A TREATISE *v DISEASES OF FEMALES. * * N ^^v^';W WILLIAM P. DEWEES, M. D. ^1 professor of midwipert i* the ckiversitt or pessbtxvajiia; member of thb AMERICA* PHILOSOPHICAL iO^lETT; OF THE nOTAL MEDICAL SOCIETY OF DENMARK, &C. 8tC. FIFTH EDITION, REVISED AND CORRECTED. 1 UiMSOH GErtfRACSOFFlCf PHILADELPHIA: I ° "^ * ^ ■ ■ ^»- ------♦ - »-—-------- CAREY, LEV & BLANCH ARD. 1835. wP 1835 Eastern District of Pennsylvania, to wit:— BE IT REMEMBERED, that, on the twentieth day of November, in the fifty- first year of the Independence of thje^-U^rted-^gtates of America, A. D. 1827, William P. Dewees, M. D., ofitfMiO^iblj^jfTatoj^deposited in this office the title of a book, the right vjj^eor he claims asTWtSSk in the words follow- ing, to wit:— f , -y "A Treatise on the Disuses of Females. v By; Wjli^am P. Dewees, M. D. treatise on the Disuses of Females. Byj W* Professor of Midwifery in the University OP P«r nnsj|rv4nia, &c. &c.' In conformity to the ActV>f the Congresfc-ef the United/states, entitled, "An Act for the EncouragemenVop*^parning, bv saApTiarthe Copies of Maps, Char^, and Books, to the AuHiQr^60iQ|rnp^ewn^jpfsuch Copies, during the times therein mentioned"—And^T**-faiitl]£jjil'>*r1^il1| il. "An Act supplemen- tary to an Act, entitled, «An Act for the Encouragement of Learning, by se- curing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the bene- fits thereof to the arts of designing, engraving, and etching Historical and other Prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. GRIGGS & CO., PRINTERS. TO 1\. OHAPJIAN, -H. D. PROFESSOR OF TUE INSTITUTES ASD PRACTICE OF PHTSIC, &t. 8tC. THIS WORK IS INSCRIBED, WITH SENTIMENTS OF THE HIGHEST ESTEEM FOR HIS MANY VIRTUES, AND TUE S1NCEREST ADMIRATION OF UIS VARIOUS TALENTS, BY UIS OBLIGED FRIEND, THE AUTHOR. 1 % ADVEUTISE.llEXT. 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 extenuation with those of a contrary feelieg. From the observations of the former, we hope to profit, should any such 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. In this fifth edition many alterations and additions will be found; and, it is trusted, improvements will be per- ceived. > CONTENTS, CHAPTER I. Page Of the Peculiarities of the Female System - - - - 13 CHAPTER II. Of the Diseases of the External and Internal Organs - -22 Sect. I. Of the Tumours and Excrescences of the External Parts........23 II. Of the Diseases of the Xymphse - ib. HI. Of the Diseases of the Clitons - - - - 25 IV. Of the Adhesion of the Labia Pudendi of Children 26 V. Of the Abscesses of the Labia - - - - 29 VI. (Edematous Swtilings of the Ixthia - - - 31 VII. Of Bloody Infiltrations in the Labia during or after Delivei-y.......33 VIII. Imperforation, and too great Density of the Hymen 41 IX. Of Pruritus, or Aphthous Condition of the Vulva and Vagina --------46 CHAPTER III. Of the Diseases of the Vagina ------ 5-1 CHAPTER IV. Of Leucorrhcea.........55 Method of Cure.........7 A CHAPTER V. Of the History of Menstruation......82 CONTENTS. CHAPTER VI. Page Of Deranged Menstruation - Sect. I. 1. Of the Tardy Appearance of the Menses - - 106 II. 2. Of the Suppression of the Menses • • -116 Case I......." 121 Case II. - - - - ' " " ib' III. 3. Of the Immoderate Flow of the Menses - - 129 IV. 4. Of Dysmenorrhea, or Painful Menstruation - 132 V. 5. Of the Decline of the Menses - - - - 146 CHAPTER VII. Of Menorrhagia........15^ CHAPTER VIII. Of the Signs which usually accompany Pregnancy - - 172 Sect. I. 1. Suppression of the Menses ... - 173 Nausea and Vomiting ----- 177 Enlargement of the Mammae - - - - ib. Areolse........ib. Formation of the Milk.....178 Enlargement of the Abdomen - - - - 179 Increased Size of the Uterus - - - - 181 Pouting out of the Navel - . - - - ib. Spitting of Frothy Saliva - - - - 182 Salivation ....... if). Of Quickening - - - - - -184 CHAPTER IX. Of the General Condition of the System, and the Effects of cer- tain Remedies during Pregnancy - 190 Bleeding - - - - - - - - -198 Purging..... . 200 Emetics --------- 201 Blisters - - - - - - . . _ 2Q2 CHAPTER X. On some of the Diseases of Pregnancy - - . 0Q3 Sect. I. Of the Febrile Condition of the System during Preo-. ™™y.......° - ib. II. 2. III. 3. IV. 4. V. 5. VI. 6. VII. 7. VIII. 8. IX. 9. X. 10. XL 11. CONTENTS. IX Page Sect. II. Of Vomiting -......208 III. Of Heartburn.......212 IV. Of Salivation.......214 V. Of Pain in the Right Side - - - - 215 VI. Of Inquietude and IVant of Sleep - - - 217 VII. Of Costiveness - -.....219 CHAPTER XI. Of Hemorrhoids, or Piles.......223 CHAPTER XII. Of Palpitation of the Heart......231 CHAPTER XIII. Of the Displacements of the Uterus.....234 Sect. I. Prolapsus of the Uterus - **• II. Of the Chronic Inversion of the Uterus - - 248 CHAPTER XIV. Of the Diseases of the Uterus, Ovaria, and Tubes - - 254 Sect. I. Of the Disorders and Diseases of the Uterus - - ib. II. Of the Diseases of the Ovaries - - - - 255 III. Of the Diseases of the Tubes - - - - 256 CHAPTER XV. Of the Particular Diseases of the Uterus - - - - 258 Sect. I. Of the Carcinoma Uteri.....259 II. Of the Treatment of Carcinoma Uteri - - - 261 1. Abstracting Blood - - - - - 263 2. Purging - . - - 265 3. Abstemious Diet.....267 4. Cleanliness ...--- 268 5. Rest - - - - - - 270 III. Of the Polypus of the Uterus - - - -280 Case I. - .-- 286 Case II........287 Caselll. ......%b- Case IV...... ■ 288 CaseV. - - - - -289 Case VI. .-- -291 X CONTENTS. Page Sect. IV. Mode of applying the Ligature for Polypi - - 292 V. Of the Cauliflower Excrescence - - - - 296 VI. Of the Symptoms ------ 299 VII. Of the Prognostics......300 VIII. Of the Treatment of Cauliflower Excrescence - 301 IX. Of Hydatids of the Uterus - - - - 305 X. Of the Irritable Uterus.....313 CHAPTER XVI. Of Uterine Hemorrhage ....... 336 Sect. I. 1. Of the Connexion of the Ovum with the Uterus ib. II. 2. Of the Causes which may tend to-destroy this Connexion - - - - - - - 337 III. 3. Of the Mode of Action of certain of the remote Causes - - * - - - - - ib. IV. 4. Of the Periods of Pregnancy at which Hemor- rhage may take place ----- 342 First Period -----.. 344 Second Period ...... 352 V. Delivery considered as a Mode of arresting Hemor- rhage - - - , .. . _ .355 CHAPTER XVII. Hysteritis, or Inflammation of the Uterus - 361 Sect. I. Species First. 1. Causes - 362 2. Symptoms ----... 353 3. Constitutional Symptoms - 364 II. Species Second. On the mixed Inflammation of the Uterus, or accidental Puerperal Fever - - 369 Treatment -----___ 37-1 a. Bleeding - - - _ . . - ib b. Purging ----.__ o~r> c. Fomentations - - - _ _ - ^74 d. Blisters - •» - - to. e. Sudorifics - 0~~ 1. Upturn --____ ., g. Emetics......_ '^ CHAPTER XVIII. Of Puerperal Fever ----__ History - - 380 Predisposing Causes - QOri CONTENTS. XI Page Prophylactics........385 Seat of the Disease, and its proximate Cause - - 388 Period of Attack, and Symptoms - 406 Diagnosis -------- 413 Prognosis - - - - - - - - -A 15 Contagious Nature of Puerperal Fever - - - 419 Treatment ........ 420 1. Bleeding, Stage First.....432 Purging........448 Emetics ........ ib. Blisters........452 Fomentations ....... ib. Spirit of Turj)entine ------ 453 Mercurial Frictions ------ 454 2. Of the Gangrenous Stage ----- 457 3. Of the Stage of Effusion.....462 General Directions and Rules ------ 463 CHAPTER XIX. Phlegmasia Dolens, or Milk Leg ...... 466 Symptoms and general Character of Phlebitis - - -481 Case I.........483 "Case II........484 Case III. -......485 Case IV........486 Method of Cure.........491 Blood-letting and Leeching.....ib. Purging, fyc.........492 Topical Applications ...... ib. Opium -----.-_. 493 External Applications - - - 494 Blisters.........ib. Bandaging - - 495 CHAPTER XX. Of Milk Abscess - -......496 Of the Treatment........500 1. Local Applications ...... 502 2. Regimen - - -*.....504 3. Purging........505 4. Puncturing -------- ib. 5. Caustic........506 6. Seton - .....ib. 7. After Treatment.......507 XII CONTENTS. CHAPTER XXI. Page Of Hysteria - - -.....508 Sect. I. Of the predisposing Causes - - - - -515 II. Of the exciting Causes ------ 517 1,2. Wind and tough Phlegm - 518 3. Worms ....... 523 4. Aliments, improper in Quantity or Quality 525 5. Scirrhous or other Obstructions in the Sto- mach, or Intestines, fyc. - 526 6. Violent Affections of the Mind - - - ib. III. Of the Phenomena of Hysteria - 528 IV. Diagnosis - - - - - - - -531^ V. Treatment ----.... 532 Case I........537 Case II........538 1. Of the Paroxysm --._.. 539 2. To prevent the Recurrence of Paroxysms - - 550 Explanation of the Plates - - - - _ _ . 565 Index -----____. 57-7- THE DISEASES Of* tfiBlAI.ES. 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 effect- ing 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 ap- proximation of physical and moral similarity has been observed; though they have never been able to alter the general charac- ter of the female so much, as to leave the slightest doubt to which of the sexes the individual belongs, even independently of sexual peculiarity. The intentions of nature in the formation of man, are not, nor cannot be fulfilled, by one sex alone; both must concur in this great object; 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 alicna- 3 14 PECULIARITIES OF THE FEMALE SYSTEM. tion, or exchange, in the exercise of the functions resulting from it.* 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 dis- eases, altogether her own. For both her particular organization, and her temperament, are made subservient to the important part she is destined to perform: upon ber 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 vi- sited 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 be- fall two sexes. The anatomical and physiological peculiarities of the female are both numerous and curious; we shall only, however suc- cinctly 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 • Alphore le Roi is of opinion, that most of the causes which degenerate the human family, or.gmate with the female; he says, « With a view rnZ i ally to follow the labyrinth of the human economy, it apneaTn J ^ effeCtU" that of the female: in this we may perceive moreceSHnf^ *,*** in that of the man, the cause and process omJ^^J^T" *" tion of the species always begins in nature with the female, to studv th f "^ of them, is to arrive atthe source of all that belong to the „! * ^^^ toire NatureUe de la Grosses* et 1'Accouchmen" p ^? ^ SpeCieS> His" PECULIARITIES OF THE FEMALE SYSTEM. 15 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 form- ing nearly right angles with the spine; and these bones them- selves, 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 calculated to subserve one of the most important as well as interesting 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 character of the bones, as well as their connex- ions with each other, differ from those of the male; their angles are le-s 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 sys- tem, 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 grande3, moins elles sont durable, parce que la mollesse et la flaccidile des solids leur faisant opposer moins de resistance, leur reaction est moins forte, et cesse bientot." " 11 n'en est pas de me me dans l'homme; la rigidite et la force 16 PECULIARITIES OF THE FEMALE SYSTEM. de ses solides exigent plus d'energie et un plus grand degre d'enlensite dans la cause qui agit sur lui; mais aussi 1'effect est plus durable, par la grand resistance que sont en etat d'opposer ses organs, resistance qui le fait souvent succomber. Je compa- rerois volenticrs, dans ce cas, la femme a ce frele roseau, qui, in- capable de resistance, flechit humblement la tete sous l'effort de la tempete, et la releve doucement quand le calme est revenue; et 1'homme a ce chene altier, qui se trouve abattu, par la seule raison qu'il est fort et capable de resister."* 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- 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- * Maladies des FemmCs. Vol. i. p. 40. PECULIARITIES OF THE FEMALE SYSTEM. 17 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 attend- ed with paleness of the skin, cedema, dropsy, and hemorrhagies, 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 lym- phatic vessels are more numerous; and when they have a certain predominance, they constitute a temperament; and then, unfor- tunately for the possessor, it but too certainly and too frequent- ly, becomes the seal 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 are 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 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 tbem, as with the male, every tem- perament may be seen. 11 has, however, been given so generally ; that some object must attach to its frequency; and perhaps the opinion of Vigarous, is as plausible as any. He says," destinees, comme elles le sont (females) a passer de revolutions en revolu- tions, a eprouver des transitions brusques dans leur maiere d'etre, la nature a du former les femmes d'une trempe molle, pour les mettre en etat de re sister aux orages auxquels elle sont exposees," p. 39, vol. i. Besides the systems just enumerated as belonging to the human 18 PECULIARITIES OF THE FEMALE SYSTEM. system, many are disposed to give to the female another, name- ly, the uterine system; and which they endow with an extent of influence 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 body; hence, the aphorism of Hippocrates, " morborum om- nium qui muliebres vocantur uteri in causa sint." That it not only forms, or governs the moral character of the female, but regulates the physical movements of her body; hence, the de- claration 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. Aretaeus 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* Sydenham, Cullen, Good, and very many others, have given 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 acencv in * Chambon. PECULIARITIES OF THE FEMALE SYSTEM. 19 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 se- veral parts of the body sympathize with the uterus; as the sto- mach, 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 sympa- thetic influence; yet it has never been asserted, that either of • these parts had at any other time, or under any other circum- stance but disease, an agency in producing or modifying the af- fections 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 others parts, so long as the functional process is carried on healthily; and that during this period, we have hitherto not been able to detect 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 suf- fer 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 dysmenorrhcea, 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- 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. 20 PECULIARITIES OF THE FEMALE SYSTEM. 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 condi- tion of any of the other viscera would be followed by the same consequences. 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.* 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, Aretaeus, 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 * 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 mammx, 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 function^ The nature and extent of these intercommunions are loo well known to n^ ' particular mention. need a PECULIARITIES OF THE FEMALE SYSTEM. 21 others, that certain wounds or injuries of the cerebellum, entail impotence. It is, therefore, much more rational to look for some disturbance of the brain or nervous system, as long since suggest- ed by Willis, for the origin of hysteria, ttc, than to any direct influence 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 a3 an organ we arc 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 diminish, 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. Xor are we to be supposed to countenance the opinions ad- vanced by Mr. Fogo,* 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 va- lue 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, ac commodating 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 " accommo- dating;" 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 wellbe 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 • See an answer to Mr. Fogo's paper, in " Essays connected with Midwifery," by William P. Dewees, M. D., &c. 4 22 DISEASES OF THE EXTERNAL AND INTERNAL ORGANS. 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 per- forming, or giving evidence of its best state of health; namely, during gestation. CHAPTER II. OF 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 mar- ried, or the pregnant, woman. Women, especially the married, 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 uhimpregnated, 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 foe tor; owing, most probably, to their very cellular structure; this tissue is found to die more easily when much accumulated, than when in more spare pro- portions. We may also add, that parts thus organized, granu- late 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 nymphie and labia, they become sometimes very much enlarged, from very slight irritation; and when there has been a DISEASES OF THE NYMPHJE. 23 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 per- severed in. This happens especially with those who have a dread of water after the catemenial 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. The prejudices 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 nymphae are more frequently the seats of these affections than other portions of the vcstibulum. The nymphae 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 Nympha:. When these bodies become much enlarged, they present a very dark colour* are dense, and sometimes studded with a num- ber of little tumours resembling warts. From their position, they are constantly liable to irritation; and in cold weather, to excoriation. Sometimes violent inflammation seizes upon these parts in consequence of the reaction, which follows a great re- duction 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 • Mr. Burns wys, white; but this we have never seen. 24 DISEASES OF THE NYMPH2E. 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 nymphas 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- dued venereal taint. When they are in the form of waits, 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 nymphae, 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 com- pletely 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 kept sepa- DISEASES OF THE CLITORIS. 25 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 accomplish- ment, succeeded in about a fortnight to remove every excre- scence, so as not to leave a vestige behind. It was truly remarkable to see with what rapidity these para- site 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 arc 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 nymphne and excrescences removed by the knife, without the necessity of tying a single blood vessel. In- trod. Francis's ed. p. 100. In certain parts of the world, the nymphae 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 Per- sian 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 has 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; while the cicumference of the stem measured five. It is the augmentation of this part, and especially when it as- 26 ADHESION OF THE LABIA PUDENDI. 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 proportion 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 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 mammalioe, 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 com- port with the general analogy of nature, that one should possess 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 Labia 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 al- ways adventitious, and owing principally to a want of cleanli- * Denman, p. 106. ADHESION OF THE LABIA PUDENDI. 27 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 lusly 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 perform- ance of it, to carefully inspect these parts from time to time; par- ticularly until the child is fifteen or eighteen months old, in or- der that the 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 lime 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 infancy, 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 im- portance; and because it has not sufficiently attracted attention. Sometimes, unfortunately for the female, it has not been disco- vered during infancy; and it is especially unfortunate, when it remains concealed until womanhood; when, perhaps, the first in- timation she may receive of her situation, is at a time, when, of all others, she would wish to have been ignorant of it. The al 28 ADHESION OF THE LABIA PUDENDI. ternative, 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 adviseable to operate, until the existing state of things were changed. We directed soft bread and milk poultices, and a cathartic. On our next ex- amination, 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 coales- cence. 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 en- tirely concealed. The child passes its water with some little difficulty; and when the complaint has been suffered to run on, or not discovered until womanhood, the menstruous fluid is eva- cuated through the same external aperture, by which the urine is discharged.* 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- * 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." ABSCESSES OF THE LABIA. 29 rior junction of the labia. A small dossil of lint, moistened with sweet oil, may be insinuated between the separated por- tions. The wound heals without the smallest difficulty, in two or three days. Dr. Denman, however, gives another opinion upon this sub- ject: he says, "In such cases, we have been directed to sepa- rate them (the labia) with a knife; and how far such an opera- tion 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 de- pend upon the judgment of the surgeon. But, in infants, such an operation is neither requisite nor proper; because a separa- tion 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 out 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 lightly astrin- gent liquor, should be applied every night when the child is put to rest, to prevent the reunion, to which there is a great dispo- sition." 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 adbcsions 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 recommended by Dr. D., can only arise from an ill-founded dread of the knife; it would, unquestionably, have required vio- lent exertions to have torn some of the adhesions we have seen; and much pain and inflammation, we think, would have followed such efforts. Sect. V.—%/Ibscesses of the Labia. 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, contribute much 5 30 ABSCESSES OF THE LABIA. 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 reso- lution have been so uniform, that of late years we do not attempt it; on the contrary, the immediate application of the ung. hy- drarg. fort, sine tereb., or of a warm bread and milk poultice, 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 procure resolution. The suppurative stage we have known to take place in a few hours; and it seldom continues beyond three or four days. 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 sit- ting down, or crossing the legs. The internal face of the labium is found distended, very red, and protruding beyond the exter- nal 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 appli- cations, 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 accompa- nied in children, as in older people, by fever; and require a strict antiphlogistic treatment. We have thought the applica- tion of the ung. hydrarg. fort, sine tereb., to be more useful than poultices, 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 abscess of this kind we remem- ber to have seen, arose from a young lady sitting down sudden- ly upon a hard pin-cushion: this case was treated exclusively with the qj itment, until the moment the matter 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 inter- EDEMATOUS SWELLING OF THE LABIA. 31 nal face of the vulva, it is apt, when inflamed and much distend- ed, to take on the erysipelatous form, and very quickly become vesicated; and if not soon relieved, will often slough. On this ac- count, we have been in the habit, for some years, of exclusively employing the mercurial ointment, for this species of inflamma- tion. 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 hap- pens, 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 re- mote 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 well be 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, who are much upon their feet, and who may be disposed to ana- sarca, are also more subject to this complaint than others. 32 OSDEMATOUS SWELLING OF THE LABIA. It rarely happens, however, that this affection is confined to the labia; it sometimes pervades the whole of the lower extremi- ties, 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 labour; we have never seen this connexion ; on the contra- ry, when excessive, we have thought it rather retarded this ope- ration, 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 inflammation of the erysipelatous kind; and considerable sloughing followed, attended by a great discharge of ill-concoct- ed pus, or rather of sanies. This case has made me attentive to these swellings before la- bour is expected, whenever consulted for them. When it is pure- ly 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 accompanied by a full, hard pulse; constipated bowels, and paucity of urine ; not- withstanding that these swellings have their origin in a mechani- cal cause. We have sometimes found great advantage from the loss of a 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 best to take off the distension 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- em.lfttle can be done towards a eure, until after delivery: though ft must be constantly pr„per to relieve the bursting skL by punctures, should labour even be beeun w i. i. obliged to do this in several instances, before i.^"^ BLOODY INFILTRATIONS, &C 33 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 en- tirely to the bed, for the last week or ten days of her time; and 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, ei- ther 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 condi- tion 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 al- ways immediately; but this is by no means constant; as we are informed by Drs. Maitland and Perfect, that the swelling oc- curred 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. Mr. 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. 60. I am of opinion, 34 BLOODY INFILTRATIONS IN that the blood proceeds from vessels situated rather within the vagina; for those which compose the vaginal plexus, immediate- ly 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 entire- ly escaped through the os externum. Dr. Maitland accounts for 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 burst." Med. Comment. vol. vi. p. 89. Now, it must be evident, that the nymphae can- not be put upon the stretch while the head is confined within the pelvic cavity; and, perhaps, the hardness of the head may contribute to the occurrence of the accident, as I have not seen, or found related, a case in which it took place, where any other part had presented. * The vessels which furnish the blood must be of considerable size; as the tumour which constitutes the disease, is very sud- denly formed, and is oftentimes enormous. The cases which I have witnessed, were all of this rapid kind ; occupying but a few minutes for the formation of the tumour. Mr. Burns, however, declares, that " it has been known to advance so slowly, as not to attract attention for two days," p. 60. This may, doubtless, have happened, since the rapidity of the formation of the tumour must necessarily depend upon the size or the number of the ves- sels injured. In these slow cases, mentioned by Mr. Burns, it may have arisen from the rupture of a vessel in one of the nympha?. This complaint has been mistaken for the distended and pro- truding membranes, and for a hernia; but a careful examina- tion of the deranged part, will soon remove these errors. For it exhibits neither the position nor the colour presented in either of the cases, with which it has been confounded. Its position is lateral, unless both labia are involved; in which case, the natu- ral sulcus must be observable; and its colour is that of extreme lividity, or entirely black, which resembles neither the mem- branes nor hernia. Owing to the unequal density of the external covering and in ternal face of the labium, it becomes irregularly distended • and scarcely any thing is seen but its excessively stretched, internal THE LABIA PUDENDI. 35 surface. So much so is this the case, that Dr. Maitland tells us, in the instance he witnessed, " the inside of the labium was turned so much outwards, that, on the first application of the hand, the skin and hairs of the part were not felt. The internal lining of the labium gives way sometimes from the excessive distention it has been made to suffer; this permits a quantity of fluid blood or a few coagula to escape, which tends very much to diminish the extreme anguish of the patient. In all instances of this kind, much pain is endured; and, in some cases, it has been so severe as to cause syncope; a case of this kind is related by Dr. Reeve, in the ninth volume of the London Medical Journal. Sometimes the tumour bursts before the child is born; Dr. Perfect relates a case of this kind; and the first case related below, may be considered as a similar instance. But, if this bursting does not take place, as sometimes happens when the size of the tumour is not enormous, the internal face of the labium is sure to yield in a short time, from gangrene taking place through its whole extent. This condition has been pre- ceded, in two of the cases I have witnessed, by innumerable ve- sications containing a yellowish serum, spreading themselves over the whole surface of the tumour, formed by the stretching of the internal membrane of this part, but which very soon after the swelling has acquired considerable size, yields, from the loss of life; and the patient, in consequence, feels considerable relief. When the part sloughs, it exposes a large surface of coagu- lated blood, which quickly becomes decomposed, and yields a stench that is altogether intolerable. Should the parts not give way, the pain arising from distention is unceasing and truly agonizing; fever of a very active kind is quickly kindled; delirium sometimes attends, and the woman's life becomes severely threatened. Her sufferings are also aug- mented by the retention of urine; as its passage is provented by the tumour pressing firmly against the meatus externus of the urethra. The patient can lie only upon her back, with her knees drawn up, and the thighs widely separated. She cannot bear the pressure of the bed-clothes, nor the lightest applica- tions; therefore it is in vain to offer relief, until the distended parts yield spontaneously, or, are made to do so, by artificial means. The severity of the patient's sufferings, calls for prompt and 36 BLOODY INFILTRATIONS IN efficient relief; this must be administered, by both general and local means. If fever attend, blood-letting must be employed to an extent that will ensure the reduction of arterial action; and be repeated, pro re nata. With a view to give the earliest op- portunity for the extravasated blood to escape, a free incision should be made the whole length of the tumour with a scalpel, or the shoulder of a lancet. I am not certain whether this plan has ever been insisted on by any writer, when the tumour pre- serves its integrity; but whether or not, I am convinced at the present moment it is the best mode of treatment. Several advantages present themselves from making the inci- sion just recommended: first, we may prevent sloughing, which is always desirable when these parts are concerned; secondly, the patient is quickly relieved from the excessive pain which constantly attends this complaint; thirdly, the extravasated and decomposing blood has a better opportunity to discharge itself, and consequently the progress of the cure hastened ; fourthly, it will sooner allow of antiseptic applications, to correct the ex- treme fetor of the putrefying coagula. The urine must be relieved as soon as the distention of the bladder becomes troublesome; this may generally be effected, by pressing the enlarged labium gently to one side, and slightly elevating it—should this not succeed, the catheter must be in- troduced, pro re nata. The bowels must be purged by any of the neutral salts; but the patient must not be permitted to rise during their operation; cloths must be placed under her to receive the fasces, as well as to catch the urine, when she is about to pass them. If she be permitted to get out of bed, it will create much unnecessary pain, besides incurring the risk of the renewal of the bleeding, by the rude and too sudden separation of a coagulum. The strictest antiphlogistic regimen should be observed. We are told of cases, where the bleeding has been considerable after the part has given way; to arrest which, the wound was crammed with lint, and the vagina itself firmly plugged. I have never seen any bleeding follow the plan just suggested; nor do I see how it can well occur, without attempts have been made too early, and too rudely, to separate, or remove the impacted coagula. This must be carefully avoided; and their separation confided strictly to the powers of the system, unless it be the portions that separate THE LABIA PUDENDI. 37 themselves in consequence of the putrefaction of the blood itself, or by very gentle pressure. The detached coagula of course should always be removed, as often as they may separate. It contributes greatly to the comfort of the patient, as well as being important to the cure, to keep the parts as clean as possible by frequent washing—for this purpose plain soap and water is as useful as any other mere detergent. The charcoal poultice is highly important, and should be constantly employed. The best mode of applying the poultice is to spread over its surface a piece of gauze or very thin muslin, that the charcoal may not adhere to the wound. Every loose portion of coagulum should be re- moved at each dressing, by carefully washing the part, as just directed; and the poultice should be changed every three or four hours, at farthest. The wound may be washed with a mixture of the pyroligneous acid and water; and the same acid may be profitably employed in its concentrated form over the poultice, by wetting folded linen with it. Before the wound heals, the patient generally becomes consi- derably weakened from the excessive discharge of pus, &c. Her strength should be supported by a decoction of bark, the sul- phate of quinine, elixir of vitriol, and a more generous diet, pro- vided no febrile irritation remain. The following cases, (all I have witnessed,) will illustrate the routine of practice. Case I.—1806, April 24th. I was called by Mrs. Rose, the elder, to Mrs. G., who was in labour with twins. At 1 o'clock, P. M., she was delivered of a female child. About ten minutes after its birth, the right labium pudendi became excessively swelled, which alarmed the midwife, and occasioned my being called. The part was found upon inspection by Mrs. R. to be dis- tended to its utmost bearing; extremely black; and nothing but the internal surface of the labium presented itself. Before I ar- rived, however, the tumour had burst, from the efforts made to expel the second child. When I examined the patient, there was little swelling remaining in the labium, but there was discovered a considerable opening from its superior portion to its insertion in the perineum. The second child was well situated ; pelvis faulty; pains pretty frequent and severe; and great pain was ex- perienced immediately above the pubes. In about fifteen minutes after my seeing the patient, the labium was again distended, and again it discharged itself: this took place four times before the birth of the child. This frequent bursting destroyed the con- 6 38 BLOODY INFILTRATIONS IN nexion of the labia with each other so completely, as to leave nothing but the common skin at the perineum to support the pressure of the child's head when passing through the external parts; this proved insufficient to sustain the force with which it was urged against it, and an extensive laceration, even to the verge of the anus, took place, notwithstanding every precaution which a timely fear could suggest. She lost from the part, by this laceration, at least twelve ounces of blood. 25th. Complains of no soreness in the parts; the swelling nearly subsided; is feverish; some slight after-pains; passes no water; ordered a tea-spoonful of the sweet spirit of nitre, and a purga- tive enema. 26th. She passed water freely, after the sweet spirit of nitre and the enema. From this time but little inconvenience was ex- perienced, except that which arose from the lacerated perineum. She was confined for some time to a horizontal posture, and at the end of the month was pretty well recovered. This case differs very much from the two about to be related; first, in the blood being discharged from the tumour almost as soon as formed; secondly, in the integrity of the perineum being very much injured by the repeated yielding of the labial tumour, and in laceration being inevitable; thirdly, in the wound healing up in the labia without trouble, in consequence of its cellular structure retaining no coagula. Case II.—1809, July 2d. Mrs. A. was delivered, at 11 o'clock, A. M., of her second child, which was very large, after a severe labour of four hours. She appeared very well after delivery, ex- cept the frequent recurrence of severe after-pains, which, how- ever, were relieved by the use of opium. At 9 o'clock, P. M. she complained of much pain, soreness, and tension, in the right labium pudendi, which, upon examination, was found to be much swelled; it continued to increase until it acquired a very large size, and quickly became vesicated. The internal lining of the labium was stretched to extreme thinness; was very black; and studded all over with little blisters, which contained a yellowish serum. I made with the point of a lancet a number of punctures, from which issued a considerable quantity of bloody serum ■ this afforded much relief. 3d. Pain rather less; fever and delirium ; no discharge of urine owing to the pressure of the tumour upon the mouth of the ure- thra. She was ordered to lose twelve ounces of blood—the urine THE LABIA PUDENDI. 39 was relieved by pressing tjie tumour to one side, and at the same lime raising it a little. An incision was made with the shoulder of a lancet through the extent of the inner portion of the tu- mour; this brought into view the coagula, with which the whole of the cellular structure of the part was completely engorged; much relief followed this operation. A strict antiphlogistic re- gimen was ordered. 4th. Pain and fever much diminished; urine relieved as yester- day; a considerable discharge of thin, grumous, fetid blood; bow- els confined; an ounce of the sulphate of magnesia was given, and the charcoal poultice was directed. 5th. Pain less; urine unobstructed. The salts operated well. The discharge from wound considerable, but extremely fetid. Fever diminished—poultice continued. 6th. Freer from pain and fever; urine free—fetor of the dis- charge extreme. Four or five ounces of coagulum dislodged by gently and firmly pressing the external and inferior portion of the tumour. Poultice continued. 7th. Nearly free from pain; fetor of discharge diminished; the tumour lessened in size. More of the coagulum discharged by the same means. Fever nearly gone—urine free; bowels confined. Salts repeated. 8th. No pain—can turn on either side—fever gone—fetor less, though the discharge is considerable. 15th. The coagulum entirely evacuated—healthy pus; fever, none; fetor gone. From this time the parts healed kindly, and in the sixth week they were entirely well. Her strength much improved by the bark in decoction, and the elixir vitriol. I at- tended this lady with several children after this time, without the smallest accident happening to the parts. Case III.—1809, August 30th. Mrs. C. was delivered about 5 o'clock, P. M., of a large first child, after a labour of six hours. The midwife left her about an hour after, as well as is common. At 10 o'clock, the same evening, I was sent for in great haste, in consequence of a large and sudden swelling taking place soon after the midwife had taken her leave. Upon inspection, the left labium was found much distended, very livid, and extreme- ly painful. The distention or tumour not so great as in the pre- ceding case; this, however, was, perhaps, in a degree, owing to my having been sent for immediately after the part was observed to swell, and its farther progress interrupted by my puncturing 40 BLOODY INFILTRATIONS, &C. the tumour in several places, which gave opportunity for a con- siderable quantity of the thinner part of the blood to escape from them, which afforded some relief; or at least prevented farther distention. The part was ordered to be covered with a soft bread and milk poultice, and as she was suffering much pain, a full dose of laudanum was directed. 31st. Still in great pain; high fever, and the tumour as large as it was the preceding evening, and vesicated as in the former case. Directed the loss of blood; made an incision the whole length of the tumour, which afforded much relief. The charcoal poultice was ordered, and the urine relieved as in the former case. Matters remained pretty much the same until the 5th of September. On my visit this day, I was enabled, with- out much force, to express a large portion of coagulum, and did so every succeeding day, until the 15th; considerable quantities had come away at every dressing; and at this time, (the 15th,) the sore was entirely free from it, and presented a large, but a healthy surface. The charcoal poultice was continued until the wound suppurated; it was then, as well as in the other case, dressed with simple cerate. The wound was entirely closed by the end of the fifth week. Her strength was improved by bark, &c. In neither of the three cases just related, was there any fungus produced, to interrupt the progress of the cure; a circumstance much to the advantage of the patient. The mode of treatment pursued in these cases, appeared to succeed so well, that I have been induced to relate it pretty much in detail; and I have been more strongly induced to this, as I have met with no account of the particular mode of treating this accident, so painful and alarming to the patient, and embarrass- ing to the young practitioner. The incision through the extent of the tumour, I am induced to believe to be the best mode of treating it; for we can never expect the extravasated blood to be absorbed; and when the distention of the parts is not very quick- ly taken off, the whole of the internal membrane of the labium will be sure to slough. I have, therefore, been led to believe it to be the belter practice, though I have no authority for it. It is true thatLe Dran mentions his having evacuated twenty ounces of blood by an incision; but the plan does not appear to have been adopted as a general practice. But, from the relief it afforded in the two cases in which I employed it, and the opportunity it im- mediately gives to the confined coagulated blood to escape, and IMPERFORATION, &C 41 also from its enabling us more effectually to remove the fetor, I am every way convinced it is the proper mode of treating these tumours. I have ventured to recommend the use of the pyroligneous acid, from analogy, rather than from experience in this particu- lar complaint. But its efficacy in removing the stench of putre- faction, evei* that of cancer, I have repeatedly witnessed; and I recommend it for the complaint in question, with as much con- fidence as can arise, where it has not been absolutely tested. Sect. VIII.—Imperforation, and too great Density of the Hymen. A dispute has long been maintained, by a number of celebrated anatomists, whether there really belongs to the female organs of generation, the appendage called hymen. The dispute is far from being settled to this day; nor is it a matter of much consequence whether it ever be, or even whether it ever can be, if the same mode of reasoning be followed by all who deny its existence. If it be attempted to demonstrate its presence, they, like Ambrose Pare, declare it to be an unnatural production. For if the occa- sional absence of a production is to be assumed as the natural condition, in defiance of its frequent presence, it would " con- found all our philosophy;" for acephali would be considered as the natural state of the human body, in spite of the ten thousand examples to the contrary. All that has been urged by Fallopius, Vesalius, De Graaf, Buf- fon, and many others, amounts but to this negative; that they did not always find the hymen when they sought for it. And the cause of this is, perhaps, satisfactorily accounted for by Cu- vier, by saying, " Pendant longtemps il y a eu des disputes assez ridicules sur 1'existance de cette membrane; on avait peu d'oc- casions de la voir, a une epoque ou l'anatomie ne s'exen.-ait que sur les cadavrcs criminels, et l'on s'appuya ensuile sur des obser- vations incomplettes, pour soutenir des sysiemes hazardes."— Diet, des Scien. Med. art. Hymen. If the existence of the hymen be denied, it would be in vain to talk of its imperforate state; yet, those who have done so, have furnished examples of this condition. With respect to this state of the hymen, we have nothing to add from our own expe- rience, as we have never met with an instance of imperforation. 43 IMPERFORATION, &C. All, therefore, that we can say upon this subject, must be derived from the observations of others. The first inconvenience that is experienced, is soon after pu- berty: the menstruous fluid is duly secreted; but, not finding an outlet, it accumulates from time to time, until the uterus itself, after the vagina is completely filled, becomes distended, and this sometimes to a very large size, before the cause of suffering is discovered. Thus, Dr. Denman relates an interesting history, where this state existed in a young lady, who, after incurring the ill-natured suspicions of those around her, submitted to an exa- mination, which eventuated in the discovery of the imperforate state of the hymen. The Doctor says, " the circumscribed tu- mour of the uterus was found to reach as high as the navel, and the external parts were stretched by a round soft substance at the entrance of the vagina, in such a manner, as to resemble that ap- pearance which they have when the head of a child is passing through them; but there was no entrance into the vagina. On the following morning, an incision was carefully made through the hymen, which had a fleshy appearance, and was thickened in proportion to its distention. Not less than four pounds of blood, of the colour and consistence of tar, were discharged;* and the tumefaction of the abdomen was immediately removed. Seve- ral stellated incisions were afterwards made through the divided edges, which is a very necessary part of the operation; and care was taken to prevent a reunion of the hymen till the next period of menstruation, after which she suffered no inconvenience."— Introduction to Mid. Francis's ed. p. 110. * Dr. Denman observes of this blood, that "it was not pntrid, nor coagulated, and seemed to have undergone no other change, after its secretion, but what was occasioned by the absorption of its more fluid parts." This is one among the many proofs that present themselves, that the menstruous fluid is not com- mon blood. Frank mentions a case, (torn. 3, p. 243,) from " Les Actes Medico- Physiques," of a young girl of fifteen years of age, in which the hymen was im- perforate. Her abdomen was distended as much as is usual at the sixth month of pregnancy, from the accumulated blood behind the obstacle. She was sub- ject to violent pains in the back, hypogastrium, and in the genitals; and thought she felt something within her. An incision was made through the hymen from which was discharged five pounds of thick black blood, without any disagreea- ble odour, and by which she was entirely relieved. He also mentions one fur- nished by one of his pupils, of a young girl, whom every body accused of being pregnant—an incision through the hymen, gave issue to several pints of blood, no ways changed; this operation was followed by fainting, but the girl's reputa- tion was saved. P " OF THE HYMEN. 43 When the hymen is imperforate, the patient suffers at each re- turn of the menstrual period; and these pains so much resemble the pains of labour, as to have been sometimes mistaken for them. Dr. M'Cauley confesses, that, in one instance, he mistook the protrusion of the hymen for the membranes forced down by the pains of labour; this case, like that of Dr. Denman, was relieved by incision through the dense and resisting membrane. Smellie's Col. I. No. 1. Case V. In the case just related from Smellie, the patient suffered se- verely; and what added to her distress much, was the suppres- sion of urine, which was not relieved until the contents of the vagina were discharged.* There is something curious in the economy of the uterus, when its body becomes distended by the accumulation of the menstruous fluid: it seems to yield for a time without much opposition; but by and by, it makes an effort to discharge its contents, and pains are excited. After these pains have continued awhile, they cease; nor are they renewed, until another menstrual period arrives. It is now again stimulated to contraction, and pains again declare themselves; and, in this man- ner, things proceed until art affords relief. The most remarkable circumstance attending these cases, is the cessation and renewal of pain. The menstruous fluid is, to all intents and purposes, an extraneous substance to the cavity of the uterus when retained there; the surprise is, that it should not continue its painful con- tractions without ceasing, but this is not the case—for after con- tinuing a certain time, the patient enjoys an interval of ease; nor is the calm disturbed; until a fresh secretion, by renewing dis- tention, again provokes it to contraction. This calm may be, and most probably is, owing to the thinner parts of this fluid being absorbed. In consequence of the vagina and uterus being filled with this fluid, its pressure after awhile becomes very severe; it not only produces pain, as just stated, but it also interrupts two important functions; namely, the discharge of urine, and the evacuation of the faeces. And in a case related by Mr. Fynney,t convulsions were repeatedly produced. Mr. Fynney, in his case, had to con- tend with a hymen " more than an inch thick;" this is not, how- • A similar case is reported by Mr. Coley, in the " Provincial Medical and Sur- gical Transactions." In Uiis case, recourse was had to the division of the hymen, with entire success. " Nearly four pints of tar-like fluid gushed out."—See Me- dico-Chirur. Rev. for July, 1833, p. 190. f Med. Comment. Vol. III. p. 194. 44 IMPERFORATION, &C. ever, usual, agreeably to Mr. Burns, who declares they are gene- rally thin. The quantity of fluid discharged is sometimes very large. In most of the cases it is said to be at least two quarts; but Benevoli, as quoted by Mr. Burns, makes the quantity in his patient to be thirty-two pints. They appear all to agree as to the appearance of the evacuated fluid—for in no instance is it mentioned, that it is found coagulated. The remedy, in all instances, appears to be the same; it is to cut through the confining membrane. In some instances, as just noticed, the hymen has been found very thick; which, of course, will require additional caution in the performance of the opera- tion. It is desirable, upon such occasions, that the parts be well distended, as it not only gives greater facility to the operation, but also additional safety. Dr. Denman says, " Some caution is required when the hymen is closed in those who are advanced in life, unless the membrane be distended by the confined menses, as I once saw an instance of inflammation of the peritoneum be- ing immediately produced by the operation, of which the patient died as in the true puerperal fever, and no other reason could be assigned for the disease." Introd. p. 110. And, in confirmation of this opinion, we will mention a case of imperforate hymen, in which the operation was performed, and was followed by death. In a report of the " Lowestoft Infirmary," there is a case record- ed by Mr. W. C. Worthington, of a girl of fourteen years old, on whom was performed the operation for the retained menses, by cutting through "a dense cellular structure, of half an inch in thickness, situated at the orifice of the vagina," and through which was discharged " about a pound of dark-coloured fluid." " The third day after the operation, severe pain in the abdomen, with exquisite tenderness, supervened, together with exquisite gastric irritation. Notwithstanding a strict, antiphlogistic plan of treatment was adopted, the patient died on the following morning." On examination, it was evident, that exquisite peritonitis was the cause of death, as just mentioned by Dr. Denman. Mr. Wor- thington, or the editor of the Med. Chir. Rev., relates a case from Professor Langenbec, very analogous to this: the patient died on the fifth day, and, in consequence of which, he gives precisely the opposite opinion of Dr. D., namely, that the operation should be performed early, and before the accumulation is great. In con- sidering these cases, we should be inclined to the opinion of Dr. D., and for the reason he urges. In the case above related by Mr. OF THE HYMEN. 45 W., it is evident that the parts were but very moderately dis- tended, as but " about a pound of fluid " was evacuated. In the fatal cases related, it is more than probable that a portion of the vagina was cut through, and the peritoneum thus wounded; now if this be true, it is evident, that the more the parts are distend- ed, the less will be the risk of this accident. The hymen is sometimes found extremely dense, though per- forated sufficiently for the passage of the menses, but not enough to admit with freedom the venereal congress. Vet it seems it does not prevent conception, however it may embarrass coition. A number of unquestionable cases arc upon record, where this act was never properly consummated; yet the women were im- pregnated, and the child's passage through the os externum was facilitated by an operation at the last period of labour. Ilildanus, Pare, Ruysch, Mauriceau, and many others, make mention of such cases. The late Dr. Cleaver, invited my friend, Dr. Chapman, and myself, to witness a case of this kind. The woman had been in labour with a first child, for at least twelve hours, when we saw her; the pains were now strong and frequent; the perineum very much distended, and alone supported the efforts of the uterus. The os externum was entirely closed, if we except an opening of about the size of a common goose-quill. Things had been pre- cisely in this situation, several hours before we were called; and as all chance of spontaneous dilatation, or even one effected by the force of pain, was at an end, it was thought best to cut the rigid hymen, and give a chance to the vagina to dilate, and the perineum to unfold. I accordingly passed a probe-pointed bistoury between the child's head and the hymen, and made a slight incision in the latter, which enabled me to introduce a finger, by which, I di- lated, or rather broke down, the whole of the resisting mem- brane, in such a manner, that there was nothing but the natural resistance of the parts to contend with. In about two hours more the child was safely delivered, and without the parts sustaining any injury, by the passing of the head. The mode of operating in this case, perhaps may not have been different from that pursued by others under similar circumstances; for none, so far as I know, have described the exact manner in which it was performed. But, as they have been silent upon this point, and as my previous impressions as to the mode of afford- 7 46 PRURITUS. ing relief, were altogether different from what I found necessary in this case, I think it best, it should be clearly understood, that all that can be necessary to ensure success to the operation is, merely to destroy the continuity of the hymen in one part of it; for by this means the opening will be large enough immediately for the finger to pass; and by the aid of which, by giving it a ro- tatory motion, the adhesions of the hymen with the vagina may certainly be destroyed—at least, so it appears from its success in this case. I cannot think it ever necessary, on reflecting upon the mechanism of these parts, to cut into either the vagina or pe- rineum, or even to wound them. Sect. IX.— Of Pruritus, or the Aphthous Condition of the Vulva and Vagina. One of the most troublesome and distressing complaints to which the female is subject, is the pruritus, or itching of the pu- dendum. Women who are not pregnant, are subject to this com- plaint; though not equally liable, as those who are; in both, the desire to scratch is so indomitable, as sometimes to put decency at defiance. I knew one instance in which the itching was so se- vere, and so continued, that the lady was obliged to keep her chamber for three months. The only relief that was found in this case, was from the almost constant application of water, in which ice was dissolved. Every remedy that could be suggested by two eminent practitioners of this city, was tried in vain. No relief was obtained, until after delivery. This case came to my knowledge in the year 1796, by being related by one of the gen- tlemen in attendance. The parts were not examined; the child was delivered perfectly healthy, though the mother was much exhausted by her long sufferings, and the severe discipline to which she submitted in hope of relief. The disease may attack the whole of the vulva, and sometimes it affects the vagina. It sometimes commences in the early part of pregnancy; when this happens, and is neglected, it may con- tinue until delivery takes place. At other times, and this I be- lieve to be the most common, it does not attack until the sixth or seventh month. If cleanliness be not observed, the complaint is sure to be much aggravated; though no attention of this kind of itself is capable of preventing or overcoming this complaint. A great variety of causes have been assigned for this disease- such as want of cleanliness; an acrid secretion within the labia* PRURITUS. 47 an inveterate eruption; the pediculi pubis; varicose veins; an aphthous efflorescence, &c. It is certain, that in a number of the cases which have fallen under my notice, a want of cleanliness could not be considered as a cause; though we are persuaded, it is well calculated to in- crease it. There must be a secretion of some acrid fluid in all cases of pruritus, be the remote cause what it may; and it seems to renew the itching whenever it may happen. In some in- stances, this itching has intervals of longer or shorter duration; and its return seems to be produced by a discharge taking place of a thin and generally limpid serum, of which the woman is perfectly conscious; and aware, at the same moment, that her troubles are about to be renewed. I have met with no instance in which a dartrous eruption, or pediculi pubis, could be consi- dered as causes; nor have I met with one, where it has arisen from a varicose vein. The aphthous efflorescence, as an attendant on this complaint, we believe we were the first to point out; and for this discove- ry we were indebted to accident, as will be now mentioned. The precise nature of this affection, had not been pointed out; and accident furnished me with an opportunity of detecting a condition of the parts, where this complaint was in full force, which has never, I believe, been noticed by any one; and which led to, generally, a very successful mode of practice. A lady, whose husband was more notorious for his gallantries than for his domestic virtues, was attacked in the incipient stage of pregnancy, with an intolerable itching in the pudendum, and even within the os externum. The woman suspecting the affec- tion to be venereal, I was sent for in April, 1815, and she gave such an account of her feelings as to make me think it might truly be the case; I therefore proposed an examination of the parts; which was finally acceded to. Upon separating the labia, the whole face of the vulva, the os externum, and as much of the vagina as could be viewed, were covered with an incrustation of aphthae. I assured the patient, her disease was not what she sus- pected, but one, I hoped, that could be quickly removed. I ac- cordingly ordered a strong solution of borax in water, and re- quested her to wash the parts with it four or five times a day; as well as to throw it up the vagina by means of a syringe. She did so; and was perfectly well in twenty-four hours. I was led to the employment of the borax in this case, from the analogy which the thrush in children furnished; and its sue- 48 PRURITUS. cess since, has led me to regard it, if not as a certain, yet as a very valuable remedy: it has rarely failed in my hands, or in the hands of others, as far as I have hitherto learned. It therefore always deserves a trial; especially as I have never known it ag- gravate the complaint. I have had a number of cases within the last few years, in nearly all of which it proved completely suc- cessful; but not with equal speed. Two of the cases just men- tioned were pretty obstinate, but especially one: in both, I was obliged to bleed and purge liberally; and to confine the patients to a low diet; but in one, I was under the necessity of applying leeches to the part, before the disease would yield. I thought that small doses of magnesia, with the daily use of lime water and milk, were useful in this case. But, in the others, the dis- ease yielded, almost immediately, to the simple application of the borax and water. Where this complaint proves at all obstinate, depletion adds very much to the influence of the borax; I therefore would ad- vise attention to this circumstance. I am now certain, however, that in every case of pruritus, there does not exist this aphthous efflorescence. I have had but three opportunities of examining the parts, under such circumstances: in two of which, the aph- thous condition obtained; but in the other, the parts were as de- scribed below.* We do not know in what proportion of cases this state of the parts may exist—we are well satisfied, it is not present in all. This fact we were enabled to ascertain a few years since: in this case, the external labia, the whole vestibulum, the carunculae myrtiformes, and as much of the vagina as could well be viewed, * Cases certainly do occur, in practice, that have not yielded to the plan we have suggested; therefore we feel grateful for the knowledge of any remedy that has proved successful, when the ordinary means have proved otherwise. We, therefore, feel indebted to Dr. Philip Younge, of Thomaston, Georgia, for the following case, in which dry calomel proved highly useful. " I had it sprin- kled," says the Doctor, "over every spot of inflammation within the vulva, as thoroughly as the nature of things would permit, three or four times a day. Whenever the itching became urgent, my advice was to wash the part, by means of a syringe, with cold water, and reapply the dry calomel, which immediately calms the most insufferable irritation. I have pursued this plan, when the disease appeared perfectly unmanageable, with the happiest effects: although the dispo- sition to recur was manifested until delivery, this remedy always appeased the" distress."—Amer. Jour, of Med. Sci. for Aug. 1833, p. 555. Dr. Canon du Villards, says he has employed, with much advantage lotions of the distilled water of the Primus laura-cerasus, in this complaint, after^it had re «isted every other application.—Id. for Nov. 1834. PRURITUS. 49 were swelled, and much inflamed. The appearance of the in- flammation was singular; it was of a copper-red colour, with a number of slight abrasions; by which the sensibility of the parts was very much increased. From the whole of the inflamed sur- face, an ichorous dew seemed to be distilling constantly; and when this accumulated in a sufficient quantity to make the wo- man sensible a discharge was taking place, a most intolerable itching would begin; nor would it cease, until the poor woman would be almost exhausted, by her efforts to appease it. Cold iced water was her only solace; and this afforded but a very tem- porary suspension of her misery. This patient, it may be proper to remark, was not pregnant; she was advancing towards the critical period of life, and had been always, at least for many years, subject to fluor albus. Sus- pecting some disease in the uterus itself, I examined my patient per vaginam: this afforded no room to suspect any thing wrong with this organ; I also carefully traced the urethra, but could de- tect nothing amiss in it. I prescribed a free use of the saturated solution of the borax, both as a wash, and as an injection: from this, much relief was experienced; but the disease not yielding, as I had frequently found it to do in other cases, I began the use of the balsam copaiva, agreeably to a suggestion of my friend, Dr. Ruan, of its usefulness in this complaint: in this she persevered, and in a few days she was completely relieved. I believe the balsam, in this case, contributed much to the re- lief of the poor woman; this belief is founded on its success in another instance, where it alone was used, if we except frequent bathing with lukewarm water, one bleeding, brisk purging, and an extremely abstemious diet. Dr. Ruan informs me he has succeeded with copaiva, after the borax had failed in several instances; and, so far, I am dis- posed to consider it a valuable aid to this article. In cases of pruritus accompanied by the aphthous incrustation, I think the borax will almost always succeed; therefore, I prescribe it in all instances for which my advice is required; but what proportion these cases bear to those without this efflorescence, I am alto- gether unprepared to say at this moment. In a case of great violence, and as great obstinacy, where it did not yield to depletion, to low diet, nor the borax, instant re- lief was obtained by an injection of a small tea-spoonful of the aqua ammonia purae, to a half pint of water. This mixture was had recourse to in the middle of the night by the patient, while 50 PRURITUS. under great agony from the violence and pertinacity of the itch- ing; and which she considered rather as a desperate experiment, than as a probable means of relief; yet it succeeded like a charm. During the time the itching was troublesome, it was used for several days, with almost instant advantage; but after this, it seemed to lose its influence. The borax was again resorted to; and it completely succeeded; this lady was three months advanced in pregnancy ; and had been, before, obnoxious to this complaint, when in this situation. A^XJmx^much pleasure in stating, since this period, 1 hav^Wm^mur^^«5*fc^erived from the use of the ammoniated vy&ter as just dir-ected, rtShtferal very trouble- some cases of prurif The cases which occur during pregnancy Sbfem more obstinate than those which take plgce at other ti^esj* we except such as occur towards the declifres^j^nG' AerJsjg^rnd where there is evi- dently a disease of the wombT In these latter cases relief may be obtained; but they are perhaps never cured, unless the affection, of which pruritus is a symptom, is also removed. Much will de- pend upon frequent washing, and often rinsing out the vagina by means of a large and powerful syringe. The solution of borax may be used for this purpose with advantage; and the balsam copaiva might perhaps be useful in such cases: but of this, I have no experience. Opium, or opium and camphor, at bed-time, in pretty full doses, have a temporary good effect; at least, it pro- cures a degree of rest, that would otherwise be denied. The wo- man should exercise much forbearance, and not too easily yield to the gratification of the predominant feeling. I have had a case lately, in which this complaint followed abortion—it was imme- diately relieved by the borax. This complaint has been generally confounded with one of a very different character; named the furor uterinus; but they are very easily distinguished from each other; the latter is a volup- * In the treatment of this disease it is of much consequence that the local re- medies should be thrown up the vagina by a syringe, as the following history will show. Mrs. K., in her sixth month of pregnancy, was attacked with pru- ritus. The solution of borax was recommended—on calling on her a few days after, she informed me she was not relieved in the slightest degree. I inquired whether she was careful in the use of the injection; she seemed surprised at the question. I now learned that her husband had omitted this part of the directions, as he understood that bathing the parts was all that was necessary. The syringe was now made use of, and the patient was entirely and promptly relieved. From this it would appear, that the efflorescence may occupy the vagina to a considera- ble extent. PRURITUS. 51 tuous sensation, accompanied by venereal desire; and is not ac- companied by an itching, properly so called; but by a sensual irritation, which makes the rubbing of the parts contribute in a degree to gratification. The pruritus, on the other hand, is an intense, and an indomitable itching, not accompanied by volup- tuous desire; but which finds, to a certain extent, a relief from scratching. For, were the feelings excited in these cases to be allayed by any mechanical application, one would be selected that would better comport with the pruriency of the thoughts which suggested the necessity, and the nature of the means; while the other, would seek relief from the application of the nails," or some other equally rough substance. The two com- plaints must therefore be looked upon as altogether distinct in their nature and objects; nor does the one ever degenerate into the other, as some have imagined; for there is no analogy what- ever between pruritus, and furor uterinus. For the one, as we have said, is an ungovernable lasciviousness; the other, an in- tolerable itching, without the slightest desire. Indeed, from all I can learn on this subject, pruritus is so far from being accom- panied by desire, that women at such times manifest the greatest repugnance to the venereal act. We have known a complaint communicated to the male, by intercourse with a woman labouring under pruritus; it was very similar to that which infested the female, in its general charac- ter; that is, there was great itching and swelling of the prepuce; the whole internal surface of which, together with the glans pe- nis, were covered with an aphthous efflorescence. When this occurs with the married man, much disturbance is sometimes created, from a supposition that the wife has been unfaithful, and the contrary; and much will depend upon the good sense and experience of the medical attendant, that it shall not be sub- versive of domestic peace. Indeed, it has occurred in more instances than one, within our own knowledge, where the woman has thought herself the injured party: and in one case, the recrimination was mutual. In this instance, the friends of the parties assembled to determine on the terms of separation; when it was suggested by one of them, who happened to be more rational than the rest, that before they pro- ceeded to such an extremity, their family physician should be consulted; and, that it should be left to him to determine, whether there really was any cause from the nature of the disease in question, to justify such a measure. We were accordingly sent 52 PRURITUS. for. We gave an attentive hearing to both sides of the question. From what was related, we were at once of opinion, that there was not the slightest ground, for either to be charged with a want of fidelity. We requested to speak to the gentleman in private: when he withdrew, we solicited an examination of the parts sup- posed to be so much injured, and found the prepuce and glans penis in the condition staled above. From the appearance of the penis,'we were convinced that the lady had nothing but "pruritus;" and we assured the husband that this was the case ; and upon a private conversation with the lady, we were confirmed in the opinion given to the husband; and also fortunate enough to make her suspend all farther pro- ceedings, if not entirely to satisfy her that she had nothing to apprehend, as we had previously done, with the husband. It was mutually agreed, therefore, that no farther steps should be taken in the business; in the mean time, we were to satisfy each, that they had nothing to complain of. The borax wash and injections were ordered for the wife; and for the husband, the borax wash alone. In three or four days both one and the other were perfectly well; and, to this moment, most happy in the explanation they had so fortunately received. Chambon* describes a variety of pruritus which we have never seen: it is where the neck of the uterus is the seat of the itching. As we have never met with this case, we shall employ his own description of it. " Le prurit du col de la matrice est plus intole- rable qui celui de la vulve, parce qu'on ne peut satisfaire le desir de grater cette partie. Quand il est porte a un certain degre d'in- tensil6, il cause un emportement, uneapparence de fureur, etdes movemens convulsifs, des distorsions du tronc, des gonflemens du bas ventre, et des suffocations semblables a celles qu'on remarque dans la passion hist6rique. Les femmes qui voient leurs maris dans cet etat, deviendroient furieuses, si la liqueur seminale de l'un et de l'autere ne temp6roit pas la chaleur du col de la uterus." He recommends no particular treatment for this affection; nor indeed for the other, save the most feeble that can well be ima- gined: as bathing, fumigations, and injections, together with de- coctions of some of the mucilaginous grains, as flaxseed, quince- seed, &c. Dr. Denman says, " When this complaint, independently of pregnancy, originates from an affection of the uterus, and is of • Des Maladies des Filles, vol. ii. p. 73. PRURITUS. 53 long continuance, the application must be varied, and such medi- cines given as promise relief by changing the state of that part. Sulphur, taken internally, has sometimes been of much service; or applied to the part as a powder, liniment, or lotion. The burnt sponge, with nitre, and the extractum cicutae, have also been given with advantage; together with a lotion composed of equal parts of the aqua zinci vitriolati cum camphora and rose water; or the application of the ung. hydrargyr. fort. I have also frequently given five grains of Plummer's pill every night at bed-time for a month, and a pint of the decoction of sarsaparilla daily; though there was no suspicion of any venereal infection.'"* Dr. Denman farther observes, " It is sometimes occasioned by a disease or affection of the bladder, and i3 then equivalent to the itching of the glans penis in men."—" When this complaint has been occasioned by an affection of the bladder, the constant or daily use of a bougie in the urethra has, in some cases, effectual- ly cured the patient, "f In young female children, we very often witness an inflamma- tion and swelling of the labia, accompanied by a discharge of ra- ther a purulent appearance, attended by great and frequent itch- ing. To relieve which, they rub the parts violently, and even in sleep, until they become denuded sometimes of the cuticle. This, however, I believe never happens, but where there is a great neglect of cleanliness; at least frequently washing the parts with warm water, has always cured it. Dr. Denman also says, that " those women who carry dead children are more subject to this disease than those who carry living children." This remark is not confirmed by my own ex- perience. I have known many instances, where dead children were carried, without this disease being present; and I have known a number of cases of pruritus, where the children were certainly born alive. Gardien recommends the application of blisters, in those cases of pruritus which proceed from a dartrous eruption. He says, " si ce prurit derive d'une dartre fixee vers ce lieu, on ne peut attendre de soulagement que des medicamens propres a changer l'etat de la malade, telsque les bains sulfureux, 1'usage interieur du soufre, et autres moyens adaptds a la nature de Inflection. Un vesicatoire place a la partie interne de la cuisse est souvent le * Introduction to Midwifery. Francis's ed. p. 109. f Ibid. 8 54 DISEASES OF THE VAGINA. moyen le plus sur de deliver la femme de ce prurit en deplagant la dartre: on pourrait l'appliquer sur les grandes levres memes, pour changer la mode de sensibilite de la partie en y etablissant momentanement un autre mode de douleur."—Trait6 Complete, vol. i. p. 73. CHAPTER III. OF THE DISEASES OF THE VAGINA. The diseases of the vagina may be either natural or accidental. The natural consists, 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 but one such case; and this was not so excessive, as altogether to destroy the usefulness of the part.f A great difficulty was at first expe- rienced from coition; but this gradually lessened, though never altogether removed. Upon an 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 * 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 veiy short, and had no uterus at its termination." Burns, p. 87. ■J- 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 manned 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 nevef 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 re- lieved by an operation. LEUCORRHCSA. 55 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 indica- tions 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 irri- tated them, as to produce a purulent discharge from them, which was mistaken for a venereal affection. The inflammation was sub- dued by the ordinary means, and living for a time absque mari- to: the parts were afterwards dilated by means of tents and bou- gies of various sizes. After her return to her husband, she be- came pregnant; and was safely delivered, after a slow, but not an uncommon labour. The accidental, consists of cohesions of the sides from previ- ous 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 bleed- ing seems to be the only remedy. See System of Midwifery, chap, on Tedious Labour, by the author. CHAPTER IV. OF LEUCORRHffiA. 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 opprobria medicorum. Women seem to be obnoxious to leucorrhcea 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- 56 LEUCORRHCSA. pending mischief, rather than to have been constitutionally enti- tled 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 in- fluence, or so modify common agents, as to render them capable of producing it. Thus, women of high and mountainous coun- tries, who enjoy a pure and dry air, are freer from this complaint, than those who inhabit a moist and cold climate. 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 luxurious idleness, are al- most sure to have this complaint. 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 leucorrhcea; 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 of 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 LEUCORRHCEA. 57 predisposition to the complaint, from hereditary taint, or original temperament.* 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 leucorrhcea than those who indulge in what the others cannot enjoy; provided the latter do not abuse these privileges and comforts. Women, who are constantly exposed to the abuse of venery, from their calling or their necessities; or those who may too freely indulge in the gratifications of love without that necessity; and especially those who selfishly abuse the enjoyment, are al- ways obnoxious to leucorrhcea. Those who may suffer from long-protracted and difficult labours, or who may have been under the necessity of yielding to artificial modes of delivery; those, who from the relaxation of the system generally, and the uterine in particular, and have sudden labours; those who have become debilitated from menorrhagia, diarrhoea, hemorrhoids, or who labour under irregularity, or suppression of the menses, are ever prone to this complaint. Nervous and hysterical women are also liable to this complaint: it may not commence with these affections, though it is pretty sure to follow them; especially if great irritability of temper ac- company, and this indulged in, by giving vent to sudden bursts of passion, or displays of bad humour. Some are of opinion, that the season of the year has considera- ble influence on this discharge. Leake says, "I have attended more patients labouring under fluor albus in autumn than at any other season of the year, especially when the weather was un- commonly moist and cold." Diseases of Women, vol. i. p. 107. I have never observed this influence; and I am rather disposed to believe it accidental, if it occur. A disease of such longstand- ing, as leucorrhcea almost always is; one for the most part, so * Gardien, and some others, think, leuconhoea is sometimes hereditary; he says, " Le catanhe uterin peut attaquer, des le bas Age, les filles qui ont eu pour meres des femmes sujettes habituellement a un ecoulement; mais cette leuconhee hereditaire ne peut pas etre distinguee de celle qui est entretenue par la debilite de la constitution: comme cette derniere, elle depend de l'organi- sation primitive, qui est faible et Jache." Traite Complete, &c. vol. i. p. 321. 53 LEUC0RRH03A. obstinately confirmed by local irritation and habit, is not very likely to be influenced by mere change of temperature, or mois- ture. It is not a sufficient explanation of this (perhaps assumed) fact, to say, that the surface which yields the discharge, is, like those mucous membranes which are affected by the changes of the atmosphere; and may like them, be attacked by inflamma- tion, and urged to an increase of discharge; for from their locali- ty and perfect defence against the vicissitudes of season, they cannot be ver,y liable to their influence. I fear there is rather too much refinement in these opinions, to be confirmed by fact.* The only causes, capable of influencing this discharge, as far as I have been able to ascertain, are those which affect the system at large, or the uterus in particular; such as, fever; passions or emotions of the mind; too stimulating diet; gastric irritations; the approach, and the cessation of the menstrual discharge at each period ; pregnancy; and excessive coition. Now, all the causes just enumerated, will be acknowledged capable of such a consequence, since,the whole arterial system is acted upon; and of course the uterus and vagina, constituting important portions of the general system, must partake of the general effect. I know several ladies, who are not habitually liable to fluor albus, yet will be attacked by this discharge, whenever their systems are excited by fever. Others, will have an immediate leucorrhceal discharge, when angered, alarmed, or overjoyed. Others, upon drinking a glass of wine extraordinary, or eating very highly seasoned victuals, will feel an increase of vaginal secretion; others, when their stomachs are acid, or otherwise irritated, will have fluor albus more abundantly; very many are only sensible of the existence of this disposition of the vagina, just before the catamenia are about to take place, or immediately after they have ceased. Most women, who are accustomed to leucorrhcea, will have an augmented discharge when pregnant; while some will have it at no other time; and all perhaps will have it more abundant, after too great venereal indulgence. Almost all the authorities I have consulted on the subject of • The mucous membranes very generally sympathize with impressions made upon the skin; thus, the lining of the trachea; of the nostrils; of the throat; of the frontal sinuses, &c, are very often brought into morbid action through the medium of the skin, by the changes in atmospheric temperature; but the uterus and vagina, We believe, are very rarely affected by such vicissitudes, however utrongly they may affect the external surface. LEUCORRHffiA. 59 leucorrhcea, make it a constitutional disease; and hence the nu- merous causes assigned for its origin ; and hence the multiplica- tion of species and varieties by systematic writers. Thus, Pinel enumerates— 1st. The constitutional. 2d. The accidental. 3d. The vicarious. 4th. The syphilitic. 5th. The critical.* While Blattin, who has writtin a very long and erudite work upon the subject, wishes to add to the above— 6th. From derangement of the menses. 7th. Hereditary. 8th. From indigestion. Gardien, however, makes but three— 1st. Leucorrhcea from irritation. 2d. Constitutional or adynamic. 3d. Metastatic leucorrhcea; but observes, he would think it proper to add to these three species two others, where leucor- rhcea is only symptomatic; one of these he would call " spasmodic leucorrhcea," and the other " sympathetic leucorrhcea." That a variety of causes may dispose the uterus and vagina to take on the leucorrhosal action, we have no hesitation to believe; but the production of the complaint requires an immediate ex- citing cause, and that cause must be of an irritating kind. I would therefore only acknowledge— •1st. The leucorrhcea of direct irritation. 2d. The leucorrhcea of remote or indirect irritation. 3d. The leucorrhcea of habit. I can form no idea of Pinel'^ first species ; that is, I have no conception of any separate or distinct constitutional power, which, independently of local irritation, shall produce the disease in question: or, in other words, thus to influence the mucous mem- brane of the vagina and uterus, to an inordinate secretion. His second species must necessarily comprise the exciting, or local cause: if so, it becomes the leucorrhcea of direct or indirect irritation; for the parts are only accidentally or fortuitously irri- tated, and brought into diseased action. His third, or the vicarious, we have never witnessed, if we • Diet, des Scien. Med. art. Leucorrhcea. 60 LEUCORRHCEA. comprehend the term; that is, leucorrhcea by metastasis, or by an assumption of action. Yet we are not prepared to deny the possibility of such a condition of the uterus and vagina; for me- tastases are not unfrequent in arthritic or rheumatic constitutions; or where there has been a suppression of an accustomed evacua- tion, it may happen that other parts, may assume a morbid action. But if this be admitted, it will only prove that there has been a transfer of irritation ; consequently, it forms " the leucorrhcea of irritation." His fourth, or " syphilitic," is obviously the product of irri- tation ; the syphilitic virus being the remote cause, the irritation consequent upon its application produces an increase of discharge from the surface to which it is applied; but this discharge is one of a specific nature, and not the matter discharged in common leucorrhcea; therefore, is nothing more nor less, than syphilis itself, so long as the syphilitic action continues. But after a time the surface may cease to secrete a morbid poison; though an ir- ritation of sufficient force continue to maintain an increased se- cretion ; therefore the disease, in this last form, is the leucorrhcea of direct irritation, and habit. His fifth, or "critical," may exist: we have never witnessed it; but if it occur, it must necessarily resemble his " vicarious," in its general phenomena; and, like it, becomes a leucorrhcea of irritation. Those added by Blaltin resolve themselves into the same spe- cies; or the leucorrhcea of irritation ; therefore the sixth, or that from disordered menstruation, becomes the leucorrhcea of indi- rect irritation; while the seventh is only a modification of Pi- nel's first, or constitutional leucorrhcea, which, like it, can only produce predisposition; for we do not believe that children are ever born with this disease upon them, or even subject to it very soon after birth ; and, were this even the fact, it might not be dif- ficult to account for it, provided (he mother was labouring under the affection at the time of the child's birth ; for the matter of leucorrhcea might be applied to the child in transitu, and produce the disease, as it does sometimes, purulent ophthalmia. His eighth, or " leucorrhcea from indigestion," must necessa- rily be considered a disease of sympathy, or leucorrhcea of indi- rect irritation; since the source of irritation is the disordered stomach, with which the uterus and vagina sympathize. The division of Gardien is much less exceptionable; for he LECORRHCEA. 61 reduces the species to three. His first, or the leucorrhcea of irri- tation, we cheerfully adopt, as it, strictly speaking, comprehends every thing. His second is exceptionable, as it is but a modifi- cation of Pinel and Blaltin. We have no idea of a disease of pure weakness. His third is an adoption of the third of Pinel, and, of course, liable to the same objections. In a practical point of view, very little is gained by the multi- plication of knowledge of the remote causes of disease; and it is fortunate, in a general sense, that it is so—for were an abso- lute knowledge of the remote cause essential to the cure of the proximate, or the disease itself, we should be much less success- ful in the cure, than we are at present; for, in very many in- stances, we are entirely ignorant of the remote cause. In the " leucorrhcea from derangement in the digestive organs," (if it really exist,) the knowledge of the fact might be useful; as the remedies calculated to alter the condition of these organs should be addressed to them, with a view to destroy the source of irritation, and thus diminish the intensity of sympathy. In the case under consideration, much uncertainty would exist, whether the long-continued discharge from the vagina is not the cause of the derangement of stomach, as in chlorosis, rather than the derangement of stomach, the cause of the discharge from the vagina. Gardien declares, " Le derangement des digestions ac- compagne constamment la leucorrhee constitutionnelle. Les ti- raillement d'estomac ont aussi toujours lieu dans le catarrhe uterin chronique," p. 322. But this offers no illustration, or ex- planation, of which is the cause, or which is the effect. Besides, we feel rather disposed to doubt the frequency of this combina- tion; for of one thing we are certain, that we have seen many in- stances of leucorrhcea without derangement of stomach; and we have as certainly seen many cases of dyspepsia, without leucor- rhcea. Indeed, he seems to confess, that causes are admitted with too much facility; for he immediately after adds, "Les causes predisposanteset determinantes du catarrhe uterin sont ex- trement variees: peut-etre pourrait—on reprocher aux auteurs d'en avoir admis plusieurs trop legerement, et d'avoir souvent conclu post hoc, Ergo propter hoc. Dans la recherche des causes, on a souvent regarde comme lies deux phenomenes qui n'etaient, que coexistans," p. 322. In the syphilitic leucorrhcea, as it is called, it would also be useful to know of its existence; since syphilis itself would re- 9 62 LEUCORRHCSA. quire a distinct treatment from common leucorrhcea: in this case, the disease, as just observed, would not be leucorrhcea, but sy- philis, during the active stage; but the remote effects would re- quire no specific treatment, as the leucorrhcea following syphilis, would yield to the same remedies as leucorrhcea from any other cause. • Gardien's occasional extension of species into, 1st, sympathe- tic leucorrhcea; 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 natural- ly range itself under the head of leucorrhcea, from remote or indi- rect 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 leucorrhcea 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 introduced into it; a prolapsed uterus;* tumours within the vagina; injections of too stimulating a kind; or from the simple inflammation of the parts, as every portion of the body is liable to such attacks, with- out our being able to determine why this, or that part may have been selected. We have known, in a number of instances, leu- eorrhcea to follow a lingering or tedious labour, both where in- struments may have been used, and where they were not, &c. Under the second head, or l{ the leucorrhcea 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; pro- ducing, or becoming, what is called chlorosis; as when the men- strual action is about to furnish tlue catamenial discharge; or just after that action has ceased. With the rectum, when subject to * Of this particular cause, we have had occasion to speak under the head of " Prolapsus Uteri," which see. LEUCORRHffiA. 63 hemorrhoids; 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 enumerate those instances, which continue after the active or inflammatory 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 suscepti- ble of action, may have that action to continue after it has been once excited, though the exciting cause be removed: we wit- ness it in the nervous, and muscular systems, as in chorea, hoop- ing-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 gonorrhoea, and in gleet, in the following manner. " The venereal inflammation is of such a na- ture 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 leucorrhcea: the mucous membrane of the vagina may be irritated, by a spontaneous inflammation; by mechanical agencies; by acrid substances; by morbid poisons; or perhaps by some sympathetic influence, so as to produce leucorrhcea. The irritating causes may, nevertheless, 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 leucorrhcea of long standing, is always much more difficult to overcome, than the one which is in its primitive and active con- dition. But this last species, it may be remarked, very rarely occurs, and is perhaps more common after gonorrhoea, than after any other cause. 64 LEUCORRHCEA. Gardien seems desirous to establish a species of leucorrhcea "purely local;" we have endeavoured to prove them all to be so: but in this effort he unquestionably confounds two distinct condi- tions of the mucous membrane of the vagina. He says, " The acuteftterine catarrh is a purely local affection, and depends on a peculiar irritation of the genital organs. It offers four periods in its progress; the first is announced by an itching, at first slight, of the vulva and interior of the vagina, which is occasionally ex- tended to the womb. The woman complains of a considerable heat in the vicinity of this organ ; of a feeling of dryness, which suspends immediately the secretion of the mucosities which lubri- cate the vagina, and of pains of the back and loins; the itching increases, and sometimes becomes insupportable. In some cases it augments the sexual appetite; if this disposition 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 yellowish colour, varying in intensity according to the degree of irritation; the ardor urinae becomes more fatiguing, the labia majora, the va- gina, and sometimes the urethra, show signs of inflammation. Fever sometimes ensues; the pains, at first concentrated 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 urinae 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 flocculenl, 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 " leucorrhee 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 augmen- LEUCORRHCEA. 65 tation of it, (which he considers either sympathetic or critical,) he classes under the same head, but looks upon them as consti- tutional. But a disease which he admits to be local and acute, and of which we have given his own,account, he also makes a leucorrhcea; 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 au- thors. See section on Pruritus. The discharge constituting leucorrhcea, is declared by authors to proceed from the uterus and vagina. To determine this point, 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, leucorrhcea would be li- mited 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—leucorrhcea, 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 slate, pour out the menses." From this'definilion of fluor albus, it will be perceived at once (hat 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, • All that portion of the vulva, which is anterior to the hymen in virgins, and the carunculs myrtiformes in those who are not, is called the vestibulum. 66 LEUCORRHCSA. 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 its 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." Is it 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 abundant. Is not secretion an action; and if that action produces a greater quantity of a material, than it does when it is acknowledged 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, thit 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 ves- sels 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 LEUCORRHCEA. 67 quantity, than in a state of health. Will any one declare the ves- sels of the kidneys to be in a state of weakness in diabetes, be- cause 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 errone- ous opinion; thus, Chanjbon, Denman, Leake, Vigarous, Gardien,* Capuron, Burns, &c, all talk of debility, either local or constitu- tional, as the cause of leucorrhcea. 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 ap- plied to the animals performing an uncommon or additional ac- tion, 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 Dr. Cullen; for, though we admit it to be a fact, in many in- stances, that the discharge is increased " a little before " the ap- pearance 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 vesselsof 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- * Gardien, it must be observed, has scarcely done more than give a literal U-anslation of a great part of Cullen's chapter on this subject. 68 LEUCORRHCEA. 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. * 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 pro- portion as the leucorrhcea 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 con- gestive 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, f But the assumption of Dr. Cul- len, that the menses diminish in proportion to the increase of leu- corrhcea, is contradicted by all observation ; for all writers declare, that those women who are subject to menorrhagia, are most lia- ble to leucorrhcea. Indeed, he says himself, that it often follows, or accompanies this complaint. li 4th. From the leucorrhcea continuing after the menses have entirely ceased, and with some appearance of its observing a pe- riodical recurrence." This statement appears to us to be conclusive against the Doc- tor's argument; for,if the same vessels furnished both the men- strual and leucorrhceal discharge in the early part of life, why * 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 in- creased by any irritations applied to the uterus." f 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 surfaces, be these discharges sanguineous, serous, or purulent, or wherever situated. LEUCORRHOCEA. 69 should these vessels be unable to furnish the menses in the latter part, if they are still as capable as formerly, of throwing out the discharge of fluor albus? It must, however, be remembered, that leucorrhcea is by no means so common after the cessation of the menses as before, unless there is some organic lesion of either the uterus or vagina; and when this is the case, every body seems to agree, that this discharge should not be considered as a genuine leucorrhcea. 5th. From the leucorrhcea being accompanied with the ef- fects of the menorrhagia."* This is a most hasty and ill-founded conclusion; for hemor- rhoids, a diseased liver, or diseased viscera of any kind; a sore leg, &c. &c, will have, after a certain time, almost every symp- tom described by Dr. Cullen, as belonging to menorrhagia. "6th. From the discharge having been neither preceded by, nor accompanied with, symptoms of any topical affections of the uterus." Now, if this prove any thing, it should be the reverse of what Dr. Cullen seems to insist on, namely, that leucorrhcea " pro- ceeds from the same vessels, which, in their natural state, pour out the menses;" for how a want of evidence, of " topical affec- tions of the uterus," should prove the indentity of the vessels which furnish at one time the menses, at another the matter of fluor albus, is really beyond our comprehension. His seventh argument we shall not notice, as it has not the slightest bearing upon the subject. I have never been perfectly satisfied, but in three or four in- • stances, of the very many cases of leucorrhcea which-have been under my care, that the discharge in question proceeded from • "When, in consequence of the circumstances, and the repetition of them, (the too frequent, and too abundant menses,) the face becomes pale; the pulse grows weak; an unusual debility is felt in exercise; when, also, the back becomes pained from any continuance in an erect posture; when the extremities become frequently cold; and when, in the evening, the feet appear affected with (Edema- tous swellings; we may, from these symptoms, certainly conclude, that the flow of the menses has been inmoderate, and has already induced a dangerous state of debility." First Lines, par. 972. ** The debility thus induced, does often discover itself also by the affections of the stomach, anorexia, and other symptoms of dyspepsia; by a palpitation of the heart, and frequent faintness; by a weakness of mind liable to strong emotions from slight causes, especially when suddenly presented." Par. 973. 10 70 LEUC0RRH003A. the cavity of the uterus.* In all these cases, the following pecu- liarities were present. 1st. During the night, there would be no discharge whatever; but upon rising, there would be a very abun- dant one, of a glairy, tenacious substance ; sometimes mixed with . some of a purulent appcarance.f 2d. That during the day, when it did escape, it was always suddenly, and accompanied by a sen- sation of effort within. 3d. That when a piece of sponge was introduced into the vagina at night, with a view of determining the point, it was never found filled with the kind of matter, that would very quickly issue when this was removed. 4th. All these cases I found to be incurable, though capable of some relief. 5th. All these women were barren. These considerations make us believe, that fluor albus has its seat, for the most part, in the vagina. We believe, farther, that it is almost always local; but from the excess of quantity, or pe- culiarity of quality, the system frequently becomes involved. Mr. Clarke says, " The constitution is rarely affected in this dis- ease: the action of the heart and arteries is not increased, and the functions of health are seldom interrupted." Vol. ii. p. 14. This statement is in entire conformity with my own experience, as far as regards the first, and sometimes the second stage, that I make of this complaint, as I shall observe presently; but in the third, the system suffers, in a greater or less degree, the same alterations which any long-continued irritation or excessive dis- charges of any kind produce upon it. The quantity of the dis- charge will almost necessarily determine in what degree the sys- tem at large suffers, or at least when this complaint is idiopathic; • It will be seen, that I am not disposed to deny altogether, that leucorrhcea may occasionally have its seat in the uterus; I only wish to be understood, that 1 do not by any means think it as common as authors would lead us to suppose, i Morgagni tells us expressly, he pressed from the orifice of the uterus a matter resembling that which the woman was wont to render from the vagina while living. But he also tells us of an instance, in which the matter was confined to the vagina alone; and which, he expressly states, had no higher origin than the vagina. Epist. xvi. art. 47. | "The uterus is lined throughout with a mucous membrane;" the "secretion from this membrane is permanent;" the mucus secreted by this membrane " re- sembles, in consistence and appearance, the uncoagulated white of an etrtr and does not differ from mucus in other parts of the body." (a) (a) •' According to the experiment* of Mr. William Brandc, mucus consists of albumen and soda."—Clarke on the Diseases of Females, vol. i. p. 15—Am. Eu. LEUCORRH0EA. 71 and such it almost always is. But when this discharge is purely sympathetic, the disease, of which it may be merely an anoma-. lous symptom, must, in great measure, determine the degree of injury the system may sustain—as in cases of ascarides; hemor- rhoids; prolapsus uteri, &c. &c, though it will be evident, that the two diseases will deteriorate the constitution faster, than ei- ther would alone. But whether this discharge proceed from the uterus or vagina, or both, it is evidently maintained by some local, or, perhaps, specific irritation; but of the nature of which I am not prepared to decide; but its influence is evidently spent upon the vaginal lacunae, or glands, which, in a state of health, furnish the mois- ture so important to this part. In my present consideration of this subject, I would wish to be understood, not to include the discharge, which is symptomatic of some derangement of the proper substance of the uterus, or that which always accompanies a prolapsus of this organ: these will be treated of under their re- spective heads. The idiopathic forms of this disease may be divided into three stages; each of which requires a little difference of management; in the first, or most simple form, the matter discharged is glairy and transparent; or resembling a thin starch made by boiling: this, from its tenacity, very often accumulates in considerable quantity within the vagina, and is suddenly discharged, from time to time, either by its own weight, or from some sudden exertion of the woman; especially, upon stooping, or lifting a weight—this never becomes acrid, unless there is the most repre- hensible neglect of cleanliness; nor, so far as I have observed, is the sanguiferous system generally implicated, though it may take place occasionally in women constitutionally plethoric, or very feeble, and where it is easy to suppose it might be called into ac- tion by a trifling irritation. But the irritation, or inflammation, which provokes this increase of discharge from these parts, is in common so local, and so mild, as to exert no influence whatever upon the general system. But this is not always so, as we have • just admitted; especially, if the system be easily brought into sympathy from local irritations: in this case, as we shall observe presently, the sanguiferous system will be found disturbed. It is probable, that this peculiar mucus may be furnished by the neck of the uterus alone; and, therefore, this first stage may consist of the inflammation of this part; since, agreeably to Mr. 72 LEUCORRHOSA. Clarke, this part yields a fluid differing, at least in sensible qua- lities, from that found upon the surface of the vagina. He in- forms us, that " the mucus secreted by the glands of the neck of the uterus, contains less water than any other mucus in the body, , approaching nearer to the nature of a solid than that of a fluid body; it is semi-transparent, and possessed of great tenacity; it adheres to the fingers like bird lime." " These glands, (of the neck of the uterus,) in a state of health, perform the office of secretion in pregnancy only; or if at any other time, the matter secreted is of a ^ery different kind, so resembling common mu- cus, as not to be distinguished from it." Clarke, vol. i. p. 17. In the stage now under consideration,* (namely, the first,) we sometimes find the discharge vary from time to time, without the 1 woman being able to account for the difference of appearance: but these changes must have causes, however occult they may be: I think I have almost always traced them to some impru- dence on the part of the patient; for, though the complaint is \ confessedly a troublesome one, it does not always challenge the attention of those labouring under it, sufficiently to secure their best aid in getting well of it—hence, errors in diet will be com- mitted; costiveness permitted for a long time together; cleanli- ness will oftentimes be neglected; over-exertions will be made, or a series of fatiguing duties will be submitted to, all of which will have more or less influence upon the parts concerned in the production of this discharge. During the attempt to cure this complaint, every thing capable • It has been thought by some, that the difference in the appearance of the discharges in leucorrhcea, and from which we derive the stages into which we have divided this complaint, did not indicate the degree, or the inveteracy of it; but rather determined the part of the genital system which furnished it, or the specific nature of the inflammation that produced the matter discharged. Thus, Chambon f thinks, when the discharge is green, that it proceeds from " une dis- position prochaine au scorbut, qui ont un vice dartreux ancien, ou scrophuleux ou eresipelateux." But the various shades of colour which this discharge assumes, only manifest the intensity of the irritation. Notwithstanding, we have divided the complaint into three stages, because, in general, when left to itself, it goes regularly through them, yet the force of the irritating cause may be so very great, as to make the first discharge observed by the woman, of the quality of the third stage. We have seen this in a number of instances; but we think it has almost always happened after some severe mechanical injury done to the vagina; hence, it is more frequent after severe labours. t Vol. ii.p. us. LEUC0RRHG3A. 73 of increasing it should be carefully avoided; and the female will find her best interests involved in the most strict conformity to the physician's directions for this purpose. While, on the other hand, the physician will find it best to be very particular in his inquiries respecting the quantity and the appearance of the dis- charge, as he can only prescribe with certainty and effect, while his attention is directed to these points. It is but by the uniform, or varying appearances of the discharge, that he can determine the actual state of this disease; whether his remedies are acting according to his intentions, or that he can be led to suspect a want of fidelity to her own health, on the part of the patient. It is possible that the inflammation, (or perhaps only a form of it,) which gives rise to the first stage of fluor albus, may be con- fined to the neck of the uterus alone for a considerable length of time; but if it be suffered to remain unheeded, it will sooner or later, and in different degrees, involve the surface of the vagina. Or the inflammation may suffer various degrees of intensity, while its location is confined to its original seat, namely, the neck of the uterus. It may look like a gratuitous assumption to those who make leucorrhcea consist solely in a " weakness " of the uterus and va- gina, to declare, that in the first stage of this complaint, an in- flammation really exists in the neck of this organ. But such is the fact; at least so far as certain phenomena, without the aid of ocular demonstration, will warrant such a conclusion. In the first place, it seems that the quality of the natural secretion of this part is altered;* for from being of extreme tenacity, and conside- rable density, it becomes less tenacious, transparent, and thinner; in the second, that still farther changes can be imposed upon the discharge by such causes as are calculated to augment the gene- ral action of the system, or to increase local determination;! in • It has just been declared above, that the natural secretion of the neck of the uterus, was " semitransparent, and of great tenacity, adhering to the fingers 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 resembles, in consistence, a mixture of starch and water made without heat, 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. ■j- An attack of fever, high living, excess of venery, exercise carried.to fatigue, intemperance in drinking, over-stimulating injections, excessive costiveness, an 7-1 LEUCORRnCSA. the third place, when this part is touched, and even this not rudely, pain is invariably produced;* in the fourth place, that parts both adjacent and remote are frequently brought into sym- pathy from this condition of the neck of the uterus,t and in the fifth place, the remedies found most effectual for the removal of the complaint, are opposite in quality to those which would be employed, did the discharge in fluor albus depend upon weak- ness, x Method of Cure of the first Stage of Leucorrhcea. The cure should be commenced, by directing the parts to be regularly washed with warm water, three or four times a day — if the patient be plethoric, I cause her to be well purged; confine her to milk and vegetable diet; and sometimes order her to lose blood§—when the pulse is sufficiently reduced by these means, or if the pulse be in a proper condition without them, I exhibit the tincture of cantharides; of this I direct thirty drops every morning, noon, and evening, in a little sugar and water; increasing the dose every third day, five drops at a time, until strangury|| attack of hemorrhoids, and approach of the menstrual period, will each occa- sionally 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. \ 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 in- cautious 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 Fe- males, vol. i. p. 300. It will be seen, that we acknowledge but the first of these as an original dis- ease; and that when the inflammatory stage is subdued, and the discharge con- tinues, it then becomes " the leucorrhcea of habit;" which almost always takes place before the cure is completed. § It may be well to observe, that a strict antiphlogistic plan is constantly pur- sued during the cure of either stage of this complaint, until we are assured the discharge is maintained by habit. 11 always direct my patient to desist from the use of the tincture, as soon as she feels the approach of strangury, and not to resume it until all uneasiness dis- LEUC0RRHC2A. 75 is produced, unless the disease is arrested, which is not unfre- quently the case before this symptom appears. Should the com- plaint withstand the first strangury, I am not discouraged, but recommence the tincture at the original dose of thirty drops, and increase it as before, until a difficulty in making water is again experienced—it rarely, however, withstands the second irritation of the bladder. Astringent injections are employed as soon as a change is ob- served in the discharge; that is, by its becoming thinner and more abundant, but never until then, should this require three or four stranguries to effect it. The best kind of astringent in- jections, are the acetate of zinc, in the proportion of five or six grains to the ounce of water, or the sulphate of copper in solu- tion, in the proportion of a scruple to half a drachm to eight ounces of water; either of these may be employed three times a day, taking care to wash out the vagina with soap and water pre- viously. During the treatment of leucorrhcea, too little attention is com- monly paid to cleanliness; if this necessary act be neglected as reprehensibly as it generally is, very little good will be derived from the prosecution of the best plan of cure. On this account, we importunately urge the compliance with the direction, of fre- quent washings with warm water, as well as the cleansing of the vagina, by throwing up it several syringes-full of warm soap suds; especially before the injections, intended immediately for the complaint, are administered. By this plan, two important objects are gained; first, the matter occupying the vagina, is re- moved, frequently; and thus is prevented all the injuries that might arise from its stagnation; secondly, the surface of the vagi- na is deterged by this means, and the medicated injections have full opportunity to exert their influence upon the inflamed sur- face that furnishes the discharge. It is also difficult to secure compliance, as regards diet and appears. If the strangury be severe, the free use of flax-seed tea, barley water, or gum Arabic water is directed—to take five and thirty drops of laudanum, and go to bed. Should this not succeed, an enema of a gill of thin starch, a tea- spoonful of laudanum, and thirty grains of finely powdered camphor must be given—so far as I recollect, this enema has never failed. It may also be proper to mention, that the tincture of cantliarides I employ, is fifty per cent, stronger than the ordinary tincture of the shops; or, in other words, where they use two drachms, I use three for making the tinctiu-e. 76 LEUCORRHOEA. drinks—the patient, her friends, and, perhaps, the physician, de- clare the disease to be a disease of " weakness;" one, which re- quires tonic and stimulating remedies for its cure; hence, the most stimulating and nutritious articles of diet, are generally had recourse to, to the manifest injury of the patient. We have never witnessed an instance of the first stage of this complaint, attended by such a degree of debility as would require either tonics, or animal diet for its relief. Mr. Clarke has fallen into an error upon this subject, at which we are not a little sur- prised; especially, as his general view of the disease is correct and well founded. He says, " The food should be of the lightest kind, such as animal broths and jellies; vegetable jellies, bread properly fer- mented and well baked."* This selection of food seems in direct variance with his opinions of the complaint, for he has declared ! the neck of the womb to be in a state of inflammation; and has also said, that " if this disease arises from inflammatory action, this must be removed before any endeavour to restrain it is em- ployed; for as the discharge during its continuance lessens the disease which occasioned it, it should not be checked until such inflammatory action is diminished."! Yet he advises "animal broths and jellies" during the inflammatory stage of this com- plaint; than which nothing can be more contradictory. He appears, however, to look upon the modifications of animal substances to do away their specific nutritive and stimulating qualities; for in the very paragraph in which he advises the use of " animal broths and jellies," he tells us, "it will be better that the patient should not eat solid animal food until the powers of the stomach are, in some degree, restored." Now, it is very well ascertained that the stomach will almost always better assimilate small quantities of solid animal food, than the preparations he has recommended. Butil when the powers of the digestive organs T become more vigorous, recourse may be had to animal food;" and this is not all, for he also says, " Wine, either pure or mixed with water, as may best suit the palate or the stomach, may be allowed in moderate quantities.''^ The medical treatment con- sists of the exhibition of the various tonics, both vegetable and mineral. We are not acquainted with the agency that a difference of climate, constitution, and mode of life may have, to render • Vol. I. p. 316. t Vol. I. p. 34. * Ibid. p. 16. LEUC0RRHC3A. 77 the above plan successful in the part of the world in which Mr. Clarke resides; but certain it is, we could not succeed with such treatment in this country, even in those cases, where debility might appear to be the most certain of the causes, which pro- duced the disease in question. It is true, that the view Mr. Clarke has taken of this complaint, in the instances for which the above plan is recommended, would certainly justify the treatment recommended, were it a true one; namely, that it is a disease of " weakness;" but this character of the disease, is_the debateable point; and here we are unfortu- nately at issue—he believes in the existence of the complaint from "weakness;" we declare, that until it becomes the " leucorrhcea of habit," local inflammation is always present; and that with this state of the neck of the uterus, the system at large sometimes sympathizes so much as to require strict attention to be paid to its condition; and that this condition requires, for some time, depletion, and an antiphlogistic regimen. But notwithstanding this, we will not say that Mr. Clarke has not met with cases to justify the mode of treatment he recommends; we mean merely to insist, that we have never met with a case, where the anti- phlogistic plan was not necessary, when there was evidence of this inflamed condition of the neck of the uterus. But what is still more surprising, Mr. Clarke declares in ano- ther part of his work,* that " in ordinary cases, the most suc- cessful mode of treatment is to take away some blood, either by cupping or by leeches applied to the groin or to the back; and it may be necessary to repeat the local bleedings several times. If sympathetic fever be present, it will be prudent to open a large vessel, but this is seldom necessary, and all useful purposes are answered by local blood-letting." It may not be thought amiss, to repeat that where there is evi- dence of this condition of the neck of the uterus, it must be met by blood-letting, purging, and low diet. It must, however, be admitted that the degree of inflammation is rarely so high as to require a repetition of blood-letting, either general or topical. The low-seated pain at the very bottom of the back, pain within the vagina upon sitting down, together with a somewhat severe irritation about the neck of the bladder, with frequent desire to make water, though very strongly characterizing the disease in a certain stage, are but rarely met with. * Vol. II. p. 24. 11 78 LEUCORRHCEA. It is a circumstance worthy of remark, and one every way cal- culated to confirm the correctness of the pathology adopted of this complaint, that the discharge successively alters its character as the disease diminishes by the successful application of the re- medial means. For as the pain and inflammation abate, the dis- charge becomes thinner and more transparent, and if the cantlia- rides have been successful, nothing but the natural discharge of the part is discovered to issue from the vagina. In this stage of the complaint, medicated injections are not al- ways necessary; for after the system will bear with profit the tinctura ly Use, it for the most part soon puts a stop to the discharge. Should the discharge, however, be copious and obstinate, after it has become thinner, it is best to aid the cure by injections, pro- vided it is not a young girl that is the subject of the complaint; or should the discharge resume its late appearance, the system must again be acted upon by blood-letting, or a few repetitions of smart purging. Exercise of a very moderate kind may be indulged in, but fa- tigue should always be very carefully avoided ; passions or emo- tions of the mind should be guarded against, and venery very little indulged in. .A In the second stage, the matter discharged has a white, yel- -Jfl lowish, or purulent appearance—it is usually more abundant J than in the first stage; and is constantly leaving the vagina by a uniform stillicidium. If proper attention be not paid to cleanli- J ness, it may become offensive, or may even excoriate—this state is almost always accompanied with pain in the back, hips, and. in the region of the pubes; the woman's complexion is generally sallow; and when the discharge is excessive, she becomes sub- ject to a train of nervous symptoms, which are both troublesome to the patient, and difficult of management to the physician. This stage consists of an extension of the inflammation with which the first stage commenced; it has now spread to the vagina, the sur- face of which at this time principally furnishes the fluid that is discharged. The character of the fluor is also changed; it is now of a deep white, or yellowish colour, resembling thick cream that has stood some time. The system is almost always distinctly involved in this second. stage; for if the pulse be carefully examined, it will be found hard, wiry, and irritated—in this stage, as in the former, the most scrupulous attention to cleanliness is recommended__I purge LEUC0RRHC3A. 79 most commonly; confine the patient to a vegetable diet; and sometimes bleed—I am sure, that in every stage of fluor albus, time is always saved, as well as a material point gained, by a brisk catharsis in the commencement of the curative plan; it should therefore never be neglected. When the pulse is in a proper state to bear the tincture of cantharides, it is to be exhi- bited as above directed; subject to the same restrictions and dis- tinctions, but with this difference, that we may commence ad- vantageously, in proper subjects, with injections; but they should be of the sedative kind; a weak solution of the acetate of lead is perhaps the best :* tjiis may be used several times a day, preceded by the soap and water, as just mentioned. In the third stage, there is an aggravation of all the symptoms of the second; the discharge is of a greenish colour, and is fre- quently tinged with blood—I consider both the last forms but exalted degrees of the first; that is, the inflammation is greater in their numerical order; in the last, therefore, we have more to contend with than in the second; and more in the second than in the first. It seems that this complaint, when neglected, is apt to run spontaneously through all these changes, and is truly one of the diseases which rarely cures itself. These changes are more certain and strongly marked in women who are a little advanced in life, than in younger subjects; and especially with those who have borne many childrenTafid who are inattentive to cleanli- ness; and in such, it is also more difficult to remove. It is thought by many that there is a risk in stopping this com- plaint too suddenly; indeed, almost all the writers upon this sub- ject may be considered as of this opinion. Yet our experience goes to prove that its effects upon the constitution are such as to render its cure a most desirable thing; for it not only does in- jury to the woman, but also to her offspring. The latter, indeed, are seldom other than puny, and not unfrequently die in early infancy. But it is not very strange, that the notion that there is danger in curing leucorrhcea should exist, since it is commonly thought to be critical or sympathetic. From an experience in many hundred cases, we have never known the slightest incon- venience to arise from the cure of this complaint; nor is it pro- bable that any can arise, however inveterate the disease may have been; and for this plain reason—that in proportion to the dura- • The solution of the sugar of lead, should not exceed a scruple to eight ounces of water. 80 leucorrhoza. tion of the disease, will be the difficulty of arresting it; and, agreeably to our own experience, this is effected always gradu- ally; for it requires great perseverance to produce a change in the quantity discharged; the system becomes, in consequence, in every respect prepared for the change. So much is this the case, that we have never seen an instance of the sudden stopping of leucorrhcea when this complaint was of long standing; and in re- cent cases, nothing is to be apprehended from a speedy arrest of the complaint. But, as regards the cure, the same general direc- tions are applicable to all the stages. Nothing can compensate for the neglect of cleanliness—this must, therefore, be insisted on ; the bowels must be purged ; and as the system is more frequently, and extensively implicated in this, than in the former stages, we are oftener obliged to bleed, and to enforce a strict observance of a vegetable and milk diet. We may, as in the second stage, where the subject will permit, commence with the injections of a weak solution of the acetate of lead; then perseveringly employ the cantharides—in using it in this stage, I depart from the me- thod just recommended, if the disease be of long standing, by more gradually increasing the dose, or making the intervals of in- crease two or three days longer. My reasons for this is, that the system may not too suddenly be affected by it; for I have observed, that when strangury is hastily induced, the effects are neither so satisfactory, nor so permanent, as when more slowly brought on —I may, however, remark in general, that the more susceptible the system is of the influence of this medicine in moderate doses, the more easily the cure is accomplished. In this stage, as on the other occasions, I do not use the astrin- gent injections until the sign for their employment shows itself; that is, an increase and thinning of the discharge. Even the first injections of this kind should be rather more feeble than those formerly directed; but the strength must be increased as the parts become more accustomed to them. I go on, again and again, to renew the strangury, should the first not be sufficient. Nor am I discouraged, if the complaint does not yield to several; for I am very rarely disappointed in the opera- tion of this medicine, when sufficiently persevered in. I confess, however, that I have occasionally found the cantha- rides unsuccessful; but cannot this most truly be said of every known remedy? I have now and then succeeded with the balsam copaiva, after the other has been fully tried without advantage; LEUC0RRH03A. 81 and I have also effected cures in some obstinate cases, by the use of alum and nitre—five grains of alum and ten of nitre, given three times a day, have proved very successful after other reme- dies have failed. In a late work, (1830,) on the subject of Leucorrhcea, by Mr. Jewell, the solution of the nitrate of silver, applied to the neck of the uterus and vagina, by means of a piece of sponge, canula, or syringe, is highly spoken of. He commences with a solution of two or three grains to the ounce of water, and gradually in- creases it to four or five grains, as the parts become accustomed to its action. It is to be used three times a day, unless it produce too much pain—in which case it is to be reduced in strength, or wait until the irritation cease. In the use of this remedy, care must be taken to guard against its stain, which is indelible. This will be best obviated by the patient guarding herself as if she were labouring under a catame- nial period; or by wearing, during its use, black muslin or calico shifts. The sponge appears to be the least exceptionable mode of using this solution; this is done by saturating a piece of this sub- stance, of sufficient size to be retained after being well imbued, with the solution—this is to be renewed three times a day. Or the curved pipe syringe may be employed three or four times a day, unless it irritates too much—a sensation of warmth after its use is rather to be coveted. He appears to have ill-founded prejudices against the employ- ment of cantharides. He also recommends the tincture of iodine in small doses; but he has not produced any indisputable evi- dence that it has been useful. He appears to have adopted all the principles and opinions contained in this chapter, and though he makes respectful mention of the author, he gives him no credit for his opinions upon this disease, though all his distinctions, and plans of cure, are identical with those contained in this chapter. Mr. Graham recommends the sulphate of zinc in this disease— three grains of the sulphate made up with common turpentine, three times a day; the dose to be increased if necessary. Edinb. Med. and Surg. Journ. vol. 26. The discharge which attends the prolapsus uteri is owing alto- gether, or at least in great part, to the mechanical irritation the surface of the vagina suffers, from this displaced organ, and does not come under our present consideration. The leucorrhcea of habit, is sometimes more obstinate than any other form of this complaint; especially if it be of very long 82 HISTORY OP MENSTRUATION. standing, and in persons beyond the middle period of life, and who are inattentive to cleanliness. It will, however, yield, for the most part, to the remedies already mentioned, if sufficiently persevered in; though it may require the exciting of strangury rather oftener. I have, in a few instances of this kind, used an injection made of two grains of corrosive sublimate to an ounce of water, with great advantage. It should be used but once a day, for the first two or three days; then twice a day for an equal period ; and then three times a day, until heat or other signs of irritation be perceived, unless it has been previously excited. This irritation must be kept up for a week or ten days; it may then be followed by the saturnine injections.* Leucorrhcea proceeding from hemorrhoids, I believe will admit of no relief, until the latter complaint be removed. The same may he said of the leucorrhcea arising from ascarides: this con- dition of the vagina, however, is chiefly confined to children. CHAPTER V. OF THE HISTORY OF MENSTRUATION. The diseases connected with menstruation are so important, that I have thought it best to premise them with a general his- tory of this process, that the deviations from health should be seen in stronger contrast, as well as better understood. The menstrual discharge may, with much propriety, be con- sidered as peculiar to the human female; if there be exceptions to this rule, they are few, and but ill ascertained.! We are told that the female of a certain species of monkey is liable to it; but, perhaps, in no other way than the bitch, the cow, the mare, the female elephant, &c, are said to be; for these, in the time of heat, have sometimes a sanguineous discharge from the vagina. • The secale cornutum is recommended with great confidence in leucorrhcta, and also in gonorrhoea, both by Dr. Negri and Dr. Ryan. About five grains, three times a day, is the average dose in these cases: they recommend its suspension, if it excite much pain. Of its utility, in such cases, we can say nothing from our own experience. See London Med. Journ. for 1834. f " De tous les etres vivans, la femme seule eprouve pferiodiquement une eva- cuation sanguine naturelle, et independante d'aucune alteration pathologique."__ Frank. HISTORY OF MENSTRUATION. 83 But this must not be considered as a genuine menstrual evacua- tion, as it proceeds merely from the rupture or abrasion, of some small vessel, during the excessive engorgement that is wont to take place in the vaginae of these animals at such times. Be- sides, no moral end could be answered in the brute, as in the hu- man female, by such a discharge. Indeed, some would deny the menstrual discharge to be an original function, even in the human female, as Roussel, and after him Emmet; that this evacuation is the result of the social condi- tion of man, and not the consequence of organization. Roussel has endeavoured to prove this, by declaring that man, in a state of society, feeds more than is absolutely necessary for his exigen- cies ; and that he becomes plethoric in consequence; and that this condition must be relieved by some artificial drain; in the male, by hemorrhage from some part or other of the body; and, in the female, by the menstrual discharge. He declares, " Que le flux mcnstruel, bien loin d'etre une in- stitution naturelle, est au contraire un besoin factice contracte dans Vetat social."* But, it may be asked, what is to be under- stood by " l'etat social?" If it be declared, it does not express the condition of man in a state of refinement, it must be admit- ted to mean, man united by some social compact: yet, so far, wherever he has been found, we have unquestionable proof that women menstruate; notwithstanding Roussel declares, that the uterus of the Brazilian woman does not perform this function. But, were this true with these particular women, (a circum- stance much to be doubted,) it would be but an exception, and should not be taken, or rather mistaken, for the rule. Among all the aboriginal females of this country hitherto examined, no such exception prevails: yet, were this a design of nature, it might most reasonably be looked for, among these varied, widely spread, and simple people. Why this opinion of Roussel should have found abettors, it is difficult to say; since it has neither facts nor reasoning to sus- tain it. The hypothesis is founded upon circumstances totally inadequate to the effect—namely, " Les hommes rassembles ont toujours cherche a resserrer les liens de la cordiality dans les fes- tins. La joie est plus vive, et les epanchmens plus tendres dans ces momens ou la machine se remonte par une nouvelle nourri- • Systeme Physique et Morale de la Femme, p. 113. 84 HISTORY OF MENSTRUATION. ture: on est alors plus content des autrcs parcequ'on est plus content de soi meme; 1'abscnce de soucis laissc alors a la nature la liberie de jouir de tous ses droits, et meme d'cn abuser; car il arrive souvent que, ne demelant plus la sensation des mets d'avec l'impression de la gaite, elle prend le change, et se surcharge d'alimcnsqu'elle croit encore necessaires, longtemps apresque le besoin est satisfait."* The consequence of these indulgences, he supposes to be a plethora; and this plethora finds an abatement in the female by the menstrual discharge; and in the male, by hemorrhages from various parts of the body, according to the period of life; or if the hemorrhages do not take place, the consequences of the ex- cess of blood show themselves in a variety of other forms; as af- fections of the chest, rheumatism, hypochondriasm, stone, gout, asthma, &c. &c. It will be perceived, that this doctrine is but a modification of the one long before promulgated by Galen—the only difference is, that Galen thought women were ever subject to the menstrual discharge; and that a plethoric condition of the system was es- sential to its production: while Roussel supposes this plethora to be of artificial origin; and that the menstrual discharge is the fortuitous consequence, and intended to relieve the system from danger. A few observations will be sufficient to destroy this curious and ill-established speculation. 1st. From no record of the his- tory of the human race, does it appear other than, that the fe- male was always obnoxious to this discharge—thus, by Moses, it is distinctly stated to have obtained among the women of his time, and we have every reason to believe, as an arrangement of nature; so also among all the tribes of the most savage people. In this country, most abundant proof is given, in the journeys of Major Long, that the menstrual evacuation is a constant attend- ant on the females, and where they existed in the greatest possible simplicity. 2d. The cause assigned by Roussel, namely, " ple- thora," exists where this discharge has been interrupted ; and to recall the means often requires the abstraction of blood and other debilitating remedies. 3d. This function is oftentimes per- formed with the utmost regularity, and in the accustomed quan- tity, where the most decided debility prevails. 4tb. That this * Systeme Physique et Morale de la Femme, p. 113. HISTORY OF MENSTRUATION. 85 discharge is certainly prevented, however long and regularly it may have been established, by the removal of, or from the dis- eased condition of the ovaries. 5th. That an abstraction of blood just before the period, or at any other time, does not pre- vent it. Besides, very many, indeed all the mammiferous animals, have, at certain periods, a discharge from the vagina, which is either essential to fecundation, or gives evidence of the capacity for, or of the desire of, the animal at that moment to be impregnated; and this discharge is sometimes coloured, accidentally, as ob- served above, but not necessarily; and that this evacuation is, in some manner, connected with impregnation, is evident, since it never appears in its healthy condition, but at the periods when the animal is capable of fecundation.* Now, it is equally cer- tain that the human female is also capable of being impregnated after each healthy menstrual period. Nor is this discharge in the brute, a mere increase of quantity of the ordinary secretion of the parts—it differs essentially from it, at least in its sensible qualities; as is made evident to the dis- criminating olfactories of the male. Thus, it would appear, that nature intended some end should be answered by this peculiar condition of even the brute; is it not, then, equally certain, a si- milar end is answered in the human female, by the menstrual evacuation ? Again, this discharge commences only when the female is in a condition to meet and overcome the ordinary contingencies of * Frank appears to be of a different opinion upon this point; he says that •'nature has subjected the females of all well-organized animals to this menstrual tribute, but that she does not always require it with the same rigour; that is, un- der the penalty of sterility." Now, we think Dr. F. has assumed rather too much in his hypothesis; first, because there are steril animals, and we believe they are only so in the absence of this sign of coalescence; for it is constantly the practice of breeders of animals, to wait for an evidence of heat before they are subjected to the male; secondly, because it is notorious that animals do not conceive if put to die male, or entirely refuse him, if this modification of the menses be not pre- sent; thirdly, he is certainly of opinion, from his own words, that it is, for the most part, an essential to generation; and, therefore, must, as a general rule, have been intended for this purpose; and, consequently, if impregnation do take place, and this discharge be absent, it is only an exception to the rule with such animal, and, in this respect, is like the human female; for he declares that this has taken place in females so circumstanced, and, therefore, is as much a law with the one, as with the other. 12 8C HISTORY OF MENSTRUATION. impregnation and delivery.* Now, were this merely a fortuitous discharge, why should it occur only at the period at which the female can propagate her species, and always at a certain period of female life? For I must protest against the opinion of Rous- sel and some others, who suppose impregnation may take place, before the menstrual action has been awakened, or after it has become dormant.f That impregnation has taken place before there was a coloured discharge from the vagina, and even after it has ceased, I am every way willing to admit: but neither of these circumstances prove the absence of the menstrual action; or that action which only exists during the integrity of the ovaria; but which ceases, or never takes place, when these bodies are imperfect; and which action is essential, either directly, or indirectly, to impregnation. RousselJ declares menstruation to be " less a cause than a sign of fecundity." In this I agree: for the menstrual action cannot be a cause of fecundity, since this capacity is known to depend upon the ovaria. Yet it is every way essential to propagation, that the internal secreting surface of the uterus be in a healthy condition, and this manifested by a healthful catamenial dis-, charge; or, in other words, only when the quantity and quality of the menses are free from objection, and the ovaries, at the same time, in perfect health. It may, therefore, be considered as highly probable, that the absence of the capacity to be impregnated, will sometimes de- • Mr. Bourne, a respectable and intelligent South Sea missionary, when asked by Mr. Roberton, " Have you observed that early marriages (giving the ages at which they occur) are generally soon productive?" answered, that in very early marriages several years elapsed. In this Mr. Ellis, the celebrated missionary, concurred.—Mr. Roberton on Menstruation, Edinburgh Medical and Chirurgical Journal, for October, 1832. This would seem to prove the position laid down in the text. For it was long since observed by Mr. John Hunter, that "when a woman begins to breed at an early period, as at fifteen, and has her children fast, she seldom breeds longer than thirty or thirty-five; hence, we may suppose either that the parts are then worn out, or that the breeding constitution is over. If a woman begins older, aa at twenty or twenty-five, she may continue to breed to the age of forty or more." —Phil. Trans, vol. Ixxvii. p. 233. f 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. HISTORY OF MENSTRUATION. 87 pend upon the imperfect condition of either the uterus itself, or of the ovaries. If the former, it may consist in some derange- ment of the secreting surface of this organ ; for, though there may be a regular discharge of a coloured fluid, and this so nearly re- sembling the perfect secretion as to deceive the senses, it may yet want an essential condition or quality, and thus entail barren- ness—hence, all women are not fruitful who may have a regular catamenial discharge; though, as far as can be determined by appearances, this discharge is every way healthy, and, at the same time, the ovaries free from fault. Nor is it, perhaps, difficult to explain, or rather to imagine, how .this may happen. I adopt the opinion that the menstrual dis- charge is a genuine secretion, and that the internal face or lining of this organ is the portion which furnishes it: now, it will be evi- dent, that whenever this part is in any way deranged, the quality of its product must also be impaired; but the injury does not con- sist so much in the imperfect elaboration of the menstrual fluid, as in the inability of this surface to furnish a healthy decidua 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 unper- ceived 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 pow- ers 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 secreting surface of the uterus ; the catamenial discharge may, therefore, 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. 88 HISTORY OF MENSTRUATION. Yet it may be safely admitted, as a general rule, that women who menstruate regularly without pain, or the expulsion ol co- agula, 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 aitach 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. 1 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- ing 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 nature, or from disease, she either never becomes impregnated) or ceases to become so, if she ever have 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,* as well as after their final cessation. Tht explanation of this seeming exception is not difficult, for the rea- son already assigned; namely, that becau.se 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. Now, it is admitted by practical writer.vf 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 this process. This is especially the case with those, who have this discharge to commence early. • Rondelet mentions a woman who was delivered twelve times; and Joubert another, who bore eighteen children, neither of whom had ever menstruated.- Gardien Traits* cfaccouchemeru, Vol. I. p. 220. t Gardien says, « Si quelquefois le sung sort brusquement sous couleur rouge le plus constamment les regies commencement par un flux sereux et finissent de meme."—Trait f complet. d'aceouckemens, Vol. I. p. 238. HISTORY OF MENSTRUATION. 89 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 menstrous 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 labouring under a diseased spine, but who was also afflicted with headach, 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 inclina- tion 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, however, 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 leucorrhcea. This was done: she reported there were considerable marks upon her linen; and this was observed for at least four periods: after this the menses, with their usual appearances, were established, and con- tinued with tolerable regularity up to the present time. This is the third instance I have witnessed of rather precocious menstru- ation in girls with diseased spines; whether there be a connexion between this affection, and the functions of the uterus, must be left to future observations to determine. Thus we see, it is easy to err on this point with young girls, and to suppose they may have conceived before the catamenial period had commenced; nor is the error less liable to be made in those rare instances of impregnation, after the final cessation is supposed to have taken place; for in several well-attested in- stances of pregnancy at advanced periods of life, it was found, upon close examination, an effort had been made by the system to restore the catamenial flux by a periodical serous discharge. In one case, which fell in part under my own notice, this effort wa3 certainly made; but perhaps without the knowledge of the person concerned; yet it was sufficiently evident to the indivi- dual who washed her clothes, and who furnished me with the account; for it is presumable, with such evidence of returning youthfulness, she would scarcely have risked the consequences which followed her amour. 90 HISTORY OK MtNSTRI ATION. 1 was requested, in the month of March, 1795, to visit a young child, ill with the natural small-pox. At almost every visit I paid the child, I observed an aged woman much afflicted at its danger- ous condition. Having an opportunity during the absence of this person to inquire who she was, I was informed, to my great sur- prise, that she was the mother of the child. I thought my in- formant was attempting to impose upon me, and told her so; but she seriously declared I might rely upon the fact. I was now in- formed that the mother of the child had never been married, and that she was in her sixty-first year when the child was born. The case interested me much, and my inquiries became more particular; and from much conversation I learnt, that the old i, woman had ceased to menstruate at forty-five, but that, about two years before the period of my attendance on the child, she, (the nurse of the child, and the washerwoman of the mother,) had observed monthly evidence of a return of the catamenia; it was not much coloured, yet sufficiently so to excite attention. Now, this case would certainly pass for an instance of impregna- tion after the menses had ceased; and it must be admitted to be one, every way calculated to mislead. I have therefore concluded, that the cases upon record, purporting to be of this kind, may have been similar to the one now related.* So far, facts seem to oppose the idea, that impregnation can take place before the menstrual action has been established, and after it has finally ceased: let us now see if reasoning will not corroborate them. It will not be disputed, that a part cannot perform its peculiar or appropriate action, until such part is completely developed, or its organization perfected; consequently, the uterus will not be subject to the menstrual action, until the surface which furnishes this fluid is perfect in its arrangement; and not then, unless it re- ceive the peculiar stimulus given by, or it sympathize with, the perfect ovarium, or ovaria. Now, by all we learn from either v experiment or accident, it is certain, that the menstrual action is for ever prevented, by the extirpation or destruction of the ovaria; consequently, this action is dependent for its existence upon a state of perfectness of one or both of these bodies. It is equally certain, that if the ovaria be incomplete, they can- * A case is related in the Edinb. Ann. Register, Vol. IX. p. 608, of a Mrs. Ashby, of Firnby, near Spibby, who was delivered of twins in her fifty-fourth year; and Haller gives instances still more extraordinary—viz. one at fifty-eight one at sixty-three, and another at seventy. HISTORY OF MENSTRUATION. 91 not furnish perfect ova, or ova capable of fecundation: nor can they give or excite that action which furnishes the menstruous fluid. If, on the other hand, the ovaria be properly developed, and the menstrual action does not take place, it is but reasonable to suppose, that some imperfection must exist in the uterus itself; and if this be admitted, it would seem to follow, that a perfect action cannot be expected from an imperfect organ; and it will be farther granted, that no process in the human system requires greater perfection of organs, than those subservient to generation. Therefore, as regards the main point, it is unimportant whe- ther the imperfection be seated in the ovaria, or in the secreting surface of the uterus; for, if it exist in either, coition cannot be entirely successful. If an ovarium furnish a perfect ovum, it may be fecundated, though the menstrual action had never taken place; but this is but one step in the march of generation; for if the ovum be not properly cherished after it shall have been de- posited in the uterus, it will soon perish and be cast off For, that it may be sustained and properly developed, it is essential, that the uterus produce the decidua; and that it cannot furnish this sine qua non, is highly probable, as the organization which is to yield it, is the same as that which performs the menstrual secretion; and that this part is imperfect is put beyond doubt, since it has not formed this fluid. That impregnation may be successful, a healthy condition of the internal surface of the uterus is required, and a sound condi- tion of at least one of the ovaria. For if these organs be imper- fect, either fecundation cannot result, or it will take place una- vailingly. Thus, if the ovaria, from disease or imperfection, can- not furnish an ovum that cannot profit by the application of the male semen, fecundation will not ensue: if, on the other hand, the internal face of the uterus be diseased, and incapable of fur- nishing the decidua, the ovum must perish, though fecundated. It is, therefore, but reasonable to conclude, that if the uterus be not sufficiently developed to secrete the menstruous fluid, it must be imperfect; and if imperfect,it cannot perform what is essen- tial for the preservation of the ovum after it has been placed in its cavity. Fecundation, after the cessation of the menses, must be equal ly doubtful; since it is probable it would require a renewal of the menstruous action, that fecundation should be successful. At present we are not sufficiently acquainted with the conditions es- sential to this cessation; or, in other words, what changes take 02 HISTORY OF MENSTRUATION. place in either the ovaria, or in the secreting surface of the ute- rus itself, when this period arrives. We only know it docs take place; but how, we are altogether ignorant. The moral cause of the cessation is better comprehended than the physical. It would seem but fair to conclude, that if the early part of female life require a certain condition of the uterus and ovaria, to render coition successful, it would be no less necessary at the more advanced stage: I have attempted to prove this necessity; and the same arguments will also serve for the later period. For it is evident, that the ovaria and uterus must have suffered a change, or the woman would have continued to menstruate: now, it is of little moment whether the change occur in the uterus or in the ovaria; since a certain ulceration in either will incapaci- j tate the woman, both for menstruation, and conception. It is, however, probable, that the ovaria suffer deterioration earlier than the uterus; as many women continue to menstruate regularly for a considerable time, before the final cessation, with- out conceiving. The ovaria may cease to produce ova to be fe- cundated; and the absence of this power may eventually cause the final departure of the menses; since they would be no lon- ger necessary, or useful. It is, also, probable, from impregnation now and then taking place long after the disappearance of the menses, that an ova- rium may regain its productive powers, and furnish a new and healthy ovum; and when it does regain this capacity, the inter- nal face of the uterus may reassume its menstrual action, and impregnation may, under such circumstances, be the consequence. But that it may be eventually successful, precisely the same con- dition of the uterus must exist, namely, the formation of the de- cidua, as when this process was successful in the earlier periods of life; for, if this be wanting, the same consequences must ne- cessarily follow, as would then result. It seems that the production of efficient ova is governed by some general law in each individual female: in the brute it is re- gulated with great exactness, as they have regular periods of sa- lacity; and this salacity may depend upon the presence of a per- fected ovum or ova. In the human female these periods are not so exactly limited, as individuals differ very much in their capa- city to be impregnated; and each has a marked period, eastern paribus. Thus, some women are impregnated every twelve or thirteen months; others every eighteen months or two years; while others enjoy much longer intervals. HISTORY OF MENSTRUATION. 93 I know a lady who conceived but once every seven years, and she bore four children at these intervals. I have known several to have a lapse of three years between each pregnancy, &c. It would seem, from these facts, that it requires a lapse of a certain period to perfect an ovum; and that this process is much more rapid in some instances than in others. But when the ovaria lose the power of furnishing ova, as at the cessation of the menses, impregnation ceases, of course. Impregnation after the final cessation of the menses,'is of ex- tremely rare occurrence, and should be ranked among those ex- traordinary instances, in which the system makes an attempt to renew certain lost functions, or to repair lost parts. Thus, the eye-sight has been restored, after having remained imperfect many years; the hearing, in like manner, has returned after long deaf- ness; the teeth have been renewed after they had been many years lost, &c. Is it not then more than probable, that when such cases occur, all the functions ordinarily esteemed essential to this process in the early part of life, should obtain when it takes place after the menses have ceased? Now, a healthy menstrual action is a sine qua non to impregnation, in the earlier parts of life; it would seem, therefore, to be indispensable to this end, at the latter period: and where impregnation has obtained, we can- not well question, but it has been preceded by this action. The period at which the menses make their appearance, is va- rious : it is much influenced by constitution, climate, and mode of life. As a general rule, it takes place at puberty, or at that pe- riod at which the female is capable of propagating her species; and this period varies, as climate may differ. They constantly, however, keep pace with the development of the body; where this is rapid, they will appear proportionably earlier; where this process is slower, they will appear later: but whenever the menses appear as regular evacuations, they mark the period of puberty; thus, in hot countries, women commence to menstru- ate at eight or nine years of age, and are not unfrequently mo- thers at ten. In the more northern regions, as in Lapland, &c, this evacuation is generally delayed until the female has attained her eighteenth, or nineteenth year: in the temperate latitudes the average period will be found from the fourteenth to the sixteenth year. A dif- ference will, nevertheless, be found in the women who may reside in cities, and in those who dwell in the country of each respective 13 94 HISTORY OF MENSTRUATION. portion of the globe. It may also be observed, that in cold coun- tries, women continue to menstruate for a longer period than in warm; and as a general rule, it will be found, they are ob- noxious to this discharge, double the period that elapses before it commences. Thus, women who have not this discharge until eighteen, will be found to have it until beyond fifty; those who commence at fourteen or fifteen, will leave off at about forty-five; those who begin so early as eight or nine, will have it cease at twenty-five or six. This fact appears to be disputed by Frank;* he says, that "the early appearance of the menses does not hasten the period of ces- sation; for in the Milanese, where he practised ten years, this discharge takes place one or two years earlier than in Germany; yet it is no uncommon thing to see women perfectly regular at the forty-eighth or fiftieth year." This may be ; and most proba- bly is the case—but this account tells but the half that is neces- sary to the establishment of the law he lays down; for he has not declared, that the females he found regular at forty-eight or fifty, had in every instance begun a year or two sooner than the women of Germany, and which would be essential to the fact he thus attempts to prove. There are, however, a number of curious exceptions to the ge- neral rules we have attempted to lay down : these consist in the precocious appearance,f and unusual protraction of the menses. Haller, Van Swieten, &c, give instances of each kind. I have seen several cases where this discharge was regularly continued until the fifty-fourth or fifth year.J • Traite de Medecine Pratique, torn. 3, p. 397. f There have been instances of the catamenia commencing soon after birth. An instance of this kind is given by Mr. Whitmore, in Med. Chirur. Trans. Lon- don, vol. 4th. This patient had this evacuation regularly from birth, at stated intervals of three weeks. In her fourth year she died, after a very short illness. On dissection, an unusual development of the uterus, &c, were discovered. The other daughters of this family had nothing peculiar. t The following table, exhibits the ages of three hundred and twenty-six fc. males, at which they began to menstruate. It is furnished by Mr. Roberton, in the North of England Medical and Surgical Journal. In their 11 th year, 6. In their 16th year, 54. 12th, " 12. 17th, «« 50. 13th, " 31. 18th, « 19. 14th, " 60. 19th, " 18. 15th, " 72. 20th, » 4. To this list may be added the case related by Madame Boivin, in her account of a new cause of abortion. The subject of this case commenced to menstruate »t seven years, and did so regularly after her tenth year. HISTORY OF MENSTRUATION. yS This evacuation rarely fails to be announced by a variety of symptoms, of greater or less severity, or danger: among girls who have been delicately and luxuriously brought up, and who have their nervous system rendered morbidly sensible or vibra- tile, a great variety of nervous symptoms, as they are called, pre- cede the eruption of the menses; such as ringing of the ears; a sense of suffocation; palpitation of the heart; starting from slight and sudden noises; precarious and whimsical appetite; loathings and cravings; convulsive twitchings; convulsions; chorea sancti viti,&c; all of which are sometimes instantly relieved by a trifling discharge from the vagina; and this not necessarily coloured. The last mentioned circumstance, must have been observed by every attentive practitioner, who may have had charge of females; and it is one worthy of note, as it goes to confirm what has been advanced above of the identity of the action which produces these fluids, though so different in their appearance. The vascular system is sometimes also much disturbed: we often witness determinations of blood to various parts of the body; as to the head; the lungs; the mammae; the stomach and bowels, &c.; for the relief of which, we are obliged to abstract blood, or employ other remedies, if a kindly discharge from the uterus do not quickly tranquillize the disturbed and embarrassed circulation. Sometimes the inconveniences are confined to the genital sys- tem—in such cases, a sense of weight; bearing down; ardor urinae; pain in the region of the uterus, &c, are experienced; all of which, for the most part, announce the approaching discharge. It is at this period, also, that nature perfects her work, both as regards development and proportion ; it is the period of the most perfect beauty, of which the female is susceptible ; it is the one at which the moral changes are not less remarkable than the physical; it is a moment, of all others, the most replete with consequences to the inexperienced and confiding female. At this period a great variety of interesting and curious phe- nomena present themselves; the voice is found to change; the neck and throat to increase in size, and to become more symme- trical; the mammas to swell; the nipple to protrude; the chest to expand; the eyes to acquire intelligence, and an increase of brilliancy; in a word, a new being, almost, is created. The quantity of fluid expended at a menstruous period, differs in different individuals; with girls who precociously menstruate, the quantity is in general smaller, and the returns less regular. Climate exerts an influence upon the quantity discharged, as well 9G HISTORY OF MENSTRUATION. as upon the periods at which this evacuation shall commence. Thus, in the equatorial and more northern regions, it is less than in the more temperate climates.* A variety of causes, independent of climate,t are said to have the power of increasing the menstrual discharge; as all circum- stances suited to increase the activity of the system; and thus tend to its more hasty development. Such are the passions of the mind frequently indulged in, as anger and joy; a diet, rendered too stimulating by either spices or spirits of any kind. All such as would have a tendency to produce a plethora of the uterus, and thus increasing its sensibility; as the frequent use of foot- baths, foot-stoves, &c, all such as excite a pruriency of the imagi- nation; and lastly, those which augment the quantity of blood; as too full a diet, especially chocolate as a constant article of food;J too long indulgence in feather beds, and the want of suffi- cient exercise. It would be difficult to ascertain the exact quantity of fluid evacuated at each period, as it cannot be well subjected to mea- surement; hence the discrepancies upon this subject. Hippocrates set it down at twenty ounces: there can be no doubt but this is very much overrated: at an average, from four to six ounces may be considered as the proper mean. It usually employs from three to six days for its evacuation, and, for the most part, is extremely regular in its returns. I know a number of females who can tell not only the day on which it will return, but even indicate the hour at which it will show itself.§ With other females, however, it is less regular; but it rarely exceeds the twenty-eighth day with such as are in good health, if we except, when it approaches the period for its final cessation. When the time approaches at which this evacuation is about to * Gardien, p. 227. f Of tliis several instances have occurred, to prove that uterine development may be independent of the general influence of climate; for a case is mentioned, that in Kentucky a girl of eleven was safely delivered of a living child; the parent bore all the usual marks of complete development. And another instance has been communicated to me by Mr. William M. Egbert, in which a girl in New Jersey became a mother at twelve; and is now the mother of several other children. * Almost all of the French writers mention the influence of this article upon the genital system. § A lady lately informed me, she could, with the utmost exactitude, tell the day and hour at which this discharge would take place. This was made known to her by the appearance of certain feelings, which constantly took place one «'<*ek, to the hour, before the eruption of her menses. HISTORY OF MENSTRUATION. 97 cease, agreeably to the arrangement of nature, this flux becomes more desultory, as regards the periods of return, and the quan- tity eliminated. The discharge may return every two or three weeks, or it may procrastinate, until the fifth or sixth week, or sometimes even longer; and instead of the four or five ounces which were wont to be effused, twenty, or even more, may be evacuated. But it must be remarked, that when the quantity becomes so excessive, it is not a genuine menstruous product that is poured out—for this process is now accompanied by a true he- morrhage; as is evinced by the expulsion of coagula. From the last expression it may be collected, that I consider the menstruous fluid not as a pure or unmodified blood: I shall therefore state the reasons for this belief. " 1st. Its colour is between the arterial and venal blood, being less brilliant than the former, and more florid than the latter. 2d. It never separates into parts; blood drawn or evacuated from any other part of a healthy body, does separate in a short time into its component parts. 3d. It never coagulates, though kept for years; while other blood, when free from disease, quickly does when exposed to the influence of the air. 4th. Its odour is remarkably distinct from that of the circulating mass; and it is less disposed to pu- trefaction." It has been supposed, because the menstruous fluid does not coagulate, that it contains no fibrin; but it is more probable that this substance has been deprived of the power of coagulation, by being subjected to the influence of the vessels of the secerning portion of the uterus. This opinion is strengthened by recurring to the fact, that the coagulating lymph always accompanies the red globules, wherever the latter may be found. The menstruous blood may therefore be considered as a sub- stance differing from the blood of the circulating mass in at least two remarkable properties; namely, in not coagulating; and, se- condly, in not separating into parts. It is true, there are many of high authority, who declare a contrary belief. Hippocrates declares it to be pure blood; similar to that of a victim, if the victim be in health; and this opinion has been handed down to the present day, without being challenged by inquiry, or subject- ed to dispute.* * We believe we are safe, when we say, that a large majority of those who have written on the subject of menstruation, consider the menstrual fluid as a pure hemorrhagic blood: some few seem to agree to a modification of this opi- 98 HISTORY OF MENSTRUATION. If mere blood were evacuated from the uterus at the menstrual periods, it would be, strictly speaking, a hemorrhage; but that this is not the case, the whole phenomena of this process seem to declare. I have stated, above, some reasons for my disbelief on this point; and shall now add, that had this operation con- sisted in the mere evacuation of unchanged blood, it would be attended by precisely the same inconveniences as almost always attend hemorrhage from this part; namely, pain of an alternate kind, arising from the contractions of the uterus to expel coagula, which always form, and which require for their expulsion the efforts of the uterus. It may also be added, that in cases of imperforate hymen, the accumulated menstruous blood constantly remains fluid, though a little thickened; and when relieved by an operation from its confinement, it is found to flow with considerable freedom from the orifice made for this purpose. No coagula present them- selves, as would be the case, were the fluid unchanged blood. That the menstruous blood may contain all the constituent parts of common blood, I do not mean at present to dispute, since I am not prepared to say in how many, or how few details it may differ, upon a strict analysis: it is sufficient for my present purpose to state, that it must experience some change during its elimination, as it is uniformly deprived of the property of coa- gulation when in a healthy state. This last circumstance, from its uniformity, must have a mean- ing; I have just stated what I believe to be the probable inten- tion of this change, namely, the comfort of the woman; but it may have a higher object; it may be essential to the propagation of our species. Certain it is, the sensible properties of this eva- cuation differ in certain individuals; and it is found, that when this discharge is very profuse or very sparing; when many coa- gula are thrown off; when it is thin and pink-coloured; when very black, and resembling, in some measure, coffee-grounds; or, when it is discharged with pain, and accompanied by a whitish membrane, the women, so circumstanced, are constantly barren, so far as my observations have extended. As I do not believe this discharge to be a mere exudation from the internal surface of the uterus, and constituting a genuine he- morrhage, it is proper to declare, what I believe its real nature is. I look upon this discharge to be a genuine secretion, from nion; but this does not amount, either to a concession or denial of its being a se- cretion; of this number, are Bichat and Broussais. HISTORY OF MENSTRUATION. 99 the mucous membrane with which the cavity of the uterus is lined; since it would be difficult to explain by any other process than some peculiar mode of arterial action, the change which evi- dently is wrought upon the coagulating lymph; and we know that this constituent of the blood is, in many instances, under the immediate influence of this set of vessels, as is proved in eases of scurvy; death from a blow on the stomach; a certain stage of yellow fever; small-pox, &c. In these cases, the blood loses the power of coagulation by some peculiar arterial action; and this, sometimes, in a very short time. The same effect is produced by the uterine arteries during the menstrual process; and this process may, with much propriety, be termed a secretory process. The menstrual fluid has been considered as a secretory pro- duct for very many years, and this opinion is now adopted by many of the physiologists of the present day: thus, Haller, Bor- deu, Sanders, John Hunter, &c, called menstruation, without hesitation, a secretion. It is perhaps, at the present day, impos- sible to say who first broached this doctrine. The credit has been given to each of the gentlemen just named, but not with justice, as I shall show immediately. In Rammazini's "Essai sur les Maladies des Artisans," p. 214, we find the following passages: " II y a tout lieu de croire que le sang des regies a quelque qualite maligne et cachee; et on lui a donne a juste titre le nom de secretion et excretion." In this passage, the word secretion appears to be familiary employed, and was the one most probably used in common parlance among the medical men of the day. Fourcroy, the translator of this work from the Latin, in a note to a part of the paragraph from which the above extract is taken, says, " Rien cependant n'etoit plus naturel, sans avoir recours aux phenomenes chymiques, que de concevoir le flux des regies, comme une secretion, qui a son organe, ses periods reglees, sa marche et son department, ainsi que toutesles autres secretions," p. 216. From these extracts, it is evident that neither of the gentle- men above mentioned is justly entitled to the honour of the sug- gestion: for the first edition of Rammazini's work was published in 1700. Indeed, it would seem, from the manner in which it is mentioned in this work, that the doctrine was not new at that time: at least there is no claim laid to originality by Ram- mazini. 100 niSTORY OF MENSTRUATION. I consider the uterus to be lined with a membrane of the mu- cous class, as taught by Bichat and others, notwithstanding its existence has been lately called in question. In examining the latest authority "on this subject within my reach, I find it doubt- fully mentioned by Meckel, in his Manuel d'Anatomie, as trans- lated by Jourdan and Breschet, vol. iii. p. 611. He says— "La face interne de la matrice est tapiss6 par une membrane muqueuse rougeitre, presque lisse, garnie seulment de villosit6s tres fines, qui se continue superieurement, et de chaque cot6, avec celles des trompes, inferieurement avec celle du vagin. Dans P6tat frais, cette membrane adh6re d'une maniere si intiine a la substance fibreusesous-jacente, qu'on ne petit 1'en isolcr, quoique sa structure annonce assez qu'elle appertient a la classe des mem- branes muqueuses; mais, avec du soin et de precautions, on par- vient a en detacher quelques lambeaux, apres avoir soumis, la malrice a la maceration." " Son union intime avec le reste de la substance de la matrice a fait revoquer son existence en doute par plusieurs analomistes."* It is truly a matter of surprise, that it should be questioned for an instant, that the uterus is lined with a membrane, and this of the mucous kind; for neither the authority of Morgagni, Boer- haave, nor Haller, all of whom Chaussier has called to his aid to support the opinion, can possibly alter the structure of this part; for a membrane is obvious to the eye; and when macerated, is tangible to the fingers; and the nature of its discharges proves it to be a mucous membrane. It has been thought by some to be of the deciduous kind, and regularly cast off after each delivery, or even after abortions. There is much reason, from the appear- ance of this part after delivery, to countenance this opinion—it, however, wants confirmation. But, if this suggestion were ad- mitted in its fullest extent, it would not militate against the pre- sumption that it is a mucous membrane. For this membrane must be considered as possessing a considerable variety of func- tion under particular circumstances: for mucous membranes are made to throw out, not only mucus, but pus, and even modifica- tions of these substances. • " C'est l'opinion de Chaussier et de Kibes. Me. Boivin dit aussi n'avoir jamais apercu cette membrane muqueuse, et pense que la face interne de la matrice n'est formee que par 1'extremite des vaisseaux exhalans qui s'y ouvrent Une pareille explication est tres vague, sinon meme tout A fait inintelligiblc L'Analogie, quand il n'y aurait pas d'autre motif que celui-la, ne permettrait pa» de douter que la face interne de la matrice ne soit tapissee par une membrane."— Notes des Traducteurs. HISTORY OF MENSTRUATION. 101 It is, in truth, most intimately connected with the substance of the uterus, and cannot, perhaps, ever be separated from it in the recent and sound state. But this only proves the closeness of its connexion, and not its non-existence. Indeed, this strict union strikes me as highly useful in the economy of gestation: for were it loosely and uncertainly attached to the substance of the uterus, much inconvenience would necessarily result from the great distention this organ undergoes during pregnancy. Upon opening an unimpregnated uterus, and viewing the ca- vity it presents, we are immediately struck with the smoothness and polish of its surface: now, it may be proper to ask, what is this whitish and shining surface which presents itself? Can it be the extremities of the exhalants of Me. Boivin? or the proper substance of the uterus, as insisted on by Chaussier? Will an ar- rangement like that of Me. Boivin, or Messrs. Chaussier and Ribes, secrete a mucous fluid; yield a fluor albus; or render a pus? Or, in other words, will any other surface, save a mucous surface, display the phenomena of a confessed mucous mem- brane. The existence of this membrane is denied, because it cannot be separated from the substance of the uterus. And when it is urged that this can be effected by maceration, or incipient putre- faction, they declare the separated portion to be no membrane, but some accidental concretion. It is said by Chaussier and Ribes, that the membrane which lines the vagina, terminates at the ori- fice of the uterus. The quality of the menstrual blood has been a matter of much dispute with many of the writers upon this subject. It is by some considered perfectly innoxious, and by others as extremely dele- terious. The ancients attributed to it the most baleful effects upon both living and inanimate matter. Thus, Pliny declares the approach of a menstruating woman will turn new wine sour, ren- der fruit trees steril, or even destroy them; burn up the seeds and fruit of a garden, if she should sit near them, &c. &c; while Fallopius, Rodrigue a Castro, Baillou,* &c, assure us, in its na- tural slate, that it is perfectly free from all bad qualities. La Motte, though apparently willing to remove the imputation urged against the menstrual blood by Pliny and others, cannot altoge- ther divest himself of the prejudices of the times and of educa- * Rammazini, p. 214. 14 10^ HISTORY OY MENnTHUATION". tion. He seems disposed, however, to compromise between (he force of opposing facts, (which he confesses daily to have ob- served,) and the influence of names and of instruction, by relating, with great naivete, the following story. After having timidly attempted the refutation of Pliny and others, " that the menstrual blood is most injurious," he say*, "But I sec sufficient to make me apprehend the presence of wo- man in this situation, especially if she have red hair. I had a servant of this kind. One day I gave a breakfast to a number of my friends; white wine is the kind which is usually preferred ,< upon these occasions; especially if you intend to eat oysters; and mine was excellent; and was drawn by this servant. My friends expatiated upon the goodness of my wine. The next day I breakfasted in like manner with one of the friends who had been with me; but he had no wine but red; 1 immediately sent for some of my white wine; but it was found so spoiled as to serve for nothing but vinegar. The same servant aided in salting some T pork, which was afterwards found to be spoiled; though the part which was salted by another person, in another cellar, was per- fectly good." He adds, however, with his usual candour, " but I cannot say whether this may not have been the fault of the salt."* It must be admitted that this secretion is acrid, occasionally, and will leave traces of its acrimony upon the parts over which it flows; but when this happens, it must be recollected that this discharge is in a deranged state, and no longer a pure menstru- ous evacuation. This occurs more frequently towards the decline, than in the early part of life; and especially if there be a tendency to cancer. It must, however, be recollected, that even in such instances, the general system is not contaminated in the com- mencement of this condition of the uterus; the acrimony of the discharge results from an altered action of the vessels concerned in the process of elimination, and its exposure to the air; and it is not until portions of this discharge are absorbed, or until the sys- tem at large sympathizes with the diseased parts, that any evi- dence of the uterine affection is betrayed by the skin or other portions of the body becoming diseased. The idea of the impurity of the menstruous blood took its rise from the supposition, that this discharge was intended to relieve the woman from certain noxious humours generated in her body • Traite des accouchemens, p. 57. HISTORY OF MENSTRUATION. 103 from her sedentary habits, as well as other causes. Hence, so much dread was entertained, when this evacuation was interrupt- ed from any other cause than pregnancy. But no alarm was ex- cited when this flux was arrested by gestation; as it was then employed, they said, for the purposes of the foetus, and they ap- pear willing to think the embryo cannot be injured by it. This opinion they thought supported by the appearance of cer- tain eruptions upon various parts of the body when this discharge was suppressed, and which yielded only to such remedies as re- stored this evacuation. But this fact, at the present day, would be explained upon very different views of the animal economy; and will no longer serve to support the notion of the deleterious effects of suppressed menses. Indeed, we may with much plausi- bility suppose, that the dogma of the impurity of the menstruous blood, originated in a medico-political necessity, in the warm climate which first gave rise to the suggestion. Moses was fully aware of the consequences of the want of cleanliness among his people; and no stranger to the inconveniences which arise from a neglect of it: he therefore looked upon women, during the pe- riod of their catamenial flow, as impure, and that they would re- main so, until they were well absterged; hence his pointed di- rections, and observances at this period. To ensure success to this scheme of cleanliness, the aid of medical speculation was re- quired, and, most probably, it was not reluctantly obtained. The ancients, in a word, we»e scrupulously exact upon this point; for they considered the health of the woman materially connected with the menstrual discharge, and looked upon repose of body and tranquillity of mind as essential to the best performance of this secretion—they therefore forbade their females to appear in public, during its flow, lest agitation, or over-exertion, should de- range this natural and important function; and, to ensure compli- ance, urged the morbid nature of the menstruous fluid. Indeed, they went so far, as to even forbid the employment of the ban- dage, now in almost universal use with females who are men- struating, because they declared, it prevented the immediate flow of the menses, and thus permitted this fluid to accumulate, and stagnate, in the vagina. It was also supposed, that hemorrhages from other parts of the body must be a necessary consequence of the uterus failing to se- crete the menstruous blood; and we find, in books on medicine, very many instances, purporting to be illustrative of this hypo- 104 HISTORY OF MENSTRUATION. thesis. I am not prepared to say that such a thing never has ex- isted;* but I can with the most entire confidence declare I never witnessed such examples; and when they occur, they must be considered, if entitled to any weight, but as exceptions to the rule. Have not instances occurred of foetuses being found in the ovaria of virgins? At the present day, I believe, no one will imagine, that he ob- serves a woman's health to be worse, as a regular occurrence, as she approaches the period for her catamenial flow; nor think that he sees an improvement, after this period has passed over: yet it would seem essential to the support of this conjecture, that both one and the other should happen. Nor is there much reliance to be placed upon the existence of the " menstrual fever " of the older writers, though supported by the later authority of Bordeu. That fever may occasionally be perceived at such periods, I have • Gardien relates a curious case, upon the authority of Mr. Bruit', which he considers as a proof of the diversion of the menstrual action, but which I cannot regard but as a periodical hemorrhage; and altogether analogous to the bleeding hemorrhoids, which, in females, frequently observe as much regularity when the menses are regular, as when they may be absent. " First deviation.—The menses were suppressed in a young girl, whose life had been a series of illnesses up to that moment. She became regular after this; for six months the discharge was evacuated from little wounds in the legs, occa- sioned by the breaking of some small vesicles. " Second deviation.—There appeared upon the left arm some vesicles or pim- ples, (boutons,) which yielded blood at the menstrual period during a year. u Third deviation.—This was succeeded by a whitlow on the left thumb, and a chap upon the first phalanx; and at the end of two months the menstrual blood flowed periodically from this part for six months. " Fourth deviation.—The girl was now attacked by an erysipelas in the face and the left eye, which terminated by two openings, one at the angle with the nose, and the other in the middle of the upper eyelid: these two openings yield- ed an evacuation periodically for two years; it then ceased from these parts, to be voided by the left thumb. " Fifth deviation.—An erysipelas now showed itself upon the abdomen, at tended by great itching; the navel was very painful, and for five months the blood flowed regularly from this part at each menstrual period. " Sixth deviation.—A slight accident happened to the left internal malleolm of the ankle, and the blood flowed regularly from this part for four months. " Seventh deviation.—An acute pain was felt in the left ear; a discharge took place from this part for two months. " When the blood did not flow from any determinate spot, it would vent it- self by a hemorrhage from the nose, or from the stomach by vomitings, pre- ceded by headach and giddiness."— Trait* Complet. d'Accouchement, Uc. Vol I. p. 239. DERANGED MENSTRUATION. 105 no reason to deny; but that it is an attendant upon this discharge, as one of its phenomena, I have much reason to doubt. When this opinion arose, it vvas the order of the day to be minute ; and an accidental circumstance was recorded, for an essential charac- ter. What shall we say of women who have never menstruated? Do they enjoy equal health with those who do? Are they capa- ble of fecundation? As regards our own experience, we would answer each of these questions in the negative—but Frank enter- tains a different opinion upon each of these points. He says, "We rarely meet with women who have never menstruated; however, there have been such instances, and such women have enjoyed the most perfect health; a strong constitution; they were even fruitful." Med. Pract. Tom. 3, p. 3S2. To these observations, we must say, that they must have greater confirmation, ^efore they can be relied upon as facts—for the reverse has been the constant result in the few cases which have fallen under our own notice. Nor is it very difficult to un- derstand, that this must be the case ; since it clearly proves, that when this evacuation does not take place, it must be owing to some decided imperfection in some one part, at least, of the geni- tal system; and that for the purposes of propagation, we are of opinion the most healthy condition of these organs is required. And we think that Frank himself" yields the point completely, by his attempt to explain it. For he adds, immediately after what is above quoted, " If we meet with a great number of women thus situated, and who do not conceive, we must not accuse a defect of menstruation for it, but a vicious conformation of the genital parts." Ib. CHAPTER VI. DERANGED MENSTRUATION. After giving the history of menstruation, it would seem pro per we should furnish an account of the various derangements to which this function is liable, and the mode of treating them. The derangements to which this discharge is liable, are as follow:— 1st. Its too tardy appearance. 10G TARDY appearand: of the mense>. 2d. Its interruption after having been established, commonly called the suppression of the menses. 3d. Its excess of quantity. 4th. Menorrhagia. 5th. Dysmenorrhea, or painful menstruation. 6th. Its irregularity towards the decline of life. Sect. I.—1. Of the Tardy Appearance of the Menses. In our history of menstruation we have shown, that this pro- cess is more regulated by the condition of the system than by the age of the female; and that though the climate and manners of each portion of the globe exert an influence upon the human constitution, yet that this influence is constantly observed to ma- nifest itself in the more early, or tardy development of the ge- nital organs. This being the case, the period of puberty, or that period at which the human female is capable of propagating her species, and of which condition the menstrual discharge is the sign, will arrive at different periods of female life; but never, un- til the organs destined to furnish this evacuation, are sufficiently developed, to meet, and overcome, all the ordinary contingencies of impregnation and of labour. It will therefore follow, as a general rule, that climate will de- termine, in the female constitution, a period, for the development of these organs; and, consequently, for the appearance of the menses, in each particular portion of the globe. This being the case, a general period is established, at which this evacuation may be looked for; and this is so nearly constant, (cseteris pan- bus,) that any deviation in this respect is looked upon as a state of derangement, if not of disease; hence, the surprise that is al- ways expressed, when this evacuation anticipates the common period ; and the solicitude, when it does not take place at the or- dinary time. In consequence of this general law,—a law established by cli- mate and manners,—many vulgar errors have arisen, which have too successfully exerted an influence upon the conduct of those who may have charge of females at this critical and interesting period of life. The average period for the first appearance of the menses, may be between the fourteenth and the fifteenth year in this country. When they fail at this time, much anxiety is evinced on the part TARDY APPEARANCE OF THE MENSES. 107 of the friends of the girl so circumstanced; and every indisposi- tion with which she may be attacked, is sure to be attributed to this cause. In the hope of provoking the menses, now due, as they suppose from the age of the girl, she is almost always con- demned to medical discipline, and but too frequently injured by submitting to its rules. Nothing, perhaps, would be more diffi- cult to overcome than the prejudice of the necessity of this dis- charge, at a certain period of female life; and this period deter- mined by the number of years which have passed. Women, upon this subject, are but too often incorrigibly wrong-headed; and we are sometimes obliged to yield, for the patient's sake, an appearance of acquiescence. In many instances, did we attempt to convince them of their error, it would not only be labour lost, but, what is worse, would too often deliver the patient over to the discipline of some rapacious quack, or some ignorant practi- tioner of medicine. The lapse of a certain number of years is not all that is re- quired, that the menses may make their appearance: the uterus, and ovaria, must be developed, and be in good health, if I may so term it, before this discharge will show itself; and this condi- tion of the genital system is always indicated by corresponding changes in certain other portions of the system—there must, and will be, evidences of womanhood, before this event can happen;* and when these are absent, the girl should never be tortured by the class of medicines called emmenagogues. There seems to be four conditions of the female system, in which the menses are tardy in their appearance: a, Where there is little or no development of the genital organs; 6, where this is taking place very slowly; c, where the development is interrupt- ed by a chronic affection of some other part: d, where the most perfect development has taken place, yet they do not appear. The management of each of these conditions is different—I shall, therefore, treat of them in order. Condition a, or where there is little or no development of the genital organs. This condition of the system is easily detected by the absence of all the signs which should characterize puber- * I have lately seen three instances whick contradict this rule—in neither of which was there the slightest development of the mammze; but, in each of these cases there was a diseased spine. Whether this condition of the spine has any influence upon the appearance of the menstrual evacuation, remains to be proved. See page 89. 108 TARDY APPEARANCE OF THE MENSf>. ty__the breasts do not swell; nor are there capilli always on the pubes. In a girl thus circumstanced, who otherwise is in good health, it would be more than idle, it would be cruel and disho- nest, merely because she had attained her fourteenth or fifteenth year, to subject her to medical rule, or goad her system by sti- mulating emmenagogues. In such a case, if the mother or friends are rational, and to be trusted, we may honestly give our opinion of the entire insufficiency of medicine to produce the desired end. We should explain, so far as we can, the nature of the function of menstruation, and of the prerequisites to this dis- charge; and attempt to produce on their minds the important conviction, that time, under proper circumstances, is all that is required, to effect the anxiously hoped for change. I have encountered many such cases—with some I have suc- ceeded, in bringing the friends to my opinion; in others I have not been so fortunate;—the latter may be divided into two classes—the one, though not convinced by our reasoning, dare not openly bid defiance to it; because, they fear responsibility; and thus will yield a reluctant acquiescence. The second, con- fident in their own judgment, will sometimes act upon it, to the imminent risk, if not to the destruction, of the poor girl, who may be the object of their solicitude. With the latter, when importunate, we should use a tempo- rizing plan; and by the administration of some entirely inert me- dicine, gain time, and save the patient from permanent ill health, or an untimely grave. I but too often Call to mind, with bitter recollection, the fate of a most amiable, and interesting young creature, for whom I vvas requested to prescribe for the expected menses, but who had not one mark which would justify an inter- ference; and, especially, as she was in perfectly good health— she was fifteen, it is true; and this was all that could be urged by the mother in favour of an attempt to " bring down her courses." I relied too much upon the good sense of her anxious parent; and freely explained myself to her—she left me appa- rently satisfied with my reasoning; and I heard nothing of the poor child for six months; at the end of this time I was suddenly summoned to attend her, as she was said to be alarmingly ill. When I saw her, she was throwing up blood in considerable quantities from the lungs; she died a few days after, from the excess of this discharge. The distracted mother told me, that, though she appeared satisfied with what 1 had said when she left TARDY APPEARANCE OF THE MENSES. 109 me, she was convinced I was wrong; and that her daughter's health required the immediate establishment of the menstrual evacuation. With this view, she determined upon the trial of a medicine of much celebrity in similar cases, vended by a quack. She procured it; and gave it according to directions: in a few days her daughter became feverish, lost her appetite, and fre- quently puked; her strength failed, and after a short time she was confined to her bed—she called upon the "Doctor," and made known to him the condition of her daughter; he encouraged her to persevere: and told her, that the fever, &c, was an effort nature vvas making for the end proposed—she persevered, fatally persevered; for, in a few days more, she lost her lovely and only daughter. I examined the medicine which had been exhibited; it proved to be the oil of savin. Condition b, or where the development is taking place slowly. This condition is known by the partial.alteration the mammas have undergone; by some expansion of body; and the protrusion of capilli on the pubes. The general health sometimes suffers slightly; especially if the girl has passed the fifteenth year, and she grow rapidly—she is assailed by a train of nervous symp- toms, as they are called; such as palpitation of the heart, ring- ing in the ears, headach; a temporary diminution of strength upon any sudden exertion, loss of appetite, or a whimsical state of it, &c. This condition is not unfrequently accompanied by fluor albus; and when it is, it more particularly deserves notice. This case merits attention, when the health appears to suffer; but must not be meddled with, when it does not. Our exertions, in favour of such patients, should tend to the invigoration of the system in general, and the development of the uterine system in particular. The first should be attempted, 1st, by the establishment of a regular course of exercise:-—such as riding on horseback, when practicable; walking in proper weather; skipping the rope within doors, when the weather will not permit exercise abroad; dancing moderately, and with strict regard not to become over-heated, and cooling too suddenly: 2dly, by proper attention to dress; wearing flannel next to the skin in cold weather, and properly protecting the feet and legs against cold; carefully avoiding damp and wet places, and partial streams of cold air, especially when warm: 3dly, by a diet of easily di- gested substances, both of the animal and vegetable kind; avoid- 15 110 TARDY APPEARANCE OF THE MENSES. ing all stimulating drinks, such as wine, spirits, or beer, &c, under the specious pretext of their being strengthening. The second must be accomplished by such medicines as have a direct or indirect action upon the uterus itself; of the direct, the tincture of cantliarides appears to be the most efficient, and should be preferred to all others when leucorrhcea attends: thirty drops should be given three times a day, until this discharge cease. We may gradually increase the dose, should the com- plaint be obstinate; for it is of primary importance that it be removed; for we need scarcely look for the catamenia, while this remains in any force—leucorrhcea is a kind of local deple- tion, and prevents that congestion of the uterus so favourable to development, and the production of the catamenial discharge. The parts should be regularly bathed every day with warm wa- ter; especially during the continuance of the fluor albus. Of the indirect kind, aloes seems to be the more certain—the influence of this drug upon the uterus has been very long ac- knowledged, and was much extolled for this purpose by Mor- gagni and his contemporaries—it should be given in very small doses, and perseveringly continued; this medicine i3, perhaps, preferable to the tinct. canth. where leucorrhcea does not attend'; the following is the formula I generally employ:— S>. Gum. aloe. sue. gss. Pulv. Rhxi. opt. 3J. 01. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhaci. q. s.—M. f. pil. lx. One of these to be given every night, night and morning, or every other night, as they may affect the bowels—the object is to keep the bowels free, but not purged. This prescription is a remarkable instance of the power of combination; for the very small dose just recommended, will sometimes act with great force upon the bowels—so much so, sometimes, as to oblige us to reduce the above quantity one-half. The same regard must be paid, at the same time, to air, exercise, and diet, as just re- commended. Condition c, or where this development is prevented by a chro- nic affection of some other part. The condition is readily de- tected, by the presence of any such disease, as may be capable of interrupting this discharge, after it has been thoroughly well- established; such as phthisis pulmonalis; chronic inflammation TARDY APPEARANCE OF THE MENSES. Ill of the liver, or spleen; dropsy, &c. Under the existence of either of these diseases, the menses will almost always be sus- pended; because it will certainly interrupt the development of the organs essential to the formation of this discharge, however favourably this expansion may have commenced. This case constantly exposes the physician to the importuni- ties of the friends of the patient, for something "to bring down the menses;" it is in this case, of all others, that they are per- suaded, nothing more is wanted, to re-establish health—the phy- sician must here conceal his real sentiments; for, however con- vinced he may be of the inefficacy of remedies for this purpose, he must not say so, if he regard the welfare of his patient. For no reasoning will convince them, that the disappearance of the catamenia depends upon the diseased condition of some other part of the body; and, consequently, that until this be removed, their reappearance is not to be expected. Indeed, the attempt would be mischievous; for the patient would most probably be taken from his, and consigned perhaps to worse hands. He should, however, declare to the friends of the patient, that this circumstance, (the absence of the menses,) has been duly weighed, and will influence his prescriptions. In such cases, no prescription can be availing, but that calcu- lated to remove the original disease, and of the diseases which may interrupt the menstrual action, it is not our immediate pro- vince to speak, as they are not peculiar to females. It is true, however, that the long-continued suppression of the menses may seriously involve other viscera than the uterus; and their cure, when thus implicated, may depend upon the restora- tion of this discharge; but when this is the case, it constitutes the chronic idiopathic suppression of the catamenia. A want of attention to these different stales of dysmenorrhcea, that is, whe- ther they be idiopathic or symptomatic, has led to an empirical mode of treatment Condition d, or when the most perfect development has taken place, but the menses do not make their appearance. This con- dition is easily known, by the girl having all the outward signs of womanhood; the menses is all that is wanting to complete her title to it, and fit her for the duties she is destined to fulfil. This case is sometimes attended by fluor albus: when it is, it must be treated as recommended above. At other times, there is a manifestation of an attempt by the uterus to produce the dis- 112 TARDY APPEARANCE OF THE MENSES. charge; this is known by a pain in the back, hips, and loins, with a sensation of fulness in the pelvis, attended sometimes with a forcing or bearing down. These symptoms sometimes recur periodically; and may even be attended by a serous discharge from the vagina, resembling whites. The tinct. canthar., as re- commended above, will rarely fail to produce the discharge, if given steadily for two or three weeks; or the madder may be given, especially if the period for the return of the pains just spoken of, be near at hand. Indeed, this seems to be the only period at which this substance is more decidedly useful than any other of the emmenagogue medicines: it acts at times so prompt- ly, as almost to call in doubt its agency ; but repeated success, under such circumstances, has convinced me of its efficacy. From its possessing no general stimulating property, it becomes very valuable in cases of great irritability of the system, or whew there may be slight febrile paroxysms; for it seems to be a law of the animal economy, to institute fever, whenever strength is considerably impaired: hence, we almost always see it after wasting discharges of every kind. I have, found that a strong decoction of this wood is of equal efficacy with the substance, and is much more easily taken. A pint of boiling water is directed to be poured upon an ounce of finely powdered madder and a scruple of bruised cloves; and then to be gently simmered for fifteen minutes; when cool,strain off and give a wine-glassful every three hours. I have lately had a case of this kind, where the madder succeeded most promptly. This case rarely gives much trouble, unless the interruption has been occasioned by imprudent exposure to wet or cold: in this instance, it must be treated as an obstruction. A remarkable case of the non-appearance of the menses, vvas lately under the care of my friend Dr. Physick and myself. A lady of thirty years of age, had the usual concomitants of pu- berty at the ordinary age; these signs, however, were not fol- lowed by the catamenial flow, though periodical pain in the hips, loins, abdomen, particularly in the region of the uterus, numb- ness of the thighs, &c, seemed to promise it would be so. In this situation this young lady has remained from the time of pu- berty to her present age. Previously to my seeing her, she had tried, without the least benefit, all the known emmenagogues; as her sufferings were severe, and so long-continued several me- dical gentlemen were consulted previously, and so effectually TARDY APPEARANCE OF THE MENSES. 113 were all the established remedies tried, that I wa3 left almost without resource. On examining her per vaginam, nothing faulty could be discovered about the uterus. The only thing that suggested itself, as a possible remedy, was to pass a flexible catheter into the cavity of the uterus, under a hope, that something in the neck of this organ might obstruct the flow of perhaps accumulated menses. This suggestion was accordingly acted upon; and the extremity of a catheter was passed an inch and a half through the neck of the uterus. The withdrawing of the instrument was not followed by a discharge of any kind; and, consequently, our hopes were immediately de- stroyed, and our patient nowise relieved. She has never been troubled with leucorrhcea, or any other discharge from the vagi- na. This case we looked upon as not less ambiguous, than hope- less. The sufferings of this patient were great; the abdomen, during the periods of pain, was very tender to the touch, and a little distended; a considerable hardness was felt immediately over the region of the pubes; but no circumscribed tumour, like the distended uterus, could be discovered. This case is remark- able for several of its circumstances: 1st, there is every outward manifestation of the development of the genital system; 2dly, at every return of the period at which this discharge should take place, there is pain and other symptoms which commonly an- nounce this discharge to be at hand, when not regularly esta- blished ; 3dly, as far as an examination per vaginam could ascer- tain, there was no defect in the uterus itself. In this case, the most probable conjecture I can make is, that there is an anato- mical defect in the secreting surface of the uterus itself; and that the pains which are endured at each returning four weeks, may be owing to the plethoric, or engorged state of this organ, and which is not relieved, as in common, by the secretion of the menstrual fluid. In a very recent Work, on the practice of physic, by Dr. Mack- intosh, Vol. II. p. 340, we find two or three cases strongly re- sembling the one just related, and which were relieved by means similar to that recommended, or rather employed in that case, and may be regarded as instances of amenorrhoea arising from an imperfect or imperforate state of the os uteri. It may not be amiss to direct the attention of the reader to a remarkable cir- cumstance connected with the history of these cases; namely, that there was no collection of menstruous blood in the uterus, and that the menstrual secretion did not appear to take place 114 TARDY APPEARANCE OF THE MENSES. until after the perforation of the os tincae. Is this a uniform oc- currence in similar cases? Does menstrual secretion require, as a sine qua non, an outlet for its production? " A young woman, aged twenty-two, came from the country to consult Dr. J. A. Robertson, who sent her to me in the begin- ning of the winter, 1826. I collected the following particulars from herself and a female friend who accompanied her; that the menstrual discharge had not yet appeared; that she had always been healthy till she reached the age of sixteen, from which pe- riod her health began to suffer, and since which she has regularly complained every month of pains in the back and loins, together with a sense of weight and bearing-down in the passages. For some time her sufferings were slight, and she was still able to per- form her duties as a servant, but for the last two years she has be- come comparatively weakly and emaciated, and has not known what it is to enjoy a day's ease; and she stated, that she would readily submit to any thing which might cure her. The girl ap- peared to be above the middle stature, the mammae were unde- veloped, she was of an awkward shape, and indeed her appearance, colour of skin, and sound of voice, were rather masculine. Her abdomen was not tumid, but I was told it was occasionally swollen, particularly after meals. She seemed to be of a nervous tempera- ment, and was exceedingly shy and timid. Upon examination, my fingers passed readily into the vagina, and the uterus was felt much lower than usual, but I could discover no orifice. Dr. Ro- bertson had previously detected the same fact, but had not then communicated the circumstance to me, thinking he might be m* taken. I repeated the examination many times, and after feeling the spot where the orifice ought to have been, which was distin- guished by a small dimple, I attempted to introduce one of the smallest silver probes I could get made, but was unsuccessful in every attempt. It then occurred to me, that the malformation might be owing to an extension of the mucous membrane over the orifice, in which condition we sometimes see the urethra of a new- born male child. I determined upon giving her the chance of a cure, particularly as the means to be used would not certainly pro- duce severe pain. Accordingly, the sharp and triangular extremity of a silver probe was introduced, directed by the finger, carried to the part above described, and a perforation made by employing a rotatory motion; the instrument was then withdrawn,and the round point, introduced, which then readily passed up to the fundus of the TARDY APPEARANCE OF THE MENSES. 115 uterus. For several days she complained of slight pain, attended with some discharge of mucus, a little tinged here and there with bloody specks, and I did not think proper to interfere farther until the irritation had subsided. In about eight days I began to attempt a farther dilatation, which vvas persevered in daily, the size of the instrument being increased, till, by the twelfth or thirteenth day, I vvas able to introduce No. 6, male bougie to the fundus of the uterus. On the following day there was the appear- ance of so much irritation, both local and constitutional, that I made no farther attempt. In two days afterwards she menstru- ated, and has been regular ever since, and suffers neither pain nor inconvenience. Her health and strength soon recruited, and in a short time her appearance became quite feminine. I saw her accidentally a few weeks before this article was written, and she is still in the enjoyment of good health. "In the case of amenorrhcea from imperfectly formed os uteri, the patient had at various times been afflicted with violent ner- vous symptoms; pain in the abdomen, sometimes of a distressing nature, and obstinate affections of the stomach and bowels; toge- ther with occasional retention of urine, and anomalous hysterical complaints. At every menstrual period she passed a little mucus, which was now and then slightly tinged, but had never the na- tural appearance, and it vvas always attended with great pain. After attaining the age of twenty-three, when her health vvas greatly impaired, and after she had tried all known remedies in vain, she most reluctantly, and after great delay, submitted to ex- amination, and the os uteri was found so small as to be scarcely perceptible. She menstruated satisfactorily after several bougies had been passed through the os uteri, but I never succeeded in penetrating completely into the cavity of the uterus, either from an obstruction in the cervix, or, from what appears to me to be more probable, a curvature of the canal. Nevertheless, after di- lating the passage as far as could be reached, (up to No. 7, bou- gie,) she menstruated naturally, freely, and without pain, and her health became wonderfully improved. It is but fair to men- tion, however, that this case vvas also complicated with extensive constriction of the rectum, which, I fear, is not yet completely removed^' 116 SUPPRESSION OF THE MENSES. Sect. II.—2. Of the Suppression of the Menses. By a suppression of the menses, we are to understand, the want of return of this discharge at the accustomed period, after it had been well established, when not interrupted by pregnancy or suckling. J For, however well established the menstrual discharge may be, it is liable to be interrupted from a variety of causes, inde- pendently of pregnancy and suckling. The little regard which the generality of females pay to this period, exposes them too frequently to a derangement of the menses; nay, some I have known so reckless of consequences, as designedly to interrupt > them, by putting their feet in cold water when engaged for a party of pleasure. Frank mentions the case of a young lady who put her feet se- veral times in cold water during the flow of her menses, because ; she expected her lover, which quickly arrested them; an inflam- I mation of the womb followed, and she was brought, dying, into the hospital at Vienna. He also states, on the authority of a cele- brated surgeon of Helmstadt, that a young lady was attacked with I amaurosis of one eye, in consequence of the sudden suppression I of the menses from putting her feet in cold water—and when this I discharge was recalled, she fortunately recovered the sight of her I eye. And of one of his relations, of fine health and rare beauty, fl who, after having danced all night, with her menses on her, left T the ball-room in full perspiration; she would not wait for her I carriage, but proceeded home, which vvas not far off. She was attacked with metritis, and died on the fourth day, It is not, perhaps, unworthy of observation, that amaurosis has followed in a number of cases, the sudden stoppage of the menstrual discharge. In addition to the case just related by Frank, we may add the one by Mr. Brown, in vol. XXVI. of the Edinb. Med. and Surg. Journ. p. 279. In this case the patient was about forty years of age—she had become very much heated by a long walk in hot weather—at the end of her walk she was seized with her cata- menia, but which vvas entirely suppressed by a drink of cold milk; this vvas followed by headach, oppression, hemiplegia, and amaurosis of the left eye. Mr. B's. attention vvas directed to the restoration of the menses, in which he succeeded in about six months; at which time her sight was restored. Perhaps the SUPPRESSION OF THE MENSES. 117 suppression of any sanguineous discharge might have the same consequences—that the eyes are particularly liable to affections from such like causes, is rendered at least probable, by the case of spectral illusion from suppressed haemorrhoi's, related in Hufe- land's Journal, for September, 1824. "A gentleman of Carlsruhe in Silesia, sixty years of age, and of upright character, liberal, unprejudiced, constantly engaged with his profession, and inclined to nothing so little as to com- munings with the kingdom of spirits, had long enjoyed good health, except that he had occasional colic on exposing himself to cold, vvas liable from time to time to a hemorrhoidal flux, and had a cataract in one eye, and dimness and weakness of sight in the other. A short time before he was seized with the affection about to be related, he received a visit from his niece, who was far advanced in pregnancy, accompanied by her husband. Soon afterwards the family received an alarm from a house taking fire near their dwelling. On the evening of that day, his wife re- marked that he was restless, and put questions in a singular way. About six, when the candles were lighted, he insisted with his wife, that his niece had entered the room, taken his hand, and retired on his rising to meet her; that her husband escorted her; and that three other persons whom he did not know were also in the room. On going up stairs to supper, the spectral company went along with him, and after supper they returned with him to the lower room, and two of them went to bed with him. At length, tired of the illusion, he drew the coverlet over his eyes, and, leaving the spectres to their fate, fell asleep. Next morning his spiritual friends did not make their appearance; but a new illusion of sight took their place. He thought the walls of his apartment were all checkered like a chess-board, and so vivid vvas the deception, that it obliterated a number of engravings which hung on the walls. This lasted two days, and after it dis- appeared, his vision returned to its "natural state. For some time after, he complained of weakness, giddiness, and anxiety in the chest. His appetite, however, was good; he slept well; and the pulse vvas natural. He had not had any hemorrhoidal discharge for some time before. Gentle laxatives; bathing of the feet; and afterwards the tincture of cinchona, restored him soon to his usual state of health. His mind, excepting so far as regarded the spectral illusions, appears to have been quite entire." Cold, in some form or other, may be considered as the most 16 118 SUPPRESSION OF THE MENSES. frequent remote cause of this suppression; and it may be applied either in the interval, just as they are making their appearance, or after they have flowed some time. When cold is applied in the interval, with sufficient force to prevent the recurrence of this discharge, the first notice the wo- man has of its influence is, the want of return of the menses at the period next expected. For the most part, at first, neither pain, nor other inconvenience is felt; but if they have failed for several periods, the approach of ill health is then perceived, and she becomes an object of medical care. She now becomes pale, emaciates, and is much enfeebled—a train of nervous symptoms may be superadded; as palpitation of the heart, difficulty of breath. ing, a sense of suffocation, especially after any thing has hurried the circulation—to these fluor albus may be added, which soon aggravates the previous unpleasant symptoms. If cold be applied when the menses are about to appear, or after they have flowed some time, the symptoms may be very much varied: in such cases, the patient is attacked with violent pain in the head, back, or bowels; and this with such severity, some- times, as to create great anxiety for her safety. I have known temporary derangement, violent hysteria, and severe colics, re- sult from this cause. For the relief of these, we are obliged to have recourse to blood-Jetting, purging, warm bath, camphor, opium, asafcetida, &c; and, for the time being, are necessitated to treat the complaints as if they were independent of such a cause. For we can very rarely re-establish the discharge, after it has been thus interrupted; nor should it always be attempted; for sometimei ■ much injury is done by neglecting the consequences of this stop- page, by directing the force of our endeavours to a recall of the discharge. I admit, that after bleeding and purging have been performed, advantage is sometimes derived from either the gene- ral or partial warm bath, or hot fomentations to the abdomen, especially if pain be experienced in the region of the uterus. Should pain be severe, I have found nothing answer so well as an injection composed of a gill of thin starch, a tea-spoonful of lauda- num, and thirty grains of finely powdered camphor. If it be com- plicated with hysteria, the addition of three tea-spoonsful of the tincture of asafcetida, instead of camphor, may be useful; this may be repeated pro re nata. If colic supervene upon the interrup- tion of the menses, (after bleeding, should the pulse have in- dicated it,) I have found the most certain relief given, by half- SUPPRESSION OF THE MENSES. 119 ounce doses of the elix. proprtetat. every three hours: in warm sweetened milk, until the bowels are open. Having pointed out, in a cursory manner, the plan of treat- ment for the consequences of a sudden interruption of the menses, I shall now proceed to the consideration of such measures as will tend to invite their return. In doing this, I must be considered as speaking of the idiopathic suppression only, and of the mode of treatment proper for it. I must here premise, that I do not look upon every deviation in regularity, as a legitimate reason for medical interference; for in many instances with young girls, and especially those who began precociously to menstruate, there will be a want of precision in return, that must not be mistaken for disease; for, did we subject the woman to medical treatment for every aberration of this kind, we should be condemning her to most improper discipline. So, also, it many times happens with hale, robust young women, that a temporary suspension of the menses takes place from cold, or passions or emotions of the mind,* but which after a certain time will return without medi- cal application, or even the slightest premonition. My rule on this point constantly is, never to interfere, unless there be some evidence that the health is suffering by the absence of this dis- charge. For it very often happens, if we draw blood, (especially perhaps from the foot,) to the amount of eight or ten ounces, or as near as it can be ascertained, that the menses should flow if they were not obstructed, we very often succeed in immediately removing the obstruction. The general health rarely, if ever, suffers, before three or four successive periods have passed, unless this obstruction be accom- panied by a bad state of fluor albus. If this attend, the health may be earlier affected; and then require to be immediately noticed. The remedies for this condition of the system will vary accord- ing to the state of the system; and I cannot too earnestly re- commend attention to this important practical point, as success in the treatment of these complaints, almost exclusively depends upon the discrimination. Perhaps there is not in the whole range of medical practice, such a departure from principles as in the • A lady informed me, that while menstruating, she fell down stairs; and from that moment,'the discharge was suspended; nor did it reappear, until the next period. And a case is related in the Lancet, where a suppression took place, from a violent fit of passion. Lancet, Vol. I. Case ix. p. 497. See also Case, p. 126. 120 SUPPRESSION OF THE MENSES. treatment of certain female complaints—they seem to be pre- scribed for with determined empiricism; as if the laws which go- vern disease in general, were not applicable to them. The want of success, in many of the complaints of females, is owing almost altogether to the determination to discover specifics for them; for the existing condition of the system is never taken into calcula- tion, when a prescription is made; hence, the almost uniform failure of certain remedies in the hands of some practitioners, which are almost as uniformly successful in the hands of others. A practitioner acquires, by long habit, and correct observation, a control over certain diseases, that will not yield even to the same remedies, when indiscriminately used by others—this tact in the use of certain medicines, is but the result of accurate observations on the various conditions of the circulating system; and when this study is neglected, it is a moot point whether the remedy succeed or not. In prescribing, then, for the disease, or rather derangement, under consideration, it were almost hopeless to employ remedies without the strictest attention to the existing state of the circu- lating system; the remedy which will relieve in one case, may not only be unavailing, but perhaps injurious in another; it there- fore behooves every one to become familiar with the various states of the pulse, before he prescribes his remedies, if he ex- pect to succeed by their employment. The fear of debility has occasioned the death of thousands; and perhaps to the end of time it will have its victims—every inter- ruption of a natural action, which may involve the system at large, with nine-tenths of the writers upon diseases, originates io debility; hence the whole class of diseases we are considering, is supposed to either originate in, or be perpetuated by weakneu: thus fluor albus, and the deranged conditions of the menses, are considered as diseases of weakness; than which, as a general rule, nothing can be farther from the truth. The most opposite reme- dies will, in their turn, remove the same diseases; and the person who cannot understand the reason of this simple fact, will never be able to combat them with success. Having stated some general notions on the management of the complaints under consideration, I shall now proceed to detail the practice essential in each particular slate of the system. When the suppression is of recent date, that is, not more than of three or four months' standing, I almost always find that the pulse, so SUPPRESSION OF THE MENSES. 121 far from betraying marks of debility, manifests a tendency to an excess of action: when this is the case, we should commence the treatment with such remedies and regimen as will reduce the pulse to a proper standard, before we proceed to the exhibition of such medicines as shall have a direct tendency to produce the menstruous discharge; which is to be done, by blood-letting, by purging, and by a strict vegetable diet. This plan is so effective, in some cases, as to require nothing more for the re-establish- ment of health; and in others so indispensable, that success can only result from its employment as a preparative step. 1 will illustrate both of these states by appropriate cases. Case First. Miss-----, after having stood a long time on a damp brick- paved cellar on a hot day, and at the warm employment of" pre- serving," found herself chilly, and her menses arrested: her mother had her daughter's feet put in warm water, and gave her some hot pennyroyal tea; this removed the chilliness, but did not restore the discharge; she was occasionally taking remedies without effect, until some time after the third month; at this time she became more indisposed, and I vvas requested to visit her—I found her labouring under severe headach, which was much increased by sitting up, or motion; her pulse full, and a little quickened; her tongue slightly furred, her appetite im- paired, and her bowels costive. I directed her to lose twelve ounces of blood; to be freely purged by senna; and to confine her- self to rennet-whey, barley water, or thin tapioca, for nourishment. Her symptoms were much less severe next day, but not en- tirely removed—I ordered another dose of senna tea, and the same diet to be continued: on my next visit she appeared per- fectly relieved; but I insisted on her using a spare diet for some time longer, and to take an aloetic pill every night: this plan was pursued for several days, at the end of which time her menses made their appearance. Case Second. Miss-----, after a stoppage of her menses for four months, de- sired my advice; her health of late began to suffer considerably— she vvas pale and emaciated; had some fluor albus; headach; loss 122 SUPPRESSION OF THE MENSES. of appetite; and was readily agitated by slight causes; much pal- pitation of the heart; especially on going up stairs. Ilcr pulse was tense and hurried, skin hot, and tongue considerably furredj especially in the morning. I ordered her to lose ten ounces of blood; to be purged by senna, and to be confined to a vegetable dief. She was relieved by these remedies; but as the force of her pulse was not entirely subdued, I thought it best to keep the bowels loose, and confine her still to a vegetable diet. This plan vvas strictly persisted in for about ten days, which reduced her pulse sufficiently to bear the tincture of cantharides, in doses of five and thirty drops, three times a day: in a few days the fluor albus stopped; and in a few more, the menses made their appearance. Upon these two cases, I shall merely remark, that had I given any emmenagogue medicine in the commencement, I should not have had the pleasure of seeing my patient so quick- ly restored—or, in other words, had these cases been treated as cases of debility, I am certain the complaint would have been aggravated; yet, in the last, there were strong marks of debility, agreeably to the common notions upon this subject. The madder may be given more safely than any other remedy with which I am acquainted, without such particular attention being paid to the pulse, as it excites no increase of action in it. I am in the habit of using this drug without previous prepara- tion, when applied to near the period at which the menses should appear; and sometimes succeed most promptly with it— indeed, this is the only time at which it seems to be successful; for if it fail then, it is rarely more fortunate afterwards.* When the madder fails, I commence, in recent cases, with the tincture of cantharides, aftpr having duly prepared the system for its reception. I rarely increase the quantity more than ten or fifteen drops beyond the original dose, as the moderate doses of thirty-five or forty have always been found sufficient with me, when the medicine would succeed at all. Should the can- tharides fail, the volatile tincture of guaiacum is then ordered: which, when exhibited in proper cases, has never yet failed in my hands. I give it, for this purpose, with a confidence I attach to no other medicine. This confidence is the result of very many years'experience of its efficacy. I have often succeeded with it, where almost all the other emmenagogues have failed; nay, I have •Seep. 112. SUPPRESSION OF THE MENSES. 123 done more; I have found it to answer completely, after it was said to have had a fair trial—but this fair trial was very far from being so.* As it is much more stimulating than the madder, or cantharides, I am more attentive to have the system properly prepared. I therefore generally reduce the pulse lower, than for the medicines just named: this is easily effected by the loss of a little more blood than in the other cases; purging more freely; and insisting on a low diet, for a few days. When speaking of the tact that is acquired in the administra- tion of certain medicines in certain diseases, I had particular re- ference to the employment of the tincture of guaiacum as an em- menagogue. I have, for more than forty years, almost daily used this medicine, in suppressed catamenia; and more especially, in those of long standing, without Us having failed in any case pro- per for its usef—more cannot be said of any remedy. I say this in the most perfect good faith, as I have learned that some of my brother practitioners have not been equally success- ful with it—but I think I can readily account for their failure: 1st, From their not placing the system in a proper situation for its use; and, 2dly, by not properly persevering in the remedy. Neglecting these important points, it can readily be imagined, that it may not succeed; for I deem an attention to them essen- tial to its success; more especially in those cases, where many months of interruption have existed. I think one of its superi- orities consists in its certainty in cases of very long standing; and I could readily furnish, from my note book, a number of instances, where it succeeded to restore the menses after an interruption of from nine months, to nearly three years. * Mr. Jewel has used this tincture in the MiddJesex Infirmary, and remarks, "In the administration of this medicine, it is but justice to state, that I have ex- perienced that, which in common we experience from all—occasional disappoint- ment: at the same time, I conceive there is no medicine whose effects are more certain, provided the catamenial suppression does not exist as a consequence of any organic disease."—Lond. Med. and Phys. Journ. And Dr. Macleod, the editor of this Journal, in a note to Dr. Jewel's Report, says that he has been in the habit of employing the medicine, "and, in general, with very satisfactory results." ■J- liy a proper case, I mean, where the suppression is idiopathic, and not one, in which the uterus has its functions interrupted by disease, or pregnancy—for, in the latter, I have in two or three instances been imposed upon, notwithstanding all my caution; and where I dared not suppose this condition to exist. But by these-few cases, I learned, so far as they would go, that it would not produce abortion. 124 SUPPRESSION OF THE MENSES. The mode of using it is, a ten-spoonful every morning, noon, and evening, in a wine-glassful of sweetened milk ; or, where not forbidden by some peculiarity of circumstance, as much white wine, as Sherry, Teneriffe, or Madeira. The dose must be gra- dually increased, in those cases where a perseverance beyond four or five weeks becomes necessary. Should this medicine disturb the bowels too much, a few drops of laudanum must be added to each dose; but if, on the contrary, they should notbesufficiently opened, the addition of a little of the resin of jalap, or of pow- dered rhubarb, will be an improvement. As the tincture I employ is different from the tincture of the shops, I think it right to subjoin my formula. g<. Pulv. G. Guaiac. opt. 3£iv. Carbon, sod. vel potas. jiss. Pulv. Piment. - - - !§i. Alcohol, dilut. --- fly. digt.—for a few days. The volatile spirit of ammonia is to be added, pro re nata, in the proportion of a drachm, or two, to every four ounces of tinc- ture; or less, or more, agreeably to the state of the system. M. Guibert highly recommends the use of Venice turpentine, in the amenorrhcea of feeble, nervous women of lymphatic tem- perament. He directs the following form for its exhibition:— £. Terebinth, veneta. sjij. Sapo. venet. - - giij. Pulv. Rad. Glycyrrh.' q. s. f. mass. div. in pil. lxxv.—Two to be taken every four hoim He says, that he is rarely obliged to continue this medicine be- yond twelve days, even in inveterate cases. Dr. Lavagna has published a number of cases treated with in- jections of ammonia in solution. They are highly interesting, as they discover a new resource in this sometimes highly obsti- nate derangement of the menstrual action. He observes, "If we consider the different medicinal sub- stances which compose the list of supposed emmenagogues, and the consequences which generally follow retarded or suppressed men- struation; if we examine the mode in which these substances act on the human body, it will be readily perceived that the ani- mating influence of love, and the physical effects of a rational in- dulgence of the desires by which the species is reproduced, cor- respond with the practical views by which we arc guided in the SUPPRESSION OF THE MENSES. 125 treatment of amenorrhoea." And he adds, « There is hardly a physician, however limited his practice, to whose lot it has not fallen to observe young females, who, at the age of puberty, were dull, languid, pale, and labouring under scanty menstruation, sud- denly restored to bloom, animation, and vigour, and to the salutary sanguineous evacuation, by an opportunity being afforded them of participating in conjugal duties. Whenever I reflected on this fact, and considered the numerous coses by which it was esta- blished, I never doubted that any stimulating medicine which might have the effect of determining an increased sanguineous afflux to the matrix would succeed in exciting suppressed men- strual evacuations. Under this impression, I determined to make a trial of liquid ammonia, in cases of amenorrhoea. This highly stimulating volatile medicine, added to warm milk, or any other fluid, if injected in suitable quantity into the cavity of the matrix, or along the canal of the vagina, is calculated to produce a sen- sation of orgasm, similar to that which is known to be most fa- vourable to the cure of suppressed menses." Lancet, Vol. I. p. 497. We have thought proper to introduce to the reader, the rea- soning of Dr. Lavagna; and though we do not altogether agree to his theory for "restoring the suppressed menses," we never- theless think, that the cases by which he illustrates his practice, are no less important than convincing. We are of opinion, that his plan should be tried in cases where the ordinary means have failed: these, however, we are disposed to believe would be few, if the plans we have suggested were correctly put in practice, and duly persevered in. It is true, that the remedies we have pro- posed, require oftentimes a long perseverance, and the stomach loathes them, from their quantity and constant use. Yet with , these certain disadvantages, we are of opinion, that the unmarried women in this country, would very reluctantly submit to the al- ternative, however imperious the necessity. The mode of using it is, to throw up the vagina, by means of a female syringe, ten or twelve drops of the aqua ammonia purse in an ounce of milk or water, four or five times a da)'. It should be of such strength, as to excite an unpleasant irritation in the part, after each trial of it. If this prove rather excessive, the ammonia should be more diluted, or used in a smaller quantity. It would appear from the history of Dr. L's. cases, that some un- pleasant feelings are essential to the success of the remedy. If there be no mistake in the details of the cases, the action of 17 126 SUPPRESSION OF THE MENSKS. the ammonia was very prompt, even where the suppression had assumed a chronic form.* Most of the cases required a perseve- rance of but a very few days in the injections. And, as a last resource for the girl under such circumstances, marriage, from the time of Hippocrates downwards, has been re- commended, though of late, with less confidence than formerly. As a mechanical irritant it may be occasionally useful, though our | own experience goes but a little way to confirm its utility. For we are of opinion, that authors have been led into error upon this point, by not discriminating between the sanguineous discharge, I after a first coitus, and which is consequent either to the rupture of the hymen, or from the severe distention of the parts, and a genuine menstrual discharge—for the first almost invariably takes place with virgins, though they may be perfectly regular, and J may have menstruated, but a few days previously. There is another remedy proposed by Dr. C. Patterson, namely, stimulating the external surfaces of the mammae; which we give for what it is worth, until experience decides upon its powers. Catherine Power, aged 19 years, applied to me on the 14lh \< Sept. 1832. She complained of headach, languor, loss of appe- tite, and inability to attend to her usual business, that of a ser- vant. She stated, that, about the middle of April, the menstrual discharge being then present, she incautiously exposed herself to cold in washing clothes at a river. The catamenia then suddenly ceased, had not since returned, and from that period she had been constantly subject to ill health. She had consulted differ- ent medical gentlemen, and taken a great variety of medicine!,-: with little advantage. I directed that the clavicular half of the right mamma should , be covered with a sinapism. It was allowed to remain on for thirty minutes; and on visiting her in six or seven hours after ill removal, I found the whole right breast considerably swollen, hot, and painful. The next morning the enlargement of the mamma vvas very much increased, the tumefaction having extended to the clavicle and axilla of the irritated side. There vvas no hard cir- cumscribed or prominent tumour, but a painful diffuse elastic di«- • Dr. Hosack (New York Med. and Phys. Journ.) declares, he treated a ca« successfully, of ten years' standing, by means of this remedy, after many othfl* had been unavailingly employed. He directed a drachm of the ammonia, and* pint of rain water, to be thrown up the vagina, three times a day. The curt was effected in five weeks. I am soiTy I cannot confirm the favourable account of Drs. Lavagna and Hosack—in my hands it lias utterly failed. SUPPRESSION OF THE MENSES. 127 tention of the mammary gland and surrounding cellular sub- stance. On the evening of the day next succeeding the applica- tion of the sinapism, the poor girl, with much joy, reported that the catamenia had appeared. The flux having continued for three or four days in moderate quantity, she then found herself greatly relieved of the headach and other most distressing symp- toms; and in a week her health vvas so far restored that she ceased to require any farther attendance. In this case cold evaporating lotions and gentle saline aperi- ents were employed to moderate the local phlogistic engorge- ment. She has continued to menstruate at her regular periods. From the facility with which the menstrual flux was induced in the preceding case, it would seem that the beneficial effects, in amenorrhoea, lately observed to arise from the long continued. daily application of one or two leeches to the breasts, was en- tirely owing to the great irritation which the leech-bites had eventually produced in these organs. The abstraction of blood by leeches from the mammae, has not, according to the reports of the cases in which they were employed, the least perceptible influence over the uterine functions, until pain, heat, and ex- cessive tumefaction of the breasts had been first developed. Phlogistic engorgement of the mammae being, then, the essen- tial movement, which, in this instance, determined the flow of the cateTnenial discharge, it must be obvious, that, for the pro- duction of the necessary irritation to effect that engorgement, the simple application of a sinapism would have been, in every respect, infinitely preferable to the tedious and troublesome process of the daily repetition of leeching. But it must not be supposed that mammary irritation is applicable to every form of amenorrhoea. I know that it will not be successful in every ease, for I have found it to fail. Analogous to suppression, may be considered the very sparing quantity of the menstrual discharge—this may happen, 1st, to young women in the prime of life; and, 2dly, to women pretty far advanced towards that period, at which the menses are about to cease. With the first, when the usual quantity fails to be dis- charged, it always excites alarm, and recourse is almost instantly had to the nostrums of old women, or perhaps regular application is made to the physician—I have seen many of these cases; and they may be classed under two heads;—1st, Where this takes place from some accidental irregularity in the secreting powers of the uterus; and, 2dly, Where there is too early a tendency to 128 SUPPRESSION OF TUE MENSES. cessation. The first may be again divided into two states: 1st, When, after it has continued some time, the health seems to be impaired pretty much after the same manner, as if a decided suppression were present; for it has very much the same accom- panying symptoms; and, when this happens, the complaint, for the most part, seems to be relieved by the same remedies; espe- cially, by the tincture of cantharides.* In the second state, it seemed to be, in a number of the instances which fell under my notice, an habitual condition of the uterus; and, though the quan- tity discharged vvas sometimes extremely small, yet all the natu- ral or prolific powers of the genital system appeared to be pre- served; for I have known pregnancy to follow in several cases. I have prescribed all the usual remedies for each of these cases, without effecting any change in the quantity discharged; yet, after marriage, some of these women became mothers. I have, therefore, of late years, not interfered with them, where there was no evidence of ill health. However, it must be confessed, though ill health may not attend, some who are thus circum- stanced are not fruitful; but in these, so far as I have seen, it has been the anticipation of a final cessation. I have met with three instances, where this evacuation had ceased altogether before the twenty-fifth year; and two before the thirtieth year—the health of these women appeared to be as perfect, as if they had had this discharge in its most regular manner. When scanty menstruation takes place in women in the de- cline of life, it is not generally so regular in its periods as in young women; yet, as we have never witnessed any unpleasant consequences to arise, we never thought it proper to interfere; especially in women after their five and thirtieth year. This condition of the menses is more apt to take place in unmarried women, and in widows, than in married women. In some instances of young married women, I have had strong reason to believe it was owing to a deranged condition of the ovaria; for they were not only barren, but had never discovered any desire for sexual intercourse; or, at least, were perfectly in- different to it. It would seem to follow, from these observations, that the cases of deficient menstruation, in which the health appears to suffer in a greater or less degree, are those of the most easy manage- * Dr. Lavagna uses the ammoniacal injections in these cases, with apparent success. IMMODERATE FLOW OF THE MENSES. 129 menl; but, in the treatment of them, the same regard must be paid to the condition of the vascular system, as if an absolute obstruction existed—I shall relate a case, by way of illustrating the material points in question. Mrs.----, aged twenty, during a period of her catamenial flow, suddenly heard of the death of her absent husband—the menses were immediately suspended, and continued so for five months; during which time she suffered much from a train of most untoward nervous symptoms: at the end of five months there was a slight show, which vvas repeated at the end of another month, and so on, for two or three periods: but her health did not improve, as was fondly hoped, by this slight discharge, and I was now consulted. I found her, as stated above, with a variety of nervous symptoms; which were easily exacerbated by the slightest mental distress; together with considerable leucorrhcea—much headach; hot skin towards even- ing: costive bowels—she lost ten ounces of blood; was purged by aloes and rhubarb; kept upon a milk and vegetable diet; took the tincture of cantharides; and the next month she had an ample discharge. Sect. III.—3. Of the Immoderate Flow of the Menses. This complaint is much more rare than we should be led to believe, did we regard popular opinion; or even some of the writers of practical systems of either medicine or midwifery. 1 have seen, comparatively, very few cases of superabundant menses—for in my consideration of this subject, I shall confine myself to what should be strictly called an inordinate menstrual secretion. This complaint has been very often confounded with uterine hemorrhage;* because the latter almost always com- mences with a genuine menstrual evacuation, which continues for two or three days, and is then followed by a discharge of pure common blood; all of which, by careless observers, has been classed under an "immoderate flow of the menses." Should this confusion be admitted into the description of this complaint, we need not be surprised at the avowed frequency of immoderate menses. There is an almost endless variety of uterine constitution, if I may so term it; consequently, there will be a corresponding va- * Mr. Burns says, "some women menstruate more copiously or more fre- quently, than by the general laws of the system they ought to do. The dis- charge is menstruous, and does not coagulate, which distinguishes this state from uterine hemorrhage." Vol. I. p. 155, James's Ed. 130 IMMODERATE FLOW OF THE MKNSES. riety in the performance of its duties: hence, one woman will discharge twice or three times as much of the menstruous fluid us another, without suffering from this apparent excess. For, as re- spects this discharge, excess must be regarded as a relative term; and it should only be considered excessive, when it has an injii- rious effect upon the general health; if it produce no debility, or other disagreeable symptoms, we have no right to call this dis- charge immoderate, or excessive; for it is only so, as compared with those who may evacuate less, but yet be in no better health. 1 must therefore repeat that this discharge, in excess, is of very rare occurrence; and that, so long as it does not impair the con- stitution, it should never be meddled with ; especially if it be not inimical to impregnation. I am well acquainted with a lady, who has more than once as- sured me, that from her earliest recollections of this discharge after it had commenced, (which was at her twelfth year,) she never enjoyed a longer exemption from it than ten days, unlea she were pregnant, or suckling; yet, during the whole of that time, she had never suffered the slightest indisposition that could be attributed to that cause: she was, therefore, two-thirds of her time, with the exceptions just mentioned, giving issue to this discharge. She also declared her belief, that, from what she could learn from others, she evacuated daily, as much as women in general; consequently, she must have parted with at least three or four times as much as is commonly lost during a com- mon period. Should this complaint prove excessive, in our acceptation, of the term, namely, where health suffers from this cause, it should be treated, perhaps, as a hemorrhage, properly so called—I say perhaps; because, I have seen but one case, where, from the quantity of the discharge, debility, and other evils, were induced; and this case was treated as a common hemorrhage. Miss-----, aged seventeen, was seized with a severe tertian, which, before it could be arrested, required much depletion, and left her for some time in a state of great weakness. After it was thought she was recovered, her menstrual discharges became very abundant, and recurred, as they were always wont to do, every three weeks. The quantity discharged vvas very great, as far as could be determined by the pulse at the time, and its appearance upon the cloths. She was very feeble, and was confined to her bed from weakness, before I visited her. I saw her when her men- strual period was upon her; she was greatly reduced in strength, IMMODERATE FLOW OF THE MENSES. 131 and vvas much emaciated. Her pulse was frequent and weak; her feet and hands cold; she was extremely pale; distressed by palpitation of the heart; ringing in the ears; and great sickness of stomach. She was immediately ordered to have bottles of warm water placed at her feet; to take thirty drops of laudanum, with as much of Hoffman's anodyne liquor; two grains of the sugar of lead, with a third of a grain of opium, every hour, until the discharge should be moderated. The character of the discharge I was particular to ascertain; and, from the most cautious examination, I had no hesitation to believe, (contrary to my first impression,) that it was a genuine menstrual flux, of unusual severity. By the plan just mentioned, the discharge was much moderated in the course of a few hours; but early the next morning, I was sent for in great haste, as the flow had very much increased. I now ordered twenty grains of the sugar of lead, a tea-spoonful of laudanum, and a gill of lukewarm water, as an injection—this quickly ar- rested the discharge; which did not return from that time; if we except a very moderate stillicidium of three or four days' con- tinuance. In the interval, a nourishing diet was directed—quiet, and a mattress to sleep upon; also twenty drops of the elixir of vitriol, in strong, sweetened rose-leaf tea, four times a day, and the bowels kept open by small, but repeated doses of the sulphate of magnesia. On the arrival of the next period, she was again attacked with a flow as abundant as on the former occasion; the same remedies were again successfully employed. During the succeeding interval, two grains of the sacch. sat. every morning, noon, and evening, were ordered in lieu of the vitriol; she was directed to drink freely of cold chamomile, and orange-peel tea; a plaster of Burgundy pitch to be applied to the back; and the legs and feet to be kept very warmly clothed. The next discharge was considerably more moderate, but still too abundant; the sugar of lead pills were now given every two hours until the flow should cease. The interval was conducted as before; and, after this time, there was no farther necessity of medicine. Exercise, and sea-bathing, very soon confirmed her health; nor did she afterwards suffer any return. The plan just detailed proved successful in the instance men- tioned; but whether it would be so in other cases, my limited experience in "excessive menstruation," will not permit me to declare—though I am disposed to think it might; and, under simi- lar circumstances, I should certainly adopt it. 132 PAINFIT, MENSTRl'ATION. Sect. IV.—i. Dysmcnorrhwa, or painful Menstruation. This disease is very common in our climate; and is one from which not only great suffering is experienced, but also very fre- quently one of great obstinacy. The woman is obnoxious to it during every part of the menstruating period of life. It would, perhaps, be very difficult to assign all its remote causes: the most common are, the application of cold during the flow of the menses; taking cold after abortion; and, in several in- stances, I have known it to follow the consummation of marriage. This latter cause is, perhaps, the most difficult of explanation; for it would seem to have no such agency, reasoning a priori. In a number of other instances, the causes appeared to be so hid- den, as not to be cognizable. The married and the single woman are alike subject to it. The suffering, at the menstrual periods, is sometimes severe beyond description: it resembles, in intensity, the pains of labour, or of abortion, properly so called; for, to either, the case may be said to have a strong analogy. It usually commences by a slight menstruous discharge, which is pretty suddenly arrested: pain now almost instantly ensues; this is described by women to be of a forcing, bearing down kind; returning at longer or shorter in- tervals, until a membranous substance, or small coagula, are dis- charged.* If it be a membranous substance, it will be found of unequal size; sometimes small, at other times large, and some- times it resembles the cavity from which it has been expelled; at other times, it will be broken into many fragments. After the expulsion of this substance, the woman enjoys ease, unless there * It is to be lamented that gentlemen who quote the opinions of others, should not give such opinions fairly. Dr. Eberle, in " offering some remarks upon the pathology and treatment of Dysmenorrhoea," (Western Journal,) states that "some writers, and among these, Dr. Dewees, seem to think that this complaint depends invariably on the formation of a psuedo-membranous substance over the internal surface of the uterus, by which the orifices of the menstrual exhalanti are obstructed." Now, it is only necessary to compare the text with this quota- tion, to absolve the author, at least, from such a sweeping assertion, and to prove how carelessly Dr. E. must have read,—for I neither say that the formation of i membranous substance is essential to dysmenorrhoea, nor intimate that "the ori- fices of the menstrual exhalants are obstructed." I mention that either a mem- branous substance or coagula are formed, and I believe that this obtains in all cases of uncomplicated or idiopathic dysmenorrhoea—when pain attends the menstrual process, without either of these products, it will be found that the pa- tient is labouring under the " irritable uterus," and not dysmenorrhoea. PAINFUL MENSTRUATION. 133 be a fresh production; in which case it requires, for its expulsion, fresh contractile exertions of the uterus. The quantity discharged is very various; sometimes it is small, and at other times very abundant. I have seen a portion not much larger than my nail; and, again, 1 have witnessed as much as would fill a large tumbler. The periods employed for the ex- pulsion of this substance also vary; sometimes requiring but a few hours, at other times several days. The degree of suffering is not always in proportion to the quantity of the substance ex- pelled; indeed, the pain would rather appear to be less, when much is discharged; which, perhaps, is not of difficult explana- tion. There appear to be two distinct states of this affection: one, where the mammas sympathize with the uterus, by becoming tu- mid, and oftentimes extremely painful; the other is, where there is no such affection. These two conditions are not equally ma- nageable: the one accompanied with painful breasts, so far as my observations have gone, is the more so of the two. Dr. Eberle, in the paper just alluded to, confirms the correct- ness of these observations, and offers the following exposition of this sympathy. He observes that I have offered no explanation; but he thinks it admits of one, and says, " I have observed, for instance, that in nearly every case, where the breasts become tumid and painful, the concreted pseudo-membranous substance, (if any is cast off,) is thick, and of much consistence; and in those where the mammae do not sympathize, it is usually thrown off in the form of a thin membrane. In the former case, the uterus is much more distended, approaching the condition of early pregnancy; and we may presume that this state would be most apt to awaken the uterine sympathies, and thus to excite the mammary glands." To this explanation we would urge the following objections— first, that we have never observed the connexion between the condition of the mammae, and thickness or thinness of the "pseudo-membranous substance;" for we have known this sym- pathy to take place where the quantity discharged vvas very small, and we have known it absent where this product was abundant, and where even small coagula were discharged. Se- condly, because Dr. E., himself, admits the same thing, virtually; for, he says, that " In nearly every case where the breasts be- come tumid, the concreted pseudo-membranous substance, (if 18 134 PAINFUL MENSTRUATION. any is cast off,") &c. Now, is it not evident, that the doubt con- veyed by the words "if any is cast off," implies that he has seen instances of mammary sympathy, without this substance, (either thick or thin,) being cast off? And if this be so, what become* of his explanation, since it altogether depends upon the thick- ness and consistency of the false membrane? Thirdly, Because we do not consider the substitution of one inexplicable pheno- menon for another equally inexplicable, as an explanation—for suppose this membrane should irritate the uterus so as to cheat it into the belief, that it was "approaching the condition of early pregnancy," has he informed us, or does any body know how this change is effected in the mamma; by every conception? We are all aware of the fact, but we can offer no " explanation " of it. Fourthly, Assuming Dr. E's. "explanation " to be correct, does it inform us why such cases are the most easily reliey^dj^-4 Besides the alternate or labour-like pains, just mentioned", tuete is almost always a permanent one in the back, hips, and loins, which continues until the alternate pains have ceased; indeed, this aching pain sometimes precedes the other, and announces the discharge to be at hand. In another place, I have declared, that the menstruous fluid is the product of a secretory process;* I have there given my rea- sons for this opinion; I now assume it as a principle; and upon this principle, attempt to account for the formation of the mem- branous production, so often yielded in dysmenorrhoea. But, be- fore I attempt an explanation of the formation of this membrane, I must again direct attention to a very remarkable circumstance in the character of the menstrual blood, namely, its not possess- ing the property of coagulation. From this, it appears that the blood, or a part of it, has suffered some change by the action of the uterine vessels; and that this change has been imposed upon the coagulating lymph, by the process of secretion. I have as- signed reasons for this change, when speaking of menstruation.! Now, it is not difficult to suppose that the uterus, like every other organ, may have its functions or actions changed, or al- tered; in consequence of which, the texture of the coagulating lymph, instead of being so subdued as to prevent coagulation, as it is wont to be when the uterine secretory action is perfect, re- mains nearly the same as when it entered this viscus; except that • See p. 98, et seq. f See p. 97. PAINFUL MENSTRUATION. 135 it may be attenuated, as in some inflammatory diseases: and it will, from this imperfect elaboration, be thrown into the cavity of the uterus, without being dispossessed of the power of sepa- ration, and of coagulation. It is poured into the uterus in a very gradual manner; and, from this circumstance, may tarry there sufficiently long to se- parate into its constituent parts: for it now resembles common blood; the coloured part, or red globules, from their greater weight, will leave the imperfectly subdued coagulating lymph, and fall to the bottom of the uterus, and, sooner or later, be dis- charged; while the coagulating lymph, either in part or altoge- ther, will be left to spread itself over the internal face of the uterus, and there quickly assume, as is usual with it when in contact with living parts, the appearance of a membrane.* This membrane will be, to all intents and purposes, an extraneous sub- stance to the uterus; and will sooner or later urge it to repeated contractions, to throw it off; which contractions will be painful, like those of labour: hence, the pain in this kind of menstrua- tion. Dr. Eberle considers this explanation as contrary to sound pa- thological principles, and to the import of the essential pheno- mena of dysmenorrhoea, and proves this by ringing the changes upon the word "impaired." Now, this word, as connected with the other portions of the text, does not mean " weakened," but merely altered, or changed; and if this explanation of its mean- ing be accepted, Dr. E's. objection to the pathology offered, is not perhaps so irreconcilable as he appears to think. Besides, we must again accuse the Doctor of reading carelessly, or else of wresting the meaning of our words. He adds, that " Analogy also affords us good grounds for this opinion;" (namely, that in dysmenorrhoea, the uterine system approaches to a state of in- flammation.) "Lymph is never thrown out so as to form mem- branous concretions, except from inflamed, or highly irritated surfaces." • Morgagni explains the production of the membranes formed in the case he relates, differently, but perhaps not more satisfactorily. He says, " It was easy to conceive, that the viscid particles of the serum of the blood, issuing from the uterine orifices of the vessels, which had formerly been discharged in the form of a fluor albus, were now become more viscid, and adhered to all the internal parietes of the uterus, and by this means were concreted into a polypous mem- brane."—Epist. xlviii. art. 12. 136 PAINFUL MENSTRUATION. To the objections of Dr. E., we would observe, first, that we have never pretended to point out the pathological condition of the internal surface or other portions of the uterus, in dysmenor- rhcea__all we have advanced is, that some change vvas effected in the secretory surface, and that, instead of the fluid discharged during the menstrual period, presenting the appearances it is wont to do in the healthy condition of this surface, it permits a separation of its constituent parts, thus proving some change or imperfection in the action which produced it. Now, whether this be owing to inflammation, or high irritation, we have neither declared nor denied. Secondly, we have in no part of this chap- ter, declared, intimated, nor do we believe, that " lymph" alone is poured out, as from inflamed surfaces, in dysmenorrhoea, on the contrary, we have expressly stated, that the lymph and cov louring matter of the blood were both present in the ]AUhr^ menstruous fluid—but that, in healthy menstruation, the q*mpn>] was alterated by the process of elimination, as it no longer coagu- lated; but not so in dysmenorrhoea. Thirdly, that Dr. E. is at variance with himself; for, he first attempts to show, that the phenomena of dysmenorrhoea declare, that " the whole uterine system is morbidly increased, and that it approaches to the state of inflammation." To prove this, he says, there is a "sense of fulness and pain in the pelvis, loins, and thighs—the accelerated, and often tense pulse—the hot and feverish skin, decidedly indi- cate a congested and irritated slate of the pelvic organs." We shall not remark at present upon the fidelity of this history of symptoms, as the assumption of their truth will best at this mo- ment serve our purpose—which is, to show what we have just asserted, that Dr. E. is at variance with himself. Now, we will ask any candid person, at all conversant with pathology, whether the Doctor has not made out clearly, that in dysmenorrhoea, there is both an inflamed and highly irritated surface, in the uterine cavity. Yet he wants to prove, that there is no lymph poured out; because, "lymph is never poured out so as to form membranous concretions, except from inflamed or highly irritated surfaces!!" The treatment of this complaint consists in the temporary, and the permanent; the first consists in the administration of remedies to relieve pain at the commencement of, and during, the attack; and the most efficient, and uniformly certain for this purpose, PAINFUL MENSTRUATION. 137 that I have yet discovered, is camphor in sufficient doses; the following is the formula I generally use:— S<. Gum. Camph. Ql. Sp. vin. rect. q. s. f. pulv.—Adde Pulv. G. Arab. ^i. Sacch. alb. q. s. Aq. Cinnam. simp. gi. M. One-half of this draught is to be given the instant pain is expe- rienced; and if it be not relieved in an hour or two, the other half is to be given—this quantity, however, is not always sufficient to subdue pain; in this case, let the mixture be repeated—or the same quantity of camphor may be finely powdered, and given in ten grain doses every hour, entangled in a little sirup, of any kind, until relief be procured. Sometimes the stomach is much deranged in this complaint, and will suffer nothing to remain upon it; when this happens, 1 order thirty or forty grains of cam- phor to be rubbed down with a few drops of the spirit of wine, to a very fine powder; one drachm of laudanum; and three ounces of thin starch or flax-seed tea, as an injection. Should this be too suddenly discharged, or fail in giving relief, it may be repeated. Opium, in various shapes, has also been administered; either alone, or in combination with camphor, or ipecacuanha. The ergot has also been recommended. I have tried it; and, with one exception, it has failed. It must, however, be declared, that my experience in the use of this substance has not been exten- sive; and even in the few trials I made, perhaps I may not have given it a fair chance. These doubts have lately arisen, from two or three of my friends telling me it had been entirely successful with them; and, also, from a case of success occurring within a short time in my own practice. As the case was unusual, by combining with it a rare occurrence, namely, menorrhagia, I will relate it. In October, 1825, Mrs. -----applied to be relieved of painful menstruation, together with an immoderate discharge of blood. The pain appeared to be produced by the discharge of coagula; at least there was no appearance of membrane in the fluid she passed. She also had leucorrhcea to a considerable extent. I ordered her the ergot in the following form:— Ik. Pulv. secale cornut £ss. Ext. gentian. ji. M. f. pil. xv. One every morning, noon, and evening. 138 PAINFUL MENSTRUATION. She began the use of the pills about a week after a period, and continued them until the next made its appearance. At this time she found herself much relieved, both as regarded pain, and the quantity discharged. The next period was still better; and since, she has had no farther trouble. Warm bath, pediluvium, and bleeding, have also been prescribed; but nothing has succeeded with me so well as camphor.* The radical treatment consists in the exhibition of remedies in the interval, with a view to prevent the recurrence of pain—the one which has proved most successful, is the volatile tincture of guaiacum, given as directed in suppressed menses. The same regard to the state of the system as is there recommended, is also here insisted on. Perseverance, for two or three months, is often- times necessary. I think I have observed that this medicine it^ more decidedly useful, where the first menstrual period, after itsa use, is more than usually severe. This has been pretty uiuforrnljH found a favourable sign, 9 Though the tincture of guaiacum has been generally successful it has not been uniformly so.t In two instances where it failed, the ext. cicutae succeeded; and in one other, where it had not been successful, the tincture of cantharides gave perfect relief. I have never met with a case of fruitfulness where there was a * discharge of membrane, though Morgagni relates one in which it was otherwise.J As this is a rare and curious case, I shall take • In severe cases, or those which resist the camphor or laudanum, might not the hodrocyanic acid be useful? • I am sorry to say, that I cannot answer this query in the affirmative at present I have used this substance but a few times, and then without the slightest advan- tage. The acetate of ammonia has been vaunted in this complaint; but it has en- tirely failed in the two or three trials I have made of it, though given in much larger doses than has been recommended. ■j- This remedy, in the hands of others, I learn has not been equally succe» ful. I can only account for this in one of two ways: first, they have not, per- haps, prepared it as directed; secondly, and the most probable, they have not persevered sufficiently long in its use: for it is still successful, in most cases, in my hands. t It may be well to correct an error of quotation in this place, that has crept into a recent work. It makes me say, that no woman can conceive who 'is la- bouring under dysmenorrhoea: now, this is nowhere advanced by me. Yet I do not hesitate to say, that so far as my experience goes, I have never met with an instance of fruitfulness, where this membranous product was expelled: I there- fore fully agree with Dr. Denman upon this point. Dr. Mackintosh seems to PAINFUL MENSTRUATION. 139 the liberty of introducing it. " A noble lady, of tall stature and good health, had suffered several miscarriages in the early part of her pregnancies; but between these miscarriages, she would carry her children to the full time* She sometimes had twins, and very difficult labours. She was also troubled slightly with leucorrhcea. Of this she had become well about her thirty-fourth year; but was afflicted, at each return of her menses, with pains resembling labour. About the second or third day she would discharge a membranous body of a triangular form, and which appeared to have filled up the whole of the cavity of the uterus. "The exclusion of this substance was followed by a great lo- chial discharge; it did not always come away whole; but when this happened, the lochia also followed. As the patient had ab- stained for some time from intercourse with her husband, and had [Suffered much, she began to think it would be more advantageous ■to her, if she could be free from the pains for nine months at "least, and determined to lie alone no longer: wherefore, in the month of March, 1824, she became pregnant, but only carried the foetus until June. "But in July, and the two following months, her menstrua flowed properly, and without uneasiness. In October, she had no return of her menses; and the pains returned in November, with the discharge of a membranous body. She continued to suf- fer from time to time after this, until the cessation of the menses put an end to it." Epist. xlviii. art. 12. It is evident that impregnation took place in the instance above named; yet the patient miscarried at the third month, and was not made to conceive afterwards. It therefore forms only an ex- ception to the rule. I have seen a few instances of fruitfulness where there was painful menstruation, without this membranous production, but where a few small coagula were discharged. But such cases are rare. Does this disease reside in the ovaria, or in the secreting sur- face of the uterus? I believe it has its seat in the latter; and that have fallen into a similar error, when he thinks Dr. D. wrong upon this point; for Dr. D's. declaration is precisely what we have stated above, namely, that a woman does not conceive when this membrane is produced—but does not say, that no woman conceives who is labouring under dysmenorrhoea; for to dysme- norrhoea, this membranous production is not a sine qua non; and where this mem- brane is not formed, impregnation may occasionally take place. 140 PAINFUL MENSTRUATION. its being unfavourable to impregnation, is not owing to any in- fluence it may exert upon the ovaria, (for I have reason to believe that ova have been impregnated, but not finding the uterus in a condition to receive them, have perished:) but to either the im- perfect or the non-formation of the decidua. I believe the s.irne surface furnishes both the menstrual secretion, and the efflores- cence called the decidua; it would seem then to follow, if it per- formed the first of these offices imperfectly, it would also the latter; and, consequently, the ovum would perish for want of a proper nidus. This opinion is strengthened by the facts, that so soon as this wrong action is changed, the woman is instantly capable of being impregnated; or, in other words, fecundation becomes successful; and also, by the influence of camphor, a temporary change is in- duced in the secerning vessels of the uterus, and the formation of, membrane is prevented. Were it necessary, I could illijslj^e both of these positions by very many cases; but, as it is the most remarkable I have met with, I shall confine myself to one of the former. In 1791, I was applied to by a lady, who had always suffered at her menstrual periods; and who, at such times, discharged a number of membranous portions. She had been married nine- teen years without being impregnated. After due preparation, for she was very plethoric, I put her upon the use of the tincture of guaiacum; in this she persevered for three months. The first period after she commenced the use of this medicine, was one of prodigious severity; so much so as to make her resolve on aban- doning it. I, however, persuaded her to persevere. The next pe- riod was better; and the one after was without pain. She con- i ceived immediately after, and was delivered, in due time, of a fine girl. She took twenty-four ounces of the tincture.* As this disease is one of great interest—one, to use the lan- guage of Dr. Good, " the frequent returns of which, embitter the life of the patient, and effectually prohibit all hope of a family," we feel it a duty to give to our readers the advantage of every suggestion for its relief that may come from a respectable source. We therefore copy Dr. Mackintosh's views upon this subject in his own language. • We could furnish very many instances of similar success from the use of the guaiacum—indeed, more than a hundred. PAINFUL MENSTRUATION. 141 " It always appeared to me, that there might be some mecha- nical cause for dysmenorrhoea; but it was not till the year 1823, that I first entertained a belief it might be owing to the small size of the os uteri. In that year a medical friend presented me with a preparation of the uterus and its appendages, in which the os uterus vvas so small as scarcely to admit a hog's bristle; since that period 1 have had many opportunities of investigating this interesting subject, and have now obtained many preparations taken from the bodies of individuals who died of different dis- eases, particularly of phthisis, and whose histories prove that they had laboured under dysmenorrhoea from the very beginning of their menstrual lives. In these preparations of the uterus, the orifices, instead of being shaped like the mouth of the tench fish, are either circular or nearly so, and some of them are so small as only to allow a bristle to pass; others are a little larger, admitting a small silver probe. "lam far from alleging, however, that dysmenorrhoea is al- ways produced by a small os uteri; on the contrary, I believe it may occasionally depend on inflammation of the lining mem- brane of the uterus, as well as on inflammation in the substance of the cervix uteri, and on the encroachment of tumours dimi- nishing the caliber of the passage through the cervix. I only maintain that the condition of the os uteri, above described, ac- counts satisfactorily for many cases of dysmenorrhoea,—so far as my investigations have extended, I am inclined to say, it will account for the majority; although in candour I must mention, that one preparation in my possession appears to invalidate the evidence afforded by the others; in it, the mouth of the uterus is very small, and yet the woman to whom it belonged had had several children; she died in a public establishment, but the his- tory of her menstrual life is unknown. "By this condition of the os uteri, not only are all the pheno- mena which take place in dysmenorrhoea most satisfactorily ac- counted for, but also the intractable nature of the disease, and the unsatisfactory result of every mode of treatment hitherto re- commended. The menstrual discharge, after it is secreted in the uterus, cannot readily escape, in consequence of the small size of its orifice; distention of the organ is the consequence, which, by exciting the contraction of its fibres, produces uneasiness and pain in the pelvic region. When the os uteri is very small, and the secretion viscid, or mixed with coagulated blood, shreds of 19 142 PAINFUL MENSTRUATION. membrane, or organized masses, then the distention becomes more considerable, and stronger contractions are excited. Some- times the action of the abdominal muscles is called into plav. and bearing down or expulsive pains, are produced, resembling in every particular the pains of labour, and continue till the expul- sion takes place. Mr. Burns, in speaking of the disease, states, that it 'sometimes produces, besides uterine pain, spasmodic af- fection of the bowels, or violent bearing down efforts of the abdomi- nal muscles, as if it were intended to expel the womb itself.' "During these periodical attacks, inflammation of the lining membrane of the uterus, if it do not already exist, is sometimes excited, and in the end the sufferings occasion an entire breax-up of the constitution. That dysmenorrhoea should be so intractable, and the action of remedies so very unsatisfactory as to render the disease an opprobrium to medical science, are not to be won- dered at, if my views be hereafter found to be correct. Before I had any opportunity of putting these opinions to the test of ex- periment, they also appeared to me to be corroborated in a very striking manner by two circumstances:—1. By the action of the ergot of rye, which increases the force of the uterine contrac- tions, quickly expelling the contents of that organ, thus shorten- ing the patient's sufferings materially: 2. By the admitted fact which has been already mentioned, that women affected in this manner, rarely, if ever, conceive. The small size of the os uteri, renders impregnation almost an impossibility, by offering a me- chanical obstruction to the passage of the semen into the cavity of the uterus, where il is proved it must reach, by the accurate experiments of that ingenious and distinguished physiologist, Dr, Blundell, of London, as well as by other facts which it is unne- cessary to mention in this place. " These views appear to me to be farther supported by seve- ral preparations in my museum; in one of which the cavity of the uterus is divided into two compartments, by a strong trans- verse adhesion ; in a second, occlusion of the passage exists at the upper part of the cervix, which has every appearance of having been produced by the irritation of a polypous tumour; and in a third preparation, the os uteri became sealed up by inflammatory action; on dissection, the uterus was found enlarged, and con- tained about two ounces of puriform matter. '• Treatment of Dysmenorrhoea.—After the facts and obser- PAINFUL MENSTRUATION. HS vations above mentioned were collected, my mind became occu- pied with devising the best means likely to cure the disease. Mechanical dilatation appeared to be the only remedy; but I hesitated for some years to carry it into execution, or indeed to propose it, beyond mentioning it in my lectures, till the case of the young woman affected with amenorrhoea, [quoted at page 114] presented itself in the year 1820. Since that period I have treated fifteen cases of dysmenorrhoea, by dilating the os uteri, and have permanently cured all the patients: among these the two cases of amenorrhoea, formerly mentioned, are not included. " Of the fifteen patients, eight were either young unmarried women, or living in a state of widowhood; seven were married, and living with their husbands: of these seven, four subsequently fell with child. " The instruments employed to produce the dilatation are the common metallic bougies, of different sizes from that of the ordi- nary small silver probe to No. 8, or 10. The operation is per- formed, (the patient lying in the position in which women are usually delivered in this country,) by introducing the forefinger of the left hand, till it reaches the os uteri, for the purpose of di- recting the instrument to the part, which is then to be gently in- sinuated by a rotatory motion, till it arrives at the fundus of the uterus; much force ought not to be employed, and little or no pain is produced by the operation. The unpleasant consequences which sometimes take place in treating stricture of the urethra by similar means, viz. shivering, followed by fever, occurred in two instances; the fever, however, was slight, and soon termi- nated by copious perspiration; and in these, some days were al- lowed to elapse, before the instrument was again used. In two of the cases, the os uteri was sufficiently large, and well shaped; but the passage became so narrow in the course of the cervix of the uterus, that it required long-continued efforts before the smallest instrument could be introduced; but by perseverance the ob- structions were at last removed, and the patients cured. In one of these last two, menstruation vvas performed without pain till after marriage, when dysmenorrhoea occurred. The other was a young unmarried woman, who menstruated with ease for seve- ral years, but after long exposure to cold and moisture, the men- strual discharge became for a time suppressed, and ever after was performed with pain. The late Dr. Kellie of Leith, was also con- sulted about this case, and had I not been encouraged by his ad- 144 PAINFUL MENSTRUATION. vice, I should not have attempted the operation; as on the pos terior lip of the os uteri, several small elevations, like incipient tubercles, were felt. This woman called upon me eighteen months afterwards in good health, and stated, that she had not felt any uneasiness, or experienced any bad symptoms since the dilatation was effected. " A lady, the subject of one of the fifteen cases, was also per- feclly healthy, and menstruated easily till the period of marriage; but her health became impaired soon after, in consequence of her monthly sufferings. On making an examination, an enlargement vvas discovered about half the size of a chesnut, on the posterior surface of the cervix of the uterus. I undertook the operation in consequence of the urgent entreaties of her friends, who hap- pened accidentally to know of the happy results which had at- tended it in other cases, but 1 held out little hope of being able to do any good; notwithstanding which, a striking improvement in'her health soon took place; and, this in the end, proved to be one of the most successful cases, for menstruation became easy, the tu- mour rapidly declined, and upon making an examination in about twelve months afterwards, it could scarcely be felt. "None of the women operated upon had suffered for a shorter period than two years; some for three or four; and others for ten. Of the four who subsequently fell with child, one had been mar- ried between seven and eight years, and was reduced to a shadow from constant ailments; but after the operation, she recovered her health, strength, and flesh, and became pregnant at about the termination of nine months from the date at which the bougie* was used for the last time. " Another had been married three years, and had suffered con- siderably in constitution, with severe nervous symptoms every month, till at last she became entirely obstructed; and the abdo- men being enlarged, I was consulted upon the supposition that she was five months gone with child. From some circumstances which it is unnecessary to mention, I entertained a suspicion that she had deceived herself; and upon making an examination,when she supposed herself to be in the seventh month, ascertained be- yond all doubt that this was the case. In the process of time, the operation was performed, and the passage completely dilated: some months afterwards, impregnation took place, and I have since delivered her of two children at separate births. " A third case is that of a lady who had been married two PAINFUL MENSTRUATION. 145 ✓ years, and who had had painful menstruation from the first ap- pearance of the discharge; she was in a miserable slate of health, had taken a great deal of medicine, but only with temporary re- lief. Impregnation took place after the third menstrual period subsequent to the dilatation. " The subject of the fourth case had also been affected from the first of her menstrual life, and laboured under the impression that she was therefore never to have a child. After dilating the passages with No. 6, bougie, menstruation took place with so much ease, that she supposed herself quite cured, and would not again submit to the operation. Several months afterwards, how- ever, she felt a return of the pain, the operation vvas again had recourse to, and the dilatation carried as far as it could be effect- ed with No. 10, which was accomplished two days before her ex- pected period. Menstruation took place freely, and without the slightest uneasiness: she subsequently fell with child, and was delivered of a boy." We are certainly much indebted to Dr. M. for his novel illus- tration of dysmenorrhoea, though we cannot suppose his patholo- gical views to be applicable to all cases of this complaint. We shall therefore take the liberty to declare, that his history of this complaint, amounts to no more than as a variety of dysmenor- rhoea, and that this variety is most probably but a consequence of the previous condition of the internal cavity of the uterus, or of its neck; namely, the result of previous irritation or inflam- mation: though we are not prepared to deny, that it may have existed as an idiopathic condition of the neck of the uterus. Our reasons for thinking that this "mechanical cause of dys- menorrhoea," is but a rare and secondary cause, are, First that in many instances the woman menstruates regularly and health- fully for a long time; but from exposure to cold; upon marriage; after an abortion, or sometimes a labour, this painful condition of the menstrual process takes place—in neither of which do we see how the os tineas can be so reduced in size, as to be only sufficient to transmit a bristle; unless we suppose that either of the causes named is capable of producing so much irritation or inflammation as to cause the disorganization just named; and, if this be admitted^ the dysmenorrhoea thus produced is but a consequence of the pre- vious irritation or inflammation. Secondly, if this first reason be admitted, it must give us strong grounds for belief,, that the degree of irritation and inflammation capable of disorganizing the 146 DECLINE OF THE MENsEs. neck of the uterus, might also be sufficient to induce painful men- struation without this disorganization; and that when this disor- ganization has taken place, it could only add to the difficulties, and not be the exclusive cause of them. Thirdly, that this last suggestion is rendered not only highly probable, but is almost demonstrated to be true, by the effects of camphor in temporarily relieving pain; and by that of the guaiacum, permanently re- moving it—for we cannot suppose that the action of either of these substances, would remove the " mechanical cause of dysmenor- rhoea." Yet, as we have just observed, we have seen very many cases of dysmenorrhoea removed by the guaiacum, and impregna- tion follow in married females. Nevertheless, we gratefully acknowledge the value of Dr. M's, cases and his mode of treatment; and we shall certainly attempt to follow it in cases that arc of unusual obstinacy, and where the patient will yield to the remedy. We are, however, far from thinking that Dr. M. strengthens his cause by citing the action of ergot upon the uterus, as a proof of the smallness of the os uteri; or by a reference to the experi- ments of Blundell. For the benefit derived from the use of the ergot, (if any do arise,) is from its increasing the power of the fundus and body of the uterus, to expel the foreign body that is within it—and which only proves an increase of power in these portions of the uterus, and not in any way, under such circum- stances, that the neck of the uterus is narrower than natural. And, as regards the experiments of Blundell, they are far from being confirmative of the necessity of the presence of the semen in the cavity of the uterus, that impregnation may take place, except, perhaps, to those who have this particular hypothesis to sustain. Sect. V. —5. Of the Decline of the Menses. The nearer a woman approaches her forty-fifth year, (cateris paribus,) will be the risk of some irregularity in the menses; and as this period is more frequently the one at which any latent disease of the uterus shows itself, it is always looked forward to with much anxiety by women. Indeed, so replete is this time with horrors to many, that we may very justly suspect apprehen- sion to be the cause of some of the distressing symptoms which sometimes accompany this interesting process of the human uterus. DECLINE OF THE MENSES. 147 Delicate women, and especially those who have lived idly, have this period of life arrive earlier than those of a contrary constitution, and opposite habits. We have already noticed, in our section on suppression, that this change sometimes takes place at a very early period of life, and this without leaving any inju- rious consequences behind it: and, on the other hand, we find many cases on record, where this discharge had continued with regularity to a much longer period than the ordinary one. Gar- dien mentions a case which fell under his own notice, where this evacuation continued with great exactness, until beyond the se- venty-fifth year; others, still more uncommon, are mentioned by various writers.* The reason of this discharge leaving the woman at this time of life, appears to be founded in the highest wisdom and benefi- cence; it is to prevent child-bearing beyond that period, at which the mother would be capable, from the common chances of hu- man life, of extending her care to her offspring; and, consequent- ly, submitting her child to the doubtfularianagement of strangers, or subjecting it to the waywardness and caprice of those, who could not feel a parent's affection, nor yield a mother's devotion to its necessities, at a time when its helplessness would most re- quire the kindest offices. This change is sometimes effected so silently, that the woman scarcely notices her altered condition; at others, its approach is so gradual, as not to attract observation, until the diminished quantity gives warning that it is about to take its leave for ever-t while, again, the irregularity, both in period and quantity, may be such, as justly to give alarm, as well as to produce the most serious danger. But, as a general rule, it may be observed, that when the wo- man arrives at about her forty-fifth year, she finds her menses to become irregular, both in the quantity of fluid evacuated, and in the periods they observe; being sometimes in advance, and at others, not appearing until long after the accustomed time. The woman also finds some alteration has taken place in her general health; she becomes pale, debilitated, and nervous; arising, hovv- • I have had, very lately, a lady under my care, who menstruates with the most perfect regularity; though she had laboured under a prolapsus of the uterus to a great extent for several years. She is now in her sixty-fifth year. Her uterus is now effectually supported by a pessary, which has much improved her general health. 148 DECLINE OT THE MENKES. ever, for the most part, from the loo frequent returns of this dis- charge, or its too great abundance. At this time, also, the woman sometimes becomes the victim of a strange illusion, should the menses not have returned for se- veral periods; for she now supposes herself to be pregnant, as her abdomen enlarges, as do the mammae; her appetite becomes capricious, or she has strange longings, &c, the whole of the ra- tional signs of this condition being present, even, in her imagi- nation, to the motion of the child. This delusion is most com- mon to women who marry late in life, and who are very de- sirous of offspring; more, sometimes, we fear, from an anxiely to give a proof of their youthfulness, than from a wish to be- come mothers, at their time of life. But this youthful hope is soon to be destroyed—and, perhaps, for ever. For now the breasts lose their intumescency; the morning sickness vanishes; the swelling of the abdomen subsides; the imagined stirrings of the foetus cease, or the sensation becomes so unequivocal as to satisfy that it arises froi^ the movement of wind ; and, to put every thing beyond hope, the menses return in overwhelming quantity, and thus the poor woman but too certainly becomes the butt of the unfeeling, and the ridicule of the unthinking. It is, therefore, highly proper, that practitioners, and especially the younger part of them, should be put upon their guard in respect to this condition of the patient, and not too easily yield credence to all her wishes may dictate, or absolutely to treat as an impos- sibility, a circumstance of which there is occasionally an example. It seems that the apprehensions of this period of life have arisen mainly from the notions entertained of the final cause of the menses; namely, that it gives vent to peccant humours. But females should be made to know, that all this is purely the theory of the vulgar; as the menstrual blood is formed from the general mass; and, consequently, if that be pure, the other will be; therefore, the idea is altogether ill founded. But, unfortu- nately, whenever this discharge is less abundant than usual, the most serious fears are entertained, that there will be a retention of a portion, which will cause disease, either in the uterus itself, or in some other part of the body: hence, a diminished menstru- ous secretion is always more alarming to the female, than an un- usual flow. But it may be well to remark, that there is a great difference between the cessation of this discharge, and the sup- pression of it. In the one instance, it is an event which nature DECLINE OF THE MENSES. 149 has designed should take place, and is effected altogether by ar- rangements of the system itself; and, of course, one of its na- tural processes; in a word, as much so as its commencement: but the suppression, from some morbid agency, is in direct opposi- tion to the intentions of nature, and will, of course, be followed by some baleful consequence, if it continue beyond a certain period. The vulgar error, that " women at this period of life are always in danger," is replete with mischief to the suffering sex: and I feel it a duty to declare, that they are not necessarily more ob- noxious to disease at this, than at any other period of their exist- ence.* That they are somelimes liable to a disease at this time; and that disease, one of the most terrible in the long list of hu- man infirmities, I admit; but must, nevertheless, insist, that Can- cer, (the disease to which I allude, and the one so much dreaded,) is more rare in the uterus than in certain other portions of the body; for instance, the mammae; and, perhaps, I am within the truth, when I say, that there are three instances of the latter, for one of the former. If latent dispositions to disease, either in the uterus or other parts, become active about this period of life, it is not because the declining menses excite them; but because the disease is slow in developing itself, and is, perhaps, kept in check for a long time, by the menstrual discharge serving as an impor- tant evacuation; especially when the uterus may be the seat of the complaint. In such instances, the foundation of the disease was laid, perhaps, at a time when the menses were the most per- fect, as regards period and quantity; consequently, they could have had no agency in its production ; but, on the contrary, from its frequently relieving the engorgement of the vessels, served to keep it in subjection for a long time; not as a specific discharge, but as a mere depletion; or, in other words, that if an equal quan- tity of blood could have been by any other means as certainly abstracted from the uterus, the same favourable result would have followed. Coincidences in the human system are so common, that they are frequently mistaken for cause and effect: hence, the * Indeed, it would seem that this period of female life is freer from diseases causing death, than almost any other. By some late observations made on the bills of mortality in France, it appears that fewer women die between the age9 of forty and fifty, than men, or indeed at any other period of their lives, after puberty. And, farther, that if this change is effected without much disturbance, that they live not only longer than men, but are freer from morbid inconveniences. 20 150 DECLINE OF THE MENSES. cessation of the menstrual discharge, and the appearance of scir- rhi and cancers, are considered as cause and effect. At this period of life, nothing will so effectually secure the woman against injuries which may arise from the irregularities of the menstrual discharge, as- a well regulated regimen. By re- gimen, in this place, we would wish to be understood, not only eating and drinking, but exercise of both body and mind, in- cluding the proper government of the passions; in a word, every thing which relates to both moral and physical existence. A well-ordered course of exercise in the open air in well-se- lected weather, and great simplicity of diet, is of the utmost im- portance to the female at this period of life, and should never be neglected, if it be possible to indulge in them. By these means, the nervous, muscular, vascular, and lymphatic systems, are all preserved more certainly in equilibrium with each other, since they are the best calculated to ensure a reciprocation of their respective offices; and, consequently, to maintain that conditio! of the system, termed health. Hence, the justness of the remark, that the women who live in the country, and who exercise freely in the open air; who have fulfilled their duties scrupulously aa mothers, by suckling their children, agreeably to the views of nature; who do not goad their systems by over-stimulating food and drinks; who do not relax their bodies by too long indulgence in bed, have but little suffering at this period. From this it will follow, that a milk and vegetable diet, toge- ther with pure water as a drink; regular exercise, not carried to fatigue; keeping the bowels open, by well-selected food, as the fruits of the season in proper quantities: the bran bread, if necessary; but not by medicine, unless absolutely required. Governing the temper; restraining the passions, as well mental as animal, will largely contribute to the safety and comfort of this period. All that we have just recommended, is calculated to place the system in a condition, by which it shall preserve iti various forces; have its irritability diminished; its sensibility mo- derated; and pretty certainly prevent that condition of the blood vessels, most decidedly unfriendly to the general health at this time, called plethora. And, though last, not least in fair es- timation, is an attention to cleanliness. The external organ! should be washed with lukewarm water at least twice a day, and the whole body once a week, by going into a lukewarm DECLINE OF THE MENSES. 151 bath. In using the bath, care should be taken to come out of il as soon as the purposes of cleanliness are answered. Our next concern is with the derangement of the discharge at or about the period of cessation; this will consist, 1st, in a dimi- nution of the proper quantity; and 2dly, in an excess of it. As regards the first, I have already said enough when treating of the suppression of the menses; and, with respect to the second, it must be treated according to the rules prescribed for the ma- nagement of hemorrhage from the uterus from any other cause; that is, first, to diminish the quantity discharging; secondly, to prevent an excessive return. The first indication is best fulfilled by rest; by cool air, and drinks; by cold bcal applications; by the acetate of lead and laudanum ; and by the use of the tampon.* We should imme- diately confine a patient so circumstanced to a horizontal posi- tion ; and strictly forbid motion of every kind, even turning in bed. We should admit cool air with freedom where practica- ble; and give neither nourishment, nor drinks, except they be cooled—the latter may even be iced. Cold, applied to the ab- domen, is frequently useful in excessive discharges of this kind ; the best mode of applying it, is by large bladders not quite filled with water, in which there is ice, if it be in summer, or during hot weather; cold water alone will be sufficient, if it be winter: during the use of this, care should be taken that the feet and legs be kept warm. We should also give, by the mouth, two or three grains of the acetate of lead, every hour or two; guarded with a sufficient quantity of opium, or laudanum, or a scruple of it with a drachm of laudanum, and two or three ounces of water, as an injection—this is to be repeated pro re nata. And, should these not control the discharge upon fair trial, recourse must be had to the sponge tampon. I have repeatedly seen the discharge of blood at this period of life, so enormous and so rapid, as to threaten almost instant exhaustion. When thus excessive, it can only be met successfully by the most prompt application'of the most efficient remedies. Whether this disease show itself in the rapid expenditure of fluid blood, or in the repeated expulsion of large coagula, it must be opposed by the same remedies—these two conditions present no difference of indication, nor any essential difference in the complaint itself: the former, however, generally requires more * See Chapters on Uterine Hemorrhage, and Menorrhagia. 153 DECLINE OF THE MENSES. prompt interference than the latter, as more blood is expended in a given time. The second indication must be fulfilled by blood-letting; by purgatives; by hemlock; and by tonics. Notwithstanding the immense loss of blood, which sometimes takes place suddenly at each period of return of this hemorrhage, it does not prevent the almost continual draining off of this fluid, even when its vio- lence is much abated; hence, we sometimes find a greater or levss discharge almost always present: this renders the woman not only feeble, but keeps her mind in a state of extreme appre- hension, from one period to another. These two causes, namely, the excessive discharge, and mental anxiety, keep the system in a constant state of excitement; and if the pulse be examined, it will be found quick and corded. We are, therefore, under the frequent necessity of abstracting a few ounces of blood during the interval of each discharge; especially towards the approach of the period the disease has assumed for its movements—this, however, varies in different individuals; and in even the same individual, if any error have been committed in either diet or exercise. But, when all things are equal, we find the period pretty certainly marked; and it may be every three or four weeks; or sometimes even longer. I have known two or three violent cases, where the discharge returned every two weeks. To aid the vessels to contract, we should confine the patient to a strictly vegetable diet; or to a diet of milk, if this should agree with her: all kinds of liquor, and spices, should be forbid- den; and exercise absolutely prohibited. The patient should sleep upon a mattress; and should be directed to repose herself upon it, or a sofa, as often as she may feel a little weakened, or fatigued by sitting up. The feet and legs should, however, be kept warm; and, if habitually cold, should be rubbed two or three times a week with spirit or brandy, in which a quantity of the flour of mustard is mixed, or use the mustard bath. (See note to page 159.) The bowels should be kept open, by diet, if possible, as just suggested, or by the exhibition of some mild purgative, as rhu- barb, sulphur, magnesia, or any of the neutral salts. Against the use of aloes there is much clamour; but, I have some reason to believe,without just cause. I do not wish by any means to decide the point at this time; as my experience in its use is yet too limited to decide with certainty, though my favourable im- pressions continue to be strengthened. I think it proper, howe- DECLINE OF THE MENSES. 153 ver, to direct the attention of the practitioner to it, that I may be aided by the experience of others, in determining the powers of this medicine—but I will relate what I know upon the sub- ject, and leave it to the farther employment of this drug, either to confirm, or destroy my present opinion. Fothergill and Gar- dien are decidedly opposed to its use. A lady, aged forty-two years, for whom I had prescribed al- most all the known remedies for the hemorrhage under conside- ration, with very little benefit, was told by some old woman, that the hiera picra was a certain cure in her complaint: she men- tioned this,-and I very candidly stated my own, as well as the general prejudices against the principal ingredient in this com- pound; but, at the same time, observed, that as the old woman who had recommended it, cited the cases of two or three ladies who were relieved by it, and who were known to her, it would be easy to make the inquiry; and, if it were as she stated, it would be well to give it a trial, as every thing else had failed— the medicine was warmly recommended by these ladies; and she proceeded to make use of the old woman's prescription; which was half an ounce of the hiera picra to a pint of gin; of this a wine-glassful vvas directed at bed-time—it was taken, and the lady vvas completely intoxicated all night, and very sick next morning. Thinking the effects would next night be less severe, she again ventured on if, and with similar results. She vvas now determined to abandon it, unless some less ob- jectionable mode could be adopted for its exhibition—I pre- scribed it for her in the manner following:— 3<. Hiera Picra. gij. 01. Caryoph. gut. x. Sapo Venet. gr. xij. Syr. Rhaei. q. s. M. f. pil. xl. One of these was directed every morning, noon, and evening, unless they should prove too purgative—this did not happen, as the patient was of an extremely costive habit. She soon per- ceived, after she began the use of this medicine, a diminution of the discharge; and by the time she had finished the pills pre- scribed above, it was so much reduced in quantity, as to give no farther uneasiness. Since this case, it is proper to state, that se- veral of a similar kind have been under my care, with the same results, from the same means. 154 DECLINE OP THE MENSES. Several cases, of less severity, were entirely relieved after the use of the same formula : from this it appears, that in a number of cases in which this remedy has been prescribed, the patients got well; but the precise agency of the medicine remains to be determined by future observation. I am, however, convinced of the importance of pretty constant, but gentle purging, in this oftentimes tedious complaint. One of the most successful general remedies I have employed, is the extract of cicuta; beginning with a minimum dose, and in- creasing it gradually, but, at the same time, as rapidly as the sys- tem will well bear. When decided marks of its influence, such as vertigo, headach, or sickness of stomach, begin to show them- selves, the dose is not to be increased until they go off: when this happens, an increased dose may again be given; and so on, until the complaint has so far yielded, as to render its farther exhibition unnecessary, or until we are convinced that it will not succeed in arresting it. I have thought this medicine most useful in those % cases where the discharge was chiefly by coagula. I have used the secale cornutum in tincture, with great advantage, in Some instances of this kind, though, by no means, so certain as in the more active uterine hemorrhages. A small tea-spoonful, every four or five hours, in sweetened water, has, in some cases, put an almost immediate stop to the discharge: in obstinate cases, it al- ways deserves a trial. No class of medicine has done so much mischief in the com- plaint I am now treating of, as tonics—and this from a wrong view of the disease in question; for it has been treated as one of debility; consequently, all the most powerful tonics have been put in requisition for its cure. Bark, steel, wine, and all the bit- ters have again and again been unavailingly tried, and oftentimes the patient abandoned to the ravages of this disease, because it could not be conquered by tonics—the opposite mode of treat- ment, with such views, would necessarily be considered as death to the patient, and, of course, would not be employed. I well recollect a case, where three pounds of bark had been taken in less than two months, with a proportionate quantity of the elixir of vitriol, to the manifest increase of the disease: this patient was afterwards entirely cured, by an extremely low diet, gentle purging with neutral salts, quiet, and repeated blood-let- tings. I must, therefore, caution the young practitioner against the use of tonics in such cases, though they may be attended by DECLINE CF THE MENSES. 155 absolute weakness in the. muscular system; for the state of the vascular system alone is to be attended to; and here a corded pulse must not be mistaken for a weak one, because it may hap- pen to be a small one. But how shall we reconcile the contend- ing opinions of the pathology of this complaint, and that of the suppression of the menses, with each other'! It is insisted on, by many, that it is the debility of the extreme vessels that prevents the formation of the menses when they are suppressed: to over- come this, tonics and stimulants are advised. In the menorrha- gia of this period of life, the cause of the too abundant flow is debility; and tonics and stimulants are here recommended to re- strain the excess of discharge ! With respect to the preparations of iron, I have perfectly con- vinced myself, that they can never be usefully employed during the active state of any hemorrhagy: in my hands they have never failed to do mischief; I have not used them, therefore, for many years, in the cases of which I am now speaking. The use of wine, I am also certain, has done mischief: it is port wine alone, however, that has any reputation in such cases; and this has arisen from its possessing a slight astringent property—but this must also be strictly forbidden. The bitters will fall under a slighter censure than the barks; because they are generally much less powerful: the same objections, however, attach to them, but in a minor degree. Tonics are only admissible where there is nothing but debility to contend with; they may then be advantageously employed, in properly regulated doses. The diet may now consist of more generous living; and, when well ordered, and properly pursued, may be looked upon as the best possible tonic. Hitherto, I have been considering the severer forms of this complaint: I shall now say a few words upon the occasional ir- regularities of the menses, both as to period and quantity. The periods of return may be anticipated, or protracted; and the quantity may be very small, or more or less excessive; or it may employ a great many days for its evacuation, without the aggre- gate quantity being very great. I have constantly advised against any interference at this period of life, for mere irregularity, or ir- regularity with a diminished discharge; and for this plain reason, that no other inconvenience is experienced; and this is so trifling, as not to merit consideration. But if, with the irregularity, the 'discharge be too abundant, I treat it as directed already for he- 156 DECLINE OP THE MENSES. morrhage, and try to prevent the recurrence, by bleeding a little before the expected return, a low diet, and purging with the neutral salts: these means rarely fail to give relief. When a great many days are employed in the discharge, or as the women term it, " being almost constantly unwell," and where the aggregate quantity may not greatly exceed the com- mon monthly amount, I have frequently succeeded by the tinc- ture of rathany in two-drachm doses, three or four times a day. Gardien speaks in very high terms of the " rathany." He thinks it merits more confidence than the alum, the sanguis draconis, tho kino, the nutgalls, or catechu. He says that M. Ruitzused both the extract, and the decoction of the root of the rathany. The extract should be given in doses of half-drachm or a drachm. .In severe cases, it may be given to the amount of two drachm#jj& day.* Agreeably to M. Ruitz, the second or third dose rareh/j fails to produce the desired effect. The remedy should be con-.'jS tinued some time after the discharge has ceased; but the quant'y|J may be gradually diminished. To prevent the nausea vvhj£Jgg|| bitterness sometimes creates, he advises the mouth to bdjrinsed^ with lemonade. Frequently bathing the parts with coldfcatef; abstaining from too much exercise; and refraining from a snWu- lating diet, are of much consequence to the cure. The alum whey has often been useful in similar cases, and deserves a trial; the sugar of lead, in small doses with opium, given daily for some time, has many times answered every end.t In every form of the disease under consideration, I have thought, that very decided advantage has constantly resulted from injections of the solution of the acetate of lead thrown up • I have, of late, substituted the extract for the tincture, and give it in the fol- lowing form:— jjt. Ext. Rathan. £ij. Pulv. Rhaei. Jss. Syr. Rhaei. q. s. M. f. pil. xl. Of these, two are directed to be taken every morning, noon, and evening. 1' will be seen that I do not give it in any thing like as large doses as M. Kuitz, having found the quantity prescribed above to answer; I, however, should not hesitate to give it in much larger quantities, if it were necessary. ■j- The prejudices against the use of the sugar of lead appear to be ill-founded: we have given it very often, without witnessing any inconvenience, except in one instance; in this case it had been too long continued: it produced obstinate vomiting. DECLINE OP THE MENSES. 157 the vagina several times a day;* except during so profuse a flow of blood, as to render the use of the tampon necessary.f It may also be proper to remark, that the sponge, or tampon, should not be suffered to remain within the vagina longer than ten or twelve hours at a time. When taken away, it should be carefully washed with soap-suds; and before it is again returned, it should be im- bued thoroughly with vinegar; or, if it can be procured, with the pyroligneous acid: on this account, there should always be two pieces of sponge. We have already adverted to the fact, that if there be any la- tent disposition in the system to produce scirPhus, or to convert scirrhus into cancer, that it most frequently manifests itself at this .period of life; hence, as before observed, the dread the wo- ^rnan has of the " disappearing of the menses." And this is espe- *;~ci&Hy the case, when the uterus is the seat of the affection. We foThave also declared, that this manifestation of disease, at this time, Bto-not the direct consequence of this change in the uterine sur- ^fTace; but because a powerful local means of preventing conges- tion Mjfthat organ, is now removed by the menstrual fluid not be^pfcrmed, to relieve the engorged state of the uterine vessels. It is highly probable, that the congestion which always pre- ceded the menstrual discharge, would continue to take place from time to time, though the menstrual secretion might be in- terrupted; and this congestion not being relieved as before, may induce a part already strongly disposed to diseased action, to take on inflammation, and hastily develope scirrhus, or cancer. On this account, it is important that females should so regulate their regimen, as to prevent any thing like undue excitement in the arterial system: for this end it is necessary to reduce the quanti- ty of nourishment; to adopt a properly regulated system of ex- ercise, to govern, or control moral influences. By these modes, we are persuaded that the predisposition to these dangerous af- fections can be kept long in subjection. And, as the disposition of the system at this period strongly inclines to plethora, this state must be carefully guarded against, by every means capable of such an effect. Therefore, besides the rules suggested for the " regimen " of the woman, she must lose • The injections should be made of two drachms of the sugar of lead, to about a pint and a half of water. tl fetely succeeded in arresting a constant and long-continued flow, by in- jections of warm alum water. A half-ounce of alum to a pint of water, was used. 21 II- he i he | 158 DECLINE OF THE MENSES. a few ounces of blood from time to time, if the pulse and other symptoms declare this state to be present, or if there be a well marked tendency to it. The blood may be abstracted from the arm upon common occasions; but if there be pain in the region of the pubes, back, hips, and rectum; and especially if this be of the lancinating kind, accompanied by a sensation of heat about the seat of the uterus, it should be taken by leeches, or by cup- ping, as near the parts as it can well be drawn. The top of the sacrum, just over the pubes, the groins, or the labia pudendi, are the best places.* The bowels must be gently, but regularly, purged by neutral salts; and the woman should be confined to a very strict diet; she must also avoid all kinds of exertion during this commenced state of excitement. The patient should be attentive at the same time to cleanli ness, as before directed; especially, as will most probably be the case, if these symptoms be attended by leucorrhcea. If these measures be rigorously adopted, and steadily persevered in, there is much reason to believe, that this congestive condition of the uterus will be much relieved; and, of course, the evils arising from it diminished, if not altogether subdued. A variety of other affections show themselves at the period we are now considering; such as eruptions, erysipelatous inflamma- tions, rheumatic pains, swelling of the lower limbs, violent head- ach, and a great variety of nervous or hysterical symptoms. None of these require any peculiarity of treatment, except that the loss of the menses, and the tendency to plethora, must al- ways be kept in view. It must, however, be remarked, that though hysterical symp- toms are wont to appear about this time, and to be sometimei even violent, owing to an augmented sensibility of the nervous system, yet this complaint almost always disappears, so soon as the system becomes accustomed to the change in the natureof the circulation, and its more general determinations over the other parts of the system. It is highly important, that the cutaneous circulation and sen • For the last two years, we have directed the leeches to be applied to the in- side of the thigh, about its centre; so also, for the cupping. It is very much It* inconvenient, and is certainly, to say the least, as efficacious. I think we have paid too little attention, in this country, to the practice of the French physiciw upon such occasions; they almost always apply leeches at a distance from the af- fected part, upon a well-founded belief, I am incl'med to think, that a revulsivi effect is thus produced. MENORRHAGIA. 159 sibility be properly preserved; for this reason, the woman should avoid all causes which may tend to impair them; such as cold, damp places; too humid an atmosphere; too thin, or wet, or damp clothing, or partial draughts of air. To maintain an equality of excitement of the circulation, she should wear flannel next her skin, and carefully protect her feet and legs, by shoes of a proper thickness, and stockings of a proper quality. Should she be ha- bitually subject to cold feet, she should employ the mustard bath at least twice a week, so long as this symptom continues.* CHAPTER VII. OF MENORRHAGIA. By this term, we would understand an immoderate discharge of fluid blood, properly so called, or coagula, or both, from the internal cavity of the uterus; recurring at the menstrual period, and following the secretion termed the menses. I have already said, that this discharge consists of blood, pro- perly so called, in contradistinction to the fluid yielded by the internal uterine surface every lunar month, called the menses. When treating of the catamenia generally, the difference between the menstruous fluid and the circulating blood, was insisted on; and it is important, that this distinction be preserved, that two different conditions of the uterus may not be confounded.t It will probably ever remain a matter of doubt, whether the blood which is expended in menorrhagia, be from the same ves- sels as furnish the menstrual fluid, or from a distinct set, which may terminate upon the internal uterine surface; nor, is it, per- haps, at this moment, of very great consequence to determine, since it would not lead, with our present knowledge, to any prac- tical good. Reasoning, perhaps, would be against this identity; and would tempt us to believe, that the blood of hemorrhagy • The mustard bath is made by putting two or three table-spoonsful of the flour of mustard, to a gallon of warm water. The feet are to be put in this just before getting into bed for the night, and rubbed until they glow. f Gardien evidently confounds these two conditions, both by the caption of his chapter on this subject, (de la menorrhagia ou flux immod6ri da regies,) and by his text. 160 MENORRHAGIA. does not proceed from the same vessels which furnish the men- strual fluid: for menorrhagia is always, so far as we have wit- nessed, preceded by the regular menstrual discharge;* which it would be but rational to suppose, would effectually relieve any engorgement that might be supposed present at this time; pro- vided this accumulation were confined to the vessels concerned in the production of the menstrual fluid. i Besides, did this flow of blood proceed from the same vessels I as the menstruous fluid, we should be at a loss to understand how | a hemorrhage should take place from vessels, after distention was diminished by the evacuation of a portion of their contents; which must be the case, did the vessels which' ordinarily furnish the menstrual blood, also yield that of menorrhagia. But, if we suppose that a distinct set of vessels is concerned, we can more readily understand how they might be forced, or induced, from any given local cause, to open themselves, so as to pour out blood; since their distended condition may not be relieved by ' i the catamenial discharge; for it is not difficult to conceive, that the whole uterus may be in a congestive state at this time. Gardien, (Traits complete d'Accouchemens, vol. i. p. 289,) declares, that "so great a relation exists between menorrhagia and the menstrual flux, that it would be difficult to determine where the one ends and the other begins." Again: "In fact, all spontaneous hemorrhages have the strongest analogy with the menstrual flux. The phenomena which accompany the issue of blood, are absolutely the same in both cases: only, in menor- rhagia, the flow partly belongs to an original law, while that of hemorrhages is accidental," p. 289. It is evident from these passages, that he looked upon both discharges to be the common blood of the system; yet, it is no- • Under the head of menorrhagia, we do not include those hemorrhagic! which arise from a lesion of the internal surface of the uterus, or a portion of it* I proper substance; as in open cancer, or other ulcerations of this organ. We confine ourselves to that discharge of blood which follows or accompanies the menstrual action. We pretend not to account for this condition of the utenu; we only know the fact, that it takes place; and that the woman may be liable to it so long as the menstrual periods continue, be these longer or shorter. Wo- men are therefore obnoxious to this state of hemorrhagy, during a great part of their lives, that is, during the whole menstrual period; for we have no evidence that thw takes place after the congestion of the uteras, (so necessary for the menstrual secretion,) ceases to take place; though hemorrhagiea from letioo. and some other causes, do very often happen after this time. MENORRHAGIA. 161 torious they differ widely in many particulars. The one is the result of a secretory process; the other is blood which has escaped from confinement, by the rupture, or the opening of the vessels which contained it. Now, were it true that the menstrual fluid, and the blood thrown off in menorrhagia were the same, there would be no difference between the menstrual flux and menor- rhagia, except in the quantity of blood which might be expended: and, consequently, that menorrhagia is nothing but an excessive secretion of the menstrual fluid; or that the menstrual fluid is nothing but proper blood. Mr. Hunter declares, " it (the menstrual fluid,) is neither si- milar to blood taken from a vein of the same person, nor to that which is extravasated by accident in any other part of the body; but is a species of blood changed, separated, or thrown off from the common mass, by an action of the vessels of the uterus, simi- lar to that of secretion, (see p. 59,) by which action the blood loses the principle of coagulation, and, I suppose, life." Dr. Good* observes upon this subject, that, " as this distinction has not been sufficiently attended to, either by nosologists or physio- logists, many of the diseases occurring in the present arrange- ment, (his own,) under Paramenia,! have been placed by other writers under a genus named Menorrhagia, (a morbid flow of blood alone,) from the menstrual vessels. And we have here not only a wrong doctrine, but the formation of an improper genus; for menorrhagia is, correctly speaking, only a species of the genus Hemorrhagia." We have just intimated, that, as we are at present ignorant of the agency of remedies upon the different portions of the uterine system, a knowledge, whether the blood expended in menorrha- gia be from the vessels which prepare the menstrual fluid, or from a distinct set of vessels, would be of little consequence in a prac- tical point of view; yet the time may arrive, and that soon, when such knowledge might be highly useful. For, at the present moment, we are acquainted with the influence which the ovaria exert over the internal surface of the uterus in the production of the menstrual fluid; and, consequently, that it may be essential in the various deviations in the formation of this fluid, that the restorative remedies be addressed to these bodies; whereas, if a • Study of Medicine, vol. iv. p. 30. Amer. Ed. f " Morbid evacuation, or deficiency of the catamenial flux." Amer. Ed. 162 MENORRHAGIA. different set of vessels from the menstrual yield the blood, the cure might require remedies that would exert an influence upon the extreme vessels of the uterine surface. At first sight, it may appear idle to anticipate the possession of remedies that would exert an exclusive control upon each portion of the uterine system. Yet even the present history of the Ma- teria Medica will justify the expectation. The ergot, for instance, manifests its action upon the fibres of the body and fundus of the uterus, and not upon the neck; the sugar of lead acts upon the extremities of bleeding vessels; the spirit of turpentine, upon the mucous surfaces; mercury upon the salivary glands, &c. &c. Is it, then, unreasonable to hope we may soon be in possession of substances, whose action shall be confined to the ovaria or to the internal surface of theuterus? for until we do find such specifics,* our practice, in the inordinate flow of the menses, and in menor- rhagia, will be rather uncertain. It may be asked, of what practical value would the knowledge be, whether the fluid expended in menorrhagia be an increased secretion of the menstrual fluid, or truly a hemorrhage? We would answer that the truth is always of consequence, either di- rectly or indirectly; and that, if they be the same fluids, the dis- ease in question would consist of a morbid condition of a natural action; and if they be not, as we believe they are not, the menor- rhagic discharge would consist of a morbid condition of some other portion of the uterine surface, than that which furnishes the menstrual blood; the knowledge of which may lead to great practical results. Be this as it may, the disease is of such fre- quency and consequence, as to render a complete knowledge of • Every substance which can exert an influence upon the animal system, causei its own peculiar mode of action; and, from what we already know, there is ever/ reason to believe, that each organ belonging to the human fabric, has appropriate stimuli in a state of health, or counter-agents in a state of disease, among the varied productions of nature; and that these stimuli, or counter-agents, are capable of changing the mode of action of such parts, on which they are destined to act If this be true, how important is it that the peculiar action of every substance should be closely watched when administered to the living animal? It is only by such attention to the influence of medicines, that remedies can be discovered, and pro- perly classed; and it is by the same kind of scmtiny that an individual article of that class, shall at one time, or occasion, merit a preference over every other indi- vidual of the same class. To prove this, we need but refer to every day's expe- rience, in the choice of cathartics; emetics, astringents, &c., when prescribing for the body in a state of disease. MENORRHAGIA. 163 its mode of treatment highly important. We shall, therefore, proceed to give a history of this disease, together with the mode of treatment. When treating of the " immoderate flow of the menses," we observed, that excess of discharge must be considered as a rela- tive term; and that we should rather consider the consequences of the quantity, than the quantity itself. But, with respect to menorrhagia, it will be found the best practice to attempt to arrest it in limine: we have, therefore, for many years, treated this dis- ease as one that would most probably increase if neglected, though the hemorrhage may be small at the time. Gardien,* however, says, that " we should judge less by the quantity expended, that menstruation is immoderate, than by the loss of strength that is the consequence of it." This advice, we have agreed, would be correct, if the discharge were that of the menstrual blood; but we cannot agree it would be proper in menorrhagia. We have just declared that Gardien had confound- ed these two conditions of the uterus, and this in mere compliance with a preconceived notion; and that notion, in our opinion, founded on no better ground than the weight of authority.t Hip- pocrates compared the purity of the menstrual blood to that of an immolated victim; and declared it would coagulate as quickly, if the woman were in good health. This opinion has been copied into almost all the books of medicine since that time, and handed down and believed, by many at this moment. Our own inquiries upon this subject, and they may strictly be called extensive, have constantly led to an opinion, contrary to that entertained by Hip- pocrates; and we are certain that this discharge, when in a state of health, differs widely from the blood of hemorrhage.^ We have, in our definition of menorrhagia, declared it to be a discharge "of fluid blood, or coagula, or both;" and in these re- spects, it differs widely from the product of the menstrual action. If a coloured fluid escape from the vagina, which will coagulate when exposed to the air; or if it be expelled in form of coagula, • Vol. L p. 289. f " L'hemorrhagie naturelle qui constitue les regies est arterielle: a cette epoque de la vie, presque toutes les hemorrhagies sont arterielles." Vol. I. p. 223. In this quotation it is perceived that he calls the menstruous action a hemor- rhage; and an arterial hemorrhage. t See p. 97. 104 MENORRHAGIA. we no longer consider this the healthful process termed menstru- ation, but the disease called menorrhagia ; and, when applied to for this purpose, we prescribe for a state of disease; for it is agree- ble to observation, that when this condition obtains, the uterus is not in an entire healthy state. And we may urge, as a proof of this, that those women who habitually expel coagula to any amount, do not conceive, until this state of the uterus is changed. Women who live indolently, and indulge in stimuli; who use little or no exercise; who keep late hours; who dance inordi- nately ;* who are intemperate; who have borne many children; who have been subject to febrile affections; who have much leu- corrhcea ; who are too prodigal of the joys of wedlock; who arc advancing towards the non-menstrual period; who yield too readily to passions or emotions of the mind, are those most ob- noxious to menorrhagia. This complaint is almost always announced by certain unplea- sant feelings, which the woman after awhile recognises to be the harbingers of this hemorrhagy; such as lassitude, and especially of the limbs; back-ach; a sense of fulness; and pressure about the region of the uterus; a dragging sensation about the groin; frequent inclination to make water; chilliness; a variety of ner- vous symptoms; feverishness; quick pulse, and oftentimes tense, full, &.c. All of which disappear, or are much moderated so soon as the discharge takes place. This discharge is almost always the true menstrual secretion in the commencement; but it is either arrested, or is, more properly speaking, confounded with the blood, or coagula which now make their appearance; and which may continue a longer or shorter period; and of which more or less may be expended. It may take place without any premonition; especially if the operation of a moral cause has produced it; and the quantity thrown out may be so moderate as to induce very little weakness, or any other inconvenience, save that which arises from its dura- tion ; or it may be so profuse, as to suddenly prostrate the strength, and become quickly alarming. It may continue but the ordinary menstrual period; or it may persevere for many days beyond • Gardien, especially, condemns the " Waltz." He says " il n'en est point de plus propTe a produire cet effet que cette danse voraptuease connue «duj k nom de Walse." Vol. I. p. 296. MENORRHAGIA. 165 it. It rarely ceases suddenly; but gradually declines, both in quantity and in the intensity of its colour, several days before it stops altogether. When it has continued for many days together, it becomes se- rous towards the decline; and this change is almost always at- tended with an unpleasant odour; sometimes extremely offensive, and occasionally even acrid. If it has been habitual for some time, the woman becomes pale, feeble, and emaciated. The breasts lose their fulness, and become flaccid. Leucorrhcea is almost always an attendant; which may be very abundant, and even offensive. The digestive organs become involved, and be- tray many distressing dyspeptic symptoms. Every thing turns sour upon the stomach; the bowels become constipated, or are urged to diarrhoea; the feet swell; and, if not arrested, dropsy :i«ay ensue. There are evidently two conditions of this affection; one, where the whole system participates; and plethora may exist, or even a distinctly formed fever may be excited, just before the hemorrhage lakes place. In this case, the face, the eyes, the spirits, all partake of this general state of excitement; nor does this condition subside, until the uterine irritation ceases. The other seems to consist of a mere local determination to the uterus; producing an engorgement of this organ, but which does not im- plicate the general system, except from the waste of strength it occasions, when the discharge is profuse, or long-continued. Most writers on the subject of hemorrhages, have divided them into active and passive; but there is great room to question at least the propriety of this mechanical distinction, if there be not sufficient ground to reject it altogether. Broussais powerfully opposed the doctrine of passive hemor- rhages : he contended, that, in all cases, there existed an irritation in the part that yielded the blood; and that weakness, without irritation, could no more produce hemorrhage than inflammation. It is supposed, by those who advocate the doctrine of passive he- morrhage, that the expended blood proceeds from the relaxed, or partially paralyzed exhalents. But he contends, that this cannot be the case, since Bichat, and other modern physiologists, appear to have proved, that after the blood arrives in the capil- lary system, it is no longer subject to the action of the heart. If this be admitted, where is the power that can force the blood into these orifices ? 22 166 MENORRHAGIA. Dr. Caldwell,* in a note on Cullen's division of hemorrhagics into active and passive, observes, that this distinction " is utterly unfounded, and ought to be rejected from pathological science. The phraseology leads to a physiological error. The expression, < passive hemorrhagy,' as applied to living matter, is a gross misnomer. During life, no hemorrhage can possibly be passive. Blood flows from the vessels that contain it, at least in part, by means of the action of that vessel. Now, is it possible for such action to cease, otherwise than by the cessation of life in the part? But the cessation of'life is the commencement of gangrene. A hemorrhagy really passive, therefore, cannot take place, except from gangrenous vessels. But from such vessels, unless they be very large, blood does not flow at all. The reason is obvious, They act on the blood which they contain, like dead matter; and we well know, that the action of dead matter on blood forces it to coagulate. Hence, in the vessels of a gangrenous part, the blood does coagulate, and prevents the hemorrhagy that would otherwise ensue, "f " Every hemorrhagy, therefore, that does or can take place from the living body, is really an active one. It arises, not from the absolute want of action in the part, but from its wrong ac- tion. The vessels dilate, or rather contract and dilate alter- nately, when they ought to contract only, and thus prevent the escape of the blood they contain." For these reasons, and because we have never been able to per- ceive any practical benefit from the division of hemorrhagies • Ed. of Cullen's Practice, p. 734. f It seems to be a law of the system, that the tendency of the blood to coagu- late, is in proportion to the diminution of vital energy. This law is one of great consequence and efficacy, in those threatening lesions of the body, called heme* rhagies; for, oftentimes, death would instantly ensue from these causes, did not the blood, by a sudden coagulation, prevent the farther waste of this fluid. This disposition to coagulate, is almost certain, when the powers of life are put sud- denly upon the wane from the expenditure of blood, by inducing a state of syn- cope. Now, syncope is a kind of counterfeit death; all the vital energies are suspended for awhile, almost as effectively as if death had really taken place, and the law of coagulation is put in operation, by coagula forming, and thus put- ting a stop to farther bleeding. These facts are well ascertained. Therefore, when syncope takes place, the blood vessels are almost in a state of death, or at least, of temporary paralysis; they no longer propel by acting upon their contents; consequently, tlieir contents remain quiescent. But, agreeably to the doctrine of passive hemorrhage, the blood should now flow faster, since the vessels are in a state of the greatest possible relaxation. MENORRHAGIA. 167 into active and passive, we shall consider the hemorrhagy of which we are treating, always to be of the active kind. We have stated above, that there are two varieties of menor- rhagia; and that the first owes its character to the plethoric con- dition of the blood vessels, and the general participation of the system: hence, the fevered cheek; the brilliant, and sometimes engorged eye; the quick, hard pulse; pain and other uneasiness about the back, and uterine region, just before the hemorrhage takes place; as well as the peculiar character of the fluid which is discharged. The blood discharged in this variety of menorrhagia, is sure to betray the general condition of the system; for it is always found pretty florid, dense, with but little serum, and much dis- posed to coagulate. The quantity evacuated, will, of course, differ in different individuals; but, whatever may be,the quanti- ty, it is sure to present the qualities just named. This hemorrhagic disposition of the uterus may take place at any moment of the menstruating period; and at any age within that limit. But the vigorous and plethoric, who are liable to the influence of the exciting causes, are more subject to it than the feeble-pulsed, and those who do not encounter such causes. Thus, we find women of cities more obnoxious to menorrhagia than those of the country; because the physical and moral causes, which tend to produce that condition of the system, are applied with more force and certainty to the former than to the latter. But, independently of the causes which may tend to induce a general plethoric disposition of the body, there are some which act by creating a local congestion of the uterus itself. Thus, the frequency of this complaint among the women of Holland, is at- tributed to the almost constant use of foot stoves, and the inor- dinate drinking of hot thin liquids, as tea and coflee: they are also indolent and luxurious.* Dancing immoderately, and then permitting the body to cool suddenly; tight lacing; ill-protected lower extremities; frequent use of demi-baths; excess of venery, &c, may be considered as the most common of such causes. The most frequent of the exciting causes, are all such as may suddenly augment the force of the circulation, and the motion of the heart; or such as shall tend to have a direct action upon the uterus itself. Of the first kind, is an over-stimulating diet; pas- sions or emotions of the mind; violent exercise, or exertion of a * Dr. Rush, MS. Lectures, Leake, Gardien, &c. 168 MENORRHAGIA. sudden kind. Of the second kind, emmenagogue medicines, as the tincture of cantharides, aloes, savin, immoderate venery, especially during the flow, &c. The indications of cure in the first species, may be readily de- duced from the premonitory and accompanying symptoms. They all show the plethoric condition of the system in general, and of the uterus in particular; therefore, the means to be employed to prevent this hemorrhagy, will consist, first, of such as are applied during the absence of the hemorrhagy; and, secondly, those during the period of the discharge. For the first, The predisposing causes should be withdrawn as effectually as possible, by obliging the patient to renounce her indolent habits; by taking regular and well adapted exercise in proper weather in the open air; to live upon a milk and vegetable diet; to abstain from all spirituous and fermented liquors; to indulge in no stimu- lating articles of diet, as spices, or other condiments; to keep the bowels regular, or even a little loose; to sleep, (and that not too long at a time,) in a cool room, upon a hard bed, and without too many bed-clothes, or even curtains; to keep the feet and legs warm; and occasional blood-lettings.* To shun the exciting causes enumerated above, with the most scrupulous care. During the flow, the first object is to diminish the force of the circulation, by blood-letting from the arm, rest, a horizontal pos- ture, cool air, and cold drinks; secondly, to reduce the quantity of the discharge, by such means as favour the contraction of the • Blood-letting should always be employed in the intervals, in cases of this kind, whenever the pulse is active; and it must be repeated as long as the puke is tense, irritable, or full. The best time to abstract blood, we think, is a few days after the discharge has ceased, provided the pulse be active at this time: if it be not, let it be watched, and when it is found to be acquiring strength, let the blood be taken then, and in sufficient quantity to reduce both the size and vigour of the artery; for bleeding is useful in such cases, in proportion to the contrac- tion it produces in the vessels. If the pulse rise only near the period for the re- newal of the hemorrhagy, blood must then be abstracted, by all means, and in larger quantity than at the other periods just indicated. For, if this direction be not attended to, very little advantage will be derived from the operation, as the desired object, (the contraction of the vessels,) will scarcely take place, as those of the uterus are so insulated, and independent of those of the general sys- tem. I have thought I derived much advantage, at these times, from the application of leeches to the small of the back; for eight or ten ounces abstracted by them, seems to have more control over the uterine circulation, than double that quantity taken from the arm. MENORRHAGIA. 169 vessels concerned in the hemorrhage, and favour the coagula- tion of the blood. Of the remedies which are calculated to fulfil these useful purposes, the sugar of lead seems at present to stand foremost: it should be given in liberal doses, often repeated, if necessary; but always guarded with opium. The following is our usual formula:— 8«. Acetat. plump. 9j. Gum. opii. gr. iv. M. f. pil. xij. One of these to be given every half hour, hour, two hours, or more seldom, as the necessity may be.* If this make the stomach sick, or if nausea and vomiting at- tend, which sometimes happens, it may be administered in the form of an enema, as follows: a scruple of the acetate dissolved in two ounces of warm water, to which must be added a tea- spoonful of laudanum. Should this be discharged soon, it may be repeated. We, however, from late experience, prefer the vinous tincture of the secale cornutum; twenty drops in a little sweetened water, every hour until uterine pains are produced. The medicine is then suspended until this irritation passes off: it is then to be re- ✓ peated until similar effects are produced; but given at longer and longer intervals. Cold applications, consisting of equal parts of whiskey or brandy, and vinegar, should be applied over the pubes, and re- newed as soon as it becomes warm. In warm weather, the addi- * Dr. Porta recommends "tannin" in menorrhagia, in doses of three grains, every three hours; and is led to the following conclusions in regard to its use:— 1. That whenever the uterus is the seat of irritation, which gives rise to an active or hypersthenic flooding, and also when this discharge depends upon a chronic metritis, this medicine acts specifically upon the uterus. 2. But when acute metritis gives rise to menorrhagia, the inflammation must be subdued by copious and sufficient blood-lettings. 3. But when menorrhagia proceeds from any organic alterations in the uterus, this medicine has no efficacy. 4. That a preference should always be given to this medicine in the treatment of menorrhagia, as it is very prompt in its effects: it produces no unpleasant symptoms; and the stomach bears it well even in a state of irritation.—Archiv. Gen. from the Annali Univ. de Med. April, 1827. It may be well to observe, that " tannin," in its pure state, is very difficult to procure, and, consequently, in that condition, cannot be well employed, in gene- ral practice. It certainly abounds in the Rad. rathanat; therefore the extract of this substance, is perhaps as good a form as any we can employ. We have al- ready mentioned this substance, when treating of the decline of the menses, page 156. 170 MENORRHAGIA. tion of ice is very important. The best mode of applying the cold mixture, is by cloths wrung out of the mixture; or by means of a large bladder, partially filled. If the latter be used, cold water is as good as the mixture just named, as the fluid does not come in contact with the skin; its whole virtue being in its cold- ness. The plan just detailed is intended only for such cases as are attended by a profuse and threatening discharge; for, in ordina- ry cases, the sugar of lead, as prescribed above, answers every purpose without the cold application. We deem, however, the other cautions important, even in very moderate cases; as very slight errors will sometimes create a great deal of mischief. Rest, cool air, a very low diet, and cold drinks, should be always in- sisted on, if we expect a permanent cure, even in cases where the patient does not think it important to lie by. Where the dis- charge is very profuse and alarming, which sometimes happens even with young girls, but more especially with women pretty well advanced in life, and the means above recommended have not proved successful, the tampon must be had recourse to. The variety we have just described, is generally of much ea- sier management than the second; which consists "in a mere lo- cal determination to the uterus, producing an engorgement of this organ; but which does not implicate the general system, ex- cept from the waste of strength it occasions, when the discharge is profuse, or long-continued." The variety now under consideration, is most common to wo- men of an irritable and feeble constitution; and where, agreea- bly to Gardien, there exists an accumulation of vital power to- wards the uterus. This variety, like the one just spoken of, is accompanied by some pain and heaviness in the uterine region; heat, and some- times itching in the pudendum. The pulse is small, and rather frequent; the extremities disposed to become cold; the face pale, and sometimes cachectic; the appetite feeble; the tongue frequently found furred, especially in the morning; palpitation of the heart; and respiration hurried upon motion. The indications in this variety, are, to destroy or diminish this congestive tendency of the uterus; and to moderate, or interrupt the unnatural discharge. The first indication is to be fulfilled by equalizing the circula- tion as much as possible, by determining it towards the surface; by well-regulated exercise; by wearing flannel next the skin; MENORRHAGIA. 171 by keeping the lower extremities warm; by a nutritive and ea- sily assimilated diet; abstaining, however, from stimulating con- diments and drinks; by preventing constipation, by even purging with aloetic medicines;* by diverting the current of blood to some neighbouring part, by dry cupping the small of the back, and blistering the inner side of the thighs; and by the application of leeches to the groin, or inner part of the thighs. This last re- medy is found to be particularly useful, when used three or four days before the expected sanguineous eruption: three or four ounces abstracted in this manner is every way sufficient. Eme- tics, and especially the ipecacuanha emetics, are thought to be useful in this variety of menorrhagia: they were first proposed by Dr. Bryan Robinson for hemorrhagy, and have since been re- commended in menorrhagia; but of these, we can say nothing decisive from experience. If at all useful, in such cases, it must be just before the menstrual eruption; for, during the flow, we never remember to have seen vomiting abate the discharge when it came on spontaneously, though it may have been pretty se- vere. Taking a grain of the sugar of lead with a little opium, three or four times a day, in the absence of the discharge; or drachm doses of the tincture of rathany, or the extract, as di- rected at page 156, will be found highly useful. To fulfil the second indication, the means are precisely the same as recommended in the first variety; with this exception, that if the discharge be long continued, we may employ the dry cupping and apply blisters. In both varieties, we have often found decided advantage from injections per vaginam, made of the solution of the acetate of lead, of sufficient strength—that is, two drachms to a pint of lukewarm water. Half of this, or one-third, may be thrown up the vagina by means of a syringe, three or four times a day. In all cases of menorrhagia, opium is found highly useful, when combined with small portions of ipecacuanha; and should always be exhibited, as soon as the pulse will bear its stimulus. * We have in several cases of Menorrhagia, in women somewhat advanced in life, found great advantage from the hiera picra as a cathartic; it may be used agreeably to the following formula:— 5<. Hiera Picra, - - 3j. Sapo. Venet. - - gr. viij. Syr. Rhsei. q. s. m—f. pil. xx. One or two of these taken every night, until the bowels are found free. See p. 153. 172 SIGNS ACCOMPANYING PREGNANCY. It should be certainly given at night, if pain prevents sleep; or even during the day, if necessary. Gardien makes a third variety of menorrhagia; namely, "a spasmodic." Of this variety I can say nothing; nor do I believe in its existence; the only evidence of the species, agreeably to him, is, that menorrhagia is sometimes relieved by opium, or other antispasmodics. CHAPTER VIII. OP THE SIGNS WHICH USUALLY ACCOMPANY PREGNANCY. In a work treating exclusively of the diseases peculiar to the female, we have thought it important that the inexperienced practitioner should be well acquainted with what are termed the rational signs of pregnancy; and for the following reasons:— 1st. Because pregnancy often influences our prescriptions, in both the acute and chronic diseases that may accompany this con- dition. 2d. Because the physician's opinion may decide the fate of a female in a court of justice, when she wishes to take advantage of the privileges which pregnancy claims, when she may have forfeited her life to the laws of her country by her crimes. Or, 3d. Where the duration of human gestation may involve the character or property of individuals. Therefore, the value of the signs of pregnancy should be as well ascertained as the nature of things will_ permit, that error may not be committed in our prescriptions; and that the innocent may not be injured, or the guilty absolved: consequently, in a medico-legal point of view, a knowledge of the symptoms about to be considered, is every way of great importance. As soon as impregnation takes place, various parts sympathize, either directly or indirectly, with this condition of the ovarium. These sympathies, or disturbances, are generally so uniform in their nature, and so regular in their appearance, that they have been considered as evidences of pregnancy: the first, and most usual, is the interruption of the menstruous discharge; secondly, nausea, and vomiting; thirdly, enlargement of the breasts; fourth- ly, the areolae round the nipples; fifthly, the secretion of milk; SUPPRESSION OF THE MENSES. 173 sixthly, the enlargement of the abdomen; seventhly, the increased size of the uterus; eighthly, pouting out of the navel; ninthly, spitting of white frothy mucus; tenthly, salivation. Although almost every pregnancy has nearly the whole, or the greater part of the signs we have just enumerated, yet their union may not, in a given individual cas"e, so positively decide this condition as to render it free from all doubt; especially, where the subject may become an object of judicial proceeding; and where life, character, or property, may be involved in the consideration. On this account, chiefljr, we will spend a few moments on each of these reputed signs of pregnancy. Sect. I.— 1. Suppression of the Menses. The suppression of the menses, in a married woman, or in a woman who has had illicit commerce with a man, may justly give rise to the suspicion, that impregnation has taken place; and, as a general sign, may safely be looked upon as one of the most unequivocal that may present itself; yet a variety of causes, inde- pendently of pregnancy, may produce the same effect, both in the married and in the unmarried woman: 1st. Exposure to cold and damp at the time the menses are about to appear, or imme- diately after they have shown themselves. 2d. Certain chronic affections, as phthisis pulmonalis, scirrhous liver, or other visceral obstructions. 3d. The operation of certain powerfully depressing passions, or emotions of the mind; some imperfection in either the ovaries or the uterus itself. 4th. Accidents by falling, or se- vere blows; and, lastly, the precocious cessation of this function, If, then, the absence of the menses do not positively evinee pregnancy, will their presence prove that it does not exist? This- question would, unquestionably, be answered in the affirmative by Dr. Denman, and, perhaps, many others; not because they have not seen coloured discharges from the vagina during preg- nancy; but because, from a preconceived notion of the functions of the utefus, they deny these discharges to be menstrual.. In declaring women may menstruate after impregnation, I have no favourite hypothesis to support;, nor am I influenced by any affectation or vanity, to differ from others; neither do I believe I am more than ordinarily prone to be captivated or misled by the marvellous; for I soberly and honestly believe what I say and pledge myself for the fidelity of the relation of the cases I adduce in support of my position. 23 174 srrrRESsioN of the menses. Nothing can be more vague and unsatisfactory than Dr. Den- man^ definition of menstruation; namely, " from the uterus of every healthy woman, who is not pregnant, or who does not give suck, there is a discharge of blood, at certain periods, from the time of puberty to the approach of old age." Now, from this definition it would necessarily follow, that if a woman menstruate, she must be in good health; but the experience of every day is against this conclusion. Again, if a woman has a discharge of blood, while she is suckling, she must, by the terms of this defini- tion, be either no nurse, or this discharge is not menstruous blood. Dr. Denman would certainly agree to this last deduction, but what proof has he to support this belief? So far as my own, and the experience of many others go, I should say none. I wish to be understood to mean, whenever I use the terms, menstruous discharge, menstruous blood, menses, or any other designation, that legitimate discharge from the uterus, which would, under the best circumstances of health in general, or condition of the uterus in particular, constitute this important function in its most perfect form—I do not mean to include discharges of blood, pro- perly so called, and properly so being, as coming within my views and meaning of the above terms. I employ the terms named above, to express the result of a peculiar action of the in- ternal surface of the uterus, but which differs widely from the common circulating fluid, called blood; and precisely what Dr. Denman wishes to be understood to mean, when he speaks of " menstruation." The only argument adduced by Dr. Denman in support of hia hypothesis, is, " that, if a woman menstruated, while pregnant, she must very often miscarry, as a part of the ovum must neces- sarily be detached from the uterus at each period." I would ask, why a part of the ovum must be necessarily detached to give issue to this discharge? I see no reason why this should be so; as I am persuaded, that this can happen without any such con- sequence. Dr. Hunter, Dr. Denman himself, Mr. Burns, Baude- locque, &c* all declare, that for the first two or three months, the inferior portion of the uterus, and more especially the neck, are not always occupied by the decidua, but are left as free, and * " En general, elles, (les regies) se suspendent durant la grosscsse, ct l'al- lajtement,- mais il est des cas ou leur £coulement continue dans ces circon- stances; relativement a la grossesse, il se borne ordinairement aux premiers mois, rarement se soutient-il jusqu' a Paccouchement."—Frank. SUPPRESSION OF THE MENSES. 175 as unembarrassed, as before impregnation: of this I have no doubt; and it is from this unoccupied portion, that the men- struous discharge takes place. If it be said, that this surface is insufficient in extent to yield the quantity that is ordinarily discharged, I would answer: First, I am not contending for the quantity, but the quality of the eva- cuation. And I admit, that, when this evacuation takes place during pregnancy, it is not so abundant as it usually is under other circumstances. Second. That the following fact will show, how capable a small healthy portion of the internal surface of the uterus is, of yielding a quantity of menstruous blood. My friend, Dr. Coxe, the present Professor of Materia Medica, gave me a diseased uterus, in the cavity of which there vvas a healthy portion of surface, not exceeding in size a common thumb-nail; and from this surface was yielded, at every menstruous period, a quantity of fluid; and which, as far as could be detected by its sensible properties, was of a perfectly healthy quality. Again, I well know a number of women, who habitually-men- struate during pregnancy, until a certain period; but, when that time arrives, menstruation ceases; several have menstruated un- til the second or third month; others longer; and two until the seventh month: the last two were mother and daughter. I am certain there was no mistake in the cases to which I now refer. My interrogatories were numerous, and the answers bore all the marks of candour:—first, the menses were regular in their re- turns; not suffering the slightest derangement from the impreg- nated condition of the uterus; secondly, from two to'five days were employed for their completion; thirdly, the evacuation dif- fered in no respect from the discharge in ordinary; except, they thought it less abundant; fourthly, there were no coagula in any one of these discharges; consequently, it could not be the common blood, or the blood of hemorrhagy; fifthly, in the two protracted cases, the quantity discharged regularly diminished after the fourth month, a circumstance, not perhaps difficult of explana- tion. I may also cite, in favour of my position, the authority of Heberden, Hosack, and Francis.* With regard to nurses menstruating, every accoucheur must be familiar with the fact, as it is of frequent occurrence; happening, ten times, perhaps, to the other once. Here the same difficulty * Francis's ed. of Denman, p. 231. 176 SUPPRESSION OF THE MKNSES. does not exist; for the uterus is now unoccupied: and the only matter of surprise is, that it does not more frequently occur. Though I have strenuously contended for the fact, and attempted an explanation of it, yet I am well persuaded it is but an ex- ception 'to the rule, and not an ordinary arrangement of nature. In one extraordinary case, which fell under my notice in 1791, the contrary of suppression took place at pregnancy: a woman applied for advice for a long-standing suppression of the menses; indeed, she never had menstruated but twice. She had been married a number of months, and complained of a good deal of derangement of stomach, &c.—I prescribed some rhubarb, and steel pills. About six months after this, she again called to say that the " medicine had brought down her courses, but she wag more unwell than before; her sickness and vomiting had increased, besides swelling very much in her belly;" I saw that this was pretty much distended, and immediately examined it, ns I sus- pected dropsy—but from the feel of the abdomen, the want of fluctuation, and the solidity of the tumour, I began to think it might be pregnancy, and told the woman my opinion. She now became anxious to understand her situation exactly, and submit- ted, for this purpose, to an examination per vaginam; this proved her to be six months advanced in pregnancy; after this time, she had Ihe regular returns of her catamenial period until the full time had expired. During the period of suckling, she vvas free from the discharge: she vvas a nurse for more than twelve months; she weaned her child, and, shortly after, she was again surprised by an eruption of the menses, which, as on the former occasion, proved to be a sign of pregnancy. Whether this peculiarity pursued her still farther, I cannot say; as she removed from the neighbourhood, soon after the birth of her second child. Whether there vvas a periodical discharge of a colourless fluid in this case, as a compensation for the regular menses, I am un- able to say, as I did not examine the woman on this point, not having, at that time, the same interest as now, in such minute in- quiry. 1 merely state the main facts, though they bid defiance to calculation, and almost to example, Deventer* being the only .author, so far as I know, who has furnished a similar example. • Chap. XV. p. 65. ARE0LJE. 177 Sect. II.—2. Nausea and Vomiting. Nausea and vomiting, though a very usual concomitant, is very far from being a certain sign of pregnancy; it occurs sometimes where the menses have been delayed by other causes: it may, however., be considered as adding to the general testimony in proof of this condition. Sect. III.—3. Enlargement of the Mammae. Enlargement of the mammae is a very common attendant upon genuine pregnancy, though it is not uniformly so—I have known a number of cases where they did not swell even at the latter pe- riods of gestation; nor was it until after delivery, that they gave evidence of capacity to perform their ordinary functions: on the other hand, I have known them to enlarge considerably, where the menses were interrupted from other causes than pregnancy. Sect. IV.—4. Areolae. The areola?, which are sometimes formed round the nipples, must be considered as equivocal in any but a first pregnancy: in this case did areolae form, I should place great dependence upon them; for, so far, I have not been deceived. They do not, how- ever, always present themselves; and may not be easily detected even when formed, in very dark-skinned women: there is al- ways, I believe, an enlargement of the little sebaceous glands which surround the nipples, when areolae encircle them; and they, as far as my observations go, serve to strengthen the sus- picion of pregnancy. So far as I recollect, this blush is not mimicked by obstructed catamenia, or from any other cause than pregnancy. It is possible that they may attend a false con- ception or mole; but of this I have no experience. In a second, or other pregnancies, I do not place the same reliance upon this sign; as a trifling irritation, or other causes, I believe, may pro- duce them; or they may, as I have often noticed, be absent alto- gether. The marks I have been speaking of, must not be con- founded with the permanent stain left around the nipple after a woman has suckled a child; and great care should be taken to conduct this inquiry in such a manner as to give no false im- pressions. 178 FORMATION OF MILK. When the nipples are to be examined, the woman should open her bosom so as to expose the whole breast: she must not be suffered to draw it above the margin of her clothes by placing her hand beneath it—in doing this, the nipple oftentimes is irri- tated by the pressure of the fingers, which gives a new character to the appearances. I have, in a number of instances, detected pregnancy by this examination, where the patients insisted their irregularity proceeded from cold or other causes. It must, how- ever, be remembered, that the absence of these areolae does not prove the woman unimpregnated. Sect. V.—5. Formation of Milk. The formation of milk in the mammae, is coeval, in some preg- nant women, with their swelling; while in others it is not formed until after delivery. When this secretion takes place, it is looked upon by the vulgar as a certain sign of pregnancy; but I have oftentimes known this fluid, (or at least a fluid bearing all the marks of the first formed milk,) plentifully secreted without pregnancy, merely by the interruption of the menses. It has been produced in women past the period of child-bearing, and even, it is said, in men* by the repeated application of a child to ithe nipple. It has also been produced in a girl of eight years old, as we are informed by Baudelocque. (See his very interesting ease, Vol. I. page 219.) I once knew a considerable quantity of milk form in the breasts .of a lady, who, though she had been married a number of years, had never been pregnant; but who at this time had been two years separated from her husband. She mentioned the fact of her having milk to a female friend, who, from an impression that it augured pregnancy, told it to another friend as a great secret; who in her turn mentioned it to another friend, and thus, after having enlisted fifteen or twenty to help them keep the secret, it * The following case is in proof of this assertion: it is communicated by Mr. Heber Chase, of New Hampshire. A Mr. James Hildreth, of Hopkinton, New Hampshire, was, about three years since, (Dec. 9th, 1834,) from the abundant secretion of milk in his right breast, enabled, by pressing it with his fingers, to project milk from the nipple two or three feet. Mr. Chase declares he has seen him do so often at the young people around him. He was a blacksmith by trade, and a muscular, robust man, some- what dissipated; but not so much so as to interfere with his business. He was about thirty years of age, and the father of several children. ENLARGEMENT OF THE ABDOMEN. * V J got to the ears of the lady's brother. His surprise was only equalled by his rage; and, in a paroxysm, he accused his sister in the most violent and indelicate terms, of incontinency, and menaced her with most direful vengeance. The lady, conscious of her innocence, desired that I should be sent for, forthwith; and insisted her brother should not leave the room until I arrived: some time elapsed before this could be ac- complished, as we were several miles from each other, during. the yellow fever of 1798. During the whole of this time she bore his threats and revilings, with the most exemplary pa- tience, and silence. I at length arrived; and, in the presence of the brother and a female friend, she informed me of what I have just stated; and said her object in sending for me vvas, to submit to such an examination as I might judge proper to determine, whether she were pregnant or not—she would not permit her brother to leave the chamber; and I conducted the examination without his withdrawing. This thing turned out as I had antici- pated, from the history given at the moment, of her previous health. I pronounced her not pregnant; and she died in about; eight months after, of phthisis pulmonalis, in which disease the obstruction of the catamenia is not an unfrequcnt occurrence. Sect. VI.—0. Enlargement of the Abdomen. The enlargement of the abdomen, perhaps, is one of the most* equivocal of the enumerated signs, since it may take place from so many other causes: as, 1st. Dropsical affections, of either the abdomen, uterus, or ovaries.* 2d. A chronic disease of the ova- rium, or uterus itself. 3d. A retention of the menses, from some accidental cause preventing their flow.f 4th. Enlargement of al- • Dr. Blundell relates the following interesting case, which should be kept in recollection, as a beacon to shun a similar error. Dr. Haighton was sent for in consultation with a distinguished London surgeon, to a case supposed to be ascites, for which the patient was to be tapped the next day. Dr. Haighton suggested that this swelling might be a dropsy of the uterus, but no particidar examination was made to ascertain this. During the night, the sac containing this fluid gave way, a " flood of fluid was discharged, and the ab- domen collapsed rapidly, a foetus not larger than the first joint of the finger escaped, the woman escaped the paracentesis and did well."—Princip. and Prac. ofObstet.p. 78. f See Miss F's. case, in Essays on various Subjects connected with Midwifery, page 337, by the author. 180 ENLARGEMENT OF TUE ABDOMEN. most any of the abdominal viscera. 5lh. The simple obstruction of the catamenia. For these reasons, but little reliance can be placed upon this circumstance alone, or even when combined with several others. For I have had the pleasure, in several in- stances, of doing away an injurious and cruel suspicion, to which this enlargement had given rise. Within a short time, I relieved an anxious and tender mother, from an almost heart-breaking ap- prehension for the condition of an only, and beautiful daughter, on whom suspicion had fallen, though not quite fifteen years of age. This case, it must be confessed, combined several circum- stances which rendered it one of great doubt; and without having had recourse to the most careful, and minute examination, might readily have embarrassed a young practitioner. This young lady's case was submitted to a medical gentleman, who, from its history, and the feel of the abdomen, pronounced it to be a case of pregnancy; and advised the sorrow-stricken mother to send her daughter immediately to the country, as the best mode of concealing her shame. Not willing to yield to the opinion of her physician, (a young man,) and moved by the positive denials of her agonized child, the mother consulted me. The history of the case vvas thus briefly given by the mother: " Her daughter commenced, between twelve and thirteen, to menstruate, and continued to do so, regularly, until late last fall ;* at which time she had a very smart attack of the prevailing epi- demic; of this she was, however, relieved by the usual remedies; but since which time, she had never menstruated; she gradually swelled in the belly; her stomach vvas much affected, especially hi the morning; and the breasts were a little enlarged." I examined the mammas, and found them a little tumid, but without areolae; the abdomen was much enlarged, tense, and hard, in consequence of a large tumour which vvas confined to the left side of this cavity, and which could be easily traced throughout its right and inferior margin, and proved, (at least in my opinion,) to be an enlarged spleen; no tumour was found in the pubic region; consequently, the uterus vvas not found en- larged: the navel vvas sunk;,and upon an attempt to pass the finger into the vagina, I found so much evidence of her conti- nency, that I did not persevere, being perfectly satisfied, from the condition of the parts, that she was a virgin. I unhesitatingly, * 1823. POUTING OUT OF THE NAVEL 131 and with no common degree of pleasure, declared the poor child to be free from the charge, so heedlessly and cruelly preferred against her. Sect. VII.—7. Increased Size of the Uterus. An increased size of the uterus, especially in young women, either married or single, will necessarily create a suspicion that it may arise from pregnancy; particularly if its surface, as dis- tinguished through the abdominal parietes, be uniformly round, smooth and elastic; and if there be combined with these marks, several of the rational signs of pregnancy—but it is far from being infallible. This distention of the uterus may arise, 1st, from a dropsical state of the uterus; 2dly, from disease within its cavity, as tumours, or excrescences; 3dly, from moles, or false conceptions, or hydatids; 4thly, from a retention of the menstru- ous discharge from the occlusion of the os tincae, &c. The case referred to, of Miss F., is strictly in point; and was one among others, where injurious surmises were, for a long time, most cruelly entertained.* « Sect. VIII.—S. Pouting out of the Navel. Pouting out of the navel, if it take place, only proves that there is something behind, which makes it protrude; but it by no means follows, that it is the uterus distended by pregnancy: I believe it invariably takes place in pregnancy after the sixth month, or sometimes even earlier; and I think the following conclusions may pretty safely be drawn from this condition of the navel: 1st, If the woman be pregnant, it will, by its projection, indicate the advancement to be at least six months; yet the woman may be advanced to the fifth or a little beyond it, without this part under- going a change; 2dly, If this part protrude, it will by no means • Since this period, 1 have met with a case very similar to that of Miss F's. in a married lady, but who had never been pregnant. This case, naturally enough was looked upon as one of pregnancy, as there was no apparent incapacity-all the rafconal signs of this condition were present; and it was supposed that the pat.ent was in her seventh month of gestation. On the fifth of May, 1830 she was suddenly surprised by a large flow of a fluid resembling blood, but in which there was neither coagula, fcctus, nor placenta. The abdominal intumescence quickly subS1ded, and the patient was very soon relieved of all the symptoms which resembled pregnancy. 24 182 SALIVATION. follow, without the concurrence of other signs, that the woman is pregnant; for this may happen from any cause, independently of pregnancy, that is capable of distending the uterus to a size equal to the sixth or seventh month; as in ascites, when the ab- domen is much stretched ; from sanguineous sarcoma; from hyda- tids; chronic enlargements of the liver, and, perhaps, of some other of the abdominal viscera. When this part docs not pro- trude, we are not to conclude that the woman is not pregnant; as it requires the presence of the uterus behind it, to make it ap- pear; and, therefore, whatever is capable of preventing its pre- sence immediately behind the navel, as insufficient development, or its sinking unusually low in the pelvis from the extraordinary size of this cavity, is capable of interrupting this protrusion. Sect. IX.—9. Spitting of Frothy Saliva. Spitting of very white frothy mucus, is by no means a constant attendant upon pregnancy; but, when it does occur, it very cer- tainly points out this condition. This saliva is very tenacious, and very difficult to deliver from the mouth; it is extremely white and a little frothy; and, when discharged upon the floor, assumes a round shape,"and about the size of a shilling piece: hence the expression, that the person is " spitting English shil- lings, or cotton;" and, so far as I have remarked, it is almost a certain sign of pregnancy. Sect. X.—10. Salivation. Salivation, like the sign just mentioned, is not a constant at- tendant upon pregnancy, except in a very moderate degree; in- deed, it is not very rare, though it seldom exists in excess: but, when it does happen, it very decidedly points out this condition —I do not remember to have observed this symptom from any other state of the uterus.* * Since writing the above, I have met with two instances of salivation in fe- males, which was not produced by pregnancy, or any other known cause. One was extremely profuse, and lasted full three weeks, in defiance of all applica- tions. The fluid was nearly tasteless, and was without the slightest odour: it ceased gradually, and I may say spontaneously; for no remedy that was used, appeared to make the slightest impression upon the discharge. This affection seemed to arise from some condition of the stomach, as much nausea attended. The other was less profuse, and more obedient to remedies—a strong infusion of cinnamon appeared to afford complete relief, though it was altogether unavailing in the other instance. OF QUICKENING. 183 From what has been said, it appears, that the rational signs, (as they have been termed,) of pregnancy, may exist in stronger or weaker combination, without proving it unequivocally; though they may leave little or no room for reasonable* doubt of its ex- istence. There is, then, but one mark, by which pregnancy can be absolutely determined—and that is, the movements of the foetus itself within the uterus. In judging of this, we are not to rely upon the ipse dixit of the woman, as she may be deceived, or have motives to mislead; upon this point, therefore, we must determine for ourselves. Upon this point Dr. Blundell furnishes us with the following curious facts: " I know an instance of a lady, possessing more than average intelligence, the mother of twelve children, who vvas led by certain abdominal movements, into an erroneous persuasion that she was again pregnant; for spasms of the abdo- minal muscles, and flutters of the bowels, may now and then be mistaken for the movements of a child. It ought, moreover, to be known, that some women possess the power of similating the foetal movements, by the action of the abdominal muscles, so ex- actly, that even an experienced accbucheur might be deceived. A female who possessed considerable skill of this kind, former- ly exhibited her talents in this town, (London,) for hire; she was visited by Lowder, Mackenzie, and some other celebrated accoucheurs of the day, and after satisfying themselves that the uterus vvas not enlarged, they made the usual examination of the abdomen, when they all agreed, that the movement was so ex- actly analogous to that of a foetus, that no distinction could be clearly made, adding, if there had been no internal examination made, they should, judging from this only, have satisfied them- selves that the woman vvas with child. To do this, it is necessary to place the hand upon the bare abdomen, and wait for the motion of the child; or we may en- deavour to provoke it, by having the hand either hot or cold, ac- cording to the season, as recommended.by Morgagni; and as has been often practised successfully by myself. Should the weather be hot, we should have the temperature of the hand reduced by cold water, or ice; or, if the weather be cold, have the tempe- rature raised, by placing the hand in warm water for a short time. By these means, we rarely fail to excite the foetus to ac- tion; and we may succeed in having it, even pretty frequently, repeated, by repeating the same means. Of this fact I am per- 184 OF QUICKENING. .fectly certain; but, lo account for it, is beyond my ingenuity. By touching per vaginam, we may ascertain, that the uterus contains a solid body within it; but we cannot, by this method, determine whether it be a living being, or an imperfectly orga- nized mass. Will the absence of all motion within the uterus determine the woman not to be pregnant, when a sufficient number of the rational signs combine to render it more than probable that she is? 1 must answer this question in the negative; as instances have occurred to others,* and one to myself, where the motions of the child were never perceived, during the whole period of utero-geslation. In such cases, an examination per vaginam, will aid much; especially at the latter period of pregnancy—the state of development of the uterus; the feel of the substance contained in it; the condition of the os tincae; the height of the fundus, &,c, will, when taken into consideration, and found per- fectly to correspond with the woman's history of herself, prevent any serious error in our estimate. Sioct. XI.—11. Of Quickening. By quickening we are to understand the first perception the woman has of the child's muscular action. It is presumable, that it has in a very feeble manner exerted itself very often before it is or can be noticed by the mother; and the moment at which this action becomes obvious to her, must be at different periods of pregnancy, in different women, owing to the greater or less strength of the foetus; the quantity of the. liquor nmnii; and the sensibility of the uterus itself. I once knew a lady of great nervous sensibility, who constantly perceived the motions of her children at twelve weeks; others are longer, and may be said to be at every period between the twelfth week and seventh month —the medium period is the most common; and when I declare the most usual to be at the fourth month, I am, perhaps, as«near the truth as can well be ascertained.t An anonymous writer in the Medical and Physical Journal for June, 1S12, under the name of" Medicus," has puzzled himself, besides appearing willing to puzzle every body else, by a learned " Levret, as quoted by Baudelocque, Vol. I. p. 240. \ See Chapter on the Term of Utcro-gestation, in System of Midwifery, by the author. OF QUICKENING. 185 attempt to explain the cause of quickening by physical and meta- physical reasoning upon the subject. He evidently confounds two circumstances totally distinct, (if one of them really has an existence,) in their natures, under one general term; namely, the first perceptible motion of the foetus, is confounded with a sup- posed sudden change in the uterus, at the period the fundus usually appears above the superior strait. The disposition to syncope, which is sometimes felt by women at about the fourth month, he calls quickening; and declares it to be owing to the sudden escape of the uterus from restraint to liberty, by mount- ing above the brim of the pelvis, and there enjoying greater freedom and repose. He will not admit that any motion of the child constitutes quickening; but that it essentially depends upon the change of position of the uterus itself. He rejects the com- mon and " ancient" explanation of quickening, for the following reasons:— 1st. " The sensation of quickening, (by which he does not wish to be understood to mean any muscular action of the foetus,) is not constant and universal; some women never experience it, others with some of their children only. 2d. It has a distinct character from any subsequent motion of the child; no woman ever admits that it resembles, in the slight- est degree, the struggles of the foetus. 3d. This sensation is never repeated in the same pregnancy, which must happen if it arose from the motion of the child. 4th. " It is totally incomprehensible that any motion of which the foetus is capable, in the fourth month, should communi- cate such a sensation to the mother, as to produce deliquum animi."* The whole of these arguments go to declare, that when the uterus suddenly overcomes any restraint to its passage out of the brim of the pelvis, the woman is wont to feel faint; and he con- founds this feeling, (if it exist,) with the sensation which all wo- men, (as a general rule,) experience, after the foetus has acquired sufficient strength to make itself felt; and which increases in force, and is multiplied in frequency, as gestation advances; or, • We were much surprised to find this notion of " quickening," adopted by Mr. Morley, a late writer, " upon the symptoms of pregnancy, &c." We think it probable, that this gentleman will be induced to call things by their right names, when he has more experience to aid him. 1S6 OF QUICKENING. in other words, he calls the sensation created by the uterus sud- denly rising above the superior strait, quickening; but declares it to be distinct from the motions of the foetus—In this I most fully agree; as I do not believe that the uterus is ever so sud- denly elevated into the abdomen, as to produce the sensation of faintness. I am, by no means, convinced of this sudden eleva- tion of the uterus, by the inquiries I have made of women, (who, one would suppose, were the best judges upon this subject.) My inquiries, however, have resulted in the establishment of the following facts:—1st. That all women experience, some sooner, others later, the sensation, which they term quickening; 2d. In some, this feeling is accompanied by a disposition to faintness, or rather of sinking, as they express it; and this is experienced, in some few instances, whenever the motion of the child is repeated, until after the fifth month; 3d. That those who " quicken" very early, are most obnoxious to this enfeebling sensation; 4th. That, when the feeling of faintness comes on, Jhey arc certain it is always produced by the motion of the child&beifei 5th. That none have ever been sensible of any dispositioTPIJ^^l'quum, but from the stirrings of the foetus. .«# ., These facts are conclusive, that the sensation in question, is the result of the muscular agitations of the child; and that the explanation of" Medicus," is at variance with this opinion; con- sequently, not calculated to explain the phenomenon. Besides, the circumstance mentioned by " Medicus," of the sudden eruption of the uterus from the pelvic cavity, has no existence; and even if it were true, I do not see why this change of position is to be confounded with the absolute stirrings of the foetus. If he can make out his position, that the uterus suddenly surmounts cer- tain difficulties in its attempt to rise higher in the pelvis, and that this is accompanied by deliquum animi, il is well; but, for the sake of precision, and of logic, do not let him confound it with quickening. Besides, there is a want of ingenuousness in the statement of facts by "Medicus;" for we are yet to discover, that any one has explained the term "quickening," by saying it was owing " to life being suddenly imparted to the embryo,"—this would in itself be absurd, and contrary to all belief upon the subject; for I do not hazard much, when I say, that there is no one at present, nor perhaps ever has been, who supposed that the em- bryo did not possess life from the instant it obeyed the stimulus OF QUICKENING. 187 of the male semen for development; and for this plain and sim- ple reason; that if it were not alive, it must be dead; and if dead, it must be cast off by the womb, as an extraneous substance. There must be a period when the embryo is not sufficiently de- veloped, to move; another when this can be but feebly, and im- perfectly performed ; and another, when it can move with suffi- cient force to give evidence of this increase of power; and this moment is instantly recognised by the mother, who then saj^s, she has " quickened ;" and that this novel sensation should be ac- companied by novel effects, and even sometimes by syncope, is no way surprising. The older writers merely wished to be un- derstood, by the term quickening, that moment at which the em- bryo gave the first physical proof of life; and not the moment it received it. That an abatement of the severity of the symptoms of preg- nancy takes place about the period of "quickening," I am well convinced; and that this takes place with greater certainty, when the uterus can repose itself upon the anterior portion of the pel- vis; yet I am unwilling to admit, that this change is owing to the sudden rising of the uterus above the brim of the pelvis, as is de- clared by « Medicus:" 1st. Because, I do not know that this has ever taken place as a natural arrangement; and 2d. Because if it did, it might create the unpleasant sensations agreed upon by « Medicus." To me the melioration of symptoms at this period, appears to depend upon two circumstances mainly; 1st. Upon the. uterus being enabled to repose upon the symphysis pubis and its neigh- bourhood; therefore, no longer liable to be depressed in the ca- vity of the pelvis, by the often repeated impulses of the abdomi- nal viscera. 2d. To the sensibility, and irritability of the uterus, being diminished, by the frequent repetitions of the child's mo- tions; in this, obeying the law, which seems to govern every other portion of the system as regards the operation of stimuli, by becoming less and less sensible to them, in proportion to the fre- quency of their application: hence, parts pretty uniformly sym- pathizing with the uterus when impregnated, will cease to do so, or will do so in a more moderate degree, as that viscus shall be itself less affected. From what has been said, it will be evident, that much diffi- culty exists in determining that condition of the female called " pregnancy." We have endeavoured to show, that the "rational 188 OF QUICKENING. signs " of this state are particularly liable to error; and therefore, that where it becomes highly important to determine this point, they are not to be absolutely relied upon, however strongly they may be marked, or however numerously they may be combined. In the more early advancement of this process, even to the fourth month, the difficulty of arriving at entire certainty is acknow- ledged by all who have any experience upon this subject; and, that the one so much relied upon by Baudelocque and many other experienced accoucheurs, namely, the motion of the child, has lately been looked upon as doubtful by Mr. Morley. He says, it is possible for wind or other intestinal motion to be mistaken for the motions of the child.* Now, this we declare to be impossible to the experienced accoucheur, who has been attentive to this part of practice; though we acknowledge it to be every way pro- bable, to the inattentive and inexperienced practitioner. Mr. Morley appears to have fallen into this mistake from ihe opinion he has so inconsiderately adopted, of the cause, or rather the na- ture, of "quickening;" namely, the ascent of the uterus through the upper straight of the pelvis, instead of the motion of the child, by the exercise of its muscular powers within the uterus, as has already been noticed above. The "accoucheur who has ever experienced the stirrings of a foetus in utero, cannot mistake the movement of flatus for the motion of the child; therefore, after the fifth month, we think there can be little difficulty in distinguishing the pregnant condition of the womb; but up to that time, it is constantly involved in much doubt. But fortunately at the present time, the uncertainty just spoken of appears to be removed, by the discovery of the heart's mo- tion, and the noise of the placental arteries,.by means of the ste- thoscope, by Kergaradec; and since verified by a number of prac- titioners, especially by J. C. Furguson, A. M. M. B.,f and Dr. Kennedy.J Both these gentlemen find, that the double beat of • Dr. Blundell informs us, that the motions of the child in utero can be by the designing so similated, as to deceive those who have had a very enlarged expe- rience in midwifery: in proof of this, he informs us that a woman in London, de- ceived both the experienced lecturers, Lowder and Mackenzie, and they honest- ly confessed they would have been imposed upon, had they not ascertained, by an examination per vaginam, that the uterus was empty.__Principles and Practice of Obstetricy, &c. p. 156. The case is referred to in page 183. f See Dublin Med. Trans. Vol. I. Part 1, New Series. * See Dublin Hospital Reports, Vol. I. OF QUICKENING. loa the child's heart can be distinctly heard through the uterine and abdominal parietes, and this as early as between the second and third months; and proportionably stronger, as gestation advances. The following rules for the use of the stethoscope appear to be very satisfactorily established. First. That the instrument can be advantageously used, over the patient's common clothes; but that it is better to have but a single covering over the abdomen, and the patient lying down.* Second. That in the early months, the instrument must be ap- plied immediately above the pubes—and though the iliac arteries may give the " bruit soufflet," as well as the uterine and placen- tary arteries, yet they can never resemble the double stroke of the heart; nor can they be well heard,except in the groin; where- as, the other may be heard over some extent of the abdomen; especially in the more advanced stages of pregnancy. Third. That the beat of the foetal heart, agreeably to Mr. Fur- guson, may be heard in almost every region of the abdomen. Fourth. That the beat of the foetal heart is not always heard in the same place in the same individual; that is, it may be found at one point to-day, and at another to-morrow, owing, doubtless, to the change in the position of the foetus itself. Fifth. That the pulsations of the child's heart are often double that of the mother's; and its double beat is well and distinctly marked, f Sixth. That a foetal heart, not exceeding in size a hazel-nut, can be distinctly heard to beat by the stethoscope. The value of this discovery, in a medico-legal point of view, as well as oftentimes in the common routine of practice, need not be commented on. While on this subject, it may be well to mention, that Dr. Beccaria thinks he has discovered a new symptom, by which pregnancy in the early months is very certainly detected. This author thinks he has observed, in many instances, during several years' practice, a painful pulsating sensation beset the woman, in that portion of the skull which Gall terms the organ of amatfve- * Fodera recommends the application of the ear to the naked abdomen, when it can be done with propriety, as the sounds are then more distinct. f Mr. Furguson found, in one instance, the beats of the mother's heart 80, and that of the foetus 136. In another, mother's 90, foetus 130. In another, the mo- ther's was 100, and the foetus's but 28. 25 190 GENERAL CONDITION OF THE SYSTEM DURING ness; this feeling is accompanied by giddiness upon the least mo- tion of the head. Such females as feel this pain, are suddenly seized with it, and without premonition. It continues some time, and is followed by sleepiness, which being yielded to for a short time by the patient, she awakens free from pain, and with a great appetite. This pain returns daily, at about the same hour, for about eight days. It leaves the patient spontaneously, and with- out the aid of art. This symptom manifests itself without being accompanied with the usual signs of pregnancy, and without the woman suspecting herself to be in this situation.—(See Amer. Jour, of Med. Sci. for May, 1S31.) CHAPTER IX. OF THE GENERAL CONDITION OF THE SYSTEM, AND THE EFFECTS OF CERTAIN REMEDIES UPON IT DURIJ^S PREGNANCY. Dr. Denman seems rather unwilling to calf the various affec- tions to which the female is liable from impregnation, diseases. He says, " The state of pregnancy is an altered, but cannot with propriety be called a morbid state." We are of opinion, that pregnancy is not necessarily a disease, but that the impregnated uterus very frequently induces it in olher._prgans of the body, from a strong sympathetic influence, though it may be free from disease itself. The uterus being occupied with the rudiments of a new be- ing, agreeably to the arrangement of nature, cannot properly be said to be in a morbid condition: on the contrary, it is essential to the object of this condition, that it preserve almost inviolate its healthful integrity. For if the uterus become diseased, in the strict meaning of the word, the intentions of this condition will, almost to a certainty, be frustrated. It therefore has a decided power over other parts, by exciting them to diseased, or at least to deranged action, while it preserves itself in the most healthful state. Indeed, the healthful state of this organ, seems necessary to the power it has, of calling other parts into sympathy. PREGNANCY, AND THE EFFECTS OF REMEDIES. IJl This is abundantly proved, by the fact, that the process of ges- tation goes on, as a general rule, best, when certain, or what are termed the rational signs of pregnancy, are present, and even in full force: such as nausea, vomiting, salivation, heartburn, swell- ing of the breasts, &c. &c, and, consequently, proving pregnancy to be a healthful condition. This is a fact, almost universally admitted by the writers upon the subject of midwifery. " It is a popular observation," says Dr. Denman, " confirmed by expe- rience, that those women are less subject to abortion, and ulti- mately fare better, who have such symptoms as generally attend pregnancy, than those who are exempt from them," p. 225. Is it not then certain, that the uterus is in the best health, wheii it excites the various parts concerned in the affections just enumerated? and when it does not move them to sympathy as above stated, that it is performing its functions less healthily: since it may be excited, and very often is, in the absence of these symptoms, to abortion ? For habitual aborters, are very rarely attacked with the more common affections belonging to preg- nancy.* The uterus, when impregnated, produces commotions in vari- ous degrees, in other portions of the system, while it preserves itself in the most healthy condition, as if these various sympathies were intended to divert all evil from it, that the great object of nature, (the propagation of the species,) should not be circum- vented with too much facility. Very frequently, in civilized life, and not uncommonly in savage life, the " breeding symptoms" are very often called forth; now, it is not reasonable to suppose that all the severe sufferings to which the pregnant woman is subjected, can be idly instituted, without a physical end, or a moral purpose! It cannot be that the severe privations, and the absolute evils of gestation, should have been intended as an af- fliction without an object! The sympathies called forth by pregnancy, though they are, strictly speaking, but chains of morbid actions, so far as the parts immediately affected are concerned, yet they are not, like most morbid actions, called forth by a morbid cause; and we must still insist, that pregnancy, abstractly considered, is not a disease. • It must, however, be admitted, that there are exceptions to this rule: we have seen several instances of extreme sickness of stomach, vomiting, 8tc. at. tend, when the patients have aborted, and this repeatedly. 192 GENERAL CONDITION OF THE SYSTEM DURINtJ For we have already shown, that the uterus, the part most im- mediately and extensively concerned in the process of gestation, must preserve its healthy powers, that this function shall not cease. It is, therefore, unlike any other process in the human body; for it seems to provoke disease in oiher parts, in order to preserve the perfection of its own operations. The disturbances arising from impregnation have the tendency to prevent plethora, or to divert excitement. And these objects are chiefly effected through the agency of the stomach, the part most generally subjected to this kind of vassalage. Hence, nau- sea, vomiting, loss of appetite, disgust, or loathings, or longing for certain unnulritious substances, &c. These affections are in- stituted, that the quantity of circulating fluids may be lessened, and excitement diverted; and thus prevent the evils so sure to attend that condition of the system, called plethora. Now, if the subjects be closely examined, it will pretty generally be found, that the sympathetic affections are violent, in proportion to the necessity of subduing this state of fulness, or uterine excitement. We may be told, that many women " breed " without any, or but very few of the affections which commonly attend pregnancy. This is admitted; but in such cases there is, perhaps, no necessity for instituting this subduing process; as there may be little or no tendency to the fulness spoken of. Generally, the women who are exempt from this common penalty, are those who possess great physical powers, and are in the habit of constantly employing them. In these cases, the same end is answered by another means. The excitability of the sys- tem is expended by the regular application of the stimulus of exercise; and, consequently, that state of irritability of the mus- cular and vascular systems, so injurious at this period, is pre- vented. Besides, people who employ their physical powers in useful exertion, have few provocatives, save that of regular ex- ercise and regular rest, to produce appetite; no artificial condi- tion of the stomach is created; they satisfy their cravings by a simple, but nutritious diet; and no more blood is formed, than is sufficient for the exigencies of the system. In these cases, also, the irritability of the uterus never becomes so excessive, as where the contrary life is led. For the uterus, being a muscle, participates, like the other muscles of the body, in the general benefit derived from healthful and regular occupa- PREGNANCY, AND THE EFFECTS OF REMEDIES. 193 tion and exercise. The nervous system has less mobility, for the same reason; of course, the uterus will be less disposed to be thrown into contraction, by the application of either physical or mental stimuli; consequently, there will be less disposition to abortion. With those who lead indolent lives, and who feed luxuriously, the case is very different. In such, more blood will be made, than can advantageously be employed; consequently, there will be "plethora"—and not only plethora, but augmented irritabili- ty; and therefore, a liability on the part of the uterus to be thrown into contraction, by smaller causes, sometimes, lhan ordinary. Now, should such females not be visited by the common affec- tions of gestation, the liability to abortion will be increased in proportion to the disposition of the system to become plethoric. Hence, the truth of the remark, that " those women are less subject to abortion, and ultimately fare better, who have such symptoms as generally attend pregnancy, than such as are exempt from them." We know a lady that is easily provoked to abortion, who can tell, soon after the stopping of her catamenia, whether she will carry her child or not, by the stale of her stomach. If she have no morning sickness, vomiting, loss of appetite, or disgust, she is certain to abort. She has now acquired sufficient knowledge of herself to prevent this accident; and whenever she faithfully acts up to the dictates of her reason and experience, she is sure to carry her child safely. If after the interruption of her menses, she do not become af- fected with the common consequences of impregnation, she in- stantly reduces the ordinary quantity and quality of her food; drinks nothing but water; keeps her bowels soluble; and some- times, but not always, loses a little blood; (but this, never without the advice of her physician;) uses very little exercise, lest she produce fatigue; in a word, so conducts her regimen as to very much reduce, if not entirely prevent, plethora; and she so ma- nages her physical exertions as not to convert them into unusual stimuli to her nervous and muscular systems. But, at other times, when she becomes pregnant, and has the ordinary accompanying signs, she takes no extraordinary trouble to regulate the condition of her system, as she finds they are al- most always sufficient to subdue the tendency to plethora. But 194 GENERAL CONDITION OF THE SYSTEM DURING should she feel headach, or other marks of fulness, she loses a lit- tle blood, or cats less. During pregnancy, the system is in a state of constant stimula- tion from this very cause. First, there is the stimulus of disten- tion constantly operating, from the first six weeks to the full pe- riod of utero-gestation. This is the most obvious in the first few months; and, for this reason, the uterus yields with more reluc- tance at this, than at any subsequent period, either from its own specific density, or from the smallness, as well as feebleness, of the distending cause within.* Hence, in the first few months of pregnancy, the sympathetic affections are more violent than at the after periods. 2d. Joined to the stimulus of distention, is that disturbance which is, and must be, consequent upon the change of position of all the abdominal viscera, and which is sometimes very considerable. (See section on the pain in the right side of pregnant women.) 3d. The constant, though not uniform pres- sure upon the intestines, both above the fundus, and below its posterior and lateral portions, giving rise sometimes to many un- pleasant symptoms; such as cramping pains, from the unequal distention of the bowels; constipation; diarrhoea; &c.f .*' * So reluctantly does the uterus yield at this period, sometimes^ that much in- convenience is experienced on the part of the patient, from severe alternating pains in this part, which are tranquillized with difficulty, by bl^od-letting, opium, &c. At other times, it absolutely refuses to yield farther tbajn S certain point; contractions are excited, and the ovum is eventually expelled—this is one of the causes of abortion. f " There is every reason to believe that the uterus, and, therefore, its cavity, is not enlarged solely by the distending power of the.ovum; as, in cases of extra- uterine pregnancies, it has been known to be much<-larger than in the natural state, and to be lined with the decidua."—Review of xlewees on Females. N. Amer. Med. & Surg. Journ. Vol. III. p. 302. In reply to the above critic, it is but necessary to observe that I have no where asserted that the increase of the uterus was owing solely to the'distending power of the ovum. I have only declared that the uterine cavity was enlarged by the ovum; and that it is, in eveiy way, evident, as the most perfect relation between them is constantly established, after a certain period of pregnancy. Now, if the ovum do not make room for itself, it must be evident some other power must ex- ist for this purpose. Can any other power be pointed out? Is it not clear, to de- monstration, that the ovum is the agent, when, if this be broken, and the liquor amnii discharged, that the uterine parietes contract to the altered size of the ovum? No, says the reviewer; for "the uterus is found to be much larger than in the natural state, in cases of extra-uterine pregnancies." Can the reviewer bring any case of extra-uterine pregnancy, where the uterine cavity was found of PREGNANCY, AND THE EFFECTS OF REMEDIES. 195 The combination of these causes, keeps the system in a state of constant excitement; the pulse is, therefore, almost always ac- celerated. The nervous system directly, and the arterial indi- rectly, are always found to bear stimuli ill. Hence, in their ex- hibition at such periods, there is much caution necessary. The young practitioner should never lose sight of the im- portant fact just mentioned, if he expect to be successful in the treatment of the diseases of the female, at such periods. We have known many errors committed for want of due attention to this state of the female system: some of greater, and others of minor a size equal to that at which it would have arrived, had the pregnancy been a uterine one? We are sure he cannot That die uterus becomes larger in cases of extra-uterine conceptions, we admit without hesitation; for, in such cases, blood is sent to its parietes, and the decidua is formed, as in a natural pregnancy; and hence its enlargement in such cases. But this proves no more than is here set down; namely, that the uterus is larger than in its natural state; and this is all that has ever been asserted by the relators of such cases. Let us now ask, does this prove any thing contrary to what I have declared upon this point? All that has been said upon the distention of the uterus, therefore, remains uncontradicted; for I have never advanced that the in- crease of this organ from gestation was solely owing to the ovum. On the con- trary, I have maintained the influence of the increased quantity of blood, and the consequent augmentation of the vessels in the proper substance of the uterus as contributing materially to its enlargement; and to these two causes do I still attribute the enlargement of the uterus in a natural or healthy pregnancy. The reviewer farther declares, "it is not correct to assert that the greater suf- ferings of the woman, in the earlier periods, depend upon the stimulus of disten- tion being greater at that time; as, in some individuals, these sympathetic affec- tions appear before we have any proofs of the ovum having reached the uterine cavity."—Ib. To this logic we would only answer, that, if there be " no proofs of the ovum having reached the uterine cavity," there can certainly be none that it has not; and, consequently, we have as much right to the positive assumption were it in any way important to our views, as the reviewer has to the negative. But this is of little consequence. We believe we are borne out by all physio- logists, when we assert that later than thirty days has never been fixed for the ovum to gain possession of the uterine cavity; and we believe that all observation confirms the declaration, that sooner than this, the rational signs of pregnancy ne- ver appear: indeed, six weeks is very early for these symptoms to manifest them- selves. Nor is it of any kind of consequence to the subject in question whether the distention of the uterine cavity be effected by the ovum, or by any other agency, since the reviewer himself admits that the uterus increases, even in extra- uterine conceptions. The ovum, however, must always be regarded as infinitelv the most common cause, and was consequently chosen to illustrate the principle contended for. And we may add, that when the signs of pregnancy appear earlier than is here stated, they are the exceptions to this rule. 196 GENERAL CONDITION OK THE SYSTEM DURING importance; but all erroi'3 of this kind should be avoided with great care. , To show the susceptibility of the system to stimuli at this period, in some cases, we will relate one instance of many of a similar kind, which have fallen within our own knowledge. Mrs. -----, pregnant with her sixth child, and at the eighth month complete of utero-gestation, complained suddenly of sick- ness, accompanied by a distressing sensation of the stomach; she was advised by a young practitioner of medicine, who happened to be present, to take a little pretty strong brandy and water; which he accordingly prepared, and gave to her. She had not swallowed the mixture more than fifteen minutes, before she felt the distressing sensation increase, though the nausea vvas abated ; at the same time she experienced a confusion, and severe pain in the head, which seemed more concentrated in the forehead, immediately above the eyes; a dimness, or rather a temporary loss of sight, with strong twitchings in the muscles of the arms and legs. The physician, as well as the family, became alarmed lest this should eventuate in a "fit;" and we were requested to see the lady immediately. When we visited her, she was labouring under the above named symptoms, and which had been gradual- ly increasing from the beginning of the attack. We found her with an accelerated pulse; a flushed face, and considerable confusion of intellect. The remedy, in such a case, could not be mistaken. Her arm was immediately tied up, and blood abstracted, until her head and senses were perfectly re- lieved: it did not, however, require more than fourteen or fif- teen ounces of blood to effect this. She had no return of any unpleasant symptom after that evening. So much docs pregnancy modify the affections of the system, that even the sensations called nervous, can rarely be relieved by the usual remedies, however successful they may have been with the same patient at other times ; but under different circum- stances. The common symptoms by which hysteria shows itself, such as palpitation of the heart; a sense of suffocation ; difficulty of swallowing, &c, can rarely be controlled by the common re- medies, unless they are anticipated by a bleeding of a greater or less extent. This should be borne in mind; for success will not follow the use of remedies, without attention be paid to it. But the susceptibility of the system to stimuli during preg- PREGNANCY, AND THE EFFECTS OF REMEDIES. 197 nancy, is more evident when the woman is attacked with an acute disease; such as fever. To relieve her, at this time, is found more difficult always, than at any other; for the system is now so susceptible, so disposed from the circumstances of preg- nancy to maintain morbid action, that remedies of the most ap- propriate kind, succeed with difficulty. And if it be attempted to accelerate convalescence by tonics, even of the mildest sort, they are almost sure to disappoint the practitioner, if they should not even recall the disease. Nothing, perhaps, shows the difficulty of employing tonics during pregnancy, more than the want of success of the Peru- vian bark in intermittents. In substance, we scarcely ever suc- ceed in arresting the paroxysms, as we might calculate to do in ordinary cases, unless its exhibition has been succeeded by very ample depletion. We have seen a number of instances where an intermittent has been quickly converted into a remittent, by the exhibition of the bark. Indeed, it is hardly ever safe to trust it, even after very liberal evacuations. The sulphate of qui- nine, however, is less objectionable, or less treacherous. In a word, we rarely use tonics of the more powerful kind, in the convalescence of females, after acute diseases, when com- plicated by pregnancy, especially in the earlier months. After the fifth month, up to the full period, the system is less irrita- ble. For soon after quickening, almost all the sympathetic af- fections begin to moderate; and sometimes, nay, very often, cease altogether. This, it is probable, is owing to the following causes:__1st. From the uterus now making greater demands upon the system at large for blood; from the increased size of itself and foetus; and, consequently, relieving, in a degree, the state of plethora! 2d. By the system having become more familiar to the peculiar stimulus of pregnancy, from its long continuance. 3d. To less irritation being experienced by the greater disposition of this organ to be distended. For, after the fifth month, the resistance of the fundus and body is less; 1st, from its increase of vascula- rity; and, secondly, from the ovum augmenting in power. Hence the melioration of symptoms after the fifth month. We will now consider the effects of certain remedies during gesta- tion. 26 198 OF BLEEDING DURING PREGNANCY. 1 st. 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. This prejudice, for so it truly is, is founded upon false views of the functions of the uterus, and the economy of the foe- tus, during the period of utero-gestation. It is imagined, that every ounce of blood the mother loses deprives the foetns 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 friends frequently arrests the lancet, when its employment is most essential to the welfare of the mother/ There are few mistakes of greater magnitude thari the one just noticed; and, though founded in error, it has, nevertheless, often prevented, or very much interfered with the free and un- biassed practice of medicine. It very often causes the young practitioner to abandon some of the best established principles in the practice of his art; namely, 1st, that women bear the loss of blood belter, when pregnant, than at'any other period; and, 2dly, that all the acute diseases by which they may be attacked require a more extensive use of the lancet. If, then, the inter- ference of friends interrupt the free exercise of 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 re- sponsibility 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 contin- OF BLEEDING DURING PREGNANCY. 199 gent condition of the general circulation of the system; and that no one viscus in the body is so little influenced by changes 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 vvas 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 vvas 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. We may be told, that the foetus is by no means so secure as is represented, when the mother suffers 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 directly from it, as in floodings: we have only declared, that when this fluid is drawn from the general system, as in bleedings performed for the relief of disease, that very large quantities might be abstracted, without making the uterus give up any por- tion 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 ta 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. 200 OF PURGING DURING PREGNANCY. 2d. Of Purging during Pregnancy. 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 con- sent between the uterus and rectum. Hence, the occurrence sometimes 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 remedy, in the acute forms of disease. We mean that a preg- nant woman would not bear, with safety, as much purging, as if she were not pregnant; yet she bears it with advantage, when carried to a considerable extent, especially if tenesmus be not excited, 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 the pregnant woman will bear, without risk, any common or necessary degree of purging, unless she be prone to abortion. We would 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 irri- tation in the rectum, and very frequently excites tenesmus. 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 cathartic were to produce this effect, it would be equally improper, 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 diarrhoea, 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 tenes- OF EMETICS DURING PREGNANCY. 201 mus accompanying it; and it is with us a doubtful point, whether the diarrhoea is not, in such cases, a concomitant, rather than a cause. For there is no fact belter 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 be- tween these parts is reciprocal; and, consequently, when a reme- dy 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. 3d. Of Emetics during Pregnancy. Emetics should be given sparingly to pregnant women: they 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 202 OF BLISTERS DURING PREGNANCY. 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 be said, there is more nausea than vomiting. But, even in the early periods, emetics are to be used with caution; and when de- termined on, the ipecacuanha should be made choice of. 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- Mr. Hcwson first taught us, that when this coat appeared on the surface of drawn blood, it vvas owing to the thinning"" of ihe serous parts of this fluid, which enabled the colouring matter, and other denser parts of it, to separate, and precipitate themselves to the bottom of the vessel. That the density of this "coat" may differ in two instances, we have no objection to admit, since this will not prove, that both are not one and the same thing; namely, the coagulating lymph. Besides, to our view, the cause of ibis peculiarity appears so analogous in both instances, that we do not hesitate to admit them to be the same; namely, an in- creased arterial action, which we call inflammatory, for want of a more definite term. We have already said, that this condition of the arterial sys- tem is so general, as almost to force us to the belief, that some specific 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 mis subject. It seems nowpretty generally admitted, that the foetus in utero is not nourished by SYSTEM DURING PREGNANCY. 205 blood furnished directly by the mother; that is, there are no con- tinuous vessels from mother to child; consequently, the commu- nication 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 Placentae 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 nourishment 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 better 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 intOithe 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 um- bilical veins, whose radicles accompany those of the umbilical ar- tery. Nevertheless, the lateral pores of these arteries deposite the fluid which the foetus could not elaborate, or which requires 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 portion of the placenta, and by this means convey an additional quantity 206 FEBRILE CONDITION OF THE 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 fcetus 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, &e, where the sanguineous system is tending to typhoid action? And also in other cases not of the exanlhematous kind, where this typhoid disposition prevails? So also in puerperal convulsions, where the parox- ysms 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 il is, wpmen 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 formatforkof fever; or in local determinations, giving rise to pain or other inconvenience, as headach, giddiness, imperfect vision, difficulty of breathing, pain in the side which is augmented by breathing, a fall 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 happens, the system calls for remedies. A few ounces of blood abstracted from the arm; a vegetable diet; and keeping the bowels opertby 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 oilj Seidlitz powders; sulphate of magnesia; or flower 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 gentlejnan, though oftentimes obliged to do so, SYSTEM DURING PREGNANCY. 207 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 thos*e 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- quences of pregnancy, the fatigues of labour, and the contin- gencies of the puerperal slate, 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 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 exer- cise,, 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 sto- mach. 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. It 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------> P^gnant with her first child, complained of slight headach; heat and restlessness at night; disagreeable taste in the mouth; a furred tongue in the morning; loss of appetite, or ra- ther 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 208 VOMITING DURING PREGNANCY. 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 livingfor some time with great ad- vantage, she was told she was very wrong to live so abstemious- ly, 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. W.-'-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 subduing plethora. Its advan- tages, however, are confined to the early periods. When it con- tinues after quickening, or renews, itself with severity towards the latter period of gestation, its usefulness is equivocal, if not decidedly mischievous. ' Dr. Denman says, "if the vomiting should not be violent, and occur only in the early part of the day, though very trouble- some, it is so far from being detrimental, that it is generally found to be 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 reasoning1} 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 vo- miting can bring the stomach into a better*"state than it would be, when there is neither a necessity nor a disposition to this ef- fect, 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 compre- hend; but this certainly does not bring this organ into a better state than it was before such matters had deranged ft. Vomiting we believe to be only useful as it may reduce or prevent 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: secondbjp^by severe and distressing nausea, with- out much vomiting; thus controlling the inordinate actions of the VOMITING DURING PREGNANCY. 209 system by this subduing sensation, and by diminishing or sus- pending the powers of digestion. Now, this is for the most part only useful, as we have already said, in the earlier months of pregnancy; for, in the latter months, the increasing demands of the fcetus 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 reme- dies. .'<;>•*.■■ < We have seen several instances wfyere1ve thought it would* be right to bring on premature labour, and would" ■">* one instance have done so, had not this taken place spontaneous!}, very soon. after it had been determined on. In such extreme cases, we think it every way reconcilable to the most scrupulous morality, to induce premature delivery for the preservation of the mother. But it should*titeo be recommended to the attending physician, in such cases, never to perform this operation, unless it be sanc- tioned by the result of a consultation. The sickness commonly occurs as soon as the patient leaves her bed,.and frequently harasses 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 now and 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 emetie of ipecacuanha will frequently be found useful, and may, in the 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. 210 VOMITING DURING PREGNANCY. 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:— 8<. Bi-carbon. sod?e, 3Jss. Pulv. G. Arab. 3'ij. 01. menthse, gut. iv. Sacch. alb. 3'ij. Aq. Seltzer. %iv. M. Of this a table-spoonful is to be taken every hour or two, as occasion may re- quire. 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- spoonful of milk every fifteen or twenty minutes, and n$ one thing beside; this rarely fails to tranquillize the stomach, and enable it to take food with advantage: we may occasionally add a spoonful of lime water to the milk, until the stomach be re- lieved. ■*• But such is the predominance of acids, that none of the'ant- acids is capable of overcoming it, though administered with a li- beral, or even a daring hand. I rarely persevere in the use of the alkaline remedies, when I find that considerable doses will " . x* scarcely have a temporary effect: when this is the case, ^-recom- mend the use of acids, for the relief of this most distressing state of the stomach. Both vegetable and mineral acids have been em- ployed by me, with perhaps about equal suecess; but the vegeta- ble will merit the preference in general, on account of the teeth. I have, in several instances, confined patients, for days together, upon lemon juice and water, with the most decided advantage.* In two instances I have witnessed the best effects from substi- tuting 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 • One lady took the juice of a dozen lemons daily, and 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 peck a day. VOMITING DURING PREGNANCY. 211 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 headach 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*#poonful of clove tea* act most promptly and successfully. Wkjh respect tQ tjhe diet of patients so circumstanced, it would be in vain to point it out; as any plan we could devise would scareely apply to any two patients—I generally direct the use of such articles, as, their experience has proved best suited to their condition.; jhtf, sometimes, it is truly astonishing to observe the waywardness of the stomach upon such occasions. I have lately had a p"atient 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 experienceof 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 opi- ates, when violent pain, or any other urgent symptom demands 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 form, when given by the mouth; but the most decidedly useful mode is, by enemata. An enema may consist of a gill of lukewarm water and a large tea- spoonful of laudanum. This may be repeated pro re nata. We have lately found the most prompt advantage, in two or three cases of excessive vomiting, from a plaster applied over the * This tea is made by bruising about twenty ©tyves, on which you pour a half pint of boiling water, and permit it to stand covered until cool. 213 HEARTBURN DURING PREGNANCY. region of the stomach, composed of equal parts of opium, cam- phor, and hard soap, moistened sufficiently to spread, by lau- danum. Sect. III.—Heartburn during Pregnancy. This very distressing symptom is sometimes one of the first the woman experiences after impregnation—at other times it does not make its appearance until gestation is pretty well ad- vanced; and sometimes is absent altogether. It is generally very distressing, and very difficult to subdue. I have known large and repeated doses of the alkalies given, with scarcely a tempo- rary truce following their exhibition, much less permanent be- nefit; in consequence of which, I have for many years past ceased to urge them in large quantities, where I find smaller ones pro- duce no effect. In such cases, I think it better to abandon the attempt to neutralize the acid, and begin with the use of the acids, so soon as the other class of remedies shall prove useless. Dr. James, in a note, (see his Edition of Burns,) makes the following remarks upon this condition of the stomach: "The late much regretted Dr. Young, of Maryland, in his ingenious experiments on the digestive process, has almost reduced it to a certainty , that the acid which exists in the stomach is to be re- ferred to the liquor gastricus; that it is the phosphoric acid, and that the acidity of dyspeptic and pregnant women is owing to the morbid quantity of this acid. Hence, as he justly remarks, the superiority of lime water as a corrector, from its great affi- nity to the phosphoric acid," p. 219. He recommends, from his own experience, the formula of Dr. Sims for this complaint, viz. 3<. Magnesia Ustse, ^j. Aq. Ammoniae purse, gj. Sp. Cinnam. giij. Aq. purae, Jvss. M. Two or three spoonsful to be taken either occasionally, or when the symptoms are more continual, immediately after every meal. I have already, under the head of vomiting, mentioned the ad- vantage of acids, to counteract the acidity of the stomach, and they well deserve a trial. The vitriolic, or the citric, may be used freely in such cases; but the latter, as already observed, merits the preference. HEARTBURN DURING PREGNANCY. 213 Magnesia and chalk are in familiar use; and in moderate c.ases are every way competent to the exigency, especially the former. Magnesia should always be preferred to chalk, except a looseness of bowels accompanies this complaint. The chalk is never so pure as magnesia, and is always sure to constipate the bowels— sometimes it is used in immoderate quantities, and then it is al- ways with decided injury. I formerly attended a lady with se- veral children, who was in the habit of eating chalk during her whole term of pregnancy; she used it in such excessive quanti- ties as to render the bowels almost useless. I have often known her without an evacuation for ten or twelve days together, and then it was only procured by enemata; the evacuations were li- terally chalk. Her calculation, I well remember, was three half-pecks for each pregnancy—she became as white, nearly, as the substance itself; and it eventually destroyed her, by so de- ranging her stomach, that it would retain nothing upon it. When heartburn is moderate, it may be relieved by soda wa- ter, lime water, and milk, and the occasional use of magnesia. The operatiori of these substances, in the cure of an acid stomach, is easily understood; but the action of a few blanched almonds, or a "few roasted ground-nuts, is not so easily explained; yet both of these substances I have known most successfully employed where the complaint was mild. They should be taken from time to time, as the acidity may prevail. Confining the patient to any one article of diet, of either the vegetable or animal kind, is sometimes productive of great advan- tage ; as simple boiled rice, oysters, milk, or cream, or very sweet butter and stale bread, &c. Costiveness is very common, and should be carefully guarded against; the diet should be made to conform to this end, whene- ver practicable; where the stomach will bear bread or biscuit, they should be made of unbolted flour. The ship bread, as it is called, I have occasionally found to answer a valuable purpose— but where this is not sufficient, or it cannot be used, I have found the following pills of great advantage, when properly persevered in:— &. Gum Aloes, sue. gss. Pulv. Rhaei. 3L 01. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhaei. q. s. M. f. pil. xxx. One of these every night, or every otner night, as may be found 28 2M SALIVATION DURING PREGNANCY. necessary. One of these pills is generally found to be sufficient; but the dose must be determined by the habit of the patient. Sect. IV.— Of Salivation during Pregnancy. The sympathy between the salivary glands, and the impreg- nalcd uterus, is, perhaps, as remarkable as any that takes place. In a very moderate degree it may be considered as a pretty ge- neral attendant upon gestation; as almost all women, at such times, have more than an ordinary quantity of saliva secreted. In this mild form it will scarcely require attention; for it may even pass without notice. But it becomes very distressing and en- feebling, when excessive. It is almost always accompanied with acidity of the stomach, and constipation of the bowels; the fluid discharged from the mouth, for the most part, is perfectly colour- less and transparent; at other times, it is more tenacious and frothy, and the quantity poured out is sometimes incredibly pro- fuse. It almost always has an unpleasant taste, though not at- tended with an offensive smell;—it keeps the stomach in a state of constant irritation, and not unfrequently provokes vomiting, especially if the saliva be tenacious, and require an effort to dis- charge it At night it is often very troublesome, interrupting sleep by the frequency of the necessity of emptying the mouth. If it continue long, the woman becomes weak, both from the quantity of fluid poured from the mouth, as well as the inability to take and retain sufficient food upon the stomach. I have ne- ver known this complaint to prove fatal; though I have wit- nessed two cases in which the patients were in great jeopardy— one of which I will relate, as it is remarkable for the extent to which the salivation ran. I was called upon to prescribe for Mrs. J., who was advanced to the fifth month of her pregnancy. At the second month she was attacked by a profuse salivation ; she discharged daily from one to three quarts of saliva; and was, at the same time, harassed by incessant nausea, and frequent vomitings: so irritable was the stomach, that it rejected, almost instantly, any thing that was put into it. She now became extremely debilitated; so much so, as to be unable to keep out of bed; and when she did attempt to sit up, she would faint, if not quickly replaced. From a belief that the affection might be local, astringent gar- gles were freely employed, with marked disadvantage. A large PAIN IN THE RIGHT SIDE. 215 blister was next applied to the back of the neck, with decided, but transient benefit—that is, the salivary discharge was less, the nausea diminished, and the vomiting less frequent; but this fa- vourable impression vvas but of three or four days' duration: for, after this time, all the unpleasant symptoms returned with their former severity. An emetic of ipecacuanha was now exhibited, followed by a cathartic of rhubarb and magnesia, without the smallest benefit;—soda water, lime water and milk, milk itself, &c, were, in turn, unavailingly employed. I now put my pa- tient upon a diet altogether of animal substances, and ordered ten drops of laudanum morning and evening, and fifteen at bed-time: this plan succeeded most perfectly in the course of a few days; the nausea and vomiting ceased, and the discharge vvas reduced to less than a pint per diem; and, perhaps, the force of habit had no inconsiderable agency in the production of this quantity. The bowels, during this plan,-were kept open by the extract of butternut and rhubarb, in the form of pills. The lady never had any return of this complaint in her subsequent pregnancies. As a ge^fej^pT^fc of treatment in this complaint, either when moderate of ^sv^-e, I endeavour to destroy the acidity of the stomaejr by the various antacids; to keep the bowels free, by the frequent "use of magnesia; rinsing the mouth often with lime vvater^and the use of solid animal food; together with a strict injunctlf||U'oir/e patient to resist the desire to discharge the saliva from the mouth, as much as possible. This complaint, when moderate, almost always abates, if it does not altogether cease, after the fifth or sixth month; but when severe, its^p'eriodjs uncertain. A lady informed me, that this affection confirmed with considerable force, during the whole period of gestation, in one of her pregnancies. Sect. V.—Of Pain in the Right Side during Pregnancy. A little after, and seldom before the fifth month, the woman is sometimes attacked with a deep-seated, and rather obscure pain, immediately in the region of the liver. It first begins with a very trifling sensation in this part, and gradually increases as gestation advances. It is rarely extremely painful; but is al- most constant, both day and night; and is especially severe during the latter. It is not increased by respiration, unless this be made very 216 PAIN IV THE RIGHT SIDE. full, and then the pain is rather more acute than ordinary. No cough, as a necessary attendant, accompanies this complaint; but if one be present, there is an augmentation of pain, but not of the sudden and embarrassing kind, which attends an inflam- mation of the pleura, and may, therefore, by this circumstance, be easily distinguished from this affection. Besides, fever does not necessarily belong to this complaint; and if one be present, it may be considered as independent of it; and may, therefore, most commonly, be looked upon as coincident, rather than as a necessary consequence. The woman, with a view of relieving this pain, leans almost constantly to one side when sitting; and if standing, she may be observed frequently to place her hand over the pained part, and press it pretty forcibly. She often seeks relief, by stretch- ing herself upwards, and maintaining this position as long as she well can; or until she finds herself somewhat relieved. She can lie upon either side; but better on the left than on the right. A sensation of heat is frequently experienced in the pained part, at the time she may feel pain. This is sometimes very distressing; and is occasionally very permanent. The bowels are not necessarily influenced by this affection; they maintain, most probably, the condition they would be in, were this pain not present. As pains in the side are familiarly treated by blood-letting, so it is almost always had recourse to in this complaint; but never, as far as we have observed, with the slightest advantage. Nor has any other treatment which we have advised, been more suc- cessful. Leeching, cupping, and blistering, have in turn been employed without benefit. Indeed, we have now ceased to pre- scribe for this complaint, unless it be attended with some altera- tion in the circulating system; if this be disturbed, and the pulse tense and frequent, advantage is sometimes experienced from the loss of blood, and gentle purging, as this pain may be aggra- vated by this condition of the system. But in this instance, we prescribe for the general condition of the system, and not for the local affection—as we should have to do most probably as much, were this pain in the side not present. A woman, with her first child, is more liable to this affection than with the subsequent ones; unless she carry her child very "high" as it is called. After a woman has borne several chil- dren, the anterior obliquity of the uterus generally prevails which INQUIETUDE, &C DURING PREGNANCY. 217 frees them from the risk of this complaint; for it is caused, we believe, altogether by the mechanical pressure which the fun- dus of the uterus makes against the liver, as it mounts up in the progress of gestation. Our reasons for thinking that this is the cause, are, 1st, because the woman who has the fundus of the uterus thrown in advance of the symphysis pubis, is never trou- bled with this complaint, so far as we have yet observed; 2d. be- cause it never commences, until after the uterus has risen some distance out of the superior strait; 3d. because the woman who has the fundus of the uterus thrown to the right side, is more severely afflicted, than if the right lateral obliquity of the uterus did not exist; 4th. because, after the eighth month has passed, the woman experiences great relief, if the uterus sink into the pelvis, as it is wont to do at this period; or undergoes that change, the women term "falling;" 5th. because this pain is increased, whenever the diaphragm is suddenly and powerfully forced down, as in coughing, and in sneezing, though it is not felt in ordinary respiration; 6th. because the pain increases almost in proportion to the development of the uterus, or the advancement of the fun- dus; 7th. because the woman feels less pain when standing, than while lying; for when standing, the uterus sinks a little, and thus dfminishes the pressure against the liver; 8th. because the woman can relieve herself, by placing herself in certain positions; as, leaning to one side, or stretching herself upwards; and lastly, because very short women suffer most. From this account of the cause of the pain in the right side, it will at once be seen, that nothing can relieve this affection but the removal of the fundus of the uterus from its contact with the liver. It may be asked, if this explanation be true, why do not all women suffer it? The answer is easy; all women have not the fundus of the uterus to press against the liver; because all have not the right lateral obliquity; because many have a ten- dency to the anterior obliquity, after the third or fourth child- and, in neither of these instances, does the fundus press against this viscus. Sect. VI.—Of Inquietude and Want of Sleep during Preg- nancy. Many women experience much inquietude towards the latter end of pregnancy. This is so annoying at times, as to prevent sleep. The limbs are agitated by involuntary contractions of the 218 INQUIETUDE, &C. DURING PREGNANCY. muscles, which, by the frequency and suddenness of their mo- tion, instantly interrupt the sleep, to which the woman vvas at the moment strongly inclined. In most cases, there is a strong desire to sleep; but it cannot be indulged in, in consequence of this particular state of the ner- vous system;—this ennui of the limbs, if we may so term it. We have known it so severe at times, as to make the woman dread to lie in her bed ; for she is sure, until near daylight, to be doomed to constant restlessness. To relieve this inquietude, she traverses the room, until fatigue, or diminution of the paroxysm, affords the long-desired rest. This repealed loss of sleep, does not sen- sibly impair the health of the woman; for, as Dr. Denman very correctly observes, " after a short repose at the dawn of day, she seems as much refreshed as after the most quiet night." Dr. Denman's method of treatment, does not by any means comport with his theory of this affection. He says, " Perhaps the confinement of the air of the room, and the heat of the bed, may be the immediate cause of this complaint; but I have gene- rally considered them as arising from the constant and strenuous demands for nourishment, made by the child upon the constitu- tion of the parent; for it is remarkable, that those women who suffer most on this account, though reduced in appearance, bring forth lusty children, and have easy labours," p. 245. From this explanation, and from what he afterwards says, it would seem that the fcetus makes larger demands than the mother can well supply: now, were this so, there should be a deficiency of blood in the general system of the mother; but this is not the case; for the Doctor recommends almost the only remedies we have seen useful in this case; namely, " bleeding in small quan- tities, and the occasional use of cooling and laxative medicines." Now, is it not self-evident, that were a deficiency of blood in the mother's system the cause of this inquietude, that it could not possibly be relieved, by diminishing, still more, the quantity of blood? We believe, that this inquietude arises from that peculiar irritability of the nervous system, which seems so constantly to attend upon a fulness of the system, rather than on a deficiency of blood. In proof of this, the pulse is always quickened and full in the evening, and during the night; and is a true exacerbation, or febrile paroxysm, which spends itself by morning, and permits the patient to sleep at that time. Again, bleeding, purging, low diet, cool air, and cold water, are the best remedies for this complaint. COSTIVENESS DURING PREGNANCY. 219 The quantity of blood to be drawn, must be regulated by the fall of the pulse; and it must be repeated pro re nata. A mat- tress should be substituted for a feather bed, even in winter; the room should be well ventilated; and the patient should be prohi- bited animal food, suppers, or any stimulating drink. The bow- els should be kept gently open. Dr. Denman says, that " a glass of cold water drunk at bed-time, is not a contemptible remedy." We know, that bathing the face and hands in cold water is an excellent one, and should always be resorted to. Dr. Denman says, " Preparations of opium have little effect, unless they are given in large quantities, and often repeated." This is the very reverse of our mode of exhibiting the prepara- tions of opium. We never prescribe opium in any form, unless the necessity is very urgent, and when bleeding and the other remedies have failed; and when we do order it, it is always in small doses. We prefer the denarcotized, or the acetated tinc- ture, or black drop, to any other form of opium; of the first, we give twenty drops at first; of the latter, only ten; and if they do not tra'nquillize? in two hours, we direct from five to ten drops more; believing, if this quantity does not succeed, a larger one will not: we therefore never urge its use. After bleeding, &c, the Liq. Anod. Hoffm. answers, for tie most part, admirably, and should always be tried. Sect. VII.—Of Costiveness during Pregnancy. It seems that this condition of the bowels is almost sure to at- tend the early periods, and the latter stages of pregnancy. For the most part, it is only mischievous when excessive; though it is always inconvenient. Dr. Denman is willing to attach some importance to this state of the alimentary canal; with what pro- priety, remains to be proved. I am fully persuaded, however, that it is only decidedly injurious when it exists in excess: when so, I have known much trouble to arise from it, and sometimes alarm for the safety of the fcetus. When this state is allowed to continue beyond two, or at most three days, much disturbance is sometimes created by the gene- ration of flatus, and colicky pains, with a frequent and unsuccess- ful desire to evacuate the rectum. When permitted to continue beyond this time, it is sure to occasion headach, flushing of the face, frequent desire to make water, and tenesmus. The stomach 220 COSTIVENESS DURING PREGNANCY. is also not unfrequently disturbed by heartburn, sour eructations, and vomiting, if these had been previously suspended; or an in- crease of them, if they had not ceased. To those who may be occasionally liable to abortion, it is par- ticularly desirable to have this state of the bowels altered; as we have every reason to believe it has, in a number of instances, caused it. We have known some ladies so regardless of conse- quences, as to allow this confined state of the bowels to continue for ten or twelve days together. One lady in particular, had reason to blame costiveness for three consecutive miscarriages. When she became pregnant again, she vvas put under my care, with a hope that I might be able to interrupt this unlucky habit. I learned from her, that so soon as she becomes pregnant, her bowels become so tardy, as not to have a spontaneous op'ening oftener than once in ten, twelve, or fourteen days. Hitherto, she had concealed this condition from her friends, from the mere aversion she had to taking medicine, even of the most simple kind; and honestly confessed, she thought her former miscar- riages were altogether owing to this cause; but said, she began to feel there would be a criminal neglect on her part, did she per- mit this to continue; she therefore determined upon changing this habit; and vvas now willing to submit to any plan we would think proper to direct. She suffered dreadfully from sickness of stomach, and vomiting; severe and constant headach; palpitation of the heart; and, now and then, long-continued syncope. She was in her third month of pregnancy; and declared she began to feel as she had always previously done, for two or three weeks before she would mis- carry; that is, she rested ill at night, had great thirst, severe pain in her back, together with considerable leucorrhcea, which, she observed, always preceded the more violent symptoms. At the time she vvas giving me this information, she had not had an eva- cuation for more than a week. Her pulse was full, frequent, and tense; face flushed, and skin dry and hot. I directed the loss of a few ounces of blood; to have an injec- tion simply of flaxseed tea; to take small doses of castor oil, at intervals of two hours, until it should operate ; to drink nothing but water, or molasses and water; to abstain from animal food and broths; to use light, but regular exercise; to take rennet- whey freely; and to eat no other bread but that made of unbolted flour. She readily consented to a compliance, and as faithfully COSTIVENESS DURING PREGNANCY- -e*1 performed her promise; for which she was amply repaid, in the melioration of all, and the entire extinction of some, of her more troublesome symptoms, besides carrying her child to the full pe- riod. She was, however, chiefly indebted to the brown bread for the permanent soluble stale of her bowels; for, after she had com- menced its use, she had but very rarely to aid it by magnesia. To women who are habitually costive, this bread is most im- portant, and should always be used; and though not always suf- ficient to do away the tendency to constipation, it nevertheless renders any mild aperient much more successful. A tumbler-full of rich bran tea, sweetened or otherwise, taken before breakfast, has had a very good effect upon the bowels. Coffee, sweetened with manna, answers very well; honey, where the stomach will bear it, is useful. Injections, made to act rather by their bulk than their quality, are exceedingly proper in all states of cosliveness; but when it is excessive, they should always be made to precede the use of purgative medicine: we have seen much inconvenience arise from a neglect of this caution. The severe effort which is always required to discharge hardened feces, is almost sure to produce hemorrhoids. Mr. Burns says, this state of costiveness is "partly owing to the pressure of the uterus on the rectum, and partly owing to the increased activity of the womb producing a sluggish motion of the bowels." We would ask, in what does the " increased acti- vity of the womb " consist? Is there any evidence of such acti- vity? Is it not at the period at which costiveness is most common, passive, and obedient to the distending forces within it? Would not abortion follow an increased activity of this organ? for we see no way in which the uterus ever displays "activity," but by contracting; consequently, costiveness cannot depend upon an " increased activity of the womb;" for did it contract actively, abortion would almost certainly follow. This slate of the bowels depends chiefly upon that irritation of the stomach, which gives rise to either nausea or vomiting; and thus diverts or diminishes the regular or habitual force of the peristaltic motion of the lower intestines. As a proof of this, where there is obstinate costiveness, we almost always see an irritable stomach. Indeed, Dr. Denman remarks, that " the sto- mach of pregnant women is often in such a state, that no internal medicines can be retained, and we are obliged to have recourse 29 222 COSTIVENESS DURING PREGNANCY. to clysters," p. 239, art. Costiveness. And, farther, we may add, that there exists between the rectum and the stomach, a re- ciprocal influence of this kind ; for the inordinate motions of the latter are most successfully allayed by irritating the former by stimulating injections. But, let the cause of costiveness be what it may, it i3 alwaya important to guard against it in the pregnant woman; but it should, as suggested above, be by the gentlest methods; for sti- mulating, or drastic medicines must be carefully avoided. For, though Dr. Denman informs us, lhat " experience has proved that abortion most frequently happens to those who are subject to too relaxed a state of the bowels," it does not prove, that constipation is either useful or innocent. Indeed, we are of opinion that though the fact is precisely as stated by Dr. Denman, yet it does not prove, that diarrhoea, in such cases, is the cause of abortion; on the contrary, we are fully persuaded, that it is but the consequence of an irritation in the uterus to cast off its contents; and that the intestines, in these in- stances, only sympathize with this condition of this organ. We may perhaps be told, as an evidence that diarrhoea is the cause of abortion, that this accident has been prevented in such casea by the application of opium to the rectum. We believe it to be strictly true, lhat abortion has been prevented by this means; yet we cannot admit it as evidence of the fact insisted on; for this re- medy is equally, if not more certainly useful in threatened abor- tion when used in this manner, when there is no diarrhoea. It quiets the irritation of the uterus, through the medium of that sympathy which is known to exist between these parts; as the same sympathy excites the intestines to looseness, when the ute- rus is the seat of irritation. HEMORRHOIDS, OR PILES. 223 CHAPTER XI. OF HEMORRHOIDS, OR PILES. We have observed, that the bowels of pregnant women are disposed to become costive; in consequence of which, a tendency to piles is very often induced, which, if not early relieved, will end in inflammation, and extreme distention, sometimes, of the hemorrhoidal veins. We may add to this, the constant and strong pressure, which the increasing uterus exerts upon the ves- sels within the pelvis. Another cause may aid and confirm the disposition to hemorrhoids; namely, the sedentary habits of many women during gestation. Joined to all these, is the habit many sedentary women have, of using soft cushions to sit upon. This permits the vessels to distend, though gently compressed; and by and by a hemor- rhoidal "fit" is produced. In others, again, piles are brought on by long standing; hence, all such as are obliged to be a great deal upon their feet during pregnancy, are much disposed to this affection. A sensation of fulness and aching is first felt in the verge of the anus; this is followed by a slight throbbing, which disposes the woman to make a pressure with her hand upon the part; swelling in various degrees soon succeeds, accompanied by more or less pain. As a general rule, the pain is in proportion to the size and degree of inflammation of the tumours which constitute the disease, and the degree of contraction of the sphincter ani. Frank says, lhat these tumours sometimes acquire a size equal to, that of a goose-egg; the sphincter ani contracting upon them, produces the severest suffering.—Traite de Medecine Practique. And that, in women, in consequence of the contiguity of the hemorrhoids with the vagina, that they occasion in this canal a heat or burning, and an itching; so- as to render conjugal inter- course painful, and accompanied with a discharge of blood.— Traite de Medecine Practique, torn. 3, pp. 339, 340. Such cases we have never seen; nor have we ever witnessed their prevent- ing the descent of the head in the time of labour by their size, as stated by the same author. 224 HEMORRHOIDS, OR PILES. We have said, that the pain is generally in proportion to the 6ize of the tumours, and the degree of inflammation, &c; but thia is not always so: for we have seen prodigious suffering from small-sized piles; and once witnessed the mo>t intense,and long- continued anguish, from a pile not larger than a very small fil- bert. Why the pain vvas so intense, in this instance, we have never been able to account; it resisted puncturing, lcechings, cold, hot, and anodyne applications, and purging. A horizontal position, with elevated hips, &c, for several days, appeared to be the only source of comfort to the patient. Dr. Pbysick informed me, when speaking on this subject, lhat a patient of his suffered the most intense anguish from a tumour not larger than a pea, situated in the verge of the anus, and for which almost every probable remedy had been prescribed un- availingly—the patient vvas at last relieved by the removal of it by the knife. The degree of distention which these tumours sometimes suf- fer, is almost beyond belief. We have seen two or three at one time, of the size of small walnuts, of a very dark red, or mo- dena colour, or even livid; and of such exquisite tenderness, as not to permit the lightest touch, without great pain.* In these cases, the sphincter ani acted like a ligature moderately drawn; and the tumours themselves had the appearance of strangula- tion. Indeed, Mr. Copelandt considers the action of the sphincter ani one of the causes of piles; especially in those who possess this power in a high degree, and who are, in consequence, subject to a spasmodic stricture of the rectum. In such persons, he sup- poses, lhat, at every attempt to pass the feces, a portion of the internal membrane of the rectum, with its vessels, is protruded and detained by the forcible constriction of this muscle; hence, ihe formation of piles. Mr. Burns thinks this disease is "chiefly to be attributed to a sluggish stale of the alimentary canal, communicating a similar torpor to the hemorrhoidal veins," p. 223. Now, we do not un- derstand how torpor of the intestinal tube is to communicate tor- • The degree of pain which attends the active stage of piles, depends very much upon the constitutional force of the sphincter ani. \\ here this is very active, and constricts the protruded pile with great firmness, much suffering will be endured; while an equal, or even greater degree of swelling, in lax and dcbi» litated habits, will be attended by less. f Observations on the Principal Diseases of the Rectum, &c, p. 68. HEMORRHOIDS, OR PILES. 325 por to the hemorrhoidal veins; or how torpor, any way commu- nicated to these veins, shall give the phenomena of piles. Certain it is, a paroxysm of this disease is as frequently, or, at least, as readily produced by purging, as by costiveness. For, generally speaking, the paroxysm of piles takes place when costiveness is about to be removed, and not during the passive state of the co- lon and rectum. Costiveness, then, as a sign of the "sluggish state of the intestinal tube," is rarely the exciting cause of the disease in question; for it takes place with most certainty when this " torpor " is absolutely removed, and the bowels are stimu- lated to brisker action. Therefore, the mechanical pressure of the feces may have some agency in producing a "spell."5* Besides, it is familiar to every body, with what facility a "fit" of the piles is brought on by a brisk purgative, when the hemor- rhoidal veins are varicose; nor is this, perhaps, difficult to under- stand, when we take into view, that the action of the bowels, and that for the returning of the blood through the vessels concerned, are in opposite directions; and that the peristaltic action of the colon and rectum, must be superior to that of the hemorrhoidal veins; hence, the accumulation of blood in them, and sometimes their severe distention; and that this distention takes place the more readily as these veins do not possess valves. Again, relief from suffering is sometimes obtained only by in- ducing a "torpor" in the rectum, by means of sedative applica- tions, and opiate injections. When this disease attacks the pregnant woman, it is almost sure to produce feverish excitement in the system; and this often attended with severe headach, and pain in the small of the back. Blood-letting is here clearly indicated; but the local is preferable to the general abstraction of blood. Six or eight ounces of blood should be drawn from the tumours, and their immediate neigh- bourhood, by leeches, and their bites encouraged to bleed after their dismissal, by the application of a soft bread and milk poul- tice. The bowels should be opened by the most gentle laxatives; the best of which, for immediate purposes, is the castor oil, when the patient may have no fixed aversion to it. If leeches cannot be procured, puncturing them with the point of a sharp lancet in several places, will often afford great relief, * Costiveness is not always necessary, either as a remote, or as an exciting cause to this disease. We have known this complaint to be occasionally violent, where the bowels were never costive for a day, during a long life. 226 HEMORRHOIDS, OR riLES. c when the tumours are much distended and very thin. But when the swelling is less, and the coats of the tumours appear thick and dense, we do not recollect to have seen any advantage follow puncturing. Probably we had better not employ it. Local applications are rarely found to be of benefit during the very active stage of hemorrhoids; indeed, for the most part, they seem but to aggravate the pain, unless it be after leeching or puncturing; then, as already directed, a simple bread and milk poultice, or a poultice of the flour of linseed, is sometimes found to afford much relief.* This application should always follow either of these operations; and it may be renewed frequently. During this time, the patient should be kept in a horizontal position, with her hips elevated, and the knees drawn up; and when the leech biles, or the punctures have ceased to bleed, there is sometimes much comfort derived from cold applications; even ice itself. This is best managed by being enclosed in a small bladder, in which there is some water. A weak solution of the acetate of lead, that is, in the proportion of a scruple to eight ounces of water, and a few drops of the acetated tincture of opium, sometimes affords much relief. -It may be necessary to reapply leeches, or repeat the punc- turing : this will especially be the case, when the sphincter ani acts as a ligature; for nothing effects the relaxation of this mus- cle like blood-letting. The bleeding may be followed by the poultices; and these by the cold applications, or the saturnine so- lution and the opium. When the hemorrhoidal tumours are neither very large nor very painful, much advantage is sometimes obtained by dis- charging the blood from them by a very gentle, but persevering, pressure by the ball of the thumb, or extremity of a finger. This succeeds best, where the sphincter ani is contracted upon the tu- mours ; but, in order to secure the good effect of this pressure, the pile must be returned beyond the verge of the anus, by the fin- ger following it within the sphincter. When the sphincter is re- laxed, we have seen no advantage derived from this practice; as the vein prolapses again immediately. To succeed in putting up the pile, much patience must sometimes be exercised in making the pressure; for, if it be done suddenly, much pain is * The poultices must be renewed every three or four hours; they should be thin, and always applied between very fine rags. HEMORRHOIDS, OR PILES. 227 excited, and no advantage gained. Mr. Burns recommends, for the same object, a pressure made by the thumb and finger. This disease is almost always more severe after labour than during pregnancy; and, though it is not strictly a disease of the female, she may yet be considered as more obnoxious to it than the male; and as it is an attendant upon gestation, and is almost always a follower of delivery, it seems every way entitled to our notice. Much maybe done during labour to prevent a severe "spell" of piles, by the accoucheur making a firm pressure upon the verge of the anus with the palm of his hand, guarded by a diaper, during the progress of the head through the external parts; and by care- fully returning them immediately after the expulsion of the pla- centa, as the sphincter is now fatigued, and will not oppose their ascent. In lying-in women, this complaint rarely becomes severe until the fourth or fifth day; and then it is generally after the operation of the medicine which has been judged proper to give previously to this time. The hemorrhoidal veins sometimes swell enormously at this period, as^they are probably weakened by the distention they have suffered during the progress of labour; and especially as they regain the power of contracting with great difficulty. They arc, however, to be treated as above directed; except that we cannot use the cold applications with the same freedom. In or- der to prevent as much as possible the accession of this disease, with those who are subject to hemorrhoids after delivery, we should open the bowels a day or two earlier than is usual; that is, the day but onp after the termination of the labour. This should be done by the very mildest means; and small, or divided doses of the purgative should be given, instead of a full dose at once. Thus, half an ounce of castor oil should be given; and repeated in four hours, if the first does not answer. Or coffee may be sweetened with manna, and the patient take a cup of it once in two or three hours, until the effect is produced. The le- nitive electuary is also an excellent aperient at this time; the size of a nutmeg may be taken every three hours, until the bowels are stirred. The sulphate of magnesia in lemonade, in small doses, is also very gentle, and very certain. But the magnesia itself, we think, is always productive of much irritation in the rectum at this time. Dr. Jackson, of Northumberland, recommends in 228 HEMORRHOIDS OR PILES. very decided terms, rhubarb as a cathartic in all stages of hemor- rhoidal suffering. All the more stimulating cathartics should be carefully avoided; and even the effects of the milder ones be stopped in such cases, when they appear to be proceeding loo far—this may be readily effected by a few drops of laudanum. The diet of the patient should consist altogether of the vegetable jellies, rennet, or cremor tartar whey: we should, for the time being, forbid tea and coffee, unless the latter is sweetened with the manna. Sago, tapioca, arrow root, or gum Arabic, may be given freely ; but they should always be made thin; and the bran bread should be eaten. Substances may be made palatable by a little lemon juice and sugar; they should be looked upon ra- ther as drinks, than be considered as food. This plan has ad- vantages which are rarely considered: it not only affords an am- ple, and very mild nourishment, but the recrement is less in quantity, as well as much less firm in quality, than that from more solid food. Milk, at this time, should be used sparingly, if not absolutely forbidden, as the curd becomes impacted in the rectum, and produces great irritation. We have known much inconvenience to arise from a perseverance in this article as a diet, from the great firmness of the feces. The pregnant woman may derive both comfort and advantage from sitting in a demi-bath of cold water for five or ten minutes at a time, two or three times a day, when the complaint is ad- vancing, or when about to retire; that is, after the severer in- flammatory symptoms have abated, or before they are high. During the progress of treatment, and for some time after, the patient should be as little as possible upon her feet. Sufficient attention is not paid to this circumstance; and the neglect of it, obliges the woman to go through her troubles again. The ves- sels should be allowed to contract as much as they are capable of doing, before the woman is permitted either to stand or walk much; for the mere effect of gravitation will renew the com- plaint, when it has but imperfectly receded, or has but for a short time ceased to be troublesome. We have said, purging should be carefully avoided; but cos- tiveness should be equally shunned. The patient, therefore, should have such a plan laid down, as will ensure one liquid eva- cuation per diem; this will be best effected, by using the bran HEMORRHOIDS, OR PILES, 229 bread constantly, instead of the common bread. This article, then, will form an exception to the rule suggested above, of allow- ing no other than fluid nourishment. And when all inflamma- tory action has ceased, she may be indulged daily with chicken water, or beef tea. Should the bran bread be found insufficient to keep the bow- els open, a large tea-spoonful of the following electuary should be taken at bed-lime; either every night or oftener, or every other night, as its effects may be upon the bowels. 9<. Lac sulpli. Crem. tart. aa. jfss. Syr. commun. vel lemon, q. s. f. elect Dr. Leake is prejudiced against the use of sulphur in this com- plaint ; he says, " From what I have repeatedly seen of its effects, I cannot think favourably of it, having twice observed a very dangerous and profuse discharge of blood from the womb, occa- sioned by its liberal use."—Treatise on Child-ied Fevers, vol. i. p. 173. The experience of Dr. Leake, from its extent, should, upon most occasions, go for much; but in this instance, we think he has yielded to a prejudice, resulting from coincidence, rather than from a conviction arising from correct observation. For, were the sulphur capable of producing such discharges as one of its common effects, it would certainly have been oftener observed by the doctor; at leastjt would have been confirmed by the ob- servations of other practitioners. As regards ourselves, it is one of the most common of our prescriptions in this complaint; yet we have never seen any thing like the effect supposed to be ob- served by Dr. Leake; we are therefore inclined to believe, that the discharges of blood spoken of, must have been accidental, or coincident. Dr. Good observes of this article, " Sulphur has long been re- garded as a specific for piles; but I do not know that it possesses any other virtue than that of being a mild aperient. It seems, however, to be an aperient particularly calculated to act upon the large intestines; since, being soluble with difficulty in animal fluids, it dissolves slowly, and does not spend itself till it has de- scended to a considerable depth in the alvine canal. And it is on this ground, perhaps, if any, that it sometimes proves service- able in the present disease."—Study of Med. vol. i. p. 237. 30 230 HEMORRHOIDS, OR PILES. Dr. Cullen speaks favourably of the balsam of copaiva. He says, " I have learned from an empirical practitioner, that it gives relief in hemorrhoidal affections, and I have frequently employed it with success."—Mat. Med. part ii. cap. v. p. 1!)0. Of this medicine I can say nothing from experience; if it be use- ful in this complaint, it must, most probably, like turpentine, be in cases accompanied by discharges of blood. Dr. Good seems to think differently; and he may be right, as he has experience of its effects, on his side. He says, " I have tried this medicine often, frequently without the slightest benefit, though I have varied the dose: and when it has appeared useful, it has been chiefly in the mucous piles," p. 237. "Where the tubercles are not very sore, they will often yield to a layer of gypsum, or, what is better, fuller's earth, which, however, should be rubbed into as soft a paste as possible. Thiff is a remedy which has been long employed on the contihent; and I have sometimes prescribed it with singular advantage, and have known piles, when softish, and compressible, removed by it in a single night."—Study, p. 238. These excrescences often remain of considerable size, and ra- ther painful, even after the more active stage of inflammation has been removed; and, if they be neglected at this time, a re- turn of them is most easily provoked. Experience has proved the value of the vegetable astringents for this purpose; but they are too indiscriminately used, not to make some caution necessary. The astringents are indicated, only in the decline of the in- flammatory stage of this affection, or after it has entirelj"pub-$£;-fr- sided. If used before this period, as is but too frequently the case, they aggravate the complaint, and render it sometimes very unmanageable; therefore, the period at which they can be em- ployed with advantage, is that slated above. The nutgall has long held the first rank in the L?i of the vegetable astringents; and the following formula is justly entitled to much praise for its convenience and efficacy. £. Gallae Alep. subtil, pulv. ^j. Cerate Simp. - ^j. M. Adde Ess. Lemon, - gut. xx. vel. xxx. ' Acct. Lythrag. - gut. xxxx. Tinct. Thebaic, - gut. xxxx. M. A little of this ointment is to be rubbed upon the parts, morning and evening. Should it excite much smarting, it must be re- duced by incorporating a little more of the cerate with it. PALPITATION OF THE HEART. 231 At the stage of the disease now spoken of, much benefit has occasionally been found, from dusting the parts with the flowers of sulphur. Another substance has gained, in a certain district of this state, the title of a specific in this complaint, at the stage we are now considering; namely, the brown powder contained in the fungus, commonly called the " Puff Ball," when dry; the dust of which is to be incorporated with hog's lard^ and used in the same manner as the gall ointment. CHAPTER XII. OF PALPITATION OF THE HEART. This is not an unfrequent attendant upon pregnancy; especial- ly before the period of quiekening. After this time, it often ceases, and* does not return until towards the latter part of the term of gestation. This complaint may arise from very different causes; and it is important that .their effects be not confounded, as they require sometimes very opposite remedies for their relief.* It may proceed from mere nervous irritability, and may be looked upon but as a symptom of hysteria; to which some deli- cate women are particularly liable during gestation; or it may arise from fulness of blood, joined to a nervous temperament, or from fulness alone* _ >' In the first case, the palpitation will be attended by other symptoms which mark the nervous temperament, such as globus hystericus; large discharges of limpid urine; coldness on the top of the head, &c.; and these may not be accompanied by any ex- traordinary fulness of the circulating system. Should it not, we may administer, with immediate advantage, almost any of the remedies in familiar use for such affections; as the asafcetida, Hoffman's anodyne liquor, orange flower water, hartshorn spirit, &c. It is, however, best, in all such cases, to in- quire into the state of the digestive organs, and ascertain if there • We do not mean to extend our views in this place, to the forms of palpita- tions of the heart which arise from organic causes; but merely to such occur- rences of it, as may, with strict propriety, be called sympathetic. 232 PALPITATION OF THE HEART. be not some derangement there, which may give rise to it—such as acidity or indigestion. The first may be detected by a sense of burning at the pit of the stomach, sour eructations, or belchings tasting like unsound eggs. If this be the case, the regimen must be regulated, by for- bidding such substances as will readily turn sour upon the sto- mach; as tea, coffee, vegetable substances, fruit, porter, wine, &c, and confining the patient to simple water as a drink; and animal substances for food. Giving at the same time small doses of magnesia mixed'in milk, several limes a day, if the bowels be confined; if not, the extra soda water, lime water and milk, aq. amnion, purae, &c. If from indigestion, which is a frequent cause, by avoiding such substances as are known not to sit well upon the stomach; by a dose of rhubarb and magnesia to carry off the offensive material, and confining the patient for the next twenty hours to chicken water or beef tea. If, with these symptoms, the pulse be accelerated, or full, and tense, and especially if there be a throbbing at the temples, blood should be abstracted, to an amount sufficient to restore the natu- ral force of the arterial system. When this is accomplished, the "nervous medicines" just enumerated, may be given with ad- vantage, if the bleeding has not relieved the palpitation. Where this complaint is habitual at these periods, and particu- larly when it observes a pretty regular movement, much advan- tage is found from taking a small tea-spoonful of the Liq. Ataod, Hoffm., about half an hour before it comes on. * If the P§4aJ| * We feel it a duty to express our indignation at the almost constant suoMftuJ 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 wa& 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 —stimulating and heating: whereas the other is soothing and tranquillizing, be- yond any other substance, in certain cases, with which we are acquainted. Sdly, To the parsimonious conduct of the practitioner himself; of whom the manufac- PALPITATION OF THE HEART. *«*<* 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:— Ri. Tinct. Valerian vol. ~) -- z: X/f * -----Castor $aa-3j' M- Of this, a tea-spoonful in sweetened water, may be taken three or four times a day; or whenever the palpitation is troublesome. In the second place, if palpitation be unaccompanied by other nervous sensations; if there be headach; flushed face; giddiness of the head; and if these be increased upon rising up: if a sense of fulness in the head, with a feeling of oppression about the chest; and if sleep be disturbed by unpleasant dreams, we shall find, almost always, that the arterial system is too much loadedj the pulse will be found tense, full, or creeping; irregular, and sluggish; which nothing will relieve, but the loss of blood, gen- tle purging, and an abstemious diet. Should stimulating remedies be given, as is too common, un- der the persuasion that weakness is the cause; or that all nervous affections are to be treated by stimuli, much mischief may ensue;. such as intense headach, fever, and, sometimes, even convulsions. ■,--..' Mr, Burns says, that "Roderic a Castro prescribes a draught ...'-'' of hot water." This remedy, we have learnt, is sometimes very ;'/-.:*j$ificactPus; it must be, however, only when the stomach is in '^^jHsDme' fcanner 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 ir- ritation. turer complains, that he will not give the price for the genuine article;, the last is reprehensibly sordid, if not palpably dishonest. 234 PROLAPSUS OF THE UTERIS. 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 agreeably 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 posi- tion of this organ, as coming within the meaning of " displace- ment," that is not attended with more or less inconvenience to the patient. I shall, however, confine myself, in the present work, 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 fotfr 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. Gardien* 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 9 * Traite Comp.p. 179. PROLAPSUS OF THE UTERUS. 235 dragging towards the groin and the umbilicus. In the second s degree, the woman complains of a sensation of weight about the fundament, and a dragging about the groin, back, and umbilicus, which are more severe than in the first degree, and are augmented when the woman is on her feet, or walks. If a horizontal posi- tion be observed for some time, it always affords relief; and the woman every morning would think herself cured, did she not know from experience, all those symptoms would return 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 exter- nal 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 com- plete protrusion in a female of twenty-one, who, it was said, la- boured 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 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- 236 PROLAPSUS OF THE UTERIS. quency of debilitating discharges from the vagina, sapping as it were the very foundation of its support, we need neither be sur- prised at its often occurrence, nor at the obstinacy of Ibis dis- tressing 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 remarked, 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 the support of this organ—and this is the vagina itself. This office of the vagina 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, lhat the vagina is the efficient support of the uterus.—It then follows, that what- ever is capable of weakening the foundation, will tend to injure the superstructure: hence, leucorrhcea; frequent deliveries;* too early rising after delivery; very large children; a very large pelvis; habitual coughs; severe pukings, and ill-conducted in- strumental 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 over- stretched ; thus preventing the return of its natural firmness and resiliency; or bj^ the frequently repeated concussions this part must suffer, from the abdominal viscera, by coughing anjLvotnit- ing. f -Vfei The degree of precipitation to which the uterus may-l»e liable, will depend upon 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 modified by the greater or less descent of the uterus in ihe vagina —they will be intense in proportion, (caeteris paribus,) to the ex- * 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 eiror in this statement, as it is a fact well known to every experienced practi- tioner, that these parts never recover their former condition with so much cer- tainty as after a first labour. PROLAPSUS OF THE UTERUS. 237 tent of the displacement; but in all there will be a sense of some- 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 tire patient's attention, which, if she obey, almost always end 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 horizontal one. In some few instances, the woman is obliged to throw her body very much in advance; or is obliged to sup- port herself by placing her hands upon her thighs when she at- tempts to walk. But all these unpleasant symptoms subside almost immediately if she indulge in a recumbent posture, and this circumstance pretty strongly designates the disease. In addition to the inconveniences we have just stated, there is always from the vagina, more or less discharge of a purulent ap- pearance: this, in severe cases, is frequently tinged with blood, and occasionally is offensive. In addition to this, we often find ... • the meases suffers some derangement: they are almost always £iV.^more-anundant, and sometimes more frequent than they should be,—this, with the accompanying leucorrhcea, 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 from 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- 31 238 PROLAPSUS OF THE UTERIS. 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 uterus. " 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 consi- derable pain, they are apt to lay them aside, and neglect their condition. The prolapsed parts will, therefore, become ulce- rated, 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 may be 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 thai the hands and feet need not be tied. The operator seizes one labium between 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 PROLAPSUS OF THE UTERUS. 239 fingers' breadth from the margin of the labium itself. This cut must be carried by a bold sweep of the knife to thefour- chelte, where it should terminate ivith a slight inclination inwards. In this manner, a slip of the labium will be re- moved of the breadth of one finger. By a similar procedure, a portion of the other labium, of the same size, must be ex- cised, taking care to unite the two incisions about a fingers9 breadth below the four chette, at an acute angle, and include a portion of that frsenum. After securing the bleeding ves- sels, and arresting the oozing of blood from the spongy tissue, by sponging the part ivith cold water, the lips are to be brought together by suture in the common way. Previously to doing this, however, the operator should examine carefully the condition 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 trans- fixed by a ligature, 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 ligatures. 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 discharge, and the mucus of the vagina, and may, even, the consummation of the venereal act. Should con- ception take place, it will be easy, by means of a small inci- sion, to make room for the passage 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 instru- ments within the last five and forty years; and in no one in- stance 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 he have witnessed such effects, it must have arisen from the bad struc- ture of the instrument itself, an unskilful mode of applying it, or from the cases being of an improper kind for the use of the 240 PROLAPSUS OF THE UTERU.s. 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, properly introduced, and the uterus and vagina free from inflammation, schirrhus, 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 formidably presented by Dr. F., that it has proved not only a complete remedy for prolapsus, but, in several cases, for leucorrhcea, that had resisted other remedies. For, in some instances, this deranged 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 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 reduction. Sec 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 belter 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 lhat 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- PROLAPSUS OF THE UTERUS. 241 rated by a couple of fingers; one placed on each labium,* and the pessary then pressed gently, but firmly, against the os exter- num, 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 to- wards one of the sacro-iliac junctions.t We continue to press the instrument 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 pessary must correspond with the small diameter of the infe- rior 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 witn 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 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.J 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. • It is generally best to use ttie left hand for this purpose. See note following. f 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 introduc- tion of the pessary with his right hand. * In some instances, we have found it best to confine the patient to a horizon tal position for three or four days, with the intention of giving the pessary an op- portunity of bedding itself in the vagina. This is particularly necessarv, where there 1S much sensibility in the puts, or where the instrument causes a little un- easiness after its introduction, though it well fits the passage. 2 12 PROLAPSUS OF THE UTERUS. The relief afforded by the introduction of the pessary, in many instances, is immediate; but, if not, it i^ almost always secured, in a short time, if the instrument be of n 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 leucorrhcea, 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;* this give6 it 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, re- quire a longer time, where the woman is more aged, and where the complaint is of long standing—one of my patients wore the instrument a year; but this was the longest time I have known it to be required, f Besides the inconveniences just related, this condition of the uterus gives rise to a fixed pain in one of the sides, but especial- ly the left, which bids defiance to all general as well as local ap- plications, hitherto employed for its removal. Larrey, the celebrated French surgeon, proposes a very diffe- rent pathology of this complaint as well as mode of treatment. * Indeed, it is not always necessary to remove it so often; we have had many pa- tients, 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 mo- ral pain. And the glass one can be worn even longer, without any disadvantage. ■f- 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 it. Two others have had the pessary 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 casei show, that impregnation takes place notwithstanding the presence of the pessary. PROLAPSUS OF THE UTERUS. 243 He says, it is owing to two causes, either an asthenic (debili- tated) thickening of the uterine parietes or an elongation of the ligaments, 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 safely be repeated: this to be aided by a horizontal posture, elevation of the pelvis, and flexion of the lower extremities; cold astringent applications, and injections, 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 exempli- fy 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 common than is generally suspected, and as it cannot be re- moved, 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 attention of practitioners might be directed to its consideration. Cask 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, leech- ing, &c, without the slightest benefit. The pain was not in- creased by respiration, pressure, or motion, but some relief was constantly experienced upon lying down, and, especially, as the night advanced. 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 success than those who had preceded me; and began seriously to despair of being any way useful to her, when, thinking the leucorrhcea, with which she was severely afflicted, might have some agency in weakening her, and believing this, from the de- scription of her feelings, to arise from a prolapsed uterus, 1 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 244 PROLAPSUS OF THE UTERI'S. for three weeks, with as much advantage as I had contemplated —for the only benefit I expected from them, was to give 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 desired'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>affeclions 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 cer- tain articles—her bowels were constipated, and she had a pro- fuse leucorrhcea 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 blis- tered, without the smallest advantage—took mercury to a con- siderable extent—was freely purged and puked—but to no pur- pose. When the pain was unusually severe, it vvas considered as spasm of the stomach. From the detail of her symptoms, I vvas led, however, to suspect a prolapsus of the uterus, and inquired whether that opinion had been given by her physicians at home— but she said it never had been suggested; it was considered as an affection of the stomach altogether, and all remedies were ad- dressed to it, either directly or indirectly. I proposed an examination per vaginam, to which she very reluctantly consented—but that examination confirmed my first PROLAPSUS OF THE UTERUS. 245 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 recurrence 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 vvas 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 tolerably good night's rest. I saw her the next morning, and found her labouring under the distressing after-effects of the lau- danum, but comparatively easy. She gave the following his- tory of her complaint. She was attacked about twelve years before with a pain in her left side, which was occasionally so se- vere as to produce hysteria, and other disagreeable nervous af- fections. The pain vvas not augmented by pressure, cough, or respiration. She would swell sometimes very suddenly, and when this happened the pain vvas increased. She was much in- commoded 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 leucorrhcea to a great extent—was much debilitated—ex-" tremely pale—her appetite feeble-and her digestion bad She vvas much afflicted with headach, and pain in her back- also with a severe numbness down the thighs, after standing awlule upon her feet. She had tried a great many remedies 32 246 PROLAPSUS OF THE UTERU*. for the period above stated, and she considered herself growing worse daily. 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 vvas 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 lo 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 lo 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 vvas accordingly requested to visit her again, and to make the proposed search—this proved ihe 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 circum- stances like those detailed above, lo 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 in- variably 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 sufficient to establish a rule." • I think it probable, that the seat of the painful affection of the left side, ii in the spleen; as this viscus is known to sympathize largely with the uterus. The pain, however, is not uniformly on the left side; it is occasionally found on the right, immediately below the spurious ribs. In these cases, I will not pre- PROLAPSUS OF THE UTERUS. 247 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. 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 regards the objects just stated; and as the small ends of the oval instru- ment are more easily acted upon than the circular, and in conse- quence more easily displaced; we give, after many trials, the preference to the circular form. Gardien says, "Le pessaire de forme ronde est plus facile a placer: il est en outre moins sujet a sortir," p. 183. Gardien speaks of replacing the ulerus 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 vagi- na; 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 .s down. See art. " Of the Irritable Uterus." tend to say, which part of the abdominal viscera may be involved; but that it i. not a mere coincidence is evident, for the pain almost always ceases, after the pessary is applied. 248 CHRONIC INVERSION 0» THE UTKRUS. In some cases, a subsequent pregnancy and delivery have cured a moderate prolapsus. We have, in a number of instances, re- commended 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, however strongly we may urge its importance. This method requires 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. Sect. II.— Of the Chronic Inversion of the Uterus.* 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 Ihe inversion. She will be liable, for a long time, to a sanguineous discharge from the sur- face of the uterus, as well as to a leucorrhceal 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.t * I 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. j- 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, thougli the discharge was still considerable. Hest, nourishing diet, as- tringent injections, the extract of rathany, 8tc, were prescribed with considera- ble advantage for a time; but about every two or three weeks there would be • return of hemorrhagy, which would continue with more or less violence for se- veral days. In this way, things went on for about five months, by which time the CHRONIC INVERSION OF THE UTERUS. 249 It will be seen, by referring to case second,* 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 fundusof.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 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 Uken place after an inversion of the uterus. iSardien observes, "Les femmes dont la matrice n'a pas et6 rec uite dans les premiers temps sont probablement inhabiles a la conception: cependant, une observation communiquee au Pro- fesiieur Baudelocque par M. Chevreul, medecin d'Angers, sem- blerait indiquer que la conception peut encore s'operer dans l'une dej, trompes dont les extremites ut6rines 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 f is opinion, lhat it vvas 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.f patient became so reduced, that it was resolved, in consultation, that the uterus should be removed by ligature, as the only chance for life—but the patient died before the operation could be performed. • See System of Midwifery, p. 516. f 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 di- rect conveyance of the semen through the os uteri, is not the mode by which im- pregnation 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. 250 CHRONIC INVERSION OF THE UTERUS. 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 accident, they have enjoyed for some time, a tolerable share of health: this vvas the case with Mrs. P., in case second, before refered to; the only one which has occurred in my practice, of an unrestored uterus after inversion.* I have seen altogether but eight cases; three of which were fatal; two, to this moment remain inverted; and the three other 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 treatment, 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 repeat, is by no means necessarily fatal.f Experience sufficiently proves, that in by far the greater number of instances, the uterus may be restored, if the proper moment 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 manoeuvre 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 prevent lhat condition of the uterus which gives rise to it; yet the acci- dent, and its fatal consequences, will be comparatively rare with him. And when it does occur in such hands, it will almost al- ways be a manageable disease, as it will be discovered, before the fundus and body have entirely escaped through the os uteri, to constitute the complete inversion ; in which case, it will be rare- ly otherwise than reducible. And when not reducible, though the inversion be not complete, as will occasionally happen, immediate death may perhaps be prevented, by making it complete. See System of Midwifery, p. 464. 3d. edit • 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. f Ruysch, however, says, "If this accident be not immediately remedied, death presently follows." Obs. X. CHRONIC INVERSION OF THE UTERUS. 251 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 exist- ence for years. Sufferings, both severe and long-continued, await the woman who has an unreduced uterus; her life is that of mise- ry and wretchedness; and these augment in proportion to her incapacity 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 ex- cision 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 mis- take 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 authori- ties extant; and, after carefully collating their opinions, he re- duces them to the following summary. "Il 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 impos- sibility of passing the finger around the neck of the tumour, between 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;* by the insensibility of the tumour in the one case, • 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 252 CHRONIC INVERSION OF THE UTERI'S. and by its extreme sensibility in the other; by the comparativefix- ity of the one tumour, and the extensive sphere of motion of the other; by the rough and fungous surface of inversion, contrasted with the smooth and polished surface of polypus; and by the pre- vious history of the patient's disease." " But it is clear, that thr-e 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 re- viewing the foregoing testimonies, we shall be induced to con- clude, 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 or- der 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 tumour, 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 portion of the uterus, which has been inverted in the usual way, or by the long-continued dragging of polypus upon Us fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its en- larged base, and narrow peduncle, we must also recollect the abun- dant evidence to prove, that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity; and we shall still be left in inexplicable difficulty," p. 82. " But shall we not find some more infallible guide in those other characteristics, which have been given as certain diag- nostics? 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 examination,—while, loo, it must be remembered, of the neck, in both the natural and inverted condition of this organ, consequent- ly, the mark mentioned by Mr. N. cannot be present, but by some unusual ar- rangement; and, of course, must not be considered a diagnostic. CHRONIC INVERSION OF THE UTERUS. 253 that the sensibility 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 as- certain 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 ab- sorbents:—that in either case, and interchangeably, according to the different period and circumstances of the disease, the surface of the tumour 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, and have only first passed into the vagina, immediately after the expulsion of the fcetus, 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; il vvas 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 vvas 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 recommend- ed by Mr. Clarke for the removal of a polypus. See Chapter on Polypus. 33 254 DISORDERS AND DISEASES OF THE UTERUS. 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 miniitety 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 ihe diseases of this system as consist in sensible altera- tions 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 applica- tion of sufficiently powerful exciting causes, may give rise lo malignant developments that may prove destructive to the dif- ferent 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. DISEASES OF THE OVARIES. 255 2d. Under thus head may be comprised, a. Extreme smallness of this organ. b. Where this organ is double, or is divided into two compartments. c. Where this body is cartilaginous, or scirrhous. 3d. Under this head may be classed, a. Tumours of various kinds. b. Abscesses. c. Ulcerations. d. Cancer. e. Tubercular, spongy, or polypous excrescences. f. Hydatids. g. Cauliflower excrescences. 4th. Under this head may be included, a. Cartilaginous rings of the os uteri. k. Its complete occlusion from 1. Excrescences filling it up. 2. Stones obstructing it, 3. Membranes forming within it, and from mem- branes 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, lhat has a decided operation on Ihese bodies; consequently, they are very little under the con- trol of remedies, whose operations are felt upon the general sys- tem, or of those which may exert an influence on certain por- tions of it. It is probable, that, during an active state^of disease, as inflammation, 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 instance, with which we are acquainted, would lead us to the conclusion, that any remedy has removed a disordered con- dition of these parts. 256 DISEASES OF THE TUBES. They seem to be removed so far from the general sympathies of the system; so insulated in position; so independent in func- tion; lhat the common agents for the removal, or control of dis- ease, seem to waste themselves in unavailing attempts to influ- ence their actions, or to modify their affections. Who flatters himself that he has removed a dropsy; resolved a scirrhus; or interrupted a suppuration in these bodies? We believe, if he be candid, 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 to time, we become acquainted with substances, which have a specific ac- tion upon certain tissues of the human body. The time may ar- rive, when we will be in possession of a substance, the action of which shall be confined to the ovaries alone, or to similar orga- nizations, 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. Scirrhus, 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. Ertormous 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 lo the physician's skill. 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 DISEASES OF THE TUBES. 257 is rarely any other change in these bodies than that which in- flammation produces,* and they chiefly consist, 1. In the obliteration of their canals; or of one of them. 2. In adhesions with the ovaria, by meaqs of their (imbri- cated extremities. 3. Sometimes, in a great distention of one of them, from the partial development of an ovum. 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 lo 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 lubes; for, to this moment, we are altogether unacquaint- ed 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 m left of the symphysis pubis, but posteriorly. If the part be pressed upon pretty firmly, some pain will be felt; and upon turning suddenly in bed, it 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 occasionally sick, and easily provoked to vomit, if offended by medicine or food. The pa- tient is easier on her back than side; but altogether unable to sit up without great agony. Efforts to puke, 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 • They are, however, said sometimes to be involved, as also the ovaria, ii cer of the uterus. 258 PARTICULAR DISEASES OF THE UTERUS. 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 destro}ing the severity of suffering. I have witnessed this pain on both sides of the pelvis at tho ' same lime; 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. 1 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 tincture of guaiacum. Before this remedy was employed, the complaint had abated much of its severity; though the patient suffered considerably at the time il was commenced. I am, however, by no means certain, that the disease now de- scribed, vvas an inflamed tube or tubes; but think it probable. That it was a disease of some one of the female organs of gene- ration, I am pretty firmly convinced, as I never met with a simi- lar 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 to some of them; while others, from their incura- ble nature, will require little more than their history; as the me- thod of cure is unknown to us at present. Thus, it would be proper to dwell upon all the derangements of menstruation, menorrhagia, leucorrhcea, prolapsus, retrover- sion, inversion, &c; while a short account of the carcinoma, cau- CARCINOMA UTERI. 259 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 explanation. It seems to follow, as a natural consequence, that that part of the body which receives the most injury from mechanical or other violence, vvill be the most liable to disease; but whether these violences be capable of themselves of producing an original com- plaint, like carcinoma, &c, or only act as exciting causes upon- certain predispositions, remains to be determined. We believe these injuries, however, may be capable of doing. both the one and the other; hut the character of the diseases pro- duced under these different circumstances, will be very different. Thus tumours, or other indurations of the uterus, pass too com- monly under one common name as schirrhi: but without scirrhus being the disease. While, on the other hand, when a predispo- sition 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 tnan 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 in 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, therefore, mainly depend upon the descriptions given by Mr. Clarke, in his excellent work upon the diseases of females, as they entirely agree with our own experience. Mr. Clarke observes, that cases of carcinoma uteri* are fre- * " 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 disposed to ulcerate." Diseases of Females, p. 207. Am. Ed. 260 CARCINOMA UTERI. quently met with in practice, but that very young women are seldom attacked ; women of middle age are much more liable lo 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 ibis observation. For tumours of this organ, elsewhere situated, are of a different character; having different symptoms and terminations.* In the dead body, they have some resemblance to carcinoma, but they are never found ulcerated. Carcinoma particularly affects glandular parts; hence, its attack 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.f 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. • 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 abdomen, 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 an absence of those lines which characterize scirrhus."—Mackintosh's Prac- tice of Physic, Vol. II. p. 314. + Dr. Horner and myself attended a lady with carcinoma, complicated with a poly- pus nearly the size of a hen's egg, which masked in great measure the condition of the neck of the uterus until it was removed by ligature. After the removal of the polypus, the neck of the uterus was found Jo be ulcerated to a considerable 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 ulceration 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 promise of 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. TREATMENT OF CARCINOMA UTERI. -»bl 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 stomach be not mistaken for the disease; as they are only symptomatic^ of the condition of the uterus—they augment as the disease ad- vances; 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, vvill be perceived on some part of the neck of the uterus; the other por- tions remaining healthy. In either case, pressure produces a lancinating pain.* 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 hemor- rhagies.—Clarke on Female Diseases. Sect. II.—Of the Treatment of Carcinoma Uteri. 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. • It is now well ascertained, that there are many affections of the neck of the uterus, that are not carcinomatous. 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 bleeding, 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 which they have derived the most prompt and satisfactory advantage. 34 262 TREATMENT OF CARCINOMA UTERI. Clarke;* 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. 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 lo be clone by the re- duction of the local inflammation, (which is essential to the dis- * 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, con- stant pain in the pelvis, which at times becomes highly aggravated, especially during the menstrual period. This discharge is sparing, veiy dark-coloured, and irregular. There is some leucorrhcea, 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, and appetite feeble and whimsical; feet swollen, but not excessively; very pale, and eyelids 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 en- larged, 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 pre- cipitated 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 unyielding—the whole of the parts that can be touched with the fin- ger exceedingly painful, especially the neck of the uterus. Coition impractica- ble, 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 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 regular, and sufficiently abundant. This improved condition has continued now for fourteen montlis without interruption—in a word, the patient considers her- self perfectly restored to health. TREATMENT OF CARCINOMA UTERI. 263 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. 5th. 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 abstrac- tion of a few ounces of blood becomes highly important from time to time; but if the catamenia have ceased, it becomes ab- solutely 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 severe throbbing pain just above the sacrum, much immediate relief 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, though that relief may be but temporary. We have constantly found, when pain was severe, the pulse frequent and tense, or wiry; (forso 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 264 TREATMENT OF CARCINOMA UTERI. 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.* 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 tbe 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 phlegmasia? of the uterus, when attended with an engorged condition of its neck. The efficacy can be easily believed; but, to get ou^.fair countrywomen lo sub- mit to these applications, I fear vvill be a work of no small diffi- culty—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 prejudices, 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 wis 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 individuals concerned. As regards ourselves, we have but too * For the last few years, we have been in tbe 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. 265 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 vvill operate without pain, and afford copious discharges of fluids from the intestines them- selves. Such are the neutral salts; they therefore merit the pre- ference. 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 quan- tity 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 266 TREATMENT OF CARCINOMA UTERI. 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 sub- stituted. 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 perseve- rance in purgative remedies is absolutely necessary, as it very sel- dom requires an increase of dose if it be regularly administered. 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:— 5<. Gum Aloes sue. £ss. Pulv. Rhaei. £j. 01. Caryoph. gut. iv. Sapo. Venet. gr. viij. Syr. Rhxi. 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 bow- els are rendered costive by opium, which is very likely to hap- pen, 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 proscribed 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 prejudice. 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 vvas labouring. It happens not unfrequently, that the bowels become obstinate- ly 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 agen- cy 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 difficulty; TREATMENT OF CARCINOMA UTERI. 267 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 partially ob- literated 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 se- rous discharges from the intestines, with a view to relieve the 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 inconve- niences to contend with; 1st, the body will be unnecessarily de- bilitated 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-inflamma- tion 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, has 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. 3. Abstemious Diet. There is no disease, unless it be one very much more acute that so decidedly suffers aggravation from errors in diet, as the one under consideration. We have known severe and long-conti- nued 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 266 TREATMENT OF CARCINOMA UTERI. thing else remedial, should be made conformable to the gr< ;it indications; namely, to diminish the quantity of circulating fluids; and to abate, both locally and generally, arterial action. Therefore, the most bland articles must be selected for this purpose; as milk, and vegetables. If milk agree with the pa- tient, 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 al- most always costiveness. The fruits of the season, tapioca, oat- meal, sago, Indian meal gruel, &c, may also be taken, the ren- net 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 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 quantity of blood, and improperly increase the vigour of the sys- tem," p. 22!>. 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 rigour, 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, lo conduct it with advantage. TREATMENT OF CARC1N0MI UTERI. 269 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, lhat advantage has rarely, if ever been gained, by this practice; unless a substance has been ex- pressly added to destroy the fcetor of the discharge, by its che- mical agency. If the disease has proceeded to ulceration, the smell some- times becomes almost insupportable; for now a quantity of blood is almost constantly issuing from the ulcerated surface, which, 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. AH 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 fcetor, both mechanically and chemically; mechani- cally, by frequent washings with warm water, or the flaxseed tea; and chemically, 1st, by carbonic acid gas; 2d. by lime; 3d by the pyroligneons 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 ef the vagina, by means of a flexible tube of sufficient 35 470 TREATMENT OF CARCINOMA UTERI. 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 re- lieved the severity of pain whenever it was employed, as well as diminished the offensiveness of the discharge. 2. 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 quick lime is slacked 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 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 certain is its control over the putrid exhala- tions. 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 to be renewed when dry. The cheapness of this article enables the patient lo 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 appli- cation. 5. By Rest. Rest is a sine qua non in thii complaint; whether it be in its incipient stage, or at a more advanced period of its progress But TREATMENT OF CARCINOMA UTERI. 271 by rest, do not let us be understood to mean absolute confinement to bed. By rest, we mean the indulgence of a horizontal position for the body, without intervening exercise. This auxiliary acts by equalizing the circulation; by diminishing its force; by ab- stracting the stimulus of motion; by preventing the consequences 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 lime as so many leechings, from which the patient derives much immediate comfort, if not eventual be- nefit. Upon the same principle, he should not attempt to arrest the purulent discharge from the vagina, by the employment of as- tringent or stimulating injections. We have already directed strict attention to cleanliness, by means of simple warm water: with this, there can be no fear of doing mischief by any stimu- lating 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 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 ven- ture 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 272 TREATMENT OF CARCINOMA UTERI. both the patient and the practitioner, to persevere in the use of the remedies pointed out; shows that this formidable and loath- some disease 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 enlargements 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 al- ternative 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, not- withstanding absorption has commenced, and ulceration is pro- gressing, 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 case. 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 mu-l not create alarm; for the state of the system declares its propriety. Indeed, nature seems to offer TREATMENT OF CARCINOMA UTERI. 273 this relief by producing a hemorrhage from the part, which hard- ly ever fails to afford it. Besides, it is sure to place the system in a more favourable condition for the operation of narcotics, 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 protract- ed, as to quicklv destroy their power. For this purpose, we be- lieve 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 encomiums which have been bestowed upon them. I am happy to find myself supported in this experience, by Dr. Chauffard.* 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 nar- cotics; but do not let us forget, that in such cases, two or three grains of opium vvill 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 altoge- ther 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 common laudanum is, perhaps, the most so of any; even more so * Memoire sur 1'emploi et l'abus des medicaments stupefiants les plus usites- Trans. Med. &c. for Julv, 1830. 274 TREATMENT OF CARCINOMA UTERI. than 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 tendencies are obviated altogether; and almost always, are very much dimi- nished. It is seldom followed by headach or nausea; nor does it constipate the bowels, in any like degree, as the laudanum. It therefore always merits the preference, when it can be command- ed: and when it cannot, much of the inconvenience of the lauda- num may be avoided, by mixing the doses with sweetened vine- gar ; or by the addition of a few grains of the carbonate of soda or potash.* It has been a usual practice in carcinoma, to give the cicuta in increasing doses. We have thought we have sometimes derived a temporary benefit, but we have never witnessed a permanent advantage from it, to whatever extent we may have carried it. We have thought, however, that opium was more certain 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 an- other, even under the same circumstances, as far as could be de- termined. Why this has happened, we cannot pretend to say: but when opium has failed, we have found that camphor, in li- beral 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 ul- cerated 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 pro- cured sleep, when it could not be obtained by opium. The same may be said of the liq. anod. Hoffm. in tea-spoonful doses, f • 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- tised 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 gene- rally obnoxious to them. Morphia itself offers a valuable resource; it is very cer- tain in its effects, and is not usually followed by the inconveniences of the other preparations. It may be given either in substance or in solution: one-sixth of a grain, is about equal to one grain of the opium, or thirty drops of laudanum. f Care should always be taken that this substance has been faithfully prepared. See note to page 232. TREATMENT OF CARCINOMA UTERI. 275 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. When the stomach becomes affected, the case is always more deplorable, for reasons easily imagined. This rarely takes place as a sympathetic affectionj 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, wheTf 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 appoase 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 suffi- ciently 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 disease But, from the practitioner who may have such a case in hand and whose resources are nearly exhausted, we fear no such cen- sure: 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 276 TREATMENT OF ( ARCINOMA UTERI- 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 carcinomatous ulcerations of tbe internal parts, in which the discharges are more likely to be retained, than where the disease attacks external sur- faces. If it were only that the fcetor attending such sores would be removed by cleanliness, attention to this circumstance 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 balh; 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 ihe 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 carefully injected into the vagina by a small syringe. The quantity of the discharge is frequently increased by the means above mentioned, but the comfort which the patient will derive from it, will abundantly compensate her for any debility which may be produced by the remedy; and excruciating attacks of pain, are sometimes 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 TREATMENT OF CARCINOMA UTERI. 277 by experience to tranquillize all irritable sores; and, in some, to expedite the healing process. Amongst the different applications for this purpose, the extraclum conii, or extractum hyosciami, may be 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 Ihe 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 ap- .plied. Three or four ounces of either of these fluids, impreg- nated with sedative substances, may be thrown into the rectum, in those cases where relief is not obtained by their application lo the vagina; but when opium is used for this purpose, the practi- tioner should be very careful to watch over its effects, as it has sometimes happened that unpleasant consequences have arisen from the application of this drug to the rectum, such as vomit- ing, syncope, cold extremities, and irregularity of circulation. The action of the absorbents of the rectum is, in all probabi- lity, 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 lime. Plasters and lini- ments, 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 practi- tioner may be required to diminish the suffering 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. 5<. Acidi acetici, .... z^. Aqux distillate, - - - Oj.—M. f. Injecuo. B<. Acidi nitrici, .... gUtt. x. Aquae distillate, - - . Oj.—M. f. Injectio. Or, 5<. Liquons plumbi acetatis, £j. Acidi acetici, .... ?;;, Sp. Vinosi.....*?•, Aqu* distillate, . . . gxvss.-M. f. Injectio. 36 278 TREATMENT OF CARCINOMA UTERI. " If the discharge should become so profuse, as to induce great debility, injections which possess an astringent power, must be sought for. 5<. Decocti corticis granati, - - - - Oj. Sulphatis aluminx, .....3ss.—M. f. Injectio. Or, &. Zinci sulphatis,......- 3s8, Aquae distillatae, .....- ^xv. Tinct. Rino.........3J.—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 il 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 i— g<. Argenti nitratis, ------ gr. x. Aquae distillate, ......Oi.—M. Or, B<. Cupri sulphatis, .-.-.- sfss. Decocti cinchonae, .....Oi.—M. "Respecting internal remedies, although no one has as yet discovered any medicine capable of removing the disease, it may not be too much to state, that there is scarcely a medicine of any class, which may not, in some way or other, or at some period or other, be useful in this complaint. Various are the symptoms which may arise; various must be the means of obviating them; and he will be the best practitioner, who best understands the adaptation pf these means to their end. To point them out here, would be an endless labour, and a waste of the reader's time. "It may be sufficient to observe, that the patient should be treated upon general principles, bearing in mind, on the one hand, the hitherto intractable nature of the malady, and on the other, the sufferings of humanity, which call loudly for relief. "Pain, the great evil of life, is the symptom by which the patient will be most distressed; and, happily, in the sedative class of medicines, there are to be found many capable of re- lieving it. "It should be a rule of practice, never to exhibit a sedative of great power, when a milder will produce equal relief; because TREATMENT OF CARCINOMA UTERI. 279 the disease is one of long duration, of increasing suffering, and every medicine vvill at length fail in producing its effect. " Hyosciamus and conium may be amongst the first employed, and the dose of each may vary from three to eight, or len grains: larger doses have been exhibited; but the object is not to know how much of these, or of any other drug can be taken with im- punity, but how much is necessary to produce the desired ef- fect. If they are wantonly employed, the patient vvill be ex- posed to another set of symptoms, arising from a disturbed state of the stomach, and of the brain; as flatulence, heartburn, erue- tations, delirium: the necessity for the exhibition of these me- dicines, must regulate not only their dose, but the frequency of their exhibition. " Extractum slramonii is another serviceable remedy in allay- ing pain, and it may be given in doses of a grain. "The writer is not in the habit of exhibiting belladonna, having once seen a patient nearly destroyed by two small doses of it. Other practitioners, however, have employed it, it is said, with advantage. Mr. Brodie has informed the writer, that he has seen the happiest effects produced by a suppository contain- ing extractae belladonnae, gr. j. in cases of irritable bladder, and also of carcinoma of the rectum. Perhaps, therefore, in those instances, in which the administration of other sedatives is una- vailing, it may be adviseable to administer the above medicine in the form alluded to. " As the symptoms beeome more pressing, and as the suffer- ings of the patient increase, still there will remain to the practi- tioner one resource, and to the patient one solace, in opium, by means of which, her distresses may be alleviated, and her passage from this world to another, rendered less agonizing. It will not be sufficient simply to prescribe a dose of opium, at stated inter- vals; that dose must be proportioned to the necessity for its use; and the skilful combination of it with other medicines, and the selection of its different preparations, will call forth the happiest efforts of the practitioner: in one case, opium in a solid form, will be found to agree; in another, the tinctura opii, of the phar- macopoeia will better answer the purpose; in the third, the pre- paration known by the name of black drop; in a fourth, the li- quor opii sedatives of Mr. Beattie, will quiet the patient, and at the same time, produce the leastdisturbance in the system; whilst the irritable state into which some patients fall, will be most sue- 280 TREATMENT OF CARCINOMA UTERI. cessfully diminished by the very small quantity of opium which enters into the composition of the tinctura camphora* composita. " In the greater number of painful diseases, which call for the use of opium, less care is required; but the sympathy of the sto- mach is so actively called forth, when the uterus is the scat of this disease, that it vvill be capriciously inclined towards one me- dicine, whilst it receives another with great comfort and advan- tage. If, as always happens towards the close of ulcerated car- cinoma of the uterus, vomiting should come on, the combination of spices with opium, will render this medicine more agreeable to the stomach. The julepum menthae, cinnamon water, and, in some cases, weak brandy and water, will form the best vehi- cles for the different preparations of opium; sometimes, a mix- ture of confectio opiatae and spiritus aetheris sulphurici composi- tus, given in peppermint water, in small doses, at short intervals, vvill relieve, in an expeditious and certain manner, the vomiting, singultus, and eructation, more effectually than any other combi- nations of medicines." Sect. III.—Of the Polypus of the Uterus. This disease of the uterus, the author has never seen;* he is therefore under the necessity of drawing his account of the poly- pus from the experience of others. He has endeavoured to give a • Since the period stated above, I have seen several cases of " polypus of the uterus," one of which was fatal. Mrs.----, aged forty-five years, was attacked with pains resembling labour. After they had continued with more or less seve- rity for thirty-six hours, I was requested to visit her. I found her labouring un- der powerful pains, which were almost without intermission, and of great force. I immediately examined per vaginam, and found a tumour of the size of a child's head at seven months, occupying, or rather advancing through the vagina. Sus- pecting the nature of the tumour, and fearing it would invert the uterus if it did escape from the os externum, I opposed its passage, with all the strength I could make to bear upon the part, but without success, for in defiance of all opposition, the tumour was pushed without the vulva. It was attached to the uterus by a short neck, and the tumour had inverted this organ upon its escaping from the vagina. I endeavoured to restore the mass, but without success, as the parts were so extremely sensible, that the woman could scarcely support the slightest touch. The tumour soon became black, and very offensive; the woman bad been exhausted by a long-continued discharge of blood of some months' standing, to- gether with a considerable hemorrhage during the effort the uterus made to dis- lodge the tumour: she died the next day. Leave could not be obtained to exa- mine the body, as it was in extremely hot weather, and vvas to be removed some distance into the country. POLYPUS OF THE UTERUS. 281 faithful history of this complaint, by consulting those he esteems, to be the best authorities upon this subject; namely, Levret, Denman, and Clarke. It would seem to be fairly presumable, that this disease is of more rare occurrence in this country, than in Europe; since, in the practice of the gentlemen just named, many cases have oc- curred; while in this, the experience of a number of gentlemen whom I have consulted, has not furnished one. This would also seem to call in doubt, one of the causes assigned for the produc- tion of this disease; namely, injuries which the uterus may have sustained during labour; for it is to be presumed, lhat were this a common cause, the American women would have a greater claim to polypi, than they appear to have. Dr. Denman says, " The cause of polypi is supposed to be some accidental injury done to the part at the time of labour, or other- wise ; but more commonly, it is a spontaneous disease, proceed- ing from a certain disposition of the constitution, or of the part itself; as those who have a polypus of the uterus, are apt to have excrescences from other parts; and they sometimes exist in those who have never been pregnant, and even in virgins."—Introd. Francis' Ed. p. 123. Mr. Clarke defines polypus to be an "insensible tumour at- tached to the internal part of the uterus by a small neck, forming a disease of a very important character," p. 243, vol. i. This de- finition does not exactly correspond with the history given of this complaint by Dr. Denman: he says, "Some of them hang by a small pedicle, and others have a broad basis, especially at their commencement,"* p. 123. Nor is it so satisfactory as the defi- nition of Levret; he makes it "an indolent circumscribed tumour, more or less salient, resembling a fleshy or fungous excrescence, covered by the membrane from which it takes its rise, and which is of greater or less thickness."—Obser. sur la Cure radical de- pleusiers Poly, de la Matrice, &c. p. 2. • A Udy from Savannah, Georgia, considted me for a polypus of the uterus, in July, 1830. Upon examination, it proved to be small, and its pedicle very shm. It was seized v>y two fingers and the thumb, and drawn down to the os externum; in doing tins thetumour separated at its attachment with the uterus- it caused no pain, nor did the smallest hemorrhage follow: as I have not heard from the lady since, I presume she has suffered no farther inconvenience, though she had been very much reduced previously by repeated hemorrhage from this tumour. Since the above was written, ihave heard from her ,msband who ^ sures me she is perfectly well. 282 POLYPUS OF THE T'TERU*. Levret makes three species of uterine polypi; but this is cer- tainly an unnecessary distinction, since his species are derived from the situation of the polypus in the uterus, and not from a difference in their organization; therefore, properly speaking, it is a mere difference of location, lie says his first species, which he declares at the same time to be the most common, has its origin or attachment from the fundus of the uterus; the second, which is less frequent, takes its origin from the neck of this or- gan; and the third, which is the most rare, has its pedicle attached to the marginof the orifice of the uterus," p. 14. He has given plates, to prove the different locations of these tumours, which we have copied. See plate IV. These substances are vascular in different degrees; and, agreea- bly to Levret, the veins are large in proportion to the arteries. The latter become varicose in that species, which is confined within the cavity of the uterus, or has its origin from its fundus. The first species of Levret, is always attended, at a certain period, by hemorrhage; and is of course always accompanied by an increase of size of Ihe uterus. A sense of weight, or bearing down, is experienced, of more or less intensity, as the polypus may be large or small. It is of uncertain size; and may employ a longer or shorter period for such a growth as shall be either very troublesome, or strongly engage the woman in a considera- tion of her situation. It occasionally grows very large, and distends the uterus so much that it can be distinctly felt above the pubes. When it acquires this volume, and oftentimes before, there is found a dis- charge from the vagina, which in the commencement is serous; but may soon become purulent and sanguineous. If a finger be introduced into the vagina, the os uteri will be found open to an extent much beyond its natural size; and will permit the point of the finger to penetrate the cavity of the uterus, in which a substance will be felt of greater or less firmness, and of different degrees of inequality. The finger, if it be made to pass a sufficient distance within the womb, can be turned round the body, which the uterus seems to enclose. This examination may be followed by a very small, or a very large flow of blood. The woman is almost always troubled with a discharge of blood, which at times seems to assume * periodical movement; or it may only be more abundant at certain periods, while a constant but moderate flow fills up the interval. Pain of a periodical kind POLYPUS OF THE UTERUS. 283 sometimes ensues; and this may be so long-continued and severe, as to force the tumour from the cavity of the uterus into the va- gina, and even through the os externum.*—When this takes place, it is generally mistaken for the uterus itself, and has been called by many a descent of this organ. The following case vvill show the nature of this disease. Mrs. B. had suffered from time to time nearly eighteen months with a profuse discharge of blood from the vagina, for which much had been done, but to no useful purpose. She was about twenty-three years of age, had had two children, and was pre- viously to these discharges of a good constitution. She came lo this city to place herself under my care—at this time, she was very feeble, and almost bloodless, as she had suffered a most pro- fuse hemorrhage a few days before. By an examination per vaginam, I discovered a polypus about the size of a walnut, the pedicle of which was within the uterus. I begged the assistance of my friend Dr. Horner. We applied a ligature without difficulty close to the os tincae around the neck of the tumour—it separated in about four days without any unpleasant symptoms, though the patient laboured under the fever from excessive hemorrhage, for nearly two weeks. This, however, yielded gradually; and she returned home, free from disease, and continued to improve up to the last account we received of her. It is this condition of the polypus, which has given rise to the absurd stories related by many of the older authors, especially Cesalpinus, iEtius,Paul Eginetta, Carpi, &c; of the uterus having been amputated, and the woman conceiving afterwards. Levret, sur Polypes Uterine, p. 29. The mechanism of the expulsion of the polypus, is very simi- lar to that of an abortion;f that is, the os uteri is gradually, but successfully opened so far, as to permit the extrusion of this sub- stance. When this takes place, the body of the polypus is with- • See Dr. Denman's cases, at the end of this chapter; and the case just related page 280. ' f The explanation of Levret, of the mechanism which nature employs when she attempts the expulsion of this species of polypus, is so ingenious, and so con- formable to the general laws which govern the uterus, that we cannot resist the temptation to transcribe it at length. «« Le polype uterin de la premiere espece ayant une fois pris naissance au fond de la matrice par quelque cause que ce puissc &re, croit pen, a peu sans que la femme ni le chirurgien meme s'en appercoivent; en effet, lorsque la malade se plamt pour la premiere fois, en ne peut d'abord decider si la cause de son mal est un 28-1 POLYPUS OF THE UTERUS. out the os uteri, while its pedicle maintains its attachment to the inner surface of the uterus itself. If it be examined now, it will appear to occupy the vagina, and might be supposed to proceed from its surface; yet, by a careful search,its pedicle will be found to be within the uterus, and the os uteri surrounding it cntirclv, as a sphincter; and as such it acts, agreeably to Levret. The polypus has been suddenly discharged from the cavity of the ute- rus, by falls or other violence. He says, that in this species, hemorrhage is necessarily a con- sequence; but that it never appears, until the body of the tumour has in a great measure freed itself from the orifice of the uterus, and until it begins to extend itself into the vagina; then the sphincter of the uterus, (that is, the os uteri,) compresses the external veins of the polypus; in consequence of which, these veins become varicose, and finally burst; and their rupture gives rise to a hemorrhage, which is renewed at irregular periods," p. 25. These frequent bleedings, if not relieved by the removal of the tumour, eventually exhaust the woman; but rather by their pertinacity, than by their immediate excess; yet examples arc upon record, where a sudden hemorrhage has destroyed the wo- man immediately. Levret, p. 30. polype ou toute autre maladie: car il n'y a dans les premiers terns aucun signe characteristique de son existence. " Ce corps etranger ayant acquis avec le tems plus de volume, oblige la ma- trice a se dilater, quoique par degres tres-insensibles; mais comme 1'attache dc cette tumeur occupe, dans tous les terns, au fond de la matrice bien moini d'eipace que le placenta d'un enfant en quelqu' ctat d'accroissement que soit ce dernier, toutes choses neanmoins etant d'ailleurs egales, il faut, non pas que le fait dilater Farriere-faix dans la grossesse; mais que les parois de ceviscerc se pretent un peu, de meme de son fond, a cette puissance dilatante etrangere. Or il n'est point en ce cas de loix naturelles a sa destination qui sollicitent les parois de cette organe; elles doivent dcric resister: le polype doit etre comprime; il doit done aussi f'al- longer plus ou moins, a raison de son plus ou moins solidite. Alors il s'insinue dans le col de cet organe, parce qu'il y trouve moins de resistance. Parvenu au sphyncter de l'orifice, il le force peu a peu, et s'introduit dans le vuide qu'il »'* pratique, comme le feroit un coin: enfin 1'extremite du polype ne trouvant plus rien que le g&ne s'etend en avant et au large dans le vagin, et la tumeur prend plus ou moins de volume, selon que le permettent mille diverses ctrconstanccs, que sont plus aisees a concevoir qu'a detailler. " Le pedicule ne peut pas s'etendre au large comme lc rcstc de la tumeur, l'orifice de la uterus qui souffre un espece de violence, le comprime, le polype est done comme etrangle en cet en droit: il faut qu'il prenne la figure pyrifbrme, de la naisscnt les varices; e'est la vraie cause dc rhemorrhagie," p. 38. POLYPUS OF THE UTERUS. 285 Thc3c. polypi seem not in general to do injury to the proper substance of the uterus; for several relate, that this organ was found sound after deaths occasioned by the wasting hemorrhagies from the surface of the tumours. Levret, p. 42. Agreeably to Levret, the signs of this species of polypus are, " whenever we examine a woman, who has been labouring un- der a discharge of blood from the vagina, or of a falling of the womb, whether they are both found together, or separately, if we find in the vagina a pyriform body, the insulated top of which passes through the orifice of the uterus, without destroying its circular form, we may always with certainty be assured, if we except pregnancy, that it is a polypus attached by its pedicle lo the uterus, and lhat it is in the most favourable condition for the ligature," p. 48. See figure 1. Plate IV. In the second species, the finger cannot pass entirely around the pedicle, as in the first; and the point which opposes the finger making its circle, is a little above tbe orifice of the uterus, and is found to be the pedicle of the polypus, inserted on the outside of the neck of the uterus. The os uteri may also be felt. See fig. 2. Plate IV. This species is not commonly accompanied by hemorrhage, because the pedicle does not become strangulated, as in the first; but there is an increase of vaginal secretion. This species, never- theless, is a genuine polypus. The third species is thus distinguished; when there is in the vagina a moveable tumour, with a narrow neck attached to the orifice of the uterus, but in such a manner as to leave the orifice free, we may be pretty certain, that it is a polypus of this kind. In this case, the mouth of the uterus will be obliquely situated, as regards the axis of the vagina, in consequence of that part of the neck of the uterus lo which the tumour is attached, descend- ing a little lower than the other portions of it, from the weight of the tumour. This species is not necessarily attended by hemor- rhage. All these species have but one common remedy ; namely, ex- tirpation by ligature. In the first, it will be seen, that this re- medy cannot be applied, until the tumour has descended into the vagina, and consequently vvill not admit of a cure, until that event takes place. It would then seem desirable that this escape of the tumour from its confinement, should be promoted, if possible, so soon as it shall be determined that there exists a polypus within 37 286 POLYPUS OF THE UTEUUS. the uterus. But how shall it be ascertained, that there is a tu- mour in the cavity of the uterus, since no particular >ymptom8 mark this condition until it fall into the vagina? There may be a great difficulty in distinguishing this condition at such a period; but we are informed, before this takes place, the woman suffers pain resembling labour; and when pregnancy cannot account for these pains, nor dysmenorrhoea, it might be well to examine the patient par vaginam. In such an examination, the tumour might be felt, making its way through the os uteri: if so, it would be every way desirable to facilitate its progress; and for this pur- pose I would ask, what would be the probable effect of the sccale cornutum? The uterus will also be found enlarged, and may be felt above the mons veneris; at least this will be the case for a certain pe- riod; or until the tumour shall pass, either in part or altogether, through the os uteri. Nothing illustrates the routine of practice so well as the recital of cases; and no cases can be more interesting and satisfactory than those related by Dr. Denman. We shall, therefore, tran- scribe them for the benefit of those who may not have the advan- tage of possessing his work; as well as conveying (o such in per- spicuous language, the histories of several highly useful cases, treated with all the ability, that that great metropolis, London, could furnish.. Case First. " A single lady, twenty-two years of age, had, for a considera- ble time, been subject to frequent and profuse returns of uterine hemorrhage, which resisted all the means that could be devised for her relief, and at length reduced her to a state of great weak- ness. Dr. Turton, (whose worth and continued friendship to me, I am happy on every occasion to acknowledge,) was the physician who attended; and he, suspecting some local disease, desired I might be permitted to make inquiry. I discovered a polypus, not of a large size, lying low in the vagina. When I came to paM the ligature, there was much embarrassment from the state of the parts, any injury to which I vvas solicitous toavoid. On the fifth day from the time of my passing it, it came away; but the poly- pus could not be extracted without much caution tuwl trouble. There was no return of the hemorrhage; she soon recovered her POLYPUS OF THE UTERUS. 287 strength, and in a few months was married. She has since had seven fine children, with safe and easy labours. This polypus weighed four ounces." Case Second. "Another young lady had long suffered from frequent uterine hemorrhages, together with most violent pains, recurring in the manner of those of labour. High up in the vagina, just cleared through the os uteri, I discovered a small polypus, round which a ligature vvas with difficulty passed. The late Mr. Hunter was with me at the time. When I began to tighten the ligature, she complained of very severe pain, and presently vomited. The ligature was immediately slackened, but on every future attempt to draw it tighter, the symptoms were instantly produced. After many trials, I was obliged to desist altogether, leaving the liga- ture loose round the polypus; merely to keep up in the mind of the patient, some faint hope of benefit. The health of this patient was very bad when I first saw her, and, in about six weeks from the time of the operation, she died." "Leave being given to open the body, the uterus was found inverted, and the ligature to have passed over the inverted part, which occasioned all the symptoms before mentioned. This polypus could not have weighed more than one ounce, and had a very short, if it could be said to have a stem; so that the ute- rus could not in this case have been inverted mechanically, but by its own vehement action, excited to expel the polypus, which, like any other extraneous and offending body, was a perpetual cause of irritation." Case Third. " Many years ago, I visited a lady, who had for a long time suffered greatly from various uterine complaints, and was sup- posed to have a cancer in the uterus, of which a general aspect gave very strong indications, but on examination I found a large polypus in the vagina. The late Dr. Ford, than whom no one vvas more intelligent or expert in practice, was in consultation with me. I passed the ligature and drew it tight, confidently expecting a happy termination of the case. The stem of the poly. pus was very thick, and it required eight or nine days' action of the ligature to divide it. When I had removed the polypus, I was very much mortified to find a new substance, nearly of the 288 POLYPUS OF THE UTERUS. size of that which had been taken away, in the vagina. Iler health being very infirm, it vvas thought adviscable for her to go a short distance in the country, for the chance of establishing her health, before another operation. But a colliquative diarrhoea, with aphtha?, came on; she gradually declined, and about the end of the month she died. " Of this repullulation, if it were such, I have never seen any other instance, so early after the operation; and it might be at- tributed, 1st, to the thickness of the stem; or, 2d. lo the slow decay of the stem; or, 3d. to a cancerous disposition of the ute- rus; or, 4th. lo a large portion of ihe polypus remaining in the uterus; besides what was discoverable in the vagina. If a case similar to this were again to occur to me, I should certainly act more speedily with the ligature, and however reduced the pa- tient might be, should feel justified in passing the ligature on the second excrescence, as affording the only chance of saving the patient; but this is, perhaps, to be considered as an instance of the great mischief done to the constitution, by too long delaying the operation." Case Fourth. "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 the greatest danger. When she permitted me to take 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." 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 vvas 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 • In this case, the secale cornutuin would most probably have succeeded in ex- pelling the tumour, and should always be tried in such cases. POLYPUS OF THE UTERUS. 289 • 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 lhat 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 vvas occasioned, that I thought Ihe patient would have died instantly. Was a case similar to 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,) subse- quent trials, even in the polypi which are of the largest size, may be more fortunate. I have very great pleasure in relating ihe 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 different kind and complexion, by which her strength was very much re- 290 POLYPUS OF THE UTERUS- duced. 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 vvas indeed very much surprised; for not only the whole vagina vvas filled up with a fleshy substance, but the os uteri vvas 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 hesilated whether I should make an attempt to pass the ligature, as I could not reach the stem of the substance, but after delibe- rating 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 stop- ping, on the appearance of any untoward symptom, I determined to make a trial. The first and second attempts to pass the liga- ture 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, vvas at liberty on the sixth day. The external parts were unusually contracted, and as any endeavours to bring away the polypus at lhat 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 as those of labour, and when the os externum became somewhat dilated, I kid hold of a portion of the tumour, first with my fingers, 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 vvas not any discharge of any consequence. Then she menstruated regularly, and returned home in perfect health. " This polypus, which vvas 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, allowing 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 in- stances,- and their bulk hourly lessening by decay, their extrac- tion is rendered more easy. POLYPUS OF THE UTERUS. 291 "These cases lead to an observation on the difference between what is properly meant by the term 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, (hough 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 na- tural, 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, a restricted an- tiphlogistic diet was ordered, with injections, per vaginam, of pretty strong lead water; that is, two drachms of the acetate, to ftsiss. of waW, three or four times a day. These would seem to control the hemorrhage temporarally, but they would recur, at short intervals, and by very slight exertions. The cicuta, in in- creasing doses, together with liberal doses of the extract of Ra- thany, were steadily persevered in, with some degree of advan- tage as regarded the quantity of discharge. This plan was per- severed in until August; at this time, an alarming discharge took place, so as almost to exhaust my patient. On an examina- tion now, the neck of the 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 in- tervals, 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, con- firmed the opinion I had given: the hemorrhage was now very much diminished; and could always be stopped by a small tam- pon of sponge. In this manner, things went on for several months, the substance gradually protruding itself, by the occa- J!) J MODE OF OPERATING FOR POLYPI. sional 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 pedicle of considerable thickness, more than an inch in diameter. I applied the wire ligature, and the tumour fell oil' on the eleventh day; no unpleasant symptom attended its application or followed its separation: my patient is rapidly recovering from the immense loss of blood, during a pe- riod of more than two years' continuance. " 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 different cases, and as the distance of its neck from the os exter- num 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, lias 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 meani 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 tbe cxtre- MODE OF OPERATING FOR POLYPI- 293 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- nes?, as neither to cut the neck of the tumour, nor to break, nor block up the cannula.* 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 practition- er'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 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 li- • 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 m applying the ligature. We merely mention the fact, without un- dervalumg Mr. Clarke's instrument. The failure may have been owing to our own mal-adro,tness rather than to the want of suitableness in the instrument itself. We however, succeed with difficulty with the long silver double cannula. We think the follovvmg advantages attach to the cannula and wire. First its whole powers are more at the command of the operator. Secondly, the loop can al- ways be enlarged or diminished at pleasure. Thirdly, it can be more easily re- moved, or have ,ts location changed, if this be necessary. Fourthly, any degree of pressure can be made, by a pair of pliers, that may be deemed expedient. Fifthly, he tumour ,s more completely strangled, and, consequently, will be soon detached by ulcerat.on. Sixthly, it requires but one instrument. 38 294 MODE OF OPERATING FOR POLYPI. gature round the neck of the tumour with the finger. In doing this part of the operation, great care is to be taken not to in- clude 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 twist- ed round the shoulders of the cannula, where they are to be made secure. The ligature, therefore, should be long enough to encir- cle the neck of the tumour, to be carried through the cannula, and a sufficient length of it should remain to be affixed to the shoulders of it. More than one ligature should always be pre- pared, lest that which is first used should become too slippery to be managed. "After threading the eye of the rod, one extremity of the li- gature is to be twisted once or twice round the instrument, whilst the otljer hangs loose. The patient should be made acquainted with the shape and situation of the instrument, that it may not be liable to be moved 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 cau- tion, there is reason to believe that the cannula has been inad- vertently pressed against, and its extremity pushed through the uterus of the patient, so as to occasion her death. In the en- graving given of the polypus cannula, there may be seen a con- trivance, 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. MODE OF OPERATING FOR POLYPI. 295 " Every day the practitioner is to examine the state of the li- gature; and as often as it is found at all to slack, it is to be tight- ened. The mode of tightening it requires particular attention. If the cannula should happen to be long, the practitioner 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 for- cibly and suddenly pushed by the left hand against the internal parts of the woman. In order to avoid this accident, the can- nula should be firmly held close to the external parts of the wo- man, 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 va- gina 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 tbe 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 vvill be accom- plished in some cases with ease, by one or two fingers introduced 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 ea- sily 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 instrument-: so that if it should slip, the parts of the woman may not be in- jured by it. "The cavity of the vagina should afterwards be cleansed by injecting some tepid water, and this should be repealed during: several days. " The mucus and bloody discharge seldom continue 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. 296 CAULIFLOWER EXCRESCENT U- "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 tbe 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 Ihe time at which tha-ligature came away; that at tbe end of fourteen days it vvas impossible to ascertain lhat 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 thai the tumour vvill 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 slate 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 consisting of a decoction of bark, with sulphuric acid, may be taken three times in 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 CAULIFLOWER EXCRESCENCE- 297 be accounted for: they all were relieved by astringent injections, the tincture of cantharides, the bals. copaiv., &c* The late Dr. John Clarke, of London,t 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 among the in- curable diseases of these parts, though considerable relief has been experienced, at different times, by the application of the li- gature, &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 vegetable." Clarke, p. 59. The whole of this excrescence is covered by a membrane of an extremely fine texture; from the surface of which, an aqueous fluid is poured in great quantity; and thus gives a par- ticular character to this disease. This tumour occupies, for a long time, the upper part of the va- gina, 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 lo 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. • I lately witnessed a case of profuse and acrid discharge of water from the vagina, which resisted all the remedies I employed, and eventually terminated in death. The neck of the uterus, when examined per vaginam, was much thiclc- ^ ened, tender, and opened so much as to permit the finger to pass. The whole I uterine mass seemed to fill up the lower portion of the pelvis, and appeared to be 1 attached to the whole of the surrounding parts, so firmly, as to be immoveable i in the pelvic cavity, by any force which could be applied by the finger. There , was also a considerable 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 com- plaint about six months. Leave could not be obtained to inspect the body. There were 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. t See his paper, in Transactions of the Society for the Improvement of Medi- cal Knowledge, 1812. 298 CAULIFLOWER EXCRESCENCE. 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 vagina;. Hence, in married women, who have borne many children, the tumour in- creases very rapidly; and, on the contrary, " the pressure of the sides of a less capacious vagina, as in single women, will great- ly tend to control its enlargement, acting like a bandage."— Clarke, p. 61. It would seem, that the enlargement of the tumour, at least, when it is so large as to protrude beyond the labia, occasions in- convenience by its mechanical pressure; as the parts immediately in contact with it, will not unfrequently ulcerate. It is not ascertained what gives rise to this disease; conjecture even seems at bay. The mechanical violences of labour, are al- together insufficient to account for its production; for " married women, who have never been pregnant; nay, single women, are liable lo 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 society, 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; SYMPTOMS OF CAULIFLOWER EXCRESCENCE. 2991 indeed, this excrescence seems to be but a mass, or congeries 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, Ihe whole tumour shrinks, and leaves nothing which resembles itself. All that can be perceived of the former tumour, however large it may have been, is "a soft, flaccid, slimy, whitish substance, re- sembling 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 vvas thrown in from the pipe of the injecting syringe." Many attempts had 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. Sect. VI. — Ojfthe Symptoms of this Complaint. This complaint begins by an aqueous discharge from the vagina; this is but little attended to in the beginning; nor, indeed, until ihe 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, vvill sometimes be followed by a great loss. 300 TREATMENT OF CAULIFLOWER EXCKESCENCE. The watery discharge diminishes, in proportion as the sangui- neous increases. From these multiplied discharges, the system 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 supervene, to aggravate the distresses of the already oppressed patient. 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 profusencsn 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 prognostic. lie says, " As the enlargement of vessels in other situations is much influenced by pressure, so it vvill be found, that the compression of the sides of the vagina will greatly retard the growth of this tumour. 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 tumour has there- by been little subject to compression, the prognostic to be given to the friends of the patient, as to the probable duration of life, should be less favourable than when the steles 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 Ihe constitution still possesses a considerable degree of vigour: so that the capacity of the vagina, in this instance, as well as in many others, is by no means a bad criterion of the strength re- maining 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 dis- ease." "The symptoms, in some cases of the disease, are di- minished more easily than in 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 paribus, without destroying life." TREATMENT OF CAULIFLOWER EXCRESCENCE. 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 it^ quality, though it may not be profuse. Unfortunately, this com- plaint, 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 communicate lo 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 con- tingent discovery, for the present, as it has been heretofore. From the nature of the formation, or rather organization, of this species of tumour, it is evident, that its extension or dimi- nution will very much depend upon the state of the circulating system, bolh 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 may be taken by cups, or by leeching, from about the sacrum or thighs: this will diminish the quantity of blood immediately present, and will afford relief. But this benefit will be transient, if new accu- mulations be not prevented, by severely restricting the patient to a very bland and unnutrilious 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 exci- tability 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. 39 302 TREATMENT OF CAULIFLOWER EXCRESCENT!:. 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 proper for a woman in this situation. Were we to direct upon such an occasion, we would confine the patient to black tea, thin coffee, and stale bread, for the meals of morning and evening; and ve- getables alone for dinner. These may consist of rice, the pota- to, 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, buttermilk, baked or roasted apples, thin vegetable jellies, as that of the tapioca, rice, or arrow root. Her drink should absolutely be water, barley water, molasses and water, toast water, or thin flaxseed tea. A recumbent posture must also be insisted on, or but little ad- vantage will be derived from the attempts made to reduce the force of the circulation. But it should be remembered, lhat 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 bow- els; 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 favoura- ble 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 parts of cremor tartar and the flour 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 mag- nesia and the flour of brimstone, is a very certain laxative. The solution of the sulphate of magnesia in small doses, taken before breakfast, is also very certain. At all events, costiveness muat be avoided. Should it, however, accidentally occur, it should be removed in the most gentle manner; or the strong efforts of the TREATMENT OF CAULIFLOWER EXCRESCENCE. 303 abdomen must be avoided. This vvill be best done by very mild injections, such as warm molasses and water, thin soap suds, making the quantity such as vvill ensure their operation, 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 lo 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:— £. Infus. lini, Jxv. Aluminis, !jij. Tinct. kino, §j.—M. Or, 8<. Cupri sulphat. grs. x. Aquae Flor. samb. Mist, camphors, gvj.—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 portion 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 wuhsitr,»cep.7be ,i8ht,y touched with a soft sponge welted As this complaint is sure, sooner or later, to be attended by great debility the woman should be supported by tonics when th.s occurs. The sulphuric and muriatic acids are recommended or this purpose with the infusion of orange peel, or of rose leaves, with great confidence, and, we believe, justly: at least, we think 304 TREATMENT OF CAULIFLOWER EXCRESC ENT F.. 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, Ihe 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 applica- tion in the one case than in the other; the cauliflower excre- scence 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. u After the removal of the disease, (tumour,) it is recommend- ed 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 external orifice blocked up with a dossil of lint, so as to prevent the too sodden 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:— *. Argenti nitrat. grs. xij. Aq. distillat. 3xij. *"• sol. Or, *. Cupri sulphat grs. xviij. Aqua ros*, 3XIJ- *"• 8°^" HYDATIDS OF THE UTERUS. 305 A piece of lint, wetted with either of these solutions, may be introduced, and placed against the diseased portion of the os ute- ri. " 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 maybe 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 prac- titioner, 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 organization, and functions.* Of their origin we know nothing; and almost as lit- • This disease has been long known to physicians; for it is said that JEtius has d.stinctly 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 ar- rangement; but which, from some morbid cause, have enlarged themselves. De- sormeaux, 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 animals, and to be the taenia hydatigena of Pallas, and declares, (6) that he has seen them move, when exposed to the action of salt and vinegar. While («) Nouvelle* Recherche*, sur l'orgjne, &c. (*) Diet, de Medecine, Art. CEaf. Vol. XV. 306 HYDATIDS OF THE UTERUS. lie 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 incipient pregnancy—after awhile the uterus enlarges, some- times more, and at other times less rapidily, and may be felt in the hypogastrium swelling of the mammae most generally, toge- ther with the formation of a fluid, which may be discharged by the nipples—and areolae as in true pregnancy—sometimes an al- ternate discharge from the vagina, of serum or blood; and the absence 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.* See note to page 307. It is not, however, ascertained that pregnancy is always ne- 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 -m- predated ovum. For she declares, that this vesicular cluster is covered by a membranous expansion, which is divisible into two lamina-one of which re- sembles the epichorion or decidua reflexa, while the other differs in noth.ng from the amnios. . _ ... * 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 pa- rietes 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 appear- ance like pus. The hydatids contained pure lymph." See Plate \ III. (e) Corvisart, Journ. de Medecine, XXII. 197. HYDATIDS OF THE UTERUS. 307 cessary for their production.* Indeed, in the only case we ever witnessed of this disease, it certaintly was not immediately so, if reliance can be placed upon the general good character of the pa- tient. 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 were swollen. Her friends suspected she was pregnant; and when she was attacked with periodical pains, they were certain their con- jectures were well founded: at this time we were sent for. Be- fore our arrival/however, the uterus had relieved itself, by ex- pelling nearly a chamber-potful of hydatids; at least so we sup- posed them to be; for they had been thrown out unfortunately before we came. 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 alarm- ing 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 recovered 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 (he 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 Madame 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 • Mdme. Boivin and some others, think that impregnation is essential to the production of the uterine hydatid. Ruysch thought, that a retained placenta would give rise to hydatids. 308 HYDATIDS OF THE UTERUS. would perhaps have been condemned by Madame Boivin, had the appeal been made to her. We therefore look upon the - hypothesis of this lady, if adopted in its full extent, to be highly dangerous, and must remain so, unless her opinion be unequivo- cally 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 lo 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 inconveniences of this complaint, arise, as in preg- nancy, from the pressure of the distended uterus upon the sur- rounding parts: hence, we sometimes have cramps of the lower extremities, cedemalous swellings of them, retention of urine, &c. as in a genuine pregnancy. I cannot find, in any memoranda of the case 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 ex- periments to determine their chemical resemblances, or discre- pancies. No remedy has hitherto been discovered for the relief of this complaint. The patient is not to be led to expect any great be- nefit 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 vvas 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 HYDATIDS OF THE UTERUS. 309 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 tilillation at the os uteri with the finger, stimulating injec- tions per anum, frictions'upon the hypogastrium, and the appli- cation of cold to the lower part of the trunk, lo be more effica- cious and safe. Injections into the uterus, of a stimulating kind, are useful, she says, when it does not contract, or if the hemor- rhage continues after it has contracted. But we are of opinion that the "ergot," as vvill be recommended presently, would su- persede 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 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 tbe adhering .portions of the hydatids, and bringing them out with the band It will be perceived, that this direction cannot be complied with in al 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. J c We would propose, and we think will, a fair prospect of sue ce*, the free use of ,he secale cor„u.„m i„ this complaint ,o procure the expulsion „f lhe hydalids; especia„ .„ ^ ' ° wot, d not easlly ad ., (he han(); ^ where J ase as the uterus were too feeble, or insufficient to their extrusion So far as analogy, ami reasoning upon a subject, will justifv Che empboyment of a novel remedy, we have then, on oi *£. 40 ' 310 HYDATIDS OF THE UTERUS. for it is certain that the union of hydatids with the uterus is not more strict than the ordinary connexion of the placenta with lhat 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 vvas 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- rhagy, and obviating the excessive weakness of the stomach. But, notwithstanding, the symptoms continued to increase in violence, so much so as to endanger the life of the patient. She had become very much exhausted by the repeated loss of blood, and inability 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 satisfactory 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, judg- ing from analogy that it would prove decidedly effectual in pro- ducing an expulsion of the heterogeneous mass. The event proved that he was not mistaken in his conjecture; for he had civen the ergot but a very few minutes, when it began to show its specific operation upon the uterus, and succeeded in a complete evacua- tion 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 "Diseases of Women," is admirable. The floodings immediately ceased, and did not re- HYDATIDS OF THE UTERUS. 311 turn. The woman rapidly recovered, until at length she has at- tained her former health and vigour, and I believe she 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 vvas 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 consider 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 Madme. 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, was close, and no discharge from thence. The pains persisted, without any alteration in the cervix or os uteri. This state continued three days more, when it was perceived that at each bearing-down pain, there was some dis- charge of clear water. This was followed, some days afterwards by a large number of hydatids, of various sizes, from an inch in diameter downwards. She continued to pass these bodies for nf teen days. In the mean time the size of the uterus rapidly in- creased, and rose out of the pelvis. It was now ascertained that there was a fcetus in utero, and yet the hydatids were discharged daily in considerable quantities.* Three or four months after his 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 • Does this case seem to prove, that hydatids do not depend upon a diseawd ovum, as suggested by Madame Boivin! "»«wea 312 HYDATIDS OF THE UTERUS. patient recovered, and did well. She has since become preg- nant." We will give another case of this rare and interesting affection; as all lhat we can learn of a disease so uncommon and so impor- tant, will fall short, perhaps, of being sufficient to establish its diagnosis and best mode of treatment. In the case following, we are disposed to believe, that had "ergot" been duly admi- nistered, it would have been more prompt in its action, and less equivocal in its safety, than the one pursued—it, however, ter- minated 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 incessant vo- miting, the abdomen increased rapidly in size, and became tender to the touch, the legs also became cedematous 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 be- came 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 ensued, which vvas at first checked by cold applications, but soon afterwards re- turned more violently. At the same time a large mass of hyda- tids, as big as two fists, was discharged. The accoucheur, 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 vvas a hand's breadth above the navel, and the tu- mour formed by the womb was regular, not elongated or lying lo one side as is usually the case in Ibis disease. The os uteri was dilated to the size of a half dollar, and vvas very tender to Ihe touch. Masses of hydatids projected from il into the vagina; and there vvas constant hemorrhage. The treatment adopted in these circumstances consisted in the administration 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 labour-pains, which had al- most ceased, were speedily renewed, and rapidly increased in strength; masses of hydatids were, at the same time, discharged; and, ere long, the hemorrhage abated 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 IRRITABLE UTERUS. 313 descended still lower; the hemorrhage ceased; a warm perspira- tion 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 re- mains of a membrana decidua." Sect. X.—Of Irritable Utents. 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 lit- tle beyond it; rarely showing itself before the five and twentieth year, and, perhaps, still less frequently after the menstrual pe- riods have passed. Dr. Gooch,* who has devoted an excellent chapter to this subject, and was, as far as we know, the first au- thor who treated of it, defines this disease to be "a painful and tender state of the uterus, neither attended by, nor tending to produce change in its structure." The latter part of this defi- nition 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 General Symptoms.—The general symptoms are, an increased frequency, and a preternatural firmness of pulse.t This frequency is commonly augmented towards evening; the skin then becomes warmer, and the cheeks are reddened by a slight hectic blush. But tbe 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 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 and becomes cleaner- more or less thirst attends, particularly in the after part of the day. The natural perceptions of the tongue are frequently per- • In his work entitled " An Account of some of the most important Diseases peculiar to Women, by Robert Gooch, M. D." ■f Dr. Gooch says, "The pulse is soft, and not much quicker than natural, but is easily quickened by the slightest emotion," p. 313. 314 IRRITABLE UTERl'ST verted; so much so sometimes, as to lead the patient to the be- lief 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 resembles 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 frequency. - 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 appetile is impaired or very capricious, and eventually dyspepsia becomes established. The bowels are either too much confined, or are urged to diarrhoea; and if an 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 deposile—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 with some difficulty, and even pain is felt along the course of the ure- thra. Occasionally, the urine is suppressed or retained, for many hours together, and is then voided with considerable suffering. Local Symptoms.—Sometimes the patient represents the parts 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. More or less leucorrhcea pretty certainly attends; the colour of which varies almost in proportion to the degree of suffering; when IRRITABLE UTERUS. 315 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, offensive. The uterus is almost always lower in the vagina than natural, and sometimes, indeed not unfrequently, it is found prolapsed.* 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.t The neck is almost always a little shortened, enlarged, and exquisitely sensible to the touch, and the os tincae is rather more closed than natural. The pain vvhjch attends this com- plaint is always increased by an erect position, and it as certain- ly abates by a recumbent one. Pain is usually felt immediately behind the mons veneris and brim of the pelvis, especially its anterior portion. :.-;.» The sensibility of the neck of the uterus is aUu-mes 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 particular- ly if upon a hard resisting 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,J or Dr. ' Addison,§ or M. Genest:|| Ihis is a pulsating, throbbing, or flut- tering sensation within the vagina or pelvic cavity. So far, we * 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. f Dr. Gooch says, "The ringer can be introduced into the vagina, and be pressed against its sides, without producing uneasiness," p. 312. t Opera Citata. § " Observations upon the Diseases of Females." || Recherches sur l'Hysterialgie ou Neuralgie Uterine, et son Traitement. Gt- zette Med. de Paris, Sept. 1830. 316 IRRITABLE UTERIS. 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 always: this sensation, however, is not constant; it often suffers abate- ment, 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 " irrita- ble uterus," have added many symptoms that do not belong to this affection when simple and uncomplicated. To be convinced of this, it will only be necessary to compare the symptoms we have detailed above, with those enumerated by these gentlemen. Dr. A. lays down the^jfpUpwing marks, as belonging to, or pro- duced by, " uterine ijra^rtion." He declares the most frequent symptoms of this condition to be— " Irregular mflbK^^lion, the discharge being preceded or ac- companied by&ljfij^ljlhe back, loins, thighs, or in the region of the uterus itse^&Sftfended with forcing or bearing down; the dis- charge being flrTfexcess, either in point of mere quantity, in con- tinuance, or inrecurrence; 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, last- ly, leucorrhcea. The most frequent symptoms, however, are, un questionably, painful menstruation and leucorrhceal discharge. Such are the few, plain, simple indications of a state of uterus which is repeatedly overlooked, though productive of the most serious disturbance, both of the general health, and of particular organs; disturbance which, when once produced, stamps a cha- racter upon the general and local ailments of the sufferer, strong- Ik ly indicative, to the experienced man, of uterine irritation; a cha- racter which confirms us in the belief lhat it is from such irrita- tion that the evil originates, and that it is to correct the condition of the uterine system lhat 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 oHmportant 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. IRRITABLE UTERUS. 317 Second. He makes the causes of " uterine irritation " consist in " irregular menstruation ;"* wjiereas, we are of opinion that the aberrations of the menstru'«H di&harge, if there be any, are owing to the inflamed or irritable condition of the neck of the uterus. Third. The initial sympj&mf 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 virtualh^fhe same as those to which the inflamed spine gives rise, and vyTfcch 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 Ihe right hypochondrium; in the situation of the left or right co- Jc^l^^^tepain generally over the whole belly, or in the re- giono'tt^.bbidder or kidncys-^always be upon your guard; and i£ up^nwq'uiry, you find few or many of the constitutional symp- tvfcwfel-'Save described, together with uterine irritation, as show by pain" ~\n the pelvis, in the loins, or in the thighs, before or during the flow of the catamenia; by too frequent or too profuse menstruation; or by leucorrhceal discharge: I say, when you find such an assemblage of symptoms and circumstances, your sus- picions will amount to a high degree of probability that the com- plaint 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 " irriteble uterus" may exist in its * He says that " menstruation continues as usual, or perhaps a little more abun- dant; but, generally, it is less, and sometimes suppressed." From this we should be led to conclude that dysmenorrhoea, or even irregularity, in his estimation, are the causes of this complaint. We are every way certain that we have seen the " irritable uterus " unaccompanied by dysmenorrhoea; 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 " ir- ritable uterus " in many instances, while, in many others, they are unattended by . jthem. 41 31S IRRITABLE UTERIS. 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 thtffescending and descending colon; pain affecting the whole abdomen; pain in the region of tbe stomach; and, lastly, pain in the region of the kidneys; sometimes extending down the course of the ureters to the bladder, p. 22. Now, in our opinion, the first five of these symptoms do not belong to the pure, or idiopathic, " irritable uterus." First, because we have known them to be absent in several instances of exquisitely formed "ir- ritable uterus;" 2dly, because they are constantly present in hys- teria, 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 enumerated 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.* 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 ab- , sence, at least, as far as we have observed, of the general, or 2 * 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 dis- ease are present, even to the prolapsed state of the uterus. This is a case of great interest, as it occurs in a young person, who, in other respects, enjoys a fair proportion 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 scrofulous 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 sur- faces in other pails of the body. IRRITABLE UTERUS. 319 what we have termed the constitutional symptoms, especially the evening febrile movement. 2d. There is seldom, (nor is there ever, necessarily,) 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 va- gina. 4th. Nor is the uterus so sensible to the touch, unless it be examined during the painful continuance of the paroxysm, and then, perhaps, 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 constantly observe periodicity, but which the " irritable uterus" is free from. 5th. In neuralgia, a paroxysm may be suddenly induced by passions or emotions of the mind, which is never the case in the " irritable uterus," though the latter is sus- ceptible of great, and occasional augmentation of pain, through the medium of the circulation, by errors in diet, or improper ex- posure. 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 sup- posed to be the cause of all the inconveniences experienced; and hence, the frequent failures of the pessary when it has been ap- plied for the relief of the prolapsus. Nay, sometimes serious and permanent injury has been done by this instrument in these cases, without 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, suggest the observance of the following precautions, when an examination 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 immediate- ly above the neck, and the sides of the vagina—inquire if there be 330 IRRITABLE UTERUS. 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 he introduced, until this has been abated by suitable means. In this case the patient will be labouring under "irritable uleru^," and not a simple pro- lapsus. Besides, in the "irritable uterus," the prolapsus 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 throvy 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 tincze 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 al- I most entire filling up of the vagina, by tbe increased size of the uterus. ■ m The " irritable uterus" has also been confounded with dysme- | norrhcea, but from this functional derangement of the uterus it is [j easily distinguished. First. In dysmenorrhoea pain is only felt t during the menstrual action; whereas, in the other, the suffering is more or less constant, though subject to occasional aggravation, t and this of a severe kind, at other than the catamenial periods. Secondly. The "irritable uterus" is not necessarily attended fyr , ' dysmenorrhoea, nor is dysmenorrhoea usually attended by thit-VVf irritable condition of the uterus; for we have seen very marry in- Utfi? stances to the contrary. Pathology.—We have already declared our belief that this J disease consists in a chronic,or sub-acute inflammation of perhaps J all the tissues, that compose the neck of the uterus. The patho- 1 logical condition of the womb, in this complaint, has, however, never been ascertained, by a 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 oppor- tunity present—as we are of opinion, lhat 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 IRRITABLE UTERUS. 331 with several cases in which the size and form of the neck of the uterus vvas 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 slight- ly swollen/ldjp. 312,) though he denies a change in its structure. M.N Genest dechjres the same thing,- indeed, the latter seems but to have copied J)r. 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 disposed 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 impreg- nation 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 chronic inflammation. He says 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 indefi- nite period, in some instances, without any very manifest derange- ment of a part; and lhat there is some derangement in the " ir- ritable uterus," we are, from many observations, very certain__ besides, there are present in this affection all the common cha- racters of inflammation—as heat, swelling, and pain; but whe- ther there be unusual redness also, we are not prepared to deter- mine. 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. 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 exami- nation of the part leaves pain for hours; it is always in pain; but ^ this is greatly increased every month, immediately before the men- (ujt rstrual period. Although apprehensions are entertained of cancer, ^: pulsion. CHAPTER XVII. HYSTER1TIS, 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 frequent- ly blended with the former: this has arisen almost entirely from not allowing that puerperal fever is an inflammation of some one portion, or the whole of the peritoneum; and in not think- ing 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 • 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. 362 INFLAMMATION OF THE UTERUS. call Ihe simple or pure; the second, the mixed or accidental in. flammatipn of tbe 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 perito- neal covering. The second where the latter is implicated with the former. It has been rendered highly probable, from the late observations of Mr. Dance, and M. Tonnelle, that in hysteritis, it is the veins of ihe uterus that are inflamed, and constituting a genuine phlebitjs. Dr. Conquest says, " the substance of the ute- rus 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 vvill be supposed abscesses of the proper tissue ex- ist, when the vessels only are affected. Sect. I.—Species 1.—Causes. The causes which may produce inflammation of ihe uterus, are all, or any of the violences to which this organ may be exposed in the exercise of its functional powers, during the expulsion of the child ; from those to which extrinsic aid may give rise, when its powers have been insufficient for the purposes of delivery; 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 si- tuation 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 placenta; or to the injuries it may sustain from a placenta that has been too adherent. INFLAMMATION OF THE UTERUS. 363 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 lo produce inflammation of the uterus, we find that it generally betrays itself wilhin 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 occasionally 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 the 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 wit- nessed in peritoneal 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 dis- 364 INFLAMMATION OF THE UTERUS. charges with it be not mistaken for the tone of colour of the urine itself. 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,* if the febrile irritation be not soon relieved. The tongue is white, much loaded, and Dr. Clarke says, dry; but this we have never witnessed at the beginning of Ihe disease. It is true, there is less moisture than is usual in the mouth, and the little fluid there is, is more clammy than is common 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 nol very great; rarely a hundred.! 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 be- ginning 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 * It may be looked upon as almost a character of hysteritis, that delirium almost always attends it; while in the unmixed puerperal fever, of peritoneal inflammation, it rarely occurs. f This is another peculiarity in hysteritis, as distinguished from peritonitis, and serves to show how much inflammation of particular structures influences die circulating 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. 365 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 vessels, or rather on the degree of contraction of the uterus. Conse- quently, their being more or less abundantj must depend upon the state of the vessels which furnish them ; and the state of these 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 withdrawn, and the quantity discharged will consequently be less. It must, therefore, follow, that the diminished lochia is but a consequence of this condition of the uterus, and not the cause of it. It would be as rational to say, because there is a sparing secre tion 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 prevents the consequences that would most probably followr its over-exertions, as well as promotes the tonic contraction of this organ. But, as their existence altogether depends upon the de- gree 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 ves- sels of the uterus may influence the lochia, but the lochia cannot affect the vessels of the uterus; for they are not lochia until dis- charged from these vessels. The return of the lochia, after they have been arrested, how- ever, is justly considered as a favourable sign; and this circum- 47 366 INFLAMMATION OF THE UTERUS. stance has been urged, as 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 extremeties of the uterine vessels; and this lessened re- sistance is owing to the abatement of the swelling which had in- terrupted its flow; and the reduction of the swelling is but a con- sequence 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 dimi- nution, 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- mation,) vvas 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 mammae sympathize with the uterus much less than in periloneal inflammation, or puerperal fever; for we must be permitted to use them synonymously. (See Chap- ter on Puerperal Fever.) On this account, we never have an en- tire suppression of this secretion, as in puerperal fever, unless the disease runs an unusually long course, or has peritoneal in- flammation added, or combined with it. Indeed, in a number of cases we have seen the offices of the breasts remain undisturbed during the whole continuance of the disease. This circumstance is worthy of notice; since it not only scrtw as a distinguishing mark between the two species of hysteriji^* but also proves to us that the influence of the peritoneum, or 'r some one portion of the genital system, has a stronger influence ^/ over the formation of milk, than the uterus proper itself. Is thi*r the peritoneal coat of the uterus? or is it only when the ovarfa become involved, that this secretion is so decidedly interrupted, or suspended? We believe it to be the latter. Does not this fact serve to account for certain discrepancies in the accounts we have of the inflammation of the womb, and of puerperal fever? In one instance, the disease is called hysteritia, INFLAMMATION OF THE UTERUS. 367 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 ihe uterus, as we shall say more particularly, presently. In the second 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 being 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 other morbid affec- tion;" state of milk not mentioned. In this case, " the omentum was melted dowrr." In case VIII., "the omentum was much in- flamed; but the greater part of it vvas destroyed by suppuration." " 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 de- fective, neither vvas there a want of milk till after the febrile at- tack." Case XI., the omentum was suppurated, and converted into thick matter." " The substance of the uterus was sound." " The secretion of milk vvas 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 natural appearance, and was per- fectly sound." The stale 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 abdomen, 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 368 INFLAMMATION OF THE UTERUS. 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 most serious mischief; especially as this takes place while the uterus is labouring under inflamma- tion, as we have had occasion more than once to see; the suffer- ings then are very severe and even menacing. Under such cir- cumstances, we have known the uterus to acquire a size nearly equal to lhat 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; forjiovv 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 charac- ter 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 thai intensity of suffering, which she expe- riences from the same effort in peritonitis. The bowels are variously affected; but, in the beginning, as 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 a9 constituting the first stage of this disease; or the stage of high inflammatory action, which may terminate either in resolution, or in suppuration. When the disease is about lo yield, there is an alleviation of all the more distressing symptoms; there is a softening, or reduc- tion of the uterine tumour, with an abatement of its tenderness; the pulse loses its febrile and inflammatory character; it is less frequent; softer, and more yielding; the skin becomes relaxed, and disposed to become moist. Headach abates, and delirium, INFLAMMATION OF THE UTERUS. 36.9 if it had been present, subsides; the tongue begins to clean, and the thirst diminishes; the lochia return, and their appearance changes to a more florid colour. The urine becomes more abun- dant, and less high-coloured; the milk is more freely secreted, &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 in suppurations in various parts of the pro- per substance of the uterus, and which are almost sure to be followed by death. Sometimes, however, there is reason to be- lieve, that the abscess opens within the cavity of the uterus, and escapes through the os uteri; in which case, the woman may re- cover. We have seen two or three instances, in which we be- lieve 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 Puerperal Fever. When the peritoneum, covering either the uterus, or its ap- pendages, becomes the seat of inflammation, the disease is called by Dr. Clarke, a mixed case; and is one of almost certain fata- lity. For we have an inflammation now besieging two very dif- ferent tissues or structures, and its effects upon either may be 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 370 INFLAMMATION OF THE UTERUS. symptoms, to the unpleasant ones belonging lo 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; di- arrhoea, &c. When the disease, by its extension, becomes the second spe- cies of hysteritis, it may be considered as almost necessarily fa- tal: at least, we recollect no instance of recovery. Nor is this surprising; since a highly dangerous complaint makes its appear- ance at a time the system is debilitated from the force of a pre- vious disease, and the effect of remedies; and is from these causes unable to support the farther use of means for its relief. The pa- tient, therefore, almost necessarily dies. Dr. Clarke has furnished us with the appearances 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 se- creted fluids in the cavity of the abdomen, when the disease has existed simply. The peritoneal surfaces have been also disco- vered free from disease in some cases; in others, however, Ihe 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 bloo.d. The ovaria, too, are often affected in the same way. "The uterus vvill commonly be found very firm in its sub- stance, but larger than when naturally contracted. Upon cutting into the substance of the uterus, pus is often found, which, in ail the cases I have met with, is situated in the large veins of lhat part* Pus is also sometimes found in the cavity of the Fallo- pian tubes, and also in the substance of the ovaria, which are dis- tended by inflammation and matter, so as to equal in bulk, in some cases, a pigeon's egg. " 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 ap- * In these cases, it is more than probable that the disease was a genuine phle- bitis of the uterine veins. INFLAMMATION OF THB UTERUS. 371 pearance of the cervix; but it is to be remarked, that instru- ments hao* 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 lo the full extent the system will well bear; or it will not, nor 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 as 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, lo be, " of all the serious complaints, which attack the woman in the puerperal state, the least fatal," he*js not to be understood to mean, that this is the tase when-this complaint is not boldly treated. For immediately after, he says,'*" Every art which has a tendency in any manner to dimmish 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 372 INFLAMMATION OF THE UTERUS. blood-letting, our plan has generally been as follows: lo bleed from the arm, until it produces sickness of stomach, at least; if syncope take place, we have no objection. It vvill almost always be found, after this, that the fever and other signs of inflamma- tion will be much diminished; but this, in many cases, vvill be of short duration : for the system, if the bleeding has not been suffi- cient to " strangle" the disease, vvill react in the course of a few hours, and pain, fever, &c, vvill again be renewed. Whenever this takes place, be the period longer or shorter, it is to be repeat- ed 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 lo 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 ab- stractions of 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 perito- neal inflammation. Perhaps there is scarcely a disease which demands such exten- sive 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 ecb- ^ nomy of this organ, it becomes very readily filled with blood, but parts with it, unless under particular circumstances, as in he- morrhagies from this part, with great difficulty, or at least very slowly, as is proved by its bulk several days after delivery; con- sequently, large quantities may be taken from the general sys- tem, without greatly influencing the quantity contained in the substance of the uterus. Thirdly, owing to the lax and distensible condition of the ute- INFLAMMATION OF THE UTERUS. 373 rine vessels, they are readily re-stretched by any influx of blood; and, consequently, they again become charged by a fresh quan- tity of it, which now becomes another cause of irritation (by distention,) to the newly provoked inflammation; and thus in- viting a greater flux of blood to this part. Fourthly, that when the uterus becomes thus refilled, the vessels cannot be relieved from this engorgement, as the only agent by which their capacities can be diminished, and, of course, this state relieved, is now suspended, (namely, the tonic contraction of this organ:) hence the enlargement of this viscus in this disease ; and hence it is a favourable symptom, when it diminishes in size, as it shows a return of the tonic contraction, and, consequently, 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. b. Of Purging. To co-operate with bleeding, purging has been advised ; this, to say the least, is a doubtful remedy. Dr. Clarke says, " neither can I recommend a course of purging, as serviceable in the in- flammation of the uterus, which follows delivery. It is always, I believe, right, in the first instance, to procure two or three stools; but afterwards, it will be enough to preserve the regular motions of the bowels, by giving, from time to time, small quantities of castor oil, or a little rhubarb, mixed with other medicines, which may be proper. The objection which I have found to long-con- tinued purging is, it has always the effect of preventing that gentle perspiration, which, if it can be produced and kept up, will do more towards curing the disease than any remedy which I know," p. 75. The bowels should be kept open by the gentlest means: of these the clyster is the best remedy. This should be done daily at least. 48 374 INFLAMMATION OF THE UTERUS. c. Of Fomentations. Dr. Clarke recommends fomentations to the abdomen: we never advise them, for we have never seen them of the slightest use in hysteritis, and we have known them do mischief. They do mischief by the intensity of their heat; by their weight; by exposing the woman to chills; and by keeping her constantly wet. They are particularly inadmissible in the early stage of this disease, as they increase the circulation by their warmth. In such cases of hysteritis as may be accompanied by after- pains arising from coagula within the uterus, which is known,as we have said, by its alternate movements, we have seen an appli- cation of dry, or merely moist substances, very useful; by pro- moting the contractions of the uterus so as to expel these foreign bodies. The one we have most commonly used is the "tansy pancake." This is made by mixing flour and water together to the consistence of a batter, and adding to it a quantity of tansy; and then to be fried like a pan-cake; but made much thicker; (say half an inch,) when done, it is to be placed between two cloths, and is applied to the abdomen. Under the circumstances, for which we recommend this application, it will, we think, be found highly useful; at least it has proved repeatedly so with us. It certainly combines all the good properties of the fomentation, without its disadvantages; but let it be clearly understood, its employment is confined to the cases above stated ;namely, where the uterus, distended with coagula, produces much pain, and the ordinary efforts of this organ are found insufficient to expel them. The French are fond of fomentations, but we think too much good is ascribed to them. 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 lo decide; their efficacy, if they possess any, is unquestion- ably 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 INFLAMMATION OF THE UTERUS. 375 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 ven- ture to recommend them. They are too perturbating. e. Of Sudorifics. 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 watch- fulness and a dry skin. We think we have seen the occasional use of Dover's powder, given at bed-time in ten-grain doses, use- ful. But our rule is, never to rely upon them, to the exclusion 0 of evacuants. f. Of Opium. In the commencement of the disease, the pain which some- times attends hysteritis, has led to the free use of opium; but it is always unfortunate for the patient; for it never subdues the pain, and it is sure to augment the existing evils by its stimulus, and by its constipating effects upon the bowels. It is, therefore, clear, it is not proper in the beginning of the disease; nor is it much more eligible in its decline, as it may interrupt the dis- charges from the bowels, at a time they may be much needed. In combination, as in Dover's powder, it may be now and then useful; but we think no decided advantage is gained by its use, unless it be to relieve some sudden symptom, as severe and unex- pected pain in the bowels, from flatulency, or other causes, when the fever is pretty well under command; to moderate unnecessa- rily severe purging, or hypercatharsis, or to give temporary com- fort to an exhausted or irrecoverable patient. Indeed, if deple- tion has been ample, there is very little use in the opium.* • Dr. Clarke is much in favour of opium in this disease; this, perhaps, arises from his not carrying bleeding and purging as far as we are in the habit of doing; 376 PUERPERAL FEVER. g. Of Emetics. Emetics have been thought highly useful in almost every complaint of the puerperal woman. From their reputed efficacy in peritoneal inflammation, as recommended by Mr. Doulcet, they have been thought useful in inflammation of the uterus, and, accordingly, have been recommended in such cases. Our expe- rience exactly coincides with that of Dr. Clarke on this point, that they " constantly add to the pain, by the agitation they oc- casion, and the pressure made by the muscles on the inflamed uterus," p. 77. From all, then, lhat has been said upon the various remedies proposed for the relief of this disease, it will appear that our dependence is chiefly upon bleeding and purging. The treatment for the second species, or the mixed inflammation of the uterus, will be learnt under the head of Puerperal Fever. CHAPTER XVIII. OF PUERPERAL FEVER. This term, by some, is now looked upon as generic; and should, therefore, be employed with more severe restrictions than it for- merly was. Dr. Conquest says, that " in reality it designates only a prominent symptom of disease, but which, in ordinary usage, embraces complaints having little or no resemblance or connexion, either in their essential nature, their seat, or their treatment. For I fearlessly appeal to every cautious, intelligent, and reflecting man, whether the term is not, in daily use, equally to designate spasmodic and inflammatory affections of the peri- toneal investments of the uterus, and abdominal viscera; inflam- mation of the muscular fibres; inflammation of the veins of the the consequence is, that pain is much more permanent, in cases which have not been freely bled, and may require, for temporary purposes, the aid of laudanum. Its indiscriminate use, however, cannot be too severely condemned, in diseases of high action. PUERPERAL FEVER. 277 uterus; phrenitis; irritative fever; diarrhoea; and spasms of the in- testinal canal, so frequently confounded with inflammation."*— Observations on Puerperal Fever. If this statement be true, and we have no doubts but it is from the respectability of the authority, the term puerperal fever is used in Great Britain much more vaguely than in this country. And though our notions respecting this disease are not logically accurate, they are, nevertheless, more definite than they appear to be in England, agreeably to Dr. Conquest. For we do not be- lieve, that any well-instructed practitioner here would agree to call all the affections enumerated above, by the sweeping term, "Puerperal Fever." We have observed already, in treating of the inflamed womb, that much confusion existed; as both hyss teritis and peritonitis were expressed by the same term; though very different tissues were implicated in the two diseases: yet, with this admission, we are by no means prepared to say at this moment, that much practical mischief has arisen from this wrong location of the inflammation, as both, caeteris paribus, require very much the same treatment, though we profess to be warm sticklers for correct pathology. We will, therefore, at once de- clare, that by puerperal fever we understand,- inflammation of some one portion or other of the peritoneum, which attacks wo- men almost immediately, or within a few days after their deli- very; and is distinguished from every other affection of Ihe fe- brile kind, by being always attended by a more highly accele- rated 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, lo be its pathognomonic symptoms. And, perhaps, in no disease of the febrile kind, can 90 many pe- culiarities be enumerated, as almost constantly present themselves in this; such as the highly accelerated pulse; the failure in the m * 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 this writer, as it will embrace all the febrile affections to which the woman may be liable after delivery, however varied their seat or nature. 37^ PUERPERAL FEVER. 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 deli- rium ; 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 arc more fatal than this: as far as I have observed, three-fourths of those who have been seized, have fallen sacrifices to its severity." Es- says, 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, or 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, lhat 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 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 ramollisse- ment 20; inflammation of the ovaries 58; with ulcers 14;—to- tal 190. Alterations in the uterine veins and lymphatics—pus was found in 90 instances in the veins; in 32 it was found in the lym- phatics; and in 3, it was observed in the thoracic duct; with in- PUERPERAL FEVER. J ' J flammation and suppuration of the inguinal and lumbar glands, in 9 instances, making 134;—total changes effected in the ute- rus, 324. Suppuration of the veins of the uterus, 32; with ramollisse- ment or putrescency, 11 ; wilh metritis and ramollisement, 5; wilh 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: wilh ramollissement of the uterus with sup- puration, 6; with simple peritonitis, 3; without any other altera- tion, 2;—in all 44. Inflammation of the ovaries with simple peritonitis, 29; with alterations of tbe uterus, 27; with simple metritis, 8; without any other alteration, 2;—in all, 62.* 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 vvas 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 autopsic examination, we are 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 • It is proper to remark, lest this table should appear to contradict itself, that the reason of the whole amount of the two classes of affections, exceeds in number all the cases dissected, is, that in many cases peritonitis was complicated with metritis. 380 PUERPERAL FEVER. is, to all intents and purposes, peritonitis, and not metritis. But be this as it may, the observations of M. TonnelI6 arc no lc.«*s 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,* 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, " Il will always be found most fatal, when most epidemical, that is, during the distempe- rature 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 slate, (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 wilh us, a lia- bility. • 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. 381 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 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 contrast- ed 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, twen- ty miles south of Leeds, where it was prevalent and fatal. It began there early in the year 1808, nearly two years before it became 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 vvas 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 farther 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 Bri- tain. See Dr. Gordon,* Dr. Joseph Clarke,f Dr. John Clarke, &c4 • See Dr. Gordon's account of the puerperal fever, when it appeared as an epi- demic in Aberdeen, in Scotland. f See Dr. Joseph Clarke's account, as it appeared in Dublin in 1760. Dun- can's Medical Comment for 1790. It again appeared in Dublin in 1767. * 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 1761. Treatise on manage- 4.9 382 PUERPERAL FEVER. 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, culled the " weed," are frequently met with; for here, as well as elsewhere, improprieties during the first few days of confinement will be committed, and the pa- tient be subjected, in consequence, to the fevers just mentioned.* 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 lying-in 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. b. Of the Predisposing Causes. Much diversity of opinion exists as to the remote or predis- posing causes of puerperal fever; especially when il may appear as an epidemic. Cold, moisture, labour, itself, &c, have been assigned; but it seems that nothing satisfactory has yet been as- certained upon these points. For M. Tonnellef has pretty satis- factorily ascertained, that neither cold nor moisture can be looked upon as causes. For, when thi3 disease raged in " la Materni- tie," the hospital to which he was attached, as the pupil of the late M. Desormeaux, neither of these powers could have ope- ment of lying-in women, p. 165. Dr. Leake's account for 1770, as it appeared in the 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. * 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. f Des Fievres Puerpferales Observfces a la Maternitie de Paris. PUERPERAL FEVER. JO° rated. As regards cold, it was observed, that though the disease was very common in January, which vvas 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 ap- peared 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 drought vvas very unusual in degree and in duration. In a word, the disease prevailed in its greatest extent during cold dry weather; in temperate weather, as well as during moist tempe- rate weather—while, at other periods of the year, when similar weather prevailed, the disease was neither more frequent nor more severe. Neither could the frequency or severity of the disease 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 Ihe 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.* Besides, the male is unquestionably lia- ble to peritoneal inflammation as well as the female; and when it occurs in them, the same general phenomena present them- * 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 retained her senses; the abdomen was much swollen, and ex- tremely distended—she died six hours after. I am of opinion that this was an instance of inflammation of the peritoneum preceding delivery. 384 PUERPERAL IE VER. selves. Thus, Dr. Armstrong, p. 2, assures us, " it docs 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 at- tack, 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- 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. Moreover, 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,* or the bladder, may predispose to, if it does not • 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. 385 actually produce the disease; and I believe it is often an occa- sional 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 pow- erfully, 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 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 foundation for the opinion just named above; so far at least, as certain medi- cal treatment comprises that peculiar care bestowed upon women who have had laborious labours, alluded to by Dr. Denman; for 386 PUERPERAL FEVER. 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 phy- sician, and a most important discovery to the afflicted, or those liable to be afflicted; since a sure prophylactic vvas at hand, or a remedy in waiting, which vvas 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 accouchment, it was my practice to give a purgative on the clay succeeding the delivery; which, if it did not prevent the disease, afforded some advan- tage 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. • Nor does it appear from the history of his cases, that those who got well were indebted lo the anticipating purgative alone, as blood-letting and farther purging were con- stantly had recourse to. From all we can learn from the testimony of Dr. Gordon him- self, and from Mr. Hey, who followed his practice, it does not appear, lhat 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.t Indeed, it would be extremely difficult to ascertain when it did prevent the onset of this disease; for the fact amounts but to this • Indeed, Mr. Hey informs us, immediately after, p. 155, that "some of the worst cases in his practice, occurred after an excessive operation of the purga- tive." f Mr. Hunter long since taught us, that we may cure a disease, but that we can- not destroy a predisposition. Even the anticipating purging cannot always be proper, if carried to any considerable extent. We see this illustrated in the prac- tice 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. PUERPERAL FEVER. 387 negative; that some of the women who look it, escaped the dis- ease ; but this is no proof that the calomel and jalap prevented it; for it is not fair to presume, that every newly delivered wo- man would have had puerperal fever. Besides, were 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 lo the practice of both Dr. Gordon and Mr. Hey, every newly delivered woman vvas treated alike, as regards the exhibition of the purgative; yet, those who had easy labours were more certainly liable to puer- peral 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 Ihe proper substance of the ute- rus, and of the vagina, which follow almost necessari'ty- 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, lhat "not one instance has been ob- served, of any woman, who had an abscess in the breast, bein°- 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?"* Denman. Introd. Francis's Ed. p. 574. * 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 predisposition to the disease, and would have escaped the fever, without the abscess; 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 free- dom 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 considered as having any agency in procuring the ex- emption. 388 PUERPERAL FEVER. But notwithstanding the powers of a mercurial purgative have been in our opinion rather overrated, it is every way certain lhat 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 Seal 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 inflam- mation ; nay, even the pleura and lungs have been found inflamed; and we have shown by the tables of M. Tonnelld, that the whole of the uterine system may be involved, even to the very vessels of these parts themselves, as the veins, lymphatics, &c. 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 cavity of the abdomen, in the few days the peritoneal inflammation had lasted, during the usual species of child-bed fever." On the ab- sorbents, p. 116. 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. PUERPERAL FEVER. 389 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; rupture of the uterus, if the woman should not die loo soon, is always, we believe, accom- panied 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 periloneum 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- 50 390 PUERPERAL FEVER 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 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 deposition; 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 in- flammation; 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 theresolution of inflammation, 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 ihe inflammation of a portion of the peri- toneum could excite portions to effusion which are not inflamed, it would of course be admitting, that effusion can take place with- out 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 expe- rienced in some one portion of the abdominal cavity, before the fever is welj 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 thafthe lochia did not flow as usual." PUERPERAL FEVER. 391 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.* 4. Because, whatever excites inflammation in the peritoneum, by local irritation as tapping, sometimes; rupture of the uterus; inflammation oflhe proper substance of theuterus,when it involves this membrane, &c, but not until then; extraneous substances passing from the stomach and bowels into the cavity of the abdo- men; punctures or wounds in this cavity, give the same pheno- mena; proving beyond doubt that when this membrane is indis- putably the seat of inflammation, the system at large sympathizes in the same manner as in puerperal fever. From these facts, and others developed by dissection, wc have no hesitation to declare, lhat 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.t Dr. Clarke says, p. 135, lhat * We may include, with much propriety, under the head of delivery, those instances 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. 228. Mr. Hey also informs us, that he met with two cases of puerperal fever after abortion, p. 27. See note to page 383. f 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 inflam- mations: for the pain goes off suddenly, and even the soreness sometimes, but the tumefaction continues; the pulse becomes more frequent; the strength is more de- pressed, 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 por- tion was destroyed by suppuration. Case IX. The greater part of the omentum was suppurated; the remaining portion much inflamed, &c. Case XHl. 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 pre- 392 PUERPERAL FEVER. "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 comingfrom so ve- racious and candid a man as Dr. Clarke; and completely esta- blishes Bichat'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 disease. Il 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. "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 Ihere was nei- ther mortification nor gangrene discoverable in any portion of tbe cavity of the abdomen. Yet, the phlegmonous, the erythematous, and erysipelatous inflammations, when violent, will each termi- nate 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 com- paring the symptoms he details as belonging to each, as well as the post mortem appearances, making allowances for seasons, loca- tions, epidemic consitution of the air, and, consequently, the type which these will impose upon certain parts of the character of the disease.* vious inflammation, 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 sto- mach was considerably inflamed. • Dr. Clarke says, " It is very well known, that during the strong exertions of Ubour, every woman suflers a kind of temporary fever; or, in other words, PUERPERAL FEVER. 393 In both of the diseases which he describes, (Essays, sect. III. p. 81, and Sect. VI. p. 102,) the peritonetic 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 began to be formed, it is immediately suspended. In b6th, does the woman discover indifference to her offspring; in both, is the state of stomach, the appearance of the tongue, the condition of the brain, the feel of the skin, &c, the same; or, at least, they are without a marked difference in any respect. In bolh, dose the pulse increase in rapidity, as the soreness and distention of the abdomen increase; and both have the same attending 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 the 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 the action of the heart and arteries is very considerably accelerated. Now, ir 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 cir- cumstances, 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 circum- stances, (of predisposition,) " the same disease would always arise, if the same occasional causes were applied, which is not the case," p. 151. He farther adds, p. 151, " Now the nature of the epidemic constitution, which had prevailed at the time when this disease was prevalent at Paris in 1746, and in London in 1787 and 1788,. was a disposition to diseases of debility; with such a predispo- sition, 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 af- fected. 394 PUERPERAL FEV ER. 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."* "Avery large quantity of a fluid is generally collected in Ihe 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 particularly 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 abdo- men, 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 wilh in the human body, either in health, or in disease.! Where it is in large quan- tity, all the surfaces of all the viscera, and of the peritoneum ge- nerally, will be found covered with a crust formed of a solid part of this matter, resembling coagulating lymph. Its particles co- here but slightly, so that, by a little agitation, it will mix with the fluid matter. The parts lying under this coat or crust, are • 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. f 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 mini have been an error in the text from which we quoted. PUERPERAL FEVER. 395 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 dis- ease has been of short duration, not exceeding two or three days. They seem, also, as far as I am able to judge, lo bear no proportion to the degree of inflammation, or the extent of in- flamed surface; since we often find a large quantity of both, where the redness of any surface has been very inconsiderable, and by no means general. In most instances, there has been some slight degree of inflammation in some part of the cavity of the abdomen; but il 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 vvas any,"t 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 every 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 dif- ferences; but we cannot view them in this light; since the appa- rent discrepancies can easily be accounted for, without the neces- • 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. -J- 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 appearances 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. 396 PUERPERAL FEVER. aity 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; and then attempt to account for the seeming differences. 1st. In both cases, the extravasated fluid, agreeably to Dr. Clarke's own statement, are 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. 2d. In the inflammation of the peritoneum, Dr. Clarke says, the surfaces of all the viscera in their turn, or altogether, may be inflamed; he says, that precisely the same thing happens, but not lo the same extent, in " the low child-bed fever:" it is then Ihe degree of inflammation, agreeably to this, and not the absence of it, in the latter instance, that constitutes the difference of the two cases, for we think we have rendered il more than probable from - the nature of the fluids found in the abdominal cavity, that in both instances, they are the resull 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 tbe 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; butcspecially in PUERPERAL FEVER. 397 one so liable lo 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 become epidemic.* If this be so, it can only happen from the sporadic cases acquiring the intensity which the epidemic consti- tution 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, lhat 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 sajd, 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 pu- erperal 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. v But without resorting lo 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 therapeutical * 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. 51 31)8 PUERPERAL FEVER. 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 attacked great numbers of patients. The ulcerous sore throat, with or without the scarlatina, had been very general, both in London, and also in the country at a distance from the capital. Most of the fevers had been of the low, nervous, and malignant kind, ap- proaching 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 innoculation 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,"* 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 consti- tution, into a low type" p. 150. Yet, wilh all this evidence before him, Dr. Clarke insisted on the slight difference which he 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. * Much more difference will be perceived between the small-pox under ordi- dinary 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. 399 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 ob- served 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- 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.* 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 abundanlty 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 * 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. 400 PUERPERAL FEVER. 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 certainly be understood to declare, that they generally are; and, if they generally are, the appearance of inflammation must produce a stronger resemblance to the peritoneal inflam- mation, 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 women, 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. 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 PUERPERAL FEVER. 401 arising from the peculiarity of the inflammation, but which pe- culiarity vvas the result of an epidemic influence; and the re- duction of this inflammation kept pace with the profuseness of the effusion. In the other instance, the same circumstances ob- tained precisely; that is, the abatement of inflammation was in the 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 propriety of his practice, by detailing such phenomena and ef- fects, 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 putrefaction, led to the belief that it could be no other than a putrid, or typhoid fever; and the want of success in curing it, by the remedies proper for such diseases, was not attributed to the improper nature of the means employed, but to the indomitable nature of tbe disease itself. Therefore, wrong pathological views led them, either to a feeble or inefficient practice-, or to one decidedly wrong.* • 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 402 PUERPERAL FEVER. 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. Wilh this in view, he divides the de- rangements of the uterine system,* 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. The doctor was solicitous that these several affections should not be confounded ; to prevent which, he admonishes the inex- perienced practitioner in the following words: " Before I close this part of my subject, I must beg leave lo caution those of my readers, whose experience imy have been short, to be very careful in distinguishing these diseases from cases of fever consequent to labour, occurring in debilitated constitutions, in large towns, and in hospitals more particularly, where there is any disposition to epidemic complaints, which have a low tendency," p. 92. purely inflammatory action—but on the contrary, that in " la Maternitie," this condition was comparatively rare; hence, they have divided it into the inflam- matory, typhoid, and the ataxic varieties. The typhoid was by far the most fre- quent, 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 appeared 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 treat- ment of this disease in this country. This peculiarity in the influence of an hos- pital atmosphere, has been lately proved in the Pennsylvania Hospital of this city; for the cases of puerperal 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 inflamma- tory stage, and this is all that we absolutely contend for. • 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 co- vering. PUERPERAL FEVER. 403 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 been short," (and we may add, those whose experience has been long,) to distinguish, wilh any profitable accuracy, the different condi- tions 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 in- forming us, in what, or from what, condition of the system this fever proceeds. For it will be perceived, lhat 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 vvill 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. 384, 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 peri- toneum, which we hold to be impossible. And were it possible, no kind of practical good could result from tbe 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. 384. From what we have said, we think we may safely draw the following conclusions: first, that the distinctions attempted to be 404 PUERTERAL FEVER. 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 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 internal 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 385. 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- volved in the same condition as that part; hence, if the inflamma- tion 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 ori- ginal focus. A want of attention to this circumstance, has led all the wri- ters,* 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 inflam- mation of the uterus, properly so called, is a very distinct dis- ease from peritoneal inflammation. (See Chap, on Inflammation of the Uterus.) Dr. Denman very properly observes, "There is undoubtedly much difficulty in forming a just idea of a very complicated dis- ease; and in proportion to the difficulty, 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- * Dr. Armstrong might have been looked upon as an exception, as he men- tions " simple hysteritis;" did he not immediately after appear to lose sight of the distinction, by following Dr. Denman and Dr. Baillie; especially the latter, who speaks of "the inflammation of the uterus and its appendages," under the head of inflammation of the uterus.—-Morbid Anatomy, p. 362. See abo text below. PUERPERAL FEVER. 405 ment may be enjoined, wilh 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 state of child-bed; because the uterus readily admits of a return of the lochial discharge, which always affords relief, and some- times cures the disease." Here we are at a loss to understand, whether, by an inflamma- tion of the uterus, it is intended to include its coverings, or to strictly confine the inflammation to the substance of the uterus without its covering being involved. We are, however, inclined to believe he meant the whole mass of this organ, from what im- mediately follows: " because the uterus readily admits of a return of the lochial discharge, which always affords relief, and some- times cures the disease," Ib. We shall merely remark upon this last passage, en passant, that Dr. Denman has evidently mistaken an effect for a cause. For in inflammations of the uterus, the lochia do not return until this condition is relieved; and if the inflammation be relieved by any cause, so as to permit the lochial discharges to return, it is evident that the reduction of the inflam- mation is the cause of the return of the lochia, and that the dis- ease is subsiding, but not a proof that the lochial discharge is the cause of the diminution of the inflammation; for this discharge would not take place, unless preceded by this reduction of in- flammation, though it may ultimately contribute to this end by its continuance. Dr. Armstrong, however, quotes the above passages different- ly : he makes Dr. Denman to say, *" when simple hysteritis takes place," &c. But this reading of Dr. Armstrong is entirely gra- tuitous; for there is no mention made of the simple inflammation of the uterus, by Dr. Denman ; and this is the very fault we com- plain of. Nor does Dr. Baillie discriminate any better; for, in speaking of the inflammation of the uterus, he says, " the inflam- mation is sometimes confined to the uterus itself, (evidently meaning it as a whole,) or its appendages;" and, that he means 52 40G PUERPERAL FEVER. to distinguish this organ from its neighbouring parts, is indispu- table ; for he adds, " but the peritoneum in the neighbourhood is most commonly affected, and frequently over its whole extent." That is, (as we understand it,) when the uterus is. inflamed, the neighbouring peritoneum is also most commonly inflamed; con- sequently, if this be so, it is, to all intents and purposes, puerperal fever, and not a simple inflammation of the uterus. It would, in our opinion, be always best, when post mortem examinations are related, in which the fundus of the uterus is found inflamed, to say, that the peritoneal covering of the uterus was found " inflamed;" instead of saying, " the uterus was in- flamed ;" for this may not have been the case, strictly speaking. See Chapter on Inflammation of the Uterus. And, secondly, we may conclude, that Dr. Clarke has failed to establish any other difference between " peritoneal inflamma- tion," and the cause of the " low fever of child-bed," than that which is frequently observed to exist between "sporadic and epidemic puerperal fever." We have already said enough re- specting epidemic influence, to convince any one of the extent of its agency upon this, and many other diseases. Of the Period of Attack and Symptoms. In comparing the histories of the symptoms of this disease, as detailed by a number of authors, with what we ourselves have seen, we think, taking the whole of the description together, that drawn up by Dr. Denman appears to be the most faithful. It seems to be the result of very extensive observation, and com- bines, within a very moderate space, all that is essential to dis- criminate the disease in its commencement; and to recognise it easily in its advancement and terminations. For this reason, we will detail the symptoms and characters of this disease in his own words. We are the more disposed to do this, because our experience, though sufficient to convince us of the fidelity of his account of the disease, has not been so ample, as to enable us to make any important divisions. " The time when women are chiefly subject to this fever, is uncertain. There are not wanting instances, in which it has been evidently forming before delivery, or during labour, or at any intermediate period for several weeks afterward; and the sooner from the time after delivery the patient is attacked, if in an equal PUERPERAL FEVER. 407 degree, far greater is the attendant danger. But the most frequent time of its appearing, is on the third or fourth day after delivery,* when the patient is seized with a shivering fit, from the violence and duration of which, we may generally estimate the danger of the succeeding disease.f In some cases, however, there has been no cold or shivering fit, or none which was observable; and in others, the shivering fit in the state of child-bed, has not been followed by those symptoms which wej*e to be apprehended.J " Before the shivering fit, the patients have been much debili- tated,§ and have complained of wandering pains in the abdomen, which very soon became fixed in the hypogastric region, where a swelling or fulness, with exquisite tenderness, soon ensued.|| As the disease advances, the whole abdomen becomes affected and tumefied, sometimes nearly to its size before delivery, the woman herself being sensible of, and describing its progress. She also • Authors differ a little as to the period at which the disease may attack after delivery. Hey says about forty-eight hours; Armstrong from twenty»four to thirty hours; Clarke on the second, third, and even the eighth day; Leake on the evening of the second day, or the morning of the third, &c. \ This disease is not always announced by rigour or chill. Hull, Hey, Arm- strong, Leake, &c, agree it is generally preceded by shivering; but that they are by no means essential to its formation. Clarke says it rarely happened, Mr. Hey says, that "some of the worst cases were unattended by rigour; and in others, equally severe, there was no more than a slight chilliness," p. 28. And Dr. Marshall Hall says, that in puerperal diseases, " pure inflammation is less marked by rigour, heat, and other obvious symptoms, than the effects of intesr final irritation. t Dr. Denman has not discriminated with his usual accuracy in this instance; a mere shivering, or rather trembling after delivery, is no veiy uncommon occur- rence; but this agitation is not accompanied by the sensation of cold, though it goes under the name of a chill or shivering by those who are unacquainted with the phenomena 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, § 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 severe 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 consequenpe of the fever; for it is here declared, pain, &c. existed before the rigour. 408 PUERPERAL FEVER. feels great pain in the back, hips, and sometimes in one or both legs, and other parts affected in uterine complaints. " She scarcely can lie in any other position than on her back, or on one side, with her body incurvated; and if the disease be confined to the uterus, the seat of the pain seems to be changed when she alters her position.* " There is either a vomiting of a green or yellow bitter mat- ter, or a nausea or loathing of the stomach, with an offensive taste in the mouth.f An instantaneous change both In the quan- tity and appearance of the lochia takes place; and sometimes, though rarely, they are wholly suppressed.J The milk, if se- * 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 re- mark 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 my experience and reading, may be reduced to two denominations, the sporadic and the epidemic puerperal fevers; in which I in- clude inflammation of the uterus and peritoneum. Dr. Armstrong runs into the same error. f Dr. Clarke supposes that many of the local symptoms arise from an inflam- mation of that portion of the peritoneum which may invest the particular organ or part; " sucli 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 of 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 declara- tion; and when it does occur, it is, almost always, in the second: it is then obsti- nate, and may be regarded as a most unfavourable symptom; and this, for die reason assigned by Dr. Clarke. • t All the writers on the subject of puerperal fever, agree in die uniformity of these symptoms. All declare the change which takes place in the lochia, im- mediately 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 dis- ease? or does it show there is a prevailing sympathy between the inflamed peri- toneum and the surface which yields the lochia? 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' PUERPERAL FEVER. 409 creted, recedes, or is diminished, and the taste, with the appear- ance, is much altered.* " 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.f 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 twen- ty-four hours of the first attack; and I have seen a few, whq never grew warm after the rigour, which then resembled a con- vulsion. In some, death has followed quite unexpectedly, either from inattention, or from the scarcely perceptible but insidious progress of the disease, the indications not having been at all proportionate to the danger. " In other cases, the shivering fit is succeeded by heat, thirst, • 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 mamm* are influenced to the secre- tion 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 af- fected, as in simple hysteritis, the breasts are never so much affected, and some- times, not at all. t 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 eases, 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. 410 PUERPERAL FEVER. 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 pathognomic or chief si^n of the disease. It seems necessary to enumerate all the symptoms, which commonly, though not exclusively, attend Ihis fever, and not in any individual patient; yet cases will occur in practice,in which there will be much variation, depending on the^egrjpto^^ disease, the parts affected, the constitution of the patient, and'lti&,'>:- period»after delivery when the fever makes its appearance. .'-* "The pulse has almost invariably, in this disease, an unusual"* quickness from the beginning.* 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, andthat the powers of the system • 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 in- flammation, (peritoneal.) I am enabled to say, from careful observation, tliat 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 361. The latter declaration we fully agree to; but it adds no support to the former part of his observations. Wt are the more inclined to suspect a want pf accuracy in Dr. Hall's observation, from the loose manner in which he has con- veyed bis notions of the seats of the inflammation constituting the disease in ques- tion. 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 un- frequently, participate in this morbid condition," p. 156. Now, from this quota- tion, it would appear evident, that the appendages of the uterus, and tbe 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 may be inflamed, without implicating tbe other tissues pf 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. 411 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 pe- -iflpus signs*of inflammation or fever, is not to be considered as indicating^fenger; experience having shown that very irritable ^pEttienUhave sometimes an unusually quick pulse, unaccompa- fiiecTwIin 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.* 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. Petechias or vibices are often found in the unwholesome situations, and in some constitutions of the air, at a very early period of the disease, and there are fre- quently miliary eruptions; but the latter seem to be rather a con- • This circumstance is familiar to all who have witnessed the most inflammato- ry of all fevers, namely, the yellow fever. This disease runs its course some- times with such rapidity, that the stages, from the highest inflammation, to that of gangrene, 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 applica- tions, to terminate in the manner just noticed of puerperal fever. It was this ra- pid 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 called,) and which regulated, with too many, the mode of treatment in the commencement of the disease. The apprehensions suggested by its peculiar ter- mination, made physicians spare, or rather dread, the employment of the only re- medies 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 purging, rarely lost a patient. Dr. Gordon did not lose a pa- tient out of thirty that were treated by ample blood-letting and liberal purging; and Mi\ Hey seems to have been successful in equal proportion. The great se- cret in treating such diseases 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, 8cc. Mr. Hunter explains this by saying, " debili- ty begins very early, because the inflammation itself is interfering immediately with the actions of life." 412 PUERPERAL FEVER. sequence of the method of treatment than of the disease, for they do not afford that relief which sometimes follows their appear- ance 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 yest. It is also remarkable that, after the long continuation of the looseness, when the patient has taken little or no solid nourish- ment, large and hard lumps of excrement will be sometimes dis- charged, 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 tu- mour, 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 disease has been found to have affected the uterus principally, or its ap- pendages. "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 atlack, though in one sense it may indicate the degree of disease, always contributes to its abatement, and sometimes proves critical; as does likewise a spontaneous vomit- ing, sometimes even towards the last change, when all hopes of recovery were abandoned. " The profuse sweat, which follows the shivering fit, has very PUERPERAL FEVER. 413 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 eruption of ihe lochia are always a favourable symp- tom, and are to be reckoned among the most certain signs of amendment,. 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?* 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 suck- ling, may be in some way connected wilh 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 testicles produce the passion for propagation; and the passion in its turn affects the disposition for secretion." But to what circumstance 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 peritoneal in- flammation 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, ha3 so many well-marked characters, that it cannot be well confounded wilh any other af- • It has lately fallen to my lot to see a case of completely developed puerpe- ral fever, in which this symptom proved fallacious. This case will be related pre- sently. 53 414 puerperal Fever. fection; and, we believe, that we may safely rely upon the follow- ing symptoms for its diagnosis:— 1st. Pain or tenderness in the hypogastric region, occur- ring after delivery, from the first few hours to several days.* 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 great- er or less force. 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.t 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. • 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 mammx 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 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. f Dr. Denman, as noticed above, says, this sweat has, in many instances, proved critical. PUERPERAL FEVER. 415 7th. By a diminution, alteration, or suspension of the lo- chial discharge.* 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 con- fined ourselves to the mention of such only as may be considered 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 ob- tain in others, but which may be dependent for its existence upon some peculiarity of constitution, or accidental cause. It is, there- fore, impossible 4o 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 history of this fever, from its formation to its termination. And we trust, from what has just been laid down, lhat this disease cannot well be mistaken for any other. Of the Prognosis. There is, perhaps, no disease, upon the issue of which the phy- sician of experience, feels greater reluctance to pronounce than • 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 tliere, was of a very remarkable character in several important points; and differed from every other of which we have read any account. 1. Tliere 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." 7. An unusual degree of headach. From Dr. Leake's account, it is evident that the epidemical constitution of the air had imposed a veiy 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, 8cc, farther, he would have cured all his patients. 416 PUERPERAL FEVER. puerperal fever. This unwillingness proceeds from several causes, each of which suggests the propriety of caution in making a deci- sion. 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 sub- siding of the abdominal swelling,* tlje less frequency of the pulse, seem but the prelude to a condition, from which no human exer- tion, or power of remedy, seem capable of saving the patient. Yet the symptoms now mentioned are precisely those upon which we Vvould 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, nevertbeles, 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; • "When the abdomen subsides, without being preceded by copious stools, and with a dry skin, it threatens the utmost danger."—Desmak. PUERPERAL FEVER. 417 the countenance haggard, wild, and expressive of the greatest distress. Delirium, vomiting,* involuntary discharges of both the feces 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 less sud- denness. The absence of milk in the breasts, and especially if this be attended writh an entire indifference to the child, must be looked upon as almost certainly fatal. If joined lo 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 uniform- ly is danger increased by the earliness of the attack, that it is noticed, 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 danger- ous, nay, almost always fatal. Dr. Clarke says, " It has not oc- curred in my sphere of observation, to see any recover, in whom the swelling of the belly has been in any very great degree,"f 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. • 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 these 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 coffee-coloured fluid," p. 31. Yet gangrene, or mortification, have not been observed in any of the dissections we have read of. f I shall relate a case presently; in which tliere was great distention of the ab- domen, but where the woman recovered. Yet this must be looked upon but as a rare exception to the rule. 418 PUERPERAL FEVER. Dr. Armstrong observes, that " an excess of sensibility i* always to be dreaded; for I have had opportunities of remark- ing, that those patients seldom recover, who arc tremblingly alive to every surrounding impression. It is well known, that unmarried women do not recover so well as married ones; the mental irritation, necessarily attendant upon their situation, con- siderably increasing the febrile excitement, and rendering them extremely restless," p. 2G. Dr. Clarke has remarked the same thing. "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 delivery 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. 569. The signs which may be looked upon as favourable, are— 1st. A diminution of frequency of the pulse, with an increase 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 appearance. 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, accompanied by condition first. 7th. If the urine become more abundant, and deposites a la- teritious sediment. Sth. 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 cxtremelies, after having been preternatu- rally cold, accompanied by the signs just referred to. PUERPERAL FEVER. 419 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 patient will generally do well; but if the pulse keep very quick, af- ter the abdominal symptoms have entirely disappeared, affections of the chest,* and oflhe glandular system, or deep-seated suppurations, may be dreaded."f Arm- strong, p. 32. Of the Contagious Nature of Puerperal Fever.% 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 Britian, this, and a num- ber 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 writ- * " 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. f " Some of those who survived, recovered slowly, and were affected with wandering pains, and paralytic numbness of the limbs, like that of chronic rheu- matism. Some had critical abscesses in the muscular parts of the body, which were a long time coming to suppuration, and when broke, discharged a sanious ichor." Leake, vol.li. p. 56. t "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. 420 PUERPERAL FEVER. ten an excellent work upon this disease, says, that " the puerperal fever is not an infectious disease, any more than the iliac p;i>>ion, 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 1 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 lo the opinion that puerpe- ral fever is not contagious; but seems afraid to decide absolutely 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 cily, so far as we know, it has always shown itself as a sporadic disease; and in this form, it has never been looked upon as contagious, except by Dr. Armstrong. 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 supported by those who believe in the contagious power of the epidemic. In Northumberland, in this state, (see p. 380,) 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 PUERPERAL FEVER. 421 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 necessary 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 con- veying 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 has 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 autopsic 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 examiners of bodies dead from puerperal fever. Let us take Drs. Leake, Gordon, and above all, the accurate and faithful Clarke, as illus- trative of the position now advanced, and it will be perceived, 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 gan- grenous, the uterus or the ovaries were said to be in either of these conditions; being altogether ignorant that the peritoneum cover- ing these parts may be in a pathological condition, without impli- cating the other structures of these organs. Again, pus has been found in various portions of the uterus, when it vvas cut into: this pus was supposed to be the result of the inflamed 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 vvas often declared to be in a state of gangrene from puer- peral fever; but modern research has proved, that this organ may be "softened," (ramollissement,) and this without any par- ticular tendency to putrefaction. And once more, that phlebitis of the uterine veins gives a typhoid character to the accompany- ing 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 54 • 422 rUKRTKRAL KKVt.K. this, upon certain portions of it, (see our history, A. c. of (his dis- ease,) in other cases, the parenchyma of the ulerus is (specially attached; 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 wc have already observed, puerperal fever is considered by Conquest and some of the French writers, as a generic term. See page 377, &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 confounded1—it is, also equally evident, that we have much lo learn in diagnosis. However, let it be understood, that though puerperal females in this country must, necessarily, like those of Europe, be obnoxious to remote causes; yet, that here, such causes, be they what they may, tend more frequently to the production of a pure inflam- matory 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 shalLgive the experience » of Professor Desormeaux, and his pupil MTTonnelle upon this point, though we are, at the same time, persuaded, that, in this 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 his successes, and this at several seasons of the year; for this gentleman found, lhat a mode of treatment which may have been successful at one pe- riod, might not prove so at another. Among the more active re- medies he used, we may reckon general bleeding, leeching, ipe- cacuanha emetics, salivation; the auxiliary means were, warm hip-bath, laxatives, enemata, bark, cataplasms, and emollient washes for the uterus. PUERPERAL FEVER. 423 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 imperi- ously 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 questionable utility, as this first stage so quickly ran its course. On this ac- count, local bleeding was resorte'd to, to overcome the local af- fection 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 gene- ral and local blood-letting, three-fourths recovered. Ipecacuanha, as an emetic, he states, was only used in the ear- ly 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 vvas it found to answer in the typhoid type of this disease. For the suppurative stage, or the typrfoTO variety of this disease, MM. Desormeaux and Tonnelle think they have found an important remedy in mer- curial salivation; for, though by far the greater number of such cases must prove fatal, still, if salivation increases 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 to employ it, without having derived advantage from it in their trials. We have directed attention to this remedy, (see p. 454, on mercurial frictions.) Mercury was only used in the advanced stage of inflammatory puerperal fever, or in typhoid cases, or where neither blood-let- ting, or leeching, or ipecacuanha would be useful. It was used in form of ointment—two ounces were rubbed in every twenty- 424 PUERPERAL FEVER. four hours—the abdomen and thighs were the parts selected. The auxiliary remedies mentioned 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 absolute- ly relied on; as the successful cases may not have been such from the particular treatment, but from their want of intensity; and therefore might have yielded to either plan adopted by De- sormeaux 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 con- dition, when the plan is 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.* 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, and 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.f * 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 pu- tridity in the latter, was proportionate to the degree of inflammation in the for- mer." Dr. Denman says, " When the fever has remained for a very few days, the pu- trid symptoms, which are usually according to the degree of the preceding inflam- mation, advance very rapidly." We repeat these observations, because of their unquestionable truth, and practical value. ■j- " 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- PUERPERAL FEVER. 425 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 informs 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 sup- port the strength, and diminish the irritability." It may be said, lhat, in the epidemic described by Dr. Clarke, there vVas but litlle evidence of inflammation, and much of" pu- tridity;" but this should not be too hastily assumed, as we have attempted to prove at p. 392. Nor can an inference be drawn in favour of his pathological views, from the success of his practice. The public are much indebted to Dr. Denman for the candid re- nunciation 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 Bri- tish practitioners; and they became almost the standard for the treatment of puerperal fever. Fortunately for the fate of hun- dreds, a more extended experience, and more correct notions of the nature of the disease, led him to renounce, with much mag- nanimity, 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 it. 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 suaded that debility is the principal thing to be counteracted from the beginning- 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. ' 426 PUERPERAL FEVER. 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 xtL. mischief which he cannot then remedy, and an event'which 'foe *~> can only deplore." . *L.- \ "> We are told, that it is of the utmost consequence W?tne cuij: r.f of this disease, lhat we distinguish between the true injfamirra-* tory, and the putrid puerperal fever. This would be moat t«ue* and important, did such a difference really exist as is here*mli- mated; but the distinction attempted, has been based, we believe, upon the violence of ihe 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. 401. 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 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 ihe 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 il then abso- lutely requires the opposite treatment; and we are sure it has been the death of thousands. The supposed tendency to typhus, in fevers of every descrip- tion, when the patient has become weak, artd especially if the tongue has become brown or dry, has led unhappily to the use of tonic and stimulating remedies, by far loo many practitioners; for were the results of such treatment faithfully recorded, we are convinced there would be but little evidence in ils favour—in- deed, so confident 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 Ihe position we have assumed, by taking part of cases IX. p. 89, and XXViI. p. 206, as related by Mr. Hey. PUERPERAL FEVER. 427 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 vvas 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. Thirty drops spt. aether, sulph. were ordered lo 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 pro- per intervals. She was quite sensible, and more composed; and had regained the power of putting out her tongue, which before she had lost. Pulse one hundred and six, and the tongue con-! tinued clear. Ordered to take, at regular intervals, a draught of infus. rosae made with decoct, cinchonse, and to have occa- sionally Maderia 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 increasing 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 inco- herent and stupid; her tongue became clean, and her pulse was reduced from a hundred and thirty-two to a hundred and six. 428 PUERPERAL FEVER. 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. a?ther. sulph. in small, but repeated quantities. Now, is it not evident tha^,the amendment of this patient was owing to her being only very moderately stimulated by the aether? a stimulus, at the moment, ***fffr in point of power, exactly suited to the condition of the sjstem; and had the physicians been contented to " let doing welljjjpi.uj,"../'' it is probable she would have recovered. But, overanxious for/' their patient, they must prescribe several stimulfat onc&ii^mcjY, bark, wine, &c, and thus undo in a moment all they hacR&op- pily achieved by their previous moderation; for Mr. Hey in- forms us, that "these favourable symptoms did not continue long." In this case, the system was evidently over-stimulated, and the patient succumbed; or, 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 inflamma- tion after ample depletion. Indeed, in many other inflammations, we have seen its salutary influence when the other diffusible sti- muli 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 11th 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 terminated in it; especially as the pulse was so much reduced in frequency, as to be at a hundred and six in the 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 manifested 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 PUERPERAL FEVER. 429 her body. It vvas, however, enlarged, and though not very tender, was sensible to pressure. The symptoms of active inflammation having given place to those of a typhoid character, the purgatives had been omitted, and the evacuations had consequently decreased. I recommended such a repetition of the purgative as might pro- cure an evacuation about once in four hours, and a continuation of the saline mixture in a state of effervescence. The strength of the fjatient was supported by a light, But nutritious, diet, such ^ as bro^s, jellies, chocolate, and milk. *& ^his^plan was regularly pursued for four days, and the patient ^%#ben convalescent. TJlij&c'ase is fill 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, ihere was what Mr. Hey himself considered a " typhoid character: the tongue vvas 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 sys- tem an opportunity of righting itself, by the abstraction of offen- sive 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 vvill not—he will put bark, wine, ammonia, &c. &c, in immediate requisition; and be rewarded for his anxiety 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 re- course to the same remedies.* It is truly a matter of surprise, that Dr. Leake did not profit more by his experience in the fever of the " Westminster lying- • 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; name- ly, that though a patient may not bear the loss of blood, or sustain other evacua- tions 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. 55 430 PUERPERAL FEVER. 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 vvas 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 re- covery, (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. VIII.* IX. XII. XV. XVI., were bled and purged, and recovered. IV. Bled ^viij. on or about the seventh day—died. V. Bled Ivj. on the third day - - died. XI. Bled |vij. on the third day - - - died. VI. VIII. X. XIII. XIV. XVII. XVIII.f not bled; 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 success- ful—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 ex- tract blood on the seventh or eighth day. This circumstance shows the comparative mildness of the disease as it then ap- peared; and Dr. Leake informs us, p. 57, that " when the disease proved mortal, the patient generally died on the tenth or eleventh day of 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 * It may be proper to notice, that case VIII. is not case VIII. in Dr. Leake ■ series; it is included under the history of case VII. f This case, like case VIII., mentioned above, is also recorded in die history of case VII. See Treatise on Child-bed Fever, Vol. II. PUERPERAL FEVER. 431 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 shorter time," p. 165. Yet, the success following the plan pursued by Mr. Hey, vvas considerably greater than that which attended Dr. Leake, in a much milder form of the disease; and this success was owing to a bolder prac- tice, and one belter 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 unin- terrupted 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 depletions of one kind or another, and in twenty-nine of them, calomel was exhibited in doses of a scruple, or half-drachm, at the beginning, and occasionally repeated in the course of the distemper," p. 70. Dr. Gordon, whose method of treating puerperal fever con- sists 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 fi-ve 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 viscus.* But this inflammation may be more or less extensive; • See pages 377-8. 432 PUERPERAL FEVER. 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 remedial agents, as employed by the best instructed, and most experienced 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, vvas 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 lhat 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,"* since it is at a time in which * We are by no means satisfied with the term employed to designate die 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 PUERPERAL FEVER. 433 the vessels have not absolutely lost their life, though they are on the very verge of it. It is at this period that blood-letting can do no good, and stimulants will destroy. We shall have occasion 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,* sometimes ter- minating in a little more than twenty, and sometimes continuing as long as seventy hours, but always being shorter in the epide- mical, than in the peritonitic fever."f 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, strict- ly speaking, consists in the duration of the active slate of inflam- mation ; and this will vary, as just observed, from the contin- gencies of season, constitution, age, epidemical influence, &c. In the epidemic described by Dr. Leake, this stage continued, in a number 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 day4 part which approaches death, but it is not death; because parts sometimes reco- ver from it. If properly managed, that is, if not over-stimulated, the powers of the system may be such, as to recover the part from the condition in which over- action had placed it. * 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. ■j-By the "peritonitic fever," we presume Dr. A. means the sporadic puerpe- ral fever; as every body seems to agree that the latter is less viplent in itssymp- toms, 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. * 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 434 PUERPERAL FEVER. 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 cxi>t, with which 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 he 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, wilh 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 fre- quency of the pulse, or by any other symptom, from bleeding co- piously, 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 1 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. Hey'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 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. PUERPERAL FEVER. 435 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 tbe mode of action of these important viscera is peculiar, and every way highly characteris- tic 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, (hat the assertion of Mr. Hey would al- most certainly lead to; and, on the contrary, would decidedly re- commend to him the study of the pulse, and other signs in puer- peral fever, with a hope that the secret characters of peritoneal inflammation, 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, lhat 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 pro- fession 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 de- sired. 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- 436 PUERPERAL FEVER. stitution as any other action that takes place in it, though it is nol 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 real- ly be found. Frequency of pulsation in a given time is measura- ble by instruments; 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. 1 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 stroke will then be soft; yet softness is not to 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 quotalion from that high au- thority, 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; lhat one part of the pulse belongs to the heart alone, another to the arteries alone, and PUERPERAL FEVER. 437 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, wilh 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. * ne hardness, the vibra- tory thrill, the slowness of the systole, with the fulness and smallness of the pulse, belong to the arteries. As the pulse arises from the solids, or the machine, its stale will be of course ac- cording to the nature of the machine at the time; and is, therefc. 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 regulated 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 inqui- ries 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- 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 dias- tole, 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 diastole of the artery is not regularly uniform and smooth, but proceeds by a vast number of stops and interruptions, which are so quick as to give the feel of a vibration, or what we would express by a thrill." Ib. 56 138 PUERPERAL FEVER. These quotations are sufficient to prove, that the condition of the artery in disease, as regards its volume, its firmness, its soft- ness, its frequency, or its peculiarities of action, very much de- pends 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 fol- low, that the peritoneum, in a state of inflammation, vvill give to the heart and arteries a character of action which exclusively belongs to that condition of this membrane; and that the actions of the artery vvill of course vary, with the varying condition 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 because, 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.* 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 injurj^in others, of blood-letting; and this probably is the amount of information upon the subject: hence, perhaps, the rule for withholding the lancet in certain epi- demical puerperal fevers, being regulated by hou^s; for it would seem, that in each individual epidemic of this nature, there is a period, caeteris 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 • 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 action, and has neither the characteristics of heat of surface nor obstruction of the genen.1 secretory system. PUERPERAL FEVER. 439 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 epidemic, 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.* 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 characteristic, he should have added, that these chills are not followed im- mediately by a sense of increased heat. 440 PUERPERAL FEVER. hundred and forly 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 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. Hey'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 fatally in thirty-five hours; and its commencement "was accompanied with a full strong pulse." In his 6th 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 num- ber 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 wilh certainty by even close attention, as it seems to countenance the opinion hinted above, that the inflammatory stage most probably is ac- companied by a distinctive arterial action, however evanescent 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 soreness of the abdomen often continues through the whole disease; and though never absent from the first stage, it is nevertheless con- stantly present in the second. The breathing is not more decisive; vomiting is less frequent in the first than in the second stage. The tongue affords no criterion; it remains sometimes as de- scribed 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 PUERPERAL FEVER. 441 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, by diminishing in size and sensibility; provided, the remedies exert a control over the disease, generally. Tbe 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, moderates 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 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 following 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 neither of which is 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 4 12 PUERPERAL FEVER. 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 ihe effects of her own remedies. Fourth ; to the fear of censure at- taching 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 ihe 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 vvas seldom called until some hours afier 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 ex- periment, upon different occasions; that, though there were dis- crepancies in appearance in these statements, yet there were none in reality; as the conclusions were drawn from individual expe- rience, in each of the epidemics, of which they gave the histo- ries, and, consequently, that neither the short periods of Arm- strong 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 if epidemic, as well as in sporadic cases, there may be a difference of period at which it might be proper to bleed; and lhat 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 late employed. As regards, then, the period after the attack at which we are PUERPERAL FEVER. 443 to draw blood, it is a concurrent opinion, tbe earlier, most de- cidedly the better: as respects tbe 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. 2d. Having ascertained the propriety of blood-lelting in the early period of the disease, the questions next in importance are, first, what quantity must be drawn; and secondly, must it be re- peated, 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 vvill not answer, and more is not generally required.* In this country, we are not in the habit of regulating our bleedings by ounces; in severe illness we almost altogether regulate the quantity by its effects; and we are dis- posed to believe this lo be the safer, and the more efficient plan. For it is not to be supposed that every constitution will be affect- ed 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 absolute- ly 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 * Dr. Armstrong says, "the quantity of blood drawn at once in puerperal fe- ver, 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, I found that twenty-four ounces of blood, taken away at one bleeding, within six or 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 always 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. 444 PUERPERAL FEVER. 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 1<£ gain ground: we should, therefore, draw it as quickly as the slatft 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 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 He- PUERPERAL FEVER. 445 gree of acute pain without much distention of the abdomen, are much more certain marks of the continuance of active inflam- mation, or the first stage, than any other 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.* 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. Hey's rule is, " if the pain and soreness of the abdomen are not removed, or very materially alleviated, in six 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- 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 • 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. 57 446 PUERPERAL FEVER. 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 per- suaded we have seen bleeding do much good after a much longer period, where the force of the disease has been abated by Ihe 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 reme- dies; therefore, a greater latitude, as regards hours, we thinUT, may he permitted, provided the symptoms do not display t§£-'. * same intensity, yet evidently remain unsubdued. ***■->* - Dr. Armstrong discovers still greater apprehension of repeat- ing 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 pos- sible between the first and second bleeding," p. 76. Why this -directionshould be guarded by the condition, "absolutely neces- sary," we cannot say, as we presume, in such cases, when em- ployed, 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 ac- count, 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, belter 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 lo 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 to itself, or timidly encountered, or if aggravated by improper treatment, will run its first stage with great rapidity. That ilfl second stage consists in the termination of the previous inflam- matory stage, in that state known by the term "gangrene;" which always is of short duration; for it either retraces it* steps PUERPERAL FEVER. 447 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 attempts 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 vvas not great; and while the mam* ma? 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 lo be regulated by ounces, and not by the number of leeches.* 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 the ge- neral; 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™tient * The size of the leech in this country not only varies very much, but also are 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 die 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. 448 PUERPERAL FEVER. rarely shivers much, but has repeated chills; vomits dark, gru- 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 3d-*'* " mit of remedy, or at least it is not absolutely fatal. It is, bftvy-i^j^- ever, a stage necessarily replete with danger, though it m^ftaoi^- >'• 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 forbidden. 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 ex- pect, 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 TOfour of emetics in puerperal fever, agreeably to a plan suggested by M. Doulcet, there is the most extraordinary testimo- ny 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 PUERPERAL FEVER. 449 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- 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 upby^a potion composed of two ounces of oil of sweet almonds, one ounce of sirup of marsh mallows, and two grains of Kermes mineral. The common drink is linseed tea, or an infusion of Scorzenera root, edulcorated with sirup of althsea; and towards the seventh or eighth day of the disease, the patient takes a mild purgative, which is repeated three or four times, according toi the exigency of the case. The efficacy of this method of cure consists 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 irre-. parable, 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 Account, p. 417. v 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 suggested by M. Doulcet, has been attended with obvious disadvantage.— The agitation of vomiting, by the necessary pressure made on the contents of the cavity during their operation, has always aggra- 450 PUERPERAL FEVER. vated 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 vomiting is an attendant 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, j^h fail so constantly in the hands of others 1 This question, it vvftild be difficult perhaps to answer satisfactorily; but we may sug^J gest, that it might have depended altogether upon some peeplj- arity of the epidemic itself, but of which peculiarity we have no knowledge. It was certainly of less rapid course than those of Aberdeen 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 irrepa- rable ; the very reverse of the two epidemics just named. It seems to have borne a strong resemblance to that which at- tacked the " Westminster lying-in Hospital," and of which we have an account 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 antimoaial 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 PUERPERAL FEVER. 451 belief, that the nausea and bad taste in the mouth are always indicative of the oppressed state of the stomach, and that this condition would be relieved by puking; for we must, in such cases, be careful to distinguish between the sickness, occasional vomiting, 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 ;W\- dovfh a short time before. This vomiting arises, either from the 'S^&sstomach sympathizing with the inflamed peritoneum at a dis- *zT taiice from it, or from ils 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 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 system, and almost every symptom of inflammation and fever entirely 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.beeq given to a considerable ex- tent, without completely relieving the pain and tenderness 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 -152 PUERPERAL I •'EVER. us, from all we can learn, that emetics are of doubtful efficacy as principal remedies; and we are scarcely disposed to look upon them as useful auxiliaries. 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 tliat 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 vvill seldom be necessary; buthas 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 always .extremely inconvenient, where the patient is to be so frequently 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. 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 lo 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 becoming wet,against which no care can guard; thirdly, they oppress from their heat, and appear always to increase the frequency of the pulse; fourthly, we have never seen them of the smallest benefit. Bladders, partially filled with warm water, is the best mode of applying fomentations, if they be insisted on. PUERPERAL FEVER. 453 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, vvill always justify a trial; but we are sorry to say that so far, in our hands, we have not had suf- ficient reason to rely solely upon it; though, as an auxiliary, 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 employ ment,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 termi- nation 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 combina- tion with castor oil; thereby forming one of the most certain and peculiar cathartics we know. It might deserve a trial at this period.* • 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. Zorns, Perkin, and Shaffer: Mrs. L. was safely delivered two days previously, though considerable hemorrhage succeeded. Soon after the abate- ment of the flooding, she was attacked with severe pain in the abdomen, fol- lowed by great distention and tenderness, great distress of stomach, and vomit- ing, &c, which continued with unabated violence 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 drunk. Her pulse very small, and so frequent as scarcely to be counted; ex- tremities cold, and her whole body covered with cold sweat, breathing laborious, 58 454 PUERPERAL FEVER. 7. Mercurial Frictions. This remedy has lately been proposed for puerperal fever; and Mr. Velpeau has given in "Revue M6dicale," for January, 1827, several very interesting cases, in which vvas employed, and apparently with advantage, mercurial frictions upon the ab- domen. But he very honestly confesses his experience lo be in- sufficient at the time he wrote his essay, to determine Ihe 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 oflhe mer- cury upon it, to diminish the quantity to one or two drachms, and to make the intervals of application longer.* Thirdly, To wash off, with warm water and soap, or with sweet oil, the crust, which the ointment forms upon the skin, that in its future application it may be more certainly placed in contact wilh 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 her abdomen enormously distended, and extremely sore to the touch. We re- tired, 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 con- tingency of her surviving the night. 1 lib. I was agreeably surprised by a request to meet the above-named gentlemen at 9 o'clock, A. M. We found our patient much relieved of every enumerated symptom—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 ap- peared to have a most decided control over the disease—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 was 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. 455 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 wilh it; namely, the spirit of turpentine. I vvas requested by Dr. Mitchell to visit Mrs.-----, who was very ill with puerperal fever. This patient had been delivered safejy>by the Dr. of her first child, and nothing alarming pre- sented itself, until the second day. Milk had been freely se- cretedi-jind there vvas every promise of a good " gelling up," until the beginning of the third. At this time she vvas attacked with a pretty severe chill, which vvas followed by great heat, thirst, tenderness of the abdomen, and a very frequent pulse. She vvas bled, purged, leeched, and blistered on the abdomen, and kept upon a 6trict 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; breath- ing short, very frequent, and rather laborious; tbe alae nasi ex- panding and contracting with great frequency; the stomach rejecting every thing offered to it; the lips dark and dry; the milk entirely gone: slight mental alienation, though not amount- ing to delirium; the abdomen excessively distended and tympa- nitic; the feet and legs cold; extreme fcetor of the lochia, which were small in quantity, and very dark: in a word, so certainly did we look upon her being in articulo mortis, that no appoint- ment 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 turpentine were ordered to be given every hour; an ounce of strong mercu- rial 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. 456 PUERPERAL FEVER. The next morning Dr. M. favoured me with a call, as had been agreed upon the evening before, provided he found the patient alive. And I honestly confess, I vvas much surprised when he reported our patient to be rather better than we had left her in the evening. Upon visiting her, this vvas 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 subdued; the abdomen rather less tender. The ointment was to be continued, as well as thelu/--* pentine: of the latter she complained, as creating a disa^rcJRwile heat in the stomach. To remedy this, a tea-spoonjul of sivect oil was directed to follow in fifteen minutes, each dose4>f 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 event- ually a rapid convalescence. During the whole treatment, it may be proper to observe, lhat 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, tbe 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 relieved 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. PUERPERAL FEVER. 457 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 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 mammae 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; tbe 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 cheeks 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. * " 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, is not precisely what we would wish to be understood, when we describe " the gangrenous state of puerperal fever," therefore, we would wish to employ precisely the definition which Galen gave of gangrene; which is that state or condition, " when a part, from violent inflam- mation, 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 oflhe part." Morbid Anatomy, p. 78. In this state of a part, the previous action, or inflammation, exceeded the powers of the part to sustain that action; and, consequently, there existed 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. 458 PUERPERAL FEVER. The respiration hurried, and rather laborious; but not so frequent as the last stage, but much more so than the first. A tendency to delirium, or a manifest forgelfulness 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 practi- tioners; 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 great simplicity and inertness, by withholding all stimuli; but con- tinuing a gentle^epletion from the bowels." 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; oris 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. * Maintaining the depletion from 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, " tliat many cir- cumstances in life, as, also, many applications to parts, will call forth the contrac- tion 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. 459 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 tbe balance which ought to subsist between tbe 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, confectiocardiaca,serpentaria, &c, have been given in as large quantities as the case appeared to require, or the constitution could bear; by which means an artificial or temporary appearance of strength has been produced, while it was only an increased action. Cordials and wine, upon the prin- ciple on which they have been given, are rationally administered; but there are strong reasons for not recommending them, arising from the general effect which they possess, of increasing the ac- tion, 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 irrecoverable."—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 dangerous 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, 4G0 PUERPERAL FEVER. 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 without considerable hazard; they are indispensable in the first stage, and I have seen them occasionally succeed wljin^^glu^^ order seemed advanced into the second,"* p. 8Wfcl"^v^^^r7^^ Mr. Hey says, "If these means, (evacuantsy) fail (9 cure the . t\yfa disease, from being employed either too late, or in an improper *' '• 1 manner, grateful cordials may be given in its latter stages to allc viate the distressing feelings of the patient; bufcordials, or ionics/ can afford no other advantage," p. 166. As we cannot appreciate exactly the powers of the system, when under discajfejhowever desperate that disease may be, is it not improper, frorrftoji,mo- tive 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- 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 stimulating; 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 refresh- • 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 should prefer a less, to a greater number, and for the reasons before stated; a lets number would seem every way sufficient for the removal of offensive matters in the intestines, besides occasioning a competent increase of serous secretion. PUERPERAL FEVER. 461 ing; they may, therefore, be given; the sweet spirit of nitre, also makes an agreeable beverage. Under some of the most unfavourable conditions of the system in this disease, there have occasionally been recoveries; such are the cases of Dr. Gordon, after effusion, and others, perhaps, whose exact histories we are not acquainted with. The restorative powers -of the system in some instances are great: and they are occasion- alive xerted successfully, under circumstances, where no reason- "Tng'upoft tne subject, could for a moment justify a hope; thus, women Rave recovered, after rupture of the uterus, &c. But in 11 these cases, nature was freed as much as possible from as many £?•.'• of the retarding causes as it well could be, and left to manage the ig.-^-injury in her own way. So, in the disease under consideration, £WL*vere nature left undisturbed to the exercise of her powers, we hould, perhaps have more instances of recovery. .TjjejjSrstem 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 hemor- f rhages from almost every part of the body; but in all these in- i stances, little vvas 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 vvas 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, irregu- lar, and tense pulse; and the sores occasioned by the blisters, quite livid. The bark and wine were omitted; the patient was bled and purged; and all applications to the blistered parts were for- bidden. The following day he was better; but his pulse conti- nuing tense, he was again bled, and purged with calomel and jalap. He continued to mend; the livid look of the blistered parts vvas converted into one of high inflammation. He was bled once more; the fever left him in 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- 59 462 PUERPERAL FEVER. ing the system, the action of the parts retrograded, first to that of active inflammation, and then to that degree of it only, that was necessary to the restoration of the parts which had 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 lo 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 demands require. Stimulants, cordials, opiates, may be administered 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 second. There is something remarkable in the tendencies of this dis- ease to gangrene, (in our acceptation of the word, see p. 457,) 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. 388, &c.,) but must be looked upon as almost necessarily fatal.* 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- charge from the uterus, of a bloody sanies, or black grume. De- lirium, or perfect collectedness; the tongue frequently moist, • "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. 166. PUERPERAL FEVER. 463 and an attempt is sometimes made at cleaning; (sometimes,) con- vulsions; death. Sect. 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 tjie discharge of her duties; that she have sufficient understand- ^riog tbwcbijiptehend the directions of the physician; enough good sense^an^afia'elify to put them in practice; resolution to with- • starJd 4he fkjggnvard and improper demands of the patient, should :-> thay be mal^-and courage enough to bear up against the en- ^•■efeacbmewtsTof 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 deliver- ing them circumstantially, and without ambiguity, or the possi- bility of misapprehension. Nothing should be left to construc- tion; the directions must be so peremptory and clear, as to pre- vent 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 Iheir success mainly depends, especially on the proper quantity of blood lo 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 464 PUERPERAL FEVER. 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 antiphlo- gistic regimen; and, as this will refer lo a variety of particulars, we shall consider them in detail. First. The air of the room should be frequently changed by a well-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 pre- served, 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 de- stroyed 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 pyrolig- neous acid and water, should be kept near tbe parts; or, if this cannot be commanded, 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 win- dows, if at a proper season, or in a proper state of atmosphere, 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 unplea- sant vapours or smokes, under the pretext of purifying it; for every kind of combustion is injurious. Secondly. The diet should be made lo 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 PUERPERAL FEVER. 465 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 pos- sible; or as may be compatible with the circumstances of the patient, or as a due regard to not exposing her to unnecessary rNfatigue, will permit. - Fourthly. That, as the abdomen is always very tender, and oftentimes very much swollen, the weight of the bed-clothes should be taken from il, 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, lhat the wetting of the abdominal surface fre- quently, 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 two first; a spoon for the second, and a bed-pan for the last; knowing it to be of the utmost consequence to hus- band the strength, and prevent all needless hurry of the circu* lation. 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 il 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. 466 PHLEGMASIA DOLENS. CHAPTER XIX. PHLEGMASIA DOLENS. We have retained the name of phlegmasia dolens, (the phleg- masia aPba 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, whcn^ we believe was the first that gave any satisfactory account of it; for the description left by Rodrigues a Castro, can scarcely be tortured, by anj;partrality for antiquity, into the disease of which we are a|fout to treat, though Dr. Hull complacently inclines lo the belief,',,mat be was,.- acquainted with it. And we doubt whether the disease oflhe apothecary's wife, as described by Wiseman, was really the dis- ease in question, as it is but casually mentioned in his chapter upon u Abscesses and Corrosive Ulcers, arising from Distempers of the Womb in Child-bed," and what renders it especially doubtful, 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 ihe 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 appears to have been familiar to a number of practitioners, as Mauningham, Mes- It'was, however, found after a time, lhat the appearance of this disease did not obey any particular state or condition of the lochia; and that as it was very commonly accompanied by a diminution 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 sugges- tion; 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. PHLEGMASIA DOLENS. 467 Van Swieten, Lieutaud, Raulin, Selle, &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 dis- ordered condition of the lymphatics, and be vvas 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 labour, " yet he could easily conceive, that the obstruction to the return of the lymph may commence in the primary inflammation of a trunk or trunks, and that probably this may be the case more frequently than he had hitherto discovered or suspected it to be." Mr. Trye was followed by Dr. Hull, in a valuable and highly learned work upon this obscure and debateable disease. Dr. H. says, " The proximate cause consists in an inflammatory affec- tion, producing suddenly a considerable effusion of serum and co- agulating lymph from the exhalants into the cellular membrane of the limb." Dr. Davis, of London, next offered a new patholo- gical view of the proximate cause of phlegmasia dolens, and makes it consist in an inflammation of " one or more of the principal veins within and in the immediate neighbourhood of the pelvis, producing a thickening of their coats, the formation of false mem- branes on their internal surface, a gradual coagulation of their con- tents, and occasionally, a destructive suppuration of their whole texture; in consequence of which, the diameters of the cavities of these important vessels become diminished, sometimes so totally obstructed as to be rendered mechanically incompetent to carry forward into their corresponding trunks the venous blood brought to them by their inferior contributory branches."* Thus, we have five different hypotheses for phlegmasia dolens; of either of which it would be difficult to make a choice, if we consulted their value, either in relation to the phenomena this disease presents, or to the pathological condition of the parts affected, as far as has yet been revealed, by dissection. On these several opinions we shall pass a few remarks; and believing neither to be the true proximate cause, that it is right to give the arguments against each, that our reading has supplied us with, as well as those that have suggested themselves to us from having • Lond. Med. Chlr. Trans. Vol. XII. p. 426. 468 PHLEGMASIA DOLENS. attentively observed the phenomena of this painful affection at the bed-side. The two first opinions, (namely, that phlegmasia dolens is caused by some derangement of the lochia, or from a metastasis of the milk,) will scarcely require a remark, as subsequent ob- servation has abundantly proved, that neither has ever had the slightest agency in its production, either as a remote, or as an exciting cause. And farther, were either or both to be admitted as contributing to this affection, the pathological condition of the seat of the disease, as caused by them would still remain unex- plained. >!»"'" Mr. White, of Manchester, must be considered jh'e'nrst writer who had attempted a pathological exposition of phlegmasia dolens, and much credit is due to his industry and {Jfrning upon this subject, though we cannot yield to him the merijtof having been' satisfactory, or perhaps even clear. He decl ires this trtsjjA^|j»^ " Is owing to the child's head pressing the vessel or vessels which arise from the lower extremities, against the brim of the pelvis during a labour pain, so as to stop the progress of the lymph; that the number of valves will effectually prevent it from ■ regurgitating, and if the head continues any time in this situation, while the lymph is driven on through the valves by the peristaltic contraction of the coats of its vessels, by the great exertion of the muscles, and the strong vibration of the inguinal artery, though its coats, (the lymphatics,) should be allowed to be stronger than those of the blood-vessels, it must at last burst and shed its contents. When the orifice made in the lymphatic is heated, and the diameter of the tube is contracted, or totally closed by the cicatrix, the lymph is retained in the lymphatic vessels and glands of the limb, and the labia [labium] pudendi, and distends them to such a degree, and so suddenly, as to occasion great pain and swelling, which always begin in the part next to that in which the obstruction is formed, and when the obstruction is in parlor wholly relieved, or the lymph has found a fresh passage, the part next to it is consequently relieved," pp. 49, 50. He adds, " If the above hypothesis be true, the predisposing cause may, in all probability, be a weakness in the coats of the lymphatics in such subjects only, as have these vessels formed into one principal trunk under Poupart's ligament," p. 55. Objections to these conjectures of Mr. White vvill readily pre- sent themselves; for it supposes that some obstructing cause or PHLEGMASIA DOLENS. 459 pressure to be absolutely necessary. Now, if it be even admitted that the child's head affords this pressure at tbe brim of the pelvis in some cases, it could not have done so in all the instances in which this disease has appeared. For, 1st, this pressure cannot take place to the necessary extent, but in a very few instances, for it is notorious to accoucheurs, that for the most part, in a well-formed pelvis, ihe head may be even larger than it is usually found, and yet pass without difficulty. 2dly. The portion of the brim of the pelvis at which, in ordinary circumstances, this pres- sure is found to exist, is not that at which the lymphatics would ^jbe sub^^ojts influence; for, as a general rule, it would be be- hl'm^^^r^fehe acetabula. 3dly. That no other part save the |^eaCco\ld eteciually exert this pressure; yet it is agreed on all ^^a'nds,*that no potion of the child yet discovered, is more effi- tcicay ,in rts.pijtJduetion than another. 4thly. That a pressure so T^l^fcfcim tin tied ,..asftd so effectual "as lo stop the progress of the lymph," and eventually to cause a lymphatic to burst, must ne- cessarily produce upon the intervening parts, a gangrenous con- dition; yet this is a casualty we have never heard of. 5thly. Se- veral circumstances connected with the history of this disease would still remain unaccounted for; as the occurrence of the dis- ease in the opposite limb, and this not simultaneously, but after a considerable interval, and not until after, as a general rule, the first affection is yielding; to the pain and swelling first occurring iu the calf of the leg, as it sometimes does; for if Mr. White's statement be true, that "pain and swelling always begins in the part next to which the obstruction is formed," p. 51, the pain and swelling must primarily exist in this part of the limb; therefore is not indebted to pressure exerted on the brim of the pelvis for its existence. The arguments just urged might appear sufficient for the pur-. pose intended by ihem; but as several conclusive ones have been employed by Mr. Trye to the same end, we think we should not be rendering justice to this gentleman, did we altogether omit them. He observes, lhat " no experiment has shown that the lymphatics can be torn, without doing equal violence to the other vessels of the part. That practical anatomists have ascertained that these vessels will bear a weight of quicksilver, equal in effect to a much greater force than is required to circulate the lymph towards the thoracic duct. That the force exerted by the child's head in its passage, cannot exceed that of the pad of a tourniquet 60 470 PHLEGMASIA DOLKNs. on the arm or thigh. That if the trunk of a lymphatic be com- pressed, its contents are forced inwards towards the thoracic duct, if no obstruction exist; in this case its sides arc squeezed to- gether, and vvill consequently occupy so little space, that it can- not well be ruptured at the compressed part. If a rupture then takes place, it must be below the compressed part—but no reason can be given for this taking place always in one place, namely, within Poupart's ligament, rather than in the leg or thigh." Besides, we have known two instances of this complaint to follow abortions in the early months; and once in a premature delivery between the sixth and seventh month; in thjs instance the child had been dead at least one month previously to its de- livery. Again, my friend Dr. Chapman informs me of a violent case having occurred in a patient in our Alms-house, labouring under cancer uteri. But above all, it has happened to the arm of the male, as recorded by Dr. Ferriar,* besides an instance of the same kind, that fell under our own notice in 1788. A gen- tleman, pretty far advanced in life, received a severe contusion on the point of his shoulder, by the overturning of the mail coacb. He, however, paid but little attention to it, and merely rested it in a sling, as it did not prevent his attention to business for several days; but at the end of that time, the arm became very painful, and swelled rapidly, considerable fever was excited, and the gentleman was obliged to keep his bed. The control of the motions of the limb was entirely lost; and every attempt to move it was attended by exquisite torture. The character of the swell- ing was precisely that of the milk leg, to which it vvas compared at the moment, by my preceptor—that is, he declared, had the same affection befallen the leg of a lying-in woman, he would have called it a milk leg. After a tedious but an active treat- ment for three months, symptoms of amendment showed them- selves ; but it required a long time to restore the limb to its former usefulness—indeed, from what we afterwards learnt, it never became as strong as the other. This case is not unique: several instances purporting to be of this kind are recorded; all of which, perhaps, are not entitled to the distinction. Dr. Ferriar's case is not an instance, perhaps, of genuine phlegmasia dolens; nor do we regard the one related by Littre, under the care of Luminier, to be without exception, * Medical Histories, Vol. HI. p. 92. By Dr. Ferriar. PHLEGMASIA DOLENS. 471 as there was well-marked red inflammation.* Yet that related by Dr. Heermans appears to have been a genuine instance of phlegmasia dolens in the male.f Besides, we are informed, that phlegmasia dolens has happened to women not pregnant; of this we speak from the authority of others; for we have just said above, that this took place in a patient under the care of Dr. Chapman, in our Alms-house; and Dr. Beck mentions a case where it occurred in a woman of fifty- two years of age. And we may add to these, the observations and cases related by Dr. Tweedie in Edin. Med. and Surg. Jour. Vol. -30^. p. 250. Dr. T. introduces the history of the disease by- saying, *Vitjjj6rresponds very much in its character and progress with the, puerperal phlegmasia dolens, although, from its resem- blance fothe cedematous swelling of the lower extremities, which occasionally appears after cases of protracted fever, its real na- ture and treatment are apt to be overlooked. " This disease, which I conceive to be inflammation of the cellular tissue of the limbs, differs, however, in many particulars. For example, in all the instances I have seen, the swelling has been confined to one extremity, making its appearance first about the upper part, extending gradually over the whole limb, and being attended with acute pain. It does not retain the im- pression of the finger, as in common oedema, which generally commences round the ankle and foot, and seldom extends much higher. " I have treated several cases of this affection within the last four years at the London Fever Hospital. All the subjects of it were females, two of whom were under twenty years of age, and unmarried. I have been informed, however, that one case ^occurred in a male, but I have not been able to trace the history or treatment. " It may be remarked, that in all the instances which came under my notice, active depletion had been employed in the treatment of the fever, so that the convalescence vvas rendered somewhat tedious; and the first warning of the disease was given by symptoms of general excitement, which led me to expect either relapse or some visceral inflammation. In a few hours, however, the cause of the general disturbance became more ap- • Medico-Chirurgical Review, for April, 1829. \ Dr. Francis's Memoir, p. 9. 472 PHLEGMASIA DOLBN*. parent, from the patient complaining of stiffness in one of the lower extremities, followed by aching pain either about the up- per and inner part of the thigh, or in the ham, around the knee or calf of the leg; and as iheumatism is by no means an unfre- quent accidental accompaniment of fever at certain seasons, the uneasiness and pain in the limb are, at first, very apt to be as- cribed to this canfe. " In the course of twelve to eighteen hours the pain and stiff- ness increase, and, on the limb being examined, it is found some- what swollen and perceptibly hotter than the opposite; but there is no redness of the skin, which, on the contrary, has a smooth, white, shining appearance, and the cutaneous veins are distended with blood, and occasionally tortuous. As the disease advances, the swelling extends uniformly over the limb from the upper part of the thigh to the toes, and feels tense and elastic, but not at all diminished by the semiflexed position of the limb, which the patient generally prefers. " I also remarked the total inability to move the limb, not so much on account of pain, as from want of command over the voluntary muscles. This peculiarity has been noticed by Mr. Burns in the puerperal phlegmasia dolens. tl When active treatment has been adopted, the pain abates, the swelling loses its elasticity and tension, so as to retain par- tially the impression of the fingers about the foot and ankle, and the heat of the limb diminishes, but the power of moving it con- tinues for a long time considerably impaired." Dr. Moore, of Ipswich,* makes a singular remark upon the opinions of Mr. White, the force of which we cannot perceive, though it purports to overthrow at once his doctrine. He says, " In refutation of Mr. White's opinion, I will state, that, in no instance thai has come to my knowledge, has the disease pre- ceded parturition." Now, how this refutes Mr. W's. opinion we cannot understand; for, in no instance does Mr. W. require that parturition should always happen before this disease can be pro- duced; and, in our humble opinion, had Dr. Moore known an instance of phlegmasia dolens preceding parturition,! it would have told very much more against Mr. W's. hypothesis, as the * New-England Medical Journal, Vol. II. p. 229. + Puzos relates two instances of this kind; one took place at the fourth, and the other at the seventh month of utero-gestation. And we have seen two in- stances in which it followed premature deliver)'. PHLEGMASIA DOLENS. 473 great agent in producing this disease, in Mr. White's opinion, would have been wanting; namely, pressure from the child's head during labour. But Dr. M. should not have attempted to pass his want of knowledge of such cases for more more than it is worth; since many cases of the kind alluded to may have taken place, without his being apprized of them; for, certainly, it has happened, as stated above, that this disease has occurred to unimpregnated females. Now, if this be so, we do not see by what law of pregnancy, the woman is secured against an attack. By the by, we may remark, that Dr. M. dismisses the hypo- theses of Dr. Trye and Dr. Ferriar still more cavalierly, and with still greater brevity. Of the first he says, it " is mere sup- position ;".of Hie second, " in reply to Dr. Ferriar, I will adduce the fact, that phlegmasia dolens as frequently follows natural and easy labour, as difficult and laborious." These assertions of Dr. Moore, purporting to be refutations, were to pave the way for an explanation which he immediately after offers, in the following terms:— " After an attentive observation of cases, and a careful exa- mination of the subject, I vvill humbly offer the following expla- nation as the most satisfactory to me. "During gestation, the abdominal muscles, their vessels, and integuments, are in a state of great preternatural distention; immediately after parturition, when the distending cause is re- moved, these parts powerfully contract in order to regain their natural dimensions. If this effort be unequally exerted, if it be suddenly excited by the application of cold, if Ihe lymphatic vessels be over distended at the time, if plethora, or great debi- lity subsists in tbe vessels themselves, an interruption and accu- mulation of the fluid ensues; the great and long accumulation of which, acting as an extraneous and offending cause, will oc- casion inflammation. In persons of a plethoric and irritable ha- bit, inflammation may quickly supervene; while, on the other hand, in a person of a contrary habit, it may be more tardy in its progress," p. 230. We would now ask, if ever hypothesis was more heavily laden with conjecture and supposition than this—it has not even the merit of ingenuity, much less an imposing probability, to reconcile its meager pretensions. The initial postulate is not founded in fact; for we cannot look upon the distention imposed 474 PHLEGMASIA DOLENS. upon " the abdominal muscles, their vessels, and integuments," as " preternatural," since, in being put upon the stretch by preg- nancy, they are but performing one of the offices for which they were designed. His second is no better grounded; for, after parturition has removed the distention, " the abdominal muscles, their vessels, and integuments," do not "powerfully contract in order to regain their natural dimensions;" for this is performed silently, and gradually, and requires for its completion, many days. We have just shown how reluctant Dr. M. is to permit either Mr. Trye or Dr. Farriar, to conjecture, or to suppose; yet, he says himself, in the attempt to make out his explanation, " if this effort," &c. " if it be suddenly," &c; " if the lymphatic vessels," &c.; such and such things will happen. That is, wc shall have inflammation from an accumulation of lymph in the lymphatic vessels; and in what essential point docs this "expla- nation" differ from that of Mr. White, or Mr. Trye? In none, that we can see, if we except the agent by which the interrup- tion to the circulation of the lymph is affected—in one instance it is the head of the child; in the other it is cold and debility. We should not have thought it necessary to notice this " ex- planation " in an especial manner, had not the doctrine it incul- cates led lo a mischievous and reprehensible plan of treatment; for the Doctor observes, " in the ordinary mode of treatment, much time is lost in the inefficacious use of diuretics; and much mischief and pain produced by the application of blisters, and other stimulating remedies." " From the view here taken of the subject, I am fully disposed to regard it as a local disease, and decidedly recommend the early application of a large emollient poultice, which, by its relaxing and resolving power," (recollect the Doctor's opinion of the cause of the disease, is debility and over-distention,) " vvill, in a great majority of cases," (has he ever seen a sufficient number to determine this important point? the Doctor only mentions two cases, and neither of which vvas the disease in question,) » prevent the formation of a distressing and tedious disease. And when it does not produce this most desirable effect, I should recommend its continuance, with an in- tention of producing early suppuration, which I think, next to re- solution, the most speedy and safe termination of the disease," p. 231. Was ever a disease less understood; or a more preposterous remedy ever proposed! The continued application of an emol- PHLEGMASIA DOLENS. 175 lient poultice is every thing that is necessary for the relief of a milk leg! We have good grounds for believing Dr. Moore had never seen a case of phlegmasia dolens, if we take the two cases he details as specimens. In the first case, the patient complained of a pain in the right hip and back; rigours and watchfulness; a rigidity and soreness of the abdominal muscles; pain in moving the limb; the pulse a little increased, slight thirst, and perfectly clean tongue. For this state of things, antimonials, cathartics, and fo- mentations were prescribed. These proved ineffectual; bark, guaiacum, and a continued blister to tbe thigh were employed. " This course evidently increased tbe local affection. The upper part of the thigh, the inguinal glands, and right iliac region, become more tumefied, which gradually extended to the hypogastrium and labium pudendi. " In the early stages of the swelling it appeared in ridges and bunches, occasionally assuming a livid, and at other times a pur-> pie hue. It became more uniformly diffused, tender, hotter than natu- ral, shining, but not much discoloured. The fever kept pace with the local affection; the pulse was small and very frequent, The swelling increased. " With an intention of rousing the ac-> tion of the absorbents, a volatile stimulating liniment vvas applied, and in turn hot vinegar; but these had no better effect than the blistering!! "Digitalis vvas now administered; this increased the debility; the inflammatory appearances became more evident; the pain, heat, soreness, and redness increased, until a discharge took place from a ruptured lymphatic in her side, about an inch from the inferior spinous process of the ilium," p. 228. The second case is still farther removed than the first, in our opinion, from a case of phlegmasia dolens. This occurred in a person of robust constitution; it supervened on natural labour. On the second day after the delivery, the patient experienced a great rigidity of the abdominal muscles, which increased in ten- derness, and presented an appearance of "ridges and bunches;" the constitutional symptoms high; these increased until suppura- tion took place from an " opening a little below the navel." We have italicized such parts of these histories, as show at once, that they were not instances of phlegmasia dolens; and 476 PHLEGMASIA DOLENS. also such, as have excited our wonder, in regard to the treat- ment. If the cases ju*t related, and others, that we shall have occasion to mention presently, be received as instances of genuine phlegmasia dolens, the pathology of this disease vvill remain un- settled to the end of time. We have already cursorily mentioned the opinion of Mr. Trye, of the proximate cause of phlegmasia dolens; we shall now ex- pose it more in detail. He says, p. 70, "I have considered the proximate cause of the swelling to be seated in the lymphatic glands. I will not contend that it must be so universally, be- cause there is a probability that the original seat of obstru^tidJH and inflammation may, in some instances, be in the B|rTi(M[rJk trunks of the absorbents within the pelvis, independent dfcanfL abstracted from, the iliac glands; in which case the inflammation' may be continued along the absorbent vessels downwards; that is, towards the labia pudendi, leg, &c, as well as upwards, or towards the thoracic duct." Dr. Ferriar is also mentioned as an inventor of a theory for phlegmasia dolens; but he does not appear to be entitled to this claim, since he has only adopted the opinion of Mr. Trye upon this subject. And were we even to admit he had not seen Mr. T's. work, he must at least have been familiar with the opinions of Drs. Denman and Latham. The lectures of the former he most probably attended. We shall make no observations upon the opinions of Mr. Trye and Dr. Ferriar, until we have noticed the hypothesis of Dr. Hull, which we shall now give in his own words. He states, that " from an attentive consideration of the whole of the phenomena observable in this disease, and of its remote causes and cure, no doubt remains in my mind, that the proximate cause consists in an inflammatory affection, producing suddenly a considerable effusion of serum and coagulating lymph from the axhalents into the cellular membrane of the limb." " The seat of the inflam- mation I believe to be in the muscles, cellular membrane, and inferior surface of the cutis. In some cases, perhaps the inflam- mation may be communicated from these parls to the large bloodvessels, nerves, and lymphatic vessels, and glands imbedded in them." We have united the hypotheses of Mr. Trye, Dr. Ferriar, and Dr. Hull, because they are essentially one and the same; namely, Phlegmasia dolens. 477 that the proximate cause is an inflammation of the lymphatics and glands of the groin ; though, as a whole, Dr. Hull's assumes a much broader ground; so much so, indeed, that Dr. Davis styles it with much point, " a capacious theory." The objections which present themselves to these explanations, are, first, their incompatibility with one especial phenomenon of the disease, namely, the shining white appearajice of the limb throughout the whole course of the disease; and this so noto- riously so, as to have it as one of its genuine characters. In all instances of inflammation of either muscle, skin, lymphatic,* or lood vessels, redness is a never-failing attendant, as is well *"^fefWJ|yo all who are familiar with this disease. Yet this does -nolnfeppen in phlegmasia dolens, notwithstanding the numerous lTSS#re Dr. Hull involves in the mischief. 2d. That if all these tissues were in a state of inflammation, this inflammation would manifest itself by the ordinary phenomena of this affection; namely, heat, redness, swelling, pain; yet we find redness always wanting in phlegmasia dolens, when this disease is pure and uncomplicated. If muscle be inflamed, redness is sure to be present; if the skin, the same thing occurs; if the trunks of lym- phatics, (absorbents,) be the seat, we have frequent opportunities to witness that they become red; and when the lymphatic glands are in this condition, redness notoriously attends. And though Dr. Hull does not suppose that all these parts are simultaneously affected, but successively, yet it alters not the fact, that in phleg- masia dolens, redness is always absent during the whole course of the disease. 3d. Besides, this progressive extension of inflammation cannot well be sustained, as the rapidity of the disease is such some- times, as to involve the whole limb in the course of a very few hours; whereas, the transmission of inflammation by contact even, is sure to be much slower; yet it would not fail to betray its pro- gress by all the common phenomena of inflammation, were it to exist in such parts. * In the time of Dr. Hull, the term "lymphatics" was understood to mean the lymphatic absorbents; the researches of Bichat had not then made it necessary to distinguish this set of vessels, and those whose office it is to convey the lymph, being either the termination of arteries, or the beginnings of veins. And we beg the reader to keep in mind, that where "lymphatics" are mentioned in the quotations of either Mr. White, Mr. Trye, Drs. Hull, Ferriar, or Moore, that the lymphatic absorbents are to be understood. 61 478 PHLEGMASIA DOLENS. 4th. When the lymphatic glands become inflamed by the ab- sorption of some acrid substance or specific poison, ihe venereal poison for instance, they not only become red themselves, but the lymphatics even that convey the poison, can be distinctly traced in their course, by the vivid red that marks their inflamed coats. 5th. The ordinary inflammation of the several parts declared to be involved in phlegmasia dolens, moreover, do not thus sud- denly effuse serum: of this proofs present themselves every day in the usual progress of inflammation, as in rheumatism, wounds, contusions, the insertion of poisons, &c. 6th. When ihe lymphatics are inflamed, together wilh their glands, it is acknowledged by Dr. Ferriar himself, that " the • vessel can be distinctly traced in its course by its hardness'andjkgft enlargement, and frequently by a slight inflammation of the^-»- superincumbent skin, forming a red or purple streak, and ex- tending with the affection of the vessel."* 7th. We do not agree with Dr. Ferriar in the assertion, that " the violent pressure on the internal iliacs, and the accompany- ing veins and nerves, which takes place during delivery, must undoubtedly be considered as a powerful occasional cause of lym- phatic inflammation," p. 120. Now, if this were true, phleg- masia dolens would be of more frequent occurrence than it is; since this pressure is common to many labours, yet the disease in question is one of very rare occurrence. 8th. Because, in phlegmasia dolens, one of its inseparable cha- racters is the exquisite sensibility of the whole limb; so much so in most, instances, that the patient cannot bear the slightest pres- sure, or the slightest motion, yet Dr. Ferriar informs us that «the pain in lymphatic inflammation is referred to the enlarged glands, and is not remarkably increased by motion; there is more stiffness than actual pain in the whole limb," p. 102. 9th. Because, in the twelve or fourteen cases of exquisitely formed phlegmasia dolens, that we have seen, we never were able to trace the " inflamed lymphatics," or to feel the « enlarged conglobate glands;" yet, bolh of these circumstances are declared to be constantly present, by those who espouse the pathology under consideration.! • Med. Hist. Vol. III. p. 95. + Dr Hull declares the same inability: he says, " 1 have never met with either enlargement or inflammation of the lymphatics in any stage of the complaints PHLEGMASIA DOLENS. 479 10th. Because, Dr. F. furnishes a case himself, which dis- proves his own explanation, viz. "Jane Waters, aged twenty- five, was delivered by an accoucheur, of her second child, De- cember 26th, 1797, after being four days in labour. During de- livery she lay upon her left side. December 27th, she was af- fected with pain and swelling of the left knee, which descended to the leg and foot of the same side. On the 28th of December the swelling began to rise from the left knee and to affect the thigh. It extended up to the left groin and labia pudendi. I saw her for the first time on the 3d of January, 1798. I found ^-the swelling tense, uniform, not discoloured; that there was a ; 3&ffra*aensation of rigidity in the limb, and that it was extremely l&afhful on being touched or moved. She felt exquisite pain in the i^B&fJ* where I could perceive the lymphatics a little enlarged. The ti&ands of the groin were not affected, p. 127. In this case there was an exquisitely formed phlegmasia dolens; for it was attended by all the essential characters of the disease; the limb vvas exquisitely tender to the touch; the swelling was uniform and elastic ; it vvas not discoloured; the glands of the groin were not affected, and the lymphatics in the ham could be perceived to be "a little enlarged." Here then was a case of genuine milk leg, without inflamed "lymphatics" or " conglo- bate glands." We think we have said enough to prove that this pathology is not well-founded; and that if inflamed lymphatics, or enlarged glands be present, that they are the consequences, and not causes of the disease called phlegmasia dolens. The next hypothesis in order, and it is the last wilh which we are acquainted, is one of late date; it is by Dr. David Davis, a teacher and practitioner of considerable celebrity in London. Dr. Davis attempts to prove, that phlegmasia dolens is the consequence of an inflammation of one or more large veins; end- ing in the production of an extraneous membrane, or olher ob- structions, within their cavities; and thus offering remorae to the returning blood from the extremity. This view of the subject, from its supposed truth, has gained much more notoriety than can be sustained by facts, though supported by the powerful aid of Velpeau; and we may add, that I am therefore convinced that this is a rare occurrence, and by no means essential to the disease."—Essay on Phlegmasia Dolens, p. 116. It will therefore be per- ceived, that our observations apply to Dr. Hull only, as far as he admits th« lym- phatics to be involved. 480 PHLEGMASIA DOLENS. of Bouillaud and Ribes. When we say this, we would not wish to be understood as implying the slightest disbelief of the truth of Dr. Davis's statement: on the contrary, we are fully persuaded that neither he nor the gentlemen who, both directly and indi- rectly, support his doctrine, have set down nothing that they did not see—the only question then is, were the dissections of these gentlemen, cases of phlegmasia dolens? this is the point at issue— whether phlebitis and phlegmasia dolens are identical; or, in other words, are the cases related as cases of the latter, any other than instances of the former? Before we proceed farther in the examination of this question, it will be proper to determine the absolute character of phlegma- sia dolens from the best accredited practitioners; for to them alone should the appeal be made. And, perhaps, one of the older writers of this kind will be the safest guide upon this occasion. Callisen has summed up the characters of this disease most hap- pily in a very few words, making allowance for the introduction of one of its supposed causes in his time, namely, a melastasia of milk. " OZdema puerperarum, aliis lacteum est tumor elasticus, albescens, renitens, calidus, dolens, foveam impressi digiti baud retinens, puerperis haud infrequenter, gravidis rarissime infes- tus." He has, however, omitted a very material feature of the disease, namely, fever; for, as far as we have seen, this condition of the system has always been present, and sometimes to an alarming degree. The essential characters then of phlegmasia dolens may brief- ly be stated to consist of the following strongly marked charac- ters. 1st. Fever always to a grealer or less degree. 2d. Pain generally commencing in the hip, groin, and sometimes the back. 3d. Swelling commencing at the seat of pain, and proceeding with more or less rapidity down the whole limb. 4th. The swell- ing elastic, not retaining the impression oflhe finger. 5th. The whole swoln part white, even more so than natural, in some in- stances, but never red when uncomplicated. 6th. The whole limb exquisitely sensible to the touch. 7th. Total inability to move the limb, and action always creating great suffering. 8th. The temperature of the whole affected part much above the na- tural temperature. 9th. The labium pudendi of the diseased side almost always participates in the swelling, but never extending to the other labium, unless the other limb be also affected. 10th. After the first leg begins to improve, or is, perhaps, nearly well, PHLEGMASIA DOLENS. 481 the opposite leg runs through a similar course, and sometimes with an aggravation of symptoms. 11th. That the limb thus af- fected, rarely suppurates. 12th. That this disease is rarely at- tended by danger. 13th. That after the more violent stage of inflammation is abated, which generally happens, under proper treatment, about the sixth or eighth day, that the swelling abates its elastic character, and takes on that of a common oedema. 14th. The milk usually diminishes, and sometimes disappears. We have been thus particular, )?et, we trust, strictly faithful, in enumerating the essential characters of phlegmasia dolens, that the coincidences and discrepancies between it and phlebitis, may be^mo»e readily subjected to comparison. Symptoms and General Character of Phlebitis. In giving an analysis of the symptoms of phlebitis, we have chosen the one condensed in the Medico-Chirurgical Review, Vol. IV. p. 509, from Recherches Cliniques pour servir a l'His- toire de la Phlebite; par M. J. Bouillaud, M. D. Revue Med. Avril et Juin, 1825; and from Expose succinct des Recherches faites sur la Phlebite; par M. F. Ribes, M. D. Revue Med. Ju- illet, 1825. We have chosen this in preference to other autho- rities, because they are the latest who have written on this sub- ject, though we have no evidence that they consider phlebitis identical with phlegmasia dolens. We shall give the English version, as contained in the above named Review. First of Dr. Bouillaud. "Symptoms.—1. The symptoms of inflammation in the trunk of a superficial or external vein are easily recognised. The member swells, becomes hot, painful, or is even the seat of phlegmonous erysipelas. The vessel itself feels tense, hardt knotty, or like a cord. Abscesses not unfrequently form in the course of the vein.* The pain, our author thinks, is more de- * It seems, from late observations, that there is a marked difference in the pathological conditions of the internal coats of the arteries, and that of the veins: in the former, the adhesive form of inflammation is almost sure to occur; while in the latter, the suppurative is very certain to take place. This latter circum- stance has been frequently observed in the veins of the brain, and in those of the uterus. Dr. Clarke observed this condition of the uterine veins in women who he declared had died of puerperal fever; but, most probably, it was from hysteritis; and Dr. Abercrombie and M. Gendrin saw marks of a similar kind in the venous tubes of the brain. It must, however, be admitted, that the internal 482 PHLEGMASIA DOLENS. pendent on an affection of the neighbouring nerves, than on in- flammation of the vein itself. QEdema of the limbs is a very common attendant on phlebitis of one or more of the princi- pal veins, and evidently arises from the mechanical obstruction to the return of the blood—the veins being now acknowledged to be the principal conductors of the serous exhalations, (see note to page 477,) that take place into the cellular tissue. Such are the signs of local phlebitis. " 2. When the inflammation extends to the whole, or to a great portion of that vast membrane which lines the internal sur- face of the venous system, we constantly find that a violent fever is lighted up. Among many of our patients, the fever presented all those characters which are attributed to what are called putrid, adynamic or typhoid fevers; and indeed the term putrid is perfectly applicable, since after, nay before death, there are un- equivocal signs of decomposition, or a kind of putrid fermenta- tion of the fluids." Second. Mr. Ribes says, " The veins are very frequently inflamed, and this affection is a very dangerous one." (Yet phlegmasia dolens is a rare disease, and is very seldom danger- ous.) "In incipient phlebitis, the patient experiences a slight pain in the track of the veins affected. These vessels sivell and become prominent, presenting a light bluish colour, and sub- sequently a brownish pale hue. The circulation ceases in the vessel, and the blood becomes more or less decomposed. If the circulation should be re-established, the contents of the vein are carried into the current of the circulation, and dangerous conse- quences may ensue," p. 512. "Phlebitis is a serious malady, and is often quickly mortal." Ibid. We have thus brought into opposition the characteristic symp- toms of phlegmasia dolens, and phlebitis, which we now submit to the reader's candour to determine the strength of their analogy; or rather, how far they have a right lo be considered as absolute indentity. Let him run his eye over such parts of the description and consequences of phlebitis as are emphasized, and compare them with the general history of phlegmasia dolens, and he will coat of the veins have yielded lymph when inflamed, and obliteration has fol- lowed, as in the arteries. Dr. Baillie relates a case, in which the lower cava, from the emulgent veins to the entrance of the venx cava: hepoticse, was oblite- rated, as he believed to have been produced by the effusion of lymph and conse- quent adhesion. PHLEGMASIA DOLENS. 483 at once perceive, we are certain, their discrepancies, and deter- mine their entire want of sameness. But lest it be thought that we have drawn our conclusions from premises not attempted to be sustained by Dr. Davis, we will produce in a very short compass all the symptoms detailed in his histories, that he may speak for himself. "Case I.—Caroline Dunn, set. 21; -weak constitution, deli- vered on the 7th of February; severe labour; some hemorrhage after delivery; placenta removed artificially. 8th. Pulse 90; tongue white and moist; no pain in the abdomen from pressure; soreness in vagina. On the 13th, slight fever; pulse full and quick; costive; tongue white and dry; the labia pudendi in- flamed and ozdematous; some headach; respiration difficult; discharge from vagina resembling cream. 17th, better; 21st, much better; 22d, still better; 26lh, worse; leg and thigh much swollen; pain in the groin; no signs of inflammation; no pitting on pres- sure; 28th, no better; leg pitted on pressure; March 3d, total in- sensibility; limb equally swollen; 4th, died." We shall introduce a part of the dissection as performed by Mr. Lawrence, "which is a sufficient guarantee for its correct- ness."* Dissection.—"The left lower extremity presented a uniform cedematous enlargement, without any external discoloration, from the hip to the foot. This was found, on farther examination, to proceed from the ordinary anasarcous effusion into the cellular membrane." The inguinal glands a little enlarged, as they usually are in a dropsical limb, but without any sign of inflammation. The femoral, external iliac, common iliac, firmly plugged appa- rently by a coagulum of blood. The other veins thickened, ex- cept the saphena and branches, which were healthy. That the substances occupying the cavities of the vein were the product of inflammation. We cannot do better than present the observations on this case contained in a review of Dr. Davis's work on phlegmasia dolens. "We take the liberty of differing from Dr. D. on the identity of the case described with that of real phlegmasia dolens. We ground our first doubt on the fatal issue of the case, which is contrary to the general experience of the profession hitherto; for it must be recollected that Zinn's patient died of asthma, and not of phlegmasia dolens. If, then, there are very few cases on record, • Med. Chir. Review, p. 381. 484 PHLEGMASIA DOLENS. where phlegmasia dolens in itself proved fatal, we have at least grounds for supposing, (we do not say it amounts to proof,) either that Dr. Davis's case was not phlegmasia dolens, or that its proxi- mate cause was different from the proximate cause of phlegmasia dolens in general."* The reviewer asks, in a note, " Is it likely that so serious, and generally so fatal a disease as an inflammation of the internal coat of veins, under other circumstances, should be almost invariably devoid of danger in phlegmasia dolens?"f "Our main doubt, however," continues the reviewer, " is grounded on the anatomical, or rather, the pathological difference between Dr. Davis's case, and those described by authors. We have Mr. Lawrence's authority that the enlargement of the limb proceeded from ordinary anasarcous effusion into the cellular substance. Does this state harmonize with the description of phlegmasia dolens as given by authors, or as seen by practition- ers. It is contradistinguished, by all the writers we have pe- rused, from anasarcous infiltration, (and certainly from our own observation in at least four or five cases,) by the tense, or hard, or, at all events, elastic swelling of the limb—not pitting on pressure," p. 382. Dr. Bateman runs the following parallel between the two dis- eases:_«The swelling is general and equal over the whole limb; it is much harder and firmer than in anasarca, in every stage of the disorder; it is not so cold, in any state of.the disease, as in the dropsical swelling, nor so much diminished by the horizontal position; neither does it pit when pressed upon by the finger, nor does any water issue from it when it is punctured by means of a lancet."* " When these descriptions are compared with Mr Lawrence's dissection, we think every unprejudiced mind will agree with us, that Dr. Davis's case was of a character wholly different from genuine phlegmasia dolens," p. 383. "Case II —A lady of a sanguineous, irritable temperament, died suddenly in the midst of apparently high and perfect health, on the 20th of September, 1819, six weeks after confinement. She was seized with peritoneal inflammation the day after deli- Verv which yielded to active measures. Ten days atler this, she complained of a deep-seated pain in the groin, and along the ^reat vessels. Dr. D. found the limb swelled, and very painfu, but % leeches and blisters, this new inflammation was speedily re- . Med. Chir. Rev. Vol. V. No. 18, p. 382. t «*!. $ Rees's Cyclopaedia, Vol. 28. PHLEGMASIA DOLENS. 485 duced, and in a week, the swelling had entirely subsided, the pa- tient having recovered the perfect use of the limb. From this period she convalesced rapidly and satisfactorily, but died, as above stated, in the midst of apparent health." In what possible respect can this case be looked upon as a case of phlegmasia dolens? Is there a single coincidence of symptom between the two diseases? Tbe only circumstance on which even a remote analogy can be based, is " a deep-seated pain in the groin," and that " the limb was considerably swelled and exquisitely painful." But will such conditions of a limb alone, constitute phlegmasia dolens? " Case III.—This is a case communicated by Dr. Davis's friend, Mr. Oldknow. A woman was delivered, by an easy la- bour, in September, 1820. She did well for about three weeks. She was then attacked by a violent diarrhoea, for which she took astringents. Fever continued. On the thirtieth day after deli- very the diarrhoea returned, and *the left lower extremity be- came swollen and painful, with considerable increase of fe- ver.' Four days afterwards, she died," p. 435. In this case, Ihe only pretence for calling this a case of phleg- masia dolens, during the life of the patient, was the existence "of swollen and painful lower extremity;" and no proof of its having been a case of this kind, is adduced by the examination after death. The whole attention of the operator appears to have been occupied in the examination of the blood vessels; "the femoral vein and iliac veins were much enlarged, and contained adherent layers of coagulated blood. The same appearances, but in a lesser degree, were observed in the cava as far as the en- trance of the renal veins. The coats of the veins were highly inflamed, and intimately attached to the surrounding parts. The absorbents and glands were slightly enlarged." These morbid changes may, perhaps with propriety, entitle this case to stand with those of phlebitis; but it has no possible right to be ranked with those of phlegmasia dolens. The sudden death of this patient, we conceive, vvill effectually prevent her case from being acknowledged as one of phlegmasia dolens,* for we believe from what we have seen and read of this • It is true, that in the case related by Puzos, the patient died on the fifth day; but she appears rather to have "died of the doctor," than of phlegmasia dolens. He relates another that took place in the fourth month of pregnancy, and which proved fatal on the ninth day. 62 486 PHLEGMASIA DOLENS. disease, that it is the first instance, if it be one, that has termi- nated so suddenly in death. Indeed, this termination is so con- fessedly rare, that phlegmasia dolens has never been looked upon as a disease of danger,* though one for a time of great suffering, and almost always one of tedious convalescence. Case IV.—A lady of a delicate constitution, an irritable habit, was delivered on the 2d of July, 1S21. She was doing well un- til the seventh day; on this day she was exposed to cold, and was seized with a rigour. During the forming of the hot stage, she felt a pain in her left side, which increased rapidly, and for which she was bled without much relief. She was afterwards bled, leeched, and blistered. The affection of the chest was relieved, but fever continued. In the evening of the 9th, "unequivocal symptoms of phlegmasia dolens declared themselves." She died on the 23d of the same month. " On dissection, there was effusion and inflammation in the chest, 'the left lower extremity, from the hip to the toe, was considerably, but not greatly enlarged, and there was an evident enlargement of the labium pudendi.' The iliac veins on both sides were unusually turgid with blood. When the left was opened, it was found to contain a firm coagulum of blood,' not ad- herent to the vessel at that place. Higher up, however, in the common iliac portion, the coagulum was adherent to the internal surface of the vessel. The left internal iliac vvas greatly inflamed, and the diameter so much contracted as to be almost impervious. " In the above case, we have to regret that nothing is said of the state of the limb from the 9th of July, • when the unequivo- cal symptoms of phlegmasia dolens commenced,' till the patient's death. In the dissection, again, nothing is said of the pathologi- cal condition of the limb. The whole attention is concentrated on the vessels. Now it ought to have been Dr. David's chief and main object to prove, in all these cases, that the disease was really phlegmasia dolens, by an accurate description of the symp- toms and state of the limb, and then to have traced the cause, if he could. But it is evident that the first and main object is al- most totally neglected—or where it is adverted to, as in Mr. Lawrence's dissection, it makes against the question—and, there- • Dr. Francis relates a case on the authority of Dr. Mann of Boston, in which death took place from sphacelus, in consequence of the limb being punctured with a view to draw off the water supposed to be present. PHLEGMASIA DOLENS. 487 fore, we do not consider ourselves bound to subscribe to our au- thor's etiology, without having the necessary documents respect- ing the symptoms and dissections of the cases."* We cannot, however, hesitate to believe, that the swelling spoken of was produced by Ihe inflammation and obstructions discovered by dissection, as Ribes tells us it is one of the com- mon symptoms of phlebitis; but we must deny that that swell- ing, and the swelling attending phlegmasia dolens, are of one and the same kind, as this author expressly calls it, "cedematous." From all the facts adduced by Dr. Davis in support of his pa- thology of phlegmasia dolens, sufficient evidence is not afforded, that "the proximate cause of this disease is a violent inflamma- tion of one or more of the principal veins within and in the im- mediate neighbourhood of the pelvis," &c. Nor, in our opinion, is this pathology sustained by the cases related by Velpeau, pur- porting to illustrate the cause of this disease, though they coin- cide with the observations of Dr. Davis. Dr. Velpeau has drawn the same conclusion as regards the proximate cause of phlegmasia dolens as Dr. Davis, though not aware he had been anticipated in this by tbe latter gentleman. » We will briefly relate his cases—that is, we vvill mention every circumstance which may bear upon the question. Case I.—Valette, eighteen years old, had a tedious labour; on the third day she vvas much affected by some melancholy tidings. She now laboured under an acute pneumonic affection. Eleven days after delivery she had chills and fever, pain in the groin, hypochondria, and left side of the pelvis. On the forty-first day, the left leg was found lo be swelled, with pain in tbe hip and groin, and ultimately in the whole limb. " The whole extremity oedematous." Pressure gives pain only in the groin. On the sixtieth day she died. Dissection.—"When the left extremity was cut into, it was found much infiltrated in the cellular tissue. The lymphatic glands of the groin were much swelled and red—the muscles small and pale"—crural vein red externally, and its cellular coat thickened. This was the case in all its deep-seated branches. Purulent matter was found in these veins, and pus in the cava, and purulent deposition in other places. Can any one recognise phlegmasia dolens in the history of this case, or in the details of • Med. Chir. Rev. p. 385. 488 PHLEGMASIA DOLENS. the dissection? There vvas a swelled leg, it is true—but it is ex- pressly declared to be " oedematous," and this is the only re- semblance. Case II.—Damiens, thirty-five years of age. She had a quick delivery. During the three first days nothing remarkable oc- curred. Fourth, fever, and deep-seated pain in the pelvis. On the thirteenth day the lower extremities are much swelled and painful, especially the left. Fifteenth, breathing affected, diffi- culty in passing water, diarrhoea. Twentieth, the lower extre- mities more swelled and red, (enflees et rouges,) belly swelled and painful. Twenty-sixth day, died. In the dissection, there was nothing to justify the opinion lhat this was a case of phleg- masia dolens; or perhaps that it vvas a case even of phlebitis. Case III.—Has even less claim to the title assumed for it, than Ihe preceding—the only possible circumstance to rest such an opinion upon is, that "there were pains in the upper and lower extremities—the latter beginning to shoiv cedema. Such are the kind of cases which of late have been foisted upon the medical public, for instances of phlegmasia dolens; than which, nothing; can be less similar. Dr. Davis has evaded all the difficul- lies that might attach lo a regular history of the appearances of the limb, by declaring, in some instances, that "to-day unequi- vocal signs of phlegmasia dolens appeared:" we must there- fore take his word for the truth of the observation; not, however, that we would insinuate, that he would in the slightest degree misrepresent the appearances which led him to this conclusion, but lhat he was satisfied with symptoms which we think did not constitute the disease. The cases of Bouillaud and Ribes, are pre- cisely of the same character as regards their relation to phlegmasia dolens, though they may be looked upon as instances of phlebitis. But to Velpeau, we cannot even accord this acknowledgment. We find also a case recorded in the Medico-Chirurgical Review, for 1825, Vol. HI., New series, p. 540, which purports to be a case of phlegmasia dolens, that required the amputation of the leg in consequence of an apprehended sphacelus. The only circumstance on which the title of the case is founded, is, that "Me limb was not evidently swelled, but there was a good deal of tenderness in and about the ham." But unfortunately for Mr. Davis, the narrator of this case, he had just before in- formed us, that" the limb became instantly paralyzed, from be- lowtheknee to the toes,hysi sudden metastasis of excruciating pain PHLEGMASIA DOLENS. 489 from the left loin and hip, which suddenly flew down to the leg and foot." On dissecting the amputated limb, "the veins were found completely distended with firmly coagulated blood; their coats were thickened, and their inner surfaces very much in- flamed." In consequence of which Mr. Davies declares, that "the morbid appearances tend to confirm the truth of Dr. Davis's views of the pathology of phlegmasia dolens." To which we might perhaps agree, if there had been a single symptom of this disease present; or if Dr. Davis had proved that phlebitis, and phlegmasia dolens, were one and the same disease; or even, if in phlegmasia dolens, that phlebitis were constantly present. This latter, how- ever, we confess, would have been a most difficult task, as the rare fatality of phlegmasia dolens leaves but very scanty chances to do so; while phlebitis is very frequently fatal. But what will be said by the advocates of this new doctrine of phlegmasia dolens to the observations of M. Tonnelle upon puerperal fever, and in which the subject of phlebitis is mentioned as a frequent occur- rence; and which has a direct bearing upon the subject in question; and we may add, with a peculiar force, as his facts were not intended to be applied to the use to which we now wish to apply them—namely, that of 324 cases of puerperal fever, there were 134 in which pus vvas found in the veins and lymphatics; yet even oedema was present but in one instance; and not one word is said of phlegmasia dolens! Could such a state of a limb have been overlooked by apparently so careful an observer as M. T., had it been present? And if uterine phlebitis be the cause of phlegmasia dolens, would it not be reasonable to have expected one case of it, among so many instances of phlebitis? And farther, that phlebitis uniformly gives rise to a typhoid form of fever, a cir- cumstance well worthy of note, as no such type of fever has ever been found to belong to pelegmasia dolens. Having thus reviewed the several opinions which have been offered on the proximate cause of phlegmasia dolens, we are every way assured, lhat they will appear to the greater part of medical practitioners, as unsatisfactory as they have to us; but, that they unequivocally prove, thai this interesting subject of pathological research remains still unsettled. We have upon this subject but two suggestions to make; namely—1st, be the affection seated in whatever tissue it may, its character is highly inflammatory; 2d. that in our opinion, that this inflammation occupies exclusively the white lymphatic vessels of the cellular membrane of the 490 PHLEGMASIA DOLENS. several textures of the limb; for we are every way satisfied that redness is not essential to inflammation, as we have before de- clared. We therefore agree in part with Dr. Hull, since he ad- mits among the tissues he particularizes as being involved in this disease, the cellular membrane as one. And in support of the opinion we have adopted respecting inflammation, we think we cannot do better than employ his arguments against redness be- ing a sine qua non to its existence. " Should it be objected to this theory that there is no redness of the external surface of the cutis, my answer is, lhat redness, though a general attendant of inflammation in the human body, does not constitute inflammation, nor is it a circumstance essen- tially necessary to inflammation. The cheek in blushing, for example, presents redness, and increase of heat to the eye and touch; but there is no pain, consequently no inflammation. The cornea, on ttTe other hand, when we cannot trace a single vessel carrying red blood beyond its margin, is frequently affected with inflammation; there is pain, heat, &c, and small abscesses or ul- cers, or depositions of coagulable lymph, commonly called specks or pearls, take place in it. Animals which have no red blood in any part of their system, are not exempt from inflammation. And the less acute kinds of inflammation, which take place in the membranes of the brain, the pleura, peritoneum, tunica va- ginalis, testes, &c, are not always characterized by an evident redness, especially when an extravasation of coagulating lymph, or a large effusion of serosily soon happens and moderates them, as in peritonitis conjunctiva, and in apoplexia hydrocephalica Cul- leni and the acute stages of hydrothorax, ascites, and hydrocele. Hence, it may happen, that when the symptoms of a disease in- duce the attending physician to consider it as a phlegmasia, dis- section may be supposed to show lhat he is mistaken as to the nature of the complaint, if redness be admitted as an essential mark, a sine qua non of inflammation. Indeed this point ap- pears to be almost entirely given up by late pathologists. What the exciting causes may be of this disease, we are not exactly prepared to say, as it takes place in two diametrically opposite conditions of the system; namely, that of repletion and of exhaustion. Thus, we have seen it in two highly plethoric females- with one the labour vvas rapid and easy; in the other it • Hull on Phlegmasia Dolens, p. 209. PHLEGMASIA DOLENS. 491 was rather tedious, and very painful. In several others we have witnessed it to follow severe and extensive uterine hemorrhages, and, were we to decide from our own experience as to the fre- quency of its occurrence after any one condition of the system, we should say, it was most apt to follow severe uterine losses of blood, than from any other single cause. Method of Cure. However writers may disagree as regards the particular struc- ture occupied by this disease, they are unanimous with respect to the nature of it—they all maintain it to be inflammatory. About this there can be no mistake, as all its symptoms and habits de- clare this condition of the tissue lo be present. We have fever with a highly active pulse; a hot dry skin; acute pain; and swell- ing, attended by heat of the part; excessive soreness of the limb to the touch; great thirst, sometimes; white tongue, &c; in a word, every thing that betrays an active local inflammation. Blood-letting and Leeching. The means of cure consist in depletion from the circulating system, both general and local—we therefore abstract blood from the arm, to the full extent the system will bear at the time; but which must be repeated, if the fever be but little or none abated, and the pain be undiminished. So soon as the force of the pulse is diminished, if the fever continue, leeches should be applied to the diseased limb, in such number as shall secure the loss of five or six ounces of blood. Our practice in the use of leeches, is to have them pretty much dispersed over the surface of the limb, that their bites may not be too near each other; as they some- times leave troublesome sores, when crowded together where the skin is much distended. The leeching may be repeated in a day or two, provided the pain, heat, and elastic feel of the swelling, remain severe or unabated. We, however, never apply the leeches until arterial force is weakened by bleeding from the arm; as relief is by no means certain unless this has taken place. In two or three cases we were obliged to repeat the bleeding six or seven times, and the leeching two or three, before the disease yielded. 492 PHLEGMASIA DOLENS. Purging, fyc. In aid of blood-letting, we employ purging to a liberal extent, during the continuance of the active stage of the disease; and, for this purpose, we prefer the saline cathartics; especially when combined with an equal weight of calcined magnesia; the follow- ing are the usual doses: R. sulph. magnes., magnes. alb. ust. au. 3iij. M. div. in iij. One of these portions is to be given every two hours, in a wine-glassful of sweetened water or lemonade, until they operate freely. We have, also, found decided advantage in the nitrous anti- monial powders, until fever is reduced, or perspiration estab- lished. The regimen, throughout the active stages of the dis- ease, is to be strictly antiphlogistic. Topical Applications. Much injury is oftentimes done by the injudicious employment of stimulating embrocations or liniments; this should be peremp- torily forbidden. No kind of application whatever should be made to the limb itself until after the fever has abated and the pulse is reduced by bleeding; or leeching the limb. When this is effected, the vinegar vapour bath may be used, two or three times a day, with great advantage, but not before. The mode of employing this is as follows; the limb should be bared in the bed, and the bed-clothes be raised from it by means of a common hoop from a barrel, being cut in two and tied to- gether at right angles wilh each other; this must be made to straddle the leg. Three bricks must be heated pretty hot, and then plunged in vinegar; after they are loaded wilh the vinegar, they may be folded in cloths, and one applied to each side of the limb, and the other to the foot. The bed-clothes must now be returned over the spider, to keep in the vapour arising from ihe bricks. This steaming should be continued until the patient complain of feeling weak; Ihey are then to be removed. This process is almost certain to produce a copious perspiration over the whole extent of the limb. Should this, however, not be found to be the case upon examining the limb in fifteen or twenty minutes after the application of the bricks, but, instead, the limb is found to be hot and dry, these articles should be removed, as PHLEGMASIA DOLENS. 493 they will not succeed if they are even allowed to remain, as the heat of the limb is beyond the sweating point. When this happens, we may be certain that the bricks have been applied too early—that is, before arterial action was suffi- ciently reduced. In this case, we must renew the depleting re- medies, either general or local, or both. On this account, it is always well to examine the pulse carefully before we have re- course to this remedy. But when perspiration is induced, the patient is almost certain to experience great relief, though, for the most part, but temporary at first; it must, therefore, be re- newed whenever the pain becomes excessive. Opium. From pain, and that excessive for the most part, being the constant attendant upon this complaint, it has been thought too generally, that opium, in some form or other, should be adminis- tered—but this, in our hands, has always been found highly inju- rious in tbe early and active stage of phlegmasia dolens. It should, therefore, never be given until the system be sufficiently reduced to bear this drug wilh advantage. And when it is eli- gible, the best mode of administering it is by injection. And, for this purpose, a tea-spoonful of laudanum, in a gill of warm wa- ter, may be used as occasion may require. Or Dover's powder may be used at bed-time in the dose of ten grains, when the sys- tem can bear with profit the stimulus of its opium, and especial- ly when the skin is indisposed to perspiration. As a general rule, the system will not bear the use of opium as long as the swelling preserves its elastic character, and this is generally from six to eight days. Nor should any stimulating applications to the limb be resorted to, until the intumescence puts on the appearance of oedema; for, until this change takes place, the active, inflammatory stage, has not passed away. About the time above specified, (for we have known it happen earlier or be retarded later,) pain, heat, fever, and swelling, begin to abate, and the patient is able to support her sufferings with less complaint. She can now, for the most part, bear the limb to be moved, or its position changed, without so much torture, though still very far from being relieved. 63 494 PHLEGMASIA DOLENS. External Applications. We have always made the changes now spoken of, the guide for an additional application to the affected limb; (that is, when there is an abatement of the constitutional symptoms, and the swelling will retain the impression of the finger,) we now order a moderately stimulating embrocation, consisting of a beef's gall mixed in three half pints of brandy, rum, or whisky. With this the limb is to be bathed, (not rubbed,) two, three, or four times a day, as the patient can best bear it, having it a little warmed previously. We would here suggest a caution to the nurse, that is more important than might at first sight appear—namely, to literally bathe the part, and not to rub it. Very great mischief is oftentimes done, by not paying attention to this rule, in all lo- cal applications; for nothing but evil can follow the other mode, so long as inflammation, (however moderate,) continues to occu- py the parts. But after this condition is removed, we believe that advantage may be derived by gentle friction, as it appears to contribute to absorption. Blisters. These remedies have been recommended by almost every writer on the subject of phlegmasia dolens—but why, we are at a loss to understand. For they are either not the appropriate remedies, or we have been very unskilful in their application. We have never had recourse to blistering but twice, and sorely did we repent each application. The disagreeable irritation pro- duced by its operation in the first instance, and the tedious, disa- greeable ulcer that followed, we imagined might have been owing to some accidental condition of the system, or perhaps idiosyn- cracy; this led us to a second trial, but we experienced the same inconveniences: since when, we have altogether abandoned their use. Before we ordered this remedy, it is proper to state, that we thought we had reduced the system to the proper blistering point, but in this we may have been mistaken. Besides, hovv- ever,'the disadvantages just mentioned, arising from blistering, there are others which should not be lost sight of—namely, pre- venting other local applications, and especially the one mentioned above, which, in our opinion, is very much more useful; and, se- condly, by obliging the patient to maintain one position unneces- sarily long, which is of no trifling moment to the invalid. PHLEGMASIA DOLENS. 495 Bandaging. This application has been recommended in phlegmasia dolens by some practitioners, ab initio; but our own experience obliges us to say of it, that we have either been very unfortunate in our lot of patients of this kind, or if this be not so, that those who have professed to have derived advantage from it have mistaken oedema for phlegmasia dolens. For we certainly have never met with a case of this disease, lhat could bear, without severe com- plainings, the weight of the bed-clothes upon the affected limb, much less a bandage tightly drawn. We, however, must be ho- nest, and confess, that we have ever been deterred from the appli- cation of the bandage in the early stage of the disease, from the presence of so much sensibility in the part; in the last stage, we have known peculiar benefit derived from its use. It is almost a constant sequence, that after all inflammation has disappeared, that the limb will remain swollen and feeble. For this condition, much advantage is derived from bandages, frictions with the dry hand, fumigating the limb with the smoke of burn- ing rosin, and exercise in a carriage. The fumigation is conduct- ed as follows: the patient's limb is to be placed across a tub, in the bottom of which there is a small chafing-dish with hot embers ATtttle powdered rosin is to be strewed upon the embers, and the fumes prevented from escaping by having a blanket spread over the limb and tub—this may be repeated twice a day. It vvill be proper to observe that the limb should be kept a lit- tle elevated during the whole of the disease; this is best done by a board well protected by pillows, and placed under the leg, with its lower end raised as high as the patient's feelings vvill permit. After the febrile symptoms have disappeared, the patient's diet may be a little more generous: she may take thin chocolate, a few oysters, chicken water, or soft-boiled egg, &c, and if there be much debility, any of the tonics in common use may be employed wilh advantage; and these will be aided by a well-regulated sys- tem of exercise, which must, of course, be left to the discretion of the physician, and to the circumstances of the patient • 496 MILK ABSCESS. CHAPTER XX. OF MILK ABSCESS. It is scarcely necessary to mention, that the female constitu- tion is much disposed to fever after parturition; the various cir- cumstances attending gestation and labour, which are calculated on the one hand, to produce predisposition, and on the other, to excite fever, leave the system but little opportunity to escape this evil, unless much care be paid to guard the woman against all exciting causes. But, unfortunately, the practice of those who have charge of females at this period, is the very reverse of what is dictated by reason, or is sanctioned by experience; and hence, the production of fever, in a greater or less degree. From the changes which almost invariably take place during pregnancy, and immediately after delivery, it is evident, that it is the design of nature that the mother shall provide nourishment for the child, at a certain period after delivery; and for the fulfil- ment of this design, milk is generally formed in the breasts, as soon after delivery as the necessities of the child require. The evidence of the capacity of the mammas for the produc- tion of this fluid, consists in their tumefaction; and when this se- cretion is best performed, it is neither attended with excessive swelling nor painful distention. Nor is the arterial system ex- cited to fever, for the purpose of preparing milk, as is erroneous- ly supposed by many. But we too frequently witness the very reverse of what should have taken place under proper manage- ment, from the neglect of the most obvious rules of propriety, and the total disregard of the suggestions of nature. Milk fever is so familiarly spoken of, and is so constantly ex- pected, as to be considered a sine qua non to the production of this fluid; hence, it is rarely guarded against by suitable restric- tions; and hence, the frequency of the mischief it creates when too violent, or when unrestrained. It is evident, from this view of the subject, that there must be an error in the premises assumed respecting this function; it is this error which we now wish very briefly to point out, that the consequences may be avoided. MILK ABSCESS. 497 It is, in our view, an absurdity to suppose that nature designed the child should be furnished with nourishment at so much ex- pense of health and comfort to the mother. That she should run the risk, not only of ill health herself, but also of being de- prived of the capacity to fulfil the object for which this secretion is intended; or, in other words, that the capacity to furnish sup- port for the child, should deprive the mother of the power of making the provision. For in how many instances do we see the useful purposes of the breasts destroyed by inflammation and suppuration? These considerations make us pronounce the fever, which ac- companies the swelling of the breasts previously to the formation and discharge of the milk, a disease of artificial origin; in proof of which, beside what we have endeavoured to establish from reason, it can always, or with very few exceptions, be avoided, by proper observances on the part of the patient herself, and those who may have charge of her.* The rules for this purpose are simple, and of easy execution. First. After delivery, let no stimulating article be given the patient, as wine, or liquors of any kind; spices, chocolate, &c. Second. To allow her no animal substance whatever, either in a liquid or solid form, as soup, &c. Third. To permit her the free use of cool drinks, as toast wa- ter, balm tea, water alone, or lemonade. Fourth. To give, on the morning of the third day, a cathartic of sufficient power to procure three or four evacuations. Fifth. To allow fresh air lo pass freely through the room, and around her bed; and not to heat her body, by an over-quantity of bed-clothes, or by being surrounded by curtains. But the last direction must be so conducted, as not to endan- ger her taking cold. Sixth. To apply the child early and frequently to the breast. By observing these rules, we know that milk fever may be avoided in almost every instance. But should these rules not be observed, the distention of the breasts may become so great as to excite severe pain; and from an overstretching of the tubuli lacti * We have occasionally met with cases where the formation of milk was always attended with fever, notwithstanding every precaution was used to prevent it These instances must be looked upon, as the exceptions to the rule; for fever to any extent does not occur, perhaps, once in a thousand times. 498 MILK ABSCESS. feri, inflammation may be excited, which may terminate in sup- puration. * It must, however, be acknowledged, that milk fever is not the only cause of mammary swelling and abscesses. There is a pe- culiar liability to this disease, during the first fifteen or twenty days after delivery; and the causes may be various and obvious, as well as special and hidden. Blows or bruises; bad nipples; exposure to cold, either general or partial; a neglect of discharging the milk in proper time from them; pressure from stays or corsets; metastasis, &c. At other times the breast swells and inflames, without our being able to determine the cause. Some women are more liable to this affection than others; and they will some- times have a repetition of it with almost every child they may have. Sometimes a chill announces a derangement in the system; soon after which, a pain is felt in one of the breasts, and, upon examination, a tumour may generally be discovered in the sub- * We shall relate a very extraordinary case of the accumulation of milk in the breast, from Prof. Scarpa, both on account of its singularity as well as for its practical value. " A young peasant, of small stature, but robust constitution, perceived, ten days after a second accouchment, a tumour in the left arm-pit, not preceded by any inflammatory symptoms or pain. She continued to suckle her infant from both breasts—but more especially from the left, in the hope of dissipating the swelling; but the effect was quite contrary to her expectations, for the flow of milk in that breast diminished every day; while the tumour in the axilla increased. This tumefaction gradually extended to the mamma, and, at last, occupied the whole of it. In the course of two months the breast got to such a size that it measured thirty-four inches in circumference, and, when sitting, the mamma rest- ed on the thigh of that side. The skin covering this tumour presented no parti- cular alteration in appearance, except that it was rather tense and shining, the subcutaneous veins being dilated. Prof. Scarpa thrust a middle-sized trocar into the tumour near the axilla, where the integuments appeared thin. A flow of pure milk flowed, and ten pints were drawn off in a continued stream. The celebrated Dr. Frank was present at this operation, and was not a little asto- nished. When the milk was evacuated, the mamma was scarcely more volumi- nous than the other. The wound made by the trocar was enlarged, and a tent introduced for the purpose of facilitating any farther discharge. The milk was sent to M. Scopole, Professor of Chemistry, and its analysis showed, that notwithstanding the long sojourn of the fluid in the breast, it differed in none of its physical or chemical qualities from the recently secreted milk of a female. "The obliteration of the cavity where the milk was lodged, could not be ef- fected till a seton was established there. The cure was ultimately complete." Med. Chirur. Rev. Jan. 1827, p. 221. MILK ABSCESS. 499 stance of it; at other times, no such tumour can be felt, but the breast is observed to swell, and be tender when pressed. From this variety in the early stage of this complaint, it is evident that ihe seat of inflammation is not always confined to the same tissue in this organ; sometimes it is a portion of the gland which is attacked, and at others it would appear to be the cellular substance alone that is involved. When the gland is attacked, it suddenly increases in size, be- comes extremely tender to the touch, and gives a great deal of acute pain. The breast sometimes swells to an immense size, especially such as are naturally large, and what is called fleshy. The woman finds no comfort or ease in any posture, and the weight of the breast itself occasions much severe suffering. Fever is excited in the early formation of the local affection, and will be of different degrees of intensity, as the inflammation of the gland may be extensive, or as the system may be disposed to febrile action, or as it may be confined to the cellular mem- brane. The progress of the inflammation to suppuration, though al- ways constant, if not interrupted, is not always equally rapid; sometimes it requires many weeks before the pus will discharge itself, or permit an outlet to be made for it. But much will de- pend upon the seat of the gland that may be affected; if it be deep, it will require a longer time, and so on. It may, however, be observed as a constant rule, lhat the inflamed gland is always longer before it suppurates than the cellular membrane when it is the seat of the inflammation. It is beside very much more painful; and is attended with higher sympathetic fever, though the breast never becomes so large as in the other instance. In the variety of this complaint now lo be noticed, the same remote and exciting causes may have operated; though we can- not say why the cellular membrane should have been selected for its seat. It commences by the same general phenomena, ex- cept we believe, that it is always preceded by chill; and the first intimation the woman may have, that it has " fallen on the breast," is a swelling and tenderness of the part upon pressure. The breast is now rapidly distended, and generally in an equal man- ner; that is, without a circumscribed tumour within its sub- stance. The whole progress of the inflammation, &c, in this variety, is vastly more rapid than in the other, and were we to judge 500 MILK ABSCESS. merely from appearances, is more alarming; the swelling is much greater; but the pain is much more moderate. Indeed, we have seen it run on to suppuration, without the slightest pain, except from pressure. This variety passes through the same stages as the other; and pretty much after the same manner, if we except the rapidity of its march. We have seen it pass on to suppura- tion in the course of a week. The external inflammation is much less intense, and is very rarely attended by oedema. Indeed, we, have seen very extensive suppuration, with scarcely any discolo- ration of the skin. It is also much less amenable to remedies; for it is very rarely made to resolve itself, however early at- tacked or vigorously pursued the plan may be. The two varieties may be combined, and it is not very unfre- quent that they are: when this takes place, the inflammation of the gland always appears first, and the cellular membrane after- wards becomes implicated, either from an extension of the origi- nal inflammation in the gland, or by taking on this action later; for we have never witnessed the cellular membrane injured, until some time after the gland; nor have we ever seen the gland in- jured from the inflammation of the cellular membrane. However, if the progress of the gland to suppuration be slow, or the diseased part be very deep-seated, the cellular membrane may remain free for a long time, unless the complaint have been treated by stimulating or other improper applications; or by the early use of poultices. In this case, the part becomes enormously swelled; the epidermis separates from the true skin; a great num- ber of small vesications appearand the depending part of the breast becomes oedematous, and sometimes even discharges a considerable quantity of serum; indeed, the whole of the skin, covering the inflamed part, appears thickened, and saturated with a fluid, which escapes upon the smallest injury done to the part. This is so conspicuous sometimes, as to disguise the inflamed ap- pearance of the integuments; and if it be pressed by the point of the finger, the impression vvill remain a long time, though it be not in a depending part. Of the Treatment. There is no inflammation of the phlegmonous kind, that runs on to suppuration with so much certainty, and sometimes with so much rapidity, as that which attacks the mamma. On this MILK ABSCESS. 501 account, not a moment is to be lost in temporizing; for an im- pression must be made, and that quickly, or all efforts vvill be unavailing, and the woman often be made to suffer for a long time an acute and almost never-ceasing pain. Is this failure to procure resolution a necessary and an una- voidable consequence? Or is it, in part, owing to the first period of the inflammation being either neglected, or improperly treated? We have said, that the inflammation of the breast runs on to sup- puration with great certainty: by this, we would wish to be un- derstood, that, if let alone, or if ill managed, it vvill rarely fail to suppurate; therefore, if an attempt be made to counteract this constant tendency, the remedy should be of the most decidedly antiphlogistic kind, and applied early. • But our want of success in resolving mammary inflammation, does not exclusively arise from the pertinacity of its course; for ihere are several other causes, which almost constantly operate with equal certainty. First. It is almost constantly submitted to the management of the nurse, or subjected to the "infallible cure" of some old woman. Second. To very inadequate means being advised, and perse- vered in, until the time for the successful application of the pro- per remedies is irretrievably lost; or, Third. To stimulating and beating applications being used, which quickly inflame the skin externally; which unites with the one which has already attacked the breast within; and thus making it necessary to contend with two enemies instead of one. Fourth. To a want of perseverance and conformity to the pre- scriptions of the physician, after he has seen the breast, because immediate relief may not be experienced, or because some other plan has been advised. Fifth. To a false delicacy and fear on the part of the patient, lest the part be examined. The above causes are almost sure to operate against the early use of proper remedies; and it is almost certain to happen, that the physician is not consulted, until so much mischief is done, lhat he cannot, but in part, repair it. From what we have ex- perienced, when a fair chance has been offered us to oppose this disease, we are of opinion, that it need not suppurate near so often as it does. This holds out a strong inducement to the woman not to temporize, lest she incur an injury that will not be repaired through life. 502 MILK ABSCESS. It is never too soon to oppose this disease; and if a very early opportunity occur, the woman should be advised so soon as pos- sible to employ the remedies, and to follow the plan now to be advised. 1. Local Applications. We have never found any application s6 successful in the very early stage of this disease, as the frequent use of warm vinegar to the part. Its efficacy appears to us so certain, when sufficient- ly soon employed, that we need not in many instances look for any other remedy. It is particularly prompt in that condition of the breasts, in which a want of proper drawing leaves them; or where they become greatly and painfully distended by the sudden secretion of milk, but which cannot be extracted with ease, or in sufficient quantity to relieve the tension, either from a defect in the external or inferior extremities of the tubuli lac- tiferi, or a proper conformation of the nipples themselves. These accumulations are always painful, and easily provoked to inflammation, by either the use of improper food, or improper local applications. It is therefore every way important that this tendency should be arrested in limine. For this purpose the vi- negar is the most comforting, and, at the same time, the most certain, with which we are acquainted. This application is highly useful also in the commencement of both the first and second varieties of mammary abscesses; and should be employed most perseveringly for at least twenty-four hours. If the pain or intumescence be not abated by this time, leeches should be applied in sufficient number lo abstract from eight to ten ounces of blood, and their wounds encouraged to bleed by cloths wrung out of warm water, or a soft bread and milk poultice.* The poultice is, however, to be removed so soon as the bleeding ceases, and its place supplied by a piece of linen rag, spread with fresh hog's lard; or a plaster of hog's lard and common flour, incorporated, and spread upon a cloth suffi- ciently large to cover the breast. These applications are to be continued until the leeches' bites * 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 nortion of it, as is usually done. We would therefore recommend the applica- tion of the leeches to be made about an inch below the circular marg.n of the mamma. MILK ABSCESS. 503 are sufficiently healed to bear again the use of the vinegar, or the reapplication of leeches. We would use the first, when we are certain the disease has diminished; and the second, if we thought the disease to be gaining ground, or stationary. For it must be recollected, no truce is safe with this inflammation. We would therefore persevere in the leeching until we cannot hope to pre- vent suppuration. When this happens, let it be remembered, we are not to pro- mote the tendency to suppuration by poulticing, &c.; for this only increases the pending mischief, by the formation of a great- er quantity of pus, and the consequent destruction of a greater quantity of the substance of the breast, by which its future use- fulness may be entirely destroyed. It should therefore be a ne- ver-failing rule, to treat a mammary inflammation as if it were not to suppurate. From the period in which we look with certainty for the breast to suppurate, to the time at which this takes place, some saturnine application should be employed steadily. We are in the habit of using the following liniment for this purpose, and we think with advantage. &. 01. Olivar. Opt. - - gij. Liq. Plumbi sub. acetatis, gj. Mther Vitriol. - - - 3'j- Tinct. Thebaic. - - £j. M. A rag to be moistened'with this liniment, and applied to the part frequently. Dr. Clarke speaks highly of the following formula, for the same purpose. g<. Cerussa acetata, gj. Acetum. Distil. gij. f. sol. adde. Sp. vin. rect. ^j. Aq. Distil. - gv. M. This is to be applied constantly to the breast, cold, by means 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. Caffe states, (Journ. Hebdom. vol. ii. p. 23,) that in secre- tions of milk, attended by swelling and acute pain, that the fol- lowing embrocation acted with immediate benefit and relief. 5<. Aq. distil. Prun. Laur. ceras. gj. .Ether Sulph. - - - 3J- Ext. G. Opii, - - - grs. »j. M. Apply it by means of fine linen, well wet with it. 504 MILK ABSCESS. And Ranque recommends another application in the following terms:— " The swelling of the breast, which precedes the formation of mammary abscess, 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 mamma; 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 be ame- nable to the common methods of treating local congestions and inflammations. "All practical men are, consequently, obliged to adopt vari- ous methods of treatment; and the skilful accoucheur is often en- abled, by attention and pains, to save his patient from the suf- fering accompanying such affections." Ranque, impressed with certain theoretical ideas, which it is unnecessary here to discuss, was led lo the use of the following liniment:— $. Extracti Belladonnae, 9"ij. Aqua Laur. cerasi, §ij. JEtheris Sulphurici, gj. Ft. Linimentum. This must be well shaken before it i. used. It is to be rubbed into the breasts, as high as the axilla, morning and evenmg, and h breast must be then covered with fine flannel, -afed ,n e iniment. This proceeding must be repeated every day, un., heXelling disappears, which is usual.y on the second or th.nl day The ether has a smel., which, to some, .s very d.sagre a- bit but they ought to bear this inconvemence, ,f poss.b.e, for it adds essentially to the efficacy of the remedy. 2. Regimen. I„ aid of the local applications mentioned above, the patient must be restricted to a severe anHj,dogisltcregtme«; no an, 1Unbalance in any form should be allowed; nor any k,nd of Z^™^ She *» h8Ve *"' ^ ^^ mi'k ' 9 MILK ABSCESS. 505 water; rennet-whey; very thin tapioca; thin sago; arrow-root; roasted apjples; fruits of the season, &c. Her drink should be water; toast-water; molasses and water; apple-water; or thin le- monade. 3. Purging, c/c. Her bowels should be freely purged daily, by any of the neu- tral salts, magnesia, senna, &c. And, should there be much fe- ver, she should lose blood from the arm, again and again, if ne- cessary. 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 enve- loped 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 mat- ter is 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 al- lowed 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 piece of rag interposed between the thumb and finger. Should this, however, occasion pain, or blood discharge itself while 506 MILK ABSCESS. making this effort, it must be desisted from; tbe 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 lo be frequent- ly 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 mighl 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 vvill 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 corro- sive 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 vvill 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 Ihe substance of the breast, to ils 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 MILK ABSCESS. 507 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 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 ispassed 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 upon, 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 lo 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 508 HYSTERIA. sorption; this creates a good deal of uneasiness in the palient, lest it be a scirrhus. On this point, her fears may bo composed; as the tumour which remains vvill 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 side next to the breast; if in summer, a piece of fine flannel will an- swer 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 al- ways well defined. This variety creates a difficulty, which we are persuaded, every practitioner has encountered in the com- Ilent of his practical career; but with which he becomes familiar from a longer acquaintance and study of morbid phe o- laminar iro 0 ^ tolerabIe certa.nty, rb^e^eyt modifying the dise.es of theothcr yLms; Lean determine very nearly, in what degree they may be considered as belonging to the nervous system. The disease under consideration, may be justly ooked upon „ the assemblage of very many symptoms, the nature, and ex- „t "h, must necessarily be much diverged, as the sea , Xmpathy in several organs of the body may be ,n a fewer or 1 S number; and as these may be more or less .mporlant. a grewer nm , . . th t ,he affections under consi- The ancents were of op „ on ^^^ deration, arose from some derangeuie. onwWeh theybestowed verymany gratu.tous powers. Indeed, HYSTERIA. 509 many modern practitioners are still of the opinion so boldly ad- vanced by their predecessors. Dr. Good* says, "With a morbid 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 other portion of the body, may givfe 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 secondarily affected, there cannot be a doubt. But lhat every derangement of function, or even lesion of this organ, will produce hysteria, there is the most unquestionable reasons to deny; indeed, it seems, that when the uterus is seriously affected, as in cancer, there is verj often an absence of those distressing symptoms which every body agrees to call nervous.t 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 exemption 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, be- fore 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 * Study of Medicine, vol. iii. p. 352, Am. Ed. f 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, whiclyre think essential to its existence. He considers hysteria a misnomer, if this jRise 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 com- 510 HYSTERIA. 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, per- haps, are its functions performed precisely alike, at least, as far as can be determined by external phenomena. Nor is it probable that we shall ever be much more enlightened upon this subject; since we know nothing, or but very little, of its condition in ab- solute 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 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 condi- tions 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 absolute health, either as regards action or organization? All derangements of this organ cannot consist in the alterations above mentioned. There must be many others, where the attempt to develope them bv the knife would be vain. It is, therefore, not sufficient for tbe best purposes of patho- lozVAlfl declare, that the brain was not concerned in the disease of wll-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 HYSTERIA. 611 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 were 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.* 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- • 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 dis- sections of those who have died of them, that the stomach and intestines, liver, spleen, omentum, mesentery, or uteras, have frequently been found obstructed, scirrhous, or otherwise unsound; yet, as in many other cases of the same disorders, no such morbid appearances have been observed in the body after death; it fol- lows, that these symptoms may frequently proceed from causes, whichjkiding our senses, are not to be discovered by dissection. Nay, obstructionJQ^^K and other disorders 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. 584 512 HYSTERIA. 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 degluti- tion, and respiration, and sometimes the whole muscular sys- tem, &c. &c* In hysteria, a 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 lo sympathize with this condition of the brain; and thus give rise to several phenomena peculiar to the part thus sympathizing; hence, the " Protean shapes " 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 a diminished secre- tion of bile; biliary calculi; pain in the right side; with a sense of fulness and distention ; obstructions, &c. If the kidneys, an immoderate flow of pale, or limpid urine; or a very much dimi- mished 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, faintness, &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 hystericus. If the muscular system, violent convulsions, or nervous twitchings, as they are called, &c. In hysteria, certain parts of the body sympathize with the • 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 cdflCon "the relation between the nervous and sanguiferous systems." He says, tH^neither mechanical nor chemical stimuli, applied to the nervous sys- tem, excite the muscles of voluntary motion, unless they are applied near the ori- gin of the nerves, and spinal marrow." l'hil. Trans, for 1815, p. 444. HYSTERIA. 513 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 always participate in the affection, and declare its exist- ence. 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 exist, this peculiar condition of the system betrays itself, and mark 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 malig- nant tendency; though they are by no means incompatible with a plethoric condition of the system; or with fevers of very mo- derate 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, simi- late 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 produced; various affections arising from ossifications of the heart, and large arteries, have been mimicked, but the assumption has been eva- nescent, &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 ner- vous, 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 stajte of the brain. And it would most probably be in vain, even where syncopes had been a habit of the system, (if we may so term it,) 514 HYSTERIA. to recognise the peculiarity of the brain, which gave rise lo them, by a post mortem search. In epilepsy, the whole of the muscular system is for awhile violently 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." Ep. 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 ila history creates a belief that this affection can really produce al- most every disease to which the body is liable; hence, the various 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, wilh excessive vomiting, palpitation of the heart, a dry cough, iliac passion, pains resembling a fit of the stone, cholera morbus, swelling 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 individual at different periods, as predispo- sitionaexist,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 HYSTERIA. 515 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 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 continued, 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 af- ter, the system is much more affected by the remote causes of hysteria. Before puberty, the system seems less liable to affec- tions, the remote causes of which act upon the brain and nerves, than after this state has arrived; for before this period, improper physical 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 habitual- ly too much excited. There are, however, exceptions to this rule; I have seen se- veral instances of well-developed hysteria, before the menses had made their appearance; aiyl a number after this discharge had ceased. From all I have observed, there is no absolute connexion or sympathy between any particular condition of the uterus, and hysteria; that is, as genuine cause and effect. It is true I have 516 HYSTERTA. 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 menstruous periods, by causes usually capable of producing it. Besides, I have seen a number of instances of genuine hysterical parox- ysms in men; especially in those who have possessed great social virtues, and readily moved to strong sympathies. 1 do not rec- kon as instances, the idiotic blubbering, or the unmeaning laugh- ter, of very old men. Whytt* considers, as " occasional causes of hysteria," &c.f 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 bloody 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 predis- position is to hysteria, hysteria vvill show itself; if to epilepsy, epilepsy will follow, &c, but in neither of the cases can these causes act but indirectly—or, in other words, they never direct- • Works, p. 551. f We would rather call them predisposing causes. $ 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. HYSTERIA. 517 ly 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 do, occasion convulsions; and though every hysterical paroxysm is attended wilh 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 vvill show. Mrs.----, from an early period of her life, vvas subject, from even slight causes, to severe hysterical paroxysms. During her pregnancies she vvas often attacked by this affection, and vvas re- lieved by the common remedies. In one instance, she had a pa- roxysm during labour; but it neither deranged the economy of this process, nor required any particular treatment. After the birth of the child, she was attacked with a violent and exhaust- ing flooding, from which she was relieved only by the most ac- tive 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. The liability to attacks of hysterical paroxysms, is very vari- ous in different individuals; while some have them provoked by the slightest causes, others require that Ihey shall be either pow- erful, or long-continued. Instances have fallen under our obser- vation, where the most trifling alarm, the smallest disappoint- ment, or the slightest provocation, would almost instantly pro- duce 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 lo them. They all, however, seem to act through the medium of the sensorium commune; at least, this would seem lo be the case with genuine hysteria; and may serve to distinguish it from se- veral affections of the system with which it is almost constantly confounded. Thus, we see syncope, from exhaustion; from pe- culiar 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. 66 518 HYSTERIA. Whylt* enumerates six different occasional, or exciting causes, "•of nervous, hypochondriacal, and hysteric disorders;" for he confounds them under one consideration: they are as follow; namely:— 1. Wind, } 2. A tough phlegm, C in the stomach and bowels. 3. Worms, ) 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.f 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 ibis phenome- non does not necessarily attend the hysterical diathesis; for these parts do not necessarily become affected by the prevalent dispo- sition, 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. But, 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. • Works, p. 570. f To these may be added, "the inflammation of a portion of the spinal co- lumn," 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, differ 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 rules, we have found but three cases in which the tenderness he describes, in some'portion of the spine, was sufficiently obvious to make us resort to leech- ing, cupping, blistering, or irritating it with the tartar emetic ointment, for its relief. It is, however, only just to say, that in these three insUnces the plan of treatment proved successful. HYSTERIA. 519 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 tbe stomach and intestines. We believe that the latter circumstance obtains most frequent- ly in hysteria; the former is most common to 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, 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, vvas much subject lo 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 which 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 the abdominal muscles, that can well be imagined; the abdominal 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 manner, 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 vvas 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 520 HYSTERIA. quiet. Indeed, the paroxysm would almost certainly go off, if sleep could be indulged in, undisturbedly; but that vvas a matter of great difficulty, as the slightest noise would awake her; and the instant she vvas roused the spasms would return with extreme 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 vvas disposed of. It vvas certainly not discharged by either mouth or anus; yet it vvas certainly dissipated, by some agency or other.* 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, vvas to continue the abstraction of it, until there was an abatement of these threat- ening symptoms. I do not recollect a single instance of failure when the blood was freely abstracted; it has occurred that this operation vvas 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. The loss of twenty or five-and-twenty ounces would answer some- times, 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 vvas it ever controlled by any of the usual remedies for such affections Im- mense doses of anodyne, and antispasmodic medicines were given, • 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 suffo- cation. .HVSTER1A. 521 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 vvas 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 vvas constantly proposed; but, singular to say, that notwithstanding tbe uniform and sudden relief procured by it, notwithstanding tbe employment of il was importunately urged in the commence- ment of the affection, its use was resisted wilh a pertinacity that could not be overcome by a long-continued and severe suf- fering. Sometimes this remedy was resisted until the disease shifted its ground, and the head would become the seat of the metastasis: when this look place, blood-letting, as just remarked, vvas the only remedy. After bleeding, it was not unusual to find Ibis hysteri- cal paroxysm terminate by a violent gush of tears, or by obstre- perous laughter, and an immense flow of perfectly limpid urine. It has been remarked, lhat 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 continue, alternately sleeping and suffering, from twenty-four, to eighlland forty hours; or until the paroxysms seemed to wear themselves 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 this form, it 522 HYSTERIA. •was always found necessary to bleed; and this never failed lo 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 vvas 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 palient 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 stale of the stomach. Dr. Cullen* 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, Ihe 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 recog- nised " a tough phlegm " in the stomach, as noticed above, as an " occasional 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, t 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 vvas not always evacuated; for an emetic vvas not always exhibited. And when the brain took up the wrong action, the paroxysm was sure to be terminated by blood-letting. • First Lines, vol. ii. p. 256, par. 1519. + It seems that hysteria is not the only disease classed under the nervous that xperiences relief from the discharge of viscid matter. Whytt 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 a few days by a natural looseness, by which she voided a great deal of slimy stuff." HYSTERIA. 523 The second mode of relief is by the removal of the painful distention of the stomach; for this organ suffers extremely some- timesfrom " wind" confined in it; as we see when "gas" is ex- tricated 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, perhaps, at present impossible to say, as we do not know that any expe- riments have been made to ascertain it. In the case of the lady above related, when the wind vvas dis- charged by the rhoulh, it would pass in so continuous a stream as to suspend respiration for a considerable time; and the quan- tity disengaged vvas so enormous as to justify us in setting it down at several gallons. 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 tbe " gas" belched by dyspeptic patients, smells and tastes almost always of the food from which it is liberated. 3. Worms. 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 ir- ritate 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 iheir 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 524 HYSTERIA. 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 vvas 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, vvas produced. During a paroxysm she was bled, took asafcetida, laudanum, &c, and was, after a few hours, restored to her usual health, which was still pretty good, though evidently on the decline, notwithstanding 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 ra- pidly; 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 vvas much disturbed; almost constant headach, &c. The " fits" now bore a stronger resemblance to epilepsy than to hysteria; lhat 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 vvas much shorten d She would, however, remain very feeble for several days afie «ch"tt.ck; and be assailed by the feelings common to nervous "progress and changes stated above, occupied a period of abou th^years; the " fits" now returned every « a tirmt this time she was auvi»cu u^ About tnis iin« morning, for nine mornings, for f^Zi&ZZZZZ woX Sl>e did so .- Z lution, Dy o measured. Iler health in length, as was supposed, tor it vvas nui HYSTERIA. 525 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. 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 vvill 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 vari- ety of dispositions (if we may so term it) in the human stomaeh; it is capricious at limes, in the extreme, while at others it will suffer great abuses, and this for a long time, without resistance or complaint. Experience alone, in many instances, is the only safe guide by which the food, in either quantity or quality, can be re- gulated 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 unsuccessful, if not improper; hence, nothing is more common than peculiarities in the digestive process. Indeed, the same article, and in the usual quantity, vvill 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 ne- ver fail to inquire whether any thing unusual has been taken into the stomach, when about to prescribe for an hysterical paroxysm. 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.* When under this impression she vvas 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, • The hysterical paroxysms in this lady were periodical; the attacks, though severe, were by no means frequent, yet she rarely had an attack without a warn- ing of two or three days; or, in other words, she had occasionally certain feel- ings, which she knew would terminate in an hysterical "fit," if she did not stu- diously avoid exciting causes. 67 526 HYSTERIA. on the other hand, if she was successful in avoiding mental ex- citement, and did not overtax 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 headach for several days. 5. Scirrhous or other Obstructions in the Stomach, Intes- tines, 8fC. Whytt* 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 evidence what- ever, that the affections developed by the knife, gave rise to the few nervous symptoms detailed in the cases. At all events, there was no hysteria produced; hypochondriasis may have been; since the stomach, in almost every case, was much diseased. 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 perpetuate the disposition, by preventing the return of healthy action in the system, but there is strong reason to doubt of their being the re- mote 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 of the Mind. No one can for a moment hesitate to acknowledge the influence nf the mind upon the nervous system. Passions and emotions ly not only prove the exciting, but they may also serve as the remote causes, of hysteria. The experience o almost every body caXnish illustrations of these facts, and medical records abound » Works, p. 575. HYSTERIA. 527 with remarkable examples of them. They must, therefore, be admitted as such, though we cannot pretend to explain by what agency or by what changes it is effected. Through the medium of each sense,* h}7steria 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 lo 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,f as having happened at the poor-house at Harlaem. The disease, in the first place, vvas excited by the operation of terror upon the sensorium 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, * With the exception, perhaps, of the sense of taste, I have never'met with an instance of hysteria produced by disgust to the palate. f Kaau Boerhaave, the nephew of the celebrated Boerhaave, relates an oc- currence of a very remarkable kind, as having taken place at the Harlaem hospi- tal. A girl was brought into the ward in convulsions, of a periodical kind; the convulsion was repeated the next day, which affected severat who beheld her, in the same 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 ex- cite 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 fur- nace 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. 52S HYSTERIA. 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 paroxysm, properly so called, is where the system is thrown into that vio- lent agitation called "a fit of hysterics." A vast variety of symp- toms may from time to time manifest themselves, such as palpi- tation of the heart, globus hystericus, large flow of limpid urine, rumbling of wind in the bowels, belchings, acid stomach, whim- sical appetite, tremblings, cold feet and hands, &c; but these are termed nervous symptoms.* 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 ihe fit to be at hand, such as headach, of a piercing kind: oppression about the prascordia; 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- • 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 eveiy 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 atten- tion; 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 these 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 pro- fessed to treat upon this subject, as well as those who, for the sake of gratifying curiosity, have published detached cases of hysteria under various other designa- tions." , L • *>.• j- We confess this condition of the dorsal vertebrae to be, m this disease, new to us- 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 vertebra 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 vertebra: 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. HVSTERIA. 520 toms of hysteria—they may alternate wilh 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 threat- en dislocation of every joint; while the swoln face, the protruded tongue, the starting 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, parti- cipate in this unnatural state of action; for it is found contracted so firmly sometimes, as lo prevent the introduction of the pipe of a small syringe.* The abdominal muscles also are violently contracted sometimes during the fit, and especially about its cen- tral 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 constitutions;" but it is not confined to such ; for the nervous and irritable are also liable to Ibis affection. By the nervous and irritable we understand, such constitutions, as are affected, or easily moved, by slight ex- eiting causes. This condition of the system may be either con- stitutional or acquired. Improper physical education will render almost any constitution nervous or irritable, if it be continued sufficiently long; hence, Ihose who indulge in habits of idleness, too high living, lying in bed too much, night watching, &c. &c, * Cullen. 530 HYSTERIA. are almost sure lo possess this peculiarity; or this peculiar con- dition may exist as an original state of stamina.* 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, synco- pes, &C; though otherwise enjoying very good health. In such, also, may readily be excited hysterical paroxysms, or convulsions; 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 syslem; as it now becomes ob- noxious to causes, which would not previously have affected them. Hence, the wonderful effects of certain odours, medicines, or even sounds, in such a condition of nervous peculiarity. I have known two or three instances where Ihe smell of the tube-rose, the lily, or the lilac, have been followed by faintness and palpitalion of the heart; though previously to the illness they had no such tendency.f I have known the very name of rhu- • 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."* Works, p. 543. t Kaau Doerbaave. HYSTERIA. 531 barb, and of the Peruvian bark, excite the most violent disgust, and sickness of stomach. I know a gentleman who cannot drink a glass of any of the white wines, though formerly fond of them, in consequence of having frequently been puked with antimonial wine during a tedious fever. Mr. Boyle, (Usefulness of Expe- rimental 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 vvas near and violent. And Boyle, (Usefulness of Experimental Philo- sophy,) 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 idio- syncracy of nerve, are peculiarly unfortunate; as they are con- stantly liable to be affected by causes which have not the slight- est 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 enjoys otherwise very good health, it is with too much facility supposed, 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 hysteria in women, and hypochondriasis in men, is so strong, as to con- sider them as one and the same complaint; but this is certainly not the case. Hoffman looks upon them as distinct diseases; and Cullen strongly inclines to the same opinion; at least he arranges them under different genera. He places hypochondriasis in the class of Neuroses, and the order Adynamia;; 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 temperament will constitute a difference; for we have noticed that hysteria is most common to women, and those of a sanguine and plethoric 532 HYSTERIA. constitution; whereas, hypochondriasis has more frequently men of a melancholic 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" convulsive struggling paroxysms, the sense of a suffocating ball in the throat, the fickle- ness of temper, and the copious and limpid urine, have no neces- sary 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 dejected spirits, and gloomy ideas, that characteristically mark hypochondriasis, have as little necessary connexion with hysteria, and are in di- rect opposition to its ordinary course." Vol. iii. p. 353. An attention to these marks vvill serve to discriminate ihe two dis- eases perfectly. Sect. V.— Treatment. The whole history of hysteria shows that the nerves of cer- tain parls of the body are more liable than others to lhat parti- cular stale which gives rise to its phenomena; and that this con- dition oflhe nervous power declares itself almost always in cer- tain portions of the system. This condition seems to have an election, if we may so term it; or, in other words, certain parls more constantly 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 but 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 derangement of this organ, where no hysterical symptoms have aUDoduebtiess 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 wellas.n character, according to the state of predisposition and power of he exc Ung cause. But when this occurs, the nature of the affection will almost always betray itself by the presence of some other HYSTERIA. 533 symptoms which may be considered as pathognomonic of hyste- ria; such as palpitation of the heart; a sense of coldness on the top of Jhe 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 vvill 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 ac- tive malady, as inflammation, there is for the most part an ex- emption from the symptoms constituting hysteria; consequently, for the production of this, a peculiar condition of the nerves of the part seems to be always required. 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 sys- tem, how far they must be considered as the cause or the effect of existing 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. 68 534 HYSTERIA. 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 disease 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, perhaps, by a brisk cathartic. However ill depletion may agree with nervous constitutions under a want of excitement in the vascular system, it is never- theless 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, asafcetida, &c.,in an hysterical paroxysm, because attention had not been paid to the circulatory system 1 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- tem 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 stimuli. For the force of stimuli must be regulated by the susceptibility of the vascular system to action, if success is to fol- low their exhibition—thus, ten or fifteen drops of laudanum, un- der certain conditions of the system, may be more successful than three times this quantity under another stale of arterial action; and the same observation will apply to many other reme- dies employed in nervous affections; for the success of remedies must depend upon their being administered in due force, to the existing condition of the system. It is every way certain lhat plethora will often give rise to a train of nervous symptoms, or to hysteria: now, these cases, if HYSTERIA. 535 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 vvas ordered to lose ten ounces of blood ; and to take a dose of rhubarb and magnesia. She vvas immediately bled; and so effectual vvas the relief from it, that she did not think it ne- cessary 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 mind- ful of the state of the circulation during the use of active reme- dies; 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 in- jury. For however proper these remedies mayjjie, they can only 530 HYSTERIA. be so certainly in appropriate doses; if these be exceeded, cither no relief will be obtained or the complaint will be increased. It should, therefore, ever be a rule in practice, even in nervous dis- eases, 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,* 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 lo 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 benefit 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- cliondriaci,) non licet praefinire tern pus mensis unius aut anni, sicut in aliiscontingat; sed oportet in toto vitae suae tempore cura- tioni opcram dare, interdum curationi, interdum praeservationi, attendo." Hysteria is seldom cured so effectually, as that the patient shall have no farther returns of it, should an exciting cause be applied; yet we know, from ample experience, lhat it can be much miti- gated 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. Tnis 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, * Works, p. 632. HYSTERIA. 537 appear lo 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 causes, vvill, 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 disease shall be better understood, might be successful. But if hysteria 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 vvill cease. The lues venera, inlermittents, and, doubtless, many other diseases, were, at different periods of tbe 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. Mrs.----, of sanguine temperament, married early in life, and became the mother of a large healthy family. She herself enjoyed uninterrupted good health, until her previous habits were broken up, by her husband becoming very rich, from suc- cessful speculations. She vvas now under no necessity of work- ing for the sake of her family; every thing that money could pur- chase was at her command. She occupied a large house; employed a number of servants; and performed in a carriage that which vvas 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 O^o HYSTERIA. peevish to all around her, and extremely jealous of her husband. Every action of his life was misinterpreted, though he vvas 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 slate for a number of years; and became so debilitated at last, that she could not leave her chamber, for months together; and it vvas thought by her medical attendants she must soon sink under her malady. But at this time, the scene of prosperity vvas, by one of those changes common to mercantile life, suddenly changed for that of compa- rative 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, vvas no less sudden than salu- tary; and that which it vvas 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 reassumed her former habits, as far as her slate of health would at the moment permit. In consequence of this change of circumstances, her moral en- ergies were roused, and she quickly showed to the world, that her temporary elevation had not unfitted her for a profitable re- turn lo 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. Case Second. 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 hemorrhagies. She became very hyste- rical; and paroxysms would be produced by the slightest causes. Her physicians advised she should be taken to a northern climate; 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 vvas still labouring under a coloured discharge from the vagina. The usual tonics were administered with ad- HYSTERIA. 539 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 ihe 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 lo hasten his departure, or exercise forbearance; for which we can- didly gave our reasons. He went; and his wife improved daily under the use of the cold bath, air, exercise, and a strictly regu- lated diet, both as lo quantity and quality. Her strength im- proved daily; her appetite increased; her digestion vvas well per- formed; 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. Iri consequence of her improved health in this climate, she has been permitted to remain. These cases show, that established hysterical paroxysms, with their attendants, were subdued by changes of a moral and phy- sical kind; and lhat they hold out encouragement to treat this affection as one capable of cure. But we must repeat, that suc- cess can only be expected, where the patient vvill most sedulous- ly 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 paroxysm 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 540 HYSTERIA. of blood lo 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." 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, iherefore, always be received with hesitation, and acted upon with caution. We have remarked above, that ibis 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 slate 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 vvill 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 ihis surprise us, when we reflect upon the period of life, the kind of temperament, the nature of ihe exciting causes, and the importance of the parts principally concerned in the disease. Besides these general rea- sons, 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. We therefore, with very few exceptions, direct the loss of blood to an extent lhat shall decidedly diminish the force of the pulse, before we employ any other remedy. Bleeding does not often Dut an end to the fit immediately, nor is this expected of it; it, however, lays the foundation for other remedies to be successful, ^Tch would not be the case without it. Nor is this all: i tal- Z's, we believe, shortens the « fit;" and certainly very often ^events its becoming protracted, or ending in mischievous en- ^Weeding, we can employ remedies agreeably to the Pre- Bentin* indications, with much more certainty and safety. We houW 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- f the mind: if this be so, sedatives and antispasmodics Cld be givl. These may be administered by the mouth or fytte recfum, as may be most expedient. If the patient can HYSTERIA. 541 be made to swallow, and it rarely happens that she cannot, if ad- vantage be taken of an interval; laudanum, in a full dose, should be given, and may be repeated in half an hour, hour, or mbresel* dom, as necessity may require. It may be combined with a so- lution or the tincture of asafcetida, 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 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 vvas 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 f'nothing from our own experience, but the authority of Dr. Whytt .? sufficient to produce reliance in it. The only objection we perceive in the use of the pediluvium, is the difficulty of its application at the moment the patient is convulsed—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, that "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 practised by all by-standers, to hold volatiles, and other stimulating things or substances to the nostrils during the "fit."* This is certainly • Dr. Whvtt 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 mto more violent convulsions," p. 693. 543 HYSTERIA. 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 substances in syncope; but between syncope and an hysterical convulsion there is not the slightest analogy; in one instance, the muscular, Ihe arterial, and nervous symptoms 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 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 palient soon "came out of ihe 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 asafaetida 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 asafcetida, or if the watery solution of the asafcetida 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 anolher 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. 529. 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- HYSTERIA. 543 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, u: til it appears that the stomach is cleansed. This case, agiv.i ably 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.* It sometimes becomes necessary to apply blisters to the calves of the legs, or sinapisms to the feet; these are, however, only useful where there is a disposition to coma after the convulsions have ceased, f The paroxysms are of longer or shorter duration; and it is nol unusual to find the patient, after a severe "^t," rouse up, as if little or nothing had happened: when this is the case, the dis- ease 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 sub- stances to the nostrils, it may do mischief, by renewing the con- vulsions as stated above. Therefore, when this condition occurs, it should not be interrupted by improper officiousness; for this state of tranquillity k the best possible thing for Ihe patient. When the patient has warning of an approaching paroxysm, it may frequently be interrupted by a timely dose of laudanum, asafcetida, 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 sweeetened water, provided much headach does not attend; • 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 espe- cially the case when the convulsions are frequent, and when attended by strong evidences of determination to the head. + Mr. Tate, in conformity with his pathological views, (see note at page 528.) declares he has seen the most decided beneficial effects from the use of the tar- tar emetic ointment-rubbed upon the dorsal vertebrae until it produces vesi- cation. 544 HVSTK.RIA. 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.* 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 possessed any remarkable advantages over the asafcetida, (almost the only one now employed,) they would unquestionably have been re- tained as certainly as it has been. Indeed, we are disposed to believe that they would never have been introduced among the anti-hysterical medicines, but from their strong smell exciting an analogy to the asafcetida, which has ever merited some confi- dence in hysteria. Dr. Hamilton believing the disease to be sealed in the stomach 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, • 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 with 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 in- formation they may contain. HYSTERIA. 545 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 vvas much attached, and whom she for some days had hourly expected to see, vvas instantly seized with such an alien- ation of mind, as to pervert the kind offices of her best friends into attempts to injure her. She talked incessantly of her bro- ther; 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 vvas repeated, 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 of exhibiting opium, is in that form of lauda- num called the " black drop," or the tinct. thebaic, acetat.* 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-spoonfuls of sweetened vi- negar, which answers nearly the same purpose. In the use of 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; oihers can only use the solid opium; and some few we have met • We may give the new preparation of opium, called the " denarcotized lau- danum," 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. 546 HYSTERIA. with, who cannot use the black drop, yet vvill bear the common laudanum well, &c. &e. 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 idiosyncracy. " A middle-aged lady, whom four or five drops of laudanum, taken by the mouth, affected wilh a violent pain and cramp in^her stomach; and sixteen drops, taken in a clyster, though Ihey did not occasion ihose complaints, made her deliri- ous 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 unfor- tunate, as it deprives the palient of the use of the only remedy capable of relieving the existing symptoms. We have two pa- tients 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 shunted, it might be well lo follow the suggestions of Whytt upon this subject. 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;" whicb 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:— jc. Gum camph. - - gij. Sp. vin. rect. - - q. s. f. pulv. adde. Pulv. g. Arab. - £ij. Tinct. thebaic, acetat. gut. Ix. Sacch. alb. - - giij. Aq. font. - - gvj.—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 or quantity, will disagree, it may be omitted, and the 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 HYSTERIA. 547 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 applica- tions to the region of the uterus, are of much benefit. It is almost the universal practice of tbe 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 bands must be unclenched, at all events; and very often, in the performance of this work of supererogation, much injury issustained 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 ce- dar, or pine, of sufficient length, and shaped like a wedge, may be advantageously employed. After ihe 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 .1 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. 543 HYSTERIA. ** MY DEAR SIR, " In your note of last evening, you requested me lo inform you more particularly of the employment of cold water in hys- teria, which I mentioned, in conversation a few days past, I had found a prompt and beneficial remedy, in some cases of lhat af- fection. In compliance with your desire, I present you wilh 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 overheated. 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 vvas 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 vvill, 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 waler, or cold pump water, sweetened, was given in repeated small draughts; cold affusions were directed to the head, and when the circulation vvas excited, and the skin hot, blood-letting vvas practised, with cold ablutions to the general surface. The relief, from the cold draughts and affusions, vvas immediate. The convulsive efforts became calm, and the patients expressed, in ex- travagant terms, the agreeable sensations they experienced from them, and the rapid disappearance of their sufferings. The mor- bid 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 stomach, produced by improper food, or other irritants, I was led to repeat the same HYSTERIA. 549 practice. The result vvas equally prompt and favourable. In all those cases, however, gastric irritation was welfc characterized; the epigastrium vvas 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 him. She lives retired, and uses very little exercise. She had been distressed in mind some days—complained of want of ap- petite and headach—vvas constipated. She dined on fresh pork; after dinner took a cold bath, which vvas 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 vvas seized with spasms in the stomach, vo- mited, and became much agitated. The spasms of the stomach recurred at intervals of from five lo ten minutes; and during each, there was a tonic spasm of the voluntary muscles, a loss of consciousness of surrounding objects, stifled, suffocated 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 vvas 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 vvas 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 wa- ter. In a case where the heat of the skin and bead 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 70 550 HYSTERIA. of nearly similar composition, which preside over the various in- tellectual and pathetic faculties, and voluntary motion. The me- dulla 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. Irrita- tion 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 ihe 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 medul- la oblongata. " The varieties observable in hysteria, will depend, 1st, on the intensity and extent oflhe cerebral irritation; 2dly, on the local visceral irritation, by which it is excited j 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 ac- complish those functions. " Wilh 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 lo the continued influence of the exciting causes; or to the great difficulty of se HYSTERIA. 551 curing this system sufficiently long against the operation of these causes, that the nerves may recover iheir ordinary healthy standard. The difficulty just suggested, is particularly great in the disease now treated of, owing to the constant liability of exposure to the exciting causes; for, almost any severe intellectual operation, or any undue exercise of any of the senses, may endanger with relapse, the ill-restored nervous system; hence, the difficulty and uncertainty of a radical cure of hysteria. Besides, the best con- certed plan that can be devised, vvill be too certainly useless, if co-operation fail on the part of the palient. We have already ad- verted lo 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 lo secure their good effects. To every patient afflicted with hysteria it should be incul- cated, that much may be done by a proper and persevering ex- ercise 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, lhat without the healthful play of these powers, medicine alone can- not prevent the return of evil, though it may occasionally alle- viate a present misery. It vvill 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 human 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 eauses. The physical exciting causes may be avoided with more cer- tainty, or tlieir 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.. 552 HYSTERIA. 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* be true; namely, 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." Thus it seems, that hysteria, like gout, may ward off severer blows. The first general indication in the cure of hysteria, is to aller 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 hysteria, or at least to nervous symptoms. The intensity of these symptoms, will therefore necessarily depend upon the force with which they may sympathize with the brain, or upon their sensibility, or altered condition from health; hence, the same force of cause will produce very different degrees of effect, in different individuals. In some, symptoms may be limited to pal- pitation of the heart, globus hystericus, &c; while in others, it may be followed by a severe hysterical paroxysm. It vvill follow, therefore, caeteris paribus, that the greater the mobility of the nervous system, the more difficult will it be to effect a cure; and that the remedies to be employed must be either of greater power, or they must be continued longer. • The reme- * Works, p. 631. HYSTERIA. 553 dies must be addressed to the nervous system, through the me- dium of the stomach, skin, and mind. These remedies will consist of tonics, antispasmodics, the cold bath, and agreeable impressions on the mind. The tonics will comprise the various bitters, steel, and food. The bitters may be the Peruvian bark, sulphate of quinine, gentian, orange peal, Co- lumbia root, quassia, &c: tbe preparations of iron, may be the car- bonate of iron, the sulphate of iron, the muriate of iron, the aro- matic tincture of iron, &c. The antispasmodics may be, the castor, asafcetida, valerian, Hoffman's anodyne liquor, ether, &c. The food, all such as is of easy assimilation; as beef, mutton, poultry, venison, &c. In using the various substances above enumerated, especial care should be taken, that they are not exhibited in alcoholic men- strua. Much mischief has been produced by not attending to this injunction. Dr. Whytt recommends even large doses of the bark and brandy to patients labouring under nervous or hysterical affections; and the weight of his character has too certainly per- petuated the practice, both in his own, and in this country; for he particularly extols the efficacy of the tincture of bark, in his own person. He says, " I have myself taken the above tincture, (the tinc- ture of bark,) in the morning, for eight months together, and with remarkable advantage. For three or four years before, I had been troubled with much wind in my stomach, a giddiness, and sometimes a faintness. I observed in the morning, soon after taking this medicine, a grateful sensation in my stomach, accom- panied with better spirits than I had at any time through the day, or than I ever found from drinking wine, even when I used it freely. I have ordered this tincture to many patients, who have taken it for two or three months successively, and after intermit- ting it for some time have begun again. Most have found bene- fit, and those most who used it longest," p. 635. Notwithstanding the respectability of the authority, and the high encomiums bestowed upon this preparation of the bark, we must, and do conscientiously, protest against the spirituous form of this, or any other of the bitters. We are certain it is not the best under any circumstance in which it is desirable or proper to use these drugs; and when employed in the form of tinctures, and especially to the extent Dr. Whytt recommends, it very of- ten leads to the habitual indulgence of alcohol, in some shape 554 HYSTERIA. or other. We declare this, from repeated and ample observa- tion. Indeed, it may not be amiss, in this place, to protest against the employment of any of the tinctures which require large doses, when it can be avoided; and especially, the long continuance of them, as is too frequently done in chronic affections. The vehicle which is brandy, commonly, or even alcohol itself, usually con- tains but little of the effective ingredient; and the patient, to ob- tain this little, is obliged to swallow so much ardent spirit, that no advantage is obtained from it, and is sure to be injured by the excessive use of the vehicle. To females, particularly, medicines in this form should never be exhibited; we have known but too often serious evils to arise from them. Modern chemistry has most happily discovered the active principle of the Peruvian bark, and it is now exhibited with great advantage in the form of a sulphate or an extract. One grain of either is supposed, and we think justly, to be equal to at least one drachm of the best bark; therefore, when either of these articles is thought to be eligible, it can be given in pills or in solution. The solution, it must be remarked, is the more ac- tive of the two forms, if the sulphate be used. The bark may be given in watery infusion, or decoction, when the sulphate or the extract cannot be commanded, but these should be made fresh every day, and care taken to employ none other than the best. The other bitters should always be given in infusion or in de- coction, not alone, for the reasons just assigned, but because the principle on which their virtues depend, is, perhaps, less concen- trated than that of the bark, and consequently, the alcoholic so- lutions of it would be too feeble for exhibition with the slightest chance of benefit. In using the bitters, care should be taken not to continue them too long at a time. Steel, in one shape or another, has been the preferred tonic from time immemorial; Sydenham employed the filings, and Ri- verius the sulphate of this substance, while the carbonate is the favourite form of many. The one to which we are the most wedded, is the bitter tincture of iron, and is made as follows :— a.. Limat. Ferri - - dJ" Rad. Gentian, cont. - 3'j- Cort. Aurant. - - 3J' Sue. e pomis expres. vel Cider ^- Ifeij. M. and macerate three weeks. Of this, twenty or thirty drops are given in a little sweetened HYSTERIA. 555 water, morning, noon, and evening, about fifteen or twenty minutes before eating. This medicine agrees admirably with stomachs disposed to be dyspeptic, and labouring under loss of appetite; il may be gradually augmented if necessary. Should it produce a sensation of weight, or as if the stomach was con- tracting painfully, the dose should be diminished or desisted from. Steel may be continued almost to any necessary period without the slightest injury. It will sometimes disagree with the stomach, but this is a rare occurrence; and when it does, it should be in- stantly abandoned. * It sometimes purges; when this happens, five drops of lauda- num should be added to each dose: at other times it constipates the bowels; this should be obviated by a rhubarb pill taken every night. Antispasmodics should only be considered as palliatives in the cure of hysteria; but they often become necessary during the attempt to prevent the recurrence of the convulsive or other paroxysms. When the patient is oppressed by flatulency, troubled with globus hystericus, or palpitation of heart, either of the above named medicines may be advantageously employed, especially the asafcetida, and the Hoffman's liquor. The asafcetida is best in watery solution or in tincture. If the former be employed, the following formula may be used:— &. Gum asafoetid. - - 3'j* Aq. fervent. - . ^iv. f. sol. Of this a table-spoonful may be given pro re nata; if the tincture be used, a tea spoonful in a wine-glassful of water may be given and repeated as occasion may require. If the Hoffman be pre- ferred, a small tea-spoonful may be given in an ounce of sweet- ened water, taking care that the sugar and water be prepared before the liquor is poured out, and that it be drunk immediately after it is mixed. It vvill be necessary to avoid too near approach to a lighted candle when the Hoffman is preparing. Ether may also be given with advantage, under the same restrictions as the Hoffman; but the latter, generally speaking, is the preferable medicine. The other remedies named as antispasmodics may be administered with advantage, when the symptoms are not very severe, but they are decidedly less effective than those just pro- posed- ,. . A very strict attention should be paid to diet in all nervous or 556 HYSTERIA. hysterical affections: we are sorry to say, that this part of the curative plan is too much neglected by practitioners. It is sup- posed that the various articles of diet merit but little considera- tion, because the system is labouring under no very active or acute disease; hence the palient is generally directed to cat any thing light. This indiscriminate order is almost constantly abused; for the patient, not willing to be restricted, too readily obeys the directions, though certain many of the articles of diet which they are in the habit of taking are not friendly to the stomach, and they all interpret the word " light" in favour of the articles they like. It should, therefore, be distinctly ordered, that no article which is known to disagree with the stomach or bowels, should be in- dulged in. Food may disagree in a variety of ways: it may re- main a long time before it is digested; it vvill then occasion eruc- tations, a sense of weight or pain about the stomach, a palpita- tion of the heart, headach, constipation, diarrhoea, or vomiting. It may turn acid, giving rise to flatulency, burning in the stomach, pain, regurgitations of the contents of the stomach, oppression, distention of the abdomen, &c. It may simply produce costive- ness, or provoke diarrhoea, but in whatever manner it may disturb the stomach or bowels, it should be forbidden the patient, and some other articles substituted. As a general rule, certain ani- mal substances will be found best, such as beef, mutton, lamb; poultry, as fowls and turkeys; fish, both scaled and shelled, espe- cially the oyster; wild animals, as the deer, rabbit, partridge, pheasant, grouse, &c. Eggs also, when soft boiled, are almost always acceptable to the stomach. Vegetables should not be too freely indulged in, especially cab- bage, cucumbers, cauliflower, beans, onions, peas, &c. The best are potatoes, well mashed, after being boiled or roasted; rice, turnip, beat, &c. But in directing either of these, (for no two should be eaten at a time,) reference should always be had to the experience of the patient. The drinks of such patients should be pure water, or toast and water, as a general rule; it may occasionally be necessary to in- dulge them with something a little stimulating, as weak brandy and water, or good sherry or Madeira wine; but these only at dinner. Tea and coffee should be forbidden when the stomach is disposed to acidity, and milk or chocolate substituted, where these will agree. Good butter may be taken with advanlage HYSTERIA. 557 oftentimes, but bad should be most sedulously avoided. Hot breads, and cakes of every descripton should be prohibited, and suppers most carefully refrained from. Costiveness must be carefully guarded against, by either diet or medicine, or both, if necessary. The substance best calculated for this purpose, as an article of diet, is the bread made from the unbolted wheat flour; this, if regularly persevered in, by making it the substitute for every other kind of bread, will rarely fail to answer this purpose. And as a medicine for this end, the rhu- barb, either alone, or in combination with aloes, will rarely fail. The best form of the latter that we know of, is as follows:— Gum aloes sue. 3ss. Pulv. Rhaei. • 5j- 01. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhsei. q. s. M. f. pil. xxx One of these taken every night, or every other night, as the ne- cessity may be, will rarely fail to answer the purpose effectually. The cold bath has justly been looked upon as one of the most efficient remedies of the materia medica, in hysterical and nervous affections; its known power in restoring muscular vigour after debilitating illnesses, its efficacy in imparting tone to the nervous system, and its acknowledged control over the vascular system, have ever rendered it a popular, as well as a very important remedy, in cases of general, and of local debility. But that it may be productive of its best effects, its use must be regulated by the state of the system, or the condition of cer- tain parts of it. There are few remedies more unequivocally abused than the cold bath, owing to the empirical manner in which it is prescribed ; on this account, great caution must be exercised when it is about to be used, that it may not be con- verted into an evil. The primary effects of the cold bath, are to produce a sensa- tion, which is familiarly termed a shock; the skin becomes pale, and unequal, and hence the term cutis anserina, from its resem- blance to the skin of a newly-plucked goose. The head expe- riences a sense of weight; the respiration for a time is suspended, and then becomes quick, and sometimes even laborious; a severe oppression in the chest, as though it were tightly corded, is fre- quently experienced, which sometimes does not pass off alto- 71 558 HYSTERIA. gether, until the secondary stage, or the stage of reaction takes place. The stage of reaction almost always takes place very soon after the fluids have been driven from tbe surface to the more internal parts; and it is one of the proofs of the usefulness of this remedy, and of the propriety of continuing it; for should no reaction follow, this application must be abandoned. On this account, the cold bath must be used with caution, and its effects well ascertained; for its temperature must be carefully regulated by the powers of the system to produce an after glow upon the surface. It would follow from hence, that this remedy may do mischief, if the temperature be neglected, at a time it might have been highly useful, had this important point been duly at- tended to. Hot and cold are but relative terms, when applied to the hu- man body; nor will the thermometer always settle the point, where the sensation of the one begins, or where the other ends. On this account, it is always best to determine the propriety of the bath, by the sensation the application of water may produce upon the skin. This will necessarily vary in different individuals, and in the same individual under different circumstances. It will, therefore, always be best to commence with a temperature that shall produce but a very slight shock, as it can be gradually reduced, as the capacity of the system to produce reaction in- creases. . , We are told that the Buxton waters, (England,) are at eighty- two degrees; yet they produce a slight but a decided shock; therefore, it vvill be well to commence with water at this tempe- rature, and reduce it pro re nata; or as the sensation of cold may be less unpleasant, and the reaction more decided. For if reac- tion do not take place, no advantage can be derived from cold bathing; and this circumstance very properly forms one of the contra-indications to the use of this remedy. The cold bath must not be used when there exists any viscera obstruction; or where there is any pulmonary affection, or local congestion of the chest. It may be used daily if judged necessary, when the system reacts promptly; or every other day if reaction be less decided, or only twice a week, if it be feeble. But we may be always justified in persevering in the use of the cold bath, if reaction takes place even very moderately; since we almost always have HYSTERIA. 559 it in our power to regulate the force of depression, by the tem- perature of the water. There are two modes of employing this remedy; first, by plunging into the water; or secondly, by the water being showered over the body—the latter is generally the preferable mode: it can be done without exposure, and the temperature of the water accurately ascertained. The best time to use the bath, where the constitution is pretty vigorous, is early in the morning; if it be less robust, about two or three hours after breakfast. Some are in the habit of going to bed after using the bath; we cannot think this ever necessary, if the bath agree with the pa- tient ; but should the system react with difficulty, or too feebly, it may be useful to employ warmth to the surface in this way. But in cases of this kind, it would be better to abandon the remedy, unless it be certain it was employed at too low a temperature, than to persevere in it, and require artificial means to promote reaction. For we must repeat that the cold bath can only be useful, where it is followed by a kindly glow upon the surface. Where the system reacts slowly and feebly, we have seen advantage from drinking a cup of warm camomile tea; indeed, almost any other warm liquid might be employed upon such occa- sions, together with moderate exercise, by walking briskly over the floor. But in all such instances, immediate attention should be paid to'the temperature of the water; it should be increased to at least eighty-two degrees; and should this produce so much collapse, as to render reaction difficult, or very tardy, we believe it would be best to abandon the remedy altogether; or at least, until such change may take place in the constitution, as will enable it to bear water at this temperature. There are consti- tutions which never profit by the use of the cold bath; we have seen several such. It does not depend upon the absence of mus- cular power, or upon visceral derangements; but is, as in many, other instances of peculiarity, an idiosyncracy; the system vvill not react, but after a long time, and then feebly and transitorily; a languor and an indisposition to motion, is experienced; the spirits remain depressed for many hours together; the lips remain livid; and the whole countenance is pale, shrunken, and distressed. With such peculiarity, the cold bath must not to be used. With those whose systems react feebly, or those disposed to take cold upon the continuance of wet applications to any part of the body, the head should always be covered with a cap of 560 HYSTERIA. oiled silk during the bathing. Care should be taken to dry the body, after coming out of the bath, as soon as possible; and if the body be well rubbed with a coarse towel, at this time, it will contribute much to its efficacy, as it vvill hasten, and almost ensure the reaction. Salt may be dissolved in the water with advantage; especially to those whose systems are tardy in react- ing, or those who are debilitated, or have any tendency to the lymphatic, or scrofulous diathesis. The mind should, if possible, be led from the contemplation of the ills of the body: it is the very nature of hysterical and nervous complaints, so to disorder the judgment, that a true esti- mate cannot be formed of the nature, extent, or the degree of importance, that should attach to any painful or distressing sensation. The idea of danger, is almost constantly connected with every feeling oflhe body; a trifling inconvenience is readily magnified into a serious evil; and such patients will often declare themselves to be dying, when little or nothing ails them. Notwithstanding this palpable error in the estimate of their indisposition, it is not always best to declare how little we think of it. It is the duty of the physician lo relieve his patient by the best means in his power: he should, therefore, employ them in such a manner as will produce the best possible effect; and whether they be administered through the medium of the mind, or by the agency of the stomach, it matters not, provided the greatest advantage be procured. It should not, therefore, be considered disingenuous in the physi- cian, if he apparently yield belief to the statements of his patients, or permit them to indulge, lo a certain extent, in their delusion; for, by so doing, he oftentimes obtains an advantage that could not be gained in any other way: by it, he almost always secures the confidence of his patient, and sometimes excites even her gratitude; for it matters not, as regards the feelings and persua- sions of the patient, whether the pain or inconvenience under which she labours be purely imaginary, or whether it has a real corporeal existence. The following case in a male, will well illustrate our meaning. In the year 1803, Mr. S. called upon me for advice on his case, which he declared to be an ill-cured venereal affection. He was a married man; and when under the influence of wine, was led to illicit enjoyment. This was his first, and only aberration; he condemned himself so severely for this act, that he constantly HYSTERIA. 561 dwelt with intense solicitude upon the probability that he might have contracted disease. He watched every sensation and ap- pearance of his body, with the most painful anxiety; both of which were so exalted by his imagination, that he fancied he had the venereal disease in its most decided form. Ashamed to make his situation known to his family physician, he applied to a quack, who confirmed his fears. Mercury was administered, and a profuse salivation excited; but the symptoms he so carefully cherished, did not change. He became dissatisfied, and sought another, and another quack; each in his turn gave mercury, which so reduced him that he was scarcely able to walk. This discipline continued for about fourteen months; at the end of which time he found his health nearly destroyed, and his little property dissipated, to satisfy the rapacity of these mer- ciless pretenders to medicine. At this period I was consulted: upon a careful investigation of his history, we were perfectly satisfied, that he had never been in the slightest degree injured, and frankly told him so, and to be satisfied that this was the case. He appeared at the moment gratified and happy at our assurance, and went away without a prescription. He, however, returned in a few days, and declared I must be mistaken; for that he was certainly diseased. Finding this notion to be firmly fixed, I thought it best to meet him upon his own terms: I acknowledged him to be diseased; but that his disease was completely under the control of medicine, provided he would strictly adhere to instructions. He was delighted with this declaration; and promised the most faithful compliance with any directions we might give. I had a box of pills prepared for him, composed of bread, co- loured with a little rhubarb, and scented with the essential oil of aniseed. One of these was directed to be taken every morning, noon, and night; his diet was prescribed, &c. He returned much delighted at the end of a week, declaring, that the pills had acted like a charm; that his appetite had returned; it was even vora- cious ; that his strength was improved, and that all his venereal symptoms were much abated. He now begged to be allowed to increase the doses of the pills; this I peremptorily forbade. He persevered in the plan laid down for him for six weeks, at the end of which time, he confessed himself to be perfectly well, and every way capable of attending to his long-neglected business. Success, in this instance, depended altogether upon yielding 562 HYSTERIA. in appearance to the perverted judgment of the patient; in the same manner we have often succeeded with hysterical and ner- vous patients. It must, however, be remarked, that there are two distinct classes of hysterical and nervous patients; the first must be in- dulged in their4>elief, that they are seriously diseased; the other must be convinced, that though they experience many disagree- able feelings, yet they have not a dangerous tendency. It re- quires some caution, or investigation, to ascertain to which of these classes any individual patient may belong; especially, if we are not previously acquainted with their opinions on the subject of their indisposition. A little address, and some inquiry from friends, will always prevent one class being mistaken for the other. In each, however, the mind must be beguiled into the belief that their malady is susceptible of cure. Cheerful company, agreeable reading, and change of scene,* should be among the auxiliary remedies; they should, however, be so managed, in almost all instances, that the patient shall not be sensible they are prescribed for her. A little management will effect this desirable end, without the object being revealed. No impatience should be discovered, while listening to the ex- tended history of a patient's feelings and sufferings; for nothing is gained, in point of-time, in attempting to cut it short; and much is lost if she be led to imagine we are regardless of what she says: we hnve ever found it best to devote sufficient time to learn all they can say at once; for the subsequent visits may then be short, since her whole history has been revealed before. After having attentively heard the detail of symptoms, the patient always becomes anxious for the name of her disease: our answer must depend upon which of the two classes the patient belongs. If she belong to the first, we must beware how we call her complaint hysterical or nervous; if lo the second, it often becomes a source * We may effect this in a variety of pleasant manners; riding-, walking, and sailing', will offer great resources of this kind; and they should be alternated, or continued, as circumstances may force, or utility suggest. Neither of them should be persevered in so long as to produce either listlessness or fatigue: some judg- ment will therefore be required to render either profitable; but this must be left, in a great measure, to the attending physician. Gilchrist speaks in high terms of sailing: this mode of exercise is too much neglected in this country, but we trust this will not long remain a reproach, since our steamboats are becoming so numerous, and offer such facilities of conveyance, and such con- veniences of regulation, as to tempt the invalid to frequent excursions. HYSTERIA. 56T of comfort, that we pronounce it nervous; but explaining dis- tinctly at the same time, that by nervous, you wish to be under- stood a real affection, but not a dangerous one; for most females are well aware, and willing to allow, that complaints of this kind are not often serious in their terminations, however permanent and inconvenient they may be in their continuance. Patients of the hysterical and nervous class, should be kept from gossiping old women, and never be permitted to listen to the dismal ac- counts of the diseases of others. For every sensation or symptom belonging to another, is in- stantly transferred to themselves; and they will have as many diseases in turn, as they have heard described to exist in others. The many disagreeable sensations connected with hysteria, make it desirable, that they should be relieved from time to time by applications suited to such symptoms; and, happily for the poor patient, we have the most common, as well as the most dis- tressing of them, under pretty certain control. These symptoms are, palpitation of the heart; flatulency; glo- bus hystericus; and oppression about the praecordia. All of these sensations are very much under the command of the same reme- dies; namely, the antispasmodics already mentioned; such as the asafcetida, Hoffman's anodyne liquor, ether, valerian, &c. But neither of these should be prescribed at random: it should be carefully ascertained that the system will bear these stimuli, be- fore they are given; accordingly, the pulse should be examined; and if the artery does not betray a plethoric condition of the vas- cular system, they may be advantageously given. But should the patient be plethoric, the loss of a few ounces of blood will almost ensure the success of the remedies just named; or it may even of itself remove the whole of the unpleasant symptoms, as mentioned above. / i~ . f .-,: -n~' ■r r m ^ t&:\ / HI EXPLANATION OF THE PLATES. PLATE I. # A very distinct view of Carcinoma Uteri, and of the changes which take place in that viscus in consequence of this disease. A. The carcinomatous tumour seated at the posterior part of the cervix of the uterus. B. The os uteri much enlarged, which forms one of the prin- cipal characters of this disease, especially when the sides of the opening are hard and resisting. A small portion of the vagina is left surrounding the opening. C. The cavity of the uterus near the cervix. D. The cavity of the uterus near the fundus, E. The fundus of the uterus. The sides of the uterus are kept asunder by two pieces of quill, placed transversely across the preparation. 72 566 EXPLANATION OF THE PLATES. PLATE II. A posterior view of the same preparation. A. Shows a section of the carcinomatous tumour, a part of which only could be exposed in Plate I. B. The fundus of the uterus. As the size of this drawing does not exceed the actual size of the preparation, it is obvious that all the parts of the uterus have undergone some degree of enlargement. • I'l :i /£ "•N •/. Drayltm /v .; /h'm Mr .(htrnetlp't C.■U.t.-n.n EXPLANATION OF THE PLATBS. 567 PLATE III. This engraving shows a Polypus of the Uterus. A. The polypus, in which may be perceived a longitudinal de- pression, made probably by the meatus urinarius. It is at- tached to the fundus of the uterus by a small neck. The tumour has descended out of the uterus into the vagina which has been slit open to bring it into view. B. The vagina; a few rugae remaining below the tumour. Higher up they are obliterated by the distention of the parts. C. The fundus of the uterus, by which the preparation is sus- pended. D. One of the round ligaments. E. A part of the left ovarium. 568 EXPLANATION OP THE PLATES. PLATE IV. Views of the three different species of Polypi, as described by Levret. See chapter on Polypus. Fig. 1. A. The body of the uterus. B. The pedicle of the polypus. C. C. The uterus. D. A portion of the peritonaeum. E. The bladder. F. F. The ovaries. G. G. The Fallopian tubes. H. H. The fringed extremities of the Fallopian tubes. I. I. Portions of the round ligaments. K. K. Supporters of the preparation. Fig. 2. A. The polypus. B. The orifice of the uterus. 0. The uterus, with its appendages. Fig. 3. This figure represents," 1st. The top of the os tineas. 2d. The vagina opened all its length. 3d. A small polypus arising from a portion of the internal mem» brane of the uterus. ^ */////////:> // ///< ///(■<< /a'/////('.) ('/' (/// '/■{//(' > A'/t//j{ / Vro//, { / ./. /Jr,i»/in EXPLANATION OP THE PLATES 569 PLATE V. Fleshy Tubercle of the Uterus. A. The edge of the tubercle. B. An incision made from the fundus of the uterus to the cervix, which shows lhat the sides of the uterus are not thickened. C The surface of the tubercle, having several irregularities upon it. D. The os uteri, having undergone no change; indeed, its ap- pearance, together with that part of the uterus which pro- jects a little into the vagina, may be looked upon as a specimen of a perfectly healthy os uteri. E. The vagina slit open; the rugae, and the very irregular manner in which they are disposed, are also very cor- rectly shown. 570 EXPLANATION OP THE PLATES. PLATE VI. At the lower part of the plate, there is a rod for passing a li- gature round a polypus of the uterus. The handle is made hol- low, so as to admit a part of the rod, which is secured by a spring in the handle. At the upper part of the plate is a wire, by -means of which the ligature can be drawn through Ihe cannula. Immediately below this is the cannula, furnished with a shield, to prevent the instrument being pushed into the vagina higher than intended by the operator. In the centre of the plate is a drawing of a hip-bath, the di- mensions being given in inches. On-the left side of the plate is described the best form of a female syringe. Tl. 6 V n.ni: i fr \ 7 >V.y )7 ,A\ /;'//(/'r t7t„- <>rww rt„\n. H EXPLANATION OP THE PLATES. 573 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 origi- nally 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 cauli- flower excrescence. The preparation is suspended by the Fallopian 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 cir- . cumference. C. C. The ovaria. D. An incision made through the parietes of the uterus, which are somewhat thickened. 7:J 574 EXPLANATION OP 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. C. A small cyst in the broad ligaments, containing pus. vi.wk I" ,/r,,ir„ /iy J. Sbv.til Jr. PI.VIE 11 Z/r.K-n Jy Jl>*» SUn.it ■*" EXPLANATION OF THE PLATES. 575 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 raiher 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 ulcera- tion with great thickening in carcinoma. B. The Fallopian tube. 576 EXPLANATION OP THE PLATES. PLATE XII. Circular gilt Pessary. v 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. l, five and a half te s of an inch deep. c. A section of the central holr \ o.* Fig. 1. I'l.ATK /:' l«'i«-.2. *&$&%$>-.*.* ,ii,'n rlrr.'iiirfi fl" uittre. Flim TDr..)t % INDEX. Page ABOPTION, liability to, increased by plethora - - 193 produced by hydatids .... 306 mere increase in the circulation not suffi- cient to produce it - - - - • 338 Abscess, in the labium, --.... 29 milk -------- 496 Acetate of lead, in uterine hemorrhage, - 348 Acid, nitro-muriatic in carcinoma uteri - 275 sulphuric in do. do. - - - - .ib. pyroligneous in do. do. - - - 274 Alum, in irregular menstruation.....156 Anatomical peculiarities of the female - 14 Aphthous efflorescence on the female organs - - 47 on the male organs - - 51 Asafcetida in hysteria ------ 542, &c. Astringents in uterine hemorrhage - - - - 354 their modus operandi - - ib. Leroux's objection to their use ib. Leake's ... - ib. their decided utility - - ib. in leucorrhcea -.....75 B. Balsam copaiva, in hemorrhoids.....230 Bleeding, in carcinoma uteri.....263 decline of the menses - - - - 158 hysteria.....- 540 menorrhagia - - - - ■ -171 milk abscess.....502 pregnancy - - - - - -196 puerperal fever.....432 suppression of the menses - - - - 121 uterine hemorrhage . - - 347 Blisters during pregnancy......2°2 in menorrhagia..... *'* in puerperal fever......*J* in hysteria ... - - - 543 578 INDEX. Page Blood, appearance when drawn during pregnancy - 204 Bloody infiltrations in labia pudendi ... 33 causes.......11 symptoms, (see cases) - 35 treatment.....35, &c. Borax in pruritus.......*7 C. Calomel in puerperal fever ------ 386 Camphor in painful menstruation - 137 in carcinoma uteri ■> 275 in hysteria ------ 546 Cantharides, tincture of, in leucorrhcea - 74, &c. in suppression of the menses - 122 Carbonic acid gas in carcinoma uteri ... 269 Carcinoma uteri _-__-_- 259 first stage, symptoms of, ... 260 treatment of, - 261 by bleeding ... 263 purging ... 265 abstemious diet - - 267 cleanliness ... 268 rest - - - 270 second stage, or where symptoms of ulce- ration have commenced 272 treatment, by narcotics - - 273 antacids - 275 sweet cream - ib. diet - - 267 Mr. Clarke's remarks respecting the treat- ment ..... 275 Cauliflower excrescence of the uterus - 296 symptoms of, - 299 prognosis ..... 300 treatment by bleeding - 301 diet --_-•-. ib. laxatives.....- 302 astringents.....303 tonics -.--.._ ib, ligatures......304 Cellular system of the female, peculiarities of, - - 16 Cicuta in decline of the menses .... 154 carcinoma uteri ------ 274 Clarke, his classification of the diseases of the uterine system ... 396 objections to 397 INDEX. 579 Page Clitoris, diseases of ------- 25 given rise to the opinion of hermaphrodites 26 scirrhus of ------ - ib. Copaiva in hemorrhoids ------ 230 pruritus ------ 49 Cold bath in hysteria ------- 557 Costiveness during pregnancy - - - - - 219 consequences of - - - - ib. treatment ... - 220 Cream in carcinoma uteri ------ 275 Cutaneous system of the female ----- 16 D. Diet in carcinoma uteri ------ 267 cauliflower excrescence of the uterus - 297 decline of the menses ----- 150 during pregnancy -.....207 hemorrhoids -.....228 leucorrhcea -------76 suppression of the menses ... - 121 menorrhagia - - - - - - -170 puerperal fever ------ 464 milk abscess - - - - - - - 504 hysteria ... - ... 556 Diseases of the labia -------29 external and internal organs - - 22 Dysmenorrhoea...... *?2 symptoms ------ to. causes ------- to* treatment - - - * - ' 1JP during the flow.....#• Ihe interval ... - 138 Dr. Mackintosh's view of dysmenorrhoea - - - 141 E. 201 Emetics during pregnancy - - - *" in menorrhagia - " ' in puerperal fever - - - 440 in hysteria - .„ Ergot in difficult menstruation - - lai uterine hemorrhage ' ' ' " ' VS Extirpation of the uterus 580 INDEX. F. I'agc Female, peculiarites of the.....-13 peculiar diseases of - - - 1 l Fever, menstrual.......104 milk, rules for preventing - 497 puerperal ........376 definition of ----- - i°. history ------- 380 period of attack . . - - - 406 predisposing causes ----- 382 delivery, as a cause ... - 383 opinions of Armstrong, Hey, and Clarke 384 prophylactics ------ 385 purgatives, as - 386 Dr. Gordon's opinion respecting - - ib. Hey's.......ib. the author's......387 seat of.......388 appearances on dissection, in the thorax - - to. in the abdomen - ib. is an inflammation of the peritoneum - - ib. this inflammation terminates in effusion ib. the belief that this inflammation is not the effect of active inflammation, erroneous - 390 Dr. Denman's opinion respecting - - 404 symptoms of......ib. diagnosis ------ 413 prognosis.......415 contagious, nature of - - - - 419 the author's opinion of - 420 Dr. Hulme's opinion of - ib. Dr. Hull's - - - ib. Mr. Hey's ... ib. Dr. Armstrong's - - ib. Dr. Leake's - - - ib. treatment of......ib- bleeding.....422, &c. stages of.......432 1st stage......ib. bleeding in.....ib. pulse as a guide for bleeding, &c. - 434 rules for bleeding in - - - 441 2d stage -......446 purging in .... 445 emetics .....ib. INDEX. 581 Page Fever, puerperal, 2d stage, blisters in 452 fomentations ... ib. spirit of turpentine - - 453 mercurial frictions - - 454 gangrenous stage - 457 symptoms of ib. treatment of ... 458 stage of effusion, treatment of, - 462 general directions and rules - 463 Fluor albus, (see leucorrhcea).....55 Forceps in uterine hemorrhage.....360 Fomentations in puerperal fever ... - 452 G. Galls as an application to hemorrhoids - 230 Guaiacum, volatile tincture of, in suppression of the menses 124 H. Heartburn during pregnancy - 2J2 treatment of, - *1J Hemorrhage, uterine - - ".,".." A connexion of the ovum with the uterus ib. causes which may destroy this 337 mode of action of certain of the remote causes of - ib. periods of pregnancy at which it may F take place - 342 1st period, the first four and a half months of pregnancy - 344 treatment during this period 345 2d period, the remaining time of utero- 1 gestation - 352 danger in this greater than in the first ib. indications of cure - - " 343 treatment at this period - - tb. delivery as a mode of arresting hemorrhage - - 355 vicarious, of the menses - - 104 Hemorrhoids during pregnancy ^ ^ _-_"_- f£ treatment of - 226 227 after labour - - ., treatment of - - - »?• Hiera picra in the decline of the menses - _ - l" Hip bath in carcinoma uteri 582 INDEX. Page Hoffman's anodyne liquor in carcinoma uteri - - 274 Hydatids of the uterus......305 causes of 306 case of - - - - - ib. diagnosis ----- 308 treatment - ib. ergot recommended - - - 310 Hymen, opinions respecting its existence - - - 41 imperforate -------42 symptoms of, ib. consequences of, - - - ib. treatment of, 44 Dr. Denman's case of, - - 42 Dr. Cleaver's case of, - - - 45 Hysteria during pregnancy, treatment of, - 196 Hysteria........508 seat of,........509 sympathetic affections simulated by - - 513 predisposing causes ----- 515 importance of attending to the state of the vascular system, in the treatment of - - 533 case illustrating this ----- 535 period of life at which it most usually occurs 515 causes of, according to Whytt - 516 symptoms of, ----- - 526 those most obnoxious to it - - - - 527 exciting causes of,.....517 wind and tough phlegm in the stomach and bowels - - 518 case - - - - 519 worms ----- 523 case.....ib. improper aliments - 525 scirrhous and other obstructions in the stomach and intestines - - 526 violent affections of the mind - ' ib. phenomena of, -___-_ 528 diagnosis......- 531 treatment.......532 of the paroxysm - - - - 539 bleeding ----- 540 sedatives and antispasmodics - ib. pediluvium - 541 stimulants to the nostrils - - ib. enemala.....542 emetics ----- 543 INDEX. 583 Page Hysteria, treatment of the paroxysm, blisters - 543 purgatives - 544 opium ----.- 545 case illustrating the utility of ib. camphor ----- 546 local applications - - - - 547 restraint ----- to. cold water ----- 548 bath ... - 556 to prevent the recurrence of the paroxysm 550 tonics ------ 553 antispasmodics - - - - 555 diet......*°- amusements in - - - - 559 cases illustrating the utility of ib. cases showing that hysteria may be sub- dued by moral and phy- sical causes - - 560 Hysteritis........361 first species, causes of.....36.2 symptoms......363 constitutional......364 mixed.......369 treatment, bleeding.....371 purging.....S"73 fomentations.....374 blisters.....«&• sudorifics ----- 375 opium - i°' emetics .... - 376 Impregnation requires the united perfection of. the internal uterine surface, and at least one of the ovaria ----- 90 periods of - - - m * . - " JJ2 never takes place before the inception ot the menses - 88> &0- never occurs after the cessation of the menses ib. Inquietude and want of sleep during pregnancy - - 217 Inflammation of the peritoneum, (see fever, puerperal) 376 Injections in lucorrhcea - - - ' ?<\ pruritus......4J carcinoma uteri - - - - ^7W'?± cauliflower excrescence of the uterus - «2J7 584 INDEX. Tage Infiltrations, bloody, in labia pudendi - - 33 Iron, preparations of, in the decline of the menses, injurious 155 Irritable uterus - - - - - 313 Labia, abscess of - . - - - 29 symptoms of 30 adhesion of - - - - - 26 prophylactic measures - - 27 treatment of - - - - 28 Dr. Denman's plan - - 29 erysipelatous inflammation of - - - 30 treatment of - ib. cedematous swellings of - - 31 those most liable to - ib. sequela? of - 32 treatment of - - ib. Labour, its influence on puerperal fever - - 383 Lead, acetate of, in irregular menstruation - 156 uterine hermorrhage - - 348 menorrhagia - - - 171 Lucorrhcea - - - - - 55 causes which predispose to - ib. those most obnoxious to - - to. circumstances which influence the discharge 57 different varieties of - - - 59 var. a. L. of direct irritation - to. b. L. of indirect irritation - ib. c. L. of habit - - ib. Gardien's species of ib. seat of - . - - 65 stages of- - - - -71 first stage ... - 72 symptoms of - - - to. treatment of - - 74 second stage 78 symptoms of - - to. treatment of - - - ib. third stage - - - - 79 symptoms of - - - t'6. treatment of - - ib. nitrate of silver in - - 81 Ligatures in polypus of the uterus - - - 292 cauliflower excrescence of the uterus - 296 Lime in carcinoma uteri - 270 Lymphatic system of the female 67 INDEX. 585 M. Page Madder in suppression of the menses - 122 Menorrhagia ------ -159 nature of the discharge in - ib. vessels by which the discharge is furnished - ib. those most obnoxious to - - - - 164 symptoms of ----- - ib. two varieties of - 165 first variety - ib. those most obnoxious lo 167 treatment of ... 168 second variety ----- 170 those most obnoxious to - ib. symptoms of - - - - ib. treatment of - %b. a third variety, supposed to exist by Gardien - 172 Menses, period at which they make their appearance 93, &c. causes which influence the - - - - 96 premature appearance of 39, 93 derangement of ihe ----- 105 tbe too tardy appearance of the - 106 four conditions of the system in which this occurs 107 cond. a. where there is little or no development of the genital organs - - to. characters of this condition - ib. management of this condition - - ib. cond. b. where the development is taking place very slowly - - - - 109 character of this condition - - ib. management of this condition - ib. cond. c. where this development is interrupted by a chronic affection of some other part - - - - * *Q character of this condition - »»■ management of this condition - - 111 cond. d. where the most perfect development has taken place - - - ly- character of this condition - - w, management of this condition - 113 cases of - - - - to. quantity usually expended - - - ?6 causes which influence the - - *o. sparing quantity of the - J2? treatment of - - - " Joq immoderate flow of the - - - l4J 586 INDEX. Page Menses, suppression of the.....116 cold, the most common cause of - t'6. symptoms - - - - 118 treatment of - - - - 119 treatment of sudden - - 118 cases of 121 every deviation from regularity does not require medical interference - 119 decline of the - - - - - - 146 symptoms attending the - - - 147 treatment - - - - - 150 derangements about the period of the 149 concomitant affection - ib. may return after they have ceased - - - 91 Menstrual action essential to impregnation - - 86 discharge, a genuine secretion - - - 98 furnished by the lining of the uterus 99 in what it differs from pure blood t'6. derangements of - - - 106 quality of ... 101, &c. hemorrhages vicarious, of the - 103 fever, does not exist.....104 Menstruation, history of......82 peculiar to the human female - - t'6. an original function ... - 83 Roussel's opinion - - . t6. Galen's - - - - 84 not a fortuitous discharge ... 86 symptoms of - - - - . - 95 period employed by 96 precocious......39 painful......132 causes ot.....*°« two states of - - - - 133 membrane discharged during - t6. treatment of 137 as a sign of fecundity ... - 89 Menorrhagia - -......*^? two varieties - - - - - -165 exciting causes.....*o. treatment - - - - - - 168 Mercurial ointment, in erysipelatous inflammation of the labia.........30 in puerperal fever ... 454 Milk abscess - - -.....496 causes of, and prevention - 498 INDEX. 587 Page Milk abscess, symptoms of......498 progress of ----- - 499 treatment of ------ 500 local applications, vinegar - - 502 leeching ------ t*6. regimen ------ 504 purging ------ 505 puncturing ----- £6. caustic......506 seton, operation of Dr. Physick - t'6. after treatment ----- 507 Mother and fcetus, mode of communication between - 205 Schreger's opinion respecting t6. Muscular system of the female ----- 15 N. Nervous system of the female - - - - - 15 Nitrate of silver, its use in leucorrhcea - 81 Nymphae, enlargement of ------ 23 inflammation of ----- 24 extirpation of ------ 25 Osseous system of the female ----- 14 Ovaria, when incomplete, cannot furnish perfect ova - 90 may regain their power ... - 92 diseases of the __.--- 255 classification of 256 P. Pain in the right side during pregnancy ... 215 cause of - ' - 217 treatment of - t'6. Palpitation of the heart......231 causes of ----- t6. treatment of ib. Pessary, description of the one used by the author - 240 directions for placing it *6. r 241 proper size ot ------ *•*!. remedies to be administered, before applying it 242 period it must be worn - - - - - ib. Placenta, circumstances in uterine hemorrhage, in which it ought to be removed - 351 directions for removing it - *6. 588 INDEX. Page Polypus of the uterus.......280 definition of 281 causes of ib. three species made by Levret - 282 1st species having its origin from the fundus - ib. symptoms - t'6. mechanism of expulsion - 283 signs by which it may be known 282 2d sp. having its origin from the neck 285 3d sp. having its attachment to the orifice of the uterus - ib. characters by which it may be known ib. treatment of - ib. cases of - - - - 286 application of ligature - - - 292 Pregnancy, general condition of the system during - 190 febrile, do.......203 signs generally accompanying it - - 172 1. suppression of the menses - - 173 2. nauseau and vomiting - - 177 3. enlargement of mamma? - - ib. 4. areolae.....ib. 5. formation of milk - 178 6. enlargement of the abdomen - 179 7. increased size of the uterus - 181 8. pouting of the navel - - ib. 9. frothy spittle - - - - 182 10. salivation - ib. 11. quickening - - - • - 184 itself not a morbid state - - - 190 peculiarities during.....193 propriety of bleeding during - - - 198 purging do. ... 200 vomiting do. - 201 blistering do. - - - - 202 liability to abortion during - 193 diseases of ------ 203 vomiting.....208 heartburn ----- 212 salivation.....214 pain in the right side - 215 inquietude, and want of sleep - 217 costiveness - - - - -219 hemorrhoids - 223 INDEX. 589 Page Pregnancy, diseases of, pruritus.....46 Phlegmasia dolens.......466 phlebitis different from - - - 481 cases......483 treatment - - - - / - 491 blood-letting, &c. - - - «*• 4Q2 purging - - - - - ™ topical applications - - «°. opium ----- 493 external applications - - 494 blisters ... - ib. bandaging ... 495 Prolapsus uteri,........2i*4 causes of.....ly~ Gardien's three degrees of - - - ib. symptoms - - 235 diagnosis, difficult - 237 remedy - - - ib. cases of 243 Pruritus.........46 causes of........*"' 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.......*3 treatment of.....%b- Puberty, female diseases at.....14 Puerperal fever, (see fever,) - - - - - 376 Pyroligneous acid in carcinoma uteri - - - 270 184 Quickening, what..... R. Rathany in irregular menstruation - 156 Rest in carcinoma uteri - ™ Retention of urine, from blisters • S. Salivation during pregnancy - - " ' 2.14 symptoms attending it - to. treatment of 215 Sanguiferous system of the female 16 590 INDEX. Page Secale cornulum, in hydatids ----- 309 Sleep, inquietude and want of, during pregnancy 217 Dr. Denman's theory of 218 treatment of - - - ib. Sulphur, its use in hemorrhoids - 229 Dr. Leake's opinion of - ib. Dr. Good's - - ib. Sympathies called forth in pregnancy - 191 Sympathy between the uterus and rectum - - - 201 Tampon, directions for forming and applying it - - 348 objections which have been urged against fts use 354 modus operandi of the - - - - - ib. Temperament, predominant one in females - - 17 Tonics during pregnancy - - - - - - 197 in derangement of the menses, about the period of T their decline ------ 155 Tubes, diseases of - • - - - --••_.. 254 Tumours and excrescences oflhe external parts - "-.'. 23 Turpentine, spirit of, in carcinoma uteri - .-, - 274 in puerperal fever - r> - - 453 U. Umbilical vein, uses of......205 Urine, retention of, from blisters ----- 202 Uterus, displacements of......234 hemorrhage from ------ 336 connexion of ovum with - - ... ib. causes which may destroy it - - - - 337 displacements of, action of remote causes ■ *.-:' ib. periods at which it may take place - - 342 first period, a. ...... 344 second period, b. ----- 352 delivery in hemorrhage - - - - 355 lined by a mucous membrane - 100 lining of, supposed by some to be deciduous - ib. prolapsus of, (see prolapsus) ... - 234 inflammation of, (see hysteritis) - - - 361 chronic inversion of......248 irritable.......313 diseases -------- 254 circinoma of.......259 particular diseases of......258 INDEX. 591 Page Uterine system, influence of......18 opinion of Sydenham, Cullen, Good, &c, respecting - - ib. the author's opinion ib. Mr. Fogo's.....21 contraction, how far we can control it - - 339 Mr. Burns' opinion - *6. the author's - - - - - ib. case of, in which we should not interfere 3i0 in all other cases, should try to preserve the ovum - - - t6. V. Vagina, natural diseases of -.....54 abbreviation, or contraction of *6. treatment - - t6. accidental diseases of.....55 cohesion of the sides of.....l£ cicatrices of..... !f • treatment of.....lb' Vein, umbilical, uses of......205 Vinegar in«fnilk abscesses - - - - - ".- ™ ..»,-■• Vomiting during pregnancy, (see pregnancy) - .. " ^'$1""-^> -V-^ • *• •" * W. Warts on the vulva, treatment of.....23 THE END.