danger of the patient is in proportion to the quantity of the discharge, it follows that whenever the vagina has lost its tone, and the tu- mour has thereby been little subject to compression, the prognos- tic to be given to the friends of the patient, as to the probable TREATMENT OF CAULIFLOWER EXCRESCENCE. 279 duration of life, should be less favourable than when the sides of the tumour are supported by the sides of a more contracted canal. Added to this, the very pressure of a contracted vagina is an evidence that the constitution still possesses a considerable de- gree of vigour: so that the capacity of the vagina, in this in- stance, as well as in many others, is by no means a bad criterion of the strength remaining in the constitution. "When the tumour occupies only a small part of the os uteri, the opinion to be given should be more favourable, than when the whole circumference of the opening is involved in the disease." "The symptoms, in some cases of the disease, are diminished more easily than others; of which circumstance no knowledge can be obtained until the experiment has been made; the greater the effect, therefore, which local remedies produce in controlling the discharge, the longer will the disease continue, caeteris pari- bus, without destroying life." SECT. VIII. Treatment of the Cauliflower Excrescence. This disease, like some others of the uterus, if let alone, never cures itself. The debilitating nature of the discharges with which this complaint is always attended, will soon exhaust the woman that may be the subject of them the watery from the excess of its quantity, and the sanguineous from the importance of its quality, though it may not be profuse. Unfortunately, this complaint, in its commencement, does not excite as much alarm as its mischievous tendency should create. It were desirable that females should be better acquainted with the symptoms which forerun and accompany many of the dangerous diseases to which they are unavoidably liable, were it always safe to com- municate to them such information. But, unfortunately, the imagination exerts such influence over the happiness of mankind, as to render it extremely doubtful, whether more would not be lost than gained by such knowledge : it must, therefore, be left to contingent discovery for the present, as it has been hereto- fore. From the nature of the formation, or rather organization, of this species of tumour, it is evident that its extension or diminu- tion will very much depend upon the state of the circulating sys- tem both as regards its excitement, and its quantity of blood : and experience appears to have proved that nothing keeps it in subjection like controlling the force of the arterial system ; and nothing is so effectual to this end, as lessening the quantity of blood ; directly, by bleeding ; and preventing its accumulation by a well-regulated diet. Blood may be abstracted from the arm by the lancet; or it 280 TREATMENT OF CAULIFLOWER EXCRESCENCE* may be taken by cups, or by leeching, from about the sacrum or thighs : this will diminish the quantity of blood immediately pre- sent, and will afford relief. But this benefit will be transient, if new accumulations be not prevented, by severely restricting the patient to a very bland and unnutritious diet. The articles of diet must be not only void of stimulus, but should also be but little nourishing. If this be not attended to, no good can result from the abstraction of blood ; on the contrary, it may be even injurious, as the excitability of the system is increased by the loss of it. Mr. Clarke appears to prefer local to general bleeding. He also prefers cupping, to the application of leeches ; but without assigning any reason for the preference: we cannot see why either would not do. , Mr. Clarke says, " The diet should be of the mildest kind, such as puddings, white fish, and vegetables." In this country, we should look upon "puddings and white fish," as very substantial fare ; and would be far from the articles we should select as pro- per for a woman in this situation. Were we to direct upon such an occasion, we would confine the patient to black tea, thin cof- fee, and stale bread, for the meals of morning and evening ; and vegetables alone for dinner. These may consist of rice, the po- tato, the turnip, the parsnip, the carrot, the tomato, and the ripe fruits of the season. We might permit a little variety, by allowing rennet-whey, butter-milk, baked or roasted apples, thin vegetable jellies, as that of the tapioca, rice, or arrow root. Her drink should ab- solutely be water, barley water, molasses and water, toast water, or thin flaxseed tea. A recumbent posture must also be insisted on, or but little advantage will be derived from' the attempts made to reduce the force of the circulation. But it should be remembered, that it is not a matter of indifference on what the patient reposes ; it should be either a good elastic mattress, a sacking bottom, or a sofa. A feather bed would be directly injurious, by maintaining too much warmth about the pelvis. And Mr. Clarke insists, that, "if the patient be married, she should be separated from her husband's bed; to which she should never return." An unceasing attention should be paid to the state of the bowels ; a loose stool should be procured daily. When this can be effected by diet, it is always best it should be. For this purpose, the bread which the patient eats should be made of unbolted wheat flour; or this may be made into mush, and eaten with molasses. Indian meal gruel, sweetened with molasses, has also a favourable effect upon the bowels. But should these be found insufficient for the purpose, the pa- tient may chew daily a little of the root of rhubarb ; or take equal TKEATMENT OF CAULIFLOWER EXCRESCENCE. 281 parts of cremor tartar and the flower of brimstone, made into an electuary by molasses. The lenitive electuary alone, or a little increased in power, if necessary, by a small addition of powdered jalap, is oftentimes very effectual. Equal parts of calcined magnesia, and the flower of brimstone, is a very certain laxative. The solution of the sulphate of magnesia, in small doses, taken be- fore breakfast, is also very certain. At all events, costiveness must be avoided. Should it, however, accidentally occur, it should be removed in the most gentle manner ; for the strong efforts of the abdomen must be avoided. This will be best done by very mild injections, such as warm molasses and water, thin soap suds making the quantity such as will ensure their opera- tion, rather by their bulk than their stimulus. Mr. Clarke speaks in high terms of cold applied to the outside of the pelvis; and by injections of cold fluids within the vagina. The former to be applied by sponges, and the latter by the female syringe : these to be repeated twice each twenty-four hours. With a view to diminish the size of the tumour, Mr. Clarke recommends astringent applications. For this purpose, he ad- vises the sulphate of zinc, in the proportion of four or five grains to the ounce of water ; or alum, in the proportion of ten or twelve grains, with a little of the mucilage of gum Arabic ; or alum and the tincture of kino, as follows : R. Infus. lini, gxv. Aluminis, 3;ij. Tinct. kino, |j. M. Or, R. Cupri sulphat. grg. x. Aquae FJor. sarab. Mist- camphorae, vj. M. He gives several other formulae, much of the same character, but we think of no more efficacy. He suggests, with much pro- priety, the necessity of great care in throwing up these injections into the vagina, lest the extremity of the pipe should break a por- tion of the tumour, and occasion a bleeding. The round-headed pewter female syringe is the best for this purpose ; and even this should be introduced but a little way beyond the os externum. If the tumour has so far increased as to appear at the os ex- ternum, or just within the labia, it is advised, that the astringent fluids should be used by means of a common earthen butter boat; the woman having her hips elevated during the operation. And when the tumour has actually protruded, Mr. Clarke directs "compresses dipped in an astringent fluid to be applied to it; or the surface may be lightly touched with a soft sponge wetted with it," p. 98. 282 TREATMENT OF CAULIFLOWER EXCRESCENCE. As this complaint is sure, sooner or later, to be attended by great debility, the woman should be supported by tonics when this occurs. The sulphuric and muriatic acids are recommended for this purpose, with the infusion of orange peel, or of rose leaves, with great confidence, and, we believe, justly : at least we think they agree better than any other tonics we have tried, in wasting diseases. Bark in decoction, is also a favourite remedy with most prac- titioners, but it is sometimes difficult to restrain its effects on the bowels. The sulphate of quinine has not the same tendency to pass through the bowels, as the bark, in substance or in decoc- tion; it, therefore, merits the preference. The decoction of the cascarilla, (cortex eleuth.) has an admirable effect sometimes, where the bark is indicated but cannot be used. Of the general plan of treatment now laid down, Mr. Clarke speaks in the following terms. " The author is justified in re- peating that, by a strict attention to, and compliance with, the rules above suggested, nearly every case of this disease may be made tolerable ; and, perhaps, such a change wrought in the size or the actions of the excrescence, in a few instances, as to re- move all the symptoms," p. 104. He confirms these hopes by the recital of several successful cases. The ligature, however, he considers as an important auxiliary. It is to be applied as recommended for the polypus of the uterus. He declares, however, that more care is necessary in its appli- cation in the one case than in the other ; the cauliflower excres- cence being so very liable to bleed, when any violence is offered it. The shield recommended for the polypus is not so necessary in the cauliflower excrescence, as the tumour will be cut through in a much shorter time. The objection to the use of the shield in this operation is the possibility that the weight of it may tear through the tumour before the blood has coagulated in the ves- sels above. " After the removal of the disease, (tumour,) it is recommended that the vagina should be washed out with cold water, and that a solution of alum, in a strong decoction of oak bark, should be thrown into the vagina twice or three. times a day, and the ex- ternal orifice blocked up with a dossil of lint, so as to prevent the too sudden escape of the fluid. " A weak solution of the nitrate of silver, or of the sulphate of copper may be preferable, in some instances, to any other in- jection: it may be used in the following proportions : R. Argenti nitrat. grs. xij. Aq. distillat. 3 X 'J- ^ s0 ^ Or, R. Cupri sulphat. grs. xviij. Aquae rosae, o x 'J- ^ s l-" HYDATIDS OF THE UTERUS. 283 A piece of lint, wetted with either of these solutions, may be introduced, and placed against the diseased portion of the os uteri. "By such means, a slight inflammation may be excited in the blood vessels, so as to produce a consolidation of the parts diseased; and thus the regeneration of the tumour may be more tardy. " However favourable appearances may be in that part of the uterus which can be examined by the finger, there may exist out of reach, and consequently without the knowledge of the practi- tioner, morbid changes of structure, which may, of themselves, prove fatal," p. 112. We have chosen to quote the opinions of Mr. Clarke upon the subject before us pretty much at large, as his experience quali- fies him to give directions for the management of this disease, which our entire ignorance would not justify. The high stand- ing of this gentleman, as a successful practitioner, adds much value to his practical directions, and what enhances these opi- nions still more is, that they are altogether free from learned parade without elucidation ; and of ingenious speculations with- out practical improvement. SECT. IX. Of Hydatids of the Uterus. By hydatids is understood a congeries of vesicles of various sizes, containing a transparent lymph; attached to the internal face of the uterus, and with each other, by filamentous footstalks, much resembling a bunch of grapes. These vesicles differ in size, from the smallness of a pin's head, to the size of a walnut. They are looked upon as animals of extremely simple organiza- tion, and functions. 1 Of their origin we know nothing, and 1 This disease has been long known to physicians ; for it is said that ^Etius has distinctly alluded to it, yet the cause, and the precise nature of the product, is still unsettled. Valesneri looked upon this product as an enlargement of glo- bules or pouches, which he says he has discovered by the microscope to belong to the lymphatic vessels of the placenta, chorion and amnios, as a natural arrange- ment; but which, from some morbid cause, have enlarged themselves. Desor- meaux, aided by the microscopical observations of Velpeau,(a) has taken nearly the same view of the subject as Valesneri; while Percy looks upon them as ani- mals, and to be the tnenia hydatigena of Pallas, and declares(i) lhat he has seen them move, when exposed to the action of salt and vinegar. While Madame Boivin(c,) reverts to the old doctrine, that the vesicular mole, as she terms it, does not consist of hydatids, but is bona fide a degeneration of the impregnated ovum. For she declares that this vesicular cluster is covered by a membranous expan- (a) Nouvelles Reclierchcs, sur 1'orgine, fcc. (6) Diet, de M6decine, Art. CEuf. Vol XV. (c) Contort, Journ. de M6dtcine. XXII. 197. 284 HYDATIDS OF THE UTERUS. almost as little of their habits. Nor do we know how many species there may be of them, as several are sometimes found in the same animal. A large hydatid has several small ones attached to it, by small filamentary processes. These animals sometimes increase with great rapidity; and when their seat is in the cavity of the uterus, they distend it in proportion as they acquire size, or increase in number. The symptoms of this disease resemble very much those of in- cipient pregnancy after awhile the uterus enlarges, sometimes more, and at other times less rapidly, and may be felt in the hy- pogastrium swelling of the mammae most generally, together with the formation of a fluid, which may be discharged by the nipples and areolae, as in true pregnancy sometimes an alter- nate discharge from the vagina, of serum or blood ; and the ab- sence of a solid body immersed in a fluid, as takes place in preg- nancy, when the woman is examined by the touch. This last sign, when united with the rational signs of pregnancy, Madame Boivin considers as highly characteristic of the disease. And after the expulsion of this body, lochia follow, the breasts swell, and milk is secreted. The cause of the disease under consideration has never been discovered. These animals sometimes attack the external cover- ing of the ovum, and thus produce abortion. 1 See note below. It is not, however, ascertained that pregnancy is always ne- cessary for their production. 2 Indeed, in the only case we ever witnessed of this disease, it certainly was not immediately so, if reliance can be placed upon the general good character of the patient. The patient was more than thirty years of age, and had been a widow upwards of three years, when she was attacked with hydatids of the uterus. She observed herself to swell gradually, and also to decline in health; her menses were arrested, and her lower extremities sion which is divisible into two laminae one of which resembles the epichorion or decidua reflexa, while the other differs in nothing from the amnios. 1 A case of this kind, with a drawing of the ovum, has been kindly furnished me by Dr. Atlee of this place, accompanied by the following account of it. " The above is a rough drawing of an ovum beset with hydatids, which was expelled from the uterus of a particular friend, aged about forty-five years, who had had slight floodings every day, at intervals, for one month, unattended with pain; at the expiration of which time, labour pains came on, and the ovum soon escaped. The rationale of the case I have supposed to be thus: the hydatids forming and increasing gradually, separated by degrees the ovum from the parietes of the uterus, at each renewed separation causing hemorrhage, and soon the death of the embryo, which, on cutting into the ovum, was let out, in appearance like pus. The hydatids contained pure lymph." See Plate VIII. "Mdrne. Boivin and some others, think that impregnation is essential to the production of the uterine bydatid. Ruysch thought that a retained placenta would give rise to hydatids. HTDATIDS OF THE UTERUS. 285 were swollen. Her friends suspected she was pregnant ; and when she was attacked with periodical pains, they were certain their conjectures were well founded: at this time we were sent for. Before our arrival, however, the uterus had relieved itself by expelling nearly a chamber-potful of hydatids ; at least so we supposed them to be ; for they had been thrown out unfortunately before we came. 1 They said what came from her was like a very large bunch of grapes of different sizes ; from the size of a currant to that of a large fox grape. When we arrived, we found the woman very much exhausted by the discharge of blood, and which was still flowing in an alarming degree. This was, however, arrested by frictions upon the abdomen, ice, and large doses of the acetate of lead and opium. In the course of two years she had several attacks of this kind, each of which was less severe than the former ; and at last they seemed to cease spontaneously, and the woman reco- vered her health, without any thing particular having been done for her, except sea-bathing for a whole season. As connected with medical jurisprudence, it would be of the highest importance to determine whether impregnation be a sine qua non to the production of "hydatids but whether this will ever be satisfactorily determined, must be left to contingency, as neither reasoning, nor experiment, can well decide the ques- tion. We would, however, suggest, that as the opinion of Ma- dame Boivin rests upon assumption, as well as that of Percy, a jury should incline to the side of mercy, when a question of this kind is agitated. We therefore altogether applaud the decision of Percy, who acquitted a young religieuse of incontinence, by de- claring, that vesicular moles are merely hydatids, though she would perhaps have been condemned by Madame Boivin, had the appeal been made to her. We therefore look upon the hypo- thesis of this lady, if adopted in its full extent, to be highly dan- gerous, and must remain so, unless her opinion be unequivocally proved but, fortunately, hydatids is a rare disease, and cannot often compromit character or life. In consequence of the delicacy of the covering of the hydatid, it is easily destroyed by pressure, or any conquassatory motion of the abdominal muscles or uterus : hence they frequently burst, and give rise to a discharge of a pale transparent fluid, without odour or tenacity. And this circumstance may be said to be the only one which characterizes this complaint; for every other at- tending symptom is so common to many other affections of the uterus, that they would not serve to distinguish it. The greater part of the inconvenience of this complaint arises, as in preg- 1 " They are known to have remained in utero longer than other kinds of moles. Duges relates a case where 15 pounds weight of hydatids were discharged, which had been five or six years accumulating," 286 HYDATIDS OF THE UTERUS. nancy, from the pressure of the distended uterus upon the sur- rounding parts : hence we sometimes have cramps of the lower extremities, oedematous swellings of them, retention of urine, &c., as in a genuine pregnancy. I cannot find, in any memo- randa of the cases just related, any notice taken of the condition of the mammae from this diseased occupation of the uterus. This disease may be known from the cauliflower excrescence, by the occasional discharge of a watery fluid, and this in differ- ent quantities at different times ; whereas, in the latter disease, the quantity of fluid discharged is much greater, and more con- stant. As regards the sensible qualities of each, they perhaps resemble each other pretty strictly; but we know of no experi- ments to determine their chemical resemblances or discrepan- cies. 1 No remedy has hitherto been discovered for the relief of this complaint. The patient is not to. be led to expect any great benefit from art ; at least in the progress or in the interval of the disease. All it can do is to afford a degree of relief by aiding in a species of labour, which will sooner or later take place, from the distention of the uterus. Percy declares that after the discharge of vesicles had com- menced, he found great advantage from injecting a solution of salt in vinegar into the uterus. He declares this was followed by a rustling noise in the pelvis, occasioned, as he supposes, by the agitation into which the hydatids were thrown by this un- usual stimulus. On this point Mdme. Boivin declares her fear of either its utility or its safety, as in one of her own patients threatening symptoms of inflammation after its employment en- sued; and in another, it was of no advantage. She considers gentle titillation at the os uteri with the finger, stimulating in- jections per anum, frictions upon the hypogastrium, and the ap- plication of cold to the lower part of the trunk, to be more effi- cacious and safe. Injections into the uterus, of a stimulating kind, are useful, she says, when it does not contract, or if the hemorrhage continues after it has contracted. But we are of opinion that the "ergot," 2 as will be recommended presently, would supersede all these remedies. Mr. Clarke declares, " When this period arrives, at which the uterus is striving to unload itself of its contents, then all the skill and energy of the practitioner will be wanting, and all his efforts will be called forth to control the hemorrhage, and to sustain the powers of the constitution. With this view, the patient should 1 "They contain a fluid, which, in the smaller ones, is transparent, and in the larger ones I have seen them of a beautiful pink. It is less dense than distilled water; does not burn vegetable blue, red; it is not coagulable in either heat or acids." Nauche. 3 We believe we were the first to recommend the " ergot " in these cases. HYDATIDS OF THE UTERUS. 287 be kept perfectly still, in a horizontal posture : she should not be allowed to take any stimulating food or drink.' Cold applica- tions to the loins, abdomen, and external organs," &c. Treating it as any other case of uterine hemorrhage, by promoting, by every possible means, the contraction of the uterus. "Should any portions of the hydatid remain, and if the hemorrhage should continue profuse, an attempt should be made to remove these, in order to produce complete contraction of the muscular fibres." Vol. I. p. 120. This is to be done by introducing the hand, well lubricated, into the cavity of the uterus, and carefully detaching the adhering portions of the hydatids, and bringing them out with the hand. It will be perceived, that this direction cannot be complied with in all instances; for in all instances, the uterus will not be suffi- ciently distended by the hydatids to permit the passing of the hand with ease; and violence must never be employed in this, or any other instance, in passing the hand into the cavity of the uterus. We would propose, and we think with a fair prospect of suc- cess, the free use of the secale cornutum in this complaint, to pro- cure the expulsion of the hydatids ; especially in such cases as would not easily admit the hand, or where the contractions of the uterus were too feeble, or insufficient for their extrusion. So far as analogy and reasoning upon a subject will justify the employment of a novel remedy, we have them on our side ; for it is certain that the union of hydatids with the uterus is not more strict than the ordinary connexion of the placenta with that body ; and we know, from experience, that this connexion may be destroyed, most fortunately, sometimes, by this very peculiar and interesting drug. As regards ourselves, we shall not hesitate a moment to employ it. Since writing the above, I have been favoured with a letter from Mr. Anderson, of Hagerstown, Maryland, giving an account of the " ergot" in this complaint, which I shall have much plea- sure in detailing. The trial of this substance was made by Dr. W. D. Macgill, of the above named place. "Early last spring, Dr. M. was called to see Mrs. W., aged forty years, who had previously enjoyed good health, and had been the mother of several children. She was labouring under a very painful affection of the womb, accompanied with periodi- cal hemorrhagy, occurring once in twenty-four hours, usually in the evening, attended by febrile symptoms, and much disturbance of the digestive functions, and which was evidently making rapid inroads upon her constitution. During its farther continuance, her stomach became exceedingly irritable, so much so, indeed, as scarcely to retain nourishment of any description. Dr. M. ad- dressed his remedies principally to the restraining of the hemor- 288 HYDATIDS OF THE UTERUS. rhagy, and obviating the excessive weakness of the stomach. But notwithstanding, the symptoms continued to increase in violence, so much as to endanger the life of the patient. She had be- come very much exhausted by the repeated loss of blood, an ina- bility to take food, '(for she had now suffered for more than three months,) when the doctor made an examination per vaginam, (after having made them frequently before without any satisfac- tory result,) and discovered something protruding through the os uteri, which he extracted, and found that the poor woman was labouring under hydatids of the womb. He immediately sent for the ergot, judging from analogy that it would prove decidedly effectual in producing an expulsion of the heterogeneous mass. The event proved that he was not mistaken in his conjecture ; for he had given the ergot but a very few minutes, when it began to show its specific operation upon the uterus, and succeeded in a complete evacuation of its contents. The mass of hydatids equalled in size the head of a large child at birth, and afforded a very good specimen of the disease, a part of which we have made a preparation of. The representation in your book on the 'Dis- eases of Women,' is admirable. The floodings immediately ceased, and did not return. The woman rapidly recovered, until at length she attained her former health and vigour, and I be- lieve is again pregnant. She says her mother died of a disease exactly similar." "P. S. Dr. Macgill had not heard of your suggestion until after the delivery. He was led to the employment of the ergot solely from analogy." It seems, however, that the progress of gestation is not always interrupted by the presence of hydatids, as the following case proves. "Mad. Hec , aged forty years, had been plunged in misery and distress, from her own bad conduct, for some years. She was subject to attacks of lipothymia after eating. For four months the menses had been wanting, and it was supposed that she was pregnant. Dr. T. examined, but could not decide on this point. The woman herself, who had borne nine children, did not con- sider it as pregnancy. She believed, from the vomiting after food, that she laboured under scirrhus of the stomach, of which complaint her mother had died. Low diet and diluents were prescribed. There was now developed much irritation about the uterus, and leeches were applied to the groin and vagina. The irritation was removed. The stomach complaint was now much relieved. A month or more after this, our author was hastily summoned to Madame H., who was said to be in labour. The uterus was now much larger than when last examined, and seemed to fill the pelvis. There were bearing-down pains, and in these the uterus felt very turgid. The os uteri, however, HYDATIDS OF THE UTERUS. 289 was close, and no discharge from thence. The pains persisted without any alteration in the cervix or os uteri. This state con- tinued three days more, when it was perceived that at each bear- ing-down pain there was some discharge of clear water. This was followed, some days afterwards, by a large number of hy- datids, of various sizes, from an inch in diameter downwards. She continued to pass these bodies for fifteen days. In the mean time the size of the uterus rapidly increased, and rose out of the pelvis. It was now ascertained that there was a foetus in utero, and yet the hydatids were discharged daily in considerable quantities. 1 Three or four months after this she was delivered of a child at the full term, the hydatids having never ceased one day to be discharged. There were one hundred and forty-eight of these bodies collected, and the number broken and unobserved could not be estimated. The patient recovered, and did well. She has since become pregnant." We will give another case of this rare and interesting affec- tion ; as all that we can learn of a disease so uncommon and so important, will fall short, perhaps, of being sufficient to establish its diagnosis, and best mode of treatment. In the case follow- ing, we are disposed to believe, that had "ergot " been duly ad- ministered, it would have been more prompt in its action, and less equivocal in its safety, than the one pursued it, however, terminated well. A woman, after being six times pregnant, imagined herself with child for the seventh time, in consequence of the cessation of the catamenia. Soon afterwards she was attacked with in- cessant vomiting, the abdomen increased rapidly in size, and became tender to the touch ; the legs also became oedematous and the breathing short. These symptoms, however, she conceived to arise from twins, and she did not apply for medical assistance. In the fifth month of the supposed pregnancy the swelling of the belly became rapidly enormous, the oedema extended over the trunk, and her respiration became very difficult, when, at length, labour-pains suddenly set in, and considerable hemorrhage en- sued, which was at first checked by cold applications, but soon afterwards returned more violently. At the same time a large mass of hydatids, as big as two fists, was discharged. The ac- coucheur, who now saw her for the first time, found her pale, fainting, without pulsation at the wrist, and breathing slowly and laboriously. The fundus uteri was a hand's breath above the navel, and the tumour formed by the womb was regular, not elongated or lying to one side, as is usually the case in this dis- ease. The os uteri was dilated to the size of a half dollar, and 1 Does this case seem to prove, that hydatids do not depend upon a diseased ovum, as suggested by Madame Boivin? 19 290 IRRITABLE UTERUS. was very tender to the touch. Masses of hydatids projected from it into the vagina ; and there was constant hemorrhage. The treatment adopted in these circumstances consisted in the admi- nistration of tincture of castor every fifteen minutes, spirituous frictions of the abdomen, and the injection into the uterus of a solution of salt acidulated with vinegar. In consequence the la- bour pains, which had almost ceased, were speedily renewed, and rapidly increased in strength; masses of hydatids were at the same time discharged; and, ere long the hemorrhage ab'ated considerably. In the course of two hours the fundus uteri had descended to within a hand's breadth above the pubis ; in the course of the day it had descended still lower ; the hemorrhage ceased ; a warm perspiration broke out, accompanied with rising of the pulse, and the patient soon recovered. Milk appeared in the breasts on the third day, but receded again without any bad consequence. The hydatids weighed six pounds. They were attached to the remains of a membrana decidua." SECT. X. Of Irritable Uterus. By the "irritable uterus" we are to understand a peculiar and permanent sensibility of this organ, but more, especially of its neck, which attacks the female about the middle period of life, or a little beyond it; rarely showing itself before the five and twentieth year, and, perhaps, still less frequently after the men- strual periods have passed. Dr. Gooch, 1 who has devoted an excellent chapter to this subject, and was, as far as we know, the first author who treated of it, defines this disease to be "a pain- ful and tender state of the uterus, neither attended by, nor tend- ing to produce change in its structure." The latter part of this definition we do not think exactly correct, as we have always found some change in this part. This morbid condition of the uterus shows itself by both ge- neral and local disturbances. Of the G-eneral Symptoms. The general symptoms are, an increased frequency, and a preternatural firmness of pulse. 2 This frequency is commonly augmented towards evening ; the skin then becomes warmer, and the cheeks are reddened by a slight hectic blush. But the pulse is always more frequent and corded than natural, even in the absence of the exacerbation, but least so early in the morning. We have never observed any thing like a regular rigour attend this complaint, though we have often 1 In his work, entitled " An Account of some of the most important Diseases peculiar to Women, by Rohert Gooch, M. D." * Dr. Gooch says, " The pulse is soft, and not much quicker than natural, but is easily quickened by the slightest emotion," p. 313. IRRITABLE UTERUS. 291 heard the patient complain of chilliness, before an exacerbation of pain, especially if this were about to prove violent. The tongue is paler and whiter than natural, especially early in the morning ; towards evening it reddens andjbecomes cleaner ; more or less thirst attends, particularly in the after part of the day. The natural perceptions of the tongue are frequently per- verted ; so much so, sometimes, as to lead the patient to the belief that there is a hair upon it ; some say that the mouth feels as if there was dry flour in it ; while others declare the sensation re- sembles that of grease, &c. Headach almost always attends, and it is generally the back part of the head that suffers : this, for the most part, increases as the day advances, or as the pulse increases in force and fre- quency. The skin is always dry while the disease remains in full force ; and its general temperature is increased, if we except that of the hands and feet, which is much below the natural standard, espe- cially the latter: we have rarely known the febrile exacerbation terminate in sweat. The stomach is almost sure to suffer if the disease continue for a long time obstinate, though we have occasionally known it not to be implicated in the general mischief but the latter circum- stance may be looked upon rather as an exception to the rule ; as, for the most part, the appetite is impaired or very capricious, and eventually dyspepsia becomes established. The bowels are either too much confined, or are urged to diarrhoea; and if au attempt be made to remove the former condition by purgative remedies, the latter is certain to follow, by which every local symptom is severely augmented ; and thus the patient suffers al- most alike, from either of these conditions. The urine, for the most part, is sparing, high-coloured, strong- smelling, and throws down, when at rest, a large deposit or it is pale, abundant, and free from deposition ; but when this occurs, we have reason to suspect the disease is complicated with a cer- tain form of neuralgia. The urine is generally discharged witli some difficulty, and even pain is felt along the course of tho i urethra. Occasionally, the urine is suppressed or retained for many hours together, and is then voided with considerable suffer- ing. Local Symptoms. Sometimes the patient represents the parf.s as being a little swelled : but this we believe is always transient. Walking, riding, or indeed any kind of exertion, is sure to be accompanied or followed by severe lancinating pains within the pelvic cavity, especially from near, or in the course of, the ure- thra, to about the centre of the sacrum ; and when the severity of the pain has abated, it subsides into a permanent dull pain in the same direction, but more diffused. 292 IRRITABLE UTERUS. More or less leucorrhcea pretty certainly attends ; the colour of which varies almost in proportion to the degree of suffering ; when this is not very intense, it is thin and nearly transparent, pretty abundant, and without odour; while, on the contrary, when the pain is very severe and permanent, the discharge is thick, puru- lent, and is, if strict regard be not paid to cleanliness, oifensive. The uterus is almost always lower in the vagina than natural, and sometimes, indeed not unfrequently, it is found prolapsed. 1 There is considerable heat in the vagina, and always, so far as we have observed, a more than ordinary degree of sensibility in its parietes. In this we differ from the respectable authority of Dr. Gooch, who says this tenderness is confined to the neck of the uterus. 8 The neck is almost always a little shortened, en- larged, and exquisitely sensible to the touch, and the os tincse is rather more closed than natural. The pain which attends this complaint is always increased by an erect position, and it as cer- tainly abates by a recumbent one. Pain is usually felt immedi- ately behind the mons veneris and brim of the pelvis, especially its anterior portion. The sensibility of the neck of the uterus is at times so exqui- sitely great, that the woman shrieks if it be rather rudely touched ; nor does this pain cease, even for a very long time after it has been excited, especially at the lower part of the sacrum. Dr. Gooch tells us, that in a patient of his, it would remain for many hours, with great severity. Indeed, this tenderness is so great and so constant, in many instances, that great suffering is experienced if the patient incautiously sit down too suddenly, and particularly if upon a hard, unresisting seat; and the privileges of matrimony cannot be consummated without much suffering. Besides these local inconveniences, there is a symptom which is almost constantly present, and which seems, according to our experience, in an especial manner to characterize the "irritable uterus," but which is not noticed by either Dr. Gooch, 3 or Dr. Addison, 4 or M. Genest : 5 this is a pulsating, throbbing, or flut- tering sensation within the vagina or pelvic cavity. So far, we have never known this symptom wanting in this affection, though it differs very much in degree. In some few instances we have known it to interrupt sleep ; but this is not the usual state of this symptom, though it is represented to be very disagreeable al- ways. This sensation, however, is not constant; it often suffers * By prolapsus, we would wish to be understood, such a descent of the uterus as causes it to rest upon the internal face of the perineum. " Dr. Gooch says, "The finger can be introduced into the vagina, and be pressed against its sides, without producing uneasiness," p. 312. * Opera Citata. 1 " Observations upon Diseases of Females." * Recherches sur 1'Hysteralgie ou Neuralgic Uterine, et son Traitement Ga- zette Med. de Paris, Sept. 1830. IRRITABLE UTERUS. 293 abatement, and occasionally is absent but when present, it marks the irritable uterus in an especial manner. Dr. Gooch and Dr. Addison, in their descriptions of the "ir- ritable uterus," have added many symptoms that do not belong to this affection when simple and uncomplicated. To be con- vinced of this, it will only be necessary to compare the symp r toms we have detailed above, with those enumerated by these gentlemen. Dr. A. lays down the following marks, as belonging to, or produced by, "uterine irritation." He declares the most frequent symptoms of this condition to be "Irregular menstruation, the discharge being preceded or ac- companied by pain in the back, loins, thighs, or in the region of the uterus itself, attended with forcing or bearing down ; the dis- charge being in excess, either in point of mere quantity, in con- tinuance, or in recurrence ; tenderness of the womb itself, upon pressure made either externally or per vaginam ; a tenderness so great as to interfere with the privileges of matrimony, and, lastly, leucorrhosa. The most frequent symptoms, however, are, un- questionably, painful menstruation and leucorrhoeal discharge. Such are the few plain, simple indications of a state of the ute- rus which is repeatedly overlooked, though productive of the most serious disturbance, both of the general health, and of par- ticular organs ; disturbance which, when once produced, stamps a character upon the general and local ailments of the sufferer, strongly indicative, to the experienced man, of uterine irritation : a character which confirms us in the belief that it is from such irritation that the evil originates, and that it is to correct the condition of the uterine system that his chief attention is to be directed," p. 12. In addition to these symptoms, Dr. A. enumerates a long train of nervous symptoms as belonging to this affection in a word, he describes a well confirmed hysteria. Indeed, the description given by Dr. A. and that given by us, do not agree in a sufficient number of important points, to induce us to believe we are de- scribing one and the same disease. First. The greater part of the symptoms enumerated by Dr A. is descriptive of simple dysmenorrhoea. Second. He makes the cause of "uterine irritation" consist in "irregular menstruation;" 1 whereas, we are of opinion that 1 He says that " menstruation continues as usual, or perhaps a little more abundant; but generally it is less, and sometimes suppressed." From this we should be led to conclude that dysmenorrhoea, or even irregularity, in his estima- tion, are the causes of this complaint. We are every way certain that we have seen the " irritable uterus " unaccompanied by dysmenorrheea ; and we are equally certain that we have seen the latter many times extremely severe, without the former these conditions appear to be rather the consequences than the cause of the " irritable uterus" in many instances, while, in many others, they are unat- tended by them. 294 IRRITABLE UTERUS. the aberrations of the menstrual discharge, if there be any, are owing to the inflamed or irritable condition of the neck of the uterus. Third. The initial symptoms of the "irritable uterus " are not those of nervous mobility, though these symptoms are almost sure to follow, if the disease persist for a considerable time. Fourth. The symptoms laid down by Dr. A. are virtually the same as those to which the inflamed spine gives rise, and which affection, agreeably to Mr. Tate, produces the hysterical pheno- mena. These symptoms, however, do not necessarily belong to the "irritable uterus," but may be looked upon as purely ner- vous, and arise out of a morbid condition of some other part, or may be the result of an ''irritable uterus." Dr. A. thus cautions upon this point: "Whenever a female complains of a pain under the left breast, with or without palpitation or pulsation of the heart ; of pain in the right hypochondrium ; in the situation of the left or right colon : or acute pain generally over the whole belly, or in the region of the bladder or kidneys always be upon your guard; and if, upon inquiry, you find few or many of the constitutional symptoms I have described, together with uterine irritation, as shown by pain in the pelvis, in the loins, or in the thighs, before or during jthe flow of the catamenia ; by too frequent or too pro- fuse menstruation; or by leucorrhoeal discharge: I say, when you find such an assemblage of symptoms and circumstances, your suspicions will amount to a high degree of probability that the complaint is not of an inflammatory nature," p. 31. Now these very symptoms, we must repeat, Mr. Tate declares to belong to the inflamed spine. We must, therefore, say, that when these symptoms prevail, that neuralgia is either combined with, or is existing independently of, the "irritable uterus;" for we are of opinion, that the "irritable uterus" may exist in its gravest form in a state of combination with neuralgia, or it may be present without this complication, and exist independently. We think this opinion is abundantly confirmed by the symptoms enumerated by Dr. A. as constituting, or as arising from, "ute- rine irritation;" but which, as we have just said, Mr. Tate claims for inflamed spine. Such as a pain seated under the left breast, or under the margin of the ribs of the same side ; or pain under the margin of the ribs of the right side ; pain in the course of the ascending and descending colon ; pain affect- ing the whole abdomen ; pain in the region of the stomach ; and, lastly, pain in the region of the kidneys ; sometimes extend- ing down the course of the uterus to the bladder, p. 22. Now, in our opinion, the first five of the symptoms do not belong to the pure, or idiopathic, "irritable uterus." First, because we have known them to be absent in several instances of exquisite- IKEITABLE UTERUS. 295 ly formed "irritable uterus;" 2dly, because they are constantly present in hysteria, where the uterus may be in a perfectly healthy state for we have witnessed them in women who bear healthy children ; but we have never known conception to take place in women who labour under "irritable uterus." And the last enu- merated sign belongs more properly to the carcinomatous than to the "irritable uterus." Fifth. Dr. A. makes very young females liable to the disease which he describes; now we have seen the "irritable uterus" only in women who had arrived near, or had passed, the middle period of life. 1 Diagnosis. The "irritable uterus " may be distinguished from a neuralgic condition of this part by the following important par- ticulars. 1st, In neuralgia of the uterus there is an entire absence, at least as far as we have observed, of the general, or what we have termed the constitutional symptoms, especially the evening febrile movement. 2d, There is seldom, (nor is there ever, neces- sarily,) a vaginal or leucorrhoeal discharge; if it be present, it may have been habitual, and have existed before the neuralgic attack. 3d, There is no preternatural heat in the vagina. 4th, Nor is the uterus so sensible to the touch, unless it be examined during the painful continuance of the paroxysm, and then, per- haps, it is even more exquisitely sensible than it is in the pure "irritable uterus ;" besides, in neuralgia, the pain is less constant, but is more violent during the paroxysms, and these pretty con- stantly observe periodicity, but which the "irritable uterus" is free from. 5th, In neuralgia, a paroxysm may be suddenly in- duced by passions or emotions of the mind, which is never the case in the "irritable uterus," though the latter is susceptible of great and occasional augmentation of pain, through the medium of the circulation, by errors in diet, or improper exposure. The "irritable uterus " is, however, more frequently confound- ed with prolapsus uteri than with any other complaint, as the local symptoms of the latter are a miniature representation of the former. And as the womb is almost sure to descend more or less in the " irritable uterus," this precipitation has been supposed 1 Since the above was written, I have been consulted by letter, in the case of a young lady, only eighteen, who, I have not the smallest doubt, is labouring under " irritable uterus," and forms an exception to the general rule of the period of life at which this disease may show itself. All the symptoms that mark this disease are present, even to the prolapsed state of the uterus. This is a case of great in- terest, as it occurs in a young person who, in other respects, enjoys a fair propor- tion of health; but which will, and must very soon, be destroyed, if this terrible affection be not speedily removed. There is, in this young lady, a strong scrofu- lous tendency, with some development. We have recommended absolute rest; a milk and vegetable diet; the rhubarb pill; occasionally, leeching or cupping; the iodine, and injections of the solution of the nitrate of silver, on the faith of its influence upon certain inflamed surfaces in other parts of the body. 296 IRRITABLE UTERUS. to be the cause of all the inconveniences experienced; and hence, the frequent failures of the pessary when it has been applied for the relief of the prolapsus. Nay, sometimes serious and perma- nent injury has been done by this instrument in these cases, with- out the practitioner being exactly aware why mischief should be caused by a machine that had been so often successful in cases so apparently alike. Consequently, it is a matter of much moment, that the two affections should not be confounded; we would, therefore, sug- gest the observance of the following precautions, when an exami- nation is about to be made per vaginam, for prolapsus uteri. First. Let the patient be placed upon her back with the knees drawn up. Second. Let the parts be well lubricated, that no pain may be excited by the introduction of the finger, lest a wrong conclusion be drawn from the complainings of the patient. Third. After the finger has possession of the vagina, a gentle search should be made for the neck of the uterus, and when found, the patient's attention should be solicited to the degree of sensation produced by touching it ; the portion of the body of the uterus immediately above the neck, and the sides of the vagina inquire if there be any extraordinary sensibility in either of these parts ; and if there be, in which of the parts it resides ; and if either of these parts be morbidly tender, the pessary must not be intro- duced, until this has been abated by suitable means. In this case the patient will be labouring under "irritable uterus," and not a simple prolapsus. Besides, in the "irritable uterus." the pro- lapsus is not always permanent but sometimes only so in the erect position of the body, as in standing. The "irritable uterus" has also been confounded with carci- noma of this organ, when it has been about to throw off its indo- lent condition, and to commence the ulcerative process. But the "irritable uterus " is easily distinguished from the carcinoma, by the neck of the uterus, in the latter, still retaining the original marks of carcinoma; as a thickening of the whole of its substance; by its having a cartilaginous feel ; by its being shorter ; and the os tincae being more open than natural; by tumours still occupy- ing the neck and pelvic portion of the body of the uterus ; by a pretty abundant and sometimes constant discharge of a serous fluid, which may be occasionally tinged with blood, and the almost entire filling up of the vagina by the increased size of the uterus. The "irritable uterus" has also been confounded with dys- menorrhosa, but from this functional derangement of the uterus it is easily distinguished. First. In dysmenorrhoea pain is only felt during the menstrual action ; whereas, in the other, the suf- fering is more or less constant, though subject to occasional ag- gravation, and this of a severe kind, at other than the catamenial IRRITABLE UTERUS. 297 periods. Secondly. The "irritable uterus" is not necessarily at- tended by dysmenorrhcea, nor is dysmenorrhoea usually attended by this irritable condition of the uterus; for we have seen very many instances to the contrary. Pathology. We have already declared our belief that this, dis- ease consists in a chronic or sub-acute inflammation of perhaps all the tissues that compose the neck of the uterus. The patho- logical condition of the womb, in this complaint, has, however, never been ascertained, by post mortem examination, as it very seldom, or perhaps never, of itself, destroys the patient. It were much to be desired, that an examination be made, should opportunity present as we are of opinion, that more derange- ment of structure would be found in some cases, than appears to be allowed to exist by either Dr. Gooch or M. Genest, for we have met with several cases in which the size and form of the neck of the uterus was much altered from its natural condition. Indeed the admission of Dr. G. and M. Genest would seem to declare the same thing. Dr. G. admits that "the neck of the uterus is slightly swollen," (p. 312,) though he denies a change in its structure. M. Genest declares the same thing; indeed, the latter seems but to have copied Dr. G.. in his account of this disease. It is true, he has seen the disease, and appears to have been attentive to its phenomena; yet we would be rather dis- posed to question his accuracy, as he mentions that this disease continued during the whole of a pregnancy that terminated happily. Now, as far as we have had opportunities of noticing this disease, (which have been many,) we have never known a single instance of impregnation in a patient labouring under the "irritable uterus." We admit that, in an unmixed or idiopathic neuralgia of the uterus, very little, if any, derangement of structure takes place ; from which circumstance, we are disposed to believe, that when this undisturbed condition of the womb is met with, it betrays the neuralgic form of this disease. Dr. Gooch will not admit the uterus to be in a state of chro- nic inflammation. He saya that chronic inflammation, like the acute, is always "a disorganizing process;" but if we are not very much in error, a chronic inflammation may exist for an almost indefinite period, in some instances, without any very manifest derangement of a part ; and that there is some derange- ment in the "irritable uterus," we are, from many observations, very certain besides, there are present in this affection all the common characters of inflammation as heat, swelling, and pain; but whether there be unusual redness also, we are not prepared to determine. We are, therefore, disposed to believe that the conclusion of Dr. Gooch is rather hasty; for, indeed, his attempt to support his opinion is rather by analogies than by pathological observation. IRRITABLE UTERUS. |U f He says, "The disease which I am describing resembles a state which other organs are subject to, and which, in them, is deno- minated irritation. Surgeons describe what they call an irritable tumour in the breast. It is exquisitely tender; an ungentle exa- mination of the part leaves pain for hours; it is always in pain; but this is greatly increased every month, immediately before the menstrual period. Although apprehensions are entertained of cancer, it never terminates in disease of structure." "Mr. Bro- die describes a similar state in the joints." It chiefly occurs amongst hysterical females; it is attended by pain; at first with- out any tumefaction ; but the pain increases, and is attended with a puffy, diffused, but trifling swelling; the part is exceedingly tender ; this assemblage of symptoms lasting a long time, and being often little relieved by remedies, occasions great anxiety, but "there never arise any ultimate bad consequences." "The disease," says Mr. Brodie, "appears to depend on a morbid con- dition of the nerves, and may be regarded as a local hysteric affection." "These painful states of the breast, and of the joints, appear to be similar to that which I have been describing in the uterus ; similar in the kinds of constitutions which they attack ; similar in pain; in exquisite tenderness; in resemblance to the commencement of organic disease ; and in proving ultimately to be only diseases of function," p. 318. Now, we would ask, if the condition of the parts here described, and that of the portion of the womb implicated in the disease we are treating of, were identical, would it prove, that the symptoms to which they give rise do not depend upon a modified inflamma- tion? Does the attempt to illustrate the condition of a part in- volved in disease, by adducing the inexplicable phenomena pre- sented by diseases of other parts, (however strong their analogy may be,) throw any light upon its pathology ? Is not the patho- logy of " the irritable breast," or, "certain affections of the joints," as entirely unascertained as the situation of the structure involved in the " irritable uterus?" Does any definite pathological condi- tion of a part present itself to the mind, by saying that the phe- nomena of the diseases offered as illustrations depend " upon a morbid condition of the nerves, and may be regarded as a local hysteric affection?" or, in other words, is our knowledge of the pathology of the "irritable uterus" any way advanced by de- claring it is the same as in a "local hysteric affection?" Who has demonstrated the condition of either the brain or the nerves, which give rise'to the phenomena of hysteria; of the glands of the mamma in "the irritable tumour of the breast," or of the joints, in the disease of these parts, as described by Mr. Brodie ? Has it been proved, that the affection of a part called inflamma- tion, (either acute or chronic,) has no agency in the production of the symptoms which characterize the several diseases just named? Certainly it has not. IRRITABLE UTERUS. 299 Does Dr. Gooch's denial, that the "irritable uterus" depends upon a chronic inflammation of the neck, and perhaps a portion of the body of the womb, derive any support from Dr. Anderson declaring the same thing? We think not. In fact, whilst Dr. Gooch denies the presence of inflammation, he at the same time furnishes us, in the history of his cases, with sufficient evidence that this condition of the parts concerned really exists. Thus, in relating the history of the disease in question, one of his patients, he says, " In the lowest part of the abdomen, or a little lower even than that internally, she first felt a sense of heat ; to this was speedily added a sense of throbbing, then a sense of distention, as if there was a tumour within, which gradually expanded till it felt ready to burst: then began spasms; these she described as shooting, or electric shocks, darting from the tumour up into the abdomen ; they recurred every five or ten minutes, making her start with such violence as to shake the bed. I have been in the adjoining room when she has been in this state, and have perceived the shock; between the spasms she felt what she called a convulsive pain. Nothing relieved these spasms but a small local bleeding ; she has used fomentations, simple and medicated, for many hours, hip baths, opium in draughts, and in injections, without relief; but as soon as four or six leeches were applied, and had drawn blood, the spasms, distention, throbbing, and heat, speedily sub- sided, leaving a dull permanent uneasiness. The uterus was so tender, that the examination of it was torture, and left severe suffering for hours," 1 p. 335. Need better proof be given of the inflammatory nature of the irritable uterus than the treatment of this case ? Certain sensa- tions of spasms accompanied this complaint ; the sensations are described as consisting of local heat, throbbing, and expansion, to a feeling like bursting; the spasms as shooting or electric shocks, darting from the uterus up into the abdomen, which we are in- formed neither opium nor other means would appease, though persisted in for hours, yet were "instantly relieved by four or six leeches!" Causes. The remote causes of this very tedious and painful affection are involved in great obscurity indeed it may be ques- tioned whether any satisfactory remote or predisposing cause has ever been assigned, though we are in possession of a number of the exciting. These consist chiefly in severe fatigue, or other bodily exertion, as it almost always shows itself, after this has taken place, where predisposition has existed. Dr. Gooch says 1 We have never met with such an exquisite degree of sensibility in the genuine uncomplicated irritable uterus, as is here spoken of; where this has existed, to the extent described by Dr. Gooch, we have always had reason to suspect neuralgia was added. 300 IRRITABLE UTERUS. "In one patient it came on after an enormous walk during a menstrual period; in another, it was occasioned by the patient's going a shooting with her husband, not many days after an abor- tion ; in a third, it came on after standing for several hours many successive nights at concerts and parties ; in a fourth, it originated in a journey in a rough carriage over the paved roads of France ; in a fifth, it was attributed either to cold or an astringent lotion, by which a profuse lochia was suddenly stopped, followed by intense pain in the uterus ; in a sixth, it occurred soon after, and apparently in consequence of matrimony," p. 314. It is evident that the causes here enumerated were only ex- citing causes ; in none do we discover the predisposing, if we ex- cept the instance of abortion. It is more than probable that this effort of the uterus may be one of the common predisposing causes of the " irritable uterus;" we at least can say, that three of the severest cases we have met with were preceded by abortion. But, if abortion be admitted as the predisponent, it must also be granted that there may be many other causes, as we witness the "irritable uterus" in the unmarried, and in the widow fe- male, where abortion has had no agency. Dr. Gooch says, his " patients had previously manifested signs of predisposition to it ; they were all sensitive in body and mind : many of them had been previously subject to the ordinary form of painful menstruation." He then adds, with a view, we pre- sume, of conveying some idea of the pathological condition of the uterus, that "the disease seemed to consist in a state of the uterus similar to that of painful menstruation, only permanent instead of occasional," p. 315. Upon these observations, we beg leave to offer a few remarks, that our experience in the affection under consideration has sug- gested. First, it by no means accords with our observations, that those who are "sensitive in body and mind," are more ob- noxious to the "irritable uterus " than those of an opposite tem- perament for we have seen this disease in its most aggravated form in the hale and robust, and especially such as were of the sanguine temperament. Secondly, That no analogy exists be- tween that state of the uterus which gives rise to dysmenorrhoea, and that in which consists the "irritable uterus." For dysme- norrhoea is owing to a certain pathological condition of the in- ternal and secreting surface of the uterine cavity; whereas, in the "irritable uterus," some change has been produced in the parenchyma composing the neck of this organ, and to which the disease is confined, agreeably to Dr. Gooch's own showing. Thirdly, As we do not know in what manner the inner lining of the body and fundus of the uterus is affected, to produce painful menstruation, so we cannot be enlightened in regard to the pa- thological condition of the neck, while labouring under the con- IRRITABLE UTERUS. 301 dition vie are treating of. Fourthly, In dysmenorrhrea, the pain that accompanies the secretion of the menstrual blood, is not caused by any particular condition of the secreting organ, ab- stractly considered ; but to the changes wrought upon this fluid itself during its elimination, causing it to remain within the uterine cavity, until it becomes, to all intents and purposes, a foreign body, and requiring the aid of uterine contraction to expel it hence the pain of dysmenorrhoea, and, consequently, between it, and that attendant upon the "irritable uterus," there is not the slightest resemblance in either kind or cause. Fifthly, Were there the strongest resemblance between the pathological condi- tion of the internal surface of the uterine cavity, and that of the neck of the uterus, in the two affections under consideration, we should not profit from the analogy, as Dr. G. has not pointed out the condition of the former, that we might benefit from its resemblance to the latter. Dr. Gooch insists that the "irritable uterus" is "a disease of function, and not of structure," p. 316. We would ask of what function ? For Dr. G. admits that the menses continue to be dis- charged, though not in the most healthy manner ; but we have endeavoured to show that there is no necessary connexion be- tween the discharge and the disease in question for we have- seen them, as we have observed before, altogether independent of each other. And, if it be not the catamenial function to which he alludes, we are altogether at a loss to what other to assign it. Treatment. Would it were in our power to say that the treatment of the "irritable uterus" were as well understood, and as void of difficulty and uncertainty, as its obstinacy and seve- rity render it desirable ; for were we candid, we must honestly confess that the contrary of this is nearer the truth. This diffi- culty, however, does not arise so much from the indomitable na- ture of the disease, as from the length of time required to over- come it, and the privations to which the woman must submit who looks forward to its cure. Patience becomes exhausted, and confidence in the efficacy of remedies is too quickly destroyed ; for relief is not only almost ahvays tardy, but is too often un- certain; especially with patients whose circumstances and avo- cations will not permit them to fulfil any plan, however judi- ciously laid down, or however important its adoption may be to their welfare. We have just declared that relief in this disease is almost al- ways tardy; for however judiciously remedies may be advised, or however faithfully they may be applied, they are far from being uniformly speedy in their effects: in this opinion we do not stand alone ; for it is the declaration of the several authorities we have quoted above, and but too certainly confirmed by our own experience ; months, nay years, are sometimes required to 302 IRRITABLE UTERUS. accomplish a cure ; and if this be effected even after a very long trial of means, the woman may felicitate herself that she has been able to procure health, even at so great a price. In no disease does recovery so much depend upon the conduct of the patient herself, as in the "irritable uterus." The patient .must make up her mind to a long and irksome confinement to bed; she must consent to, perhaps, the frequent use of external applications and internal remedies, and submit to a system of diet or abstinence that will not bear infraction with impunity, if she expect to recover from this painful, wayward, and perplex- ing affection. All this should be fairly and candidly stated, and the patient's mind should be duly impressed with the absolute necessity of perseverance, and of the penalties that will await neglect, or that will follow infringement. On the part of the practitioner, much caution, as well as pru- dence is required, that no ill-founded hopes may be raised, or that the patient may not be unnecessarily sunk to despondency. He should not make a false estimate of the persevering nature of the disease, from its apparent mildness, at the momenttof its investigation ; nor be too suddenly elated, at the seeming success of his plan; for the symptoms of the "irritable uterus" afe not uniformly severe, or constantly obstinate, yet there is, perhaps, no disease of the female system more wayward in its intensity, nor more liable to recurrence, from either neglect or imprudence. He should be well aware of a truth, proved by multiplied expe- rience that no affection brooks trifling with so bad a grace as the " irritable uterus ;" and that all departures from prescribed rules is almost sure to be followed by penalties much beyond the seeming importance of the trespass. But, notwithstanding the unyielding nature of the disease of which we are treating, much may be done towards its relief, if we cannot always promise its removal; and we are rather dis- posed to believe that the difficulty of its management arises very often from the impatience, the imprudence, or the circumstances of the patient, rather than from the insurmountable nature of the disease itself. The first prevents the best application of the remedies ; the second may defeat their best operation ; and the third will perhaps interrupt their due employment. Having thus pointed out some of the difficulties inseparable from the management of this disease, and suggested certain cautions, that must never be lost sight of during this treatment, we will now proceed to detail all that experience has hitherto suggested for its relief. The therapeutical means will consist, first, of rest ; secondly, of bleeding, both general and local ; thirdly, of purging ; fourthly, of blistering, or of the employment of rubefacients ; fifthly, of narcotics; sixthly, of injections per vaginam; seventhly, of re- IRRITABLE UTERUS. 303 gimen; eighthly, of the application of the pessary; and, lastly, of tonics. Of Rest. A steady and persevering repose of body is a sine qua non in the treatment of a confirmed " irritable uterus." By rest, we are to understand almost absolute quiet in a horizontal position. The patient may make her election as regards the substance on which she is to repose: it may be a bed, a mat- tress, a couch or sofa; or she may occasionally vary either of these, provided these changes are neither made too often, nor too suddenly, nor at the expense of the patient's own exertions. The patient, for instance, may be carefully removed from either her bed or her mattress, to a couch or sofa, and this daily, if she choose this change, but she must preserve the horizontal position under all circumstances. She must not sit up even in the bed, or on the mattress or sofa, even for a short time, as this slight indulgence is almost sure to be followed by an increase of pain, or other inconvenience; a fortiori, she must not be permitted either to stand for any time upon her feet, or to walk. Nothing shows the extreme sensibility of the uterus, (or rather a portion of it,) more decidedly, than that augmentation of pain, which almost instantly takes place from an erect, or even a semi- erect position, and which obliges the woman, almost instinctively, to return to a horizontal one. All her unpleasant symptoms are suddenly increased ; especially the throbbing sensation, which, as we have declared above, so particularly characterizes this disease. This increase of pain most probably arises from two causes: first, from the uterus being obliged to sustain much of the weight of the abdominal viscera ; and, secondly, this position retards the return of blood from these parts. At first, the confinement to bed is extremely irksome ; but the patient should be encouraged to perseverance, by the assurance that this unpleasant sensation will wear off in a short time; and that she will not only become reconciled to the horizontal posi- tion, but will absolutely covet it, from the immediate and certain relief she will experience by returning to it after having sat up for a few minutes, or, sometimes from even attempting it. The cause of this increase of pain we have endeavoured to explain above. Of Bleeding. First, we shall say a few words upon the occa- sional necessity of bleeding from the arm or foot. We would employ general bleeding only under two circumstances of the system first, where the circulation is vigorous ; the pulse tense or chorded; where there is much pain, and especially in the ab- domen, accompanied by cough or headache. In such cases we would abstract blood from the arm, to an amount that would afford relief even during its flow, did this require but eight or ten ounces, or a much larger quantity: for we have uniformly 304 IRRITABLE UTERUS. found that the proper abstraction of hlood from the system at largo, in the beginning of our treatment, was sure to be followed by advantages that could be procured in no other way besides, if we draw blood in sufficient quantity at first from the arm, we need rarely repeat this operation ; while, at the same time, its abstraction gives a more decided efficacy to other remedial means. Secondly, should the symptoms enumerated above be attended with a sparing menstrual discharge, we would abstract eight or ten ounces of blood from the foot, and this should be repeated five or six days before the next menstrual period, if the first has not succeeded. But the "irritable uterus" will require the abstraction of blood from parts near the seat of the affection, and this again and again the parts hitherto selected for this purpose have been the sa- crum, or the abdomen ; but multiplied experience has convinced me that as much advantage, to say the least, but we really think much more has followed, when the blood has been drawn from the inner part of the thighs, three or four inches below the vulva ; it may be drawn from one or both thighs at the same time, by either cupping or leeching, and should be repeated every four weeks, a few days before the menstrual period, until pain, &c., are much abated, or until the patient can bear to be placed upon her feet, or even walk, without much inconvenience or discom- fort. Four or five ounces may be drawn at each time. We have had, within the last year, a number of exquisitely formed cases of this disease ; and we are happy to state, that if blood be abstracted by leeches, immediately on the womb, to the amount of four, five, or six ounces, (as the inflammation may be more or less attended by a high degree of sensibility of the ute- rus,) the most decided advantage will quickly result. This ope- ration is one of less difficulty in its execution than would, at first sight, be supposed. The greatest difficulty is to get the patient to submit to it. It gives less pain than leeching from an exter- nal surface. We have seen several cases of irritable uterus yield to this plan, and the other means, diet, rest, &c., in a very short time, and much more completely. A tube is introduced into the vagina, through which the leeches are conducted to the neck or other portions of the uterus. The after bleeding is generally more considerable than from the skin. The application of leeches to this organ is a great improvement in the management of any of its affections. In judging, however, of the diminution of pain, it must be kept in view, that the effects of long confinement in a horizontal posi- tion be not mistaken for the consequences of the change of posi- tion upon the affected parts. We should, therefore, inquire into the nature of the existing feelings, and compare them, both in degree, and in their nature, with those that really belong to the 305 disease. To aid us, therefore, in forming a correct judgment upon this important point, we should, from time to time, make a careful examination per vaginam, with a view to determine the existing degree of sensibility in the neck of the uterus, and the several portions of the vagina. By doing this, we shall be able to determine the exact impression we are making upon the dis- ease ; and, consequently, thereby ascertain the extent of neces- sity for perseverance. In making this estimate we must never fail to take into consideration the state or degree of the "throb- bing sensation" we have mentioned, as particularly belonging to the disease. By this very much may be learned ; for, if this feeling do not dimmish with the sensibility, we may be certain that the affection has only made a truce, but has not retrograded; while, on the other hand, we may be assured, that, in proportion to the abatement of this unpleasant feeling, is the abatement of the disease itself. Purging. There is no one of the remedies proper in this disease so difficult to manage as purging -for there is no doing with or without it, as the bowels in this complaint are always either constipated, or too easily made free, and either condition is sure to aggravate the suffering. In tWs opinion I am happy to be supported by the experience c^" Dr. Gooch. But, not- withstanding these difficulties, it i? every way important that the bowels should be moved once a day; neither less nor more; and for this purpose nothing answers better than the simple rhubarb pill. Blistering and Rubefa'ienta. We are much at a loss to de- termine the exact valno of blistering in the "irritable uterus,'' as it has in some instances, we have thought, proved useful, while in others we have /eared it has proved mischievous ; on the whole, therefore, we s'e distrustful of this remedy. But not so of rube- facients, or resicating with the tartar emetic ointment. We have uniformly found the mustard bath of great utility in this disease, as there is a prevailing coldness of the feet and legs. This bath should be used whenever the coldness of the feet claims atten- tion, be this daily, more seldom, or oftener. The ointment should be applied to a pretty large surface of the abdomen twice a day, until a pretty extensive vesication is produced, and re- peated from time to time, as the vesicles may heal, and as the urgency of the symptoms may require. 1 * ' 1 We have frequently had cause to lament the tardy effects of this ointment. though pretty well aware of the causes. The first is, the adulteration of the tar- tar emetic; and the second, from the imperfect manner in which the ointment is prepared. We were, therefore, happy in meeting with M. Mialhe's directions for making it. As the efficacy of the ointment depends upon the minuteness of the division of the tartrite of antimony, M. M. recommends that "a saturated solution of it be made-in cold water, and that it be then precipitated with alcohol. A very small quantity of the latter will suffice, he says, to precipitate the tartar emetic 20 306 IRRITABLE UTERUS. Narcotics. Agreeably to our experience much caution is re- quired in the use of narcotics, at least of opium ; for, to this drug only, in one form or other, do we fly, when it is proper to sub- due pain by this means. Much mischief, we are persuaded, has been done by the too free use of this medicine, when exhibited to abate pain (coute qui coute,) when the disease has been mis- taken, or not well understood. For, as we have persuaded our- selves that the disease is inflammatory, we can readily under- stand why opium has done mischief, or why, at least, it has not proved always successful. This opinion must not be taken for a prejudice, or as one founded upon a hypothesis ; for the medicine has failed in other hands, as is abundantly proved by Dr. Gooch's cases. Yet there is a period at which there is both propriety and advantage in the use of opium and this is, after the gene- ral febrile symptoms have been removed or abated, and when the local ones are diminished in intensity. The neck of the bladder, and the whole tract of the urethra, are sometime* in a highly sensitive condition, and give much pain, especially in the effort to pass water ; for the relief of which much benefit has bt^n derived from smearing the parts just men- tioned, morning and evening, with the following ointment, con- ducted to the parts by tt^ point of the patient's own finger. R Ext. Belladon.J"/-- ''S^"fam. Cerate simp, receh preparat. j. M. When this period arrives, we do not hesitate to give opium, laudanum, black drop, or preferably ike sulphate of morphia in adequate doses at bed time, or oftenes, if suffering require. Opium may be given with much advantage 'a\ either of the forms now mentioned, in enemata, as well as by th^ mouth. But we should carefully watch the influence of this medicine upon both the general and local symptoms ; and if either be increased after its exhibition, or, in other words, if it fail in procuring relief, the quantity should be diminished, or it should be withheld altogether, until the system be farther relieved of its susceptibility to stimuli. To prove how important an attention to this circumstance is, we need only refer to the case we have related from Dr. Gooch, where opium, and many other means were employed, without benefit ; yet the patient was almost instantly relieved by the application of a few leeches. In a word, if opium is to be useful, it must only be employed under a reduced state of the arterial system. Of Injections. Under this head, we will comprehend, first, such as will deterge the vagina, and, at the same time, sooth the in the form of a powder of extreme tenuity. The precipitate is to be collected on a filter and dried. Two drachms ll "LD"!*! "Jt) i ! - fcl> Until the period of four and a half months, or even to the fifth, the ovum, when separated entire from the uterus, appears to be an ovular, spongy, fleshy mass; it bears evidence of attachment to the parietes of the uterus, in every point of its surface and it would seem to show, that at any one part of this it may be sub- ject to separation; and this separation will necessarily constitute a solution of continuity of more or less vessels; and a consequent hemorrhage. I have just intimated that this separation may be at any point of the ovum ; but the effects will be in some measure different, as it may happen near the neck, at the body, or at the fundus of the uterus. If the separation happen at the body or fundus, the blood proceeding from the lesion must increase the mischief, by separating other portions of the connecting medium of the ovum and uterus, before it can issue from the os tincee; it will, therefore, follow, that when this takes place, the chance of arresting a flooding, and preserving the ovum, must be diminished in proportion to the destruction of the connecting medium. But when the disunion takes place near the neck, the mischief will be less serious, though the discharge may be very abundant. It has been thought by some that the os tincge was always soon affected in cases of hemorrhage threatening abortion. But I am disposed to think that the uterus has been supposed to be open merely because clots were expelled from the vagina but this is by no means a proof of an open condition of the os uteri; UTERINE HEMORRHAGE. 319 for the coagula are always, perhaps, but certainly much the most frequently, formed in the vagina, when an ovum occupies the ca- vity of the uterus. Of this the most decisive proof can often be given, in the very early months of pregnancy, by a mere survey of the size of an expelled coagulum; for many times, it is five or six times the bulk of the uterine cavity. But little information can be derived from an examination of the state of the uterus in the commencement of a flooding at this time; for the os tincse may be completely closed for a long time, in some instances, though the ovum may be eventually cast off; while in others, it may be naturally a little open, without offering additional risk to the embryo. But I may safely declare, when the neck of the uterus is dis- tended, so as to resemble in feel the extremity of an egg, that abortion will sooner or later take place, however small the open- ing of the os tincse may be. In this case the uterus is thrown into complete action, and the extension of the neck of the uterus, just spoken of, is the effect of these contractions. There is another mark equally unequivocal ; and to which it may be proper now to advert, namely, the cessation of morning sickness ; a diminu- tion of the abdominal tumour ; but, above all, the mammae be- coming painful and distended with milk, and these pretty quickly followed by flaccid breasts. In both of these cases, all attempts to save the ovum will be unavailing ; and our whole care must be directed to the state of the flooding. Nor is the quantity of blood expended, in itself, however exces- sive, positive evidence that abortion will take place ; especially when unaccompanied by pain for I have repeatedly seen a -very large waste, without any other evil attending ; while, on the con- trary, I have witnessed the expulsion of the ovum with the loss of a very few ounces, when accompanied by pain. 1 As a general rule, perhaps, it may be said that flooding following any violence, more certainly ends in abortion, than those which come on silently and slowly, without any apparent cause. No reliance should be placed upon the opinion, that a mode- rate discharge of blood from the vagina during pregnancy, is use- ful by removing topical plethora. 2 On the contrary, we should look upon every appearance of this kind with great suspicion, and treat it as if it were to become decidedly mischievous. There- fore every sanguineous discharge from the vagina of a pregnant woman should be treated with the utmost care all the essential 1 Pain accompanying flooding should not make us abate our endeavours to save the ovum, but under the circumstances stated above, for I have seen ii preserved; while I have witnessed several instances of ova being cast off, where neither pain nor flooding accompanied the expulsion. * Kok says that local plethora is a cause of hemorrhage. (See Pasta, p. 275.) 320 UTERINE HEMORRHAGE. indications for hemorrhage should be instantly complied with; and no time should be lost by temporizing. The essential indications are, 1st, to arrest the bleeding ; 2d, subdue pain, if present ; and, 3d, prevent a recurrence of the he- morrhage. These three points are constantly to be kept in view, as the preservation of the ovum, or even of the woman, is dependent upon their fulfilment. Therefore, whenever a woman is attacked with hemorrhage from the uterus, the sooner it be arrested the better: every known remedy of efficacy is to be employed in suc- cession, should the antecedent ones fail of success; and every ad- vantage must be given to these means, by the patient and her attendants, by a strict adherence to the directions enjoined. It would be in vain for the physician to prescribe, if either the pa- tient or attendants run counter to his instructions ; and in no case, perhaps, is their observance of more decided consequence than in the complaint we are now considering. One of the first steps to be taken is to command the most per- fect possible rest of body and of mind. The patient should be placed upon^t mattress, sacking-bottom, or even the floor, in pre- ference to a feather-bed. The room should be well ventilated ; the patient very thinly covered ; her drinks, toast-water, cold balm-tea, lemonade, ice-water, &c. No stimulating substance of any kind should be permitted. Care should be taken, even in the administration of food and of drinks, that the patient does not exert herself to receive them ; she should be strictly confined to a horizontal position. Her food should be of the same general character as her drinks such as thin sago, tapioca, gruel, or pa- nada in neither of these should wine, or any other liquor, find admission; they can be rendered agreeable by lemon juice, sugar, or nutmeg. All animal food, or the juices of them, in the com- mencement of a flooding, should be forbidden. Let "'whatever is given, be given cool. Absolute rest of every member of the body should be enjoined. The officiousness of nurses and of friends very often thwarts the best directed measure of the physician, by an overweening de- sire to make the patient " comfortable." This consists in changing of cloths, "putting the bed to rights," or altering her position. All this should be strictly forbidden. Conversation should be pro- hibited the patient ; and all company excluded. Much mischief is sometimes done by the talking of the by-standers ; for they, for the most part, delight in the marvellous, and relate the his- tories of cases every way calculated to appal the already too much alarmed patient. This kind of gossiping should be pe- remptorily forbidden, even at the risk of giving oflence, rather than permitted, to the certain injury of the sick. u-; ,- Having established a proper system for the repose of the pa- r. :;_>/! UTERINE HEMORRHAGE. 321 tient, and the government of the attendants, we should next de- termine the propriety of blood-letting this becomes very often of high importance; especially at this division of our subject: plethora is a usual attendant at this time; nay, may be, as I have hinted above, the very cause of the alarm. Blood should be taken from the arm in a quantity proportionate to the force of the ar- terial system ; remembering we do little or no good by the ope- ration, if we do not decidedly diminish the force of its action ; let the pulse rather sink under the finger than otherwise ; its re- petition must be regulated by circumstances ; recollecting, how- ever, that hemorrhage is sometimes maintained solely by exalted arterial action ; as the following case will very clearly show. I was called to Mrs. B. in January, 1796, whom I found much exhausted by uterine hemorrhage, in the fourth month of gesta- tion. She had several days previous to my visit, returns of flooding, which were little attended to. The usual means were now employed, and for the time, the discharge was arrested; this was early in the morning of the 16th. She remained very well until 5 o'clock, P. M. At this time she had a return of flooding: I was instantly sent for; and, living but a few steps from the patient, was very quickly at her bed-side. She was found to be flooding very rapidly ; the pulse was very active ; and the eruption of blood appeared to have been preceded by a slight rigour, followed by high arterial action ; she was instantly bled from the arm, until there was a reduction in the force and fre- quency of the pulse ; and the abdomen covered with ice and snow. So soon as this took place, there was an abatement of the dis- charge ; this condition was followed by slight alternate pains in the back, shooting towards the pubes. Forty-five drops of lau- danum were now given; and strict injunctions left, that the patient should be kept as quiet as possible: and in case of return of the flooding, that I might be instantly apprized of it. 17th, A. M. The patient was found free from fever, and almost free from dis- charge ; she continued so until about 5 o'clock, P. M., when the whole scene, as mentioned before, was renewed ; she was again bled; subjected to the application of the ice: and the laudanum was repeated for the same reasons as yesterday. 18th, A. M., 8 o'clock, I was called suddenly to my patient, as she again had a return of fever, with hemorrhage: she was again bled, &c. In this manner did matters proceed for several days; it was now found, that the arterial exacerbations observed no regular period; but whenever they did occur, there was uniformly a re- turn of the flooding; and would continue during this state of ex- citement. With a view to interrupt this condition, or to abridge it as much as possible, I placed a young gentleman at the patient's bed-side, with orders to bleed her the moment he perceived an in- crease- of pulse ; this was accordingly done; and from each bleed- 21 322 Vt UTERINE HEMORRHAGE. ing decided advantage was discovered. The loss of five or six ounces of blood was sure to put a stop to the uterine discharge, in the course of a few minutes ; and sometimes would prevent its appearance, when it could be very promptly used. By proceed- ing in this manner until the 23d, the patient was entirely freed from this distressing complaint. She was bled seventeen times ; and lost, by computation, one hundred and ten ounces of blood in the course of seven days. She gradually gathered strength, and was safely delivered at the proper time. The acetate of lead should now be given, in doses and frequen- cy proportionate to the extent of the discharge. From two to three grains may be given, guarded with opium, every half hour, or less frequently, as circumstances may direct ; or in case the stomach be irritable, a very efficient mode of exhibiting it is, per anum twenty or thirty grains may be dissolved in a gill of wa- ter, to which must be added a drachm of laudanum, and this be repeated, pro re nata ; or we may give the extract of rhatany with great advantage, in the manner already recommended at p. 143, only the quantity should be repeated every hour or two. If pain attend, opium should be given until a decided impres- sion be made upon the uterine contractions ; or until its exhibi- tion appears to be totally unavailing. Should the discharge be profuse, the application of equal parts of cold vinegar, and spirit of any kind may be applied to the region of the pubes ; or what is still better, a large bladder, two-thirds filled with ice and wa- ter : the tampon should be introduced without farther delay. For the discharge from the uterus, when very profuse, will not always yield to these remedies ; and if it do not, it will very soon become highly alarming. To save even a few ounces of blood, is always desirable ; and sometimes it is highly important ; should the means just recommended fail in moderating, or stop- ping the threatened symptoms, no time should be lost in employ- ing the tampon. The best, I believe, is a piece of fine sponge of sufficient size to fill the vagina. It should have pretty sharp vinegar squeezed from it several times, with a view to clean it, and to have it imbued with this acid ; it may then be intro- duced into the vagina, and suifered to remain until its object is answered. Previously, however, to the introduction of the sponge, it will be well to examine the state of the neck of the uterus and the os tincse ; their condition will very much govern our decision and prognostics. Should the one be found entirely closed, and the other of its original shape, we may, notwithstanding the pro- fuseness of the discharge, and even the presence of pain, still en- tertain a rational hope of preserving the ovum ; but if, on the con- trary, the form of the neck be altered, and the mouth opened, we are pretty certain it will sooner or later be cast off. But neither UTERINE HEMORRHAGE. 323 of these conditions is to affect our conduct, as regards the hemor- rhage ; for this is to be stanched, though we are certain the em- bryo will be lost. Much error is sometimes committed, under an impression that the ovum must be expelled; and that nothing can be done advan- tageously for the woman, until this be effected. I have known a hemorrhage suffered to continue, almost to the exhaustion of the patient, because pain was considered essential to the throwing off the ovum, though on each return of it a large coagulum has been expelled ; or the discharge has been augmented by injudi- cious manual attempts to aid the expulsion of the ovum. Both of these mistaken methods cannot be too severely reprehended one for blameable supineness; and the other, for rash inter- ference. Whatever may be the rapidity of the discharge in such cases, it is ever under command, so far as my experience will warrant the assertion, by the use of the tampon. This should be instantly resorted to ; and its effects will be quickly perceived. 1 I deprecate with much earnestness, frequent and unnecessary touching. This is not only injurious, by fatiguing the patient, but by removing coagula, that may be important to the stopping of the hemorrhage. This should, therefore, always bo avoided ; except at such times as it may become necessary to ascertain whether the mouth of the uterus be yielding to the influence of pain. It therefore can only be necessary in such cases as are, or have been accompanied by uterine contractions. I also must seriously forbid all attempts to remove the ovum so long as the greater part of its bulk is within the cavity of the womb; lest its covering be broken, and the liquor amnii evacu- ated. We must let no false theory get the better of multiplied experience : all the latter goes to prove the impropriety of such a procedure ; for it is agreed by the most enlightened upon this subject, that it is mischievous to effect it, and unfortunate, when it spontaneously happens. The reason is obvious. The embryo is expelled, but its involucrum is retained; in consequence of which, the flooding is perpetuated, and much pain, and other in- convenience, if not danger, are experienced, before it is thrown off from the uterus. I must therefore repeat it as a rule, that the ovum is never to be pierced before the commencement of the fifth month, 2 unless the flooding js very profuse, the pains very urgent, and the os uteri pretty well opened. 1 Dr. Meigs informed me, however, of a case that fell under his notice, in which the discharge continued in an alarming quantity, though a tampon had been em- ployed. In such a case it might be well to make a piece of sponge occupy the os externum completely, and its escape prevented by continued pressure against it with the hand. * Burton, and some others, advise the rupturing of the ovum even at the second month than this, nothing can be less conformable to either souud itiioiuiig or good practice. 324 UTERINE HEMORRHAGE. In this advice I depart from the very high authority of Baude- locque, with whom it is not very safe to differ: he recommends this to be done always after the third month; provided the mem- branes do not tear of themselves. But very ample experience has convinced me, that it is safer to preserve them so long as the os uteri remains closed, be the pains ever so frequent or power- ful, or the flooding ever so profuse ; for the one may be diminished by opium, and the other arrested by the tampon. And if no pain attend, it almost becomes criminal to do so; since the ovum may, by the use of the tampon and the other remedies above suggested, be preserved. I have ever found, in such cases, that much effort is required to expel the secundines ; nor will we be much surprised at this, when we recollect the strong disposition the mouth of the uterus has to close itself at this period of utero-gestation. Indeed, I have repeatedly witnessed most alarming floodings from the placenta engaging in the mouth of the uterus, and am certain that they arose from the presence of the placenta, as the discharge always ceased so soon as this mass was removed. When the hemorrhage is contained in this manner, the pla- centa should be removed as quickly as possible ; but this is the difficulty. At the early periods of pregnancy, (those compre- hended within the first five months,) the uterine cavity is too small to admit the hand, or even a couple of fingers; indeed, sometimes, not even one; therefore, any attempt to deliver it by the hand alone, must almost always fail. If this mass be entirely within the uterus, or even nearly so, the os uteri will be found most generally, so much closed, even at the fifth month, as to prevent the introduction of the finger to hook down the placenta : and as we descend from this to the second month, or lower, it will certainly be so small, as to prevent the intromission of even one. Whenever this is attempted, (especially by the experienced,) it is almost sure to end in disappointment. Sometimes a portion of the placenta is felt without the os tincge ; and should its greater bulk be so situated, we can sometimes remove the whole, by pressing it between two fingers, and withdrawing it; and thus put a stop to the discharge; but it is rare that we are so fortu- nate. 1 In such cases, I have employed, with the most entire success, a small wire crotchet. This instrument is very simple in its con- struction, as well as in its mode of action. 2 ' From some late experience, I am induced to believe, that the ergot, if given at this time, will often supersede the necessity of the " crotchet." It must, how- ever, be borne in mind, that it is only in cases in which we cannot command the removal of the placenta by the fingers that is, where this mass continues to oc- cupy the uterine cavity, or but very little protruded through the os tincse. 1 The drawing I have given of this instrument is upon a reduced scale; the reduction is one-third. I consider this much more simple than the pince a faux UTEKINE HEMORRHAGE. The manner of using it is as follows: The forefinger of the right hand is to be placed within, or at the edge of the os tincse ; with the left, the hooked extremity of the crotchet is conducted along the finger, until it be within the uterus ; it is now to be gently carried up to the fundus, and then slowly drawn down- wards, which makes its curved point fix in the placenta : when thus engaged, it is gradually drawn downwards, and the pla- centa with it. The discharge instantly ceased, in every case in which I have used it. In all the instances to which I here refer, I am persuaded the women's lives were saved. In illustration of what I have just urged, I will relate one of the cases of the several that have fallen immediately within my notice. I was called to Mrs. H , on the third of August, 1807 ; she was at the third month of pregnancy, and was flooding violently; pains were frequent and severe; large doses of the acetate of lead and opium were ordered, together with cold applications externally the mouth of the uterus was a little open ; the ovum protruding; quiet, cold drinks, &e. were ordered. I now left my patient, and returned at twelve o'clock, three hours after the first visit the hemorrhage not abated ; pains increased ; the os tincaj more dilated, and the ovum more tangible. At three o'clock, P. M., the ovum opened spontaneously, and the embryo escaped flooding violent; pains trifling; syncopes frequeht; pulse very small and quick ; the placenta in part engaged in the os uteri a stimulating injection was ordered, with a hope it would bring away the placenta. Four o'clock, P. M., the injec- tion failed in the object for which it was given ; hemorrhage continues; syncopes frequent; pulse scarcely perceptible. The placenta was now removed by the wire crotchet; the flooding ceased instantly; the subsequent symptoms were very mild. Sometimes, when the ovum has opened, and the embryo es- caped, but has left its involucrum behind, the hemorrhage may not be violent, but may be of long continuance; at least it will be as long as this mass remains. In such cases where time is not so precious to the safety of the woman, I have, in several instances of this kind, administered the ergot in twenty-grain doses, with very decided and prompt advantage. The peculiarity of this period consists in the ovum not having the transparent membranes formed; and the practice founded upon this, as a general rule, is never to break the wails of it. germe, as proposed by Levret, and recommended by Lerouxand Baudelocque; or that of Burton, for the same purpose. 326 UTERINE HEMORRHAGE. - Second Period. This comprises all the time from the fourth and a-half, or the fifth month, to the entire completion of utero-gestation. The woman is liable to hemorrhage during any part of this period, by the action of any of the remote causes already enume- rated ; and in proportion to the advancement of pregnancy, will be the risk from flooding, as the quantity of blood thrown out in a given time is, cseteris paribus, greater and more difficult to arrest. Therefore, when a woman is attacked with a discharge of this kind, however moderate it may be in the commencement, we have no security against its increase, at any after-moment she is to be carefully watched, and most fully advised. We should insist upon compliance with the rules directed for the first period, and we must employ the remedies already proposed, as early as the nature of the case may require. I have already intimated, that a hemorrhage from the uterus during pregnancy, can only happen from a portion of the pla- centa being detached. It will follow that the issue of blood will be in proportion to the extent of surface so exposed ; to the ad- vancement of pregnancy and the force of the circulation. Now as the advancement of pregnancy is greater in this, our second division, than in the first, the chances for a more profuse dis- charge of blood are increased in an equal proportion : hence it is agreed upon all hands, that the risk the woman runs is very great; so great, indeed, sometimes, as to be very speedily fatal ; since we can have no influence over the extent of separation of the placenta, nor always have control over the force of arterial action. The indications, however, are precisely the same as for the "first period;" but their fulfilment is not always effected after the same manner. It is my practice, in cases of a threatened flooding, during pregnancy, or when from the rapidity of the discharge the woman's strength would be quickly exhausted, to use, in addition to the means just mentioned, the tampon. I have already said, I have found fine sponge the best; but where this cannot be procured, fine flax, or very well picked tow, or old linen, may be substituted. When the latter substances are chosen, they should be used in portions of moderate size, and well moistened with sweet oil, or melted lard they should be introduced one by one, until the vagina is completely filled; the whole may be secured by a com- press and T bandage. This latter precaution is not necessary when a sponge is used, if the piece be of proper size. From its compressibility, it is introduced without the least inconvenience, UTERINE HEMORRHAGE. 327 if previously prepared as directed ; and I believe it promotes coagulation quicker than any other substance, from its numerous cells giving speedy passage to the finer parts of the blood. It almost instantly puts a stop to the hemorrhage ; and in some instances, I believe I was entirely indebted to it for the preser- vation of the lives of my patients. Some object to the employment of the tampon ; they say there is danger of local inflammation from the use of vinegar : but ex- perience has proved it to be futile. The mode of action of the tampon in stopping hemorrhage is precisely the one nature employs, when she alone effects this end. A coagulum is formed from the tampon to the mouth of the bleeding vessels, and thus puts a stop to, or very much dimi- nishes, the farther issue of blood. It would seem, from all we know upon this subject, that there is a strong disposition in the cut or divided extremity of a blood vessel when at rest, or nearly at rest, to form a coagulum within itself, for the purpose of put- ting an end to the farther issue of blood; hence, the importance of coagula at the mouths of the bleeding arteries ; the formation of which is the first step towards spontaneous suppression. Puzos, 1 many years since, had pretty nearly the same notion upon this subject ; he said, that the coagula acted as corks to the mouths of the bleeding vessels. The internal remedies for the suppression of uterine hemor- rhage, when successful, must act by disposing the blood to co- agulate more speedily ; or immediately, upon the open extremi- ties of the bleeding vessels, so as to induce them to contract. Hence, the almost universal employment of that class of medi- cines called astringents. Leroux, 2 however, forbids them in uterine hemorrhage, after delivery ; but he does this upon a wrong principle. He says, "Dans 1'hsemorrhagie uterine violente qui succ6de al 1'accouchment, ils ne peuvent etre d'aucune utilite. Pour s'en convaincre, il suffit de se repr6senter la route qu'ils sont obliges, de suivre avant de parvenir ou lieu aii leur pour- rait etre utile, le temps qu'ils mettent si parcourir ce trajet, et les changemens qu'ils 6prouvent avant d'y arriver." In like manner, from their mode of action, Leake 3 objects to the use of astringents or styptics in this complaint ; and upon no better ground, I think, than Leroux ; for I know that certain of 1 "Ces sages precautions ont suspendu souvent, et quelquefois ont fait cesser des pertes de sang accompagnfees de petits caillots ; non pas en soudant, pour ainsi dire, a 1'interieur de la matrice Ie3 portions du placenta separees, mais en donnant le temps au sang arrete a 1'embouchure dps vaisseaux de'sy cailleboter, et d'y former de petis bouchons moules sur leur diametre capableg d'arreter le sang." (Mem. de 1'Acad. torn. i. p. 211.) ' Observations, &c. p. 209. On Child-bed Fever, vol. ii, p. 301. 328 UTERINE HEMORRHAGE. them, as the sugar of lead, (especially.) produces sometimes the most decided and prompt effects, let its mode of action be what it may. In many instances, it exerts a control over the bleeding ves- sels, as sudden as the ergot does upon the uterine fibre ; and, from the extent and certainty of this action, we might be tempted, without doing much violence to the delicacy of medical specula- tion, to call its action specific. In a word, we may justly ques- tion, whether any internal remedy can be successful in uterine hemorrhage, which does not exert an action somewhat specific. But neither internal remedies nor external applications should be exclusively relied upon, longer than is decidedly consistent with the safety of the patient ; for neither astringents of any kind, nor the tampon, can be availing in all cases ; and when they fail, there is but one resource, namely delivery; the considera- tion of which brings us to the other modes employed by a large class of practitioners, for stopping uterine hemorrhage ; namely, those who consider delivery the only resource. SECT. V. Delivery considered as a Mode of arresting (t Hemorrhage. From the time of Mauriceau and Dionis to the present mo- ment, the number belonging to this class is very considerable ; and if numbers merely were to be considered, the weight of evi- dence would be in favour of their practice. The want of proper knowledge in treating uterine hemorrhage by other means ; the fatal rapidity of its termination sometimes, where rupturing of the membranes, or delivery, was not performed, or where a feeble plan had been pursued : the occasional success of delivery, toge- ther with the strong probability of uterine contraction after this organ is emptied, and the influence of this contraction in arrest- ing the bleeding, has but too easily, and too generally, found ad- vocates for its almost exclusive employment. Thus, La Motte 1 thought it impossible to restrain hemorrhage, when the placenta was detached in part or entirely, but by the extraction of this mass; Dionis declared we should not defer the delivery of the foetus, if blood in great quantity and without interruption escaped from the uterus. 2 Mesnard advised delivery, if there was a flood- ing sufficient to cause fainting; 3 and Heister 4 and Puzos' were of the same opinion, &c., &c.; for it would be easy to multiply authorities, to considerable extent, to the same end. 1 Traite des Accouchemens, Obs. 216. Des Operations, p. 249. 1 Pasta, p. 170. Surgery, part ii. p. 257. 1 Mem. de 1'Acad. vol. i. p. 224. UTERINE HEMORRHAGE. The advocates for delivery, as the only means of arresting he- morrhage, may be divided into two classes ; first, those who paid no regard to the condition of the uterus when the operation was undertaken. The second, those who evacuated the liquor amnii previously to delivery, with a view to promote the contraction of the uterus, and hy this means put a stop to the flooding; the latter may be subdivided into three : 1st. Those who did not regard the situation of the os tincae, when they ruptured the membranes ; and if this operation did not immediately succeed, entered the uterus with the hand, by forced means, and imme- diately effected the delivery. 2d. Those who, having torn the membranes and gained the feet, were contented to bring them to the orifice of the uterus, and then trust to the natural efforts to perform the delivery. 3d. Those who never pierced the mem- branes but when the mouth of the uterus was either dilated or dilatable; and who, after rupturing them, permitted them to escape gradually, and finish the delivery slowly, or waited for the efforts of nature. From the improvements which midwifery has received within the last fifty years, I should not have expected to meet with an advocate for indiscriminate delivery, at the present day ; yet in Meygrier we find that advocate. That the most mischievous consequences have followed the practice of those who compose the first class, 1 we have the authority of Pasta, 2 who deprecates the practice as both cruel and dangerous ; of Kok, 3 who says he has seen it followed by inflammation of the womb; of Leroux, 4 who declares it to be dangerous to both mother and child ; of Baudelocque, 3 who insists that nothing can justify the accou- cheur, who persists to deliver while the neck of the uterus retains its natural thickness and firmness. And I may add my own ex- perience, as I once witnessed death as the consequence of such a proceeding. The method pursued by those of the first division of the se- cond class, is not free from serious inconveniences, and is, per- haps, scarcely inferior to the first, as the same violence must al- most necessarily be committed. The plan of the second division of the second class, (which I shall, in conformity with custom, call Puzos' method,) is far from being the one most conformable to the principles of the art : since, in its performance, great vio- lence is frequently obliged to be resorted to. 1 Among the first class, may be reckoned all the accoucheurs prior to the time of Mauriceau. To the second class, and the first division of that class, belong Mauriceau, Dionis, La Motte, Deventer, &c. &c. To the second division, we may place Puzos, Smellie, Delourie, &c. &c. And to the third, we have Lerouz, and most of the late writers upon midwifery. a Vol. i. p. 132. ' Pasta, p. 276. 4 P. 241. Vol. ii. p. 90. 330 UTERINE HEMORRHAGE. The objections to this scheme are, 1st, that every flooding during pregnancy is not necessarily followed by delivery; but if we adopt this method, it must, within a short period, take place, and this, perhaps, to the destruction of the foetus. 2d. Because the mouth of the uterus may be so placed as to render this operation very difficult, if not impossible; especially when the uterine orifice is still very thick and rigid ; for Puzos 1 himself confesses he was an hour or more before he could pierce the membranes ; and this was a loss of most precious time to the patient, as the flooding still went on, and he began to despair of the success of his method, from the excessive loss of blood, and was fearful he should be obliged to have recourse to forced de- livery. 3d. That the hemorrhage does not always cease after the rup- ture of the membranes ; but, on the contrary, sometimes becomes more violent at this operation. 4th. That the presentation of the child, if it be preternatural, and the presence of the placenta over the mouth of the uterus, will render this method ineligible. 5th. It is sometimes impossible to make a forced delivery ; es- pecially from the fifth to the sixth and a half month; of this La Motte 2 gives on example, and Smellie 3 another and I once saw a similar failure. And, above all, they have not pointed out any alternative when this plan shall have failed. It is only upon the method of those who compose the third divi- sion of the second class, or those who never pierce the mem- branes but when the os uteri is dilated or dilatable, that we can safely place reliance, in cases of severe flooding. It may be asked, what are we to do in cases of profuse he- morrhage, at any period from the fifth month to the full time, when the discharge threatens the life of the patient, and when the os uteri is closed and rigid? Are we supinely to witness her death, rather than employ some violence to relieve her ? Certainly not. If there really were no other remedy, forced deli- very, with all its disastrous consequences, might be justifiable ; but as we have the power of plugging the vagina, and prevent- ing the farther issue of blood, we should have immediate recourse to it: and this plan, so far as I have witnessed, has not failed; and this experience is so supported by that of Leroux, as to entitle it to entire confidence. By this means, time is permitted to the natural agents of delivery for the performance of their duties; and this is done, for the most part, with both certainty and success. The importance of the tampon is, perhaps, never so clearly 'Mem. sur. les Pertes, &c. p. 336. "Obs. 452. 2 Collect. 33, No. , Ob. 1. UTERINE HEMORRHAGE. 331 demonstrated, as when it is employed in cases where the flooding has proceeded to almost complete exhaustion, and where every ounce of blood is of immense value. In such cases, (before de- livery,) I have seen it arrest a profuse flow in almost a moment, and where the farther loss of* a few ounces must have been fol- lowed by death. Syncope, and even convulsions, have ceased upon its application. Though it be confessed that after the failure of the remedies recommended for the suppression of hemorrhage, as the applica- tion of the tampon, &c., there is but one means left in our pos- session, (namely, delivery,) by which the flooding can be arrest- ed, and the life of the woman preserved, yet it may be asked, is there no condition of the patient, in which it would be im- proper to attempt this, besides the rigidity of the os uteri ? To this, I answer, yes, I would say, that a woman reduced to the last extremity of weakness, but with a suspension of the dis- charge, should not be meddled with, so long as the hemorrhage is kept in check. But suppose the same degree of weakness, with a continuance of the flooding, to exist; should we, in such case, attempt delivery? I have no hesitation in answering this in the affirmative : but, previously to the operation, the condition of the patient should be candidly stated to her friends: it must be undisguisedly de- clared to them, that no undue calculation should be made of the benefit of delivery; but, as this operation offers the only possible chance of relief, it might be adopted. We may be encouraged to do this, as it now and then happens, that the woman recovers, under such circumstances, contrary to all expectation. Hitherto, I have said nothing of opium as a remedy in uterine hemorrhage ; the reason is simply this it has never merited the smallest commendation in my hands ; for it has never been at- tended with the slightest success; of course, I cannot be of opi- nion, that it deserves the encomiums which have been so lavishly bestowed upon it by Dr. Hamilton and others. I have read, dis- passionately, and with care, Dr. Stewart's book upon this subject; and have cautiously examined the cases detailed by him ; but they have not afforded me the slightest ground to believe that the opium had any agency in arresting the floodings for which it had been so liberally administered: the cessation uniformly appeared to be the result of the natural powers of the system in general, and of the uterus in particular. That it is sometimes beneficial, previous to delivery, in allaying pain, and in this way putting a stop to farther mischief, I most freely confess; but I cannot yield any thing more. I am not alone in this respect : Dr. Denman seemed to entertain the same opinion ; and Barlow has advanced similar sentiments. It may be proper to say a few words upon the subject of cold 332 UTERINE HEMORRHAGE. applications, as no remedy has been more extensively employed, or more constantly abused. Cold, as a means to arrest flooding, is in almost universal employment, is usually one of the first re- sorted to, and the last that is abandoned it has acquired so much popularity among the vulgar, as to render it unsafe for the reputation of the practitioner, who has omitted it in his treatment of this complaint. But, though confessedly an agent of great power, it has never- theless its limits of usefulness ; and beyond which, it should never be urged for its efficacy is very much confined to its influence over the circulating system, by diminishing its vigour, and aba- ting its velocity, though it may also act as a stimulant to the uterus when its shock is first perceived, and thus induce contrac- tion ; but its greatest value seems to be in controlling arterial action. After these ends are answered, it is truly doubtful whether it should be farther persevered in; at least its utility is very much diminished. I employ it very liberally ; and sometimes, if the case be urgent, even at a very low temperature in general, the best mode of applying it, is by a large bladder, as has already been directed but, in very sudden and alarming cases, I have caused it to be teemed from a height upon the abdomen ; and this method of using cold, from its promptness, and the extent of its effects, has a very decided preference. But if the pulse flag, and the woman be much exhausted, I not only forbid it, but have a warm blanket, or other warm articles, to supply its place. During the use of cold water, &c., to the abdomen, warm applications should be made to the feet and legs ; a bottle or jug of warm water, well corked, is one of the best and most handy: this last direction should never be omitted when the feet and legs are preternaturally cold. We, also, should be particularly careful not to wet the bed and clothes of the patient, if it can be possibly avoided, as it creates much inconvenience, by rendering her situation extremely unpleasant, besides obliging her to be disturbed, that dry things may be substituted. The injecting of cold water, cold alum-water, the solution of the acetate of lead, the introduction of ice into the vagina, and even into the uterus, &c., have been practised ; and, it it said, with advantage. The merits of such applications must rest upon the authority of those who recommend them ; for I confess I have no experience in either of them ; nor should I be tempted to rely upon them in very pressing cases. 1 It may be proper to observe, in addition to the remedies and modes of proceeding pointed out in this division of our subject, 1 See chap, on " Unavoidable Uterine Hemorrhage, 5 ' in the author's System of Midwifery, for a variety of means lately proposed for the relief of hemorrhage. INFLAMMATION OF THE UTERUS. 333 that in certain cases of uterine hemorrhage, the forceps are the only means to be employed or relied upon. They are exclusively indicated, 1st, Where the discharge is threatening, and the labour well advanced ; but where the membranes have been long rup- tured, and the uterus is firmly embracing the body of the child, or the head does not advance with sufficient rapidity to afford security. 2d, Where the head is low in the pelvis, and has escaped from the orifice of the uterus in this case, turning must not be thought of, however recent may have been the escape of the waters; or however moveable the head may be in the pelvis. 3dly, Where the uterine efforts are either feeble, or suspended ; and 'where the os uteri is sufficiently distended, but where the waters have been long discharged. 4thly, Where the head oc- cupies the inferior strait ; the orifice of the uterus sufficiently ex- panded; the waters either recently or a long time expended; but where the natural agents of delivery would act too slowly for the safety of the patient. 1 5thly, Where the natural powers are in- competent to the sufficiently speedy delivery of the patient ; owing either to the waZ-position of the head, or to such a disparity be- tween it and the pelvis, as shall prevent its timely expulsion. CHAPTER XVII. HTSTERITIS, OR INFLAMMATION OF THE UTERUS. THERE is more ambiguity, or at least a greater want of pre- cision, in the accounts of the acute diseases which attack the puerperal woman, than in any others whatever. This does not arise from an absolute necessity; for they are neither obscure nor numerous. Those which attack the uterine system and its dependencies, have chiefly created the confusion; and this has mainly arisen from an overweening desire for great accuracy of distinction, without a corresponding power to give the signs by which each should be ascertained. Or in some instances, from a blameable generalization, making every febrile affection puer- peral fever. Thus, the disease now under consideration has almost always been confounded with puerperal fever; and the latter as fre- quently blended with the former: this has arisen almost entirely 1 From late experience, we have reason to believe that the secale cornutum may, occasionally, supersede the necessity of the forceps in this case : it should, at all events, be tried. 334 INFLAMMATION OF THE UTERUS. from not allowing that puerperal fever is an inflammation of some one portion or the whole of the peritoneum; and in not thinking, or believing, that the proper substance of the uterus can be inflamed without necessarily involving this membrane ; though the latter may become so secondarily. On this account it will be proper to divide hysteritis into two species; the first we shall call the simple or pure ; the second, the mixed or accidental inflammation of the peritoneum, or superadded puerperal fever. The first we shall define to be an inflammation of all or any portion of the proper substance of the uterus, except its peritoneal covering. The second where the latter is implicated with the former. It has been rendered highly probable, from the late ob- servations of Mr. Dance, and M. Tonnelle, that in hysteritis it is the veins of the uterus that are inflamed, and constituting a genuine phlebitis. Dr. Conquest says, " The substance of the uterus is sometimes infiltrated with pus, and becomes livid and spongy, or it may contain small abscesses ; and the uterine veins, particularly those containing blood from the spermatic arteries, may be inflamed, and contain coagula or pus." Obs. on Puerp. Inflam. And M. Tonnelle says if proper care be not taken in dissection, it will be supposed abscesses of the proper tissue exist, when the vessels are only affected. SECT. I. SPECIES 1. Causes. The causes which may produce inflammation of the uterus are all or any of the violences to which this organ may be ex- posed in the exercise of its functional powers, during the expul- sion of the child ; from those to which extrinsic aid may give rise, when its powers have been insufficient for the purposes of deli- very ; from those which may arise from the artificial delivery of the placenta ; or those which may act independently of either, but not readily cognizable. Under the first head we reckon, 1st, the long and reiterated efforts the uterus is occasionally forced to make to overcome the resistance which opposes the expulsion of the child; whether this arise from the rigidity of the neck of the uterus ; or of the ex- ternal soft parts ; the construction of the pelvis ; or the size or situation of the child. 2d. To violences committed in the use of instruments of any kind; to injuries sustained in the act of turning; or to ill-directed manoeuvres executed on the' neck of the uterus in attempting its dilatation, or by too frequent handling. 3d. To lesions of the internal face of this organ, from a sud- den, rude and unnecessary interference in the separation of the INFLAMMATION OF THE UTERUS. 335 placenta ; or to the injuries it may sustain from a placenta that has been too adherent. 4th. To those which may arise from exposure to cold ; checked perspiration; some secret influence of the air; improper regi- men, &c. 2. Symptoms. Whichever of the causes may have acted with sufficient force to produce inflammation of the uterus, we find that it generally betrays itself within the first five or six days after delivery. The woman complains of a pain at the very lower part of the abdomen, which gradually increases or can easily be augmented by pressure made immediately above the symphysis pubis. It is also increased by any motion which may disturb the repose of the uterus, as turning in bed ; sitting up ; passing of water ; or going to stool. If the fingers be made to press upon the uterus externally, it will be pretty readily distinguished by its size being greater than is usual at such a period after delivery; by its hardness, (which is very resisting,) and by its unusual tenderness. The pain which the woman feels is constant ; or it may be oc- casionally lancinating ; but it is always greatest when the uterus contracts and produces after-pains. From the after-pains with which it is sometimes confounded, it may be distinguished by th'e latter being always alternate ; and when the contractions subside which produce them, the woman is altogether free from pain, until they are again renewed. There is no swelling of the abdomen in the commencement of this disease, unless it arise from the augmented size of the uterus itself; but which is never so great at the onset of the complaint as to make it conspicuous. The abdomen does not participate in the slightest degree with the uterus, in simple hysteritis ; hence there is none of that tenderness which is witnessed in pe- ritoneal inflammation, or puerperal fever. Sometimes there is a frequent desire to make water, attended with more or less pain : or there may be a retention of urine ; especially if mechanical aid has been required to effect the deli- very; and the passing of water is accompanied by a sense of heat or burning in the urethra and vulva. The urine is almost always high-coloured ; generally scanty, and will deposite a lateritious sediment. In judging of the urine, however, we must take care that the mingling of the uterine fya- charges with it be not mistaken for the tone of colour of the urine itself. 336 INFLAMMATION OF THE UTERUS. . \ 3. Constitutional Symptoms. The symptoms which we have just enumerated may be looked upon as strictly local, and such as would necessarily arise from an inflamed condition of the uterus ; but these symptoms exist but a short time independently of constitutional disturbance. Soon after pain, &c., as above described, is felt, we find the heat of the body very much increased, without, for the most part, the interposition of "chill." The head becomes painful, the face flushed, and very frequently there is delirium, 1 if the fe- brile irritation be not soon relieved. The tongue is white, much loaded, and Dr. Clarke says dry; but thip we have never witnessed at the beginning of the dis- ease. It is true there is less moisture than is usual in the mouth, and the little fluid there is, is more clammy than is com- mon in fevers of an ordinary kind. This creates a great, and sometimes almost an insatiable thirst. The pulse is full, strong, and hard ; its frequency is not very great ; rarely a hundred. 2 Dr. Clarke says, from one hundred to a hundred and twenty strokes in a minute. This we have never seen in the simple hysteritis ; nor does it become so, unless the disease is running on to a fatal termination. The stomach, we believe, is never much affected in the begin- ning of the disease ; certainly never, or but very rarely, pro- voked to vomiting. As the disease progresses, or rather as soon as the constitu- tional symptoms commence, the pain extends itself to the back, and down the thighs ; and sometimes a pretty severe one is felt beneath the lower part of the ribs on the left side. As the lochia are interrupted to a greater or less extent in in- flammation of the uterus, it has been commonly supposed that the disease is produced in consequence of that obstruction. But, as the lochia are nothing but evacuations of the blood, with which the uterus was filled, and with which it will continue to be filled, until the vessels of this organ and their open orifices contract so much as to refuse to transmit more, the lochia must be looked upon as a discharge dependent upon the condition of these ves- sels, or rather on the degree of contraction of the uterus. Con- sequently, their being more or less abundant must depend upon the state of the vessels which furnish them ; and the state of these 1 It may be looked upon as almost a character of hysteritis, that delirium al- most always attends it; while, in the unmixed puerperal fever, of peritoneal in- flammation, it rarely occurs. a This is another peculiarity in hysteritis, as distinguished from peritonitis, and serves to show how much inflammation of particular structures influences the cir- culating system. There is no instance of pure hysteritis, so far as we have seen, in which the pulse is as quick as it is in puerperal fever. INFLAMMATION OF THE UTERUS. 337 vessels must necessarily be influenced by other portions of the uterus, by the degree of inflammation. Now, the uterus when inflamed, swells ; and this swelling, in consequence of its effect upon the extremities of the exposed vessels, prevents the usual flow of the lochia ; and from which two effects are produced : first, an accumulation of blood in the uterine vessels, which stretches them anew; and second, an aggravation of the inflam- mation from this distention, as well as augmentation of pain. We may assign another reason, indeed, for the lochia being less abundant at this time; which is, the tonic contraction of the uterus being suspended ; consequently, one of the causes by which the lochia are forced through the vessels of the uterus is with- drawn, and the quantity discharged will consequently be 'ess. It must, therefore, follow, that the diminished lochia is but a con- sequence of this condition of the uterus, and not the cause of it. It would be as rational to say, because there is a sparing se- cretion of urine in nephritis, that this scarcity is the cause of the inflammation of the kidneys; or that a diminished quantity of bile is the cause of the inflammation of the liver in hepatitis. It is true that the lochial discharge is highly important at this time to the uterus itself; since it unloads its vessels, and thus pre- vents the consequences that would most probably follow its over- exertions, as well as promotes the tonic contraction of this organ. But, as their existence altogether depends upon the degree of permeability of the vessels which open within the uterine cavity, their quantity and quality must necessarily be influenced by the condition of these vessels; therefore, the state of the vessels of the uterus may influence the lochia, but the lochia cannot affect the vessels of the uterus ; for they are not lochia until discharged from these vessels. The return of the lochia after they have been arrested, how- ever, is justly considered ad a favourable sign ; and this circum- stance has been urged s an additional argument in favour of their agency in producing this disease. But here the effect is evidently mistaken for the cause. The return of the lochia is only an evidence of the diminished resistance to the flow of blood at the extremities of the uterine vessels ; and this lessened resist- ance is owing to the abatement of the swelling which had inter- rupted its flow; and the reduction of the swelling is but a conse- quence of the retiring of the inflammation. Therefore, the lochia being diminished, or arrested, would tend to increase the inflammation that was the cause of this di- minution, or stoppage ; as there would now be an accumulation in the substance of the uterus, not only of all the blood sent there to supply the lochial discharge, but also that which always at- tends upon inflamed vessels. And, on the other hand, when the cause which arrested or diminished the lochia, (namely, inflam- 22 338 INFLAMMATION OF THE UTERUS. mation,) was so far diminished as to leave the extremities of the uterine vessels free, which, by again transmitting their contents to the cavity of the uterus, would not only relieve the engorge- ment with which they were accidentally affected, but tend also to relieve the vessels of the inflamed portion of this organ; and in this way is the lochial discharge useful. In pure hysteritis, the mammse sympathize with the uterus much less than in peritoneal inflammation, or puerperal fever; for we must be permitted to use them synonymously. (See Chapter on Puerperal Fever.) On this account we never have an entire suppression of this secretion, as in puerperal fever, un- less the disease runs an unusually long course, or has peritoneal inflammation added, or combined with it. Indeed, in a number of cases we have seen the offices of the breasts remain undis- turbed during the whole continuance of the disease. This circumstance is worthy of notice ; since it not only serves as a distinguishing mark between the two species of hysteritis, but also proves to us that the influence of the peritoneum, or some one portion ol the genital system, has a stronger influence over the formation ol milk than the uterus proper itself. Is this the peritoneal coat ot the uterus ? or is it only when the ovaria be- come involved, that this secretion is so decidedly interrupted, or suspended? We beluve it to be the latter. Does not this fact seiye to account for certain discrepancies in the accounts we have of the inflammation of the womb, and of puerperal fever? In one nuance the disease is called hysteritis, though the secretion of milk was interrupted; and in the other, denying the disease to be "genuine" puerperal fever, because this secretion was so little disturbed. In the first case it was a misnomer to call the disease hysteritis ; for so soon as peritoneal inflammation takes place, the disease is, strictly speaking, puerperal fever, though its cause may have been a preceding violent inflammation of the uterus, as we shall see more particularly, presently. In thcsecond case, the disease has been refused the title of puerperal fever, because the mam- mary secretion was but partially disturbed though a true peri- toneal inflammation existed. Thus we find that the epidemic fever described by Dr. Leake, as it appeared in the "Westminster lying-in hospital," was re- markable for the following peculiarities : first, the omentum be- ing the most common seat of the inflammation ; 2d, the almost total exemption of the uterus, and its appendages, from disease; 3d, the little disturbance of the lactiferous secretion, as will appear from the following statements. In case V., "the uterus as well as the bladder, was perfectly sound, and without mark of inflammation, or rather morbid affec- tion ; (state of milk not mentioned.) In this case " the omen- INFLAMMATION OF THE UTERUS. 389 turn was melted down." In case VIIL, "the omentum was much inflamed ; but the greater part of it was destroyed by sup- puration." "She had milk in her breasts until a day or two before her death." " The fundus uteri seemed to partake of the general inflammation which had attacked the omentum." " The lochia was not defective, neither was there a want of milk till after the febrile attack." Case XL, " the omentum was suppu- rated, and cop verted into thick matter." " The substance of the uterus was sound." "The secretion of milk was moderate on the third day ;" on the fifth, "her breasts subsided, and the milk suddenly disappeared." She died on the seventh day. Case XIII., " the omentum was destroyed." " The uterus had a na- tural appearance, and was perfectly sound." (The state of the milk not mentioned.) Case XVI., " the contents of the pelvis were sound." Milk not mentioned. In none of these cases is there any mention of the inflammation of the ovaria. The abd'omen, we have said, does not swell in hysteritis ; un- less it be merely in proportion to the increase of size of the uterus itself. This, however, we have seen pretty considerable, owing to confined coagula, but which has always subsided so soon as these were expelled by the contractions of the uterus. Indeed, this circumstance alone produces much pain ; and, for a short time, even threatens more serious mischief: especially as this takes place while the uterus is labouring under inflammation, as we have had occasion more than once to see : the sufferings then are very severe and even menacing. Under such circum- stances, we have known the uterus to acquire a size nearly equal to that at the seventh month of pregnancy. In this case the abdomen becomes very tender, and the system is always excited to fever ; the pain is constant, and scarcely to be borne; for now the uterus is suddenly put upon the stretch, and this during its inflamed condition. But this state, as far as we have witnessed, does not continue long; for the uterus be- comes stimulated to contraction after being thus painfully dis- tended ; its mouth opens, and the coagula are either expelled by one or two efforts, or it may require a number for this purpose. After the removal of these offensive clots, the woman is greatly relieved, and she is rarely exposed to a second attack. In hysteritis, then, so long as the disease maintains the cha- racter of the first species, the abdomen may be considered as but little affected; nor does it suffer at any period of the disease as it does in puerperal fever, either original, or induced; as, for in- stance, in the second species of hysteritis. On this account, the sufferings are not so severe, and the woman is enabled to change her position, without that intensity of suffering which she expe- riences from the same effort in peritonitis. The bowels are variously affected; but in the beginning, as 340 INFLAMMATION OF THE UTERUS. in peritonitis, they are generally disposed to constipation ; or this complaint may be ushered in by diarrhoea ; but this is rare, though no unusual attendant in the progress or last stage of the disease, though it may become critical. The symptoms we have just detailed may be looked upon as constituting the first stage of this disease; or the stage of high inflammatory action, which may terminate either in resolution, or in suppuration. When this disease is about to yield, there is an alleviation of all the more distressing symptoms ; there is a softening or re- duction of the uterine tumour, with an abatement of its tender- ness; the pulse loses its febrile and inflammatory character; it is less frequent, softer, and more yielding; the skin becomes re- laxed, and disposed to become moist. Headache abates, and de- lirium, if it had been present, subsides; the tongue begins to clean, and the thirst diminishes ; the lochia return, and their appear- ance changes to a more florid colour. The urine becomes more abundant, and less high coloured; the milk is more freely se- creted, &c. But should the disease not have abated, either owing to its in- tensity, or the feebleness of the means employed, the inflamma- tion may terminate by suppuration in various parts of the proper substance of the uterus, and which is almost sure to be followed by death. Sometimes, however, there is reason to believe that the abscess opens within tb.e cavity of the uterus, and escapes through the os uteri; in which case the woman may recover. "We have seen two or three instances, in which we believe this had occurred. A disposition to suppuration may be suspected, from the pulse becoming more irritated ; by its increasing both in frequency and quickness ; by the skin being alternately partially dry and moist ; chills of more or less intensity, with dark flushings on the cheek, or cheeks : by the tongue becoming dry and red; by the lochia escaping in a larger quantity, but very fetid ; in a word, the wo- man now sinks from irritative fever. Or, the inflammation may communicate itself to the peritoneal coat of the uterus, by pass- ing along the Fallopian tubes, or otherwise; and thus adding puerperal fever to the inflammation of the uterus, making the second species. SPECIES II. The mixed Inflammation of the Uterus, or accidental or /Second- ary Puerperal Fever. When the peritoneum, covering either the uterus, or its ap- pendages, becomes the seat of inflammation, the disease is called f: INFLAMMATION OF THE UTERUS. 341 by Dr. Clarke, a mixed case; and is one of almost certain fata- lity. For we have an inflammation now besieging two very different tissues or structures, and its effects upon either may bo sufficient to destroy life. This extension of inflammation may be always dreaded, when the first species remains unsubdued; especially after a vigorous treatment has been pursued; for it now betrays a disposition to run on to its second stage. This extension of inflammation to the peritoneum announces itself by the addition of several new symptoms to the unpleasant ones belonging to the second stage of the first species ; such as a great increase in the frequency of the pulse; hiccough; tenderness and swelling of the abdomen; vomiting ; an inability to lie, other than on the back ; a total stop- page of the lochia ; a cessation of the mammary secretion ; cold sweats ; muttering delirium ; a dry, husky, blackish tongue ; diarrhoea, &c. When the disease, by its extension, becomes the second species of hysteritis, it may be considered as almost necessarily fatal : at least we recollect no instance of recovery. Nor is this surpri- sing; since a highly dangerous complaint makes its appearance at a time the system is debilitated from the force of a previous disease, and the effect of remedies ; and is from these causes un- able to support the farther use of means for its relief. The patient, therefore, almost necessarily dies. Dr. Clarke has furnished us with the appearance of the parts after death, in both species of inflammation of the uterus. He says, " Upon examining the bodies of women who have died under this disease, we have found little or no extravasated or secreted fluids in the cavity of the abdomen, when the disease has existed simply. The peritoneal surfaces have been also dis- covered free from disease in some cases ; in others, however, the peritoneum which covers the uterus has been partially inflamed, and that covering the posterior part of the bladder. Inflamma- tion is often observed running along the Fallopian tubes, which, when cut into, will be seen loaded with blood. The ovaria, too, are often affected in the same way. " The uterus will commonly be found very firm in its sub- stance, but larger than when naturally contracted. Upon cut- ting into the substance of the uterus, pus is often found, which, in all the cases I have met with, is situated in the large veins of that part. 1 Pus is also sometimes found in the cavity of the Fallopian tubes, and also in the substance of the ovaria, which are distended by inflammation and matter, so as to equal in bulk, in some cases, a pigeon's egg. 1 In these cases it is more than probable that the disease was a genuine phle- bitis of the uterine veins. 342 INFLAMMATION OF THE UTERUS. "I have never had occasion to meet with any case in which mortification had taken place in any part of the substance of the uterus, except in one instance, where there was a gangrenous appearance of the cervix ; but it is to be remarked, that instru- ments had been employed in that case, by the gentlemen who attended the labour." Essays, p. 69. Treatment. The history of this disease will suggest at once its general treatment. a. Of Bleeding. The high inflammatory character of this complaint, especially in this country, declares the necessity of the most ample deple- tion, and the most abstemious diet. Blood-letting must be employed to the full extent the system will well bear ; or it will not and cannot be successful. The extent of bleeding in this disease must be regulated only by its effects ; its quantity must ever be of minor consideration, so long us the symptoms continue to demand its repetition. Dr. Clarke says, " In the repetition of the operation, (bleeding,) we must be governed by the same circumstances, and the effect of the former evacuation upon the disease ; and it must be observed, that it will frequently be found necessary, not only a second, but a third time," p. 73. From the histories of the dissections of those who have died of hysteritis, it is evident that nothing but very ample blood- letting and other depletions, can prevent the fatal termination of this disease ; or, at least, prevent its ending in suppuration, from which the escape with life must necessarily be rare. And though this disease is declared by Dr. Clarke, to be, " of all the serious complaints which attack the woman in the puerperal state, the least fatal," he is not to be understood to mean, that this is the case when this complaint is badly treated. For immediately after, he says, "Every art which has a tendency in any manner to diminish the quantity of the circulating fluids, and weaken the action of the heart and arteries, should be employed in order to subdue the inflammation at the very outset," p. 72. This exactly corresponds with our own experience in this dis- ease : we have, in every instance in which we have encountered it, abstracted blood, both from the system at large by bleeding, and also by large leechings upon the abdomen. With regard to blood-letting, our plan has generally been as follows : to bleed from the arm, until it produces sickness of stomach, at least ; if INFLAMMATION OF THE UTERUS. syncope take place, we have no objection. It will almost always be found, after this, that the fever and other signs of inflamma- tion will be much diminished ; but this, in many cases, will be of short duration ; for the system, if the bleeding has not been suffi- cient to "strangle" the disease, will react in the course of a few hours, and pain, fever, &c., will again be renewed. Whenever this takes place, be the period longer or shorter, it is to be re- peated again and again; nor do we know any reason for stopping, but the reduction of the disease. But our bleedings are not always renewed from the arm; for, as soon as we get the pulse pretty well down by this means, we have leeches applied over the parts nearest to the fundus of the uterus, and also to the vulva, in such numbers as shall abstract at least eight or ten ounces of blood, and encourage their after- bleeding by the application of moist warmth. Should these abstractions j)f blood not prove effective, and pain, fever, and other unpleasant symptoms continue ; but especially, great pain and tenderness in the parts ; if the pulse does not call for general bleeding, we repeat the leeching, nor stop until the end is an- swered, or until we are convinced our efforts will be unavailing, by the approach of the second stage, or by the addition of peri- toneal inflammation. Perhaps there is scarcely a disease which demands such ex- tensive bleeding as the simple hysteritis; several reasons concur to render this necessary, nay, indispensable. First, from delivery having lately taken place, the uterus is much engorged with blood, at the period at which it is attacked by inflammation ; its vessels, therefore, are still distended, and its whole substance in a highly irritable state ; consequently, a new quantity of blood is invited to its parietes. Secondly, owing to the insulated position and independent economy of this organ, it becomes very readily filled with blood, but parts with it, unless under particular circumstances, as in hemorrhages from this part, with great difficulty, or at least ver/ slowly, as is proved by its bulk several days after delivery ; con- sequently, large quantities may be taken from the general system without greatly influencing the quantity contained in the sub- stance of the uterus. Thirdly, owing to the lax and distensible condition of the ute- rine vessels, they are readily restretched by any influx of blood; and consequently, they again become charged by a fresh quantity of it, which now becomes another cause of irritation (by disten- tion,) to the newly provoked inflammation ; and thus inviting a greater flux of blood to this parti Fourthly, that when the uterus becomes thus re-filled, the ves- sels cannot be relieved from this engorgement, as the only agent by which their capacities can be diminished, and of course, this 344 INFLAMMATION OF THE UTERUS. state relieved, is now suspended, (namely, the tonic contraction of this organ:) hence the enlargement of this viscus in this dis- ease; and hence it is a favourable symptom, when it diminishes in size, as it shows a return of the tonic contraction, and conse- quently, an abatement of inflammation. All these circumstances show the necessity of blood-letting : .and at the same time prove, that it will require much to be ab- stracted, before this particular condition of the uterus can be re- lieved. It also shows us the importance and propriety of local bleeding, by either leeching or cupping ; as the blood abstracted by these means acts with more certainty, as well as more promptly, upon this part. 'j'jAti&fs Herfa uv' xJftM/a jjbifca #ri ^yfer.r esli/p* oafas bmt -tOjl iivtlr si'fiiLfflort') h/iB jfoioiJ 1o r finfto &ti 10 4d^?5 W4- 4 vfU w.l I*-i.<>.rtfa #u<- , . . d. Of Blisters. It is very doubtful whether blistering the abdomen in cases of hysteritis is of benefit : we are at a loss, from what we have seen, how to decide; their efficacy, if they possess any, is un- questionably very limited. Dr. Clarke and others are decidedly against their use, and we are rather disposed to coincide with them ; not that we are satisfied they are injurious, but because we are not convinced they are decidedly useful, and because they are very inconvenient, especially to such patients as may have diarrhoea. It is many years since we last used them ; and we cannot venture to recommend them. They are too pertur- bating. e. Of Sudorifics. A, M>C.. :.;.!;, -i^qi, Uiv )l , 'i?i\ti-nii :--\'>- ^ Our opinion of this class of remedies may be collected from what we have already said on the subject of "perspiration:" we shall only add, that, in the early stage of the complaint, their powers are altogether inadequate to the state of the disease ; and, when it is on the decline, they are generally unnecessary. We have thought them occasionally useful, where the force of the pulse had been abated by the treatment, and nothing but a little feverishness came on in the evening, accompanied by watchful- ness and a dry skin. We think we have seen the occasional use of Dover's powder, given at bed-time in ten-grain doses, useful. , njn ; ' 346 INFLAMMATION OP THE UTERUS. But our rule is, never to rely upon them, to the exclusion of eva- cuants. f. Of Opium. - 1 ;;.w>j!; : i'jptr ifrwff otf" ..i\\fa^Wk:ln& *Y' ** -'';' ?"> '' PUERPERAL FEVER. 347 CHAPTER XVIII. OF PUERPERAL FEVER. - f;'> ! * '.Ki 1 For these reasons M. Tonnelle prefers the term puerperal fever to more spe- cific names, as we shall have occasion to say presently. Strictly speaking, puer- peral fever means a fever that may attack a woman in child-bed and, as the term has no pathological meaning, it is preferred by the writer, as it will embrace all the febrile affections to which the woman may be liable after delivery, however varied their seat or nature. 348 PUERPERAL FEVER. some one portion or other of the peritoneum, which attacks wo- men almost immediately, or within a few days after their delivery ; and is distinguished from every other affection of the febrile kind, by being always attended by a more highly accelerated pulse ; by a painful soreness of the abdomen; and with more or less distention, (after a short time,) of this cavity. This disease is frequently, but not always, ushered in by a chill. For however much authors may disagree about the essential nature of this disease, its remote and proximate causes, or its mode of treatment, they, nevertheless, one and all consent to con- sider the marks just stated to be its pathognomonic symptoms. And, perhaps, in no disease of the febrile kind, can so many pe- culiarities be enumerated, as almost constantly present them- selves in this ; such as the highly accelerated pulse ; the failure in the secretion of the milk, if it has not taken place previously to the attack of the disease; its almost immediate arrest, if it has begun to be formed; the diminution or suppression of the lochia; the constipated condition of the bowels ; the peculiar character of the alvine discharges; the exemption, for the most part, from delirium; the loss of maternal feeling, &c. The fatal character of this fever is almost proverbial : Dr. Den- man declares "it occasions the death of much the greater part of those who die in child-bed;" and many others bear a like tes- timony of its dangerous tendency. Dr. Clarke declares, that three out of four die. "Perhaps there is scarcely a disease with which we are acquainted, whose consequences are more fatal than this; as far as I have observed, three-fourths of those who have been seized have fallen sacrifices to its severity." Essays, p. 132. The accuracy of this statement may, at the present time, be very well questioned, if accuracy in pathology be strictly adhered to for it is but just to suppose, that in the time of Dr. Denman and Dr. Clarke, and as it has almost ever been since, agreeably to Dr. Conquest, many other complaints, nay, almost all of the febrile kind that befell the lying-in-woman, were called puerperal fever. This indiscriminate use of the term is found much fault with, as we have just shown, by Dr. Conquest, while M. Ton- nelle prefers the term to peritonitis, or metro-peritonitis, as being more comprehensive ; and as it expresses nothing of itself that is, that it has no pathological reference ; for he has satisfactorily shown that neither peritonitis, nor metro-peritonitis, will express the pathological condition of all that have fever, or die in child- bed ; or by puerperal fever, if we employ the term specifically. Thus, M. Tonnelle found, that in 222 cases of puerperal or child-bed fever, the peritoneum was found affected in 193 ; the uterus and its appendages in 197. In 165 cases, the changes in the peritoneum and uterus were differently combined; those of PUERPERAL FEVER. 349 the peritoneum simply were 28, those of the uterus were 29. In 79 cases, the alterations of the uterus were produced by simple metritis; superficial ramollissement, 29; profound ramollissement, 20; inflammation of the ovaries, 58; with ulcers, 14; -total 190. Alterations in the uterine veins and lymphatics pus was found in 90 instances in the veins : in 32 it was found in the lymphatics ; and in 3, it was observed in the thoracic duct ; with inflammation and suppuration of the inguinal and lumbar glands, in 9 instances, making 134; total changes effected in the uterus, 324. Suppuration of the veins of the uterus,32; with ramollisse- ment or putrescency, 11; with metritis and ramollissement, 5; with peritonitis without any other alteration, 34 ; entirely insu- lated, 8 ; total 90. Suppuration of the lymphatics with the veins, 20 ; with those of the uterus, 13 ; with ramollissement of the uterus with suppu- ration, 6 ; with simple peritonitis, 3 ; without any other alteration, 2; in all 44. Inflammation of the ovaries with simple peritonitis, 29 ; with alterations of the uterus, 27 ; with simple metritis, 8 ; without any other alterations, 2 ; in all 62. 1 It appears from these tables that the alterations of the uterus exceed by a little those of the peritoneum, if taken collectively ; but if taken alone, they very much exceed them. And that in 134 cases there was pus in the veins and lymphatics. It is difficult to assign the cause of the results observed by M. Tonnelle ; for they differ, (if other observers are correct,) from what would seem to be the experience of others upon this point. As regards our own experience in autoptic examination, we arre willing to take it at its absolute value, for our opportunities have been nothing, when compared with those of M. Tonnelle; yet the little we have seen leads to a belief that there must have existed some predominating cause for the very frequent lesions of the uterus itself; as we very rarely have witnessed any altera- tions in that organ, in the few bodies we have examined. Besides, neither Leake, Hulme, Clarke, Hey, nor Armstrong, have made the same observations. Nor do we think, that the result of hos- pital experience is always the best authority for the character of any disease, as this is known to be modified by local causes, how- ever inscrutable these causes may be. We are therefore much inclined to the belief, that peritoneal inflammation is very much more common in this country, than metritis, properly so called; for, if the abdominal, or that portion of the uterus that is covered by peritoneum, be inflamed, and no other tissue of this organ, it 1 It is proper to remark, lest this table should appear to contradict itself, that the reason the whole amount of the two classes of affections exceeds in num- ber all the cases dissected, is, that in many cases peritonitis was complicated with metritis. 350 PUERPERAL FEVER. is, to all intents and purposes, peritonitis, and not metritis. But be this as it may, the observations of M. Tonnelle are no less interesting than curious ; and he has proved, that of the very many deaths of women in child-bed, a large proportion of them was not owing to acute peritonitis, as metritis and phlebitis of the uterus come in for a large share; at least this was found to be the case in hospital practice. a. History of Puerperal Fever. In Europe, 1 it frequently becomes epidemic; and when this happens, its ravages are sometimes truly awful, as its malignity is thought to be increased by the peculiar constitution of the air, which renders it epidemical. In this, almost all the writers upon this subject agree. Dr. Leake says, "It will always be found most fatal when most epidemical, that is, during the distempera- ture of the air; and least of all so, when it happens in healthy seasons, from accidental causes." Obser. on Child-bed Fevers, p. 101. Mr. Hey and others declare the same thing. In this country, this disease very rarely presents itself as an epidemic; the only record of this kind that offers itself to my recollection at this moment, is that of Dr. Jackson. He says, it prevailed "both in Northumberland and Sunbury, in this state, (Pennsylvania,) in the fall of 1817, and in the spring of 1818. And though treated evidently with both vigour and ability, about one half died." Eclectic Repertory, vol. viii. p. 202. So far as we know, this disease has never appeared as an epi- demic in this city ; though sporadic cases have been more fre- quent at one time than at another. It has always, however, been a disease of great danger, and is sure to excite great alarm when- ever it may occur. It does not appear to attack the poor, more frequently than the females in the higher ranks of life ; for when it occurs, one class seems as liable to it as another ; if we can call any thing happening so rarely as this disease does with us, a liability. Yet, notwithstanding the infrequency of this disease in this place, it does not seem to invalidate the observation of Dr. Den- man, that " it destroys the greater part of the women who die 1 In the year 1746, this disease raged in Paris to a terrible extent, especially in the Hotel Dieu. It attacked only the poor women; yet it was neither so vio- lent nor so common when they were delivered at their own houses, as when placed in the hospital. In this place it was remarked, that of twenty women who were attacked, scarcely one escaped. The character of the disease, according to the writers of that day, resembled in every particular the puerperal fever of Great Britain, and of this country. Quoted by Clarke, in Essays, p. 104. PUERPERAL FEVER. 351 in child-bed:" for when deaths occur In the puerperal state, this disease has its full share of them. But deaths in child-bed are comparatively of rare occurrence in this country, when contrasted with their frequency in Europe. This is partly owing to our not having a class of people that exactly corresponds with the class called "the poor" in Europe ; and among whom this dis- ease commits dreadful ravages, and especially at the time it be- comes epidemic. In Great Britain, it occurs perhaps more frequently as an epi- demic than on the Continent; the cause of this we cannot pre- tend to explain ; but such appears to be the fact. Mr. Hey and others describe this disease as an epidemic of frequent occurrence, and one that visits one district after another, without any appa- rent cause* Thus, he tells us, that "for some years past, the puerperal fever has prevailed epidemically in different parts of Yorkshire." Again, that "it> appeared first at Barnsley, twenty miles south of Leeds, where it was prevalent and fatal. It be- gan there early in the year 1808, nearly two years before it be- came general in Leeds," p. 15. Again, "About two years before the fever which I am about to describe, made its appearance, a puerperal fever was epidemic in this town, (Leeds,) which was similar in its nature to that now under consideration ; but it was more partial in its extent, afflict- ing only one district of the town, and being confined chiefly to the poor," p. 15. He further states that " there was a perpetua- tion of this disease from November, 1809, to about Christmas, 1812," p. 16. These facts incontestably prove the frequency and the extent of the disease, (in England, at least,) when compared with this country; and the account given by Mr. Hey is but one of many of the histories of this epidemic, which has occurred in Great Britain. See Dr. Gordon, 1 Dr. Joseph Clarke,* Dr. John Clarke, &c, 3 We are, however, not to be understood to mean, that fevers do not occur in child-bed in this country; we only declare, that this particular fever is one that we very rarely see. The milk fever, the ephemeral fever, called the "weed," are frequently met with; for here, as well as elsewhere, improprieties during 1 See Dr. Gordon's account of the puerperal fever, when it appeared as an epi- demic in Aberdeen, in Scotland. 9 See Dr. Joseph Clarke's account as it appeared in Dublin in 17GO. Duncan's Medical Comment, for 17i)0. It again appeared in Dublin in 1767. 3 See Dr. John Clarke's account of the low fever of child-bed, in 1787 and 1788. Mr. White's account of it at Manchester, in 17H1. Treatise on manage- ment of lying-in women, p. 1H5. Dr. Leake's account for 1770, as it appeared in tne Westminster Hospital. Prac. Obs. p. 241. Mr. White's account as it ap- peared in Edinburgh in 1773. Tenon's account as it appeared in Paris from 1774 to 1781. I 352 PUERPERAL FEVE*. the first few days of confinement will be committed, and the pa- tient be subjected, in consequence, to the fevers just mentioned. 1 Besides, we have every now and then inflammation of the womb, which sometimes passes for puerperal fever. In the account we shall give of this disease, we shall confine ourselves to that inflammation of the peritoneum that succeeds delivery. For we are of opinion, that this will embrace "the low malignant fever of lyingrin women," as- detailed by Dr. Clarke, as well as the disease described by Hulme, Kirkland, Leake, Denman, Gordon, Armstrong, Hey, &c. It is true, that several of these include in their accounts what they term an in- flammation of the uterus, as Hey and Denman ; yet the simple inflammation of the uterus is a very different disease from puer- peral fever : so much so, in our opinion, that they should never be confounded ; and, for this reason, we have given them a sepa- rate consideration. ^f *' o' 1 ^ "li'uf tft'f'^f -trwi >f *; -^t* .^> : Hi vf '>'* >;!) < ''Iji-ilj 'M^ b. Of the Predisposing Causes. Much diversity of 'opinion exists as to the remote or predis- posing causes of puerperal fever; especially when it may appear as an epidemic. Cold, moisture, labour itself, &c., have been assigned: but it seems nothing satisfactory has yet been ascer- tained upon these points. For M. Tonnelle 8 has pretty satisfac- torily ascertained that neither cold nor moisture can be looked upon as causes. For when this disease raged in "la Mater- nite," the hospital to which he was attached, as the pupil of the late M. Desormeaux, neither of these powers could have ope- rated as regards cold, for it was observed, that though the disease was very common in January, which was very cold and dry, yet in December it was very rare, though this month was similar as regards temperature and dryness ; and the agency of moisture appeared to be equally uncertain ; for, in the summer, which was both cold and wet, cases were numerous, yet they were rare at other times, when the weather was similar ; while on the other hand, they were very common during the spring, when the draught was very unusual in length and duration. In a word, the disease prevailed in its greatest extent during cold, dry weather; in temperate weather, as well as during moist, tem- perate weather while at other periods of the year, when similar weather prevailed, the disease was neither more frequent nor 1 We consider the milk fever certainly, and the "weed" most probably, of ar- tificial origin: for we believe we are correct in saying, where the nursing has been properly conducted, they never appear; or if they do, it is very rarely. a Des Fievres Puerperales Observees a la Maternite de Paris. PUERPERAL FEVER. 353 * more severe. Neither could the frequency or severity of the dis- ease be traced to a vitiation of the atmosphere of the hospital. Indeed, the disease prevailed in the most whimsical manner, now existing extensively and severely, and then disappearing, and as suddenly reappearing. M. T. is decidedly opposed to the doctrine of its being contagious. And, with respect to the influence or agency of labour itself, in producing this disease, it would appear from the testimony of all the writers on puerperal fever, and in this M. Tonnelle agrees, that a difficult delivery has no greater agency in the production of this fever, than the most easy or the most natural. All that appears to be necessary to its appearance is the emptying of the uterus; and even this is not always essential to its production, as instances have been recorded, where this fever manifested itself before delivery. 1 Besides, the male is unquestionably liable to peritoneal inflammation as well as the female; and when it occurs in them, the same general phenomena present themselves. Thus, Dr. Armstrong, p. 2, assures us, "it does not seem to depend upon the difficulty of labour, for in most of the women in whom it occurred, parturition was remarkably easy, and the placenta was cast off after a proper interval, and without more than usual pain. Nor was the lochial discharge, before the attack, in any way apparently affected." Mr. Hey says, p. 21, "It is somewhat remarkable, that I have scarcely known an instance in my own practice, of this disease coming on after a preternatural labour. I do not mean to imply that such cases were more exempt from it than others, but so it happened ; and the fact shows that it was independent of any thing untoward in the labour. It has, on the contrary, most frequently occurred, within the compass of my experience, after the most easy and natural labours." But Dr. Clarke seems inclined to a contrary opinion, though not exactly satisfied with his own sentiments. He observes, "For some reason or other, there seems to be a great aptitude in the peritoneum to be inflamed in women after delivery, so that causes applied to the body, which generally have a tendency to excite inflammation of internal parts, seem to be peculiarly di- 1 A case of this kind occurred lately. A lady was delivered at 6 o'clock, P. M ., of a six months' child; she became extremely ill by the next morning:, all the sad signs of puerperal fever declaring themselves : she died at 3 o'clock, P. M., of the same day that is, twenty-three hours after delivery. It was the opinion of Dr. James, who saw the patient in consultation with Dr. Moore, that the fever had commenced before he saw her the pulse,at his first visit, being extremely frequent. Her labour was sufficiently easy for a premature delivery; but the patient sank rapidly until the moment of death. When I saw her, (9 o'clock, A. M., fifteen hours after the birth of the child,) she was nearly without pulse, though she re- tained her senses; the abdomen was much swollen, and extremely distended she died six hours after. I am of opinion that this was an instance of inflammation of the peritoneum preceding delivery. 23 354 PUERPERAL FEVER. rected in their operation, to this part, during the time of child- bed. Hence this disease, (the inflammation of the peritoneum,) is very frequent, and has been also called puerperal fever." " It has been conceived, that this predisposition might depend upon some change in the state of these parts, or of the cavity of the abdomen, succeeding to the act of labour, or the contraction of the uterus. Yet it seems not to be conformable to the wisdom of nature, to construct parts so that the circumstances to which they must necessarily be exposed in a state of health, should either prove a predisponent, or an immediate cause of disease. More- over, the alteration of the state of the cavity of the abdomen is so frequent an occurrence, and this complaint is comparatively so uncommon, that it is hardly credible that so many should escape, and so few be liable to its influence. "In some cases, the pressure made by the child's head, in entering the pelvis, against the peritoneum, either covering the cervix uteri, 1 or the bladder, may predispose to, if it does not actually produce the disease ; and I believe it is often an occa- siona-1 cause. It may be said, that this also would more frequently produce the disease, than we find in fact that it does. But, on the other hand, it should be remembered, that it is only in cases where the head is comparatively large, that so great a degree of pressure can happen, as to occasion the disease. Where the head is small, in proportion to the upper aperture of the pelvis, or is of the usual size, any violent degree of pressure can hardly take place, which is the reason why the disease does not occur after every labour." Essays, p. 81. Now, the hypothesis of Dr. Clarke is contradicted by almost every other writer ; for they declare, that the severity of the act of parturition has no agency in producing the disease; and Dr. Denman informs us, that "Women are certainly not attacked so often with this fever after difficult labours." Again, were this a cause, it should be an ever-acting one; yet, in this country, the disease is scarcely known, though the females of it have their share of children, whose heads are of full size, and which exert as strong a pressure upon the upper aperture of the pelvis, and consequently compress the peritoneum as certainly and as power- fully, as in England, or other portions of Europe. We might readily multiply authorities to prove this curious fact ; and from its importance it should challenge the attention of the physician to an investigation of the cause of it ; for we are not altogether satisfied with the explanation that Dr. Denman gives of this singular exemption; namely, "Because of the par- ticular care with which they are then managed." Were this the 1 Dr. Clarke has committed a little mistake in his anatomy; the cervix uteri is not covered by the peritoneum; it is only the body and fundus that derive a coat from this membrane. PUERPERAL FEVER. 355 cause alone, it would be easy to arrest the progress, or at least to mitigate the violence of this malady, by bestowing the same attentions ; especially upon those who have easy labours, while the disease was ravaging as an epidemic. Indeed, it would seem that the public had some right to expect a practical illustration of the suggestion from the author of it ; and we truly regret that he had not turned his attention to it. c. Of Prophylactics. It is true, there appears, from the practice of some, a founda- tion for the opinion just named above ; so far, at least, as certain medical treatment comprises that peculiar care bestowed upon women who have had laborious labours, alluded to by Dr. Den- man ; for Dr. Gordon informs us that when the puerperal fever raged as an epidemic at Aberdeen, a bolus composed of calomel and jalap, given in the morning, the day after delivery, either prevented the disease entirely, or answered the good purpose of anticipating the cure before the attack. Treatise on Puerperal Fever, p. 100. This must certainly have been a most consoling fact to the physician, and a most important discovery to the afflicted, or those liable to be afflicted ; since a sure prophylactic was at hand, or a remedy in waiting, which was capable of disarming this terrible malady of its dangers. The only matter of surprise is, that after this discovery we should have heard any more of the dangers, or even of the occurrence of puerperal fever ; for if the value of the remedy had been really as great, as the eulogium passed upon it declared it to be, we ought not. Mr. Hey has furnished us with his experience of the use of this remedy : he says, " In every case of accouchement, it was my practice to give a purgative on the day succeeding the delivery; which, if it did not prevent the disease, afforded some advantage in its cure," p. 154. Now, as Mr. Hey has not given us the proportions of success of this plan, we can only conjecture, that neither its prophylactic, nor its sanative powers, could have been very great; since he constantly was acquiring patients, some of which he lost. 1 Nor does it appear, from the history of his cases, that those who got well were indebted to the anticipating purga- tive alone, as blood-letting and farther purging were constantly had recourse to. From all we can learn from the testimony of Dr. Gordon him- 1 Indeed, Mr. Hey informs us, immediately after, p. 155, that "some of th? worst cases in his practice occurred .after an- excessive operation of the purga- tive." 356 PUERPERAL FEVER. <. self, and from Mr. Hey, who followed his practice, it does not appear that the plan under consideration deserves the sweeping encomium bestowed upon it by its inventor; that it was highly proper and very useful, we have every disposition to believe ; but that it ever prevented the disease, we very much doubt. 1 Indeed it would be extremely difficult to ascertain when it did prevent the onset of this disease ; for the fact amounts but to this nega- tive ; that some of the women who took it escaped the disease ; but this is no proof that the calomel and jalap prevented it ; for it is not fair to presume that every newly delivered woman would have had puerperal fever. Besides, weVe this power of preventing the onset, or of abating the force, granted to the calomel and jalap, it still leaves the fact unexplained, of women, who must have had laborious labours, being less liable to this disease ; since, agreeably to the practice of both Dr. Gordon and Mr. Hey, every newly delivered woman was treated alike, as regards the exhibition of the purgative : yet, those who had easy labours were more certainly liable to puerperal fever than those who had difficult times. From all this, it would appear that the subject is still open for inquiry; and we would earnestly recommend it to those whose practice will furnish them with opportunities to inquire into the fact, and endeavour to discover the cause why a tedious and pro- tracted labour should be any way instrumental in diminishing the liability to puerperal fever. For we may well ask how it is, that long suffering, and very certainly, lesion of some kind, and to various extents, should diminish the predisposition of this dis- ease, or abate the force of the exciting causes ! Will a slight inflammation of the proper substance of the ute- rus, and of the vagina, which follow almost necessarily as a con- sequence of a long-protracted or preternatural labour, interrupt the tendency to peritoneal inflammation ? Is this rendered pro- bable by other facts relative to this disease which are certainly no less singular, namely, that "not one instance has been ob- served, of any woman, who had an abscess in the breast, being attacked with this fever ; nor of any who, in consequence of their labour, had such an affection of the bladder as to occasion a sup- pression of urine?" 2 Denman, Introd. Francis's Ed. p. 574. 1 Mr. Hunter long since taught us that we may cure a disease, but that we cannot destroy a predisposition. Even the anticipating purging cannot always be proper, if carried to any considerable extent. We see this illustrated in the practice of Mr. Hey, just alluded to ; for the powerful operation of a cathartic may be, and doubtless is, sometimes, the exciting cause of the disease. ' We do not mean that these facts should be taken for more than they are worth; for we are aware that different explanations may be given of them ; for, of the first it may be said, that the woman who lives free from the disease long enough to have milk secreted, and an abscess to form, most probably had no pre- disposition to the disease, and would have escaped the fever, without the abscess ; PUERPERAL FEVER. 357 '** '* But notwithstanding the powers of a mercurial purgative have been in our opinion rather overrated, it is every way certain that it has been highly useful ; we should, therefore, from both facts and analogy, recommend the adoption of the plan first suggested by Dr. Gordon, of purging briskly at the end of the first eighteen or twenty hours, or earlier, after delivery, whenever there was a tendency in puerperal fever to become epidemic, or where spo- radic cases were more than ordinarily frequent. " d. Of the Seat of the Disease, and its proximate Cause. Post mortem examinations have satisfactorily shown puerperal fever to consist in peritoneal inflammation. This inflammation does not confine itself to any one portion of this membrane. The mesentery, omentum, the liver, the mesocolon ; in a word, every portion of the abdominal contents may be the seat of this in- flammation ; nay, even the pleura and lungs have been found in- flamed ; and we have shown by the tables of M. Tonnell6 that the whole of the uterine system may be involved, even to the very vessels of these parts themselves, as the veins, lymphatics, &e. Before death, it is not uncommon for this inflammation to ter- minate in effusion ; hence the immense quantity which is some- times found within the abdomen ; and perhaps an evidence of some peculiarity of the lining of this cavity, since no other serous membrane pours out an equal quantity in the same time ; nor does equal danger attend the inflammation of them. Mr. Cruikshank informs us that he has "taken away often forty or sixty pints of water, which had accumulated in the ca- vity of the abdomen, in the few days the peritoneal inflammation had lasted, during the usual species of child-bed fever." On the absorbents, p. 11(5. Dr. Clarke says, " The first thing which, in the greater number of instances, (of dissection,) presents itself, is a collection of fluid in the general cavity of the abdomen, sometimes very large in quantity, inasmuch as I have often absorbed, by means of a sponge, several pints of it." Essays, p. 135. When effusion is extensive, the existence of a previous inflam- mation is less evident: this has led some to conclude, that this effusion was not the effect of active inflammation ; but rather the result of a certain disposition of the vessels of the parts affected, essentially different from, an inflammatory action. and, that the abscess was only an evidence of this want of disposition, and not of its being prophylactic. Of the other, it may be said that the freedom from this fever should be referred to the tedious and painful labour of which the suppression of urine was a consequence; and, therefore, that this symptom should not be con- sidered as having any agency in procuring the exemption. 358 PUERPERAL FEVER. *l ' It is easy to refine too much, and nowise difficult for a sturdy polemic to deny the force of the most obvious facts. What but the resolution of inflammation yields such a quantity of fluid as is found after puerperal fever? what but inflammation giving out coagulable lymph will account for the interstices of the intestines being filled up; their surfaces covered; and. their various convo- lutions connected in masses? what but an inflammation, and that of the most active kind, will give rise to such an acceleration of pulse; such immoderate heat; such intense pain; such exquisite soreness, as almost constantly combine in the puerperal fever? In a word, we must repeat, what other condition of the blood vessels, than inflammation, induces them to give out so suddenly and so excessively their fluids? Besides, inflammation of the peritoneum from other causes, is known to terminate in large effusions within the abdominal cavity: the rupture of the uterus, if the woman should not die too soon, is always, we believe, ac- companied by a large effusion. Now, it is a fact, very well ascertained, indeed we had almost said, not disputed, that when the vessels of an inflamed surface proceed to effusion, there is an immediate reduction of that in- flammation; nay, sometimes, a complete removal of it; so much so is this occasionally the case, that disappointment has followed the search for it, where there previously existed every evidence but ocular demonstration. Had Dr. Clarke been sufficiently acquainted with this fact, or permitted it to have had its full weight, we would scarcely have consented to have agitated the following questions: I. "Does the fever in a puerperal woman dispose the perito- neum to effuse the fluid, which, being of a coagulable nature, forms a coat on different surfaces? II. "Does an inflammation of a small part dispose the whole of the peritoneum to throw out the coagulating fluid? III. "Does the inflammation precede or follow the effusion? If the latter, is the inflammation excited by a stimulating quality of the matter itself? or lastly, are the fever, the inflammation, and the effusion of fluid, entirely independent of each other, as to cause and effect, and are they only parts of one whole, which is a disease sui generis?" p. 157. If the first question mean, as we presume it does, that the fever in question may so act upon the peritoneum as to force it to effusion without any intermediate condition, as inflamma- tion, we would answer it in the negative, and for the following reasons: 1st. Because we know of no instance of an effused fluid re- sembling the one found in the cavity of the abdomen, without the intervention of some altered condition of the parts concerned; nor of any other fluid, to the same extent in the same space of PUERPERAL FEVER. 359 time. In cases of large collections of water in cavities, as in as- cites, &c., it is always very gradual; and seems to be rather owing to the defect of absorption, than to an increase of deposi- tion ; though in some instances there is strong reason to believe it to be the result of a previous inflammatory action. 2dly. Because, we know, when serous effusions take place in other portions of the body, that they are always preceded by inflammation ; as in hydrothorax, hydrocele, hydrocephalus, &c. ; and when they take place upon the surface of the body, as from blisters, burns, or scalds, we know that inflammation existed be- fore the effusion ; nor do we ever see it but as the result of highly excited vessels. 3dly. Because, in all instances of the resolution of inflamma- tion, by effusion, a serous fluid is thrown out; and when thrown out, the inflamed surface which yielded it is always relieved from the excitement, either in part, or altogether. II. The second question we would answer also in the negative ; and for reasons that might be in part collected from the answers to the first; for, 1st, if the inflammation of a portion of the peritoneum could excite portions to effusion which are not in- flamed, it would of course be admitting, that effusion can take place without inflammation, or that a sound part can perform the functions of a diseased one; a position we must entirely deny. 2dly. Were this admitted, it would be supposing that an inflamed surface, and one which is not inflamed, would yield the same fluid, which is contrary to all experience. III. To the third query and consequences, we would say, that inflammation always precedes effusion; and that the fever is but the result of the local inflammation. 1. Because a sense of soreness and tenderness is always ex- perienced in some one portion of the abdominal cavity, before the fever is well formed ; and in the accounts we have of this fever, as it appeared in the Hotel Dieu, we are told that " after the escape of the waters, the uterus became dry, rigid, painful, and swelled, and that the lochia did not flow as usual." 2. Because the excitement of the arterial system keeps pace with the inflammation of the peritoneum. 3. Because fevers from other causes have no tendency to pro- duce peritoneal inflammation ; as milk fever, the weed, or even erysipelas; consequently, that there must be a disposition in the peritoneum to take on inflammation after delivery. 1 * We may include, with much propriety, under the head of delivery, those in- stances of abortion, which have been followed by puerperal fever. Dr. Hull says, " It sometimes attacks women who have suffered an abortion, or who have been prematurely delivered, as well as those who have gone their full time of utero- gestation." Treatise on Phlegm. Dolens, p. SW8. Mr. Hey also informs us, that he met with two cases of puerperal fever after abortion, p. 27. See note to page 341). 360 PUERPERAL FEVER. 4. Because, whatever excites inflammation in the peritoneum, by local irritation, as tapping, sometimes; rupture of the uterus ; inflammation of the proper substance of the uterus, when it in- volves this membrane, &c., but not until then ; extraneous sub- stances passing from the stomach and bowels into the cavity of the abdomen; punctures or wounds in this cavity, give the same phenomena; proving beyond doubt that when this membrane is indisputably the seat of inflammation, the system at large sym- pathizes in the same manner as in puerperal fever. From these facts, and others developed by dissection, we have no hesitation to declare, that puerperal fever is an inflammation of the peritoneum. This inflammation always terminates in effusion or suppuration before death ; and never, or but very rarely, in gangrene, so far as dissections have yet discovered. 1 Dr. Clarke says, p. 135, that "the inside of the uterus, or of the intestines, has not been found inflamed in any of those whom I have had an opportunity of ex- amining after death ; much less have I found any signs of gan- grene or mortification." These are curious facts as regards this disease ; and they are particularly valuable as coming from so veracious and candid a man as Dr. Clarke; and completely esta- blishes Biehat's doctrine of the tissues ; the disease which killed the patients he examined was "the low fever of child-bed," and had, agreeably to him, a strong tendency to "putridity," as his practice declares, and as on one occasion he avows, p. 115. For he expressly says, that "all the medicines which have been employed with a view to the diminution of an inflammation, have, in the course of my experience, failed in curing the dis- ease. It became, therefore, next an object, to try whether such as have a tendency to support the strength and diminish the irritability, would be attended by better success. 1 Dr. Fordyce intimates, from the character of the symptoms, and the analogy of the circumstances, that we might suspect gangrene sometimes ; but there is no mention that this has ever taken place. He says, that " the suppuration is very different in its effects from the suppuration which takes place in other inflamma- tions : for the pain goes off suddenly, and even the soreness sometimes, but the tumefaction continues; the pulse becomes more frequent; the strength is more depressed, and the patient is cut off in from six to twenty-four hours afterwards ; so that from the symptoms it might be supposed, that gangrene had taken place in these cases." Hull, p. 234. And Dr. Leake says, in Case VIII. p. 197, " On opening the body, the inferior lateral portion of the omentum was found much inflamed ; but the greater portion was destroyed by suppuration. Case IX. The greater part of the omentum was suppurated ; the remaining portion much inflamed, &c. Case XIII. Great part of the omentum was destroyed, and converted into matter; what remained had become gangrenous:" this is the only mention made of gangrene by Dr. Leake, and the part being in this condition, must have been the result of previous inflam- mation, but which had not relieved itself by effusion, and thus died. For he makes no mention of a fluid in the abdomen, but declares that that portion of the omentum which is inserted round the great curvature of the stomach was considerably inflamed. PUERPERAL FEVER. 361 " As soon, then, as any very considerably increased frequency of the pulse is discovered, I believe that it is right to begin im- mediately with exhibiting the Peruvian bark very freely, and in as large quantities as the stomach will bear," &c., p. 162. Now, the mode of treatment here pointed out declares the tendency to the typhoid, (or putrid) state, if you please; yet there was neither mortification nor gangrene discoverable in any portion of the cavity of the abdomea. Yet the phlegmonous, the ery- thematous, and erysipelatous inflammations, when violent, will each terminate sometimes in gangrene or sphacelus. Dr. Clarke has endeavoured to prove that the inflammation of the peritoneum of a puerperal woman, and " the low fever of child-bed," are essentially different diseases. But he has not been successful in this attempt, as may readily be proved by comparing the symptoms he details as belonging to each, as well as the post mortem appearances, making allowances for seasons, locations, epidemic constitution of the air, and, conse- quently, the type which these will impose upon certain parts of the character of the disease. 1 In both of the diseases which he describes, (Essays, sect. III. p. 81, and Sect. VI. p. 102,) the peritonitic inflammation, and the puerperal fever, attack at the same period after delivery : they are both preceded, sometimes by rigour, and sometimes not. Both have a soreness, tenderness, and distention of the abdomen; in both the pulse is accelerated in a remarkable degree, very soon after the tenderness of the abdomen is experienced. In both, the secretion of the milk is interrupted, if it has not been se- creted ; or if begun to be formed, it is immediately suspended. In both does the woman discover indifference to her offspring; in both is the state of the stomach, the appearance of the tongue, the condition of the brain, the feel of the skin, &c., the same; or, 1 Dr. Clarke says, "It is very well known, that during the strong exertions of labour, every woman suffers a kind of temporary fever; or, in other words, the action of the heart and arteries is very considerably accelerated. Now, if this should happen to a woman under the influence of the causes adverted to above, (namely, the epidemic constitution of the air, &c.,) and if, under these circum- stances, any occasional cause of fever should occur, such as exposure to cold, or infection, the disease thence arising will be most susceptible of that type to which the system has the greatest aptitude," p. 152. And to show his entire belief in the power of the air, he says, the epidemic disposition of the season must likewise always be taken into the account ; otherwise, under these circumstances (of pre- disposition,) " the same disease would always arise, if the same occasional causes were applied, which is not the case," p. 151. He farther adds, p. 15J, " Now the nature of the epidemic constitution, which had prevailed at the time when this disease was prevalent at Paris in 174G, and in London in 17rt7 and 1788, was a disposition to disease of debility; with such a predisposition, if any diseased state, especially fever, should appear in a parturient woman, it would almost certainly put on that character which the preceding history of this disease fully justifies." Now it is evident, that in such cases the nature of the disease is not changed, it is only the character of the type that is affected. 362 ^PUERPERAL FEVER. at least, they are without a marked difference in any respect. In both does the pulse increase in rapidity, as the soreness and distention of the abdomen increase ; and both have the same at- tending symptoms, and the same period for their fatal termina- tions. Both have the same kind of effusions. The differences observed in post mortem examinations are, in- deed, very trifling; in the inflammation of the peritoneum, "the appearances, upon examining th^ bodies of women who have died of the disease, have been those of inflammation of this mem- brane, covering the different viscera. Upon the whole, that of the neck of the uterus and bladder will be found more generally inflamed than of other parts; nevertheless, there is no part on which inflammation is not sometimes found. The surface of the stomach, liver, spleen, omentum, great and small intestines, ute- rus, the internal peritoneal lining of the muscles of the abdomen will, in their turns, or altogether, be found to partake of the dis- ease : and, as far as my experience leads me to judge, no part more than another." 1 "A very large quantity of fluid is generally collected in the cavity of the abdomen, resembling serum mixed with pus; but it differs from both of them in this respect, that it is not homoge- neous in its texture, but intermixed with portions of a solid mat- ter, resembling pieces of the same solid matter as is found on the surfaces of the peritoneum, the nature of which will be more par- ticularly taken notice of hereafter," p. 88. Of the examinations he made of those who died of "the low fever of child-bed," he says, "The first thing which presents it- self is a collection of fluid in the general cavity of the abdomen, sometimes very large in quantity ; insomuch, that I have often absorbed with a sponge several quarts of it. It is of the same nature with that which I have described in a former section, (namely, the above,) as far as can be ascertained by its sensible qualities. There is something very remarkable in the smell of this fluid, which is peculiar to itself, and distinguishes it from any other fluid which I have ever met with in the human body, either in health or in disease. 2 Where it is in large quantity, all the sur- 1 Walter is said to have dissected more than five hundred (a) women who had died in child-bed. He constantly found, in those who died of puerperal fever, the peritoneum, throughout its extent, smeared with a pus-like substance ; but never found the mucous or muscular structure implicated. Med. Chirur. Journ. vol. iv. p. 420. 1 Is not this circumstance absolutely conclusive of the identity of the two dis- eases ? Does not this peculiar smell of the extravasated fluids prove the sameness of the inflammation which yields them? and do not the various seats of the in- flammation establish their kindred nature ? For Dr. Clarke informs us it was not confined, in either case, to any one particular part. (a) We have, at a venture, changed the number to 500 from 5000, believing there must have been an error in the text from which we quoted. PUERPERAL FEVER. faces of the viscera, and of the peritoneum generally, will be found covered with a crust formed of a solid part of this matter, resembling coagulating lymph. Its particles cohere but slightly, so that, by a little agitation, it will mix with the fluid matter. The parts lying under this coat or crust are not always inflamed.* If there be any interstices between the intestines, or the other viscera of the cavity of the abdomen, they are frequently filled with large masses of the same, making an accurate cast of such interstices. " The quantity of fluid extravasated, and of the solid part float- ing in it, or incrusted, is prodigious sometimes, when the disease has been of short duration, not exceeding two or three days. They seem, also, as far as I am able to judge, to bear no proportion to the degree of inflammation, or the extent of inflamed surface; since we often find a large quantity of both, where the redness of any surface has been very inconsiderable, andby no means general. In most instances, there has been some slight degree of inflam- mation in some part of the cavity of the abdomen ; but it has not been confined invariably to any particular part." " Sometimes the peritoneal surface of the intestines, sometimes of the liver, and sometimes the investing membrane lining the muscles, have been found partially inflamed; but I have scarcely ever seen any extensive degree of inflammation in any case, and in some I could hardly say that there was any," 2 p. 135. Now, the only difference we can discover from the histories of the dissection of the two diseases is, that the neck of the uterus and bladder are generally more inflamed than other portions of the peritoneal surface: in effcry other respect, they are so faith- fully alike, as not to raise a suspicion of a difference. It is true, that Dr. Clarke, and, perhaps, others who may have embraced his opinions, might insist that there are other very remarkable differences; but we cannot view them in this light; since the ap- parent discrepancies can easily be accounted -for, without the ne- cessity of supposing them unrelated to each other. We have marked by italics the points of resemblance. We will first notice, however, the coincidences of appearances ; 1 Dr. Clarke's observation only amounts to this, that after effusion has taken place, redness is not always found; but this happens from a cause familiar to every practitioner; namely, that when inflamed vessels effuse serum, they become re- lieved, and the redness disappears. 1 "We have, indeed, been told, that in the dissections of some who are said to have died of this disease (puerperal fever,) no appearances of inflammation have been discovered; but I should suspect, that in such cases some important appear- ances had been overlooked, or that error had been committed as to the nature of the disease, and probably in its treatment." Denman, Introd. to Mid., Francis's Ed. p. 583. "Whatever be the cause of puerperal fever, the cause of death is the same in all its varieties; namely, abdominal inflammation." Gordon, p. 117. 364 PUERPERAL FEVER. and then attempt to account for the seeming differences. 1st. In both cases, the extravasated fluid, agreeably to Dr. Clarke's own statement, is the same; as he says, "it is of the same nature" in both instances. Now let us ask, is it probable that dissimilar diseases of the peritoneal surface shall produce fluids alike in every respect, as far as can be determined by their sensible or chemical qualities ? and especially as Dr. Clarke observes, that "there is something very remarkable in the smell of this fluid, which distinguishes it from every other fluid." Does not this fact satisfactorily prove, if that inflammation of the peritoneum called puerperal fever yields a fluid of particular qualities or pro- perties within the abdominal cavity; and if a fluid of precisely the same kind is found in the abdomens of those who die of " the low fever of child-bed," that the same action must have yielded both, and that they must be one and the same disease? We think the force of this conclusion is irresistible. 2. In the inflammation of the peritoneum, Dr. Clarke says the surfaces of all the viscera in their turn, or altogether, may be in- flamed ; he says, that precisely the same thing happens, but not to the same extent, in "the low child-bed fever:" it is then the degree of inflammation, agreeably to this, and not the absence of it, in t\\e latter instance, that constitutes the difference of the two cases, for we think we have rendered it more than probable, from the nature of the fluids found in the abdominal cavity, that in both instances they are the result of a similar inflammation. Having cursorily remarked upon the coincidences of the fevers, we shall attempt to account for their seeming discrepancies. I. Dr. Clarke tells us, that in the low fever of child-bed, a coat most probably of coagulating lymph, covers the whole or a part of the abdominal contents ; but the parts under this coat or crust are not always inflamed; whereas, in the fever from peritoneal inflammation, this condition is obvious, especially about the neck of the uterus and bladder ; and no crust is noticed. This, at first sight, might lead some to suppose that a very material difference existed between the two diseases ; and espe- cially if they be not aware that a number of causes may make a difference in the intensity of any given disease ; but especially in one so liable to become epidemic as puerperal fever. For the sporadic cases, of all such diseases as may become epidemic, are milder ; and consequently more manageable than when they be- come epidemic. 1 If this be so, it can only happen from the spo- radic cases acquiring the intensity which the epidemic constitu- ' This fact has ever been notorious in our yellow fevers. The histories of this disease, as it appeared in its several visitations in Philadelphia, show that the an- ticipating cases, if they may be so termed, were comparatively mild, and that the malignancy increased in proportion to the continuance of the disease, or at least until the type was modified by cool weather or frost. PUERPERAL FEVER. 365 tion of the air gives any particular epidemical disease. Thus, Dr. Leake says, that puerperal fever "will always be found most fatal when most epidemical ; that is, during a distemperature of the air." Treatise on Child-bed Fevers, p. 73. Mr. Hey says, " I am persuaded that this circumstance (the influence of the air) is deserving of the greatest attention ; and that whoever attempts to cure an epidemic puerperal fever by such means as are com- monly sufficient for the sporadic cases, will find himself greatly disappointed in the result," p. 13. It is to be remarked, that this difference between a sporadic and epidemic disease is not confined to the puerperal fever ; for it is incident to all the diseases, as we have said, which may be- come epidemical. This has frequently been experienced in the yellow fever, the dysentery, and the remittent and intermittent fevers of this country. It is therefore probable, nay, we believe, certain, that the spo- radic puerperal fever might furnish the description Dr. Clarke has given of the peritoneal inflammation, and the epidemical puerperal fever might afford the appearances recorded of "the low fever of child-bed," and yet be one and the same disease; that is, both caused by peritoneal inflammation. But without resorting to these suggestions, which may be by some looked upon as gratuitous, we will mention a fact familiar to every body who has paid attention to epidemics, which is, that the reigning disease may differ very essentially in type at the different periods of its visitations. Thus, no two yellow fevers, as epidemics, were precisely alike in this city. The fever of 1793 was very different from that of 1798 ; and that of 1797 different from both, as regarded the conditions of the system ; and this, consequently, made it necessary to change our thera- peutical views. Yet, in all post mortem examinations, they were found to resemble each other in so many important points, as not to leave a doubt of the identity of the diseases. Besides, an epidemical constitution of the air may exert an influence upon more than one disease at the same time ; and this fact gives the strongest evidence of a distemperature of the air. Thus, Dr. Gordon informs us, that erysipelas, and the puerperal fever, "began in Aberdeen at the same time; and afterwards kept pace together; they both arrived at their acme together, and they both ceased at the same time." Treatise on Puerperal Fever, p. 50. Dr. Clarke says, " Inflammatory diseases had been extremely infrequent; or, if they occurred at all, they were principally of the erysipelatous kind. Eruptive diseases, particularly those which are attended with great depression of strength, had at- tacked great numbers of patients. The ulcerous sore throat, with or without scarlatina, had been very general, both in Lon- 366 PUERPERAL FEVER. don, and also in the country at a distance from the capital. Most of the fevers had been of the low. nervous, and malignant kind, approaching to that type which has been by some called putrid," p. 115. "About the same period, also, in some situations in the country, especially in low marshy places, the generality of patients under inoculation had recovered with great difficulty. Abscesses formed in the axillae ; large ulcers and sloughs took place, both there and at the place of insertion of the matter," 1 p. 116. Again, " The stimulus of her labour, (the woman whose case he is relating,) brought on a degree of fever, which degenerated in consequence of the nature of the then prevailing epidemic constitution, into a low type," p. 150. Yet, with all this evidence before him, Dr. Clarke insisted on the slight difference which he had observed between the sporadic puerperal fever, (for such were the cases of peritoneal inflamma- tion which he describes,) and "the low fever of child-bed," which was a puerperal fever, or an inflammation of the peritoneum, in an epidemic form, to be different diseases ; and seriously admo- nishes the young practitioner not to mistake the one for the other. Every body familiar with the diversifying influence of an epi- demical constitution of the air, knows the variety of type it will force the same disease to assume, at the different periods of its visitations, or even in different situations. Some, who have not been attentive to the influence of the cause just mentioned, and who neither recognise its existence, nor acknowledge its power, have been led into serious, and we had nearly said, absurd errors, on the subject of puerperal fever. Thus, Dr. Kirkland supposes that the genuine puerperal fever is never epidemic; at least he says, that "the puerperal fever which has been observed in hospitals, is owing to some causes peculiar to hospitals;" and that when it occurs in such places, "it should be considered as an adventitious disease, happening to women in child-bed." Treatise, p. 73. When we consider the circumstances under which females are placed, even in the best regulated hospitals, we are nowise surprised that the puerperal fever should be more common, and more fatal to them, than to patients in private life. That there may be, and most probably are, causes in hospitals, which pretty constantly operate in such a manner as to give a peculiar type to a disease similar to that which an epidemic constitution of the air might effect, we have no hesitation to believe ; since, in such situations, the disease is not only more common, but is some- 'Much more difference will be perceived between tbe small-pox under ordinary circumstances, and the form it assumed in the cases just stated by Dr. Clarke, than between " peritoneal inflammation" and " the low fever of child-bed," yet Dr. C. did not hesitate to call both " small-pox." PUERPERAL FEVER. 367 times exclusively confined to them. But in granting this, it does not do away the possibility of its prevailing as an epidemic else- where. Indeed, the history of this disease as an epidemic, abundantly proves that the situations remote from hospitals, or even from cities, have been visited by this fatal malady. 1 On this head Mr. Hey says, that "It must be allowed that the puerperal fever has occurred, as an epidemic, most frequently in hospitals; but if any proof were wanting that it may be epidemical, independently of any cause peculiar to hospitals, that proof is abundantly supplied by the instances of this fever which have occurred at Aberdeen and Leeds; where it was not confined to situation, rank, or cir- cumstances ; affecting alike the rich and the poor, the young and the old, the inhabitants of the town and of the country," p. 12. Besides we are quite at a loss to comprehend the meaning of Dr. Kirkland's appellation, "the genuine puerperal fever," if a distinction be intended by it ; for a fever happening to a lying-in woman must be a genuine puerperal fever, if the peritoneum be inflamed ; or, if it be not inflamed, it must be some other variety of fever ; therefore, a puerperal fever must be a genuine puer- peral fever, or it is no puerperal fever whatever. A spurious puerperal fever cannot exist : for, unless the peritoneum be in- volved in inflammation, there is no propriety in the title; and if it be, it cannot be other than genuine. But to return, Dr. Clarke says, that "the parts under the crust or coat," (of coagulable lymph,) "are not always inflamed;" this must be certainly understood to declare, that they generally are; and, if they generally are, the appearance of inflammation must produce a stronger resemblance to the peritoneal inflamma- tion, than he appears to have been willing to admit. Not that we consider this circumstance essential to the establishment of our position, that the peritoneal inflammation of child-bed wo- men, and "the low fever of child-bed," are one and the same disease. For, had Dr. Clarke told us he had never found " the parts under the crust or coat inflamed," it would not have permitted us to doubt for a moment the identity of the affections, for the reasons stated above. For this, and every other species of in- flammation may throw out even large quantities of fluid under certain stages of its continuance ; but when it does, the inflam- mation which gave rise to the effusion becomes relieved, either altogether, or in part, as this effusion may be more or less exten- sive, or as the inflammation may have been more or less exalted. "We have noticed above the prevalence of puerperal fever, as an epidemic in Northumberland (in this state,) and its neighbourhood; situations very remote from either hospitals, or towns of any considerable size. 368 PUERPERAL FEVER. These effects are familiar to every body ; for they present them- selves to us almost daily, in the consequences of burns, scalds, and blisters. II. We are led to suppose, that Dr. Clarke infers a difference in the two diseases under consideration, from the immense quan- tity of fluid found in the cavities of the abdomen of those who have died of the "low fever of child-bed," and which bears no proportion to the " degree of inflammation, or the extent of in- flamed surface," and the extent of the inflammation and the smaller quantity of fluid found in the abdomen of those who died from peritoneal inflammation. Now, in our estimation, this should show the most entire iden- tity of the two diseases, instead of proving a difference. For, in the one instance, there was a stronger disposition to effusion arising from the peculiarity of the inflammation, but which pe- culiarity was the result of an epidemic influence; and the reduc- tion of this inflammation kept pace with the profuseness of the effusion. In the other instance, the same circumstances obtained precisely; that is, the abatement of inflammation was in exact proportion to the effusion; hence, more inflammation and less effusion was discoverable in one case than in the other ; because, in the one case the extent of inflammation was less, or there was less disposition to effusion. Physicians and surgeons have ever entertained their own no- tions as regards the type of every epidemic with which we are acquainted: and their mode of treatment must, consequently, be predicated upon such opinions. Thus, in the yellow fever of 1793, some physicians looked upon it as a "putrid fever," and, accordingly, treated it with bark, wine, and other stimuli ; while others considered it slightly inflammatory in the commencement, but typhoid in its progress: these bled a few ounces on the first or second day; purged gently; and then used bark, wine, carbo- nate of ammonia, &c. Others looked upon it as a fever of high inflammatory character; to subdue which, extensive, and some- times repeated bleedings, profuse purging, and a strict antiphlo- gistic plan was pursued. Now, it cannot be supposed, that all these opinions were right; yet each attempted to support the pro- priety of his practice, by detailing such phenomena and effects as were most likely to answer this end. Hence resort was had to dissections, and each found a justification of his practice, as he supposed, in the post mortem appearances. But, after awhile, it was discovered, that the first plan was entirely without success ; that the second had some, but it was very limited ; while the third was attended by a fair proportion of recoveries. Just so has it been with puerperal fever; for the rapidity of its march, and the strong tendency of the body after death to putre- faction, led to the belief that it could be no other than a putrid, or PUERPERAL FEVER. typhoid fever; and the want of success in curing it, by the reme- dies proper for such diseases, was not attributed to the improper nature of the means employed, but to the indomitable nature of the disease itself. Therefore, wrong pathological views led them either to a feeble or inefficient practice, or to one decidedly wrong. 1 Dr. Clarke, intent upon advancing the interests of his profes- sion, and indefatigable in the duties which a large share of busi- ness constantly imposed upon him, attempted to remove the ob- scurities which seemed always to await this formidable disease, by making the various affections of the puerperal state conform to a certain classification. With this in view, he divides the de- rangements of the uterine system, 2 and the peritoneum, into the following classes : 1st. Into the inflammation of the uterus and ovaria. 2d. The inflammation of the peritoneum. 3d. Cases of inflammation of the uterus, ovaria, and Fallo- pian tubes, or of the peritoneum, connected with an inflammatory state of the system. 4th. The low fever of child-bed, &c. 3 The doctor was solicitous that these several affections should not be confounded; to prevent which, he admonishes the inexpe- rienced practitioner in the following words: "Before I close this part of my subject, I must beg leave to caution those of my readers, whose experience may have been short, to be very care- ful in distinguishing these diseases from cases of fever consequent to labour, occurring in debilitated constitutions, in large towns, 1 It is but just, however, to state, that the researches of Tonnelle and Duplay have led to the conclusion, that puerperal fever does not always consist of a purely inflammatory action but on the contrary, that in "la Maternitfe," this condition was comparatively rare; hence, they have divided it into the inflammatory, ty- phoid, and the ataxic varieties. The typhoid was by far the most frequent, and the ataxic the most rare, while the purely inflammatory occurred but thirty-nine times in two hundred and twenty-two of the fatal cases examined by them. This, however, must only be received as the reports of the type of the disease as it ap- peared in that hospital ; and though no modifying circumstance could be discovered in that institution, yet it is every way certain there must have been one, and that this account will not serve as an infallible guide for the treatment of this disease in this country. This peculiarity in the influence of an hospital atmosphere has been lately proved in the Pennsylvania Hospital of this city; for the cases of puer- peral fever which presented themselves were fatal in an unprecedented degree, yet this disease was confined to this place, as it did not occur in private practice, at least we did not meet with a single case. Yet even in the most frequent form of this disease, (the typhoid,) in the Paris Hospital, it was acknowledged that the typhoid symptoms were preceded by an inflammatory stage, and this is all that we absolutely contend for. a By the uterine system, we would wish to be understood only such portion of it, as is within the abdominal cavity, or such parts as have a peritoneal covering. ' Modern pathologists pay no attention to which part the inflammation makes its appearance it is very essential to the production of puerperal fever that any portion of the serous or peritoneal coat be the seat. 24 370 PUERPERAL FEVER. and in hospitals more particularly, where there is any disposition to epidemic complaints, which have a low tendency," p. 92. But, notwithstanding the apparent propriety of these divisions, and the earnestness of his cautions, he has not, in the smallest degree, facilitated " those whose experience may have heen short," (and we may add, those whose experience has been long,) to dis- tinguish, with any profitable accuracy, the different conditions he has described. Nor is this to be wondered at ; as he has, in the very threshold of his inquiry, created confusion by neglecting a most important part of his subject; namely, not informing us, in what, or from what, condition of the system this fever pro- ceeds. For it will be perceived, that notwithstanding his attempts at distinctions in this division of the seats of this disease, they are truly without differences ; as they are at last all resolvable, and this, strictly speaking, into peritoneal inflammation. In his first division, he declares the uterus and ovaria to be involved: now, it is obvious in this case, that the ovaria cannot well be inflamed to the exclusion (for we will omit the condition of the abdominal portion of the uterus) of their peritoneal covering; consequently this first division must mean "puerperal fever," if this fever con- sists of an inflammation of the peritoneum, as we have already insisted on. His second division, a fortiori, must be considered as puerperal fever; since its distinctive mark consists in an "inflammation of the peritoneum." We have already noticed, p. 354, Dr. Clarke's attempt to institute a distinction between this condition of the abdomen, and the "low fever of child-bed; " we shall, therefore, not repeat what we have said there. His third division is still more exceptionable; because it insi- nuates that an inflammation of that portion of the peritoneum which covers the uterus, ovaria, and Fallopian tubes, is different from an inflammation of other portions of this membrane; and he considers it necessary that an inflammation of these parts should be distinguished from inflammation of other portions of the peritoneum, which we hold to be impossible. And were it possi- ble, no kind of practical good could result from the discrimination. His fourth appears to be in opposition to his own facts, or even reasonings. In this, he attempts to prove that " the low fever of child-bed" is not a peritoneal inflammation. We have already noticed this effort, p. 354. From what we have said, we think we may safely draw the following conclusions : first, that the distinctions attempted to be made, of an essential difference in the nature of the disease from the location of the inflammation within the abdomen, is without foundation. For it does not appear, from all we learn from others, that the inflammation of puerperal fever is ever confined. PUERPERAL FEVER. 371 strictly, to any one portion of the peritoneum; and from Dr. Clarke's own acknowledgment, "The surface of the stomach, liver, spleen, omentum, great and small intestines, uterus, the in- ternal lining of the muscles of the abdomen, will, in their turn, or altogether, be found to partake of the disease ; and, as far as my experience leads me to judge, no part more than another" See page 355. We must look upon the peritoneum as a unit; and that when inflamed in any one part, the same general symptoms will arise ; and that the whole of it is now liable, from this cause, to be in- rolved in the same condition as that part: hence, if the inflam- mation commence at any given point, it may travel over the whole, or a great portion of its surface, or it may be confined to the original focus. A want of attention to this circumstance has led all the wri- ters, 1 so far as we recollect, into the error of considering the in- flammation of the peritoneal covering of the uterus as a distinct disease from puerperal fever, by calling it an inflammation of the uterus. In this, there is a great want of precision ; for the inflammation of the uterus, properly so called, is a very distinct disease from peritoneal inflammation. (See Chap, on Inflam- mation of the Uterus.) Dr. Denman very properly observes, " There is undoubtedly much difliculty in forming a just idea of a very complicated dis- ease ; and in proportion to the difliculty, every attempt to make accurate distinctions is deserving of commendation." To this we most willingly assent. But he adds immediately after, "But, however symptoms may vary from affections of particular parts, or in particular constitutions, there is but one essential nature of the disease ; and if we have a true notion of this, we have less reason to be solicitous about the cause, or the determination of the part originally or principally affected. For a similar treat- ment may be enjoined, with equal propriety, for an inflammation of the uterus, omentum, peritoneum, or intestines, or perhaps any of the contents of the abdomen ; whether the disease remain local, or a fever be produced by its influence being extended to the constitution in general." Introd. to Mid., Francis's ed. p. 565. Yet is Dr. Denman himself betrayed into a want of precision in the very next sentence ; for he says> that " the inflammation of the uterus is far less dangerous than an equal degree of inflam- mation of any of the viscera of the abdomen, especially in the :.ii "'mil ?',*' " c\'/i ' ill or shivering, by those who are unacquainted with the pheno- mena of fever. It is, therefore, represented to the physician as such; but he does not find it to be followed by reaction; hence it is said, the chill was not followed by fever. 1 We presume Dr. Denman means, by their being much debilitated, a sudden loss of strength, which is by no means uncommon, previously to the attack of se- vere and dangerous fevers; this is remarkably the case in those seized by yellow fever. It cannot mean, they " were much debilitated" by the fatigue of labour; for he and many others declare that the contingencies of labour do not appear to have any agency in the production of the disease. * We would wish to direct the attention of the reader to this circumstance; it is one in which all appear to agree; and which seems to settle the point agitated by Dr. Clarke and others, namely, whether the fever was the consequence of a local inflammation of the peritoneum; or whether the inflammation was the COM- sequence of the fever; for it is here declared, pain, &c., existed before the rigour. 3 Dr. Denman unquestionably means, by the " uterus," the peritoneal covering of this organ and its appendages. But this mode of expressing the condition of this part must unavoidably create confusion, as we have taken occasion to remark in another place, as this viscus is liable to become inflamed, independently of its peritoneal coat, and which is a very different and much less dangerous disease. Mr. Hey is also faulty in this respect, for he says, " But all the varieties, so far as I can judge from ray experience and reading, may be reduced to two denomina- tions, the sporadic and the epidemic puerperal fevers, in which I include inflamma- tion of the uterus and peritoneum* Dr. Armstrong runs into the same error. 4 Dr. Clarke supposes that many of the local symptoms arise from an inflamma- tion of that portion of the peritoneum which may invest the particular organ or part, " such as constant sickness and vomiting of bilious matter, when the stomach is attacked," p. 84. This we believe to be a sound explanation of the vomiting when it occurs in puerperal fever, unless it be in such instances, in which this action proceeds from offensive matters in the stomach. But vomiting is by no means a constant symptom in the early stage of peritonitis; indeed we would say that it is rare, if our limited experience will authorize such a declaration; and when it does occur, it is almost always in the second: it is then obstinate, and may be regarded as a most unfavourable symptom; and this for the reason as- signed by Dr. Clarke. * All the writers on the subject of puerperal fever agree in the uniformity of PUERPERAL FEVER. creted, recedes, or is diminished, and the taste, with the appear- ance, is much altered. 1 " The urine is voided often, with pain, and in small quantities, and is remarkably turbid. A tenesmus or frequent stools come on, and, from the general disturbance, it is often manifest that all the contents of the pelvis are at once affected by the disease. " The tongue becomes dry, though sometimes it remains moist, and is covered with a thick brown fur; but, as the disease ad- vances, its appearance varies, and in some dangerous cases it has been little changed. 2 The patient immediately entertains the strongest apprehensions of her danger, and usually labours under vast anxiety, her countenance bearing indubitable marks of great suffering both in body and mind. "The progress of this disease is sometimes extremely rapid, and especially in unfavourable seasons, and in hot climates. In- stances have occurred in which women have died within twenty- four hours after the first attack ; and I have seen a few who never frew warm after the rigour, which then resembled a convulsion, n some, death has followed quite unexpectedly, either from in- attention, or from the scarcely perceptible but insidious pro- gress of the disease, the indications not having been at all pro- portionate to the danger. these symptoms. All declare the change which takes place in the lochia imme- diately after the disease is formed, if we except Leake, who says it was not affected either in quality or quantity ; a presumption, he says, that the uterus was not affected; and all agree that it constitutes one of the most decided symptoms in this complaint. By what agency is this change effected ? Does it prove that the uterus, both in its substance and covering, is always implicated in this disease ? or does it show there is a prevailing sympathy between the inflamed peritoneum and the surface which yields the lochia t Is the first rendered probable by the lochia being deranged when the substance of the uterus is known to be affected, in the same manner as when the peritoneum is inflamed ? Mr. Hey, however, says it is sometimes not affected, p. 23. Are we to pronounce in such cases that the uterus is uninjured? or, if not uninjured, what part has escaped. 'The want of secretion of the milk, if the disease occur before the breasts are prepared for it; and its cessation, if it has been secreted immediately after the formation of puerperal fever, is one of the most uniform, as well as one of the most remarkable symptoms attending this disease; and it would seem to prove one of two things : first, that the inflamed peritoneum has a control over this secretion, a sympathy only manifest at this particular time; or secondly, that that condition of the uterus by which the mamma; are influenced to the secretion of milk, is changed, by the presence of inflammation, either in its covering, or substance, or both: but most probably from its peritoneal covering being affected, as in simple hysteritis, the breasts are never so much affected, and sometimes not at all. * Mr. Hey, in speaking of the Leeds puerperal fever, says, " The tongue was never incrusted with the brown dry fur of typhus, except the disease was of long continuance, or had been improperly treated. It was generally moist and soft, and though it was not unfrequently covered with a thick white or brownish fur, yet it was often but little altered from its natural appearance, to the last, even in bad cases," p. 32. Dr. Armstrong says, " The tongue was much paler than usual, and appeared as if it had been recently rubbed or dusted with a very fine whitish powder : in some instances the tongue was tolerably clean and moist about the edges," p. 2. 376 PUERPERAL FEVER. "In other cases the shivering fit is succeeded by heat, thirst, and other symptoms, according to the course observed in other fevers ; but the pain which originated in the abdomen, joined with these, is to be esteemed the pathognomonic or chief sign of the disease. It seems necessary to enumerate all the symptoms, which commonly, though not exclusively, attend this fever, and not in any individual patient; yet cases will occur in practice, in which there will be much variation, depending on the degree of disease, the parts affected, the constitution of the patient, and the period after delivery when the fever makes its appearance. c * The pulse has almost invariably, in this disease, an unusual quickness from the beginning. 1 It has often that strength and vibration observed in the disorders of the most inflammatory kind, in robust constitutions; and yet is sometimes exceedingly feeble and quick, beyond what might be expected from the con- curring circumstances. The latter is to be reckoned among the most dangerous signs, proving, perhaps, increased irritability, with great violence of disease, and that the powers of the system are unable to struggle with it, or scarcely to bear the operation of the medicines which might be necessary for its relief. " There is much variation in the subsequent stages, but there is scarcely a worse omen than a very weak and accelerated pulse, even though the other symptoms may seem to be abated. But the mere^ quickness of the pulse, if not attended with other perilous signs of inflammation or fever, is not to be considered 1 The frequency of the pulse in peritoneal inflammation has been so invariable, agreeably to our observations, that we regard it as pathognomonic. We were, therefore, not a little surprised to find this condition of the artery denied by Dr. Marshall Hall, in his Essays on some of the more important Diseases of Females, p. 177. He says, " Frequency of pulse is not a less uncertain indication of inflam- mation (peritoneal.) I am enabled to say, from careful observation, that the pulse is but little accelerated in many cases of puerperal inflammation within the abdomen, whilst it is excessively, and even alarmingly, frequent in some cases in which inflammation does not exist." We cannot but suspect that the doctor la- bours under a great error in this statement; at least, in the first part of it we think he has probably confounded pure hysteritis with peritoneal inflammation. See page 365. The latter declaration we fully agree to; but it adds no support to the former part of his observations. We are the more inclined to suspect a want of accuracy in Dr. Hall's observation, from the loose manner in which he has conveyed his notions of the seats of the inflammation constituting the disease in question. For he says, " Considering the important and sudden changes which take place in the condition of the uterus, in parturition, we cannot be surprised that its appendages, the adjacent viscera, and the peritoneum at large, should, not unfrequently, participate in this morbid condition," p. 156. Now, from this quo- tation, it would appear evident that the appendages of the uterus, and the abdo- minal viscera may be inflamed in puerperal women, independently of the perito- neum, a circumstance that has not, we believe, been verified by late pathological research. The uterus itself may, beyond all doubt; but the abdominal viscera do not appear to follow this rule. Dr. H. seems to forget that Bichat has taught us that investing membranes maybe inflamed without implicating the other tissues of the organs over which they spread; and, consequently, that an inflammation of the peritoneum covering the liver, is not an inflammation of this organ, &c. PUERPERAL FEVER. 377 as indicating danger ; experience having shown that very irritable patients have sometimes an unusually quick pulse, unaccompanied with any other alarming symptom. " The signs of inflammation, joined with those of extreme irri- tability, continue for a few days, when those of putridity appear ; sooner, perhaps, in this, than in most other diseases, which are originally of the truly inflammatory kind. 1 The teeth very early collect a brown adhesive sordes, and all kinds of food and drink are nauseated, except such as are agreeable from their coldness or sharpness. "A singultus attends; every return of which affects the ab- domen in the most painful manner. Petechise or vibices are often found in unwholesome situations, and in some constitutions of the air, at a very early period of the disease, and there are frequently miliary eruptions ; but the latter seem to be rather a consequence of the method of treatment than of the disease, for they do not afford that relief which sometimes follows their ap- pearance in true eruptive fevers. " The bowels are in general very much disturbed, and in some cases a looseness takes place immediately upon the accession ; in others, in three or four days after, or not till the last stage of the disease ; but it very seldom fails to attend, nor can it be removed without the greatest difficulty, as well as danger, before the dis- ease is terminated. The stools, before the close, often come away involuntarily, being always preceded by an increase of pain ; and every evacuation gives a momentary relief. They are uncom- monly fetid, of a green or dark brown colour, and working like yeast. It is also remarkable that, after the long continuation of the looseness, when the patient has taken little or no solid nou- 1 This circumstance is familiar to all who have witnessed the most inflammatory of all fevers, namely the yellow fever. This disease runs its course sometimes with such rapidity that the stages, from the highest inflammation to that of gan- grene, can scarcely be observed ; bidding defiance, very often, to remedies of every kind. Indeed, we may remark it to be the common course with all the diseases of Very high excitement, when not under the control of medical applications, to terminate in the manner just noticed of puerperal fever. It was this rapid course, with puerperal fever especially, which gave rise to the conflicting accounts we have of its nature ; (its termination in gangrene, or in " putridity," as it is cal led,) and which regulated, with too many, the mode of treatment in the commencement of the disease. The apprehensions suggested by its peculiar termination, made physicians spare, or rather dread, the employment of the only remedies capable of preventing such an issue. Thus, both Dr. Gordon and Mr. Hey, (indeed, we might enumerate others,) after they used, with liberal hand, blood-letting and pur- ging, rarely lost a patient. Dr. Gordon did not lose a patient out of thirty that were treated by ample blood-letting and liberal purging; and Mr. Hey seems to have been successful in equal proportion. The great secret in treating such dis- eases as yellow fever and puerperal fever, (at least, under ordinary circumstances,) consists in preventing the death of the blood vessels from over-excitement, by bleeding, &c. Mr. Hunter explains this by saying, " Debility begins very early, because the inflammation itself is interfering immediately with the actions of life." 378 PUERPERAL FEVER. rishment, large and hard lumps of excrement will be sometimes discharged, which one might suspect to have been confined in the bowels a long time before delivery. With regard, however, to this symptom, it is very necessary to observe, that in delicate constitutions, great disturbances of the bowels are frequently oc- casioned by mere irritation, which are soon removed by the well- timed exhibition and repetition of some cordial opiate. " There is a peculiarity in this fever, which I believe has not been hitherto observed or mentioned. It is an erysipelatous tumour, of a dusky-red colour, on the knuckles, wrists, elbows, knees, or ankles, about the size of a shilling, and sometimes larger. This is almost universally a mortal sign, and on the in- spection of those who have died with this appearance, the dis- ease has been found to have aifected the uterus principally, or its appendages. "When this fever commences soon after delivery, and con- tinues its progress with violence for a few days, our hopes of a favourable event will often be disappointed, and the impending danger may usually be foretold by the uninterrupted progress of the symptoms, or by returns of the rigour. A looseness imme- diately succeeding the attack, though in one sense it may indi- cate the degree of disease, always contributes to its abatement, and sometimes proves critical; as does likewise a spontaneous vomiting, sometimes even towards the last change, when all hopes of recovery were abandoned. " The profuse sweat, which follows the shivering fit, has very often been completely critical. In some there has been a trans- lation of the disease to the extremities, where the part has in- flamed, and a large abscess has been formed: a similar abscess has also in some cases been formed on one side of the abdomen, which has been healed by the most simple treatment. "Fresh eruptions of the lochia are always a favourable symp- tom, and are to be reckoned among the most certain signs of amend- ment. A subsidence of the abdomen after copious stools, and with a moist skin, is a fortunate alteration for the patient; but that circumstance, without evacuations, and a dry skin, threaten the utmost danger." Introd. Mid. Francis's Ed. p. 568, et seq. Dr. Clarke, p. 121, and other writers, have noticed a symptom of a remarkable kind, to which we have also borne witness, and which, so far as we have observed, has always been a fatal one ; namely, the indifference of the mother to the child, and some- times even refusing to suckle it. From whence does this indif- ference proceed ? or why should it be a symptom of so much danger ? x 1 It has lately fallen to my lot to see a case of completely developed puerperal fever, in which this symptom proved fallacious. This case will be related pre- sently. PUERPERAL FEVER. 379 Dr. Clarke, p. 123, accounts for this state of the mind in an ingenious and plausible manner, by observing, " It is probable that the secretion of the milk in the gland, and the desire of suckling, may be in some way connected with each other, and the existence of the desire may depend upon the presence of the secretion, in like manner as the power of secretion in the testi- cles produces the passion for propagation ; and the passion in its turn affects the disposition for secretion." But to what cir- cumstances shall we attribute this total extinction of sympathy between parts so constantly in the habit of exercising it ? Is it owing to any condition of the uterus itself? or does it arise from the peritoneal inflammation simply? or does it require the ovaria to be involved ? Is this last conjecture strengthened by the fact, that the breasts become flaccid and waste away, when these organs are severely diseased, wasted, or extirpated ? Of the Diagnosis. The disease we have been describing has so many well-marked characters, that it cannot well be confounded with any other af- fection ; and we believe that we may safely rely upon the fol- lowing symptoms for its diagnosis : 1st. Pain or tenderness in the hypogastric region, occur- ring after delivery, from the first few hours to several days. 1 2d. Swelling or tension in that portion of the abdomen where the pain or tenderness is felt. 3d. By these symptoms almost always being followed by a chill or rigour, of longer or shorter duration, or greater or less force. 1 Mr. Hey says that the pain experienced by the woman, soon after delivery, "was a very deceitful symptom; and when it was not preceded by rigour, occa- sioned great embarrassment by the irregular manner of its attack; and the conse- quent difficulty of distinguishing it from after-pains," p. 30. We believe that the following marks will, with much certainty, distinguish the pain of peritoneal inflammation from that of "after-pains." 1. After-pains are always alternate, and regularly have three periods a period of increase, acme, and decline; they always observe regular intervals, be these longer or shorter. 2. The pain, when occasioned by after-pains, is never so acute; and is confined to the lower part of the hypogastric region. 3. There is always more or less discharge of the lochia, during the continuance of the after-pain, and this without a change in its appearance. 4. The mammae are not interrupted in their offices, if the pain proceed purely from uterine contraction. 5. If the hand be laid upon the abdomen, during the pain, the uterus will be found very hard at one moment, and softer the next. 6. The pulse will never be so much accelerated, as when the peritoneum is the seat of the disease; but both of these pains may be united; and when that is the case, the pain arising from the contractions of the uterus offers no indication, as it is then of minor importance. 380 PUERPERAL FEVER. 4th. By the rigour being followed by reaction, terminating, for the most part, in a profuse sweat, and without this sweat moderating the fever or other symptoms. 1 5th. By this fever being accompanied by an accelerated pulse; rarely less than one hundred and twenty, and oftentimes as many as one hundred and fifty or more strokes in the minute. 6th. By the absence of milk in the breasts ; either because it has not been secreted, or because the secretion has been interrupted. 7th. By a diminution, alteration, or suspension of the lo- chial discharge. 2 If a woman, within a short period after delivery, be attacked with the above symptoms, we may, we think, with much safety, pronounce her to be labouring under peritoneal inflammation, or puerperal fever. In this enumeration of symptoms, we have confined ourselves to the mention of such only as may be con- sidered as almost exclusively pathognomonic. There are many other symptoms besides those enumerated that attend this disease ; and, perhaps, each individual case may be attended by some one peculiar circumstance, which does not obtain in others, but which may be dependent for its existence upon some peculiarity of constitution, or accidental cause. It is, therefore, impossible to anticipate every symptom which may arise in any given instance. The symptoms, as detailed by Dr. Denman, we believe, comprise every thing essential in the his- tory of this fever, from its formation to its termination. And we trust, from what has just been laid down, that this disease cannot well be mistaken for any other. 1 Dr. Denman, as noticed above, says this sweat has, in many instances, proved critical. * We have elsewhere remarked that Dr. Leake says, " The lochia, from first to last, were not obstructed," p. 52. Dr. Leake's account is of an epidemic puerperal fever, which attacked the pa- tients of the " Westminster Lying-in Hospital," and the disease, as it appeared there, was of a very remarkable character in several important points ; and dif- fered from every other of which we have read any account. t. There was very little pain in the abdomen. 2. Very much less frequency of pulse. 3. The uterus almost invariably sound. 4. Little change in the powers or functions of the mammae. 5. No change in the lochial discharges. 6. The omentum being the chief seat of disease, or found "melted down." 1. An unusual degree of headache. From Dr. Leake's account, it is evident that the epidemical constitution of the air had imposed a very mild character on this disease its inflammation appeared to be of the phlegmonous kind, from the quantity of suppurated fluid found upon dissection, and from the common expression of the " omentum being melted down," &c.; and it is farther evident, we think, that, had he carried his bleedings, &c., farther, he would have cured all his patients. PUERPERAL FEVER. 381 Of the Prognosis. There is, perhaps, no disease, upon the issue of which the physician of experience feels greater reluctance to pronounce than puerperal fever. This unwillingness proceeds from several causes, each of which suggests the propriety of caution in making a decision. First, From its very frequent tendency to a fatal result, even under the most prompt, proper, and vigorous treatment. Secondly, From the rapidity of its march it gives but small opportunity oftentimes for the operation of remedies, even when they are applied early. Thirdly, From the impossibility, very often, of repairing the ravages a few hours' neglect has occasioned, however faithfully and properly the remedies may be afterwards employed ; and, Fourthly, From the oftentimes treacherous nature of the dis- ease, which will sometimes suddenly terminate in death, when circumstances apparently promise recovery. These reasons should teach the young practitioner to be ex- tremely guarded in his prognosis, lest disappointment follow im- properly raised hope ; or recovery take place when he had caused it to be abandoned. We may particularly caution him against that deceitful amendment recognised by most writers on this sub- ject, which takes place sometimes as early as the first twenty hours, or as late perhaps as the third day. Here the abatement of pain, the diminution of the soreness of the belly, the subsiding of the abdominal swelling, 1 the less frequency of the pulse, seem but the prelude to a condition, from which no human exertion, or power of remedy, seems capable of saving the patient. Yet the symptoms now mentioned are precisely those upon which we would build our hopes of .amendment, if not followed by the prostration of every power of the system: consequently, it will require much caution not to be betrayed into error. However promptly the disease may have been met, even by the most suitable remedies, the disease will, nevertheless, some- times progress with alarming rapidity. The pain and swelling will so augment, as to leave the woman no choice of position : she finds a trifling mitigation of her sufferings while on her back, with her legs drawn up, that the abdominal muscles may be re-" laxed. The pulse increases in frequency, but diminishes in force. The respiration becomes difficult; the tongue dry, and brown, or not altered, while the face and extremities are bedewed with a cold, clammy sweat. The face becomes pale, or partially flushed ; the countenance haggard, wild, and expressive of the greatest 1 " When the abdomen subsides, without being preceded by copious stools, and with a dry skin, it threatens the utmost danger." DENMAN. 382 PUERPERAL FEVER. distress. Delirium, vomiting, 1 involuntary discharges of both the fauces and urine, and death. But before the scene is finally closed, the woman seems to be relieved of a part of her sufferings, by a change taking place in some of the more urgent and painful symptoms. Distention is diminished, or even sometimes entirely removed the swelling of the abdomen subsides ; and pain ceases with more or less sud- denness. The absence of milk in the breasts, and especially if this be attended Avith an entire indifference to the child, must be looked upon as almost certainly fatal. If joined to these, there be little expression of suffering, a very quick pulse, and considerable swelling; and if the attack has been very early after delivery, the case must be looked upon as almost hopeless. So uniformly is danger increased by the earliness of the attack, that it is no- ticed, we believe, by every writer upon the subject; therefore, this circumstance should always be kept in view, when an opi- nion is about to be formed of the degree of danger. The extent of the abdominal swelling seems to be of more consequence than the degree of soreness or of pain ; and when it is excessive, and becomes tympanitic, it is extremely dange- rous, nay, almost always fatal. Dr. Clarke says, "It has not occurred in my sphere of observation, to see any recover, in whom the swelling of the belly has been in any very great de- gree," 2 p. 133. Also, That "those who have the disease at later periods after deli- very are not attacked with the same violence ; the depression of strength is not so great, the tumefaction of the abdomen is less extensive, and the chance of recovery is, consequently, better," p. 133. Dr. Armstrong observes, that " an excess of sensibility is al- ways to be dreaded ; for I have had opportunities of remarking, that those patients seldom recover who are tremblingly alive to every surrounding impression. It is well known, that unmarried women do not recover so well as married ones ; the mental irri- tation, necessarily attendant upon their situation, considerably increasing the febrile excitement, and rendering them extremely restless," p. 26. Dr. Clarke has remarked the same thing. 1 We have seen more than one instance of puerperal fever terminating in "black vomit," similar to that observed in "yellow fever:" we have also seen the same appearances after rupture of the uterus. Dr. Gordon informs us, that "when there were symptoms of mortification, what the patient vomited was black, and had a strong resemblance to coffee grounds," p. 10. Dr. Armstrong considers it as a highly dangerous symptom, " when there are frequent vomitings of a cofiee-coloured fluid," p. 31. Yet gangrene, or mortification, has not been ob- served in any of the dissections we have read of. * I shall relate a case presently, in which there was great distention of the ab- domen, but where the woman recovered. Yet this must b looked upon but as a rare exception to the rule. PUERPERAL FEVER. 383 "Costiveness is always an unfavourable circumstance," Dr. Armstrong says, "increasing in no inconsiderable degree the difficulty of cure ; while an open state of the bowels before de- livery tends to mitigate the severity of an early attack, and a diarrhoea coming on afterwards, carries off the disease," p. 30. Dr. Denman says, as already noticed, that a diarrhoea may be critical, and carry off the disease, p. 568. The signs which may be looked upon as favourable, are 1st. A diminution of frequency of the pulse, with an in- crease of its volume. 2d. A reduction of the swelling of the abdomen, with an abatement of pain ; provided, the first is gradual, and the latter not sudden ; and accompanied by condition first. 3d. Changing posture without suffering inconvenience ; but jactitation must not be mistaken for it. 4th. A return of milk to the breasts, attended by solicitude for the child. 5th. A restoration of the lochial discharge after it has been suppressed; especially if it change to a healthful ap- pearance. 6th. The tongue becoming moist; losing its white appear- ance, and cleaning at the edges; or, if it has been brown and dry, becoming whitish and moist, accom- panied by condition first. 7th. If the urine become more abundant, and deposits a lateritious sediment. 8th. If the skin become cooler, and moist throughout its whole extent ; especially if attended by conditions first, second, third, fourth and fifth ; or if a natural warmth return to the extremities, after having been preternatu- rally cold, accompanied by the signs just referred to. 9th. "A subsidence of the abdomen after copious stools, and with a moist skin, is a fortunate alteration for the patient." Denman. 10th. "If the pulse can be kept under one hundred and twenty in the minute, for the first twelve days, the pa- tient will generally do well ; but if the pulse keep very quick, after the abdominal symptoms have entirely dis- appeared, affections of the chest, 1 and of the glandular system, or deep-seated suppurations, may be dreaded." 2 Armstrong, p. 32. 1 " If any disease hath taken its immediate origin, as it were, out of the puer- peral fever, and been combined with it, it hath been the peripneumony. I have met with several instances of this kind." Hulme, p. 15. 4 "Some of those who survived, recovered slowly, and were affected with wandering pains, and paralytic numbness of the limbs, like that of chronic rheu- 384 PUERPERAL FEVER. Of the Contagious Nature of Puerperal Fever. 1 Had not the belief that puerperal fever was a contagious dis- ease, and had not this belief a great effect upon the minds of fe- males who are pregnant, or who are in the puerperal state, and consequently may very much influence their happiness, we should not have touched upon this subject; believing, as we do, that the opinion is altogether without foundation, at least in this country. In Europe, and especially in Great Britain, this, and a number of other diseases, are believed to be contagious ; while in this country it only amounts to a fear, and not to a conviction. The disease in question, scarlatina, erysipelas, &c. &c., are in these countries looked upon as possessing the power of propagating themselves by some specific quality of their own. We shall not attempt any formal refutation of the doctrine of contagion, by exhibiting the arguments on both sides of the ques- tion: we shall merely select the opinions of such as had ample opportunities to decide the question, and whose conclusions are adverse to the opinion "that puerperal fever is contagious." Dr. Hulme, whose experience was ample, and who has written an excellent work upon this disease, says that " the puerperal fever is not an infectious disease, any more than the iliac passion, a pleurisy, a nephritis, or an inflammation in any other part of the body." Treatise on Puerperal Fever, p. 164. Dr. Hull, whose opportunities were equal, perhaps, to any who may have written upon this subject, says, "As far as my obser- vation goes, peritonitis puerperalis is not infectious. I have never seen a case, wherein I had reason to suppose that the effluvia, arising from the patient, produced puerperal fever, or typhus, or any other disease in another person, either directly or indirectly. The disease in question frequently arises where there is not the least foundation for a suspicion that infection has been applied," p. 248. Mr. Hey appears strongly inclined to the opinion that puer- peral fever is not contagious ; but seems afraid to decide abso- lutely upon the question. In this country, under no circumstance that puerperal fever has appeared hitherto, does it afford the slightest ground for the belief that it is contagious. In this city, so far as we know, it has always shown itself as a sporadic disease; and in this form, matism. Some had critical abscesses in the muscular part of the body, which were a long time coming to suppuration, and when broke, discharged a sanious ichor." Leake, vol. ii. p. 56. 1 "By contagion, is understood effluvia, arising directly or indirectly from the human body under particular diseases, and capable of exciting the same disease in other persons to whom it may be applied." Hull, p. 247. PUERPERAL FEVER. 385 it has never been looked upon as contagious, except by Dr. Arm- strong. He says, "The peritonitic fever, when completely formed, is, in kind, though not in degree, as contagious as the epidemic :" in this sentiment he stands alone ; not even support- ed by those who believe in the contagious power of the epidemic. In Northumberland, in this state, (see p. 350,) where it was epi- demic, there was no evidence that it was contagious. Dr. Leake says, decidedly, the sporadic puerperal fever is not infectious; and it is only so, when epidemic, under particular circumstances, vol. ii. p. 140. Now, it would be very extraordinary to declare, for it would obtain no belief, that sporadic small-pox, measles, or hooping- cough, were not contagious ; for we must ask, what is the differ- ence between the sporadic form or quality of a disease, and the epidemic form or quality of a disease ; except that the latter has its type affected by some occult influence in the air, which gives rise, at the same time, to the epidemic prevalence of the disease? g. Treatment. We have now to consider the most important part of our sub- ject, namely, the treatment. As regards this, much discrepancy must necessarily prevail, as scarcely any two authorities can have viewed the disease under the same aspect, as the disease is so variously modified. In confirmation of this, it is only neces- sary to refer to the late researches upon this point we say the late researches, as we believe these to be very much the most to be relied upon. We do not wish, however, to be understood as conveying any oblique censure upon former observation ; we only mean, that pathological inquiries are now conducted with much more care and with much more success, than thirty or forty years ago. For improvements in this highly interesting and important study, we are particularly indebted to the French, and especially since the writings of Bichat have made us acquainted with the in- dependent and important role that each separate tissue performs. We do not pretend that the same phenomena did not present themselves to former autoptic inquirers we only declare they were not so well understood and defined. This fact can be very easily proved by a reference to some of the most careful exa- miners of bodies dead from puerperal fever. Let us take Drs. Leake, Gordon, and, above all, the accurate and faithful Clarke, as illustrative of the position now advanced, and it will be per- ceived, that no distinction is made between the parenchyma of the uterus or ovaries, and their peritoneal coverings, as seats of disease ; for were this membrane inflamed, had it suppurated, or were it gangrenous, the uterus or the ovaries were said to be in 25 386 PUERPERAL FEVER. either of these conditions ; being altogether ignorant that the pe- ritoneum covering these parts may be in a pathological condition, without implicating the other structures of these organs. Again, pus has been found in various portions of the uterus, when it was cut into : this pus was supposed to be the result of the in- flamed parenchyma of this body ; for they were not aware this fluid was produced by suppuration of the internal mucous coat of the veins. Again, the uterus was often declared to be in a state of gangrene from puerperal fever; but modern research has proved that this organ maybe "softened," (ramollissement,) and this without any particular tendency to putrefaction. And once more, that phlebitis of the uterine veins gives a typhoid character to the accompanying fever, &c., for we could easily extend examples. Now, it is rendered every way probable that some occult cause may operate to produce a particular tendency in some one tissue or other, to become the seat of the disease : thus, we find in some instances the peritoneum to be the principal seat of disease ; and this, upon certain portions of it, (see our history, &c., of this dis- ease,) in other cases, the parenchyma of the uterus is especially attacked; or its veins, or its lymphatics, and perhaps even its nerves ; and each variety giving a particular character to the phenomena of the disease hence, as we have already observed, puerperal fever is considered by Conquest and some of the French writers, as a generic term. See page 347, &c. It must, therefore, be evident, if these observations be correct, that much practical acumen is necessary to the successful treatment of this disease, that the different forms may not be confounded it is, also, equally evident, that we have much to learn in diagnosis. However, let it be understood, that though puerperal females in this country must necessarily, like those of Europe, be obnox- ious to remote causes ; yet that here such causes, be they what they may, tend more frequently to the production of a pure in- flammatory condition of the peritoneum, than the same causes do in other portions of the globe. We say more frequently, for this does not appear to be the case uniformly for, in the late in- stances in the Pennsylvania Hospital, we believe that all who were attacked died, notwithstanding the most prompt and active antiphlogistic means were pursued. In these cases it must be evident that some local but inscrutable cause operated, as no such condition of liability was observed in private practice. From these statements, it will be understood that no one mode of treatment can be applicable to every epidemic visitation of puerperal fever, or even every sporadic case ; and, with a view to establish this point more firmly, we shall give the experience of Professor Desormeaux and his pupil, M. Tonnelle, upon this point, though we are, at the same time, persuaded that, in this PUERPERAL FEVER. 38T country, and in private practice, the disease is almost uniformly highly inflammatory. From the views entertained by Desormeaux of this disease, he was led to adopt several different modes of treatment, the result of which he has given, together with the successes, and this at several seasons of the year; for this gentleman found, that a mode of treatment which may have been successful at one pe- riod, might not prove so at another. Among the more active remedies he used, we may reckon general bleeding, leeching, ipecacuanha, emetics, salivation: the auxiliary means were, warm hip-bath, laxatives, enemata, bark, cataplasms, and emol- lient washes for the uterus. The contradictory means, as laid down by authors, for the cure of this disease, induced M. Desormeaux to give fair trial to such as came recommended by good authority ; and, not to remain satisfied by either success or failure, he tried the same means at different seasons of the year. General blood-letting was often found highly useful as the initial remedy, as it was found impe- riously demanded by the violent action of the system, in cases that he judged to be purely inflammatory ; but, for the most part, this benefit was limited to the early stage of these cases, as it failed to subdue the local inflammation, and was often of ques- tionable utility, as this first stage so quickly ran its course. On this account, local bleeding was resorted to, to overcome the local affection of the uterus and its appendages forty or fifty leeches were applied to the abdomen, and these followed by a hip-bath, or poultice, and this was sometimes repeated two or three times in thirty-six or eight and forty hours. When this plan proved successful, it was speedily followed by a copious perspiration. But the good effects of this method were confined to the early stage, and previous to suppuration. He estimates the rate of success in the following manner. Of 165 cases treated by general and local blood-letting, three-fourths recovered. Ipecacuanha, as an emetic, he states, was only used in the early stage : this was sometimes successful, and at other times not, depending upon seasons, as he supposes. However, of forty cases treated by it, four-fifths recovered. This remedy was not useful after the suppurative stage had taken place ; nor was it found to answer in the typhoid type of this disease. For the suppurative stage, or the typhoid variety of this disease, MM. Desormeaux and Tonnelle think they have found an important remedy in mercurial salivation ; for, though by far the greater number of such cases must prove fatal, still, if salivation in- creases the number that get well, it must be looked upon as a valuable therapeutic means; and perhaps we should have the more confidence in this plan, since the inveterate prejudices of the French against the use of mercury, would not permit them PUERPERAL FEVER. to employ it, without having derived advantage from it in their trials. We have directed attention to this remedy, (see page 414, on mercurial frictions.) Mercury was only used in the advanced stage of inflammatory puerperal fever, or in typhoid cases, or where neither blood-letting, or leeching, or ipecacuanha would be useful. It was used in form of ointment two ounces were rubbed in every twenty-four hours the abdomen and thighs were the parts selected. The auxiliary remedies men- tioned above were thought to be useful, especially emollient injections, once in six hours. This mode of treating any one disease is too exclusive to be absolutely relied on ; as the suc- cessful cases may not have been such from the peculiar treat- ment, but from their want of intensity ; and therefore might have yielded to either plan adopted by Desormeaux and Tonnelle, while the unsuccessful instances may have proved such from their overwhelming violence, or from delay, rather than from the particular treatment being inefficient. It is necessary to the establishment of any exclusive mode, that all the patients should be as nearly as possible in the same condition, when the plan ia first put in execution. Therefore, any plan may be either only more or less useful, or otherwise quo ad hoc. Most of the errors on the subject of puerperal fever have arisen from a want of the necessary discrimination between the stages of this disease, and to an ignorance that the peculiarity of the subsequent ones are entirely dependent upon, or only the neces- sary and inevitable consequences of, the first stage. 1 Few have so far shut their eyes against the facts revealed by dissections, as not to admit that its first stage is that of high inflammation. But, as this inflammation runs its course rapidly, and is succeeded either by a gangrenous tendency, or an effusion of large quan- tities of serum in the cavity of the abdomen, and as the body, quickly after death, manifests a strong disposition to decompo- sition, it was thought by many, that the disease, from its com- mencement, had a strong septic tendency; and remedies were employed to guard against the consequences, rather than for the removal of the cause; namely, the first or inflammatory stage. 2 1 Dr. Armstrong, Facts and Observations, &c., p. 60, says, " The first stage " of Puerperal Fever, " is marked by highly inflammatory, the second, by highly typhoid characters; and it has always appeared to me, that the tendency to putridity in the latter was proportionate to the degree of inflammation in the former." Dr. Denman says, " When the fever has remained for a very few days, the putrid symptoms, which are usually according to the degree of the preceding in- flammation, advance very rapidly." We repeat these observations, because of their unquestionable truth, and practical value. '"I cannot help suspecting," says Dr. Armstrong, "that some distinguished authors, having formed their opinion from the appearance of the disease, and the ill effects of venesection, at this period, (the gangrenous,) have thus been per- suaded that debility is the principal thing to be counteracted from the beginning, PUERPERAL FEVER. 389 To prove this, let the treatment and the result of the plans of Denman, Gordon, Hey, Armstrong, and even Leake, be con- trasted with the mistaken practice of Clarke, and some others. In the practice of the first of these gentlemen, recoveries were common ; in that of the latter, very few escaped. Dr. Clarke in- forms us, that three out of four died, p. 132. The patients un- der his care were treated, from the beginning, with large doses of bark, and such other remedies " as have a tendency to support the strength, and diminish the irritability." It may be said, that, in the epidemic described by Dr. Clarke, there was but little evidence of inflammation, and much of *' pu- tridity;" but this should not be too hastily assumed, as we have attempted to prove at p. 360. Nor can an inference be drawn in favour of his pathological views from the success of his prac- tice. The public are much indebted to Dr. Denman for the can- did renunciation of his errors upon this subject. In the early part of his practice, he entertained great doubts of the propriety of blood-letting in puerperal fever: he thought it weakened the patient, without lessening the disease ; and for a long time, he informs us, he did not take away blood in any quantity. The influence of this highly cultivated and respectable practi- tioner was so great as to give tone to public opinion ; his mode of practice and his views were extensively adopted by the British practitioners; and they became almost the standard for the treat- ment of puerperal fever. Fortunately for the fate of hundreds, a more extended experience, and more correct notions of tne nature of the disease, led him to renounce, with much magnani- mity, the errors of his early life. Therefore, so soon as he was convinced of the insufficiency or total inefficacy of his plan, he gave it up with a candour which all must admire, though few may imitate if. He says, in the last edition of his works, as edited by Dr. Francis, p. 576 "I am now convinced, by manifold experience, that my reason- ing was fallacious, and my fears groundless; and that what I had considered as proofs of insufficiency or impropriety, of bleeding, in the true inflammatory puerperal fever, ought in reality to have been attributed to the neglect of performing it in an effectual manner, at the very beginning of the disease. In short, if the first stage be permitted to pass unheeded, bleeding will then cer- tainly be injurious, the opportunity having been lost; and the physician called in afterwards, however great his talents may be, will too often have the mortification of being the spectator of and during the whole course of the fever. Be this as it may, the stimulant treat- ment is at once the most delusive and dangerous which can be adopted ; and it is much to be lamented that it has the weight and authority of some eminent names." Facts and Observations, p. 63. PUERPERAL FEVER. mischief which he cannot then remedy, and an event which he can only deplore." We are told, that it is of the utmost consequence to the cure of this disease, that we distinguish between the true inflammatory and the putrid puerperal fever. This would be most true and important, did such a difference really exist as is here intimated; but the distinction attempted has been based, we believe, upon the violence of the complaint at different times, and under different circumstances, rather than upon any essential difference in the absolute nature and seat of the diseases. See note to p. 369. Thus the sporadic puerperal fever is more easily subdued, and will bear bleeding even at a later period than the epidemic puer- peral fever ; because the former is less rapid in its course, owing to the accompanying inflammation being less exalted; and not to the latter being of a putrid character ; for when this state exists, we must repeat it, it is owing to the inflammation being so tran- scendent, that the parts must die, if not speedily relieved. And though the system, under such circumstances, cannot bear, perhaps, the abstraction of blood, yet it cannot support the action of stimuli. We are persuaded there are few errors in practice greater than that founded on the belief that when a disease will not bear depletion with profit, that it then absolutely requires the opposite treatment; arid we are sure it has been the death of thousands. The supposed tendency to typhus in fevers of every description, when the patient has become weak, and especially if the tongue has become brown or dry, has led unhappily to the use of tonic and stimulating remedies, by far too many practitioners ; for were the results of such treatment faithfully recorded, we are convinced there would be but little evidence in its favour indeed, so con- fident are we on this subject, that we never fail to consider the cures of such a state of fever by this method, but as escapes. Let us illustrate the position we have assumed, by taking part of cases IX. p. 89, and XXVII. p. 206, as related by Mr. Hey. On the tenth day of this patient's disease, it is said, " She had had no sleep in the night, and was very restless, with some de- gree of delirium. We found her incessantly talking, but could procure no answer from her to any question that was proposed. She refused all medicine. Pulse one hundred and twenty. "In the course of the day, the abdomen became tumid, from flatus confined in the bowels : the tumefaction was unattended by pain or soreness, and entirely subsided as soon as evacuations were procured by an injection. "Ten, P. M. she was in all respects worse. Her urine came away involuntarily ; she had some rattling in her breathing, and appeared to be sinking. Pulse one hundred and thirty-two. PUERPERAL FEVER. 391 Thirty drops spt. aether, sulph. were ordered to be given now and then as a grateful cordial. "29th, (eleventh day of illness,) we were agreeably surprised to find our patient much better. During the night she had been able to retain her urine, and had made a large quantity with proper intervals. She was quite sensible, and more composed ; and had regained the power of putting out her tongue, which be- fore she had lost. Pulse one hundred and six, and the tongue continued clear. Ordered to take, at regular intervals, a draught of infus. rosse, made with decoct, cinchonas, and to have occa- sionally Madeira wine. "These favourable symptoms did not long continue. In the evening the pulse got up to one hundred and twenty, and the heat had increased. " From this time the patient became gradually weaker, her pulse was accelerated more and more, and her urine was again discharged involuntarily. She lived two days in a state of great anxiety and increased restlessness, and died on Sunday night, the 1st of July," that is, on the 15th day of the disease. On this case, so far as we have related, we shall offer a few remarks: on the eleventh day of this patient's illness she was found to be surprisingly improved; all the favourable circum- stances, which usually announced the decline, or almost absence of the disease, were present. She was able to retain her urine, and which she made abundantly and properly, after its having passed from her involuntarily ; she was sensible, after having been incoherent and stupid ; her tongue became clean, and her pulse was reduced from a hundred and thirty-two to a hundred and six. She had regained the power of putting out her tongue, "which before she had lost." The day previously to this amendment she was extremely ill, as above stated ; she was then ordered the spt. aether, sulph. in small but repeated quantities. Now, is it not evident that the amendment of this patient was owing to her being only very moderately stimulated by the aether ? a stimulus at the moment, in point of power, exactly suited to the condition of the system ; and had the physicians been contented to "let doing well alone," it is probable she would have recovered. But, over-anxious for their patient, they must prescribe several stimuli at once ; namely, bark, wine, &c., and thus undo in a moment all they have so hap- pily achieved by their previous moderation ; for Mr. Hey informs us, that " these favourable symptoms did not continue long." In this case the system was evidently over-stimulated, and the patient succumbed ; for, had a free use of opium been made, it would, we think, have been the congenial stimulant, for this article never acts more favourably than in peritoneal inflammation after ample Depletion. Indeed in many other inflammations, we have seen 392 PUERPERAL FEVER. its salutary influence when the other diffusible stimuli would have proved most probably injurious. It may be said that these favourable appearances now and then take place, yet disappoint the hopes they have created this may be the case in the early stage of the disease; but when these changes take place so late as the llth day, we should be disposed to look upon them as announcing a return to health ; and had this amendment been properly cherished, it might have termi- nated in it ; especially as the pulse was so much reduced in fre- quency as to be at a hundred and six in a minute. Case XXVII. united, on the 8th and 9th days, as many bad symptoms as are generally recorded upon such occasions ; that is, "the pulse became more frequent, and the patient appeared more sunk. The abdomen remained much tumefied, but mani- fested but little sensibility upon pressure. She still complained chiefly of the pain in her head." On the 10th day, says Mr. Hey, "I accompanied the surgeon in the evening to visit his patient. She appeared very low, and her pulse was frequent and feeble. Her tongue was dry and brown, and her teeth were incrusted with sordes. Her head was yet affected with pain, but she made but little complaint of her belly. It was, however, enlarged, and though not very tender, was sensible to pressure. The symptoms of active inflamma- tion having given place to those of a typhoid character, the pur- gatives had been omitted, and the evacuations had consequently decreased. I recommended such a repetition of the purgative as might procure an evacuation about once in four hours, and a continuation of the saline mixture in a state of effervescence. The strength of the patient was supported by a light, but nutritious diet, such as broths, jellies, chocolate, and milk. This plan was regularly pursued for four days, and the patient was then convalescent. This case is full of valuable instruction in the treatment of this disease, and indeed of every other, where there is what is termed a " tendency to typhus." It must be observed, that on the tenth day of the disease, there was what Mr. Hey himself considered a "typhoid character: the tongue was dry and brown, and there was great weakness." Yet, notwithstanding these evidences, he did not, as in the former case, goad the system to dissolution, by bark, wine, and other stimuli ; on the contrary, he gave the system an opportunity of righting itself, by the abstraction of offensive matters from the bowels ; and though he says he had omitted the purgatives, he yet " contrived to have a stool once in four hours." Now, will any dreader of typhus permit his patient to have six stools per diem, or give the neutral mixture by way of cor- dial? Certainly he will not he will put bark, wine, ammonia, PUERPERAL FEVER. 393 &c., &c., in immediate requisition; and be rewarded for his anx- iety and exertions by the loss of his patient. There is not the smallest doubt upon my mind, that Mr. Hey would have lost the patient last mentioned, as certainly as he did the other, had he had recourse to the same remedies. 1 It is truly a matter of surprise, that Dr. Leake did not profit more by his experience in the fever of the "Westminster lying- in Hospital;" and by the freer use of the lancet, have saved most probably more patients than his account of cases now exhibits. We have thought proper to make a scale of these cases, to show that the disease he had to encounter was comparatively a mild one, and would most probably have yielded in almost every in- stance to a more liberal plan of depletion. Dr. Leake had cer- tainly a correct notion of the nature of the disease ; as his dissec- tions displayed to him in every instance the ravages of previous inflammation. Why his hand was withheld from the lancet, it is impossible to say ; for had he examined the result of his own practice he must have perceived that the only instances of reco- very, (at least of those he has recorded,) were those in which bleeding and purging, to a greater or less extent, were employed ; and not a single instance of recovery when it was not employed. We have the histories of eighteen cases, the terminations of which were as follow, viz.: Cases I. II. VII. V.III." IX. XII. XV. XVI., were bled and purged, and recovered. IV. Bled ^viij. on or about the seventh day, . . died. V. Bled ^vj. on the third day, >+ ' '. : ' ;- : \ .1 .-* -.'. .%,!',- * died. VI. VIII. X. XIII. XIV. XVII. XVIII. 3 not bled, y ,,,, died. This little schedule speaks volumes as to the comparative modes of treatment. Out of the eleven patients which were bled, eight recovered ; and of the three who died, it may be truly said, the bleeding could not be expected to have been successful, for it was employed both sparingly and late. Case IV. was seen by Dr. Hunter in private practice ; and he thought from the nature of the symptoms, it would be giving a chance to extract blood on the seventh or eighth day. This circumstance shows 1 We are not informed, however, by Mr. Hey, of the motives which induced him not to employ the common routine of stimuli for his patient ; but this is of no consequence as regards the event, as it establishes the principle insisted on; namely, that though a patient may not bear the loss of blood, or sustain other evacuations to the extent they had previously been employed, yet that she will bear them to a certain extent ; and that she will sink under the action of stimuli, when urged beyond a very moderate degree. Q It may be proper to notice that case VIII. is not case VIII. in Dr. Leake's series : it is included under the history of case VII. * This case, like case VIII. mentioned above, is also recorded in the history of case VII. See Treatise on Child-bed Fever, Vol. II. 394 PUERPERAL FEVER. the comparative mildness of the disease as it then appeared; and Dr. Leake informs us, p. 57, that "when the disease proved mortal, the patient generally died on the tenth or eleventh day from the attack; consequently it should be looked upon as one of a mild type." In the epidemic so well described and so successfully treated at Leeds by Mr. Hey, the success was still greater, though the disease was of much greater malignity. For we are informed by Mr. Hey, that "it was by no means uncommon for the fever at Leeds to finish its course in forty-eight hours : and in many cases, it proved fatal in a much snorter time," p. 165. Yet, the success following the plan pursued by Mr. Hey was consi- derably greater than that which attended Dr. Leake, in a much milder form of the disease ; and this success was owing to a bolder practice, and one better adapted to the nature of the complaint. Mr. Hey states that "of fourteen patients treated without bleeding, only three recovered," p. 165. And farther, that after "I had determined to use bleeding in addition to purging, of thirty-three patients whom we (he and his father) attended, only three died; the last twenty-six having recovered in uninterrupted succession;" to this he adds, in a note, copious bleeding was used in all these cases except one, which was rather slight, and was cured by purging alone, p. 168. At Sunderland, where the disease was, perhaps, rather less malignant than at Leeds, Dr. Armstrong says, " Those patients who were copiously bled and purged, and vomited successively, were usually convalescent on the fourth or fifth day, and from that time regained their health and strength rapidly," p. 73. He says, " Of forty-three distinctly marked cases of puerperal fever, only five cases of the whole number terminated fatally. The thirty-eight successful cases were all treated by copious de- pletions of one kind or another, and in twenty-nine of them ca- lomel was exhibited in doses of a scruple, or half-drachm, at the beginning, and occasionally repeated in the course of the dis- temper," p. 70. Dr. Gordon, whose method of treating puerperal fever consists in large bleeding early in the disease, and plentifully purging, with the interposition of opiates, informs us that in a fair trial of his method in fifty cases, only five died. And farther, that all the five died before he had discovered, by the dissection of his fourth case, the true method of treating the disease; and that of thirty patients treated in this way, not one died. It is evident, from all that can be collected from the history of puerperal fever, and all that is revealed by numerous dissections, that this disease consists of an inflammation of some one portion of the peritoneum, and is not necessarily confined to any one PUERPEEAL FEVER. 395 viscus. 1 But this inflammation may be more or less extensive ; it may be more or less violent; and it may run its course with greater or less rapidity, as its type may chance to be. But, be it in extent unlimited or confined ; be its mildness or violence what it may; be its course rapid or slow, it nevertheless consists of inflammation of very important and influential structures of the human body ; and requires for its extinction extensive blood- lettings ; sometimes less than at others, but always liberal purging, with a most strict antiphlogistic regimen. This being premised, we shall go on to say a few words on each of the most usual re- medial agents, as employed by the best authorities, and most ex- perienced practitioners in this complaint. ''"" ^ '>/; . 1. Bleeding. This remedy was first extensively employed by Dr. Gordon for the cure of the epidemic puerperal fever which appeared at Aberdeen in the year 1789, and continued in that place, with more or less violence, until 1792. Soon after the appearance of this disease, he discovered that early and large bleeding, with very liberal purging, was almost sure to cure this complaint ; but, that the first remedy could not be advantageously used after a certain period had elapsed; consequently, its efficacy was con- fined to that stage of the disease which consists in an active in- flammation. If bleeding were performed after this active stage had passed, it was either ineffectual or injurious; and on this ac- count it is proper, in a pathological, as well as in a therapeutical view, that we should ascertain the causes which render a diffe- rent plan of treatment necessary, as the disease progresses ; for this purpose, we shall divide its progress into three stages, each of which requires a certain modification of treatment. a. Stage First. Dr. Armstrong makes but two stages of puerperal fever : but we are of opinion that a third is essential to the well-understand- ing of the disease. We are certain that an "intermediate state, or stage, takes place in puerperal fever, between the cessation of the inflammatory stage and the period of effusion; and may be termed the "gangrenous stage," 2 since it is at a time in which 1 See pages 347-8. ' We are by no means satisfied with the term employed to designate the state of the parts at this period of the disease: we use it, then, with a full conviction that it does not express the idea which we would wish to convey. It is a state of a part which approaches death, but it is not death; because parts sometimes re- cover from it. If properly managed, that is, if not over-stimulated, the powers 396 PUERPERAL FEVER. the vessels have not absolutely lost their life, though they are on the very verge of it. It is at this period that hlood-letting can do no good, and stimulants will destroy. We shall have occa- sion to describe the stage more fully hereafter. The third stage is that at which effusion takes place, and at which all remedies are, as a general rule, unavailing. Dr. Armstrong describes the first in the following manner: The first stage is variable as to its duration, 1 sometimes ter- minating in a little more than twenty, and sometimes continuing as long as seventy hours, but always being shorter in the epi- demical than in the peritonitic fever." 2 It will be seen, at once, from the histories already given of this disease, that the duration of this stage must vary, not only as the disease may be sporadic, but also when it is epidemic, owing to the type which occult causes may impose upon it. In a practi- cal point of view, therefore, the limit of this stage must not be rigidly fixed by any certain number of hours. This stage, strictly speaking, consists in the duration of the active state of inflamma- tion ; and this will vary, as just observed, from the contingencies of season, constitution, age, epidemical influence, &c. In the epidemic described by Dr. Leake, this stage continued, in a num- ber of instances, much longer than the greatest limit proposed by Dr. Armstrong; for, in a case in which Dr. Hunter was con- sulted, (case IV.) he advised bleeding on the eighth day. 3 It would be of great importance, in the treatment of this dis- ease, were there certain, or infallible signs, which would charac- terize this stage. But, unfortunately, none such exist, with which of the system may be such as to recover the part from the condition in which over action had placed it. 1 It must be borne in mind that Dr. Armstrong is deducing his stages from a particular epidemic; and, consequently, that the duration of them will only apply with strictness to that especial puerperal fever; or, rather, as the puerperal fever exhibited itself at that time and place. 4 By the "peritonitic fever," we presume Dr. A. means the sporadic puerperal fever: as every body seems to agree that the latter is less violent in its symptoms, and less rapid in its course, than when this disease prevails as an epidemic. If this be not his meaning, we are certainly at a loss for it; since he has declared, in the initial paragraph of his preface, that " under the common term puerperal fever, are comprehended both the ordinary peritoneal inflammation, and the 'low malignant fever of lying-in-women,' as these are considered as modifications of the same disease." Preface, p. 1. 1 We may also refer with advantage, as regards the treatment of this disease, to Mr. Hey's twenty-seventh case. In this case, he bled with much advantage, for the first time, on the fifth day; repeated it on the evening of that day, and on the day following; yet Dr. Armstrong says he " never dared to recommend blood- letting when the disease had continued longer than thirty hours," p. 76. This declaration of Dr. Armstrong is an additional proof of how much importance it would be to have other marks, than the number of hours which may elapse, to judge of the continuance, or cessation, of the first stage of puerperal fever ; for it must be recollected, as before observed, that the fever at Leeds was rather more malignant than that of Aberdeen. .<; :>. ?;'- 7 .1 " a r* ,t *&' M : ; ; '..">i<*.- '' ''I "-'" PUERPERAL FEVER. 397 we are acquainted; at least, none "with so much certainty as to remove all doubt. Under such circumstances, we are obliged to rely upon symptoms; though pretty strongly marked, yet must not be looked upon as unerring. The pulse, which, in most other inflammations, so faithfully directs us, here deserts us ; at least, we cannot judge of it in puerperal fever, as in pleurisy, or common fevers ; as this disease imposes a character upon it, which, with our present notions, would greatly mislead us. Mr. Hey says, " The state of the pulse affords little information, either as to the propriety of bleeding, or the quantity of blood proper to be taken away ; and if we are deterred either by the apparent weakness of the patient, by the feebleness and frequency of the pulse, or by any other symptom, from bleeding copiously, we shall generally fail to cure the disease," p. 161. This statement clearly shows that neither Mr. Hey, nor those who have preceded him, were in possession of any sign by which they could, with absolute certainty, determine the existence or termination of the first stage of this disease. The pulse, the common, and, generally, the certain guide in other febrile affec- tions, we are warned not to rely upon, for it will deceive us ; on what, then, are we to rely? Mr. Hey says, "If the disease is clearly ascertained, no other consideration is of much import- ance," p. 161. This assertion is not made with Mr. Key's usual caution and discrimination ; for puerperal fever is still puerperal fever throughout its stages ; yet Mr. Hey is particular, in other places, that the treatment of one stage should not be pursued in another. We are willing to admit that "the state of the pulse affords little information," in our present state of knowledge of that function; but we cannot be persuaded but that every active morbid condition of the system, has a modifying influence upon the heart and arteries; and which could be detected, were our powers of discrimination equal to the necessity and usefulness of such a knowledge. In the disease in question, a disease of such deadly tendency, and rapid termination, the importance of the structure which is its seat, the decided control it has over some of the powers or actions of the heart and arteries, would lead us almost necessarily to conclude, that the mode of action of these important viscera is peculiar, and every way highly characteristic in puerperal fever, did we but possess the tact to detect it. We would, therefore, earnestly caution the practitioner against being betrayed into an indifference about the state and character of the pulse, that the assertion of Mr. Hey would almost certainly lead to; and, on the contrary, would decidedly recommend to him the study of the pulse, and other signs in puerperal fever, with a hope that the secret characters of peritoneal inflammation, 398 PUERPERAL FEVER. in its various grades, may be detected ; and thus confer upon society a never-ending benefit. For, that there are characters of pulse in puerperal fever, (we must repeat,) we are persuaded; and, that they are susceptible of development, we as confidently believe; but to detect them with a certainty that may be useful, will perhaps require much experience and patient application, together with a most nice and discriminating touch. This faculty, (the touch,) like all our other faculties, may be much improved by well-directed disci- pline; its powers should, therefore, be carefully cultivated by the physician who is desirous of extending the benefits of his profession to his fellow creatures. For, it is but by repeated trials and careful observation, that the faculty of discrimination can exist in an accurate or an exalted degree ; and when it does not exist in such a degree, it cannot serve the purposes so much desired. Farther, the touch, like the other faculties, exists in various degrees of perfection, as an original condition ; consequently, it is not, in every instance, susceptible of the same cultivation : but in all it is capable of much improvement ; or at least with very few exceptions. We would, therefore, earnestly recommend the attempt. As illustrative of this point, and some others connected with the pulse, we think we cannot do better than to employ the language of Mr. Hunter upon this subject. "The pulse is often as strong a sign of the state of the con- stitution as any other action that takes place in it, though it is not so always ; but, as the pulse has but one circumstance at- tending it that we can really measure, all the others being refer- rible to the sensation or feeling of the person who is the judge of it, the true state of the pulse is not easily ascertained. The knowledge of the soft, the hard, and the thrill, are such as can only be acquired with accuracy by the habit of feeling pulses in these different states, and, by many, is not to be attained; for simple sensation in the minds of any two men is seldom alike. "The late Dr. Hunter was a striking instance of this, for, though he was extremely accurate in most things, he could never feel that nice distinction in the pulse that many others did, and was ready to suspect more nicety of discrimination than can really be found. Frequency of pulsation in a given time is measura- ble by instrument; smartness or quickness in the stroke, with a pause, is measurable by the touch ; but the nicer peculiarities in the pulse are only sensations in the mind. I think I have been certain of the pulse having a disagreeable jar in it, when others did not perceive it ; when they were only sensible of its frequency and strength: and it is, perhaps, this jar that is the specific dis- tinction between constitutional disease or irritation and health. Frequency of pulsation may often arise from stimulus, but the PUERPERAL FEVER. 399 stroke will then be soft; yet softness is not be depended on as a mark of health : it is often a sign of dissolution ; but then there must be other attending symptoms." Treatise on the Blood, Am. ed. p. 265. From what has been said, it is evident that the touch is more or less perfect in its condition, as an original sense; and that it is capable of much improvement in its powers of discrimination; and from what follows, it will be found there is much to learn of the various conditions of the pulse, as. depending upon the nature, seat, and force of disease ; and that the opinion, that the state of the heart and arteries, if duly distinguished, may lead to the knowledge of the condition or state of morbid action, in any particular structure of the body, is not altogether chimerical. To prove this, we shall continue our quotation from that high authority, Mr. Hunter. "In the consideration of the peculiarities of the pulse, it is always necessary to observe, that there are two powers always acting to produce them, the heart and the arteries; that one part of the pulse belongs to the heart alone, another to the arteries alone, and a third is a compound of both. But the action of the heart and arteries do not always correspond ; the heart may be in a state of irritation, and act quickly in its systole, while the arteries may be acting slowly ; for the heart must be considered as local, while the vessels must be considered universal, or even constitutional. The stroke, which is the pulse, with the number of them that are made in a given time, whence the pulse is commonly called quick or slow, their regularity or irregularity, as to time, and the quick- ness of the stroke itself, belongs to the heart. The quickness of the heart's action often takes place, though the pulsations are not frequent, which gives a kind of rest or halt to the artery, or pulse, especially if the pulse be not frequent. The hardness, the vibra- tory thrill, the slowness of the systole, with the fulness and small- ness of the pulse, belong to the arteries. As the pulse arises from the solids, or the machine, its state will be of course according to the nature of the machine at the time; and is, therefore, capable of being, in either of these states, natural and diseased. " In most diseases of the constitution, whether originating from it, or arising in consequence of diseases of parts, where the con- stitution becomes affected by sympathy, the pulse is altered from a natural to a diseased state, the degree of which will be regu- lated by those affections. This alteration is commonly so constant, and so regularly of the nature of the disease, that it is one of the first modes of intelligence we have recourse to, in our inquiries into its nature: but alone it is not always a certain guide." "The varieties which the pulse admits of are several. It is increased in its number of strokes, or it is diminished. It is re- 400 PUERPERAL FEVER. gular, or it is irregular, as to time in its stroke; it is quick in its stroke, or diastole, and slow in its systole. It is hard in its diastole, and it vibrates in its systole. "In most cases, probably where the constitution is in a state of irritation, the pulse will be quick and frequent in its number of strokes in a given time, and the artery will become hard, from a constant or spasmodic contraction of its muscular coats, so as to give the feel of hardness to the touch ; besides which, the dias- tole of the artery is not regularly uniform and smooth, but pro- ceeds by a vast number of stops, and interruptions, which are so quick as to give the feel of vibration, or what we could express a thrill." Ib. These quotations are sufficient to prove that the condition of the artery in disease, as regards its volume, its firmness, its softness, its frequency, or its peculiarities of action, very much depends upon the nature of the disease which imposes the altera- tion; and that the diseased action itself will be influenced by the particular structure or structures which are the seat of it. If this be true, and we can see no reasonable doubt of it, it seems to follow, that the peritoneum, in a state of inflammation, will give to the heart and arteries a character of action which exclu- sively belongs to that condition of this membrane ; and that the actions of the artery will of course vary with the varying con- dition of the part or parts inflamed. As regards ourselves, we profess to have much reliance upon the pulse in all acute affections of the body ; and almost always make it the guide of our prescriptions ; yet we confess we have less dependence upon it in puerperal fever, than in any other disease with which we are acquainted. Not, perhaps, because it is unfaithful in its reports of the condition of the system, but be- cause, we fear, we do not exactly understand them. The study of the pulse, therefore, in puerperal fever is almost a new one ; and we most earnestly recommend it to those who may almost Constantly have the charge of females, with a firm conviction that they will be amply repaid for their labours. 1 But to return. We would ask, what is the evidence that the first stage has run its course? This is an important question; and one, from our present data, that cannot, we fear, be answered satisfactorily. Hitherto this condition of the disease has been inferred, rather than ascertained. It has been inferred, from the little advantage in some cases, and the marked injury in others, of blood-letting ; and this is probably the amount of information upon the subject; 1 Mr. Travers says that the pulse of real fever does not exceed a certain limit, and that consists with a property of distinctness. When it is innumerable, and from that cause indistinct, it ceases to be fever ; it is a powerless automatic ac- tion, and has neither the characteristics of heat of surface nor obstruction of the general secretory system. PUERPERAL FEVER. 401 hence, perhaps, the rule for withholding the lancet in certain epi- demical puerperal fevers, being regulated by hours ; for it would seem, that in each individual epidemic of this nature, there is a period, cseteris paribus, at which the first stage runs its course, and this period has been signified by hours, because, when the disease had continued beyond this time, and blood-letting resorted to, it either proved unavailing or mischievous ; consequently, the first stage was supposed to be past. Thus, Dr. Gordon would not promise success from bleeding, if the disease had continued from twelve to twenty hours ; be- cause this was probably the average period for the first stage, in the Aberdeen epidemic; and Dr. Armstrong says he has " never dared to recommend it when the disease had continued longer than thirty hours," p. 76 ; because in the Sunderland epi- demic, this may have been the period for the change from the first to the second stage, &c. It is true that Dr. Armstrong has attempted the character of the first stage, by detailing certain symptoms, and has perhaps succeeded better than any one else in defining and ascertaining its bounds ; nevertheless, he must not be considered as being al- together successful. It is, however, a praiseworthy attempt; and he is entitled to the thanks of the profession, for the lucid manner in which he has treated the subject. "In the first stage," he says, "after the rigours have ceased, the pulse is hardly ever less than one hundred and twenty, and sometimes, though, as far as I have observed, very seldom, as high as one hundred and forty in a minute : the blood does not seem to flow in a soft, easy, and natural current, but comes against the finger with a kind of vibratory motion, and more than ordinary pressure is commonly required to stop its course along the artery, which feels rather hard and tense. The skin is dry, and hotter than natural; the patient complains of great pain and soreness of the abdomen, breathes nearly forty times in the minute, vomits mucus and bile, is generally bound in the belly, has a white, dry tongue, considerable thirst, and labours under all the restlessness and irritation of fever," p. 59. This description looks as if it were every way competent to the purposes for which it is designed; yet there is not a symp- tom, well defined as it seems to be, that may not accompany the second stage, if we except, perhaps, "rigour," which must be looked upon, when it takes place, as the initial symptom of the constitutional affection, and is of short duration. 1 The pulse is said to be from one hundred and twenty to one 'Dr. Armstrong, however, includes chills in his second stage: to have made these characteristics, he should have added, that these chills are not followed in> mediately by a sense of increased heat. 26 402 PUERPERAL FEVER. hundred and forty strokes in a minute ; so it happens in some instances of the second stage ; and Dr. Gordon says he has bled in some cases with good effect, when the pulse has been one hun- dred and sixty ; therefore, if the bleeding with advantage be the proof of the presence of the first stage, the second cannot be characterized by a pulse of one hundred and forty; since one hundred and sixty have been witnessed during the first stage. In Mr. Key's case, (3d,) the pulse is recorded to be at between one hundred and thirty and one hundred and forty on the fifth day, and at a time when all hope was abandoned; and it was but one hundred and forty-four, (a number considerably within the range at which Dr. Gordon says he has bled profitably,) a short time before death. Mr. Hey's case, (5th,) terminated fa- tally in thirty-five hours; and its commencement "was accompa- nied with a full, strong pulse." In his sixth case, the pulse was one hundred and thirty in the last stage. We might furnish many more cases of similar import ; but these are sufficient to prove that the number of pulsations of the artery in a given time will neither mark the first, nor characterize the second, stage of this disease. We should place much more reliance on that peculiarity of the pulse which Dr. Armstrong describes, "where the blood does not seem to flow in a soft, easy, natural current," &c.; if it were found to be a constant symptom, and to be detected with cer- tainty by even close attention, as it seems to countenance the opinion hinted above, that the inflammatory stage most probably is accompanied by a distinctive arterial action, however evanes- cent it may be in duration, or however difficult of detection. The state of the skin is very much less characteristic than even the pulse ; for in the first stage it is frequently moist, nay, wet ; and in the second, it is both hot and dry. The pain and sore- ness of the abdomen often continue through the whole disease ; and though never absent from the first stage, it is nevertheless constantly present in the second. The breathing is not more decisive ; vomiting is less frequent in the first than in the se- cond stage. The tongue affords no criterion ; it remains some- times as described above, until death closes the scene. Thirst is sometimes insatiable in the last stage; and the restlessness and irritation from fever attend sometimes to the last moment. We should, however^ place some reliance upon the character of the pain and soreness, mentioned as belonging to the first stage : it is generally of an acute, pungent kind ; more easily excited by pressure at one portion of the abdomen than another ; and very frequently confined to the hypogastrium : there may be some swelling from the very commencement, which is sure to augment as the disease gains ground, giving to the hand the sen- sation of more or less solidity; but the distention is never exces- sive during this stage ; is obedient to the influence of remedies, PUERPERAL FEVER. 403 by diminishing in size and sensibility; provided, the remedies exert a control over the disease generally. The patient is some- times disposed, and sometimes does, turn upon her side; though obviously inclined to maintain her position, for the most part, upon her back ; because the abdominal muscles, by being relaxed, moderate pain. It would appear, then, that the first or inflammatory stage of puerperal fever, the stage in which bleeding has been so emi- nently successful, has no discovered character by which it can be distinguished from the second, in which this operation is for- bidden after the lapse of a few hours. This circumstance we must regard as unfortunate, but perhaps not without remedy : for we must still insist that there cannot be such a departure from the usual economy of the system, as to make puerperal fever the only exception. We must be borne with, therefore, if we still persist in recommending to physicians a more exclusive devotion to and study of the several stages of this disease, that their now hidden characters may be developed. The rules which are to govern the loss of blood in this com- plaint are therefore necessarily reduced to rather uncertain and narrow limits; and are more dependent upon contingencies than fixed principles. These rules are comprised in the follow- ing directions : 1. Bleed as early in the disease as possible. But, 2. Bleed, at that time, as much as the system will well bear. 3. Repeat, pro re nata. 1st. Every practitioner is aware of the difficulty which almost constantly attends the execution of the first direction : this arises from several causes; but none of which are absolutely insur- mountable. First; to the initial symptoms of the disease being frequently mistaken for the common occurrences of child-bed if chill attend, as is most common, or if fever ensue without it, it is commonly attributed to the "coming of the milk," or that ephemeral called the "weed;" or to some slight exposure, or unforeseen negligence. Second, to the desire on the part of the nurse to be thought competent to any little indisposition incident to this period of child-bed. Third, to the consequence of this belief of the nurse; losing thereby much time in witnessing the effects of her own remedies. Fourth, to the fear of censure attaching to the nurse for any indisposition by which her patient may be attacked; therefore withholding early information. Fifth ; to an ignorance of the nature and fatal tendency of the disease. Sixth, if pain commence early, to its being mistaken for after-pains. For the reasons just assigned, it will, in very many cases, be out of the physician's power to treat the disease as early, or as vigorously, as its ferocity demands ; therefore he should prevent, as far as possible, the operation of the above causes, whenever 404 PUERPERAL FEVER. the necessity may exist, by following the plan adopted by Mr. Hey, during the prevalence of the puerperal fever at Leeds. He requested to be sent for "without delay, on the accession of shivering or unusual pain." But he adds, "Notwithstanding my urgent request, I was seldom called until some hours after the attack," p. 76. This declaration diminishes our hopes of early applications, it is true ; but the plan should be tried, as it is the only one we can adopt for the end proposed. We have already mentioned the latest periods, in the opinions of several of the best authorities on this subject, at which it would be useful or proper to bleed ; we also attempted to show that these directions were founded upon experience, or rather experiment, upon different occasions ; that, though there were discrepancies in appearance in these statements, yet there were none in reality; as the conclusions were drawn from individual experience, in each of the epidemics of which they gave the histories, and, consequently, that neither the short periods of Armstrong and Gordon, nor the more extended ones of Denman and Hey, should be taken for absolute guides. Therefore, in every instance of puerperal fever, especially in epidemic, as well as in sporadic cases, there may be a difference of period at which it might be proper to bleed ; and that this period should be discovered as early as possible, and its limits ascertained with as much precision as it is susceptible of. For, by this means, we may extend the benefits of this operation be- yond what might at first be expected, as well as be prevented from doing mischief by it, if too lately employed. As regards, then, the period after the attack at which we are to draw blood, it is a concurrent opinion, the earlier, most de- cidedly the better: as respects the one at which this would no longer be useful, we have but very uncertain marks ; therefore, much must be left to the experience and judgment of the practi- tioner who may have the care of the case. 2. Having ascertained the propriety of blood-letting in the early period of the disease, the questions next in importance are first, what quantity must be drawn ; and secondly, must it be repeated, and when, or under what circumstances ? All the writers who have treated this disease with adequate boldness, prescribe the loss of a given quantity of blood; thus, Gordon, Hey, and Armstrong, limit it from twenty to thirty ounces ; believing that less will not answer, and more is not gene- rally required. 1 In this country we are not in the habit of regu- 1 Dr. Armstrong says, " The quantity of blood drawn at once in puerperal fever should seldom be less than twenty-four, and, perhaps, never more than thirty ounces," p. 76. Dr. Gordon says, " I have limited the quantity of blood necessary to be taken away, and fixed the time when taking away that quantity will cure. Thus, 1 found that twenty-four ounces of blood, taken away at one bleeding, within six or PUERPERAL FEVER. 405 lating our bleedings by ounces ; in severe illnesses we almost alto- gether regulate the quantity by its. effects ; and we are disposed to believe this to be the safer and the more efficient plan.' For it is not to be supposed that every constitution will be affected precisely alike ; nor that the disease, in every constitution, will yield to exactly the same force of remedies. In one instance, perhaps, a less quantity than twenty or thirty ounces might be sufficient, while another might require a much larger quantity ; therefore, in the one more blood may be drawn than is absolutely necessary, (though we confess it to be erring on the safer side,) and in the other, which is much more material, an inadequate quantity is too confidently relied upon. As regards our own practice, in such cases, we have always abstracted as much as the system would well bear ; that is, until the pulse was changed, pain abated, fever diminished, and there was a disposition to syncope. These alterations would take place sometimes from the loss of a smaller, and sometimes a larger quantity of blood: but until these did take place, we could not flatter ourselves that we had strangled, or, perhaps, even weak- ened, the disease ; but this we always attempted, did it require only twenty ounces, or did it demand forty. In constitutions wont to faint from the loss of a little blood, we cannot always get at one bleeding the necessary quantity ; the operation is, therefore, to be repeated so soon as the system reacts with decided force; unless all the expected relief be ob- tained by that which has already been done. We do not wait for the lapse of any certain number of hours to repeat the bleed- ing; for we are persuaded, in doing so, we permit the disease to gain ground ; we should, therefore, draw it as quickly as the state of reaction will permit, if the symptoms continue. Dr. Armstrong says, " If the patient, as sometimes happens, faint under the first operation, when only four or five ounces of blood have been taken away, unless there be an abatement of all the urgent symptoms, another vein ought to be opened, after the lapse of one or two hours, and about twenty ounces taken in a full stream," p. 78. We would ask, why we should "wait an hour or two" in this case, before we repeat the bleeding ? The answer may be, because there is "an abatement of all the urgent symptoms:" this, we admit, will almost certainly be the case during the temporary prostration of the system, but no longer, in some instances ; as eight hours after the attack of the disease, together with a single purgative, never failed, at once, to cure the puerperal fever," p. 84. On this, Mr. Hey makes the following remarks : " Though I have found great advantage from the rules laid down by Dr. Gordon, yet it is incumbent upon me to say, that they were not al- ways infallible, either as to the quantity of blood which was necessary for the cure, or the time within which it should be taken," p. 156. 40G PUERPERAL FEVER. there is commonly a renewal of all the more violent symptoms the moment reaction is re-established ; therefore the period of re- action should be the rule. For, in some remarkable cases, this state of fainting may continue beyond the period prescribed, when it would be highly injudicious to repeat the bleeding; while in others, reaction may take place in a few minutes : in such a case, it would be losing precious time to wait "an hour or two" for the second bleeding ; and in the other we might draw blood at an improper moment. Besides, the rule we have laid down is void of all ambiguity. 3d. The necessity for farther bleeding must be determined by the existence and urgency, of the original symptoms; such as fever, with accelerated pulse ; vomiting ; heat ; and pain without much swelling. Indeed, as far as our experience will warrant the deduction, the state of the abdominal swelling, and the de- gree of acute pain without much distention of the abdomen, are much more certain marks of the continuance of active inflamma- tion, or the first stage, than any others we are acquainted with ; and that it is much safer to rely upon them than upon the pulse ; because the various conditions of the latter are but very ill un- derstood. So far these circumstances have directed us, and, we may add, successfully. We have already declared, however, that our experience has not been extensive. 1 Our rule hitherto has been, when the first bleeding, which, as we have observed, we always make a very liberal one if called to the disease early, does not abate the severity of the symptoms in three or four hours, to repeat it without hesitation : but not to the extent of the first, as evidences of its influence manifest them- selves before an equal quantity is drawn. Nor do we limit it to this single repetition ; for, if the disease be not abated in severity, we know of no other general remedy that has the slightest con- trol over it. And we are persuaded that the farther abstraction of blood is necessary, either from the arm, or locally, by leeches. It is, however, to be understood, that purging is to be imme- diately commenced after the first bleeding, and persevered in, as we shall direct more particularly presently. Mr. Key's rule is, "If the pain and soreness of the abdomen are not removed, or very materially alleviated, in nix hours, the bleeding ought to be repeated ; nor should a considerable degree of faintness, or even deliquium, make us suppose that farther bleeding is either unsafe or unnecessary. In short, I know not, from any experience of my own, that scarcely any other limit should be put to the quantity of blood, than the removal, or con- 1 The reader will readily understand the reason of this, by what has already been said of the rare appearance of this disease in this city. PUERPERAL FEVER. 407 siderable diminution of the pain ; provided all that is requisite be drawn within twelve hours of the first evacuation," p. 161. We think the plan just mentioned a very good one ; though we should prefer making the interval rather shorter, provided the symptoms continue to be urgent; for we are well persuaded nothing is gained by delay, unless there be an abatement of the symptoms ; and we believe that this should be the rule upon most occasions. The temporary amendment procured by the bleeding must not be mistaken for such a reduction of the disease as to render the repetition unnecessary ; for, if there be a renewal of all the distressing symptoms, the disease must be considered as being still in full force, though the rapidity of its march may be a little abated by what has already been done. We must object to an entire conformity with Mr. Hey's pro- viso, namely, that "all the blood designed to be drawn should be within twelve hours of the first evacuation ; " for we are persuaded we have seen bleeding do much good after a much longer period, where the force of the disease has been abated by the preceding evacuations. For it is but reasonable to suppose, even in the puerperal fever, which runs its course rapidly, that the tendency to disorganization will be diminished by proper remedies; there- fore, a greater latitude, as regards hours, we think, may be per- mitted, provided the symptoms do not display the same intensity, yet evidently remain unsubdued. Dr. Armstrong discovers still greater apprehension of repeating the bleeding. He says, " The quantity of blood drawn at once in puerperal fever, should seldom be less than twenty-four ounces ; but a repetition of venesection ought, if possible, to be avoided, though occasionally it may be absolutely necessary ; and when this is the case, there should be as short an interval as possible between the first and second bleeding," p. 76. Why this direc- tion should be guarded by the condition, "absolutely necessary," we cannot say, as we presume, in such cases, when employed, it is always absolutely necessary. We are very desirous, on practical points, not to mislead, by attaching too much importance to any mode or plan we may have adopted for the cure of a disease, when, in our own opinion, that plan has not been sufficiently tested by experience. On this account, we feel that we are not in possession of any infallible marks, by which we can distinguish the two early stages of this disease from each other better than those who have preceded us. We can, therefore, only give a detail of such circumstances as have hitherto directed us in the treatment of the disease in ques- tion, and have led us to suppose we were generally correct. We believe that puerperal fever consists in a most active in- flammation of the peritoneum ; and that this inflammation, if left 408 PUERPERAL FEVER. to itself, or timidly encountered, or if aggravated by improper treatment, will run its first stage with great rapidity. That its second stage consists in the termination of the previous inflam- matory stage, in that state known by the term "gangrene;" which is always of short duration ; for it either retraces its steps to inflammation, or resolution, or terminates in profuse effusions within the cavity of the abdomen. That the only chance of re- covery arises from the immediate extinction of the inflammation by resolution ; and that, when this is not effected, death will al- most inevitably ensue ; for, unless the inflammatory stage can be cured, the attempt for the relief of the others is altogether con- tingent; as all experience, or with extremely rare exceptions, is much against favourable results from any mode of treatment hi- therto pursued. We have thought it safe and necessary to bleed in puerperal fever, as long as the pulse possessed any firmness ; the abdomen great tenderness and acuteness of feeling, or severe occasional pain ; provided the distention was not great ; and while the mam- mee secreted milk, or they retained a certain degree of fulness, and especially, if the woman exhibit the feelings of a mother to- wards her child. We have not always chosen to draw the blood by the lancet; we have sometimes preferred the employment of leeches, and the quantity drawn by them to be regulated by ounces, and not by the number of leeches. 1 We desist from abstracting blood in any way, when we believe our second stage is about to take place, or has actually occurred. This stage Dr. Armstrong has very well characterized in gene- ral ; we shall therefore repeat it, and make such observations as we think the case requires. "In the second stage, the pulse is never under one hundred and forty, and frequently rises above one hundred and sixty in the minute, while it is always exceedingly variable, weak, and compressible ; the tenderness of the belly is usually much dimi- nished, and the fulness increased ; cold partial perspirations first break out about the face, neck, and extremities ; the centre of the body, particularly the surface of the abdomen, remaining dry, and of a pungent heat, for some time afterwards. The patient rarely shivers much, but has repeated chills ; vomits dark, gru- * The size of the leech in this country not only varies very much, but also is very small when compared with the European leeches. But the leechers here soon become acquainted with the capacities of these animals, and will very accu- rately determine, by an average, the quantity of blood they will abstract. As a general rule, however, eight American leeches will be required to draw an ounce of blood, so that the calculation is easily made. These animals should be applied to the abdomen generally, but a greater number should be placed upon the most painful portions of it, or they may be placed with advantage upon the inner sur- face of the thighs. PUERPERAL FEVER. 409 mous matter ; seldom breathes less than sixty times in a minute ; has generally a loose belly, a brown, black, or reddish parched tongue ; unquenchable thirst, tremulous hands, lightness and swimming in the head, confusion of thought, or delirium : and several hours before death a remarkably relaxed, cold, damp skin," p. 59. In this account, Dr. Armstrong has confounded the " gangre- nous stage " with the "stage of effusion;" some of the symptoms belonging to the one are blended with those belonging to the other, which, for the sake of precision, should be separated, as the stages are not equally desperate ; for the gangrenous may admit of remedy, or at least is not absolutely fatal. It is, how- ever, a stage necessarily replete with danger, though it may not always eventuate in death, unless goaded to it by a mistaken theory, or a false pathology. It is the stage in which bleeding can never be proper ; and the one in which stimulants must be for- bidden. It is the one in which we must always rely upon the powers of the system; and, consequently, from which we must not look for many recoveries, though we may have a right to expect now and then an escape. We will presently attempt to separate the symptoms which in our opinion mark these two stages. 2. Of Purging. Nothing can be said in favour of this remedy in this disease ; mild aperients may be occasionally useful. 3. Of Emetics. In favour of emetics in puerperal fever, agreeably to a plan suggested by M. Doulcet, there is the most extraordinary testi- mony ever presented to the public. In 1782 the King of France directed "the Royal Medical Society of Paris" to make a re- port upon the memoir of this gentleman, containing "a new me- thod of treating puerperal fever." This report declares that " puerperal fever had made its appearance more frequently than ever in the Hotel Dieu of Paris, since the year 1774 ; and that it had always proved fatal to every person it attacked. They farther report, that in four months, during which this epidemic disease raged with great fury, nearly two hundred women were saved to society by Doulcet's new method of treatment." Clarke's Essays, p. 106. M. Doulcet's method of cure "consists in taking the advan- m 410 PUERPERAL FEVER. tage of the moment of attack, and giving, without losing an in- stant of time, fifteen grains of ipecacuanha, in two doses, at the ' distance of an hour and a half from each other, and repeating them again the next day, in the same manner, whether the vio- lence of the symptoms be abated or not ; and if the disease should continue much the same, they are repeated again the third, and even the fourth day, according as the case may require. In the intervals between the doses the effect of the ipecacuanha is kept up by a potion composed of two ounces of oil of sweet almonds, one ounce of syrup of marsh mallows, and two grains of Kermes" mineral. The common drink is linseed tea, or an infusion of Scorzonera root, edulcorated with syrup of althaea ; and towards the seventh or eighth day of the disease, the patient takes a mild purgative, which is repeated three or four times, according to the exigency of the case. The efficacy of this method of cure con- sists wholly in its early application, namely, in the moment when the disease first commences ; and though experience has since taught us that the loss of a few hours is not always irreparable, yet it seldom happens that ipecacuanha has the same complete success, when the first moment of attack is lost." Whitehead's Translation of Doulcet's Method, &c., as quoted by Hull; Treatise on Phleg. Dol., p. 267. See M. Desormeaux's Ac- count, p. 417. The simplicity of M. Doulcet's plan has much to recommend it; and if its efficacy had been equal in other places, and in other epidemical puerperal fevers, as it was in that of the Hotel Dieu, it would be irresistible. But, unfortunately for the interests of humanity, the success of this plan has been very much confined to the hands of its inventor. In the early part of our practice, we adopted this plan in two or three instances, but it failed alto- gether ; neither of the patients having survived the fifth day. And Dr. Clarke says, "A repetition of vomits on the plan sug- gested by M. Doulcet, has been attended with obvious disadvan- tage. The agitation of vomiting, by the necessary pressure made on the contents of the cavity during their operation, has always aggravated the pain, and tends farther to exhaust the powers of the woman, already sufficiently reduced." Essays, p. 161. This accords precisely with what was observed in the use of emetics, in the few cases in which we exhibited them. And this consequence can always be deduced, when the vomiting is an at- tendant on puerperal fever; we have never known either the spontaneous or provoked puking produce a favourable change in the disease, though we have occasionally witnessed temporary relief, when bile or other offensive substances have been thrown from the stomach. It may be asked how it has happened that emetics in the hands of M. Doulcet should have been invariably successful, and PUERPERAL FEVER. 411 fail so constantly in the hands of others ? This question it would be difficult perhaps to answer satisfactorily ; but we may suggest that it might have depended altogether upon some peculiarity of the epidemic itself, but of which peculiarity we have no know- ledge. It was certainly of less rapid course than those of Aber- deen or Leeds ; for the seventh or eighth day is mentioned, as if it were a common period to arrive; and also, that they found by experience that the loss of a few hours was not irreparable ; the very reverse of the two epidemics just named. It seems to have borne a strong resemblance to that which attacked the " Westminster lying-in Hospital," and of which we have an ac- count by Dr. Leake. The occasional use of emetics is recommended by Dr. Den- man, who seems to be convinced of their utility ; yet it would appear that the benefit procured by them was but temporary, and entirely dependent upon the condition of the stomach. For he says, "If a sickness, loathing of stomach, or offensive taste in the mouth attend the commencement of the disease, this medi- cine, (the antimonial powder,) never fails to occasion vomiting, and the patient, with a countenance strongly expressive of the benefit she has received, will attest the advantage of the method pursued." But it must be remarked that Dr. D. in no instance relies upon this method exclusively; for he says, "At the same time that we avail ourselves of the advantage of the antimonial powder, we must not neglect the use of those means which con- tribute to procure immediate ease or relief to the patient." In- trod. p. 281. From what has just been said, we must not be led into the belief, that the nausea and bad taste in the mouth are always in- dicative of the oppressed state of the stomach, and that this con- dition would be relieved by puking ; for we must, in such cases, be careful to distinguish between the sickness, occasional vomit- ing, and disgust, which may arise from something offensive in the stomach, and the vomiting, &c., which is really sometimes a symptom of the disease. The first rarely occurs but in the very commencement of the disease, while the other only appears from one to several days after. The vomiting which really belongs to the disease is seldom accompanied by the discharge of crudities from the stomach; it merely procures the discharge of mucus and the drinks taken down a short time before. This vomiting arises, either from the stomach sympathizing with the inflamed peritoneum at a dis- tance from it, or from its own covering being the seat of it; both of which, when this happens, constitute a part of the dis- ease, and, of course, can only be aggravated by the use of emetics. Dr. Armstrong is decidedly in favour of emetics : he says, "In 412 PUERPERAL FEVER. addition to bleeding and purging, Mr. Gregson was induced, from an accidental circumstance, to prescribe antimonial emetics, and on repeated trials, fully proved them to be excellent auxiliaries, never using them, however, till the patient had been freely bled and purged ; and this is certainly the best way of administering them in puerperal fever. Three very severe cases which I at- tended were treated by blood-letting, purging, and vomiting, successively employed in less than twelve hours, and the united influence of these remedies was certainly very striking, a com- plete change having been brought about in the circulatory sys- tem, and almost every symptom of inflammation and fever en- tirely subdued," p. 68. Mr. Gregson, in his communication to Dr. Armstrong, says, "My attention was particularly turned to the usefulness of emetics, from an accidental occurrence in a case in which purgative medicines had been given to a consi- derable extent, without completely relieving the pain and tender- ness of the abdomen; which, however, were soon removed by free vomiting, occasioned by a large dose of calomel and jalap. And, from that period, I have repeatedly used antimonials, with the intention of exciting nausea or vomiting, when bleeding and purging, or when purging, alone, had been premised," p. 113. Yet, it appears to us, from all we can learn, that emetics are of doubtful efficacy as principal remedies ; and we are scarcely dis- posed to look upon them as useful auxiliaries. LI J"it* 1 * f *J r v > *' * * ' * * : ^ * T ' A T>T * 4. Blisters. Considerable diversity of opinion exists with regard to the propriety of applying blisters in puerperal fever. Dr. Clarke thinks them inconvenient, and of very doubtful efficacy, if not injurious. Dr. Armstrong is of opinion they may be useful, if applied before the second stage commences ; but confesses that since he had bled and purged so freely, that he had rarely found it necessary to employ them. Mr. Hey considers them incon- venient ; and that they will seldom be necessary ; but has thought them useful if applied before the last stage. See Chap, on In- flammation *of the Uterus. Our own opinion is, that they are less useful in this inflamma- tion than in any other: we have used them formerly, but have abandoned them altogether of late years; because they are al- ways extremely inconvenient, where the patient is to be so fre- quently disturbed by the operation of purgative medicine, and never, as far as we have seen, decidedly useful. If they are employed, it should be after the first or second liberal bleeding, and after the bowels have been well purged, and the inside of the thighs should be their seat. 1 * - f ' '} '.' W~* fc- *** * * " PUERPERAL FEVER. 413 5. Fomentations. Many are in the habit of employing -warm fomentations to the abdomen ; Mr. Hey recommends them as soothing, and as free from mischief. We have for many years ceased to employ them, for the following reasons : first, they are oppressive from their weight, and offensive from the vapour which arises from them ; secondly, they expose the woman to injury from her bed be- coming wet, against which no care can guard ; thirdly, they op- press from their heat, and appear always to increase the fre- quency of the pulse ; fourthly, we have never seen them of the smallest benefit. Bladders, partially filled with warm water, are the best mode of applying fomentations, if they be insisted on. 6. Spirit of Turpentine. Were we to pass this substance unnoticed, it might be looked upon as an important omission. The character it has obtained with many respectable physicians will always justify a trial ; but we are sorry to say that so far, in our hands, we have not had sufficient reason to rely solely upon it ; though as an auxi- liary, in two or three recent instances, we thought it highly useful. We confess ourselves, however, to have laboured under preju- dices, or rather apprehensions of its effects in the beginning of the disease, or as a substitute for bleeding and purging, as recom- mended by Dr. Brenan. As we are not familiar with its use, or acquainted from experience with either the proper moment for its employment, or the proper quantity to be exhibited under varying circumstances, it appears, at present, at least, a doubtful remedy ; yet we would not wish to be understood, by this declaration, as doubting the veracity, or impugning the motives, of those who have borne unqualified testimony to its control over this disease. Our want of extensive experience in this remedy will only permit us to say that it appears to be only proper at the termina- tion of the first stage ; here it may be useful ; but here we have forbidden stimulants. But is this substance to be ranked under the same head with wine, brandy, opium, volatile alkali, &c.? We think not, for it appears to be a stimulus of peculiar powers, as we see in burns, &c. Were we to suggest then a trial of the sp. tereb., it would be at the period just designated, and in com- bination with castor oil ; thereby forming one of the most certain 414 PUERPERAL FEVER. and peculiar cathartics we know. It might deserve a trial at this period. 1 7. Mercurial Frictions. This remedy has lately been proposed for puerperal fever ; and M. Velpeau has given in "Revue Medicale," for January, 1827, several very interesting cases, in which was employed, and appa- rently with advantage, .mercurial frictions upon the abdomen. But he very honestly confesses his experience to be insufficient, at the time he wrote his essay, to determine the precise degree of confidence to be placed upon his plan ; yet he appears pretty strongly inclined to attach considerable importance to it. His mode of using this remedy is . First, To have the whole abdomen smeared with from two to four drachms of the unguent, every two, three, or four hours. Secondly, If the pain and swelling of the abdomen, and espe- cially if the mouth betray any mark of the influence of the mer- cury upon it, to dimmish the quantity to one or two drachms, and to make the intervals of application longer. 2 Thirdly, to wash off, with warm water and soap, or with sweet oil, the crust which the ointment forms upon the skin, that 1 The following case has occurred to us since the period of the above remarks. May 10th, 1830, 5 o'clock, P. M. Was called to visit Mrs. L., in consultation with Drs. Zorn, Perkin, and Shaeffer. Mrs. L. was safely delivered two days pre- viously, though considerable hemorrhage succeeded. Soon after the abatement of the flooding, she was attacked with severe pain in the abdomen, followed by great distention and tenderness, great distress of stomach and wmiting, &c., which continued with unabated viqlence up to the moment of my first visit. She was at this moment vomiting violently, and discharging very large quantities of a dark green-coloured fluid, and quadruple or more than the quantity drank. Her pulse very small, and so frequent as scarcely to be counted; extremities cold, and her whole body covered with cold sweat; breathing laborious; her abdomen enormously distended, and extremely sore to the touch. We retired, and I really looked upon the case as utterly beyond the reach of remedy. But as it was very proper to make some effort for the relief of the patient, it was agreed that twenty or thirty drops of the spirit of turpentine should be given every hour, and the whole of the abdomen covered with ung. hydrargyr. fort, without regard to weight. As the case was so utterly forlorn, an appointment for meeting was not formally made another consultation was left to the contingency of her surviving the night, 1 1th, I was agreeably surprised by a request to meet the above named gentlemen at 1) o'clock, A. M. We found our patient much relieved of every enumerated symp- tom the remedies were continued, and her amendment under it so rapid, that I withdrew from the consultation on the fourth day from my first visit. In a short time after I was informed by Dr. Perkin that Mrs. L. was entirely recovered. In this case the turpentine appeared to have a most decided control over the dis- ease it was probably aided, however, by the mercurial ointment. In another case, soon after this, however? the turpentine and mercurial ointment failed, though the case \vas neither so rapid in its progress nor so violent in its symptoms, for the patient continued until the seventh day. * In neither of the cases in which we used the mercurial ointment were the salivary glands affected in the slightest degree. PUERPERAL FEVER. 415 in its future application it may be more certainly placed in con- tact with the skin. Fourthly, To continue the ointment, if circumstances warrant it, (that is, if the patient live long enough, or if her system be obedient to its influence,) until either signs of salivation show themselves, or until such amendment take place, as shall render farther perseverance unnecessary. A very interesting case of puerperal fever has lately presented itself, in which the mercurial ointment was very liberally used ; but I should be very unwilling to decide upon the extent of the agency it had in the recovery of the patient, as another cele- brated remedy was employed simultaneously with it; namely, the spirit of turpentine. I was requested by Dr. Mitchell to visit Mrs. , who was very ill with puerperal fever. This patient had been delivered safely by the Dr. of her first child, and nothing alarming pre- sented itself until the second day. Milk had been freely se- creted, and there was every promise of a good "getting up," until the beginning of the third. At this time she was attacked with a pretty severe chill, which was followed by great heat, thirst, tenderness of the abdomen, and a very frequent pulse. She was bled, purged, leeched, and blistered on the abdomen, and kept upon a strict antiphlogistic regimen, &c., before I saw her. There was such an appearance of amendment for two or three days after this time, that scarcely a fear was felt but that she would surmount her disease ; but the expectations so fondly indulged in in the morning, were entirely destroyed in the eve- ning, by finding our patient with a cold, clammy skin ; a pulse scarcely to be numbered, very small, nay, almost extinct; breathing short, very frequent, and rather laborious ; the alee nasi expanding and contracting with great frequency ; the sto- mach rejecting every thing offered to it; the lips dark and dry; the milk entirely gone; slight mental alienation, though not amounting to delirium; the abdomen excessively distended and tympanitic; the feet and legs cold; extreme foetor of the lochia, which were small in quantity, and very dark ; in a word, so cer- tainly did we look upon her being in articulo mortis, that no ap- pointment was made for a visit next morning. Notwithstanding, however, these unfavourable appearances, Dr. M. and myself thought it a duty to do every thing that lay in our power accordingly, thirty drops of the spirit of turpen- tine were ordered to be given every hour: an ounce of strong mercurial ointment was directed to be rubbed on the abdomen during the night, sinapisms were ordered to the feet and legs, and an enema of sixty drops of laudanum and a gill of warm water was to be thrown up the rectum. The next morning Dr. M. favoured me with a call, as had been 416 PUERPERAL PEVER. agreed upon the evening before, provided he found the patient alive. And I honestly confess, I was much surprised when he reported our patient to be rather better than we had left her in the evening. Upon visiting her, this was found to be the case. The skin and extremities were warm ; the pulse more expanded, and considerably less frequent ; her breathing more natural ; the countenance more composed ; the mind more upon the alert ; the vomiting and nausea greatly subsided ; the abdomen rather less tender. The ointment was to be continued, as well as the tur- pentine : of the latter she complained, as creating a disagreeable heat in the stomach. To remedy this, a tea-spoonful of sweet oil was directed to follow, in fifteen minutes, each dose of the turpentine, which effectually removed this inconvenience. Barley water and very thin sago were directed as drink and nourishment; also the juice of sweet oranges, which proved very refreshing. The remedies were ordered to be continued in the evening. On the morning following there was so much amend- ment that the turpentine was discontinued: the pulse was still too frequent, but the abdomen was less swelled, much softened, and very much less tender. The ointment, however, was again applied. From this time she improved hourly, and had even- tually a rapid convalescence. During the whole treatment, it may be proper to observe, that a solution of gum Arabic was her chief food and drink ; and that at no time were internal stimulants, if we except the turpentine, for an instant employed. I have since been informed by Dr. M., that four or five days after I had taken my leave of this patient, that upon her com- plaining of some pain in her bowels, the nurse, (a new one,) gave her some brandy to relieve it: this immediately exasperated the pain, and re-excited fever. She was under the necessity of losing twelve ounces of blood, and to be purged, which soon re- lieved the pain and fever : she recovered soon after this without farther interruption. It may be as important, as it is interesting, to state, that after an entire cessation of the milk for two weeks, it was restored, and continues sufficient to nourish the child: this was effected by the persevering application of the child to the breast. b. The gangrenous Stage? We believe that from the moment that the pulse increases in frequency, from one hundred and twenty, to one hundred and 1 " Gangrene may be considered as a partial death; the death of one part of the body, while the other parts retain their natural powers." Sir Astley Cooper's Lectures, Am. Ed. p. 98. The state of a part here described it not precisely what we would wish to be PUERPERAL FEVER. 417 forty, the system is verging towards the second, or gangrenous stage. At this time the pulse not only increases in frequency, but also abates in force, and even perhaps in volume. Hiccough now takes place, with more or less violence. The mammse lose their milk entirely, and become more flaccid. Vomiting of the drinks, almost as soon as swallowed, sometimes takes place. The tenderness of the abdomen is diminished; and the character of the pain changes from the acute "to the obtuse; the swelling is increased in the belly, and an approach to tympanitis may be perceived by striking against its sides. The urine is extremely high-coloured, offensive in smell, and very scanty in quantity. If there be lochia, they are offensive and very dark. A lividity commences on the cheek and lips. The mouth is dark-coloured, and parched ; the tongue is generally, but not necessarily, dry and rough ; but when so, it requires several efforts to thrust it beyond the teeth; and when placed thus, it is either not retracted until the patient is bidden to do so, or is withdrawn very slowly and reluctantly. The teeth are covered with a mahogany-coloured scruff, and the gums nearly livid. The skin is dry and husky. The respiration hurried, and rather laborious ; but not so frequent as the last stage, though much more so than the first. A tendency to delirium, or a manifest forgetfulness of the im- mediately preceding events; a total indifference to the child and the surrounding circumstances. Complains but little ; and, if interrogated, answers vaguely, or contradictorily. The pulse is rapid and rather indistinct; and the wrists colder than the other portions of the arms. This stage is very evanescent ; rare- ly continuing more than twelve hours, though it may, perhaps, be protracted a little longer by proper remedies ; or be shortened by improper ones. It is this stage which receives the name of typhus ; it is at this time that the nature of the remedies is changed by most practitioners ; and it is at this period that this change usually seals the fate of the patient. The management of this stage should be reduced to one of understood, when we describe "the gangrenous state of puerperal fever," there- fore, we would wish to employ precisely the definition which Galen gave of gan- grene : which is that state or condition "when a part, from violent inflammation, is not absolutely dead, but is about to die." Huger's Inaugural Dis. on Gangrene and Mortification, p. 6. Dr. Armstrong says that "medical writers have justly made a distinction be- tween gangrene and sphacelus; the circulation, animal heat, and .sensibility re- maining in the first, but not in the last; the one being the threatened, the other the actual, death of the part." Morbid Anatomy, p. 78. In this state of a part, the previous action or inflammation exceeds the powers of the part to sustain that action; and, consequently, there exists a great dispro- portion between the action and the power. Now, it must be evident in such a case, that the only relief that can be expected, is from a reduction of the action to the state of the power, as we shall state more fully presently. 27 418 PUERPERAL FEVER. great simplicity and inertness, by withholding all stimuli ; but continuing a gentle depletion from the bowels. 1 Diarrhoea some- times comes on at this stage, and occasionally proves critical, if it be not arrested upon false principles, by astringents. The sys- tem sometimes rights itself, when it is not opposed by officious- ness or overweening anxiety ; or is not overturned by stimulation. Has any one seen a recovery from this stage, when bark, wine, opium, ammonia, &c., have been employed? We believe few can answer this question in the affirmative. Even under the management of the judicious Hey, we have reason to believe, in one or two instances, he but hastened the fate of his patients. See cases IX., XXVII. Dr. Armstrong, though he does not ap- pear to recognise the exact condition of the system at this period, was nevertheless perfectly aware of the injurious tendency of cordials, or of stimulants. The views of Mr. Hunter, on the subject of inflammation and Its consequences, are truly valuable, and every way in point, as regards our present subject. He says, " I consider inflammation as an increased action of that power which a part naturally pos- sesses ; and in healthy inflammations, at least, it is probably at- tended with an increase of power; but in inflammations which terminate in mortification, there is no increase of power, but, on the contrary, a diminution of it. This, when joined to an in- creased action, becomes a cause of mortification, by destroying the balance which ought to subsist between the action and the power of every part. If this account of mortification arising from no specific nature be just, we shall find it no difficult mat- ter to establish a rational mode of cure ; but, before we do this, let us take a view of the treatment which has hitherto been re- commended, and see how far it agrees with our theory! It is plain, from the common practice, that the weakness has been at- tended to; but it is also plain that the increased action has been overlooked; and, therefore, the whole aim has been to increase the action, in order to remove the weakness. "The Peruvian bark, confectio cardiaca, serpentaria, &c., have been given in as large quantities as the case appeared to require or the constitution could bear; by which means an arti- ficial or temporary appearance of strength has been produced, * Maintaining the depletion of the bowels is in strict conformity to the theory adopted of this complaint for the augmented secretion from the mucous surface of the bowels acts like topical depletion, as it must necessarily diminish the contents of the vessels concerned in the inflammation, and thus permit them to contract; and by contracting, they acquire an increase of power, and, at the same time, suffer a diminution of action; because one of the unnatural stimuli is, in part, withdrawn; namely, that of distention. Mr. Hunter says, that "many circum- stances in life, as also many applications to parts, will call forth the contraction of the vessels : we are, therefore, to apply such means ; and whatever will do this without irritation, will so far counteract the effects," Treatise on the Blood, Am. Ed. p. 279. PUERPERAL FEVER. 419 while it was only an increased action. Cordials and wine, upon the principle on which they have been given, are rationally ad- ministered ; but there are strong reasons for not recommending them, arising from the general effect which they possess, of in- creasing the action, without giving real strength. The powers of the body are, by this treatment, sunk afterwards in the same proportion as they had been raised, by which nothing can be gained, but a great deal may be lost; for, in all cases, if the powers are allowed to sink below a certain point, they are irre- coverable." Introd. to Treatise on the Blood, p. 20. Dr. Armstrong also states, p. 63, " The stimulant treatment, (in the second stage,) is, at once, the most delusive and danger- ous which can be adopted, and it is much to be lamented that it has the weight and authority of some eminent names." Again, p. 81, he observes, that " the system is uncommonly susceptible of stimulants, such as strong wine and cordials in the second stage, and, if freely administered, they generally destroy the patient, whose remaining powers are best supported by milk, nourishing broths, and the like." He also appears well acquainted with the propriety, nay, the necessity, of continuing the discharges from the bowels. He says, " Speaking from my own personal observation, I do not know the period of the disease in which cathartics can be omitted with- out considerable hazard; they are indispensable in the first stage, and I have seen them occasionally succeed when the disorder seemed advanced into the second," 1 p. 80. Mr. Hey says, "If these means, (evacuants,) fail to cure the disease, from being employed either too late, or in an improper manner, grateful cordials may be given in its latter stages to al- leviate the distressing feelings of the patient; but cordials or to- nics can afford no other advantage," p. 166. As we cannot appre- ciate exactly the powers of the system, when under disease, how- ever desperate that disease may be, is it not improper, from any motive of humanity, to give that which cannot relieve, but which may injure by interrupting the powers of the system, in an at- tempt at restoration ? In the stage we are now considering, the patient's safety depends upon "doing" (almost) "nothing." Light vegetable jellies, acidulated by the sulphuric .acid; gum Arabic in solution, acidulated; rennet-whey; cream of rice. Strong coffee is often very grateful, and sits well upon the sto- 1 It must, however, be understood, that purging must not be carried on to the same extent as in the more active stage of the disease; for, if carried too far, it may irritate the bowels too severely, and thus increase the debility. Mr. Hey's plan, of an evacuation every few hours, is perhaps rather excessive; we shouM prefer a less to a greater number, and for the reasons before stated; a less num- ber would seem every way sufficient for the removal of offensive matters in toe intestines, besides occasioning a competent increase of serous secretion. 420 PUERPERAL FEVER. mach, and may be administered freely, especially if vomiting be troublesome. We cannot agree with Dr. Armstrong, and Mr. Hey, in the use of broths, or any other animal substance ; for, in our opinion, they should always be excluded from the room of the puerperal patient. In the early stage they are too sti- mulating ; and in the second, too soon become decomposed in the bowels, and add to the existing mischief. Drinks may be given freely, and may be made to convey sufficient nourishment; but they must have in them no stimulating ingredient whatever. Saline draughts in a state of effervescence, Mr. Hey says, are re- freshing ; they may, therefore, be given ; the sweet spirit of ni- tre, also, makes an agreeable beverage. tinder some of the most unfavourable conditions of the system in this disea&e, there have occasionally been recoveries; such are the cases of Dr. Gordon, after effusion, and others, per- haps, whose exact histories we are not acquainted with. The restorative powers of the system in some instances are great ;. and they are occasionally exerted successfully, under circum- stances where no reasoning upon the subject could for a mo- ment justify a hope ; thus, women have recovered after rupture of the uterus, &c. But in all these eases, nature was freed as much as possible from as many of the retarding causes as it well could be, and left to manage the injury in her own way. So, in the disease under consideration, were nature left undisturbed to the exercise of her powers, we should, perhaps, have more in- stances of recovery. The system sometimes recovers itself from this gangrenous state of fever by means of its own, when it is not stimulated to unnecessary, or rather to deadly, exertion; but after a manner which can neither be foreseen nor imitated. Thus, we have seen recoveries from yellow fever, after black vomit and hemorrhages from almost every part of the body; but in all these instances, little was done towards aiding nature; she was permitted to do her work in her own way. Yet there are instances in which the system can be much as- sisted, even in desperate cases, when the indications are obvious, and of easy execution ; as the following case will prove : A young man, of strong constitution, was attacked with a bilious remittent fever, which, after fourteen days, took on the form of typhus, as it was called ; and for which, bark, wine and blisters were employed. On the seventeenth day of the disease, I was called on to visit him. I found the patient with a quick, irregular, and tense pulse; and the sores occasioned by the blis- ters, quite livid. The bark and wine were omitted ; the patient was bled and purged ; and all applications to the blistered parts were forbidden. The following day he was better ; but his pulse 421 continuing tense, he was again bled, and purged with calomel and jalap. He continued to mend; the livid look of the blistered parts was converted into one of high inflammation. He was bled once more : the fever left him a few days after ; the sores healed kindly, and he was soon perfectly well. Here, from a state of most violent action, by removing the irritating cause, and lower- ing the system, the action of the parts retrograde, first to that of active inflammation, and then to that degree of it only that was necessary to the restoration of the parts which have suffered from the over-stimulation of the blisters. 3. Stage of Effusion. This stage is one of almost entire hopelessness ; the wretched patient must, in great measure, be abandoned to her fate, as re- gards medical treatment ; but, if comfort of any kind can be af- forded her, it may be given with as liberal a hand as her de- mands require. Stimulants, cordials, opiates, may be adminis- tered without reserve or apprehension; for the disease has spent upon her the full force of its powers ; for in this instance we do not know what can injure, or what can benefit, the case ; in this stage, then, we may depart from the rule laid down in the se- cond. There is something remarkable in the tendencies of this dis- ease to gangrene, (in our acceptation of the word, see p. 416,) and from gangrene to extensive effusion. It is this act of effu- sion that prevents the inflammation from ending in sphacelus ; and well accounts for Dr. Clarke not finding " the parts in a state of gangrene," (sphacelus.) The effusion is not only sometimes excessive, (see p. 357, &c.,) but must be looked upon as almost necessarily fatal. 1 This ef- fort of the over-exerted vessels is marked by the following symp- toms : Pulse fluttering, and scarcely to be numbered ; the belly enor- mously swelled, and tympanitic; cold sweats over the whole body, or confined to the face and extremities. The skin on the hands sometimes is shrivelled, as if they had been immersed in warm water for a long time; repeated chilliness, without reac- tion ; vomiting, or rather gulping up, a dark brown, or coffee- coloured fluid; involuntary stools, and sometimes a profuse dis- 1 " The mischief which takes place in the cavity of the abdomen, whether by extravasation, suppuration, or gangrene, renders the disease incurable ; ex- cept in the two former cases, by some extraordinary efforts of nature, of which Dr. Gordon has related three instances, where the confined fluid made its way by a direct outlet; in two at the umbilicus, and in the third by the urethra." Hey, p, Ifc6. 422 PUERPERAL FEVER. charge from the uterus, of a bloody sanies or black grume. De- lirium, or perfect collectedness ; the tongue frequently moist, and an attempt is sometimes made at cleaning; (sometimes,) convul- sions; death. SBCT. VIII. General Directions and Rules. It is of the utmost consequence to the woman labouring under puerperal fever, that her nurse or attendant should be faithful in the discharge of her duties ; that she have sufficient understanding to comprehend the directions of the physician ; enough good sense and fidelity to put them in practice; resolution to withstand the wayward and improper demands of the patient, should they be made ; and courage enough to bear up against the encroachments of friends, and the preposterous recommendations of visiters. Every direction of the physician should be most promptly put in practice by the nurse, or other attendants ; and that it may be done to the letter, it should be impressed again and again upon the minds of those who may have charge of the sick, by delivering them circumstantially, and without ambiguity, or the possibility of misapprehension. Nothing should be left to con- struction ; the directions must be so peremptory and clear as to prevent the possibility of subterfuge. To ensure this in the best manner, the physician should ascertain, at each visit, whether his orders have been strictly complied with; and if they have not, he should not pass over the neglect, or it will surely be repeated. As this disease advances rapidly to a fatal termination when unchecked, as nothing can give this check but the most prompt application of suitable remedies; and as on the extent and force of these remedies their success mainly depends, especially on the proper quantity of blood to be drawn ; the physician should per- form this operation himself, or be present when it is performed, that he may be satisfied that his intentions are properly fulfilled. The blood should be carefully preserved, that its quality may, in some measure, serve as a guide for the subsequent use of the lancet. But let us caution the young practitioner against being deterred from a repetition of this operation, if the symptoms continue ur- gent, because the blood may not manifest the common signs of inflammation, for the general symptoms of the disease will be a better guide than any appearance the blood 'may assume. When the blood has been abstracted, let him order purgative medicines immediately, and this may be in any manner he shall think most proper ; let him prescribe minutely the regimen of his patient, which must be most strictly antiphlogistic. But let us, however, be exactly understood what we mean by antiphlogistic PUERPERAL FEVER. 423 regimen ; and, as this will refer to a variety of particulars, we shall consider them in detail. First. The air of the room should be frequently changed by a veil-conducted and careful ventilation; its temperature should never exceed sixty degrees; but it may sometimes be lower, when a lower can be commanded. Its purity should be preserved by removing all offensive substances from the room as quickly as possible, when they are tangible; but, if they emanate from the patient herself, the cause should be diminished or destroyed whenever practicable. The lochia, (when not arrested,) are sometimes very offensive: when this is the case, the vulva should be washed several times a day with warm water ; the cloths often changed ; and one constantly wet with the pyroligneous acid and water, should be kept near the parts ; or if this cannot be com- manded, powdered lime should be placed under the bed-clothes, and in various parts of the room. No curtains or other obstructions to the passage of the air should be permitted to surround the bed ; and the doors and windows, if at a proper season, or in a proper state of atmo- sphere, should be frequently or constantly open. The air should not be contaminated by unnecessary breaths ; company, noise, and light, should be excluded. The air should not be loaded with unpleasant vapours or smokes, under the pretext of purify- ing it ; for every kind of combustion is injurious. Secondly. The diet should be made to conform most strictly to the indications to be fulfilled ; namely, the reduction of the quantity of blood, and the action of the blood vessels; food, therefore, containing much nourishment, or any stimulus, should be carefully withheld ; it should be restricted to toast water, thin barley water, molasses and water, thin rennet-whey, balm tea, lemonade, or gum Arabic water. Every shape and form of animal substance should be peremp- torily forbidden no chicken water or beef tea should approach the lips of a fever patient ; and none should more particularly be forbidden it than the one labouring under puerperal fever. We are persuaded much mischief is created or perpetuated by a want of attention to this circumstance ; and it was not without surprise, indeed, we might say, astonishment, that we saw enu- merated in the list of antiphlogistic articles in the treatises of Hey and Armstrong "chicken water," than which, few things, in our opinion, can be more improper. Thirdly. The bed, bed-clothes, body linen, and every other article which may surround the woman, should be changed, aired, or washed, (as their natures may require,) as often as possible; or as may be compatible with the circumstances of the patient, or as a due regard to not exposing her to unnecessary fatigue, will permit. 424 PHLEGMASIA DOLENS. Fourthly. That, as the abdomen is always very tender, and oftentimes very much swollen, the weight of the bed clothes should be taken from it, by placing a spider, made of sections of a large hoop, tied together in their centres, at right angles with each other, and so placed as to suspend the clothes, and thus protect the abdomen from their pressure. And, as we know from experience, that the wetting of the abdominal surface frequently, by passing a sponge over it, imbued with some volatile fluid, as camphorated spirit, alcohol, or spirit of turpentine, is not only most grateful, but we have reason to believe has been also most useful, the patient should be indulged in it. Fifthly. The greatest care, and the most delicate management should be observed in administering diet, drinks, or medicine to the patient, or in attending to the effects of the latter ; and, that she be not made to suffer unnecessary fatigue, by frequent rising for these purposes, we would recommend the use of the "sick cup " for the first two; a spoon for the second, and a bed-pan for the last ; knowing it to be of the utmost consequence to husband the strength, and prevent all needless hurry of the circulation. Sixthly. To permit the child to be placed every now and then to the breast, that by its gentle and appropriate stimulation it may invite the secretion of the milk, if it has not been formed ; or to retain it, if it has been secreted; provided this be managed with so much address . as not to worry or fatigue the mother. The sympathy between the mammae and the diseased parts is obvious, by the effect produced on the one by the situation of the other. We think we have seen this useful. CHAPTER XIX. 9; !,:-' .--:-4 'JiM.; - -M '.MI. >.:.*i- ; jr. ;;!.-: r- *,/ ^afcfji ^|X&$ PHLEGMASIA DOLENS. We have retained the name of phlegmasia dolens, (the phleg- masia alba dolens puerperarum of White,) for a peculiar condition of the lower limb, because its pathology is still as unsettled as it was in the time of Mauriceau, whom we believe was the first that gave any satisfactory account of it; for the description left by Rodrigues & Castro, can scarcely be tortured by any partiality for antiquity into the disease of which we are about to treat, though Dr. Hull complacently inclines to the belief that he was acquainted with it. And we doubt whether the disease of the apothecary's wife, as described by Wiseman, was really the dis- PHLEGMASIA DOLENS. 425 ease in question, as it is but casually mentioned in his chapter upon " Abscesses and Corrosive Ulcers, arising from distempers of the Womb in Child-bed," and what renders it especially doubt- ful is, that he declares matter formed in various places. There cannot be a question, however, that Mauriceau was well acquainted with this disease; as his description is still in the main a pretty faithful one. By this author, and several others, the disease was attributed to some derangement of the lochia, which, when not sufficient, was thrown upon the large nerves of the thigh, and thus created pain and swelling, &c. From the time of Mauriceau, to that of Puzos, the disease ap- pears to have been familiar to a number of practitioners, as Manningham, Mesnard, &c. ,; ,-, ' It was, however, found after a time, that the appearance of this disease did not obey any particular state or condition of the lochia; and that it was very commonly accompanied by a dimi- nution or suppression of the milk. A new hypothesis was invented, and it was made to consist of a metastasis of this fluid. Puzos, with a great show of reason, has a prior claim to Levret for this suggestion ; as the latter himself refers to the former's "Memoires sur les Depots Laiteux," and speaks approvingly of them. These great men were followed by Astruc, who treats expressly upon this subject. Sauvages fully adopted these notions in his noso- logy, and treated of them under different genera and species. Van Swieten, Lieutaud, Raulin, Sell, &c., all seem to have acknowledged the great influence of the milk upon the constitu- tion, and each has treated of its metastasis. Mr. White, of Manchester, was the next to invent a theory of this disease ; he made it consist of an obstruction, rupture, or a disordered condition of the lymphatics, and he was followed in this opinion by others. Mr. Trye pretty freely criticised the opinion of Mr. W., and said, that though he could not discover any grounds for supposing the trunks of the lymphatics to be ruptured in lab 1$. Cerussa acetata, gj. Acetnm. Distil, gij. f. sol. adde Sp. vin. rect. Jj. Aq. Distil. gv. M. This is to be applied constantly to the breast, cold, by means 1 Late experience has convinced us, that leeching is very much more success- ful when it is performed below the breast, instead of from the tumid or inflamed portion of it, as is usually done. We would therefore recommend the application of the leeches to be made about an inch below the circular margin of the mammae; 458 MILK ABSCESS.. of a piece of linen. By this plan we prevent the formation of an over-quantity of pus; we preserve the integrity of the exter- nal covering, and we prevent oedema almost certainly. Dr. Gaffe states, (Jour. Hebdom. vol. ii. p. 23,) that in secre- tions of milk, attended by swelling and acute pain, the follow- ing embrocation acted with immediate benefit and relief. ]$. Aq. distil. Prim. Laur. ceras. %]. jEtherSulph. , i( /.-^ 3J- ',.. Ext. G. Opii, '' f - grs. iij. M. Apply it by means of fine linen, well wet with it. And Ranque recommends another application in the following terms : " The swelling of the breast which precedes the formation of mammary abscesses is caused, in the first instance, by the reten- tion of milk and the consequent distention of the lactiferous ducts. But this is not the only cause of the local derangement that so rapidly follows ; for the vascular system of the mammse is wonderfully increased preparatory to and during lactation ; and, therefore, when this augmented circulation of the breasts is baffled in the performance of its proper function, the secretion of milk, it often tends to form, with great rapidity, vicarious and unhealthy products. Hence arises the obstinacy of many such cases; and hence they are frequently not found to he ame- nable to the common methods of treating local congestions and inflammations. " All practical men are consequently obliged to adopt various methods of treatment; and the skilful accoucheur is often ena- bled, by attention and pains, to save his patient from the suffer- ing accompanying such affections." Ranque, impressed with certain theoretical ideas, which it is unnecessary here to discuss, was led to the use of the following liniment : K. Extract! Belladonnas, ^ij. Aquae Laur. cerasi, ij. ./Etheris Sulphurici, ^j. Ft. Linimentum. This must be well shaken before it is used. It is to be rubbed into the breast as high as the axillae, morning and evening, and the brecist must then be covered with fine flannel soaked in the liniment. This proceeding must be repeated every day, until the swelling disappears, which is usually on the second or third day. The ether has a smell which to some is very disagreeable ; but they ought to bear this inconvenience, if possible, for it adds essentially to the efficacy of the remedy. * MILK ABSCESS. 459 2. Regimen. In aid of the local applications mentioned above, the patient must be restricted to a severe antiphlogistic regimen ; no ani- mal substance in any form should be allowed ; nor any kind of liquor be permitted. She may have tea; weak coffee; milk and water ; rennet-whey ; very thin tapioca ; thin sago ; arrow-root ; roasted apples ; fruits of the season, &c. Her drink should be water; toast- water; molasses and water; apple-water; or thin lemonade. 3. Purging, c. Her bowels should be freely purged daily, by any of the neu- tral salts, magnesia, senna, &c. And, should there be much fever, she should lose blood from the arm, again and again, if necessary. She should be confined to the bed, and made to lie upon her back, to favour the retiring of the blood from the breast. The breast should be very lightly covered, instead of being enveloped in many folds of flannel. The temperature of the air should be very moderate, and her drinks cool. This regimen, &c., should be persevered in, though suppura- tion be inevitable ; indeed, it should be continued until the matter 13 discharged, either spontaneously, or by art. 4. Puncturing. If matter form in spite of our exertions, the breast must be treated as an abscess usually is. Our general rule is, to let it dis- charge itself, if the collection be small ; but if the quantity be large, and the skin very thin and dark-coloured, we always punc- ture it with a lancet, and take from it but a small quantity of pus at a time. After we have allowed an ounce, or a little more, to flow, we place a piece of lint upon the orifice, and, for this time, stop any farther discharge. At the end of three or four hours we direct the dressings to be removed, and a fresh quantity allowed to escape, and so on, until the whole has passed. If there be pain at this time, we direct a soft bread and milk poultice; if there be none, we have it dressed with simple cerate. Sometimes the discharge from the wound is arrested by a portion of dead cellular membrane getting into the orifice; and this is particularly the case in the second variety of this abscess. If this happen, it should be removed by taking hold of it with a ' . 460 MILK ABSCESS. piece of rag interposed between the thumb and finger. Should this, however, occasion pain, or blood discharge itself while making this effort, it must be desisted from ; the external portion cut off close to the breast, by a pair of sharp scissors, and the portion in the orifice pushed back by the extremity of a probe, and kept by this means from obstructing the wound, until a suffi- cient quantity of the pus be extracted. This has to be frequently repeated in some cases. Some are in the practice of making a large orifice for the dis- charge of the matter; but this is a reprehensible practice. It is sure to destroy a large portion of the surrounding skin, which is now weakened by distention ; it will also occasion a large and deep wound, in which granulations spring up too rapidly for the part to heal soundly. Fungus is almost sure to arise ; and a long, painful and weakening sore is left; all of which might have been avoided by pursuing the plan just recommended. 5. Caustic. It is not unfrequent for milk or serum to pass through the wound when it is near healing ; and this continues sometimes to be maintained a long time : this is owing to a small portion of fungus having possession of the orifice this should be removed by the application of the nitrate of silver; which will permit the wound to heal immediately, unless it be the opening of a sinus of some depth. If the sinus be superficial, it is to be removed, by enlarging the orifice by caustic, and then apply pressure ; or by exciting inflammation, by injecting in it a solution of corrosive sublimate, in the proportion of a grain to an ounce of water. 6. Seton. But when a deep-seated portion of the gland has suppurated, the wound sometimes will not heal ; a deep sinus is formed, which continues to yield pus, in spite of every attempt to close the ori- fice. For the destruction of this sinus, Mr. Hey recommends cutting through the substance of the breast, to its bottom ; an operation, confessedly of great severity, and one which very few would have courage to encounter. Yet, as it is a disease which never cures itself; as it is always attended by more or less induration of the breast ; and as it always excites much uneasi- ness, and not unfrequently great alarm, lest it be the forerunner of cancer, the woman becomes very desirous that something should be done for her relief, and will therefore willingly submit to any moderate degree of pain, or privation, for this purpose. Fortunately, a much milder operation than Mr. Hey's has been MILK ABSCEBS. 461 recommended ; and it has succeeded most satisfactorily in all the cases in which it has yet been tried. This improvement is the seton operation of Dr. Physick, to whom the profession is already so largely indebted for his very many valuable suggestions in practical surgery. This operation is performed in the following manner: a probe is passed along the sinus, so far as it will go. If the direction be outward, towards the portion of the breast next to the arm, so much the better ; but if not, let the point be carried towards the side it most inclines to. When the probe has passed as far as it can along the sinus, the point is urged laterally, until its point is perceived to press against the skin without ; at this point it is to be cut down, and the probe forced so far through this little wound, as to enable the operator to seize it either with his thumb and finger, or with a pair of forceps. The probe, which was pre- viously armed with a portion of braid, soft half-inch tape, or a piece of silk riband, is now to be drawn through. The seton is permitted to remain from three to four weeks, without being disturbed ; or until, from the healthy appearance and diminished quantity of pus, there is reason to believe the sinus will heal by withdrawing it. But, should there be a ten- dency in the external orifices to close too soon after the seton is removed, or before the sinus is supposed to be healed, they are kept open by a small piece of bougie, or sponge tent, until the healing takes place. Should the matter become hard around the seton, and obstruct the farther flow of pus, it must be removed by carefully washing it with warm water, or by the application of a soft bread and milk poultice. Dr. Physick assured us, that this plan had suc- ceeded entirely to his satisfaction, in the several trials he had given it; one of which we witnessed ourselves. And he is of opinion, that this operation will always succeed if there be no cancerous tendency in the parts. 7. After- Treatment. After the healing of the abscess, a considerable hardness re- mains in the breast, which will require a long time for its ab- sorption; this creates a good deal of uneasiness in the patient, lest it be a scirrhus. On this point, her fears may be composed ; as the tumour which remains will eventually be taken up by the absorbents, as it is nothing but coagulated lymph ; but the ab- sorption may be promoted by keeping the part warmly covered, or by the repeated application of warm vinegar. If this occur in winter, a piece of rabbit skin may be used, with the furred 462 HYSTERIA. side next to the breast; if in summer, a piece of fine flannel will answer very well. Or the part may be rubbed twice a day with opodeldoc. CHAPTER XXI. HYSTERIA. THE nervous system, like the vascular, the muscular, &c., is liable to certain and specific derangements. The symptoms arising from this disordered condition of the brain and nerves are familiarly called nervous; but to which it would be difficult to affix any precise or distinct meaning, as they are not only very numerous, and varied, but at the same time peculiar, and not always well defined. This variety creates a difficulty, which, we are" persuaded, every practitioner has encountered in the commencement of his practical career; but with which he be- comes familiar from a longer acquaintance and study of mor- bid phenomena; and is at length able to decide, with tolerable certainty, the extent of their agency in modifying the diseases of the other systems; or can determine, very nearly, in what degree they may be considered as belonging to the nervous sys- tem. The disease under consideration may be justly looked upon a< the assemblage of very many symptoms, the nature and extent of which must necessarily be much diversified, as the seats of sympathy in several organs of the body may be in a fewer or a greater number; and as these may be more or less important. The ancients were of opinion that the affections under consi- deration arose from some derangement or lesion of the uterus ; on which they bestowed very many gratuitous powers. Indeed, many moderate practitioners are still of the opinion so boldly advanced by their predecessors. Dr. Good 1 says, " With a mor- bid condition of this organ, indeed, hysteria is, in many instances, very closely connected, though it is going too far to say, that it is always dependent upon such condition; for we meet occasion- ally with instances, in which no possible connexion can be traced between the disease and the organ, and sometimes witness it in males as decidedly as in females." That a certain condition of the nerves of the uterus, like any ' Study of Medicine, vol. iii. p. 352. Am. Ed. HYSTERIA. 463 other portion of the body, may give rise to that combination of symptoms termed hysteria, or from some lesion of other portions of this organ the nerves of the part so injured may be seconda- rily affected, there cannot be a doubt. But that every derange- ment of function, or even lesion of this organ, will produce hys- teria, there is the most unquestionable reasons to deny ; indeed, it seems that when the uterus is seriously affected, as in cancer, there is very often an absence of those distressing symptoms which every body agrees to call nervous. 1 Many facts seem to confirm this last observation. For when this organ is labouring under an active malady, as inflammation, &c., there is, for the most part, nay, almost always, an exemp- tion from the symptoms constituting hysteria ; for there must be a particular condition of the nerves of the part to give rise to the symptoms called nervous or hysterical ; or, in other words, there must exist some peculiar condition of the nerves of an organ, before the brain or other portions of the nervous system are called into sympathy with it. The seat of hysteria would seem to be in the brain itself, in- stead of the uterus ; but the exact condition of this organ that gives rise to the various phenomena of this affection, is by no means ascertained. We know so little of the state of this organ when in health, that we may very readily be deceived by the appearances furnished by post-mortem examinations. It is but reasonable to suppose that each individual has some difference, or peculiarity of organization of the brain; since, in no two, perhaps, are its functions performed precisely alike, at least as far as can be determined by external phenomena. Nor is it pro- bable that we shall ever be much more enlightened upon this subject; since we know nothing, or but very little, of its condition inr absolute health. Our knowledge of the human brain is exclusively derived from dissections performed after death ; but what alterations may not take place during the progress of disease, or in articulo mortis? It is true we are very often told by those who have inspected this mass after death, "that the brain was found perfectly healthy." But where can a standard of comparison be found to warrant 1 The reviewer of this work, in the North American Med. and Surg. Journal, vol. iii. p. 318, says that " no one, at least of any authority in pathology, has ever maintained that the irritation producing hysteria was located in the uterus, to the exclusion of cephalic irritation. The gentleman appears to have forgotten, or overlooked, the opinion of Villermay upon this subject. This author is a stre- nuous advocate for uterine influence in this complaint; and that as far as we un- derstand a great many of his (to say the least of them,) singular and very doubt- ful notions, altogether independent of that condition of the brain which we think essential to its existence. He considers hysteria a misnomer, if this disease be not exclusively confined to females; and which he, at great length, attempts to prove is the case, because this organ is so universally the seat of this complaint. 464 HYSTERIA. such a conclusion ? Because there was no evident lesion of this organ, does it follow that it was in a perfectly healthy condition during life? Is there not much reason to doubt this, as we very rarely see instances of death where this organ performs its func- tions without more or less aberration, especially towards the last moments of life? And we know of very many others where the seat of disease had been certainly in the brain, as far, at least, as can be determined by symptoms, yet after death it has been declared to have been found in a state of health. We are frequently told of altered structure, of inflammation, of too great a density, too great a degree of softness, &c. of this organ. Now these facts only go to prove that in certain con- ditions of this organ certain changes must have taken place. But does it follow, that in the instances in which no evident change has been found, that this organ was in a state of abso- lute health, either as regards action or organization? All de- rangements of this organ cannot consist in the alterations above mentioned. There must be many others, where the attempt to develope them by the knife would be vain. It is, therefore, not sufficient for the best purposes of patho- logy, to declare, that the brain was not concerned in the disease of which the patient may have died, because no trace of derange- ment presented itself upon a post-mortem examination. Who will pretend to point out, by the knife, the difference of condition of the brains of the moping hypochondriac and the furious mad- man? between the pitiable idiot and the man of genius, &c. &c.? Has the cause of idiopathic epilepsy, of tetanus, of hydrophobia, ever been unequivocally detected by any marks left in the brain after death? It is true, we have been furnished with the observations of the pathologist and anatomist upon each of these points ; but the ap- pearances described by them have so often been seen where neither of these diseases was the cause of death, as to render it extremely doubtful of their agency in the production of them. Besides, we have much reason to believe that a deranged action of the brain may cause death, without leaving the slightest evi- dence of its nature. No direct proof, perhaps, can be offered that the brain is the seat of hysteria; for few dissections can have been made with a view to ascertain its condition in this disease, as it very rarely proves mortal; and of these few, none occur to my recollection. 1 1 I cannot call to mind the dissection of a "nervous person," (if I have ever met with one,) in which any particular condition of the brain is noticed, though many examinations have been made of those who have died of " nervous disor- ders." Upon this subject Whytt observes, "Although it appears, from the dissec- tion of those who have died of them, that the stomach and intestines, liver, spleen, amentum, mesentery, or uterus, have frequently been found obstructed, scirrhous, or otherwise unsound; yet, as in many other cases of the same disorders, no such HYSTERIA. 465 The opinion is founded rather on the causes of this disease, both remote and exciting ; upon the phenomena which it presents ; and < the remedies most successful in relieving the paroxysms, and in- terrupting their returns ; of these I shall speak in their proper places. The brain, like almost every other portion of the body, has parts which more readily sympathize with it than others; and these sympathies show themselves variously, not only as regards phenomena, but very differently in different portions of the sys- tem, as the brain may be labouring under one affection or other. Thus, in passions or emotions of the mind, the liver and stomach are wont to be disturbed; the one, to the more abundant secre- tion of bile, and the other to the effort of throwing it off. In melancholy, the bowels become torpid: the stomach dyspeptic, &c. In tetanus the whole muscular system is involved, or only certain portions of it. In hydrophobia the muscles of deglutition and respiration, and sometimes the whole muscular system, &c. &C. 1 In hysteria this peculiar condition of the brain certainly exists ; but in what this peculiarity consists, we can neither name nor demonstrate ; yet, in this state we see many powerful, nay, awful sympathies called forth, and give rise to a suit of symptoms, which are, by common consent, called nervous. There is no part of the human body that may not have its nerves to sympa- thize with this condition of the brain ; and thus give rise to several phenomena peculiar to the part thus sympathizing; hence, the "Protean shapes' 1 this disease is said to assume. Thus, if the nerves of the stomach be the principal seat of sympathy, we shall have a train of gastric symptoms presenting themselves; such as eructations ; sour belchings ; gastrodynia ; pyrosis ; indigestion ; globus hystericus, &c. If the intestines, we may find tympanitis ; spasms; diarrhoea; costiveness; contractions of the abdominal muscles, &c. If the liver, an inordinate, or diminished secretion of bile; biliary calculi; pain in the right side; with a sense of fulness and distention ; obstructions, &c. If the kidneys, an im- moderate flow of pale or limpid urine; or a very much dimi- morbid appearances have been observed in the body after death ; it follows that these symptoms may frequently proceed from causes, which, eluding our senses, are not to be discovered by dissection. Nay, obstructions, scirrhi,and other dis- orders of the viscera, observed in those who have died, after suffering from long nervous ailments, seem sometimes to have been the consequences of a long state of bad health, rather than the causes of it.'' Works, p. 584. 1 What renders it more probable that the brain, or, at least, the origin of the nerves of this organ, is the seat of that condition which gives rise to the convul- sive motions in hysteria, are the experiments and observations of Dr. Philip, in his inquiry on " the relation between the nervous and sanguiferous systems." He says, that" neither mechanical nor chemical stimuli, applied to the nervous system, excite the muscles of voluntary motion unless they are applied near the origin of the nerves, and spinal marrow." Phil. Trans, for 1815, p. 444. 30 466 HYSTERIA. nishcd secretion ; and the little yielded of a very high colour, and sometimes very offensive ; severe pain in the parts, resem- bling the passage of a calculus ; bloody urine, &c. If the bladder, incontinence of urine ; mucous discharges ; retention, &c. If the heart, we shall have palpitations, irregular contractions, faint- ness, &c. If the scalp, a coldness on the top of the head ; or a sense of heat on the back part ; great tenderness to the touch ; clavus hystefricus. If the muscular system, violent convulsions, or nervous twitchings as they are called, &c. In hysteria certain parts of the body sympathize with the brain more constantly and extensively than others; indeed, it seems, that when the brain is in that particular condition which gives rise to the phenomena constituting this disease, that the kidneys, the stomach, the oesophagus, the heart, and the scalp, almost al- ways participate in the affection, and declare its existence. It is not necessary to the detection of hysteria, that all these parts should be simultaneously affected ; they may be so in a stronger or weaker force of combination ; or they may present themselves separately and alternately; but whenever all, or even one of them exists, this peculiar condition of the system betrays itself, and marks out the plan to be pursued for its relief. It may be justly doubted whether any of these symptoms show themselves during the time the system is labouring under high arterial action ; as in fevers of great force, or those of malignant tendency; though they are by no means incompatible with a plethoric condition of the system; or with fevers of very mode- rate force ; a circumstance to be noticed, as it is of much prac- tical importance. Hysteria does not really create or produce the variety of dis- eases insisted on by Sydenham ; the nerves of the different por- tions of the body, when under the hysterical impression, similate a disease to which the part is liable. Thus, a fit of the stone has been similated, but a stone has not been generated ; diabetes has been imitated, but a genuine diabetes has not been pro- duced ; various affections arising from ossifications of the heart and large arteries, have been mimicked, but the assumption has been evanescent, &c. &c. Therefore, as remarked above, when the nerves of certain parts of the body become affected by sympathizing with the brain when disposed to hysteria, the part thus situated will assume that peculiarity of action, which it seems agreed upon to call nervous, or hysterical, if you please. Syncope, or a disposition to it, may be considered as a symp- tom of the hysterical affection, and may be looked upon, if not as one of the most dangerous forms, at least as one of the most frightful. Syncope may be regarded as A universal, but tempo- rary paralysis of all the muscular portions of the body : this con- dition of the system doubtless arises from some peculiar state of HYSTERIA. 467 the brain ; and it would most probably be in vain, even where syncope had been a habit of the system, (if we may so term it,) to recognise the peculiarity of the brain, which gave rise to them, by a post mortem search. In epilepsy the whole of the muscular system is for awhile vio- lently agitated, while the lymphatic and glandular systems seem to be but little disturbed : yet in hysteria, all these systems are made to participate with this condition of the brain in certain cases, while in others the glandular alone may be involved. The phenomena presented in hysteria will therefore vary, as it may be the nerves of one or of another part of the body that may be affected, as the force of the exciting cause may be more or less powerful, or as the predisposition may be greater or less. Hysteria has been called a Proteus by Sydenham ; and he de- clares, this disease *'is not more remarkable for its frequency, than for the numerous forms under which it appears, resembling most of the distempers wherewith mankind are affected. For in whatever part of the body it be seated, it immediately produces such symptoms as are peculiar thereto ; so that if the physician be not a person of judgment and penetration, he will be mistaken, and suppose such symptoms to arise from some essential disease of this or that particular part, and not from the hysteric passion." Ept. to Dr. Cole, vol. ii. p. 106. The account of hysteria as given by Sydenham has been ac- ceded to by almost every medical writer since his time, and its history creates a belief that this affection can really produce almost every disease to which the body is liable : hence, the va- rious forms or disguises under which it is described. Thus Sydenham declares the hysteric passion appears under the form of apoplexy, of epilepsy, violent pain in the head, with excessive vomiting, palpitation of the heart, a dry cough, iliac passion, pains resembling a fit of the stone, cholera morbus, swell- ing of the hands, fauces, shoulders, thighs and legs, pains in sound teeth, pains in the back, remarkable coldness of the sur- face of the body, copious discharges of limpid urine, sometimes fetid urine with acid eructations, disturbance of mind, and low- ness of spirits, &c. &c. All these symptoms, or certainly a great part of them, may by turns affect the same individuals at different periods, as predispo- sitions exist, or as exciting causes may be applied ; and this with- out any manifest disease in either the vascular, muscular, or lymphatic systems; or several of them may be present, when some one of these systems may be labouring under a disease of mild form. These combinations, however, as just observed, are rarely present when the arterial system is powerfully excited, as in fever; nor when the muscular system is much involved, as in general rheumatism, or in tetanus. They frequently combine 468 HYSTERIA* with affections of the lymphatic system ; because in affections of this system, when moderate, neither the vascular nor muscular systems are much implicated; but when the glandular or lym- phatic system becomes much diseased, as in the last stages of scrofula, the nervous or hysterical symptoms will disappear, should they have been present. SECT. I. Of the Predisposing Causes of Hysteria. It seems that whatever has a tendency to destroy the general tone of the system, especially if this be done gradually, will dis- pose the body to hysteria ; hence, the certain influence of too se- dentary a life, over stimulating diet or medicines, if too long con- tinued, long watching, disappointed hope, or abused affection, grief, terror, prolonged anxiety, &c. Some of these causes will act, by preventing the nervous system acquiring its proper tone, others by taxing its sensibility too highly, and others by exhaust- ing or too much diminishing its energies, &c. Hence, hysteria is most frequent in females, and at that period which intervenes between puberty and the final cessation of the menses. About the period of puberty, and for a considerable time after, the system is much more affected by the remote causes of hys- teria. Before puberty, the system seems less liable to affections the remote causes of which act upon the brain and nerves, than after this state has arrived ; for before this period, improper phy- sical education, or other causes, have not generally had time to do their worst, by impairing, or interrupting the force of the muscular system; or by exalting the sensibility of the nervous. And after the menses have ceased, the nervous system has less sensibility, provided it had not, up to that period, been habitually too much excited. There are, however, exceptions to this rule: I have seen seve- ral instances of well-developed hysteria, before the menses had made their appearance; and a number after this discharge had ceased. From all I have observed, there is no absolute con- nexion or sympathy between any particular condition of the ute- rus, and hysteria; that is, as genuine cause and effect. It is true I have repeatedly seen hysteria in its most aggravated form, attend each return of the menses in very young women ; but in all such cases the particular state of the uterus, at these periods, served but as an exciting cause to this affection ; for hysteria could be excited in these individuals at other times than the men- struous periods, by causes usually capable of producing it. Be- sides, I have seen a number of instances of genuine hysterical paroxysms in men; especially in those who have possessed great social virtues, and readily moved to strong sympathies. I do HYSTERIA. 469 not reckon as instances the idiotic blubbering or the unmeaning laughter of very old men. Whytt 1 considers as "occasional causes of hysteria," &c. 2 1st. Some morbid matter bred in the blood. 2d. The diminution or retention of some accustomed evacua- tion, as the menses, or hemorrhoids. 3d. The want of a sufficient quantity of blood, or of blood of a sufficient density. As regards the first, there is much reason to doubt whether any absolute cause of disease ever formally exists in the blood, 3 at least we have no decided evidence of such a condition ; the instances produced, purporting to illustrate or prove this as- sumption, can be better explained by known laws of the animal system, which do not recognise this condition of the circulating mass. The matter of gout, as it is called, is very frequently blamed for the production of nervous complaints ; but whether any such substance really exist, is much to be doubted: at all events the proofs offered of it are very equivocal and not to be relied on. As to the second set of causes, namely, "the diminution or retention of some accustomed evacuation," they can only be con- sidered as producing some general affection of the system with which the nervous system may sympathize ; and if the predispo- sition is to hysteria, hysteria will show itself; if to epilepsy, epi- lepsy will follow, &c., but in neither of the cases can these causes act but indirectly or, in other words, they never directly produce that peculiar condition of the nervous system which is essential to the existence of hysteria. The third set of causes may, and we believe, sometimes does, occasion convulsions, and though every hysterical paroxysm is attended with convulsions, yet, every convulsive motion of the body is not an hysterical paroxysm. When the hysterical pre- disposition exists, any severe and exhausting discharge may oc- casionally produce the hysterical paroxysm ; but not always, as the following case will show. Mrs. , from an early period of her life was subject, from even slight causes, to severe hysterical paroxysms. During her pregnancies she was often attacked by this affection, and was relieved by the common remedies. In one instance she had a paroxysm during labour, but it neither deranged the economy of this process, nor required any particular treatment. After the 1 Works, p. 551. 4 We would rather call them predisposing causes. 1 We do not mean by this to deny that the constituent portions of the blood may not be variously modified, and give rise to various phenomena, symptoms, or even active or chronic disease. We only object to the assumption of a super- added something as a cause of hysteria. 470 HYSTERIA. birth of the child, she was attacked with a violent and exhausting flooding, from which she was relieved only by the most active treatment. She continued very feeble for several months ; but during which time she had no hysterical paroxysm ; nor did any occur until she again recovered her usual health. SECT. II. Of the Exciting Causes. .L ,, . !** i r\f -. r< i !' ivX * *Vi-T ' * The liability to attacks of hysterical paroxysms is very various in different individuals; while some have them provoked by the slightest causes, others require that they shall be either powerful, or long-continued. Instances have fallen under our observation, where the most trifling alarm, the smallest disappointment, or the slightest provocation, would almost instantly produce a " fit " of longer or shorter duration, or of greater or less violence ; while, on the other hand, we have known it require the most powerful of the exciting causes to give rise to them. They all, however, seem to act through the medium of the sensorium commune; at least this would seem to be the case with genuine hysteria; and may serve to distinguish it from several affections of the system with which it is almost constantly con- founded. Thus, we see syncope, from exhaustion ; from peculiar odours; from pain; from nausea, &c., confounded with hysteria, with which, perhaps, it has no necessary connexion ; though it must be admitted, that the hysterical diathesis, if we may so term it, may give rise to syncope in certain cases. Whytt 1 enumerates six different occasional or exciting causes "of nervous, hypochondriacal, and hysterical disorders," for he confounds them under one consideration: they are as follow; namely: 1. Wind, V Y.' 2. A tough phlegm, Vin the stomach and bowels. 3. Worms, J 4. Aliments improper in their quantity or quality. 5. Scirrhous or other obstructions in the viscera of the lower belly. 6. Violent affections of the mind. 2 1 Works, p. 570. 1 To these may be added " the inflammation of a portion of the spinal column," agreeably to Mr. Tate. Since reading his work upon this subject, we have been very attentive to the condition of the spine in affections generally termed nervous but the result of the examinations we have made differs very materially from those laid down as constantly obtaining agreeably to Mr. T.; for of upwards of fifty spines which we have carefully examined agreeably to his roles, we have found but three cases in which the tenderness which he describes, in some portion of the spine, was sufficiently obvious to make us resort to leeching, cupping, blistering, or ir- ritating it with the tartar emetic ointment, for its relief. It is, however, only just to say, that in these three instances the plan of treatment proved successful. HYSTERIA. 471 -!:*'- ' f.-Mli.'jrtfflj *; 1, 2. Wind and tough Phlegm in the Stomach and Bowels. One of the most common symptoms attendant upon nervous affections is the elimination of air in the stomach and bowels, when these parts are the seats of sympathy: but this phenome- non does not necessarily attend the hysterical diathesis; for these parts do not necessarily become affected by the prevalent disposition or diathesis ; and when they do not, the extrication of "gas" will not take place. But should the stomach and bowels be involved in the general diathesis, these parts may suffer great distention from flatulency. In such cases, the "wind in the stomach and bowels" is but the effect of a certain condition of these parts, and, conse- quently, cannot be the exciting cause of hysteria, or any other nervous affection. In what this particular condition which gives rise to the extrication of "gas" consists, it is impossible to say; but that such a disposition exists is notorious to every body. This condition may perhaps consist of two states of these parts, altogether different from each other ; one is said to be occasioned by relaxation, which suffers them to be distended by the air dis- engaged from the ingesta, during an imperfect digestion: hence, a "windy stomach" almost always attends dyspepsia. The Other state consists, perhaps, in the secretion, or elimination of "gas" from the extremities of the vessels terminating upon the internal surface of the stomach and intestines. We believe that the latter circumstance obtains most frequent- ly in hysteria ; the former is most common in dyspepsia; yet it is possible they may interchange. It is now some years since the belief of the "secretion of air" in various parts of the human, subject was suggested ; (by whom, it is not at this moment recol- lected,) and that the stomach and bowels appear to be more ob- noxious to it than any other parts of the body. This secretion or extrication takes place under certain circumstances indepen- dently of any permanent loss of tone in these parts ; and this with a suddenness that is sometimes truly astonishing. And it disap- pears sometimes with a celerity that is incredible. The follow- ing case is one of the most remarkable we have met with : Mrs. , aged twenty, was much subject to hysteria of a vio- lent kind, whenever her mind was disagreeably affected. The manner in which this showed itself was very remarkable, as it seemed to be almost constantly subject to metastasis ; that is, after the convulsive action had continued for some time, it would sud- denly cease ; she would regain possession of her senses, and would talk rationally upon any subject that might present itself. This calm, however, would last but a short time ; for she would now be seized with the most violent spasms of the intestines, and of 472 HYSTERIA. the abdominal muscles, that can well be imagined ; the abdomi- nal muscles would be drawn backwards with such force, as to make the belly resemble that of a person who was extremely emaciated; when of a sudden, nay, almost in the twinkling of an eye, it would become distended almost to bursting ; in this man- ner these conditions would alternate with each other, several times in the course of a few minutes ; then an interval of perhaps an hour or two might take place, or even longer, if the patient were not disturbed. There was a strong disposition to sleep, whenever the pain would abate sufficiently to permit it ; and this would be enjoyed for a longer or shorter period, as she could be kept more or less quiet. rf Indeed, the paroxysm would almost certainly go off, if sleep could be indulged in, undisturbedly; but which was a mat- ter of great difficulty, as the slightest noise would awake her ; and the instant she was roused the spasms would return with ex- treme violence. The distention of the abdomen was sometimes enormous: full as large as she ever was at the last period of utero-gestation ; yet this fulness would oftentimes be removed in almost an instant, without our understanding in what manner the gas was disposed of. It was certainly not discharged by either mouth or anus ; yet it was certainly dissipated by some agency or other. 1 The spasms of the bowels, and the production of gas, would cease sometimes suddenly ; the patient would then become very drowsy, nay, for awhile, lethargic ; but from which she would generally awake, after a longer or shorter time, perfectly well. At other times, when the brain would become more powerfully assailed, she would have the appearance of apoplexy ; the breath- ing would be laborious, and even stertorous; the cheeks and lips livid; convulsive twitchings of the muscles of the face; the skin cold and clammy, and the pulse depressed. Nothing relieved this state of the system but large blood-lettings ; and these never failed when they were carried to a sufficient extent: indeed, the only rule we observed in drawing blood was to continue the ab- straction of it until there was an abatement of these threaten- ing symptoms. I do not recollect a single instance of failure when the blood was freely abstracted ; it has occurred that this operation was re- peated; but this was constantly owing to too small a quantity being taken at first. These paroxysms, of cerebral determination, were sometimes more easily relieved than at others ; that is, the loss of much less blood would answer at one time than at another. 1 We do not wish to be understood to say that it never passed by the mouth, for it certainly did so occasionally but it was rare: yet when it did, it was in such a continuous torrent as to suspend respiration so long as to threaten suffoca- tion. HYSTERIA. 473 The loss of twenty or five-and-twenty ounces would answer sometimes, but it might require forty upon another occasion. While the affection was confined to the stomach and bowels, nothing could exceed the severity of suffering; nor was it ever controlled by any of the usual remedies for such affections. Im- mense doses of anodyne, and antispasmodic medicines were given without the slightest abatement of pain; but an emetic of ipe- cacuanha would almost immediately put an end to the spasms. From the uniform relief procured by emetics, it might be sup- posed the symptoms arose from some undigested substance in the stomach; but this was not the case; for the emetic did not bring off the remains of food previously taken, in a single in- stance the discharge would consist of a small quantity of a thin watery substance, of an acid smell. I do not think, in any in- stance, that the quantity thrown up would exceed a pint ; but no sooner was this discharged than the patient would be relieved al- together, or have but slight and distant returns of pain. In this case the obvious remedy was an emetic ; and this was constantly proposed ; but singular to say, that notwithstanding the uniform and sudden relief procured by it, notwithstanding the employment of it was importunately urged in the commence- ment of the affection, its use was resisted with a pertinacity that could not be overcome by long-continued and severe suffering. Sometimes this remedy was resisted until the disease shifted its ground, and the head would become the seat of the metastasis : when this took place, blood-letting, as just remarked, was the only remedy. After bleeding, it was not unusual to find this hysterical paroxysm terminate by a violent gush of tears, or by obstreperous laughter, and an immense flow of perfectly limpid urine. It has been remarked, that during the sleepy state of this dis- ease, the patient was easily roused ; indeed, a morbid sensibility of the ear seemed to be always present: a person speaking even below the ordinary tone of voice; the moving of a chair, how- ever cautiously ; the fall of the smallest body upon the floor, which would scarcely be noticed by those around, would rouse her with alarm, and renew the spasms. These would continue sometimes for half an hour with much severity ; they would then either abate, or she become so overpowered by drowsiness, that she would again relapse into sleep, from which she might again be disturbed by the slightest noise. In this way she would con- tinue alternately sleeping and suffering, from twenty-four to eight and forty hours ; or until the paroxysms seemed to wear them- selves out or were interrupted by an emetic, or by a large blood- letting. I never knew the spasms to return after they had been translated from the stomach and bowels to the brain, and then producing the apoplectic condition just mentioned; for, under 474 HYSTERIA. this form it was always found necessary to bleed ; and this never failed to relieve. But, when merely heavy sleepiness was produced, they would be very frequently renewed, as just stated; unless she could be kept perfectly silent, which was next to an impossibility, owing to the slightness of the noise that would disturb her. It is very common for the stomach to eructate a great deal of "gas," at the termination of an hysterical paroxysm, from which the patient finds much relief. In consequence of this, it has been supposed, that "wind" pent in the stomach was the exciting cause of the hysterical paroxysm ; whereas, it is only a conse- quence. For this "wind " from the stomach takes place some- times where there is not a dyspeptic state of the stomach. Dr. Cullen 1 corroborates this by saying, " Persons liable to hysteria are sometimes affected at the same time with dyspepsia." They are often, however, entirely free from it. The relief obtained in such cases is in two ways ; first, the paroxysm terminates, (most probably,) by the vessels of the sto- mach pouring out "gas;" as inflammation is often relieved by the vessels concerned pouring out serum. It may also be re- lieved in some cases, by the vessels freeing themselves of serum, and this, perhaps, of a particular quality. Whytt has recognised " a tough phlegm" in the stomach, as noticed above, as an "oc- casional cause" of hysteria: we, however, only contend for its presence, and its being the effect of a paroxysm. In the case above related, immediate relief was constantly experienced if an emetic were given ; yet the emetic never did more than bring off a quantity of fluid mucus, of an acid smell. 2 The emetics, in these instances, most probably hastened, or aided the vessels to relieve themselves. For certain it is, this fluid could not be the cause, since it was not always evacuated ; for an emetic was not always exhibited. And when the brain took up the wrong ac- tion, the paroxysm was sure to be terminated by blood-letting. The second mode of relief is by the removal of the painful distention of the stomach ; for this organ suffers extremely some- times from "wind" confined in it; as we see when "gas" is extricated from food over which it has not sufficient control. The precise nature of the "gas" eliminated in such cases, from the extreme internal, or surface vessels of the stomach, is, per- 1 First Lines, vol. ii. p. 26, par. 1519. " It seems that hysteria is not the only disease classed under the nervous that experiences relief from the discharge of viscid matter. Wbytt relates the case of "a girl aged fourteen years, who had been troubled with chorea sancti viti, who was seized with measles. A few days after her recovery she had a return of her former distemper, which, after it had continued a fortnight with little abatement, notwithstanding the use of several remedies, was entirely removed in n few days by a natural looseness, by which she voided a great deal of slimy stuff." HYSTERIA. 475 haps, at present impossible to say, as we do not know that any experiments have been made to ascertain it. In the case of the lady above related, when the wind was dis- charged by the mouth, it would pass in so continuous a stream as to suspend respiration for a considerable time; and the quan- tity disengaged was so enormous as to justify us in setting it down at several galtons. We witnessed several instances of the escape of this "gas :" it had no taste to the lady, nor had it smell to the by-standers. In this latter respect, it certainly differed from the air disengaged during the process of an imperfect di- gestion; for the "gas" belched by dyspeptic patients smells and tastes almost always of the food from which it is liberated. 3, Worm. Worms in the intestinal canal will produce, as is well known, a great variety of formidable symptoms, especially in children ; such as great appetite, distention of the abdomen, cough, vomit- ing, tremors, convulsions, &c.; but such symptoms should not be considered as hysterical. For these events take place almost always before the hysterical diathesis is generated; nor do they, perhaps, require any particular condition of the system, like hys- teria, to have them produced: it is sufficient that these animals irritate the intestines to a certain extent, to have the above train of symptoms, and sometimes many more, to present themselves. At a period of life beyond that of childhood, these vermin may prove the exciting cause of an hysterical paroxysm where this diathesis exists ; or they may be even the remote cause of this condition of the system. We have witnessed, in a lady, violent attacks of hysterical "fits," from the presence of a tape worm; which continued pretty regular in their attacks for several years. The following relation of the case may not be unacceptable. Mrs. , the mother of several children, and generally en- joying good health, though of a nervous temperament, was seized, about the beginning of the year 1821, with a variety of nervous symptoms; such as palpitations of the heart; globus hystericus ; disposition to cry, from very slight, or even no apparent cause ; vertigo; ringing in the ears; headach; and large discharges of pale urine. She took a variety of remedies for these affections, by the advice of her mother, and other friends, with temporary advantage. But it was found that each of these symptoms in- creased in force as well as frequency, and from slighter causes than before ; and, at length, a regular hysterical paroxysm, of great violence, was produced. During a paroxysm she was bled, took asafoetida, laudanum, 476 HYSTERIA. &c., and was, after a few hours, restored to her usual health, which was still pretty good, though evidently on the decline, not- withstanding the employment of a number of " certain cures," for her complaint. The " fits " were now repeated from time to time, but each succeeding one appeared to acquire an increase of force and duration. Her appetite and strength now failed rapidly ; she vomited a glairy tenacious substance almost every morning, which was without taste: severe pains in the abdomen, especially on the left side; her rest was much disturbed; almost constant headache, &c. The "fits" now bore a stronger resemblance to epilepsy than to hysteria, that is ; she would be seized, while walking the floor, with only an instant of warning; whereas, formerly, the " con- vulsion" would be preceded by the usual premonitions of hys- teria. There was less struggle during the paroxysm, and some frothing at the mouth ; but the duration was much shortened. She would, however, remain very feeble for several days after each attack; and be assailed by the feelings common to nervous affections. The progress and changes stated above occupied a period of about three years: the "fits" now returned every three, four, or five weeks, without any apparent exciting cause; but these pe- riods would be occasionally anticipated, when her mind was af- fected by any unlooked-for occurrence of a disagreeable kind. About this time she was advised by some friend to try strong salt and water, in pint doses, every morning, for nine mornings, for it was now believed she had a tape worm. She did so most per- severingly, notwithstanding the severe effect it produced on her stomach and bowels ; and she was amply rewarded for her reso- lution', by the discharge of a portion of a tape worm, seven yards in length, as was supposed, for it was not measured. Her health improved very much after this, though occasionally subject to slight hysterical paroxysms, but nothing like so frequent or so severe. She has had but two for the last eighteen months, and these were light. She has since borne a fine healthy child, after an interval of seven years. : oiv;' ?' ,' .' ' i i fr '.K fcCK.i?tftqfi '<;: ;{''ff: ," ;*:* 7 LI ' - ; c*:yj/> ^r'Ytrrf^a oo nvrj !< ,'.i!j;il> VH* m-sit /rv> CM iviijie-.q*;." 4. Aliments improper in their Quantity or Quality. Almost every body has experienced the truth of the old pro- verb, that "what is one man's meat is another's poison;" and consequently, it will be ever found difficult to regulate diet by any prescribed quantity, or any particular quality, for they must be looked upon as relative terms. Nothing can exceed the variety of dispositions (if we may so term it) in the human stomach ; it is capricious at times, in the extreme, while at others it will suffer HYSTERIA. 477 great abuses, and this for a long time, without resistance or com- plaint. Experience alone, in many instances, is the only safe guide by which the food, in either quantity or quality, can be regulated in nervous and dyspeptic patients. It is therefore not to surprise us, that directions for the use of food in such constitutions will often prove successful, if not improper ; hence, nothing is more common than peculiarities in the digestive process. Indeed the same article, and in the usual quantity, will sometimes fail to be digested, though it may gene- rally prove very grateful to the stomach; for should this organ be in a state of sympathy, or of nervous excitement, the most familiar and commonly acceptable food may prove the exciting cause of an hysterical paroxysm. For this reason we should never fail to inquire whether any thing unusual has been taken into tho stomach, when about to prescribe for an hysterical pa- roxysm. I knew a lady subject to hysteria, who could tell by her feel- ings two or three days before, that she was about to have an at- tack. 1 When under this impression she was obliged to be very careful in the government of her mind, as well as cautious in her diet, for as certainly as the one was unpleasantly excited, or the other neglected, she would have an hysterical paroxysm. While, on the other hand, if she was successful in avoiding mental ex- citement, and did not over-tax her stomach, she would generally avoid the "fit." But it must be remarked, though she avoided a paroxysm, she was sure to be inconvenienced by headache for several days. 5. Seirrhom or other Obstructions in the Stomach, Intestines, $c. Whytt 2 has taken some pains to establish the opinion, that scirrhous affections of almost any of the abdominal viscera will occasion nervous, hypochondriacal, and hysterical affections. He has given several histories of cases, with dissections, but neither of which proves the point at issue, for there is no evi- dence whatever that the affections developed by the knife, gave rise to the few nervous symptoms detailed in these cases. At all events there was no hysteria produced; hypochondriasis may have been ; since the stomach in almost every case was much diseased. 1 The hysterical paroxysms in this lady were periodical ; the attacks though se- vere, were by no means frequent, yet she rarely had an attack without a warning of two or three days; or, in other words, she had occasionally certain feelings, which she knew would terminate in an hysterical " fit," if she did not studiously avoid exciting causes. 1 Works, p. 575. 478 HYSTERIA. So far as our own observations have extended, we have had no reason to suspect hysteria to be produced by derangements in any of the chylopoietic viscera ; these derangements, however, may, and perhaps do, augment the paroxysms, or they may per- petuate the disposition, by preventing the return of healthy action in the system, but there is strong reason to" doubt of their being the remote cause of this affection. We have repeatedly seen great derangements in the liver, spleen, stomach, intestines, and even the uterus itself, where there was the most entire exemption from hysteria. We do not, however, mean to insinuate that these two conditions may not exist in the same person ; we wish merely to deny that these ob- structions in themselves are causes of hysteria. 6, Violent Affections qf the Mind. lsk> one can for a moment hesitate to acknowledge the influence of the mind upon the nervous system. Passions and emotions may not only prove the exciting, but they may also serve as the remote causes of hysteria. The experience of almost every body can furnish illustrations of these facts, and medical records abound with remarkable examples of them. They must, therefore, be admitted as such, though we cannot pretend to explain by what agency or by what change it is effected. Through the medium of each sense, 1 hysteria has been produced, if we credit writers upon the subject; nor does it require much credulity to believe them from what we constantly witness from a part of them. I have a patient in whom the globus hystericus can be excited instantly, if she smell camphor. This peculiarity took its rise from a strong aversion being excited from having taken large quantities of it in a fit of severe illness. I know another, who has become a severe sufferer from hysteria from having taken an excessive dose of it by mistake. It produced mania at first, which continued for nearly three months. Before this accident, she had never betrayed the slightest disposition to any nervous affection. Thus hysterical paroxysms have been produced by seeing others afflicted with it. The most' remarkable instance of this kind is the one related by Kaau Boerhaave, 2 as having happened 1 With the exception perhaps of the sense of taste, I have never met with an instance of hysteria produced by disgust to the palate. * Kaau Boerhaave, the nephew of the celebrated Boerhaave, relates an occur- rence of a very remarkable kind, as having taken place at the Harlaem hospital. A girl was brought into the ward in convulsions of a periodical kind ; the convul- sion was repeated the next day, which affected several who beheld her in the same HYSTERIA. 479 at the podr-house at Harlaem. The disease, in the first place, was excited by the operation of terror upon the sensoriurn commune, and it was arrested by a terror of a more violent kind, through the same medium. I knew a lady who would be thrown into an hysterical paroxysm by the sudden report of a gun. Certain odours, as noticed above, have been known to do the same, at least to produce fainting. I once saw a lady thrown into a se- vere "fit" by placing her hand accidentally upon the back of a cat, for which animal she had a great aversion. SECT. III. Of the Phenomena of Hysteria. When a predisposition to hysteria exists, or the disease has been once called into activity, a great variety of causes may ex- cite a paroxysm of greater or less force. An hysterical parox- ysm, properly so called, is where the system is thrown into that violent agitation called " a fit of hysterics." A vast variety of symptoms may from time to time manifest themselves, such as palpitation of the heart, globus hystericus, large flow of limpid urine, rumbling of wind in the bowels, belchings, acid stomach, whimsical appetite, tremblings, cold feet and hands, &c. ; but these are termed nervous symptoms. 1 V manner, and, in a few days more, all were affected who were in the same ward, whether they were girls or boys. This became so general as to excite great alarm; every means which experience had found useful hitherto in such affections, were Tried in vain. They at length, sent for Boerhaave himself. He directed that a variety of iron implements should be heated red hot in a furnace in the ward, and be in readiness at the time these convulsions were wont to make their appearance; and ordered, that the first one that was seized with the disease, should be burnt on the arm, with a heated iron, to the bone. This so alarmed the subjects of this affection, that in an instant a stop was put to the complaint. 1 Mr. Tate, (Treatise on Hysteria, p. 39,) says, "The next circumstance, and the most important of the whole list, whether as regards the discrimination of the disorder, or its treatment, is this that in every case there is a distinct pain upon the application of pressure or of heat, to three or four of the six superior dorsal vertebrae. This is a point upon which I desire to fix the reader's attention; for this spinal affection, whatever its intrinsic quality, is clearly chargeable with most of the curious images and fantastic forms that hysteria is accustomed to put on; and yet, notwithstanding its constant occurrence in those forms of hysteria, and its frequent existence where there is even a tendency to hysteric disorder, it is a circumstance that has been overlooked by those who have professed to treat upon this subject, as well as those who, for the sake of gratifying curiosity, have pub- lished detached cases of hysteria under various other designations." We confess this condition of the dorsal vertebras to be, in this disease, new to MS; and it may become an important item in diagnosis, if future observations con- firm it. We, however, must declare, that up to this period we cannot. If pres- sure be made upon the dorsal vertebras when in this pathological condition, it not only excites pain in the part, but in other parts very often, as through the chest, left side, or sometimes both, and generally oppresses the breathing. Mr. Tate says this pain is not always equally severe; sometimes the vertebrae are very tender, at others they are less so, depending, he thinks, upon the force of the affection, but it is always present in a greater or less degree. 480 HYSTERIA. Sometimes the paroxysm comes on very suddenly, and is in full force in an instant ; at others, there will be a number of symp- toms which announce the fit to be at hand, such as headache, of a piercing kind: oppression about the prsecordia; heaving of the chest; difficulty of breathing; alternate laughing and crying, &c. All these symptoms, however, may exist without being followed by a "fit;" but when they are present, it is always to be appre- hended, especially when crying or laughing be of the number. Laughing and crying are among the most remarkable symp- toms of hysteria they may alternate with each other, or they may exist separately ; but whether combined, or alternate, they are almost always accompanied by an alienation of mind, which discovers itself by a rapid, incoherent, or desultory talking ; and constantly dwelling upon the cause of their indisposition, if the exciting cause has been of the moral kind. At other times, the patient employs herself in singing melancholy or lugubrious airs. I have seen this^last circumstance produce a wonderful effect upon the attendants of the patient. I knew a lady who sang most sweetly at all times; but when under an hysterical parox- ysm, her voice, manner, and the subjects of her songs, were so touching as to dissolve all those around her into tears. An "hysterical fit," when violent, is extremely awful; the violent and varied contortions of the body would seem to threaten dislocation of every joint ; while the swollen face, the protruded tongue, the staring eyes, the gnashing teeth, the appalling scream, render the whole scene one of great horror. Sometimes the hair is deracinated by handfuls; the chest is beaten by the clenched fist, with threatening violence ; while the whole muscular system, when thrown into action, is endowed with a strength that bids defiance to all attempts at restraint. The sphincter ani, like the other muscles of the body, partici- pates in this unnatural state of action ; for it is found contracted so firmly sometimes, as to prevent the introduction of the pipe of a small syringe. 1 The abdominal muscles also are violently contracted sometimes during the fit, and especially about its central portion, the navel. Dr. Cullen says, and it entirely agrees with our experience, that this disease "more especially affects the females of the most exquisitely sanguine and plethoric habits, and frequently affects those of the most robust and masculine constitution; but it is not confined to such ; for the nervous and irritable are also liable to this affection. By the nervous and irritable we understand, such constitutions as are affected, or easily moved, by slight ex- citing causes. This condition of the system may be either con- stitutional or acquired. Improper physical education will render 1 Cullen. HYSTERIA. 481 almost any constitution nervous or irritable, if it be continued sufficiently long; hence, those who indulge in habits of idleness, too high living, lying in bed too much, night watching, &c. &c., are almost sure to possess this peculiarity ; or this peculiar con- dition may exist as an original state of stamina. 1 Under such circumstances, hysteria will almost certainly be generated, if the exciting causes be applied ; and hence it is, that delicate females are more liable to it than robust women or men ; and hence women of this constitution are almost sure to be af- fected with nervous tremblings, palpitation of the heart, syn- cope, &c. ; though otherwise enjoying very good health. In such, also, may readily be excited hysterical paroxysms, or con- vulsions ; for either the active passions, or emotions of the mind, as anger, revenge, jealousy, and even surprise; or the passive ones, as fear, grief, or disappointed hope, will oftentimes, in a moment, have this effect. Disease may produce this state of the nervous system in con- stitutions not previously disposed to this condition ; hence, we sometimes see hysteria follow recoveries from long-protracted illnesses ^especially in females. In such cases, there does not appear to be any increase of nervous sensibility ; it is rather an altered condition of the nervous system ; as it now becomes ob- noxious to causes which would not previously have affected them. Hence, the wonderful effects of certain odours, medi- cines, or even sounds, in such a condition of nervous peculiarity. I have known two or three instances where the smell of the tube- rose, the lily, or the lilac, has been followed by faintness and palpitation of the heart ; though previously to the illness they had no such tendency. 2 I have known the very name of rhu- barb, and of the Peruvian bark, excite the most violent disgust, and sickness of stomach. I know a gentleman who cannot ' Mr. Tate mentions another symptom which he thinks goes far to distinguish or characterize hysteria it is an acute pain in the left side just below the left breast, and about the fifth or sixth rib, it is very circumscribed in extent, but is extremely acute. This affection, as one of the characters of hysteria, is also new to us, though we have frequently noticed the symptom. In one or two instances it has been of great severity, but in neither were the patients subject to any ob- vious form of hysteria. In both of the cases in which we had occasion to pre- scribe for this affection, the pain was constantly removed by rubefacients applied immediately to the spot. Mr. Tate thinks that this pain has frequently produced the lateral curvature of the spine, as it is sometimes of very long continuance, and the patient with a view to its relief constantly leans towards the affected side. * Dr. Whytt details several similar instances from this kind of change in the nervous system; he says, "Thus, several delicate women, who could easily bear the stronger smell of tobacco, have been thrown into fits by musk, ambergris, or a pale rose." " The smell of cheese has almost always occasioned the bleeding of the nose in some." 1 Works, p. 543. ' K 'au Boeibaave. 31 482 HYSTERIA. drink a glass of any of the -white wines, though formerly fond of them, in consequence of having frequently been puked with anti- monial wine during a tedious fever. Mr. Boyle, (Usefulness of Experimental Philosophy,) tells us of a gentleman who could be more violently puked by coffee than by crocus metallorum, or other strong emetics ; and was made sick constantly by its smell ; though he formerly drank it without the slightest inconvenience. I knew a lady, after recovery from a protracted typhus, agonized by the sound of distant thunder ; she was less affected when it was near and violent. And Boyle, (Usefulness of Experimental Philosophy,) also relates the case of a lady, who upon hearing the sound of a bell, or any loud noise, would swoon so deeply as scarcely to be distinguished from death. Those who have the misfortune to labour under this idiosyn- cracy of nerve are peculiarly unfortunate ; as they are constant- ly liable to be affected by causes which have not the slightest influence on others; and to such become, but too often, the object of cruel and ill-directed ridicule. Because affections of this kind do not often kill; and because the subject of them very often en- joys otherwise very good health, it is with too much facility sup- posed that every ill of which they complain is but the ima- ginings of a distempered brain. SECT. IV. Diagnosis of Hysteria. Sydenham, and some others, think the analogy between hys- teria in women, and hypochondriasis in men, is so strong, as to consider them as one and the same complaint; but this is cer- tainly not the case. Hoffman looks upon them as distinct dis- eases; and Cullen strongly inclines to the same opinion; at least he arranges them under different genera. He places hypochon- driasis in the class of Neurosis, and the order Adynamise; and hysteria, in the same class, under the order Spasmi. It is not a little surprising, that Sydenham, one so proverbial for accuracy, should have confounded these diseases ; especially as their respective characters are pretty strongly marked. 1st. The subjects of attack are by no means the same, as far as tem- perament will constitute a difference ; for we have noticed that hysteria is most common to women, and those of a sanguine and plethoric constitution ; whereas, hypochondriasis has more fre- quently men of a melancholy temperament for its objects. 2d. Hysteria is relieved very often as life advances; whereas the other is almost always aggravated. 3d. The pathognomonics of hysteria, as Dr. Good very justly observes, such as, "the con- vulsive struggling paroxysms, the sense of a suffocating ball in the throat, the fickleness of temper, and the copious and limpid urine, HYSTERIA. 483 have no necessary connexion with hypochondriasis, and are never found in this disease, when strictly simple and idiopathic. While, on the contrary, the sad and sullen countenance, the de- jected spirits, and gloomy ideas, that characteristically mark hy- pochondriasis, have as little necessary connexion with hysteria, and are in direct opposition to its ordinary course." Vol. iii. p. 353. An attention to these marks will serve to discriminate the two diseases perfectly. SECT. V. Treatment. The whole history of hysteria shows that the nerves of certain parts of the body are more liable than others to that particular state which gives rise to its phenomena ; and that this condition of the nervous power declares itself almost always in certain por- tions of the system. This condition seems to have an election, if we may so term it; or, in other words, certain parts more con- stantly sympathize with the brain, and become more liable, or more easily involved, than others. It is true, Hoffman locates hysteria in the stomach ; nor is this difficult to understand; since, in severe stages of this affection the stomach is very apt to be deranged ; but this is only the effect of this certain or hysterical, (if we may so term it,) condition of the brain. For there have been many, instances of hysteria, and some of which I have witnessed, where the stomach was in a most perfect state of health ; and I have seen cases of great de- rangement of this organ, where no hysterical symptoms have at- tended. Doubtless the stomach, like any other organ of the body, may be a seat of hysterical sympathy : in this case we shall have a va- riety of gastric symptoms, which will vary in force, as well as in character, according to the state of predisposition and power of the exciting cause. But when this occurs, the nature of the affection will almost always betray itself by the presence of some other symptoms which may be considered as pathognomonic of hyste- ria; such as palpitation of the heart; a sense of coldness on the top of the head; an increased flow of urine, &c. But should neither of these symptoms declare itself, we are pretty certain that the gastric affection is of an idiopathic nature, and may very often be justly named dyspeptic. The same observations will apply when the derangement shall be in the bowels, or some one of the abdominal viscera ; hence, the importance of attending to this distinction, in all affections of these parts. For when this organ is labouring under an active malady, as inflammation, there is for the most part an exemption from the symptoms constituting hysteria; consequently, for the HYSTEKIA. production of this, a peculiar condition of the nerves of the part seems to be always required. b^V---- On the presence of the affections just alluded to, and now about to be more particularly mentioned, we may almost always detect the existence of this condition of portions of the nervous system, and determine the extent of their agency, either in modifying or giving rise to new phenomena in the other systems of the body. Thus, palpitation of the heart, large discharges of limpid urine, a ball rising in the throat, a sense of coldness on the top, or back part of the head, with a disposition to cry or laugh, will always point out the peculiar disposition of the nerves concerned in the functions of the various parts just enumerated; and it can be pretty certainly determined by the state of the vascular system, how far they must be considered as the cause or the effect of ex- isting symptoms. In a practical point of view, an attention to the above sugges- tions is of the utmost consequence for certainly it is not too much to affirm, in very many instances, that that practice cannot be successful which throws out of sight this condition of the vas- cular system. In every affection of the body the state of the blood vessels should constantly be kept in view ; for on this our success will very much depend, when treating affections in which hysterical phenomena are present; for it will almost certainly point out whether the nervous or vascular system is most to be attended to, and in what succession. There are few errors more common in practice, than that of treating nervous symptoms independently of the circulatory sys- tem; and hence, the too often want of success of the common remedies when administered without attention being paid to it. The constant belief, that blood-letting, or any other depletion, is injurious in nervous diseases, has very often prevented the suc- cess of the best remedies ; and consequently, has caused a dis- ease to be protracted and obstinate, which would have yielded almost instantly to the common agents, had their administration been preceded by the loss of a few ounces of blood, or even, per- haps, by a brisk cathartic. However ill depletion may agree with nervous constitutions under a want of excitement in the vascular system, it is neverthe- less indispensable, when hysterical symptoms are accompanied by an exalted arterial action ; and it should therefore always be premised. Whoever expects to be successful in the treatment of nervous patients without paying attention to the state of the pulse, will find himself constantly disappointed; and the applica- tion of such medicines as are known to exert an influence upon the nervous system, will be sure to be unsuccessful, if not mis- chievous. Who has not witnessed the want of success of opium, camphor, HYSTERIA. asafoetida, &c., in an hysterical paroxysm, because attention had not been paid to the circulatory system ? Yet after the loss of a few ounces of blood, they have often been rendered immediately efficient. The connexion between the nervous and arterial sys- tems is more intimate than is generally admitted ; and, to be suc- cessful in prescribing for derangements of the former, we must have a scrupulous regard to the state of the latter. Indeed, a case can scarcely occur, in which it would be safe to disregard the state of the circulation altogether in the treat- ment of nervous affections; for though it may not be labouring under any undue excitement at the moment, yet it may be very easily roused into morbid action by the undue application of sti- muli. For the force of stimuli must be regulated by the suscep- tibility of the vascular system to action, if success is to follow their exhibition thus, ten or fifteen drops of laudanum, under certain conditions of the system, may be more successful than three times this quantity under another state of arterial action ; and the same observation will apply to many other remedies em- ployed in nervous affections ; for the success of remedies must depend upon their being administered in due force, to the exist- ing condition of the system. It is every way certain that plethora will often give rise to a train of nervous symptoms, or to hysteria: now these cases, if treated from the commencement by stimulants, or antispasmo- dics, will surely be aggravated ; while the abstraction of a few ounces of blood will almost instantly tranquillize the system, and render farther applications perhaps unnecessary. It will be well to illustrate this by a case. Mrs. B., aged thirty years, three months pregnant with her fifth child, complained of great palpitation of the heart ; lowness of spirits ; head felt as if girded by a cord ; easily provoked to tears, hands and feet cold, with very frequent discharges of urine; loss of appetite; nausea, and occasionally vomiting: pulse full and tense. She was ordered to lose ten ounces of blood ; and to take a dose of rhubarb and magnesia. She was imme- diately bled ; and so effectual was the relief from it that she did not think it necessary to take the purgative medicine. Had this case been treated with stimulants, or antispasmodics, there is no doubt that every symptom would have been aggra- vated ; at all events they would not have been relieved. I do not, however, mean to insinuate that every case attended with the above enumerated symptoms would be relieved by the loss of blood. I wish merely to inculcate the necessity of ascer- taining the state of the arterial system, before a prescription is made for what is familiarly termed nervous symptoms ; and if this be found too active, it must be reduced before stimulants and antispasmodics are administered. It is also important to be 486 HYSTERIA. mindful of the state of the circulation during the use of active remedies ; for it may happen, nay, it very often does, that during the exhibition of them the pulse becomes too much excited, and all the nervous symptoms become aggravated. To relieve this condition it is but too common a practice to increase the doses of the stimulants in use ; which, instead of pro- ducing the desired effect, but augment the difficulty. In such cases the loss of a few ounces of blood; a brisk purge; a sus- pension of the remedies ; or even, sometimes, a reduction of the quantity, will have the happiest result. In the treatment, therefore, of hysterical or nervous affections, too much latitude is commonly given to patients ; than which nothing can be more erroneous. It is generally supposed by them, that if a small dose will do good, a larger will do better ; or, at all events, a quick repetition of it is every way necessary: they accordingly act upon this principle; and, but too often, to their injury. For, however proper these remedies may be, they can only be so certainly in appropriate doses; if these be ex- ceeded, either no relief will be obtained, or the complaint will be increased. It should, therefore, ever be a rule in practice, even in nervous diseases, to suit the force of the remedy to the state of the system, as far as this may be practicable. It will be acknowledged, almost upon all hands, that this im- portant point has been too much neglected ; hence the but too frequent failure of remedies in the diseases in question. Dr. Whytt, 1 when about to lay down the cure for " nervous disorders," makes use of the following judicious language: "It will be proper to observe, that, as it is generally in the power of medicine to relieve, it is frequently beyond the power of art to eradicate the disorders we now treat of; and, therefore, it may be often of use to intimate this to our patients, especially to such as have fortitude enough to bear those evils which can neither be wholly prevented nor fully cured. It is farther necessary to acquaint every patient, that without a long perseverance in a course of medicines, diet, and exercise, no great or lasting bene- fit can be expected." To this purpose is the following passage of Montanus, which equally deserves the attention of such patients as are affected with nervous ailments, and of the physicians who undertake their cure. " In curatione hujus morbi, (sciz. hypo- chondriaci,) non licet praefinire tempus mensis unius aut anni, sicut in aliis contingat ; sed oportet in toto vitse suae tempore curationi operam dare interdum curationi, interdum prseserva- tioni, attendo." Hysteria is seldom cured so effectually as that the patient shall have no farther returns of it, should an exciting cause be * Works, p. 632. HYSTERIA. 487 applied ; yet we know from ample experience that it can be much mitigated by proper moral and medical discipline. Too much, we believe, has been taken for granted by medical men upon the subject of this disease; for it seems to be admitted, and this with by far too much facility, that little or nothing can be done for hysterical patients beyond the temporary relief of the paroxysm. This indifference upon the subject of hysteria has prevented suf- ficient inquiry into the nature and causes of this formidable dis- ease; and the modes of treating it remain very much the same as they did in the time of Sydenham. The difficulties experienced in the treatment of this complaint appear to us to be rather accidental than essential ; and this be- lief is founded on the following well established facts : namely, first, we now and then see females, who have been subject to it at one period of their lives, exempt from it at another; secondly, care taken to avoid the exciting cause will, for many years to- gether, prevent the return of the paroxysms. Now, it would seem, that if this affection can be removed, or even considerably relieved, either by means which we do not exactly understand, by the proper exercise of moral restraints, or by the removal of certain exciting causes, we might be encouraged to hope that the proper application of means, when the pathology of the dis- ease shall be better understood, might be successful. But if hys- teria be always looked upon as one of the opprobria medicorum, it cannot be expected we shall ever be much better acquainted with its nature or method of cure. It is ever proper that the medical man should hold the opinion that every disease is susceptible of cure ; for this belief will sti- mulate him to investigations which may result in success ; but if he permit himself to think that certain diseases are without re- medy, exertion will be paralyzed, and inquiry will cease. The lues venerea, intermittents, and doubtless many other diseases, were, at different periods of the world, thought to be incurable, however easy of subjection they may be at the present day. The following cases will show that this formidable complaint may be subdued by moral and physical causes. Case First. ft ' '(' :\ji<' tr vj rf Hi'.!j-i ' .: .. -t. : ..; ; . t JSf Mrs. , of sanguine temperament, married early in life, and became the mother of a large healthy family. She herself on- joyed uninterrupted good health, until her previous habits were broken up by her husband becoming very rich from successful speculations. She was now under no necessity of working for the sake of her family; every thing that money could purchase was at her command. She occupied a large house ; employed 488 HYSTERIA. a number of servants; and performed in a carriage that which was before done on foot. She fed high, and became really luxu- rious. But this change of fortune had penalties; and they were severe ones; she soon became very corpulent, listless, and ex- tremely nervous. She was frequently assailed by hysterical pa- roxysms of great severity, and of long duration. She became peevish to all around her, and extremely jealous of her husband. Every action of his life was misinterpreted, though he was one of the best and most moral men in the world ; and frequently did her "fits" arise from this overweening anxiety of her husband's supposed bad conduct. She continued in this fretful and anxious state for a number of years; and became so debilitated at last, that she could not leave her chamber for months together ; and it was thought by her me- dical attendants she must soon sink under her malady. But at this time the scene of prosperity was, by one of those changes common to mercantile life, suddenly changed for that of compara- tive poverty. Her husband gave all his effects to his creditors ; and after satisfying them, little remained. The effect of this re- verse upon the disease of the lady was no less sudden than salu- tary ; and that which it was thought would cause her death proved her cure. For from this moment she discharged her servants ; gave up her coach; dismissed her physicians; reinstated herself in her former occupations, and re-assumed her former habits, as far as her state of health would at the moment permit. In consequence of this change of circumstances, her moral energies were roused, and she quickly showed to the world that her temporary elevation had not unfitted her for a profitable re- turn to her former habits: and by exercising them, she soon re- gained that health which had been so completely sacrificed at the shrine of wealth; for after the first shock was over, she never had an hysterical paroxysm. !irif,")iii '' r-J fiiu.r; ).'; <' fU lo fcl>!.'hv.: Jiiorjfii!.' !;: ,>n',.; Y/ --tic. i.i~tr b >r:av jintvoii. 4 . -.-i'i A lady, born in a northern climate of Europe, went with her husband, after being the mother of three children, to one of the West India Islands. Here her health soon suffered from the cli- mate; she had frequent abortions, by which she was much re- duced by the attending hemorrhages. She became very hyste- rical; and paroxysms would be produced by the slightest causes. Her physicians advised she should be taken to a northern cli- mate ; and she arrived in Philadelphia in a most reduced state. She would not unfrequently have three or four "fits" in a week, for some time after her arrival. She had aborted a few weeks before, and was still labouring under a coloured discharge HYSTERIA. 489 from the vagina. The usual tonics were administered with ad- vantage, and she soon acquired an addition of strength ; the ute- rine discharge was arrested, and the hysterical paroxysms were diminished both in force and frequency. The first object in view was the renewal of strength ; and the second to prevent impreg- nation, while she continued so feeble, as had been the case too often before. The husband had business in Europe ; and we begged him to hasten his departure, or exercise forbearance ; for which we candidly gave our reasons. He went ; and his wife improved daily under the use of the cold bath, air, exercise, and a strict- ly regulated diet, both as to quantity and quality. Her strength improved daily ; her appetite increased ; her digestion was well performed; and her alvine excretions regular. She would now be weeks together free from hysterical attacks ; and by pursuing this plan regularly for fourteen months she lost them altogether; for she has had no return up to this moment, a period of several years. Her husband returned after an absence of eighteen months, and she has since had two live born children. In consequence of her improved health in this climate, she has been permitted to remain. These cases show that established hysterical parox- ysms with their attendants, were subdued by changes of a moral and physical kind ; and that they hold out encouragement to treat this affection as one capable of cure. But we must repeat, that success can only be expected, where the patient will most sedu- lously co-operate with the exertions of the physician. The treatment of hysteria will embrace what is proper to be done during the paroxysms, and what may be necessary in the intervals. 1. Of the Paroxysms. The management of the paroxysms is oftentimes one of great difficulty, from the excessive force with which it agitates the body. The whole muscular system is violently exercised, and this to a degree that almost exceeds belief, even in women who are at other times very feeble. The circulatory system is almost always excited, and a strong determination to the head is declared by the suffused cheeks, the swollen face, the blood-shotten, pro- truding eye, the distended jugulars, the throbbing carotids, and the never-failing but temporary mental alienation. Notwithstanding these strong evidences of the determination of blood to the head, many practitioners doubt the propriety of blood-letting in hysteria, because they declare it to be a "nervous disease, and that drawing blood is always injurious in such cases." 490 PYSTERIA. Such sweeping declarations must necessarily be very often wrong, and tend too decidedly to retard improvement in the practice of medicine, since they are almost always based upon narrow or imperfect views of the animal system. They should, therefore, always be received with hesitation, and acted upon with caution. We have remarked above, that this prejudice against blood-letting, (for it deserves no better name,) has retarded the cure of many of the affections termed nervous : this apprehension should there- fore be laid aside, and more reliance placed upon the state of the circulating system. The pulse should constantly be the guide upon all such occasions, and if this be properly studied and well understood, it will always direct us safely in the employment or the withholding of the lancet. The condition of the system during an hysterical paroxysm is almost always one of high excitement; nor will this surprise us, when we reflect upon the period of life, the kind of tempera- ment, the nature of the exciting causes, and the importance of the parts principally concerned in the disease. Besides these general reasons, which are of no small force, we shall find one still more powerful in the pulse itself. It will almost always be found rapid, full, and tense, and most unequivocally declaring a necessity for abstracting blood, and sometimes even to a large amount. \Ye, therefore, with very few exceptions, direct the loss of blood to an extent that shall decidedly diminish the force of the pulse, before we employ any other remedy. Bleeding does not often put an end to the fit immediately, nor is this expected of it; it, however, lays the foundation for other remedies to be suc- cessful, which would not be the case without it. Nor is this all : it always, we believe, shortens the "fit;" and certainly very often prevents its becoming protracted, or ending in mischievous engorgements. After bleeding we can employ remedies agreeably to the pre- senting indications with much more certainty and safety. We should inquire into the nature of the exciting cause, and be much directed by its nature. It may be owing to a passion, or an emo- tion of the mind; if this be so, sedatives and antispasmodics should be given. These may be administered by the mouth or by the rectum, as may be most expedient. If the patient can be made to swallow, and it rarely happens that she cannot, if advantage be taken of an interval, laudanum, in a full dose, should be given, and may be repeated in an hour, half an hour, or more seldom, as necessity may require. It may be combined with a solution or the tincture of asafoetida, in drachm doses. Cold water may be freely dashed upon the face, or even a stream of it turned upon it. Dr. Whytt, (Works, p. 693,) after enumerating a number of HYSTERIA. 491 remedies thought to be useful in the paroxysm, winds up with the following declaration : "But there is no remedy which I have found so effectual in removing hysterical faintings, with convul- sions, as the warm pediluvium; for after many other things had been tried to no purpose, I have seen the patients restored to their senses almost instantly, by putting their feet and legs in water a little more than blood warm. And it was remarkable, that upon the discontinuing the pediluvium too soon, the faintings and catchings often returned in a less degree, and the pulse became smaller and irregular. In a few cases, where the patients were plethoric, and the convulsions very strong, the pediluvium has failed." Of this remedy in the convulsive stage of hysteria we can say nothing from our own experience, but the authority of Dr. Whytt is sufficient to produce reliance on it. The only objection we perceive in the use of the pediluvium is the difficulty of its ap- plication at the moment the patient is convulsive flannels, or a blanket wrung out of hot water and applied to the legs might answer. His last observation on the cause of the failure of this remedy, is worthy of remark, namely, but "where the patients were plethoric, it failed : " this clearly points out the necessity of that strict attention we have recommended to the state of the pulse. It is recommended by almost all writers, and certainly prac- tised by all by-standers, to hold volatiles, and other stimulating things or substances to the nostrils during the "fit." 1 This is certainly a very doubtful practice where the system is much excited, and the convulsions violent. It is applying a powerful stimulus to a very sensitive part, a part that very powerfully sympathizes with the brain, and most probably the brain with it, at a time when the abstraction of stimuli is highly desirable. This practice most probably arose from the success of such sub- stances in syncope; but between syncope and an hysterical con- vulsion there is not the slightest analogy : in one instance, the muscular, the arterial, and nervous systems are violently excited; in the other, they are, for the time being, paralyzed. At a very early period of our medical practice, the propriety of this plan was doubted : this arose from seeing a person in an hysterical paroxysm constantly thrown into a convulsion by the 1 Dr. Whytt recommends the employment of such substances during the fit, and says, "These medicines, by the strong and sudden impression they make on the very sensible nerves of the nose, not only tend to excite the several organs into action, but to lessen and destroy the disagreeable sensation in that part of the body which brought on the fit." Works, p. 692, 693. But a little while after we find him at variance with himself, by saying, that " warm water is not only the speediest, but the safest cure for hysteric faintings; while strong vola- tiles, held to the nose, are apt to throw some delicate women into more violent convulsions," p. 65)3. 492 HYSTERIA. i application of the volatile spirit of hartshorn to the nose, while she lay in a state of comparative tranquillity after an exhausting "fit." In this instance, the volatile was no sooner applied than the convulsion was renewed : the practice was peremptorily for- bidden, and the patient soon " came out of the fit." Since that period we have never permitted the employment of volatiles in an hysterical paroxysm ; and so far we have been perfectly satis- fied with the plan. Should the patient be unable to swallow, we direct the laudanum and asafoetida to be given by "injection," having the bowels previously emptied by one consisting of a pint of warm water and a large table-spoonful of common salt. The anodyne and antispasmodic enema is to consist of two wine-glassfuls of luke- warm water, a full drachm of laudanum, and as much tincture of asafoetida, or if the watery solution of the asafoetida be at hand, it may be used instead of the plain water. This injection may be repeated pro re nata, every hour or two, as the exigency may demand. It is sometimes difficult to administer an enema during the "fit," for we have remarked that the struggle during this time is severe and irresistible ; besides there is another difficulty to this process, which arises from the contracted condition of the sphinc- ter ani, but this can always be overcome by perseverance and ad- dress, so far as we have yet witnessed ; it should not therefore be abandoned too soon, if the patient cannot swallow. See p. 480. Hysterical paroxysms sometimes depend upon something taken into the stomach, as too large a quantity of indigestible food, &c. When this is ascertained to be the case, an emetic should imme- diately follow the bleeding, if this has been judged necessary. Sydenham recommended this practice long since, and the expe- rience of almost every body since his time has confirmed its effi- cacy. Sometimes severe vomiting attends the paroxysm : when this is the case, it should be encouraged by warm water when practicable, until it appears that the stomach is cleansed. This case, agreeably to Sydenham, requires a larger dose of laudanum than where no vomiting attends. If there be much costiveness, besides the injection of salt and water, a strong infusion of senna should be given, in such doses as the patient can be made to swallow, and at such intervals as shall be judged necessary, until it operate freely. 1 It sometimes becomes necessary to apply blisters to the calves of the legs, or sinapisms to the feet ; these are, however, only 1 The senna seems to be peculiarly appropriate in this case, for its griping has sometimes advantages not to be derived from other cathartics. This is especially the case when the convulsions are frequent, and when attended by strong evi- dences of determination to the head. HYSTEKIA. 493 useful where there js a disposition to coma after the convulsions have ceased. 1 The paroxysms are of longer or shorter duration ; and it is not unusual to find the patient, after a severe "fit," rouse up, as if little or nothing had happened: when this is the case, the disease is habitual, for the most part, and not of much force. At other times they appear to fall into a profound sleep after each struggle; and if now let alone, they would awake perfectly well. But if anxiety has put in practice the application of volatile substances to the nostrils, it may do mischief, by renewing the convulsions, as stated above. Therefore, when this condition occurs, it should not be interrupted by improper officiousness; for this state of tranquillity is the best possible thing for the patient. When the patient has warning of an approaching paroxysm, it may frequently be interrupted by a timely dose of laudanum, asafoetida, or Hoffman's anodyne liquor; or what we have fre- quently found to answer well in such cases, is equal parts of the volatile tincture of valerian and castor, in drachm doses, mixed in sweetened water, provided much headache does not attend ; for if this be the case, the paroxysm can only be put aside, or moderated, by a bleeding, followed by a brisk cathartic. A pa- tient of ours rarely fails to prevent a "fit" by this plan. 2 In no disease, perhaps, has so many remedies been employed, as in hysteria ; at least, during the paroxysm : almost all the strong-smelling plants, oils, gums, and chemical products, have been employed, and lauded, condemned, and laid aside, in their turn. In this, perhaps, we have lost nothing ; for had they pos- sessed any remarkable advantages over the asafoetida, (almost the only one now employed,) they would unquestionably have been retained as certainly as it has been. Indeed, we are dis- posed to believe that they would never have been introduced among the anti-hysterical medicines, but from their strong smell exciting an analogy to the asafoetida, which has ever merited some confidence in hysteria. Dr. Hamilton believing the disease to be seated in the stomach 1 Mr. Tate, in conformity with hia pathological views, (see note at page 479,) declares he has seen the most decided beneficial effects from the use of the tartar emetic ointment, rubbed upon the dorsal vertebrae until it produces vesication. * Patients afflicted with hysteria frequently experience sensations which warn them that a paroxysm is at hand, and waiting only for an exciting cause to call it into play under such impressions relief or prevention is sought, in various ways, by different individuals. Some seek cheerful company and amusements, others active occupation; some let blood, others stimulate, &c.; and all, as is often in their power, after they have become well acquainted with their malady, shun well-known exciting causes. A lady with whom we are well acquainted, and who is well versed in the premonitory symptoms of hysteria, will not, while labouring under these sensations, open a letter of any kind addressed to her. They are thrown aside, until she feels she may encounter with impunity any information they may contain. 494 HYSTERIA. and bowels, gives, with his usual freedom, purgative medicines ; the good effects of which, on this presumption, he illustrates by several cases. But these cases prove nothing in favour of his pathology ; since purging is but a mode of depletion ; and one which is as familiarly employed for affections of the brain as for those of the abdominal viscera. In young, robust and healthy women, and especially those in whom the disease has not yet assumed a chronic form, we have always found purging highly useful, and never fail to employ some of the most active of the class for this purpose ; such as senna, calomel and jalap, various combinations of gamboge, scammony, &c. Hysterical paroxysms may be excited by a variety of causes, and especially those which act directly upon the mind ; and when these cannot absolutely be removed, the consequences may fre- quently be diminished by the repeated use of opium. The cases in which laughing, crying, a sense of suffocation, palpitation of the heart, and mental alienation, without convulsions, occur, can almost always be restrained by the liberal use of this drug ; pro- vided no plethora exist, or after it may have been removed by a bleeding. The following case will serve as one of many, as an illustra- tion. Mrs. , hearing suddenly of the death of a brother, to whom she was much attached, and whom she for some days had hourly expected to see, was instantly seized with such an aliena- tion of mind, as 'to pervert the kind offices of her best friends into attempts to injure her. She talked incessantly of her brother; cried and laughed by turns ; complained she was strangling, and required air, &c. We persuaded her to take a little coffee, in which was mixed thirty-five drops of "black drop:" this was re- peated once an hour for four doses. She now became calm ; was unconscious of any thing that had happened, and fell into a sound sleep, which lasted twelve hours. She awoke from this state perfectly restored. The best form for exhibiting opium is in that form of lauda- num called the "black drop," or the tinct. thebaic, acetat. 1 In this form it rarely leaves behind the unpleasant feelings the com- mon laudanum does. It is of about double the strength of the common laudanum. But should this preparation not be at hand, the common lau- danum should be mixed with two tea-spoonsful of sweetened vi- negar, which answers nearly the same purpose. In the use of 1 We may give the new preparation of opium, called the " denarcotized lauda- num," with still greater impunity, as it more rarely offends than the black drop. If this preparation be made choice of, it should be given in as large doses as if the common laudanum were employed. Or with equal, if not greater advantage, the sulphate of morphia a grain of which is about equal to one hundred and twenty drops of laudanum. HYSTEKIA. 495 this medicine strict attention should be paid to the peculiarities of the system as regards opium. There are many who cannot use the smallest quantity when given in one form, yet can bear full doses when exhibited in certain other forms ; for instance, we know several who cannot take the common laudanum in any\ quantity, yet can use the black drop with freedom and without the slightest inconvenience ; others can take the laudanum, when mixed with a few grains of the carbonate of potash, or of soda : others can only use the solid opium ; and some few we have met with, who cannot use the black drop, yet will bear the common laudanum well, &c. &c. Attention should always be paid to such peculiarities, when they exist; for, on them, very often, much will depend. Dr. Whytt gives a remarkable instance of this kind of idiosyncrasy. A middle-aged lady whom four or five drops of laudanum, taken by the mouth, affected with a violent pain and cramp in her stomach ; and sixteen drops taken in a clyster, though they did not occasion these complaints, made her delirious for twelve hours." Works, p. 645. We have seen several instances in which the "black-drop" invariably gave colic. This peculiarity, as regards opium, is oftentimes very unfortu- nate, as it deprives the patient of the use of the only remedy ca- pable of relieving the existing symptoms. We have two patients, much subject to cough ; neither of whom can bear opium in any form we have been able to invent. One of them dare not use it even externally. In constitutions thus peculiarly constituted it might be well to follow the suggestions of Whytt upon this sub- ject. He observes, that the lady, (whose case has just been re- lated,) "having afterwards begun with one drop of laudanum, gradually raised it to twenty-five drops; nay, she has sometimes taken that quantity thrice a day, without feeling any of its former bad effects;" which would seem to declare, that this unfortunate peculiarity might be overcome by beginning with very small doses, and gradually, and almost insensibly, increasing them. When the hysterical paroxysm precedes the eruption of the menses, it is generally best relieved by camphor, or camphor and opium conjoined: this may be given in julep, or in powder, as may be most convenient. The following formula we have found to answer very well R. VTUIII < .mij'll. Sp. \in. rect. Pulv. g. Arab. Tinct. thebaic. Sacch. alb. Aq. Font. icetat. q. s. f. pulv. adde gut. lx. $"') IVJ.-M Of this, a table-spoonful may be taken every hour or two, as the case may be more or less urgent. In cases where it is known that opium in almost any shape 490 HYSTERIA. or quantity will disagree, it may be omitted, and tlie simple cam- phorated julep used in its stead. But it should be well ascer- tained that the system does not require lowering by blood-letting before even the camphor is given: for, should the pulse be too active, much less advantage will be obtained from it ; and it will render the exhibition of opium altogether improper. Local applications are sometimes of advantage in such cases, especially if the feet be cold pediluvium, as warm as can be well borne, will be found highly serviceable, according to Whytt; and we know, that sinapisms to the feet, and warm dry applications to the region of the uterus, are of much benefit. It is almost the universal practice of the attendants on a person in the "hysterics," to oppose by violence, as far as their strength will enable them, every motion of the patient's body. They sup- pose the hands must be unclenched, at all events ; and very often, in the performance of this work of supererogation, much injury is sustained by the muscles that flex the hand and fore-arm. This violence should be reprobated, as it is highly improper; especially as it is every way calculated to do mischief, and never to do good. The patient may be suffered to grasp the hand of some one, as the spasms approach; but if the hand be contracted, it should be suffered to remain so, until it becomes relaxed. All that is useful in such cases is to make such opposition to the patient's struggles as will prevent doing herself mischief, by striking herself too forcibly ; or by bruising her limbs against any hard body that may be in the way ; or throwing herself from the bed. Again, a solid metal body is thrust into the mouth, such as the handle of an iron, pewter, or silver spoon, to prevent injury being done to the tongue ; but all such substances are improper, as they frequently do much injury to the teeth. A piece of cedar or pine, of sufficient length, and shaped like a wedge, may be advantageously employed. After the struggling is over, the patient will sometimes be very sick at stomach, or even vomit violently : in such case nothing is better than a draught of water, as warm as can well be swal- lowed ; and this may be repeated whenever the necessity recurs. We should not attempt to force medicines upon the patient while the stomach is thus disordered. In a late conversation with my friend Dr. Jackson, I learned from him, that he had found cold water highly serviceable in hysteria of a certain character : he has kindly furnished me with his views upon this subject, and I shall, I am sure, be rendering an acceptable service by inserting his letter entire. "MY DEAR SIR, " In your note last evening, you requested me to inform you more particularly of the employment of cold water in hys- HYSTERIA. 497 teria, which I mentioned, in conversation a few days past, I had found a prompt and beneficial remedy, in some cases of that af- fection. In compliance with your desire, I present you with the following observations, and shall be pleased to find you should consider them as meriting your attention. " I was first led to the practice from observing some cases of spasmodic or convulsive movements of the voluntary muscles, in robust men, but having a nervous temperament, and which were excited by a high degree of gastric irritation. In some, the acci- dents were attributed to drinking cold water whilst over-heated. But irritants of various kinds, as indigestible food, alcoholic li- quors, &c., had also been taken : and the symptoms revealed, when attentively examined, an intense irritation of the stomach. In these cases, the convulsive agitation of the muscular system was unattended with any tendency to coma or stupor ; the patients were unable to express, in language, their feelings; they were conscious of every thing doing about them ; their attention was wholly riveted on their sensations ; and when relieved they ac- cused the stomach and head as the seats of their sufferings. The convulsive movements of the voluntary muscles were evidently the result of the gastric irritation, forcing the will, and reflected, without its concurrence, into the locomotive apparatus. All con- curred in stating, they found it impossible to restrain the violence of their movements. From the view I took of those cases, iced water, or cold pump water sweetened, was given in repeated small draughts; cold affusions were directed to the head, and when the circulation was excited, and the skin hot, blood-letting was practised, with cold ablutions to the general surface. The relief from the cold draughts and affusions was immediate. The convulsive efforts became calm, and the patients expressed, in extravagant terms, the agreeable sensations they experienced from them, and the rapid disappearance of their sufferings. The morbid condition of the system, in the cases alluded to, bears a strong analogy to hysteria, as it is occasionally presented to us. " Having subsequently met with some cases of hysteria, the exciting cause of which was irritation of the stomach, produced by improper food, or other irritants, I was led to repeat the same practice. The result was equally prompt and favourable. In all those cases, however, gastric irritation was well characterized; the epigastrium was highly sensible ; sentiment of interior heat excited, and thirst. " The following case, which came under my care a few days past, illustrates the state of the system, the morbid phenomena I allude to, and the treatment. " Mrs. W. is about thirty years of age, of short stature, full make, dark complexion. Her husband has been absent on a voy- age several weeks, and no intelligence has been received from 32 498 HYSTERIA. him. She lives retired, and uses very little exercise. She had been distressed in mind some days complained of want of ap- petite and headache was constipated. She dined on fresh pork ; after dinner took a cold bath, which was prolonged an unusual time; coming out of the bath, she drank iced punch made of old Jamaica rum, and early in the evening took tea. Immediately after this meal, she was seized with spasms of the stomach, vo- mited, and became much agitated. The spasms in the stomach recurred at intervals of from five to ten minutes ; and, during each, there was a tonic spasm of the voluntary muscles, a loss of con- sciousness of surrounding objects, stifled, suifocated breathing, the eyes watery, and rolled upwards. In the intervals, weeping and great depression of mind. The slightest pressure on the epigastrium gave uneasiness sensation of heat was experienced in the stomach, and thirst. "At first I gave her hydrant water, none colder being in the house, sweetened with sugar, to drink. It did not relieve the gastric distress ice was sent for, and a large piece put in the pitcher of water. She drank small quantities every two minutes. It was highly grateful. A single paroxysm, only, recurred after the iced water was taken. The head was washed with cold water. In a case where the heat of the skin and head was intense, cloths dipped in cold water and affusions were employed. "I mentioned my practice to our friend Dr. La Roche, who put it in operation in a case of hysteric spasms, that came under his care, after he had tried the usual routine of antispasmodics, and which had failed to give relief. The effect was prompt. " The pathology of hysteria has been variously given by dif- ferent writers. The most correct view, and which is deduced from an attentive examination of its phenomena, refers to the cerebral structure for its seat. The brain is a collection of organs of nearly similar composition, which preside over the various in- tellectual and pathetic faculties, and voluntary motion. The medulla oblongata appears to be the central organ of perception and volition, and its lower portion and the upper part of the spinal marrow, govern the expressions and respiratory muscles. Irri- tation of the upper portion of the medulla occasions spasms, con- vulsions, &c., of the voluntary muscles ; and of the lower portion, irregular and spasmodic contractions of the muscles of respira- tion, of the voice, and of the face, as expressing the passions. Hence, the sense of suffocation, sighing, screaming, crying, laugh- ing, weeping, and the various distortions of the countenance. "Individuals who experience frequent attacks of hysteria, have this portion of the central structure in a permanent state of irri- tation, of feeble grade, and which is increased by any sudden and strong impression. An unexpected noise, sight, or intelligence, becomes in them an exciting cause of the hysteric paroxysm. Venereal irritation, sufficiently intense to be transmitted to the HYSTERIA. 499 brain, is often communicated to its central organ, and excites the symptoms of hysteria. The stomach and uterus are those parts from which this irritation is most commonly transmitted, ,and is effected through the great sympathetic, which anastomoses with the pneumogastric or par vagum that has its origin in the me- dulla oblongata. " The varieties observable in hysteria will depend, 1st, on the intensity and extent of the cerebral irritation ; 2dly, on the local visceral irritation, by which it is excited ; 3dly, the organ that is the seat of the primary irritation. " This pathology of hysteria is founded on the symptoms, the disturbances of functions it presents, and the organs that accom- plish those functions. " With respect, yours truly, " SAMUEL JACKSON. " To Dr. Wm. P. Dewees, June 29, 1826." Preventing the Recurrence of the Paroxysms. There are no affections of the other systems of the body so liable to recurrence as those which affect the nervous system. This may be owing either to the difficulty of restoring the ner- vous tone when impaired, though not subjected to the continued influence of the exciting causes ; or to the great difficulty of se- curing this system sufficiently long against the operation of these causes, that the nerves may recover their ordinary healthy standard. The difficulty just suggested is particularly great in the dis- ease now treated of, owing to the constant liability of exposure to the exciting causes ; for, almost any severe intellectual opera- tion, or any undue exercise of any of the senses, may endanger with relapse the ill-restored nervous system; hence the diffi- culty and uncertainty of a radical cure of hysteria. Besides, the best concerted plan that can be devised will be too certainly use- less, if co-operation fail on the part of the patient. We have already adverted to this difficulty, and it is repeated with a view to lessen an expectation of the efficacy of remedies, so commonly indulged in by patients of this class, without using their efforts to secure their good effects. To every patient afflicted with hysteria, it should be inculcated that much may be done by a proper and persevering exercise of the moral faculties, and by the judicious employment of their physical powers ; and that on these, vastly more depends for a cure, than on the exhibition of medicine; and, farther, that with- out the healthful play of these powers, medicine alone cannot prevent the return of evil, though it may occasionally alleviate a present misery. i 500 HYSTERIA. It will be seen at once, that part of this plan must be difficult of execution ; since the exciting causes are almost constantly presenting themselves ; at least it is so with those of the moral kind; and these seem to require more than human resolution, or hmman foresight, to either interrupt their operation, or to avoid encountering them. Yet we know much can be done, when reason is properly exercised, or forbearance duly main- tained. It should, therefore, always be shown to patients, how much depends upon themselves for a cure, by pointing out the importance of not yielding to sudden impulses, nor indulging in destructive forebodings. By the one the system is thrown into violent and ungovernable agitation ; and by the other it is ren- dered so morbidly sensitive as to be operated on by the slightest causes. The physical exciting causes may be avoided with more cer- tainty, or their presence more easily removed, than the moral ; yet to be successful in preventing their operation, requires much self-denial, and entire conviction of the necessity of the sacrifice. It would be difficult to point out the causes of the diminution of this disease within the last thirty years, in this city, though the fact is certain, so far at least as we can rely upon our own ob- servations. Have the temperaments most liable to this disease been changed, by either physical or moral causes? Certain it; is, that at present we are rarely called upon to attend in an hys- terical paroxysm, whereas formerly such calls were frequent. ' Is this change to be considered a real advantage to the female ? It might be doubtful if the observation of Whytt 1 be true; namely y that "however troublesome and obstinate nervous disorders may often be, they have some advantages attending them; for the weak state of the blood and vascular system, in many of these cases, renders such patients much less subject to inflammatory diseases than those of a stronger constitution." Thu it seems, that hysteria, like gout, may ward off severer blows. The first general indication in the cure of hysteria is to alter that peculiar state of the brain and nervous system, which gives rise to the disease when the exciting causes are applied. This condition may consist in too great a sensibility of the nervous system ; or in such changes of their sentient power, as to render them liable to be affected by agents not ordinarily offensive, nor inordinately stimulating, as already explained above. Now could this indication always be fulfilled, we could always cure nervous or hysterical diseases. We have already remarked that the nerves of almost every part of the body may, from their sympathy with the brain, be- come affected with this peculiar condition, which gives rise to "A 1 " : ."V'W-* '-'7 '',/' ttir Orttnt . , ;$^gprFp| ( IT. "Ita&'L. fjtfT -,-*"'- ~jF "' ' i"*Jtf ''?&' TflFA 3 ^-'-'**'*'* ;.^^rj:f.^--^f >',, S/ffK*^^%p5p EXPLANATION OF THE PLATES. 519 PLATE IX. In this plate are two figures of the cauliflower excrescence of the uterus. Fig. 1. Conveys an exceedingly good idea of the disease, as met with in the living body, the surface being studded with a number of little granules heaped upon each other, forming masses of an irregular shape. The lines drawn from letters A. and B. terminate in different parts of the mass. The letter A. in a portion which has a granulated appearance; the letter B. in a small flocculent portion, which, having lost the blood originally contained in it, forms a fine light substance, which floats in the spirit. Fig. 2. Shows the uterus of a patient who died of the cauliflower excrescence. The preparation is suspended by the Fallo- pian tubes. A. Points to the loose flocculent substance always found after death in patients who have laboured under the disease. During life, the flocculent substances being vascular, are filled with blood, and a solid mass is thereby formed; but these small vessels emptying themselves, nothing remains but their coats, which are seen lightly floating in the spirit in which the preparation is placed. B. Shows a part of the os uteri, which remains perfectly healthy. Perhaps this part may be about two-fifths of its whole circumference. C.C. The ovaria. D. An incision made through the parietes of the uterus, which are somewhat thickened. 520 EXPLANATION OF THE PLATES. / * PLATE X. A preparation of the corroding ulcer of the os uteri. A. Shows the ulceration. A piece of quill is placed so as to bring the whole surface into view. It will be observed, that the os uteri is entirely destroyed by the ulcerative process, but there is not the smallest thickening of the circumjacent parts. B. Shows the vagina in a healthy state. 0. A small cyst in the broad ligaments containing pus. '*&#- rr.vri: II 1 EXPLANATION OF THE PLATES. 521 PLATE XI. Ulcerated carcinoma of the uterus. This plate, when contrasted with the former, shows the uterus altogether much thickened, the cervix of the uterus especially. Two lines meet at A. ; these diverging, lead to the upper and lower, or rather to the anterior and posterior parts of the cervix uteri. All traces of the os uteri are destroyed. The points particularly deserving of notice in these plates are ulceration without thickening in the corroding ulcer, and ulceration with great thickening in carcinoma. B. The Fallopian tube. 522 EXPLANATION OF THE PLATES PLATE XII. Circular gilt Pessary. Fig. 1. This plate represents the middle-sized pessary. From a, a. Two inches and four-tenths. b. A central hole to permit any discharge to pass, three-tenths of an inch in width, c, c. An excavation for the neck of the uterus to lie in. Fig. 2. Is a central section of the pessary. a, a. Represents the internal cavity of the pessary. b, b. Represents the depth of the excavation of c, c, of Fig, 1, five and a half tenths of an inch deep. c. A section of the central hole, 6, of Fig. 1. J'.LuJ. TK 1* tlntiiii/li ilit 1 INDEX A. Page. ABORTION, liability to, increased by plethora . . . . 182 produced by hydatids . . . -:.. 284 mere increase in the circulation not sufficient to pro- duce it .. . . . . 313 Abscess, in the labium ...... 32.V milk ...... 451 Acetate of lead, in uterine hemorrhage .... 322 Acid, nitro-muriatic in carcinoma uteri .... 256 sulphuric in do do . . . . ib. pyroligneous in do do .... 255 Alum, in irregular menstruation . . . . . 147 Anatomical peculiarities of the female .... 18 Apththous efflorescence on the female organs ... 47 male organs . . . 51 Asafoetida in hysteria ...... 492, &c. Astringents in uterine hemorrhage ..... 327 their modus operand! . . ib. Leroux : s objection to their use . ib. Leake'a ... ib. their decided utility . . ib. in leucorrhcea ... 72 B. Balsam copaiva, in hemorrhoids . . . . .214 Bleeding, in carcinoma uteri . . : . . 245 decline of the menses ..... 149 hysteria . . . . . 490 menorrhagia . . . . . .146 milk abscess . . L . . . 456 pregnancy ....... 185 puerperal fever . . . . . 395 suppression of the menses . " ^ 126 uterine hemorrhage . . . ** 321 Blisters during pregnancy . . .'.-.'. . 190 in menorrhagia . . . ^ . 146 524 INDEX. Page. Blisters in puerperal fever . . . . . .412 in hysteria ...... 492 Blood, appearance when drawn during pregnancy . . .192 Bloody infiltrations in labia pudendi .... 35 causes . . . . . 15 symptoms, (see cases) .... 37 treatment . . . . . .37, &c. Borax in pruritus ....... 48 c. Calomel in puerperal fever ...... 354 Camphor in painful menstruation . . . . 130 in carcinoma uteri ..... 255 in hysteria ...... 495 Cantharides, tincture of, in leucorrhcea . . . .72, &c. in suppression of the menses . . 116 Carbonic acid gas in carcinoma uteri .' . . .251 Carcinoma uteri ....... 242 first stage, symptoms of . . . 243 treatment of . . . . 244 by bleeding .... 245 purging . . . 247 abstemious diet . 249 cleanliness . . . 250 > rest ..... 252 second stage, or where symptoms of ulceration have commenced .... 253 treatment by narcotics . . 254 antacids . . 256 sweet cream . . ib. diet ... 249 Mr. Clark's remarks respecting the treatment . 256 Cauliflower excrescence of the uterus .... 275 symptoms of ..... 278 prognosis . . . . . ib. treatment by bleeding .... 280 diet ...... ib. laxatives ...... ib. astringents . . . . . 281 tonics ...... ib. ligatures ..... 282 Cellular system of the female, peculiarities of . .20 Cicuta in decline of the menses . . . . . 145 carcinoma uteri ...... 255 Clarke, his classification of the diseases of the uterine system . 364 objections to ..... 365 Clitoris, diseases of . . . . .'*'; 28 given rise to the opinion of hermaphrodites . . ib. scirrhus of . . '.;' 29 Copaiva in hemorrhoids . . . . . .215 pruritus ...... 49 INDEX. 525 Page. Cold bath in hysteria .... (.4. . . 505 Costiveness during pregnancy .... . T. 206 consequences of . . * ' ^06 treatment . . . . ,, . .'. ib. Cream in cancinoma uteri . . . ' '". . . f ., . 256 Cutaneous system of the female . . -. t . ( ... ' . 20 D. Diet in carcinoma uteri ...... 249 cauliflower excrescence of the uterus . . . 276 decline of the menses . . . . .142 during pregnancy . . . . . 195 hemorrhoids ....... 213 leucorrluBa . . . . . . 73 suppression of the menses . . . . .115 menorrhagia . . . . . . 159 puerperal fever .... V > . 423 milk abscess . . . . . . 459 hysteria . . . . . ' . 504 Diseases of the labia ...... 32 external and internal organs ... 25 DysmenorrhcBa . . . . . . . 125 symptoms ..... ib. causes ...... ib. treatment . . . . . .130 during the flow . . . . . 129 the interval . . . . .131 Dr. Mackintosh's view of dysmenorrhcea . . . 133 E. Emetics during pregnancy . . . 189 in menorrhagia . . . . . . 160 in puerperal fever ...... 444 in hysteria . . . . . . 491 Ergot in difficult menstruation . . . . .130 uterine hemorrhage ..... 328 Extirpation of the uterus ...... 233 F. Female, peculiarities of the .... 17 peculiar diseases of ..... 18 Fever, menstrual .... . 100 milk, rules for preventing .... 452 '*? 526 INDEX, f Page. Fever, puerperal . . . . .''' 347 definition of . . . .'?.! ib. history ....... 350 period of attack . . . . . 373 predisposing causes ..... 352 delivery, as a cause . . . . 353 opinions of Armstrong, Hey, and Clarke . . ib. prophylactics ...... 355 purgatives, as . . . . . ib. Dr. Gordon's opinion respecting . . . 356 Key's ....... ib. the author's . . . . . 391 seat of ....... 357 appearances on dissection, in the thorax . . ib. in the abdomen 'V . ib. is an inflammation of the peritoneum . . ib. this inflammation terminates in effusion . ib. the belief that this in effusion is not the effect of active inflammation, erroneous . . . 358 Dr. Denman's opinion respecting . , . 371 symptoms of . . . . . ib. diagnosis ...... 379 prognosis . . . . . .381 contagious nature of . . . . . 384 the author's opinion of . . ib. Dr. Hulme's opinion of . . ib. Dr. Hull's ib. Mr. Key's ... ib. Dr. Armstrong's . . . 385 Dr. Leake's ... ib. treatment of , . . . . . ib. bleeding . . . , . . 386, &c. stages of ...... 395 1st stage ...... ib. bleeding in . . . ib. pulse as a guide for bleeding, &c. . . 397 rules for bleeding in . . . 403 2d stage ...... 407 purging in . . . . . 409 . emetics ..... ib. blisters in . . . . .412 fomentations . . . . 413 spirit of turpentine . . . . ib. mercurial frictions . . , . 414 gangrenous stage . . . . .416 symptoms of . . . . 417 treatment of . . , .418 stage of effusion, treatment of . . . 421 general directions and rules . . 422 Fluor albus, (see leucorrhoea) ..... 55 Forceps in uterine hemorrhage . . . . .333 Fomentations in puerperal fever . . . . 413 f.* INDEX. 527 G. ... Page. Galls as an application to hemorrhoids .... . ;' " . 215 Guaiacum, volatile tincture of, in suppression of the menses . 118 H. Heartburn during pregnancy ... .199 treatment of ... 200 Hemorrhage, uterine . . . . . . .311 connexion of the ovum with the uterus . ib causes which may destroy this . . 312 mode of action of certain of the remote causes of . . ib. periods of pregnancy at which it may take place . . 316 1st period, the first four and a half months of pregnancy . . 318 treatment during this period . . 320 2d period, the remaining time of utero-gesta- tion . . . 326 danger in this greater than in the first . ib. indications of cure . . . . ib. treatment at this period ... ib. delivery as a mode of arresting hemorrhage . . 328 vicarious of the menses . . . 100 Hemorrhoids during pregnancy . . . 208 cause of . . . 210 treatment of . . .211 after labour . . ib. treatment of . ib. Hiera picra in the decline of the menses . 145 Hip bath in carcinoma uteri ... 257 Hoffman's anodyne liquor in carcinoma uteri . 255 Hydatids of the uterus ... causes of case of ib. diagnosis .... 286 treatment .... ib. ergot recommended . . 287 Hymen, opinions respecting its existence imperforate ... . symptoms of . . ib. consequences of . il>. treatment of . . . .44 Dr. Denman's case of . 42 Dr. Cleaver's case of . 45 Jf- * .wp 528 INDEX. I Page. Hysteria during pregnancy, treatment of . ,. . . 85 Hysteria ...... |KY . 462 seat of ....... 463 sympathetic affections stimulated by . . 466 predisposing causes ..... 468 importance of attending to the state of the vascular system, in the treatment of ... 484 case illustrating this ..... 485 period of life at which it most usually occurs . . 468 causes of, according to Whytt .... 469 symptoms of ...... 478 those most obnoxious to it . . '. 479 exciting causes of . . . . . . 470 wind and tough phlegm in the stomach and bowels . . . 471 case .... ib. worms . ... . . . 475 case .... ib. improper aliments .... 476 scirrhous and other obstructions in the stomach and intestines . . 477 violent affections of the mind . . ib. phenomena of . . . . . 481 diagnosis ....... 482 treatment ...... ib. of the paroxysm ..... 489 bleeding ..... 490 sedatives and antispasmodics . . . ib. pediluvium . . . . . 491 stimulants to the nostrils . . ib. enemata ..... 492 emetics . . "" . . . ib. blisters ..... 493 purgatives ..... 494 opium ..... ib. case illustrating the utility of . .495 camphor ..... ib. local applications .... 496 restraint ..... ib. cold water ..... ib. bath ..... 504 to prevent the recurrence of the paroxysm . . 598 tonics . . . . . . 501 antispasmodics . . . . .502 diet ...... ib. amusements in . . . . 507 cases illustrating the utility of . . ib. cases showing that hysteria may be subdued by moral and physical causes . . ib. Hysteritis ....... 333 first species, causes of . . . . ib. symptoms . . . . . . 335 constitutional . . . . . .336 mixed ....... 340 treatment, bleeding ' it ' ' .341 INDEX. PL Pa?e - Hysteritis, treatment, purging . '| ' "', . ' , "' 344 fomentation . . ik ' ib. blisters . . . < . .' 345 sudorifics . .^ '>. ib. opium . . . *. % . 31o emetics . ib. I. Impregnation requires the united perfection of the internal uterine surface, and at least one of the ovaria . 86 periods of .... 88 never takes place before the inception of the menses . . . . 84, &c. never occurs after the cessation of the menses 85 Inquietude and want of sleep during pregnancy ' . . 20 4 Inflammation of the peritoneum, (see fever, puerperal) . . 347 Injections in leucorrhoaa ..... 72, &c. pruritus ..... 49 carcinoma uteri . . . 258, &c. cauliflower excrescence of the uterus . 27(5 Infiltrations, bloody, in labia pudendi .... 35 Iron, preparations of, in the decline of the menses, injurious . 146 Irritable uterus . 290 Labia, abscess of ....... symptoms of ...... ib. adhesion of . . . . . .29 prophylactic measures . . . ib. treatment of. . . . . .30 Dr. Derunan's plan . . . . 31 erysipelatous inflammation of .... 32 treatment of . . ib. axlematous swellings of . . . .33 those most liable to 34 sequelae of . . . ib. treatment of ... ib. Labour, its influence on puerperal lever . . ''. 3. r >.'J Lead, acetate of, in irregular mens raation . . 1-17 uterine hemorrhage .... 32 - 2 menorrhagia ... J63 Lencorrhrpa ... C .... 5.3 34 <*. 530 INDEX. Page. Leucorrhcca. causes which predispose to . . * . 55 those most obnoxious to . . T . ib. circumstances which influence the discharge . . 57 different varieties of .... 58 var. a. L. of direct irritation ... 59 6. L. of indirect irritation . . ib. c. L. of habit . . . . ib. Gardien's species of .... ib. seat of . . . . . . .63 stages of ...... 69 first stage ...... 70 symptoms of .... ib. treatment of . . . .72 second stage . . . . . 75 symptoms of . . ib. treatment of .... ib. third stage .... V . 83 symptoms of . . . . ib. treatment of . . . ib. nitrate of silver in ... 77 Ligatures in polypus of the uterus . . . . .271 cauliflower excrescence of the uterus . . 275 Lime in carcinoma uteri . ... . . , 251 Lymphatic system of the female .... 65 M. Madder in suppression of the menses . . . .116 Menorrhagia . . . . . . . 150 nature of the discharge in . . . ib. vessels by which the discharge is furnished . ib. those most obnoxious to . . . .154 symptoms of . . . . . ib. two varieties of . . . . .155 first variety ..... ib. those most obnoxious to . 1 57 treatment of . . ib. second variety . . . . .159 those most obnoxious to . . 160 symptoms of ib. treatment of . . . ib. a third variety, supposed to exist by Gardien . 161 Menses, period at which they make their appearance . 90, &c. causes which influence the . . . .92 premature appearance of .... 85, 89 derangement of the . . . . .101 the too tardy appearance of the ... ib. four conditions of the system in which this occurs . 203 cond. a. where there is little or no development of the genital organs . . . . ib. characters of this condition . T* ib. management of this condition . . . ib. INDEX. 531 Menses, cond. b. where the development is taking place very slowly ..... 104 character of this condition . . * .+, ll ib. management of this condition .* . . ib. cond. c. where this development is interrupted by a chronic affection of some other part . 106 character of this condition ... ib. management of this condition . . . ib. cond. d. where the most perfect development has taken place ..... 107 character of this condition ... ib. management of this condition . . . ib. cases of . . . . . ib. quantity usually expended .... 92 causes which influence the ... ib. sparing quantity of the . . . . .121 treatment of ..... ib. immoderate flow of the . . . .122 suppression of the . . . . . 1 10 cold, the most common cause of . Ill symptoms . . . . 112 treatment of . . . .113 treatment of sudden ... ib cases of . . . .116 every deviation from regularity does not require medical interference . . . 113 decline of the . . . . . .138 symptoms attending the . . . 139 treatment . . . . .142 derangements about the period of the . 141 concomitant affection . . . ib. may return after they have ceased ... 87 Menstrual action essential to impregnation . . .83 discharge, a genuine secretion . . . ' 95 furnished by the lining of the uterus . . ib. in what it differs from pure blood . ib. derangement of .... 102 quality of . . . . 97, &c hemorrhages vicarious, of the ... 99 fever, does not exist ..... 100 Menstruation, history of ...... 80 peculiar to the human female . . . ib. an original function . . . . .81 Roussel's opinion ... ib. Galen's ..... ib. not a fortuitous discharge ... 83 symptoms of . . . . . .91 period employed by .... 92 precocious ...... 85 painful . . . . . . 125 causes of . . . ib. two states of . . . . 126 membrane discharged during . . ib. treatment of .... 161 as a sign of fecundity .... 85 Menorrhagia . . . . . . . 150 two varieties .... .155 532 INDEX. Page. Menorrhagia, exciting causes Vi' * * ' *^ treatment I , . . . , 157 Mercurial ointment, in erysipelatous inflammation of the labia . 32 in puerperal fever . . . . 414 Milk abscess . . . v . ^; .!.. . 451 causes of, and prevention * 453 symptoms of . ; r-. < .*" . ~zA . . ib. progress of . . ; Jf . rfc . 454 treatment of . . . . .455 Milk abscesses, local applications, vinegar . . . 456 leeching ..... ib. regimen ..... 459 purging . . . . ib. puncturing . . . . . ib. caustic ...... 460 seton, operation of Dr. Phy sick ... ib. after treatment . . . i& , 461 Mother and fetus, mode of communication between . . 193 Schreger's opinion respecting . . ib. Muscular system of the female . . . . . 19 N. Nervous system of the female . . . . .19 Nitrate of silver, its use in leucorrhcea .... 78 Nymphse, enlargement of . . . . .26 inflammation of . " . . . . ib. extirpation of .... 27 0. Osseous system of the female ..... 18 Ovaria, when incomplete, cannot furnish perfect ova . . 87 may regain their power ..... diseases of the ...... 237 classification of . 238 P. Pain in the right side during pregnancy .... 202 cause of .* . 203 treatment of . . ib. INDEX. 533 Page. ^ Palpitation of the heart . '< . . . .216 causes of . . > . . ib. treatment of . . . * > |p ib. Pessary, description of the one used by author . . 223 directions for placing it . . . . . 224 proper size of ...... ib. remedies to be administered, before applying it . . 226 period it must be worn .... ib. Placenta, circumstances in uterine hemorrhage, in which it ought to be removed . . . 324 directions for removing it . . . . * . ib. Polypus of the uterus . . . . . * , 260 definition of . . . ib. causes of . . . J f . ib. three species made by Levret . . 262 1st species having its origin from the fundus ib. symptoms . . . . ib. mechanism of expulsion . . 263 signs by which it may be known . 262 2d sp. having its origin from the neck . 265 3d sp. having its attachment to the orifice of the uterus . . V* ib. characters by which it may be known . . ib. treatment of . . . ib. cases of . . . . 266 application of ligature . . .271 Pregnancy, general condition of the system during . '. 180 febrile do. . . . . . . *' 191 signs generally accompanying it . . 161 1. suppression of the menses . . . 162 2. nausea and vomiting . . . 167 3. enlargement of mammae . . . 168 4. areolse ..... ib. 5. formation of milk . . . .169 6. enlargement of the abdomen . . 170 7. increased size of the uterus . . . 171 8. pouting of the navel . . . 172 9. frothy spittle ... . ib. 10. salivation . . . . . 173 11. quickening ..... 174 itself not a morbid state . . . . 180 peculiarities during ..... 182 propriety of bleeding during . . . 186 purging do. ..... 187 vomiting do. . . . . 189 blistering do. . . . .190 liability to abortion do. . . . . 182 diseases of . . . . .191 vomiting . . . . . . 195 heartburn v . . . . . .199 salivation ..... 200 pain in the right side .... 202 inquietude and want of sleep . . . 204 costiveness ...... 205 hemorrhoids ..... 208 pruritus ...... 46 534 INDEX. Page. Phlegmasia dolens .... : ._..."" !*. 424 phlebitis different from . . . 438 cases . < A '''' 439 treatment p ; -.- ' . 446 blood-letting, &c. : , ....;. ^v . 447 purging . . . '**r- . ib. topical applications ..; ^ < . ib. opium . . |^.:: . 448 external applications . . ~, . 449 blisters .... ib. bandaging . . . . ' 450 Prolapsus uteri , . . . . . . 218 causes of . . ;.w . . ib. Gardien's three degrees of . . . 219 symptoms . */' . . ib. diagnosis, difficult . . 221 remedy . . '"I . ibj cases of ... 226 Pruritus ........ 46 causes of ...... ib. treatment of ...... 49 a distinct affection from furor uterinus . . 50 may be communicated to the male . . . 51 variety of, described by Chambon . . . 52 in children . ..... 53 treatment of .... ib. Puberty, female diseases at . . . . . .18 Puerperal fever, (see fever,) . . . . 347 Pyroligneous acid in carcinoma uteri . . . .251 Q. Quickening, what . . . . -.- . . 174 R. Rest in carcinoma uteri . . . ..." * . . 252 Retention of urine, from blisters .... 190 Rhatany in irregular menstruation . . . . .146 s. Salivation during pregnancy f 200 symptoms attending it . . ib. treatment of . '*-.,. 202 Sanguiferous system of the female . . v J 9 INDEX. 535 Page. Secale cornutum, in hydatids . . . '. * 286 Sleep, inquietude and want of, during pregnancy f*, . 204 Dr. Denman's theory of . . ib. treatment of . '' . *. 205 Sulphur, its use in hemorrhoids . . . . .214 Dr. Leake's opinion of . . ib. Dr. Good's ib. Sympathies called forth in pregnancy . . . . 181 Sympathy between the uterus and rectum . . . .189 T. Tampon, directions for forming and applying it . 322 objections which have been urged against its use . 327 modus operandi of the ..... ib. Temperament, predominant one in females . . . 21 Tonics during pregnancy ...... 185 in derangement of the menses about the period of their decline 145 Tubes, diseases of ...... 236 Tumours and excrescences of the external parts ... 26 Turpentine, spirit of, in carcinoma uteri . . . 255 in puerperal fever . . . .413 IT. Umbilical vein, uses of . . . . .193 Urine, retention of, from blisters .... 190 Uterus, displacement of, . . . . . .218 hemorrhage from . . . . . 311 connexion of ovum with ..... ib. causes which may destroy it . . . 312 displacements of, action of remote causes . . ib. periods at which it may take place . . . 316 first period, a. . . . . .318 second period, 6. ..... 326 delivery in hemorrhage ..... 328 lined by a mucous membrane .... 96 lining of, supposed by some to be deciduous . . ib. prolapsus of, (see prolapsus) . . . . 218 inflammation of, (see hysteritis) . . . 333 chronic inversion of . . . 231 irritable * ..... 290 diseases of ...... 236 carcinoma of ...... 242 particular diseases of . . . . 240 Uterine system, influence of . . . . .21 opinion of Sydenham, Cullcn, Good ; &c.. respecting ib. the author's opinion .... 22 Mr. Fogo's . . . . ' 24 >> * 536 INDEX. Page. Uterine contraction, how far we can control it ' . J ;i . 313 Mr. Burns' opinion . : '' . 314 the author's . . . . ib. cases x)f ; in which we should not interfere . . 315 in all other cases, should try to preserve the ovum ib. V. Vagina, natural diseases of . . . . . .54 abbreviation, or contraction of .... ib. treatment . . . ib. , accidental diseases of ..... 55 cohesion of the sides of >V ; . . . ib. cicatrices of . ; . ib. treatment of . . . ib. Vein, umbilical, uses of . . . . . . 193 Vinegar in milk abscesses . . . . . 456 Vomiting during pregnancy, (see pregnancy) . .* . 195 w. Warts on the vulva, treatment of . . . .26 THE END. " * ""V 3 1970 00488 9561 ^r 4', RK-iU'-AL LIBRARY FACILITY A 001 285131 7