1 i* 1 11 ' ^. : * 1 n MKr I liiii'I'1 .■' * ■ C5630 ■ ■UHlil I lliiiii t j 13U2 1 ||M jffljfyiglll • ^E . >.«K&* h Klllffl ft f j1,1 ||i;HI||ff .: r 7 <*'• lllhi:;'; :■'"'•■>' i ffl! Ill i! fc:^, .W J 4 1 ■ ! *lt * i n i1. i Hi' ■,-»'!i- 'viiiii liTilnt i'l'ili ^inllfil 1 ill 11 111 u till i. *, :f'.f ffiy.M, f-A\ ■■ ':;• C It lift ■■> .< ft' 1 "iili'i m lliii 1 IS Ml • ''I'M &M-%'-: •'r/jv ■:■,]■■'■■■■■■«■■i-Vw* ,;, :■.,•*::'■• ' ii-.;U r-i,- .■• !! « 1 lUSfii ti'-i -i'l * r * f ;uJ- NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland OBSERVATIONS THE DISEASES INCIDENT TO PREGNANCY AND CHILDBED. BY FLEETWOOD CHURCHILL, M.D., / Licentiate of the King and Queen's College of Physicians in Ireland; Physician to the Western Lying-in Hospital, and to the Adelaide Hospital; Lecturer on Midwifery and Diseases of Women and Children, in the Richmond Hespital School of Mediciue, etc. etc. PHILADELPHIA: HASWELL AND JOHNSON, NINTH AND CHESTNUT. 1842. t) *'% * i ;•.'* / ?va -;*w! f, x\ . ' :.?:■:.1- 'l-l-l*. PREFACE. In the preface of a former work, " On the Diseases of Females," I stated, that if the profession approved of the method and arrange- ment therein adopted, it was my intention to publish a second volume, " On the Diseases of Pregnancy and Childbed," upon the same plan. After the flattering and very gratifying manner in which the first volume was received, I could not hesitate a moment in preparing for the fulfilment of my promise ; and the present volume is the result of my researches. In it I have strictly followed the arrangement of the former work, Sfivino- a condensed statement in the text, with such confirmations and amplifications as have appeared desirable, in notes—with re- ferences to numerous sources of information. I may add, that almost all these references have been made by myself to the original authorities, and therefore. I trust, will be found correct. I fear, that, notwithstanding all the care I have taken, many de- ficiencies will still be found; for the authorities are so numerous, that it is not easy to ascertain them all. I must therefore entreat my reader's indulgence for these and other defects. I have also to apologise for certain irregularities of arrangement— (such, for instance, as including Rupture of the Uterus occurring IV PREFACE. during gestation, among Diseases of Childbed,)—which could not have been avoided, without inconveniently dividing the subjects, or leaving certain chapters incomplete. 1 have debated long with myself, whether it would be better to translate all the French quotations, or none of them, and the result has been the adoption of a middle course. When the quotation possesses peculiar and definite interest, or refers to cases, or success in practice, Liiave thought it better to quote the original, the other extracts I have translated. Such as it is, I commit this work to the Profession, hating no doubt of their kindness and consideration, and earnestly hoping that it may prove useful in facilitating the acquisition of a thorough knowledge of this class of diseases. THE AUTHOR. CONTENTS. DISEASES INCIDENT TO PREGNANCY. PAGE. Chapter I.—On tho Local and Constitutional Consequences of Pregnane}*, . 5 II.—On the General Management of Pregnant Females, ... 15 SECTION I.--DISEASES OF THE GENITAL ORGANS IN PREGNANT FEMALES. Chapter I.—Oedema of the Labia,........19 II.—Pruritus of the Vulva,........*2 III.—Vaginal Leucorrhcea,........~3 IV.—Menstruation during Pregnancy,......24 V__Discharge of Watery Fluid from the Vagina, .... 29 VI.—Dropsy of the Amnion, . . •.....qq VII.—Rheumatism of the Uterus, ....••• 38 VIII.—Hysteritis, ..........4d SECTION II.--DISORDERS FROM SYMPATHETIC IRRITATION. Disorders of the Chylopoietic Viscera. Chapter I.—Toothache,..........~ II.—Salivation,..........0L III.—Fastidious Taste, and Capricious Appetite, .... 54 IV.—Nausea and Vomiting,.......* *J, V.—Cardialgia and Pyrosis,........'* VI.—Cramp of the Stomach and Duodenum,.....I* VII.—Hematemesis, .........' VIII.—Constipation, •.....' IX.—Diarrhoea,........ g„ X.—Jaundice, ......... Disorders of the Circulating System. 85 Chapter I.—Palpitation of the Heart,..... • gg II.—Fainting,.......... Disorders of the Respiratory System. 91 Chapter I.—Dyspnoea, ....... g3 II.—Cough,.........* 9C III.—Hemoptysis, . ... l(.>nt;:.n rs. Disorders of the JVervous System and Si mis. page. Chapter I.—Sleeplessness,..........98 II.— Hypochondriasis, •........ 100 III.—Headache...........103 IV.—Convulsions.........• • 10G V.—Nervous Affections of ihe Eyes, ....". 125 Disorders of the Ma intra. Chapter I.—Mastodynia, ,.....128 SECTION III.--DISORDERS FROM MECHANICAL PRESSURE. Chapter I.—Hernia,...........130 II.—Piles............133 III.—Spasm of Ureters..........137 IV.—Incontinence of Urine, ........ 138 V.—Dysuria, or Retention of Urine, ...... 140 VI.—Cramps and Irregular Pains,.......141 VII.—Varicose Veins,.........145 VIII.—ffidema. Anasarca,........147 IX.—Ascites. Hydrothorax, ........ 150 DISEASES INCIDENT TO CHILDBED. Chapter I.—On Convalescence after Parturition,......]55 II.—On the Management of Females during Convalescence, . . 162 III.—On the Variations from Ordinary Convalescence, . . . 167 IV.—Sanguineous Tumour of the Labia, . . . . . . 174 V.—Inflammation and Sloughing of the Vagina, .... 180 VI.—Puerperal Fever, "........183 VII.—Rupture of the Uterus and Vagina, .....229 VIII.—Vesieo-Vaginal and Recto-Vaginal Fistula, .... 246 IX.—Laceration of the Perineum, ....... 257 X.—Phlegmasia Dolens, ........265 XI.—Puerperal Mania,........ . 274 XII.—Ephemeral Fever, or Wi id,.......280 XIII—Miliary Fever, . . .......282 XIV.—Sore Nipples,.....\ . , . jj85 XV.—Inflammation and Abscess of the Breast,. . . . - . 287 PART I. OBSERVATIONS ON THE DISEASES INCIDENT TO PREGNANCY. The investigation of the disorders and diseases of pregnancy upon which we are about to enter, will be much facilitated if we first consider, very briefly, some of the local changes and constitutional sympathies which are the result of conception and utero-gestalion : to which may be added some general instructions as to the manage- ment of pregnant females. CHAPTER I. ON THE LOCAL AND CONSTITUTIONAL CONSEQ.UENCES OK PREGNANCY. "It is a popular observation," says Dr. Denman,1 "that those women are less subject to abortion, and ultimately fare better, who have such svmptoms as generally attend pregnancy, than those who are exempt from them. The state of pregnancy is then an altered, but cannot with propriety be termed a morbid slate. But if the term disease be used on this occasion, with the intention of giving 1 Introduction to Midwifery, 7th edit. p. 144. 6 churchill's observations. a more intelligible explanation of the temporary complaints to which women are then liable, or to denote their irregularity or an excessive degree of them, it may be retained." Pregnancy, then, may be strictly considered as a physiological state, but as one bordering so closely upon the pathological, that it is sometimes difficult to point out the boundary between them ; and not unfrequently this boundary is palpably transgressed, in several organs or in their functions. In the present chapter, the changes which are induced by gesta- tion, considered as an "altered," but not " morbid" process, will be enumerated, in order that we may more distinctly appreciate the diseased actions which occasionally require our interference. For this purpose, our attention may be first directed to the anatomical changes which occur in the uterus, ovaries, fallopian tubes, w1*g day was 14__d 3 church 34 churchill's observations. very uncommon; at least the difference of the patient's size in two pregnancies is often no otherwise explicable than upon the supposi- tion of the liquor amnii being more abundant at one time than another. . Cause.__There can be no doubt that the proximate cause is the excessive action of the secreting vessels of the amnion;1 but whether this is invariably the result of inflammation may be doubted, though the researches of M. Mercier would appear to favour this opinion.2 It would appear also that it may be connect- ed with diseases of the placenta, such as cysts, tubercles, induration, dropsy, &c. (Burns.3) It is not improbable that some disease in the mother, as lunacy or syphilis, may be amongst the more remote causes of this disease; and we have ground for this supposition, in the fact of its recur- rence in the same woman. (Burns.) Symptoms.—As we might expect, the principal symptoms are dependent upon the mechanical distention of the abdomen, lbe uterus is much larger than usual, and proportionably more weighty, rendering the patient very uncomfortable in the upright position and in walking.4 If it be the third or fourth gestation, and the ab- dominal integuments be tolerably flaccid, the uterus will fal for- ward, causing what has been called " pendulous belly,"5 and adding greatly to the distress. In most cases some inconvenience is felt from the increased pres- sure upon the bladder, and in some from pressure of the stomach and intestines. ... c *u„ ^ua^ It would naturally be supposed that the greater size of the abdo- men would more decidedly obstruct the various trunks of the lower extremities, and so occasion the legs and feet to swell more than usual;-but this does not appear to be the case. (Puzos, Burns.) The constitutional symptoms are not very remarkable: the tongue is generally whitish, the urine scanty, and the digestive functions imperfectly performed.8 copious, if not profuse. On the third day after delivery the oedema of'the exf emities had considerably diminished, and the secretion of milk had duly taken place In ten days afterwards the oedema had entirely disappeared but th ^ lochia continuedl to flow till the fifteenth In six weeks the patient was Suite restored. At the end of two years she again became pregnan Tnd went through the process of parturition in the most favourable manner." __Davis's Obstetric Medicine, p. 906. fl, , „ . •Consequently it is rather a disease of the ovum than of the uterus, and would havebeen omitted here but for ^e inconvenience caused by n. « Tournal Gen. de Med. vol.xlhi. p. 165, vol. xlv. p. 256. bee also a case by M DavillTe», Jon* Gen. de Med.vol xlii. p. 252; andI one by M. Des- marais, in Recueil Periodique de la Soc.ete de Sante, vol. v.. p. 357. * SS? Sc^C^e in Journ. Comp. des Sciences Med. vol. i. p. 91. s Ante, p. 14. 8 Traite des Accouchemens, p. 86. 7 Midwifery, p. 242. Q_ * Joerg, Handbuch der Krankheiten des We.bes p. 497. Siebold, Frauenzimmerkrankheiten, vol. ii. p. dba. Carus. Gvnaecologie, vol. ii. p. 238. EXCESS OF LIQUOR AMNII, OR DROPSY OF THE AMNION. 35 The infant, however, does not escape so well: it is either very feeble or diseased, when born at the full time, or it dies before the completion of utero-gestation. (Mauriceau,1 Puzos,2 Burns,3 Bun- sen, Kyi I.) 1 Mai. des Femmes grosses, vol. i. p. 178. 2 " L'amas de serosites dans la matrice peut se faire dans une quantite tres considerable, et c'est presque toujours aux depens de l'enfant, qui profite moins dans cette hydropisie de matrice qu'il ne se flottoitque dans une quan- tity d'eau ordinaire."—Puzos, Trait6 des Accouchemens, p. 86. 3 " All of these causes do not operate uniformly to the same extent, but the foetus suffers in proportion to their operation. It is either born very feeble and languid, and is reared with difficulty ; or it dies almost imme- diately ; or it perishes before labour commences; and this is generally the case where the diseased state exists to any great degree. The period of the child's death is usually marked by a shivering fit, and cessation of motion in utero, at the same time that the breasts become flaccid. Afterwards irregu- lar pains come on, with or without a watery discharge. Sometimes the woman is sick or feverish for a few days before labour begins."—Burns s Midwifery, 9th ed. p. 242. In the British and Foreign Medical Review for October, 1839, pp. 564, 5bo, there are four cases of "morbid accumulation of the liquor amnn," ex- tracted from the Neue Zeitschrift fur Geburtskunde,Band 7, Heft 1. Three cases are by Dr. Bunsen, of Frankfort-on-the-Main, and one by Dr. Kyi 1,. of Cologne. In case 1, the placenta was very large, and the child hydro- cephalic0; in a subsequent pregnancy, the placenta was still large*but the quantity of liquor amnii was not excessive. The child was very feeble. Case 2: child born with ascites, and lived only twenty hours. The placenta was very large. Case 3: The child was healthy. Case 4, I shall extract: " The patient, a lady aet. 28, first came under Dr.Kyll's care in consequence of having been infected with syphilis, by a girl whom she had employed to draw her breasts after her first confinement. After having suffered from this disease for eight months, she applied to Dr Kyll who prescribed cor- rosive sublimate with advantage; but when nearly well, she aborted at the third month of her second pregnancy. Three months afterwards having perfectly recovered, she became again pregnant, and suffered much during ?hL pregnancy from varicose veins of the thighs. Venesection, however, afforded her great relief. At the end of the sixth month without any as- signable cause, the liquor amnii began to drain away, two days after which Sur set in, and a female child was born, which struggled a little, and then died The expulsion of the child was accompanied with the escape of a very large quantity of liquor amnii. At the expiration of two hours the Senta which was universally adherent, was removed, when Dr.-Kyll wa^s" uck bvits Remarkably large size. The circumference of the organ was more than a Third greater than natural, and its thickness was double Tat TfanoZi^arvplacenla. It was of a pale red colour, and of a spongy tuctur"but on divid ng it, its tissue appeared perfectly natural, save that I e blood-vesseTs were larger than usual, as were also the umbi heal arteries a .,«:„., oifKniiah the child wanted three months of the full term, i nree X™ after*\ehZt the pat ent lost a considerable quantity of blood from the an examination ot it, a targe qudiiwiy ui o T. ,• pr was verv it8 ca.Uy, a„d between .he .^Si.A^JS 36 churchill's observations. Whether the injury arises from pressure, from the fluid being less nutritious, or from some other cause, it is difficult to say. Besides the inconveniences resulting from this disease during pregnancy, it sometimes occasions delay in labour, (Merriman, &c.) from the too great stretching of the muscular structure of the uterus —which, however, is easily remedied—and flooding afterwards, from a kind of paralysis from previous over-distention, which in- terferes with the due contraction of the womb. Diagnosis.—The principal diagnostic marks of this disease are the disproportion of the size of the uterine tumour to the period of pregnancy, the presence of certain signs of pregnancy ; and in some cases the situation of the child (Burns,1) and the feebleness 6f its movements.2 It may be distinguished from ascites by the presence of the signs of pregnancy. If we find the defined uterine tumour, " ballottement," and the change in the breasts, we can have no doubt of its being more than ascites. Treatment.—It does not appear that this disease is much under the control of medicine. Various means are recommended, less with the hope of curing than for the purpose of mitigating certain distressing symptoms, or improving the general health. If the pa- tient be feverish, or if there be much pain in the uterus, the abstrac- tion of a few ounces of blood from the arm, or by cupping from the sacrum, will be found beneficial". (Burns.1) placenta, and the consequently increased quantity of blood which the liver would receive. The enlargement of the placenta is, in his opinion, owing rather to congestion than to inflammation, since the results of inflammation are obliteration of vessels from exudation, and consequently diminished nutrition of the organ; owing to which it shrinks, and its structure becomes more compact and firmer than natural, sometimes attaining to an almost cartilaginous hardness." "Inflammation involves some portions only of the placenta, while hypertrophy extends to the whole organ, which is increased in all its dimensions; its vessels are often enlarged, and its tissue rendered spongy, and easily lacerable, though neither infiltration nor hepatisation of its substance exists." 1 " In some instances the child occupies the upper part of the uterus, and the water the under, at least during labour. Twice in the same woman, in succeeding pregnancies, I found the child contained in the upper part of the uterus, and embraced by it, as if it were in a cyst, whilst several pints of water lay between it and the os uteri. When the water came away, filling some basins, then the child descended to the os uteri, but was born dead, with the thighs turned firmly up over the abdomen, and other marks of de- formity."— Burns's Midwifery, 9th Ed. p. 242. 2 " Les signes que l'eau est immediatement avec l'enfant dans les mem- branes sont le peu de mouvement de l'enfant quoiqu'il soit en vie, ou nul mouvement quand il est mort, d'ailleurs l'enfant perit plus communement dans l'hydropisie de cette espece, que dans celle qui se trouve entre les deux membranes ou entre les membranes et les parois de la matrice; et le ventre est d'une grosseur enorme, sans que les cuisses et les jambes "soient fort enflees, et sans que la respiration soit extremement genee, parceque le poids du ventre l'enlraine plus sur les cuisses qu'il ne le porte du cote du dia- phragme."—-Pmzos, Traite des Accouchemens, p. 89. 3 Midwifery, p. 243. EXCESS of liquor amnii, or dropsy of the amnion. 37 Tonics have been used with benefit to the health. Diuretics seem to have failed completely. Some good may be done by restricting the patient to a dry diet. Dr. Burns speaks rather favourably of the use of the cold bath. If there be any suspicion of a syphilitic origin, it may be well to submit both parents to a mild course of mercury, "conducted prudently." Should the distention be enormous, and the distress very great, we shall be justified in having recourse to the induction of prema- ture labour, especially because in those cases the child is generally lost when left to nature. Whilst this operation is in our power, it appears to me quite unjustifiable to have recourse to abdominal pa- racentesis, as recommended by some authors. (Scarpa, Desmarais,1 Davis.2) Should we see the patient for the first time at the commencement of labour, and find, as would be the case,3 the excessive accumulation of liquor amnii impeding the action of the uterus, we must rupture the membranes at once. It will be necessary to watch carefully until the pains set in, lest, in the emptied and flaccid condition of the uterus, flooding should occur. When the uterus has been emptied, and the patient is convales- cent, we should very carefully consider whether any thing can be done for preventing the recurrence of the disease. If syphilis be in question, mercury of course must be used. Pro- bably more benefit will be derived from counter irritation to the sacrum, and vaginal injections of cold water, or the use of the "bidet," than from any other plan of treatment. Professor Burns says, " When it proceeds from some more latent cause, I think it useful, for preventing a repetition of the disease, to make the mother nurse, even although her child be dead."* 1 Receuil Periodique, vol. vi. p. 349. See also Baudelocque's Memoirs in same volume. 2 " Seveial cases of dropsy of the amnion have occurred, and have been recognised as such, subsequently to the date of M. Merciers papers. The author has seen two cases of it within the last few years ; one in consultation with Mr. Langstaff, which was soon afterwards published in the transactions of the Medico Chirurgical Society by that gentleman ; and the other in the practice of the Maternity Charity. The former was treated by abdominal paracentesis, which speedily proved inductive of labour, and the patient re- covered from the immediate effects of her confinement; whilst the other was treated by the operation for the induction of premature labour, of which the result proved in every respect successful, excepting that the child, a poor meagre child, of about 7 months' growth, was stillborn."— Davis's Obstetric Medicine, vol. ii. p. 906. 8 See Denman, Burns, Merriman, &c. &c. * Midwifery, p. 243. 38 churchill's observations. CHAPTER VII. rheumatism and spasm of the uterus. Rhumatisme de V Uterus. Fr. Rheumatismus des Schwangern Gebarmutter, G. Rheumatismfcattacking the pregnant uterus has been very slightly noticed in these countries, though on the Continent it has been ob- served and described by several distinguished individuals. Both Alphonse le Roi and Chambon seem to- have observed it, but from them it did not receive that attention which it deserved. In Ger- many it has been described by Wigand,1 Cams,2 Schmidtmuller,3 Joerg, Velten,4 Haase,5 Betschler,6 Henne,7 Busch,8 and Witcke. M. Dezeimeris9 has published a very able paper in a late number of a French periodical, in which he quotes cases and analyses the labours of his predecessors. Of his researches I shall freely avail myself in this chapter. > ' Bertrage zur theoretischen und pratischen Geburtshiilfe, &c. 2 Diss, de Uteri Rheumatismo, Gynaecologie, vol. ii. p. 232. s Handbuch der Medicinischen Geburtshulfe, vol. i. b. 1. ch. 7. 4 In Rust's Magazine, 1823, vol, xiv. p. 537. 6 Zeitschrift fur Geburtskunde, vol. iv. p. 435, vol. vii. p. 7. 6 Annalen der Klinischen Anstalten der Universitat der Breslau, &c. T In Siebold's Journal, vol. viii. p. 161. 8 Die Geburtshiilfliche Klinik an den Konig. Fried. Wilh. Universitat zu Berlin. 9 L'Experience Journal de Med. et de Chir. May and June, 1839. As a good example of the disease, I give the following case, taken from Siebold's Journal, vol. iv. p. 446:—<" La femme Dorothie Sch.....de Marburg, agee de 33 ans, enceinte pour la quatrieme fois, a la suite d'un reftoidisse- ment, eut, quatre semaines avant le terme de sa grossesse, une douleur tensive et avec elancements dans la matrice accompagnee defievre. Les diaphoreti- ques diminuerent cette douleur, mais elle fut remplacee par d'autres qui se ftxerent tanlot sur les extremities superieures, tantot sur les inferieurs. Lors du travail du parturition, les contractions uterines furent excessivement douloureitses, et de les premiers moments dn travail elles arrarhaient des cris a la malade, sans determiner la moindre dilatation de I'orifice uterin. On ne pouvait toucher Puterus meme avec la plus grande precaution, sans causer une forte douleur. Une saignee detrois pallettes, et des fomentations chaudes, avec des especes emollientes, calmerent ces douleurs, amenerent des douleurs veritables de parturition, et l'accouchement se termina en peu de temps. Les premiers jours qui suivirent furent bons; la troisieme jour la douleur rhumatismale de I'uterus reparut, et exigea I'emploi de la saignee, de I'ammoniaque et du calomel. Tout a coup, les douleurs de la matrice ces- serent, et la maladie prit son siege aux muscles des deux avant bras, avec assez de force pour mettre la malade dans l'impossibilite de tenir elle meme son enfant au sein. Elles disparurent aussi brusquement de la pour se porter sur le genou gauche. Toute indisposition cessa alors dans le reste du corps, mais le genou gonfla, les douleurs y devinrent intolerable ; on aurait pu craindre une exudation dans I'article, si Hon n'eut ete a temps par ('application d'un grande nombre de sangsues et par des frictions avec l'onguent napoliiain." For other cases see Cams de Uteri Rheumatismo, p. 23; Dezeimeris in I'Experience, May 1839, p. 130. rheumatism and spasm of the uterus. 39 " Rheumatism," says Wigand, " may attack the fibres of the uterus, as well as the muscles and their sheaths, marking its pre- sence, as in other parts, by pain, the effect of which is to impede the contractility and motion, by_ increase of heat, swelling, &c. Along with rheumatism of the uterus, there sometimes exists a general affection of the same nature ; but more frequently the uterus, its ap- pendages, and the organs immediately surrounding it, are affected, owing to its great irritability during gestation." It may occur at any period of gestation, but is much more fre- quent towards the termination, when the uterus has acquired its maximum distension. There can be but little doubt that many ex- amples of what are called false pains, are in truth instances of this rheumatic affection of the womb. (Dezeimeris.) Causes.—Probably the principal of these is cold, acting upon an organ whose nervous power, and consequent irritability, has been so greatly increased. It has been especially noticed, that the figure of pregnant females, by projecting the clothes from the lower part of the body, is a peculiar cause of cold. (Wigand,1 Joerg,2 Bnsch.3) The disease was remarked by Velten during a general epidemic of rheumatism.4 Symptoms.—If the attack be mild, the patient will complain of sudden shooting pains in the region of the uterus, coming on in paroxysms, with intervals of more or less complete ease. In some cases the spasm is limited to a small space ; in others it affects the organ generally. If it be more severe, it may be preceded by head-ache, uneasiness, giddiness, and general irritability.5 Suddenly, without apparent 1 " Outre les causes generates des affections rhumatismales, il y a nne particuliere pour la rhumatisme de I'uterus, c'est la facilite avec laquelle cet organe, sous les tegumens amincis de l'abdomen, ressent l'impression du froid, dans les derniers temps de la grossesse, le ventre n'en etant garanti, dans la lieu qu'il occupe, que par les vetemens excessivement legers qui s'y appliquent immediatement, tandis que la region lombo-sacree est souveut roal protegee par des camisolles trop courtes."—Wigand in Dezeimeris. 2 Krankheiten des Weibes, p. 506. 3 Handbuch der TEntbindungskunst, p. 266. 4 Rust's Magazin fur die ges. Heilkunde, 1823, vol. xiv. p. 537. " Dans les derniers mois de l'annee, 1821, le Dr. Velten remarqua que la constitution catarrho-rhumatismale, exercait unegrande influence sur I'uterus aux diverses periodes de la grossesse. Chez les femmes grosses dequelques mois seulement, dans trois cas, le mal se manifesla sans movement febrile notable, par un besoin frequent de rendre les urines et par la douleur qui accompagnait leur emission. La chaleur de lachambre et du lit, un regime general diaphoretique, une infusion de fleurs de sureau avec addition de liqueur de mindererus, retablirent Faction de la peau et dissipeiont bientot le mal." In the case related by Professor Henne, of Konigsberg (Siebold's Journal, vol. 8, p. 161,) the bladder was first affected, then the uterus. 6 " Les convulsions (spasms of uterus during pregnancy) sont quelquefois precedees de pesanteur de tete, d'eblouissement, de veitiges, de viyacites, d'impatience sans motifs, quiannonce une plethore, ou une excesd'irritabilite dans le systeme cerebral. Plus souvent, elles se manifestent subitement, sans 40 churchill's observations. cause, the patient will be seized with severe pain in the region of the uterus, of a spasmodic character, with distinct contractions of the uterus, and so much suffering during the whole of their dura- tion, as will distinguish them from real labour pains.1 Wigand says that there is no dilatation of the neck of the uterus; but in this Cams differs from him,2 and points out the possibility of mistaking rheumatism for the commencement of labour. It does not follow, however, that the expulsive efforts thus inauspiciously begun, will continue ; though, if neglected, abortion or premature delivery has sometimes resulted. The proper remedies will generally arrest the uterine action, and the os uteri will resume its usual state.3 The ir- ritation is generally propagated to the bladder, occasioning an urgent desire to make water, and pain when the desire is gratified. (Joerg, Velten, Henne.) The intestines also sometimes sympathise with the womb, and then the patient may suffer from colic, or diarrhoea, or both. The motions of the child are a source of great torment, owing to the increased sensibility of the womb—and from some sympathy symptdmes precurseurs, par des mouvemens deregles dans les membres. Le figure se decompose, les traits s'alterent et prennent un caracteie con- vulsif: tout le corps se raidit et il se fait dans le ventre, et specialement daus la region uterine, des mouvemens qui correspondent a ceux du corps." —Nauche", Mal. des Femmes, vol. ii. p. 449. 1 " Resumes en peu de mots, les signes caracteristiques du rhumatisme de I'uterus sont les suivants: sans qu'aucune violence ait ete exercee sur cet crgane, il survient un endolorissement general de la matrice, qui ne support pas d'etre palpee, cet etat est suivi de contractions uterines assez regulieres, si ce n'est qu'elles sont accompagnees non pas seulement vers leur fin (comme dans l'etat naturel) mais des teur debut ou a leur milieu, d'une vive douleur qui arrete, enchaine le mouvement."— Wigand in Dezeimeris Es- say. 2 Gynsecologie, vol. ii. p. 232. 3 "Dans un cas de ce genre neglige pendant cinq jours, chez une femme enceinte pour la premiere fois et dans le cinquieme mois de sa grossesse, ou les douleurs de travail etaient deja survenues, ou l'orifice uterine etait ouvert au point d'admettre le doigt explorateur, et tres sensible au moindre attouchement, les douleurs furent arretees par I'emploi des moyensindiques, auxquels on ajouta un peu d'opium, emploi qui fut suivi des sueurs abon- dantes. En pratiquant de nouveau le toucher le lendemain, on trouya que l'orifice uterin s'etait ferme et qu'il avait perdu sa sensibilite de la vieille."— Velten, in Dezeimeris Essay. ': Le rhumatisme durant la grossesse se montra dans une serie des cas et se fit reconnoitre principalement a l'endolorissement de la matrice, ordinaire- ment avec symptomes rhumatismaux febriles, mais quelquefois sans ces derniers. Dans deux cas, il survint, plusieurs semaines avant l'accouche- ment des douleurs uterines tres fortes, qui persisterent tout un jour, deter- mine'rent l'ouverture de l'orifice uterin et offrirent ainsi les apparences d'un commencement de travail. En meme temps que l'affection rhumatismale fut calmee, l'orifice de la matrice se referma, les douleurs uterines cesserent et la grossesse se continua jusqu' a son terme naturel. Le trailement debuta o-eneralement par une saignee, il consista ensuite dans I'emploi des diapho- retiques, de l'ipecucuanha, avec les sels," &,c.-Busch, Die Geburtshulflichc Klinik, $c. 1837. rheumatism and spasm of the uterus. 41 (it may be supposed) with the mother, it not unfrequently happens that these motions are peculiarly lively.1 Joerg has remarked that the child is less frequently injured by rheumatism than by simple inflammation of the uterus.2 In the mild form there is little or no impression made upon the constitution ; but the more severe attack occasions great disturbance. The pulse is quickened, and the skin made hot; the patient is sleepless and restless. Nauche adds, that the irregular contraction of the womb is sometimes extended to the limbs. When the affection occurs during parturition, th'e pains are as it were arrested; they become tedious, ineffective, and often sudden and interrupted, occasioning more suffering than usual. The patient is hot, thirsty, and irritable, unable to remain long in one posture— the pulse quick, and either full, soft, and undulating, or small and hard, (Wigand.) • The uterus becomes very tender, the weight of the bed clothes occasioning much pain. The sensibility may extend to the neck, rendering examination very painful, (Dezeimeris.) During a paroxys.n the uterine tumour feels much harder than usual. If the case be left to itself, we shall find the pains become weaker, or even entirely suspended for some hours. If the patient should fall into a perspiration and sleep, the natural pains will re- cur, and the delivery terminate favorably.3 The Prognosis is in almost all cases favourable, except where the patient may have been neglected until the rheumatic contractions have caused labour to commence. Diagnosis.—It will be of some importance to distinguish an at- tack of rheumatism of the uterus, from inflammation, and it may not at first sight always be easy to do so. Generally speaking, when inflammation occurs during gestation, it is more limited, and con- sequently the pain will be more localised than in rheumatism. Then the occurrence of paroxysms, as a marked feature of the 1 Burns's Midwifery, p. 276. 2 Krankheiten des Weibes, p. 505. 3 "Deux fois," dit le Dr. Haase (of Dresden,) " le rhumatisme de I'uterus fut observe des avant le travail de parturition, il rendit l'accouchement dif- ficile, mais il ceda a des onctions faites avec une pommade opiacee et a I'emploi interieur dtr laudanum; dans un de ces cases, neanmoins, il fallut terminer l'accouchement avec le forceps."—Gemeinsame Deutsche Zeit- schriftfur Geburtskunde, vol. iv. p. 435. Dezeimeris. "Le rhumatisme de I'uterus s'est presente plus frequemment lors de l'ac- couchement et le faisant trainer en longueur, particulierement pendant la premiere et la seconde periode de la parturition. Les contractions uterines etaient excessivement douleureuses, la matrice etait sensible au toucher, la peau etait seche, et ordinairement il survenait bientot des symptomes feb- riles. Ou dut assez souvent accourir a la saignee, apres quoi on employait 1'ipecacuanha ou le vin emetise, et presque toujours ce traitement etait suivi de succes. Dans quelques cas neanmoins le mal resistait pendant toutes les periodes du travail et Ton fut quelquefois oblige de terminer l'accouchement avec le forceps. On observa aussi plusieurs cas dans lesquels le rhumatisme degenera en une veritable inflammation, laquelle se prolongea a la suite des couches."—Busch, Die Geburtshulfliche Klinik, p. 40. 42 Churchill's observations. disease, is peculiar, for the most part, to rheumatism. Again the setting in of rheumatism is much more sudden than that of inflam- mation. An attack very similar in symptoms to rheumatism of the womb occasionally occurs just before labour comes on ; and notwithstand- ing, the labour is easy and natural. In such cases it has been con- cluded that the bladder, and other parts adjacent to the womb, have been affected, but not the womb itself. (Wigand, Dezeimeris.1) Treatment.—Our principal reliance must be placed upon moder- ate antiphlogistic measures, aided by sedatives and diaphoretics. If there be much feverishness, or if the pain be excessive, and nothing in the patient's condition forbid it, blood may be drawn from the arm, in amount varying from G or 8oz. to 12 or 14oz.2 After this, a gentle diaphoretic may be given at intervals during the day, and at bed-time it may be combined with an anodyne. Dover's powder answers both purposes exceedingly well. (Joerg.) If the pain be severe, it will be necessary to give anodynes in con- siderable doses, and perhaps the best mode of administration is in the form of enemata. An opium or belladonna plaster to the abdo- men will be found useful, carefully avoiding the impression of cold, (Wigand;) or an opiate lotion or liniment may be used. Counter irritation to the sacrum is recommended. The bowels must be kept free by gentle laxatives. In addition to this exhibition of medicines, the patient must be warmly clothed. The bed in which she lies must be kept comfortably warm—warm flannel should be applied to the abdomen, and round the hips, and bottles of hot water, or hot bricks, applied to the feet. A warm drink of whey, or other bland fluid, should be given occasionally, and especially at bed time. The diet should be light and nourishing, but without stimulants. In a report by Professor Bnsch, of the Berlin Lying-in Chanty, publish- ed in the Lancet about a year ago (1 do not recollect the number,) it was stated that in consequence of rheumatism of the uterus, it had ■"Une remarque qui n'avait pas echappe a l'esprit d'observation de Wigand, c'est que, dans certains cas ou des femmes se pla.gna.ent depu.s auelrjues iours avant l'accouchement de douleurs dans le ventre, accompagnee de fievre eTde disposition rhumatismale, l'accouchement, contre toute at; fente s'e'st faite dePla maniere la plus naturelle et la phis prompt cela t.ent a ce que la matrice elle meme n'etait point le siege de ^flection, et que celle- ci residait dans les parois abdominales la vessie et la rectum."-i^mem, UExperience, June 1S39, p. 144. 2 " The practice, even when the case is clearly spasmodic, consists in de- tracting blood and after opening the bowels, giving effective doses of opium, Shei by the mouth or in JlystJrs, and this remedy must be repeated as often as neceesarv."—Burns's Midwifery, 9th Ed. p. 27b. " Le t akement le plus efficace, selon Wigand, consiste dans l'usage des boissons chaudes et dans l'administration de l'opium urn a l'.pecacuanha, pre- cedeTd'une saignee dans le cas ou il existe de la plethore ou il parait y avoir disposition a une etat inflammatoire."-/W™m, VExpenence, June 1839, p. 144. HYSTERITIS. 43 been found necessary to induce premature labour. Such a case must be extremely rare, as I have met with no other on record. The treatment of the disease, when it sets in during labour, does not vary materially from that described above—bleeding, opiates and sudorifics being our main resource. Itappearsthat neither form is very obstinate. CHAPTER VIII. hysteritis. Inflammation de la Matrice, Fr. Entzundung der Gebarmutter, G. I have already described inflammation of the womb; as it occurs in the unimpregnated uterus, and must hereafter describe puerperal hysteritis; so that were it not for some practical differences, I should scarcely have thought it worth while to occupy another chapter with it. But there are some peculiarities about the disease, in preg- nant women, which demand a careful notice. As we might expect from the anatomical and physiological changes which take place after conception, and especially from the higher degree of irritability which the uterus acquires, the occurrence of inflammation is much more frequent during gestation than in the unimpregnated state, though less so than after delivery. (Joerg, Siebold.2) It would seem that females of a sanguine temperament are most liable to its attacks. . The disease very seldom occupies the entire uterus, except in the very early months ; subsequently, the more advanced the pregnancy, the more limited is the affection. (Joerg.3) It is o-enerally seated in some portion of the body or fundus often that part to which the placenta is attached, (Siebold,4 Busch,s) and at a late period only, in the lower portionsorcervix, owing probably to the pressure against the upper outlet of the pelvis. (Joerg.) 1 hat this portion should be less frequently the seat of inflammation, might be anticipated from its lower degree of vascularity and irritability. It is worthy of remark, however, that the os uteri is never closed in consequence. . c , , The seat of the inflammation is the muscular tissue of the womb, though the other tissues may be involved.6 The character of the 1 Krankheiten des Weibes, p. 470. 1 Frauenzimmerkrankheiten, vol. ii. p. 275. 3 Krankheiten des Weibes, p. 470. 4 Frauenzimmerkrankheiten, vol. ii. p. 350. « Handbuch der Entbindungskunst, p. 276. .. ""The seat of inflammation of the impregnated uterus is either the ex- ternal or internal membrane, or the muscular tissue In i[he^st case the inflammation is more of an erysipelatous character ; in the latter, ot a men matic^or phlegmonous. The attack also may be either id.opath.c or symp- tomatic."— Siebold, Frauenzimmerkrankheittn, vol. n. p. 6oO. 44 CHURCHILL S OBSERVATIONS. inflammation has been variously described, but I do not know that these varieties are sufficiently ascertained, to be of any practical value. Causes.—Cold, mechanical injury, &c. may give rise to it; or the inflammation may extend itself from neighbouring organs. Symptoms.—The patient complains of a severe and constant pain or stitch in some part of the abdominal tumour, limited gene- rally to a small space—tender on pressure, increased upon walking and by the movements of the child. The pain does not come on in paroxysms. It sometimes extends to the back and groins. Should the inflammation occupy the lower portion of the uterus, the bladder or rectum may be affected, and dysuria or a frequent desire to void urine, diarrhoea and pain on going to stool, be the consequence. The constitution is often considerably affected—the pulse is quickened, the skin hot—there is much thirst, with vomiting, (fee. (Burns.1) If the disease be very limited, the child may escape injury, and gestation be completed ; but rf more extended, the foetus will pro- bably perish in utero, or be prematurely expelled. (Joerg,2 Siebold.3) Unless the disease be completely cured, and the tissue of the womb restored to its healthy condition, the consequences during parturition may be very serious. Dr. Gason, of Enniskerry, in- formed me that he has met with three cases of inflammation attack- ing some part of the womb during pregnancy; and that in these three cases, rupture took place during labour in the exact spot pre- viously diseased.4 As showing the importance of these local inflammations during pregnancy, I may quote from Dr. Ed. Murphy's valuable paper on rupture of the uterus, one of his conclusions: "That in most in- stances where it occurs, it may be traced to morbid lesions, either previously existing, or produced by inflammation," (fee.5 Pathology and Terminations.—The pathological changes con- sequent upon inflammation of this organ are best shown by point- ing out"the different terminations. 1. It may terminate in resolution, and the woman go the full time, and be safely delivered. 2. It may terminate in the effusion of lymph, firmly uniting the placenta to the uterus, and after delivery requiring its manual sepa- ration from that organ. The coincidence of the inflamed spot, and the implantation of the placenta, may be always ascertained by the stethescope, unless they be situated posteriorly. The same means ' Midwifery, p. 275. 2 Krankheiten des Weibes, p. 473. 3 Frauenzimmerkrankheiten, vol. ii. p. 356. 4 See also Dr. Spark's case, Med. Gazette, vol. iii. p. 213. Mr. Else's case, Med. Gazette, vol. ii. p. 400; and Dr. Murphy's Paper, Dublin Journal, vol. vii. pp. 210, 215, 218, 219, 222. 5 Ibid, p. 228. HYSTERITIS. 45 may enable us to ascertain that they do not correspond, and this may relieve our minds of all fear of a retained placenta after de- livery. (Renton.1) 3. It may terminate in a softening of the tissue at the part affect- ed, without any morbid change. (Murphy.2 Kennedy.3) 4. An abscess may be formed in the uterine tissue, (Siebold,4 Busch5) which may open into the uterine cavity, or perforate the bladder or rectum, and so be evacuated by their natural outlets. It may also be effused into the abdominal cavity, and either be absorb- ed, or, sinking down into the pelvis, form a soft tumour between the uterus and rectum. After the escape of the matter, the abscess may heal, or it may remain an open ulcer. (Siebold.4) 5. Gangrene.—This is not a very frequent termination, though it may occur, (Siebold, Busch,) and of course it is a most fatal one. It 1 Edinburgh Medical and Surgical Journal, No. 139, p. 390, et seq. The following case illustrates one cause and some consequences of inflam- mation of the uterus: " Mrs. M., about 30 years of age, was confined on the 6th of November, 1837, of her seventh child, after a very easy labour. In the early months of her pregnancy, she received, when in bed, a severe kick on the pubic region from one of her children, which occasioned great local pain. Within twenty-four hours, uterine action supervened, and consider- able hemorrhage per vaginam took place on the following day. She was bled at the.arm by Mr. Monteath, and underwent very active treatment, which was found necessary for allaying the inflammatory symptoms which arose, and for preventing the miscarriage with which she was threatened. She was long confined to bed, and was never free from a burning hot pain in the uterine region during the whole course of pregnancy." The child was born three hours before Mr. Renton saw her, but the placenta was retained. " Ex- ternally the uterus felt very irregularly contracted, bulky, and flaccid, ex- tending from the pubis to the scorbiculus cordis." On examining internally il was discovered that " about one fourth of its (the placenta's) lower portion was detached, and the remaining part adhered, not closely and intimately, but by means of detached bands from below the middle, along the anterior wall of the uterus, which was puckered transversely and very irregularly, forming a striking contrast to the posterior side, which was uniformly smooth and free'from contraction, firm, and greatly thickened." " The uniting bands felt like dense cellular membrane, and of the consistency of those adhesions by which the pleura pulmonalis is connected to the pleura costalis after in- flammatory attacks."—Mr. Renton's Paper on " Adhesion of the Placenta to the Uterine Surface," in the Edin. Journal, April, 1839, p. 397. See also Denman, Merriman, Ramsbotham, &c. 2 Dublin Journal 'of Med. Science, vol. vii. p. 218, 219, 222. 3 At a meeting of the Pathological Society of Dublin, Jan. 26, 1839, "Dr. E. Kennedy presented a specimen of ' softening of the uterus,' taken from the body of a female who died on the day of her admission into the Lying- in-Hospital, and without having presented any remarkable symptom, except pain at the upper and inner part of the thigh, where a slight redness was observable. The csesarian section was performed, but the child was found dead, though perfectly formed. On dividing the parietes of the abdomen, ihe uterus appeared a deep purple, or almost black colour; its texture was remarkably soft, and its mucous surface covered with grumous blood."— Dublin Journal of Medical Scif-nce, May, 1839, p. 290. 4 Frauenzimmerkrankheiten, vol. ii. p. 359. 6 Handbuch der Entbindungskunst, p. 276. 46 Churchill's observations. has been described by German writers under the title of Putres- cenz, (flicker1) or Putrescirung- of the Uterus. (Boer.2) Diagnosis.—When inflammation attacks the impregnated uterus, we have the advantage (at least for the greater part of gestation) of being able to examine the affected parts manually, which we can- not do when the uterus remains of the ordinary size, and is con- cealed in the pelvis. This will add to the facility of diagnosis, and with other signs may enable us to detect it. 1. From Rheumatism. Although in both there is pain and tenderness on pressure, yet in rheumatism the pain is more in paroxysms, and the tenderness less circumscribed, than in inflam- mation. The constitution, too, suffers more when the uterus is inflamed. The cause will also sometimes clear up the diagnosis. 2. From Peritonitis. Should the peritoneal covering of the uterus alone be inflamed, no doubt at first it would be difficult, if not impossible, to distinguish it from inflammation of the deeper tissues; but the peritonitis would soon spread over the abdominal viscera, instead of continuing in one limited spot; and, besides, the tenderness on pressure is more superficial, and more acute, in in- flammation of the serous membrane, than of the muscular tissue. In general peritonitis the tenderness is universal, whilst in the disease we are contemplating the tenderness is quite local and limited. 3. It may be distinguished from inflammation of the other ab- dominal organs by its local signs, and by the absence of their pecu- liar symptoms. Prognosis.—It will be necessary to give a very guarded prog- nosis, as some of the terminations and consequences of even cir- cumscribed inflammation may be very serious. If, however, the placental souffle should be heard at a distance from the affected part, we shall be relieved of part of our fears ; the normal connec- tion between the uterus and#placenta will not be altered. Treatment.—The disease being most generally limited in extent, it will probably be sufficient if we apply leeches, without having recourse to venesection, though this must not be omitted if neces- sary. Leeches, then, in sufficient quantity, are to be applied to the affected part, and repeated if the tenderness and pain continue. At the same time, calomel and opium, in moderate doses, should be given; and it may be requisite sometimes to touch the gums. Hip baths have been found useful, but our employment of them will depend a good deal upon the period of pregnancy, and the threatening of labour or not. Anodyne clysters may be given for the relief of the pain, and for procuring rest. When the acute stage has passed, much benefit will be derived from blisters, either repeated or kept open. Stimulating and anodyne liniments have also been recommended. 1 Siebold's Journal fur der Geburtshulfe, &c. vol. xi. p. 62. 3 Naturliche Geburtshulfe, &c. vol. i. p. 202. hysteritis. 47 If we suspect the formation of matter, we may find it necessary to give quinine, and to support the patient's strength by nutritious diet. If the purulent deposit be in the neck of the womb, we are advised to evacuate it by the aid of Savigny's Fistula Knife, or Osiander's Hysterotome.1 If the matter escape by any other outlet, we must treat the case according to circumstances. 1 Siebold's Frauenzimmerkrankheiten, vol. ii. p. 364. 48 Churchill's observations. SECTION II. DISORDERS FROM SYMPATHETIC IRRITATION. We shall commence" the consideration of this class of diseases with those of the chylopoietic viscera, as amongst these the dis- turbance occasioned by conception is first felt; and then proceed to those of the circulating, respiratory, and nervous systems; conclud- ing with the sympathetic irritations of the breasts. DISORDERS OF THE CHYLOPOIETIC VISCERA. CHAPTER I. tooth-ache. Odontalgie, Mal des Dents, Fr. Zahnsclimcr- zen, G. Pain along the jaw, or in individual teeth, is of frequent occur- rence with pregnant women.1 It is more common in the earlier months, and with some it is the first indication of conception.2 I have known several cases of this kind. (Capuron,3 Gardien,4 Im- bert.5) It may either be continued, with but few and short intervals, 1 Denman's Introduction, p. 161. Davis's Obstetric Medicine, vol. ii. p. 900. Blundell's Obstetricy, p. 201. 2 "Generally speaking, this is a complaint of the earlier months, but pa- tients have attacks of it throughout the whole period of pregnancy. Some- times it never occurs till within two or three days of the commencement of labour. This is often a purely sympathetic affection; it is excited through the influence of the uterine on the nervous system. There is not a more fertile source of tooth-ache than torpid bowels."—Campbell's Midwifery, p. 518. 3 " Certain women suffer from tooth-ache as soon as they have conceived, and even recognise their condition by this symptom. The pain varies in degree, and at different times; sometimes dull and aching, it may disappear at intervals; at other times acute and piercing, it may continue night and day. Then the sleep is lost, the appetite diminishes, the digestion is im- paired, the patient becomes feveiish, and sometimes abortion occurs."—Ca- puron, Mal. des Femmes, p. 357. 4 Traite des Accouch. vol. ii. p. 66. 6 Traite Theorique et Pratique des Mal. des Femmes, 1839, p. 398. TOOTH-ache. 49 or (more generally) it occurs in pardxysms. Its effects upon the comfort and well-being of the patient are often very distressing —she loses her sleep, the appetite is lessened, digestion is impaired, and if not relieyed, abortion may result. (Campbell, Capuron.) It appears to be the effect of the uterine irritation upon the nerv- ous system, and localised in this particular part. (Capuron, Camp- bell, Gardien.) Causes.-^!. In many cases it appears to be a simple neuralgia ; and this is the case, I believe, in all those instances where it recurs with each pregnancy. 2. The gum may be attacked by inflammation. (Capuron.1) 3. It may result from a general catarrhal affection. (Gardien.2) 4. It may be caused by a carious tooth. The diagnosis is of some importance in the choice of remedies; for instance, the treatment for the nerfralgia differs from that for caries. The point to be settled is, whether the attack beneuralgic, inflammatory, or arising from organic disease of the tooth ; and to satisfy ourselves, a very careful examination of the mouth must be made, and the state of the mucous membrane of the mouth and the general health be investigated. The probability of pregnancy, and the occurrence of tooth-ache in other pregnancies, will materially aid-us in determiping the character of the present attack. TreatmenU^-Oxxx first object, then, is to determine the character of the complaint. If we .decide that it is^neuralgic, we may try any of the essential'oils, as cloves, peppermint, cinnamon, &c. A little-alcohol, held in the mouth at the affected side,will sometimes afford relief. Fomentations are equally useful, especially when the whole jaw. is painful. The effects of opium vary a good deal—it often relieves the pain, or lessens it, but sometimes/ails. Creosote is often a valuable remedy. Gardien speaks highly of the extract of the.seeds of stramonium. Dr. Bhindell says, "The volatile tincture of-valerian bark, and carbonate of iron,, are the principal remedies here.'*3 - ' Mal. des Femmes, p. 360. 2 " Tooth-ache may depend upon different causes; it may be the result of plethora, or the consequence of a catarrhal affection. ' The state of the stomach, or an affection of some distant part, may also give rise to it. Some- times it arises from caries, at others it is merely a dental neuralgia."—Gar- dien, Traite des Accouch. vofc ii..p. 66. 8 " I was once called to a. Greek lady, a Smyrniqte, at the other end' of the town, suffering violently from.this disease, night by night, so that she could get no rest. All the ordinary remedies had been tried, in ordinary doses, but in vain. I gave her the volatile tincture of valerian, and ba.rk, as largely as the stomach could bear, and with the effect of arresting the disease, so that throughout the remainder of her gestation she continued almost entirely free." —Blundell, Princ. and Pract. of Obstetricy, p. 201. " Si elle est continue, je donne quatre, cinq, six, ou meme dix pilules de meglin." . . . " Ces pilules, quand elles n'arretent pas la douleur, la rendent intermittente. Aussitot qu'elle prenne cette forme, j'administre le quina, et je coupe I'acces. Le remede doit etre donne a doses assez fortes que Ta maladie dure depuis quelques temps. II y a quelques mois que j'eus 14—e 4 church 50 Churchill's observations. Counter-irritation externally, by a small blister to the temple or behind the ears, is occasionally of use (Capuron ;) though as Gar- dien1 remarks, it not unfrequently fails in cases of neuralgia. This list of remedies might easily be lengthened, but I prefer enumerat- ing the principal ones, and leaving it to each person's experience to modify the general principle according to the individual case. After all our endeavours, we shall find ourselves in many instances unsuccessful; but then, on the one hand, it often disappears spon- taneously. " We have seen," says M. Capuron, " tooth-ache, amenable to no remedies, spontaneously disappear towardsXhe third or fourth month of pregnancy."2 If the gum be inflamed, it wili be advisable to scarify it, or to apply leeches internally or externally. When the patient is hot, restless, aad feverish, moderate general bleeding has been found beneficial. (Mauriceau.) The loss of blood should be followed by hot fomentations to the face, and the holding of warm water in the mouth. A purgative, with'some mild medicine, according to the state of the stomach and'bowels, should be exhibited. When the tooth-ache is a consequence of a more general catar- rhal affection, stimulating applications, or sialagogues, as they are termed, are useful (Gardien.) A small portion df the radix py- rethri, or of tobacco-, or a stimulating lotion, maybe used, and often with complete success. Blisters have also been recommended. If the catarrhal affection be acute or extensive, it may be necessary to commence by taking away some blood; but, generally speaking, this is unnecessary. • Many of the remedies- already enumerated may be tried with carious teeth—such"as theessential oils, tobacco, opium, creosote; and to them ma"y be added nitric acid, (Ryan3) and the application of a red hot knitting-needle to the hollow in' the teoth. But if all these remedies fail, as fail fhey often wjli, ate we then to extract the tooth ? Some authorities decide one way, some the other. Dr. Burns says, "I haVe known the extractien followed in a few rninu-tes by abortion." Dr. Bkmdell would not extract, because he considers the attatk neuralgic.4 Dr. Campbell5 is in favour of a trailer une neuralgie semblable, qui ne peut etre coupe que par une potion faite avec un gros d'extrait de quina et neuf grains de sulfate de quinine. SM'etat de l'estoraac ne permet pas l'administration de ce remede dans une potion, on donne un lavement fait avec une once de poudre de quina et au- tant de racines de valeraine. Ces remedes doivent etre pris environ une heure avant Faeces."—Imbert} Mal. des Femmes, p. 361. 1 Trait6 des Accouch. vol. ii. p. 66. 8 Mal. des Femmes, p; 361. 3 Essay on Tooth-ache, London Med. a.nd Surg. Journal, vol. vii. * Obstetricy, p. 201. 8 "When the tooth is carious, however, nor permanent advantage can be derived from any remedy but nitric acid and extraction. In a "habit predis- posed to abortion, it is said that the removal of a tooth is apt to occasion this accident; but I have nevei seen premature uterine action induced by it; while, as is well known, abortion has been excited by violent and long con- tinued odontalgia."—Campbell's Midwifery, p. 519. PTYALISM. 51 extraction, seeing more probability of abortion in continued pain. M. Capuron1 argues with him, and so does M. Gardien—adding, however, that if after extracting two or three teeth, the pain be not relieved, we had better stop.2 It appears to me that extraction may be advisable, provided other medicines have failed, that the tooth is evidently diseased, aud that there is no predisposition to abortion. CHAPTER II. salivation or ptyalism. Ptyalisme, Fr. Speichelfluss, G. It is difficult to explain the sympathy between the uterus and salivary apparatus, though there is abundant evidence of its exist- ence. Salivation, though not very frequent, is yet sufficiently so to have been set down among the signs of pregnancy. It is men- tioned by Hippocrates, and has been noticed by many writers since his time. (Van Sweiten,3 Rcederer,4 Capuron,3 Gardien,6 Imbert,7 Burns,8 Blundell,9 Campbell,'0 Montgomery," Dewees.12) r Mal. des Femmes, p. 360. * Traite des Accouch. vol. ii. p. 69. 3 Commentaries, vol. xiii. p, 271. 4 Elementa, p. 45. * Mal. des. Femmes, p. 316. 6 Mal. des Femmes, voh ii. p. 32. 7 Mal. des Femmes, vol. i. p. 396. 8 Principles of Midwifery, p. 267. - 9 "1 saw a case of this sort, whkh strongly'resembled mercurial ptyalism, but the fetor was wanting, and the gums were not ulcerated: there was merely the high action of the salivary apparatus."—Blundell, Prin. and Prac. of Obstetricu, p. 202. 10 Midwifery, p. ol9. • . " Signs of Pregnancy, p. 55. 18 Midwifery, p. 115, from which the following case is quoted:— "We were 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 vomit- ings: sov 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 oCbed; and when she did. attempt to sit up, she would almost instantly faint,, if not instantly replaced. From a belief that the affection might be local, astringent gargles were freely employed, but with marked disadvantage. A large blister was next applied to the back of the neck, with decided hut transient benefit—that is, the salivary discharge was less, the nausea diminished, and the vomiting less frequent; but this favourable impression was but of three or four days' duration; for after this time, all the unpleasant svmptoms returned with their former se- verity. An emetic of ipecacuanha was now exhibited, followed by a cathar- tic of rhubarb and magnesia, without the smallest benefit;—soda water, 58 Churchill's observations. It generally oocurs at a -very early period of-gestation, and may cease or abate about the third or fourth month. (Dewees.) It some- times, however, continues throughout the entire period, as in one case under my care. It almost always ceases immediately after delivery, though cases are on record where it continued a month or two afterwards. (Imbert.1) It is possible that it may be somewhat dependent upon the con- stitution of the woman, though this is not clearly made out. Ca- puron says that it only occurs in those of nervous temperaments. ■ This is not the place to estimate its value as an evidence of pregnancy; I must refer the reader to the different authorities on the subject. Cause.—It appears to be an affection of the salivary glands (which are sometimes swollen and tender) principally, in which the mucous membrane of the mouth participates to a certain extent. (Campbell.) In a case under my care, the left parotid only was affected. The gums are neither spongy nor ulcerated. The dis- charge is generally of the ordinary quality of the saliva, without fetor, but sometimes the taste is unpleasant. (Dewees.2) The quantity varies from somewhat above the ordinary amount, to several quarts; and from the necessity of frequently emptying the mouth, it proves very annoying. I subjoin a case which illustrates this point very well.3 lime-water and milk, milk itself, Ac. were in turn "oavatlingly employed We- now put our patient upon a strictly amrnal diet, and ordered ten drops of laudanum morning and evening, and fifteen at befl-u" J-'^P'^i ^ ceeded most Derfectlv in the course of a few days; nausea and vomitin return of this complaint in her subsequent pregnancies. ' • Mal. des Femmes, vol. \P; 39£ fa , m attended with an • « It almost always bas an^unpleasan: taste, 11nouS irritation, and offensive smell; it keeps 'by'om"c£l^ not unfrequently projoke.Puk.ng, J^^^X' very troublesorne in- is the mother of three children, ***™£&fcth he?fitst child, after and salivation have troubled her. S^ *»£ aff(jcted wilh head-ache, and a being pregnant about one Jon*J'^liva% continually running into her large quantity of clear fluid, like »,l*a' spat out during the day St^sothlt sometimes two ^Z^m^^^J^S^ Sh, s that sometimes two orltreeg *~&^ had ^ , At the expiration of the ourt. month that « ^J^gnaacy, precisely the the salivation left her entirely. lJur,nb ^renon stopping im- Sme series of ^t^n/ The tl" were generally costive, and grea mediately after quicta^- J^c[nn were taken, for■•>*»«■ ^ f« thirst was complained of. wo meu. Dming this last gestation, rier her retaining most things od, he^om| ^ J finf appeared about a old complaint had ^ei^me tha ^ &s much as fwr quarts, month after conception. Some aay PYTALISM. 53 When the discharge is moderate, the patient suffers merely in- convenience ; but when excessive and long continued, the stomach is weakened and irritated, and sometimes evacuates its contents. The patient complains of weakness, and acidity of stomach. Constipation is very frequently an accompaniment. The only error in diagnosis into which we could fall, would be that of mistaking the salivation caused by pregnancy for that caused by mercury. The distinction is sufficiently clear in the disease we have been describing; the gums are- neither sore, spongy, nor ulcerated, nor is there any fetor from the mouth. The patient being pregnant will also serve to clear up the diagnosis. (Mont- gomery.1) Treatment.—By several writers, especially the French, we are cautioned against employing any remedies for the purpose of re- straining or suppressing thethe strength of the argument, but said he would turn it over in his mind, and meet me again in the even- ing. At this time; unluckily for the patient, she had retained about half a pound of nourishment, and the sickness had not increased. He thought it proper, therefore, again to defer the operation, although I explained that this was only one of those delusive intervals which terminated in diarrhoea. So indeed it proved; for the next day.she was exceedingly ill. I now told him, if he had not made up his mind, that I had. I added, that if he chose to undertake the bringing oh of premature labour, he might; but I thought the time was past, and so did he. In two day's more the patient sunk. Now I do not think it right to say that this woman would have recovered if pre- mature labour had been brought on in proper time : but it is my opinion that it would have given her a great chance.*'—Davis's Obstetric Medicine, vol." ii. p. 871. 1 Dr. Johnson's case, in Lancet, March 3, 183S, p. 825. * Obstetric Medicine, vol. ii. p. 871. , f 3 Two cases, by M. Dance, Hotel Dieu, Paris, with post mortem examina- tions, are given in the Medico-Chirurgical Review, from the Repertoire: "Case 1. Sophy Pepin, aet. 21, meagre, nervous, and irritable, entered the Hotel Dieu, April 15, 1826. Three months and more previously the cata- menia had stopped, and soon afterwards she was affected with weight and pain in the epigastrium, and.considerable derangement of the general health. During the preceding two months she was harassed with almost constant vomiting of every thing she took, liquid or solid, attended with rapid emacia- tion. Yet her tongue was clean and moist, without any redness at the sides. The physician who attended her in the city, never perceived any febrile movement in the system. The epigastrium was now devoid of teuderness on pressure, and only^a pulsation rather more than natural could be felt— sleep interrupted—habitual constipation—vomiting both night and day indif- ferently, preceded by a disagreeable sensation of twisting in the epigastrium. The matters ejected were often of a greenish or limpid character, and small in quantity. The patient did not think herself pregnant, and there was no enlargement of the hypogastric region. Leeches—ice, externally and inter- nally—and various oiher means, had been tried in vain to stop the vomiting. The anti-emetic draught of Riverius was tried on ihe 16th at the hospital, but ineffectually—opium plaster was applied lo the pit of the stomach, with nausea and vomiting. 63 It has been remarked, that when the progress of gestation is ar- rested by the death of the foetus, the vomiting generally ceases spon- taneously. (Burns.1) There are also cases recorded where the violence of the vomiting has ruptured the uterus, or some internal organ.2 The flu id ejected may be thin, watery, or glairy and colourless ; or it may consist partly of bile or blood,3 depending probably upon the violence and duration of the vomiting. In the severer cases " it is either greenish or blackish, according to the extent and duration of the disease ; and there is tenderness of the epigastrium, with great depression of strength." (Burns.] In addition to the effects of continued vomiting already described, we shall find the pulse reduced in strength and quickened, the tongue often loaded,.and the bowels constipated. (Davis. Dewees.) as little success. Twenty other remedies, including leeches and blisters, were put in requisition, without having the slightest effect in checking the vomiting. By the end of May, emaciation had made great^ progress, and now the hypogastrium began to become prominent, and pregnancy was ascer- tained to exist. On the 2d of 5uue, this afflicted creature ceased to suffer. " Dissection.—No lesion could be detected in the stomach, except a slight reddish tint in the mucous membrane. The wholepf the intestinal tube was sound. The uterus rose a few inches above the pubes, and its parietes were preternaturally soft and flabby, but without any other appreciable change of structure. The membranes of the foetus were transparent throughout; but between these and the uterus there were false membranes, forming a layer some lines in thickness%exactly resembling those found between the pleurae after inflammation. The«ame was found between the placenta and the uterus, but more of a purulent character." _ Case 2d. " Anglae Leroy, cet. 20 years, not married, became irregular in her menstruation'in Nov. 1824, and soon afterwards was troubled with sick- ness, malaise, cephalalgia, and vomiting of bilious matters. She entered the Hotel DieUjDec. 30, 1824, and at this time she was suspected to be preg- nant. The vomitings were very frequent, and there was some pain on pres- sure of the epigastrium, but no fever. The tongue was moist, and slightly red at the sides. She was cupped on the epigastrium, but without any benefit. Various means were employed to allay the vomiting, but they were attended with only" temporary" relief. In the beginning of February the sickness was as"bad as ever. Her stomach Would retain no kind of food, and she expired, exhausted, on the 13th of the same month." " Dissection.—The emaciation was great, no appreciable lesion in the head or thorax—some red and softened spots near the cardiac orifice of the stomach. The uterus rose some inches above the pube's, and its parietes were exceed- ingly thin—scarcely a fine and a half in thickness. They were also very soft and gorged with blood. The membranes were transparent—the embryo appearedlo be about three months old ; and there was no other appearance of disease."—Medico Chirurgical Review for 1829, vol. 8, p. 149, New Series. 'Midwifery, p. 253. 2 Duparcqu'e. Lond. Med.Gaz. Jan. 19, 1829. 3 " The fluid thrown up is generally glairy or phlegm; and the mouth nils with water previous to vomiting: but if the vomiting be severe or repeated, bilious fluid is ejected."- Burns's Midwifery, p. 252 ; Devees s Compendium of Midwifery, p. 110; Siebold's Frauenzimmerkrankheiten, vol. n. p. 7. "The rejected matter varies in its composition. Independent ot the ingesta, sometimes bloody mucus is brought up, at other times pure bile. — Campbell, p. 520. 64 Churchill's observations. Causes.— [n the milder cases the vomiting is simply owing fo the sympathy with the gravid state of the uterus,1 the condition of the stomach is healthy in most cases. Temperament will doubtless have much influence on this class. A plethoric condition has been supposed to give rise to it. Carus says, " A second cause, often combined with the former, is overfulness of the portal system, in consequence of the increased vascular action of the genital system, which plethoric condition often gives rise to inflammatory affec- tions."2 When the vomiting comes on, especially for the first time, towards the end of pregnancy, it is probably partly to this sympathy, and partly to mechanical pressure of the gravid uterus upon the stomach. (Siebold.3) In the more violent and long-continued cases of vomit- ing, it is impossible to doubt that the stomach becomes actually in- flamed. (Siebold.4 Carus.) It is a very interesting question, how far some of these worst forms may be dependent upon a peculiar and diseased condition of the uterus itself, or of its contents. ' J fear our facts are too few at present to enable us to come to any very definite conclusion ; but there are some cases which would seem to justify the suspicion of a connection between the two. The cases related by M. Dance,-already quoted, are of this kind. Dr. Burns observes, "Obstinate vomitingbas also appeared to proceed from a morbid condition of the uterus, which after death has been found slightly inflamed ; or even pus has been, found between the surface of the uterus and membranes, although during life no pain was felt in the uterine region. The parietes are soft, the uterus-flaccid, with an exudation of fibrine in some places-between the uterus and deci- dua. The stomach is sound, and jseldom bas been pained."5 1 Mauriceau, Traite des Accouch. vol. i. p. 129. Puzos, Traite des Ac- couch. p. 73. De la Motte, Traite des Accouch; p. 70. Siebold's Frauen- zimmerkrankheiten, vol. ii. p. 8. 2 Carus, Gynfficologie, vol. ii. p. i98. " This affection is observed most frequently soon affer conception, especial- ly in women of great sensibility; some, however, do not experience it till about the fourth month, and others only towards the end of gestation. In the first case it is the effect of uterine irritation, communicated to the diges- tive system ; in the second it would seem owing to a plethoric condition, pro- duced by suppression of the menses, particularly in women of a sanguine temperament, in whom menstruation is excessive; in the third it is to be at- tributed to mechanical pressure, or the pushing up of the stomach by the uterus, which gradually rises to the epigastrium, and occupies the greater portion of the abdomen.— Capuron, Mal. des Femmes, p. 370. " L'etiologie que je vieus de proposer sur le vomissement qui survient dans les premiers temps de la grossesse, suppose deux choses: la premiere qu'il peut exister lesion dans un organe parceque les fon,ctions d'un autre sont troublees; la seconde, que cette.affection symptomatique peut quelquefois augmenter la sensibilite et d'autres fois la diminuer."—Gardien, Traiti' des Accouch. vol. iLp. 46. > 3 Frauenzimmerkrankheiten, vol. ii. p. 8. 4 Ibid, vol. ii. p. 10. - Gynaecologie, vol. ii. p. 198.- 6 Midwifery, p. 254. nausea and vomiting. 65 Among the occasional exciting causes, we may place bad smells,1 peculiar odours, and indigestible food, or a torpid state of the bowels.2 We can scarcely, I think, attribute it to the secretions of the stomach.3 "" Diagnosis.—The first point to be ascertained in any case of re- peated vomiting is, whether it arise from pregnancy or disease. Its occurrence only in the morning, with the absence of the menses, and an alteration in the areola and nipple, will afford good grounds of suspicion, though not of absolute proof. When the vomiting is very frequent and obstinate, without other evidenceof disease of the stomach, but with such signs of conception as are developed accord- ing to the supposed period of pregnancy, we shall have good ground for treating the case as dependent upon gestation. As to its posi- tive and relative value as a sign of pregnancy, I must refer the reader to works upon the subject; I have only to treat of it as a disease. Treatment.—The choice of remedies will depend very much upon the constitution of the woman, upon the amount of the dis- order, and upon the period of pregnancy. In slight cases, at an early period, no treatment will be necessary ;4 and even when more severe, it may be wise often to try the effect of time, inasmuch as in the majority of cases it ceases after the third or fourth month.5 It is probable that, when the stomach is disturbed by its contents, or the ingesta are of an indigestible character, a moderate degree of vomiting may be beneficial. (Denman.) Nausea is so much more distressing than vomiting, that in such cases we are advised to give a gentle emetic. (Denman.6 Blundell.7) 1 "Dr. Lowder had a patient who was effectually re4ieved by removing from the factory of her husband—a coachmaker; for when she became preg- nant, the smell of the paint continually excited the stomach."—Blundell s Obstetricy, p. 187. ' ... 2 " These affections chiefly arise from the influence of the uterus, in a high state of irritation, en the stomach ; and another very fertile source of nausea and vomiting in the gravid state is torpor of the bowels; to which we may certainly add, indulgence in liquids and vegetables.^'— Campbell's Midwifery, P- 520. . ,' , . t . 8 " I do not regard these fluids (contained in the stomach) as corrupted, although many excellent writers/do. I make a wide difference between superfluous and corrupted fluids. Corruption changes the nature of things ; superfluity merely consists in their abundance."— De la Motte, Traite des A(*(*ChlJ(*n P7YLP77S T) 72 *" One need neither be surprised nor disturbed at the vomiting in the early months, provided it be moderate, and without much effort; but if it continue after the fourth month, it is to be remedied, if possible; inasmuch as the food being constantly rejected, the mother and child will be much weakened. - Mauriceau, Mal. des Femmes, vol. i. p. 130. ,, „„ r « " These disorders are common to favourable and unfavourable cases of pregnancy .with this difference, however, that in the favourable cases they disappear towards the third or fourth month: their disappearance is ai cer- tain sign of favourable gestation," (d'une bonne gro3sesse.)-P«*o«, Iraite des Accouch. p. 73. 6 Denman's Midwifery, p. 153. * Obstetricy, p. 177. g ^^ 66 Churchill's observations. If at any period of pregnancy the vomiting be so excessive as to call for our interference, and the patient be of a plethoric habit, there can be no question of the propriety of venesection ; but in most cases this can only be done at an early period of the vomiting, as by its continuance the patient is so much reduced as to prohibit this remedy.1 Manning recommends this particularly at the menstrual periods.2 Small and repeated bleedings are preferable to the ab- straction of a large quantity at once. If venesection be objection- able, leeches may be applied to the epigastrium. Gentle purgatives should be given, so as to keep up a constant action of the bowels, especially if there be evidence of irritating mat- ters being retained in the intestines. (Mauriceau.3 Davis.4 Blun- dell.5 Imbert.6) l"In general, bleedipg is the most successful remedy. Some women even feel the necessity of it by the increase of vomiting."—Puzos, Traite des Accouch. p. 76. Mauriceau relates a case of violent vomitings, accompanied by a kind of convulsive movement, in the second month of pregnancy. " The patient was of a sanguineous disposition. She had formerly aborted, and had had a false conception the year before. She was now bled at the arm, and she went on to her full time, and was safely delivered."—Mal. des Femmes grosses, vol, ii. p. 21. In another case the vomiting occurred in the ninth month of pregnancy, and was cured by bleeding from the arm twice,succeeded by opiates, and sooth- ing " lavemens."—Mauriceau, Mal des.Femmes grosses, vol. ii. p. 310. " Smellie relates several cases. " In about four months after this accident, the same woman became pregnant; and being attacked with sickness at her stomach, and retchings, in her second month, Dr. Smellie was requested to see her. Finding that she had exceeded her usnal catamenial period, he ordered her to lose eight ounces of blood from the arm. The vomiting was im- mediately relieved. From this time forward^ till about the middle of the fifth month, venesection was repeated every four weeks, with the same success ; aud she happily went on to her full time."—Cases in Midwifery, vol. ii. p. 83. See also vol. ii. p. 84. See Denman's Midwifery, p. 152. " Of the utility of this practice, the general testimony of practitioners, and my own observation, fully convince me. It does good by relieving that state of the origin of the eighth pair of nerves, which occasions the irritability of the stomach, just as it would abate vomiting on other more formidable cerebral affections. It also acts on the sympathetic nerve, the caeliac plexus of which sympathises with the uterine,"—Burns's Midwifery, p. 253. " As the irritability which prevails during the early months must be ascrib- ed to suppression of an accustomed evacuation, so the most effectual mode of relieving it is by venesection. If the patient can support blood-letting, or have no objection to it, from four to six ounces should be taken from the arm monthly, al or near the period when the menses should have appeared. When the individual is too delicate to bear phlebotomy;-or has a dislike to it, let an adequate number of leeches be applied either to the epigastric region, or the groins."—Campbell's Midwifery, p. 521. 8 Diseases of Women, p. 302. 5 Traite des Accouch. vol. i. p. 132- 4 Obstetric Medicine, vol. i. p. 859. 6 Obstetricy, p. 177. 6 Mal. des Femmes, voi. i. p. 389. NAUSEA AND VOMITING. 67 Benefit is frequently derived from counter-irritation to the epigas- trium by means of a blister, turpentine, or mustard poultice. If the sickness be not very severe, effervescing draughts will oc- casional ly afford relief. If necessary, a few drops of laudanum may be given with each. Narcotics and opiates are frequently successful, and especially after bloodletting (Denman,1 Davis,*); but their constipating effect must be corrected by enemata or cathartics. A very useful method of exhibiting laudaiium is by wetting a cloth with it, and applying that to the stomach. Dr. Heberden states that " the application of a piece of folded cloth, moistened with laudanum, to the region of the stomach, has been of considerable service, when internal medi- cines of the highest estimation have proved ineffectual." (Burns,3 Blundell.4) Or the opium may be given in an enerna of starch or warm water. (Campbell.5) Denman has thrown out a doubt as to the effect upon the fcetus ; but I have not met with any cases which confirm his view.6 Various kinds of antispasmodic remedies have been tried, but without much benefit; in fact, it would be as useless as difficult to enumerate all the remedies that have been employed, and often in vain, against this distressing complaint. When the ejected matter is acid, charcoal and other alkaline substances are found useful; and if these fail, acids may be tried. (Dewees7, Ashwell,8 Blundell.9) Hydrocyanic aeid has been tried, ' Midwifery, p. 152. 1 Obstetric Medicine, p. 859. 3 Midwifery, p. 254. * Obstetricy, p. 178. 6 Midwifery, p. 521. 6 " Perhaps no well grounded objection cau be made to the occasional use of opiates, when violent pain, or any other urgent symptom, demands them. But I have persuaded myself that their habitual or very frequent use is pre- judicial to the fcetus—either by debarring it from a proper supply of nourish- ment, or by depraving that with which it is actually supplied: but of this opinion I begin to have some doubt."—Midwifery, p. 152« " " We rarely persevere in the use of the alkaliue remedies, when we find that considerable doses will scarcely have a temporary effect. When this is the case, we have recourse to the acids themselves for the relief of this most distressing state of the stomach. Both vegetable and mineral have been employed by us, with about perhaps eqaal success; but the vegetable will merit the preference in general, on account of the teeth. We have in several instances confined the patients for days together upon lemon juice and water, with the most decided advantage." " One lady, a patient of ours, took the juice of a dozen lemons daily, for many days together, with the most decided advantage, and no earthly thing besides."— Compendium of Midwifery, p. 111. 8 On Parturition, p. 193. 9 "It seems, d priori, not very probable that powdered charcoal can be of use in these cases, but learning from a friend that in the hospital in New York it had been tried in vomiting with advantage,I was induced to give it an ' essai;' and I can at least aver, that I have seen no ill effects from it, not to add that it seemed to be of real efficacy. The method of administering it is in the form of a very fine powder, twenty grains every two or three 68 Churchill's observations. and successfully, in doses of from two to five drops, in mucilage, several times in the course of the day. (Waller,1 Blundell.3) Slight bitters, especially infusion of columba, are occasionally beneficial (Dewees.3) Spearmint tea is also recommended. (Manning.4) Iced water will sometimes check the vomiting, and in most cases it is extremely grateful. (Dewees, Ashwell.J In all cases the diet should be of the lightest kind, without stimu- lants, and taken in very small quantities at a time, and at that time of day when the stomach is least irritable. It may be necessary to diminish the quantity to the very least sufficient for nourishment; or even to nourish patients by enemata. (Burns,5 Davis,6 Blundell,7 Ash well.8) Some patients obtain a great diminution of their distress by preserving the horizontal position. (Denman.9) If the stomach should exhibit symptoms of inflammation, it must be treated in the ordinary antiphlogistic manner, by venesection, ,or leeches and blisters—due regard being had to the state of the patient; and the same may be employed when the liver takes on inflammatory action, as is not very uncommon. Should the vomiting, occurring in the latter months, be principally or wholly the result of pressure, we are advised to use bandages, so as to depress the uterus (Smellie); but this would be vefy hazard- ous (Gardien, Capuron10); the 6ame effects may generally be ob- tained by change of position. The mere enumeration ofthe various modes of treatment is a proof of the difficulty of combating the disease. In some cases we shall fully succeed; in others afford some temporary relief; but in hours, till it has produced an effect. I ought to observe,, that it makes the stools very black."—Blundell's Princ. and Prac. of Obstetricy, p. 178. 1 Ed. of Denman, Nate, p. 153. ! Obstetricy, p. 177. 3 Compendium of Midwifery, p. 110. 4 Diseases of Women, p. 301. 5 Midwifery, p. 253. . 6 Obstetric Med. p. 859. 7 "Hildanus has reported the case of a.woman, who, from irritability of the stomach, rejected all. food during the space of five weeks; but she was supported the whole time in the way above intimated (by enemata), being cured, and becoming at length the mother of a vigorous infant."—Blundell's Obstetricy, p. 180. • 8 "We do occasionally meet with severe and alarming cases of continued vomiting, where it is necessary to maintain an almost entirely empty state of the stomach, nourishment being by glysters of beef tea and jelly. In one of these instances, after having giyen opium, I ordered a tea-spoonful of lime-water, or soda-water and milkj-every ten minutes. In the course of the day the lime-water was omitted, and the quautity of milk increased, till at length the stomach could retain small quantities of solid food. Small doses of the calcined magnesia, taken two or three times daily in milk, will frequently relieve the sickness, by inducing an aperient state ofthe bowels. A few leeches to the pit ofthe stomach, followed by a small blister or opium plaster, will occasionally produce much good."—On Parturition, p. 193. 9 Midwifery, p. .153. 10 Mal. des Femmes, p. 375. NAUSEA AND VOMITING. 69 many utterly fail. These latter cases are generally those in which the vomiting is most violent and incessant; and by these, conse- quently, the patient is most injured. Exhausted by the constant effort, and wasted by the incapability of retaining nourishment, the patient has no prospect but death to herself and child. In such a case, almost any remedy would be justifiable; and one that may afford an additional chance of safety to one of the parties impli- cated, must be hailed as a boon of great magnitude. Dr. Denman, I believe, was the first to propose the induction of premature labour in such cases: and he says, "The propriety of this practice has also been considered when women have during pregnancy suffered more than common degrees of irritation, and especially when the stomach is in such a state that it cannot bear nourishment of any kind, or in any quantity, and the patients are thereby reduced to a state of dangerous weakness. Presuming that these symptoms are purely in consequence of pregnancy, it may, perhaps, be justifiable to bring on premature labour"." Fortified by experience, we can now not only assert the " propriety" of this operation, but give abundant evidence of its success. Dr. Ash well states, " If, notwith- standing .every remedy, the vomiting goes on to debilitate tbe patient, she may be reduced to a state of extreme danger; ip these circum- stances, after consultation, we think it very justifiable to induce premature labour."1 And Dr. Blundell,2 "Again, should all these remedies fail, you have yet another, and that" is, the induction of premature delivery; for when delivery occurs, there is reason to hope this vomiting will cease. In determining on the use of this remedy, however, remem- ber in the first place, that if the woman is very much reduced, there is always danger in these cases, lest the patient should sink under accidental flooding; this ought to be mentioned to the friends before the operation is performed! Nor is it to be forgotten, that when premature delivery is thus brought oh, children are often presenting preternaturally—the leg or the uates, the arm or the shoulder, being placed over the centre ofthe pelvis instead ofthe vertex; nor that°the child may perish under the best management, in conse- quence of this unfavourable position." Dr. Davis has recorded successful cases:—"The author has performed the induction of premature labour, in the circumstances above described, three times. 'In one of them it was had recourse to in the seventh month, the patient having made an error of one month in he.r reckoning. The child, which was born alive, died in about two hours afterwards; the mother was soon and perfectly restored. The second case was on the whole mo.re prosperous. The child, which had the appearance of one of eight months' growth, was given to a wet nurse who lived in the house, and who took ex- cellent care of it. The mother also eventually recovered. Her 1 On Parturition, p. 194. 2 Princ. and Pract. of Obstetricy, p. 181. 70 lhurchill's observations. sickness left her immediately after delivery; but she was the subject of feeble health, accompanied by a dyspeptic state of the stomach, for some years afterwards. The subject ofthe third case might be said to have been in a cachectic condition before her preg- nancy. When arrived at her sixth month inclusive, she was ex- ceedingly harassed by an intense irritation, from the effect of inani- tion, as the author supposed, which threatened a speedy and an alarming issue. The operation for the induction of premature labour was performed. The child of course was lost. The mother recovered rather rapidly, and enjoyed moderate good health after- wards, and has since borne several living children at the full period."1 Dr. Merriman has also related a successful case, occurring in the practice of a " provincial surgeon of considerable eminence."2 " She was teased with a severe cough, and her stomach was so irritable as to retain no food whatsoever, nor even opium in a solid form. She had taken absorbents, stomachics, bitters, aromatics, and opiates, without experiencing any relief: liniments, fomentations, and blisters, had been extensively applied, without benefit, and she was thought to be sinking into her grave, when it was proposed, as a last resource, to bring on premature labour, six weeks before the full time, and the patient was delivered of a living child, and ulti- mately recovered." Dr. Burns witnessed this operation twice in one patient.3 These authorities and cases will, I think, be admitted as fully bearing out the opinion I have expressed of the propriety of the operation, as a last resource, in this disorder. Dr. Blundell has mentioned, very cautiously, this class of patients as suited for the operation of transfusion ;—" In cases of extreme emaciation in consequence of this gastric or intestinal irritability, you will not suppose that I design rashly to advise you to nourish the patient by the injection of blood into the vessels : I cannot how- ever forbear remarking, on this occasion, that this mode of treat- ment is not altogether impracticable."4 I do not know of any cases in which this plan has been tried but I readily admit that to avoid a fatal result, almost any remedy would be justifiable. 1 Obstetric Medicine, vol. ii. p. 871. 2 Med. Chir. Trans. 3 Midwifery, p. 254. 4- Prin. and Pract. of Obstetricy, p. 181. CARDIALGIA—PYROSIS. n CHAPTER V. heartburn or cardialgia. pyrosis. Soda. Fer chaud, Fr. Sodbrennen, G. A great number of women suffer from this form of disease dur- ing gestation, but the degree varies much. It may occur at a very early period (Campbell1), and even be amongst the first symptoins by which the patient will recognise her condition (Dewees2); but in general, it is not until the latter half of pregnancy that it is trouble- some. (Imbert.8) Cardialgia and pyrosis seem to be merely different forms of the same disease. Women of a nervous and hysteric tem- perament are peculiarly obnoxious to the disorder. (Capuron.) Causes.—There is no doubt that certain articles of food may give rise to it, or aggravate it,4 though more frequently it is owing to the condition of the stomach, induced by sympathy with the gravid uterus. It has been attributed to a morbid alteration of the gastric fluid (Campbell,5 Gardien), or to the presence of bile in the stomach. (Gardien.6) Dr. Burns attributes pyrosis to a complicated affection of the eighth pair of nerves.7 Mental emotions, or a de- ranged state ofthe bowels, may give rise to it. (Campbell.) Symptoms.—The patient complains of pain and heat at the pit of the stomach, extending along the oesophagus, with occasional eructations of a sour or bitter fluid.8 Eating greatly aggravates 1 Midwifery, p. 523. 1 Compendium of Midwifery, p. 112. 3 " Antoine Petit places this disease among those which occur at the latter end of pregnancy : 1 have seen it always in the early mouths; and Hermann mentions a case'in which it commenced immediately after conception. — Mal. des Femmes, vol. i. p. 394. 4 Denman's Midwifery, p. 155. 5 "A morbid state of the gastric juice obviously exists, trom the super- abundance of acid."—Midwifery, p. 523. 6 " This affection may be caused by the bile remaining too long in the stomach, or by the gastric acids: it ought then to be considered as idiopathic. These acids may become so acrid as not merely to excite inflammation, but even to corrode the coats of the stomach. Examples of sudden death from this cause are on record. But in most cases, this sensation of burning, called soda or pyrosis, is purely sympathetic in pregnant females. —Gar- dien, Traite des Accouch. vol. ii. p. 58. 7 Midwifery, p. 258. . , 8 "Some patients complain of a burning pain at the pit of the stomach, extending alonsr the oesophagus to the gullet, resembling the impression produced by a hot iron upon these organs. This is what nosolog.sts have called 'soda,' or existed as to the use of opium in puer- peral convulsions. As far as the author feels himself warranted by experi- ence in entertaining a positive opinion on this subject, he feels disposed to recommend the exhibition of a full dose of opium after ample bleeding provided the patient might be in a situation to swallow it; and if not so situated, he would advise the administration of an opiate enema of propor- tional strength, should it not be required, as a more imperative duty to ex- hibit a purgative enema, as has been already adverted to."—Davis's Ob- stetric Medicine, vol. ii. p. 1028. 4 " The exhibition of opiates or of stimulants, in these alarming cases is justly exploded. But after free evacuations, the injection of an enema composed of a proper quantity of opiate, with a solution of assafcetida or oil of turpentine, has in some cases seemed tome to be beneficial "—Pract Ohs in Midwifery, vol. ii. p. 271. ' "Many of our best writers have actually condemned the use of opium in convulsions, stating it to be most injurious—some even destructive Ample experience has convinced me, that it is not only harmless, but highly benefi- cial in those cases where the fits continue after delivery. And I should hope the cases adduced will prove satisfactorily that it is also useful under EPILEPTIC convulsions. 119 to affect the constitution, has been found beneficial. Dr. Collins speaks very highly of tartar emetic, in doses sufficient to produce nausea, but not vomiting.1 It will be necessary to insert a wedge of leather or wood between the teeth, to prevent injury to the tongue, and also to remove every thing out of the way, by striking against which the patient might hurt herself. This treatment applies equally to convulsions occurring before, during, or after labour—except that in the latter case the quantity of blood taken must be modified according to the state of the patient. The next important question is, whether we are to interfere with the progress of gestation or parturition. I believe there is no dispute that until labour sets in naturally, interference would be injurious; so that in convulsions duringges- tation, we have nothing to do with the uterus, but must confine ourselves to the treatment ofthe convulsive disease. If the attack take place at the commencement of labour, some practitioners have been anxious to hasten the operations of nature by manual dilatation ; but this has been abandoned, and very pro- perly, as likely to increase the convulsions, without advancing the progress of the^delivery.2 Belladonna has been applied to the cer- vix uteri, for the purpose of dilatation, but I should doubt its utility, and dread its poisonous effects.3 The older writers, with some many other circumstances, when proper steps had been previously taken. Its combination with tartar emetic, and occasionally with calomel, is most advantageous."—Pract. Obs. in Midwifery, p. 227, note. 1 " In every severe case of convulsions, after having carried into effect the ordinary mode of treatment, as bleeding freely, acting briskly on the bowels, with calomel and jalap, and at the same time adopting the means usually had recourse to for protecting the patient during a paroxysm, I en- deavoured to bring her under the influence of tartar emetic, so as to nauseate effectually, without vomiting. With this view, a tablespoonful of the fol- lowing mixture was given every half hour:— f< Aquas Pulegii ^viii. Tartar Emetici gr. viii. Tinct: Opii gtt. xxx. Syr: Simpl: 3ii. M. " In some cases the quantity of tartar emetic used was only four grains to an eight-ounce mixture; and in others, the quantity of opium was somewhat increased."—Pract. Obs. in Midwifery, p. 212. 2 "When the os internum began to dilate, I gently assisted during every pain, but being soon convinced that this endeavour brought on, continued, or increased the convulsions, I desisted, and left the work to nature."—Den- man's Introd. to Midwifery, p. 430. - » " It will frequently happen that the os uteri does not dilate during the most violent convulsions—hence Chaussier recommends the application of a pommade, containing belladonna. This preparation consists of two drachms of the extract, softened with an equal quantity of water, and triturated with about an ounce of prepared lard. A piece the size of a small nut is to be introduced into a female syringe, open at the extremity, and conveyed to the os uteri, where it is to be applied by pushing onwards the piston. In cases of unyielding rigidity ofthe os uteri, Van Swieteu advised an incision 12U CHURCHILL S OBSERVATIONS. modem, have proposed incision of the cervix, but the risk would outbalance any benefit to be derived from so "heroic" a remedy. But supposing the os uteri to be dilated or dilatable, are we then to proceed to deliver by art? This question has been much debated, and opposite opinions have been advocated. Some advise instant interference, and others no interference at all.1 The true plan seems to be to avoid both extremes. We are not necessarily to interfere at this stage ofthe labour, beyond rupturing the membranes, which sometimes advances the progress of the labour.3 Version, or turning, has been often recommended, but from all cases I have seen or collected, it would appear a most hazardous measure. Dr. Ramsbotham advises it,3 and yet all the three cases in which he practised it proved fatal. Five patients out of seven are generally lost. (Collins.) Dr. Collins is strongly opposed to it.4 We may therefore conclude that version is not to be attempted. But when the head has descended into the pelvis, so as to be to be made through its margin. Dubois, and subsequently Lauverjat, Bodin, and Coutouly, who considered it perfectly justifiable after bloodlet- ting, the warm bath, and other means usually employed, had failed, have had recourse to this operation."—Blundell's Obstetricy, p. 950, note. 1 "These rules have nevertheless led to two methods of practice, offered with sufficient confidence, though diametrically opposite to each other. Ac- cording to the first (Mauriceau, a°d ^casions to the pEtmuchPa7n and d.fficuhy in walking, and many other inconveniences at h? imf f labour.»-JDenman's Midwifery, p. 167. leniences at the time of "Painful sensations are apt to be produced in thesp m,rt* /-ho l u n and loins,) either by the general caLe afready menuoned ' £"*{ be'Ly' weight and pressure ofthe uterus, by the too ereat e^^nl n f • i™6'7' the or by violent straining, and other eLerLufj^ gerous, unless when they proceed from the last oHhese cause" ota^otr'- CRAMPS. 143 venting the patient's taking exercise. It is influenced by the state of the stomach, more than cramp in any other situation (Burns), and is often combined with heart-burn or water-brash ; but is easily distinguished from pain in an internal organ, by its spasmo- dic character. I have seen this kind of cramp fix itself about the symphysis pubis, and extend down into the labia pudendi, probably depending upon pressure, congestion, or dragging of the round ligament. (Capuron,1 Davis.2) 2. In the back. The lumbar muscles are sometimes the seat of cramp; and when it is severe, it greatly impedes the movements of the patient,.especially the assumption of the upright position. (Gardien.3) Occasionally the distress is extended from the crest of the ilium to the sacrum, affecting the origin of the muscles. It may be the result o! distention, or of pressure on the nerves. In some few cases, I have known the pain limited to the lower part of the sacrum, and to the coccygeal region. 3. In the inferior extremities. It is seldom that both legs are affected together, and it generally happens that the pressure is greatest on the leg of that side on which the patient habitually reclines. The pain may be seated on the anterior and inner side of the thigh, taking the course of the crural nerve :4 or it may run along the sciatic nerve, down to the calf of the leg, and even to the heel and sole of the foot. These cramps may depend upon the pressure of the enlarging uterus, whilst it fills the cavity of the pelvis : or upon its downward pressure during the latter months. When the pelvis is sufficiently capacious to allow the head of the fcetus (covered by the cervix wise extremely violent; but in either of these cases, an abortion may certainly be the consequence."—Manning, Diseases of Women, p. 323. 1 "C'est encore en considerant l'origine et l'insertion des ligamens ronds de la matrice, qu'on explique les douleurs des aines, du pubi&'et des grandes levres. L'autopsie ou I'ouverture des cadavres prouve que ces productions vasculo-nerveuses s'eogorgent, et prennent une apparence charnue au com- mencement de la grossesse, tandisqu'a une epoque plus avancee elles doivent etre necessairement tiraillees et comprimees soit par la volume, soit par la poids de la matrice qui s'incline en devant."—Capuion3 Mal. des Femmes, p. 465. Also, Gardien, Traite d'Accouch. vol. ii. p. 77. 1 Obstetric Medicine, vol. i. p. 875. s Traite des Accouch. vol. ii, p. 76. * " La matrice, parvenue k une certaine volume, comprime aussi les rami- fications nerveuses que le plexus lombaire envoie aux parlies anterieures et internes des cuisses. De la, ces douleurs et ces crampes plus ou moins vives que la femme eprouve des qu'elle veut marcher, lorsqu'elle fait quelque faux pas, et qu'elle resle trop long temps a genoux; de la encore ces chutes plus ou moins frequentes, et cette vacillation dans la marche, qu'on attribue mal a propos a la saillie de I'abdomen et au deplacement du centre de gravite."—Capuron, Mal. des Femmes, p. 466. 144 Churchill's observations. uteri) to descend into the pelvis, the pressure being great, the .pain is unusually severe. (Capuron.1) These pains are often very acute, and attended sometimes with muscular contraction.3 They generally come on suddenly, and often render the patient's footing very insecure. This is particu- larly the case when they attack during walking; and in fact they, and not the change in the centre of gravity, are the principal cause ofthe severe falls which happen to preguant females. The attack may occur during the night as well as the day, especially soon after lying down. We sometimes see a minor degree of. this affection, when the limb is what is commonly called—asleep: the patient is greatly annoyed by numbness, or a sensation of pricking as of pins or needles; and this may alternate with the cramp.3 It is evidently owing to the same cause. It is very rare that any form or degree of cramp is accompanied with much constitutional sympathy, unless indeed the patient should be long deprived of rest. Treatment.—As this affection depends chiefly upon pressure over which we have very little or no control, it is evident that * " Enfin, chez les femmes dont le bassin est naturellement tres evase, la matrice descend de bonne heure dans l'excavation du petit bassin, et y cora- prime les nerfs sacrees d'un cote, rarement de tous les deux a la fois. Telle est la cause des crampes, des engourdisseraens, enfin de la neuralgie'femoro- popbtee qui tourment les femmes a l'approcbe du terme de la grossesse et surtout pendant le travail de l'accouchement."— Capuron, Mal. des Femmes p. 466. * ' 8 "Tonic contraction of the muscles of the limbs receives the name of cramp when occurring during pregnancy ; it has also (in France) been named goutte cramp; it is commonly accompanied with very severe pains I he muscle spontaneously contracts, and remains a longer or a shorter period id this morbid state; the cessation of pain is an instantaneous conse- quence of relaxation. Pregnancy singularly favours the development of this affection, which sometimes attacks the muscles of the. arm, of the hand, and SrS 5 M°nnlI",ieS U ma",fests !tse!f in {he posterior muscles of the leg and of fhp ^ ? Cn att"butes th,s l^t mentioned symptom to compression ItT'"^ WheD PreS.nancy.ls so far advanced that the head of tol ?nSSlQSTK-reSt UP°D ,hCir .Tsia.S' (Trait€ d'Accouch. vol. i. p 260 vol. ,.. p 78.) This may very well explain the occurrence of cramp in the inferior bmbs; but when cramp affects the superior extremities it annears to me to depend essentially on the sympathetic influence of the me us These cramps sometimes remain during the whole period of ffMtation nnH ! reheved until after delivery-a? evident proo? that tfey aTucder the in fluenceof that accidental state of the uterus which i« '^ZLa t ,', -Bryden's Translation of Miquel, p 2T °Cd by PreSnancy-" * "No complaint happens mure frequently to nreffnant wnm«n tk„ in the hips, with numbness of the inferior extreffil T^T * VT occasioned by the outward pressure made by the en fa^e^uteru'Tnn^h6 pa'rtc'rVeVS"" th°Se ^^ P3SS thr°Ugh the P^al^Ton-th^erior ^iX^ to it."-Denman's Midwifery, p. 161. g ' llttle attent,on P*"* VARICOSE veins. 145 the treatment can only be palliative, and must often be unsuc- cessful. The condition of the stomach and bowels must be carefully attended to, in all cases. In very severe cases, blood-letting has been tried, and often with success; but ordinarily it is unnecessary. An anodyne draught of some kind will be necessary. Locally, we may use some counter-irritation. I have found friction with spirits of turpentine very useful. Sometimes great benefit will be derived from an opium or bella- donna plaster. But all these remedies will fail, unless we can place the patient at rest in a position which will—in some degree at least—take off the pressure; and if we can do this, very active remedies will be needless. CHAPTER VII. varicose veins. Les Varices. Veines Variqueuses, Fr. Bluta- derknoten. Kindsadern, G. A dilatation of the veins, with a consequent thickening of their coats, as a consequence of the arrest of the ascending column of blood, is a very frequent accompaniment of pregnancy—though neither a dangerous nor a very troublesome one.1 Women of a lax and plethoric habit appear peculiarly obnoxious to it. Varicose veins vary as to situation. They are perhaps most fre- quent on the leg, below the knee; but if the cause be repeated, the veins ofthe thigh are speedily involved. More rarely, we find the veins of the labia majora, the vagina, and even the os uteri, rendered varicose from the same cause. (Capuron, Gardien.2) Cause.—There can be no doubt that the principal, if not the sole cause, is the pressure of the gravid uterus during the latter half of 1 "II faut distinguer deux genres de dilatation dans les vaisseaux veineux; l'un n'est qu'une esp6ce de plenitude; c'est une espece de plethore locale, dans laquelle la veine est plus voluraineuse qu'elle ne doit l'etre; l'autre est une alteration des tissues; ses parois ont perdus leur elasticite, semblable a la vessie qui, dilatee outre mesure par l'accumulation des urines, perd la force de les expulser. Ces deux varietes de la maladie, expliquent ce qui arrive apres l'accouchement chez les femmes qui en sont atteintes. duand il n'y a qu'une plenitude du systeme veineux, elle dispardit aussitdt que la cause qui l'entretenait est enlevee. Quant aux veritables varices, elles deviennent moins doloureuses, moins tumefiees, mais elles ne guerissent pas."—Imbert, Mal. des Femmes, vol. i. p. 418. * Traite d'Accouch. vol. ii. p. 92. 15__e 10 church • 146 churchill's observations. gestation.1 It is uncommon for the effect to be produced during a first pregnancy, but it is very frequent afterwards, increasing in amount with each pregnancy.2 The first time varicose veins result from this cause, they do not appear till towards the end of gestation ; but when once the veins have acquired a certain degree of dilatation, a very slight increase in the bulk of the uterus suffices to distend them. I had a patient, in whom a distended state of the veins of the leg was the first symptom of conception in several pregnancies. When the womb inclines more to one side of the body than to the other, one limb will be affected, whilst the other retains its natural condition. A constipated state of the bowels will of course aggravate the dis- order, and perhaps may have a share in the production of that form which I have mentioned as seated in the vagina. Though varicose veins be caused by pregnancy, they are, I need scarcely say. not peculiar to it alone. Ovarian or uterine disease may equally produce them. Symptoms.—The symptoms are not remarkable: the patient usually complains of stiffness and heaviness of the limb, with difficulty of walking, but there is seldom any pain. When the veins of the vulva or vagina are affected, there is a fulness, weight, and sense of bearing down. An examination of the limb will at once point out the cause of these symptoms, and on making a vaginal examination, we shall find the passage somewhat nar- rowed, by the swollen, unequal, lining membrane. A similar sensation will be communicated to the finger, when the cervix uteri is affected. It sometimes, though rarely, happens, that when the distention is very great, the coats ofthe vessels give way, and blood is effused. This is much more likely to occur with the veins of the cervix uteri, during labour; but I do not know that any unpleasant results have followed. 1 "We can hence easily understand why, and in what class of females, the inferior extremities appear covered with varices, especially in the course "of the femoro-popliteal or saphena vein, and most frequently towards the eighth or ninth month of gestation: also, why it is we meet them in the vagina, vulva, or cervix uteri; why one side only is affected; and why they diminish during the night, by the rest in bed."— Capuron, Mal. des Femmes, p. 417. 8 " This condition of the veins I never met with to any extent, during a first pregnancy; but when it does appear, even in a trivial degree, it gra- dually increases in severity with every succeeding gestation. Females of a lax delicate habit of body, are most disposed to it; but it may be developed under a variety of circumstances; and 1 have had many proofs that such occupations as compel individuals to be much in the erect posture will occa- sion it Plethoric females are more liable to varices than those of an oppo- site habit Indolence predisposes to it. Relaxation and interruption to the return of the blood, by the common iliac veins, from uterine pressure, are the most obvious causes. This affection is not at all dangerous, except when the coats ofthe vessels give way."-Campbell's Midwifery, p. 513. • OSDEMA. 147 After delivery, the veins gradually return to nearly their natural size, unless the patient have had many children in quick succes- sion ; in which case, the coats of the veins are so hypertrophied, that the disease becomes permanent, at least for many years. 1 have remarked in several patients who suffered from this disease during pregnancy, a great liability to inffammation of a portion of these varicose veins, after delivery. Treatment.—As the disease results from a mechanical cause, which we cannot remove, it is evident that we cannot hope to cure it, until after delivery. All we can do, is to support the limb, and diminish the venous distention by firm bandaging, which should be applied in the morning, as then the veins are least distended. Firm pressure will command the hemorrhage in most cases, when a rupture ofthe veins takes place. Rest in the recumbent posture will also be needful; and if one limb only be affected, the patient should recline on the opposite side. The bowels must be carefully regulated. Various methods have been proposed for the radical cure of the disease; but as none of them ought to be practised during preg- nancy, they do not require description here. CHAPTER VIII. (edema, anasarca. (Edeme, F. Wassergeschwidst der Schioangern, G. During the latter months of gestation we frequently find patients complaining of a swelling of the lower extremities, increasing to- wards evening, and occasioning a certain amount of inconvenience. Females of a leucophlegmatic temperament are the most obnoxi- ous to the disorder, although the robust and plethoric do not always escape. The extent of the effusion varies much—it may be confined to the feet and legs, or it may involve the thighs, vulva, and hips. In a few cases, the anasarca is still more general, and we find the upper part of the body, the hands, and the face cedematous.1 Causes.—In a large class of cases, the oedema is caused by the 1 " Although the oedema generally affects the inferior extremities only, it may extend over the whole body: at other times it is limited to the vulva, to the feet or lower part of the leg; or it may ascend the thighs, distend the labia majora, and form a species of ring (' bourrelef) around the hips."— Imbert, Mal. des Femmes, vol. i. p. 421. 148 churchill's observations. pressure of the gravid uterus simply, or according to M. Imbert, with the addition of an affection ofthe nervous system.1 In a second class it has been said to depend upon an atonic con- dition ofthe constitution. (Capuron, Gardien.3) In a third class it appears of a more active character, depending perhaps upon plethora, or that affection ofthe cellular tissue which ends in general effusion. The symptoms of the latter are very different from the former. The amount of distention in many cases appears to be in propor- tion to the size of the uterus—thus, in case of twins or triplets, it has frequently been found excessive. (Mauriceau.) Symptoms.—When the effusion is passive, or the result of pres- sure, there are none but mechanical symptoms. The limb is swollen, of a semi-transparent, pearly appearance. It feels heavy, and the patient cannot walk as well as usual. The secretion of urine is generally diminished'. These inconveniences are much aggravated if the swelling extend to the thighs; the patient may not be able to approximate them, and may find it as distressing to sit, as to stand or walk. But little additional distress is occasioned during gestation by the swelling of the labia; but if verylarge, they may be a serious impediment to the exit of the child3 Change of posture has great effect upon the oedema ; in the morning the swelling is but slightly perceptible, but during the day i d We must acknowledge that compression, and obstacles to the course of the blood and lymph, are predisposing causes only ; but that for the production of serous effusion a peculiar condition of the constitution is necessary. In fact, the temperament ofthe patient, the state of her constitution, her mode of life, &c. is not sufficient to produce oedema; we must discern some influ- ence in addition to all these predisposing causes—and that is an affection of the nervous system."—Imbert, Mal. des Femmes, vol. i. p. 420. * " The oedema of pregnant women may be of two kinds—one depending upon a state of plethora, the other upon a state of atony. In young plethoric women, oedema is sometimes accompanied with pain, heat, tension, and a slight inflammatory blush upon the skin, in place ofthe pallor which charac- terises leuco-phlegmasia from atony."—Gardien, Traite d'Accouch. vol ii. p. 90. 3 " La matrice est souvent si pleine d'humiditez, qu'elle en regorge jusques sur les parties exterieures et principalement sur celles qui luy sont voisines, comme sur les levres de la partie honteuse, qui en deviennent quelquefois si grosses et si tumefiees a certaines femmes, qu'elles ne peuvent pour cet sujet approcher leurs cuisses 1'une de l'autre; ce qui les empGche de pouvoir marcher, si ce n'est avec peine et tres grande incommodite. J'ay souvent remarque que les femmes qui sont grosses de pleusieurs enfans, sont tres sujettes k cette indisposition vers les derniers mois de leur grossesse et qu'elles ont aussi toujours les jambes fort enflees en ce temps. Cette enflure des levres de la matrice est pour lors lucide, et presque transparente, ainsi que seroit une hydrocelle, a cause de la quantite de l'eau claire dont elle est pleine; et comme elle pourrait etre bien douleureuse, et incommode a la femme pendant son accouchement: d'autant que par cette boursoufflement les passages en sont rendus plus etroits, il sera besoin d'y remedier aupara- vant."—Mauriceau, Mal. des Femmes Grosses, vol. i. p. 179. (EDEMA. 149 it increases, and towards night the part arrives at the maximum of distention. After delivery, the effusion disappears immediately, without any unpleasant result. This is the ordinary course of the disorder; but it may be unpleasantly varied by an attack of erysipelas of the distended skin or phlegmon of the subcutaneous cellular tissue. The former at- tack may run the usual course, and subside; or the inflammation may extend to the cellular tissue, and end in abscess.1 The skin covering the abscess may go through the usual process of absorp- tion, to give exit to the matter; or it may become gangrenous. When the disease depends upon a dropsical diathesis, it is much more general, affecting the superior as well as the inferior parts of the body, and accompanied with heat, tenderness, and tension of the parts.2 The pulse is quickened, and there is more or less fever. This is a much more serious form of disease, and should be carefully distinguished from the passive variety. Its course is different from the others, inasmuch as it does not necessarily disap- pear after delivery.3 It may also be complicated with effusion into the serous cavities, and involve, in consequence, the life of the patient. Diagnosis.—There are two points of diagnosis: the first is to ascertain that the effusion arises from, or is connected with, preg- nancy, and not from disease; and the second is to distinguish between the passive and active forms of cedema. The presence or absence of the signs of pregnancy will solve the first question, and the second will be decided by the presence or absence of constitu- tional distress. Prognosis.—As long as the disease is passive, and not excessive, the prognosis is favourable; but it will be modified if erysipelas or phlegmon occur, according to the extent of this complication. 1 "Dans les cas ou il est peu etendu, il procure une simple pesanteur; mais quand il a atteint les cuisses et la vulve, il gene la marche, et meme la station assize, et cause beaucoup de malaises et de douleurs. Quelquefois la peau distendue s'enflamme et se couvre de plaques rouges sur differents points; d'autres fois au lieu de cette inflammation erysipelateuse, c'est le tissu cellulaire qui se phlogose; c'est autpur des aines ou vers le perine que ces inflammations se manifestent. J'ai vu deux fois cette complication, qu' Antoine Petit a mentionnee dans son ouvrage ; elle se termine ordinairement par la gangrene de la peau qui recouvre le tissu cellulaire malade."—Imbert, Mal. des Femmes, vol. i. p. 421. 2" Q,uand cette enflure, qui occnpe les jambes et les cuisses, monte aux reins, pour y former ce qu'on nomme le bourrelet, et qu'elle gagne les parties superieures et bouffit le visage et les mains, c'est une vraie hydropisie, sur- tout si une fievre lente et l'alteration l'accompagnent."—Puzos, Traite" des Accouch. p. 84. *" The cedema which does not depend upon pregnancy, but upon some constitutional disorder, does not disappear after confinement. In such cases we have seen females become anasarcous and dropsical, and the lochia sup- pressed. Death is almost inevitable in these cases."— Capuron, Mal. des Femmes, p. 430. 150 churchill's observations. When the dropsy is general and acute, the prognosis is always grave, and it may be altogether unfavourable if the attack be violent.1 Treatment.—Rest in the recumbent posture will be sufficient for moderate degrees of the cedema from pressure; but if more excessive, we must try mild saline purgatives, with diuretics— though it must be confessed that they often fail. In cases of extreme distention, where we dread the skin giving way, it will be better to evacuate the fluid by small punctures with the lancet, or a needle, in the leg ot foot. (Gardien.3) The fluid must also be evacuated in those cases where the size of the labia offers an impediment to the completion of labour; but this is better done by repeated blisters than by punctures. (Gardien.) When erysipelas attacks the cedematous limb, we are recom- mended to make free incisions into the inflamed part, in addition to the ordinary modes of treatment. If an abscess form, it will undoubtedly be advisable to afford an exit to the matter. When the dropsy is general, and accompanied by fever, the treatment must be much more active, and of an antiphlogistic character. Blood should be taken from the arm, and an active purgative administered. Tartar emetic in small doses will also be found useful. These remedies are to be repeated or modified, according to the violence or continuance of the attack; and in general we shall succeed in subduing it, if we are called sufficiently early. CHAPTER IX. ascites, hydrothorax. Ascite, Fr. Wassergeschwulst der Schwangern, G. In some females we find the dropsical diathesis so strongly marked, that the effusion is not confined to the cellular tissue but occupies one or other ofthe great cavities ofthe body.3 '"The prognosis in this affection is favourable, especially when it sub- sides after the patient has been for some little time in the recumbent posture • but when it is connected with plethora and a frequent pulse, it requires to be watched and actively treated."— Campbell's Midwifery, p. 516. If the infiltration be so considerable, that there is reason to fear that the skin will burst, it will be netter to give issue to the fluid by slight punctures ( legeres mouchetures') in the feet and legs. If we wish to dissipate serous infiltration ofthe labia, it will be better to apply a blister between the thighs and labia, than to puncture the parts. In following this suggestion of Levret we shall avoid the formation of cicatrices, which might become an impedi- m'« p Jt U-?e oyelivery.»-tf«r^n, Traite d'Accouch. vol. ii Hi *„„ a S[des *hlS ffidema> wbich is so frequent, and unattended with any danger, there is a dropsical affection, which is noticed by others, and ascites. 151 These cases are almost always examples of the acute or inflam- matory dropsy, excepting when caused by organic disease (as of the liver) preceding or accompanying pregnancy. The attack seldom occurs till the latter months of gestation. Symptoms.—The quick pulse, feverishness, and pain, which I have already described as accompanying acute dropsy, may be present with an unusual enlargement ofthe abdomen for the period of pregnancy.1 There is very little tenderness of the abdomen; but fluctuation is very evident. The stomach is sometimes disor- dered, the skin dry, and the urine scanty. The audible signs of pregnancy are more faint and distant than usual, and the motions of the child are scarcely perceptible externally. The patient finds great difficulty in moving about, because of her increased bulk, and when she lies down she generally suffers from dyspnoea and sleeplessness, or if she do sleep, from dreams. Ascites is generally accompanied or preceded by some cedema of the feet and ancles; but it may form a part of that general dropsy to which I have before referred. In many of these cases, labour comes on prematurely, and the child is lost. In others, the ascites disappear before the full time, and the labour terminates naturally and successfully. Lastly, in some the irritation and fever subside, but the dropsy remains. At the time of labour, the accumulation of fluid in the peritoneal sac will lengthen the labour, by depriving the patient, to a great extent, of the assistance of the abdominal muscles; but there is seldom any danger in the delay. If the effusion disappear after labour, the patient will do well, but this is not. always the case, and then the convalescence maybe tedious or imperfect; and if the constitution be much injured, she may die soon after delivery. It is difficult to say what effect the ascites has upon the child, or how far it may inherit the diathesis. In some cases it has been born dead, with effusion into the abdomen; but in others it has been strong and healthy. The disappearance of the fluid after delivery is generally owing to active absorption, or to suspended secretion ; but occasionally it which I myself have seen in two cases, where the woman, during preg- nancy, has a tendency to a general effusion—water exuding in all the prin- cipal parts of the body, the legs, the arms, the peritoneal sac, the chest, the head; the disease sometimes predominating in one part of the body, and sometimes in another; but all the principal parts being affected at once."— Blundell's Obstetricy, p. 184. 1 " The first symptoms of ascites are, infiltration of the ancles and feet, most obvious in the evening, gradually extending along the extremities; scanty urine, dry skin, thirst, dyspepsia, and the abdomen enlarging with unusual rapidity. To these succeed troublesome cough, difficult respiration, and restless nights, from frequent startings during sleep, unpleasant dreams, and inability to remain long in the recumbent posture."— Campbell s Mid- wifery, p. 517. 152 Churchill's observations. has been known to escape throHgh the fallopian tubes into the uterus, and so issue from the natural passages.1 Some few cases are on record, and I have also seen such, where the pleura or arachnoid was apparently the seat of the effusion, giving rise to dyspnoea, and sense of smothering, or to sleepless- ness and stupor.2 These cases, if not actively treated, frequently prove fatal. Diagnosis.—The first question for our solution will probably be, whether the patient be pregnant or dropsical; and secondly, if 1 "Although the abdominal water of ascites, and the liquor amnii, are in distinct cavities, yet it has happened in some rare instances, that the water in the cavity of the abdomen has made its escape through the uterus. In these cases the water insinuates itself into the fallopian tubes; the fimbriated terminations of those tubes opening into the pelvis, and the other ends into the cavity ofthe uterus. The hydropic water is supposed to insinuate itself into the fallopian tubes after the expulsion of the fcetus. It has also been supposed that something more than mechanical action must be the cause of this—for it has sometimes been observed, when there has been a brisk dis- cbarge, that a sudden cessation of it has taken.place. It might therefore be concluded, that as long as the tubes are pervious, agreeably to the idea of a mechanical insinuation of the water into them—or as long as they are dis- posed to act as living tubes, so as to perform the function of absorption, agreeably to the other idea—parturition might be looked to as a natural cure for dropsy of the abdomen. But such hopes are not likely often to be realised. The fallopian tubes may, indeed, sometimes act as absorbents, and take up all the accumulated fluid in the manner stated. The author has known one woman who had several of these accumulations pass through the uterus, or at least discharged by the way of the genital passage. After that result, and by the use of warm medicines and chalybeates, she entirely recovered her health. Some time subsequently, she became pregnant, and afterwards did quite well. Upon the whole, therefore, our answer should be, that sometimes the disease is cured by delivery, and sometimes not—so as neither much to elevate, nor ou the other hand greatly to depress, the hopes ofthe patient."—Davis's Obstetric Medicine, vol. ii. p. 878. 211 A woman of vigorous constitution enough, was seized during preg- nancy with general effusion; parturition however came on, and the com- plaint ceased. Becoming pregnant again, she was a second time seized with effusion, which took place in the legs, the chest, and the abdomen. A very eminent practitioner was called in consultation with myself in this case; nothing very active was attempted; we did not see our way clearly to blood- letting; the water continued to accumulate, and the woman ultimately died, apparently from hydrothorax." "Some time afterwards I was called to another patient, also of a constitution tolerably sound ; in this case the effu- sion had taken place iato the legs, the abdomen, and probably the head; for at the time when I saw her she was insensible, and had occasionally con- vulsive fits. This woman was very freely bled, to the amount of forty or fifty ounces at least, in the course of two or three hours; premature delivery was intended, but parturition came on of itself in the course of the four- and-twenty hours; the next day I found the patient a great deal better; the day afterwards, she was so much improved that she appeared to be in a state of speedy convalescence; unfortunately, however, she was seized with the puerperal fever, a complaint very prevalent and very fatal at the time, and though she was in the hands of a very excellent practitioner, she sunk under the disease."—Blundell's Obstetricy, p. 187. ascites. 153 dropsical, whether she be pregnant also. Mistakes have been made on both these points, as the records of midwifery prove. Our main reliance is upon a careful investigation into the signs of preg- nancy ; and if they be present, a due estimation of the modifications in them which are caused by ascites.1 These rules have been so well laid down by writers on legal medicine, and especially by my friends Drs. Kennedy and Montgomery, that I cannot do better than refer to their works. It will also be found very difficult to distinguish ascites during pregnancy, from dropsy of the amnion. But sometimes, if the abdomen be not tense, the smaller uterine tumour can be distin- guished in the midst of the dropsical effusion, when the patient is lying down. Prognosis.—From what has been said, it will be evident that our prognosis should be extremely guarded. The patient may recover under favourable circumstances; but if the irritation be great, or the constitution injured, she may sink after delivery, whether she go the full time or not.2 Treatment.—As long as the effusion is very moderate, little need be done, beyond keeping the bowels free; but if it occasion distress, and there be much general irritation, bloodletting may be employed, followed by diuretics and saline purgatives, so as to afford some relief, and enable the patient to complete the full term of gestation. The posture must be so regulated as to afford the greatest ease. The diet should consist chiefly of solid food, of a nutritious quality. If the effusion, either into abdomen or chest, be extreme, and not diminished by the remedies employed, it may be necessary to decide 1 " The late Dr. Haighton used to mention a case to which he had been called in consultation with a surgeon of the first eminence, who was about to perform the operation of paracentesis, prior to which, the doctor requested to be allowed to make an examination, per vaginam. He found the os uteri a little open, and the membranes protruding; on rupturing the bag, a very large quantity of liquor amnii was discharged ; presently afterwards followed a shrivelled fcetus, and the ascitic symptoms, as might have been expected, instantly disappeared."—Denman's Midwifery, p. 166. 2 " The prognosis should be guarded, more especially when the disease appears in more than one pregnancy; for after delivery, in such cases, it makes rapid strides, and proves fatal. One patient, of a delicate habit of body, in my own practice, had ascites in two successive pregnancies. In the first it was with difficulty removed subsequent to delivery; but after the second, the patient, though left in the most favourable condition, died in twelve.hours. Scarcely two pounds of water w£re found in the abdomen, nor any morbid appearance to account for death. Sometimes premature labour is induced by the combined irritation of the dropsy and pregnancy, and the patient gradually sinks after delivery. I once witnessed a case of this kind, where the disease had been brought on by chronic inflammation of the liver. Another example happened in this city, where a similar state of the liver and ascites had been induced by a frequent indulgence in stimuli; and the patient died undelivered, under the most pusillanimous treatment. Such cases are exceedingly intractable."— Campbell's Midwifery, p. 517. 154 churchill's observations. between abdominal paracentesis,1 and the induction of premature labour.2 If the child be strong and lively, it may be desirable, for its sake, in some cases, that the mother should incur the risk of the former operation ; but in the majority of cases I should unhesitatingly prefer the latter, especially at or after the seventh month, as avoiding all risk to the mother, and perhaps saving the life of the child. Moreover, paracentesis is not unfrequently fol- lowed by premature labour; the mother thus incurring all the risk, without any benefit. It has also this advantage, that should the practitioner have been deceived as to the abdominal effusion, the mother's life is not com- promised by the operation, as in paracentesis. If we perform the operation of tapping, great care will be neces- sary, to avoid wounding the uterus, and to prevent subsequent peritonitis. For the mode of operating, I refer the reader to Cooper's Surgical Dictionary. Little can be done to afford relief where the ascites is owing to organic disease; but it may be necessary to tap the abdomen, or to induce premature labour, if the effusion compromise the mother's safety. 1 " If thejswelling increase," Burns says, " paracentesis must be performed ; and I am surprised that there should even have been a moment's doubt as to its propriety, for there certainly can be none as to its safety. When the navel projects much, and is very thin, it has been proposed to puncture it with a lancet. In one case, related by M. Ollivier, the fluid continued to be discharged for twelve days, after which the puncture closed. In another the patient herself pierced the navel fifteen or twenty times with a needle."— Burns's Midwifery, p. 269. 2 " There is, too, another remedy, peculiar to this form of dropsy, and not to be lost sight of, and that is, the delivery of the woman; for the disease, being connected wiih pregnancy, and evidently of danger, in the more press- ing cases, we are justified in bringing gestation to a close as soon as may be."—Blundell's Obstetricy, p. 186. PART II. OBSERVATIONS ON THE DISEASES INCIDENT TO CHILDBED. It is, I fear, impossible to make any scientific arrangement oi this class of diseases, involving so many tissues, and occurring so irregularly. In consequence of this difficulty, I have determined to describe those diseases and accidents first, which affect the uterine system; then, those which seem to be propagated from it; and lastly, certain febrile affections and disorders ofthe breasts. But in order that the limits of disease may be more perfectly defined, I have prefixed a notice of the ordinary phenomena of convalescence, with some variations therefrom, not involving or- ganic disease, and some directions for the management of pregnant females. CHAPTER I. ON convalescence after parturition. In considering this subject, we shall assume that the patient, previous to labour, was strong and healthy; that the labour has been natural (under twenty-four hours), with the first and second stages bearing their usual proportion (2 to 1) to each other, and neither accompanied nor followed by any accidental complication, as convulsions, hemorrhage, &c. 156 churchill's observations. No one can examine the condition of such a patient, before and after a labour of even a few hours' duration, without being struck by the change which has taken place. It is not the mere fatigue which might have followed muscular exertion of the same amount at anytime; but there is evidently a much more profound im- pression on the entire system. The nervous system is more or less affected; the secretions are altered; new ones are established ; the uterine system in itself, and in its relations, is completely changed; the circulation is disturbed, &c. The importance of preserving the horizontal posture has already been stated; I shall.therefore mereljradd, that the patient should never leave her bed, even to'have it made, before the fourth day, and if she can be persuaded to limit her exertions to this point for eight or nine days, so much the better.2 Far more mischief results from premature exertion, than from all the errors in diet added to- gether. The regulation of the diet is, nevertheless, of considerable im- portance, as excess, by inducing feverishness, may retard the con- valescence. The patient should be confined to slops—gruel, panada, arrow- root, milk, whey, weak tea, &c.—with bread or toast and butter, or • requisite to secure a daily evacuation, if the woman suckle her infant, unless the reduction of the uterus to its natural size in the unimpregnated state proceed tardily. In that case, (viz. where the reduction of the uterine is tardy,) some medicine, calculated to produce in the course of its operation, four or five copious evacuations, of such a nature as to denote an increased secretion from the surface of the intestines, ought to be prescribed every second, third, or fourth day'according- to circumstances. Combinations of rhubarb, with the compound powder of jalap, and the compound tincture of senna, are in general the appropriate medicines for such cases. But in some individuals, other combinations of purgative medicines are required. Fourthly. If the woman be be not able to suckle her infant, she ought to Jiave every second or third day, according to her strength, till the secretion of milk cease, and the tension ofthe mamma? subside, a dose of some pur- gative, calculated to produce several loose chylous evacuations; and for this purpose, combinations of rhubarb, or senna, or colocynth, or scammony, with neutral salts, or other aperients adapted to the individual's case, are to be prescribed."—Hamilton's Pract. Obs. part ii. p. 31. 1 "Covering the surface of each mammae with some gently stimulating liniment (in those cases where the milk is to be discouraged,) not only re- lieves the unpleasant feeling of tension, but'also promotes the absorption of the milk. The preparation recommended by fhe author is, one ounce of unbleached bees' wax, two ounces and a half of fine olive oil, and two drachms of pure honey, melted together."-^Hamilton's Pract. Obs. in Mid- wifery. 2 " For these reasons, if there were no other, it seems right that no woman should rise before the end of the third or fourth day, even to have the bed jnade; and if she be a weakly or delicate subject, she should even observe an horizontal position longer,"— Dr. John Clarke's Essays, p. 34. variations from ordinary convalescence. 167 biscuit, for three or four days.1 When the excitement produced by the secretion of milk has subsided, if there be no counter-indication, she may take some broth, and on the seventh or eighth day some chicken, or mutton chop, with some wine and water. In all that concerns the diet, or the assumption of the upright position, or making exertion, it cannot be too strongly impressed upon all, that an excess.of caution is an error on the safe side. In conclusion, I would observe that the patient should not be left until an hour after delivery, and that she ought to be visited again in six or eight hours, at which time careful inquiry should be made as to the different points we have noted, and strict and minute di- rections given. CHAPTER III. on certain variations from ordinary convalescence. The phenomena of ordinary convalescence have been described as they occur in the most favourable cases; but there are many variations from such a course, arising either from some peculiarity of constitution, or from the character of the labour, or the pressure exercised upon some of the organs.2 Even without any reference 4p the influence of the labour, there are certain irregularities which arise with or without special cause, but which occasion-great anxiety to the patient, and even to the medical attendant. Many of these issue in serious disease, and will be treated of in their place; whilst others, even more numerous, aTe mere tempo- rary deviations from the normal course—but requiring some fami- liarity and nice discrimination, in order to distinguish them from the graver attacks. Of these it is proposed to treat briefly in the present chapter. 1 "In general it is better, I believe, to avoid animal food of all kinds, till the stimulus, arising from the secretion of milk, has subsided. But even this must be done with some limitations, because there are some very weak and delicate women whom it is necessary to support by more substantial food than gruel or barley water, however proper they may be for the strong and plethoric."—Dr. John Clarke's Essays on the Management of Preg- nancy and Labour, p. 26. 2 "Again, when there has been unusual suffering during labour, the ordi- nary changes after delivery cannot be expected to proceed in a healthy, regular manner, because the exhaustion of sensorial power must more or less paralyse the minute internal actions of every part of the system. Secondly, the>violent pressure to which all the parts concerned in the me- chanism of labour had been subjected, must excite an unusual tendency at least to inflammation; and thirdly, the long-continued and violent actions of the respiratory organs, must not only render them liable to derangement, but, by their influence upon the capillaries of every part of the body, must occasion an inequality of circulation that may prove highly injurious."— Hamilton's Prac. Obs. part ii. p. 9. 168 churchill's observations. 1. The nervous shock may be very severe. In these cases, the patient complains of great exhaustion ; the senses are either unna- turally dull, or morbidly acute, the breathing is hurried, and pant- ing, and the accordance between the respiration and circulation is broken. The aspect of the patient is that of a person in a state of collapse. The countenance is expressive of suffering, anxiety, and oppression. The pulse may be either very slow and laboured, or unusually rapid, very small, and fluttering. There are many cases, however, where the shock, though far from being so severe as in the case I have supposed, is quite sufficiently so to excite the fears of the medical attendant. Reaction is long before it occurs; or it may take place imperfectly or excessively, and the patient remain for some time in a very weak condition. Under proper treatment, the patient will gradually recover from this state of exhaustion or collapse; unless the shock be excessive, and then death will supervene in a few hours. I have seen several cases of this kind: in one case, the labour was tedious, but termi- nated naturally; two others were instrumental deliveries; but in none where a post mortem examination was obtained, was there either injury or disease discovered. A due estimate of the nervous shock is of great importance in severe cases; for in almost every instance, the progress of the con- valescence is in inverse proportion to the amount of this disturb- ance.1 The best remedy in these cases is opium, either in a large dosp or in small and repeated ones; it not only gives the patient a chance of sleep, the best restorative of all; but even if it fail in this, the system will be quieted, and respiration rendered more equable, the pulse slower and more natural, and the relation between these two systems restored. The exhibition of stimulants (wine, or brandy and water) in moderate quantities, is necessary; but we must be careful not to 1 "From the moment of delivery it is of the utmost importance to attend to the state ofthe nervous system. In some individuals slight circumstan- ces increase in a wonderful degree the susceptibility of impression; and if this be overlooked, very serious consequences follow." " Various means are required to prevent or remove this increased sus- ceptibility of impression, but in the greater number of cases it will be found that the following treatment answers the purpose. Instead ofthe farinaceous diet, which in ordinary cases ought to be enjoyed for the first few days, chicken broth, or boiled chicken, ought to be recommended; and even in some cases, a moderate proportion of diluted wine." " Any attempt at suckling the infaut should be discouraged ; for in certain constitutions the drain of milk, independent altogether of the fatigue, is apt to occasion very serious nervous affections, such as melancholia, &c." "Six or eight hours of uninterrupted sleep every twenty-four hours should if possible be procured." "In cases of violent palpitations of the heart, the musk will be found superior to every other medicine, provided it be administered in a sufficiently large dose. The author has invariably prescribed in similar cases two scruples, that is, forty grains, as the smallest dose."—Hamilton's Prac. Obser. in Midwifery, part ii. pp. 19, 20 21. VARIATIONS FROM ORDINARY CONVALESCENCE. 169 exceed, or they will do mischief instead of good. The amount of stimulants given in most cases of collapse should have reference as well to the probable reaction as to the present state of the patient: thus an excessive quantity of wine given during the collapse ofthe nervous shock, may render the reaction so extreme as to give rise to fever, or puerperal mania. Ammonia or musk are the best medi- cinal stimulants, and they may be combined with the opium. The diet of the patient, when the effects of the shock have subsided, must be nutritious. It may be necessary to postpone the application ofthe child to the breast for some days, or even to give up suckling altpgether in some cases. All that has been said already upon the necessity of perfect quiet, applies with ten-fold force to these cases of extreme nervous shock. 2. The state of the pulse. One variation from the usual alter- nations of the pulse has just been noted, in cases of great nervous shock, when it either sinks below its due proportion, or more fre- quently remains very quick, weak, and fluttering, during the period of collapse. In almost all the cases of flooding after labour, when I have had an opportunity of examining the pulse up to the time ofthe occur- ence, I have found it remain quick, and perhaps full, instead of sinking after delivery. This has been so marked in several cases, that I now never leave a patient so long as this peculiarity remains; and in more than one instance I believe the patient has owed her safety to this precaution: Three cases occurred within a very short time of each other, in which I noted this undue quickness of the pulse without any other untoward symptom ; at that, time there was no excessive discharge, andthe uterus was well contracted. In all these, alarming hemorrhage occurred within an hour,-and was with difficulty arrested. I have also remarked an undue frequency of pulse when the after- pains are extremely violent; and as the uterus is in such cases rather tender on pressure, it requires care to distinguish between this state and the commencement of puerperal fever. This observation will also apply to the quickening of the circu- lation, which takes place when lactation commences, and which in addition is accompanied by rigours. A careful estimatCof all the symptoms in either case will gene- rally elucidate the nature of the excitement, and the subsequent diminution instead of increase ofthe pulse will decide the question. Again, in cases where a large coagulum is contained in the uterus, the pulse is quickened. I had noticed this repeatedly before I could explain it; but having found it subside immediately on the discharge of clots, I have no doubt that this was the cause. Lastly, the pulse may be accelerated if the patient suffer from diarrhoea or gastric disturbance; and as it is not always easy to foresee the issue of such an attack, the utmost watchfulness will be required. The diagnosis may be very obscure, and it may be necessary to adopt certain measures, rather suited to the attack we fear, than to L70 churchill's observations. the disturbance from which the patient is suffering. Along with the soothing and astringent medicine adapted to the state of the bowels, it will be prudent to administer small doses of blue pill or calomel, in combination with opium. All the observations I have made, fully confirm Dr. John Clarke's observation, that no woman can be considered as safe, whose pulse exceeds one hundred. 3. The state of the uterine system. With regard to the varia- tions from the ordinary size of the womb, and its gradual decrease, I have found sometimes, on the fourth or fifth day, that its bulk had increased, and that it felt less firm than previously ; this, combined with an increase of frequency in the pulse, has made me fear an attack of hysteritis; and this fear was not diminished by the un- comfortable sensations of the patient; nor by the fact, that in some cases the lochia had suddenly diminished in quantity. However, upon applying hot fomentations to the abdomen, a quantity of co- agula were discharged, affording instant relief to the patient, and indicating the source of the symptoms. Purgative enemata also favour tbe expulsion of the clots; and in such cases may be given with great benefit. It has been already mentioned that the uterus is not free from tenderness in cases where the after-pains are severe; and if it be rudely pressed, the outcry of the patient may lead us to suspect the presence of serious disease. It will be observed, however, that this tenderness is greatest during each uterine contraction^ and that as these contractions subside, the soreness diminishes. Fomentations to the abdomen will generally mitigate this sensi- bility; but if the after-pains be severe, and the tenderness consider- able, a full dose of laudanum, followed by an aromatic purgative,1 will probably .relieve both. The vagina may be attacked with inflammation, which some- times proves extremely distressing: this will form the subject of a separate chapter. In cases where the lochia are acrid, the orifice of the vagina, with the labia and external parts, are apt to be excoriated. The patient may suffer extremely either from a smarting pain, or from itching; and it is difficult to say which is the more distressing. Extreme cleanliness, frequent bathing, lead lotions, black wash, or vaginal injections of warm water, may be tried, and will ordinarily afford re- lief: if not, the disease will generally subside with the cessation of the lochia. Neglect in the application of the binder, is very apt to result in an excessive relaxation of the integuments of the abdomen, and an unpleasant prominence of the belly, which at a subsequeut labour may prove inconvenient, and is at all times unsightly. The best means of removing this relaxation is by friction with stimulating liniments, cold bathing, and a moderately tight bandao-e.1 1 " When suitable attention has been paid, the relaxation 'of the parietes of the abdomen has always been removed, and in several cases where, from VARIATIONS FROM ORDINARY CONVALESCENCE. 171 After a subsequent labour, it will not be difficult, by careful band- aging, to prevent its recurrence. 4. The after-pains. Instead of coming on about half an hour or an hour after the labour, in a moderate degree, and ceasing after a short time, I have known them to commence immediately after the exclusion of the placenta, continue far beyond the usual time, and occasion excruciating agony.1 In these cases, the tenderness of the uterus was very marked; bu't when under the influence of remedies the pain ceased, the tenderness disappeared also. The pulse was increased in frequency for the time. This state does not depend upon the presence of coagula in the uterus, as in the worst cases I ever saw, none were expelled; but it seems to be rather a spasmodic contraction ofthe uterine fibres.2 The remedy is a large dose of opium in the most convenient form. Less than forty drops should not be given ; and it may be necessary to repeat this dose once or twice. At the same time hot flannels may be applied to the abdomen and vulva. neglect and mismanagement during successive lyings-in, the individual had such a state of the belly that the parietes hung over the pubes like an apron, keeping up a constant irritation and excoriation on the surface of the groins and upper part of the thighs, he has succeeded in removing that unseemly and uncomfortable condition of the person after a subsequent delivery, by means chiefly of stimulant frictions and pressure."—Hamilton's Pract. Obs. in Midwifery, part ii. p. 16. 1 "After delivery the uterus itself, or its appendages, or any of the con- tents of the abdomen, may be affected from this cause with pain, varying in degree, but sometimes extremely severe. This may often be relieved by lightly rubbing the abdomen with a warm hand, or with some anodyne em- brocation, or the application of warm flannels wrung out of some spirituous fomentation."—Denman's Introd, to Midwifery, p. 469. 2 " Several cases of violent spasms of the uterus have fallen under the Editor's observation, which have been speedily relieved by the liberal ex- hibition of opium. In one case he administered a teaspoonful of laudanum, and repeated the dose at the expiration of a quarter of an hour. These spas- modic attacks may usually be known by the hard and stony feel of the uterus, through the abdominal coverings; by there being little or no increase of pain on pressure, besides what may be naturally expected so soon after delivery; by the pulse remaining steady and the tongue clean."—Dr. Wal- ler's note, p. 470, in Denman's Midwifery. " Hysteralgia (spasmodic pains) may occur soon after delivery, and is marked by severe pain in the back and lower belly, frequent feeble pulse, sickness and faintness. This is sometimes accompanied with discharge, or succeeded by the expulsion of a coagulum. In other cases, although at- tended with severe bearing down, we have no expulsion of coagulum, no retention of urine, no inversion of the uterus. Another modification of this comes on later, but always within three or four days after delivery, and attacks in general very suddenly. Perhaps the patient has risen to have the bed made, becomes sick, vomits, and is seized with violent pain in the lower part ofthe, belly, or between the navel and pubis. There is no shivering, at lefrst"'ir*is*-not a common attendant, and the pulse becomes very rapid, being sometimes above 120; the skin is hot, the lochia usually ob- structed, and the uterine region is somewhat painful on pressure. After some hours, the severity abates, and presently, by proper means, the health is restored."—Burns's Midwifery, p. 564. 172 Churchill's observations. The after-pains sometimes continue, at intervals, for several days, and are especially severe whenever the patient attempts to give suck. They occasion a good deal of distress and exhaustion, by preventing sleep; and on this account, it is desirable to suspend them after some time. This may be done by cordials, aromatic purgatives, or a dose of laudanum. 5. The lochia. Perhaps no deviations from the ordinary pheno- mena of convalescence excite more alarm in the patient's mind, than variations In the quantity, quality, and odour of the lochia. She will scarcely be persuaded that such are not the unfailing evi- dences of organic disease. Yet very remarkable differences do oc- cur, without any morbid affection ofthe uterus or vagina. The discharge may cease a few hours after delivery—especially after the birth of still-born or putrid children—without any un- pleasant symptoms. The discharge may continue the usual time, but in very small quantity; and this is commonly the case when flooding occurs during or after delivery.1 On the other hand, it may be excessive, though not prolonged beyond the usual time; or without being excessive, it may con- tinue unusually long. In these cases it may be necessary to allow the patient a better diet,, and to give tonics, such as bark, prepara- tions of iron, &c.a In some cases, the lochia, after decreasing in quantity for some time, are suddenly discharged in double quantity, and of a red colour, but without coagula. This generally happens when the patient is permitted to sit up too soon. Or it may happen at a later period, in consequence of walking about too much. A little extra rest will, however, suffice to restore the patient to her former state.3 Again, the os uteri is sometimes obstructed by a clot, and the 1 " If there be little or no evacuation ofthe lochia, and the woman be in health, no remedies are required; and if she be diseased, the means appro- priated to the relief of her complaints will reproduce it."—Dr. John Clarke's Essays, p. 32. 2 " The lochia, however, from various causes, will continue for a great length of time—nay, during the whole month, or even longer, to the mani- fest injury ofthe patient." " We have sometimes found this discharge kept up by a febrile condition of the system, which has been perhaps produced by an improper considera- tion of the case by the friends of the patient, who cannot imagine that any other cause'than debility can produce the discharge in question, and accord- ingly give wine, bark, and cordials, with a view to arrest it; and thus per- petuate the evil they intended to cure." (t In cases like those we have just described, we cannot expect to relieve the dischargevuntil we have subdued the febrile condition ofthe system."—Dewees's Compendium of Midwifery, p. 209. 3 " In the course of these changes, the appearance of blood will return sometimes, even after the serous discharge has begun, from any little irregu- larity of diet or exercise, which increases the quickness of the circulation, and the force of the heart."—Dr. John Clarke's Essays, vol. i. p. 31. ' VARIATIONS FROM ORDINARY CONVALESCENCE. 173 lochia are greatly diminished, or perhaps altogether restrained, until the expulsion of the clot affords an exit to the accumulation. Instead of the usual changes, from red to yellow, or greenish, the red discharge may persist: or after these changes have taken place, the red discharge may return. In these cases, it is necessary to be on our guard, as the change may be the precursor of secondary hemorrhage. The patient should be confined to the horizontal position, and clothed very lightly. The lochia, after going through their ordinary changes, may terminate in uterine leucorrhcea, which may become permanent. This will be best remedied by counter-irritation to the sacrum, and the internal exhibition of copaiba, iron, or ergot of rye. Again, the unusual colour of the lochia may excite alarm. In- stead of the transition from red, to a pale red, yellowish, or greenish colour, they are sometimes a dark brown, and perhaps more tena- cious than usual—or acrid, so as to excoriate the vulva. Lastly, examples occasionally occur where the lochia have a very offensive foetid odour, occasioning great annoyance both to the patient and her friends. The discharge is generally of a dark colour and often acrid.1 It may arise from the decomposition of a small portion ofthe placenta or membranes which .are left behiqd, or from the putrefaction of coagula.2 I have never seen any serious results from it; and certainly it does not necessarily indicate disease of the uterus. The vagina should be syringed, twice or- three times a day, with warm milk and water, or a very weak solution of chloride of lime. 6. The bladder. " After severe labour, the neck of the bladder and urethra are sometimes extremely sensible, and the whole ofthe vulva is tender, and of a deep red colour. This is productive of vejy distressing strangury, which is occasionally accompanied with a considerable degree of feVer. It-is long of being removed, but yields at last to a course of gentle laxatives, opiates, and foment- ' " There is another condition of the lochia, which is not only very trou- blesome, but, from its offensive smell, extremely Loathsome; this is when the coloured discharge has,disappeared, but is succeeded by a profuse watery one, of a greeaish-colour ; and. from this circumstance-, k galled by the old women, the 'green water.' It is frequently so acrid as to excoriate, and always extremely offensive to smell. The woman is almost always much debilitated by this noisome evacuation: and in some few cases we have seen a kind of hectic disposition has supervened."-Dewees's Compendium °^TheloThia' are 'sometimes observed to be foetid; and this has often been supposed to be a proof of disease. But the fcetor of the lochia often depends upon accidental circumstances, where there is certainly no^ease -such as a very small portion of the placenta left behind; or portions,of the decidua, whicl/putrefy and come away; or the coagula of blood wh«ch had been formed in the extremities of the veins and arteries of the u mis, (espe cially if it have not acted very strongly at the time of expelling the: p a- centaj putrefying and coming away, give a fcetor to all the rest of the dis- chaiges."-^Dr. John Clarke's Essays, p. 32. 174 churchill's observations. ations. Anodyne clysters are of service. An inability to void the urine requires the regular and speedy use ofthe catheter."1 7. The breasts. Variations in the .period of the secretion of milk are frequent, but of no moment. If the vascular action be exces- sive it must be moderated by antiphlogistic remedies, such as tar- tar-emetic, fomentations, &c. and by the frequent application of the child. If, as in some rare cases, no secretion should take place, the child will require a wet nurse, but the mother will not suffer. When the nipples are deficient or mal-formed, we must endea- vour to draw them out by the breast-pump; but if this do not suc- ceed, we must obviate the ill effects of secretion by tartar emetic, saline purgatives, fomentations. &c. CHAPTER IV. sanguineous tumour of the labia. Tumeur sanguin des grandes Levres, Fr. Blutgeschwulst der ekissern Geburts- theile, G. This disease was first described in these countries by Dr. Mac- bride, of Dublin, who, in the year 1776, published two cases in the Medical Observations and Enquiries.2 1 Burns's Midwifery, p. 568. "Dr. Macbride, of Dublin, is generally supposed to be the first- author who described this kind of tumefaction of the labium, in 1776; but I have met with a very exact description of it in the Observations of Vesligius, published in 1647: he says, Obs. 50, " Alias jam bis observassem ab effuso intra tunicas vagina? sanguine in nartu difficili pudendi labium ingenti tumore distensum fuisse, quo aperto sanguineque atro paulatim evacuato, mulieres evasere." Professor Boer, of Vienna, in his Medicina Obstetricia, has a chapter, Defluxu quodam sanguinis in Puerperis ante incognito, in which he des- cribes a most* extensive separation of the vagina from its attachments, in consequence of an immense "effusion of blood into the cellular substance."— Merriman'sSynopsis, p. Ill, note. 2 I shall extract the first case from Dr. Macbride's paper.—" One morn- ing, in the month of August, in the year 1776, I was called on by a gentle- man's servant to visit his wife, who, he said, had been delivered about an hour before, but, nevertheless, continued in very great pain, and by the peo- ple about her was believed to be in a dying way. Upon examination I soon found that the distress was occasioned by a large and very painful swelling of one of the labia, which the woman told me had formed itself soon after delivery, though she had a natural and easy labour." "I sent for Dr. Cleg- horn and the gentleman who had delivered her. By the time that these gentlemen came, which was about an hour, the swelling had acquired the size of a new-born child's head, was exceedingly painful and hard and ex- tending itself to the perinaeum, had a most frightful aspect, as the'skin was sanguineous tumour of the labia. 175 A third case was read by Dr. Rainey, of Dublin, in 1774; a fourth was published by Dr. Maitland, in the year 1779;' and a fifth by M. Perfect, in 1783.2 Since that time, it has been noticed by many writers on midwifery. Denman,3 Burns, Merriman,4 De- wees,5 Hamilton,6 Campbell,7 Davis,8 &e. &c A case by M. Champion is related in the Dictionnaire des Sci- ences Medicates f and Mad. La Chappelle quotes one.10 It is also described by Schreider,11, Siebold,12 Ebert, Carus." Latterly, the disease has been more frequently observed. In his excellent and elaborate address, delivered at the fourth grown livid. The case being new, none of us could wejl ascertain the true nature of this tumour; but having directed the application of stupes wrung out of a spirituous fomentation, we agreed to see her again in the evening. At the second visit, we found the pain nothing abated, but the swelling more enlarged, the integuments mortified, and ready to burst at the most promi- nent part of the tumour. In the course ofthe night this actually happened, and a large quantity of coagulated blood having discharged itself from the opening, the pain ceased in a great measure, and the swelling was found re- duced at least three-fourths, by the time that we paid our morning visit." "There being now a considerable space of the skin in a mortified state, the fomentation was ordered to be continued, and proper digestives applied, with a view of encouraging the separation of the sloughs. For about a week, the quantity of coagulated blood that came away in lumps, was considerable at each dressing; but this discharge gradually abated, and the remainder of what had been extravasated was either melted down in the course of the suppuration, or taken back by absorption—so that by the end of two months, there were no remains left of the.swelling, the sore healed up, and the woman found herself free from all complaint."—Dr. Macbride's Essay in Med. Obs. and Enquiries, vol. v." p. 90. 1 Med. Commentaries, vol. vi. p. 86. 2 Cases, vol. ii. p. 63. 3 " Sometimes, but very rarely indeed, one of the labia becomes suddenly and enormously enlarged, either towards the conclusion ofthe labour, or im- mediately after delivery, from an effusion of blood into the cellular mem- brane of that part; and in a short space of time after the accident, the skin bursts, from the violence of the distention. This complaint was first de- scribed by Dr. Macbride, of Dublin, in the year 1776; and since that time, I have been called to three instances. It occasions very great pain : yet one most important part of it is the surprise it occasions, and the alarm it gives, when it is not well understood. But I believe it is void of danger, not hav- ing seen or heard of any dangerous consequences from it, or ever found any thing necessary to be done, but to wrap the tumefied part in a flannel wrung out of warm water and vinegar; and on the discharge of the coagula, which should -not be hastened, to dress the sore with some soft liniment."—Den- man's Introd. to Midwifery, p. 466. 4J8ynopsis, p. 111. 6 Diseases of Females, p. 32. 6 Outlines of Midwifery, p. 87. 7 Midwifery, p. 328. 8 Obstetiic Medicine, vol. i. p. 45. 9 Vol. xxxiv. p. 268. 10 Prat, des Accouch. vol. vi. p. 200. See also. Recueil Period, dela Soc. de Sante de Paris. 11 Siebold's Journal, vol. xi. p. 103. 12 Frauenzimmerkrankheiten, vol. ii. p. 482. 13 See Med. Chir. Rev. vol. xxii. p. 224. 176 churchill's observations. anniversary meeting of the Provincial Medical and Surgical Asso- ciation, held at Manchester, July 2\, 1836, Mr. Crosse1 remarks: " In no branch of midwifery have more contributions been furnish- ed, within the recent period to which I refer, than in regard to cer- tain varices attaining an enormous size, and bursting, so as to form sanguineous extravasation into the labia or cellular texture of the pelvis and vagina, often with a suddenly fatal result. Within the sphere of my own observation, one such case has recently transpir- ed, which led to a coroner's inquest,2 as unfortunate cases in this line of practice are not unfrequently found to do—affording strong proof of the responsibility incurred by the accoucheur. The names of Phillipart,3 Naegele, jun.,4 Stendel,5 and others,6 may be enu- merated, in the impossibility which I find of dwelling upon the sub- ject; and the elaborate paper of Mr. Ingleby upon tumours7 ob- structing delivery, maybe consulted as. affording the best rule for discovering and treating such cases." From the history I have given, it is evident that the disease is of very rare occurrence. This disease, which consists of an effusion of blood into the cellular tissue, may affect one or both labia {Baudelocque), and may extend into the pelvis, and downwards to the perineum. It may occur during labour, previous to the delivery of the child (Mait- land,8) but more frequently immediately after.9 1 Trans, of Provincial Med. and Surg. Assoc, vol v. p. 95. 2 During a protracted labour, rapture of the left labium took place, to the extent of two or three inches, followed by a great loss of blood, and the pa- tient died undelivered." '"During expulsive efforts in labour, the left labium became greatly swollen, and burst ' avec une bruit;' great loss of blood, syncope, and death in an hour." " L'enfant fut laisse dans le sein de sa mere, et trouva la mort ou il recut la vie."—>Bull. Med. Beige, vol. i. p. 90. *"Four cases are here collected. One fatal; in a second, the swollen labium burst, the coagulum was removed-, styptic powder introduced, (plug- ging and pressure would have answered, belter,) delivery of a dead child effected by the process, recovery; in a third, the labium burst whilst the for- ceps were being applied ; the blood lost appeared arterial; pressure for three hours; delivery then of a dead child with forceps; recovery. In a fourth case, ten ounces of blood Were*removed from the labium by an incision, and labour was afterwards completed with safety to the child and mother."— Heidelberger, Klinische Annalen, vol. x. pp. 417—31. Crosse. 6 "A woman near the conclusion«of her third labour, observed a swelling ofthe labium, which diminished on her being blooded, but soon returned. This tumour burst during labour; between six and seven pounds of blood were lost; the patient fainted and expired. Delivery was speedily complet- ed by the forceps."—Kleinert's Repertorium, May, 1835, p. 31. 6 "Several cases (none fatal) are related in the Journal de Med et de Chir. Prat., Oct. 1835. " Edinburgh Med. and Surg. Journal, vol. xlv. p. 107. 8 "But there is a difference between the two examples he (Dr. Macbride) relates and the one now under consideration ; both the former appeared after delivery, the latter began during labour, and therefore we have thought pro- per to describe it, especially with a view to prevent the danger of mistaking it for the protrusion of the membranes of the foetus distended bv the waters sanguineous tumours of the labia. 177 In general the tumefaction is sudden, increasing rapidly; but in a few raro cases it has been observed to grow more gradually. (Burns.) The size varies very much ; in some cases it is enormous—as large as a child's head. (Macbride.) As much as six or seven pounds of blood have escaped. (Schedel.) Causes.—There can be no question that the effusion arises from the rupture of some vessel, by the pressure of the child's head during its passage through the pelvis; but there is some doubt from what vessels the blood escapes. The quantity is so great that it has been supposed impossible that it could proceed from the vessels supplying the part, which are ordinarily small; but it must be recollected, as previously stated, that these vessels are often in a varicose state during pregnancy. Dr. Burns supposes some of the vessels in the nymphas to be ruptured; Dr. Dewees, that the vessels of the vagina give way ;* and Drs. Davis2 and Campbelf,3 the pudic vein. —a mistake which could not fail to occasion much confusion and groundless apprehension."—Dr. Maitland's Case, Med. Comment, vol. vi. p. 89.] Also, Davis's Obstetric Med. vol. i. p. 45, 46. 8 " This accident, in every instance in which I have witnessed it, has taken place after delivery ofthe child, though not always immediately; but this is by no means constant; as we are informed by Drs. Maitland and Perfect, that the swelling occurred before the child was delivered. Dr. Maitland says, in his patient he found a soft tumour covering the os exter- num, very much" resembling the distended membranes, which proved to be the right labium pudendi, distended to^the enormous size of a child's head." —Dewees's Diseases of Females, p. 33. 1 "I am of opinion that the blood proceeds from vessels situated rather within the vagina; for those which come from the vaginal plexus, imme- diately 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 escaped through the os externum."— Dewees's Diseases of Females, p. 34. 2 "The sudden intumescence of tbe labia, from the accumulation of ex- travasated blood during labour, of which there are recorded some interesting examples, are probably in many cases indebted for their predisponent cause to a varicose condition of the veins, aequired during pregnancy; or, as perhaps more frequently happens, to the same condition of the various branches communicating with them. The more distended portion of those structures, having their tunics enfeebled in proportion to thefr distention during pregnancy, are obviously not a little exposed to the danger of a solution of their continuity, when they become the subjects of a stiff greater distention, which they can scarcely fail to do during labour of great severity. The vessels which more frequently give way in the extravasations here referred to, are probably portions of the pudic veins."—Davis's Obstetric Medicine, vol. i. p. 46. 5 " The source of the effusion must be the pudic vein, ruptured possibly by premature distention of the part. In from three to seven hours, the labium gives way on its inner surface, when a quantity of coagula are discharged, and cicatrisation speedily takes place."— Campbell's Midwifery, p. 328. 15__g 12 church 178 Churchill's observations. Symptoms.—There is nothing in the character of the labour to excite alarm—the cases have almost always occurred with natural labours. s The patient's attention is first attracted by the swelling of the labia, and the feeling of weight and bearing down. If we examine at this period, we shall find one or both of the labia irregularly distended j1 and if the tumefaction be great, the labium is everted, so that it appears to be covered by the mucous membrane. This has given rise to its being mistaken for the protruded membranes. The colour is livid, almost black, and the parts are extremely tender. "The tumefaction rapidly increases, until it covers the vulva and the perineum. The pain is very great,3 and goes on augmenting in proportion to the distention. A considerable degree of fever is excited, the pulse becomes quick, the skin hot, there is severe pain in the head, and delirium. The distress is often increased by retention of urine, from the swollen labium pressing upon the orifice of the urethra. The patient lies on her back,"scarcely able to move, and with the thighs widely separated, She cannot bear even the weight of the bed-clothes.3 After the lapse of a few hours, relief from the agony is obtained by the rupture ofthe labium, which always takes place on its inner surface, and the.discharge of blood.4 The mucous membrane is 1 "Owing to the unequal density of the external covering and internal face of the labium, it becomes irregularly distended"; and scarcely any thing is seen but its excessively stretched internal surface."—Dewees's Diseases of Females, p. 34. 2 " In this disease ofthe labia magna in time of labour, we find in general that the swelling gradually increases to such a degree as to give excessive pain; and at length, when the tumour bursts, the pain immediately abates." —Perfect's Cases, vol. ii. p. 70. 3 " Should the parts not give way, the pain arising from distention is un- ceasing and truly agonising; feyer of a very active kind is quickly kindled ; delirium sometimes attends, and the woman's life becomes severely threat- ened. Her sufferings are also augmented by the retention of urine, as its passage is prevented by the tumour pressing firmly against the meatus ex1 ternus 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 applications—therefore it is in vain to offer relief till the distended parts yield spontaneously, or are made to do so by artificial means."—Dewees's Diseases of Females, p. 38. 4 ll The internal lining of the labium gives way sometimes from the ex- cessive 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 cases 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 9th volume of the London Medical Journal. Sometimes the tumour bursts before the child is born Ur. Perfect relates a case of this kind, and the first case related- below mav be considered a similar instance."— Dewees's Diseases of Females p 35 sanguineous tumours of the labia. 179 observed to vesicate, and then to become gangrenous, after which, it yields to the pressure.1 A portion of the blood escapes ; but some coagula remain attached, and as these soon puetrefy, the wound be- comes very offensive. By degrees, however, it is thrown off, or absorbed, and the wound heals. This rupture sometimes takes place during the labour; and in such cases, as well as in those where it occurs before the blood is coagulated, the loss is sometimes so great as to occasion fainting, or even death.2 (Crosse, Pbillipart, Naegele, jun., Schedel.) This is not always the oase, however. Dr. Macbride's patient recovered speedily, notwithstanding the labium burst during labour. When the distention is enormous, and occurs before the birth of the child, it may prove a very serious obstacle, requiring surgical interference for the preservation ofthe infant's life. Diagnosis.—The tumour has been mistaken for—1, hernia— but the rapidity of its formation, its size, and its appearance, are so different, that a careful examination will at once decide the point.3 2. It is said to resemble the " bag of the waters;" and in Dr. MaitlancTs case it was punctured by the midwife under this sup- position ; but the ba*g of the waters can be isolated from the labia, and traced up to the os uteri, rendering the distinction easy. Moreover, in many cases the sanguineous tumefaction does not occur till after delivery. Treatment.—As all the distress of the patient is attributable to the distention of the labium, the most direct means of relief is, evidently, to remove this by an incision into the swelling; but it would not be prudent to.do so until a sufficient time has elapsed to allow the blood to coagulate. Meanwhile, the catheter tnay be 1 "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 preceded in two of the cases I have wit- nessed, by innumerable vesications, 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 swell- ing has acquired a 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 coagulated blood, which quickly becomes de- composed, and yields a stench that is altogether intolerable."—Dewees's Diseases of Females, p. 35. 1 " Three cases terminating in death, and one in* recovery, are related in Med. Chir. Review, vol. xxii. p. 224." 3 "This complaint has been mistaken for the distended and protruding membranes, and for a hernia; but a careful examination of the deranged part will soon remove these errors; for it exhibits neither the position nor the colour presented in either of these cases, with which it has been con- founded. Its position is lateral, unless both labia are involved, in which case the natural sulcus must be observable ; and its colour is that of extreme lividity, or entirely black, which resembles neither ihe membranes nor hernia."—Dewees's Diseases of Females, p. 34. 12* 180 churchill's observations. passed, and the urine drawn off. In some few cases it has been necessary to bleed from the arm, on account of the fever and gene- ral irritation. After an hour or two has elapsed, a large incision may be made into the labium, and the blood allowed to escape.1 The coagula which are adherent to the cellular tissue should not be disturbed, as the bleeding might be reproduced. A charcoal poultice may be applied ; or a lotion of spirit and water, vinegar and water, chloride of lime, or any antiseptic. As the coagula separate, they should be removed, and the parts kept very clean, by washing with soap and water. This treatment is equally suited to those cases where rupture takes place spontaneously. If the bleeding continue after the incision, a compress of lint should be laid on the wound, and pressure applied. The diet of the patient should be strictly antiphlogistic, so long as the fever continues; but after suppuration is established, it will be necessary to allow good diet, with wine and tonics. The bowels should be kept free. If the labium rupture during labour, our efforts must be directed to arrest the hemorrhage by pressure, cold and styptic applications, &c; but if it do not burst, but by its size impede the exit of the child, we have no resource but to open the swelling, and guard against hemorrhage the best way we can. CHAPTER V. inflammation of the vagina. Inflammation du Vagin, Fr. Entzundung der Mutterscheide, G. After an ordinary labour, whatever irritation or inflammation of the vagina may arise, speedily subsides, unless the irritation be kept up by an acrid discharge. But when the second stage of the labour has been tedious, so that the head has remained a.long time in the pelvis, pressing upon the soft parts ; or when there has been a difficulty, from narrow- ness ofthe passage ; or lastly, in malpresentations, and in all cases where an operation is required, the vagina is exposed to be attacked by severe inflammation. ' " Several advantages present themselves from making the incision just recommended: first, we may prevent sloughing, which is always desirable when these parts are concerned ; secondly, the patient is quickly released 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 ofthe cure is hastened; and fourthly, it will sooner allow of antiseptic applications, to correct the extreme fcetor of the putrefying coagula."—Dewees's Diseases of Females, p. 36. INFLAMMATION OF THE VAGINA. 181 Symptoms.—After the smarting pain caused by the distention of the parts has ceased, the patient complains of heat in the vagina and external parts: this is soon followed by pain and scalding. There is also a sense of fulness and weight in the pelvis. If we make an examination, we shall probably find the external parts swollen, and as it were bruised. On turning aside the labia, and gently dilating the vagina, it will be found thrown into large rugae of a bright red colour. The heat is greatly increased, and the slightest touch gives acute pain. If the red lochia have ceased, we may find the discharge thickened and rendered opaque by a puriform secretion from the vagina, though at an early period, as is usual in inflammation of mucous membranes, there is but little discharge. Terminations. 1. In resolution.—If the disease be detected early, and the proper remedies applied, it may subside quietly, with- out doing permanent mischief. The decrease of pain and soreness will be an evidence that it is thus terminating. 2. In suppuration.—If the inflammation be obstinate, we shall find, after some days, the mucous membrane converted into a sloughing surface. The extent of these sloughs will vary—they may be limited to the spots where the pressure has been most severe, or, as in a case lately under my care, they may involve the whole vagina. An internal examination will detect their extent, and when the sloughs separate, we shall find the canal denuded of mucous membrane to a gr-eater or less degree. In general, the destruction does not penetrate deeply, except at the back of the bladder and the under surface ofthe urethra; and it is not uncom- mon to find an opening formed in these parts, which may occasion much trouble and distress. Sometimes, though less frequently, a recto-vaginal fistula is formed.. As the process of healing goes on in the denuded surface of the vagina, extremely troublesome cicatrices frequently form, consist- ing of irregular bands of firm tissue—disposed across the vagina, or in the form of circular or spiral rings. These cicatrisations diminish the calibre of the vagina, render sexual connection difficult, painful, or perhaps impossible, and materially impede the progress of labour, should the patient become pregnant sub- sequently. It is only by the greatest care and watchfulness, during the healing of the sloughs, that these unpleasant consequences can be prevented. 3. In gangrene.—If the pressure Tiave been very great, the parts most subjected to it may mortify and slough- When these sloughs separate, we may find a vesico-vaginal fistula,1 and during ' "If, in consequence of the long pressure ofthe child's head, at that part of the vagina where its outward surface is attached to the back and under part of the bladder, the mortification affects the coats ofthe vesica urinaria, as well as those of the vagina, when the slough falls ofl, the urine will pass 182 Churchill's observations. the healing, circular cicatrices may form, as already described.1 It is very seldom that the rectum is perforated. Treatment.—In the inflammatory stage, the remedies must be antiphlogistic, varying in amount according to the intensity of the inflammation. It may be advisable to take some blood away from the arm, or to apply leeches to the vulva. I have found tartar emetic, in combination with a saline purga- tive, of great use. It should be given so as to nauseate the patient, without producing vomiting. The external parts should be well fomented two or three times a- day, and during the intervals, a large poultice may be applied over the vulva. Two or three times a-day also, the vagina should be syringed with tepid milk and water, or a weak solution of the acetate of lead. After the sloughs have separated, a careful examination should be made every second day, to ascertain the progress of healing; and when the surfaces begin to be covered with new membrane, we must take measures for preventing the formation of cicatrices. This can only be done by the repeated introduction of bougies, and the best kind are tallow or wax candles. At first a small-sized one should be oiled and introduced, night and morning, and allowed to remain a quarter of an hour. Afterwards, as the tenderness dimi- nishes, the size of the candle should be increased, and it should be introduced oftener and retained longer. The warm injections should be continued, and the milk and water may be changed for some slightly astringent fluid. If this plan be carefully and steadily pursued, we shall, in most cases, prevent the narrowing of the vagina. In the case under my care already alluded to, the slough- ing was most extensive, yet by these means the vagina has healed, with a perfectly smooth surface. The treatment necessary for the vesico-vaginal or recto-vaginal fistula, will be described when speaking of " lacerations." If the patient be much exhausted, tonics and good diet will be necessary, after the inflammation has been subdued. that way, and hinder the opening (if. large) from being closed."—Smellie's Midwifery, vol. i. p. 246. 1 "If the pressure hath beeri so great as totally to obstruct the circulating fluids in those parts, a mortification ensues—either total, by which the woman is soon destroyed, or partial, when the mortified parts separate, and cast eff in thick sloughs, then digest, and are healed as a common sore—pro- vided the patient be of a good habit of body: but if the opposite parts are also affected in the same manner, and both sides pressed together, as for example in the uterus, os internum, vagina, or os externum-; or if the inter- nal membrane ofthe whole inner surface sloughs off, then there is danger of a coalescence, or growing together, by which callosiiies are formed."— Smellie's Midwifery, vol. i. p. 246. PUERPERAL FEVER. 183 CHAPTER VI. puerperal fever. Fievre puerperale, Fr. Puerperal fieber. Kindbett-fieber, G. This is, perhaps, the most fatal disease to which puerperal women are liable, and it is by no means infrequent. Its phenomena vary very much, and it has consequently been differently described, and under various names—(Puerperal Fever, Childbed Fever, Peritoneal Fever, Low Fever of Childbed, &c.) —by different authors. Another source of apparent contrariety has been the prevalence ofthe disease epidemically, and the varying characteristics of these epidemics. Unfortunately the uniformity of the disease was as- sumed, until comparatively recent times; and, as Dr. John Clarke observes, each author erected his own experience into a standard, by which to judge of the descriptions and practice of others. A slight notice of the literary'history of the disease, and of the different epidemics, may very well precede a more detailed description. According to Dr. Hulme's researches, the older writers were not ignorant of this disease. It is described by Hippocrates and Avi- cerina. Plater (1602) makes it to consist in inflammation of the uterus. Sennert (1656) describes it, and recommends bleeding. Riverius (1674) attributes it to suppression of the lochia, and Sylvius (1674) to deficiency of the lochia. Willis (1682) takes the same view of its nature as Plater. The earliest English work on midwifery is that of Thos. Ray- nalde, who, in his Birth of Mankinde, 1634, says, "In is also to be understood, that many times after the deliverance, happeneth to women either the fever, or ague, or inflammation ofthe body ; either trembling in the belly, or else, commotion ; or setting out of order of the mother or matrix."—p. 120. Dr. John Peachey, in the Compleat Midwife's Practice Enlarged, (1698, 5th Ed.) does not refer to this disease distinctly, though he seems aware of it. In the Child-bearer's Cabinet, 1653, chap. xvi. we have directions how to help the wringings and pressings of the belly in childbed women, by outward and inward means, and drinks. Strother, in his Work on Fevers, (1716,) describes it, and was the first who gave it the name of puerperal fever., Mrs. Jane Sharp, in her Compleat Midwife's Companion, (4th Ed. 1795,) treats of fevers after-childbirth. The disease is not mentioned by Giffard, (1/34;) Chapman, (1735, 2d Ed.;) Memis, (1765 ;) Exton, (1750;) or Pugh, (1754.) 184 churchill's observations. Cooper, Compendium of Midwifery, (1766,) speaks of fever arising from suppression of the lochia. Dr. Denman was, I believe, the first to publish a distinct essay upon the subject, which he did in 1768, and which was the first reference to epidemic puerperal fever. The form he describes was inflammation of the peritoneum; and amongst other remedies he gave tartar emetic. In the year 1760 (which is about eleven years after the first in- stitution of lying-in hospitals in England), the puerperal fever was epidemical in London. From the 12th of June till the end of December, Dr. Leake informs us that twenty-four women died of it in the British Lying-in Hospital.1 "A gentleman, whose veracity I can depend on, informs me that he attended a small private Lying-in Hospital in London, in the latter end of May, June, and the beginning of July, 1761; during which time the puerperal fever was very fatal there—that to the best of his recollection they lost about twenty'patients in the month of June; that during this month he himself delivered six women in a short time, in the hospital, of natural births, and they all died."2 Dr. Burton (1769), attributes inflammation of the womb to sup- pression ofthe lochia, and recommends venesection. In the year 1770, puerperal fever was very fatal in the London hospitals. In the Westminster Hospital,-between November 1769, and May 1770, sixty-three women were delivered, nineteen had puerperal fever, and fourteen died. (Leake.)3 In the British-Lying-in Hospital, eight hundred and ninety were delivered, and thirty-five died. (White.) In a third hospital, not named by Mr. White, two hundred and eighty-two were delivered in 1771, and ten died.4 In 1772 Dr. Hulme published a Treatise on the puerperal fever, in which he describes an epidemic, and attributes it to inflammation of the omentum. This was shortly followed by Dr. Leaker's Work on Diseases of Women, in vol. ii. of which, he describes puerperal fever, taking the same view as Dr. Hulme ; and giving statistics of the frequency and mortality. He says that from Dec. 13, 1768, to Dec. 12, 1769, one hundred and eighty women died.' From December-12, 1769, to December 11, 1770, two hundred and seventy women died. From December 11, 1770, to December 10, 1771, one hundred and seventy-two Women died. 1 Leake, on Childbed Fever, last page. 2 White, on the Management of Lying-in Women. 3 Leake, on Childbed Fever, p. 241. 4 White, on Lying-in Women, p. 337. PUERPERAL FEVER. 185 Dr. William Hunter was in the habit of informing his pupils, that of thirty-two patients who were attacked with the disease during two months, only one recovered. "We tried various methods. One woman we took from the beginning, and bled her, and she died. In another, we gave cooling medicines, and she died. In a third, we gave confect: aromat: and other cordials and stimuli, and she also died." In the year 1773, the puerperal fever appeared in the Lying-in Ward of the Royal Infirmary, Edinburgh; and is thus-described by Professor Young: " It began about the end of February, when almost every woman, as soon as she was delivered, or perhaps about twenty-four hours after, was seized with it; and all of them died, though every method was used to cure the disorder. This disease did not exist in the town.'" "In 1814-15, it visited the Lying-in Hospital of this city; and'of nine who were taken ill, only one recovered."2 Dr. Moor, in his book on Midwifery, (1777), has a section on puerperal fever, which he considers to be inflammation of the abdominal viscera, as well as of the omentum, at least in bad cases. Dr. Foster, (178L,) and Mr. Dease, both treat of it. The latter mentions that the first epidemic in Dublin occurred in the year 1774. Dr. Kirkland, in 1775, published a treatise on childbed fevers ; he seems to ascribe the cause of the puerperal fever chiefly to an irritable state of the uterus, its inflammation, and to an absorption of putrid blood from this part. Dr. Hamilton, sen., of Edinburgh, (1784,) does not mention it: but Dr. Spence, ofthe same city, (1784,) in his System of Midwife- ry, has a chapter upon it. Dr. Butler, in 1775, published an account ofthe puerperal fever. After giving the general description of the disorder, he concludes that the proximate cause of the puerperal fever is a spasmodic affection ofthe first passages, together with a morbid accumulation there. Puerperal Fever is noticed in Manning's Diseases of Females, 1775. Dr. Jos. Clarke, (then Master of the Lying-in Hospital in this city,) published an account of the puerperal fever in 1791, in the Med. Comment, vol. xv. He says:—"The puerperal fever first visited the Lying-in Hospital of Dublin in the year 1767, about ten years after it was first opened for the reception df patients. From the first of December till the end of May, of three hundred and sixty women delivered, sixteen died. "Seven years afterwards, this fever re-appeared. Of two hun- 1 Dr. Jos. Clarke's Essay in Med. Comment, vol. xv. 2 Mss. Notes of Professor Hamilton's Lectures for 1816-17-18.— Camp- bell's Midwifery, p. 17. 186 churchill's observations. dred and eighty women delivered during the months of March, April, and May, in the year 1774, thirteen died. " From the year 1774, till the year 1787, this fever was unknown as an epidemic in Dublin. From the 17th of March in this year, till the 17th of April, one hundred and twenty-eight were delivered in the hospital; eleven of whom were seized with symptoms of puerperal fever, and seven died. " In November, 1788, the same fever appeared for the fourth time,- since the institution of the hospital. During this, and the two succeeding months, three hundred and sixty-five women were delivered, seventeen were, attacked by the fever, and four- teen died. " The disease corresponded with the London epidemic described by Dr. Hulme, and the appearances, on dissection, were those of peritonitis. In no instahce did the appearance of inflammation seem to penetrate deeper than the peritoneal coat on any of the viscera of the abdomen or pelvis." In 1795, Dr. Gordon, of Abderdeen, published an Essay on puerperal fever,describing an epidemic which occurred in that city. "The disease made its appearance at Aberdeen, in December, 1789, and prevailed as an epidemic among lying-in-women till the month of March, 1792, when it finally ceased. This epidemic seemed in every respect to answer the description of the puerperal, or childbed fever, on which many authors have written, particularly Drs. Hulme, Denman, and Leake." " In my practice, of seventy-seven women who were attacked with the puerperal fever, tvVenty-eight died—so that very near two- thirds of my patients recovered."1 In 1793, Dr. John Clarke, of London, published a valuable little work on the Management of Pregnancy and Labour, &c. in which he described the epidemic of 1787 in London, and spoke of several forms of the disease, such as 1. Inflammation ofthe uterus and ovaries. 2. Peritonitis. 3. Local inflammation connected with inflammatory affection of the system. 4. Affections of the uterus from portions of the placenta left behind. 5. Low fever of childbed. Mr. Dun has described an epidemic of puerperal fever at Hallo- way, near London, in the year 1812.2 In 1S14, Dr. Armstrong published an account of an epidemic of puerperal fever, which prevailed -during 1813, in the counties of Durham and Northumberland, and especially at Sunderland, where he then resided. It appears to have closely resembled the Aberdeen and Leeds epidemic, and to have chiefly consisted in an inflamma- 1 Gordon's Essay, pp. 1, 42. 1 Ed. Med. and Surg. JournaI,Jvol. xii. p. 36. puerperal fever. 187 tory affection of the peritoneum, with more or less fever. In all, forty-three cases occurred, and five terminated fatally. Mr. Hey published an essay on puerperal fever in 1815, and he states that an epidemic of puerperal fever commenced at Barnsley, in Yorkshire, in 1808, and at Leeds in November, 1809—con- tinuing in the latter town till Christmas, 1812. It presented exactly the same characters as that described by Dr. Gordon, and was coincident with an epidemic of erysipelas. Dr. Burns, in his Principles of Midwifery, makes three varieties of puerperal fever, viz.—inflammation of the uterus—peritonitis— and malignant puerperal fever. ' Puerperal fever was epidemic in the Lying-in Hospital of Edin- burgh'in 1821-2; but the mortality is not known. (Campbell.) Dr. Douglas, of this city, published a notice of puerperal fever, in the Dublin Hospital Reports, vol. iii. (1829,) drawn chiefly from his experience ofthe epidemic which prevailed in the Great Britain- street Lying-in Hospital, during the years 1810-11. In 1822, Dr. Campbell published his essay on puerperal fever, describing the epidemic in Edinburgh. " It was in the latter end of March, 1821, when the weather was extremely changeable, accompanied with sudden variations of tem- perature, that the first case occurred in my practice. From this period, until the early part of September, 1822, when the last cases occurred, we delivered 789 patients, of whom seventy-nine were affected with the epidemic, itk various degrees of violence, and twenty-two died. During the dry warm months, th£ disease sub- sided considerably; and from the 16th of July, to the 14th of October, 1821, we had only six cases. At this time the epidemic was not so fatal, for although two of the six fell victims to it, one of them was past recovery when we were first sent for. After the last of these dates, the cold, rainy weather set in, and with it the disease returned. It was now more frequent and fatal than for- merly ; for in less than two months we had no fewer than twenty- six cases, of which number eight died. In the warm months of 1822, similar to what happened in the former year, the disease became less frequent, and assumed a milder character; and of all the cases which occurred from the latter end of April, until the early part of September, none proved fatal. During the above period, the puerperal fever was very fatal at Stirling, and other country towns; in Glasgow particularly, it committed great ravages."1 In 1822, also, Dr. Mackintosh, of Edinburgh, published his essay on puerperal fever, in which he speaks of it as an inflammatory affection of the peritoneum* and recommends free bloodletting, and antiphlogistics. Dr. Hamilton, Jun. in his Outlines of Diseases of Females, 1824, describes malignant childbed fever, as a disease "sui generis." Dr. Dewees, of Philadelphia. U. S. in his work on Diseases of 1 Campbell on Puerperal Fever, p. 17. 188 churchill's observations. Females, 1827, describes simple hysteritis—hysteritis with puerpe- ral—and puerperal fever. « He says: "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 in Sunbury, in this state (Penn.) in the fall of 1817, and in the spring of 1818; and though treated with both vigour and ability, about one half died."1 Dr. Gooch's classical work on Diseases of Women, was published in 1829; and in it he describes two forms of puerperal fever—one resembling the Aberdeen epidemic; and the other much milder, and more manageable. In 1833, Dr. Lee's valuable work on the more important Diseases of Women2 appeared, containing copious details upon the various forms of this disease. " From the 1st of January, 1827," he says, " to 1st of October, 1832, 172 cases of well-marked puerperal fever came under my immediate observation in private practice and in the British Lying- in Hospital, and other public hospitals in the western districts of London." " Of fifty-six cases which proved fatal, the bodies of forty-five were examined, and in all were found some morbid changes, decidedly the effect of inflammation, either in the peri- toneal coat of the uterus, or uterine appendages, in the muscular tissue, in the veins, or in the absorbents of the uterus—accounting in a most satisfactory manner for the constitutional disturbance observed during life. The peritoneum and uterine appendages were found inflamed in thirty-two cases; in twenty-four there was uterine phlebitis; in ten there was inflammation and softening of the muscular tissue ofthe uterus ; and in four, the absorbents were filled with pus." Details more or less copious will be found in recent works on midwifery; Blundell, 1831 ; Ashwell, 1834; Ramsbotham, &c. Dr. Cusack published a valuable paper on puerperal fever in the Edinburgh Medical and Surgical Journal, No. 98. Mr. Ceely, of Aylesbury, has described an epidemic which occurred in that city and neighbourhood in the year 1831.3 Dr. Collins, in his excellent Practical Treatise on Midwifery, (1835,) p. 380, gives an account of the puerperal fever as it occur- red in the Lying-in Hospital in this city. " Puerperal fever," he says, " first became epidemic in the Lyino-- in Hospital of Dublin, in the year 1767, about ten years after the institution was established.; since which time it has been epidemic in the following years:—1774, 1787, 1788, 1803-10-11-12-13-18 -19-20-23-26-28, and 1829. The mortality in some of these attacks was not great, and in others the contrary. In the year preceding my appointment as master, which took place in Novem- 1 Dewees, Diseases of Females, p. 380. * Lee, on Diseases of Women, p. 3. 8 Lancet, March 7, 1835. PUERPERAL FEVER. 189 ber, 1826, puerperal fever prevailed in the hospital to an alarming extent. In the succeeding year, 1827, the mortality from the dis- ease was slight. Typhus fever was, during these periods, very prevalent in Dublin, many cases of which appeared in the hospital. In 1828, the attack of puerperal fever was much more severe, proving fatal to twenty-one women. It continued to increase in violence considerably, in the months of January, February, and the early part of March, 1829, after which it-disappeared, and for the four remaining years of my mastership, we did not lose a single patient from this disease." A very good resume of the different opinions upon puerperal fever, will be found in. Mr. Moore's prize essay, published* in 1836. In Dr. Beatty's Second Report of the Cumberland-street Lying- in Hospital, in this city, from July, 1835, to August, 1837, he says:—" The hospital was visited by this terrible malady twice during the period embraced by the present report. Both attacks took place in the month of January, and at each time erysipelas was raging as an epidemic in the surgical hospitals, and diseases of a typhoid type vyere very prevalent in this city."1 Dr. Beatty lost eight patients out of thirteen. About the same time I saw several patients similarly attacked; but the epidemic did not enter the Western Lying-in Hospital. Dr. Evory Kennedy informs me, that during his mastership, puerperal fever has been occasionally prevalent in the Lying-in Hospital, Great Britain-street. In 1839, Dr. Ferguson published the first of a valuable series of Essays on the more important Diseases of Women ; " On Puerperal Fever," founded on 204 cases occurring at the General Lying-in Hospital, during the previous twelve years, of whom sixty-eight died. He divides the disease into four varieties—1, the peritoneal; 2, the gastro-enteric ; 3, the nervous ; and 4, the complicated. It will be seen that I have not scrupled to avail myself of the information afforded by any of these writers; but [ would espe- cially acknowledge my obligations to Drs.- Lee and Ferguson. Ainomgst the early French midwifery authors, the disease was known, but not as an epidemic : thus Viardel, 1774, " Obs. sur la pratique des Accouch. natprels," &c. speaks of cold giving rise to inflammation and gangrene of the uterus. Peu, 1694, "La pratique des Accouchemens," speaks of inflam- mation ofthe abdomen, caused by retained placenta, and relates cases. Jacques Mesnard, 1753, "Le Guide des Accoucheurs," describes inflammation of the uterus. F. A. Deleurye, 1770, " Traite des Accouchemens," treats of "depots laifeux" in different parts of the body and uterus. The first epidemic on record in France, I believe, is that of 1746, 1 Dublin Journal, vol. xii. p. 297. 190 churchill's observations. " The winter of 1746 at Paris,1 was most destructive to puerperal women, and they died between the fifth and seventeenth day after their confinement. The epidemic attacked the indigent, but much less frequently those delivered at their own habitations, than in the Hotel Dieu. Of twenty women in childbed, affected with the disease in February of that year, in the Hotel Dieu, scarcely one recovered." M. Malouin thus describes the epidemic of 1746: " The disease usually commenced with a diarrhoea ; the uterus became dry, hard, and painful; it was swollen, and the lochia had not their ordinary course; then the woman experienced pain in the bowels, particu- larly in fhe situation of the broad ligaments; the abdomen was tense; and to all these symptoms were sometimes joined pain of the head, and sometimes cough. On the third and fourth day after delivery, the mammae became flaccid. On- opening the bodies, curdled milk was found on the surface of the intestines, a milky serous fluid in the hypogastrium; a similar fluid was found in the thorax of certain women, and when the lungs were divided, they discharged a milky or putrid lymph. The stomach, the intestines, and the uterus, when carefully examined, appeared to have been inflamed. According to the report ofthe physicians, there escaped clots on. opening the vessels of this organ." (Lee.) Jussieu also describes the epidemic of 1746 ; inflammation ofthe stomach, intestines, and uterus, was discovered, with suppuration ofthe ovaries. " In 1750, an epidemic attacked many puerperal Women, which was characterised by severe abdominal pain, and tumefaction of the. hypogastrium. 'On examining the bodies of two of these women, Ponteau states that the uterus was found very large, the internal membrane was soft and black, and the substance of the parietes was of a livid red colour, and in a gangrenous state." (Lee.) In 1774, an epidemic attacked the puerperal women in the Hotel Dieu, Paris, and committed the greatest ravages. It re-appeared every winter, till 1781. These facts are stated by M. Tenon, who alsD states, that all women seized with this epidemic die, and that of twelve, seven are frequently attacked ; so that " L'Hotel Dieu perd quelquefois plus de la moitie des femmes qui y vont accoucher." (Dr. Jos. Clarke.) " Thus, the epidemic of 1746 was characterised by,the suppres- sion of the lochia; whereas, in that of 1774, the lochial discharge deviated little or nothing from its,natural condition. Hemorrhagies occurred in the epidemic of 1764, and the uterus was not found to be dry, hard, and tumefied, as in that of 1746 ; yet the disease was equally fatal in each instance." (Moore.) M. Tenon has given a graphie description of this epidemic,3 which has been partly translated by Dr. R. Lee. 1 Memoirs sur les H6pitaux de Paris, p. 243. Lee, p. 6. 2 Mem. sur les Hdpitaux de Paris, p. 243. See p. 6. PUERPERAL FEVER. 191 In 1812, M. Gastellier published a treatise upon puerperal peri- tonitis, and its varieties. Capuron, 1824, " Maladies des Femmes,1' speaks of puerperal peritonitis as the only form of puerperal fever.' Gardien, 1826, " Traite' des Accouchemens," describes puerperal peritonitis, with certain complications, as constituting puerperal fever; More recently, the labours of Andral, Luroth, Dance, Tonnelle, and Dupley, have thrown much light upon the true pathology of this disease. " In the epidemic of 1829, at Paris, numerous opportunities occurred of examining the morbid appearances in those who were cut off by the disease. In 132 out of 222 fatal cases, puri/orm fluid was found in the veins and absorbents of the uterus; and in 197 some important alterations of structure were found in the uterine organs." (Tonnelle, Lee.) L. I. Boer, of Vienna, (1790), published three valuable essays upon puerperal fever, in his work, " Die Natiirliche Geburtshulfe," vol. 1 and 2, in which he notices the peritoneal disease, and some secondary affections. Osiander, in his " Denkwtirdigkeiten fur die Heilkunde und Geburtshulfe," vol. 1, 1792, relates two fatal cases of puerperal fever, which occurred in the Lying-in Hospital at Gottingen, and in the second volume mentions its occurrence. In Osiander's Neue Denkwiirdigkeiten, &c. vol.' i. part 2, Dr. Jaeger has given an account of a very fatal epidemic which pre- vailed in the Lying-in Hospital at Vienna in the year 1795. The local diseases were peritonitis, hysteritis, and gangrene of the inner surface ofthe womb. Another epidemic occurred at Vienna in 1819. " The bodies of fifty-six wpmen were examined, who had died of puerperal fever in the General Hospital at Vienna, in the autumn of 1819 ; arid in all of these, with the exception of two, where de- livery had taken place a considerable time previous to death, effu- sions of sero-purulent fluid were found in the abdominal cavity, and traces, of inflammation in one or more of the abdominal viscera. The ovaries and fallopian tubes were always more or less swollen, red, and tender; and the body of the uterus was, in consequence of inflammation, flabby, tender, and easily broken down with the finger. It is also stated in this report that the accession of fever is always preceded by marked changes in the whole system, particu- larly in the uterus, clearly indicating an inflammatory state."1 The disease is noticed by Carus, " Gynascologie," 1828; Froriep, " Die Geburtshulfe," 1832 ; Siebold, " Frauenzimmerkrankheiten," 1821 ; Joerg, " Krankheiten des Weibes," 1832. A report of the secondary Midwifery Institution at Vienna, by Dr. Bartsch, was published in the Lancet,2 in which it is stated, 1 Medical Annals ofthe Austrian States, 1822. Lee, p. 8. 2 Lancet, April 16th, 1836. 192 churchill's observations. that of 2,218 women delivered at that institution between October 15th, 1833, and December 31st, 1834, 175 had puerperal fever, of whom 109 died. In this report, puerperal fever is distinguished from peritonitis and metritis. " The cases of puerperal fever, occurred seldom under the form of puerperal peritonitis, but generally as inflammation ofthe uterine veins, giving rise to the production of pus in these vessels, and the general symptoms accompanying its absorption." From the preceding slight sketch, it is evident that the disease prevails more extensively, and is more virulent in hospitals. It is every where more frequent among the lower classes than the higher.' In Dublin this is even more remarkably the case than in London.2 " That the cause of the prevalence in lying-in hospitals is the number of patients in a ward,3 the want of proper ventilation,4 and the too rapid succession of fresh patients before the wards have been properly cleansedj is rendered almost certain by the success which has followed attempts at remedying this evil.5 These four points—isolation of patients, cleanliness, ventilation, and allowing the ward in which the disease has appeared, to be idle for a while, are the chief means of guarding against the dis- ease in hospitals; and in private -practice, we can do little more than has been laid down in the Rules for the Management of Lying-in Women. 1 " In this country, the disease seldom attacks individuals in the better ranks of society! It occurs chiefly among the lower classes, who inhabit confined apartments, in narrow, dirty, ill-ventilated lanes."—Hamilton, Diseases of Females, p. 198. * " In private practice among the higher classes in Dublin, puerperal fever, accompanied by the low typhoid symptoms, so prevalent in hospitals, is scarcely known. The late Dr. Joseph Clarke informed me, that in the course of forty-five years' most extensive practice, He lost but four patients from this disease."—Dr. Collins's Pract. Treatise on Midwifery, p. 380. 3 " I am afraid no methods will be effectual where several lying-in women are in one ward. It will be very difficult to keep the air pure, dry, and sweet, and at the same time to accommodate the heat of the ward to their different constitutions and symptoms. If separate apartments cannot be allowed to every patient—at least, as soon as the fever has seized one, she ought immediately to be moved to another room, not only for her immediate safety, but for that of the other patients. Or it would be still better, if every woman were delivered in a separate ward, and were to remain there for a week or ten days, till all danger from this fever was over."—White, on Lying-in Women, p. 173. 4"I am well informed, that this fever and obstruction occur more fre- quently in the lying-in hospitals than in private practice. What can this arise from but the different states of air? This, in my opinion, is the cause; for though very great care is taken in those hospitals, yet, as the apartments and furniture will imbibe some of the morbid effluvia arising from the patients, the air must always be more or less tainted."—Johnson's Mid- wifery, p. 253. 6" Every symptom of fever subsided, as our patients were received into clean wards. Of 150 admitted after our refit, scarcely one had any serious illness."—Dr, John Clarke, Med. Comm. 1791, p. 318. n PUERPERAL FEVER. 193 For the purpose of giving a more distinct view ofthe prevalence of puerperal fever, I have made out (as accurately as possible) a chronological list of the different epidemics, with the names of the authors by whom they are noticed or described, and the pathologi- cal characteristics described-when ascertained. DATE PLACE. AUTHOR. LOCAL AFFECTION. OF EPIDEMIC. * 1664 Paris Peu (Leu) - 1746 Paris Malouin Peritonitis, Hysteritis, &c. Jussieu Disease of Ovaries. 1750 Lyons Doulcet Peritonitis, U. Phlebitis. 1750 Paris Pouteau Hysteritis erysipelatous. 1760 London Le£ke Inflam. of Omentum, &c. 1760-61 Aberdeen Gordon 1761 London White Peritonitis. 1767 Dublin- Jos. Clarke 1770 London Leake Peritonitis (Partial.) 1771 London White 1773 Edinburgh Young 1774 to 81 Paris Tenon, Doulcet, &c. 1774-87, 88 Dublin Jos. Clarke Peritonitis. 1782 Paris Doulcet Peritonitis, Hysteritis. 1783 London Osborn Peritonitis. 1795 Vienna Dr. Jaeger Peritonitis, Phlebitis. 1786 Paris Tenon 1787 Gottingen Osiander 1788 London Jos. Clarke Hysteritis, Peritonitis, &c. 1787-8 London Do. Peritonitis, Hysteritis, &c. 1789-90,91,92 Aberdeen Gordon Peritonitis. 1803^10,12, 13 Dublin Collins, Douglas Peritonitis.^ 1808 Barnsley, Yorksh. Hey Peritonitis. 1812-13 Leeds, Yorkshire Hey Peritonitis. Sunderland, coun- „ 1813 ties of Durham & Northumberland " Armstrong Peritonitis. 1811 Heidelberg Naegele, Bayrhof-fer 1812 Holloway, London Dun Peritonitis. 1814-15 Edinburgh Hamilton 1816 Paris Tenon U. Phlebitis, Hyster. Perit. 1817-18 Pennsylvania, TJ. S. Dewees Peritonitis. 1818-19,20-23 Dublin Collins Peritonitis. 1819 Vienna Boer I 1819 Glasgow Burns 1821-22 Edinburgh Gampbell Peritonitis. 1821-22 Glasgow, Stirling Campbell Peritonitis. 1827-28 London Gooch Peritonitis. 1827-28, 29 . London • Ferguson Peritonitis, Hysteritis. 1835-36-38 London Do. Phlebitis, &c. 1825-27, 28,29 Dublin (Lying-in Hospital) Collins . Inflam. of Peritoneum, Ute- 1829 Paris (Maternite) Tonnelle rus and appendages, and Uterine Phlebitis. 1829-40, occa-sionally Dublin (Lying-in Hospital) E. Kennedy 1831 Aylesbury^ Ceely 1833-34 Vienna Bartsch Uterine Phlebitis. 1836-37 Dublin (new Lying-in Hospital) Beatty Peritonitfs, Pleuritis, &c. 16__b * 13 church 194 churciiill's observations. An examination ofthe foregoing table will render it no matter of surprise that authors should differ as to the pathology of this affec- tion ; and as each appears to have regarded his own experience as a standard for all, we cannot wonder at, though we must ever regret, that various and bitter controversies should have arisen in conse- quence. It would occupy far too much time to enter upon the various arguments adduced by different writers in favour of their own views; it will be quite sufficient to enumerate the opinions, and to classify the authorities, referring the reader to the various sources of minute information already quoted. Puerperal fever, then, has been regarded as Inflammation of the Uterus,1 by Hippocrates, Mauriceau, Galen, , La Motte, Celsusy Sydenham, iEtius, Boerhaave, Paulus Avicenna, Van Swieten, Raynalde, Hoffmann, F. Plater, Jussieu, Sennert, Villars, Riverius, ~ ,Astruc, Sylvius, ' Pouteau, . Strother, Denman. Inflammation ofthe Omentum and Intestines, by Hulme, Leake, La Roche. Peritonitis, by Waller, Capuron, Johnston, Gordon, Forster, Hey, Cruikshank, Armstrong, Bichat, Clarke, Pinel, , Campbell, Gardien. Collins. Peritonitis, connected] with Erysipelas, or of an Erysipelatous character,2 by Pouteau, , Gordon, Home, 'Armstrong, Lowder, . Hey, Young, Campbell. Abercrombie, 1 Campbell, on Puerperal Fever, p. 21. 2 At the time of the prevalence of puerperal fever described by many of these authors, there was also an epidemic of erysipelas. PUERPERAL FEVER. 195 Fever of a peculiar nature, by Willis, Doublet, Puzos, Hamilton. Levret, Disorder of a putrid character, by Peu, Le Roi, Tissot, White. Disease of a complicated nature, by Petit, Tenon, Selle, Tonnele, Kirkland, Lee, Walsh, Ferguson. Fever, with Biliary disorder, by Finch, Stoll, Doulcet. t Various are the causes assigned by different authors, for the pro- duction of this disease. " We also find fever after parturition ascribed to difficult labour;1 to inflammation ofthe uterus;2 to accumulation of noxious kumours, set in motion by labour;3 to violent mental, emotion, stimulants and obstructed perspirations;4 to miasmata; admission of cold air to the body, and into the Uterus; to hurried circulation; to suppression of lacteal secretion; diarrhoea;5 liability to putrid contagion, from changes in the humours during pregnancy;6 hasty separation of the placenta; binding the abdomen too tight ;7 sedentary employ- ment; stimulating, or spare diet; fashionable dissipation; retained portions of placenta ; floodings, from non-contraction, according to one ;8 from violence, but not from non-contraction, according to another;9 to inflammation of the intestines and omentum; from the pressure of the gravid uterus against them;10 to atmospheric distcmperament; to internal erysipelas ; metritis, phlebitis; and to contagion of a specific kind: It will be seen that some of the symptoms ofthe malady are mistaken for causes."11 1 Of 114 cases in the Dublin Lying-in Hospital, in 1819 and 20, sixty-eight were first labours; but they were not remarkable. • «F Plateri Praxis Med. 1686, vol. ii. ch. 12. Hoffmann, 1734, vol. iv. part 1. sec. ii. ch. 10. Burton, 1751. Essay on Midwifery, part 4. Smellie, Tissot, Kirkland, p. 58. Denman. Broussais, prop. 313, & the breasts continue dis- tended. 4. From hysteritis.3 The main distinction is the character and situation of the tenderness; in puerperal peritonitis, the slightest touch on the abdominal parietes causes acute torture; whereas, in hysteritis, the /patient can bear pressure very well, until we can feel the enlarged uterus. Any increase of pressure, after the abdo- minal parietes are in contact with the uterus, gives acu-te pain. The symptoms of hysteritis, are also more-local. Prognosis..—The general prognosis is unfavourable, even in sporadic cases, but still more so when the disease is epidemic.3 Dr. Hulmejieclares it to be as bad as.the plagjie. lochia nor the secretion of milk are suppressed. The febrije- attack is usually preceded by evident signs of derangement of the bowels, such as flatulence, nausea, vomiting, constipation, or diarrhoea. .Puerperal peri- tonitis is'developed, in a large proportion of cases, before the end. of the fourth day, after delivery—whereas this affection rarely appears unUl the termination of the first week."—Lee on Diseases of Women, p. 22. ' "The ephemera called 'the weed,' is "ushered in by strong rigors;' which commonly in less than an hour are" followed by heat, thirst, and general excitement, the whole train of symptom*being terminated in twenty-four or thirty hours by profuse perspiration. The absence of abdominal irritation is generally sufficient to prevent the possibility of mistaking the disease for puerperal fever."—Armstrong on Puerperal Feveri p. 22. * " Simple hysteritis may be known by a burning, throbbing pain, fulness and oppressive Weight, in the region Of the uterus; by frequent calls to make Water, which js passed "With great pain and difficulty; by the uterus itself feeling hard, hot, and enlarged—being exquisitely sensible when pressed upon—by violent pains darting through tp the back, and down to the groin and thighs—by an increase of pain from raising the trunk erect; and by the soreness and fulness being more confined to the lower part of the abdomen throughout the attack, than m the puerperal fever."—Armstrong on Puer- peral Fever, p. 20. " *" For some time after the commencement of this fatal malady, it proved fatal in every case that came within my knowledge ; and though a few patients recovered, under the treatment which my father and I had formerly found successful with puerperal fever, yetiheiuccess was very small till theunethod hereafter described was fully adopted,"—Hey on Puerperal Fever,p. 10. 16—c 14 church 210 Churchill's observations. Dr. Leake lost 13 cases out of 19. Dr. W. Hunter, 31----------32. Dr. Clarke, 21----------28. Dr. Gordon, 28----------77. Dr. Campbell, 22---------79. Dr. Armstrong,, 4--------— 44. Dr. Lee, 40---------100. Dr. Collins, 56.---------- 88. Dr. Ferguson, 68----------205. In the epidemic in Paris, (1746,) in Edinburgh, (1773,) and in Yienna, (1795,) none recovered. "If we take the results of treatment adopted in various puerperal epidemics, by various practitioners, we shall find that on a large scale, one in every three will die, with all the resources which me- dicine at present offers. To save two out of three, then, may be termed good practice in ah epidemic season." (Ferguson.1) Treatment.—It must be borne in mind, when any peculiar mode of treatment is advised,-that the character of the epidemic is the test of its propriety. Forget fulness of this rule has been the source of much controversy, and no slight acrimony. As Dr. John Clarke remarks, each author takes the epidemic he has witnessed as the type of all, and remorselessly condemns all treatment which does net agree with that which h^ has found successful. There is no question that the employment of antiphlogistic remedies, by Gordon, Hey, Armstrong, &c. was a great improvement upon the old methods ; but it is .easy to conceive an epidemic in which this plan must be strikingly rnodified, or altogether abandoned. Having premised thus much, I shall describe the treatment which has or- dinarily been found the most efficacious. If the pulse be firm, a large quantity of blood should be taken from the arm. Dr. Gordon recommends from 20 to 24 ounces at the beginning, and if necessary this may be repeated.2 The blood generally exhibits the buffy coat. (Hulme, Gordon, Hey.) ' On Puerperal Fever, p. 112. 2 " In the childbed fever, therefore, bleeding is the only remedy which can give the patient a chance for life."—Leake on Childbed Fever, p. 101. " When the pulse is firm and regular, we should not hesitate to use the lancet at whatever time we are applied to."—Campbejl on Puerperal Fever, p. 262. "As to the repetition of bleeding, and themanner.of conducting it, I think it most important to remark, not only in reference to this, but to all puerperal" diseases, that the mode proposed by Dr. Hall, to place the patient upright and to bleed to incipient syncope is one of extreme value, affording at once perhaps, the safest rule, and the best diagnostic in these cases."—Ashwell, on Parturition, p. 481. " Bleeding in puerperal fever is advocated by the following practitioners : Dr. Denman, (in his old age ;) Dr. Leake; Dr. Gordon, (boldly ;) Dr. Butler; Dr. Kirkland, (if the lochia be little ;) Dr. Hall, (the robust only :) Dr. Arm- strong, (boldly;) Mr. Hey, (boldly;) M. Vigarous and M. Gardien, (in some PUERPERAL PERITONITIS. 211 Should any circumstances forbid a repetition of the venesection, a number of leeches, (from 60 to 100, Campbell,) may be applied to the abdomen, and when they fall off, the abdomen should be foment- ed, or covered with a light bran poultice. (Gooch.) The fomentation, or poultice, may be repeated at intervals, as it has a very soothing effect. After full depletion, the next most powerful remedy is mercury, alone or in combination with opium.1 Without explaining its modus operandi, it is sufficient to state the fact, that it has been found to exercise a remarkable influence over inflammation of serous membranes. It may be given in large doses/(gr. x. every three or. four hours,) or in.smaller ones, more frequently repeated, (gr. ii. every hour;) and it should be continued until an impression is made upon the disease, or until the mouth is affected, unless purging be induced. After a decided effect is produced, the dose may be diminished, and the intervals lengthened. For the purpose of preventing intestinal irritation, it is Usual to combine it with Dover's powder or.opium. Perhaps it is not too much to say, that the benefit* of the opium in this combination is not confined to the prevention of intestinal disturbance, but that it exerts a positive and beneficial influence upon the inflammation. Mercurial frictions are a valuable mode of affecting the system. varieties:) Dr. Campbell, Dr. Macintosh, (boldly;") Dr. Douglas, (in first and second varieties;) Mr. S. Clarke; Dr. Jos". Crarke ; M. Duges; M. Ton- nelle; Dr. Blundell ; Dr. Conquest; Dr. Gooch; Dr. Dewees; Dr.'Rye; Dr. Lee, &c. ccc."—Moore on Puerperal Fever, p. 210 " In 15 only ofthe 88, did we deem it advisable to bleed generally; seven of the fifteen recovered." "lam satisfied, however, that in hospital, the immediate application of three or four dozen leeches, followed by the warm bath, in which" the patient should remain as long as her strength will bear it, will be found in the great majority the most judicious means of removing blood."— Collins, Pract. Treatise on Midwifery, pp. 391-393. 1 "At the same time, eight or ten grains of calomel, in combination with five grains of antimonial powder, and gr. iss. orgr. ii. of opium, or gr. x. of Dover's powder, should be administered; and this should be repeated every three or four hours, until the symptoms begin to subside."—Lee on Diseases of Women, p. 103. " In the mean time, after the bowels had been acted on by tbe oil draught, we used every effort to'bring the patient, as speedily as possible, under the influence of mercury." " In general, I ordered four grs. ot calomel, with as much ipecacuanha powder, to be given every second, third, or fourth hour." " The quantity of calomel and ipecacuanha, taken in this way, in many in- stances was very great, to the amount of three, four, or five hundred grains or upwards." " In several instances, a scruple of calomel was given every second or third hour, and carried to a great extent. One patient took more than an ounce. I could not observe any better effect from the large doses than the small; the system was not more speedily influenced ; and when they did so act, it was often with violence^ so as.to endanger the destruction ofthe soft parts about the palate."— Collins, Pract. Treatise on Midwifery, pp. 394-5-6. 212 churchill's observations. They were first employed, I believe, by Velpeau,1 in this complaint, and are now generally used. When the calomel acts on the bowels, it may be omitted, and the opium alone continued; and I have seen as mnch benefit from it alone, as from the calomel. Some years ago, I saw a case, of puer- peral peritonitis, in consultation with a friend, and we administered large doses of opium, (gr. i. every hour,) with the greatest benefit. Since then, several similar cases have occurred to me. My friend, Dr. Stokes, was the first to point out the value of opium, in bad cases of peritonitis, where bleeding was inadmissible ; and I have repeatedly verified his observations. Tartar emetic was recommended by Hulme, and used by several since his time with apparent benefit. The state of the stomach, in many cases, however, will prevent its exhibition.8 Purgatives have been warmly recommended by sqjne writers— (Hulme, Denman, Gordon,3 Hey, Armstrong, Chaussier, Stoll,)and as strongly reprobated by others—(Baglivi, John Clarke, Cederskiol, Thomas, Campbell;) " My own experience," says Dr. Ferguson, " with regard to aperients, is, that whenever they create tormina there is the greatest risk of an attack of metro-peritonitis succeeding. This so constantly r occurs, that I invariably mix some anodyne—usually Dover's powder, or hyosciamus, or hop—with the purgative."* If the bowels be constipated, an enema of turpentine and castor oil will be useful. The spontaneous diarrhoea is not always beneficial, but will often need to be restrained by astringents or opiates. Emetics were employed before 1782, by English practitioners. and in 1782"they were recommended by Doulcet, of Paris, who relied upon them exclusively, and derived from them extraordinary success. Other practitioners have also used them successfully— (Hufeland, Osiandep, Desormeaux ;5) but they have failed so often. as to have gone out of use, especially in these countries, perhaps in consequence of our mistaking the proper cases.8 1 Revue Medicale, Jan. .1827. 2 ti when the tartarum emeticum or vinum anlimoniale are made use of, they are to be given in small doses every two or three hours, till they pass through the intestinal canal."—Hulme on Puerperal Fever, p. 59. 3 "The purging, therefore, is to be early excited, and continued without intermission, till there be a complete termination ofthe disease, which gene- rally happens on the fifth day."— Gordon on Puerperal Fever, p. 49. * On Puerperal Fever, p. 211. 5 "M. Tonnelle states that M. Desormeaux first made trial, of them about the end of 1828, with great advantage. During the following year, they were again employed, but most frequently they entirely failed; but they never appeared to produce any aggravation of the pain or other symptoms. Another trial was made of them after this, and they were again followed by the most Happy results." kt September, 1829, they succeeded; but in Oc- tober and November they failed."—Lee, Diseases of Women, p. 109. 6 " The practical question then, is, what are these cases in which the PUERPERAL PERITONITIS. -213 In 1814, Dr. Brennan of this city proposed the use of turpentine, which he praised as almost a specific. He gave it in doses of a table-spoonful at a time, in a little water, sweetened. Drs. Douglas,1 J. A. Johnson, Dewees, Payne,2 Kinneir, Blundell, and Waller, have found it more or less useful. Dr. Clarke and other practitioners tried it, but without success.3 It is certainly beneficial when the intestines are tympanitic, espe- cially in the form of enema, and as a counter-irritant to the abdo- men ; but I have never seen it exert any remarkable influence upon the disease. At an advanced stage of the disease, blisters are very useful.— They may be applied to any part or the whole of the abdomen, and dressed with mercurial ointment. Recolin, Dance, and Tonnelle, have recommended injections of warm water, into the vagina and uterus, three or four times a day. Drs. Lee and Campbell have tried them in a few cases, with de- cided advantage. 1 have frequently syringed the vagina with warm water, with benefit; but I never threw the injections into the uterus. Hip baths have been found useful by Desormeaux and Collins; but the pain of moving fhe patient is an insurmountable obstacle to their frequent use. Loefflerand Ceeley'of Aylesbury have seen good effects result from the application of cold to the abdomen. The irritation of the stomach may be allayed by effervescing draughts containing a few drops of laudanum, or by a few grains of the subcarbonate of potash, dissolved" in aq. menth. virid. A selection of these remedies will afford a tolerably good chance to the patient, if we are called early ;• but in many insta-uces we shall fail, either in cutting short the disease, or in curing it ultimately.4 remedy is applicable. The clue has been already given, I imagine, by Doul- cet himself; it is, wherr the violence of the malady has fallen on the liver especially ; and when there is early nausea, and spontaneous vomiting."— Ferguson on Puerperal Fever, p. 204. 1 Dublin Hospital Reports, vol. iii- 2 Edin. Med. and Surg. Journal, vol. xviii. p. 538. 3 " In addition to the usual routine of practice, numerous trials were made ofthe rectified oil of turpentine, in dosesr- from six to eight drachms: some- times in plain water; sometimes combined with an equal quantity of castor oil. The first few doses were generally agreeable to the patient; and seem- ed to alleviate the pain. Bv a few repetitions, it became extremely nau- seous; and several patients declared that they would rather die than repeat the dose. In more than twenty trials of this kind, not a single patient re- covered."— Dr. Clarke's Letter to Dr. Armstrong. 4 "When called in the beginning of the disease—that is, within six or eight hours after the attack—I was often able to put an immediate stop to it; even when the pulse was at the rate of 140. But when the patient had been ill twelve or twenty-four hours before I was called, I was not able to bring the disease to an immediate conclusion ; the most I could do in such cases, was to check its violence, and overcome it by degrees ; for I could seldom bring it to a complete termination before the fifth day. But when the patient 214 • churchill's observations. It is ofthe greatest importance, however, that all the means at our command should be tried perseveringly, and that our forebodings should not be allowed to diminish our exertions.' 2. Inflammation of the Uterine Appendages.—Under this head is included inflammation ofthe serous membrane, and proper tissue ofthe ovaries, fallopian tubes, and broad ligaments. It is not always possible to separate these affections from inflam- mation ofthe peritoneal cavity, with which they are so often con- joined ; but there are cases in which they exist alone, or predominate in a striking manner, or where the consequences of the disease con- tinue longer in these parts. Puzos has described such cases by the term, " Depots laiteux dans Vhypogastre," and Levret as " Engorgemens laiteux dans le bassin." The observations of MM. Husson and Dance likewise prove that this is a frequent, and often fatal, termination *of inflammation ofthe peritoneal coat ofthe uterus, and its appendages. M. Tonnelle found 58 cases of inflammation of the ovary, and four of abscess, out of 190 cases of puerperal fever. Symptoms.—As inflammation ofthe uterine appendages is gene- rally combined with more or less inflammation of the-peritonealsac, it consequently presents similar symptoms; but, in addition, we find local distress in the situation of these appendages. The pain is somewhat less acute than in general peritonitis, and is seated in one ofthe iliac fossa, or the lateral par,ts of the hypogas- trium, extending to'the groins, and down the thighs, accompanied with great tenderness on pressure. An examination per vaginam, will often throw light upon the disease; that canal will be found hot.and painful at the upper part, and in some cases a tumour may be discovered through its parietes, laterally. The disease generally commences with rigors, thirst, headache, quick pulse, &c. presenting an array of constitutional symptoms had been ill for a longer space than twenty-four hours before I was sent for I generally found thar the disease was no longer in the power of art "—Gor- don's Essay on Puerperal Fever, p. S. • "I cannot too strongly urge the necessity of continuing to employ the remedies whilst the slightest hope of recovery is entertained. I have" seen several patients restored to health, where the pulse had risen to 160 and was so feeble as scarcely to be felt at the wrist, when there was constant delirium, and the most alarming prostration of strength. Recovery has even taken place in some cases which I have observed, where the abdomen has become tympanitic, and effusion to a considerable extent taken place into the abdominal cavity. In no acute disease is it of greater consequence than in this now under consideration, that the patient should be visited by the medical attendant at short intervals; and that the effects of the remedies he pre- scribes should be narrowly watched."-/>e, Dis. of Females p 112 INFLAMMATION OF UTERINE APPENDAGES. 215 very similar to those in peritonitis, which, therefore, I need not repeat. If the disease be extensive, there is generally observed much ex- haustion following the first stage, and the attack may prove quickly fatal. Should the disease not prove fatal, the attack may terminate-- 1. In resolution, without the organs being seriously injured; or in some cases, adhesions may be formed between contiguous portions ofthe serous membrane, which, though for the present innocuous, may be injurious subsequently. Boivin and Duges relate a case, in which anteversion was caused by these adhesions. If the fallopian tubes have been involved, the cavity of one or both may be obliterated, or they may become adherent to some neighbouring part, so as to prevent altogether their ordinary func- tions. 2. In suppuration. Matter may form in either ovary or broad ligament, and may escape into the peritoneal sac—through the parietes of the vagina—or through the abdominal parietes, near Poupart's ligament.1 (Boivin and Duges.) A case of the latter kind occurred at the Meath Hospital, last winter; and several have recently been published by Mr. Thomson.13 Morbid Anatomy. In some cases we find, on dissection, that the disease-has been confined to thpserous membrane, presentingsirhilaj phenomena to those already noticed—thickening, effusion of lymph. or serum, mixed" with blood and lochia.2 1 " Its substance is soft and flabby, and its contractile powers so tho- roughly suspended as to present no diminution of its volume. It is as large, len days after delivery, as it was immediately after the expulsion ofthe pla- centa. Small abscesses are found occupying various depths of the uterine walls. There are patches of thoroughly dissolved uterine matter, the soft- ening almost always commencing in the inner surface of the viscus, and sinking towards its peritoneal coat."—Ferguson on Puerperal Fever, p. 37. See also M. Nonat's Essay, in Revue Med. Franc, et Etrang. 1837. "M. Tonnelle also states that the disorder in Paris assumed two different forms—the softening of the uterus, properly so called, and the putrescence. In One form, the softening affected only the internal membrane of the uterus, and it presented itself under the appearance of irregular superficial patches, of a red or brown colour, which occupied afmost all the points of this sur- face ; its limits were not determined, the diseased tissue passing by^irregular gradations, or shades, into the healthy f-issue. In the second species, the softening extended deep into the substance of the uterus. The tissue of this organ was so softened that the fingers could riot seize it without passing through it in all parts. The superficial softening was combined almost always with some alteration of structure—peritonitis, metritis, or uterine phlebitis; and it did not appear to M. Tonnelle that the existence of these had a very sensible influence on the progress of the symptoms. The soften- ing in the second degree was also sometimes combined with other disorders ; but it formed usually the principal alteration, often the only one, and inva- riably impressed upon the disease the most decided typhoid character."— Lee, Diseases of Women, p. 38. "In other circumstances, where death has followed at a later period, tbe cervix uteri has presented the same blackish colour, with softening, so as to be easily scraped off with the scalpel, under th)e form of grayish fetid pap. We have seen a case in which, three months- after a difficult labour, the uterus was softish .and pale, containing in its interior a fleshy portion, as broad as the finger-nail, and two lines in thickness—a real eschar, detached from an ulceration, with a whitish base, and very nearly of the same size. M. Dupley has given a good account of these circumscribed mortifications —these eschars—which he compares with those made by the caustic potassa. He has observed them frequently in the cervix uteri, and about the superior angles -of the body of the uterus."—Boivin and Duges, Diseases of the' Uterus, p.. 325. 2 " But if this fetor be coincident with a black or blackish colour, arising from the matters which line the uterus; if these matters adhere firmly to the surface, or form a thick layer; if they penetrate the uterine tissue to the depth of several lines ; if this tissue, blackened and softened, admits of being torn by the nail, and reduced to pulp by scraping—we may safely conclude that there is a gangrenous state, and infer the previous existence ofthe disease, called by Biier putrescentia uteri, which formed the subject of a Thesis presented by M. Lnroih, in 1827, to the Faculte of Strasburgh; puerperal hysteritis. 221 The cause of this peculiar softening,has been much debated— some attributing it to a specific action of the parts, or to alteration ofthe blood—and others to inflammation ; with the latter of whom I am disposed to agree. Diagnosis.—When complicated with peritonitis, the diagnosis is very difficult ;* but when the uterus is alone affected, it is easier to distinguish it. 1. From after-pains, weed, Sfc. it differs very widely, in its per- sistence, and in the gravity of the accompanying constitutional symptoms. 2. From puerperal peritonitis. The most marked distinction between them, is the tenderness on pressure i which, when the pe- ritoneal sac is inflamed, is general and superficial, rendering the slightest pressure intolerable ; whereas, in hysteritis, the abdomen will bear pressure very well xall over, until we ourselves feel that we are pressing the enlarged and hardened uterus. The only ex- ceptions to this rule, I have met with, are those cases of peritonitis where there is no abdominal tenderness. The pulse in hysteritis is weaker, and the patient sinks more rapidly than in peritonitis ; the lochia are also more frequently disordered. Prognosis.—In the severe form, the prognosis is in almost every case unfavourable; but of the milder cases, I have seen many recover. Treatment.—In the mild variety, venesection will be necessary, followed by leeches, poultices, and fomentations. The benefit of calomel and opium is seen here, eVen more strikingly than in peri- tonitis ; most patients recover who are brought fairly under their influence. If the calomel disturb the bowels, it should be omitted, and the opium given alone.2 and which M. Danyau named gangrenous metritis, in the dissertation ad- dressed by him, in 1829, to the Faculte de Pari,s."—Boivin and Duges on Diseases of the Uterus, p.#323. " The inner surface of the uterus is often smeared with a thick layer of gelatinous blood,"underneath which, patches of reticulated lymph, tinged greenish, brown, or modena colour, are found. Cruveilhier, Duges, Seiler, have all looked on this layer as a false membrane, and not the remains of the deeidua. I have examined the uterus, to verify this opinion, and I am, on the whole, satisfied of its correctness."—Ferguson on Puerperal Fever, p. 38. ' " The diagnosis of this variety of uterine inflammation, particularly when it is complicated with peritonitis, or phlebitis, which is frequently the case, is extremely difficult. The prostration of strength, and the alteration of the features', whjch often exist from the commencement, the frequency and rapidity of the puls'e, the irregular, fetid state of the lodhia, are not such constant symptoms as to be considered pathognomonic ; and they may arise from other causes. The most attehtiye consideration of the phenomena will only lead to a probabiliiy'as to the nature Of the affection, and some- times its existence cannot be determined^ during life."—Lee on Puerperal Fever, p. 40. ' . , . , "* 2 "The opium may be increased, both in quantity (above half a grain J and the frequency of repetition, so as to'quiet the pain, which alone will aggravate the disease."— Dr. John Clarke's Essays, p. 70. 222 Churchill's observations. When the acute stage has passed, I have seen great benefit from a succession of blisters over the region of the uterus. The bowels should be kept free; but active purging is injuri- ous.' Enemata, of castor oil and turpentine, answer the purpose very well. None of our remedies seem to have much power over the severe form ; but antiphlogistics must be tried in the early stage : subse- quently, opium, and tonics, or stimulants, with counter-irritation, are our only resources. 4. Inflammation of the Veins of the Uterus. Uterine Phlebitis.—This form of disease has been frequently noticed by authors; amongst others, by Dr. J. Clarke, Mr. Waller, Meckel,3 Ribes, Louis, Dance, Tonnelle, John Clarke, Burns, Lee, Boivin, and Duges, Ferguson, &c. ;. and recently in a series of papers on " Metro-peritonite," by M. Nonat.3 Nor is it very rare ; for M. Tonnelle found pus in the veins in ninety-three cases ; and in the thoracic duct in three cases out of 134; and Dr. Robert Lee, in forty-five cases, had twenty-four of uterine phlebitis. Causes.—Dr. Robert Lee considers that it may be the result of mechanical injury to the uterus, either during the labour, or by the force used to extract the placenta.4 1 "Neither can I recommend a course of purging, as serviceable irT the inflammation of the uterus, which follows delivery."—Dr. John Clarke's Essays, p. 68. 8 " All the veins," Meckel observes,*" which surround the bterus, the hypogastric trunks, and the vena cava inferior, were greatly enlarged in volume. The place where the placenta liad adhered, was distinguished at the posterior part of the uterus by afungous mass. The veins, whose ex- terior appearance had arrested the attention, were examined with care ; they were separated from the surrounding cellular substance, and in this state the whole system 6f uterine and spermatic veins presented an extra- ordinary augmentation of the calibre of the ves«els, and thickness of their coats. When opened, there escaped from them a true purulent fluid. The vena cava, where the right renal vein entered, presented a resisting tume- faction, and when laid open, its coats were double the natural thickness, and the cavity was filled with pus, and a polypus formed of pseudo-mem- branous and puriform concretions."—De vasorum sanguiferorum inflam- matione. Auctore, J. G. Sasse. Halle, YV$1. Lee, p. 58. * Revue Med. Franc, et Etrang. for 1837. * " Uterine phlebitis appears to result from the mechanical injury inflicted upon the uterus by protracted labour, from tbe force required for the extrac- tion of the placenta fn uferine' hemorrhage, from retained portions of the placenta undergoing decomposition in the uterus; the application of cold, and perhaps of contagion ; qr from any of the causes which produce the other varieties of uterine inflammation. M. Dance considers deranged states ofthe lochia to.be a frequent cause of the disease; but these are con- sequences, and not causes, of-uterine phlebitis."—Lee, p. 54. uterine phlebitis. 223 It may follow after hemorrhage, or arise from cold, or the de- composition of retained portions of the placenta. It may be excited -by any of the causes of the other varieties of puerperal fever.1 Symptoms.—In women of previous good health, the attack com- mences generally in twenty-four or thirty-six hours after delivery. The patient complains of pain in the uterus, more or less acute, preceded, accompanied, or followed by rigors. The uterus is tender.on pressure, and the lochia and milk are both suppressed. There is headache, and slight incoherence—a sense of general uneasiness, and sometimes nausea and- vomiting, with acceleration of the pulse. After a time, these symptoms are succceeded by increased heat of surface, tremors ofthe muscles of the face and extremities, great thirst, dry browri tongue, frequent vomiting of green fluid, rapid full pulse, hurried respiration, &c. The head becomes more involved, and we find the patient in a state of drowsy insensibility, or violent delirium and agitation, followed by extreme exhaustion. The surface of the body assumes a deep sallow, or yellow colour; and occasionally petechial or, vesicular eruptions have been ob- served on different parts of the body. The pain, may or may not increase, but the uterine tenderness is certainly augmented, and the abdomen is often swollen and tym- panitic. In some very rare cases, there is little or no local distress, and the existence of the disease could not be discovered except for the secondary affections. Such is the case with a patient under my care at this moment. She had no uterine pain or disturbance—no 1 "As to the causes under which uterine phlebitis was developed, we found it occurring most frequently— 1. In women who approached the critical age of life, especially if they were primiparous. 2. In women affected* with varicose tumours ofthe thigh and external genital organs. 3. In females who, during pregnancy,-were submitted to the influence of depressing passions—fear of exposure, jealousy, sorrow, » Compte Rendu de la Maternite de Bourg, 1827. For full details upon this subject, I may refer the reader to the following 230 churchill's o6servations. Making a total of 65 cases in 42,768 patients—or about 1 in 657. Dr. Burns says that it occurs about once in 940 cases. It rarely occurs with first children. Of Dr. Jos. Clarke's cases—one was the second pregnancy; one was the third; two, the fourth; one, the seventh; one, the eighth, and one, the ninth. Of Dr. M'Keever's cases—four had two children ; five had three; four had six ; two had seven ', two had eight, and one had nine. Of Dr. Ramsbotham's cases1—two were second pregnancies; one was the fourth, and three were the seventh. Of Dr. Collins's thirty-four cases—seven were first pregnancies; six were second; six, third; two, fourth; two, fifth; five, sixth; one was the eighth pregnancy; one, the ninth ; two were tenth pregnancies, and two were eleventh. Di\ Cathrall's case was a first pregnancy.2 Dr. Sims's patient had had several children.3 Dr. Hooper's case was the fourth pregnancy.4 Mr. Kite's case was the second pregnancy.5 Dr. Frizell's case was the seventh pregnancy.6 Mr. Powell's cases was the first pregnancy.7 Mr. Birch's cases were the third and fourth pregnancies.8 Mr. Partridge's case was the seventh pregnancy.9 Thus, of seventy-five cases, nine occurred in the first pregnancy; works, among others.—Denman's Introduction to Midwifery, p. 260. London Pract. of Midwifery, p. 279. Hamilton's Outlines of Midwifery, p. 76. Burns's Principles of Midwifery. Dewees's_ Compendium of Midwifery. Garthshore on Rupture of the Uterus. Douglas on Rupture of the Uterus. Goldson's Case of Lacerated Vagina. M'Keever on Ruptuie of the Uterus, Merriman on Difficult Parturition, p. 111. Jos. Clarke's Report of the Ly- ing-in Hospital, Dublin ; Transactions of-Association, vol. i. Ramsbotham's Pract. Obs. in Midwifery, parr i. p. 377. Collins, Practical Treatise on Miawjfery, p. 240. Hamilton's Pract. Obs. part 2, p. 343. Baudelocque, L'Art des Accouchemens, vol. ii. p. 488. Capuron, Cours d'Accouchemens, p. 579. Velpeau, Traite d'Accoucb., p. 348; Brussels ed, Nauche, Mal. des Femmes, part i. p. 262. Deparcque, Histoire complete des Ruptures et des dechnures de TUterus, &c. 1836. Spiering, die Pratische Geburtshulfe, p. 330, 1801. Hussian, Handbuch der Geburtshulfe, 1827. Osiander, Hand- buch der Eutbindungskunst, vol. ii. p. 71. Carus, Gynaecologie, vol. ii. p. 416. Joerg, Handbuch der Geburtshulfe, p. 236. Busch, Lehrbuch der Ge- burskiinde, p. 386. Siebold, Frauenzimmerkrankheiten, vol. ii : Journal vol. xv. p. 249. - • - ' 1 "I have never met with a rupture ofthe uterus in a first lyin^-in. The accident has happened, in those cases which I have seen, in a subsequent labour j and sometimes after several difficult births, though living children have been expelled."—Ramsbotham, Pract. Obs.3 vol. i. p. 383. * Med. Facts and Observations, vol. vin. p. 146. 8 Ibid. p. 150. * - 4 Mem. of Med. Society, vol. ii. p. 118. 5 Ibid. vol. iv. p. 253. 8 Trarrs. of Association, vol. it. p.-15. 7 Med. Chir. Trans, vol. xii. p. 537. • 1 Ibid. vol. xiii. p. 357. q Ibid. vol. xix. p. 72." RUPTURE OP THE UTERUS. 231 fourteen in the second; thirteen in the third, and thirty-seven in the fourth, or subsequent pregnancies. Causes.—Various causes may give rise to it, and it may happen at different periods— 1. During gestation. That form of extra-uterine pregnancy which is called interstitial fcetation, may give rise to it. The ovum, instead of passing direct fcom the fallopian tube into the uterine cavity, is retained in. an interstice of the uterine fibres, where it grows, up to a certain point. As it increases, the outer portion ofthe uterine parietes becomes gradually thinner by absorp- tion, (as in the case of abscess,) and at length gives way, and the fetus is precipitated 'into the abdomen, converting the case into one of ventral fetation. (Bush,1 Dance, Mondiere*) It may also be the consequence of disease, as in Mr. Else's2 and Dr. Spark's3 cases; from softening, and from abscess in the walls, as related by Duparcque.4 Any violent accident—snch as a fall or a blow—may give rise to it.5 It sometimes occurs without any assignable cause; the patient, perhaps, is awakened from sleep by it.6 1 Lehrbuch der Gebuitskiinde, p. 387.. * Med. Gazette, vol. ii. p. 400. 3 Ibid. vol. iii. p. 218. A similar case was recorded by Dr. Rainey, of this city, in 1766> * Ruptures de 1'Uterus, pp. I5j 16. 6 " Sometimes, the uterus seems -to be predisposed to this accident, by a fall or bruise. Rei'dliuus relates one instance of this. Behling, Steidele, and Perfect furnish us each with another. Salmuthus considers a thinness of the uterus as a predisposing «»use-of rupture ; and Dr. R-ess relates a case where it seemed to have this effect, the womb not being above ihe eighth part of an inch thick, and tearing-like paper."-*Burns\<* Midwifery, p. 529. " The uterus may be ruptured by violent accidents happening to the mother in the advanced state of pregnancy."— Denman's Introduction to Midwifery, p. 260. 6 "In the Medical Repository, vol", vji. Mr. Hot, of Bromley, relates a case of rupture of the uterus in the sixth morrth of pregnancy. The patient waja awakened from her sleep by a sudden pain about the umbilicus. She had no return of pain, but gradually sank and died. On examination after death, a rupture was found at the fundus uteri, through which the faztus, envelop- ed in its membranes, had escaped into the abdomen."—Merriman's Synop- sis, p. 112. The following case, which occurred to Mr. Glen, of Brompfon, is related by Dr. Merriman, in tha Appendix to his Synopsis, (p. 268:)—" The lady was pregnant of her sixth child, and wanted six weeks to the completion of the full period of utero-gestatioji; her health was generally good, her habit was rather plethoric; but she was active and temperate. In rjer for- mer parturitions, she was particularly fortunate in the speedy recovery of her health and strength. This lady was,attacked while.sitting with her husband in the parlour, and was in'the act of stoopfng, when she suddenly exclaim- ed: ' My dear, something has given way in my stomach; did you not hear it break?' He endeavoured, .to per§uad_e Jier it arose from flatulence. Mr. Glen was sent for, but there.did not appear to be any occasion for alarm, and after prescribing some slight medicine, he left her. " In an hour from this time," he continues, "I was sent for in all haste, and was, indeed, shocked 232 Churchill's observations. It has been attributed to irregular action of the uterine fibres. (Burns.) 2. During labour.—a. If the uterus have been attacked by in- flammation during pregnancy; its tissue may have been so much weakened or disorganised, that the violent contractions which take place during labour may rupture it, from the want of consentaneous action in the part affected,1 or from the pressure of some part of the child against it. Steidele2 relates a case where rupture occurred in consequence of gangrene. My friend, Dr. Murphy, has published an excellent paper, illus- trative of this cause of tupture, with cases where the uterus was atrophied, thinned, or softened in texture.3 Duparcque quotes cases of thinning of the uterine walls, soften- ing, scirrhus, and gangrene.4 In some cases, the seat ofthe laceration corresponds exactly with the situation of the previous pain. beyond expression, at the great change in the state of my patient. She was now in bed, extremely restle&s, her countenance pale, and depicting great anxiety and intensity of suffering—pulse extremely rapid, and evidently sinking; slight nausea; great pain referred to the hypogastric region; con- stant tenesmus, and a slight discharge of grumous blood from the vagina." The patient died immediately after the extraction of a dead foetus. A post mortem examination was made the next day. "On laying open the abdo- men, we found the uterus still there, uncontracted, and presenting nothing unusual in appearance; but on raising the body, and turning it forwards, a rupture was discovered, extending frorA fundus to cervix, through which an immense mass of coagulated blood had passed into the abdomen. We could discover no disease in its textnre, and could perceive nothing by which to account for such a deplorable accident, except a very slight extenuation of substance of that part of the uterus which rests upon the bodies of several ofthe vertebras, but which latter did not appear to-project further than usual." A case somewhat similar is related in the Gazette Medicate for February, 1837. The woman was in the sixth month of pregnancy when she was attacked with uterine hemonhage. Slight labour pains came on, which pro- duced but little effect upon the position of the child ; and during the night, all the syrriptoms of rupture of the womb came on, and she died the next day. There was nothing discovered at the autopsy to account for the acci- dent. 1 "Or if the uterus, which had acquired its proper thickness, became af- fected with inflammation, or any other disease, weakening its power, and speedy in its progress, the texture of the part so affected might be destroyed, and the uterus ruptured, by its own action at the time of labour."—Denman's Introd. to Midwifery, p. 260. 2 Diss, de Ruptu in partus doloribus"iUtero. * Dublin Journal, vol. vii. p. 198, ejseq. I shall extract one or two of his inferences:— k: 1. That a perfectly healthy uterus is very rarely ruptured, except from external injury. "2. That in most of the instances where it occurs, it may be traced to morbid lesion, either previously existing, or produced by'inflammation ; and even in some cases, where this cannot satisfactorily be proved from inspec- tion, the history ofthe case would seem to indicate it." 4 Duparcque, Ruptures de l'Uterus, p. 131, et seq.' RUPTURE of the uterus. 233 The period of labour at which the rupture may occur from this cause, will vary; it may be at the beginning—before the rupture of the membranes, (Duparcque)—during the passage of the head through the pelvis—or after the delivery.1 b. A certain amount of narrowing of the upper outlet may give rise to it. This is a purely mechanical cause. The head of the child is forced downwards by violent labour pains, but is unable to enter the pelvis, from the contraction ofthe upper strait; now if the pains continue with great power, the head is turned to one side or the other, or posteriorly, and the only obstacle here being the uterine or vaginal parietes, the head is driven through them at the weakest part. They offer the less resistance, probably, from the woman having generally borne several children. In one of Dr. Clarke's cases, the antero-posterior diameter ofthe upper outlet measured but three inches; in two others three and a half. In case 18 of Dr. Douglas, the pelvis measured but two inches antero-posteriorly ; and in another case (20) there was a bony ridge on Ihe top ofthe symphysis fubis, to which the rent corresponded'. In one of Dr. Ramsbotham's cases, the antero-posterior diameter was only two inches; in another three inches; and a third had always had difficult labours previously. In one of Dr. CollinsVcases, the same diameter measured two and a half inches; and in several it appeared narrower than usual. The sex of the child will contribute to the increase of this dis- proportion—male children having the larger heads. (Clarke.) Now, of the twenty cases mentioned by Dr. M'Keever, fifteen children were males, and five females; and of Dr. Collms's thirty-four cases, twenty-three were males. The age of the patient does not appear to have any marked in- fluence. Dr. Collins found one patient of the age of 16 years; one of 21; one of 24; three of 25; two of 26; one of 27; three of 28; one of 29; seven of 30-; two of 32; one of 33; one of 34; three of 35; five of 36 ; one of 37, and one of 40 years pf age. c. The oblique position of the uterus has been assigned as a cause, from its directing the force of the child's head against the side ofthe cervix uteri and vagina.2 d. Some one of the tissues of"the uterus may give way previous 1 " Laceration may take place during any stage of labour, and even before the membranes have burst; but this is uncommon. It may take.place when the head has fully extended the pelvis; or in the moment when the child is delivered."—Burns's Midwifery, p. 528. 2 " Sometimes the laceration appears to haVe been produced from the un- toward situation of the uterus in the pelvis; hence ulceration has taken place, and the foetus has been transferred into the cavity of the pelvis; and finally discharged through the vagina in return, in a dissolved and putrid state."—Merriman's Synopsis, p. 112.. See also Bartholinus de insolitis human! partus viis. Garthshore on Rup- tures of the Uterus, &c. Duparcque, Ruptures de l'Uterus, p. 24. 234 churchill's observations. to or during labour; perhaps from previous disease; perhaps from some peculiarity of structure; and in some cases, without any ap- preciable cause. Dr. Clarke' published a case, in which the peritoneal covering of the uterus alone was torn ; and similar cases have been since recorded by Mr. Partridge,2 Mr. White,3 Dr. Ramsbotham,4 Mr. 1 Trans, of Assoc, for the Improvement of Medical and Surgical Know- ledge, vol. iii. 1 "Mrs. Barr, the mother of six children, was seized about 11, a.m. on Sunday, Aug. 25, 1833, (being then in the beginning of the eighth month of utero-gestation) with abdominal pain, and vomiting of bilious matter. After the lapse of two hours, a watery discharge, mingled with coagulated blood, took place from the vagina. I saw her at 3, p.m., when she appeared pale, faint, and sunk in countenance, like a person suffering from extreme hemorrhage, though the quantity of blood she had lost was inconsiderable." " The sickness continuing, about five O'clock one of her attendants gave her some brandy, which allayed it; but shortly after, labour pains commenced —and about seven, I was sent for in haste: and, on my arrival, found the patient just delivered of twins—each child enveloped in its proper mem- branes, with the placenta attached. The contents of the uterus were ex- pelled by a single violent contraction, which left her much exhausted." "The pain continued very severe, and I gave her another dose of opium, but without any alleviation ofthe pain, which increased in intensity till she expired at a quarter before nine." Post mortem examination.' On opening the abdomen, a quantity Of thin dark-coloured blood was found, which amounted to about forty ounces. There were no coagula. The uterus was well contracted: and on its ante- rior part, natural, excepting an enchy-mose appearance of the cellular texture around the tubes and ovaries; but on the posterior surface, a considerable number of transverse lacerations were discovered, all more or less curved in form, with the convex part towards the fundus, averaging from half an inch to two inches in length, and varying iu depth ; some were mere fissures, as though made.by a penknife. One was particularly large, measuring three inches in length, and nearly two in breadth, in its centre. A flap of perito- neum had fallen down, and the raw and fibrous structure from which it had been torn was exposed as completely as it could have been done by the most careful dissection."—Mr. Partridge's Case, Med. Chir. Trans., vol ix. p. 72. ' 3 "Mrs. W------:, oet. 32, well formed, married fifteen years, the mother of eight living children, .bad nearly gone to tbe vfull period of utero-gestation of her ninth child, when, on the 10th December, 1824, she met with some fright that caused her to turn round quickly; she was at the same moment seized with pain in the lower part ofthe back, which extended round to the abdomen, attended with, a sense of faintness, and great palpitation of the heart. She recovered soon from th» immediate effects of the shock; and being of a very cheerful disposition, and of a very active turn of mind, no further apprehensions-were entertained, either by herself or those about her although it was observed that she looked paler, and appealed more languid' than usual. However, she attended to her domestic affairs, until the morn- ing of the 18th, when, going up stairs, she was attacked With darting pains in the lowec.abdommal region, attended with a peculiar sensation which she could not well describe; she became agitated, pale, and ghastly. A lgte eminent accoucheur was immediately sent for/who found her labouring under great difficulty of breathing, threatening suffocation, pain of her heart pulse quick and fluttering; there was no appearance or symptom of her labour coming on; and seeing her situation becoming more alarming Dr. RUPTURE OP THE UTERUS. 235 Chatto,1 and Dr. Davis.3 Dr. Collins has also met with a case of this kind. Mr. Radford published two cases in which the muscular coat was torn—the serous membrane remaining uninjured.3 Dr. Ramsbo- tham met with a case nearly similar; and Dr. Collins met with nine such cases.4 Duparcque relates two, and Velpeau one. Though the extent of mischief is less in these cases, yet they are equally fatal. e. Violence in turning the child may give rise to it,5 and it may accompany this operation, in certain states of the cervix, without any fault ofthe operator. /. Rigidity ofthe os uteri, or imperforation, may occasion lacera- tion.6 (Perfect.) g. There are several cases on record where.'the os uteri has been torn completely off during labour. Steidele7 aud Mr. Scott, of Nor- wich,8 have each recorded one, and three others occurred in this Cheyne was called in consultation. About nine, p.m., Mrs. W------was seized with labour, and after a few feeble uterine pains, she was delivered of a full-grown still-born male child*, but in less than three quarters of an hour, she gradually sunk and expired." Post mortem examination. " Abdominal cavity.—On opening the abdo- men, a large quantity of fluid blood wa« found in the vicinity of ihe uterus, the broad ligaments of which were injected with blood; the uterus had not contracted ; the right ovarium was much enlarged, and contained two hyda- tids of considerable size ; on the anterior surface of the uterus were two long tears or lacerations* and one of a smaller size,'through the peritoneal coat, and also through a few superficial fibres ofthe uterus,-from which the blood had issued. All tbe other parts, both of the pelvis^and abdomi-nal cavity, were perfectly sound; and on opening the" cavity-of the vagina and uterus, nothing was observed but what is usual after parturition."—Mr. White's Case, Dublin Journal, vol. v. p. 325, (1834.) 4 Pract. Observations, vol. i. p.'409. 1 Mr. Chatto has related a similar case. "The rupture occurred after the commencement of labour at the full-time, and was attended with the usual symptoms. The patient died six hours after delivery. Upon examining the body, a large quantity of blood was found effused in to., the abdomen. The posterior surface of the uterus, near the fundus, was found ruptured to a considerable extent; "and near this laceration, were, found three or four ^smaller cracks. These lacerations extended but a very short distance into the muscularstiucture. The inner membrane was found entire."—London Med. Gazette, 1832, p. 630. 2 Obstetric Medicine,-vol. ii. p.-1067. 3 London Med. and Surg. Journal, vol. ii. * Pract. Treatise on Midwifery, p. 306. 6 " If ihe uterus be strongly contracted, it may be ruptured also by attempts to pass the hand, for the purpose of turning the child; but in this case, a rupture could only happen when the force with-which the hand was intro- duced, was combined with the proper action ofthe uterus; for the strongest person has not the power to force his hand through a healthy and unacting uterus."—Denman's Introduction, p. 260. Also, Duparcque, Ruptures de l'Uterus, p. 187. 6 Carus, vol. ii. p. 439. Hamilton's Cases, p. 138. T Wasserberg's Diss. F. 1. Com. Lip. xxi. p. 518. 8 "The patient had been in labour about thirty-nine hours, with rigid os 236 churchill's observations. city, within a short time of each other.' It appears to be the result of pressure at the brim ofthe pelvis, rendering the texture of the cervix soit, and easily torn. 3. At an advanced period of life. The structure of the cervix uteri is much changed in old age; it becomes close and dense, re- sembling cartilage, and the canal through it is always reduced in size, and sometimes obliterated. When the outlet for the escape of the uterine mucus is thus closed, it accumulates; and if the quan- tity be sufficient to distend the cavity, a process of thinning or absorption commences in some part of the walls of the uterus, and proceeds until an opening is made into the peritoneal sac. The same process will take place with any other fluid thus de- prived of exit. Duparcque q,uotes two cases ofthe kind.2 Among the direct causes, are enumerated blows, falls, anger, con- vulsions, excessive movements ofthe child, over-distention, &c. uteri, when she felt something snap, or, to use her own words, ' that the web of her body had given way.' The pains ceased suddenly, a discharge of blood followed, with fainting, cold sweats, feeble pulse, and vomiting of a brownish fluid. Among the coagula, Mr. Scott discovered a substance which was pronounced by competent judges, ' to be a portion of the uterus contain- ing the os uteri, and an irregular part of the cervix surrounding it.'" " By great care and attention, the patient recovered ; and upon examination, per vaginam, three weeks after delivery, Mr. Scott found a continuous cavity, without any distinction, between vagina and uterus."—Med. Chir. Trans., vol. xi. (1821.) 1 At a meeting of the Dublin Obstetrical Society, April 4th, 1839, Dr. E. Kennedy exhibited two os uteri which had been torn off during labour, and stated the-following particulars: "Catharine Kelly was delivered in the hospital of her sixth child, on the 7th of March, 1839, after a labour of seven hours; ten hours after delivery, attention was directed to a fleshy substance, protruding from the vulva, which made its appearance after the expulsion of the placenta. It was found connected with the os uteri anteriorly, and to the right side, and was evidently two thirds of the labia of the os. The remain- der he separated by torsion, and the whole was found completely to corres- pond to the neck of the uterus. No hemorrhage or constitutional symptoms followed. The other case (that of Curtis, pregnant for the first time) was one of tedious labour, arising from a congested and undilatable state ofthe os uteri, with a pelvis of rather under-sized dimensions. On the 1st of April,at 10, a.m., os dilated to size of half a crown, and beginning to be ccdematous, pains frequent, waters discharged; tartar emetic was given with liule effect. On the 2d, at 10, a.m., os two thirds dilated, very much con- gested, of a deep purple colour, pains not frequent, anterior lip scarified. At 9, p.m., os somewhat more dilated posteriorly; head had descended a little. An attempt was made to support with the finger? the anterior lip during the pains; the posterior part spontaneously separated and appeared without the vulva. The remainder Dr. Kennedy removed. She had a tedious convales- cence."— Dublin Journal, vol. xvi. p. 154. A similar case occurred in the practice of Mr. Hugh Carmichael, of this city,and is related by his colleague, Mr. Power. "The os uteri was undilat- able ; and after many hours labour, it was determined to perforate the head ; but just then, a violent pain occurred, which tore off a circle of the cervix' and expelled the head."—Dublin Journal, vol. xvi. p. 54. * Ruptures de l'Uterus, pp. 13, 14. RUPTURE OF THE UTERUS. 237 In one case, M. Malgaigne attributed it to the mal-administration of ergot of rye. Morbid Anatomy.—If the laceration be the result of disease, it may take place at any part ofthe organ—the body, fundus, or cer- vix; and it will generally be found to correspond to the situation of the pain felt by the patient previously. The edges of the rent ex- hibit marks of disease, the tissue is thinned, softened, and pulpy, breaking down easily under the finger. The colour may be changed to a deep red, or brown colour, and occasionally the.odour is offensive. When the laceration is the result of mechanical causes, it gene- rally takes place near the cervix, and involves both the uterus and vagina.1 It may run along the anterior or posterior surface of the uterus, or at one side. In six of Dr. Jos. Clarke's cases, it was on the anterior surface, and in one, posteriorly. In Dr. Sims's and Hooper's cases, it was anteriorly; in Mr. Birch's posteriorly; and in Mr. Cathrall's case, on the right side. In three of Dr. Ramsbo- tham's cases, it was posteriorly; in one along the right side ; and in another along the left. Of twenty-three cases, Dr. Collins found one on the right, and one on the left side—eleven posteriorly, and ten anteriorly. The direction ofthe rent may be nearly perpendicular, or inclin- ing to one or other side, or running transversely. (Douglass, M'Kee- ver, Collins.) In these'cases, the structure ofthe uterus is scarcely altered; its texture is firm, and its colour natural, except where blood is ecchymosed. The edges ofthe rent are jagged and uneven. Occasionally, but very rarely, the bladder has also been torn. (Douglass, Davis, Duparcque, Soussa, Ferras,* Lecieux.3) When the serous membrane alone is injured, we find numerous small incisions, resembling scarifications, (Clarke, Chatto,) from a quarter to half an inch in length, and one or two lines in depth, or a smaller number of larger lacerations. (Partridge, White.) They are almost always curved, with the convex part towards 1 " The part of the uterus which generally gives way, whether posterior, which is most common, or anterior, or lateral, is usually near the union of the cervix with the vagina, in which such a change is made at the time of labour, when the os uteri is completely dilated, that the distinction between them is lost, the vagina and uterus forming together one cavity, though of unequal dimensions."—Denman's Introduction, p. 260. "Any part of the uterus may be torn; but generally the rupture takes place in the cervix, and the wound is transverse. It is more frequently in the posterior than the anterior part; but either may be torn. It is rare that it is confined to that side. Perpendicular rents are not common; and when they do occur, the hemorrhage is generally not so great as in the transverse." —Burns's Midwifery, p. 527. * Archives Gen. de Med. vol. xviii. p. 109. * Laennec-Piquet, These, 1822, Paris.—Velpeau. 238 churchill's observations. the fundus, and may be situated on the anterior (White) or poste- rior wa|l of the organ, (Clarke, Chatto.) In all the cases hitherto mentioned, more or less blood is found effused in the peritoneal sac, and in many, the usual products of peritonitis. When the muscular structure alone is injured, it may present either a simple solution of continuity, or evidences of disease. Blood may be found in the cavity of the uterus,'and the serous membrane may become inflamed, with the usual results. The cervix uteri, when separated, has generally a bruised ap- pearance; is swollen, and of a red colour. The edges are ragged and uneven. The canal of. the vaginalis rendered continuous with that of the uterus, but the connection between them is not compro- mised. When the uterus of an old person is ruptured, from the cause assigned, we shall discover a perforation in some part of it, with a considerable thinning ofthe walls around it. In all these cases—with the exception of those in which the os uteri is torn off, or the muscular structute alone injured, we find marks of extensive peritonitis, unless the patient die of the shock. Symptoms.—These vary very slightly, whether the uterus be torn completely through, or whether the peritoneal or muscular tissues alone be injured.' Certain authors have pointed out what they deem premonitory symptoms; but these are exceedingly ambiguous. The circum- stances which may justly excite our fears are—the occurrence of partial hysteritis during gestation; and during labour, the coinci- dence of violent labour pains with a narrow pelvis. Rupture ofthe uterus and vagina is marked by a sudden, acute, and intolerable pain like a cramp; a sense of some part bursting, giving way, or tearing, with an audible noise, according to the tes- timony of the patient; the suspension of the labour pains; hemor- rhage from the vagina; and a rapidly succeeding state of collapse.2 ' " A rupture of the peritoneal coat of the uterus somatimes happens. without extending itself into the uterine structure. Under this occurrence, we observe all the symptoms of actual rupture ofthe uterine structure itself' in a diminished degree, except those connected with the escape of the child." —Ramsbotham's Pract. Obs., vol. i. p. 382. 2" The rupture of the uterus is accompanied with a sense of something giving way internally, always perceptible by the patient, and sometimes audible by the attendants."—Denman's Introduction, p. 261. " Certain symptoms take place, which are evidences of its having happen- ed ; one is a sensation of a sudden and most excruciating pain, which always comes on at the moment of rupture." " This state of pain is succeeded by famtness, from two causes, hemorrhage and pain."—London Pract. of Mid- wifery, p. 280. ' " The rupture is said sometimes to be accompanied by a noise which has been distinguished by the by-standers; a discharge of blood of greater or less extent is found to take place Trom the vagina—her face becomes cold and pale—her respirations hurried—she is sick at stomach, and most fre- quently vomits—the matter discharged is sometimes the common contents of RUPTURE OP THE UTERUS. 239 Of these symptoms, the excruciating pain and the collapse are the most constant, as in some cases the bursting or tearing is not felt;' and when only one tissue suffers, the labour may continue, and there may be no hemorrhage.3 The pain continues, with little or no intermission. The stomach is disturbed, and vomiting ensues—at first, of the contents of the stomach ; then of a greenish, and ultimately of a black matter—the "-coffee-ground vomit." The countenance is pale and ghastly, with an expression of intense suffering and anxiety; the surface is cold and clammy. The pulse is very rapid, small, feeble,and fluttering; the respira- tion hurried and difficult; and the patient desires to be raised in bed. There is almost always a discharge of blood from the vagina; sometimes slight, and at others so considerable as to cause death.3 We know, also, from post mortem examination, that in most cases, hemorrhage takes place in the abdominal cavity; and some authors have attributed the state of collapse to this cause; but though it may aggravate the collapse, we know that this is present when there is no internal hemorrhage. the stomach; at others times it consists of a very dark even black-coloured substance, resembling coffee grounds—the pulse is extremely frequent, small, fluttering, or extinct—she complains of a mist before her eyes; loss of sight, and extreme faintness—a cold clammy sweat bedews the whole surface ofthe body, and if not speedily relieved, convulsions and death follow."— Dewees's Compendium, p. §63. 1 " Rupture ofthe uterus may take place, without being attended with that sensation of tearing, or giving way, described by our author. In two cases which have come under the observation of the'editor, this symptom was ab- sent ; the period at which the rupture happened not being marked by any peculiar sensation. Both these patients complained throughout the labour, of intense lancinating pain just behind the symphysis pubis. On opening the body of one of them, the laceration was found to be there situated. In the other case, no examination was allowed. One of these females died imme- diately, from the accompanying hemorrhage; the other lived till the follow- T ing day : in the latter case, very extensive inflammation had been set up."— Waller s Note in Denman's Introduction, p. 262. 2 "We are not to expect, howevei, that in every instance the symptoms will be so obvious, or so well defined as those I have stated. Thus, where the head is low down, firmly impacted in the pelvis, and that the injury is. confined to the muscular substance of the uterus, its peritoneal covering continuing entire, we are deprived of several of the leading marks. In ihe first place, there will be no hemorrhage externally, in consequence of the vagina being blocked up; secondly, there will be no receding of the pre- senting part; and lastly, we will be unable to distinguish any part of the infant under the abdominal parietes." "Even the constitutional disturbance, \ have on some occasions known to be so very trifling for many hours, nay, even fof some days, as to excite considerable doubts about the real nature of the case."—M'Keever, hupture of the Uterus, pp. 9-13. - 3 " Cette hemorrhagic peut etre comme foudroyante, la femme pent subi- tement soit avant la deliverance, soit immedialement apres, sans qu'aucun signe ait fait seupconner la rupture."—Duparcque, Ruptures del' Uterus, $c. p. 162. 240 Churchill's observations. When the rupture is complete, the expulsive efforts cease, be- cause the child escapes partially or wholly from the cavity of the uterus, into the abdominal cavity, where it may be felt by the hand through the abdominal parietes. (Dewees,1 Duparcque.8) The presentation, which was probably within reach before the accident, cannot now be ascertained by the finger. When the rupture is complete, a loop of intestine may escape through it, and give rise to the symptoms of strangulated hernia. Duparcque quotes three cases of this kind from Remigius, Percy, and Beauregard.3 A case is related by Dr. M'Keever^ where a yard and a half of intestine became strangulated, and sloughed off. This state of collapse may continue for some time, if it do not prove fatal; but at length a certain amount of reaction takes place; inflammation sets in, and the patient exhibits all the symptoms of peritonitis—acute pain, exquisite tenderness of the abdomen on pressure, tympanitis, decubitus on the back, with the knees drawn up, quick, small, hard pulse, hurried respiration, &c &c Terminations.—The patient may die of the shock a few hours after the accident, or after delivery:4 or she may survive the shock, and die of the peritonitis;5 or lastly, she may be carried off by secondary diseases, as sub-peritoneal, lumbar abscess, (fee. (Collins, Duparcque.6) Of Dr. Jos. Clarke's patients—one died undelivered; one died in four hours; one, in twenty hours; two in twenty-four, and one in thirty hours. i et When the abdomen is examined by the hands externally, the foetus, if the rupture be complete, may readily be distinguished.through its parietes; if the fetus cannot be thus detected, it is presumable that it has not escaped entirely from the uterus ; but we are to ascertain this by a careful and more extensive examination."—Dewees's Compendium, p. §65. 2 Ruptures de I'Uterus, p. 159. s Duparcque, Ruptures de I'Uterus, &c. p. 165. 4 "The interval which elapses between the accident and the death is various; but whether the patient be delivered or not, she, notwithstanding the many recorded instances of recovery, generally dies within twenty-four hours : often in a much shorter time. Steidele, however, relates a case where the patient lived till the twelfth day. Dr. Garthshore's patient lived till the twenty-sixth; and in the Coll. Soc. Havn., vol. ii. p. 236, there is the case of a woman, who, after being delivered, lingered for thre.e months. In a patient of Dr. J. Wilson's, recovery seemed to be going on for five or six days, when, after a fit of passion, she sunk in consequence of internal hemorrhage."—Burns's Midwifery, p. 531. 8 "The death ofthe patient usually follows soon, though not immediately after the accident; but I have seen one case, in which there was reason to believe that the woman walked a considerable distance, and lived several days after the uterus was ruptured, before her labour could be properly said" to commence."—Denman's Introduction, p. 261. ' I 8 " Dr. Monro's patient was sitting in a chair, when she suddenly scream- ed, and the uterus was lacerated ; she was not delivered, but lived from Tuesday till Friday.—Burns's Midwifery, p. 528. RUPTURE OF THE UTERUS. 241 Of Dr. Ramsbotham's—three died shortly after delivery; two in one hour, and one in three days. Of Dr. Collins's cases—four women died immediately after de- livery ; one died in two hours; three, in four; one, in ten ; two, in fourteen; one, in seventeen; one, in twenty-four; one, in twenty- five, and one in thirty hours; four died on the second day ; one, on the third; four, the fourth; one, the fifth; two, the eighth; one, the ninth ; one, the eleventh ; one, the fourteenth, and one on the twentv-fourth day. In by far the greater number of cases, the accident proves fatal. Of Dr. Smellie's three cases, two died; Dr. Jos. Clarke's eight, seven ; Dr. Merriman's one, one; Dr. M'Keever's eleven, nine ; Dr. Ramsbotham's ten, ten; Dr. Collins,'s thirty-four, thirty-two; and of Dr. Beatty's one, one died. Some cases, however, are on record where the patient recovered. Heister relates a case mentioned to him by Rungius; and Spiering, one cured by Forquosa. M. Peu,1 Dr. Hamilton,2 Dr. James Ham- ilton,3 Dr. Jos. Clarke,4 Dr. Douglass,5 Dr. Labatt.6 Dr. Frizell,7 Mr. Ross,* Mr. Kite,9 Mr. Powell,10 Mr. Birch," Mr. Smith,12 Mr. Maclntyre,13 Dr. Hendrie,'4, Mf. Brook,15, Dr. Davis,16 have each recorded one case of cure. Dr. M'Keever,17 and Dr. Collins,18 have each related two. Du- parcque has'collected four from French authorities.19 Osiander states that he has known several cases of recovery.20 Velpeau quotes several cases.21. There are a very few instances on record where the patient has recovered, although the foetus remained in the peritoneal cavity." (Duparcque.22) In cases of interstitial fetation, also, the patient has sometimes survived both shock and inflammation. 1 Pratique des Accouch. p. 341. 2 Outlines of Midwifery. 3 Select Cases in Mid. p. 138. 4 Trans, of Association, vol. i. 6 Essay on Rup. of the Uterus, p. 7. _ 6 Dublin Med. Essays, p. 343. 7 Trans, of Association, vol. n. p. 15. 8 Annals of Med., vol. iii. p. 377. 9 Mem. of Med. Soc, vol. iv. 253. 10 Med. Chir. Trans, vol. xii. p. 537. .. 11 Ibid. vol. xiii. p. 357. ,2 Med. Chir. Trans, vol. xui. p. 37o. 13 Med. Gazette, vol. vii. p. 9. 14 Am. Jour, of Med. Sci., vol. vi. p. 351. 15 Med. Gazette, Jan. 17, 1829. 16 Obstetric Medicine, vol. ii. p. 1070. » Ess. on Rup. Uterus, p. 41, et seq. '8 Pract. Treatise, p. 248. 19 Rupture de I'Uterus, p. 265, etseq. 20 Handbuch der Entbindungskunst, vol. ii. p. 84. "M.Eisille enumerates, in addition the following cases of fecoveries from rupture of the uterus:-« One by M. d'All'Ara, of Ravenna at the third month; one by M. Bengo, at seven months; one by M. Stein, at seven months ; one by M. Wetl, at seven months ; one by Sommer, during labour, &c. &c."— Velpeau, Traite d'Accouch., Brussels ed., p. 356. 21 Ruptures de I'Uterus, p. 87, et seq." 242 Churchill's observations. Diagnosis.—The sudden acute pain; the cessation of labour; the collapse; and the recession of the child,1 will render it easy to recognise the case. But when the rupture is partial, it may be more difficult; and we must rely mainly upon the sudden pain, and the collapse for our diagnosis. The occurrence of peritonitis subsequently, will serve to clear up the difficulty. The sudden occurrence of peritonitis in old women, may excite a suspicion of its origin; but it will not be easy to arrive at certainty in our diagnosis. Prognosis.—From the details already given, it is almost unne- cessary to state, that the prognosis is always grave. So very few are saved that there is but a faint hope of the recovery of the patient. Treatment.—The first question which presents itself, when a rupture ofthe uterus is recognized, is, "shall the patient be deliver- ed at once, or left to nature?" When the os uteri is undilated, instant delivery may be impossible:9 but in all cases where it is possible, the testimony of experience is in favour of immediate de- livery. (Denman, (early edition,) M'Keever, Burns,3 Dewees,4 John 1 I am indebted to the researches of rrry friend, Dr. Aquilla Smith, for the following extract from the "Manuscript Memoirs of the Medical and Phi- losophical Society ofDubbn," which gives the credit of the discovery of this diagnostic sign of rupture of the uterus, to Dr. Fleury, of ttas city. After reading (7th December, 1775,) two cases of ruptured uterus, Dr. F. says— "Although it be unphilosophical, and in many cases extremely dangerous, to draw general conclusions from particular instances, I am nevertheless inclined, from the consideration of these two cases, and the mechanism of delivery, to conclude that the receding of the child, which prese/Hs by the head, so far as to be no longer within reach of the operator's fingers, after having been distinctly so for some time, and the os tinea; fully dilated by labour pains, a pathognomonic sign of a ruptured uterus." 2 "I was called to a very extraordinary case, in which the part where the vagina and uterus are united, was ruptured; the child remaining in the cavity ofthe uterus, the os uteri being little dilated. Here, my advice was, not to attempt to deliver, because so much force would be required for dilat- ing, that it was feared the uterus would he completely torn from the vagina before the hand could be passed into the uterus—at least before the child could be extracted; and then the case would have been more horrible."— Denman's Introduction, p. 262. 3 " This process is usually easy, when the rent is in the cervix uteri or the vagina. When the rent is higher, there is sometimes great difficulty owing to the contraction of the uterus, which may be affected spasmodically or may have universally contracted, and the rent become very small" "It would be both cruel and useless to attempt delivery in such a case"— Burns's Midwifery, p. 532. 4 "Upon a review of an equal number of cases of those who were deli- vered after rupture, and those who were not delivered, it was found that those women who were delivered, lived much longer on the average than those who were not delivered Now, if death be suspended by our' efforts, it will follow-it becomes a duty to make them; and if we add to this what we have very confidently asserted, that there is no instance of recovery where delivery has not been performed, we must terminate this first part of our enquiry by declaring it is almost always proper to interpose art in cases of ruptured uteri."-Dewees's Compendium of Midwifery p 559 rupture of the uterus. 243 Clarke,1 Jos. Clarke,2 Hamilton,3 Merriman,4 Ramsbotham,5 Col- lins, Spiering, Osiander, Carus, Busch, Siebold, Baudelocque, Ca- puron, Gardien, Boivin, Velpeau, Nauche, Duparcque.) And the cases of recovery confirm this decision ; for in all, but one or two,6 the women were delivered. (Hamilton, Jos. Clarke, Labatt, Douglas, Garthshore, Frizell, Kite, Ross, Powel, Macln- tyre, Birch, Smith, Hendrie, Brook, M'Keever, Collins, Lachapelle.) Dr. W. Hunter and Dr. Garthshore advised that the case should be left to nature; and subsequently to the publication of his Intro- duction to Midwifery, Dr. Denman came to the same conclusion. The evidence of facts, however, must be allowed to counterbalance even such illustrious names; and that evidence is unquestionably in favour of delivery. The mode of delivery will depend altogether upon the circum- stances of the case. 1. If the head have not receded, and be within ieach, or be already in the pelvis, it will be well to deliver with the forceps if possible; but if not, we must have recourse to the perforator.7. Jt is an argument of weight in favour of trying the forceps, that in these cases the child generally lives for some time after the accident. 2. If the-child have escaped into the cavity of the abdomen, the hand must be introduced into the vagina, and, if practicable, passed through the laceration, and the feet seized and brought down, so that the child may be extracted through the rent.8 ' London Practice of Midwifery, p. 281. 8 Transactions of Association, vol. i. 3 Outlines of Midwifery. 4 "I must believe that either of these plans ir to be'preferred, according to circumstances. If in a case of this kind, rt should be found that the child had only in part escaped into the cavity of the abdomen, I should consider that it was the best practice to bring down the feet, if they were within reach, or to deliver by means of the-forceps, if the situation of the head allowed ofthe application of these instruments. And even if the child had been wholly forced through the rent, that it would be expedient to extract it by the feet, provided the accident had not been of long.duration, and there wars a ready passage for the hand into the cavity of the abdomen; but if some hours had elapsed, after the parts had given way, or if there were a difficulty in passing the hand, on account of the contraction ofthe uterus, it would then, perhaps, be more prudent to leave the event to nature."—Merri- man's Synopsis of Difficult Parturition, p. 115. s Pract. Obs. in Midwifery, vol. i. p. 385. 6 " Dr. Naegele, jun. has recorded a curious case of ruptured uterus, in which neither delivery per vias naturales, nor gastrotomy were attempted. Part of the child was discharged per vaginam, and part through the abdo- men, and the woman recovered."—-Brit, and For. Med. Renew, vol. v. p. 581- • , . . 7 " With regard to the perforator, I have only to observe, that in order as much as possible to guard against the retrocession of the head, the opening in the cranium should be made, not in the most prominent point of that cavity, as in ordinary cases, but rather to one side-'-so that the force employ- ed in perforating may be directed, not towards the axis, but rather against the walls, ofthe pelvis."—M'Keever on Rupture ofthe Uterus, p. 31. 8 " Of the thirtv-four cases, four were delivered by the natural efforts ; 244 Churchill's observations. The placenta is then to be removed,1 the vagina cleansed, &c. In all these cases the child is born dead. 3. If the uterus have contracted very firmly, it may be impossi- ble to pass the hand through the rent; or the pelvis maybe too narrow to admit of the child being extracted footling, or even of the passage of the hand. 4. In such cases we are advised to perform the Caesarian section, and extract the child and secondines through the abdominal parie- tes.2 Successful cases are related by Thibault des Bois,3 Lassus,4 Ha- den, Baudelocque, Latouche and Jopel,5 Lambron, Glodat,« &c. (Duparcque.7) nineteen by the crotchet; in seven the children were brought away by the feet; in two the delivery was effected by lessening the thorax, and bringing down the breech ; and in two, the mode of delivery has not been stated."— Collins's Practical Treatise on Midwifery, p. 247. 1 " After the delivery of the infant, the placenta will in general be found lying detached in the vagina: having removed il, as also any loose clots of blood that may remain in the passages, we next examine whether any por- tion of intestine has become protruded through the rent; and if so, we cautiously return it into the abdomen, following it with our fingers for some distancewithin the lips of the wound."—M'Keever on Rupture ofthe Uterus, p. 31. Dr. M'Keever has related a remarkable case, in which a large portion (one yard and a half) of intestines sloughed, and came away. The patient re- covered.—p. 44. See also Deparcque, Ruptures de I'Uterus, p. 95. 2 "When either the body or fundus, or both, have suffered, and *he child has escaped into ihe abdomen, the delivery, per vias naturales, may be either difficult or impossible, even in a well-formed pelvis; for the uterus will most probably contract itself so much as to render the re-passage of the child impracticable; the only chance in this case is the immediate performance of gastrotomy; but should a contracted pelvis complicate this case, tbe latter operation is the only alternative. But should the uterus remain flaccid, and lts. ™?!"n y'elding, and the pelvis well formed, we may succeed, though with difficulty, through the natural passages; but if this flaccid state of the uterus be attended by a deformed pelvis, the abdominal section is the onlv resource."— Dewees's Compendium, p. 567. "It may happen that great'deformity of the pelvis prevents delivery -In such circumstances, we must either perform the Caesarian operation, or leave the case to nature. If we have been calkd early, and before the abdominal viscera have been much irritated by the presence of the fcetus, we ought to extract the child by a small incision, This is assuredly safer than either eav.ng the child, or bringing it down, either with or without perforation through a contracted pelvis."—haras's Midwifery p 533 3 Journal de Med. Mac. 1768. 4 Pathologie Chirurgicale, vol. ii. p. 237. 5 Quarterly Journal of Foreign Medicine, vol. ii «TM°^d,e!;e'S Essay ia Re™e Med- Franc- et Etrang, Dec 1837 r5; *?° e,re qU°te/ a V,ery reraarkable case of a woman who had the Cae.ar.an section performed, on account of narrowness of the pelvis She became again pregnant: and at the seventh month, the cicatrices ofthe for- mer incision gave way, and she was delivered through the wound -Revue M«L Franc, et Etrang, December, 1837, p. 28. EncyclographS?/ Jafuary! 7 Ruptures de I'Uterus, p. 289. RUPTURE OP THE UTERUS. 245 To these may be added cases related by the following:—MM. Coquin,1 Sommer,3 Ceconi,3 Ruth,4 Rust,5 Gais, Naegele, Wein- hardt,6 lleim,7 Busch, Demay,8 Lechaptois et Lair,9 Velpeau.10 6. This will be the only mode of delivery, in ruptures occurring during gestation, before labour has commenced. During the stage of collapse, it may be necessary to give stimu- lants—ammonia, camphor, musk, wine, (fee.: but this should be done with great judgment, so as just to attain our object, and no more; bearing in mind, that whilst we may be relieving the col- lapse, we may be aggravating the reaction, and increasing the dan- ger at that period. A large dose of opium may be given after the delivery. When inflammation sets in, of course the treatment must be actively antiphlogistic. Three or four dozen leeches should be applied over the abdomen, and repeated if necessary. Large bran poultices are useful, and hip baths are recommended. Calomel and opium, or opium alone, is the most valuable remedy we possess. It should be given in large doses, or in smaller 'ones more frequently, so as to influence the system rapidly. If the rupture have arisen from narrowness of the upper outlet of the pelvis, and the patient recover, and again become pregnant, premature labour should be induced, at such a period of gestation as will allow the fcetus to pass without difficulty. It is of course desirable that the operation should, if possible, be deferred until the fcetps is 'viable;' but I do not think this a " sine qua non," as it may be worth while sacrificing the child to save the mother. Dr. Collins relates a successful case of this kiild, in which the patient was delivered the first time by artifical premature labour, and after- wards naturally. In Dr. Douglas's case, the patient was delivered by turning, the first pregnancy after the accident, and naturally the second. It would, however, be much wiser for the patient to avoid the risk of a subsequent delivery. » Bulletin dela Faculte, 1812,*p. 86. 3 Bulletin de Ferussac, vol. v. p. 47. s Luroth, Ibid, vol. xix. p. 85. 7 Ibid. * Journal Gen. vol. i. p. 187. 3 Ibid. 4 Ibid, vol. vi. p. 280. 6 Ibid. 8 Journal Gen. vol. v. p. 58. 10 Traite d'Accouch. p. 355. 246 Churchill's observations. CHAPTER VIII. VES1C0-VAGINAL AND RECTO-VAGINAL FISTULA. Fistles VOginO- vesicales et vagino rectales, Fr. Harnblasen-fistel. Scheiden- harn fistel, G. Perforation of the coats of the vagina, anteriorly or posteriorly, with the subjacent organs, the bladder or rectum, is not very rare, and is one ofthe most distressing and intolerable, accidents to which females are subject; and the more so, as a cure is but seldom effected. Indeed vesico-vaginal fistula has long been considered as one of the opprobria of surgery-; and, with some exceptions, of late years the cure has been given up as hopeless. Vesico-vaginal fistula are more frequent than perforations of the rectum; they are generally found separately, but in some cases co- exist.1 A case was received into the Meath Hospital some years ago, in which the bladder and rectum were both perforated, the perineum lacerated, and the canal of the vagina distorted by cicatrices, and closed at its upper part by adhesions. Causes.—Various causes may give rise to these accidents: 1. Either wall ofthe vagina may be wounded, accidentally or on purpose, by cutting instruments. Such has been the result of cri- minal attempts to procure abortion. In these cases, however, a cure often takes place spontaneously. 2. The long retention of a pessary in the vagina, may give rise to inflammation and ulceration ofthe vaginal tunics, and ultimately to perforation of the bladder or rectum. This, however, but seldom occurs, and then only in aged females, for whom little can be done in the way of cure.2 3. In powerless or difficult labours, where the head of the child is long retained in the pelvis, or whereby its size, it makes great pressure, the vagina may be the seat of inflammation, ulceration, and perforation, involving either ofthe subjacent organs, but much more frequently the bladder. In these cases, the vagina is frequently narrowed, or deformed by 1 " Breaches of the same kind through the recto-vaginal septum, which are indeed of much less frequent occurrence than those of the neck of the bladder, and the urethra, are also happily in many cases less miserably constant and durable in their results."—Davis's Obstetric Medicine, vol. i. p. 123. 2 " M. J. Cloquet (Path. Chir., p. 100,) gives the particulars of a case, in which a pessary was met with in tbe body of an old woman, the broad lower end of which had perforated the rectum; while the upper narrower one had produced ulceration ofthe vesico-vaginal septum, and entered the bladder." — Cooper's Surg. Dictionary, Art. Pessary, p. 1090. VESICOVAGINAL FISTULA. 247 irregular, circular, or spiral cicatrices, rendering the detection of the fistula somewhat difficult. (Nauehe,1 Davis.2) 4. A maladroit use of instruments may occasion this injury. Cases of both kinds of fistula could easily be adduced from authors, as the result of carelessness or incompetence in the operator. 5. Retention of urine during labour will generally involve more or less pressure upon the bladder; if within certain limits, perfora- tion will be the result of subsequent inflammation ; if the distention be excessive, and the bladder protrude into the pelvis, so as to be pushed before it by the descending head of the infant, then, most probably, rupture ofthe bladder and vagina will take place.3 6. The bladder is occasionally lacerated in rupture ofthe uterus, though there may not necessarily be a perforation ofthe vagina.4 7. In corroding ulcer and cancer of the uterus, the ulceration may involve either or both walls of the uterus, and perforate the bladder, or rectum, or both. For these cases, however, nothing curative can be attempted. The situation of the perforation is of great importance in the cure of vesicovaginal fistula. It may be at the junction of the urethra with the bladder—in the neck of the bladder—or in some part of its body. The opening may be more or less circular in form, or it may be a rent running longitudinally from before, backwards, or transversely. The curability ofthe fistula will depend, in a great degree, upon its being attended with a loss of substance or not. Recto-vaginal fistula are uncertain in situation and form, occupy- ing any point of the intermediate septum, and running antero-pos- teriorly, or transversely. Symptoms.—These depend primarily upon the cause of the fistula, and will vary according to it; and secondarily, upon the escape of the contents of the wounded organ. Whichever organ be wounded, the result is inexpressible distress to the patient. The escape of faeces or urine is attended with so marked and irrepressible 1 Mal. des Femmes, vol. ii. p. 273. 2 Obstetric Medicine, vol. i. p. 123. See also Journ. de Med., vol. iii. p. 551. London Med. Journ., vol. i. p. 335. Saviard's Surgery, pp. 7—72. 3 "Between the case of rupture, and that in which an opening is produced by slough, there is a considerable difference. In slough, there is not merely the aperture, but the removal of a part, both of ihe womb and vagina; in rupture, no substance is wanting—the injury being effected by the simple disruption ofthe texture." "Do not however, hastily take up the notion, that in these ruptures, the bladder is always, or even generally healed, for this I very much doubt; such closures, however, most undoubtedly occur sometimes, and I have seen one very suspicious instance of it."—Blundell, Diseases of Women, p. 80. 4 " The vesical cyst may give way posteriorly into the peritoneal sac—the urine becoming interfused among the viscera; or the laceration may be seated in front°the water making Its escape into the ctiiular web which lies about these parts, and covers the contiguous surfaces."—Blundell, Diseases of Women, p. 69. 248 churchill's observations. an odour, that the patient is placed ' hors de society Obliged to confine herself to her own room, she finds herself an object of dis- gust to her dearest friends, and even to her attendants. She lives the life of a recluse, without the comforts of it, or even the consola- tion of its being voluntary. It is scarcely possible to conceive an object more loudly calling for our pity and strenuous exertions, to mitigate, if not remove, the evils of her melancholy condition. In addition to the offensive smell, the escape of the urine gives rise to excoriation of the vagina, external parts, and thighs. The flow of urine is constant when the neck of the bladder is the seat of the injury, and at intervals when the wound is situated more posteriorly. In all cases, a careful examination should be made, by passing the catheter into the bladder, and a finger into the vagina; then placing the points of both in apposition, the whole posterior surface ofthe bladder should be passed over, and carefully examined.1 At some one point the finger and catheter will come in contact: the catheter may then be passed into the vagina, and the extent of the damage ascertained. The same process will detect any injury of the recto-vaginal septum. When the vagina is not cicatrised, it is not generally difficult to obtain the information we desire ; but when deformed by cicatrices, it will require both care and patience. It may sometimes be necessary to use the speculum. In the majority of cases, little is to be hoped for from the efforts of nature ; the borders ofthe wound become thickened and callous, and the case remains stationary during the patient's life. In some few cases, however, the result is more favourable; as, for instance, when the wound has been inflicted by a sharp instru- ment. In two cases under my care, where the wound was precisely at the insertion of the urethra into the bladder, and was followed at first by absolute incontinence of urine, a cure was obtained natu- rally. The Wound slightly contracted, without healing, and the muscular fibres of the bladder assumed the office of a sphincter mus- cle, and closed the orifice, so that the patient could retain urine almost as long as previous to the accident, and could evacuate it at pleasure. Treatment.—We cannot wonder that many methods should have been tried to remedy so offensive an accident, nor that so few should have succeeded, when we recollect the obstacle presented by 1 This is the more necessary, inasmuch as a temporary incontinence of urine is not uncommon after delivery. It generally also comes on soon after labour, so that at first either may easily be mistaken for the other. A vagino- vesical examination will always enable us to distinguish them. This incon- tinence, which arises from a species of paralysis of the bladder is best treated by the frequent evacuation ofthe urine—rest—and when the lochia have ceased, by cold local bathing. VESICO-VAGINAL FISTULA. 249 the constant passage of urine or faeces. We shall first treat ofthe cure of— ' 1. Vesico-Vaginal Fistula, which is by far the most difficult.1 The probability of relief depends partly upon the situation and partly upon the character of the fistula. When it is far back in the posterior wall of the bladder, and when there has been much loss of substance, a cure is seldom obtained ; but when near the neck, we may sometimes succeed. I shall now notice the principal plans which have been proposed. 1. DessauWs method,2 as it has been called, consisted in main- taining a catheter constantly in the urethra, so as to afford an outlet for the urine, and at the same time preventing its escape, by plug- ging the vagina.3 Chopart succeeded in curing a case by this means, where the wound was in the neck; but he failed in one where it was in the body ofthe viscus. Peu,4 S. Cooper,5 and Blundell, each relate a case of cure. J. Cloquet has added a kind of syphon to the catheter. There is no doubt that much relief may occasionally be derived from this plan. I had a case in which the patient was ultimately enabled to retain her urine for two hours, without dribbling, though the wound did not entirely close ; but in some of the cases on re- cord, the wound completely healed. There is this objection to the plan, however, that in many in- stances the patients cannot bear the catheter above an hour at a time.6 I saw two examples lately, where this circumstance proved a serious obstacle to the cure. 1 For more detailed information, see Kilian's Rein-chirurgisches Opera- tionen des Gebertshelfers, p. 237, et seq. 2 " En suivant ce procede, nous sommes venus a boutde guerir ces fistules urinaires et vaginales tres anciennes. a travers lesquelles nous pouvions porter le doigt dans la vessie."—Dessault, CEuvres Chir. vol. iii. p. 299. 3 " The cure (according to some) consists in keeping a flexible catheter always in the bladder, that the urine may be continually solicited to come through the urethra, rather than through the vagina; but if this precaution hath been neglected, and the lips of the ulcer are turned callous, we are directed to pare them off with a curved knife, buttoned at the point, or con- sume them with lunar caustic ; and if the opening is large, to close it with a double stitch, keeping the flexible catheter in the bladder until n is entirely filled up: but I wish this operation may not be found impracticable." Smellie's Midwifery, vol. i. p: 247. A case is related as having been cured by constantly wearing a catheter for months— Recueil, Period, de la Societe de Sante de Paris, vol. l. p. 187. 4 Pratique des Ace, p. 384. 5 Ryan's Manual of Midwifery, p. 253. 6 " The goodness of the principle of keeping a catheter constantly in the bladder, has been long acknowledged ; and in some few cases, its applica- tion has been attended with a successful result. The only objection to it in practice, is the extreme irritability of the bladder—by reason of which, few patients have been able to tolerate the retention of a catheter within its cavity for a sufficient length of time to comply effectually with the principle of its indication."—Davis's Obstetric Medicine, vol. l. p. 127. 250 Churchill's observations. 2. Cauterisation.—This is obtained by the repeated application of the nitrate of silver, or the strong acids. Dupuytreu, who, I think, first proposed the plan, used the "nitrate acide de mercure," or nitrate of silver. Relief has occasionally been afforded by this means ; but a cure is very rarely, if ever effected. Where there is much loss of sub- stance, it affords no chance. I have seen it fail more than once. However, Dupuytren, and Delpech, and Baravero, are said to have thus cured several cases. (Velpeau.) The best mode of applying the caustic is by means of a specu- lum, which will leave the upper surface of the vaginal canal ex- posed; or by Lallemand's "porte caustique." The caustic should be lightly applied, as the object is not to produce a slough, but merely a contraction. 3. Actual Cautery.—If tbe loss of substance be slight, and the wound small, there is no doubt that a cure may be obtained by this means.1 Dupuytren, who first proposed it, cured several ;2 Dr. jVTDowell, one;3 Dr. Kennedy, two;4 Mr. Liston, four or five;5 and others have been equally successful. Dr. Colles has tried it 1 " Cauterisation has been employed by many surgeons in the treatment of vesico-vaginal fistula. -It has been successful in many cases, when they were seated in the neck of the bladder, or in the urethra." "Mais qu'il s'agisse d'une fistule du bas-fond de la vessie avec perte de substance et d'une date ancienne, la scene change alors la face."—Jeanselme, L'Experience, January, 1838, p. 48. 1 " Lancet, June 23, 1838. "Nous avons vu guerir par Dupuytren, apres trois cauterisations de feu, une incontinence complete d'urine occasioned par une perte de substance disposee en forme de fente longitudinale qui partait de I'urethre, dont la paroi inferieure etait completement detruite et s'etendait jusqu'au bas-fond de la vessie."—Sanson, Nouveaux Elemens de Pathol. Med. Chir vol v p. 294. ' ' 3 London Med. and Phys. Journal, 1831. 4 " The operation may require to be several times repeated. Whether by repeating it sufficiently often, we should even in the majority of cases suc- ceed in closing the aperture, I cannot say, but rather think not. Fortunately however, it does not require that the aperture should be actually closed to enable our patients to retain their urine, as a very good substitute for the adhesion of the sides of the fistula occurs in the extension of its margin or lip across the aperture, thus forming a kind of valvular closure of it by which means the bladder becomes capable of retaining the urine almost as well as if the opening were closed. In a patient whom Dr. Breen saw with me, this effect was produced in a striking degree; and although her urine was constantly escaping from her before the cautery was had recourse to she was enabled afterwards to retain it without difficulty, for six or seven hours. In a case Dr. Collins saw with me, although the operation was per- formed six times, yet the aperture did not completely close; but thickening ofthe margin ofthe fistula took place—in consequence of which, the woman was able to retain her urine through the entire night, and for several hours (even when walking, and using active exertion) during the day, although on her coming to me, it was constantly escaping."-Kennedy's Essay*in Dublin Journal, vol. u. p. 241. J 5 Lancet, June 23, 1838. VESICO-VAGINAL FISTULA. 251 successfully where the orifice was not too large ; but without bene- fit where the fistula was extensive. I witnessed a successful case treated by my friend, Dr. Ferrall, of St. Vincent's Hospital. I also tried it in a case under my own care,.but it failed, as I anticipated, on account ofthe large size ofthe opening. The facility with which the operation is performed, will depend upon the situation ofthe fistula being more or less anterior. The patient may be placed upon her back, as for lithotomy, or upon her knees and elbows. Dr. Kennedy adopted the former; but I have found the latter far more convenient, and I think less offensive to the patient's feelings. The light can reach the part more readily, and the position of the operator is more convenient. The patient must be placed before a window, or a candle must be used. The next point is to dilate the vagina, so as to ensure access to the wound,-without contact with the vagina. This may be done by three brazen spatulse, sufficiently long to reach beyond the rent, and broad enough to protect the vagina—or by a double-bladed speculum. I have also used with great facility and safety, a metal cylinder, closed at its extremity, but with an opening in the side, a little dis- tance from the end, and corresponding to the fistula. I am indebted for this suggestion to Dr. Montgomery, A catheter should be passed into the bladder, and through the fistula, to guide the operator, and to keep the mucous membrane of the bladder from protruding. Having these preliminaries adjusted, the cauterising iron, at a white heat, should be lightly applied around the edges of the wound, and withdrawn. The dilators, or speculum, may then be removed, and the pa- tient placed in bed. If it do not occasion irritation, it will be ad- vantageous to allow the catheter to remain in the bladder. The patient should be kept quiet, and the bowels freed by medi- cine. A certain amount of local irritation generally succeeds, which subsides in the course of a few days; after which the operation may be repeated as often as necessary. The operation should not produce a slough, or the patient will not be benefited, but merely a corrugation or shriveling of the edges.1 If we thus reduce the wound, so as to bring the edges in contact, adhesion may then take place, and the patient be cured. But it must in candour be confessed, that whilst it is not difficult or un- common to benefit the patient to a great extent, a complete closure of the fistula is very rare. 1 " The effect ofthe cautery is to produce a thickening ofthe margin, and consequent contraction and diminution of the aperture—and ultimately, an adhesion of its edges, closing it up altogether. Upon the size and position ofthe aperture, will depend the greater or less likelihood of perfect cure."— Kennedy's Essay in Dublin Journal, vol. ii. p. 241. 252 churchill's observations. 4. The Suture.— This method is said to have been invented by Roonhuysen (Naegele); at all events, it has been long known and practised by the profession, with varying results. Of late years, it has been performed with success by Dieffenbach, Blandin, Chanam, and Jobert, (who operated seven times, and cured three patients,') Sanson, who failed; Deyber, who nearly, if not quite cured his patient; Malagodi of Bologna, who has pub- lished his successful case; by MM. Lallemand, Duges, and Roux, who failed ; and by M. Naegele. Mr. Earle cured^ three cases by this means. Mr. Hobart, of Cork, formerly published a successful case in a London Journal,2 and now states that he has since perfectly cured at least ten by the suture.3 A successful case is related in the American Medical Recorder.4 Dr. Evory Kennedy has succeeded in diminishing the orifice several times, and in one case in which the twisted suture was used, the cure was complete. Mr. Hay ward, of Boston, U. S., has recently published a very interesting case, which was perfectly successful.5 On the other hand, Dr. Colles (whose name alone is a sufficient guarantee for all that science, and skill, and care could do,) of this city, has allowed me to state that he has repeatedly tried the com- mon interrupted suture, but though he has by this means lessened the orifice, he has never succeeded in closing it entirely: and this was the result under very favourable circumstances. He has also seen very unpleasant consequences result from the operation—hemorrhage (the edges of the fistula having been re- moved by the knife) to a great amount—fever, hectic, °r wifc Tnflam mation of mucous membrane, as angina, catarrh, &c. It is to these affec ions that we must refer the miliary&fevers obser'ved by au hors especiaIIv the species which Levert calls malignant, and which exhibit adynamkTor ataxic symptoms."-Capuron, Mal. des Femmes, p. 567 aaynamic or SORE NIPPLES. 285 Treatment}—The proper management of women in childbed, will generally prevent the occurrence of these cases altogether. But if we are called to one of the slight febrile kind 1 have de- scribed; a gentle emetic may arrest its course. If not, but little medicine will be necessary. The bowels should be freed, and acid drinks (unless counter-indicated) given. The room should be well cooled and ventilated, and only light bed-clothing allowed. The diet should be bland and nutritious. The surface may be sponged with tepid water, and the linen frequently changed. When the febrile access has subsided, bark and diluted sulphuric acid should be given, with a better diet. If there be aphthae in the mouth and fauces, we may use borax and honey, or acid gargles, until they are removed. When the miliary eruption is an accompaniment of more serious fevers or local affections, it is the latter to which our attention and treatment is to be directed; and we may be satisfied, that in pro- portion as we succeed in relieving the primary disease, so the secondary affection will disappear. CHAPTER XIV. sore nipples. Erosion du Mammelon, Fr. Wundseyn der Brustwarzen, G. This is a very frequent and troublesome occurrence, and far more painful than would be supposed. It is more frequent with first children, but some women suffer from it after each confinement. It comes on generally after two or three days' suckling, and con- tinues for an uncertain time. Causes.—In the majority of cases, it is simply the reiterated ap- plication of the child which causes it, by removing the sebaceous secretion—so that the skin, when dry, contracts, slightly hardens, and cracks. This progress is aggravated by a slight degree of in- flammation. , But sore nipples may be owing to the state of the child s mouth, as is frequently seen when the child suffers from aphthae; and on the • '"In the first place, we order the ablution of the body every morning with tepid water; secondly, we direct the bowels to be regulated by means oV compound jalap, or magnesia and rhubarb; thirdly some tonic must be prescribed, as the diluted sulphuric acid, or the sulphate of quinine; and fourthly, the apartment to which the patient ,s confined requires o be freely vemilated, and a load of bed-clothes avoided."- Campbell's Midwifery, p, 343. 266 churchill's observations. other hand, the discharge from the nipple may inflame and exco- riate the child's mouth. Symptoms.—At first the nipple and areola are observed to be dry, rough, and harsh; then a great number of minute cracks may be seen ; or the surface becomes excoriated, and pours out a serous discharge, which in some cases is acrid, and spreads the excoriation to the surrounding skin. Or the nipple may exhibit deeper fissures, dividing it into two or three portions. Lastly, in some cases the nipple becomes ulcerated, and part, or nearly the whole destroyed. Each attempt at suckling makes the nipples worse for sometime, and occasions them to bleed. The torture to the patient is very great, and it requires all her fortitude to persist in nursing, at the cost of so much suffering. Treatment.—To prevent this disorder, the nipples should be washed with soap and water, and dried, and afterwards bathed with spirit and water, night and morning, during the last month of preg- nancy. In many cases this will be successful. "A combination of white wax and butter is a popular remedy, and is often useful. Stimulating ointments, such as ung. hyd. nit., diluted with axunge, are sometimes of service; or the parts may be touched with burned alum, or nitrate of silver, or dusted with some mild dry powder."1 © When excoriation or "chapping" has occurred, spirit lotions may be applied, or one formed of sulphate of alum, zinc, or copper, ace- tate of lead, &c. dissolved in rose water; but the one I have found most effectual is a weak solution of nitrate of silver, to be applied after each time-of suckling—care being taken to wash the nipple previous to the next application ofthe child. Various mechanical means have been contrived to cure the dis- ease. Nipple shields, of wood, ivory, or silver, may be procured, which, intervening between the child's mouth and the nipple, will often relieve the irritation altogether. But in many cases the child can- not draw the milk through them, and then we may have recourse to "calves'teats," properly prepared, or to a piece of chamois leather, shaped and protruded in the form of a nipple, and pierced with many holes. If any of these plans succeed, the nipple will heal in a few days, and the child may be applied to it. Feeding the child two or three times in the day, or giving it to another person to nurse, will facilitate the cure, provided we do not allow the milk to accumulate too much—in which case, inflamma- tion may be excited, and terminate in abscess. In very few cases is it necessary to give up suckling. Even if our remedies fail, the irritation will generally subside in a fortnight or three weeks. • 1 Burns's Midwifery, p. 628. inflammation of the breast. 287 CHAPTER XIV. inflammation and abscess of the breast. Inflammation et Abscees des Mammelles, Fr. Entzundung der Bruste, G. Females are obnoxious to inflammation of the breast after each pregnancy, and at any period of suckling; the more especially with first children, and during the first three months of nursing. Causes.—The irritation and congestion which takes place for the secretion of milk, varies in amount. If these be within certain limits, the secretion takes place with slight feverilhness for a day or two; if they exceed these limits, the secretion is arrested; the breasts become hot, tense, and painful, and unless the usual means reduce this extreme irritation, it will run on into inflammation and abscess.1 This excessive congestion may be regarded as the most frequent cause of mammary abscess, soon after delivery, and with first children. Exposure to cold, mental emotion, moving the arms too much at the time the breasts are so much enlarged, are all said to give rise to it. Inflammation may extend itself from the nipples to the deeper tissues, as already mentioned. Sympto?ns.—.The severity ofthe symptoms will depend upon the depth and extent of the inflammation. When the subcutaneous cellular tissue and the skin alone are involved, there will be 'some local pain and soreness, with a circumscribed hardness and tension, and a flush of inflammation upon the skin. But when the fascia, or gland, is involved, the pain is very severe, extending to the axillas—the swelling considerable, the tension great, and the constitution suffers proportionably. The pulse is quick and full, the skin hot, there is headache, thirst, sleeplessness, &c. The skin covering the inflamed part may be of a uniform red, or red in patches. If the gland be inflamed, the breast has a nodulated feel, as if it consisted of several large tumours.2 1 "Some have the breasts prodigiously distended, when the milk first comes, and the hardness extends even to the axillae. If, in these cases, the nipple be flat, or the milk do not run freely, the fascia, particularly in some habits, rapidly inflames. Others are more prone to have the dense substance, in which the acini and ducts are imbedded, or the acini themselves inflam- ed."—Burns's Midwifery, p. 623. 2 " The inflammation may affect the mammary gland itself, or be confined Vo the skin and surrounding cellular substance. In the latter case, the inflamed part is equally tense; but when the glandular structure of the breast is also affected, the enlargement ft irregular, and seems to consist of one or more tumours, situated in the substance ofthe part. The pain often extends to the axillary glands. The secretion of milk is not always sup- pressed when the inflammation is confined to the integuments"; and suppu- 288 churchill's observation*. The secretion of milk is, at least for a while, suspended ; but it will take place after the acute stage has somewhat subsided. After the inflammation has continued some time, suppuration takes place, and the matter makes its way to the surface. This occurrence is marked by shivering, followed by heat and perspira- tion, and a sense of fluctuation in the tumour, which is prominent and smooth.1 The pointing is generally in the neighbourhood of the nipple.2 By degrees the intervening substance is absorbed, and the cuticle giving way, the matter is evacuated. The matter of superficial abscesses is simple, or, as it is called, " laudable" pus; but when the abscess is more extensive, sloughs of cellular tissue and fascia are discharged. In a healthy person, when the matter has been completely eva- cuated, the absdfess soon heals up, leaving only a degree of hardness for some time. Such is the general course of the disease; but there are some important variations. " It sometimes happens," says Dr. Burns, "if the constitution be scrofulous, the mind much harrassed, or the treatment at first not vigilant, that a very protracted and even fatal disease may result. The patient has repeated and almost daily shivering fits, followed by heat and perspiration, and accompanied with induration or sinuses in the breasts. She loses her appetite, or is constantly sick. Suppuration slowly forms, and perhaps the abscess bursts; after which the symptoms abate, but are soon re- newed, and resist all internal and general remedies. On inspecting the breast, at some point distant from the original opening, a degree of cedema may be discovered—a never-failing sign of deep-seated matter there; and by pressure, fluctuation may be ascertained. This may become distinct very rapidly, and therefore the breast should be carefully examined, at least once a day. Poultices bring forward the abscess, but too slowly to save the strength, and there- fore the new abscess, and every sinus which may have already formed or existed, must be at one and the same time freely and completely laid open; and so soon as a new part suppurates, the same operation is to be performed. If this be neglected, numerous sinuses form, slowly discharging fcetid matter, and both breasts are often thus affected. There are daily shiverings, sick fits, and vomiting of bile, or absolute loathing at food; diarrhoea, and either ration is said to come on more quickly than in the affections of the mammary gland itself."—Cooper's Surgical Dictionary, p. 945. 1 "A particular prominence and smoothness are observed at one part of the tumour, with a sense of fluctuation, from the presence of matter. The constitution is also highly irritated, which is evinced by the occurrence of shivering, succeeded by heat, and profuse perspiration. Over the most prominent part of the swelling, the cuticle separates, ulceration follows in the cutis, and the matter becomes discharged through the aperture thus pro- duced."—Sir A. Cooper's Illustrations of Diseases of the Breast, p. 7. 2 " The matter is sometimes contained in one cyst or cavity, sometimes in several; but the abscess generally breaks near the nipple."—Cooper's Surg. Dictionary, p. 94§. inflammation of the breast. 269 perspiration, or a dry, scaly, or leprous state of the skin ; and some- times the internal glands seem to participate in the disease, as those of the mesentery ; or the uterus is affected, and matter is dis- charged from the vagina. The pulse is frequent, and becomes gradually feebler—till, after a protracted suffering of some months, the patient sinks."1 Treatment.—The first indication is to subdue the inflammation, and so prevent the formation of an abscess. For tthis purpose, the patient may be bled if the fever run .high : or a number of leeches may be applied, and repealed if necessary, followed by a large soft poultice, or fomentations. When the bleeding has ceased, the poultice or fomentations may be continued ;3 or an evaporating cold lotion substituted. The bowels should be briskly purged by saline medicines, and their effect is much increased if tartar emetic, in moderate doses, be joined with them.3 Indeed, this medicine has a more powerful effect in abating inflammation of the breast than any 1 have ever tried. The diet should be bland, and chiefly fluid. The milk should be gently drawn away at intervals, and the breast supported by a sling. When we find that our efforts are unavailing to prevent the for- mation of matter, the second indication must be fulfilled. We must facilitate it as much as possible, and by no means can it be done more effectually, than by constant poulticing—changing the poultice three or four times a day. Opium alone, or in combination with salines, should be given, to lessen the pain and induce sleep. There is some difference of opinion as to the propriety of open- ing the abscess when the matter is detected. My own experience coincides with Cooper's rule:—" Perhaps, as a general rule, the surgeon should never wait for an abscess of the breast to approach 1 Burns's Midwifery, p. 625. 1 "A convenient and simple mode of applying warmth, is to immerse a wooden bowl in hot water, and having wrapped some flannel around the breast, place it in the bowl. By this means, an effectual and equable warmth may be kept up for a considerable length of time."—Earle, London Med. Gazette, vol. x. p. 153. * "I have been in the habit of combating this affection in a way first com- municated to me by my friend, the late Mr. Gregory, who employed it with great success in the Coombe Lying-in Hospital. The remedy to which I allude is tartar emetic, whose power of controlling inflammatory affections of the breast would lead one to imagine that it excited a specific action on the mammaty gland. On the accession of inflammatory symptoms in the breast, after purging the patient, I administer this medicine in doses of one sixteenth of a grain, repeated every hour, so as to induce slight nausea. It is never my object to cause free vomiting; and if this should occur, I omit the medicine for an hour or two, and then recommence its use at longer intervals. In ordinary cases, I usually find, after twenty-four hours, that the pain and fever are mitigated, and the breasts are smaller and softer."—Es* say by Dr. Beatty, Dublin Journal, vol. iv. p. 340. 16—h 18 ch7trch 290 churciiill's observations. the sutface, but make an opening as soon as the slightest degree of fluctuation is perceptible; for if this be done, and the abscess is not very superficial, the matter will spread, and form sinuses in differ- ent directions.1 When quite superficial, a longer delay may be allowed ; but I am quite satisfied that it is better to open them, than to allow them to open spontaneously. After the matter is discharged, the diet may be improved ; and if considerable discharge continue, tonics may be necessary. The opiate at night may be continued for a short time, and then omitted. If the abscess be small, the child may suck the affected breast; but if large, it had better be artificially drawn, and the infant con- fined to the other breast. (A. Cooper.) In some cases the child must be removed altogether, as the suck- ling may lead to abscess in the sound breast. (Earle.) When sinuses form, the only remedy is to lay them all open. (Hey.) It will require care to prevent the patient sinking. Wine, bark, and good diet, will be necessary. ' Cooper's Surgical Dictionary, p. 946. " If the abscess be quick in its progress; if it be placed on the anterior surface of the breast; and if the sufferings which it occasions are not exces- sively severe, it is best to leave it to its natural course. But, if, on the con- trary, the abscess in its commencement is very deeply placed—if its progress be tedious—if the local sufferings be excessively severe—if there be a high degree of irritative fever, and the patient suffer from profuse perspiration, and want of rest, much time is saved, and pain avoided, by discharging the mat- ter with a lancet."—Sir A. 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